South Aberdeenshire LCHP Health Needs Assessment Report

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South Aberdeenshire LCHP Health Needs Assessment report

South Aberdeenshire LCHP

Health Needs Assessment

November 2009

Mary Bellizzi, Health Improvement Policy Advisor

Fiona Murray, Public Health Co-ordinator, south Aberdeenshire LCHP

Contact details for authors:

Dr Mary Bellizzi

Mobile: 07906 001511 Email: [email protected]

Fiona Murray

Tel: 01569 792074 Mobile: 07799470006 Email: [email protected]

Contents

Acknowledgements ...... 6 Glossary ...... 7 Summary...... 8 1. Introduction ...... 13 1.1 What is health needs assessment?...... 13 1.2 Why undertake this HNA? ...... 13 1.3 How does this HNA support national and local priorities?...... 13 1.4 What influences health? ...... 14 1.5 What are the benefits of this HNA? ...... 14 1.6 What next? ...... 14 2. Geographic area covered by health needs assessment ...... 15 2.1 Kincardine & Mearns ...... 16 2.2 Marr8 ...... 16 2.3 Garioch8...... 16 3. Information used for the health needs assessment (methodology) ...... 16 3.1 Main information sources used...... 16 3.2 The Health and Wellbeing Needs Assessment Questionnaire...... 17 3.2.1 Questionnaire development ...... 17 3.2.2 Distribution of final questionnaire...... 17 3.2.3 Questionnaire analysis...... 17 3.3 Community Health and Wellbeing Profiles 2008 and Traffic Lights...... 18 3.3.1 Background on Community Health and Wellbeing Profiles ...... 18 3.3.2 Traffic Lights ...... 18 3.3.3 Intermediate zones selected for HNA ...... 19 3.4 Quality and Outcomes Framework (QOF) 2006-08...... 19 3.4.1 What is QOF? ...... 19 3.4.2 QOF data used for this HNA ...... 19 3.4.3 Using QOF data ...... 19 3.5 An Atlas of Tobacco Smoking in Scotland...... 20 3.6 Carstairs Deprivation Index by Practice Population 2009……………………………………20

4. Health and wellbeing needs assessment questionnaire results...... 20 4.1 Response rate ...... 20 4.2 Population groups having health and wellbeing issues (question 1) ...... 20 4.2.1 Particular issues affecting young people ...... 21 4.2.2 Children and families ...... 21 4.2.3 People living in remote and rural isolation ...... 21 4.2.4 Older people ...... 22 4.3 Health issues and priorities (questions 2 and 3)...... 22 4.4 What affects people’s health (questions 4 & 5) ...... 23

4.5 Positive and negative impacts on the health of the community (question 5a and b)...... 24 5. Community Health and Wellbeing Profiles 2008 and Traffic Lights main findings (results) ....25 5.1 Overview of south Aberdeenshire Traffic Lights...... 25 5.2 Road traffic accidents and injuries in south Aberdeenshire LCHP ...... 27 5.3 Areas of further interest ...... 28 5.3.1 Banchory-Devenick and Findon (IZ059) ...... 28 5.3.2 Mearns North and Inverbervie (IZ050)...... 28 5.3.3 Mearns and Laurencekirk (IZ049)...... 29 5.3.4 Stonehaven South (IZ051)...... 29 5.3.5 East Cairngorms (IZ056)...... 30 6. Quality Outcome Framework (QOF) main findings (results) ...... 30 6.1 QOF an overview of findings ...... 30 6.2 QOF: diseases and conditions across south Aberdeenshire LCHP ...... 30 7. Smoking Prevalence using ‘An atlas of Tobacco Smoking’ ...... 33 8. Practice population by Carstairs Deprivation Categories………………………………………..32

9. Bringing all the health and wellbeing information together (discussion) ...... 34 9.1 Limitations of the information used...... 34 9.1.1 Health and wellbeing needs assessment questionnaire ...... 34 9.1.2 Using Quantitative Information...... 34 9.1.3 Community Health and Wellbeing Profiles and Traffic Lights ...... 34 9.1.4 QOF data ...... 35 9.1.5 An Atlas of Tobacco Smoking in Scotland ...... 36 9.1.6 Carstairs Deprivation Index by Practice Population...…………………………………..35

9.2 Population groups in south Aberdeenshire LCHP with health and wellbeing issues...... 36 9.3 Main health and wellbeing issues...... 37 9.3.1 Health and wellbeing issues from the questionnaire...... 37 9.3.2 RTAs and unintentional injuries ...... 38 9.3.3 Heart disease, cancer, stroke and diabetes...... 39 9.3.4 Chronic kidney disease and atrial fibrillation...... 40 9.3.5 Asthma...... 40 9.3.6 Obesity and high blood pressure ...... 41 9.3.7 Depression and stress ...... 41 9.3.8 Smoking Prevalence………………………………………………………………………...

9.4 Health inequalities across south Aberdeenshire LCHP...... 42 9.5 Determinants of health ...... 43 10. Summary findings and recommendations...... 45 10.1 Summary findings of health and wellbeing issues/needs ...... 45 10.2 Recommendations...... 45

List of annexes

Annex 1: Health and Wellbeing Needs Assessment Questionnaire ...... 47 Annex 2: Key Partners - Questionnaire...... 51 Annex 3: Community Health and Wellbeing Traffic Lights – how do they work? ...... 52 Annex 4: IZ for the health needs assessment, by GP practice and CSN...... 53 Annex 5: Population Groups having health and wellbeing issues by area (%) (Q1)...... 56 Annex 6: Comments about health and wellbeing issues by population groups (Q1) ...... 57 Annex 7: Positive impact on the health of the community (Q5a) ...... 61 Annex 8: Negative impact on the health of the community (Q5b)...... 65 Annex 9: Map Estimates of smoking prevalence……………………………………………………70

List of tables

Table 1: Geographical groupings across south Aberdeenshire ...... 15 Table 2: Data sources used in HNA and level at which expressed...... 17 Table 3: Responses to questionnaire according to areas and professional groups...... 20 Table 4: Groups with health and wellbeing issues (Q1) (ranked) ...... 21 Table 5: Ranked JHIP Health Issue Priorities (Q2)...... 22 Table 6: Ranked health issues (Q3)...... 23 Table 7: Ranked factors affecting people’s health (Q4) ...... 23 Table 8: Headings for positive and negative issues impacting on community health (Q5a & b) 24 Table 9: Summary of Traffic Lights for south Aberdeenshire LCHP ...... 25 Table 10: Traffic Lights for south Aberdeenshire LCHP...... 26 Table 11: RTAs all ages and Unintentional injuries at home during 2004-06 ...... 27 Table 12: QOF Traffic Lights by GP Practice...... 31 Table 13: Summary of QOF Traffic Lights by GP practice...... 32 Table 14: Summary of QOF Traffic Lights by conditions and diseases ...... 32 Table 15: Percentage of patients in each Carstairs Deprivation Category for south Aberdeenshire LCHP 2009 ...... 33 Table 16: List of IZ selected for the HNA with corresponding code ...... 53 Table 17: School children by CSN and Intermediate Zone ...... 53 Table 18: GP Practices by Intermediate Zones ...... 54

Acknowledgements

A number of people helped with the work that went into producing this report. We would like to thank and acknowledge the support from Aberdeenshire CHP, particularly Dr Jennifer Hall and Kim Penman who gave input throughout all the stages of this work and during the report writing. We also wish to thank NHS Grampian, particularly Fred Nimmo for ongoing epidemiological and statistical advice and Dr Linda Leighton-Beck and Jackie Fleming for Traffic Lights input. Last but not least, we would like to thank all the respondents of the pilot questionnaire and the final postal questionnaire we sent out. The views collected were very helpful in informing this health needs assessment.

Glossary AF Atrial Fibrillation Bp Blood Pressure CA Cancer CHD Coronary Heart Disease CHP Community Health Partnership CSN Community Schools Network CKD Chronic Kidney Disease CPP Community Planning Partnership DepCat Deprivation Category GP General Practitioner HEAT Health Improvement, Efficiency, Access and Treatment HNA Health Needs Assessment IZ Intermediate Zone K & M Kincardine and Mearns LCPG Local Community Planning Group LCHP Local Community Health Partnership NHS National Health Service QOF Quality Outcomes Framework RTAs Road Traffic Accidents ScotPHO Scottish Public Health Observatory

Summary

Introduction South Aberdeenshire Local Community Health Partnership (LCHP) is committed to assessing the health needs of its population. This will ensure work is focused on addressing health needs and inequalities that are relevant to south Aberdeenshire. The last assessment was carried out in 2005 for the Westhill area. More up-to-date information is now available. Local Community Health and Wellbeing Profiles for different areas in Aberdeenshire are now available. However, these profiles are presented purely as a series of data with no interpretation or cognisance of information available from other sources.

The aim of this Health Needs Assessment (HNA) was to identify the main health issues in the south Aberdeenshire LCHP area using various data sources. The whole geographic area within south Aberdeenshire LCHP is covered by this HNA.

South Aberdeenshire LCHP is committed to taking a community development approach and working in partnership with community planning partners and community representatives to tackle identified health priorities. This HNA provides an ideal opportunity for partnership working and should usefully inform areas of work such as: local delivery plans, community plans, specialised services commissioning, joint planning and general practice strategic plans.

Quantitative and qualitative information was collected by different methods and then examined using a triangulation approach1. This enabled findings to be corroborated across data sets, thereby reducing the impact of potential biases and providing a more rounded picture of the health needs in the south Aberdeenshire Local Community Health Partnership (LCHP) area.

Methods The following data sources were used to assess the health and wellbeing needs in the south Aberdeenshire LCHP area: 1. A questionnaire sent out to key partners in south Aberdeenshire at the end of 2008 2. Community Health and Wellbeing Profiles 2008 compiled by the Scottish Public Health Observatory with the associated Traffic Lights prepared by NHS Grampian 3. GP practice level data from the Quality Outcomes Framework (QOF) 2006-08 4. Carstairs Index of Deprivation for practice populations 2009.

The questionnaire was mailed out to 315 key partners. Respondents were asked to identify the groups they thought had health and wellbeing issues in their community, the health priorities and the factors that affect health. Results were collated within the 6 community school network areas (CSNs).

The 18 intermediate zones (IZ) in the south Aberdeenshire LCHP area were selected for the Community Health and Wellbeing Profiles and the associated Traffic Lights2 information. The profiles comprise 61 indicators of health and wider determinants of health (e.g. education, employment and income). Data is standardised by age and gender where appropriate.

QOF data recorded by all the 12 GP practices in south Aberdeenshire on 15 diseases and conditions were used in the HNA. Crude prevalence rates (how common a disease is) are provided by QOF. This means that the information is not standardised by age or gender. QOF

1 Triangulation is a “short-hand term” for analysing data from multiple sources. 2 NHS Grampian assigns colour codes to the Community Health and Wellbeing Profiles to facilitate the interpretation of information. For the health indicators, a red light indicates levels worse than the Scotland average, amber is around the Scotland average and a green light is better than the Scotland average.

traffic lights were also developed (by Bellizzi M) using similar methodology as the Community Health and Wellbeing Profiles Traffic Lights.

The Carstairs Index of Deprivation for populations in all the GP practices in south Aberdeenshire was used. This information is produced by the Public Health Directorate of NHS Grampian.

Results and discussion Overall populations in south Aberdeenshire LCHP have a relatively good health status when compared with the rest of Aberdeenshire, especially north Aberdeenshire and Scotland. A few areas have worse levels of heart disease, cancer and stroke compared with Scotland.

More detailed results from this HNA are reported under the main headings of: • Main population groups that have health and wellbeing issues • Main health and wellbeing issues in south Aberdeenshire LCHP • Health inequalities across south Aberdeenshire LCHP • Main factors (determinants) influencing health in south Aberdeenshire LCHP

Main population groups that have health and wellbeing issues A response rate of 36% for the questionnaire was achieved and responses came from a wide range of professional groups across south Aberdeenshire.

50% or more of the respondent thought that the following population groups have health and wellbeing issues (11 population groups were presented for respondents to choose from): • Young people (68.8%) • Children and families (55.4%) • People living in remote and rural isolation (53.6%) • Older people (50.0%)

Overall, only about a quarter of all respondents thought that homelessness and ethnic minorities and gypsy/travellers were an issue in south Aberdeenshire LCHP. However a much larger proportion of those responding from a more strategic level of Kincardine and Mearns, Marr and south Aberdeenshire felt that these groups had health issues in their area.

Detailed comments were made by the respondents in terms of the specific health issues that they thought these groups have and these are included in the Appendix of the report.

Main health and wellbeing issues in south Aberdeenshire LCHP

Qualitative information Respondents to the questionnaire ranked Aberdeenshire’s Joint Health Improvement Plan (JHIP) health priorities in the order of: • Mental health (most important) • Substance misuse • Obesity • Smoking • Sexual health • Oral health (least important)

When presented with a more detailed list of 15 health issues, including the JHIP ones, mental health, substance misuse, smoking and obesity were still considered as high priorities. Oral health fell lower in the priority list after heart disease, cancer, nutrition, sexual health, asthma

and diabetes. Stroke was considered as the least priority but this may be due to few deaths resulting from stroke. Breastfeeding was identified by a few respondents as important.

Main factors (determinants) influencing health in south Aberdeenshire LCHP Respondents to the Health Needs Assessment questionnaire identified friends and family relationships as the most important factor affecting health. Income was next, followed by living in remote/rural areas, social isolation and housing, all of which received similar ranking.

More detailed comments were made by the questionnaire respondents and these have been included in the Appendix of this report.

Quantitative information From the Community Health and Wellbeing Profiles/Traffic Lights, road traffic accident casualties (RTAs) were significantly worse in all of Aberdeenshire CHP, including most of south Aberdeenshire LCHP. No age breakdown is available for this indicator.

Unintentional injuries at home in the under 15 year olds is also significantly worse in Aberdeenshire and most of the IZ in south Aberdeenshire CHP have worse levels compared with the Scotland average (red lights). However, this may be due to differences in hospital admission rates, with children having head injuries being more likely to be admitted in Aberdeen3.

The QOF data showed most of the populations in the south Aberdeenshire LCHP practices had worse obesity rates when compared with the Scotland average. Diseases associated with high blood pressure, such as chronic kidney disease, atrial fibrillation and stroke also appear to be worse than the average for Scotland across three quarters of the practices.

As with the Community Health and Wellbeing Profiles/Traffic Lights, the QOF data indicated geographical differences in the prevalence of diseases and conditions. Some practices, such as Skene and Portlethen had a relatively healthier population compared with the rest of south Aberdeenshire and Scotland. Once again populations within practices in the K & M area and this time also in some parts of Marr were found to have a cluster of red QOF lights (prevalence worse than Scotland average). Some, but not all, of these geographical differences may be related to the age profile of the practice population. Practices in Marr such as Braemar, Ballater and Tarland have a much more elderly population than for example Skene, Portlethen, Laurencekirk and Inverbervie

Health inequalities across south Aberdeenshire LCHP The quantitative data from the Community Health and Wellbeing Profiles/Traffic Lights and the QOF suggest that there are health inequalities across south Aberdeenshire. The cluster of red QOF lights for chronic disease and conditions such as heart disease, stroke, diabetes and high blood pressure around practices in Marr were observed, but this may be due to an age effect since a larger proportion of the population in these areas is elderly.

A clustering of red lights for indicators from the Community Health and Wellbeing Profiles, Traffic Lights as well as the QOF traffic lights in some areas in K & M where the populations tend to be young to middle aged suggests that other factors may be contributing to these patterns.

The Carstairs Index of Deprivation and other population indicators from the Community Health and Wellbeing Profiles suggest that within a narrow range of socio-economic status in south Aberdeenshire, there are areas of relative deprivation. Areas identified by the traffic lights as having worse levels of diseases and conditions are also areas that have higher proportions of

3 Fleming J and Foster K. Unintentional Injury in Children. NHS Grampian 2005.

people within more deprived categories of the Carstairs Index. Health is strongly related to income differences within rich societies.4

The IZ (and GP practice populations5) identified as having relative health deprivation are:

Banchory-Devenick and Findon (IZ059) (Portlethen Medical Centre) Mearns North and Inverbervie (IZ050) (Inverbervie Medical Group) Mearns and Laurencekirk (IZ049) (Laurencekirk Medical Centre) Stonehaven South (IZ051) (Stonehaven Medical Group) East Cairngorms (IZ056) (Ballater and Braemar Health Clinics)

Summarised list of health and wellbeing issues/needs in south Aberdeenshire

• Overall populations in south Aberdeenshire LCHP have a relatively good health status when compared with the rest of Aberdeenshire, especially north Aberdeenshire and Scotland. • From the questionnaire, JHIP priorities were ranked in order of importance as: Mental health, Substance misuse, obesity, smoking, sexual health and oral health. • Young people, children and families, people living in remote and rural isolation and older people were considered as groups having health and wellbeing issues. • Friends and family are considered to be very important in affecting health of the south Aberdeenshire LCHP. Income is also important followed by living in remote/rural areas, social isolation and housing. • As for the rest of Aberdeenshire, Road Traffic Accident casualties significantly worse across south Aberdeenshire LCHP compared with Scotland average. • Unintentional injuries at home worse in many areas of south Aberdeenshire LCHP compared with Scotland average. This may be due to hospital admission policies. • GP Practice data suggests that obesity appears to be widespread across the whole of south Aberdeenshire LCHP with levels worse than Scotland average in most areas • Four areas in Kincardine and Mearns have emerged as having health inequalities including: Banchory–Devenick and Findon (Portlethen Medical Centre), Mearns North and Inverbervie (Inverbervie Medical Group), Mearns and Laurencekirk (Laurencekirk Medical Centre) and Stonehaven South (Stonehaven Medical Group) • East Cairngorms (Ballater and Braemar Medical practices) in Marr has also emerged as an area with health inequalities. This could be associated with a higher elderly / deprived population in this GP Practice • GP Practice data highlights high prevalence of chronic disease which could be due to the population profile for the identified practices detailed above. • Diseases associated with high blood pressure, such as chronic kidney disease and atrial fibrillation, are worse than the Scotland average for the populations in about 75% of the GP practices

4 Wilkinson R and Pickett K. The Spirit Level: Why More Equal Societies Almost Always Do Better published by Penguin in March 2009. 5 The practice in brackets is the main, but not the only, practice serving the population in the stated IZ.

Recommendations

Recommendation 1: Further exploration of information is required in relation to ethnic minorities, migrant workers and homelessness to determine the extent of issues in south Aberdeenshire. Any existing information should be collated and communicated to local key partners in south Aberdeenshire to develop a shared understanding of the local issues. Informed decisions can then be made regarding future action. Recommendation 2: The Community Health and Wellbeing indicator for RTAs covers casualties for all ages. Aberdeenshire Community Safety Partnership are currently supporting a variety of programmes to promote and encourage safe driving, particularly with young people. However they are not the only group progressing safe drive programmes. A co-ordinating approach to this work is required to reduce supplication of work and support communication.

Recommendation 3: Further analysis of the levels of unintentional injuries in the home in Aberdeenshire should be undertaken to conclude if these higher levels are directly a consequence of hospital admission policy. The previous study should be reviewed using the more recent Aberdeenshire figures from the Community Health and Wellbeing profiles 2008.

Recommendation 4: Obesity is a major public health concern and is a risk factor for a number of conditions, including diabetes. QOF data suggest that levels in nearly all of south Aberdeenshire are worse compared with the Scotland average. Given the priority the tackling of obesity has both nationally and locally, further assessment of data available and identification of additional data to better understand the position should be undertaken.

Recommendation 5: Mental Health is considered as a top priority by key partners in south Aberdeenshire. A coherent approach towards addressing mental health in its wider sense should be co-ordinated across south Aberdeenshire.

Recommendation 6: A Grampian wide Smoking Cessation Group has been set up to consider the need to improve the quit rate across Grampian. To date, in Aberdeenshire baseline data has been produced to support work towards the HEAT 6 target. In addition there is a requirement to promote relevant training opportunities for Smoking Cessation across Aberdeenshire.

Recommendation 7: A wealth of qualitative and quantitative information now exists about health and the wider health determinants in south Aberdeenshire. The information available within this needs assessment should inform LCHP and CPP planning.

Recommendation 8: A community-led health approach should now be progressed in those communities identified as experiencing health inequalities. This process should engage and support local communities to review their health needs and develop a realistic local health plan with partners.

1. Introduction

1.1 What is health needs assessment? A HNA is a systematic method for reviewing the health issues facing a population, leading to agreed priorities and resource allocation that will improve health and reduce inequalities6. This HNA aims to present in-depth information about the health and wellbeing needs of populations in the south Aberdeenshire LCHP area which should inform local planning.

1.2 Why undertake this HNA? The last HNA that was carried out in south Aberdeenshire was in 2005 in Westhill. South Aberdeenshire LCHP decided that a more comprehensive HNA was needed which covers the whole of the LCHP area. The Public Health Co-ordinator was entrusted with developing a questionnaire to gather qualitative information from key partners in south Aberdeenshire about the health and wellbeing needs of communities in the area. The Health Improvement Policy Advisor was commissioned to help with the HNA by supporting the analysis of the questionnaire and sourcing and analysing quantitative information related to health indicators, as well as the writing of the report.

1.3 How does this HNA support national and local priorities? The government is committed to improving health and reducing health inequalities. A range of health and social policy documents at national and local level have been developed over the last five years which have provided the impetus for driving forward the health improvement agenda. This HNA provides a vital tool to meet this objective as a way of helping planners identify local needs and set these needs into the wider policy context.

Key national and local policies that this HNA will support include: • Better Health Better Care which outlines targets for health improvement (HEAT7) that NHS Boards, together with their CPP must deliver on.8 • Equally Well: Report of Ministerial Task Force on inequalities in health which specifically addresses health inequalities.9 • At the local level the Single Outcome Agreement10 acts as the umbrella plan guiding community planning. Within this are outcomes for health improvement. These draw upon local needs identified in other documents, including JHIP, Delivery Plan (apportioned HEAT) Community Plan, Neighbourhood Regeneration Plans and local community plans

Current policy also places the Community Health Partnership (CHP) at the heart of health and social care delivery. CHPs have a key role to play in improving health. They are expected to work with local communities and partners to: • Prevent ill health • Identify and treat physical and mental health problems • Ensure services meet the needs of ‘hard to reach’ groups and who have the poorest life circumstances • Be creative in refocusing delivery of services and initiatives to improve access to and uptake of services to ensure equity of health outcomes • Ensure that work to achieve health improvement is integrated into the work of all those involved in the CHP.

6 Cavanagh S and Chadwick K. Health Needs Assessment – A Practical Guide. Health Development Agency 2009 7 HEAT targets: Health improvement, Efficiency, Access and Treatment targets. 8 Better Health Better Care. Scottish Government, 2007. http://www.scotland.gov.uk 9 Equally Well – The Report of the Ministerial Task Force on Health Inequalities. Scottish Government, 2008. http://www.scotland.gov.uk 10 Aberdeenshire Single Outcome Agreement. Community Planning Partnership 2009. http://www.ouraberdeenshire.org.uk

1.4 What influences health? There are complex, multi-layered factors that influence the health of individuals. At the centre there are factors including age, gender and genetic inheritance11. In the second layer are behavioural patterns such as smoking, diet and physical activity. In a third and fourth layers are the wider determinants of health which include socio-economic factors, cultural and environmental conditions.

Tackling health inequalities requires action within these layers of influence. This HNA presents information about some of these influences and should therefore help the LCHP, CPP and the community to prioritise effective action. In addition data gathered will also be used to engage with local communities. Using Community Development approaches the community will then be supported to develop action to tackle their specific health needs.

Figure 1: Determinants of health

1.5 What are the benefits of this HNA? This HNA presents a detailed picture of the health profile in the various areas covered by south Aberdeenshire LCHP. There are several benefits associated with undertaking this HNA, including: • Strengthening CPP involvement in decision making • Improved team and partnership working • Improved communication with other agencies and the public • Better use of resources.

Overall this HNA has successfully accessed information on: • Perceptions of service providers and managers • The size of important aspects of health conditions and diseases, population characteristics and factors that impact on health.

1.6 What next? Community input is absolutely essential to drive changes forward. There is now a wealth of information both in terms of the hard quantitative statistics as well as the equally useful and important qualitative information about what the key planning partners in south Aberdeenshire think are the main health and wellbeing issues. This HNA should serve as a tool to support shared planning with CPP and the community-led health support process.

11 Dahlgren G and Whitehead M Policies and Strategies to promote social equity in health. 1991.

2. Geographic area covered by health needs assessment This health needs assessment (HNA) covers the whole geographic area within south Aberdeenshire Local Community Health Partnership (LCHP) (Figure 1). The total population covered by the LCHP is 73,735 constituting 32% of the whole of the Aberdeenshire population. The population is served by 12 GP Practices that range in practice population size from over 13,000 in Skene and Stonehaven Medical Groups to less than 1,000 in Braemar Health Clinic and Tarland Surgery (Table 1). South Aberdeenshire LCHP geography includes the whole of the local authority’s administration area of Kincardine & Mearns (K & M) and some of Marr but only covers Westhill from the Garioch area. There are 6 Community School Networks (CSNs) within the south Aberdeenshire LCHP area.

Figure 2:

Table 1: Geographical groupings across south Aberdeenshire CSN GP Practice (practice population size*) Council Admin Area Westhill Skene Medical Group (13,801) Garioch

Portlethen Portlethen Medical Centre (12,135) Kincardine & Mearns

Stonehaven Stonehaven Medical Group (13,437) Kincardine & Mearns Inverbervie Medical Group (5,505)

Laurencekirk Laurencekirk Medical Centre (4,757) Kincardine & Mearns Auchenblae Medical Centre (1,760)

Banchory Banchory Group Practice (11,952) Marr Torphins Medical Practice (1,796)

Aboyne Aboyne Health Centre (5,471) Marr Tarland Surgery (808) Ballater Clinic (2,090) Braemar Health Clinic (562)

* Practice size taken from the Quality Outcomes Framework for 2007/08

2.1 Kincardine & Mearns12 The main towns in K & M are Stonehaven (10,61413), Portlethen (6,632), Newtonhill (3,066), Inverbervie (2,053) and Laurencekirk (2,110). There are also a number of smaller villages such as Drumoak, St Cyrus, Fettercairn, Johnshaven and Gourdon. Marked by 37 miles of coastline to the east and the foothills of the Grampian mountains to the west, the area is varied with development to the north and rich agricultural land to the south.

This area is diverse. In the North proximity to Aberdeen has encouraged considerable development of population and industry. The Southern part contains the rich farmland of the Mearns, northeast Scotland’s greatest resource of prime agricultural land and a series of attractive former fishing villages.

K & M is very much integrated with Aberdeen particularly in the north where considerable proportions of the working population commute into the city. Nevertheless, a new business centre has opened in Stonehaven and growth has also taken place around Portlethen. Some of the main employers include McIntosh Donald, Asda, Baker Hughes Inteq and Cooper Cameron.

2.2 Marr8 Marr covers almost half of Aberdeenshire’s geographic area but only 15% of its people. The main towns are Banchory (6,593), Huntly (4,353), Aboyne (2,378), Alford (2,082) and Ballater (1,739). Some of the smaller villages include Tarland, Torphins and Braemar with much of the landscape defined by the spectacular Cairngorms to the west. All these towns and villages, apart from Huntly and Alford, are sometimes collectively referred to as the Deeside area.

Agriculture, forestry and tourism play a key role in Marr's traditional rural economy. The east of Marr benefits from its proximity to Aberdeen with around 2 in 5 Alford and Banchory residents commuting to Aberdeen. Some of the key employers include RB Farquhar, Hilton Craigendarroch Hotel and Country Club, Deans of Huntly and Bancon Developments. Huntly and Alford fall into central Aberdeenshire LCHP and therefore are not included in this HNA.

2.3 Garioch8 Garioch's population is increasing significantly particularly along the Inverurie A96 corridor. The two main towns in Garioch are Inverurie (11,062) and Westhill (10,392) while other settlements include Kemnay, Newmachar, Kintore and Insch. Only Westhill falls within the south Aberdeenshire LCHP boundaries and as such has been included in this HNA.

3. Information used for the health needs assessment (methodology)

3.1 Main information sources used This health needs assessment (HNA) drew upon qualitative and quantitative information. This included: (i) the Health and Wellbeing Needs Assessment Questionnaire 2008 (ii) the Community Health and Wellbeing Profiles 2008 and Traffic Light Data 2009 (iii) the Quality Outcomes Framework (QOF) 2006-08 (iv) an ATLAS of Tobacco Smoking in Scotland 2007 (v) the Carstairs Deprivation Index by Practice Population 2009.

Although there is no neat fit in terms of geography and population size between the different data sources (Table 2), key priorities were identified by viewing the various datasets using a

12 Aberdeenshire Community Planning Partnership www.ouraberdeenshire.org.uk 13 The population sizes given in brackets are for 2006 and were taken from Population Estimates and Forecasts 2007 Update: Aberdeenshire Settlements www.aberdeenshire.gov.uk/statistics/

triangulation approach14. This is an approach to data analysis that synthesizes data from multiple sources.

Table 2: Data sources used in HNA and level at which expressed Data Level at which reported

(i) Health and Wellbeing Needs Assessment CSN level, however some responses were Questionnaire 2008 expressed at Council Administration Area level and at total south Aberdeenshire Level.

(ii) Community Health and Wellbeing Profiles Intermediate Zones (IZ) with a population of 2,500 to 2008 and Traffic Lights 2009 6,000 and grouped according to Council Admin Areas.

(iii) Quality Outcomes Framework (QOF) GP practice level prevalence data. Sizes of 2006-08 populations in south Aberdeenshire GP practices vary from IZ size to datazone numbers of around 750.

(iv) an ATLAS of Tobacco Smoking in CHP level smoking prevalence data Scotland 2007

(v) Carstairs Deprivation Index by Practice GP practice level deprivation data. Population 2009

3.2 The Health and Wellbeing Needs Assessment Questionnaire

3.2.1 Questionnaire development From research of previous needs assessments, a pilot questionnaire was developed by the south Aberdeenshire Public Health Co-ordinator which included a variety of ranking questions and a diagram of the ‘wheel of health.’ The questionnaire was piloted with five professionals from a variety of agencies including Community Planning Officers, Locality Support Manager, Public Health Link Support and Community Learning and Development staff. Along with completing the questionnaire, professionals were asked for feedback / comments on how easy the pilot questionnaire was to complete and were asked for amendments which would make questionnaire better. From the feedback provided the questionnaire was amended including the removal of ‘wheel of health’ diagram. The final questionnaire comprised five questions (Annex 1).

3.2.2 Distribution of final questionnaire The final questionnaire was sent out to 315 key partners. The contact list for circulation of the questionnaire was initiated from the previous needs assessment and local knowledge. The final contact list included a variety of partners (Annex 2) including Community Councils. Stamped self addressed envelopes were provided along with the questionnaire to encourage response. All questionnaires were coded to allow non-response follow-up.

The questionnaire was sent to the full contact list at the beginning of September with a deadline of 31st October 2008. A further questionnaire and cover letter with an extended deadline of 12th December 2008 was sent to those who did not respond. During the consultation period partners were also made aware of the needs assessment through multi-agency meetings.

3.2.3 Questionnaire analysis The information from the questionnaire was entered on Excel spreadsheets by the Public Health Co-ordinator and the analysis and interpretation of this information, together with the

14 Triangulation. Prevention and Public Health Group. University of California www.igh.org/triangulation/

analysis of the qualitative information, was carried out by the Health Improvement Policy Advisor.

Question 1 presented respondents with a list of population groups and they were asked to identify those that have particular health and wellbeing issues and then to specify what these issues are. Total numbers ticked for each population group were counted. The comments next to each population group were documented in full.

Questions 2, 3 and 4 asked respondents to rank health issues or wider health determinants (e.g. income, housing) from 1 to 6, with 1 being the most important and 6 the least important. To facilitate the interpretation of these responses, weighting was assigned to the priorities. Those issues ranked 1 were weighted as 6, those ranked 2 were weighted as 5 and so on up to rank 6 given a weighting of 1. The total weights were added to give a single score for each issue.

Question 5 was an open-ended one asking for positive and negative issues that impact on the community wellbeing. The responses were grouped under broad headings.

3.3 Community Health and Wellbeing Profiles 2008 and Traffic Lights

3.3.1 Background on Community Health and Wellbeing Profiles Community Health and Wellbeing Profiles comprise 61 indicators of health (e.g. ill-health & injury and mortality) and wider determinants of health (e.g. education, employment & prosperity and environment). These profiles have been compiled by the Scottish Public Health Observatory (ScotPHO) Team at the Information Services Division (ISD) of NHS National Services Scotland. The 2008 profiles build on the 2004 community health profiles previously published by NHS Health Scotland.

Community Health and Wellbeing Profiles for particular areas are compiled by using data from published sources. These include, among others, Census information, Information Services Division (ISD), General Register Office for Scotland and Scottish Morbidity Records. Definitions and sources for each of the indicators featured in the profiles are found in the technical report www.scotpho.org.uk/profiles.

3.3.2 Traffic Lights The Public Health Unit of NHS Grampian assigns a colour code ‘Traffic Lights’ to the Community Health and Wellbeing Profiles to make it easier to understand all the health and population information and see differences between geographical areas. The 2008 traffic lights are at the Intermediate Zone (IZ) level which are an aggregation of data zones, and contain between 2500 and 6000 people.

The health indicators are assigned red, amber and green lights. Red signifying levels worse than the Scottish average, green better and amber within the Scottish average range. The population indicators are assigned blue lights. Dark blue is higher than Scottish average, light blue lower and mid-blue within the Scottish average range. With the blue lights dark blue does not necessarily mean better or worse. For example some areas may have much higher elderly population levels than other areas. More detail on how the Traffic Lights work is provided in Annex 3. A Traffic Lights report is available for the Aberdeenshire’s Council administration areas. Detailed Traffic Lights, including values for the indicators and statistical significance compared with Scotland average are also provided online (www.nhsgrampian.org/).

3.3.3 Intermediate zones selected for HNA The 18 Intermediate Zones (IZ) that are within the south Aberdeenshire LCHP geography were included in this HNA. Populations in all these IZ are covered by the health services and CSNs in south Aberdeenshire. The selected IZ and corresponding IZ code are given in Annex 4. Lists of the 6 CSNs and 12 GP practices with the corresponding IZ for their populations are also provided. A map of the IZ across all of Aberdeenshire is given in Annex 4 (Figure 2).

3.4 Quality and Outcomes Framework (QOF) 2006-08

3.4.1 What is QOF? QOF measures achievement against a range of evidence-based indicators, with points and payments awarded to GP practices according to the level of achievement. One element of QOF is that it is a data source on the prevalence of specific diseases or health conditions at GP practice level. It is a fundamental part of the General Medical Services (GMS) contract, introduced on 1st April 2004. Participation by general practices in the QOF is voluntary. All GP practices in south Aberdeenshire LCHP record information used in QOF.

The robustness of this dataset partly depends on the data recording by the individual GP practices. All the practices in south Aberdeenshire LCHP have achieved an average 98% recording record for many of the conditions or diseases considered by this HNA. If interpreted with caution, they can potentially be used to examine the prevalence of the chronic diseases and conditions included in the clinical domains.

QOF prevalence rates are provided as "raw" or "crude" rates. A QOF prevalence rate is simply the total number of patients on the register, expressed as a proportion or percentage of the total number of patients registered with the practice at one point in time.

3.4.2 QOF data used for this HNA The 2007/08 QOF data have been used for this HNA. The following conditions and diseases were selected: obesity, high blood pressure (hypertension), diabetes and depression, coronary heart disease, stroke, cancer, chronic kidney disease, atrial fibrillation, asthma, chronic obstructive pulmonary disease (COPD), heart failure, dementia and learning difficulties. Definitions for each of these conditions and diseases can be found on www.isdscotland.org/isd/3746.html.

3.4.3 Using QOF data Bar charts of the selected conditions and diseases have been plotted for all the south Aberdeenshire LCHP practices (Annex 9). The Aberdeenshire CHP, NHS Grampian and Scottish average prevalence rates have been included in the bar charts for comparison.

The frequency with which a condition occurs and the practice population number, are important when calculating the prevalence rate. A slightly elevated number of cases in a small practice would result in a high prevalence rate (and so a high level on the bar charts). To account for this, prevalence rates were compared with the Scottish average to determine whether levels were significantly higher or lower using a statistical analysis (T-Test). A colour coded system similar to the health indicators of the Traffic Lights was developed as a way of summarising the various bar charts (Annex 3). These will be referred to as the QOF Traffic Lights.

3.5 An ATLAS of Tobacco Smoking in Scotland 2007 The Tobacco ATLAS provides smoking prevalence estimates at a variety of relevant geographical levels, particularly for small areas, as a resource to support smoking cessation and prevention acitivities within NHS Boards, CHP’s and Councils across Scotland. The prevalence calculations are a synthetic estimation applied to smoking status data from the 2003/04 Scottish Household Survey and a range of characteristics of the local population from the 2001 Census. Essentially this approach generates estimates of the numbers of people in a particular ‘target’ who, given certain assumptions based on their characteristics in census data,

might be expected to be ‘current smokers’. Thus this is based on modelling of what ‘should be the case based on population profile; so if historically it is a high (or low) smoking prevalence area, then it would not necessarily be shown as such.

3.6 Carstairs Deprivation Index by Practice Population 2009 The Carstairs index is based on four census indicators: low social class, lack of car ownership, overcrowding and male unemployment. The index is divided into 7 deprivation categories (DepCat), with DepCat1 being affluent and DepCap7 being deprived.15 Each postcode sector is assigned to a DepCat based on the 2001 census. These scores are then used in conjunction with the community health index population for 2009 to determine deprivation by postcode sector and by GP practice.16

4. Health and wellbeing needs assessment questionnaire results

4.1 Response rate Of the 315 questionnaires sent out, 112 questionnaires were returned (35.6%) with responses covering a broad spectrum of professional groups and areas across south Aberdeenshire LCHP (Table 3 and Annex 2). Some responses may have been completed on behalf of teams, but it is not possible to know to what extent this has been done.

Table 3: Responses to questionnaire according to areas and professional groups

Aboyne B’chory L’Kirk P’lethen S’haven Westhill K&M Marr SA Totals

GP 8 4 1 2 4 4 23 South LCHP 2 2 1 3 5 8 7 3 31 C Council 3 2 3 1 9 CSN 5 3 5 4 7 3 27 LA 1 2 2 1 2 1 3 1 2 15 Police 1 1 Voluntary 3 2 1 6

Totals 19 13 12 10 18 10 14 10 6 112 C Council = community council; LA = Local Authority; CSN = Community Schools Network; B’chory = Banchory; L’kirk = Laurencekirk; P’lethen = Portlethen; K & M = Kincardine and Mearns; SA = south Aberdeenshire

A few responses to questions 2, 3 and 4 had to be discarded as they were completed incorrectly17. Other respondents did not tick all the requested 6 priorities of health issues or factors affecting people’s health in questions 2 to 4. These responses were included in the analysis.

4.2 Population groups having health and wellbeing issues (question 1) When asked which population groups have particular health and wellbeing issues, 69% identified young people (Table 4). Around half identified children and families, people living in remote and rural isolation and older people as also having particular health issues. Homeless as well as ethnic minorities & gypsy travellers were identified least as groups having particular health issues in the community.

15 Carstairs V, Morris R. Deprivation and health in Scotland. Aberdeen: Aberdeen University Press, 1991. 16 Nimmo F. Practice Population by Carstairs Deprivation Category. NHS Grampian. 17 Question 2: 10 responses discarded, Question 3: 18 responses discarded, Question 4: 13 discarded.

There are differences between the CSN areas themselves and between the CSN areas and the more strategic levels of K & M, Marr and whole of south Aberdeenshire (Annex 5). Main ones are: • 70% of responses from Westhill CSN area and 60% from Marr identified migrant workers as a group having health and wellbeing issues compared with much lower percentages for the other CSN areas • Ethnic minorities and Gypsy/Travellers were considered by only small proportions of respondents at CSN level (ranging from 5% to 30%) as having health and wellbeing issues in their areas. 60% of responses at the Marr level thought that this group has health issues. • A higher proportion of responses (40 to 50%) at the Marr, K & M and south Aberdeenshire levels and Westhill CSN area considered the homeless to have health issues in their area compared with much lower percentage of respondents from most of the other CSN areas.

Table 4: Groups with health and wellbeing issues (Q1) (ranked) Yes No Yes No % % Young people 77 11 68.8 9.8 Children & Families 62 21 55.4 18.8 People living in remote & rural isolation 60 20 53.6 17.9 Older people 56 15 50.0 13.4 Carers 49 23 43.8 20.5 Women & children affected by domestic abuse 48 23 42.9 20.5 Migrant Workers 41 30 36.6 26.8 Working lives 36 24 32.1 21.4 Homeless 28 39 25.0 34.8 Ethnic Minorities & Gypsy/Travellers 23 37 20.5 33.0 Other 7 6 6.3 5.4 Total number of respondents = 112

Respondents were asked to comment on specific issues affecting each group. The main issues expressed for the 4 population groups most frequently identified across the whole of south Aberdeenshire LCHP as having health and wellbeing issues are outlined next. More detailed comments for all the population groups by area are given in Annex 6.

4.2.1 Particular issues affecting young people Alcohol use, in particular underage drinking, drugs, mental health, including exams pressure, lack of local recreational opportunities, sexual health, teenage pregnancy and absence of links to services were all common themes emerging across south Aberdeenshire. Road traffic accidents were identified as an issue by the Aboyne respondents (Annex 6).

4.2.2 Children and families A wide range of comments emerged for this population group and included: shortages of facilities and services such as recreational, speech and language therapy, holiday support, affordable childcare. Specific health issues were also identified and included diet, obesity, mental health, sleep (lack of), sexual health and post natal depression.

4.2.3 People living in remote and rural isolation Comments about transport (cost, poor bus routes, links etc.) emerged from most of the CSN areas but not Westhill. Isolation, social support, access to services and shops, lack of facilities and mental health were identified.

4.2.4 Older people Limited day care provision and social outlets, transport (also to clinics, dentist etc.), respite, insufficient psychiatric services, rural isolation, financial difficulties and heating were some of the comments that emerged as affecting older people. Specific health issues were also identified and these included dementia, COPD, falls and mental health.

4.3 Health issues and priorities (questions 2 and 3) In questions 2 and 3 respondents were asked to rank a series of health issues in order of priority. Question 2 enquired about the 6 Aberdeenshire Joint Health Improvement Plan (JHIP) health priorities for 2007–10, while question 3 expanded on this and included the same 6 JHIP priorities as well as a number of other ones.

A large majority responding to question 2 indicated that across the whole of south Aberdeenshire LCHP area, mental health is the top priority out of the JHIP priorities. This was followed by substance misuse, obesity and smoking, with oral health being at the bottom of the list (Table 5).

Table 5: Ranked JHIP Health Issue Priorities (Q2) Rank 1 2 3 4 5 6 Ranked Issue (n) (n) (n) (n) (n) (n) score Mental health 51 13 13 10 8 3 472 Substance misuse 19 36 19 7 9 5 414 Obesity 19 15 13 23 20 5 355 Smoking 7 18 21 27 14 3 328 Sexual health 5 11 19 14 25 17 270 Oral health 1 5 11 8 13 53 178 (n) refers to the number of respondents

Responses from question 3 indicated that, with the exception of coronary heart disease (CHD) which is not a JHIP priority, the top 4 health priorities identified by the respondents are similar to the JHIP ones chosen in the previous question (Table 6). Cancer, nutrition, sexual health and asthma and respiratory diseases were ranked towards the middle of the list. Physical injury (including violence and accidents) and stroke were considered by the respondents as being least of a priority. A few respondents identified breastfeeding in the ‘other’ category.

Table 6: Ranked health issues (Q3) Issue Rank 1 2 3 4 5 6 Ranked (n) (n) (n) (n) (n) (n) score Drug and Alcohol Use 19 14 11 8 7 5 271 Depression/psychiatric disorders 25 3 10 11 8 10 264 Smoking 4 10 9 14 7 7 173 CHD 6 13 7 8 5 3 166 Obesity 5 14 6 7 6 6 163 Cancer 9 7 8 4 4 6 147 Nutrition 5 5 6 10 3 5 120 Sexual Health 3 4 10 4 8 5 111 Asthma and respiratory disease 7 2 4 6 10 4 110 Diabetes 1 3 4 6 5 5 70 Oral Health 2 2 3 5 2 4 57 Disability 2 2 4 2 3 2 52 Self harm/ suicide 2 4 2 1 2 3 50 Other 2 4 2 0 0 3 43 Physical Injury (including 2 2 1 1 4 2 39 violence and accidents) Stroke 0 2 2 0 6 4 34 (n) refers to the number of respondents

4.4 What affects people’s health (questions 4 & 5) Friends and family relationships was a major factor that was identified in affecting people’s health followed by income (Table 7). Social isolation and living in remote/rural areas were next. There was only one person who identified religion as being important in affecting people’s health.

Table 7: Ranked factors affecting people’s health (Q4) Rank 1 2 3 4 5 6 Ranked Issue (n) (n) (n) (n) (n) (n) score Friends & family relationships 20 15 15 8 10 3 302 Income 21 12 7 8 3 9 253 Living in remote/rural areas 14 6 9 7 4 7 186 Social isolation 7 12 5 14 8 6 186 Housing 5 13 11 7 7 5 179 Sense of community 3 13 6 8 3 5 142 Access to Health care services 6 4 8 9 11 3 140 Transport 2 1 11 10 9 14 123 Un/employment 7 3 6 3 8 7 113 Ease of access to service 3 6 6 4 7 13 111 Education 4 4 6 6 9 4 108 Work environment 2 4 2 4 4 2 62 Cost of services 2 2 2 4 5 4 56 Other 3 18 Religion 1 3 (n) refers to number of responses

4.5 Positive and negative impacts on the health of the community (question 5a and b) Question 5 of the questionnaire asked respondents for any positive or negative issues that have an impact on the community. Several comments emerged which were grouped under a number of headings (Table 8).

Overall 11 general headings emerged for the positive (question 5a) and negative (question 5b) issues (Table 8). The first eight headings were similar for the positive and negative issues. Only positive comments were made about school/education, local staff and partnerships. On the other hand only negative issues emerged under isolation/rurality, older people/carers and parenting.

Table 8: Headings for positive and negative issues impacting on community health (Q5a & b) Positive issues local services/facilities, access to services, transport, environment, economy, lifestyle, housing, community/community groups, school/education, local staff and partnerships

Negative issues lack of services/facilities, access to services, transport, environment, economy, lifestyle, housing, community/safety, isolation/rurality, older people/carers and parenting

Comments under the different headings by the different areas are given across the whole of the south Aberdeenshire LCHP area are given in Annex 7 and Annex 8. In some instances positive and negative comments were made about the same key issues e.g. the role of community activists. It may therefore be useful for local community planning partnerships to look more closely at these comments when planning and delivering services.

5. Community Health and Wellbeing Profiles 2008 and Traffic Lights main findings (results)

5.1 Overview of south Aberdeenshire Traffic Lights Overall south Aberdeenshire LCHP has a large number of health indicators that are better than the Scotland average (green) with the majority (n=214) being significantly better18 (Table 9 and Table 10). 13% (n=54) of the lights are worse than the Scotland average (red lights) with 11 being statistically significant. 7.3% (n=30) of the health indicators are no better or worse than the Scotland average (amber).

Table 9: Summary of Traffic Lights for south Aberdeenshire LCHP

Better Worse Around average (green) (red) (amber) number 330 54 30 % of all lights (n=414i) 79.7 13.0 7.3

Number that are 183 11 - significantly differentii i 23 health indicators for each of the 18 IZ selected = 414 ii All the red lights that are significantly different to Scotland rate are for ‘Road traffic accidents for all ages’ and ‘unintentional injuries in the home for under 15 year olds’ Source: Public Health Directorate, NHS Grampian www.nhsgrampian.org/

‘Road traffic accidents for all ages’ and ‘unintentional injuries in the home for under 15 year olds’ stand out from all the other health indicators because nearly all the IZ across south Aberdeenshire LCHP have rates that are worse than the Scotland average (red) (Table 11), with many of them being significantly different to the Scotland rates.

Some IZ within south Aberdeenshire have levels of ‘stroke for hospital patients’, ‘early deaths from CHD’, ‘early deaths from cancer’, ‘patients registered with cancer’, ‘mothers smoking during pregnancy’, ‘low weight live births’ and ‘unintentional injuries in the home - patients <15’ that are all worse (red) or around the Scotland average (amber) (Table 10).

18 Data on statistical significance associated with the Traffic Lights is available from the Public Health Directorate of NHS Grampian.

Table 10: Traffic Lights for south Aberdeenshire LCHP

5.2 Road traffic accidents and injuries in south Aberdeenshire LCHP

Road Traffic Accident (RTA) Casualties all ages RTAs in the whole of Aberdeenshire are significantly higher when compared with the Scotland average. During 2004 to 2006 there were 964 accidents in Aberdeenshire, of which 271 (28.1%) occurred in the south Aberdeenshire LCHP area (Table 11). 15 out of the 18 IZ in the south Aberdeenshire LCHP area are worse for RTAs (red lights), with 7 IZ significantly worse than the Scotland average.

Unintentional injuries at home in <15 year olds Just over a third (35.7%) of all accidents in Aberdeenshire were in south Aberdeenshire (Table 11). This is expected given that a third (32%) of the Aberdeenshire population lives in the south. 15 out of the 18 IZ considered were assigned a red light of which 5 were significantly worse than the Scotland average. There was also 1 amber light.

Table 11: RTAs all ages and Unintentional injuries at home during 2004-06 home RTA1 injuries2 Name numbers rate numbers rate Garioch Garlogie & Elrick 5 55.37 31 1470.59 Westhill Central 8 63.37 28 1201.72 Westhill North & South 12 123.3 41 1644.6 Kincardine & Mearns Mearns South & Benholm 13 128.97 23 1130.22 Mearns & Laurencekirk 17 186.4 26 1349.25 Mearns North & Inverbervie 20 166.03 44 1670.46 Stonehaven South 17 140.33 41 1886.79 Stonehaven North 16 109.28 47 1271.3 Fetteresso, Netherly & Catter 15 160.72 37 1624.95 Newtonhill 10 111.38 32 1634.32 Portlethen 13 104.37 46 1619.15 Banchory-Devenick & Findon 8 73.53 31 1521.1 Dunect, Durris & Drumoak 20 165.04 40 1375.99 Marr Aboyne & South Deeside 17 166.31 37 1424.17 East Cairngorms 22 241.01 13 1009.32 Banchory 23 129.00 49 1445.43 Crathes & Torphins 12 165.29 33 1308.49 Cromar & Kildrummy 23 194.19 22 992.78

Total south Aberdeenshire LCHP 271 621

Total Aberdeenshire 964 148.2 1741 1346.4

Source: Figures obtained from Public Health Directorate, NHS Grampian. www.nhsgrampian.org/ Figures in bold signify that rates that are statistically significantly worse than Scotland average 1 For RTAs: numbers expressed as total of 3 years 2004-06 and rates 3-year average directly age-sex standardised rate per 100,000 population per year 2 For Injuries at home: numbers expressed as total of 3 years 2004-06 and rates 3-year average crude rate per 100,000 population per year

5.3 Areas of further interest Out of the 18 intermediate zones, the following five emerged with the most red and amber lights: Banchory-Devenick and Findon (IZ059), Mearns North and Inverbervie (IZ050), Mearns and Laurencekirk (IZ049), Stonehaven South (IZ051) and East Cairngorms (IZ056).

The whole of Aberdeenshire, especially south Aberdeenshire, enjoys a relatively good health status when compared with the rest of Scotland. This means that, in general, levels for health indicators are lower than the Scotland average and so emerge as green lights. However, the health of the Scottish population does not compare favourably with other European countries19. To compensate for this, some comparisons of the health indicators as well as the population indicators (blue lights) have been made against the Aberdeenshire average20. In this way areas in south Aberdeenshire that are worse, compared with the rest of Aberdeenshire are identified.

5.3.1 Banchory-Devenick and Findon (IZ059) • Early deaths from CHD and Cancer, CHD hospital patients, alcohol related deaths, mothers smoking during pregnancy and unintentional injuries in the home of <15 year olds are all higher (red lights) compared with the Scotland average (Table 10). • Patients registered with cancer, emergency admission hospital patients and multiple admission hospital patients in +65 year olds around average for Scotland (amber) (Table 10) • Significantly more 0 to 15 year olds and 16 to 64 year olds compared with the Scotland average (dark blue lights). • Although less crimes were committed in 2004 (43.68 per 1,000 population) when compared with the average for Scotland (53.5 per 1000), the rate was higher than the Aberdeenshire average (30.2 per 1000). • 11.2% of total population in this IZ lived within 500 metres of derelict site in 2007 compared with 8.5% in Aberdeenshire as a whole. • The number of adults claiming incapacity benefits/severe disability allowance (5.04% of 16+ of population) in 2007 was higher than the Aberdeenshire average (4.4%).

5.3.2 Mearns North and Inverbervie (IZ050) • This IZ includes Gourdon – situated on the coast. • Early deaths from CHD, road traffic accident casualties, mothers smoking during pregnancy, low birth weight live births and unintentional injuries in the home of <15 year olds are all higher (red lights) compared with the Scotland average (Table 10). • Patients registered with cancer, CHD hospital patients and emergency admissions around Scotland average (amber) (Table 10). • The percentage of estimated smokers (24.4% of +16 year olds) was higher than Aberdeenshire average (22.8%) in 2003-4. • The number of patients released from hospital (annually) with alcohol related and attributable conditions was 763.08 (per 100,000 population per year standardised for age and sex – three year average) compared with 633.2 for Aberdeenshire. • Significantly more 0 to 15 year olds and live births compared with the Scotland average (dark blue light) and significantly less of 65+ year olds during 1996 to 2006. • The percentage of +60 year olds claiming pension credit (17%) in 2007 was higher than Aberdeenshire average (13.5%).

19 A review of current approaches, knowledge and recommendations for new research directions. Leon DA, Morton S, Cannegieter S and McKee M. London School of Hygiene and Tropical Medicine for the Public Health Institute for Scotland. 20 Statistical significance information is not available for comparisons between south Aberdeenshire LCHP and Aberdeenshire CHP and therefore must be interpreted with caution. The source for the data is the detailed Traffic Lights available on www.nhsgrampian.org/

5.3.3 Mearns and Laurencekirk (IZ049) • Early deaths from cancer, stroke hospital patients, road traffic accident casualties, mothers smoking during pregnancy and unintentional injuries in the home of <15 year olds are all higher (red lights) compared with the Scotland average (Table 10). • Patients registered with cancer and psychiatric hospital patients around Scotland average (amber) (Table 10). • Percentage of estimated smokers in 2003-4 (23.4% of +16 year olds) was higher than Aberdeenshire average (22.8%). • Significantly more 0 to 15 year olds and live births compared with the Scotland average (dark blue light). • Significantly more 65+ year olds compared with the Scotland average (dark blue light) but significantly less of 16-64 year olds (light blue). • Higher percentage of lone pensioner households (14.7% of all households in 2001) compared with 12.9% for Aberdeenshire. • Higher percentage of lone parents claiming income support (13.9 per 1,000 population aged 16-64 in 2007) compared with 8.2 per 1,000 for Aberdeenshire. • The number +60 year olds claiming pension credit (14.3%) in 2007 higher than Aberdeenshire average (13.5%).

5.3.4 Stonehaven South (IZ051) • Early deaths from CHD and stroke, road traffic accident casualties and unintentional injuries in the home of <15 year olds are all higher (red lights) compared with the Scotland average (Table 10). • Patients registered with cancer, stroke hospital patients and unintentional injuries in <15 year olds around Scotland average (amber) (Table 10). • The number of patients released from hospital (annually) with alcohol related and attributable conditions was 713.6 (per 100,000 population per year standardised for age and sex – three year average) compared with 633.2 for Aberdeenshire. • Higher percentage of adults with limiting long-term illness (16.5%) in 2001 compared with 15.3% for Aberdeenshire. • Significantly more 65+ year olds compared with the Scotland average (dark blue light). • Significantly less 0-15 year olds compared with the Scotland average (light blue light). • Higher percentage of lone pensioner households (18.4% of all households in 2001) compared with 12.9% for Aberdeenshire. • Higher crime rates in 2004 (49.1 per 1,000 population) compared with Aberdeenshire average (30.2 per 1000). • Higher percentage of population living within 500 metres of derelict site in 2007 (22.1% of total population in IZ) compared with the Aberdeenshire average of 8.5%.

5.3.5 East Cairngorms (IZ056) • Stroke hospital patients rate, road traffic accident casualties and low birth live weights higher than Scotland average (red light). • • Mothers smoking during pregnancy, deaths from suicide, unintentional injuries in the +65 year olds, patients registered with cancer and early deaths from CHD around the Scotland average (amber). • The number of patients released from hospital (annually) with alcohol related and attributable conditions was 712.6 (per 100,000 population per year standardised for age and sex – three year average) compared with 633.2 for Aberdeenshire. • Higher percentage of adults with limiting long-term illness (18.1%) in 2001 compared with 15.3% for Aberdeenshire. • Significantly more 65+ year olds compared with the Scotland average (dark blue light). • Significantly less 0-15 year and 16 to 64 year olds compared with the Scotland average (light blue light). • Higher percentage of lone pensioner households (20.5% of all households in 2001) compared with 12.9% for Aberdeenshire.

6. Quality Outcome Framework (QOF) main findings (results)

6.1 QOF an overview of findings The prevalence rates for the selected QOF indicators present a varied health pattern across the south Aberdeenshire LCHP area, with Skene and Portlethen practices having better than the Scotland average levels across the majority of the diseases and conditions (Table 12 and Table 13) (detailed bar charts of diseases and conditions by GP practice are given in Annex 9).

At the other end of the scale are Tarland, Braemar and Ballater practices whose populations have the majority of the selected conditions and disease with levels that are worse or around the Scotland average.

The other practices fall in-between, with varying numbers of reds and ambers.

6.2 QOF: diseases and conditions across south Aberdeenshire LCHP Looking at the diseases and conditions across south Aberdeenshire LCHP more closely (Table 14), obesity is the only condition for which none of the populations in GP practices have prevalence rates that are better than the Scotland average. In fact a majority of practice populations have significantly worse levels compared with the Scotland average.

Chronic kidney disease, followed by atrial fibrillation and dementia are next in having more than half of the GP practices with levels worse than the Scotland average (red). However, the numbers of cases for dementia are less than 20 for several practices contributing to less than 1.5% of the overall prevalence rates at practice level (Annex 9).

Chronic Obstructive Pulmonary Disease (COPD), learning difficulties and diabetes have the least practices with levels worse than the Scotland average. However, for diabetes there are 5 practices with levels around the Scotland average (amber). As for learning difficulties the practice prevalence rates are less than 20 for half of the practices and do not contribute more than 0.6% of the practice prevalence (Annex 9).

The other diseases and conditions (high blood pressure, stroke, cancer, asthma and heart failure) show a varied picture in that around half of the GP practices (but not necessarily the same practices), having levels that are worse or similar to the Scotland average. None of the practices have significantly higher rates of stroke compared with Scotland. However, Ballater, Braemar and Tarland practices have rates that are on the high side and nearly reach statistical significance for red.

Table 12: QOF Traffic Lights by GP Practice21 high Atr Heart Learng obesity bp diab CHD CKD Fibrl Stroke CA COPD Asthma Deprsn Demnta Flre Diff Skene Medical Group * * * * * * * * * * * Aboyne Health Centre * * * * * * * Ballater Clinic * (*) * * (*) * <20 * * <20 *<20 Braemar Health Clinic * * (*) * * * <20 <20 <20 * <20 * * <20 <20 <20 Tarland Surgery * * <20 (*) <20 <20 <20 <20 <20 Torphins Medical Practice * <20 * <20 * <20 * <20 <20 *<20 Banchory Group Practice * * * * * * * * Portlethen Medical Centre * * * * * * * * * * * * Stonehaven Medical Group * * * * * * * * * (*) Auchenblae Medical Centre * * * <20 * <20 * <20 <20 *<20 Inverbervie Medical Group * * * - * * Laurencekirk Medical Centre * * * * - * * * * (*) *<20 Red is prevalence higher than Scotland average, green is lower than Scotland average and amber is around Scottish average * means statistically different from Scotland average <20 means that prevalence is less than 20 cases (*) has nearly reached significance - means it is close to being amber

High bp = high blood pressure; diab = diabetes; CHD = coronary heart disease; CKD = chronic kidney disease; Atr Fibrl = atrial fibrillation; CA = cancer; Deprsn = depression; Demnta = dementia; Heart Flre = heart failure; Learng Diff = learning difficulties.

21 Detailed bar charts for all the above diseases and conditions by GP practice are found in Annex 9 31

Table 13: Summary of QOF Traffic Lights by GP practice22 GP practice Red Amber Green

Tarland Surgery 10 2 2 Braemar Health Clinic 10 - 4 Ballater Clinic 10 0 4 Banchory Group Practice 7 5 2 Laurencekirk Medical Centre 6 1 7 Aboyne Health Centre 6 4 4 Inverbervie Medical Group 4 2 8 Stonehaven Medical Group 4 1 9 Auchenblae Medical Centre 3 2 9 Torphins Medical Practice 2 3 9 Portlethen Medical Centre 2 - 12 Skene Medical Group - 2 12 Ranked by the number of reds (worse than Scotland average)

Table 14: Summary of QOF Traffic Lights by conditions and diseases18 Disease/condition Red Amber Green

Obesity 9 3 - Chronic kidney disease 8 - 4 Atrial fibrillation 7 - 5 Dementia 7 1 4 High blood pressure 5 2 5 Coronary heart disease 4 1 7 Stroke 4 2 6 Cancer 4 - 8 Asthma 4 3 5 Heart failure 4 2 6 Depression 3 3 6 Diabetes 2 5 5 COPD 1 - 11 Learning difficulties 1 - 11 Ranked by the number of reds (worse than Scotland average)

22 Totals are derived from Table 12

7. Smoking Prevalence using ‘An Atlas of Tobacco Smoking’ There are higher estimated prevalence rates of smokers particularly in certain areas of south Aberdeenshire, namely Inverbervie, Laurencekirk, Ballater and Braemar. Annex 9 provides a map of the estimated smoking prevalence for Aberdeenshire.

8. Practice population by Carstairs Deprivation Categories Grampian has no patients in DepCat7 and Aberdeenshire has no patients in DepCat 5 and 6 either23, but the categories still indicate progressively worse deprivation. In south Aberdeenshire LCHP patients fall mostly in categories 1, 2 or 3 (Table 15). Skene, Banchory and Torphins practices have more than 95% of their patients in the least deprived category 1. Braemar, Ballater, Laurencekirk and Inverbervie practices have less than 1% of their patients in DepCat 1 and more than 95% in DepCat 3.

Table 15: Percentage of patients in each Carstairs Deprivation Category for south Aberdeenshire LCHP 2009* Practice N/A 1 2 3 4 5 6 7 Skene Medical Group 0.1% 99.6% 0.2% 0.1% 0.0% 0.0% 0.0% 0.0% Aboyne Health Centre 0.8% 22.2% 75.3% 1.7% 0.0% 0.0% 0.0% 0.0% Ballater Clinic 0.0% 0.0% 3.4% 96.6% 0.0% 0.0% 0.0% 0.0% Braemar Health Clinic 0.2% 0.0% 0.3% 99.5% 0.0% 0.0% 0.0% 0.0% Tarland Surgery 0.1% 8.5% 90.5% 0.9% 0.0% 0.0% 0.0% 0.0% Torphins Medical Practice 0.2% 96.6% 3.2% 0.0% 0.1% 0.0% 0.0% 0.0% Banchory Group Practice 0.2% 98.4% 1.4% 0.0% 0.0% 0.0% 0.0% 0.0% Portlethen Medical Centre 0.1% 36.3% 63.5% 0.0% 0.0% 0.0% 0.0% 0.0% Stonehaven Medical Group 0.1% 18.7% 80.8% 0.4% 0.0% 0.0% 0.0% 0.0% Auchenblae Medical Centre 1.5% 18.9% 3.4% 76.3% 0.0% 0.0% 0.0% 0.0% Inverbervie Medical Group 0.2% 0.3% 3.6% 96.0% 0.0% 0.0% 0.0% 0.0% Laurencekirk Medical Centre 0.4% 0.4% 2.1% 97.1% 0.0% 0.0% 0.0% 0.0% Source: Nimmo F, NHS Grampian. * Carstairs Deprivation Index based on data derived from 2001 Census. The population is based on April 2009 figures.

Category 1 is least deprived while category 7 is most deprived. N/A data not available

23 The Scottish Index of Multiple Deprivation (SIMD) indicates that Grampian, including north Aberdeenshire, has some datazones that are amongst the 5%, 10% and 15% most deprived, while the Carstairs indicates that there are no patients within DepCat 7. The anomaly between Carstairs and SIMD is due to the different population levels at which these two indices operate. The Carstairs Index looks at deprivation at the larger postcode sector level (101 postcodes in Grampian) while the SIMD looks at the smaller datazone level (684 datazones in Grampian). It is therefore to be expected that the SIMD will identify small clusters of population as being among the most deprived. However, the mortality pattern across quintiles is pretty much the same for Carstairs and for SIMD, despite the different population bases they identify.

9. Bringing all the health and wellbeing information together (discussion)

The discussion is divided into the following sections: − the limitations associated with the information used − population groups in south Aberdeenshire LCHP having health and wellbeing issues − main health and wellbeing issues in south Aberdeenshire LCHP − health inequalities across south Aberdeenshire LCHP − main determinants of health in south Aberdeenshire LCHP

Recommendations are highlighted in bold. These, together with the summary of health and wellbeing issues/needs in south Aberdeenshire LCHP, are brought together in section 9.

9.1 Limitations of the information used Different advantages and disadvantages are associated with the various methods of data collection. However, the examination of quantitative and qualitative information collected by different methods using a triangulation process enables findings to be corroborated across data sets, thereby reducing the impact of potential biases that can exist in a single study. Furthermore, the use of various datasets provides a more rounded picture of health needs in the community.

9.1.1 Health and wellbeing needs assessment questionnaire The questionnaire was returned by a wide range of key partners, many of which work closely with the various communities and others work at a more strategic level. This ensures that broad ranging views about the heath needs in south Aberdeenshire are represented.

The response rate was on the low side (36%). Some responses were completed by team leaders or managers and may have been submitted on behalf of teams. However, it is not possible to determine to what extent this has been done. The disadvantage of a low response rate is that the information cannot be analysed at a local level by the different professional groups as the resulting numbers are too small. So, for the most part the information from the questionnaire is discussed at the south Aberdeenshire level, although some key differences between the CSN areas are pointed out.

9.1.2 Using Quantitative Information The quantitative information about diseases and conditions used in this HNA comes from two sources: 1) the Community Health and Wellbeing Profiles 2008 and associated Traffic Lights and 2) QOF data at GP practice level. There is some, but not complete, overlap in terms of indicators covered. For example, data on road traffic accidents and injuries at home are only available from the Community Health and Wellbeing Profiles 2008 (and Traffic Lights). Data on heart disease, stroke and cancer are available from both datasets, although different statistics are used. Data about other diseases and conditions are only available from QOF.

9.1.3 Community Health and Wellbeing Profiles and Traffic Lights The profiles are a collation of 61 indicators of health and the wider determinants of health at IZ level24. The information is a compilation of data that have been compiled from a wide range of reliable sources, using clearly defined methodologies. Where appropriate, the information is standardised by age and gender, enabling direct comparison between various geographical areas.

24 Profiles at CHP and Scotland levels including data on NHS boards, are also available.

The Traffic Lights associated with these profiles make it easier to understand all the health and population information and see differences. Levels for health and population indicators are compared with the corresponding Scotland average to determine whether it is better or worse.

Some of these indicators, such as deaths from heart disease, cancer and stroke, have been standardised for gender and age. This standardisation means that the burden of diseases that tend to become more common in older age is not immediately evident in those areas with an elderly population. This is illustrated by the east Cairngorms IZ (IZ056), whose population is covered by Ballater and Braemar practices (Table 10). Only one of these chronic disease indicators (stroke) emerges as being worse than the Scotland average.

Comparing the Aberdeenshire IZ data against the Scotland average means that for many health indicators the levels emerge as significantly better. However, in 1995 life expectancy in Scotland for women was the lowest in the European Union, and for men, the second lowest after Portugal. Scottish men could expect to live 4.2 years less than men in the leader, Sweden. Scottish women could expect to live 5.2 years less than women in France. Scotland is only now achieving levels of life expectancy seen in the best performing European countries in 1970.25 Overall the health profile for Aberdeenshire is good compared to the rest of Grampian and Scotland. However this must be read in context of Scotland’s position when compared to other European countries.

9.1.4 QOF data QOF prevalence rates are what is known as "raw" or "crude" rates - which means that they take no account of differences between practice populations in terms of their age or gender profiles, or other factors that influence the prevalence of health conditions. A QOF prevalence rate is simply the total number of patients on the register, expressed as a proportion or percentage of the total number of patients registered with the practice at one point in time. This could mean, for example, that practices with an older population, such as Ballater, Braemar and Tarland, would appear to have higher prevalence rates for age-related conditions such as cancer or stroke than other practices with a younger population such as Skene, Portlethen and Auchenblae.

Some QOF registers are restricted to include only persons over a specific age. However, the QOF prevalence rates use as their denominator the total (all ages) number of patients registered to the practice at one point in time. Diabetes registers are based on patients aged 17 and over; chronic kidney disease and learning disabilities registers are based on patients aged 18 and over; and obesity registers are based on patients aged 16 and over. This means that for these conditions the QOF-reported prevalence will appear lower than would be the case if the age restriction was also applied to the population denominator.

25 Leon DA, Morton S, Cannegieter S and McKee M. A review of current approaches, knowledge and recommendations for new research directions. London School of Hygiene and Tropical Medicine for the Public Health Institute for Scotland 2003.

Figure 3 : south Aberdeenshire LCHP - Practice Population 2008

Source: Based on GP practice population figures derived from QOF 2007-8

QOF prevalence rates can also be affected by other factors such as: • health care seeking behaviour - people differ in the readiness with which they seek health care when they are not well; • access to services - people are more likely to consult for a condition if services are readily accessible; • diagnostic practice - it is impossible to completely standardise the methods clinicians use to make diagnoses; • data recording - there may be variations in the completeness and accuracy of practice records.

9.1.5 ATLAS of Tobacco Smoking The atlas of tobacco smoking provides estimates of smoking prevalence using estimates from the Scottish Household Survey 2003/04 and a range of characteristics of the local population from the 2001 Census.

9.1.6 Carstairs Deprivation Index by GP Practice The Carstairs Deprivation Index for populations by GP practices uses recent population figures (April 2009). The Index itself is based on 2001 Scotland census indictors26 at postcode sector level (101 postcodes in Grampian).

9.2 Population groups in south Aberdeenshire LCHP with health and wellbeing issues Young people are considered by a large majority (69%) of those who responded to the Health and Wellbeing Needs Assessment questionnaire as having particular health and wellbeing issues. Young people are considered as a main group with health needs, even when the responses of CSN staff are removed from the calculation. Children and families, people living in

26 Indicators used in Carstairs Index of Deprivation are: low social class, lack of car ownership, overcrowding and male unemployment.

remote and rural isolation and older people are considered by around half of the respondents as groups having health and wellbeing issues.

As expected, there are some differences between areas in terms of which groups are considered to have health and wellbeing issues (Annex 5), (although this information needs to be interpreted with caution owing to the smaller numbers of responses when viewed at a more local level). Differences exist both between CSN area level and at the more strategic levels of Marr, K & M and south Aberdeenshire about ethnic minorities and gypsy/travellers, migrant workers and homeless. A higher proportion of the more strategically placed respondents feel that these groups are a concern.

9.3 Main health and wellbeing issues

9.3.1 Health and wellbeing issues from the questionnaire A comprehensive list of issues affecting health was given in the comments sections in question 1 of the questionnaire (Annex 6). Several recurring themes cut across all areas of south Aberdeenshire LCHP, for example the underage drinking and substance misuse in young people and obesity and diet for children and families. Many of these health issues were identified as priorities in other parts of the questionnaire.

Comments about various aspects of mental health weave through all the population groups. For example, for young people some respondents said a health issue is “exams pressure”, for children and families comments included “sleep (lack of)”, “post natal depression”, for the working lives group “offshore work causing strains and pressures”. Not surprisingly, mental health was identified as the most important health issue in questions 2.

Four of the six of Aberdeenshire’s Joint Health Improvement Plan (JHIP) priorities were considered a higher priority by the questionnaire respondents. These were mental health, substance misuse, smoking and obesity. When presented with a more detailed list of health issues in question 3, coronary heart disease, cancer and nutrition ranked above sexual health and oral health (the other 2 JHIP priorities) (Table 6).

Oral health was ranked low as a health priority. This may be due to the ongoing work in this area and hence the perception that it is not a priority any more. The National Dental Inspection Programme of Primary 1 children show that oral health is a priority. In 2007 Primary 1 children from all CSN’s apart from Laurencekirk and Westhill had more than 40% of children with dental disease. Portlethen CSN had the worst percentage of all CSN’s in Aberdeenshire with nearly 60% of Primary 1 children having dental disease27. Oral health is also one of the HEAT targets28 set by Scottish Government for NHS Boards and is included in Aberdeenshire’s Single Outcome Agreement (SOA).29

27 Annual National Dental Inspection Programme, 2007 28 HEAT target for oral health: 80% of all three to five year old children to be registered with an NHS dentist by 2010/11. The Aberdeenshire Single Outcome Agreement also includes a second target for oral health: 60% of school children in primary 1 will have no signs of dental disease by 2010. 29 http://www.ouraberdeenshire.org.uk/index.php?option=com_content&task=view&id=273&Itemid=36

Some respondents commented in questions 1 and 5b that road traffic accidents (RTAs) are an issue. The Traffic Lights data lend support to these concerns: RTAs emerge as a significant health issue in the whole of Aberdeenshire, including the south Aberdeenshire LCHP area, when compared with the rest of Scotland.

Breastfeeding as a form of infant feeding was mentioned under the “other” category in question 3. Promoting breastfeeding is one of the HEAT targets set by Scottish Government for all NHS Boards and is also a target in Aberdeenshire’s SOA30. The Grampian Infant Feeding Audit indicated a breastfeeding rate of 56.7% for south Aberdeenshire in 2007. Compared to Scotland as a whole this is a good rate, however it masks areas where rates are lower. Returns for new mums who were exclusively breastfeeding at 6 weeks were as low as 20.3% in Laurencekirk compared to 41% for south Aberdeenshire as a whole in 2007.31

Of all the 16 options of health issues presented in the questionnaire, stroke was ranked at the very bottom (Table 6). This is at odds with the quantitative data from the Traffic Lights and from QOF which suggest that a number of areas in south Aberdeenshire LCHP may have elevated levels of stroke compared with Scotland (section 8.3.3).

9.3.2 RTAs and unintentional injuries Based on the Community Health and Wellbeing Profiles 2008 and corresponding Traffic Lights, south Aberdeenshire LCHP appears to have a better health record when compared with other areas in Aberdeenshire and with Scotland as a whole.32 However two area stand out; road traffic accident casualties – all ages (RTAs) and unintentional injuries in the home of under 15 year olds are the only two health indicators in Aberdeenshire that are significantly worse than the Scotland average (red lights).

A detailed breakdown of the RTA rates and numbers for each of the IZ average for south Aberdeenshire are provided in this report (Table 11). East Cairngorms, Cromar and Kildrummy and Mearns and Laurencekirk are three areas with the highest RTA rates which are significantly worse than Scotland.

A local review of childhood traffic accidents carried out a few years ago revealed that in Grampian the most common cause of child death (0-19 yr.) in the period 1993 to 1999 was RTA33,34. There is ongoing work to help reduce childhood road accidents. Aberdeenshire Council’s School Travel Plan Strategic Group looks at traffic accident data involving children to support planning. This group has representation from various council services, including education and transport and infrastructure as well as partner agencies including police and health. A Road Safety Officer is also assigned to each CSN.

Recommendation 2: The health and wellbeing indicator for RTAs covers casualties for all ages. Aberdeenshire Community Safety Partnership are currently supporting a variety of programmes to promote and encourage safe driving, particularly with young people. However they are not the only groupprogressing safe drive programmes. A co-ordinating approach to this work is required to reduce duplication of work and support communication.

In the case of unintentional injuries in the home, there is no routinely available national or local data collection for the incidence of unintentional injury, with the result that emergency hospital admission rates are used as a proxy for incidence. In 2005 Fleming and Foster reported

30 HEAT for Breastfeeding: Increase the proportion of new-born children in Scotland exclusively breastfed at 6-8 weeks from 26.6 in 2006/7 to 33.3% in 2010/11. The SOA target for Aberdeenshire is 42.9% of infants breastfed by 2010/2011. 31 Grampian Infant Feeding Audit. Update of Breastfeeding Rates at 6 weeks for 2007 (June 2009) 32 Traffic Lights www.nhsgrampian.org/ 33 Foster K. Review of child deaths 1993 to 2002. NHS Grampian. Unpublished Mimeograph, 2004 34 Foster K. Review of childhood road traffic accidents. NHS Grampian 2004

considerable variation in the rates between NHS boards. Grampian had a slightly higher standardised mortality ratio (103.9) for deaths as a result of unintentional injury compared to the Scottish figure (100). However, the Grampian standardised rate of emergency hospital admissions as a result of unintentional injury was much higher than the Scottish figure (150.6 vs 100)35. It appeared that Grampian children presenting with a head injury have a much greater likelihood of being treated as an inpatient.

The higher emergency hospital admissions rate reported by Fleming and Foster was predominantly for Aberdeen City. At the time the Aberdeenshire and Moray rates were similar to Scottish rates. The unintentional injuries rates for Aberdeenshire reported in the Health and Wellbeing profile for 2004-06 are significantly worse compared with the Scotland average.

9.3.3 Heart disease, cancer, stroke and diabetes By their very definition, chronic diseases are those involving a long course in their development or their symptoms. They are a major health problem in all developed countries, accounting for a high proportion of deaths, disability and illness. Yet many of these diseases are preventable, or their onset can be delayed, by relatively simple measures.

Most chronic diseases do not resolve spontaneously and are generally not cured completely. Some can be immediately life-threatening, such as heart attack and stroke; others are often serious, including heart disease, various cancers, depression and diabetes. However, they all persist in an individual through life (but are not always the cause of death).

Although family history for these diseases is important, adopting healthy behaviours such as controlling body weight, eating nutritious foods, avoiding tobacco use, controlling alcohol consumption and increasing physical activity can prevent or delay the development of many chronic diseases. The flipside of this is that these same behaviours can also be the risk factors for chronic diseases in an unhealthy lifestyle.

Overall the Traffic Lights for the Community Health and Wellbeing Profiles 2008 suggest that south Aberdeenshire LCHP has relatively better levels of these chronic diseases compared with Scotland given the few red and amber lights (Table 9).

The Community Health and Wellbeing Traffic Lights reveal a small cluster of red lights for early deaths (< 75 years) from coronary heart disease (CHD), cancer and stroke primarily in K & M in IZ’s but not in the Marr area where there is a more elderly population.

The QOF data for CHD, stroke and cancer also present with a cluster of red lights in some K & M practices where the population is younger. However, there is also a cluster or red lights for these diseases for practices in the Marr area where the population is more elderly. This apparent lack of consistency between the Community Health and Wellbeing Traffic Lights and the QOF lights may be due to the fact that the health and wellbeing mortality data are age and gender standardised while the QOF data are crude rates. It is therefore to be expected that the QOF data would reveal higher prevalence of chronic diseases for those practices with a more elderly population.

35 Fleming J and Foster K. Unintentional Injury in Children. NHS Grampian 2005

With regards to stroke, the actual number of deaths resulting from stroke is very low as indicated by the Community Health and Wellbeing data. There was only 1 death over 2004-06 resulting from stroke for each of the IZ with a red light. However, the number of cases for patients hospitalised for stroke are higher, for example there were 30 stroke hospital patients in the East Cairngorms IZ during 2004-06 and in Mearns and Laurencekirk IZ there were 26 hospital patients during the same period. These findings are largely supported by the QOF, with Deeside practices that have a more elderly population also having worse levels of stroke compared to Scotland average. The QOF data for Inverbervie and Laurencekirk practices show that levels are close to the Scotland average, just missing from being amber.

With improved medical care, survival rates from stroke are better (although stroke can still be a debilitating condition). This may explain the perception of the questionnaire respondents towards stroke being of a low priority in their area.

Only Ballater and Braemar practices have diabetes rates that are worse than the Scotland average. Obesity is a major risk factor for adult onset diabetes. Both Braemar and Ballater practices have significantly worse obesity rates than Scotland. Five practices (Aboyne, Tarland, Banchory, Inverbervie and Laurencekirk) have diabetes rates around the Scotland average (amber). All these five practices have worse obesity levels (red) compared with the Scotland average. The lack of age standardisation coupled with the other cautionary notes about the use of QOF data (section 8.1.3) only allows for very broad interpretation of comparisons between diabetes and obesity prevalence rates.

9.3.4 Chronic kidney disease and atrial fibrillation Chronic kidney disease (CKD) and atrial fibrillation (AF) both have high blood pressure as a risk factor. CKD is a condition where there is a gradual and usually permanent loss of kidney function over time. This happens gradually over time, usually months to years. Although chronic kidney disease sometimes results from primary diseases of the kidneys themselves, the major causes are diabetes and high blood pressure.

AF does not occur as frequently as CKD. It is a condition in which the heart beats either faster or slower than normal. Atrial fibrillation is often associated with current heart problems, but other causes include uncontrolled high blood pressure, thyroid problems, and lung problems. While atrial fibrillation is rarely cured, it can usually be managed with proper treatment. Treatment options include medication and changes in diet and lifestyle.

Eight of the twelve GP practices in south Aberdeenshire LCHP have prevalence rates of CKD that are worse than the Scotland average with all but one being significantly worse (Annex 9). Similarly, AF rates across a number of GP practices across Marr and K & M are worse compared with the Scotland average.

To some extent it is expected that practices in the Marr area which have a more elderly population (Ballater, Braemar and Tarland) would present with higher crude rates of CKD and AF. However, these chronic diseases also appear to be highly prevalent in areas where there is a younger to middle-aged population, such as those covered by Laurencekirk, Inverbervie and Banchory.

9.3.5 Asthma Asthma is common, affecting millions of adults and children worldwide. A growing number of people are diagnosed with the condition each year, but it isn't clear why. A number of factors are thought to increase the chances of developing asthma36. These include: • A family history of asthma

36 Asthma Risk Factors. www.mayoclinic.com/health/asthma/ds00021/dsection=risk-factors

• Frequent respiratory infections as a child • Exposure to second hand smoke • Living in an urban area, especially if there's a lot of air pollution • Exposure to occupational triggers, such as chemicals used in farming, hairdressing and manufacturing • Low birth weight • Being overweight

All the practices in K & M (Portlethen, Stonehaven, Auchenblae, Inverbervie and Laurencekirk) have asthma rates that are worse or similar to Scotland average, although only one is significantly worse (Laurencekirk). None of the Deeside practices that have a more elderly population presented with worse levels of asthma when compared with the Scotland average (Awaiting information on age association and asthma)

9.3.6 Obesity and high blood pressure From QOF, the high prevalence of obesity (patients aged 16 and over with a body mass index of 30 or over) appears to be widespread across the whole of the south LCHP ranging from the GP practices serving coastal populations such as Inverbervie to the inland Deeside populations of Ballater and Braemar. This suggests that obesity is now prevalent across the adult population across all the geographical areas and economic status in south Aberdeenshire.

Overall about half of the GP practices present with a rate of high blood pressure that is either worse or similar to the Scotland average. Once again, as expected practices with a more elderly population are amongst these (Ballater, Braemar and Tarland), but others with a more mixed-age range profile also have significantly worse levels compared with Scotland (Laurencekirk and Banchory).

9.3.7 Depression and stress The QOF data show three practices in south Aberdeenshire LCHP where rates of depression37 are worse than the Scotland average, with only Braemar Health Clinic being significantly so. Despite this relatively low incidence of depression in south Aberdeenshire, mental health including stress due to exam pressure, social and rural isolation etc. emerged as a main priority from responses to the health and wellbeing needs assessment questionnaire.

Mental and emotional wellbeing, as defined by the World Health Organisation38 is “a state of wellbeing in which the individual realises his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community”. The QOF indicators do not cover the emotional wellbeing (stress) aspect of mental health. The Community Health and Wellbeing Profiles include some indicators, such as “self assessed health not good” as assessed by the Census. This is a very subjective and broad question and does not fully explore mental and emotional wellbeing.

37 QOF: Depression in those patients with new diagnosis of depression, recorded between the preceding 1 April to 31 March, the percentage of patients who have had an assessment of severity at the outset of treatment using an assessment tool validated for use in primary care. 38 World Health Organisation Report 2001.

Stress may be a contributory factor to a number of health outcomes. A significant relationship between daily stress and the occurrence of both concurrent and subsequent health problems such as flu, sore throat, headaches, and backaches has been reported39. Furthermore, individuals with unsupportive social relationships and low self-esteem were also reported to be more likely to experience an increase in psychological and somatic (affecting the body not the mind) problems both on and following stressful days than were participants high in self-esteem and social support. Evidence is also emerging linking stress to overeating40.

Recommendation 5: Mental health is considered as a top priority by key partners in south Aberdeenshire. A coherent approach towards addressing mental health in its wider sense should be co-ordinated across south Aberdeenshire.

9.3.8 Smoking

From the atlas of tobacco smoking data, there are areas in south Aberdeenshire which display high prevalence of adult smoking. These areas are: Inverberive, Laurencekirk, Ballater and braemar. This data would be supported from the QOF data on chronic diseases.

Aberdeenshire’s smoking cessation target (HEAT 6) “Through smoking cessation services, support 8% of the Board’s smoking population is successfully quitting (at one month post quit) over the period of 2008/09 – 2010/11”. The target for Aberdeenshire is 3201 by 2010/11. To date 2459 successful quits have been recorded in Aberdeenshire, thus 77% of the target has been achieved so far.

9.4 Health inequalities across south Aberdeenshire LCHP From QOF data, some areas have worse rates of chronic diseases when compared with the Scotland average. This is to be expected in the Deeside area, given the distinct older population profiles in the area. What is unexpected is that a few areas with a younger to middle-aged population along the coastal strip of Aberdeenshire also have worse rates of chronic diseases and conditions as shown by QOF and by the Community Health and Wellbeing profiles when compared with other areas in south Aberdeenshire and with the Scotland average.

Five IZ were identified as areas having relative health inequality compared with the rest of south Aberdeenshire (section 5.3):

Banchory-Devenick and Findon (IZ059) (Portlethen Medical Centre) 41 Mearns North and Inverbervie (IZ050) (Inverbervie Medical Group) Mearns and Laurencekirk (IZ049) (Laurencekirk Medical Centre) Stonehaven South (IZ051) (Stonehaven Medical Group) East Cairngorms (IZ056) (Ballater and Braemar Health Clinics)

39 DeLongis A, Folkman S and Lazarus R. The impact of daily stress on health and mood: Psychological and social resources as mediators. Journal of Personality and Social Psychology. Vol 54(3), Mar 1988, 486-495. 40 Halford J. and Dovey T. http://www.liv.ac.uk/news/press_releases/2004/10/chocolate.htm 41 The practice in brackets for each IZ is the main, but not the only, practice serving the population in the stated IZ.

The first four areas are all in the K & M and have young to middle-age population. The other IZ is East Cairngorms in Marr and populations here are covered for by Ballater and Braemar practices with a more elderly population.

In addition to age, it appears that there are other factors associated with the disease patterns across south Aberdeenshire LCHP area. The Carstairs Index of Deprivation shows that the population in the south Aberdeenshire LCHP falls mainly into deprivation categories (DepCat) of 1 to 3 out of a range of 1 to 7 (1 being least deprived and 7 most deprived). Laurencekirk and Inverbervie practices have more than 95% of their patients in Depcat 3 as do Braemar and Ballater practices.

Stonehaven and Portlethen practices have a wider mix of patients in DepCat 2 and 3. Both practices are amongst the largest in the LCHP, having populations of 13.5 and 12 thousand respectively (Table 1). This means that health inequalities of smaller pockets within the practice populations are being averaged out by better health outcomes of the more affluent patients in the same practices, resulting in levels from the QOF dataset of diseases and chronic conditions that are in the middle range (amber or green) (Table 12).

Overall, these findings suggest that even within this narrow band of deprivation status, there may be a link between deprivation and disease patterns. The older population in Marr in turn experiences the double effect of old age and deprivation.

Wilkinson and Pickett reported that health is related to income differences within rich societies42. Physical health, mental health, drug abuse, education, imprisonment, obesity, social mobility, trust and community life, violence, teenage births, and child well-being are all very substantially worse in more unequal societies.

9.5 Determinants of health Valuable information is now available for south Aberdeenshire about factors that impact on health. Friends and family relationships were considered by many of those who responded health and wellbeing needs assessment questionnaire as being the most important factor affecting health (Table 7). This finding is encouraging in that the key partners in south Aberdeenshire recognise the importance of supportive social relationships as discussed under the section dealing with stress. Income was the next factor that respondents thought important. Once again this supports evidence relating to health and social deprivation. Living in remote/rural areas, social isolation and housing followed with similar ranking.

A much more detailed breakdown of positive and negative factors that have an impact on health were also identified (question 5a and b) (Annex 7 and Annex 8). Obviously these comments are all very subjective and sometimes biased towards the particular background that the respondent comes from. However the detailed comments that have emerged still provide a vivid picture of determinants of health in the various parts of south Aberdeenshire.

Recommendation 8: A Community Led Health approach should now be progressed in those communities identified as experiencing health inequalities. This process should

42 Wilkinson R and Pickett K. The Spirit Level: Why More Equal Societies Almost Always Do Better published by Penguin in March 2009

engage and support local communities to review their health needs and develop realistic local health plan with partners.

10. Summary findings and recommendations

10.1 Summary findings of health and wellbeing issues/needs

Young people, children and families, people living in remote and rural isolation and older • people were considered as groups having health and wellbeing issues.

• Friends and family are considered to be very important in affecting health of the south Aberdeenshire LCHP. Income is also important followed by living in remote/rural areas, social isolation and housing. • As for the rest of Aberdeenshire, Road Traffic Accident casualties significantly worse across south Aberdeenshire LCHP compared with Scotland average. • Unintentional injuries at home worse in many areas of south Aberdeenshire LCHP compared with Scotland average. This may be due to hospital admission policies.

• GP Practice data suggests that obesity appears to be widespread across the whole of

south Aberdeenshire LCHP with levels worse than Scotland average in most areas

• Four areas in Kincardine and Mearns have emerged as having health inequalities including: Banchory-Devenick and Findon (Portlethen Medical Centre), Mearns North and Inverbervie (Inverbervie Medical Group), Mears and Laurencekirk (Laurencekirk Medical Centre) and Stonehaven South (Stonehaven Medical Group). • East Cairngorms (Ballater and Braemar Medical practices) in Marr has also emerged as an area with health inequalities. This could associated with a higher elderly / deprived population in this GP practice. • GP Practice data highlights high prevalence of chronic disease which could be due to the population profile for the identified practices detailed above.

• Diseases associated with high blood pressure, such as chronic kidney disease and atrial fibrillation, are worse than the Scotland average for the populations in about 75% of the GP practices.

10.2 Recommendations

Recommendation 2: The Community Health and Wellbeing indicator for RTAs covers casualties for all ages. Aberdeenshire Community Safety Partnership are currently supporting a variety of programmes to promote and encourage safe driving, particularly with young people. However they are not the only group progressing safe drive programmes. A co-ordinating approach to this work is required to reduce supplication of work and support communication.

Annex 1: Health and Wellbeing Needs Assessment Questionnaire

Health and Wellbeing Needs Assessment Questionnaire

South Aberdeenshire Local Community Health Partnership is conducting a Health Needs Assessment to develop the evidence base for health to ensure work is focused on areas of inequality across South Aberdeenshire. This information along with local and national data will be analysed and the areas where inequalities in health exist identified. Due to the nature of this project we might like to contact you in the future, and would be grateful if you could provide contact details. Please respond by Friday 12th December 2008.

Name of Organisation ______

Job title ______

Please identify the geographical areas your work covers in South Aberdeenshire

______

1. In your area do you think that any of the population groups listed below have any particular health and wellbeing issues?

EXAMPLE

POPULATION GROUP NO YES IDENTIFIED ISSUE YOUNG PEOPLE √ UNDERAGE DRINKING

POPULATION GROUP NO YES IDENTIFIED ISSUE Carers Children and Families Ethnic minority groups and Gypsy/Travellers Homeless Migrant Workers Older People People in living remote and rural isolation Women and children affected by domestic abuse Working lives Young People Other(Please specify below)

2. The Joint Health Improvement Plan has identified 6 priorities for Aberdeenshire, with tackling health inequalities as an overarching theme. From the 6 JHIP priorities please rank (1-6 – 1 being the highest priority) in order for your area of work?

Please identify what Your grouping in the Community Health Issue Ranking population this (1-6) affects. With reference to Q1. Improving mental health and

wellbeing Reducing smoking Reducing substance misuse

(especially alcohol) Reducing the rate of increase of

obesity Improving sexual health Improving oral health

3. From the following, please rank from 1-6 (1 being the highest priority) what you think the top six more specific health issues are for your community?

Your Health Issue Community Ranking (1-6)

Asthma / Respiratory Disease Cancer Coronary Heart Disease Depression / Psychiatric Disorders Diabetes Disability Drug and Alcohol use Nutrition Obesity Oral Health Physical Injury (including violence and accidents) Self harm / Suicide Sexual Health Stroke Smoking Other (please specify below)

4. A wide range of factors affect people’s health. Please rank from 1-6 (1 being the factor that affects health the most) the top five wider factors that affect the health and wellbeing of your community?

WIDER DETERMINANTS YOUR RANKING (1-6) Income Housing Access to health care services Living in remote/rural areas Sense of community Friends and family relationships Work Environment Education Un/Employment Cost of services Social Isolation Ease of access to services Transport Religion Other(please specify below)

The next question asks for positive and negative impacts on the health of the community. An example of this might be access to services.

5. a) Is there anything you feel has a positive impact on the health of the community?

3. b) Is there anything you feel has a negative impact on the health of the community?

Any further comments would be appreciated 2.

Any further comments would be appreciated

Could you please provide your contact details here (Name, address and e-mail)

Thank you for taking the time to complete the questionnaire.

Please return your completed questionnaire by Friday 12th December 2008 to:

Fiona Murray Arduthie Lodge Kincardine Community Hospital Kirkton Road Stonehaven AB39 2QJ Tel: 01569 792074 Secretary: 01569 792056 e-mail: [email protected]

Annex 2: Key Partners - Questionnaire Professional Grouping Profession No. Responses Community School Network (CSN) Teacher 27 Medical G.P. 23 Other Health Locality Manager 2 Professions Community Nursing 1 Team Leader 4 Midwife 5 School Nurse 4 Assistant Health Improvement Officer 3 Health Visitor 7 Primary Mental Health Care Worker 1 Physiotherapist 1 Lead Nurse 1 Speech & Language Therapist 1 Lead Occupational Therapist 1 Local Authority Community Learning & Development (CL&D) 9 Area Manager – Community Planning 3 Partnership Social Work 2 Housing 1 Police Police 1 Voluntary Homestart 2 Mearns & Coastal Healthy Living Network 1 Gemini Project – Barnardos 1 Alzheimer Scotland 2 Council Voluntary Services 0 Working for Families 0 Foyer 0 Mental Health Aberdeen 0 Community Council Chair 9

Annex 3: Community Health and Wellbeing Traffic Lights – how do they work?

Health Indicators – Traffic Lights Red – more than 5% worse than the Scottish average Green – more than 5% better than Scotland average Amber – within + or – 5% of Scotland average

Population Indicators – Blue Lights For some indicators, being different to the Scotland average does not mean being ‘worse’ or ‘better’, but it might still be useful information – e.g. it may be helpful to know that the population has a higher percentage of elderly in the population. Light blue – more than 5% less than Scotland average Dark blue – more than 5% more than Scotland average Mid blue – within + or – 5% of Scotland average.

These profiles have statistical significance attached to them and details can be found www.nhsgrampian.org/

The QOF Traffic Lights Red – more than 5% worse than the Scottish average Green – more than 5% better than Scotland average Amber – within + or – 5% of Scotland average

Annex 4: IZ for the health needs assessment, by GP practice and CSN

Table 16: List of IZ selected for the HNA with corresponding code Garioch Kincardine & Mearns I-Zone Code I-Zone Code IZ052 Stonehaven North IZ062 Garlogie & Elrick IZ050 Mearns North & Inverbervie IZ063 Westhill Central IZ051 Stonehaven South IZ064 Westhill North & South IZ058 Portlethen IZ048 Mearns South & Benholm Marr IZ053 Fetteresso, Netherly & Catter IZ057 Banchory IZ049 Mearns & Laurencekirk IZ054 Aboyne & South Deeside IZ059 Banchory-Devenick & Findon IZ065 Cromar & Kildrummy IZ055 Newtonhill IZ060 Crathes & Torphins IZ061 Dunect, Durris & Drumoak IZ056 East Cairngorms

Note: IZ062 code is equivalent to S0200062 code and this applies across the rest of the codes

Table 17: School children by CSN and Intermediate Zone % children % children I-Z Code IZ name from IZ I-Z Code IZ name from IZ ABOYNE CSN STONEHAVEN CSN S02000054 Aboyne and South Deeside 61.02 S02000052 Stonehaven North 100 S02000060 Crathes and Torphins 51.1 S02000051 Stonehaven South 100 S02000061 Dunecht, Durris and Drumoak 3.13 S02000048 Mearns South and Benholm 18.37 S02000056 East Cairngorms 80 S02000049 Mearns and Laurencekirk 1.58 S02000065 Cromar and Kildrummy 39.61 S02000050 Mearns North and Inverbervie 27.64 S02000053 Fetteresso, Netherley and Catter 81.1

BANCHORY CSN WESTHILL CSN 100 S02000057 Banchory 100 S02000063 Westhill Central 3.57 S02000049 Mearns and Laurencekirk 2.08 S02000061 Dunecht, Durris and Drumoak 2.69 S02000050 Mearns North and Inverbervie 1.78 S02000066 Kintore and Blackburn* 80.19 S02000054 Aboyne and South Deeside 38.37 S02000062 Garlogie and Elrick 96.72

S02000060 Crathes and Torphins 47.83 S02000064 Westhill North and South

S02000061 Dunecht, Durris and Drumoak 38.69 S02000053 Fetteresso, Netherley and Catter 6.03

LAURENCEKIRK CSN PORTLETHEN CSN S02000048 Mearns South and Benholm 81.04 S02000058 Portlethen 100 S02000049 Mearns and Laurencekirk 96.32 S02000055 Newtonhill 100 S02000050 Mearns North and Inverbervie 70.58 S02000061 Dunecht, Durris and Drumoak 13.53 S02000053 Fetteresso, Netherley and Catter 12.42 S02000059 Banchory-Devenick and Findon 100 *Kintore and Blackburn not selected as this IZ falls within the Central Aberdeenshire LCHP area.

Table 18: GP Practices by Intermediate Zones

% of % of % of I-Zone Practice I-Zone Practice I-Zone Practice Code Population Pop. Code Population Pop. Code Population Pop.

Skene Medical Group Portlethen Medical Centre Stonehaven Medical Group S0200003 29 0.2 S0200001 1 0.0 S0200010 2 0.0 S0200004 2 0.0 S0200002 22 0.2 S0200015 1 0.0 S0200007 127 0.9 S0200006 5 0.0 S0200048 2 0.0 S0200014 16 0.1 S0200008 1 0.0 S0200049 2 0.0 S0200017 1 0.0 S0200010 1 0.0 S0200050 34 0.3 S0200020 1 0.0 S0200011 1 0.0 S0200051 4992 37.3 S0200035 241 1.8 S0200018 2 0.0 S0200052 6061 45.3 S0200043 3 0.0 S0200023 1 0.0 S0200053 2138 16.0 S0200060 1 0.0 S0200024 1 0.0 S0200055 143 1.1 S0200061 991 7.2 S0200051 2 0.0 S0200078 1 0.0 S0200062* 3519 25.7 S0200052 3 0.0 S0200063* 4468 32.7 S0200053 991 8.2 S0200064* 3853 28.2 S0200055 2937 24.2 Auchenblae Medical Centre S0200066 108 0.8 S0200058 4720 38.9 S0200001 3 0.2 S0200068 321 2.3 S0200059 3264 26.9 S0200005 1 0.1 S0200061 180 1.5 S0200048 65 3.8 S0200078 1 0.0 S0200049 254 14.8 S0200050 995 58.1 Ballater Clinic Aboyne Health Centre S0200051 22 1.3 S0200054 46 2.2 S0200003 1 0.0 S0200052 22 1.3 S0200056 2002 96.6 S0200054 3265 59.3 S0200053 348 20.3 S0200065 23 1.1 S0200056 107 1.9 S0200055 1 0.1 S0200088 2 0.1 S0200057 4 0.1 S0200061 1 0.1 S0200060 649 11.8 Braemar Health Clinic S0200061 3 0.1 Inverbervie Medical Group S0200054 1 0.2 S0200065 1470 26.7 S0200048 1545 28.2 S0200056 569 99.6 S0200068 1 0.0 S0200049 93 1.7 S0200096 1 0.2 S0200080 1 0.0 S0200050 3582 65.4 S0200081 1 0.0 S0200051 4 0.1 Torphins Medical Practice S0200104 1 0.0 S0200052 7 0.1 S0200013 1 0.1 S0200053 246 4.5 S0200054 16 0.9 Tarland Surgery S0200059 1 0.0 S0200057 8 0.4 S0200054 44 5.7 S0200060 1401 77.1 S0200056 5 0.6 Laurencekirk Medical Group S0200061 130 7.2 S0200057 2 0.3 S0200048 832 17.8 S0200065 259 14.3 S0200060 18 2.3 S0200049 3290 70.3 S0200068 1 0.1 S0200061 4 0.5 S0200050 524 11.2 S0200065 698 89.7 S0200053 34 0.7 Banchory General Practice S0200068 3 0.4 S0200003 15 0.1 S0200074 2 0.3 S0200053 3 0.0 S0200080 2 0.3 S0200054 1423 11.9 S0200057 6526 54.7 S0200060 2301 19.3 S0200061 1509 12.6 S0200062 24 0.2 S0200064 5 0.0 S0200065 122 1.0 S0200068 6 0.1 * Only these 3 IZ are within South Aberdeenshire LCHP. Together these IZ account for 86.6% of the Skene Medical Group practice population.

Figure

Annex 5: Population Groups having health and wellbeing issues by area (%) (Q1)

Aboyne (n=19) Banchory (n=13) L'kirk (n=12) P’lethen (n=10) S’haven (n=18) Westhill (n=10) K & M (n=14) Marr (n=10) SA (n=6) Y N Y N Y N Y N Y N Y N Y N Y N Y N Carers 26.3 36.8 46.2 15.4 50.0 25.0 40.0 40.0 44.4 11.1 50.0 40.0 50.0 0.0 50.0 10.0 50.0 0.0 Children & Families 42.1 31.6 53.8 30.8 66.7 16.7 40.0 30.0 38.9 16.7 60.0 30.0 78.6 0.0 60.0 0.0 83.3 0.0 Ethnic Minorities & Gypsy/Travellers 5.3 57.9 7.7 61.5 8.3 16.7 10.0 20.0 22.2 16.7 30.0 70.0 28.6 14.3 60.0 10.0 33.3 16.7 Homeless 15.8 57.9 7.7 61.5 0.0 25.0 30.0 30.0 16.7 27.8 40.0 70.0 42.9 7.1 50.0 10.0 50.0 0.0 Migrant Workers 31.6 47.4 15.4 46.2 33.3 25.0 20.0 0.0 44.4 16.7 70.0 50.0 21.4 14.3 60.0 20.0 50.0 0.0 Older people 42.1 26.3 38.5 23.1 58.3 8.3 20.0 20.0 55.6 11.1 70.0 10.0 50.0 0.0 60.0 10.0 66.7 0.0 People living in remote & rural isol’n 52.6 26.3 53.8 23.1 50.0 16.7 10.0 20.0 38.9 16.7 70.0 30.0 78.6 7.1 80.0 10.0 50.0 0.0 women & children affected by domestic abuse 42.1 36.8 38.5 30.8 25.0 33.3 30.0 20.0 38.9 11.1 60.0 30.0 50.0 0.0 40.0 10.0 83.3 0.0 working lives 15.8 36.8 38.5 30.8 33.3 8.3 50.0 10.0 27.8 27.8 40.0 50.0 14.3 0.0 60.0 10.0 33.3 0.0 young people 63.2 26.3 69.2 15.4 75.0 8.3 80.0 0.0 61.1 11.1 70.0 10.0 78.6 0.0 50.0 0.0 83.3 0.0 other 0.0 10.5 0.0 7.7 0.0 0.0 20.0 0.0 5.6 5.6 0.0 20.0 7.1 0.0 10.0 0.0 33.3 0.0 The percentages are expressed as % of total responses within each area NOTE: The numbers of respondents from each area are small; therefore the above values need to be viewed with caution

DRAFT

Annex 6: Comments about health and wellbeing issues by population groups (Q1) Young people Aboyne: drink & drug issues, sexual health, road traffic accidents, smoking, physical activity, lack of motivation; after school care, mental health. Banchory: drink & drugs, sexual health, mental health issues, relative lack of organised activities in rural areas Laurencekirk: Alcohol & drugs misuse, underage drinking, not sufficient recreational opportunities locally (e.g. pool, sports centre, youth clubs), sexual health, mental health Portlethen: sexual health, underage drinking, alcohol use, mental health, smoking, peer pressure Stonehaven: dedicated social meeting places (lack of clubs and meeting places etc), alcohol, inactivity, obesity, anti-social behaviour, drugs, behaviour & respect, smoking, alcohol support, mental health, pregnancy, sexual health, access to sexual health advice & contraception Westhill: alcohol, underage drinking, sexual health, counselling, limited recreation, mental health, diet, exam pressure, peer pressure, self esteem, smoking, potential obesity, substance misuse K & M: Alcohol use, lack of facilities, lack of local recreation, lack of services / underage drinking/drug use, no direct contact in schools, teenage pregnancy, sexual health, no link to services, access to leisure facilities for people with acute disabilities Marr: underage drinking, sexual health, mental health issues, bullying, self confidence, self harm, affected by working lives, lack of family networks, social isolation, lack of resources, health issues, obesity, lack of facilities, eating properly, healthy drink, risk taking SA: Mental health, behaviour problems, child protection, substance misuse, drink/drugs

Children and families Aboyne: holiday support, lack of health visitor access; after school care, drink & drug issues, social & wellbeing, lack of childcare 0-12yrs, healthy eating, obesity, post-natal depression Banchory: some problem families, acute illness & injuries, relationships, mental health, parenting skills, child development, diet, mental health, vulnerability across the board e.g. housing and health Laurencekirk: poor public transport, childcare - especially wrap around care for school children sadly lacking in area, little local support for families, activities, no affordable childcare, diet Portlethen: parenting, lack of recreational facilities, mental health Stonehaven: childhood obesity, lack of exercise, support for families with disabled youngsters, shortage of speech and language therapy, limited opportunities for dental checks in schools, require support groups & voluntary services, lack of family support finance/debt, transport/rural isolation Westhill: single parents, isolation, mental health, diet K & M: access to services aimed at families (mental health), parenting, isolation, lack of transport, lack of local amenities, obesity, financial difficulties, links to schools & CSN, rural isolation, social capital, post natal depression Marr: social isolation away from families e.g. offshore working, lack of facilities, sexual health issues, bad food habits, lack of childcare, diet, sleep, parenting - linked to mental health SA: mental health, lack of support, emotional practical support, child protection, social isolation, poor housing, poverty in some instances, drink/drugs

People living in remote and rural isolation Aboyne: social isolation, access to services, public transport, fresh fruit & vegetables, mental health, drugs and alcohol

DRAFT Banchory: poor bus routes, lack of public transport, chronic illness, dementia, living alone, isolation, Laurencekirk: prices – cost; lack of good transport links Portlethen: Stonehaven: transport - poor bus services, facilities & groups that parents can easily access, mental health, access local facilities Westhill: social support, access to services K & M: transport issues, equity of support across South, depression, loneliness, support given, rural isolation, lack of facilities & access to shops and services, social isolation Marr: transport issues & isolation, depression due to isolation, accessing clinics e.g. parent craft, post natal care, organisational difficulties due to distance / proximity to acute hospital SA: transport / access, problems with transport & cost

Older people Aboyne: basic home care, dementia group, transport to clinics, optician, dentist etc., rural isolation & access to services Banchory: language difficulties = limits access, loneliness, chronic illness, dementia, living alone, isolation Laurencekirk: activities, respite, access to services, rural isolation/transport, diet, mental health Portlethen: insufficient psychiatric services Stonehaven: general health - more of them! Frail, isolated, no social clubs or meetings, loneliness & care at home, access to services and facilities/transport, isolation, mental health Westhill: social support, limited recreation, transport (lack of public) K & M: social isolation, transport difficulties, equity of support across South, financial, heating, nutritional needs, long term conditions (COPD, falls), social events, rural isolation, more services, depression, fitness Marr: support to meet needs, recreation needs, popular retirement area, lack of resources, transport service availability, isolation - mental health problems SA: lack of general support for well-being, limited daycare provision / social outlets, unaware of services there are that could help

Carers Aboyne: organised cover for breaks / illness, lack of carers, drink & drug issues, social & wellbeing, especially young carers, stress & sleep deprivation Banchory: valuable support, absence of quality carers in middle class population, very short SW carers, instrumental support, support for child carers in school Laurencekirk: poor public transport, lack of respite care, not valued sufficiently, mental health, stress, isolation etc Portlethen: insufficient respite care, parenting, financial support Stonehaven: availability of flexible assistance, lack of carers, stress, lack of support & respite, isolation, transport issues, mental health issues Westhill: support, respite care, home care, accessing support K & M: Family carers for long term conditions need respite, isolation, lack of support for carers, isolated working, mental health issues Marr: stress, alcohol abuse, not as many support opportunities as in city for support groups etc, lack of resources SA: mental health, lack of support, lack of respite care

DRAFT Women and children affected by domestic abuse Aboyne: no local service, no local facility, support groups, high for percentage of population, mental health, drugs and alcohol Banchory: women’s refuge locally, hostel in Banchory, support in school environment Laurencekirk: women’s domestic abuse team in North, more likely to contact Police than visit Portlethen: lack of support from other agencies, refuge accommodation & support Stonehaven: recognition & safe support, mental health, transport to access services - isolated, mental health issues - depression, esteem etc. Westhill: K & M: isolation, services available limited, housing- safety, physical harm, emotional harm, support given, mental health issues, Housing Dept. Marr: increasing, lot of stress, support; access to services support, mental health & confidence issues, depression, low self esteem, physical injuries SA: mental health & general well-being - knock on effects to children & education, emotional practical support, social isolation, risks to children, itinerant lifestyle (temporarily) – stigma, parents encourage drink culture

Migrant workers Aboyne: language, social isolation, rural isolation Banchory: housing, diet & accessing health Laurencekirk: English as a Second Language, parents of pupils, mental health, stress, overwork, isolation Portlethen: isolation Stonehaven: little knowledge & understanding of English, lack of support groups, transport, access to services, isolation, cultural support, need language skills Westhill: accessing services, elsewhere but not identified in Westhill K & M: language and cultural barriers, financial, lack of support Marr: isolation, increasing, language problems, access to services, isolation - mental health problems SA: mental health, lack of support, itinerant lifestyle

Working lives Aboyne: access to sports facilities, health care and child care; after school care, stress Banchory: stress, alcohol, hurried lives, financial stress Laurencekirk: cost of after school clubs Portlethen: credit crunch, unemployment, commuting - long hours for after school facilities, pressure on families - both parents have to work, low income Stonehaven: stress, child care, transport to access services - isolated, alcohol support, potential literacy needs Westhill: stress, counselling, too busy - dual careers etc., work-life balance, impact of commuting K & M: clinic times, occupational health, appointments to GP clinics Marr: childcare support to meet needs of working parents, more wrap around care required, lots of offshore workers causes lots of strains and pressures, low pay, inadequate housing, time off for clinics, parentcraft, mental health SA: opening hours of surgeries, clinics & pharmacies

DRAFT Homeless Aboyne: very long waiting times for council housing & high rent in private sector, employment / health care Banchory: limited numbers, alcohol misuse Laurencekirk: Portlethen: housing not available in the area, poor availability of LA housing Stonehaven: no housing available for single / families, transport, access to services, isolation, awaiting housing Westhill: access to services as in Aberdeenshire but focus in Aberdeen, affordable housing K & M: lack of housing huge issue, access to support, housing/money, mental health, alcohol, drug misuse, more affordable housing, not enough emergency/temp accommodation Marr: alcohol & drug misuse, overcrowding, hidden homelessness, lack of affordable housing, support suitable access accommodation, isolation - mental health problems SA: mental health, lack of support, substance misuse - difficulty accessing Health Services

Ethnic minorities and gypsy/travellers Aboyne: Banchory: access to services Laurencekirk: Portlethen: Stonehaven: language barrier, limited services, ongoing support Westhill: immunisation, accessing services, need site K & M: short term stay, hard to contact, language barrier, alcohol Marr: education & engagement, language, communication barriers, access to health care; access to services, isolation - mental health problems SA: mental health, lack of support

DRAFT

Annex 7: Positive impact on the health of the community (Q5a) Aboyne Portlethen Stonehaven Laurencekirk Westhill Banchory Marr K & M SA services which ASDA with excellent leisure good facilities, integrated reduced time to good community good services/ lots of services exist locally, new reasonably priced facilities, improved sports centre services offered action referral to health care, plenty quality but hard to fruit& veg. in the fruit & veg., sport and leisure associated from new Westhill professionals, leisure activities infrastructure, promote in village, Tarland extended opening facilities, local classes, quality of Medical Centre, more help for good local effecting change

Medical Practice, hours, very good services good, the local health centre availability of individuals – hospital, sports for those who confidence in the Dr Surgery, good crèche, good swimming pools, counselling and leisure need it, good health & social health service childcare good local services, wide services, range of services, care services, provision, Youth services – mostly, range of services, additional services rapid response diabetic clinic, Centre, available / counselling, new Surestart services e.g. smoking service, some excellent health & affordable leisure medical centre at Hill of Banchory cessation classes excellent services care services, facilities Community & Primary Mental already available good health Centre, good Health Care centre, good medical services / Worker, health medical facilities medical centre seeing & talking to people in their Local Services / Facilities / Services Local workplace, new family resource centre in Portlethen & Stonehaven good health / access to fitness / access to services access to services access to health good all round access to sports & accessible more local education access, sporting facilities, – health care, / transport to services health services leisure efficient G.P services being access to access to local services if health services with early access, opportunities, services, access made available,

services, facilities, accessible e.g. Red Cross, access to Primary easily accessible to health care easy & timely teenagers from community access to health Care is good, to G.P’s & health service i.e. G.P access to remote areas facilities care, access to accessibility to services, extended hours, services, access being able to accessible, services services e.g. Well Community outpatients clinics to facilities i.e. access access to health Child Clinic at Hill Hospital and KCH, easy access sports centre / information, services of Banchory, access to local to medical centre, clubs etc access to supermarket services & minor access to sports & swimming pool home delivery injuries leisure Access to services to Access service department, opportunities access to health services

Access to good transport transport / shops dial a bus transport good transport community mini links – ability to buy service, good

bus, access / fresh produce transport links transport

Transport 61

DRAFT

Aboyne Portlethen Stonehaven Laurencekirk Westhill Banchory Marr K & M SA

health promoting education schools efforts to AHIO school links, input through a good local school campaigns active schools national initiatives, school initiative / facilities, the new provide education school link with school personal & school, education, on healthy living / programme, good access to accreditation, community on the benefits of community, CSN, social education good social – healthy eating, health education, information &

health curriculum, school, good healthy eating & Active Schools / programme, education, good education & health education, training active schools community links exercise, better AHIO, school pastoral support health education, support, good participation, through Primary education, good initiative to young people & education adults & schools, regular school School, education access powerfully affect families, Young young people, preventative events involving community school to services & good child & family, Minds CPD interventions & whole community, work by health promoting training education community school community schools, health used by general learning being part of School / Education / School public, self- curriculum, esteem access to information

sense of community feeling lively community community links / growth in identity a cohesive social interaction, K & M – social good support community, active spirit / close knit community of Westhill community rather periods of respite integration, network, community life community, organisations – if especially than a layered from caring role, communities community spirit – having a village good positively development of one, vibrant / volunteering being empowered peer support, hall & local effect mental town centre positive opportunities to direct, opportunities for church, health & help community opportunities for activities (no-one confidence within people to access activists who take involvement appears to be the community / services community with including maximising this) being part of the them, sense of volunteering community, core belonging e.g. of population hold participating in

traditional values community & are very groups, people supportive of the respecting & school, listening to other’s

Community community events points of view, / initiatives e.g. availability of green eco friendly carers etc., projects supportive community with sense of responsibility

DRAFT

Aboyne Portlethen Stonehaven Laurencekirk Westhill Banchory Marr K & M SA

social support / community groups new PEEP group informal groups active sporting contact with parenting groups targeting e.g. clubs meetings in available locally clubs others with similar – education (MH, Surestart speedy school has e.g. parent needs / problems, HV), Home Start therapy improved support groups / contact with & groups & similar opportunities for toddler groups, professional for support parents of young over 50’s walking services good children to meet group, positive relationship regularly, plenty of parenting – community supported by services i.e. health service, playgroups / support for young

Community Groups Community sports groups for parents children, support groups

better care for support for young early years work – caring accessible Health Visitors dedicated staff children – child people, mental CL&D (Social health care minders, input health worker, Work), Active workers from youth School Nurse Schools Co- workers ordinator Local Staff Local working with other work of IAF will co-ordinated good joint working links to Local health impact, good services – health, between health & Authority i.e. Care professionals multi-agency social care & social services Management /

working, inter- education Home Care, agency working strong links with through CSN, leisure & health, input from range agencies working of professionals – together for pupil support benefit of local Partnerships workers / CL&D community, staff / Police Liaison

good income, low deprivation, relatively affluent favourable physical & manual overall high low area economic status / employment

income level, unemployment most people income employed

Economy

DRAFT

Aboyne Portlethen Stonehaven Laurencekirk Westhill Banchory Marr K & M SA

the good quality of there are country local environment, good location, safe community, safe communities, rural environment, walks on doorstep being in the walking to the parks / open lack of pollution, pleasant countryside is next village for the spaces, beautiful open spaces environment, uplifting, location more active, fresh countryside, available for clean air, safe of the village – air – no city weather – sunny exercise, plenty friendly beautiful setting, pollution, crime days etc, climate, gardens – the environment, low crime / safe free environment community has fresh air / environment, more access & countryside areas, relatively safe ability to grow fruit

Environment weather, community & veg availability of open land for exercise, low traffic levels

lifestyle choices, tooth brushing social norm is positive health breastfeeding favourable social scheme reasonably promotion, culture, positive background, drug healthy lifestyle smoking ban, parenting, stop & alcohol misuse*, campaigns to smoking, sexual health / stimulate exercise family planning / under youngsters confidentiality, (walking & cycling

Lifestyle good diet to school), food co-operative at *This may be Braemar when it referring to health was running, promotion work affordable reasonable good housing access to good adequate housing housing, housing quality housing, good low cost housing Housing

DRAFT Annex 8: Negative impact on the health of the community (Q5b) Aboyne Portlethen Stonehaven Laurencekirk Westhill Banchory Marr K & M SA lack of voluntary lack of lack of lack of facilities, lack of family planning lack of facilities: lack of services & limited social services, lack of recreational counselling inadequate sports counselling, lack clinics & G.P food stuff, leisure access to them: outlets for old Dentists nearest areas, lack of facilities, poor centre / no pool of recreation hours (lack of facilities, very little doctors, dentist, people one Banchory / meeting places sports facilities, attached to facilities, lack of evening clinics), on offer for young optician, shops Balgowrie, for young Mums, dilapidated secondary school, public transport – lack of facilities for adults – get bored selling healthy closing of education lack of leisure impact on elderly young, access to cause trouble foods, sports dispensary for facilities, lack of facilities, lack of & youth facilities, loss of start drinking, facilities; reduced Newtonhill clubs facilities for especially, relative maternity unit, poor health care home care patients opportunities for community as a lack of provision services, lack of support, early meeting socially, whole, lack of for mental illness amenities, lack of discharge from lack of services in lack of health activities for & psycho-geriatric services, KCH; closing of Portlethen e.g care everyone, services for & centralising “cottage bank & lack of professionals e.g support struggling services hospitals”, town centre, Physio / OT centralisation of to cope with centralisation of

Lack of Services / Facilities / Services of Lack services in demand, lack of services e.g. Aberdeen / dental facilities, closing of Post Dundee Office etc.

access to inequality with access to access to services difficulty lack of access to lack of access, poor access to surgery hours, services regard to services cheaper e.g. sexual health accessing services available health care not quality food, poor access to especially out of e.g. city vs shire supermarkets services for young services to families within accessible i.e. access to sports services & clinics hours, long waits limited as above, people, waiting Aberdeenshire vs city boundaries, dentists, facilities i.e lack for some hospital limited access to times for hospital Aberdeen City, access to A&E of, speciality, limited services, admissions / services, access distance from access to consultant to many (medical) secondary care services i.e. appointments investigations is

health services sexual health – poor / slow, e.g. dentistry, nearest clinic is ease of access to Aberdeen services, Stonehaven is a small place no access to condoms etc, access to key Access to services to Access services, access to services,

DRAFT Aboyne Portlethen Stonehaven Laurencekirk Westhill Banchory Marr K & M SA poor transport young people lack of transport, lack of transport, lack of transport lack of transport, transport, poor transport, links, public feeling isolated transport is lack of suitable post caesarean poor public transport – transport, transport issues, from activities due expensive for transport, section, transport, poor access to poor public to lack of public those on low transport, access Ambulance public transport, services transport, transport, incomes, poor to transport / services, transport amenities, lack of transport, provision, lack of transport, integrated public

Transport transport system, cost of transport for outlying communities

rural isolation, isolation, social isolation, remote / rural low self-esteem & isolation – social social isolation social and rural social isolation, areas isolation, & geographical isolation, lack of some rural access to extended family, employment services, remote remoteness – issues, location, social easy to hide away

Ruraliity isolation, in terms of Isolation / services

boredom, alcohol smoking, alcohol alcohol culture promotion of time / strain from mobility of family high stress jobs people working in alco-pops, / drugs abuse, use, affects whole unhealthy foods, excessive units, nutrition in etc, drinking silos, poor working away chip van, lack of diverse range of cheap readily commuting to deprived culture of parent nutrition, bottle from home, education & community – available alcohol, work, alcohol communities, poor generation, bad feeding culture, domestic knowledge, seen as socially over reliance on abuse by children, social – family food habits / food choice, violence, not acceptable, fried food (chipper) depleted & over circumstances, culture of eating isolation – lack of much for young obesity is a worked health nothing for lot of fatty foods & support & lack of people to do – problem but not visiting, the “yob adolescents to do little veg, fast food education about tend to drift into necessarily a culture” – heavy at night, & unhealthy health issues, drinking / drug medical one in drinking eating & drinking, use itself especially, peer smoking,

Lifestyle pressure, inconsistency in approach to sexual health education, alcohol, drug

DRAFT

Aboyne Portlethen Stonehaven Laurencekirk Westhill Banchory Marr K & M SA

distance from vandalism, lack lack of support & speeding traffic, rapid expansion community unsafe media, difficult to centre, of community groups, high level without clear activists who do communities, not Police illegal community networks, no of vandalism mechanism to not take feeling listened activities, too engagement – centre in within the promote community with to, road safety – keen to meet lack of, Portlethen, no community, community them, road traffic road deaths, policy / strategic sense of a town culture of passive integration & accidents & fear dangerous cross planning with centre, young acceptance rather engagement, of them (barrier overs on nearby little impact for people feeling than active broken bottles / to exercise) dual carriageway those who really involved in buzz participation in litter etc in (A90), some need it of city life, community playgrounds deprived areas affairs, need to which are engage with affected by low group of people income, poor diet,

Community / Safety / Community most at risk smoking; lack of particularly strategic direction younger, for community / voluntary sector in rural areas,

low income, high low income unemployment, cost perception that as low income, lack high cost of living too much money, poverty unemployment, credit crunch well off area we of employment (fuel) property unemployment cost of services, have fewer prices high, cost levels that are problems of living high

Economy

increasing activities for older lack of carers & Home Care lack of carers, loss of friends amounts of people valuing them as a services large number of elderly with group generally elderly? - complex care struggling to cope resources, needs, low rate of with pay for caring in care homes, demand,

Older people/carers Older

DRAFT

Aboyne Portlethen Stonehaven Laurencekirk Westhill Banchory Marr K & M SA

weather Weather bad weather

nment Enviro

lack of housing, poor housing lack of housing, damp old rural lack of affordable K & M –

poor housing, (lack of housing – lack of housing, housing, housing, lack of inadequate affordable council housing – lack of housing housing, housing), properties, availability, opportunities

Housing

training in lack of parenting parenthood – lack groups, lack of of affordable childcare, lack of childcare for working parents, grouping Parenting challenging families together in one location

DRAFT

08 - QOF Prevalence by GP Practice for 2006 for Practice GP by Prevalence QOF : 9 Annex Annex

DRAFT

DRAFT Annex 9: Map 1 Estimates of smoking prevalence (%) in the adult population (aged 16 and over), Grampian NHS Board, 2003/04

The smoking prevalence figures presented are estimates, based on the characteristics of the local population and the regional setting, and represent a reasoned, robust ‘best guess’ of local smoking prevalence

Source: An atlas of tobacco smoking in Scotland: A report presenting estimated smoking prevalence and smoking attributable deaths within Scotland. NHS Health Scotland 2007