The North Yorkshire Winter Health Project - Warm and Well - Implementing the NICE guideline NG6

The Strategic Aim of the North Yorkshire Winter Health project was to implement the NICE guidelines NG6 by developing a multiagency Winter Health Partnership, a strategy and an implementation plan.

The aim of the Winter Health Strategy is ‘To improve and maintain health during winter months and prevent avoidable ill-health and Excess Winter Deaths (EWD) by working together to reduce fuel poverty and the adverse health effects of cold weather for individuals, families and communities in North Yorkshire.’

 The seven strategic objectives adopted were:

1. Reduce preventable, Excess Winter Death (EWD) rates.
2. Improve Health and Wellbeing among vulnerable groups.
3. Reduce pressure on health and social care services.
4. Reduce ‘fuel poverty’ and the risk of fuel debt or being disconnected from gas and electricity supplies.
5. Increase Influenza Immunisation Uptake Rates.
6. Reduce injury resulting from accidents, trips and falls.
7. Reduce Emergency admissions to hospital.

The aim was to work in partnership across North Yorkshire in order to reduce the variation in impact of winter on the health and wellbeing of the population of North Yorkshire. The expectations were that a North Yorkshire-wide multiagency Winter Health strategy would result in a coherent, coordinated approach with clear priorities for action. This would avoid duplication and clarify lead organisations roles/responsibilities. The strategy and accompanying implementation plan would identify key actions needed to meet the Strategic Goals and Objectives above.

It was intended that a winter health strategy, as part of the winter planning process would galvanise partners (statutory and non-statutory organisations, the community and businesses) within North Yorkshire to collectively reduce the adverse health consequences of winter across rural North Yorkshire, by addressing compounding factors such as fuel poverty and living in a cold home.

The strategy outlines the co-ordinated approach between 2015-2020. Work began in 2014/5 to raise awareness among leaders, professionals and the public about how to ‘keep well, keep warm and keep safe’ in winter. The proposed awareness raising campaign was developed and piloted to ensure that we continue to build on the on-going work across the county, informed by the latest data and information collected within the JSNA process, using the best evidence of what works where available, and taking into account best value.

The Size of the Problem – Fuel Poverty, Excess Winter Deaths and Influenza Immunisation

Overall, the health and wellbeing headline figures for North Yorkshire across public health and the wider socio-economic determinants of health are largely good. However, clear inequalities and variations do exist at all levels, from granular up to large scale geography. The information and intelligence presented in the Joint Strategic Needs Assessment (JSNA) about EWDs, Fuel Poverty and Influenza Immunisation rates were cause for concern for the Health and Wellbeing Board, particularly the variations across Districts and Clinical Commissioning Group (CCG) boundaries. This variation became an impetus for action, compounded by the fact that for every EWD there were potentially 8 avoidable hospital admissions.

North Yorkshire has a population of 601,536 countywide. North Yorkshire County Council hosts the public health team which interfaces with 7 districts, 6 Clinical Commissioning Groups and dozens of third sector partners. The JSNA (Feb 2015) showed that Craven, Richmondshire, Ryedale and Scarborough have above average percentage of houses classed as ‘fuel poor’. Being fuel poor does not in itself constitute a health risk. However, householders who need to spend more than 10% of their income on fuel in order to maintain recommended safe temperatures seldom do so. Householders in rural areas face stark choices about expenditure on heating fuel or transport / food costs or debt. Additional challenges include older, poor quality housing and many households being off-grid particularly in the most remote rural areas. This compounding effect of rurality and cold homes impacts on the health of the North Yorkshire population, particularly those most at risk e.g. the ageing population. 

The annual ‘winter planning’ cycle already existed in agencies including NYCC, CCGs, District Councils and the third sector partners. These forums meet to prepare organisations for the impact of winter and to maintain business continuity, through Local Resilience Forums (LRFs) and Strategic Resilience Groups (SRGs). There are also a number of groups specifically looking across districts at winter warmth and fuel poverty which included a wide range of partners.

A need was identified to ensure that these plans complement each other and include actions to address the potential negative health impacts of winter. A wide range of good work was already being delivered in North Yorkshire but to avoid duplication, maximise benefit and ensure value for money, a joined up approach with a strategic direction was required.

The North Yorkshire Health and Wellbeing Board initiated the implementation of the NICE guideline NG6 by supporting the need for coordinated action across in order to tackle the issues impacting on the population each winter. The primary proposal was to develop a Winter Health Strategy (NG6 Recommendation 1), drawing upon actions in the implementation plan from NG6 (Recommendations 2-12).

 Enablers:

• Working in partnership was well-established across NY.
• Reducing variations in health outcomes and protecting the vulnerable was an existing priority for the Health and Wellbeing Board.
• Ensuring effectiveness and value for money whilst encouraging innovation was an existing approach for all partners.

 Key project actions and costs

1. The Winter Health Strategy was coordinated, produced and launched by the multiagency strategic Partnership, and funded and facilitated by the public health grant (cost £53,331)
2.  The Warm and Well North Yorkshire project implementation (£393,282)

British Gas Energy Trust funding was awarded to Rural Action Yorkshire (RAY) to coordinate the delivery of the project. This included:

• delivery of training to health professionals and frontline workers
• one-to-ones and practical around energy switching advice, administering crisis funds, fuel debt support and small home improvements
• the pilot and delivery of a single point of contact for winter health needs, as recommended by NICE guidelines NG6
• innovative engagement methods such as a draught excluder campaign and creation of a ‘cold comic’ for primary schools (The Case of Evil Dr Freeze and the Zombie Penguins)
• events and resources for the general public
• winter health awareness raising campaign focussed on:

• Keep Well (e.g. Flu jabs; Healthy Eating; Stay Active).
• Keep Warm (e.g. Heat your home; Save energy; Winter fuel payments).
• Keep Safe (e.g. Emergency Contact; Befriending; Home safety)

  3.  Influenza Immunisation (Costs included in point 1. above)

In NYCC less than 7% of the staff identified as having ‘direct client contact’ received their Influenza Immunisation. An awareness campaign was targeted at NYCC staff and analysis of the potential barriers to uptake was conducted through surveys. . Provision of the Influenza Vaccine was through designated Pharmacy outlets. Employees were required to complete a form to present to the pharmacy in order to receive their free influenza vaccine.

4. Development of an implementation plan

An implementation plan was developed and agreed by partners at an annual conference, which included workshop sessions to identify key actions and priorities. All attendees were also asked to pledge an action that they/their organisation would carry out to contribute towards the delivery of the implementation plan. The plan is monitored by the Winter Health Strategic Partnership.

There were no direct cost savings attributable to this project, so far. Potential non-cashable benefits included:

• Improved coordination of activity
• Reduction in duplication (e.g. coordinated communications)
• Likelihood of reduced staff absence (e.g. flu vaccination)
• Improved energy efficiency of homes through the provision of advice and support and through physical improvements to the properties
• Household incomes improved, through benefits maximisation, energy switching and changes to fuel tariffs.
• Health outcomes improved in that households in fuel poverty were able to keep warm and well during cold weather, reducing seasonal morbidity and mortality during cold spells.
• Frontline staff who took up flu vaccination were less likely to contract flu and as a result less likely to pass the virus to vulnerable people they came into contact with. The EWD rates since the start of the project in 2014/5 are still awaited.
• Time and resources saved for frontline staff and professionals through the creation and delivery of a single point of contact, enabling speed and efficiency of patient referrals into winter health support.

A robust and coordinated evaluation approach was developed by the Partnership. Three evaluation forms were developed to be used in different levels and types of interventions. Individuals receiving interventions were asked health specific questions (such as number of GP visits, flu vaccination uptake and prevalence of coughs/cold/flu) and follow up surveys will be conducted to evaluate impact.

An overarching evaluation of the British Gas Energy Trust funded practical support is being conducted by RAY and results of the evaluation are expected in March 2017. This should provide robust evaluation of a wide scale project which has included innovative work and pilots.

Ensure that all deadlines are clear from the outset.

The Strategy was originally planned to be launched in Feb 2016 but the HWB Board requested signoff in November 2015 to include Winter 2015/6

Use a range of methods are used to engage with partners e.g. e-meetings, emails, e-newsletters, Skype

The partnership approach required a significant commitment by partners. Some partners had limited capacity (time, travel, ability to commit to additional subgroup meetings etc), particularly CVS organisations as their funding and working structure requires them to be working on funded projects. Thus subgroup meetings did not occur as regularly as planned and some attendance to meetings and engagement with plan development was patchy.

Allow sufficient time to develop implementation plan

The deadline slipped as plan development took longer than expected. This was due to the range of work being conducted by a number of partners, which was difficult to capture and that some partners were unable to provide extensive comments due to capacity constraints.

Be flexible to incorporate national messages into campaigns

The awareness raising campaign was reliant on the release of the national NHS campaign material. The campaign in winter 2015/16 had to be developed in a standalone fashion, as the NHS Winter campaign had not yet been released. Therefore the NY campaign had to be flexible to incorporate national messages.

Use varied methods to engage with front line staff and work closely with Communications team early

Engagement with front line staff to improve flu vaccination uptake was challenging due to difficulty engaging with front line staff who do not have access to the intranet, the primary method of communication

Use varied evaluation methods

Monitoring flu vaccination uptake amongst staff was challenging as we do not currently monitor frontline staff who receive the vaccine free of charge from their own GP. Ensure evaluation approach is flexible for different contexts and acknowledge constraints of evaluating practical support being delivered in challenging contexts.    

Continue to hold multi-agency winter health partnership events

There was a good attendance from a range of partners to the two conferences. They were engaging and productive events, and indicating widespread commitment to the agenda.

Develop future plans in partnership

The implementation plan was developed with partners at the partnership event. This enabled contributions from a wide range of partners, sharing best practice and prioritising actions with insight from frontline workers. The plan was developed and owned by the entire partnership with continued high levels of engagement from partners.

Conduct thorough consultation process for future strategies

There were good rates of feedback from a wide range of partners during the consultation of strategy.