Chapter 3: Health and Wellbeing in Wirral - Overview

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1 Chapter 3: Health and Wellbeing in Wirral - Overview Key Issues Wirral is not on track to meet the PSA Life Expectancy Target (December 2011). The relative gap from the baseline of 1995/97 has increased by 30% for men and 33% for women. The impact of deprivation on life expectancy appears to be greater for males than females and this should be examined in more detail to identify potential protective factors. Action is needed to address the gap in life expectancy between the most deprived areas of Wirral and the more affluent areas. These are amongst the widest gaps between wards in the same borough in England. The male mortality rate from potentially preventable causes is higher than the England rate, which could be an indication that men in Wirral are not accessing health care services in a timely manner. It is however important to ensure that local healthcare services are designed to meet the needs of men in Wirral. Mortality from chronic liver disease (under 75 s) is considerably high in Wirral, particularly in men. The rise in mortality from liver disease and other digestive disorders is mainly caused by alcohol and is contributing towards the failure to meet the target for a reduction in the life expectancy gap. Wirral has made considerable improvements in reducing mortality from cardiovascular disease (CVD); however death rates in the more deprived areas are almost twice as high as they are in Wirral as a whole. This is a key inequalities issue in Wirral. It is estimated that there are around 3,600 people in Wirral with undiagnosed Coronary Heart Disease (CHD). Wirral has established a Locally Enhanced Service (LES) to screen the population and identify undiagnosed cases of CHD; the number of undiagnosed cases should be reviewed in the future to evaluate the impact of the service over the longer term. Wirral is performing fewer coronary revascularisation procedures than expected, given the age and deprivation of the local population. Increasing numbers of people in Wirral surviving a stroke and heart attack and being left with a disability as a result is an issue that commissioners need to be aware of as it could have significant implications for health and social care services. There is a need to ensure women are being invited and are attending appointments for cervical screening. There has been a recent downward trend in the number of women attending appointments (this has been observed both nationally and locally). The gap in Chronic Obstructive Pulmonary Disease (COPD) mortality between England and Wirral does not appear to be closing for females. Based on the current picture, it is projected that incidence of COPD will show a steady increase over the next two decades, which could have a considerable impact on health and social care services in the future. People with diabetes living in the most deprived areas of Wirral are significantly more likely to be admitted to hospital as emergencies. It is estimated that there are approximately 1,800 undiagnosed diabetics in Wirral. It is estimated that nearly 38,000 people in Wirral have hypertension but are currently undiagnosed (approximately half of people diagnosed) and are at an increased risk of CHD and Stroke. Whilst this is inline with national figures this is still of concern.

2 Whilst adult obesity estimates indicate that Wirral has slightly lower rates than national and regional averages, this still remains a key issue as rates are likely to increase significantly over the next few decades. Wirral needs to closely monitor local obesity prevalence and prepare for a likely increase in the numbers of people who develop co-morbidities such as diabetes and CVD. The prevention of overweight and obesity should also remain a priority. The rate of MRSA and Clostridium Difficile is lower in Wirral hospitals than the North West average, although public concern about healthcare acquired infections in Wirral is high. Wirral is making slow progress on the Government target to reduce the number of people killed and seriously injured on Wirral roads by 40% at If current progress continues, Wirral is unlikely to achieve this target. Wirral has however exceeded its target to reduce the number of slight causalities, although it is still behind national performance. Smoking is related to a range of chronic and fatal conditions such as CVD, cancer and COPD. Deaths from these diseases are higher in areas of deprivation as is smoking prevalence. Targeting smoking interventions in these areas, both in terms of prevention and treatment should remain a priority. Although fruit and vegetable consumption has increased over the last few years, there are still areas that are lagging behind the general improvements in trends; in particular women living in the most deprived areas, and males generally reported eating fewer fruit and vegetables overall. Over the last few years Chlamydia has consistently been the most diagnosed sexually transmitted infection at Arrowe Park Hospital, whilst the Wirral Chlamydia Service is recognised as one of the top performing services in the country. In 2008/09, admissions to hospital resulted in over 62,428 excess bed days at a cost of almost 14 million. Excess bed days were more likely for non elective admissions and genitourinary conditions accounted for over 1 in 4 of all excess bed days. This warrants further investigation. Conditions relating to pregnancy was the single biggest cause for a non-elective admission, this equates to almost three non elective admissions related to pregnancy for every baby born in Wirral. Wirral is currently not on track to meet the local target set for the National Indicator 130 which means that not enough social care clients are receiving Self Directed Support. Wirral is also under performing in the National Indicator 141 which means that too few clients in short term accommodation are moving on in a planned way to greater independence. A range of measures have been introduced to address this with year on year targets set to demonstrate improvement. Findings from the 2008 National Patients Survey, which asked for patients feedback on a range of primary health care indicators shows that Wirral is performing well when compared to the feedback nationally.

3 Life Expectancy Trends in life expectancy at birth (by sex) Life expectancy is an estimate of the average number of years a new born baby would live if they experienced the age specific mortality of the area in which they live. Life expectancy is one of the national headline targets for reducing health inequalities. The national public service agreement (PSA) target for life expectancy aims to: Starting with local authorities, reduce by at least 10% the gap in life expectancy between the fifth of areas with the worst health and deprivation indicators and the population as a whole by As a spearhead Primary Care Trust (PCT), Wirral will need to reduce by 10% the gap in life expectancy at birth by compared with the England average for the baseline year of Table 1a shows the trend in life expectancy at birth for Wirral and England ( to ) and also the gap between them. Table 1a: Life expectancy at birth in Wirral and England for to ercentage (%) Change in Relative Time Period England Wirral Gap (years) Gap from Baseline males females males females males females males females % 0.0% % 45.4% % 33.1% % 38.6% % 2.8% % 9.5% % -2.5% % 2.3% % 19.6% % 12.9% % 22.2% % 33.3% Source: ONS, 2009 Whilst life expectancy is increasing in Wirral, it is not improving at the same rate as England as a whole. The latest data ( ) shows a gap in life expectancy of 2 years for males and 1 year for females between Wirral and England. The gap has actually increased in both males and females since when it was 1.46 years for men and 0.72 years for females. Data from onwards indicated that Wirral was closing the gap amongst males (albeit inconsistently), however progress amongst females has been less positive, with only one time period ( ) showing a small reduction in the gap. According to this latest data, Wirral is not on track to meet the PSA life expectancy target along with many of the other Spearhead areas. It is important to note that the initial gap was relatively small, so even minor increases in life expectancy can impact greatly on the gap and can lead to fluctuations in the data.

4 Life expectancy at ward level Statistics on life expectancy at ward level were produced by the Office for National Statistics (ONS) and defined as experimental statistics. This means they do not fit the strict criteria required to be classed as official statistics. They have not been reproduced since first released showing the data reproduced below. Figure 1a shows this ward level life expectancy data for Wirral (using combined data). Figure 1a: Life expectancy at birth by ward and gender for Wirral PCT: Life expectancy at birth by ward for Wirral PCT, 1999 to 2003 Life expectancy (years) Females Males NW Females NW Males England Females England Males Bebington Bidston Birkenhead Bromborough Clatterbridge Claughton Eastham Egerton Heswall Hoylake Leasowe Liscard Moreton New Brighton Oxton Prenton Royden Seacombe Thurstaston Tranmere Upton Wallasey Source: ONS, 2007 From , there were 12 wards out of the 22 (pre-2004 ward boundaries) in Wirral where male life expectancy was well below the England average. For females, there were also 12 wards which had life expectancy below the England average. Male life expectancy ranged from 68.3 years in Birkenhead to 79.9 years in Heswall. Female life expectancy ranged from 75.3 years in Birkenhead to 84.9 years in Bebington. These are amongst the widest gaps between wards in the same borough in England and this is a key issue for Wirral. The difference in life expectancy between males and females within wards is also quite considerable; the biggest gaps between males and females are in Bidston ward with a difference of 9.4 years, followed by Leasowe with a gap of 8.6 years, Bebington 7.7 years and Birkenhead 7.0 years. The gap between males and females for all Wirral wards averages out at 5.1 years ( ). Those wards which have particularly low life expectancy for men (and the largest gaps between males and females) appear to be those which are

5 amongst the most deprived, suggesting men may be more susceptible to the effects of deprivation than women. Life expectancy gap by disease The data showing the specific conditions and diseases which are contributing towards the gap between Wirral and England for life expectancy is shown in table 1b (split by gender). Table 1b: Life expectancy gap by disease ( ) for Wirral: percentage by gender Disease Number of deaths Male Female Infectious and parasitic diseases Oesophageal cancer % 1.5% Stomach cancer % 0.5% Colorectal cancer % Lung cancer % 14.3% Breast cancer % 3.7% Other cancers % 17.4% Endocrine, nutritional, metabolic diseases % 1.0% Mental and behavioural disorders % Diseases of nervous system %.. Coronary Heart Disease % 0.0% Heart failure 123 Stroke % 8.2% Other cardiovascular disease % 0.1% Pneumonia % Chronic obstructive airways disease % 16.2% Other respiratory disease % 1.4% Stomach/duodenum ulcer % 0.9% Chronic liver disease including cirrhosis % 11.5% Other digestive diseases % 2.9% Musculoskeletal diseases Genitourinary diseases %.. Perinatal conditions % Congenital anomalies %.. Ill defined conditions % 0.9% Land transport accidents %.. Other accidents % 6.2% Suicide and undetermined injury % 7.3% Other external causes %.. Other % 3.8% Deaths under 28 days Total 100.0% 100.0% Source: LHO (London Health Observatory), denotes that the calculated gap with England is negative The causes of death that contribute most to the gap in life expectancy between England and Wirral for men include: lung cancer, coronary heart disease (CHD), chronic liver disease including cirrhosis, respiratory disease (other than pneumonia and COPD), accidents and suicide and undetermined injury. For women, the causes which most contribute to the gap are lung cancer, other cancers, stroke, COPD, chronic liver disease including cirrhosis and stroke.

6 Mortality All Age, All Cause Mortality (AAACM) All age, all cause mortality (AAACM) was introduced as a proxy measure for life expectancy because the data will be available more frequently than life expectancy data, is easier to interpret, is more straightforward to performance manage locally and it correlates well with life expectancy. AAACM rates are three-year average, directly standardised death rates per 100,000 of the population for all ages and all causes of death. Figure 1a shows AAACM in Wirral over fifteen years by gender. Figure 1a: All Age, All Cause Mortality, Directly Standardised Rates for Wirral, North- West & England, 1993 to 2008, by gender All Age, All Cause Mortality, Directly Standardised Rates, Wirral, North-West & England, 1993 to 2008, by gender England Males North West Males DSR's Wirral Males England Females North-West Females Wirral Females Year Source: NCHOD, 2009 Wirral has a higher AAACM rate than England, and this has consistently been the case for the last ten years. Mortality rates are higher in the 3% most deprived group nationally and the LSOAs which are in the 20% most deprived nationally (this info currently missing, hasn t yet been updated!!!) Whilst overall mortality rates have improved in Wirral, in some of the most deprived areas (3% most deprived nationally) they have actually worsened. (we don t know this yet) Mortality from causes considered amenable to healthcare Mortality from causes considered amenable to healthcare is a definition based on the concept that deaths from certain causes could be avoided through preventing the onset of disease or via timely and effective health care. The concept was originally developed

7 as a measure of the quality of healthcare. Those diseases thought to be potentially avoidable or amenable to healthcare are displayed in Table 1a. Table 1a: Description of diseases thought to be potentially avoidable Age group Disease 0-14 years Intestinal infections Whooping cough 1-14 years Measles 0-44 years Uterine cancer Leukaemia 0-49 years Diabetes mellitus 0-74 years Tuberculosis Other infectious diseases (such as diphtheria, tetanus & polio) Septicaemia Colon and rectal cancer Cervical cancer Breast cancer Testicular cancer Hypertensive disease Ischaemic heart disease Hodgkin s disease Thyroid diseases Skin cancer Epilepsy Chronic rheumatic heart disease Source: NCHOD, 2008 Figure 1b shows directly standardised mortality rates from causes considered amenable to healthcare, for Wirral and England ( ).

8 Figure 1b: Mortality from causes considered amenable to healthcare by gender: comparison of Wirral and England (DSR s) Mortality from causes considered amenable to healthcare by gender, Wirral, North-West & England (DSRs), DSR' s Males Females Persons England North-West StHA Wirral Source: NCHOD, 2009 Overall, Wirral has a higher mortality rate for causes considered amenable to healthcare than England as a whole and the North-West region. Mortality is higher for men than women and this is the case regionally and nationally also It is well documented that men access services less often than women and may present later for treatment. This may influence mortality trends locally and nationally This would indicate that a key issue locally is the need to ensure that men in particular access effective healthcare services in a timely manner to help reduce the likelihood that they will experience poorer outcomes. Figure 1c below shows the same information, but for individual years over time (rather than three years pooled as per the above data) to show any trends.

9 Figure 1c: Mortality from causes amenable to healthcare: Wirral, North-west & England (DSRs), by gender, Mortality from causes amenable to healthcare: Wirral, North-West & England (DSRs), by gender, DSRs England Males England Females NW Males NW Females Wirral Males Wirral Females Source: NCHOD, 2009 As Figure 1c above shows, nationally, mortality from causes amenable to healthcare appear to have shown a slight fall in the years since Locally however, the picture seems more mixed, with greater fluctuation (probably due to smaller numbers) and no real, discernable downward trend. If anything, the gap between mortality amongst Wirral men compared to men nationally looks to have widened. Main causes of death The main causes of death (in actual numbers, by diagnosis group) are shown for males and females in Wirral in the two graphs below. Data is from , allowing trends to be observed.

10 Figure d1: Main causes of death: number of deaths in Wirral females, by diagnosis group Number of Deaths (Wirral females) by Diagnosis Group 600 Number of Deaths Neoplasms (C00-D48) IHD (I20-I25) Cerebrovascular (I60-I69) Other circulatory (other chapter I) Respiratory (chapter J) Other Source: ONS, 2008 The main causes of death for women in Wirral in (in order) were neoplasms (cancer), other causes, respiratory conditions, ischaemic heart disease, cerebrovascular disease and circulatory disease. Overall there has been a small but observable decline in the number of deaths attributable to ischaemic heart disease and cerebrovascular disease amongst women in Wirral since Neoplasms (cancers), other causes and respiratory diseases did appear to be decreasing but have recently begun to rise again. In the case of other causes and respiratory disease, they are now higher than their former levels in 2002 against a backdrop of a fairly stable (albeit ageing) population.

11 Figure 1e: Main causes of death: number of deaths in Wirral males, by diagnosis group Number of Deaths (Wirral males) by Diagnosis Group 600 Number of Deaths Neoplasms (C00-D48) IHD (I20-I25) Cerebrovascular (I60-I69) Other circulatory (other chapter I) Respiratory (chapter J) Other Source: ONS, 2009 The main causes of death for men in Wirral in , in order, were neoplasms (cancer), other causes, ischaemic heart disease, respiratory disease cerebrovascular disease and circulatory disease. There has been a slight decrease in the numbers of men dying from all causes in 2008, except circulatory disease which remained the same as in 2007 and shows a slight increase on 2002 levels. For men, overall, there has been a decrease in the number of deaths per annum for most of the main causes since For women, the picture is more mixed. Deaths from many of the main causes appear to be fairly static, whilst others seem to be showing a slight upward trend in the last two years.

12 Cardiovascular disease (CVD) Cardiovascular disease (CVD) includes diseases of the heart and circulation, including coronary heart disease (angina and heart attack), and stroke. Cardiovascular disease is the most common cause of death in the UK. In Wirral, CVD is a major contributor to premature deaths and is a leading cause of health inequalities. Reducing levels of CVD in the under 75 s in the areas of poorest health is likely to be an effective and cost effective method to reduce the gap in life expectancy. Overall, since 1993, Wirral has made considerable improvements in reducing mortality from CVD. There is a significant difference between CVD mortality rates amongst males and females, both locally and nationally. See figure 1a. Figure 1a: Under 75 s CVD mortality rate per 100,000: Wirral and England ( ) Cardiovascular disease mortality in under 75 year olds, 1993 to 2007 (3 year averages) 250 Directly standardised rates per 100, England (males) Wirral (males) England (females) Wirral (females) Source: NCHOD, Whilst mortality rates from cardiovascular disease in the borough overall has reduced in recent years. Mortality in the most deprived areas of Wirral however has actually increased. Death rates (directly age standardised) from CVD for people under 75yrs in the most deprived areas of Wirral are almost twice as high as they are in Wirral as a whole (see Deprived Communities Chapter for more detail). Mortality rates from CVD in Wirral men aged under 75 have reduced considerably from 229 per 100,000 population in to 124 per 100,000 in The gap between England and Wirral has remained fairly stable. The latest figures show that CVD mortality rates have also reduced considerably for Wirral females from per 100,000 in to per 100,000 in The rate is now slightly lower in Wirral females than the England average, this has not been observed since

13 Mortality from Coronary Heart Disease (CHD) Coronary heart disease occurs when the coronary arteries become narrowed by a buildup of fatty material and cause angina or heart attack. Premature deaths (that is deaths in people aged under 75) from CHD in the form of directly standardised rates are shown in figure 1b for Wirral, the North West and England for 3 pooled years, Figure 1b: Premature mortality rates for CHD in Wirral by gender: directly standardised rates for Wirral, England & North West, 3 years pooled Premature Mortality for CHD in Wirral by gender: directly Standardised Rates for Wirral, England & North-West, DSR Males Females Persons England North West Wirral Source: Information Centre, 2009 The rate of premature death from CHD in Wirral is higher than that for England, but lower than the rest of the North West for both men and women. The rate of premature mortality from Coronary Heart Disease for men is more than double the rate for women Diagnosed cases versus modelled estimates of CHD prevalence Numbers of patients with a diagnosis of CHD are recorded by their GP on the Quality and Outcomes Framework (QOF) register. This does not tell us total prevalence however, only how many have been diagnosed. If conditions such as CHD are undiagnosed, and therefore unmanaged, outcomes are likely to be poor (for example, premature death or disability due to heart attack). There are currently 14,163 on the QOF register diagnosed with CHD (or 4.3% of the population) in Wirral In order to estimate the total number of people in Wirral with CHD, including those currently undiagnosed, various statistical models can be used. They use data on

14 factors such as deprivation and age of the population to calculate the estimated number of patients likely to have certain conditions in any given population. According to the modelling estimates of CHD prevalence for Wirral, there are 17,768 people with CHD. This means the number of people with undiagnosed CHD in Wirral is probably in the region of 3,600 (Source: QMAS & APHO, 2009) Wirral attains high standards in the QOF compared to other areas, and is continuing to invest in implementing the National Service Framework which are all helping to address inequity of service provision. The Intermediate Heart Centres in Birkenhead and Wallasey have also helped to ensure easier access to diagnose, assess and refer patients with CHD. In addition, a Locally Enhanced Service has been implemented for the screening of the population to identify those undiagnosed cases of CHD. CHD Incidence: Myocardial Infarctions admission rates as a proxy Myocardial Infarctions (MI s, more commonly known as heart attack) occur in patients with advanced CHD. As the exact incidence and prevalence of CHD is unknown, MI can be used as a proxy measure to indicate levels of CHD in the population. Figure 3.1.6c shows, the standardised admission rate (SAR) of hospital admissions for MI for both men and women in Wirral (adjusted to take into account the effect of deprivation). SAR is a measure of how likely a person is to have an admission to hospital compared to the England average (100); a SAR of 100 indicates an average admission rate. Figure 1c: Standardised Admission Rate (SAR) for Myocardial Infarction by sex: Wirral 2008/09 (adjusted for deprivation) 120 Acute Myocardial Infarction by sex: Wirral SAR Wirral England 20 0 All Female Male Source: Dr Foster, 2009 Admission rates overall were very similar to the average rate for England (102.7 compared to 100 for England).

15 This is masking a large difference between males and females however. While the MI rate in Wirral is slightly lower than the England average for men (93.9), for females, it is 117 (17% higher). This suggests that CHD is more of an issue for women in Wirral than it is for men, when MI s are used as a proxy. Admissions for Cardiac Revascularisation Coronary or cardiac revascularisation is carried out to improve the flow of blood to the heart via vessels that have suffered narrowing (or occlusion) due to build up of the fatty cholesterol deposits which characterise CVD. In recent years, Percutaneous Transluminal Coronary Angioplasty (PTCA) has come to be regarded as a less invasive and valid alternative to the surgical intervention Coronary Artery Bypass Graft (CABG) for many cases of CVD. There is however, still wide variation in the provision of both types of revascularisation in the UK and evidence that they are procedures which are much underused. Figure 3.1.6d shows the combined CABG and PTCA procedure rate by sex in Wirral. Figure 1d: Revascularisation admission rates in Wirral by sex: (adjusted for deprivation) SAR Admissions for CABG & PTCA in Wirral by sex: (adjusted for deprivation) All Females Males Wirral SAR England Source: Dr Foster, 2009 In there were 20% fewer revascularisation procedures performed on Wirral residents than would be expected given the age and deprivation of Wirral's population. The Wirral rate is significantly below the England average and what would be expected given the age and deprivation of the local population. In males, rates are 18% lower than the England average.

16 In females, they are 23% lower. This is however, a slight improvement on the previous year, when the revascularisation procedure rate for women in Wirral was 31% below the England average As low and varying rates of coronary revascularisation in England was mentioned in the Chief Medical Officers Report (DH, 2006) as an inequalities issue, increasing rates of revascularisation should be a key issue for Wirral, especially amongst women. Mortality from Stroke Stroke is a manifestation of CVD and is the third largest cause of mortality in England. There are two main types of stroke, ischaemic (caused by occlusion of the blood vessels) and haemorrhagic (caused by bursting of the blood vessels). Like many diseases, acute stroke can be amenable to prevention through control of blood pressure, diabetes, cholesterol and lifestyle factors such as smoking, alcohol and diet. Figure 3.1.6f shows premature mortality (DSR) from stroke for Wirral, the North-West and England by gender. Figure 1e: Premature mortality (under 75 years) from stroke by gender: DSR s for Wirral, North-West and England, 3 year pooled rates Mortality from stroke: directly age-standardised rates for under 75 year olds, Directly standardised rates per 100, Males Females Person Wirral North West England Source: NCHOD, 2009 Rates of premature mortality due to stroke in Wirral are lower than the North-West region, but higher than England, Men have higher rates of mortality from stroke than women and this is the case nationally and regionally, not just in Wirral Stroke and Transient Ischaemic Attack (TIA) prevalence Transient ischaemic attack (TIA) is sometimes known as a minor or mild stroke and does not usually result in the levels of death and disability seen with acute stroke. Symptoms of TIA usually resolve themselves within 24 hours, but it is usually a sign that extensive atherosclerosis may be present and indicates a high risk of a future stroke. Nearly one in four patients who have an ischaemic stroke recall having a TIA at some point before their

17 stroke, almost half of these occur in the week prior to the stroke (Rothwell & Warlow 2005). In Wirral 7,354 patients were on GP QOF registers as having had a stroke or TIA in This is 2.19% of patients (QMAS, 2009). The prevalence for England in was 1.63% (NCHOD, 2009). Hospital admission rates for cerebrovascular disease as a proxy for stroke incidence Acute cerebrovascular disease includes stroke, brain haemorrhage, cerebral infarctions and occlusion of brain vessels. Admission rates for these conditions gives an indication of how many new cases per annum (incidence) we have of stroke in Wirral. Figure 1f shows admission rates for acute cerebrovascular disease for Wirral, with rates for men and women shown separately. Figure 1f: Hospital admission rate for acute cerebrovascular disease in Wirral by sex: Admission rate for acute cerebrovascular disease in Wirral by gender: Apr 2007-Mar 2008 (adjusted for deprivation) SAR 60 Wirral England All Female Male Source: Dr Foster, 2009 Hospital admissions for acute cerebrovascular disease in Wirral were higher than would be expected in , even when rates are adjusted to take into account the deprivation of the local population. Admission rates were 13% higher than expected for both men and women The total number of admissions during was 718. Projected longstanding health conditions as a result of cardiovascular disease Those who survive a stroke are often left with a disability. In the UK, on average, twothirds of patients survive stroke, but half of those are left with a disability (commonly affecting mobility, cognition, sight and communication and mental health). Figure 3.1.6h

18 shows projections for the number of people in Wirral who may be left with a longstanding health condition as a result of stroke from 2008 up to Figure 1g: Wirral people aged 65 and over predicted to have a longstanding health condition caused by a stroke, by gender and age: People predicted to have a longstanding health condition caused by stroke in Wirral: by age & gender: Number Males aged Males aged Females aged Females aged Total population aged 65+ 1,512 1,559 1,714 1,873 2,112 Source: Projecting Older People Population Information (POPPI) System, 2009 The number of people in Wirral projected to be living with a longstanding health condition caused by stroke is projected to rise steadily, increasing from 1,512 in 2008, to 2,112 in 2025, an increase of 40%. This is mainly due to an increase in the older population over this period. As with stroke, those who survive myocardial infarction are also often left with a longstanding health condition as a result. Figure 3.1.6i shows projections for the number of people in Wirral who may be left with a longstanding health condition as a result of heart attack from 2008 to 2025.

19 Figure 1h: Wirral people aged 65+ predicted to have a longstanding health condition caused by myocardial infarction (heart attack), by gender and age: People predicted to have a long term health condition caused by heart attack in Wirral: by age and gender ,500 5,000 4,500 4,000 3,500 3,000 2,500 2,000 1,500 1, Males aged ,142 1,193 1,378 1,411 1,344 Males aged ,054 1,220 1,477 Females aged Females aged 75+ 1,219 1,233 1,280 1,353 1,561 Total population aged 65+ 4,059 4,180 4,624 4,954 5,346 Source: POPPI, 2009 The number of people in Wirral projected to be living with a longstanding health condition caused by a heart attack is also projected to rise steadily by around 30%, reflecting increasing survival rates. Hypertension Hypertension or high blood pressure is a significant risk factor for development of cardiovascular diseases such as CHD and stroke. Treatment includes medication and lifestyle change such as achieving a healthy weight, regular physical activity, a healthy diet, reducing alcohol consumption, stopping smoking and reducing the amount of salt in the diet. In the UK, it is estimated that half of all people over the age of 65 have hypertension, but many are undiagnosed and unmanaged, which puts them at risk of serious health issues. Table 1i shows the estimated prevalence of hypertension (diagnosed and undiagnosed) in Wirral compared to the observed prevalence from the local QOF register.

20 Table 1a: Recorded prevalence of hypertension from QOF against expected prevalence as predicted by the Association Public Health Observatory (APHO) model Model Estimates Actual figures (QOF) Difference Numbers % of Actual % of model % in model based on registered numbers registered minus not on QOF 2008/09 population on QOF population actual registers (i.e. populations 2008/09 on QOF (N) undiagnosed) Wirral 85, % 47, % 37, % Source: QMAS, 2009 & Association of Public Health Observatories, 2008 There are likely to be around 38,000 people in Wirral who have hypertension but are unaware and undiagnosed. Around six in ten people with hypertension in Wirral are on the QOF register. The projected number of people in Wirral surviving stroke and heart attack and being left with a disability as a result is a key issue with significant implications for those planning the health and social care needs of the population.

21 Cancer, screening & palliative care Cancer Of the six main causes of death in Wirral, cancer accounts for the most deaths in both men and women (in actual numbers). Cancer registrations (incidence) Cancer registrations or incidence describes all new cases of cancer per annum. Figure 1a shows the directly age standardised rates (DSR) for all cancer registrations for Wirral (three pooled years, ). Figure 1a: Directly Standardised Incidence Rates for the four main cancers by sex: all ages, Wirral, North-West & England, DSR per 100,000 population Breast Prostate Lung Males Lung Females Lung All Colorectal Males Colorectal Females Colorectal All England North West SHA Wirral PCT Source: NCHOD, 2009 Breast and prostate cancers are the most commonly diagnosed cancers in Wirral The chart below shows cancer incidence the four main sites by locality health directorate (LHD) for the same 3 pooled yrs ( ), this is expressed as a standardised registration ratio (SRR). The SRR is a ratio of the observed number of registrations in a population relative to the expected number of registrations in the same population. Ratios above 100 indicate that the number of events observed was greater than expected given the standard rates and ratios below 100 that it was lower.

22 Figure 1b: Indirectly Standardised Cancer Incidence Ratios by site, all ages: Locality Health Directorates & Wirral, SRR Breast Cervical Lung Males Lung Females Lung All Colorectal Males Colorectal Females Colorectal All Bebington & West Wirral Birkenhead Wallasey Wirral Source: NWCIS, 2009 Breast cancer incidence overall is lower than the national average. This is also true for cervical cancer. Lung cancer incidence in Wirral is almost 30% higher in females and 25% higher in males than the national average. In Birkenhead locality the number of new cases is more than 50% higher than the national average. Colorectal cancer incidence in males is 15% higher than the national average in Wallasey locality, however overall it is below the national average. Cancer Mortality This describes death rates from cancer (when cancer was recorded as the primary cause of death). Figure 1c shows mortality rates (DSR per 100,000) from cancer in the under 75 s for Wirral, North West and England, adjusted for the age profile of the population.

23 Figure 1c: Mortality from all cancers by sex: Under 75 s, Wirral, North West & England, directly standardised rates per 100,000, DSR per 100,000 population Males Females All England North-West Wirral Source: NCHOD, 2009 Cancer mortality for both sexes aged less than 75 in Wirral is higher than the England average and North West average. Women in Wirral have higher cancer mortality rates than women in England and the North West overall (and this is true of all ages, not just those aged 75+) For men in Wirral, mortality is higher than England and the North West Cancer Trends Trends in cancer deaths have been fluctuating over the years and are slowly improving for specific cancers. Figure 1d illustrates deaths from all cancers in the under 75s, for Wirral, North West, & England, for the period of

24 Figure 1d: All Cancer Mortality Trend by sex, Under 75yrs: England, North West & Wirral, England (males) Wirral (males) England (females) Wirral (females) North West (males) North West (females) DSR per 100,000 popualation England (males) Wirral (males) England (females) Wirral (females) North West (males) North West (females) Source: NCHOD, 2009 Cancer mortality by site The most common sites for cancer deaths both locally and nationally are lung, colorectal, breast and prostate. Figure 1e shows deaths from cancers at these sites for England, North-West & Wirral. Figure 1e: Directly Standardised Mortality Rates by site: England North-West, & Wirral, DSR per 100,000 population Breast Prostate Lung Males Lung Females Lung All Colorectal Males Colorectal Females Colorectal All England North West Wirral Source: NCHOD, 2009

25 The highest cancer mortality rates are observed for lung cancer. This is true for both men and women in Wirral, but also in England and the North West. The rate for deaths from lung cancer in Wirral is significantly higher than the England average for males and females. Epidemiology data has identified a strong relationship between lung cancer and deprivation in Wirral, smoking prevalence is likely to be the most important factor in this relationship. Evidence on cancer treatment and palliative care suggests there is no inequity between the least and most deprived areas (Wirral Cancer Equity Audit Group, 2006). The chart below shows cancer mortality the four main sites by locality health directorate (LHD) for the 3 pooled yrs ( ), this is expressed as a standardised mortality ratio (SMR). The SMR is a ratio of the observed number of deaths in a population relative to the expected number of deaths in the same population. Ratios above 100 indicate that the number of events observed was greater than expected given the standard rates and ratios below 100 that it was lower. Figure 1f: Indirectly Standardised Mortality Ratios by site, all ages: Localities & Wirral, SMR Breast Prostate Cervical Lung Males Lung Females Lung All Colorectal Males Colorectal Females Colorectal All Bebington & West Wirral Birkenhead Wallasey Wirral Source: PHMF, 2009 Wirral breast cancer mortality overall is slightly higher (8%) than the national average. In Birkenhead locality it is below the national average. Cervical cancer mortality is significantly higher than the national average for Wallasey and Birkenhead locality, 143 and 119 respectively. Lung cancer deaths for females is over 60% higher than the national average in Wallasey locality and over 50% higher in the Birkenhead locality. Deaths from colorectal cancer in females overall is 25% higher than the national average.

26 Prostate cancer overall is below the national average however, Wallasey locality has over 20% more deaths than the rest of Wirral. Screening Cervical cancer screening: 5 year coverage rate by age (25-64yrs) Cervical Cancer Screening aims to detect cancer at an early stage when it is amenable to intervention. The cervical screening programme is highly effective and is estimated to save up to 5,000 lives each year nationwide (NHS Cervical Screening Programme, 2006). The effectiveness of the programme is judged by the proportion of women in the target group (25-64 years) screened in the last five years. It is important to note that in 2003 the NHS cervical screening programme changed the age and frequency of screening. The change involved women being invited for screening for the first time at 25 years (instead of 20) and being routinely recalled every three years until the age of 49. Women between the ages of 50 and 64 are then screened every 5 years. Evidence suggests that an overall coverage of 80% could lead to around a 95% reduction in death rates over the long term. Data for Wirral in 2008/09 demonstrates that almost 77, 000 women have had a cervical screening test in the previous five years, providing a coverage rate of 77.5%. This is below the 80% target. This is slightly lower than the North West and England coverage rates that are 78.5% and 78.9% respectively. Table 1a: Wirral cervical screening: 5 year coverage by age group (2008/09) Age of women at Eligible No. adequately Coverage (%) 31 March 07 population screened ,994 8, ,472 9, ,919 11, ,965 12, ,135 11, ,648 9, ,856 8, ,207 7, Total 99,194 76, Source: KC53 return (COM, 2009) Screening uptake is lower in the age group and dips again in the age group The 35 to 54 age groups have the greatest level of coverage. Cervical cancer screening trend data Trend data demonstrates that there has been a gradual downward trend in screening coverage over the last decade. This trend is not unique to Wirral and is also apparent nationally and regionally. Figure 1h displays trend data for Wirral and England since 1999.

27 Figure 1h: Cervical cancer screening coverage (5yr): Wirral & England, England Wirral Coverage / / / / / / / / / / /09 Year Source: KC53 return (COM, 2009) and Information Centre, 2009 Since the coverage for cervical screening has fallen in Wirral. In the coverage fell by 1% on the previous year In coverage had fallen again by 1. 4% on the year before. In , coverage had again decreased, by just over 1%, but in , coverage had shown a very slight increase on (of just over 0.5% ). Figure 1i: Cervical Screening: Annual Change in coverage in Wirral % 0.50% Relative percentage change 0.00% -0.50% 1999/ / / / / / / / / / % -1.50% Year Source: KC53 return (COM, 2009) and Information Centre The fall in 5 year coverage (the one year of notwithstanding) although of concern, is a trend that is apparent across the UK. Whilst targeted interventions are required to

28 increase coverage amongst the younger population (25-29 years) as coverage is particularly low in this group, there is also a need to specifically target the older groups in Wirral, to ensure that they are invited for screening and are attending appointments. Breast cancer screening: uptake by age (50-70yrs) This is an effective method of detecting breast cancer at an early stage, which may be more amenable to treatment. Women aged between 50 and 70 are routinely invited every 3 years for breast cancer screening. Women over the age of 70 years are not automatically invited but are encouraged to make their own appointments. It is estimated that the programme is saving around 1,400 lives every year in England. The minimum standard for breast screening coverage is 70% In 2007/08 Wirral achieved this target, with 79.6% of eligible women screened see Table 1j. Data for the two old PCTs which formed Wirral PCT are shown for pre-2006 data. Table 1b: Coverage of NHS Breast Screening Programme: Women aged 53-64, Wirral, North-West & England, to PCT of residence Coverage (%) 2002/ / / / / /08 Bebington & West 84.50% 85.50% 84% 83.90% - - Wirral PCT Birkenhead & 77.30% 78.70% 79.10% 77.90% - - Wallasey PCT Wirral PCT % 80.10% 79.00% 79.60% North West 76.10% 75.70% 75.60% 74.10% 74.00% 75.40% England 75.30% 74.90% 75.50% 75.50% 76.00% Source: Information Centre, % Breast screening coverage in Wirral compares favourably to national and regional coverage rates of 76% and 75% respectively. Bowel cancer screening: cancer detection rate (national pilot) Following a national pilot programme, Wirral introduced the national bowel screening programme locally in People aged years across Wirral are automatically be sent an invitation to participate in the screening programme (over a two year period). During , the Bowel Screening Programme invited over 114,000 individuals in Wirral? to take part over 60,000 returned a sample which resulted in an uptake of 53.18%. This is slightly more than the regional average (Midlands and the North West) of 52%. Palliative Care Palliative care is the care of any patients with advanced incurable disease involving the control of symptoms such as pain and improvement of quality of life for both patients and families. Currently, most specialist palliative care is provided for people with cancer. Wirral has a higher need for palliative care than average, according to the Palliative Care Needs Assessment for Cheshire & Merseyside. The number of cancer deaths per 100,000 population in in Wirral is

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