3. Mapping Fuel Poverty and Public Health Policy

The Scottish Government has outlined strategies to tackle fuel poverty as well as the various health conditions mentioned in the previous chapter. However, it is unclear to which extent the Fuel Poverty Strategy interacts with the public health policy landscape. Considering the need to explore fuel poverty through a public health lens, it is vital to understand the current interactions between these policy areas. The following identifies any overlaps, gaps, and areas of potential by mapping out each policy area. Table 1, below, summarises these findings.

Table 1 – Summary of main findings

3.1 Fuel Poverty

The Fuel Poverty Strategy covers several policy areas, with the focus largely being on net zero and economic factors. Conversely, health has received only little attention, with only two out of the 55 policy actions outlined in the Fuel Poverty Strategy directly addressing health. Notably, health is addressed more broadly instead of focusing on specific health conditions. While some actions may have a possible indirect impact on health, this impact is currently not measurable. Hence, the focus will remain on the actions that directly address health.

The first action addresses strengthening partnership working between income maximisation services and health settings. These partnerships could be extended to other organisations that address fuel poverty, leading to a more holistic approach.

The second action is targeted at those who face the greatest fuel poverty-related health risks, ensuring they continue to receive support through the Warmer Homes Scotland scheme. This support is vital as energy efficiency measures, such as retrofitting, can create indirect positive co-benefits for health-related outcomes (Wang et al., 2022). Studies have shown that energy efficiency measures can reduce respiratory symptoms and blood pressure as well as improve general health; anxiety and depression symptoms as well as feelings of isolation are lessened (Wang et al., 2022). These effects are attributable to the fact that energy efficiency measures make it easier and cheaper to warm the home and maintain ambient temperatures (Wang et al., 2022). Hence, energy efficiency measures are vital for promoting good health. Despite these positive co-benefits for health-related outcomes, energy efficiency measures often take a long time to install and are costly to implement. Immediate support needs to be available, not only for those who face the greatest health risks, but also those who already live with long-term health conditions that may be exacerbated by fuel poverty. Hence, it is necessary to make the connection between poor health and poor housing, and to incorporate health more broadly into fuel poverty policies and vice versa. Health needs to play an essential, encompassing role within the fuel poverty policy landscape.

3.2 Air Quality

The Cleaner Air for Scotland 2 (CAFS 2) Strategy addresses outdoor and indoor air quality and recognises the negative impact of pollution on health. It is complementary to the Respiratory Care Action Plan and Heart Disease Action Plan, which both reference the CAFS 2. Moreover, it acknowledges that almost half of households in Scotland that use solid mineral fuels experience fuel poverty, highlighting that households in fuel poverty will have overall worse indoor air quality. The emissions from burning solid mineral fuels will also impact outdoor air quality negatively. It emphasises energy efficiency measures as essential interventions to combat air pollution and, thus, improve health, calling for a coordinated effort with related policy areas.

However, it is vital to recognise that there can be unintended negative health outcomes of energy efficiency measures. For example, thermal wall insulation can help with keeping heat in and blocking outdoor air pollution by making the building more airtight. At the same time, research has shown that these energy-efficient measures can increase exposure to indoor radon and other pollutants as improved wall insulation can make it easier to trap polluted matter in the house, leading to poor air quality and posing a significant risk to health (Wang et al., 2022). Similarly, there is a link between increased airtightness and higher levels of relative humidity, resulting in a higher presence of mould and dust mites, which could particularly promote and exacerbate respiratory conditions (Shrubsole et al., 2014). This problem can be mitigated through the installation of mechanical ventilation systems (Wang et al., 2022). However, research estimates that only 11% of all households across the UK had the minimum mechanical ventilation systems installed in line with established building standards and had received information on how to operate these systems (Van Rooyen and Sharpe, 2024). Similarly, these ventilation systems often do not perform in line with building standards due to poor installation and a lack of maintenance (Shrubsole et al., 2014). As a result, homes could experience heat losses and exposure to outdoor air pollution due to increased ventilation and airflow, rendering energy efficiency gains redundant and increasing fuel bills (Shrubsole et al., 2014; Wang et al., 2022).

Accordingly, it is necessary to ensure that households have mechanical ventilation systems that are installed correctly and regularly maintained, and they receive information on their operation in order to avoid unintended negative health impacts. Generally, this suggestion also applies to other energy efficiency measures. For example, poor installations of new heating systems can cause more damage to a person’s health, while a lack of knowledge on how to operate these systems efficiently offsets the intended benefits, such as lower fuel bills and emissions (Shrubsole et al., 2014). Hence, it is vital that sufficient skilled heating and energy efficiency installers are available, with proper training and good working conditions.

Notably, there are no regulations for indoor air pollutants in domestic settings in the UK, although several guidelines have been published (Scottish Government, 2021). Still, it is unclear whether households are aware of these and to which extent they adhere to these and keep them in mind. A study by Pollard et al. (2019) demonstrates that, once thermometers were supplied to households in fuel poverty (who already received other assistance), they maintained a higher average temperature in their homes. Similarly, households could be provided with monitors that, in addition to temperature, also measure humidity and carbon dioxide concentrations, which can be vital indicators for a home’s indoor air quality and subsequent impacts on health. The existing guidance can assist households in assessing whether their indoor air quality is adequate. Where it is inadequate, guidance should be given on the steps that households can take to improve the indoor air quality.

3.3 Heat in Buildings

The Heat in Buildings Strategy explicitly references fuel poverty; however, similarly to the Fuel Poverty Strategy, this reference is mainly in the context of net zero, climate change and economic impacts. Hence, energy efficiency measures are seen as interventions that primarily drive climate change targets and lowering fuel poverty. The positive as well as unintended negative health impacts of energy efficiency measures are not addressed. While the strategy commits to introducing energy efficiency and zero emissions regulations that will consider people’s health and wellbeing, this statement is broad and vague. A more explicit link to health is necessary to ensure positive health outcomes for people in fuel poverty.

3.4 Respiratory Conditions

The Respiratory Care Action Plan explicitly references cold homes as a significant risk factor for the development and exacerbation of respiratory diseases. It acknowledges the vital role of eliminating fuel poverty in the prevention of respiratory conditions. Similarly, it links to poor air quality and poor diets as risk factors for respiratory diseases. As these are deeply interwoven with fuel poverty as well, a well-rounded preventative care strategy is presented that could benefit people in fuel poverty. A commitment was made to work with these relevant policy areas to ensure preventative measures related to cold homes, poor air quality and poor diets are embedded in respiratory care.

Yet, areas of potential remain. The plan commits to using high quality data more effectively to understand areas for improvement. As of the writing of this report, current data does not identify whether a new asthma or COPD case is linked to residing in a cold, mouldy home. While this data could help assess the effects of fuel poverty on health nationally, it could also target health interventions more effectively. Arguably, if a person receives respiratory care without addressing the underlying causes and exacerbations (e.g., cold and mouldy homes), the treatment will not be as effective as it could be. Moreover, asking patients about their housing conditions as potential risk factors could ensure that it does not fall through the gaps and point them to the appropriate services.

The plan supports a service by Chest, Heart, Stroke Scotland called Hospital to Home, which helps people in the transition period after returning home from the hospital. This service focuses entirely on medical care but could be expanded to consider the social determinants of health, such as housing, as these can impact health outcomes in a person’s recovery (Cheetham et al., 2025; Snigdha et al., 2022). Even before a person is discharged from the hospital, it should be ensured that they are not returning to a cold home to avoid rehospitalisation. This suggestion is in line with the Rehabilitation and Recovery Plan, of which the Respiratory Care Action Plan has also been supportive.

3.5 Cardiovascular Conditions

Both the Heart Disease Action Plan and Stroke Improvement Plan – which is an extension of the former – do not mention fuel poverty as a risk factor. Other factors, such as clean air, diet and nutrition, which are inextricably connected to fuel poverty, are acknowledged, whereby their respective policies are considered to be complementary to the Heart Disease Action Plan. Notably, the plan discusses heart-related risk factors, such as high blood pressure and high cholesterol, exclusively, which are caused by the aforementioned factors. However, considering the impact of cold, damp homes on these heart-related risk factors and cardiovascular conditions more broadly, it is vital to have fuel poverty policy inform the Heart Disease Action Plan. While the Cleaner Air for Scotland 2 strategy emphasises the need for energy efficiency measures to improve health, the link needs to be made more explicit in the Heart Disease Action Plan. Similarly to the respiratory conditions, if a person receives cardiovascular care without addressing the underlying causes and exacerbations, the treatment will not be as effective as it could be.

Even though fuel poverty is not directly mentioned, the Heart Disease Action Plan offers areas of potential. For example, the plan proposes a community model of care be implemented in Scotland whereby cardiovascular health is promoted through close partnership with primary care, third sector organisations, and community pharmacists, among others. This model of care can help reach people who may face higher barriers within the healthcare system. When working with third sector organisations, energy-focused organisations could be included in the promotion of cardiovascular health. Even though research posits that people in fuel poverty are concerned about their physical health (Liddell and Guiney, 2015), it is possible that they do not know the specific ways in which cold, damp homes affect their health and the symptoms they may cause. As energy-focused organisations may be their first point of contact, these organisations could highlight potential health impacts and direct them to the appropriate services.

Furthermore, people with suspected high blood pressure are provided with a blood pressure monitor and asked to check their blood pressure regularly, known as telemonitoring. If the blood pressure is too high, they are advised to contact their doctor or nurse. This contact could provide an opportunity for the medical team to inquire further about the patient’s general wellbeing and underlying causes (e.g., cold homes), redirecting them to the appropriate services.

Finally, the plan emphasises the importance of developing a multi-disciplinary assessment tool for cardiac rehabilitation, which is in line with the Rehabilitation and Recovery Plan’s suggestion of including physical, mental and social assessments (including housing) in any rehabilitation setting. This multi-disciplinary approach could be integrated more broadly across the Heart Disease Action Plan, from prevention to rehabilitation. Considering housing and energy needs throughout the plan could help identify underlying causes early on, ensuring better health outcomes for people in fuel poverty.

3.6 Mental Health

Scotland’s Mental Health and Wellbeing Strategy does not explicitly mention fuel poverty as a risk factor of poor mental health. However, it acknowledges housing as a key policy area for improving mental health. Similarly, poverty is seen as the single biggest driver of poor mental health and social isolation. While fuel poverty is not explicitly mentioned, the outlined policies could still have an indirect benefit for people in fuel poverty. For example, this strategy takes an intersectional approach, recognising that people have multiple intersecting identities and thus experience varying needs for care. It particularly focuses on marginalised people who experience discrimination and stigma based on protected characteristics and highlights that these groups often face barriers to accessing effective care. Consequently, it aims to remove those barriers by adopting a whole person approach to care.

The Fuel Poverty Strategy could stand to benefit from a similar intersectional, whole person approach. While factors like age, disability and other forms of poverty (e.g., food poverty) are considered, the focus needs to go beyond that. For example, research indicates that ethnic minorities and women are disproportionately affected by fuel poverty and face higher barriers to accessing support (Champagne et al., 2023; Lee et al., 2022). As a result, these groups might slip through the gaps and not receive the proper support suited to their needs. Consequently, an intersectional approach can help us understand the complexities of fuel poverty better and effectively deliver better support.

Furthermore, both the mental health and fuel poverty policies focus on tackling stigma associated with their respective areas. Reducing the stigma for both mental health and fuel poverty, while acknowledging that they interact with each other, could enable vital conversations and ensure that people receive the help they need without escalation. One way in which stigma can be combatted is through peer support, which is also suggested in the Respiratory Care Action Plan. Research suggests that peer support can combat isolation and loneliness while creating hope and community (Stefancic et al., 2021), ultimately breaking down barriers that would have kept people from seeking support. Thus, providing tailored peer support for people in fuel poverty might have positive effects on their mental health.

The Mental Health Plan outlines a policy whereby support for people in mental health crisis is expanded and improved through Scotland’s national approach on Time, Space and Compassion (TSC). Even though TSC is primarily for people experiencing suicidal crisis, the core principles could be extended to people experiencing fuel poverty, ensuring better and more positive outcomes for those seeking support.

Table 2 – Core Principles of TSC

3.7 Diet & Nutrition

Scotland’s Diet & Healthy Weight Delivery Plan outlines policies that are primarily focused on population-wide interventions rather than individual behavioural changes. The plan does not explicitly mention fuel poverty, but it recognises poverty and deprivation as barriers to eating more healthily. Despite the well-known ‘heat or eat’ dilemma, the Fuel Poverty Strategy primarily addresses this problem through universal free school meals in primary and special schools. Consequently, this area could be expanded on. For example, free school meals could be extended to eligible secondary pupils. The Diet & Healthy Weight Delivery Plan’s focus on tightening nutritional standards for school meals would ensure that students eat healthy, nutritious food throughout their academic career. The Scottish Government started a trial phase for free school meals for S1 to S3 pupils who receive the Scottish Child Payment in eight local authorities in August 2025 (Scottish Government, 2025b). Consideration could be given to both expanding this programme to the remaining local authorities and extending free school meals to eligible S4 to S6 pupils.

Furthermore, the Scottish Government’s Islands Cost Crisis Emergency Fund handed out food vouchers to households affected by fuel poverty. This scheme could be expanded across Scotland to help households in fuel poverty avoid the ‘heat or eat’ dilemma and ensure they have access to fresh, healthy food. Similar to the Best Starts Food scheme and other policy actions outlined in the Diet & Healthy Weight Delivery Plan (particularly Action 4.4 to 4.7), it could enable and support people to make healthier decisions. This type of support could be essential, especially for people living with long-term health conditions that may be exacerbated by fuel poverty.

Many councils offer a service called ‘meals on wheels’ to provide nutritious, healthy meals to older and/or disabled individuals who cannot leave their homes to go shopping or cook for themselves anymore. Beyond the nutritional benefits of the meals, this service can also improve mental health through regular social connections, reducing loneliness and isolation, and promote a sense of independence (Papadaki et al., 2023). However, this service is typically associated with a charge per meal. Older and disabled individuals in fuel poverty may not be able to afford this additional charge and resort to cheaper, unhealthy foods. Expanding this service to provide free meals – or at least at a discounted rate – to older and disabled people in fuel poverty could help significantly to ensure they eat well.

3.8 General Health

The Population Health Framework (PHF) does not refer to fuel poverty but supports the contribution of better housing to health. Specifically, it argues for cross-government collaboration to ensure that health outcomes are maximised. Strengthening the partnership between health and housing can have benefits for people who are at risk of ill health due to fuel poverty. Similarly, it advocates for progressing the Housing (Scotland) Bill, particularly rent control, and providing more affordable housing. Both rent control and affordable housing can ensure that people can spend more of their income on keeping their homes warm, ultimately combatting the negative health impacts of cold indoor temperatures. Furthermore, the PHF mentions social prescribing, which serves as a vital connection between the NHS, local government and the voluntary sector. It ensures that more people can access health support within their communities. Especially people who might otherwise face higher barriers to accessing care would benefit from social prescribing. Finally, it calls for a greater involvement of the NHS in income maximisation. Essentially, people who need income assistance should be able to access support within the healthcare setting. Enabling this support could further reduce barriers and complexities of navigating the welfare system.

Housing to 2040 references fuel poverty explicitly and recognises that adequate housing and living spaces can improve physical and mental health. It further mentions that new regulation for zero emissions heating and energy efficiency will consider people’s health and well-being, which is also outlined in the Heat in Buildings Strategy. Additionally, the strategy proposes an integrated approach of housing, social care and health services to enable independent living through accessibility retrofits for old and/or disabled people. There is also emphasis on building new homes in areas that already have health services to make it easier to access these (20-minute neighbourhoods). These interventions could significantly benefit people in fuel poverty.

3.9 Fairer Scotland Duty

The Fairer Scotland Duty requires public bodies to consider how to reduce inequalities of outcomes created by socio-economic disadvantages when making strategic decisions. Out of the policies mentioned above, only the Fuel Poverty Strategy, Heat in Buildings Strategy, and Scotland’s Diet & Healthy Weight Delivery Plan explicitly reference the Fairer Scotland Duty. Notably, the Heart Disease Action Plan and CAFS 2 mention having conducted an Equality Impact Assessment, while the PHF utilises the Population Health Dashboard to carry out assessments, including socio-economic indicators. Housing to 2040 notes conducting equality impact assessments on individual policies associated with the strategy. The other policies do not mention impact assessments.