St.Helens Joint Strategic Needs Assessment 2015

2. Life Expectancy, Mortality, and Major and Long Term Conditions

1

Life Expectancy 81.6 79 YEARS 78 YEARS 74.3 YEARS YEARS The increase in male life

2003 expectancy in 2013

St.Helens is the

nd 2 highest in the

North West

Mortality 1837 Deaths

Cancer (30%) Cardiovascular (26%) Respiratory (16%) Mental (8%) Digestive (6%) Other (15%)

Under 75 Mortality 702 Deaths

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Male 59% Female 41% Contents

1. Introduction ...... 5

2. Key Findings ...... 6

3. Life Expectancy ...... 7

4. Mortality ...... 11 4.1 Mortality by Condition ...... 14 4.2 Mortality by Age Group ...... 16 4.2.1 Premature Mortality (under 75 years) ...... 17 4.3 Specific Causes of Mortality ...... 21 4.3.1 Liver Disease ...... 21 4.3.2 Suicide and Undetermined Injury ...... 22 4.3.3 Excess Winter Deaths in St.Helens...... 23 5. Major Long Term Conditions ...... 26 5.1 Cancer ...... 26 5.1.1 Introduction ...... 26 5.1.2 Key Statistics ...... 26 5.1.3 Cancer Incidence (new cases) and Survival Rates ...... 30 5.1.4 Cancer Incidence by Site ...... 31 5.1.5 Cancer Mortality by Site ...... 32 5.1.6 Lung Cancer ...... 33 5.1.7 Colorectal Cancer (Bowel Cancer) ...... 34 5.1.8 Breast Cancer ...... 36 5.1.9 Oesophageal cancer ...... 38 5.1.10 Prostate cancer ...... 39 5.1.11 Evidence based treatments ...... 40 5.1.12 Assets for Cancer within St.Helens ...... 42 5.1.13 Future and Recommendations ...... 42 5.2 Cardiovascular Disease ...... 43 5.2.1 Introduction ...... 43 5.2.2 Hypertension (High Blood Pressure) ...... 44 5.2.3 High Cholesterol ...... 46 5.2.4 Prevalence of Cardiovascular disease ...... 47 5.2.5 Mortality due to Cardiovascular Disease ...... 48 5.2.6 NHS Health Checks ...... 54 5.3 Respiratory Diseases ...... 56 5.3.1 Introduction ...... 56 5.3.2 Respiratory Disease Mortality ...... 56 5.3.3 Chronic Obstructive Pulmonary Disease (COPD) ...... 59 5.3.4 Asthma ...... 62 5.4 Diabetes ...... 65 5.4.1 Introduction ...... 65 5.4.2 Key statistics ...... 67

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5.5 Mental Health and Wellbeing ...... 69 5.5.1 Introduction ...... 69 5.5.2 Key Statistics ...... 69 5.5.3 Local Need ...... 70 5.5.4 Social and economic factors ...... 71 5.5.5 Future and recommendations ...... 75 6. Hospital admissions ...... 76 6.1 Healthcare Activity and Health Inequalities ...... 76 6.2 18-64yrs Hospital Admissions ...... 78 6.2.1 Summary ...... 79

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1. Introduction

This section of the JSNA considers the key public health issues of life expectancy, mortality and major long term causes of illness. Indeed, life expectancy (and inversely, mortality) may be considered one of the ultimate measures of public health.

Life expectancy across the UK has been rising continuously over the previous two centuries, (where we have reliable records). As well as improvements in healthcare, much of this increase has been due to improvements in wider determinants of health, such as housing, sanitation and nutrition.

Over the last 30 years, life expectancy at birth in the UK increased by eight years for men and six years for women (between 1982 and 2012).1 This is highly positive, however it is also very important to ensure that quality of life stays high as well. Therefore we have also considered healthy life expectancy in comparison against comparator areas.

These increases in life expectancy also pose their own challenges, and have contributed to the ageing of the population of St.Helens illustrated in the JSNA Section 1 – Demographics and Wider Determinants. An older population potentially means more people living with long term conditions, such as cancer or respiratory diseases such as chronic obstructive pulmonary disease. Therefore this section also considers these major conditions, including current prevalence. Potentially increases in the number of people living with these conditions both increases the effect on local people and increases pressures on healthcare and social care services. This information should be used by commissioners and providers to plan services to best meet current and future need, both improving people’s quality of life and reducing demands on health and social care services.

1 http://www.ons.gov.uk/ons/rel/lifetables/historic-and-projected-data-from-the-period-and-cohort-life- tables/2012-based/stb-2012-based.html#tab-Life-Expectancy--ex--at-Birth

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St.Helens Joint Strategic Needs Assessment 2015

2. Key Findings a. Life Expectancy  Life expectancy at birth for men in St.Helens is now 77.7 years and female life expectancy is now 81.5 years.  Male life expectancy in St.Helens has increased by 3.7 years in the last decade. This is the highest increase in Merseyside and the 2nd highest in the North West.  There is more than 10 years difference in life expectancy between the highest and lowest wards in St.Helens for men, and nine years difference for women. b. Prevalence of Disease  In 2013/14 St Helens CCG GPs reported 3.07% of the population (5,954 patients) had diagnosed chronic obstructive pulmonary disease (COPD), which is significantly higher than the England average of 1.8%.  St Helens CCG had the lowest cancer incidence rates amongst its neighbouring CCGs and was lower than the Cheshire & Merseyside average. c. Mortality  Male mortality is higher than female for all causes apart from diseases of the nervous system.  Cancer mortality rates in both males and females have risen in 2014 from the previous year.  Premature mortality in St.Helens (less than 75 years) reached its lowest rate in 2011 for both men and women, but since then rates have increased. The 2014 under 75 mortality rate was the highest since 2009. This increase in premature mortality was in large part due to increases in early cancer deaths.  Mortality in under 75 males due to prostate cancer is lower than the regional and national averages.  Cardiovascular disease mortality rates have been falling over a number of years, and despite an increase in 2012, rates have reduced by 26% since 2008.  Rates of early deaths due to cancer are more than double in the highest ward (Parr, 228.4) compared to the lowest ward (Eccleston, 102.6). d. Treatment and Screening  St.Helens performs better than neighbouring CCGs for percentage uptake of breast cancer screening (2013/14-2014/15).  For bowel cancer screening, St.Helens performs better than many of the other Merseyside CCGs (60-74 year olds).

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3. Life Expectancy

Life expectancy at birth is an estimate of the average number of years a newborn baby would survive if he or she experienced the particular area’s age-specific mortality rates for that time period throughout his or her life. It is not therefore the number of years a baby born in the area could actually expect to live, both because the death rates of the area are likely to change in the future and because many of those born in the area will live elsewhere for at least some part of their lives. (Public Health England)

In St.Helens between 2012 and 2014, the life expectancy was 77.7 years for men and 81.5 years for women. As shown in Figure 1, life expectancy has decreased since 2011-2013 (by 0.3 years for men and 0.1 years for women), and the gap between men and women has increased.

For 2011-2013, the life expectancy at birth for St.Helens was significantly worse than the England average (78.0 years for males in St.Helens compared to 79.4 years across England; 81.6 years for females in St.Helens compared to 83.1 years across England).

Figure 1. Life expectancy at birth trends in St.Helens, males and females, 2007-14

100 Males Females 90 80.3 80.9 81.4 81.6 81.6 81.5 78.0 78.0 80 75.9 76.4 77.3 77.7

70

60

50

40

Life Life Expectancy(Years) 30

20

10

0 2007-2009 2008-2010 2009-2011 2010-2012 2011-2013 2012-2014* Three-year average

Source: Office for National Statistics; * St.Helens Public Health Intelligence from Primary Care Mortality Database

Over the past decade, the life expectancy of people in St.Helens has increased. Male life expectancy has increased more than for females, reducing the gap between the sexes. In men, life expectancy has increased by 3.7 years between 2001-03 and 2011-13, which is the highest in Merseyside. Furthermore, the increase for St.Helens is greater than the England average and the 2nd highest in the North West.

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St.Helens Joint Strategic Needs Assessment 2015

Figure 2. Increase in male life expectancy at birth (2001-03 to 2011-13)

Oldham St. Helens 3.7 Manchester

Stockport

Liverpool Cheshire East Rochdale Salford Halton Trafford Tameside Knowsley Wigan Bolton Sefton Lancashire Cumbria

All NWAll Upper Tier Local Authorities Blackburn w Darwen Increase Bury England Cheshire W and C Wirral Warrington Blackpool .0 .5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 4.5 Increase (years) Life expectancy in females has also increased, by 2.6 years, over the past 10 years. Female life expectancy in St.Helens increased more than the England average and the 5th highest in Merseyside.

Figure 3. Increase in female life expectancy at birth (2001-03 to 2011-13)

Blackburn w Darwen

Liverpool

Oldham

St. Helens 2.6

Cheshire W and C

Cheshire East

Wirral

Rochdale

Halton

Stockport Increase All NWAll Upper Tier Local Authorities England Blackpool

Bury .0 .5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 4.5 5.0 Increase (years)

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Within St.Helens, life expectancy varies substantially. For male life expectancy (Figure 4), there is more than 10 years difference between wards, varying between 71.7 years in Town Centre and 82.4 years in Rainford. For women there is a 9 year difference, increasing from 76.7 years in Town Centre to 85.8 years in Eccleston (Figure 5).

Figure 4. Life expectancy by ward for males (2012-14)

100 St.Helens 90

80 70 60 50 40 30

Life Life expectancy(years) 20

10

71.7 73.4 74.4 76.3 76.3 76.9 78.0 78.1 78.2 78.5 78.7 79.1 80.3 80.6 80.8 82.4 0

Source: St.Helens Public Heath Intelligence from Primary Care Mortality Database; ONS population estimates Figure 5. Life expectancy by ward for females (2012-14)

100 St.Helens 90

80 70 60 50 40

30

Life Life expectancy(years)

20

10

76.7 77.6 78.7 79.0 80.5 80.6 81.2 81.7 81.7 81.8 82.1 82.9 83.4 83.4 85.5 85.8 0

Source: St.Helens Public Heath Intelligence from Primary Care Mortality Database; ONS population estimates

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St.Helens Joint Strategic Needs Assessment 2015

Healthy life expectancy adds a quality of life aspect to the life expectancy measure by estimating the time spent in self-rated "very good" or "good" health, as recorded in local surveys. St.Helens had a lower healthy life expectancy than the England average in 2011-13. Men in St.Helens had an average 62.5 years in good health compared to 63.3 for England, and women had 62.0 years in good health compared to 63.9 for England.

Table 1 compares life expectancy and healthy life expectancy at birth for St.Helens and neighbouring local authorities in 2011-2013. It shows that life expectancy in St.Helens is ranked third for males and fourth for females; however when looking at healthy life expectancy, St.Helens ranks highest for men and third for women.

For healthy life expectancy amongst all 150 Upper Tier Local Authorities in England, St.Helens ranks 84th for males and 97th for females.

Table 1. Life expectancy (LE) and Healthy life expectancy (HLE) 2011-2013

Males Females Local authority LE HLE Local authority LE HLE Warrington 78.3 62.0 Sefton 82.5 63.6 Sefton 78.1 60.8 Wirral 82.3 61.8 St.Helens 78.0 62.5 Warrington 81.8 61.7 Wirral 77.8 59.8 St.Helens 81.6 62.0 Wigan 77.7 61.1 Wigan 80.9 62.5 Halton 77.3 58.3 Knowsley 80.8 57.9 Knowsley 76.7 57.5 Liverpool 80.5 59.6 Liverpool 76.2 57.2 Halton 80.4 61.0

Source: Office for National Statistics, 2015

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4. Mortality

All age all-cause mortality is a key indicator of the overall health of the Borough. This gives an overall rate of mortality over all age groups and is standardised by age to allow fair comparisons between different areas. It is linked to life expectancy so if the mortality rate falls, life expectancy increases.

In 2014, there was a slight change in all age all-cause mortality rates in St.Helens. For males, the rate decreased from 1318.3 per 100,000 in 2013 to 1303.2 per 100,000 and for females, decreased from 990.5 to 960.4. Mortality rates in St.Helens are slightly higher than those for the North West for 2013, but are statistically significantly higher than the national average for both men and women.

Mortality rates for both males and females in 2014 were significantly lower than in 2009. Female mortality rates have decreased since 2009 although there was an increase between 2012 and 2013. Male mortality fell significantly between 2009 and 2011, but rates increased in 2012 and 2013 before falling by a small margin in 2014.

In numbers, 910 men and 927 women died in St.Helens in 2014.

Figure 6. All age all-cause mortality rate, 2009-2014

1,600.0

1,400.0

1,200.0

1,000.0

800.0

600.0

400.0 St.Helens - Males St.Helens - Females North West - Males

200.0 North West - Females England - Males England - Females Directly Directly standardisedrateper 100,000

0.0 2009 2010 2011 2012 2013 2014* Year

Source: Office for National Statistics; * St.Helens Public Health Intelligence from Primary Care Mortality Database

The long term trend in mortality in St.Helens is downward, which is very positive, and the inequality in mortality rate between men and women has narrowed over the last 20 years. Male mortality has fallen by over a third (38%), with female mortality rates falling by a quarter (25%) over the past 20 years.

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St.Helens Joint Strategic Needs Assessment 2015

Figure 7. Long-term all-cause mortality rate in St.Helens, 1995-2014

2,500.00

2,000.00 Males Females

1,500.00

1,000.00

100,000 100,000 population 500.00 Directly Directly standardisedrateper 0.00

Year

Source: Office for National Statistics; * St.Helens Public Health Intelligence from Primary Care Mortality Database

Figure 8 displays the causes of death across St.Helens in 2014 by type. Cancer (30%) and cardiovascular diseases (26%) are the greatest causes.

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Figure 8. Main causes of death in St.Helens, 2014

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St.Helens Joint Strategic Needs Assessment 2015

4.1 Mortality by Condition Further information can be gained by analysing the causes of deaths by condition type. Table 2 provides the annual mortality rates by condition for all ages. The year with the highest rate for each condition is highlighted.

Table 2. Directly standardised rates of mortality in St.Helens for males and females by year and condition, 2008-2014

Males 2008 2009 2010 2011 2012 2013 2014 All Cause 1506.5 1461.1 1316.6 1265 1303 1318.3 1303.2 Cancer 379.7 434.5 371.1 354.8 357.9 338.7 373.1 Cardiovascular Diseases 502.2 448.3 419.7 393.6 392.4 367.5 356.3 Respiratory Diseases 269.7 218.2 245.6 229.3 216.5 260 199.6 Mental & Behavioural Disorders 56.3 41.9 44.4 49.6 66.6 90 97.7 Digestive Diseases 53.3 91.3 58.4 62.6 60.1 60.4 89.2 Diseases of the nervous system 37 42.1 21.6 29.5 64.3 52.5 41.2 Death not caused by disease 58.7 64.5 54.2 46.8 67.9 53.7 57

Females 2008 2009 2010 2011 2012 2013 2014 All Cause 1094.9 1052.4 1028.8 963.9 953.9 989.5 960.4 Cancer 255.5 267.7 256.6 263.7 255.7 252 260.8 Cardiovascular Diseases 317.3 283.5 264.1 231.4 238.3 226 236.6 Respiratory Diseases 201.8 188 187.6 165.8 165 193 160.2 Mental & Behavioural Disorders 48.9 59.1 58.3 81.1 95.1 111.6 94.1 Digestive Diseases 65.2 70.7 69.4 57 57.2 55.2 53.5 Diseases of the nervous system 24.2 21.8 45.9 34.3 44.9 34 45.5 Death not caused by disease 31.4 31 41 38 17 23.2 21.2 Source: St.Helens Public Heath Intelligence from Primary Care Mortality Database; ONS population estimates

Cancers had the highest rate of death in St.Helens in 2014, and accounted for 30% of all deaths in 2014. This was closely followed by cardiovascular diseases (CVD), such as heart disease and stroke. Together, cancer and CVD contributed to over half of all deaths in St.Helens. Previously the highest cause of mortality for men was CVD; however in 2014 cancer became the highest cause. This is because male deaths due to CVD have fallen significantly since 2008, while the rate of cancer deaths has stayed steady.

Table 2 highlights that men have a higher rate of mortality than women for all types of condition except for diseases of the nervous system, which includes Alzheimer’s and Parkinson’s. The following charts (Figure 9 and Figure 10) display the changes in mortality by condition for men and women between 2008 and 2014. Rates of CVD have tended to fall amongst both males and females, although female mortality from CVD increased between 2013 and 2014 from 226 to 236.6 per 100,000, although not significant this corresponded to 19 more deaths.

14

Mortality by Condition

In 2014, respiratory disease mortality rates were the lowest since 2008 for both men and women. The respiratory mortality rate for males and females combined fell significantly in 2014 compared to 2013 (217.8 to 172.7 per 100,000); this corresponded to 56 fewer deaths in 2014 compared to 2013.

Deaths due to mental and behavioural disorders in males in 2014 were the highest since 2008; an 83% increase in 7 years. Female mortality due to disease of the nervous system was the highest in 2014 since 2010; and has increased by nearly 90% since 2008. Although a proportion of these increases may be due to a change in cause of death coding, the recent rise will be as a result of increased prevalence of conditions such as dementia and Alzheimer’s.

Figure 9. St.Helens all age mortality rates for males, 2008-2014

600 500 400

300 200 100

population) 0 2008 2009 2010 2011 2012 2013 2014 Registered year of death

Directly Directly standardisedrate (per 100,000 Cancer Cardiovascular Diseases Respiratory Diseases Mental & Behavioural Disorders Digestive Diseases Diseases of the nervous system Death not caused by disease

Source: St.Helens Public Heath Intelligence from Primary Care Mortality Database; ONS population estimates Figure 10. St.Helens all age mortality rates for females, 2008-2014 600

500

400 300 200 100

100,000 100,000 population) 0

2008 2009 2010 2011 2012 2013 2014 Directly Directly standardisedrate(per Registered year of death Cancer Cardiovascular Diseases Respiratory Diseases Mental & Behavioural Disorders Digestive Diseases Diseases of the nervous system Death not caused by disease

Source: St.Helens Public Heath Intelligence from Primary Care Mortality Database; ONS population estimates

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St.Helens Joint Strategic Needs Assessment 2015

4.2 Mortality by Age Group The mortality rates for males and females by age bands are shown in the following two charts. Over the past 7 years, 2014 saw the highest rates for both males and females in the 50-64 age group. For males the mortality rate amongst those aged 50 to 64 years increased by 25% between 2013 and 2014 (29 extra deaths), with females increasing by 21% in 2014 (19 extra deaths).

The mortality rate amongst males and females aged 85+ is at its lowest since 2008, although there has been an increase in the number of deaths compared to 2008, which is due to more people living until they are 85 and over.

Between 2013 and 2014 the mortality rate amongst males aged 35 to 49 decreased by 10% (7 fewer deaths); there have also been slight reductions in mortality rates for women aged 75 to 84 and 85 years and over (8 and 15 fewer deaths respectively).

Figure 11. St.Helens mortality rates for males by age, 2008-2014

25,000

20,000 85+ yrs

15,000 75-84 yrs

10,000 65-74 yrs

100,000) 50-64 yrs 5,000 35-49 yrs 0 20-34 yrs

Directly Directly Standardised(perRate 2008 2009 2010 2011 2012 2013 2014 Registered year of death

Source: St.Helens Public Health Intelligence from Primary Care Mortality Database and ONS population estimates.

Figure 12. St.Helens mortality rates for females by age, 2008-2014

20,000

85+ yrs

15,000 75-84 yrs 10,000 65-74 yrs

5,000 50-64 yrs (per100,000) 35-49 yrs 0 Directly Directly StandardisedRate 2008 2009 2010 2011 2012 2013 2014 20-34 yrs Registered year of death

Source: St.Helens Public Health Intelligence from Primary Care Mortality Database and ONS population estimates.

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Mortality by Age Group

4.2.1 Premature Mortality (under 75 years) The following tables and charts provide the rates of mortality for St.Helens residents aged less than 75 years. This is to allow a consideration of premature death and avoid the charts being dominated by residents aged 75 years and over.

Out of the 1,837 deaths in St.Helens in 2014, 702 were aged under 75. Cancer, as is the case with all ages (Figure 8), is the most common cause of death amongst under 75s (Figure 14). More than four in ten (41%) premature deaths were due to cancer (285 deaths), compared to 30% across all ages. Deaths from digestive diseases and those not caused by disease made up a larger proportion of all deaths in under 75s than across all ages (6.6% and 3.5% respectively). Within digestive diseases, all deaths due to alcoholic liver disease (33 deaths) occurred amongst those aged under 75.

The chart below displays the mortality rates for primary causes of death in St.Helens for 2014. Generally male mortality rates are higher for all causes, apart from diseases of the nervous system which is higher in females, 14.2 compared to 12.8 per 100,000 population.

Figure 13. Directly standardised rates of under 75 mortality in St.Helens for males and females by condition, 2014

250

195 200 Males Females 150 150 114

100

60 58 53 33 43 48

50 DSR DSR per 100,000 population 13 14 11 6 5 0

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St.Helens Joint Strategic Needs Assessment 2015

Figure 14. Main causes of death amongst under 75s in St.Helens during 2014

18

Mortality by Age Group

Table 3 gives the changes in mortality rates for men and women aged less than 75 years, by year, since 2008. Premature mortality in St.Helens reached its lowest rate in 2011 for both men and women, but since then rates have increased, (from 430.1 per 100,000 in 2011 up to 521.6 in 2014 for men, and an increase from 301 per 100,000 to 342.1 for women).

This increase in premature mortality was in large part due to increases in early cancer deaths. These increased in 2014 compared to 2013 for both males and females, which corresponded to an additional 28 deaths. Female cardiovascular and respiratory disease mortalities have also increased since 2011.

Table 3. Directly standardised rates of under 75 mortality in St.Helens for males and females by year and condition, 2008-2014

Males 2008 2009 2010 2011 2012 2013 2014 All Cause 582.6 585.7 501.5 430.1 502.7 521.2 521.6 Cancer 198.1 208.4 183.6 159.3 171 177.3 195.2 Cardiovascular Diseases 170.9 158.3 141.1 101.9 133.1 141.5 114.2 Respiratory Diseases 65 52.6 57.3 52.1 60.4 61.5 53.2 Mental & Behavioural Disorders 9.4 7.9 5.2 2.7 6.7 6.8 6.1 Digestive Diseases 40.7 63.5 46.9 38.9 32.9 40.9 57.6 Diseases of the nervous system 16.4 14.5 8.1 6.7 21.1 21 12.8 Death not caused by disease 41 54.6 25.4 34.6 48.7 33.6 48.1

Females 2008 2009 2010 2011 2012 2013 2014 All Cause 363.8 356.9 323.7 301 323.5 311.7 342.1 Cancer 153.7 144.6 128.4 135.3 138 132.1 149.6 Cardiovascular Diseases 89.2 78.7 74.5 46.8 49.6 56.9 59.9 Respiratory Diseases 35.1 34.7 40.4 35.3 39.9 39.8 43.2 Mental & Behavioural Disorders 1.1 6.4 5 7.7 4.9 6.2 4.8 Digestive Diseases 35.5 39.2 28.3 28.6 42 26.5 33.3 Diseases of the nervous system 8 9.9 14 8.2 15 9.8 14.2 Death not caused by disease 13 16.3 10.3 18.5 3.9 17.3 11

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St.Helens Joint Strategic Needs Assessment 2015

Figure 15. Under-75 mortality rate (DSR per 100,000) for males and females in St.Helens

700.00

600.00

500.00

400.00 Males 300.00 Females

200.00

100.00

0.00 2009 2010 2011 2012 2013

Source: HSCIC, 2015

When compared to neighbouring authorities, St.Helens under-75s mortality for all persons is lower than the majority with only Sefton and Wirral having better rates in 2013. All of the Merseyside local authorities have a higher (worse) rate of under-75 mortality than England.

Figure 16. All persons under-75 mortality rates (DSR per 100,000) in Merseyside over 5 years.

600.00

500.00

St Helens 400.00 Halton Knowsley 300.00 Liverpool Sefton 200.00 Wirral England 100.00

0.00 2009 2010 2011 2012 2013

Source: HSCIC, 2015

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Specific Causes of Mortality

4.3 Specific Causes of Mortality

4.3.1 Liver Disease Liver disease is one of the top causes of death in England and increasingly people are dying from it at younger ages. Most liver disease is preventable and much is influenced by alcohol consumption and obesity, which are both amenable to public health interventions.

Liver disease rates are calculated using the total number of deaths from viral hepatitis, liver cancer, portal vein thrombosis, oesophageal varices, liver disease and, liver transplant failure and rejection.

Public Health England publishes information highlighting premature mortality across England, with rates of deaths before 75 years compared between 149 upper tier local authorities from 2011 to 2013. The St.Helens annual rate of 27.4 deaths per 100,000 between 2011 and 2013 was the third highest mortality rate for liver disease across Merseyside, and ranked 137th of 149 authorities in England. This has improved since 2009-2011 figures, when St.Helens was the highest in Merseyside and third worst in England. The rate in St.Helens corresponds to 132 actual premature deaths over the three years, averaging 44 deaths per year.

The highest total number of deaths before 75 years from liver disease in the last six years was in 2014, when 66 people died. The number of women dying prematurely from liver disease in 2014 (24) was the highest since 2008 and was 50% higher than the total for 2013. There were 42 deaths amongst men aged under 75 due to liver disease in 2014, more than double the number in 2012.

In males, mortality rates from liver disease reduced by 51% between 2009 (56 per 100,000) and 2012 (27.6 per 100,000), however between 2012 and 2014 (61.4 per 100,000) rates have risen to the highest value since before 2008.

Mortality rates from liver disease in females has remained fairly constant despite peaks in 2012 and 2014; in particular the rates for women aged 50-64 years has almost doubled between 2013 and 2014; from 39.7 to 76.1 per 100,000 population.

Figure 17. St.Helens under 75 liver disease mortality rate by gender, 2008-2014

60 Males Females

50

40

30

20

100,000 100,000 population) 10

Directly Directly Standardised(perRate 0 2008 2009 2010 2011 2012 2013 2014 Registered year of death

Source: St.Helens Public Health Intelligence from Primary Care Mortality Database and ONS population estimates.

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St.Helens Joint Strategic Needs Assessment 2015

4.3.2 Suicide and Undetermined Injury Suicide is a major issue for any area as even small numbers of suicides have a great impact on immediate family and friends and the wider community. Nationally one person dies every 2 hours as a result of suicide and often these are young people with many years of life to live. Also nationally, men are three times as likely to take their own lives as women, and the highest rates of suicide are amongst those aged 35 to 49 years old.

As can be seen from the rates in Figure 18, most of these deaths were men, and indeed all the deaths due to suicide and injury undetermined in St.Helens in 2012 were men.

It must be stressed however that the overall number of deaths per year is very low; however we cannot be complacent and need to understand the overall reason behind the suicides and what additional prevention activities we can initiate to mitigate a continued rise. Therefore further work to understand these trends may be necessary.

It is known from the past that during periods of high unemployment or economic problems have been associated with higher rates of suicide. It is thought that although in England the rates have been low when benchmarked against the rest of Europe that the recent upturn nationally may be due to the economic situation. In relation to the overall trends in suicides the trend in St.Helens is upward and amongst our immediate local authority neighbours we have the second highest rate and are statistically higher than the overall England rate.

In terms of numbers in St.Helens, the lowest number of deaths due to suicide and injury undetermined in the last ten years was in 2010 with nine. The two highest years in the last ten were 2011 and 2012 with 20 and 23 deaths, respectively.

Figure 18. St.Helens suicide and injury undetermined, 15+ years, 3-year mortality rate, 2008 – 2014

30

25 Persons Males Females 20

15

10

5 100,000 100,000 population) 0 Directly Directly Standardised(perRate 2008-2010 2009-2011 2010-2012 2011-2013 2012-2014 Registered year of death

Source: St.Helens Public Health Intelligence from Primary Care Mortality Database and ONS population estimates.

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Specific Causes of Mortality

4.3.3 Excess Winter Deaths in St.Helens Excess winter deaths are defined as any increase in deaths that occur for a population between the months of December and March, compared the number of deaths that would be expected, given the same chance of death across the rest of the year. Nationally there is an increase in mortality during these months, with frequent increases in deaths due to respiratory disease for example. Also, the elderly are particularly vulnerable to higher death rates in winter. However, there is evidence that excess winter deaths are preventable and that mortality in England increases more in winter than in countries with colder climates. Reducing excess winter mortality is one of the outlined outcomes for the “Healthy Life Expectancy and Preventable Mortality” domain in the Public Health Outcomes Framework ‘Healthy lives, healthy people: Improving outcomes and supporting transparency’ published in January 2012.2

Excess winter deaths can be described by an index (EWDI). For example, the EWDI for England across the three year period of 2010 to 2013 is 17.4. This means that close to one in six extra deaths occurred across England between December and March than in non-winter months. Figure 19 provides the EWDI for all local authorities in England (324) for the three winters between 2010 and 2013 (i.e. 2010/11, 2011/12, 2012/13).

Figure 19. Excess winter deaths index, 3 year rate, 2010/11-2012/13

40 North West England

35

30

25

Three Year EWDIndex St.Helens 20

15

10

5

0 Unitary Authorities (324) Source data: ONS, 2014

St.Helens has a higher rate of excess winter deaths (20.8), compared to the national and regional averages (17.4 and 17.1 respectively). The rate of EWDs in St.Helens in 2010/11-12/13 is the 4th highest in the North West. In terms of numbers, the average annual number of excess winter deaths in St.Helens between 2010/11 and 2012/13 was 113. Although there has been an increase in EWDs

2 Department of Health, 2012. ‘Healthy lives, healthy people: Improving outcomes and supporting transparency’ Public Health Outcomes Framework. [online], published on 23rd January 2012. Available at http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_132358

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St.Helens Joint Strategic Needs Assessment 2015 between 2009/10-11/12 and 2010/11-12/13 the value has decreased significantly since 2007/08- 2009/10 (26.8). However, when plotted by year (see Figure 20), the majority of this high index score is due to the winter of 2008/09, where the EWDI in St.Helens increased to 39.7, more than double the rate of most years.

The annual rates are shown in the chart below, along with the rates for the North West overall, and the published average winter temperatures for the North West and North Wales from the Met Office. In 2012/13, St.Helens had a higher EWDI than the North West for the first time since 2009/10, although the differences have not been statitically significant since 2008/09.

Figure 20. Annual excess winter deaths index, 2006/07 to 2012/13

St. Helens North West Average Winter Temperature

60 6

50 5

C)

40 4 ̊ (

30 3

20 2 Temperature

10 1 Excess Excess Winter Deaths Index

0 0 2006-07 2007-08 2008-09 2009-10 2010-11 2011-12 2012-13

Source data: ONS; Met Office. (Please note, average winter temperature is based on December to February, while excess winter deaths are taken from December to March).

Within St.Helens, excess winter deaths vary substantially. The EWDI in the highest ward (Rainhill, 40.2) was nearly ten times higher than the lowest ward (Thatto Heath, 4.6). Two wards, Rainhill and Billinge and Seneley Green, were significantly higher than the St.Helens average. Three wards (Thatto Heath, Eccleston and West Park) were significantly lower than the St.Helens average.

The proportion of excess winter deaths can be affected by non-winter deaths. For example, Town Centre has the highest number of deaths during the winter months but also has the highest average number of non-winter deaths. This means that although winter deaths are high in Town Centre, when compared to non-winter deaths, the EWDI is the fourth lowest in the Borough.

Housing quality and insulation levels may well be important differences contributing to the variations within St.Helens, and it may be that areas such as Rainhill and Billinge and Seneley Green could be targeted specifically for winter support in the future.

24

Specific Causes of Mortality

Figure 21. Excess Winter Deaths by Ward, 2009/10 to 2013/14

St.Helens Public Health Intelligence. Source: Primary Care Mortality Database © Crown Copyright and database right 2011. Ordnance Survey 100050516.

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St.Helens Joint Strategic Needs Assessment 2015

5. Major Long Term Conditions

5.1 Cancer

5.1.1 Introduction Cancer is a collective name for related diseases when abnormal cells in the body divide in an uncontrolled way, which can then spread to cause a lump or tumour. Many cancers start due to gene changes that happen over a person’s lifetime, but some cancers are genetic; when a faulty gene is inherited.

The most recent national cancer strategy was published in January 2011 ‘Improving Outcomes: a strategy for cancer’ with an aim to improve outcomes in relation to cancer survival through early diagnosis and access to the best possible treatment. Cancer survival in the UK is behind many of the developed countries and a significant proportion of cancers were only diagnosed once a patient is admitted as an emergency (1 in 4).

Commissioning of cancer treatment and care is the responsibility of the Clinical Commissioning Groups (CCG), screening such as bowel cancer screening, breast screening and cervical screening is commissioned by NHS England, whereas the prevention of cancer programmes lie with public health within Local Authorities. A plan of work has been developed to ensure that locally we are striving to achieve better outcomes for our residents.

5.1.2 Key Statistics At the end of 2010 5,200 people were living in St.Helens for 20 years with and beyond cancer diagnosis; this is largely due to better detection and treatment programmes. Based on population trends and current prevalence an estimated 10,000 could live with or be free from cancer by 2030. To improve this figure we need to detect cancer early enough to improve survival and life expectancy.

5.1.2.i Why is Cancer a significant health issue? Cancer is very common with more than one in three people will develop some form of cancer over their lifetime. The four biggest causes of cancer are lung, colorectal, breast and prostate accounting for 53% of all new cases nationally in 2011. St.Helens reflects the national picture however in 2014 there were a greater number of deaths from oesophageal cancer than prostate cancer. Nationally, breast cancer is the most common cancer in women and whilst prostate is the most prevalent in men.

Cancer is the biggest cause of death in St.Helens both for all ages and for people dying early, under the age of 75. In 2011 for the first time cancer rather than cardiovascular disease was recorded as the biggest cause of death, with 30% of all deaths; the trend remaining similar through to 2014. In 2014 there was a rise in the number of deaths due to cancer (545 compared to 498 in 2011).

Despite cancer being our biggest cause of death the overall trend is downwards. Since 1995 the rate in St.Helens has fallen by 18.9% just slightly more than the England rate (18%) and more than the

26

Cancer

rate in the North West (16.3%). These rates have not fallen as steeply as other conditions such as cardiovascular disease and the last few years have seen little progress in the rate of reduction.

The overall picture shows that rates are high, but compared to our neighbours for early deaths due to cancer in 2013, only Wirral had a lower rate. The rate in St.Helens was also lower than that for the North West (Figure 22).

Figure 22. Under 75 cancer mortality rate by local authority, 2013

250 North West England

200

150

100

DSR DSR per100,000 50

0 Knowsley Liverpool St Helens Sefton Wirral Halton Local Authority

Source: Health & Social Care Information Centre

Cancer is specifically more prevalent in older age groups due to gene changes over time; this is illustrated the age profile of cancer deaths in St.Helens seen in Table 4.

Table 4. St.Helens cancer mortality rates by age, 2008-2014

2008 2009 2010 2011 2012 2013 2014 85+ yrs 2783.0 3798.9 3577.0 3212.2 3364.6 2989.6 3511.2 75-84 yrs 1997.9 2305.0 1763.0 1992.0 1818.4 1578.2 1657.7 65-74 yrs 1102.3 1030.7 819.8 826.6 884.4 851.5 1087.9 Males 50-64 yrs 262.4 353.9 346.9 253.1 261.0 288.1 279.2 35-49 yrs 57.3 36.8 57.3 36.6 51.1 70.2 26.3 20-34 yrs 7.1 14.3 7.2 6.2 0.0 0.0 12.8 All age 379.7 434.5 371.1 354.8 357.9 338.7 373.1

85+ yrs 1800.7 1951.2 2069.1 2142.4 2129.0 1950.5 1886.5 75-84 yrs 1086.3 1344.1 1354.0 1338.9 1182.6 1277.6 1193.4 65-74 yrs 781.1 663.4 667.6 597.3 561.8 603.9 563.8 Females 50-64 yrs 233.7 245.1 211.6 206.4 273.6 247.2 305.0 35-49 yrs 47.1 56.3 20.9 72.5 58.0 20.3 83.1 20-34 yrs 7.1 12.5 0.0 26.5 6.0 12.3 0.0 All age 255.5 267.7 256.6 263.7 255.7 252.0 260.8

Source: St.Helens Public Health Intelligence from Primary Care Mortality Database and ONS population estimates.

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St.Helens Joint Strategic Needs Assessment 2015

Cancer mortality rates for men and women increased in 2014 compared to 2013, both for all ages and amongst under 75s. Female deaths due to cancer in those aged 50-64 and 35-49 increased in 2014 to their highest rates since 2008. In 2014, there were 12 more deaths amongst 35-49 year olds and 10 more amongst 50-64 year olds compared to 2013.

Despite a general decrease in male deaths due to cancer 2010 to 2013, there has been an increase in 2014, specifically in the over 85s and the 65-74 age group. Rates for males aged 65-74 had been fairly consistent between 2010 and 2013; however 2014 has seen a sharp increase. This increase amongst 65-74 year olds relates to 21 more deaths in 2014 compared to 2013.

Men have higher cancer mortality rates than women in the older age groups, with rates amongst males aged 85+ and 65-74 years nearly double their female counterparts. In the younger age groups of 50-64 and 35-49 years, females had higher rates than males in 2014.

5.1.2.ii Geographical Variations Table 5 shows the mortality rates (under 75) by cancer site for electoral wards. Rates for all cancers show a link between increased deprivation and increased early cancer deaths. The link between deprivation and early deaths is less evident amongst prostate cancer deaths (although these differences are not significant).

Table 5. Under 75 Cancer deaths by ward and major sites, 2010 - 2014

Under 75 All Cancers Lung Colorectal Breast Prostate Ward (Persons) (Persons) (Persons) (Females) (Males) Eccleston 102.6 11.6 11.2 13.0 7.2 Rainford 103.4 28.8 10.6 16.7 8.2 Rainhill 113.5 25.7 12.9 27.3 10.5 Billinge and Seneley Green 128.0 32.4 10.8 25.6 15.0 Haydock 131.5 40.1 10.5 7.0 12.0 Bold 150.1 39.4 23.2 9.6 0.0 West Park 150.4 32.5 9.0 42.0 4.4 Moss Bank 150.9 40.3 15.9 22.0 17.9 Sutton 167.3 43.8 21.4 21.7 7.4 Windle 169.8 46.8 9.8 27.6 8.5 Newton 183.3 39.4 13.8 13.7 15.5 Blackbrook 183.8 39.9 10.2 15.1 22.5 Thatto Heath 192.2 71.4 22.6 15.8 4.1 Earlestown 207.5 53.5 23.3 31.5 0.0 Town Centre 208.7 60.8 24.4 24.4 4.6 Parr 228.4 83.5 12.2 22.9 13.5

Rates of early deaths due to cancer are more than double in the highest ward (Parr, 228.4) compared to the lowest ward (Eccleston, 102.6). Rates in Parr are significantly higher than six wards across the Borough.

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Cancer

Figure 23. Under 75 mortality from cancer by ward, 5 year rate (2010-14)

St.Helens Public Health Intelligence. Source: Primary Care Mortality Database © Crown Copyright and database right 2011. Ordnance Survey 100050516.

The gender split in early cancer deaths is at its greatest in Sutton, where male mortality rates (216.2) are nearly double those seen amongst females (121.9) in the ward. Bold is the only ward in the Borough which has higher mortality rates for females compared to males (152.4 and 147.7 per 100,000 respectively).

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St.Helens Joint Strategic Needs Assessment 2015

Figure 24. Cancer mortality rates by ward, Under 75’s, Gender, 2010-2014

300 Persons Males Females

250

200

150

100 DSR DSR per100,000 50

0

Ward

5.1.3 Cancer Incidence (new cases) and Survival Rates Describing cancer incidence allows us to know how many new cases we have in order to understand how effective the local prevention strategies are; and of those diagnosed, at what stage they were diagnosed to assess our early detection strategies and understand what the survival prospects were and how effective the treatments were.

5.1.3.i Cancer Incidence St Helens CCG had the lowest cancer incidence rates amongst its neighbouring CCGs and was lower than the Cheshire & Merseyside average, although the differences were not significant. Among the CCGs compared, St.Helens was the only CCG to have rates similar to the England average (not statistically significantly different).

Figure 25. Cancer incidence rates by CCG, all age and under 75, 2012

Source: Local Cancer Intelligence; PHE National Cancer Intelligence Network and Macmillan Cancer Support

Source: Local Cancer Intelligence; PHE National Cancer Intelligence Network and Macmillan Cancer Support

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Cancer

Net cancer survival is an estimate of survival from cancer after adjustment for other causes of death after one year of diagnosis. Figure 26 indicates that St.Helens survival rates have improved, and by 2012 they were better than the England average and Merseyside as a whole; in relation to our Merseyside neighbours only NHS Southport and Formby CCG has better survival rates.

Figure 26. Net cancer survival at one year after diagnosis, by CCG, 1997-2012

73.0 71.0 69.0

67.0 65.0 63.0

Percentage 61.0 59.0 57.0 55.0 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

England Merseyside Halton Knowsley Liverpool South Sefton Southport and Formby St Helens Source: Office of National Statistics

A publication by the All Party Parliamentary Group on Cancer has recently reported on cancer survival3, within this document St.Helens is quoted as one of the top ten improved areas in the country (2011 to 2012). However, in order to improve outcomes for people with cancer there needs to be awareness of symptoms in the general public and to seek help early. If the cancer is diagnosed early, outcomes and survival rates can be improved for individuals.

Data from Cheshire and Mersey Cancer Intelligence Service reports the stage of disease when people received a diagnosis. In St.Helens 49% of the diagnoses were at a late stage, which ranks St.Helens in 7th position of the 12 areas in Merseyside. In order to ensure that we improve this statistic, effective campaigns raising awareness of symptoms need to be continually promoted and work with general practice to ensure that symptoms are acted upon promptly. This can be a challenge as some of the symptoms can be very generic and linked to a host of different issues.

5.1.4 Cancer Incidence by Site Whilst lung cancer is the biggest cause of death for cancers it is only the 4th biggest when it comes to new cases. This suggests that whilst the rates of new cases are lower, the outcomes are worse than they are for some other cancers.

3 All Party Parliamentary Group on Cancer (2015) One year cancer survival rates: measuring progress

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St.Helens Joint Strategic Needs Assessment 2015

Figure 27. Rate of cancer incidence by site, all ages, 2010-12

300.00 250.00 St Helens 200.00 England 150.00 North West 100.00 50.00

Incidence,per DSR 100,000 0.00

Cancer by site

Source: Health and Social Care Information Centre

5.1.4.i Patient Experience In St.Helens, 92% of people rate their overall care as excellent or very good; the England average is 88%. People rate each aspect of their care differently: e.g. 64% reported that hospital and community staff always worked well together (compared with the England average of 64%).

5.1.5 Cancer Mortality by Site Overall the charts below describe both all deaths and early deaths (under 75) due to cancer in the Borough, relative to England and North West rates. The rates show that St.Helens is not significantly different from England for either early or all deaths from cancer. Data for 2014 is not yet available nationally but we know in St.Helens we have seen increases particularly in colorectal cancer deaths.

Figure 28. Cancer mortality by site, all ages, 2011-2013

90.00 80.00 St Helens 70.00 England 60.00 North West 50.00 40.00 30.00 20.00 10.00

0.00 Mortality DSR. Per 100,000 (All age)

Cancer by site Source: Health and Social Care Information Centre

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Cancer

5.1.6 Lung Cancer As of the end of 2010, around 190 people in St.Helens were living with and beyond lung cancer up to 20 years after diagnosis. There were 104 new lung cancer diagnoses per 100,000 people in 2012; this is higher than the England average (85 per 100,000).

Lung cancer is still the biggest cause of cancer death in St.Helens and follows the national trend. The rate of early deaths due to lung cancer in St.Helens is just above the regional average, but is lower than its similar neighbours (Knowsley, Liverpool and Halton). Lung cancer is most commonly diagnosed in people between the age of 70 and 74 and although people who have never smoked can develop lung cancer, smoking is the major cause of the disease (90% of cases).

Figure 29. Under 75 lung cancer mortality rate by Local Authority, Persons, 2013

70 North West England

60

50 40 30

20 DSR DSR per100,000 10 0 Wirral Sefton St Helens Knowsley Liverpool Halton Local Authority

Source: Health & Social Care Information Centre, 2015

Early deaths due to lung cancer show wide inequalities within St.Helens (Figure 30), with rates in the highest ward (Parr, 83.5) over seven times higher than those in the lowest ward (Eccleston, 11.6). It is likely that a significant proportion of this variation is due to smoking prevalence.

Figure 30. Under 75 lung cancer mortality rate by ward, Persons, 2010-2014

120

100 80 60 40

DSR DSR per100,000 20 0

Ward

Source: St.Helens Public Health Intelligence from Primary Care Mortality Database and ONS population estimates.

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St.Helens Joint Strategic Needs Assessment 2015

5.1.7 Colorectal Cancer (Bowel Cancer) Colorectal cancer, otherwise described as bowel cancer, is cancer of the large bowel (colon cancer) and of the back passage (rectal cancer). Bowel cancer is the 3rd most common cancer in the UK. The causes of bowel cancer are not known but we know that 80% of cases are diagnosed in people over the age of 60. However there are certain risk groups that are known about:

 Being over 60  Having a family history of bowel cancer  Inherited conditions, familial adenomatous polyposis and hereditary non polyposis colorectal cancer  Being Ashkenazi Jew - About 1 in 10 Ashkenazi Jews have a faulty gene called I1307K  Having benign polyps  Ulcerative colitis or Crohn’s disease  If you have had cancer before  Some medical conditions such as diabetes

Colorectal cancer is the second biggest cause of cancer deaths in St.Helens in both 2014 and 2013. There were big increases in deaths between 2013 and 2014.

The rate of early deaths for colorectal cancer in St.Helens in 2013 is lower than the England and North West, as well as its neighbouring local authorities, however we have seen increases in 2014 showing that this site of cancer is still a challenge.

Figure 31. Under 75 colorectal cancer mortality rate by Local Authority, Persons, 2013

20 North West England

15

10

DSR DSR per100,000 5

0 St Helens Wirral Halton Liverpool Sefton Knowsley Local Authority

Source: Health & Social Care Information Centre, 2015

There are no statistically different wards for early deaths from colorectal cancer (Figure 32). Rates do not follow deprivation as closely as lung cancer, with Eccleston and Parr having similarly average rates (11.2 and 12.2 respectively).

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Cancer

Figure 32. Under 75 colorectal cancer mortality rate by ward, Persons, 2010-2014

45 40

35 30 25 20 15 10 5 DSR DSR 100,000 per 0

Ward

Source: St.Helens Public Health Intelligence from Primary Care Mortality Database and ONS population estimates.

Figure 33 shows the proportion of people in St.Helens diagnosed with colorectal cancer at a late stage, compared with other CCGs in Cheshire and Merseyside. Nearly 59% in St.Helens were diagnosed at a late stage, however this ranged from the best of 42% in Eastern Cheshire to Wirral where 67% were diagnosed at a late stage.

Figure 33. Percentage of colorectal cancers diagnosed at a late stage by CCG, 2012

80% 70% 60% 50% 40% 30% 20% 10% 0%

CCG

5.1.7.i Bowel Cancer Screening The national screening committee recommends that bowel screening in the 60 – 69 year old population, every 2 years, is an effective way of detecting pre cancer and early cancers in the bowel. Regular bowel screening has been shown to reduce the risk of dying from bowel cancer by 16%4 . The target for bowel cancer screening is to screen 60% of the eligible population; this target is the level that will improve mortality based on the evidence.

44 Cochrane database of systematic reviews, 2006, Screening for colorectal cancer using faecal occult blood test: an update

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St.Helens Joint Strategic Needs Assessment 2015

Data from the National Cancer Intelligence Network reports that although St.Helens is just below the national rate, it performs better than many of the other Merseyside CCGs for bowel cancer screening (60-74 year olds). Over the past few years there has been a steady increase in the proportion of those who are eligible taking up screening, as the national bowel cancer screening programme only began in 2006, understandably it has taken time to reach the necessary level of uptake. Although there has been a steady increase in the screening uptake, levels need to increase by a further 5% to hit target.

5.1.8 Breast Cancer Breast cancer is the third most common cause of cancer death in St.Helens. It mainly affects women over the age of 50 (8 out of 10 cases) and can, in rare cases, affect men. One in eight women will develop breast cancer in their lifetime in the UK.

Some of the major risks relating to breast cancer include:

 Being over 50 years of age  Having a family history of cancer  Strong family history of breast cancer where breast cancer genes are identified  A previous breast cancer  Previous cancer  Certain sex and other hormones can have an impact  A higher risk if using Hormone Replacement Therapy for 5 years after menopause  The contraceptive pill – the combined contraceptive pill is linked with a high risk  Not having children or having them later in life  Starting periods early or staring the menopause late5

The rate of early deaths for breast cancer in St.Helens (19.4 per 100,000) is lower than the England (22.6) and North West (23.8), as well as its neighbouring LAs.

Figure 34. Under 75 breast cancer mortality rate by Local Authority, Females, 2011-2013

35 North West England

30 25 20 15 10 DSR DSR per100,000 5 0 St Helens Wirral Liverpool Knowsley Sefton Halton Local Authority

Source: Health & Social Care Information Centre, 2015

5 There are other factors and risks relating to breast cancer but the list above describes the biggest risks.

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Cancer

There are no statistically different wards for early deaths from breast cancer. As with colorectal cancer, rates do not follow deprivation, with Billinge and Rainhill amongst the highest rates for the Borough.

Figure 35. Under 75 breast cancer mortality rates by ward, Females, 2010-2014

45 40

35 000

, 30 25

100 20 15 10 5 DSR DSR per 0

Ward

Source: St.Helens Public Health Intelligence from Primary Care Mortality Database and ONS population estimates.

Unlike many other cancers such as colorectal, lung and prostrate, where a high proportion of the cancers are diagnosed at a late stage, the proportion of breast cancers diagnosed at a late stage is considerably lower. Across Cheshire and Merseyside CCGs the proportion ranges from a low of 14.6% in Vale Royal to a high of 23.9% in South Sefton. In St.Helens the percentage diagnosed late is 18.6%.

At the end of 2010, around 1,460 women in St.Helens were living with and beyond breast cancer up to 20 years after diagnosis. There were 139 new breast cancer diagnoses per 100,000 women in St Helens CCG in 2012. This is lower than the England average (164 per 100,000). Net breast cancer survival at 1 year for St.Helens is 96.8% which is similar to England at 96.4%.

5.1.8.i Breast Cancer Screening The breast cancer screening programme in the UK has been established to screen every woman between the ages of 50 and 74 through mammograms to assess for unusual results and lumps in the breast. The reason the age group was decided was the links with age associated breast cancers i.e. 8 out of 10 cancers are diagnosed in women above the age of 50 but also the breast tissue in women of this age is less dense and more likely to show up anomalies that can be further investigated. A review of the breast cancer screening programme by an independent panel in 2012 estimated that the potential benefit of breast screening was it could save 1 breast cancer death for every 250 women invited. The panel estimated that an invitation to breast screening could produce about a 20% reduction in breast cancer mortality. For the UK screening programmes, this currently

37

St.Helens Joint Strategic Needs Assessment 2015 corresponds to about 1,300 deaths from breast cancer being prevented each year or equivalently about 22,000 years of life being saved.6

Data from NHS England (Table 6) shows that although St.Helens has not reached the national target of 80% of eligible women attending for a breast screen, compared to its neighbours St.Helens consistently has higher proportion of women attending. St.Helens generally performs better than the national and North of England uptake rates for breast screening. However, enhancing performance even further will help to reduce the mortality rates and increase early detection and survival rates for breast cancer.

Table 6. Percentage uptake of breast screening by CCG, Q1 2013/14 to Q2 2014/15

Q1 Q2 Q3 Q4 Q1 Q2 CCG 2013/14 2013/14 2013/14 2013/14 2014/15 2014/15 Halton CCG 70.9% 70.3% 69.9% 71.4% 71.5% 71.9% Knowsley CCG 63.8% 65.5% 65.5% 64.7% 64.1% 64.0% Liverpool CCG 65.5% 65.2% 64.1% 63.8% 63.5% 60.6% South Sefton CCG 66.3% 66.9% 67.7% 68.2% 66.7% 68.5% Southport & Formby CCG 72.0% 71.2% 72.3% 68.9% 70.7% 69.6% St Helens CCG 71.8% 72.5% 72.9% 70.5% 73.0% 73.8% NHS Merseyside 67.7% 67.9% 67.7% 66.9% 67.2% 66.4% Source: NHS England 5.1.9 Oesophageal cancer In 2014 oesophageal cancer was the 4th biggest cause of cancer deaths and in 2013 was bigger than breast cancer in relation to deaths. It is generally quoted as the 9th most common cause of cancer in the UK but causes a greater proportion of deaths in St.Helens.

The oesophagus is the tube that takes food from the throat to the stomach. Generally this type of cancer the symptoms are: weight loss, persistent cough, difficulties swallowing and throat pain.

People are at increasing risk as they get older and the cancer is more common in men than women. People who smoke and drink are at bigger risk, particularly if it is combined. People who drink heavily but do not smoke are 4 times more likely to develop oesophageal cancer than non-drinkers. People who smoke and do not drink are twice as likely to develop oesophageal cancer as those who do not smoke. People who smoke and drink heavily are 8 times more likely to develop oesophageal cancer than those who do not smoke or drink.

Oesophageal cancer mortality rates particularly at younger ages link to key risk factors of smoking and drinking. Although death rates in the under 75s in St.Helens (10 per 100,000) are not significantly higher than England (7.6 per 100,000), it is still nearly a third higher than the national figure.

6 The Independent UK Panel on Breast Cancer Screening (2012) The benefits and harms of Breast Cancer Screening: An Independent Review. A report jointly commissioned by Cancer Research UK and the Department of Health (England), October 2012

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Cancer

Figure 36. Under 75 oesophageal cancer mortality rate by Local Authority, Persons, 2011- 2013 16 14 England North West 12 10 8 6 4

2 DSR. per 100,000 DSR. 100,000 per 0 Halton Sefton Liverpool Wirral St Helens Knowsley Local Authority

Source: Health & Social Care Information Centre, 2015

There are no statistically different wards for early deaths from oesophageal cancer.

5.1.10 Prostate cancer Prostate cancer is the most common cancer in men in the UK. Local cancer prevalence shows that at the end of 2010, around 730 men in St.Helens were living with and beyond prostate cancer up to 20 years after diagnosis.

The prostrate is a small gland which can become enlarged due to cancer and affect urination. The causes of prostate cancer are not fully understood but those at increased risk are:

 Men aged 50 or older  Men in African-Caribbean and African descent and less common in men of Asian descent  Men who have first degree male relatives affected by prostate cancer.

The rate of early deaths for prostate cancer in St.Helens is lower than the England and North West, as well as its neighbouring LA’s.

Figure 37. Under 75 prostate cancer mortality rate by Local Authority, Males, 2011-2013

16 North West England

14 12 10 8 6

4 DSR DSR per100,000 2 0 St Helens Liverpool Sefton Knowsley Wirral Halton Local Authority

Source: Health & Social Care Information Centre, 2015

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St.Helens Joint Strategic Needs Assessment 2015

There are no statistically different wards for early male deaths from prostate cancer. As with colorectal cancer, rates do not follow deprivation, with Bold and Town Centre amongst the lowest rates for the Borough.

5.1.11 Evidence based treatments There are effective treatments for cancers if caught early enough which include surgery, drug regimes, chemotherapy and radiotherapy. Treatment will be specific to the site. However because the UK lags behind other European countries in relation to cancer survival there is a big push to have people referred quickly.

5.1.11.i Cervical Screening Although cervical cancer is not as common in relation to incidence or mortality, the national screening programme is effective at picking up pre-cancerous cells and therefore preventing cancer before it spreads. Cervical screening can prevent around 75% of cancer cases in women who attend regularly. Around half of all cervical cancer deaths are in women who have never attended for a cervical screen, so the biggest risk factor for cervical cancer is non-attendance for a screen. Screening rates in St.Helens are better than our neighbours however we still need to increase our screening rates by around 5% to hit the 80% national targets.

Table 7. Percentage uptake of cervical screening by CCGs in Mersey Q1 2013/14 to Q2 2014/15

Q1 Q2 Q3 Q4 Q1 Q2 CCG 2013/14 2013/14 2013/14 2013/14 2014/15 2014/15 Halton CCG 71.7% 71.7% 71.0% 71.4% 72.1% 71.9% Knowsley CCG 73.1% 73.1% 72.7% 73.0% 73.6% 73.1% Liverpool CCG 68.9% 68.6% 68.0% 68.3% 69.0% 68.8% South Sefton CCG 70.1% 69.9% 69.6% 70.0% 70.6% 70.4% Southport & Formby CCG 72.6% 73.0% 72.9% 73.4% 74.1% 73.9% St Helens CCG 75.7% 75.5% 75.2% 75.6% 75.8% 75.4% NHS Merseyside 71.2% 71.1% 70.6% 71.0% 71.6% 71.3%

5.1.11.ii HPV Vaccine and cervical cancer The HPV vaccine or Human papilloma virus vaccine helps to prevent cervical cancer. In 99% of cervical cancer cases the cancer occurs as a result of infection from high risk HPV. Therefore a programme to vaccinate girls at the age of 12-13 in school has been rolled out since 2008. The target is to vaccinate 90% of all girls. The vaccine is expected to be effective for 20 years and will protect girls from HPV which is spread through sexual intercourse and therefore will prevent many cervical cancers from starting. In St.Helens, the national vaccination target is being met.

5.1.11.iii Waiting times Cancer that is diagnosed at an early stage, before it has had the chance to get too big or spread is more likely to be treated successfully. If the cancer has spread, treatment becomes more difficult, and generally a person’s chance of surviving is much lower.

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Cancer

An urgent referral means that you have symptoms that could be due to cancer, although they are usually due to other conditions. An urgent referral means that you should see a specialist within 2 weeks of the GP making the referral. These guidelines are set by the National Institute for Health and Care Excellence (NICE). The Government have also set waiting time targets in England and Wales for treating cancer patients. The current targets are

 No more than 2 months wait between the date the hospital receives an urgent GP referral for suspected cancer and starting treatment  Starting treatment no more than 31 days after the meeting at which you and your doctor agree the treatment plan

If patients have to wait longer, it should be because they choose to or because they need extra tests to fully diagnose their cancer. Most hospitals are meeting this target for most of their patients.

Waiting time figures for St.Helens and Knowsley Hospitals NHS Trust show that the area is performing better than the target for cancer related waiting times (Table 8). Nearly all patients (98.8%) are treated within 31 days of a diagnosis, which is a very positive result.

Table 8. Cancer waiting times, St.Helens and Knowsley Hospitals NHS Trust, 2014/15

St.Helens & Knowsley Target Hospitals Two Week Wait (urgent referral): All cancers 94% 93%

31 day (diagnosis to treatment) wait for first treatment: All cancers 98.8% 96%

62 day (urgent GP referral to treatment) wait for first treatment: All cancers 90.2% 90%

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St.Helens Joint Strategic Needs Assessment 2015

5.1.12 Assets for Cancer within St.Helens St.Helens is in a unique position in that there is access to specialist cancer treatment services at some of the major hospitals in the area such as Clatterbridge, but also ‘The Lilac Centre’ at St.Helens hospital provides chemotherapy, cancer therapy and support to patients, along with alternative therapies including massage, yoga and reiki.

Other support services such as ‘St.Helens Cancer Support Group’; this is a registered charity that offer support for patients and carers. The aim of the group is to; offer mutual emotional support and understanding; to ease the stress and suffering experienced by cancer suffers and their carers through friendship and encouragement; to provide social support; to provide accurate, practical information but do not give advice or make recommendations; work in co-operation with professionals.

5.1.13 Future and Recommendations Although the cancer statistics for St.Helens are better than some of its geographical neighbours, cancer is a significant burden to the population of St.Helens. There are health inequalities between wards in St.Helens and there is some way to go to improve the situation. In order to improve outcomes there need to be an emphasis on ensuring the population know what the symptoms are and seek help early, we also need to ensure that where there are evidence based screening programmes that these are promoted and we ensure uptake especially in populations with low uptake.

Without improving early diagnosis and cancer screening uptake and HPV vaccine cancer will continue to be the biggest cause of early death in St.Helens and will continue to have significant health burden on our communities. However, as shown with early diagnosis people can live 20 years and beyond after their cancer diagnosis. Cancer does not need to be the life sentence it once was.

Recommendations

 Continue to promote BE CLEAR ON CANCER campaign along with the national campaigns  To promote early detection and cancer screening in communities most affected by cancer  Link the risk factors of cancer with lifestyle programmes particularly around smoking, diet, alcohol  Promote cancer screening and examine ways to improve uptake  Improve access to cancer diagnosis tests within the 4 week time frame

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Cardiovascular Disease

5.2 Cardiovascular Disease

5.2.1 Introduction Cardiovascular disease describes disease of the heart or blood vessels. Blood flow to the heart, brain or body can be reduced due to blood clots or fatty deposits that narrow and harden the arteries. There are four main types of cardiovascular disease:

1. Coronary heart disease: when blood flow is reduced or stopped by a build-up of fatty materials. This can cause angina or a heart attack 2. Stroke: when the blood supply to part of the brain is cut off 3. Peripheral artery disease: when there is a blockage in the arterial blood flow in the limbs, often the legs 4. Aortic disease: when the largest blood vessel becomes affected, the most common is aortic aneurysm when the wall of the aorta vessel becomes weakened and bulges outward causing pain

Cardiovascular disease is the second biggest cause of death in England after cancer and accounts for around a quarter of all deaths, 160,000 a year in the UK. On top of this around 7 million people in the UK are living with cardiovascular disease. The total cost of premature death, lost productivity and hospital treatment is estimated at £19 billion a year.7

In St.Helens cardiovascular disease is also the second biggest cause of death accounting for 26% of all deaths and 21% of premature deaths (before the age of 75). Coronary heart disease is caused 219 deaths in 2014 nearly 12% of all deaths and more than the number of deaths from lung cancer.

Whilst cardiovascular disease has high levels of deaths associated with it, many people in St.Helens live with cardiovascular disease, such as heart disease and stroke, and need to manage this long term condition. Long term conditions were identified as a Health and Wellbeing priority in the St.Helens Health and Wellbeing Strategy 2013-2016. Other long term conditions such as diabetes are risk factors for cardiovascular disease and therefore good management of diabetes and prevention will help to reduce the prevalence of the disease. The NHSE Five Year Forward View highlights the importance of managing long-term conditions to avoid unnecessary pressures within our health and care systems.8

The most significant element of cardiovascular disease (CVD) is that it is preventable. The key risk factors for CVD are:

 high blood pressure (hypertension)  smoking  high blood cholesterol  diabetes  lack of exercise  being overweight or obese

7 British Heart Foundation (2015) Cardiovascular disease statistics factsheet https://www.bhf.org.uk/research/heart-statistics 8 NHS (2014) Five Year Forward View. NHS England

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St.Helens Joint Strategic Needs Assessment 2015

 family history of heart disease  ethnic background

Having sustained high blood pressure is the most significant risk factor as the pressure can damage the artery walls and increase the risk of a blood clot. Apart from family history and ethnic background, most of the other risk factors are affected by lifestyle and therefore there are interventions that can improve primary prevention. There are also medications that can modify risk factors such as statins for cholesterol and blood pressure treatments for hypertension (secondary prevention).

Significant risk factors for cardiovascular disease include  smoking and tobacco use; the toxins damage arteries, increasing susceptibility to coronary heart diseases  Being overweight or obese increases the risk of developing diabetes which is also a risk factor for cardiovascular disease  Lack of exercise can be related to high blood pressure, higher cholesterol and higher stress levels and can also make it more difficult to maintain a healthy weight.

5.2.2 Hypertension (High Blood Pressure) High blood pressure is a significant risk factor for CVD. Having continuous high blood pressure (hypertension) is the second biggest risk factor (after smoking) for premature death and disability in the country. High blood pressure is often preventable and can be modified by changing lifestyle factors such as diet and physical activity, however there can be a family link similar to cholesterol. People in deprived areas are 30% more likely to have high blood pressure than those from the least deprived areas. High blood pressure is not only a major risk factor for cardiovascular disease (including heart attack and stroke) but also chronic kidney disease, cognitive decline (including dementia) and premature death. It accounts for 80% of all causes of premature heart disease. Detecting people early will help to manage cardiovascular risk and therefore improve outcomes for individuals.

Based on GP registers, 17.1% of the population are recorded as having high blood pressure (2013/14) in St.Helens; this equates to an estimated 61% of those who may have high blood pressure. This means that nearly 18,000 (39%) people in the Borough may have high blood pressure and are not aware of it. As high blood pressure is often present without symptoms the public will not be aware to seek health advice and that is why it is often called the ‘silent killer’.

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Cardiovascular Disease

Figure 38. Percentage of the population on GP registers diagnosed with high blood pressure

18 16 14

12 10 8

6 population 4 2

Percentage ofregistered GP 0 NHS NHS NHS Wirral NHS Halton NHS South NHS NHS St Liverpool Knowsley CCG CCG Sefton CCG Southport Helens CCG CCG CCG and Formby

Figure 39 illustrates that whilst St.Helens still has a high number of people that are expected to have high blood pressure but have not yet been diagnosed, the GP’s in St.Helens are more proactive at diagnosing high blood pressure than other parts of the Mersey. St.Helens has the highest percentage of the population recorded with high blood pressure in Merseyside with Liverpool only recording just under 54% of their estimated population with high blood pressure. The range across the country for CCGs is from 37% in Westminster to 65% in Stoke on Trent. St.Helens GP’s are the 6th best in the country at recognising and diagnosing high blood pressure. Of those that have been diagnosed in St.Helens and are under the age of 80, 73% of them are managed well i.e. their blood pressure is below 140/90.

Figure 39. Percentage of the population registered with high blood pressure against expected levels

70 61.3 57.3 59.6 60 53.9 54.1 54.7 56.2

50 40 30

population 20 10

Percentage ofregistered GP 0 NHS NHS NHS Wirral NHS NHS Halton NHS South NHS St Liverpool Southport CCG Knowsley CCG Sefton CCG Helens CCG CCG and Formby CCG

New estimates suggest that the annual burden to the NHS in England from conditions attributable to high blood pressure is over £2bn.

It is estimated that 7,000 quality adjusted life years could be saved and £120m not spent on health and social care costs over a 10 year period, if England achieved a 15% increase in the proportion of adults who have their high blood pressure diagnosed.

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St.Helens Joint Strategic Needs Assessment 2015

According to the Department of Health (2013)9, 45% of hypertension remains undiagnosed until an acute event occurs. Substantial savings are therefore realised as case finding for this undiagnosed cohort increases. Even though prescribing and management savings reduce as case finding increases, the savings in secondary care are much greater as the number of acute events reduces. A recent report from Essex found that improving case finding by approximately 10% would result in £386,000 of net savings in the first year, and £1,668,000 over three years, due to reductions in secondary care admissions for stroke, vascular dementia and ischaemic heart disease10. The report also calculated monetary net savings of approximately £300 for every £1 invested by the CCG in terms of costs.

Key interventions to help prevent and improve high blood pressure are:

 Reducing salt intake to 6g a day  Improve potassium levels by ensuring people eat five pieces of fruit and vegetables a day  Improve physical activity uptake  Decrease overweight and obesity levels  Improve the proportion of people sticking to recommended alcohol intakes

5.2.3 High Cholesterol Cholesterol is a fatty substance carried in your blood and is normally produced by the liver but can also be found in some foods. Lipids are needed for normal functioning. However, high cholesterol can increase the risk of narrowing of the arteries, heart attack, stroke or mini-stroke. The factors that increase cholesterol that we can prevent or modify are:

 smoking  diet high in saturated fats  having diabetes or high blood pressure (ensuring a healthy weight will help to reduce the risk of diabetes and reducing salt and other factors highlighted in the hypertension section)

Key facts from the charity Heart UK illustrates the importance of reducing cholesterol to reduce the risk of cardiovascular disease:

 It is estimated the 6 out of 10 adults in England have raised cholesterol  Reducing the populations Low Density Lipids by 5% would prevent 64,000 cases of cardiovascular disease  Reducing the populations Low Density Lipids by 1 mmol/l could reduce coronary heart disease by 19%

Figure 40 uses quality and outcomes data 2013/14 to show the proportion of people in St.Helens who are on GP registers for coronary heart disease whose total cholesterol is 5 mmol/l or below.

9 DH Cardiovascular Disease Team, March 2013, Cardiovascular Disease Outcomes Strategy, Gateway reference 18747, Department of Health, London. Public Health England,(May 2014) CVD Commissioning for Value Focus Packs 2013/14. www.gov.uk/phe www.ncvin.org.uk

10 Wake, I (2013). Preventing Stroke and Ischaemic Heart Disease through Improving Case Finding of Hypertension and Clinical Management of Hypertension and CHD in Basildon and Brentwood CCG. [Report] Basildon and Brentwood Clinical Commissioning Group. April 2013

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Cholesterol of 5 mmol/l or below is the recommended guidance and can help prevent secondary heart problems. St.Helens has more people with coronary heart disease whose cholesterol is managed effectively than the rest of Merseyside and is statistically significantly better than England.

Figure 40. Proportion of people with Coronary Heart Disease with a cholesterol less than 5mmol/l – quality and outcomes data 2013/14

80 % cholesterol < 5mmol/l England 78 76 74 72 70 68 66 64 NHS Wirral NHS NHS South NHS Halton NHS NHS NHS St a cholesterol less a cholesterol less than5mmol/l CCG Liverpool Sefton CCG CCG Southport Knowsley Helens CCG Percentage Percentage of peoplewith CHD with CCG And CCG Formby...

5.2.4 Prevalence of Cardiovascular disease Cardiovascular disease covers a wide range of conditions which affect the heart and blood vessels. Some of these specific conditions such as Coronary Heart Disease are diagnosed and registers are kept within primary care. For cardiovascular disease however there are not registers but mortality data shows whether we have high proportion of people dying from cardiovascular disease. This data is usually expressed as early deaths under the age of 75 and those that are described as preventable deaths.

Trends in cardiovascular disease mortality have been decreasing over the years for St.Helens and England alike, however the rates in St.Helens have been decreasing at a faster rate and by 2011-13 were lower than the rate for the North West but still worse than the overall rate for England.

Figure 41. Mortality due to Cardiovascular Disease in people aged under 75 200

St.Helens North West England 150

100

50 DSR per 100,000 per DSR 0

Three-year period

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St.Helens Joint Strategic Needs Assessment 2015

When mortality rates are shown for males and females (under 75) it can be seen that deaths for men are a lot higher than women. Mortality rates for men are also higher than the rates for men in England, whereas for women the rates in St.Helens in 2011-13 are similar to the England rate.

Figure 42. Trend in cardiovascular disease mortality, under 75’s, males and females

Males St Helens Males England Females St Helens Females England 250

200

150

100

50 DSR. DSR. Per100,000 0 2001-03 2002-04 2003-05 2004-06 2005-07 2006-08 2007-09 2008-10 2009-11 2010-12 2011-13 Three- year period

Deaths under the age of 75 due to cardiovascular disease that are considered preventable have been reducing over time and in the most recent years are just slightly higher than the overall England rate and lower than the rate in the North West. Within Merseyside only Sefton and Wirral have lower rates than St.Helens. Liverpool, Halton and Knowsley all have preventable death rates that are statistically higher than the rate for England.

Figure 43. Trend in cardiovascular disease mortality, considered preventable in people aged under 75

160 St.Helens North West England 140

120 100 80 60 DSR DSR per100,000 40 20 0 2001-03 2002-04 2003-05 2004-06 2005-07 2006-08 2007-09 2008-10 2009-11 2010-12 2011-13 Three-year period

5.2.5 Mortality due to Cardiovascular Disease Cardiovascular disease is one of the major causes of death in under 75s in England. There have been huge gains over the past decades in terms of better treatment for CVD and improvements in lifestyle, but to ensure that there continues to be a reduction in the rate of premature mortality from CVD, there needs to be concerted action in both prevention and treatment.

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In St.Helens, CVD mortality rates have been falling over a number of years and, despite an increase in 2012, rates have reduced by 26% since 2008. The St.Helens under 75 CVD mortality rate between 2011-13 was 87.2 per 100,000 which was lower than the North West average (92.8 per 100,000) but significantly higher than England (78.2 per 100,000) (PHE, 2015).

In 2014, 473 people (242 males and 231 females) died as a result of CVD; 9 more people than in 2013.

Some key age groups have seen considerable reductions in premature mortality rates, with rates amongst males aged 65 to 74 years having halved since 2008 and decreased by 41% from 2013 (from 755.7 per 100,000 in 2013 to 449.2 per 100,000 in 2014).

Mortality from CVD in those aged 50-64 increased in 2014 compared to 2013 for both men and women.

Table 9. St.Helens cardiovascular disease mortality rates by age, 2008-2014

2008 2009 2010 2011 2012 2013 2014 85+ yrs 7335.9 6484.4 6462.6 7308.4 5849.6 4810.6 5327.2 75-84 yrs 2512.0 2187.9 1995.4 1816.8 1923.1 1822.5 1834.1 65-74 yrs 972.6 734.5 700.3 456.4 676.2 755.7 449.2 50-64 yrs 198.3 228.2 220.5 173.2 184.3 174.8 220.3 Males 35-49 yrs 57.9 77.5 31.5 46.3 61.3 72.8 60.4 20-34 yrs 14.0 33.1 28.5 7.2 7.1 0.0 6.0 All ages 502.2 448.3 419.7 393.6 392.4 367.5 356.3 Under 75 170.9 158.3 141.1 101.9 133.1 141.5 114.2

85+ yrs 5096.9 4217.2 4825.1 3862.2 4508.2 3912.2 4563.9 75-84 yrs 1672.9 1637.6 1164.0 1420.5 1237.2 1175.5 1045.7 65-74 yrs 467.0 426.1 461.6 261.2 232.2 271.7 266.4 50-64 yrs 131.9 101.0 81.4 54.1 77.9 69.3 108.6 Females 35-49 yrs 30.3 34.3 10.2 10.2 26.6 40.5 15.4 20-34 yrs 0.0 0.0 7.0 13.2 0.0 6.5 11.3 All ages 317.3 283.5 264.1 231.4 238.3 226.0 236.6 Under 75 89.2 78.7 74.5 46.8 49.6 56.9 59.9

Source: St.Helens Public Health Intelligence from Primary Care Mortality Database and ONS population estimates.

Within St.Helens there are significant variations in early deaths from CVD. Between 2010 and 2014 the highest ward rate in St.Helens was in Parr (168.8 per 100,000); over three times higher than the lowest rate in Eccleston (50.6 per 100,000). Cardiovascular disease mortality rates are closely linked with deprivation in St.Helens; the highest rates are observed in the most deprived areas such as Parr, Town Centre, Earlestown and Bold, with the lowest rates in least deprived areas such as Eccleston, Rainhill and Rainford.

Although Eccleston has the lowest early mortality rate in St.Helens, it does have the greatest inequality between men and women. Under 75 CVD mortality rates are 75% higher amongst men in

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St.Helens Joint Strategic Needs Assessment 2015

Eccleston compared to women. All wards across the Borough show higher rates for men, with the smallest gender inequality seen in Haydock and Windle.

Map 1: Under 75 mortality due to cardiovascular diseases

Under 75 Mortality Cardiovascular Diseases DSR per 100,000 population (2010-14)

St.Helens Public Health Intelligence. Source: Primary Care Mortality Database © Crown Copyright and database right 2011. Ordnance Survey 100050516.

Coronary heart disease is diagnosed when the hearts blood supply is blocked or interrupted. Data from 2013/14 that calculates the proportion of the population on GP practice registers that have been diagnosed with coronary heart disease (CHD). This data shows that St.Helens has the highest rates of diagnosed CHD in Cheshire and Merseyside. They are significantly higher than the prevalence in England as a whole.

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Figure 44. Coronary Heart Disease prevalence - quality and outcomes framework 2013/14

NHS St Helens CCG 4.6% NHS Knowsley CCG 4.5% NHS Southport And Formby... 4.3% NHS South Sefton CCG 4.3% NHS Halton CCG 4.3% NHS Wirral CCG 3.9% NHS South Cheshire CCG 3.8% NHS Warrington CCG 3.7% NHS Vale Royal CCG 3.7% NHS Liverpool CCG 3.7% NHS West Cheshire CCG 3.6% NHS Eastern Cheshire CCG 3.6% Cheshire and Merseyside NHS region 3.9% England 3.3% 0.0% 0.5% 1.0% 1.5% 2.0% 2.5% 3.0% 3.5% 4.0% 4.5% 5.0% Percent

Whilst prevalence of CHD is 4.6% in St.Helens, it is still expected, based on modelling, that the prevalence should be 5.6%. This suggests that there may be more with the disease that are unaware they have it.

Whilst prevalence rates are the highest in St.Helens, hospital admissions for coronary heart disease are not the highest in Cheshire and Merseyside, but still significantly higher than the overall for England.

Figure 45. Coronary Heart Disease – Hospital admissions 2013-14

NHS Halton CCG 737 NHS Knowsley CCG 719 NHS Liverpool CCG 668 NHS Warrington CCG 632 NHS St Helens CCG 613 NHS South Sefton CCG 603 NHS Wirral CCG 560 NHS Eastern Cheshire CCG 506 NHS Southport And Formby... 485 NHS Vale Royal CCG 482 NHS West Cheshire CCG 451 NHS South Cheshire CCG 424 England 560 0 100 200 300 400 500 600 700 800 900 DSR per 100,000

The rate of premature deaths from CHD in people under the age of 75 years has been steadily declining since 2002. In 2011 and 2012 St.Helens were close to the England rate, however a rise in 2013 means that St.Helens rate is now the highest in Cheshire and Mersey. The high prevalence of CHD will have an impact on mortality rates. Reducing the key risk factors in the population and

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St.Helens Joint Strategic Needs Assessment 2015 ensuring effective management of people with CHD once diagnosed are priorities to reduce deaths from coronary heart disease.

Figure 46. Trends in premature mortality (under 75) due to Coronary Heart Disease, persons 140 St Helens England 120

100 80 60 40

DSR DSR per100,000 20 0 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Despite the higher rate of coronary heart disease generally, the overall rate of mortality due to myocardial infarction (heart attack) in St.Helens is similar to the rate for England and Wales.

Table 10. Mortality due to myocardial infarction, 2011-13, DSR per 100,000

Males Females Persons England and Wales 26.16 8.56 17.12 North West 32.34 11.66 21.76 St.Helens 28.50 8.03 17.87 Source: HSCIC (2015)

5.2.5.i Heart Failure Heart failure happens when the heart fails to pump enough blood around the body at the right pressure. The overall prevalence of heart failure is small in comparison to CHD but there is an increasing number of people with the condition.

In 2013/14, 2,178 people were on GP registers in St.Helens diagnosed with heart failure or 1.1% of the population. Only South Sefton in Cheshire and Merseyside had higher rates with 1.2% of the population. Hospital admissions for heart failure in St.Helens are some of the lowest in Cheshire and Mersey and statistically better than the overall rate for England (98.9 St.Helens, 133.7 England, DSR per 100,000 2013/14).

5.2.5.ii Stroke Stroke is when the blood supply to part of the brain is cut off. When this happens, the brain cells begin to die and it can lead to major disability or death.

Stroke is the fourth largest cause of death in the United Kingdom, and one occurs every 3 minutes and 27 seconds. Half of people who have a stroke are left with a disability, this can include aphasia, physical disability, loss of cognitive and communication skills, depression and other mental health

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problems. It affects between 115 and 150 people per 100,000 population in the UK each year (depending on the population being studied), and approximately 12% of those having a stroke will die within 30 days and 25% will die within a year.11

In St.Helens, 1.98% of the population are on stroke registers within primary care. This is higher than the rate for England which is 1.71%. The range across Cheshire and Mersey is 1.7% in Liverpool and Warrington to 2.3% in South Sefton. Modelled estimates for St.Helens show that the rate should be 2.3% of the population.

Table 11. General Practice Stroke Registers in St.Helens

Area Percentage of population on stroke registers St.Helens 1.98 Merseyside 1.87 England 1.71

The number of early deaths per year in St.Helens due to stroke is low generally under 40 per year. However as a death rate St.Helens has a high rate of deaths compared with the other areas in Cheshire and Mersey (Table 12).

Table 12. Mortality rate due to stroke under the age of 75, persons Area Directly age standardised 95% Lower 95% upper mortality rate per 100,000 confidence confidence (under 75) England 13.7 13.4 14.1 NHS Knowsley CCG 24.1 15.8 35.1 NHS South Cheshire CCG 20.6 14.1 28.9 NHS Liverpool CCG 19.9 15.4 25.4 NHS St Helens CCG 17.6 11.8 25.4 NHS South Sefton CCG 16.2 10.2 24.3 NHS Wirral CCG 15.4 11.2 20.6 NHS Warrington CCG 13.1 8.3 19.7 NHS Halton CCG 11.1 5.7 19.6 NHS West Cheshire CCG 10 6.2 15.3 NHS Southport and Formby 9.8 5 17.1 CCG NHS Eastern Cheshire CCG 9.2 5.4 14.6 NHS Vale Royal CCG 5.2 1.7 12.2

The overall trend in mortality rate for stroke under 75 is downward in St.Helens but is subject to year on year variation due to small numbers.

11 State of the Nation, Stroke Statistics 2015 The Stroke association and references therein

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St.Helens Joint Strategic Needs Assessment 2015

Figure 47. Trend in stroke mortality, under 75 years, persons

35

NHS St.Helens CCG

) England

30

000 ,

100 25

20

15

10

5 Directly Directly standardisedrate(per

0 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 Year

5.2.6 NHS Health Checks NHS Health Checks is a service which helps to identify people aged between 40 and 74 years with cardiovascular risks early. Based on the 851 people who have had a Health Check the following data shows what health risks have been uncovered and new diagnoses.

Table 13. Risk factors and new diagnoses found through NHS Health Checks April 2015 to July 2015 Risk/Disease Number Percentage Smokers 116 13.6% Not physically active 416 48.9% Have a poor diet 11 1.3% High Alcohol 40 4.7% Overweight 256 30.1% Obese 217 25.5% High blood pressure 163 19.2% High cholesterol 133 15.6% Put on statins for CVD risk 21 2.5% Diagnosed hypertensive 18 2.1% Diagnosed diabetics 4 0.5%

Many of these individuals were not known to be at high risk of cardiovascular disease and yet significant lifestyle risks are present especially lack of physical activity, overweight and obese and smoking. The proportion with high blood pressure is just under 20% and subsequently 2% have been diagnosed as hypertensive and 4 people diagnosed with diabetes. NHS Health Checks has an important contribution to make to reducing CVD deaths by reducing risks in the population, and in

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Cardiovascular Disease

identifying people with high blood pressure and diabetes. Diabetes has a significant burden on health care and can cause serious health complications therefore finding 4 people who would otherwise have not been aware of their diagnosis is important in managing the condition and reducing emergency admissions for complications due to diabetes. a. Future and recommendations Whilst the trend for cardiovascular disease is downward in relation to mortality we still have key risk groups and people that have not yet been diagnosed with Hypertension, Coronary Heart Disease or Diabetes. The push in the next 3 to 5 years should be to ensure effective early detection through the NHS Health Check Programme and Hypertension Programme and to ensure effective management of those with a diagnosis.

 Improve uptake of NHS Health checks  Ensure an effective programme is developed to identify people early with hypertension  Work with primary and secondary care to ensure effective management of people with CVD.  Use our assets in the community through third sector organisations and volunteers to push programmes such as ‘Know your numbers’ and take up of NHS Health Checks  Link NHS Health checks to the prevention agenda’s for obesity, physical activity and tobacco control to ensure prevalence of risks decreases for the long term

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St.Helens Joint Strategic Needs Assessment 2015

5.3 Respiratory Diseases

5.3.1 Introduction The category of respiratory diseases covers a wide range of conditions and diseases. Locally these range from relatively rare diseases such as tuberculosis (TB), through to the most well recognised and commonly encountered chronic obstructive pulmonary disease (COPD) and asthma. COPD and asthma are both long term conditions which cannot be cured.

5.3.2 Respiratory Disease Mortality Respiratory disease is one of the top causes of death in England in under-75s and smoking is the major cause of chronic obstructive pulmonary disease (COPD), one of the major respiratory diseases.

Mortality rates due to respiratory disease decreased for males and females in 2014 and rates for all persons have fallen by a quarter since 2008. The St.Helens under 75 respiratory disease mortality rate between 2011/13 was 47.9 per 100,000; higher than the North West average (43.9 per 100,000) and significantly higher than England (33.2 per 100,000) (PHE, 2015).

In 2014, 288 people (133 males and 155 females) died as a result of a respiratory disease; 55 fewer people than in 2013. Despite decreasing by over a third since 2008, respiratory disease mortality rates amongst 50-64 year old males increased by over 50% between 2013 and 2014. Respiratory disease mortality amongst St.Helens residents aged 85 and over has decreased substantially since 2008, and rates fell by over 40% for both males and females in 2014 compared to 2013.

Table 14. St.Helens respiratory disease mortality rates by age, 2008-2014

2008 2009 2010 2011 2012 2013 2014

85+ yrs 5500.2 4298.6 4871.9 4203.9 3802.0 5215.3 3104.6 75-84 yrs 1124.5 966.9 1102.4 1182.1 1023.2 1133.7 1132.1 65-74 yrs 314.2 371.4 370.3 334.7 293.2 381.4 307.5 50-64 yrs 100.2 34.3 40.2 45.3 100.8 40.5 64.0 Males 35-49 yrs 20.7 10.4 20.5 16.3 21.5 22.2 12.0 20-34 yrs 7.0 0.0 6.2 0.0 0.0 6.0 6.0 All ages 269.7 218.2 245.6 229.3 216.5 260.0 199.6 Under 75 65.0 52.6 57.3 52.1 60.4 61.5 53.2

85+ yrs 4163.4 3972.7 3814.8 3299.9 2888.8 3686.2 2018.8 75-84 yrs 1012.3 878.3 852.7 787.4 869.1 994.9 1083.8 65-74 yrs 188.7 196.6 195.5 173.6 219.6 246.0 246.9 Females 50-64 yrs 39.9 44.8 76.6 60.2 62.4 53.3 57.1 35-49 yrs 20.6 10.4 0.0 10.1 5.1 0.0 5.3 20-34 yrs 0.0 0.0 7.2 0.0 0.0 0.0 0.0 All ages 201.8 188.0 187.6 165.8 165.0 193.0 160.2 Under 75 35.1 34.7 40.4 35.3 39.9 39.8 43.2

Source: St.Helens Public Health Intelligence from Primary Care Mortality Database and ONS population estimates.

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Respiratory Diseases

Mortality rates for early deaths due to respiratory diseases show large differences within St.Helens (0). Between 2010 and 2014 Town Centre had the highest rate (111.6 per 100,000), and was over 6 times higher than the lowest rate in Rainford (17.2 per 100,000). Areas of lower deprivation such as Rainford, Eccleston and Billinge and Seneley Green had the lowest rates, with more deprived areas such as Town Centre, Thatto Heath and Parr having higher rates of respiratory deaths.

The majority of areas in St.Helens had higher rates for men compared to women, although five wards had higher female respiratory mortality rates (Billinge and Seneley Green, Moss Bank, Newton, West Park and Parr). The largest difference between men and women was in Thatto Heath.

Map 2: Under 75 mortality from respiratory diseases by ward, 5 year rate (2010-14)

St.Helens Public Health Intelligence. Source: Primary Care Mortality Database © Crown Copyright and database right 2011. Ordnance Survey 100050516.

The charts below show the COPD mortality for St Helens CCG compared to neighbouring areas within Merseyside. St.Helens is below the Merseyside average however higher than the England rate. Mortality from COPD is higher in females than males across Merseyside.

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St.Helens Joint Strategic Needs Assessment 2015

Although there has been a downward trend of male mortality from bronchitis, emphysema and other COPD, St.Helens is higher than Merseyside and the England rates. For females, the overall rates have remained fairly static since 1995.

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Respiratory Diseases

5.3.3 Chronic Obstructive Pulmonary Disease (COPD)

5.3.3.i Introduction COPD is a term which refers to a number of lung diseases – chronic bronchitis, emphysema and chronic obstructive airways disease. People with COPD have difficulties breathing, primarily due to the narrowing of their airways, this is called airflow obstruction.12 Typical symptoms of COPD include:

 increasing breathlessness when active  a persistent cough with phlegm  frequent chest infections

The main cause of COPD is smoking and it is a progressive disease as the lungs become more obstructed over time, early diagnosis and treatment can markedly reduce the associated morbidity and mortality. The best way to reduce the symptoms and progression rate is via smoking cessation. Smoking cessation coupled with treatment with medication can markedly enhance sufferers' quality of life, in particular taking part in pulmonary rehabilitation programs helps to reduce symptoms, enhance confidence to self-manage the condition, support medication reviews and increase ability to exercise13,14.

It is recommended that all those on GP COPD registers are invited for annual influenza vaccination as there is evidence that the vaccine decreases exacerbation of COPD thereby reducing the morbid effects of COPD15.

There are around 900,000 people currently diagnosed with COPD in the UK and an estimated 2.1 million people with COPD who remain undiagnosed16. Despite improvements in early diagnosis, treatment and on-going management, COPD is still a significant contributor to mortality in the UK; data shows that premature mortality from COPD in the UK was almost double the European average in 200817.

Whilst COPD is well understood and can be well managed in the community, exacerbations continue to occur often resulting in hospitalisation. There are high financial costs associated with hospitalisation but also a high burden on patients and carers with this disruption to their lives and the diminution of their quality of life.

12 http://www.nhs.uk/Conditions/chronic-obstructive-pulmonary-disease/Pages/Introduction.aspx 13 Puhan MA, Gimeno-Santos E, Scharplatz M, et al (2009) Pulmonary rehabilitation following exacerbations of chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews 2009; 1: CD005305 14 Burtin C, Decramer M, Gosselink R, Janssens W, Troosters T (2011) Rehabilitation and acute exacerbations. Eur Respir J; 38:702-712 15 Poole P, Chacko EE, Wood-Baker R, Cates CJ. (2006) Influenza vaccine for patients with chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews 2006, Issue 1. Art. No.: CD002733. DOI: 10.1002/14651858.CD002733.pub2 16 NHS Choices (2014) Chronic Obstructive Pulmonary Disease. http://www.nhs.uk/Conditions/Chronic- obstructive-pulmonary-disease/Pages/Introduction.aspx 17World Health Organisation (2011) Mortality indicators by 67 causes of death, age and sex (HFA-MDB). http://www.euro.who.int/en/what-we-do/data-and-evidence/databases/mortality-indicators-by-67-causes- of-death,-age-and-sex-hfa-mdb

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In 2013/14 St Helens CCG GPs reported 3.07% of the population (5,954 patients) had diagnosed COPD which is significantly higher than the England average of 1.8%. There is a significant difference between reported COPD rates across practices; the lowest rate is at Longton Surgery (1.8%) whilst the highest at 4.8% is Park House, potentially reflecting the difference in the affluence of the areas. (This excludes Eldercare as it has a vastly different patient profile).

a. Estimated vs. reported COPD prevalence The estimated local COPD prevalence rate for registered patients in St Helens CCG is 3.94%18. There is a range across the three localities, St.Helens North, St.Helens South and Newton and Haydock cluster of between 2.92% up to 3.21%. In turn this variance is a result of the considerable variation of reported prevalence across St.Helens GP practices. In 3 out of 36 St.Helens practices COPD diagnosis rates were below 50% of their expected rate.

The estimated number of undiagnosed cases of COPD for St.Helens registered patients is 1,697 based on the difference between estimated and known. Reported 2013/14 prevalence rates, calculated at national, regional and cluster level are given below

b. Admissions for COPD Locally both the numbers of patients being admitted to hospital for COPD and the associated costs stayed relatively constant between 2013 and 2015. There is some seasonal variation with lower numbers of admissions during the summer months however the admission profile can be unpredictable, for example the number of admissions in February 2013 (60) was 66% higher than for February 2014 (36), with associated costs of £124,824 and £67,710 respectively for the month. The indirectly standardised annual hospital admission rate is 298 per 100,000 compared to the national average 205 per 100,000.

Table 15. COPD admissions and costs

Financial Year COPD Admissions Cost of Admissions 2013/14 541 £1,128,535 2014/15 538 £1,109,752 Grand Total 1,079 £2,238,287

18Public Health England – Respiratory disease profile for St Helens CCG GPs 2011, data/all ages, http://fingertips.phe.org.uk/profile/general-practice

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Respiratory Diseases

c. Forecasting Growth of COPD The POPPI (Projecting older people population information system) reports that bronchitis and emphysema is forecast to increase for both males and females ages 65 and over.

Table 16. Predicted prevalence of COPD

Bronchitis/Emphysema by Gender 2014 2015 2016 2017 2018 Males aged 65-74 predicted to have a longstanding health condition caused by bronchitis and 228 233 238 240 240 emphysema Males aged 75 and over predicted to have a longstanding health condition caused by bronchitis 132 139 141 145 149 and emphysema Females aged 65-74 predicted to have a longstanding health condition caused by bronchitis 103 104 107 107 108 and emphysema Females aged 75 and over predicted to have a longstanding health condition caused by bronchitis 125 125 127 130 133 and emphysema Total population aged 65 and over predicted to have a longstanding health condition caused by 588 600 613 622 630 bronchitis and emphysema

d. Screening The most recent review of scientific publications on COPD recommended against a national screening programme to detect COPD at an early stage19. The review found that:  There is not an accurate test to detect early COPD  The best treatment for early COPD is to stop smoking

However, evidence does exist that identifying COPD in people with symptoms is cost effective and there are national guidelines for doctors to follow20.

e. COPD Mortality In St.Helens in 2014 there were 288 deaths (all ages) due to respiratory disease, this equates to a total of 16% of all deaths in St.Helens making respiratory disease the third highest cause of all age mortality in the Borough. Amongst the contributors to this respiratory mortality was pneumonia (94 deaths) but by far the largest factor was bronchitis, emphysema and other Chronic Obstructive Pulmonary Diseases, accounting for 128 deaths. The numbers of deaths from COPD has fallen significantly for males over the past 18 years however female mortality remains constant albeit lower than males.

19http://www.screening.nhs.uk/copd 20 http://www.nice.org.uk/guidance/CG101

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5.3.4 Asthma

a. Prevalence of Asthma In 2012/13 St.Helens GPs reported a prevalence rate of Asthma of 7.41%. This is based on 14,368 patients with Asthma recorded by the practices. Haydock & Newton appear to show the highest rates of Asthma prevalence within St.Helens.

Figure 48. Asthma Prevalence rates 2013/14

0% 1% 2% 3% 4% 5% 6% 7% 8% 9%

England Average 5.90%

Merseyside Average 6.10%

NHS St Helens CCG 7.41%

- St Helens North Cluster 7.39%

- St Helens South Cluster 7.19%

- Haydock & Newton Cluster 7.70%

b. Asthma Prevalence by Locality In contrast to COPD prevalence there is not a direct correlation with socioeconomic status, this is to be expected since there are a wide range of proven and likely causes of asthma21 whereas 90% of cases of COPD are linked to smoking where rates are correlated to socioeconomic status and 25% of smokers will develop COPD.

21 http://www.nhs.uk/Conditions/Asthma/Pages/Causes.aspx

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Respiratory Diseases

Figure 49. Asthma Prevalence by GP Practice 2013/14

12% GP Reported CCG Reported Merseyside Average England Average

10%

8%

6%

4%

2%

0%

ELDERCARE

MARKET STREET MARKET

CENTRAL SURGERY CENTRAL

PARKFIELD SURGERY PARKFIELD

DR RAHIL'S SURGERY RAHIL'S DR

THE ACORN PROJECT ACORN THE

GARSWOOD SURGERY GARSWOOD

NEWHOLME SURGERY NEWHOLME

HOLLY BANK SURGERY BANK HOLLY

LIME GROVE SURGERY GROVE LIME

PARK HOUSE SURGERY HOUSE PARK

CORNERSTONE SURGERY CORNERSTONE

PHOENIX MEDICAL CENTRE MEDICAL PHOENIX

MILL STREET MEDICAL CTR. MEDICAL STREET MILL

RAINFORD HEALTH CENTRE HEALTH RAINFORD

NEWTON MEDICAL CENTRE MEDICAL NEWTON

BETHANY MEDICAL CENTRE MEDICAL BETHANY

THE SPINNEY MEDICAL CTR. MEDICAL SPINNEY THE

RAINHILL VILLAGE SURGERY VILLAGE RAINHILL

THE CROSSROADS SURGERY CROSSROADS THE

HAYDOCK MEDICAL CENTRE MEDICAL HAYDOCK

ORMSKIRK HOUSE SURGERY HOUSE ORMSKIRK

RAINBOW MEDICAL CENTRE MEDICAL RAINBOW

SHERDLEY MEDICAL CENTRE MEDICAL SHERDLEY

LONGTON MEDICAL CENTRE MEDICAL LONGTON CENTRE HEALTH ACRE FOUR

BILLINGE MEDICAL PRACTICE MEDICAL BILLINGE

LINGHOLME HEALTH CENTRE HEALTH LINGHOLME

SANDFIELD MEDICAL CENTRE MEDICAL SANDFIELD

LANCASTER HOUSE MED.CTR. HOUSE LANCASTER

ECCLESTON MEDICAL CENTRE MEDICAL ECCLESTON

HALL STREET MEDICAL CENTRE MEDICAL STREET HALL

BERRYMEAD FAMILY MED.CTR. FAMILY BERRYMEAD

PATTERDALE LODGE MED CTRE MED LODGE PATTERDALE

THE BOWERY MEDICAL CENTRE MEDICAL BOWERY THE

KENNETH MACRAE MED CENTRE MED MACRAE KENNETH NEWTON COMM. HOSPITAL PRACTICE HOSPITAL COMM. NEWTON St.Helens South Haydock St.Helens North Cluster Cluster & Newton

The numbers of admissions and associated costs for asthma rose between 2013/14 and 2014/15 as shown in below. The indirectly standardised annual hospital admission rate is 106 per 100,000 compared to the national average 124 per 100,000 (note this national figure was from 2011/12 the most recent available, the St.Helens rate is from 2012/13 closest match to the national)

Table 17. Number of hospital admissions relating to asthma and the associated cost

Financial Year Asthma Admissions Cost of Admissions 2013/14 207 £206,254 2014/15 227 £224,624 Grand Total 434 £430,878

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St.Helens Joint Strategic Needs Assessment 2015 c. Recommendations COPD

 Case finding initiatives where reported prevalence rates are low compared to estimated rates  Smoking cessation support and promotion  Continued enhanced referral to pulmonary rehabilitation  Inhaler technique checks  Increased appropriate early supported discharge for COPD admissions  Increased community support to prevent admission and encourage self-management

Asthma

 Smoking cessation support and promotion  Promotion of the use of self-management techniques  Inhaler technique checks  Asthma medication reviews to ensure optimum management

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Diabetes

5.4 Diabetes

5.4.1 Introduction Diabetes is the fastest growing health condition of our times and is now an urgent public health issue. Since 1996, the number of people living with diabetes has more than doubled to 3.2 million people. A further 0.5 million have it but don’t know about it and 9.6 million people are at high risk of developing it.

Diabetes mellitus is a chronic disease which can cause substantial morbidity and mortality. There are three main types of diabetes: Type 1 (average age on onset 12 years), where cells producing insulin are destroyed, Type 2 which is a combination of a lack of insulin being produced and ‘resistance’ to how the insulin works, and Gestational Diabetes (occurring during pregnancy). Type 2 diabetes is the most common and accounts for approximately 90% of all diabetes. Diabetes mellitus and its complications can cause severe difficulties for sufferers and their families. There is no cure for diabetes and the condition entails a heavy burden on health services. Effective control of blood glucose and hypertension can prevent the development and progression of complications.

Obesity is the primary modifiable risk factor for Type 2 diabetes and the increasing prevalence of Type 2 diabetes in younger people can be attributed to the obesity epidemic in these age groups. In addition to obesity, smoking and poor control of one’s diabetes are risk factors for vascular complications in people with diabetes. 86% of people with Type 2 diabetes are obese.

Other risk factors for Type 2 diabetes include family history, high blood pressure, having previously had a stroke or a heart attack and polycystic ovary syndrome.

Impaired Glucose Regulation, or ‘pre-diabetes’, occurs in people with raised levels of glucose in their blood, but they are not high enough for a diagnosis of diabetes. It puts the person at increased risk of developing Type 2 diabetes and heart disease so it is important to focus on the steps that can be taken to minimize this risk.

The impact of diabetes on morbidity and mortality should not be underestimated. In 2013, people with Type 1 diabetes were 131% more likely to die than their non-diabetic peers and those with Type 2 diabetes 32% more likely.

£10 billion of the NHS budget per year is spent on people with diabetes (80% of which is spent on complications, most of which could be prevented) and the total direct and indirect costs of diabetes are £23.7 billion per year (forecast to rise to £39.8 billion by 2035). Every year 24,000 people die prematurely with diabetes; 100 people per week suffer amputation, diabetes is the leading cause of blindness and renal failure and greatly increases the risk of heart attack and stroke.

Medicines used to treat diabetes in England now account for a tenth of the annual primary care prescribing bill. The cost of GP prescriptions in England & Wales in 2014/15 according to the HSCIC was £8.70 billion, with the cost of managing diabetes £867 million.22 This was 10.0% of the total, compared with 9.5 per cent in 2013/14 and 6.6 per cent in 2005/06. There were 47.2 million items

22 http://www.hscic.gov.uk/catalogue/PUB18032

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prescribed for diabetes, a 4.6 per cent (2.1 million) increase from 45.1 million items in 2013/14 and a 74.1 per cent (20.1 million) rise on 2005/6 (27.1 million).

People with diabetes are more likely to be admitted to hospital (increase with angina 139%, heart attack 94%, heart failure 126%, stroke 63%, amputation 400% and renal replacement 272%) and they stay longer, with some 12-15% of all hospital inpatients having diabetes (1.087 million admissions in 2009/10 at an annual cost of £2.5 billion), and 608,000 excess bed-days.

There were 116,884 admissions with diabetic foot problems alone leading to 1.2 million bed-days, that is 17.6 admissions per 1000 people with diabetes and 184.1 occupied bed-days per 1000 people with diabetes. For the average practice with 10,000 patients, there will be 450 with diabetes of whom 16 (4.5%) will require emergency foot care and 135 regular foot care i.e. 0.37% of the whole population are at risk of diabetic foot ulceration and 0.13% of the whole are likely to require emergency foot care.

Diabetes can be prevented by increasing public awareness of the condition and early symptoms. Those at increased risk need to be supported to change their lifestyle by losing weight, becoming more physically active, and eating healthier. Also vital for diabetes prevention are environmental and policy changes to tackle obesity. Diabetes can be well-controlled and treated to successfully delay and even prevent long-term complications. However, poorly managed diabetes can lead to heart disease, stroke, kidney failure, eye disease, mental ill health, and limb amputations.

5.4.1.i Implications for commissioning The number of people diagnosed with diabetes increases each year; nationally, the pace of the increase has been approximately 25% over the past six years. Commissioners need to ensure service capacity to cope with rising numbers of diabetes patients.

Type 2 diabetes is by far the most prevalent diabetes and the one that is increasing. Local diabetes prevention strategies aiming to reduce the incidence of Type 2 diabetes need to engage especially with deprived wards within the Borough.

Early identification of complications is paramount to reducing the impact of diabetes as well as its associated conditions.

Education and supported self-management improves quality of life, improves self-management and reduces service use but only 2.4% of people with Type 1 diabetes and 6% of people with Type 2 diabetes were offered structured education nationally in 2012/13 and only 1.1% and 1.6% respectively were recorded as having attended.

Nationally, QOF (Quality Outcomes Framework) treatment target achievements related to diabetes are beginning to stall. The National Diabetes Audit suggests that increasing levels of obesity may be a barrier to further improvement in glucose and blood pressure control in Type 2 diabetes. Accordingly, the impact on diabetes management of the societal changes in obesity needs to be recognised and addressed; health promotion, physical activity, and diabetes education should be developed and supported.

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5.4.2 Key statistics

5.4.2.i Prevalence of Disease According to QOF data in 2015 there are 10,975 (5.8%) people aged 17 years and over diagnosed with either Type 1 or Type 2 diabetes in St.Helens (QOF Dashboard, 2015) compared to 5.6% (10,844) in 2014. 883 people with Type 1 diabetes; 97 with gestational diabetes and the remaining 9,588 with Type 2 diabetes. There are also wide differences in prevalence rates for diabetes between practices and wards within St.Helens. GP lowest rate is 5.3% and highest rate being 18%. This suggests a huge variation in many life factors.

The risk of developing Type 2 diabetes is 20-80 times higher for people who are obese compared to those of normal weight. It is estimated that 11.1% of adults in St.Helens are obese compared to Merseyside (11.3%) and NHS England (9.8%). Obesity is increasing significantly across the country. By 2025 it is projected that 42% of men and 39% of women in England will be obese. Diabetes is expected to increase significantly as a result. a. Diabetes in disadvantaged groups  The most deprived in the UK are 2.5 times more likely to have diabetes.  80% of people with Type 2 diabetes are overweight or obese at diagnosis.  1.3 million people with diabetes are aged over 65.  People from black and minority ethnic groups are up to 6 times more likely to develop diabetes.  One in five people with a severe mental illness have diabetes.  The prevalence of diabetes in nursing homes is up to 25% compared to 3% in the general population.  Complications of diabetes such as heart disease, stroke and kidney damage are three and a half times higher in the lower socio economic groups.  People from deprived or ethnic communities are less likely to have their body mass index or smoking status recorded. They are also less likely to have records for HbA1c, retinal screening, blood pressure, and neuropathy or flu vaccination.  Those who are least well educated are more likely to have retinopathy, heart disease and poor diabetes control. b. Comparisons with neighbouring local authorities The table below compares St.Helens with our neighbouring Local Authorities for the number of people diagnosed with either Type 1 or Type 2 diabetes

Table 18. Prevalence of Diabetes compared to neighbouring authorities Local Authority Age 2015 2020 18-65 3623 3685 St.Helens 65+ 4436 4846 18-65 2599 2599 Halton 65+ 2697 3064 18-65 6562 6823 Wigan 65+ 7436 8068 Source: POPPI, July 2015

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c. Future and recommendations  Assessment and regular monitoring/analysis of the Public Health Outcomes Framework indicators linked to diabetes are necessary, such as adult obesity and recorded diabetes.  Commissioners are currently redesigning the Diabetes Education Programme for newly diagnosed and established diabetics to ensure this service meets the future needs of our population.

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Mental Health and Wellbeing

5.5 Mental Health and Wellbeing

5.5.1 Introduction There has been an emphasis on improving mental health and wellbeing nationally. Leading agencies in the field of mental health services advocate strategic planning for ‘Parity of Esteem’; whereby mental health issues should be afforded the same level of priority and investment as physical need.

Despite national drivers to improve outcomes for people with mental health needs and create environments that protect the population’s wellbeing, there is still a long way to go.

Mental health is a key priority for local leaders and the local population alike and there is a real appetite to drive forward action, both locally and nationally there is a commitment to improvement. St.Helens Council and Clinical Commissioning Group have developed a Mental Health and Wellbeing Strategic Framework which has been approved by the Health and Wellbeing Board. The Strategic Framework has 6 implementation plans to drive forward improvements in Mental Health and Wellbeing, the action plans cover:

 Promote good mental wellbeing  Children and Young Peoples Mental Health  Primary care mental health  In patient care, continuing health care and community support  Suicide Prevention  Dementia

Reform of mental health services was also identified as a priority for the Clinical Commissioning Group in their Clinical Commissioning Strategy 2013-16. HealthWatch consulted with the local population about the priority areas for action and Mental Health was identified as one of the top two areas for action.

The St.Helens Child Health Summit 2014 which was attended by multi-agency stakeholders across the borough identified child and adolescent mental health issues as an area of concern. Teachers and the local safeguarding board also described issues in relation to accessing some child mental health services and concern about levels of self-harm locally. As a result of this Overview and Scrutiny have undertaken a review of what is being implemented to tackle self-harm locally. The next section illustrates why there is a need to drive forward change based on local health statistics.

5.5.2 Key Statistics Nationally  1 in 4 adults experience at least 1 mental health disorder at some time in their lives  Mental health is the single biggest cause of disability, accounting for 22.8% of disability  Mental health reduces life expectancy by an average of 10 years  Mental health costs the NHS between £8 billion and £13bn a year  Mental health of people with serious physical ill health is often overlooked  Mental health affects the likelihood for people to be compliant with medicines  The wider economic impact of mental health is estimated at £105bn/year

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5.5.3 Local Need Key population groups at risk of mental health problems include: families with multiple problems, those people misusing drugs and alcohol, people who are homeless, military veterans and offender populations.

 St.Helens Council has identified families that have complex needs relating to youth crime/anti-social behaviour, poor school attendance/exclusions and adult worklessness through the ‘priority families’ agenda. These complex health and social issues mean that all members of these families are at risk if not already experiencing difficulties with mental health and resilience.  The scale of drug and alcohol problems in the borough can be difficult to quantify, however local indicators suggest that alcohol misuse is a significant issue in St.Helens. There are 326 upper and lower tier local authorities in England, and St.Helens ranks in the worst ten, for alcohol-specific hospital admissions for females (322nd) and alcohol-related hospital admissions for both men (322nd) and women (319th).

The Cheshire and Merseyside Health Needs Assessment for Ex-Armed Forces Personnel (LPHO 2013), reported in the St.Helens JSNA 2013, showed evidence that people serving in the Army had a risk of death 150 times higher than the wider population, and gave some evidence that alcohol misuse is a problem amongst former Armed Service personnel.23 In terms of mental health, the Ministry Of Defence’s Departments of Community Mental Health (DCMH) assessed 5,351 people as having a mental disorder in 2013/14, representing a rate of 30.4 per 1,000.24 A survey of Forces personnel and families found that mental health support is required by just under a quarter of families but not accessible to 46% of these. St.Helens has 985 residents who receive an Armed Forces pension, furthermore data from local general practice from 18 of the 36 practices in St.Helens indicate that there were 2153 ex-servicemen coded on the clinical systems. This indicates a higher population than previously estimated in St.Helens.

 People who are homeless often have pre-existing mental health issues or are considered to be an at risk group. The true level of homelessness is difficult to record, however data from the Mental Health Profiles reports that the rate of statutory homelessness in St.Helens in 2013/14 was 1.2 per 1,000 households, this is equivalent to the North West rate and lower than the national rate. From this data 92 households were classified as being statutory homeless; however the number of people affected is likely to be higher.

In St.Helens the rate of first time entrants into the criminal justice system has decreased over time. 2013/14 data indicates the rate per 100,000 10-17 year olds (464 per 100,000) in St.Helens was slightly higher than both the regional and national rate (423 and 432 respectively). However the rate had in the previous 3 years had been lower. This rate relates to 74 young people in St.Helens which has reduced from a high of 369 in 2007/08. This data however maybe reflect changes in policy relating to definitions of first time entrants.

23http://www.liv.ac.uk/media/livacuk/instituteofpsychology/publichealthobservatory/93,Health,needs,assessment,f or,ex-Armed,Forces,personnel.pdf 24 Armed Forces National Mental Health Report, July 2014

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Figure 50. Rates of young people aged first time entrants to the youth justice system per 100,000 10-17 year olds in the population, 2003/04 to 2013/14.

2,500

2,000 17 17 yearolds - 1,500 St. Helens 1,000 North West England 500

Rate per 100,000 16 0

Source: Ministry of Justice, 2015. 5.5.4 Social and economic factors The true size of the mental health problems in the Borough can be difficult to quantify. People will often move in and out of services, may access more than one service and some people may not enter services until they are at crisis point. We know that around a quarter of people will suffer a mental health problem in any one year with the most common condition being mixed anxiety and depression. One of the ways we have of capturing the number of people affected is within general practice; there are 3 key data items collected to register those people known to have depression, mental health and dementia. Based on data from 2013/14 the table below shows the prevalence in these 3 areas for St.Helens compared with the other CCGs within Merseyside.

Table 19. Prevalence of depression, mental health and dementia based on Quality and Outcomes Framework data 2013/14

Prevalence of Prevalence of Prevalence of depression - mental health - Dementia -

percentage percentage percentage St.Helens 8.23 0.99 0.75 Halton 7.25 0.8 0.59 Knowsley 8.69 0.91 0.68 Liverpool 7.12 1.25 0.57 South Sefton 6.82 1.17 0.68 Southport and Formby 4.52 1.02 0.98 Source: Health and Social Care Information Centre

The data shows that based on recording in general practice there are high levels of depression and dementia in St.Helens. These high levels may be because GPs in St.Helens code people with these

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conditions more accurately than in other areas, or we have higher levels of depression and dementia locally. We know for example that there has been active work in St.Helens to diagnose people effectively with dementia. National prevalence studies suggest that there is an under recording of dementia in all areas of the country. This proactive approach in St.Helens has seen the number of people diagnosed increase and ensures that people diagnosed early have an improved chance of better outcomes.

Prevalence of mental health problems within GP records is less than 1% and relatively low nationally, but based on information from national surveys a significantly higher proportion of the population indicates that they have a long term mental health condition.

Figure 51. Percent of the population reporting a long term mental health problem (2012/13) – GP patient survey

% with long term mental health problems England 8 7

6 5 4 3

%of population 2 1 0 St. Helens Halton Knowsley Liverpool South Sefton Southport and Formby

Source: Public Health England, Community Health Profiles http://fingertips.phe.org.uk/profile-group/mental- health

Alongside the high numbers of people diagnosed with depression on GP records, data for 2013/14 (April-Feb) shows that prescribing of anti-depressants in St.Helens is higher than the overall rate for England. High prescribing levels are seen in all Merseyside CCGs apart from Southport and Formby. The rate of prescribing calculated based on average daily quantities per population (age/sex weighted). The cost per ASTRO-PU (Age, Sex and Temporary Resident Originated Prescribing Units) for the Clinical Commissioning group for the same period was £2094.12 compared to a cost of £1252.07 over the whole of England.

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Table 20. Anti-depressant prescribing – average daily quantities per STAR-PU (2012/13) Prescriber Name 2014/15 ADQ Usage Per 1,000 ADQ based Antidepressant Star PU Knowsley CCG 2,045.93 St Helens CCG 2,041.06 Liverpool CCG 1,971.57 Halton CCG 1,929.21 South Sefton CCG 1,794.65 Southport and Formby CCG 1,486.43 Merseyside CCGs 1,915.26 England 1,411.39

The rate of accident and emergency attendances where the person has a psychiatric disorder are higher in St.Helens than nationally, but lower than Knowsley and Liverpool, which have exceptionally high rates.

Figure 52. Rate of Accident and Emergency Attendances for psychiatric disorders per 100,000 population 2012/13

A&E attendances with psychiatric disroder per 100,000 2012/13 Merseyside England 900 800 700 600 500 400 300 200 100 0 NHS St Helens NHS Halton CCG NHS Knowsley NHS Liverpool NHS South NHS Southport CCG CCG CCG Sefton CCG And Formb...

Source: Public Health England, Community Health Profiles http://fingertips.phe.org.uk/profile-group/mental- health

Other outcomes can be illustrated in the death rates due to suicide and undetermined injury. Whilst overall number of deaths per year is low, rates in St.Helens have fluctuated over time, since 2001-03 we have generally seen a gradual increase. There has been a steep incline since 2009-11 which is thought to have been partly due to economic and financial pressures in the parts of the population.

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a. Key findings based on St.Helens results of the North West Mental Wellbeing Survey The second North West Mental Wellbeing Survey was commissioned in 2012 by the former North West Public Health Observatory. The survey used a wellbeing tool based on the short Warwick and Edinburgh Mental Wellbeing Score (sWEMWBS) which used 7 key questions:

The maximum score was 35 with a minimum score of 7. The residents in St.Helens had an average score of 26.39 which was the third lowest in the North West. In St.Helens, male respondents had better levels of mental wellbeing than females. Key findings are described below:

 Educational level was associated with mental wellbeing, low mental wellbeing more common among participants with fewer educational qualifications.  Self-perceived health was directly related to mental wellbeing; participants with better self- perceived health had better mental wellbeing.  Doing no physical activity and consuming one or no portions of fruit and vegetables were associated with worse mental wellbeing.  St.Helens respondents were less likely than those across the North West to report doing no physical activity (22.8% vs. 29.7%).  A greater proportion of St.Helens respondents reported spending leisure time outdoor every day than across the North West (29.8% vs. 21.6%).  Using cannabis and drinking alcohol at increasing or higher risk quantities was associated with better levels of mental wellbeing. There was no association between mental wellbeing and smoking status.  Being satisfied with personal relationships, interacting with friends, family and neighbours regularly, feeling well supported and being more trustful of others were associated with better mental wellbeing.  Childhood experiences were strongly related to mental wellbeing, with low well-being significantly more likely in those who reported having had violent or unhappy childhoods.  Compared with the North West sample, St.Helens respondents were more likely to report violent childhoods and less likely to report happy childhoods.  Living alone was associated with worse mental wellbeing.  Being satisfied with the local area, feeling you can influence decisions in local area, and feeling safe were all associated with better mental wellbeing.  There was a clear and significant relationship between social capital and mental wellbeing; those with high social capital were more likely to have high mental wellbeing and those with low social capital were more likely to have low mental wellbeing.  Social connections were lower in St.Helens than across the North West, with social support less available, interaction with friends, family or neighbours less frequent and trust lower.

b. Local Views Mental health was the second most important topic that the public asked Health Watch to consider as part of their actions in 2014-15. The development of the Mental Health and Wellbeing Strategic Framework for St.Helens of which the section’s above are taken from have highlighted the importance of mental health to the public and professionals alike. There have been a number of consultations in which the public and professionals have raised issues about either mental health services or factors that impact on the mental wellbeing of our local population.

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Table 21. Estimated number of people with common mental health problems in the 16- 74 year old age group

Type of mental health problem Percentage of population with Estimated Number of People in this mental health problem Borough with this mental health problem Mixed anxiety and depressive 11.24% 14,591 disorder Generalised anxiety disorder 6.6% 8,585 Depressive episode 2.8% 3,628 All phobias 2.69% 3,494 Obsessive Compulsive Disorder 1.75% 2,268 Panic disorder 0.30% 392

There are delays in accessing local services. For example, the percentage of people waiting more the 28 days from referral to first treatment in psychological services (IAPT) in quarter 3 2014/15 was 7.6% and this was the second highest in Merseyside, with many of the other areas seeing people more quickly, for example only 1.6% had been waiting 28 days in Halton. Waiting times for treatment are a specific issue as whilst people are waiting they could deteriorate. However, for people with mild to moderate depressive orders there are many assets in our communities that may support service users. Using social prescribing to access other social assets such as physical activity programmes, books on prescription, arts on prescription can help people to keep well.

Both the national strategy ‘No health without mental health’ and the ‘Future in Mind’ make recommendations about evidence based strategies and interventions to support mental health and wellbeing, these strategies have been used to develop the framework for action within St.Helens.

5.5.5 Future and recommendations The risk factors associated with mental ill health described in the key statistics section show that many of the factors that impact on mental wellbeing in St.Helens are prevalent within our communities for example, drug and alcohol problems, social and economic deprivation. There needs to be continued emphasis and investment into mental health services so that they are equivalent to physical ill health services.

5.5.5.i Recommendations  To approve and deliver on the actions within the Mental Health and Wellbeing Strategic Framework  To continue to monitor the impact of actions on key indicators  To ensure that mental health is afforded the same priority as physical health through promoting parity of esteem.

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6. Hospital admissions

6.1 Healthcare Activity and Health Inequalities There are health inequalities in the use of health services, particularly in emergency admissions to hospital (non-elective).

Ideally, people who need treatment in hospital should be admitted before their illness reaches a critical stage where they have to be admitted as an emergency. Where illnesses are left to a late stage, this often involves more suffering on the part of the patient and poorer outcomes of treatment. Emergency admissions are also less satisfactory, as less advance planning is possible and patients are commonly seen by more junior staff.

Lack of advance planning is particularly relevant for people with learning or physical disability where it is helpful if staff can make reasonable adjustments in anticipation of the patient’s needs.

The chart below shows that areas that are more deprived (such as Town Centre, Parr, Thatto Heath, Bold and Haydock) have a significantly higher rate of emergency admissions than the rest of the borough. Indeed, Town Centre ward has a significantly higher rate than all other wards. This pattern has remained the same in St.Helens over recent years. Haydock and Earlestown are noticeably the two wards which have worsened during this period. Thatto Heath and Windle have both shown slight improvements with reduced rates (DSR) for emergency admissions per 100,000 population.

Figure 53. St.Helens emergency admissions all persons, all ages 2014/15

25000 St Helens 20000 15000 10000 5000

0 DSR DSR per100,000 population

Source: SUS data

However, in terms of planned admissions to hospital there is not the same degree of correlation between admission rates and highest rates of need. This may suggest that people from more deprived areas may not have sought health interventions early enough to prevent an emergency admission. A ward which supports this theory showing higher planned care admissions compared to emergency admissions is Blackbrook, which has a higher than average DSR per 100,000 for planned care and a lower than average DSR per 100,000 for emergency admissions. Earlestown are the opposite of this with low planned care compared to average and higher than average emergency admissions.

Figure 54. St.Helens Planned care admissions all persons, all ages 2014/15

25000 St Helens 20000

15000

10000

5000

0

Source: SUS data

The top 10 reasons based on directly age standardised rates to hospital for emergency admissions are shown below. The highest cause of admission is not related to any one condition but relates to health where there is no definite diagnosis. However, in relation to emergency conditions with a specific diagnosis, injury and poisonings, and respiratory conditions are the highest two causes.

Table 22. Top 10 reasons for emergency admissions to hospital in 2014/15

(Directly age standardised rates per 100,000 Population)

Top 10 Emergency Admissions by Diagnosis Group Emergency As % of All Ages, 2014/15, Directly Age Standardised Rates per 100,000 Admissions Total Symptoms, signs and abnormal clinical & laboratory findings NEC 2,890 22.8% Injury, poisoning and certain other consequences of external causes 1,972 15.6% Diseases of the respiratory system 1,633 12.9% Diseases of the circulatory system 1,160 9.2% Diseases of the digestive system 959 7.6% Diseases of the genitourinary system 760 6.0% Infectious / parasitic diseases 639 5.0% Diseases of the musculoskeletal system and connective tissue 634 5.0% Diseases of the skin and subcutaneous tissue 338 2.7% Endocrine, metabolic or nutritional diseases 277 2.2% Source: SUS

In order to ensure that we improve health outcomes it is important that the correct people are being targeted for health interventions and that there is good access to services. This should reduce the need for emergency hospital admissions and ensure that there is planned health care.

Table 23. Planned hospital admissions in 2014/15

(Directly age standardised rates per 100,000 Population)

Top 10 Planned Care Admissions by Diagnosis Group Elective/ As % of All Ages, 2014/15, Directly Age Standardised Rates per 100,000 planned Total Admissions Diseases of the digestive system 3,397 22.0% Diseases of the eye, adnexa, ear and mastoid process 1,937 12.5% Diseases of the genitourinary system 1,799 11.7% Diseases of the musculoskeletal system and connective tissue 1,746 11.3% Malignant neoplasms 1,317 8.5% Diseases of the circulatory system 958 6.2% Non or malignancy unknown neoplasms 843 5.5% Symptoms, signs and abnormal clinical & laboratory findings NEC 741 4.8% Factors affecting health status and contact with health services 716 4.6% Injury, poisoning and certain other consequences of external causes 424 2.7% Source: SUS

In terms of planned admissions to hospital, problems of the digestive system, eyes and ear diseases, genitourinary system and musculoskeletal problems account for the greatest number of people.

Injury and poisonings account for a high proportion of planned and emergency admissions. Although there are many different causes of injuries covered in this section, two areas that need to be targeted in relation to health interventions are fractured neck of femur (Hip Fracture) and poisonings; including excess alcohol intake, accidental and deliberate poisoning.

In relation to deaths and hospital activity, circulatory conditions and cancers still need further attention, particularly to reduce the internal health inequalities in St.Helens. Pneumonia, COPD and asthma admissions are high and this is the 3rd biggest areas of mortality

Avoiding emergency hospital admissions is a priority for all age groups not only because of the high costs of emergency admission compared with other forms of care, but also because of the disruption it causes to elective health care such as inpatient waiting lists – and to the individuals admitted. Age is a risk factor for emergency hospital admissions, with younger people and older people being at higher risk of admission.

6.2 18-64yrs Hospital Admissions For 18-64 year olds, 40% of all admissions to hospital are emergencies. This is much lower than the 63% emergency for those under-18s, and in line with the rate in people over 65 (45%). The highest proportion of these is due to signs and symptoms not classified in the major disease categories. Injuries and poisonings are the biggest cause of emergency admission. Mental health also appears within the top 10, this could be related to some poisoning admissions.

In order to ensure that health services are meeting health needs we would want to see more people receiving care for the health issues early and therefore only be admitted to hospital for planned care and not as an emergency, therefore we would like to see the proportion of emergency admissions further reduced.

Table 24. Emergency hospital admissions in 2014/15 for adults aged 18-64

Top 10 Emergency Admissions by Diagnosis Group Emergency As % of Ages 18 to 64 years, 2014/15 Admissions Total Symptoms, signs and abnormal clinical & laboratory findings NEC 2422 26.5% Injury, poisoning and certain other consequences of external causes 1532 16.8% Diseases of the digestive system 825 9.0% Diseases of the circulatory system 685 7.5% Diseases of the respiratory system 670 7.3% Diseases of the genitourinary system 522 5.7% Diseases of the musculoskeletal system and connective tissue 521 5.7% Pregnancy, childbirth and pueperium 307 3.4% Diseases of the skin and subcutaneous tissue 295 3.2% Mental and behavioral disorders 292 3.2% Source: SUS

In terms of planned admissions to hospital the biggest causes are digestive disease, followed by diseases of the genitourinary system and musculoskeletal system.

Table 25. Planned hospital admissions in 2014/15 for adults aged 18-64

Top 10 Planned Care Admissions by Diagnosis Group Elective As % of Ages 18 to 64 years, 2014/15 Admissions Total Diseases of the digestive system 3414 24.8% Diseases of the musculoskeletal system and connective tissue 1873 13.6% Diseases of the genitourinary system 1802 13.1% Diseases of the circulatory system 937 6.8% Malignant neoplasms 804 5.9% Symptoms, signs and abnormal clinical & laboratory findings NEC 777 5.7% Diseases of the eye, adnexa, ear and mastoid process 740 5.4% Non or malignancy unknown neoplasms 721 5.2% Factors affecting health status and contact with health services 617 4.5% Injury, poisoning and certain other consequences of external causes 466 3.4% Source: SUS 6.2.1 Summary  Digestive system disease is a leading cause of hospital admissions (both emergency and planned admission) in all people aged 18-64.  Genitourinary diseases are a cause of both planned and emergency for all age groupings.  Male emergency admissions are higher than average for ages up to 40 years, with the exception of 10-14s.  Female emergency admissions are extremely low compared to planned care for ages 25-34.

6.2.1.i Ward and gender specifics in St.Helens  Rainhill is the only ward with higher male emergency admissions than female  Blackbrook is the only ward with higher male planned care admissions than female  Haydock, Bold, Thatto Heath & Billinge are higher than average for female emergency  Haydock and Earlestown are higher than average for female planned care admissions

St.Helens Health and Wellbeing Board

Members:

St.Helens Council St Helens Clinical Commissioning Group Halton and St.Helens Voluntary and Community Action Healthwatch St.Helens NHS England Helena Partnerships Bridgewater Community Healthcare NHS Trust 5 Boroughs Partnership NHS Trust St.Helens and Knowsley Teaching Hospitals NHS Trust Merseyside Police

Contact Details Public Health Tel: 01744 676789 Atlas House St.Helens [email protected] WA9 1LD www.sthelens.gov.uk/health