Full Document Text

                
The Health Impacts 
of Cold Homes and 
Fuel Poverty
Marmot Review Team
Marmot Review 
Team

The Health Impacts 
of Cold Homes and 
Fuel Poverty
Written by the Marmot Review Team for 
Friends of the Earth
Marmot Review 
Team
Published May 2011 by 
Friends of the Earth & the 
Marmot Review Team
ISBN 978–1–85750–343–2
Friends of the Earth England, 
Wales and Northern Ireland
26–28 Underwood Street
London  
www.foe.co.uk
 020 7490 1555
 020 7490 0881
Marmot Review Team
Department of Epidemiology  
& Public Health
University College London
1–19 Torrington Place
London  
www.marmotreview.org
 020 3108 3156
Published thanks to support from
The Baring Foundation

          
I am delighted that Friends of the Earth have 
commissioned us to write this report. Fuel poverty 
is a long-standing health issue: the impact of cold 
housing on health and the stresses brought on by 
living in fuel poverty have been recognised for 
decades by researchers, medical professionals and 
policy makers alike. At the same time, it is an issue 
that often gets dismissed as the ‘tough nature of 
things’ because our housing stock is old and cold 
housing is so widespread that many have come to 
regard it as a normal state of affairs.
 It should not be so. Cold housing and fuel pov-
erty can be successfully tackled through policies 
and interventions if there is a will to do so. There 
is a social gradient in fuel poverty: the lower your 
income the more likely you are to be at risk of fuel 
poverty. I have always said that inequalities that are 
avoidable are fundamentally unfair - fuel poverty 
is avoidable and it contributes to social and health 
inequalities. 
 When we published Fair Society, Healthy 
Lives, one of our recommendations was to 
“improve the energy efficiency of housing across 
the social gradient” in order to achieve affordable 
warmth and a reduction in energy usage as well as 
fuel poverty. We advocated aligning the agendas of 
climate change and health inequalities by exploit-
ing low carbon solutions, based on the principles 
of sustainable development. We do so again in 
this report: improving the energy efficiency of the 
housing stock brings multiple health and environ-
mental gains. 
 Building on the evidence presented in the 
Review of Health Inequalities, this report brings 
new light to the issue of cold housing and fuel 
poverty; it highlights not only the variety of health 
outcomes that are caused and aggravated by cold 
housing, but also how children, the elderly and the 
vulnerable are greatly affected by fuel poverty. 
 Public health must address the social determi-
nants of health: this report comes at a crucial time 
in policy making for public health as the White 
Paper is setting the new framework for reducing 
health inequalities. The proposed outcomes frame-
work includes five domains, among these is the 
wider determinants of health, and I am so pleased 
that one of the indicators under this heading is fuel 
poverty – it initiates the momentum for a renewed 
effort to tackle such an important factor and it 
provides a drive to addressing this issue at both the 
national and local level.
Professor Sir Michael Marmot
Department of Epidemiology and Public Health
UCL
ForewordSponsoring organisations

 Friends of the Earth Save the Children
National Children’s Bureau
Citizens Advice Bureau
UK Public Health Association
Climate and Health Council
National Energy Action
Faculty of Public Heath
Chartered Institute of Environmental Health
Disclaimer
This publication contains the collective views of the Marmot Review Team and does not necessarily represent the decisions or the stated policy 
of Friends of the Earth, Chartered Institute of Environmental Health, Save the Children, National Children’s Bureau, Climate and Health Council, 
Citizens Advice, UK Public Health Association, National Energy Action or Faculty of Public Health. The mention of specific organisations, compa-
nies or manufacturers’ products does not imply that they endorsed or recommended by Friends of the Earth, Chartered Institute of Environmental 
Health, Save the Children, National Children’s Bureau, Climate and Health Council, Citizens Advice, UK Public Health Association, National Energy 
Action or Faculty of Public Health. All reasonable precautions have been taken by the Marmot Review Team to verify the information contained 
in this report. However, the reported material is being distributed without warranty of any kind, either expressed or implied. The responsibility for 
the interpretation and use of the material lies with the reader. In no event shall the Marmot Review Team be liable for damages arising from its use.

          
Report writing team
Ilaria Geddes
Ellen Bloomer
Jessica Allen
Peter Goldblatt
at Department of Epidemiology  
and Public Health, UCL
Acknowledgements
5 Foreword
6 Acknowledgements
7 Table of Contents
9 Executive Summary
11 Chapter 1
 Introduction
13 Chapter 2
 The policy context
17 Chapter 3
 Climate change and health
19 Chapter 4
 Fuel Poverty and Energy Efficiency
21 Rural Homes
23 Chapter 5
  Direct health impacts of living 
in a cold home
23 5.1  Mortality: Excess Winter Deaths
25  The number of excess winter deaths 
attributable to cold housing
25 International comparisons
26 5.2  Morbidity: Health Conditions
27 Circulatory diseases
28 Respiratory problems
29 Mental health
29 Other conditions 
31 Chapter 6
  Indirect health impacts of living  
in a cold home
32 6.1  Social benefits of improved housing
33 Chapter 7
 Conclusions
34 Ensuring effectiveness of interventions
35 7.1  Policy Recommendations
37 Appendix
39 Endnotes 
40 References
Table of Contents
  

          
This report reviews the existing evidence of the 
direct and indirect health impacts suffered by those 
living in fuel poverty and cold housing. It makes the 
case for aligning the environmental and health agen-
das and reviews the evidence on the health benefits 
of reducing fuel poverty and improving the thermal 
efficiency of the existing housing stock.
 The main findings on the direct health impacts 
of cold housing and fuel poverty are:
  —  Countries which have more energy efficient 
housing have lower Excess Winter Deaths 
(EWDs).
  —  There is a relationship between EWDs, low 
thermal efficiency of housing and low indoor 
temperature.
  —  EWDs are almost three times higher in the 
coldest quarter of housing than in the warmest 
quarter (21.5% of all EWDs are attributable to 
the coldest quarter of housing, because of it being 
colder than other housing). 
  —  Around 40% of EWDs are attributable to cardio-
vascular diseases.
  —  Around 33% of EWDs are attributable to res-
piratory diseases.
  —  There is a strong relationship between cold tem-
peratures and cardio-vascular and respiratory 
diseases.
  —  Children living in cold homes are more than 
twice as likely to suffer from a variety of res-
piratory problems than children living in warm 
homes.
  —  Mental health is negatively affected by fuel pov-
erty and cold housing for any age group.
  —  More than 1 in 4 adolescents living in cold hous-
ing are at risk of multiple mental health problems 
compared to 1 in 20 adolescents who have always 
lived in warm housing.
  —  Cold housing increases the level of minor illness-
es such as colds and flu and exacerbates existing 
conditions such as arthritis and rheumatism.
The main findings on the indirect health impacts 
of cold housing and fuel poverty and on other social 
benefits deriving from improved housing are:
  —  Cold housing negatively affects children’s edu-
cational attainment, emotional well-being and 
resilience.
  —  Fuel poverty negatively affects dietary opportu-
nities and choices.
  —  Cold housing negatively affects dexterity and 
increases the risk of accidents and injuries in 
the home.
  —  Investing in the energy efficiency of housing can 
help stimulate the labour market and economy, 
as well as creating opportunities for skilling up 
the construction workforce. 
Many different population groups are affected by 
fuel poverty and cold housing, with various levels of 
health impacts relating to different groups:
Children
Significant negative effects of cold housing are evi-
dent in terms of infants’ weight gain, hospital admis-
sion rates, developmental status, and the severity and 
frequency of asthmatic symptoms. 
Adolescents
There are clear negative effects of cold housing and 
fuel poverty on the mental health of adolescents.
Adults
There are measurable effects of cold housing on 
adults’ physical health, well-being and self-assessed 
general health, in particular for vulnerable adults 
and those with existing health conditions.
Older people
Effects of cold housing were evident in terms of 
higher mortality risk, physical health and mental 
health.
Improving the energy efficiency of the existing stock 
is a long-term, sustainable way of ensuring multiple 
gains, including environmental, health and social 
gains.
 Government policy documents and reports, 
including the Chief Medical Officer report of 2009 
and the recent Public Health White Paper, recognise 
the tangible impact of cold housing and fuel poverty 
on people’s health and well-being. 
Executive Summary
 

         — 
Government policies, actions and financial support 
for interventions aimed at reducing fuel poverty and 
improving the energy efficiency of existing stock 
need to match its stated commitment to both the 
public health and climate change agendas. 
 The Government’s current support and financial 
commitment to addressing the problem of poor ther-
mal efficiency of housing remains inadequate, given 
the potential it has to improve the health and well-
being of the population and help mitigate climate 
change.
  A renewed effort is needed to support pro-
grammes and policies which have shown to be suc-
cessful in increasing energy efficiency of homes and 
improving the health of their residents, such as the 
Warm Front Programme, and in encouraging local 
government action in addressing fuel poverty, such 
as the National Indicator 187 – Tackling Fuel Poverty.
Living in cold conditions is a risk to health. The aim 
of this report is to review the existing evidence of the 
direct and indirect health impacts suffered by those 
living in fuel poverty and cold housing. Many such 
households will be living in homes that have poor 
thermal efficiency and are therefore hard or expen-
sive to heat, as well as accounting for a significant 
share of CO2 emissions from the housing stock (1), 
thus negatively contributing to climate change.
In 2008, 18% of households in the UK were esti-
mated to be living in fuel poverty (2). Fuel poor 
households must choose either to spend more 
than 10% of their income on heating, which has a 
detrimental impact on other aspects of health and 
well-being, or to under-consume energy and live in 
a cold home to save money. Deprived and vulner-
able households – especially those who do not have 
access to social housing - are more likely to live in 
energy inefficient housing, and less likely to have the 
resources or the resilience to deal with the negative 
impacts of cold homes and reduced income. 
 The World Health Organisation (WHO) recom-
mends that indoor temperatures are maintained at 21 
degrees in living rooms and 18 degrees in bedrooms 
for at least 9 hours a day.
 Fuel poverty is defined as having to spend 10% or 
more of a household’s net income to heat their home 
to an adequate standard of warmth (3). Over the 
years this definition has been accepted by various 
Government departments with responsibility for 
fuel poverty1. However, there has been disagreement 
about what constitutes a household’s income: the 
Government’s definition includes housing benefit, 
council tax benefit, income support, and mortgage 
payment protection insurance, although many esti-
mates are calculated with a formula that excludes 
housing subsidy. 
Being in fuel poverty is the product of three factors:
  The energy efficiency of the house which deter-
mines how expensive it will be to heat.
 The cost of heating fuel.
  The household income, which determines how 
much a 10% spend on heating would be.
Improving the energy efficiency of the housing stock 
is an essential step to reduce the number of house-
holds in fuel poverty, mitigate climate change and 
bring associated health benefits. Poverty more widely 
affects health, but fuel poverty should be considered 
distinctly because:
  — Not all who are income poor are also fuel poor.
  —  Factors other than income poverty can be tack-
led to reduce fuel poverty.
  —  Although their causes are inter-related, the 
effects of fuel poverty are distinct from the 
effects of income poverty. They relate to specific 
health conditions rather than health as a whole 
and negative health outcomes are more immedi-
ate than the outcomes caused by income poverty.
  —  Fuel poverty is more amenable to change than 
income poverty.
This report makes the case for aligning health and 
environmental agendas, and reviews the evidence 
on the health benefits of reducing fuel poverty and 
improving the thermal efficiency of the existing 
housing stock. 
 Excess winter deaths (EWDs) and health condi-
tions attributable to cold housing will be described 
and assessed based on existing evidence. The pri-
mary and secondary benefits of improvements in 
energy efficiency will be examined. Further, the 
report reviews the evidence on the proportion of 
households in fuel poverty affected by different 
health conditions and estimates the proportion of 
EWDs attributable to cold homes. The report also 
analyses the relationship between energy rating and 
the predicted health improvement which could be 
obtained through increased energy efficiency of 
housing stock.
: 
1
Introduction
We could prevent many of the yearly excess winter 
deaths – 35,000 in 2008/09 – through warmer 
housing...
[Public Health White Paper, 2010]

          
There are three possible ways to move the major-
ity of the population out of fuel poverty: one is to 
increase income (the Winter Fuel Payment is an 
example), a second is to regulate fuel pricing and 
third is to improve energy efficiency of homes. 
Reducing fuel poverty exclusively through financial 
support is dependent on the economic situation, 
energy prices, and political will. Further, it will not 
tackle CO2 emissions as it allows people to use more 
energy to reach a comfortable level of heating thereby 
increasing carbon emissions. On the other hand, 
making homes more energy efficient is a long-term, 
sustainable solution, which will allow people to use 
less energy to heat their homes adequately with a 
positive impact on carbon emissions. 
 The EU policy directive 2010/31/EU on the 
energy performance of buildings of 19 May 2010 
(EPBD) requires member states to set requirements 
for the energy performance of new buildings (4). 
When undergoing major renovation, the energy 
performance of the building or the renovated part 
should be upgraded to satisfy current minimum 
requirements. Building elements that form part of 
the building envelope and have a significant impact 
on the energy performance of that envelope (for 
example, window frames) should also meet the 
minimum energy performance requirements when 
they are replaced or retrofitted. The directive also 
requires member states to develop a common meth-
odology for calculating the energy performance of 
buildings, which has to be implemented by July 2013 
and will have an impact on current methods used for 
Energy Performance Certificates (EPCs).
Only since the Code for Sustainable Homes (5) was 
introduced in 2007 have English energy standards 
for new buildings approached levels similar to those 
of other Northern European standards. The strict 
targets imposed by the Code make it extremely 
unlikely that anyone living in properties built accord-
ing to its standards will fall into fuel poverty: it has 
initiated the most significant change in the thermal 
efficiency of the housing stock. However, the propor-
tion of homes built since its introduction is minimal 
in comparison to stock built prior to 2007, which 
houses most of the population.
 In 2000 the UK Government set out the Decent 
Homes Standard. This is a measure by which the 
quality of homes is rated, and includes statutory 
minimum standards for housing as well as thermal 
comfort – encompassing both efficient heating and 
insulation. Regulations aimed to ensure that all 
social housing met standards of decency by 2010, 
and the target was extended to include a minimum 
of 70% of private dwellings occupied by vulner-
able households2 also meeting the standard. These 
targets have not been achieved: it was estimated that 
3.8% of Registered Social Landlord (RSL) proper-
ties and 12%-14% of council properties would be 
non-decent as of the end of 2010 (6) and a renewed 
policy effort, coupled with better levers and incen-
tives is needed in order to reach such targets.
 Improving standards and energy efficiency of 
properties in the private rental sector has proven 
particularly difficult as private landlords are only 
required to upgrade homes in line with health and 
safety regulations rather than any thermal efficiency 
standards.
:   
2
The policy context
The HHSRS system came into effect on 6 April 
2006 and replaced the fitness standard as the statu-
tory element of the Decent Homes Standard.
 However, HHSRS is a risk assessment proce-
dure and does not set a standard. It measures the 
risks within the home against a series of hazards 
which range from indoor pollution to hygiene to 
structural safety and also include:
  —  Excessive Cold Temperature: Hazards 
arising from consistently low indoor 
temperatures.
  —  Damp and Mould Growth etc: Includes 
risks from house dust mites, mould and 
fungal spores.
It has been identified that the majority of failures in 
achieving a certain rating relate to the inadequate 
thermal efficiency of housing. 
For further information visit:
http://www.communities.gov.uk/publications/
housing/hhsrsoperatingguidance
Case study: The Housing Health and Safety Rating System (HHSRS)

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Further, the Warm Homes Discount is a new manda-
tory scheme that requires energy suppliers to provide 
a fixed amount rebate to vulnerable customers. This 
replaces the voluntary scheme of social tariffs previ-
ously provided by energy suppliers on an ad-hoc 
basis in different areas and for different households.
The Feed-in Tariffs (FIT) and Renewable Heat 
Incentive (RHI) aim to provide financial support 
for those who install renewable energy systems which 
qualify for support under the schemes. The schemes 
are designed to support meeting the requirements 
of the EU Renewable Energy Directive, which sets 
a binding target of having 20% of the EU’s energy 
consumption coming from renewable sources. 
It is expected that households and landlords will 
take advantage of the scheme; it is likely that such a 
scheme will appeal to those for whom other options 
to improve energy efficiency are not viable or cost-
efficient, such as those in older rural housing or who 
are not connected to the grid.
 Local government action has been driven by 
National Indicators 186 and 187, which monitor CO2 
Even when health and safety regulations are contra-
vened, private tenants may not exercise their right to 
address the problem because they fear eviction, from 
which they are not protected under UK law. It has 
often been reported that landlords take advantage 
of legislation to evict a tenant inappropriately if they 
have recently taken steps to enforce their statutory 
rights on disrepair and health and safety issues (7). 
The recent EPBD builds on the previous directive 
(2002/91/EC), which specifically mentions rented 
buildings with the aim of ensuring that property 
owners, who do not normally pay charges for energy 
expenditure, are required to take necessary action to 
comply with minimum standards (8).
The Fuel Poverty Strategy was launched by the 
Government in 2001 in response to the legal duty 
put on the Government by the Warm Homes and 
Energy Conservation Act of 2000 to eliminate fuel 
poverty by 2016. This strategy included improving 
the energy efficiency of homes in order to reduce fuel 
consumption and therefore reduce levels of vulner-
ability to fuel poverty. Progress was initially made in 
reducing the number of households in fuel poverty 
during a period when energy prices were stable, but 
since 2004 this trend has reversed due to fuel price 
increases. 
 The previous Government’s support for 
improvement in energy efficiency of the existing 
stock was mainly through the Warm Front Scheme, 
which provided grants to eligible households to 
improve either home insulation or heating systems 
and recently piloting systems for hard to treat prop-
erties. Applications to the Warm Front programme 
were recently suspended but have now re-opened 
with tighter eligibility criteria. However, the 
Comprehensive Spending Review suggests that the 
programme will be phased out from 2013–2014, thus 
completely removing central government funding to 
improve energy efficiency. Meanwhile, other pro-
grammes to tackle energy efficiency of housing and 
fuel poverty are ongoing and place the obligations on 
energy suppliers. These are the Carbon Emissions 
Reduction Target (CERT), an obligation on suppli-
ers to install energy efficiency measures, although 
only a proportion (40%) of this programme is aimed 
at priority groups3, and the Community Energy 
Saving Programme (CESP), which also requires 
gas and electricity suppliers to deliver energy saving 
measures to consumers in specific low income areas.
 Pilot schemes aimed at involving communi-
ties in reducing CO2 emissions have been led by 
Government departments as well as private partners. 
These provided the communities with information 
and funding to reduce their CO2 emissions and 
much funding was invested in improving the energy 
efficiency of their housing. Such projects include 
DECC’s Low Carbon Communities Challenge, 
NESTA’s Big Green Challenge and British Gas’ 
Green Streets. The Department of Health also 
funded a pilot project aimed at identifying and tar-
geting the population suffering from cold housing 
and fuel poverty through the development of a part-
nership between PCTs and Local Authorities – this 
project is described in the case study box below.
Although the CESP is likely to benefit a number 
of low-income households, at present there is no 
open programme aiming to reduce fuel poverty by 
targeting people on low incomes. There is a risk 
that households on higher incomes and in better 
quality homes living in low income areas will benefit 
more from this programme, rather than those who 
are most in need. Additionally, many low-income 
households live in areas outside the designated areas 
of deprivation. They will be missed by a programme 
targeting low-income areas rather than low-income 
households.
 At the time of this report’s publication, the 
Energy Bill is passing through Parliament. This 
seeks provision for merging the CERT and CESP 
programmes, which are running through to 2012, 
into the Energy Company Obligation (ECO). It 
sets out the Green Deal framework to enable provi-
sion of improvements to the energy efficiency of 
domestic, as well as non-domestic properties, which 
would be financed by the private sector and repaid 
by a charge on energy bills. The bill sets out powers 
for the Secretary of State to introduce regulations 
on energy efficiency in the private rented sector no 
earlier than 2015. These could prevent residential 
landlords from refusing tenants’ reasonable requests 
for energy efficiency improvements and require them 
to improve some of the least energy efficient proper-
ties. However the use of powers is dependent on the 
outcome of a review and other strict conditions.
 National Government also provides financial 
support to cope with energy bills through the Winter 
Fuel Payment – a yearly one-off payment for all 
those who have reached pension age. This is supple-
mented by the cold weather payment during periods 
of extreme cold weather for households in receipt 
of certain benefits such as pension credits, income 
support, jobseeker’s allowance and employment 
and support allowance. However, the efficiency of 
such schemes in reaching the populations in need is 
contested, as shown Table 1.
“A Citizen’s Advice Bureau in West Sussex 
reported a couple with two young children whose 
property was in serious disrepair. When the 
landlord refused to carry out essential repairs, 
the clients complained to Environmental Health 
who issued a schedule of works to be done. The 
landlord then served a Section 21 Notice on the 
clients. When the bureau contacted the home-
lessness department on the clients’ behalf, the 
homelessness officer said it was common practice 
for landlords to seek to evict tenants who involved 
Environmental Health.” (Crewe 2007)
The programme originates from the UK Public 
Health Association (UKPHA) Health Housing 
and Fuel Poverty Forum, funded by Defra. The 
forum, made up of national figures from the health, 
housing and energy sectors, and practitioners from 
across England, developed the ‘Central Clearing 
House’ model. Their research concluded that a 
model of local area partnerships that linked health, 
housing and fuel poverty services was the most 
effective approach for directing services to the vul-
nerable. The CCH model identified the key systems 
and processes necessary to access the vulnerable 
fuel poor, identify high risk groups, streamline 
referral and delivery systems and implement moni-
toring and evaluation processes.
 The CCH model was piloted in Manchester, 
with the implementation of the Affordable Warmth 
Access Referral Mechanism (AWARM). Funded 
by the Department of Health, the pilot was a part-
nership with Salford City Council and Primary 
Care Trust. 
 Greater Manchester invested approximately 
£100,000 each year into AWARM. Since April 
2008 AWARM activity resulted in over £600,000 
of investment in new and replacement central 
heating systems and insulation. During the first 
year of the project over 1000 referrals were made 
by frontline professionals from social services, 
voluntary, local government, housing and health 
sectors. In 12 months the programme trained 1,359 
professionals, a third in health, with the remainder 
in social services, voluntary/community services, 
local government and housing. The lessons learned 
from the pilot include:
  —  There are numerous opportunities to share 
data between local authorities, GPs and PCTs 
to improve how referrals are targeted.
  —  A pop-up system on GP patient electronic 
records would help to immediately direct refer-
ral to a one-stop-shop.
  —  Involving energy companies as active project 
partners can help identify novel ways to target 
vulnerable individuals and neighbourhoods.
The funding ended in 2010, yet the project 
improved local delivery systems and increased the 
numbers receiving funding to reduce fuel poverty. 
Like many other ill health prevention projects, 
funding was invested only in a pilot, regardless 
of the outcomes. In this case, this means a project 
showing successful short-term outcomes may not 
be rolled out.
 For more information see www.ukpha.org.uk/
fuel-poverty.aspx
Case study: Working in partnership to reduce fuel poverty
 Scheme name Targeting efficiency
 % of recipients that are fuel poor % of fuel poor that are eligible
Winter Fuel Payments 19%  (Boardman, 2010) 50%*
Warm Front 25 – 40% (NAO, 2009) 35% (NAO, 2009)
Home Energy Efficiency 30% 54%
Scheme (Wales) (WAG, 2005) (Boardman, 2010)
EEC2 Priority Group (Includes 20% 58–70% (Boardman, 2010 
people on passport benefits)  and Lees, 2008)
CERT Priority Group (Includes 24% (England) Unknown
those on passport benefits and all  (Tandy, 2010)
over 70s)
Table 1  Targeting efficiency of existing fuel poverty schemes
Source: Association for the Conservation of Energy (9) 
* All over 60s received WFPs, 50% of the fuel poor are estimated to be over 60 (Boardman, 2010)
 :    

          
emissions and levels of fuel poverty respectively at 
the local level, as well as by the requirements of the 
Home Energy Conservation Act (HECA), which 
placed an obligation on local authorities to draw up 
plans to increase domestic energy efficiency in their 
areas by 30% between 1995 and 2010. Some local 
authorities have been very pro-active in encouraging 
residents to access funding to reduce energy use 
and fuel poverty. These have been awarded Beacon 
status for best practice in tackling fuel poverty and 
have produced a toolkit for other local authorities to 
develop effective strategies to reduce fuel poverty 
taking account of local circumstances. However, 
further progress of local action on fuel poverty is 
likely to be hampered by the funding cuts to Local 
Government, the abolition of HECA and the fact 
that National Indicator 187 will become optional 
from 1 April 2011.
3
Climate change and health
:    
Protecting and improving health, reducing health 
inequalities, and the mitigation of climate change 
have a shared agenda. Measures and policies 
intended to respond to climate change can help 
reduce health inequalities and vice versa (10). 
There is sufficient evidence to link the agendas and 
argue for concerted Government action to tackle 
fuel poverty and thereby improve quality of life and 
health, as well as reducing CO2 emissions: climate 
change is predicted to result in an increase in deaths, 
disability and injury from extreme temperature and 
weather conditions, heat waves, floods and storms 
including health hazards from chemical and sewage 
pollution (11). Less direct long-term impacts include 
the effects on mental health of flooding and other 
climate-related events, which could cause anxiety 
and depression (12).
 Domestic energy use is responsible for around 
a quarter of the UK’s CO2 emissions. The greatest 
share of such emissions – over 70% - is through space 
and water heating (12). It is estimated that poor 
insulation means around £1 in every £4 currently 
spent heating UK homes is wasted. A third of CO2 
emissions from housing relate to domestic space 
heating and could be reduced through making the 
existing stock more energy efficient (13). Improving 
energy and fuel efficiency are the mechanisms to 
reduce fuel poverty and improve health and these 
efficiencies are also beneficial to the climate change 
agenda. 
 Those likely to be most vulnerable to the health 
impacts of climate change are those already deprived 
by their level of income, quality of homes, and their 
health (14) – the same groups more likely to live in 
fuel poverty. People on low incomes in the UK are 
more likely than the better-off to live in urban areas 
which will be worse hit by extreme weather events, 
and therefore to be at greater risk of heat stroke (15), 
such as during the heat wave of summer 2003. They 
are more likely to live in homes that are less well 
protected (15) and in areas that are more exposed 
to weather extremes and flooding (16). They are 
also less likely to have access to insurance against 
risks associated with climate change such as storm 
and flood damage (17). Improving the thermal 
performance of homes can help mitigate climate 
change, while protecting households from summer 
overheating as well as winter cold.
 There is a strong relationship between the 
individual house and its immediate neighbourhood 
not just in terms of vulnerability to climate change, 
but also in terms of domestic energy use. How a 
neighbourhood is planned and designed can take 
more or less advantage of natural resources such 
as solar energy and green cover, which can also aid 
energy conservation as well as mitigating climate 
change. Consideration must be given to the wider 
environment when considering interventions to 
improve energy efficiency, reduce fuel poverty and 
mitigate climate change. 

          
0
5
10
15
20
25
30
35
Household income quintiles
Percent of households in fuel poverty
    Poorest fifth 2nd Middle fifth 4th Richest fifth
This section describes how fuel poverty is distrib-
uted across the population and how this relates to 
certain housing characteristics, including age of 
property, tenure and thermal efficiency.
 As the graph below shows, the risk of fuel poverty 
rises sharply as household income falls – very few 
households with above-average incomes are in fuel 
poverty.
 Other factors besides household income affect 
whether a household is in fuel poverty or not, such 
as housing costs and type of ownership. Barnes, Butt 
& Tomaszewski (19) used the Families & Children 
Survey to estimate that children in families with a 
black mother, a lone parent, or with a number of 
debts were twice as likely to experience persistent 
cold indoor temperatures than other children.
As a proportion of the total number of households 
for a given tenure (for example private rented, owner 
occupier or social housing) households living in 
private rented accommodation have a higher likeli-
hood of living in fuel poverty – 19% of households 
in private rented were in fuel poverty compared 
with 11% in other tenures (20). There are various 
reasons for this: tenants in the private rental sector 
can be put off seeking help to improve the energy 
efficiency of their homes because they may not see it 
as worth the effort or investment if they plan to move, 
they may not know it is an option that they could 
take advantage of, subject to the agreement of the 
landlord, or they may even fear eviction if some cost 
or disruption might fall on the landlord. Financial 
incentives are also low for landlords, who are put 
off improving properties by the upfront costs while 
most financial benefits will be to the tenants through 
lower energy bills.
 Despite policies such as Warm Front and the 
Winter Fuel Payment, the number of fuel poor 
households in England dramatically increased 
4
Fuel Poverty and Energy Efficiency
:     
Figure 1 The risk of fuel poverty according to household income, 2009
Note: Percent in fuel poverty relates to households in fuel poverty after deducting housing costs
Source: ONS(18)

          
electric or oil-heated, with solid walls, either 
double or single glazed. The average SAP for 
single glazed homes of this type is under 20. 
These tend to be large and old rural homes.
Whether households living in such properties are 
in fuel poverty depends on the household’s income. 
A number of households living in large and older 
properties at the higher end of the housing market 
may not be in fuel poverty due to high incomes. 
However, the fact remains that households living in 
such properties are either in fuel poverty or at risk 
of quickly falling into fuel poverty if their family 
circumstances or income change. Moreover, such 
properties are detrimental to the environment as – in 
order to keep warm - the households residing in them 
are bound to emit more CO2 than they would if their 
home’s efficiency was improved.
Rural Homes
Fuel poverty is a particularly concerning problem in 
rural areas, where it is estimated that half of homes 
in sparsely populated English communities have 
an energy efficiency rating of below SAP30, which 
is considered a significant health hazard. In 2006, 
21% in rural areas were in fuel poverty compared 
with 11% in suburban and 10% in urban areas (24). 
Rural homes are likely to be detached and larger in 
size than urban homes (25), meaning that they are 
more difficult and more expensive to heat, or to make 
more energy efficient. 
 Access to mains gas is rare in most areas more 
than about 5 or 10 miles from an urban area (25) , 
meaning many rural homes must pay more for their 
fuel and a high percentage of them are in fuel poverty 
(The House of Commons Select Committee on 
Energy and Climate Change, March 2010, cited in 
(26)). They are heated by electric, oil or solid fuel, 
which tends to be more expensive and less efficient. 
 Many rural homes are older buildings. They are 
more likely to have solid walls (almost all homes built 
before 1919 are solid walled), which are generally less 
well-insulated than cavity walls (as can be found in 
nearly all homes built after 1945) (25). While over 
60% of homes in urban areas and rural towns are 
cavity walled and on mains gas, this is true of only 
32% in villages and 21% in hamlets (25).
 These factors mean that it is on average more 
difficult and more expensive to improve the energy 
efficiency of a rural home and need to be considered 
when developing policies and interventions aimed at 
reducing fuel poverty. 

between 2004 and 2010 from 1.2 million to 4.6 mil-
lion (20). The winter of 2009/10 saw 25,400 deaths 
in England and Wales (21). Much of the increase in 
fuel poverty in 2008/9 was due to the increased costs 
of energy and it is estimated that in the long term, 
energy costs will increase (20), potentially increasing 
a typical annual energy bill by 50% (20).
 One of the most sustainable ways of tackling 
fuel poverty and limiting the impact of fuel price 
increases is to build energy efficient housing and 
retrofit the existing housing stock to an energy 
efficiency level that would make it extremely hard 
for people to fall into fuel poverty, as space heat-
ing accounts for the greatest share of energy use 
in homes – over 50% (12). This is known as ‘fuel 
poverty proofing’ and it has been estimated that rais-
ing all properties in England to SAP 81 (equivalent 
to Energy Performance Certificate band B) would 
lift 83% of households out of fuel poverty (22). 
 While new homes need to become highly energy 
efficient by 2020, in line with European directives, 
typical energy efficiency for the existing stock is 
much lower than current building regulations 
require. The Standard Assessment Procedure (SAP) 
is the Government’s approved mechanism for meas-
uring home energy efficiency: it calculates a home’s 
typical annual energy costs for space and water heat-
ing as well as lighting. The SAP scale runs from 1 
(low) to 100 (high). Energy Performance Certificate 
(EPC) bands are based on the SAP scores, and run 
from G (low) to A (high). Current building regula-
tions require a SAP rating of between 65 and 81 as a 
base-line, ie. a level above EPC band D – more than 
50% of the existing housing stock falls well below this 
standard, as shown in Table 2 below.
 F and G band homes have very low standards 
of energy efficiency. There is a broad correlation 
between these homes and those which constitute 
a category 1 hazard for excess cold, as defined in 
English and Welsh environmental health legislation.
 Damp and mould are more likely to occur in cold, 
poorly insulated homes, and thermal efficiency is 
strongly linked to the age of the property: on aver-
age properties that were built before the 1920s fall 
within the F and G categories and average indoor 
temperatures are lower the older the property, as 
shown in Table 3 below.
 F and G rated homes are characterised by a 
number of elements which mark them as poor in 
energy efficiency. The Energy Saving Trust (1) has 
highlighted that properties falling into these two 
categories tend to be:
  —  Large or medium sized, semi or detached 
houses, gas heated and double-glazed, but with 
an unfilled cavity wall, which are generally rated 
as F. These are estimated to be about a third of all 
properties falling in categories F or G.
  —  Properties which lack gas- or oil- fired heating 
system. These are estimated to be about half of 
F–G rated homes.
  —  Smaller homes (flats or terraces), which are elec-
trically or oil-heated and are single glazed. These 
tend to fall in the G banding, but are estimated 
to be only a small number.
  —  Large, semi or detached houses, generally 
:     
 EPC SAP % homes in England
Ages of  
property 
Number of  
dwellings 
Mean  
measured temp 
(°C)
Temp under 
standard  
conditions 
% of households 
with hall temp  
<16°C at standard 
conditions
A/B 81+ 0.3
C 69–80 10.0
D 55–68 35.4
E 39–54 37.4
F 21–38 13.4
G 1–20 3.5
Pre 1900 660 17.3 16.7 38.8
1900–44 1,157 17.5 16.8 36.0
1945–64 853 17.6 17.0 35.8
1965–80 621 19.1 18.4 17.6
Post 1980 116 19.5 18.7 14.7
Table 2 Percentage of homes in England by EPC banding and SAP rating, 2008. Source: EST 2010 (1)
Table 3 Indoor temperature by age of property (23)
Percentage of homes in England by EPC banding and SAP rating, 2008. Source: EST 2010(1)

          
The direct health impacts of living in a cold home 
can be divided into higher risk of mortality and 
increased morbidity rates. There is a longstand-
ing body of evidence describing the relationship 
between higher mortality rates in winter and cold 
temperatures (27) as well as higher morbidity rates 
(28). Fuel poverty itself is also detrimental to health, 
especially mental health, through the financial stress 
that it causes to households.
5.1 Mortality: Excess Winter Deaths 
The graph below shows the levels of excess winter 
mortality over the past ten years. In 2009/2010 there 
were an estimated 25,400 excess winter deaths. 
Although this represents a 30% decrease from the 
previous year due to low levels of influenza (21), the 
level remains persistently high when compared to 
other European countries (see Table 5)
 The Office for National Statistics calculates 
excess winter deaths as the difference between 
the number of deaths in December – March and 
the average of deaths in the preceding August – 
November and the following April – July. If a two 
month period is taken instead of the four months, 
the peak of excess winter deaths is consistently more 
than 40% higher than the summer trough (23). 
Each centigrade degree reduction below 18°C in 
temperature in the UK corresponds with an extra 
3500 deaths (29). 
:         
5
Direct health impacts of living in a cold home
We could prevent many of the yearly excess winter 
deaths – 35,000 in 2008/09 – through warmer 
housing...
[Public Health White Paper, 2010]
60
 1999/00 2009/102008/092007/082006/072005/062004/052003/042002/032001/022000/01
50
40
30
20
10
0
Number of deaths (thousands)
Winter period
Figure 2 Excess winter deaths 1999–2010
Source: ONS(18)

          
The number of excess winter deaths attributable to 
cold housing
Excess winter deaths occur in both cold and warm 
housing. However, there is a greater risk of death in 
colder housing than in the warmest housing. The 
authors of this report have estimated that 21.5% 
of all EWDs can be attributed to the coldest quar-
ter of housing, due to it being cold, over and above 
the amount of deaths which would have occurred 
had these houses had the same winter excess as the 
warmest housing. This means that EWDs in the 
coldest quarter of housing are almost three times as 
high as in the warmest quarter.
 This estimate was based on existing estimates 
of the risk of excess winter deaths due to living in 
cold housing, as calculated by Wilkinson in 2001. 
More recent estimates are not available as there are 
no comprehensive sets of measured indoor tem-
peratures since the English House Condition Survey 
stopped collecting such data in 1996.
 Wilkinson estimated that, in winter, death rates 
in the 25% of coldest homes rose to 1.5 times the 
summer minimum for all types of housing. The cor-
responding risk ratio for the 25% of warmest homes 
was 1.3. His estimate was based on mortality rates 
for the period 1986–1996 in England and Wales and 
a household sample of 3337.
 We used these risk ratios to calculate estimates of 
excess winter deaths in cold housing and of numbers 
expected if rates for warm housing applied. The 
difference between these estimates is the number 
attributable to the house being cold rather than other 
factors (e.g. flu epidemics, air pollution, cold outside 
temperature, etc.). This value was than divided by 
the average EWDs for the period 1986–1996 in order 
to calculate the proportion of EWD attributable to 
cold housing in this period (21.5%). The details of 
the calculations and key assumptions used to develop 
the model and calculate the estimate are given in the 
appendix. 
International comparisons
Healy carried out an analysis of excess winter deaths, 
describing variations in excess mortality in southern, 
western and northern European countries (35). 
Table 5 below shows the different levels of excess 
mortality rates: it is clear that these do not necessar-
ily match different climatic conditions – meaning 
that often higher rates are found in countries with 
less severe, milder winter climates (“the paradox of 
excess winter mortality”), such as Greece, the UK, 
Spain, Ireland and Portugal. These findings high-
light that colder countries, which have had higher 
building standards than the UK for many years, have 
much lower rates of excess winter deaths.
 For this study levels of fuel poverty were cal-
culated using a set of indicators which included 
housing conditions, affordability of home heating 
and energy efficiency levels based on a consensual 
approach5  (35). It is suggested by this study that the 
paradox of excess winter mortality being highest in 
warmer countries could be explained by the fact that 
countries with milder climates often have the worst 
domestic thermal efficiency. Table 6 below shows the 
countries’ differences in thermal efficiency variables 
and how they relate to the coefficient of seasonal vari-
ation6: the study shows that cross-country levels of 
cavity wall insulation, double glazing, and floor insu-
lation are all significant at the 5% level in the model.
 The study also analyses the impact of different 
lifestyle factors on excess winter mortality, in par-
ticular smoking and obesity. Interestingly, it shows 
that there is no relationship between these factors 
and excess winter mortality despite the fact that 
these factors are strongly associated with higher non-
seasonal mortality rates. The study concludes that 
variations in mortality rates are due to differences 
in indoor temperatures, healthcare spending and 
socio-economic circumstances.
 Other studies have supported Healy in associat-
ing excess winter deaths with internal temperatures, 

There are many factors which play a part in excess 
winter deaths: increases in deaths from respiratory 
and circulatory diseases cause most of the excess 
winter mortality, influenza is a contributing factor 
rather than a main cause of death (18). Cold weather, 
and in particular cold homes, is believed to be a main 
factor in causing the winter increase of respiratory 
and circulatory diseases (30). 
 It has been noted by researchers that EWDs do 
not usually relate to socio-economic deprivation 
(32–35). This is because socio-economic depri-
vation indices do not include an energy efficiency 
variable and although deprivation and fuel poverty 
are related, they are not the same – the lack of a 
significant relationship between deprivation and 
excess winter mortality suggests that in the UK those 
who are deprived often live in social housing, which 
is, on average, more energy efficient.
 Wilkinson and associates (23) analysed 80,331 
deaths from cardiovascular disease in England, 
between 1986–96, linked by postcode of residence 
to data from the 1991 English House Condition 
Survey. Deaths from cardiovascular disease were 
22.9% higher in winter months than the average 
for the rest of the year. There was a statistically 
significant excess winter mortality seen with the age 
of the property (28.8% in properties built before 
1850 compared to 15% in properties built after 1980) 
and with poor thermal efficiency ratings, where a 
gradient can be seen with SAP rating.
 Further, there was a strong association between 
excess winter deaths and lower indoor temperatures, 
with residents of the 25% coldest homes having 
around 20% greater risk than those in the warmest. 
‘The findings provide strong, although not conclu-
sive, evidence that winter mortality and cold-related 
mortality are linked to sub-optimal home heating’ 
(23). 
Circulatory diseases are believed to cause around 
40% of excess winter deaths, while respiratory dis-
eases are responsible for about a third (31). Deaths 
directly attributed to influenza or hypothermia rep-
resent a small proportion of excess winter mortality 
(32). While there is a clear link between marked 
winter mortality peaks and the incidence of influ-
enza, cold housing still plays a role in the develop-
ment of health complications from influenza, and 
there is still excess winter mortality in years when 
influenza incidence is at a low level. For example, in 
Scotland in 2000/2001 there were an estimated 1500 
to 3000 EWDs while flu rates were lower than 150 
per 100,000 (32). 
 The elderly are subject to the greatest increase 
in deaths in winter, with 20,200 more deaths in 
the UK among those aged over 75 years during 
the winter of 2005/06 compared with levels in the 
non-winter months. Older people are more likely to 
be vulnerable to cold weather, partly because they 
are more likely to have existing medical conditions. 
Further, their temperature control is weaker because 
of less subcutaneous fat, making them vulnerable to 
hypothermia (29). In older people, a 1°C lowering 
of living room temperature is associated with a rise 
of 1.3mmHg blood pressure, due to cold extremities 
and lowered core body temperature (33). Older peo-
ple are more likely to be fuel poor, as they are likely 
to spend longer in their homes than other people and 
therefore require their houses to be heated for longer 
periods (34). 
 Other groups are also vulnerable, including 
children and people with long term illness (30). In 
addition, many of the most vulnerable members of 
society spend longer in the home than most, and 
therefore require the heating on all day, and not just 
in the morning and evening (31). 
Property age 
(n=80,331)
Winter 
deaths
 CSVM 95% CI
% excess 
in winter
Risk (95% confidence interval) 
relative to baseline group
P-value 
for trend*
Pre 1850 701 28.2 1.0 0.001
1850–99 5,469 25.6 0.98 (0.88–1.09) 0.001
1900–18 3,063 24.1 0.97 (0.87–1.08) 0.001 
1919–44 6,978 26.0 0.98 (0.89–1.09) 0.001 
1945–64 6,709 23.9 0.97 (0.87–1.07) 0.001 
1965–80 6,612 17.1 0.91 (0.82–1.01) 0.001 
Post 1980 935 15.0 0.90 (0.79–1.02) 0.001 
Finland 0.10 0.07 to 0.13
Germany 0.11 0.09 to 0.13
Netherlands 0.11 0.09 to 0.13
Denmark 0.12 0.10 to 0.14
Luxembourg 0.12 0.08 to 0.16
Belgium 0.13 0.09 to 0.17
France 0.13 0.11 to 0.15
Austria 0.14 0.12 to 0.16
Italy  0.16 0.14 to 0.18
Greece 0.18 0.15 to 0.21
UK 0.18 0.16 to 0.20
Spain 0.21 0.19 to 0.23
Ireland 0.21 0.18 to 0.24
Portugal 0.28 0.25 to 0.31
Mean 0.16 0.14 to 0.18
Table 4 Excess winter deaths by age of property (23)
Table 5 Coefficient of seasonal variation in mortality (CSVM)4 in EU–14 (mean, 1988–97)(35)
“Diseases of the circulation – including heart 
attack and stroke – account for around 40% of 
excess winter deaths. Around one third of excess 
winter deaths are due to respiratory illness…” 
[Chief Medical Officer Report, 2009]
* The p-values test for a trend of increasing or decreasing risk across ordered groups (for example, increasing age). However, in the case of 
region, there is no logical order and the p-value tests whether the winter excess varies between regions.
:         

          
Programme (CHP), the New Zealand Housing, 
Insulation and Health Study (HIHS), and Housing, 
Heating and Health Study (HHHS), a NATCEN 
longitudinal study of housing conditions and their 
association with English children’s well-being, and 
the US Children’s Sentinel Nutritional Assessment 
Programme (C-SNAP).
 Liddell concludes that, despite the risks to physi-
cal health from cold homes, improvements to energy 
efficiency and the reduction of fuel poverty achieved 
by some of the programmes had a modest meas-
urable impact in improving the physical health of 
adults. However, the potential for measuring such 
effects is hampered by methodological limitations 
in the evaluations, including the sample sizes of the 
studies. Measuring the health impact of improve-
ments in energy efficiency and reduced fuel poverty 
is particularly difficult for adults who may have long 
term health conditions related to cold housing which 
are the result of lengthy exposure to cold houses. 
The impacts are easier to measure in children, who 
are more readily susceptible to changes, and for 
the elderly who are at higher risk of mortality or 
developing life-threatening conditions. The main 
findings across the studies are summarised in the 
points below, while some of the detail is discussed 
further in this report:
  —  Significant effects on the physical health of 
the young were evident, especially in terms of 
infants’ weight gain, hospital admission rates, 
and caregiver-rated developmental status, as well 
as self-reported reduction in the severity and 
frequency of children’s asthmatic symptoms.
  —  Mental health impacts emerged as extremely 
strong amongst both adults and adolescents.
  —  After improvements have been made to homes, 
health improvements for adults were measur-
able, although modest, and mostly related to per-
ceptions of physical well-being and self-assessed 
general health.
  —  Large-scale studies suggest that impacts of 
cold temperatures as a function of poor housing 
on mortality and morbidity are almost certain 
across the whole population. 
Circulatory diseases
Much of excess winter mortality can be attributed 
to cold temperatures, and a significant proportion 
can be attributed to cold housing. Excess winter 
deaths that are attributable to circulatory diseases 
are estimated to be between 40% (43) and 50% (44). 
Cold affects circulatory health because temperatures 
below 12 degrees celsius result in raised blood pres-
sure (Collins et al., 1985, cited in (44)) caused by the 
narrowing of blood vessels, which also leads to an 
increase in thickness of the blood as fluid is lost from 
the circulation. This, with raised fibrinogen levels 
due to respiratory infections in winter, is associated 
with increased deaths from coronary thrombosis in 
cold weather. Increases in blood pressure, along with 
increased blood viscosity, increases the risk of strokes 
and heart attacks (31).
 Barnett et al. (45) studied people aged 35–64 in 
21 countries who had had a coronary event between 
1980–95 and found a small overall increase in the 
number of heart attacks in cold periods (26.3% 
events were in 25% of periods). More significantly, 
fatal events (compared with non-fatal events) were 
more common in cold than warmer periods. The 
researchers also found that women were 1.07 times 
more likely to suffer a coronary event in a cold period 
than men.
 It has been suggested that exposure to cold 
temperatures only brings forward those events 
that would have happened within the next couple 
of weeks (the mortality displacement hypothesis). 
However, in a Barnett and associates (45) study 
of cold weather and coronary events, there was no 
increased odds (above the population average) of 
experiencing a coronary event during a cold period 
for people who had previously had heart attacks. 
This suggests that the cold temperature mechanism 
affects both high and low risk groups equally.
 Although the relationship between cold tempera-
tures and circulatory diseases is evident, there is little 
research on the relationship with cold housing. One 
study, which monitored cardio-vascular health in 
the elderly population (aged 75 and over) monthly 
for one year, found that there was no relationship 
between indoor temperature and excess circulatory 
ill-health (46). However, there are shortcomings to 
this research, such as the fact that measures were 
taken only once a month during a mild winter, and 
the population in the warm housing was in residen-
tial or sheltered accommodation, which means that 
they might have been more vulnerable to ill-health 
in the first place.
 More recently, research using case control study 
has shown significant improvements in circula-
tory health through improvements in the thermal 
efficiency of housing (47). In this study the blood 
pressure of individuals subject to interventions fell 
significant and there were improvements to their 
general health including self-reported reduction in 
the use of medication and hospital admissions, while 
no changes were recorded for the control subjects 
whose housing had not been upgraded.
 During the summer months, heat waves can be 
detrimental to people’s health, and cause additional 
avoidable deaths. During the heat wave of August 
2003, when temperatures were much hotter than 
usual, it is estimated that there were 2139 excess 
deaths in England and Wales (48), mostly through 
circulatory diseases. This was particularly signifi-
cant for those over 75 years of age, and those living 
in the London region (48), showing that vulner-
ability to excess heat was found among the elderly 
population, which is also the most vulnerable to 
cold temperatures. However, urban areas were at 
higher risk of excess heat. Although many energy 
efficiency improvements are likely to protect from 
extreme outdoor temperatures, hot or cold, the 
problem of summer excess deaths should be taken 
into consideration when carrying out home energy 
efficiency improvements, particularly when consid-
ering materials used and the adequacy of ventilation. 
:         
 CSVM Cavity wall 
insulation  
(% houses)
Roof  
insulation  
(% houses)
Floor insu-
lation (% 
houses)
Double 
glazing 
(% house)
Finland 0.10 100 100 100 100
Germany 0.11 24 42 15 88
Netherlands 0.11 47 53 27 78
Sweden 0.12 100 100 100 100
Norway 0.12 85 77 88 98
Denmark 0.12 65 76 63 91
Belgium 0.13 42 43 12 62
France 0.13 68 71 24 52
Austria 0.14 26 37 11 53
Greece 0.18 12 16 6 8
UK 0.18 25 90 4 61
Ireland 0.21 42 72 22 33
Portugal 0.28 6 6 2 3
Table 6 Coefficient of seasonal variation in mortality and domestic thermal efficiency in EU–13 (35)
  —  Countries which have more energy effi-
cient housing have lower EWDs.
  —  There is a relationship between EWDs and 
low SAP rating/low indoor temperature.
  —  EWDs are almost three times higher in 
the coldest quarter of housing than in the 
warmest.
  —  21.5% of all EWDs are attributable to the 
coldest quarter of housing, because of it 
being colder than other housing.
  —  Around 40% of EWDs are attributable to 
cardio-vascular diseases.
  —  Around 33% of EWDs are attributable to 
respiratory diseases.
demonstrating a strong association between excess 
winter mortality and levels of domestic heating (33) 
or protection from low outdoor temperatures (36).
Summary
5.2 Morbidity: Health Conditions
The main health conditions associated with cold 
housing are circulatory diseases, respiratory 
problems and mental ill-health. Other conditions 
influenced or exacerbated by cold housing include 
the common flu and cold, as well as arthritis and 
rheumatisms. The level to which such conditions rise 
during the winter months and their relationship with 
cold housing is harder to measure than for mortality, 
which is systematically recorded. The literature on 
excess winter morbidity is reviewed below.
 Low indoor temperatures have been shown to 
be associated with poor health (41), excess winter 
mortality (37), as well as a variety of social and 
economic problems for residents (38). Trends such 
as the ageing population, rising unemployment, and 
an increase in numbers of people working from home 
will make the need for a warm home even more 
crucial (39). There are recommendations from the 
World Health Organization (WHO) to keep indoor 
temperatures above 18 degrees, but there are also 
some critical thresholds around acceptable tem-
peratures in relation to health (40). For instance, the 
longer an individual is exposed to cold temperatures, 
the greater risk of harm to health (41). The impact is 
exacerbated for vulnerable individuals and the colder 
the temperature the greater the risk of harm:
  —  Temperatures that are lower than 16 degrees 
appear to impair respiratory functions.
  —  Temperatures below 12 degrees place strain on 
the cardiovascular system. 
  —  Temperatures below 6 degrees place people at 
risk of hypothermia.
Liddell (42) has reviewed the main large scale stud-
ies of the health impacts of fuel poverty carried 
out over the past 10 years. These were the Warm 
Front Evaluation, the Scottish Central Heating 

          
a number of concerns surrounding home energy-
efficiency measures and their negative impacts 
on health. Insufficient ventilation in increasingly 
airtight houses may lead to increased levels of indoor 
pollutants such as radon, carbon monoxide, nitrogen 
dioxide, and formaldehyde, and the higher relative 
humidity might promote growth of mould and dust 
mites, which are implicated in the development and 
worsening of asthma. 
 Risk of overheating in heatwave conditions, 
increasing the risk of illness and death from condi-
tions, most commonly cardio-vascular and respira-
tory disease, is a further concern. These impacts, 
however, are not a result of home energy-efficiency 
measures per se, but rather inappropriate choice and 
maintenance of ventilation systems and design and 
refurbishment of buildings, and these are the issues 
that should be addressed. These findings around 
worsening of respiratory health in a minority of 
cases receiving increased air-tightness in the home 
reiterate the importance of ensuring adequate and 
high-quality refurbishments of the existing stock.
Mental health
A study carried out by Shelter in 2006 suggested that 
children in bad housing conditions, including cold 
homes, are more likely to have mental health prob-
lems, such as anxiety and depression, to contract 
meningitis, have respiratory problems, experience 
long-term ill health and disability, experience slow 
physical growth and have delayed cognitive develop-
ment (60). These adverse outcomes reflect both 
the direct impact of the housing and the associated 
material deprivation.
The Warm Front and the Scottish CHP evaluation 
assessed mental health impacts on adults and both 
found that effects were prominent in the mental 
health domain, in particular for borderline anxi-
ety and depression. In the short and medium term, 
receiving a Warm Front package is associated with 
significantly better mental health. The study showed 
that as average bedroom temperature rose, the 
chances of occupants avoiding depression increased. 
Residents with bedroom temperatures at 21°C are 
50% less likely to suffer depression and anxiety than 
those with temperatures of 15°C (61). 
 Even greater impacts were found in the New 
Zealand HIHS study. This could perhaps be 
accounted for by the fact that all households were at 
clinical risk in the New Zealand study. “It is possible 
that the joint effects of fuel poverty and ill health 
(especially if one is perceived to exacerbate the other) 
generate a significantly greater toll on mental health 
than might be evident in a more diverse range of 
healthier households.” (42) 
 The NATCEN study found that lack of afford-
able warmth was associated with multiple mental 
health risk for young people, meaning that they 
manifested four or more negative mental health 
symptoms: 28% were classified as having such risk, 
compared to 4% of young people who had always 
lived in warm homes (19). A significant proportion 
of children living in cold homes felt unhappy in their 
family – 10% as opposed to 2% of the group living in 
warm homes. Complementary studies point to the 
fact that young people living in cold homes try to find 
respite and privacy in other venues outside home, 
where they are more exposed to mental health risks 
(62,63).
Other conditions
Medical conditions exacerbated and/or complicated 
by exposure to cold and which show winter associa-
tions include diabetes complications, certain types 
of ulcer exacerbations, osteoarthritis knee pain 
severity and hip fracture (29). Chronic conditions 
may also lower body metabolism which means the 
body generates less heat, while stroke, Parkinson’s 
disease and dementia restrict activity, slowing body 
heat generation and conservation (29). Cold housing 
may also delay recovery following discharge from 
hospital (64). 
 As part of the Warm Front health impact evalua-
tion, Gilbertson and associates (58) conducted semi-
structured interviews with 49 households which 
received home energy improvements under the 
scheme from five urban areas. Almost all reported 
improved and more controllable warmth. Two 
thirds of participants reported improved comfort, 
while those with limited mobility all acknowledged 
the warmer home environment as beneficial. 20% 
reported less minor illness during the winter. The 
Warm Front health impact evaluation also found 
improvements to mental health and emotional 
security. 24.5% reported feeling more relaxed and 
content, 55.1% reported feeling better, and 26.5% 
reported better mood and temperature (58).
The Warm Front health impact evaluation found 
that 24.5% of respondents reported easing of chronic 
conditions such as arthritis (30).
 A survey-based evaluation of a programme to 
tackle fuel poverty by installing energy efficiency 
measures in homes in a rural community in 
Northern Ireland demonstrated that energy effi-
ciency intervention can lead to improvements in 
:         
Despite evidence of unusually hot summers caus-
ing excess summer deaths in the UK, these excess 
summer death rates are relatively low in comparison 
to excess winter deaths. Excess summer mortality 
sometimes receives considerable media attention as 
it did during the heat wave of August 2003. Excess 
summer mortality occurs to a lesser, though still 
notable, extent in England and Wales. Circulatory 
morbidity and mortality are higher in the winter than 
even the warmest of UK summers. The increase 
in the number of heart attacks during the winter 
months and an analysis of excess non-fatal heart 
attacks and strokes in relationship to cold housing is 
an obvious avenue of research to explore the causes 
of increased cardio-vascular morbidity during the 
winter months.
Respiratory problems
Cold air affects the normal protective function 
of the respiratory tract, with increased broncho-
constriction, mucus production and reduced mucus 
clearance. The relationship between respiratory 
problems and cold temperatures is evident in the 
seasonal level of contact between sufferers and the 
healthcare services. Increased contact for adults 
during the winter months has been related to fuel 
poverty (49), and increased contact and symptoms 
for children has been strongly associated with cold 
housing (42).
 Hajat, Kovats & Lacowycz (50) found that GP 
consultations for respiratory tract infections can 
increase by up to 19% for every one degree drop 
in mean temperature below five degrees celsius. 
Hospital admissions for respiratory conditions and 
ischaemic heart disease (reduced blood supply to 
the heart) also increase substantially during winter 
months (51). 
 Afza & Bridgman (52) support this in their 
paper which looks at the contribution of respiratory 
disease to the burden of excess winter (November- 
February) hospital admissions in the North 
Staffordshire district, 1995–2000. They found that 
respiratory disease related emergency admissions 
increased twofold in the winter months. Cold, damp 
houses also promote mould growth, which lowers 
resistance to respiratory infections, thus increasing 
the risk of respiratory morbidity during winter (31).
 A study by Gilchrist (53) focused on measur-
ing morbidity in relation to fuel poverty: costing 
emergency respiratory admissions followed by the 
probability of dying following admission. The paper 
could not conclude whether there was a relationship 
between mortality and fuel poverty, but it showed 
that morbidity counts rise with increasing fuel pov-
erty risk, with a notably large effect in December, 
over and above the underlying effect of winter itself. 
Effects were particularly relevant for age and gender, 
with higher counts for older people and lower counts 
for women.
 A time series analysis of short-term effects of 
temperature on daily GP consultations made by peo-
ple over 65 for lower (LRTI) and upper respiratory 
tract infections (URTI) was conducted over a ten 
year period (1992–2001) in 16 urban UK locations 
(54). This showed an association between low tem-
peratures and an increase in LRTI consultations in 
all 16 locations. A slightly weaker relationship was 
observed in the case of URTI consultations. 
Importantly, a large scale study which looked at 
residents aged over 65 in the London Borough of 
Newham, calculated ‘excess winter morbidity’ 
(EWM) based on emergency hospital episodes for all 
respiratory diagnosis codes, and ranked this against 
a Fuel Poverty Index (FPI) which included factors 
of energy efficient housing, low income, householder 
age and under-occupation. The FPI was shown to be 
a predictor of EWM, indicating supporting evidence 
of a relationship between energy-efficient housing 
and winter respiratory disease among older people 
(28).
 Barnes, Butt & Tomaszewski (19) used the 
Families & Children Survey to estimate that 13% of 
children spent at least a year living in inadequately 
heated accommodation between 2001–05. Damp is 
more likely to occur in cold, poorly insulated homes, 
and this often results in mould which may trigger an 
allergic response such as asthma. Children living in 
damp, mouldy homes are between 1.5 and 3 times 
more prone to coughing and wheezing – symptoms 
of asthma and other respiratory conditions – than 
children in dry homes (55) (Peel et al 1998, cited in 
(19)). Children persistently living in accommoda-
tion with inadequate heating and poor conditions 
were more than twice as likely to suffer from chest 
and breathing problems, such as asthma and bron-
chitis (19).
 A child who develops asthma this way is likely to 
have it for many years and possibly life, and this is 
particularly concerning given 2009 estimates that 
1.1 million children in the UK are affected by asthma 
(39). Brambleby and associates (56) estimated the 
cost of asthma is at least £847 millions per annum, 
just under 1% of the national NHS budget in 2008 
(39). 
 Adequate heating systems have been shown 
to improve asthma symptoms and home energy 
improvements have reduced the number of sick days 
off school by 80% in children with asthma or recur-
rent respiratory infections (57).
 The Warm Front Programme showed that a 
majority of participants suffering from respiratory 
problems reported improvements in breathing, how-
ever a small but significant proportion felt that the 
new heating systems aggravated their chest condi-
tions (58). Bone and associates (59) also highlight 
“I’m all right, but I worry about my husband 
because he’s got bronchitis. In the summer, he can 
do the dishes in the kitchen. But in the winter, he 
can’t because it’s too cold in there because of the 
draught coming in from the roof.” (Susan, retired 
couple) [Harrington et al, 2005]
Interviewer: If you are cold in your house, 
what effect does that have on your life in general?
Respondent: It makes you feel depressed, very 
much so. (Edwin, single middle aged)
[Harrington et al, 2005]
Interviewer: How important is being warm for 
you?
Respondent: Very, because I can’t stand the cold 
very much because I get pains in my legs from the 
cold. (Claire, young mother, living with husband 
and children) [Harrington 2005]

          
health and well-being, increased levels of comfort 
in the home and a reduction in the use of health 
services. Key findings include a reduction in the 
occurrence of condensation, a reduction in the 
numbers of people reporting arthritis/ rheumatism, 
a reduction in the use of health services, an increase 
in temperature satisfaction for those who had a new 
heating system installed, and for those who did not, 
there was an increase in benefit uptake (70).
Cold conditions can also increase the risk of minor 
illnesses. The common cold replicates faster in a cold 
nose whereas the immune system becomes more 
sluggish in colder temperatures, meaning a com-
mon cold is more likely to develop. This can have 
more severe consequences for patients with existing 
conditions, as it may lead to a chest infection in 
patients with chronic obstructive pulmonary disease 
(COPD) (44). 
Evans (65) carried out a study of wider housing qual-
ity and children’s health and well-being. Housing 
quality was based on an observer-rated standardised 
index7 which included indoor temperature, as well 
as other variables (structural quality, privacy, haz-
ards, cleanliness/clutter, and children’s resources). 
The study found that independently of household 
income, children residing in poorer quality housing 
have more psychological symptoms and less task 
persistence than their counterparts living in better 
quality housing. There were no gender differences. 
The research showed not only that housing quality is 
associated with psychological health in children, but 
that it may also affect certain aspects of children’s 
motivation. The motivational data suggests that 
chronic exposure to poor housing conditions may 
lead to greater helplessness8.
 Significant improvements in health-related qual-
ity of life were found in a randomised controlled trial 
of home insulation, which concluded that target-
ing home improvements at low-income households 
significantly improved social functioning and both 
physical and emotional well-being (including res-
piratory symptoms) ((41) cited in (66)). 
 The level of energy efficiency affects people with 
low incomes more severely because it affects life 
chances and how they spend disposable income on 
other basic items such as food and clothing  (14). 
Poor families will face the choice to “heat or eat”: 
either less money can be spent on basics such as a 
sufficient, healthy diet (with obvious health impacts 
such as obesity or malnutrition), or less can be spent 
on heating their homes to a reasonable temperature.
 Warmer homes could bring potential physical 
health benefits from improvements in cooking and 
nutrition. Interviews with participating households 
as part of the Warm Front health impact evaluation 
found that 10% of householders felt more and better 
quality food could be purchased because of cost 
savings, and 20% reported improved cooking since 
previously cold kitchens were now comfortable to 
work in (58).
 Bhattacharya and associates (67) looked at the 
impact of cold weather periods on family budgets 
and nutritional outcomes in poor American families. 
Their results suggested that these families tended to 
decrease spending on food by a similar amount to 
the extra spent on fuel during cold spells, and both 
children and adults reduced their caloric intake by 
about 200 calories in winter months. Rich families, 
on the other hand, increased spending on food, dem-
onstrating that deprived families are more likely 
to suffer from some of the indirect impacts of cold 
weather. 
 Cold, damp homes increase the risk of arthritic 
symptoms. This impacts on strength and dexterity, 
which both decrease as temperatures drop, increas-
ing the risk of non-intentional injuries. A cold house 
increases the risk of falls in the elderly (31). Domestic 
accidents, including fatalities, are more common in 
cold homes in winter. This can result in periods of 
prolonged immobility, making it even more difficult 
to keep warm (44).
 Social isolation among older people is exac-
erbated by living in a cold home. Costly fuel bills 
prevent them from going out, they fear returning, 
already feeling cold, to a cold home, or they are 
reluctant to invite friends into a cold house (44). 
Older people who are unable to keep their homes 
warm, who have a health condition exacerbated by 
the cold or have sustained injuries due to the cold, 
may need increased care or need to go into residential 
care, increasing the financial burden on the country 
(44).
Some respondents to a survey carried out after the 
Warm Front programme tended to think of cold 
indoors as exacerbating health problems rather than 
causing them. This may illustrate lay beliefs rather 
than the absence of causality, but it also shows a 
clear perception on the part of the respondents that 
cold housing had an impact on their well-being. In 
particular, respondents identified positive effects of 
warmer homes on social relationships and mental 
health (68).
6
Indirect health impacts of living in a cold home
:          
Interviewer: Do you think being warm is con-
nected to your health?
Respondent: Yes, because you can catch more 
colds [if colder]. (Betty, retired couple)
[Harrington 2005]
  —  There is a strong relationship between cold 
temperatures, cardio-vascular and respira-
tory diseases, which has been associated 
with fuel poverty and cold housing.
  —  Children living in cold homes are more 
than twice as likely to suffer from a variety 
of respiratory problems than children liv-
ing in warm homes.
  —  Mental health is negatively affected by 
fuel poverty and cold housing for any age 
group.
  —  More than 1 in 4 adolescents living in 
cold housing are at risk of multiple mental 
health problems.
  —  Cold housing increases the level of minor 
illnesses such as colds and flu and exacer-
bates existing conditions such as arthritis 
and rheumatisms.
Summary
Interviewer: If you’re cold in your own home, what 
effect has that on your life in general?
Respondent: Terrible. Sometimes we go to bed 
at 7 o’clock, and all our regular visitors know it’s 
pointless coming after that time because they 
know where we are. We find it easier to go upstairs 
to sit underneath the blankets to keep warm. 
(Evelyn, middle aged couple) [Harrington 2005]

          
Cold housing and fuel poverty not only have direct 
and immediate impacts on health, but also indirect 
impacts and a wider effect on well-being and life 
opportunities, as well as on climate change. The 
evidence reviewed in this paper shows the dramatic 
impact that cold housing has on the population in 
terms of cardio-vascular and respiratory morbid-
ity and on the elderly in terms of winter mortality. 
It also highlights the stark effect that fuel poverty 
has on mental health across many different groups, 
while also having an impact on children and young 
people’s well-being and opportunities.
 Addressing energy inefficient housing and bring-
ing all homes up to a minimum standard of thermal 
efficiency would have the strongest positive impact 
on the poorest households, even though households 
from a variety of socio-economic backgrounds are 
likely to be residents of such properties. 
 A medium scenario model for fuel price increases 
developed in 2008 predicted fuel poverty in England 
to jump to four million by 2016 if improvements to 
the energy performance of the housing stock, and 
growth in the incomes of low-income households, 
were maintained at only current rates (69). Fuel 
poverty has now already risen to this level because 
the fuel price increase was much higher than the 
model predicted: the current energy efficiency of 
the existing housing stock is unable to mitigate such 
high increases. However, it is unlikely that anyone 
living in a dwelling built to current and near-future 
standards will be at any risk  of being in fuel poverty 
(70). The Government should aim to make improv-
ing energy efficiency standards a priority: any step 
forward in achieving certain minimum standards in 
the existing housing stock will reduce the risk of fuel 
poverty for current and future households and bring 
associated health benefits.
 The Energy Savings Trust estimate that the 
overall total cost of improving to an E band all F and 
G homes would be £12.5 billion. Other estimates 
for upgrading all fuel poor homes to a SAP 81 range 
from £21 to £28 for England or £49 to £64 bil-
lion for the whole of the UK (71). If all homes in 
England were brought up to an EPC E band, 9.4Mt 
CO2 would be saved, just under 2% of the UK’s net 
CO2 emissions10. Major energy efficiency retrofit 
programmes that would bring homes to a SAP of 
81 have been estimated to reduce fuel bills of the 
fuel poor by half, thus removing 83% of fuel poor 
households from fuel poverty, as well as reducing 
CO2 emissions related to domestic energy require-
ments by over 50% (22).
NHS costs are associated mainly with morbidity 
rather than mortality, and the Department of Health 
in 2009 estimated that for every cold-related death 
there are eight non-fatal hospital admissions (39). 
In the coldest months of the year, NHS expenditure 
was reported as rising by 2% in 1998 (Hansard 1998, 
cited in (39)) , and Brenda Boardman estimated that 
the annual cost to the NHS of cold-related ill-health 
is almost certainly in excess of £1 billion (39).
 An investment in upgrading all homes in England 
would be recouped though savings in energy con-
sumption and NHS costs; additional savings would 
be gained through mitigating climate change, while 
achieving large scale environmental and social ben-
efits through the number of lives saved and improved 
health and quality of life for all households affected 
by cold housing and fuel poverty.
 Improving the energy efficiency of the exist-
ing stock is the only long-term sustainable way of 
ensuring a number of multiple gains: environmental 
gains, health gains, the mitigation of climate change 
and social gains through a reduction in health and 
environmental inequalities. It is also a good lever 
to stimulate the economy and the labour market in 
relation to the green economy, as well as providing 
opportunities for the up-skilling of the workforce in 
building construction and related sectors.
 Government policy documents and reports, 
including the Chief Medical Officer report of 2009 
and the recent Public Health White Paper, recognise 
the tangible impact of cold housing and fuel poverty 
on people’s health and well-being. However, there 
is a clear contradiction between the Government’s 
recognition of the link between health and cold hous-
ing, its statements of support for the reduction of fuel 
poverty and CO2 emissions and its lack of identifiable 
commitment to support this agenda through regu-
lation, target setting, guidelines, or funding. The 
recent cuts to Warm Front with its clearly reported 
: 
6.1 Social benefits of improved housing
The main benefits arising from improving the 
thermal efficiency of the existing housing stock are 
the beneficial effects on the health of residents and 
the reduced carbon emissions from heating needs. 
However, there are other benefits to warmer homes 
and to investing in thermal efficiency.
A study found that an increased duration of living in 
inadequately heated accommodation is significantly 
associated with having multiple negative outcomes 
across the range of the Every Child Matters out-
comes framework9. For example, 67% of children 
who persistently lived in inadequately heated accom-
modation had not had a holiday in the past year 
compared to 50% who lived in inadequately heated 
accommodation on a short term basis, they were 
more likely to feel safe and less likely to fail to attend 
school (19).
 Further, an increased duration of living in inad-
equately heated accommodation is significantly 
associated with having no quiet place at home to 
do homework (19). This may be because the family 
can afford to only part heat their home and heating 
is focused on the most used (and therefore noisiest) 
rooms. This can affect a child’s educational attain-
ment and therefore work opportunities in later life 
(31). Educational and work factors are particularly 
important determinants of long-term health (66): 
cold housing, its impact on family life and early years 
can heavily weight on other spheres of life, which 
affect long-term health outcomes. 
 The investment in energy efficiency measures 
can also help with neighbourhood renewal by creat-
ing more local jobs and improving local economies 
(10). Area based approaches such as the Community 
Energy Savings Programme currently being trialled 
throughout the UK could help to deliver this. Such 
investment can bring vitality to the green economy, 
work opportunities in the building industry and 
opportunities for up skilling the building workforce 
(14). 
  —  Cold housing negatively affects children’s 
educational attainment, emotional well-
being and resilience.
  —  Fuel poverty negatively affects dietary 
opportunities and choices.
  —  Cold housing negatively affects dexterity 
and increases the risk of accidents and 
injuries in the home.
  —  Investing in the energy efficiency of hous-
ing can help stimulate the labour market 
and economy, as well as creating oppor-
tunities for skilling up the construction 
workforce. 
Summary
7
Conclusions
“The annual cost to the NHS of treating winter-
related disease due to cold private housing is £859 
million. This does not include additional spend-
ing by social services, or economic losses through 
missed work. The total costs to the NHS and the 
country are unknown. A recent study showed that 
investing £1 in keeping homes warm saved the 
NHS 42 pence in health costs...”
[Chief Medical Officer Report, 2009]

          
7.1 Policy Recommendations
The studies reviewed in the sections above have 
shown not only that cold housing and fuel poverty 
have an impact on physical and mental health, but 
also that policies aimed at improving the thermal 
efficiency of homes and reducing fuel poverty can 
reduce mortality and morbidity. In this section we 
propose some areas for policy development and high-
light interventions that are likely to have the greatest 
impact in improving cold homes and reducing fuel 
poverty.
 The Energy Saving Trust (EST) has carried out 
an analysis of the measures needed to improve all 
houses to SAP39, thereby getting rid of all F and G 
homes (17% in 2008). The main measures needed 
are loft installation, full cavity wall insulation, a 
modern gas condensing boiler and double glazing. 
These homes will cost less than £3000 to raise to a 
band E. However, there are a small proportion of 
hard to make decent homes which will cost more 
than £5000 to bring to an E band. These should 
not be ignored when considering policy assistance 
measures. 
 Improving the energy efficiency of housing has to 
occur in all communities, across the social gradient 
and not just where it might be ‘easy’. At times the 
households in most urgent need are those who are 
least likely to access support, such as tenants in the 
private rental sector, or who live in homes that are 
hardest to upgrade such as older rural housing.
  It is vital that programmes and funding remain 
in place to reduce fuel poverty and improve the 
health of those on low incomes through improve-
ments in the energy efficiency of homes at no cost 
to vulnerable consumers. Such funding should 
be provided to low income households through 
a renewed Warm Front Scheme and through the 
proposed Energy Company Obligation (ECO), 
which is currently planned to pass the costs on 
to consumers, regardless of income, though not 
upfront and with potential longer-term savings. 
This scheme needs to be adequately financed 
and its details should ensure that low-income 
households and vulnerable groups should be 
exempt from meeting costs.
  The Warm Front programme, which provided a 
package of insulation and heating improvements 
to qualifying households, has been shown to have 
a positive impact on mental health, alleviating 
respiratory problems in children and reducing 
deaths among older people (61). In the context 
of increasing energy prices and an ageing popu-
lation, as well as the need to mitigate climate 
change and adapt to more extreme weather 
events, it is recommended that the Warm Front 
Scheme is not only renewed to at least its pre-
CSR levels, but its eligibility criteria widened or 
at least maintained, rather than restricted as is 
currently proposed.
 
  Funding mechanisms must be in place to 
enable households across all tenures to upgrade 
their homes. However, beyond supporting low 
income households in any area, more intensity 
of intervention is also needed on two other lev-
els: deprived areas should be targeted through 
programmes such as the Community Energy 
Savings Programme, and poor quality housing 
should be targeted through the introduction 
of a renewed energy-focused Decent Homes 
Standard, as suggested by the Communities 
and Local Government Committee (75). 
Low-income households could also be aided by 
further increasing targeting for the social hous-
ing sector, as suggested by the Home Energy 
Management Strategy, which proposed a mini-
mum SAP standard of 70 for all social housing, 
as well as further action engaging with landlords 
to improve efficiency in the private rental sector 
(76).
  More appropriate legislation must be developed 
on the side of tenants in private rented accom-
modation who are put off seeking help to make 
energy efficiency improvements to their homes. 
The Government should develop targets for 
upgrading the energy efficiency of the exist-
ing stock, including some form of minimum 
energy efficiency regulation for the private rental 
sector, which is supported by the Fuel Poverty 
Advisory Group (20). This could be facilitated 
through a statutory register for landlords held 
by local authorities, which could help identify 
non-decent homes, at risk households and imple-
mentation of regulation. This has the potential of 
raising 150,000 households from fuel poverty if 
privately rented F and G rented properties were 
brought up to a band E (72).
  National Indicators are effective levers for local 
action and we recommend that the National 
Indicator on fuel poverty should be maintained 
as mandatory and a new National Indicator of 
housing quality, focused on energy efficiency, 
and specifically related to the private sector 
should be made available to local authorities. 
Fuel poverty has been included as an indicator 
in the proposed public health outcomes frame-
work (77), while at the same time much of the 
responsibility from public health will move to 
local authorities: it is fundamental that data on 
fuel poverty at the local level continues to be col-
lected if the this indicator is to be implemented 
and monitored.
 
  Energy standards and guidelines should be 
coupled with quality standards for adequate 
ventilation when sealing homes. This is par-
ticularly necessary when ‘quick fixes’ such as 
double-glazing and draught proofing are carried 
out to properties. In major refurbishment and 
regeneration projects consideration should be 
given to using solar heat gain, while at the same 
time avoiding summer overheating through 
 :  
record of health improvement, ahead of any sig-
nificant detail on the future level and arrangement 
of the Energy Company Obligation (ECO), are of 
particular concern. The impact of the funding cuts 
to local authorities on investment in fuel poverty and 
energy efficiency programmes is likely to be highly 
detrimental, especially when combined with the 
removal of National Indictor 187 and the repeal of 
the Home Energy Conservation Act. 
 While an estimated £3 to £8 billion annually is 
needed to address fuel poverty (71), ECO is planned 
to deliver only about £1 billion of investment through 
energy companies’ contribution (72), while other 
existing schemes and requirements are being either 
reduced or abolished. The Government’s current 
support and financial commitment to addressing 
the problem of poor thermal efficiency of housing 
remains inadequate, given the potential it has to 
improve the health and well-being of the population 
and to help mitigate climate change. 
Ensuring effectiveness of interventions
Some studies (74;79) have shown that, following 
interventions aimed at improving thermal efficiency, 
trade-offs have taken place between energy use and 
thermal comfort. In some cases, the benefits of 
improved fuel efficiency were taken in the form of 
reduced fuel consumption rather than extra warmth, 
which may indicate more disposable income (68). 
These cases were often elderly householders, who 
found it difficult operating new heating controls 
or feared higher energy bills because they were 
unsure how the improved efficiency would impact 
on consumption. 
 These issues can undermine the potential health 
benefits of interventions. However, susceptible 
households can be identified and thermal efficiency 
interventions can be supplemented by other actions 
aimed at avoiding subsequent trade-offs.
 A number of households who received improve-
ments through the Warm Front programme reported 
a preference for retaining colder homes following 
improvements. Such preference was based partly 
on a long-term adaptation to low temperatures expe-
rienced throughout life and partly on lay beliefs of 
what constitutes a healthy temperature (73). 
 Interventions, especially in older people’s homes, 
should be coupled with training in the use of new 
heating systems and ideally easy-to-use smart 
metres, which can indicate how much is being spent 
on fuel consumption. Such training should include 
information on what constitutes a healthy indoor 
temperature.
 If heating or efficiency improvements are hard to 
implement and/or the household income is extremely 
low, upgrading the worst homes to a higher standard 
would still leave a number of households in fuel 
poverty. These cases need to be identified and 
consideration should be given to financial support 
with meeting energy bills for at-risk households, 
which would bring health benefits. Even better, the 
Government should give consideration to imple-
menting a strategy for ensuring investment into 
upgrading such homes to a high efficiency standard, 
such as bands A and B. This would bring dual health 
and environmental benefits as well as making current 
and future households less susceptible to energy 
price increases.
 A study showed that at pre-existing temperatures 
of 16.5C, about 30% of the benefit of an energy 
efficiency improvement would be taken as a tempera-
ture increase and the rest as an energy saving. This 
means that the great majority of interventions bring 
a multiple health and environmental gain. Where 
pre-existing temperatures were as low as 14C, such 
as in very poor standard homes or very low income 
households, a 50% energy saving is achieved and 
the rest is taken as a temperature increase. In cir-
cumstances where the house is already maintained 
at 20C on average, energy efficiency improvements 
will achieve a 100% energy saving (74). 
 This means that once the trade-off issues for 
at-risk households are addressed, energy efficiency 
interventions always bring multiple health and envi-
ronmental gains.

          
Appendix
Methodology for developing model and 
calculating estimate of EWDs attributable to 
cold housing
The details of the calculations are given below. They 
are based on a simplistic model for estimating what 
proportion is attributable to cold housing and make 
some key assumptions:
  The difference between the relative risk of death 
in cold and warm housing was constant over the 
4 winter months.
  The average risk for the non-winter months was 
half way between the summer minimum and the 
average level for the 4 winter months.
  The population at risk in the 25% of coldest 
homes comprised a quarter of the general popu-
lation and had the same age-sex profile.
A similar calculation could be performed for any 
other time periods if estimates of the risk for cold 
and warm housing were available for these other time 
periods. An assumption cannot be made that the 
difference in risks would be the same for other time 
periods, as it is not possible to predict how outdoor 
temperature and flu epidemics would influence this 
difference in risk.
The calculation was as follows:
Retrieved from ONS data
A  Total EWDs for 1985/6–1995/6 = 368,850
A1   Total registered deaths 1986–1996 = 
6,251,491
Calculations
B   Average EWDs (A÷11) 
C   Monthly average EWDs (B÷4)
D   The total number of deaths excluding EWDs 
(A1–A) 
E    The average monthly deaths excluding 
EWDs (D/(12×11)) 
F    The average summer minimum (E–C) 
G    The monthly winter deaths in the coldest 25% 
of housing (F×1.5÷4) 
H    The monthly winter deaths that would be 
expected in 25% of housing based on death 
rates for the warmest housing (F×1.3÷4) 
I    Monthly winter deaths due to the coldest 25% 
of housing (G–H) 
J    Deaths due to the coldest 25% of housing over 
the winter period (I×4) 
K    Proportion attributable to the 25% of coldest 
housing (J/B) 
Notes 
All estimates are based on the period 1986–1996
Risk factors were taken from Wilkinson et al. 2001
Registered deaths, mortality rates and estimates of 
EWDs for the period 1986–1996 are all taken or 
derived from ONS data.
  
shading and shelter belts. Some building mate-
rials – especially natural materials with a high 
density perform much better in avoiding sum-
mer overheating than light-weight counterparts, 
such as rockwool or polystyrene. Government 
funded projects should specify materials that 
address both problems.
  Ensuring that all F and G rated homes are 
upgraded to an E standard by 2016 is a basic step 
towards achieving carbon emission reduction 
targets and ensuring that the existing housing 
stock is ready for upgrades to nearly zero-energy 
standards when undergoing further renovations 
as suggested by the EU policy directives on the 
energy performance of buildings (4). It is there-
fore recommended that, whenever viable, homes 
are upgraded to as high a standard as possible. In 
a few cases where some of the worst homes are 
involved and where it is cost-efficient, considera-
tion should be given to demolition and rebuilding 
to current standards as this may avoid further 
expenditure in the future. It is often cost effec-
tive to deliver measures as packages, bringing 
them up to a band D or C, for example internal 
solid wall insulation and window replacements 
are usually most cost effectively delivered at the 
same time.
 
  Past Government policies aimed at tackling 
fuel poverty have not equitably addressed those 
issues faced by rural communities. There are 
no policy instruments supporting the financing 
of double glazing, limited policy measures sup-
porting financing for solid wall insulation and 
no strong incentive encouraging homeowners 
in inefficient homes to switch away from electric 
heating systems (1). It is recommended that 
policy instruments and incentives to implement 
the above are included in the Green Deal. There 
has been a lack of funding to assist off-gas prop-
erties, and remote areas suffer higher costs of 
delivery when it comes to home energy efficiency 
measures (26). Specific policies and interven-
tions need to be developed to address the energy 
efficiency of rural homes, in particular FIT and 
RHI should be adapted to provide further sup-
port to low income households in rural homes.

          
Endnotes
Denoted by n in the text
1 Although the emphasis in the definition is on 
heating the home, fuel costs in the definition of fuel 
poverty also include spending on water heating, 
lights and appliance usage and cooking costs.
2  Defined as those in receipt of one of the 
principle means tested or disability related benefits.
3  Those in receipt of certain income and dis-
ability benefits and those over the age of 70.
4  The CSVM is the proportionate increase in 
mortality during the winter months (Dec–Mar) 
in comparison to the average for the other two 
quarters of the year (Apr–Jul and Aug–Sep).
5  The ‘consensual approach’ is a method to 
measure poverty by looking at direct measures of 
living standards as determined by public opinion 
and identifying the population subject to an 
enforced lack of such standards.
6  The CSVM is proportionate increase in 
mortality during the winter months (Dec–Mar) 
in comparison to the average for the other two 
quarters of the year (Apr–Jul and Aug–Sep).
7  This index comprised 88 items which were 
scored between 0 and 2 by trained independent 
observers according to criteria listed in the index.
8  The definition of  ‘learned helplessness’ is 
used here: a behavioural trait by which humans, 
following persistent lack of control over their sur-
rounding environment, stop attempting to improve 
their circumstances, to achieve better results, or to 
change their own behaviour and environment.
9  This is an indicator framework of chil-
dren’s health and well-being developed by the 
Department for Children, Schools and Families 
in 2008 (http://www.dcsf.gov.uk/childrensplan/
downloads/ECM%20outcomes%20framework.
pdf)
10  The total UK net Co2 emissions in 2009 were 
473.7Mt (http://www.decc.gov.uk/assets/decc/
Statistics/climate_change/1214-stat-rel-uk-ghg-
emissions-2009-final.pdf)
  

          
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events within and beyond the control of human 
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9 Association for the Conservation of Energy 
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Climate Change (2010) Warm Homes, Greener 
Homes: A Strategy for Household Energy 
Management.
77  Department of Health (2010) Healthy Lives, 
Healthy People: transparency in outcomes, 
proposals for a public health outcomes framework.

The Health Impacts of Cold Homes and 
Fuel Poverty
www.marmotreview.org 
www.foe.co.uk
Marmot Review 
Team
Published May 2011 by 
Friends of the Earth & the 
Marmot Review Team
ISBN 978–1–85750–343–2
Friends of the Earth England, 
Wales and Northern Ireland
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Marmot Review Team
Department of Epidemiology  
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University College London
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Published thanks to support from
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