Winter Warmth Pilot with Public Health England (PHE)

Public Health England (PHE) tell us that nationally approximately 30,000 older people die unnecessarily each winter. There are a variety of contributory factors, such as poorly insulated housing, health inequalities, social isolation and loneliness as well as increased influenza activity. We also know that those most affected are typically women aged over 75 who live alone in either private or privately rented accommodation and may suffer from one or more limiting conditions. There is a growing realisation of the effectiveness the Fire and Rescue Service (FRS) can have in supporting prevention and wellbeing, particularly in reducing pressure on the health/social care systems and improving health outcomes through the use of data-led approaches. Consequently PHE have approached the Chief Fire Officers Association (CFOA) to deliver interventions in three pilot FRS' to tackle winter pressures, specifically around cold homes, social isolation, falls prevention and signposting to flu inoculations. Greater Manchester Fire and Rescue Service (GMFRS) is one of the FRS, the others being Staffordshire FRS and Gloucestershire FRS.

Our proven track record in prevention work over the past ten years has seen a significant reduction in the number of accidental fires in the home, and deaths and injuries from fire; we know that poor health and fire risk are closely related and factors common to both include mental health, alcohol and drugs, smoking, mobility and medication. In recent years we have considered health in so much as it impacts on fire risk, however our access in Greater Manchester to more than 60,000 homes each year to carry out home visits affords us 60,000 opportunities to see, say or do more. We have therefore broadened the scope of our home visit so that these and other factors are considered in their own right i.e. from a health perspective as well as their impact on fire risk.

The focus of the pilot is falls & frailty, warm homes and social isolation, which will test the optimisation of fire and rescue resources to minimise winter pressures, improving outcomes relating to health and wellbeing and also contribute to reducing demand on our own and other services, including accident and emergency departments, during the winter months.

Fire and Rescue Services are being recognised as an asset by colleagues in health and social care. Our delivery of simple interventions address a broad range of risks that predispose a person to risk of fire and also address many of the social determinants of ill health. Our approach to prevention also provides practical support to people who require it to stay in their homes, whilst at the same time reducing the demand on other services.

The development of our home safety check into a holistic, person centred 'Safe & Well' visit gives us the opportunity to expand our prevention activity, addressing not only fire risks but other health and wellbeing issues.

The ‘Consensus Statement' on Improving Health and Wellbeing between NHS England, Public Health England, Local Government Association, Chief Fire Officers Association and Age UK’ describes the intention to work together to encourage joint strategies for intelligence-led early intervention and prevention, ensuring people with complex needs get the personalised, integrated care and the support they need to live full lives, sustain their independence for longer and in doing so reduce preventable hospital admissions and avoidable winter pressures/deaths.

Demand for health and social care is rising as a result of an increase in the numbers of children and adults with long term conditions, alongside an ageing population. The NHS Five Year Forward View highlights the need for an increased focus on integration and prevention so that resources are utilised more effectively, outcomes are improved and demand is reduced. It also recognises the need to broaden and deepen the involvement of the third sector in developing solutions. Fire and Rescue Services (FRS) and in particular GMFRS, are seen as beacons in prevention and have provided a significant amount of best practice in prevention activities. At the same time the number of fires has decreased due to preventative work by FRS and regulatory measures. This has resulted in new opportunities for FRS to complement and further support the health and social care sector.

Greater Manchester Fire & Rescue Service delivery teams operate across the city region, from all 41 fire stations as well as Prevention Delivery teams covering the ten local authority areas. Whilst operational staff already provide a 24/7 service, we are currently moving to a model that allows our non-operational risk reduction teams to provide a service 7 days a week including evenings.

The principles of a 'Safe & Well' visit include:

• A ‘light touch’ health check of all individuals in the home
• Identification of risk while in the home and provision of brief advice to mitigate the risk
• Provision of appropriate risk reduction equipment
• Signposting and/or referral to specialist advice or support if appropriate

In Greater Manchester, we had already developed a comprehensive eight day training package, supported by Royal Society for Public Health (RSPH), PHE and partners in mental health and falls services, in order to equip staff with skills, knowledge and confidence to deliver 'Safe & Well' visits effectively.

NICE NG6 Recommendations 6 and 9 encourage non-health care and other organisations to assess heating needs and help people whose homes may be too cold. Our ‘winter pressures' online training package includes guidance on this and other areas, and has been used by not only GMFRS staff but staff in the other pilot areas. Specifically around cold homes, our training supports staff to make a risk assessment as follows:

1. Observing the home, looking for signs of cold, damp or poor heating
2. Understanding occupiers’ concerns about high fuel bills
3. Signposting occupiers to energy saving and cheaper fuel services
4. Being aware of medical or long term health concerns
5. Making an assessment of mobility or frailty using the ‘Get Up and Go’ test and falls risk assessment tool
6. Signposting occupiers to GPs for flu vaccinations
7. Providing risk reduction equipment where appropriate such as room thermometers and ‘winter warmth’ packs that include hat, gloves, blanket and hot water bottle.

Age UK is supporting by sharing knowledge, resources and expertise with the PHE/CFOA advisory board and fostering support amongst local Age UKs who can offer FRSs useful assets and expertise to achieve success.

NICE Recommendation 4 suggests ways in which primary care and home care practitioners should identify people at risk of ill health from living in a cold home, however GMFRS’ risk analysts have also used local data sources as well as the over 65s NHS ‘Exeter Data’ and other internal existing datasets, (including fire incidence and mosaic lifestyle data) in order to produce lists that identify those most at risk. These have been broken down by age, gender, single household and an indication of whether property may be privately owned or privately rented; this gives us a much more targeted list of approximately 6,500 addresses in Greater Manchester. Local managers are working closely with partners in our ten local authorities to facilitate data sharing of people who are known to them to be at increased risk as a result of winter conditions.

The Fire and Rescue Service (GMFRS) has existing processes and systems in place to record and report on information gathered during home visits. Our internal database allows us to report on the numbers of safe and well visits as well as the numbers of ‘winter warmth’ interventions. Our visit involves a suite of Yes/No questions for statistical/data reporting purposes as well ‘free text’ recording which should articulate:

• The risk(s) identified
• Actions taken to mitigate risk
• Identification of further action needed, if any
• Identification of appropriate internal/external agency to progress any further actions.

Quality assurance of records is carried out in line with current practice by local managers to ensure that any follow up action is complete. This may involve local prevention teams carrying out further follow up visits where appropriate to ensure that risk has been mitigated to an acceptable level, and/or to work with partners to do this. The pilot is being independently evaluated by ICFI in London on behalf of PHE, which has taken the following format:

• Pre pilot interviews with GMFRS staff
• During pilot follow up interviews with GMFRS staff
• Identification of relevant agencies and contacts across the City region to take part in interviews
• Contacting people in receipt of a Safe & Well/winter warmth intervention (via ‘opt in’ and ‘opt out’ letters) to take part in follow up telephone interviews to discuss their experience

Between 2^nd November 2015 and 22^nd February 2016, 2006 occupants provided information and were given advice on winter warmth, of which 1055 were aged over 65 years.

One example of our work is: A couple (Mr and Mrs A) aged 90 and 89 years respectively contact the service to report a defective alarm. On visiting the property, our crews carried out a 'Safe and Well' visit and reported the following:

• Both occupants had mobility issues and were not known to a falls service.
• The property was a ground floor flat, housing association owned, with hoarding issues such that Mr and Mrs A were living, sleeping and cooking in one room.
• Mr A was partially sighted and hearing impaired.
• It was noted that Mrs A asked the same questions several times
• Neither Mr nor Mrs A were known to any other services
• The flat was cold and Mr A expressed concerns about high fuel bills and limited pension income
• Mr and Mrs A have since been referred by us for a health and social care assessment, and Age UK have also been contacted to assist.

One of the challenges of this pilot has been the identification of the most appropriate resource to signpost or refer to, as well as increasing the skills, knowledge and confidence of our staff in delivering low level interventions to address risk.

Now that we have a greater emphasis on local initiatives to deliver prevention interventions for our vulnerable populations, and to support local action to deliver better health and wellbeing outcomes, engagement with our partners across the health and local authority networks has been key to making this a success. Navigating the complex health, social care and local authority systems and processes has been a challenge – we have tried to overcome this by ensuring that we communicate at all levels, not just at a strategic level.

Effective communication, internally and externally, is key to the success and understanding of our approach. The vision for Greater Manchester devolution is to ensure the greatest and fastest possible improvement to the health and wellbeing of its 2.8 million citizens and every opportunity has been taken to communicate our own vision of ‘fire as a health asset’ at the highest levels. We have taken advantage of local media coverage, such as the launch in November of our work around winter warmth with PHE. Our employees are updated on a regular basis with developments, useful documents and training materials, using a combination of methods which include eLearning and face to face communications

We know that our brand and the esteem in which the service is held gives us access to people’s homes that others cannot achieve; people seem more likely to engage in difficult conversations with our staff than with others. However, we accept that some people will not expect us to discuss health and wellbeing issues. Our internal Contact Centre advises callers of our Safe & Well & winter warmth offer at the time of booking, and we are also in the process of reviewing and updating our leaflets and resources to reflect this.