To the Mayor and Councillors of the London Borough of Lambeth

b To the Mayor and Councillors of the London Borough of Lambeth

SUPPORTING DOCUMENTS FOR AGENDA ITEM 8

YOU ARE SUMMONED TO ATTEND A MEETING of the COUNCIL to be held in Council

Chamber, Lambeth Town Hall, Brixton Hill, SW2 1RW on Wednesday, 28 January 2009 at 7.00 pm

DERRICK ANDERSON CHIEF EXECUTIVE

Contact Tim Stephens Department of Finance and Tel/Voicemail: 020 7926 2754 Resources Fax: 020 7926 2361 Legal & Democratic Services Email: [email protected] London Borough of Lambeth, Website: www.lambeth.gov.uk Lambeth Town Hall, Brixton Hill, London, SW2 1RW

Tuesday, 20 January 2009

AGENDA

Appendices to reports – bulky appendices are published on the website www.lambeth.gov.uk and can be obtained from Democratic Services. They are not circulated with the agenda.

Page 8. Nos.

a) Health in Lambeth Report 1 - 242

Health Profile 2008 Page 1 Agenda Item 8a Lambeth This is a Spearhead area

This profile gives a snapshot of health in your area. With other local information, this Health Profile has been designed to support action by local government and primary care trusts to tackle health inequalities and improve people's health.

Health Profiles are funded by the Department Lambeth at a glance of Health and produced annually by the Generally, the health of people in Lambeth is Association of Public Health Observatories. • significantly poorer compared with the England To view Health Profiles for other local authorities average. Life expectancy in males and females is and to find out how they were produced, visit lower, deaths from smoking and early deaths from heart disease and stroke and from cancer appear www.healthprofiles.info higher than the rest of England. Rates of violent crime

2 0 0 4 5 A 0 13 1 0 5 11 A 9 0 A 6 0 1 2 0 2 2 A A 1 and drug misuse are also significantly higher. 0 1 4 4 0 1 A 1 1 4 4 A A A 3 A A City 0 2 A120 1 2 0 0 2 A40 2 6 LONDON • Lambeth is amongst the most deprived areas A A 2 0 A 2 4 1 2 0 A 3 2 2 1 0 1 3 2 0 0 0 A4 2 2 0 0 5 1 4 A 3 3 A 1 A 1 3 A 3 A A nationally, with all wards having higher than average 3 2 0 5 2 0 0 A21 0 2 31 1 2 98 WESTMINSTER 3 A 6

A A 0 A A 3 0 2 4 3 A3 2 0 A201 1 2 A 0 2 2 deprivation. All ethnic groups in this area have a 1 0 3 A 0 8 7 3 2 A 6 08 21 A22 A3 A 214 3 A3 Vauxhall 22 0 A significantly higher percentage of children eligible for 8 A3212 3 21 2 A3 0 4 4 0 Kennington free school meals compared to the rest of the country. 3 Image found and displayed. 9 A A321

6 3 Over the past ten years, all age all cause mortality has 0 • 1 3 205 3 0 A3 A A 3 A 22 A 22 14 A 15 fallen for both men and women in Lambeth, but it 3 Stockwell 2 0 7 A 20 7 3 21 A2 remains above the England average. Early death rates A3 Clapham A205 Brixton A 3 #Name? from heart disease and stroke have also fallen. 2 0 T) 9

A • In Lambeth, more than 40% of children live in families 2 1 9 9 Streatham Hill Tulse Hill receiving means tested benefits. Rates for GCSE A2 04 A achievement are also low when compared to England. 2 1 4 West Dulwich West Norwood • Lambeth has higher than average rates for adults who A A2 Streatham 2 218 2 1 6 smoke, however people eat more healthily and are

A 2 1 Norwood 8 more physically active than average. The rate for

Streatham Vale

A A 2 breast feeding initiation is the highest in the country. 38 2 3 2 1 3 4 015 A 9 6 1 2 1 2 A 2 A A A 2 Lambeth PCT has prioritised staying healthy, mental 4 •

2 1 A 2 health, long term conditions, children and young people POPULATION 272,000 and sexual health in its Strategic Commissioning Plan. Based on Ordnance Survey material. © Crown Copyright. All rights reserved. DH 100020290 2008. Other map data © Collins Bartholomew. • For further information, please refer to the Annual Public Health Report at www.lambethpct.nhs.uk ©CrownCopyright 2008

Lambeth Page 2 Deprivation: Deprivation: a national perspective a local perspective

This map shows differences in deprivation between This map shows differences in deprivation between small areas in this local authority, compared to the small areas in this local authority, compared to the local whole of England (based on IMD 2007). authority as a whole (based on IMD 2007). National deprivation groups Local deprivation groups 1 Least deprived fifth of areas in England 1 Least deprived fifth in this local authority 2 2 3 3 4 4 5 Most deprived fifth of areas in England 5 Most deprived fifth in this local authority

11 11

1212 1212 t. t.

1111 1111

2121 2121 1414 1414

1010 1010 8 8 0 0

0 44 66 0 44 66 2 55 2 55 0 0

9 88 9 88 2 2 0 0

2 33 2 33 0 0

0 22 0 22 2020 2020 0 2020 0 2020 1 1818 1 1818 H H D D . 1515 1919 . 1515 1919 d 1515 d 1515 e e v v r r e e s s e e r r 1717 99 1717 99 s s t 1313 77 t 1313 77

h 77 h 77 g g i i r r l l l l Based Based Ordnanceon Survey material. ©CrownCopyrigh A Based Ordnanceon Survey material. ©CrownCopyrigh A 1616 1616

Ward legend Health inequalities: a local perspective 1 Bishop's 2 Brixton Hill Inequalities in life expectancy (2002-2006) for men and 3 Clapham Common women who live in areas with different levels of 4 Clapham Town deprivation (within this local authority). 5 Coldharbour 92 6 Ferndale 7 Gipsy Hill 90 8 Herne Hill 9 Knight's Hill 88 10 Larkhall 86 11 Oval 12 Prince's 84 13 St Leonard's 82 14 Stockwell 15 Streatham Hill 80 16 Streatham South 78 17 Streatham Wells 18 Thornton 76 19 Thurlow Park 74 20 Tulse Hill 21 Vassall Life expectancy at birth (years) 72

68 MMMMFFFF M F 66 1 2 3 4 5 Least Local deprivation groups Most deprived deprived fifth M = Males fifth Ward boundaries 2005 are superimposed upon MSOA (Middle Super Output F = Females Area) boundaries. Each MSOA is shaded by Index of Multiple Deprivation (IMD) 2007. For details refer to www.communities.gov.uk. Numbers 95% confidence interval. These indicate the level of uncertainty about each value correspond to ward legend. Ward boundaries may have changed. on the graph. Longer/wider intervals mean more uncertainty. When two intervals do not overlap it is reasonably certain that the two groups are truly different. Lambeth www.healthprofiles.info Health inequalities: changes over time Page 3 Trend 1: These trend graphs show how changes in health for this All age, all cause mortality local authority compare with changes for the whole of England. Data points are mid-points of 3 year moving 1300 averages of annual rates i.e. 1996 represents the 3 year 1200 period 1995-97. 1100 1000 Trend 1 compares death rates (at all ages and from all 900 causes) in this local authority with those for England. 800 700 600 population. Trend 2 compares rates of early death from heart 500 disease and stroke (in people under 75) in this local 400 300 authority with those for England. Age-standardised rate/100,000 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 Years Trend 3 compares rates of early death from cancer (in Men:England Men: Lambeth people under 75) in this local authority with those for Women:England Women: Lambeth England.

Trend 2: Trend 3: Early death rates from heart disease and stroke Early death rates from cancer

220 220 200 200 180 180 160 160 140 140 120 120 100 100 population. population. 80 80 60 60 40 40 Age-standardised rate/100,000 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 Age-standardised rate/100,000 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 Years Years England Lambeth England Lambeth

Health inequalities: ethnicity

This chart compares the percentage of children in each ethnic group who are eligible for free school meals (2007). Eligibility for free school meals is an indicator of deprivation, and people who suffer more deprivation tend to have poorer health. Comparing deprivation by ethnic group helps identify potential health inequalities between groups.

Percentage and number of children eligible for free school meals

Ethnic Group Percentage Number Where the total school population in an ethnic group in White 2400 the local authority is less than 30, no data have been presented and the Mixed 1193 number column shows n/a. Where the number is less than 5, no Asian 451 percentage is shown.

England - average

Black 5662 Lambeth

Chinese & any other ethnic 613 group

0 10 20 30 40 50 60 70 80 90 100 Confidence intervals are shown for local data © Crown Copyright 2008 www.healthprofiles.info Lambeth Health summary for Page 4 Lambeth The chart below shows how people's health in this local authority compares to the rest of England. The local result for each indicator is shown as a circle, against the range of results for England which is shown as a bar. A green circle may still indicate an important public health problem.

Significantly worse than England average Not significantly different from England average Regional average England Average Significantly better than England average England England Worst Best No significance can be calculated 25th 75th Percentile Percentile * relates to National Indicator 2007

Local No. Local Eng Eng Eng Dom ain Indicator England Range Per Year Value Avg Worst Best 1 Deprivation 140357 51.9 19.9 89.2 0.0 2 Children in poverty * 21193 43.2 22.4 66.5 6.0 3 Statutory homelessness 1277 10.3 4.4 14.4 0.0 4 GCSE achievement (5 A*-C) * 793 56.0 60.1 35.8 82.7

Ourcommunities 5 Violent crime 8344 31.0 19.3 38.9 4.5 6 Carbon emissions * 1474 5.5 7.6 20.6 4.6 7 Smoking in pregnancy 266 6.6 16.1 38.8 4.4 8 Breast feeding initiation * 3687 90.9 69.2 33.2 90.9 9 Physically active children * 13147 81.5 85.7 63.3 99.2

health 10 Obese children * 253 13.3 9.9 16.1 4.9 Children's and and Children's young people's young 11 Children's tooth decay (at age 5) n/a 1.7 1.5 3.2 0.4 12 Teenage pregnancy (under 18) * 328 83.1 41.1 83.1 12.5 13 Adults who smoke * n/a 28.1 24.1 40.9 13.7 14 Binge drinking adults n/a 16.8 18.0 28.9 9.7 15 Healthy eating adults n/a 30.3 26.3 14.2 45.8 lifestyle 16 Physically active adults n/a 14.8 11.6 7.5 17.2 Adults' health and and health Adults' 17 Obese adults n/a 18.6 23.6 31.2 11.9 18 Under-15s 'not in good health' 588 12.2 11.6 20.8 6.4 19 Incapacity benefits for mental illness * 6760 34.6 27.5 68.6 8.4 20 Hospital stays related to alcohol * 901 388.1 260.3 741.1 87.6 21 Drug misuse 5029 25.5 9.9 34.9 1.3 22 People diagnosed with diabetes 10659 4.0 3.7 5.9 2.1 23 Sexually transmitted infections Disease and poor health poor Diseaseand 24 New cases of tuberculosis 137 50.0 15.0 102.0 0.0 25 Hip fracture in over-65s 128 433.9 479.8 699.8 219.0 26 Life expectancy - male * n/a 75.1 77.3 73.0 83.1 27 Life expectancy - female * n/a 80.1 81.6 78.3 87.2 28 Infant deaths 28 5.8 5.0 10.3 0.0 29 Deaths from smoking 300 274.2 225.4 355.0 139.4 30 Early deaths: heart disease & stroke * 209 116.2 84.2 142.4 39.7 causesdeath of

Life expectancy Life and 31 Early deaths: cancer * 231 130.4 117.1 167.8 76.7 32 Road injuries and deaths * 175 64.6 56.3 194.6 20.8

Note (numbers in bold refer to the above indicators) 1 % of people in this area living in 20% most deprived areas of England 2005 2 % of children living in families receiving means -tested benefits 2005 3 Crude rate per 1,000 households 2005-2006 4 % at Key Stage 4 2006-2007 5 Recorded violence against the person crimes (crude rate per 1,000 population) 2006- 2007 6 Total end user CO2 emissions per capita (tonnes CO2 per resident) 2005 7 % of mothers smoking in pregnancy where status is known 2006-2007 8 % of mothers initiating breast feeding where status known 2006-2007 9 % 5-16 year olds who spend at least 2 hrs/wk on high quality PE and school sport 2006- 2007 10 %. Schoolchildren in Reception year. 2006-2007 11 Average (mean) number of teeth per child which were actively decayed, filled, or had been extracted (age 5) 2005-2006 12 Under-18 conception rate per 1,000 females (crude rate) 2004-2006 (provisional) 13 %. Modelled estimate from Health Survey for England. 2003-2005 14 %. Modelled estimate from Health Survey for England. 2003-2005 15 %. Modelled estimate from Health Survey for England. 2003-2005 16 % aged 16+ 2005/06 17 %. Modelled estimate from Health Survey for England. 2003-2005 18 % who self assessed general health as ‘not good’ (directly age standardised) 2001 19 Crude rate per 1,000 working age population. 2006 20 Directly age and sex standardised rate per 100,000 pop. 2006-2007 21 Crude rate per 1000 population aged 15-64. No significance calculated for lower tier authorities. 2004-2005 22 % of people on GP registers with a recorded diagnosis of diabetes. 2005-2006 23 Indicator blank as data not yet available for local authorities. 24 Per 100,000 population (3-year average crude rate) 2004-2006 25 Directly age-standardised rate for emergency admission 2006/07 26 At birth, years 2004-2006 27 At birth, years 2004-2006 28 Rate /1,000 live births 2004-06 29 Per 100,000 population age 35+, directly age standardised rate. 2004-2006 30 Directly age standardised rate/100,000 pop. under 75 2004-2006 31 Directly age standardised rate/100,000 pop. under 75 2004-2006 32 Per 100,000 population (3-year average crude rate) 2004- 2006 For more information from your regional PHO, visit www.apho.org uk You may use this profile for non-commercial purposes provided the source is acknowledged. 'Source: APHO and Department of Health. © Crown Copyright 2008.'

LONDON BOROUGH OF LAMBETH

JOINT STRATEGIC NEEDS ASSESSMENT

Preliminary assessment Version 4

Lambeth JSNA – Preliminary Assessment 1 Version 4 November 2008 Page 6

Version control

Title Lambeth JSNA – Preliminary Assessment

Version: Version 4

Author Lambeth PCT and London Borough of Lambeth

Publication Date: November 2008

Target Audience: PCT CEs, NHS Trust CEs, SHA CEs, Foundation Trust CEs , Medical Directors, Emergency Care Leads, Community and voluntary sector, public.

Description: Lambeth Joint Strategic Needs Assessment – Preliminary Assessment to be published in November 2008 is the preamble to the final JSNA to be document in June 2009.

Superseded version/docs: Version 1, 2 and 3

Action Required: Approval from the JSNA steering group to publish the preliminary assessment. Closed.

Contact Details: Ruth Wallis – Director of Public health, Lambeth Primary Care Trust, NHS. Email - [email protected]

Jo Cleary – Director of Adult and Social Services, London Borough of Lambeth Email - [email protected]

Phyllis Dunipace – Director of Children and young people services, London Borough of Lambeth. Email - [email protected]

Lambeth JSNA – Preliminary Assessment 2 Version 4 November 2008 Page 7

Contents

No. Item Page No.

1. Introduction 4

2. Overview 11

3. Demographics 12

4. Health of Lambeth residents 30

5. Economic development 47

6. Children and young people 59

7. Community safety 75

8. Consultation with stakeholders 86

9. Review of needs assessments 91

10. Lambeth priorities 100

11. Sustainable community strategy priorities 115

Appendix I JSNA project plan 118

Appendix II Customer focus – Literature review 131

Appendix III Glossary 150

Lambeth JSNA – Preliminary Assessment 3 Version 4 November 2008 Page 8

1. Introduction

The concept of Joint Strategic Needs Assessment (JSNA) was introduced in the Department of Health’s (DH) Commissioning Framework for Health and well-being document published in March 2007. The Local Government and Public Involvement in Health Act (2007) [Clause 116] places a duty on upper tier local authorities and Primary Care Trusts (PCT) to undertake a Joint Strategic Needs Assessment (JSNA). This provision came into force in April 2008. The Director of Public Health, Director of Adult Social Services and Director of Children’s Services are jointly expected to take a lead in producing a strategic needs assessment through strong partnership.

The DH describes JSNA as ‘a systematic method for reviewing the health and well- being needs of a population, leading to agreed commissioning priorities that will improve health and well-being outcomes and reduce inequalities. The JSNA is expected to “describe the future health care and well-being needs of local population and the strategic direction of service delivery to help meet those needs”. A key element of JSNA is that it should involve all the important stakeholders in identifying needs and take appropriate actions to address those. The assessment process is expected to make use of existing information, identify gaps, actively engage stakeholders including patients and public for their views, understand local service provision; and most importantly, the outputs or findings be translated into actions for the commissioning and delivery of health and social care services, health improvement and well-being programmes and interventions.

The World Class Commissioning competencies emphasise the role of JSNA in driving the long term commissioning strategies of PCTs and their collaborative work with community partners including public and patient engagement. The JSNA is envisioned as a dynamic process periodically updated and is expected to contribute immensely as a key tool to achieve a shift towards commissioning to improve health and well-being outcomes and reduce inequalities.

This document reviews the demography and health profile of Lambeth residents and attempts to identify the health inequalities in terms of the wider determinants of health and well-being with due regard to the health and well-being outcomes. This document will identify priorities based on the current health and well-being status of Lambeth residents and review of existing needs assessments conducted. However provision of recommendations will follow consultations with stakeholder, mapping and understanding local services and review of evidence of effectiveness of interventions.

At present like in other boroughs, Lambeth PCT and the London Borough of Lambeth have set priorities which have been highlighted through the PCT’s Commissioning Strategy Plan 2007-2012 and the council’s Sustainable Community Strategy for 2008-2020. The JSNA will focus on prioritisation and joint commissioning for the next three years and we foresee this process to be a dynamic one where the outputs from the JSNA will inform the commissioning (and joint commissioning) cycle continuously and regularly starting 2008-09 and continuing for the next three years.

Lambeth JSNA – Preliminary Assessment 4 Version 4 November 2008 Page 9

National policies

The Department of Health’s (DH) Commissioning Framework for Health and well- being document published in March 2007 set out the concept of JSNA. There are three recent national documents that are most relevant to the development of this Commissioning Strategy:

1. Our Health, Our Care, Our Say. 2. Choosing Health. 3. Commissioning for Health and Well-being.

All are available in full on the Department of Health website. In addition there is a very wide range of guidance and technology appraisals from the National Institute of Clinical Excellence (NICE).

Finally, this section briefly considers the national health targets set by the Healthcare Commission against which PCT performance is measured.

Our Health, Our Care, Our Say

The White Paper on community services, ‘Our Health, Our Care, Our Say,’ emphasised the importance of good commissioning in providing integrated services, building on good local partnerships. The White Paper stated that NHS commissioners should commission for ‘health and well-being’ to ensure that health improvement is at the heart of the commissioning process. This 2006 White Paper aims to set a new direction for the health and social care system, changing the way services are delivered so that they are more ‘personalised’ and give people a ‘stronger voice so the they are the major drivers of service improvement’.

It aims to achieve this by a focus on providing better, higher quality care, providing an improved patient experience and providing better value for money. In doing so, particular emphasis is placed on:

- Enabling better health and well-being. - Better access to General Practice and community services. - Support for people with longer-term needs. - Delivering care and services closer to home.

The paper also highlights: - The importance of Practice Based Commissioning as a way of driving up quality, choice and value for money. - Encouraging innovation by greater patient and user choices. - Allowing different providers to compete for services.

Choosing Health – Making Healthy Choices Easier

This 2006 White Paper proposes improving health and health inequalities by supporting people to make healthy lifestyle decisions. There is a particular focus on protecting children and young people’s health. The paper has a number of chapters outlining how this is to be achieved, encompassing: - Children & Young People – starting on the right path. - Local communities leading for health. Lambeth JSNA – Preliminary Assessment 5 Version 4 November 2008 Page 10

- Health as a way of life. - A health-promoting NHS. - Work & health.

Commissioning Framework for Health & Well being

Central government has stated a clear intention to shift the focus of healthcare from treating sick people towards prevention and supporting well-being, not least to enable NHS funds to be spent on non- NHS services that have a preventive benefit for the NHS. This 2007 Commissioning Framework is designed to help commissioners achieve the overall objective of improving health and well-being, with the aim of looking further than just physical health problems in promoting well-being, to include issues such as social care, work and housing. The Framework proposes the following key actions: - A shift towards services that are personal, sensitive to individual need and that maintain independence and dignity. - A strategic reorientation towards promoting health and well being, investing now to reduce future ill health costs. - A stronger focus on commissioning service and interventions that will achieve better health, across health and local government with everyone working together to promote inclusion and tackle health inequalities. The aim is a move to look further than just physical health problems, to promoting well-being, which includes social care, work and housing.

NICE Guidance

The National Institute of Clinical Excellence (NICE) produces a wide range of well-researched clinical guidance and technology appraisals. The full details of these are available on the NICE website. Lambeth PCT’s has found NICE recommendations to be a very helpful tool in driving up quality and clinical outcomes on a consistent basis across providers.

Lambeth JSNA – Preliminary Assessment 6 Version 4 November 2008 Page 11

Lambeth PCT Commissioning Strategy Plan – 2007-2012

The PCT has identified its commissioning priorities for the next five years. The three historic priority areas mentioned under this paragraph have benefited hugely from the focus they have received and there is widespread confidence in the strategies that are currently in place to deliver improved outcomes and reduced inequalities in both the short and long term. However, for each of these priorities, there were particular areas that it was considered would benefit from further work over the next five years:

Children & Young People - pre-natal to under 5s Sexual Health - health promotion, prevention & screening Long Term Conditions – co morbidities and acute conditions

There was strong consensus that there were three new priorities emerging that the PCT would increasingly like to put more focus on in the next five years:

1. Staying Healthy Focused specifically on increasing investment over the strategic period in health promotion and prevention activity and in doing so on addressing key health risk factors in Lambeth such as smoking, obesity, alcohol and drug abuse.

2. Mental Health The PCT is a clear outlier in terms of prevalence of serious mental illness despite the fact it is also an outlier on how much it spends on mental health services. It was considered that current care pathways are complex and difficult for both users and professional to navigate through.

3. End of Life Care This represents an area where there is significant scope for service redesign and the development of more responsive and better quality models of care with greater choice for patients.

The PCT has completed work to develop draft-commissioning intentions for each for each of these six areas, plus the other key areas of commissioning work. In addition the PCT has considered further the implications of implementing the proposed commissioning intentions on primary and community services, as many of the proposals include a focus on shifting services from hospital-based settings to community-based settings.

In summary, in developing this 5 year Commissioning Strategy, Lambeth PCT has identified these key areas of work over the next five years:

1. Children & Young People Current priorities to be 2. Sexual Health‘ phased out’ over 3. Long Term Conditions the next 3 years

4. Staying Healthy New local priorities 5. Mental Health to be ‘phased in’

Lambeth JSNA – Preliminary Assessment 7 Version 4 November 2008 Page 12

6. End of Life Care over the next 5 years

a) Planned Care b) Unplanned Care Other key areas c) Primary Care and Community Services areas for commissioning d) Older People e) Learning Disabilities f) Physical Disabilities g) Substance Misuse h) Prison Health

Although the initial three priority areas are described as ‘phased out’ after three years, this certainly does not mean work in these areas will cease after this time. It simply highlights the PCT’s expectation that it will have developed comprehensive and robust plans and strategies for these areas within this period. Therefore, by the end of three years, the focus will move from planning to the on going implementation of strategies that will improve services and outcomes in Children and Young People, Sexual Health Long and Term Conditions.

The Lambeth JSNA will incorporate the needs assessment conducted to understand the priorities in Lambeth while continuing the work on identifying unmet needs of the population of Lambeth.

The PCT has also refreshed the Commissioning Strategy Plan for 2008/09 and details are included in the recommendations section towards the end of the document.

Lambeth JSNA – Preliminary Assessment 8 Version 4 November 2008 Page 13

Lambeth Sustainable Community Strategy – 2008-2020

In June 2008 the London Borough of Lambeth published its Sustainable Community Strategy. This strategy provides a shared framework for Lambeth First (the borough’s Local Strategic Partnership). It sets out an agreed approach to improving quality of life for the people who live and work in the borough and ensures organisations from the private, public and third sector pool their resources and work together to tackle problems jointly.

This strategy is an evidence driven document. The partnership has utilised a series of data sources such as the State of the Borough report, wide ranging community consultation and advice from policy experts to inform our strategic direction and guide us in identifying what we have to do to meet the needs of the borough. In reviewing this evidence we concluded that worklessness is the central issues that needs to be addressed within Lambeth. This is a relatively new concept which describes people who are out of work but who want a job. It includes people claiming unemployment benefits, people not currently in paid work who are seeking employment and those who are economically inactive.

We know that worklessness is one of the key causes of crime, poverty and social exclusion. These challenges often lead to lower than average skills/educational attainment, poor health and poor living environments. Clearly there is a cycle in motion which can only be addressed head-on and as a whole.

Within the Sustainable Community Strategy, Lambeth will seek to deliver the following seven outcomes - delivery of which will improve quality of life and tackle the causes/effects of worklessness:

x Lambeth is a great place to do business with higher levels of investment and business growth x Greater wellbeing for households through higher numbers of residents in employment x Children and young people are on the path to success through the provision of good quality education, training and jobs which reduces the risk of exclusion and offending. x Empowered, safe and cohesive places where people have the confidence to play active roles in their communities x Improved health and wellbeing of people which enables them to live active and independent lives x Lower levels of poverty and social exclusion in Lambeth by helping more of our socially excluded adults in employment, education and training x Mixed and sustainable communities with an increased supply of new homes, improved existing dwellings and a high quality physical environment

Underpinning the delivery of the Sustainable Community Strategy is our Local Area Agreement (2008-11) and wider partnership thematic strategies such as the Children and Young People’s Strategic Plan, Health and Wellbeing Framework and Safer Lambeth Partnership Delivery Plan.

Lambeth Local Area Agreement 2008-2011

In order to take forward the delivery of the Sustainable Community Strategy, Lambeth First completed the development of a new-look Local Area Agreement in June 2008. This agreement, between central government and Lambeth, sets out the top priorities for the Lambeth JSNA – Preliminary Assessment 9 Version 4 November 2008 Page 14 borough and should be seen as the first three-year delivery plan for the Sustainable Community Strategy.

The Local Area Agreement contains 35 designated performance indicators, 16 mandatory CYP performance indicators and two local performance indicators. Lambeth First will seek to make improvements against these indicators over the next three years. Specifically they focus on the following issues:

x Increasing businesses in the local area – to provide more job opportunities for Lambeth’s residents x Increasing basic and intermediate skills – to enable more of our residents to access the employment opportunities created locally and across the capital x Raising attainment and overall wellbeing of our young people – to ensure the next generation of Lambeth residents can access employment and fulfil their ambitions x Cutting crime and creating stronger communities – to tackle the number one concern of Lambeth residents and make Lambeth an attractive place to locate new businesses x Improving health and the independence of older people – to ensure the health of our residents is not a barrier to accessing employment/living the lives they wish to lead x Cutting poverty and social exclusion – by undertaking tailored/targeted training and employment support for vulnerable communities within the borough x Improving the quality/quantity of housing and improving the local environment

Lambeth First has moved rapidly to put in place mechanisms to deliver our Local Area Agreement and begin making a real difference to people’s lives on the ground. Progress is monitored by the Lambeth First Executive Delivery Group with performance updates provided at each meeting. . Once complete, the JSNA will central to the refresh the Sustainable Community Strategy and its Local Area Agreement. The analysis/needs assessment within the JSNA will be used to test the robustness of the Sustainable Community Strategy and the way in which we meet local need in the medium term through the Local Area Agreement.

Lambeth JSNA – Preliminary Assessment 10 Version 4 November 2008 Page 15

LAMBETH JOINT STRATEGIC NEEDS ASSESSMENT Preliminary Assessment 2008

2. Overview This Preliminary Assessment is the first step in the development of a JSNA for the borough of Lambeth. The assessment is underpinned by a provisional framework of Health and Wellbeing outcomes derived from those already defined within the statutory frameworks for Every Child Matters, Supporting People and CSCI Adult Social Care service provision. The information has been gathered through the JSNA Primary dataset which includes analysis and interpretation of various indicators.

In this first phase, available information on needs across Lambeth has been mapped against this framework to illustrate the current status of each outcome in the borough and to highlight any readily identified inequalities. Alignment with national priorities as set out in the National Indicator set has been clarified through provisional mapping of the indicators to the framework. Finally, capture of details of related, local priority actions has begun to show how work already underway through current strategies and plans is contributing to achievement of the outcomes.

The next stage of investigative work will be driven by commissioners from across the partnership. They will help to narrow the focus of the assessment by recommending areas which merit detailed review of the effectiveness of existing service provision. In parallel with this, assessment of market capacity (including skills base) of the borough will take place to identify any capacity building or workforce planning implications for future service delivery.

Further work on the provisional health and wellbeing outcome framework is already underway to refine it in partnership with patients, service users and community and voluntary organisations. Stakeholder engagement is simultaneously being taken forward and it is hoped that the newly formed Lambeth LINk (Local Involvement Nerwork) will help to take this aspect forward.

In view of the magnanimity of the task and provisional time table for delivery of elements of JSNA, it has been identified that gap analysis is crucial to having agreement of strategic recommendations jointly. This will require agreement on methodology of the JSNA so that it can be applied to areas of need. The JSNA methodology is being drafted which will offer a systematic method for reviewing the issues related to health and well-being faced by the local population leading to identification of met and unmet needs. This will then be applied to gap areas which will inform the next refresh of the Sustainable Community Strategy, due for 2011. The project plan sets out the provisional milestones to achieve this. It should be noted that a JSNA is a dynamic process and will follow parallel to commissioning cycles. The following chapters provide a profile of health and social care in Lambeth.

Lambeth JSNA – Preliminary Assessment 11 Version 4 November 2008 Page 16

3. Demography of Lambeth

Demographics Lambeth has the largest population compared to all the inner London boroughs. It is also one of the densely populated areas in the country with the fifth highest density in the UK. Lambeth has a highly mobile and ethnically diverse population. Over 60% of Lambeth’s population are not of UK origin and over 150 languages are spoken across the borough. The public health findings show that, on average, the population of Lambeth has performed worse of several health indicators than the rest of London or UK as a whole. The estimated resident population of Lambeth is 271,950 (Office for National Statistics, 2006 mid-year estimates (MYE)). The Greater London Authority (GLA) 2007 round interim projections (RIP) for population estimate for Lambeth for 2008 is 285,580. The general practice (GP) registered population in Lambeth is 361,680 (Apr, 2008) as seen in the graph below.

Lambeth Population estimates

400000 361680 350000

285580 300000 271950

250000 ONS - MYE 2006 GLA 2007 RIP estimates 200000 GP registered (Apr 2008)

150000

100000

50000

0 ONS - MYE GLA 2007 RIP GP registered 2006 estimates (Apr 2008)

The population make up shows approximately 52% within the age group 20-44 years showing a high proportion of young employable adults within the borough as seen in the population pyramid below. The population estimates are derived from the GLA 2007 Round interim projections for Lambeth.

Lambeth JSNA – Preliminary Assessment 12 Version 4 November 2008 Page 17

Population - Mid Year Estimate 2007

20-44 age group = 52% 85+ Age Bands 80-84 Females 75-79 Males 70-74

65-69

60-64

55-59

50-54

45-49

40-44

35-39

30-34

25-29

20-24

15-19

10-14

5-9

0-4

15 12 9 6 3 0 3 6 9 12 15 percent

The Greater London Authority’s (GLA) Data Management and Analysis Group (DMAG) released population projections for every local authority, borough and district within the UK were used in calculations. The GLA 2007 demographic projections use the structural results from the CLG (Communities and Local Government) based household projections. GLA offers borough level projections with inputs on fertility, future survival, migrations and uses updated estimates of recently completed development, the latest local trends in fertility and mortality and the latest data on migration affecting London. GLA incorporates ONS (Office for National Statistics) estimates and ONS national labour force projections, for population projection. The estimates projected by GLA have been used to understand the demographic change in the Lambeth population over the next five years and beyond.

The following graph compares the ONS, GLA and GP registered population in different age-groups in Lambeth.

Lambeth JSNA – Preliminary Assessment 13 Version 4 November 2008 Page 18

Population of Lambeth Age-Specific number

45,000

40,000 ONS GLA GP List 35,000

30,000

25,000

20,000

15,000

10,000

5,000

0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85-Plus Source: National Statistics; GLA 2007Round Ward Population Projections Age

According to GLA 2007 round interim projections, the population in Lambeth is expected to rise from 285,580 in 2007 to 295,505 by 2014 - a rise of 11,626 as seen in the table and graph below. Lambeth population projections (GLA) Males Females Persons 2005 139420 141487 280907 2006 140204 142834 283038 2007 140336 143543 283879 2008 140924 144656 285580 2009 141533 145734 287267 2010 142157 146784 288941 2011 142790 147812 290602 2012 143465 148849 292314 2013 144100 149816 293915 2014 144739 150765 295505 Source: GLA 2007 RIP projections

Lambeth JSNA – Preliminary Assessment 14 Version 4 November 2008 Page 19

Lambeth Population Projection - Source: GLA 2007 RIP

350,000

300,000

250,000 Lambeth population estimates Males 200,000 Lambeth population estimates Females 150,000 Lambeth population estimates GLA 2007 RIP projections 100,000

50,000

0 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Lambeth's population is ethnically diverse with the BME community accounting for 35% of the total population. Of this ethnically diverse population, black Caribbean and black African communities form the majority accounting for 26% of the total Black and Minority Ethnic (BME) population as shown in the graph below.

% Black and Minority Ethnic Communities in Lambeth Population - 2007 estimates

12.0% 11.5%

10.0% 9.8%

8.0%

6.0% 4.7% 4.0% % Population % 2.7% 2.0% 1.6% 1.8% 0.9% 0.9% 1.1% 0.0%

Indian Other Pakistani Chinese Black Other Bangladeshi Other Asian Black African Black Caribbean Ethnic background

Ethnic group projections from GLA suggest that the Black Caribbean group in Lambeth is likely to decrease by 2% of the total population in the next 25 years, compared to an increase in the Black African population by 15% and in the Asian population by 26%. These projections are based on the Census ethnic complexity of Lambeth’s communities and this pattern is not expected to change during the period 2008-2033.

Lambeth JSNA – Preliminary Assessment 15 Version 4 November 2008 Page 20

Population Projection by Ethnicity, 2006 to 2021

40,000

35,000

30,000

25,000

20,000 Number of people Number of

15,000

10,000

5,000

0 Black Black Black Other Indian Pakistani Bangladeshi Chinese Other Asian Other Caribbean African

2006 31,589 33,233 14,057 4,738 2,607 2,402 3,349 4,679 7,765 2026 29,239 38,354 16,138 4,521 2,784 2,940 3,969 6,009 11,060

Source:GLA 2005 Round Interim Ethnic Group Projections

GLA projections suggest Lambeth is to remain a young borough, with most increases within ethnic groups occurring in the 0-19 and 20-44 year old age ranges. It should be noted that these are long-term projections on ethnicity and there are social and political factors such as change in immigration laws, cultural balance; that can influence change in the ethnicity within the population over a period of time in any given area or region. Lambeth is one of the most densely populated boroughs in the country with a rapidly growing population that is projected to grow by 15% over the next 20 years. In 2006, the density (measured in terms of people occupancy per square kilometre) in Lambeth shows an increase compared with 2005 by 77 people per Sq. Km almost similar to that of London. People per Sq Area (Sq Km) MYE Km England 130281 50,726,382 389 London 1572 7,512,372 4779 Lambeth 27 271,950 10072

Lambeth JSNA – Preliminary Assessment 16 Version 4 November 2008 Page 21

Population Density

12000 10072 10000

8000

6000 4779

4000

People per square km square per People 2000 389 0 England London Lambeth

The 2007 Index of Multiple Deprivation (IMD) places Lambeth as the 5th most deprived borough in London and 19th most deprived in England. Poverty and social exclusion are some of the social challenges in the borough.

Changes in Deprivation ranking Lambeth and Comparable LAs 15 Brent 10 8 5 3 Hackney 0 Haringey -5 -3 -10 -5 Lambeth -15 -13 Lewisham -20 -18 Newham -25 -30 Southwark -35 -40 -35

Local Score Score authority 2007 Rank 2004 Rank Change Status

Brent 29.22 53 24.85 88 -35 Worsening Hackney 46.10 2 42.90 5 -3 Worsening Haringey 35.73 18 36.11 15 3 Improving Lambeth 34.94 19 32.21 32 -13 Worsening Lewisham 31.04 39 28.43 57 -18 Worsening Newham 42.95 6 39.33 11 -5 Worsening Southwark 33.33 26 34.74 18 8 Improving

Lambeth JSNA – Preliminary Assessment 17 Version 4 November 2008 Page 22

The above table describes the relative change in deprivation indices for the London cosmopolitan boroughs. It is notable that Lambeth is now the 5th most deprived borough in London. Lambeth has 177 super output areas (SOA’s) - with roughly 1,500 residents. In 2007, 26 (14.7%) of these were in the 10% most deprived in the country compared to 20 (11.3%) in 2004. Overall the most deprived are the areas of Coldharbour between, roughly, Railton Road and the Moorlands Estate; the Crown Lane area of Knights Hill ward and the Angell Town Estate in Coldharbour.

Mobility There is relatively high mobility within the Lambeth population compared to inner London boroughs. There appears to be high mobility both in the internal as well as international migration. Statistics show the net inflow of over 8.5% and a net outflow of over 10%. Economic advantage and cosmopolitan nature of Lambeth makes its population very mobile. It should be noted that this has a predominant influence on measuring impact of health interventions on the local population over a period of time. Migration

Internal Migration in Lambeth 2006-07 ONS publication 12.0%

10.0%

8.0%

6.0%

4.0%

2.0%

0.0%

-2.0%

-4.0%

-6.0%

-8.0%

-10.0%

-12.0% Camden Islington Lambeth Hac kney Newham Haringey Lewis ham Southwark Chels ea Fulham Westminster

Wandsworth Internal migration % In Tower Hamlets InternalKensington and migration % out Hammersmith and Internal migration (Inflow and Outflow) in Lambeth expressed as a percentage of population 2006-07

How many people live in Lambeth? STATUS x The latest mid-year population estimate (2006) from the Office for National Statistics is almost 272,000 people. This gives Lambeth the second highest population in Inner London, after Wandsworth (279,000), and 7th largest in Greater London. x The GLA 2007 population projections differ slightly, putting Lambeth’s population at 285,580 in 2008. x The population registered with GPs in Lambeth is 343,600 (Dec 2007). This is likely to be an overcount of Lambeth residents since it includes people Lambeth JSNA – Preliminary Assessment 18 Version 4 November 2008 Page 23

living in other boroughs but within the surgery catchment areas and people who have moved but not informed their doctors. PROJECTED CHANGES x ONS project total Lambeth population as 279,500 by 2028, a 5% increase on 2008. x GLA figures project the total population in Lambeth by 2028 as 322,300 people. This is an increase of 12.9% on 2008.

What is the male/female ratio of people in Lambeth? STATUS x According to the 2001 census, the gender split in Lambeth of 49% male and 51% female reflects that of London and the country more broadly. PROJECTED CHANGES x There is no agreement on the predicted ratio. The GLA population projections predict that the female population of the borough will increase to 52% by 2028 while the ONS projections show the opposite proportions (with males representing 52% and females 48%).

What ages are the people of Lambeth? STATUS x Almost half (45%) of Lambeth’s population is aged between 20 and 39 years, compared with just over a third (36%) for London and three in ten (28%) nationally1. x Approximately one in five of Lambeth’s population are aged 19 or under (59,711 or 21.9%). Of these, a third (19,455) are aged 0-4 years. (2006 Mid Year Estimate) x Lambeth has one of the highest teenage populations of the Inner London boroughs (18,522 13-19 year olds). x Older People aged 65 and over account for just 1 in 10 residents, a smaller proportion than elsewhere.

PROJECTED CHANGES x Both the GLA and ONS population projections predict a substantial increase of around 50% in the number of 50-69 year olds by 2028. x The ONS figures predict that by 2028, the 0-30 year old population will have dropped below 2003 figures. The GLA figures also project a 5% drop in the 19-34 year old population by 2028. x Moderate increases are projected in 5-16 age band, 45-49 age band, 70-74 age band (GLA figures only) and over 85 year olds.

What are their ethnic backgrounds? STATUS x According to the 2001 Census, a third (33%) of Lambeth's then population were from ethnic minorities, the seventh highest proportion in the country. x The borough has the second highest proportion of Black Caribbean residents of any UK local authority (after Lewisham) and the fourth highest proportion of Black African people (both 11%). x Around six in ten residents have a white ethnic origin.

1 2001 Census Lambeth JSNA – Preliminary Assessment 19 Version 4 November 2008 Page 24

x 10% of residents are from a mix of other ethnic groups, including 4% of residents from Asian backgrounds. x Unlike other London boroughs where it is the younger population who tend to come from diverse backgrounds, Lambeth has an ethnically complex older population. A third of those Lambeth residents born in the Republic of Ireland and a third of those born in Jamaica are of pensionable age (34% and 31% respectively). PROJECTED CHANGES x Projections from the GLA suggest that the Black Caribbean group in Lambeth is likely to decrease by 2% of the total population in the next 25 years, compared with an increase in the Black African population by 15% and in the Asian population by 26%. x Although the whole black Caribbean population is projected to decrease over time, Black Caribbeans aged over 60 years are projected to grow by a third (34%) by 2025. Similarly, Black Africans aged over 60 are projected to increase by 250%, though from a smaller baseline.

What languages do they speak? STATUS x Based on reports from schools, approximately 132 different languages are spoken by families in the borough, with the most common languages after English being Yoruba and Portuguese.

What are their faiths and beliefs? STATUS x There are fewer residents in Lambeth who identify themselves as religious than nationally (71% compared with 82% nationally). x 60% classify themselves as Christian, 5% as Muslim and 8% report belonging to another faith or religion.

What are their sexual orientations? STATUS x The 2006 residents’ survey asked a question about sexuality for the first time and found 3% of respondents identified themselves as lesbian, gay or bi-sexual. x This is likely to be an under representation since the LGBT matters report2 commissioned by Lambeth Council looking at lesbian, gay and bi and trans- sexual needs in the borough conservatively estimates that LGBT communities represent 5% of London’s population, with higher concentrations in inner-London areas like Lambeth.

Where do they live? x Lambeth is one the most densely populated areas in the country with almost all Super Output Areas in Lambeth having between 1,300 and 1,700 residents. x The areas of highest population density are mostly in the central part of the borough, in Brixton, Stockwell and Clapham. As expected, the areas with the lowest population density include parks or open spaces.

2 The full report can be accessed at http://www.sigmaresearch.org.uk/files/report2006c.pdf Lambeth JSNA – Preliminary Assessment 20 Version 4 November 2008 Page 25

How do they live? x There are 118,454 households in the borough (Census 2001) x In 2001, the percentage of lone parent households with dependent children was above London and national averages (12.1% compared to 8.9% and 7.1% respectively). x Households in Lambeth can be categorised using Mosiac data from Experian: Mosaic Type Mosaic Group Lambeth Percentage What areas have Name of Lambeth high numbers of Households these households? People living High density social Social tenants x Mursell and in social housing, mostly in South Lambeth housing, with inner London, with estates uncertain high levels of 26% x Stockwell Park employment diversity estate in deprived x Mawby Brough areas and Wyvill Estates Educated, Neighbourhoods Single house x Streets around young single with transient sharers Tulse Hill people living singles living in Station in areas of multiply occupied 21% x Flaxman Road, transient large old houses near population Loughborough Junction x Clapham Road Educated, Economically Successful 16% x Fawnbrake Lambeth JSNA – Preliminary Assessment 21 Version 4 November 2008 Page 26

young single successful singles, singles Ave/ Brantwood people living many living in Rd in Herne Hill in areas of privately rented x Clapham Rd/ transient inner city flats South Island population Place in Oval ward x Telford Avenue/ Salford Rd in Streatham Hill Educated, Young Young x Gubyon young single professionals and professionals Avenue, people living their families who and their Dorchester in areas of have gentrified families Drive in Herne transient terraces in pre 11% Hill population 1914 suburbs x Rosendale Road in Thurlow Park ward Close knit, Multi-cultural inner Multi-cultural x Milkwood Road inner-city city terraces second In Herne Hill town and attracting second generation ward manufacturing generation settlers 10% x Amesbury communities from diverse Avenue/ communities Hailsham Drive

Career Financially Wealthy professionals successful people senior x Dorchester living in living in smart flats professionals Drive/ sought after in cosmopolitan Brantwood locations inner city locations Road in Herne Career Highly educated 6% Hill professionals senior x Clapham Old living in professionals, town sought after many working in x Belevedere locations the media, politics road in Bishops and law x Wards can also be analysed between Mosaic categories. The table shows the percentage of households in each ward in each Mosaic category, with town centre and borough comparators. Green shows high numbers in an area, red low numbers.

North Lambeth Town North Bishop’s Oval Prince’s Vassall Lambeth Centre Lambeth Single house sharers 27.1 20.4 18.5 25.4 22.5 21.1 Successful singles 7.2 31.3 7.8 9.0 14.6 15.8 Young profs. & families 4.3 2.3 4.3 1.3 2.9 10.9 Social tenants 35.7 31.4 46.2 49.5 41.0 25.8 Wealthy senior profs. 13.8 7.3 8.9 2.0 7.5 6.0 Multi-cultural 2nd Gen. 1.6 2.8 1.8 7.8 3.6 10.0 Other 10.3 4.5 12.6 4.9 7.8 9.8

Brixton own Centre Brixton Cold - Herne Tulse Ferndale Brixton Lambeth Hill harbour Hill Hill Single house sharers 28.6 24.4 25.8 24.2 30.4 26.8 21.1 Successful singles 21.6 3.3 35.4 13.9 12.3 17.7 15.8 Young profs. & families 11.8 4.6 6.5 21.5 9.7 10.4 10.9 Social tenants 19.4 56.3 23.1 12.0 33.1 29.2 25.8 Wealthy senior profs. 0.5 0.1 0.7 5.4 1.2 1.4 6.0 Multi-cultural 2nd Gen. 12.9 6.6 5.2 11.6 6.6 8.4 10.0 Other 5.1 4.8 3.3 11.4 6.8 6.1 9.8

Clapham & Stockwell Claph. Claph. Larkhall Stock- Thorn- Claph & Lambeth Lambeth JSNA – Preliminary Assessment 22 Version 4 November 2008 Page 27

Town Centre Commn Town well ton Stock

Single house sharers 9.1 17.8 19.9 18.3 8.5 15.4 21.1 Successful singles 25.5 26.2 21.2 7.7 11.3 18.7 15.8 Young profs. & families 14.3 13.3 7.7 6.4 21.6 12.0 10.9 Social tenants 13.3 18.5 40.8 54.4 42.4 34.3 25.8 Wealthy senior profs. 29.7 12.9 3.8 6.3 2.4 10.7 6.0 Multi-cultural 2nd Gen. 1.2 8.3 4.2 2.5 4.9 4.3 10.0 Other 6.9 3.0 2.3 4.4 9.0 4.8 9.8

Streatham Town Centre St. Streat. Streat. Streat. Streat- Lambeth Leonard. Hill South Wells ham Single house sharers 19.5 25.0 12.4 19.0 19.5 21.1 Successful singles 25.6 16.8 1.9 22.5 17.5 15.8 Young profs. & families 18.0 16.5 7.0 20.5 16.0 10.9 Social tenants 0.6 10.1 2.5 13.4 7.0 25.8 Wealthy senior profs. 11.8 5.8 7.2 4.4 7.2 6.0 Multi-cultural 2nd Gen. 13.9 15.7 29.0 7.1 15.7 10.0 Other 10.7 10.1 40.0 13.1 17.0 9.8

Norwood Town Centre Gipsy Knight's Thurlow Norwood Lambeth Hill Hill Park Single house sharers 21.5 16.8 24.6 20.7 21.1 Successful singles 6.8 4.6 9.4 6.8 15.8 Young profs. & families 5.5 13.0 23.0 13.7 10.9 Social tenants 18.6 14.5 7.2 13.6 25.8 Wealthy senior profs. 2.7 1.1 9.1 4.1 6.0 Multi-cultural 2nd Gen. 30.8 27.2 9.9 23.0 10.0 Other 14.1 22.7 16.8 18.1 9.8 Mosaic September 2007

How many people move into/out of the borough? x It is difficult to be exact about the numbers of people moving in and out of the borough. The latest data, from the 2006 ONS Mid-Year population estimate is that total migration in 2006 was 22.4% of the population. This means that 10.9% of the population lived somewhere else the year before, and 11.5% moved out of the borough during the year. x The largest group of new job-seeking immigrants between 2002 and 2006 were from Poland with 3,550 new National Insurance registrations for Polish people living in Lambeth. x The next two largest totals for new NI registration were for immigrants from Australia (2,830) and Jamaica (1,750).

How many people have informal care responsibilities? x It is estimated from the 2001 census that there are approximately 18,500 carers in Lambeth (7% of the resident population). x Adult carers may be family, friends or neighbours, or may be partners within marriage or civil partnerships. Some care for those with mental health issues, physical or learning disabilities, whilst others have the additional complication of caring for someone with a dual/complex diagnosis. Some are parent carers caring for a child with a disability. x There are a number of young carers aged under 16 living in the borough. In 2001 there were 483 carers aged 0-15 in Lambeth (37 of these were providing 50+ hours of care per week). x In 2001 there were 106 carers aged over 85 in the borough (44 of these providing 50+ hours of care per week).

Lambeth JSNA – Preliminary Assessment 23 Version 4 November 2008 Page 28

x Many carers in Lambeth come from Black and Minority Ethnic (BME) communities, with a disproportionate number coming from the Asian communities. x The majority of carers (68%) provide 1-19 hours of care per week. 13% provide 20-49 hrs and the remaining 19% provide 50+ hrs each week. x In 2001 over half of carers worked full or part-time. 782 carers combined work with 50+ hours of care each week.

How many people are economically active? x 76.2% of the population of Lambeth is economically active; this compares with 75.1% for London and 78.6% nationally.3 x The overall employment rate in Lambeth is 68.5%. This compares with the London employment rate of 69.8% and a national figure of 74.3%. x 18.7% of the economically inactive are neither in employment nor unemployed and do not want a job; this compares with 18.0% for London and 16.1% nationally.4 x In May 2008, 3.6% of the resident working age population for Lambeth is claiming Job Seekers Allowance (JSA), compared with 2.6% for London and 2.2% nationally. At 63.10% of claimants, Lambeth is below the London average (65.50%) for claiming up to 6 months JSA, but higher than London averages for claimants over 6 up to 12 months and over 12 months.5 x Lambeth has 9.6% of young people aged 16-18 not in education, employment or training (NEET), compared with 9% for Southwark, 5.5% in Wandsworth and just 0.8% above the London average. This is down from 15.3% in 2004. Projections show that just 8.6 % will not be in paid work or preparing for it in Lambeth by 2009-10, closing the gap on the England average.6

How many people are claiming benefits? x The percentage of working age people on out of work benefits is16.5%. In the worst performing neighbourhoods this increases to 27.7% (Q2 2007). x Just over a third (36%)7 of children in Lambeth live in families on key benefits compared with 28% in London. Lambeth ranks as the 11th highest rate for this nationally and 27th out of the 33 London boroughs. x The number of people claiming incapacity benefits represents approximately 7.1% of the working age population (London 6.1% and nationally 7.2%). x The number of people claiming lone parent benefits represents approximately 4.0% of the total working age population (compared with London 3.1% and nationally 2.0%).

3 NOMIS Official Labour Market Statistics (Oct 2006 – Sep 2007). Percentages are for those of working age (16-59/64). Economically active are people who are either in employment or unemployed. 4 People who are neither in employment nor unemployed includes, for example, all those who were looking after a home or retired. Also people wanting a job, these are those not in employment who want a job but are not classed as unemployed because they have either not sought work in the last four weeks or are not available to start work. 5 The Jobseeker's Allowance (JSA) is payable to people under pensionable age who are available for, and actively seeking, work of at least 40 hours a week. 6 London Borough of Lambeth. CYPS Performance Digest Report. March 2008 7 Government Office for London /DWP August 2008, based on 5% sample. Lambeth JSNA – Preliminary Assessment 24 Version 4 November 2008 Page 29

How is Lambeth ranked on deprivation measures? x Lambeth as a whole is slightly more deprived than Inner London, and considerably more deprived than England as a whole. x It is ranked overall the 19th most deprived local authority district in England, compared with 23rd in 2004. x North Lambeth is the most deprived town centre with all wards other than Bishops wholly in the 30% most deprived in the country. x Coldharbour is the most deprived ward in the borough with 60% of its area classified in the 10% most deprived nationally.

How do the people of Lambeth rate their own health and well-being? x Just over three quarters of Lambeth residents rate their own health as good or very good. This rises to 89% among private renters (compared with 71% among council tenants), 90% among 18-34 year olds and 86% among AB residents and full time workers. Health ratings are unsurprisingly lower among people with long-term limiting illness (27%) and older people (55%). Black Caribbean residents (69%) are less positive about their health. x In 2001 only 55% of Carers assessed their own health as “Good”.

Which groups of people within Lambeth could be considered to be vulnerable? x The main groups of people in the borough who could be considered to be vulnerable are: older people with support needs including the frail elderly people with a long-term limiting illness people with mental health problems including mentally disordered offenders people with learning disabilities people with physical disabilities or sensory impairments. people with substance misuse (drug and/or alcohol) problems carers women at risk of domestic violence homeless people rough sleepers travellers offenders/people at risk of offending people with HIV/AIDS refugees and asylum seekers x The groups of children and young people who are vulnerable to doing less well against some or all of the national outcomes include: Looked After Children young people leaving care young people at risk of harm young carers children with special educational needs or disabilities children who are very mobile, e.g. traveller and refugee children children from different faith groups Lambeth JSNA – Preliminary Assessment 25 Version 4 November 2008 Page 30

some BME children and young people young people at risk of offending and misusing substances teenage parents children from low income families. Older people x Lambeth has a relatively lower number of older people compared with other areas though this is expected to change with the numbers of those aged over 85 expected to increase (see age projections above). x More older people are helped to live at home in Lambeth than compared with both London and England (107 per 1,000 population in 2006/07 compared with 91 in England). People with a long-term limiting illness x In 2001 there were 36,763 residents who classified themselves as having a long-term limiting illness (14%) of the following ages:

0-15 2,334 16-44 10,766 45-59 8,376 60-64 3,324 65-74 5,824 75+ 6,141 Total 36,765 x This is a smaller proportion of adults living with long-term illness than is seen across England (21%). People with mental health problems x Lambeth has a higher prevalence of mental health needs than other comparative areas of London8. x 4,169 people are currently recorded with severe and enduring mental health needs under the Care Programme Approach (CPA). x An estimated 37,000 people are engaged with primary care for treatment for varying degrees of anxiety and depression. x There are disproportionately high numbers of people with mental health needs within ethnic minority communities, particularly African Caribbean males. x The proportion of people with Severe Mental illness and dual diagnosis of substance misuse is very high at 50%. People with learning disabilities x In Sept 2007 there were 863 adults on the Lambeth register for people with learning disability. x In Sept 2007 ethnic minorities made up 19% of people with learning disabilities aged 50-59 years, but 60% of those aged 20-29 years and 70% of the 0-9 age group. People with physical disabilities or sensory impairments x There is not yet a detailed picture of the number of Lambeth residents with physical disabilities or sensory impairments.

8 Bexley, Bromley, Greenwich, Lewisham, Southwark. Lambeth JSNA – Preliminary Assessment 26 Version 4 November 2008 Page 31

People with substance misuse problems x The Home Office estimates 5,029 Problematic Drug Users (PDUs) of opiates and/or crack cocaine in Lambeth (estimate based on 2004/05 data). The total number of Problematic Drug Users PDUs known to treatment in 2006/07 was 1,991. x 2,033 drug users accessed treatment during 2007/08. 149 of these (7.3%) were aged 17 or under. 79% of individuals were retained in structured treatment for more than 12 weeks. x 72% of adult drug users in treatment in Lambeth are male (28% female). x The proportion of BME clients in treatment is not significantly different from the proportions in Lambeth’s overall resident population. x 13% of those accessing treatment for the first time in 2007/08 had a dual diagnosis of mental health problems alongside their substance misuse issues. x CHAIN data for Lambeth shows that 88% of all rough-sleepers have alcohol and/or drug support needs. This is notably higher than the proportion across other London boroughs.9 x It is estimated that 23-24% of Lambeth’s population drink excessively and that Lambeth has a higher rate of alcohol related hospital admissions than London and England. The largest single categories of hospital admissions are for alcohol related disorder and then liver disease.10 x The general profile for an excessive drinker in Lambeth is that of a white male. Carers x It is estimated from the 2001 census that there are approximately 18,500 carers in Lambeth (7% of the resident population). x There are a number of young carers aged under 16 living in the borough. In 2001 there were 483 carers aged 0-15 in Lambeth (37 of these were providing 50+ hours of care per week). Women at risk from domestic violence x Research suggests that 13% of women experience domestic violence at some point in their lives. x The National Domestic Violence helpline received 322 calls from Lambeth women between Jan and June 2005. This was the highest rate of any London borough and 100 more calls than the second highest borough. x The Gaia Domestic Violence refuge centre supported 626 Lambeth women between May 2006 and March 2008. Homeless people x The number of households accepted as being homeless has been successfully reduced from 1,651 to 735 over the last 5 years. x There are currently 2,100 people waiting for an offer in Temporary Accommodation. x Lambeth has one of the highest rates of teenage homelessness, with figures that are above London and national averages. Rough sleepers x There are approximately 13 people sleeping rough in Lambeth on any one night.

9 CHAIN (2007) 10 Alcohol Needs Assessment 2006/07 Lambeth JSNA – Preliminary Assessment 27 Version 4 November 2008 Page 32

x CHAIN data for Lambeth shows that 88% of all rough-sleepers have alcohol and/or drug support needs. This is notably higher than the proportion across other London boroughs.11 Travellers x The GLA estimates 42 Travellers in Lambeth based on estimated national population apportioned to Lambeth on basis of population.

Offenders/people at risk of offending x An estimated 1500 Lambeth residents are received into London prisons a year.12 The probation caseload is around 2500 (60% custody, 40% community). x There are higher proportions of BME offenders from Lambeth than the London average (25% British White vs. 37% average and 33% Black Caribbean vs. 15% average).3 x Of Lambeth offenders who had an Offender Assessment completed (267), the average need score was 8th highest of the 32 London boroughs (City of London excluded). The rank order of criminogenic needs for Lambeth is very similar to the London average, though Lambeth has a higher % of its offenders with a need in most areas and within employment, training and education. It has one of the lowest scores for alcohol with only 18% (average 24%) of its offenders assessed as having an alcohol need linked to their offending.3 People with HIV/AIDS x The HIV and AIDS reporting system (HARS) assesses national prevalence at 801 patients diagnosed and receiving care per 100,000 of population. Refugees and asylum seekers x The GLA estimates 105 asylum seekers, calculated as an apportionment to Lambeth of national applications for asylum on the basis of population size. Looked after children x There were 525 looked after children (LAC) in Lambeth in 2007/08. The number of LAC exceeds London and national averages but has reduced from 660 in 2005/06. Young people leaving care x Young people at risk of harm x At 31 March 2007 there were 62 children aged 4 and under and 113 children aged 5-15 on the child protection register (CPR).13 By 2007/08 there were 245 in total. The numbers of children on the CPR exceed London and national averages. Children with special educational needs or disabilities x 27% of pupils have some form of special educational need. x Data from the ICOUNT Disability Register in 2007 shows that there were 621 registered children with disabilities and a further 324 who are thought to be eligible for the Register. Estimates by the PCT, however, suggest that

11 CHAIN (2007) 12 London Area Office LISAR (initial screening and referral) data 2007 13 London Borough of Lambeth. Childcare Sufficiency Assessment. 2007 Lambeth JSNA – Preliminary Assessment 28 Version 4 November 2008 Page 33

there are approximately 1,000 children under 5 with a disability or SEN. There are also 5,390 children aged over 5 who have been seen by a health professional in relation to a disability or SEN. Teenage parents x

On which issues does Lambeth differ significantly from the national average? (as reported in the 2001 census) x The Census Area Classifications categorise Lambeth as London Cosmopolitan, similar to Southwark, Lewisham, Hackney, Islington, Haringey and Brent. The classification is generated using census variables. x Census variables with a proportion in Lambeth far below the national average are: People aged between 45 and 64 Pensioners who live alone Households with two adults and no dependent children People who live in a detached house People who live in a two car household People who provide unpaid care Women who work part-time People who work in manufacturing. People who work in the wholesale or retail trades x Census variables with a proportion in Lambeth far above the national average are: Children aged four or under People aged between 25 and 44 People who identify themselves as Black African, Black Caribbean or Other Black People who were not born in the United Kingdom People who are not living in a couple and are separated, widowed or divorced People who live alone but who are not Pensioners People who live in lone parent households People who rent their accommodation privately People who live in flats Average no of people per room People with a higher education qualification People who take public transport to work People who are students People who are unemployed Men who work part-time.

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4. Health of Lambeth residents?

Overview x Just over three quarters of Lambeth residents rate their own health as good or very good. This rises to 89% among private renters (compared with 71% among council tenants), 90% among 18-34 year olds and 86% among AB residents and full time workers. Health ratings are unsurprisingly lower among people with long-term limiting illness (27%) and older people (55%). Black Caribbean residents (69%) are less positive about their health. x In general, the health of people in Lambeth is significantly poorer compared with the England average x Life expectancy in males and females is lower and deaths from smoking and premature deaths from circulatory diseases and cancer are higher than the rest of England. x Lambeth is amongst the most deprived areas nationally and the average deprivation in all wards is higher than the average deprivation in all England wards. x Smoking prevalence is high in Lambeth especially in deprived areas and in people lower socio-economic group and in manual occupation. The deaths attributable to smoking every year are also high in Lambeth compared to the national average. x Lambeth has higher than average levels of physical activity probably resulting in lower percentage of obesity in adults. However, obesity in 10-11 year olds is very high with 1 in 4 children obese in that age group. x The all age all cause mortality has fallen significantly in the past few years but it remains above the England and London average. x The rate of inequality between Lambeth residents and the England and Wales average has reduced for women, with the cancer reduction particularly notable, bringing Lambeth down to E&W averages. Further challenges remain in relation to securing an equivalent improvement in men's health. x Exponential projection using number of births in previous year, shows a growing trend in births over the next five years. x Birth weight (Awaiting returns from hospital (Acute and Community) x Crude birth weight (Awaiting returns from hospital (Acute and Community) x The infant mortality rate is 5.7 children per 1,000 live births. This is compared with 4.9 and 5 per 1,000 in London and England.14 The infant mortality rate is reducing and the inequality gap is getting narrower plans are to further reduce this gap further over the next five years. x The gap in the death rates from cardio-vascular diseases between men and women is slightly worsening while the gap in deaths rates from cancer in men in Lambeth and England is widening. x Coronary heart disease remains the single and preventable cause of all deaths in Lambeth followed by cerebro-vascular diseases (stroke), cancer and chronic lung diseases. x The top 10 causes of hospital admissions in Lambeth in 200708 were: Pregnancy related conditions, Digestive disorders, Genito-Urinary system, Neoplasms, Injuries and Poisonings, Circulatory diseases, Respiratory diseases, Musculoskeletal disorders, Eye related, Nervous System. Overall there has been a fall in total

14 London Borough of Lambeth. Draft State of the Borough: The evidence base supporting the Sustainable Community Strategy. 2008. Lambeth JSNA – Preliminary Assessment 30 Version 4 November 2008 Page 35

admissions in 2007-08 over 2006-07 and admissions due to circulatory diseases and skin have fallen in comparison to the total admissions in 2007-08. x Lambeth has a higher incidence of mental illness than other cosmopolitan areas in London. There were approximately 4500 people with severe and enduring mental illness receiving treatment through a care programme approach via the integrated mental health service in Lambeth.

STATUS x In general, the health of people in Lambeth is significantly poorer than the England average. x Life expectancy in males and females is lower and deaths from smoking and early deaths from heart disease, stroke and cancer are higher than the rest of England. x Just over three quarters of Lambeth residents rate their own health as good or very good. This rises to 89% among private renters (compared with 71% among council tenants), 90% among 18-34 year olds and 86% among AB residents and full time workers. Health ratings are unsurprisingly lower among people with long-term limiting illness (27%) and older people (55%). Black Caribbean residents (69%) are less positive about their health. Life expectancy x A baby boy born in Lambeth during 2004-06 could on average expect to live 75.1 years and a baby girl could expect to live to 80.1 years15. Ten years ago these figures were 71.3 and 78.1 years respectively, so life expectancy has lengthened and gap between the sexes has narrowed. However, a baby boy in Lambeth lives 2.2 years less and a baby girl 1.5 years less than the equivalent babies in England and Wales where males live to 77.3 years, and females to 81.6 years on average. Birth rate x Exponential projection using the number of births in the previous year shows a growing trend in births over the next five years. x Birth weight / Crude birth weight (awaiting returns from hospital (Acute and Community)) Mortality rate x The infant mortality rate is 5.8 children per 1,000 live births.1 This compares with 4.9 and 5 per 1,000 in London and England.16 The infant mortality rate is reducing and the inequality gap is getting narrower with plans in place to further reduce this gap over the next five years. x The all age all cause mortality rate in Lambeth has fallen significantly in the past few years but it remains above the England and London average. x Coronary heart disease remains the single most preventable cause of all deaths in Lambeth followed by cerebro-vascular diseases (stroke), cancer and chronic lung diseases. x The rate of health inequality between Lambeth residents and the England and Wales average has reduced for women, with the cancer reduction particularly notable, bringing Lambeth down to E&W averages. Further challenges remain in relation to securing an equivalent improvement in men's health.

15 Department of Health area profile 24 June 2008. 16 London Borough of Lambeth. State of the Borough: The evidence base supporting the Sustainable Community Strategy. 2008. Lambeth JSNA – Preliminary Assessment 31 Version 4 November 2008 Page 36

x The gap in the death rates between men and women from cardio-vascular diseases is slightly worsening while the gap in deaths rates from cancer in men in Lambeth and England is widening.

Hospital admissions x The top 10 causes of hospital admissions in Lambeth in 200708 were: Pregnancy related conditions Digestive disorders Genito-Urinary system Neoplasms Injuries and Poisonings Circulatory diseases Respiratory diseases Musculoskeletal disorders Eye related Nervous System. x Overall there has been a fall in total hospital admissions in 2007-08 over 2006-07 and admissions due to circulatory diseases and skin have fallen in comparison to the total admissions in 2007-08.

x Diabetes – The case-detected prevalence of diabetes in Lambeth (2.95%) is lower than the national average (3.6%) and detection in primary care is good with up to 90% cases detected and registered. However the prevalence models provided by the APHO (Association of Public health observatories) shows a prevalence of 3.8% meaning around 1% of diabetics are still undetected in the population. x Circulatory: CHD – The case detected prevalence of CHD (Coronary Heart disease) in Lambeth is approximately 1.4% however the modelled prevalence is around 3% meaning there are over 5000 cases in Lambeth with CHD and who need to be on the CHD register in primary care and who need to be on preventative medication. x Circulatory: Stroke – Although the prevalence of stroke is lower in Lambeth the directly standardised mortality rate from stroke although declining is still higher than the England average. x Cancer: Cancer is the third main cause of death in Lambeth and the incidence of cancer in Lambeth for males is higher than the England average while it is similar for females. x Cancer: by site (analysis is being done) x The POPPI (Projecting Older People Population Information) system estimates approximately 11,044 people aged 65 and over with a limiting long-term illness in Lambeth. Projections show a reduction in 2010 through 2015 followed by a rise of approximately 5-7% in 2020 through 2025. x Infectious: hospital-acquired infections – the rate of health care acquired or hospital acquired infections is lower than the London and national average in Lambeth. x Dental: decay – Approximately 9% of 12 year olds, 28% of 5 year olds in Lambeth have active dental decay which is lower than the national average. x Aural x Optical Lambeth JSNA – Preliminary Assessment 32 Version 4 November 2008 Page 37

x Trauma: falls – The mortality rate (directly standardised rate) from accidental falls is almost twice that of the London average when measured on a three rolling average. The rate in males is more than 2.5 times that of the female rate. x Musculo-skeletal: arthritis x Musculo-skeletal: osteoporosis x Pharmaceutical

NATIONAL PRIORITIES Reference Indicator NI 137 Healthy life expectancy at age 65 NI 120 All-age all-cause mortality rate NI 119 Self-reported measure of people’s overall health and wellbeing

Are they physically healthy? STATUS Limiting long-term illness x The POPPI (Projecting Older People Population Information) system estimates approximately 11,044 people aged 65 and over with a limiting long-term illness in Lambeth. Projections show a reduction in 2010 through 2015 followed by a rise of approximately 5-7% in 2020 through 2025. Diabetes x The case-detected prevalence of diabetes in Lambeth (2.95%) is lower than the national average (3.6%) and detection in primary care is good with up to 90% cases detected and registered. However the prevalence models provided by the APHO (Association of Public Health Observatories) show a prevalence of 3.8% meaning around 1% of diabetics are still undetected in the population. Circulatory: Coronary Heart Disease (CHD) x The case detected prevalence of CHD in Lambeth is approximately 1.4%. However the modelled prevalence is around 3% meaning there are over 5,000 cases in Lambeth with CHD who need to be on the CHD register in primary care and who need to be on preventative medication. x 31 Lambeth residents were admitted to hospital with an acute myocardial infarction (heart attack) between April and December 07; this would equate to 41 people over 12 months. x 73 people were admitted to hospital with heart failure during the same period (equating to 97 people over 12 months). Circulatory: Stroke x Stroke is the third most common cause of death in England and Wales, after heart disease and cancer (The Stroke Association). x Although the prevalence of stroke is lower in Lambeth and although the directly standardised mortality rate from stroke is declining, it is still higher than the England average. x From April to December 07, 120 Lambeth residents suffered a stroke and were admitted to hospital, this equates to 160 people annually. Cancer: General

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x Cancer is the third main cause of death in Lambeth and the incidence of cancer for males in Lambeth is higher than the England average; it remains similar for females. Cancer: by site x (awaiting analysis) Infectious: hospital-acquired infections x The rate of health care-acquired or hospital-acquired infections in Lambeth is lower than the London and national average. Infectious: respiratory x The rate of new cases of tuberculosis in Lambeth is significantly higher than the England average but in line with the London average. Preventative: Immunisations x In Lambeth, rates of immunisation among children are amongst the lowest in the country, with primary immunisations at two years of age in Lambeth at approximately 82%, compared with 88% across London and 94% in England. x Immunisation take-up has turned a corner as resistance to the MMR jab has abated. However, the London Assembly in 2003 found that take-up of the first and second MMR together by a child’s fifth birthday remained at less than half in Lambeth (48%), Greenwich (33%), Bromley (47%), and Lewisham (47%). These poor take-up statistics compare with over 70% in Harrow and Havering. Dental: decay x Approximately 9% of 12 year olds and 28% of 5 year olds in Lambeth have active dental decay; these rates are in line with the average for London. Trauma: falls x Approximately one third of the population aged 65 yrs and over fall each year. This means approximately 6,900 people in Lambeth. Falls are the commonest cause of injury and accident-related death in this age group. 5- 10% sustain a fracture. x It is estimated that one in two women and one in five men will suffer a fracture after the age of 50. x According to the National Osteoporosis Society, one year after an osteoporotic fracture, the majority of patients are not prescribed any pharmaceutical agents for the prevention of a further fracture. This is despite the fact that drug treatments have been shown to reduce the risk of fractures by up to 50%. x The mortality rate (directly standardised rate) from accidental falls in Lambeth is almost twice that of the London average when measured on a three year rolling average. The rate in males is more than 2.5 times that of the female rate. x POPPI (Projecting Older People Population Information) estimates that by 2008 approximately 475 hospital admissions in Lambeth of people over 65 each year will be as a result of a fall.

SIGNIFICANT INEQUALITIES IDENTIFIED x Although people aged over 65 comprise 8.75% of the population, they account for 12% of A&E attendances and 19% of SELDOC calls. x African-Caribbean and South Asian people are at least five times more likely to have diabetes than the white population (Diabetes UK).

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NATIONAL PRIORITIES Reference Indicator NI 121 Mortality rate from all circulatory diseases at ages under 75 NI 122 Mortality rate from all cancers at ages under 75 Diabetes: Modelled and/or recorded prevalence implications (e.g. Life expectancy) CHD mortality CHD Modelled and/or recorded prevalence Hospital admission rate for MI Admissions for cardiac revascularisation Stroke mortality Hospital admission rate for Stroke Cancer registrations COPD Modelled and/or recorded prevalence COPD mortality TB notifications %DMFT in 5-yr olds Hospital admissions for fractured neck of femur Admissions for hip and knee replacement Aural Optical Musculo-skeletal: arthritis Musculo-skeletal: osteoporosis Pharmaceutical

CURRENT RELEVANT STRATEGIC PRIORITIES x Long term conditions x End of life care x Sexual health x Mental health

Do they enjoy good mental health? STATUS x Lambeth has a higher incidence of mental illness than other cosmopolitan areas in London. There were approximately 4,500 people with severe and enduring mental illness receiving treatment through a care programme approach via the integrated mental health service in Lambeth. Emotional health x Lambeth schoolchildren listed exams (57%), friendships (41%) and getting into trouble (43%) as the 3 things they worried about the most (Tell Us 2 survey 2007). Dementia x In Lambeth over 1500 people are estimated to have dementia and are this number is projected to rise to 1700 by 2025. Of these, it is predicted that up to 700 individuals may not be in contact with mental health services. Lambeth JSNA – Preliminary Assessment 35 Version 4 November 2008 Page 40

Typically the BME community have a higher prevalence of early onset dementia (6.1% compared to 2.2% for rest). x POPPI (Projecting Older People Population Information) estimates that by 2008 there will be 1,598 over 65s in Lambeth predicted to have dementia, of which 1,358 (84%) will be over 75. x The NICE Clinical Guideline on Dementia gives a prevalence of 30% for those over the age of 85 developing dementia. This would mean an increase from 908 in 2001 to 1032 in 2010 in the over 85s. Depression x It is predicted that 1 in 6 individuals in Lambeth suffer from depression. Suicide x The mortality rate (standardised mortality ratio) from suicides and undetermined injuries is declining in Lambeth but is still higher than the national average.

SIGNIFICANT INEQUALITIES IDENTIFIED x The BME community have a higher prevalence of early onset dementia (6.1% compared with 2.2% for rest).

NATIONAL PRIORITIES Reference Indicator NI 50 Emotional health of children NI 51 Effectiveness of child and adolescent mental health (CAMHs) services NI 58 Emotional and behavioural health of looked after children

CURRENT RELEVANT STRATEGIC PRIORITIES x Mental health (copy from LPCT CSP)

Are they sexually healthy? STATUS Teenage pregnancy x From the baseline year of 1998, Lambeth's teenage conception rate rose year on year, peaking in 2003. x However, data for 2004 and 2005 demonstrates a decline in the conception rate. Data for 2005 shows Lambeth’s under-18 conception rate was 84.1 per 1,000 girls aged 15-17. This compares with the 2003 rate (103.3 per 1,000) and 2004 rate (85.2 per 1,000) and represents a reduction of 6.6%. from the 1998 baseline The 2005 rate compares with 46 per 1,000 for London and 41.3 per 1,000 for England. x The latest provisional data for quarter one in 2006 shows a further decline. In addition to this, the difference between Lambeth’s conception rate and the national average has narrowed from nearly two and a half times in 2003, to nearly twice in 2005. Based on a review of 2006 data, early indications from the Government Office for London (GOL) are that Lambeth is no longer an accelerated borough under the review process. GUM services x Lambeth JSNA – Preliminary Assessment 36 Version 4 November 2008 Page 41

HIV/AIDS x Contraception x 20% of General Practitioner (GP) practices have achieved “Young People Friendly” status regarding facilitating access to preventative and treatment services for sexually transmitted infections. Abortion x The legal abortion rate for under 18s in Lambeth in 2006 was much higher than average with 44 terminations per 1,000 of the population compared with 24 in London and 18 in England. Maternity services x SIGNIFICANT INEQUALITIES IDENTIFIED x NATIONAL PRIORITIES Reference Indicator NI 112 Under 18 conception rate NI 113 Prevalence of Chlamydia in under 25 year olds NI 126 Early access for women to maternity services Under 18 Repeat conceptions Under 16 conceptions Under 16 Repeat conceptions KC60 GUM STI data, particularly gonorrhoea Offer of an appointment at a GUM service within 48 hours New diagnoses of HIV/AIDS Late diagnosis of HIV Long acting reversible contraception methods as a % of all contraception Access to NHS funded abortions before 10 weeks gestation CURRENT RELEVANT STRATEGIC PRIORITIES x Sexual health (copy from LPCT CSP)

Do they have healthy lifestyles? STATUS x The CACI Health ACORN profiles for 2006 show Lambeth as the 4th worst borough in London for unhealthy lifestyles. x 97% of Lambeth schools are participating in the National Healthy Schools Programme with 58% of our schools achieving the Healthy Schools status as at December 2006. 50% of those schools accredited with HSS are taking part in the extended healthy schools model as part of the LAA stretch target. x From our consultations and survey results, however, we know that local children and young people want more access to out of school leisure and sporting activities as well as more general information about healthy lifestyles, including healthy eating, drugs, alcohol, and local facilities. Diet and Obesity x It is estimated that 30.3% of Lambeth adults eat a healthy diet. This is in line with the average for London and above the national average of 26.3%.17

17 Modelled estimate from Health Survey for England. Lambeth JSNA – Preliminary Assessment 37 Version 4 November 2008 Page 42

x The level of obesity in Lambeth adults (18.6%) is lower than the England average (23.6%), probably as a result of the higher than average levels of physical activity in Lambeth. However obesity in children aged 10-11 is high with up to 1 in 4 obese. x 13.3% of children at reception level are obese in Lambeth compared with 11% in London, and 9.9% in England.18 Breastfeeding x The average rate of breastfeeding is 90.9%, although rates fall significantly after hospital discharge. These rates are higher than the national and London averages. 1 Hypertension x Uncontrolled hypertension increases the risk of heart disease, diabetes, stroke and vascular dementia. In December 2007 30,948 Lambeth residents were on the hypertension register, and of these, 12,795 (41%) were uncontrolled. x The prevalence of hypertension in Lambeth is approximately 9.9% compared with the modelled prevalence of 19.9% which means there could be up to 34,000 individuals in Lambeth who have hypertension but have not been detected and who are not being treated. However these estimates have to be used with caution and detection and treatment of hypertension is monitored through primary care. Exercise x Sports participation levels are the 4th highest in London and the UK.19 x The number of visits to Lambeth leisure centres during 2007-08 was 2.19 per head of the population.20 x 81% of residents live within 5 mins. of a public open space (see map below). x 25.6 % of adults regularly participate in a minimum of 30 minutes of moderate intensity exercise at least 3 times a week. 21 x Of the 48,900 men aged 30-44 in Lambeth, 2.6% participate 3 x week, 2.2% participate 1-2 x week, 3.5% are inactive22 x Lambeth has: 30,980 people aged 60+ 11% participate 3 x week, 7% participate 1-2 x week, 76% are inactive. 8 x Of the 52,759 people on low incomes in Lambeth, 18% participate 3 x week, 11% participate 1-2 x week and 63% are inactive. x Of the 95,726 people from black and minority ethnic communities in Lambeth, 1.9% participate 3x week, 1.9% participate 1-2x week and 5.2% are inactive. 8

18 London Borough of Lambeth. State of the Borough: The evidence base supporting the Sustainable Community Strategy. 2008. 19 Sports England Active People Survey 20 ECCS Performance Digest 2007-08 21 Sports England Survey 2005-06. http://www.sportengland.org/061206_active_people_london_region_factsheet_embargo_7_dec(2).p df 22 Office for National Statistics (2007). Quinary age groups and sex for local authorities in the United Kingdom;estimated resident population Mid-2006 Population Estimates (T 09).

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x 100% of schools are signed up to the Schools Sports Partnership Programme with 86% offering a minimum of at least 2 hours of good quality Physical Education (PE) and sports. x 82% of school pupils participate in at least 2 hours of high quality PE and out of hours school sport in a typical week; this is lower than both the London and England averages. 5 x 33 % of pupils were involved in inter school sports competitions during the academic year compared with 35% nationally.23 x 25% of Lambeth pupils participate in one or more community sports, dance or multi skill clubs linked to school, in line with the national average. x 59% of young people who responded to the Residents’ survey 2007 said they used sports and leisure facilities. x 2.6% of adults volunteer to support sport for a minimum of 1 hour per week. 5 x 5% of Lambeth pupils are actively involved in sports volunteering and leadership compared with 12% nationally. x 120 people participated in the 2005-06 ACTIVEwalks programme in the borough, 96% of participants enjoy and regularly attend these sessions. Health plans x The Healthy Lifestyles team referred 743 patients onto the exercise referral scheme were referred last 2007/08. Since 2004 participation has increased from 150 to 800, with 50% being from BME groups. x 67 children followed the ‘Mind, Exercise, Nutrition Do it’ programme in 2007. Feedback from the families demonstrated that 80% were successful in achieving their aims. x 19 out of 54 Lambeth GP surgeries have signed up to provide a specialist, enhanced service to patients with Learning Disabilities. These surgeries carry out yearly health checks and draw up Health Action Plans (HAPs) with the patients to address any specific health needs. There are currently 110 patients with HAPs. x 85.5% of all schools in Lambeth have a School Travel Plan in place, resulting in significant shifts with walking to schools increasing by 9%, car driving decreasing by 7% and cycling increasing by 7%. Smoking x Smoking prevalence is high in Lambeth especially in deprived areas and in people in lower socio-economic groups and in manual occupations. The deaths attributable to smoking every year are also high in Lambeth compared with the national average. However, the numbers of mothers known to be smoking during pregnancy is lower than both the London and England averages.24 x Between April 2005 and March 2007 approximately 1,841 people reported quitting smoking, with an expected success rate of around 50%. Whilst encouraging, this should be balanced against the countervailing increases in young people taking up smoking.

SIGNIFICANT INEQUALITIES IDENTIFIED

23 DfCSF (2007). 2006/7 School Sport Survey Research Report DISF-RW024. 24 Department of Health area profile 24 June 2008. Lambeth JSNA – Preliminary Assessment 39 Version 4 November 2008 Page 44

x The African-Caribbean and Indian older people population is predicted to increase over the years and these groups are at a higher risk of having hypertension. x 71.2% of people with disabilities compared with 40.3% of people without impairments are inactive.25 x Prevalence of obesity among children aged 2-10 is higher and has grown from 9.9% in 1995 to 13.7% by 2003.26 x 63.1% of people from the lowest socio-economic group compared with 34.1% from the highest socio-economic group are inactive.8. x 51.8% of people from Black and Minority Ethnic cultures compared with 40.4% white groups are inactive. x 34.6% of males aged 30-44 compared with 19.2% males aged 16-29 are inactive. x 76% of older people 60+ compared to 39% people aged 16-59 are inactive. x 25% of Lambeth’s children responding to the TellUs2 Survey cited lack of parental consent as one of the main reasons for them not being involved in activities such as sports and recreational activities. This compares with 11% nationally. x Not being able to participate in out of school leisure and recreation because of carers’ concerns about their safety is also a key issue for children looked after (LAC) (raised in the Young London Matters consultation 2007).

NATIONAL PRIORITIES Reference Indicator NI 52 Take up of school lunches NI 53 Prevalence of breast-feeding at 6-8 weeks from birth NI 55 Obesity among primary school age children in Reception NI 56 Obesity among primary school age children in Year 6 NI 8 Adult participation in sport and active recreation NI 57 Children and young people’s participation in high quality PE and sport NI 123 Stopping smoking Obesity Modelled and/or recorded prevalence Hypertension Modelled and/or recorded prevalence Modelled and/or recorded drinking behaviour Reducing underage sales of alcohol

CURRENT RELEVANT STRATEGIC PRIORITIES x The North Lambeth and Southwark Sport Action Zone is one of the original 12 Sport Action Zones established to empower and support local communities to develop sustainable and inclusive sport and physical activity in areas of high deprivation. It has encouraged sports among young people through local partnerships. Higher levels of participation are observed in northern Lambeth where the Sport Action Zone has been most active.

25 Lambeth Needs Assessment for Physical Activity, March 2008 26 London Borough of Lambeth. Draft Parenting and Family Support Strategy 2008-11. 2008. Lambeth JSNA – Preliminary Assessment 40 Version 4 November 2008 Page 45

Overview of green spaces and Council leisure facilities in Lambeth

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Overview of the main exercise providers and programmes in Lambeth

Do they choose not to abuse alcohol or illegal drugs? STATUS Illegal Drugs Lambeth JSNA – Preliminary Assessment 42 Version 4 November 2008 Page 47

x The Home Office estimates 5,029 Problematic Drug Users (PDUs) of opiates and/or crack cocaine in Lambeth (estimate based on 2004/05 data). The total number of Problematic Drug Users PDUs known to treatment in 2006/07 was 1,991. If the Home Office estimate of 5,029 is correct, that would mean that there are 3,038 PDUs who are treatment naïve (have not engaged with treatment since 2004/5). x During 2006/07, 894 clients entered treatment and 603 were discharged. x 2,033 drug users accessed treatment during 2007/08. 149 of these (7.3%) were aged 17 or under. 79% of individuals were retained in structured treatment for more than 12 weeks. x 72% of adult drug users in treatment in Lambeth are male (28% female). x 59% of adult drug users in treatment in Lambeth are white; 26% are Black which includes 10% Black Caribbean. x The age profile of adult drug users in treatment in Lambeth puts 8% aged 20-24; 26% aged 25-34; 41% aged 35-44% and 16% aged 45-54. 2% are aged 18-19 and a further 4% are aged 55+. x National data has shown that clients who are retained in treatment for longer than 12 weeks (84 days) have achieved significantly better outcomes. In 2006/7, 74% of Lambeth clients were retained for more than 12 weeks. This was 2% higher than the London average. This figure rose to 77% for Lambeth DIP clients. Furthermore, only 3% of Lambeth clients were “triaged only” (i.e. received a triage assessment, but did not engage in treatment), compared with the London average of 7%. x The proportion of Lambeth clients receiving treatment outside the borough has significantly reduced from 10% to 5%. x The proportion of BME clients in treatment is not significantly different from the proportions in Lambeth’s overall resident population. x 61% of individuals were discharged from structured treatment in a planned way in 2007/08. x 31% of referrals for treatment were self-referrals. One in seven of all referrals are self-referrals entering through SLaM Stockwell CDT. x Slightly less than a fifth of all clients were referred from the Criminal Justice system in 2007/08; this is a similar proportion to last year. x 13% of those accessing treatment for the first time in 2007/08 had a dual diagnosis of mental health problems alongside their substance misuse issues. x The number of young people aged 15-17 who used drugs in the last year is estimated at 2,210.27 x 46 out of 85 schools have achieved the National Healthy Schools Status for drug education with a further 10 working towards it. x CHAIN data for Lambeth shows that 88% of all rough-sleepers have alcohol and/or drug support needs. This is notably higher than the proportion across other London boroughs.28 x Preliminary statistics from the Aftercare Team show that most carers engaging with treatment services are affected by their dependents’ poly- drug use (including alcohol), with only 6% affected by alcohol only. Nine out

27 London Borough of Lambeth. Draft Needs Assessment for Young People’s Specialist Substance Misuse Treatment. 2007. 28 CHAIN (2007) Lambeth JSNA – Preliminary Assessment 43 Version 4 November 2008 Page 48

of ten carers were females (88%), and seven of ten (71%) were direct relatives (the remaining as partners or friends). Alcohol x It is estimated that 23-24% of Lambeth’s population drink excessively and that Lambeth has a higher rate of alcohol related hospital admissions than London and England. The largest single categories of hospital admissions are for alcohol related disorder and then liver disease.29 x The public perception of drunk and rowdy behaviour in Lambeth is consistent with London in general with 37% seeing it as a very or fairly big problem (against 39% inner London and 40% London-wide). 6 out of 10 people did not see it as a very big problem at all (Residents’ survey 2007). x The general profile for an excessive drinker in Lambeth is that of a white male. x Most drink drivers in Lambeth are male aged over 26 years. Almost 60% of arrests take place between midnight and 0700 hours in the morning with 39% of those arrested coming from outside the borough. It is assumed, though not known, that a large number of drink drivers would have been socialising in the borough. x Only 27% of Lambeth schoolchildren admit to having drunk an alcoholic drink, significantly lower than the national average of 48%. However, 17% preferred not to say, higher than the national average of 10%. (Tell Us 2 survey 2007). x 46% of Lambeth schoolchildren would like more/better information on alcohol (against 27% nationally) and 39% would like equivalent information on drugs (31% nationally). (Tell Us 2 survey).

SIGNIFICANT INEQUALITIES IDENTIFIED Illegal Drugs x The proportion of young adults in treatment in Lambeth in 2006/07 was lower than the London average (16%). However, these clients were retained successfully (80%) compared with the borough retention rate for all ages (74%) and the London retention rate for young adults (68%). x 95% of young people engaged with the Youth Offending Service reported as using illicit drugs. x PDUs using crack cocaine are far less likely to engage in treatment, and clients using both crack cocaine and heroin are far less likely to be retained in treatment for more than 12 weeks. x Mandatory drug testing is carried out on all those arrested for so-called drug related “trigger offences”. Of those testing positive from April-Nov 2007, 89% were male and 58% were from BME communities including 21% recorded as British Caribbean. 42% were categorised as White. The high proportion of BME positive testers illustrates an over-representation within this group and is significantly different from the borough’s overall BME population. x The age profile of those testing positive highlights that 91% are aged between 18 and 44 with 18 to 24 yr olds representing the largest proportion at 21%.

Alcohol

29 Alcohol Needs Assessment 2006/07 Lambeth JSNA – Preliminary Assessment 44 Version 4 November 2008 Page 49

x Alcohol related ambulance call outs are geographically aligned to wards with strong night time economies where levels of alcohol and violent crime are high. Alphabetically these are Bishops, Clapham Town, Coldharbour, Oval and Princes.

NATIONAL PRIORITIES Reference Indicator NI 39 Rate of hospital admissions per 100,000 for Alcohol-related harm NI 40 Number of drug users recorded as being in effective treatment NI 115 Substance misuse by young people

CURRENT RELEVANT STRATEGIC PRIORITIES x Reduce the harm caused by problematic drug use and Alcohol consumption (Safer Lambeth strategic plan 2008)

Department of Health Area Profile for Lambeth Health Profiles for every local authority and region across England were published on 24 June 2008 by the Department of Health and the Association of Public Health Observatories. The Profiles use key health indicators to capture a picture of the nation's health down to local level. The summary chart for Lambeth is included below.

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5. Economic development - Are they economically secure? Are they economically active where possible? STATUS Individuals x 76.2% of the population of Lambeth is economically active; this compares with 75.1% for London and 78.6% nationally.30 x 23.8% of the population of Lambeth is economically inactive, this compares with 24.9% for London and 21.4% nationally. x 18.7% of the economically inactive are neither in employment nor unemployed and do not want a job; this compares with 18.0% for London and 16.1% nationally.31 x The overall employment rate in Lambeth is 68.5%. This compares with the London employment rate of 69.8% and a national figure of 74.3%. x The unemployment rate in Lambeth is 9.5% of the economically active population compared with 6.9% for London and 5.3% nationally. x In 2006-07, 66.9% of supervised juveniles in Lambeth were in full-time education, employment or training (EET), compared with 70.3% in our Nearest Neighbour (NN) group and 70.2% nationally32. In 2007-08 this has improved to 68.9%, compared with 73.5% for our NN and 70.3% nationally. x Lambeth has 9.6% of young people aged 16-18 not in education, employment or training (NEET), compared with 9% for Southwark, 5.5% in Wandsworth and just 0.8% above the London average. This is down from 15.3% in 2004. Projections show that just 8.6 % will not be in paid work or preparing for it in Lambeth by 2009-10, closing the gap on the England average.33 x The Lambeth Year 11 Annual Activity survey 2007 of 1,783 pupils showed that 90.4% remained in education, compared with 87% in 2006. 1.7% are in full-time training, compared to 1.4% in 2006. 1.8% are in full-time employment, compared to 1.4% in 2006. x When asked which things would do most to make their life better, 19% of Lambeth schoolchildren indicated that they would like more help to plan for their future, compared with 17% who gave this response nationally. x 16% of young people have made use of Connexions in the last 12 months. 64% said they had used the Connexions in their local area (Residents Survey 2007).

30 NOMIS Official Labour Market Statistics (Oct 2006 – Sep 2007). Percentages are for those of working age (16-59/64). Economically active are people who are either in employment or unemployed. 31 People who are neither in employment nor unemployed includes, for example, all those who were looking after a home or retired. Also people wanting a job, these are those not in employment who want a job but are not classed as unemployed because they have either not sought work in the last four weeks or are not available to start work. 32 NN = nearest neighbour group consists of a comparable group of local authorities; Southwark, Hackney, Islington, Haringey, Lewisham, Hammersmith and Fulham, Tower Hamlets & City of London, Greenwich, Brent. 33 London Borough of Lambeth. CYPS Performance Digest Report. March 2008 Lambeth JSNA – Preliminary Assessment 47 Version 4 November 2008 Page 52

x In May 2008, 3.6% of the resident working age population for Lambeth is claiming Job Seekers Allowance (JSA), compared with 2.6% for London and 2.2% nationally. At 63.10% of claimants, Lambeth is below the London average (65.50%) for claiming up to 6 months JSA, but higher than London averages for claimants over 6 up to 12 months and over 12 months.34 x 88% of people using mental health services in Lambeth are unemployed. x The number of adults with learning disabilities in employment was 2.3% in 2007/08. x Over 53% (9,132) of working age people who said that they were carers in the 2001 Census worked full or part time. 782 combined work with 50+ hours of caring each week. x In common with other London boroughs, childcare is a barrier to employment. In Lambeth, a large majority of people use relatives for childcare, and those that pay, pay an average of £85 per week, compared with the national median average of £23 per week. Business x LABS 200735 cites Lambeth’s economy as contributing 0.53% of total British economic output and it is ranked 29th out of 408 Local Authorities in terms of size and its economy36. x In 2007, there were around 10,000 businesses in Lambeth; but more than three-quarters of these had fewer than five employees (Association of British Insurers 2007). x The 2007 Lambeth Economic Digest showed that 99.65% of businesses in the borough are Small or Medium Enterprises (SMEs). However, in the north of the borough there is a cluster of large firms, 48 of which employ more than 200 employees; among these are the national headquarters of IBM, Shell, and the ITV network. x North Lambeth currently accommodates 61,500 jobs, almost 45% of the borough’s total. 37 x Lambeth businesses comprise38: SMEs 99.65% Family owned 50.04% Social Enterprises 12.38% Ethnic minority owned businesses 40.62%

x The biggest contribution of businesses is from Real estate, renting and business activities sector. There are higher concentrations of other community services, hotel and restaurant sector, publishing sector, education, health and social work sector and construction sector compared with London.39

34 The Jobseeker's Allowance (JSA) is payable to people under pensionable age who are available for, and actively seeking, work of at least 40 hours a week. 35 Lambeth Businesses (LABS), Source: LABS; Annual Business Inquiry (ABI) 2007 36 Regeneration Delivery Plan 2007/08; Building a Better Lambeth. 37 Economic Development Strategy 2007-2010 38 From LABS boosted analysis, 2007 39 Lambeth Economic Digest 2008. Lambeth JSNA – Preliminary Assessment 48 Version 4 November 2008 Page 53

x The business sectors with lower concentrations compared with London are business and professional services, banking and finance, wholesale and retail and transport and communications. x At the start of 2007, there were 7,870 VAT registered businesses. The VAT registration rate during 2006 was 44 per 10,000 working age population. 985 new registrations were made during 2006 and 600 businesses de- registered in the same period.

SIGNIFICANT INEQUALITIES IDENTIFIED x The BME employment rate is 50.9%40 and there has been a 2% decrease in the non white JSA claimant rate form March 2008 to April 2008. x 61% of 19 year old care leavers known to Connexions are in education, employment or training (EET). x 12.9% of 16-19 year olds with learning difficulties or disabilities were NEET in December 2007. This is a significant decrease of 29% from December 2006. 74.5% were in EET. x Currently, 45% of teenage mothers are in EET. This represents an increase of 22% on 2006 figures. x The numbers of young offenders in full-time EET has increased by 6% during the last two years to above 76%, which is higher than the average for London, and the national average. x Lambeth has extraordinary levels of social exclusion e.g. 96% unemployment rates for people using community mental health teams.41 Growing professional awareness of vocational possibilities for patients with severe mental illness should mean that many patients could return to competitive employment and return to mainstream society. x There is evidence of documentation relating to vocational needs in only 18% of out-patients; 8% in patients of community mental health teams; and 39% in acute wards; 8% of patients were engaged in work schemes; 10% of patients were in education; and 9% were engaged in vocational interventions with their care coordinator; the latter was less likely if the patient was from a Black or minority ethnic group. 42 x The more care that people provide, the less likely they are to be economically active. In a national survey 87% of working age Carers who care 20+ hours per week said that they would like to return to work, but four out of five of them felt that it would be difficult or impossible for them to do so. NATIONAL PRIORITIES Reference Indicator NI 151 Overall Employment rate (working-age) NI 144 Offenders under probation supervision in employment at the end of their order or licence NI 146 Adults with learning disabilities in employment NI 150 Adults in contact with secondary mental health services in employment NI 117 16-18 year olds who are not in education, training or employment (NEET) NI 45 Young offenders engagement in suitable education, employment or training

40 NOMIS/ APS October 2006 – September 2007.(data prior to his period has to be re-weighted) 41 Vocational and social inclusion service proposal, Mark Bertram, SLaM 42 Bertram & Howard, Occupational care planning for service users. Psychiatric Bulletin (2006), 30, 48-51 Lambeth JSNA – Preliminary Assessment 49 Version 4 November 2008 Page 54

NI 7 Environment for a thriving 3rd sector NI 171 New business registration rate NI 172 Percentage of small businesses in an area showing employment growth NI 182 Satisfaction of business with local authority regulatory services NI 183 Impact of local authority trading standards services on the fair trading environment

CURRENT RELEVANT STRATEGIC PRIORITIES x Increase the number of young people in education, employment and training, developing skills for adulthood. (Lambeth Children and Young People’s Plan 2 2007-10) x The Sustainable Communities Strategy contains identifies worklessness priorities supported by indicators within the Local Area Agreement. x The Lambeth Employment and Skills Plan have agreed a target this year of an employment rate of 70% by 2012. x The Economic Development Strategy has a central objective of creating training and employment ‘pathways’ for people to realise their talents and take advantage of employment opportunities alongside demand side objectives to support employer engagement through initiatives such as the ‘Employer of First Choice’ programme. The EDS offers an underpinning framework for the future rollout of projects and interventions. x Support Carers so that they can work, or continue with their education or training (Carers Strategy 2008)

Do they possess valuable skills and qualifications? STATUS x The average point score per student in post 16 education has increased from 547.6 in 2006 to 578.4 in 2007. Although these point scores are below inner London and national figures the increase is larger than both inner London and national increases. x 39.543% of the Working age population in Lambeth is qualified to at least Level 4 or higher. x 51.2% of the Working age population in Lambeth is qualified to at least Level 3 or higher. x 61.4% of the Working age population in Lambeth is qualified to at least Level 2 or higher. x The LABS report reveals that the top three biggest problems facing Lambeth businesses are availability of appropriately skilled employees, size of current premises and cost of labour. x Lambeth residents are employed by sector as follows: Manufacturing 2.7% Construction 2.7% Services 94.0%

43 NOMIS: ONS Annual Population Survey, Jan 2006 – Dec 2006. Lambeth JSNA – Preliminary Assessment 50 Version 4 November 2008 Page 55

x Lambeth residents are employed in the service industry sectors as follows44: Public administration, education & health 35.6% Finance, IT and other business activity 28.5% Distribution, hotels and restaurants 16.3% Other services 8.2% Tourism 7.2% Transport & Communications 5.4%

SIGNIFICANT INEQUALITIES IDENTIFIED x Lambeth has much higher percentages of residents who have no qualifications than both London and nationally and it appears that the gap is growing. 21.3%45 of working age residents in Lambeth have no qualifications compared with 13.9% for London and 13.8% nationally. The difference Jan– Dec 2005 was 5.4% higher compared with London but for Jan– Dec 2006 the difference was 7.4% higher than the London percentage.46 x The lack of the appropriate skills is a barrier to employment. Less than 50% of adults with low or no qualifications are in work.47 x Conversely, Lambeth has consistently had higher levels of residents qualified to NVQ 4 and above compared with London and national averages. For the period Jan– Dec 2006 the NVQ4 qualification level in Lambeth was 4.9% higher than London and 12.1% higher than the national average.

NATIONAL PRIORITIES Reference Indicator NI 161 Number of Level 1 qualifications in literacy (including ESOL) achieved NI 162 Number of Entry Level qualifications in numeracy achieved NI 163 Proportion of population aged 19-64 for males and 19-59 for females qualified to at least Level 2 or higher NI 164 Proportion of population aged 19-64 for males and 19-59 for females qualified to at least Level 3 or higher NI 165 Proportion of population aged 19-64 for males and 19-59 for females qualified to at least Level 4 or higher NI 174 Skills gaps in the current workforce reported by employers

CURRENT RELEVANT STRATEGIC PRIORITIES x Support Carers so that they can work, or continue with their education or training (Carers Strategy 2008)

44 NOMIS: ONS annual business inquiry employee analysis (2006) 45 NOMIS APS, Data for Jan 2006 –Dec 2006 46 Lambeth Economic Digest 47 Lambeth Economic Development Strategy 2007-2010 Lambeth JSNA – Preliminary Assessment 51 Version 4 November 2008 Page 56

Do they enjoy access to sufficient income? STATUS x Average gross weekly earnings of employees in Lambeth is £537.348, this compares to £558.9 and £613.3 for neighbouring boroughs of Southwark and Wandsworth respectively and the London average of £553.3. x The 2001 Census showed that one-quarter (17,000 out of 67,000) of Lambeth’s under-19s live in areas of income deprivation.49 x 51% of Inner London children live in poverty50 compared with 41% across London and 28% nationwide. Borough level figures are not available but Lambeth can be expected to exceed the Inner London figure.51 x 23% of Lambeth residents surveyed (2007), felt the housing benefits service was good or excellent compared with 21% across London and 22% nationally. 20% of respondents said they actually used the service compared with 13% for London and 18% nationally. x The percentage of working age people on out of work benefits is16.5%. In the worst performing neighbourhoods this increases to 27.7% (Q2 2007). x Just over a third (36%)52 of children in Lambeth live in families on key benefits compared with 28% in London. Lambeth ranks as the 11th highest rate for this nationally and 27th out of the 33 London boroughs. x The number of people claiming incapacity benefits represents approximately 7.1% of the working age population (London 6.1% and nationally 7.2%). The number of people claiming incapacity benefits allowance has fallen by 3%, a reduction of 390 claimants between November 2006 and November 07. x The number of people claiming lone parent benefits represents approximately 4.0% of the total working age population (compared with London 3.1% and nationally 2.0%). The total number of people claiming lone parent benefits has decreased by 13% over the period November 2003 to 2007. x 38% of secondary school pupils are eligible for free school meals, which is the fifth highest proportion in England. x The proportion of primary school pupils eligible for free school meals is 37.4%, which is the eighth highest proportion of primary school pupils across England.53 x Lambeth has the highest take-up nationally of the childcare element of working family tax credit at 27% (compared with 11% for England).

SIGNIFICANT INEQUALITIES IDENTIFIED x Vassall and Coldharbour wards display the highest working age benefit claim rates within Lambeth with approximately 25% of the total working age population claiming some form of working age benefit (i.e. incapacity

48 ONS annual survey of hours and earnings - resident analysis [2007] 49 This is the number of children and young people living in 10% most deprived Super Output Areas by Income deprivation affecting children. 50 Households living in poverty subsist on an income 60% below the median household income. Calculation of poverty rates control for geographic variations in house prices. 51 London Child Poverty Commission. 52 Government Office for London /DWP August 2008, based on 5% sample. 53 London Borough of Lambeth. Draft State of the Borough: The evidence base supporting the Sustainable Community Strategy. 2008. Lambeth JSNA – Preliminary Assessment 52 Version 4 November 2008 Page 57

benefit, job seekers allowance, lone parent benefits). (Based on DWP Ward Count May 2007/working aged population). x In Vassall ward, there was a 2% reduction in the number of people claiming working age benefit . from February 2008 to May 2008. x In Coldharbour ward, there was a 3% reduction for the same period. x The Households Below Average Income data 2004/5 (DWP) showed that 21% of children nationally are from families on out of work benefits. Within London there are 105 local wards where the percentage of children on benefits is at least twice the national average. Lambeth had 2 wards (Coldharbour, 48.2% and Tulse Hill, 43.85%). Southwark had 5 wards, Wandsworth and Lewisham also had 2 wards.54

NATIONAL PRIORITIES Reference Indicator NI 166 Median earnings of employees in the area NI 152 Working age people on out of work benefits NI 153 Working age people claiming out-of-work benefits in worst performing neighbourhoods NI 173 Flows on to incapacity benefits from employment NI 181 Time taken to process Housing Benefit/Council Tax Benefit new claims and change events NI 116 Proportion of children in poverty NI 118 Take up of formal childcare by low-income working families NI 180 The number of changes of circumstances which affect customers’ HB/CTB entitlement within the year. Proportion of Older People in poverty

CURRENT RELEVANT STRATEGIC PRIORITIES x Do they live in decent homes? STATUS x The mix of housing stock in Lambeth is fairly typical of an inner London borough with 37% owner-occupied properties, 38% social housing and 25% privately rented. x There is very high demand for housing in Lambeth reflected in an average house price of £356k (Land Registry Dec 2007), almost double the national average. x Private renting in Lambeth is also expensive costing an average of £230 per week for a 2 bedroom property, compared with less than £80 per week for a social let (Housing needs survey 2007). x Lambeth is estimated to have 5.16% of households in fuel poverty55; this compares with a London average of 5.4%.

54 http://www.jrf.org.uk/child-poverty/documents/London.doc

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x Approximately 16,000 households are currently registered on the general needs waiting list. Of these households only 30 (excluding sheltered) were allocated social housing in 2007/08. 85% of all new social lettings are to homeless households in temporary accommodation. x There are currently 2,100 people waiting for an offer in Temporary Accommodation. x Through a successful homelessness prevention strategy, the number of households accepted as being homeless has been successfully reduced from 1,651 to 735 over the last 5 years. x There are approximately 13 people sleeping rough in Lambeth on any one night. x Around 10% of households living in rented accommodation (both social and private) are overcrowded. This compares with only 1.2% of owner-occupied households. x There are an estimated 28,000 or 22% of all households in the borough under-occupying their homes (using the criteria of having more than one spare bedroom). x 1.8% of private sector properties are vacant for over six months. x It is estimated that 4,881 additional affordable housing units would need to be built each year if all affordable needs were to be met. This is an increase on the 2002 survey estimate of 3,050 per annum. This rise is due both to a decreased level of supply compared with 2002 and an increasing level of need due to the significant rise in house prices over and above the ability of households to afford them (Housing Needs Assessment 2007). x Lambeth secured the second highest allocation of NAHP funding for the 2006/08 programme in London and successfully delivered 872 new units of affordable housing between 2005-07. x From April 2008 the Council has put in place a Choice Based Lettings scheme with the aim of improving choice for people in housing need. People looking for a home act directly by registering their interest in any advertised council or housing association homes in Lambeth for which they are eligible. Because of the severe shortage of social housing to rent in Lambeth, the bidder in the greatest need is then invited to view the property. x There is a government target that all social housing should meet the Decent Homes Standard by 2010. For a home to be decent it needs to: meet the current statutory minimum for housing be in a reasonable state of repair have reasonably modern facilities and services provide a reasonable degree of thermal comfort. x 66% of council homes and 88% of RSL homes meet the Decent Homes standard. 11% of Private Sector properties are deemed unfit for purpose (2004 Private Sector Stock Conditions Survey). x 62% of tenants are satisfied with the landlord services provided by Lambeth (2006 Tenant Satisfaction Survey). However, the housing management service provided by Lambeth Council will shortly be transferred to an Arms Length Management Organisation (ALMO), Lambeth Living. x 18% of residents surveyed in 2007 rated our council housing as good to excellent, compared with the London-wide figure of 21%. 18% also rated our housing as poor to very poor, in line with the inner-London average.

SIGNIFICANT INEQUALITIES IDENTIFIED

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x With an average house price of £356k (Land Registry Dec 2007) almost double the national average, residents on average incomes of £31k are struggling to get onto the property ladder. x Those from BME communities are over represented in social housing, homelessness and over-crowding statistics. x BME Households are likely to be larger than White households and more likely to live in the social and private rented sectors. Black African households represent the largest ethnic group in Lambeth that suffer from high levels of overcrowding. Whilst there is not a sizeable Asian community in the borough, proportionally the second ethnic group suffering from high levels of overcrowding are Asian households. x 73% of those placed in Temporary Accommodation over the year ending Dec 2007 were of Black, Asian and Minority Ethnic backgrounds. x Single, pregnant women and families with children combine to make up 75% of the 2,100 people currently awaiting an offer in Temporary Accommodation. The average number of weeks spent by these households in shared hostel accommodation in Lambeth is 11.2 weeks (2006/07) (London median figure of 12.2 weeks) and in shared bed and breakfast accommodation is 1.8 weeks (London median of 2.4 weeks). x There are significantly high levels of homelessness among 16-17 year olds with approximately 104 currently in Temporary Accommodation, above London and national averages. x Households with two adults without children (totalling 43%) are in greater need of affordable housing compared with other household compositions. x Older People tend to live in properties that are under occupied when compared with other household types, but are reluctant to move into smaller accommodation. This group is least likely to be in housing need. x There are high levels of worklessness associated with those living in social housing with 60% of social tenants being in receipt of housing benefit. x 12% of residents in private sector properties move for work-related reasons; this drops to only 0.1% of those in social housing. x Receipt of incapacity benefit can be used as an indicator to demonstrate correlation between health deprivation and social housing. In Lambeth there are higher levels of incapacity benefits concentrated within social housing estates. Lambeth has a high rate of Incapacity Benefit claimants within the Brixton wards of Coldharbour and Vassall. These wards are among the most deprived areas in London and also have higher levels of worklessness and social housing than other wards in the borough. NATIONAL PRIORITIES Reference Indicator NI 158 % non-decent council homes NI 160 Local Authority Tenants’ satisfaction with landlord services NI 155 Number of affordable homes delivered (gross) NI 154 Net additional homes provided NI 156 Number of households living in Temporary Accommodation NI 157 Processing of planning applications NI 159 Supply of ready to develop housing sites NI 170 Previously developed land that has been vacant or derelict for more than 5 years NI 187 Tackling fuel poverty - % of people receiving income based benefits living in Lambeth JSNA – Preliminary Assessment 55 Version 4 November 2008 Page 60

homes with a low energy efficiency rating NI 46 Young offenders access to suitable accommodation

CURRENT RELEVANT STRATEGIC PRIORITIES x Increase the supply of dwellings in the borough (Housing Strategy 2008) x Improve the condition of existing stock (Housing Strategy 2008) x Improve access to housing (Housing Strategy 2008) x Mixed, sustainable communities (Housing Strategy 2008) x Worklessness (Housing Strategy 2008) x Empowering tenants (Housing Strategy 2008) Do they enjoy easy access to transport? STATUS x 50.9% of households in Lambeth have no access to a car, one of the highest proportions in the country (see map below) (Census 2001). x Lambeth has the highest proportion of population who travel to work by public transport: 58.6% compared with 14.1% nationally. x 69% of Lambeth residents rate local public transport as good or excellent compared with 66% of inner-London residents and 61% of Londoners overall (Residents’ survey 2007). x 64% of young people in Lambeth rate local public transport as good or excellent compared with 63% of young inner-London residents and 57% of young Londoners overall (Residents’ survey 2007).

SIGNIFICANT INEQUALITIES IDENTIFIED x Residents in the south of the Borough face a number of difficulties in trying to undertake local trips or access central London by public transport. They are generally restricted to using buses which are slow due to a lack of priority measures. In addition, since they are mainly focused on north-south radial routes, they do not adequately serve some of the housing estates (see map below).

NATIONAL PRIORITIES Reference Indicator NI 176 Working age people with access to employment by public transport (and other specified modes) NI 177 Local bus and light rail passenger journeys originating in the authority area NI 178 Bus services running on time NI 167 Congestion – average journey time per mile during the morning peak NI 168 Principal roads where maintenance should be considered NI 169 Non-principal classified roads where maintenance should be considered

CURRENT RELEVANT STRATEGIC PRIORITIES x The Lambeth Transport Local Implementation Plan sets out how Lambeth will deliver the London Mayor's Transport Strategy and forms the basis for future funding bids for projects until 2011. Included action areas: Road

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Safety, Parking and Enforcement, School Travel Plan Strategy, Cycling Action Plan, Strategic Environmental Assessment.

OVERVIEW OF CAR ACCESS WITHIN LAMBETH

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OVERVIEW OF PUBLIC TRANSPORT WITHIN LAMBETH

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6. CYP - Do they enjoy and achieve in their lives? Do the children and young people of Lambeth attend and enjoy high-quality pre-school childcare, school and college? STATUS x 83% of Lambeth school children view themselves positively as learners and try their best at school compared with 81% London-wide (TellUs2 Survey 2007). x 55% of Lambeth school children enjoy school always or most of the time compared with 58% for London (TellUs2 Survey 2007). x Lambeth children would welcome more help with their studies from families and friends, somewhere quieter at home to do homework, more help from teachers and less noisy and disruptive classes (TellUs2 Survey 2007). x Attendance levels at primary schools stand at 94.5% overall in Lambeth, a 0.8% improvement. Primary attendance levels are below the national average of 94.8% for 2006-07. x Attendance levels at secondary schools stand at 92.5% overall in Lambeth, a 0.3% improvement. Secondary attendance levels are 0.3% above the national average of 92.2% for 2006-07. x Lambeth has a higher permanent exclusion rate in secondary schools of 0.36% of school population compared with London (0.32%) and England (0.24%) respectively. x Population projections from the GLA and analysis of current school rolls indicate that there will be a shortfall in both primary and secondary school places across Lambeth by 2015. The GLA’s projection for primary school places indicate that 17 forms of entry will needed by 2017 to meet the demand. x A Primary School Places Expansion Project has been initiated to examine options for addressing the projected shortfall in primary places. It is working alongside the creation of a Primary Estate Master Plan which, by October 2008 will have produced a strategy for the expansion of Lambeth’s primary estate to meet the rising demand for primary school places. x Lambeth was the first London Council to start construction of secondary schools under the Building Schools for the Future (BSF) Programme in January 2007. By 2013, the Lambeth BSF programme will have created an additional 2,370 secondary school places, including a new 180 place school. x 40% of Lambeth primary schools are now offering the full core of extended services, exceeding the national target by 33%. x Only 1 primary school currently requires special measures. Prior to this judgement, no Lambeth schools had been in the category of concern for the previous five years. x 75% of schools inspected were judged as Good or Outstanding by OFSTED. x Lambeth’s value-added measure improved this year from 100.3 to 100.6. x 67% of Lambeth primary schools achieved a positive value added score for Key Stages 1 and 2. x 11 schools are in the top 5 percent of schools in the country in terms of value-added.

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x 80% of Looked After Children were offered their first choice secondary school. x In 2006 80% of children leaving care went onto further education.56 x Data on the supply of childcare in Lambeth suggests that the number of children per place for under 5s in Lambeth is better than the national average. For instance, there are 2.0 children per place (across private, voluntary and independent (PVI) group settings, childminders and maintained provision) in Lambeth, compared to between 4.2 and 4.52 nationally. x 53% of childcare providers were judged good or better for Nursery Education in inspections in March 08, increased from 42% in March 07. x In 2007, 8% of residents said they used the nursery education (under 5’s). 24% of those asked thought the local nursery education was good to excellent compared with 29% for inner London. x During 2006-07, 60% of integrated early years settings had a leader qualified to NVQ level 4 or above. x 26 Children’s Centres covering all wards in Lambeth are now in place. All Children’s Centres offer the following core services: On-site childcare or information and access to childcare in the local area Information on parenting, drop-in groups and opportunities to access parenting support and education Antenatal and postnatal services, child health services and information on health issues Information about employment, education and training Information at points of transition, including information sessions around the time of the birth of their child, and on entry to primary school, which as part of the extended services programme will be offering sessions for mothers and fathers as their child starts school. x The percentage of full day care providers participating in the Childcare Affordability Programme (CAP) increased from 31% to 52% in the first three quarters of 2007/08. x The percentage of flexible childcare providers participating in the Childcare Affordability Programme (CAP) increased from 45% to 47% in first three quarters of 2007/08.

SIGNIFICANT INEQUALITIES IDENTIFIED x On average, over half (52%) of year six primary school pupils move on to secondary schools outside the borough. x There is an over-representation of BME children and young people amongst those who are permanently excluded from school.

NATIONAL PRIORITIES Reference Indicator NI 85 Post-16 participation in physical sciences (A level Physics, Chemistry and Maths) NI 86 Secondary schools judged as having good or outstanding standards of behaviour NI 87 Secondary school persistent absence rate

56 Lambeth Children and Young People’s Plan 2 2007-2010, CYPSP Version 5.5 July 2007. Lambeth JSNA – Preliminary Assessment 60 Version 4 November 2008 Page 65

NI 88 Percentage of schools providing access to extended services NI 89 Reduction of number of schools judged as requiring special measures and improvement in time taken to come out of the category NI 90 Take up of 14-19 learning diplomas NI 91 Participation of 17 year olds in education or training NI 106 Young people from low income backgrounds progressing to higher education NI 109 Delivery of Sure Start Children’s Centres NI 114 Rate of permanent exclusions from school

CURRENT RELEVANT STRATEGIC PRIORITIES x Increase access to quality local school places and good quality childcare places (Lambeth Children and Young People’s Plan 2 2007-10)

Do the children and young people of Lambeth achieve national educational standards? STATUS x Those Lambeth school children who complete their GCSEs are doing far better than previously. Between 1996 and 2006 the gap between Lambeth students and those in England gaining 5 or more A-C grades reduced from a 20% point lag to 4% points behind the national average score. 56% of Lambeth students gained five or more A*-C GCSE passes in 2007 compared with 62% nationally. x Reading and mathematics at KS1 showed an improvement of 2% and 1% respectively. x KS2 results increased 1% to 71% in mathematics while science was up 2% to 85%. x Mathematics and science results at KS3 both improved by one percentage point. x At both Key Stage 2 (KS2) and at Key Stage 4 (KS4), the achievement gap between young people who are eligible for free school meals and those who are not is less than both the London and England gaps for English, Maths and Science. x 30% of children met the Foundation Stage Profile criteria to achieve the points score target compared with 46% nationally. (The target is at least 78 points across the Foundation Stage Profile with at least 6 points in Personal, Social and Emotional Development, and Communication, Language and Literacy). x 53.7% of young people leaving care achieve one or more GCSE A*-G grades, an increase of 8.7%.

SIGNIFICANT INEQUALITIES IDENTIFIED x Only 60% of Lambeth students achieved a Level 2 qualification by age 19 in 2006 compared with 71% of London and England students. x The performance of Caribbean pupils is improving at a slower rate than in Lambeth overall. The gap between Caribbean pupils and the average widened at KS1 by 3 percentage points, at KS1 by 2 points and at KS3 by 4 percentage points.

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x For each Key Stage and for GCSE, Portuguese children are the lowest achieving group with performance being especially low in reading and writing at KS1, and in English at KS1. However, they have made the greatest gains since 2001 of 11% at KS2, of 36% at KS 3 and 25% at GCSE.

NATIONAL PRIORITIES Reference Indicator NI 72 Achievement of at least 78 points across the Early Years Foundation Stage with at least 6 in each of the scales in Personal Social and Emotional Development and Communications, Language and Literacy NI 73 Achievement at level 4 or above in both English and Maths at Key Stage 2 NI 74 Achievement at level 5 or above in both English and Maths at Key Stage 3 NI 75 Achievement of 5 or more A*- C grades at GCSE or equivalent including English and Maths NI 76 Reduction in number of schools where fewer than 65% of pupils achieve level 4 or above in both English and Maths at KS2 NI 77 Reduction in number of schools where fewer than 50% of pupils achieve level 5 or above in both English and Maths at KS3 NI 78 Reduction in number of schools where fewer than 30% of pupils achieve 5 or more A*- C grades at GCSE and equivalent including GCSEs in English and Maths NI 79 Achievement of a Level 2 qualification by the age of 19 NI 80 Achievement of a Level 3 qualification by the age of 19 NI 81 Inequality gap in the achievement of a Level 3 qualification by the age of 19 NI 82 Inequality gap in the achievement of a Level 2 qualification by the age of 19 NI 83 Achievement at level 5 or above in Science at Key Stage 3 NI 84 Achievement of 2 or more A*- C grades in Science GCSEs or equivalent NI 92 Narrowing the gap between the lowest achieving 20% in the Early Years Foundation Stage Profile and the rest NI 93 Progression by 2 levels in English between Key Stage 1 and Key Stage 2 NI 94 Progression by 2 levels in Maths between Key Stage 1 and Key Stage 2 NI 95 Progression by 2 levels in English between Key Stage 2 and Key Stage 3 NI 96 Progression by 2 levels in Maths between Key Stage 2 and Key Stage 3 NI 97 Progression by 2 levels in English between Key Stage 3 and Key Stage 4 NI 98 Progression by 2 levels in Maths between Key Stage 3 and Key Stage 4 NI 99 Looked after children reaching level 4 in English at Key Stage 2 NI 100 Looked after children reaching level 4 in mathematics at Key Stage 2 NI 101 Looked after children achieving 5 A*-C GCSEs (or equivalent) at Key Stage 4 (including English and mathematics) NI 102 Achievement gap between pupils eligible for free school meals and their peers achieving the expected level at Key Stages 2 and 4 NI 104 The Special Educational Need (SEN)/ non-SEN gap – achieving Key Stage 2 English and Maths threshold NI 105 The Special Educational Needs (SEN)/non-SEN gap – achieving 5 A*- C GCSE including English and Maths NI 107 Key Stage 2 attainment for Black and minority ethnic groups NI 108 Key Stage 4 attainment for Black and minority ethnic groups

CURRENT RELEVANT STRATEGIC PRIORITIES x Raise attainment levels for all pupils and achieve floor targets to enable pupils to achieve their full potential (Lambeth Children and Young People’s Plan 2 2007-10) x Narrow the achievement gaps for specific groups (Lambeth Children and Young People’s Plan 2 2007-10) Lambeth JSNA – Preliminary Assessment 62 Version 4 November 2008 Page 67

Do the people of Lambeth participate in recreational, social and developmental activities? STATUS Leisure x 34% of adult residents use the sport and leisure facilities in Lambeth, compared with 43% inner London average. However, only 32% of residents rated these facilities good to excellent compared with 41% inner London average and 25% rated them poor against inner London 18% (Residents’ survey 2007). x 67% of adult residents make use of the parks and open spaces in Lambeth, compared with 74% inner London average. 64% of residents rated them of a good/excellent standard. x 75% of young people in Lambeth have used their local sports or leisure facilities within the last 12 months. However, only 44% of young people rated these facilities good to excellent compared with 62% inner London average and 25% rated them poor against inner London 12%. Main reasons given for not using local facilities were “better facilities elsewhere” ( 25%) or simply “none in my local area” (43%) (Residents’ survey 2007). x 31% of young people in Lambeth have used their local adventure playgrounds within the last 12 months and 28% have used local youth clubs and centres. x The percentage of young people aged 13-19 reached by publicly funded youth services is 24.6%, increased from 13.5% last year. x There are now 47 FTE youth workers in Lambeth, an increase of 10. This means an improved ratio of 1FTE youth worker per 553 young people aged 13-19, down from 1,935.2 last year. x There is concern among both adults and young people about the availability and quality of activities available for young people. Only 10% of adults rated the existing provision of activities for teenagers as good/excellent (against 14% inner London average) and 43% listed additional provision as a key priority for giving children a better start in life. Among young people themselves, 31% felt available activities were good/excellent but 35% rated them as poor (Residents’ survey 2007). Cultural x 19% of adult residents enjoy the arts and cultural services activities in Lambeth and while 28% of residents rate them as good/excellent, 20% of residents rate them as poor (Residents’ survey 2007). x The 2006- 07 Satisfaction survey for Cultural Services showed: 38% satisfied with Sports & Leisure activities 57% satisfied with Libraries 32% satisfied with Museums and galleries 31% satisfied with theatres and concert halls 76% satisfied with parks and open spaces. x 15,294 children and young people participated in the arts across the borough for a minimum of 3 hours, compared with 13,861 last year. 36% of young people consider available arts and cultural activities to be good (against 41% inner London average) (Residents’ survey 2007). Informal or life-long learning x In March 2008 14% of the Lambeth population were active library book borrowers.

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x During 2007-2008 there was a total average of 398 visits recorded to Lambeth libraries each month and an average of 69,000 items issued each month. x During 2007-08 our library home visitors provided for 345 individual customers and 40 venues including residential homes. x 54% of adult residents use Lambeth libraries (against 64% inner London average) and 50% rate them as good/excellent facilities (66% inner London average) (Residents’ survey 2007). x Encouragingly, 92% of young people have used their local library in the last 12 months though only 59% rate them as good/excellent (73% inner London average) (Residents’ survey 2007). x 6,388 people attended the life-long learning courses in 2006-07. 70% of these were female and 73% were from BME groups. Of the total, 17% of people were learners with learning difficulties/disabilities. The highest numbers of attendees were from Coldharbour and Stockwell wards. Most learners were aged 25-39yrs (39%) and 40 – 59yrs (32%). x 8% of adult residents attend evening classes or other adult education in Lambeth but 28% of adult residents consider the adult education provision available to be good/excellent (35% inner London average) (Residents’ survey 2007). x Following their life-long learning course, attendees planned to: Do further studies (65%) Find a job (14%) Help their children with their learning (7%) Use their new skills through volunteering (14%).

SIGNIFICANT INEQUALITIES IDENTIFIED x

NATIONAL PRIORITIES Reference Indicator NI 9 Use of public libraries NI 10 Visits to museums or galleries NI 11 Engagement in the arts NI 199 Children and young people’s satisfaction with parks and play areas Social capital

CURRENT RELEVANT STRATEGIC PRIORITIES x Increase opportunities for all young people to participate in out-of- school activities (Lambeth Children and Young People’s Plan 2 2007-10)

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Do they live in strong, cohesive and respectful communities? STATUS Lambeth JSNA – Preliminary Assessment 65 Version 4 November 2008 Page 70

x 83% of adult residents definitely agreed or tended to agree that people from different backgrounds get on well together in Lambeth (Residents’ survey 2007). x However, 50% of adult residents felt that “people not treating other people with respect or consideration” was a very or fairly big problem in Lambeth. x 34% of Lambeth residents perceive a “high” level of ASB within Lambeth. x The highest proportion of recorded ASB incidents were categorised as “Disregard for Community/Personal wellbeing”57 x Main concerns relating to ASB highlighted by adults in the Residents’ survey 2007 were “parents not taking responsibility for their children” (52% rated this a very/fairly big problem), “teenagers hanging around on the streets” (50%), and “people using or dealing drugs” (50%). x Overall, 70% of adult residents of Lambeth are very or fairly satisfied with Lambeth as a place to live (Residents’ survey 2007).

SIGNIFICANT INEQUALITIES IDENTIFIED x NATIONAL PRIORITIES Reference Indicator NI 1 % of people who believe people from different backgrounds get on well together in their local area NI 2 % of people who feel that they belong to their neighbourhood NI 5 Overall / general satisfaction with local area NI 17 Perceptions of anti-social behaviour NI 22 Perceptions of parents taking responsibility for the behaviour of their children in the area NI 23 Perceptions that people in the area treat one another with respect and consideration NI 35 Building resilience to violent extremism

CURRENT RELEVANT STRATEGIC PRIORITIES x Support more active and respectful communities (Safer Lambeth strategic plan 2008) x Facilitate the development of an independent, borough-wide Multi-Faith Forum (Lambeth Communities First strategy 2007-10) x Work with interested parties and groups to prepare a Together as One plan (Lambeth Communities First strategy 2007-10) x Contribute to the defining and piloting of neighbourhood working in Lambeth (Lambeth Communities First strategy 2007-10)

Do they enjoy informed access to a broad range of support services, personalised to their needs and abilities? STATUS x 81% of initial requests for social care support made by residents aged 18 or over are progressed through to a completed assessment within the 28 day

57 Comprising: Rowdy behaviour (shouting, swearing, fighting, drunken behaviour, hooliganism), Noise, Nuisance behaviour (including fireworks, urinating in public, arson, throwing missiles, climbing on buildings, impeding access, games in restricted/inappropriate areas, misuse of air guns, letting down tyres), Hoax calls, Animal related issues. Lambeth JSNA – Preliminary Assessment 66 Version 4 November 2008 Page 71

statutory time limit (NI 132 2007/08). This is a new baseline for this information. x The care support services for 94% of residents aged 65 and over are in place within the statutory time limit of 28 days from their completed assessment (PAF D56 2007/08). This is in line with the inner London average of 94%. x 13% of carers received a specific carer’s service (PAF C62 2007/08). This is above the inner London average of 10.8% for 2006/07. x 17 care service users have their own individual support budgets through the In Control pilot scheme allowing them to seek and buy alternatives to traditional care services. x 239 people aged 18 or over received direct payments in 2007-08. This equates to 127.13 people per 100,000 population. The inner London average for 2006/07 was 115 people per 100,000 population. x The level of delayed transfers of care per 100,000 population aged 65 and over is 21.2 (PAF D41 2007/08). There is considerable variation between councils with values ranging from 4 to 55 in 2006/07. x 84% items of equipment and minor adaptations were delivered within 7 working days (PAF D54 2007/08) This falls below the inner London average of 90% for 2006/07. x 48% of users of the adult social services provision in Lambeth rate the services good/excellent and 53% of users of children/family social services rate them good/excellent (Residents’ survey 2007). x 61% of residents rate local health services good/excellent (up from 47% in 2003 and 58% in 2005) However, positive ratings are lowest among middle class residents (AB 56%, C1 54%), those who work full or part-time (56% and 55% respectively), Black Caribbean (55%), residents of Norwood (56%) and of Streatham (52%).

SIGNIFICANT INEQUALITIES IDENTIFIED x

NATIONAL PRIORITIES Reference Indicator NI 140 Fair treatment by local services NI 132 Timeliness of social care assessment (all adults) NI 133 Timeliness of social care packages following assessment NI 54 Services for disabled children NI 127 Self reported experience of social care users NI 128 User reported measure of respect and dignity in their treatment NI 130 Social Care clients receiving Self Directed Support per 100,000 population NI 131 Delayed transfers of care NI 134 The number of emergency bed days per head of weighted population NI 103 Special Educational Needs – statements issued within 26 weeks NI 135 Carers receiving needs assessment or review and a specific carer’s service, or advice and information NI 175 Access to services and facilities by public transport, walking and cycling

CURRENT RELEVANT STRATEGIC PRIORITIES

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x 84% items of equipment and minor adaptations were delivered within 7 working days (PAF D54 2007/08) This falls below the inner London average of 90% for 2006/07.

Can they live their lives in the way they choose? STATUS x 4,370 people aged 18 or over are supported to continue to live in their own homes within Lambeth (NI 136). This equates to 2,315 adults per 100,000 population (weighted using the Relative Needs Formulae). This is a new baseline for this information. x 488 adults aged 18 or over received a provision of intensive home care services which enabled them to remain at home, or go home following hospital treatment or a period spent in a residential home. This equates to 20.74 per 1,000 population aged 65 or over. The inner London average for 2006/07 was 25.6. x There were a total of 1,386 service users aged 18 and over in permanent/temporary residential and nursing care in 2007/08 and of those 48% were placed outside the borough. x 26 adults aged 18-64 were admitted on a permanent basis to residential/nursing care during 2007/08. This equates to 1.8 per 10,000 population and puts Lambeth below the inner London average 2006/07 of 2.0. x There were 176 older people permanently admitted to residential/nursing care during 2007/08 and this equates to 74.8 per 10,000 population. This is above the inner London average 2006/07 of 72.7 per 10,000 population. x A total of 28 adults with learning disabilities were in an adult placement during 2007/08 and of those 68% were placed outside of the borough. x 98% of vulnerable people using Supporting People service users have been supported to establish and maintain independent living in 2007/08. x 76% of vulnerable people using Supporting People service users have moved on in a planned way from temporary living arrangements during 2007/08. These 848 planned moves are an increase on the 674 planned moves in 2006/07 and also above the target 769 planned moves for 2007/08.

SIGNIFICANT INEQUALITIES IDENTIFIED x 51% of Offenders and People at risk of offending using Supporting People services have moved on in a planned way from temporary living arrangements during 2007/08. This rate is significantly below the planned target of 75%. x 59% of Rough Sleepers using Supporting People services have moved on in a planned way from temporary living arrangements during 2007/08, below the planned target of 66%.

NATIONAL PRIORITIES Reference Indicator NI 136 People supported to live independently through social services (all adults) NI 139 The extent to which older people receive the support they need to live independently at home NI 124 People with a long-term condition supported to be independent and in Lambeth JSNA – Preliminary Assessment 68 Version 4 November 2008 Page 73

control of their condition NI 125 Achieving independence for older people through rehabilitation/intermediate care NI 129 End of life care – access to appropriate care enabling people to be able to choose to die at home NI 141 Percentage of vulnerable people achieving independent living NI 142 Percentage of vulnerable people who are supported to maintain independent living NI 138 Satisfaction of people over 65 with both home and neighbourhood

CURRENT RELEVANT STRATEGIC PRIORITIES x

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Can they make a positive contribution? Do they engage in decision making, confident that they can express their needs and choices and be heard? STATUS x 1,000 people attended 3 People First Expos in 2008, 60% of whom had not attended a local, formal meeting before. x 49% of adults responding to the Residents’ survey 2007 felt that the council listens to their concerns (against 53% across inner London) and 47% felt they were involved in decision making (in line with 46% inner London). Both these figures have dropped slightly since 2005 when 53% felt listened to and 51% felt involved in decision making. x 70% of adult residents feel that they are kept informed about what the council is doing; this compares with 64% across London. However, only 35% are satisfied with the opportunities to participate in local decision making. x 48% of adult residents agree that they can actually influence decisions made which affect their local area, higher than across both London 46% and inner London 43%. However, only 20% of adults had actually taken part in any consultative survey or meeting in the last 12 months. x Young people in Lambeth feel less well informed with only 43% of young people feeling they are kept up-to-date with what the council are doing (in line with 41% across London). x 40% of young people feel that the Council does listen to them and 35% feel involved in the decision-making process, higher than the London average of 29%. 8% of young people aged 11-17 years in Lambeth have written to their local Councillor, which is 5 points higher than across London. x Young people in Lambeth (50%) are more likely to have voted in a school election than young people nationally (43%). (Tell Us2 Survey 2007). x 30% of young people aged 11-17 years have been a member of their school council, six percentage points higher than the London average (Residents’ survey 2007). x 46% of Lambeth schoolchildren in years 8 & 10 feel that their views are listened to in the running of the school compared with 53% nationally (Tell Us2 Survey 2007). x Young people in Lambeth are more likely to have been involved in a school council or parliament (17% against 14% nationally) with overall 10% fewer reporting that they had not been engaged in decision making processes at all compared with the national figures. x There has been high involvement of Looked After Children in the decision- making process through engagement in Corporate Parenting and consultation groups. The participation of LAC in reviews has also improved from 85% to 96%.

SIGNIFICANT INEQUALITIES IDENTIFIED x

NATIONAL PRIORITIES

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Reference Indicator NI 4 % of people who feel they can influence decisions in their locality

CURRENT RELEVANT STRATEGIC PRIORITIES x Increase opportunities for children, young people and their families’ voices and views to be heard, enabling them to make a positive contribution to their community (Lambeth Children and Young People’s Plan 2 2007-10) x Develop a capacity building plan to support Friend of groups to develop their role and influence over parks and green spaces service design and delivery. (Lambeth Communities First strategy 2007-10)

Do they contribute to the wellbeing of their community? STATUS x There are currently 2,426 active 3rd Sector organisations recorded on the council’s GIFTs database operating within Lambeth. x The council’s GIFTs database records 467 residents who have attended local, community meetings and have expressed a wish to play an active part in community life. x 24% of adult respondents have volunteered in the last 12 months, 58% of these within the Lambeth area. 81% of these volunteers contributed 5 hours or fewer of their time each week. This is a new baseline from the Residents’ Survey 2007. x One in five (21%) young people aged 11-17 years have volunteered (seven points higher than across London), and one in ten (10%) have been a peer educator (Residents’ Survey 2007). x The council has devolved assets to community groups who are using them to operate new and improved services for wider community benefit. Recent examples include the transfer of Raleigh Hall to the Black Cultural Archives and the transfer of Woodlawns to the Streatham Derby and Joan Club.

SIGNIFICANT INEQUALITIES IDENTIFIED x NATIONAL PRIORITIES Reference Indicator NI 3 Civic participation in the local area NI 6 Participation in regular volunteering NI 110 Young people’s participation in positive activities

CURRENT RELEVANT STRATEGIC PRIORITIES x Develop a pilot Local Leadership Programme targeted at people who need to work within a community and neighbourhood setting. (Lambeth Communities First strategy 2007-10)

Are they law-abiding and avoid causing harm to others? STATUS x During 2006-07 there were 468 first time entrants to the youth justice system in Lambeth.

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x In the latest available performance Lambeth has the seventh lowest rate of re-offending of the 32 London boroughs as measured by the Youth Justice Board and is within the top 30% of YOTs nationally. x A reduction of above 20% in young people entering the criminal justice system has been achieved in 2007/08, with the majority of these from BME communities. This was against an LAA target to reduce the number of young people entering the criminal justice system by 3%, with an additional 1% for young people from BME groups. x Lambeth’s rate of youth re-offending has reduced from 63% recidivism in to 57% in 2005. The average for our Nearest Neighbour group in 2005 was also 57%; this compared with the England and Wales average of 64%. x A reduction of over 60% has been achieved in the frequency of re-offending of young BME people subject to the Intensive Supervision and Surveillance Programme against an LAA target of 10%.

SIGNIFICANT INEQUALITIES IDENTIFIED x 75% of young people in the youth justice system come from BME communities.58

NATIONAL PRIORITIES Reference Indicator NI 18 Adult re-offending rates for those under probation supervision NI 19 Rate of proven re-offending by young offenders NI 30 Re-offending rate of prolific and priority offenders NI 31 Deleted NI 111 First time entrants to the Youth Justice System aged 10-17

CURRENT RELEVANT STRATEGIC PRIORITIES x Prevent young people from drifting into crime, in particular young black and minority ethnic (BME) boys (Lambeth Children and Young People’s Plan 2 2007-10)

Do they live sustainably and try to minimise their impact on the environment? STATUS x In 2006/07 Lambeth had the 3rd lowest weight of household waste collection compared with out nearest neighbours with 351.6 kg/head. The average of the nearest neighbours group was 428.7 kg/head.59 x Of the London authorities which send their waste to landfill in 2006/07, Lambeth sends 84.7%, Hammersmith & Fulham 82.5%, Kensington & Chelsea 81.9% and Wandsworth 79.2%. x At the end of 2007/08, Lambeth reached the target of 25% of household refuse being recycled or composted. x 75% of our adult residents use the recycling facilities provided (in line with 78% across inner London) with 63% of residents rating these recycling

58 London Borough of Lambeth. Draft Parenting and Family Support Strategy 2008-11. 2008. 59 Hammersmith and Fulham, Haringey, Wandsworth, Hackney, Tower Hamlets, Ealing, Croydon, Brent, Southwark, Islington, Waltham Forest, Newham, Greenwich, Lewisham, Hounslow.

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facilities good to excellent (64% inner London). 55% of young people in the borough think the recycling facilities are good to excellent (54% inner London). x Local street and environmental cleanliness for 2007/08 was measured at 18.7% for litter & detritus, 6% for graffiti and 0.5% for flyposting. The lower the figure, the cleaner the environment therefore the 2006/07 figures show a slight improvement from 25%, 6% and 1% respectively. Compared with our London nearest neighbour group, Lambeth is below the average of 23.90% for litter & detritus and above the average of 10.24% for graffiti and 2.27% for flyposting. x Lambeth had a total 12,530 incidents of fly-tipping in 2007/08. The summer months see a higher number of incidents than the winter months. x 85.5% of all schools in Lambeth have a School Travel Plan in place, resulting in significant shifts with walking to schools increasing by 9%, car driving decreasing by 7% and cycling increasing by 7%. x The 2007/08 mode of transport by school survey results showed that 9.5% of children travelled by car, 0.5% car shared, 19.7% used public transport 43.6% walked, 0.8% cycled and 2.1% other. x 58.6% of the resident population of Lambeth travel to work by public transport (2001); this compares with nearest neighbours Wandsworth 56.2%, Southwark 52.6% and Lewisham 51.4%. x Lambeth’s Energy Efficiency - Average Standard Assessment Procedure Rating was 65 compared with the Nearest Neighbours group average of 69 and the top quartile of 70. (Based on a scale from 1 to 120 and on the annual energy costs for space and water heating). x There are currently 32 active 3rd sector organisations recorded on the council’s GIFTs database which list a specific environmental or sustainability focus to their activities. x Lambeth has two parks with a Green Flag Award (Milkwood and Vauxhall Parks) and two further candidates for the award in 2008 (Ruskin Park and St Paul’s Churchyard). In order to retain the award the council must ensure that the public space is managed, maintained and developed to meet the community’s needs and engages with all its users through appropriate consultation.

SIGNIFICANT INEQUALITIES IDENTIFIED x NATIONAL PRIORITIES Reference Indicator NI 191 Residual household waste per household NI 192 Percentage of household waste sent for reuse, recycling and composting NI 186 Per capita reduction in CO2 emissions in the LA area NI 195 Improved street and environmental cleanliness (levels of litter, detritus, graffiti and fly-posting) NI 196 Improved street and environmental cleanliness – fly tipping NI 197 Improved Local Biodiversity – proportion of Local Sites where positive conservation management has been or is being implemented NI 198 Children travelling to school – mode of transport usually used NI 185 CO2 reduction from Local Authority operations NI 188 Planning to Adapt to Climate Change

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NI 189 Flood (and coastal erosion) risk management NI 190 Achievement in meeting standards for the control system for animal health NI 193 Percentage of municipal waste landfilled

CURRENT RELEVANT STRATEGIC PRIORITIES x

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7. Community safety - Are they safe? a. Are they safe from maltreatment, neglect, violence and sexual exploitation? STATUS x Considerable progress has been made in safeguarding vulnerable adults from abuse in Lambeth through improved awareness, reporting and investigation. This is reflected in an annual upward trend in reported abuse, from 126 alerts in 2005/06 to in excess of 300 in 2007/08. x 93% of Lambeth school children felt very or quite safe from being hurt by other people at home compared with 95% of children nationally (Tell Us 2 survey 2007). x 87% of Lambeth school children felt very or quite safe from being hurt by other people while in school compared with 85% of children nationally (Tell Us 2 survey 2007). x At 31 March 2007 there were 62 children aged 4 and under and 113 children aged 5-15 on the child protection register (CPR).60 By 2007/08 there were 245 in total. The numbers of children on the CPR exceed London and national averages. x Re-registrations on the CPR were reduced from 12.5% in 2006/07 to 10.1% in 2007/8, indicating effective intervention. x There were 525 looked after children (LAC) in Lambeth in 2007/08. The number of LAC exceeds London and national averages but has reduced from 660 in 2005/06. x The number of actions on registration on safety for new childcare providers has significantly reduced from 59% in March 07 to 16.9% in March 08 and on child protection from 17.9% in March 07 to 12% in March 08.

SIGNIFICANT INEQUALITIES IDENTIFIED x Over 70% of LAC are from BME communities. x 74.31% of children and young people on the CPR at 31 March 2008 were from BME communities.61 NATIONAL PRIORITIES Reference Indicator NI 70 Hospital admissions caused by unintentional and deliberate injuries to children and young people NI 68 Percentage of referrals to children’s social care going on to initial assessment NI 59 Percentage of initial assessments for children’s social care carried out within 7 working days of referral NI 60 Percentage of core assessments for children’s social care that were carried out within 35 working days of their commencement. NI 64 Child protection plans lasting 2 yrs or more NI 65 Percentage of children becoming the subject of Child Protection Plan for a second or subsequent time NI 66 Percentage of looked after children cases which were reviewed within required timescales

60 London Borough of Lambeth. Childcare Sufficiency Assessment. 2007 61 CPR3 Statutory Return 07/08 Lambeth JSNA – Preliminary Assessment 75 Version 4 November 2008 Page 80

NI 67 Percentage of child protection cases which were reviewed within required timescales

CURRENT RELEVANT STRATEGIC PRIORITIES x Improve support to families who have identified additional needs and where there is a responsibility to safeguard children and young people (Lambeth Children and Young People’s Plan 2 2007-10)

b. Are they safe from accidental injury and death? STATUS x Accidents and unintentional injuries are the third main cause of premature mortality in Lambeth. x In 2005-06, Lambeth had the highest number of adults killed or seriously injured on our roads compared with our NN group with 162 accidents, compared with the average of 112. x Figures for people killed and seriously injured on the roads (adults and children) are steadily decreasing in line with DfT targets and the Mayor’s enhanced targets. However, there remain two areas of particular concern, where casualty figures have remained constant or only decreased by a small amount: cyclists and motorbike riders. This is in common with other London boroughs. x There are now 69% fewer serious child road accidents in Lambeth than 10 years ago. This reduction has exceeded both the national (50%) and London (60%) targets. x Lambeth had the 3rd lowest figure of 7 children killed or seriously injured in 2005-06, amongst our NN group, the average being 11. x There were 161 recorded arson incidents in 2005-06, 5th lowest within the NN group, with the average incidents across the group being 189. x There were a total of 436 new service users aged 65 and over that received one or more items of Telecare equipment during 2007/08. x In 2005-06, 87.5% of all food businesses were contacted. Of these, 100% of those classed as ‘high risk’ premises were deemed compliant with food hygiene law. For medium and low risk premises, they were 93.4% and 90.2% compliant respectively. 62 x In 2006, Lambeth had 235 reported incidences of food poisoning compared with the London average of 201.63 x In 2007-08 there was a total weight of 1,079 kg of sex/drugs hazardous waste collected. x Road traffic continues to be the primary cause of air pollution in London with over 90% of all air pollution caused by road vehicles. Vehicle pollutants of greatest concern are Nitrogen Dioxide, Fine Particles (PM10), Carbon Monoxide and Volatile Organic Compounds such as Benzene and 1, 3- Butadiene. Ozone is also a pollutant of some concern. x Lambeth is not currently meeting the Government Air Quality standards for Nitrogen Dioxide and PM10 and the whole borough has been declared an Air Quality Management area in common with other central London boroughs.

62 BVPI returns for 2006-07 63 Food Poisoning Notification Received by the HPA Lambeth JSNA – Preliminary Assessment 76 Version 4 November 2008 Page 81

SIGNIFICANT INEQUALITIES IDENTIFIED x Hospital admission for Serious Unintentional Injury for 0-4 year olds was 98.8 per 100,000 in 2003-04. The London figure was 93.4, and in England and Wales it was 90.24.64 x In 2006, high and very high levels 65of PM10 pollution were recorded at Christchurch Road, Vauxhall Cross and Loughborough Junction. Vauxhall Cross was the worst within the borough with 86 days recorded very high levels of PM10.

NATIONAL PRIORITIES Reference Indicator NI 47 People killed or seriously injured in road traffic accidents NI 48 Children killed or seriously injured in road traffic accidents NI 49 Number of primary fires and related fatalities and non-fatal casualties (excluding precautionary checks) NI 184 Food establishments in the area which are broadly compliant with food hygiene law NI 194 Air quality - % reduction in NOx and primary PM10 emissions through local authority’s estate and operations

CURRENT RELEVANT STRATEGIC PRIORITIES x Lambeth will seek a genuine reduction in danger for all road users by identifying and controlling the principle sources of threat. (Lambeth Road Safety Plan, based around the Mayors casualty reduction targets for 2010, part of the wider Transport Local Implementation Plan 2005 - 2011).

c. Are they safe from bullying and discrimination? STATUS x 69% of Lambeth school children say that they had never been bullied in school in the past 4 weeks compared with 70% in England as a whole (Tell Us 2 survey 2007). x All Lambeth schools have anti-bullying strategies in place. x 30 primary schools and 4 secondary schools have developed a peer mediation service to tackle bullying. x 54% of Lambeth school children felt their schools dealt very well with bullying compared with 57% of children nationally (Tell Us 2 survey 2007). x 8% of Lambeth school children say that they had been bullied most days in school in the past 4 weeks compared with 5% in England as a whole (Tell Us 2 survey 2007).

SIGNIFICANT INEQUALITIES IDENTIFIED x

NATIONAL PRIORITIES

64 Lambeth PCT. Health Risks in Lambeth: Annual Report of the Director of Public Health. 2006. 65 ‘High’ = Significant effects may be noticed by sensitive individuals and action to avoid or reduce these effects may be needed (e.g. reducing exposure by spending less time in polluted areas outdoors). Asthmatics will find that their 'reliever' inhaler is likely to reverse the effects on the lung. ‘Very high’ = the effects on sensitive individuals described for 'High' levels of pollution may worsen. Lambeth JSNA – Preliminary Assessment 77 Version 4 November 2008 Page 82

Reference Indicator NI 69 Children who have experienced bullying

CURRENT RELEVANT STRATEGIC PRIORITIES x Supporting young people (Safer Lambeth strategic plan 2008) x Support more active and respectful communities (Safer Lambeth strategic plan 2008)

d. Are they safe from crime and anti-social behaviour? STATUS Perceptions x Crime overwhelmingly remains the number one priority of Lambeth residents with almost two thirds (61%) of adult respondents highlighting it as their main concern in the Residents’ survey 2007. This compares with 62% Inner London average and 54% across London as a whole. x 43% of adult residents thought that policing in the Lambeth area was good or excellent; this compares with 47% across inner London (Residents’ survey 2007). x In common with the rest of London, the top 4 concerns of young people in Lambeth are crime, bad behaviour, bullying and drug users or drug pushers (Lambeth Residents’ Survey 2007). 59% of young people put crime as one of their top 3 issues of personal concern. 32% of young people included bad behaviour in their top 3. x 80% of adult residents felt “Very/Fairly safe” in the area where they live during the day but that dropped to 45% after dark. (Lambeth Residents’ Survey 2007) This compares with Inner London (average of 78% by day; 46% after dark) and London (average of 79% by day, 46% after dark). x 75% of young people felt “Very/Fairly safe” in the area where they live during the day but that dropped to 31% after dark. This compares with Inner London (average of 68% by day; 35% after dark) and London (average of 70% by day, 36% after dark) (Lambeth Residents’ Survey 2007). x 71% of Lambeth school children feel very safe or quite safe from being hurt by other people around their local area compared with 74% of children nationally (Tell Us 2 survey 2007). x 50% of adult respondents to the Residents’ survey 2007 felt that “teenagers hanging around on the streets” was a very or fairly big problem. x 50% of adult respondents to the Residents’ survey 2007 felt that people using or dealing drugs was a very or fairly big problem compared with 41% across Inner London. x “Groups of Youths”, “People around the area” and “the reputation of the area” are the main reasons influencing how safe people in the community feel (Fear of Crime and Victimisation survey 2007).

Crime x Lambeth is a high crime area with continuing levels of serious crime and offending above the national average. Lambeth ranks 12th out of the top 40

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high crime partnership areas in England66 and within the top 3 high crime boroughs in London. x Since April 2005, success in reducing crime has been measured using a basket of British Crime Survey (BCS) comparator crimes PSA167. Lambeth is within the 3 top high crime boroughs in London on its level of PSA1 crime but has achieved a 30% reduction in the 3 years to 2007/08. This above- target reduction was the 3rd highest percentage decrease in the Metropolitan Police Service (MPS) area over that period. x In comparison with the neighbouring boroughs of Wandsworth and Southwark in 2006/07, Lambeth has the highest cost of estimated crime of all 3 boroughs at £310.5m. However, of the 3 boroughs Lambeth has enjoyed the greatest reductions in cost over the 3 year period to 2006/07 (£42m reduction). x Although murder accounts for a very small percentage of Total Notifiable Offences (TNOs), Lambeth is currently ranked highest on a count basis of the 31 London boroughs. Lambeth had 23 murders in 2007/08, up from 15 in 2006/07. x Lambeth has the highest levels in its CRDP family68 of robbery (both personal and business) but has seen an encouraging 15% reduction in personal robbery since 2003/04. x Lambeth has the highest level of recorded rape offences in its CRDP family but has seen a very significant 23.5% reduction in recorded offences in 2006/07 when compared with 2002/03. x A 19% decrease was achieved in Grievous Bodily Harm (GBH) offences in 2007/08 compared with the previous year. Lambeth is currently ranked 4th highest of the London boroughs on a count basis for GBH. x Lambeth saw a decrease of 6.8% in Gun-enabled crime in 2007/08 when compared with the previous year. The borough is ranked second highest of the CRDP family on a count basis. x Drug and alcohol misuse are seen as the key ‘drivers’ that lie behind much crime and fear of crime in the borough. More residents in Lambeth see drugs as a significant problem than the London average and drugs appear to be easily available, particularly in open, street based markets such as Brixton. More than 70% of arrests in Brixton are for possession or supply of cannabis. The links between drugs and violent and acquisitive crime is well established and 48% of arrests in Lambeth in 2006/7 were for drug related offences. x A quarter of Lambeth’s population is estimated to drink excessively and it is thought that the borough has higher levels of alcohol related hospital admissions than the average for London or England69. Links between alcohol and domestic violence are well known, though links with other violent crime types in Lambeth is less clear. It is likely that alcohol can exacerbate incidents of violent crime such as stranger violence, mugging rape and MPS believe that robbery victims in entertainment and transport

66 The areas with the highest rates of recorded crime per head of population plus the highest crime levels (each being given equal weight) as measured using the BCS comparator in 2003/04. 67 PSA1 consists of Robbery of Personal Property, Burglary dwelling, Theft of motor vehicle, Theft from motor vehicle, Motor vehicle interference & tampering, Theft person – snatch, Theft person – pick pocket, BCS wounding, BCS criminal damage, BCS common assault, Theft of pedal cycle. 68 CRDP family comprise Brent, Camden, Greenwich, Hackney, Hammersmith and Fulham, Haringey, Hounslow, Islington, Lewisham, Southwark, Tower Hamlets, Waltham Forest, Wandsworth. 69 Lambeth Alcohol Needs Assessment 2006/07 Lambeth JSNA – Preliminary Assessment 79 Version 4 November 2008 Page 84

hubs at night are more likely to be drunk. TfL and BTP also link alcohol to violent crime on transport networks, generally at night. x Youth offending is higher in Lambeth than the London or national average. The borough has a higher rate of first time entrants to the youth justice system and young people tend to be involved in more serious types of offending – 12% of convictions result in custodial sentences in Lambeth compared to only 8% in London and 6% nationally. There is significant over- representation in the youth justice system of BME males, 76% of the youth offending population in 2006/07. x The involvement of young people in serious violent offending is increasing across London and this is mirrored in Lambeth. For example, the average ages of both suspects and victims in Operation Trident70 investigated shootings has dropped significantly in the past four years – from 24yrs three years ago to 19yrs now. Five young people age 18 or under were murdered in Lambeth in 2007/8. x The 2007 MPS survey found 27 youth gangs in Lambeth out of 171 in London. x As with other crime types, reported Hate crimes have been falling in recent years. Lambeth has seen a decrease of 13% in Racial incidents in 2007/08 compared with the previous year. There has also been a decrease of 21% in Homophobic incidents in 2007/8 compared with the previous year. x The National Domestic Violence helpline received 322 calls from Lambeth women between Jan and June 2005. This was the highest rate of any London borough and 100 more calls than the second highest borough. x The Gaia Domestic Violence refuge centre supported 626 Lambeth women between May 2006 and March 2008. 47.3% of these clients were self- referrals. x 37.1% of clients using the Gaia centre between May 2006 and March 2008 were aged 18-29. A further 42.8% were aged 30-44. x Where the information was available for Gaia centre clients between May 2006 and March 2008, 15.3% of clients had a substance misuse need, 35% had a mental health need, 19.7% had a disability and 44% had a suicidal tendency. x 40.1% of the perpetrators of domestic violence on women using the Gaia centre between May 2006 and March 2008 were current spouses or partners. 46.2% of perpetrators were ex-spouses or ex-partners. x During 2006/07, 24.7% of domestic violence crimes were repeat offences. x 30% of people surveyed reported that they had been a victim of crime within Lambeth in the last 12 months and 20% had been victimised more than once. Of those who had been victims of crime, only 57% had reported it to the police (Fear of Crime and Victimisation survey 2007). Anti-social behaviour x The reported incidence of Anti Social Behaviour (ASB) in Lambeth is recorded by the MPS according to the National Standard for Incident Recording (NSIR) categories as follows:

Substance Misuse Malicious / Nuisance Abandoned Vehicle Vehicle Nuisance / Communications Inappropriate Vehicle use

70 This is an ongoing MPS-wide operation preventing and investigating shootings in London. Lambeth JSNA – Preliminary Assessment 80 Version 4 November 2008 Page 85

Rowdy / Rowdy / Nuisance Hate Incident Trespass Inconsiderate Neighbours Behaviour Street Drinking Noise Nuisance Prostitution Related Begging / Vagrancy Activity Possess / Sale / Use Animal Problems Hoax call to Environmental of Fireworks Emergency Services damage / littering

x The MPS are not the only recording agency in Lambeth, but currently provide the most comprehensive data set for analysis. However, there is a recognized deficit in environmental content due to under reporting of these incidents to the Police. x A combined baseline total of 26,664 ASB incidents were recorded in 2006/07 across Lambeth. This is a combined total of data on ASB type incidents held by the Police, Park Rangers, Local Authority Noise statistics, British Transport Police and Housing (Housemark) data. x Most reported incidents of ASB were reported in Coldharbour (1st) and Bishops (2nd) wards. These two wards stand out, especially when compared with Tulse Hill (3rd) which had only approximately half the count of Coldharbour. x Rowdy / Inconsiderate behaviour is the highest reported type of incident in all 21 wards. x There are more reported incidents in the northern half of the borough in comparison with the south. x Although no long-term trend data is yet available, when considered in overview there appears to be peak of ASB offences in the summer months (July-August) with a further spike in October (coinciding with Bonfire night) followed by a drop from November through the winter. x 24% of adults avoid using the bus due to anti-social or violent young people. 27% avoid using it because of behaviours classified as disorder. x In 2007-08, there were 992 complaints made about noise during the day time and a further 4,221 complaints received regarding noise at night time.

SIGNIFICANT INEQUALITIES IDENTIFIED Perceptions x 51% of young people aged 11 to 17 felt that not enough was being to protect young people in the borough. This is up from 47% in 2005 and higher than both the London (42%) and inner London (50%) averages. (Lambeth residents’ survey 2007). Crime x Young people (aged 10-17 inclusive) accounted for only 15% of all persons accused of Notifiable Offences (in comparison with adults) in 2006/07. x MPS research of robbery of personal property showed that 56% of suspects were aged 16-20 years with those aged 11-15 years accounting for 22%.The victims of robbery are also most likely to be aged 15-19.

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x The peak age of both victims and perpetrators involved in Trident- related gang and group violent offending in London fell from 24 years in 2004 to 19 years in 2006. x Of those surveyed who reported being victims of crime to the Police in the last 12 months, 44% were aged 16-19 years old and 42% were Asian (Fear of Crime and Victimisation survey 2007). x Women victims of crime in the last 12 months were found to be slightly more likely to report the crime to the Police. Black and mixed groups were least likely to report being a victim of crime as well as those who had disabilities (Fear of Crime and Victimisation survey 2007). x Victims of property crime and disorder were most likely to report crime where as only 59% reported violent crime and 33% reported hate crime (Fear of Crime and Victimisation survey 2007).

Anti-social behaviour x 14 out of 21 wards record substance misuse as the second most prolific issue (after rowdy behaviour). The 14 wards are (alphabetically) Brixton Hill, Clapham Common, Coldharbour, Ferndale, Gipsy Hill, Herne Hill, Knights Hill, Larkhall, Oval, Princes, Stockwell, Thornton, Tulse Hill and Vassall. x 6 out of 21 wards record street drinking as the second most prolific issue (after rowdy behaviour). The 6 wards are (alphabetically) Bishops, Clapham Town, St Leonards, Streatham Hill, Streatham Wells and Thurlow Park. x 93% of all fireworks incidents are reported during October and November, in the run up to and around bonfire night. Tulse Hill ward had the highest count of firework reports, followed by Coldharbour. x Over 50% of all “Prostitution Related Activity” (NSIR definition) occurs in Tulse Hill ward. x There is a significant increase in the level of Low Level Disorder offences committed by/perpetrated on young people coinciding with the end of the school day.

NATIONAL PRIORITIES Reference Indicator NI 15 Serious violent crime rate NI 16 Serious acquisitive crime rate NI 20 Assault with injury crime rate NI 28 Serious knife crime rate NI 29 Gun crime rate NI 26 Specialist support to victims of a serious sexual offence NI 33 Arson incidents NI 32 Repeat incidents of domestic violence NI 34 Domestic violence - murder NI 36 Protection against terrorist attack NI 37 Awareness of civil protection arrangements in the local area NI 38 Drug-related (Class A) offending rate

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NI 27 Understanding of local concerns about anti-social behaviour and crime by the local council and police NI 21 Dealing with local concerns about anti-social behaviour and crime by the local council and police NI 24 Satisfaction with the way the police and local council dealt with anti-social behaviour NI 25 Satisfaction of different groups with the way the police and local council dealt with anti-social behaviour NI 41 Perceptions of drunk or rowdy behaviour as a problem NI 42 Perceptions of drug use or drug dealing as a problem

CURRENT RELEVANT STRATEGIC PRIORITIES x Reduce serious and violent crime (Safer Lambeth strategic plan 2008) x Support more active and respectful communities (Safer Lambeth strategic plan 2008) x Supporting young people (Safer Lambeth strategic plan 2008)

e. Do they have stability and are they cared for? STATUS x 7,643 adults in Lambeth of all age groups over 18 received social care support services from the council during 2007/08. Of these, 6,217 are supported to live at home and 1,426 are supported in residential or nursing care homes. x The numbers of adult clients of all age groups receiving services during 2007/08 were as follows: Aged 18-64 Aged 65+ Physical disabilities 1,390 4,341 Mental Health 727 232 Learning Disabilities 660 45 Substance Misuse 116 15 Vulnerable People 30 87 TOTAL 2,923 4,720

x 5,095 vulnerable people receive services from Lambeth Supporting People as follows: Number of % of service service users users Older People with support needs 2,200 43.18% People with mental health problems 428 8.4% Single Homeless with support needs 423 8.3% Young People at risk 280 5.5% Rough Sleepers 241 4.73% People with alcohol problems 192 3.77% Offenders/People at risk of offending 146 2.87% Adults with learning disabilities 121 2.37% Women at risk of domestic violence 116 2.28% Teenage parents 78 1.53% Lambeth JSNA – Preliminary Assessment 83 Version 4 November 2008 Page 88

Frail elderly 58 1.14% People with HIV/AIDS 52 1.02% Refugees 31 0.61% Mentally disordered offenders 21 0.41% People with drug problems 12 0.24% Total 5,095 100% x 75% of vulnerable people receiving Supporting People services are Lambeth residents, above the London average of 70%. In 2007/08, 6% of referrals originated from LB Southwark and 4% from LB Westminster. The highest proportion of referrals from outside Lambeth under the London cross-authority protocols are for Rough sleepers and Women at risk of Domestic Violence. x Lambeth provided 64 domestic violence refuge beds in 2007/08; this equates to 2.6 per 10,000 population, more than twice the London target of 1.20 per 10,000 population. x The following groups of vulnerable children and young people access council services: Looked After Children Children at risk of harm Young carers Children with special educational needs or disabilities Children who are very mobile, e.g. traveller and refugee children Children from different faith groups Some BME children and young people Young people at risk of offending and misusing substances Teenage parents Children from low income families. x The long-term stability of LAC has improved with the number of LAC with 3 or more placement moves reduced from 15.4% to 12.6% in 2007/08. x 83% of looked after children and young people in Lambeth are placed in foster care or family placements. The percentage of 10-15 year olds in residential accommodation has reduced from 16.5% to 6.6%. x The adoption rates of LAC have improved from 4.1% in 2006/07 to 6.1% in 2007/08. x There are currently 5 young people over the age of 18 whose SEN require ongoing accommodation and support. A further 26 young care leavers over the age of 21 who are in higher education also receive continued support. x 160 Personal Education Plans (PEP) were completed between April 2006 and March 2007 for a school age cohort of 385 LAC, which equates to 42%. x The number of existing childcare providers judged good or outstanding in Ofsted inspections on Staying Safe rose from 38.7% in March 2007 to 44% in March 08. x Each year approximately 550 young people appear in court for a range of offences and 14% are sentenced to custody, mostly for less than one year.71

71 London Borough of Lambeth. Draft State of the Borough Report: The evidence base supporting the Sustainable Community Strategy. 2008 Lambeth JSNA – Preliminary Assessment 84 Version 4 November 2008 Page 89

SIGNIFICANT INEQUALITIES IDENTIFIED x Lambeth falls within the ‘bottom 10’ priority hotspot areas with lowest performance for Adults with Learning Disabilities in Settled Accommodation. Lambeth has 57%, Wandsworth 61%, Lewisham 63%, compared with the England overall figure of 73% in 2005/06.72

NATIONAL PRIORITIES Reference Indicator NI 145 Adults with learning disabilities in settled accommodation NI 149 Adults in contact with secondary mental health services in settled accommodation NI 61 Timeliness of placements of looked after children for adoption following an agency decision that the child should be placed for adoption NI 62 Stability of placements of looked after children: number of placements NI 63 Stability of placements of looked after children: length of placement NI 71 Children who have run away from home/care overnight NI 147 Care leavers in suitable accommodation NI 43 Young people within the Youth Justice System receiving a conviction in court who are sentenced to custody NI 44 Ethnic composition of offenders on Youth Justice System disposals NI 143 Offenders under probation supervision living in settled and suitable accommodation at the end of their order or licence

CURRENT RELEVANT STRATEGIC PRIORITIES x Improve transition arrangements for vulnerable young people, in particular Looked After children and Children with Disabilities (Lambeth Children and Young People’s Plan 2 2007-10)

72 www.cabinetoffice.gov.uk/social_exclusion_task_force/psa Lambeth JSNA – Preliminary Assessment 85 Version 4 November 2008 Page 90

8. Consultation with stakeholders

Citizen’s forum – Commissioning Strategy Plan – Lambeth PCT

The PCT organized a citizen’s forum to discuss it’s objectives and get an agreement on the priorities identified and objectives or goals set, through the five- year Commissioning Strategy Plan 2007-2012. The main aim of this workshop was to ensure that views of Lambeth residents influence the PCT’s strategic plans including defining priorities and visions for services as well as ensuring particular services meet users’ needs. PCT groups who are helping develop the Commissioning Strategy Plan, were asked to take carefully consider intelligence on public and user views, and to ensure that this is taken into account when defining PCT commissioning priorities, intentions and delivery plans.

The PCT has a great wealth of information on public, patient and user views on healthcare delivery. Much of this information came from direct involvement on a particular subject or service and was either very local or service-specific in nature. This available information was used in addition to the responses received through this citizen’s forum.

This citizen’s forum focused on overall commissioning models and priorities across a range of services and client groups. The questions included in this survey gave intelligence that is Lambeth-specific and very local in nature and therefore highly applicable to our services.

Methodology

Lambeth PCT commissioned OPM to organise a Citizen’s Forum for Lambeth residents. This was to give a sample of the local population an opportunity to engage in some detail on the content of the CSP.

One hundred and sixteen residents were recruited on-street for the event, according to a sample specification designed to reflect the local demographics of the borough. To ensure the desired mix on the day, potential participants were asked to complete a recruitment questionnaire, with questions relating to their occupation, household composition, age, ethnicity and quality of health.

A further 30 participants were recruited from various hard-to-reach groups. This ensured that groups such as older people, specific patient groups, minority ethnic groups and young parents were represented. These participants were recruited through Lambeth-based community and voluntary sector bodies and organisations, which identified and invited suitable service-users on our behalf. It should also be noted that both recruitment phases were limited to English speakers.

105 people attended the event. 79 of these were drawn from the on-street recruitment and the remaining 26 were service users or representatives from the selected hard-to-reach groups. An incentive of £65 was offered to all participants.

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A great deal of useful feedback on the draft CSP was received as part of the pre- consultation process. This was considered very relevant to the full consultation and therefore those responses have been incorporated into this report’s findings.

Identifying Stakeholders

A CSP Communications & Engagement Strategy was developed and relevant stakeholders were identified by the following groups:

Health and social care partners Representatives Influencers Patients & carers Community Internal, including independent practitioners and PBC consortia ‘Hard to Reach’ groups (identified by information Public Health)

A variety of different methods were used to engage with these groups.

Engagement

The methods used to involve stakeholders and the public in the consultation process included: - Sending consultation documents out and inviting comments - Meetings - Media press release - Use of PCT website - Internal communication

Hard to reach groups: In addition, the PCT made specific efforts to engage with ‘hard to reach’ groups using public health expertise to identify which groups were priority targets for the consultation process i.e. those that had not been adequately engaged by other aspects of the consultation process and who would be affected by the CSP proposals. Hard to reach groups included refugees, homeless, disabled (both children and adults), housebound Older Adults.

Consultation feedback

Throughout the consultation, target audiences were given four routes for submitting feedback:

Email Website online questionnaire Post Direct feedback to PCT staff at consultation meetings, including formal meetings, forums or focus groups

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In addition, the Citizen’s Forum and ‘hard to reach’ focus groups hosted by OPM also provided valuable feedback on the contents of the CSP.

Main findings 1. A strong and very widespread level support for the contents of the CSP. Its strategic goals, themes and the priority areas were backed and welcomed by the vast majority of respondents; many said these were congruent with their own priorities or areas of work. 2. A great deal of support for including Staying Healthy and Mental Health as priorities. 3. There was concern about the ‘phasing out’ of priorities over time – particularly Children and Young People. 4. There is a perception that the PCT could do more to communicate better with both the public and stakeholders on an ongoing basis. 5. Many respondents queried whether patient and public involvement to ensure services are responsive had been given enough emphasis in the document. 6. It was felt that dentistry had not received the attention and emphasis it required in the CSP. 7. Children with disabilities were highlighted by respondents as a particular area of concern that was not adequately addressed by the CSP. 8. Respondents consistently emphasised the importance of working closely with the council to achieve these improvements, coupled with a perception that current joint working is poor. 9. In addition, there was a great deal of re-emphasis on the importance of working with and placing services within schools in order to achieve the objectives described for the Staying Healthy and Children and Young People’s strategies. It is therefore suggested these issues need to be expanded in the next iteration of the CSP. 10. The lack of close working with the voluntary sector was also highlighted as a concern by some – and one that should be addressed further in the CSP. 11. The difficulty of accessing both primary and secondary care services (both GP and hospitals) was an issue that recurred in feedback.

Actions

After reviewing the findings, several actions were suggested as a consequence of consultation. Detailed feedback received was collated and categorised and then shared with relevant leads in the various directorates. This will allow them to incorporate specific ideas and feedback into their own plans and implementation processes.

Conclusions

Overall, the Consultation on the Commissioning Strategy Plan (alongside Healthcare for London) is one the largest consultation exercises the PCT has ever engaged in. This has generally proven to be extremely successful and has yielded very useful feedback and supported engagement with local stakeholders and residents. However, it should also be acknowledged that this has required strong senior leadership and some financial investment to be successful. Lambeth JSNA – Preliminary Assessment 88 Version 4 November 2008 Page 93

The main finding of the consultation is that there is strong and widespread support for the main contents of the Commissioning Strategy Plan. Hence, it reaffirms that the internal PCT planning processes have been robust and responsive to what is known about public and user priorities. This should give the organisation confidence developing and implementing the proposals of the CSP over the next few years.

The challenge going forward for the PCT is to ensure that the detailed feedback received meaningfully impacts and informs how commissioning intentions are framed and implemented. Moreover, the lessons learned from this consultation exercise should be used to inform future public involvement work. Specifically, the PCT needs to develop a stronger framework for engaging in an ongoing dialogue with the local public, other stakeholders and hard to reach groups on issues relating to the PCT and its strategic plans.

In addition, the health and social care Voluntary and Community sector forum will be focussing on the work related to consultation with the voluntary sector representatives to identify any gaps that need to be addressed to achieve better health and well-being outcomes especially for vulnerable groups. This forum is made up of over 200 voluntary organisations, both funded and unfunded groups, small local organisations working with Lambeth’s residents. It is co-chaired by two representatives from the voluntary sector and two from the statutory sector.

Customer focus programme – Literature review.

Summary of a recently conducted review by the Research and Policy division of LBL, drawn from a variety of sources detailing service satisfaction is enclosed below.

This literature review has drawn on a variety of sources detailing service satisfaction and citizens’ perceptions of their customer experience in Lambeth. These have included the 2007 residents’ survey, BVPI surveys and qualitative research carried out with residents. A full list of sources is listed in the bibliography. This review only contains data that was made available and is by no means exhaustive.

Based on the customer service data available, well-performing services include parks and open spaces, nursery education, recycling and public transport. Services where the customer experience needs improving are council housing, parking, leisure and sports facilities and planning.

Communications at Lambeth are improving and 70% of residents believe Lambeth are good at keeping them informed which is better than London. People’s preferred channels of communication are Lambeth Life, information provided by the council and the website. Service users prefer to get information relevant to their specific service use through direct letters and would like to be better informed about what services they are entitled to and how to access them.

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People are keen to hear how services are performing and whether they are keeping their promises. They would like to see balanced, realistic reporting (not just good news) that shows how money is being spent to tackle important local issues.

Most people contact the council by telephone (70%) followed by face to face contact at 13%. Face to face contact increases to 34% for housing tenants. Whilst happy to use it as a source of information, people have less faith in using the internet for interactive contact.

It is getting easier to get through to Lambeth on the phone, phones are answered promptly and staff are perceived to be polite and helpful. However, customers across service areas are less satisfied with the resolution of their problems. It can be difficult to speak to the correct person and there is perceived to be a lack of joined-up working between front and back office staff. Prompt resolution of problems is an important area of customer service to be addressed.

Half (48%) of Lambeth residents currently feel that they can influence local decisions which is higher than the London average (43%). There is an appetite among Lambeth residents to be involved in local decision making with 40% keen to be involved regardless and 52% dependant on the issue. One in five (20%) residents have taken part in consultation, an increase from 16% in 2005, but there is a need for consultation to be meaningful and for honest feedback that shows how people’s views have been taken into account.

Recommendations for further research - At Lambeth Council, we currently have a weak understanding about how Lambeth residents view the services offered by partnership organisations: What do people think of their customer experience of Job Centre Plus, Metropolitan and community police services, health services, the voluntary and community sector and fire services within the borough? How well do council services link up with partnership services? How can these services complement each other and work better together?

- Research has shown that there are two groups of people accessing services within Lambeth. One group uses a lot of services and require detailed contact specific to their needs. They like to contact us by phone or in person. The other group use very few services and may potentially want less contact. Research could be carried out to determine whether this is the case and how customer service can best be structured to meet the needs of heavy and light users of local services.

- There is currently little information available on the views of business users. It would be interesting to understand their views on the services they use and how they could be improved.

- Although people see the internet as an important source of information, there appears to be barriers to using technology interactively for contacting services, making payments and resolving problems. Further work could investigate the barriers to interactive contact via the internet.

The entire review is enclosed as an appendix. Lambeth JSNA – Preliminary Assessment 90 Version 4 November 2008 Page 95

9. Review of needs assessments

Health Needs assessments are a primary source of identifying gaps in services for health and service improvement. Lambeth PCT conducts needs assessment routinely to influence commissioning decisions. A proforma was created and used for reviewing health needs that are completed in health and social care as part of the Joint Strategic Needs Assessments. The following health needs assessments were reviewed: Alcohol, Physical Activity, children and young people, older people, teenage pregnancy, sexual health.

Summary of findings and recommendations where provided by the needs assessments are as follows:

Alcohol

Summary of needs Met Epidemiology x Male predominance in deaths due to alcohol fallen from 87% to 56% (2001-5) Service access x ARP (Alcohol Recovery Project) and acute services believed to be high quality when accessible Unmet Epidemiology x Rising mortality in females from alcohol; projected to exceed males x Underestimation of extent of problem in A+E and ambulance, as ICD-10 coding not used Service access x Low self-referral to services (3% in Lambeth vs. 36% nationally) and poor links between acute and rehabilitation services x 67% in-patient referral below target of 80% x 61 and under have less knowledge than nationally (0.5% vs. 78% nationally) x Alcohol services at maximum capacity, poor accessibility, not culturally specific, not holistic x Poor use of community strategies and integrated care pathway

Summary of recommendations Medical care x Screening and brief interventions in community/primary settings, complex care should be referred to specialist centres. Development and use of integrated care pathways x Ensure quality of care through use of standards such as DANOS/NOS Service provision and configuration x Need to increase capacity, community based specialist outreach services, shared care with primary care. x Ensure accessibility and targeting of specific groups (BAME, young people, women etc) Health promotion x Need for media and marketing strategy in both health and non-health centres Information, monitoring and performance management x Need to improve A+E and ambulance coding. Data needs to be collected on alcohol attributable appointments in primary care setting

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Licensing and community approaches x Extension of existing licensing process and health promotion strategies

Summary of implementation plan x Use Models of care for alcohol misusers (MoCAM) guidance as framework for commissioning x Increase capacity through community based specialist outreach services, increase accessibility through more walk-in centres and out of hours services x Develop programmes and services to target specific groups x Develop media and marketing strategy (e.g. leaflets, posters) and target health and non- health settings, including alcohol service directory x Data collection and analysis of A+E and ambulance use, primary care appointments and alcohol services use attributable to alcohol. Analysis along integrated care pathway x Extend “Safer Socialising” scheme with incorporation of general health promotion e.g. Night Club Health interventions x Use the Licensing process to ensure use by local businesses.

Children and young people

Summary of needs Met Antenatal-infancy x Higher breastfeeding rate than nationally x Maternal smoking rate equivalent to nationally Age 1-5 x Lower tooth decay than nationally x Increase in number of nursery places between 1997 and 2004 Age 5-15 x Lower level obesity than nationally Unmet x High number of children living in poverty Antenatal-infancy x Lower immunisation coverage than nationally, lower than 95% target x Significantly low birth rates in Tulse Hill, Coldharbour and Vassall wards Age 5-15 x Significantly raised under-15 mortality rate Age 16-19 x Higher teenage pregnancy rate than nationally Children with disabilities x Disability register not up to date Children and adolescent’s mental health x Children whose 1st language is not English may not be known to housing/family support/health services and often have higher mental health needs x Children in care homes and looked after children have poorer outcomes x Higher prevalence mental health problems in boys and white children x Unmet need for treatment of conduct disorders, psychotic disorders, eating disorders (? Incomplete data)

Summary of recommendations Antenatal-infancy x Antenatal Care: Ensure mobility within borough and between boroughs, chase addresses, universal electronic record keeping, improve communication between Lambeth JSNA – Preliminary Assessment 92 Version 4 November 2008 Page 97

professionals x Domestic Violence: increase capacity, implement guidelines (DH) and develop maternity liaison committee x Improve interpretation services x Improve parent support (e.g. from specialist Health Visitor), improve specialist training and increase capacity in health visiting, especially infant mental health x Make care pathway more flexible for vulnerable groups Age 1-5 x Upgrade IT systems and improve information exchange and communication x CAMHS to involve parents more and carry out earlier interventions x Joint commissioning, pooled budgets x Immunisation – improve funding for Coordinators, educate parents and professionals x Accidents – develop multiagency forum x Nutrition – develop group to take forward general nutrition issues and target specific groups Age 5-15 x Develop school and non-school settings and reach children/families that don’t attend x Effective joint commissioning (PCT and LBL in particular) x Nutrition –encompass physical activity, restrict fast-food and similar outlets near schools x Safeguard needs of children from emerging communities Age 16-19 x Risky Behaviour: involve young people in development and monitoring of services, integrate adolescent services x Adolescent services: focus on cultural change and challenging values, co-ordinate transition and family support x Effective joint commissioning (PCT and LBL in particular) x Healthy lifestyles: Behaviour and education, more voluntary sector investment and input Children with disabilities x Make use of Sure Start and Children Centres for early intervention x Effective joint commissioning (e.g. Looked after children & Children with disabilities), x Make use of key worker for transition x Make use of health visitor support for families with complex needs x Share and validate data Children and adolescent’s mental health x Improve staff cultural sensitivity and awareness x Implement wide multi-agency working to target “risky behaviours” in CYP x Promote emotional well-being, using positive language. Improve the confidence of the local population in accessing services x Agree inter-agency protocols and pathways, clarify communication (tier 1 to 4) and agree a shared vision x Expand tier 1 (universal) training e.g. health visitors and pre-school day-care x Improve understanding of what is available to CYP and parents with mental health/behaviour issues and how to access such resources x Integrate prevention services into comprehensive CAMHS x Intervene early and provide family support x Ensure smooth transition to adult mental health services

Summary of implementation plan Antenatal-infancy x Antenatal care: CYPSP, Commissioning Group and TPPPB to ensure improved record Lambeth JSNA – Preliminary Assessment 93 Version 4 November 2008 Page 98

keeping, use of electronic record and improved access to primary care x Domestic violence (DV): CYPSP to implement DH guidelines, develop maternity liason committee (MLC) and increase DV capacity x Access: PCT shared services aim to reduce waiting times and increase access x Mental health: CAMHS and NHS commissioning and NHS Provider Group to increase capacity in health visiting and improve training, improve parent support and raise awareness of parental mental health issues x Care pathway: CYPSP, NHS Provider and Commissioning to map care pathway and increase its flexibility Age 1-5 x IT: NHS Commissioning to upgrade to RIO system x Partnership: CYPSP to develop joint commissioning and pooled budget x Health: NHS Commissioning, Provider group and Immunisation group to mainstream funding, set up helpline, improve and disseminate education resources regarding immunisation. Expand remit of TOILS obesity group. Implement vision screening and oral health policies x Vulnerable children: Joint commissioning Age 5-15 x School/non-school setting: breakfast clubs, parent education (re: smoking, chronic disease, literacy), improved Health School, deliver counselling and therapy x Nutrition: involve Youth Council and CYP Forum to regulate fast food outlets, promote healthy eating interventions, increase sports facilities, target hard to reach children x Joint commissioning x Safeguarding Board to protect vulnerable children from emerging communities Age 16-19 x User involvement: CYPSP to map use and identify gaps x Promoting healthy lifestyles: Encourage more voluntary sector involvement, target at-risk groups x Risky Behaviour: Sexual Health Strategy Group to improve access to integrated services x Adolescent services: Child and young person centred transition policy x Joint commissioning Children with disabilities x Transition: develop key worker role x Common data set x Access: CYPSP to improve Sure Start and Children Centres resources x Early intervention and Support: CYPSP to improve health visiting and Common Assessment Framework Children and adolescent’s mental health x Access: CAMHS to develop single directory of services available and how to access x CAMHS to promote emotional well-being and cultural sensitivity and develop multi- agency “risky behaviours” interventions and forum. Inter-agency working x Training: CAMHS Commissioning Group to increase tier 1 (universal) training

Teenage pregnancy

Summary of needs Met Services x Low GUM clinic waiting times x Services more user friendly following Modernisation Initiative x Good links with public health

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x Good peer SRE education (SHARES service), good community involvement where available Unmet Services x Low uptake of EHC from Sexual Health Services (SHS). Lower number of accredited pharmacists than neighbouring boroughs x Lower uptake of LARC than neighbouring boroughs x SRE education does not meet demands. However half of secondary school age Lambeth children educated outside borough, so SRE provision unknown Specific groups x Boys, young men and fathers are not adequately targeted x BME groups, asylum seekers, looked after children and care leavers, single parent children, children at special schools, children living on housing estates, children with drug alcohol and mental health issues are not adequately targeted x Emotional support, raising self-esteem, tackling family issues not adequately done

Summary of recommendations x TPPPB should work with other partnerships e.g. Crime and Disorder Reduction Partnership, have more senior representation and widened membership and mainsteam TP funding x Develop a borough wide comprehensive media, marketing and communications strategy to include health promotion, the community and the “night-time economy”. x Development of SRE x Increase capacity of SHS by service redesign and increased investment. Greater prescribing of LARC, improved uptake of Emergency Contraception and condoms in these settings. x Recruit performance specialist to monitor and evaluate services

Summary of implementation plan x Use of life course based approach to TP to map whole care pathway x Appointment of director level members to TPPPB board and widening of membership to include community paediatricians and involve young people’s views x TPPPB to ensure implementation of Local Implementation Grant (LIG) to protect funding of Sure Start Plus x Set up of finance and governance group x Creation of information sub-group to monitor and evaluate services and to report to TPPPB. Development of common dataset x Consider use of small grants scheme to engage with community and voluntary sector x Formation of partnerships to link with smoking in pregnancy, breastfeeding and mental health (e.g. Mental Health Promotion Strategy in PCT). Work with Extended Schools, Children’s Centres and Children’s Services x Broaden scope of Speakeasy programme to help communication between children and parents x Encourage schools to aim for Healthy School Status, involve School Nurses and Health Visitors to improve SRE. Consider starting SRE in primary school x Use Locally Enhanced Services in GP contract to increase LARC prescription and new pharmacy contract to expand EHC provision. Improve signposting and advertising of abortion services x Development of borough-wide comprehensive marketing, media and communications strategy with involvement of PCT and Borough Communications teams

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Physical activity

Summary of needs Met Children aged 1-14 years Follow national guidelines for physical activity better than national average Girls and Young Women Lower levels of inactivity in 16-24 year old girls than nationally Middle aged men (30-44) Initiation of North Lambeth and Southwark Sport Action Zone (SAZ) Older people (60+) Targeted and safe areas for exercise (e.g. active walks, SLIPS, Age Concern Festival, Sheltered Housing Scheme Pilot, Fit as a Fiddle project, Ageing Well project) Increased sports participation in over 55s in England BAME community Lower levels of inactivity in BAME community than nationally People on low income Initiation of North Lambeth and Southwark SAZ Disabled people Lower levels of inactivity in disabled group than nationally Unmet Children aged 1-14 years Continued increase and projected increase in prevalence of obesity Girls and Young Women Highest teenage pregnancy rate in Europe, resulting in higher inactivity Middle aged men (30-44) Higher inactivity than nationally Older people (60+) Higher inactivity than nationally BAME community None of Sport England’s 19 segments are driven by ethnicity, resulting in poor local provision for BAME groups People on low income Higher inactivity than nationally, poor provision of sports facilities in several wards Disabled people Few and sparsely distributed locations in Lambeth with provision for disabled persons

Summary of recommendations Children aged 1-14 years x London Borough of Lambeth to take lead, bringing together various strategies x Strategic marketing x Provision of wide range of activities, strengthen volunteer and club base x Extend exercise referral, continue MEND scheme Girls and Young women x Trail blazing projects (e.g. Recruiting Mothers and Daughters Together), multi- agency Alive and Active programmes x Define and dedicate lead agency and dedicated resource for girls and young women. Establish Girls and Young Women’s Physical Activity Focus/Steering Group Middle aged men (30-44) x Early recruitment to physical activity.

Lambeth JSNA – Preliminary Assessment 96 Version 4 November 2008 Page 101 x PCT to lead initiatives. Integration with initiatives such as SAZ, family orientated exercise Older people (60+) x Agree on an agency to lead strategic development of physicial activity for this age group: Borough Council, PCT, Age Concern x Continue with Age Concern Communities for Health- Healthy Ageing Project BAME community x Interventions should reflect population demographics x Consider results of Sport & Physical Activity Action Plan for Black, Asian and Ethnic Minority Communities in London People on low income x Extend North Lambeth and Southwark SAZ Disabled people x Local strategic planning linked with regional Inclusive and Active plan x Encourage participation, volunteering, increase opportunities

Summary of implementation plan x Communication and translation of health benefits message to policy makers, investment and service managers and community leaders x Development of multi agency Strategic Framework for Physical Activity and Sport x Employ Partnership Manager to establish effective CSPAN x Build pathways using practical examples/Trail Blazer projects for children and young people x Lead sub-groups, ensure priority given to each group through CSPAN. Highest priority for young people, older people, disabled people, low income groups. Secondary priority for middle aged males and young girls and women. Integrated approach to BAME x Shared delivery of health promotion and targeted exercise delivery x Identify low participation and deficiencies, tactical targeting x Building Schools for the Future programme to enhance provision of sport facilities x Invest in volunteers and workforce development x Sustained long term investment x Incorporation of social marketing (findings of five Pro-Active Sport and Physical Activity Partnerships) into Strategic Framework for Physical Activity and Sport in Lambeth

Prisons needs assessment

Summary of needs Met Service provision x Good range of services provided and involvement of specialist services, new provision of art and drama therapy Nov 2007 x 1:1 smoking cessation advice available Health problems x Good identification of patients with diabetes, coronary heart disease, epilepsy Substance misuse x Integrated drug treatment service Unmet Service provision x Lack of electronic data and unlinked data systems, resulting in incomplete information on prisoner and difficulty linking with community health systems x Primary health care service separate from and unlinked to GP service x Variation in staff-prisoner relationship in prison medical services

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x Prisoners sometimes use nicotine patches to supplement cigarette use Health problems x Under-diagnosis of hypertension and smoking cessation intervention x No cardiovascular risk assessments done x Prison Health Performance Indicator for Hepatitis B vaccination not met Mental health x Low uptake of referrals to outreach team- poor management of common mental disorders x Insufficient time in nurse-led mental health outreach service for interventions x Only 1/3 of prisoners referred to mental health services attend- possible causes are release from prison, simultaneous activities, lack of communication regarding appointment, shortage of prison officers x Long waiting times to access acute mental health services (24% wait more than 3 months), resulting in treatment of acutely unwell patients under common law in prison Self-harm/suicide/attempted suicide x Self harm under Safer in Custody directorate with poor link with medical services Substance misuse x Drugs smuggled into prison and injection of controlled drugs occurs in prison x Higher than expected for Brixton Prison number of prisoners on drug detoxification programme x Less drug testing than nationally Sexual health x Condoms only available on request Health promotion x Health promotion plan 2005 not fully implemented. Lack of health promotion leaflets, health promotion induction varies. Less material than nationally Physiotherapy x Only one gym open or 2 available Complaints x Recorded but not always acted on. Often reported to perpetrator Dental x Long waiting times to see dentist: median 33 days, up to 454 days

Summary of recommendations Service provision x Screen all patients for mental illness, chronic diseases, controlled substances by person with appropriate training x Ensure one electronic record with linked database x Integrate primary healthcare wing with GP service x Training for all staff on primary mental health care and common medical emergencies Health problems x Urgently consider harm reduction measures e.g. needle exchange, disinfectant tablets, free condom availability for prevention/reduction HIV/Hep B and C x Follow guidance for Hepatitis B vaccination x Address dental waiting list proactively Mental health x Prioritise management of self harm with mental health lead, strategy and evidence based implementation plan

Lambeth JSNA – Preliminary Assessment 98 Version 4 November 2008 Page 103 x Audit suicide deaths against best practice guidance x Increase counselling and cognitive behavioural therapies for management of common mental illnesses x Discussion about pan-London diversion of prisoners with acute mental illness to NHS facility Substance misuse x Regular and mandatory drug testing Health promotion x Enhance health promotion, including peer education, self-help, smoking cessation advice, information on mental health symptoms, self harm, substance misuse, Hepatitis B and C and TB. x Seek innovative opportunities for exercise

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10. Lambeth priorities

Prioritisation

Why do we prioritise in Public Health?

The growing pressure to meet the 2010 target has placed a strong emphasis on an area approach. This has emphasised a drive to target spearhead areas to reduce health inequalities resulting in a limited scope of action at local level in disadvantaged areas.

PCTs are required to commission health services to “improve health and well being “of the population subject to an available budget. Therefore decisions on how best to allocate available resources need to be taken. However improving well being of the population is too broad criteria for the available resources. History has shown that the demand for care will always exceed the capacity of available resources despite the improvement of knowledge; technology and socio-economic status.

With the labour government priority has been given to reducing health inequalities whilst keeping within budget, which requires that PCT select interventions which bring the maximum benefit for the given resources. So the question is: Which package of services is likely to bring the highest reduction of health inequalities, reducing the gap in health status between socio-economic population groups?

The need to prioritisation has been a powerful force in narrowing the scope of action and potential interventions. However, considerations should be accorded to the fact that prioritising interventions in minority areas that experience most health inequalities may not always be a cost-effective option. This features in the action to prioritise interventions so that benefits are maximised within available resources. NHS is run on public money and at times difficult decisions are made in terms of prioritising investment to focus on reducing the overall burden of disease that is likely to affect quality of life and healthy life expectancy in the long term, while giving due consideration to health inequalities.

How do we prioritise in Public Health?

Public health agenda is dominated by two key objectives - Protection of health and Preventing diseases in the local population. Cost-effective interventions that ensure maximum benefits within available resources with an aim to reduce health inequalities is the main outcome of prioritisation.

Cost-effectiveness Efficiency refers to a service having results (improvement of the health condition) without wasting time, effort or resources ), therefore leading to saving or “added value.” In the NHS, choice of intervention is based on cost effectiveness so long as there is evidence to support it. At PCT level the challenge is to adapt to local needs and find out the most cost-efficient way to deliver a service which is known to be effective. Ensuring that those in needs access the service and that those who Lambeth JSNA – Preliminary Assessment 100 Version 4 November 2008 Page 105 accessed the service all benefit of it, increases cost-efficiency or added value of the services.

The prioritisation process produces a list of potential interventions aiming at reducing or preventing health inequalities by ensuring that resources are distributed according to needs.

There are several drivers that inform and affect public health priority setting. While there may be different approaches to priority setting, this process is largely driven by National priorities set through the Operating framework by the DH where providers need to explicitly plan for delivery especially in terms of following: x Cleanliness and healthcare-associated infections x Improving access x Keeping adults and children well, improving their health and reducing health inequalities x Experience, satisfaction and engagement x Emergency preparedness

The Healthcare Commission’s annual health check drives improvements in healthcare for patients by monitoring progress of work towards meeting targets through the set of indicators included in the National and Local indicator set. A new approach within the Operating Framework 2008-09 for planning and managing priorities both nationally and locally are ‘vital signs’. ‘Vital signs’ can be used to develop local operational plans to deliver against national priorities and inform decisions on local targets.

There has been a shift in approach to improving local services delivered by the NHS, local authorities and public services. The focus has shifted from nationally set targets driving service improvements to a focus on improved outcomes that matter for individuals and local communities, which respond to the local context. Integral to this is partnership working across health and social care and between local and regional organisations. The advent of local area agreements (LAA) and the recent requirement for PCTs and Local Authorities to conduct a Joint Strategic Needs Assessment will be changing the way we prioritise in public health.

Local Area Agreements (LAA) and Joint Strategic Needs Assessment (JSNA)

LAAs deliver prioritisation and co-ordination at a local level and provide a platform for local leadership. LAAs are an agreement between the public and the local authority/NHS. They set out the priorities for a local area agreed between central government and a local area (the local authority and Local Strategic Partnership) and other key partners at the local level.

The Local Government and Public Involvement in Health Act (2007) [Clause 116] places a duty on upper tier local authorities and Primary Care Trusts (PCTs) to undertake a Joint Strategic Needs Assessment (JSNA). This provision has come into force since April 2008. The Director of Public Health, Director of Adult Social Services and Director of Children’s Services are jointly expected to take a lead in producing a strategic needs assessment through strong partnership. (Details in Chapter 6) Lambeth JSNA – Preliminary Assessment 101 Version 4 November 2008 Page 106

The following describes the process of priority setting in light of JSNA and LAA.

JSNA

Primary Local Care Trust Authority

LSP (Local Strategic Partnership)

Priorities

PCT Local Area Commissioning Agreement Priorities

-Mental Health -Healthier Communities & -Long term conditions Older people - Sexual health -Economic Development -Children & Young People -Children & Young People -End of Life care -Community Safety -Staying healthy -Active Communities

The following chart elicits the hierarchy that exists in terms of bureaucracy at present.

Central Government

Department Govt Office Communities of Health For London & Local (Monitoring) Government

NHS Local PCT Authority

Monitored by Monitored through -Health Care Commission -CAA-Comprehensive -Audit Commission Area Assessment -APA Annual Performance Assessment -CSCI – Commission for Social Care Inspection

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What are the PH priorities?

Main public health priorities:

- Improve life expectancy (LE) - Reduce infant mortality. - Reduce premature mortality (deaths under 75 years) from heart disease. - Reduce premature mortality (deaths under 75 years) from cancer.

Additional priorities

In addition to LE and reducing premature deaths from circulatory diseases and cancer, following are PH priorities with regard to prevention, detection & treatment:

Obesity Cancer Screening Hypertension Mental health Smoking CVD risk CHD Sexual health Alcohol assessment Diabetes (TP & HIV)

Smoking, obesity, alcohol and substance misuse have a direct co-relation with circulatory disease and cancer while hypertension, diabetes contribute to the development of circulatory diseases leading to reduction in the healthy life expectancy. Mental health has a direct correlation with physical health and is identified as a priority in Lambeth.

Early intervention provides effective outcomes in the long-term and importance to prevention and early detection and treatment have been highlighted through the Staying healthy work stream developed in the PCT following the five year Commissioning Strategy Plan.

‘Hiten’s Red Box’ (figure below) used traditionally by the PCT, states the areas of high burden and low burden depending on performance and also states whether they are worsening or improving.

Hiten’s red box: update 2006/7 Cardiovascular disease mortality Healthy living issues (smoking, obesity, poor diet, low physical (slower improvement compared for activity, alcohol, drug use) nationally) Chronic liver disease deaths & Cancer mortality morbidity Chronic renal disease morbidity High Burden High Teenage conceptions Hypertensive disorders Mortality from infectious and parasitic disease HIV prevalence STIs prevalence Severe mental illness morbidity Diabetes mortality & morbidity

Infant mortality Drug misuse Immunisation uptake All cause mortality in boys under 15 years All cause mortality in girls under 15 years Mortality from gastric, peptic and

Low Burden Low duodenal ulcers

Improving Worsening

What are Lambeth PCT’s Commissioning Priorities?

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Lambeth PCT’s Commissioning Strategy Plan (CSP) refresh – October 2008

The PCT’s CSP has been developed following use of extensive information sources including the JSNA primary dataset, the Public Health statistical bulletin, the Annual Public Health report 2007/08 amongst others.

The summary of the PCT’s CSP refreshed this year is as follows:

The PCT held a workshop in June 2007 to review what the PCT’s commissioning priorities should be for the next five years. The objective was to consider all the information from our strategic drivers, outlined in Section 2, (such as Public Health data and patient and users’ views), in the context of achieving the PCT’s vision and strategic goals, to determine where the PCT’s efforts should be focussed in the next five years. The Workshop drew from a wide range of expertise, including: 1. The PCT Board 2. The PCT Professional Executive Committee 3. Lambeth Practice Based Commissioning Consortia Leads 4. Lambeth Local Authority Colleagues 5. PCT Commissioners 6. PCT Public Health Consultants 7. PCT Quality and Professional Development Leads 8. Primary Care and Community Services Leads Lambeth JSNA – Preliminary Assessment 105 Version 4 November 2008 Page 110

The comprehensive discussion and analysis at this workshop led to a very clear consensus at this meeting that this 5 year commissioning strategy should focus on the following six priorities:

These were chosen because they are all areas: x Of high local need and inequality x That reflected information on public and user concerns x Where there is clear evidence on effective interventions / models of care that the PCT could implement to improve health outcomes x Where the PCT felt it could do more in terms of its commissioning to secure service change and improvement

The PCT’s Public Consultation on the 5 year Commissioning Strategy plan showed very strong support from local public, users and stakeholders for this choice of 6 priority areas.

The six outcome measures then PCT has identified for WCC assurance are shown in the table below: Priority area Outcome Rationale Long Term Hypertension – the Fit to PCT vision and goals and HfL Conditions proportion of patients themes. with hypertension, CHD, Hypertension management a key stroke and diabetes Lambeth risk factor - success in whose blood pressure is delivering outcome will have a major controlled at 150/90. impact on improving health and inequalities and significant population impact also. Lambeth detection rates lower than national average. Measurable and deliverable but challenging. Effective hypertension management beings patients in to the heath care system, but also promotes self care, early intervention to avoid deterioration and improved health and well being. Children and Maternity - Percentage Fit to PCT vision and goals and HfL Lambeth JSNA – Preliminary Assessment 106 Version 4 November 2008 Page 111

Young People of women booked by 12 themes. weeks Improves access to population group fundamental to delivering parenting and early years strategies. Linked to overall improved outcomes – low birth rate, ethnic inequalities. Low levels of performance currently (40~% achievement) – scope for significant improvement. Measurable. Sexual Health Sexually Transmitted Fit to PCT vision and goals. Disease – the Prevalence of STIs, including percentage of the 15-24 Chlamydia high – with ethnic population screened for inequalities also. Chlamydia. Facilitates access to high risk population groups and hard to reach younger populations – links therefore to prevention of other STIs, including HIV, teenage pregnancy. Evidence of cost effectiveness. Service model and redesign in place to support delivery. Measurable. Mental Health Early intervention and Fit to PCT vision and goals and a Treatment – to increase major priority area within the PCT’s access to psychological mental health strategy. therapies. Areas of current service gap and inequality – implementation of talking therapies review from October 2008 – identification as an outcome will enable assessment of progress and impact.

Staying Healthy Smoking - to achieve Fit to PCT vision and goals and HfL targets for smoking themes. quitters per 100,000 High prevalence with significant health population. impact. Significant inequality in smoking rates between Lambeth and nationally. Current performance against targets is challenging, although services comprehensive – need to explore more innovative approaches. Measurable. End of Life Care Choice – the percentage Fit to PCT vision and goals and HfL of [people who die in the themes. place of their choosing. Current performance (nationally and locally) poor – scope for significant improvement. Will require service development and redesign – supported by Guy’s and St Lambeth JSNA – Preliminary Assessment 107 Version 4 November 2008 Page 112

Thomas’ Charity and Marie Curie initiatives. Inequalities issues – need to ensure consistent focus across cancer and all end of life care.

Further work, utilising the same baseline data and information as above has also been carried out to identify the final two outcome measures. These are as follows: Priority area Outcome Rationale Long Term Diabetes blood sugar Fit to PCT vision and goals and HfL Conditions levels themes. Lambeth detection rates low. Effective management will improve health outcomes and deterioration of morbidity for diabetic patients. Diabetes represents the PCT’s biggest opportunity for shift to out of hospital care (emergency admissions high and hospital check ups). . Measurable. Alcohol or An outcome related either Further work is required to confirm Patient to alcohol or patient the PCT’s final outcome measure. Experience or experience. Flu Vaccines The PCT is keen to include an outcome related to responsiveness of care, linked to its CSP strategic goal. However it wishes to consider further whether the DH measures will provide the optimal outcome for measuring progress in delivering this goal and WCC.

Similarly the PCT is keen to include an outcome related to alcohol, as this is an area of significant need and a key risk factor for the population. Again however it wishes to consider further whether the DH measures will provide the optimal outcome for measuring progress in delivering this goal and WCC.

A further alternative is to include an outcome measure on flu vaccination.

The above outcomes have been identified following a workshop at which all the proposed outcomes were discussed and assessed. The workshop included the PCT’s Board, PEC and Management Team, Practice Based Commissioners, PCT

Lambeth JSNA – Preliminary Assessment 108 Version 4 November 2008 Page 113 public health and commissioning leads, and representatives from key external stakeholders. Over the next few weeks the PCT will carry out the following further work on its 10 outcomes, to ensure a final sub mission in line with final CSP/WCC deadlines.

Staying healthy

1.1. Initiative Outcome Indicators

1. To have completed the first pro-active vascular risk screening of the eligible population (40-74 years)

2. To increase the % of practices with validated registers of patients without symptoms of cardiovascular disease with an absolute risk of CVD events greater than 20% over the next 10 year

3. To reduce smoking prevalence in line with the national targets

4. To increase the range of options available to support increasing physical activity in adults with a CVD risk of greater than 20% over the next 10 years and those just below 20% risk

5. Increase the number/% of patients assessed using the FAST tool (for alcohol consumption). To increase the range of settings in which FAST is used across care settings, with the specific aim of extending its use within and beyond general practice

6. To increase the number of settings actively promoting the mental health and well-being of pre-school and primary age children using evidenced interventions to an agreed standard

7. To reduce the percentage of Lambeth adults and children classified as obese, though the effective implementation of the PCT’s obesity strategy

8. To increase the percentage of Lambeth residents classified as suffering from mental health and well being issue using evidenced interventions to an agreed standard

9. To increase the proportion of PCT spend on health promotion/prevention year on year.

Mental health Lambeth JSNA – Preliminary Assessment 109 Version 4 November 2008 Page 114

Initiative Outcome Indicators

1. Increased access to psychological therapies in line with IAPT: increase in no's of people seen

2. Percentage of adults in contact with secondary MH services in employment: VSC8: N1 150

3. Percentage of adults in contact with mental health services in settled accommodation: VSC06

2- 4: Psychosis: Delivery of 200 new cases by early intervention team

4. High percentage of people with SMI accessing physical health care checks (QOF)

5. Proportion of older people diagnosed with dementia

Children and young people

Initiative Outcome Indicators The approach taken to establishing outcomes for birth is to consider outcomes along the care pathway, from maternity to adolescents. In addition outcomes have been defined for two cross cutting client groups: children and adolescents with mental health issues, and children with disabilities.

1. Maternity - % women booking by 12 weeks - Optimising the health of mother and infant and reducing health inequalities – investment is already underway which will deliver increased capacity in the Healthy Start teams, which include health visitors. In order for women to gain access to key advice and screening it is essential that they access maternity services in a timely way. This will give them access to advice on diet, smoking, antenatal screening, mental health screening, domestic violence screening etc all factors which influence the health of the mother and unborn child.

2. Infancy and early years – Immunisation rates by 2nd and 5th birthday for MMR - Infancy and early years - To have a completed schedule of childhood immunisations, focusing on MMR at age 2 and 5 – immunisation rates in Lambeth continue to below national averages. There is a strong evidence- base surrounding immunisations preventing ill health in infancy and early

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years.

3. School aged children – No. of Lambeth schools achieving advanced Healthy Schools status - To attain 50 of Lambeth schools reaching advanced Healthy Schools status – Good progress has been made in attaining Healthy Schools status in Lambeth, however the advanced program will give the opportunity to give additional focus on emotional well being, substance misuse and sexual health. It is proposed to broaden the programme to do some targeted work on obesity, in addition to any national initiatives.

4. Adolescents – No. of services awarded You’re Welcome Status - Improve youth engagement in health services – there is a high incidence of ill health linked to risky behaviours in Lambeth including, sexual health and substance misuse. Engagement of young people in health services, would promote improved prevention and treatment.

5. Child and Adolescent Mental Health – Young people and their parent’s satisfactions with CAMHS – ‘Value Added’ measure of the Strengths and Difficulties Questionnaire (SDQ) - To maximise young people and their parents satisfaction with CAMHS – to date significance focus on CAMHS has been on ensuring the right processes/services are in place eg 24 hour access. Patient satisfaction is being used nationally as a proxy measure for outcomes rather than process. One of the key priorities identified in the CAMHS strategy is to ensure that a systematic method of obtaining patient feedback is developed in order to improve both the commissioning and the provision of services.

6. Children with disabilities – National Survey, by Borough, of parents of children with disabilities - To maximise young people and their parents satisfaction with services for children with disabilities – There is anecdotal evidence that the number of children with disabilities is increasing. A health needs assessment is currently underway which will allow us to better under stand the issue. Additional investment has already been made with LBL on increased school nurse capacity in special schools, and the Aiming High agenda will specifically increase provision of short breaks for children with disabilities and their families.

Long term conditions

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Initiative Outcome Indicators

1. HbA1c of 7.5 or less (in the last 15 months for diabetic patients) for 70% of diabetic patients by 2013

2. To increase the proportion of patients with hypertension, CHD, stroke and diabetes whose blood pressure is controlled at 150/90

3. To increase in the percentage of stroke admissions given a brain scan within 24 hours

4. Increase the percentage of patients with COPD for whom diagnosis has been confirmed by spirometry

5. A personalised care plan for all patients with a long term condition, starting with patients at highest risk of admission

Sexual health

Initiative Outcome Indicators The following key outcomes and quality improvements are planned through the implementation of the sexual health strategy:

1. GUM 48 hr appointment wait 2. 17% 15-24 year olds screened for chlamydia (as a proxy for prevalence 3. Increase in community service uptake by (a) young people under 25 and (b) by men 4. Increased uptake of long-acting reversible contraception (LARC) 5. Transfer of services from hospital to community settings. 6. Improved patient experience

End of life care

Initiative Outcome Indicators

1. More people to be able to express a choice of place of death - Most people given a choice would prefer to die at home (this definition includes forms of residential care i.e. care homes). Often however the wishes of people coming to the end of their life are not discussed or documented and therefore robust care planning to enable the wishes of the patient are often not in place or happen towards the very end of life. The use of the Preferred Priorities for Care (PPC) document and the monitoring of the use of the PPC Lambeth JSNA – Preliminary Assessment 112 Version 4 November 2008 Page 117

will ensure that we are able to record, communicate and carry out the patient’s wishes.

2. More people dying in the place of their choice - To maximise the number of people who die in the place of their choice and to ensure they receive excellent end of life care where ever that is. While most people express a wish to die at home it is essential that good end of life care is available in all settings.

3. Access to care at home - Most people would prefer to die at home as long as high quality care can be assured and as long as they do not place too great a burden on their family and friends. The Gold Standards Framework (GSF) is now being used by 64% of Lambeth GP practices and there has been an increase in the number of people receiving fully funded palliative continuing care. However patients, carers and referrers report that access to health and social care support and practical help is variable, is not always available 24/7 and in an emergency and can lead to carer burnout.

4. End of life care in care homes - Of the 14 care homes in Lambeth, 5 have been involved in some way with implementing the GSF and 2 of those are progressing to full accreditation. The PCT will be working with other stakeholders to explore additional ways of incentivising care homes to implement both the GSF and Liverpool Care Pathway (LCP). End of life care for people with dementia has been highlighted as a priority area as part of both the MCCP and Modernisation Initiative.

5. Acute care - A 3 year project is underway at GSTT to roll out the LCP across the trust and so far 17 wards have implanted it. Work undertaken as part of the MCDC programme has highlighted discharge planning as an area that needs further work.

6. Access to bereavement services - The PCTs baseline review of EOLC services completed early in 2008 identified a gap in bereavement services. Work is underway with the national charity Cruse to develop a local Lambeth bereavement service.

Planned care

Initiative Outcome Indicators

1. Reduction in cancer mortality

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2. Proportion of eligible population offered appropriate screening e.g. breast, cervical and bowel (TBA)

3. Continued implementation of improved outcome guidance

4. Shift in outpatient attendances to community settings for defined conditions and improved patient reported outcomes

5. Case management offered to 90% of patients identified as at risk of admission (approximately 1600 patients)

Unplanned care

Initiative Outcome Indicators

1. To increase access to walk-in urgent care services

2. To increase access to routine and urgent care services outside the ‘normal’ working week.

3. To increase capacity in urgent care responses in primary care and community services.

4. To reduce the need for urgent / emergency care.

5. To regionalise major trauma services in London (working with Healthcare for London ) and to develop a Sector based trauma networks.

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Sustainable community strategy priorities: To realise our long-term term vision, Lambeth First has identified key priority areas for the next three years. These are set out in our Local Area Agreement, which was approved in June 2008. See Appendix 1 for further details. Vision Lambeth is a diverse, dynamic and enterprising borough at the heart of London

Sustainability Economic Well-Being Social Well-Being Environmental Well- Being Universal Issues Community Cohesion, Equalities, Sustainability and Culture Sustainable Lambeth is a great place Greater wellbeing for Children and young people are Empowered, safe and cohesive places where people have the confidence Improved health and Lower levels of poverty and Mixed and sustainable Community to do business with higher households through higher on the path to success through to play active roles in their communities wellbeing of people which social exclusion in Lambeth by communities with an Strategy 2020 levels of investment and numbers of residents in the provision of good quality enables them to live helping more of our socially increased supply of new Outcomes business growth employment education, training and jobs active and independent excluded adults in employment, homes, improved existing which reduces the risk of lives education and training dwellings and a high exclusion and offending quality physical environment

Lambeth Local Increasing the overall Increasing the number of Improving the emotional health Increasing the percentage of people who feel they can influence Reducing mortality rates Reducing the proportion of Increasing the number of Area Agreement employment rate working age people with a of children decisions in their locality from all circulatory children in poverty affordable homes Level 2 qualification or higher diseases for people under delivered (gross)

75 Priority Areas for Increasing VAT Reducing obesity in primary Increasing overall satisfaction with the local area Increasing the number of adults Improvement Page 119 registration rate for new Increasing the number of 19 school children with learning disabilities in Reducing the number of companies year olds with Level 2 Increasing the number of employment households living in qualifications Building resilience to violent extremism within Lambeth clients receiving self- temporary 2008 - 2011 Improving the stability of directed support accommodation placements for looked after Increasing the number of adults

Reducing the number of 16- children Increasing young people’s participation in positive activities in contact with secondary mental 18 year olds not in education, Increasing the number of health services in employment Reducing per capita CO2 employment or training vulnerable people living emissions in the local

Reducing the under 18 Increasing take-up of formal childcare for low income working families independently authority area conception rate Increasing young offenders

Increasing migrants English engagement in suitable language skills and Reducing serious violent crime Increasing carers needs education, employment or Improving street and knowledge Reducing the gap in assessments undertaken training environmental cleanliness achievement between pupils (levels of graffiti, litter, eligible for free school meals and Reducing serious acquisitive crime detritus and fly posting) Reducing working age people their peers at Key Stage 2 and 4 Increasing offenders under (local PI) claiming out of work benefits probation supervision in Tackling perceptions about drug use and drug dealing employment at the end of their

Reducing the rate of permanent order or licence exclusions from school Reducing the percentage Tackling concerns about anti-social behaviour and crime by the local of non-decent homes (local PI) council and police

Increasing the numbers of volunteers registering (local PI) Our new way of Neighbourhood Working – Where appropriate we will deliver services at the neighbourhood level working

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Chapter 6. Recommendations

The next phase of work as a part of the JSNA will be to identify gaps in terms of understanding current service provision in health and social care to achieve the desired health and well-being outcomes and to reduce inequalities.

To ensure the above, it is important that there is a good understanding of currently provided service and evidence of their efficacy. In addition, a review of evidence to determine cost-effective interventions will complement provision of strategic recommendations in terms of commissioning or decommissioning of service across the health and social care remit.

The areas of work identified are further consultation with stakeholders including the community and voluntary sector, mapping local services specifically those where there are unmet needs in the population, understand market capacity for effective commissioning or decommissioning of services and local impact assessment of proposed recommendations.

Appendix I. JSNA Project Plan. II. Customer focus – Literature review. III. Glossary IV. References documents a. Lambeth - State of the Borough report. b. Lambeth PCT Commissioning Strategy Plan. c. Lambeth Annual Public Health Report. d. Lambeth Public Health Statistical Bulletin. e. Lambeth Sustainable Community Strategy. f. Lambeth Local Area Agreement.

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Appendix 1

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LAMBETH JOINT STRATEGIC NEEDS ASSESSMENT (JSNA)

PROJECT PLAN Version 3.

Jun 30, 2008

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JSNA Project Plan

Overview of Project Background

The concept of Joint Strategic Needs Assessment (JSNA) was introduced in the Department of Health’s (DH) Commissioning Framework for Health and well- being document published in March 2007. The Local Government and Public Involvement in Health Act (2007) [Clause 116] places a duty on upper tier local authorities and Primary Care Trusts (PCT) to undertake a Joint Strategic Needs Assessment (JSNA). This provision came into force in April 2008. The Director of Public Health, Director of Adult Social Services and Director of Children’s Services are jointly expected to take a lead in producing a strategic needs assessment through strong partnership.

The JSNA is expected to “describe the future health care and well-being needs of local population and the strategic direction of service delivery to help meet those needs”. A key element of JSNA is that it should involve all the important stakeholders in identifying needs and take appropriate actions to address those. The assessment process is expected to make use of existing information, identify gaps, actively engage stakeholders including patients and public for their views, understand local service provision; and most importantly, the outputs or findings be translated into actions for the commissioning and delivery of health and social care services, health improvement and well-being programmes and interventions.

Aims and Objectives

Aim

To understand the current and future health and well-being needs of the population; over both short term (3-5 years) to inform Local Area Agreements (LAA), and the longer term (5-10 years) to inform strategic planning and commissioning. Lambeth JSNA – Preliminary assessment 119 Version 4 October 2008 Page 124

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Objectives:

x To develop a process for conducting the Joint Strategic Needs Assessment. To form a steering group and working group. To agree governance arrangements for the JSNA process To agree communication strategy to ensure adequate internal and external communication To list partners and stakeholders to be engaged in development of JSNA. To agree resource requirements.

x To design methods to develop the Lambeth Joint Strategic Needs Assessment. To agree the scope of work. To develop a joint outcomes framework that can be used to describe the health and wellbeing needs and inequalities across Lambeth. To develop and/or agree a prioritisation methodology to identify strategic priorities and offer strategic recommendations for service planning and improvement following the needs assessment.

- To ensure that the output from the JSNA is disseminated to all stakeholders and used in future commissioning. To consult with the public on the final JSNA To disseminate the findings to key stakeholders within the LBL and Lambeth PCT.

Overall Approach

The Department of Health guidance on Joint Strategic Needs Assessment states that the JSNA will provide a framework to examine all the factors that impact on health and well-being of local communities including employment, education, housing and environmental factors. To achieve this, it is proposed that a core dataset be formed which will signpost users to a range of existing data from data sources to assist in the JSNA process. Regarding engagement with stakeholders, Strong and Prosperous communities emphasises that citizens and communities know what they want from services and what needs to be done. It is within the remit of this project to use patient and user experience and build on the duties to consult and involve the stakeholders through LINKs and other such networks.

The JSNA work is expected to deliver the following as a minimum:

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x Achieve a shift towards commissioning to improve health and well-being outcomes and reduce inequalities. x Identify priorities and offer strategic recommendations for service planning and improvement. x Provide evidence about the population on which services are planned to address health inequalities; x Identify gaps in equitable distribution of services; x Create cross-sectoral partnership working and develope creative and effective interventions; x Engage with the populations and enable them to contribute to targeted service planning and resource allocation;

Important factors to ensure objectives are delivered are:

x Joint working, partnerships and collaboration of PCT and various local authority directorates and range of stakeholders. x Agreeing scope of work in terms of deliverables. x Availability and access to range of information related to health, and wider determinants of health and well-being as well as on services currently provided within the borough.

Project Outputs

The JSNA will be presented as a working document which will include the following as a minimum:

1. A joint health and well-being outcomes framework. 2. Analysis of primary and secondary data to illustrate the health and well- being status of local communities. 3. A profile of the population with regard to inequalities and inequities in the context of wider determinants of health and well-being such as environment, economy, transport, housing etc. 4. Map of local statutory services as well as voluntary services contributing to improved health and well-being outcomes. 5. Consultation with stakeholders and gap analysis. 6. Review of evidence of effectiveness of interventions to provide recommendations for cost-effective use of resources while reducing inequity and inequalities.

The presentation of information in the JSNA will be discussed with the commissioners and approach or methods agreed through a series of workshops. The JSNA working draft structure will be agreed jointly with the commissioners and other stakeholders. There are three possible suggestions on presentation of information in the JSNA:

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1. A population-based approach where information related to various indicators including the wider-determinants will be detailed for children and young people, Adults and older people separately.

2. An outcomes based approach will see presentation of information by outcomes to be achieved.

3. A service or specialty specific approach such as mental health, sexual health, housing, environment etc.

Project Outcomes

x Agreeing methodology and process for JSNA and its cyclical review locally. x Prioritisation based on identified needs. x Strategic recommendations to inform commissioning cycles within the PCT and Local Authority. x Feedback to the local community and stakeholders. x Informing the development and/or refresh of the local Community Strategy, PCT Commissioning strategy plan, PCT Local Delivery Plan, Children and Young People’s Plan, PBC Commissioning plans, Community regeneration strategies, Housing strategies, Community Safety Strategy, Carer’s strategies, Workforce planning strategies and other key strategies..

Stakeholder Analysis

Stakeholder Interest / stake Local National health service (PCT) Statutory organisation - General Practitioners & allied staff. - District nurses. - Family planning providers. - Health promotion teams. - Patient Advice and Liaison Service (PALS) - Community pharmacists.

Local Authority Statutory organisation - Neighbourhood services - Social care staff

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- Environmental officers - Housing leads - Community safety leads - Economic development leads - Schools

Community and Voluntary sector Voluntary sector representation Private providers

Risk Analysis

Risk Probability Severity Score Action to (1-5) (1-5) (P x Prevent/Manage Risk S) Staffing 3 4 12 Agree resources to fund additional staffing requirements. Organisational 2 4 8 Effective engagement of partners and good governance arrangements. Technical 2 4 8 Ensure accessibility and availability of sources of information and analytical expertise. Related to external 3 4 12 Communication strategy to partners be developed. Legal 2 5 10 Ensure robust methodology in conducting the JSNA and consultation with legal advisors where need arises.

Standards

Name of standard or Version Notes specification Standards for better Governance 5b health – Public health Patient Focus Healthcare organisations promote, protect D8,9&10 and demonstrably improve the health of the community served, and narrow health Public Health inequalities.

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C22a,c D13a,b&d Core Healthcare organisations identify and act standard C22a upon significant pubic health problems and and c health inequality issues, with primary care trusts taking the leading role;

Technical Development

The JSNA will be a dynamic process with cyclical updates to specific pieces of work such as population health and service related information that will include various indicators (outcome indicators, health indicators, performance indicators). The technical development will be led jointly by lead Directors from Lambeth PCT and the local Authority – London Borough of Lambeth.

Project Management and Resources Project Partners

No. Partner Roles

1. Lambeth Primary Care Trust (Local Joint Lead partner NHS)

2. London Borough of Lambeth Joint Lead partner - Adult and Social Service - Children’s Service

3. The community and voluntary sector Partner (represented through the Lambeth Voluntary Action Council – LVAC)

Project Management The Local Strategic Partnership with have the overarching responsibility to deliver the JSNA while the JSNA Steering Group will provide support and will steer the JSNA Working Group’s progress of work. The JSNA Working Group will be working closely with representatives from the various theme boards such as the Children and young people theme board; Healthier communities and older people board; Economic development and

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DRAFT enterprise and Community safety board. Following is the proposed governance arrangement chart followed by the composition of the JSNA Steering Group and the JSNA Working Group.

The output of JSNA will be fed through the newly formed cross-cutting commissioning group as described in the following chart: Joint Strategic Needs Assessment – Governance

Lambeth Lambeth PCT Cabinet Children & Young People Local Strategic Transformation Partnership Cross Cutting Board Commissioning Safer & Group Stronger Health & Social Communities Care Transformation Partnership Board Children & Adults & Young People Joint Strategic Community Partnership Needs Assessment Steering Group Services DLT Housing Partnership Strategy & Corporate Services Joint Strategic DLT Needs Assessment Metropolitan Working Group Police

Inform Governance

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JSNA Steering Group membership

Role Name Title Programme Sponsor Jo Cleary Executive Director – ACS Ruth Wallis Director of Public Health Phyllis Dunipace Executive Director – CYPS Strategic Commissioning Helen Charlesworth-May Divisional Director, Strategy and Commissioning, ACS Technology & Mary Cotterell Business Transformation Manager – STT Transformation Policy & Performance Sophia Looney Divisional Director - Policy, Equalities & Performance Commissioning & Doreen Redwood Divisional Director Strategy & Performance Performance, CYPS Regeneration & Housing Paul Cooper Assistant Director Programme Manager Kate Hargreaves Senior Transformation Manager Local Area Agreement Active Communities John Kerridge Assistant Director Area Services Community Safety Simon Harding Assistant Director Community Safety Project consultant lead Hiten Dodhia Public Health Consultant (PCT) Project Sub-lead Ash More Lead on JSNA from PCT Project Manager Christian Fleming Lead on JSNA from Lambeth Metropolitan Police TBA TBA

The JSNA Working Group membership

Ash More Public Health Specialist PCT Tarek Iskander AD Strategy and Commissioning PCT Sarah Yandell Health and Social Care Officer LVAC Christian Fleming Head of Performance and Workforce LBL Development, ACS Kevin Dillon Head of Policy, CYPS LBL John Kerridge Asst Director Area Services LBL Ann Skinner Head of Supporting people LBL Ruth Staff Performance Manager, ECCS LBL Megan Jones DAAT Manager, Community Safety LBL Tom Tyson Policy manager, Regen. & Housing LBL Geoff Wade Partnership development and Improvement, LBL Community safety Charlie Conyers Business & Housing Options Development LBL

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Manager, Regen. & Housing Sushma Maharaj Data Analyst, Corporate Regeneration LBL Georges Sen- Research analyst, Quality Performance and LBL Gupta Research Theron Newman Finance manager, ACS policy LBL

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Project timetable with provisional dates Task Initiation date Completion Target date Jun 2008 date status Process Establishing Oct 2007 Oct 2007 Oct 2007 Steering Group Establishing Working Nov 2007 Nov 2007 Nov 2007 Group Agreeing Jan 2008 Mar 2008 Apr 2008 Governance arrangements Resource allocation Nov 2007 In progress May 2008 (Staffing and administrative support) JSNA elements Developing preliminary Jan 2008 Jun 2008 Jun 2008 outcomes framework Demographic and Jan 2007 In progress Sep 2008 health profile - Overview Inequalities in terms of Jan 2007 In progress Sep 2008 wider determinants (housing, environment, economics, etc) Review of needs Apr 2008 In progress Sep 2008 assessments complete and review scope of those underway Consultation with In progress Dec 2008 public and patients (Stakeholder Apr 2008 consultation) Map of local services To be started n/a Sep - Dec 2008 Review of evidence of To be n/a Sep 2008 – Mar effectiveness of started; Pan 2009 interventions London approach also being considered 1.1.1. Output Prioritisation in terms To be started n/a Jan-Mar 2009 of health and well- being needs of the population Strategic To be started Mar-Jun 2009 Lambeth JSNA – Preliminary assessment 128 Version 4 October 2008 Page 133

DRAFT recommendations Lambeth JSNA – Apr 2008 Sep 2008 Preliminary assessment (first draft) Lambeth JSNA – Apr 2008 In progress June 2009 Full assessment (first draft) n/a = Not applicable

Programme Support

The JSNA work relies heavily on engagement of all partners/stakeholders including patient and public engagement. The JSNA project also relies on good governance arrangements and effective communication strategy for both internal communication and external communication especially related to dissemination of findings.

Intellectual Property Rights

The JSNA will be owned jointly by the Lambeth PCT and London Borough of Lambeth through the Local Strategic Partnership; and; the Director of Public Health, Director of Adult and Social Service and Director of Children Services will be the official sponsors of the project.

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Appendix II

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Literature Review

September 2008 Produced by Philippa Hughes Research and Consultation Team Quality, Performance and Research 020 7926 2680 [email protected]

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Executive Summary

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Recommendations for further research

- At Lambeth Council, we currently have a weak understanding about how Lambeth residents view the services offered by partnership organisations: What do people think of their customer experience of Job Centre Plus, Metropolitan and community police services, health services, the voluntary and community sector and fire services within the borough? How well do council services link up with partnership services? How can these services complement each other and work better together?

- There is currently little information available on the views of business users. It would be interesting to understand their views on the services they use and how they could be improved.

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Introduction

What is the Citizens’ Focus Programme?

Lambeth Council and its partners want to improve Customer Services and are committed to developing a shared Customer Focus Programme (CFP) which will achieve this. There is also a desire to link customer services to our ambitions for engaging our communities and improving democratic participation as stated in the corporate plan

Objectives of the strategy x It will be a strategy for the whole council – not just the customer services functions x It will embrace all of our partners – becoming a strategy for Lambeth public services not simply Lambeth council services – and therefore it will be located within the LSP rather than the council x It will respond to the new national agenda for reducing avoidable contact and personalising services which means it may impact on both the design and delivery of our services x It will move beyond seeing people as customers of individual or groups of services, and address them as citizens with broader rights and interests. It will therefore look at how we can use our customer services infrastructure to further our community engagement and democratic objectives. This may mean we should talk in terms of a citizens’ services strategy.

Research underpinning the Customer Focus Programme There is a need to identify what we already know about our citizens; what are their views are about the services offered by the council and partnership organisations? What are they currently happy with and where do they feel improvements are needed?

This literature review is part of a four stage research project which will answer these questions and underpin the development of the CFP. The CFP research project covers: 1. Literature review. 2. Mosaic analysis of 2007 residents’ survey results. 3. Staff workshops with customer-facing staff 4. Complaints analysis This literature review will be complemented by analysis of the Lambeth 2007 residents’ survey results by Mosaic categories of respondents. Staff workshops will also be run with customer-facing staff and complaints will be analysed to Lambeth JSNA – Preliminary assessment 134 Version 4 October 2008 Page 139

DRAFT identify key issues. This initial research will be combined to enable any gaps in knowledge to be identified. New research will then be commissioned to address these gaps.

Scope of literature review There is a wealth of information available about the council and partnership performance. This report aims to draw together satisfaction data from across all services with a view to identify key strengths as well as areas for improvement. It also aims to identify gaps and areas for future research. It is important to remember that this review focuses on the perceptions of Lambeth’s citizens and so may not reflect actual service delivery and only contains data that was made available. It is by no means exhaustive. If you have further data that you would like included, please contact the Research and Consultation team on 020 7926 2680 or [email protected]

Key findings

How important is customer service?

When compared against issues such as tackling crime and antisocial behaviour, customer services are rated as less of a spending priority by Lambeth residents. However, we know from Ipsos MORI research that customer service is a key driver of overall satisfaction.

Research conducted as part of the 2008/09 budget consultation found that any customer service cost savings that can be implemented without too much impact on service delivery would be welcomed by Lambeth residents, including taking a slightly longer time to answer phones and reducing opening hours of call centres in less busy times. However, people are against cost saving measures that they feel will impact on the quality of service delivery. Voice recognition software was not welcomed and people were critical of any move to relocate the Lambeth service centre outside of the borough to save costs73.

73 Your Lambeth, your money, your opinion. Budget consultation 2008. Lambeth JSNA – Preliminary assessment 135 Version 4 October 2008 Page 140

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Service delivery

The table below shows the percentage of users who rated services as good to excellent in the 2007 residents’ survey with the exception of the planning data which is drawn from the 2006 BVPI survey.

High rated services Low rated services Parks and open spaces 71% Activities for young people 74 Nursery education 70% 31/10% Recycling facilities 69% Council housing 33% Public transport 69% Road repairs 35% Libraries 69% Parking 42% Primary education 68% Leisure and sports 42% Planning75 43%

Parks and open spaces (+13), street lighting (+8), housing benefit (+5) and public transport (+4) have all improved since 2005 while planning (-10)76 refuse collection (-6) and policing (-5) are perceived to have gotten worse.

Although perceptions of libraries have improved over time in the 2006 BVPI survey we recorded the lowest score of any borough across London. Interestingly, more recent and reliable data from the 2007 residents’ survey shows that libraries are perceived highly by residents who do use them (69%).

There are occasions where service specific data can tell a different story to the residents’ survey. Four in ten (43%) residents rated the policing in their area as good to excellent in the residents’ survey, compared to 72% who were very or fairly satisfied with the way their local area is policed in a 2007 metropolitan police survey (MPS)77. Similarly, the 2006 tenants’ satisfaction survey shows 62% of tenants are very or fairly satisfied with the service, compared with only 33% who rate it as good or excellent in the residents’ survey.

The four main problems identified by respondents to the 2007 MPS survey were vandalism, graffiti and other deliberate damage to property or vehicles, teenagers hanging around on the streets, people being drunk or rowdy in public places and rubbish or litter lying around.

Activities for young people rate the lowest with only 10% of adults and 31% of young people rating them as good or excellent. So any improvements that can be

74 31% = young people’s view, 10% = adults view. 75 Planning data is taken from the Planning BVPI survey 2006. 76 Planning data is taken from the Planning BVPI survey 2006. 77 Mps public confidence report 2006- 07. Lambeth JSNA – Preliminary assessment 136 Version 4 October 2008 Page 141

DRAFT made to customer services elements would be welcomed and may impact on perceptions of these services overall.

Residents are also less satisfied with the financial management of the council. The budget consultation found that only 30% of residents believe that the council provides good value for money for the council tax they pay and only 17% believe that Lambeth has good financial management. Satisfaction with these measures has decreased since 200578. This ties in with the picture painted by the residents’ survey which shows that although Lambeth has maintained its ratings, it underperforms inner London on five of the six key measures of corporate performance - Providing good value for money for council tax paid (8 points lower), doing a good job (8 points lower), being efficient and well run (6 pints lower), making the area a better place to live (6 points lower) and doing a better job than one year ago (5 points lower).

Satisfaction with the service offered by the planning service is also decreasing with satisfaction having dropped ten percentage points between 2003 and 2006. Six in ten applicants are pleased with the explanation provided for the planning decision, but 37% believe that the information provided about the progress of their application has gotten worse, and 46% believe that their application was dealt with less promptly. These aspects of customer service should be prioritised for improvement79.

The 2007 residents’ survey shows that 61% of Lambeth residents rate local health services as good or excellent. Research conducted by Lambeth PCT about GP practices in 200680 shows that patients are largely satisfied with and were complimentary about reception teams, clinicians and the standard of healthcare that they receive. Patients were less satisfied with the ease of booking appointments and the length of time they have to wait in the surgery before being seen (53%), the lowest satisfaction score. Access to a doctor on the phone for advice remains an issue for many people and has the second lowest level of satisfaction at 59%. These findings suggest that, across the PCT, patients are generally less satisfied than they were in 2005, but are in line with 2004 figures.

In 2008 the national survey of local health services surveyed people over the age of 16 who are registered with a GP. Lambeth is in the best scoring 20% of trusts for receiving answers from the doctor that patients could understand (scoring 89/100), being kept informed about how long they would have to wait to see a doctor (34/100), receiving information regarding any potential side effects their medicine may have (76/100) and receiving copies of letters sent between their GP and a specialist (62/100). However, Lambeth is in the lowest scoring 20% of trusts for the length of time patients have to wait to see a doctor (79/100), being

78 Your Lambeth, your money, your opinion. Budget consultation 2008. 79 BVPI Planning Survey 2006. 80 Lambeth PCT General Practice Assessment questionnaire 2006. Lambeth JSNA – Preliminary assessment 137 Version 4 October 2008 Page 142

DRAFT treated with respect by their doctor (95/100) and not receiving enough support to manage a long term condition (53/100)81.

Given resource constraints, it is not possible to improve service delivery and customer service across all services concurrently. Therefore the CFP should initially focus on improving the customer service experience of low rated services – activities for young people, planning, council housing, parking and road repairs.

Contact

The contact people have with the council and its partners has an important influence on their perceptions of these organisations.

The 2005 residents’ survey showed that just under half of residents (47%) had contacted the council in the previous 12 months. The most popular reason for contacting the council was to make a complaint (39%), to apply to use a service (33%) and to ask for advice or information (32%). The main complaints residents make are about housing (24%), parking (15%) refuse collection/ recycling (13%) and council tax (12%)82.

Telephone is by far the most popular way to contact the council, in 2005, 69% used the phone to make a complaint and 74% for other contact. Only 13% of Lambeth residents reported using face to face contact with the council83, but this is a more popular method for housing tenants (37%)84 and for people to contact their local police (40%)85.

In 2005 written correspondence including email, accounted for a small percentage of contact (15%). However, access to the internet in Lambeth is increasing with just under one in four residents (24%) having no access at all in 2007, a fall of 8% since 200586. Older people and more deprived residents are less likely to have access or the skills and confidence to use it87.

Qualitative research conducted in 2005 shows that while people will use the internet to find information about the council, there is a reluctance to use this method for issues where either a response is required or a transaction is needed to take place. Many people perceive the council to be inefficient and believe their transaction will not be handled correctly or they will not receive a reply. They

81 National survey of local health services 2008. Healthcare Commission. 82 2005 Residents survey. 83 2005 residents survey 84 STATUS tenants survey 2007 85 mruk Metropolitan Police Survey 2006/07. 86 2007 Residents survey 87 Understanding our residents focus groups 2005. Lambeth JSNA – Preliminary assessment 138 Version 4 October 2008 Page 143

DRAFT would rather speak or visit someone in person88. It would be interesting to explore the extent to which these perceptions are still held given the significant rise in internet penetration.

Satisfaction with customer services has improved since the opening of the Lambeth Service Centre which provides the first point of contact for all phone queries and Lambeth Contact, the first joint service centre for walk-in queries. Users of both of these are generally satisfied with the service provided. Customers believed that the phone is answered promptly, it is easy to navigate the system and the staff are friendly and polite89. There is however, a conflict between satisfaction with resolution of problems. Users of the joint service centre believed that the staff there were able to successfully resolve their problem (92%)90; compared with 59% of Lambeth Service Centre users who stated their problem was not resolved at all91.

Prompt resolution of problems or queries was the most important priority for residents when contacting the council or partners, yet across the majority of service areas where we have data including housing, LSC customers, council tax, benefits and Adult and Community Services, the final resolution of a problem was the area that most people were dissatisfied with. Issues that were perceived to contribute to the lack of resolution include a lack of joined up working between front line and back office staff and people not being sure who is the correct person to contact to resolve a problem.

This lack of prompt resolution of problems needs to be addressed by the Citizens Focus Programme.

In 2006/07, 10% of borough residents said that they had let the police know their views on policing, crime or anti-social behaviour compared with less than 0.5% in 2005/06. The most common way that people contacted the police was through an informal chat with a local officer92.

Southwark carried out research in 2007 into the national ‘tell us once’ project. This aims to enable customers to notify government once of a birth, death or change of address and overall make contact easier. Overall 72% of respondents believe that such a service would be helpful compared to only 8% who feel it wouldn’t be. People see the main benefits as saving them time (18%), saving them having the same conversations with different organisations (15%) and being sure that all the relevant parties were informed (14%). However, people do have concerns about who would have access to their personal information

88 Understanding our residents focus groups 2005. 89 Lambeth Service Centre Customer Satisfaction Survey 2007. 90 Lambeth Contact User Satisfaction Survey 2007. 91 Lambeth Service Centre Customer Satisfaction Survey 2007. 92 MPS public confidence report 2006/07. Lambeth JSNA – Preliminary assessment 139 Version 4 October 2008 Page 144

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(25%), that their personal data may not be securely stored (17%) and that the service might not be reliable (16%)93.

Communication

IDeA/ MORI research shows that how well informed people are shapes their opinion of the council and partners and drives overall satisfaction. Therefore in considering a Customer Focus Programme, it is important to think about how we communicate with our residents.

The 2007 residents’ survey shows that 70% of Lambeth residents believe that the council keeps residents informed. This is 6 percentage points higher than the rest of London at 64% and represents continuous improvement from 2003. This contrasts with the picture from the BVPI survey which recorded a decline in satisfaction between 2003/04 and 2005/06 which likely reflects its methodology.

People feel most informed about how to pay bills to the council (88%) and how and where to register to vote (86%). In contrast around three in four feel uninformed about what the council is doing to tackle antisocial behaviour in the local area (80%), whether the council is delivering on its promises (75%) and how well the council is performing (74%)94.

Most people find out information about Lambeth via information provided by the council (39%). The next most popular methods are local media (19%), the council website/ internet (17%) and word of mouth (11%)95.

Based on research findings, the main source of information provided by the council is Lambeth Life, a fortnightly newspaper distributed to all homes in the borough. The publication changed format in January 2008 from a monthly magazine to a fortnightly newspaper. In October 2007 in its previous format, distribution was good and satisfaction was fairly high. Three quarters (77%) had received a copy through their door in the last three months. Of these 74% of people read some or all of it and 65% rated it as good or excellent96. Research is planned to evaluate the success of the new format.

Regardless of format, qualitative research conducted in 2006 found people want to hear balanced, realistic reporting about how the council is performing, how it spends council tax money and whether it is keeping its promises. There should be less focus on good news with people concerned that this is simply council propaganda. The key issue for residents was that Lambeth Life should demonstrate openness and honesty about what the Council does to address problems, with whom, and over what timescales97.

93 94 BVPI survey 2006. 95 BVPI survey 2006. 96 Lambeth Residents Survey 2007 97 Lambeth Life Research report. December 2006. Lambeth JSNA – Preliminary assessment 140 Version 4 October 2008 Page 145

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The Lambeth Youth Council consultation project asked young people how they would like to be kept informed by the council. The top choice was through newsletters or youth magazines, chosen by 36% of primary school and 37% of secondary school children. The second most popular choice was through a website chosen by 34% of primary and 36% of secondary children98.

Service users, especially within housing and ACS like to get written information about the services they use and feel that it is important that they are notified clearly and with notice about any changes99.

The Metropolitan Police Service report shows that Lambeth police are good at keeping people informed. 56% of borough residents said that they felt very or fairly well informed about what the police in their area had been doing over the previous year. This is significantly higher than the rest of London at 47% and has improved when compared to 44% of people in Lambeth in 2005/06100. The main sources of receiving information are local newspapers, television, radio and national newspapers. Less well disseminated is information about Lambeth Safer Neighbourhood Teams with only 19% of residents having received information. However, this is the same percentage as the rest of London. However, the 2007 resident’s survey shows that only 37% feel informed about what is being done to tackle antisocial behaviour.

Participation

The 2007 Lambeth residents’ survey shows that a third (35%) are satisfied with opportunities for participation in local decision making compared to 20% who are dissatisfied. This is in line with the 2006 BVPI survey which shows 31% satisfied and 26% dissatisfied. Satisfaction is significantly higher in North Lambeth and Brixton at 48% and 43% respectively and significantly lower in Streatham at 23%. Just under half (48%) of Lambeth residents feel that they can influence decisions affecting their local area.

One in five Lambeth residents (20%) had taken part in a consultation in the last 12 months, an increase from 16% in 2005.101. There is an appetite for involvement in Lambeth with 40% of people wanting to be more involved in the decisions made and 52% wanting to be involved depending on the issue102.

However, people strongly believe that consultation needs to be meaningful and want to see positive action happening from their views. It is vital that honest feedback is given to participants about the outcomes of consultation and people

98 Lambeth Council Youth Consultation project. April 2007. 99 STATUS tenants survey and ACS satisfaction reports. 100 Source: mruk Metropolitan Police Service Public Attitude Survey 2006/07. June 2007. 101 Lambeth 2007 residents’ survey. January 2008. 102 BVPI survey 2006. Lambeth JSNA – Preliminary assessment 141 Version 4 October 2008 Page 146

DRAFT are shown what has happened as a result of their involvement. This is a key part of the community engagement strategy – Lambeth Together.

Priorities for particular groups

Different groups within Lambeth have different needs, prioities, and perceptions of services. It is important to understand the requirements of our diverse communities in order that we can meet their needs.

Young people Most of the Council’s services are rated in line with the London-wide average by young Lambeth residents, with the exception of leisure and sports facilities (-13) and libraries (-6) which received lower ratings. Lambeth achieved a higher rating for local health services (+9) among young people.

In 2007, 43% of young people in Lambeth believe that the council keeps them informed about what is happening. This is similar to 2005 and in line with the rest of London.

Two in five young people believe that the council listens to the concerns of young people and 35% believe that young people are involved in decision making. These are similar results to 2005 and across London. However, younger residents are less likely to have participated in consultations and surveys than adults, and fewer report reading Lambeth Life103.

Older people Older residents in Lambeth tend to be more positive on a range of measures. They are more likely to think the council is doing a good job. Despite the fact they are more concerned about council tax they rate council tax collection more positively than average. They also rate a number of other services more positively including street lighting, refuse collection, recycling and public transport.

Disabled people Disabled people are more negative about parking, parks, leisure and arts and cultural facilities in the borough.

General satisfaction among users of adult and community services is high with 70% of service users with a physical or sensory disability, 63% of home shopping service users, 84% of elderly home care service users and 78% of home care service users satisfied with the overall service they receive. The overwhelming reason that people gave for being satisfied was getting on well with their carer and their carer doing their job properly104.

103 Lambeth 2007 residents’ survey. January 2007. 104 Variety of ACS documents. Lambeth JSNA – Preliminary assessment 142 Version 4 October 2008 Page 147

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Half of service users with a physical or sensory disability (49%) did not think they were provided sufficient information by Lambeth in relation to services available at home compared with 38% who did. People were happy with the leaflets they received as they were easy to understand and found the staff approachable and responsive. The biggest complaint was that service users felt that they were not aware of what services they may be entitled to and how the system works to find out. Service users also felt that Lambeth was not proactive enough in communicating with them about changes to their service or their entitlements. There are also problems with staff answering the phone unable to answer their enquiry and getting passed around several people before finding someone who can help. There is also a lack of joined up information and support when people come out of hospital. Again there is confusion over who should be phoned and how to get through to the appropriate person.

Seven in ten (70%) of elderly home care users say that they are always or usually kept informed about changes in their care. There appear to be discrepancies between the information given by the different home care provider companies with only one in five (21%) of Care UK users informed compared to 43% of Keratome users.

In 2007, 71% of service users with a physical or sensory disability stated that they had contacted the council or the care provider about their service; one in five interviewees (18%) stated that they found it easy or fairly easy to contact ACS. However, a larger proportion of service users, just under a third (31%) reported that they found it difficult or fairly difficult. Some respondents were frustrated following a number of attempts to contact relevant personnel had failed, staff were unable to deal with their enquiry and there was a sense of being passed from pillar to post. Half of the respondents did not know which team they had contacted within ACS.

Information received on how to complain differed across services. 70% of hot meals service users and elderly home care users and 60% of home shopping service users said they knew how to complain compared with 35% of service users with a physical or sensory disability.

Service users with a physical or sensory disability stated that their preferred method of complaint is by phone.

Council tenants/ more deprived residents For many tenants the Housing Department is the Council and their views of Council performance are shaped largely by their experiences of the housing service105.

105 Source: TNS Understanding our Residents. July 2005. Lambeth JSNA – Preliminary assessment 143 Version 4 October 2008 Page 148

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Although council tenants are less likely to feel the council is doing a good job they tend to be more positive than average about a range of local services including nursery, primary, secondary and adult education, street cleaning and parking. They are also more positive about non-council services like health and policing. The unemployed are more likely than average to feel that the council listens to them and council tenants are more likely to feel council staff are friendly and polite. Council tenants are more satisfied with opportunities for involvement, are positive about Lambeth Life and are more likely to feel informed about what is being done to tackle anti-social behaviour. However, there are a number of issues which need to be addressed with Lambeth’s more deprived residents. They are more negative about refuse collection and council tax collection and are less likely to recycle and use the borough’s parks.

Overall satisfaction with the landlord service provided by Lambeth is relatively low with six in ten tenants (62%) satisfied. This places Lambeth 24th across London. However satisfaction is improving and Lambeth shows a strong, above average rate of improvement (5%) in overall tenants’ satisfaction when compared with the average for inner London boroughs, improving at 1%106. However in contrast, the residents’ survey shows that users of council housing are less satisfied in 2007 than 2005, with a decrease of twelve percentage points to 33%.

Repairs and maintenance was the most important service for 79% of Lambeth tenants and it was used as an illustration of why the Council was seen by tenants as slow, wasteful and inefficient. Criticisms of the repairs service fall into three categories: Problems with reporting the problem, the speed of addressing the problem and the quality of the work carried out to resolve the problem. One in five comments received through the Lambeth Service Centre users’ survey was regarding the need to improve the housing repairs service107. However satisfaction levels with repairs in particular are improving showing an improvement of nine percentage points from 2004 to 2006. The overall quality of the home is the aspect of housing that tenants believe most needs to be improved (90%).

Another factor that affects tenants’ satisfaction was the reduction in opening hours and the closure of neighbourhood housing offices. Tenants complained about difficulties in accessing their housing officers and of the attitude of some housing officers108.

Seven in ten Lambeth council tenants (71%) believe that the council is good at keeping them informed, the same proportion as 2005. Only just over one in ten

106 Source: STATUS Tenant Satisfaction Survey 2006. 107 Source: Lambeth Service Centre Customer Satisfaction Survey. Annual Summary Report 2006/07. 108 Source: TNS Understanding our Residents. July 2005. Lambeth JSNA – Preliminary assessment 144 Version 4 October 2008 Page 149

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(12%) consider the landlord to be poor at keeping them informed. This is a slight improvement on 2004 results rising from 68%109.

The most popular method of contacting Lambeth Housing is via the telephone and over half (52%) select this as their favoured method. This is followed by nearly four in ten (37%) who prefer contact in person at the housing office. When asked how they would like to be contacted regarding their views on decisions affecting their home, three quarters (75%) of Lambeth tenants state that they prefer to be contacted by letter. The next most popular methods of contact are telephone at 34% and by home visit at 27%110.

Those tenants who had contacted Lambeth Housing in the 12 months prior to the survey were asked to rate various aspects of their contact. Generally staff are considered to be helpful and able to deal with problems, although nearly three in ten (29%) indicate staff were difficult to get hold of. These perceptions may well have improved as a result of the introduction of the LSC in March 2004. Tenants are less satisfied with the final outcome of their query, with half (50%) expressing satisfaction compared to nearly four in ten (38%) expressing dissatisfaction – a pattern consistent with other London Boroughs.

In line with other London boroughs, just under half of all council tenants are satisfied with the opportunities for participation in decision making (49%). Tenants do think that their views are taken into account with 49% thinking Lambeth does so ‘a little’ and 25% ‘a lot.’ Improvements are needed however, with 85% of tenants believing that taking their views into account needed improvement. In terms of the avenues through which they could participate, tenants thought that the format of tenants’ meetings was acceptable, although were critical about the lack of positive outcomes. Those involved in tenants’ committees or the Tenants’ Council felt that they were time consuming and unproductive111. Improving feedback to these groups about the outcome of their participation is therefore vital.

Parents Satisfaction levels are higher for nursery and primary education within Lambeth with 70% and 68% of users rating them as good or excellent respectively. Satisfaction decreases for the older education service providers with just over half satisfied with secondary education (51%) and adult education (55%) within the borough112. Only 22% of all residents think Lambeth secondary education is good or excellent compared to 34% across London. Positively, satisfaction with all types of education has improved since 2003 and fewer residents are concerned about education than in 2005. A focus group with parents conducted in 2005 found they were pleased with the nursery and primary schools that their children attended, but became concerned when it was time for them to transfer to secondary school. Five of the seven parents with children at primary school stated that improvement to secondary schools in the borough was their top

109 STATUS Tenant Satisfaction Survey 2006. 110 STATUS Tenant Satisfaction Survey. 2006 111 STATUS Tenant Satisfaction Survey 2006. 112 Source: TNS Social Lambeth Residents Survey 2007/08. January 2008. Lambeth JSNA – Preliminary assessment 145 Version 4 October 2008 Page 150

DRAFT priority for improvement. The main problems identified with secondary schools included lack of choice, lack of communication with parents and schools being unable to address the problems between pupils113.

More affluent residents On the whole, residents from higher social backgrounds tend to be more satisfied with the council, with more saying that the Council is doing a good job and rating contact and engagement positively. In particular, they are more likely to feel the council delivers value for money, more likely to feel informed, listened to and involved in decision-making. In terms of specific services those from social class AB are more positive about council tax collection and parks, and they are more likely to recycle than others. However, this group are less likely to rate education services positively and are more likely to identify education as a key concern. They are also more likely to rate parking, road and pavement repairs, activities for children and teenagers and leisure facilities poorly (despite the fact that they actually use leisure services more). Little is known about how these ‘light’ users of council services would prefer to contact and receive communication from the council. Although the 2003 residents’ survey indicates that leaflets may be popular for general communications, further research would be useful to explore how best to serve the needs of this relatively large group.

New residents to the borough Those who have lived in the borough for less than two years are more likely to feel the council is doing a good job, they are also more positive about street cleaning, street lighting and refuse collection. However, there are some specific communications and engagement issues which need to be addressed. New residents are less likely to feel involved in decision making, are less likely to feel Lambeth council listens to its residents and feel less informed about what is being done to tackle anti-social behaviour.

Long term residents Residents who have lived in Lambeth for over five years are less positive about the council114. This was echoed in the ‘understanding our customers’ focus groups run in 2005 and the 2007 budget consultation where several long term residents of the borough brought up the issue of trust. For them, reputation was not just about performance, it was about whether they felt they could trust the council or not115. In many cases this was based on experiences in the distant past which continue to colour current perceptions.

Ethnic minority residents The black Caribbean community are more concerned than average about jobs and rate parks less positively, although they are more positive about adult

113 Source: Understanding our residents. July 2005. 114 Source: TNS Social Lambeth Residents Survey 2007/08. January 2008 115 Understanding our res Lambeth JSNA – Preliminary assessment 146 Version 4 October 2008 Page 151

DRAFT education provision in the borough. In contrast, the black African community is more positive than the Lambeth norm and tend to rate services well. In particular street cleaning, nursery, primary and secondary education, libraries and parking all received higher than average ratings116.

Small businesses

Small business owners are concerned about crime. Research carried out by the Federation for Small Businesses (FSB) in 2004 showed that 57% of small businesses in London had been a victim of crime in the previous 12 months117. Many of these crimes are not reported to the police because small business owners feel that ‘it would not achieve anything’ (40%), that the police are unlikely to catch the perpetrators (27%) and because they do not want to make a claim against their insurance (22%).Other concerns for small business owners are too much legislation, red tape and regulations. Owners are dissatisfied with the complexity (60%) volume (59%) and rate of change (56%) of legislation. Legislation that was received least positively by owners was higher insurance premiums and increases in National Insurance contributions118.

The FSB also calls for improvements to local government procurement procedures to benefit small businesses. Suggestions include breaking down contracts instead of aggregating them, so reducing the need to only purchase from large suppliers. All contracts should be widely advertised regardless of their value to encourage more participants to apply and there is a need to make it easier to understand how to get on approved supplier lists and simplify pre qualification paperwork.

Small businesses also want affordable town centre parking to enable people to use their business. They believe there is also a need to standardise parking across London borough’s provide more information about the offence on the parking ticket and allow appeals and refunds against unfair tickets.

Recommendations for the CFP to address

x The priority services to focus on to improve the customer experience are:

- Council Housing especially the repairs service - Parking - Leisure and Sports facilities - Planning especially the promptness of resolution and keeping people informed with the progress of their application.

116 Lambeth residents’ survey 2007. 117 Federation of Small Businesses, Lifting the barriers survey 2004. 118 Federation of Small Businesses, Lifting the barriers survey 2004 Lambeth JSNA – Preliminary assessment 147 Version 4 October 2008 Page 152

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Other issues that the CFP should seek to improve:

x Resolution of problems and issues when people contact the council. x The way complementary services work well together. x Information about what services Lambeth and its partners offer and people’s entitlement to them.

Gaps and further research

We currently have limited information about the following:

- Partnership data about how Lambeth residents view the services offered by partner organisations. What do people think of their customer experience of job centre plus, police, health services, voluntary and community sector and fire service within the borough and how well do council services link up with these organisations for people who need to use multiple services? How can these services complement each other and work better together?

- There are two distinct groups of people accessing services within Lambeth. One uses a lot of services and want a lot of contact specific to their needs. They like to contact us by phone or in person. The other group use very few services and may potentially want less or easier contact. Research should be carried out to determine whether this is the case and how customer service can best be structured to meet their needs.

- There is currently little information available on the views of business users. It would be interesting to discover their views on the services they use and how they could be improved.

- Although people see the internet as an important source of information, there appears to be barriers to using technology interactively for contacting services. Investigate the barriers to interactive contact via the internet.

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APPENDIX III

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Abbreviations A&E Accident & Emergency ACS Adult and Community Services AIDS Acquired Immuno-deficiency syndrome BME Black & Minority Ethnic C&YP Children & Young People CAA Comprehensive area assessment CAMHS Child & Adolescent Mental Health Services CHD Coronary Heart Disease CLG Communities and Local Government COPD Chronic Obstructive Pulmonary Disease CPA Care Programme Approach CSP Commissioning Strategy Plan CVD Cardio Vascular Disease CYP Children and Young people DASS Director of Adult and Social Services DH Department of Health E&W England & Wales GLA Greater London Authority GP General Practitioner GPAQ General Practice Assessment Questionnaire GSF Gold Standards Framework GST Guy’s & St Thomas’ NHS Foundation Trust GUM Genito Urinary Medicine GSF Gold Standards Framework HIV Human Immunodeficiency Virus IMD Index of multiple deprivation JSNA Joint Strategic Needs Assessment LBL London Borough of Lambeth LTC Long Term Conditions MH Mental Health MI Myocardial Infarction NHS National Health Service NICE National Institute of Clinical Excellence NSF National Service Framework ONS Office for National statistics

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PCT Primary Care Trust PEAT Physical Environment Assessment Team PEC Professional Executive Committee POPPI Projecting Older People’s Population Information system PR Public Relations QMAS Quality Management Analysis System QOF Quality Outcome Framework RSH Reproductive Sexual Health SCS Sustainable Community Strategy SH Sexual Health SIPs Service Improvement Proformas SLAM South London & Maudsley NHS Foundation Trust SMI Serious Mental Illness STIs Sexually Transmitted Infections TAC Team Around the Child YLL Years Life Lost YLD Years Lived with Disability

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Annual Public Health Report

Lambeth 2007/08

Health Needs and Outcomes

1 Page 158

Produced by the Public Health Directorate, Lambeth PCT / London Borough of Lambeth 1 Lower Marsh London SE1 7NT Telephone 020 3049 4444

Illustrations by Tom Gauld / Heart

Further copies of this report are available from the above address, the Lambeth PCT website www.lambethpct.nhs.uk and the Lambeth Council website www.lambeth.gov.uk

Any portion of this document may be copied without charge provided this is not done for gain and the copyright of Lambeth PCT is acknowledged.

Where production is for commercial purposes Lambeth PCT reserves all rights.

2 Page 159

3 Page 160

4 Page 161 Contents

Page

Preface 7

Introduction 8

1. Population Need 11

1.1 Living in Lambeth 11

1.2 Clinical and Costs Effectiveness 21

1.3 Fairness 25

1.4 Views of Local People 31

2. What are we trying to do? 35

3. Recommendations for the future 55

Appendices Review of previous years recommendations 56 Statistical Dataset - Lambeth’s Population 61

Glossary of terms 83 Bibliography 84 Acknowledgements 86

5 Page 162

In order to illustrate some of the themes and concepts inherent to public health, this report is punctuated by the illustrations of the nationally renowned illustrator and cartoonist Tom Gauld. Taking key themes and topics, such as measurement, complexity, priorities and equity as his starting point, we believe that Tom's illustrations add enormously to the report, bringing a fresh perspective to many of the issues taken for granted in the modern NHS. We hope that you will find them intriguing, illuminating and inspiring in your thoughts about public health in Lambeth.

6 Page 163

Preface

This report focuses on the different elements that inform our understanding of health needs in Lambeth, helping us to set priorities and agree the health outcomes which reflect these.

Lambeth is a place with high levels of health need, reflecting many different health issues including poor mental health, disability and premature mortality. There are significant inequalities between health in Lambeth and health in other parts of London and England and Wales. There are however now a number of areas where health is improving (these include teenage pregnancy, childhood immunisation and cancer mortality). The PCT and its partners are investing resources in improving health, and have made Staying Healthy one of the strategic priorities over the next five years. The focus of the Sustainable Community Strategy on worklessness provides an important opportunity to improve health and wellbeing for local residents.

Working effectively with partners is fundamental to improving health; work on Joint Strategic Needs Assessment provides an opportunity to develop a better understanding of local health issues, including the perspectives of local

people, and to work towards outcomes which really matter in Lambeth.

Ruth Wallis Director of Public Health September 2008

7 Page 164 Introduction

Lambeth is a unique borough. It has the vitality of central London, with one of the most diverse and densely concentrated populations displaying extremes of affluence and poverty. It is home to some of the most recognisable landmarks in London, as well as some of its least known backwaters. Challenges are presented by its rapidly growing and changing community, home to some of the most deprived areas in the country, sitting alongside those of both relative and real affluence and privilege.

Providing and commissioning the best in healthcare for Lambeth’s population, and tirelessly working to reduce the barriers to good health for all within the borough will always be a challenge with finite resources. Assessing needs to enable prioritisation is key to decision making at all levels within Lambeth PCT and amongst its partners, especially in their aim to deliver high quality services in the most equitable way. With stacks of national targets to meet, and recognising the complex needs of the local population, Joint Strategic Needs Assessment offers the PCT and its partners the opportunity to focus on these, and to commission the services needed to achieve the maximum of health outcomes for the local population.

Reducing the burden of disease and the unjust and unacceptable inequalities in health drives the prioritisation process in Lambeth. Equity and fairness are important concepts also, to ensure that the “inverse care law” (where those with the least health needs receive most health service), is reversed so that those with the highest needs are prioritised.

Public health skills and knowledge are essential to unlocking the inherent dilemmas and determining the priorities for healthcare and for a healthier more inclusive community in Lambeth. The public health directorate at Lambeth PCT uses these skills and knowledge and disseminates them widely, increasing the capacity of partners both within the PCT and outside to skillfully employ the best evidence to assess needs, reduce inequalities and prioritise interventions with best effect. Methods used to assess need and set priorities include: • Epidemiology to assess the burden of disease; • Health needs assessment - defined by the ability to benefit from interventions and using an epidemiological approach. This includes an assessment of cost-effectiveness, corporate and comparative analysis and a focus on outcomes;

8 Page 165 • Health equity audit – identifying how services respond to the needs of different groups and communities with different health needs; • Patient and public involvement – giving the local people a voice and the power to influence local service planning and delivery; • Drug appraisals – where new drug treatments are assessed for strength of effectiveness; and • Exceptional treatment arrangements - where services not normally commissioned by the PCT can be commissioned for a patient in exceptional circumstances.

These tools and methods are set out in the report and examples are given to illustrate the broad range of interventions and actions undertaken in Lambeth as well as the dilemmas faced.

Health improvement and healthcare cannot be delivered by the NHS alone. Partnerships between NHS organisations and Local Government, the independent sector and the voluntary and community sector are critical, and Joint Strategic Needs Assessment (JSNA) between Lambeth Council and the PCT can only strengthen the already strong joint working arrangements.

The PCT has recently set out new commissioning priorities for the next five years, developed in conjunction with patients and the public, and which set out the broad themes for priority activity. These are: staying healthy; mental health; and end of life care. These are supplementary to the existing three priorities of sexual health, children and young people, and long term conditions.

The PCT is developing detailed plans under each of these three new priorities, informed by the best of available data on the local population and their health. This is summarised for readers of this report as a statistical appendix.

Recommendations are set out in this report to highlight the necessary steps for the PCT and its partners in the year ahead.

9 Page 166

10 Page 167 Chapter 1. Population Need

1.1. Living in Lambeth

Public health data is collated by various bodies including the Office for National Statistics, Department of Health, Local Authorities and other partners. This section briefly summarises the health profiles of Lambeth residents and what the current data tell us about health and well-being in Lambeth in terms of the wider determinants of health.

The minimum dataset required to understand the local statistics is included with this report as Appendix 2. Please refer to the Appendix for detailed statistics and description of main health and well-being indicators.

Inner city London Lambeth is an inner London borough comprising of 21 wards with six major town centre areas namely, Brixton, Clapham, North Lambeth, Norwood, Stockwell, and Streatham. The Census area classifications describe Lambeth as a “London cosmopolitan area” similar to Southwark, Lewisham, Hackney, Islington, Haringey and Brent.

Population profile Lambeth is one of the most densely populated boroughs in the country with a rapidly growing population. The resident population is projected to grow by a further 15% to 317,000 by 2028. Lambeth has a high proportion of young population compared with the rest of the country with approximately 50% of individuals in the 20-44 age group.

Deprivation The 2007 Index of Multiple Deprivation places Lambeth as the 5th most deprived borough in London and 19th most deprived in England. Poverty and social exclusion are challenges in the borough. One in twenty Lambeth residents live in fuel poverty and the proportion of children and young people living in poverty is higher than average. It is estimated that 40% of Lambeth workers are well qualified (at NVQ level 4 or better) and the average income is above national average. However, there are high numbers of economically inactive people living in Lambeth and among adults seeking jobs, 60% have no qualifications or low level qualifications.

11 Page 168 Worklessness Lambeth has recognised worklessness to be a major barrier to success and a key factor in poverty and exclusion. There is a clear link between worklessness, poor health and education standards, low aspirations, higher crime and communities which are less integrated.

Tackling worklessness therefore will be an important consideration for the coming years. The benefits of tackling worklessness will be to make improvements in financial prosperity, improve community interaction, improve living standards and promote economic activity. Focussing on worklessness is now a priority in Lambeth's Sustainable Community Strategy (2008-2020).

Diversity Lambeth is highly ethnically, socially and economically diverse and there is high mobility within and outwith the borough every year. Lambeth’s Black and Minority Ethnic (BME) community account for 35% of the borough’s total population

Mobility The high mobility within the borough poses challenges in measuring life expectancy and reductions in premature death rate. In this respect, Lambeth is similar to the inner London boroughs of Lewisham, Hackney, Tower Hamlets and Newham. In terms of internal migration, Lambeth has the highest outflow of London boroughs with 10.6% of population, whereas it stands in the fourth place in terms of inward internal migration, at 8.6%.

Wellbeing indicators As happiness and mental wellbeing depend on different factors, it is important to measure at least some of these to understand how mentally healthy a population is (as opposed to how many people suffer from poor mental health or mental illness). Some of the factors in the table are being measured by local partners such as perceptions about crime in Lambeth and numbers of people involved in volunteering. Fear of crime remains high in Lambeth relative to falling reported crime levels and improving detection rates.

Figure 1 lists some specific objective health and wellbeing indicators showing whether they are improving or worsening in Lambeth compared either with previous values or with the national average.

12 Page 169 Figure 1: Health and wellbeing indicators Status in Health indicators 2007* Life expectancy - Males Improving Life expectancy - Females No change Infant mortality rate Improving Deaths from alcohol related conditions No change Deaths from cancer < 75 years - males Improving Deaths from cancer < 75 years - females No change

Deaths from heart disease <75 years - males Improving Deaths from heart disease < 75 years - females Improving Teenage pregnancy rate Improving Smoking prevalence Improving Obesity in children Worsening Obesity in adults Improving Employment rate Worsening Socio-economic Children in poverty No change indicators Reported crime Improving

* The performance status mentioned for the above indicators is a comparison of the previous year's data to the latest available data which is either 2006-07 or 2006. For certain indicators such as death rates from cancer or circulatory diseases a three year rolling average is the appropriate comparator which is used to describe the performance status (e.g. 2003-05 compared with 2004-06).

Life expectancy Male life expectancy in Lambeth has shown more improvement compared with the female life expectancy, although nationally, life expectancy is improving at a faster rate compared with the spearhead PCTs which includes Lambeth PCT. (Spearhead PCTs are 20% of PCTs in England with the highest levels of deprivation).

Birth rate The birth rate in Lambeth is high and has been rising since 2001. The exponential projections show a transient rise in the number of births until 2013.

Infant mortality Deaths of infants aged under 1 year have fallen from 8.8 per 1000 live births in 1995-97 to 5.8 per 1000 live births in 2004-06 - a reduction of over 26%. However there still is a need for further reduction in the gap between local and national rate.

13 Page 170 Teenage conception rate Lambeth has amongst the highest rates of teenage conception in England, which is now beginning to reduce significantly. The teenage conception rate has dropped from 86.6 per 1000 females aged 15-17 years in 2004 to 78.1 per 1000 females in 2006.

Healthy lifestyles Lifestyle issues such as high smoking prevalence; worsening obesity levels related to poor diets and lack of physical activity; and alcohol and drug misuse are having a major impact on Lambeth residents. These are associated with poorer health outcomes such as higher levels of mortality and morbidity related to, for example, chronic liver disease, renal disease and diabetes. In addition, Lambeth has one of the highest incidences of mental health need in London.

Smoking Smoking prevalence in Lambeth is high, especially in deprived areas and amongst people of lower socio-economic groups or in manual occupations. Estimates show that up to 350 residents may be dying due to smoking related conditions per year. However, it is notable that between April 2005 and March 2007 around 3,000 people attempted to give up smoking using NHS stop smoking services, with a success rate of around 50%.

Alcohol and drugs Alcohol and substance misuse is a general problem in the borough. It is estimated that 23%- 24% of Lambeth’s population (70,000 approx.) drink excessively and Lambeth has higher levels of alcohol-related hospital admissions than both London and England. Mortality from alcohol-related conditions in Lambeth is statistically higher than for the rest of London for men (68 people compared to 52 in London and 50 in England per 100,000 population) and somewhat higher for women (31 people compared to 27 in London and 28 in England per 100,000 population).

Obesity and physical activity It is estimated that 30.3% of Lambeth adults eat a healthy diet. This is in line with the average for London and above the national average of 26.3%. The level of adult obesity in Lambeth (18.6%) is lower than the England average (23.6%), probably as a result of the higher than average levels of physical activity in Lambeth. However, obesity in children aged 10-11 is high with up to 1 in 4 obese. 13.3% of children at reception level are obese in Lambeth compared with 11% in London, and 9.9% in England.

14 Page 171 Hypertension prevalence Similarly the case detection rate of hypertension in Lambeth residents is around 9% compared to 11.3% nationally. There are estimated to be over 34,000 individuals in Lambeth with hypertension who are undetected and who need to be treated to avoid development of coronary heart disease.

Figure 2: Modelled prevalence versus detected prevalence

Hypertension - 45% T; 55% U. CHD: 50%-T; 50%-U. Diabetes: 75%-T; 25%-U. T=Treated. U=Untreated 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Hypertension CHD Diabetes

Total treated Total untreated

Source: QMAS - Quality Management Analysis System – 2008 PBS: Prevalence models for Hypertension, CHD and diabetes. Reference in Lambeth APHR 2007-08.

Coronary heart disease (CHD) prevalence The case detection rate of CHD in Lambeth residents is 1.3% compared to 2.3% nationally. There is estimated to be over 5000 individuals in Lambeth with CHD who are undetected and who need treatment to avoid premature complications and/or death.

Premature deaths from circulatory diseases Overall there has been a 33% reduction in mortality rates from circulatory disease in Lambeth (2004-06) from baseline year 1995-97. For men there has been a 32% reduction in mortality from circulatory disease and for females 36% reduction. Overall there has been a 4% reduction in the absolute gap from circulatory disease between Lambeth and England and Wales (2004-06).

15 Page 172 Diabetes prevalence The case-detection rate of diabetes is around 3% which is similar to the national average. However, it is estimated that over 1000 people may still have undetected diabetes and be in need of treatment. Undetected disease is a serious issue in Lambeth, and makes a significant contribution to ill health and premature mortality. It is linked to inequality – especially as it disproportionately affects men and black and minority ethnic communities.

Premature deaths from cancer Overall there has been a 19% reduction in deaths from cancer in Lambeth (2004-06) from the baseline year of 1995-7, with deaths for males reduced by 17% and for females by 21%. Overall there has been 33% narrowing of the absolute gap (2004-06).

Mental ill health In Lambeth common mental illness is widespread however, it is difficult to estimate levels of anxiety and depression and other common mental health problems using local data. National survey data (ONS 2000) suggest that about 38 800 adults in Lambeth are experiencing these types of symptoms. Over 24 000 of these are probably sufficiently severe to need treatment. In adults there are marked differences between men and women and for different ages. Between 1000 and 1600 people over the age of 75 years in Lambeth may experience symptoms.

In March 2008, 3941 patients were known to primary care to be experiencing severe mental illness (mainly schizophrenia). This equates to almost 1.2% of the adult GP registered population. The number is likely to be an underestimate because some people are not being followed up in primary care or not registered with a GP. There has been an increase in this figure over the last 3 years but GPs have only recently started recording serious mental illness so the most likely reason for the increase is improvement in recording.

Health inequalities Health inequalities in Lambeth are high compared to other boroughs in London as well as England; as observed through health indicators such as infant mortality; teenage pregnancy; childhood obesity; primary and secondary school permanent exclusion levels; and the proportion of 16-18 year olds who are not in education, employment or training.

Wellbeing Mental wellbeing is about how people think and feel. It is subjective but strongly influenced by things that can be changed. The new economics foundation suggests that there are four

16 Page 173 elements to wellbeing (see diagram below). all of which can be measured. For instance, in the top left box, personal feelings can be measured by asking people directly using different types of questionnaires. An assessment of how people feel about the social sphere (the top right box) can be also measured by asking people for instance about their experience of their neighbourhood or about friendships and support networks. It also includes the extent to which people gain a sense of being valued at work so employment levels can be important. People’s ‘personal functioning’ (bottom left box) can be measured by assessing their skills, and educational background and asking them about their motivation and levels of control especially in work or financial terms (people in poverty have much less control over their life). The bottom right box is about how society functions; are people actively contributing to civil society? To what extent do people belong to community groups, vote or volunteer? Do employers put something back into the local community?

Figure 3: Table showing the four elements of mental wellbeing, as proposed by the New Economics Foundation; www.neweconomics.org

Social wellbeing Personal wellbeing (interpersonal) Happiness Satisfaction (life, job, Belonging Feeling income) Social support (having, being) Depression Respect Optimism Fear of crime Self esteem Autonomy

Competence Social engagement Functioning Interest in learning Altruism (doing) Goal orientation Caring Sense of purpose

Resilience

In Lambeth a measuring wellbeing handbook has been developed which is available for use by voluntary organisations, employers or projects to assess the mental wellbeing of staff, clients, members etc. As part of the Local Area Agreement many of the elements above are being measured in one way or another. A review undertaken by the New Economics Foundation for Lambeth recommended which of these measures could be used to measure mental wellbeing more directly in Lambeth. The aim is to develop a ‘wellbeing report’ for Lambeth based on some of these and other measures.

17 Page 174 Hiten’s Red Box The Red Box is informed by detailed epidemiological assessment and highlights the areas of high burden where the status is worsening for priority attention. Hiten’s Red Box informed the PCT’s Commissioning Strategy Plan (CSP), which was then further shaped by the views of local people through a citizen’s forum event.

Figure 4: Hiten’s Red Box

Healthy lifestyle issues (smoking, High Cardiovascular disease mortality obesity, poor diet, low physical Burden activity, alcohol, drug use) (Slower improvement compared to national) Chronic liver disease deaths and morbidity

Cancer mortality Chronic renal disease morbidity

Hypertensive disorders Teenage conceptions HIV prevalence

Mortality from infectious and STI prevalence

parasitic disease Severe mental illness morbidity

Diabetes mortality and morbidity

Infant mortality Drug misuse

Immunisation uptake All cause mortality in boys aged under 15 years

All cause mortality in girls aged Mortality from gastric, peptic and under 15 years Low duodenal ulcers Burden

Improving Worsening

The Commissioning Strategy Plan This is a five-year plan setting out the PCT’s objectives for the commissioning of services for the period 2007-2012.

Methods Lambeth PCT commissioned external consultants to organise a Citizen’s Forum for Lambeth residents and enable a sample of the local population to engage with the content of the CSP.

18 Page 175 116 residents were recruited on-street for the event, to reflect the particular demographics of the borough. To ensure this mix, potential participants were asked to complete a recruitment questionnaire, with questions relating to their occupation, household composition, age, ethnicity and quality of health.

A further 30 participants were recruited from traditionally excluded or marginalised groups, which include older people, specific patient groups, minority ethnic groups and young parents. These were recruited through Lambeth-based community and voluntary sector bodies and organisations, which identified and invited service-users on behalf of the PCT. Both recruitment phases were limited to English speakers. 105 people attended the event. 79 of these were drawn from the on-street recruitment and the remaining 26 were service users or representatives from traditionally excluded or marginalised groups. A cash incentive was offered to all participants.

Results and main findings The Citizen’s Panel reported the following findings: • There was difficulty in accessing healthcare services (both GP and hospitals). • There was a perception that the PCT could do more to communicate better with the public and other key stakeholders on an ongoing basis. • Respondents emphasised the importance of working closely with the council & the voluntary sector to achieve improvements, recommending improved joint working. • The needs of children with disabilities were not felt to be adequately addressed by the CSP. • The importance of working with and placing services within schools to achieve the objectives described for the Staying Healthy and Children and Young People’s strategies.

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20 Page 177 1.2. Clinical and cost effectiveness Clinical and cost effectiveness are the tools used to assess the magnitude of health benefit and costs incurred to produce that health benefit. An intervention can be clinically effective but have low cost-effectiveness because it is very expensive. This is exemplified by some of the new drug treatments for cancer.

A large number of new drug treatments have become available in the last few years. Many of these drugs are to treat patients with advanced cancer and will not cure the disease but may add a few months of life and improve quality of life. They are usually very expensive and attract considerable media attention. The National Institute of Health and Clinical Excellence (NICE) issues guidance on many of these drugs and PCTs are required to fund drugs that have been approved by NICE. However, NICE does not currently consider all new drugs and for the ones that they do there is often a considerable time period between the drug being licensed and NICE issuing guidance. This means PCTs are faced with difficult decisions about whether to fund routinely these new treatments that NICE is not considering, or treatments before NICE has made a decision. PCTs across the country have made different decisions on which drugs they will routinely fund according to their local priorities and financial position. This has produced what has been termed the ‘postcode lottery’. This should not be considered a criticism of individual PCTs as it is a product of a system that allows some local decision-making based on local need. In other words, unless all funding decisions are made centrally there will always be different treatments available in different places.

If a PCT decides not to routinely fund a new drug, patients and their doctor can still apply to receive the treatment through the Exceptional Treatment Arrangements (ETA) which considers treatments for individual patients. However, the ‘postcode lottery’ extends into the ETAs as different PCTs make different decisions on individual cases and individual drugs.

Currently there is a national discussion on whether patients should be able to pay privately for the latest drug for their condition if it has not been approved by NICE and still receive the remainder of their care funded by the NHS. Presently patients have to opt either to receive the treatment offered by the NHS, or opt to be treated privately for their whole package of care. The debate is polarised between patient choice on the one hand and maintaining equality on the other. Both of these are legitimate but it is difficult to see how both can be satisfied at the same time when funding is finite. A decision is expected in October 2008. Whatever the outcome it is likely there will be increasing scrutiny on how the PCT makes funding decisions for new drugs and other technologies as there is

21 Page 178 considerable coverage in the media on this issue. Lambeth and the other SE London PCTs have developed a strategy to fund new cancer drugs in SE London in 2007/08, which is described below.

Prioritisation of new systemic cancer treatments in South East London The South East London Cancer Network (SELCN) was asked by PCTs in SE London to work to prioritise new cancer drug regimens to inform commissioning of cancer services for 2008/09.

Methodology A prioritisation tool was designed which built on an earlier tool developed in 1998 in S. E. London, published in the British Journal of Cancer in 2000. The new tool was tested on five cancer drugs for which NICE had published technical appraisals, three of which were positive and two which were negative. The tool correctly discriminated between those drugs recommended by NICE and those not recommended.

The tool has five domains of effectiveness and a rating of the strength of evidence to support effectiveness. Each domain attracts a numeric score on a sliding scale and the rating of strength of evidence from A to U. The highest possible ranking is 20A i.e. strong evidence of high clinical and cost-effectiveness, with the lowest ranking 0A i.e. strong evidence of low clinical and cost effectiveness. Domains of the prioritisation tool: 1 Magnitude of benefit 2 Quality of life 3 Place in treatment pathway 4 Alternative standard treatment 5 QALY (Quality Adjusted Life Year)

Process Cancer doctors in S.E. London were asked to identify new drug regimens that they felt should be available to local patients. A small group of clinicians scored each indication using the prioritisation tool on published peer-reviewed evidence.

A seminar was held to which clinicians and PCT commissioners were invited. Prior to the seminar, clinicians had been sent the prioritisation tool and asked to score the regimens that they themselves wished to prescribe. At the seminar they were asked whether they agreed with the score that the group had given to each of these regimens.

22 Page 179 Results Clinicians agreed with the scoring for 30 out of the 33 regimens. Two regimens were scored one point higher as it was agreed that there was the evidence to support this. For one indication it was claimed there was new evidence that the group had not considered but the details of this were not available. This new evidence has since been scrutinised and the score remains as it was. After confirming the score for each regimen there was a discussion on what level of evidence was required to support a regimen and what numerical score should merit funding. It was agreed that published randomised data should be generally required (evidence strength A-C).

Possible exceptions could be very rare tumours where it is difficult to accrue sufficient patient numbers to do a randomised study, and where the evidence suggests clinical benefit, or where a regimen scored highly on magnitude of benefit but the research base was relatively immature. The numerical score was more difficult to judge. The top regimen score was 11 and the bottom 0. There was an agreement that those regimens scoring more heavily in domain 1 (magnitude of benefit) should merit further consideration but no overall numerical cut off point was agreed. There was also recognition that some regimens have specific issues, such as small subgroups benefiting considerably more than the patient population as a whole. Additionally, regimens that could have significant offset costs, cost savings or improve patient experience, e.g. an oral drug as opposed to an infusion. The ranking was then set against whether the London Cancer New Drugs Group (LCNDG) had made a recommendation and, if so, whether this was positive or negative. The results were presented to the SE London Executive Commissioning Group and it was agreed that drugs ranked highly and recommended for use by the LCNDG would be funded from 1 April 2008. Other high ranked drugs would be funded when and if the LCNDG gives a positive recommendation during 2008/09.

Figure 5. Examples of Cancer drugs funded through this system in 2008/09

Drug Type of Cancer Score LCNDG Rituximab Lymphoma 11A YES Dasatinib Type of leukaemia 9C YES Docetaxel Head and neck 8B AWAITED Premetrexed Mesothelioma 6B YES Sunitinib Kidney 6D YES Lenalidamide Type of blood cancer 5A AWAITED Sorafenib Liver 4D AWAITED

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24 Page 181 1.3. Fairness

Health Equity Audit (HEA) Fairness and equity was a founding principle of the NHS, and more recently, Acheson’s 1998 “Independent Inquiry into Inequalities in Health” established the need for equity profiles as a way to assess progress towards reducing health inequalities.

Health Equity Audit was then explained in “Tackling health inequalities: a programme for action” as: “The health equity audit cycle is a mechanism to use evidence about health inequalities to inform service planning and delivery”.

Figure 6. Diagram detailing the Health Equity Audit Cycle

1. Agree priorities and

6. Review partners progress and 2. Carry out an impacts against Measuring equity profile needs targets Service Measuring data service access analysis & outcome 5. Secure 3. Identify

changes in effective local Statistical investment and action to tackle analysis service delivery inequities 4. Agree local targets with

partners

Action plan Interview/ focus group with public, users and stakeholders Minimum data set Modelling alternative interventions

Literature review on best practices to address equal opportunity

What is Health Equity Audit? HEA is a process that prioritises interventions based on their effectiveness in reducing health inequities - defined as ‘differences in health that are unnecessary, avoidable, or unfair’. It is an audit process seen through an ‘equity lens’, and identifies how fairly services or other resources are distributed and used in relation to the health needs of different groups of people, or areas by virtue of socio-economic status, gender or ethnicity. It highlights the actions required to provide services according to needs and identifies service

25 Page 182 effectiveness gaps which are avoidable, between different groups of people or areas across which disadvantage may exist. It guides allocation of extra resources or the redistribution of existing resources to achieve more health equities, but may be less favourable in terms of cost effectiveness unless reducing the gap is considered when assessing cost–effectiveness.

Why prioritise through Health Equity Audit? Despite the increase in resources allocated to health and technological progress, there continue to be large disparities in health status according to socio-economic status, gender or ethnicity. Examples of the inequalities present in Lambeth’s population are as follows:

In Lambeth: • People on average die younger than in the rest of England • Men die younger than women - 75 years compared to 80 years • The two main causes of early death in both men and women are cancers and circulatory diseases • Infants born in England to women who were born abroad - especially those from the BME community - have a higher risk of dying within first year of birth than infants born to mothers who were born in England.

Access to services is described by the inverse care law. Those who need health care least use the services more often and more effectively, than those with the greatest need. This effect is seen in both health promotion and the treatment of illness and disease. The increasing social, cultural, and economic diversity in English society affects not only the risk of disease and the ability to prevent and self manage illness, but also attitudes towards the health care system. The main modifiable risk factors of the causes of health inequalities are associated with lifestyle and behaviours. Not only is there an unequal distribution of the risk factors but also unequal distribution of opportunity to adopt healthier lifestyles.

In HEA the distribution of access to and effectiveness of the service across categories of people is assessed and compared to needs and equity standards. The observed difference of effectiveness between socio-economic groups, gender, age or ethnic categories, or area of residence may be called the “effectiveness gap”.

HEA provides a phased approach to prioritisation. At each step specific criteria lead progressively to a focused priority. This process is described in the “prioritisation ladder” covering the first five stages of the HEA cycle.

26 Page 183 Figure 7. The decision ladder of health equity audit

6. How much it costs to reduce inequity gap.

5. Are there effective interventions in reducing the avoidable gaps? Health service performance 4. Are there avoidable gaps in access and benefit? analysis 3. What are the distribution of needs, access & benefits of the service?

2. Which of the risk factors can be addressed and minimised? Epidemiological analysis 1. What are the health inequalities and their causes?

Example of a HEA: Smoking cessation services An equity profile of the specialist Smoking Cessation Service (SCS) was initiated in February 2005 as the first step of the Health Equity Audit (HEA) process provided by the PCT. Smoking cessation services have been provided to Lambeth smokers since 2000, with the aim of reducing smoking, one of the risk factors of cardiovascular diseases and cancer, and an important component of the inequalities in health status and the death rate among social classes in the UK. The equity profiling aimed to identify inequalities and inequities in the use and effectiveness of the service and establish a baseline against which to monitor the impact of service provision. Inequalities were identified as differences in rate of service use and quit rate between age groups, genders, ethnic groups and wards within different deprivation categories. An equitable service was defined as a service that provides access proportional to needs and equal opportunity to stop smoking for all smokers independently of their demographic and socio-economic characteristics.

Overall a small number of smokers living in Lambeth used the smoking cessation services with 4 in 100 smokers having set a quit date between January 2000 and January 2005. The proportion of smokers who relapse has been rising up to 12% in the 9 months April 2004- January 2005. The current strategy resulted in equitable use of SCS with a higher proportion of smokers living in deprived wards using the service than in better off wards. However smokers from black minority groups were less likely to set a quit date than white smokers. Findings of the equity profile suggest that the needs of male smokers have not been addressed as well as the need of female smokers with 4 in 100 male smokers setting a quit date compared to 7 in 100 for female smokers.

27 Page 184 SCS in Lambeth have a lower short-term effectiveness than the England average with 34% of smokers with a quit date reporting not smoking by 4 weeks compared to 61% nationally. This low effectiveness is partially explained by a high proportion of smokers who did not come back to the service after having decided to stop smoking, especially among young and ethnic minority smokers.

Findings of the equity profile suggest that a standardised and vertical service provision may not suit the needs of the most vulnerable to smoking in Lambeth: quit rate decreases with increasing ward deprivation level, and 1 in 4 black smokers quit smoking compared to 1 in 3 white British smokers (after controlling for confounding effect of age, gender, addiction and ward deprivation level). The findings of the equity profile suggest that there is a risk for the target-based approach to widen the inequality gap because of the inequitable service outcome.

The wide variation of individual and environmental factors, which influence smoking behaviour, is a challenge for the provision of effective smoking cessation services. SCS have to adapt to the needs of specific groups especially pregnant smokers, youth and smokers living in deprived areas if service effectiveness is to be equitable. To reach a similar outcome for all groups more resources are required for deprived populations than the better off population.

While the current strategy for SCS provision allowed equitable use of the service, further improvement is required to provide equal opportunity to men, youth and ethnic minorities, and smokers living in deprived wards to adhere to the cessation process and have a successful outcome. Reducing the inequity of SCS effectiveness will contribute to reaching the target because of the significant contribution of smokers from deprived areas and ethnic minorities to the overall number of smokers living in Lambeth. Different types of interventions will be critical to reach the target while addressing equity issues: • Improving data quality through computerising data entry, update and define the dataset with a written operating manual for users of the database. Agree a minimum dataset to monitor equity. • Exploring other existing databases such as Quality and Outcomes Framework (QOF) data to develop monitoring of local smoking behaviour trend. • Improving effectiveness of SCS through: o Better understanding of the constraints to stop smoking and culturally appropriate channels for delivering smoking cessation and tailoring of the service

28 Page 185 to the needs of the ethnic minority smokers and those living in a deprived environment. Social marketing research will clarify perceptions and communication channels; o Strengthening the management of language and cultural diversity by building the capacity of health service providers and PCT employees in working in a multicultural environment, and reviewing the use and delivering modalities of the interpreter services; o Partnership and integration of smoking cessation services with interventions aiming at decreasing incidence. A smoking cessation strategy clearly spelt out for the next 3 years, as part of the tobacco control strategy, will provide the framework.

Figure 8. Summary of equity issues for Stop Smoking services.

Characteristics Use of service Present at follow up Quit after 4 weeks

A higher proportion of Similar rate for men and Similar rates for men Gender women than men women and women

Younger smokers less Older smokers more Quit rate decreases with Age likely to access likely to be present at age follow up

Same proportion of Ethnic minority groups White British 22% more Ethnicity white smokers & black 14-29% more likely to likely to quit than other smokers be lost to follow up than ethnic groups white

Increases with Does not vary with ward Quit rate decreases with Deprivation deprivation deprivation level the Indices of Multiple Deprivation ward level

Conclusions • Health equity audit informs service provision. Achieving equitable outcomes requires increased investment. • The stop smoking service is reaching a small proportion of Lambeth residents who smoke. • Stop smoking services are an essential part of the tobacco control strategy for Lambeth.

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30 Page 187 1.4. Views of local people

The most recent guidelines on community engagement from the National Institute for Health and Clinical Excellence (NICE) suggest that different levels of patient and public involvement can directly and/or indirectly affect health. They suggest a number of approaches to facilitate successful community engagement, and recommend that four interlocking themes should be taken forward: a) pre-requisites for success (including policy development); b) infrastructure (to support practice on the ground); c) approaches to support and increase levels of community engagement; and d) evaluations (2008).

The degree of patient and public involvement can be defined by the public’s relationship to authority, represented by a ‘ladder of participation’. All five stages of the ladder constitute a level of engagement with different levels used depending on the particular circumstances.

Figure 9. The Ladder of Participation (Adapted from Wilcox, D. 1994)

Empowerment Supporting groups to develop and implement their own solutions

Involvement / Participation Working with others to make decisions and carry through the action agreed

Consultation Sharing views, options generated jointly and a course of action agreed upon

Communication Having choice between pre-determined options, but no opportunity to propose alternatives

Information Giving a message but not requiring feedback or comment

The PCT Board adopted a Patient & Public Involvement (PPI) strategy in March 2005. This states that “ …PPI will be embedded in our service development, planning and delivery … (and) understood and practised across the organisation with managers and staff”. This strategy was evaluated in 2007 by the PPI team, revealing high levels of awareness and regard for PPI amongst managers; with clarity of purpose and understanding of processes.

31 Page 188 However, it was revealed that patient and public involvement was not clearly embedded in daily PCT practice and largely remained “erratic” or “ad hoc”. This issue is addressed by the recommendations of this report on page 55.

There are good examples of PPI being performed within the PCT, as detailed below. The principles of which have been to: • Seek out those who feel they have little power over their own lives • Promote the idea of people acting together to create change • Work on the assumption that health changes cannot be made by individuals alone • Build on a premise of community empowerment • Promote the sharing of knowledge and skills between the PCT and communities • Value the engagement process as a means of facilitating the growth of self esteem and confidence • Involve the community in the definition of issues.

The HIV Service User Review South East London has the highest prevalence of HIV in London and Lambeth has the highest rate in the UK. Sector expenditure on HIV treatment through the HIV Consortium is £56,138,669, with South East London PCTs also making significant investments in HIV prevention, care and support. An important underlying principle is that local services should be responsive to the needs and preferences of service users. However, in order to plan and deliver services effectively, providers and commissioners require constructive, ongoing input and feedback from service users and must ensure that arrangements for involvement are fit for purpose and deliver value for money. Two HIV service user groups provide consultancy to local HIV treatment centres by involving service users within their specific service.

Aim: To develop a sustainable system of service user involvement in South East London that enables a broadly representative proportion of people living with HIV to contribute to service development, delivery and commissioning and which is valued by service users, service providers and commissioners.

Objectives: To map the extent of current service user involvement in statutory and voluntary sector services in South East London; to find out from service users whether and how they would like to contribute to service delivery, planning and commissioning; to review the aims, objectives and activities of the two user groups in order to understand how they fit within the South East London commissioning systems.

32 Page 189 Methods: These included face-to-face interviews, questionnaires and focus groups capturing perspectives from a cross section of service users and other stakeholders.

Results: As many of the care and support services for people living with HIV are commissioned jointly as part of the South London Partnership, it was agreed to extend the review to cover South West London PCTs. The fieldwork is now complete and a draft of the final report will be available in mid September 2008.

Teenage Pregnancy Media and Communication Strategy 2007-10 Lambeth has the highest rates of teenage conception in England, although these are now beginning to reduce significantly.

Aim: To support the Lambeth Teenage Pregnancy Strategy in achieving a reduction in the conception rate in under-18s in Lambeth.

Objectives: To promote positive sexual attitudes and behaviours; reduce the proportion of young people having unsafe sex; and increase the proportion of young people having safer sex.

The messages for this strategy are consistent with national good practice, targeting audiences such as: those who are curious about sex; those who are already engaging in sex; parents/carers and the wider community (including BME and faith organisations); and professionals.

Methods: A literature review identified best practice and examples of effective local initiatives. A topic guide and survey was developed to support focus groups with young people in order to gain an insight and understanding of the behaviours that led to teenage pregnancy, and to identify the types of media young people accessed. Consultation took place with young people including looked after children, the Lambeth Youth Council, children excluded from school, Lambeth Youth Outreach, Lambeth Youth Offending Service and teenage mothers. The key messages to be promoted are: • Addressing peer pressure and delaying sex • Information & advice • Condom use negotiation • Sexually Transmitted Infections (STIs) • Myths • Drugs and alcohol

Results: The campaign is now into its first year with bus shelter posters on display, and postcards distributed. Local radio adverts are also in production.

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34 Page 191 2. What are we trying to do?

This chapter sets out the steps the PCT is taking to respond to the assessed health needs of its population. Using World Class Commissioning competencies, the PCT will commission health services to meet the explicit outcomes necessary to meet needs, identified through joint strategic needs assessment.

Joint strategic needs assessment The Local Government and Public Involvement in Health Act (2007) [Clause 116] places a duty on local authorities and PCTs to undertake a Joint Strategic Needs Assessment (JSNA). This provision came into force from April 2008. The Director of Public Health, Director of Adult Social Services and Director of Children’s Services are expected to take a lead in producing a joint strategic needs assessment through strong partnership. The Department of Health (DH) published Guidance on Joint Strategic Needs Assessment in December 2007 in partnership with Communities and Local Government (CLG) and the Department for Children, Schools and Families.

A strategic needs assessment is intended to provide: • Evidence about the population on which services are planned to address health inequalities; • An opportunity to engage with the population and enable them to contribute to targeted service planning and resource allocation; • Information on gaps in equitable distribution of services; • An opportunity for cross-sectoral partnership working and developing creative and effective interventions; • An opportunity to identify priorities and offer strategic recommendations for service planning and improvement. • A key tool to achieve a shift towards commissioning to improve health and well-being outcomes and reduce inequalities.

To identify priorities and offer recommendations, the following steps will form an important part of the JSNA: • Profiling the population in terms of current health and well-being status. • Populating the primary dataset proposed in the DH guidance on JSNA (2007). • Mapping of current services against identified needs e.g. deprivation, population projection etc. 35 Page 192 • Review of existing and ongoing needs assessments in the Local Authority, PCT, academic and tertiary and voluntary sector. • Stakeholder consultation undertaken across statutory and non-statutory agencies in Lambeth. • Review of evidence of effectiveness, and cost-effectiveness, of existing and planned interventions from a commissioning perspective.

Figure 10. Diagram depicting the prioritisation process regarding JSNA and LAA

Joint Strategic Needs Assessment (JSNA)

Primary LSP Local (Local Strategic Care Trust Authority Partnership)

Priorities

PCT Lo cal Area Commissioning Agreement Priorities

- Mental Health - Healthier Communities - Long Term Conditions & Older People - Sexual health - Economic Development - Children & Young People - Children & Young People - End of Life Care - Community Safety - Staying Healthy - Active Communities

JSNA is an opportunity to influence and inform several strands of work by providing evidence to prioritise work areas, through the following strategies/plans:

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PCT and Local Authority PCT Pharmaceutical needs commissioning strategies assessments PCT Local Delivery Plans Supporting People strategies Children and Young People’s Plan Housing strategies Practice Based Commissioning Community Strategies plans Carers strategies Local development plans Workforce planning strategies Community regeneration strategies

A range of data and tools are expected to inform JSNA such as Health Survey for England, Health Inequalities Intervention Tool, disease prevalence models, National Centre for Health Outcomes Development, Projecting Older People Information System, Disease Management Intervention Tool, NICE guidance . The development of LINks (Local Involvement Network) and implementation of the Connected Care model will play a central role in design and delivery of services planned to address priorities. JSNA will lead the process of prioritisation by identifying local needs and recommending interventions to achieve the desired future health and well-being outcomes.

World Class Commissioning Commissioning describes the process by which the PCT purchases healthcare services, on behalf of the local population, from various providers within an allocated budget to meet identified needs and priorities. Commissioning is a core responsibility of PCTs. By deciding which services are commissioned, the PCT can have a positive impact on the health and wellbeing of the local population. World Class Commissioning (WCC) aims to deliver a more strategic and long-term approach to commissioning services, with a clear focus on delivering improved health outcomes.

In essence, WCC is expected to deliver: • Better health and well-being for all o People will live healthier and longer lives; o Health inequalities will be dramatically reduced. • Better care for all o Services will be evidence-based and of the best quality;

37 Page 194 o People will have choice and control over the services that they use, so they become more personalised. • Better value for all o Investment decisions will be made in an informed and considered way, ensuring that improvements are delivered within available resources; o PCTs will work with others to optimise effective care.

The process has been designed to be: • Transparent: a clear assessment methodology with clear descriptions of incentives and interventions and how these can be applied; • Standardised: one nationally consistent system managed locally by the SHAs; • Relative: recognising the starting point of different organisations and focusing on improvement; • Flexible: so that the framework can adjust over time as PCTs improve, and to support local innovation; • Challenging: matching or exceeding the rigour that ‘Monitor’ applies to Foundation Trusts; • Developmental: focusing on supporting improvement as PCTs move towards World Class Commissioning; • Incentivised: with clear incentives for PCTs that show improvement and interventions for those that do not; • Proportionate: focusing on the key indicators of performance and capabilities rather than being an all-encompassing audit; • Consistent: with the developing NHS performance regime.

Outcomes framework In order to meet these requirements, the Public Health Directorate of Lambeth PCT has developed an outcomes framework that attempts to integrate these expectations and principles. It also begins to integrate with the broader partnership health agenda related to Local Area Agreements, Sustainable Community Strategy, and Joint Strategic Needs Assessments. The following diagram and description outlines the framework.

38 Page 195 Figure 11. The outcomes framework

High Stay Stay Enjoy and Positive Economic Level Healthy Safe Achieve Contribution Security Goals

Care Pathway

1 2 3 4 5 6 7

High level Adding years Reducing Reducing Screening or Reducing Avoiding Adding life to life and avoidable avoidable early risks / harm risks and to years and Outcomes complications reducing the deaths and detection of and reduce reduce the / or gap premature from disease / disease and the gap gap wellbeing increasing deaths and reduce the and reduce quality of life reduce the for people gap the gap gap with disease and reduce the gap

Priority Areas e.g. Health Inequality

e.g. e.g. Specific Life Deprivation Outcome expectancy Score or proxy (male + Indicators female)

All cause death rates per 100,000

The framework is divided into three levels:

High level goals: indicating the borough level contribution to aspirational goals such as staying healthy, staying safe, enjoying and achieving, positive contribution and economic security.

High level outcomes: to help achieve the aspirational goals. These reflect a care pathway approach combining universal, ‘upstream’ prevention and population approaches together with the more ‘downstream’ individual care and specialist approaches. Two high level outcomes are given: outcome 1: increase quantity of life and outcome 7: increase quality of life/wellbeing and this reflects the first expectation of WCC outlined above. This latter outcome also reflects what in public health terms would be the “wider determinants of health”.

39 Page 196 This level of outcomes is what public health aims to achieve, i.e. reduce the incidence of disease where possible (within the context of the current evidence) and manage prevalent chronic disease (by early detection or screening programmes). Health inequality cuts across all of these high level outcomes.

Specific outcome or proxy indicators: that are specific to a condition/disease, measurable, attributable (i.e. causally related), valid, reliable, and time related. An example of such an outcome measure would be the reduction in premature mortality from all circulatory disease by 2010 from the baseline year of 1995/7 by 40% and to reduce the absolute gap in mortality in the most deprived PCTs by 40% compared to the national average.

This level can be used to look at indicators for specific PCT priorities and can also be used to take into consideration a particular condition and used to work out systematically specific indicators across all high level outcomes.

Process Using the above framework, Public Health has mapped existing indicators from vital signs and other sources by the key commissioning priority areas of the PCT. Other indicator sets can be added to the framework provided the data is statistically robust and data collection is not an onerous burden. In order to prioritise outcome indicators Public Health has suggested the following criteria and broad definitions:

• Size of the problem : (based on measures of incidence, prevalence, mortality rates). The size can be considered in terms of the condition being very common (1:100 cases), common (1:1000 cases), rare (1: 10,000 cases) or very rare (1:1,000,000 cases).

• Impact of intervention/cost effectiveness : high impact at low cost; medium impact at low cost; high impact at high cost; low impact at low cost or no impact/negative impact.

• Gap in service provision or quality of care : new service development; existing service but low coverage/update; existing service with medium uptake; high uptake. In terms of quality, clinical audit shows low quality service, medium quality service or high quality service.

• Inequality: there is good evidence of avoidable health inequality (inequity) in terms of mortality, service access, service uptake and/or other outcomes with reference to

40 Page 197 race/ethnicity, gender, age, disability, sexual orientation and social status. This can be quantified as very high, high, medium, low or very low impact.

• Patient and public perception : can be broadly classified or benchmarked as poor perception, average perception, and high perception.

• Overlap between LAA and vital signs : no overlap, some overlap or common overlap/outcome between partners.

Based on these criteria it is suggested that the specific indicators chosen for the priority areas are scored on a scale of 1-5 with: 1 = Very low priority 2 = Low priority 3 = Medium 4 = High 5 = Very high priority

Using this scoring system the highest priority should be given to outcome measures that focus on a common condition, where the impact of intervention is high at low cost, where there is a service or quality gap, i.e. new development or low uptake/coverage levels; there are issues related to avoidable health inequality; there is a poor perception amongst patients or the public, and there is a good overlap with between different partners.

41 Page 198

42 Page 199 Public health interventions Interventions designed to improve health outcomes cover a wide range of methods, and settings. They are delivered by practitioners from the complete spectrum of public health practice, including GPs and primary care nurses, community and neighbourhood workers, voluntary organisations and workers in other public sectors such as education, social care and the emergency services.

Interventions will work to different timescales and will deliver beneficial outcomes at different times, across the range from short to long term. For instance, ‘upstream’ interventions aimed at reducing the prevalence of diabetes through prevention, will benefit those at risk from developing diabetes, but will not benefit those people with diabetes related complications such as retinopathy whose needs could be met by downstream interventions.

There is huge variety in the methods available for interventions, for instance, one intervention could focus on medical screening to identify risk so as to prescribe a drug which reduces this risk; whilst another intervention could be to encourage parents on an estate to work together to improve play facilities for the under 5s. Commissioning from such a wide variety of public health interventions is not straightforward due to competing demands on resources, the different methods and timescales, and the vastly differing scopes and remits. When commissioning interventions, we routinely consider: 1. The treatment of chronic disease 2. Fairness 3. Patient choice 4. The balance of treatment and prevention

Outcomes Some current public health interventions in Lambeth work towards the following outcomes: • Reducing risk of contracting healthcare associated infections through the strengthening of infection control across primary and secondary care and improvement of care pathways for those found to be infected; • Reducing disease related to alcohol misuse through improved screening and intervention in primary care settings; • Preventing transmission of HIV through specific work programmes based in African Muslim communities; • Reducing blindness and eye complications in people with diabetes through retinal screening and management of retinopathy for people with diabetes.

43 Page 200 The following matrix model has been developed, which groups interventions, making comparisons and prioritisation more straightforward.

Figure 12. Matrix of interventions

A B

Short term Short-term Short-term outcomes community based health service intervention based intervention

C D

Long term Long-term Long-term outcomes community based health service intervention based intervention

Community based Health service based input input

Values for the development of outcomes • Outcomes should address the major health issues in Lambeth: CHD, Cancer, HIV, and Diabetes • Outcomes should address inequalities • Outcomes should not be exclusive, but inclusive • Outcomes should be evidence based • Outcomes should be informed by the views of local people.

44 Page 201

45 Page 202 Examples of public health interventions in Lambeth

A B Example of a short-term community based intervention -

Improving infection control across the primary / secondary care interface – C D

healthcare associated infections (HCAI) care pathway development

Outcome: To reduce HCAI in Lambeth residents

Aims: To strengthen infection control across primary and secondary care by enhancing existing arrangements, agreeing local care pathways and by sharing with all local stakeholders.

Nationally, infection control has been driven up the agenda by a number of high profile reports e.g. Healthcare Commission (HCC) reports into outbreaks of Clostridium difficile (C. difficile ) and policy e.g. Hygiene Code; and the strengthening of infection control targets.

In early 2007, the Guy’s and St. Thomas’ Trust (GSTT) quality monitoring schedule incorporated infection control through national targets and local standards. Later in 2007, the Director for Infection Prevention and Control (DIPC) presented the team’s work at the Board, where additional funding was agreed to deliver on this high priority target.

This HCAI care pathway project has arisen out of a need to improve cross organisational working when addressing infectious conditions. There are links between the community and acute trust (hospital) settings in relation to infection control. Rates of infection in the acute trust are affected by rates of infection in the community and vice versa. Cases of MRSA and C. difficile may be acquired in either setting and be transferred between them. Root cause analyses of MRSA bacteraemia episodes recorded in the acute trust showed that about 13% were present on admission and 30% were in patients who were difficult to manage because of poor venous access and social problems (including for example, intravenous drug users). The Department of Health MRSA improvement team are now recommending that acute and community sectors should work together to reduce MRSA bacteraemias acquired in the community on, or within 48 hours of admission. This project is building on existing close working between Lambeth PCT and GSTT infection control teams (ICTs).

In 2007, the Department of Health released funds to be allocated regionally for local work to improve infection control and cleanliness. Lambeth PCT and GSTT submitted a successful joint bid to NHS London for this funding.

46 Page 203

Lambeth PCT has employed a project team, consisting of a project nurse and project worker, to take this forward. This team has been working on the following: • Establishing remote access to laboratory data from key community locations • Developing an investigation process for community MRSA bacteraemias and C. difficile for those diagnosed within 48 hours of admission through close working with acute and community staff • Strengthening the MRSA and C. difficile care pathway by enhancing existing arrangements and developing a locally agreed care pathway • Improving communication with staff, patients and the public by sharing infection control information with all local stakeholders. Work is underway to develop the PCT’s infection control intranet and internet sites

In April 2008, a multi-agency workshop was held to start the process of agreeing the HCAI Care Pathways in the form of algorithms. The project will be completed by the end of summer 2008. Agreed pathway processes will be implemented by the infection control team.

A B Example of a short-term health service based intervention Local Enhanced Service (LES) for Alcohol Screening Services in Primary Care C D

Outcome: Decrease alcohol related ill health in Lambeth.

Aims: To improve screening for problematic alcohol misuse in primary care, and ensure this is provided in a more systematic way, becoming embedded in routine primary care services. To increase knowledge and skills in primary care with regards to screening for and management of alcohol misuse, including onward referral where appropriate. To provide brief interventions for alcohol misuse in general practises. To develop a register of identified patients with alcohol dependence and problematic alcohol misuse, to inform service development.

• Alcohol is the most widely used drug in the UK – consumed by over 90% of the population. • Crude estimates of excess drinking based on standardised data suggest that in Lambeth (based on intake on the heaviest drinking day in the last week, aged 16 and over, HSE 2004 survey): o 31,790 (30%) of men drink excessively (8 units or over)

47 Page 204 o 20,717 (19%) women drink excessively (6 units or over) o In total, about 52,508 (24.4 %) people drink excessively o 9,804 (5%) of the 16-64 yr old Lambeth population are dependent drinkers, a subset of the excessive drinkers figure above (London estimate). o Little difference is seen between ethnic groups in dependent drinking • A pilot ‘Alcohol Use Survey, 2005’ in Lambeth general practices suggested that 23% of people surveyed were misusing alcohol and, in line with national data, the risk factors were being young, male and white. • Levels of alcohol associated violent crime in Lambeth have risen since 2000 and are higher than those of neighbouring areas, and are associated with the night-time economy and alcohol availability. • The report also highlighted significant unmet need. There has been an increase in admissions to hospital attributable to alcohol in recent years. Services in Lambeth tend to be focused on dependent drinkers and there is a need to improve services for all alcohol misusers.

The National Treatment Agency guidance and “Our Health, Our Care, Our Say”, highlight the need for more preventative action within primary care and community settings. The Department of Health’s Models of Care for Alcohol (which in effect provides a National Service Framework for the development, commissioning, management and evaluation of the range of health focused treatment interventions in relation to alcohol) guided the development of the LES for alcohol with the Alcohol Health Needs Assessment 2006-7 for Lambeth.

The practices incorporate alcohol screening using the FAST screening tool, into new patient checks (over 16 years old), and as part of routine care for patients receiving enhanced substance misuse services, and patients on the severe mental illness register. Screening is offered where clinically appropriate, triggered by consultations on conditions recognised to be associated with alcohol misuse.

Patients with an identified need are offered a brief intervention, using the protocol for simple structured advice, and referred on to specialist services, as appropriate. The LES will be evaluated by reviewing the numbers of patients screened, the number of brief interventions delivered, and the number of referrals onto other services. Where possible, comparison will be made with baseline activity levels before the LES was available.

48 Page 205 Questionnaires and feedback will be monitored, and effective innovations encouraged at practice level to increase uptake of screening and development of ‘best practice’. The evaluation will be used to inform future local service developments, and change and development of the LES in future financial years.

Since the end of July 2008, over 20 practices have contracted to provide the service. These practices have identified a lead GP and lead nurse for the alcohol screening services, both of whom have attended training sessions run by the PCT. They are required to cascade training internally to all clinicians working in the practice.

A B Example of a long-term community based intervention Lambeth Southwark and Lewisham African Muslim Campaign against HIV C D

Outcome: To prevent transmission of HIV in African Muslim communities.

Aim: To involve the Muslim community in; raising awareness on HIV and STIs; preventing HIV transmission; showing compassion, support and help to Muslims living with HIV so they can live without stigma and discrimination.

Africans constitute a significant part of Lambeth’s population with well-established communities from East Africa, the Horn of Africa and West Africa, and since 1996, Africans have been the group in which the greatest number of newly diagnosed cases of HIV infection have occurred in South East London. This now exceeds the number of new infections in the gay community, and whilst the majority of infections in Africans were acquired outside of the UK, there is evidence of primary transmission taking place locally. In 2006, 2,306 Lambeth residents where known to be living with HIV, with approximately 24% of these being African people.

The epidemiology of HIV within Lambeth identifies this population as a priority because it faces a significant burden which is getting worse. Work with this community has increased over recent years in the following ways: • Facilitating an Islamic leader’s circle to discuss these issues • Funding a sessional worker at an Islamic cultural centre to support the work • Workshops for mentors to develop knowledge and skill in spreading HIV prevention messages within the community

49 Page 206 • Youth activities, including discussion and information groups on HIV, STIs and teenage pregnancy, resisting peer pressure, and the use of Islamic rap and drama. • Setting up a support group for HIV positive Muslim people which is facilitated by a Muslim person living with HIV. The work has resulted in increased participation and project ownership by the African Muslim community, including parental commitment to supporting sexual health campaigns as well as supporting their teenage children in taking an active part in sexual health promotional activities.

The project has also improved understanding of the impact of stigma and isolation of people who are HIV positive, leading to increased community support networks for individuals and families living with and affected by HIV. Access to local sexual health services has also been encouraged including referral for HIV testing. Referrals have also been made to other Islamic cultural centres and mainstream services such as housing benefit, immigration and social services.

Challenges to the work have included: • The autonomy of mosques, which necessitates individual approaches to leaders to build the necessary trust and not threaten their authority. • The insecurity felt in relation to the current political climate and Islamophobic views of sections of the media. • Whilst Islam (as well as many other religions) stresses abstinence and mutual fidelity within marriage as the moral ideal, a pragmatic approach acknowledging that not all Muslims practice their faith to the letter is needed. • There are a diverse range of African traditional beliefs which also influence people’s behaviour. Sometimes it is difficult to separate cultural from religious issues. • The full involvement of women has been integral to this project. As some mosques may not encourage female attendance, different strategies to engage women are needed.

Factual public health messages can be combined with Islamic teachings and values. Ownership and involvement of the community is key. With a correct and thoughtful approach most Muslim communities are not “hard to reach” and are concerned about health.

50 Page 207 A formal evaluation of the project is now underway, and plans are to involve more Islamic Centres in Lambeth, Southwark and Lewisham as full partners. The project won the 2008 London Health and Social Care Improving Access Award.

A B An example of a long-term health service based intervention Retinal screening and early management of retinopathy for people with diabetes C D

Outcome: To reduce blindness and eye complications in people with diabetes through retinal screening.

Aim: To reduce the risk of visual impairment and blindness due to diabetes; risk is substantially reduced by quality assured early detection and effective treatment of diabetic retinopathy. To identify those with sight-threatening retinopathy who may require preventive treatment. Screening and treatment for diabetic retinopathy will not eliminate all cases of sight loss, but will minimise the number.

Diabetes affects increasing numbers of people in the UK and the burden of serious complications and their consequences can be considerable for both individuals and health services. Diabetic retinopathy is the leading cause of blindness in people of working age in industrialised countries and also a major cause of blindness in older people. In its early stages, diabetic retinopathy is symptom free. Progression of disease can be prevented by laser treatment, therefore early detection by regular screening is beneficial. At any time up to 10% of people with diabetes will have retinopathy requiring ophthalmological follow up or treatment. 20 years after the onset of diabetes, more than 60% of people will have diabetic retinopathy. The personal and social costs of blindness in terms of higher possibility of dependence, loss of earning capacity, and increased likelihood of greater social support needs, are significant for individuals, for the caring services and for society. The quality of life of those who develop visual impairment can be improved by access to low vision aids, information, psychological support and appropriate welfare benefits.

The National Screening Committee (NSC), NICE guidance, Diabetes NSF and delivery strategy have given this intervention national priority. The rising prevalence of diabetes means that retinopathy will remain a major health and economic problem.

51 Page 208 In 2002, NICE Clinical Guideline “Retinopathy Screening and Early Management (Management of type 2 diabetes), Feb 2002” identified screening as an important priority. The Diabetes NSF highlighted important standards whose aims were to minimise the impact of the long-term complications of diabetes by early detection and effective treatment and by maximising the quality of life of those who develop long-term complications. These include:

• Standard 10: All young people and adults with diabetes will receive regular surveillance for the long term complications of diabetes • Standard 11: The NHS will develop, implement and monitor agreed protocols and systems of care to ensure that all people who develop long-term complications of diabetes receive timely, appropriate and effective investigation and treatment to reduce their risk of disability and premature death • Standard 12: All people with diabetes requiring multi-agency support will receive integrated health and social care

The Diabetes NSF delivery strategy and the planning and performance framework in 2003- 06: Improvement, Expansion and Reform: the next 3 year s, set the priorities for the NHS for that period. It established two critical diabetes specific targets for eye screening and registers in the early stages of delivery: • By 2006, a minimum of 80% of people with diabetes to be offered screening for the early detection (and treatment if needed) of diabetic retinopathy as part of a systematic programme that meets national standards. • By 2007, 100% coverage of those at risk. Implementing the screening programme has become a key element of the Lambeth PCT Long Term Conditions Strategy.

A Retinopathy Steering Group has been charged to monitor the implementation of the programme by the two Diabetes NSF Networks of Lambeth, Southwark and Lewisham. The lead commissioner is Lambeth PCT and the lead provider is Guys and St Thomas Foundation Trust (GSTT).

Additional funding has been provided across the three PCTs. Progress on the key requirements of the programme recommended by the NSC are summarised as follows: • Programme size: minimum 12,000 patients Lambeth is part of a three borough programme with an estimated 30,000 people with diabetes. • Accurate Data Collection 52 Page 209 This remains an important gap. Work is underway to accurately identify all patients with diabetes from primary care and develop a central collated call-recall list. • Central management of call-recall lists and administration The programme office is based at GSTT with the call-recall lists being administered from this office. All administrative staff are now employed to develop the required processes to manage call-recall for the programme. • Implementation and effective use of appropriate software A major change programme was carried out in 2007 following extensive tendering process and a PASA approved software has now been implemented to run the screening programme. • Screening method Only the use of digital photography, using approved cameras and capture software in now acceptable. Ophthalmoscopy is NOT acceptable and slit-lamp bio microscopy was only acceptable until December 2006. DECS has been using digital photography for a number of years and as part of the capital funding, upgraded to approved cameras and capture software. • Secure and efficient links to eye departments The clinical lead for the programme is now a consultant ophthalmologist with a special interest in retinal disease. Another consultant ophthalmologist has been appointed to King’s who will provide the service at King’s and Lewisham. In addition, the new IT systems should help facilitate better sharing of screening and treatment data for quality assurance purposes.

Based on cumulative data our current levels of people with diabetes offered screening is 95% with exclusions (84% without exclusions). The actual number screened is 86% with exclusions (77% without exclusions).

53 Page 210

54 Page 211 3. Recommendations for the future

Conclusions • Lambeth residents have poorer health and increased mortality compared with England and Wales. Health need includes a wide range of health issues. • Detection of long term illness is improving in primary care, but significant numbers of local people have serious undetected and untreated conditions (diabetes, high blood pressure). • Population based prevention reduces health inequality, and requires long term investment. • In Lambeth prevention needs to be both population based and targeted. • Health outcomes in Lambeth are improving. • Delivering services which produce equitable outcomes usually requires additional resources.

Recommendations 1. The PCT must continue to work closely with the Local Authority to improve the understanding of health and wellbeing issues in Lambeth, and to improve information sharing. 2. The JSNA should include evidence of effectiveness for a range of interventions in assessment of need. 3. The PCT should pilot and evaluate outcomes based commissioning for a defined population group/health need in 2009/10. Extra resources are needed for this. 4. Develop and resource common approaches to consultation, patient and public involvement and community engagement across the Local Authority and PCT. 5. The PCT should work with the Local Authority to develop programmes to improve health and wellbeing that reach the most deprived communities (using the health trainer model), via estates, schools and faith communities. 6. The Local Authority should invest resources in the partnership work necessary to deliver health and wellbeing improvement programmes. 7. The PCT should continue health equity audit for the three priority areas (Mental Health, Staying Healthy and End of Life Care) in 2009/10. 8. Partners should ensure that the Sustainable Communities Strategy focus on worklessness will improve health and wellbeing, and develops partnerships between health practitioners and employment and training services. 9. Support Health Scrutiny to develop a plan to reduce alcohol consumption in Lambeth.

55 Page 212 Appendix 1. Review of Recommendations 2005-6

The APHR fed into the PCT’s priorities and has been used by the PCT to draw up its 5-year plan in particular the Staying Healthy element.

The PCT should invest resources to support the strategic shift needed to improve health and reduce future demands for healthcare. This should include:

Recommendation Progress & Outcome 1 Ensuring that health improvement and This is being taken forward directly as part of health protection are developed elements the Staying Healthy work, one of six priorities within major programmes such as NSF of the PCT’s 5 year Commissioning Strategy implementation, care pathways, demand Plan (CSP). The other CSP’s priorities are management, and neighbourhood renewal. focusing on implementing the strategic shift along the core pathway to improve health and reduce future demands for healthcare.

2 Commissioning specialist health promotion The service was re commissioned in 2007/08 on the basis of local needs, new contract and integrated more closely with the provision and service specification which is outcomes of community services and the development of based (including evidence of effectiveness). Public Health strategy. The new teams are commissioned to provide support to the newly established Staying Healthy Programme.

3 Mainstreaming the posts which This is being taken forward as part of the enable/inform health improvement, World Class Commissioning work streams including immunisation coordination, health that form part of the PCT’s 5 year equity audit and tobacco control. commissioning strategy.

4 Asking public health to undertake a A detailed alcohol health needs assessment detailed needs assessment which has been completed. Safer Healthier Socialising documents the impact of alcohol health in Lambeth will address harm minimisation in and wellbeing in Lambeth, and makes the night-time economy. A local health recommendations to the Local Strategic promotion strategy for alcohol is being Partnership in 2007. In 2007/2008 there developed. A Local Enhanced Service (LES) has should be investment in specific been developed and implemented for GPs to interventions to reduce harmful drinking perform screening and brief interventions for for Lambeth residents. new patients and those registered with certain chronic conditions for example diabetes.

56 Page 213 Frontline staff are our biggest resource available to promote health, and need to be supported to fulfil this role. It is recommended that:

5 The job descriptions, workplans, This is being taken forward as part of the professional development plans of clinical Staying Healthy work stream that forms part staff reflect their role in health promotion, of the PCT’s 5 year Commissioning Strategy and the need to maintain skills and Plan. There is a specific work-stream on knowledge in this area. embedding health promotion delivery within community health services.

6 Induction and training support the Public health provides a programme of maintenance and development of health infection control training. Training is also promotion and health protection skills, provided in a number of non-health settings, (including infection control) and their for example, SRE training for Youth workers availability is audited. based at the council.

7 That consistent evidence based health This is being taken forward by the Staying education material is available to support Healthy Board as part of the Staying Healthy clinicians in their health promotion/health work stream that forms part of the PCT’s 5 protection role. In 2007/2008 an audit of year commissioning strategy . health education material in use should be called out. Health education supporting health promotion related to PCT priorities should be commissioned.

The role of hospital trusts in health improvement should be supported by:

8 Commissioning service specifications Infection control and tobacco control have should include requirements to promote been implemented in acute contracts in and protect health, and to produce 2008/09. Introduction of specific requirements monitorable plans. for other lifestyle factors are being developed for future service specifications for 2009/10.

9 The PCT should ensure that all hospitals Lambeth PCT has a quarterly quality are compliant with Health Act monitoring meeting with GSTT which includes requirements, and inform the Health infection control. Lambeth PCT is represented Protection Unit of incidents of significant on the GSTT Infection Control Committee, healthcare associated infections. and so is able to monitor compliance with the Act.

57 Page 214 Low income is a significant risk in Lambeth. Outstanding recommendations from previous annual Public Health Reports not actioned:

10 Ensuring the mainstreaming of Sure Start Maintained through the St. Michael’s Plus. Fellowship. Jointly funded by PCT and LA on a 3 year rolling contract.

11 To review and evaluate uptake of welfare Taken forward as an LAA target with an benefits in adults and children in Lambeth. agreed action plan.

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59 Page 216

60 Page 217 Appendix 2. Statistical Update 2006-07

Page

1. Lambeth wards and localities 62

2. Population of Lambeth 63 Breakdown by sex 63 Age-profile graph 64 Population projection 64 Migration 65

3. Ethnicity 66

4. Density 68

5. Deprivation – Change 2004 to 2007 69

6. Life expectancy 71

7. Infant mortality 72

8. Mortality and Morbidity 73 Causes of deaths by localities 76 Cancer – DSR – three year rolling average 80 CVD – DSR – three year rolling average 81

9. Vital statistics – Total births, deaths, fertility rate etc. 82

61 Page 218 1. Lambeth wards and localities

Lambeth is an inner London borough with its northern boundary on the river Thames and is situated with Wandsworth to the west, Southwark to the east and Croydon to the south. Lambeth is one of the most densely populated boroughs in the country with a rapidly growing population and relatively high levels of deprivation. Lambeth has 21 wards and comprises six town centre areas namely, North Lambeth, Stockwell, Clapham, Brixton, Streatham and Norwood. The census area classifications describe Lambeth as a London Cosmopolitan area similar to Southwark, Lewisham, Hackney, Islington, Haringey and Brent. According to this classification, Lambeth has a breadth of ethnic and cultural traditions which have established their presence in particular town centre areas and quarters. Lambeth PCT has further divided the borough into three localities - North, South East and South West locality - for facilitation of primary care programmes and interventions

Lambeth Wards and localities

62 Page 219 2. Population of Lambeth

Age Profile Mid 2006 Estimate

Lambeth males Lambeth females London males London females England males England females

4 female

0 Percent 0-4 5-9 85+

2 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84

4 male

8 Age Bands 10

Source: National Statistics Mid-2006 Population Estimates

Lambeth population age profile

Population The Office for National Statistics (ONS) published 2006 mid-year estimate showing the population of Lambeth at 271,950. Greater London Authority (GLA) 2005 estimates show the Lambeth population at 286,400. The General Practice registered population in Lambeth in March 2007 was 323,868.

Gender The 2006 ONS estimates show 51.2% males and 48.8% females in the Lambeth population, while GLA estimates show 49% males and 51% females within the Lambeth population.

Age profile London has a relatively young age profile compared to the whole country and in Lambeth around 45% of the population is in the age group 20-39 years compared with 36% in London in that same age group. The following figure 2b shows the age profile in the three localities of Lambeth compared to the Lambeth average and England.

63 Page 220

Age profile of Lambeth PCT Population and Localities 18

8 % Population % 6

0 0-4 5-9 85+ 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 Age Bands

North Locality SouthWest Locality SouthEast Locality Lambeth England

Source: National Statistics Mid-2006 Population Estimates

Population Projection

Population Change, ONS 2004 based Population Projections, 2006 - 2021, Male vs Female 120

100 Lambeth males % Change Lambeth females % Change 80 England males % Change England females % Change 60

0 0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+

-20

-40 Age Bands

Source: ONS 2004 based Population Projections

The GLA population projections estimate Lambeth’s population will reach 317,000 by 2028. The projections predict Lambeth will remain a young borough with most increases in the

64 Page 221 ethnic group occurring in the 0-19 and 20-44 year age ranges, indicating a high proportion of employable adults within the borough.

Male Female Persons Age Group % Change Diff % Change Diff % Change Diff 0-4 8.08 800 8.33 800 8.21 1600 5-9 16.90 1200 20.29 1400 19.42 2700 10-14 3.08 200 6.25 400 4.65 600 15-19 -20.29 -1400 -16.92 -1100 -17.91 -2400 20-24 -15.73 -1400 -8.00 -800 -11.64 -2200 25-29 -6.42 -1200 1.09 200 -2.70 -1000 30-34 1.45 300 10.39 1600 5.54 2000 35-39 4.24 700 0.00 0 2.42 700 40-44 16.24 1900 -6.73 -700 5.43 1200 45-49 45.57 3600 3.75 300 24.53 3900 50-54 58.33 3500 23.81 1500 41.46 5100 55-59 48.98 2400 38.46 2000 42.57 4300 60-64 44.12 1500 31.71 1300 39.19 2900 65-69 3.12 100 8.11 300 5.80 400 70-74 -7.14 -200 6.67 200 1.75 100 75-79 -18.18 -400 -12.00 -300 -14.89 -700 80-84 7.14 100 -10.00 -200 -2.94 -100 85+ 77.78 700 -5.26 -100 21.43 600 ALL AGES 8.97 12500 5.28 7000 7.17 19500

Percentage Change in Population from 2006 to 2021 in Lambeth: ONS 2006 mid-year Population Projections

Migration

Internal Migration in Lambeth 2006-07 ONS publication 12.0%

10.0%

8.0%

6.0%

4.0%

2.0%

0.0%

-2.0%

-4.0%

-6.0%

-8.0%

-10.0%

-12.0% Camden Islington Lambeth Hackney Newham Haringey Lewisham Southwark Chelsea Fulham Westminster

65 Page 222 3. Ethnicity

Lambeth has an ethnically diverse population with the Black and Minority Ethnic (BME) community accounting for 35% of the total population which is the seventh highest proportion in the country. In Lambeth over 68,000 (approximately 23%) people are classified as Black with almost equal proportions of Black African (11.5%) and Black Caribbean (11.5%). The borough has the second highest proportion of Black Caribbean residents after Lewisham and fourth highest proportion of Black African residents. Approximately 21% people within the inner London boroughs speak a foreign language at home and based on reports from schools, around 132 different languages are spoken by families within the borough.

White Caribbean African Other Indian Pakistani Bangladeshi Other Chinese Other (Black) (Black) (Black) (Asian) Asian ENGLAND 90.397 1.645 1.240 0.202 2.164 1.495 0.587 0.523 0.514 1.232 LONDON 70.687 5.651 5.886 0.838 6.110 2.047 2.178 1.913 1.229 3.463 Lambeth 63.559 13.375 11.717 1.990 2.063 1.032 0.884 0.847 1.253 3.316

Population figures from different ethnic groups.

Ethnicity Breakdown Percentage 2002 MYE

16 % 14 England London 12 Lambeth 10

k) ni e er c a hi ian s h a t es s t is ine O (Bl k A a er n P h Ch ea anglad B Ot African (Black) Other (Black) Indian (Asian) ribb Ca

Source: ONS; Estimated resident population by ethnic groups, age, sex, mid-2002 (experimental statistics)

66 Page 223

Population Projection by Ethnicity, 2006 to 2021

40,000

35,000

30,000

25,000

20,000 Number of people Number 15,000

10,000

5,000

0 Black Black African Black Other Indian Pakistani Bangladeshi Chinese Other Asian Other Caribbean 2006 31,589 33,233 14,057 4,738 2,607 2,402 3,349 4,679 7,765 2026 29,239 38,354 16,138 4,521 2,784 2,940 3,969 6,009 11,060

Source: GLA 2005 Round Interim Ethnic Group Projections

67 Page 224 4. Density

Lambeth is one of the most densely populated boroughs in the country with a rapidly growing population that is projected to grow by 15% over the next 20 years. In 2006, the density (measured in terms of people occupancy per square kilometre) in Lambeth shows an increase compared with 2005 by 77 people per Sq. Km almost similar to that of London.

Area (Sq Km) MYE People per Sq Km England 130281 50,726,382 389 London 1572 7,512,372 4779 Lambeth 27 271,950 10072

Population Density

12000 10072 10000

8000

6000 4779

4000

People per square km square per People 2000 389 0 England London Lambeth

Source: Estimated Resident Population Mid-2006, ONS

Population Density

68 Page 225 5. Deprivation

Changes in Deprivation ranking Lambeth and Comparable LAs 15 Brent 10 8 5 3 Hackney 0 Haringey -5 -3 -10 -5 Lambeth -15 -13 Lewisham -20 -18 Newham -25 -30 Southwark -35 -40 -35

Local authority Score 2007 Rank Score 2004 Rank Change Status

Changes in IMD deprivations scores and ranks 2004 - 2007

69 Page 226 Deprivation map The map below shows the deprivation levels of areas in Lambeth, according to their rank in all areas in England. This shows that most areas in the borough are in the top 20% of deprived areas in England. Poverty and social exclusion are some of the social challenges in the borough.

70 Page 227 6. Life Expectancy

Lambeth male life expectancy has shown improvement compared to the female life expectancy, although nationally, life expectancy is improving at a faster rate compared to the spearhead PCTs of which Lambeth is one. (Spearhead PCTs are the 20% of PCTs in England with the highest levels of deprivation).

Life Expectancy at Birth all Ages

England males* England females* London males London females Lambeth males Lambeth females

76 number of years of number

3 7 2 6 94 03 04 000 -19 2 -200 -20 20 8- 9-2001 2- 91-199 92 93-1995 94-1996 95-199 96-1998 97-1999 9 9 00 01 0 03-2005 04-200 9 19 19 19 19 19 1 19 19 19 20 20 20 20 20

* for England, non-resident deaths excluded

Source: Estimated Resident Population Mid-2006, ONS

1991- 1992- 1993- 1994- 1995- 1996- 1997- 1998- 1999- 2000- 2001- 2002- 2003- 2004- 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 England male * 73.69 74.02 74.18 74.44 74.61 74.84 75.09 75.38 75.71 76.00 76.23 76.53 76.90 77.32 London male 73.30 73.60 73.70 73.90 74.10 74.50 74.90 75.20 75.50 75.77 76.01 76.44 76.90 77.42 Lambeth male 71.0 71.3 71.2 71.3 71.6 72.0 72.6 72.6 73.0 73.1 73.5 74.1 74.9 75.1 England female * 79.12 79.37 79.44 79.64 79.69 79.84 79.97 80.19 80.42 80.66 80.72 80.91 81.14 81.55 London female 79.30 79.50 79.50 79.70 79.70 80.00 80.10 80.30 80.50 80.80 80.80 81.10 81.40 82.00 Lambeth female 77.8 78.1 78.2 78.6 78.4 79.0 79.2 79.1 79.2 79.4 79.8 80.0 79.8 80.1 * England, non-resident deaths excluded

Life Expectancy at birth all ages 1991-2006

The estimated life expectancy for Lambeth males increased from 74.1 in 2002-04 to 75.1 in 2004-06. The projected life expectancy of males in Lambeth by 2009-11 is 76.1 years.

The estimated life expectancy for Lambeth females remains unchanged from 80.0 in 2002-04 to 80.1 in 2004-06. The projected life expectancy of females in Lambeth by 2009-11 is 80.8 years.

71 Page 228 7. Infant mortality

Infant mortality (deaths of infants aged under 1 year) has dropped from 8.8 per 1000 live births in 1995-97 to 5.8 per 1000 live births in 2004-06 which is a reduction of over 26%; however there is still a gap when compared to the London rate as seen in the graph below.

Deaths Under 1 year, Standardised per 1,000 Live Births 3 Years Rolling Average 1990-2006 10 Lambeth Inner London London

6 Rate per 1000 live 1000 Rate births per

2 3 5 6 8 0 1 3 4 6 9 9 9 0 0 0 99 00 -19 -1994 -19 1 -1997 -19 -1999 -20 -2002 -20 2 -2005 -20 2 5 7 0 3 90 991-199 93 994- 96 998 999-200 01 002- 04 19 1 199 19 1 199 19 199 1 1 200 20 2 200 20

3 Year Rolling Average

Source: Office for National Statistics (ONS). NCHOD – National Compendium of Health Outcomes Development. ( www.nchod.nhs.uk )

1991- 1992- 1993- 1994- 1995- 1996- 1997- 1998- 1999- 2000- 2001- 2002- 2003- 2004- 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 Lambeth 8.4 8.0 8.2 8.2 8.8 8.0 7.4 6.9 7.2 7.0 7.2 6.8 6.3 5.8 Inner London 7.7 7.6 7.3 7.1 6.9 6.8 6.8 6.5 6.5 6.3 6.3 5.9 6.0 5.2 London 6.9 6.6 6.4 6.4 6.2 6.0 5.9 5.8 5.8 5.7 5.7 5.4 5.2 5.0

Mortality in Infancy 1991-2006

72 Page 229 8. Mortality and morbidity

The bar chart below summarises the current mortality and morbidity burden by International Classification of Disease chapter (ICD 10) as measured by Disability Adjusted Life Year (DALY) - a measure of the years of life lost (YLL) and years lived with disability (YLD) from an ideal standard (the standard expected years of life). The diagram illustrates that the current burden in Lambeth when ranked for both mortality and morbidity by ICD 10 chapter is highest for mental disorders (including dementia), followed by cardiovascular disease and neoplasms (cancers).

DALYs in Lambeth 2005 * 10000 9000 8000

7000

6000 YLL YLD 5000 DALYs 4000 3000 2000 1000

Ear Eye Skin Blood System Mental Nervous Perinatal

Digestive Disorders Infectious Endocrine Symptoms Pregnancy Circulatory Circulatory Respiratory Neoplasm's Congenital malformations Genito-urinary External causes External Musculoskeletal ICD10 chapter * using standard LE & 3% discounting

Source: Lambeth Commissioning Strategy Plan 2007-2012

Early intervention provides effective outcomes in the long-term and the importance of prevention and early detection and treatment has been highlighted through the “Staying Healthy” work stream adopted and developed by the PCT in its five year Commissioning Strategy Plan (CSP).

Hypertension One of the conditions that put individuals at high risk of premature morbidity and mortality – especially from cardio-vascular disease - is hypertension. Case detected prevalence of hypertension (from GPs’ QOF data) was similar throughout the three localities of Lambeth PCT. This equates to approximately 34,000 people in Lambeth who may have hypertension but are not diagnosed, and therefore not receiving treatment.

73 Page 230 Comparison of case detected prevalence in Lambeth and actual population prevalence estimated using the “PBS prevalence models” published by the Association of Public Health Observatories estimate approximately 30,000 in Lambeth who are undiagnosed as having hypertension. QMAS data shows an average case detected prevalence of 8.9% in Lambeth. The PBS model estimates the actual prevalence in Lambeth to be 19.9% - over 10% higher than detected prevalence. The GP register data shows that out of the 9.1% detected hypertensive patients around 6.6% are receiving treatment at the moment.

Coronary Heart Disease (CHD) The graph below shows CHD prevalence from Lambeth QOF data compared to prevalence measured using the Association of Public Health Observatories’ (APHO) PBS model.

4.5 4 4 3.6 3.5 3 3 2.5 2.3 2 1.5 1.318 1 0.5 0 England (2004-5) London (2004-5) Average for PBS Prevalence PBS Prevalence Lambeth for England for Lambeth

Source: CHD (Coronary heart disease) Prevalence model. YHPHO – Yorkshire and Humber Public health observatory. Doncaster PCT. 2006

When CHD case-detected prevalence is compared with the population prevalence using the model, the findings show that there may be over 5000 undiagnosed cases of people with CHD in Lambeth. Cardio-vascular diseases have a direct impact on the quality of life of an individual. In addition they are directly associated risk factors causing premature mortality. Lambeth PCT aims to detect hypertension early and to offer timely and cost-effective treatment for cardio-vascular diseases, using the health inequalities intervention tool published by the London Health Observatory to plan interventions.

74 Page 231 Diabetes The graph below shows diabetes prevalence from Lambeth QOF data compared to prevalence measured using the APHO PBS model.

% prevalence England (2004-05) London (2004-05) 5 Average for Lambeth (2006-07) 4.5 PBS prevalence for London PBS prevalence for Lambeth 4 3.5 3 2.5 2 1.5 1 0.5 0 England London Average for PBS PBS (2004-05) (2004-05) Lambeth prevalence prevalence (2006-07) for London for Lambeth

Source: Diabetes PBS Model Phase 2. YHPHO – Yorkshire and Humber Public health observatory. 2005.

QMAS data shows an average case detected prevalence of 2.9% in Lambeth, whilst the PBS model estimates the actual prevalence in Lambeth as 3.8% and 4.4% in London. This equates to roughly a quarter of cases in Lambeth (about 1000 patients) which may be undiagnosed in the community. Uncontrolled diabetes can lead to several complications such as eye, kidney and heart problems, which can significantly affect the quality of life of an individual.

75 Page 232 Cause of Death

Lambeth Top 10 Causes of Death 2006

Ischaemic Heart Disease I20-I25 14%

Cerebro Vascular Diseases All Other Causes I60-I69 45% 9%

Malignant Neoplasm of Tracchea, Bronchus & Lung Dementia C33-C34 F01-F03 7% Pneumonia 2% J12-J18 Gastric and Duodenal Ulcer 4% k25-k27 Malignant Neoplasms of 1% Digestive Organ Bronchitis, Emphysema and C15-C26 Chronic Obstructive Pulmonary Diseases of the Liver 6% Other Heart Disease Disease k70-k77 I26-I52 J40-J44 3% 4% 5%

Source: Public Health Mortality Files, ONS, 2006

Code Description Count % All Cause All Cause 1640 I20-I25 Ischaemic Heart Disease 231 14.09 I60-I69 Cerebro Vascular Diseases 143 8.72 C33-C34 Malignant Neoplasm of Trachea, Bronchus & Lung 107 6.52 C15-C26 Malignant Neoplasms of Digestive Organ 106 6.46 J40-J44 Bronchitis, Emphysema and Chronic Obstructive Pulmonary Disease 81 4.94 J12-J18 Pneumonia 71 4.33 I26-I52 Other Heart Disease 66 4.02 k70-k77 Diseases of the Liver 53 3.23 k25-k27 Gastric and Duodenal Ulcer 18 1.10 F01-F03 Dementia 25 1.52 All Other Causes 739 45.06 Source: Public Health Mortality Files, ONS, 2006

Lambeth top 10 Causes of Death, 2006

The data on cause of death is derived from the Public Health Mortality Files which are provided by the ONS annually. The pie charts show the proportion of each cause of death. As noted in previous years, the top three causes of death in Lambeth are ischaemic heart disease, cerebro-vascular diseases and malignant neoplasms or cancer, followed by chronic obstructive lung disease at fourth place. The following pie charts present the cause of death in North, Southeast and Southwest localities of Lambeth. 76 Page 233

Lambeth Top 10 Causes of Death, North Locality 2006 Ischaemic Heart Disease I20-I25 13.00% All Other Causes Cerebro Vascular All Other Causes Diseases 40.58% I60-I69 12.47%

Malignant Neoplasm of Tracchea, Bronchus and Lung C33-C34 6.63% Malignant Neoplasms of Breasts Malignant Neoplasms of C50 Digestive Organ 1.86% C15-C26 5.57%

Dementia Bronchitis, Emphysema F01-F03 and Chronic Obstructive 1.59% Pulmonary Disease J40-J44 Gastric and Duodenal Other Heart Disease 5.57% Diseases of the Liver Pneumonia Ulcer I26-I52 k70-k77 J12-J18 k25-k27 2.92% 1.59% 4.51% 3.71% Source: Public Health Mortality Files, ONS, 2006

Code Description Count % All Cause All Cause 377 I20-I25 Ischaemic Heart Disease 49 13.0 I60-I69 Cerebro Vascular Diseases 47 12.5 C33-C34 Malignant Neoplasm of Tracchea, Bronchus and Lung 25 6.6 C15-C26 Malignant Neoplasms of Digestive Organ 21 5.6 J40-J44 Bronchitis, Emphysema and Chronic Obstructive Pulmonary Disease 21 5.6 J12-J18 Pneumonia 14 3.7 I26-I52 Other Heart Disease 11 2.9 k70-k77 Diseases of the Liver 17 4.5 k25-k27 Gastric and Duodenal Ulcer 6 1.6 F01-F03 Dementia 6 1.6 C50 Malignant Neoplasms of Breasts 7 1.9 All Other Causes 153 40.5836 Source: Public Health Mortality Files, ONS, 2006

Lambeth Top 10 Causes of Death, North Locality 2006

77 Page 234

Top 10 Causes of Death, South West Locality 2006

Ischaemic Heart Disease I20-I25 Cerebro Vascular Diseases 13.76% I60-I69 All Other Causes 7.53% All Other Causes 42.15% Malignant Neoplasm of Tracchea, Bronchus and Lung C33-C34 7.53%

Malignant Neoplasms of Digestive Organ C15-C26 Malignant Neoplasms of Breasts 5.81% C50 1.72% Bronchitis, Emphysema and Chronic Obstructive Pulmonary Disease Dementia J40-J44 F01-F03 6.45% 2.15% Pneumonia Gastric and Duodenal Ulcer J12-J18 Other Heart Disease k25-k27 4.09% Diseases of the Liver I26-I52 1.29% k70-k77 3.87% 3.66%

Source: Public Health Mortality Files, ONS, 2006

Code Description Count % All Cause All Cause 465 I20-I25 Ischaemic Heart Disease 64 13.76 I60-I69 Cerebro Vascular Diseases 35 7.53 C33-C34 Malignant Neoplasm of Tracchea, Bronchus and Lung 35 7.53 C15-C26 Malignant Neoplasms of Digestive Organ 27 5.81 J40-J44 Bronchitis, Emphysema and Chronic Obstructive Pulmonary Disease 30 6.45 J12-J18 Pneumonia 19 4.09 I26-I52 Other Heart Disease 18 3.87 k70-k77 Diseases of the Liver 17 3.66 k25-k27 Gastric and Duodenal Ulcer 6 1.29 F01-F03 Dementia 10 2.15 C50 Malignant Neoplasms of Breasts 8 1.72 All Other Causes All Other Causes 196 42.15 Source: Public Health Mortality Files, ONS, 2006

Lambeth top 10 Causes of Death, South West Locality 2006

78 Page 235

Top 10 Causes of Death, South East locality 2006

All Other Causes All Other Causes 44.61% Ischaemic Heart Disease I20-I25 14.79%

Cerebro Vascular Diseases Malignant Neoplasms of Breasts I60-I69 C50 7.64% 1.63%

Malignant Neoplasm of Tracchea, Bronchus and Lung Dementia C33-C34 F01-F03 6.77% 1.13% Malignant Neoplasms of Digestive Organ Gastric and Duodenal Ulcer C15-C26 k25-k27 7.14% 0.75% Bronchitis, Emphysema and Chronic Obstructive Pulmonary Disease Diseases of the Liver J40-J44 Other Heart Disease Pneumonia k70-k77 3.76% 2.38% I26-I52 J12-J18 4.64% 4.76%

Source: Public Health Mortality Files, ONS, 2006

Code Description Count % All Cause All Cause 798 100 I20-I25 Ischaemic Heart Disease 118 14.79 I60-I69 Cerebro Vascular Diseases 61 7.64 C33-C34 Malignant Neoplasm of Tracchea, Bronchus and Lung 54 6.77 C15-C26 Malignant Neoplasms of Digestive Organ 57 7.14 J40-J44 Bronchitis, Emphysema and Chronic Obstructive Pulmonary Disease 30 3.76 J12-J18 Pneumonia 38 4.76 I26-I52 Other Heart Disease 37 4.64 k70-k77 Diseases of the Liver 19 2.38 k25-k27 Gastric and Duodenal Ulcer 6 0.75 F01-F03 Dementia 9 1.13 C50 Malignant Neoplasms of Breasts 13 1.63 All Other Causes All Other Causes 356 44.61 Source: Public Health Mortality Files, ONS, 2006

Lambeth Top 10 Causes of Death, South East Locality 2006

79 Page 236 Mortality from all Cancers

Mortality from cancer in under 75 year olds per 100,000 European Standardised population

E&W males E&W Females London Cosmopolitan Males London Cosmopolitan Females Lambeth Males Lambeth Females 200.0

180.0

160.0 DSR 140.0

120.0

100.0

01 0 93-1995 00-2002 9 0 1 1994-1996 1995-1997 1996-1998 1997-1999 1998-2000 1999-2 2 2001-2003 2002-2004 2003-2005 2004-2006 3 Year Rolling Average Source: National Statistics, www.nchod.nhs.uk, July 2007 Source: National Statistics, NCHOD December 2007

Mortality from all Cancers – 3 years rolling average 1993-2006

1993- 1994- 1995- 1996- 1997- 1998- 1999- 2000- 2001- 2002- 2003- 2004- 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 ENGLAND male 167.89 164.98 160.78 157.58 152.88 149.29 144.70 142.11 139.44 136.51 132.90 130.37 LONDON male 167.51 165.79 161.46 158.55 153.68 148.47 143.84 141.46 139.85 135.80 131.60 130.08 Lambeth male 186.48 184.17 185.21 189.41 179.74 163.26 156.88 165.37 171.77 162.12 152.20 152.62 ENGLAND female 129.08 126.85 124.52 121.96 119.29 116.97 114.72 112.66 110.32 108.33 106.55 105.10 LONDON female 129.05 126.68 125.16 123.79 120.31 117.27 113.89 111.44 108.54 105.87 103.45 100.95 Lambeth female 131.25 134.24 140.52 132.42 122.81 113.01 115.00 113.94 112.60 109.83 113.70 110.35 Source: www.nchod.nhs.uk

Mortality from all Cancers Aged Under 75, 3 Year Rolling Average 1993-2006

There has been a relatively small change in the reduction in mortality rate from cancers in Lambeth residents in 2004-06 compared to the 2003-05 average.

80 Page 237 Mortality from all Circulatory Diseases

Mortality rate from all circulatory diseases in under 75 year olds per 100,000 European Standardised population E&W Males E&W Females LondonMales London Females Lambeth Males Lambeth Females 300.0

250.0

200.0

150.0 Rates

100.0

50.0

0.0

5 96 99 01 03 05 9 997 998 9 000 0 002 0 004 004 0 006 -1 1 1 -1 2 -2 2 -2 2 2 -2 2 3 -199 94 97 98 99- 00 01- 03 04- 9 9 0 0 19 19 1995- 1996- 19 1997- 19 1 20 2 2002- 20 2 Source: National Statistics, www.nchod.nhs.uk

Source: National Statistics, NCHOD, December 2007

Mortality from all Circulatory Diseases – 3 years rolling average 1993-2006

1993- 1994- 1995- 1996- 1997- 1998- 1999- 2000- 2001- 2002- 2003- 2004- 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 ENGLAND male 217.0 206.6 198.4 189.2 179.3 170.0 160.2 151.4 143.7 135.6 127.0 118.4 LONDON male 218.2 211.6 203.7 193.5 183.2 176.4 167.2 160.5 153.6 146.7 137.5 127.5 Lambeth male 235.8 238.6 239.7 232.2 212.3 218.3 210.4 201.6 179.3 171.0 164.7 163.0 ENGLAND female 97.0 92.9 89.6 86.3 82.0 77.5 72.5 68.3 64.8 60.6 56.4 52.2 LONDON female 94.0 90.6 87.5 83.9 81.0 77.4 74.5 70.6 67.8 63.5 59.2 54.0 Lambeth female 120.6 119.3 115.7 110.6 109.7 108.1 100.7 89.3 79.3 80.3 77.6 73.8 Source: www.nchod.nhs.uk

Mortality from all Circulatory Diseases Aged Under 75, 3 Year Rolling Average 1993-2006

There has been a marked reduction in the death rates in females from circulatory diseases in 2004-06 compared to 2003-05 three year rolling average. There has been a small reduction in death rates in males. The target of 10% reduction in relative gap by 2010-11 from 1995-97 baseline is still challenging for both indicators.

81 Page 238

9. Vital Statistics

Lambet h Lambeth London London England England

Type 2004 2006 2004 2006 2004 2006

Crude Birth Rates 17.70 18.05 15.60 16.09 12.1 12.52

General Fertility Rate 63.8 67.9 63.8 65.4 58.5 60.3

Period Fertility Rate 1.87 1.9 1.79 1.86 1.8 1.85

Still Birth Rate 6.1 5.9 6 6 5.4 5.4

All Births Proportion Under 2500 Grams 8.6 8.8 8.7 8.3 7.6 7.9

Crude Rate Deaths, All Ages 6.10 6.10 7.10 6.82 9.6 9.27

Standardised mortality ratios 1 108 114 95 95 100 100

Infant Mortality Under 1 Year 6.1 5.7 5.1 4.9 5 5

Infant Mortality Under 4 weeks 4 4.7 3.4 3.6 3.4 3.5

Perinatal 9.4 9.4 8.5 8.8 8 8

82 Page 239 Glossary of terms

A&E Accident and Emergency LA Local Authority AGI Africans Getting Involved LAA Local Area Agreements AIDS Acquired Immunodeficiency LCNDG London Cancer New Drugs Group Syndrome LES Local Enhanced Service APA Annual Performance Assessment LDP Local Delivery Plan APHO Association of Public Health LINks Local Involvement Networks Observatories LSL Lambeth Southwark and Lewisham BME Black or Minority Ethnic persons or LSP Local Strategic Partnership groups MMR Measles Mumps and Rubella vaccine CAA Comprehensive Area Assessment MRSA Methicillin Resistant Staphylococcus CHD Coronary Heart Disease Aureus CLG Communities and Local Government NHS National Health Service CSCI Commission for Social Care NICE National Institute for health and Inspections Clinical Excellence CSP Commissioning Strategy Plan NRT Nicotine Replacement Therapy DALY Disability Adjusted Life Year NSC National Screening Committee DECS Diabetes Eye Complication Screening NSF National Service Framework DH Department of Health (a government ONS Office for National Statistics department) OPM Office for Public Management DIPC Director for Infection Prevention and PASA Purchasing and Supply Agency Control PBC Practice Based Commissioning DSR Directly Standardised Death Rate PCT Primary Care Trust EIA Equality Impact Assessment PPI Patient and Public Involvement ET Exceptional Treatment QA Quality Assurance ETA Exceptional Treatment Arrangement QALY Quality Adjusted Life Year FSL Feedback South London QMAS Quality Management and Analysis GLA Greater London Authority System GSTT Guy’s and St Thomas’ Foundation QOF Quality and Outcomes Framework Trust SELCN South East London Cancer Network HCAI Healthcare Associated Infections SELECG South East London Executive HCC Healthcare Commission Commissioning Group HEA Health Equity Audit SCS Smoking Cessation Services HIV Human Immunodeficiency Virus STI Sexually Transmitted Infection ICD 10 International Classification of Disease TP Teenage Pregnancy (10 th Revision) VFM Value For Money

ICT Infection Control Team WCC World Class Commissioning JSNA Joint Strategic Needs Assessment WHO World Health Organisation

83 Page 240 Bibliography

Population need

Doncaster PCT. Coronary Heart Disease Model - Developed in discussion with Department of Health, Eastern Region Public Health Observatory and Yorkshire and Humber Public Health Observatory . 2006. Available from: http://www.apho.org.uk/resource/item.aspx?RID=39385

Eastern Region Public Health Observatory and Yorkshire and Humber Public Health Observatory. Hypertension Model . 2006. Available from: http://www.apho.org.uk/resource/item.aspx?RID=39384.

Greater London Authority: GLA 2005 Round Interim Ethnic Group Projections . 2007.

Lambeth PCT. Lambeth PCT Commissioning Strategy Plan 2007-2012 . 2007.

Lambeth PCT. Quality Management Analysis System (QMAS) extracts for GP registered population and case detected prevalence . 2008.

Office for National Statistics. ONS 2004 based Population Projections . 2006.

Office for National Statistics. Public health birth and mortality files: Lambeth . 2006.

Office for National Statistics. National Compendium of health outcome (indicators) development. Mid-2006 population estimates. 2007.

Yorkshire & Humber Public Health Observatory. PBS Diabetes Population Prevalence Model Phase 2. 2005. Available from: http://www.york.ac.uk/yhpho/diabetes.htm

Views of local people

Department of Health. Choosing Health: Making healthy choices easier . 2004.

Department of Health. Commissioning A Patient Led NHS . 2005.

Department of Health. Our Health Our Care Our Say: A new direction for community services. 2006.

HM Government. The Health and Social Care Act. 2001.

HM Government. The Local Government and Involvement Health Act. 2007.

Lambeth PCT. Patient & Public Involvement (PPI) strategy . (Unpublished). 2005.

NICE. Community Engagement Guidance . 2008.

Wilcox. D. The Guide to Effective Partnerships .1994. Available from: http://www.partnerships.org.uk/guide/guide1.pdf

84 Page 241 What are we trying to do?

Department of Health . National Service Framework for Diabetes . 2002.

Department of Health. Improvement, expansion and reform: the next 3 years priorities and planning framework 2003 – 2006. 2003.

Department of Health. National Service Framework for Diabetes: Delivery Strategy . 2003.

Department of Health. The Health Act 2006, Code of Practice for the Prevention and Control of Healthcare Associated Infections. Rev. 2008.

Department of Health. World Class Commissioning: Vision. 2008. Available from: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidanc e/DH_080956

Healthcare Commission. Investigation into outbreaks of Clostridium difficile at Maidstone and Tunbridge Wells NHS Trust . 2007.

Healthcare Commission. Investigation into outbreaks of Clostridium difficile at Stoke Mandeville Hospital, Buckinghamshire Hospitals NHS Trust . 2006.

Lambeth PCT. The alcohol health needs assessment for Lambeth 2006/07. 2007.

National Screening Committee (NSC), UK National Screening Committee Essential Elements in Developing a Diabetic Retinopathy Screening Programme . 2007.

NICE. Clinical Guideline: Retinopathy Screening and Early Management (Management of type 2 diabetes), 2002.

85 Page 242 Acknowledgements

The report was edited by Darrell Gale. APHR Project Team: Ruth Wallis, Jamie Ferguson, Darrell Gale and Liz Fierro Bayley. Special thanks to Felicity Howden and Jacqueline Spiby for proof reading and for their helpful suggestions.

Many thanks to all who made contributions to this report: Karen Attridge Laura Gallagher Bimpe Oki Sarah Corlett June Hitchcock Emma Robinson James Crompton Sukainah Jauhar Teresa Salami-Adeti Monica Desai Shewa Melesse Sylvia Smith Alice Devall Abdu Mohiddin Jean Spencer Hiten Dodhia Ash More Marie-Noelle Vieu Vivienne Fresson Gemma Novis Edward Wynne-Evans

The information within the statistical update is derived from various sources. While every precaution is taken to ensure that the information is accurate; interpretation of information from certain data sources should be treated with caution. For e.g. mortality rates and prevalence rates from GP practice registers (QMAS) [as these are case detected prevalence rates and do not reflect the true prevalence]. These are only examples; if you have any queries please contact the Lambeth Public Health Intelligence Department:

Dr. Ash More Public Health Information Specialist Lambeth PCT 1, Lower Marsh Waterloo, London – SE1 7NT Email: [email protected] Tel: (+44) 020-30494236

Comments and feedback Your comments on this report are very welcome. We would urge you to let us know what you think about the report, and about public health in Lambeth. Please e-mail your comments to us at: [email protected]