Fuel poverty affects a significant proportion of UK households and can cause or worsen many common physical and mental health problems. This article discusses the key medical consequences and how to minimise its overall burden.
Fuel poverty affects a significant proportion of the UK population and is associated with deleterious effects on health. In this article, we discuss the epidemiology of fuel poverty, followed by a review of the key medical consequences and what may be done to minimise its overall burden. For the purposes of this journal, the discussion on health matters is confined to older adults; however, it must be appreciated that children are another vulnerable group who may be significantly affected.
Fuel poverty is defined as the inability to afford adequate home heating, or specifically, the need to spend 10% or more of household income on heating the home to an acceptable standard.1 Even using relatively rigid definitions, the government’s estimate is that during the last year for which complete data is available (2016), 2.55 million (11.1%) of households in England were in fuel poverty.2
The fuel poverty status of a household depends on three interacting drivers: household income, energy efficiency and fuel prices.2 While there is a link with deprivation in general, it is not a linear one; most low-income households are not fuel poor, and conversely, an individual or family with a reasonable income living in an energy-inefficient dwelling may slip into fuel poverty.
In international terms, the UK performs poorly in this domain compared to most other developed nations, particularly Scandinavian countries.3 This has been linked to the relative thermal inefficiency of much of the UK housing stock in comparison to countries with colder winters, who have a longer tradition of fuel-efficient design, and the generally wider socio-economic extremes in the UK.3
Within the UK, fuel poverty is positively associated with poor fuel efficiency ratings (bands D to G), not being connected to the gas grid (relative risk 1.5), living in private rented accommodation (relative risk 2), and unemployment (relative risk 4).2 Lone parent and multi-occupancy households are the highest risk, reflecting a strong association with absolute deprivation.2 Conversely, single people under 60 are at lowest risk, as this cohort mainly comprises affluent single professional men and women; however, the risk rises for older people who live alone.2
There is significant regional variation; within England, the most affected areas are the North East, North West, West Midlands, and Yorkshire and Humberside, whilst the least affected are London, the Home Counties and Eastern England, generally tracking regional income levels.2 The notion that rural life is idyllic is deeply embedded in the British psyche, unhelpfully belying the reality of much greater deprivation, physical isolation and aged, fuel-inefficient housing stock all contributing to higher rates of fuel poverty.4
No single illness or syndrome is exclusively caused by fuel poverty. Rather, it is a factor in causing or exacerbating the relative risk of several common conditions. At the hub of this is the long-recognised phenomenon of excess winter deaths (EWDs), defined as the comparison of mortality between December-March relative to the previous August–November and subsequent April-July. This rate has been falling in the UK but remains significant, for example, in 2009/10 it was 25,400 despite the absence of a ‘flu epidemic.5
Furthermore and paradoxically, the UK and other countries with relatively mild winters such as Greece, Spain, Portugal and Ireland actually suffer more EWDs than countries with colder winters which have more fuel-efficient housing.6 A comprehensive review of fuel poverty conducted by Sir Michael Marmot and his team in collaboration with Friends of the Earth7 usefully divides the health consequences into circulatory diseases (responsible for about 40% of EWDs),8 respiratory disease (responsible for about a third),8 mental health and other, less direct health impacts, a blueprint this review follows.
It is well recognised that mortality from both coronary heart disease and cerebrovascular disease is more likely in cold temperatures,9 and there are pathophysiological responses that explain this. One study demonstrated that a 1 degree C lowering of room temperature raised blood pressure by 1.3mmHg, as the neuro-humoral catecholamine response to cold led to progressive peripheral vasoconstriction in a bid to preserve core body temperature. Another important contributory biomechanical factor is the thrombogenic effect of raised plasma fibrinogen and factor VII levels,10 which may themselves be at least partly caused by the immune response to concomitant respiratory infection.10 Another study from Scotland showed cold to be a significant factor in the total burden of hypertensive disease.11
Significant respiratory disease is strongly linked to cold and damp housing.12 Hajat et al demonstrated a 19% rise in GP consultations for respiratory tract infection for each degree drop below 5 Celsius.13 This is also reflected in markedly increased hospital admission rates.14 As with circulatory disease, much of this increased risk may be logically explained by the pathophysiology of cold, causing bronchoconstriction and increased mucus production, reducing resistance to infection and forming a nidus in which microbes thrive. Acute bronchitis, pneumonia, and exacerbations of asthma and COPD are closely associated.13 A particular hazard of cold, damp conditions is mould, important as a cause or exacerbation of asthma and of aspergillosis, the latter being an easily-missed diagnosis particularly important to consider in patients with atypical or prolonged coughs, particularly when more obvious explanations have either been excluded or treated.15
The Warm Front evaluation study assessed the mental health impact on adults, concluding that anxiety and depression were strongly associated.16 Furthermore, a significant dose-response link emerged, with bedroom temperatures of 21 degrees being associated with a 50% reduction of anxiety and depression relative to temperatures of 15 degrees.16
Numerous common health problems are associated with cold exposure, including diabetic complications, peptic ulcer disease, osteoarthritis and hip fractures.17 Many of these exacerbations are due to increased adrenal stress-response hormones i.e. catecholamines and glucocorticoids, whilst hip fractures may follow the increased risk of falls in the elderly as cold adversely affects mobility and dexterity.17 Many struggling with fuel poverty have to compromise on food, both in terms of quantity and quality (the ‘heat or eat’ dilemma), risking relative malnutrition and weight loss which will further exacerbate the effects of cold; Bhattacharya and colleagues found that poor Americans reduced their daily calorific intake by 200 during cold spells.18 Social isolation consequent upon a reduced ability to leave the home or to welcome visitors into it has been identified as a significant issue.19
Whilst it is not reasonable for the medical profession to assume responsibility for a largely social problem,20 from a clinical perspective, it is worth bearing it in mind as a potential ‘red flag’ in cases such as frequent exacerbations of asthma or COPD, especially if patients feel more unwell that objective markers of illness such as spirometry and peak flow would indicate. In practice, it is most likely to be community-based clinicians such as GPs, district nurses and community matrons who flag this up, and there are agencies which may help.
In some parts of the country, GPs can become part of ‘warmth on prescription’ schemes through which they refer patients to public health and housing services that can deliver interventions. Such referral schemes can be provided by local authorities, public health and housing functions or third sector organisations.21 Core funding is required for these services and, since they are not a statutory duty, their number and scope has been reduced during the recent years of local authority austerity.
There are few examples of referral schemes funded by CCGs or other NHS organisations, although a case could be made that it would yield substantial health benefits. Estimates by the Building Research Establishment are that substandard housing costs the NHS in England £1.4bn a year in first-year health treatment costs relating to specific hazards, almost certainly an underestimate of the total costs.22
Cold homes referral schemes can be co-ordinated alongside other public health initiatives. Citizens Advice has recently published a toolkit for use by both local authorities and health bodies to deliver a joined-up approach.23 Additionally, a referral system would only be useful if there are appropriate systems in place to deliver support. Over 65s can access the Warm Home Discount, the Winter Fuel Payment and the Cold Weather Payment.24 These payments may go some way to help address the ‘heat or eat’ dilemma. However, they are a year-on-year intervention that may prove more expensive in the long run than measures which improve the long-term fuel efficiency of homes.
Energy supply companies have an energy company obligation ‘ECO’ to invest some of their revenues in improving home energy performance. This funding has for many years supported large scale programmes of boiler replacement and cavity wall insulation for elderly people. Since 2017 changes to the ECO programme require that the majority of funding be directed only to those households that meet the government’s strict definition of fuel poverty.25 Whilst this is intuitively fair, it does not capture all vulnerable households. For example, elderly pensioners living in their own homes may be asset-rich, whilst still cash flow-poor.
Local Authorities have powers to deem households in their area as warranting support based on locally determined criteria, which could comprise health criteria.26 This has the potential to be coordinated with local referral schemes, and then a relatively limited national budget for ECO funding can be merged with other housing programmes designed to improve housing quality. Since no single organisation is ultimately responsible for addressing the challenge of ill health associated with cold homes, success will be reliant on the robust partnership between multiple organisations, including local health services.
NICE has published guidelines on reducing the risk of death and ill health associated with living in a cold home.27 These call for action across sectors and for Health and Wellbeing boards to develop a local strategy. The NHS Long Term Plan encourages more NHS action on prevention and health inequalities, but emphasises local authorities’ role for funding and commissioning preventive health services.28
Fuel poverty affects a significant proportion of UK households and can cause or worsen many common physical and mental health problems. Given that the three main drivers of fuel poverty are low income, fuel cost and fuel-inefficient housing, the wider social obligations of all professionals concerned, whether working in healthcare, social care or in the environmental and sustainability sector, is to push for changes in all three domains. The significant wealth inequalities in the UK are a recognised factor in why many health outcomes here are worse than in many nations of comparable and even lower overall economic standing.29
For individual cases, there are several potentially helpful agencies to which concerned clinicians can signpost patients. A vital part of the long-term solution, however, will be proactively ensuring that existing homes are made more fuel-efficient, and this should be an essential priority for future construction.
General Practitioner, Chorleywood Health Centre, 15 Lower Road, Chorleywood, Hertfordshire
James G. Johnson
Head of Regional Programme, Local Energy North West Hub, Liverpool Region Local Enterprise Partnership, 1 Mann Island, Liverpool
Competing interests: None.
2. Department for Business, Energy & Industrial Strategy. Annual Fuel Poverty Statistics Report, 2018 (2016 Data). https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/719106/Fuel_Poverty_Statistics_Report_2018.pdf (accessed 30th January 2019).
3. Cronin de Chavez, A, Gilbertson J, Tod, A, Nelson, P, Powell-Hoyland, V, Homer C, Lusambili, A and Thomas B. Using environmental monitoring to complement in-depth qualitative interviews in cold homes research. Indoor and Built Environment 2017; Vol. 26(7):937-950
7. The Marmot Review Team for Friends of the Earth. The Health Impacts of Cold Homes and Fuel Poverty. London: Marmot Review Team and Friends of the Earth; 2011. https://friendsoftheearth.uk/sites/default/files/downloads/cold_homes_health.pdf (accessed 30th January 2019)
14. Gascoigne C, Morgan K, Gross H, and Goodwin J. Reducing the health risks of severe winter weather among older people in the United Kingdom: an evidence-based intervention. Aging and Society 2010; 30: 275-297
21. Ruse J, Garlick K. Under One Roof, Health and Housing Sectors Tackling Fuel Poverty and Cold-Related Ill Health Together. NEA 2018 file:///C:/Users/User/Desktop/NEA-Under-One-Roof-FULL-REPORT-FINAL-Feb-19.pdf (accessed 11th March 2019)
25. Energy Company Obligation: ECO3 2018 TO 2022. The Government Response. Department for Business Energy and Climate Change, 2018. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/727065/Energy_Company_Obligation_ECO3_2018-2022.pdf (accessed 11th March 2019)
26. ENERGY COMPANY OBLIGATION: ECO3, 2018–22 FLEXIBLE ELIGIBILITY GUIDANCE, 2018. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/776540/energy-company-obligation-3-LA-flexible-eligibility-guidance_.pdf (accessed 7th March 2019)