Catherine Homer Health Promotion Specialist, NHS Rotherham

This presentation presents independent research commissioned by the National Institute for Health Research (NIHR) under its Research for Patient Benefit (RfPB) Programme (Grant Reference Number PB-PG ). The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health.

Outline Background to KWILLT and how we did it What we found Pen Portraits Assumptions Next Steps

Aim: Keeping Warm in Later Life (KWILLT) A study to examine the knowledge, beliefs and values of older people with a focus on keeping warm at home and barriers to accessing help to keep warm With the findings we will develop solutions and strategies to overcome these barriers in an attempt to prevent seasonal excess deaths

So, why Rotherham? Approx population 250,000 Aging population Poor health trends High levels of Excess Winter Deaths and Fuel Poverty Challenges with type of housing stock Uptake of affordable warmth interventions

How we did it Stage 1: 50 older people (aged 55-95), face to face in depth interviews, temperature/humidity measurements 25 health and social care staff, face to face in depth interviews Stage 2: Six focus groups with older people and frontline/strategic staff (n=42) Stage 3: Consultation event (today)

KWILLT Findings: Themes Situation or context factorsAttitudinal factorsBarriers  Money  Age  Social connections  Housing type and tenure  Health  Making ends meet o Thrift o Competing priorities o Pride o Struggling  I can manage o Thrift o Hardiness o Stoicism  Its my business o Mistrust o Pride o Privacy  I'm frightened o Privacy o Personal safety/vulnerability  I'll stay as I am o Struggle with change o Like routine o Fear o Trust  Awareness o Knowledge o Information o Experience  Technology o Heating o Information o Banking  Disjointed systems o Fragmentation or services o Local differences o Lack of referral systems  Visibility o Fuel o Money o Information o Older people

Four Groups of Older People Can’t affordCan affordCold ‼ ? Can afford Can’t affordWarm

Pen Portraits Lonely, Pearle Proud, Fred Dependent, Meena Getting by, Bob and Joan Just about managing, Enid Isolated, Pat

KWILLT Findings: the segmentation model for older people who are cold Segmentation group Pen Portrait Name Description Isolated and not wanting to cause a bother Pat Low income household and fuel poor, over 55, socially isolated and frightened, lacks information and understanding about keeping warm, private rented housing, long term mental health problems (depressions/anxiety) Getting by cautiouslyBen and Joan Low income household and fuel poor, over 65, some social connections but not well informed about keeping warm, privately owned house, live with a partner with chronic health problems Dependent and poorly informed Meena Low income household and fuel poor, over 55, limited social connections with strong cultural ties, poorly informed about keeping warm, privately owned housing, poor health and mobility and very dependent on close family. Just about managingEnid Can pay for home heating but values thrift, over 70, some social connections but is private and trusts few people so is poorly informed about keeping warm, social housing, physical health problems and sensory impairment Lonely and out of touchPearle Financially secure but lives in a cold home, over 70, widowed, and socially isolated, poorly informed about keeping warm, privately owned house, physically well but bereaved. Proud and wants to be self-sufficient Fred Low income but not fuel poor, over 70, regular but superficial social connections, poorly informed but values stoicism and hardiness and think they don’t need any help, social housing, good health, minor ailments.

What is the model for? Six pen portraits have been developed using the model to illustrate how some older people experience the factors that influence their ability to keep warm The pen portraits help staff and organisations to: -Find people who are at risk -Recognise people at risk -Understand the reasons why they are cold, the context, attitude and behaviour that contribute to this -Support staff and organisations in the design and delivery of acceptable and accessible services -Identify strategies to overcome barriers -Promote strategies to support self management to keep warm

Ben and Joan Mid 60s Low income, now retired Ben =chronic ill health Joan = carer Children nearby but Ben and Joan don’t like to be a bother Some social contact Live in an old mid-terrace (Right to buy) Central heating system old, not serviced and use supplementary heating Pay for fuel by direct debit but don’t understand how they work

Ben and Joan: Drivers of behaviour Factors that drive Ben and Joan’s decisions and behaviour include: Thrift Pride and being debt adverse Fear of disruption in the home Mistrust of organisations like energy companies and banks Fear of technology Own and friends experience and media accentuates mistrust and difficulty dealing with change: “Oh yes, because I was trained to be frugal, it was part of my upbringing. You didn’t have a lot so you were careful with what you did have. And with the costs rising now, I’m certainly not extravagant with the heating, I’m very wary” (Older person participant in KWILLT) “Oh yes, because I was trained to be frugal, it was part of my upbringing. You didn’t have a lot so you were careful with what you did have. And with the costs rising now, I’m certainly not extravagant with the heating, I’m very wary” (Older person participant in KWILLT) ” We changed from 'Company A' to go to 'Company B', and it was a nightmare, and I spent hours on the phone trying to get money back that they owed me. And you inform them and they say oh you can ring this number and you can get help. They did nothing! They said they would but they did nothing! I had to do it all myself and I bet that went on for over six months and I said well if that’s changing I’m never going to change again. It was a nightmare”. (Older person participant in KWILLT) ” We changed from 'Company A' to go to 'Company B', and it was a nightmare, and I spent hours on the phone trying to get money back that they owed me. And you inform them and they say oh you can ring this number and you can get help. They did nothing! They said they would but they did nothing! I had to do it all myself and I bet that went on for over six months and I said well if that’s changing I’m never going to change again. It was a nightmare”. (Older person participant in KWILLT)

“I can put that heater on and that’s plenty for me in the daytime, I don’t want anything else, and therefore it can’t be as expensive as heating the whole house”. (Older person participant in (KWILLT) “I can put that heater on and that’s plenty for me in the daytime, I don’t want anything else, and therefore it can’t be as expensive as heating the whole house”. (Older person participant in (KWILLT) Beliefs and values Ben and Joan are thrifty, proud and fear being in debt. They want to be in control of their life but would be reluctant to ask for help. They will cut down on other things to afford fuel They often think it’s not worth putting the central heating system on. As it doesn’t work properly it will take a while to work and it doesn’t seem as responsive and warming as the electric fire “I keep tabs on all my bills and all my doings. You’ve got to have a programme, you know what I mean. You’ve got to be a budget, know what’s coming on… I’ve managed to pay my bills, but I do have really expensive bills”. (Older person participant in KWILLT) “I keep tabs on all my bills and all my doings. You’ve got to have a programme, you know what I mean. You’ve got to be a budget, know what’s coming on… I’ve managed to pay my bills, but I do have really expensive bills”. (Older person participant in KWILLT)

A Day in the Life of Ben and Joan Ben and Joan wake up in a cold bedroom and a cold house. The day starts at seven when they get up and make a cup of tea which they drink whilst making breakfast. They use the cooker to heat the kitchen whilst they make breakfast. They sit in the living room to eat their breakfast with the electric heater on They don’t heat the whole house and especially the bedroom as they were brought up and a belief that hot bedrooms are bad for you They often think it’s not worth putting the central heating system on. As it doesn’t work properly it will take a while to work and it doesn’t seem as responsive and warming as the electric fire “When we were little we had coal fires. I can remember the oven top and in the winter my mum used to take the trays out of the oven, they were about that thick, and she used to wrap them in a blanket and put them in bed for us. I can’t get into a warm bed. It has to be cold for me to get into…. not too warm, that’s unhealthy isn’t it”? (Older person participant in KWILLT)

What could help Ben and Joan? Warm Front Energy Companies and social tariff Swopping providers Green Deal Fuel Payments Winter Fuel Payments.

So in the future how will people like Ben and Joan …. Manage their energy bills? Engage with advances to new technology? Respond to policy changes?

So what do we know? It’s a complex picture! People don't always do what you think they will do

Assumptions! People aren’t cold these days Its only the really old who are effected Only people who are fuel poor are cold Other people are tackling the problems Family will help People know that there are health impacts of being cold People are aware of what healthy room temperatures are People know how to use technology – heating and banking Vulnerable people read and act on information from organisations such as energy companies, banks and Government bodies People will access interventions to help e.g. Social fuel tariffs and affordable warmth interventions e.g. Green Deal Vulnerable people will engage with processes to obtain help Interventions don’t have adverse consequences

Next steps Develop an e-learning resource for front line staff from all organisations to develop their knowledge of the pen portraits and how to identify and support householders they work with Produce a DVD to raise issues of affordable warmth and fuel poverty with front line staff and householders Gain funding for a research study focussing on Children and Families and cold homes