Rochdale Life Expectancy Profile

Transcription

1 Public Health Annual Report 2008 for the Borough of Joint Strategic Needs Assessment of Life Expectancy Rochdale

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3 CONTENTS MAY, Foreword Introduction highlighting life expectancy and deprivation information Mosaic Profile of the Borough Recommendations CardioVascular Disease Respiratory Health Cancer Healthy Lifestyles Healthy Eating and Physical Activity Smoking and Tobacco Control Obesity Infant Mortality Mental Health and Well-being Alcohol and Drugs Sexual Health Health Protection and Emergency Planning Data

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5 FOREWORD This Public Health Annual Report focuses on Life Expectancy and health Inequalities. It covers the main contributors to the Borough being below the national average in both areas. This report is intended to be part of the Joint Strategic Needs Assessment for the Borough and the baseline health needs compendium for the PCT and partners. It provides a basis for action on our top public health priorities. The overall aim of the recommendations contained within this report is to add years to life and life to years as we move towards 2010 and beyond. The Joint Strategic Needs Assessment for the Borough is well underway and our phased approach will lead, over time, to a comprehensive understanding of the needs of our population and enable us identify solutions in the priority areas. We then need to ensure we act upon these in partnerships that include local people. The initial phase of the Joint Strategic Needs Assessment has focused on older people and our most deprived Super Output areas (3%) but we will be rolling out the learning and needs assessment process to all key areas in Overall the team praised the partnership working within the Borough and the progress that we had made given the level of need and inequality that exists. A key message moving forward is that we need to evaluate the effectiveness of current work, industrial scale our interventions as many are currently piloted within small geographic areas as well as systematically plan actions to identify and address our priority areas in a timely way that reflects changes occurring over time. The Borough Lifestyles Strategy was well received and gives us a strong foundation for medium to long term improvements but we need to invest in increasing those interventions that will give us increased life expectancy in the short term. We will develop a systematic approach to health needs assessment, equity audit and impact assessment to enable us to adapt our interventions to respond to changing needs and new challenges. In commending this report to you I would like to thank everyone who contributed to it and to give special thanks to Wendy Meston, Consultant in Public Health for all her hard work in editing this report as well as contributing to it and Shabana Khan, Graphic Designer for her design work. 5

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7 INTRODUCTION LIFE EXPECTANCY The local challenge This Report focuses on the two national aims of World Class Commissioning 1) Life Expectancy and 2) Health Inequalities and the main contributors to our poor performance in both areas. Given that we are in the process of producing our series of Joint Strategic Needs Assessments this report also provides a baseline assessment of our top public health priorities aimed at adding years to life and life to those years as we move towards 2010 and beyond. During 2007 we welcomed the National Support team for Health Inequalities to the Borough to provide some external scrutiny of our work and their recommendations are detailed in this section. Overall the team praised partnership working within the Borough and the progress that we have made given the level of need and inequality that exists. A key message in moving forward is that we need to industrial scale and systematically plan for how we will address our priority areas. We need to balance the actions needed for short term gain in life expectancy and health improvement gains with actions that address the longer term health improvement challenges that we face. Gaps in life expectancy at birth in Rochdale Gender Life expectancy HMRPCT Life expectancy Region Life expectancy Nationally Gap men Male gain 0.5 years (6 months) 0.4 years (4.8months) 0.42 years (5.04 months) women Female gain 0.4 years (4.8months) 0.4 years (4.8months) 0.45 years (5.4 years) Our headline life expectancy target and performance is set out below. What we can see is a steady improvement in life expectancy in line with national trends, but this is not a sufficient improvement to close the gap between Rochdale and the national average. Disability free life expectancy at birth In general Life Expectancy shows an improvement that continues to mirror that seen Nationally, with Male life expectancy closing Gender HMRPCT Region Nationally men women Disability free life expectancy aged 65 Gender HMRPCT Region Nationally men women the gap on the national average slightly. In addition to overall life expectancy, the Office of National Statistics (ONS) is now reporting disability free life expectancy. As this is the first year this has been calculated there is no trend data available. Disability free Life Expectancy is derived statistically by the ONS combining data from age and sex standardised mortality rates with age and sex standardised reporting of good / fairly good health from the 2001 census. Again, we see that we are below the Regional and National rates.

8 Life Expectancy at Birth - Female 1991 to Years fo Life England and Wales North West Rochdale MCD Linear (Rochdale MCD) Year Life Expectancy at Birth - Male 1991 to Years of Life England and Wales North West Rochdale MCD Linear (Rochdale MCD) Year Causes of our poor life expectancy The tables on page 9 highlight the causes of our variation since The darker blue bars showing the most recent information (2002-4). This analysis has been used to inform the local prioritisation of health improvement issues. This analysis shows our need to focus on coronary heart disease, cancers, stroke, self harm, respiratory disease and infant mortality. Taking analysis further we have identified in the following chapters some key cross cutting issues that contribute to the mortality in these areas. These cross cutting priorities include tackling obesity, smoking, mental health and deprivation. 8

9 Women Men Overall many outcomes have improved Life expectancy has increased Cardiovascular disease (CVD) mortality rates have reduced Cancer mortality has reduced Smoking quitters targets have been met But More care is provided closer to home Clinical outcomes have improved for many Waiting times have reduced for many We have more joint working across agencies We have more choice We still have significant health inequalities within the 9 Borough and between the Borough and across the region There is still a need for more joint working to achieve better health outcomes There is not enough of a focus on early intervention, prevention and self care Choices are limited for some people

10 We propose from the needs assessment and analysis that the following should be the prioritised to increase life expectancy Reducing mortality from CVD Reducing mortality from cancers Reducing mortality from respiratory disease Reducing Infant Mortality Reducing mortality due to suicide, overdose and poisoning Commissioning Healthcare for Best Outcomes Population Focus 5.Informed Choice 4. Responsive Services 1.Known Population Health Needs Optimal Outcome Appropriate Utilisation 12. Balanced Service Portfolio Challenge to Providers 10. Patient/Public Involvement 9. Accessibility 2. Expressed Demand 7. Local Clinical Effectiveness 6.Known Intervention Efficacy 3. Equitable Resourcing 8.Cost Effectiveness 11.Adequate Service Volumes Cross cutting priorities to impact on the above are Reducing Tobacco use and smoking prevalence Promoting mental health and wellbeing Tackling Obesity (Adult and Childhood) Reducing the adverse impact of alcohol on health Continued implementation of the Healthy Lifestyles Strategy Targeted increases in the uptake of screening and vaccination programmes Developing Public Health capacity Developing Public Health Intelligence Developing and rolling out the Joint Strategic Needs Assessment process Health Impact Assessment of key developments Health equity audit programmes Ensuring there are robust health protection systems in place National Inequalities Review The Department of Health National Inequalities Team came to the Borough of Rochdale to review our current progress and plans towards meeting the 2010 target. The above model was used to assist us to analyse progress we are making. The review highlighted our strengths within the Borough that included: Good partnerships, communications and engagement The Borough Healthy Lifestyles Strategy Public health priorities in Primary Care Trust Pledges, Rochdale Metropolitan Borough Council (RMBC) plans and Community Plan Use of joint posts and joint projects Networks across Greater Manchester Good reductions in CVD and Infant mortality rates Health trainers and community health development joint working Some good Quality Outcome Framework and statin prescribing outcomes reported The team proposed some key recommendations which will assist us in ensuring we progress to meet our 2010 targets, including: The development of a strategic framework and action plans for each priority area from now to 2010 Plans should be industrial scale and systematic in approach Leading and developing the Joint Strategic Needs Assessment process to underpin whole system change Ensuring integrated pathways of care are developed 10

11 Opportunities taken to augment all pathways with health gain initiatives to address smoking, alcohol problems and obesity should be built into all business plans Extend the role of Practice Based Commissioning Population needs considered as priority criteria in option appraisals. All estates strategies and facilities development to aim to improve access for vulnerable groups across the whole system. This will involve building Health Impact Assessment into all proposals Opportunities taken to improve community engagement Where services are being changed or developed proactive arrangements to pre-empt and address potential inequities in outcomes The development of a bespoke MOSAIC profile of the borough The PCT and RMBC jointly develop a Health Gain Schedule for provider services making at least tobacco, alcohol, affordable warmth and weight management everybody s business Systematic programme to strengthen the primary care workforce capacity to address access and health improvement issues National Support Team (NST) for Inequalities feedback presentation 2007) We need to ensure that these recommendations are built into plans going forward. One area that the NST raised as a national issue was the contribution of excess seasonal deaths to health outcomes. We have begun to look more closely at this issue This was highlighted by the NST as an area that makes a significant national contribution to health inequalities. In response to this we analysed the local data using the same analytical methods. Health Inequalities and deprivation In 2007 the updated Index of Multiple Deprivation (IMD) was produced. This is a good proxy for exploring if outcomes are improving within the Borough relative to other areas. Given the strong link between deprivation and poor health these maps need to inform our commissioning and provision of services. The above map highlights the areas that are in the most deprived 3%, 10% and 20% in the country. Due to the concern 11 regarding our inequalities in outcomes the local Joint Strategic Needs Assessment Board has chosen the 3% most deprived areas as a key focus of the first phase of the work. Consultation about the initial findings will take place in June 2008.

12 Deprivation at Small Area Level There are 135 Super Output Areas (SOAs) in Rochdale borough each having approximately 1500 people living in them. In the overall IMD 2007: 4 are in the 100 most deprived SOAs in England (compared with 2 in 2004) 16 are in the 3% most deprived SOAs in England (compared with 13 in 2004) (red areas) 36 are in the 10% most deprived SOAs in England (the same as in 2004) (dark green) 57 are in the 20% most deprived SOAs in England (compared with 58 in 2004) (light green) Are areas getting better or worse? The following map shows if areas are better or worse than Work is underway to try to understand the reasons thereby informing future action. This work is being led by the local authority, Neighbourhood Renewal Strategic Team. The 2010 timescale for increasing life expectancy and reducing mortality from CVD, cancers, infant mortality and suicide focuses attention on action to stop premature death for those at high risk. The key risk factors of smoking, obesity, diabetes and alcohol are increasing or not reducing sufficiently therefore these areas need urgent action if our improvements are to be sustained and improved furthered. To reduce the health inequalities gap within the Borough it is essential that all programmes (whether addressing the determinants of health, improved prevention, self help or care) are accessed by those who currently experience the poorest poorest outcomes. Further information and data on deprivation is available from RMBC Research and Intelligence - Richard Pinkney, Public Health Intelligence Analyst, Tel:

13 MOSAIC PROFILE OF THE BOROUGH On the recommendation of the National Inequalities Team, Heywood, Middleton and Rochdale PCT purchased the Mosaic Public Sector data from Experian Ltd for use in the Joint Strategic Needs Assessment work. Mosaic is a socio-economic classification system that uses 400 data items from all the households in England. 54% of the items are taken from the census and 46% from their consumer segmentation database which uses sources such as the electoral role, consumer credit activity, post office address file, shareholders and directors lists, house price data from the land registry, lifestyle surveys and local levels of into 11 Mosaic groups. This can then use to describe different subsets of the population by council tax banding. The noncensus data is updated at least annually. Qualitative research was used by Experian to validate the accuracy of data on the ground across the UK. Mosaic allocates post codes of every household to one of 243 Mosaic segments. These segments are aggregated into 61 Mosaic Lifestyle Types which are then aggregated indication of attitudes and values and types. Behaviours and types of media the may be more receptive to. There are some limitations to the data which needs to be taken into account when interpreting the Mosaic data for the Borough. Not every postcode matches exactly to one of the mosaic lifestyle types and they focus on types which individual cases approximate to with different degrees of accuracy. Households of the boundaries of areas may not be allocated to the most suitable catagory. Mosaic Public Sector Data Sources 54% of the data used to build Mosaic is sourced from the 2001 Census. The remaining 46% is derived from our Consumer Segmentation Database. It includes the edited Electorol Roll, Experian Lifestyle Survey information and Consumer Credit Activity, alongside Post Office Address File, Shareholders Register, House Price and Council Tax information. All of this information is updated annually. Qualitative research was also undertaken covering the whole of the UK. This validated the accuracy of Mosaic 'on the ground'. We employed a number of the UK's leading experts in the fields of consumer psychology, human geography and economics to interpret the classification. This research also links to a number of authoritative sources of market research, including BMRB's Target Group Index (TGI), The British Crime Survey, MORI's Financial Research, The Expenditure and Food Survey (EFS), Forrester's Technographics and Internet User Monitor, the English and Welsh Index of Multiple Deprivation, National Pupil Database, Health Survey for England and Hospital Episode Statistics. 13

14 The following tables show the overall Mosaic profile of the Borough of Rochdale and the table compares our Borough with the England population profile. This then identifies the population types that are under or over represented in the Borough. The index of 100 is the England average. Mosaic Public Sector Group Profile Mosaic Public Sector classifies all citizens in the United Kingdom by allocating them to one of 61 Types and 11 Groups. The Groups and Types in these profiles paint a rich picture of UK citizens in terms of their socio-economic and sociocultural behaviour. Mosaic Public Sector Groups Your area/file % Comp. % Pen. % Index A B C D E F G H I J K Career professionals living in sought after locations Younger families living in newer homes Older families living in suburbia Close-knit, inner city and manufacturing town communities Educated, young, single people living in areas of transient populations People living in social housing with uncertain employment in deprived areas Low income families living in estate based social housing Upwardly mobile families living in homes bought from social landlords Older people living in social housing with high care needs Independent older people with relatively active lifestyles People living in rural areas far from urbanisation 11, ,203, , ,842, , ,053, , ,816, ,048, , ,773, , ,234, , ,117, , ,536, , ,833, ,322, Total 207, ,782, Your Area/File vs Comparison Area/File By Mosaic Public Sector Groups 40 Percentage Your area/file Comparison Area/File A B C D E F G H I J K Mosaic Group 14

15 We can see from this table that in our Borough we have more households in catagories D, F, G and I. We have significant under representation of catagories A, J and K and we have no households in category E. The % of our population in each group is as follows with a comparison with the England average. Ranked Mosaic Groups Your area/ file % Comp. % Pen. % Index Group G 31, ,234, Group D 65, ,816, Group I 9, ,536, Group F 15, ,773, Group B 24, ,842, Group H 19, ,117, Group C 24, ,053, Group A 11, ,203, Group J 5, ,833, Group K ,322, Group E ,048, Total 207, ,782, The catagories are then broken down further and our main types within these segments are in the data section of this report. The top ten Mosaic types in our Borough are: Ranked Mosaic Type Your area/ file % Comp. % Pen. % Index Type 24 Low income families living in cramped Victorian terraced housing in inner city locations Type 23 Owners of affordable terraces built to house 19th century heavy industrial workers 3 Type 42 Families with school age children, living in very large social housing estates on the outskirts of provincial cities 4 Type 26 Communities of lowly paid factory workers, many of them of South Asian descent 5 Type 43 Older people, many in poor health from work in heavy industry, in low rise social housing 6 Type 15 Senior white collar workers many on the verge of a financially secure retirement 7 Type 12 Middle income families with children living in estates of modern private homes Type 37 Young families living in upper floors of social housing Type 44 Manual workers, many close to retirement, in low rise houses in exmanufacturing towns Type 21 Mixed communities of urban residents living in well built early 20th century housing

16 When we then look at the description of our main types they are as follows : The following map shows where our main groupings live in the Borough. USE OF MOSAIC Over the next year we will use the Mosaic classification system in key areas to assist our social marketing programme. We will profile priority issues and use the information to improve access to services, demand management, tackling inequity and inequalities. 16

17 RECOMMENDATIONS The following chapters detail the issues we need to address to improve our low levels of life expectancy. The following are my key recommendations for action if we are to address the unacceptable health inequalities local people experience: Cross Cutting 1. The clear ownership by all local partners of health outcomes and the. contribution they can make clearly outlined in business plans. 2. The commissioning, delivery and monitoring of action plans for each of the main contributors to low life expectancy. 3. Population health needs clearly considered and utilised in interventions and decisions. 4. Explicit consideration and tracking of the use of evidence from the Joint Strategic Needs Assessment process. 5. Joint strategy in place to increase community engagement and development particularly in areas of deprivation and for vulnerable groups. 6. Systematic programs to strengthen primary care capacity to address priority public health issues. 7. Use of equity audit tools to address inequalities in access and or outcomes. 8. Use of health impact assessment to ensure major developments and plans to improve health. Issue based 1. Further work by all partners to tackle excess winter deaths in relation to those aged years. 2. Further develop programmes across agencies to assess and manage peoples risk of cardiovascular disease (CVD). 3. Ensure that CVD programmes are accessed by those at greatest risk in the Borough. 4. Developing and ensuring equitable access to CVD treatment, care and rehabilitation. 5. Improving uptake of cancer screening programmes. 6. Diagnosing cancers early and fast access to treatment. 7. Prioritise and implement the local tobacco action plan. 8. Implement NICE guidance on smoking cessation. 9. Strengthen the work focusing on pregnant smokers and routine and manual workers. 10. Expand local weight management and physical activity schemes. 11. Develop local specialist obesity service. 12. Continue to monitor levels of obesity. 13. Evaluation of lifestyle schemes and redesign based on results. 14. Refresh the Healthy Lifestyle action plans and implement further Develop a coordinated social marketing programme across agencies on priority issues. 16. Re-emphasise the 5 A Day message and increase community development work on food issues. 17. Develop programmes to increase the availability of low cost healthy food. 18. Ensure a coordinated physical activity plan that focuses on those with low levels of activity. 19. Implement the UNICEF Community Baby Friendly programme. 20. Improve early access to midwifery and support services in pregnancy. 21. Maintain the focus on reducing teenage pregnancy. 22. Implement the Borough mental health promotion strategy. 23. Ensure the physical health needs of people with mental health problems are addressed. 24. Develop a multi agency suicide prevention strategy. 25. Implement the recommendations to prevent alcohol related harm focusing on hospital admissions. 26. Introduce the human papilloma virus (HPV) vaccination programme and ensure good uptake of all immunisation programmes 27. Maintain a focus on emergency preparedness and business continuity.

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19 CARDIOVASCULAR DISEASE CVD is the single biggest contributing cause to the gap in life expectancy in Rochdale Borough

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21 CARDIOVASCULAR DISEASE (CVD) Changes to modifiable risk factors, particularly smoking, during the period gained almost four times as many life years as cardiological treatments CONTEXT Cardiovascular Disease (CVD) is the single biggest contributing cause to the gap in life expectancy in Rochdale Borough. 46% of the life expectancy gap for men and 39% of the life expectancy gap for women is caused by deaths from circulatory disease (heart disease and strokes). The premature death rate in Rochdale from heart disease and stroke is higher than both the England and North West averages and is the third highest in England. Reducing premature death from CVD is a top priority crucial to closing the gap in life expectancy and enabling people in Rochdale to live longer, healthier lives. Death Rate per 100, Death Rate per 100,000 England & Wales North West Heywood, Middleton and Rochdale The following chart illustrates the progress currently being made toward the CVD target including the stretch trajectory (set because we are a spearhead Primary Care Trust) and the consistent reductions in mortality we need to see in Rochdale to start closing the gap in life expectancy. The yellow line shows the historic deaths and future projections for CVD deaths in England and Wales. The blue line shows past death rates and the future targets for reducing CVD deaths (including the stretch) for Rochdale if the 2010 target is to be achieved. Deaths per 100,000 for All Circulatory Disease (Age Under 75) 1993 to 2010 (Projected) Rate per 100, Rochdale Borough (actual data to 2006) England and Wales Linear (Rochdale Borough (actual data to 2006)) (OHN Baseline) Year

22 The following table explains the fall in CHD deaths and the contribution of various risk factors. Explaining the fall in Coronary Heart Disease deaths in England and Wales ( ) Risk Factors worse +13% Obesity (increase) +3.5% Diabetes (increase) +5% Physical activity (less) +4.5% Risk Factors better -71% Smoking -48% Cholesterol -9% Population BP fall -9% Deprivation -3% Other factors -8% Treatments -42% AMI Treatments -8% Secondary prevention -11% Heart failure -12% Angina: CABG & PTCA -4% Angina: Aspirin etc -5% Hypertension therapies -3% MONITORING PROGRESS IN CVD WORK Primary and secondary prevention work is driven forward and monitored by a number of strategic groups and networks that include patient input for example local cardiac support groups including Middleton Heartline. These groups met regularly during 2007 and include: The Rochdale Borough Coronary Heart Disease (CHD) local implementation team (LIT) which monitors progress toward the targets and milestones within the National Service Framework for Coronary Heart Disease. The Stroke LIT The North East Sector Cardiac Board - monitoring cross cutting work between the 4 PCTs in the NE Sector and Pennine Acute Hospitals NHS Trust (PAHT). The Cardiac Network - monitoring work across Greater Manchester and Cheshire. RAISING AWARENESS IN THE COMMUNITY During 2007 Heywood, Middleton and Rochdale became part of the Healthy Communities Programme to raise awareness of CVD risk factors in the population, particularly amongst harder to reach groups. We have a full time worker coordinating the programme and establishing local groups across the Borough. Longer term these groups will act as local initiators for awareness raising events and activities including encouraging people over 35 years of age to have a risk assessment completed by their GP or pharmacist. 22 WORKING WITH PRIMARY CARE PROVIDERS During 2007 work continued on establishing CVD risk registers in primary care. This work targets people aged who are smokers or have raised cholesterol or blood pressure and identifies them as eligible for CVD risk assessment. Anyone found to be at increased risk of developing CVD is put on a CVD risk register and is given appropriate lifestyle advice and/or medication to manage and reduce their risk. During 2007 Public Health visited each of the newly formed Practice Based commissioning groups to highlight the importance of prioritising CVD work, particularly work on the risk registers.

23 Actions for 2008 We have a clear action plan for 2008/09 focussed on work in the following areas: Equity Audit of heart disease registers - to determine if those on registers are receiving optimum services and treatment Audit of CVD deaths - to determine if those patients received optimum care in primary care Audit of smokers on CHD registers Increasing the number of patients on CHD registers whose blood pressure and cholesterol are managed Effectively increasing the numbers of patients on hypertensive registers Increase numbers receiving risk assessment Expand and develop the work of the healthy communities collaborative with all agencies Expand cardiac rehabilitation Work with NE Sector PCTs and Pennine Acute Hospital to deliver improved patient pathways, shared goals around reducing morbidity and mortality and the NE Sector reconfiguration plans for the locality hospital. TACKLING INEQUALITIES IN CVD Evidence suggests that people in lower socio-economic groups are more likely to be at increased risk of developing CVD including higher numbers of smokers, and more people with raised blood pressure, raised cholesterol and increased body fat/body mass index (BMI). Some studies have indicated that socio-economic status has an effect both on the rate of occurrence, and rate of survival after coronary events suggesting that socio-economic grouping affects not merely death rates from myocardial infarction, but also rates of heart attack and chance of admission to hospital. A visit to HMRPCT at the end of 2007 from the National Support Team for Health Inequalities gave us the opportunity to really focus on the actions we need to take to address both CVD and local inequalities. As a result of this visit, during 2008 we will be carrying out a health equity audit of our practice based CHD registers to explore a range of issues including age, gender, postcode, ethnicity and access to medication. Alongside this we will carry out a retrospective audit of deaths from CVD to assess whether patients received optimum primary and secondary care interventions. THE EVIDENCE BASE Nationally, deaths from Coronary Heart Disease have been falling over time, and this is also the case in Rochdale. A major study has analysed the factors which have contributed to the fall in deaths in England and Wales during the period (ref) and has found that modifiable risk factor changes including reducing smoking, reducing cholesterol levels, reducing blood pressure and improvements in social and 23 economic deprivation explain a greater proportion of the decline in deaths than medical treatments, this finding has been repeated by other large studies across the world. Primary prevention has a greater impact on reducing mortality than risk factor reduction in patients with CHD - secondary prevention. The greatest impact overall has come from the fall in smoking prevalence during this time period, although some of the reduction in mortality attributable to risk factor reduction has been wiped out by an increase in other risk factors such as obesity, diabetes and lack of physical activity. Changes to modifiable risk factors during gained almost four times as many life years as cardiological treatments. The cornerstones of our local approach to reducing mortality from CVD include improving access to cardiac treatments and risk factor changes for those with existing CVD, and tackling primary prevention by changing modifiable risk factors including smoking, diet, physical activity, reducing obesity (particularly abdominal obesity) and reducing cholesterol and blood pressure. The breadth of this work is described in the multi agency Healthy Lifestyles Strategy and the associated action plans, which aim to deliver or expand upon a range of lifestyle change programmes of activity across the Borough. REFERENCE (Unal B et al Explaining the Decline in Coronary Heart Disease mortality in England and Wales between Circulation 109 (9)

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25 RESPIRATORY HEALTH Quote needed

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27 RESPIRATORY HEALTH Social inequality causes a higher proportion of deaths in respiratory disease than any other disease area 44% of all deaths from respiratory disease are associated with social inequalities compared with 28% of deaths from Ischaemic Heart Disease CONTEXT Respiratory disease covers a range of conditions including asthma, chronic obstructive pulmonary disease COPD and cancers. This chapter will concentrate on those respiratory conditions that make the biggest contribution to the reduced life expectancy in the Borough. Respiratory diseases are a huge health and economic burden in the UK, a higher proportion of people consult their GP for respiratory conditions each year than for any other group of diseases. Combined lung cancer and nonmalignant respiratory disease cause around 1 in 4 deaths in the UK. Cancer (with the exception of Mesothelioma) is dealt with in a separate chapter of this report. British Thoracic Society (2001) Burden of lung disease 27

28 CHRONIC OBSTRUCTIVE AIRWAYS DISEASE Nearly 900,000 people in the UK are diagnosed as having Chronic Obstructive Pulmonary Disease (COPD) and half as many are thought to be living with undiagnosed COPD (National Collaborating Centre for Chronic Conditions 2004). COPD is the term used to describe patients who in the past may have been diagnosed with Chronic Bronchitis, Emphysema, or Chronic Obstructive Airways Disease (COAD). Pulmonary diseases have become an increasingly important cause of morbidity and mortality. COPD is the most common lung disease and major cause of disability and death (GOLD 2001). The disease is predominately caused by smoking (NICE 2004) and affects about one in 6 smokers (British Thoracic Society, BTS 2001). Standard therapy is important in alleviating the symptoms of COPD, particularly the distressing symptom of breathlessness. However, many patients living with COPD are left to cope with a chronic, irreversible and disabling disease process. LOCAL PREVALENCE Over recent years, the number of people within the Borough diagnosed with COPD has gradually increased. This trend is set to continue with an estimated 5.11% of our current population having COPD (Eastern Region Public Health Observatory 2007). However only 1.76% of of patients registered with GP practices have a diagnosis of COPD (QMAS data). Many patients are therefore first diagnosed when they have an unplanned admission to hospital with respiratory problems. Early intervention and structured care management can prevent this from happening and can slow the progress of the disease and it s subsequent impact on the individual and on services. The under identification of cases with a subsequent lack of structured care increases the costs to the Primary Care Trust e.g. emergency admissions between cost 1,517,079, this is increased by protracted lengths of stay in many of these cases. HMRPCT has a slightly lower average length of stay of 9.35 days and 5.9 days in comparison to national average figures of and 6.3 days for COPD with and without complications, respectively. The predicted costs for for emergency admissions alone is 1,551,339 (based on activity data) if the service provision remains unchanged. Current service provision for COPD in borough is not yet fully compliant with NICE guidance and will need to be developed in order to meet the current and anticipated future needs of residents. The focus should be on the development of community based services that will meet care guidelines and reduce inpatient costs, by having a focus on prevention, early detection and case management. COPD WORKFORCE PROJECT The aim of this project was to establish a robust community based, patient centred COPD service, ensuring equitable high quality care is provided for all registered patients with COPD across the Borough, close to the patient s home where possible. A number of GPs and practice nurses across the PCT have undertaken a diploma in the management of Asthma and COPD. The COPD workforce project was undertaken by a multidisciplinary group with membership representing health and social care. An integrated service and workforce planning model was adopted (the NHS North West, Brookes and Bosma 2003, 5 step model) to shape the proposed development of services and associated workforce planning to deliver model for patients with COPD based on the need. The model is patient centred and supports planning across traditional health and social care boundaries to provide integrated care. Patient involvement in the planning processes was also achieved by having a breathe easy representative on the group from the regional British Lung Foundation office in Liverpool. The needs of the client group were assessed from likely numbers with undiagnosed COPD through to end of life care needs. This was then mapped against current service provision and a workforce development plan produced. The next step is to develop an action plan for the implementation of the project findings across the PCT. 28

29 This will include: Providing people with quality and timely care Providing accurate information, advice and education about the condition Ensure early identification of risks Reducing the overall length of stay through appropriate early supported discharge Age Specific Death Rates (ASDRs) for COPD - Heywood, Middleton and Rochdale PCT Rate per 100, Predicted Future Trend for Mortality from COPD in HMR PCT Rate per 100, The aim of local services is to reduce illness and death from COPD and through this to improve life expectancy. The trend for death from COPD shows a reduction over the next five years but the rate of decline might be slower than the trend based on the data might suggest. However, as long as the prevalence of smoking in the Borough does not increase then the incidence of COPD in the Borough is not expected to rise. 29

30 RECOMMENDATION HMRPCT to support the development of community based services for local people living with COPD by implementing the recommendations of the COPD Workforce project. EXCESS WINTER DEATHS Although the Borough does better than nationally in avoiding excess winter deaths the biggest contributors to the excess deaths seen are heart disease (see chapter) and chest infections. As can be seen from the below table the RMBC area is, with the exception of the 65 to 74 age group, well below the regional and national average for excess winter deaths. However we do see an excess and the data has been analysed in an attempt to identify the biggest contributors to this. HMRPCT Excess Winter deaths (shown as a percentage of all deaths) 2005 to 2006 Age group RMBC NW E&W total to 2007 Age group RMBC NW E&W total Excess Seasonal deaths by disease group all ages 30

31 The age group where we see the highest rates of excess winter deaths is the 65 to 74 age group where respiratory causes are the single biggest contributor. COPD will contribute to this figure which Excess Seasonal deaths by cause ages 65 to 74 strengthens the case further for the recommendations around developing services for this group of patients. Asbestos and Mesothelioma An area of local concern is the impact of the disused decommissioned Turner and Newell Asbestos factory on the health of the local population and in particular on the incidence of Mesothelioma. Nationaly there is a marked increase in deaths from Industrial lung disease (including mesothelioma). However, locally, we are not currently seeing this trend. There is no increase in Mesothelioma deaths over the period from 2003 to 2007 Mesothelioma deaths in HMR: However, we need to continue to monitor this given the local history of exposure to asbestos in the community working in and living around the old factory site. In planning the future use of the land the issue of asbestos contamination must be fully addressed. British Thoracic Society (2001) Burden of lung disease 31

32 DIABETES Diabetes is a serious and lifelong disease where the body fails to produce enough insulin and is therefore unable to control the amount of sugar in the blood. Without proper management it can lead to a number of complications including foot ulcers and diabetic retinopathy which if not managed can lead to amputations and blindness. Untreated it will also result in premature death. There are two forms of diabetes type 1 and type 2. Type one usually presents in childhood and is insulin dependent, type 2 is often referred to as adult onset diabetes and ranges in severity from being managed through controlling the diet to being insulin dependent. Type 2 diabetes is commoner in some ethnic minority groups including those from the Indian Subcontinent and the incidence is increasing in all population linked to obesity and poor diet. Whilst there is no cure, early diagnosis and good management will significantly reduce the risk of complications and premature death. The predicted prevalence of diabetes for the Borough is in excess of 11,500 people (by 2010) and whilst screening in primary care is identifying people with diabetes the number on the diabetes register is still well below expected, the latest figure was 9,458 in March Work is underway to Provide high quality information at the time of initial diagnosis Provide relevant patient education courses Expand the diabetic retinopathy screening service Expand foot care services A comprehensive review of services will be undertaken during 2008 to identify potential gaps in capacity in order that the PCT can ensure there is sufficient capacity in local services to meet the predicted needs of the expected 11,500 people who will be diagnosed with diabetes by 2010 and to ensure that those services are accessible, equitable and meet the needs of different patient groups. Mortality from Diabetes ASDRs for Diabetes - Heywood, Middleton and Rochdale PCT Rate per 100,

33 Predicted Future Trend for Mortality from Diabetes in HMR PCT Rate per 100, RECOMMENDATIONS That the PCT continue to develop the Expert Patient Program for patients living with long term conditions The development of the Looking After Me course to support carers of people with long term conditions Evaluation and if appropriate expansion of the Self Care for People pilot aimed at the hardest to reach groups in the Borough Development of appropriate psychological support for people in the Borough with long term conditions Increased screening in primary care for long term conditions, Diabetes and COPD in particular to ensure that all those with this type of disease (or at risk of developing it) are identified and receive appropriate treatment with regular reviews That the number of people with chronic respiratory conditions who have their diagnosis confirmed by spirometrty is increased The maintenance and expansion of appropriate warning systems for patients with long term conditions e.g. early warning of adverse air quality conditions for patients with COPD. REFERENCES British Thoracic Society (2001) Burden of lung disease. A statistics report from the British Thoracic Society. BTSpages.pdf Brookes, C. & Bosma, T (2003). A patient centred approach to workforce planning. The University of Manchester Eastern Region Public Health Observatory (2007) Global Initiative for Chronic Obstructive Lung Disease (2004) Update: Executive Summary, Global Strategy for the Diagnosis, Management, and Prevention of COPD. National Institute for Clinical Excellence (2004). Chronic Obstructive Pulmonary Disease. Management of Chronic Obstructive Pulmonary Disease in Adults in Primary and Secondary Care. Clinical Guideline 12. NHS: 1-54 Royal College of General Practitioners. Morbidity Statistics from General Practice. Fourth National study. 33

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35 CANCER Remember that although cancer will affect one in three people in the UK in their lifetime, most cases occur in people over the age of 65. And today, more people in this country survive cancer than ever before. Cancer Research UK

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37 CANCER Smoking is the single largest preventable risk factor for cancer INTRODUCTION Cancer is one of the biggest contributors to the health inequalities gap in the Borough. Currently there are, on average, an extra 20 deaths a year from cancer in those aged under 75 (16 of which are from lung cancer). Patients, once known to the healthcare system, access care in a timely manner and survival rates are generally good. However, there is increased incidence in most cancers and in particular those associated with tobacco use. There is some evidence to suggest that later presentation to services may be a factor in the poorer outcomes seen locally. The outcomes evidence suggests that not all individuals with cancer are currently seeking treatment early enough. A study is currently underway to look at the stages of cancer at presentation across the North West to confirm whether or not there is an issue with late presentation to services. The biggest preventable contributory factor is tobacco use and the recent cancer reform strategy suggests that over half of all cancers could be prevented by changes to lifestyle. Currently all patients with suspected breast, bowel or lung cancer are seen within two weeks of referral and are treated within the timescales set by the NHS (31 and 62 days). This will shortly be extended to include all suspected cancers and women with nonspecific breast symptoms. Targets The following are the key targets relating to cancer: Type of Target Headline Description Public Service Agreements Cancer Under 75s By 2010:20% reduction Under 75s 6% reduction in inequalities gap (bottom fifth most deprived v rest) Public Service Agreements Life Expectancy Reduce health inequalities by 10% by 2010 PCT Business Plan pledges: This commissioning plan contributes to the delivery of the following pledges within the PCT s Business Plan (2007). within 3 years to reduce mortality rates from cancer by 20% in people under 75 within 5 years to help men to live 18 months and women to live 12 months longer on average 37

38 Cancer Needs and Progress to date Locally we had been seeing an increase in the rates of cancer in the under 75s until last year which showed a marked decrease. Early figures suggest this may go up again slightly next year. Trends in cancer death rates (including Local Development Plan (LDP) trajectory to 2010). Deaths per 100,000 for All Cancers (Age Under 75) 1993 to 2010 (Projected) Rate per 100, (OHN Baseline) Year Rochdale Borough England and Wales Linear (Rochdale Borough) The cancer deaths chart above shows a marked improvement in the data for 2006 which has put us back on trajectory to achieve our target. However early data for 2007 suggests that the figure for that year will be higher than that seen in Cancer deaths (including projected figure for 2007). Deaths per 100,000 for All Cancers (Age Under 75) with Estimate for Rate per 100, Rochdale Borough England and Wales Linear (Rochdale Borough) (OHN Baseline) Year Overall there is still an improvement but the biggest contributor to the higher death rate is still smoking related cancers. 38

39 SCREENING Cervical Currently our uptake rates are 79.3% for cervical screening compared to a National figure of 79.5%. We are about to undertake an audit of the programme to identify where the uptake is lowest and the reasons for this. Then we will make the required adjustments to the delivery of the programme with the aim of increasing uptake above 80% (a target we achieved until the latest data year). Breast Uptake rates for Breast Cancer screening are 74.4% compared to a National Rate of 76%. We are working with the Screening Programme to identify additional sites for the Screening Van across the Borough, including one at the new joint services centre in Heywood. This will improve accessibility to the service for local women and should therefore increase the uptake of the service. We have just completed a catch up programme with the screening service and are planning a waiting list initiative for 2008, to ensure our round length (the time between screening invitations) is now within the National target of 36 months. The new National Bowel Screening Programme has been offered within the Borough since March Information letters and testing kits will be sent to all those in the Borough between the ages of 60 and 69 years. It is planned to increase the upper age to 75 by 2010 however from the beginning of the program anyone over the age of 70 can request a kit. All eligible individuals will have kits sent to them every two years, it will take the two year period to cover all of the eligible individuals in the Borough. The test is self administered (the kits come with step by step instructions). Results are sent to both the patient and the GP. The interval between screening tests is two years. Prostate Prostate cancer screening is available through General Practice in line with National Guidance. The National Cancer Strategy and the North West Cancer Plan have included within them plans for the required infrastructure development, including workforce capacity planning to maintain and develop these services. We will be working closely with our partner agencies to ensure these plans are implemented. Whilst screening programmes achieve their uptake rates across the borough the incidence of both Breast and Cervical cancer locally suggests that there must be areas where the uptake is well below that needed to reduce cancer rates. Increased uptake of screening needs to be targeted to these areas. SERVICE DEVELOPMENT The recent government publication The Cancer Reform Strategy reviewed the evidence and set out the following strategy and good practice guidance: Preventing cancer Over half of all cancers could be prevented by changes to lifestyles therefore improving awareness and encouraging people to adopt healthy lifestyles is crucial to improving cancer outcomes. Smoking is the single largest 39 preventable risk factor for cancer and the evidence linking obesity to cancer is strengthening. Excessive alcohol consumption is strongly linked to an increased risk of several cancers and skin cancer incidence is rising rapidly nationally. The availability of a vaccine for Human Papiloma Virus (HPV) presents an opportunity for cervical cancer prevention. Please see the Healthy Lifestyles section for more information The PCT will be implementing the HPV immunisation program in line with National Guidance. This will protect young women from one of the causes of cervical cancer. Diagnosing cancer earlier In general, the earlier a cancer is diagnosed the greater the chance of a cure. This means that awareness of the signs of cancer and easy access to diagnostic services is key to reducing the death rate from cancer. Community development, health trainers and social marketing will all provide local support for national campaigns to raise awareness. Screening is vital to diagnosing some cancers early and there are plans to build on these programmes nationally which will have local implications. These include: Increase the number taking up screening. Extending breast screening to between 47 and 73, facilitated by digital mammography. Expanding the bowel screening programme.