TEES JSNA WEBSITE


Date: 22/11/2019

Tees JSNA

Welcome to the website for Joint Strategic Needs Assessment (JSNA) in the Tees area.  The website contains a JSNA for each of the four Tees areas: Hartlepool, Middlesbrough, Redcar & Cleveland and Stockton-on-Tees.

Content for each of the JSNAs is arranged into five themes, with detailed topic contented available within each theme, as follows:

People
  • Children
  • Transition years
  • Adults
  • Older people
Vulnerable Groups
  • Learning disabilities
  • Autism (content in learning disabilities topic for Middlesbrough and Stockton)
  • Physical disabilities
  • Sensory disabilities
  • Sexual violence victims
  • Domestic violence victims
  • Carers
  • End of life care
  • Ex-forces personnel
  • Migrants
  • Travellers
  • Offenders
Wider Determinants
  • Crime
  • Education
  • Employment
  • Environment
  • Housing
  • Poverty
  • Transport
Behaviour and Lifestyle
  • Alcohol misuse
  • Illicit drug use
  • Smoking
  • Diet and nutrition
  • Physical inactivity
  • Obesity
  • Sexual health
Illness and Death
  • Cancer
  • Circulatory diseases
  • Diabetes mellitus
  • Injuries
  • Mental health and behavioural disorders
  • Oral health
  • Respiratory diseases
  • Self-harm and suicide

Core data has also been uploaded for population age and sex structure, ethnicity, births, deaths, life expectancy and some ward-level population data.  There are some details regarding Mosaic in the Segmentation section.

Previous JSNAs for each partnership area can be found at www.teespublichealth.nhs.uk.



Hartlepool

Hartlepool's Joint Strategic Needs Assessment (JSNA) can now be found at:

http://www.hartlepool.gov.uk/jsna



Submenu Links


A to Z


Middlesbrough

The Joint Strategic Needs Assessment has been developed jointly by a range of partners that all have an interest in understanding the multiple overlapping needs of our children, young people, adults and older people. The JSNA helps us to understand the key issues we face in improving the health and wellbeing of our population.  Going forward this will become a live document, shared with partners and embedded within individual performance management arrangements to ensure that it informs practice and commissioning priorities.

 

As Middlesbrough Council is working to finalise the newest iteration of the Joint Strategic Needs Assessment, the content on this site for both Children and Young People and Adults and Older People represents the previously published JSNA for Middlesbrough.

 

For more information read Middlesbrough's Children and Young People JSNA here -  http://middlesbrough.gov.uk/sites/default/files/Children-Young-People-JSNA-Nov18.pdf

 

The Joint Strategic Needs Assessment for Adults and Older People will be published in 2019.

 

Please forward any queries to Nicola Mahood – JSNA Co-ordinator – email: Nicola_mahood@middlesbrough.gov.uk – Tel: 01642 729299



Submenu Links


Executive Summary

Unmet needs and commissioning intentions arising from Middlesbrough JSNA 2012-15

 



Steering Group


Core Strategies

Middlesbrough Joint Health and Wellbeing Strategy 2013-2023

NHS South Tees Clinical Commissioning Group A Clear and Credible Plan for Commissioning Health Services for the Populations of Redcar and Cleveland and Middlesbrough 2012-2017

NHS Sustainability and Transformation Plan (STP) 2016-2021

 

Director of Public Health Annual Reports

Dementia Friendly Middlesbrough - Director of Public Health Annual Report 2015/16

Mental health and emotional wellbeing in Middlesbrough - DPH Annual Report 2014/15

Moving upstream: Middlesbrough Director of Public Health Annual Report 2013

 



Population


Intelligence


Inequalities
Segmenting life expectancy by cause of death

Public Health England has developed a resource which provides information on the causes of death that are driving inequalities in life expectancy at local area level. Targeting the causes of death which contribute most to the life expectancy gap should have the biggest impact on reducing inequalities.

For males and females, the tool provides data tables and charts showing the breakdown of the life expectancy gap in 2012-14 for two comparisons:

  • The gap between the Local Authority as a whole and England as a whole.
  • The gap between the most deprived quintile and the least deprived quintile within the Local Authority.

 

The gap between Middlesbrough and England
For both men and women, the largest portion of the gap between Middlesbrough and England is caused by higher rates of cancer mortality.  Within the cancer category, lung cancer is a main contributor to the gap.  External causes (such as suicide and accidents), circulatory diseases and respiratory diseases have large contribution to the gap for men. Respiratory diseases and circulatory diseases significantly contribute to the gap for women.

Middlesbrough inequality gaps with England cause of death scarf chart 2012-14

 

The gap within Middlesbrough

For women, cancer forms the largest part of the gap between the most and least deprived communities in Middlesbrough, whereas for men, circulatory diseases have the greatest contribution to the gap.  For males, external causes of death  have a much greater contribution to the gap between deprived and affluent communities in Middlesbrough compared with females.

Middlesbrough gap in cause of death most and least deprived, 2012-14

Full details, including number of deaths and numbers of excess deaths can be found in The Segment Tool: Key results for Middlesbrough.

 

Premature mortality

Premature mortality, that is to say deaths before age 75 years, is a symptom of high disease burden as well as underlying health inequalities.  Know your numbers: premature mortality provides an analysis of the main causes of premature mortality in Tees Valley, and estimates how many premature deaths would need to be prevented to achieve rates similar to the North East and England.  In Middlesbrough the greatest burden of premature mortality is due to cancer, followed by circulatory disease.

Middlesbrough premature mortality rates and numbers

 



A to Z


People

Summary of topics.

Content under development, see individual topic pages for details.



Children and Young People

The Joint Strategic Needs Assessment has been developed jointly by a range of partners that all have an interest in understanding the multiple overlapping needs of our children, young people, adults and older people. The JSNA helps us to understand the key issues we face in improving the health and wellbeing of our population.  Going forward this will become a live document, shared with partners and embedded within individual performance management arrangements to ensure that it informs practice and commissioning priorities.

 

As Middlesbrough Council is working to finalise the newest iteration of the Joint Strategic Needs Assessment, the content on this site for both Children and Young People and Adults and Older People represents the previously published JSNA for Middlesbrough.

 

For more information read Middlesbrough's Children and Young People JSNA here -  http://middlesbrough.gov.uk/sites/default/files/Children-Young-People-JSNA-Nov18.pdf

 

The Joint Strategic Needs Assessment for Adults and Older People will be published in 2019.

 

Please forward any queries to Nicola Mahood – JSNA Co-ordinator – email: Nicola_mahood@middlesbrough.gov.uk – Tel: 01642 729299

 



Adults and Older People

The Joint Strategic Needs Assessment has been developed jointly by a range of partners that all have an interest in understanding the multiple overlapping needs of our children, young people, adults and older people. The JSNA helps us to understand the key issues we face in improving the health and wellbeing of our population.  Going forward this will become a live document, shared with partners and embedded within individual performance management arrangements to ensure that it informs practice and commissioning priorities.

 

As Middlesbrough Council is working to finalise the newest iteration of the Joint Strategic Needs Assessment, the content on this site for both Children and Young People and Adults and Older People represents the previously published JSNA for Middlesbrough.

 

The Joint Strategic Needs Assessment for Adults and Older People will be published in 2019.

 

Please forward any queries to Nicola Mahood – JSNA Co-ordinator – email: Nicola_mahood@middlesbrough.gov.uk – Tel: 01642 729299

 



Vulnerable Groups
Introduction

Some people are more vulnerable to poor health than others.  This poor health may arise for a variety of reasons, including the effects of deprivation and difficulty accessing services.  The health needs of vulnerable groups are often complex and require a co-ordinated and flexible response from services. It is easy for clients to fall into the gaps between different services leading to unplanned care and the risk of clients revolving through the system.

This theme summary groups together the complex health needs of many vulnerable groups, some of which may overlap and others that are highly specific.


Learning disabilities and Autism

  • Ensure the availability of choice and cost-effective provision which meets needs locally.
  • Promote personalised systems which place the person at the heart of any process, provide information and advice, and stimulate universal access to all services.

Physical disabilities and Sensory disabilities

  • Demand for community-based services is increasing, with increased requirement for supported living and reduced reliance upon residential care.
  • Promote personalised systems which place the person at the heart of any process, provide information and advice and stimulate universal access to all services.
  • The number of older people with moderate or severe visual impairment is expected to increase from about 2,000 in 2014 to 2,700 in 2030, a 35% increase.  There will be a similar increase in those with moderate or severe hearing impairment, from 9,800 to 13,400

Domestic violence victims and Sexual violence victims

  • It is believed that many cases of both domestic and sexual violence are unreported.
  • The majority of known sexual violence victims are female and aged under 25 years.  Women are more likely to suffer domestic violence, particularly those aged under 30 years.
  • People from vulnerable groups (those with a physical disability, learning impairment and mental illness) are more likely to experience sexual violence, but may have difficulty verbalising their abuse.
  • There is a need for better data collection to enable improved analysis.

Carers and End of life care

  • A comprehensive assessment of carers’ needs is required.  There is a high number of carers who are unknown to carer support services.
  • Remove the stigma surrounding death and dying.  Encourage healthcare professionals and people with end of life care needs, their families and carers to engage in open conversations.
  • Increase choice and personalisation within integrated, high quality services that meet the needs of people approaching the end of life.

Migrants and Travellers

  • Ensure migrants and travellers are aware of local health, care and education services and that these services are responsive to individual needs.


Ex-forces personnel

  • Provide adequate signposting to health and care services for armed service leavers.
  • Former forces personnel are more likely to need mental health care and rates of alcohol misuse are higher than for the general population.  This is particularly so for younger, male veterans who held lower ranks and were exposed to combat.
  • A small but significant proportion of veterans experience homelessness.

Offenders

  • Prisoners have high rates of: poor mental health; alcohol and substance misuse; smoking; suicide and attempted suicide; and learning disabilities.
  • There are high levels of educational need.  About half of male, sentenced prisoners were previously excluded from school compared with 2% in the general population.
  • Offenders have increased difficulty in accessing employment and housing, and tend to be socially isolated.
Recommendations

The recommendations below relate to the Marmot review: Fair Society, Healthy Lives, the former National Support Team recommendations for tackling Health Inequalities and latest national policy and professional guidance.

Short-term (1-2 years)

  • Continue to develop personalised services and further improve access to universal services for vulnerable groups.
  • Improve data collection, in particular, identification of vulnerable members of society who are unknown to local services.

Medium-term (3-5 years)

  • Increase the supply of housing which meets the needs of vulnerable groups.

Long-term (over 5 years)

  • Ensure that service capacity is sufficient for the anticipated increase in some of these vulnerable groups, particularly those with physical and sensory disabilities.

 

 

 

Summary author

Leon Green
Public Health Intelligence Specialist
Tees Valley Public Health Shared Service
 



Learning disabilities

A learning disability affects the way a person learns new things in any area of life.  It affects the way they understand information and how they communicate.  Learning disability can be defined as:

  • the presence of a significantly reduced ability to understand new or complex information, to learn new skills (impaired intelligence, often defined as an IQ level of 70 or less), with;
  • a reduced ability to cope independently (impaired social functioning);
  • which started before adulthood, with a lasting effect on development.

People with a learning disability can have difficulty understanding new or complex information, learning new skills and coping independently.  A learning disability can be mild, moderate or severe. Some people with a mild learning disability can talk easily and look after themselves, but take a bit longer than usual to learn new skills. Others may not be able to communicate at all and may have more than one disability.

Adults with learning disabilities are one of the most vulnerable groups in society, experiencing health inequalities, social exclusion and stigmatisation.  In general, adults with learning disabilities have greater and more complex health needs than the general population, and often these needs are not identified or treated.  Life expectancy of this group is shorter than the general population.  Adults with learning disabilities often experience barriers to accessing healthcare services, and poor levels of care.  They are more likely to die from a preventable cause than the general population.  Health needs amongst adults with a learning disability are different to the general population.

There are about 1.5 million people in the UK with learning disabilities.

This topic is linked with:

 



Autism

This subject is included in the Learning disabilities topic.



Physical disabilities

The Equality Act 2010 defines disability as an impairment that has a substantial and long-term adverse effect on a person’s ability to perform normal day-to-day activities. Such impairments can vary considerably and include both congenital and acquired disabilities.

In England it is estimated that there are 3.3 million people aged 16-64 with a moderate or severe physical disability (PANSI, 2012).  In addition there are 4.3 million people aged 65 and over with a limiting long-term illness (POPPI, 2012).  Furthermore an estimated 0.8 million children in the UK have a disability (DWP, 2012), approximately 670,000 in England.  Combining these shows about 8.3 million people in England have a physical disability.

People with physical impairments face many barriers to living a fulfilling and independent life. Not only do they have the practical problems of everyday life to struggle with that a physical disability brings but they have to face the negative public perceptions of disabled people and problems gaining access to everyday facilities and services. The support required for people with physical impairment may be multi-dimensional and therefore needs to be tailored to address their specific individual needs.

People with physical impairment also face prejudice.  Prejudice is not always hostile; benevolent prejudice results from the belief that a disabled person needs looking after.  Benevolent prejudice can be just as consequential as hostile prejudice, making it likely disabled people will be treated less favourably in respect of the opportunity for advancement because they are seen as less capable.

This topic is most closely linked with:

 



Sensory disabilities

Sensory disabilities refer to visual and hearing impairment.

Visual impairment (blind or partially sighted)

There are two main areas that are looked at when measuring a person’s vision:

  • Visual acuity: This is the central vision used to look at objects in detail, such as reading a book or watching television;
  • Visual field: This is the ability to see around the edge of your vision while looking straight ahead.

Hearing impairment (hard of hearing or deafness)

There are three main types of hearing loss:

  • Conductive hearing loss: Sounds are unable to pass from the outer ear to the inner ear, often as the result of a blockage such as earwaxglue ear or a build-up of fluid due to an ear infection, a perforated ear drum or a disorder of the hearing bones;
  • Sensorineural hearing loss: Sensitive hair cells either inside the cochlea or the auditory nerve are damaged, either naturally through ageing, or as a result of injury;
  • Mixed hearing loss: It is possible to get both types of hearing loss at the same time.

Dual sensory impairment

Dual sensory impairment is the combined loss of hearing and vision.

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Evidence indicates that the prevalence of visual and hearing impairments increases with age. With an ageing population, this means there will be more people acquiring these conditions.

Most sensory impairments develop gradually and are often secondary to other disabilities.

The impact of sensory loss and other health determinants can dramatically increase risk and demand on health and social care services. 

People with sensory loss are at greater risk of social isolation.

It is estimated there are more than ten million people in the UK with some form of hearing loss.

There are around 360,000 people who are registered as visually impaired in England. As many as 2 million people in the UK may be living with some degree of visual impairment.

It is estimated that around 1 in 5 people over the age of 75-years-old have some degree of visual impairment.

Age-related macular degeneration leading cause of blindness in adults. Other significant causes of sight loss are glaucoma, cataracts and diabetic retinopathy.

For adults with sight loss there is a correlated loss of independence and an increased   risk of poverty.

Sensory disabilities is linked with the following JSNA topics:

Carers

Employment

Housing

Transport

Education

Diabetes

Mental and behavioural disorders



Sexual violence victims

Introduction

Sexual violence is any unwanted behaviour perceived to be of a sexual nature or sexual contact that takes place without consent or mutual understanding.

The World Health Organisation defines sexual violence as:    

“Any sexual act, attempt to obtain a sexual act, unwanted sexual comments or advances, or acts to traffic, directed against a person’s sexuality using coercion, by any person regardless of their relationship to the victim, in any setting, including the home” (World Health Organisation Report on Violence and Health, 2002)

There are two sub-categories of sexual offences depending on the seriousness of the crime:

  • Serious sexual crime including rapes, sexual assaults, and sexual activity with children;
  • Other sexual offences (including soliciting, exploitation of prostitution, and other unlawful sexual activity between consenting adults).

 

The effects of sexual violence on victims can include depression, anxiety, post-traumatic stress disorder, drug and substance misuse, self-harm and suicide. However, when victims receive the support they need when they need it, they are more likely to take positive steps to recovery. It is therefore important that victims of sexual violence have good access to effective services, whether or not they wish to report incidents to the police. 

It is estimated that in England & Wales, up to 9 in 10 cases of rape go unreported and 38 per cent of serious sexual assault victims tell no one about their experience. Each adult rape is estimated to cost over £76,000 in its emotional and physical impact on the victim, lost economic output due to convalescence, early treatment costs to the health service and costs incurred in the criminal justice system. The overall cost to society of sexual offences in 2003-04 was estimated at £8.5 billion.

Addressing the needs of victims of sexual violence through the provision of accessible specialist services can deliver benefits in terms of better health and well-being and quality of life. There are also long-term productivity savings in services and costs to society when the immediate effects of sexual assault are managed effectively.

This topic links with the following JSNA topics:

Sexual health

Sensory disabilities

Physical disabilities



Domestic violence victims

The cross-government definition of Domestic Violence and Abuse (DVA) is:

“Any incident or pattern of incidents of controlling, coercive or threatening behaviour,  violence or abuse between those aged 16 or over who are or have been intimate partners or family members regardless of gender or sexuality. This can encompass but is not limited to the following types of abuse:

  • psychological
  • physical
  • sexual
  • financial
  • emotional

Controlling behaviour is: a range of acts designed to make a person subordinate and/or dependent by isolating them from sources of support, exploiting their resources and capacities for personal gain, depriving them of the means needed for independence, resistance and escape and regulating their everyday behaviour.

Coercive behaviour is: an act or a pattern of acts of assault, threats, humiliation and intimidation or other abuse that is used to harm, punish, or frighten their victim.”[1]

The Government definition which is not a legal definition, includes so called ‘honour’ based violence, female genital mutilation (FGM) and forced marriage, and is clear that victims are not confined to one gender or ethnicity.

The Crime Survey for England & Wales (CSEW) 2012/13 found that, overall, 30% of women and 16.3% of men had experienced any domestic abuse since the age of 16. These figures were equivalent to an estimated 4.9 million female victims of domestic abuse and 2.7 million male victims

On average about seven women and two men are killed by their current or former partner every month in England and Wales (ONS 2012/13)

The relationship between the effects of domestic violence, physical and mental well-being is well documented. Psychological and physical effects of abuse can be felt for many years often with the continuation of psychological/mental health issues, chronic physical health problems as well familial and socioeconomic impacts.

Domestic violence is linked most closely to the following JSNA topics:

Crime

Alcohol misuse

Mental and behavioural disorders



Carers

A carer is someone who helps another person, usually a relative or friend, in their day-to-day life. This is not the same as someone who provides care professionally, or through a voluntary organisation. (Department of Health, 2014).

Recognising carers and the contribution they make to society is important for raising their profile and identifying better ways of helping them to help others. Historically the needs of carers have been overlooked. Whilst this situation is improving, many carers remain socially excluded, suffer from caring-related ill-health and, once they have ceased caring, find themselves in a difficult economic position, often with little or no pension provision.  This can lead to the carers needing to access health and social care services for themselves and may impair their ability to continue providing care to the cared for person.

The economic value of unpaid care is estimated to be £132 billion nationally (Carers UK, 2015).  For Middlesbrough this would be around £328 million.

This topic links most closely with:

 



End of life care

Around half a million people die in England each year, of whom almost two-thirds are aged over 75. The large majority of these deaths follow a period of chronic illness such as heart disease, cancer, stroke, chronic respiratory disease, neurological disease or dementia. Most deaths occur in NHS hospitals.

The pattern of deaths in relation to age profile, cause of death and place of death have changed radically over the course of the past century. One hundred years ago most people died in their own homes and acute infections were a much more common cause of death.  A far higher proportion of deaths occurred in childhood or early adult life.

With the changes in the past century, familiarity with death within society as a whole has decreased. Many people nowadays 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.

Although individuals may have different ideas 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.

 

Some people die as they would have wished, but many others do not. Some people experience excellent care in hospitals, hospices, care homes and in their own homes. But the reality is that many do not. Many people experience unnecessary pain and other symptoms. There are distressing reports of people not being treated with dignity and respect and many people do not die where they would choose to.

How we care for the dying is an indicator of how we care for all sick and vulnerable people. It is a measure of society as a whole and it is a litmus test for health and social care services.

In the past, end of life care within the NHS and social care services had a relatively low profile. Reflecting this, the quality of care delivered has been very variable. Implementation of this strategy will make a step change in access to high quality care for all people approaching the end of life. This should be irrespective of age, gender, ethnicity, religious belief, disability, sexual orientation, diagnosis or socioeconomic deprivation. High quality care should be available wherever the person may be: at home, in a care home, in hospital, in a hospice or elsewhere (National End of life Strategy, DH, 2008).



Ex-forces personnel

The military needs to recruit about 20,000 men and women each year to the armed forces. This workforce is drawn from a broad section of society, including areas of high unemployment and people with few qualifications. Recruits are required to adapt to military life and ethos and, where essential, give up a few of the freedoms they had as civilians.

To equip personnel with the necessary skills and attitudes for the full spectrum of military operations (including war fighting), the services instil a culture of discipline, reliance on others and acceptance of orders. Although personnel can have a long fulfilling career, the majority of them will leave the armed forces at least 25 years before the current national retirement age and will need to pursue a second career. When individuals leave the armed services they are often referred to as ‘veterans’.

A veteran is anyone who has served for at least one day in the armed forces, whether regular or reserve. This also applies to Merchant Navy seafarers and fishermen who have served in a vessel at a time when it was used for military operations by the armed forces. 

The veterans’ community is a wide and disparate population (there are an estimated 4.5 million veterans in the UK). However, as an individual’s circumstances change over time, the needs of veterans will not be identical and will be determined by factors such as their experience before, during and after their military service, including their transition from military to civilian life.

The veterans’ community can be divided into three broad groups. These groups are veterans who:

  • Following a service career, return successfully to civilian life;
  • Have suffered ill health or injury as a result of service. In cases of death, their widows and dependants should receive proper support from the government or community;
  • Have been unable to make a successful transition to civilian life.

When servicemen and women leave the armed forces, their healthcare is the responsibility of the NHS. All veterans are entitled to priority access to NHS hospital care for any condition, as long as it's related to their service, whether or not they receive a war pension.



Migrants

Migrants are widely described as people who belong to (or have an allegiance) to one state/country, but move into another for the purpose of settlement.

Migrant populations are diverse, and many have social, cultural and health needs. Migration is driven by many reasons (including economic, family reunion, study, humanitarian reasons or human trafficking). As a consequence migrants may have several diverse health and social care needs.

Migrant populations have different health and wellbeing issues depending on lifestyle risk factors, cultural practices, country of origin, genetic and hereditary factors and wider determinants (poor housing, lower economic opportunities, unemployment and living in deprived areas).

This topic links to the following JSNA topics:



Travellers


Offenders

The term ‘offender’ refers to an individual who has come into contact with the criminal justice system by committing a crime or violating a law.

The link between offending, re-offending and the impact on health is well known.

Offenders and ex-offenders are far more likely to be more socially isolated and marginalised than the general population and to have a broader range of health concerns. As the number of people who come into contact with the criminal justice sector increases, there will be an increasing number of ex-offenders in communities.

There is a real need to divert offenders who have serious mental health problems away from prison and into the appropriate health service facilities. The needs of those suffering from physical health problems and from substance misuse and abuse must also be addressed.

This topic links with the following JSNA topics:



Child Sexual Exploitation

A focus on child sexual exploitation (CSE) has been in place in Middlesbrough for some years, with the commissioning of Barnardos in 1998 to work with children and young women caught up in what was then described as prostitution.
 

The key touchstone for strategy in Middlesbrough is the Tees-wide Vulnerable, Exploited, Missing and Trafficked (VEMT) strategy (2013 - 2016), which is delivered at sub-regional and local tier with a VEMT strategy group for each of the four local authority areas.  CSE is also a part of the Local Safeguarding Children Boards (LSCB) plan and accountability for delivery is both to the Teesside wide cross agency group and to each of the LSCBs.
 

In October 2014, a review of the implications of the Jay Report and the outcome of a CSE scrutiny by the Community Safety and Leisure Scrutiny panel, led to further consideration of the work in Middlesbrough and further actions being agreed by the Executive. Work is underway to refresh the governance and to consolidate the VEMT with the other emergent action plans into a revised strategy and plan. This includes a focus on the development of a quality assurance and performance framework, a clear area for development.

CSE is an important local issue. In addressing the issue, local partners are clear that perpetrators should be targeted regardless of ethnic origin. In the context of challenging media responses and actions from English Defence League (EDL) local elected members endorse the actions being taken to address CSE and the lead member takes an active interest. Successful prosecutions in 2014 were against men from BME communities and there is an on-going focus on groups of BME and eastern European men identified as emerging risks to young people. However most perpetrators are white men acting alone. The model of CSE includes the grooming of children by men from BME communities and emergent Eastern European communities but the majority are white men who contact children on line, at parties and hotspots.

Attitudes towards victims of CSE have rightly moved away from disbelief and blame. The local response to CSE requires professionals to ensure that the voice of the child informs improvements in local practice. Work is underway to build on the opportunities provided by Barnardos for children to talk safely about their experiences and the services they are offered, possibly through the Children in Care Council and other avenues.

 



Wider Determinants
Introduction

In his review of health inequalities, one of Sir Michael Marmot’s key messages is that “Health inequalities result from social inequalities. Action on health inequalities requires action across all the social determinants of health.”  The review identified six policy objectives which require action to reduce health inequalities.  These are:

  • Give every child the best start in life;
  • Enable all children, young people and adults to maximise their capabilities and have control over their lives;
  • Create fair employment and good work for all;
  • Ensure healthy standard of living for all;
  • Create and develop healthy and sustainable places and communities; and
  • Strengthen the role and impact of ill-health prevention.

The topics within this theme are important contributors to the social determinants of health.  This summary attempts to identify the most important issues contained within each topic and, from these, highlight those which are the most important for action in addressing health needs and inequalities in Middlesbrough.

What are the most important messages from each topic?

 

Crime

  • Alcohol consumption is linked to 44% of offences, creates problems at weekends and in particular locations, and is associated with antisocial behaviour.  It is common to three of the four commissioning priorities about offenders, troubled families and location of crime.
  • There is a common thread in the commissioning priorities that data and information systems are not used to their full potential.

 

Education

  • There is a problem with school readiness for children and adults.  There is a particular need for readiness for primary school for both children and parents, but readiness is also needed for the transition to secondary school, working for GCSE and other qualifications, and going on to further and higher education.
  • We need to create a population that values education by understanding both the opportunities it can bring and the barriers presented by a lack of qualifications.

 

Employment

  • There is a need to get young people (aged 18-24) working.  In particular there seems to be a lack of employment for young men, and high rates of unemployment in the north and east of Middlesbrough.

 

Environment

  • Middlesbrough must create an environment that supports health and wellbeing, including both physical and emotional wellbeing.

 

Housing

  • A high proportion (40%) of private rented housing is of low quality, contributing to fuel poverty, winter mortality and affecting illness.
  • The housing needs of vulnerable and disadvantaged groups are not always being met.
  • Homelessness prevention.

 

Poverty

  • There are between 11,500 and 16,300 people in Middlesbrough who are not claiming benefits that they are entitled to.  If all of these benefits were claimed, this could be worth between £17million and £28million to the people and economy of Middlesbrough.  A systematic approach to maximising rightful benefit uptake would help the most vulnerable and disadvantage people.
  • The educational attainment of disadvantaged children is worse than that of other children, perpetuating a cycle of poverty.

 

Transport

  • Too many people are killed or seriously injured in road traffic collisions.  Children in the 10% most deprived areas in England are three times more likely to be pedestrian casualties than those in the least deprived areas.  41 of Middlesbrough’s 88 LSOAs are in the most deprived 10% in England, with a total population of 65,700.
  • Opportunities for physically active transport (walking and cycling) in the relatively compact town of Middlesbrough need to be maximised to help both physical and mental health.
  • Cuts to public transport limit people’s access to employment in the early morning and may isolate some residents from public services and could affect mental health by limiting access to social opportunities in the evening.

What should be the highest priorities for commissioners? 

Short-term (1 to 2 years)

  • Tackling alcohol-related crime.  This would help relieve weekend pressures on A&E services, reduce domestic violence, and tackle location-based hotspots.
  • Develop a systematic approach to maximising benefits claimants, improving the lives of disadvantaged people and boosting the local economy.

Medium-term (3-5 years)

  • Ensuring school readiness of children and parents.
  • Improving the quality of housing in the private rented sector, including thermal efficiency.
  • Optimise opportunities for job creation for all, but with a focus on young people in the north and east of Middlesbrough.

Long-term (over 5 years)

  • Develop transport infrastructure to maximise physically active travel and minimise injury and death.
  • Create an environment which supports health and wellbeing.

 

Summary authors

Heidi Douglas
Specialty Registrar Public Health
Middlesbrough Borough Council

Leon Green
Public Health Intelligence Specialist
Tees Valley Public Health Shared Service

 



Crime

Crime and the fear of crime are key factors that affect people’s quality of life and sense of well-being.

There is a direct link to health through such things as violent injury, rape and other offences against the person, and less directly via the psychological trauma of experiencing crimes such as burglary or vandalism.

Fear of crime affects the health of the wider community via, for example, restrictions on unsupervised outdoor play for children and social isolation of older people.

It has been acknowledged that the actual rick of becoming a victim of crime is much lower than the perceived fear of crime and victimisation. Fear of crime can have a devastating effect on quality of life and more focus is being placed upon providing reassurance to residents and ensuring that they know how best to protect themselves from becoming a victim without raising fear unnecessarily.

Crime reduces the effectiveness of healthcare systems through violence against NHS staff, damage to property, and costs of replacement, repairs and security. Alcohol and illegal drug dependency increase crime, and have an impact on health care services. http://www.wales.nhs.uk/sitesplus/888/page/43763

This topic is associated with:

Offenders

Alcohol misuse

Illicit drug use

Domestic violence victims

Sexual violence victims



Education

Education creates greater opportunity for economic and social choice. The educational opportunities of children and young people are affected by a range of factors including poor levels of self-esteem and physical activity. Future life chances and health are directly linked to educational attainment.

This topic is most closely related to the following topics:

 



Employment

Employment has a major positive impact on an individual’s long-term health and wellbeing as well as that of their family members.  It can influence social mobility, economic independence, housing, and income levels.

Unemployment, however, can be both a cause of and a result of ill health.  The negative effects of unemployment on health and wellbeing can be linked to poverty and low income levels.  Long-term unemployment; limiting illnesses; low paid, short-term and temporary employment; and low level skills can affect an individual’s ability to gain and sustain employment.  The current economic climate presents particular obstacles to gaining employment for specific age groups (for example, 18-24 year olds and people aged over 50 years) and also for people who have recently been made redundant and may need to re-train to secure available employment opportunities.

This topic has strong links to the following JSNA topics:

 



Environment

The environment has a significant effect on health and wellbeing.  High quality environments have a key part in helping people to live healthier and happier lives. Environmental problems such as noise, air pollution, food safety, pest control and contaminated land can have a significant impact on individual and population health.  Climate change continues to pose significant future risks to human health if actions are not taken now both to reduce carbon emissions and reduce energy demands to sustainable levels.

This topic is most closely associated with:

 



Housing

Housing has an important impact on health and well-being: good quality, appropriate housing in places where people want to live has a positive influence on reducing deprivation and health inequalities by facilitating stable/secure family lives.  This in turn helps to improve social, environmental, personal and economic well-being.  Conversely, living in housing which is in poor condition, overcrowded or unsuitable will adversely affect the health and well-being of individuals and families.

The value of good housing needs to been seen as more than ‘bricks and mortar’. The Department for Communities and Local Government (DCLG, 2006) define a decent home as ‘a home that is warm, weatherproof and has reasonably modern facilities’. Failure to address the investment needs of poor housing conditions will have a detrimental impact on the occupiers’ health and well-being.

A decent, affordable home is an essential requirement for tackling health inequalities and reducing the burden on health and social care services and cost to the public purse.

This topic includes homelessness and fuel poverty.

This topic is most closely linked with:

 



Poverty

In his recently published review of health inequalities – many of which are greatly determined by poverty – Professor Sir Michael Marmot said:

‘People with higher socioeconomic position in society have a greater array of life chances and more opportunities to lead a flourishing life. They also have better health. The two are linked: the more favoured people are, socially and economically, the better their health. This link between social conditions and health is not a footnote to the ‘real’ concerns with health – such as health care and unhealthy behaviours – but should become the main focus.

Consider one measure of social position: education. People with university degrees have better health and longer lives than those without. For people aged 30 and above, if everyone without a degree had their death rate reduced to that of people with degrees, there would be 202,000 fewer premature deaths each year. Surely this is a goal worth striving for.  It is the view of all of us associated with this Review that we could go a long way to achieving that remarkable improvement by giving more people the life chances currently enjoyed by the few. The benefits of such efforts would be wider than lives saved. People in society would be better off in many ways: in the circumstances in which they are born, grow, live, work, and age. People would see improved well-being, better mental health and less disability, their children would flourish, and they would live in sustainable, cohesive communities.’

Fair Society, Healthy Lives, February 2010

Many health-related issues are worse for people living in poverty, including an increased risk of dying prematurely.  People living in poverty are less likely to benefit from education to the same degree as others; are less likely to be in professional, managerial and skilled jobs; and are more likely to live in poor housing and in neighbourhoods where crime is more prevalent and where community safety is threatened.  All of these conditions and circumstances can have an adverse effect on physical and mental health and well-being.

Poverty, or relative poverty, is commonly defined in terms of households with an income which, after tax, is below 60% of the median (average) household income (Aldridge et al, 2012).  As such, the income required to prevent poverty depends upon household composition.

This topic is most closely associated with:



Transport

Transport has an impact on health through transport-related accidents, active travel, public transport, air quality and access to a range of services. 

Transport can affect people by giving access to employment opportunities, education, leisure, healthcare and diverse food supplies. The development of an efficient transport network and vehicles has the potential to benefit health.

Increasing levels of motorised traffic have contributed to air pollution, noise, vibration, danger from vehicles and an increased fear of traffic. These issues particularly affect the most deprived and most vulnerable people in communities.

The rise in personal car use has meant liberation for people who are young and more affluent. More deprived, elderly and disabled people can become trapped in ‘residential islands’ surrounded by dense traffic, or without the means to access more distant facilities and services in out-of-town developments. This also applies to people in rural areas faced with dwindling local facilities and longer travel times.

Road traffic casualties are still one of the main public health challenges in the UK particularly for children and young adults.

The rise in personal car ownership levels has contributed to people being less active. This is a significant contributor to obesity, diabetes and cardiovascular disease.

This topic has links to the following JSNA topics:



Behaviour and Lifestyle
Introduction

Behaviours, such as smoking, excessive use of alcohol, the use of illicit drugs, low levels of exercise and physical activity, engaging in unsafe sex, and a poor diet all impact on physical health and mental wellbeing.  It is known that each of these lifestyle risk factors is unequally distributed in the population and that there are differences in these behaviours associated with income, educational achievement and social class.

There is compelling evidence that lifestyle risk factors tend to cluster than present in isolation.  It is estimated that in England 70% of the adult population have two or more lifestyle risk factors (King’s Fund, 2012).  Whilst there has been an overall decline in the proportion of the population with three or four unhealthy risk factors from 33% of the population in 2003, to 25% in 2008, these reductions have not been equally distributed across the population. The percentage of people with three or more lifestyle risk factors is continues to increase for people from lower socio-economic and educational groups. For instance  people with no educational qualifications were  more than five times as likely as those with higher education to have four lifestyle risk factors in 2008, compared with only three times as likely in 2003.

This variation in the distribution of lifestyle risk factors contributes to the gaps in length and quality of life between deprived and affluent groups locally and nationally. The major causes of illness and premature deaths (deaths before age 75 years) in Middlesbrough are circulatory diseases, cancer, respiratory disease and digestive diseases (including liver disease).  Lifestyle risk factors such as smoking, excessive alcohol use, poor diet and physical inactivity are known to contribute to these major causes of premature deaths.

Alcohol misuse

  • Levels of alcohol-related harm in Middlesbrough are among the highest in England.  There are a higher number of alcohol-related hospital admissions and higher alcohol-specific mortality compared to the England average.
  • Alcohol misuse impacts upon physical and mental health, as well as having a detrimental effect on social cohesion, crime, violence and community safety.
  • Alcohol-related harm is a major problem in Middlesbrough impacting on individuals, families and communities.

Illicit drug use

  • Middlesbrough is estimated to have high levels of drug misuse.  It has the highest estimated rate in the country for opiate and crack users (25.13 per 1,000 adults), more than double both the North East (10.57) and England (8.67) rates.
  • Injecting drug use in Middlesbrough is estimated to be 9.10 per 1,000 adults, more than three times the national estimate (2.71).
  • The number of people accessing structured treatment continues to grow; this includes treatment for heroin and cocaine use. Overall there has been growth for both opiate (4%) and non-opiate (76%) clients in 2012/13 since 2011/12.

Smoking

  • 26.6% of adults in Middlesbrough are estimated to smoke regularly. The smoking prevalence rises to almost one in two adults in some deprived wards and disadvantaged population groups.
  • In Middlesbrough, 27% of women smoke throughout their pregnancy posing a significant health risk both to mother and unborn child.  This is double the national average (13.5%) and higher than the regional average.
  • Nearly one in five (18%) of all deaths among adults over 35 in Middlesbrough are estimated to be as a result of smoking.

 

Diet and nutrition

  • Eighty percent of adults and 83% of school-aged children in Middlesbrough do not eat the recommended five daily portions of fruit and vegetables.
  • Breastfeeding rates in Middlesbrough are among the lowest in England and the gap is widening.
  • There is low uptake of healthy start vitamin supplements in babies and infants.
  • Poor oral health is a robust indicator of poor nutrition and the prevalence of dental decay for children in Middlesbrough children is almost double the national average.

 

Physical inactivity

  • Approximately half of the adult population of Middlesbrough is inactive, with only 11.5% taking part in the recommended weekly levels of physical activity.
  • The proportion of Middlesbrough school pupils doing three hours of PE per week is just above the national average.  In Middlesbrough, walking to school has fallen by 9% since 2008, but cycling has increased by 20%.
  • The groups with the lowest levels of physical activity are women (particularly those aged 14-24 years); black and minority ethnic (BME) groups; those with a limiting illness/disability; and lower socioeconomic groups.

Obesity

  • Obesity rates in Middlesbrough adults continue to be significantly higher than the national average and increasing. There are inequalities in relation to the prevalence of obesity according to income, social deprivation, age, ethnicity and disability:
  • Childhood obesity doubles from 10% in reception year to almost 20% in year 6 pupils.
  • Maternal obesity in Middlesbrough is higher than the regional and national averages with  an increase in the number of pregnant women with a body mass index (BMI) greater than 40.  
  • The increasing prevalence rates of obesity increases demand on health services and costs to the NHS and wider economy.

Sexual health

  • Middlesbrough has higher than regional average rates for gonorrhoea, syphilis and HIV.
  • Local teenage pregnancy rates are higher than regional and national averages.
  • There is a lower uptake of termination of pregnancy (in under-18s) and a lower uptake for Long Acting Reversible Contraception (LARC) compared to the regional and national averages.
  • There is low uptake of screening and preventative services, particularly for chlamydia and HIV.
Recommendations

The recommendations below relate to the Marmot review: Fair Society, Healthy Lives, the former National Support Team recommendations for tackling Health Inequalities and latest national policy and professional guidance.

Short-term (1-2 years)
1. Commissioning and delivery of integrated public health services and programmes that address multiple lifestyle risk factors rather than taking an approach that focuses solely on single issues. Ensure that these interventions are accessible and acceptable to those at highest risk.
2. Ensure equitable access to sexual health services (prevention, early identification, awareness and treatment services) at address the high teenage pregnancy rates and sexually transmitted infections. 
3. Give all children the best start in life by tackling smoking in pregnancy, obesity in pregnancy, breast feeding and uptake of healthy start vitamins.

Medium-term (3-5 years)
1. Maximise the opportunities of creating a health promoting environment through enforcement, planning, regeneration and licence application processes.  This could include considering the restriction of planning permission for hot-food takeaways, alcohol premises (representations and cumulative impact areas), tackling availability, supply and demand for illicit drugs and tobacco.   
2. Strengthen the role of primary care, social care and VCS organisations in delivering lifestyle and behaviour modification programmes
3. Strengthen the use of community assets in addressing lifestyle risk factors

Long-term (over 5 years)
1. Ensure that all town planning, regeneration and transport programmes incorporate active transport routes and that future planning complements strategies to reduce alcohol related crime and violence in the town centre. 
2. Improve maternal and child health by addressing the social causes of poor health including; teenage pregnancy, educational attainment, unemployment, food poverty and maternal mental health

Heidi Douglas
Specialty Registrar Public Health
Middlesbrough Borough Council

Leon Green
Public Health Intelligence Specialist
Tees Valley Public Health Shared Service


Reference

King’s Fund (2012). Clustering of unhealthy behaviours over time: Implications for policy and practice.

 



Alcohol misuse

PLEASE NOTE: Content yet to be reviewed by Tees Valley Public Health Shared Service and maybe subject to change.

Alcohol misuse is consuming more than the recommended limits of alcohol.

Many people are able to keep their alcohol consumption within the recommended limits, so their risk of alcohol-related health problems is low. However, for some, the amount of alcohol they drink could put them at risk of damaging their health.

There are three main types of alcohol misuse:

  • Hazardous drinking: Drinking over the recommended limits;
  • Harmful drinking: Drinking over the recommended limits and experiencing alcohol-related health problems;
  • Dependent drinking: Feeling unable to function without alcohol.

Many people who have alcohol-related health problems are not alcoholics.

In 2009/10, around one million hospital admissions were due to an alcohol-related condition or injury.

The short-term risks of alcohol misuse include:

  • Alcohol poisoning, which may include vomiting, seizures (fits) and unconsciousness;
  • Injuries requiring hospital treatment, such as a head injury
  • Violent behaviour that might lead to being arrested by the police;
  • Unprotected sex that could potentially lead to unplanned pregnancy or sexually transmitted infections (STIs);
  • Loss of possessions, such as a wallet, keys and/or phone, leading to feelings of anxiety. 

Long-term alcohol misuse is a major risk factor for a wide range of serious conditions, such as:

  • Heart disease;
  • Stroke;
  • Liver disease;
  • Liver cancer and bowel cancer.

As well as health problems, long-term alcohol misuse can lead to social problems such as unemployment, divorce, domestic abuse and homelessness.

The Department of Health’s national alcohol strategy ‘Safe. Sensible. Social’ outlined the next steps for reducing the harm associated with alcohol. Within the strategy, it defines the following terminology for drinking categories:

  • Low risk drinking: Drinking alcohol within the current guidelines on alcohol consumption;
  • Increasing risk drinking: Drinking between 22 and 50 units per week for males and between 15 and 35 units per week for females;
  • Higher risk drinking: Drinking over 50 units per week for males and over 35 units per week for females and experiencing harm such as alcohol-related accidents, acute alcohol poisoning, hypertension or cirrhosis of the liver;
  • Dependent drinking: Continued drinking despite harm usually characterised by an inner drive to consume alcohol with the drinker experiencing withdrawal symptoms when they cease drinking;
  • Binge drinking: Drinking over eight units a day for men and over six units a day for women.


Illicit drug use

Drug misuse refers to the use of a drug for purposes for which it was not intended or using a drug in excessive quantities.

‘Drug addiction is a chronic condition characterised by the risk of repeated relapse and remission. It can take an individual several attempts over a number of years to finally overcome his or her dependency and lead an addiction-free life. There is no quick solution and what may work for one person will not necessarily work for another’ (Drug Treatment & Recovery in 2010/11, National Treatment Agency for Substance Misuse, October 2011).

All sorts of different drugs can be misused, including illegal drugs (such as heroin or cannabis), prescription medicines (such as tranquilisers or painkillers) and other medicines that can be bought off the supermarket shelf (such as cough mixtures or herbal remedies).

In the UK there are high levels of drug misuse, including high rates of heroin and crack cocaine use.

People who misuse drugs often have a range of health and social problems, which may have lead them to misuse drugs or may be a consequence of their addiction.

The 2009/10 British Crime Survey estimates that 8.6% of 16 to 59-year-olds living in England and Wales had tried illegal drugs in the last year.

Among young people, this figure is more than twice as high, with an estimated 20% of 16 to 24-year-olds having used illegal drugs in the last year.

For the people who take them, illegal drugs can be a serious problem. They're responsible for between 1,300 and 1,600 deaths a year in the UK, and destroy thousands of relationships, families and careers.

This topic links with the following JSNA topics:

Alcohol misuse

Crime

Offenders

Housing

Employment



Smoking

Smoking is the single largest cause of preventable mortality in England. This is recognised in the Government’s Public Health White Paper ‘Healthy lives, healthy people', which states that ‘reducing smoking rates represents a huge opportunity for public health.'

Approximately 8.5 million people in England smoke and about half of all long-term smokers will die from smoking with half of those in middle age.

Tobacco use is one of the Government’s most significant public health challenges and causes over 80,000 premature deaths in England each year.

The health risks from tobacco smoking are well established. In 2006-7 there were approximately 1.4 million hospital admissions with a primary diagnosis of a disease that can be attributable to smoking.

Smoking is estimated to cost the NHS in England £2.7 billion a year and £13.7 billion in wider costs to society through sickness, absenteeism, the cost to the economy, social care, environmental pollution and smoking-related fires.  This burden impacts on every GP surgery and hospital, every local authority and every family whether they smoke or not. 

As a drug medically proven to be every bit as addictive as heroin, most tobacco users start as children.  The majority wish they could stop and are overwhelmingly in favour of helping stop the next generation becoming addicted to smoking.

About one-third of all cancer deaths can be attributed to smoking.   These include cancer of the lung, mouth, lip, throat, bladder, kidney, stomach and liver.

Chronic obstructive pulmonary disease (COPD) is the second most common cause of emergency admission to hospital and one of the most costly diseases in terms of acute hospital care (DH, 2010).  This is primarily a ‘smokers’ disease.

Provision of effective local NHS Stop Smoking Services is just one of a range of local tobacco control measures that need to be in place to reduce smoking prevalence.   Fresh North East has developed an evidence-based multi-component tobacco control programme based on an eight key strands approach that local alliances are encouraged to follow.

Smoking is linked most closely to the following JSNA topics:

Respiratory diseases

Circulatory diseases

Cancer

Poverty

Alcohol misuse

Illicit drug use



Diet and nutrition

Good nutrition has a key role to play both in the prevention and management of diet-related diseases such as cardiovascular disease (CVD), cancer, diabetes and obesity (World Health Organisation, 2003). Healthy eating during childhood and adolescence is vital as a means to ensure healthy growth and development and to set up a pattern of positive eating habits into adult life. The promotion of evidence-based healthy eating messages is fundamental. Alongside this, it is necessary to ensure that guidelines concerning a nutritionally adequate diet are implemented to help prevent diet-related deficiencies and malnutrition in vulnerable infants, children and adults.

In the UK, the poorer people are, the worse their diet, and the more diet-related diseases they suffer from. This is known as food poverty. Poor diet is a risk factor for the UKs major causes of death: cancer; coronary heart disease (CHD); and diabetes. It is only recently that the immense contribution it makes to poor health has been quantified: poor diet is related to 30% of life years lost in premature death and disability (De Rose et al, 1998).

Tackling food poverty is recognised as key to achieving government targets on reducing inequalities; reducing illness from cancer and CHD; and improving the health of children and older people. However, action needs to be more than health professionals giving advice to individuals. It must change the ‘food environment’ – that is, accessibility, affordability, culture – in which people live (O’Neil, 2005).

Poor diet is a major health risk. It contributes to:

  • almost 50% of CHD deaths
  • 33% of all cancer deaths
  • increased falls and fractures among older people
  • low birth weight and increased childhood illness and mortality
  • increased dental disease in children.

This topic is most closely linked to:

 



Physical inactivity

Increased levels of physical activity can assist in tackling many of the important health challenges faced by the UK. It can help in the prevention and treatment of over 20 chronic conditions, including coronary heart disease, stroke, type two diabetes, cancer, obesity, mental health problems and musculoskeletal conditions (Department of Health, 2004). An evidence review concluded that physical activity could be the best buy in public health (Morris, 1994).  Helping inactive people to move to a moderate activity level will produce the greatest reduction in risk of ill health (Department of Health, 2009).

Physical activity in childhood has a range of benefits including healthy growth and development, maintenance of energy balance, mental well-being, improved academic performance and social interaction, and reduces osteoporosis risk in later life (Department of Health, 2004).  Active children are less likely to smoke, or to use alcohol/get drunk or take illegal drugs (Physical Activity Task Force, 2002).  Active children are more likely to become active adults (Telema, 2009).

Physical inactivity in England is estimated to cost £8.2 billion a year; this includes both the direct costs of treating major lifestyle-related diseases and the indirect costs of sickness absence (Department of Health, 2004). The NHS cost alone is £900 million based on 2006/07 costs (Scarborough et al, 2011).  In 2006/07, physical inactivity cost Middlesbrough PCT nearly £2.7 million (Department of Health, 2009).

This topic is most closely associated with the following JSNA topics:

 



Obesity

The prevalence of obesity in England is increasing at all ages; almost two-thirds of adults and one-third of children are either overweight or obese.  If present trends continue, 60% of men, 50% of women and 25% of children will be obese by 2050.

Overweight and obesity are major risk factors for disease and mortality including cardiovascular disease, cancer and disability during older age.   It contributes to a decrease in life expectancy.  Furthermore, obesity is associated with serious chronic conditions such as type 2 diabetes, hypertension, and hyperlipidaemia, which are major risk factors for cardiovascular disease (Health Survey for England, 2009).   Risk factors for some of these conditions start at a relatively low body mass index (BMI), and this will cause future health service costs to rise significantly.  In Middlesbrough alone, NHS costs of principal diseases related to obesity are estimated to be £47.5 million (Department of Health, 2010).

The rising trend in obesity is one of the biggest threats to the health of the population of Middlesbrough. The prevalence of obesity in Middlesbrough is significantly higher than the national average for both adults and children.  The trend of weight problems in children and young people is of particular concern because of evidence suggesting a ‘conveyor belt’ effect in which excess weight in childhood continues into adulthood (Department of Health, 2008). In addition to the increased health risks in later life, children and young people face immediate health and psychological consequences of obesity including increased risks for elevated blood pressure and type 2 diabetes, low self-esteem, anxiety and depression.

The causes of obesity are complex and relate to a wide variety of societal and behavioural factors which cannot be tackled in isolation. Social determinants have an important impact on the likelihood of becoming obese and they need to be addressed.

The inequalities, health risks and costs associated with obesity combine to make the prevention of obesity a major public health challenge.

This topic is linked with the following JSNA topics:

 



Sexual health

Sexual health is an integral part of physical and mental health. Good sexual health depends on safe and equitable relationships and ready access to high quality information and sexual health services. Relationships and sexual behaviour are influenced by a number of different factors which include: personal attitudes and beliefs, social norms, peer pressure, religion, culture, confidence and self-esteem, drug and alcohol misuse, abuse and coercion as well as access to information, prevention and services. Deprivation and social exclusion also impact on sexual health, with a higher burden of disease in the population living in more deprived areas.

Sexual health services offer services in relation to contraception, relationships and STIs (Sexually transmitted Infections) including HIV and abortion.  A wide range of providers including community sexual health services, outreach services, acute hospitals, general practice, pharmacies and the voluntary, charitable and independent sector is involved in delivering sexual health services.

The commissioning of sexual health services has changed since April 2013. The main responsibility to provide open access services for the local populations lies with local authorities. CCGs (Clinical Commissioning Groups) and NHS England are commissioning distinct aspects of sexual health as detailed in the table below.



Illness and Death
Premature deaths in Middlesbrough

Life expectancy in Middlesbrough continues to improve.  However, latest reports show that the gaps in life expectancy between the deprived and affluent areas within Middlesbrough, and between Middlesbrough and England are widening. The Slope Index of Inequality (an estimate of the range in life expectancy at birth from most to least deprived) shows changing inequalities in Middlesbrough. The gap in life expectancy has widened for males from 14.8 years in 2006-10 to 16.4 years in 2009-11.  For females, the gap has also widened from 11.3 years in 2006-2010, to 12.3 in 2009-2011

The major causes of illness and premature deaths (deaths before age 75 years) in Middlesbrough are circulatory diseases, cancer, respiratory disease and digestive diseases (including liver disease). Charts 1 and 2 below illustrate the contribution of these conditions to the gap in life expectancy between Middlesbrough and England and for the also gap between deprived and affluent areas within Middlesbrough.

Middlesbrough and England premature mortality gap scarf chart 2009-11

Middlesbrough inequality gap causes of premature mortality scarf chart

To reduce premature mortality in Middlesbrough, the focus should be on the major causes of premature deaths.  The following chart shows the number of deaths in people under the age of 75 years that need to be prevented to close the gap between Middlesbrough and the regional and national averages.

Premature mortality differences, Middlesbrough, North East and England, various dates

 

Long-term conditions, cancer and mental health in Middlesbrough

There are increasing numbers of people with more than one long-term condition receiving support from the NHS, social care and voluntary and community services. However, their care is not always co-ordinated, resulting in variation in their outcomes and quality of life.

Whilst the deaths from cardiovascular disease in people under 75 have continued to fall, the same pattern has not been observed for cancer, respiratory disease and liver disease. Premature deaths from cancer in Middlesbrough remain significantly higher than the England average and are the largest contributor to local health inequalities in Middlesbrough. Breast, lung, colorectal and prostate cancer account for over half of all cancer cases and deaths. Lung cancer incidence and mortality in Middlesbrough is statistically significantly higher than the regional average for males and female.

Outcomes for babies, children and young people remain poor. Infant mortality rates continue to improve but remain higher than the England average (although the difference is not statistically significant). Emergency admissions are higher than the England average for respiratory illness, dental health, injuries, under 18 alcohol-related and under 18 self-harm and these mirror the patterns of deprivation across the town.

There is an over reliance on urgent care for addressing health issues within Middlesbrough. This is characterised by higher than regional average levels of attendance at accidents and emergency, emergency admissions and less planned care with a geographical (ward level) distribution that mirrors deprivation.

There are higher levels of mental health, behavioural and psychiatric morbidity characterised by:

  • a prevalence of depression that is higher than England.
  • a higher rate of emergency admissions for self- harm compared to England.
  • a higher rate of in-year bed days for mental health is higher than national average.
  • higher numbers of children and young people with significant mental health and psychiatric conditions.
  • higher prevalence of suicide and self-harm compared to England.

The local prevalence of dementia is similar to England.  However, consideration needs to be given to projections of future need and service configuration.

There are considerable gaps between the number of people known to health services compared to the expected numbers with diseases such as circulatory diseases (heart disease, stroke, high blood pressure), respiratory diseases (chronic obstructive pulmonary disease (COPD) and asthma) and diabetes.  This suggests that there is a high number of people with undiagnosed disease – ‘the missing thousands’.

There are variations in diagnosis, treatment, quality of care and outcomes in primary care for patients with long-terms conditions (asthma, COPD, circulatory diseases and diabetes).

There is lower uptake of preventative, screening and early detection services for cancers and long-term conditions (NHS Health Check, Abdominal Aortic Aneurysm (AAA), diabetes, lung health) in deprived and disadvantaged communities in Middlesbrough.

Recommendations

The recommendations below summarise the topic recommendations for the illness and death theme.  They are similar to those identified in the Marmot review: Fair Society, Healthy Lives, the former National Support Team recommendations for tackling Health Inequalities and latest national policy and professional guidance.

Short-term actions (1-2 years)

  • Ensure that people with existing disease are managed effectively: Reduce variation in clinical management of long-term conditions, cancer, mental health and dementia to ensure equitable access, across all social groups, to effective care, which minimises progression, enhances recovery and promotes independence.
  • Ensure that people at high risk are identified and managed at the earliest opportunity: Increase uptake of preventative and early intervention programmes with more targeted approaches for deprived and vulnerable groups (such as people with learning disability, mental health).
  • Increase early identification of long-term conditions, cancer, mental health and dementia by raising community awareness and promoting health seeking behaviours (targeted at high risk groups and those ‘seldom seen, seldom heard’ and socially isolated or excluded).

Medium-term actions (3-5 years)

  • Make all care ‘planned care’: reduce reliance on urgent care, emergency admissions and delayed/late stage presentations for cancer, circulatory diseases, diabetes and other long-term conditions, including mental health and dementia.
  • Prevent illness by addressing lifestyle risk factors: design community based interventions that tackle obesity, smoking and alcohol misuse with a clear focus on improve mental wellbeing. 

Long-term actions (over 5 years)

  • Address the social causes of poor health and premature deaths: continue to address the ‘causes of the causes’ of illness and premature deaths such as unemployment, poor quality housing, fuel poverty, raising literacy and educational attainment
Summary authors

Heidi Douglas
Specialty Registrar Public Health
Middlesbrough Borough Council

Leon Green
Public Health Intelligence Specialist
Tees Valley Public Health Shared Service

 



Cancer

More than one in three people in England will develop cancer at some stage in their lives and one in four will die from it. Consequently the prevention, detection and treatment of cancer are key priorities for Middlesbrough.

Over 250,000 people in England are diagnosed with cancer every year and around 130,000 die from the disease. Currently, about 1.8 million people are living with cancer. (Department of Health, 2011a).

The earlier a cancer can be diagnosed the greater the prospect of survival. Evidence suggests that later diagnosis of cancer has been a major factor in the poorer survival rates in the UK compared with some other countries in Europe.

Cancer is the leading cause of premature death (people under 75) nationally and the second highest cause of death across all age groups. Locally, cancer poses particular challenges to the health of the population of Middlesbrough. Overall, incidence of cancer is higher than national levels and survival from some cancers, is among the worst in the country.

Cancer services have changed considerably over the last decade. The NHS Cancer Plan (2000) and the Cancer Reform Strategy (2007) set out the objectives and vision to improve cancer services across the UK.

Lives can be saved from cancer, primarily through better awareness of the signs and symptoms and earlier diagnosis of cancer.

This is made even more important by the fact that the burden of cancer is increasing dramatically: it is expected that there will be 100,000 more cases per year over the next 15 years in the UK.

This topic is most closely linked to:

 



Cardiovascular Disease

Cardiovascular disease (CVD) refers to a group of related diseases and conditions of the heart and blood vessels linked by a common set of risk factors leading to atherosclerosis. Atherosclerosis is the gradual build up of fatty material ‘atheroma’ in the walls of arteries leading to narrowing and stiffening of the arteries. Cardiovascular conditions include:

  • Coronary heart disease (CHD) is a disease in which the coronary arteries are narrowed by arthrosclerosis or obstructed by blood clots resulting in a reduced or sudden stop of the blood supply to the heart muscle. This leads to angina, heart attack and heart muscle damage  
  • Cerebrovascular disease is a disease in which the cerebral arteries are narrowed by arthrosclerosis or obstructed by blood clots resulting in a reduced or sudden stop of the blood supply to the brain.  This leads to transient ischaemic attacks (TIA) and stroke.
  • Peripheral vascular disease is a disease in which the arteries of the arms and legs are narrowed by arthrosclerosis or obstructed by blood clots resulting in a reduced or sudden stop of the blood supply to arms and legs. This leads to claudication.

Other conditions such as vascular dementia, chronic kidney disease, cardiac arrhythmias, sudden cardiac death, and heart failure are related because they either share common risk factors or have an impact on the prognosis and outcome of CVD.

Nearly five million people in the UK aged 16 and over are a estimated to suffer from CVD. This means that about every 7th adult in the UK suffers from a cardiovascular condition. The older people get the more likely they are to develop CVD. .

Deaths from CVD have fallen by over a third between 2001 and 2010, but CVD is still one of the main causes of death in the UK and accounts for about one-third of all deaths. In 2011, almost 160,000 people in the UK died from CVD. 74,000 of these deaths were caused by coronary heart disease - the UK's single biggest cause of death. 

A number of common risk factors are known increase the risk of arthrosclerosis leading to CVD. These risk factors can be divided into three broad groups.

  • Non-modifiable and non-behavioural risk factors including age, sex, family history/genetic factors, ethnicity and deprivation are considered to estimate the overall risk of CVD for an individual.
  • Modifiable and behavioural risk factors such as smoking, physical inactivity, poor diet, obesity and binge drinking are reflecting individual circumstances and choices which can be prevented or changed by lifestyle changes.
  • Conditions associated with an increased risk such as hypertension (blood pressure) , hyperlipidaemia (blood fats), diabetes and atrial fibrillation can be prevented or reversed in their early stages but usually need medical treatment.

This topic links with the following JSNA topics:

Smoking

Physical inactivity

Diet and nutrition

Diabetes mellitus

Obesity

 

 



Diabetes mellitus

Diabetes is a condition where the amount of glucose in blood is too high because the body cannot use it properly. This is because the pancreas does not produce any insulin, or not enough, to help glucose enter the body’s cells – or the insulin that is produced does not work properly (known as insulin resistance).

There are three main kinds of diabetes: Type 1 diabetes is commonly treated with insulin and often diagnosed in people aged under 30.  Type 2 diabetes can be treated with diet alone, tablets or insulin injections and can be diagnosed at any age, but most commonly from middle-age onwards.  Type 2 diabetes can be associated with being overweight.  Gestational diabetes affects pregnant women and often goes away after birth.  Women who’ve suffered gestational diabetes have an increased risk of going on to develop type 2 diabetes in later life.

Diabetes is a common life-long health condition. There are 2.8 million people diagnosed with diabetes in the UK and an estimated 850,000 people who have the condition but don’t know it.

Health spending on people with diabetes is typically higher than average.  With type 2 diabetes particularly affecting older people, and the number of older people set to rise, having robust plans to meet the future needs of people with this illness is essential.

This topic is associated with the following JSNA topics:



Injuries

Childhood injuries are the leading cause of avoidable death and disability. It is one of the most common reasons for admissions to hospital (Audit Commission 2007).

There is strong evidence to show that injuries to children and young people are more likely in more deprived communities. People from poorer communities are more likely to die as a result of unintentional injury. Nationally, although the number of accidental deaths has fallen in recent years, the rate of deaths among the poorest children has risen.

There are persistent and widening inequalities between socioeconomic groups for childhood deaths from accidents (Children’s Accident Prevention Trust, 2012).

Childhood injuries are accepted as an inevitable part of normal child development. Although protecting children and young people from every perceivable harm would be impossible, there is evidence to suggest that a large proportion of unintentional and intentional injuries are preventable.

The cost of childhood injuries to the NHS is estimated to be £2.2 billion. The wider costs to the NHS associated with domestic injury is estimated to be in the region of £25 billion (this includes indirect costs such as days lost to education, parents and carers taking leave from the workplace and the psychological effects caused by some injuries). (Audit Commission, 2007)

Preventing childhood injuries is an important public health priority and has been identified by the government within the Public Health Strategy ‘Healthy Lives Healthy People (DH 2010). Hospital admissions due to unintentional and deliberate injury have been included as an indicator within the Public Health Outcomes Framework (DH 2012).

This topic is most closely linked to:

Education

Housing

Transport

Poverty



Mental and behavioural disorders

Mental wellbeing is the foundation for positive health and effective functioning for individuals and communities.  One in four people will experience mental health problems at some point during their life.

Mental ill-health is common with a significant impact on individuals, their families and the whole population. 22.8% of burden of disease in UK is due to mental disorder and self-reported injury compared to 15.9% for cancer and 16.2% for cardiovascular disease (WHO 2008).

The causes of mental illness are extremely complex – physical, social, environmental and psychological causes all play their part. The problems are unevenly distributed within the population and having mental ill-health further widens existing inequalities.  The impact of mental health problems has wide-ranging and long-lasting effects, including trans-generational impacts which occur more often in groups at higher risk.

Mental health conditions are strongly associated with socioeconomic deprivation.  The connection between rates of mental illness and other factors such as poverty, unemployment and social isolation is well established.

The cost of mental health problems to the economy in England is estimated to be £105 billion, and treatment costs are expected to double in the next 20 years (DH, 2011).
Employment opportunities for people with mental health problems in Middlesbrough are very limited and of those long term unemployed claiming incapacity benefit, two thirds have a mental health problem.

The mental illness needs index (MINI) for Middlesbrough, shows that there are significantly higher estimated needs than the national average with 11 out of 23 wards in the highest 20% of need and no wards in the lowest 20% of need.

Mental health needs in Middlesbrough are demonstrably higher than the national average.  The promotion and development of good mental health is essential to the human, social and economic development of Middlesbrough. The potential to promote good mental health lies with a number of agencies such as those responsible for housing, regeneration, social care, employment, leisure and health.

This topic is linked with:



Oral health

Oral Health is an integral part of healthy living and a key marker of the health of a community. Poor oral health can cause discomfort, pain and disability and affects appearance and self-confidence with a major impact on quality of life. Oral diseases are largely preventable; however dental disease remains a major public health problem.

The oral health of the UK has improved significantly over the last few decades and the types of disease present now have also changed. However the oral health of the Tees region is significantly worse than that of the national level in children and oral health for adults in the North East is worse than the English average.

Health inequality is a common feature in dental disease; high levels of dental disease tend to affect those in low income families and those living in socially deprived conditions (National Children’s Bureau, 2015).

More people are keeping their teeth as they age, whereas in the past older populations had fewer teeth. As people get older the combination of frailty, ill health and social and economic constraints make looking after their oral health and accessing services more difficult. This leads to an increase in the burden and complexity of dental care needed for this group.

Oral cancer is a disease for which the outcome and prognosis can be significantly improved if it is caught early. Risk factors for oral cancer are smoking, excessive alcohol consumption and the Human Papilloma Virus (HPV) infection.

This topic is most closely linked to:



Respiratory diseases

Respiratory diseases are conditions that affect the lungs such as asthma, chronic obstructive pulmonary disease (COPD); infections like influenza, pneumonia and tuberculosis; and lung cancer and many other breathing problems.  This section focuses on asthma and COPD which contribute hugely to health inequalities, ill health and premature death.

The similarities in the symptoms of both diseases can lead to misdiagnosis and poor management. Hence, expert assessments are required to separate their relative contribution to ill health. About 15% of patients with COPD also have asthma.

Asthma
Asthma is a chronic condition that affects airways in the lungs, causing them to become inflamed and swollen. Typical symptoms include breathlessness, tightness in the chest, coughing and wheezing. Environmental factors such as viral infections, allergens, pollution, tobacco smoke, workplace sensitisers and exercise can make the condition worse.

The causes of asthma are not well understood so prevention is not currently possible. However, the condition does not usually deteriorate over time and the aim of treatment is for people with asthma to be free of symptoms and lead a normal life.

It is estimated that about 5 million (1.4 million are children aged under 16 years) people in the UK are affected by asthma. There are between 1000 and 2000 deaths from asthma per year, but it is estimated that 90% of these deaths are associated with preventable factors.  Asthma is a common cause of large numbers of emergency admissions in those aged less than 19 years. High numbers of hospital admissions for asthma are considered to represent a mismanagement of the condition.


COPD
Chronic obstructive pulmonary disease is a chronic disabling disease which causes a gradual decline in lung function, with increasing episodes of chest infections and exacerbations as the condition progresses. It is a general term which includes chronic bronchitis and emphysema. It mainly affects people over the age of 40 and risk increases with age. Smoking is the main cause in the vast majority of cases.

COPD is incurable but treatments help to slow down the decline in the lung function, so early diagnosis and support for effective self-management and self-care can help patients live an active life.  About 835,000 people in the UK are currently diagnosed with COPD and an estimated 2.2 million people have the condition but do not know it.

COPD is the fourth biggest killer in the UK, the second most common cause of emergency admissions to hospital and one of the most costly in-patient conditions treated by the NHS.

Integrated working between health, social and leisure services and people with asthma and COPD is critically important to improve health and wellbeing and reduce the health inequalities associated with these conditions.

This topic links with the following JSNA topics:



Self-harm and suicide

Suicide
Suicide is a major public health concern.  Nationally the number of people who take their own lives has been reducing in recent years.  Nevertheless, about 4,200 people aged 15 and over took their own life in 2010 in England.  Suicide is often the end point of a complex pattern of risk factors and distressing events, and the prevention of suicide has to address this complexity.

Suicides are not inevitable; indeed most are preventable (WHO 2004).  There are many things that can be done in communities, outside hospital and care settings, to help those who think the only option is to end their own life.

The average cost of suicide for those of working age in England is estimated to be around £1.67m per case (at 2009 prices). If this estimate is applied to the North East of England the projected cost to the local economy is £345million for the 238 cases of suicide and undetermined injury in 2009.

Self-Harm
Self-harm is defined as ‘self-poisoning or self-injury, irrespective of the apparent purpose of the act’ (NICE, 2004). An individual episode of self-harm might be an attempt to end life.  However, many acts of self-harm are not directly connected to suicidal intent.

It must be recognised that the rate of suicide for people who have had an episode of self-harm is 100 times higher in the year following the episode than that of the general population.

The extent of economic burden associated with self-harm is significant dependent upon both how it is defined and the method of economic evaluation (Drummond et al., 1997).

The suicide and self-harm prevention agenda is cross-cutting and relates most closely to the following JSNA topics:

Offenders
Domestic Violence Victims
Ex-Forces Personnel
Alcohol Misuse
Illicit Drug use
Mental Health and Behavioural Disorders
Employment
Carers



Redcar & Cleveland

Welcome to the Joint Strategic Needs Assessment (JSNA) for Redcar & Cleveland, undertaken by Redcar & Cleveland Borough Council and South Tees NHS Clinical Commissioning Group, in partnership with people and their communities.

While some progress has been made since our first JSNA was published in 2008  in addressing key issues, and our partnership working is already delivering some key outcomes, including a reduction in maternal smoking, improving people’s diet, risk assessment for and prevention of cardiovascular disease, and increasing participation in sport, we still face a significant challenge:

  • In linking actions more coherently to have greater impact for people;
  • In narrowing the avoidable gaps in health and wellbeing experienced by people living in Redcar & Cleveland.

The national recession is affecting local people and will increase stress, thus how people cope and so affect many health and wellbeing issues.

We have already benefited from earlier JSNAs as tools for ensuring our health improvement activity focuses on evidence-based need, and commissioning plans including the Ageing Well Strategy, the development of the Health Improvement Strategic Delivery Plan, and the new Carers Strategy have all been informed by the JSNA.

Our challenge still is to use this second JSNA and our partnerships to improve local services and the quality of life for people living in Redcar and Cleveland.

Edward Kunonga

Interim Director of Public Health

Redcar & Cleveland Borough Council

 



Redcar Submenu Links


Executive Summary

Unmet needs and commissioning intentions arising from Redcar & Cleveland JSNA 2012-15

 



Steering Group


Core Strategies

Redcar & Cleveland Health and Wellbeing Strategy 2013-2018

Redcar & Cleveland Borough Council (2012). Our Plan 2012-17

NHS South Tees Clinical Commissioning Group A Clear and Credible Plan for Commissioning Health Services for the Populations of Redcar and Cleveland and Middlesbrough 2012-2017

NHS Sustainability and Transformation Plan (STP) 2016-2021

 

Director of Public Health Annual Reports

Health & Poverty: Improving the health and wellbeing of our population through wealth equity - Redcar & Cleveland DPH Annual Report 2015/16

Redcar & Cleveland Public Health Annual Report 2014/15

Redcar & Cleveland Public Health Annual Report 2013

 



Population


Intelligence


Inequalities
Segmenting life expectancy by cause of death

Public Health England has developed a resource which provides information on the causes of death that are driving inequalities in life expectancy at local area level. Targeting the causes of death which contribute most to the life expectancy gap should have the biggest impact on reducing inequalities.

For males and females, the tool provides data tables and charts showing the breakdown of the life expectancy gap in 2012-14 for two comparisons:

  • The gap between the Local Authority as a whole and England as a whole.
  • The gap between the most deprived quintile and the least deprived quintile within the Local Authority.

 

The gap between Redcar & Cleveland and England
For both men and women, the largest proportion of the gap between Redcar & Cleveland and England is caused by higher rates of cancer mortality.  Within the cancer category, lung cancer deaths contribute about one-third of male excees deaths and three quarters of female excess deaths due to cancer.  Circulatory diseases contribute similarly to the gap for both men and women.  External causes of death are an important difference for men in Redcar & Cleveland compared with England, and respiratory diseases are an important difference for women.

R&C inequality gaps with England cause of death scarf chart 2012-14

 

The gap within Redcar & Cleveland

For women, respiratory diseases and cancer are responsible for two-thirds of the gap between the most and least deprived communities in Redcar & Cleveland, whereas for men, circulatory diseases have the greatest contribution to the gap.  For males, external causes of death (such as accidents and suicide) and digestive diseases have a much greater contribution to the gap between deprived and affluent communities in Redcar & Cleveland compared with females.

R&C gap in cause of death most and least deprived, 2012-14

Full details, including number of deaths and numbers of excess deaths can be found in The Segment Tool: Key results for Redcar & Cleveland.

 

Premature mortality

Premature mortality, that is to say deaths before age 75 years, is a symptom of high disease burden as well as underlying health inequalities.  Know your numbers: premature mortality provides an analysis of the main causes of premature mortality in Tees Valley, and estimates how many premature deaths would need to be prevented to achieve rates similar to the North East and England.  In Redcar & Cleveland the greatest burden of premature mortality is due to cancer, followed by circulatory disease.

Redcar premature mortality rates and numbers

 



A to Z


People

Summary of People topics in Redcar and Cleveland.

Content under development, see individual topic pages for details.



Children

Sir Michael Marmot’s review of health inequalities recommends that action in the early years is crucial to giving every child the best start in life to reduce health inequalities across the life course.  The foundations of many aspects of human development (including physical, intellectual and emotional) are laid in utero and in early childhood.

The importance of the health and wellbeing of children is well documented.  There is national recognition of the importance of health/behaviour during pregnancy and the early years of life, with significant emerging evidence related to neo-natal science.  In particular, the importance of early experiences, responsive parenting and secure attachment.

The following JSNA topics are the most significant factors that increase a child’s risk of poor life chances:

Wider determinants of health

Education

Children who achieve low educational attainment are likely to suffer from lower life chances.

Poverty

Growing up in poverty can affect every area of a child’s development and future life chances.  Children from low income households are less likely to achieve their academic potential, less likely to secure employment as adults, more likely to suffer from poor health, more likely to live in poor quality housing and they are more likely to reside in unsafe environments.

Behaviour and lifestyle

Alcohol misuse

Alcohol misuse during pregnancy poses a significant health risk to the unborn child.

Children living with parents who are dependent on alcohol are more likely to suffer from emotional and educational neglect.

Children living in homes with adults who abuse are at a higher risk of becoming alcohol abusers themselves.

Illicit drug use

Children living with parents who abuse drugs are more likely to suffer from emotional and educational neglect.

Children living in homes with adults who abuse drugs are at a higher risk of becoming drug abusers themselves.

Smoking

Smoking during pregnancy poses a significant health risk to both the mother and unborn child.

Parents who smoke around their children are significantly increasing their child’s risk of disease and ill-health.

Diet and nutrition

Breastfeeding gives a child the best start in life and is beneficial for the health of the mother.

Nutrition has a key role in the prevention and management of diet-related diseases (such as cardiovascular disease, cancer, diabetes and obesity).

Obesity

Obesity is one of the biggest risks to the health of the population. 

Obesity in children can lead to poor physical health (including increased risks for elevated blood pressure and Type 2 diabetes) and poor mental health (including low self-esteem, anxiety and depression).

Illness and death

Injuries

Injuries are a leading cause of death and illness of children and one of the most common reason for hospital admissions. 

Mental health

One-in-ten 5 to 15-year-olds has a mental health problem. Many continue to have mental health problems as adults.



Transition Years


Adults

In his review of health inequalities, Sir Michael Marmot suggests that health inequalities are as a result of social inequalities and that the lower a persons position in society, the worse their health will be. The report from this review ‘Fair Society, Healthy Lives’ shows the benefits that action to address health inequalities will have on society broadly, including the benefits to the economy through a reduction in illness linked with health inequalities, which impacts on treatment costs and claims of welfare payments.

The priorities proposed as a result of the review of health inequalities highlighted economic growth as the most important measure of the countries success, which will impact more on working age adults and their families; but also produced six policy objectives to address health inequalities:

  • Give every child the best start in life
  • Enable all children, young people and adults to maximise their capabilities and have control of their lives
  • Create fair employment and good work for all
  • Ensure healthy standard of living for all
  • Create and develop healthy and sustainable places and communities
  • Strengthen the role and impact of health protection

The health status of the people in Tees Valley, some of whom live in the most deprived electoral wards in the country, provides significant evidence of the high demands placed on local health care, and Redcar & Cleveland is no exception. There is a need to further shift the focus of our health and social care provision to improving health outcomes and reducing inequalities, to improve the overall health of the local population within the available resources. Historically, the area has been highly dependent on heavy industry for employment and this has left a legacy of industrial illness and long-term conditions. This, coupled with a more recent history of high unemployment, as the traditional industries have retracted, has led to significant levels of health deprivation and inequalities that rank amongst the highest in the country. The area faces continuing challenges to health including: high premature mortality, low life expectancy and higher than national average levels of smoking, binge drinking and obesity.

This section cover issues principally affecting adults aged 18-65, plus those issues which are common to all adults in Redcar & Cleveland, including young adults and/or older people.  It brings together the major issues facing this population age group from the JSNA topics in the Vulnerable groups, Wider determinants, Behaviour and lifestyle and Illness and death themes.

 



Older People

There is no one commonly accepted definition of ‘old age’ or older people. The National Service Framework for Older People (Department of Health, 2001) defined three groups of older people:

  • Those entering old age on completing paid employment and child-rearing (50-60 years);
  • Those in the transitional stage between healthy active life and frailty (70-80 years); and
  • Frail older people who are vulnerable because of health or social care needs.

In 2011, the average age at which the public defined the start of ‘old age’ was 59 (Age UK, 2011).

The Department of Work and Pensions (DWP) refers to people aged 60 and over as older people, but also includes people in their 50s as a period when many people take early retirement or prepare for retirement (DWP, 2005).

 



Vulnerable Groups
Introduction

Some people are more vulnerable to poor health than others.  This poor health may arise for a variety of reasons, including the effects of deprivation and difficulty accessing services.  The health needs of vulnerable groups are often complex and require a co-ordinated and flexible response from services. It is easy for clients to fall into the gaps between different services leading to unplanned care and the risk of clients revolving through the system.

This theme summary groups together the complex health needs of many vulnerable groups, some of which may overlap and others that are highly specific.


Learning disabilities and Autism

  • Ensure the availability of choice and cost-effective provision which meets needs locally.
  • Promote personalised systems which place the person at the heart of any process, provide information and advice, and stimulate universal access to all services.

Physical disabilities and Sensory disabilities

  • Demand for community-based services is increasing, with increased requirement for supported living and reduced reliance upon residential care.
  • Promote personalised systems which place the person at the heart of any process, provide information and advice and stimulate universal access to all services.
  • The number of older people with a limiting long-term illness is expected to increase from about 16,200 in 2015 to 17,300 in 2020 and 18,700 in 2025.
  • The number of older people with moderate or severe visual impairment is expected to increase from about 2,600 in 2015 to 3,100 in 2025, a 21% increase.  There will be a similar increase in those with moderate or severe hearing impairment, from 12,400 to 15,600 between 2015 and 2025.

Domestic violence victims and Sexual violence victims

  • It is believed that many cases of both domestic and sexual violence are unreported.
  • The majority of known sexual violence victims are female and aged under 25 years.  Women are more likely to suffer domestic violence, particularly those aged under 30 years.
  • People from vulnerable groups (those with a physical disability, learning impairment and mental illness) are more likely to experience sexual violence, but may have difficulty verbalising their abuse.
  • There is a need for better data collection to enable improved analysis.

Carers and End of life care

  • There is a high number of carers who are unknown to carer support services.
  • Provide carers with the support required to enable them to continue their caring roles.
  • Remove the stigma surrounding death and dying.  Encourage healthcare professionals and people with end of life care needs, their families and carers to engage in open conversations.
  • Increase choice and personalisation within integrated, high quality services that meet the needs of people approaching the end of life.


Migrants and Travellers

  • Ensure migrants and travellers are aware of local health, care and education services and that these services are responsive to individual needs.

Ex-forces personnel

  • Provide adequate signposting to health and care services for armed service leavers.
  • Former forces personnel are more likely to need mental health care and rates of alcohol misuse are higher than for the general population.  This is particularly so for younger, male veterans who held lower ranks and were exposed to combat.
  • A small but significant proportion of veterans experience homelessness.

Offenders

  • Prisoners have high rates of: poor mental health; alcohol and substance misuse; smoking; suicide and attempted suicide; and learning disabilities.
  • There are high levels of educational need.  About half of male, sentenced prisoners were previously excluded from school compared with 2% in the general population.
  • Offenders have increased difficulty in accessing employment and housing, and tend to be socially isolated.
Recommendations

The recommendations below relate to the Marmot review: Fair Society, Healthy Lives, the former National Support Team recommendations for tackling Health Inequalities and latest national policy and professional guidance.

Short-term (1-2 years)
1. Continue to develop personalised services and further improve access to universal services for vulnerable groups.
2. Improve data collection, in particular, identification of vulnerable members of society who are unknown to local services.

Medium-term (3-5 years)
1.  Increase the supply of housing which meets the needs of vulnerable groups.

Long-term (over 5 years)
1. Ensure that service capacity is sufficient for the anticipated increase in some of these vulnerable groups, particularly those with physical and sensory disabilities.

Summary author

Leon Green
Public Health Intelligence Specialist
Tees Valley Public Health Shared Service

 



Learning disabilities

A learning disability affects the way a person learns new things in any area of life.  It affects the way they understand information and how they communicate.  Learning disability can be defined as:

  • the presence of a significantly reduced ability to understand new or complex information, to learn new skills (impaired intelligence, often defined as an IQ level of 70 or less), with;
  • a reduced ability to cope independently (impaired social functioning);
  • which started before adulthood, with a lasting effect on development.

People with a learning disability can have difficulty understanding new or complex information, learning new skills and coping independently.  A learning disability can be mild, moderate or severe. Some people with a mild learning disability can talk easily and look after themselves, but take a bit longer than usual to learn new skills. Others may not be able to communicate at all and may have more than one disability.

Adults with learning disabilities are one of the most vulnerable groups in society, experiencing health inequalities, social exclusion and stigmatisation.  In general, adults with learning disabilities have greater and more complex health needs than the general population, and often these needs are not identified or treated.  Life expectancy of this group is shorter than the general population.  Adults with learning disabilities often experience barriers to accessing healthcare services, and poor levels of care.  They are more likely to die from a preventable cause than the general population.  Health needs amongst adults with a learning disability are different to the general population.

There are about 1.5 million people in the UK with learning disabilities.

This topic is linked with:

 



Autism

Autism is a lifelong development disability that affects how a person communicates with, and relates to other people.  It also affects how they make sense of the world around them.

Autism is a spectrum condition which means that, while all people with autism share certain difficulties their condition will affect them in different ways.  Some people with autism are able to live relatively independent lives but others may have accompanying learning disabilities and need a lifetime of specialist support.

Types of autistic spectrum disorders (ASD)
There are three different types of ASDs:

1. Autistic disorder (also called "classic" autism)
This is what most people think of when hearing the word ‘autism’.  People with autistic disorder usually have significant language delays, social and communication challenges, and unusual behaviours and interests.  Many people with autistic disorder also have intellectual disability.

2. Asperger syndrome
People with Asperger syndrome usually have some milder symptoms of autistic disorder. They might have social challenges and unusual behaviours and interests. However, they typically do not have problems with language or intellectual disability.

3. Pervasive developmental disorder – not otherwise specified (PDD-NOS – also called "atypical autism")
People who meet some of the criteria for autistic disorder or Asperger syndrome, but not all, may be diagnosed with PDD-NOS. People with PDD-NOS usually have fewer and milder symptoms than those with autistic disorder. The symptoms might cause only social and communication challenges.

Signs and symptoms
ASDs begin before the age of 3 and last throughout a person's life, although symptoms may improve over time.  Some children with an ASD show hints of future problems within the first few months of life. In others, symptoms might not show up until 24 months or later.  Some children with an ASD seem to develop normally until around 18 to 24 months of age and then they stop gaining new skills, or they lose the skills they once had.

A person with an ASD might:
not respond to their name by 12 months
not point at objects to show interest (‘point at an airplane flying over’) by 14 months
not play "pretend" games (pretend to ‘feed’ a doll) by 18 months
avoid eye contact and want to be alone
have trouble understanding other people's feelings or talking about their own feelings
have delayed speech and language skills
repeat words or phrases over and over (echolalia)
give unrelated answers to questions
get upset by minor changes
have obsessive interests
flap their hands, rock their body, or spin in circles
have unusual reactions to the way things sound, smell, taste, look, or feel.

This topic is most closely associated with

 



Physical disabilities

The Equality Act 2010 defines disability as an impairment that has a substantial and long-term adverse effect on a person’s ability to perform normal day-to-day activities. Such impairments can vary considerably and include both congenital and acquired disabilities.

In England it is estimated that there are 3.3 million people aged 16-64 with a moderate or severe physical disability (PANSI, 2012).  In addition there are 4.3 million people aged 65 and over with a limiting long-term illness (POPPI, 2012).  Furthermore an estimated 0.8 million children in the UK have a disability (DWP, 2012), approximately 670,000 in England.  Combining these shows about 8.3 million people in England have a physical disability.

People with physical impairments face many barriers to living a fulfilling and independent life. Not only do they have the practical problems of everyday life to struggle with that a physical disability brings but they have to face the negative public perceptions of disabled people and problems gaining access to everyday facilities and services. The support required for people with physical impairment may be multi-dimensional and therefore needs to be tailored to address their specific individual needs.

People with physical impairment also face prejudice.  Prejudice is not always hostile; benevolent prejudice results from the belief that a disabled person needs looking after.  Benevolent prejudice can be just as consequential as hostile prejudice, making it likely disabled people will be treated less favourably in respect of the opportunity for advancement because they are seen as less capable.

This topic is most closely linked with:

 



Sensory disabilities

Sensory disabilities refer to visual and hearing impairment.

Visual impairment (blind or partially sighted)

There are two main areas that are looked at when measuring a person’s vision:

  • Visual acuity: This is the central vision used to look at objects in detail, such as reading a book or watching television;
  • Visual field: This is the ability to see around the edge of your vision while looking straight ahead.

Hearing impairment (hard of hearing or deafness)

There are three main types of hearing loss:

  • Conductive hearing loss: Sounds are unable to pass from the outer ear to the inner ear, often as the result of a blockage such as earwaxglue ear or a build-up of fluid due to an ear infection, a perforated ear drum or a disorder of the hearing bones;
  • Sensorineural hearing loss: Sensitive hair cells either inside the cochlea or the auditory nerve are damaged, either naturally through ageing, or as a result of injury;
  • Mixed hearing loss: It is possible to get both types of hearing loss at the same time.

Dual sensory impairment

Dual sensory impairment is the combined loss of hearing and vision.

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Evidence indicates that the prevalence of visual and hearing impairments increases with age. With an ageing population, this means there will be more people acquiring these conditions.

Most sensory impairments develop gradually and are often secondary to other disabilities.

The impact of sensory loss and other health determinants can dramatically increase risk and demand on health and social care services. 

People with sensory loss are at greater risk of social isolation.

It is estimated there are more than ten million people in the UK with some form of hearing loss.

There are around 360,000 people who are registered as visually impaired in England. As many as 2 million people in the UK may be living with some degree of visual impairment.

It is estimated that around 1 in 5 people over the age of 75-years-old have some degree of visual impairment.

Age-related macular degeneration leading cause of blindness in adults. Other significant causes of sight loss are glaucoma, cataracts and diabetic retinopathy.

For adults with sight loss there is a correlated loss of independence and an increased   risk of poverty.

Sensory disabilities is linked with the following JSNA topics:

Carers

Employment

Housing

Transport

Education

Diabetes

Mental and behavioural disorders



Sexual violence victims

Introduction

Sexual violence is any unwanted behaviour perceived to be of a sexual nature or sexual contact that takes place without consent or mutual understanding.

The World Health Organisation defines sexual violence as:    

“Any sexual act, attempt to obtain a sexual act, unwanted sexual comments or advances, or acts to traffic, directed against a person’s sexuality using coercion, by any person regardless of their relationship to the victim, in any setting, including the home” (World Health Organisation Report on Violence and Health, 2002)

There are two sub-categories of sexual offences depending on the seriousness of the crime:

  • Serious sexual crime including rapes, sexual assaults, and sexual activity with children;
  • Other sexual offences (including soliciting, exploitation of prostitution, and other unlawful sexual activity between consenting adults).

The effects of sexual violence on victims can include depression, anxiety, post-traumatic stress disorder, drug and substance misuse, self-harm and suicide. However, when victims receive the support they need when they need it, they are more likely to take positive steps to recovery. It is therefore important that victims of sexual violence have good access to effective services, whether or not they wish to report incidents to the police. 

It is estimated that in England & Wales, up to 9 in 10 cases of rape go unreported and 38 per cent of serious sexual assault victims tell no one about their experience. Each adult rape is estimated to cost over £76,000 in its emotional and physical impact on the victim, lost economic output due to convalescence, early treatment costs to the health service and costs incurred in the criminal justice system. The overall cost to society of sexual offences in 2003-04 was estimated at £8.5 billion.

Addressing the needs of victims of sexual violence through the provision of accessible specialist services can deliver benefits in terms of better health and well-being and quality of life. There are also long-term productivity savings in services and costs to society when the immediate effects of sexual assault are managed effectively.

This topic links with the following JSNA topics:

Sexual health

Sensory disabilities

Physical disabilities



Domestic violence victims

The cross-government definition of Domestic Violence and Abuse (DVA) is:

“Any incident or pattern of incidents of controlling, coercive or threatening behaviour,  violence or abuse between those aged 16 or over who are or have been intimate partners or family members regardless of gender or sexuality. This can encompass but is not limited to the following types of abuse:

  • psychological
  • physical
  • sexual
  • financial
  • emotional

Controlling behaviour is: a range of acts designed to make a person subordinate and/or dependent by isolating them from sources of support, exploiting their resources and capacities for personal gain, depriving them of the means needed for independence, resistance and escape and regulating their everyday behaviour.

Coercive behaviour is: an act or a pattern of acts of assault, threats, humiliation and intimidation or other abuse that is used to harm, punish, or frighten their victim.”[1]

The Government definition which is not a legal definition, includes so called ‘honour’ based violence, female genital mutilation (FGM) and forced marriage, and is clear that victims are not confined to one gender or ethnicity.

The Crime Survey for England and Wales (CSEW) 2012/13 found that, overall, 30% of women and 16.3% of men had experienced any domestic abuse since the age of 16. These figures were equivalent to an estimated 4.9 million female victims of domestic abuse and 2.7 million male victims

On average about seven women and two men are killed by their current or former partner every month in England and Wales (ONS 2012/13)

The relationship between the effects of domestic violence, physical and mental well-being is well documented. Psychological and physical effects of abuse can be felt for many years often with the continuation of psychological/mental health issues, chronic physical health problems as well familial and socioeconomic impacts.

Domestic violence is linked most closely to the following JSNA topics:

Crime

Alcohol misuse

Mental and behavioural disorders



[1] Home Office Definition – November 2013 https://www.gov.uk/domestic-violence-and-abuse

 



Carers

The Department of Health report Commitment to Carers 2014 states that – ‘a carer is anybody who looks after a family member, partner or friend who needs help because of their illness, frailty or disability. All the care they give is unpaid’

Recognising carers and the contribution they make to society is important for raising their profile and identifying better ways of helping them to help others. Historically the needs of carers have been overlooked. Whilst this situation is improving, many carers remain socially excluded, suffer from caring-related ill-health and, once they have ceased caring, find themselves in a difficult economic position, often with little or no pension provision.  This can lead to the carers needing to access health and social care services for themselves and may impair their ability to continue providing care to the cared for person.

The economic value of unpaid care is estimated to be £87 billion nationally (Carers UK & University of Leeds, 2011).  For Redcar & Cleveland this would be around £268 million.

This topic links with

 



End of life care

Around half a million people die in England each year, of whom almost two-thirds are aged over 75. The large majority of these deaths follow a period of chronic illness such as heart disease, cancer, stroke, chronic respiratory disease, neurological disease or dementia. Most deaths occur in NHS hospitals.

The pattern of deaths in relation to age profile, cause of death and place of death have changed radically over the course of the past century. One hundred years ago most people died in their own homes and acute infections were a much more common cause of death.  A far higher proportion of deaths occurred in childhood or early adult life.

With the changes in the past century, familiarity with death within society as a whole has decreased. Many people nowadays 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.

Although individuals may have different ideas 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.

 

Some people die as they would have wished, but many others do not. Some people experience excellent care in hospitals, hospices, care homes and in their own homes. But the reality is that many do not. Many people experience unnecessary pain and other symptoms. There are distressing reports of people not being treated with dignity and respect and many people do not die where they would choose to.

How we care for the dying is an indicator of how we care for all sick and vulnerable people. It is a measure of society as a whole and it is a litmus test for health and social care services.

In the past, end of life care within the NHS and social care services has had a relatively low profile. Reflecting this, the quality of care has been very variable. Implementation of this strategy will make a step change in access to high quality care for all people approaching the end of life. This should be irrespective of age, gender, ethnicity, religious belief, disability, sexual orientation, diagnosis or socioeconomic deprivation. High quality care should be available wherever the person may be: at home, in a care home, in hospital, in a hospice or elsewhere (National End of life Strategy, DH, 2008).



Ex-forces personnel

The military needs to recruit about 20,000 men and women each year to the armed forces. This workforce is drawn from a broad section of society, including areas of high unemployment and people with few qualifications. Recruits are required to adapt to military life and ethos and, where essential, give up a few of the freedoms they had as civilians.

To equip personnel with the necessary skills and attitudes for the full spectrum of military operations (including war fighting), the services instil a culture of discipline, reliance on others and acceptance of orders. Although personnel can have a long fulfilling career, the majority of them will leave the armed forces at least 25 years before the current national retirement age and will need to pursue a second career. When individuals leave the armed services they are often referred to as ‘veterans’.

A veteran is anyone who has served for at least one day in the armed forces, whether regular or reserve. This also applies to Merchant Navy seafarers and fishermen who have served in a vessel at a time when it was used for military operations by the armed forces. 

The veterans’ community is a wide and disparate population (there are an estimated 4.5 million veterans in the UK). However, as an individual’s circumstances change over time, the needs of veterans will not be identical and will be determined by factors such as their experience before, during and after their military service, including their transition from military to civilian life.

The veterans’ community can be divided into three broad groups. These groups are veterans who:

  • Following a service career, return successfully to civilian life;
  • Have suffered ill health or injury as a result of service. In cases of death, their widows and dependants should receive proper support from the government or community;
  • Have been unable to make a successful transition to civilian life.

When servicemen and women leave the armed forces, their healthcare is the responsibility of the NHS. All veterans are entitled to priority access to NHS hospital care for any condition, as long as it's related to their service, whether or not they receive a war pension.



Migrants

Migrants are widely described as people who belong to (or have an allegiance) to one state/country, but move into another for the purpose of settlement.

Migrant populations are diverse, and many have social, cultural and health needs. Migration is driven by many reasons (including economic, family reunion, study, humanitarian reasons or human trafficking). As a consequence migrants may have several diverse health and social care needs.

Migrant populations have different health and wellbeing issues depending on lifestyle risk factors, cultural practices, country of origin, genetic and hereditary factors and wider determinants (poor housing, lower economic opportunities, unemployment and living in deprived areas).

This topic links to the following JSNA topics:



Travellers

Gypsies and travellers have been a part of British society for centuries. There are around 300,000 Gypsies and travellers in the United Kingdom. In England, between 90,000 and 120,000 Gypsies and travellers live in caravans and up to three times as many live in conventional housing.   

Gypsies and travellers have significantly poorer health than the general population.

This topic has links to the following JSNA topics:



Offenders

The term ‘offender’ refers to an individual who has come into contact with the criminal justice system by committing a crime or violating a law.

The link between offending, re-offending and the impact on health is well known.

Offenders and ex-offenders are far more likely to be more socially isolated and marginalised than the general population and to have a broader range of health concerns. As the number of people who come into contact with the criminal justice sector increases, there will be an increasing number of ex-offenders in communities.

There is a real need to divert offenders who have serious mental health problems away from prison and into the appropriate health service facilities. The needs of those suffering from physical health problems and from substance misuse and abuse must also be addressed.

This topic links with the following JSNA topics:



Child sexual exploitation

Redcar & Cleveland Council seeks to create an environment where child sexual exploitation is prevented, identified and challenged by communities and professionals.

The vision is to ensure that children, young people and families whose lives are affected by child sexual exploitation receive an appropriate level of support to address their needs, that perpetrators are held to account for their actions, and where possible brought to justice.

The definition of child sexual exploitation as identified in Working Together to Safeguard Children (2015) and the National Working Group for Sexually Exploited Children and Young People is:

‘situations, contexts and relationships where young people (or a third person or persons) receive ‘something’ (e.g. food, accommodation, drugs, alcohol, cigarettes, affection, gifts, money) as a result of them performing, and/or another or others performing on them, sexual activities. Child sexual exploitation can occur through the use of technology without the child’s immediate recognition; for example being persuaded to post images on the internet/mobile phones without immediate payment or gain.  In all cases, those exploiting the child/young person have power over them by virtue of their age, gender, intellect, physical strength and/or economic or other resources. Violence, coercion and intimidation are common, involvement in exploitative relationships being characterised in the main by the child or young person’s limited availability of choice as a result of their social/economic or emotional vulnerability’.

Sexual exploitation can take many forms from the seemingly ‘consensual’ relationship where sex is exchanged for attention, affection, accommodation or gifts, to serious organised crime and child trafficking.  What marks out exploitation is the imbalance of power within the relationship.  The perpetrator always holds some kind of power over the victim, increasing the dependence as the exploitative relationship develops.  Perpetrators of child sexual expolitation are found in all parts of the country and are not restricted to particular ethnic groups.



Children in need

'Children in need of help and protection’ refers to children and young people who have been, or are subject to, a social care assessment as they are considered eligible for support and services under section 17 (child in need) or section 47 (child protection) of the 1989 Children Act.

There are many reasons why children may be in need of help and protection – for example, it may be due to disability, mental health needs, family dysfunction, abuse or neglect. Their circumstances may make them vulnerable and impact on their social, emotional and mental wellbeing and development. They may need support to help them develop and thrive and to access the same opportunities as their peers.

The acronym CIN is used to refer to Children in need.

Children’s Services overall aims are:

•     To safeguard and prevent harm

•     To support families to provide the best start in life

•     For children to realise their potential

Children’s Services in our borough are planned in line with the Child Wellbeing Model adopted by Redcar and Cleveland Borough Council and its partners. The Lord Laming inquiry into the death of Victoria Climbie, published in 2003, resulted in new legislation in the form of the Children Act 2004, which placed greater emphasis on integrated working and early intervention.

Further legislative drivers are the Children Act 1989, Leaving Care Act 2000, Children and Families Act 2014 and SEN reforms, Care Act 2014.

The purpose of this approach is to identify support on a continuum of need and allow analysis to take into account the various levels of intervention to enable effective, proportionate commissioning. 

This plan will take into account duties and powers of the Local Authority and its partners, as well as looking at how we can provide improved outcomes and early intervention via services for children, young people and their families that are delivered at the best value available.

There is an ever-changing landscape within commissioning and service improvement due to the introduction of new government policy. A major challenge for commissioners is to manage these changes locally in order to meet legislative requirements, as well as develop services to meet local need and continue to commission quality, cost-effective services that effect better outcomes in the long term.  It is, therefore, important that our local commissioning intentions are based on sound overarching principles and identify a solid direction for commissioning so that while new initiatives are being introduced, we have a firm set of outcomes that that underpins the work that we do, regardless of how this is achieved.



Looked after children

The term ‘looked after’ refers to children under 18 who are subject to a Care Order, (including an Interim Care Order), or who are Voluntary Accommodated under the Children Act 1989.

Looked After Children (LAC) are one of the most vulnerable groups in society. The majority of children and young people who become looked after do so as they have experienced abuse or neglect. It is acknowledged that looked after children can be at greater risk of poorer life chances and outcomes.

A poor start in life, past experiences,  involvement in care processes and transitions between placements and services can all result in inequitable access to services at both universal and specialist level.  Looked after children can have significantly higher levels of health needs than children and young people from comparable socio-economic backgrounds who have not been looked after.

The Local Authority’s duty to meet the social care needs of looked after children is set out in the 1989 Children Act and subsequent amendments. The Local Authority has specific duties to:

  • Receive a child who is the subject of a care order into care and to continue to look after them while the care order is in force.
  • Safeguard and promote the welfare of looked after children – finding out the wishes and feelings of child/parents before making any decisions and giving due consideration to those wishes and feelings and to the child’s background.
  • Promote the educational attainment of children in its care.
  • Regularly review the needs and circumstances of a child in care and to appoint independent reviewing officers to do this.
  • Provide appropriate advocates for children in its care.
  • Continue to support young people after they have left the local authority’s care.

The duty to meet the health needs of looked after children for both the NHS and Local Authorities is clearly laid out in ‘Statutory Guidance on Promoting the Health and Wellbeing of Looked After Children’.

This guidance states that the NHS is required to make arrangements to secure appropriate health services for the child in accordance with the health assessment and the child’s health plan and need to understand the current flow of looked after children both in and out of the Clinical Commissioning Group (CCG) area and ensure that services are commissioned to meet the needs of all Looked After Children.

Children and young people in care become looked after when their parents or carers are unable to provide ongoing care in either a temporary or permanent capacity.  Children may be placed with family and friend’s carers, foster carers or in residential placements, depending on individual circumstances.

In 2002 the document Promoting the Health of Looked After Children (DoH) was published.

http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4060424.pdf

This identified children and young people in Local Authority care as being amongst the most socially excluded groups in England.   The guidance was produced in response to substantial research which indicated the health outcomes of children in care are too often very poor in comparison to that of their peers.  This guidance was revised and reinforced under Statutory Guidance on Promoting the Health and Well-being of Looked After Children (DCSF and DH) 2009 and Promoting the Quality of Life of Looked After Children and Young People (NICE and SCIE) 2010.

http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_108592.pdf

http://www.nice.org.uk/nicemedia/live/13244/51173/51173.pdf

In our role as corporate parent, we are fully committed to ensuring that looked after children and young people are not only safeguarded from harm, but have a good experience in care that promotes better outcomes in all aspects of their lives. Our aspiration is for every looked after child and care leaver of Redcar and Cleveland to:

  • Experience high quality care and stable relationships.
  • Be nurtured and grow up with a sense of identity and belonging.
  • Feel their needs are given the highest priority and that they are valued and cared about not just cared for.
  • Have opportunities and support to achieve their full potential.
  • Have a successful transition to adulthood

The Strategic Plan for Children in Care outlines the vision of the Safeguarding, Children and Families division within the Adult and Children’s Directorate, for our Children in Care from October 2011 to October 2013. This is currently under review and being updated

http://intranet/intra.nsf/Web+Full+List/598BE47680BE43408025795D004E889F?OpenDocument



Wider Determinants

Introduction
In his review of health inequalities, one of Sir Michael Marmot’s key messages is that “Health inequalities result from social inequalities. Action on health inequalities requires action across all the social determinants of health.”  The review identified six policy objectives which require action to reduce health inequalities.  These are:

  • Give every child the best start in life;
  • Enable all children, young people and adults to maximise their capabilities and have control over their lives;
  • Create fair employment and good work for all;
  • Ensure healthy standard of living for all;
  • Create and develop healthy and sustainable places and communities; and
  • Strengthen the role and impact of ill-health prevention.

The topics within this theme are important contributors to the social determinants of health.  This summary attempts to identify the most important issues contained within each topic and, from these, highlight those which are the most important for action in addressing health needs and inequalities in Redcar & Cleveland.


What are the most important messages from each topic?

Crime

  • Two thirds of offences are recorded as having been committed under the influence of alcohol and/or drugs.
  • Acquisitive crimes (other theft & burglary); antisocial behaviour and related crime/incidents; drugs and alcohol misuse; reducing offending and re-offending; and violence (domestic, sexual and alcohol-related) have been identified as priority problems which require addressing.


Education

  • Achievement at secondary school is unsatisfactory.  Attainment at age 11 is similar to England, but by age 16 is below England.
  • Too many young people are not in education, employment or training.
  • There is a need to create a population that values education by understanding both the opportunities it can bring and the barriers presented by a lack of qualifications.


Employment

  • Unemployment is higher than the England average.  There are six wards with particularly high rates of unemployment: Grangetown, South Bank, Kirkleatham, Coatham, Newcomen and Dormanstown.  There is a need to increase the capacity of organisations working with residents to overcome barriers to employment, especially for these areas.
  • Graduate unemployment is a significant issue in Redcar & Cleveland.
  • Redcar & Cleveland’s economy has traditionally been dominated by a few large employers, especially in shipbuilding and heavy industry.  There is a need to diversify the economy, supporting a culture of enterprise and business creation.


Environment

  • There is a need to reduce emissions from industrial and commercial sectors.
  • Rising fuel costs, low household income and homes with poor energy efficiency lead to an increase in households in fuel poverty.


Housing

  • It is estimated that 12,400 households (20.9%) in Redcar & Cleveland are in fuel poverty.  On average there are an extra 60 deaths each year in winter months compared to other times of the year.
  • There is a lack of affordable housing and, with an ageing population, additional homes with care and support will be needed.


Poverty

  • There are between 11,200 and 16,100 people in Redcar & Cleveland who are not claiming benefits that they are entitled to.  If all of these benefits were claimed, this could be worth between £17million and £27million to the people and economy of Redcar & Cleveland.  A systematic approach to maximising rightful benefit uptake would help the most vulnerable and disadvantage people.
  • The educational attainment of disadvantaged children is worse than that of other children, perpetuating a cycle of poverty.


Transport

  • The rural geography of some parts of Redcar & Cleveland leads to a risk of isolation among residents of those areas. Public sector cutbacks may lead to decreased bus services in the more rural areas limiting people’s access to employment in the early morning, may isolate some residents from public services and could affect mental health by limiting access to social opportunities in the evening..
  • Opportunities for physically active transport (walking and cycling) need to be maximised to help both physical and mental health.
What should be the highest priorities for commissioners?

Short-term (1 to 2 years)

  • Tackling alcohol-related crime.  This would help relieve weekend pressures on A&E services, reduce domestic violence, and tackle location-based hotspots.
  • Develop a systematic approach to maximising benefits claimants, improving the lives of disadvantaged people and boosting the local economy.

Medium-term (3-5 years)

  • Improve educational attainment at age 16 and reduce the number of young people who are not in education, employment or training.
  • Improving the quality of housing in the private rented sector, including thermal efficiency.
  • Optimise opportunities for job creation for all, but with a focus on young people.

Long-term (over 5 years)

  • Develop transport infrastructure to maximise physically active travel and minimise injury and death.
  • Create an environment which supports health and wellbeing.
Summary author

Leon Green
Public Health Intelligence Specialist
Tees Valley Public Health Shared Service
 



Crime

Crime and the fear of crime are key factors that affect people’s quality of life and sense of well-being.

There is a direct link to health through such things as violent injury, rape and other offences against the person, and less directly via the psychological trauma of experiencing crimes such as burglary or vandalism.

Fear of crime affects the health of the wider community via, for example, restrictions on unsupervised outdoor play for children and social isolation of older people.

It has been acknowledged that the actual rick of becoming a victim of crime is much lower than the perceived fear of crime and victimisation. Fear of crime can have a devastating effect on quality of life and more focus is being placed upon providing reassurance to residents and ensuring that they know how best to protect themselves from becoming a victim without raising fear unnecessarily.

Crime reduces the effectiveness of healthcare systems through violence against NHS staff, damage to property, and costs of replacement, repairs and security. Alcohol and illegal drug dependency increase crime, and have an impact on health care services. http://www.wales.nhs.uk/sitesplus/888/page/43763

This topic is associated with:

Offenders

Alcohol misuse

Illicit drug use

Domestic violence victims

Sexual violence victims



Education

Education creates greater opportunity for economic and social choice. The educational opportunities of children and young people are affected by a range of factors including poor levels of self-esteem and physical activity. Future life chances and health are directly linked to educational attainment.

This topic is most closely related to the following topics:

 



Employment

Employment has a major positive impact on an individual’s long-term health and wellbeing as well as that of their family members.  It can influence social mobility, economic independence, housing, and income levels.

Unemployment, however, can be both a cause of and a result of ill health.  The negative effects of unemployment on health and wellbeing can be linked to poverty and low income levels.  Long-term unemployment; limiting illnesses; low paid, short-term and temporary employment; and low level skills can affect an individual’s ability to gain and sustain employment.  The current economic climate presents particular obstacles to gaining employment for specific age groups (for example, 16-18 year olds and people aged over 50 years) and also for people who have recently been made redundant and may need to re-train to secure available employment opportunities.

This topic has strong links to the following JSNA topics:

 



Environment

The environment has a significant effect on health and wellbeing.  High quality environments have a key part in helping people to live healthier and happier lives. Environmental problems such as noise, air pollution, food safety, pest control and contaminated land can have a significant impact on individual and population health.  Climate change continues to pose significant future risks to human health if actions are not taken now both to reduce carbon emissions and reduce energy demands to sustainable levels.

This topic is most closely associated with:

 



Housing

Housing has an important impact on health and well-being: good quality, appropriate housing in places where people want to live has a positive influence on reducing deprivation and health inequalities by facilitating stable/secure family lives.  This in turn helps to improve social, environmental, personal and economic well-being.  Conversely, living in housing which is in poor condition, overcrowded or unsuitable will adversely affect the health and well-being of individuals and families.

The value of good housing needs to been seen as more than ‘bricks and mortar’. The Department for Communities and Local Government (DCLG, 2006) define a decent home as ‘a home that is warm, weatherproof and has reasonably modern facilities’. Failure to address the investment needs of poor housing conditions will have a detrimental impact on the occupiers’ health and well-being.

A decent, affordable home is an essential requirement for tackling health inequalities and reducing the burden on health and social care services and cost to the public purse.

This topic includes homelessness and fuel poverty.

This topic is most closely linked with:

 



Poverty

In his recently published review of health inequalities – many of which are greatly determined by poverty – Professor Sir Michael Marmot said:

‘People with higher socioeconomic position in society have a greater array of life chances and more opportunities to lead a flourishing life. They also have better health. The two are linked: the more favoured people are, socially and economically, the better their health. This link between social conditions and health is not a footnote to the ‘real’ concerns with health – such as health care and unhealthy behaviours – but should become the main focus.

Consider one measure of social position: education. People with university degrees have better health and longer lives than those without. For people aged 30 and above, if everyone without a degree had their death rate reduced to that of people with degrees, there would be 202,000 fewer premature deaths each year. Surely this is a goal worth striving for.  It is the view of all of us associated with this Review that we could go a long way to achieving that remarkable improvement by giving more people the life chances currently enjoyed by the few. The benefits of such efforts would be wider than lives saved. People in society would be better off in many ways: in the circumstances in which they are born, grow, live, work, and age. People would see improved well-being, better mental health and less disability, their children would flourish, and they would live in sustainable, cohesive communities.’

Fair Society, Healthy Lives, February 2010

Many health-related issues are worse for people living in poverty, including an increased risk of dying prematurely.  People living in poverty are less likely to benefit from education to the same degree as others; are less likely to be in professional, managerial and skilled jobs; and are more likely to live in poor housing and in neighbourhoods where crime is more prevalent and where community safety is threatened.  All of these conditions and circumstances can have an adverse effect on physical and mental health and well-being.

Poverty, or relative poverty, is commonly defined in terms of households with an income which, after tax, is below 60% of the median (average) household income (Aldridge et al, 2012).  As such, the income required to prevent poverty depends upon household composition.

This topic is most closely associated with:



Transport

Transport has an impact on health through transport-related accidents, active travel, public transport, air quality and access to a range of services. 

Transport can affect people by giving access to employment opportunities, education, leisure, healthcare and diverse food supplies. The development of an efficient transport network and vehicles has the potential to benefit health.

Increasing levels of motorised traffic have contributed to air pollution, noise, vibration, danger from vehicles and an increased fear of traffic. These issues particularly affect the most deprived and most vulnerable people in communities.

The rise in personal car use has meant liberation for people who are young and more affluent. More deprived, elderly and disabled people can become trapped in ‘residential islands’ surrounded by dense traffic, or without the means to access more distant facilities and services in out-of-town developments. This also applies to people in rural areas faced with dwindling local facilities and longer travel times.

Road traffic casualties are still one of the main public health challenges in the UK particularly for children and young adults.

The rise in personal car ownership levels has contributed to people being less active. This is a significant contributor to obesity, diabetes and cardiovascular disease.

This topic has links to the following JSNA topics:



Behaviour and Lifestyle
Introduction

Behaviours, such as smoking, excessive use of alcohol, the use of illicit drugs, low levels of exercise and physical activity, engaging in unsafe sex, and a poor diet all impact on physical health and mental wellbeing.  It is known that each of these lifestyle risk factors is unequally distributed in the population and that there are differences in these behaviours associated with income, educational achievement and social class.

There is compelling evidence that lifestyle risk factors tend to cluster than present in isolation.  It is estimated that in England 70% of the adult population have two or more lifestyle risk factors (King’s Fund, 2012).  Whilst there has been an overall decline in the proportion of the population with three or four unhealthy risk factors from 33% of the population in 2003, to 25% in 2008, these reductions have not been equally distributed across the population. The percentage of people with three or more lifestyle risk factors is continues to increase for people from lower socio-economic and educational groups. For instance  people with no educational qualifications were  more than five times as likely as those with higher education to have four lifestyle risk factors in 2008, compared with only three times as likely in 2003.

This variation in the distribution of lifestyle risk factors contributes to the gaps in length and quality of life between deprived and affluent groups locally and nationally. The major causes of illness and premature deaths (deaths before age 75 years) in Redcar & Cleveland are circulatory diseases, cancer, respiratory disease and digestive diseases (including liver disease).  Lifestyle risk factors such as smoking, excessive alcohol use, poor diet and physical inactivity are known to contribute to these major causes of premature deaths.

 

Alcohol misuse

  • Levels of alcohol-related harm in Redcar & Cleveland are higher than England.  There are a higher number of alcohol-related hospital admissions and higher alcohol-specific mortality compared to the England average.
  • Alcohol misuse impacts upon physical and mental health, as well as having a detrimental effect on social cohesion, crime, violence and community safety.
  • Alcohol-related harm is a major problem in Redcar & Cleveland impacting on individuals, families and communities.

Illicit drug use

  • Redcar & Cleveland is estimated to have increasing levels of drug misuse. 
  • The rate of successful exit from drug treatment services is below the national average.
  • The number of people accessing structured treatment for opiate and/or crack use is in decline.

Smoking

  • Nearly one-quarter of adults in Redcar & Cleveland smoke. The smoking prevalence rises to almost one in two adults in some deprived wards and disadvantaged population groups.
  • In Redcar & Cleveland, 25% of women smoke throughout their pregnancy posing a significant health risk both to mother and unborn child.  This is nearly double the national average.
  • The number of premature deaths (under the age of 75 years) in Redcar & Cleveland that are attributable to smoking is higher than the national average.

Sexual health

  • Some sexually transmitted infection (STI) rates are high and/or increasing, particularly gonorrhoea and syphilis. 
  • Teenage pregnancy rates in Redcar & Cleveland are higher than England.  There is inconsistency in the provision of dedicated young people’s sexual services, particularly those linked to educational establishments and in electoral wards with the highest teenage pregnancy rates.
  • There is low uptake for Long Lasting Reversible Contraception (LARC) compared to regional and national averages. 

Diet and nutrition

  • About four out of five adults in Redcar & Cleveland do not eat the recommended five daily portions of fruit and vegetables.
  • Breastfeeding rates in Redcar & Cleveland are among the lowest in England and the gap is widening.
  • There is low uptake of healthy start vitamin supplements in babies and infants.
  • Poor oral health is a robust indicator of poor nutrition and the prevalence of dental decay for children in Redcar & Cleveland children is one-and-a-half time the national average.  There are significant dental health inequalities between wards, with those in the most deprived wards having the worst oral health.

Obesity

  • Adult obesity rates in Redcar & Cleveland are significantly higher than the national average and increasing. There are inequalities in relation to the prevalence of obesity according to income, social deprivation, age, ethnicity and disability.
  • Childhood obesity doubles from 10% in reception year to almost 20% in year 6 pupils.
  • Maternal obesity in South Tees is higher than the regional and national averages with an increase in the number of pregnant women with a body mass index (BMI) greater than 40.  
  • The increasing prevalence rates of obesity increases demand on health services and costs to the NHS and wider economy. 

Physical inactivity

  • Approximately half of the adult population of Redcar & Cleveland is inactive, with only one-in-five taking part in the recommended weekly levels of physical activity.
  • The proportion of Redcar & Cleveland school pupils doing three hours of PE per week is above the national average, but one-quarter of school children do not get three hours of PE.  Active travel to school is above the national average.

Recommendations

The recommendations below relate to the Marmot review: Fair Society, Healthy Lives, the former National Support Team recommendations for tackling Health Inequalities and latest national policy and professional guidance.

Short-term (1-2 years)

  • Commission and deliver integrated public health services and programmes that address multiple lifestyle risk factors rather than taking an approach that focuses solely on single issues. Ensure that these interventions are accessible and acceptable to those at highest risk.
  • Ensure equitable access to sexual health services (prevention, early identification, awareness and treatment services) and address the high teenage pregnancy rates and sexually transmitted infections. 
  • Give all children the best start in life by tackling smoking in pregnancy, obesity in pregnancy, low rates of breast feeding and uptake of healthy start vitamins.

Medium-term (3-5 years)

  • Maximise the opportunities of creating a health promoting environment through enforcement, planning, regeneration and licence application processes.  This could include considering the restriction of planning permission for hot-food takeaways, alcohol premises (representations and cumulative impact areas), tackling availability, supply and demand for illicit drugs and tobacco.   
  • Strengthen the role of primary care, social care and voluntary and community sector (VCS) organisations in delivering lifestyle and behaviour modification programmes.
  • Strengthen the use of community assets in addressing lifestyle risk factors.

Long-term (over 5 years)

  • Ensure that all town planning, regeneration and transport programmes incorporate active transport routes and that future planning complements strategies to reduce alcohol-related crime and violence.
  • Improve maternal and child health by addressing the social causes of poor health including teenage pregnancy, educational attainment, unemployment, food poverty and maternal mental health.

 

 

Summary author

Leon Green
Public Health Intelligence Specialist
Tees Valley Public Health Shared Service


Reference

King’s Fund (2012). Clustering of unhealthy behaviours over time: Implications for policy and practice.

 



Alcohol misuse

Alcohol misuse is consuming more than the recommended limits of alcohol.

Many people are able to keep their alcohol consumption within the recommended limits, so their risk of alcohol-related health problems is low. However, for some, the amount of alcohol they drink could put them at risk of damaging their health.

There are three main types of alcohol misuse:

  • Hazardous drinking: Drinking over the recommended limits;
  • Harmful drinking: Drinking over the recommended limits and experiencing alcohol-related health problems;
  • Dependent drinking: Feeling unable to function without alcohol.

Many people who have alcohol-related health problems are not alcoholics.

In 2009/10, around one million hospital admissions were due to an alcohol-related condition or injury.

The short-term risks of alcohol misuse include:

  • Alcohol poisoning, which may include vomiting, seizures (fits) and unconsciousness;
  • Injuries requiring hospital treatment, such as a head injury
  • Violent behaviour that might lead to being arrested by the police;
  • Unprotected sex that could potentially lead to unplanned pregnancy or sexually transmitted infections (STIs);
  • Loss of possessions, such as a wallet, keys and/or phone, leading to feelings of anxiety. 

Long-term alcohol misuse is a major risk factor for a wide range of serious conditions, such as:

  • Heart disease;
  • Stroke;
  • Liver disease;
  • Liver cancer and bowel cancer.

As well as health problems, long-term alcohol misuse can lead to social problems such as unemployment, divorce, domestic abuse and homelessness.

The Department of Health’s national alcohol strategy ‘Safe. Sensible. Social’ outlined the next steps for reducing the harm associated with alcohol. Within the strategy, it defines the following terminology for drinking categories:

  • Low risk drinking: Drinking alcohol within the current guidelines on alcohol consumption;
  • Increasing risk drinking: Drinking between 22 and 50 units per week for males and between 15 and 35 units per week for females;
  • Higher risk drinking: Drinking over 50 units per week for males and over 35 units per week for females and experiencing harm such as alcohol-related accidents, acute alcohol poisoning, hypertension or cirrhosis of the liver;
  • Dependent drinking: Continued drinking despite harm usually characterised by an inner drive to consume alcohol with the drinker experiencing withdrawal symptoms when they cease drinking;
  • Binge drinking: Drinking over eight units a day for men and over six units a day for women.


Illicit drug use

Drug misuse refers to the use of a drug for purposes for which it was not intended or using a drug in excessive quantities.

‘Drug addiction is a chronic condition characterised by the risk of repeated relapse and remission. It can take an individual several attempts over a number of years to finally overcome his or her dependency and lead an addiction-free life. There is no quick solution and what may work for one person will not necessarily work for another’ (Drug Treatment & Recovery in 2010/11, National Treatment Agency for Substance Misuse, October 2011).

All sorts of different drugs can be misused, including illegal drugs (such as heroin or cannabis), prescription medicines (such as tranquilisers or painkillers) and other medicines that can be bought off the supermarket shelf (such as cough mixtures or herbal remedies).

In the UK there are high levels of drug misuse, including high rates of heroin and crack cocaine use.

People who misuse drugs often have a range of health and social problems, which may have lead them to misuse drugs or may be a consequence of their addiction.

The 2009/10 British Crime Survey estimates that 8.6% of 16 to 59-year-olds living in England and Wales had tried illegal drugs in the last year.

Among young people, this figure is more than twice as high, with an estimated 20% of 16 to 24-year-olds having used illegal drugs in the last year.

For the people who take them, illegal drugs can be a serious problem. They're responsible for between 1,300 and 1,600 deaths a year in the UK, and destroy thousands of relationships, families and careers.

This topic links with the following JSNA topics:

Alcohol misuse

Crime

Offenders

Housing

Employment



Smoking

Smoking is the single largest cause of preventable mortality in England. This is recognised in the Government’s Public Health White Paper ‘Healthy lives, healthy people', which states that ‘reducing smoking rates represents a huge opportunity for public health.'

Approximately 8.5 million people in England smoke and about half of all long-term smokers will die from smoking with half of those in middle age.

Tobacco use is one of the Government’s most significant public health challenges and causes over 80,000 premature deaths in England each year.

The health risks from tobacco smoking are well established. In 2006-7 there were approximately 1.4 million hospital admissions with a primary diagnosis of a disease that can be attributable to smoking.

Smoking is estimated to cost the NHS in England £2.7 billion a year and £13.7 billion in wider costs to society through sickness, absenteeism, the cost to the economy, social care, environmental pollution and smoking-related fires.  This burden impacts on every GP surgery and hospital, every local authority and every family whether they smoke or not. 

As a drug medically proven to be every bit as addictive as heroin, most tobacco users start as children.  The majority wish they could stop and are overwhelmingly in favour of helping stop the next generation becoming addicted to smoking.

About one-third of all cancer deaths can be attributed to smoking.   These include cancer of the lung, mouth, lip, throat, bladder, kidney, stomach and liver.

Chronic obstructive pulmonary disease (COPD) is the second most common cause of emergency admission to hospital and one of the most costly diseases in terms of acute hospital care (DH, 2010).  This is primarily a ‘smokers’ disease.

Provision of effective local NHS Stop Smoking Services is just one of a range of local tobacco control measures that need to be in place to reduce smoking prevalence.   Fresh North East has developed an evidence-based multi-component tobacco control programme based on an eight key strands approach that local alliances are encouraged to follow.

Smoking is linked most closely to the following JSNA topics:

Respiratory diseases

Circulatory diseases

Cancer

Poverty

Alcohol misuse

Illicit drug use



Diet and nutrition

Good nutrition has a key role to play both in the prevention and management of diet-related diseases such as cardiovascular disease (CVD), cancer, diabetes and obesity (World Health Organisation, 2003). Healthy eating during childhood and adolescence is vital as a means to ensure healthy growth and development and to set up a pattern of positive eating habits into adult life. The promotion of evidence-based healthy eating messages is fundamental. Alongside this, it is necessary to ensure that guidelines concerning a nutritionally adequate diet are implemented to help prevent diet-related deficiencies and malnutrition in vulnerable infants, children and adults.

 

In the UK, the poorer people are, the worse their diet, and the more diet-related diseases they suffer from. This is known as food poverty. Poor diet is a risk factor for the UKs major causes of death: cancer, coronary heart disease (CHD) and diabetes. It is only recently that the immense contribution it makes to poor health has been quantified: poor diet is related to 30% of life years lost in premature death and disability (De Rose, Messer & Millman, 1998).

 

Tackling food poverty is recognised as key to achieving Government targets on reducing inequalities, reducing illness from cancer and CHD and improving the health of children and older people. However, action needs to be more than health professionals giving advice to individuals. It must change the ‘food environment’ – that is, accessibility, affordability, culture – in which people live (O’Neil, 2005).

 

Poor diet is a major health risk. It contributes to:

 

- Almost 50% of CHD deaths

- 33% of all cancer deaths

- Increased falls and fractures among older people

- Low birth weight and increased childhood illness and mortality

- Increased dental disease, especially in children

 

This topic is most closely linked to:

 

- Obesity

- Physical activity

- Cancer

- Circulatory diseases

- Diabetes mellitus

- Oral health



Physical inactivity

Increased levels of physical activity can assist in tackling many of the important health challenges faced by the UK. It can help in the prevention and treatment of over 20 chronic conditions, including coronary heart disease, stroke, type two diabetes, cancer, obesity, mental health problems and musculoskeletal conditions (Department of Health, 2004). An evidence review concluded that physical activity could be the best buy in public health (Morris, 1994).  Helping inactive people to move to a moderate activity level will produce the greatest reduction in risk of ill health (Department of Health, 2009).

Physical activity in childhood has a range of benefits including healthy growth and development, maintenance of energy balance, mental well-being, improved academic performance and social interaction, and reduces osteoporosis risk in later life (Department of Health, 2004).  Active children are less likely to smoke, or to use alcohol/get drunk or take illegal drugs (Physical Activity Task Force, 2002).  Active children are more likely to become active adults (Telema, 2009).Physical inactivity in England is estimated to cost £8.2 billion a year; this includes both the direct costs of treating major lifestyle-related diseases and the indirect costs of sickness absence (Department of Health, 2004).

The NHS cost alone is £900 million based on 2006/07 costs (Scarborough et al, 2011).  In 2009/10, physical inactivity cost Redcar & Cleveland PCT £2.8 million (Sport England Local Sport profile Tool, 2009/10).

This topic is most closely associated with the following JSNA topics:

 



Obesity

The prevalence of obesity in England is increasing at all ages; almost two-thirds of adults and one-third of children are either overweight or obese.  If present trends continue, 60% of men, 50% of women and 25% of children will be obese by 2050.

Overweight and obesity are major risk factors for disease and mortality including cardiovascular disease, cancer and disability during older age.   It contributes to a decrease in life expectancy.  Furthermore, obesity is associated with serious chronic conditions such as type 2 diabetes, hypertension, and hyperlipidaemia, which are major risk factors for cardiovascular disease (Health Survey for England, 2009).   Risk factors for some of these conditions start at a relatively low body mass index (BMI), and this will cause future health service costs to rise significantly.  In Redcar & Cleveland alone, NHS costs of principal diseases related to obesity are estimated to be £42.5 million (Department of Health, 2010).

The rising trend in obesity is one of the biggest threats to the health of the population of Redcar & Cleveland. The prevalence of obesity is significantly higher than the national average for both adults and children.  The trend of weight problems in children and young people is of particular concern because of evidence suggesting a ‘conveyor belt’ effect in which excess weight in childhood continues into adulthood (Department of Health, 2008). In addition to the increased health risks in later life, children and young people face immediate health and psychological consequences of obesity including increased risks for elevated blood pressure and type 2 diabetes, low self-esteem, anxiety and depression.

The causes of obesity are complex and relate to a wide variety of societal and behavioural factors which cannot be tackled in isolation. Social determinants have an important impact on the likelihood of becoming obese and they need to be addressed.

The inequalities, health risks and costs associated with obesity combine to make the prevention of obesity a major public health challenge.

This topic is linked with the following JSNA topics:

 



Sexual health

Sexual health is an integral part of physical and mental health. Good sexual health depends on safe and equitable relationships and ready access to high quality information and sexual health services. Relationships and sexual behaviour are influenced by a number of different factors which include: personal attitudes and beliefs, social norms, peer pressure, religion, culture, confidence and self-esteem, drug and alcohol misuse, abuse and coercion as well as access to information, prevention and services. Deprivation and social exclusion also impact on sexual health, with a higher burden of disease in the population living in more deprived areas.

Sexual health services offer services in relation to contraception, relationships and STIs (Sexually transmitted Infections) including HIV and abortion.  A wide range of providers including community sexual health services, outreach services, acute hospitals, general practice, pharmacies and the voluntary, charitable and independent sector is involved in delivering sexual health services.

The commissioning of sexual health services has changed since April 2013. The main responsibility to provide open access services for the local populations lies with local authorities. CCGs (Clinical Commissioning Groups) and NHS England are commissioning distinct aspects of sexual health as detailed in the table below.



Illness and Death
Premature deaths in Redcar & Cleveland

Life expectancy in Redcar & Cleveland continues to improve.  However, latest reports show that the gaps in life expectancy between the deprived and affluent areas within Redcar & Cleveland, and between Redcar & Cleveland and England are widening. The Slope Index of Inequality (an estimate of the range in life expectancy at birth from most to least deprived) shows changing inequalities in Redcar & Cleveland. The gap in life expectancy has widened for males from 13.1 years in 2006-10 to 19.3 years in 2009-11.  For females, the gap has also widened from 8.4 years in 2006-2010, to 12.3 in 2009-2011

The major causes of illness and premature deaths (deaths before age 75 years) in Redcar & Cleveland are circulatory diseases, cancer, respiratory disease and digestive diseases (including liver disease). Charts 1 and 2 below illustrate the contribution of these conditions to the gap in life expectancy between Redcar & Cleveland and England and for the also gap between deprived and affluent areas within Redcar & Cleveland.

Life expectancy gap between R&C and England, 2009-11

Life expectancy gap between affluent and deprived areas of R&C, 2009-11

To reduce premature mortality in Redcar & Cleveland, the focus should be on the major causes of premature deaths.  The following chart shows the number of deaths (in people under the age of 75 years) that need to be prevented to close the gap between Redcar & Cleveland and the regional and national averages.

Premature mortality differences, R&C, North East and England, various dates

Long-term conditions, cancer and mental health in Redcar & Cleveland

There are increasing numbers of people with more than one long-term condition receiving support from the NHS, social care and voluntary and community services. However, their care is not always co-ordinated, resulting in variation in their outcomes and quality of life.

Whilst the deaths from cardiovascular disease in people under 75 have continued to fall, the same pattern has not been observed for cancer and respiratory disease. Premature deaths from cancer in Redcar & Cleveland remain significantly higher than the England average and are the largest contributor to local health inequalities in Redcar & Cleveland. Breast, lung, colorectal and prostate cancer account for over half of all cancer cases and deaths. Lung cancer incidence and mortality in Redcar & Cleveland is statistically significantly higher than the national average for males and females.

Many outcomes for babies, children and young people remain poor. Infant mortality rates continue to improve and have been lower than the national average in recent years (although the difference is not statistically significant). Hospital admissions for injuries in those aged under 18 are higher than North East and England averages.

There are higher levels of mental illness, behavioural and psychiatric morbidity characterised by:

  • a prevalence of depression that is higher than England.
  • a higher rate of emergency admissions for self-harm compared to England.

The local prevalence of dementia is similar to England.  However, consideration needs to be given to projections of future need and service configuration.

There are considerable gaps between the number of people known to health services compared to the expected numbers with diseases such as circulatory diseases (heart disease, stroke, high blood pressure), respiratory diseases (chronic obstructive pulmonary disease (COPD) and asthma) and diabetes.  This suggests that there is a high number of people with undiagnosed disease – ‘the missing thousands’.

There are variations in diagnosis, treatment, quality of care and outcomes in primary care for patients with long-terms conditions (asthma, COPD, circulatory diseases and diabetes).

There is lower uptake of preventative, screening and early detection services for cancers and long-term conditions (NHS Health Check, Abdominal Aortic Aneurysm (AAA), diabetes, lung health) in deprived and disadvantaged communities in Redcar & Cleveland.

Recommendations 

The recommendations below summarise the topic recommendations for the illness and death theme.  They are similar to those identified in the Marmot review: Fair Society, Healthy Lives, the former National Support Team recommendations for tackling Health Inequalities and latest national policy and professional guidance.

Short-term actions (1-2 years)

  • Ensure that people with existing disease are managed effectively: Reduce variation in clinical management of long-term conditions, cancer, mental health and dementia to ensure equitable access, across all social groups, to effective care, which minimises progression, enhances recovery and promotes independence.
  • Ensure that people at high risk are identified and managed at the earliest opportunity: Increase uptake of preventative and early intervention programmes with more targeted approaches for deprived and vulnerable groups (such as people with learning disability, mental health).
  • Increase early identification of long-term conditions, cancer, mental health and dementia by raising community awareness and promoting health-seeking behaviours (targeted at high risk groups and those ‘seldom seen, seldom heard’ and socially isolated or excluded).

Medium-term actions 3-5 years

  • Make all care ‘planned care’: reduce reliance on urgent care, emergency admissions and delayed/late stage presentations for cancer, circulatory diseases, diabetes and other long-term conditions, including mental health and dementia.
  • Prevent illness by addressing lifestyle risk factors: design community-based interventions that tackle obesity, smoking and alcohol misuse with a clear focus on improving mental wellbeing. 

Long-term actions (over 5 years)

  • Address the social causes of poor health and premature deaths: continue to address the ‘causes of the causes’ of illness and premature deaths such as unemployment, poor quality housing, fuel poverty, raising literacy and educational attainment.  

 

 

 

Summary Author

Leon Green
Public Health Intelligence Specialist
Tees Valley Public Health Shared Service
leon.green@tees.nhs.uk



Cancer

More than one in three people in England will develop cancer at some stage in their lives and one in four will die from it. Consequently the prevention, detection and treatment of cancer are key priorities.

Over 250,000 people in England are diagnosed with cancer every year and around 130,000 die from the disease. Currently, about 1.8 million people are living with cancer. (Department of Health, 2011a).

The earlier a cancer can be diagnosed the greater the prospect of survival. Evidence suggests that later diagnosis of cancer has been a major factor in the poorer survival rates in the UK compared with some other countries in Europe.

Cancer is the leading cause of premature death (people under 75) nationally and the second highest cause of death across all age groups. Locally, cancer poses particular challenges to the health of the population. Overall, incidence of cancer is higher than national levels and survival from some cancers, is among the worst in the country.

Cancer services have changed considerably over the last decade. The NHS Cancer Plan (2000) and the Cancer Reform Strategy (2007) set out the objectives and vision to improve cancer services across the UK.

Lives can be saved from cancer, primarily through better awareness of the signs and symptoms and earlier diagnosis of cancer.

This is made even more important by the fact that the burden of cancer is increasing dramatically: it is expected that there will be 100,000 more cases per year over the next 15 years in the UK.

This topic is most closely linked to:

 



Cardiovascular Disease

Cardiovascular disease (CVD) refers to a group of related diseases and conditions of the heart and blood vessels linked by a common set of risk factors leading to atherosclerosis. Atherosclerosis is the gradual build up of fatty material ‘atheroma’ in the walls of arteries leading to narrowing and stiffening of the arteries. Cardiovascular conditions include:

  • Coronary heart disease (CHD) is a disease in which the coronary arteries are narrowed by arthrosclerosis or obstructed by blood clots resulting in a reduced or sudden stop of the blood supply to the heart muscle. This leads to angina, heart attack and heart muscle damage  
  • Cerebrovascular disease is a disease in which the cerebral arteries are narrowed by arthrosclerosis or obstructed by blood clots resulting in a reduced or sudden stop of the blood supply to the brain.  This leads to transient ischaemic attacks (TIA) and stroke.
  • Peripheral vascular disease is a disease in which the arteries of the arms and legs are narrowed by arthrosclerosis or obstructed by blood clots resulting in a reduced or sudden stop of the blood supply to arms and legs. This leads to claudication.

Other conditions such as vascular dementia, chronic kidney disease, cardiac arrhythmias, sudden cardiac death, and heart failure are related because they either share common risk factors or have an impact on the prognosis and outcome of CVD.

Nearly five million people in the UK aged 16 and over are a estimated to suffer from CVD. This means that about every 7th adult in the UK suffers from a cardiovascular condition. The older people get the more likely they are to develop CVD. .

Deaths from CVD have fallen by over a third between 2001 and 2010, but CVD is still one of the main causes of death in the UK and accounts for about one-third of all deaths. In 2011, almost 160,000 people in the UK died from CVD. 74,000 of these deaths were caused by coronary heart disease - the UK's single biggest cause of death. 

A number of common risk factors are known to increase the risk of arthrosclerosis leading to CVD. These risk factors can be divided into three broad groups.

  • Non-modifiable and non-behavioural risk factors including age, sex, family history/genetic factors, ethnicity and deprivation. There are considered to estimate the overall risk of CVD for an individual.
  • Modifiable and behavioural risk factors such as smoking, physical inactivity, poor diet, obesity and binge drinking. There reflect individual circumstances and choices which can be prevented or changed by lifestyle changes.
  • Conditions associated with an increased risk such as hypertension (blood pressure) , hyperlipidaemia (blood fats), diabetes and atrial fibrillation can be prevented or reversed in their early stages but usually need medical treatment.

This topic links with the following JSNA topics:

Smoking

Physical inactivity

Diet and nutrition

Diabetes mellitus

Obesity

 



Diabetes mellitus

Diabetes is a condition where the amount of glucose in blood is too high because the body cannot use it properly. This is because the pancreas does not produce any insulin, or not enough, to help glucose enter the body’s cells – or the insulin that is produced does not work properly (known as insulin resistance).

There are three main kinds of diabetes: Type 1 diabetes is commonly treated with insulin and often diagnosed in people aged under 30.  Type 2 diabetes can be treated with diet alone, tablets or insulin injections and can be diagnosed at any age, but most commonly from middle-age onwards.  Type 2 diabetes can be associated with being overweight.  Gestational diabetes affects pregnant women and often goes away after birth.  Women who’ve suffered gestational diabetes have an increased risk of going on to develop type 2 diabetes in later life.

Diabetes is a common life-long health condition. There are 2.8 million people diagnosed with diabetes in the UK and an estimated 850,000 people who have the condition but don’t know it.

Health spending on people with diabetes is typically higher than average.  With type 2 diabetes particularly affecting older people, and the number of older people set to rise, having robust plans to meet the future needs of people with this illness is essential.

This topic is associated with the following JSNA topics:

 



Injuries

Childhood injuries are the leading cause of avoidable death and disability. It is one of the most common reasons for admissions to hospital (Audit Commission 2007).

There is strong evidence to show that injuries to children and young people are more likely in more deprived communities. People from poorer communities are more likely to die as a result of unintentional injury. Nationally, although the number of accidental deaths has fallen in recent years, the rate of deaths among the poorest children has risen.

Childhood injuries are accepted as an inevitable part of usual child development. Although protecting children and young people from every perceivable harm would be impossible, there is evidence to suggest that a large proportion of unintentional and intentional injuries are preventable.

The cost of childhood injuries to the NHS is estimated to be £2.2 billion. The wider costs to the NHS associated with domestic injury is estimated to be in the region of £25 billion (this includes indirect costs such as days lost to education, parents and carers taking leave from the workplace and the psychological effects caused by some injuries). (Audit Commission, 2007)

There are two million visits to A&E departments in the UK each year as a result of unintentional childhood injuries (Audit Commission 2007)

The need to rebalance normal development and preventing serious injury was highlighted in a 2009 government review. Preventing childhood injuries is an important public health priority and has been identified by the government within the Public Health Strategy ‘Healthy Lives Healthy People (DH 2010). Hospital admissions due to unintentional and deliberate injury have been included as an indicator within the Public Health Outcomes Framework (DH 2012).

This topic is most closely linked to:

Education

Housing

Transport

Poverty



Mental and behavioural disorders

Mental wellbeing is the foundation for positive health and effective functioning for individuals and communities.  One in four people will experience mental health problems at some point during their life.

Mental ill-health is common with a significant impact on individuals, their families and the whole population. 22.8% of burden of disease in UK is due to mental disorder and self-reported injury compared to 15.9% for cancer and 16.2% for cardiovascular disease (WHO 2008).

The causes of mental illness are extremely complex – physical, social, environmental and psychological causes all play their part. The problems are unevenly distributed within the population and having mental ill-health further widens existing inequalities.  The impact of mental health problems has wide-ranging and long-lasting effects, including trans-generational impacts which occur more often in groups at higher risk.

Mental health conditions are strongly associated with socioeconomic deprivation.  The connection between rates of mental illness and other factors such as poverty, unemployment and social isolation is well established.

The cost of mental health problems to the economy in England is estimated to be £105 billion, and treatment costs are expected to double in the next 20 years (DH, 2011).

Employment opportunities for people with mental health problems in Redcar & Cleveland are very limited and of those long-term unemployed people claiming incapacity benefit, two-thirds have a mental health problem.

Mental health needs in Redcar and Cleveland are demonstrably higher than the national average.  The promotion and development of good mental health is essential to the human, social and economic development of the borough. The potential to promote good mental health lies with a number of agencies such as those responsible for housing, regeneration, social care, employment, leisure and health.

This topic is linked with:

 

 



Oral health

Oral Health is an integral part of healthy living and a key marker of the health of a community. Poor oral health can cause discomfort, pain and disability and affects appearance and self-confidence with a major impact on quality of life. Oral diseases are largely preventable; however dental disease remains a major public health problem.

The oral health of the UK has improved significantly over the last few decades and the types of disease present now have also changed. However the oral health of the Tees region is significantly worse than that of the national level in children and oral health for adults in the North East is worse than the English average.

Health inequality is a common feature in dental disease; high levels of dental disease tend to affect those in low income families and those living in socially deprived conditions (National Children’s Bureau, 2015).

More people are keeping their teeth as they age, whereas in the past older populations had fewer teeth. As people get older the combination of frailty, ill health and social and economic constraints make looking after their oral health and accessing services more difficult. This leads to an increase in the burden and complexity of dental care needed for this group.

Oral cancer is a disease for which the outcome and prognosis can be significantly improved if it is caught early. Risk factors for oral cancer are smoking, excessive alcohol consumption and the Human Papilloma Virus (HPV) infection.

This topic is most closely linked to:

 



Respiratory diseases

Respiratory diseases are conditions that affect the lungs such as asthma, chronic obstructive pulmonary disease (COPD); infections like influenza, pneumonia and tuberculosis; and lung cancer and many other breathing problems.  This section focuses on asthma and COPD which contribute hugely to health inequalities, ill health and premature death.

The similarities in the symptoms of both diseases can lead to misdiagnosis and poor management. Hence, expert assessments are required to separate their relative contribution to ill health. About 15% of patients with COPD also have asthma.

Asthma
Asthma is a chronic condition that affects airways in the lungs, causing them to become inflamed and swollen. Typical symptoms include breathlessness, tightness in the chest, coughing and wheezing. Environmental factors such as viral infections, allergens, pollution, tobacco smoke, workplace sensitisers and exercise can make the condition worse.

The causes of asthma are not well understood so prevention is not currently possible. However, the condition does not usually deteriorate over time and the aim of treatment is for people with asthma to be free of symptoms and lead a normal life.

It is estimated that about 5 million (1.4 million are children aged under 16 years) people in the UK are affected by asthma. There are between 1000 and 2000 deaths from asthma per year, but it is estimated that 90% of these deaths are associated with preventable factors.  Asthma is a common cause of large numbers of emergency admissions in those aged less than 19 years. High numbers of hospital admissions for asthma are considered to represent a mismanagement of the condition.


COPD
Chronic obstructive pulmonary disease is a chronic disabling disease which causes a gradual decline in lung function, with increasing episodes of chest infections and exacerbations as the condition progresses. It is a general term which includes chronic bronchitis and emphysema. It mainly affects people over the age of 40 and risk increases with age. Smoking is the main cause in the vast majority of cases.

COPD is incurable but treatments help to slow down the decline in the lung function, so early diagnosis and support for effective self-management and self-care can help patients live an active life.  About 835,000 people in the UK are currently diagnosed with COPD and an estimated 2.2 million people have the condition but do not know it.

COPD is the fourth biggest killer in the UK, the second most common cause of emergency admissions to hospital and one of the most costly in-patient conditions treated by the NHS.

Integrated working between health, social and leisure services and people with asthma and COPD is critically important to improve health and wellbeing and reduce the health inequalities associated with these conditions.

This topic links with the following JSNA topics:

 



Self-harm and suicide

Suicide
Suicide is a major public health concern.  Nationally the number of people who take their own lives has been reducing in recent years.  Nevertheless, about 4,200 people aged 15 and over took their own life in 2010 in England.  Suicide is often the end point of a complex pattern of risk factors and distressing events, and the prevention of suicide has to address this complexity.

Suicides are not inevitable; indeed most are preventable (WHO 2004).  There are many things that can be done in communities, outside hospital and care settings, to help those who think the only option is to end their own life.

The average cost of suicide for those of working age in England is estimated to be around £1.67m per case (at 2009 prices). If this estimate is applied to the North East of England the projected cost to the local economy is £345million for the 238 cases of suicide and undetermined injury in 2009.

Self-Harm
Self-harm is defined as ‘self-poisoning or self-injury, irrespective of the apparent purpose of the act’ (NICE, 2004). An individual episode of self-harm might be an attempt to end life.  However, many acts of self-harm are not directly connected to suicidal intent.

It must be recognised that the rate of suicide for people who have had an episode of self-harm is 100 times higher in the year following the episode than that of the general population.

The extent of economic burden associated with self-harm is significant dependent upon both how it is defined and the method of economic evaluation (Drummond et al., 1997).

The suicide and self-harm prevention agenda is cross-cutting and relates most closely to the following JSNA topics:

Offenders
Domestic Violence Victims
Ex-Forces Personnel
Alcohol Misuse
Illicit Drug use
Mental Health and Behavioural Disorders
Employment
Carers

 



Stockton

Under the Health and Social Care Act (2012) the Health and Wellbeing Board has a statutory duty to produce a Joint Strategic Needs Assessment (JSNA) to underpin the Joint Health and Wellbeing Strategy and hence the work of the Board.

The Joint Health and Wellbeing Strategy sets the strategic direction of the health and wellbeing ‘system’.  As such, the JSNA is a tool to enable strategic planning and procurement.  It aims to maximise best use of resources to improve population health and wellbeing and address health inequalities.  The JSNA is therefore not a performance monitoring tool (though performance trends form part of the intelligence within it).  Active use of the JSNA by all partners will help to align strategic planning and decision-making behind consistent priorities for health and wellbeing, so making best use of resources.

The JSNA is used by SBC and a range of organisations to:

  • inform direction and shape of strategic priorities and defining key issues to be addressed;
  • summarise levels of need (not just demand) within populations including future forecasting and highlighting needs of particular population groups to enable targeting;
  • highlight robust evidence base;
  • enable strategic planning and approach to key health and wellbeing issues; 
  • inform service design and procurement; and
  • help to summarise systems-level outcomes

Sarah Bowman-Abouna

Director of Public Health

Stockton-on-Tees Borough Council

On behalf of

Stockton-on-Tees Health and Wellbeing Board

 



Submenu Links


Executive Summary

Unmet needs and commissioning intentions arising from Stockton-on-Tees JSNA 2012-15

 



Steering Group


Core Strategies

Stockton-on-Tees Joint Health and Wellbeing Strategy 2012-2018

NHS Hartlepool & Stockton-on-Tees Clinical Commissioning Group A Clear and Credible Plan for Commissioning Health Services 2012-2017

Director of Public Health Report 2013/14: Addressing Inequalities in the Borough of Stockton-on-Tees

 



Population


Intelligence


Inequalities
Segmenting life expectancy by cause of death

Public Health England has developed a resource which provides information on the causes of death that are driving inequalities in life expectancy at local area level. Targeting the causes of death which contribute most to the life expectancy gap should have the biggest impact on reducing inequalities.

For males and females, the tool provides data tables and charts showing the breakdown of the life expectancy gap in 2012-14 for two comparisons:

  • The gap between the Local Authority as a whole and England as a whole.
  • The gap between the most deprived quintile and the least deprived quintile within the Local Authority.

 

The gap between Stockton and England
For men, over one-third of the gap between Stockton and England is caused by higher rates of cancer mortality.  For women, cancer and respiratory diseases contribute similar proportions to the gap.  Within the cancer category, lung cancer deaths are responsible for a higher proportion of the gap in women compared with men.  External causes of death (such as accidents and suicide) have a greater contribution to the gap for men compared with women.

Stockton inequality gaps with England cause of death scarf chart 2012-14

The gap within Stockton

Cancer is the biggest contributor to the gap between the most and least deprived communities in Stockton for both men and women.  About 40% of the excess cancer mortality is due to lung cancer.  For males, external causes of death have a greater contribution to the gap between deprived and affluent communities in Stockton compared with females.

Stockton gap in cause of death most and least deprived, 2012-14

Full details, including number of deaths and numbers of excess deaths can be found in The Segment Tool: Key results for Stockton-on-Tees.

 

Premature mortality

Premature mortality, that is to say deaths before age 75 years, is a symptom of high disease burden as well as underlying health inequalities.  Know your numbers: premature mortality provides an analysis of the main causes of premature mortality in Tees Valley, and estimates how many premature deaths would need to be prevented to achieve rates similar to the North East and England.  In Stockton-on-Tees the greatest burden of premature mortality is due to cancer, followed by circulatory disease.

Stockton premature mortality rates and numbers

 



A to Z


People

Summary of people topics.

Content under development, see individual topic pages for details.



Children

Sir Michael Marmot’s review of health inequalities recommends that action in the early years is crucial to giving every child the best start in life to reduce health inequalities across the life course.  The foundations of many aspects of human development (including physical, intellectual and emotional) are laid in utero and in early childhood.

The importance of the health and wellbeing of children is well documented.  There is national recognition of the importance of health/behaviour during pregnancy and the early years of life, with significant emerging evidence related to neo-natal science.  In particular, the importance of early experiences, responsive parenting and secure attachment.

The following JSNA topics are the most significant factors that increase a child’s risk of poor life chances:

Wider determinants of health

Education

Children who achieve low educational attainment are likely to suffer from lower life chances.

Poverty

Growing up in poverty can affect every area of a child’s development and future life chances.  Children from low income households are less likely to achieve their academic potential, less likely to secure employment as adults, more likely to suffer from poor health, more likely to live in poor quality housing and they are more likely to reside in unsafe environments.

Behaviour and lifestyle

Alcohol misuse

Alcohol misuse during pregnancy poses a significant health risk to the unborn child.

Children living with parents who are dependent on alcohol are more likely to suffer from emotional and educational neglect.

Children living in homes with adults who abuse are at a higher risk of becoming alcohol abusers themselves.

Illicit drug use

Children living with parents who abuse drugs are more likely to suffer from emotional and educational neglect.

Children living in homes with adults who abuse drugs are at a higher risk of becoming drug abusers themselves.

Smoking

Smoking during pregnancy poses a significant health risk to both the mother and unborn child.

Parents who smoke around their children are significantly increasing their child’s risk of disease and ill-health.

Diet and nutrition

Breastfeeding gives a child the best start in life and is beneficial for the health of the mother.

Nutrition has a key role in the prevention and management of diet-related diseases (such as cardiovascular disease, cancer, diabetes and obesity).

Obesity

Obesity is one of the biggest risks to the health of the population. 

Obesity in children can lead to poor physical health (including increased risks for elevated blood pressure and Type 2 diabetes) and poor mental health (including low self-esteem, anxiety and depression).

Illness and death

Injuries

Injuries are a leading cause of death and illness of children and one of the most common reason for hospital admissions. 

Mental health

One-in-ten 5 to 15-year-olds has a mental health problem. Many continue to have mental health problems as adults.



Transition Years

The transition period for a young person is a time of continuous change as they grow, develop and mature.  Teenagers naturally grow in independence and need to try new things, take on responsibility, and be allowed to learn from their mistakes.  Through this process young people often question and test the assumptions, rules and boundaries that shape their lives at home, in education and in their communities.

The following issues are the most significant factors affect life changes of young people:

Wider determinants of health

Education

Young people with low educational attainment are likely to have fewer opportunities in life (e.g. employment).

Employment

Unemployed young people are more likely to suffer from poor health than those who are employed.

Behaviour and lifestyle

Alcohol misuse

Adolescence is a time that young people experiment and may become involved in risk-taking behaviours.  Alcohol misuse can lead to poor health. 

Illicit drug use

Adolescence is a time that young people experiment and may become involved in risk-taking behaviours.  Illicit drug use can lead to poor health. 

Smoking

Smoking is the leading cause of preventable death; almost all (90%) smokers start smoking during their teenage years.

Sexual health

The early onset of sexual activity can have a major impact on young people’s lives and can lead to teenage pregnancy and sexually transmitted infections.

Illness and death

Self-harm and suicide

Deliberate self-harm and suicide have disproportionately high rates among young people.

Mental health

One-in-ten young people have a diagnosable mental health problem. Many continue to have poor mental health as adults.



Adults

This section of the JSNA looks at the needs of adults in Stockton-on-Tees.  Separate sections of the JSNA describe the needs of young adults in transition between services for children/ young people and adults, and the needs of older people (those aged 50 and over).  Inevitably, there is some overlap between the needs of these groups and those of adults in general. This section cover issues principally affecting adults aged 18-65, plus those issues which are common to all adults in Stockton-on-Tees, including young adults and/or older people.  It brings together the major issues facing this population age group from the JSNA topics in the Vulnerable groups, Wider determinants, Behaviour and lifestyle and Illness and death themes.

 



Older People

There is no one commonly accepted definition of ‘old age’ or older people.   The current pension scheme has age has 67 for eligibility.   The UN has not adopted a standard criterion, but generally uses 60+ years to refer to the older population.  The National Service Framework for Older People (Department of Health, 2001) defined three groups of older people:

  • Those entering old age on completing paid employment and child-rearing (50-60 years);
  • Those in the transitional stage between healthy active life and frailty (70-80 years); and
  • Frail older people who are vulnerable because of health or social care needs.

In 2011, the average age at which the public defined the start of ‘old age’ was 59 (Age UK, 2011).  More recent studies (April 2015) have argued that old age now starts at 74, with middle age lasting at least nine years longer than current estimates.  Academics from the International Institute for Applied Systems Analysis (IIASA) in Vienna, Austria, argue that old age should be measured not by age, but by how long people have left to live.  In the 1950s a 65-year-old in Britain could expect to live a further 15 years, with better healthcare and lifestyles this would take old age to 74.

The Department of Work and Pensions (DWP) refers to people aged 60 and over as older people, but also includes people in their 50s as a period when many people take early retirement or prepare for retirement (DWP, 2005).



Vulnerable Groups
Introduction

Some people are more vulnerable to poor health than others.  This poor health may arise for a variety of reasons, including the effects of deprivation and difficulty accessing services.  The health needs of vulnerable groups are often complex and require a co-ordinated and flexible response from services. It is easy for clients to fall into the gaps between different services leading to unplanned care and the risk of clients revolving through the system.

This theme summary groups together the complex health needs of many vulnerable groups, some of which may overlap and others that are highly specific.


Learning disabilities and Autism

  • Ensure the availability of choice and cost-effective provision which meets needs locally.
  • Improve the quality of primary care learning disability registers.
  • Promote personalised systems which place the person at the heart of any process, provide information and advice, and stimulate universal access to all services.

Physical disabilities and Sensory disabilities

  • Demand for community-based services is increasing, with increased requirement for supported living and reduced reliance upon residential care.
  • Promote personalised systems which place the person at the heart of any process, provide information and advice and stimulate universal access to all services.
  • The number of older people with a limiting long-term illness is expected to increase from about 17,500 in 2015 to 19,500 in 2020 and 22,000 in 2025.
  • The number of older people with moderate or severe visual impairment is expected to increase from about 3,000 in 2015 to 3,800 in 2025, a 29% increase.  There will be a similar increase in those with moderate or severe hearing impairment, from 14,100 to 18,500 between 2015 and 2025.

Domestic violence victims and Sexual violence victims

  • It is believed that many cases of both domestic and sexual violence are unreported.
  • The majority of known sexual violence victims are female and aged under 25 years.  Women are more likely to suffer domestic violence, particularly those aged under 30 years.
  • People from vulnerable groups (those with a physical disability, learning impairment and mental illness) are more likely to experience sexual violence, but may have difficulty verbalising their abuse.
  • There is a need for better data collection to enable improved analysis.
  • Alcohol is a contributing factor in a significant proportion of incidents of both domestic and sexual violence.

Carers and End of life care

  • There is a high number of carers who are unknown to carer support services.
  • Provide carers with the support required to enable them to continue their caring roles.
  • Remove the stigma surrounding death and dying.  Encourage healthcare professionals and people with end of life care needs, their families and carers to engage in open conversations.
  • Increase choice and personalisation within integrated, high quality services that meet the needs of people approaching the end of life.


Migrants and Travellers

  • Ensure migrants and travellers are aware of local health, care and education services and that these services are responsive to individual needs.

Ex-forces personnel

  • Provide adequate signposting to health and care services for armed service leavers.
  • Former forces personnel are more likely to need mental health care and rates of alcohol misuse are higher than for the general population.  This is particularly so for younger, male veterans who held lower ranks and were exposed to combat.
  • A small but significant proportion of veterans experience homelessness.

Offenders

  • Prisoners have high rates of: poor mental health; alcohol and substance misuse; smoking; suicide and attempted suicide; and learning disabilities.
  • There are high levels of educational need.  About half of male, sentenced prisoners were previously excluded from school compared with 2% in the general population.
  • Offenders have increased difficulty in accessing employment and housing, and tend to be socially isolated.
Recommendations

The recommendations below relate to the Marmot review: Fair Society, Healthy Lives, the former National Support Team recommendations for tackling Health Inequalities and latest national policy and professional guidance.

Short-term (1-2 years)
1. Continue to develop personalised services and further improve access to universal services for vulnerable groups.
2. Improve data collection, in particular, identification of vulnerable members of society who are unknown to local services.

Medium-term (3-5 years)
1.  Increase the supply of housing which meets the needs of vulnerable groups.

Long-term (over 5 years)
1. Ensure that service capacity is sufficient for the anticipated increase in some of these vulnerable groups, particularly those with physical and sensory disabilities.

 

Summary author

Leon Green
Public Health Intelligence Specialist
Tees Valley Public Health Shared Service

 



Learning disabilities

A learning disability affects the way a person learns new things in any area of life.  It affects the way they understand information and how they communicate.  Learning disability can be defined as:

  • the presence of a significantly reduced ability to understand new or complex information, to learn new skills (impaired intelligence, often defined as an IQ level of 70 or less), with;
  • a reduced ability to cope independently (impaired social functioning);
  • which started before adulthood, with a lasting effect on development.

People with a learning disability can have difficulty understanding new or complex information, learning new skills and coping independently.  A learning disability can be mild, moderate or severe. Some people with a mild learning disability can talk easily and look after themselves, but take a bit longer than usual to learn new skills. Others may not be able to communicate at all and may have more than one disability.

Adults with learning disabilities are one of the most vulnerable groups in society, experiencing health inequalities, social exclusion and stigmatisation.  In general, adults with learning disabilities have greater and more complex health needs than the general population, and often these needs are not identified or treated.  Life expectancy of this group is shorter than the general population.  Adults with learning disabilities often experience barriers to accessing healthcare services, and poor levels of care.  They are more likely to die from a preventable cause than the general population.  Health needs amongst adults with a learning disability are different to the general population.

There are about 1.5 million people in the UK with learning disabilities.

This topic is linked with:

 



Autism

Autism is a lifelong development disability that affects how a person communicates with, and relates to other people.  It also affects how they make sense of the world around them.
Autism is a spectrum condition which means that, while all people with autism share certain difficulties their condition will affect them in different ways.  Some people with autism are able to live relatively independent lives but others may have accompanying learning disabilities and need a lifetime of specialist support.

There are three different types of Autistic Spectrum Disorders (ASDs): Autistic disorder (also called "classic" autism); Asperger syndrome; and Pervasive developmental (also called "atypical autism").
A person with an ASD might:

  • not respond to their name by 12 months
  • not point at objects to show interest (‘point at an airplane flying over’) by 14 months
  • not play "pretend" games (pretend to ‘feed’ a doll) by 18 months
  • avoid eye contact and want to be alone
  • have trouble understanding other people's feelings or talking about their own feelings
  • have delayed speech and language skills
  • repeat words or phrases over and over (echolalia)
  • give unrelated answers to questions
  • get upset by minor changes
  • have obsessive interests flap their hands, rock their body, or spin in circles
  • have unusual reactions to the way things sound, smell, taste, look, or feel.

This topic is most closely associated with

 



Physical disabilities

The Equality Act 2010 defines disability as an impairment that has a substantial and long-term adverse effect on a person’s ability to perform normal day-to-day activities. Such impairments can vary considerably and include both congenital and acquired disabilities.

In England it is estimated that there are 3.3 million people aged 16-64 with a moderate or severe physical disability (PANSI, 2012).  In addition there are 4.3 million people aged 65 and over with a limiting long-term illness (POPPI, 2012).  Furthermore an estimated 0.8 million children in the UK have a disability (DWP, 2012), approximately 670,000 in England.  Combining these shows about 8.3 million people in England have a physical disability.

People with physical impairments face many barriers to living a fulfilling and independent life. Not only do they have the practical problems of everyday life to struggle with that a physical disability brings but they have to face the negative public perceptions of disabled people and problems gaining access to everyday facilities and services. The support required for people with physical impairment may be multi-dimensional and therefore needs to be tailored to address their specific individual needs.

People with physical impairment also face prejudice.  Prejudice is not always hostile; benevolent prejudice results from the belief that a disabled person needs looking after.  Benevolent prejudice can be just as consequential as hostile prejudice, making it likely disabled people will be treated less favourably in respect of the opportunity for advancement because they are seen as less capable.

This topic is most closely linked with:

 



Sensory disabilities

Sensory disabilities refer to visual and hearing impairment.

Visual impairment (blind or partially sighted)

There are two main areas that are looked at when measuring a person’s vision:

  • Visual acuity: This is the central vision used to look at objects in detail, such as reading a book or watching television;
  • Visual field: This is the ability to see around the edge of your vision while looking straight ahead.

Hearing impairment (hard of hearing or deafness)

There are three main types of hearing loss:

  • Conductive hearing loss: Sounds are unable to pass from the outer ear to the inner ear, often as the result of a blockage such as earwaxglue ear or a build-up of fluid due to an ear infection, a perforated ear drum or a disorder of the hearing bones;
  • Sensorineural hearing loss: Sensitive hair cells either inside the cochlea or the auditory nerve are damaged, either naturally through ageing, or as a result of injury;
  • Mixed hearing loss: It is possible to get both types of hearing loss at the same time.

Dual sensory impairment

Dual sensory impairment is the combined loss of hearing and vision.

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Evidence indicates that the prevalence of visual and hearing impairments increases with age. With an ageing population, this means there will be more people acquiring these conditions.

Most sensory impairments develop gradually and are often secondary to other disabilities.

The impact of sensory loss and other health determinants can dramatically increase risk and demand on health and social care services. 

People with sensory loss are at greater risk of social isolation.

It is estimated there are more than ten million people in the UK with some form of hearing loss.

There are around 360,000 people who are registered as visually impaired in England. As many as 2 million people in the UK may be living with some degree of visual impairment.

It is estimated that around 1 in 5 people over the age of 75-years-old have some degree of visual impairment.

Age-related macular degeneration leading cause of blindness in adults. Other significant causes of sight loss are glaucoma, cataracts and diabetic retinopathy.

For adults with sight loss there is a correlated loss of independence and an increased   risk of poverty.

Sensory disabilities is linked with the following JSNA topics:

Carers

Employment

Housing

Transport

Education

Diabetes

Mental and behavioural disorders



Sexual violence victims

Introduction

Sexual violence is any unwanted behaviour perceived to be of a sexual nature or sexual contact that takes place without consent or mutual understanding.

The World Health Organisation defines sexual violence as:    

“Any sexual act, attempt to obtain a sexual act, unwanted sexual comments or advances, or acts to traffic, directed against a person’s sexuality using coercion, by any person regardless of their relationship to the victim, in any setting, including the home” (World Health Organisation Report on Violence and Health, 2002)

There are two sub-categories of sexual offences depending on the seriousness of the crime:

  • Serious sexual crime including rapes, sexual assaults, and sexual activity with children;
  • Other sexual offences (including soliciting, exploitation of prostitution, and other unlawful sexual activity between consenting adults).

The effects of sexual violence on victims can include depression, anxiety, post-traumatic stress disorder, drug and substance misuse, self-harm and suicide. However, when victims receive the support they need when they need it, they are more likely to take positive steps to recovery. It is therefore important that victims of sexual violence have good access to effective services, whether or not they wish to report incidents to the police. 

It is estimated that in England & Wales, up to 9 in 10 cases of rape go unreported and 38 per cent of serious sexual assault victims tell no one about their experience. Each adult rape is estimated to cost over £76,000 in its emotional and physical impact on the victim, lost economic output due to convalescence, early treatment costs to the health service and costs incurred in the criminal justice system. The overall cost to society of sexual offences in 2003-04 was estimated at £8.5 billion.

Addressing the needs of victims of sexual violence through the provision of accessible specialist services can deliver benefits in terms of better health and well-being and quality of life. There are also long-term productivity savings in services and costs to society when the immediate effects of sexual assault are managed effectively.

This topic links with the following JSNA topics:

Sexual health

Sensory disabilities

Physical disabilities



Domestic abuse victims


 



Carers

Carers are people who provide (or intend to provide) a substantial amount of care on a regular basis to people who require support to maximise and/or maintain their independence (Department of Health, 2008). Although ‘substantial’ and ‘regular’ are not defined in legislation or guidance, in many cases the potential impact is self-evident.

Recognising carers and the contribution they make to society is important for raising their profile and identifying better ways of helping them to help others. Historically the needs of carers have been overlooked. Whilst this situation is improving, many carers remain socially excluded, suffer from caring-related ill-health and, once they have ceased caring, find themselves in a difficult economic position, often with little or no pension provision.  This can lead to the carers needing to access health and social care services for themselves and may impair their ability to continue providing care to the cared for person.

The importance of the role of carers has been reinforced with the Care Act 2014 and the Childrens and Families Act 2014. The Care Act places a duty on local authorities to identify carers with unmet needs and offer carers an assessment that considers the outcomes that the carer wants to achieve in their daily life, activities beyond their caring responsibilities.  It reinforces the key outcomes identified in the Carers Strategy Second National Action Plan 2014-16 including:

  • Identification of carers
  • Realising and releasing potential
  • A life alongside caring
  • Supporting carers to stay healthy



The economic value of unpaid care is estimated to be £132 billion nationally (Carers UK & University of Leeds, 2015).  For Stockton-on-Tees this would be around £464 million.

This topic links with

 



End of life care

Around half a million people die in England each year, of whom almost two-thirds are aged over 75. The large majority of these deaths follow a period of chronic illness such as heart disease, cancer, stroke, chronic respiratory disease, neurological disease or dementia. Most deaths occur in NHS hospitals.

The pattern of deaths in relation to age profile, cause of death and place of death have changed radically over the course of the past century. A hundred years ago most people died in their own homes and acute infections were a much more common cause of death.  A far higher proportion of deaths occurred in childhood or early adult life.

With the changes in the past century, familiarity with death within society as a whole has decreased. Many people nowadays 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.

Although individuals may have different ideas 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.

 

Some people die as they would have wished, but many others do not. Some people experience excellent care in hospitals, hospices, care homes and in their own homes. But the reality is that many do not. Many people experience unnecessary pain and other symptoms. There are distressing reports of people not being treated with dignity and respect and many people do not die where they would choose to.

How we care for the dying is an indicator of how we care for all sick and vulnerable people. It is a measure of society as a whole and it is a litmus test for health and social care services.

In the past, end of life care within the NHS and social care services has had a relatively low profile. Reflecting this, the quality of care has been very variable. Implementation of this strategy will make a step change in access to high quality care for all people approaching the end of life. This should be irrespective of age, gender, ethnicity, religious belief, disability, sexual orientation, diagnosis or socioeconomic deprivation. High quality care should be available wherever the person may be: at home, in a care home, in hospital, in a hospice or elsewhere (National End of life Strategy, DH, 2008).



Armed forces community


Migrants

Migrants are widely described as people who belong to (or have an allegiance) to one state/country, but move into another for the purpose of settlement.

Migrant populations are diverse, and many have social, cultural and health needs. Migration is driven by many reasons (including economic, family reunion, study, humanitarian reasons or human trafficking). As a consequence migrants may have several diverse health and social care needs.

Migrant populations have different health and wellbeing issues depending on lifestyle risk factors, cultural practices, country of origin, genetic and hereditary factors and wider determinants (poor housing, lower economic opportunities, unemployment and living in deprived areas).

This topic links to the following JSNA topics:



Travellers

Travellers have been a part of British society for centuries. There are around 300,000 Gypsies and Travellers in UK (Matthews 2008).  Between 90,000 and 120,000 live in caravans in England and up to three times as many live in conventional housing (CRE 2006 cited in NEEDP 2008).

In North East England, the number of caravans has remained stable in recent years and this is similar for the Stockton Borough.  However, the future need for accommodation pitches with this community is expected to increase. Anecdotal information suggests that there are many in-house Gypsies and Travellers who live in Thornaby, Stockton-on-Tees.

A report into the health status of Gypsies and travellers in England finds that these communities have significantly poorer health than the general population (Parry et al 2004, Race Equality Foundation 2008).

This topic has links to the following JSNA topics:



Offenders

The term ‘offender’ refers to an individual who has come into contact with the criminal justice system by committing a crime or violating a law.

The link between offending, re-offending and the impact on health is well known.

Offenders and ex-offenders are far more likely to be more socially isolated and marginalised than the general population and to have a broader range of health concerns. As the number of people who come into contact with the criminal justice sector increases, there will be an increasing number of ex-offenders in communities.

There is a real need to divert offenders who have serious mental health problems away from prison and into the appropriate health service facilities. The needs of those suffering from physical health problems and from substance misuse and abuse must also be addressed.

This topic links with the following JSNA topics:



Looked after children

PLEASE NOTE: Content yet to be reviewed by Tees Valley Public Health Shared Service and maybe subject to change.

The term ‘ looked after’ was introduced by the Children Act in 1989 and refers to children who are subject to care orders and those who are voluntarily accommodated. 

Looked After Children (LAC) are one of the most vulnerable groups in society. The majority of children and young people who become looked after do so as they have experienced abuse or neglect. It is acknowledged that children who are looked after are at greater risk of poor life chances and outcomes.

A poor start in life, past experiences,  involvement in care processes and transitions between placements and services can all result in inequitable access to services at both universal and specialist level.  LAC will have significantly higher levels of health needs than children and young people from comparable socio-economic backgrounds who have not been looked after.

 The Local Authority’s duty to meet the social care needs of looked after children is set out in the 1989 Children Act and subsequent amendments. The Local Authority has specific duties to:

  • Receive a child who is the subject of a care order into care and to continue to look after them while the care order is in force.
  • Safeguard and promote the welfare of looked after children – finding out the wishes and feelings of child/parents before making any decisions and giving due consideration to those wishes and feelings and to the child’s background.
  • Promote the educational attainment of children in its care.
  • Regularly review the needs and circumstances of a child in care and to appoint independent reviewing officers to do this.
  • Provide appropriate advocates for children in its care.
  • Continue to support young people after they have left the local authority’s care.

The duty to meet the health needs of Looked After Children for both the NHS and Local Authorities is clearly laid out in ‘Statutory Guidance on Promoting the Health and Wellbeing of Looked After Children’.

This guidance states that the NHS is required to make arrangements to secure appropriate health services for the child in accordance with the health assessment and the child’s health plan and need to understand the current flow of looked after children both in and out of the Clinical Commissioning Group (CCG) area and ensure that services are commissioned to meet the needs of all Looked After Children.



Children in need

PLEASE NOTE: Content yet to be reviewed by Tees Valley Public Health Shared Service and maybe subject to change.

‘Children in need of help and protection’ refers to children and young people who have been, or are subject to, a social care assessment as they are considered eligible for support and services under section 17 (child in need) or section 47 (child protection) of the 1989 Children Act. It does not refer to Looked After Children & Young People, as there is a separate JSNA  section on that topic.

There are many reasons why children may be in need of help and protection – for example, it may be due to disability, mental health needs, family dysfunction, abuse or neglect. Their circumstances may make them vulnerable and impact on their social, emotional and mental wellbeing  and development. They may need support to help them develop and thrive and to access the same opportunities as their peers.

The acronym CIN is used to refer to Children in need.



Child sexual exploitation


Wider Determinants
Introduction

In his review of health inequalities, one of Sir Michael Marmot’s key messages is that “Health inequalities result from social inequalities. Action on health inequalities requires action across all the social determinants of health.”  The review identified six policy objectives which require action to reduce health inequalities.  These are:

  • Give every child the best start in life;
  • Enable all children, young people and adults to maximise their capabilities and have control over their lives;
  • Create fair employment and good work for all;
  • Ensure healthy standard of living for all;
  • Create and develop healthy and sustainable places and communities; and
  • Strengthen the role and impact of ill-health prevention.

The topics within this theme are important contributors to the social determinants of health.  This summary attempts to identify the most important issues contained within each topic and, from these, highlight those which are the most important for action in addressing health needs and inequalities in Stockton-on-Tees.

What are the most important messages from each topic?

 

Crime

  • Crime levels have reduced significantly in recent years.
  • Alcohol consumption is linked to violent offences, creates problems at weekends and in particular locations, and is associated with antisocial behaviour.
  • There is link between antisocial behaviour, crime and deprivation. There are 18 areas in Stockton-on-Tees that have been identified as particularly vulnerable.

 

Education

  • Attainment at age 11 is similar to England, but by age 16 tends to be below England.
  • Secondary school absence is higher than England.
  • There are gaps in attainment for pupils from certain groups – particularly children with special needs; those eligible for free school meals; and boys.

 

Employment

  • Unemployment in Stockton-on-Tees is higher than England.  There are fewer than average jobs per working-age resident and higher than average number of unemployed people per vacancy.

 

Environment

  • Flooding remains a risk for 3,300 homes in Stockton-on-Tees.
  • There are over 70 additional deaths in the winter months in Stockton-on-Tees compared to the non-winter period.  Fuel poverty affects more that 20% of households and despite long-term energy efficiency improvements, a substantial number of properties still require improvement.

 

Housing

  • There are too many non-decent properties and Category 1 hazards that have a serious detrimental effect on the occupiers’ health and wellbeing.  Too many people live in fuel poverty.  This contributes towards seasonal excess deaths.
  • There is a risk of a lack of appropriate accommodation, including the supply of affordable homes, homes with disability adaptations and properties suitable for older people and people with learning disabilities to live independently.

 

Poverty

  • There are between 15,000 and 22,000 people in Stockton-on-Tees who are not claiming benefits that they are entitled to.  Claiming a fraction of these benefits could be worth millions of pounds to the people and economy of Stockton-on-Tees.  A systematic approach to maximising rightful benefit uptake would help the most vulnerable and disadvantage people.
  • Over 9,000 children in Stockton-on-Tees are growing up in poverty and there are some areas where more children are in poverty than not.  The educational attainment of disadvantaged children is worse than that of other children, perpetuating a cycle of poverty.

 

Transport

  • Too many people are injured in road traffic collisions.  Children in the 10% most deprived areas in England are three times more likely to be pedestrian casualties than those in the least deprived areas.
  • Opportunities for physically active transport (walking and cycling) need to be maximised to help both physical and mental health.

 


What should be the highest priorities for commissioners? 

Short-term (1 to 2 years)

  • Tackling alcohol-related crime.  This would help relieve weekend pressures on A&E services, reduce domestic violence, and tackle location-based hotspots.
  • Develop a systematic approach to maximising benefits claimants, improving the lives of disadvantaged people and boosting the local economy.

Medium-term (3-5 years)

  • Ensuring school readiness of children and parents.
  • Improving the quality of housing in the private rented sector, including thermal efficiency.
  • Optimise opportunities for job creation for all, but with a focus on young people in Stockton-on-Tees.

Long-term (over 5 years)

  • Develop transport infrastructure to maximise physically active travel and minimise injury and death.
  • Create an environment which supports health and wellbeing.

 

Summary authors

Sarah Bowman
Consultant in Public Health
Stockton-on-Tees Borough Council

Leon Green
Public Health Intelligence Specialist
Tees Valley Public Health Shared Service

 



Crime

Crime and the fear of crime are key factors that affect people’s quality of life and sense of well-being.

There is a direct link to health through such things as violent injury, rape and other offences against the person, and less directly via the psychological trauma of experiencing crimes such as burglary or vandalism.

Fear of crime affects the health of the wider community via, for example, restrictions on unsupervised outdoor play for children and social isolation of older people.

It has been acknowledged that the actual rick of becoming a victim of crime is much lower than the perceived fear of crime and victimisation. Fear of crime can have a devastating effect on quality of life and more focus is being placed upon providing reassurance to residents and ensuring that they know how best to protect themselves from becoming a victim without raising fear unnecessarily.

Crime reduces the effectiveness of healthcare systems through violence against NHS staff, damage to property, and costs of replacement, repairs and security. Alcohol and illegal drug dependency increase crime, and have an impact on health care services. http://www.wales.nhs.uk/sitesplus/888/page/43763

This topic is associated with:

Offenders

Alcohol misuse

Illicit drug use

Domestic violence victims

Sexual violence victims



Education


Employment


Environment


Housing


Poverty

In his recently published review of health inequalities – many of which are greatly determined by poverty – Professor Sir Michael Marmot said:

‘People with higher socioeconomic position in society have a greater array of life chances and more opportunities to lead a flourishing life. They also have better health. The two are linked: the more favoured people are, socially and economically, the better their health. This link between social conditions and health is not a footnote to the ‘real’ concerns with health – such as health care and unhealthy behaviours – but should become the main focus.

Consider one measure of social position: education. People with university degrees have better health and longer lives than those without. For people aged 30 and above, if everyone without a degree had their death rate reduced to that of people with degrees, there would be 202,000 fewer premature deaths each year. Surely this is a goal worth striving for.  It is the view of all of us associated with this Review that we could go a long way to achieving that remarkable improvement by giving more people the life chances currently enjoyed by the few. The benefits of such efforts would be wider than lives saved. People in society would be better off in many ways: in the circumstances in which they are born, grow, live, work, and age. People would see improved well-being, better mental health and less disability, their children would flourish, and they would live in sustainable, cohesive communities.’

Fair Society, Healthy Lives, February 2010

Many health-related issues are worse for people living in poverty, including an increased risk of dying prematurely.  People living in poverty are less likely to benefit from education to the same degree as others; are less likely to be in professional, managerial and skilled jobs; and are more likely to live in poor housing and in neighbourhoods where crime is more prevalent and where community safety is threatened.  All of these conditions and circumstances can have an adverse effect on physical and mental health and well-being.

Poverty, or relative poverty, is commonly defined in terms of households with an income which, after tax, is below 60% of the median (average) household income (Aldridge et al, 2012).  As such, the income required to prevent poverty depends upon household composition.

This topic is most closely associated with:

 



Transport

Transport has an impact on health through transport-related accidents, active travel, public transport, air quality and access to a range of services. 

Transport can affect people by giving access to employment opportunities, education, leisure, healthcare and diverse food supplies. The development of an efficient transport network and vehicles has the potential to benefit health.

Increasing levels of motorised traffic have contributed to air pollution, noise, vibration, danger from vehicles and an increased fear of traffic. These issues particularly affect the most deprived and most vulnerable people in communities.

The rise in personal car use has meant liberation for people who are young and more affluent. More deprived, elderly and disabled people can become trapped in ‘residential islands’ surrounded by dense traffic, or without the means to access more distant facilities and services in out-of-town developments. This also applies to people in rural areas faced with dwindling local facilities and longer travel times.

Road traffic casualties are still one of the main public health challenges in the UK particularly for children and young adults.

The rise in personal car ownership levels has contributed to people being less active. This is a significant contributor to obesity, diabetes and cardiovascular disease.

This topic has links to the following JSNA topics:



Behaviour and Lifestyle
Introduction

Behaviours, such as smoking, excessive use of alcohol, the use of illicit drugs, low levels of exercise and physical activity, engaging in unsafe sex, and a poor diet all impact on physical health and mental wellbeing.  It is known that each of these lifestyle risk factors is unequally distributed in the population and that there are differences in these behaviours associated with income, educational achievement and social class.

There is compelling evidence that lifestyle risk factors tend to cluster than present in isolation.  It is estimated that in England 70% of the adult population have two or more lifestyle risk factors (King’s Fund, 2012).  Whilst there has been an overall decline in the proportion of the population with three or four unhealthy risk factors from 33% of the population in 2003, to 25% in 2008, these reductions have not been equally distributed across the population. The percentage of people with three or more lifestyle risk factors is continues to increase for people from lower socio-economic and educational groups. For instance  people with no educational qualifications were  more than five times as likely as those with higher education to have four lifestyle risk factors in 2008, compared with only three times as likely in 2003.

This variation in the distribution of lifestyle risk factors contributes to the gaps in length and quality of life between deprived and affluent groups locally and nationally. The major causes of illness and premature deaths (deaths before age 75 years) in Stockton-on-Tees are circulatory diseases, cancer, respiratory disease and digestive diseases (including liver disease).  Lifestyle risk factors such as smoking, excessive alcohol use, poor diet and physical inactivity are known to contribute to these major causes of premature deaths.

Alcohol misuse

  • Levels of alcohol-related harm in Stockton-on-Tees are broadly similar to England.  There are higher than average rates of both alcohol-related and alcohol-specific hospital admissions compared to England.
  • Alcohol misuse impacts upon physical and mental health, as well as having a detrimental effect on social cohesion, crime, violence and community safety.
  • Alcohol-related harm is a problem in Stockton-on-Tees, impacting on individuals, families and communities.

 

Illicit drug use

  • There is insufficient information in Stockton-on-Tees regarding levels of drug misuse.
  • Hospital admissions for drug-related causes are higher in more deprived areas.
  • The proportion of successful treatment outcomes for opiate users in Stockton-on-Tees is not as high as in England, but for non-opiate users they are similar to England.

 

Smoking

  • About one-in-five adults in Stockton-on-Tees is estimated to smoke, similar to England. However, smoking prevalence rises to almost one-in-two adults in some deprived wards and disadvantaged population groups.
  • In Stockton-on-Tees, 17.7% of women smoke throughout their pregnancy posing a significant health risk both to mother and unborn child.  This is 40% higher than the national average (12.7%) and lower than the North East average.
  • More than one-in-four (28%) of all deaths aged under 75 years in Stockton-on-Tees is estimated to be as a result of smoking.

 

Diet and nutrition

  • Seventy eight percent of adults in Stockton-on-Tees do not eat the recommended five daily portions of fruit and vegetables.  In England, 82% of school-aged children do not eat five portions of fruit and vegetables each day.
  • Breastfeeding rates in Stockton-on-Tees are among the lowest in England and the gap is widening.
  • There is low uptake of healthy start vitamin supplements in babies and infants.
  • Poor oral health is a robust indicator of poor nutrition and the prevalence of dental decay for children in Stockton-on-Tees is almost 50% higher than England.

 

Physical inactivity

  • Approximately 30% of the adult population of Stockton-on-Tees is inactive, with about half taking part in the recommended weekly levels of physical activity.
  • The proportion of Stockton-on-Tees school pupils doing three hours of PE per week is similar to the national average.  In Stockton-on-Tees, walking and cycling to school is more common than in England; about six in ten pupils travel actively.
  • The groups with the lowest levels of physical activity are women (particularly those aged 14-24 years); black and minority ethnic (BME) groups; those with a limiting illness/disability; and lower socioeconomic groups.

 

Obesity

  • The adult obesity rate in Stockton-on-Tees continues to be significantly higher than England and is increasing. There are inequalities in relation to the prevalence of obesity according to income, social deprivation, age, ethnicity and disability.
  • Childhood obesity doubles from 10% in reception year (age 4 to 5 years) to 20% in year 6 (aged 10 to 11 years) pupils.  Local rates are similar to England.
  • The increasing prevalence rates of obesity increases demand on health services and costs to the NHS and wider economy.

 

Sexual health

  • Stockton-on-Tees has a higher than regional average rate for syphilis and has the fourth highest HIV prevalence among North East local authorities.
  • Local teenage pregnancy rates are higher than England.
  • There is a lower uptake of termination of pregnancy (in under-18s) and a lower uptake for Long Acting Reversible Contraception (LARC) compared to England.

 

Recommendations

The recommendations below relate to the Marmot review: Fair Society, Healthy Lives, the former National Support Team recommendations for tackling Health Inequalities and latest national policy and professional guidance.

Short-term (1-2 years)
1. Commissioning and delivery of integrated public health services and programmes that address multiple lifestyle risk factors rather than taking an approach that focuses solely on single issues. Ensure that these interventions are accessible and acceptable to those at highest risk.
2. Ensure equitable access to sexual health services (prevention, early identification, awareness and treatment services) at address the high teenage pregnancy rates and sexually transmitted infections. 
3. Give all children the best start in life by tackling smoking in pregnancy, obesity in pregnancy, breast feeding and uptake of healthy start vitamins.

Medium-term (3-5 years)
1. Maximise the opportunities of creating a health promoting environment through enforcement, planning, regeneration and licence application processes.  This could include considering the restriction of planning permission for hot-food takeaways, alcohol premises (representations and cumulative impact areas), tackling availability, supply and demand for illicit drugs and tobacco.   
2. Strengthen the role of primary care, social care and voluntary and community sector (VCS) organisations in delivering lifestyle and behaviour modification programmes
3. Strengthen the use of community assets in addressing lifestyle risk factors

Long-term (over 5 years)
1. Ensure that all town planning, regeneration and transport programmes incorporate active transport routes and that future planning complements strategies to reduce alcohol related crime and violence in the town centre. 
2. Improve maternal and child health by addressing the social causes of poor health including; teenage pregnancy, educational attainment, unemployment, food poverty and maternal mental health.

Sarah Bowman
Consultant in Public Health
Stockton-on-Tees Borough Council

Leon Green
Public Health Intelligence Specialist
Tees Valley Public Health Shared Service


Reference

King’s Fund (2012). Clustering of unhealthy behaviours over time: Implications for policy and practice.

 



Alcohol misuse


 



Illicit drug use


 



Smoking


Diet and nutrition

Good nutrition has a key role to play both in the prevention and management of diet-related diseases such as cardiovascular disease (CVD), cancer, diabetes and obesity (WHO, 2003). Healthy eating during childhood and adolescence is vital as a means to ensure healthy growth and development and to set up a pattern of positive eating habits into adult life. The promotion of evidence-based healthy eating messages is fundamental. Alongside this, it is necessary to ensure that guidelines concerning a nutritionally adequate diet are implemented to help prevent diet-related deficiencies and malnutrition in vulnerable infants, children and adults.

In the UK, the poorer people are, the worse their diet, and the more diet-related diseases they suffer from. This is known as food poverty. Poor diet is a risk factor for the UKs major causes of death: cancer; coronary heart disease (CHD); and diabetes. It is only recently that the immense contribution it makes to poor health has been quantified: poor diet is related to 30% of life years lost in premature death and disability (De Rose et al, 1998).

Tackling food poverty is recognised as key to achieving government targets on reducing inequalities; reducing illness from cancer and CHD; and improving the health of children and older people. However, action needs to be more than health professionals giving advice to individuals. It must change the ‘food environment’ – that is, accessibility, affordability, culture – in which people live (O’Neil M, 2005).

Poor diet is a major health risk. It contributes to:

 

  • almost 50% of CHD deaths
  • 33% of all cancer deaths
  • increased falls and fractures among older people
  • low birth weight and increased childhood illness and mortality
  • increased dental disease in children.

This topic is most closely linked to:

 

 



Physical inactivity


Obesity


Sexual health


Illness and Death
Premature deaths in Stockton-on-Tees

Life expectancy in Stockton-on-Tees continues to improve.  However, latest reports show that the gaps in life expectancy between the deprived and affluent areas within Stockton-on-Tees, and between Stockton-on-Tees and England are widening. The Slope Index of Inequality (an estimate of the range in life expectancy at birth from most to least deprived) shows changing inequalities in Stockton-on-Tees. The gap in life expectancy has widened for males from 14.7 years in 2002-04 to 16.0 years in 2010-12.  For females, the gap has fluctuated from 12.9 years in 2002-2004, reducing to a low of 9.7 years in 2005-07 and is now 11.4 years in 2010-2012.

The major causes of illness and premature deaths (deaths before age 75 years) in Stockton-on-Tees are circulatory diseases, cancer, respiratory disease and digestive diseases (including liver disease). The charts below illustrate the contribution of these conditions to the gap in life expectancy between Stockton-on-Tees and England and for the also gap between deprived and affluent areas within Stockton-on-Tees.

Stockton and England premature mortality gap scarf chart 2009-11

Stockton inequality gap causes of premature mortality scarf chart

To reduce premature mortality in Stockton-on-Tees, the focus should be on the major causes of premature deaths.  The following chart shows the number of deaths (in people under the age of 75 years) that need to be prevented each year to close the gap between Stockton-on-Tees and the regional and national averages.

Premature mortality differences, Stockton, North East and England, various dates

 

Long-term conditions, cancer and mental health in Stockton-on-Tees

There are increasing numbers of people with more than one long-term condition receiving support from the NHS, social care and voluntary and community services. However, their care is not always co-ordinated, resulting in variation in their outcomes and quality of life.

Whilst the deaths from cardiovascular disease in people under 75 have continued to fall, the same pattern has not been observed for cancer, respiratory disease and liver disease. Premature deaths from cancer in Stockton-on-Tees remain significantly higher than the England average and are the largest contributor to local health inequalities in Stockton-on-Tees. Breast, lung, colorectal and prostate cancer account for over half of all cancer cases and deaths. Lung cancer incidence and mortality in Stockton-on-Tees is statistically significantly higher than England.

Outcomes for babies, children and young people can be improved. Infant mortality rates continue to fall and have been lower than England in recent years (although the difference is not statistically significant). Child emergency admissions are lower than England for asthma, but higher for self-harm and substance misuse.

There is an over reliance on urgent care for addressing health issues within Stockton-on-Tees. This is characterised by higher than regional average levels of attendance at accidents and emergency, emergency admissions and less planned care with a geographical (ward level) distribution that mirrors deprivation.

There are higher levels of mental health, behavioural and psychiatric morbidity characterised by:

  • a prevalence of depression that is higher than England.
  • a higher rate of emergency admissions for self- harm compared to England.
  • a higher rate of in-year bed days for mental health is higher than national average.

The local prevalence of dementia is similar to England.  However, consideration needs to be given to projections of future need and service configuration.

There are considerable gaps between the number of people known to health services compared to the expected numbers with diseases such as circulatory diseases (heart disease, stroke, high blood pressure), respiratory diseases (chronic obstructive pulmonary disease (COPD) and asthma) and diabetes.  This suggests that there is a high number of people with undiagnosed disease – ‘the missing thousands’.

There are variations in diagnosis, treatment, quality of care and outcomes in primary care for patients with long-terms conditions (asthma, COPD, circulatory diseases and diabetes).

There is lower uptake of preventative, screening and early detection services for cancers and long-term conditions (NHS Health Check, Abdominal Aortic Aneurysm (AAA), diabetes, lung health) in deprived and disadvantaged communities in Stockton-on-Tees.

 

Recommendations 

The recommendations below summarise the topic recommendations for the illness and death theme.  They are similar to those identified in the Marmot review: Fair Society, Healthy Lives, the former National Support Team recommendations for tackling Health Inequalities and latest national policy and professional guidance.

Short-term actions (1-2 years)

  • Ensure that people with existing disease are managed effectively: Reduce variation in clinical management of long-term conditions, cancer, mental health and dementia to ensure equitable access, across all social groups, to effective care, which minimises progression, enhances recovery and promotes independence.
  • Ensure that people at high risk are identified and managed at the earliest opportunity: Increase uptake of preventative and early intervention programmes with more targeted approaches for deprived and vulnerable groups (such as people with learning disability, mental health).
  • Increase early identification of long-term conditions, cancer, mental health and dementia by raising community awareness and promoting health seeking behaviours (targeted at high risk groups and those ‘seldom seen, seldom heard’ and socially isolated or excluded).

Medium-term actions (3-5 years)

  • Make all care ‘planned care’: reduce reliance on urgent care, emergency admissions and delayed/late stage presentations for cancer, circulatory diseases, diabetes and other long-term conditions, including mental health and dementia.
  • Prevent illness by addressing lifestyle risk factors: design community based interventions that tackle obesity, smoking and alcohol misuse with a clear focus on improve mental wellbeing. 

Long-term actions (over 5 years)

  • Address the social causes of poor health and premature deaths: continue to address the ‘causes of the causes’ of illness and premature deaths such as unemployment, poor quality housing, fuel poverty, raising literacy and educational attainment.

 

Summary authors

Sarah Bowman
Consultant in Public Health
Stockton-on-Tees Borough Council

Leon Green
Public Health Intelligence Specialist
Tees Valley Public Health Shared Service

 



Cancer


Cardiovascular Disease


 



Diabetes mellitus


 



Injuries

Childhood injuries are the leading cause of avoidable death and disability. It is one of the most common reasons for admissions to hospital (Audit Commission 2007).

There is strong evidence to show that injuries to children and young people are more likely in more deprived communities. People from poorer communities are more likely to die as a result of unintentional injury. Nationally, although the number of accidental deaths has fallen in recent years, the rate of deaths among the poorest children has risen.

Childhood injuries are accepted as an inevitable part of usual child development. Although protecting children and young people from every perceivable harm would be impossible, there is evidence to suggest that a large proportion of unintentional and intentional injuries are preventable.

The cost of childhood injuries to the NHS is estimated to be £2.2 billion. The wider costs to the NHS associated with domestic injury is estimated to be in the region of £25 billion (this includes indirect costs such as days lost to education, parents and carers taking leave from the workplace and the psychological effects caused by some injuries). (Audit Commission, 2007)

There are two million visits to A&E departments in the UK each year as a result of unintentional childhood injuries (Audit Commission 2007)

The need to rebalance normal development and preventing serious injury was highlighted in a 2009 government review. Preventing childhood injuries is an important public health priority and has been identified by the government within the Public Health Strategy ‘Healthy Lives Healthy People (DH 2010). Hospital admissions due to unintentional and deliberate injury have been included as an indicator within the Public Health Outcomes Framework (DH 2012).

This topic is most closely linked to:

Education

Housing

Transport

Poverty



Mental wellbeing


Oral health

Oral Health is an integral part of healthy living and a key marker of the health of a community. Poor oral health can cause discomfort, pain and disability and affects appearance and self-confidence with a major impact on quality of life. Oral diseases are largely preventable; however dental disease remains a major public health problem.

The oral health of the UK has improved significantly over the last few decades and the types of disease present now have also changed. However the oral health of the Tees region is significantly worse than that of the national level in children and oral health for adults in the North East is worse than the English average.

Health inequality is a common feature in dental disease; high levels of dental disease tend to affect those in low income families and those living in socially deprived conditions (National Children’s Bureau, 2015).

More people are keeping their teeth as they age, whereas in the past older populations had fewer teeth. As people get older the combination of frailty, ill health and social and economic constraints make looking after their oral health and accessing services more difficult. This leads to an increase in the burden and complexity of dental care needed for this group.

Oral cancer is a disease for which the outcome and prognosis can be significantly improved if it is caught early. Risk factors for oral cancer are smoking, excessive alcohol consumption and the Human Papilloma Virus (HPV) infection.

This topic is most closely linked to:

 



Respiratory diseases

Respiratory diseases are conditions that affect the lungs such as asthma, chronic obstructive pulmonary disease (COPD); infections like influenza, pneumonia and tuberculosis; and lung cancer and many other breathing problems.  This section focuses on asthma and COPD which contribute hugely to health inequalities, ill health and premature death.

The similarities in the symptoms of both diseases can lead to misdiagnosis and poor management. Hence, expert assessments are required to separate their relative contribution to ill health. About 15% of patients with COPD also have asthma.

Asthma
Asthma is a chronic condition that affects airways in the lungs, causing them to become inflamed and swollen. Typical symptoms include breathlessness, tightness in the chest, coughing and wheezing. Environmental factors such as viral infections, allergens, pollution, tobacco smoke, workplace sensitisers and exercise can make the condition worse.

The causes of asthma are not well understood so prevention is not currently possible. However, the condition does not usually deteriorate over time and the aim of treatment is for people with asthma to be free of symptoms and lead a normal life.

It is estimated that about 5 million (1.4 million are children aged under 16 years) people in the UK are affected by asthma. There are between 1000 and 2000 deaths from asthma per year, but it is estimated that 90% of these deaths are associated with preventable factors.  Asthma is a common cause of large numbers of emergency admissions in those aged less than 19 years. High numbers of hospital admissions for asthma are considered to represent a mismanagement of the condition.


COPD
Chronic obstructive pulmonary disease is a chronic disabling disease which causes a gradual decline in lung function, with increasing episodes of chest infections and exacerbations as the condition progresses. It is a general term which includes chronic bronchitis and emphysema. It mainly affects people over the age of 40 and risk increases with age. Smoking is the main cause in the vast majority of cases.

COPD is incurable but treatments help to slow down the decline in the lung function, so early diagnosis and support for effective self-management and self-care can help patients live an active life.  About 835,000 people in the UK are currently diagnosed with COPD and an estimated 2.2 million people have the condition but do not know it.

COPD is the fourth biggest killer in the UK, the second most common cause of emergency admissions to hospital and one of the most costly in-patient conditions treated by the NHS.

Integrated working between health, social and leisure services and people with asthma and COPD is critically important to improve health and wellbeing and reduce the health inequalities associated with these conditions.

This topic links with the following JSNA topics:

 



Suicide and self-harm

Suicide
Suicide is a major public health concern.  Nationally the number of people who take their own lives has been reducing in recent years.  Nevertheless, about 4,200 people aged 15 and over took their own life in 2010 in England.  Suicide is often the end point of a complex pattern of risk factors and distressing events, and the prevention of suicide has to address this complexity.

Suicides are not inevitable; indeed most are preventable (WHO 2004).  There are many things that can be done in communities, outside hospital and care settings, to help those who think the only option is to end their own life.

The average cost of suicide for those of working age in England is estimated to be around £1.67m per case (at 2009 prices). If this estimate is applied to the North East of England the projected cost to the local economy is £345million for the 238 cases of suicide and undetermined injury in 2009.

Self-Harm
Self-harm is defined as ‘self-poisoning or self-injury, irrespective of the apparent purpose of the act’ (NICE, 2004). An individual episode of self-harm might be an attempt to end life.  However, many acts of self-harm are not directly connected to suicidal intent.

It must be recognised that the rate of suicide for people who have had an episode of self-harm is 100 times higher in the year following the episode than that of the general population.

The extent of economic burden associated with self-harm is significant dependent upon both how it is defined and the method of economic evaluation (Drummond et al., 1997).

The suicide and self-harm prevention agenda is cross-cutting and relates most closely to the following JSNA topics:

Offenders
Domestic Violence Victims
Ex-Forces Personnel
Alcohol Misuse
Illicit Drug use
Mental Health and Behavioural Disorders
Employment
Carers



About JSNA


National requirements

Department of Health guidance on Joint Strategic Needs Assessment, 2007

 

 

 

Joint Strategic Needs Assessment: a springboard for action, April 2011

 

 

 

 

NHS Confederation Briefing 221, July 2011

 

 

 

 

JSNA and joint health and wellbeing strategies explained, December 2011

 

 

 

 

Statutory guidance on joint strategic needs assessments and joint health and wellbeing strategies, March 2013



Author guidance

Topic Guide (September 2011) (PDF 641kB)

Blank topic template (Word document 805kB)

Topic Editing Manual (PDF 548kB) 



FAQ


Glossary

 

Glossary of terms

The glossary of terms is building gradually as each topic is activated.

The list of abbreviations is located below the glossary of terms.

 

Ketoacidosis:

Text here

 

Myocardial infarction:

Text here

 

Pre-diabetes:

Text here

 

Retinopathy:

Text here

 

 

List of abbreviations

The list of abbreviations is building gradually as each topic is activated.

 

BASCD         British Association for the Study of Community Dentistry

BCS             British Crime Survey

BDA             British Dental Association

BME             Black and minority ethnic (population)

CDS             Community dental service

CQUIN         Text here

DAFNE         Text here

DESMOND    Text here

HATTIE        Text here

GSF             Gold standards framework (for end-of-life care)

IOM             Integrated offender management

ISOP           Text here

ISVA            Independent sexual violence advisor

JAG             Joint action groups 

MAPPA         Multi-Agency Public Protection Arrangements

PASS           Text here - mentioned in smoking or end of life care?

PND             Police National Database

PSHE           Text here

PTSD            Post-traumatic stress disorder

SARC           Sexual assault referral centre

SECOS         Sexual exploitation of children on the streets

SOLO           Sexual offence liaison officer

SSP              Safer Stockton Partnership

SSS              Stop Smoking Service

STP              Stockton town pastors

 



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Contact Us

For information about specific topics, please contact the topic lead identified on each topic page.

For enquiries about each area please contact the following:

Hartlepool

Paul Edmondson-Jones, Interim Director of Public Health

Paul.Edmondson-Jones@hartlepool.gov.uk

 

Middlesbrough

Edward Kunonga, Director of Public Health

edward_kunonga@middlesbrough.gov.uk

 

Redcar & Cleveland

Edward Kunonga, Interim Director of Public Health

edward_kunonga@middlesbrough.gov.uk

 

Stockton-on-Tees

Sarah Bowman-Abouna, Acting Director of Public Health

sarah.bowman-abouna@stockton.gov.uk

 

For general enquiries about the Tees JSNA website, please contact:

Leon Green, Public Health Intelligence Specialist

01642 771749

leon.green@redcar-cleveland.gov.uk



Contact Us

For information about specific topics, please contact the topic lead identified on each topic page.

For enquiries about each area please contact the following:

Hartlepool

Paul Edmondson-Jones, Interim Director of Public Health

Paul.Edmondson-Jones@hartlepool.gov.uk

 

Middlesbrough

Edward Kunonga, Director of Public Health

edward_kunonga@middlesbrough.gov.uk

 

Redcar & Cleveland

Edward Kunonga, Interim Director of Public Health

edward_kunonga@middlesbrough.gov.uk

 

Stockton-on-Tees

Sarah Bowman-Abouna, Acting Director of Public Health

sarah.bowman-abouna@stockton.gov.uk

 

For general enquiries about the Tees JSNA website, please contact:

Leon Green, Public Health Intelligence Specialist

01642 771749

leon.green@redcar-cleveland.gov.uk



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