“Warmth for Wellbeing Service” in Leeds and practical application of the NICE guidelines regarding prevention of excess winter deaths and morbidity

The aim of the Warmth for Wellbeing Service in Leeds, which started on the 1^st of October 2015, was to establish a co-ordinated and complementary service where households were supported with all their affordable warmth needs. The service provides tailored solutions to needs identified by/for vulnerable people living in cold homes; incorporating face to face advice, low-cost energy saving improvements, heating serving or repairs, and referrals to relevant support such as large-scale energy efficiency improvements to their property.

The outcomes we sought from the newly commissioned service aligned to those in the NICE guidelines:

• Reduction of preventable, excess winter death and illness rates.
• Improvement of health and wellbeing among vulnerable groups.
• Reduction of pressure on health and social care services.
• Reduction of ‘fuel poverty’ and the risk of fuel debt or being disconnected from gas and electricity supplies (including self disconnection).
• Improvement of the energy efficiency of homes

Furthermore, the service’s eligibility criteria and target groups were based on those listed in the NICE guidelines. The householder must fulfil one of the following criteria:

• Be over 60 years of age;
• Be expecting, or have children under age 16;
• Have a disability or cold-related illness (as per NICE guidance);

And:

• Living in private sector housing (relates to heating/ energy efficiency improvements only).

And:

• Be in receipt of any income-related benefit, or;
• Be on a low household income (under £21,000 per annum),
• Have little or no savings.

The new service provides support to any householder who lives in the Leeds Metropolitan District and who meets the eligibility criteria. The emphasis however is on those who live in fuel poverty.

Increasing affordable warmth and reducing fuel poverty have been strategic priorities in Leeds for many years, as is evident in the city’s Affordable Warmth Strategy, Housing Strategy and Joint Health and Wellbeing Strategy (currently under review). According to the new fuel poverty definition, at least 90,000 out of a total 800,000 Leeds residents suffer from Fuel Poverty. Therefore support to reduce people’s utility bills and increase the energy efficiency of heating and properties makes a tangible difference.

Before the Warmth for Wellbeing Service was commissioned, the management of existing affordable warmth services was disconnected. Funding was primarily awarded on a short term grants or year-on-year basis rather than a long term contract. The implication was that services were in competition for ‘business’ to meet their performance targets. Although the services had cooperated on some projects previously, there was no formalised incentive to refer to each other. There were risks of double-counting. Moreover, the funders of services were not communicating systematically and consistently about what and how they expected services to deliver and work together.

The Service Specification was developed with current funders and other stakeholders, primarily in the Council’s Public Health Directorate and the Sustainable Energy and Climate Change Team. Proposed targets in the specification were based on historical performance data which was considered as the baseline. These were combined figures from ongoing Sustainable Energy and Climate Change funded services, public health short-term contracts and CCG grant agreements.

The 3-year contract was awarded to Groundwork Leeds, in partnership with Care & Repair Leeds. Service delivery commenced on the 1^st of October 2015 following a brief mobilisation period.

We are anticipating a number of opportunities to increase efficiency and save costs including:

• Formalised referral pathway between partner agencies
• Better access routes established for self-referral but also for frontline workers. For example, a freephone number was set up, online enquiry form, triage by Contact Centre based on client’s needs, linked webpages.
• Integration with social prescribing schemes in primary care.
• Streamlined contract management and project management of the service
• One quarterly performance report produced for all funders rather than separate ones, which increases efficiency at the provider side
• Co-ordinated publicity materials therefore reducing duplication

The changes we were aiming to implement were primarily achieved through a comprehensive procurement process, which was led by Council’s Projects Programmes and Procurement Unit. The various stages and documents offered opportunities for engagement with stakeholders. The key stakeholders for the commissioning of the new service were: the Adverse Weather Group led by Public Health, Clinical Commissioning Groups (via Public Health Consultants), and other funders in the Council such as Sustainable Energy & Climate Change Team.

The Procurement Plan provided the vehicle for consultation with the three Clinical Commissioning Groups (via Public Health Consultants). It enabled conversations about joint commissioning/funding, which we were seeking in order to reduce fragmentation, increase quality, co-ordination and scale of assistance offered to vulnerable householders across Leeds.

On the whole, this led to good engagement and a joint approach to commissioning where it fitted strategic aims. A mixed model across the city was achieved, meeting the needs of local people. Members of the Adverse Weather Group, and other funders, commented on the content of the Service Specification. Commissioning Managers from CCGs were engaged in the evaluation of the Bids, which was a useful way of increasing their understanding of the service as well as reinforcing their vision for the service, connections with other CCG-funded services such as social prescribing, and agree a joint approach to contract management.

There are ongoing complexities emerging from the mixed investment model for example non-recurrent and recurrent funding. Moreover the impact of cuts to the ring-fenced Public Health budget are starting to materialise.

Other than contractual costs i.e. £230,000 per annum, ‘in kind’ costs were incurred for the procurement of the service i.e. Council officers’ time, some CCG officers’ time, plus bidders’ time to prepare and complete tender documents. The ‘in kind’ costs have never been quantified but a significant amount of officers’ time was spent over the course of 6 months, followed by a months’ mobilisation period. Since the start of the service, there have been further ‘in kind’ costs for the Council as Public Health and Sustainable Energy & Climate Change Team have been involved with the marketing and promotion of the service as well as performance managing the contract.

Similar services delivered over previous winters, and funded through a combination of Department of Health ‘Warm Homes Healthy People’ grants, Public Health non-recurrent funding, and ongoing funding from the Sustainable Energy & Climate Change team, were independently evaluated by Leeds Metropolitan (Beckett) University. They concluded that services had made a tangible difference to the health and wellbeing of vulnerable clients, offering good value for money. This helped make the case for continued Public Health investment in warm homes service(s).

In previous performance reports, the Green Doctor Service and Warm Homes Service demonstrated high outputs, and excellent client satisfaction. A telephone survey found that at least 2/3 of householders noticed that they felt more comfortable, healthy and warmer at home following their Green Doctor visit.

Progress of similar services has traditionally been monitored quarterly. As “Warmth for Wellbeing” is a new service, provided in partnership, we set up monthly catch-up meetings to ensure the service’s delivery is on track. This has proven invaluable, both for commissioners and providers. Furthermore, there has been informal ad hoc communication in between.

We aim to gather evaluation data (both quantitative e.g. number of home visits and qualitative e.g. clients satisfaction) through quarterly performance reports initially. In addition, the provider has connections with Leeds University, who have provisionally pledged the support of a Masters student in Year 2 of the contract.

As the service has only been operating for 5 months, it is too early to know the impact, beyond anecdotal evidence and a limited number of powerful case studies. Preliminary findings suggest that the Freephone telephone number has experienced a month-on-month increase in calls, there have been a higher than expected number of referrals from frontline Council officers, and fruitful connections have been made with CCG-funded social prescribing schemes. Households have benefited from significant savings on utility bills mainly as a result of successful Warm Homes Discount applications and switching suppliers. Residents have had timely heating repairs and improvements ensuring that they have not been left without heat or hot water for long periods of time Where heating systems have been deemed obsolete, households are being supported to apply for free or subsidised replacements and other large energy efficiency measures.

What helped?

• Procurement process itself: A good range of technical support assists in preparation of the specification and providing a critical eye. Consultation with stakeholders and gaining formal agreements from other funders (e.g. CCGs) as early in the process as possible.
• Providers should play to each other’s strengths and build on existing activity
• Partnership agreement between providers
• Shared communication and marketing activity
• Governance by a steering group, not just quarterly contract management
• Pro-active commissioners that support the provider to achieve their objectives
• Joint contract management between public health and CCGs.
• Referral pathways with CCG-funded social prescribing schemes, creating stronger links with primary care and other third sector agencies in Leeds.
• Links with public health /CCG-commissioned work such as winter wellbeing grants scheme, Winter Friends briefing sessions, winter packs, CAB, health trainers etc.
• Links with existing Council-funded schemes such as Groundwork, Care & Repair, Better Homes Leeds etc
• Tapping into free training, coordinated/delivered by Council officers with specialist expertise e.g. Health Coaching and Green Deal legislation

 What posed a challenge?

• If joint funding between Council and CCGs is agreed, invest sufficient time in section 256 agreements and a Contract Management Plan, which is to be agreed by all who contribute funding, regardless of the amount.
• Appropriate signposting and referrals, e.g. type of tenure determines how much (or how little) can be done.
• Council-wide (including public health) budget cuts
• Some CCG funding is non-recurrent, affecting long term planning
• Limited opportunities to support households with large-scale measures such as full central heating, external wall insulation etc.