The passive dissemination of advice on heat avoidance is insufficient for health protection during a heat wave, and vulnerable people need to be actively identified and cared for, argues a public health expert in this week’s British Medical Journal (BMJ). This summer Europe has again been affected by a major heat wave, writes Sari Kovats of the London School of Hygiene and Tropical Medicine. The UK has recently had its hottest month since records began in 1660 and England triggered its heat wave response plan for the first time. Yet little research has been carried out on the social and environmental determinants of heat-related mortality.
The elderly, the socially isolated, and those with heart conditions, diabetes or mental illness are among those at greatest risk of death during a heat wave. Following the heat wave in 2003, public health measures implemented in Europe have centred almost exclusively on heat health warning systems that forecast high risk weather conditions to trigger public warnings. But, so far, no heat health system has been formally evaluated and the effectiveness of individual interventions is unknown, says Kovats.
The impact of heat waves also reveals important lessons about the care of the elderly and dispossessed in our society, both in the community and in social care, she writes. One of the striking things about the heat wave in France in 2003 was that the high mortality went undetected for so long. In the UK, several indicators of heat morbidity are now monitored routinely using data from GP practices and NHS Direct.
The EUROHEAT network, coordinated by World Health Organization (WHO) in Rome, and funded by the European Commission, is also developing good practice for health protection during heat waves as more countries develop heat health warning systems. But an inter-agency approach is needed, she says.
Heat wave systems also need to be better integrated within the disaster response agencies. Heat stress is also an occupational health problem, and health and safety agencies need to be prepared for the impact of hotter summers. London’s mayor is being particularly proactive with regard to climate change, and is developing a statutory adaptation strategy to ensure that the infrastructure is appropriate for future climates.
Climate change needs to be taken into account in health protection in Europe, this editorial argues. It would be tragic if the main response to hotter summers is to install inefficient air conditioning and to miss the opportunity to develop effective and more equitable health protection measures for extreme weather, she concludes.
During the recent heat wave, some GPs were asked by their primary care trusts (PCTs) to identify and support at-risk patients, such as those over 75 years old suffering from chronic conditions but with no other community support. GPs have in turn asked the Medical Defence Union (MDU) to what extent they are expected to follow up at-risk patients during the heatwave – should they attempt to make telephone contact, or just write to the patient with advice; should they visit those whom they cannot contact and can they delegate the process to another member of the practice team?
Dr David Morgan, MDU medico-legal adviser said: "The Department of Health (DoH) has identified various groups of people who might suffer from ill health during the current hot weather in a heatwave plan. Some GPs have been asked by PCTs to identify and monitor at-risk patients without community support and are worried that they may not be able to contact or indeed identify all such patients. We have advised members that it is ultimately for GPs to decide, based on their professional judgement and guidance such as that from the DoH, whether a patient may be at particular risk and what action to take. However, it is advisable that doctors can demonstrate they have taken reasonable steps to contact at-risk patients who could be identified."
"In the unlikely event doctors are asked to justify a decision to contact or not contact a patient in an at-risk group, they would need to be able to establish their decision was logical and capable of support by a reasonable body of medical opinion. GPs are expected to be aware of current guidance and, if they judge it is in the patient's clinical interests not to follow advice contained in national guidelines, the MDU advises that they make a careful clinical record of their reasons."
"In deciding what lengths to go to when contacting patients, GPs will need to use their clinical judgement along with their knowledge of patients, their circumstances and whether they have any support. GPs may decide to write to at-risk patients, enclosing the heatwave advice leaflet which the DoH has produced, or they may wish to contact vulnerable patients by phone, or feel that a visit is required. GPs can delegate the task of contacting vulnerable patients to other members of the practice team, provided the person to whom they delegate the task is competent to carry it out. Doctors will still be responsible for the overall management of the patient."
The MDU has advised GPs that they would normally need the consent of competent patients to pass information about them to the PCT.
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