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Background England, and the UK more generally, has a large burden of winter- and cold-related mortality/morbidity in comparison with nearby countries in continental Europe. Improving the energy efficiency of the housing stock may help to reduce this, as well as being important for climate change and energy security objectives. Objectives To evaluate the impact of home energy efficiency (HEE) interventions on winter- and cold-related mortality/morbidity, including assessing the impact of winter fuel payments (WFPs) and fuel costs. Design A mixed-methods study – an epidemiological time-series analysis, an analysis of data on HEE interventions, the development and application of modelling methods including a multicriteria decision analysis and an in-depth interview study of householders. Setting England, UK. Participants The population of England. In-depth interviews were conducted with 12 households (2–4 participants each) and 41 individuals in three geographical regions. Interventions HEE interventions. Main outcome measures Mortality, morbidity and intervention-related changes to the home indoor environment. Data sources The Homes Energy Efficiency Database, mortality and hospital admissions data and weather (temperature) data. Results There has been a progressive decline in cold-related deaths since the mid-1970s. Since the introduction of WFPs, the gradient of association between winter cold and mortality [2.00%, 95% confidence interval (CI) 1.74% to 2.28%] per degree Celsius fall in temperature is somewhat weaker (i.e. that the population is less vulnerable to cold) than in earlier years (2.37%, 95% CI 0.22% to 2.53%). There is also evidence that years with above-average fuel costs were associated with higher vulnerability to outdoor cold. HEE measures installed in England in 2002–10 have had a relatively modest impact in improving the indoor environment. The gains in winter temperatures (around +0.09 °C on a day with maximum outdoor temperature of 5 °C) are associated with an estimated annual reduction of ≈280 cold-related deaths in England (an eventual maximum annual impact of 4000 life-years gained), but these impacts may be appreciably smaller than those of changes in indoor air quality. Modelling studies indicate the potential importance of the medium- and longer-term impacts that HEE measures have on health, which are not observable in short-term studies. They also suggest that HEE improvements of similar annualised cost to current WFPs would achieve greater improvements in health while reducing (rather than increasing) carbon dioxide emissions. In-depth interviews suggest four distinct householder framings of HEE measures (as home improvement, home maintenance, subsidised public goods and contributions to sustainability), which do not dovetail with current ‘consumerist’ national policy and may have implications for the uptake of HEE measures. Limitations The quantification of intervention impacts in this national study is reliant on various indirect/model-based assessments. Conclusions Larger-scale changes are required to the housing stock in England if the full potential benefits for improving health and for reaching increasingly important climate change mitigation targets are to be realised. Future work Studies based on data linkage at individual dwelling level to examine health impacts. There is a need for empirical assessment of HEE interventions on indoor air quality. Funding This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research ; Vol. 6, No. 11. See the NIHR Journals Library website for further project information.

public health research

The impact of home energy efficiency interventions and winter fuel payments on winter- and cold-related mortality and morbidity in England: a natural equipment mixed-methods study