Invited editorial: title page

Title: Fuel poverty and health: action is needed now

Margaret Whitehead [1, *], David Taylor-Robinson [1] and Ben Barr [1]

*Margaret Whitehead, PhD, WH Duncan Professor of Public Health (corresponding author),

David Taylor-Robinson, MBChB, PhD, Professor of Public Health and Policy,

Ben Barr, PhD, Professor of Applied Public Health Research.

Address for all three:

Department of Public Health, Policy, and Systems,

University of Liverpool,

Whelan Building,

Liverpool L69 3GB

Email for corresponding author: mmw@liverpool.ac.uk

Word count of main body:884. No of references:13

Competing interests: We have read and understood the BMJ Group policy on declaration of interests and declare the following interests: none.

Title: Title: Fuel poverty and health: action is needed now

Strapline: Fuel poverty is set to rise dramatically from April 2022, resulting in further damage to health and wellbeing.

People are said to be suffering fuel poverty when they cannot afford to heat their home to a reasonable temperature. By the Government’s own figures, pre-pandemic, over 13% of all households in England (3.2 million households) were living in fuel poverty. Scotland had even higher rates at 25%, Wales 12% and Northern Ireland 18%. Families with children made up nearly half of fuel poor households.[1]

There is strong evidence for a direct health impact of growing up and living in cold homes and poor housing.[2] For older people, living in cold temperatures increases the risk of strokes and heart attacks. Respiratory diseases including flu are more common, as are the risks of falls, injuries and hypothermia.[3] Children growing up in cold, damp and mouldy homes with inadequate ventilation are more vulnerable to these poor living conditions affecting their health and educational attainment. They have higher rates of respiratory infections and asthma, chronic ill-health and disability; while being more likely to experience depression, anxiety and slower physical growth and cognitive development.[4,5] It is challenging to adequately wash and dry clothes in a cold house, increasing children’s risk of appearing unkempt and being bullied at school.

Indirect effects of fuel poverty on health are also concerning – as households spend a greater share of their budgets to heat their homes they have less to spend on food and other necessities for health. Vital ‘Heat or Eat’ decisions have to be made, leading to poorer nutrition, which in turn weakens the immune defences against heightened disease exposure. Money worries also lead to greater social isolation, with increasing unsustainable debt resulting in mental health problems for both adults and children. [3] Poverty and poor housing conditions increase family stress and the risk of interpersonal conflict, child abuse, neglect and being taken into care.[6]

The Covid-19 pandemic exacerbated fuel poverty even further when it caused widespread financial hardship, confining people in their homes for longer. School closures meant that children were at home more during the day, pushing up household fuel and food bills.[1] Now the contributory factors driving fuel poverty are set to get much worse in the coming months. Even before taking into consideration the impact of the war in Ukraine, energy costs for households were set to immediately jump by more than 50% on 1st April 2022 with the introduction of the higher energy price cap. The Resolution Foundation has estimated that, with no Government intervention, the number of households in England alone in ‘fuel stress’ (spending more than 10% of their household budget on energy) will rise to 6.2 million overnight, or 27% of all households. Older households and families with children living in inefficient homes will be hit the hardest.[7] The measures to off-set the effect of the energy price rise announced by the Government in February 2022 will help keep 1 million families out of ‘fuel stress’, but that will still leave 20% of households in England, or 5 million, in fuel stress. Nearly half of these are households with children.[8]

Further falls in real incomes - particularly for those already on low income - are also expected this year, with large rises in inflation predicted by the Bank of England pushing up the general cost of living. At the same time, people on Universal Credit have just experienced the removal of the temporary uplift of £20 per week in the benefit introduced during the pandemic, among other depletions of benefit levels.[9]

Fuel poverty, food poverty, funeral poverty, furniture poverty, period poverty, digital poverty - the list goes on. Ultimately these deprivations are the expression of a system that is failing to provide sufficient income to live healthily. The number of British households plunged into destitution more than doubled over the period of the pandemic. Child poverty was rising pre-pandemic and is expected to have risen dramatically when the figures are released later this year.[9] The solution to these problems needs to focus on root causes, addressing poverty overall, especially poverty affecting children, and providing adequate income support is a necessary first step.

What can and should doctors do to help ameliorate the health impacts of this impending fuel poverty crisis? Doctors can play a key role in advocating for policies and practices that reduce poverty. Medical organisations could advocate for much larger and more targeted support for households in fuel poverty as proposed by bodies such as the Resolution Foundation, including applying a higher uprating to benefits and broadening eligibility from April, and more vigorous use of the Warm Homes Discount than is currently planned.[7] Housing quality interventions, including a focus on addressing cold homes by improving insulation and heating, have been shown to be cost-effective in reducing hospital admissions.[10]

In their day-to-day work, doctors could help to reduce or prevent the health damage caused by fuel poverty by routinely enquiring about social conditions, family income, and housing, and providing signposting to welfare support services to maximise family income.[11] Following NICE guidance on excess winter deaths, those working in primary care could make every contact count in assessing heating needs.[12] The National Health Service also has a key role to play as an anchor institution with a duty to reduce social inequalities in health. This role includes developing local area strategies to address root causes of poor health, so that doctors don’t end up sending patients back into the conditions that made them ill in the first place.[13]

References

1	Bolton P, Kennedy S, Hinson S. Fuel Poverty. House of Commons Library.Published Online First: 2 March 2022.https://commonslibrary.parliament.uk/research-briefings/cbp-8730/ (accessed 2 Mar 2022).

2	University College London, Marmot Review Team, Friends of the Earth. The health impacts of cold homes and fuel poverty. London: : Friends of the Earth & the Marmot Review Team 2011. http://www.instituteofhealthequity.org/projects/the-health-impacts-of-cold-homes-and-fuel-poverty (accessed 2 Mar 2022).

3	Balfour R, Allen J. Local action on health inequalities: Fuel poverty and cold home- related health problems https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/355790/Briefing7_Fuel_poverty_health_inequalities.pdf.

4	Harker L. Chance of a lifetime - the impact of bad housing on children’s lives. Shelter England. 2006.https://england.shelter.org.uk/professional_resources/policy_and_research/policy_library/chance_of_a_lifetime_-_the_impact_of_bad_housing_on_childrens_lives (accessed 2 Mar 2022).

5	Barrett C, Lee AR, Abrams EM, Mayell S, Hawcutt D, Sinha I. Eat or heat: fuel poverty and childhood respiratory health. Lancet Respir Med 2021;:S2213-2600(21)00584-1. doi:10.1016/S2213-2600(21)00584-1

6	Marí-Dell’Olmo M, Novoa AM, Camprubí L, Peralta A, Vásquez-Vera H, Bosch J, et al. Housing Policies and Health Inequalities. Int J Health Serv 2017;47:207–32. doi:10.1177/0020731416684292

7	Corlett A, Judge L, Marshall , J. Higher and higher • Resolution Foundation. https://www.resolutionfoundation.org/publications/higher-and-higher/ (accessed 2 Mar 2022).

8	Corlett A, Handscomb K, Judge L, Smith J. The price is right? Resolution Foundation. https://www.resolutionfoundation.org/publications/the-price-is-right/ (accessed 2 Mar 2022).

9	Pickett K, Taylor-Robinson D,et al (2021) The Child of the North: Building a fairer future after COVID-19, the Northern Health Science Alliance and N8 Research Partnership https://www.thenhsa.co.uk/app/uploads/2022/01/Child-of-the-North-Report-FINAL-1.pdf (accessed 2 Mar 2022).

10 Rodgers SE, Bailey R, Johnson R, Poortinga W, Smith R, Berridge D, et al. Health impact, and economic value, of meeting housing quality standards: a retrospective longitudinal data linkage study. Southampton (UK): : NIHR Journals Library 2018. http://www.ncbi.nlm.nih.gov/books/NBK508015/ (accessed 2 Mar 2022).

11 Moscrop A, Ziebland S, Bloch G,Iraola J. If social determinants of health are so important, shouldn’t we ask patients about them? BMJ 2020;371:m4150. doi:10.1136/bmj.m4150.

12. NICE Guidance. Excess winter deaths and illness and the health risks associated with cold homes NICE guideline Published: 5 March 2015 www.nice.org.uk/guidance/ng6

.

13 Fenney D, Buck, D. The NHS’s role in tackling poverty. Awareness, action and advocacy https://www.kingsfund.org.uk/sites/default/files/2021-03/nhss-role-tackling-poverty.pdf.

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