sciencesearch.defra.gov.uksciencesearch.defra.gov.uk/Document.aspx?Document=...February 2013 | Frontier Economics Irbaris Ecofys i . Economics of Climate Resilience: Health and Well-Being

Economics of Climate Resilience: Health and Well-Being Theme - AnnexesCA0401

A REPORT PREPARED FOR DEFRA AND THE DEVOLVED ADMINISTRATIONS

February 2013

© Frontier Economics Ltd, London | Irbaris LLP | Ecofys

February 2013 | Frontier Economics Irbaris Ecofys

i

Economics of Climate Resilience: Health and Well-Being Theme - Annexes Annex 1: Summary of questions 2

Annex 2: Stakeholders 3

Annex 3: UK Climate Projections 2009 6

Annex 4: Technical Detail 18

Section 1: Impacts of floods on the continuity of services provided by hospitals ................................................................................... 18

Section 2: Mental health impact of flooding ........................................ 25

Section 3: The impacts of rising temperatures on older age groups ... 34

‘What if?’ scenarios ............................................................................ 42

Annex 5: Toll Bar Case Study 45

Annex 6: Adaptive capacity 52

Annex 7: Adaptation actions 65

Flooding in hospitals ........................................................................... 65

Flooding in communities ..................................................................... 73

Heatwaves in communities ................................................................. 89

Annex 8: References 101

Contents

2 Frontier Economics | February 2013 Irbaris Ecofys

Annex 1: Summary of questions

Given current policy and the current and expected adaptation, what is the case for further intervention in relation to:

• The continuity of services in NHS hospitals at risk of flooding, with illustration of Gloucestershire Royal Hospital, Worthing Hospital and Aintree University Hospital, as case studies;

• The mental health and well-being of individuals affected by floods, with illustration using the case studies of Hull and Gloucestershire and with additional commentary on Toll Bar;

• Community resilience to future weather events, focusing on flooding, with illustration of Toll Bar and Great Yarmouth as case studies; and,

• The health impacts of heatwaves and rising mean summer temperatures on older populations (those over 65), with illustration using case studies in Eastbourne and Islington.


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Annex 2: Stakeholders

GENERAL

1. Paul Cobbing National Flood Forum

2. Richard Cox and Nejla Sabberton

Cabinet Office

3. Matt Cullen Association of British Insurers

4. Kate Damiral National Council for Voluntary Organisations

5. John Henderson Department of Health

6. Professor Anne Johnson University College London

7. Katherine Knox Joseph Rowntree Foundation

8. Professor Virginia Murray Health Protection Agency

9. Catriona Carmichael Health Protection Agency

10. Carla Stanke Health Protection Agency

11. Dr Louise Newport Department of Health

12. Katy Slater, Sahra Caffarate and Jo Wybrow

Environment Agency

HOSPITALS

13. Chris Holme Department of Health

14. David Pencheon NHS Sustainable Development Unit

15. Carl Petrokofsky Department of Health

16. Phil Storr

17. Dr Sally Pearson

18. PhilDowney

Department of Health

Gloucestershire Hospitals NHS Foundation Trust

Aintree University Hospital NHS Foundation Trust

COMMUNITIES

HULL

19. Martin Budd Hull City Council

20. Hugh Deeming and Rebecca Whittle

Lancaster University

Contents


21. Mike Gent West Yorkshire Health Protection Unit

22. Steve Wragg Hull City Council

GLOUCESTER

23. Mark Evans South West Health Protection Unit

24. Hester Hunt Gloucestershire County Council

25. Georgina Smith and Tony Jackson

Gloucestershire NHS

26. Peter Wiggins Gloucester County Council

TOLL BAR

27. Lucy Easthope University of Bath

28. Rosalind McDonough Doncaster Council

GREAT YARMOUTH

29. Jan Davis Great Yarmouth Council

HEATWAVES

30. Juliette Daniels Climate UK

31. John Kolm-Murray

David Wolfe

London Borough of Islington

NHS Sussex (East)

DAs

32. Nicola Britton Welsh Government

33. Nigel McMahon Northern Ireland Government

34. Neil Riley NHS Wales

35. Julian Holbrook SNIFFER, Scotland

36. Mark Johnstone Scottish Government

37. Fergus Millian Scottish Government

38. Colin Ramsey Scottish Government

39. Ruth Wolstenhome Scottish Government

40. Alistair Montgomery Scottish Government


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41. Michael Healy Scottish Government

42. Ian Nicol Scottish Government

43. Fiona Quinn Scottish Government

Contents


Annex 3: UK Climate Projections 2009

UKCP09 projections1

The UK Climate Projections (UKCP09) provides projections of climate change for the UK. These projections cover changes in a number of atmospheric variables, using different temporal and spatial averaging. They are given for several future time periods under three future emission scenarios. Climate change over land includes more variables, at a higher resolution, than those over sea.

Projections of the climate variables in UKCP09 methodology are made using multiple climate models. The output of the climate models is used to estimate probabilities, rather than giving single values of possible changes. Probabilities are introduced to treat uncertainties associated with climate projections.

This annex begins with an explanation on the background on uncertainties associated with climate projections. It is followed by a paragraph that explains the UKCP09 methodology and how uncertainties are accounted for. The next paragraph explains how to interpret probabilities in UKCP09 output and the annex ends with a discussion on the limitations of UKCP09.

Background on uncertainties in climate projections

There are three major sources of uncertainties in estimating future climate change:

• Natural Climate Variability;

• Incomplete understanding of Earth System process and the inability to model the climate perfectly; and,

• Uncertainty in future greenhouse gas emissions

The major sources are discussed individually below.

Natural Climate Variability

Natural variability has two principle causes. One arises from natural internal variability which is caused by the chaotic nature of the climate system. Ranging from individual storms, which affect weather, to large scale variability due to interactions between the ocean and the atmosphere (such as El Nino). Climate can also vary due to natural external factors. The main causes are changes in solar radiation and in the amount of aerosols released (small particles) from volcanoes.

1 This annex is largely based on Murphy et al., 2009 and UKCP09, © UK Climate Projections, 2009.


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Representation of Earth’s System in Climate Models

The second main source of uncertainty arises due to modelling of the future climate. The only way we can calculate how the climate will change due to human activity is through the use of mathematical models of the earth’s climate system. These models are known as Global Climate Models (GCMs). They describe the behaviour of different climate components and interactions between them. The components include the atmosphere, the oceans, the land and the cryosphere. Each interact to produce many types of feedbacks, both positive and negative. The net effect will determine how climate evolves in response to changes in greenhouse gasses.

Uncertainty in models is caused by an incomplete knowledge of the climate system and the inability to model it perfectly. Representations of physical processes within the climate system are based on a mixture of theory, observations and representation. Representations may be limited by physical knowledge, as well as by computing power, and lead to errors, which inevitably cause uncertainty. All modelling groups seek to represent climate processes in the best possible way in their models. This is based on subjective judgement, which causes different strengths of feedbacks in different models. This means that different models give different results, although they all use plausible representations of climate processes.

Future Greenhouse Gas Emissions and SRES

The final source of uncertainty arises due to future emission scenarios of greenhouse gases and aerosols. This will depend on many socio-economic factors such as changes in population, GDP, energy use and energy mix. The Intergovernmental Panel on Climate Change (IPCC) published a Special Report on Emission Scenarios (SRES) (Nakicenovic and Swart, 2000), in which climate-relevant emissions were calculated based on a number of storylines. Each of these storylines describes a possible way of how the world might develop. Differences between them arise due to the different assumptions about future socio-economic changes. They assume no political action to reduce emissions in order to mitigate climate change.

UKCP09 methodology

In UKCP09, uncertainties mentioned above are accounted for when doing climate projections. Uncertainties are treated by generating projections of change as estimated probabilities of different outcomes. This means that probabilities are attached to different climate change outcomes, which provides information on the estimated relative likelihood of different future results.


To do this, UKCP09 assumes that uncertainties manifest themselves in different climate projections from different climate models. Probability distributions of the future climate can then be generated by using projections from a large number of models or variants from a single model.

UKCP09 use a combination of projections from the following models:

• A very large number of variants of the Meteorological Office Hadley Centre model; and

• 12 international models used in inter-comparison studies of the fourth IPCC report.

Probabilities are based on a large number (ensembles) of climate model simulations, but adjusted according to how well different simulations fit historical climate observations. This is done in order to make them relevant to the real world. By presenting probabilities based on ensembles of climate models, UKCP09 takes into account both modelling uncertainty and uncertainty due to natural variability.

It does not however include uncertainty due to future emissions. Currently there is no accepted method of assigning relative likelihoods to alternative future emissions. UKCP09 therefore presents probabilistic projections of future climate change for 3 future emission scenarios. They are selected from three scenarios developed in SRES and referred to as Low, Medium and High emissions, which corresponds to A1FI, A1B and B1 scenarios in SRES. Figure 1 indicates these scenarios in terms of CO2 emissions with solid lines (black: High Emissions, purple: Medium Emissions, green: Low Emissions). Each scenario also includes emissions of other greenhouse gases. Although the three UKCIP emission scenarios span the range of marker scenarios in SRES, there are additional scenarios, both higher and lower, that they do not encompass.


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Figure 1. Global annual CO2 emissions under the three IPCC SRES scenarios

Source: Murphy et al., 2009 Note: The dotted lines are two SRES emission scenarios used in previous UK Climate Projections, but not in UKCP09.

Probability in UKCP09

Probabilistic projections assign a probability to different possible climate change outcomes. Probability given in UKCP09 output is seen as the relative degree to which each possible climate outcome is supported by the evidence available. It takes into account the current understanding of climate science and observations.

Probability in UKCP09 does not indicate the absolute value of climate changing by some exact value. Instead it states the probability of climate change being less than or greater than a certain value using the Cumulative Distribution Function (CDF). This is defined as probability of climate change being less than a given amount. An example is given in Figure 2. The CDF (for the 2050s mean summer temperatures in the London area, with a medium emission scenario) shows that there is a 10% probability of temperature change being less than 1 degree and 90% probability of temperature change being less than 5 degrees. These statements also work inversely, where one could say there is a 10% probability of temperature change being greater than 5 degrees and a 90% probability of temperature change exceeding 1 degree.


Figure 2. Example of cumulative distribution function for 2050s mean summer temperatures in the London area for the medium emission scenario

Source: UKCP09

The figure above does not say that the temperature rise will be less than 5 degrees in 90% of the future climates, because there will only be one climate. It rather indicates that there is 90% probability (based on data and chosen methodology) that the temperature rise will be less than 5 degrees.

Limitations

The procedure used in UKCP09 to convert ensembles of climate models into probabilistic estimates of future climate also includes some subjective choices and assumptions. This means that the probabilities themselves are uncertain, because they are dependent on the information used and how the methodology is formulated. Furthermore, the system cannot be verified on a large sample of past cases. Current models are, however, capable of simulating many aspects of global and regional climate with considerable skill. They do capture all major physical and biochemical systems that are known to influence our climate.

Mean summer temperature

Climate projections indicate an increase in summer temperature. By the 2050s, for the central estimate (p50) of the UKCP09 medium emissions scenario, the southern part of England could see temperature rises of between 2.3 ºC and 2.7 ºC (Murphy et al., 2009). However, temperature increases will vary regionally. Parts of northern Scotland could experience temperature increases of around 1.5 ºC for the p50 medium emissions scenario. UK-wide, the projections for increases in mean summer temperatures range from 0.9 ºC under the p10 low emissions scenario, to 5.2 ºC under the p90 high emissions scenario.

The projected changes in mean summer temperature in the UK for the p10 low emission scenario (left), p50 medium emission scenario (middle) and p90 high emission scenario (right) are shown in Figure 3.


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Figure 3. Projected changes in mean summer temperature

Source: UKCP09

Mean winter precipitation

In the p50 medium emissions scenario, mean winter precipitation is projected to increase by 9 - 17% (depending on location) in the 2050s, relative to the 1961-1990 baseline. The spread in projections is wide however, ranging from -2% for the lower bound of the UKCP09 low emissions scenario in Scotland East to +41% for the upper bound high emissions scenario in South West England (Murphy et al., 2009).

Changes in winter precipitation for the p10 low emission scenario (left), p50 medium emission scenario (middle) and p90 high emission scenario (right) are presented in Figure 4.


Figure 4. Projected changes in mean winter precipitation by the 2050s (emissions scenario from left to right: low p10; medium p50; high p90)

Source: UKCP09

Sea level rise

According to the central estimates of relative sea level changes with respect to 1990s, sea level will rise between 18 and 26 cm between the low and high scenario in London and between 11 and 18cm in Edinburgh (Lowe et al., 2009).

As the earth’s crust is moving upward in the northern parts of the UK, relative sea level rise will differ over the regions. The north will be less affected by sea level rise compared to the south (Lowe et al., 2009).

Figure 5 combines the absolute sea level change estimates averaged around the UK for the medium emissions scenario and vertical land movement. Values are shown for 2095 (Lowe et al., 2009).


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Figure 5. Relative sea level rise (cm) around the UK for the 21st century

Source: Lowe et al., 2009 Note: This combines the absolute sea level change estimates averaged around the UK for the medium emissions scenario and vertical land movement. Values are shown for 2095 Table 1 displays the sea level rise forecast by the UKCP09 models by 2050, for the central estimates of the emissions scenarios. These estimates are equivalent to a sea level rise of roughly 1.8-4.3 mm per year.

Table 1. Central estimates of relative sea level changes (in cm) by 2050 compared to 1990 levels

Low Medium High

London 18.4 21.8 25.8

Edinburgh 10.5 13.9 18.0

Source: Lowe et al., 2009

Extreme weather events

As the climate warms, weather patterns and the frequency of extreme events may also change (Solomon et al., 2007). Heavy rain days (>25 mm) will likely to be more frequent over most of the lowland UK, central estimates show an increase by a factor of 2 – 3.5 in winter and 1 – 2 in summer by the 2080s under the medium emissions scenario (UKCP09).

The frequency and intensity of heatwaves could increase in future, especially in southern parts of England. The results of the ARCADIA project suggest that by the 2050s, one third of London’s summer may exceed the Met Office heatwave


temperature threshold (32 °C). (CCRA: Capon and Oakley, 2012; Hall et al., 2009).


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Figures & tables referred to in report

Figure 6: Projected number of people at significant risk of flooding (equating to an annual probability of 1.3% or 1 in 75 years on average)

Source: Ramsbottom et al., 2012


Figure 7: Projected number of vulnerable people at significant risk of flooding (equating to an annual probability of 1.3% or 1 in 75 years on average)

Source: Ramsbottom et al., 2012


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Table 2: Additional premature deaths (heat) for the medium emissions scenario, per administrative region

Source: Hames and Vardoulakis, 2012


Annex 4: Technical Detail

Section 1: Impacts of floods on the continuity of services provided by hospitals

Introduction

This annex describes the approach and assumptions which underpin the assessment of: (i) the estimated cost of flooding on hospitals in the UK; (ii) the potential scale of mental health effects of flooding and (iii) the estimated impacts of heatwaves and hotter summers on the over 65 year population.

For the purposes of analysis, these effects have been explored in illustrative case study areas. The choice of case study areas for the flooding effects (hospitals and mental health) was based on the fact that the effects of floods have been experienced in the past; in the case of heat, the areas are projected to experience higher maximum summer temperatures in the future. Case studies explored are:

Aintree University Hospital; Gloucestershire Royal Hospital and Worthing University Hospital.

Mental health effects of flooding: Gloucestershire and Hull

Heat impacts on the over 65 year age group: Islington (selected as it is a dense urban area) and Eastbourne (selected as it has a relatively high population of over 65 year olds)

In relation to community resilience, other case studies have also been explored more qualitatively. These are Toll Bar (near Doncaster) and Great Yarmouth.

Estimating the impacts of flooding on hospitals in the UK

The UK Climate Change Risk Assessment, CCRA, (Ramsbottom et al., 2012) explored the degree to which hospitals are at risk of flooding across the UK. Increased winter precipitation and sea level rise both contribute to an increased risk of flood events in the future. More frequent heavy rain days increase the risk of flooding, as soil saturation and filling of stream and river channels would be more common (CCRA: Ramsbottom et al., 2012).

Climate projections indicate that the number of hospitals in England & Wales at significant likelihood of river and tidal flooding is projected to be in the range of 50 to 70 by the 2020s rising to about 60 to 90 by the 2050s.2 Approximately 22%

2 “The data are based upon regional growth curves which are used to uplift the present day flood probabilities, which in turn are based on modelled baseline flood probabilities. The number of hospitals is based on the NRD property data, using MCM code 660. Hospital (…) numbers are based on a count of the number of points in grid cells where the annual flood probability



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of these hospitals are located in Wales; the remaining 78% in England (CCRA: Ramsbottom et al., 2012). Although there are fewer NHS buildings in Scotland their likelihood of flooding is not included within the assessment.

The CCRA results suggest the number of hospitals at significant likelihood of flooding equates to a total of 3,500-6,400 hospital beds in the 2020s and 3,650-7,750 hospital beds in the 2050s, from a baseline of almost 3,500 hospital beds. (CCRA: Ramsbottom et al., 2012)

The damage of hospital flooding is estimated to be £56M in the 2020s, climbing to £83 - 167M annually in the 2050s, assuming the medium climate change scenario.3 (CCRA: Ramsbottom et al., 2012)

This metric does not cover health centres, GPs practices or flooding of access to hospitals. It therefore only provides an indication of flood risk to health services and community facilities.

Analysis presented in the following sections builds on the CCRA (Ramsbottom, 2012; and, Hames and Vardoulakis, 2012) and explores the potential cost associated with interrupted NHS hospital services and the extent to which these costs may be lowered through adaptation action.

It is important to note that this analysis is illustrative and intended to provide a sense of scale of potential effect under different assumptions. A detailed assessment of the actual costs of any flood impact would require far more evidence and data than has been possible within the short duration of this study. For example, it is fully recognised that any flood is likely to impact on the infrastructure of the hospital estate, or to impose wider costs on staff welfare for example. More detailed work would be needed to accurately assess these. In addition, the impacts on each site in the event of a flood would be expected to differ significantly across hospitals.

Costs reflected in this analysis focus on:

The costs to the surrounding hospitals from providing healthcare services to patients displaced from the flooded hospital following a partial, or full, temporary closure.

The costs to the patient from having healthcare services disrupted (for example, having to wait longer following cancellation of an outpatient appointment).

exceeds 0.0133 (1:75 year)” – Quoted from the CCRA for the Floods and Coastal Erosion Sector: (Ramsbottom et al., 2012).

3 The disruption costs associated with hospital closure following a flood event, were derived from the Thames Estuary 2100 study. The costs are estimated to be £695M for a two month flood event per hospital. This number was multiplied by the number of hospitals at risk, times the probability of a flood event occurring in a given year (1:75 year was assumed). (CCRA: Ramsbottom et al., 2012)



Assumptions

In order to obtain indicative costs for the impacts of a flood event there are various assumptions around the length and severity of the impact, along with the types of facilities and healthcare services affected by a flood.

The key assumptions underlying the analysis are:

• A flood affects each of the three case study hospitals (Gloucestershire Royal Hospital, Worthing Hospital and Aintree University Hospital). Costs are estimated commensurate with the respective levels of activity for each hospital. Although a wide range of responses from the hospital are possible regarding the likely extent of impact, three illustrative scenarios have been explored in this analysis to indicate potential impact absent particular adaptation actions that would otherwise ensure continuity of services (for example, in practice some hospitals may be able to set up temporary sites to provide A&E services to minimise disruption). To provide a sense of potential scale of effect, the three scenarios are:

Scenario 1: temporary closure of the A&E department for 10-60 days. Costs here are those that proxy for the increase in costs for the hospitals which now treat additional A&E patients4;

Scenario 2: temporary closure of a hospital’s A&E department and the temporary cancellation of all outpatient appointments for the duration of the flood (10-60 days). Costs here are proxy for those relating to the increase in costs for the hospitals which treat additional A&E patients, plus the cost to the outpatients from having their treatment delayed for the duration of the flood;

Scenario 3: temporary suspension of all major hospital services for 10-60 days. A&E patients and inpatients are displaced to neighbouring hospitals and all outpatient and elective procedures are cancelled for the duration of the flood. Costs here proxy for those facing neighbouring hospitals from having to treat the additional A&E and inpatients, plus the costs to patients from delays to outpatient treatment and elective procedures.

It is assumed that surrounding hospitals have the capacity to absorb additional patients in the event of a hospital in the region being flooded. In practice, it is possible that several hospitals could be flooded simultaneously or that they have limited capacity available. Surrounding hospitals would be expected to change

4 This assumes, for simplicity that reference costs are the same across hospitals for a given activity – this is a simplifying assumption as such costs may differ across hospitals in the country.



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activity as they may have to postpone elective procedures in order to make way for additional A&E patients, for example.

Where patient healthcare services are postponed, the delay is assumed equivalent to the duration of the flood. For example, a flood lasting 10 days would delay the delivery of the healthcare service in question by 10 days. It is recognised that in practice, delays are likely to differ from this.

Activity and costs are as listed in Hospital Episode Statistics reference data at the Trust level, with activity scaled to the hospital level. All activities with unit cost less than £10 are excluded from the assessment as this is assumed not to be a healthcare treatment.

Where elective procedures and outpatient appointments are delayed, the cost to the patient is assumed to be equivalent to their willingness to pay to avoid the delay. This is estimated using a figure of £4.30 per patient day, as derived from Department of Health 2002/03 analysis suggesting each patient is willing to pay £3.13 to avoid waiting for NHS treatment (estimates used are calculated by uprating a figure for 2002/03 from Centre for Health Economics (2005) by GDP/capita).

To estimate activity for individual hospitals, rather than Trusts, for the purpose of the analysis activity for the relevant Trust (the level at which HES data is available) has been scaled to the hospital by assuming patients treated in each A&E are proportional to the number of A&E departments in the Trust (for example, where there are 2 A&E Departments in the Trust, each is assumed to treat half). In addition, inpatients and outpatients per hospital are assumed to be equivalent to the proportion of beds a hospital has in relation to its Trust. This suggests:

Gloucestershire Royal Hospital: 50% of the Trust’s A&E patients are treated in Gloucester Royal Hospital, and 58% of the Trust’s inpatients and outpatients.

Aintree University Hospital: 100% of the Trust’s A&E patients are treated in Aintree University Hospital as well as 100% of the Trust’s inpatients and outpatients.

Worthing Hospital: 33% of the Trust’s A&E patients are treated in Aintree University Hospital as well as 51% of the Trust’s inpatients and outpatients.

Costs accounted for in the analysis

Unit costs of treatments accounted for in the assessment are allocated to departments as follows:

A&E Accident and Emergency



Paramedic Services Inpatient Inpatient/Day Case/ Regular Day (APC) Elective Inpatients Non-Elective Inpatient - Long Stay Non-Elective Inpatient - Short Stay Elective Inpatients - Excess Bed days Non-Elective Inpatient - Long Stay - Excess bed days Non-Elective Inpatient - Short Stay - Excess bed days Outpatient Outpatient Outpatient Procedures Audiological Services Chemotherapy Consultant Led Day Case Regular Attenders Diagnostic Imaging Mental Health Non Consultant Led Radiotheraphy ‘Complex specialised’ rehabilitation services (CSRS) (Level 1) ‘Non-specialist’ Rehabilitation Services (NSRS) ‘Specialist Rehabilitation Services’ (SRS) (Level 2) Renal Daycase Day Care Facilities Regular Attendances Elective procedures Elective Inpatients Elective Inpatients - Excess Bed days Not included Community Services High Cost Drugs Other Specialist Palliative Care Direct Access Hospital Travel Scheme Patient Transport Services Specialist Services



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The following two categories of costs are estimated using the assumptions outlined above:

1. Costs to patients

Calculates the costs to those whose treatment is delayed by using a ‘willingness to pay’ per day to avoid delays and applying it to the number of people affected and the assumed duration of delay.

Willingness to pay to avoid wait for treatment x Duration x Admissions per day

2. Wider NHS costs

The costs to neighbouring hospitals from treating patients that they would not have otherwise treated in the absence of the flood owing to the need to divert patients from the flooded hospitals, is calculated by:

Average A&E patients per day x Duration x Average cost of treatment

The estimated cost of hospital flooding

The activity rates and costs of providing healthcare services in each of the three case study hospitals are shown in the table below.

Figure 8. Activity levels and costs per case study hospitals

Source: Based on Hospital Episode Statistics and associated Reference Cost data provided by the Department of Health

This illustrates the scale of healthcare service activity at risk and the costs of providing those services on a daily basis.

Figure 9 shows the estimated costs.

LocationCurrent daily A&E attendances and

(costs)

Current daily inpatient

attendances and (costs)

Current daily outpatient

attendances and (costs)

Current daily elective

procedures and (costs)

Aintree University Hospital 240 (£35,000) 295 (£295,000) 1,695 (£200,000) 30 (£60,000)

Gloucestershire Royal Hospital 145 (£15,000) 230 (£250,000) 1,645 (£225,000) 35 (£70,000)

Worthing Hospital 110 (£10,000) 190 (£215,000) 990 (£145,000) 20 (£40,000)

* attendance figures are rounded to the nearest five** costs are rounded to the nearest five thousand

Daily attendance rates* and costs** by department



Figure 9. Estimated costs of interruptions to the supply of healthcare services using three illustrative scenarios

Source: Based on Hospital Episode Statistic and Reference Cost data provided by the Department of Health

This analysis can be used to illustrate the relative benefits of adaptation. There are a number of illustrations that these results allow. For example:

• What if adaptation action is taken which reduces the duration of interruption of the flood from 60 days to 10 days?

• What if adaptation action is taken which means that instead of A&E, inpatient, outpatient and elective procedures being affected (as in scenario 3), inpatient care and elective procedures can continue to be provided?

• What if adaptation action is taken which means that instead of A&E, inpatient, outpatient and elective procedures being affected, only A&E needs to be displaced and all other healthcare services can continue to be provided?

In each of these “what if?” scenarios, the relative benefits of adaptation actions (not accounting for the investment costs of taking those actions as full cost benefit analysis is beyond the scope of this report) are estimated to be:

10 days 60 days 10 days 60 days 10 days 60 daysAintree University

Hospital 2,400 (£0.3m)14,300 (£2.0m)

19,300 (£0.4m)

116,000 (£2.5m)

22,600 (£3.4m)

135,600 (£20.2m)

Gloucestershire Royal Hospital 1,500 (£0.2m) 8,800 (£0.9m) 17,900

(£0.2m)107,400 (£1.4m)

20,600 (£2.8m)

123,200 (£16.5)

Worthing Hospital 1,100 (£0.1m) 6,500 (£0.6m)11,000 (£0.1m)

65,900 (£0.9m)

13,100 (£2.3m)

78,300 (£13.9m)

* attendance figures are rounded to the nearest hundred** costs are rounded to the nearest hundred thousand

Location

Potential scale of the threat by impact on patients* and costs of treatment (£m)**

Scenario 1: Temporary closure of A&E for 10-60

days

Scenario 2: Temporary closure of A&E and postponement of

outpatient appointments for 10-60 days

Scenario 3: Temporary closure of A&E and postponement of all

inpatient and outpatient procedures for 10-60 days



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Figure 10. Illustrative 'what if? scenarios: relative estimated monetised benefits of adaptation action (£m)

Source: Based on Hospital Episode Statistics and Reference Cost

These illustrative scenarios indicate the magnitude of potential benefit of adaptation actions if they are able to deliver a particular reduction in duration of interruption to services or ensure particular services continue to be provided. It should be noted that there is very little, if any, evaluation evidence relating to the effectiveness of adaptation actions therefore the scenarios are indicative. They do not assess the effectiveness of particular actions but rather assess the costs avoided if actions are to deliver particular outcomes. These estimates are therefore illustrative only. Further research would be required to evaluate the effectiveness of adaptation actions.

Section 2: Mental health impact of flooding Climate change is projected to increase the risk of tidal as well as river flooding in the United Kingdom. Within the CCRA, a baseline figure of 877,000 was presented for the number of people at a significant likelihood of flooding in England and Wales (equating to a return period of 1 in 75 years on average). The baseline figure is based on 2008 for tidal flooding and on 1961-1990 for river flooding. (CCRA: Ramsbottom et al., 2012)

The number of people at significant likelihood of flooding in England and Wales is projected to range from about 1.1 million to 2 million in the 2020s, rising to 1.3 million to 2.4 million by the 2050s for the range of climate change emissions scenarios illustrated (CCRA: Ramsbottom et al., 2012). Population growth is not taken into account.

Additionally, an approximate estimate in the CCRA (Ramsbottom et al., 2012) indicates that the total number of vulnerable people5 at significant likelihood of

5 It is assumed that Deprivation decile 1 corresponds to ‘vulnerable people’. This is considered a rough approximation because many vulnerable people live in less deprived areas.

Scenario 1 Scenario 2 Scenario 3 10 days 60 days 10 days 60 daysAintree University

Hospital 1.7 2.0 16.9 3.0 17.8 0.07 0.4

Gloucestershire Royal Hospital 0.8 1.1 13.8 2.5 15.2 0.07 0.4

Worthing University Hospital 0.5 0.7 11.6 2.2 13.0 0.0 0.3

What if adaptation allows the duration of interruption of services to be

reduced form 60 days to 10 days (£m)?

Relative to scenario 3, what if adaptation action now allows the continuity of

inpatient treatment and the provision of elective procedures (£m)?

What if adaptation actions allow outpatients to be treated in mobile units

(£m)?



flooding from river and tidal flooding is about 120,000. This is projected to increase to about 200,000-500,000 by the 2080s, assuming no change in overall population. (CCRA: Ramsbottom et al., 2012)

The impact due to flooding on mental health in the CCRA is estimated based on results from Reacher et al., (2004) and Tunstall et al., (2006) showing that about 36% (a range of 30-40% is considered in the CCRA) of those flooded are likely to suffer psychological distress.6

The effects of floods are assumed to be proportional to the number of people at risk due to fluvial or tidal flooding. For England and Wales, this on average amounts to 6,600-8,900 people annually in the 2020s and 8,300-11,100 in the 2050s (p50, medium scenario), from a baseline of 3,500-4,600. (Hames and Vardoulakis, 2012)

No attempt has been made in the CCRA to break these figures down regionally. The costs of additional mental health risks associated with climate change-induced flooding are projected to be £3 million – 5 million annually in the 2020s, and £5 million – 7 million annually in the 2050s (both for the p50 scenario; Hames and Vardoulakis, 2012).7

The costs related to loss of productivity (indirect costs) represent roughly 60% of the total economic impact, while an estimated 40% is related to treatment costs (Hames and Vardoulakis, 2012).

To estimate the potential scale of cost associated with mental health impacts of flooding, the case study areas of Hull and Gloucestershire were explored. There are many ways in which the costs of mental health impacts could be estimated with results highly dependent on the assumptions made. Given the significant uncertainties, this analysis must be considered illustrative only.

The mental health effects of flooding are estimated using a methodology which does not depend on a particular UKCP09 emissions scenario. Rather, the estimates are derived based on the impacts of the 2007 floods (considered to be extreme).

Assumptions

The calculations used to estimate the potential costs associated with the mental health effects of flooding are subject to a range of important assumptions:

1. The impacts are characterised in terms of adverse effects on mental health alone. Such impacts were identified as among the more important impacts

6 People who go from a GHQ-12 score of below 4 to 4 or above (as a result of a flood event) are considered likely to suffer psychological distress.

7 These costs were estimated by multiplying the projected people likely to suffer from psychological distress with a value found for the mean costs of treatment per case.



27

to health from flooding in the 2012 UK Climate Change Risk Assessment for the Health Sector.

2. Although steps may be needed to improve responses to small scale floods, the relatively small impacts on public health associated with such small flood events can usually be dealt with adequately within existing health and healthcare infrastructure. The implications of more severe floods (i.e. those with longer return periods) may require adaptation action to ensure resilience in the provision of healthcare services.

Methodology

Estimating the overall burden of mental health impacts associated with flooding is problematic because of the paucity of high-quality epidemiological evidence and because of the need to translate survey measures of mental health into clinical cases with defined treatment needs and time course.

The following calculations are used to provide order-of-magnitude estimates of the mental health impacts. The calculations estimate the attributable prevalence of Common Mental Disorder (CMD) using data on flood-related relative risks from published surveys applied to survey data that has approximate equivalence to common mental disorder. These calculations thus indicate the potential size of the populations affected by severe flood events and the associated mental health burdens which are translated to indicative costs, as summarised in Table 3, on the basis of:

monetised equivalent cost to the individual;

treatment cost to the National Health Service; and,

estimated costs in terms of lost productivity through additional sickness absence of the working age population.

Elements of the calculation

Prevalence of common mental disorder

The estimate of the underlying (non-flood-affected) prevalence of common mental disorder is based on evidence from the Health Survey for England which reports the fraction of the adult population with a General Health Questionnaire-12 (GHQ-12) score greater than or equal to 4. This is assumed to have approximate clinical equivalence to CMD - common anxiety and depression states. The derived estimate of 13.4% is broadly in line with other published surveys, and is close to the 12% prevalence figure for GHQ-12 scores of 4+ reported for the non-flood population in the epidemiological study of the 2000 Lewes floods in southern England (Reacher et.al, 2004).

Relative risk for CMD



Relative risk (RR) estimates for CMD or other mental health outcomes are available from very few studies. We take as the most relevant results of the 2004 Reacher et al. study of the 2000 Lewes floods, which reported an age- and sex-adjusted flood-related relative risk of CMD of 4.1 (for the adult population), with 95% confidence interval 2.6 to 6.4. The attributable burden of flood related CMD was calculated by application of this relative risk to the prevalence of common mental disorder obtained from the Health Survey for England. The relative risk for GHQ-12 scores of 4+ is assumed to be appropriate for the relative change in clinical mental health disorders after flooding.

A second relevant source of evidence is a study by Paranjothy et al (2011), which used mixed survey methods and validated measurement tools to ascertain the prevalence of psychological distress, anxiety, depression and probable post-traumatic stress disorder (PTSD) in two areas affected by the 2007 summer floods in England. Although providing survey evidence for the 2007 floods, the results are more complex to interpret than for the Reacher et al (2004) study because of low response rates, large between area variations, and multiple overlapping measures of outcome. However, the principal findings are broadly in line with those of the Reacher et al (2004) study, with reported 2 to 5-fold higher prevalence of adverse mental health symptoms among flood affected households. For clarity and simplicity we therefore base calculations on the relative risk estimate for CMD derived from the Reacher et al study, but use the Paranjothy et al (2011) study for evidence of potential risk modification i.e. by accounting for varying severity of mental health effect when considering the impact on the individual’s quality of life.

Flood population and Frequency

The population at risk of flooding was calculated for Kingston upon Hull by taking the number of persons flooded in Kingston upon Hull from the Environment Agency (EA) flood database (EA 2010a). For Gloucestershire, the flood population was calculated by multiplying the residential properties that were flooded in 2007 (BBC, 2007; Floodprobe 2011) by the average household size taken from the General Lifestyle Survey (2009) of 2.35.

The number of flood attributable cases of CMD

The number of flood-attributable cases of CMD was calculated as follows:

(RR – 1)*prevalenceCMD*(adult flood population)

Note that psychological disorder in children is excluded from this calculation because of the absence of evidence available.



29

Duration of illness

The time course of flood-associated impact on mental health is not clearly known. The Reacher et al (2004) study undertook a survey some nine months after the initial flooding (the flooding of Lewes occurred on 12 October 2000, survey interviews were conducted between 10 July and 16 August 2001). The GHQ-12 instrument was used to capture the way respondents had recently been feeling. This suggests that the increase in high GHQ-12 scores (and hence in common mental disorder) is observable at the nine-month post-flood time point. However, published epidemiological evidence does not allow an accurate characterisation of evolution and return to normal of flood associated mental health symptoms.

In the absence of more precise data, we assume the following estimates for duration of CMD attributable to the flooding:

central estimate – 0.5 years

conservative estimate – 0.25 years

high estimate – 5 years

More refined estimates could be made assuming a distribution for the duration of illness with the majority of people recovering quite quickly, but a few persistent cases assumed to be concentrated in more vulnerable people. Uncertainty over the duration and severity of illness represent major sources of imprecision in the risk estimates.

Additional person-years of illness

This is simply the product of the number of flood-attributable cases of CMD and the assumed duration of illness in years.

QALY weighting and cost

This is based on data published by the World Health Organization: Global Burden of Disease 2004 Update: Disability Weights for Disease and Conditions (WHO, 2008).

We assume a general figure of £60,000 per quality adjusted life year (QALY) as the basis of calculations of cost-effective investment, following an approach applied commonly by the National Institute for health and Clinical Excellence (Defra internal guidance and IGCB, 2010).

The QALY disability weights assumed are:

Post-Traumatic Stress Disorder - weight 0.105

Mild depressive episode - weight 0.14



Moderate depressive episode - weight 0.35

For the purposes of this analysis, clinical condition is assumed in the central case to be towards the more mild end of the clinical spectrum – mild depressive state, for example. However to reflect the potential for mental health effects to be more severe, calculations are presented based on alternative assumptions:

central estimate: disability weights reflecting mild depressive illness and post-traumatic stress disorder (in a ratio of 2:1);

high risk estimate: disability weights reflecting mild and moderate depressive disorder (in a 1:1 ratio); and,

low estimate: (the relative low) disability weights for PTSD only.

A summary of the costs of the mental health impacts per year is in Table 3 below.

Table 3 Costs of Mental Health impacts per year

£ £

Monetized equivalent cost of illness to person

Quality of life Assumed cost per QALY 60,000

Weights for respective disabilities from WHO

Cost of NHS treatment

Medication

Proportion of those with CMD receiving drug treatment in a year 0.29

Unit cost of medications (6 prescriptions) £53

Monetary value of medication per person-year £15 15

Consultation (primary care)

Proportion of those with CMD that consult GP about mental health 0.29

Unit cost of GP consultation (6.6 surgery consultations) £185

Monetary value of consultation for CMD per person-year £54 54

Counselling

Proportion of those with CMD receiving counselling in year 0.22

Unit cost of counselling (8 sessions) £568

Monetary value of counselling for CMD per person-year £126 126

Out-patient Proportion (with CMD) who have out-patient consultation in last year 0.04



31

visit Unit cost of out-patient visits (3 visits) 408

Monetary value of out-patient visits 16 16

In-patient stay

Proportion of those with CMD admitted to hospital in last year 0.01

Unit cost of in-patient visit £2,093

Monetary value of in-patient treatment for CMD per person year £26 26

TOTAL 237

Costs of income support for incapacity/sickness

Income support (benefit)

Proportion of those with CMD of working age receiving income support for CMD reasons 0.18

Costs of income support for those in receipt of it, including NI contributions etc £9000

Monetary value of income support related to CMD per person year 1620

TOTAL 1,620

Costs to GDP of lost productivity from sickness absence [working age only]

Average additional days of sickness per year for someone with CMD 8

Costs to GDP of sickness absence per person day (assume median £26,200/240 working days per year) £109

Monetary value of loss to GDO from additional absence from work per person year £873

TOTAL 873

Sources: NHS 2010-11 reference costs http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_131140 ; National Institute for Health and Clinical Excellence (2010); National Institute for Health and Clinical Excellence (2007)

Results

On the basis of these assumptions, the estimated costs of mental health effects have been estimated for each of Hull and Gloucestershire. The results are in Figure 11 below.


http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_131140


Figure 11. Estimated costs of the mental health impacts of flooding

These estimates demonstrate the significant uncertainty surrounding the potential health costs of flooding.

The upper bound estimates reflect the estimated costs assuming the relative risk of a mental health effect is 6.4 times greater than the likely incidence in the absence of the flood, combined with a 5-year duration of impact, and that the mental health disorder is a weighted average of mild and moderate depressive states.

The lower bound reflects the assumption that the relative risk is 2.6 times greater than absent the flood, that the duration of impact is just 3 months and that the individual experiences post-traumatic stress disorder.

These bounds are around the central case relative-risk assumptions (as assessed by Reacher et al, 2004) of a 4.1 times increase in relative risk resulting from the flooding8, a duration of impact of 6 months and that the individual experiences an impact on the quality of life equivalent to the weighted average of a mild depressive state or post-traumatic stress disorder.

It is clear from this analysis that the costs of mental illness to the individual far outweigh the costs to the NHS in terms of treatment, or the costs of lost productivity. This supports the importance of adaptation actions that are able to either reduce the duration of mental health impact (for example, by limiting the period of time over which individuals and families are displaced from their homes following a significant flood event) and/or reducing the severity of mental illness through the provision of targeted and timely support and treatment. In order to explore this, a series of what if scenarios have been considered, for illustration.

8 Note that this relative risk is not then linked to the severity of that flooding in different circumstances.

Total impact (£Ms) to persons

Per capita additional

cost per year (£s)*

Total cost to NHS (£Ms)



Total cost to economy

(£Ms)



Central 18.6 67.4 0.6 2.1 2.1 7.6High 617.1 2242.9 9.9 36.2 36.6 133.2Low 3.9 14.2 0.1 0.5 0.5 2.0

Central 10.6 84.6 0.3 2.6 1.2 9.6High 351.2 2813.2 5.7 45.4 20.9 167.1Low 2.2 17.9 0.1 0.7 0.3 2.5

* i.e. assuming cost per person is borne by w hole population of each district

Monetised equivalent of impact

Location

Costs to individual (QoL) NHS costs Costs from sickness (GDP)

City of Kingston

Upon Hull

Gloucester District

Range



33

Illustrative ‘what if?’ scenarios

There is little information available on the effectiveness of adaptation actions that could be taken to mitigate the adverse mental health impacts of floods. Recognising this uncertainty, the following ‘what if?’ scenarios were developed:

Scenario 1: what if adaptation actions are taken which reduce the duration of mental illness from 5 years to 6 months? This may be action taken to reduce the time that those affected by floods are displaced from their homes, for example by placing a greater weight on insurance companies to expedite drying of homes and cleaning.

Scenario 2: what if community support is able to lower the relative risk of a mental illness by over a third?

Scenario 3: what if the stress associated with the flood is lowered through the provision of, and access to, information (lowering from mild and moderate depressive states to a case of post-traumatic stress disorder)? This may for example be brought about through the provision of better and more timely information to raise awareness and identify where to get help.

These scenarios suggest that the extent to which costs could be reduced if adaptations were effective in bringing these outcomes are as shown in Figure 12.

Figure 12. Estimated extent of relative costs avoided to individuals through adaptation under 'what if?' scenarios (£m) (central relative risk and QALY assumed

These illustrative scenarios suggest:

• The relative avoided costs from lowering the duration of mental health effect can be significant. This could be equivalent to around £8,700 per person flooded in each area in terms of their quality of life effects. Savings to the NHS and the economy would be commensurate.

HullGloucestershire

* This assumes the relative risk is lowered from 4.1 times the no-flood risk, to 2.6 times.** This is assumed to lessen the severity of mental illness experienced by the individual

Scenario 3: what if the stress associated with the flood is lowered through

adaptation**

13.87.8

Location

Scenario 1: what if the duration of mental illness is reduced from 5 years to

6 months

Scenario 2: what if community support is able to lower the relative risk of a mental illness by over a

third?*

16.99.6

16795.1



• The relative costs avoided to individuals from lowering the relative risk of mental health impact following a flood could also be notable. This could be equivalent to around £700 per person flooded.

• If the degree of severity of mental health effect was lower than would otherwise be the case through adaptation action then the benefits in the case study areas of Hull and Gloucestershire could be £17m and just under £10m respectively. Per person flooded, the avoided cost to the individual given their relatively higher quality of life could be around £900 per person.

Section 3: The impacts of rising temperatures on older age groups The CCRA (Hames and Vardoulakis, 2012) noted that public health could be adversely affected by the projected changes in temperatures arising from climate change. These effects could result both from the expected increase in heatwaves and rising summer mean temperatures (particularly in the southern regions of the UK).

It is also important to note that there are some important differences between England and Scotland. For example, Hames and Vardoulakis (2012) indicated that the mortality and morbidity effects associated with heat and cold are projected to increase by less for Scotland relative to England.

To estimate the potential impacts on public health in terms of general medical problems associated with rising temperatures and heatwaves, analysis has been carried out using the illustrative case studies of Islington and Eastbourne.

Approach and key assumptions

The current relationship between outdoor temperature and mortality and, to a lesser degree, morbidity is well established by epidemiological studies. From the shape of the risk function it is therefore possible to predict with reasonable precision the expected number of heat-related excess deaths and cases of morbidity given the daily temperature. What is less clear is:

• How that risk function may be modified over time as people begin to respond and adapt to an (expected) higher frequency of warm summers and heat waves. Such ‘natural’ adaptation may entail simple behavioural responses (learning to cope with the heat better) or specific investments (such as a much wider adoption of air conditioning in homes, which has been shown to be effective in protecting against high outdoor temperatures, where households are able to afford to run them).



35

• What the shape of the risk function is i.e. whether there is an acceleration of risk as temperatures rise beyond those which households have experienced in the past.

The evidence is that populations exposed to warmer climates tend to experience an increase in mortality at a higher daily temperature threshold suggesting an element of ‘acclimatization’, though this may take time to be established. On the other hand, the risk function may be supra-linear with a steeper and steeper rise in risk at very high ambient temperatures.

Given the uncertainty around the extent to which such behavioural responses will occur, this potential has been explored using ‘what if?’ scenarios (explained later in this section).

A second major assumption is the degree to which heat death or hospital admission reflects a shortening of life. There has been much debate about the possibility that a proportion of heat deaths may be mortality displacement (days or weeks only) in very frail populations, implying a much smaller health impact than if members of the population with average life expectancy died of heat. To address this we calculated, using UK life tables, the life expectancy for each year of age above 65 years of the population assuming their underlying risk was 1x, 2x, 5x and 10x the average person (reflecting progressively more frail populations) and used the average loss of life that these imply. Our main results are presented for the 10x average risk (which has a loss of life expectancy of 1.52 years per heat death) and a more conservative assumption of just 4 months loss of life expectancy per heat death.

Methodology

Calculations are based on the potential impacts of heat for 10-day heat waves and the summer as a whole for the following locations:

Islington (a young, inner city population)

London as a whole

Eastbourne (with large retirement population)

Calculations are presented for the 10-day moving average maximum daily temperature for both the 2030s and 2050s using weather data derived from the UK Climate Projections 2009 (UK CP09) under the high emissions scenario (probabilities are described below).



Elements of the calculation

Population at risk

Population figures are based on age-group-specific estimates from the 2011 census published by the Office for National Statistics.

Projections by age group are used from ONS (2012b) projections to 2035 for Islington, Eastbourne and London. These are then carried forward to 2055 assuming the same 10-year growth rate for the subsequent two decades (2025-2035).

The year 2035 is assumed representative of the 2030s population and 2055 as representative for the 2050s.

Underlying population health data

Numbers of deaths are based on age-group-specific mortality rates for England and Wales, adjusted by regional/local Standard Mortality Ratio, and applied to the resident population as estimated above.

Hospital admission statistics are based on a similar tabulation of age-specific emergency hospital admission rates applied to local population estimates.

For both sets of figures, calculations were performed for all-causes combined only. Cause-specific data are not used because the heat-related increase in risk is broadly similar for most causes.

Relative risk for heat-related mortality and morbidity

Epidemiological evidence for temperature-mortality relationships by region (Armstrong et al, 2010), age-group and cause (Gasparrini et al, 2012) have been published recently. The region-specific thresholds and gradients for the temperature-mortality relationship were used to estimate the expected number of summer deaths per day using temperature profiles derived from weather generation results to derive all-cause relative risks (RR).

Temperature distributions

Temperature scenarios are based on the UKCP09 weather generator simulations for the 2030s and 2050s under a high emissions scenario (assumed to indicate the higher levels of potential climate change-related impact).

100 sets of 100-years series of daily maximum temperature were simulated giving 10,000 years of data in total. 10-day moving averages of the maximum daily temperature were calculated to identify the temperatures of significant heat waves (10 days in duration). Calculations were then restricted to summer months only (June, July and August) and the following calculated:



37

• Overall mean of the maximum daily temperatures for summer: 95th and 99th percentiles (equivalent to the hottest 5% (1 in 20) and hottest 1% (1 in 100 years)

• 10-day moving average of maximum daily temperature: 99.9th percentile, 99.99th percentile (approximately equivalent to the hottest 10-day period for every 10-years and every 100 years)

Attributable burdens

(i) Deaths

For each day of the heat episode or summer period, the numbers of heat-attributable deaths and hospital admissions were calculated as follows:

(RR – 1)*(all-cause mortality/morbidity rate) *(resident population)

where RR, the relative risk for the two-day moving average temperature, is calculated by applying the daily maximum temperature above the region-specific temperature threshold for heat effect to the temperature-mortality/morbidity gradient.

Note the underlying daily number of deaths in summer was based on an assumed sinusoidal fluctuation around the annual average.

Cases/deaths were summed over the whole summer period or for the 10-days of the heat wave.

(ii) Hospital admissions (a proxy for morbidity)

Risk functions for heat-related hospital admission are not available with the same precision and specificity as for mortality. Evidence from international literature and from Europe in particular, suggest a more complex, and generally weaker, pattern of heat impact on hospital admissions than for mortality (Ye et al (2012), Michelozzi et all (2009)). In the absence of clearer evidence we used data from a 2004 analysis comparing mortality and hospital admissions during heat waves in the UK (Kovats et al, 2004). From this paper we used the reported gradients for the relationship between high ambient temperatures and hospital admissions and that for high ambient temperatures and mortality, and used the ratio of these two relationships to calculate the impact on hospital admissions as a simple multiplier of the number of heat related deaths.

The ratio of the relative increase in hospital admissions compared with that of mortality was thus assumed to be 2.6/10.8 (2.6 was the point estimate for the increase in hospital admissions during the 29 July to 3 August 1995 heat wave and 10.8 the corresponding point estimate for the increase in mortality).



The increase in hospital admissions from heat was assumed to apply to emergency admissions only where the main specialty code was between 300 and 460 corresponding to the principal medical categories.

Data on the rate of hospital admissions for the 65+ age group were taken from the Hospital Episode Statistics (HES online) summary report by main specialty for 2010-11. The figures presented are for emergency hospital admissions (rather than finished consultant episodes (FCEs)) for the specialty codes listed above.

The number of hospital admissions was therefore calculated as follows:

Heat-attributable hospital admissions =

heat-attribute deaths * no. of emergency hosp admissions/ no. of deaths * 2.6/10.8.

The calculation of heat-attributable hospital admissions was done for heatwaves only because it is unclear what impact heat has on the overall number of hospital admissions across the season as a whole when there is the possibility of repeated admission and of reduced admission risk following a previous admission.

QALY weighting and cost

Monetization of the mortality impact was based on the calculation of years of life lost. There is insufficient data to be clear about the degree of life shortening in those who die from heat-related causes. We therefore used five separate figures: the average life expectancy above the age of 65 years (weighted for year of death) assuming that those who die have:

population average mortality risk

twice the population average mortality risk

five times the population average mortality risk, and

ten times the population average mortality risk.

The estimates of life expectancy by age of death for each of these categories was based on a life-table for England using 2009 data.

For a fifth category, we assumed a more moderate figure of four months loss of life expectancy for each heat-related death.

By assuming a general figure of £60,000 per quality adjusted life year (QALY) as the basis of calculations of cost-effective investment – following an approach applied commonly by the National Institute for health and Clinical Excellence – the average number of years of life lost for heat death were estimated from a current life table for the UK population. This has been uprated at 2% per annum to reflect rising income and willingness to pay in line with DH guidelines and discounted at 3.5% per annum.

Hospital admissions were assumed to be short duration of between 2 days and 5 days, and costed using average NHS in-patient costs for one day of hospital care



39

(£266 per day: from the CCRA, Hames and Vardoulakis, 2012) plus a willingness to pay of the patient to avoid such impacts of £625 per day (Hames and Vardoulakis, 2012) – this proxies for the welfare impact on the patient. This has been uprated at 2% per annum to reflect rising income and willingness to pay in line with DH guidelines and discounted at 3.5% per annum.

Results

The analysis allows an estimate to be provided under a series of alternative scenarios as shown in Figure 13.

.



41

Figure 13. Estimated impacts of heatwaves on morbidity, mortality and associated monetised costs (£m)

Mortality Morbidity Mortality Morbidity Mortality Morbidity Mortality Morbidity Mortality Morbidity Mortality Morbidity

1/10 years 9 9 8 8 10 10 0.6 0.01 0.1 0.0 1.1 0.031/100 years 11 10 10 9 12 11 0.7 0.01 0.1 0.0 1.3 0.041/10 years 24 23 21 20 26 25 1.1 0.02 0.2 0.0 2.1 0.1

1/100 years 28 27 25 24 31 30 1.3 0.03 0.3 0.0 2.5 0.11/10 years 536 482 473 425 584 525 34.2 0.6 6.6 0.5 63.9 1.6

1/100 years 652 586 574 516 712 640 41.7 0.7 8.0 0.6 77.8 2.01/10 years 1370 1231 1200 1079 1501 1350 65.0 1.1 12.5 1.0 121.9 3.1

1/100 years 1672 1503 1459 1312 1838 1652 79.3 1.4 15.2 1.2 149.3 3.81/10 years 8 6 7 5 9 7 0.5 0.01 0.1 0.01 1.0 0.02

1/100 years 10 7 8 6 11 8 0.6 0.01 0.1 0.01 1.2 0.031/10 years 15 11 12 9 17 13 0.7 0.01 0.1 0.01 1.4 0.03

1/100 years 18 14 15 12 20 16 0.9 0.01 0.2 0.01 1.7 0.04

Eastbourne2030s

2050s

2050s

London2030s

2050s

Costs* (£m discounted)

Central Lower UpperImpact of 10-day episodes (heatwaves) on mortality, 65+ years

Cases

Central Lower Upper

Islington2030s



‘What if?’ scenarios In order to explore the extent to which adaptation actions may lead to avoided effective costs associated with the potential mortality and morbidity effects, several ‘what if?’ scenarios have been explored. These are:

• What if natural acclimatisation (for example, behaviour change such as changing the time at which various activities are undertaken) is able to lower the relative impacts on mortality and morbidity by 20%?

• What if the most vulnerable individuals in the community are directly targeted for help and support to minimise the risk of adverse health effects (i.e. the adverse effects are 50% mitigated?)

The results of these scenarios are shown in the table below:



43

Figure 14. Estimated relative avoided cases and costs from adaptation action (illustrative what if scenarios)

Mortality Morbidity Mortality Morbidity Mortality Morbidity Mortality Morbidity1/10 years 2 2 0.4 0.01 5 4 0.5 0.01

1/100 years 2 2 0.4 0.01 5 5 0.6 0.011/10 years 5 5 1.3 0.02 12 12 1.6 0.03

1/100 years 6 5 1.5 0.03 14 14 1.9 0.041/10 years 107 96 21.6 0.4 268 241 31.8 0.56

1/100 years 130 117 26.2 0.5 326 293 38.7 0.681/10 years 274 246 73.2 1.3 685 616 92.7 1.62

1/100 years 334 301 89.3 1.6 836 751 113.1 1.981/10 years 2 1 0.3 0.00 4 3 0.5 0.01

1/100 years 2 1 0.4 0.01 5 4 0.6 0.011/10 years 3 2 0.8 0.01 7 6 1.0 0.01

1/100 years 4 3 1.0 0.01 9 7 1.2 0.02

Monetised effect (£m) Monetised effect (£m)

What if a package of adaptation actions to increase preparedness is able to lower the

adverse impacts on mortality and morbidity by 50%

Islington2030s

2050s

London2030s

2050s

Impact of adapting to a 10-day episodes (heatwaves) on mortality, 65+ years

Cases Cases

Eastbourne2030s

2050s

What if a package of adaptation actions to increase preparedness is able to lower the

adverse impacts on mortality and morbidity by 20%



These scenarios suggest that:

• The relative avoided costs are obviously greater the higher the degree of effectiveness of measures. The greatest relative avoided cost would be from taking action across London as a whole, given its population and demography.

• In London, around 100-130 lives could be saved through mitigating 20% of the effect of heat on health by taking action to prepare in advance of a 10 day 1/100 year heatwave event, should it occur in the 2030s, rising to over 270 lives by the 2050s. Attenuating 50% of the effect could save 270-330 lives in London in the 2030s or 690-840 in the 2050s.

• Adaptation to mitigate 20% of the adverse health effects would also provide benefits in terms of avoided costs of treating people in hospital following a 1/10 year and 1/100 year heatwave. These are estimated in London to be in the order of £0.4-0.5 million in the 2030s in London (£0.6-0.7m for a 50% attenuation), rising to £1.3-1.6 million in the 2050s (£1.6-2.0m under 50% attenuation).

• The relative avoided mortality costs and avoided morbidity costs are similar, and lower, for both Eastbourne and Islington in the event of a heatwave in both the 2030s and 2050s. The reduction in loss of life could be just 2 people for a 1/10 year or 1/100 year event in both areas across the 2030s and between 3 and 6 by the 2050s. The commensurate saving in hospital treatment is of a similar scale with very low associated costs.

It should be noted that this analysis has been developed using the UKCP09 weather generator. Results are therefore dependent on the underlying assumptions within that modelling framework. This should be borne in mind when interpreting the analysis.



45

Annex 5: Toll Bar Case Study Toll Bar Case Study

Doncaster was one of the worst affected areas in the major floods of June 2007. Hundreds of homes and businesses were flooded after severe rains hit the region. These floods caused disruption to road, water and electricity infrastructure and prompted a wide ranging emergency response. This case study focuses on the impact of the 2007 floods on the Toll Bar neighbourhood within Doncaster.

Demographic characteristics of Doncaster

In 2010, Doncaster’s estimated population was 290, 600, with 17.5% of this population aged 65 and over, 1% more than the national and regional averages of 16.5% and 16.4% respectively. By 2035 the population of Doncaster is projected to increase by 7.9 per cent from the base in 2010, with those 65 and over projected to increase by 54.9% from 50.8 thousand in 2010 to 78.7 thousand by 2035 (ONS, 2012).

According to the Index of Multiple Deprivation, Doncaster is the 39th most deprived local authority in England (IMD, 2010). Poor health is considered a key issue in Doncaster, with life expectancy, infant deaths, deaths from smoking and people diagnosed with diabetes worse than the England average.

Doncaster has severe and widespread health problems, with 15 of the county’s 21 wards in the top 10 per cent most health deprived in England and over 16 per cent of the population suffering from a limiting long term illness. The most deprived areas of Doncaster are the county’s former mining towns and urban centre. In 2009, the proportion of children in Doncaster living in poverty was 24%, far higher than the national average of 21.3% (ONS, 2012).

Impacts of past events

Toll Bar in Doncaster was one of the worst affected areas in June 2007, when hundreds of homes and businesses were flooded after severe rains hit the region. Around 80% of properties in the area were affected by flood water (Easthope, 2012). It was estimated that 6 square miles of Doncaster was underwater, in some cases this was as deep as 14ft. Approximately 81 per cent of properties flooded were classed as social housing with a high number of people displaced. This led to a large scale multiagency response. Doncaster accessed mutual aid9 that led to cooperation with 26 fire brigades and the setting up of 12 evacuation centres.

9 ‘Mutual Aid can be defined as an arrangement between Category 1 and 2 responders and other organisations not covered by the Act, within the same sector or across sectors and across boundaries, to provide assistance with additional resource during an emergency, which may

Annex 5: Toll Bar Case Study

Repairs were required to hundreds of homes with some residents of the South Yorkshire village in temporary caravan accommodation for almost a year after the floods hit the region. The 50-berth caravan park was set up by the Council as a way to keep the community together (Easthope, 2012).

A figure of £13.9m was indicated as being the cost of response and recovery, accommodation provision and infrastructure repair. Heavy-duty pumps were required to help contain the situation, with the pumps carrying more than 100,000 litres a minute away from the town centre. Water had penetrated most houses and shop fronts.

Following the floods, individuals’ lives were significantly affected because a large number of residents spent weeks living in local leisure centres and more than 12 months in caravans (Easthope, 2012). Impacts in terms of mental health were severe. High levels of anxiety still persist whenever there are periods of heavy rain, especially amongst children who experienced the 2007 event.

Adaptive capacity

A number of organisations were involved in the recovery. In addition to the local authority and emergency services, some of these organisations included:

British Red Cross

Salvation Army

Doncaster Lions

Doncaster churches together

Rotary Club

The Northern College

What does this mean in terms of adaptive capacity?

The combination of factors outlined above (local deprivation, limited resources and local resilience) meant that the capacity of responders was tested in a number of different ways. Emergency Planners had to manage resources in a way that matched them to need – this is included managing the numerous offers of help from individuals and organisations and fitting them to the specific situations.

The voluntary sector played a valuable role in Toll Bar. The role that may be considered traditional – providing material support - was supplemented by their ability to provide emotional support i.e. providing space where people would feel

overwhelm the resources of an individual organisation’ - Cabinet Office national Recovery guidance - http://www.cabinetoffice.gov.uk/content/national-recovery-guidance-generic-issues-mutual-aid

http://www.cabinetoffice.gov.uk/content/national-recovery-guidance-generic-issues-mutual-aid

http://www.cabinetoffice.gov.uk/content/national-recovery-guidance-generic-issues-mutual-aid


47

relaxed to talk about issues, or simply to get away from the impact of flood damage on their everyday lives. In addition the provision of space (office space, respite space) for some voluntary organisations themselves was seen as vital to managing resources.

The response of the community also came through strongly in Doncaster, as evidenced by the establishment of the ‘Monday Club’ by a local resident. The Monday Club was set up by a motivated resident who knew of a similar club that had been set up for a different purpose in London. The resident thought that the idea was transferable to the situation in Doncaster and would allow residents to get together to help one another, share stories of simply bring issues to light that may not have come to light in more ‘official’ fora.

Adaptation Actions

The response to the floods of 2007 can be contrasted against other case study areas of Hull and Gloucestershire in that there were a number of different factors (environmental, demographic, geographic etc).

Dr. Lucy Easthope10, who carried out an ethnographic study of the Doncaster floods, indicated that Doncaster embarked on a ‘different recovery pathway’. A mixture of limited public funds, high levels of local resilience amongst the population of Toll Bar and deprivation meant that the Toll Bar floods could be characterised as follows:

Local residents seeing this as ‘just another challenge’ alongside those of living in a deprived area

A creative approach to responding was needed – really having to utilise human capital to develop solutions that would help the residents of Toll Bar; the needs of the community went far beyond the physical infrastructure and engineering responses to the flood

Particular to Toll Bar was that the prevalence of social deprivation, in many ways, meant that many people felt that they could ask for help that was offered – often the opposite is true in UK emergency response to events.

Rosalind McDonagh,11 Emergency Planning Officer at Doncaster Council, outlined the main actions taken by the local authority, other statutory agencies and voluntary organisations:

10 See Lucy Easthope (2012) Technologies of Recovery: Plans and Situated Realities after Disaster. Lancaster University

11 Rosalind McDonagh was interviewed for this project.


The local authority visited people who they knew to be vulnerable to check on their welfare and needs

Nearby suitable accommodation was sourced – this was vital for those with specific needs, for example physical disability or families with young children

Fuel poverty is a central issue in areas such as Toll bar. This was exacerbated by having to use gas canisters whilst in temporary caravans. The voluntary sector stepped in to offer help and support in this

The South Yorkshire Community Foundation managed and distributed a hardship fund set up to help those who couldn’t meet the cost of responding to the flood

The Salvation Army offered a befriending service to help those who were maybe socially isolated or at risk

A furniture redistribution charity managed donations of furniture from organisations and individuals

The local authority ensured that there was a staff presence 24 hours a day to deal with any on site issues. This meant that regardless of the issue, local people could have someone to talk to about it. The consequence of this was that people could be signposted to services that were available, but which they may have felt that they did not want or need to access

Toll Bar was characterised by the community response to floods. There were specific actions that related to community cohesion and well-being that have been highlighted:

Dining clubs, sowing clubs, computer clubs – this was a response for people living in caravans, helping them to spend some time out of a confined space

The local authority had a Neighbourhood Management Team (a team of council officers, based within a cabin sited proximate to the damaged homes and also the caravan park (Easthope, 2012) and the British Red Cross was invited to engage with the community and be part of the recovery. These actions helped to generate trust that the community would be helped for longer periods than just the immediate period after only a couple of weeks (Easthope, 2012).

Help lines and additional support were flagged and delivered by the local PCT. In addition, the local authority worked with GPs to ensure people were directed to the right places for help


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Enhancing the effectiveness of actions

The experience of Toll Bar highlights several issues about the nature of recovery and the conditions under which various actions can be effective. Some key points are:

Integration and trust: the community must trust those that are seeking to help them. This takes time so the fact that those aiding the recovery in Doncaster stayed so long after the major flood event meant that they were more integrated into the recovery process. Dr Easthope found “Observationally it was clear to see that this led to a sense that ‘recoverers’ and the ‘recovering’ were in this together” (Easthope, 2012). In Toll Bar, trust was developed over time: “as the study developed the engagement with the council as a whole became more far reaching e.g. residents engaging in training opportunities, attending events, organising the exhibition and taking advantage of grants etc” (Easthope, 2012)

Recovery is a long process: it goes months, and even years, beyond the initial emergency response. “I would assert that without the many months of relationship building that went on in 2007-8, the flood warden scheme that was initiated 2008-9 would not have been as successful” (Easthope, 2012).

Collaboration is required: the diversity in any community means that there is a need for a co-ordinated response involving a range of organisations. Each brings particular expertise which together allows a coherent and comprehensive coverage of the needs of the community. There is a clear role for voluntary groups, local Councils, emergency planners, neighbourhood teams etc (Easthope, 2012), particularly where there are vulnerable groups who may not otherwise be integrated in the community.

Leadership is an important issue: the form of leadership during recovery needs to be appropriate to the situation and the timing of action required. Responsiveness to the needs of the community is important.

Finding the right means to engage is important. The British Red Cross offered manicuring, for example, because there was a realisation that in a relaxed environment, people were more likely to talk about issues affecting them. Informal channels through which experiences can be shared are an important route for identifying where people may be struggling, without them necessarily wanting, or being able to, recognise it.


Information is key: the impacts on individuals can be worsened by a lack of access to information because they are not aware of the options that they have to help themselves, or their possessions, following a flood. In Toll Bar, Dr Easthope found “neither the residents or local responders had access to this information and were instead dependent on ‘official’ risk messages” (Easthope, 2012).

Access to grants and financial measures was highlighted to those in the community and were therefore more accessible

Scenario planning helps people to engage and think through what they might do and how response and recovery processes work

A sense of place is important - for example, in flooded communities, it is not necessarily a good thing to re-locate people as this can exacerbate feelings of isolation. In Toll Bar the housing strategy was important and a caravan park was set up in existing estates so that people could stay in the same communities.

Day to day help can play an important role as long as it is tailored to what the community needs – for example, helping people fill in the forms they need to complete for financial assistance etc.

Barriers to Adaptation and lessons learned from Toll bar

Toll Bar was deprived community in addition to limited resources led to a different recovery pathway, a different approach to increasing adaptive capacity and a unique range of adaptive actions. However, barriers can be identified and lessons can still be learned and transferred to other communities that are at risk of flooding.


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Figure 15: Summary of barriers and lessons learned from experiences in Toll Bar

Barriers

• Lack of resources is always going to be an issue

• Responders actions can make people vulnerable – not thinking through the support needed for people with physical disabilities

• Those who need help may not recognise that this is the case

• Responders (operational and strategic) do not always recognise the emotional impact of flood events.

• A lack of trust in authority and statutory organisations

Lessons Learned

Planners listened to the local community – this led to an effective and appropriate recovery

Emergency planners and responders must understand the time needed to recover emotionally from an event is sometimes longer than the period of the initial emergency response and must be sympathetic towards this

Using the range of support offered and available from non-statutory organisations can help the recovery process.

Local knowledge is vital for increasing trust and cooperation. Local solutions are also welcome over one size fits all

UK Emergency Planners need a fundamental shift in: 1. Understanding the needs of those

they are helping – emotional intelligence

2. Community resilience – how we ask


Annex 6: Adaptive capacity A detailed overview of Organisational Adaptive Capacity is set out in Table 4 below.

Table 4 and 2 below set out a summary of the adaptive capacity of actors involved with health and wellbeing. Unless otherwise specified, the data in Table 4 and 2 has been compiled from interviews with stakeholders and experts.


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Table 4 Organisational adaptive capacity for Hospitals

Actor Resources

(e.g. technical, human, financial, natural)

Processes (e.g. engagement,

operations)

Organisation (e.g. leadership, connection

to decision-making processes)

Summary

Strategic health authority/ Regional level actor (considers national-local coordination)

Little data collected centrally /nationally so difficult to understand impact on services or for lessons to be learned (DH interview)

Each provider of NHS funded care also required to ensure identification of an accountable Emergency Officer to take executive responsibility and leadership at service level (Shirley-Quirk, 2012)

HPA has national and local teams

Coordinate local issues of preparedness – ensure hospitals have plans. New structure will bring in more of the community

External – DH may identify contingencies (e.g. national pediatrics requirements). There are also national records of occupancy of hospitals

HPA has overarching view of major events; they also have local teams

Depending on the scale and nature of the incident the necessary handling of the incident will be agreed between the NHS and public health at the most appropriate level (Shirley-Quirk, 2012). This allows flexibility, but also could lead to individuals not knowing who is responsible

HIGH

The HPA knows about the responses that can be best engineered in time of crisis (e.g. processes of diverting resources and share with other service

HPA does longer term planning (e.g. other facilities, serving local needs, avoiding duplication of resources)

Hospitals (including new build and existing)

No routine collection of data on capability or monitoring of a specific event (DH interview). Data is held at hospital or PCT so difficult to see national trends (DH interview)

Cost is not a major constraint in terms of implementing emergency plans (DH interview)

Requirements are less successful

The NHS motto is “survive to operate” – emergency service, must keep delivering when everyone else does not. They generally cope well (Walping, 2009).

All acute hospitals have plans for emergencies and chemical, biological, radiological and nuclear threats. DH has produced recommendations and issues are

Significant vulnerability due to dependencies on other sectors and service delivery e.g. power, water, road access (e.g. Gloucestershire hospitals in summer 2007) (DH, 2007b).

Flexibility is built into the command structure to enable hospitals to deal with emergencies (DH interview)

MED - HIGH

In terms of planning and processes being embedded, adaptive capacity is high. Hospitals are emergency service providers and it is part of their culture to respond well.

Physical infrastructure has lower adaptive capacity due to higher costs and longer

Annex 6: Adaptive capacity

at triggering a response for capital projects (Ballard et al, 2011).

Hospitals tend to have back up technical measures e.g. generator, or supplies of water, but highly dependent on electricity/water supplies. They can also use third party mobile service providers to outsource day patient operations etc where necessary

Emergency planning procedures have allowed front line organisations to address climate risks, but less success at triggering a response appropriate for capital projects such as refurbishment or new build (Ballard et al, 2011)

Adaptive capacity is lower for physical infrastructure due to higher costs and longer lifetimes and lead in times. However, some examples of ‘breakthrough projects’ e.g. De2RHECC programme (Designing and Delivering a Resilient Hospital Environment to Climate Change)

embedded in decisions (DH interview)

Hospitals have resilience registers where risks are recorded (DH interview)

Operational procedures – often down to clinical managers and how informed they are

During a flood event, processes in place to mitigate the loss of essential services e.g. HR and staff functions can be outsourced (DH interview)

Training and plans in place allow response e.g. realignment of staff, divert care, standby generators, so hospitals are ready to respond (DH interview)

Many hospital estates are on PFI contracts which may have provisions that may inhibit the ability or incentive to adapt (DH interview)

Hospitals come back after a disruption relatively quickly – usually a couple of weeks’ disruption rather than a few months. There is flexibility to move services around, so there is more resilience than one would perceive (WST, 2012; AUH, 2012). Vast amount of resource that it can relocate too, so a hospital can rationalise its service (DH interview).

Difficult to say whether differences between hospitals, but overall structure of hospital network can distribute its load, albeit with a timelag (DH interview)

lifetimes, also some maladaptation.

Highly vulnerable to interdependencies with other sectors such as transport, utilities, supplies.


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Table 5 Organisational adaptive capacity for community resilience and health

Actor Resources



operations)

Organisation (e.g. leadership,

connection to decision-making processes)

Summary

Communities

Extremely high variability – each community is different and depends on motivated individuals (Twigger-Ross, 2011a)

Individuals generally have capacity to cope with sudden extreme events (Coulthard et al, 2007)

Low capacity and awareness of what to do during a flood if never experienced it before (HPA, 2011) (e.g. 14% do not know where to go for information) (SMSR, 2012).

Generally, awareness is increasing in areas that have experienced a flood (e.g. 32% say 2007 made them take action, (SMSR, 2012)), but even then it is not high (e.g. 56% people in Hull today are not prepared for a flood (SMSR, 2012)). Significant difference between residents who have suffered and those who have not (Great

Tends to be very positive engagement between people when they form social groups or are given information and empowered (i.e. NFF case studies)

Existing social structure and networks are key to resilience (Twigger-Ross, 2011b)

Each community is different, but Hull had a history of deprivation and therefore there has been more investment in community support services, so there was a general presence of social support (University of Lancaster interview)

Communities that are more established, or have existing social networks or community groups tend to have higher

Connection to the decision-making process has tended to be low, however, community groups provide a way of bridging the gap between community and service providers, and can lobby agencies for action (e.g. Gloucester)

Self-reliance and ownership of the decisions increases capacity (Twigger-Ross, 2011b)

Tenants have least connection to decision-making processes as landlords deal with insurers/builders (Whittle et al, 2010)

Some communities have “flood champions” or incentives for engagement and participation

There is no systematic or formal

HUGELY VARIABLE – depends on community (e.g. age, how established it is, urban or rural) and its services (UCL interview)

Capacity developing with initiatives such as Community Resilience Programme (Cabinet Office, 2011)

Significant increase in adaptive capacity of communities when they have experienced an incident (Cabinet Office, 2011; Twigger-Ross, 2011a)


Actor Resources



operations)



Summary

Yarmouth Council interview).

Lack of finance can be a constraint reducing capacity for individuals. Lack of insurance or money to pay for repairs can delay recovery and reduce resilience. Lack of time or energy to deal with repairs can also reduce capacity as it is a time consuming process (Whittle et al, 2010)

Lack of information or knowledge of how flooding affects homes and therefore what to do (Whittle et al, 2010) e.g. rising damp or contamination and what has to be thrown away or can be cleaned (University of Lancaster interview)

Lack of will to face risks e.g. 58% do not want to sign up to Floodline Warnings (SMSR, 2012).

Private renters have weaker capacity as extra link in the chain to deal with (i.e. insurance dealt with by landlord) (Whittle et al, 2010)

adaptive capacity than those without. Groups include parish councils, or local sports clubs or neighbourhood associations in urban areas

In Scotland regional level Strategic Coordinating Groups (SCGs) bring together emergency responders (police, fire, ambulance, local authorities, and the NHS etc) together to plan for emergencies on a multi-agency basis. Groups come together as regional strategic co-ordinating groups (SCGs), which enable them to prepare for and respond to emergencies in a joined up way.

In Scotland, the Scottish Government publishes a “Guide to Emergency Planning for Community Groups” which provides advice on how to plan for emergencies. It has also published a Voluntary

way of sharing data or way of storing information for communities to learn from others. They are reliant on the individuals within the community or external facilitation such as NFF


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Actor Resources



operations)



Summary

Emergency Responders Guide on the functions of voluntary sector emergency response organisations.

Split by vulnerable groups i.e. older residents >60

Large proportion of community can be vulnerable, e.g. in Hull, 10% properties without insurance; 45% in Gold category – over 60s, single parents with young children, or disabled

Most likely to be exposed to climate change impacts and least capacity to cope (Simms & Johnson, 2007)

Differing levels of awareness between different demographic groups: e.g. a study in Toronto (Angus, 2006) found that although much of the general public were aware of a heat alert being declared, this was less true for the vulnerable, elderly and socially isolated (Bassil et al, 2010).

Particularly vulnerable to physical danger and injury - less capacity to

Lack of engagement for elderly who tend to be socially isolated. The recovery process can be inequitable (University of Lancaster interview)

Socially isolated – often live alone (DH, 2009)

Some elderly are marginalised as not confident dealing with insurance companies; more susceptible to being taken advantage of (Whittle et al, 2010)

Great diversity of responsibility within social housing and care home sectors. Some London Boroughs are responsible for care homes, but not all, and some registered social landlords are responsible for sheltered accommodation but not all (LCCP, 2012)

May be less in control of surroundings and therefore less able to respond (e.g. if in care homes or social housing) – they are particularly reliant on their carers

LOW - MED

Variable – many over 60 year olds have higher adaptive capacity than younger people as they have more life experience e.g. Studies have shown those >65 to have lower GHQ scores than younger people (Tunstall et al, 2006)

The majority have lower capacity and are reliant on the care of others


Actor Resources



operations)



Summary

respond once injured

Do not like to admit they are vulnerable, even if they can recognize it in others (University of Bath interview)

Some elderly have fewer financial resources to recover from a flood event. However, some have increased resources and life experience and can adapt more easily (Tunstall et al, 2006)


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Actor Resources



operations)



Summary

Split by those socially deprived

Far fewer financial resources to rely on (Curtis et al, 2007) yet in some areas e.g. Hull, the history of social deprivation meant that communities had investment e.g. wardens, support officers, who strengthened the adaptive capacity of the community considerably (University of Lancaster interview)

In Toll Bar, social deprivation strengthened adaptive capacity as residents used to challenging lives and chaotic events (University of Bath interview)

Often less education or knowledge to take on dealing with insurers/builders etc. or are less confident in doing so

Most likely to be exposed to climate change impacts and least capacity to cope (Simms & Johnson, 2007)

Tend not to have insurance therefore financially constrained, especially if in social/council housing and have fewest resources to buy new possessions

Those who are socially deprived tend to be less engaged in the social structure of communities, and left out from mainstream engagement. However, this is not always the case, e.g. Latin American communities in Chicago were socially deprived but due to tighter networks fared better in the Chicago 1995 heatwave (Klinenberg, 2002)

Can live in social housing with less ability adapt environment and less connection to decision-making

LOW-MED

Socioeconomic groups differ in their ability to cope with the stresses in a post-disaster environment (Norris et al, 2002)


Actor Resources



operations)



Summary

Local resilience fora / Local Health Resilience Partnerships

The LRFs are new organizations, so it is unclear what resources they have or what their roles and responsibilities will be

Adaptive capacity could be strengthened as multi-agency groups and can take coordinated role in emergency planning; opportunities to have representation from all key groups and develop resilience

Little information resource to draw on, no hub of best practices, so leads to reinventing the wheel

Relatively new organizations, so processes are not developed and established yet

Care home managers should be involved

Withdrawal of NI188 as a national performance indicator means there is a no national standard/benchmark for work in this area, so existing disparities between areas could grow further

The health sector needs to be able to play an effective and co-ordinated role in multi-agency planning and response to emergencies by participating in LRFs

LHRPs to be established to deliver EPRR in local context – to ensure the planning and response for EPRR

Reorganization within and across local administrative structures can lead to difficulties in long term planning. BIOPICCC (2012) found that reorganization takes place so often that it is disruptive to coordinated adaptation planning

The new health and wellbeing boards could be encouraged to mainstream resilience planning particularly from the view of commissioning and service design (BIOPICCC, 2012)

MED-HIGH

Adaptive capacity should be high due to multi-agency nature, but they are still relatively new so it will take time for them to develop and establish plans and procedures for emergencies that are embedded in decision-making


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Actor Resources



operations)



Summary

Local healthcare and other service providers (e.g. GPs)

No advice was given to GPs in Gloucester floods re mental health/long term effects (SWHPA Unit interview), yet some specific guidance is now coming out on some risks (e.g. heatwaves)

Heatwaves are not perceived to be a risk and more training is required at local level (Carmichael et al, 2012; BIOPICCC, 2012)

GPs are restrained by competing priorities and stretched human and financial resources that makes some actions in the Heatwave Plan difficult to implement (Carmichael et al, 2012)

GPs not trained fully on the long-term impacts of flood events or on heat impacts

GPs have high adaptive capacity for engaging with communities and are an important part of the community. They can be a central part of identifying vulnerable groups and checking on people

GPs play pivotal role in Heatwave Plan as able to identify, contact and engage vulnerable groups and also to provide a key information source

MED

Further information and training required, particularly as GPs play an important part in the community


Actor Resources



operations)



Summary

Local authority/ council

Variable, but examples of strong ability to cope e.g. in June 2007 floods, 750 Hull staff conducted door to door surveys in flooded areas (NFF, 2009); however, survey found 60% residents think authorities are unprepared (SMSR, 2012)

Local authorities have received very little guidance on how to deal with climate change (ARCC, 2011), e.g. BIOPICCC (2012) found that not all local authority representatives present were aware of the Heatwave Plan

Statutory duties to plan and take actions under Flood and Water Management Act (2010)

In Hull, support workers were not looked after and became overwhelmed (University of Lancaster interview)

Authorities with community posts e.g. wardens were trusted faces with information about the vulnerable (University of Lancaster interview)

Need opportunity to benefit from

Hull council set up the FLOSS database to capture all data, but over time, scope increased to catch more and more date. Scope creep occurs during emergency events where impacts of events cannot be predicted. (NFF, 2009)

The current health care reorganization makes lines of communication more difficult (Islington Borough Council interview)

Authorities have struggled with having enough staff and systems in place to deal with an event, e.g. databases of vulnerable groups or recording actions. However, those that have experienced an event have tended to implement action, strengthening their capacity

With regard to health, local authorities will have a local public health function and will deal with issues at a local level, escalating them as required (Shirley-Quirk, 2012)

Some examples of councils working with PCTs, e.g. recently Gloucester CC and the PCT created a leaflet on coping with aftermath of a major incident (Gloucestershire County Council interview)

More autonomy being given to local authorities under the localism agenda. This provides flexibility and tailored solutions, but can also lead to disparate practices and lack of support (ARCC, 2011)

Many local authorities are doing excellent work but they are doing so in isolation (BIOPICCC, 2012)

MED-HIGH

Capacity increases after an event. Increasing autonomy means more flexibility but also risk that capacity can be overwhelmed. Need ways of sharing best practice and experience with areas that have not been affected.


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Actor Resources



operations)



Summary

shared information and examples e.g. Flood Advice Service that ran for a year in Hull was not long enough to deal with all the recovery queries.

Networks with voluntary groups and residents can be weak (Twigger-Ross, 2011b)


Actor Resources



operations)



Summary

Voluntary groups

Only as good as the individuals in them

Tend to have few financial resources which can limit service delivery

Need to be empowered from bottom up – cannot go into a community and try to set up groups from top-down (NFF interview)

Sources of specialist, expert knowledge on the most vulnerable and can help provide tailored information (NCVO interview). Agents for community learning (Deeming et al, 2011)

Groups that are already existing or have a basis are most trusted and get most engagement (NCVO interview)

Important in identifying vulnerable people

Key role as they are part of the local community and know the local population – they are trusted

Link between community and statutory services. Critical role in communicating with local authorities – both top-down and also bottom-up (Great Yarmouth Council interview)

Role depends on being used effectively, e.g. capabilities’ directories of their resources (Great Yarmouth Council interview) and e.g. Gloucester developed computer system to match volunteer offers with a request for help

Low-High

The voluntary sector has a valuable part to play and councils should reach out to them more (Gloucestershire County Council interview)

Critical role in engaging with communities especially with vulnerable groups


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Annex 7: Adaptation actions Introduction

This section provides an overview of the actions different actors in the sector are expected to take to maximise opportunities or minimise risks. The adaptations range from practical, well tested methods to more innovative adaptations and from low cost to expensive capital investment schemes.

The information below has been compiled through expert assessment, stakeholder interviews, and an assessment of peer reviewed and grey literature.

Many of these adaptation actions relate to building the adaptive capacity of the healthcare sector and communities. For the purposes of this report, building adaptive capacity is not described as a separate action in itself, but is an integral part of each adaptation option, as the greater the capacity of the individual, the more likely it is for an action to be taken.

The list of actions set out here is not exhaustive, but is intended to illustrate the key types of responses to climate change that actors in the healthcare sector and communities are taking/ will take.

The actions considered are focused on three categories of risk: flooding in hospitals; heatwaves in communities (actions focus on short-term preparedness); and flooding in communities including impact on mental well-being (actions focus on response and recovery).

Flooding in hospitals Adaptation to flooding is likely to be a gradual process where defences are improved, resilience is increased and new developments take account of the increase in flood risk.

The adaptation measures for hospitals described in this report do not include consideration of measures to minimise indirect impacts of flooding, such as lack of power, lack of clean water, lack of access due to roads being flooded, strategic flood defences on a national scale etc. Instead, this report focuses only on some of the key actions that hospitals can take to minimise the direct impacts of flooding on hospital services. These measures include:

● Infrastructure (internal and external)

● Planning and early warning systems

● Continuity of services

Annex 7: Adaptation actions

(i) Infrastructure (Internal and External)

Description

These measures include the construction, siting and design of new infrastructure as well as the renovation of existing health infrastructure. It also includes the sharing of information on best practice in design (e.g. avoiding ICT equipment in hospital basements where there is a flood risk).

The external structure of a hospital can make a significant difference to its flood risk level. Much of this comes down to planning, e.g. the geographical location of the hospital. However, for existing hospitals, at site level, measures include: flood resistance measures (diversion channels, retention areas, and flood barrier systems surrounding the building (US DHS, 2012)); flood resilience measures (elevating the facility on walls, columns or compacted fill (National Kidney Foundation, 2011), building a multi-storey car park); and reinforcing the physical integrity of the building (filling windows, doors or other openings with water-resistant materials such as concrete blocks or bricks; reinforcing walls to resist water pressure; sealing walls to prevent or reduce seepage (National Kidney Foundation, 2006)).

Internally, many measures can reduce disruption to services. These include locating essential equipment above flood levels, i.e. not in the basement. This would include mechanical, electrical (e.g. back-up generators, additional electrical infrastructure: wiring & switchgear), plumbing, fire-protecting systems, as well as key medical areas, including laboratories and pharmacies. Equipment should be raised and on plinths (GOSH, 2012) where it does need to be in lower levels and protected by having watertight walls around it or around susceptible work areas. Mechanisms should be installed that prevent water entering the facility via utility and service lines (check valves) and gas-powered pumps allow water to pumped out as fast as possible (National Kidney Foundation, 2006). Lower levels of the hospital should have ‘soft’ services (offices or outpatient services) (Shroades, 2007).

Barriers

External:

Cost: A flood barrier system surrounding the Columbus Regional Hospital in the USA cost $4.7 million, despite being the most cost effective and reasonable solution out of a number of flood control measures including diversion channels, retention areas, buyouts of homes in flood-prone areas and regulations on building in flood-prone areas (US DHS, 2012).

Disruption time: Construction works to retrofit hospitals cause disruption to hospital services and can take time, e.g. construction of the Columbus Regional flood wall took a year (US DHS, 2012).



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Internal:

Lack of space: Finding areas to relocate systems can be an enormous challenge, especially if the systems require a significant amount of space. This level of space may not be available within a hospital facility itself, so other land needs to be found. For example, after flooding at the Memorial Hermann hospital in Texas, USA in June 2001, almost 200,000 square feet of above flood-level land had to be found in order to migrate systems to higher elevations (Shroades, 2007). If equipment has to be moved internally, this can have opportunity costs.

Costs: The cost of moving equipment can be extremely high. For example, the cost of elevating emergency-power transfer switches for a back up generator (in a US hospital) was $7.5m (Fink, 2009; 2010).

Extent of Adoption

Current adoption appears to be low-medium and it is expected to increase slightly in the future.

The lack of centrally held data means it is not possible to assess with certainty how widespread measures are, however, interviews with stakeholders (e.g. Chris Holme, David Pencheon) reveal that NHS facilities tend to comply with Department of Health recommendations on dealing with emergencies including flooding (DH, 2006; 2007). These include recommendations such as: buildings should use a framed construction or reinforced concrete as required by relevant British Standards and should have resilient internal infrastructure systems. Under business continuity management plans, hospitals are required to identify Points of Failure and these may include infrastructure (Phil Storr).

There are examples of flooding resilience being built in through new building projects e.g. Moreton in Marsh hospital has SUDS built in with swales and ponds and new car parks incorporate permeable paving (Georgina Smith). The new hospital at Tewkesbury also has SUDS along with a drainage strategy and landscaping rather than buildings are used in the actual flood risk area (Georgina Smith).

In other parts of the world (e.g. USA), insurers are focusing attention on risk assessment and mitigation measures that can reduce flood losses (RMS, 2001). It has not been possible to assess whether this is the case in the UK, but this is something that could be taken up in the UK under business continuity insurance.

Capital investment is not currently resilient (Ballard et al, 2011). However, changes to infrastructure are likely to increase in the future as experience of flood events become more common where making a new hospital/ward climate resilient today may require a smaller investment compared with retrofitting it to be resilient in the future (Phil Storr). Changes to infrastructure tend to be put in place as a response to an event, e.g. after floods in June 2012 Worthing Hospital


was asked to put in future-proofing flood resilience measures (WSH, 2012). Many hospitals in the USA (e.g. Columbus Regional in Indiana) have put in place flood defence systems after having been significantly affected by flooding from tropical storms and hurricanes.

Effectiveness

High

The impact of flooding on hospitals can be significant. Measures to reduce this damage can be very cost effective by preventing hundreds of millions of dollars in damages. Studies on flood damage and post-flooding measures after Tropical Storm Alison, which affected the USA in 2001, reveal significant losses due to flood damage which shows how effective measures may be (RMS, 2007). Worthing Hospital suffered a fifth serious bout of flooding in seven years in June 2012 costing £350,000 damage and leading to six months refurbishment work (The Argus, 2012). Some, if not all, of this could be reduced by putting flood resilience measures in place in hospitals in high risk flood zones.

Moving critical equipment and research data (e.g. samples) to areas above flood levels is extremely effective at preventing damage. For example, Baylor College of Medicine in Texas, USA, suffered $495m damage by basement flooding where critical storage freezers lost 25 years of research data; and basement flooding in the Memorial Hermann hospital led to $433m damage from diagnostic equipment and laboratories, as well as it taking 18 months for full recovery. Following this event, the hospital relocated sensitive systems to above flood levels (RMS, 2007).

Research in India has found that return rates are robust for lower-cost interventions eg raising plinths, community based early warning) compared to infrastructure strategies requiring capital investment (Moensch and Risk to Resilience Study Team, 2008). The effectiveness of ensuring switches and equipment is above flood level is very high. For example, at Memorial Medical in New Orleans, facilities personnel warned that “it won’t take much water in height to disable the majority of the medical center”, as the Hospital’s main emergency-power transfer switches were located only a few feet above ground level. The problem was not fixed and as a result during Hurricane Katrina, the back-up generators stopped working (Fink, 2009).

The effectiveness of maintaining the physical integrity of the building and making it resilient is high, as illustrated by the UT Houston Medical School whose unreinforced walls collapsed under the flood waters leading to $205m damage. Insurance covered $50m, and $68m was needed to retrofit and prevent future flood damage (RMS, 2001).



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(ii) Planning and Early Warning Systems

Description

These measures include: existence and practice of an emergency-preparedness plan (e.g. employee training, warning and evacuation procedures, having equipment on hand such as sandbags, plastic sheeting etc); early flood warning systems (e.g. having cameras on flood gauges at various intervals which feed live images of flood level (Shroades, 2007), direct contact with the emergency services, local and central government, and the Environment Agency); and system wide standardisation and coordination (so that in the event of a flooding, rather than moving equipments and supplies, other hospitals could accommodate patients (Cloutier et al, 1998)).

Barriers

Unpredictability of pattern of event (in terms of intensity, nature/pattern/ location of impact, etc.) makes it very difficult to be prepared or plan for an event when it does occur (Loosemore, 2010; IPCC,2012).

Lack of on-site capacity i.e. coordination and leadership: There may not be specific roles for people to take charge during a flood emergency (Loosemore, 2010). Plans may also only be effective depending on the capacity and willingness of decision-makers to modify actions (IPCC, 2012).

Lack of real-time practice: means that plans may not be implemented effectively and that people become complacent (David Pencheon, Walping, 2009).

Inaccurate or inadequate information: Information and advice can often be conflicting when received from differing sources leading to confusion and lack of protection measures being implemented (as exemplified in the 1997 flood in St Boniface General Hospital in the USA (Cloutier et al, 1998)).

Extent of Adoption

There is a high degree of emergency planning that already takes place in NHS hospitals and it is expected that this will continue and increase in the future (Chris Holme). Policy drivers exist to ensure emergency plans are made, i.e. under the Civil Contingencies Act 2004 and NHS Emergency Planning Guidance 2005 and further guidance on Emergency Preparedness Resilience and Response (EPRR) is being given this year due to the new arrangements under the Health and Social Care Act 2012 (DH, 2012). The NHS has a proactive approach to resilience and plans this into decision-making (Chris Holme).

Planning is generally about emergency readiness, rather than a specific event such as flooding. This has co-benefits, as it aids response to any threat.


Development of such plans for climate change events in general is becoming more widespread (Chris Holme; David Pencheon).

In the USA, insurers drive disaster planning, as they require hospitals to include flood scenarios in disaster recovery/contingency plans for facilities (RMS, 2001). As with all the disaster risk reduction measures, action occurs after an event. For example, CEO of Columbus Regional hospital stated, “We talk about disaster planning a lot... it certainly is a priority. It [the flood] brought it home to us how important it really is” (US DHS, 2012). Cooperation and coordination between hospitals also tends to increase after events. For example, a remarkable level of cooperation and effort was reported during the flood contingency period of the St Boniface General Hospital. It was recognized that such cooperation and flexibility could also serve the system well on an ongoing basis, and legacies, like a bed registry system for the city, have endured since the flood (Cloutier et al, 1998). In the UK, cooperation between hospitals is prevalent – hospitals have enough capacity to take patients from disrupted hospitals (e.g. during the flooding at Worthing or the fire at Royal Marsden).

Effectiveness

Medium - High

In the UK, there is little centrally held data on the effectiveness of specific measures, or their costs, however, examples and international data provide some indication.

Planning when done properly, can be very effective in aiding the flood response. For example, during the fire at the Royal Marsden, patients already had ski sheets under their beds and so could be evacuated extremely quickly (Royal Marsden, 2008) and senior nurses had lists of all patients and staff members. The importance of communication as a planning procedure was highlighted in the Royal Marsden experiences, where mobile phones were used extensively and relied on the fact that many people had numbers for other staff members and key organisations stored into their phone. A communication system is critical when phone systems may go down and use of runners may be restricted: hand held radio systems may be a solution (Walping, 2009).

The effectiveness of planning can be seen in the example of Columbus Regional hospital, USA. Although a flash flood in 2008 caused $180m damages, reports state this would have been considerably higher had the hospital not quickly enacted plans it had in place to contain damages. As a result of the plans and collaborations with the Federal Emergency Management Agency (FEMA), insurers, and area contractors, the hospital was able to reopen in six months rather than 12-15 months as initially projected (US DHS, 2012).



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Real-time practice of plans is extremely important to allow identification and correction of similar practical problems before a real incident. For example, at Royal Marsden, the revolving doors at the entrance/exist were too narrow to accommodate the mattresses on which patients were placed (Walping, 2009). This also prevents a sense of complacency in staff who may not have a real understanding of emergency procedures (David Pencheon).

(iii) Continuity Of Services

Description

Business Continuity Measures (BCM) include: guaranteeing the availability of essential (building) services (Loosemore, 2011); providing access to and from hospital for staff and patients (including helipads on roof for critical patients (Loosemore, 2011; Rolyn Companies, n.d.); accessing options for supplies before disaster strikes e.g. considering where to obtain fuel if facilities need to operate on generators for longer than three days (Shroades, 2007); ensuring that there are back-up generators that automatically take over power supply in case of any power failures; and ensuring the ability to control all communications to entire hospitals and personnel from one single source (Loosemore et al, 2010). This also includes continuity of services, such as mobile units from third parties to carry out out-patient operations.

Barriers

Indirect disruption: The largest barrier to service continuity is disruption due to electricity, water, or roads/rail being cut off e.g. as happened to several Gloucestershire hospitals in 2007 where flooding at the major pumping station meant there was no mains water available (DH, 2007). The hospital foundation trust had robust emergency plans in place, however, the severity of the floods caused unforeseen problems.

Storage difficulties: There is a danger of attracting thieves by storing excess supplies such as fuels on site, in order to ensure service continuity (DH, 2006).

Staff availability: Staff may be affected by the event at home, leading to issues for them to resolve at home, or inability to get to work. This can lead to inability to deal with surge in patient numbers (Loosemore et al, 2011). This can be dealt with by taking care to the community e.g. finding ways of connecting staff in the community with nearby patients – and reducing the numbers of people who come to hospital (NHS SDU interview).

Lack of administrative capacity: There needs to be training and roles and responsibilities need to be made clear (Walping, 2009).

Extent of Adoption


Adoption of business continuity planning is high. Hospitals have a statutory duty under the Civil Contingencies Act 2004 to ensure they can continue to provide services during an emergency event and there are standards and guidance to follow, in the form of BS NHS 25999, PAS 2015, and the NHS Emergency Planning Guidance 2005. Another reason that the extent of adoption of BCM is high, and may be expected to increase, is that protection of brand, reputation and image is paramount. Insurance companies’ requirements may also be a driver, as are corporate governance and auditors (CWP, 2010).

A report has found that “awareness of BCM in the health sector is high, and may reflect the Department of Health’s high level resilience project. BS25999 has been accepted as the basis for BCM and specific NHS guidance is being produced” (CMI, 2009). In addition, a business continuity self-assessment toolkit has tools to plan, implement, review and record business continuity, so that hospitals may work up to taking an external audit. The toolkits were supplied to each NHS Trust up to December 2010. It is assumed the majority of hospitals follow this, and recent surveys suggest 64% hospitals do business continuity management (CMI, 2011).

It is expected that BCM in hospitals will continue to grow. There has been a massive growth in the last 10-15 years (Phil Storr) and this trend is expected to continue to increase as awareness grows, for example, emergency planning is one of the top five priorities of the NHS CEO (Phil Storr). Hospitals undertake business impact assessments, which are key as these consider the system and mechanisms for the organisation as a whole. Hospitals are beginning to consider external care during an emergency, e.g. connecting staff with patients outside the hospital (David Pencheon).

Insurance requirements could become a driver for BCM. For example, in the USA after Tropical Storm Allison, insurers began to require back-up copies of blueprints for buildings in which the office of the building engineer is located in the basement, as blueprints, essential to building repair, are often kept in these areas (RMS, 2001). It is unclear to what extent insurance is a driver in hospitals the UK, as it depends on each hospital. Further research should be carried out to assess the role of insurance in driving hospital adaptation.

Effectiveness

Medium to High

There is a lack of evidence to assess the effectiveness of BCM, however, it is likely that it is highly effective in ensuring services can continue even in an emergency. As might be expected given the nature of hospitals to deal with emergencies (David Pencheon), examples of recent incidents suggest that hospitals respond well (e.g. AUH, 2011; WSH, 2012; Royal Marsden, 2008). The effectiveness of BCM depends on whether they are put into practice and



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tested, and they will only ever be as good as the infrastructure allows. Generally, business continuity and emergency planning should be part of good management practice and should not entail any particular costs.

While BCM in a hospital is very important in terms of ensuring service provision, it is also important to realise that the aging population means that there will be an increase in chronic conditions over time which will be treated outside of the traditional hospital environment. This is a very different challenge for maintaining resilience (Phil Storr).

Flooding in communities The components of the experience of flooding which contribute to psychological distress are probably varied. Flooding is a major life event, and life events, especially those that lead to loss or threat, increase the risk of the onset of a depressive illness. Minimising the impacts of those life events will therefore minimise the likelihood of mental distress, and increase community resilience.

Strong flood incident management reduces the probability of flooding by controlling flood pathways and significantly reduces the damage caused, by managing losses and influencing behaviour of individuals and organisations. Flood management responses are taken (i) in preparation of a flood event, (ii) forecasting and warning during a flood event, (iii) to reduce damages during the event, and (iv) to facilitate recovery and minimise the social, health and practical impacts of flooding after an event (Dawson et al, 2011).

The adaptation actions considered in this chapter focus on ways of minimising the need for evacuation and minimising displacement time where it is necessary: Adaptation actions include:

● Planning e.g. community emergency plan, local resilience groups, warnings

● Social support e.g. social networks, voluntary groups

● Provision of and access to information after flood event e.g. websites, helpline/advice line

● Support to reinstate/return to house after flood event e.g. insurance, loans, builders

● Health services available specific to mental health effects e.g. social care, GPs

Many of the actions concern building up spare capacity within institutions so they are able to respond to the uncertainties during and after a disaster, such as increasing cooperation between formal organisations and community groups.


(i) Planning and warnings

Resilience may be built through effective planning. At community level, this includes measures such as the local authority (as lead recovery agency) collaborating and encouraging engagements; appropriate formal/informal processes and organisation; and engagement with stakeholders on plans’ preparation and dissemination (Paranjothy et al, 2011) e.g. through Local Resilience Fora, who should compile a register of all known hazards in their area (HM Government, 2005). At individual level, this should minimise damage leading to mental distress, e.g. do not keep sentimental/valuable items in the cellar/ground floor; and encourage individual personal planning e.g.. householders can have an emergency bag with survival essentials and insurance documentation (Pitt Review, 2008). In Scotland, school children are taught about emergency events and how to respond to them, as a way of strengthening community adaptation. This is achieved by making an online resource (the Ready for Emergencies resource) available to teachers which enables them to integrate resilience into the curriculum, making links with a variety of subjects including sciences, geography and personal and social education.

Barriers

Advice and warnings are ignored: For example, people willfully dismissed even mandatory evacuation orders in areas in USA when hurricane warnings issues prior to Hurricane Katrina (Cutter & Smith, 2009; Sorensen (1991); HR Wallingford (2010)).

Flood denial: experience in Hull showed that older householders in particular actively resisted being categorized as ‘flooded’ (Whittle et al, 2010). This may have been due to ‘upheaval/hassle’ or anxieties of being moved out of safe and familiar space, away from local networks of support etc. Others are concerned that insurance companies will increase premiums as a result of a flood claim.

Lack of awareness or understanding of flood risk: People tend to be unaware they are at significant flood risk e.g. 40% of those at significant risk are aware of it (NFF interview) and this has fallen from 52% in 2001 (BMRB, 2001). In Hull, a survey found that 30% people surveyed though there was no risk, and 21% thought there was a high risk (SMSR, 2012). Lack of awareness of householders of potential problem of unrecognized (groundwater) flooding or longer-term damage that may be slow to reveal itself (Armstrong et al, 2012).

People perceive threats individually and therefore underestimate risks and potential harm that hazard events pose (Cutter & Smith, 2009).

Difference between reality and practice: Recovery as experienced on the ground does not necessarily match up with the more official templates and



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protocols focused on achieving a quick and attainable return to ‘normal’ (Whittle et al, 2010).

Lack of capacity and flexibility: Plans can become ineffective when ‘scope creep’ occurs, and issues arise that the systems in place do not have capacity or flexibility to deal with (NFF, 2009). They can also become ineffective if they are too prescriptive and handed down to communities, rather than being developed in a bottom-up way (NFF interview).

Extent of adoption

Low-high

There is no real baseline of what level of planning is happening in communities across the country and how effective it may be.

In some areas that have been affected, planning is likely to be a key part of community resilience; however, in areas that have not yet been affected, it is less likely. An EA poll showed that 9% of people at risk knew how to stay safe, and only 3% had prepared a flood kit of essential items such as insurance documents, a torch and warm clothes (BBC, 2008). The Cabinet Office reports that most local authority forums are promoting community resilience plans and local networks (Cabinet Office interview).

It is likely that planning will increase in the future becoming widespread. The occurrence of communities forming groups and making plans is increasingly widespread. People are taking steps collectively and individually to prepare, and are beginning to take responsibility for their own resilience (Cabinet Office, 2011). The number of community flood groups is widespread and is growing: the NFF works with at least 163 community flood groups (NFF, interview). It takes approximately nine months to develop a plan and set up a community flood group. However, it may develop in a patchy fashion between areas affected and those unaffected.

Acknowledgement of the issue of engaging communities and third-sector organisations has increased (as evidenced by the HM Government’s Emergency Response and Recovery 2009 compared with that in 2005).

Effectiveness

Medium – High

Dawson et al (2007) in a simulated study based on flooding in Towyn, Wales, found that a flood warning provides a tenfold reduction in exposure of the population. This highlights the importance of providing timely and good quality information and ensuring people how to react effectively when they receive it. Tunstall et al (2006) found that receiving a flood warning had a small effect in reducing health and stress impacts of flooding. Since the


1998 and 2007 flood events, there have been major efforts to enhance flood warning dissemination with a range of communication channels.

There is a move from the concept that there are purely technical solutions (e.g. flood defence) to a more holistic approach that considers community in its broadest sense (including planning, road networks, property protection etc) (NFF interview). This part of a larger cultural change, from thinking that flooding is the government’s responsibility to thinking it is the responsibility of communities and local government.

Planning brings co-benefits – in terms of emergency preparedness plans being broader than just flooding, and for any major event or climate risk. The process of planning is as important as the plan itself (Twigger-Ross, 2011b). Qualitative feedback from communities has shown the positive morale that is built from developing flood plans (NFF interview). Without reviewing all the community plans, it is difficult to know how effective they are. There is no platform for information sharing, although the Cabinet Office tries to share good practice and peer to peer support (Cabinet Office interview).

Developing a community plan requires community engagement – which is often easier to get engagement once a community has been flooded, as it can be difficult where a community does not understand the risk (NFF interview). Engagement with communities and planning can be ineffective when it is done in a top-down fashion and where people do not empower community groups (NFF interview). Current mechanisms exist that can be used more fully to identify and empower communities e.g. LEAD local flood authorities need to develop Flood Risk Management Strategies in their area.

Preparation is critical because it enables people to save their possessions. Those who lose the most personal, social and economic resources are the most devastated by mass trauma, and those who maintain their resources have the best ability to recover (Benight, 2004; Hobfoll et al, 2007).

(ii) Social support

Description

A study by Hobfoll et al (2007) found that there were three intervention principles that should be used to guide intervention efforts. These are promoting a sense of self- and community-efficacy; connectedness; and hope. These principles can be implemented by provision of social support, especially for maintaining normality after the event, rebuilding a social life, and contributing to a way of sharing experiences. It includes actions such as helping neighbours, forming voluntary groups, social networks. This is particularly important for targeting the vulnerable.

Barriers



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Difficult to engage or support the most vulnerable who are least socially connected. For example, if people are not on email or social networks, they can become even more isolated, particularly the elderly, or those who are unlikely to seek social support themselves (NCVO interview). Existing social networks tend to exclude vulnerable people (e.g. homeless, elderly, disabled) and this is exacerbated during emergency events (Paranjothy et al, 2011).

Lack of awareness of impacts on adolescents/ children. There is a lack of coordination between schools and home life so that neither side is aware of the effect of flooding at the other. For adolescents/school children, maintaining social connectedness and understanding between home and school is particularly challenging (Whittle et al, 2010; University of Lancaster interviews).

Less long-term support as flood event ceases. Community support tends to be high during the flood event, as people pull together to deal with the disaster, but it lessens over time as the immediate event ceases. Yet the need for support is still there (Kessler et al, 2006; 2008).

Disruption to networks. Displacement of residents to temporary accommodation can lead to the breakdown of community networks (Buckle et al, 2000). For this reason, in Toll Bar, temporary accommodation was set up in nearby caravan parks so that people could stay within the same community.

Extent of adoption

Low-Medium

During the 2007 floods, communities were quick to form groups and help each other – a sense of ‘blitz spirit’ has been reported (e.g. SW Health Protection Unit). In Gloucestershire, the Village Agents (focuses on older people) was a useful source of information and assistance (jointly funded by the county council and NHS). In Hull, Whittle et al’s (2010) case study found that strong networks of support existed or developed quickly. There was a feeling that people “pulled together”, supporting each other throughout the process even with neighbours they had previously not spoken to.

It is expected that the community support is increasing and will continue to increase as people adapt quickly to flood events. The floods in 2012 provided examples of communities pulling together, e.g. at Hebden Bridge people formed the “food angels” and a facebook page was set up for the Calder Valley Flood Victims (Hebden Bridge Times, 2012). It is expected that the extent of, and reliance on, community support will continue to increase as flood events increase in frequency. However, without platforms for information or shared learning or best practices and experiences, the development of such support may occur in an ad hoc fashion, leading to ‘reinventing’ of the wheel.

Effectiveness


High

Social networks are an essential part of any community (Twigger-Ross, 2011a). Qualitative evidence exists that strong networks of support help people combat stress (Whittle et al, 2010; Norris et al, 2002). Local community/informal groups can provide a quicker, more flexible response than some of the larger bureaucratic sources of help available, and flood victims often feel isolated from authorities creating more demand for familial and informal groups (Tapsell et al, 1999; Tapsell & Tunstall, 2001). In a study of residents in Hull, the most effective support they received came from friends, family and neighbours as well as informal sources at the level of community e.g. local churches or community centres (Whittle et al, 2010).

Social support is also strongly correlated with PTSD and mental health, acting as a protective factor against it (Weems et al, 2007; Lutgendorf et al, 1995). Abramson et al (2008) study looking at PTSD after Hurricane Katrina found that “informal social networks acted as a protective factor against mental ill health”. Pina et al (2008) found that young people with extra-familial support showed fewer symptoms of PTSD, depression and anxiety. The perception that others can be called on for support mitigates the perception of vulnerability and emboldens individuals (Hobfoll et al, 2007).

Social connectedness increases opportunities for knowledge essential to disaster response (e.g. where is nearest store? Is safe water available?). It provides for a range of social support activities, e.g. problem solving, emotional understanding and acceptance, sharing of experiences, mutual instruction about coping. Fostering connections as quickly as possible after the trauma and maintaining that contact is critical to recovery (Litz & Gray, 2002; Shalev, Tuval-Masiach & Hadar, 2004). Three elements of social support act to protect people affected by disasters from vulnerability to mental disorders (received support, perceived support, and social embeddedness) (Norris et al, 2002). The importance of having a sense of control over positive outcomes is one of the most well-investigated constructs in psychology (Skinner, 1996).

Those who lack social support, who are more socially isolated, must be the focus of support – keeping them connected, training how to access support, providing formalized support. Intervention in these cases should be a priority as natural support networks will have disintegrated (de Jong, 2002).

The importance of using voluntary groups as a complement to statutory service providers has been well referenced by all our stakeholders. Ensuring that volunteers are effectively used is important – for example, Gloucester now has a system to match volunteers with requests for services (Gloucestershire County Council interview).



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(iii) Provision of and access to information after flood event

Description

The provision of information, and access to it, is a key measure to help communities recover from floods and to build the capacity of the community. This can include leaflets and targeted information including details of support services, local contact details, but also provision of a national advice line or ‘one-stop shop’ website that has comprehensive information on every flood-related issue and information to aid victims to work through red tape and the complex processes involved in the tasks that emerge after mass disaster (Arata et al, 2000).

Barriers

Lack of knowledge of information sources. People often call the emergency services or the local council as they do not know where to go for information (SW Health Protection Unit interview, NHS Wales interview).

Lack of coordination between information sources: Although the EA has strategic overview, there are many different information sources from different organizations, which is confusing. Many of the stakeholders referred to the necessity of having one place/organization that communities can turn to for all related information (NFF interview).

Lack of capacity. The provision of information is not enough on its own, people need to have capacity to act on it. People need to believe they can evacuate, find temporary housing and get a job on their return and they require skills and resources to do so. Turpin et al (2005) found that sending victims home with self-help pamphlets is likely to backfire as it assumes they possess the skills necessary to enact what is recommended.

Communication methods. A study in Hull found that 69% people surveyed were not aware of any advice, and 58% did not want to sign up to Floodline warnings (SMSR, 2012).

Lack of long-term information provision. Whittle et al (2010) found that residents in Hull received little effective support or information during the so-called “recovery gap”. This is where contingency-arrangements provided by the local authority diminish and less well-defined services provided by the private sector start (e.g. insurance, building).

Extent

Low-Medium

Since the 2007 floods and the Pitt Review, many institutional recommendations have been implemented (NFF interview), including the reorganisation of the EA and many flooding information sources have been set up, e.g. the EA National Floodline. However, this provides information about flood risk only, rather than


the after-effects. The EA covers main rivers and coastal flooding, the local authority covers surface water flooding. Other sources of information include the ABI, Defra, HPA, National Flood Forum. However, in terms of dealing with practicalities in the after-math of a flood, there is no one place that people can turn to.

In the future there may be more information available, but it may not change from being provided in many different forms and from different organisations.

Effectiveness

Medium

Dissemination of information is one of the most vital adaptation actions. It is important for people to know who is responsible (HS Wales, interview). The existence and development of dedicated advice services that people can visit for support, information on what to expect and how to cope all the time has been consistently highlighted as an effective action (GCC 2007b). Effective, coordinated information is a key element of the recovery process (Pitt Review, 2008) but this does not seem to be followed.

Many stakeholders recommended establishment of an information hub, or platform for sharing knowledge and experience would help community resilience develop in a systematic and coordinated way across the country (SW Health Protection Unit interview). The Pitt Review recommended that a single website should be established providing links to all websites needed for a comprehensive set of advice on flood-related matters, and suggested that this be the Local Resilience Forum’s website (Pitt Review, 2008). This should be permanent, given the long time for flood recovery, and be additional to local short term flood advice (e.g. Hull council’s Flood Advice Service) which ran for a year and which was not long enough (Whittle et al, 2010).

Voluntary groups can provide services (e.g. the National Flood Forum) but they are reliant on diminishing funding and do not have enough capacity to deal with large numbers of users. For example, during Great Yarmouth’s floods, there was an overload on the local floodline and website (Twigger-Ross, 2011b).

Local radio stations are very effective in getting localised messages across and are widely used. In Gloucestershire, local news reports were very effective in spreading news and positive messages (GCC, 2007b). The NFF reports spikes in queries when a member has done a local radio interview. Other studies have found clear preference for local radio throughout flooding incidents, and that local newspapers were associated with clarity and feeling informed (Rundblad et al, 2010). Older consumers were unlikely to read official information leaflets and they were found to be less useful.



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(iv) Provision of financial and practical support to reinstate or return to house after flood event

Description

This includes provision of and access to: financial support, such as insurance and flood recovery grants, and practical support, such as support services to help people do project management, standards of workmanship e.g. codes of practice for post-flooding building repairs, or lists of accredited builders (Reacher et al, 2004; SW Health Protection Unit interview). This could also include new methods of drying properties to reduce drying time.

Barriers

Lack of long-term recovery process. Local authorities and agency staff have tended to see the process as one of dealing with the immediate emergency, being less aware of what is required in the long term. Support must be ongoing after the flood event as displacement did not happen immediately, but after two months, peaking at six months, and then declining. At 12 months, more than 20% flooded households still not at home, and at 24 months, still 5% (Armstrong et al, 2012).

Lack of access to insurance companies. It is not known if this was due to inadequate capacity at the companies to deal with increased requests, but there is anecdotal evidence to suggest that making contact with insurers was difficult after the floods, and this significantly added to the distress felt (Gloucestershire County Council interview, Whittle et al, 2010). There was also lack of coordination between insurers, builders, loss adjusters and letting agents (Whittle et al, 2010).

Insurance premiums are prohibitively high. A Hull North Labour MP is calling for a review of the cost of insurance after some homeowners in flood-risk areas said their premiums had risen by up to 500% and that some homes had been refused cover (BBC, 2011). Even where they are not high, parties without insurance tend to be vulnerable groups, such as renters or the socially deprived, who are also least likely to be able to undertake repairs.

Lack of incentives for insurers. Insurers have no incentive to use the more expensive new technology drying equipment to get people back into their homes more quickly (Matt Cullen). This increases displacement and the length of time displaced.

Expense of installing resilience measures is not reflected in terms of insurance policies (Whittle et al, 2010). Insurers will only cover the costs of reinstating a house to its original condition and not to make it resilient.


Lack of ownership. Some people felt a lack of ownership by not having control over repairs, as well as concern over delays and poor workmanship, when the insurance company carried it out (Whittle et al, 2010).

Lack of capacity. Householders need to project manage building works on top of trying to resume daily life and work and family obligations.

Extent of adoption

Low - Medium

Financial support is relatively widespread in the UK and is expected to increase as flood events increase: 80% properties have insurance (Chilvers, 2008), and during the floods significant grants (Flood Recovery Grant of £20m, and other grants such as waived council tax) were handed out (DCLG, 2007). In the 2007 floods, £3bn was paid out for domestic and commercial claims for flooding, in 2009 in Cumbria, the pay out was £174(Matt Cullen). The government is trying to encourage residents in flood risk areas to have insurance and resilience measures fitted as these can reduce the economic costs of flooding and ensure more rapid return to home (Defra, 2008). Practical support is far less widespread and has only begun to increase after the 2007 floods.

At present, the Statement of Principles ensures that insurers will offer cover to as many customers as possible while the government takes steps to manage flood properly, including sustained investment in flood defences. The Statement of Principles will expire in 2013 and it is currently unknown what will happen as a result: whether a free-market develops charging people prices that fully reflect risk, or whether there will be a level of market intervention. The outcome will have implications for the use of insurance (Defra, 2012a).

The home insurance product has changed since the 2007 floods. Although there was a good response to the insurance industry in the 2007 floods (e.g. 72% customers were satisfied, according to the Pitt Review, 2008) 27% thought that the industry was poor or very poor. There were many lessons learned about the emergency response of the insurance industry and procedures/processes and guidance about insurers and also a guide to repairs were put in place as a result (Matt Cullen; ABI, 2012). The insurance industry is developing and adapting as it becomes experienced in dealing with emergencies. This was illustrated in the response to the Cumbria floods of 2009 where insurers were described as the “5th emergency service” and took direct action (ABI, 2010; Matt Cullen). With the adaptive measures that have been put in place, it would be expected that the insurance industry is better prepared, and that the customer experience would be improved from 2007.

From a practical perspective, adaptation is increasing, for example, a BSI Publicly Available Standard 64 on best practice for restoring water damaged properties is



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being developed (BSI, 2012). This is aimed at builders/contractors and is a response to the Pitt Review, providing best practice on all aspects of the restoration process. PAS 64 is voluntary, but it provides a way for householders to ensure their builders do the job properly, rather than badly and causing more distress (Whittle et al, 2010). This needs to become embedded into the building market and be widely supported.

Effectiveness

High

Financial strains caused by loss of money and personal property and by difficulties in receiving insurance payments are significant stressors (Fullilove, 1996; Reacher et al, 2004; Weich & Lewis, 1998). Avoiding such losses is very significant in terms of improving mental health. Equally, evacuation may be an effective measure for human health in the aftermath of a flood, but long-term displacement can be extremely stressful and weaken community resilience as well as lead to mental illness. Returning residents to their homes and providing long-term support is an important element in avoiding or reducing mental distress.

Insurance:

Access to affordable flood insurance is a critical adaptation measure (HPA, 2012b). It can help reduce the financial consequences, stress and trauma that flooding can bring. Insurance is identified as a “key milestone” for recovery by the National Flood Forum (NFF, 2009) and another study has found that problems with insurers are the most significant factors explaining health and stress after a flood (Tunstall et al, 2006). One of the strongest determinants for PTSD for Hurricane Andrew victims was the inability to secure funds to rebuild homes (Ironson et al, 1997). Moves by the state of Mississippi to force insurance companies to pay for damages following state law was a critical intervention. The way that insurers personnel deal with flood victims is crucial in mitigating or exacerbating the effects of a flood (e.g. Tapsell et al, 1999; Tapsell & Tunstall, 2000; 2001; Tunstall et al,2006).

Insurance take-up should be encouraged, particularly in vulnerable groups such as renters. This would have co-benefits as it would cover insurance for any hazard, not just flooding (Lancaster University interview).

The two groups that tend not to take out insurance and are therefore most vulnerable and recover least well are tenants and small businesses. Tenants tend not to take out contents insurance due to high premiums and many private landlords do not have insurance either, so tenants are badly affected. According to an AXA report (2012) 80% of small businesses flooded do not recover because they do not take out proper insurance (such as business continuity).


Insurance is a very effective way of mitigating flood damage costs. The insurance industry data indicates that households pay around £340 on average for buildings and contents insurance, compared with between £20,000 and £30,000 for the average cost of damages after flooding (Defra, 2012a). An ABI study (ABI, 2011) found that 78% of 124,000 homes at significant flood risk were insured at lower premiums than they should be if risk of flooding was to be properly reflected in the price. The average premium paid by those at flood risk is £260, which is more than the average for all UK households (£220), but far less than the average risk-reflective price (£690). Most insurers do not charge a specific higher flood excess unless the customer has had at least one (usually two) flood claims (ABI, 2011). Where flood excesses are applied, most insurers do not apply an excess greater than £5,000, although this can be a large sum for people to pay.

There is an argument for linking insurance premiums with community action/householder actions, just as it is linked to larger physical infrastructure such as flood defences. However, this will be difficult to implement in a cost-effective manner for various reasons including an expensive requirement for manual underwriting in an insurance business model that is low cost and highly automated (ABI inteview). However, further work should go into the linkages between flood resilience and insurance premium.

Practical: Practical support for flood victims is important (Reacher et al, 2004). Significant efforts are involved in flood recovery, e.g. chasing quotes to phoning insurance companies, to managing builders, all on top of existing daily activities (Whittle et al, 2010). Householders must step in and project manage the actions of different organisations, which is challenging, time-consuming and stressful. Providing support so that the burden of this management role, to which many are unsuited, is reduced, would be very effective (Lancaster University, interview).

The difficulty with repairs is drying time. The critical pathway for returning people to their homes is the length of time it takes to dry it out. This depends on a number of factors, such as building material, flood level and time under water, as well s the drying method used (ABI inteview). There are ways (other than de-humidifiers) that can get dry a property far more quickly e.g. hydronic dryers or heat exchangers. The technologies are apparently more expensive and therefore not used, but other reports suggest that they are more cost-effective. For example, FloodBond reports that during the Cumbrian floods, the hydronic system was used on 122 residential properties resulting in cost savings of 50% compared to using dehumidifiers, and would have been 60% if the services had been used immediately after flooding, rather than five weeks afterwards (FloodBond, 2012). Using these sorts of technologies could significantly improve



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the experience of flood victims in the recovery process and is an area that should be looked at further.

Reinstating one’s home to include property level protection or flood resilient measures (e.g. air brick covers, door guards, sewerage bungs) does not tend to reduce insurance premiums, but they have significant benefits. They increase peace of mind, reduce damage caused to one’s property and possessions, reduce clean up costs, temporary accommodation, absence from work etc. There is an element of maladapation if the house is reinstated to be as vulnerable as it was beforehand. The house should be made resilient to flooding, so the house is as vulnerable as it was beforehand (Whittle et al, 2010). There should be incentives to encourage such measures as they can be expensive (e.g. £5,000-£40,000 for new builds and repairs and up to £70,000 for a retrofit) (Stevens & Chatterton, 2012).

Stevens & Chatterton (2012) found that the number of properties that would find it economically worthwhile to install manual resistance measures would rise to between 344,000 and 537,000 by 2080s with climate change. However, construction of strategic flood defence could mitigate the cost-effectiveness of these measures as flood risk decreases. Current funding scenarios suggest a 71% increase in the number of properties that could find it worthwhile to install these measures. The number of these properties that could benefit is not large, although their contribution may be more in terms of peace of mind (Stevens and Chatterton, 2012).

A very effective measure in reducing the level of distress people suffer would be to avoid houses being stripped out – including all possessions (Whittle et al, 2010; Lancaster University interviews). Insurers and builders should have enough information to be able to give people decontamination advice where possible and to avoid all possessions immediately being thrown away, particularly where it is family heirlooms or items of sentimental value. Codes of practice for specialist “disaster restoration companies”, for example, through training compliant with “investors in people” accreditation have been recommended (Armstrong, 2000).

(v) Provision of mental health services

Description

The measures described above can help to minimise mental distress by reducing some of the causal factors. However, it is important that those people who are suffering have ready access to help. This may include: providing information about mental impacts of floods; ensuring local GPs have information about the floods and potential impacts on mental health; and provision of additional services such as counselling.

Barriers


Health services may not be provided for long enough time. The symptoms can peak within the few months after a flood event, but they may continue for a long time after the actual flooding event.

Impact of recovery process is not straight forward. Whittle et al (2010) use the metaphor of “snakes and ladders” to describe it. These highs and lows can be closely related to specific issues in recovery management (e.g. good news from builders), but are also affected by other issues in people’s lives (e.g. work stresses, family illness). The challenges of normal life become exacerbated when coupled with managing flood recovery. There is no clear end point to recovery.

Lack of knowledge or training. Doctors need specific training and guidance in terms of recognising and dealing with the mental health impacts of flooding.

Informal support preferred. People tend to prefer using their networks of family and friends or informal community groups, than formal health providers. Families can be more effective than institutional health care providers (De Jong, 2002).

Undermines peoples’ resilience. Professional support can be ineffective where it implies the problem is with the householder rather than the recovery process. People may then assume that they cannot cope, rather than expecting to feel depressed due to the event that has occurred.

Extent of adoption

Low-Medium

In general it does not appear that additional health services are provided after a flooding event; existing providers have the capacity to cope with additional cases. It does not appear that information or advice and training is provided on specific mental impacts of floods. For example, in Gloucester, after the 2007 floods, no additional information was given to GPs in terms of what to expect, or what the longer-term impacts might be (SW Health Protection Unit interview). This is probably because it is a recently recognised issue, which is still poorly understood, for example, the Whittle et al report is from 2010 and the HPA report dates 2011.

It is expected that provision of information will increase in the future as floods become more frequent and as awareness of the issue of mental ill health from floods grows. For example, the HPA recently (July 2012) published a leaflet on essential information for front-line responders on flooding and mental health (HPA, 2012a). The most appropriate response for managing people who have been affected by flooding is based on Psychological First Aid (WHO, 2011). Hospitals (e.g. Gloucester) are beginning to offer training on “Psychological First Aid”.



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In some cases, e.g. Gloucester, drop-in centres have been set up after a flood which health specialists have attended. This has been useful as specialists are available for direct help rather than people needing to go via their GP first (Gloucestershire County Council interview).

Effectiveness

Low-Medium

This is a far less effective type of response compared with disaster risk reduction (HPA interview). It is a necessary form of recovery support, but as it deals with the symptoms rather than the causes of mental ill health, it is not as effective as the measures discussed above.

People affected by a flood should be able to get medical help. Pina et al (2008) found a positive predictive relationship between availability of professional support and not developing PTSD. The very act of intervention by a mental health professional communicates the message, that with treatment, things will get better. Interventionists are encouraged to normalise peoples’ responses and indicate that most people recover spontaneously (Resick et al, 2002) as this in itself instils hope against distressing thoughts.

The HPA (2012a) states that counselling may not recommended for affected people or for responders in the early stages of flood recovery, and that Psychological First Aid is a more appropriate response in the early stages in terms of dealing with mental distress. Psychological First Aid is not an intervention, but a set of principles and actions that can be performed by anyone. This may be because in the early stages, it is important to manage people’s expectations e.g. to let flood victims know that it is a normal response to feel some symptoms of depression after a flood event (HPA, 2011). The provision of professional help can be ineffective, where it implies that the problem is with householder rather than a response to recovery process (HPA, 2011). An overt focus on “flood” as the cause can encourage responders to pathologies of what is in fact a “normal reaction to abnormal events” (Convery et al, 2008).

A small minority of people are at risk of developing a mental health disorder and they may require specialist healthcare. It appears that existing mental health care services will absorb these cases. As such, information and training is important for GPs and healthcare providers, particularly in relation to the sort of treatment people need to get after a flooding event, which can be very important, for example, restoring hope and a sense of future. Treatment with adolescents has shown the efficacy of ongoing trauma-generated expectations, beyond symptom response, with forward looking exercises that promote developmental progression to instil hope and renewed motivation for learning and future planning (Saltzman et al, 2006).


Families can be more effective than institutional health care providers. Families are the main source of social capital within communities, and the main provider of mental health care after disasters, especially among rural populations (de Jong, 2002). The family must often substitute for professional care, so the more information given to residents, the more effective this informal mental health support can be. GPs, NHS Direct, insurers and local authorities should all have links to HPA information (or other sources of information) that let people know how they may expect to be feeling. These measures must be provided on a long-term basis, not just in the immediate aftermath (SW Health Protection Unit interview).



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Heatwaves in communities In this report, the adaptation measures for reducing health impacts of heatwaves focus on preparedness for heat waves, and on the social measures that can be taken, rather than on keeping physical infrastructure or housing cool, which is discussed in detail in the earlier Residential Housing and Overheating report. The actions described here are from the Heatwave Plan for England. A primary difficulty with assessing these measures is the lack of heatwaves that have occurred since 2003 and 2006 where the plans were developed. As a result, there is no evidence to examine their effectiveness, and so data has been drawn from experiences in other countries.

The measures include:

● Alert systems and summer preparedness

● Communication with the public

● Engagement with service providers

● Engagement with communities (focusing on support for vulnerable groups)

(i) Alert systems and summer preparedness

Description

Heat-Health Warning Systems (HHWSs) are a public health tool to reduce the adverse impacts of excessive heat on human health. They consist of (i) preparations before the onset of excessive heat; (ii) meteorology-based warning systems; (iii) rapid and coordinated actions during heat waves; (iv) criteria and procedures for deactivating the plan; and (v) evaluations following the response activities and outcomes (McGeehin & Mirabelli, 2001; Kovat & Ebi, 2007; Alberini et al, 2008).

A Heat-Health Watch alert system (described by the Heatwave Plan for England) operates in England from 1 June to 15 September each year. During this period, the Met Office may forecast heat waves, as defined by forecasts of day and night-time temperatures and their duration. The Heat-Health Watch system comprises four main levels (Kovat et al, 2006). These include: Level 1 (heatwave preparedness and long-term planning); Level 2 (alert and readiness – triggered on Met Office forecasts a few days before a heatwave); Level 3 (heatwave action – triggered once a threshold temperature is crossed); and Level 4 (national emergency – when the heatwave’s effects extend beyond health and social care) (DH, 2011).


The Heatwave Plan provides guidance to health, social care and local authorities, to care homes and hospitals, and to community and volunteer groups. The guidance covers ways of keeping environments cool, behavioural tips, focus on vulnerable individuals with health problems, and also tips for caring for others, particularly the elderly (DH, 2011).

Barriers

Lack of accounting for acclimatisation. Heatwave plans do not account for the impacts of acclimatisation. For example, alerts issued by US National Weather Services reduced impact of heat stress among the elderly by 25% in mid-west, north-east and mid-atlantics, but had negligible effect in the south (Alberini et al, 2008; Saudamini, 2010).

Vulnerable groups. The elderly and less-educated are less likely to heed advice, which is of concern as these are more vulnerable groups (Bassil et al, 2010). The messages may also not be conveyed successfully down the chain to end users, e.g. district nurses or care homes (Carl Petrokofsky).

Lack of self-perception of being at risk. There is a challenge in delivering targeted strategies to groups that do not actually consider themselves to be at increased risk (Bassil et al, 2010). A study in the UK interviewed senior populations living at home (>72 years of age) to assess heat risk perception (Abramson et al, 2009). While few recognized themselves at risk, they did recognize the risks and medical concerns in others.

Heatwaves are not considered a high priority risk. They are also short-lived and unpredictable. People are not used to considering the heat as a problem in the UK (Kolm-Murray). Heat wave plans were not widespread before 2003, so efforts were hampered by denial of the event’s seriousness and the inability of many institutions to instigate emergency-level responses (Lagadec, 2004). This makes it difficult to get people to prepare (LCCP, 2011).

Extent of Adoption

High

The extent of adoption is high as England has a national Heatwave Plan (adopted in 2004 and revised twice – relaunched in 2006 and reiterated annually) (Carmichael et al, 2012). The Heatwave Plan consists of fact sheets with advice on supporting vulnerable people; a guide for the general public; and sets out the responsibilities of a number of various organisations during a heat wave. Organisations include PCTs, local authorities, Strategic Health Associates (SHA), NHS Trusts (Kovat et al, 2006).

HWWS tend to be developed following experience of a heatwave event. For example, after 2003, several European countries quickly initiated plans to prepare



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for future events (WHO, 2006b). HHWS developed after Philadelphia suffered a heatwave in 1995, and this formed the basis of many others internationally (Ebi et al, 2004; Murray et al, 2012).

Heatwaves are already widespread and used and refined. The frequency with which they are used and referred to may increase.

Effectiveness

Medium - High

The Heatwave Plan for England is considered to be amongst the most effective in Europe (Lowe et al, 2012). However, plans can only be effective where they are implemented properly and action taken. The main features of a HHWS are timely accurate warnings, tailored communications and notifications of adapation actions to the most vulnerable populations (Lowe et al, 2011). As others have noted (e.g. Lowe et al, 2011; Carmichael et al, 2012) further research is required to address what actions were actually taken compared to those recommended as well as evaluations of the effectiveness of actions.

In France, fewer heat-related mortalities were reported in 2006 following the implementation of a HHWS and its affiliated interventions in 2004 (Toulemon & Barbieri, 2008). Similarly, in England, the estimates for each heatwave period in 2006 were lower than the estimated excess deaths in the August 2003 heatwave (around 2000 deaths over 10 days) (Mayor of London, 2006). The existence of the England Heatwave Plan in 2006 is responsible for part of this improvement.

The total cost of the HHWS in Philadelphia was $210,000 (Ebi et al, 2004). Given the relatively low cost, heat alerts and plans educating people of appropriate behaviour during hot weather are thought to be an effective adaptation strategy by many governments (WHO 1990, Menne and Ebi 2006; Saudamini, 2010). The HHWS in Philadelphia saved 117 lives between 1995 and 1998 with economic benefits estimated at $468 million12. Issuing a heat alert lowered daily mortality by 2.6 lives (Bassil et al, 2010; Ebi et al, 2004). Alberini et al (2008) found that heat advisories can reduce mortality by about 25% or more during extremely hot days (e.g., those when the heat index is 110° F or higher).

People tend to have high recall of heat alerts from broadcasts (74%) associated with a relatively high level of change of practice (63% respondents took protective measures compared with 48% the year before (Bassil et al, 2010)). Heat practices polled (such as increased hydration, closing sun-facing windows, etc.) showed an increased uptake of 15% in 2006 from 6% in 2005. Similarly,

12 This was based on an EPA value of a statistical life of $6.12 million (Smith et al, 2001) and accepted the Krupnick et al (2000) finding that VSL decline with age, being one-third lower for the 70-75 age group. They therefore assumed $4 million for the VSL of people 65 years or older in Philadelphia.


respondents reported increased efforts to support vulnerable friends and family, with 73% of respondents reported helping someone (Bassil et al, 2010). An assessment of the Heatwave Plan (Bickle & Johnson, 2011) found that there was a high awareness of the heatwave plan and most organisations found the plan assisted them before and in alert level 3 periods. However, there are still examples of LAs not being aware of the Heatwave plan or Cold Weather plan (BIOPICCC, 2012).

The Heatwave Plan is reviewed and revised each year. The sixth annual seminar on the Heatwave Plan was held in March 2012 and made a number of assessments and recommendations to aid revising the Plan before its re-launch in May (Carmichael et al, 2012). Recommendations, which have been implemented, include publishing an Easy Read version, and including high risk groups such as tourists, those fasting for Ramadan, and mass gatherings.

During heatwaves, many deaths occurring in the first two days, so Level 2 (Alert and Readiness) is an important stage to ensure readiness and swift action to reduce harm from a potential heat wave. Trigger points may need to be reviewed where alerts jump from level 1 to level 3 in one step, missing out level 2 where most of the preparation takes place. Either level 2 needs to be initiated earlier or the actions required need to happen earlier if this is likely this will be the pattern of alerts in the future (Bickle & Johnson, 2011).

(ii) Communication with the public

Description

This includes measures that communicate the Heatwave Plan, such as: providing information to the public though media before and during a heat wave; opening of designated cooling centres at public locations; information to the public through media before and during a heat wave (DH, 2011); distribution of bottled water through the Red Cross to vulnerable people; and operation of a heat information line to answer heat-related questions (Adger et al, 2007). These are awareness-raising actions of both the risks and the responses that can be taken. This is particularly important for caregivers of the old and infirm and parents of infants.

Barriers

Lack of understanding of key messages and change in practice: Information may be communicated, but it may not influence behaviour, e.g. US study shows that even through knowledge of the plan was almost universal (90%) due to pervasive media coverage (primarily television), knowledge of the details of the message of the mitigation plans were less well understood, and approximately half the population actually changed practice in response (e.g. less than 50% of over 65s changed their behaviour) (Kalkstein & Sheridan, 2007;



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Sheridan, 2007). Messages need to be specific and targeted to different groups as blanket messages can be ignored (D’Ippoliti et al, 2010)

Lack of coordinated leadership. There are different plans and different guidance from different organisations (LCCP, 2012). A survey of 1000 people in London showed that over 85% people felt that London Boroughs were responsible, 83% felt central government was responsible, 63% felt individuals were responsible and 49% felt that community groups were responsible (London Councils Omnibus, 2011).

Lack of awareness of the extent of the threat. Media such as radio, websites can be used, but these risk missing people who are not technologically connected, particularly vulnerable groups.

Lack of understanding of the real risk: There is a difference between perceived risk and real risk. Heat is still viewed as a positive thing, and it is not an obvious risk. It is therefore difficult to get people to understand and prepare for it (LCCP, 2011).

Timing of messaging. Frequent messaging can damage credibility, as people suffer from alert fatigue. In addition, greatest mortality tends to occur in the latter days of a heatwave, and high level alerts in the initial days do not address this (Montero et al, 2010). Activities need to continue after the initial onset and extend beyond the heatwave. Specificity of a trigger is therefore important (Lowe et al, 2012).

Extent of Adoption

Low-Medium

It is unclear to what extent local areas are implementing the Heatwave Plan. Since the 2006 heatwave, it has not been possible to test the extent of communication with the public as there have been no hot summers, and any public messaging regarding heatwaves at present would be lost or be inappropriate. Some councils are more proactive about engaging the public than others. For example, Islington is ran a “Help in the Heat” campaign in summer 2012, undertaking a number of proactive interventions. These include contacting vulnerable residents by door to door and conducting an informal welfare check; energy doctors on advice to avoid overheating; specifically targeting care homes to raise awareness; hosting events for the elderly (Kolm-Murray, 2012).

It is expected that communication with the public will increase in the future as awareness of heatwaves increases and as heatwave events occur with more frequency.

Effectiveness

Medium


Successful engagement in adaptation is essential for locally specific strategies (BIOPICCC, 2012). In an evaluation of the Heatwave Plan (Bickle & Johnson, 2007) it was found that most strategic health authorities felt the plan was clear and concise about their expectations and that there was a good multi-agency heatwave response. The media coverage was high and it is possible that this may have been a large contributing factor to the low level of heat related impact.

Different forms of communication should be used to cover as many people as possible. Research suggests that printed material with a combination of visual and textual information is more effective than texts or symbols alone (Fitzpatrick-Lewis et al, 2010). The Heatwave Plan is written now in large print, Braille and audio tape. Communication should take advantage of new forms of technology e.g. Twitter, Facebook. A recent study found that 60% people were willing to sign up to a mobile phone text alert system to warn them if an extreme weather event was likely (London Councils Omnibus, 2011). In rural communities a local radio station or newspaper may be more effective. These systems are low cost.

Plans and communication put in place as a result of the lessons learned during the 2003 heatwave are effective, for example, there were approximately one-third fewer excess deaths than expected (given temperature levels) due to preventative measures (approximately 2,000 excess deaths cf. 6,500 excess deaths expected given temperature levels) (Fouillet et al, 2008). The measures included increased awareness of the risks following 2003, institutional measures; and the implementation of HHWS by InVS and Meteo France (as of 2004).

Other evidence that higher levels of heat awareness and implementation of a warning system were responsible for lower levels of mortality when another heat wave occurred comes from studies conducted in Missouri and Wisconsin in the USA and in Shanghai (Weisskopf et al, 2002; Tan et al, 2007; and Smoyer, 1998).

A comprehensive source of information is very effective, e.g. Heatline in Philadelphia was called more than 2,300 times in the 2002 heatwave. In 25% of the cases, the person calling in was referred to a nurse; in 64 cases a mobile team was dispatched to the home of the distressed person (Kalkstein, 2003).

A coordinated system would increase the effectiveness of information communication, e.g an information hub or platform for sharing information between housing associations and care homes (LCCP, 2012). This was also a recommendation in the ARCC (2011) symposium – to share examples of best practice between local authorities. The BIOPICC project also recommends similar actions for more guidance to local authorities and the opportunity to share examples of good practice (BIOPICC, 2012).



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(iii) Engagement with service providers

Description

The measures taken by local NHS and social care organisations (DH, 2011) include: action to reduce indoor heat exposure (medium and short term) (e.g. provide cool rooms, monitor indoor temperatures; move critical patients or individuals in care homes); particular care for vulnerable population groups (helping GPs and social workers to identify vulnerable patients and clients and providing them with information and good practice advice); and preparedness of the health and social care system (e.g. staff training and planning, appropriate healthcare and the physical environment).

Barriers

Communication failure. Failures in communication between institutions and health services exacerbate heat impacts. For example, in Chicago in 1995, an emergency heat warning was only released by the city on the last day of the heatwave; so measures such as Chicago’s five cooling centres were not fully utilised, hospitals refused to release additional ambulances and staff and the medical system was severely taxed as thousands were taken to local hospitals with heat-related problems (Klinenberg, 2002; EA, 2008).

Lack of specialised knowledge. A lack of specialised knowledge in medical profession of the impacts of heatwaves and a lack of training means that practitioners do not know how to deal with the effects (LCCP, 2011). Heatwaves impact by exacerbating existing illnesses and impact within a couple of days, unlike cold weather which takes much longer before it impacts health (Carl Petrokofsky; John Kolm-Murray).

Extent of Adoption

Low-Medium

There is a growing awareness that GPs need particular engagement, as do other healthcare providers. The Heatwave Plan has specific recommendations for care homes, GPs, hospitals for example. In addition, the RCGPs recently published a document outlining challenges and information on heatwaves for GPs (RCGP, 2012). Although specific engagement with healthcare providers has not been particularly widespread, it is increasing and it is expected that this trend will continue.

The 2007 evaluation (Bickle & Johnson, 2011) found that 51% of the inspectors surveyed stated that a positive response had been implemented in all or the majority of the Care Homes they had visited; 12% stated they saw a positive response in half of the care homes visited; while 15% saw a positive response in


the minority of care homes visited and 4% did not see a positive response in any care homes visited.

The reorganisation of health and social care provides more opportunities for working with local healthcare providers, particularly for vulnerable people.

Effectiveness

Medium-High

Engagement with healthcare service providers is effective. A study used heat-related morbidity and mortality during 1995 and 1999 heat waves in Milwaukee, USA, to compare heat-related mortality rates and ambulance services (Weisskopf et al, 2002). The lower rates in 1999 were attributed to improvements in public health response (Bassil et al, 2010).

The importance of preparation for and awareness of possible consequences of heatwaves is that there is a very short opportunity for action to reduce excess death rates once a heatwave is established (RCGP, 2012). A Response must be quick as the HHWS alert system gives only a few days’ prediction of a heatwave.

The evaluation of the Heatwave Plan suggested ways that the plan could be even more effective (Bickler & Johnson, 2007). In PCTs there were high levels of awareness and dissemination of the plan. The majority of PCTs thought the plan was clear about what their organisation had to do, but many made commented that while they were clear, there were difficulties in achieving what was requested. It was also noted that there needed to be more clarity on responsibility and accountability.

Recommendations have been made for GPs to be further engaged and trained in the immediate and long term impacts of climate risks – not just heat waves. This would have co-benefits, as doctors in the future need to have knowledge of these impacts (ARCC, 2011; BIOPICC, 2012; Carmichael et al, 2012; RCGP, 2012).

(iv) Engaging with the community (focus on the vulnerable)

Description

These measures include provision of extra help, where possible, to care for those most at risk, including isolated older people and those with a serious illness or disability. This could come from local authorities, health and social care services, the voluntary sector, communities and faith groups, families and others. In the England Heatwave Plan, this is determined locally as part of the person’s individual care plan and will be based on existing relationships between statutory and voluntary bodies. This could include provision of cool rooms in care homes or in social housing.



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Barriers

Identification of vulnerable people: Broad definitions of who is vulnerable lead to additional efforts not being targeted (Bickler & Johnson, 2007). There is some concern whether information was actually reaching vulnerable populations given the challenge in contacting such a large number of people At local level, identifying vulnerable individuals and households is challenging. There may be multiple lists of vulnerable people held by different agencies and they are often not up to date. In addition, reaching those vulnerable people can be difficult (BIOPICCC, 2012). Buildings are also classified as vulnerable.

Lack of understanding of risks of individuals. People do not like being classed as “vulnerable” or at risk individuals (Smoyer, 1997). A survey found that the elderly were not concerned about heat (e.g., “I’ve lived here all my life, never had air conditioning, so why would I have a problem now?”) or not taking advantages of resources (e.g. “cooling shelters are only for really poor people”) (Bassil et al, 2010).

Fragmentation of responsibility: Diversity of responsibility between who is responsible for social housing and care homes which adds to the complexity and makes it harder to coordinate effective strategic and operational decisions and communicate with vulnerable groups (LCCP, 2012). The personalisation of health and social care may result in more informal care arrangements with little scope to regulate care delivery and record this information centrally (BIOPICCC, 2012).

Extent of Adoption

Low - Medium

The Heatwave Plan has recommendations for vulnerable groups and each year it is revised to include further specific guidance. However, this is unknown how widespread this is on the ground (John Kolm-Murray). Some local areas e.g. Islington Borough, are taking specific action to raise awareness and have plans to check on vulnerable groups during a heatwave (JKM) and specific events to target them (Help in the Heat, 2012). However, this is not standard practice.

There are few examples of community centres being set up to provide cool rooms. However, there a few examples of GP practices which have become centres of the community – providing a mix of primary healthcare and social care for vulnerable people, such as the Bromley by Bow Centre in London13.

According to LCCP (2012) staff in London Boroughs are trained and experienced in day to day management of buildings and residents during hot

13 http://www.bbbc.org.uk/pages/about-us.html


http://www.bbbc.org.uk/pages/about-us.html

weather. Yet this is slightly contradictory with other messages that care home nurses/managers are not well informed about managing heat risk (only 51% inspectors surveyed said care homes were managing heat risks (Bickler & Johnson, 2007).

This is likely to increase in the future as awareness of using voluntary groups grows and as heatwaves become more frequent, and the new public health role of local authorities could help to make it a joined up response.

Effectiveness

High

Heatwave measures need to include specific tailored plans for vulnerable groups. Specific targeting of vulnerable groups is extremely important as they are the ones that are most at risk and where efforts to help will make the biggest difference. According to the LCCP (2012) many individuals within the social housing and care home sectors do not currently perceive heat wave risks as serious enough to make major changes to strategic and operational decision making processes. More work with care home residents’ individualised care plans is considered essential (LCCP, 2012) as is coordination with GPs (Carmichael et al, 2012).

It is difficult to ascertain the extent to which vulnerable groups have been identified, but this is an important measure to take in the short-term. This information is held locally and depends on the local authority or the GP practices. Risk registers showing the location of vulnerable people are a useful way of targeting efforts in an emergency, e.g. the Joseph Rowntree Foundation has produced a series of national scale vulnerability maps which provide a useful national picture, and BIOPICCC produced maps for future health care at local authority area level. Vulnerability mapping is useful, but there are issues around sharing of information and confidentiality. Heat risk also varies as people move from home to work and people are not the only factor classed as vulnerable, but houses too. GPs and community knowledge should be used for targeting interventions (Carmichael et al, 2012).

In an evaluation of the Heatwave Plan, the main difficulty for the PCTs was in contacting vulnerable people. For example, 67% of PCTs were satisfied that lists of vulnerable people were drawn up at practice or other local level in the heatwave period. However, only two-thirds of those PCTs were satisfied that vulnerable individuals were contacted during levels 2 and/or 3 (Bickler & Johnson, 2007). Vulnerable groups of low socio-economic status are more effectively reached by community based strategies and more active engagement than the media or written information (Semenza et al, 2011). Clear and credible information and case studies are required to facilitate deeper engagement.



99

The voluntary sector and community groups are increasingly important and existing local networks are seen as “invaluable” (Carmichael et al, 2012, p11). They are very cost-effective (£2,000 for awareness raising programme to target 1000 elderly and £1,500 for rapid response work in the event of a heatwave) flexible and trusted by the community (e.g. North London Cares in Islington). Voluntary organisations can provide services targeting the vulnerable as they are best placed to help and are trusted (e.g. Equinox focuses on drug users and homeless, and North London Cares focusing on the elderly in Islington) (Kate Damiral; John Kolm-Murray).

Specific information should be provided to families and informal carers of at-risk individuals to ensure awareness of the dangers of heat. Coordination and collaboration with Care Quality Commission (CQC) and Nursing Homes Association should be encouraged to ensure messages are transferred and training is undertaken (Carmichael et al, 2012). This could be in the same way as the RCGP’s issued a specific document for GPs (RCGP, 2012). Carmichael et al (2012) recommend specific actions for care home staff and more engagement with them, such as providing clear messages that can be embedded into daily actions, reviewing their Major Incident Plans to see if and where heatwave planning sits, training days and using the CQC newsletter to communicate risks.


101

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Annex 8: References

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Annex 8: References

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