Guidance

Supporting vulnerable people before and during cold weather: people homeless and sleeping rough

Published 11 September 2023

Applies to England

Who is this guidance for

This guidance is for those with responsibilities for people currently sleeping rough in England. This includes:

• local authority teams for emergency preparedness, public health and rough sleeping
• non-governmental organisations working with people who sleep rough such as those providing temporary accommodation or street-based support

Not all advice provided here will be relevant to every stakeholder. It should be adapted according to service role, available resources and the local context.

Where possible, local plans should be co-developed with individuals and networks of people with lived experience of sleeping rough.

Main messages

When supporting people sleeping rough before and during cold weather, consider:

• people sleeping rough are at high risk of poor health outcomes or even death during cold weather episodes
• before winter begins, clear plans should be in place to support those who are sleeping rough, tailored to the local context
• services should sign up to, and be familiar with, the new (Cold-Health Alert (CHA)) system established in partnership with the Met Office, and local services should consider how they would trigger local Severe Weather Emergency Protocols (SWEP) in relation to the new CHA system
• identify who and where your most vulnerable individuals are, how accommodation will be provided for them when SWEP are triggered, and other ways in which you can help them through periods of cold weather
• identify factors that may affect your team’s ability to operate in cold weather and adapt care strategy and plans accordingly (such as transport disruption, and increased risk of staff illness affecting capacity)
• promote key winter preventive measures such as COVID-19 and flu vaccination for people sleeping rough, and for eligible staff members, to reduce risks of infection
• develop best practice by collaborating with local authorities, other relevant partners, and people sleeping rough, to provide mutual support and share learning

Why people sleeping rough are at risk in cold weather

Cold weather periods frequently result in an increased number of deaths, and people sleeping rough are at greater risk from cold weather than others. Sleeping rough increases the risk of cold-related illness and death. The use of health services among those sleeping rough is higher than in the general population when the weather is cold. Risks to health increase as temperatures fall. People sleeping rough are more likely to be exposed to cold, are more likely to experience significant effects from this exposure because of underlying health conditions and are less able to take preventive measures to protect themselves.

People sleeping rough are more likely to be exposed to cold because of:

• direct exposure to cold temperatures, ice, snow and the effects of wind chill, which can lead to serious health problems for those who are exposed to these conditions overnight or for prolonged periods of time
• sitting or lying on cold surfaces (for example, sleeping on concrete or tarmac)

People sleeping rough are more vulnerable to the effects of cold exposure because:

• they are more likely to have one or more chronic health conditions (such as heart, lung or kidney disease, diabetes, Parkinson’s or dementia) which may be worsened by cold exposure, but which also increase susceptibility to infection
• they are more likely to use alcohol, tobacco, and other substances, which increases the risk of developing health complications such as respiratory infections
• they are more likely to experience malnutrition and reduced access to food which limits people’s ability to tolerate cold exposure
• poor access to health and social care reduces the likelihood that acute or chronic conditions in those sleeping rough are appropriately managed, which in turn reduces resilience to cold weather
• they may be less visible to services because of their location (such as living in derelict buildings or in parks)
• they may be less likely to receive or to access assistance due to societal stigma

People sleeping rough are less able to take preventive measures to protect themselves. Measures they may take to try to protect themselves from cold exposure, such as finding cover in unsafe areas, may increase risks of accidental injury or even death.

Health impacts of cold weather

Cold exposure-related illnesses

Direct effects of cold exposure can include increased risks of:

• hypothermia, especially in those with cognitive impairment (including as a result of dementia, traumatic brain injury or from temporary causes such as drug and alcohol misuse) who are less able to recognise that they feel cold
• falls and injuries, for example by slipping on ice during cold conditions

Complications from existing medical conditions

Exposure to cold can also increase the risk of:

• heart attacks, strokes and increases in blood pressure
• respiratory disease and respiratory infections such as influenza
• complications in women who are pregnant
• mental health problems including depression

Other health impacts

These may include:

• accidents and injury (for example, from altered mental state or increased aggression, violence or risk taking under the influence of substances)
• risk of delayed medical care as severe and/or deteriorating health being dismissed as sleeping or intoxication
• air pollution tends to worsen on very cold, clear days, which can in turn increase the risk of respiratory problems

Preparation for cold weather

Preparation should occur year-round and plans for managing cold weather events should be agreed and distributed before 1 November each year. Many general actions in preparation for cold weather are outlined in CHA action cards accompanying this guidance, and specific to commissioners, providers and organisations in the voluntary and community sector.

Actions to take all year round

To support year-round action in preparation for cold weather, you should:

• sign up to the CHA system and find more information within ‘about the Cold-Health Alert system’ about the CHAs
• consider improving the existing SWEP with local partners, drawing in evidence on the effectiveness of work from previous years where available and local good practice
• consider local SWEP activation thresholds should be temperature based or aligned with new impact based CHA system
• whilst all people sleeping rough are at high risk from cold weather, if resources are limited consider identifying those most at risk and creating a risk register to help keep track of what support is being provided and to whom
• engage with individuals with lived experience to understand local context and where vulnerable individuals are likely to go during cold weather
• build relationships and trust with people sleeping rough and service partners (this must include the local authority) to strengthen resilience when operating under the physical and operational stress of cold weather, for example, through consultation on service design, and through direct participation of people sleeping rough in program development and implementation
• promote access to good quality healthcare, which will lead to improved treatment of long-term conditions
• consider targeted actions in areas with higher numbers of people sleeping rough

Actions to take during the winter

Protect service users and staff

To help protect service users and staff, you should:

• point them to general guidance on how to keep warm and well in winter including UKHSA’s guidance on Keeping warm and well: staying safe in cold weather
• promote vaccination for COVID-19 and/or flu among service users and staff members to help reduce risks from respiratory infections during winter; you can check eligibility for flu and COVID-19 vaccines online and can book flu vaccinations by searching online for pharmacies that provide them
• open severe weather accommodation to people sleeping rough in the event of local SWEP activation
• use the opportunity provided by opening severe weather accommodation to take preventive measures to protect service users’ health, such as supporting people to register with primary care providers, and screening for disease (such as tuberculosis, blood borne viruses)

Strengthen services and facilities

To make sure that services and facilities are appropriately prepared to support people sleeping rough during cold weather, you should:

• know which buildings, rooms or services (such as outreach vehicles or locations) are at risk of cold temperatures and/or mould, and apply public health principles to manage potential health risks arising from this
• ensure that night shelters apply public health principles to reduce the risk of spread of respiratory infections during the winter months, including access to single-room accommodation (especially for older people) and appropriate ventilation of communal spaces, drawing on current operating principles for night shelters guidance
• consider adjusting provision of some services, for example, extending opening hours of night-only shelters, to provide extra daytime protection during cold weather

Support training and capacity development

Build the capacity of your frontline staff by specific training, by considering:

• the relevant preventative measures in your context, such as eligibility and pathways for receiving vaccination, and support to identify accommodation (as outlined in local SWEP guidance)
• who has risk factors for poor outcomes in cold weather
• what cold-related health problems such as hypothermia and frostbite look like and what to do if they are encountered
• what actions can be taken in your local context during cold weather, many of which are contained in the action cards for providers and for the voluntary and community sector, linked to this guidance
• how concerns can be escalated and how you work with other services
• how staff can keep themselves safe in cold weather, including drawing on measures in UKHSA’s Keeping warm and well: staying safe in cold weather guidance
• how to use the relevant materials described in the additional documents section of this guidance

Provide information resources

• give relevant information (for example on access points for accommodation, access to food, and advice on other measures outlined in UKHSA’s keeping warm and well guidance) to people sleeping rough
• ensure all information is in accessible formats and delivered via trusted services and individuals, which may involve work to understand what information formats and delivery mechanisms are viewed as most accessible and most trustworthy by those who are sleeping rough

Responding to cold weather

General measures

Response plans to support individuals sleeping rough during the winter months should be developed and reviewed regularly.

Locally designed SWEP are a common approach for responding to cold weather for rough sleepers in England. Detailed guidance on SWEP development and implementation can be found on the Homeless Link website. Key components of SWEP include:

• providing emergency accommodation to people sleeping rough during cold whether
• agreement on, and planning for, specified service delivery models to meet accommodation and other needs that are likely to arise among people sleeping rough when cold weather spells occur
• applying public health principles to mitigate potential health risks in night shelters and other accommodation settings
• communication and provision of relevant information through trusted channels and in accessible formats
• measures to protect staff from the effects of cold and common winter illnesses

Typically, local SWEPs have been designed to be triggered by a specific temperature threshold. In contrast, the CHA system is based on forecasting expected health and social care system impacts of the weather. This is in alignment with the National Severe Weather Warning Service. Consider which approach to SWEP activation is most suitable for your local plans. Emergency response protocols should involve all relevant, local stakeholders to ensure robust partnership working across the local authority, other local public bodies, voluntary, community, and faith-based sector organisations.

Protecting staff

During cold weather, day-to-day practice may be disrupted. Staff may find it difficult to commute to work, or to reach service users through street outreach work. Staff absences may also be more likely due to, for example, respiratory illness. Business continuity plans may therefore need to be implemented.

Consider:

• identifying any staff who are more vulnerable to cold – and signposting them to general advice given in UKHSA’s Keeping warm and well: staying safe in cold weather guidance
• implementing business continuity plans if service disruption expected
• consider Health Safety Executive guidance on temperature in the workplace

Generating evidence on best practice

This guidance draws on information contained in the AWHP supporting evidence document and other evidence (that will be published in due course). It has been developed in consultation with stakeholders in central and local government and non-governmental organisations. This guidance will be expanded over time to cover wider definitions of people experiencing homelessness and in response to new evidence.

We recognise many providers are working in resource constrained settings and that the evidence to support guidance for those sleeping rough is underdeveloped. However, partners should aim to capture activities and lessons learnt, to share with others, and where possible conduct formal evaluations of interventions to help build the evidence base.

Further resources and information

Additional documents

• Keeping warm and well: staying safe in cold weather
• Adverse Weather and Health Plan
• Adverse Weather and Health Plan: supporting evidence
• Weather-Health Alerting System: user guide
• Supporting vulnerable people before and during hot weather: for social care managers, staff, and carers
• Supporting vulnerable people before and during cold weather: for healthcare professionals
• Homeless Link severe weather (SWEP) and extended winter provision case studies

About the Cold-Health Alert System

Cold-Health Alerts will be issued to those who have signed up to the CHA system when the weather conditions have the potential to impact the health and wellbeing of the population. The alerts will be given a colour (yellow, amber or red) based on the combination of the impact the weather conditions could have, and the likelihood of those impacts being realised. These assessments are made in conjunction with the Met Office when adverse weather conditions are forecast.

Yellow and amber alert assessments cover a range of potential impacts, for example impacts on specific vulnerable groups, such as people sleeping rough, through to wider impacts on the general population. They also cover the likelihood (low to high) of those impacts occurring. This combination of information on impacts and likelihood should help those making decisions about the appropriate level of response during an alert period. Within the alert that is issued, the combination of impact and likelihood will be displayed within a risk matrix. Red alerts indicate a national emergency with a risk to life for the general population, with wide ranging temperature impacts outside the health sector.

Once the decision is made to issue an alert, these will be cascaded to those registered to receive the alerts and made available on a dedicated web-platform. Alerts will be issued with as much lead time to the event as is possible to allow users time to make their local assessments and to initiate all appropriate actions to reduce harm to health. Users should review every alert when issued to ensure they fully understand the potential impacts and how likely they are to occur.