Introduction

This quality standard covers preventing excess winter deaths and health problems associated with cold homes. It includes people of all ages, and takes into account that some people are particularly vulnerable to the effects of the cold, such as people with cardiovascular or mental health conditions, young children and older people. For more information see the preventing excess winter deaths topic overview.

NICE quality standards focus on aspects of health and social care that are commissioned locally. Areas of national policy, such as winter fuel allowances, grants and energy pricing are therefore not covered by this quality standard.

Why this quality standard is needed

Cold weather has a direct effect on the incidence of heart attack, stroke, respiratory disease, flu, falls and injuries and hypothermia. It also has indirect effects on mental health problems, such as depression, and the risk of carbon monoxide poisoning if boilers, cooking and heating appliances are poorly maintained or ventilated. Overall, the death rate in the UK is higher during winter months (from the start of December to the end of March in the UK) and this is referred to as 'excess winter deaths' (Cold weather plan for England Public Health England).

The average annual number of excess winter deaths in England and Wales from 2010/11 to 2014/15 was 28,584 (Statistical bulletin: excess winter mortality in England and Wales, 2014/15 Office for National Statistics).

Most excess winter deaths and illnesses are caused by respiratory and cardiovascular problems during moderate outdoor winter temperatures of 4–8°C depending on the region (Cold weather plan for England Public Health England). The risk of death and illness increases as the temperature falls further.

The Standard Assessment Procedure (SAP) is the method used by the government to assess and compare the energy and environmental performance of housing (Standard Assessment Procedure Department of Energy and Climate Change). Housing is rated on a scale of 0–100, with 100 representing the most energy efficient. The SAP rating of housing across England varies considerably. In 2012, the average was 59 out of 100. The proportion of energy‑efficient housing (above 69) increased from 2% in 1996 to 18% in 2012. However, around 2 million properties (9% of housing) had a SAP of less than 30 in 2012.

A 2010 survey by the Centre for Sustainable Energy, You just have to get by, reported that people in households with an income of less than 60% of the national average income had difficulty paying their fuel bills. During the previous winter, 62% of low‑income households had cut back on heating and 47% had lived in homes that were colder than they wanted them to be. In low‑income households, 47% of people with cold homes said the cold had made them feel anxious or depressed, and 30% said an existing health problem had worsened.

Fuel poverty in England is measured using the Low Income High Costs indicator (Annual Fuel Poverty Statistics Report 2015 Department of Energy and Climate Change), which considers a household to be fuel poor if:

  • they have required fuel costs that are above average (the national median level)

  • they would be left with a residual income below the official poverty line if they met their required fuel costs.

The death rate rises 2.8% for every degree Celsius drop in the outdoor temperature for people in the coldest 10% of homes. This compares with a 0.9% rise in deaths for every degree Celsius drop in the warmest 10% of homes (Cold comfort Joseph Rowntree Foundation). Public Health England's advice is that the minimum temperature for homes in winter is 18°C (65°F) (Cold weather plan for England Public Health England).

Excess winter deaths are more common in, but are not confined to, older people. The Office for National Statistics' Statistical bulletin: excess winter mortality in England and Wales, 2014/15 reported:

  • 56% of cold‑related deaths were in people aged 85 and older

  • 27% were in people aged between 75 and 84.

In many cases simple preventive action could avoid many of the deaths and illnesses associated with the cold. Many of these measures need to be planned and undertaken before cold weather starts. Public Health England's Cold weather plan for England provides guidance on how to prepare for and respond to cold weather, which can affect everybody's health. It outlines actions for the NHS, public health, social care and other community organisations, to support vulnerable people who have health, housing or economic circumstances that increase their risk of harm.

Fire and rescue services undertake safe and well visits to help reduce winter‑related illnesses, with particular emphasis on identifying risks of falls, cold homes, flu and social isolation.

The quality standard is expected to contribute to improvements in the following outcomes:

  • excess winter deaths

  • morbidity

  • fuel poverty

  • exacerbations of current health problems

  • timely discharge

  • rates of hospital admissions and readmissions.

How this quality standard supports delivery of outcome frameworks

NICE quality standards are a concise set of prioritised statements designed to drive measurable improvements in the 3 dimensions of quality – patient safety, patient experience and clinical effectiveness – for a particular area of health or care. They are derived from high‑quality guidance, such as that from NICE or other sources accredited by NICE. This quality standard, in conjunction with the guidance on which it is based, should contribute to the improvements outlined in the following 3 outcomes frameworks published by the Department of Health:

Tables 1–3 show the outcomes, overarching indicators and improvement areas from the frameworks that the quality standard could contribute to achieving.

Table 1 Public health outcomes framework for England, 2013/16

Domain

Objectives and indicators

1 Improving the wider determinants of health

Objective

Improvements against wider factors which affect health and wellbeing and health inequalities.

Indicators

1.17 Fuel poverty.

4 Healthcare public health and preventing premature mortality

Objective

Reduced numbers of people living with preventable ill health and people dying prematurely, whilst reducing the gap between communities.

Indicators

4.1 Infant mortality* (NHSOF 1.6i).

4.3 Mortality rate from causes considered preventable** (NHSOF 1a).

4.4 Under 75 mortality rate from all cardiovascular diseases (including heart disease and stroke)* (NHSOF 1.1).

4.7 Under 75 mortality rate from respiratory diseases* (NHSOF 1.2).

4.15 Excess winter deaths.

Alignment across the health and social care system

* Indicator shared with the NHS Outcomes Framework.

** Complementary indicators in the NHS Outcomes Framework.

Table 2 NHS Outcomes Framework 2015/16

Domain

Overarching indicators and improvement areas

1 Preventing people from dying prematurely

Overarching indicator

1a Potential years of life lost (PYLL) from causes considered amenable to healthcare.

i Adults ii Children and young people.

1b Life expectancy at 75.

i Males ii Females.

Improvement areas

Reducing premature mortality from the major causes of death

1.1 Under 75 mortality rate from cardiovascular disease (PHOF 4.4*).

1.2 Under 75 mortality rate from respiratory disease (PHOF 4.7*).

2 Enhancing quality of life for people with long‑term conditions

Overarching indicator

2 Health‑related quality of life for people with long‑term conditions (ASCOF 1A**).

Improvement areas

Reducing time spent in hospital by people with long‑term conditions

2.3 i Unplanned hospitalisation for chronic ambulatory care sensitive conditions.

ii Unplanned hospitalisation for asthma, diabetes and epilepsy in under 19s.

Enhancing quality of life for people with mental illness

2.5 ii Health‑related quality of life for people with mental illness (ASCOF 1A** & PHOF 1.6**).

Improving quality of life for people with multiple long‑term conditions

2.7 Health‑related quality of life for people with three or more long‑term conditions (ASCOF 1A**).

Alignment with Adult Social Care Outcomes Framework and/or Public Health Outcomes Framework

* Indicator is shared.

** Indicator is complementary.

Italics – Indicator is in development.

Table 3 The Adult Social Care Outcomes Framework 2015–16

Domain

Overarching and outcome measures

2 Delaying and reducing the need for care and support

Overarching measure

2A. Permanent admissions to residential and nursing care homes, per 100,000 population.

Outcome measures

Everybody has the opportunity to have the best health and wellbeing throughout their life, and can access support and information to help them manage their care needs

Earlier diagnosis, intervention and reablement means that people and their carers are less dependent on intensive services

2D The outcomes of short‑term services: sequel to service.

Patient experience and safety issues

Ensuring that care is safe and that people have a positive experience of care is vital in a high‑quality service. It is important to consider these factors when planning and delivering services relevant to preventing excess winter deaths and illness associated with cold homes.

NICE has developed guidance and an associated quality standard on patient experience in adult NHS services (see the NICE pathway patient experience in adult NHS services), which should be considered alongside this quality standard. They specify that people receiving care should be treated with dignity, have opportunities to discuss their preferences, and be supported to understand their options and make fully informed decisions. They also cover the provision of information to patients and people using services. Quality statements on these aspects of patient experience are not usually included in topic‑specific quality standards. However, recommendations in the development sources for quality standards that affect patient experience and are specific to the topic are considered during quality statement development.

Coordinated services

The quality standard for preventing excess winter deaths and illness associated with cold homes specifies that services should be commissioned from and coordinated across all relevant agencies. A person‑centred, integrated approach to providing services is fundamental to delivering high‑quality care to people who may be vulnerable to the health problems associated with a cold home.

The Health and Social Care Act 2012 sets out a clear expectation that the care system should consider NICE quality standards in planning and delivering services, as part of a general duty to secure continuous improvement in quality. Commissioners and providers of health and social care should refer to the library of NICE quality standards when designing high‑quality services. Other quality standards that should also be considered when choosing, commissioning or providing a high‑quality service are listed in related quality standards.

The Health and Social Care Act 2012 introduced legal duties on clinical commissioning groups and local authorities to have regard to the need for reduction of health inequalities and to exercise functions with a view to ensuring that services are provided in an integrated way where they consider that this would reduce inequalities in access to services and outcomes achieved. There is a strong relationship between excess mortality and illness due to cold homes and factors such as age, disability and deprivation. Therefore, reducing inequality is an important consideration in providing services to prevent mortality and health problems associated with a cold home.

Training and competencies

The quality standard should be read in the context of national and local guidelines on training and competencies. All health, public health and social care practitioners involved in assessing people who may be vulnerable to the health problems associated with a cold home should have sufficient and appropriate training and competencies to deliver the actions and interventions described in the quality standard. Quality statements on staff training and competency are not usually included in quality standards. However, recommendations in the development sources on specific types of training for the topic that exceed standard professional training are considered during quality statement development.

Role of families and carers

Quality standards recognise the important role families and carers have in supporting people who may be vulnerable to the health problems associated with a cold home. If appropriate, health, public health and social care practitioners should ensure that family members and carers are involved in the decision‑making process about assessment and planned interventions.