EHJ August 2002, volume 110/08, pages 244-247 Peter Archer looks at the links between poor health and housing and considers some of the reasons why fuel poverty has become a government priority

During an average English winter it is thought that at least 30,000 people die prematurely because their homes are damp and cold, and as a result of other environmental factors. Most of the victims of this phenomenon are either older, often-frail, people or very young children. Comparative studies have shown that only Britain and Ireland suffer from this problem among European Community countries.

In 1996, there were 4.3 million families (22 per cent) living in fuel poverty in England. This means that more than one in five families could not afford to heat their homes to a level where their health would not be adversely affected by the cold in winter.

In November 2001, The UK Fuel Poverty Strategy was launched to tackle the problem. It focuses primarily on measures to improve energy efficiency and reduce fuel costs for fuel poor households, since the income measures which form part of a longer term solution are being addressed in wider poverty and social exclusion policies.

POOR HOUSING MEANS POOR HEALTH
Until very recently, no British government has accepted that there is a link between the condition of a house and the health of the occupants. In July 1997, Sir Donald Acheson, former chief medical officer of health, was invited by the Government to review and summarise health inequalities in England and to identify priority areas for the development of policies to reduce them - which led to the publication of the Independent inquiry into inequalities in health, in September 1998.¹

In the report, Sir Donald says that poor quality housing is associated with poor health, and that dampness is associated with increased prevalence of allergic and inflammatory lung diseases, such as asthma, independent of smoking and socio-economic factors. In addition, unmodernised older properties have far higher heating costs than improved and modern homes.

In 1998, a survey of older people found that 25 per cent were using less heat than they wished because of the cost. Cold housing leads directly to hypothermia, may contribute to the excess of winter deaths seen in older people and leads to fuel poverty. While the hazards of such poverty could be addressed by increasing the financial resources available to older people and others living on state benefits, a more direct approach would be to improve the energy efficiency, insulation and heating systems of affected housing.

Mechanisms to do this include further development of building regulations for new and existing buildings and through further development of government schemes which subsidise improvements to existing properties. However, current government schemes such as the home energy efficiency scheme (HEES) may not reach homes most in need, for example owner-occupiers and those living in the private rented sector.

In response to Acheson's report and to other consultations, the Government issued a white paper in July 19992 which sets out an action plan to tackle poor health. It states that: "Most people spend more time in their own home than anywhere else, so good quality housing inevitably has an important impact on health. Homes should be safe, warm, dry and well ventilated with amenities which meet minimum standards of comfort, such as indoor toilets. There are still about 1.5 million dwellings which fall short of the current fitness standard laid down in primary legislation."

According to the Government, the most significant risks to health from poor housing come from cold and damp, which cause a number of illnesses, including respiratory diseases. Very old people, small children and the chronically sick are most vulnerable to this increased risk. Typically, in any one winter there will be 2.5 million homes in England cold enough to cause ill health, with two million of these homes being occupied by people in vulnerable groups. From December to March, year-on-year, there are between 20,000 and 50,000 excess deaths in England compared with the rest of the year and cold housing is one of the factors responsible.

Consequently, the Government is reviewing the current housing fitness standard³ and has proposed its replacement with a new housing health and safety rating system (HHSRS). The new system will measure the extent of any dampness, lack of heating provision, and any deficiency in the energy efficiency of the building. An empirical judgement is then made of the likely outcome from the defects and ratings are calculated. Although there is strong support in principle for the new system, there will need to be primary legislation before it can be introduced and this cannot be effective before late 2003.

In November 2001, new findings were published on the impact of housing conditions on excess winter deaths. The research, which focused on the ten-year period between 1986 and 1996, was grant aided by the Joseph Rowntree Foundation and was undertaken by academics at the London School of Hygiene and Tropical Medicine.⁴ The Cold comfort report concluded that:

• during the winter months (December to March) there was a 23 per cent excess of deaths from heart attacks and strokes compared with non-winter months;
• the rise in deaths was greatest in older people, but there was some rise at all ages. There was little variation with socio-economic group;
• the magnitude of the winter excess was greater in people living in poorly heated dwellings;
• the percentage rise was greater in those dwellings with low energy-efficiency ratings and those predicted to have low indoor temperatures during cold periods;
• the gradient of risk increased with age of property; and
• substantial public health benefits can be expected from measures that improve the thermal efficiency of dwellings and the affordability of heating them.
  

The report concludes that: "Taken as a whole, the results suggest a credible chain of causation which links poor housing and poverty to low indoor temperatures to cold related deaths.... Hence it is likely that substantial health benefits could be achieved by measures aimed at improving thermal efficiency of homes. In particular, consideration needs to be given to the types of energy efficiency programme and the method of population targeting that will provide the greatest benefits to public health."

Figure 1 shows the seasonal fluctuation in mortality in the coldest 25 per cent of homes (blue) compared with the warmest 25 per cent of homes (red).

The potential of an early death is not the only health outcome from living in a cold home. The 1996 Energy report, published by the Department of Environment, Transport and the Regions (DETR) in 2000, showed that fewer people living in energy efficient homes reported chest, rheumatic and general health problems than those in cold homes.5 An NHS pilot study, which installed central heating in the homes of asthmatic children in Cornwall, was associated with improvement in symptoms and reduced time off school.⁶

WHAT IS FUEL POVERTY?
The common definition of a fuel poor household is one that needs to spend at least 10 per cent of its income on all fuel use in order to maintain a satisfactory heating regime. This is generally defined as 21¼C (70¼F) in the living room and 18¼C (64¼F) in other occupied rooms. The temperatures are those recommended by the World Health Organisation. Table 1 shows that although there has been a small fall in the numbers of fuel poor households since 1991, there were still 4.3 million families having to spend at least 10 per cent of their disposable income to keep their homes at a reasonable temperature in 1998. The incidence of fuel poverty in 1998 by tenure is shown in table 2.

THE UK FUEL POVERTY STRATEGY
In November 2001, the Government launched the UK fuel poverty strategy which sets out objectives, targets and an action plan to end the problem of fuel poverty, and in particular the blight of fuel poverty for vulnerable households, by 2010. Fuel poverty in other households will also be tackled once progress is made on the priority vulnerable groups. For England, the specific interim targets are: to have assisted 800,000 vulnerable households by 2004 through HEES, now marketed as the warm front team (WFT), and to reduce the number of non-decent social sector homes by one third (although not all of these will be occupied by fuel poor households).

To achieve these objectives, there will need to be a range of programmes to improve the energy efficiency of fuel poor households, including efforts by local authorities and registered social landlords as well as HEES. Continuing action to maintain the downward pressure on fuel bills is required, ensuring fair treatment for the less well off, and the development of energy industry initiatives to combat fuel poverty needs to be supported. Poverty and social exclusion also need to be recognised as multi-dimensional problems.

Recently there have been a number of new developments, including:

• warm zones, an area-based approach to eliminating fuel poverty by maximising co-ordination;
• new training schemes that are taking steps to tackle the shortage of gas engineers;
• a working group has been set up to look at the issue of gas network extension, which has now reported to ministers with recommendations; and
• pilot schemes on renewable energy sources and micro-combined heat and power systems⁷ are about to be set up to explore how these technologies can be used to help the fuel poor, particularly in areas without access to mains gas.

As the UK fuel poverty strategy has only been in operation for a short period, it is impossible to make any judgement on the likelihood of the Government meeting its objectives. However, to assess the health benefits achieved by HEES delivered through the WFT, the Energy Saving Trust (EST) is managing a major study that will evaluate the impact on vulnerable householders. The study will run over two winters, starting in 2001/02, and will examine the general health of householders over the period and consider the impact of energy efficiency measures on their use of the health service.

There are a wide range of other programmes and initiatives also aimed at improving housing and energy efficiency and regenerating deprived areas including:

• the national strategy for neighbourhood renewal;
• the new deal for communities;
• the single regeneration budget;
• the market transformation programme;
• and the proposed seller's pack.

While these will help to improve the energy efficiency of low-income households, it is difficult to determine accurately how much will be spent on investment in housing.

The proposed replacement of the hundred year-old housing fitness standard with the HHSRS will enable local authorities to take account of the health impact of cold, damp and energy-inefficient homes when considering using their powers to enforce better conditions.

Strong partnership working will be essential to deliver the desired outcomes and will include local authorities working with other local bodies such as health authorities, primary care trusts, voluntary organisations and tenant and community groups. Local authorities are uniquely placed to make contact with a wide range of organisations that have staff on the ground - GPs, health visitors, district nurses, social workers, home improvement agencies⁸ and volunteers - who are in regular contact with vulnerable households and can identify those in need and inform them of the assistance available.

The Government is supporting the warm zone initiative originally developed by the Eaga Partnership.⁹ This is a pilot programme that draws together local partnerships involving energy utilities, local authorities and voluntary groups in a co-ordinated effort to tackle fuel poverty in their area.

The aim is to substantially deal with fuel poverty in a locality within three years, using an area rather than referral-based mechanism for reaching the fuel poor. Rather than trying to identify selected households, the warm zones will operate by reaching all households in an area, providing improvement measures through the grant schemes available in that location.

To assist older people with their fuel bills, the Government has also introduced
the winter fuel payment. All households with one or more people over the age of 60 will receive the payment. For the winter of 2001/02 the payment has been fixed at £200.

WILL THE STRATEGY WORK?
A fundamental problem with programmes such as the UK fuel poverty strategy is in ensuring that assistance reaches the most vulnerable households. The HEES scheme has been run by the Government for some years, but it is only recently that it realised that more than 80 per cent of the grants awarded had gone to improve the housing of local authorities and housing associations. Yet the majority of vulnerable households are either owner-occupiers or tenants of private landlords.

Local authority EHOs and colleagues in other services working in partnership with primary care trusts, GPs and home improvement agencies have the major task of ensuring that assistance reaches the most vulnerable people living in the community. Only if these households are reached will the health of the community really improve.

References

1. Independent inquiry into inequalities in health report. London: The Stationery Office, September 1998.
2. Saving lives: Our healthier nation. Presented to Parliament by Command of Her Majesty, July 1999.
3. Section 604 of the Housing Act 1985 sets out the matters that are to be considered when determining whether a home is fit for habitation. Included within the current standard is that the dwelling must have adequate provision for heating, and must be free from dampness prejudicial to the health of the occupants.
4. Cold comfort: The social and environmental determinants of excess winter death in England, 1986 - 1996, Paul Wilkinson, Megan Landon, Ben Armstrong, Simon Stevenson, Sam Pattenden, Martin McKee and Tony Fletcher, The Policy Press, 2001.
5. English House Condition Survey, 1996 Energy Report, London: Department of Environment, Transport and the Regions.
6. Housing and health: Does installing heating improve the health of children with asthma? Somerville M, Mackenzie I, Owen P, Miles D, Public Health 2000.
7. CHP - Combined heat and power systems to generate power locally and sell back power to the national grid.
8. Home Improvement Agencies - NGOs normally known as "Staying put" or "Care and repair" assist disabled and older people to carry out minor repairs, adaptations, and improvements. Most receive financial assistance from central and local government.
9. Eaga: the Energy Advice and Grants Agency - a not for profit organisation with charitable status.

The World Health Organization (WHO) produces a series of environmental health briefing pamphlets for local authorities, which are available from Chadwick House Group Ltd. To purchase the pamphlet on Asthma, priced at £7.60 each, contact Erica Roberts on Tel: 020 7827 5830 or e-mail: e.roberts@chgl.com