Why fuel poor means health poor

Public health physican Dr Noel Olsen on fuel poverty’s fiercest impact

People do not choose to live in cold, damp housing which they cannot afford to heat sufficiently to protect their health. Yet for millions in the UK, this is the consequence of inadequate building and environmental health standards stretching back over generations. As a result, a substantial proportion of Britain’s housing stock breaches any reasonable requirements for a decent home.

One consequence is that we have an average of nearly 50,000 additional deaths each winter – the equivalent of a major aeroplane crash every day of the season. This ‘excess winter mortality’ is far worse than that in much colder countries such as Norway, where decent housing and building standards have long been seen as a duty of government. While the exact proportion attributable to cold houses requires further research, it is clearly a major factor, and apart from influenza (largely preventable by immunisation) probably that most open to reduction in the short term. It contributes to a massive burden of preventable illness such as respiratory infections, asthma, strokes and premature heart disease. In the past, other elements such as smoking, diet, inadequate exercise, poverty and poor education have usually been seen as the major causes. But epidemiological studies now show a major impact on long term health from bad housing during childhood, even after allowing for these factors. So poor housing might pose health problems of the same order of magnitude as smoking, and even greater than alcohol.

This translates into massive pressures on the NHS each winter. Waiting lists are aggravated after cold weather, with hospital beds blocked by patients with cold-related illness. Planned operations have to be cancelled – a major source of NHS inefficiency. GPs and nurses struggle with increased surgery and home visits and a higher expenditure on prescriptions. The environmental impact from wasted energy is also significant – and, as a contributor to global warming, that means further health problems across the world. If proper standards were set and enforced, particularly in rented housing (private and social), many of these consequences could be prevented.

Housing improvements require a broadbased approach: lack of insulation, dampness and poor ventilation all require attention. Of these, ventilation and its effects on relative humidity, and consequently on mould and dust mite growth, frequently tend to be forgotten. It is not enough to close off the draughts, put in some cavity and roof insulation and improve the heating system. We need to design decent ventilation into the structure of the home, not address it as an afterthought.

On the plus side, awareness of the problems is slowly growing, particularly within the medical profession. The Chief Medical and Nursing Officers wrote to all doctors and nurses last year about fuel poverty, and the BMA will shortly publish a report pulling together the available evidence on housing and health. The National Heart Forum, in association with the Faculty of Public Health, is producing a toolkit of action NHS professionals can take to help alleviate fuel poverty. Because of its large membership of medical organisations, this should have a considerable impact in raising professional awareness and catalysing action.

The health service cannot provide decent housing. But it is health professionals who see the effects of bad housing on the health of their patients. They have most contact with vulnerable people, and are often the most trusted confidants and advisers of the isolated and the elderly. Involving the NHS therefore provides an important opportunity to help those most in need, and most likely to benefit from programmes for which they are unlikely to apply on their own.

Unfortunately, collaboration between agencies is often poor, and for many health professionals the duty of confidentiality creates real barriers. For a doctor to refer an elderly and slightly confused patient to a programme that is not widely known at local level raises major ethical issues. The new primary care trusts and directors of public health have a key role in overcoming these sort of barriers. And environmental health officers need to monitor standards and enforce action where necessary: at present, some landlords provide housing which is so thermally inefficient as to make it impossible for many people on low incomes to achieve the room temperatures demanded by the WHO.

The fact that the government has at last recognised the size of the problem is one of the most important and encouraging pieces of public health policy of recent years. After generations of neglect of housing standards, the new Fuel Poverty Strategy has the potential to alleviate poverty, reduce social isolation and combat inequality. What is now needed is for the government to apply Milner’s dictum (‘If something is preventable, and it is our duty to prevent it, prevent it we must and damn the consequences’) to the primary problem – bad housing. For in public health terms, much of the housing lived in by the most vulnerable people in our society remains a disgrace.

Works well in Worksop

Eleanor Williams (85 years old) of Worksop suffered a broken hip in a fall. After a stay in hospital, she recuperated in her daughter’s house but soon wanted to return home. As her house was heated by coal fires and had no insulation or draughtproofing, social services put her in touch with NEA’s local project office, WARM (Warmth and Regeneration for Mansfield). After inspecting Mrs William’s home, NEA met her family, explaining to them the help that was available via Warm Front grants and a utility energy-saving scheme, and providing the necessary application forms.

“The forms were very straightforward. It was then a question of waiting for surveys and approval,” said son-in-law Graham Forbes. “We didn’t know there were grants available to help people in Eleanor’s situation, until we made contact with WARM.” Because Eleanor receives income support, she was eligible for a complete energy efficiency package, including a new central heating system.

“Everything took about three to four months, from the time we applied to the completion of all the work,” said Graham. “We were very pleasantly surprised at the standard of the workmanship and the courtesy of the contractors; they took trouble to explain things and were clean, tidy and efficient. To be honest, our expectations weren’t very high since this was a grant scheme, but we have had no problems with any of the work.”

“My mother-in-law is delighted with the end results. She has instant warmth without the physical challenges of making and clearing coal fires. She can also shower whenever she wants, and there are no draughts in the house.”

All the case studies in this supplement come courtesy of National Energy Action (NEA - www.nea.org.uk).

22 September 2002

Noel Olsen