Sandwell Public Health Annual Report 2010-11

Annual Report of the Director of Public Health

for Sandwell 2010/11

Public Health - a new asset

Public Health Annual Report 2010/11_Prt1 26/01/2012 15:08 Page 1

2

Acknowledgements

Editorial Team:

Dr John Middleton, Director of Public Health Jyoti Atri, Deputy Director of Public HealthAndrew Hood, Specialist Registrar in Public Health Shaukat Ali, Public Health Business Manager Dr Alexis Macherianakis, Consultant in Public Health MedicineAnna Hunt, Consultant in Dental Public HealthPaul Southon, Public Health Development ManagerDr Patrick Saunders, Consultant in Public Health

Sandwell Metropolitan Borough Council:

Wendy Dale, Interim Divisional Manager - Personalisation and Service DevelopmentRoss Bailey, Senior Performance Analyst and Researcher

Sandwell Primary Care Trust:

Ralph Smith, Deputy Head of Information and IntelligenceEnderjit Aujla, Information and Contracting ManagerGreg Barbosa, Public Health Intelligence AnalystThomas Grainger, Public Health ApprenticeNicola Howe, Public Health Analyst TraineeNathan Lauder, Business Administration Apprentice


Sand

wel

l - D

irec

tor

of P

ublic

Hea

lth

Ann

ual R

epor

t 201

0/11

3

Contents

Pages

Introduction and recommendations by Dr John Middleton,Director of Public Health

4-9

1. Back where we belong - Public Health in the LocalAuthority

10-15

2. Are we reducing the inequalities gap? 16-21

3. Tackling inequalities is everyone’s business 22-32

4. Lifestyle services for people in social care - improvinghealth and managing demand

33-41

5. Understanding winter pressures - across health andsocial care boundaries

42-51

6. Building on the tradition of improving health throughhousing

52-56

7. Health profiles for Sandwell Clinical CommissioningGroups

57-71

References/Achievements 72-74

CD and contents list 75


4

Thehighestlaw

This quote from Cicero in the 4th century BC appearsabove the entrance to a Southwark council health centrebuilding which in 1937 was one of the symbols of civic

pride in health. Local authorities provided safety net cover forhealth before the NHS. By the same score - the picture shownbelow of the West Bromwich volunteer ambulance serviceshows how people had to organise their health services beforethe NHS. Public health had grown up in local authorities in theVictorian era and has a long and as distinguished a history asthe institution of the local authority itself.

The Victorians came to recognise the vital importance of publichealth, of clean water and sanitation, of housing, educationand social care; despite their overriding commitment to freeenterprise, they recognised that there could not be a safe andcoherent society without collective provision and a safety netfor the most vulnerable. Violence, squalor and disease wouldspill over and affect the whole society in the absence ofsocietal provision. Want, idleness, ignorance, squalor anddisease were the giant evils which Beveridge later sought totackle in his vision for the welfare state. Much later still, in theBlair years, these became recast as the ‘wicked issues’. “The health

of the

people is the

highest law.

“

Dr John MiddletonDirector of Public Health

Photo: West Bromwich Volunteer Ambulance Service (from 'Memories of theBlack Country by Alton Douglas’, www.altondouglas.co.uk)

In 1989 in the first line of my first annual report I wrote,‘It’s not who your doctor is, it’s who you vote for that mostaffects your health’. This was the era in which the newpublic health movement was being invented. The Blackreport had shown that despite 30 years of the NHS,inequalities in health experience and inequalities in use ofhealth services were getting bigger between rich and poor,between the north and south of England and betweensocial groups. The arrival of AIDS suggested that infectiousdisease had not been conquered. Prevention is better thancure, when there is no cure. This mantra we now knowapplies also to all long term illness.

In 1989 there was then a local authoritys health networkand a Public Health Alliance and a renewed interest inhealth as ‘everybody’s business’.


Sand

wel

l - D

irec

tor

of P

ublic

Hea

lth

Ann

ual R

epor

t 201

0/11

5

Public health in theNHS After 40 years of public health in theNHS, public health is now destined to areturn to the local authority. Publichealth has enjoyed an accelerateddevelopment during the last ten years -including the work of the nationalsupport teams in helping primary caretrusts and local authorities to addressinequalities in their areas and increaseddedicated investment through the‘Choosing Health’ Public Health WhitePaper of 2004.

We have seen new public healthworkforces develop in smokingcessation and the health trainers and wehave developed new tools for datamanagement to stratify populationhealth risks, to measure health impactand health inequalities impact, tomeasure illness and treatmentresponses in primary care. Public bodieshave been performance managed ontheir achievements in reducing healthburdens and reducing healthinequalities - lay members of healthservice boards and local authorityscrutiny committees have become asexercised by their local rates for smokingquitters and teenage pregnancy as theyalways have been by hospital waitinglists. Public health principles aboutbeing ‘needs led, and evidence based’have gathered pace and been appliedthrough all areas of the health service.And arguments about affordability andeffectiveness are generally applied inprocesses of priority setting.

Bringing it all backhome Most people have welcomed the move ofpublic health back to the local authorities - orat least, not opposed it - the extent to which itwould be necessary if it were not for theplanned break up of the NHS is glossed over.

There is much work that can be done betterfrom a local authority base - the impact of allcouncil policies - housing, education, economicdevelopment, environmental improvementand community safety should all be steeredtowards ones with maximum health benefit.The old public health problems of squalor andinsanitary conditions still exist. Idleness,ignorance, want are all best fought from a localauthority base. Disease can best be preventedthrough education, environmental andeconomic means. Poverty is still our biggestkiller. The new manifestations of the public ill-health include problems of inactivity and overconsumption, of addiction, of loneliness,isolation; unhappiness and exclusion lendthemselves to local authority solutions.

The move to the local authority comes at aterrible time – Sandwell council is planning a30% cut in public services by 2014. Across thecountry local authority budgets are beinghammered, jobs axed and a new localauthority culture of commissioning andoutsourcing, safety net and do minimum isreplacing local provision for the collectivegood.


6

A new burden? It is difficult for councils to welcome public health as a newservice and a new responsibility; to them, it is a ‘new burden’.‘New burden’ is a term coined by the last government and itsnew burdens principles still apply. They were designed to ensurethat local authorities are fully funded for new responsibilitiesdevolved or transferred by government.

There is understandable concern by councils about whether ornot they will be fully funded for the public health function and onwhat terms and conditions public health staff will transfer. It isfully understandable that councils might see public health as anew burden.

But after 21 years as Director of Public Health in Sandwell I canreport:

Civic pride In my 1995 annual public healthreport on crime and public health,I observed that in communitysurveys, people generally say themajor concerns that they wantsomething doing about are “dogshit” and “crime”. They all knowsomeone of course who has diedfrom cancer or a heart attack - butsomehow these major healthconcerns never really make it onto the radar of local authority andcitizen priorities. In the new publichealth system we will need toraise the profile of health as amatter of civic pride.

In the first meeting of the newHealth and Wellbeing Board,Councillor Bob Badham eloquentlyraised the questions of why lifeexpectancy was better in someelectoral wards than others. Iwelcome this and would like tosee all councillors asking thequestions: what is life expectancyin my ward and if it is less thanSandwell in general what are wedoing about it? All Sandwellcouncillors should also ask: why islife expectancy less in Sandwellthan for England as a whole?

P Over 350 fewer deaths per year from heart

disease P Over 180 fewer deaths per year from cancer

P Life expectancy for men increasing in the period

2007-09 after a period of levelling

P Life expectancy for women now increasing faster

than nationally

P Epidemic measles doesn’t happen

P Healthcare acquired infections down dramatically:

The MRSA super bug down – 86% since 2006-07

Clostridium difficile down 53% since 2007-08

P Increased achievement of smoking quitters in

2010-11 following introduction of the tariff based

provision.

P Teenage pregnancy down 28% since 1996-75

fewer births per year- reducing our inequality with

the national rate.

P Drug treatment access massively increased since

2004 with corresponding massive falls in domestic

burglary since then.

P Excess winter deaths have reduced from the

highest in region in 2006 to the national average in

2010.

Sandwell council has played a key role in achieving many ofthese health gains.


Sand

wel

l - D

irec

tor

of P

ublic

Hea

lth

Ann

ual R

epor

t 201

0/11

7

A new assetSo are we a ‘new burden’? I would urge thecouncil to see public health as a ‘new asset’.

Gro Harlem Brundtland, former Director generalof the World Health Organisation attributed theSouth East Asian Tiger economic developmentto improvements in health. In the UK, DameCarol Black’s report showed the benefits ofhealth gain for more productive employmentand for economic development.

In these terrible economic times health will bean asset for:

g Better learningg Better opportunities for young peopleg Better performance in workg Enrichment of our local economy g Enrichment of our local environment g Better social support networks and personal

care

Public health will be an asset for better decisionmaking in:

g Priority settingg In risk stratification - target settingg In health impact assessment/impact

assessmentgHealth inequalities impact assessmentg In intelligent use of informationg In intelligent interpretation of research

These are really difficult times for Sandwell inthe local authority and in the health system. Thepublic health directorate will seek to maintainthe gains that have been made for the health ofSandwell people and to find ways to continuethat improvement even in times where thethreats to their health are being made worse.For Sandwell Council, we intend to be a NewAsset.

John MiddletonDirector of Public Health Sandwell Primary Care Trust and SandwellMetropolitan Borough Council

September 2011

A National service forhealth? But we also have to recognise that healthservices can do good but they can also doharm - hospitals are more dangerous placesthan roads these days - health care acquiredinfections, treatment errors, deep veinthrombosis, pulmonary emboli, osteoporosis,bed sores – there are many major harmfuleffects of health services which need to bemeasured using population health methods,and effective methods for control andprevention need to be applied. The healthservice also needs to fulfil its obligations as apublic health promoting body – making everycontact count for lifestyle health referrals,getting people to stop smoking before theiroperations, incorporating lifestyleinterventions into all clinical pathways andservice redesigns. The NHS must have apowerful voice and resource for public healthimprovement.

The Office of PublicHealth The government has recognised that as well ashealth protection and health improvement,there is a third domain of public healthnamely; health and social care related publichealth. We have been required to identify thefunding committed to public health functionfor the health services like the ones above butalso including screening management andimmunisation. The local authority publichealth service is required to supply back to theClinical commissioning groups public healthexpertise and nationally a ‘core offer’ is beingworked up. What is unclear is where thegovernment sees screening management andcoordination of immunisation being done from- all the current programmes are managed bypublic health staff and there is no prospect ofa new workforce being created. It may bebeneficial for us to pursue the idea of an Officeof Public Health or a Public health agencywhich is capable of offering public healthservices to the clinical commissioning groups,the proposed NHS commissioning board andthe local authority.


g g Develop evidence based parenting programmes

g Bring educational attainment in Sandwell up to the national average

g g Ensure schools continue to take a ‘whole child’ approach including working with families in the community

g * Support employers with ensuring that they have a healthy workforce through lifestyle programmesand the prevention of physical and mental health problems at work

g Provide support to people at risk of unemployment through ill health

g Provide lifestyle support and health care to help people return to work after ill health

g gg g

Ensure all partners are engaged in the development and delivery of the Friends and Neighboursproject aim at increasing support in the community.

g g Prioritise policies that tackle both health inequalities and climate change including, increasing activetravel (walking and cycling) and increasing accessibility to green spaces

g g Improve the food environment for communities, including community agriculture, controlling theintroduction of fast food outlets and improving the quality of fast food

g Improve energy efficiency of housing

g gg

Ensure additional funding for preventative interventions above the 4% ring-fenced budget for publichealth

g gg

Work with the NHS Commissioning Board and Clinical Commissioning Groups to identify those mostat risk of ill-health and ensure they receive appropriate preventative care

g Ensure that every contact with the public is used as an opportunity for health promotion

Summary and recommendations by chapter:For 6 1. Back where we belong – Public health in the local authority

For 6 3. Tackling inequalities is everyone’s business

g The ring-fenced budget for public health must be protected and applied to public health serviceswhich deliver maximum gains for the health of Sandwell people and most contribute to reducinghealth inequalities.

g gg

The 4% allocation should be seen as the minimum spend on health improvement, not the only spend– further investment from local authorities and clinical commissioning groups is required to ensurepeople in Sandwell achieve the healthy life expectancy that other people in England enjoy.

g gg

Sandwell needs an Office or an Agency for Public Health, housed in the council, but capable of meetingthe needs of both the council’s People and Place themes and the clinical commissioning groups.

g gg

Sandwell needs to sustain its dedicated specialist public health resource to develop policy, commissionand provide services for the local community throughout the period of full transition to local authoritymanagement. A clear and early decision to move to a Sandwell based public health service will enablestaff to concentrate on improving public health in Sandwell.

g gg g

We will need full access to local authority and health data to inform NHS commissioning and to fulfilour obligations for the Joint Strategic Needs Assessment (JSNA) .

g g As an overall commitment to the people of Sandwell, Sandwell public health services will continue todeliver the services they provide until told to transfer them to some alternative services in the NHS orlocal authority or in the NHS Commissioning Board. We will not ‘drop the ball until there is someoneelse to pick it up’.

For 6 2. Are we reducing the inequalities gap?

g g Disability Free Life Expectancy (DFLE) information should be utilised to target social research activityin communities with the poorest DFLE to further understand their behaviour in relation to healthylifestyles and identify strategies for promoting change.

8


g g Improve recording of ethnicity and lifestyle factors such as obesity and smoking prevalence

g Further investigate estimated under recording by examining the relationship with hospitaladmissions, deaths and socio-demographic characteristics

g gg

Implement a local data sharing agreement which enables public health to present data bypractice, by electoral ward, by neighbourhoods, and by commissioning groups as well as on theSandwell-wide basis

g g Sandwell MBC Housing and public health should work more closely to identify those at higher riskof housing relating ill health by incorporating evidence based approaches to housing improvements

g CCGs should prioritise housing interventions and programmes to help reduce hospital activity andhealth inequalities

For 6 4. Lifestyle services for people in social care – improving health and managing demand

For 6 5. Understanding winter pressures – across the health and social care boundaries

For 6 6. Building on the tradition of improving health through housing

For 6 7. Health profiles for Sandwell Clinical Commissioning Groups

Director of Public Health NHS Commissioning BoardsSandwell Public Health Directorate Sandwell Metropolitan Borough CouncilPublic Health with employers * Sandwell MBC, Housing and PartnersPublic Health and Adult Social Care Sandwell MBC, EducationPrimary Care All partners, especially SWBH & SMBCBlack Country Cluster Voluntary SectorStrategic Health Authority BusinessesClinical Commissioning Consortia SHUDU

KEY - Recommendations for:

*especially public sector employers

g Further develop our understanding of social care clients who might benefit from lifestyleinterventions and how they might benefit, including telephone interventions

g Survey community social care clients to explore the needs/demand for lifestyle services and howand where they should be deployed

g Undertake a needs assessment for peripatetic postural instruction

g Ensure that lifestyle assessment is a core part of the initial social services assessment

g Social care staff should be trained in addressing lifestyle issues with clients through the ‘EveryContact Counts’ programme

g The range of lifestyle services offered to people in social care settings and to vulnerable adults, suchas those with mental health problems or learning disabilities, should be expanded.

g gg

Preventative interventions to reduce seasonal variations in admissions should focus on respiratorydisease and should include ensuring adequate flu vaccination uptake and investment in winterwarmth

g g A detailed retrospective audit of case notes, tracking people across the health and social caresystems is required to fully understand the reasons for the delays

g g Investigate the reasons why there is a higher proportion on women aged 85 plus using social care,than men in the same age group

Sand

wel

l - D

irec

tor

of P

ublic

Hea

lth

Ann

ual R

epor

t 201

0/11

9


Sand

wel

l - D

irec

tor

of P

ublic

Hea

lth

Ann

ual R

epor

t 201

0/11

We have a particular issue in Sandwell wherewe have a robust health protection servicewhich has delivered massive reductions inhealthcare acquired infections, reductions intuberculosis (TB) incidence, betterimmunisations, better standards ofdecontamination, reduced genitourinarymedicine (GUM) waiting times, betterresponses to blood borne viruses and a leadingenvironmental public health tracking facility.We are concerned that the only healthprotection visible to ministers is the high profilework on national disasters like the BuncefieldFire and the Litvenyenko affair. Localaccountability for health protection will remainand as such will need resourcing at a local level.

Making the best useof resources toimprove healthThe nominal national ring-fenced budget forpublic health stands at 4%. Is this enough? Aprevious Sandwell Director of Public HealthAnnual Report2 argues this should be at least5%. We will need to invest considerablymore than other areas if we are to reducethe life expectancy gap within Sandwell andbetween Sandwell and England.

The ring-fenced budget for public healthmust be protected and applied to publichealth services which deliver maximumgains for the health of Sandwell people andmost contribute to reducing healthinequalities.

There is concern that much of this budgetwill be eroded, even before it reaches thelocal authority. Funding for Public HealthEngland (the proposed national organisationfor public health) including the currentfunctions of the Health Protection Agency(HPA), National Treatment Agency (NTA),Public Health Observatories (PHO) andcancer registries will be drawn from thisbudget. There were two previous occasionswhen money was handed back from localhealth authorities to national organisations -both the HPA and the NTA collected nationalbudgets – the amounts which then becameavailable for local services never quitematched the amounts we had previouslyheld locally.

IntroductionAs part of the current reforms to the National Health Service (NHS) in England, the delivery of publichealth is changing dramatically1. The reforms herald a return of public health to local authorities,which many regard as ‘going home’ and as the place where the greatest impacts on health outcomescan be made. Yet public health departments have been outside of local authorities for over 30 yearsand the roles and responsibilities of both entities have changed significantly in that time. In thischapter we consider some of the challenges and opportunities and how we can make the best of thismove to improve and protect health and reduce inequalities.

11


12

With public health located in the council,efficiencies will be made through a moreintegrated approach. There are many areasof connection and overlap between publichealth and current council functions.Integration will lead to reduced duplication ofeffort and synergies in areas such as researchand intelligence; physical activity, food andtrading standards and communitydevelopment. The public health departmentwill bring to the council new expertise andexperience in population measurement ofrisk, risk stratification, impact assessment -from health and health inequalities that canbe applied more widely. Our experience incarbon management and good corporatecitizenship can also be of benefit to thecouncil and our work on occupational health,knowledge management and informationgovernance could also be applied within thecouncil as a whole.

Sandwell MBC, as well as other localauthorities all over England, will be taking onresponsibility for improving health. Localauthorities are currently facing unprecedentedlevels of cuts and there has been talk of usingpublic health budgets to underpin councildeficits. Yet the ring-fenced budget is ademonstration of the Government’scommitment to improving life expectancy andSandwell MBC also regards this as a high levelpriority, as reflected in the council scorecard(a set of measures reflecting the council’spriorities). As we set out in ‘5% for health’,current public health spend is a tinyproportion of the total health service spend-Sandwell’s share on the latest evidence is justover £30 million. Of course we need to spendit most wisely and efficiently. The 4%allocation should be seen as the minimumspend on health improvement, not the onlyspend – further investment from localauthorities and clinical commissioning groupsis required to ensure people in Sandwellachieve the healthy life expectancy that otherpeople in England enjoy.

Increases in investment for prevention of illhealth reap dividends for the commissionersas money is released from reduced hospitalactivity. More importantly small increments inpublic health spend save lives and improvehealth. Councils will need to decide which ismore important - saving money, or savinglives? The public health department can helpthem to do both.

National interest has focussed on the independence of the Director ofPublic Health (DPH) to exercise judgements in the cause of achieving thebest health for local people. Fulfilling this role in the interests of the peoplemay create conflicts with other local economic and political opinions andinterests. In practice, the Director of Public Health needs to exercisejudgements and balance political imperatives to find the most effectiveapproaches to improving health. The DPH has to be a corporate chief officerin order that the best advice is heard and acted upon by the council andlives are saved. This has always been the case in Sandwell and thereforenational preoccupations should not be of major concern here.

The Director of Public Health must have astrong and independent voice


Sand

wel

l - D

irec

tor

of P

ublic

Hea

lth

Ann

ual R

epor

t 201

0/11

13

An Office of PublicHealth The distinction drawn between corporatethemes of People and Place in the localauthority requires public health to operateacross both theme areas. Theinterconnections between the widerdeterminants of health - housing,economic development, town planning,transport, crime prevention, environmentalprotection and improvement, all lie in thecouncil’s new Place Theme. Individuallifestyle choices and health servicesinterventions lie more with the Council’sPeople Theme. For example, we know thatan individual’s educational status willimpact on where they live and the type ofhousing they can afford. It will alsoinfluence their lifestyle choices and bothwill impact on their health outcomes. Inrecognition of this and as recommended bythe Healthy Lives, Healthy People Updatepaper, the DPH should report directly tothe Council Chief Executive, alongside theCorporate Directors of People and Place.Sandwell needs an Office or an Agency forPublic Health, housed in the council, butcapable of meeting both the needs of thecouncil’s People and Place themes and theclinical commissioning groups. There willalso be a major hole if the NHSCommissioning Board is to take onscreening and immunisation programmes -the people who coordinate and lead thiswork are currently in local public healthand they need to be able to continue to dothis on behalf of the NHSCB. This wouldthen be a third area of strategicrelationship for the Sandwell Public HealthAgency/Office of Public Health.

Sandwell needs to sustain its dedicated andspecialist public health resource to developpolicy, commission and provide services forthe local community throughout the periodof full transition to local authoritymanagement. A clear and early decision tomove to a Sandwell based public healthservice will enable staff to concentrate onimproving public health in Sandwell.


14

This is an exciting time for developingour understanding of needs in ourpopulation. We are rapidly developingour access to primary care recordsthrough the use of technology, which forthe first time, opens up the potential tounderstanding patterns of illness withinour population and not just of hospitaluse. We will also be able to match theserecords with hospital records and trackpatients’ journeys through the entirehealthcare system.

Public health in the local authorityshould have access to data onpreventative activities, such as smokingcessation or physical activity, which canbe added to these data sets and this willallow us to track the impact ofparticipation on reducing the risk of

disease and hospitalisation. We couldalso add in social service useinformation, as well as other data setscurrently only available in the localauthority, such as housing conditions oreducational attainment. The potential ofthese combined data sets to develop ourunderstanding of health needs, theimpact of the broader determinants onhealth and on which interventions work,is huge. Public health, located in thelocal authority, will be in a uniqueposition to develop this understandingand inform broad strategies to improvehealth. We will need full access to localauthority and health data to inform NHScommissioning and to fulfil ourobligations for the Joint Strategic NeedsAssessment (JSNA).

Leaving the NHSThe biggest influences on our health are outside the NHS – these include environment,education and economics - so called ‘wider determinants of health’. Addressing these widerdeterminants will bring the largest benefits to health outcomes, and there will be manyopportunities to do this in the local authority. Yet health services, particularly primary care(GPs, dentists, pharmacists, and opticians and community health services) but also secondarycare (hospitals) can bring added value. The Healthy Lives, Healthy People update paper madeit clear that public health in the local authority will have a role informing healthcarecommissioning. This service to Clinical Commissioning Groups (CCG) will be a ‘mandated’ (or‘required’) service from local authority public health teams. There is a risk that being placedoutside the NHS may result in a disconnection between public health and the NHS, and wewill seek to ensure this does not happen in Sandwell.


g Sandwell MBC g Clinical Commissioning Consortia g NHS Commissioning Boards g Black Country Cluster

g Strategic Health Authority g Director of Public Health g Sandwell Public Health Directorate Sand

wel

l - D

irec

tor

of P

ublic

Hea

lth

Ann

ual R

epor

t 201

0/11

15

g The ring-fenced budget for public health must be protected and applied to public healthservices which deliver maximum gains for the health of Sandwell people and most

contribute to reducing health inequalities.

g g g The 4% allocation should be seen as the minimum spend on health improvement, not theonly spend – further investment from local authorities and clinical commissioning groups is required toensure people in Sandwell achieve the healthy life expectancy that other people in England enjoy.

g g g Sandwell needs an Office or an Agency for Public Health, housed in the council, but capable ofmeeting the needs of both the council’s People and Place themes and the clinical commissioning groups.

g g g Sandwell needs to sustain its dedicated specialist public health resource to develop policy,commission and provide services for the local community throughout the period of full transition tolocal authority management. A clear and early decision to move to a Sandwell based public healthservice will enable staff to concentrate on improving public health in Sandwell.

g g g g We will need full access to local authority and health data to inform NHS commissioningand to fulfil our obligations for the Joint Strategic Needs Assessment (JSNA).

g g As an overall commitment to the people of Sandwell, Sandwell public health services willcontinue to deliver the services they provide until told to transfer them to some alternative services inthe NHS or local authority or in the NHS Commissioning Board. We will not ‘drop the ball until there issomeone else to pick it up’.

Departure from the NHS also poses a risk to thepublic health workforce. We have already seen anumber of public health staff with nursingqualifications return to a career in health visiting.The potential loss of NHS terms and conditions maylead to other members of the public healthworkforce leaving the specialty in order to retaintheir terms and conditions, resulting in a loss ofspecialist skills. Careful management of thetransition and effective workforce planning will helpto mitigate against these potential losses.

As an overall commitment to the people ofSandwell, Sandwell public health serviceswill continue to deliver the services theyprovide until told to transfer them to somealternative services in the NHS, localauthority or the NHS Commissioning Board.We will not ‘drop the ball until there issomeone else to pick it up’.


Are we reducingthe inequalitiesgap?

2

Authors: Hamira Sultan, Shamil Haroon and Andrew Hood (Specialist Registrars inPublic Health) Jyoti Atri (Deputy Director of Public Health)

16


Sand

wel

l - D

irec

tor

of P

ublic

Hea

lth

Ann

ual R

epor

t 201

0/11

17

Social inequalities lead tohealth inequalitiesHealth inequalities can be defined as: “avoidabledifferences in health, wellbeing and length of life“.

Since the 1970s, there has been an increasingacknowledgement of the limitations of healthcare toaddress inequalities in health and wellbeing. The BlackReport3 of the 1980s, established the relationship betweensocial, economic and demographic characteristics andinequalities in health, subsequently corroborated byWhitehead’s report of 19874 and the Acheson report of19985. All demonstrated that while health outcomes haveimproved since the introduction of the NHS and welfarebenefits - inequalities in health, between the most andleast well off in society, have widened.

The Marmot Review ‘Fair Society, Healthy Lives’6,published last year, adds to this body of evidence,demonstrating that inequalities in health are still prevalentin our society, with those living in the poorest areas, dyingseven years earlier, on average, than those in the richestareas. The report places high priority on reducing thissocial gradient in health.

These reports are particularly pertinent to Sandwell, the12th most deprived local council area in England7, wheremen live nearly three and a half years less than England asa whole.

In this report, we consider a set of ten indicatorsrecommended by the Marmot review, for local authoritiesand health services to measure their progress on reducinghealth inequalities.

Poverty remains the chief cause ofdisease, and it is a factor which is

beyond the immediate control of medicineHenry Sigerist“ “


18

Figure 1. The ten Marmot indicators for Sandwell compared to the rest of England (Source: London HealthObservatory)

There are multiple inequalitiesbetween Sandwell and EnglandFigure 1 shows the baseline position for Sandwell against the10 inequality indicators selected by the Marmot team and howthese compare to England as a whole. The indicators areseparated into two broad categories, health outcomes andsocial determinants. Sandwell is significantly worse thanEngland for the majority of indicators.


Men and women inSandwell still liveshorter livesLife expectancy provides a good summarymeasure for all deaths from all causes and can beused to reflect the overall health outcomes in agiven area. Figures 1 and 2 illustrate that whilelife expectancy has improved in both Englandand Sandwell, life expectancy in Sandwellremains significantly lower than the nationalaverage. The gap between Sandwell and Englandhas remained fairly stable for females (with awelcome narrowing in 2007-2009) but hasactually widened for males, from 2.5 year in2003-2005 to 3.4 years in 2007-2009. Figure 2shows the levelling of life expectancy for menbetween 2003-2008. We have previouslycommented on this. We believe it reflects theexperience of a generation of men who lost their jobs in theeighties and spent most of their lives in low paid jobs orunemployment, drinking, eating and smoking too much anddeveloping heart disease and cancer at a premature age. Thewelcome increase in life expectancy in the years 2007-08may reflect our cardiac risk management programme andbetter organised primary care for young men between theages of 45-65.

Sand

wel

l - D

irec

tor

of P

ublic

Hea

lth

Ann

ual R

epor

t 201

0/11

19

Figure 2. Life expectancy at birth for males and females, Sandwellcompared to England, 01-03 to 07-09 (Source: NCHOD)

InequalitieswithinSandwellThe Marmot Review alsoconsiders inequality in lifeexpectancy; this reflects thedifference in life expectancybetween the most and leastdeprived areas in the borough.Based on data from 2005-2009,inequality in life expectancyremains similar for Sandwellcompared to England, for bothmales and females. This mayreflect the fact that Sandwell isfairly uniformly deprived,demonstrated by the fact that17 of 24 electoral wards areamongst the 255 mostdeprived in the country.Conversely, it may reflect thefact that England as a whole isan unequal society.Nevertheless the key challengefor Sandwell is reducinginequalities between Sandwelland England.


While life expectancy provides a good summarymeasure for health outcomes for a population, it doesnot necessarily reflect quality of life. ‘Disability-free lifeexpectancy’ (DFLE) provides a measure for how longpeople live without suffering any disability. It allows usto account for chronic diseases and disability within apopulation by measuring self-reported limitations inday to day activities, such as work, school and socialactivities. The level of inequality in disability-free lifeexpectancy (1999-2003) for females in Sandwell, is notsignificantly different to England. However, for males,the data suggests that there is less inequality inSandwell than for England. Again this is likely to be areflection of universally low disability-free lifeexpectancy acrossSandwell.

Figure 3 showsSandwellneighbourhoods(Medium SuperOutput Areas –MSOAs) clusteraround the worseend of thespectrum forincome deprivationas well as for lifeexpectancy anddisability-free lifeexpectancy.

20

This shows that Sandwell has an even spreadof inequality in income,deprivation and lifeexpectancy compared with national. But it isuniformly poor. There aren’t vast inequalitiesacross the borough for this measure. Assuch, disability-free life expectancy, althougha more sensitive overall indicator of qualityof life, is of limited value to us. Thisinformation however could be utilised totarget social research activity in communitieswith the poorest DFLE to further understandtheir behaviour in relation to healthylifestyles and identify strategies forpromoting long-term change.

Figure 3. Life expectancy and disability-free life expectancy at birth, by neighbourhood incomelevel, England and Sandwell, 1999-2003 (Source for data: Marmot Review Team and ONS) (5Sandwell MSOAs)

Sandwell performs significantly worse thanEngland for the key social determinantsdeemed by the review team to have thelargest impact on health inequalities (Figure 1).Sandwell’s poor life expectancy coupled withthese poor outcomes on the socialdeterminants, adds credence to the MarmotReview Team’s views on the relationshipbetween these determinants and lifeexpectancy in Sandwell. This is furtherdemonstrated in Figure 4, showing the

relationship between these socialdeterminants and life expectancy at the localauthority level. For instance, we see that lifeexpectancy increases with the percentage ofchildren achieving a good level of developmentby age five and decreases with low levels ofyoung people not in education, employmentor training. It also decreases as the percentageof people on benefits increases. This clearlyshows how social determinants are related tohealth, such as life expectancy.

Inequalities in disability-free life expectancy withinSandwell

Sandwell demonstrates that socialdeterminants are related to health outcomes


Sand

wel

l - D

irec

tor

of P

ublic

Hea

lth

Ann

ual R

epor

t 201

0/11

21

Figure 4 Scatter plots showing the relationship between life expectancy and the social determinants of health for all localauthorities in England (Source for data: Marmot Review Team)

In the next chapter we explore the evidence base for addressing the socialdeterminants of health and reducing inequalities, we report on actions we havealready taken in Sandwell and make recommendations for future actions.

g g Disability Free Life Expectancy information should be utilised to target social researchactivity in communities with the poorest DFLE to further understand their behaviour in

relation to healthy lifestyles and identify strategies for promoting change.

g Sandwell Public Health Directorate g Sandwell MBC


24

Moving public health to the local authority will provide us with theopportunity to address the issues that can make the biggest difference totackling inequalities. Whilst the PCT has an active programme to addressthe inequalities in life expectancy between Sandwell and England throughthe strategic plan10, and this will indeed result in improvements to lifeexpectancy, they are largely a health service response to tackling theseinequalities. In order to make a real and sustained impact on inequalitiesin life expectancy, we must also reduce the gap in the social determinants.

We will need to do things differently and we now have that opportunity.We will be working alongside our colleagues who shape: the towns andbuildings we shop, live, work and spend our leisure time in; who ensurethe education of our children; who help us to find work and look after us intimes of need. These are the things that will make the difference to howlong and well we live. Working alongside our colleagues, public health canidentify those in greatest need, we can provide the evidence for the bestinterventions and we can help to measure their impact. The potential toreduce inequalities is real. However this will require commitment acrosshealth, wider public services, voluntary and community groups and thecommercial sector. Tackling inequality is everyone’s business.

In this chapter we explore how we can make reducing inequalities a reality.

How are we addressingthese inequalities inSandwell?In addition to making recommendations on theten inequalities indicators, as reported in the lastchapter, the Marmot Teview team alsorecommend six key policy objectives to addressinequalities:

• Give every child the best start in life• Enable all children, young people and adults to

maximise their capabilities and have controlover their lives

• Create fair employment and good work for all• Ensure a healthy standard of living for all• Create and develop healthy and sustainable

places and communities• Strengthen the role and impact of ill-health

prevention

Each of the six policy objectives will now beexplored in more detail, providing the evidencefrom the Marmot Review, progress we havealready made against them and further actions weneed to take.


Sand

wel

l - D

irec

tor

of P

ublic

Hea

lth

Ann

ual R

epor

t 201

0/11

25

There is a growing body of evidence showing theimportance of the first years of a child’s life. Forexample, a lack of appropriate stimulation andexperiences during the first year can influence achild’s brain development and their subsequentcognitive development. A child from adisadvantaged family is less likely to be read toregularly, less likely to have a regular bed timeand more likely to have a mother who isdepressed.

An important factor thatinfluences how well a childdoes in their education istheir ability to learn, theircognitive ability. Evidencefrom the Marmot Reviewshows that those childrenwith a high cognitive abilityat 22 months but withparents of low socioeconomic status do less well(in terms of subsequentcognitive development) thanchildren with low initialability but with parents ofhigh socioeconomic status.This is shown in Figure 1; Qrefers to the child’s cognitiveability.

A child with a lower cognitive ability at 22months but born to wealthy parents can overtakea child with a higher cognitive ability born toworse off parents. Addressing this inequality isreliant on families having access to high qualityearly years education. The responsibility for thissits within the local authority. Public health canprovide support for local authorities to ensurethat provision is evidence based, effective andreaches the most vulnerable families.

Give every child the best start in life

Figure 1. Inequality in early cognitive development of children in the 1970British Cohort Study, at ages 22 months to 10 years (Source: Fair Society,Healthy Lives (2010))


Enable all children, youngpeople and adults to maximisetheir capabilities and havecontrol over their livesResearch has shown that anindividual’s educationalachievement is one of the bestpredictors of their long-termhealth and life expectancy11. Agood education helps people toachieve their potential in life.Without this they are far lesslikely to have a good job, theyare likely to earn less, have ashorter lifespan and spend moreof their life ill or in disability.

Inequalities in educationalachievement mirror theinequalities in health and haveproved to be as difficult totackle. Figure 2. Life limiting illness rates at ages 16-74 by education level

(2001) (Source: Fair Society, Healthy Lives)

26

Sandwell achievements to date• The Good Start to Life programme is a partnership based programme to give all children and

families the best start in life. This addresses both the health determinants such as breastfeeding and maternity services and the social determinants of health such as housing.

• Sandwell Council is leading an Early Intervention and Family Support programme. Thisprovides coordinated support for the most vulnerable families. This has been identified as apartnership priority by the Health and Wellbeing Board.

• A Family Nurse Partnership initiative led by health services is supporting over 100 vulnerablefamilies with coordinated partnership support.

• Developing a coordinated approach to early intervention with families with complex needshas been identified as a key priority by the new Health and Wellbeing Board.

g g Develop evidence based parenting programmes

g Sandwell Public Health Directorate g Sandwell MBC, Education


Sand

wel

l - D

irec

tor

of P

ublic

Hea

lth

Ann

ual R

epor

t 201

0/11

27

It is important to recognise that a child ispart of a family and that the family has asignificant influence on educationalattainment. Schools need to work withfamilies and communities in an extendedschool approach if they are to contribute totackling the social determinants of health.

Education should not stop when a youngperson leaves full time education. Life-longlearning enhances people’s ability to secureemployment opportunities and improvepersonal well-being. This needs to beavailable across the social gradient, howeverthere also needs to be targeted action tosupport vulnerable groups to gain literacyand other basic skills. Learning in older ageis also important, it can help people stayindependent for longer and improve theirability to care for their own needs.

For people of all ages, including people withlong term conditions, disabilities and thosewho care for others, to have control overtheir lives they need to have the knowledge,skills and capacity to manage their own livesand their health. A good quality educationwill provide the basis for developing these.Local services must also be designed tosupport people in managing their own livesrather than creating dependence. This is a‘self care’ based approach which builds onpeople’s and communities’ strengths12. Thisfits well with the personalisation approachand individual budgets, providing peoplewith the means to have real choice over theservices they use to maintain independenceand well-being.

Sandwell achievements• Sandwell schools are working in Core Offer Partnerships

(CoOPs) which provide access to a wide range of servicesfor Sandwell families.

• There have been real successes in improving educationalachievement for young people in Sandwell. There hasbeen an improvement in the proportion of pupils whogained 5 or more A* to C GCSEs including english andmaths. In 2005/06 this was 29.7%, by 2009/10 this hadincreased to 43.6%. This reduced the gap betweenSandwell and national levels from 15.9% to 9.8%13.

• A self care approach is central to Sandwell Council’sprevention strategy. Self care is being developed acrosscouncil, health and third sector organisations throughthe Right Care Right Here programme.

• Sandwell council and health services have demonstrateda joint commitment to supporting carers with jointstrategy and funding for carers support programmes.Carer support is included within the council scorecard formeasuring excellent council performance.

g Bring educational attainment in Sandwell up to the national average

g g Ensure schools continue to take a ‘whole child’ approach including working withfamilies in the community

g Sandwell Public Health Directorate g Sandwell MBC, Education


28

Create fairemployment andgood work for allWorking is good for you; the benefitsarise from the income thatemployment provides and from thepsychological benefits that a job canbring. These include the socialinteractions, structure to daily life andsense of purpose that a job provides.However, having a low paid, insecurejob where an individual has littlecontrol over their work can causestress and have a detrimental effect onhealth14.

Conversely the consequences ofunemployment on health aresignificant. A person who isunemployed for more than a fewmonths is more likely to experiencedepression. They are also more likelyto have unhealthier lifestyles and aremore prone to physical illness. Beingunemployed can lead to poor healthand poor health can lead tounemployment15.

Figure 3 shows the proportion of theworking age population claimingJobseeker’s Allowance in Sandwellcompared with the West Midlands andGreat Britain. This shows thatunemployment in Sandwell follows thenational and sub-national trends butSandwell has significantly higher levelsof unemployment.

Figure 3: Job Seekers Allowance claimants 2008 to 2011(Source: Sandwell Trends)

Sandwell achievements• The regeneration of West Bromwich and the

development of a new supermarket will provide localjobs. This regeneration has been awarded £4.2 millionfrom the European Regional Development Fund. Thisincludes a new British Telecom call centre which willprovide 450 jobs.

• Route ways to NHS and Social Care Careers, with publichealth in a key role, has helped 114 people intoemployment in the NHS and other public sectoremployers.

• Find It In Sandwell is a council supported businessdevelopment community. This provides support to localbusinesses in finding suppliers and customers within thelocal area.

• Think Local is a council provided service which placesmore than 80 young people into work based trainingand 200 local people in employment in the constructionindustry each year.

• 38 young people who were long term unemployed arenow in apprenticeships in the health service.

• Public Health has worked with Sandwell Council todevelop the Fit for Work Pilot that provided earlyintervention with working people at risk ofunemployment due to ill health.

g * Support employers with ensuring that they have a healthy workforce throughlifestyle programmes and the prevention of physical and mental health problems at work

g Provide support to people at risk of unemployment through ill health

g Provide lifestyle support and health care to help people return to work after ill health

g Public Health with employers *especially public sector employers


Sand

wel

l - D

irec

tor

of P

ublic

Hea

lth

Ann

ual R

epor

t 201

0/11

29

There are groups within society thatare more at risk of experiencingpoverty. These include disabled adults,people with mental health problems,carers, lone parents and youngpeople. Ethnicity can also be a factor,40% of Bangladeshi and Pakistaniworking couples with children are onmeans-tested benefits compared with8% of white families.

Poverty is closely linked toemployment status and health. Morethan two fifths of adults aged 45 to 64on below average incomes have alimiting long standing illness ordisability, this is more than twice therate for those on above averageincome. Having a low income anddebts is also related to an increase indepression and anxiety and othermental health problems17.

It is possible to be in employment andstill be in poverty. This can be due to alow income or from extra pressures onthis income. Figure 4 shows theaverage pay for people in Sandwellbetween 2000 and 2010 compared tothe West Midlands and Great Britain.This shows that the average weeklypay in Sandwell has been consistentlylower than both the West Midlandsand Great Britain. Since 2008 the gaphas been widening with the pay inSandwell decreasing against continued

increases in otherareas.

Sandwell achievements• The Welfare Rights service has helped local

people claim over £40 million in additionalbenefits over two years.

• Sandwell Council and partners, includingpublic health, have developed the Friendsand Neighbours project. A community basedproject that builds on existing communityinvolvement to support vulnerable residentsand improve the capacity in the communityto improve the neighbourhood and improvehealth and wellbeing.

Figure 4: Average weekly pay in Sandwell for all full time workerscompared to the West Midlands and Great Britain (Source: ONS)

g g g g Ensure all partners are engaged in the development and delivery of theFriends and Neighbours project

g Primary Care g Sandwell MBC g Voluntary Sector g Businesses

“ “Ensure a healthy standard of living for all

Having resources that are so seriously below thosecommanded by the average individual or family thatthey are, in effect, excluded from ordinary livingpatterns, customs and activities16.

Professor Peter Townsend defined poverty as;


30

Create and develophealthy and sustainableplaces and communitiesThe environment in which people are born andlive, affects their health and wellbeing. Poorurban design, with poor air quality,environmental contamination and noisepollution, can affect how people feel about theirarea and can have an adverse effect on mentaland physical health18, 19.

Climate change is one of most significant publichealth challenges for the future and will have adisproportionate impact on the poor andvulnerable. The measures needed to minimiseclimate change are entirely compatible with themeasures required to reduce healthinequalities. These two challenges must be seenas inextricably linked and the approaches takento tackle them together coordinated.

People living in a deprived area are more likelyto experience poor environmental quality. Thereis also growing evidence that they can be moresusceptible to its effects. This is particularlyrelevant for Sandwell which experiencessignificant deprivation and has over half of itspopulation living close to an industrial process.This was discussed in more detail in theSandwell Annual Public Health Report for2009/10.

There is strong and developing evidence for thehealth benefits of green spaces. Having accessto a green space is associated with lower healthinequalities20. It can also play a part in tacklingobesity, cardiovascular disease, mental healthand antisocial behaviour21. Within Sandwell 24%of the area is green space and Sandwell Council

has developed a green space strategy tomake the most of these assets22.

Sandwell achievements• Sandwell council has invested in improving the

green space within the borough. Seven ofSandwell’s parks now have the Green Flagaward, including the first cemetery in the WestMidlands to receive this award.

• SHUDU has been recognised nationally as anexample of good practice in joint working onthe social determinants of health by theMarmot Review group24, the Local GovernmentGroup25 and the Royal Town Planning Institute26.

The living environment, people’s houses, can alsoaffect health. A cold and damp house can lead to anincrease in respiratory disease and increase the riskof heart attacks and strokes. Overcrowding and poorquality housing can have a negative impact onmental health23. An individual on a low income ismore likely to live in poor housing which is alsoenergy inefficient and expensive to heat. People witha low income are therefore at a greater risk of beingin fuel poverty.

Alongside these direct effects, the environment canalso have an indirect health impact through itsinfluence on behaviour. The lifestyle choices peoplemake have a major influence on their health, forexample, choices about smoking, levels of physicalactivity and healthy eating. Over the past decadethere has been considerable focus in national healthpolicy on helping people to make healthier choices asa way to improve population health.

Sandwell Healthy Urban Development Unit (SHUDU)is a partnership group with a membership thatincludes public health and council departments suchas urban planning, transport, environmental healthand community agriculture. SHUDU provides anexample of how public health can engage with awide range of council services to tackle the socialdeterminants of health and to create environmentsthat make healthy lifestyle choices easier.

g g Prioritise policies that tackle both health inequalities and climate change including,increasing active travel (walking and cycling) and increasing accessibility to green spaces

g g Improve the food environment for communities, including community agriculture,controlling the introduction of fast food outlets and improving the quality of fast food

gImprove energy efficiency of housing

g SHUDU g Sandwell MBC g Businesses g Sandwell MBC, Housing & Partners


Sand

wel

l - D

irec

tor

of P

ublic

Hea

lth

Ann

ual R

epor

t 201

0/11

31

Strengthen the roleand impact of ill-health preventionIt is important to continue to work withpeople to prevent ill health, to help peoplechoose and maintain healthier lifestyles.The focus on this to date has been onhealth services providing health promotionand lifestyle services and this has been ledby, and will continue to be led by publichealth. However, for this to have the largestpossible impact it needs to ensure thatevery front line contact with the public isseen as an opportunity for ill-healthprevention and health promotion. Thelargest number of such contacts is withinlocal authority services. The movement ofpublic health into the local authoritytherefore provides excellent opportunitiesto develop ill-health prevention across allrelevant services.

This role of the public sector as a majoremployer must also be recognised. Allpublic sector organisations must commit tointroducing policies and initiatives toimprove the health of their workforce. Thiscan include initiatives to encourage staff toincrease physical activity, to stop smokingand to eat a healthy diet. Examples includeprogrammes to support staff in adoptingcycling and walking and to use the stairsinstead of lifts.

Existing programmes working with otheremployers from the private and voluntarysectors need to be developed. Theseprogrammes need to help these employers

to ensure they have a healthyworkforce.

g g g Ensure additional funding for preventative interventions above the 4% ring-fenced budget for public health

g g g Work with the NHS Commissioning Board and Clinical Commissioning Groups toidentify those most at risk of ill-health and ensure they receive appropriate preventative care

g Ensure that every contact with the public is used as an opportunity for health promotion

Sandwell achievements• Through screening, 2,000 people have received

treatment to reduce their risk from cardiovasculardisease (CVD), 1,000 from diabetes, 500 from heartfailure and 1,000 from chronic obstructivepulmonary disease (COPD).

• Smoking cessations services have helped 5741people to quit over the last 3 years

• Lifestyle services have helped 19,000 people to getor keep active and 7,000 eat healthily

g Sandwell MBC g Clinical Commissioning Consortia g NHS Commissioning Boards g Sandwell Public Health Directorate

g All partners, especially SWBH & SMBC

Local residents Adrian and Patricia who featured in our“United we quit smoking” campaign December 2010.


32

DiscussionIt is the social determinants of health that have thegreatest influence on the health inequalities thatexist within Sandwell and between Sandwell andthe rest of England. The inter-relationships betweenthese determinants are complex, for example therelationships between education, employment,poverty and their effects on health.

These determinants act across the whole life course.What happens in the first few years of life affects anindividual’s life chances through education, intoemployment and for the rest of their life. This has adirect impact on their physical and mental healthand their life expectancy.

A key message is that deprivation and povertyconstrain people’s choices and opportunities. Forexample, the physical environment can limit thechoices available for a healthy lifestyle. Choice hasbeen a recurrent theme across national healthpolicy for the past few years. However, having achoice is meaningless if this does not come with theopportunities to exercise it.

The evidence for what will make a difference to thesocial determinants of health is comprehensivelyexplored in the Marmot Review of HealthInequalities. This review shows what needs to bedone at a national policy level down to local areasand communities. What is clear from this evidenceis that the health service on its own can only have avery limited influence. Within the public sector it isthe local authority that can have the greatestimpact on the social determinants of health.Another key message is that many of the changeswill take time and consistent efforts and investmentacross the public,voluntary and communityand commercial sectors.Tackling healthinequalities is everyone’sbusiness.

In conclusion, a final quotefrom Professor Sir MichaelMarmot, author of theMarmot Review.

People with higher socioeconomic position insociety have a greater array of life chances andmore opportunities to lead a flourishing life. They

also have better health. The two are linked: the morefavoured people are, socially and economically, the bettertheir health. This link between social conditions and healthis not a footnote to the ‘real’ concerns withhealth – health care and unhealthy behaviours –it should become the main focus. Professor Sir Michael Marmot, Author of theMarmot Review, December 2010

“ “Public Health Annual Report 2010/11_Prt1 26/01/2012 15:09 Page 32

Sand

wel

l - D

irec

tor

of P

ublic

Hea

lth

Ann

ual R

epor

t 201

0/11

Lifestyle services forpeople in social care –improving health andmanaging demand

4

Author: Susan Roberts (Specialist Registrar in Public Health)

33


IntroductionLocal authority adult social services aim tosupport vulnerable adults. Vulnerable adultscan be broadly categorised into those withlearning or physical disability and those withmental health issues or drug and alcoholaddictions27. There were 1.8 million socialcare clients in England in 2007/828.

Many social service users (although not all)have long term conditions29. Long termconditions can be the cause of the disabilitythat has lead to social service involvement oras a result of being a vulnerable adult (asdescribed above) an individual may be athigher risk of developing long termconditions30. The relationship between socialneed and long term condition developmentcan potentially lead to a downward spiral ofever increasing social and health carerequirements. Conversely, a reduction insocial need through intervention or proactivemanagement of a long term condition canlead to reduced disability and social andhealth care requirements. Lifestyleintervention for those in social care is apotentially cost effective way of achievingthis.

In this chapter we aim:

1. To establish the number of peoplereceiving social care that might benefitfrom lifestyle services.

2. To discuss approaches to increaseuptake of lifestyle services by peoplereceiving social care.

34


Sand

wel

l - D

irec

tor

of P

ublic

Hea

lth

Ann

ual R

epor

t 201

0/11

Table 1 - Lifestyle services offered by Sandwell Primary Care Trust

Domain: Physical Activity

Sandwell stride

Cycling Development

Walkwell (Walk Beijing to London):Walking based programme

Active lifestyle*: neighbourhoodactivities during evenings andweekends in open spaces

Active Sandwell: gentle exercise classes

Physical activity referral: 12 week program(Exercise on Prescription) for those withmodifiable risk factors

Physical activity referral (mental health)*:16 week programme and one-one supportin mainstream sessions. CPN referrals

Walk from home: Small scale home-basedbespoke programme of walking for peoplewho are housebound and at risk of falling

Cardiac rehabilitation:Includes holistic assessment (aswell as physical activity) withsignposting to other specificlifestyle interventions

Pulmonary rehabilitation:Includes holistic assessment (aswell as physical activity) withsignposting to other specificlifestyle interventions

Domain: Healthy EatingGrow well*: occasional sessionsbased on allotments and encouraginghealthy eating

Shop well*: tours aimed at increasingunderstanding of healthy eating

Cook well*: 6 week health cookingcourse. Some clinical exclusions

Domain: Smoking CessationStop smoking: one-one and groupinterventions

Domain: AlcoholAquarius: one-one, telephone andgroup interventions

Domain: Integrated Multiple Intervention ServicesSlimwell: 20 week programmeincluding weight management, foodawareness and physical activity +ongoing advice on completion

Fab tots

Well fit: Child weight management

Health trainers CVD prevention andscreening: one to one assessments forthose with a medium risk of developingcardiovascular risk, who have beenidentified by GPs, primary care CVDscreening, workplaces or othercommunity assessments

Expert patient programme

Universal 6 Targeted Primary Prevention 6 Secondary Prevention 6

Domain: Mental Health

Confidence and well-beingprogramme: One to one and groupinterventions designed to improveconfidence and well-being

35


There arepotentially4,000 adultsocial careclients whomight benefitfrom lifestyleinterventionsSandwell Council is responsiblefor the social well-being of itsresident population. Thiscomprises of a population of292,800 people, of whom234,600 are over the age of 15years old31. Each year,approximately 5% of those aged15 years and over require inputfrom Sandwell Adult SocialServices. In the 2009/10financial year, 11,630 clientsreceived social servicesprovided or commissioned bySandwell Adult Services. Themajority of adults requiringsocial services had a physicaldisability (Figure 1).

Social services can be categorised intocommunity based service and residentialand nursing care. The majority of clientsreceived community based services(Figure 2). (Source: SWIFT database,Sandwell MBC)

Figure 1. Indications for accessing adult social care, 2009/10 (Source:SWIFT database, Sandwell MBC)

N.B.Mental health figures included in the graph are of people with mentalhealth issues supported by social services commissioned by the MentalHealth Trust and not the local authority.

36


Sand

wel

l - D

irec

tor

of P

ublic

Hea

lth

Ann

ual R

epor

t 201

0/11

37

Figure 3 Types of social carereceived by community - basedclients in Sandwell, 2009-10(Source: SWIFT database,Sandwell MBC)

Clients receiving community based services arethe most likely to benefit from PCT lifestyleservices as they are likely to be relatively mobileand independent. There were 10,050 Sandwellresidents who received community basedservices during the 2009/10 financial year. Clientsin a 24 hour nursing care setting are unlikely to besuitable for lifestyle intervention as theirrequirement for 24 hour nursing care implies alevel of dependence that would make themunlikely to be able to undertake suchintervention. However, they might potentiallybenefit from peripatetic lifestyle services in thefuture or from physical activity interventionprovided by the home. There were 1,205 peoplein residential care in Sandwell during the 2009/10financial year.

There are a wide range of community basedservices offered by the local authorities (Figure

3). Many clients may have received more thanone type of service and therefore may be double-counted in the information displayed in Figure 4.Many clients receiving equipment or adaptationsmay receive more than one item of equipmentand they have only been counted once as shownin Figure 4. The number of clients that maypotentially be able to engage in lifestyleinterventions is not clear from this informationalone. Some clients that received equipmentmight have severe disabilities that prevent themto engage in lifestyle interventions (for example,those that are chair bound and have receivedhoists). However, someone that has only receiveda small item of equipment might benefit greatly.Furthermore, a patient receiving help cleaningthe house once a week is more likely to be able toengage in lifestyle intervention than a clientreceiving three carer visits a day to assist in allactivities of daily living32.


38

How can we increase theuptake of lifestyle servicesamongst adult social serviceclients?There are many potential opportunities for lifestyleinterventions during a person’s progression throughsocial services.

Of the clients receiving equipment in 2009/10, 4000 people received only one item ofequipment and no further input from social services. These people might beconsidered to be the most able to benefit from receiving social services in Sandwelland the most likely to undertake lifestyle interventions.

The 950 people that attended day care may also be suitable candidates for lifestyleinterventions, however, they may well have already been accounted for by one of theother categories. In addition, some clients receiving homecare might be suitable forlifestyle interventions depending on the intensity of care they are receiving (Figure 4).Of the clients receiving home care, 241 received up to five visits of up to 2 hoursduration, these clients might be considered most suitable for lifestyle intervention.Again, however, these clients might have also ordered equipment and therefore mighthave already been accounted for within the ‘equipment and adaptation’ numbers. Weare therefore perhaps best to estimate that 4000 people receiving community basedsocial services might benefit from lifestyle interventions. This accounts forapproximately a third of those receiving adult social services in Sandwell.

Figure 4.Breakdown ofSandwell adultservices homecare byfrequency andlength of visits(Source: SWIFTdatabase,Sandwell MBC)


Sand

wel

l - D

irec

tor

of P

ublic

Hea

lth

Ann

ual R

epor

t 201

0/11

39

Figure 5.Potentialopportunitiesfor lifestyleinterventionsfor socialservice users

Possible scenarios1. A person applies to social services for seat raisers to improve mobility whilst standing from

a chair. Part of the application process could involve a questionnaire regarding lifestylesuch as smoking/alcohol (perhaps in association with the explanation that smoking andalcohol consumption increase risk of fall-related injury). This person could be signposted toexisting lifestyle services such as physical activity programmes (EXTEND/Walk from Home),stop smoking and Aquarius.

2. A person attending a day centre could perhaps be asked regarding their lifestyle onregistering at the day centre for the first time. There could be posters up in the day centreadvertising existing services. Physical activity interventions could be arranged in the daycentre.

3. A person applying for homecare could be asked regarding their lifestyle. They might behousebound and still smoking. Smoking will be putting them at increased risk ofosteoporosis and may be worsening a long term condition. They can’t attend a clinic, butthey might be able to receive support over the telephone and have any necessaryprescriptions sent in the post. In addition they might be overweight and healthy eatingsupport over the telephone might also be of benefit.

4. A residential home client might have moved into a home as they are no longer able to cookfor themselves and they have had previous falls. These people might be able to benefitfrom postural stability exercises to prevent more falls in the future.

24 hour nursingcare

24 hour residentialcare

Home care

Equipment/adaptations

Meals Day care

Client progressionthrough social services

Opportunities forlifestyle intervention

Opportunities forlifestyle intervention

Physical activity;smoking cessation

(healthy eating,alcohol)







alcohol

Physical activity;smoking cessation,

healthy eating,alcohol


PCT lifestyle services cannot currently cater for those who are housebound, althoughthey can cater for those who are sufficiently mobile to attend day centres. The use oflocal authority venues might increase uptake of lifestyle services by people in socialcare. In some cases, specific lifestyle services might not be appropriate in particularsocial circumstances. For example, does a person who receives meals from socialservices require healthy eating advice? The answer in particular cases might be yes,depending on the number of meals a day they are receiving and the reasons behindwhy they are unable to cook for themselves. Of the people who are housebound, somemight be able to benefit from healthy eating, smoking cessation or alcoholconsumption advice by telephone.

People who live in residential care might be able to benefit from physical activityprogrammes (and to a lesser extent, smoking and alcohol advice) if they were held attheir residence, but again this would depend on the specific physical or learningdisability or mental health issue that lead them to require residential care. It mighttherefore be beneficial to contact residential care settings in order to establish anestimate of the number of residents that might benefit from a peripatetic lifestyleintervention.

Sandwell PCT has a falls and bone health strategy, which calls upon a multidisciplinaryeffort to reduce falls and fall related injuries and has involved liaison with residentialhomes. Through this work, it was ascertained that although some care homes have

activity coordinators, they willgenerally arrange seated exerciseinterventions, if any at all. Homeswere reluctant to provide more activeforms of exercise due to lack of staffmembers being available to preventfalls during the intervention andtherefore the evidence of overallbenefit is lacking. However, posturalinstability instruction has been avalidated intervention for fallsprevention. Currently there are nocare homes in Sandwell that havepostural instability instructors andfunding into this area might be worthexploring. There are over 40 homes inSandwell, so a peripatetic posturalinstructor service might not be viable.However, it might be possible to fundthe training of specific members ofcare home staff to become posturalinstability instructors as analternative33, 34.

40


Sand

wel

l - D

irec

tor

of P

ublic

Hea

lth

Ann

ual R

epor

t 201

0/11

In addition, it is imperative that cases are assessedon an individual basis, perhaps as part of apersonalised care plan (personalised care plans arebeing actively encouraged by the Department ofHealth for people with long term conditions). Theprofessionals responsible for compiling thepersonalised care plans therefore need to beaware of the lifestyle interventions available withinthe PCT and the activities they involve. There alsoneeds to be a clear referral pathway into lifestyleservices from social care in order for social servicesstaff to be confident in signposting to lifestyleinterventions. Sandwell PCT has already developeda ‘one number’ system, through which people canself-refer or be referred by their GPs to the lifestyleservices and can be triaged to the mostappropriate lifestyle service. This number needs tobe systematically circulated amongst social servicestaff as well as mental health and rehabilitation(occupational therapy and physiotherapy)professionals if this is not already the case. Socialcare staff might not currently feel confident inaddressing lifestyle issues. Indeed the NHS‘Making Every Contact Count’ initiative is aimed atencouraging both NHS and non-NHS staff to bemore confident in addressing lifestyle issues andhas provided an e-training tool that might beuseful for encouraging social service staff toaddress these issues during social serviceassessments35.

Finally, even more people would be able to benefitfrom lifestyle services if there were services thatspecifically catered for either physical or learningdisabilities or mental health issues. IndeedSandwell PCT already offers an integrated lifestyleintervention for people with mental health issuesand this category of specialist lifestyle intervention

could be expanded (Table 1).

g Further develop our understanding of social care clients who might benefit from lifestyleinterventions and how they might benefit, including telephone interventions

g Survey community social care clients to explore the needs/demand for lifestyle services andhow and where they should be deployed

g Undertake a needs assessment for peripatetic postural instruction

g Ensure that lifestyle assessment is a core part of the initial social services assessment

g Social care staff should be trained in addressing lifestyle issues with clients through the ‘Every ContactCounts’ programme g The range of lifestyle services offered to people in social care settings and to vulnerable adults, such asthose with mental health problems or learning disabilities, should be expanded

g Public Health and Adult Social Care g Sandwell Public Health Directorate

41


Understanding winterpressures - across thehealth and social careboundaries

5

Author: Jyoti Atri (Deputy Director of Public Health)

42


Sand

wel

l - D

irec

tor

of P

ublic

Hea

lth

Ann

ual R

epor

t 201

0/11

The burden of winter

Almost as predictably as the changing of the seasons, each year we see an increasein the number of deaths during the winter months (December to March),accompanied by a corresponding increase in illness manifested by increasedattendance at GP surgeries and a rise in emergency admissions to hospital.Research has suggested that for every excess winter death there are 8 hospitaladmissions and 100 consultations with the GP36. This in turn places a burden on oursocial care services which provide essential support to health care services andfacilitate people in staying out of, or leaving hospital at an appropriate time.

For the first time we have reviewed social care data alongside health care data for2010/11, to better understand these seasonal changes and to highlight potentialareas of collaborative action to reduce these winter burdens. This is the first step inunderstanding what happens across the health and social care boundaries. There ismore to know and to increase our understanding we need to be able to trackpeople across health and social care through data linkage and ideally the use of aunique identifier. This will allow us: to take stock of the range of services anindividual benefits from; identify those at greatest risk of dying or needingunplanned hospital or social care services during winter and offer thempreventative services and to evaluate the impact of any interventions.

43


44

In the West Midlands the largest contributors indisease terms are circulatory diseases, accounting for1,100 excess winter deaths across the region between2002 and 2007, followed by 927 respiratory deathsduring the same period37. Influenza also plays a part inincreasing winter mortality; however it is not usuallyrecorded as the primary cause of death.

The external temperature is a risk factor for excesswinter deaths38, however the relationship is notstraightforward, as countries with warmer winters(Portugal and Spain), have higher excess winter deathsand Scandinavian countries, with colder winters, havelower excess winter deaths. The authors of theEurowinter study put forward potential explanationsfor this which include: the colder the country the morehouses are designed to withstand cold and peopledress more appropriately for the cold in coldercountries.

Demographic characteristics also have a role to play inwinter deaths with female gender, older age,increasing risk of dying in winter. Lone pensioners arealso at increased risk of unexpected death during thewinter months39,40. No relationship betweensocioeconomic status and excess winters deaths hasbeen demonstrated41. This may be because peoplefrom lower socioeconomic groups are more likely tooccupy social housing which tends to be warmer thanprivate sector or owner occupied housing. Fuelpoverty (defined as more than 10% of the householdincome being required to maintain a comfortable levelof warmth) may affect those who may be from highersocio-economic groups during retirement, as they mayoccupy larger, older homes that may not be energyefficient.

The key role that housing has to play in excess winterdeaths and morbidity, has been well documented andis summarised in the recent Marmot reviewcommissioned by Friends of the Earth and entitled TheHealth Impacts of Cold Homes and Fuel Poverty42.Further to the risk factors noted above, this reportalso highlights the impact of cold homes: on children,who are also more likely to suffer from respiratoryproblems; on mental health at all ages and on existingconditions such as arthritis and rheumatism. Thereport also makes note of the indirect impacts of coldhomes and fuel poverty including dietaryopportunities and increased risk of accidents in thehome. Locally we are exploring the link betweenimproved housing conditions and health and this workis described in Chapter 6.

The causes of theseseasonal increases aremultiple and complex


Sand

wel

l - D

irec

tor

of P

ublic

Hea

lth

Ann

ual R

epor

t 201

0/11

45

Increasing pressure on health and social careservicesAdditional to these seasonal variations, there are factors that may lead to further pressureson both health and social services, which will impact through out the year but may peak atwinter time. People in Sandwell are living longer than before and this trend is predicted tocontinue. There are currently estimated to be 46,300 people aged 65 and over in Sandwelland this is predicted to rise to more than 58,000 people by 203043. The percentage growth inthe very elderly, those aged 85 and over, is even starker. This group is predicted to increasefrom 6,100 in 2010 to more than 10,000 in 2030.

The worsening economic environment will also impact on need during winter, risingunemployment together with forthcoming benefits changes and fuel price increases willimpact on people’s ability to heat their homes to an adequate standard and this will in turnlead to more illness and deaths during winter. In addition health and social care services arefaced with meeting these increasing needs, with reducing budgets.

Figure 1. Monthly deaths and temperature, winter 2010/11 for Sandwell PCT (Source: ONS Monthly deaths).

Winter deaths 2010/11The chart below shows the number of Sandwell residents who died per month during theperiod where excess winter mortality is recorded (also a 5 year monthly average). The chartalso shows the monthly temperature; for the months of 2010/11 and the monthly 5 yearaverage.

Despite unusually cold months in November and December, corresponding increases inmonthly winter mortality were not witnessed in December and January (based on preliminarydata, official statistics are released in autumn 2012). This may be due to investment in‘Sandwell Homes’, Sandwell’s largest social housing provider, bringing all ‘Sandwell Homes’ upto the ‘Decent Home’ standards44. The work described in Chapter 6 will explore this further.


Seasonal variations in emergency admissionsData on emergency admissions is presented in the next series of graphs. Average admissionsper day are presented to adjust for variations in the number of days in each month. Monthlybreakdowns of emergency admissions to hospital show an increase in admissions,particularly in February. In line with the lower than average temperatures in the winter of2010/11, there is a corresponding higher than average number of admissions.

Examinations of admissions by ICD 10 chapter groupings (a way of categorising diseases)shows more seasonal variations for certain disease groups. A breakdown of the individualdiseases in the ICD -10 classification can be found on the accompanying CD. Unsurprisinglydiseases of the respiratory system show the biggest increase in the December to Marchperiod, these too were higher in 2010/11 compared to the previous 4 years. Diseases such asinfluenza, pneumonia, acute and chronic lower respiratory diseases and lung disease due toexternal agents, are included in the respiratory category.

Figure 3. Average emergencyadmissions per day – J00-J99diseases of the respiratorysystem, 2010/11 (Source:Provider data received via SUS)

Figure 2. Averageemergency admissions perday (Source: Provider datareceived via SUS)

46


Sand

wel

l - D

irec

tor

of P

ublic

Hea

lth

Ann

ual R

epor

t 201

0/11

Diseases of the circulatory system (this includesheart disease and strokes) did not show a peak inthe winter months and this winter, admissionswere slightly lower than last 4 winters. This maybe due to a downward trend in admissions forcirculatory diseases.

Figure 4. Average emergency admissions per day –I00-I99 Diseases of the circulatory system, 2010/11(Source: Provider data received via SUS)

Seasonal variations in admissions for fracturedfemur are also expected due to the higherlikelihood of falls in icy conditions. There was apeak in emergency admissions for fracturedfemurs in December and these were higher thanthe average for the last four Decembers.

Figure 5. Average emergency admissions per day –S72 Fractured Femur (Source: Provider datareceived via SUS)

Seasonal variations in delayed transfers of careThe relationship between winter pressures and delayed transfers of care is complicated. Due tothe increased pressure on acute services there is an imperative need to ensure that people aredischarged appropriately and in a timely fashion. However due to the increased pressure on socialcare services, there may not be appropriate places available to discharge people to. The data ondelayed transfers of care shows an increase during late November and early December, due todelays attributable to social services, although numbers are small.

Figure 6. Delayed transfers of care for acute admissions, Sandwell and West Birmingham Hospitals NHS Trust (Source:Sandwell and West Birmingham NHS Trust)

47


Understanding social care use The social care data used in this report is drawn from the ‘SWIFT’ database which is used forboth operational management and performance monitoring. The database does not includedata on equipments used nor does it contain data relating to acute mental health activity for 18-64 year olds.

During the year 2010/11, there were 2536 people that started a social care service. Some ofthese people were already receiving social care support at the time of the new service. Anumber of people received more than one new service during the year and a total of 3597services began. Analysis of referrals to social care shows that secondary care (hospitals) is thesecond highest source for referrals.

Seasonalvariations insocial serviceuseIn line with rising demand foracute health care servicesduring winter and the increasein delayed dischargesattributable to social servicesduring November andDecember, a correspondingrise in new services startersmight be expected. Instead theincrease in new starterscorresponds more with the endand start of the financial year.A potential explanation for thisis that people leaving hospitalmay first go into intermediatecare for several weeks and thengo into social care and hencethose leaving hospital inDecember or January, may notenter social care until March orApril. Examination of newservice started to facilitatehospital discharge also do notshow an increase in the wintermonths but there is a rise innew services started to preventhospital admission in January,February and March. There arehowever small numbers inthese categories.

Figure 7. Number of social care contacts by source of referral, 2009/10 (Source:‘SWIFT’ database, Sandwell MBC)

Figure 8. Number of social care services started by month (Source: ‘SWIFT’database, Sandwell MBC)

48


Sand

wel

l - D

irec

tor

of P

ublic

Hea

lth

Ann

ual R

epor

t 201

0/11

Figure 9. Numberof social careservices started bymonth, to facilitatehospital dischargeor prevent hospitaladmission

Demographic analysis of social care use andunplanned admissionsThere were 6,426 people that received a care managed social care service during 2010/11 (this doesnot include equipment or services provided by the Mental Health Trust), accounting for 9,077 servicesreceived. Older people account for the largest client group, with numbers increasing with age. Thoseaged 85 plus, account for the majority of service use although they make up the smallest proportion ofthe population. Females outnumber male service users and this increases with age with a ratio of morethan 3 to 1 in the over 85’s age groups. Whilst there are differences in the age structure between malesand females in the population, with more females in the 75-84 and 85 plus categories, this does notfully account for the differences, as a higher proportion of women aged 85 plus are services users thanmen in the same age group. One possible explanation for this is that elderly women are more likely tobe living alone as they are more likely to outlive their male partners. This requires further investigation.

In total 48% of unplanned admissions in those aged 65-74, 52% in those aged 75-84 and 64% in thoseaged 85 and above, are attributable to women. This variation in unplanned admissions by gender is areflection of gender differences in these age groups in the population. There are large genderdifferences, which increase with age, in the rate of admissions for respiratory and circulatory diseases,with males showing much higher rates. With males having lower numbers but higher rates of admissionsat older age, the full reasons for the large gap between males and females in social care, remain unclear.

49

Figure 10. Percentage of population that are service users by age and sex (Source: ‘SWIFT’ database, Sandwell MBC)


Females Males

ICD Chapter name 65-74 75-84 85+ 65-74 75-84 85+

A00-B99 Certain infectious and parasitic diseases 0.2 0.3 0.7 0.2 0.4 0.8

C00-D48 Neoplasms 0.4 0.7 0.8 0.7 1.3 1.3

D50-D89 Diseases of the blood and blood-forming organs … 0.3 0.3 0.7 0.3 0.4 0.8

E00-E90 Endocrine, nutritional and metabolic diseases 0.5 0.9 1.3 0.6 0.9 1.2

F00-F99 Mental and behavioural disorders 0.3 0.7 1.2 0.3 0.8 1.2

G00-G99 Diseases of the nervous system 0.3 0.7 0.7 0.5 1.0 1.1

H00-H59 Diseases of the eye and adnexa 0.1 0.1 0.0 0.1 0.2 0.2

H60-H95 Diseases of the ear and mastoid process 0.1 0.0 0.0 0.0 0.0 0.0

I00-I99 Diseases of the circulatory system 2.2 4.2 8.7 3.2 6.2 10.0

J00-J99 Diseases of the respiratory system 2.3 4.5 8.4 2.8 6.5 12.8

K00-K93 Diseases of the digestive system 1.8 2.6 5.8 1.9 3.6 4.8

L00-L99 Diseases of the skin and subcutaneous tissue 0.5 0.9 1.6 0.4 0.8 1.2

M00-M99 Diseases of the musculoskeletal system and connectivetissue

1.0 1.5 2.7 0.7 1.7 2.6

N00-N99 Diseases of the genitourinary system 0.9 2.1 5.2 1.0 2.4 7.4

R00-R99 Symptoms, signs and abnormal clinical and laboratoryfindings…

4.0 6.4 12.2 4.7 10.1 14.8

S00-T98 Injury, poisoning and certain other consequences ofexternal causes

1.7 3.7 9.2 1.7 3.4 7.7

Z00-Z99 Factors influencing health status and contact withhealth services

0.0 0.0 0.0 0.0 0.0 0.0

(blank) (blank) 0.0 0.1 0.0 0.0 0.1 0.3

Table 1. Rates (percent) of age sex specific non elective admissions by cause, 2010/2011

50


Sand

wel

l - D

irec

tor

of P

ublic

Hea

lth

Ann

ual R

epor

t 201

0/11

ConclusionsThis year there has been low excess winter mortality, despite a harsh winter. However we seea higher rate of admission, compared with the average for the last four year. This may haveresulted in a higher burden on social care last winter. Contrary to historical, regionalevidence, in Sandwell for 2010/11, diseases of the respiratory system are the biggest cause ofseasonal variations in emergency admissions, and circulatory diseases did not show seasonalvariation. Although the numbers are smaller the rate of admissions in those over 85 is muchhigher for men. Preventative interventions to reduce seasonal variations in admissions shouldfocus on respiratory disease and should include ensuring adequate flu vaccination uptake andwinter warmth for those as high risk of winter admissions and death.

Secondary care is one of the largest sources of referral to social services. Facilitating hospitaldischarge and preventing hospital admission form a large part of the reasons for why peoplestart receiving social care services. Whilst there was a winter increase in the number ofdelayed transfers of care attributable to social care, there was no corresponding increase inthe number of new starters to social care. This requires further investigation and a detailedretrospective audit of case notes, tracking people across the health and social care systems.

Demographic analysis of social care use shows an in increase in service use with age, and adisproportionate number of female service users, particularly in the 85 plus age group. Thiscannot fully be accounted for by structural agedifferences between males and females or byvariations in unplanned admissions by gender. Thismay be due to the fact that elderly women aremore likely to be living alone as they are morelikely to outlive their male partners. This warrantsfurther investigation and may lead torecommendations for preventative actions.

Sharing of data at the individual level data is requiredin order to develop our understanding of flowsacross health and social care boundaries.

g g g Preventative interventions to reduce seasonal variations in admissions shouldfocus on respiratory disease and should include ensuring adequate flu vaccination uptake

and investment in winter warmth

g g A detailed retrospective audit of case notes, tracking people across the health and social care systemsis required to fully understand the reasons for the delays

g g Investigate the reasons why there is a higher proportion on women aged 85 plus using social care,than men in the same age group

g Sandwell MBC g Primary Care g Sandwell MBC Housing & Partnersg Public Health and Adult Social Care

g Sandwell Public Health Directorate

51


Building on the tradition of improvinghealth through housing

6

Author: Dr Carl Griffin (Consultant in Public Health)

52


A safe placeA home is more than just a building or a dwelling withwalls, windows and a roof. It provides shelter, security,provides an opportunity to build and support a family;provides a link with and is embedded within acommunity, and is a place for friends and family to visit.Unfortunately, as well as being protective and healthpromoting, a home and neighbourhood can have adetrimental impact on physical health and mentalwellbeing. Recent National Institute for Health andClinical Excellence guidance on Housing and PublicHealth (2005 p1) summarised the way poor housingcan lead to poor health into four areas. These are:

• Indoor environment including indoor pollutants(eg. asbestos, carbon monoxide, radon, lead,moulds and volatile organic chemicals).

• Cold and damp, housing design or layout,infestation, hazardous internal structures orfixtures, noise

• Overcrowding, sleep deprivation, neighbourhoodquality, infrastructure deprivation includingavailability and access to services, neighbourhoodsafety, and social cohesion

• Access to housing (homelessness), housing tenure,housing investment, and urban planning.

This review also pointed to the lack of good qualityresearch evidence demonstrating causal pathwaysbetween housing investment and healthimprovement (NICE 2005). This problem has beenhighlighted before (see Thomson et al 2001) and areason for this can be found in the methods used toevaluate housing improvements on health outcomes.In this chapter we will explore and describe some ofthe ways that health and housing colleagues can worktogether to provide more robust local evidencehighlighting the value of decent housing and how thisevidence can help inform housing policy in Sandwell.

The current state ofour homesIn order to fully understand the impactof housing on health we need tounderstand the condition of the housingstock in Sandwell. One useful source ofLocal Authority commissionedinformation comes from the HousingStock Condition survey. This can be usedto estimate and describe housing bytenure (e.g. privately owned, SandwellHomes or housing association), age,construction and household. In terms ofhouseholds, the most recent survey(2009) estimates that:

• 40% (n=35,805) households classed asvulnerable elderly, children, long termsick or disabled

• 24% (n=21,591) households have adisabled occupant

• 67% (n=60,276) of households hadincome <£15,000 pa

• 15% (n=13,494) households in fuelpoverty (spending more than 10% ofthe household income on heating)

• 30% (n=26,989) of households fromBlack and Minority Ethnic background

• 31% (n≈27,917) householders are agedover 65

These data are important as they enablehousing colleagues to prioritiseinvestment and identify those groups ofpeople who are in greatest need of homeimprovements. However, while thesedata can provide very useful informationin their own right, there areopportunities to begin to link housingand health data together to maximisetheir utility. In Sandwell we are part ofthe Collaborations for Leadership inApplied Health Research and Care(CLAHRC) programme. This is asignificant national research programmeand the Sandwell’s Director of PublicHealth is leading on one research themewhich aims to quantify the impact ofhousing improvement on healthoutcomes.

Sand

wel

l - D

irec

tor

of P

ublic

Hea

lth

Ann

ual R

epor

t 201

0/11

53


54

Linking housing and health informationOne key element of the CLAHRC research programme has been to develop amethod of linking local authority housing data with NHS health outcomes data inorder to understand the impact on housing on the health of residents. The firstworked example of this method, using infant mortality as a health indicator isdescribed below.

This first example uses housing datasetsprovided by Sandwell MBC and healthdatasets on birth and deaths in Sandwellfrom the Office of National Statistics. Thehousing datasets contain information onhousing tenure and address. The latter isvery important as it is used to identifythe geography of each home and theunique property reference number(UPRN) which is the key to linkinghousing tenure and health data. Table 1shows birth data 2005-7 for the six townsin Sandwell.

Table 1 – Births by Town – 2005-2007

Town Number of Births % Births

Tipton 1803 13

Rowley Regis 2138 16

West Bromwich 3040 22

Oldbury 1907 14

Wednesbury 1371 10

Smethwick 2843 21

Not known 643 5

Total Births 13745 100

Table 2 providespreliminary data onhousing tenure andinfant births anddeaths in Sandwell.The data indicatesthat rates of infantmortality vary byhousing tenure. Webelieve that the ratesin council homes arelow partly because ofthe good condition of‘Sandwell Homes’. Thehigh rates observed in RSL homes are difficult to interpretbecause the numbers of births and deaths are small andbecause of other factors that increase risk of infantmortality such as smoking, ethnicity and poverty. This datais provisional and further work is required but they doindicate how housing and health data can be combined tohelp plan and prioritise access in health services. Using aUPRN to link information across housing and healthdatasets provides a real opportunity to analyse the impactof housing on health. The success of this approach is basedon sharing accurate address information and in the futureit is crucial that we maintain access to health and housingdata for us to build detailed profiles on key housing andhealth indicators.

Table 2

Tenure Number of Births % Births Infantmortalityrate (per1000)

Private home 8775 64 7.6

Council home 2767 20 6.1

RSL home 353 3 14.2

Tenure not known 1850 13 -

Total Number of live births 13745 100 -

RSL=Residential social landlord, Council=Sandwell Homes


55

Does improving housing, improve health?As well as working with housing colleagues from Sandwell Metropolitan Borough Council we areworking in partnership with colleagues from Sandwell Homes to evaluate the impact of implementingthe Decent Homes investment and improvement programme. In Sandwell an estimated 29%(n=26,373) homes are non-decent (Stock Condition survey 2009). Figures 1 and 2 show the reasonsfor homes failing the Decent Standard (e.g. standard of general repair - external walls, roof structureand covering, windows and doors, chimneys, central heating boilers, gas fires, storage heaters,electrics) and also the mostcommon type of conditions thatresidents will experience (egcold).

Figure 2: Health and Housingsafety rating failures Source:Housing Health and SafetyRating System

The project with Sandwell Homes is looking at the impact of housing improvementsand investment undertaken since 2004 to bring all social housing up to the DecentStandard. This project will involve academic partners as part of our CLAHRCresearch programme and will provide evidence on the effectiveness and cost-effectiveness of the programme. The benefits of this are two fold. Firstly we will beable to provide evidence on the impact of all of the independent components ofthe Decent Homes programme on the health of tenants and secondly we will beable to help Sandwell Homes identify how future investment can be targeted toensure it has the maximum benefit to the most vulnerable residents.

This is only a brief description of some of the areas of joint working. There are otherpriority areas such as reducing fuel poverty or winter deaths that also require datasharing, setting joint priorities for commissioning services and evaluation that cutacross both housing and health boundaries. It is programmes like this that requirestrong and secure collaboration between both the NHS and the Local Authority inorder to ensure they have the most impact for residents in Sandwell.

Figure 1: Reasonsfor failing theDecent HomesStandard

Sand

wel

l - D

irec

tor

of P

ublic

Hea

lth

Ann

ual R

epor

t 201

0/11


56

Building on this for the futureIn Sandwell, we have a long and successful history ofeffective joint working with housing professionals within theLocal Authority. The changes in the NHS and the plan toreconfigure health organisations, health services and inparticular, transferring NHS public health to SMBC will offerboth opportunities and risks to successful joint working inthe future.

It is clear that the relationship between poor housing andhealth is a complex one and it is very difficult to disentanglethe impact of housing from other forms of deprivation andinequality (NICE 2005). This is precisely why healthprofessionals must not only continue to work with housingcolleagues but also maintain and secure links within theNHS.

Finally, we have described some projects and highlighted thevalue and the contribution that working together can offer.We believe that targeted housing investment will contributeto health improvement but we need to work systematicallytogether to build the evidence to support investment inpriority areas such as fuel poverty or reducing excess winterdeaths. Clearly, there is still a long way to go and whiletransferring NHS public health to the Local Authority willprovide opportunities, this transfer also presents risks thatneed to be acknowledged and addressed.

g g Sandwell MBC Housing and public health should work more closely to identify thoseat higher risk of housing relating ill health by incorporating evidence based approaches to

housing improvements

g CCGs should prioritise housing interventions and programmes to help reduce hospital activity and healthinequalities

g Clinical Commissioning Consortia g Sandwell Public Health Directorate g Sandwell MBC Housing & Partners


Health profiles forSandwell ClinicalCommissioningGroups

7

Authors: Andrew Hood (Specialty Registrar in Public Health) Dr Alexis Macherianakis (Consultant in Public Health Medicine)

57


58

Introduction andBackgroundThere is a wealth of data and information onpopulations within primary care, their socio-demographic circumstances and their healthstatus and lifestyle behaviours. However, thisinformation is often hard to retrieve, is heldwithin different local and national systems and isnot commonly collated in order to provide anoverall picture of health at practice level.

Given the future requirement of general practicesto collaborate as Clinical Commissioning Groups(CCGs) to commission services for their combinedpopulations, there is a need for baselinemeasurement of the characteristics and healthstatus of their populations.

Sources of data usedand methodsData used in the production of the full profileswas taken from both local and national sources.Local data from primary care records extractedfrom the MSDi system and Open Exeter (NHAIS)was used to describe the key demographiccharacteristics. Information from the nationalQOF returns and published by the NHSinformation centre45 was used to review therecorded prevalence of long-term conditions,and both of these were drawn upon for lifestyleinformation.

Data was aggregated up from practice level toCCG level using of-the-time practice to CCGreference tables. The membership of CCGs hasyet to be formally agreed by the NHSCommissioning Board and Department of Healthand is liable to change; therefore the informationcontained within the profiles may need revisingand updating as necessary.

Here we provide a summary of the profiles forthe three main consortia in Sandwell:

• HealthWorks CCG• Sandwell Health Alliance CCG• Black Country CCG


59

Figure 1. Map showing geographical distribution of practices by CCG

Sand

wel

l - D

irec

tor

of P

ublic

Hea

lth

Ann

ual R

epor

t 201

0/11


60

Key Messages for HealthWorks CCG• With over 150,000 patients, HealthWorks is the largest of Sandwell CCGs although 30% of

patients are registered to GPs currently commissioned by Heart of Birmingham PCT.• There are larger numbers of younger adults (aged 20-44) being served by the practices than

average, having resource implications on child health and maternity services.• Above Sandwell average levels of patients within the CCG smoke or are obese, increasing their

likelihood of developing heart disease or other long-term conditions in the future.• The most disproportionately high disease registers at CCG practices are those for mental

health, dementia and learning disabilities.

Key Messages for Black Country CCG:• The smallest of the Sandwell CCGs, the group is responsible for just under 110,000 patients

and has 19 practice members.• Given the demographic shift to an older population, there is likely to be an increase over time

in the prevalence of age-related long-term conditions such as heart failure, cancer, stroke,dementia and also the increased need for palliative care.

• Above Sandwell average levels of patients within the CCG smoke or are obese, increasing theirlikelihood of developing heart disease or other long-term conditions in the future.

• Patients in the Black Country CCG on the whole experience higher levels of COPD, Cancer,Heart Failure, CKD, Atrial Fibrillation and Obesity than patients in the borough as a whole.

Key Messages for Sandwell Health Alliance CCG:• Sandwell Health Alliance (SHA) and its 29 constituent practices are responsible for 112,000

patients.• On the whole, the population is younger than average for both males and females and has the

most ethnic diversity of the Sandwell CCGs.• Above Sandwell average levels of patients within the CCG smoke or are obese, increasing their

likelihood of developing heart disease or other long-term conditions in the future.• Due in part to the younger population, but also perhaps to “under-diagnosis”, the patients

registered to SHA practices generally have lower prevalence of most long-term conditionsthan average for Sandwell.


61

Opportunities for case-finding ofpeople with long-term conditionsPredictive modelling of disease prevalence based on populationfactors (age, gender, ethnicity and deprivation) and prevalencestudies can be a useful way of indicating where there are potentialgaps in identifying patients with conditions that have not yet beendiagnosed. People with genuine but undiagnosed disease may bemissing out on preventative care and treatment.

NHS comparators (NHS information Centre) use models produced byseveral research units46,47,48,49 to estimate the number of potential“missed” patients for every practice and PCT. Despite their robustdesign and input of detailed local data, there are still questions aboutthe accuracy and reliability of the underlying prevalence data thatthese models are based on, thus the output. Some data is self-reported by patients, therefore subject to recall bias and other data istaken from out-of-date studies or studies that are not reallyapplicable to the general population. Never the less, they provide uswith a good starting point to investigate potential gaps. The followingfigure shows the position for Sandwell PCT as a whole.

This information suggests that in Sandwell (2008/09 data) in absolute terms there may be tens ofthousands of obese, hypertensive or obese and hypertensive patients who have not yet been formallyclassified or diagnosed. There are also substantial numbers of people with potential kidney disease,asthma, COPD and CHD who fit the same definition.

Figure 2. Number and % of “missed” patients in Sandwell by disease group, 2008/09(Source: NHS comparators, NHS information Centre).

Sand

wel

l - D

irec

tor

of P

ublic

Hea

lth

Ann

ual R

epor

t 201

0/11


62

Commissioning group structureAs at February 2011, the commissioning group was made up of 23 practices. 14 of thesewere within the Sandwell PCT boundary, and 9 were within the Heart of Birmingham (HoB)PCT area. In total, the group is responsible for 151,181 patients.

DemographicsPatients registered to the Sandwell practices in this CCG have a fairly even spread ofpopulation by gender and across the age groups, however patients at the HoB practicespredominate in the younger working-age and child-rearing age groups (between 20 and 39years). This may have implications for maternity and child-health services.

Ethnicity is recorded foraround 65% of patientsregistered to HealthWorks CCGpractices. Although there areslight variations across ethnicgroups between Sandwell andHoB practices, overall thewhite population forms aminority of patients (47%)compared to a majority (77%)for Sandwell as a whole. TheBlack and Minority Ethnic(BME) patients are largely ofIndian, Black Caribbean andPakistani origin.

Figure 3. Age distribution of HealthWorks patients by PCT area (Source: Exeter System and PAR data, 2010).

Ethnicity Health WorksNumber*

HealthWorks % (ofrecorded)

Sandwell PCT % ** HoB PCT % (ofrecorded)*

White 46,286 47 77 36

Indian 16,519 17 9 13

Other 4,232 11 2 8

Pakistani 6,502 7 3 21

Black Caribbean 8,646 9 3 9

Black African 4,134 4 1 3

Mixed 3,037 3 2 4

Bangladeshi 2,303 2 1 6

Total recorded 98,504

Not recorded 52,677

*Source: MSDi and Graphnet extraction, March 2011 ** Source: ONS 2006 mid-year estimate

Table 1: Health Works patient ethnicity

HealthWorks CCG health profile


63

Lifestyles

Data completeness is an issue again withregard to capturing lifestyle information.Only 54% of patients registered to aHealth Works practice have their smokingstatus recorded, meaning wide margins oferror when measuring the prevalence.

Of those adults (aged 16 and over) thathave been asked whether they smoke,26% confirmed they do. If this were truefor the entire population of the CCG, thenaround 31,000 adults would smoke andwould therefore be candidates for briefinterventions around smoking cessation orreferral to specialist stop smokingadvisors. The prevalence is markedlyhigher than comparable estimates forEngland as a whole with only 5/23practices having lower than average levels.

Obesity

According to records submitted for theQuality Outcomes Framework (QOF)almost 15,000 (11.3%) Health Workspatients are clinically obese i.e. have BMIof over 30. Many of these are likely tohave existing additional long-termconditions. This compares to 10%nationally and both are likely to beunderestimates of the true prevalence.

Modelled estimates for obesity, suggestthere may be an additional 7,000 peopleat Health Works practices that might beobese but have not yet been measured forBMI.

Disease prevalence

Health Works CCG, on the whole, hashigher recorded levels of mental health,dementia and learning disabilities thanpatients in the borough as a whole, butlower recorded levels of COPD, heartfailure and atrial fibrillation.Ascertainment of COPD may be an issuegiven the much lower than expectedprevalence in practices in Health Works. Sa

ndw

ell -

Dir

ecto

r of

Pub

lic H

ealt

h A

nnua

l Rep

ort 2

010/

11


64

Figure 4. Difference in expected and observed disease prevalence, selected diseases, 2009/10 (Source: NHS Information Centre, QMAS, QOF, 2009/10).

Table 2. Recorded prevalence of long-term conditions in HealthWorks patients, 2009/10

Disease HealthWorks CCGpatients on register

HealthWorks CCGPrevalence

Sandwell PCTPrevalence

Coronary Heart Disease 4356 3.29 3.63

Stroke or TIA 2169 1.64 1.64

Hypertension 19791 14.94 15.25

Diabetes (Type 2) 7312 5.52 5.16

COPD 1954 1.47 1.73

Epilepsy 834 0.63 0.63

Hypothyroidism 4594 3.47 3.52

Cancer 1520 1.15 1.17

Mental Health 1347 1.02 0.76

Asthma 8560 6.46 6.31

Heart Failure 1081 0.82 0.91

Heart Failure (due to LVD) 647 0.49 0.48

Palliative Care 198 0.15 0.14

Dementia 690 0.52 0.45

Depression 10394 7.84 7.85

Chronic Kidney Disease 4394 3.32 3.57

Atrial Fibrillation 1618 1.22 1.34

Obesity 14919 11.26 10.81

Learning Disabilities 572 0.43 0.34

Smoking 32061 24.20 24.61


65

Commissioning group structure

As at February 2011 the commissioning group was made up of 19 practices and wereresponsible for 109,000 patients. The group is the smallest of Sandwell’s 3 CCG’s.

Demographics

Patients registered to GPs in this CCG have a fairly even spread of population by gender andacross the age groups. As expected from national patterns, there are a larger proportion ofolder females than males. Given the demographic shift to an older population, there is likelyto be an increase in the prevalence of age-related long-term conditions such as heart failure,cancer, stroke, dementia and also the increased need for palliative care.

Ethnicity is recorded for around69% of patients registered toBlack Country CCG practices.With over 8 in every 10 patients,the population is predominantlywhite. Only the Indian andPakistani population arerepresented in large numbers(>1000) in this commissioninggroup. This ethnic compositionmay be reflected in the profile oflong-term conditions, some ofwhich, such as Diabetes, aremore prevalent in minorityethnic groups than in the whitepopulation50.

Figure 5. Age distribution of Black Country CCG patients by PCT area(Source: Exeter System and PAR data, 2010).

Black Country CCG health profile

Ethnicity BC CCG Number BC CCG % BC CCG wards* % Sandwell** %

White 50930 83.3 86.1 77.4

Indian 2807 4.6 5.8 9.4

Pakistani 2335 3.8 2.3 3.4

Other 1711 2.8 1.1 2.3

Bangladeshi 1075 1.8 0.8 1.4

Mixed 980 1.6 1.5 2.1

Black Caribbean 693 1.1 2.2 3.4

Black African 594 1.0 0.1 0.6

Total recorded 61,125

Not recorded 39468

* This percentage represents the wards that BC CCG patients reside in – Source: 2001 Census** Source: ONS 2006 mid-year estimate

Table 3: Black Country CCG patient ethnicitySa

ndw

ell -

Dir

ecto

r of

Pub

lic H

ealt

h A

nnua

l Rep

ort 2

010/

11


66

Lifestyles

Data completeness is an issue with regard tocapturing lifestyle information. Fewer than 50%of patients registered to a BC CCG practice havetheir smoking status recorded, meaning widemargins of error when measuring the prevalence.

Of those adults (aged 16 and over) that havebeen asked whether they smoke, 28% confirmedthey do. If this were true for the entirepopulation of the CCG, then around 23,000adults would smoke and therefore be candidatesfor brief interventions around smoking cessationor referral to specialist stop smoking advisors.The prevalence, although marginally lower thanthe Sandwell average, is markedly higher thancomparable estimates for England as a wholewith no practices having lower than nationalaverage levels.

Obesity

According to records submitted for the QualityOutcomes Framework (QOF) almost 13,000(12.6%) of Black Country CCG patients areclinically obese i.e. have BMI of over 30. Many ofthese are likely to have existing additional long-term conditions. This compares to 10% nationallyand both are likely to be underestimates of trueprevalence.

Modelled estimates for obesity, suggest theremay be an additional 6,000 people at BlackCountry CCG practices who might be obese buthave not yet been routinely measured or had anadverse health event that meant they weremeasured for BMI.

Disease prevalence

Black Country CCG on the whole has higher levelsof recorded COPD, cancer, heart failure, CKD,atrial fibrillation and obesity than patients in theborough as a whole, but lower levels ofhypertension, mental health and palliative care.Overall BC CCG has a smaller estimated underrecording of disease when compared to Sandwelland England, except for stroke and dementia.


67

Table 4. Recorded prevalence of long-term conditions in Black Country CCG patients, 2009/10

Disease Black Country CCGpatients on register

Black Country CCGPrevalence

Sandwell PCT Prevalence


Stroke or TIA 1879 1.78 1.64


Diabetes (Type 2) 5395 5.10 5.16

COPD 2187 2.07 1.73

Epilepsy 713 0.67 0.63


Cancer 1369 1.29 1.17


Asthma 7005 6.62 6.31




Dementia 461 0.44 0.45

Depression 8461 8.00 7.85



Obesity 13307 12.58 10.81


Smoking 26364 24.92 24.61

Figure 6. Difference in prevalence of CCG and Sandwell PCT patients, 2009/10 (Source: NHS Information Centre, QMAS,QOF, 2009/10) Sa

ndw

ell -

Dir

ecto

r of

Pub

lic H

ealt

h A

nnua

l Rep

ort 2

010/

11


68

Commissioning group structureAs at February 2011, the commissioning group was made up of 29 practices. With a relativelysmall overall population (112,000) this CCG has the lowest average list size per practice inSandwell of fewer than 3,900.

DemographicsPatients registered to the practices in this CCG have a fairly even spread of population by genderand across the age groups. On the whole though, the CCG population is slightly younger thanaverage for the borough for both males and females. This may have implications for maternityand child-health services, and given current unemployment trends the same patients andfamilies may be accessing welfare and social care support.

Figure 7. Age distribution of Sandwell Health Alliance patients and Sandwell PCT(Source: Exeter System and PAR data 2010).

Ethnicity is recorded forrelatively few (43%) of patientsregistered to the SHA CCGpractices leading to widemargins of error in estimatingpopulation %’s. Of thoserecorded for ethnicity, justunder 2/3 of the CCG registeredpopulation is of ‘white’ origincompared to almost 80% forSandwell as a whole.

The CCG has significantnumbers of Indian patients, andalso large populations from theother BME groups – Pakistani,Black Caribbean, Bangladeshiand Black African. SHA isprobably the most ethnicallydiverse CCG in Sandwell.

Sandwell Health Alliance CCG health profile

Table 5: Sandwell Health Alliance patient ethnicity

Ethnicity SHA Number* SHA % Sandwell** %White 96566 63.7 77.40Indian 21268 14.0 9.44Other 9687 6.4 2.31Pakistani 8503 5.6 3.35Black Caribbean 4811 3.2 3.36Bangladeshi 3827 2.5 1.42Black African 3589 2.4 0.61Mixed 3310 2.2 2.11Total recorded 151561 100 100Not recorded*Source: MSDi extraction February 2011 ** Source: ONS 2006 mid year estimate


69

Lifestyles

Data completeness is an issue with regard tocapturing lifestyle information. Only 47% ofpatients registered to a SHA practice have theirsmoking status recorded, meaning wide marginsof error when measuring the prevalence.

Of those adults (aged 16 and over) that havebeen asked whether they smoke, 28% confirmedthey do. If this were true for the entirepopulation of the CCG, then around 26,000adults would smoke, therefore be candidates forbrief interventions around smoking cessation orreferral to specialist stop smoking advisors. Theprevalence is markedly higher than comparableestimates for England as a whole with only 3/29practices having lower than average levels.

Obesity

According to records submitted for the QualityOutcomes Framework (QOF) almost 11,000(9.5%) SHA patients are clinically obese i.e. haveBMI of over 30. Many of these are likely to haveexisting additional long-term conditions. Thiscompares favourably to national levels of 10%although both are likely to be underestimates oftrue prevalence.

Modelled estimates for obesity, suggest theremay be an additional 7,000 people at HealthWorks practices that might be obese but havenot yet been routinely measured or had anadverse health event that meant they weremeasured for BMI.

Disease prevalence

Patients in the Sandwell Health Alliance CCG onthe whole experience lower levels or recordingfor most long-term conditions than the boroughas a whole, in part likely to be related to theyounger population. Only diabetes, mentalhealth and palliative care registers appear to behigher than average. Estimates of diseaseprevalence indicate a high level of underrecording of COPD and stroke. As the risk ofthese diseases increases at older ages, thesestatistics may also be distorted by the youngerpopulation of this consortium.

Sand

wel

l - D

irec

tor

of P

ublic

Hea

lth

Ann

ual R

epor

t 201

0/11


70

Figure 8. Difference in prevalence of CCG and Sandwell PCT patients, 2009/10 (Source: NHS Information Centre, QMAS, QOF, 2009/10)

Disease Health Works CCGpatients on register

Health Works CCGPrevalence

Sandwell PCT Prevalence


Stroke or TIA 1499 1.33 1.64


Diabetes (Type 2) 5892 5.21 5.16

COPD 1714 1.52 1.73

Epilepsy 647 0.57 0.63


Cancer 1057 0.94 1.17


Asthma 6628 5.87 6.31




Dementia 397 0.35 0.45

Depression 8793 7.78 7.85



Obesity 10696 9.47 10.81


Smoking 27162 24.04 24.61

Table 6. Recorded prevalence of long-term conditions in SHA patients, 2009/10


71

Next stepsThese profiles represent the first steps in describing CCG populations andtheir needs. Our understanding of needs at the CCG level could be furtherdeveloped through improved recording of ethnicity and of lifestylemeasures.

The estimated under recording of disease presented here requires furtherinvestigation. We can compare the estimated under recording, at a practicelevel, with admissions to hospital and deaths for under recorded diseases.This can help us to test whether the estimated under recording is real andto understand the impact this is having. We also need to test therelationship between estimated under recording and socio-demographiccharacteristics such as ethnicity and deprivation.

g g Improve recording of ethnicity and lifestyle factors such as obesity and smokingprevalence

g Further investigate estimated under recording by examining the relationship with hospitaladmissions, deaths and socio-demographic characteristics

g g g Implement a local data sharing agreement which enables public health to present data bypractice, by electoral ward, by neighbourhoods, and by commissioning groups as well as on the Sandwell-wide basis

g Clinical Commissioning Consortia g Sandwell Public Health Directorate g NHS Commissioning Boards g Sandwell MBC

Sand

wel

l - D

irec

tor

of P

ublic

Hea

lth

Ann

ual R

epor

t 201

0/11


72

ReferencesChapter 1:1. Department of Health, Equity and Excellence: Liberating the NHS, July 2010

http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_117794.pdf 2. http://www.sandwell.nhs.uk/documents/publications/Public%20health%20annual%20report%20200809%20lowres.pdf

Chapter 2:3. The Black Report (1980) Inequalities in Health: Report of a research working group, London DHSS4. Whitehead, M (1987) The Health Divide, London5. Acheson Report (1998) Report of the independent inquiry into inequalities in health.

London: Stationery Office, 1998 ISBN: 01132217386. Marmot, M (2010) Fair Society, Healthy Lives, The Marmot Review7. The English Indices of Deprivation (2010). Communities and Local Government. Available at URL:

http://www.communities.gov.uk/documents/statistics/xls/1871689.xls Last accessed 20.05.2011.

Chapter 3:8. World Health Organisation. Closing the gap in a generation: Health equity through action on the social determinants of health.

2008.9. Barton, H. and Grant, M. A health map for the local human habitat, Journal of the Royal Society for the Promotion of Public

Health, 126 (6) pp252-261.10. Sandwell Primary Care Trust, Invest well – Priorities for Health, Strategic Plan, 2008/09-2012/1311. Lin CC, Rogot E, Johnson NJ, Sorlie PD, Arias E. A further study of life expectancy by socioeconomic factors in the National

Longitudinal Mortality Study. Ethnicity & Disease [2003, 13(2):240-7]12. De Silva, D. Helping people help themselves. 2011. The Health Foundation. London13. Sandwell Trends. 2011. http://www.sandwelltrends.info/lisv2/navigation/home.asp [Accessed 10 July 2011]14. Doyle, C., Kavanagh, P., Metcalfe, O., Lavin, T. Health impacts of employment: a review. 2005. Institute of Public Health in

Ireland. http://www.publichealth.ie/publications/healthimpactsofemploymentareview15. Shuildrick, T., MacDonald, R., Webster, C., Garthwaite, K. The low-pay, no-pay cycle: understanding recurrent poverty. 2010. The

Joseph Rowntree Foundation: York16. Townsend, P. The meaning of poverty. The British Journal of Sociology, 1962, 13(3).17. Department for Energy and Climate Change. Fuel poverty statistics.

http://www.decc.gov.uk/en/content/cms/statistics/fuelpov_stats/fuelpov_stats.aspx [accessed 4 July 2011]18. Kings Fund. The health impacts of spatial planning decisions. Kings Fund. 2009: London19. The Marmot Review: Implications for spatial planning. The Marmot Review. 2011: London20. Mitchell, R., Popham, F. Effect of exposure to natural environment on health inequalities: and observational population study.

2008. The Lancet 372(9650) pp1655-166021. Faculty of Public Health. Great outdoors: how our natural health service uses green space to improve wellbeing. 2010. Faculty

of Public Health. London.22. Sandwell Metropolitan Borough Council. Sandwell Green Space Strategy 2010-2020.

http://cmis.sandwell.gov.uk/CMISWebPublic/Binary.ashx?Document=35677 [Accessed 25 July 2011]23. World Health Organisation. Environmental burden of disease associated with inadequate housing. World Health Organisation.

2011. Copenhagen, Denmark24. Marmot Review. 2011. http://www.marmotreview.org/implementation/other-local-examples.aspx [Accessed 11 July 2011]25. Local Government Improvement and Development. http://www.idea.gov.uk/idk/core/page.do?pageId=23289114 [Accessed 10

July 2011]26. Royal Town Planning Institute. www.rtpi.org.uk/download/10642/Paul-Southon.pdf [Accessed 14 July 2011]

Chapter 4:27. Sandwell Adult Services. RAP returns, 2009-10.Number of clients receiving services during 2009-10, provided or commissioned

by Sandwell Adult Services, by primary client type, service type, and age group.28. Social Care Clients, England, 2007/8. http://www.statistics.gov.uk/hub/health-social-care/social-care/social-care-clients 29. Department of Health, 2005. Supporting people with long term conditions.

http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4122574.pdf 30. NHS Evidence: Learning Disabilities. Health inequalities and People with Learning Disabilities in the UK: 2010

http://www.library.nhs.uk/LEARNINGDISABILITIES/ViewResource.aspx?resID=389204&tabID=290 31. Office for National Statistics, Mid-year Local Authority quinary population estimates (table 9), 2010,

http://www.statistics.gov.uk/statbase/product.asp?vlnk=15106 32. Discussion with Ross Bailey Senior Performance Analyst and Researcher, Adult and Community Services, Sandwell.33. Electronic correspondence with Sarah Knight, Falls Management Lead, Sandwell PCT, 9th January 2011.34. Care Quality Commission: Care Directory Search, 15/02/11.

http://caredirectory.cqc.org.uk/caredirectory/searchthecaredirectory.cfm 35. NHS Local. Making Every Contact Count. http://nhslocal.nhs.uk/story/inside-nhs/every-contact-counts


73

Sand

wel

l - D

irec

tor

of P

ublic

Hea

lth

Ann

ual R

epor

t 201

0/11

Chapter 5:36. Department of Health, Health Inequalities Nation Support Team, How to reduce the risk of seasonal excess deaths

systematically in vulnerable older people to impact at population level, 2010 37. Smith, R., & Fowajuh, G., Excess Winter Deaths in West Midlands. Sandwell Primary Care Trust, West Midlands Public Health

Observatory and NHS West Midlands,38. The Eurowinter Group, Cold Exposure and winter mortality from ischaemic heart disease, cerebrovascular disease,

respiratory disease and all causes in warm and cold regions in Europe. The Lancet 349, 1341-1346. 199739. Rudge & Gilchrist, Excess winter morbidity among older people at risk of cold homes: a population-based study in a London

borough, Journal of Public Health 2005 27(4):353-358. http://jpubhealth.oxfordjournals.org/content/27/4/353.full 40. ONS, Excess Winter Mortality Statistical Bulletin – November 2010 www.statistics.gov.uk/pdfdir/deaths1110.pdf 41. Wilkinson P., et al Vulnerability to winter mortality in elderly people in Britain: population based study. BMJ 329, 644-649.

200442. Marmot Review Team. The health impacts of cold homes and fuel poverty. Written by the Marmot Review Team for Friends

of the Earth. 201143. ONS, PCOs and SHAs within England; 2008-2033 population projections by sex and quinary age.

http://www.statistics.gov.uk/downloads/theme_population/snpp-2008/InteractivePDF_2008-basedSNPP.pdf44. Department for Communities and Local Government, A decent home: definition and guidance for implementation, 2006

http://www.communities.gov.uk/documents/housing/pdf/138355.pdf

Chapter 6:45. NHS Information Centre, http://www.ic.nhs.uk/qof, accessed 16th September 201146. http://www.erpho.org.uk/viewResource.aspx?id=17922 47. http://www.doncaster.nhs.uk/about-us/our-roles-directories/public-health/public-health-intelligence-evaluation-

team/tools-resources/qof-benchmarking-tool/ 48. http://www.yhpho.org.uk/default.aspx?RID=81090 49. Knapp, M. & Prince, M. (2007) Dementia UK. London: Alzheimer's Society)50. http://www.nhs.uk/Conditions/Diabetes-type2/Pages/Causes.aspx

Achievements 2010/11

Awards

g Shaukat Ali and Dene StevensWinners Health Service Journal (HSJ) Awards 2010 in the Good CorporateCitizenship category.

g Finalists British Medical Journal (BMJ) Group Awards in the SustainableHealth Care category, 2011.

g Dr Ishraga AwadAchieved a Postgraduate Award (PGA) in Public Mental Health and Wellbeing,Warwick University

g Sharon GrantShort listed for Emergency Planning Society National Resilience Planner ofthe Year

g Dr Patrick SaundersElected Fellow of the Faculty of Public HealthAchieved Defined Specialist Registration on the UK Voluntary Register forPublic Health SpecialistsShort listed for the Association of Directors of Public Health, UK, AnnualPublic Health Report competition, 2010.


74

Publications

g Ali S, Stevens D. Good corporate citizenship andcarbon management. Health Service Journal (HSJ)Awards Best Practice Report, 2010.

g Ali S, Stevens D. Good corporate citizenship andcarbon management. Health Service Journal (HSJ)Awards supplement, 2010.

g Haroon SM, Barbosa GP and Saunders PJ. Thedeterminants of health-seeking behaviour during theA/H1N1 influenza pandemic: an ecological study. JPublic Health (2011) PMID 21460370 (epub ahead ofprint).

g Middleton J, Saunders PJ, Haroon SM. EuropeanTerrorism and Public Health. In Terrorism and PublicHealth, 2nd Edition (Sidel and Levy B, Eds). OxfordUniversity Press (in press).

g Middleton J, ed. 5% for health. The 20th AnnualPublic Health Report for Sandwell. West Bromwich:Sandwell Primary Care Trust, 2010.

g Middleton J. Labour’s chimera. Health Service Journal(HSJ), letter (re NHS reorganisations), April 2010.

g Middleton J. Managing public health - healthdividends and good corporate citizenship.International Journal of Management Concepts andPhilosophy, vol. 4 no 2: 154-176.

g Middleton J. Gimme 5: why its 5% for healthimprovement. Health Service Journal (HSJ), June 2010.

g Middleton J. Public health is a long haul. HealthService Journal (HSJ), September 2010.

g Middleton J. The new public health service, HealthService Journal (HSJ), November 2010.

g Middleton J. Public health and local authorities.Municipal Journal, November 2010.

g Middleton J. Public health reforms in England -lessons for Europe or lessons to avoid? Gesundheit,December 2010.

g Middleton J. Public health can’t survive on £4 billion.Health Service Journal (HSJ), April 2011. And LocalGovernment Chronicle website March 2011.

g Grainger D, Time 2 Trade case study (commissionedby DoH). Institute for Volunteering Research.

g Grainger D, Time 2 Trade case study, GovernanceInternational.

g Saunders PJ. Use of routine public health nuisancecomplaint data to map and address environmentalhealth inequalities. European Journal of Public Health.2010; 20 (suppl 1): 47.

g Saunders PJ, Kibble, AJ, Burls, A. Investigating allegedclusters. In Oxford Handbook of Public HealthPractice, 2nd edition. (Pencheon D, Melzer D, Gray M,Guest C, Eds). Oxford University Press, Oxford (Inpress).

Presentations

g Dr John MiddletonYoung people’s health in Sandwell. Major launch ofadolescent health strategy, CAP Centre, Smethwick,February 2010.

Three dividends for a healthier world. UK PublicHealth Association, March 2010.

Healthy town planning and resilience. UK PublicHealth Association, March 2010

Crunchtime for health, poster presentation. UK PublicHealth Association, March 2010.

Terrorism and public health. Open Universityinternational health masters course, BirminghamUniversity, June 9th 2010.

Is Sandwell getting any better? 21 years of healthimprovement in Sandwell. Sandwell Health’s otherEconomic Summit (SHOES), June 2010.

Is Sandwell getting better in 21 years? University ofthe 3rd age Sandwell, September 2010.

NICE work if you can get it: implementingcomprehensive and effective public healthprogrammes. 2nd International congress on healthpromotion and preventive medicine. Zagreb, Croatia,October 2010.

Public Health in local authorities. West MidlandsTeaching Public Health Network, Wolverhampton,November 2010.

g Dr Shamil Haroon The determinants of health-seeking behaviour duringthe A/H1N1 influenza pandemic. Poster presentation,HPA Pandemic Influenza conference, July 2010.

An evaluation of breastfeeding peer support. AnnualFaculty of Public Health conference, July 2011.

g Dr Patrick SaundersUse of routine public health nuisance complaint datato map and address environmental healthinequalities. European Public Health AssociationAnnual Conference, Amsterdam, November 2010.

Use of Sub-National Indicators to Improve PublicHealth in Europe (UNIPHE) Conference BucharestSeptember 2010. Development of Sub NationalChildren’s Environmental Health Indicators

g Dene StevensLessons for Planning & Public Health. NewPartnerships for Health & Well-being event,Birmingham, May 2011.

Exploring the sustainability agenda and its role in thefuture of public health. National Public HealthCongress, Botanical Gardens, Birmingham, May 2011.

Conferences organised

g Shaukat Ali and Dr John MiddletonSandwell Health’s Other Economic Summit (SHOES), Aclimate for health? Global, local, health and healthservices – taking the temperature. The Public, WestBromwich, July 2011.

g Health Protection TeamWorld hepatitis Day conference, The Public, WestBromwich, July 2011.


75

Detailed reports that make up Sandwell’s PublicHealth Annual Report 2010/11 are contained on theattached CD.

If the CD is not attached, you can request a copy bytelephoning 0845 155 0500. This document is alsoavailable for download on Sandwell Primary CareTrust’s website at www.sandwell.nhs.uk and click on‘Publications’.

Responsibility for the opinions expressed in thisreport rest with the Editor, Dr John Middleton,Director of Public Health for Sandwell PCT. Anyerrors or points of clarification that need to befurther addressed should be forwarded to him [email protected]

CD and contents1. CancerKey Cancer Incidence Data & Mortality Data 2009Sandwell Cancer Strategy 2010-2011 Executive SummarySandwell Cancer Strategy 2010Where do cancer patients die 2011

2. CLAHRCCLAHRC Newsletter October 2011Housing Data PresentationTelecare Presentation

3. Clinical Commissioning ConsortiaprofilesBlack Country CCGHealthworks CCGSandwell Health Alliance CCG

4. Community developmentCommunity Development Team AnnualReport 2009-10

5. Healthy start to life36 month Rolling Average Infant MortalityCDOP ReportChild Health Profile Summary Leaflet February 2011NI 116 2008 Briefing

6. JSNABME Health Needs Assessment September 2010JSNA Alcohol Report 2010JSNA Coronary Heart Disease ReportJSNA Obesity Report 2011JSNA Pan Birmingham Cancers Needs Assessment Summary 2010Sandwell JSNA Report V6

7. Life ExpectancyLife Expectancy Gap in Sandwell8. ObesityBariatric Surgery Policy ReviewSandwell Obesity Strategy 2011Triple S Programme Results

9. Older PeopleNational Falls & Bone Health Audit Report 2010Sandwell Falls & Bone Health Audit Report 2011Sandwell Falls & Bone Health Strategy 2011

10. Programme BudgetingComparative SpendSandwell PCT Health Investment Pack 2010

11. Public Annual Report 2010 – 11

12. Sandwell Health ProfileSandwell Health Profile 2011

13. Sexual HealthPASH Group Data Presentation OutlinePASH Sexual Health Data Report

14. SHUDUGreen Space and Psychological Distress

15. StrokeNational Sentinel Stroke Audit 2010 – Sandwell ResultsPerformance against the NICE Quality Standard for StrokeStroke Health Needs Assessment August 2011

16. Tobacco ControlSandwell PCT Smoking ProfileTobacco Control Annual Report 2010 – 2011

Sand

wel

l - D

irec

tor

of P

ublic

Hea

lth

Ann

ual R

epor

t 201

0/11


ISBN 978-1-900471-32-9

Sandwell Primary Care Trust438 High StreetWest BromwichWest MidlandsB70 9LD

www.sandwell.nhs.uk


Documents

Sandwell Public Health Annual Report 2010-11