Warm Homes, Better Breathing: A Neighbourhood Approach to Supporting People with COPD Affected by Fuel Poverty
Project overview, including who was involved in the project
Fuel poverty is a significant driver of poor respiratory outcomes, particularly among people with chronic obstructive pulmonary disease (COPD), asthma and pre-school wheeze in deprived communities. In Cheshire & Merseyside, an estimated 450,000 households were affected, creating a clear opportunity to address inequalities through a proactive, neighbourhood-based approach.This programme, which began delivery through the NHS England Innovations for Healthcare Inequalities Programme (InHIP), used the Combined Intelligence for Population Health Action (CIPHA) platform to identify patients at risk by linking primary care, secondary care, deprivation and housing data. Rather than creating new services, the focus was on putting data into action and connecting existing offers.
Multi-agency workshops brought together primary care, community and secondary care based respiratory teams, local authority partners and the voluntary sector to co-design neighbourhood pathways. These pathways combined clinical review and medicines optimisation with referral into fuel poverty and wider support services.
To extend reach, a digital intervention (“SMS Warmer Homes Direct”) used GP text messaging to proactively connect COPD patients in deprived communities to support, with messaging co-designed alongside patients.
A tiered participation model was developed to support spread. This enables organisations to start with low-resource, awareness-based approaches, including posters, leaflets and QR-coded materials in primary care and community settings to promote easy, trusted self-referral into support services. Organisations can then progress to targeted digital outreach using SMS, before delivering fully integrated clinical and non-clinical pathways.
This approach aligns closely with the neighbourhood health model by integrating teams, targeting prevention and using shared data to deliver locally tailored care.
Project outcomes/impact
Across participating areas (including Knowsley, St Helens, Warrington, Liverpool and Wirral), the programme has supported over 1,600 patients through integrated pathways. More than 1,200 patients received medicines optimisation, over 880 referrals were made to specialist fuel poverty services, and over £482,000 in household support funding was facilitated. Over 400 households were also added to Priority Services Registers.Evaluation was conducted with the integrated care board (ICB) Business Intelligence team and the University of Liverpool using their Real world Intervention Causal Evaluation (RICE) tool. Early findings show an approximate 10% reduction in GP appointments in the 12 months following intervention, compared with a matched control cohort (around 400 appointments avoided versus expected activity).
The SMS Warmer Homes Direct pilot demonstrated strong engagement, with 15–17% of contacted patients self-referring to support, significantly higher than typical outreach campaigns. This provides a scalable, low-cost mechanism to reach underserved populations.
Qualitative feedback highlights improved clinician confidence in addressing wider determinants of health, alongside improved patient access to support that directly impacts living conditions. Clinicians also reported incorporating questions about living conditions into routine reviews, as they now have clear pathways to support patients when needs are identified.
Overall, the programme demonstrates that addressing fuel poverty through integrated neighbourhood pathways can improve outcomes, reduce demand and support health equity without creating new services.