Wigan Council’s Affordable Warmth Access Referral Mechanism (AWARM) – the original single-point-of-contact health and housing referral service for people living in cold homes

The main aim of our project was to reduce the number of unplanned hospital admissions due to illnesses caused or exacerbated by living in a cold home. Our main objective was to upscale our existing Affordable Warmth Access Referral Mechanism (AWARM) by targeting it at a cohort of 2,000 people in fuel poverty who were likely to have unplanned hospital admissions due to illnesses caused or exacerbated by living in a cold home.

The Wigan Borough has a population of over 317,000 people forming around 139,000 households. Wigan Council has operated a single point of contact health and housing referral service, called the Affordable Warmth Access Referral Mechanism (AWARM) since 2008. AWARM receives referrals in from a range of partners, including Age UK, Care & Repair Home Improvement Agency, children’s centres, Citizens Advice, district nurses, fire service, GPs, health visitors, hospital discharge team, midwives, occupational therapists and social workers.

AWARM staff undertake a home visit to carry out a comprehensive 'Healthy Home Check' that covers energy efficiency, home repairs, home safety, home security, fuel debt,  fuel tariff, income maximisation, and health and wellbeing for each case to identify what referrals need to be made. AWARM makes referrals out to a range of partners who provide: benefit entitlement checks, draught proofing, energy switching, fire safety, fuel debt advice, heating and insulation schemes, home repairs and improvements, major and minor adaptations, and health checks. AWARM provides feedback on the action(s) taken to the original referrer in order to inform them of the outcome of their referral and encourage them to make further referrals for their other service users.

See: AWARM Leaflet in the supporting material

AWARM had helped to reduce the level of fuel poverty across the Wigan Borough to 9.4 per cent by 2012, which was the lowest rate in Greater Manchester and one of the lowest in the North West, where the average was 11.1 per cent. Despite this success, there were still 220 excess winter deaths in the Wigan Borough in 2012-13, an increase of 90 from the previous year. Based on the health risk stratification analysis for unplanned hospital admissions conducted by Wigan Borough CCG, there were around 200 excess winter emergency hospital admissions for the 65+ age group in the year August 2011 to July 2012. Circulatory Disease (ICD10 I00 – I99) and Respiratory Disease (ICD10 J00 – J99) appeared to be major contributors.

We worked with National Energy Action (NEA) on developing an innovative approach to target assistance at residents suffering from health conditions made worse by living in cold homes. The aim was to make these residents’ homes warmer so that they stay healthier and thereby reduce their need to visit their GP and reduce their risk of emergency admission to hospital.

To identify people who lived in a cold or hard-to-heat home, or were particularly vulnerable to the cold because of a medical condition, we overlaid the following data sets provided by Wigan Council’s Joint Intelligence Unit and Wigan Borough Clinical Commissioning Group (CCG):

 • people who live in an area of high deprivation;

 • people who live in privately rented terraced accommodation;

 • people aged 65 years or over in receipt of Council Tax Reduction; and

 • people aged 65 years or over who have a greater than 0 per cent risk of being admitted to hospital during winter (November to March) due to an illness of either the circulatory or respiratory system.

This identified 20 hot spot areas within the borough, which were validated against the relevant GP practice risk registers and against local officer knowledge to confirm that, in general, they appeared to contain those most in need of assistance. The GP practices within these hotspots were identified and work is being undertaken to select patients from the GP risk registers associated with fuel poverty, including coronary heart disease, chronic obstructive pulmonary disease and asthma.

In addition, NEA has been commissioned to deliver training on identifying fuel poverty and making referrals to AWARM to front line staff undertaking home visits.

A report detailing this approach was endorsed by Wigan Council’s Senior Management Team (13 May 2014), Wigan Borough Health and Wellbeing Board (25 June 2014), Wigan Council and Wigan Borough CCG Joint Commissioning Group (7 July 2014), and Wigan Council’s Health and Social Care Scrutiny Committee (11 August 2014).

This report was referenced in a business case presented to Wigan Council and Wigan Borough CCG Joint Commissioning Group (19 September 2014) in order to secure £200,000 to upscale AWARM by targeting it at a cohort of 2,000 people in fuel poverty who were likely to have unplanned hospital admissions due to illnesses caused or exacerbated by living in a cold home.

See: AWARM Business Case in the supporting material

Patients in the target hotspot areas are referred to AWARM by health and social care practitioners via a paper form, online form or the RCGP Single Click Referral Module for the SystmOne GP patient record management system. AWARM contacts each patient to arrange a home visit to complete a 'Healthy Home Check' that covers heating, insulation, property condition, financial check and health check. AWARM then makes onward referrals to the partner schemes listed in the Healthy Home Check.

See: AWARM 'Healthy Home Check' in the supporting material

Overall, the process is working well. However, the main challenge we faced was in changing the culture and mindset of health and social care practitioners to focus on prevention and early intervention in order to reduce future demand on NHS services.

Due to heavy workloads, it was difficult to motivate some practitioners to spend a little extra time with patients to explore if their housing conditions are making their health worse. This is despite AWARM making the referral process as easy as possible, such as through the RCGP Single Click Referral Module. To overcome this, we identified an enthusiastic champion in each GP practice to promote AWARM, delivered a comprehensive training session for all referrers and provided free Keep Warm Packs for practitioners to hand out to patients who agreed to be referred to AWARM.

Predicted Savings: For the year August 2011 to July 2012 there were around 1,800 additional acute hospital occupied bed days associated with around 200 excess winter emergency admissions for the 65+ age group in the Wigan borough. An estimate of the average cost of a hospital admission occupied bed day is £575. Therefore, the total cost of excess winter emergency admissions during the year examined is estimated at around £1,000,000.

The level of financial saving in reducing excess winter emergency admissions in the 65+ age group is dependant on:

• the effectiveness of identifying those at risk of fuel poverty and for whom the impact of fuel poverty is high, i.e. could lead to a winter emergency admission; and

• the effectiveness of the intervention(s), i.e. the proportion of people for whom the intervention prevents a winter emergency admission.

If we assumed (conservatively) that at the beginning of the programme 10% of the at-risk population can be identified and that the intervention is 40% effective, then the potential saving is around £40,000 per year in respect of reduced winter emergency admissions.

As the programme progresses and both identification of those at risk and the effectiveness of the intervention improve, say to 20% and 60% respectively, the potential financial savings increase to £120,000 per year.

Actual Savings: We have commissioned Sheffield Hallam University to carry out an academic evaluation of AWARM. They have produced a pre and post intervention questionnaire that will be completed for each AWARM referral. In addition, we are collecting the NHS numbers of each patient referred in order to track the number of unplanned hospital admissions that they had in the 12 months before and after the AWARM intervention. Both studies will be completed in late 2017, when we will be able to quantify the impact of AWARM and calculate the actual savings the project has made to the NHS.

To obtain the funding needed to establish and run a single point of contact health and housing referral service, you need to present a robust business case to the funding body. This needs to include the following five key elements:

• Evidence base: Collate a strong evidence base using academic research, national and local data, reports and strategies. Identify your target geographical hotspots and health conditions. Include case studies to illustrate the problem and how your project can help. Provide details on how you will monitor and evaluate your project.
• Health and Housing Language: Ensure that you use appropriate health and housing language and provide a definition for any specialist terminology used.
• Invest to Save: Ensure that your project provides prevention and early intervention in order to reduce hospital admissions and facilitate prompt hospital discharge.
• Endorsement and Support: Try to obtain endorsement and support for your project from key influencers, including:

- Director of Public Health

- Health and Wellbeing Board

- Council Senior Management Team

- Council Cabinet Portfolio Holder

- Council Scrutiny Committee

• Deliverability: Ensure that you can deliver your project quickly. To this end, it is important to have experienced teams and networks in place together with established systems and processes for your project. Ideally, you should have data sharing agreements already signed so that you can access the relevant patient records. The best way to demonstrate this is by having an existing project that you can upscale.