Warm & Safe Wiltshire


rcgp wccgFP

Invitation to Participate in RCGP Fuel Poverty Referral Pilot (Warm and Safe Wiltshire)

Tackling fuel poverty and health inequalities through an upstream primary care referral mechanism

Do you want to improve health outcomes at the touch of a button?

The Royal College of General Practitioners (RCGP) is inviting primary care organisations in Wiltshire CCG to pilot a simple referral mechanism to refer vulnerable patients for help with fuel poverty and cold homes. The pilot is funded by the British Gas Energy Trust Healthy Homes Fund.

Fuel poverty means living in an inadequately heated home. Cold homes can result in high fuel bills, poor health, and cause people to take longer to recover from illnesses, particularly those recently discharged from hospital. In Wiltshire, 20,523 households are in fuel poverty (Department for the Environment and Climate Change, 2015). Primary care is ideally placed to identify them.

Why take part?

  • Improve health outcomes for your at-risk patients
  • Tackle health inequalities in your practice area
  • Potentially reduce the number of GP and community care appointments and hospital admissions. (The Gentoo Boiler on Prescription 2014 Pilot in Sunderland saw GP appointments reduce by 28% and outpatient appointments by 33% for some patients.)
  • To deliver on recommendations in NICE guidance on Excess Winter Deaths (NG6, March 2015)

What is the referral?

The referral is to Warm and Safe Wiltshire (WSW), a service provided by Dorset & Wiltshire Fire and Rescue Service and Wiltshire Council to reduce fuel poverty in the county and make its residents’ homes warmer, healthier and safer places to live. WSW will contact the patient’s household and offer impartial energy advice support services covering: how to reduce their energy bills through energy efficiencies in their home; understand how to get the best energy deal and switch suppliers; sign-posting or referral to relevant services (fire prevention, income maximisation, health protection).

Who are we targeting?

Groups who are particularly vulnerable to cold include those with cardiovascular or respiratory conditions, babies and children under five years of age, elderly people, those with mobility difficulties or disabilities and pregnant women.

For the purposes of this pilot, the patient identification tool flags those who have one or more of seven conditions which can be negatively impacted by cold (Asthma, COPD, Stroke or TIA, Coronary Heart Disease, Hypertension, at risk of falls, Depression). It also flags those who are on the “Avoiding unplanned admissions” Register. This may be subject to change if it is found to generate too many or too few referrals. With your feedback, we will be seeking to identify workable parameters for healthcare professionals and patients. Patients living in care homes are excluded from the pilot as they are generally not at risk of fuel poverty.

A warmer home could make their condition(s) more manageable, reduce their risk of illness and help them to avoid hospital stays.

What is involved for the GP practice or Community Care Team?

The time commitment is minimal and participation is voluntary.

GP Practice or Community Care Team registers to participate.
Organisation receives a task to join the Fuel Poverty Group on SystmOne and, once actioned, can start referring patients. Each referral will take 60 seconds or less.
When the healthcare practitioner has an appointment with a flagged patient, the practitioner: Decides whether appropriate to recommend a referral to WSW. If yes, answers the template’s 3 tick-box questions. The final click generates the referral and a patient letter.

Support is available throughout from the pilot’s local clinical consultant, Dr Anna Collings, and from Ardens, the provider of the referral mechanism

When is this happening?

The project is running from November 2015 to 31 December 2016.

  • Recruitment of primary care organisations: February – June 2016
  • Primary care organisations make patient referrals: February – October 2016
  • Evaluation: September-November 2016
  • Final report and next steps announced: December 2016.Evaluation


Sheffield Hallam University will conduct an external evaluation of the pilot to identify if the referral mechanism is effective for primary care (flags appropriate patients, is easy and time efficient to use); for patients (helps make them warmer, healthier and safer in their homes); and for the local authority (helps put them in contact with residents who can benefit from their services). As with the design of the referral process, our aim is to make the time commitment minimal:

  • Referred patients will receive a letter from WSW inviting them to contact a named person at the University if they are willing to be interviewed on their experience.
  • Participating primary care organisations will receive a short electronic survey to complete. Some may be invited to participate in a short telephone interview at a time convenient to them.
  • Interviews with the delivery partners and stakeholder organisations.
  • Analysis of the anonymised data captured from the SystmOne template and WSW patient journeys.

In order to evaluate the outcomes of the initiative, the following anonymous data will be extracted automatically from your system: number of patients flagged; number of referrals made/declined; long term condition(s) and age. Further information is available on the registration webpage, link below.

For further information about the data collection, please click here

Clinical leadership and local support

It is important that this pilot be led from the GP perspective. Dr Tim Ballard, Vice Chair of External Affairs at the RCGP, and a GP at the Old School House Surgery in Wiltshire, initiated the pilot, which is led jointly by:

  • Dr Anna Collings, GP Vice Chair of North East Wiltshire CCG and GP Partner at Pewsey Surgery.
  • Dr Nina Amedzro, Freelance GP in Leeds, with an interest in addressing local health inequalities.

Wiltshire CCG is supportive of this pilot and is a member of the pilot’s steering committee.

How do I sign up and help my patients?

To sign up, please complete the registration form at the top of this page or contact Vanesa Blasco Bergelino at the RCGP ([email protected], 0203-188-7601, Monday-Friday office hours).

The referral mechanism is free for use by all Wiltshire primary care organisations using SystmOne.


If a patient is identified to be at risk of fuel poverty, they will have an alert under their name.:

  • Click the ‘ !! ‘ alert icon to open the template
  • Confirm with the patient that they are at risk of fuel poverty
  • Gain the patient’s consent for the referral
  • Print and give the patient the leaflet
  • Click ‘Ok’ on the template to complete process
  • The referral is automatically sent to Warm & Safe Wiltshire who will contact the patient for an assessment

If a patient is suitable for referring but doesn’t have the ‘!!’ icon under their name, you can still refer them by opening the template by clicking on autoconsultations > Warm and Safe Wiltshire.

Watch video demonstration (2:33)


Further help and support, please contact Ardens.


Sheffield Hallam University is conducting an external evaluation of the pilot and the results will be posted here in due course.