• The Heatwave Plan for England (HWP) aims to protect health and reduce harm from severe hot weather. It is a good practice guide underpinned by a heat-health watch alert system. The alert system is managed by Public Health England (PHE), who commission the Met Office to provide the forecast for the alerts. In the event of an upcoming period of severe weather where regionally defined temperature thresholds are predicted to be breached, heat-health alerts are cascaded to the Cabinet Office and all health, social care and public services, including NHS providers and local authorities, to enable them to implement their local protection plans. • This evaluation examined the contribution of the HWP to protecting the health of the population during hot weather by conducting: 1) a time-series analysis to establish the relationship between hot weather and adverse health outcomes; 2) case studies of local implementation of the HWP in five areas in England, along with a national survey of nurses in hospital, community and care home settings; and 3) a survey of the general public to explore whether people protect themselves and others by following the advice set out in the HWP. Epidemiological relationship between hot weather and health • The relationship between temperature and mortality, and between temperature and emergency hospital admissions (as indicators of the health impact of hot weather), suggests that hot weather in England is associated with an increase in deaths and emergency hospital admissions. • There is no evidence that general summertime relationships between temperature and mortality and between temperature and emergency hospital admissions have changed substantially in the years since the introduction of the first HWP in 2004. • Since the largest number of excess deaths and hospital admissions associated with heat take place outside of heatwave alert periods, this raises questions about the appropriateness of current threshold levels as well as the need to place more emphasis on general preparedness strategies as represented by levels 0 and 1 of the HWP. Implementation of the Heatwave Plan for England • Some interviewees noted that there could be sub-regional variation in maximum temperatures within Met Office regions, with some areas (e.g. on the coast) being less likely to experience severe hot weather even when other areas within the same region exceed the alert threshold. This led to some local authorities ignoring regional alerts, and to possibly underestimate current and future risks, as they rarely experienced temperatures that exceeded alert thresholds. • Local heatwave plans were closely aligned with the national HWP, particularly in the heat-health alert system guidance offered in the Plan. However, heatwaves were often assessed as lower risk than other weather-related hazards (such as floods and cold weather) and were often given a lower priority in planning • Heatwave planning was largely seen as an exercise in emergency preparedness and focused on ‘warning and informing’ through the alert system, rather than as a strategic objective of long-term public health and environmental planning. • The role of Clinical Commissioning Groups (CCGs) in planning and implementing local heatwave plans was not clear; in some areas CCGs were reported to be taking a key role in planning and co-ordinating the health response, while in others they were said to be acting in a more supportive role, with NHS England taking the lead. • Emergency planners, mainly in local authorities and acute trusts, said that they adopted a ‘wait and see’ approach, employing professional judgment before escalating actions during a heatwave. Some noted that plans may not work as well if a heatwave alert comes over a weekend, when relevant managers may not be at work. • Many frontline staff, including nurses surveyed, reported to be unaware of any local heatwave plans, and unfamiliar with the HWP guidance, but most said they knew what to do to protect their patients and clients ahead of and during heatwaves. However, not all the actions stated by frontline staff during the 2017 and 2018 heatwaves were appropriate or in line with HWP guidance, and many reported taking few or none of the recommended HWP actions during an alert. • Many frontline nurses surveyed said that they struggled to protect their patients during heatwaves, reporting their organisations to be often ill prepared for severe heat events. Many said that they were working in difficult and challenging conditions: often in old and poorly designed buildings not well adapted for climate change; a lack of funding and resources to implement many HWP actions; and often poor working conditions with inflexible organisational policies. • During alert periods, it was reported to be difficult to reach all high-risk groups, especially those who might be ‘below the radar’ of health or social services, such as people with social care needs who do not qualify for means-tested social support, agricultural labourers and homeless people. Managers said that they tended to rely on health information for the general public to reach these groups. • General practices may often be well placed to support these high-risk patients, as they tend to have better access to vulnerable groups missing to other NHS providers and local authorities, but their role in the HWP was not clear as they do not have contractual duties for emergency planning, and there are concerns about whether they would have capacity. • Unless there was a heat-related ‘major-incident’, few mechanisms were said to be in place to monitor activities during and following a heatwave alert, so managers were not able to formally assess how well their organisations performed during the alert period.