Heating on Prescription: Risk stratification within the GP clinical systems to identify people at risk of worse health outcomes from living in a cold home

Abstract

Background Cold weather brings an increased risk of mortality in some age groups and those with Long Term Conditions (LTC). Furthermore, deprived areas often contain housing of poor quality which are energy inefficient, leading to cold-home living, damp and mould. Fuel poverty is one of the main causes of cold homes and describes situations where people must spend a significant proportion of their income to adequately heat their home.

Aims This project aimed to proactively target a home energy efficiency service to people at increased risk of worsening health due to fuel poverty.

Method A systematic data extraction methodology was deployed using specific Read codes within Primary Care to identify high risk patients at Practice level. Target population was drawn from PCN’s in deprived communities. Identified patients were contacted via a letter, with an option to either self-refer or receive a phone referral into a Leeds energy efficiency partnership. Energy efficient interventions included, radiator panels, draught-proofing, dehumidifiers and fuel vouchers.

Results Read codes identified a clinical cohort of 1,904 patients living with a specific respiratory condition, located within deprived neighbourhoods. 127 (12%) patients were referred via the primary care route. All, with the exception of 8, were eligible for the Leeds energy efficiency service offer. 417 (40%) people made a self-referral. Referral via community-based partners included local councillors, Fire Service, Social Prescribing service, Housing and benefits agencies; 795 referrals were made. In total, 922 people were assisted with energy efficiency interventions or advice over winter 2022/23 in Leeds. 755 of which were households with at least one person living with a long-term health condition.

Conclusion This approach demonstrates a replicable and feasible method for health which proactively identifies and targets those most at risk using primary care clinical systems and a neighbourhood approach.