East Riding of Yorkshire Council and East Riding of Yorkshire Primary Care Trust

Transcription

1 DRAFT East Riding of Yorkshire Council and East Riding of Yorkshire Primary Care Trust Joint Strategic Needs Assessment 2009

2 CONTENTS Executive Summary and Introduction Population Characteristics Demography Determinants of Health and Well being Measures of Health and Illness Health Inequalities Population Voice Priorities for Health, Care and Services Obesity, Physical Activity and Nutrition Tobacco Control and Smoking Cessation Alcohol and Substance Use Sexual Health Mental Health Learning Disabilities Physical Disability Long Term Conditions Other Major Causes of Death and Ill Health End of Life Care Children, Adults and Older People Children Working Age Adults Older People Population Groups and Settings Rural and Coastal Issues Ethnic Minorities Carers Offenders Cross-cutting Themes Access Independence Quality Choice and Personalisation Finance and Resources Workforce Equality and Diversity Appendix 1 Five Major Challenges identified through JSNA refresh 2

3 Background Executive Summary and Introduction to 2009 JSNA A Joint Strategic Needs Assessment (JSNA) is a means by which PCTs and Local Authorities will describe the future health and wellbeing needs of local populations and the strategic direction of service delivery to meet these needs (Commissioning for Health and Wellbeing 2007). The Department of Health Guidance (2007) makes it clear that the JSNA is better seen as a process of understanding local needs and establishing agreed priorities, rather than as a traditional planning document to be produced at a single point in time. The process is intended to inform policies and commissioning strategies with a view to improving health outcomes and reducing health inequalities, furthermore it is a statutory requirement that a needs assessment is carried out and that this assessment is a key element in World Class Commissioning. As such the process of JSNA is very much Business as Usual. Its totality will exist in a variety of documents and ongoing processes and it will gradually evolve over time; however there is value in periodically summarising the variety of areas in which needs assessment is being carried out. In this second year of JSNA it is timely to review and refresh the work carried out in 2008, to continue to develop processes for sharing intelligence to ensure needs based commissioning for health and wellbeing in the East Riding of Yorkshire. In refreshing the 2008 JSNA we have considered not only updating the information content of the 2008 document, but also looking to capitalise on inyear development in data resources to add to our knowledge and understanding of health and social care needs and make this information more accessible to health and social care leads. Methodology Since JSNA is a complex and evolving process and we have appreciated the need to have an explicit methodology, which is consistent year on year to allow changes to be monitored, but which also evolves to make best use of inyear developments in available information and analytical capacity. Identification of potential health need has been ongoing for many years with National indicators and performance targets being used to identify inequalities initially. Existing knowledge of gaps in care and existing inequalities are supplemented by the analysis of new PCT-level indicators as they appear. Regular visits of the YHPHO, APHO and Local Authority Observatory websites allow active 3

4 horizon scanning, and close liaison with the Observatories and their Intelligence Leads networks gives alerts to new data sources and indicators (e.g. the recently developed Slope Inequalities Index") and relevant research and regional analyses etc. The Yorkshire and Humber PCTs have jointly commissioned work as part of the Health Intelligence Yorkshire and Humber (HIYAH) Collaborative programme. This has resulted in a series of projects which are already delivering valuable outputs which are supporting us in progressing through the full range WCC competencies, but have specifically produced early outputs that have supported the continuing development of the JSNA. For example HIYAH Project A2 has delivered a small area dataset for the region. This provides a range of key indicators at ward and super output area level, based upon definitions set out in the DH JSNA core dataset. The JSNA document maintains a consistent format, keeping existing Chapter headings and updating what is known in key areas. In addition we aim to undertake a Lifestyle Survey every 5 years as part of our ongoing needs assessment activity (the most recent was administered in Jan 2009). Each survey is developed from the previous one, to allow comparisons (e.g. is smoking prevalence reducing?), but supplemented with additional questions to capture new insights. For example the 2009 survey has a focus on migration into the County. Further, we systematically draw on the work of our communications team to capture insights from the public, patients etc. Where possible, data are analysed over time and by deprivation band to identify inequalities and to monitor whether inequalities as a result of deprivation are changing. Ongoing analyses are also used to inform the JSNA. For example, during the year we have developed Locality Profiles, which break data down to locality, electoral ward and super output area level. These are available at V:\ERYPCT\Public Health\Health Intelligence\Annual Reports & Profiles\Profiles\Internal\Locality Profiles Responsibility for the JSNA rests jointly with the Director of Public Health and the Director of Adult Social Services. In the East Riding, the lead for the JSNA is the Director of Public Health and work is carried out with colleagues from across the PCT and East Riding of Yorkshire Council directed through a steering group. Specific in-year developments. The Introduction section of the 2008 JSNA acknowledged that the 2008 JSNA had limitations resulting from the limited health needs assessment that had been undertaken in the past. We believe that we have addressed several of these limitations in-year, and as a result have moved forwards towards the goal of becoming World Class Commissioners, especially in the area of Competency 5. The following specific developments are particularly notable. Dr Foster. We have developed a relationship with Dr Foster Intelligence and acquired their Population Health Manager Module. 4

5 This provides easier access to data on population projections, population composition etc and a new capability in terms of population segmentation and benchmarking. Lifestyle Survey Early in 2009 we undertook a comprehensive lifestyle survey, the results of which have been invaluable in providing additional local data and uncovering further areas of potential unmet need. For example we identified a specific group of people who migrate from West and South Yorkshire to deprived coastal areas of East Yorkshire and who are more prone to a number of health issues than is the indigenous population. In addition the Lifestyle Survey has enabled us to provide up-to-date prevalence estimates for smoking, alcohol use, obesity, long term illness etc and to get insights into the effectiveness of (e.g.) nutritional food labelling in influencing healthy food choices, or the July 2007 smoking ban in changing smoking behaviour. A link to the questionnaire used for the survey can be found at g%20pcts/document%20store/press%20releases/pr%2066%20- %20attach%20Lifestyle%20Survey.pdf Locality profiles. These were alluded to above. We are currently supplementing our Locality-based analysis from the Lifestyle Survey and the datasets provided by Dr Foster. More Analytical Capacity. We have been fortunate that the Directorate has been able to expand a little, albeit slowly. We are also currently benefiting from being able to support a Trainee Analyst from the HIYAH project C1 and have sent delegates on modules of the accompanying training programme. This project has enabled us to address local capacity and capability around health information analysis with key focus areas including health needs assessment, equity audit, predictive modelling and consumer insight. More structured approach to needs assessment. Partly as a result of the above, we have been able to develop a more effective team approach to needs assessment and planning. For example current specific needs assessment activities include supporting the Pharmacy Needs Assessment led by our Medicines Management Team, and needs assessment to underpin our developing oral health improvement and commissioning strategy. We are also supporting the Local Authority led Adult Drug Treatment Needs Assessment. Overview of 2009 JSNA refresh. The 2009 refresh of the JSNA has concentrated on the investigation, analysis and updating of existing and additional data sources to enhance the work carried out in Both a summary and detailed refreshed JSNA document have been produced. The refreshed JSNA 5

6 has been circulated to individuals previously identified as leading on chapters within each theme area. Findings from the refreshed JSNA have been used in the recent health strategy refresh and have informed recommendations within the Director of Public Health s Annual report Key new data reported in the refreshed JSNA include: Results from the 2009 Lifestyle Survey Updated mortality rates Projected prevalence estimates of major illnesses Key performance indicators for both health and social care Evidence from the Place survey Some Locality data (more available from Locality Profiles) Segmentation by Mosaic groups Many of the above analyses have been undertaken by age-group, gender and deprivation band and as such are valuable in contributing to the understanding of health inequalities. A selection of health and social needs assessment criteria were used to identify the areas of greatest challenge facing health and social care agencies within the East Riding. The criteria were: Impact on health inequalities Long term impact on health & wellbeing Opportunities for joint working Highlighted performance issue Programme budgeting variance The 5 areas of greatest challenge were identified as: CHD Stroke Diabetes COPD Dementia A table detailing how these key health and social care challenges were determined, is provided in Appendix 1. OVERALL PICTURE In 2009 the health of people in the East Riding was generally better than both the England and Regional average. Life expectancy, infant deaths, deaths from smoking and premature death were all better than the England average. Significant variations exist in the socio-economic conditions across the East Riding with levels of high material deprivation and areas of relative wealth. 6

7 Significant health inequalities exist within the East Riding by gender and deprivation. Both men & women living in the less deprived areas are more likely to live longer than those living in the more deprived areas. The health of children & young people is better than or similar to England averages for most health indicators. The combination of differences in both lifestyle risk factors (such as smoking, exercise & diet) and levels of material deprivation result in significant health variations in need & demand for health & social care services. DEMOGRAPHY & SOCIO ECONOMIC CONTEXT Population Considerable population growth particularly in older groups East Riding has a population of 335,049 according to ONS Mid-2008 Population Estimates. It is a relatively elderly population with 67,000 (20.0%) being aged over 65 and 30,900 (9.2%) being aged over 75. East Riding is the second largest non-metropolitan district in England, at 2416km 2 The East Riding population is experiencing considerable growth predicted to rise from 342,200 (2009) to 362,100 in 2014, an increase of 5.8% Largest town is Bridlington (33,500) The most common lifestyle groups are wealthy achievers & comfortably off but with a significant proportion of hard pressed families Births Lower than average birth and fertility rates Live birth rates are lower than England average More Deaths than births, ongoing trend Lower fertility rate than national average Migration Inward migration of persons with poorer health New lifestyle information suggests significant inward migration from West and South Yorkshire Migrants appear to have worse health than resident population 7

8 Income Higher than average income with significant variation within area Above average levels of household income but with substantial differences within East Riding Median earnings are fractionally higher than Yorkshire and Humber, as the data refers to April 2008 which is pre economic downturn expectations could be to see a decrease this year. Significant variation exists across the East Riding in the percentage of people of working age claiming a key benefit. This ranges from 2% to 39%. Highest levels of benefit claims were reported in Bridlington South & Goole South. Overall East Riding has lower levels of benefit claimants than both the national & regional averages. Liveability Higher than average levels of satisfaction with East Riding as a good place to live. 85% of respondents to the Place Survey stated that they were either very or fairly satisfied with East Riding as a place to live. This varies from 95% in Market Weighton & Pocklington to 75% in Goole & Howdenshire. Two of out of three residents (68%) feel they belong to their neighbourhood; this is higher than the national average (59%). Nine out of ten (92.5%) older residents aged 65 & over are both satisfied with their home & their neighbourhood. This is higher that the national average of 83.9%. Satisfaction with Public Services Overall general satisfaction with public services but variation exists in levels across the East Riding Level of crime (61%), Health Services (49%) and Cleaner streets (46%) considered to be most important factors in making East Riding the good place to live Activities for teenagers (52%), Road & pavement repairs (43%) and level of traffic congestion (31%)%) considered to be most in need of improvement 83% of East Riding respondents were very or fairly satisfied with their GP 66% were very or fairly satisfied with their local hospital Satisfaction with local hospital varied from 45% in Bridlington & Driffield to 78% in Market Weighton & Pocklington. 8

9 Crime & Antisocial behaviour Local residents perceptions of antisocial behaviour are significantly lower than national averages The number of serious violent crimes has been reducing with the exception of March Car crime and burglary are up despite significant downward trend in recent years 11.5% of East Riding respondents reported a high level of perceived antisocial behaviour in their area; this is far less than the nation average of 20%. This figure varied from 4% in Market Weighton & Pocklington to 21% in Goole & Howdenshire. Over a third of respondents agreed that in their area parents take enough responsibility for the behaviour of their children. This is higher than the national average. LIFE EXPECTANCY Increasing life expectancy but not at same rate for all Life expectancy is increasing Women s life expectancy is similar to national average Men s is better than national average Both projected to meet 5 year Health Strategy target Considerable variation in life expectancy by electoral wards within East Riding. ILLNESS As population lives longer the number of people with chronic illnesses will grow significantly Prevalence of chronic conditions set to increase significantly as population ages Diabetes, COPD, Stroke and Heart Disease all projected to increase over next 5 years. Local cases of Dementia projected to increase by 78% by 2025 DEATHS Lower than expected numbers of premature deaths but big variations within area Mortality Rates Overall trend has continued to decline, down 27% from 762 per 100,000 persons (1993) to 553 deaths per 100,000 persons (2007) Rates of decline is higher for men than for women 9

10 Overall death rates for men are lower than national average but similar to equivalent areas in the country Overall death rates for women are similar to national rates but higher than equivalent parts of country, although lower than average for Yorkshire & Humber region Infant Mortality Rates Slow decline in infant mortality rates with sharper fall in recent years East Riding rate lower than both national & regional averages Both neonatal & perinatal mortality rates have remained lower than region & national rates Cause of Death Most common cause ( ) of death for men were deaths related to the circulatory system (38%), then cancer (31%) and similarly for women circulatory systems (36%) and cancer (25%) Most common cause of premature death (under 75 years of age) in men was cancer (37%) followed by diseases of the circulatory system (35%). For women it was cancer (47%) and diseases of the circulatory system (24%) Local rates of premature death from Coronary Heart Disease and Stroke have remained consistently higher than peer group for last decade. East Riding experiences higher than average rate of people killed or seriously injured in road traffic accidents. However the number of children killed or seriously injured in road traffic accidents has reduced. HOSPITAL ACTIVITY Most common elective care admission in 2008 is cataracts followed by chronic heart disease Most common non-elective admission (after pregnancy) were pain in throat & chest followed by abdominal & pelvic pain Significantly higher than average rates of hospital admission for COPD and Diabetes in most deprived parts of East Riding HEALTH INEQUALITIES Significant health inequalities exist and may be widening In comparing the most deprived 20% of East Riding with the remaining 80%, we found that there was a considerable gap in mortality rates for both men & women Gap for men has increased from 32% in 2000/02 to 45% in 2005/07 Mortality rates have fallen in most deprived 20% but not as much as the remaining 80% 10

11 For females the equivalent gap has fallen from 33% (2000/02) to 29% (in 2005/07) Overall the mortality gap for all persons has increased from 32% in 2000/02 to 39% in 2005/07 Principle contribution to health inequalities are CHD, Stroke and lung cancer Major contributory factors to health inequalities are variations in lifestyle risk factors (such as smoking, diet, exercise and alcohol consumption) and significant levels of material deprivation. LIFESTYLE FACTORS Modifiable life style factors are a major cause of health inequalities and variation in demand for health and social care within the East Riding Overall Health In the 2009 Lifestyle Survey 48% reported health to be excellent or very good (2003) The 2008/09 Place Survey reported 75% of local people stating their health in general was good or very good. This percentage is similar to the national average. Smoking Data from the 2009 lifestyle survey suggests 13.5% of people are current smokers i.e. smoked daily or smoked, but not every day. Men were slightly more likely to smoke than women with 14.5% being smokers as opposed to 12.8% of women. This figure is far lower than the previous synthetic smoking estimate of 21%. Smoking prevalence is not evenly distributed across deprivation bands, and showed a clear gradient from most deprived areas to least deprived for both men and women. In the most deprived 20% of electoral wards, 21.1% of men and 22.4% of women stated that they were smokers, but these figures fell to 9.2% and 8.9% respectively in the least deprived areas. Obesity In 2008/9 an increased proportion of East Riding children were weighed and measured to ascertain levels of childhood obesity. Prevalence of obesity in school reception year has increased marginally from 9.9% to 10.2%, whilst the prevalence of obesity in year 6 has decreased from 17.6% to 16.7% Prevalence of adult obesity within the East Riding is 19.2% for men and 19.1% for women. 11

12 Level of obesity is related to deprivation with higher prevalence in the most deprived 20% of areas. This variation by level of deprivation is greater for women. East Riding residents in the least deprived areas most likely to read the nutritional labelling on prepared foods. Women are more likely to read food labelling than men. Breast feeding 45% of infants breast fed are 6-8weeks from birth within the East Riding. This prevalence was similar to that of the national average (46%) and greater than equivalent areas (44%). Physical activity The 2009 lifestyle survey evidenced a link between physical activity and deprivation with 45.9% of men in the least deprived areas stating that they feel they take enough exercise, whilst this was true of only 36.9% in the most deprived areas. For women the contrast was less sharp but even so 37.6% of women in the least deprived areas felt that they took enough exercise whereas only 33.9% of those in the most deprived areas did so. Alcohol Misuse 70% of East Riding respondents reported having drunk alcohol in the last 7 days (77% of men, 64% of women). Of the year olds who answered this question 53.8% of young men and 50.8% of young women reported having drunk alcohol in the last 7 days. The prevalence of alcohol consumption varied between men and women and by level of deprivation, with the least deprived groups being more likely to have consumed alcohol in the last 7 days. Within the East Riding hospital admissions for alcohol related harm are lower than both the regional & national averages. Alcohol related hospital admissions were highest amongst: o People who are struggling to achieve rewards and are mostly reliant on the council for accommodation and benefits o Elderly people subsisting on meagre incomes in council accommodation o Families on lower incomes who often live in large council estates where there is little owner-occupation SEXUAL HEALTH Teenage pregnancy rates are low but not decreasing in numbers Teenage pregnancy 12

13 Rates of teenage pregnancy are not decreasing in East Riding, rates are remaining static however overall rates are far lower than both regional and national averages. Chlamydia 13% of persons aged have been screened for Chlamydia. East Riding performance remains on or above target. MENTAL HEALTH As population lives longer mental wellbeing will become major issue of concern for health and social care East Riding suicide & injury rate is similar to national average. The East Riding has experienced rates higher than equivalent areas for the last decade. Males have significantly higher suicide rates than females. Overall 24% of people reported that they had experienced feeling down, depressed or hopeless or having little interest or pleasure in doing things at some time. This proportion varied by gender and deprivation status. Dementia 1,192 persons registered with Dementia (0.38% patients) compared with an estimated actual prevalence of 4,665. This is a lower proportion for that of Yorkshire and the Humber (0.44%) and for England and Wales (0.41%). Projections suggest number of dementia patients will rise by 78% by 2025 within the East Riding 13

14 PHYSICAL DISABILITY Numbers of persons with limiting long term illness will increase with aging population In % of people in the East Riding of Yorkshire reported having a long term limiting illness, this figure was slightly below the England and Wales average of 17.6%. The 2009 lifestyle survey found that 21.5% of East Riding residents reported having an illness or disability that limited their activities or the work they could do. This equates to 31,900 people with a LLTI, which is close to the 31,666 predicted by the POPPI system for 2010 MAJOR CAUSES OF DEATH & ILL HEALTH Continued decline in premature deaths but prevalence and impact of long term health conditions projected to increase significantly over next ten years CHD Premature deaths from CHD projected to decline further. Prevalence in persons aged 16+ is projected to rise at a rate greater than the national increase from 6.2% in 2008 to 6.7% by 2015, an increase of 3,300 persons. Local rate of premature death has remained consistently lower than national and regional averages for last decade. Local rate of premature death has remained consistently higher than peer group for last decade In 2005/07 there existed a 60% gap (between most deprived 20% & remaining 80%) in premature deaths from CHD in men; this has fallen from a gap of 77% in 2003/05. The equivalent for women in 2005/07 was 105%, down from 114% in 2003/05. Cancer Overall numbers of cancer registrations remain similar to regional and national rates, whilst deaths from cancers have fallen in line with national & regional trends. Premature deaths from cancers in East Riding are similar to both regional & national rates. Breast cancer registrations have increased and remain similar to national & regional figures. In 2007 deaths from breast cancer were higher than regional & national comparators; however the trend over the last decade has remained downwards. Incidence of lung cancer in East Riding has significantly decreased for males but increased for females. Death rates are also higher than for similar parts of England. 14

15 A significant inequality gap exists in mortality rates from lung cancer for males within the East Riding; however this gap between the most deprived 20% and remaining 80% has decreased from 170% in 2004/06 to 143% in 2005/07. The East Riding has seen a large and consistent rise in the number of skin cancer registrations over the last decade. The rate within East Riding has remained significantly higher than regional and national averages. Stroke Premature deaths from Stroke have fallen over last decade Premature death rate projected to decline further. However, prevalence in persons aged 16+ is projected to rise at a rate greater than the national average from 2.7% in 2008 to 2.9% by 2015, an increase of 1,500 persons. During 1990s local rate of premature death had been lower than national and regional averages but in last 5 years rates have been similar to national average. In 2007 premature death rate was higher than both regional and national average Over last 7 years local rates of premature death have been consistently higher than peer group. Rates of death from stroke in the most deprived 20% have continued to remain higher than the remaining 80% for both men & women. Hypertension 34.7% persons aged 16+ within the East Riding in 2009 had hypertension compared with 30.4% in England. This figure is projected to rise to 37.4% by 2020 in East Riding, compared with a rise to 32.3% for England. Diabetes The prevalence of diabetes within the East Riding is projected to increase from 5.2% in 2010 to 6.3% by Estimated prevalence of type 2 diabetes in East Riding is higher than both the regional and national averages for both males & females. Deaths from diabetes in East Riding have increased in recent years and are higher than regional & national averages. This requires investigation. COPD Deaths from COPD have remained consistently lower than national and regional averages over the past decade but have remained consistently higher than peer group over the past decade Prevalence in persons aged 16+ is projected to rise from 3.1% in 2008 to 3.3% by 2015, an increase of 1,400 persons. 15

16 DENTAL HEALTH Overall dental health within the East Riding is generally good Overall Dental Health The recent Dental Health of Adults survey undertaken by the YHPHO and issued in May 2009 indicates that dental health in the East Riding of Yorkshire is generally good, having: The lowest proportion of people (23%) of all the PCTs in Yorkshire and the Humber to describe having problems with aching in the mouth (regional average 28.8%) Second highest (72.8%) in the region for stating that a regular check up is their general reason for going to the dentist (regional average 68.9%). Access to Dental Care 25% of East Riding of Yorkshire residents reported finding difficulty in getting routine care. This is slightly higher than the regional average of 22.6%. Reasons for difficulty in getting access varied across the region, but the main barriers for the East Riding were stated to be: o Dentists only treating privately (55.9% - regional average 41.8%). o No local dentist (30.1% - regional average 19.3%) o Difficulty in getting to a dentist (19.9% - regional average 8.4%), The cost of treatment was also an issue with 33.1% of respondents stating that this was a barrier to getting routine care, though this was below the regional average of 38.3% END OF LIFE CARE Improvement required in estimating preferred location of death 3408 East Riding residents died in An examination of place of death between 2001 and 2007 found that the majority of persons died in an Acute Hospital (41%), followed by dying at home (17%), in a community hospital (16%), in a residential home (12%) or in a nursing home (9%). East Riding of Yorkshire ranks 106 th out of 152 PCTs in the rate of home deaths which puts it in the bottom third of PCTs for home deaths. East Riding is notable for the relatively high proportion of hospital deaths & converse low proportion of hospice deaths CHILDREN Child poverty is major determinant of local child health inequalities Health & Wellbeing of Children The East Riding of Yorkshire has a lower than average population of 0-19 year olds compared with Yorkshire & Humber and England & Wales averages. 16

17 There exist concentrations of young people in our more deprived communities. These concentrations are even more noticeable in very young children age 0-5 years old. The use of free school meals is a proxy indicator for disadvantage. In the East Riding pupils who are from disadvantaged communities perform comparatively poorly when compared to the performance of their national peers. An examination of Child Wellbeing at small geographic areas found that extreme variation exists across the East Riding. Bridlington South has the worst Child Health Wellbeing (within 10% lowest well being group in England) in comparison with St. Mary s ward in Beverley ranking in the 10% best The rate of 0-19 year olds admitted to hospital due to unintentional or deliberate injuries has continued to decline in line with LAA target. Immunisation Pandemic influenza has been the principal focus of recent health protection activity, but activity is at too early a stage to include it in this report. Local childhood immunisation rates remain good as shown in comparison with national and regional averages, but there remains plenty of scope for improved uptake, for example in the case of Measles, Mumps and Rubella. ADULTS Deteriorating economic conditions combined with an ageing population are resulting in an increase in the need to support vulnerable residents in achieving independent living. Fuel Poverty Examination of fuel poverty reveals considerable variation across East Riding, ranging from 5% of households in fuel poverty to 9%. 16% of people receiving income benefit lived in homes with low energy efficiency Independent Living In 2008/09 63% of vulnerable people within the East Riding achieved independent living, this was below target. 98% of vulnerable people were supported to maintain independent living. 17

18 Adults with learning disabilities 50% of East Riding adults with long term difficulties were in settled accommodation. 4% of adults with learning difficulties were in employment. Care leavers 89% of care leavers within the East Riding were in suitable accommodation. 70% of care leavers were in employment, education or training. 18

19 OLDER PEOPLE As local life expectancy increases pressures will build to maintain quality of life and wellbeing Life expectancy over 65 years Life expectancy for men at age 65 within the East Riding is 18 years and 20.2 years for women. These figures have remained higher than the national average over the past decade. Health Status of Older People As the East Riding population grows relatively older, the total number of older people facing the following health problems are all predicted to increase over the next ten years: o Severe Depression o Dementia o Limiting Long Term Illness o Longstanding health condition caused by a Heart Attack o Longstanding health condition caused by a Stroke o Been admitted to hospital as a result of falls o Attended hospital A&E department as a result of a fall Information about the death rate from falls in all ages shows that good progress is being made in the East Riding, with death rates from falls being lower than national, regional and equivalent area comparators. Injuries to Older People The relative rate of emergency admissions for hip fractures in East Riding residents over 65 years of age is lower than the national average for admissions. (and higher lower than regional and equivalent area comparators) Independence and support The Place Survey 2008/09 reported that 35.4% of residents felt that older people get the support they need to live independently; this is higher than the national average of 30%. Older people (42%) were more likely than younger people (29%) to agree that there was the required level of support to help people live independently for as long as they need to. POPULATION GROUPS AND SETTINGS There exits inward migration of people with poorer health to the most deprived parts of the East Riding coast 19

20 Rural and Coastal Issues Persons migrating to the East Riding tend to have worse health than existing residents of the East Riding at all ages. A high percentage of migrants move into the East Riding from West and South Yorkshire Often into some of the most deprived coastal parts of the East Riding. Andy Kingdom Deputy Director of Public Health Oct 22 nd

21 2. POPULATION CHARACTERISTICS In this chapter, general information about the population of the East Riding is presented, both in terms of general characteristics and then in terms of measures of health and illness. Health inequalities are considered as a separate theme and the chapter finishes with consideration of the views of local people about their health and about health and social services. 2.1 Demography This section studies the populations of the East Riding and highlight changes, trends and groups over time and space. It will also encompass the size, structure and distribution of population. Population The East Riding is the largest unitary authority in England, with an area of 2,479 square kilometers. By population, the East Riding is the second largest non-metropolitan district in England. The UK population has grown by 11% from 55 million in 1971 to 61 million in Following this trend the East Riding has also experienced considerable growth in population as a whole. It is also projected that the population of the East Riding will carry on seeing considerable growth into the future (particularly in older groups). As can be seen in Figure 2.1.1, over the next 5 years the population of the East Riding is predicted to increase from 342,187 (2009) to 362,056 (2014) an increase of 5.8 % 1. The East Riding is predominantly a rural area with over half of the population living in dispersed rural communities. The East Riding s largest town is Bridlington with 33,500 people. The other major settlements are Beverley (29,000), Goole (18,500) and Driffield (11,500) as well as the Haltemprice settlements to the west of Hull; Cottingham (17,000), Anlaby/Willerby/Kirk Ella (23,000) and Hessle (15,000). Figure % 8% % 6% 5% 4% 3% 2% 1% 0% The East Riding can be grouped in to lifestyle, social factors and behaviour categories. The most prevalent category is wealthy achievers with 38.9% of 1 ONS Population Projections based on ONS 2006 Population Projections 21

22 households classified in this category compared to 25.1% in the United Kingdom. The least prevalent category is urban prosperity with only 2.3% of households classified in this category compared with 10.7% in the United Kingdom. It is clear from Figure that the East Riding differs significantly from the United Kingdom 2. 45% 40% Figure ACORN Category UK 35% 30% % of households 25% 20% 15% 10% 5% 0% Wealthy achievers Urban prosperity Comfortably off Moderate means Hard-pressed Source: CACI 2009 ***Update for 2009 As a result of acquiring the Dr Foster Population Health Module, we are now able to segment the population according to the Mosaic classification into 11 groups or 61 types. The Table below breaks down the East Riding population by Mosaic group and Locality. This illustrates clearly the difference between the population of East Yorkshire and the National population, for example more people in East Yorkshire classified as Group J (Independent pensioners living in their own homes who are relatively active in their lifestyles) and fewer in Group F (People who are struggling to achieve rewards and are mostly reliant on the Council for accommodation and benefits). However the same table also illustrates that there is significant variation across localities with (for example) Haltemprice having a high proportion of its population in Groups A (Career professionals living in sought after locations) and C (Families who are successfully established in comfortable mature homes). In contrast Bridlington and Driffield has a high proportion of its population in Groups D (Close knit inner city and manufacturing town communities) and K People living in rural areas far from urbanisation). 2 CACI Acorn

23 We are planning to develop the use of data of this type to understand health needs better and to undertake social marketing initiatives. Table 2.1.1: Breakdown of East Riding population by Localities and Mosaic groups. Locality Mosaic Group Beverley and Holderness Bridlington and Driffield Goole Howden and West Wolds Haltemprice East Riding Of Yorkshire PCT England A 7.51% 0.71% 4.65% 21.34% 7.82% 10.36% B 16.19% 7.26% 14.83% 12.78% 12.78% 11.73% C 22.33% 10.70% 18.17% 25.77% 18.87% 15.89% D 16.08% 22.99% 19.55% 14.20% 18.45% 17.12% E 0.33% 0% 0.06% 3.14% 0.75% 7.84% F 0.37% 0.21% 1.03% 0.08% 0.45% 5.32% G 4.12% 4.62% 2.38% 1.93% 3.31% 6.25% H 4.99% 5.95% 7.66% 4.58% 5.90% 10.03% I 4.06% 3.83% 4.32% 4.31% 4.12% 3% J 11.40% 27.81% 5.99% 9.59% 13.78% 7.51% K 12.61% 15.79% 20.28% 1.27% 13.22% 4.57% Z 0.01% 0.12% 1.08% 0.99% 0.54% 0.38% Total 100% 100% 100% 100% 100% 100% Age The population of the UK is ageing; the proportion aged 65 and over is increasing and the percentage below the age of 19 is generally falling; this is mirrored within the East Riding. Since 1981, the proportion of residents aged over 65 in the East Riding has been greater than that of the UK population and is predicted to increase at a much higher rate. In 2007, the population was estimated to be at 336,700 of which 66,100 people aged 65+ (20% of the total residents in the East Riding), and 30,200 people aged 75+ (9% of the total residents in East Riding) 3. Within the East Riding there are significant population trends which become evident when looking at age groups. It is projected that these trends will continue in the same way as in previous years. Compared with that of England, the East Riding has a higher than average older population and a lower than average younger population shown in Figure People over 65 are estimated to increase from 20% in 2007 to 22% of the population by People over 85 are set to increase at the same rate increasing from 2% in 2007 to 3% in Compared with that of the England average there is a particularly strong deficit between the age range of This deficit between the age ranges will remain at 14% of the population until at least ONS Population Projections

24 Figure (from Dr Foster Population Health Manager Tool) The changing demographic of the East Riding is clearly visible when ages are grouped into three categories working age, older people and children. It is clear that as both working age and children groups are decreasing within the East Riding, the older people group is increasing. This is clearly indicated in Figure Figure Change in demographics in East Riding of Yorkshire between 2006 and % Percentage of Population 60% 50% 40% 30% 20% 10% Working age Children Under 15 Children Working Age Older people Older people M=65+, F=60+ 0% Year 24

25 Figure shows considerable population growth particularly in the older agegroup East Riding has a relatively elderly population with 67,000 (20.0%) being aged over 65 and 30,900 (9.2%) being aged over 75. East Riding is the second largest non-metropolitan district in England, at 2416km2 Population growth in East Riding is experiencing considerable growth predicted to rise by 5.8% by 2014 (around 20,000 people) Largest town is Bridlington (33,500) The most common lifestyle groups are wealthy achievers & comfortably off but with a significant proportion of hard pressed families ***Update for 2009 As the population lives longer the number of people with chronic illnesses will grow significantly and the prevalence of chronic conditions is set to increase significantly as a result. For example local cases of Dementia are projected to increase by 78% by 2025 and Diabetes, COPD, Stroke and Heart Disease are all projected to increase over next 5 years. We have identified these conditions as major challenges and priorities for our health strategy and have set our reasons for doing so in Appendix 1. Births Within the East Riding in 2007 there were 54 live births per 1000 females within the population aged 15-44; this is in comparison to 61.9 for England & Wales and 60.5 for Yorkshire & Humber 4. The East Riding birth rate is clearly below England and Yorkshire & Humber. It is projected that the number of deaths will continue to outnumber the number of births; a trend experienced since The total fertility rate in the East Riding is 1.87 compared with that of England & Wales which is The total fertility refers to the average number of children that would be born per woman if women experienced the age specific fertility rates of the year in question throughout their child bearing lifespan. 4 ONS (Vital Statistics) General Fertility Rates ONS (Vital Statistics) Total Period Fertility Rate

26 Figure Live Births per 1000 Female population aged England & Wales Yorkshire and The Humber East Riding of Yorkshire Sex In the East Riding 49% of the population is male and 51% female. These are also the same proportion as in the Yorkshire and Humber region, and England. The number of males per 100 females is much more balanced than it has been - a trend that is predicted to continue. The ratio of males to females reduces with increasing age the biggest difference being in the 90 plus age range, although this is in line with life expectancy being longer for women. Ethnicity According to the census 97.6% of the local population describe themselves as White British with all age ranges having a large white population. The East Riding has a much lower than average number of people from ethnic minorities than in both the Yorkshire and Humber and England; a difference of up to 6.9%. The Asian and British Asian community is the second largest group within the population but it is also the group with the biggest difference in proportion comparison with Yorkshire and Humber and England. A large proportion of the ethnic minorities (especially Asian or Asian British 50.1%) work in professional occupations, whereas White British (14.3%) and Chinese and other ethnic groups (19.6%) have higher proportions for skilled trades. Asian or Asian British have the smallest proportion within Elementary occupations (5.8%) 6. It is also evident that as age increases the difference between the East Riding and the rest of Yorkshire and Humber and England decreases clearly highlighted in Figure ONS Mid Year Estimates

27 Figure Inward Migration Levels of inward migration evidence the desirability of life in the area. The East Riding has recorded the biggest net gain (25,300 people) of all local authorities in England and Wales over the past eight years. Elderly retired, often moving from the urban areas of West Yorkshire and Hull comprise a substantial proportion of this group, along with families attracted by high quality education, low crime, and the benefits of a rural or market town lifestyle. ***Update for 2009 From our lifestyle survey in 2009 we identified an additional area of unmet need i.e. that there exists an inward migration of people with poorer health from West and South Yorkshire to the most deprived parts of the East Riding coast. We have undertaken a detailed analysis of the health of inward migrants. A report is available from the Public Health Directorate. Economic Migrants It is clear that as a percentage of the population the migration of workers into the East Riding is relatively low especially when considering the high proportion of the population which is of retirement age. The main nationality of economic migrants into the East Riding between 2004 and 2007 is Polish. The main age group has remained constant at along with less than 3 months remaining as their intended length of stay. The hourly rate band has increased from in 2004 to in The main sector that migrants have been coming into is administration, business and managerial services between 2004 and 2007 only 45 out of a possible have come into health and medical services within the East Riding 7. 7 Local Government Analysis and Research May March

28 Figure Migration: Worker Registration Scheme -Approved Applications (% of total population) 1.1% 0.9% East Riding Yorkshire & Humber England 0.7% Percentage 0.5% 0.3% 0.1% May Dec 2006 Jan 2007-Mar 2007 Apr 2007-Jun 2007 Jul Sep 2007 Oct 2007-Dec 2007 Jan Mar % Total =3,905 (1.2% of East Riding) Please note the time period of column 1 Source: Local Government Analysis and 2.2 Determinants of Health and Well-being This section studies the Index of Multiple Deprivation 2007 which combines a number of indicators, chosen to cover a range of economic, social and housing issues, into a single deprivation score for each small area (Lower Super Output Area or LSOA) in England. This allows each area to be ranked relative to one another according to their level of deprivation. The variables focus on information such as housing, average incomes and transport within the East Riding. Summary The East Riding is the 208 th most deprived region of 354 in England on the Index of Multiple Deprivation with disparities of wealth across the region. Within this though there are areas of affluence in Pocklington Provincial and South Hunsley alongside pockets of deprivation in parts of the Bridlington and Goole. Within the East Riding 8% of households are without central heating marginally under the national average, while 20% lack a car. Crime has reduced from 77.6 crimes per 1000 population in 2002/03 to 59.1 in 2006/07. Only 12% of people feel unsafe as a result of anti-social behaviour according to the General Household Survey Bridlington South contains the Lower Super Output Area with the lowest rank in the East Riding (758 out of 32,482 in England). There are five other areas within the East Riding in the 10% most deprived LSOAs in the country, three more in Bridlington South, one in South East Holderness and one in Goole South. The East Riding has 42 LSOAs in the 10% least deprived (21 % of 8 The English Indices of Deprivation

29 East Riding LSOAs). Studying the domains individually, 6 LSOAs in the East Riding are in the 10% most deprived using the Income domain, 11 using the Employment domain, 4 using the Health Deprivation and Disability domain, 5 using the Education, Skills and Training domain, 19 using the Barriers to Housing and Services domain, 4 using the Crime and Disorder domain and 5 using the Living Environment domain 9. The distribution of LSOAs by wards is similar for most of the domains with the majority situated in Bridlington, Goole and South Holderness wards. Figure Health Health deprivation and disability identifies areas with relatively high rates of people who die prematurely or whose quality of life is impaired by poor health or who are disabled, across the whole population. Bridlington South and South East Holderness are the only wards containing LSOAs in the 10% Most Deprived category. Eleven wards contain LSOAs in the 10% least deprived category: Beverley Rural; Dale; Hessle; Howden; Minster and Woodmansey; Pocklington Provincial; St. Mary s; South Hunsley; Tranby; Willerby & Kirk Ella and Wolds Weighton 10. Within the East Riding, the percentage of dependant children living in households with no working adults is 6.1%; a much lower percentage than that of England 11 (as shown in Figure 2.2.2). Once broken down to ward level, it becomes clear that the least deprived areas within the East Riding are much 9 The English Indices of Deprivation The English Indices of Deprivation ONS Census

30 higher than that of the England average. They also follow the distribution of LSOAs that form the overall Index of Multiple Deprivation. Figure Income In the East Riding incomes are higher than the national average although there is significant variation within the area. Median earnings are fractionally higher than Yorkshire and Humber, as the data refers to April 2008 which is pre economic downturn expectations could be to see a decrease this year. Significant variation exists across the East Riding in the percentage of people of working age claiming a key benefit. This ranges from 2% to 39%. Highest levels of benefit claims were reported in Bridlington South & Goole South. Overall East Riding has lower levels of benefit claimants than both the national & regional averages. Those East Riding LSOAs which feature in the 10% most deprived in England for the Income domain can exclusively be found in Bridlington. The scores range from 0.35 to 0.42 meaning between 35% and 42% of people within these LSOAs are income deprived. That is they receive Income Support, asylum subsistence support or have an income which is below 60% of the medium calculated using benefit claims. There is one LSOA in the East Riding in South Hunsley ward, where the proportion of income deprived people is as low as 1% 12. The East Riding is ranked 204 of 354 on average income. The average household annual income in England is 31,904 compared with that of the East Riding which is 30,246. This means compared with that of England the East Riding average household income is 5.5% less than England. There is a 12 The English Indices of Deprivation

31 substantial difference in the average household incomes across in the East Riding; up to a 34,655 difference between the LSOAs 13. The East Riding has a fuel poverty index of 8.7% compared with that of 10% in England, this refers to were 10% or more of household income is spent on fuel costs 14. Benefits within the East Riding again follow the trend of deprivation with the least deprived areas again being much higher than the East Riding average. Figure All Benefits - Working age client group 12% 10% Claimants East Riding Average 8% Percentage 6% 4% 2% 0% Total =24,715 Bridlington South South East Holderness Bridlington Central and Old Town Goole South South West Holderness Minster and Woodmansey Bridlington North Driffield and Rural East Wolds and Coastal Hessle Mid Holderness North Holderness Howdenshire St Mary's Goole North Tranby Pocklington Provincial Snaith, Airmyn, Rawcliffe and Marshland Wolds Weighton Dale Cottingham South Beverley Rural Willerby and Kirk Ella Cottingham North South Hunsley Howden Source: Nomis (2009) Barriers to housing and services The barriers to housing and service indicators fall into two sub-domains: 'geographical barriers' and 'wider barriers'. This domain paints a very different picture of deprivation as it highlights the nature of isolation. The rural areas of the East Riding are ranked very highly with 19 LSOAs featuring in the 10% most deprived in the country. Five of these are in Wolds Weighton which do not normally feature in the 50% most deprived for other domains 15. The most important indicator for these areas is likely to be pertaining to road distances to services rather than overcrowding, homelessness or owner occupation issues. Access to GPs, convenience stores, primary schools and post offices are forms of deprivation experienced by many people in rural areas, especially when age and mobility are considered. East Wolds and Coastal has three LSOAs within this category; Beverley Rural, Howdenshire, Mid Holderness, Snaith, Airmyn and Rawcliffe & Marshland and South East Holderness each have two within this category and Driffield and Rural has one. In contrast with the other domains, the urban areas of Bridlington and Goole have a high 13 CACI Paycheck Private Sector Stock Condition Survey The English Indices of Deprivation

32 percentage of LSOAs in the 10% least deprived category, along with representation from the Beverley and Haltemprice wards this is clearly shown when comparing Figures and Although barriers to housing services indicators show the East Riding as being very deprived when looked at more closely the reasons behind this become evident. The proportion of residents who own their own homes within the East Riding is 10% higher than the England average. The percentage of residents who rent from the council and other social renters is 4% less than that of the England average. Households with over 1.5 persons per room within the East Riding are lower than that of England by 4%. Within the East Riding 7% of households less than the England average do not have a car or a van. Because of the rural nature of the East Riding this can go some way to explaining the reasons behind barriers to housing and services being ranked so low 17. There is no difference between managers in agriculture and services between the East Riding and England average. There is little difference between the occupations between the East Riding and England average with the biggest difference being in the skilled trades. Housing completions within the East Riding vary greatly on a yearly basis with the most 538 being completed in 2003 in Bridlington and the lowest 66 being completed in Beverley in 2006/ Higher education entrants also vary across the wards. Higher education entrants have increased from 11.7% in 1999/2000 to 13.1% in 2005/ Figure The English Indices of Deprivation ONS Census East Riding of Yorkshire Council Planning Department 19 Department for Education and Skills 32

33 Within the East Riding the average house price has risen from around 97,000 in 2003 to 157,000 in This has led to many people being unable to access suitable housing when they want or need it. The consequences of this are that some people are forced to live with family or friends in overcrowded conditions, move into rented accommodation that is too small for their needs or is very expensive or to move out of the area altogether. The health implications of this are widely documented and include stress and depression amongst adults and an increase in infectious diseases amongst children. In addition to this, 31% of private dwellings in the East Riding are classified as non-decent compared with 27% in England, with the highest rate of non-decency occurring in the private rented sector (62%). Dwellings are classified as non-decent if they fail to meet the Decent Homes Standard set out by the Housing Act The most common reason for properties failing the Decent Homes Standard in the East Riding of Yorkshire relate to inadequate thermal comfort (Table 2.2.1). With large areas of the East Riding likely to remain off the main gas network, this is a major issue for older and low-income households and those with limiting health conditions. The highest rates of non-decency by area are in Bridlington (nearly 55%) and Goole (42%) 20. The health impact on residents of non-decent properties is a higher prevalence of accidents in the home, respiratory disorders, increased risk of fire and mental health problems. Table Reasons for failing the decent home standard Reason Dwellings Percent Percent (of non decent) (of stock) Unfit dwellings 4, % 3.1% Category 1 hazard 16, % 12.2% dwellings In need of repair 14, % 11.1% Lacking modern facilities 1, % 1.1% Poor degree of thermal comfort 27, % 20.6% In the East Riding of Yorkshire, the hierarchy of reasons for failure generally follows that seen across the country. Poor degree of thermal comfort is the primary reason for failure of the Decent Homes Standard, as is the case in the East Riding of Yorkshire, with a slightly elevated failure rate than that found nationally. The proportion of properties failing for disrepair is somewhat higher than that nationally, with the proportion of properties failing because of facilities and services being slightly less than the national average. 20 Housing Strategy Issues and Options April

34 2.3 Measures of Health and Illness Life Expectancy Life expectancy is often used to compare how long people live, and by implication their health, in different parts of England. It is also possible to use it to compare different parts of the East Riding. The life expectancy figures are not a forecast, but show how long people will live if current local agespecific death rates apply throughout their lives. Within the East Riding, the life expectancy for women is similar to the national average, whilst that for men is slightly better. The national target for life expectancy is by 2010 to increase life expectancy at birth in England to 78.6 years for men and to 82.5 years for women. Within the East Riding the life expectancy for both men and women is expected to increase to meet the national target, but not at the same rate across the area. Life expectancy at birth for females within the East Riding has risen from 79.6 years in 1991/93 to 81.7 years in 2004/06. Males within the East Riding have experienced a proportionally greater increase in life expectancy than females, increasing from 74.7 years in 1991/93 to 78.1 years in 2004/06. This increase for males has reduced the gap between male and female life expectancy, however females continue to expect to live, on average, longer lives than males. 86 Figure 2.3.1: Life Expectancy 5 Year Health Strategy Life Expectancy at Birth (in years) East Riding of Yorkshire England & Wales East Riding of Yorkshire England & Wales FEMALES MALES year average Within the East Riding there is considerable variation in life expectancy by electoral ward. This information is shown in Table 2.3.1, which demonstrates National Target Local Target

35 that there is a difference among men of up to 7 years and among women up to 9 years. In both cases, the ward with the lowest life expectancy is Bridlington South. Table 2.3.1: Life Expectancy at birth by East Riding wards (2001 to 2003) Women Men Beverley Rural Cottingham North Tranby Pocklington Provincial St Mary's Bridlington North Wolds Weighton Dale Howden Willerby and Kirk Ella South Hunsley East Wolds and Coastal Howdenshire Mid Holderness South West Holderness Bridlington Central and Old Town Driffield and Rural Cottingham South Minster and Woodmansey North Holderness Goole South Hessle Snaith, Airmyn, Rawcliffe and Marshland Goole North South East Holderness Bridlington South ***Update for 2009 The Association of Public Health Observatories (APHO) has recommended a measure of health inequalities for inclusion in the 2009 World Class Commissioning Assurance Framework. The recommended indicator is the slope index of inequalities in life expectancy The East Riding scores of 7.0 for males and 4.3 for females suggest that the East Riding does not have wide range of differing levels of deprivation across the area. It does however have smaller pockets of high level of deprivation where life expectancy is particularly low. The Figures below illustrate the 35

36 position in the East Riding of Yorkshire and identify a particular issue with the most deprived decile of our population. Figure 2.3.2: Life Expectancy of Males by Deprivation Deciles: Slope Index of Inequality within East Riding of Yorkshire ( ) Slope Index of Inequality = 7.0 years (95% Confidence Interval: 3.6 to 10.3) 90 Male Life Expectancy at Birth (years) Most Deprived 10% Least Deprived 10% Level of Deprivation Figure 2.3.3: Life Expectancy of Females by Deprivation Deciles: Slope Index of Inequality within East Riding of Yorkshire ( ) Slope Index of Inequality = 4.3 years (95% Confidence Interval: 1.6 to 6.9) 90 Female Life Expectancy at Birth (years) Most Deprived 10% Least Deprived 10% Level of Deprivation 36

37 Death Rates Measurement of declining death rate is similar to measurement of increasing life expectancy. Overall death rates within the East Riding for both men and women have seen a steady decline over the last 14 years (down 27% from 762 deaths per 100,000 persons in 1993 to 553 deaths in 2007) There are lower than expected numbers of premature deaths (age under 75) but big variations within area The rate of decline in overall numbers of deaths has been greater for men than for women, furthermore death rates in the East Riding have remained lower for men than nationally or regionally, but the difference for women is much smaller. Overall death rates for men are lower than national average but similar to equivalent areas in the country. Overall death rates for women are similar to national rates but higher than equivalent parts of country, although lower than average for Yorkshire & Humber region Figure 2.3.4: Deaths from all Causes - All Ages - People Directly age standardised mortality rate per 100,000 persons 1, England & Wales Yorkshire & Humber Prospering Smaller Towns East Riding of Yorkshire Year Death rates among young children can be used as indicators of general population health and of the quality of healthcare around the time of birth. Information is presented in Figures and and there is a clear downward trend in the rate of infant mortality. Specifically the figures show Slow decline in infant mortality rates with sharper fall in recent years East Riding rate lower than both national & regional averages 37

38 Both neonatal & perinatal mortality rates have remained lower than region & national rates Figure 2.3.5: Infant Mortality Rate - 3 Year Average (Deaths under 1 year per 1000 live births) 8 7 Yorks & Humber England & Wales East Riding of Yorkshire Infant Mortality Rate - 3 Yr Avg (Deaths under 1 year/1000 live births) Year (3 Year Average) Figure 2.3.6: Neo-natal Mortality Rate - 3 Year Average (Deaths under 4 weeks per 1000 live births) 8 7 Yorks & Humber England & Wales East Riding of Yorkshire Infant Mortality Rate - 3 Yr Avg (Deaths under 4 weeks per 1000 live births) Year (3 Year Average) 38

39 Cause of Death The cause of death is an indicator of major illnesses and is an important factor that needs to be considered. Causes of death in the East Riding largely reflect those nationally, with cardiovascular disease and cancers both prominent as shown in Tables and Table 2.3.2: Most Common Causes of Death All Ages Cause of Death (ICD Chapter) Number (%) Men Circulatory system 4326 (38%) Cancers 3525 (31%) Respiratory System 1418 (12%) External Causes 403 (4%) Digestive System 386 (3%) Women Circulatory system 4660 (36%) Cancers 3231 (25%) Respiratory System 1793 (14%) Not Elsewhere Classified 827 (6%) Digestive System 576 (4%) Table 2.3.3: Most Common Causes of Death Aged Under 75 Cause of Death (ICD Chapter) Number (%) Men Cancers 1743 (37%) Circulatory system 1620 (35%) Respiratory System 358 (8%) External Causes 319 (7%) Digestive System 181 (4%) Women Cancers 1571 (47%) Circulatory system 806 (24%) Respiratory System 269 (8%) Digestive System 174 (5%) External Causes 133 (4%) Specifically Most common cause ( ) of death for men were deaths related to the circulatory system (38%), then cancer (31%) and similarly for women circulatory systems (36%) and cancer (25%) 39

40 Most common cause of premature death (under 75 years of age) in men was cancer (37%) followed by circulatory system (35%). For women it was cancer (47%) and circulatory system (24%) Local rates of premature death from Coronary Heart Disease and Stroke have remained consistently higher than peer group for last decade. East Riding experiences higher than average rate of people killed or seriously injured in road traffic accidents. However the number of children killed or seriously injured in road traffic accidents has reduced. Hospital activity Hospital admissions can also be used as a measure of need. This has the advantage that the information is readily available, but it only represents a proportion of health conditions those that need hospital admission. This information does not for example capture the range of activity in primary care and social care. Tables and show the top 10 reasons for planned (elective) and emergency or unplanned (non-elective) hospital admissions for East Riding patients in Table 2.3.4: Elective Care Admissions 2008 DESCRIPTION Total Spells Total Unique Patients 1 Other cataract Chronic ischaemic heart disease Senile cataract Other diseases of anus and rectum Gonarthrosis [arthrosis of knee] Diverticular disease of intestine Follow-up examination after treatment for malignant neoplasm Other malignant neoplasms of skin Inguinal hernia Internal derangement of knee Table 2.3.5: Non-elective Care Admissions 2008 (not including Pregnancy, childbirth and the puerperium) DESCRIPTION Total Spells Total Unique Patients 1 Pain in throat and chest Abdominal and pelvic pain Pneumonia, organism unspecified Syncope and collapse Unspecified acute lower respiratory infection Other chronic obstructive pulmonary disease Other soft tissue disorders, not elsewhere classified Other disorders of urinary system Fracture of femur Angina pectoris Acute myocardial infarction

41 The most common cause of elective care admission in 2008 was cataracts followed by chronic heart disease. The most common cause of non-elective admission (after pregnancy) were pain in throat & chest followed by abdominal & pelvic pain ***Update for 2009 As a result of having acquired the Dr Foster Population Health Manager module we are now more easily able to benchmark our activity against similar peer PCTs, Yorkshire and Humber and England. Table gives a comparison of Standardised Admission Rates for admissions from April 2007 to March 2009 for the chronic conditions that we have identified as major challenges for the future (see Appendix 1) Table 2.3.6: Standardised Admission Ratio (age/sex adjusted) for Key Long Term Conditions ERYPCT Peer PCT 21 s Yorkshire and Humber COPD Stroke Diabetes CHD With the exception of CHD admission rates in the East Riding tend to be lower than average, nevertheless we anticipate growing pressure as the population ages. Also, we have shown that admission rates vary across the East Riding with rates in the most deprived parts of the county being significantly higher than the National average. For example the rates for COPD and Diabetes in the most deprived quintile of Lower Super Output Areas are and respectively. An additional issue that we have recently identified as a result of having had the opportunity to review the NHS Choices data is an anomalous finding, that although the age sex SARs for COPD and asthma are low, the NHS Choices data, which also adjusts for deprivation identifies these as being high (123.8 and respectively). We have identified this as an area that requires further investigation in case it represents (for example) over-provision of inpatient facilities, inappropriate admissions or poor provision of support in the community. We have identified that the age/sex/deprivation adjusted SAR is not uniformly high across the county, as the example below for COPD illustrates. 21 Peers in this table are Norfolk PCT, North Yorkshire and York PCT, Shropshire County PCT and Somerset PCT 41

42 Figure Age/sex/deprivation adjusted SAR for COPD by Locality ( ) Health Inequalities The East Riding of Yorkshire is not a Spearhead area and principal indicators for deprivation and ill health show lower levels than for the country overall. Some indicators, for example relating to access to services are not so favourable. The focus for addressing health inequalities in the East Riding of Yorkshire is therefore not about bringing the overall health status closer to the national average, but rather about reducing health inequalities within the East Riding and concentrating on communities with the poorest health. The differences in health across the East Riding have already been clearly shown, for example in Table where the differences in life expectancy are considerable. Particular areas with high levels of ill health occur in Bridlington and along the coastal strip, in Goole and parts of Beverley and Haltemprice. More specific information is available in recent Director of Public Health Reports. If we divide up the East Riding into five bands based on information about material deprivation from the 2001 census, we find differences in a range of health indicators. People who live in areas of greater deprivation tend to have 22 Source: Dr Foster Population Health Manager module 42

43 poorer health. Figures show the trends in death rate over time comparing the most deprived of the five bands in the East Riding with the rest. Death rates have declined over the years and the gap between the most deprived areas and the rest has remained constant over the periods 2003/05 to 2004/06. However, when this is broken down for men and women, it is clear that the gap has become considerably smaller for women, but has increased for men. Specifically The gap for men has increased from 32% in 2000/02 to 45% in 2005/07 Mortality rates have fallen in most deprived 20% but not as much as the remaining 80% For females the equivalent gap has fallen from 33% (2000/02) to 29% (in 2005/07) Overall the mortality gap for all persons has increased from 32% in 2000/02 to 39% in 2005/07 Figure 2.4.1: Death Rate and Deprivation PERSONS Directly standardised rate per 100,000 persons % 34% 34% 37% % % / / / / / /07 3 year Average Worst DSR per All But Worst DSR per

44 Directly standardised rate per 100,000 persons Figure 2.4.2: Death Rate and Deprivation % 32% 33% 41% % 48% MALES / / / / / /07 3 year Average Worst DSR per All But Worst DSR per Figure 2.4.3: Death Rate and Deprivation FEMALES Directly standardised rate per 100,000 persons % 35% 33% 33% 29% % / / / / / /07 3 year Average Worst DSR per All But Worst DSR per Some variations in health reflect the age of different populations, but others form part of a combination of socio-economic deprivation, low educational attainment and poor health. For example, even taking age into account, deaths from cancer in the East Riding vary from 40% below the national average up to 42% above the national average. The delivery of health services does not always match areas of poor health, although it is a 44

45 complicated picture. For example, primary care services, prescribing and referrals are high in some of the most deprived parts of the East Riding, while an individual general practice may serve both prosperous and deprived communities. Quality and Outcomes Framework scores are high even in the deprived areas. Certain groups of people across different geographical areas are faced with poor health. Gypsies and Travellers have the poorest health profile of any group in the East Riding and other minority groups also face health challenges. Many communities in the East Riding are relatively isolated and this may cause difficulties for people, especially the elderly, to reach health and other services. Three prisons lie within the East Riding and the health of prisoners tends to be particularly poor. The reasons behind health inequalities are many and varied and include upbringing, education, employment history, income, lifestyle choices such as smoking, as well as factors related to health services such as access to care. Many of these factors are deeply rooted in society and may take many years to change. Others are more amenable to change in the short term. Knowledge of the specific illnesses that show the inequalities is potentially valuable as a basis for tackling them. Work from the Yorkshire and Humber Public Health Observatory 23 examining the causes of death that result in health inequalities for years of life lost between different parts of the East Riding has pointed to coronary heart disease and cancers as having the greatest influence (Table 2.4.1). Table 2.4.1: Principal Contributors to Health Inequalities by Years of Life Lost in the East Riding of Yorkshire Men Coronary Heart Disease Women Coronary Heart Disease Lung Cancer Suicide and Undetermined Injury Deaths under 1 year Lung Cancer Other cancers Other accidents

46 ***Update for 2009 Modifiable life style factors are a major cause of health inequalities and variation in demand for health and social care within the East Riding. Early in 2009 (January March) we undertook a lifestyle survey in order to understand the health needs of our population better. Detailed reports are available from the Public Health Directorate. Here we have chosen to highlight the following key findings. Overall Health In the 2009 Lifestyle Survey 48% reported health to be excellent or very good (2003) The 2008/09 Place Survey reported 75% of local people stating their health in general was good or very good. This percentage is similar to the national average. Smoking Obesity Data from the 2009 lifestyle survey suggests 13.5% of people are current smokers i.e. smoked daily or smoked, but not every day. Men were slightly more likely to smoke than women with 14.5% being smokers as opposed to 12.8% of women. However data from the National Indicator Set 2009 (synthetic estimates) suggest that the prevalence is higher, at 21.2%. The same data also suggest that 14.2% of pregnant women are smokers. Smoking prevalence is not evenly distributed across deprivation bands, and showed a clear gradient from most deprived areas to least deprived for both men and women. In the most deprived 20% of electoral wards, 21.1% of men and 22.4% of women stated that they were smokers, but these figures fell to 9.2% and 8.9% respectively in the least deprived areas. Level of obesity is related to deprivation with higher prevalence in the most deprived 20% of areas. This variation by level of deprivation is greater for women. East Riding residents in the least deprived areas most likely to read the nutritional labelling on prepared foods. Women are more likely to read food labelling than men. In 2008/9 an increased proportion of East Riding children were weighed and measured to ascertain levels of childhood obesity. Prevalence of obesity in school reception year has increased marginally from 9.9% to 10.2%, whilst the prevalence of obesity in year 6 has decreased from 17.6% to 16.7% Prevalence of adult obesity within the East Riding is 19.2% for men and 19.1% for women. 46

47 Physical activity The 2009 lifestyle survey evidenced a link between physical activity and deprivation with 45.9% of men in the least deprived areas stating that they feel they take enough exercise, whilst this was true of only 36.9% in the most deprived areas. For women the contrast was less sharp but even so 37.6% of women in the least deprived areas felt that they took enough exercise whereas only 33.9% of those in the most deprived areas did so. Alcohol Misuse 70% of East Riding respondents reported having drunk alcohol in the last 7 days (77% of men, 64% of women). Of the year olds who answered this question 53.8% of young men and 50.8% of young women reported having drunk alcohol in the last 7 days. The prevalence of alcohol consumption varied between men and women and by level of deprivation, with the least deprived groups being more likely to have consumed alcohol in the last 7 days. 47

48 2.5 Population Voice The Primary Care Trust and East Riding of Yorkshire Council are committed to empowering both individuals and communities so that they can play a greater role in shaping health and social care services. We recognise that health and social care professionals are able to provide a better service if they understand what the community needs. The Local Government and Public Involvement in Health Act (2006) strengthened the NHS duty to involve and put in place a new duty to report for the NHS. Since January 2003, every local authority with social services responsibilities (150 in all) have had the power to scrutinise local health services, and more recently social care services have been included within the remit of Overview and Scrutiny Committees (OSCs). Scrutiny applies not only to major changes but the ongoing operation and planning of services. In the period 2005 to 2008, a series of Public and Patient Involvement Forums provided a communication channel between the public and health service providers. In 2008, a Local Involvement Network (LINk) will be developed for the East Riding to make it easier for citizens to say what they want from health and social care services. The LINk will provide opportunities for the public to talk with the people who provide health and care services, and hold them to account. Current Activity A number of initiatives help to achieve a stronger voice for individuals and communities, providing opportunities for the public to tell them about their experience and expectations of services. East Riding of Yorkshire Local Strategic Partnership carries out the following activities : Annual Riding Around Consultation Local Action Teams (LATs) The East Riding of Yorkshire Council carries out the following activities : Annual Household Survey : a postal survey of a random sample of residential addresses Service-Specific Surveys HaveYourSay website SaySomething website Ethnic Minority Panel Specific work with Hard-to-Hear groups 48

49 East Riding of Yorkshire Primary Care Trust carries out the following activities: Local Health Survey Specific consultation exercises for example the major consultation concerning Community Health Services Response to individual concerns through the PALs service and Complaints service Commissioning Prospectus Feedback The following are the key points from recent health-related major involvement and consultation in the East Riding: Annual Local Health Services Survey 2005 (for former PCTs) 1 in 3 (EY) 48% (YWC) of people say they can t book appointments more than 2 days in advance when required 1 in 3 got inadequate advice on medications 1 in 4 don t understand explanation of test results to some extent the level of choice in consultant referrals still low satisfaction levels with out-of-hours services are significantly lower than with in-hours services people who wish to change to a healthier lifestyle would like it to be easier to access help Joint Older People s Inspection Recommendations 2007 The vision for future service should be effectively translated into improved outcomes for service users and carers by strengthening action plans and including detailed and specific improvement targets and monitoring processes. Strengthen the consistency of the voice of service users and carers in service development through: The review of processes for the involvement of service users in directly provided social care services Further strengthening the mechanisms for service users and carers to comment on community and hospital-based health services. Strengthen draft commissioning plans by: Including precise budget commitments Detailing service development targets. Review short-term budget constraints and ensure that the curtailed use of routine services does not lead to poor value for money Continue to develop a wider range of community-based services. Strengthen existing adult protection arrangements through agreeing and executing a monitoring process to quality-assure the skills and the implementation of the investigation and protection planning process. 49

50 Strengthen the approach to equalities work by taking a more proactive approach to engaging and making services available and appropriate for hard to reach groups. Determine a strategic approach to advocacy to empower and encourage service users to ask for the particular help they need, focusing on the most vulnerable. Strengthen information about financial arrangements and other resources needed to deliver an integrated health and social care service. PCT Commissioning Strategy for Community Health Services Consultation Feedback Support for investment in community health services Ensure close partnership working and the financial impact of the new model of care on partners Improve local access to services, particularly for older people Improve access to minor injury and out of hours services Retain, utilise and improve local hospital beds and services Recognise the additional demand for services that is being created as by the growing population Prioritise patient safety Support for developing local minor procedure and diagnostic services Consider issues around social deprivation in the East Riding Consider rural isolation, access and transport issues in the East Riding of Yorkshire NHS Yorkshire and the Humber Public Perception Survey 2007 Communicate how PCT provides good value for money Improve choice of hospitals for in-patient services Improve community care services Improve waiting times for health care. Improve satisfaction with Accident & Emergency services Improve satisfaction with NHS Dental Services ***Update for 2009 The East Riding of Yorkshire Council 2008/9 Place Survey provides information on people s perception of their local area and the local services they receive. The following findings are highlighted. 50

51 Liveability Higher than average levels of satisfaction with East Riding as a good place to live. 85% of respondents stated that they were either very or fairly satisfied with East Riding as a place to live. This varies from 95% in Market Weighton & Pocklington to 75% in Goole & Howdenshire. Two of out of three residents (68%) feel they belong to their neighbourhood; this is higher than the national average (59%). Nine out of ten (92.5%) older residents aged 65 & over are both satisfied with their home & their neighbourhood. This is higher that the national average of 83.9%. Satisfaction with Public Services Overall general satisfaction with public services but variation exists in levels across the East Riding Level of crime (61%), Health Services (49%) and Cleaner streets (46%) considered to be most important factors in making East Riding the good place to live Activities for teenagers (52%), Road & pavement repairs (43%) and level of traffic congestion (31%)%) considered to be most in need of improvement 83% of East Riding respondents were very or fairly satisfied with their GP 66% were very or fairly satisfied with their local hospital Satisfaction with local hospital varied from 45% in Bridlington & Driffield to 78% in Market Weighton & Pocklington. Crime & Antisocial behaviour Local residents perceptions of antisocial behaviour are significantly lower than national averages The number of serious violent crimes has been reducing with the exception of March Car crime and burglary are up despite significant downward trend in recent years 11.5% of East Riding respondents reported a high level of perceived antisocial behaviour in their area; this is far less than the nation average of 20%. This figure varied from 4% in Market Weighton & Pocklington to 21% in Goole & Howdenshire. Over a third of respondents agreed that in their area parents take enough responsibility for the behaviour of their children. This is higher than the national average. 51

52 In addition to the Place Survey, there have been a number of other initiatives between 2008 and the present date including local insight polling exercises and surveys involving the public, patients, clinicians etc. An audit of these exercises has recently been undertaken (October 2009) and the results of the audit formed the basis of a report to the Patient Experience Subgroup of Quality and Patient Experience Committee. The report analysed themes identified from local and national surveys, engagement activity, complaints, PALS, incidents, compliments MP correspondence and Freedom of Information requests. The public perceptions gathered were linked to the health strategy areas and recommendations for inclusion in the Service Performance Report were developed. Results and recommendations are contained in the Communications and Engagement Strategy, Section 9. 52

53 3. PRIORITIES FOR HEALTH, CARE AND SERVICES This chapter considers the principal areas that need assessment in order to address the challenges that have been set out in Chapter 1. The choice of areas is based on known areas of need, presumed areas of need based on national and local work and on areas known locally to be ones where particular needs exist. For example in order to tackle coronary heart disease and stroke there is a need to address obesity, physical activity and smoking among other areas. 3.1 Obesity, Physical Activity and Nutrition Why is this important? Low levels of physical activity, poor and unbalanced nutritional intake and resultant obesity make up a significant and increasing health problem both nationally and locally. Being overweight or obese greatly increases the risk of associated health issues such as CHD, stroke, type II diabetes, some cancers, including post-menopausal breast cancer and colon cancer, hypertension, and psychological and social problems, including reduced selfesteem and increased risk of depression. What specific areas need attention? Healthy Weight, Healthy Lives: A Cross-Government Strategy for England (2008) focuses on five activity areas in relation to obesity, physical activity and nutrition: Children, Healthy Growth and Healthy Weight where every child grows up with a healthy weight, through eating well and enjoying being active. Promoting Healthier Food Choices where individuals and families will have a good understanding of diet and be able to make informed healthy food choices. Building Physical Activity into Our Lives where individuals and families are able to exercise regularly and stay active and well throughout their lives in environments where exercise and sport is safe and accessible. Creating Incentives for Better Health where all employers value and support their employees health and wellbeing. Personalised Advice and Support where individuals have easy access to personalised advice and support regarding their diet, weight and physical activity to inform and encourage healthy lifestyle choices. Additionally, where individuals have identified obesity issues they can access personalised support services tailored to their needs, leading to maintenance of a healthy weight. 53

54 What is the need in the East Riding of Yorkshire? Breastfeeding The Health Profiles produced by the Association of Public Health Observatories and Department of Health (2009) indicate that that the percentage of mothers in the East Riding of Yorkshire who initiated breastfeeding in 2007/08 was 68.9%. This is significantly below the England average of 71.0%. Vital signs monitoring at Q1 2009/10 show that of the 144 PCTs whose data quality was adequate for inclusion, the East Riding of Yorkshire ranked 96 th, putting just in the bottom third of PCTs. Regional data provided as part of the Breastfeeding Performance Summary show that whilst most PCTs have improved their initiation rates, the East Riding s has, if anything, declined slightly. However, in terms of the proportion of babies being either exclusively or partially breast fed at 6 to 8 weeks of age, the East Riding of Yorkshire fares rather better, with 45.1% of babies being given some breast milk (Yorkshire and Humber 42.9%, England 50.5%). Of the 91 PCTs whose data quality was adequate for inclusion, East Riding of Yorkshire ranked 39 th. Childhood obesity the National Child Measurement Programme weighs and measures children at Reception and Year 6. Table indicates East Riding prevalence for 2008/09. The LAA and Vital Signs have a target of 0.2% reduction year on year in childhood obesity. Table 3.1.1: Childhood Obesity Prevalence Prevalence of obesity Reception 10.2% 95% Year % 87.5% Number measured (% measured) Adult obesity using modelled data from the Health Survey for England (HSE) it is estimated that 24.8% of the adult population is obese in the East Riding. This compares poorly with the all England average of 21.8%. Healthy eating adults using modelled data from the HSE it is estimated that 23.3% of the population are accessing a healthy diet incorporating five portions of fruit and vegetables a day. This is just below the all England average of 23.8%. Physically active children using the annual survey carried out by the School Sports Partnership in 2006/07 90% of 5-16 year olds engaged in two hours a week or more of high quality PE and school sport. This exceeds the DCSF target of 85%. Physically active adults using the Sport England Active People's Survey in 2005/06 23% of the East Riding population take part regularly in sport and active recreation. This is above the national 54

55 average of 21%. Further analysis of the data indicates that 49.3% of the population are inactive as opposed to the national average of 50.6%. The 2007 local Household Survey found that respondents priorities for increasing physical activity were better footpaths, increased cycle paths, safer roads and better quality parks. ***Update for 2009 The Headline report of the 2009 Lifestyle Survey, contains up to date data on obesity prevalence by agegroup and deprivation band. Similar data on diet and exercise are also included. Below is an extract from the headline report in the areas that relate to obesity and diet. Further analysis is available from the Public Health Directorate. Extract from Lifestyle survey report. Obesity We looked at levels of obesity amongst our sample. Overall 19.9 percent of the sample were obese and 59.6% of the sample were either overweight or obese. For men the figures were 20.1 and 66.1 and for women the respective figures were 19.7 and When the sample was weighted to take account of response rates from different agegroups sexes and deprivation bands, 19.1% of the total sample were obese and 56.3% were either overweight or obese. For men these figures were 19.2% and 63.2% and for women 19.1 and 49.6%. The complete unweighted breakdown by gender and ageband is given in Table 11. The proportion of people classified as obese rises steadily with age, but falls in the oldest agegroup and obesity is generally more prevalent in females. 55

56 Table 11. Classification of Body Mass Index by age band and gender Age Band Gender Total Male Underweight Count Normal Weight % 13.1% 2.4%.7%.4% 2.1% 1.3% Count % 70.2% 49.2% 27.5% 27.9% 45.5% 32.6% Overweight Count % 14.3% 39.4% 47.5% 50.3% 42.1% 46.0% Obese Count % 2.4% 9.1% 24.3% 21.4% 10.3% 20.1% Total Count % 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% Female Underweight Count Normal Weight % 10.2% 3.6% 1.1% 1.6% 8.4% 2.4% Count % 68.0% 61.7% 44.0% 37.5% 50.7% 45.9% Overweight Count % 17.2% 18.5% 33.3% 37.8% 31.8% 32.0% Obese Count % 4.7% 16.1% 21.5% 23.0% 9.1% 19.7% Total Count % 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% We analysed the data by deprivation band and gender to show the proportions who were obese (Chart 3) or overweight or obese (Chart 4). Chart 3 shows a slight trend in obesity across deprivation bands with obesity being more prevalent in the more deprived agegroups. Chart 4 shows a very similar pattern. There is a tendency for a higher proportion of women than men who are overweight or obese in the more deprived categories, which is not reflected in the less deprived bands. 56

57 Chart 3 Proportion obese by gender and deprivation band 50.0% 45.0% 40.0% Proportion Obese 35.0% 30.0% 25.0% 20.0% 15.0% 10.0% 5.0% 0.0% Band 1 Band 2 Band 3 Band 4 Band 5 Male 20.7% 22.8% 21.7% 17.2% 17.6% Female 23.4% 23.9% 20.6% 16.3% 15.9% Deprivation Band (1 is most deprived) Male Female Chart 4 Proportion overweight or obese by gender and deprivation band 50.0% Proportion overweigh or obese 45.0% 40.0% 35.0% 30.0% 25.0% 20.0% 15.0% 10.0% 5.0% 0.0% Band 1 Band 2 Band 3 Band 4 Band 5 Male 37.0% 42.6% 46.4% 35.6% 38.4% Female 40.3% 46.4% 41.4% 34.3% 37.6% Deprivation Band (1 is most deprived) Male Female 57

58 Diet We included several questions on dietary choices and have chosen to comment here in just 2 areas i.e. 5-a-day and food labelling. As regards eating fruit and vegetables overall only 23.7% of people (19.9% of men and 26.6% of women) reported that they ate 5 or more portions a day. However 2.5% of our sample 3.6% of men and 1.6% of women) stated that they ate no fruit or vegetables whatsoever. Overall 69.0% ate at least 3 portions. Weighting the data did not markedly affect these figures. The weighted analysis showed that 22.3 percent of the total sample (18.9% of men and 25.7% of women) ate five or more portions per day with 2.9% eating none (4.2% of men and 1.7% of women). Of the whole sample 66.9% ate at least 3 portions. We looked to analyse consumption by gender and agegroup but because of small numbers in many cells, chose to comment on those respondents who stated that they ate 3 or more, or 5 or more portions per day. The results are shown in Table 12. Table 12: Consumption of 3 or more portions of fruit and vegetables Three or more Five or more Age band Males Females Males Females % 55.2% 12.5% 11.2% % 65.4% 16.0% 16.2% % 78.0% 19.4% 30.5% % 78.9% 24.7% 29.1% % 63.4% 13.8% 17.3% Total 61.8% 74.6% 19.9% 26.6% At all agegroups women were more likely than men to consume 3 or more portions and this seemed generally true of 5 or more. Consumption rose steadily with age until all but the oldest agegroup. We looked at the effects of deprivation on consumption. Again there were small numbers of respondents in a number of cells, especially where respondents stated that they consumed no fruit or vegetables. We therefore chose to present data on those respondents who stated that they consume 3 or more or 5 or more portions. Chart 5 shows these data and demonstrates a fairly clear gradient across deprivation bands. 58

59 Chart 5: Fruit and vegetable consumption by deprivation band 80.0% 70.0% Proportion of sample 60.0% 50.0% 40.0% 30.0% 20.0% 10.0%.0% Band 1 Band 2 Band 3 Band 4 Band 5 Three or more 48.9% 59.0% 67.8% 54.6% 69.6% Five or more 15.3% 19.5% 21.1% 19.2% 24.9% Deprivation Band (one is most deprived) Three or more Five or more Given the recent emphasis on food labelling, we were keen to discover the extent to which people read and act upon nutritional labels. Table 13 shows the responses to the question around how often people read the nutritional information on prepared foods (e.g. ready meals). A high proportion of people (68.4%) responded that they read the labels at least sometimes, with 18.8% responding that they always read the label. There was a small proportion who did not consider this question to be applicable to them, possibly because they are not the main shopper for their household or they don t buy prepared food. Table 13: Do you look at nutritional information? Count Percent always % quite often % sometimes % never % not applicable % Total % We excluded the people who responded not applicable to the above question from subsequent analysis. 59

60 We looked at who is most likely to read the labels, by gender and agegroup. Of the men in our sample 69.2% read the labels at least sometimes and 16.2% stated that they always read the labels. The comparable figures for women were 83.4% and 25.0% respectively. The proportion of people who stated that they never read the labels declined across the agebands for all but the oldest agegroup Table 14. Do you look at nutritional information? Age and gender Food label quite Gender always often sometimes never Total Male Count % 12.7% 10.1% 27.8% 49.4% 100.0% Count % 12.7% 11.4% 33.3% 42.6% 100.0% Count % 15.2% 18.5% 36.1% 30.3% 100.0% Count % 19.3% 15.9% 38.1% 26.7% 100.0% 80+ Count % 16.2% 20.3% 37.1% 26.4% 100.0% Total Count % 16.1% 16.9% 36.2% 30.8% 100.0% Female Count % 13.3% 19.3% 44.4% 23.0% 100.0% Count % 18.4% 24.7% 36.2% 20.7% 100.0% Count % 27.3% 23.0% 35.2% 14.5% 100.0% Count % 25.4% 24.6% 34.2% 15.7% 100.0% 80+ Count % 24.9% 17.4% 34.4% 23.3% 100.0% Total Count % 25.0% 23.0% 35.4% 16.6% 100.0% We also looked at these data by deprivation band. Perhaps unsurprisingly there is a clear trend for both men and women across deprivation bands with the least deprived bands being most likely to read food labels. Of the men in our sample 62.5% in the most deprived band stated that they read the labels at least sometimes compared with 69.2 in the least deprived bands. For women the comparable figures were 76.2% and 88.2%. 60

61 Table 15. Do you look at nutritional information? Deprivation band Food label quite Gender always often sometimes never Total Male Band 1 Count (Most Deprived) % 14.0% 14.7% 33.8% 37.5% 100.0% Band 2 Count % 16.5% 13.8% 35.7% 34.0% 100.0% Band 3 Count % 17.3% 18.2% 36.7% 27.7% 100.0% Band 4 Count % 15.3% 16.2% 39.9% 28.7% 100.0% Band 5 Count (Least Deprived) % 17.0% 21.2% 34.9% 26.9% 100.0% Total Count % 16.1% 16.9% 36.2% 30.8% 100.0% Female Band 1 Count (Most % Deprived) 21.0% 19.5% 35.7% 23.8% 100.0% Band 2 Count % 22.6% 22.7% 37.6% 17.1% 100.0% Band 3 Count % 25.4% 21.8% 34.9% 17.9% 100.0% Band 4 Count % 28.8% 25.0% 33.9% 12.3% 100.0% Band 5 Count (Least Deprived) % 27.7% 25.8% 34.7% 11.8% 100.0% Total Count % 25.0% 23.0% 35.4% 16.6% 100.0% We were keen to know whether, of those people who read the label, they make decisions to purchase according to the information given. We asked whether people had either not bought a product, or chosen an alternative product because of its nutritional content. We analysed the responses of those people who read food labels accordingly. The results are shown in Table 16 below. Table 16. Food labelling and food choices Food Total % who %Male %Female constituent respondents changed choice Calories % 58.7% 78.9% Fat % 82.8% 89.7% Salt/sodium % 67.4% 71.7% Sugar % 65.8% 75.3% Artificial additives % 63.1% 71.1% 61

62 The Table shows that a high proportion of people who read food labels have used them to inform purchase choices. Women are more likely than men to use food labels in this way. Men seemed more concerned about fat content than other constituents, whereas women were concerned about all the constituents but especially fat and calories. What services are currently provided? Across the East Riding these include: ERYC Food Services Team. Food labelling and nutritional information awareness Promotion of healthy eating through the Heartbeat Award Scheme Implementation of the new nutritional standards for school meals Community involvement awareness raising of nutritional issues to specific groups Sports Development Healthy Living Programme which includes Healthy Lifestyles weight management programme, Walking the Way to Health Scheme,, Buggy burning walks for parents/carers, GP exercise on referral scheme, Heartlink Cardiac Rehab, Exercise in water, Swim for Health and 50. School active travel plans Brid Kids obesity programme (Due to end August 2008) Health Trainers Primary Care advice and support from GPs, school nurses and Health Visitors. Breastfeeding Friendly Award Scheme and breastfeeding peer support groups National Healthy Schools Programme (NHSP) and PHSE activity Council support of youth and adult sports development Provision of leisure and sports centres Discounted membership costs for LA & PCT employees using Sure Card Community dietetic specialist support including care pathway development Detailed implementation of strategies including the Local Obesity Strategy, Sport and Active Recreation Strategy, Public Health Strategy and Breastfeeding Strategy. What are the targets? Targets relating to obesity, physical activity and nutrition include: Developing LAA NI8 - Adult Participation in Sport. NI53 - Prevalence of breastfeeding at 6-8 weeks from birth. NI56 - Obesity amongst primary school children in Reception Year. NI56 - Obesity amongst primary school children in Year 6. NI57 - Children and Young People's participation in high quality PE and Sport. 62

63 Community Plan Children and Young People will have healthier lifestyles and improved access to health and family support services will enjoy life and learning to help them achieve maximum potential - Healthier Communities and Older People Residents participate in affordable recreational, educational and cultural opportunities across the East Riding as part of a healthy lifestyle. The lifestyles of children and young people are healthy and their parents are well informed on how to encourage and enable them to participate in all forms of sport, recreation and cultural opportunities. Current LAA/LPSA2 Targets Up to December 2008 there are still currently a number of health related targets around child and adult obesity in participation in active recreation. What makes an effective service? NICE have produced and are producing a number of Clinical Guidelines and Intervention Guidance, these include: Current CG43 Obesity Clinical Guideline CG9 Eating Disorders Clinical Guideline CG32 Nutrition Support in Adults Clinical Guideline CG37 Routine Postnatal Care of Women and their Babies Clinical Guidance PH1002 Physical Activity Intervention Guidance PH008 Promotion and Creation of Physical Environments to Support Increased Physical Activity Intervention Guidance PH11 Maternal and Child Nutrition PH13 Physical Activity Workplace Health Promotion Developing Guidance on Physical Activity, Play and Sport for Pre-School and School Age Children due January PCT Healthy Workplace Policy due March 2009 Many of our current activities such as the Sports Development Healthy Living Programme show good immediate outcomes for participants, although they have been operating for less than two years, so long term assessment has not proved possible. Similarly, GP Exercise Referral has good initial outcomes but locally little long-term data. All these programmes are supported by CG43 and PH1002. The work of the Health Trainers can be well evidenced for effectiveness when viewed against NICE guidelines. 63

64 The Brid Kids obesity programme adheres to many points of best practice including promotion of physical activity in school settings for example promoting sustainable travel to and from school and this is supported by NHSP and PHSE. The programme has shown some positive results including a slight reduction in obesity levels in the measured cohort (against a national growth trend). It is difficult to assess the impact of the improvement in the nutritional standards in school meals and those of travel plans in the East Riding as neither has been fully implemented. However, both follow positive evidence based effectiveness guidance. The provision of leisure services and school community sports development is seen as a key in the National Obesity Strategy to promote and provide services for the public, as is general awareness raising using specific campaigns, for example the salt reduction campaign Conclusion and Recommendations Service Improvements There are a number of improvements to services which could be made, these include: Expanding current work with children to include pre-school settings and all primary and secondary schools using the Brid Kids model as a basis for interventions. Currently there is no detailed weight management programme similar to Healthy Lifestyles for Children and Young People. Such a programme would offer dedicated support to overweight and obese children and young people and their parents by offering a broad and innovative choice of physical activity for example dance, gardening, trampolining, cycling proficiency, cheer leading, climbing etc along with nutrition messages through growing clubs, box schemes and food co-ops. The Healthy Lifestyles Programme is very effective; however, it is mainly based around physical activity. Service improvement should involve building in more nutritional support and a motivation programme. This would enable a balanced approach to weight management to be adopted with better long-term outcomes for participants. A key area identified in the guidance and strategy was the workplace. Through a partnership approach with groups such as the Chamber of Commerce the development of an East Riding Healthy Workplace/ Employer Award would promote the benefits of physical activity and healthy eating e.g. through the provision of healthy eating canteens, cycle racks, etc. to employers and their staff. The impending ERYPCT Staff Good Health and Well-Being Policy will support this. The effective targeting of interventions with vulnerable groups such as older people, people with learning disabilities and children will be vital and therefore the gathering of data will need to be a priority. More 64

65 resources will therefore be required to gather and interpret this data at a local level. When collected this information must be used to develop opportunities to embed healthy eating and physical activity messages in the public s awareness and increase awareness of healthy lifestyles. Health care professionals must endeavour to work with Council planners and developers to press for the planning, design and delivery of building projects, which maximise the opportunity for exercise, sport and physical activity for example through the development of safe cycle routes Currently there is only limited alignment and adoption of local policies and strategies around obesity, physical activity and nutrition. Both Council and PCT have adopted the East Riding Public Health Strategy but the Council has not adopted either the obesity, breastfeeding or health inequalities strategy. The Council and PCT should work together to jointly redevelop and adopt these core strategies. The GP Exercise Referral Scheme has been showing reducing numbers of previous years. A push should be made to increase referrals to this scheme particularly men and payment of the scheme needs reassessing. One area highlighted in the Sport and Active Recreation Strategy concerns the promotion and availability of family recreation opportunities. In a society, which is time poor, this concept of family opportunity should be examined, evaluated and if successful, supported. Finally, both PCT and Council need to examine and where necessary support sustainable delivery in localities by the third sector, building on local knowledge and enthusiasm. Resources Resources for tackling the obesity issue and promoting physical activity and nutrition lies with a large number of teams. It will be vital that these resources are identified and used to support effective interventions in whichever organisation is delivering them. As the relationship between the Council and PCT matures we must see the pooling of resources and the downstream funding of upstream preventative services. 65

66 3.2 Tobacco Control and Smoking Cessation Why is this important? Smoking is the single greatest cause of preventable ill health and premature death in the UK. It accounts for around 106,000 deaths in the UK every year and costs the NHS around 1.7 billion. Most smokers die from one of the three main diseases associated with smoking; cancer, chronic obstructive lung disease (bronchitis and emphysema) and coronary heart disease. Additionally, there is strong and consistent evidence that passive smoking increases the risk of lung cancer, heart and respiratory disease and exposure in pregnancy lowers birth weight. What specific areas need attention? As well as ensuring that overall smoking rates decline and the number of smoking quitters is maximised, the three key areas for attention are as follows: Smoking cessation among people in poorer areas smoking is a major contributor to health inequalities and is more common in poorer areas Smoking in pregnancy Smoking among younger people What is the need in the East Riding of Yorkshire? In the East Riding of Yorkshire it is estimated that 23% and 25% of adults respectively are regular smokers. However, the 2003 Hull and East Riding lifestyle survey found that the smoking prevalence rates rise to over 30% in areas of deprivation. Approximately 29% of all deaths in the East Riding area are estimated to be attributable to diseases related to smoking. ***Update for 2009 Data from the 2009 lifestyle survey suggests 13.5% of people are current smokers i.e. smoked daily or smoked, but not every day. Men were slightly more likely to smoke than women with 14.5% being smokers as opposed to 12.8% of women. However there was wide variation across electoral wards with the highest smoking rates being found in the most deprived wards e.g. 23.0% of respondents from Bridlington South stated that they were smokers. The relationship between smoking and deprivation (as measured by the index of multiple deprivation) is illustrated in Figure

67 Figure Relationship between smoking prevalence and deprivation in East Yorkshire electoral wards 25% 20% %smokers 15% 10% 5% r 2 = % IMD score Additional data on smoking from the 2009 lifestyle survey is available in a detailed report from the Public Health Directorate. Evidence shows that 80% of people in custody smoke tobacco, many of whom would like to quit despite the constraints of the environment. The Hull and East Riding lifestyle survey of young people in 2002 found that 21% of girls and 7% of boys aged 15 years reported themselves as regular smokers. The percentage of women smoking during their pregnancy in the East Riding during 2007/2008 was 14.7%, with a national average standing at 16.6%. The local target for this period was 12.03%. What services are currently provided? HALT: An alliance of statutory and non-statutory agencies across Hull and the East Riding of Yorkshire working together to achieve a smoke-free Hull and East Riding. Specialist Smoking Cessation Service: A dedicated team of smoking cessation specialists providing group and individual support in over 20 community based venues in a variety of settings including hospitals, workplaces, prisons, etc. An NRT voucher scheme is operated for clients registered with an East Riding GP. This specialist service is complemented by a support network of trained health professionals who can provide individual stop smoking support as part of their regular work programme. 67

68 Training and support for health and non-health professionals to raise the issue of smoking and/or provide stop smoking support is facilitated. Marketing and service promotion is undertaken utilising a variety of media and resources. An annual allocation of 273,500 was received from East Riding PCT to fund service provision in 2007/2008. During the period 01/04/2007 to 31/12/ smokers set a quit date and 941 quit (quit rate 68%). Smoking in pregnancy: Pregnant smokers are currently fast-tracked and offered an appointment within one week of contacting the service. Stop smoking support for their partners and significant others (i.e. close family members) is also available. Other services: Through HALT the service works in conjunction with Trading Standards, Customs and Excise, Environmental Health, Education, Fire Service etc to raise awareness of tobacco related issues and reduce smoking prevalence. What are the targets? NHS Stop Smoking Services are part of a programme of action needed to meet the national target to tackle the underlying determinants of ill health and health inequalities by reducing smoking rates to 21% or less by 2010 with a reduction in routine and manual groups to 26% or less. A target of 1586 successful quits at 4-weeks for 2007/2008 had been set in conjunction with the SHA. Performance over that period realised 1208 quits thereby reaching 76% of the required target. The actual quit rate for the period was 67%. The 4-week smoking quitters target for 2008/2009 was set at Monitoring data for 2008/9 show that there were 1607 successful quitters 68% of those who set a quit date. As a minimum, 40% of clients accessing the service should be eligible for free prescriptions based on low income. In addition, a local target relating to smoking and deprivation has been set as part of the East Riding Local Area Agreement. The target is to increase the rate of persons quitting at 4 weeks per 10,000 residents in the most deprived 20% of SOA within the East Riding of Yorkshire by 5% more than the equivalent quit rate in the remaining 80% of SOAs within the East Riding by 2010/11. The gap in rate per 10,000 population is currently 9.9 quitters in favour of the most deprived 20% and the target is to increase this gap further by 5% to that of 10.4% quitters. The national target for reducing the proportion of women smoking during their pregnancy is 15% by In the East Riding, whilst a local target is to be determined, the aim is to build on the performance achieved during 2007/08. 68

69 What makes an effective service? NICE guidance issued in February 2008 sets out the standard for local smoking cessation services and highlights the following action to be taken by PCTs: Determine the prevalence of smoking and the characteristics of the local smoking population. Develop a policy to ensure that effective smoking cessation services are provided as part of the local tobacco control strategy. Set local targets for reducing tobacco use and embed these in partnership arrangements with the local authority (e.g. LAAs). The Specialist Smoking Cessation Service has been established and developed in line with guidance issued by the Department of Health (updated 10/02/2008). This includes: Ensuring that stop smoking services are adequately resourced and able to treat at least 5% of the local smoking population per year. Ensuring that repeat interventions are made available to smokers who have relapsed. Ensuring that stop smoking staff receive on-going support and continuing professional development. Adapting to the availability of new stop smoking medicine (Varenicline/Champix) and configuring services appropriately. Ensuring that local service promotion makes full and effective use of national branding and social marketing principles. Focusing on specific groups (routine and manual, pregnant smokers, BME and vulnerable groups) while retaining an appropriate balance of resources and interventions for the general population of smokers. Reflecting the key role of primary care in the provision of stop smoking services and the importance of partnership arrangements with pharmacies and other allied health professionals. Engaging with the acute sector to provide stop smoking services to preoperative and inpatient smokers. Adopting and adhering to revised data collection methodology. Ensuring that all treatment models conform to approved quality principles. Conclusions and Recommendations Since its launch in November 1999 the service has provided mainly specialist support on a group and one to one basis. Recent developments have included the provision of Whistle Stop sessions at Bridlington and Goole. Whilst the service had excellent quit rates, performance has recently not met targets and overall improvement is needed. In addition, the following steps need to be taken to increase uptake, particularly amongst routine and manual groups and pregnant women: 69

70 A limited service to inpatients at Castle Hill Hospital has been established with weekly ward visits, but this could be developed to provide a more robust service for patients and staff and make a significant contribution to the numbers of smokers who access the service. Opportunities to further develop links with communities, and community groups, would raise awareness of the service and provide additional opportunities to support smokers to quit. The development of resources to target workplaces, particularly those employing routine and manual workers, would enhance service provision and increase service throughput. GPs and other healthcare professionals have a significant role to play in identifying smokers and referring them for support to quit smoking. Opportunities to work more closely with GP practices should be pursed to increase their awareness of the service and maximise referrals. Home visits for pregnant women are a more intensive use of resources which would require additional funding. Piloting this development of the service in specific areas, e.g. Goole, Bridlington, would be a useful exercise. The use of focus groups to influence service development, provision and resources, particularly amongst routine and manual groups. Further development of the Specialist Smoking Cessation Service in relation to the marketing of the service to clients to increase the volumes of quitters entering the service and overall performance management arrangements including responsiveness to changes in service need and demand. A focus on improving the quit rate within the 20% most deprived areas of the East Riding. 3.3 Alcohol and Substance Use Why is this Important? Problem drug use and harmful alcohol use are public health and social issues which have a significant impact on society as a whole, but disproportionately affect the most deprived communities and the most vulnerable individuals. Around a third of acquisitive crime is believed to be undertaken to fund a drug addiction and alcohol is a factor in around a half of violent crimes. Problem drug use and harmful alcohol use destroy families and contribute to a cycle of deprivation and lost opportunity. The harms are significant, wide-ranging and cost an estimated 15.4 billion for drugs and billion for alcohol. What specific areas need attention? Alcohol Alcohol is the second biggest cause of death in the UK. The national prevalence of Alcohol Use Disorders (AUDs) is 26% of adult populations and 70

71 it has been estimated that 40% of males in hospital wards misuse alcohol. National A&E survey data identifies that 41% of attendances at the weekend are alcohol related. Hospital Episode Statistics (HES) data identified less than 2% of all hospital admissions for Hull & East Riding residents as being related to an AUD. The Alcohol related indicators for East Riding of Yorkshire as published by NWPHO are included within the Needs Assessment undertaken in Drugs Problem drug use and harmful alcohol use are public health and social issues that are exacerbated by deprivation or personal problems experienced by individuals, and a lack of awareness about the risks involved. If not addressed effectively, there are wider consequences for the community in terms of increased crime and anti-social behaviour. Drug use, particularly of the Class A drugs, heroin and cocaine/crack (HCC), is a key driver for crime and offending. What is the Need in the East Riding of Yorkshire? Alcohol A Needs Assessment was undertaken in 2007 which offers a baseline for Alcohol use in the East Riding. 38% of men and 16% of women (age 16 64) have an alcohol use disorder (26% overall), which is equivalent to approximately 8.2 million people in England. Nationally, there are 21% of men and 9% of women who are binge drinkers and considerable overlap between drinking above sensible daily benchmarks and sensible weekly benchmarks for both men and women. The prevalence of alcohol dependence overall was 3.6%, with 6% of men and 2% of women meeting these criteria nationally. This equates to 1.1 million people with alcohol dependence nationally. There is considerable regional variation in the levels of alcohol related need. The prevalence of hazardous/harmful drinking varied across regions from 18% to 29%, whilst alcohol dependence varied between regions ranging from 1.6% to 5.2%. It was identified that Yorkshire and Humber region had significantly different levels of need compared to other regions in England. Yorkshire and Humber rates for hazardous/harmful drinking revealed a rate of 25.8% compared to that for England which 22.6%. Alcohol dependence identified a rate of 5.2%, the highest in the country along with the North West region. ***Update for 2009 As part of our 2009 lifestyle survey, we asked a series of questions about alcohol use. The overall prevalence of alcohol use (defined as having drunk alcohol in the last 7 days) was 69.9%. Weighting the analysis as to take into account response rates from different age, gender and deprivation groups made only a little difference, inflating the prevalence to 70.8%. The proportion of men and women who responded that they had drunk alcohol in the last 7 days was rather different at 76.7% and 64.4% respectively (weighted results 71

72 76.8% and 64.4%).Of the year olds who answered this question 53.8% of young men and 50.8% of young women reported having drunk alcohol. The age/gender breakdown is shown in Table 3.3.1, which shows the proportion of men and women in each agegroup who reported having drunk alcohol within the last 7 days Table : Breakdown of respondents who drank alcohol within the last 7 days. Age band Males Females % 50.8% % 63.6% % 71.2% % 57.8% % 42.2% Total 76.7% 64.4% At all agegroups, a higher proportion of men than women reported having drunk alcohol. For both genders the pattern of alcohol consumption by agegroup was similar with consumption increasing across the first 3 groups but declining subsequently. The prevalence of alcohol consumption varied between men and women and by deprivation band, with the least deprived groups being more likely to have consumed alcohol in the last 7 days. This relationship is illustrated in Chart Chart Prevalence of alcohol use (within last 7 days) by deprivation band. 90.0% Prevalence of alcohol consumption 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0%.0% Band 1 Band 2 Band 3 Band 4 Band 5 males 70.3% 73.6% 77.6% 78.8% 82.2% females 56.1% 62.3% 67% 59.2% 73.8% males females More analysis of alcohol use is available from the Lifestyle Survey Headline report, which can be obtained from the Public Health Directorate. 72

73 Additionally as a result of our recent acquisition of the Dr Foster Population Health Module we are now able to segment our population according to the Mosaic classification. We have shown that within the East Riding, hospital admissions for alcohol related harm are lower than both the regional & national averages. Alcohol related hospital admissions were highest amongst: People who are struggling to achieve rewards and are mostly reliant on the council for accommodation and benefits (Group F) Elderly people subsisting on meagre incomes in council accommodation (Group I) Families on lower incomes who often live in large council estates where there is little owner-occupation (Group G) People who though not well-educated are practical and enterprising and may well have exercised their right to buy. (Group H) Chart 3.3.2: Rate per 1,000 population of alcohol-related admissions by Mosaic Groups Mosaic Groups East Riding Average A B C D E F G H I J K Drugs Local From the evidence shown above, the best estimate of the prevalence of PDU s in the East Riding is 1058 and national estimates % are men and 30% are women. 58% of those in treatment and 56% of the total known to treatment are in the age group. This is in line with regional statistics. The East Riding has a higher than average number of younger users in treatment, at 16% of the treatment population compared with 12% nationally, and a lower number of 24 Source: Dr Foster Population Health Manager Module 73

74 older service users with only 26% of service users being older than 34 years (national rate = 42%). The retention rate for younger users is also higher than the national figure. The East Riding has an ageing population with 74% of the adult population being aged between 34 and 65 years. DIP services have the highest proportion of younger clients in the East Riding. What services are currently provided? Alcohol - Services The total Alcohol funding for the East Riding for 2007/2008 was 780,509. A range of services are commissioned: Alcohol Project Community Drug and Alcohol Teams including additional detoxification in 2008/2009 Open access services (joint for Drugs and Alcohol) Brief Interventions in primary care settings, other NHS settings and non NHS settings East Riding Young People s Substance Misuse Treatment Service Drugs Services The total funding of drug treatment in 2008/9 is estimated at 2.4m. Drug Treatment and support services for drug users in the East Riding, are provided by Compass, East Riding Partnership (Humber Mental Health Teaching Trust and the Alcohol and Drug Service), CDP (Challenging Dependency), Hull PCT and East Riding of Yorkshire Council. A range of services are commissioned in line with Models of Care approach: Criminal Justice Service In Patient Services Community Drug and Alcohol Teams Open access services (joint for Drugs and Alcohol) Compass Arrest Referral Through Care and Aftercare Bridlington Day Programme Compass CJ prescribing Clinic Shared Care Pharmacy Supervised Consumption Intensive Daily Treatment Service East Riding Young People s Substance Misuse Treatment Service Integrated Drug Treatment Service within the local prisons 74

75 What are the targets? Drug treatment services are monitored by the National Drug Treatment Monitoring System (NDTMS). NDTMS data is publicly available via the following website Alcohol performance will be monitored on NTAMS in Alcohol related hospital admission information is available. Joint commissioning services are monitored locally quarterly. Monitoring of safe communities issues and alcohol related crime is through Safer and Stronger Communities action group Targets and performance indicators The number of drug users recorded as being in effective treatment The number of alcohol-related hospital admissions The rate of drug-related offending The percentage of the public who perceive drug use or dealing/ drunk and rowdy behaviour to be a problem in their area NI 40 Drug Users in effective treatment NI 38 Drug-related (Class A) offending rate NI 42 Perceptions of drug use or drug dealing as a problem NI 39 Alcohol-harm related hospital admission rates NI 41 Perceptions of drunk or rowdy behaviour as a problem To reduce recorded crimes for which a link to alcohol is shown What makes an effective service? Evidence-based information is available including: NICE Guidelines Extensive NTA guidance Home Office guidance National Alcohol Strategy Public Sector Agreement (PSA) delivery Agreement 25 National Drug and Alcohol Strategy LDP Targets LAA Targets National Alcohol Strategy Toolkit Conclusion and recommendations The following general and specific recommendations will help to develop and sustain services within the East Riding in the future. Setting up Drug and Alcohol Strategy group Preparation and integration of a 3 5 year drug and alcohol strategy 75

76 Alcohol The key areas that need special attention have been identified through a local needs assessment. It has been identified that the treatment for alcohol problems is costeffective and although alcohol misuse has a high impact on health and social care systems major savings can be made. Material published by the National Treatment Agency for Substance Misuse and the Department of Health provide information on the effectiveness and commissioning of alcohol treatment services, which should be considered in arriving at appropriate integrated care pathways. Models of Care for Alcohol Mis-users identifies that a local system of alcohol misuse screening and brief intervention, assessment and treatment is commissioned to meet the needs of the local population; ensuring there is access to all tiers of intervention. To ensure resources are maximised a review current provision to ensure the interventions meet the evidence base for screening, brief interventions and treatment. This should include the provision provided throughout the care system (involving the criminal justice system, mental health services, maternity services, general medical services, care management and social housing). Commissioners and stakeholders will need to consider the impact of developing screening and brief interventions on the whole treatment system when developing ATPs. The development of an integrated alcohol treatment system and the means by which expertise, resources and treatment capacity can be maximised. Seek agreement with commissioners to provide alcohol interventions through community alcohol detoxification and alcohol withdrawal programmes on Hull sites. Combine budgets and resources across partners. Review approaches to binge drinking including the implementation of more No Alcohol Zones. Link education about alcohol make it holistic by also dealing with obesity, smoking, etc. Review the capability and capacity of agencies to provide alternative pastimes / diversions. Drugs The key areas that need special attention have been identified through a local needs assessment and national guidance. Identification of the number of drug users in effective treatment. Implementation of strategies to aid the reduction of drug-related offending. Consideration of strategies to provide a safer community leading to better social behaviour within the area. 76

77 Public health campaigns and education to raise awareness of the harms associated with alcohol and drug use and sources of support. A focus on supporting the most at risk families who are experiencing multiple problems, where parental substance misuse is often a key factor. helping people who use illegal drugs to live healthier lives by providing information and advice and for those that need it, treatment and support in re-establishing their lives, including the identification and referral of drug misusing offenders to treatment in prison and in the community. Tackling crime and the key drivers of offending, reducing the disorder and anti-social behaviour associated with alcohol and drugs and tackling the supply of drugs. Link education about drugs make it holistic by also dealing with obesity, smoking, etc. References Understanding Alcohol Misuse Needs in Hull and the East Riding, by Tom Phillips, Nurse Consultant (Addictions) Humber Mental Health Teaching Trust and Sarah Jenkins, Public Health, Hull Teaching PCT, Hull PCT 2008 Needs Assessment for Adult Drug Treatment 2007, Fiona Conyers, East Riding Safe Communities Safe. Sensible. Social: the next steps in the alcohol strategy, Home Office, 2007 Safe. Sensible. Social: Strategy implementation toolkit, Home Office, January 2008 PSA Delivery Agreement 25: reducing the harm caused by drugs and alcohol. HM Treasury October 2007 Drug Misuse and Dependence: UK Guidelines on Clinical Management. London: Department of Health (England),2007 [The Orange book]. Methadone and buprenorphine in the management of opiod dependence. NICE Technology Appraisal 114, National Institute of Clinical Excellence Sexual Health Why is it important? Tackling sexual health issues and reducing rates of unwanted teenage pregnancies are a key public health issue to be addressed. There are increasing levels of sexually transmitted infections (STIs) and England has one of the worst rates of teenage pregnancy in the western world. There are strong links with unintended pregnancies/poor sexual health and experiencing poverty and social exclusion. Family members, friends and society as a whole are affected. Reversing the current increasing trends will assist in improving individual and population health. Monies that would have been spent on treating sexual health related illness could be re-directed elsewhere within the NHS and in community service provision. What specific areas need attention? Teenage pregnancy can sometimes be seen as a positive choice for some young people, however, evidence suggests that most very young parents 77

78 experience disadvantage linked with education attainment, poverty and health. Children of young parents are more at risk of having poorer health outcomes (e.g. lower birth weight and higher risk of infant mortality) and are likely to experience disadvantage through their lives. Quick access to Genito-Urinary Medicine (GUM) clinics is critical, effective and efficient access helps to increase treatment options for those who may need to attend GUM clinics; a 48 hours access target has been set. What is the need in the East Riding of Yorkshire? Teenage pregnancy is monitored using 2 performance measures; under 18 and under 16 conception rates. Rates per 1000 female population aged and rates per 1000 female population aged are used respectively. In 1998 the East Riding rate for under 18s conceptions were 34.7 compared with 46.6 for England. Teenage pregnancy in the East Riding has always been well below the England average reaching a low of 29.1 for under 18s in However, recent years has seen an increase in rates with latest figures for 2006 showing at 32.4 for under 18s. More detailed statistics can be found at: In common with national evidence, local areas of high social deprivation also have issues around poor sexual health. For example, though teenage pregnancy across the East Riding is lower than the national average (but rising) Bridlington South, Central and the Old Town along with Tranby, SE Holderness and Goole all have higher than national rates for teenage pregnancy with Goole being in the top 20% nationally. A recent review of termination of pregnancy statistics for Hull and the East Riding also seem to indicate that family planning services are failing to meet the needs of local people, as there has been a significant increase (of 10%) in the number of terminations undertaken by our local service provider. The number/percentage of women undergoing NHS funded terminations prior to 10 weeks gestation is almost half the national target, again due to increase in demand for the service, coupled with staffing problems within our local provider. The demand for emergency contraception also continues to rise. In 2007 there were 537 NHS funded terminations covering all ages within the East Riding GP registered population. In relation to sexual health, there has been an increase in 177% in the amount of Chlamydia diagnosed within the age range in women across the East Riding. In Hull and the East Riding the cumulative number of reported HIV/AIDS cases in 2006 was 175 (112 males, 63 females). In 2000 this figure was 22 (18 males, 4 females). A total of 20 new cases of HIV/AIDS were reported locally in These comprised 16 resident in Hull and the East Riding (10 males, 6 females), and 4 out of the area (3 males, 1 female). In Hull and East 78

79 Riding the mean age of reported HIV/AIDS cases was 41 (males) and 36 (females), with the age range being (males) (females). The percentage of GUM clinic patients seen within the 48 hours target is monitored on a quarterly basis. The latest data available shows that the East Riding of Yorkshire is not performing well when compared to regional and England averages. (ERY = 42%, Y&H = 60%, Eng. = 72% for Aug-07). See the HPA Y&H, Local Sexual Health Profile, Dec 07 for more details. What services are currently provided? Sexual and Relationship Education (SRE): Is conducted in most schools with a view to increasing awareness and the need to practice safe sex. A key focus is on relationship building between partners. Secondary schools enhanced drop-in: Young people can receive confidential advice on sexual health related issues. Information can be given on the use of condoms, long acting reversible contraception or other ways of preventing unwanted pregnancies. Emergency hormonal contraception (EHC): Available at some pharmacies around the East Riding if required. Review of local NHS GUM service provision: identifies a reasonable level of service and support, delivered via a hub and spoke method. Conifer House, as the hub, provides care for patients who require STI screening, testing and treatment from 8am to 6.30 pm Monday to Friday (except Thursday am). The Conifer House GUM services also offer basic family planning support and signposting to complex family planning services. GUM care is also provided at three outreach services within the East Riding (Cottingham, Goole and Bridlington). School Nurses and Health Visitors working across the East Riding also provide a basic level of sexual health advice and Chlamydia screening in some high schools. Long Acting Reversible Contraception (LARC): offered as an alternative to condom use or taking the pill, and thus help reduce the rate of unwanted pregnancies. Voluntary sector: several excellent services are provided, for example the Cornerhouse provides outreach, street based services in both Hull and the East Riding. Chlamydia testing kits: readily available, clients can receive results in a variety of ways to suit different preferences and treatment (if necessary) confidentially. In the agegroup, 13% have been screened for Chlamydia. East Riding performance remains on or above target. 79

80 What are the Targets? A principal target is to reduce the rate of teenage conceptions by 45% from a baseline figure set in 1998 as part of the national target to reduce teenage conceptions by 50%. Targets have been set at 19.1 conceptions per 1000 female population aged by 2010 in the East Riding. The target forms part of the Local Area Agreement and NHS Vital Signs. Figure suggests that meeting the target will be a considerable challenge. Figure 3.4.1: Teenage Pregnancy - Projected Trend and Target Conception rate per 1000 females aged 15 to 17 Years 70 England & Wales Rate per 1000 females aged 15 to 17 years East Riding of Yorkshire UA Target Trend forecast Year The second principal target is the percentage of GUM clinic patients seen within the 48 hours target. The third target is for the percentage of the population aged screened or tested for chlamydia to reach at least 20% by The target is part of the NHS Vital Signs. What makes an effective service? NICE provide national guidance on how services should be provided and include; Preventing sexually transmitted infection and reducing under 18 conceptions and Personal, social and health education focussing on sexual health and alcohol. The guidance provides a series of recommendations that, if followed, should improve service provision and outcomes. The delivery of sexual health related services should not be the responsibility of one agency alone. Integrated services involving PCT, local authority, schools, voluntary and community sector resources should be established to improve delivery and related outcomes. Easy and rapid access as close as possible to the point of need is necessary. Enhanced health drop-in clinics at secondary schools, which include sexual health related advice and treatment, will improve access for secondary school age children. 80

81 Conclusion and recommendations The incidence and prevalence of sexual health related illnesses is increasing. Teenage pregnancy rates, though well below the England average, are not reducing in line with projected targets. Recommendations: Use health needs assessment and mapping to clearly understand the sexual health needs of the local population. Service provision should be informed using national guidance where available and replicate examples of best practice. Identified service need should be integrated and resourced between all stakeholder agencies. However a review of existing services does appear to identify a lack of out of hour s provision. There also appears to be a gap in the provision of more specialist services, for example services targeted at the needs of certain minority groups, for example refugees and asylum applicants; economic migrants and members of the lesbian and gay men s population. Again this is of particular concern to the East Riding as the need to meet the need of minority groups such as economic migrants and travellers is raised explicitly in the Public Health Report. The provision of free condoms, as a cost saving initiative, is advocated by the Department of Health. However, though this service is provided for men who have sex with men in some parts of Hull neither Hull or the East Riding currently provides a comprehensive condom distribution scheme. 81

82 3.5 Mental Health Why is this important? As population lives longer, mental wellbeing will become major issue of concern for health and social care. Dementia numbers are projected to increase considerably. The NCHOD has published data for Patients registered with GP practices with a coded diagnosis of dementia on the 14th February 2007 (National Prevalence Day). These data are expressed as a percentage of the total number of registered patients on the 1 st January In the East Riding of Yorkshire there were 1192 patients with a coded diagnosis of dementia, representing 0.38% of total registered patients. This is a lower proportion for that of Yorkshire and the Humber (0.44%) and for England and Wales (0.41%). However the POPPI website contains data that project the proportion of the (over 65) population projected to have dementia in future years. The predictions suggest that whereas in England and Wales the number of dementia patients will rise by 51% by 2025 over the 2008 figure, the rise in the East Riding of Yorkshire is likely to be much higher at 78%. This proportionally larger rise is the result of the projected rise in the elderly population. Mental health is more than the absence of mental illness. Improving mental health relates to the whole population individuals, families, and communities, everyone has mental health needs, whether or not they have a diagnosis of mental illness. There is a clear association between deprivation and mental illness. People living in more deprived areas are more likely to have mental health problems, and people with mental health problems are more likely to move to more deprived areas due to the location of assisted housing and cheap accommodation. What specific areas need attention? 1. Clear agreed multi-agency pathways which meet clinical and care needs that are easy to navigate. 2. Improving access to psychological interventions 3. Social Inclusion Employment for people with a mental illness Supporting the physical health needs of people with severe mental illness Housing Supporting People Programme 4. Suicide Prevention 82

83 What is the need in the East Riding of Yorkshire? The Hull and East Riding Mental Health Equity Audit published in 2007 Sections 7/8 provides information on prevalence, referrals, inpatient hospital admissions and mortality data. It also relates this information to other groups based on age, gender, deprivation, ethnicity to assess if there are potential inequalities present. The majority of the data within the audit has to be estimated based on national prevalence. A national survey which was conducted by Singleton et al assessed the prevalence of mental illness in adults aged 16 to 74 years this information was applied to the local population to provide local estimates of mental illness (please see the table below). (Source the Office for National Statistics ONS, Psychiatric Morbidity among adults living in private households). ***Update for 2009 Amongst respondents to the 2009 lifestyle survey, 24% of people reported that they had experienced feeling down, depressed or hopeless or having little interest or pleasure in doing things at some time. This proportion varied by gender and deprivation status. More detail can be found in the Headline report on the Lifestyle Survey, which is available from the Public Health Directorate. The Mental Illness Needs index (MINI) is a measure of mental illness calculated from local populations based on poverty, unemployment and social isolation and could be used to factor up or down the estimated numbers of residents with mental health problems. This information can be found in the Hull and East Riding Mental Health Equity Audit pages 16/17 and shows that the East Riding has approximately 81% of the anticipated need observed nationally i.e. 19% lower. Table 3.5.1: Prevalence of Mental Health Problems Weekly Weekly prevalence prevalence per in adults of 1000 adults of working age: East working age (ONS 2000) Riding (209,600) Depression 28 5,869 Mixed anxiety and depression 92 19,283 Anxiety disorder 47 9,851 Other neuroses (OCD, Panic 38 7,965 Disorder, phobias) Total of all common conditions ,260 (as these often co-exist) Psychoses

84 Local prevalence in adults based on Incapacity Benefit (IB) and Severe Disablement Allowance (SDA) claimed can be found in the Mental Health Equity Audit page 36; this is also broken down to ward level and shows Howdenshire, SE Holderness and Bridlington South have the highest number of claimants in the East Riding. The Office of National Statistics (ONS) suicide and undetermined injury data can be found in the Mental Health Equity Audit pages 51/53. This shows that within the East Riding figures are high within the previous Yorkshire Wolds and Coast PCT area amongst males aged years compared with England and much higher in the East Riding for males over 65 years. The local suicide audit audited 172 inquests of deaths that have occurred January 2003 December This included 140 males and 32 females the identified at risk groups were males, people with physical health difficulties, relationship issues, a forensic history, those bereaved, those people made redundant and those in debt. The East Riding suicide & injury rate is similar to national average. The East Riding has experienced rates higher than equivalent areas for the last decade. Males have significantly higher suicide rates than females. Table 3.5.2: Suicides Age group Male Female Total Under What services are currently provided? There is a wide range of services for people with mental health problems. Approximately 90% of people with a mental health problem are treated within primary care, either with medication or by a range of talking treatments. More specialist services are provided through Humber Mental Health Teaching NHS Trust or specific independent or voluntary sector providers. Occasionally, individuals with highly complex needs will be treated in specialist units out of area but this is kept to a minimum Overall, our challenge is to move away from a focus on one size fits all care services, and to start to deliver individual care, and to provide treatment which meets both health needs and social care needs. A stepped care approach through well-designed care pathways understood by all partners will lead to more health promotion, greater investment in improved practice-based 84

85 primary care services for needs led services, and investment in more community based care management to deliver truly personalised services. What are the targets? Targets and performance indicators Our East Riding The East Riding Community plan Healthier Communities and older people priority Employers recognise the aspirations and the employability of people with mental health problems, disabilities and older people Proportion of adults in contact with secondary mental health services in settled accommodation (LAA NI 149) Proportion of adults in contact with secondary mental health services in employment (LAA NI 150) Reduce the death rate from suicide by at least 20% by 2010 (DH) with the East Riding baseline of 7.5 per 100,000 population Proportion of people with depression and/or anxiety disorders who are offered psychological therapies Number of therapists funded by CSR trained in Low Intensity and High Intensity psychological therapies Number of people treated in Improving Access to Psychological Therapy services Number of people who enter employment from benefits 34 new cases of psychosis receive service from early intervention teams All patients who need them, to have access to crisis services and crisis resolution home treatment LAA NI 150 also supports the delivery of HR policies, and the PCT Disability Equity Scheme action plan. Also other LAA targets NI Working age people on out of work benefits, NI People falling out of work and on to incapacity benefits, NI people with long-term conditions supported to be independent and in control of their condition Supporting the physical health needs of people with severe mental illness - supports the LAA priorities - Health and social care and other well being services work closely together to improve quality and accessibility. Older and vulnerable people are supported to live independently. Resources are targeted at the most vulnerable residents. Also fits NI People with a long term condition supported to be independent and in control of their condition 85

86 What makes an effective service? There is also significant amount of evidence-based information to guide mental health provision including New Horizons: A shared vision for mental health services A cross government programme of action to improve the mental health and well being of the population and the quality and accessibility of services for people with poor mental health, with a view to reducing risk factors and enabling SHA's to deliver their regional visions for mental health National Service Framework for Mental Health 1999 NICE Guidelines, including management of depression, anxiety, PTSD, Eating Disorder, schizophrenia and bipolar disorder Mental Health Policy Implementation Guidance Practice Guidelines Improving Access to Psychological Therapies (IAPT) Commissioning Toolkit Commissioning guidance Vocational services for people with severe mental health problems: DH and DWP (2006) Commissioning framework Choosing Health: Supporting the physical health needs of people with severe mental illness DH (2006) National Suicide Prevention Strategy for England 2002 Work Recovery and Inclusion: Employment support for people in contact with secondary mental health services Realising Ambitions: Employment support for people with a mental health condition Working our way to better mental health: A framework for action In January 2006, the Sainsbury Centre for Mental Health published its own vision of how mental health services and society s approach to mental health should be by This focuses on mental well-being rather than illness. This vision for 2015 is clearly ambitious and demands clear leadership from the government, but it also offers a goal which local communities can strive to achieve. Employment for people with a mental illness Work is good for mental health and is central to recovery for those with mental health problems. The national long term vision is to radically increase the number of people in contact with secondary mental health services in employment by 2025, and to narrow the gap between their employment rate and that of disabled people generally. There are National commitments to improve the employment chances of people in contact with secondary mental health services. These cover actions to support people to build skills to compete for jobs, actions that 86

87 enable people to get jobs, and actions designed to support employers and employees to keep people in work. The Government will also look at how it can better help more people with mental health conditions that are workless into sustained employment. These will include: increasing capacity and dispelling myths within existing structures so they are better able to meet the needs of people with a mental health condition model of more support : implementing Individual Placement and Support (IPS) in a Great Britain context Establishing effective systems for monitoring outcomes and driving change. In 2009 the Working our way to better mental health: A framework for action was launched this is designed to: Improve well-being at work for everyone, Deliver significantly better employment results for people with mental health conditions, supporting them into work, helping them to stay in work and assisting them to return to work more quickly after sickness absences. A number of resources have been developed and published to support the Mental Health and Employment agenda these can be downloaded from Supporting the physical health needs of people with severe mental illness Based on the commissioning framework Choosing Health: Supporting the physical health needs of people with severe mental illness DH (2006) develop the well being nurse programme within primary care establishment of SMI register, completing physical health checks, undertaking physical health consultations, and supporting people to access healthcare and health promotion services. Also for all the public health key target areas (e.g. obesity, smoking, alcohol, screening programmes etc) to identify people with severe mental illness as a vulnerable group and include actions to tackling health inequalities for this target group. Suicide Prevention Progress the local strategy that was mapped against the S-Kit Suicide Prevention Local Implementation Framework - a toolkit, which includes recommendations for developing and delivering local suicide prevention strategies. The two areas for improvement are identifying champions within specific organisations for consultation and feedback into own agencies, and obtaining 87

88 feedback from agencies on their actions, which contribute to achieving strategy aims and objectives. A number of resources have been developed and published to support the National Suicide Prevention Implementation Strategy; these can be downloaded from Housing Supporting People Programme Provide a range of accommodation options and associated support services aimed at vulnerable people including those with mental health problems at a point of crisis. Conclusion and recommendations The East Riding Mental Health Partnership Board oversees the implementation of the mental health component of the PCT Health Strategy. This identifies areas of priority included below. A socially inclusive, recovery-based model incorporating e.g. developing a range of accommodation options, helping people into and maintaining employment and occupation etc. Compliance with legislation e.g. Mental Health Act (2007), Mental Capacity Act (2005), Deprivation of Liberty orders, Safeguarding Adult agenda etc. A specific focus on those groups of people who are perceived as being hard to reach and not engaged by services. Choice of access and service delivery putting people in control of their plan of care and treatment (Personalisation agenda). Developing an effective, simple and streamlined approach to Care Navigation for individuals to access information and services (Darzi review) and appropriate advocacy services. Improving Access to Psychological Therapies (IAPT) increasing capacity and ensuring delivery of evidence based treatments. Crisis Resolution and effective acute mental health pathways. Treating people locally in relevant settings who have needs/behaviours, which challenge current service provision leading to out of area provision. Clear and effective treatment models for people experiencing specific issues including: eating disorders, supporting women and families around childbirth, personality disorder and co-morbid acute physical illness. Commission preventative services including Improving the physical health care of people with severe and enduring mental health problems by developing the well being nurse programme within primary care. Ensure the needs of people with mental health problems are addressed within tackling health inequalities strategies and programmes Use new and emerging tools to improve data collection Continue to deliver the local suicide prevention strategy. Develop a well-trained, professional and competent workforce to deliver the above 88

89 All of the above recommendations must relate to and be performance managed against a clear set of criteria based on national and local targets. 3.6 Learning Disabilities Learning disability includes the presence of a significantly reduced ability to understand new or complex information, to learn new skills (impaired intelligence) with a reduced ability to cope independently (reduced social functioning) and which started before adulthood, with lasting effect on development (Valuing People 2001) Why is this important In the UK it is estimated that 1.5 million people have a learning disability, 200 babies are born with learning disability every week and 29,000 people with severe learning disability live at home with carers who are over the age of 70. Figure 3.6.1: National Learning disability prevalence Prevalence of severe and profound learning disability is fairly uniformly distributed across the country and across socio-economic groups. Mild to moderate learning disability, however, has a link to poverty and rates are higher in deprived and urban areas. Evidence suggests that the number of people with severe learning disabilities may increase by around 1% per annum for the next 15 years as a result of: - Increased life expectancy, especially amongst people with Down s syndrome - Growing numbers of children and young people with complex and multiple disabilities who now survive into adulthood - A sharp rise in the reported numbers of school age children with autistic spectrum disorders, some of whom will have learning disabilities - Greater prevalence among minority ethnic populations of South Asian origin. 89

90 Information from Valuing People a new strategy for learning disability in the 21 st century 2001 The white paper Valuing People 2001 indicated that people with learning disabilities are amongst the vulnerable and socially excluded in our society. Very few have jobs, live in their own homes or have choice over who cares for them. This needs to change: people with learning disabilities must no longer be marginalised or excluded A recent inquiry into the health needs of people who have learning disability reported that: The health and strength of a society can be measured by how well it cares for its most vulnerable members. For a variety of reasons, including the way society behaves towards them, adults and children with learning disabilities, especially those with severe disability and the most complex needs are some of the most vulnerable members of our society today. They also have significantly worse health than others (Healthcare for all. July 2008) What specific areas need attention? Valuing People was written with four specific principles rights, independence, choice and inclusion. Within these the priorities were around choice and control, supporting carers, housing, fulfilling lives and employment. Local authorities were tasked with setting up Learning Disability Partnership Boards with membership from all organisations involved in providing services to people with learning disability directly or indirectly. The boards also had to include people with learning disability and their carers. In 2008 a review of progress towards Valuing People aims suggests whilst progress has been made in some areas there remain a number of big priorities personalisation s o that people have real choice and control, what people do during the day with a focus on paid work, better health, access to housing (Valuing People NOW consultation 2008). The inquiry into healthcare for people with learning disabilities Healthcare for all makes several recommendations aimed at improving the health of people with learning disabilities and reducing inequalities. This includes annual health checks, support to attend hospital appointments, help to communicate, better information and tighter regulation and inspection. What is the need in East Riding? Demographics indicate that there are about 10,000 people in the East Riding with some form of learning disability. Of these approximately 1400 will have a significant disability which requires support and intervention. The East Riding Learning Disability Partnership Board approved the Commissioning Strategy for Learning Disability services in the East Riding in 2004 and has worked towards the aims in that document. The document was 90

91 informed by the collation of information, the SSI and best value inspections in 2003 and a series of consultations, which identified priorities in the area. Subsequently sub groups have been set up to concentrate on specific areas around employment, transport, housing, health and quality (which includes access to leisure) and transition to adulthood. These are the priority topics in the area. Two areas in the East Riding that have been identified as needing particular attention are dementia among people with Down s syndrome and Autistic Spectrum Disorder. People with Down s Syndrome who also Develop Dementia People who have Downs s syndrome are a significant group amongst people who have severe learning disability. Downs syndrome is the most common cause of developmental; disability and occurs in 1 in live births. Life expectancy of people who have Downs s syndrome has increased dramatically throughout the 20 th century from age 10 at the beginning of the century to 47+ at the end of the century. Downs syndrome is associated with a range of developmental difficulties both motor and cognitive as well as with a number of medical problems including hearing and vision defects, heart abnormalities, leukaemia, thyroid disorders and the development of Alzheimer type dementia in later life. Studies indicate that age related cognitive decline and dementia occur years earlier than in the general population. These studies indicate that a small proportion of people with downs syndrome in their 30s will show signs of dementia. This rises to 10% in their 40s and 40+% in their 50s. Some studies have suggested that this prevalence may be as high as 75% of people with Downs s syndrome over the age of 60. The pattern of cognitive change seen in some people with Down s syndrome who also have Alzheimer s is similar to those observed in the general population who develop Alzheimer s, however in some people with Downs syndrome personality changes precede obvious cognitive changes and there is often the onset of seizures. In people with Down s syndrome the progress of the disease takes around 8 years less time than in the general population. National and local experience would indicate that people with Downs syndrome who also develop dementia are ideally best cared for in their own familiar environment, however the sometimes very quick and significant problems which manifest both medically and behaviourally often make this difficult to achieve. During final stages of the disease when people require total care the need for specialist residential provision will need to be considered. Due to expected physical deterioration it is likely nursing care would be required. The East Riding picture A short study of people with Down s syndrome in the East Riding in 2003 indicated that there were 125 adults with Down s syndrome within adult services generally (approximately 25% of the overall learning disabled population using in house services). 91

92 A repeat survey in 2008 indicated that there are currently approximately 85 people with Down s syndrome using in house services. The age range of these 85 people is Of these 85 people some 26 (30%) are showing signs of dementia with 8 people having confirmed dementia. (Figures subject to final confirmation). A regular Down s Syndrome Dementia clinic has been established with a clear pathway to provide ongoing assessment support and intervention. Local Recommendations To develop and begin to implement a strategy for supporting people who have Down s syndrome and who also develop dementia (DSD) in the East Riding area. This is included as part of the dementia strategy. This strategy to consider - Support for existing services to change to accommodate needs of people DSD - Support to staff to develop skills and expertise with DSD - Different models of respite care to support older parents who may be caring for someone with DSD - Use of specialist nursing provision rather than general nursing provision for end of life care this to take into account the physical age of people with DSD and their existing learning disability. - Links to older peoples NSF, palliative care strategies, the third sector initiatives - Possibilities of development of specialist nurse role. - Clear mapping of need and future pressures Services for Adults with Autistic Spectrum Disorder (ASD) ASD is a lifelong disability that affects the way a person communicates, relates to people and to the world around them.asperger s Syndrome (or high functioning autism ) usually describes those people with ASD who have an average or above average IQ and relatively good spoken language but who also experience significant difficulties with social, occupational and other areas of their life (Powell 2002). People with ASD can have an accompanying learning disability or mental health needs, but not all people do. People with ASD experience three main areas of difficulty known as the triad of impairments. These areas of difficulties are social interaction, social communication and social imagination ( Better Services for People with an ASD 2006) Some people with ASD who need services fall through the gaps created by traditional service boundaries.good local services only exist when local people work well together ( Better services for People with ASD 2006 ) 92

93 Some work has started within the East Riding to build a picture of the total local population of people with ASD. A specialist residential service for people who have learning disabilities and ASD was commissioned and opened in October This has allowed the target of moving people from campus accommodation to be met and has also brought some people placed out of area back into the East Riding. Local Recommendations To continue to build the picture of the local population of people who have an ASD and to work to ensure that local organisations work together to provide a service that can meet their needs of people. We will ensure that individuals with a learning disability have access to the same high quality health care as the rest of the population, through Health Action Planning and the commissioning of a learning disability Local Enhanced Service. By working with our colleagues in the East Riding of Yorkshire Council, we will link into models of person centred planning to promote independence in a holistic form e.g. including accommodation, accessing transport (travel training, liberty wallet). What services are currently provided? The local authority currently provides or commissions a range of long-term residential care and supported living options for people with learning disability as well as respite or short breaks services. Day services have undergone a programme of change and localisation with further plans to ensure that services work on linking individuals into their own communities. An employment service provides support into paid work and a range of sheltered work environments. Specialist domiciliary care and outreach services provide support to people living individually or needing individualised targeted support. Humber Mental Health NHS Teaching trust is commissioned to provide a range of specialist learning disability health services including the Community Teams Learning Disability and an inpatient Assessment and Treatment Unit. Within primary care many practices offer an annual Health Check to people with Learning Disabilities. This is linked to Health Action Plans where a patient has one. What are the targets? National Indicators 145 adults with learning disabilities in settled accommodation - and 146 adults with learning disabilities in employment - have been incorporated into the Local Area Agreement. Specific targets are currently being set. Priority will be given to supporting people with learning disabilities into full and meaningful paid employment and in working to support people with learning disabilities to move into their own accommodation with support as necessary. This will also include consideration of the wishes of people currently living in residential care within or outside of the East Riding. Targets also currently being set around NI130 social care clients receiving self directed support these targets will include people who have learning disability. 93

94 Conclusions The Learning Disability Partnership Board has identified priority areas and is working to improve these areas. Targets are also being set within the wider local area agreement. 3.7 Physical Disability The number of people with complex physical needs is increasing nationally and this is reflected in the East Riding. This section considers wider needs of people with physical and sensory disability. Many of the more specific health service needs are dealt with in other sections of the JSNA or will be covered in future JSNA work. Data from the 2001 census showed that 17.3% of people in the East Riding of Yorkshire reported having a long term limiting illness, this figure was slightly below the England and Wales average of 17.6%. ***Update for 2009 Our recent lifestyle survey asked the same questions as the census. Of the respondents to the survey 21.5% indicated that they had an illness or disability that limited their activities or the work they could do. This rise may be a reflection of the growth in our older population and indeed grossing up the lifestyle survey to the size of our population suggest that we would have around 31,900 people with a LLTI, which is close to the 31,666 predicted by the POPPI system for 2010 Transport There are specific issues that people with a disability encounter in accessing public transport. In recognition of this a sub-group was created in May 2006 the group works across all age and disability focusing on inclusion and integration. The sub group have developed an action plan which has influenced major changes in the Local Authorities transport departments strategic planning. In aiding people s desire and need to travel independently the authority has recently introduced a range of initiatives such as the Liberty Wallet which alerts the transport driver that the person may need assistance. Initial feedback indicates that public transport is being used more widely by this group of people and is increasing their confidence and accessibility to employment and education. Education Embracing diversity is integral to the ethos of the adult education service and is included in the service policy so it also will feature largely in the strategic planning process. The Adult Education Service recognises that the people attending its provision have diverse needs and motivations as well as differing levels of skills, expertise and learning styles. The service seeks to ensure that 94

95 there is equality of opportunity for both staff and learners - this is articulated in the Managing Diversity Strategy. Employment Employment for people with disabilities is important for a number of reasons. Firstly, people who suffer from physical and sensory disabilities not only face their own personal barriers to accessing training and employment due to their disability, but have to try to overcome the employers pre conceptions of what the word disabled really means. For example; someone who has a hearing disability might be classified as disabled but could hold down a job with very little adaptations, but the employer will only hear that the person is disabled and would generally assume the person was a wheel chair user. Second, without the support from specific projects, these people would face a life of benefits and the longer they stay on these benefits, confidence and motivation reduce and their employment opportunities decrease due to a history of long term unemployment. The need for continuous support both pre and post employment is essential as it gives the individual confidence in coming off benefits and trying to go into employment. The Workstep project funded by Job Centre Plus is aimed specifically at people with a disability. In 2007/8 Workstep supported 5 people with paid employment of 16+ hours per week with physical and sensory impairment. Giving people the necessary support, motivation and confidence to show that they have something to offer an employer and that they can contribute something to society and lead a full and useful life. Local organisations should play a major role in the support and employment of people with physical and sensory disabilities and do not just rely on grant funding to achieve this aim. Housing There are significant housing issues with residential care being the only option for many people with complex physical disabilities. Extra care housing has proved particularly successful in providing housing options for those who are dependent on others for physical support. Social care Many people with more complex and/or long term disabilities are living at home and may be supported, through assessment, by the Local Authority Occupational Therapy service over a number of years. Specific areas that need attention are those in which the Local Authority, the NHS and Private Providers are all involved. An example is Moving and Handling where there is a need for commonality and consistency across all services to ensure continuity for the service user. A solution would be for all staff to receive the same training so that discharge from Hospital or prevention 95

96 of admission could be smoother and safer, and equipment used more efficiently. Provision of services in the East Riding of Yorkshire is constrained by its geographical size involving large amounts of time spent on travel for the staff. There is therefore a need to consolidate services where possible and having Demonstration/assessment facilities in the more populated areas would enable people receiving services through the prevention agenda to attend through an appointment system for assessment. A pilot is being run in the Beverley area providing assessment clinics. This along with further development of the Self Assessment approach would free staff to devote time to the service users who have the more profound and complex disabilities. Some particular client groups for example people with rapidly deteriorating neurological conditions such as Motor Neurone Disease may be difficult to serve as getting major adaptations done quickly is problematic and there are few alternatives in some cases. A target that the service has to meet is equipment and Minor adaptations delivered within 7 days of assessment [local indicator PI D54] and acceptable waiting times for assessment for all adults [NI 132]. The service has shown a massive improvement in meeting this target. Figure 3.7.1: Delivery of Equipment and Adaptations D54 - % of items of equipment & adaptations delivered within 7 working days Series1 Proportion per 100, /04 Outturn 2004/05 Outturn 2005/06 Outturn 2006/07 Outturn 2007/08 Outturn Year Services have shown to be most effective when the links with partner agencies is strong and there are shared training and systems. Further development in these areas will lead to greater efficiencies in the service and improvements for the service user. 96

97 Further work needs to be undertaken to address the needs of people with sensory impairment. Rehabilitation and education is something that has been identified as an area it needs to further develop for this group of people and fits with the preventative agenda. 3.8 Long Term Conditions Why is this important? Nationally there are 15.4 million people with a long term condition (LTC) with the numbers expecting to rise due to an aging population and certain lifestyle choices that people make. This is set to rise by 23% over the next 25 years with pockets of the East Riding expected to rise more steeply. It is estimated that 85% of deaths in the UK are from chronic diseases with 36% of all deaths as a result of cardiovascular disease and 7% from chronic respiratory disease (ref. DH). It is imperative that as a health community, NHS and social care services are prepared and responsive to meet the challenges that this presents. Individuals with a LTC need to be given choice of greater support, information and advice which will allow individuals to play a far more active role in managing their own condition in partnership with their clinicians and other professionals. Self care and self management strategies have the potential to alter the way LTCs are managed in the UK. Despite falling death rates for some major conditions e.g. stroke, CHD, the prevalence and impact of long term health conditions projected to increase significantly over next ten years, partly as a result of our growing and aging population. For example, modelled prevalence available from the Association of Public Health Observatories (APHO) suggest that between 2006 and 2020 the prevalence of stroke in the East Riding will rise by around 29% (almost 3000 additional cases). Similarly the prevalences of CHD, COPD and diabetes are also projected to rise. Data available from the POPPI system suggest that the prevalence of Dementia will rise by 78% in the East Riding between 2008 and 2025 ( an additional 3,500 cases). What specific areas need attention? There are a number of high level outcomes which need to be considered when designing and implementing health and social care solutions: 1. People have improved quality of life, health and well-being and are enabled to be more independent 2. People are supported and enable to self care and have an active involvement in decisions about their care and support 3. People have choice and control over their care and support so that services are built around their needs 97

98 4. People can design their care around health and social care services which are integrated, flexible, proactive and responsive to individual needs 5. People are offered health and social care services which are high quality, efficient and sustainable. There are many different long term conditions but there is common ground in the approach to overall management and needs. Chronic obstructive pulmonary disease (COPD) is considered as a specific example to highlight and emphasise the local impact of the condition, the resources available and the associated improvements, which are in development. Many of the issues however are cross cutting themes and solutions relevant to all LTCs. Diabetes is also considered as a specific example, given its high and increasing prevalence and overall health impact. Other long term conditions such as rheumatological conditions and neurological conditions give rise to major health needs both for the individual and across the East Riding. There is not scope to consider other conditions here, but future JSNAs will include additional long term conditions Chronic Obstructive Pulmonary Disease Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality in the UK and internationally. More recently there has been a recognition that evidence based medicine, both pharmacological and non-pharmacological can result in improved outcomes for patients with COPD. Locally, in the East Riding emergency admissions have increased by 14%, and emergency bed days by 10% in This is currently below the national average rate of admission per 100 population, but is on the increase. The key issues to be addressed: An Implementation strategy for adoption of the locally agreed guidelines An agreed integrated care pathway and clinical model of care which delivers pulmonary rehabilitation, primary care based oxygen assessment and patient self management Importance of smoking cessation strategies in preventing the development and progression of the disease What is the need in the East Riding of Yorkshire? Nationally there are 799,772 patients registered in the UK with COPD. The QOF registers (2007/08) indicate that there are 5248 people (1.7% of all persons) diagnosed with COPD in the East Riding. The figure in England is 1.5%. There is however a recognition that there are a number of individuals registered with asthma who are more likely to be suffers of COPD, but have not being diagnosed with the condition for a variety of reasons. APHO estimate that the actual prevalence is more likely to be around 9,000 (3.1% of persons aged 16+). 98

99 COPD is the fourth commonest cause of death in ER with 158 deaths inn 2007 according to data available from NCHOD. Of these deaths 41 were of individuals under the age of 75. COPD is responsible for high levels of hospital stay in the ER (4,220 COPD and bronchiectasis admissions (Apr Mar 2009) and in the UK it is responsible for 1,001,211 days of hospital stay. Within 90 days of an admission, 30% of patients are re-admitted and 15% are dead. Deaths from COPD have remained consistently higher than peer group over the past decade (In 2007 ERoY 23.9 per 100,000, Peer Group 21.5 per 100,000). However the death rate in the East Riding remains lower than the National rate of per 100,000. However, although the rate of deaths from COPD remained relatively static in last 7 years, prevalence in persons aged 16+ is projected to rise from 3.1% in 2008 to 3.3% by 2015, an increase of 1,400 persons. Prevention: 85% of COPD is caused by Smoking and thus there is the potential to reduce prevalence and death rates by avoiding smoking tobacco or exposure to second-hand tobacco smoke. Other lifestyle modifications that can help prevent COPD, or improve function in COPD patients, include: avoiding respiratory irritants/infections, avoiding allergens, good nutrition maintaining proper weight, and exercising. ***update for 2009 Inequalities: Figure shows clear variation in hospital admissions for COPD by level of deprivation, with the admission ratio in the most deprived 20% of LSOAs in East Yorkshire almost double the national average (Threshold) and three times higher than least deprived 20% of ERoY. Additional data to show the variation in COPD admissions across localities and standardised for age/sex and deprivation are shown on Page

100 Figure : Age/Sex/ standardised admission ratio for COPD ( ) (source: Dr Foster Population Health Module) What services are currently provided? The following are available to support patients locally with COPD: GPs and registered practice nurses, some with a respiratory diploma and experience in managing health needs in the community. Knowledge on the skills and availability of services to facilitate screening, diagnosis and treatment is unknown. Community Matrons, Macmillan nurses, physiotherapists, district nurses providing care for COPD patients on their case load Hospital outreach team at CHH provided both supported and early assisted discharge in addition, smoking cessation and 6 weekly follow up services. Acute Trust secondary care delivered on an unplanned and planned basis. ERYPCT currently spends in excess of 1.47 million on non elective spells into secondary care providers, for those admitted with a primary diagnosis of COPD. There is currently no access into pulmonary rehabilitation in the East Riding for patients with COPD and only minimal dietetics support for those with associated food absorption and nutrition issues. 100

101 What are the targets? Reduction in unplanned admissions Reduction in excess bed days Increased access to pulmonary rehabilitation Increased spirometry in primary care (measured annually via QOF) Appropriate and cost effective prescribing costs Quality of life measures (to be determined) No. of just in case drug boxes in patients with COPD Smoking quitters target (LAA NI123) Reduced emergency admissions and improved quality of life. What makes an effective service? An evidence based service would: Demonstrate the implementation of the locally agreed Hull and East Riding guidelines which support the delivery of pharmaceutical and clinical best practice Adhere to NICE guidelines Follow the NSF (shortly to be published) A recent event (March 07) has enabled an independent review together with recommendations for improvement. There are a number of significant shortfalls in the current service which are highlighted in the recommendation section. Conclusions and Recommendations There is an increasing need to provide improved services for patients with COPD as indicated by the increasing number of unplanned admissions and bed days, year on year. There are 2 strands of work which will deliver a commissioning model of care Unscheduled care programme COPD integrated care pathway development to support the implementation of the clinical guidelines Recommendations Allocation of resources on completion of the work, to facilitate delivery of the integrated care pathway, including pulmonary rehabilitation and primary care based services for oxygen assessment. A comprehensive action plan is in development which addresses financial and non financial issues and gaps. The full benefits will not be realised however until the full integrated care model for unscheduled care is implemented; however there will be a significant reduction in the current activity associated with unplanned care, which can be re-invested into new service provision. 101

102 For LTCs in general there are some conditions which have better service provision that others, but in general all require alternative services, with an increased emphasise on self care/management strategies and solutions Diabetes What is it? Diabetes mellitus is a condition in which the amount of glucose (sugar) in the blood is too high because the body cannot use it properly. Glucose comes from the digestion of starchy foods such as bread, rice, potatoes, chapattis, yams and plantain, from sugar and other sweet foods, and from the liver which makes glucose. Insulin is vital for life. It is a hormone produced by the pancreas, that helps the glucose to enter the cells where it is used as fuel by the body. There are two main types of diabetes type 1 & type 2. Type 1 Type 1 diabetes develops if the body is unable to produce any insulin. This type of diabetes usually appears before the age of 40. Type 1 diabetes is the least common of the two main types and accounts for between 5 15% of all people with diabetes. Type 2 Type 2 diabetes develops when the body can still make some insulin, but not enough, or when the insulin that is produced does not work properly (known as insulin resistance). In most cases this is linked with being overweight. This type of diabetes usually appears in people over the age of 40, though in South Asian and African-Caribbean people, it often appears after the age of 25. However, recently, more children are being diagnosed with the condition, some as young as seven. Type 2 diabetes is the more common of the two main types and accounts for between 85-95% of all people with diabetes. Why is it important? Diabetes can reduce both quantity and quality of Life. Diabetes can reduce life expectancy, by on average at least 15 years in people with type 1 diabetes and 5 years for males and 7 years for females with type 2 diabetes (at age 55 years). 1,548 hospital admissions (April 2004-March 2009) Linked with obesity to major cause of increased future health problems The prevalence of diabetes within the East Riding is projected to increase from 5.2% in 2010 to 6.3% by 2020, according to APHO. Figure shows that deaths from diabetes in East Riding have increased in recent years and are higher than regional & national averages. This requires investigation. 102

103 Life-long diabetes can have a profound impact on: Lifestyle Relationships Work Income Health and well-being. Poorly-controlled diabetes can lead to range of complications, including: Blindness Heart attacks Strokes Kidney disease Amputation Depression. A male non smoker diagnosed with diabetes at the age of 45 years who maintains HbA1c, blood pressure and cholesterol measurements within current QOF targets has an 11.5% chance of dying before his 60th birthday. This equates to a life expectancy of 17.4 years compared with 34.5 years for all men aged 45 years in the United Kingdom. A woman diagnosed at the same age has an 8.9% chance of dying before her 60th birthday and has a life expectancy 20.1 years lower than all women of the same age. Adjusting the life expectancy for these hypothetical patients to account for the lower quality of life associated with diabetes results in a Quality Adjusted Life Expectancy of 13.3 years for the man and 13.6 years for the woman. What is the need in the East Riding of Yorkshire? The overall prevalence of diabetes in the East Riding in 2005 was higher than that of both the Yorkshire and Humber region and higher than England as a whole. This gap is due to the higher levels of type 2 diabetes and this is linked to the older age profile of the East Riding. Table 3.8.1: Estimated Prevalence of Type 1 (2005) Estimated Number Estimated Prevalence Persons Male Female Persons Male Female England 170,701 98,232 72, % 0.40% 0.28% Yorkshire & the 17,139 9,834 7, % 0.39% 0.28% Humber East Riding of Yorkshire 1, % 0.39% 0.27% 103

104 Table 3.8.2: Estimated Prevalence of Type 2 Diabetes (2005) Estimated Number Estimated Prevalence Persons Male Female Persons Male Female England 2,091, ,269 1,249, % 3.40% 4.86% Yorkshire & the 212,201 85, , % 3.41% 4.87% Humber East Riding of 14,071 5,614 8, % 3.49% 5.03% Yorkshire Source: YHPHO Diabetes Population Prevalence Model Phase 3 In 2007/08 there were approximately 13,160 persons registered with East Riding general practices has having either type 1 or type 2 diabetes. This registered prevalence in 2007/08 was 4.20% of all registered patients within the East Riding (England = 3.87%, Yorkshire and Humber = 3.96%). The percentage ranged between practices from 1.8% to 6.3%. Prevalence in the East Riding of Yorkshire is projected to rise to around 18,000 by 2010 (5.2% of all persons) and to reach 5.7% by Despite a long term falling trend between 1993 and 2001, in the rate of deaths from diabetes within the East Riding of Yorkshire, recent years have seen an increase, with 2007 showing the highest rates this decade and the deaths from diabetes are now higher than the regional and national average and higher than for the peer group of prospering smaller towns. Unlike the East Riding of Yorkshire, the peer group mirrors the regional and national trend of a continuing fall in death rates. Figure 3.8.2: Deaths from diabetes within East Riding of Yorkshire: Directly age-standardised rates ( ) Directly age standardised mortality rate per 100,000 persons England & Wales Yorkshire & Humber Prospering Smaller Towns East Riding of Yorkshire

105 The estimated number of persons within the East Riding experiencing diabetes is predicted to rise from around 15,000 persons in 2005 to 21,000 by 2015 and to 28,000 by Figure 3.8.3: Diabetes Predictions East Riding of Yorkshire (2005 to 2025) 30,000 24,288 27,721 Number of people with diabetes 20,000 10,000 15,154 18,057 20, This predicted trend suggests an almost doubling of the number of people suffering from diabetes within the East Riding over the next two decades and suggests a major pressure on health and social care services in responding to this increased need and demand for services. What makes an effective service? Lifestyle interventions significantly reduce progression rates to diabetes in pre-diabetic individuals. For people who are obese, losing a fairly modest amount of weight (up to 10kg) has been shown to reduce diabetes-related mortality by 30-40%. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes. In all the studies conducted so far in people at high risk, lifestyle changes have been substantially more effective than the use of drugs. The scale of the problem requires population-wide measures to reduce levels of overweight and obesity, and physical inactivity. Informed policy decisions on transport, urban design, food pricing and advertising can all play an important part in reducing the population-wide risks of developing type 2 diabetes. Early diagnosis and treatment can reduce the risk of complications. 50% of people with type 2 diabetes have complications on diagnosis, which could have been prevented if diabetes had been detected earlier. Eye screening and treatment can reduce the risk of severe loss or blindness among people with diabetes to less than a half. 105

106 By becoming more knowledgeable about diabetes through education courses, people with diabetes can make informed choices about how to manage their condition and reduce the risk of complications and emergency visits to hospital. Patients with diabetes should receive care in the following key areas: HbA1C BMI measurement Blood pressure control Albumin measurement Creatinine measurement Cholesterol measurement Eye examination Foot examination Smoking cessation advice The Quality Outcomes Framework covers these areas and can be used to examine variations in outcomes by East Riding general practices. The prevalence of diabetic retinopathy within a diabetic population is around 30%, and amongst previously unscreened populations, 2 5% of people with diabetes will require laser treatment for diabetic retinopathy. The Diabetes NSF and supporting policy documents set a target for all PCTs: By 2006, a minimum of 80% of people with diabetes to be offered screening for the early detection (and treatment if needed) of diabetic retinopathy as part of a systematic programme that meets national standards, rising to 100% coverage of those at risk of retinopathy by end In 2009/9 92.7% of people registered within the East Riding with diabetes have a record of retinal screening in the previous 15 months. Health Inequalities: ***Update for 2009 Figure indicates a much higher ratio of hospital admissions in the most deprived 2 quintiles of LSOAs in the East Riding of Yorkshire, with these two quintiles having rates close to the National Average (threshold) or slightly above, although the less deprived quintiles have rates significantly below. 106

107 Figure 3.8.4: Standardised Admission Ratios for Diabetes in East Riding of Yorkshire ( ) (source Dr Foster population health module) Lifestyle risk factors for diabetes vary by deprivation group. The Headline Report on the Lifestyle Survey shows the trends for obesity, exercise, diet etc. Certain minority Ethnic Groups have greater prevalence. Present trend will lead to increase in inequalities in premature death. Prevention: Diabetes can be prevented by increasing public awareness of the condition and early symptoms. People at risk to be supported to change lifestyle by losing weight, increasing physical activity and eating healthier diet. Can be wellcontrolled and treated, thus delaying and preventing long-term complications. If not managed well can lead to heart disease and stroke, kidney failure, eye disease, limb amputations and mental ill-health. Joint Working: Fits with joint health weight strategy and child health work. Plus hospital at home policies. Environmental and policy changes to tackle obesity and to improve levels of physical activity are vital for diabetes prevention. 107

108 Conclusion & Recommendations Diabetes is a long term condition with a major current and likely future impact on health in the East Riding. The following recommendations are made: Improve care planning between people with diabetes and their healthcare professional. By creating a care plan with their healthcare professional a person with diabetes can set out how they will meet their lifestyle targets, such as weight management, increasing physical activity and what they will do in the event of developing emergency complications. Increase the number of people attending education courses and improving their knowledge. By becoming more knowledgeable about diabetes through education courses, people with diabetes can make informed choices about how to manage their condition. Increase the number of people with diabetes having blood glucose levels of 7.4 or less. For a person with diabetes, high blood glucose levels can lead to micro-vascular conditions such as blindness, kidney failure and nerve damage. National diabetes guidelines recommend people with diabetes should all have blood glucose levels of 7.4 or less, to prevent these complications. Variations in outcomes, and processes, of key measurements need to be reduced in general practices. Healthcare professionals providing frontline care to people with diabetes need to offer individual support to people with diabetes encouraging them to look after their diabetes. The patient s experience must be considered as important as the healthcare professionals view when creating a care plan for a person with diabetes. Levels of screening for diabetic retinopathy need to be improved within the East Riding. 108

109 3.9 Other Major Causes of Death and Ill Health Why is this important? Premature death and its associated morbidities have major personal and financial costs for the individual, their families, their communities and the local economy. Although rates of premature death have fallen in the East Riding in recent years, there still exist major variations within the area. This section considers the major causes of death and serious ill health that have been highlighted earlier. As already noted, although we see a continued decline in premature deaths, the prevalence and impact of long term health conditions is projected to increase significantly over next ten years What special areas need attention? The conditions considered here result in causes of death coded as circulatory, and cancers. The principal individual causes of ill health are: Coronary heart disease (CHD) Stroke Lung cancer Breast cancer The main cause of death and serious ill health not included here is COPD, which has been considered in Section 2.8. Below are different sections for coronary heart disease, stroke and cancers. The sections for CHD, stroke and cancers are expanded. What is the need in the East Riding of Yorkshire? Coronary Heart Disease Death from coronary heart disease continues to decline in line with national trends suggesting among other things that interventions in primary care to tackle heart disease are being effective. Death before the age of 75 is conventionally regarded as been premature death. Women tend to develop coronary heart disease at a later age than men so the rate of premature death is much lower among women. However CHD amongst women is still an important health challenge. Stroke Rates of premature death from Stroke have fallen over the last decade from 23 deaths per 100,000 persons aged under 75 years in 1993 to 14 deaths in 2006, a fall of 39%. Rates of premature death from stroke within the East Riding had been lower than the regional and national average during the 1990s but over the last 5 years have been similar to the national average. These trends are encouraging, but these conditions still cause considerable illness and there are major differences in rates between areas matching with 109

110 differences in deprivation. Further information on health inequalities can be found in the CHD health equity audit. Cancer There has been a slow decline in overall deaths from all cancers. This is in line with national and regional trends and the decline would not be expected to be as steep as for CHD. The decline in lung cancer deaths is encouraging, but premature deaths among women are not decreasing. In addition there are dramatic health inequalities with large increases in death rate among men from deprived areas (see Director of Public Health s Annual Report). Trends in breast cancer deaths in women of all ages have largely followed the national and regional pattern falling from a rate of 36 deaths per 100,000 women in 1993 to 26 such deaths in Deaths from breast cancer in women aged 50 to 69 years have fallen significantly from 86 deaths per 100,000 women to low of 52 per 100,000 in Information about cancer and health inequalities can be found in the Hull and East Riding cancer health equity audit Coronary heart disease Why is it important? Coronary heart disease (CHD) is a major cause of death and disability and indeed is the UK's biggest killer, with one in every four men and one in every six women dying from the disease. In the UK, approximately 300,000 people have a heart attack each year. Angina affects about 1 in 50 people and, in the UK, there are an estimated 1.2 million people with the condition. It affects men more than women and prevalence rises with age. What is the need in the East Riding of Yorkshire? Prevalence In 2007/08 approximately 14,625 people were registered with East Riding GPs as having Coronary Heart Disease. This gives a CHD prevalence of 4.7% which is higher than the national average of 3.5%. However, as it is likely that there are undiagnosed, and therefore unregistered cases, the true prevalence may be higher. The Association of Public Health Observatories has developed a prevalence model which estimates the local prevalence at 6.2% (17,305 persons). The same source suggests that in the East Riding, prevalence in persons aged 16+ is projected to rise from 6.2% in 2008 to 6.7% by 2015, an increase of 3,300 persons. This rise is steeper than that expected to be experienced nationally. Within East Riding general practice lists the registered prevalence ranged from 1.5% to 7%. 110

111 Table 3.9.1: Prevalence Associated with CHD Financial Year (2007/2008) East Riding of Yorkshire England Practice List Size 313,306 54,009,831 Disease Register CHD 14,625 1,892,432 Prevalence CHD 4.7% 3.5% Premature Deaths from Coronary Heart Disease In the East Riding in 2007 there were 541 Deaths (180 under 75 years). Death from coronary heart disease within the East Riding continues to decline in line with national trends suggesting among other things that interventions in primary care to tackle heart disease are being effective. Death before the age of 75 is conventionally regarded as been premature death. Women tend to develop coronary heart disease at a later age than men so the rate of premature death is much lower among women. However CHD amongst women is still an important health challenge. The rate of premature deaths in the East Riding of Yorkshire has remained consistently lower than national and regional averages for last decade. However the local rate of premature death has remained consistently higher than peer group (Prospering Smaller Towns) for last decade (In 2007: ERoY 41 per 100,000 under 75, Peer Group 34 per 100,000). These trends are illustrated in the Figures below. Figure 3.9.1: Premature Deaths from CHD in Women under 75 years Directly age standardised mortality rate per 100,000 persons England & Wales Yorkshire & Humber Prospering Smaller Towns East Riding of Yorkshire

112 Figure 3.9.2: Premature Deaths from CHD in Men under 75 years Directly age standardised mortality rate per 100,000 persons England & Wales Yorkshire & Humber Prospering Smaller Towns East Riding of Yorkshire Inequalities in premature deaths from CHD People living in the 20% most deprived areas of the East Riding were more likely to die from CHD than those living in the rest if the area. This gap in mortality for men has increased in recent years whilst remained constant for women in the East Riding. The inequality gap in premature deaths from CHD for men has remained consistently higher than for women. Specifically, in 2005/07 there existed a 60% gap (between most deprived 20% & remaining 80%) in premature deaths from CHD in men; this has fallen from a gap of 77% in 2003/05. The equivalent for women in 2005/07 was 105%, down from 114% in 2003/05. These variations are illustrated below. 112

113 Figure 3.9.3: Variations in CHD Mortality rates for Men within East Riding of Yorkshire PCT area by levels of material deprivation (banded SOAs based on IMD score) 200 Most Deprived 20% All But Most Deprived 20% CHD Deaths DSR per 100,000 Males <75 years % % % % % / / / / /07 Figure 3.9.4: Variations in CHD Mortality rates for Women within East Riding of Yorkshire PCT area by levels of material deprivation (banded SOAs based on IMD score) CHD Deaths DSR per 100,000 Females <75 years % Most Deprived 20% All But Most Deprived 20% % % % % / / / / /07 ***Update for 2009 Inequalities in hospital admissions for CHD In line with the inequalities in mortality rates, we have also noted wide variations in standardized admission rates for CHD with people living in the most deprived parts of the East Riding being 75% more likely to be admitted 113

114 to hospital with CHD than the average for England (England shown as the100 line on Figure 3.9.5). Therefore people in deprived areas who have a greater need for services are those that appear to have higher hospital admission rates. This could reflect the greater level of need, but could also indicate unmet need in primary care. Figure 3.9.5: Standardised Admission Ratios for Coronary Heart Disease in East Riding of Yorkshire ( ) (source Dr Foster population health module) CHD Admissions: SARS 2004 to Least Deprived Below average Average Above average Most deprived What services are currently provided? Spending on Circulatory Diseases and outcome both higher than national average but not significantly different (2007/08). Prevention The best way to prevent coronary heart disease is to make sure that a person s 'bad cholesterol' (LDL) level is low and that their 'good cholesterol' (HDL) cholesterol level is high. There a number of ways this can be done including: Eating a healthy, balanced diet Being more physically active Keeping to a healthy weight Not smoking or, if a smoker, giving up smoking Reducing your alcohol consumption Keeping your blood pressure under control 114

115 Keeping your diabetes under control Taking any medication that is prescribed, for example to control blood cholesterol or reduce high blood pressure As can be seen many of the risk factors relating to CHD such as smoking, diet, exercise and obesity can be prevented or reduced. Programmes to help East Riding residents make the healthy choice the easy choice are outlined in separate chapters in this document (e.g., smoking cessation, weight management etc) Treatment Coronary heart disease cannot be cured, but recent progress in the research and development of new medicines and significant improvements in surgical procedures have meant that the condition can now be managed more effectively. With the right treatment, the symptoms of coronary heart disease can be reduced, and the functioning of the heart improved. Medicines Some of the medicines that are commonly used to treat heart conditions are: Low dose aspirin and 'clot-busting' medication Anticoagulants Statins Beta blockers ACE (Angiotensin Converting Enzyme) inhibitors Angiotensin II receptor antagonists Anti-arrhythmic medicine Nitrates Cardiac glycosides Surgical procedures If a person s blood vessels are very narrow due to a build up of atheroma (fatty deposits), or if their symptoms cannot be controlled using medication, surgery may be needed to open up, or replace, the blocked arteries. Some of the main surgical procedures that can be used to treat blocked arteries are: Coronary angioplasty Coronary artery bypass Heart transplant Laser surgery Conclusion and recommendations Prevention, screening and treatment programmes should target the most deprived communities within the East Riding to help reverse the inequality gap in premature deaths from CHD. The 12 standards set out in the CHD NSF should continue to be followed. They are: 115

116 Reduce heart disease in the population East Riding PCT should further develop, implement and monitor policy that reduces the prevalence of coronary risk factors in the population and reduces inequalities in risks of developing heart disease. In addition, they should contribute to a reduction in the prevalence of smoking in the local population Prevent CHD in high risk patients To prevent CHD in high risk patients, GPs and Primary Care Teams should identify people with cardiovascular disease and offer them advice and treatment to reduce their risks and also identify people at risk of cardiovascular disease without developed symptoms and offer them advice and treatment to reduce their risks Treating heart attack and other acute coronary symptoms People with symptoms of a possible heart attack should receive help from trained individuals in the use of a defibrillator within 8 minutes of calling for help to maximise the effects of potential resuscitation. People thought to be suffering from a heart attack should get a professional assessment and receive aspirin if advised. Thrombolysis should be given within 60 minutes of calling for professional help Stable angina People with symptoms of angina should receive appropriate investigation and treatment to relieve pain and reduce the risk of coronary events Revascularisation People with angina that is increasing in frequency or severity should be urgently referred to a cardiologist. NHS Trusts should continue to create hospital-wide systems of care to ensure that patients with suspected CHD receive appropriate investigation ad treatment to reduce reoccurrence Heart failure Doctors should arrange for people with suspected heart failure to be offered appropriate investigation (e.g. electrocardiography). The cause of possible failure should be identified and treatment to reduce their symptoms and risk should be offered Cardiac Rehabilitation NHS Trusts should create protocols/ systems of care for patients to be invited to participate in multidisciplinary programmes of secondary prevention and cardiac rehabilitation to help prevent further attacks or mortality. 116

117 3.9.2 Stroke Why is it important? Stroke is a major cause of death and disability. Every year, an estimated 150,000 people in the UK have a stroke. Most people affected are over 65, but anyone can have a stroke, including children and even babies. More than 20% of local people who had a stroke in 2007 were aged 65 or under. A stroke is the third most common cause of death in the UK. It is also the leading cause of severe disability. More than 250,000 people live with disabilities caused by stroke. What is the need in the East Riding of Yorkshire? Prevalence In 2007 approximately 6000 people were registered with East Riding GPs as having experienced strokes. This gives a stroke prevalence of 2.0% which is higher than the national average of 1.6%. Also approximately 45,000 persons in the East Riding were placed on the Hypertension disease register (had high blood pressure and are therefore at risk of stroke) this gives a registered prevalence of 14.4%, again higher than the average for England. As with CHD, the APHO have developed prevalence models for stroke and hypertension, which provide substantially higher estimates of prevalence but nevertheless estimate the local prevalence as being higher than the England average and likely to increase at a steeper rate, largely because of our growing elderly population. Specifically APHO suggest that the East Riding in 2008 stroke prevalence was around 2.7% (England 2.5%) and Hypertension prevalence 34.3% (England 30.2%). It is also estimated that stroke prevalence will rise from 2.7% in 2008 to 2.9% by 2015, an increase of 1,500 persons. Table 3.9.2: Prevalence Associated with Stroke Financial Year (2007/2008) East Riding of Yorkshire England Practice List Size 313,306 54,009,831 Disease Register STROKE ,689 Prevalence STROKE 2.0% 1.6% Disease Register HYPERTENSION 45,203 6,908,055 Prevalence HYPERTENSION 14.4% 12.8% 117

118 Premature Deaths from Stroke Premature deaths from stroke within the East Riding have fallen over the last 13 years from a rate of 23 deaths per 100,000 persons in 1993 to 14 in The overall trend in the East Riding has been downward with fewer deaths than would be expected if we were to follow the national rate. During 1990s local rate of premature death had been lower than national and regional averages but in last 5 years rates have been similar to national average. Over the last 7 years local rates of premature death have been consistently higher than peer group PCTs (In 2007: ERoY 15.2 per 100,000 under 75, Peer Group 11.9 per 100,000). These trends are illustrated in Figure below. Figure 3.9.6: Deaths from Stroke People aged less than 75 Directly age-gender standardised Stroke mortality rate per 100,000 persons aged under 75 years England & Wales Yorkshire & Humber Prospering Smaller Towns East Riding of Yorkshire Year Inequalities in premature deaths from Stroke In the East Riding in 2007 there were 355 stroke deaths (69 aged under 75 years) People living in the 20% most deprived areas of the East Riding were more likely to die from a stroke than those living in the rest if the area. This gap in mortality has increased in recent years. Specifically in the last 5 years the gap has increased from 9% to 20% and appears to be larger for women than for men. 118

119 Table 3.9.3: Variations in Stroke Mortality rates within East Riding of Yorkshire PCT area by levels of material deprivation (banded SOAs based on IMD score) Males Females DSR DSR DSR DSR DSR DSR DSR DSR DSR DSR East Riding Average Most deprived 20% Least Deprived 20% All but most deprived 20% ***Update for 2009 Inequalities in hospital admissions for Stroke In line with the inequalities in mortality rates, we have also noted wide variations in standardized admission rates for stroke with people living in the most deprived parts of the East Riding being more likely to be admitted to hospital with stroke those in the less deprived parts of the area, although by and large admission rates are lower than the average for England (Threshold). This is illustrated in Figure

120 Figure 3.9.7: Variation in age/sex SARs for stroke ( ) Prevention: Both hypertension and stroke can be prevented by range of lifestyle modification and self care factors: choose good nutrition (reduce salt and saturated fat intake, increase fruit and vegetables intake); stop smoking, regular physical activity, maintain healthy weight; limit alcohol, reduce stress What services are currently provided? Spending on Circulatory Diseases and outcome both higher than national average but not significantly different (2007/8) Highlighted in CQC and quarterly performance reports as poor performance. 39% of people spend at least 90% of time on stroke unit compared with target of 65% Since lifestyle factors such as diet, drinking alcohol, smoking and physical activity affect risk, the services tackling these issues are important for stroke prevention. First stage e.g. presentation 120

121 Patient has acute stroke symptoms e.g. face or limb weakness & slurred or loss of speech Patient calls an ambulance Patient taken to local hospital Middle stage e.g. diagnosis/treatment Patient admitted to hospital and has CT scan taking between 1 and 2 days Scan reveals patient has had a stroke too late for thrombolysis (blood thinning drugs) Patient entered onto rehabilitation pathway After/ongoing stage e.g. aftercare Patient discharged after days Continuing appointments with a range of professionals e.g. GP, hospital staff Community stroke rehabilitation units and team Social care support provided to help patient cope at home Cross cutting themes Patient is reviewed/advised by GP and hospital staff especially therapists Diagnosis often delayed Acute phase of treatment takes up to 4 weeks What could happen in the future for Acute Stroke care? First stage e.g. tests and diagnosis Patient has acute stroke symptoms Patient or family calls an ambulance treating condition as brain attack Specialist is waiting to see patient in A&E Patient has CT scan immediately (reported on site or via tele-medicine link to neuro-radiologist at specialist centre Middle stage e.g. treatment Specialist confirms stroke diagnosis Patient thrombolised during CT Scan Patient cared for by a specialist Multi Disciplinary Team on dedicated stroke ward After/ongoing stage e.g. aftercare Patient returns home as soon as possible to receive rehabilitation at home Patient needs small amount of social care support Patient has much greater chance of recovery with minimal disability where thrombolysis is indicated 121

122 Cross cutting themes Early signs of acute stroke are identified promptly Patient is taken to nearest hospital with specialist stroke facilities and is treated as a medical emergency Patient is advised by specialists in stroke care throughout treatment Patient and family given full information about stroke and rehabilitation Acute phase of treatment is much reduced for a significant number of patients A transient ischaemic attack (TIA) is a mini stroke where symptoms completely resolve within 24 hours. Patients at high risk of stroke should be seen and treated within 48 hours of the event. All other TIA patients should be seen and treated within seven days. Conclusion and recommendations The main differences between now and the future for the stroke pathway as recommended in the recent Darzi review are: All efforts to be made to prevent strokes in the first place through health promotion and increased awareness of risk factors. These programmes should target the most deprived communities within the East Riding to help reverse the inequality gap in premature deaths from stroke. Patients who have a TIA need to be seen either within two or seven days, depending on risk factors Stroke is recognised as a medical emergency by every part of the NHS Patients are treated by specialists in stroke Patients have immediate access to a scan Patients have immediate thrombolysis after diagnosis Patient pathway is much shorter Outcome of treatment is much better patients recover with minimal disability Patient has no choice of hospital taken to best equipped hospital with specialists available 24/7 Patient is cared for on dedicated stroke unit The local approach and response to these recommendations The Hull & East Riding Stroke Steering Group is working across the patch to highlight the current situation in all of these aspects of the service and therefore the gap analysis to ensure a robust, local strategic plan to reflect the National Stroke Strategy. 20 key quality markers within the National Stroke Strategy have been assessed and examined and the following priorities agreed as recommendations for local commissioners: Improved access to Carotid Doppler Scanning Additional staffing on the Acute Stroke Unit Improved access to thrombolysis Service Additional Step Down facilities. 122

123 3.9.3 Cancers Cancer is a term that is used to refer to a number of conditions where the body's cells begin to grow and reproduce in an uncontrollable way. This rapid growth of cancerous cells is known as a malignant tumour. These cells can then invade and destroy healthy tissue, including organs. Types of cancer There are hundreds of different types of cancer. The most common cancers in the UK are: breast cancer, prostate cancer, lung cancer cancer of colon, or rectum, bladder cancer, and ovarian cancer. Risk factors for cancer include smoking, drinking alcohol, obesity, poor diet, lack of exercise, and prolonged exposure to sunlight. Treatments for cancer include surgery, chemotherapy and radiotherapy. Some cancers can be cured if detected early enough. Why is it important Cancer is a common condition and is a serious health problem, both in the UK and across the world. It is estimated that 7.6 million people in the world died of cancer in In the UK, cancer is responsible for 126,000 deaths per year. One in four people die from cancer. In the East Riding of Yorkshire Overall numbers of cancer registrations remain similar to regional and national rates, whilst deaths from cancers have fallen in line with national & regional trends. An examination of the various cancers demonstrates this overall pattern of increased numbers of registrations but fewer premature deaths. Premature deaths from cancers in East Riding are similar to both regional & national rates. Breast cancer registrations have increased and remain similar to national & regional figures. In 2007 deaths from breast cancer were higher than regional & national comparators; however the trend over the last decade has remained downwards. Incidence of lung cancer in East Riding has significantly decreased for males but increased for females. Death rates are also higher than for similar parts of England. This is an area of particular concern. 123

124 A significant inequality gap exists in mortality rates from lung cancer for males within the East Riding; however this gap between the most deprived 20% and remaining 80% has decreased from 170% in 2004/06 to 143% in 2005/07. The East Riding has seen a large and consistent rise in the number of skin cancer registrations over the last decade. The rate within East Riding has remained significantly higher than regional and national averages. The figures below illustrate key trends in cancer registrations and mortality for the major types of cancer and provide comparisons nationally, regionally and with our ONS peer group. Figure 3.9.8: All Cancer Registrations Directly age standardised mortality rate per 100,000 persons 3 yr average England & Wales Yorkshire & Humber Prospering Smaller Towns East Riding of Yorkshire Figure : Deaths from All Cancers Directly age standardised mortality rate per 100,000 persons England & Wales Yorkshire & Humber Prospering Smaller Towns East Riding of Yorkshire

125 Figure : Premature deaths from Cancer Directly age standardised mortality rate per 100,000 persons <75 years England & Wales Yorkshire & Humber Prospering Smaller Towns East Riding of Yorkshire Figure : Breast Cancer Registrations 111 Directly age standardised mortality rate per 100,000 persons 3 yr average England & Wales Yorkshire & Humber Prospering Smaller Towns East Riding of Yorkshire

126 Directly age standardised mortality rate per 100,000 persons 3 yr average Figure : Deaths from Breast Cancer England & Wales Yorkshire & Humber Prospering Smaller Towns East Riding of Yorkshire Figure : Incidence of Lung Cancer in the East Riding 120 Males Females Incidence Rate per 100,000 persons year average

127 Figure : Skin Cancer registrations Directly age standardised mortality rate per 100,000 persons England & Wales Yorkshire & Humber Prospering Smaller Towns East Riding of Yorkshire

128 What services are currently provided? Cancer Screening Programmes There are presently three major screening programmes operating within the East Riding. They are breast screening, cervical screening and bowel screening. They are based on the fact that early detection can save lives. Breast Cancer Screening Breast screening by mammography is an x-ray examination of the breasts and can show breast cancers at an early stage, when they are too small to see or feel. If changes are found at an early stage, there is a good chance of a successful recovery. Women aged 50 to 70 are invited for free breast screening every three years. Women over 70 can request free three yearly screening. Figure : Deaths from Breast Cancer (Woman Aged 50 to 69) Directly age standardised mortality rate per 100,000 females yrs Year England & Wales Yorkshire & Humber Prospering Smaller Towns East Riding of Yorkshire 59 The NHS Breast Screening Programme in England saves an estimated 1,400 lives per year. Thirty years ago the five year survival rate for breast cancer was around 50 per cent. Today it is around 80%. Early detection saves lives and breast-screening is an important part of this. In February 2006, the Advisory Committee on Breast Cancer Screening concluded that breast screening is saving 1,400 lives a year in England. However, it is important that women are fully informed of and understand the potential benefits and harm of participating in the screening programme. Each 128

129 invitation for screening includes a leaflet explaining the facts. Women can then make an informed choice about whether or not they wish to participate. Mammography is the most reliable method of detecting breast screening early but, like other screening tests, it is not perfect. The Cancer Reform Strategy stated that, over time, the breast screening programme will be extended to nine screening rounds between 47 and 73 years with a guarantee that women will be invited for their first screening by the age of 50. Full implementation is expected by Local Breast Screening Issues The increased waiting time for breast screening in the Humberside area has already been identified as an issue and thoroughly assessed. An action plan has already been put in place to bring the screening round length back down to 36 months for all women. A number of contributory factors had led to the increased waiting time, including the significant rise in eligible women placing demand on a service with limited staffing resources to increase capacity. This has now been addressed. The regional Quality Assurance Reference Centre, which closely monitors the breast screening services equipment, standards and performance against national standards, visited the Humberside Breast Screening service in February The team highlighted that the service had one of the best early cancer detection rates in the region. They were also very satisfied with the quality and standard of the service being provided. ***Update for 2009 The forthcoming extension of the age range of women eligible for screening is forecast to put significant pressures on the breast screening service both because of the extended population to be screened and anticipated forecast growth of our elderly population. Our early work on modelling the combined effects of these two factors, to allow for forward planning indicate that between 2009 and 2012 that population eligible to be invited for screening will grow by 32%. A report on our base model (as presented to the Breast Screening Steering Group) is available from the Public Health Directorate Cervical Cancer Screening The Cervical Screening programme within the East Riding aims to reduce the number of women who develop invasive cervical cancer (incidence) and the number of women who die from it (mortality). It does this by regularly screening all women at risk so that conditions which might otherwise develop into invasive cancer can be identified and treated. The programme aims will be achieved through the following measures: 129

130 Offering cervical screening to all women aged Offering routine screening at an interval of three or five years depending upon age (see table below) Maximising the uptake of cervical screening Maximising the quality of all aspects of cervical screening, including sample taking, laboratory services, communication and follow-up management There are two key points to note regarding the population for cervical screening: The programme is available for all women aged Cervical screening is not a test for cancer but for abnormalities which, if left undetected and untreated, may develop into cancer Research has shown that cervical screening has prevented an epidemic in the UK that would have killed about one in 65 of all British women born since 1950 and culminated in about 6,000 deaths per year in this country. 80% or more of these deaths, up to 5,000 per year, are likely to be prevented by screening. The Cancer Reform Strategy stated that the Department of Health would take action to tackle the falling participation in cervical screening of younger women aged 25 to 35. The Cancer Reform Strategy stated that all women should receive the results of their cervical screening test within two weeks by Within the East Riding work is underway to become one of the first areas in England to achieve this target. Bowel Cancer Screening When fully operational, every year around 3 million men and women in their 60s will be sent a self-sampling kit (the Faecal Occult Blood test) to use in the privacy of their own homes. The kit is then returned by post to a regional laboratory (programme hub). Men and women will be invited to participate every two years. East Riding was one of the first areas in the UK to introduce Bowel Cancer Screening as is presently in its first round of screening local residents. The FOB testing kit is used to examine stool samples to see if there is hidden blood, which is a sign of possible bowel cancer. If the test is positive, people will be invited for a full bowel scope (a colonoscopy) to check for bowel cancer in a local screening centre. 130

131 Research has shown that screening men and women aged 45 to 74 for bowel cancer using the Faecal Occult Blood test (FOBt) could reduce the mortality rate from bowel cancer by 16% in those screened. The NHS Bowel Cancer Screening Programme is designed to be a two year rolling programme, with men and women in their 60s invited to participate every two years. The two year interval is based on strong evidence from the research trials and NHS pilot. People should receive a results letter from the laboratory within two weeks of sending in their sample. This letter is copied to their GP. If they receive an abnormal result, they will be offered an appointment with a specialist nurse within 10 days. At this appointment the nurse will discuss a more detailed examination of the bowel (a colonoscopy); to see whether or not there is a problem that may need treatment. The NHS are inviting men and women aged 60 to 69 as the risk of bowel cancer increases with age, with over 80% of bowel cancers arising in people who are 60 or over. Men and women aged over 70 are able to self-refer for screening every two years. From 2010 the bowel screening programme age range will be extended from to The programme is expected to detect nationally around 3,000 bowel cancers a year. By June % of East Riding residents eligible to take part in the Bowel screening programme had done so. The initial target had been set at 60%. Cancer Treatment In treating cancer, the aim is to remove the cancerous cells while making sure that the cancer does not reoccur. This can be challenging because even if only one cancerous cell remains after treatment, it has the potential to cause a new tumour. Different techniques are often used in combination as this can increase the chances of all the cancerous cells being removed. The main techniques are: Surgery Chemotherapy Radiotherapy Hormonal therapy Monoclonal antibody therapy Immunotherapy Alternative and complementary therapies 131

132 Local Issues Locally we are part of the Humber and Yorkshire Coast Cancer network which is a collaboration of a range of organizations who s main aim is to ensure that eth services that are provided to patients with cancer in the area are complaint with national best practice and seek to improve on this where possible. We have a new Cancer Centre located at Castle Hill Hospital which provides a wide range of specialist cancer services, including specialist surgery and radiotherapy, and more general cancer services are provided by the other NHS Trusts locally. We also utilize Leeds Teaching Hospitals for a range of nationally identified specialist services and, again, a new cancer facility has just been opened there. A number of the local issues around cancer relate to prevention, earlier diagnosis, and therefore treatment, of individuals with cancer. Prevention of ill health is covered elsewhere within this document, but there are clear links between lifestyle: especially smoking, diet, alcohol intake, sun exposure; and the risk of developing cancers. We need to increase the level of awareness across the area into lifestyle changes which will reduce the risk of cancers. A number of the symptoms associated with cancer are also the symptoms for other conditions and it can be difficult for individuals to identify whether the symptom they are experiencing is one that they need to go and see their General Practitioner about. This; combined in some cases with embarrassment or fear regarding what a diagnosis of cancer may mean; means that patients are not seeking medical review and advice at an early enough stage leading to the need for more complex treatment. What could happen in the future for Cancer care? There is string national guidance regarding best practice and minimum quality levels incorporated within a wide range of Cancer Improving Outcomes Guidance and this year the Cancer Reform Strategy has been released which takes the outcomes of the NHS Cancer Plan (2000) and identifies the next stages of the journey to be made to continue to work towards the world class commissioning of cancer services. The cancer reform strategy focuses on the areas that we wish to focus on: Earlier identification of cancers More rapid diagnosis and treatment for all individuals with cancer, including those individuals who are identified with having cancer during a screening or other investigative process There is also a focus on the whole journey that the patient takes, not just the first treatment, ensuring that all treatments are provided within acceptable timescales not just the first treatment Individualized care planning and more choice around care management during the care pathway 132

133 Maintain and improve the quality of services available We are working with our main partners, including our General Practice and Social Care Colleagues. to ensure that patients are gaining access to high quality care, when and where they need it, with appropriate support to the patient and their family. Conclusion and recommendations Services for patients with cancer have come a long way in the last few years, but we are conscious that there is still a long way to travel. Until now the focus has been on getting cancer treatments right and whilst this remains a priority we are focussing more on prevention, early diagnosis and support to individuals to help them through the care journey. The key recommendations are: Improve individual s awareness, and uptake of, of lifestyle changes to help reduce individuals risk of developing cancer. Including encouraging individuals to seek expert advice when suspicious symptoms appear Continue to work towards reducing waiting times for treatments/services and ensuring that those treatments/services offer the best quality possible Ensure that there are sufficient support mechanisms for individuals, be that psychological, social or physical, to enable individuals to actively contribute to their care and self manage their illness wherever possible End of Life Care Why is it important? How people die remains in the memory of those who live on Around half a million people die in England each year, of whom almost two thirds are aged over 75. The large majority of deaths at the start of the 21 st century follow a period of chronic illness such as heart disease, cancer, stroke, chronic respiratory disease, neurological disease or dementia. In 2007, 3408 East Riding residents died. An examination of place of death between 2001 and 2007 found that the majority of persons died in an Acute Hospital (41%), followed by dying at home (18%), in a community hospital (16%), in a residential home (12%) or in a nursing home (9%). The proportion of home deaths is low, given that most people would prefer to die at home than elsewhere; however we recognise that there is a need to improve methods of estimating location of death. 133

134 What is the Need in the East Riding of Yorkshire? Annually, within the East Riding, approximately 3,500 people die. The annual number of deaths is shown in Table Table : Number of Deaths per Calendar Year Calendar year Number of deaths of East Riding residents Mean 3486 The National Centre for Health Outcomes Development collates data on deaths at home at National, Regional and PCO level. Because of ONS coding policy a home death is defined as one that has occurred at the home address and that address is not of a communal establishment i.e. care homes and residential homes are counted with Hospitals. Under this definition, in , around 19% of deaths occurred at home in England and Wales. Specifically in terms if indirectly standardised rates per 100 deaths, the rate of home deaths was as follows Table Rates per 100 Population Home Deaths AREA/AREA GROUP NUMBER OF HOME RATE DEATHS England and Wales 287, Prospering smaller 70, towns Yorkshire and Humber 28, East Riding of Yorkshire Whilst the variation in the rate of home deaths does not appear great, it is worth noting that the East Riding of Yorkshire ranks 106 th out of 152 PCTs, which puts it in the bottom third in terms of the rate of home deaths. 134

135 The Northern and Yorkshire Cancer Registry and Information Service has published data showing the place of death of cancer patients by Cancer Network and PCT for 2000 to The pooled data for the 7 years, for all cancers is shown in the table below, which gives the number cancer deaths and the proportion in each type of establishment Table : Place of Death of Cancer patients Home Hospice Hospital Care Home and Unknown Total Yorkshire Cancer network 11,464 10,844 22,141 5,086 49,535 Humber and Yorkshire Coast 4,953 2,724 12,492 2,509 22,678 North of England 18,670 6,208 35,841 7,199 67,918 East Riding of Yorkshire 1, , ,934 Yorkshire Cancer network 23.1% 21.89% 44.70% 10.27% 100.0% Humber and Yorkshire Coast 21.8% 12.01% 55.08% 11.06% 100.0% North of England 27.5% 9.14% 52.77% 10.60% 100.0% East Riding of Yorkshire 22.0% 6.72% 61.32% 9.98% 100.0% The East Riding of Yorkshire is notable for the relatively high proportion of hospital deaths and converse low proportion of hospice deaths. This may represent an unmet need for hospice facilities. The major causes of death within the East Riding are similar to those nationally. The major causes being coronary heart disease, stroke and cancer (See Table 3). An analysis of which progressive illnesses lead to most death again show the importance of heart disease and cancers. Impact of changes in Deaths Profile The demographics of death in relation to age profile, cause of death and place of death have changed radically over the course of the past century. Around 1900 most people died in their own homes. At that time acute infections were a much more common cause of death and a far higher proportion of all deaths occurred in childhood or early adult life. With these changes, familiarity with death within society as a whole has decreased. Many people today do not experience the death of someone close to them until they are well into midlife. Many have not seen a dead body, except on television. As a society we do not discuss death and dying openly. 135

136 Although every individual may have a different idea about what would, for them, constitute a good death, for many this would involve: Being treated as an individual, with dignity and respect; Being without pain and other symptoms; Being in familiar surroundings; and Being in the company of close family and/or friends. What services are currently provided? East Riding PCT currently commissions a wide range of palliative and end of life care services to support its resident population. These services are delivered in a range of venues and are designed to provide a holistic package of care that is flexible to the individual patients and families/carers needs. The services, although commissioned from a wide range of provider organisations, provide an integrated package of care for patents where barriers between different providers are minimised and professionals work together to ensure optimal care for the patient and their family/carers. However, the majority of services are based within, or have origins within, cancer related services. This gives rise to services which are more tailored to the needs of cancer patients and although, from a commissioning perspective, there should be no difference between the level and type of palliation services offered regardless of the underlying clinical condition in practice the options for non-cancer patients requiring palliation are more limited. The PCT actively encourages all professionals to work across all clinical boundaries and has seen a ready acceptance from the clinicians involved to ensuring that patients are accepted into services regardless of the underlying clinical pathology there remain some constraints into services due to professional specialities. It is estimated that around 10% of all adult patients who are requiring end of life services have a specifically case managed end of life. Where case management is in place this encompasses both health and social care services. Others get access to a wider range of support and advice but do not get specific case management throughout this crucial period. The figures for children and young adults are less clear and are potentially higher however the exact figures are unknown. Where case management is in place services are co-ordinated by an identified lead clinician, usually the Macmillan Clinical Nurse Specialist. In Adult services it is more likely to be the District Nurse who co-ordinates care with the Macmillan CNS advising on complex symptom management etc, so facilitating home death if this is the patients preferred place of care. Recent study carried out across the East Riding Macmillan Caseloads evidenced that by the promotion of proactive prescribing of 4 key drugs for symptom management we are achieving 50% Home deaths against a regional average of 18%. 136

137 The majority of services are initially accessed via a known clinician referring them into the service, however once the individuals needs have been assessed the patient is then offered direct access to refer themselves back to the service if they wish to do so at any time. The Macmillan Team have an open referral policy, patients, (or carers with patients permission) can refer in themselves in to the service as well as any professional. The remit is to see anyone with a life limiting illness requiring specialist input for complex problems irrespective of diagnosis. Conclusion and recommendations Immediate Actions: Review service access level for non-cancer palliative care patients Review options for clinical input from other specialist/specialities into existing palliative care services Develop plans to increase individual s access to individualised care management if they require/want it Review figures relating to children and young adults in the end stages of life Summary of greatest areas of need A recent baseline review of palliative care and end of life services identified four key areas of greatest need. Data Collection The review highlighted the lack of an effective composite dataset which provides adequate, timely information to enable the planning, procurement and delivery of a comprehensive range of services which meet the needs of everyone including the patient, carers and the clinicians delivering the care. Equity of access Work is required to analyse equity of access both from the perspective of those that currently access the available services and those that do not. The source of this inequity may be due to clinical presentation, complex patient needs (including vulnerable mental health status) or wider equity and diversity issues. Consultants in Palliative Care Medicine The number of Consultants in Palliative Care Medicine was felt to be inadequate for the East Riding population. A strategy needs to be developed to identify the preferred model of Palliative Care Consultant provision for the PCT and a commissioning strategy identified to procure this level of support. Towards this end a new Consultant in Palliative Medicine is starting in October 2008 in the new Cancer. 137

138 Commissioning Framework/Strategy The work needs finalising on the development of a Network wide palliative Care Commissioning Framework and the more detailed PCT level palliative care strategy Dental Health Overall Dental Health The recent Dental Health of Adults survey undertaken by the YHPHO and issued in May 2009 indicates that dental health in the East Riding of Yorkshire is generally good, having the lowest proportion of people (23%) of all the PCTs in Yorkshire and the Humber to describe having problems with aching in the mouth (regional average 28.8%) and second highest (72.8%) in the region for stating that a regular check up is their general reason for going to the dentist (regional average 68.9%). Access to Dental Care Nevertheless 25% of East Riding of Yorkshire residents reported finding difficulty in getting routine care. This is slightly higher than the regional average of 22.6%. Reasons for difficulty in getting access varied across the region, but the main barriers for the East Riding were stated to be difficulty in getting to a dentist (19.9% - regional average 8.4%), no local dentist (30.1% - regional average 19.3%) or dentists only treating privately (55.9% - regional average 41.8%). The cost of treatment was also an issue with 33.1% of respondents stating that this was a barrier to getting routine care, though this was below the regional average of 38.3% 138

139 4. CHILDREN, ADULTS AND OLDER PEOPLE This chapter presents health needs by age group not covered in other parts of the document. These include areas such as immunisation, screening and issues relating to ageing. Maternity services are not covered specifically and this is an area that will be included in future JSNA work. 4.1 Children Why is it important? Child poverty is major determinant of local child health inequalities. Putting actions in place to improve children s health will benefit them as individuals and society as a whole. A healthy child will be much happier and will not have to be in contact with health services more than necessary. A healthy child will spend more effective time at school, which will lead to a better education. This will increase their chances of getting a good job as they get older which will improve their future life chances. These issues will potentially improve the local economy and help the provision of other services for the general population. Health & Wellbeing of Children The East Riding of Yorkshire has a lower than average population of 0-19 year olds compared with Yorkshire & Humber and England & Wales averages. There exist concentrations of young people in our more deprived communities. These concentrations are even more noticeable in very young children age 0-5 years old. The use of free school meals is a proxy indicator for disadvantage. In the East Riding pupils who are from disadvantaged communities perform comparatively poorly when compared to the performance of their national peers. An examination of Child Wellbeing at small geographic areas found that extreme variation exists across the East Riding. Bridlington South has the worst Child Health Wellbeing (within 10% lowest well being group in England) in comparison with St. Mary s ward in Beverley rankis in the 10% best The rate of 0-19 year olds admitted to hospital due to unintentional or deliberate injuries has continued to decline in line with LAA target. 45% of infants breast fed are 6-8weeks from birth within the East Riding. This prevalence was similar to that of the national average (46%) and greater than equivalent areas (44%). Immunisation Pandemic influenza has been the principal focus of recent health protection activity, but activity is at too early a stage to include it in this report. 139

140 Local childhood immunisation rates remain good as shown in comparison with national and regional averages, but there remains plenty of scope for improved uptake, for example in the case of Measles, Mumps and Rubella. What specific areas need attention? The key areas that need attention for child health include the following: General overall well-being including education Safeguarding children Looked after children Injuries among children Immunisation Dental health Childhood obesity Sexual health and teenage pregnancy covered in the section on sexual health Health services are also important. The community paediatric services for the East Riding are currently being reviewed by the PCT, which will probably result in major changes in the service. This will not be completed until the end of 2008 and implemented circa April The PCT will be utilizing World Class Commissioning and strategic commissioning to improve services for children and young people. What is the need in the East Riding of Yorkshire? This section considers firstly the overall population of children in the East Riding and then covers some specific issues. Further consideration of other health and social issues will be undertaken in future JSNA work. The East Riding of Yorkshire has a lower than average population of 0-19 year olds compared with Yorkshire & Humber and England & Wales averages. Figure

141 However, there are concentrations of young people in areas that contain some of our more deprived communities (East Riding of Yorkshire 0-19 population average 2007 mid-year estimate is 22.2%; Minster and Woodmansey 24.4%, Bridlington South 22.8%, Bridlington Central & Old Town 23.8%, Goole South 25.0%, Goole North 22.5%). These concentrations are even more noticeable in very young children age 0-5 years old. Child poverty is a key determinant of health inequality in children. There are pockets of extreme poverty within our region. Supporting those families who experience poverty is necessary to help remove children from the cycle of deprivation. A child poverty map of the East Riding can be found in the Data Observatory section of the local authority website at: Safeguarding Children For the child protection plan lasting 2 years or more there has been an improvement in performance as the number of children deregistered who had been on the register for 2 years or more has decreased in the period of 01/04/07 to 31/03/08 from 22 (15.1%) to 12 (8.9%). Performance reported for year ending 31 March 2008 shows a shift to returning to be closer to the English comparator of 6% and statistical neighbour s comparator of 5% (outturns for the period). The improvement in performance is indicative of progress in multi agency working on child protection plans to get to a point in which risk to children has been addressed and assessed as not requiring a child protection plan. The performance for the period of 22 (15.1%) children deregistered and falling within this category, has been looked into as it is recognised as a significant variation - from comparators and from the previous two years of (7%) and (5%). The variation for is partly explained by the significant number of sibling groups within the numbers of children involved. Looked After Children ERYC looked after children per 10,000 of population were 43.8 in April This then increased to 44.8 by April By managing more robustly thresholds for entry into the looked after system and being more innovative in relation to supporting families in crisis by April 2008 the LAC per 10,000 of population had reduced to