Cold realities: what more can be done to address winter mortality in rural areas?

Winter is linked to increased mortality compared to other seasons, with the UK experiencing higher winter mortality rates than some colder European countries. How is winter mortality measured, what are the trends in rural communities, and what more can be done to address excess winter deaths? Jessica Sellick investigates.  

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Winter mortality rates in the UK exceed those observed in several colder European nations, indicating that a proportion of these deaths may be preventable. In recent years, the number of Excess Winter Deaths (EWD) has varied, with the highest figures so far recorded during the COVID-19 pandemic. This raises important questions: what does the data and emerging trends tell us about EWD? What factors contribute to increased winter mortality? What are the implications for rural communities, and what interventions can be implemented to address these challenges? 

What is excess winter mortality? The Office for National Statistics (ONS) defines Excess Winter Deaths (EWD) as ‘the additional number of deaths that occur in the winter period [1 December-31 March] compared with the average of the non-winter periods immediately before [1 August-30 November] and after [1 April-31 July]’. Guidance from the ONS, the UK Health Security Agency (UKHSA), and the Office for Health Improvement and Disparities (OHID), defines excess deaths as ‘the difference between the actual number of deaths in a particular period and the estimated number of deaths expected in that period’. The guidance notes that expected deaths can be derived in a variety of ways for several purposes, which means that there may be varying estimates of excess deaths published by different organisations and used for those purposes.  

In an international context, EWD takes account of ‘above the expected number of deaths under normal circumstances’ and is regarded as a means of monitoring and comparing health policies across different countries and regions. While in academic circles, some study Total Winter Deaths (TWD), defined as ‘total deaths during the four winter months, December to March’; while others focus on excess mortality more broadly, defined as ‘the deviation between the reported number of deaths in a country during a certain week or month and the expected or projected number of deaths in a country for that period under normal circumstances’.  

In a UK context, EWD considers the rate of mortality occurring during the winter season compared with that observed at other times of the year.  

How is it measured and what are the trends? Mortality statistics in the UK are reported using different methodologies. Some organisations count deaths by the ‘date of registration’, while others use the ‘actual date of occurrence’. The ONS is responsible for collecting, analysing, and disseminating statistics related to life events, including weekly deaths data. The OHID, part of the Department of Health and Social Care (DHSC), publishes monthly data on excess mortality in England. While the UKHSA produces three regular publications: weekly all-cause mortality surveillance in England, annual heat mortality monitoring in England and annual surveillance of influenza and other seasonal respiratory viruses in the UK.    

Historically, the ONS published statistics on EWD and the ‘Excess Winter Mortality Index (EWMI)’, which measured the number of excess winter deaths as a percentage of the average number of non-winter deaths. ONS analysis of EWD between 1950 and 2022 using the EWMI found:  

  • EWD declined between 1960 and the early 2000s. Between 2000 and 2018, EWD in England and Wales fluctuated between 20,000 and 50,000 people per winter period.  
  • The winter of 2019-2020 had one of the lowest EWD (10,230) and EWMI (5% in England) on record since the 1990s. This was due to the excess deaths in spring 2020 as a result of COVID-19. The following winter (2020-2021) had the highest EWD (60,760) on record since 1970, with an EWMI of 35.4% in England – this was attributed to the COVID-19 pandemic.  

In 2022, the ONS renamed EWD ‘winter deaths compared to non-winter deaths’ and the EWMI ‘winter mortality index’. Analysis published in January 2023 estimated:  

  • 13,400 more deaths occurred in the winter period December 2021-March 2022 compared with the average of the non-winter periods. This was the second lowest figure since 1950-1951.  
  • The winter mortality index in England was 7.3% lower than every winter since the series began in 1991-1992, except in 2019-2020.  
  • ONS reported that winters with increased EWD/winter deaths compared to non-winter deaths are not necessarily correlated with colder, winter temperatures, indicating that other factors affect winter mortality. For example, a study published by a research team at the London School of Hygiene and Tropical Medicine back in 2001 estimated that while 60% of EWD variation was due to cold temperatures, 40% was not.   

Following a consultation on the statistical outputs needed after the COVID-19 pandemic, ONS paused reporting of winter deaths compared to non-winter deaths and the winter mortality index. Instead, it adopted a statistical model to predict the expected number of deaths each week, accounting for population growth, ageing and long-term mortality trends. This model uses a five-year rolling baseline, and excludes weeks and months that were substantially affected by COVID-19. In sum, the model measures the difference between the expected number of deaths and the actual number of deaths to determine excess weekly mortality. ONS statistics on monthly death registration data since 2022 continues to show that mortality during the winter period in England remains higher than at other times of the year. 

Some researchers have raised concerns about the limitations of EWD and EWMI, and their successors, including how unusual patterns in non-winter deaths (such as heatwaves) can distort results, and that retrospective publication also limits real-time decision-making and action. The ONS, in collaboration with the London School of Hygiene and Tropical Medicine, DHSC and Wellcome, publishes ad hoc reports on climate-related mortality in England and Wales, and the UKHSA publishes a heat mortality monitoring report annually. 

Other researchers argue that ending EWD limits the monitoring and evaluation of winter mortality and reduction measures. Some academics have suggested alternative baselines, including moving to a five-year average to illustrate long-term trends in excess winter mortality, while others suggest using an alternative retrospective baseline derived from the lowest weekly death rates achieved in previous years and a within-year baseline based on the average of the 13 lowest weekly death rates within the same year.   

In September 2025, the UKHSA and the Centre for Climate and Health Security published the ‘2023 Health Effects of Climate Change’ (HECC) report. The ‘cold analysis’ highlighted how:  

  • Cold weather is linked to impacts on mental health such as anxiety and depression and is associated with excess deaths in the UK. Many deaths and cold related illnesses are preventable.  
  • When the weather gets colder, more people tend to stay indoors, which can make it easier for illnesses to spread, especially respiratory infections like colds and flu. In England and Wales, norovirus infections increase as temperatures get colder.  
  • Proposed cold weather indicators to monitor progress towards achieving adaptation and mitigation goals include: the proportion of housing stock with low indoor temperature, the number of households in fuel poverty, annual cold-related mortality and morbidity data, and the proportion of homes with retrofit energy efficiency upgrades by type.  

The OHID applies a similar methodology to ONS, providing excess monthly deaths breakdowns by region, local authority, age, deprivation, and cause of death.  

In an international context, since 2020 the Human Mortality Database (HMD) has been produced by the University of California and the Max Planck Institute for Demographic Research in Germany. The HMD contains calculations for ‘all-cause’ death rates and ‘cause-specific’ death rates for national populations. The HMD also contains subnational mortality databases for Australia, Canada, France, Japan, and the United States. The World Health Organization (WHO) Mortality Database also allows for comparative epidemiological studies of mortality by cause. This contains cause-of-death statistics submitted by each country’s civil registration systems on an annual basis.  

In parallel, the UKHSA calculates the expected threshold of all-cause mortality based on a European algorithm called EuroMOMO.  This has been displaying weekly excess mortality in 23 countries since 2008. Data from the HMD and Mortality Database are fed into the ‘Our Word in Data’ database.  Specific analysis looks at the risk of death from influenza, and cross-country comparisons on how excess mortality is measured drawing on the impact of the COVID-19 pandemic. However, some researchers suggest international comparisons with countries with different climatic patterns is unhelpful. 

In May 2025, the London School of Hygiene and Tropical Medicine and the Max Planck Institute published research funded by the Health Foundation analysing trends in mortality in the UK in comparison to 21 high-income peer countries. The findings revealed how:  

  • Improvements in UK mortality rates slowed significantly in the 2010s, more than in most of the other countries studied. By 2023, the UK female mortality rate was 14% higher than the median of peer countries and the UK male mortality rate was 9% higher. For both, the gap to the median widened significantly after 2011, and the UK’s ranking relative to peer countries has now worsened.  
  • There are significant geographic inequalities: Scotland and Northern Ireland have higher mortality rates than England. Scotland performs poorly compared to all of the countries studied – in 2021, only the United States had a worse mortality rate. In England, in 2021, mortality rates were 20% higher in the North East and North West of England compared to the South West.  
  • People aged 25-49 years have seen a particularly pronounced relative worsening of mortality rates. In 2023, female mortality rates for this age group were 46% higher than median peer countries, while male rates were 31% higher. 

While ONS compares excess mortality across all four parts of the UK, the UKHSA enables comparisons with other European countries, and the OHID starts to examine inequalities within England. Some commentators regard these statistics as too simplistic because seasonal changes in health do not occur according to fixed calendar dates. They also do not allow for comparisons within a season, for example, are cold-spells occurring early in the winter period worse than later ones? Similarly, not all deaths due to cold occur during the winter, and not all of the winter excess is due to the cold.  

What are the causes of winter mortality, and who is at risk? Increased mortality arises from a combination of physiological, environmental, and systematic factors. Cold temperatures narrow blood vessels, elevate blood pressure, and increase blood clotting, raising the risk of cardiovascular events such as heart attacks and strokes. Research funded by the British Heart Foundation (BHF) at the University of Bristol and University College London examined the health records of people aged over 60 years in the UK, Ireland, and the Netherlands. Findings indicated that heart attacks and strokes were more than twice as likely to occur during cold spells lasting at least four days. It has been estimated that for every 1°C drop in temperature, the risk of heart attack increases by approximately 2%.  

Cold air also exacerbates respiratory conditions. Winter months are associated with higher rates of respiratory infections, with cold exposure increasing susceptibility to chest infections and worsening existing breathing difficulties.  

Since 2009, the ONS has reported a high prevalence of excess winter mortality among people living with Alzheimer’s Disease and related dementias. This has been attributed to reduced ability to recognise cold temperatures, inappropriate clothing, and increased confusion, all of which heighten vulnerability during colder periods. 

Winter conditions are associated with higher rates of fall-related injuries requiring NHS treatment and admission. Outdoor falls on ice and snow result, while reduced mobility and worsening symptoms of arthritis increase the risks of falls indoors.  

More generally, increased time spent indoors during winter further facilitates the spread of infections. Certain viruses are more persistent in cold conditions, while reduced immunity associated with low temperatures increases susceptibility. Seasonal surges in respiratory viruses such as flu, respiratory syncytial virus (RSV), norovirus, and COVID-19 all contribute to winter mortality.  

According to figures from NHS England, an average of 2,660 patients per day were in a hospital with flu during the first week of December 2025. This represents the highest level recorded in that period of the year, and a 55% increase compared to the previous week. This surge has been attributed to influenza circulating approximately one month earlier than in the previous three years. During the same period, the number of patients in hospital with norovirus rose 35%, compounding pressures on the health system. The combined impact of these trends has led some within the NHS to describe the winter 2025 as the season of “super flu”. While admissions have dropped since then, an amber cold weather alert has been in place for all regions in early January 2026, leading NHS England to warn this could put renewed pressure on hospitals.  

Older adults, young children, individuals living in households affected by fuel poverty or residing in cold, damp homes, those experiencing social isolation, and people with multiple long-term health conditions, as well as rough sleepers and individuals who are homeless, are all at increased risk of cold-related illness and mortality.  

  • A study of adults living with long term conditions found they were 11 times more likely to require hospitalisation, with the risk of death up to 15 times higher during winter months. Winter represents a critical pressure point for the NHS, with Accident & emergency (A&E) departments and ambulance services experiencing significant surges in demand, and non-hospital care and general practice also facing heightened pressures. Analysis from ONS in January 2025 reported that patients who experienced longer wait times in A&E were more likely to die within 30 days of discharge.  
  • Fuel poverty refers to households that must spend a high proportion of their income to keep their home at a reasonable temperature. Fuel poverty is affected by a household’s income, their fuel costs, and their energy consumption. In England, households in homes with lower energy efficiency (bands D-G) who fall below the poverty line after energy costs, are officially to considered to be in fuel poverty. In 2024, an estimated 2.73 million households in England were defined as fuel poor under the Government’s Low Income Low Energy Efficiency (LILEE) indicator. However, commentators argue that this definition does not capture the full range of households facing unaffordable bills. National Energy Action estimated that approximately 4.5 million households were in fuel poverty in the UK in October 2025. Previous studies suggest that 10% of excess winter deaths could be directly attributable to fuel poverty, and 21.5% to cold homes. Back in 2019, the Local Government Association (LGA) estimated that the NHS was spending £2.5 billion a year treating illnesses linked to cold, damp, and unsafe housing conditions.   
  • Social isolation and loneliness tend to rise during the winter months, driven by colder temperatures, shorter daylight hours, and increased incidence of ill health. One study found a 3°C drop in temperature prompted individuals to recall experiences of social isolation, leading to a phenomenon described by academics as ‘ the psychological experience of coldness’. The UKHSA highlights how people who are housebound or living alone are at particular risk during cold weather. 
  • Ministry of Housing, Communities and Local Government (MHCLG) data found those experiencing homelessness or rough sleeping to be 8-12 times more likely to die prematurely, particularly from chronic cardiovascular and respiratory diseases, and those sleeping rough during winter to be at an even greater risk of ill health and long-term sickness.   

What are the implications for rural communities, and what can we do about it? While research has examined winter and cold-related mortality across the four nations of the UK and at regional levels, there is comparatively little evidence on how these patterns relate to rural areas. Addressing this is important for two reasons.  

Firstly, rural areas experience colder temperatures than urban areas. Minimum temperatures typically occur shortly after dawn, with maximum temperatures reached 2-3 hours after midday. The Royal Meteorological Society notes how the minimum temperatures experienced in urban areas tend not to be so low as those recorded in rural areas:    

Urban areas have minimum temperatures which are higher than those recorded in the rural areas, whilst cities can also have higher maximum temperatures. These effects are known as the urban heat island, and are caused by firstly, the materials used in buildings storing and then releasing heat, and secondly by the release of heat due to industrial and domestic energy consumption. 

Local geographic features have an effect on the local climate which results in rural areas recording colder temperatures relative to urban areas.   

Secondly, rural residents often present with more risk traits that heighten their vulnerability to cold-related illness and mortality, including:  

  • A higher proportion of older people: according to the Statistical Digest of Rural England population analysis, in 2022, the proportion of the population aged 65 and over in rural settlements was 26%, whilst in urban areas outside of London the proportion was 18%. Between mid-2011 and mid-2022, the average age increased by 2.1 years in rural settlements, and by 1.1 years in urban areas outside of London. The gap in average ages between rural and urban areas has been widening over time. Rural areas as a whole have a higher proportion of residents over 65 years, and over 85 years. Older residents, particularly those aged over 75 years have higher excess winter mortality than younger adults.  
  • A high proportion of households experiencing fuel poverty: according to the Statistical Digest of Rural England energy analysis, in 2024, 11.4% of households in rural areas were ‘fuel poor’ compared to 11.0% in urban areas. This would correspond to 515,000 households in rural areas and 2,219,000 households in urban areas. Over the 5 years to 2024, the proportion of fuel poor households has changed very little in rural areas, but it has fallen by almost 3 percentage points in urban areas. Households in rural areas had an average annual fuel poverty gap of £668 in 2024. This is £322 more than the average fuel poverty gap of £346 in urban areas. Since 2019 the fuel poverty gap in rural areas has risen from £413 to £668 – an increase of £255. Whilst in urban areas, over the same period, the fuel poverty gap increased by just £166 from £180 in 2019 to £346 in 2024. In 2024, rural households in homes with the poorest energy efficiency rating of F or G had an average fuel poverty gap of almost £2,000, compared to £1,600 for urban households in homes with the same energy efficiency rating. Figures for 2024 place the average fuel poverty gap at £820 for off-grid fuel poor households and £299 for on-grid households. For off-grid households the average fuel poverty gap rose by £272 between 2020 and 2024, compared to a rise of just £116 for on-grid households over the same period. Homes that are cold due to fuel poverty exacerbate health inequalities and are linked to respiratory and cardiovascular conditions, and poorer mental health.   
  • Damp problems: MHCLG housing data shows that homes more likely to have damp problems are located  in city centres (9.1%) followed by rural areas away from villages and residential developments (7.1%). Research suggests that people living in poorly ventilated homes are at higher risk of illnesses.  
  • Chronic health conditions: according to the Chief Medical Officer’s ‘health trends and variation in England, 2025’ report, the prevalence of coronary heart disease (CHD) is most prevalent in rural and coastal areas – partly related to age structure and deprivation. Cold temperatures increases the risk of heart attacks and strokes.  

Many excess winter deaths are entirely preventable. The Government has sought to implement short-term and emergency response measures each winter, as well as longer-term preventative strategies to address winter mortality. From a policy perspective, key documents include the UKHSA’s adverse weather and health plan, which was introduced in 2023 and is updated annually and seeks to protect individuals and communities from the health effects of adverse weather and to build community resilience. The 2025-2026 plan contains one reference to rural in the main document which relates to the role of parish councils in rural areas in reaching vulnerable people not already engaged with statutory services.  

Back in 2015, the National Institute for Health and Care Excellence (NICE) published guidance (NG6) on reducing the health risks associated with living in a cold home. This calls for the development of a strategy for people living in cold homes, identifying people at risk, training practitioners to help people with cold homes, raising awareness of how to keep warm at home, and ensuring buildings meet required standards – though there are no direct references to rural.  

Winter preparedness is also a key priority for the NHS – at a national level an urgent and emergency care plan is produced annually, and Integrated Care Boards (ICBs) and Trusts are also required to develop system plans.      

Short-term and emergency interventions led by Government and partners include: 

  • The UKHSA Weather-Health Alert system – the cold health alerting system is intended to provide early warning to health and social care professionals and organisations when adverse temperatures are likely to impact on the health and wellbeing of the population.   
  • Delivering vaccination campaigns targeting infectious diseases that contribute to winter mortality such as flu, COVID-19, and RSV.    
  • Financial support schemes to help vulnerable households afford heating during cold weather, including: Winter Fuel Payment, Cold Weather Payment, Warm Home Discount Scheme, and Household Support Fund.  In June 2025 the Government announced the Warm Home Discount scheme would be expanded from October 2025 to include more households experiencing fuel poverty. In October 2025, 6 million households received letters confirming £150 would be automatically deducted off their energy bill. Between September and November 2025, the Government consulted on proposals to continue support for these 6 million households for winter 2026-2027.   

There are also specific national initiatives to identify vulnerable individuals and households, such as the Priority Services Register (PSR) and Making Every Contact Count (MECC).   

In the longer-term, in its 2024 Manifesto ‘change’, Labour committed to developing a Warm Homes Plan, a mix of grants and loans, to improve energy efficiency in British homes – including a commitment to invest an extra £6.6 billion over the next parliament, and upgrading five million homes to cut bills for families. To date, this includes Warm Homes: Local Grant to help low-income homeowners and private tenants with energy performance upgrades and cleaner heating (administered by local authorities). Private tenants are also eligible for funding support under Energy Company Obligation (due to end in March 2026 though the Government is expected to set out a replacement scheme) Alongside this, the Warm Homes: Social Housing Fund replaces the Social Housing Decarbonisation Fund, and is intended to support social housing providers and tenants [wave 3 closed on 24 November 2024, with successful applicants announced in March 2025]. With the Department for Energy Security and Net Zero (DESNZ) due to publish a Warm Homes Plan in early 2026, will this contain any references to rural?    

Concerns regarding rising living and heating costs during 2022-2023 prompted local interventions to establish warm spaces. These initiatives, led by  local authorities, charities, community groups and social enterprises provide warm spaces with refreshments and, in many cases, access to wider support services. In rural areas, some of these interventions have evolved into year-round community hubs (e.g. Cambridgeshire Community Hubs Network), while other areas have adopted mobile and outreach models (e.g. Warm Optimistic Well). Other rural initiatives have focused on supporting vulnerable households to access home energy assessments, retrofits, or emergency heating support (e.g. Energy Advice in Rural Northumberland, oil buying cooperatives).  

Despite the breadth of local activity across the countryside, there remains no comprehensive picture of cold-related deaths, how excess winter mortality is being monitored, nor the trends and responses in place. If rural communities are at greater risk, further consideration is needed of the short and long term interventions needed to reduce vulnerability.  

Where next? Tackling winter mortality demands more than quick fixes – it calls for public health, social care, health, housing, energy, and communities to work together to develop long-term solutions. This is especially important for rural areas, which face greater vulnerability due to colder temperatures, fuel poverty, an ageing population, and poorer access to services. What more can we do to stop avoidable winter deaths in rural areas from remaining an annual inevitability?   

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Jessica is a project manager at Rose Regeneration and a senior research fellow at The National Centre for Rural Health and Care (NCRHC). She is currently collating initiatives and plans to tackle economic inactivity and support people into good work; developing a community masterplan; and evaluating a heritage skills programme. Jessica also sits on the board of a charity supporting rural communities across Cambridgeshire and Peterborough and is a member of her local Patient Participation Group.  

She can be contacted by email jessica.sellick@roseregeneration.co.uk  

Website: http://roseregeneration.co.uk/ https://www.ncrhc.org/  

LinkedIn: 🌈Jessica Sellick