Local authorities and local health agencies should ensure that there are adequate and sustainable resources for housing and health referral services. Local authorities and health agencies must work together to provide adequate and sustainable resources for housing and health referral services.
The role of local Citizens Advice
UK Government statistics show that there were 2.5 million households in fuel poverty in England in 2015, based on the official 'Low Income High Cost' fuel poverty indicator (BEIS, 2017b). Although our statistics do not record the fuel poverty status of our customers according to the official indicator, it is clear that we reach a significant proportion of fuel poor households in England ('difficulty keeping homes warm during winter' is a good measure of fuel poverty).
The Citizens Advice winter resilience project
When developing a new service, or changing an existing service, Citizens Advice first establishes a theory of change to describe the objectives of the planned new service. An internal evaluation of the processes developed by the pilot offices was carried out, while the Center for Sustainable Energy carried out an external evaluation of the impact of the service on customers (available here). The first phase of the pilot has now been completed (see attachment for details of each of the pilot offices) and we have recently started a smaller second phase to carry out further development work.
The first phase evaluations have now been completed and provide rich material on our experiences. One of the people helped during the pilot was Steve, a 63-year-old single man who lived in a private rental apartment and was referred by his nurse.
We reached the right people, and learned a lot about their needs
Giving back a sense of control
There is growing evidence of the close links between cold homes and mental health problems. Even in the short term, the studies found a modest improvement in the average score on three of the four ONS well-being indicators, with a 15% improvement in the average score for clients' satisfaction with life. The studies showed that the majority of clients experienced little change in their physical health, with some clients' health continuing to decline.
This was in the context of the very poor health of the referred clients and the relatively short period between the two surveys. The finding that the greatest impact of the pilot was on well-being and mental health, rather than physical health, is common to evaluations of the impact of similar energy projects on customer outcomes, for example evaluations of the Wigan AWARM scheme, the Oldham scheme Warm Homes and the Warm at Home foundation scheme (Eadson & Leather, 2017; Bashir et al, 2016; Bennet et al, 2016).
What we learned about delivery
Working with health partners
Patients feel more supported – more holistic care, which also addresses their concerns outside the usual health sphere”. See Appendix and the Housing and Health Referral Service Toolkit (page 37) for more details on Manchester CA's work. Gloucester CA has established a far-reaching partnership with the Gloucester Clinical Commissioning Group and Severn and Wye Energy Agency in which the service, called 'Healthy Homes', will take referrals from all healthcare.
Gloucester CA has employed a case manager to provide advice and co-ordinate help where home visits are an important part of the service. The project uses baseline and evaluation surveys similar to those developed for the Winter Resilience Pilot to assess the project's impact on clients' health and related issues.
Other local Citizens Advice housing & health referral services
I have really enjoyed working with Kate and Citizens Advice on this scheme and would like to continue as it is very beneficial for our patients.” This includes healthcare workers in GP surgeries, the Gloucestershire Respiratory Team and self-referrals from people who see an advert for the service. The new project is funded by the Better Care Fund - a fund specifically designed to promote integrated services.
Warm & Well in North Yorkshire
The project conducted simple pre- and post-surveys on its impact on client outcomes, with a gap of 3-6 months between the 2 surveys. Following the end of BGET funding, North Yorkshire Council decided to provide 3-year funding to a lead organization to deliver the housing and health referral service at the single point of contact and co-ordinate related activities. Citizens Advice Mid-North Yorkshire was a key partner in the original project and won the contract to provide the follow-up referral service.
Citizens Advice Mid-North Yorkshire is developing partnerships with practice managers in GP practices to encourage direct referrals. Citizens Advice Mid-North Yorkshire is also hoping to secure funding for heating measures from the National Grid's Warm Homes Fund.
Warmth for Wellbeing
The service therefore, like its predecessor project, receives referrals from a wide variety of partners or through self-referrals. To date it is not receiving direct referrals from health partners, although it hopes to make arrangements at a later date. Few customers received substantial energy efficiency measures, such as loft and wall insulation or new boilers, because there was no funding for these measures.
The review highlights the value of providing both specialist energy help and specialist debt and benefits advice. However, it has managed to revive elements of the service, such as a single point of contact for advice on debt and benefits and energy efficiency assessments, which are funded by local government (public health and adult social care).
Our legacy
Citizens Advice Brighton & Hove tried to secure replacement funding once the BGET funding ended, but was unsuccessful, partly due to significant cuts to the local Clinical Commissioning Group finances (seen as the most likely funder). The toolkit is also intended as a resource for our Energy Advocates to enable them to support local Citizens Advice to develop or participate in housing and health referral services in their area. Local Citizens Advice Bureaux with experienced energy advisers, typically those who deliver Energy Best Deal and Energy Best Deal Extra, are particularly likely to be involved.
Since the successful launch of our toolkit we have worked with Cornwall Council to develop two further toolkits commissioned by BEIS, one on setting up housing and health referral services, the other on council action to tackle fuel poverty and cold homes. We have also agreed to host the toolkits on our website and to help Cornwall County Council and BEIS promote them to their target audiences, namely local authorities, health agencies and others.
Conclusion
Alternatively, local authorities and their health partners can let third sector offices such as local citizens' advice carry out the referral service. The Gloucester Citizens Advice project illustrates this through the significant expansion of its referral service in the Gloucester area. Finally, some local councils may not currently be able to provide the coordination and strategic links needed to make the NICE referral model work.
It is therefore important that all prospective referral services ensure that their local Citizens Advice is included as an essential partner in the service. But most importantly, we urge all local authorities and health providers to act according to NICE.
Recommendations
All local authorities and local health agencies should work with voluntary sector agencies, like Citizens Advice, to provide a housing
Providing support to the most vulnerable population is key to
Public Health England should work with national partners, including NHS England and relevant government departments, to establish a
Local authorities and health agencies should work together to provide adequate and sustainable resources for housing and health
Appendix: Local Citizens Advice taking part in the winter resilience pilot
Manchester
Manchester CA was able to implement its service delivery model as planned, with delivery commencing in October 2016. Manchester CA had already developed strong partnership agreements with healthcare providers as part of its work on a related project well before it went live. '.
Stockton
This reduced the work required before starting the project and allowed for a longer referral period than other pilot offices. Stockton CA had to make changes to the referral partners and process after the project started. It initially planned to get referrals from pharmacists, but found that despite the enthusiasm of pharmacists participating in the service, there was low patient engagement.
In response, Stockton CA changed the referral mechanism to local care staff in general practitioners. As a result of changing its referral pathway, Stockton CA successfully increased the number of referrals received.
Wealden
However, by the end of the pilot period it had successfully partnered with the local dementia support team and the multi-agency care team. This was too late for referrals from these sources to contribute to the evaluation of the pilot's effectiveness. Wealden is one of the four offices participating in the second pilot phase and will thus be able to document the extent to which these new routes have generated referrals.
This was partly because volunteers did not feel comfortable asking about clients' health and partly because few referrals were made by healthcare partners. These problems should be reduced for Phase 2 of the pilot project due to the recent inclusion of health partners in the project and due to data collection.
Uttlesford
By the end of the pilot period, Uttlesford CA developed good relationships with local health partners, including a CCG and the Council's environmental health team, and is now receiving referrals from both partners. Uttlesford CA is also participating in the second pilot phase and will thus be able to offer.
Gloucester
Like Wealden, the volunteer counselors struggled with the volume of reporting and felt uncomfortable asking clients about perceived complex health problems. However, this only started relatively late in the project's development – resulting in only nine customers being served by the project during the pilot period. As highlighted in the main report, Gloucester CA subsequently established a partnership with the Gloucester CCG, again involving SWEA, to provide a referral service to all healthcare professionals in Gloucester and the district area.
The project has only been running for a while; but it already coordinates support for about 30 customers a month. The project will provide quarterly reports on its impact using similar evaluation tools to those deployed for the Winter Resilience Pilot.
Southwark
Liverpool
Liverpool's experience highlights the fact that many people on low incomes have a wide range of health problems that may or may not be related to cold homes. Given the existing number of referrals that Liverpool CA already receives from a key part of the healthcare sector, it is possible that many of the client groups identified by the NICE guidance are already receiving support in Liverpool. It is of course very likely that many more people will need support.
It may be useful to carry out further analysis of clients receiving Prescription Advice support to determine the extent to which they suffer from ill health.
Bibliography
Nicol S et al, 2015, The cost of poor housing to the NHS, Construction Research Foundation briefing paper. NICE, 2015, Excess winter deaths and illnesses and the health risks associated with cold homes, NICE guideline NG6. NHS Future Forum, 2014, The role of the NHS in public health A report by the NHS Future Forum, NHS.
Van Reenen M & Janssen B, 2015, EQ-5D-5L User manual: basic information about using the EQ-5D-5L instrument, EuroQol Research Foundation. Welsh Government, 2017, Fuel Poverty Data Linking Project Findings Report No. 1: Initial Findings on the Health Impact of the Warm Homes Nest Programme, Social Survey Number: 17/2017 Welsh Government.
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