The way that we use energy is linked with a wide range of social and environmental policies, which in turn relate to health. The needs for sustainable environmental policies clearly has long term implications for the ecology of the planet and the health of individuals.

Energy from fossil fuels must be reduced to meet international commitments on global warming, with impacts especially on health in the developing world. Energy patterns in London show falling use for industry but rising use for transport. More efficient use of domestic heating where there is fuel poverty (within the government's programme for energy conservation) could reduce excess winter deaths and disease, while traffic reduction is required to achieve overall energy targets.

The London Energy Study (Chell and Hutchinson, 1993) described supply, use and effects of energy in London at the beginning of the 1990s. London uses 1.7% of all energy in the European Community, more than Portugal, Ireland or Denmark. Sources of energy supplied are petroleum (48%), gas (38%), electricity (13%), coal (1%). [NB One fifth of all energy supply, i.e. about 40% of all petroleum, goes to London's five airports for air travel]. Approximately one third is used by industry and commerce, one third on transport and one third is domestic. Increased use in transport is the cause of current rising levels of energy use.

Reduction of energy use is required to meet EU commitments at the Kyoto conference on global warming. The greatest health consequences of failure of the developed world to meet these targets will be on the poor of the world, especially sub-Sarahan Africa, as famine, infectious diseases and deaths from migration and war (McMichael & Haines, 1997). Effects in the UK will include deaths from floods and possibly an increase in infectious diseases. In 1998 there were 21 deaths nationally from the Easter floods and £400m of damage. It is estimated that the Thames barrier will have to be lowered 300 times a year by the end of the century (current average 2-3 times a year, see Environment Agency Thames Region).

The potential benefits of an integrated approach to energy efficiency are substantial: large financial savings; large gains in employment; a reduction in fuel poverty; and a major contribution to diminishing the threat of global warming.

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Transport has an effect on energy consumption in two ways: vehicle emissions and fuel consumption. The contribution of road traffic to pollutant concentrations is discussed in the sections on air and transport and is part of the current air quality strategy that requires local authorities to set up air quality management areas following assessment and predictions of air quality relative to standards set for 8 pollutants in the NAQS.

Despite excellent examinations of transport's contribution to energy consumption (London Energy Study, 1991) and emissions in London (London Emissions Inventory, 1997), there are no data about total fuel consumption of vehicles travelling within London itself. One of the key themes is the relatively low energy efficiency rate of cars compared with public transport modes and most markedly walking and cycling. The amount of energy consumed by the differing modes of transport mirror the amount of impact the differing modes have on air emissionson to road casualties. Some of the key features of road traffic fuel consumption relate to the number of people in a vehicle (more people gets more out of the fuel in the vehicle) and the benefits of smaller engines and better driving techniques. One person riding a bike is 19 times more efficient in terms of energy consumption than a 2 litre car with four passengers and 77 times more efficient when the car has just its driver.

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Energy efficiency does not result from current 'market forces': consumers receive limited information on selected items about energy efficient equipment; energy producers get profits from increased sales rather than increased efficiency; costs to consumers of different sources of energy are confusing and vary because of external market forces; while subsidies between 'renewable' sources have been imbalanced.

While boilers burning fossil fuels can achieve efficiencies of around 80%, generating electricity is much less efficient at around 35%. Retaining heat in water pipes for central heating can raise efficiency up to 80%. This 'combined heat and power' however, requires the electricity to be generated close to housing or industrial use. CHP is not new: Battersea power station provided steam heating and hot water to housing in Chelsea until it was closed. [In Paris, a well-established system supplies 5000 buildings - including the Louvre - from 12 generating stations (40% by incineration of waste). The London Energy Study recommended that the Whitehall heating should be converted to CHP as a demonstration. CHP charges can be accurate using modern electronic meters.

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As unwanted houses are being demolished at the rate of 12 000 per annum, it would take 2000 years to replace present housing stock. (Boardman, 1991). Housing for low-income families is among the most inefficient. For example, heating using electric fires at normal electricity rates may be three times as expensive as gas central heating. Yet low income families spend less on heating, on average, than all houses, indicating that they live at colder temperature levels. Investment in upgrading housing to be fully insulated, as well as installing energy efficient heating systems, will both cut total costs and reduce energy use.

The Home Energy Conservation Act 1995 (HECA), and the Energy Conservation Act 1996, introduced as private members bills, require local authorities to assess home energy conservation needs and plan and encourage implementation. The Government has allocated an additional £3.9 billion resources to local authority and other social landlords to speed up the repair and improvement of social sector properties, including improved heating and insulation. The government advised that 'significant' improvement of energy efficiency would be 30% over ten years from 1996.

The government's programme on fuel poverty, the Fuel Poverty Strategy, seeks to provide house improvements for people who currently spend 10% or more of their income on home heating - at least 4.3 million in England in 1996 (this strategy will shortly be published as a draft for consultation). Cold homes are thought to exacerbate existing illnesses such as asthma and reduce resistance to respiratory infections. In addition, opportunity loss, caused by having to use a larger portion of income to keep warm than other households, has adverse effects on social well-being and overall quality of life. (DETR, 1999).

An updated Home Energy Efficiency Scheme (HEES) has been introduced by the government in June 2000. This scheme will provide insulation and/or for heating improvement measures for households in receipt of an income or disability based benefit. The improved scheme has two levels:

1. Grants of up to £1,000 for a range of heating improvements and insulation measures, including loft and cavity wall insulation and draught proofing, are available to:
• households in receipt of an income related benefit;
• households who receive a disability benefit.
2. Grants of up to £2,000 are available to households who are over 60 and receive an income-related benefit. This is to provide both insulation measures and, where appropriate, high efficiency central heating systems for the main living areas.

HEES is targeted at owner-occupiers and householders in the private rented sectors, who represent nearly 70 per cent of the households classified as fuel poor. It is hoped that the new scheme will provide nearly half a million households with warmer, healthier homes in the next two years thus reducing the extent of cold winter deaths.

Local authorities have a responsibility to measure the energy efficiency of all the housing stock which they are currently doing through HECA Audits. A wide variety of measures are used: National Home Energy Rating (NHER), Standard Assessment Procedure (SAP), Starpoint and BEPI. LPAC in 1998, who conduct regular borough questionnaires, found that energy efficiency had been measured in 371,963 properties of which 220,551 were under local authority control. At present data is not available that will give an understanding of the proportion of buildings that meet energy efficiency targets. However, work being led by consultants at Creative Environmental Network in the HECA data gathering project (questionnaire to households) will provide local authorities with a better indication of the energy efficiency of private and public sector homes in their borough.

There needs to be a greater emphasis on reducing the risk posed by cold homes particularly those housing the elderly. The NHS spends a considerable amount of money per year on providing extra hospital beds in the winter for the vulnerable. It is not sure how much is spent on preventive methods, particularly projects that provide access to improvements to home insulation grants for instance through health service contact. The DoH have produced an informative leaflet for community groups about fuel poverty and provides a freephone advice line. Details in 'Keep warm, keep well this winter' (DoH, 2000).

Current policy in London suggests more and more health authorities around the UK are beginning to follow local authority leads in developing projects to tackle fuel poverty with the Primary Care Trusts and Health Action Zones providing a considerable degree of impetus for the health sector. Some have concentrated on how energy efficiency and fuel poverty fit into strategic frameworks, others have looked at more specific projects that benefit the local community.

Multi-agency approaches are essential for tackling housing related ill health. The Association for the Conservation of Energy (ACE) and Projects in Partnership (PIP) have produced an excellent reference guide (ACE& PIP, 1999) of 10 case studies outlining how local authorities and health authorities across the UK have overcome institutional barriers to provide: training for health visitors; GP referral schemes and other such projects.

There are several projects in London that involve the two sectors working together that are not represented in the above set of case studies. They are as follows:

• Lambeth Southwark & Lewisham HAZ Warm Homes Project. This project will review the existing network of organisations involved in improving thermal efficiency of housing and develop a strategy within the HAZ for an effective reduction of fuel poverty through partnership. Scheme is lead by South Bank University.
• LB Newham and the health authority have set up a pilot scheme in a local health centre with 5 GP's providing information about available grants to local people so that those with fuel poverty needs can be identified and assisted, first by a one-stop surveyor (HELPCO Charity) who can provide access to necessary HEES grants. Referrals can also be sent by the GPs themselves to provide the most needy with immediate funds. Social workers and health visitor are also key players in this pilot scheme. Contact: Sue Brasil 020 8430 2640.
• LB Barnet has a joint funded post with the health authority and has put in a bid to the Energy Saving Trust to set up a scheme to target HEES resources and Home Repairs Assistance Grants at people with ill-health, liaising with the local Primary Care Groups to identify beneficiaries and to follow-up with means testing.
  Contact: Tamsin Gruelich 020 8359 4717.
• LB Tower Hamlets are hosting three events which have brought together representatives from service providers and the whole community to talk more together about fuel poverty and how impacts on the health of local people. They want to re-engineer a local strategy encompassing all players to capitalise on what can be done. Social workers for instance could assist in the targeting of funds to those most needy. Contact: Lesley Muggeridge 020 7364 2525 Energy Efficiency Unit.
• LB Camden have funded a referral worker in Kilburn area through Camden & Islington HAZ to improve access to grants for local people by working with various different local agencies. Contact: Oliver Myers 020 7413 6370
• National Energy Action Working across London to get Affordable Warmth Strategies up and running. NEA has worked with LB Barking & Dagenham, LB Camden, LB Tower Hamlets and LB Southwark. Contact: Ian Tanner 020 7713 7396

EMAS (the EC Eco-Management and Audit Scheme) is a voluntary European Commission scheme to register sites which have established an environmental management system (such as ISO 14001, the international standard) and produced an independently verified public statement about the site's environmental performance. One of the key elements of environmental management schemes is energy saving.

The scheme was established by EC Regulation 1836/93, and came into operation in April 1995. It applies to manufacturing sites and those engaged in waste disposal, recycling, mining and power generation. In the United Kingdom it has been extended to include local authorities.

EMAS enables participating sites to take a systematic and comprehensive approach to their environmental impacts, and offers consequent savings on energy and raw materials, as well as marketplace advantages through the environmental statement and the site's inclusion on a Europe-wide register. See EMAS website.

Local authorities are encouraged through the LA21 process to adopt internal environmental management systems. The most commonly sought accreditations are EMAS (environmental Management and Audit Scheme) and ISO14001. At present 1 London borough (LB Sutton) has been given EMAS accreditation (has gained 75% of their units) and two boroughs have ISO14001 accreditation. No other authorities at present have begun environmental management systems.

Several hospitals in England and Wales have put environmental management systems in practice. Only 1 business has EMAS accreditation in London. The Improvement and Development Agency (IDeA) was founded in April 1999, by local government, to work with it and for it and help it do better. They provide advice to local authorities on environmental management systems and assisted in the CLIP task force.

London energy strategy Greater London Authority

Creative Environmental Networks.

Main DEFRA website on HECA & energy efficiency.

Association for the Conservation of Energy, Westgate House, Prebend Street, London N1 8PT

Projects in Partnership, 2nd Floor, The Tea Warehouse, 10a Lant Street, London SE1 1QR

The Energy Saving Trust

The National Energy Foundation

EAGA Partnership

Healthy Building Centre, Building Research Establishment

HECA Online

Centre for Sustainable Energy

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Date	Title	Format	View
2 Dec 2003	Buildings measured for energy efficiency in 1994
2 Dec 2003	Energy consumption for different passenger transport modes at different occupancy rates
2 Dec 2003	Energy use in London boroughs
2 Dec 2003	Estimated number of excess winter deaths aged 75+, 1993-5

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• Greater London Authority - Greenlight to clean power. The Mayor's draft energy strtegy. London: GLA, 2003.
• Ace & PIP (1999) Health & Energy Efficiency: working in partnership for healthy homes Volumes 1&2 (case studies). Association for the Conservation of Energy & Projects in Partnership.
• Boardman B (1991) Fuel Poverty - from cold homes to affordable warmth. Bellhaven Press.
• Buckingham C et al (1997) London Atmospheric Emissions Inventory. London Research Centre.
• Chell M & Hutchinson D (1993) London Energy Study. London Research Centre.
• Christie I and Richie N (1992) Energy Efficiency: the policy agenda for the 1990s. London Policy Studies Institute.
• DEFRA Fuel Poverty: The New HEES - a programme for warmer, healthier homes Studies Institute.
• DoH (2000) Keep warm, keep well this winter. A joint report by Help the Aged, Age Concern, NEA, Department of Health, published by DoH.
• Henwood M (1997) Fuel poverty, energy efficiency and health. A report to EAGA Charitable Trust.
• McMichael AJ, Haines A Global climate change: the potential effects on health. British Medical Journal 1997; 315: 805-9.
• NEA (1996) Energy in the Home: 3rd edition. National Energy Action.
• Rudge J and Nicol F (2000) Cutting the cost of cold. Work edited by University of North London & Oxford Brookes University.

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