Guidance

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

Updated 21 March 2024

Applies to England

Who this guidance is for

This guidance is for those with responsibilities for people currently sleeping rough. This includes local authority teams for emergency preparedness, public health and rough sleeping, as well as non-governmental organisations, including those providing temporary accommodation or street-based support.

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

Where possible, we would promote the co-development of local plans with individuals and networks with lived experience of sleeping rough.

Main messages

Climate change is increasing the frequency of dangerous hot weather episodes in England.

People sleeping rough are at very high risk of poor health outcomes, or even death, during hot weather.

Before the summer begins, clear plans should be in place, tailored to the local context.

Services should sign up to the new Heat-Health Alert (HHA) system and be familiar with it and resources from UK Health Security Agency (UKHSA), in partnership with the Met Office. Further details about the HHA system can be found below.

Consider ways to identify who and where your most vulnerable individuals are and how you can help them.

Identify barriers and enablers to your ability to operate in hot weather, such as refrigeration capacity or accessibility of cool spaces, and seek to improve your capabilities over time.

Build best practice by collaborating with other relevant partners, including clients, to provide mutual support and share learnings.

Why people experiencing homelessness are at risk in hot weather

People sleeping rough are more at risk from hot weather because:

• they are more likely to be exposed to heat
• they are likely to be more vulnerable to the effect of heat due underlying health conditions
• they may be less able to take preventative steps for a variety of reasons, especially as a result of social exclusion

Exposure to heat

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

• sitting or lying in direct sunlight or on hot surfaces, for example, sleeping on concrete or tarmac
• hot informal accommodation, such as tents, vehicles, caravans, boats
• wearing multiple layers of clothing
• increased physical exercise, walking to find shelter or carrying heavy loads
• begging and other street work likely to take place in dense urban areas, which will be hotter due to urban heat island effect

Increased vulnerability

People sleeping rough are likely to have increased vulnerability to heat due to:

• increased rates of physical health conditions, especially heart, lung and kidney conditions as well as diabetes, Parkinson’s disease and dementia
• increased rates of mental health conditions, including those that require medication, such as antipsychotics, that may alter the body’s response to heat
• poor healthcare access limits management of acute or chronic conditions
• frailty
• alcohol use, which increases urine production and worsens dehydration
• use of recreational drugs that can increase body temperature, alter behaviour and decrease consciousness levels
• malnutrition and reduced access to appropriate food
• high smoking rates increase risk of respiratory complications
• low awareness of risk of heat by individuals and organisations
• low visibility of individuals sleeping rough to services due to location, such as, living in derelict buildings or in parks
• less likely to receive assistance due to societal stigma

Decreased ability to adapt

People sleeping rough are less able to adapt because of:

• social exclusion and isolation that reduces access to help, information and support
• low financial and material resources
• behavioural constraints, for example, from learning difficulties, brain injury, medicinal or recreational drug or alcohol use
• musculoskeletal disorders that reduce mobility
• mistrust of authorities
• fear for personal safety, for example, for a woman in male dominated settings
• reduced access to transport to move to cooler areas, including outdoor green space and cooled indoor spaces
• reduced access to cool and drinkable water

Risk assessment

The above risk factors can be used to risk assess individuals sleeping rough. It is important to consider that:

• most people sleeping rough are at increased risk of exposure to hot weather
• the presence of multiple existing risk factors that may compound and greatly increase risk
• a single risk factor may vary in severity, for example, a medical condition like diabetes can vary from well controlled to life threatening complications
• determining relative risk between individuals for resource allocation will be context specific and requires a holistic approach
• forming or adapting multidisciplinary team meetings to inform risk assessments

Health impacts of hot weather

High temperatures can cause direct heat-related illnesses, such as heat stroke, as well as worsen existing illnesses for people sleeping rough. There are also indirect effects of heat, like increased risk of drug and alcohol use, accidents and injuries.

Heat-related illnesses include:

• dehydration
• heat cramps
• heat exhaustion
• heat stroke, which can be lethal and if suspected you must call 999

More details on recognising heat related-illness can be found on the NHS website.

Complications from existing medical conditions and behaviours can include:

• worsening of lung conditions, for example, asthma attacks and exacerbations of chronic obstructive pulmonary disease (COPD)
• triggering heart problems, for example, heart failure or heart attacks
• kidney damage, from dehydration or urinary infections
• worsening mental health, including increased suicide rates
• insomnia from hot uncomfortable night-time temperatures
• increased drug or alcohol use, potentially increased due to mental stress of heat

Other health impacts can include:

• accidents and injury, for example, from altered mental state or increased aggression, violence or risk taking
• skin damage from sunburn and blistered feet from walking barefoot on hot tarmac
• increased bathing and swimming in lakes, rivers or the sea to cool down poses possible risk of injury, drowning and exposure to pollution and infectious diseases
• cold shock response from suddenly entering cold water can be lethal, for example, from jumping into a lake
• greater risk of dangerous animal exposure if moving to greener cooler areas, including dogs, rodents, mosquitoes and ticks
• infections from consumption of food that has quickly spoiled
• risk of delayed medical care as severe and/or deteriorating health being dismissed as sleeping or intoxication

Preparation for hot weather

Preparation should occur all year around and a plan should be agreed and disseminated before 1 June.

Actions to take all year round include:

• signing up to the HHA system
• considering improving or developing a severe weather emergency protocol (SWEP) with local partners, for emergency response during extreme hot weather
• identifying those most at risk using the risk factors above and consider creating a risk register
• having individualised care plans in place where possible, involving the relevant local services
• engaging with individuals with lived experience to understand local context and where vulnerable individuals are likely to go during hot weather
• building relationships and trust with people sleeping rough and service partners to strengthen resilience when operating under the physical and operational stress of extreme heat
• promoting access to good quality healthcare, which will lead to improved treatment of long-term conditions

If in your remit, work to increase publicly available water sources, such as water fountains, and access to shade, for example by the planting of trees. Consider targeted action in areas with a higher number of people sleeping rough.

Actions to take during summer

Services and facilities

Know which buildings, rooms or services, such as outreach vehicles or locations, are at risk of overheating, and know how to cool them.

Know how to access to air-conditioned areas if available.

Prioritise available cool spaces for those most at risk.

Incentivise the use of cool spaces, for example, by offering activities, entertainment, food, drinks, safe storage of belongings and accessibility for pets.

Permanent services are more likely to be used than those that are stood up and down quickly, such as an established shelter, with air conditioning versus a temporary cooling shelter.

Adjusting provisions of some services can provide extra daytime protection, for example, extending opening hours of night-only hostels.

Suggestions on how to make buildings cooler can be found within the Beat the heat guidance on GOV.UK.

Resources

If relevant to the service you provide, ensure you have sufficient sunscreen, sun hats and light cool clothing for distribution.

If distributing water, consider how you can keep bottles cool in storage and during distribution.

Use alternative means of hydration for those who do not like water, such as sports drinks or ice lollies.

Disseminate relevant information to people sleeping rough, for example, directions to public water fountains and cool spaces.

Ensure all information is in accessible formats and delivered via trusted services and individuals.

Capacity and training

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

• the relevant preventative measures in your context
• who has risk factors for poor outcomes in hot weather
• what heat-related health problems look like and what to do
• what actions can be taken in your local context during hot weather
• how concerns can be escalated and how you work with other services
• how staff can keep themselves safe in hot weather, such as increased breaks and access to fluids and cool rooms
• how to use the relevant materials described in additional documents of this guidance

Responding to hot weather

Given the increasing frequency of hot weather, it is advisable to develop emergency response plans for individuals sleeping rough. These could be linked to the new HHA system developed by UKHSA and the Met Office. Yellow, amber and red alerts will be issued based on the expected impact on health from hot weather.

For example, the Greater London Authority and others are adapting the SWEP used for cold weather, to prepare for hot weather. Detailed guidance on SWEP development can be found on the Homeless Link website.

Detailed guidance on the development of a SWEP protocol is outside the scope of this guidance. However, main components may include:

• the distribution of cool fluids, appropriate food, sunscreen and protective clothing
• the offer of appropriate accommodation or shelter proportionate to the individual’s risk and severity of hot weather
• support to access cool spaces and/or other means to cool down
• communication and provision of relevant information through trusted channels and in accessible formats
• protection of staff
• being supported by all relevant stakeholders in the local context

Such emergency response protocols should be facilitated by the local resilience forum (LRF) and involve all relevant stakeholders.

Consider other at-risk groups

This guidance has focused on people who sleep rough, but there will be other groups with similar risks to hot weather. For instance, check on those who:

• have recently slept rough
• are in informal or temporary accommodation
• are recently housed in accommodation susceptible to overheating

Consider it is possible that people may return to outdoor sleeping to avoid the higher indoor heat.

Protection of staff

During extreme heat, your day-to-day practice may be disrupted. Staff may find it difficult to commute to work and experience heat stress during work, for example during street outreach. Business continuity plans may need to be implemented.

Consider:

• identifying any staff who are more vulnerable to heat
• increasing the frequency of breaks, and ensure there is a cool area to rest and means to cool down, for example, fans, cool drinks and ice lollies
• changing working hours or daily routines to cooler parts of the day
• increased support
• implementing business continuity plans if service disruption expected

Guidance on temperature in the workplace can be found on the Health and Safety Executive website.

Evidence and best practice

This guidance has been developed following a rapid literature review of the available peer-reviewed and grey literature in April 2023. It has been developed 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 is underdeveloped. Aim to capture activities and lessons learnt to share with other stakeholders. If possible, formal evaluations of interventions would help to build the evidence base.

Further resources and information

Additional documents

• Weather-Health Alerting system: user guide
• Weather-Health Alerting system: registration form
• Adverse Weather and Health Plan
• Hot weather and health: action cards
• Supporting vulnerable people before and during hot weather: social care managers, staff, and carers
• Beat the heat resources for the general public
• Homeless Link case studies

Heat-Health Alerts (HHA)

HHA will be issued 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, as well as the likelihood (low to high) of those impacts occurring. This additional information should aid in 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 heat effects outside the health sector.

Once the decision is made to issue an alert (yellow, amber or red), these will be cascaded to those registered to receive the alerts and made available on the new dedicated web platform. Alerts will be issued with as much lead time to the event as 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.

NHS advice

The NHS provides additional advice on heatstroke and other heat-related conditions as well as sun safety and sunscreen. We have also recommended that patients and the public can phone NHS 111 or their GP if they are concerned about their health or that of others.

Information on air quality

If you would like more information about air pollution in the UK or health advice for those who may be particularly sensitive to air pollution, visit the Department for Environment, Food and Rural Affairs (Defra) website.