NHS West Lancashire Clinical Commissioning Group

Transcription

1 NHS West Lancashire Clinical Commissioning Group EXECUTIVE SUMMARY Linked to the Lancashire JSNA James Mechan Head of Public Health Intelligence NHS central Lancashire Farhat Abbas Public Health Analyst Stephen Boydell Public Health Analyst September 2012 Contributions from Lucinda Cawley Associate Director of Public Health NHS central Lancashire Jane Cass Acting Assistant Director of Public Health NHS central Lancashire Gulab Singh Assistant Director Healthy Communities NHS central Lancashire Stephen Gough Community Pharmacy Adviser NHS central Lancashire 1 of 74 1 P a g e

2 Foreword Joint Strategic Needs Assessment (JSNA) is a partnership process to identify and understand the current and future health and wellbeing needs of the local population leading to improved outcomes and reductions in health inequalities. The Local Government and Public Involvement in Health Act placed a duty on upper-tier local authorities and PCTs to undertake a JSNA and from 1 st April 2008 this became a joint statutory duty for Directors of Adult Social Services, Directors of Public Health and Directors of Children and Young People s Services. Following the passage of the Health and Social Care Act (2012), the JSNA will be central to the commissioning system. Upper tier and unitary Local Authorities and NHS Clinical Commissioning Groups, working together through the Health and Wellbeing Board, will have a duty to produce a JSNA and to have regard to it in their commissioning plans. Health and Wellbeing Boards are to use the intelligence from the JSNA to set priorities for the population's health and wellbeing within a Joint Health and Wellbeing Strategy. JSNA is defined as a process to identify and understand the current and future health and wellbeing needs of the local population leading to improved outcomes and reductions in health inequalities. In Lancashire work is progressing to extend this into capturing assets, or opportunities, for enhancing health and wellbeing, including through commissioning. It takes into account existing services and evidence of effectiveness, and informs the strategic direction of service commissioning and delivery, making them more responsive to local communities. It is a partnership duty which involves a range of statutory and non-statutory partners, informing commissioning and the development of appropriate, sustainable and effective services that are appropriate to need; as such reducing inequities. The JSNA should not be used as a performance monitoring tool but more for an evaluation of the effectiveness of locally provided services. The resultant strategies should be designed to continually improve these services. The Lancashire JSNA In Lancashire it was agreed that there would be little merit in attempting to produce an annual Lancashire-wide paper JSNA as the requirement to consider in detail the needs of twelve differing district populations would result in too unwieldy a document. Instead the Lancashire JSNA is a process with a central output of a live web-based document, with an agreed data set that would be detailed enough to be analysed at a ward, district and county-wide level. Other strands to the Lancashire JSNA are the delivery of JSNA bespoke projects focused on conditions, behaviours or population groups (for example learning disabilities, children and young people and alcohol, drugs and tobacco) and support to promote a culture of evidence based decision making, including the offer of training and regular newsletters. The data set for the Lancashire JSNA is available through the existing Lancashire Profile website and updated on a continual basis by the intelligence teams from each contributing organisation. Hyperlinks are used to access other relevant information e.g. health needs assessments, community impact assessments, health impact assessments, health equity audits, survey results. The Lancashire Profile is managed by Lancashire County Council with data and intelligence jointly updated by a small team of analysts from the LCC JSNA team and the Lancashire Public Health Intelligence teams ensuring the availability of online, immediately available intelligence to support commissioning strategies of the county council, PCTs, CCG s and local partnerships. Lancashire's Health and Wellbeing Board includes representation from all six CCGs in the county. It has considered the intelligence from the Lancashire JSNA and used this to set a small number of priorities for the county-wide Joint Health and Wellbeing Strategy. This JSNA profile has been produced using intelligence from the Lancashire JSNA. As such there is a direct line of sight between the needs reflected in the Lancashire JSNA, through the local JSNA to inform NHS West Lancashire s Commissioning 2 of 74 2 P a g e

3 Plan. This local JSNA profile will be made available to the public and partners through the JSNA section on the Lancashire Profile website. Maggi Morris (Executive Director Public Health, NHS Central Lancashire) 3 of 74 3 P a g e

4 Background A JSNA profile for NHS West Lancashire Clinical Commissioning Group We are working to promote the use of information and intelligence to improve services In March 2011, the Department of Health published a working document on The Functions of GP Commissioning Consortia in which Clinical Commissioning Groups (CCGs) are required: To contribute to the joint strategic needs assessment (JSNA) and the joint health and well-being strategy led by the relevant Health and Well-being Board(s)..to have regard to the JSNA and the joint strategy in exercising any relevant functions and To determine the nature, volume and range of services that will need to be available locally to meet needs as part of working with Health & Wellbeing Boards (HWBs) on the JSNA and developing a joint health and wellbeing strategy. CCGs represent a totally different way of working in the NHS with all GP practices in the local area having a say in how things should be run and what should constitute a priority. CCGs have a very close relationship with service users, clinical colleagues in local hospitals and the community whom they serve. It is essential that they know what needs to change to make the health services in the area even better and be able to engage with local clinicians and communities alike to drive through improvements associated with the determinants of health and wellbeing identified through use of available data, intelligence and evidence and engaging with local people, clinical and non clinician stakeholders and health and wellbeing partnerships. It is recognised that this is a large agenda and robust engagement mechanisms, with outcomes, must be established if the CCG is to successfully commission the services their communities need at the quality standards they demand. In terms of data and intelligence to inform commissioning and decision making, CCGs will have a dual role, as key contributors and key recipients of the JSNA. Having a voice of local communities reflected in the JSNA comes about through their involvement with the commissioning cycle and other sources of intelligence, such as health needs assessment, that may be used to inform the JSNA. As the JSNA develops further over time to capture assets and opportunities, participation of local communities will come as part of the JSNA process itself. The diagram below illustrates the interrelatedness of JSNA, HWBs and the commissioning cycle. 4 of 74 4 P a g e

5 This is the first JSNA profile for NHS West Lancashire CCG. It brings together a variety of information and intelligence that will be utilised to inform decisions about the planning and commissioning of health, healthcare, wellbeing and social care services for this locality. This document reflects the issues that have been recognised as priorities in several previously published strategic documents, which include (not exhaustive): Box 1: Central Lancashire PCT Lifestyle Survey (published 2007) Central Lancashire School Health Education Survey (published 2008) NHS Central Lancashire Commissioning Strategic Plan (published 2008) Central Lancashire Suicide Audit ( ) published 2009 Central Lancashire JSNA profile (published 2009) 4 District JSNA profiles (published 2009) 4 District update profiles (published 2011) Central Lancashire Pharmaceutical Needs Assessment (published 2011) Early Central Lancashire CCG profiles (published 2011) Health inequalities JSNA (published 2009) Regional Wellbeing Survey (published 2010) Children and Young Peoples Intelligence Profile (published 2010) Teenage Pregnancy Intelligence Profile (published 2010) Mental Health HNA for Central Lancashire (published 2011) Lancashire Prisons Needs Assessment (published 2011) Lancashire wide Mental Health Intelligence Profile (published 2012) 5 of 74 5 P a g e

6 The reports in Box 1 and the online JSNA information resource are part of a collaborative working approach that brings together a number of partners across Lancashire. These partners include, Public Health and Public Health Intelligence teams in each of the three Lancashire PCTs, Lancashire County Council based teams, including the JSNA team, Social Services, Police and Fire and Rescue Service, collaborating to develop comprehensive intelligence on health and wellbeing in Lancashire. This local JSNA profile has a strong focus on published data and evidence at a district and County level on the health and wellbeing of people, both resident and registered populations. It attempts to augment this geographical data with currently available data at a GP Practice and CCG level. Increasingly, however, the data and evidence will be more tailored to the configuration of NHS West Lancashire CCG and that of the population it serves. An online page has been developed for this CCG on the Lancashire profile, to support the provision of intelligence, which will routinely be updated by the Lancashire public health intelligence team. Current projects on this online page: 1 Older peoples Pan Lancashire Intelligence Profile 2 Offender health Pan Lancashire Intelligence Profile 3 Pan Lancashire Suicide Audit 4 Learning Disabilities Pan Lancashire Intelligence Profile 5 Lancashire Long Term Conditions Needs Assessment to include a total population, total pathway approach 6 Looking Ahead for Lancashire (fuel poverty and recession monitoring) 7 Refresh and update the Health Inequalities JSNA, especially in light of the current changes to the health system, which include the creation of a Health and Wellbeing Board who will create a Health and Wellbeing Strategy, and Clinical Commissioning Groups. 8 Regional Wellbeing Survey update 9 On-going analysis of Census 2011 As a living process the JSNA will be updated to reflect key issues that are identified from these projects that are relevant to the work of NHS West Lancashire CCG and its priorities. 6 of 74 6 P a g e

7 Summary of Findings In many ways NHS West Lancashire CCG mimics the country as a whole and many indicators of health and social care are comparable with averages for England. However, there are some issues of particular concern and, even where the CCG area is comparable to the average, this masks stark inequalities between areas and communities within the CCG. For instance, the health of people in West Lancashire is generally worse than the England average. These issues are described in the five main challenges below. The supporting evidence for these issues can be found in the main local JSNA document. Challenge 1 Long Term Conditions. 1. To reduce the incidence of, and mortality from, long term conditions. 2. To upscale prevention and early intervention strategies to ensure health and social care services are able to cope with this increased demand (using self-care approaches and skills). 3. To increase early diagnosis and optimise treatment to slow the development of long term conditions. 4. To support the quality of life of carers for people with long term conditions Related health issues to be addressed: 1. Higher deaths from stroke, compared to England average 2. Deaths from respiratory diseases, compared to England 3. Higher rate of CVD mortality in men compared to women 4. Higher COPD emergency admissions, compared to England average 5. Higher diagnosed prevalence of diabetes, compared to England average 6. Higher diagnosed prevalence of CHD, compared to England average 7. Higher diagnosed prevalence of asthma and COPD, compared to England average 8. Undiagnosed cases of diabetes, hypertension and COPD as highlighted by the difference between QoF reported and modelled prevalence Challenge 2 - Mental Health and Wellbeing. 1. To promote emotional health and wellbeing in children and adults. 2. To support people (of all ages) who are affected by adverse mental health to play a full and active role in society. Mental health conditions, including depression are more prevalent in those with long term conditions such as Diabetes 3. To work in partnership to address the impact the current economic downturn may have on these trends. 4. To improve the mental health and well-being of seldom seen, seldom heard groups and the unemployed populations It is recognised that in parts of the country large numbers of people are out of work because of poor mental health. Each year between 7 and 10 people commit suicide in the area; the rate of deaths from suicide and undetermined injury is not significantly different from England s rate. Related health issues to be addressed: 1. Higher percentage of binge drinking adults, compared to England average 2. Higher rate of hospital stays for alcohol related harm, compared to England average 3. In the CCG, higher prevalence of recorded depression, compared to England average 7 of 74 7 P a g e

8 Challenge 3 Maternal and child health. The Marmot review of health inequalities shows that giving every child the best start in life by supporting expectant and new families to be healthy is one of the most effective ways of breaking the cycle of health inequality from one generation to the next. Sustaining the impact of this through ensuring evidence based, need led interventions for child and adolescent health is important with some of the related key issues being: 1. To optimise the health and wellbeing of women in pregnancy including reducing the number of women who smoke during pregnancy and increasing the number of babies who are breastfed. 2. To promote and safeguard the health and wellbeing of pre-school age children (including reducing obesity and addressing low weight issues). 3. To promote breastfeeding These factors all have consequences for the health of children, particularly those in the most disadvantaged areas. Related health issues to be addressed: 1. All risk taking behaviours In the CCG, higher rates of smoking in pregnancy, compared to England Young people s sexual health including wards that feature as statistically significant hotspot areas for under 18 conceptions. 2. In the CCG, lower breast feeding initiation and duration at 6-8 weeks, compared to England 3. Higher rate of alcohol-specific hospital stays (under 18), compared to England 4. Higher percentage of 5 and 12 year olds with decayed, missing, and filled teeth, than England average Challenge 4 Improve health and independence of older people 1. To Increase healthy life expectancy for those aged 65 and over 2. To improve support for older people and their carers in playing a full and active role in society 3. To help design services to cope with the increasing numbers of older people with chronic long term conditions such as dementia, mental illness and learning disabilities. Related health issues to be addressed: 1. Undiagnosed cases of dementia, as highlighted by the difference between QoF reported and modelled prevalence Challenge 5 - Health inequalities. 1. To reduce alcohol related hospital admissions and alcohol related harm. Alcohol related admissions to hospital are higher than the national average and increasing. 2. To work with stakeholders to ensure local environments enhance positive health and wellbeing. The place in which we live, and the community of which we are a part, has a significant impact on our health and wellbeing. Our neighbourhood, the environment and the attitudes of those around us can shape the choices that we make and affect our life chances. 3. To narrow the gap in health inequalities as measured by life expectancy. 8 of 74 8 P a g e

9 These differences in living conditions, along with health behaviours, are significant contributors to the fact that people in the most affluent areas of NHS West Lancashire CCG are living at least 6 years longer than those in the more disadvantaged areas. These unfair and avoidable differences in health between social groups are defined as the health gradient in health inequalities. 4. To work through partnerships to reduce child poverty. Child poverty is on the increase, in this area. Tackling these health inequalities in this CCG will require action to improve the following areas listed below, in addition to the targets within the public health outcomes framework: Improving integrated and holistic support for children, young people and families Narrowing of the gap in educational attainment Sustainable efforts towards improving housing conditions Sustainable efforts towards breaking the link between poor health and unemployment Improving health literacy skills across the population 5. To improve health equity. Variation in some diseases by deprivation, in general, deprived areas seem to have higher health related issues. Related health issues to be addressed: 1. In the CCG, lower uptake of cancer screening programmes, compared to England target for each programme; bowel cancer screening up take is much lower than the England target compared to the other two screening programmes. 2. Female life expectancy is lower than England average 3. Difference in life expectancy between most deprived and least deprived 4. Higher road injuries and deaths compared to England average Recommendations The published strategies identified earlier in box 1 and the evidence summarised in them indicate general conclusions for commissioners to consider as they set and refine their commissioning priorities and related actions that will address the emerging challenges. The Health and Social Care Bill proposed that GP Commissioning Groups should, by 2013, deliver a sustainable healthcare system in the face of the most challenging financial and organisational environment since the introduction of the provider/purchaser split in the NHS in The following tables set out recommendations in the following areas. Table 1 The changing population Table 2 Long term conditions and disabilities Table 3 Mental health and wellbeing Table 4 - Living conditions and health inequalities Table 5 Lifestyle and behaviours Recommendations within the tables are those taken from the main conclusions of the work identified in the strategic documents identified in box 1. The majority of these recommendations require multiagency work to effectively address and include those that the CCG has direct responsibility for and those for which the commissioning responsibility lies elsewhere. As such work may need to be undertaken to identify specific CCG actions as required. 9 of 74 9 P a g e

10 Future Public Health work As mentioned previously, it is recognised that further work may be required to gain a better insight into some specific topic areas. The following programme is to be undertaken as appropriate by the Public Health Intelligence Team: 1) Trend analysis to include data on prevalence, mortality, morbidity and wider determinants of health, including community data to be published in October ) To present a summary of the key findings from the 2011 census data and its significance to NHS West Lancashire CCG. 3) Work with NHS West Lancashire CCG to undertake further insight work into topics highlighted by the NHS West Lancashire CCG JSNA. 4) Deliver an online presence from which more detailed relevant data, intelligence and evidence of best practice can be obtained. 5) Compile a CCG diabetes report. Contact: Jim.mechan@centrallancashire.nhs.uk Farhat.abbas@centrallancashire.nhs.uk Stephen.boydell@centrallancashire.nhs.uk 10 of P a g e

11 Table 1 The Changing Population CCGs will need to work in partnerships with their local community and health and wellbeing partnerships (H&WBPs) to assist; CHILDREN Develop opportunities and access to higher education to retain and attract young people to the area Promote healthy lifestyles particularly in relation to alcohol consumption, smoking and healthy eating Provide employment and training opportunities for young people to establish themselves in their communities. In partnership with H&WBPs narrow the gap between educational attainment of children from deprived backgrounds and help all to contribute to the local economy Work with H&WBPs to help youngsters make the transition from home to independence to provide affordable and healthy homes for rent or to buy Ensure effective Mental Health services particularly around CAMHS services to ensure effective care for 16 to 18 year olds OLDER PEOPLE Enhance the contribution of people over 60 to the economy and cultural life by promoting healthy living, wellbeing and community participation for this group. Expand services to cope with growing numbers of over 75 year olds. Enable older people to be as independent as possible for as long as possible. Support older people to have control over services tailored to meet their individual needs Ensure access to social care services is of the right quality in the right place and at the right time Provide integrated health and social services support in a seamless manner Encourage older people and those retiring into the area to prepare for older age by adapting their homes to lifetime standards before the need arises through disability Help to alleviate emergency admissions for falls in the home and other injuries by working with Social Services to adapt homes of vulnerable people. ALL Narrow the Gap in Healthy Life expectancy. Ensure pro-active screening in primary care to ensure that all patients are given early and good access to services. Encourage current and potential contribution of the third sector Set up systems to assess access to services and whether there is an adverse impact on health in Black and Minority Ethnic (BME) groups, migrants, disabilities and, with H&WBP s, provide positive contributions to the issues Work with local authorities to increase the number of extra care housing units that adapt to an individual s changing needs New and existing service provision should be assessed to ensure that disadvantaged groups and hard to reach groups are reached. Cultures or attitudes which lead people not to seek help they require should be challenged and all services (including primary care), should work proactively with these groups to reduce negative outcomes and improve self-care. 11 of P a g e

12 Table 2 Long Term Conditions and Disabilities CCGs will need to work in partnerships with their local community and health and wellbeing partnerships (H&WBPs) to assist; CHILDREN Working with others develop a single referral and joint assessment process in each locality Establish registers focusing on health issues such as low birth weight babies, children with disabilities and dementia to target services more effectively and to improve partnership planning. Develop an integrated service for disabled children including appropriate childcare and short care provision for children and young people Involve parents in the design of short breaks services Ensure timely assessment and provision of community equipment Establish registers for low birth weight babies and children with disabilities Increase support for parents whose children do not meet severe disabled children s criteria Support the implementation of effective transitional planning for children with special educational needs OLDER PEOPLE Modernise home care and day services to make them more flexible and promote independence Invest in falls prevention schemes Provide a targeted adaption service so people can stay in their own homes as long as possible. Raise awareness of dementia and encourage people to seek early help Expand effective support for the increasing numbers of people with dementia and learning disabilities Improve support for the family of carers of people with dementia Improve training and awareness for the health and social care workforce to ensure the early diagnosis of dementia Ensure the seamless transition and coordination between learning disability and older people s service. Continue to deliver the Closer to Home agenda with a strong emphasis on upfront Public Health initiatives, public engagement and self-management. ALL Ensure effective early detection in primary care of long term conditions such as diabetes and COPD. Early intervention for specific conditions particularly around screening programmes and long term conditions. Agree quality standards with community and hospital NHS services for people with learning disabilities. Support people to be in control of their health, care and wellbeing Improve employment services helping people with disabilities and carers to get into work. Make health action plans and health records available for all people with learning disabilities. Continue the self-directed support and individualised budgets including identifying models of service provision and, where necessary, brokers and advocates. 12 of P a g e

13 Table 3 Mental Health and Wellbeing CCGs will need to work in partnerships with their local community and health and wellbeing partnerships (H&WBPs) to assist; CHILDREN Improve equitable access to comprehensive Child and Adolescent Mental Health Services (CAMHS) Improve the integration of CAMHS services with other service areas Develop Mental Health awareness targeting at young people working in conjunction with education and 3 rd sector bodies. Increase the number of young people with non-acute mental health needs who are offered a CAMHS assessment. OLDER PEOPLE Develop and expand services for the increasing number of older people with mental health problems. Improve access to wellbeing services for older people, including psychological therapies, physical exercise, social engagement and bereavement services. ALL Target mental health support to people affected by unemployment Importance of wellbeing in affecting physical health, behaviour, social inclusion and prosperity Understand the link between poor or unsuitable housing and deteriorating mental health outcomes. Ensure that all partner organisations have appropriate access to complete, accurate, relevant and timely intelligence concerning suicides, near misses and deliberate self-harm. Assist in promoting regular physical health checks to people with severe mental illness. Improve access to psychological therapies for people with chronic physical illnesses. Ensure that all people with mental health problems and those at risk of suicide, especially people who self-harm, are identified and diagnosed early and have equitable access to services that meet their health, social and material needs. 13 of P a g e

14 Table 4 Living Conditions and Health Inequalities CCGs will need to work in partnerships with their local community and health and wellbeing partnerships (H&WBPs) to assist; CHILDREN Target children in unemployed households who may be at greater risk of alcohol/drugs misuse and suicide. Narrow the gap between educational attainment of children from deprived backgrounds. Ensure that all children and young people have access to age-appropriate services. Improve information for all young people about sexual health and contraceptive services, targeting those most at risk of pregnancy. Ensure appropriate sexual health advice, support and access to services for young people in primary care. OLDER PEOPLE Develop approaches to tackling fuel poverty which also give the opportunity for job creation through greater harnessing of renewable energy for heating homes. Support the over 50 s getting into work Encourage older people in the area and those preparing to retire to adapt their homes before the need arises Reduce reliance on residential care through increasing the availability of extra care housing ALL Ensure effective and early access to secondary care services to ensure best quality outcomes Change population and behaviours Mobilise community assets and build community resilience Support and increase access to appropriate tenancy support services for vulnerable people. 14 of P a g e

15 Table 5 Lifestyle and Behaviours CCGs will need to work in partnerships with their local community and health and wellbeing partnerships (H&WBPs) to assist; CHILDREN Support for young people and their families for drug and alcohol misuse. Safeguard children and young people Implement the North West Breast Feeding framework and delivery of tailored support programmes for breast and infant feeding among pregnant women and mothers Improve opportunities for healthy eating and increased physical activity to reduce prevalence of childhood obesity. OLDER PEOPLE Promote new methods of supporting smoking cessation, reducing alcohol misuse and promoting physical activity and healthy eating. Work with the voluntary sector to support older people to maintain an active role in their communities and prevent social isolation. ALL Changing population and behaviours Promote screening in primary care to identify hidden populations at risk Risk taking behaviours improve harm reduction and recovery Reduce economic and social harm from alcohol misuse Reduce alcohol related crime and antisocial behaviour Reduce alcohol consumption and tobacco use For alcohol and drugs, promote screening to identify hidden populations primary care, secondary care, offenders. Develop prevention programmes for families and improve food skills through school and community initiatives. 15 of P a g e

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17 NHS West Lancashire Clinical Commissioning Group JSNA PROFILE Linked to the Lancashire JSNA James Mechan Head of Public Health Intelligence NHS central Lancashire Farhat Abbas Public Health Analyst Stephen Boydell Public Health Analyst September 2012 Contributions from Lucinda Cawley Associate Director of Public Health NHS central Lancashire Jane Cass Acting Assistant Director of Public Health NHS central Lancashire Gulab Singh Assistant Director Healthy Communities NHS central Lancashire Stephen Gough Community Pharmacy Adviser NHS central Lancashire 17 of 74 1 P a g e

18 The People of NHS West Lancashire CCG Demography NHS West Lancashire CCG is the overarching consortium and overseas 23 GP practices serving primarily the local authority of West Lancashire. The CCG has a registered population of approximately 111,500 people. There are pockets of registered population residing in the districts of Chorley and Wigan. Figure 1 below indicates the density and spread of the registered population in West Lancashire. Figure 1 - NHS West Lancashire CCG Population. Source: LASCA 18 of 74 2 P a g e

19 Much of the available data to support a JSNA is based on a person s place of residence rather than the GP with which they are registered. Consequently much of this profile is focused around data for the districts of residence within the area covered by NHS West Lancashire CCG. Figure 2 below confirms the distribution of the CCG population showing the percentage of residents in each of the local boroughs. West Lancashire CCG -Population by District of Residence 2.6% 1.2% 0.1% 96.1% West Lancashire Wigan Chorley Other Figure 2 NHS West Lancashire CCG Population by District of Residence 6% West Lancashire CCG Population Pyramid 4% 2% 0% 2% < % 6% % Female % Male England % Female England % Male Figure 3 NHS West Lancashire Population Pyramid (source ONS population estimates) Figure 3 shows a large age group for both men and women accounting for 7.9% of the population. The profile varies from the England profile particularly around the middle 20s to 30s age groups. 19 of 74 3 P a g e

20 Deprivation The 2010 Index of Multiple deprivation (IMD) combines a number of indicators, chosen to include economic, health, housing, crime and social issues into a single deprivation score for each small area (lower layer super output area of which there are 32,482) in England. It allows areas to be ranked according to five levels if deprivation across the country. Figure 4 indicates the variations across the CCG registered population with a pictorial view on the map in figure 5. 25% of the CCG population reside in IMD quintile 4, the second most affluent level in the country and with 22% residing in quintile 5 the most affluent; it can be seen that West Lancashire has an affluent profile. However 20% of the population live in the most deprived quintile 1 mostly around Skelmersdale. This gives commissioners significant challenges in selecting the correct strategies for the diverse communities in the CCG. Proportion of CCG population 30% 25% 20% 15% 10% West Lancashire CCG IMD Quintile Breakdown 5% 0% IMD Quintile % of population England Figure 4 Index of Multiple deprivation (2010) 20 of 74 4 P a g e

21 Figure 5 shows the 2010 IMD map with location of NHS West Lancashire CCG practices. Figure 5 Location of CCG practices and IMD2010 quintiles 21 of 74 5 P a g e

22 Population Projections Population doesn t stand still and the CCGs will have to consider the change in their population over time. 6% 4% West Lancashire CCG Population Pyramid - 10 Year Comparison 2% 0% 2% < % 6% % Female 2012 % Male 2012 % Female 2022 % Male 2022 Figure 6 NHS West Lancashire CCG population Projections (source: ONS population projections) Figure 6 suggests that by the year 2022 the population of the CCG will increase by around 2,750 people to approximately 114,200. The biggest increase will occur in the year olds and in the 55 to 64 age groups for both genders which is simply a progression of the larger groups from There are substantial reductions in the teenage and early twenty s groups and substantial reductions in the year olds. Classification Clustering of Practices This report uses a nationally agreed method to create a set of classification groups of GP practices with similar characteristics. It also provides an overview of the main characteristics of the practices in each classification group. The following variables were used to group GP practices in England into classification groups of similar characteristics Percentage of population aged 0 to 4 years old (Source: ADS 2009) Percentage of population aged 5-14 years old (Source: ADS 2009) Percentage of population aged years old (Source: ADS 2009) Percentage of population aged 85 years or older (Source: ADS 2009) Percentage of population from Asian ethnic groups (Source: ERPHO estimates) Percentage of population from Black ethnic groups (Source: ERPHO estimates) Deprivation score for practice population (based on Index of Multiple Deprivation 2007) Whether the practice was in an urban area (population of 10,000 or greater), town or urban fringe area or village, hamlet or isolated dwellings (based on Office for National Statistics Classification of Rurality) Two-step cluster analysis was used to identify the best match of the classification groups. All CCG practices are classified into 10 groups. Classification groups 8 (Dark green), 10 (dark blue) and 7 (mid-green) (10) and mid-green (7) classification groups have a higher proportion of the practice population in older age groups (65 to 84 years and 85 years and older). Practices in red (1) brown (2) and Orange (3) classification groups have a greater 22 of 74 6 P a g e

23 percentage of the population under 15 years old. The largest average list sizes are found in the classification group 9 whilst classification group 1 has the smallest average list sizes. Figure 7 below shows the full range of definitions used in the analysis below. Cluster Description Group 1 Practices with a smaller than average list size, a high percentage of the population aged under 15 years old and fewer aged 65 years or older. A very high proportion of the population from Asian ethnic groups and a higher than average proportion from Black ethnic groups and very high levels of deprivation. 2 High percentage under 15 years. Very high percentage of black population and high than average Asian population High deprivation 3 Practices with a high percentage of children (under 15 years old) and very high levels of deprivation. 4 Practices with a very low percentage people under 15 years and a lower proportion of older people (65 years and older) and an above average proportion of the population from Asian and Black ethnic groups. 5 Practices with a higher percentage of older people (aged 65 years and older) with slightly higher levels of deprivation. 6 Practices with an average proportion of the population in younger and older age groups and generally low deprivation. 7 Located in towns or urban fringe settlements with low deprivation and few people from Asian and Black ethnic groups. 8 Practices with a high percentage of the population aged 65 years and older and low levels of deprivation. 9 Practices with large average list sizes, an average proportion of the population under 15 years old, a higher proportion aged 65 years and older and low levels of deprivation. 10 Located in villages, hamlets and isolated settlements with a small average list size and a higher proportion of the population aged 65 years and older. Few people from Asian and Black ethnic groups and low levels of deprivation. 11 unknown Figure 7 - Definitions of Clustering Methodology. Source: Yorkshire and Humber Public Health Observatory Figure 8 below shows the results of the clustering analysis of West Lancashire CCG practices and figure 9 shows the distribution of practices by cluster group. As it can be seen from figure 8 there are a higher number of practices in cluster group 1, 3 and of 74 7 P a g e

24 50 Cluster group of West Lancashire CCG Practices Cluster Group P81112 P81208 P81121 P81201 P81039 P81764 P81136 P81774 P81758 P81727 P81138 P81710 P81096 P81772 P81646 P81674 P81041 P81014 P81695 P81084 P81045 P81177 Y02903 Practice Group 1 Group 2 Group 3 Group 4 Group 5 Group 6 Group 7 Group 8 Group 9 Group 10 Group 11 Figure 8 cluster groups of practices across NHS West Lancashire CCG 24 of 74 8 P a g e

25 Figure 9 Distribution of NHS West Lancashire CCG practices by cluster The following tables provide some district profile data on a number of wider determinants of health. Sefton has been included as a comparator due to its closeness to the CCG area and due to the fact that there is a local hospital in Southport to which patients from both the CCG area and Sefton are referred. 25 of 74 9 P a g e

26 Economic profile of NHS West Lancashire CCG Employment and Education Community profiles 2012 Chorley Sefton West Wigan England Lancashire 1.2% 0.0% 96.1% 2.6% Domain Indicator number value number value number value number value Average Our Communities 2 Proportion of children in poverty 2, , , , Statutory homelessness GCSE achieved (5A*-C inc. Eng & Maths) , , Violent crime 1, , , , Long term unemployment , , Figure 10 Our Communities (Community health profiles 2012). Source: Office for National Statistics Community health profiles 2012 People living in poorer socio-economic circumstances or in the more deprived areas of the CCG tend to experience poorer health. They have higher levels of chronic disease and disability, more early deaths (under 75 years) and they experience the adverse effects of ageing at an earlier stage in their lives. They usually have difficulty accessing health and social care services and when contact is made it is often at a later stage in their condition. As a consequence they require more complex treatment and experience poorer health outcomes. They are less likely to engage with health promotion and disease prevention activities. Figure 10 above from the annually published Community Health Profiles (2012) indicate that within NHS West Lancashire CCG, Sefton district has the highest percentage of children in families receiving meanstested benefits & low income (21.0%). Chorley district has a lower rate of 13.9%, lower than that of Wigan on 20.6% and England on 21.9%. Encouragingly districts within the NHS West Lancashire CCG have generally lower unemployment rates and higher GCSE passes than that of England. With the exception of Wigan, statutory homeless is also lower in the CCG area as a whole compared to England. Violent crime rates in West Lancashire (11.5%) are lower than England (14.8%). The highest rates in the CCG are in Chorley and West Lancashire which isn t surprising due the larger areas of deprivation in these districts. 26 of P a g e

27 Burden of Disease QoF registers and Modelling of Disease Prevalence As shown in figure 11, in comparison to the rest of England there is significantly lower recorded prevalence for nine conditions (marked in green). This could reflect poor ascertainment of those in the local population suffering from these conditions by General Practitioners or the local population does indeed have a lower prevalence. Figure 11 Quality and Outcomes Framework (QoF) Prevalence in NHS West Lancashire CCG Conversely there is a higher than England average recorded prevalence for nine of the disease groups (marked in red), which could point to over recording of the conditions in general practice or that there is a genuine higher prevalence for these disease areas. Figure 11 above shows that hypertension is under recorded by practices with an estimated prevalence of 23.7% compared with a recorded prevalence of 12.7%. However, as can be seen from the England average, this is the case across the country as well. Estimated prevalence of COPD is significantly higher than the England average with a CCG prevalence of 3.23% compared with an England prevalence of 2.90%. Recorded prevalence of asthma and depression are both significantly higher than the recorded 27 of P a g e

28 England average. This could be due to genuinely higher prevalence locally or better than average recording of these conditions within the CCG. QoF reported vs. estimated QoF reported prevalences are shown in subsequent pages as funnel plots and give an indication of the relative position of practices actual prevalence against a modelled estimated disease prevalence and grouped by the clusters discussed earlier. The key to these funnel plots is contained at Appendix 2. For funnel plots in this paper the average line is where the expected is equal to the observed (actual) and so there is no variation between expected and observed. CHD Figure 12 below shows 10/11 QoF reported number of patients with CHD relative to estimated number of patients with CHD, by practice cluster group. Out of 23 West Lancashire CCG practices, in 11 practices the QoF reported number with CHD is significantly lower than estimated number. This may be due to under recording in these practices and indicate that hard to reach groups are not being included particularly in practices that have significant populations within the more deprived cluster group 3. Please see appendix 2 for practice name relating to practice number in chart. + 10% QoF reported number of patients with CHD (10/11) vs. estimated number of patients with CHD - NHS West Lancashire CCG practices 0% % % % % % Estimated number of patients with CHD QoF reported number relative to estimated Source: NHS IC & ERPHO Average 2SD limits 3SD limits Group 3 Group 5 Group 6 Group 7 Group 8 Group 9 Group 10 Figure 12 10/11 QoF reported number with CHD relative to estimated number with CHD 28 of P a g e

29 Stroke Figure 13 below shows 10/11 QoF reported number of patients with stroke relative to estimated number of patients with stroke, by practice cluster group. Out of 23 NHS West Lancashire CCG practices, in 9 practices the QoF reported number with stroke is significantly lower than estimated number. In 1 practice (group 3) the reported number with stroke is significantly higher than the estimated number. Please see appendix 2 for practice name relating to practice number in chart. + 40% + 30% QoF reported number of patients with stroke (10/11) vs. estimated number of patients with stroke - NHS West Lancashire CCG practices % 71 QoF reported number relative to estimated + 10% 0% 10% 20% 30% 40% Average 2SD limits 3SD limits Group 3 Group 5 Group 6 Group 7 Group 8 Group 9 Group 10 50% Estimated number of patients with stroke Source: NHS IC & ERPHO Figure 13 10/11 QoF reported number with stroke relative to estimated number with stroke Hypertension Figure 14 below shows 10/11 QoF reported number of patients with hypertension relative to estimated number of patients with hypertension, by practice cluster group. In all 23 NHS West Lancashire CCG practices, the QoF reported number with hypertension is significantly lower than estimated number, thereby indicating possible cases of undiagnosed hypertension. Please see appendix 2 for practice name relating to practice number in chart. Though the exact causes of hypertension are usually unknown, there are several factors that have been highly associated with the condition. These include Smoking, obesity or being overweight, diabetes, sedentary lifestyle, lack of physical activity, high levels of salt intake (sodium sensitivity), insufficient calcium, potassium, and magnesium consumption, vitamin D deficiency, high levels of alcohol 29 of P a g e

30 consumption, stress, medicines such as birth control pills, genetics and a family history of hypertension, chronic kidney disease + 10% QoF reported number of patients with hypertension (10/11) vs. estimated number of patients with hypertension - NHS West Lancashire CCG practices 0% QoF reported number relative to estimated 10% 20% 30% 40% 50% 60% Estimated number of patients with hypertension Source: NHS IC & ERPHO Average 2SD limits 3SD limits Group 3 Group 5 Group 6 Group 7 Group 8 Group 9 Group 10 Figure 14-10/11 QoF reported number with hypertension relative to estimated number with hypertension COPD (chronic obstructive pulmonary disease) Figure 15 shows 10/11 QoF reported number of patients with COPD relative to estimated number of patients with COPD, by practice cluster group. Out of 23 NHS West Lancashire CCG practices, in 8 practices the QoF reported number with COPD is significantly lower than estimated number, thereby indicating possible undiagnosed cases of COPD. In 1 practice (in cluster group 3), the QoF reported number with COPD is significantly higher than estimated number.. Those significantly below are mainly in more affluent cluster groups of 8 and 9. COPD is generally associated with two main lung diseases: emphysema and chronic bronchitis. Although both diseases have different pathological causes, both share an obstructive pattern in the lung airways, which most of the time is felt as dyspnea (shortness of breath). The main cause of COPD is tobacco smoking. Contributing factors may also be: allergies, air pollution, working in a polluted environment. Please see appendix 2 for practice name relating to practice number in chart. 30 of P a g e

31 + 30% QoF reported prevalence of COPD (10/11) vs. estimated number of patients with COPD - NHS West Lancashire CCG practices + 20% + 10% QoF reported number relative to estimated 0% 10% 20% 30% 40% 50% Average 2SD limits 3SD limits Group 3 Group 5 Group 6 Group 7 Group 8 Group 9 Group 10 60% Estimated number of patients with COPD Source: NHS IC & ERPHO Figure 15 10/11 QoF reported number with COPD relative to estimated number with COPD Dementia Figure 16 shows 10/11 QoF reported number of patients with Dementia relative to estimated number of patients with dementia, by practice cluster group. Please see appendix 2 for practice name relating to practice number in chart. Out of 22 NHS West Lancashire CCG practices (Y02903 not included in the funnel plot as Qof reported dementia number is zero), in 21 practices the QoF reported number with dementia is significantly lower than estimated number, thereby indicating possible undiagnosed cases of dementia.. 31 of P a g e

32 0% QoF reported number of patients with dementia(10/11) vs. estimated number of patients with dementia (early&late onset) -NHS West Lancashire CCG practices QoF reported number relative to estimated 20% 40% 60% 80% % Estimated number of patients with dementia Source: NHSCL Public Health Intelligence & QoF Average 2SD limits 3SD limits Group 3 Group 5 Group 6 Group 7 Group 8 Group 9 Group 10 Figure 16 10/11 QoF reported number with dementia relative to estimated number with dementia 32 of P a g e