Torfaen Health, Social Care and Wellbeing Needs Assessment 2007

Supporting the Health Social Care and Wellbeing Partnership for Torfaen

Summary Document Foreword

This second needs assessment represents the most comprehensive gathering and analysis of information from across the wide range of interests that our next HSCWB strategy will need to consider to work with to continue with our journey of health improvement in Torfaen.

That being said, there are inevitably many gaps that remain, and we hope that many of these will be filled during the consultation and engagement process to develop and share the draft strategy, later this year. Some of those gaps will undoubtedly need us to do some things very differently over the next three years (and beyond), and we would encourage all readers to keep on adding to the repository of information that has been used to prepare this summary needs assessment.

An interesting development for this round is the inclusion by NPHS colleagues of evidence-based responses for some of the main needs identified, with the aim of helping to bridge the assessment of need to potential actions within the draft strategy.

On a personal note, we would wish to thank the members of the multi agency Project Board who have been actively involved, and in particular Dr. Subu Iyer, Jon West, the NPHS Health Information Analysis Team and, Torfaen Local Public Health Team for shaping and creating this first formal stage in helping Torfaen to continuously improve local health, social care and well being.

David Congreve Sue Evans

Strategic Director for Health and Wellbeing Joint Head of Integrated Services Torfaen County Borough Council Torfaen Local Health Board/Torfaen County Borough Council

ii Background The Welsh Assembly Government, through the National Health Service (Wales) Act 2006 (the 2006 Act), has asked Local Health Boards (LHB) and Local Authorities (LA) in Wales to jointly formulate and implement the second Health Social Care and Well-being (HSCWB) strategies for the three-year period from 2008 to 2011. The first draft strategies were developed by the end of March 2004, and following public consultation were adopted by Local Authorities, Local Health Boards and many local partners by the end of December 2004. The strategies became operational from 1 April 2005 to cover the three year period 2005-2008.

The 2006 Act further confers upon the National Assembly for Wales the powers to make regulations and guidance which set out the procedure for Local Health Boards and Local Authorities in formulating and implementing the Health, Social Care and Well-being Strategy for their local area. In anticipation of the next round of Health, Social Care and Well-being Strategies in April 2008, the Welsh Assembly Government has reviewed and revised the Statutory Guidance and made amendments to the existing regulations. The new regulations are known as the Health, Social Care and Well-being Strategies (Wales) (Amendment) Regulations 2007 and they came into force on the 1st April 2007.

The reviewed Strategy Guidance (WAG 2007) states, “In preparing the strategy and especially at the needs assessment stage, there must be a wide-ranging look at the factors that affect health and well-being and opportunities for improvement”. However, the process must lead to clear choices and the final strategy must focus tightly on delivery of real improvement.

This strategic needs assessment is just the first step in achieving service transformation in HSCWB which requires collective focus on key issues for long periods of time. This document will inform the HSCWB strategy 2008 to 2011 by providing many of the priorities for action, eventually clarifying the boundaries for the ownership and leadership of work by the Health Social Care and Wellbeing Partnership leading on to the development of action plans. This, in turn, will enable the achievement of better health for the population of Torfaen over the next three years. It will also act as the reference point for more detailed, dynamic and real-time service-specific or population-specific needs assessments over the life of the strategy and beyond.

Local Public Health Directors are responsible for producing the needs assessment which will underpin the HSCWB Strategy for the three-year period 2008 to 2011. This document is a summary of the process, main findings and recommendations of the HSCWB needs assessment 2007.

iii Process and methods The approach to this needs assessment, as well as using accepted methods, was essentially about inclusivity; inclusivity of the diversity of stakeholders in health social care and wellbeing in Torfaen and inclusivity of the work undertaken locally in establishing need for HSCWB since the 2003 needs assessment.

This project was managed using PRINCE2 methodology. A Project Board was set up comprising senior users from the Local Authority, the Local health Board, Gwent Healthcare NHS Trust, Torfaen Voluntary Alliance and the Gwent Community Health Council. The senior supplier was the Local Public Health Director, National Public Health Service for Wales, and the project executive was the Strategic Director of Health and Wellbeing with Torfaen County Borough Council (TCBC). The project was managed and delivered by Torfaen Local Public Health Team.

There are three identified methods for conducting needs assessments categorised as: Corporate, Comparative and Epidemiological. This needs assessment uses a combination of the three approaches.

There has been much work in Torfaen since the last needs assessment (2003) to supplement our understanding of the need for health, social care and wellbeing. Quantitative and qualitative information/data have been gathered by a range of organisations and planning groups locally for different purposes. This information has been gathered from stakeholders and utilised or signposted within this report as the corporate approach. These documents will be made available in a knowledge repository on the internet and this must remain an ongoing process.

For the comparative approach, a vast amount of comparative information has been gathered and analysed by NPHS Health Information Analysis Team (HIAT) and has been condensed and collated locally for consideration with service performance data, Quality Outcomes Framework (QoF) data, and Business Service Centre analyses of Patient Episode Database Wales. This work is combined with the locally available qualitative information.

Together with the above approaches, the epidemiological method is completed by this needs assessment containing an evidence-based section linking to appropriate sources of evidence of effectiveness for interventions to address specific issues highlighted as areas for focus/investment. In time, this process will lead to the building of a knowledge management web-page/site which will contain reports on evidence-based practice in specific thematic areas for use by policy makers and practitioners.

This needs assessment document provides a good first step but it must be accepted that no single document can capture the complete detail of ‘need’ for the vast permutations of all populations, organisations and services, from their variety of perspectives. For this reason, the Revised Guidance (WAG, 2007) states “Needs assessment should be viewed as part of an ongoing process, not as a one-off exercise”. Therefore it is vital that continued clear direction from the HSCWB Partnership is taken up by an appropriate group to provide data, examining service provision and performance within specific areas of interest.

iv Main Findings

Demography of Torfaen Any attempt to assess the health, or the health needs, of a given population must begin by gaining an understanding of the size, structure, distribution and development of that population.

Gaining an understanding of the local population is a vital introduction to any assessment of health or other need. This section shows the structure of the all-age population in Wales and also of the under 25s and over 65s, who may be deemed to be having a greater and different need for health and social care.

Wales has less people in the 20-39 age group than the other nations and more persons aged 60 and over.

Torfaen LHB/LA area has an estimated population of 90,300 persons (ONS; MYE, 2005) of which 46,600 (51.6 per cent) are female and 43,700 (48.4 per cent) are male.

Torfaen has a population structure very similar to that of Wales, with persons aged under 25 years in Torfaen representing 31.3 per cent of the local population (Wales 31%) and, those aged 65 and older in contributing 17.5 per cent (Wales 17.6%) of the Torfaen total.

Torfaen is the LHB/LA area closest to the all-Wales population structure for those aged 65 and older of all 22 LHB areas; 65 to 74 year olds representing 9.1 per cent of the Torfaen population (Wales 9.2%), 75 to 84 year olds 6.4 per cent (Wales 9.2%), and, those aged 85 and over just two per cent (Wales 2.1%).

Compared to Wales (31%) the proportion of the total population aged under 25 years in Torfaen is slightly higher but very similar at 31.3 per cent. The proportion of the population aged 0 to four years in Torfaen is 5.4 per cent (Wales 5.4%), those aged five to nine years make up 6.1 per cent (Wales 5.9%), the 10 to 14 year age group 7.1 per cent (Wales 6.5%), 15 to 19 years 7.1 per cent (Wales 6.7%), and, the 20 to 24 year age group contribute 5.6 per cent to the total population in Torfaen (Wales 6.4%).

Population trends by age group from 1996 to 2005 in Torfaen show an annual average decrease of 90 persons in the 0 to 24 age group was experienced in this age group equates to 3.1 per cent. In those aged 25 to 44 there was another decrease, of 11.2 per cent which translates to an annual average decrease of 290 persons. In contrast, over the same time period, the age group 45 to 64 had an increase of 8.8 per cent in an average annual increase of 190 persons. In those aged 65 to 84: an increase of 3.7 per cent from 1996 to 2005; an average annual increase of 50 persons. The largest relative increase in proportion is in the age group 85 and older, 38.5 per cent higher in 2005 than in 1996, this equates to an average annual increase of 50 persons.

v General Fertility Rates and Total Fertility Rates (TFR) are higher in Torfaen than the Welsh average but the TFR is still below the rate needed to replace the current population.

Special populations Special populations may have a different profile of HSCWB needs compared to the total Torfaen population. These differences may result in inequalities of health or care. The differences in health and care needs in special populations compared to the total population might arise from age or cultural differences in the prevalence of certain illnesses or determinants of health amongst specific demographic or health- condition groups. It may also be due to differences in equity of provision or access to services and initiatives aimed at improving health, social care and wellbeing which are often designed with the majority in mind.

There are no asylum seeker groups resident in Torfaen. The proportion of persons who reported being non-white (Census, 2001) in Torfaen LHB/LA area is less than one per cent (852 persons) with the majority of these populations describing themselves as Mixed (343 persons), Asian or Asian British (238), Chinese (143), Black or Black British (84).

In Torfaen, the number of persons reporting providing any unpaid care on a weekly basis are11,504 (Census, 2001). These data can be broken down by the amount of weekly unpaid care they provide: 1,495 people provide 20 to 49 hours and 2,949 provide 50 or more hours per week.

Crude proportions calculated from 2001 Census data show that Torfaen is not very different to the Welsh average, or other LHB/LA areas in Gwent, in terms of the crude proportion of the population providing unpaid care.

At Ward level, St Cadocs and Penygarn has the highest proportion of carers providing 20 hours or more of unpaid care per week at 8 per cent of the population. Although Blaenavon has a lower proportion of 5.6 per cent providing 20 or more hours of unpaid care a week that translates to 433 people compared to 128 in St Cadocs and Penygarn.

Designed for Life Vision 2015 aims, where possible, to eliminate or reduce inequalities in health. There are therefore a variety of issues related to health and wellbeing including equity of provision or access which might require services to be planned, delivered or promoted in slightly different ways to more fully meet the needs of these populations. One size does not usually fit all.

The revised WAG Guidance on preparation of HSCWB Strategies provides an example list of populations- “groups whose needs, or some of whose needs, are sometimes neglected by mainstream services”- containing 22 special populations. Other national documents list other populations that have different needs, which should be explored and provided for.

As previously mentioned, it is outside the scope of this or any single needs assessment document to be able to comment on all the differences in needs from the diversity of special populations or specific service provision perspectives, although

vi where possible this information has been included in the needs assessment; that task is best addressed in a service-specific manner during commissioning.

There is a paucity of evidence for special need in these special populations locally; although some work has been done, it lacks robustness of method and hence validity. Therefore this information would neither be able to provide a valid picture of need to plan services nor an accurate or precise baseline from which to measure performance of strategy delivery. As mentioned previously it is vital that continued clear direction from the HSCWB Partnership is taken up by an appropriate group to provide data, examining service need, provision and performance within specific areas and populations of interest.

vii Life Circumstances Life circumstances are important factors that impact directly on the health of both individuals and communities. The higher the deprivation, higher the prevalence of risk factors such as physical inactivity, smoking, obesity and lack of a healthy diet; in turn these are linked to poor health outcomes as well. Eight of the 24 wards in Torfaen are amongst the most deprived fifth of all wards in Wales – 31 per cent of the total population of Torfaen live in these 8 Wards. Two areas in Torfaen are amongst the highest 10 per cent of deprived areas in Wales according to the Welsh Index of Multiple Deprivation (2005).

Torfaen is the eight highest of the 22 LHB/ LA areas in Wales for people aged 75 and older living alone.

Torfaen is ninth lowest of the 22 LHB/LA areas for ‘unemployment’ and has a slightly lower proportion unemployed (5.6%) than the Welsh average of 5.7 per cent. However, over half of all benefits received (57%) in Torfaen comprise Incapacity Benefit which represents 13 per cent of the working age population (ONS, 2004). Furthermore, Torfaen has a slightly lower proportion of the population who are in employment (68.5%) compared to South East Wales (69.2%) or Wales as a whole (71.1%).

In terms of education, Torfaen is the best among the south Wales valleys, with just under 23 per cent of 16 to 24 year olds with no educational, vocational or professional qualifications. However the proportion of young people in school in Torfaen achieving A* to C grades in each of the core subjects is almost five per cent lower than SEW and more than 10 per cent lower than the all-Wales proportion.

Torfaen has a similar but slightly lower proportion of children living in lone parent families to the Welsh average at just under 24 per cent.

26.3 per cent of children and young people aged 0 to 15 years in Torfaen, live in households dependent on worklessness benefits. This is an important indicator of the prevalence of child poverty.

Torfaen had the lowest rate in Wales in 2004 for road traffic injuries, at less than 200 per 100,000 of the population, lower than the Welsh average of 323 and less than half the rate of the LHB/LA area with the highest rate.

Emergency admission rate for 0-24 year olds where the principal diagnosis is injury and poisoning for LHB/LA areas in 2005 shows that Torfaen is slightly lower than the Welsh average of 1209 and is ranked eighth lowest of all 22 LHB/LA areas in Wales.

The home is the place where injuries resulting in visits to A&E occur most frequently amongst Torfaen residents aged 0 to 19 years; the second most frequent setting is ‘educational establishment’. These settings possibly reflect the places where this age group spend most time but also provide an indication of which settings might prove to be the most important for interventions to reduce unintentional injury.

viii

Smoking Smoking is the single biggest avoidable cause of disease and early death in Wales.

The proportion of children smoking daily rises substantially with age (WHO, 2004). By the age of 13, girls in Wales are almost twice as likely as boys to be smoking daily and have the second highest proportion compared to the other 33 countries that took part in the HBSC survey.

Local data suggest that 35 per cent of secondary school pupils in Torfaen stated that they had smoked a cigarette by the age of 13 or younger with 19 per cent having smoked by the age of 11 years.

7 per cent of secondary school children in Torfaen described themselves as regular smokers (Communities That Care, 2005). The Communities First electoral divisions of Thornhill and Trevethin have the largest percentage of young people starting to smoke and becoming regular smokers.

The greatest intervention in combating smoking related diseases is preventing young people from taking up smoking. There is a wealth of evidence to illustrate the need for a provision to address smoking in a school setting targeting teenage girls particularly.

The prevalence of smoking in Torfaen is reported to be 28.8 per cent (Wales, 27.1 %) in the Welsh Health Survey (2003/05) however the Torfaen Health and Environment Survey (2007) shows that smoking prevalence in Torfaen is 33 per cent.

Encouragingly, the above study indicates that smoking prevalence in Torfaen has dropped from 42 to 33 percent between 2002 and 2007, however it must be remembered that this is still above the Welsh average, and much higher than the 12- 15 per cent smoking prevalence observed in several cities and states in the USA.

In 2006-07, 470 people attended the smoking cessation service in Torfaen, of whom 200 set quit dates and 133 successfully quit at 4 weeks. A concerted effort from all healthcare professionals in Torfaen is required to motivate and refer smokers to attend the smoking cessation service. General practitioners and practice nurses have a big role to play in this area.

In order to achieve a uniformed approach to tackling the needs of Torfaen residents in relation to tobacco/smoking related issues a Tobacco Control Forum has been established. The work of this forum needs to be strengthened with greater commitment from stakeholders to provide a multi-level and cross-policy focus for action.

Sexual Health Teenage conceptions and sexually transmitted infections continue to be a matter of concern in Torfaen.

Although most recent data on teenage conceptions are for the year 2004 –‘05, these demonstrate that contrary to the trend in England and in Wales in general, the rate of pregnancies and terminations in the under 20 age group in Torfaen have increased over the last few years, and are now the highest among all LHB/LA areas in Wales. There are approximately 218 babies per year being born to mothers aged under 20 years, which is 62 more per year than if the Welsh rate were applied to the Torfaen population.

The rate in Torfaen for conceptions in those aged under 16 years has continued to rise from 6.8 per 1000 (1999-2001) to 10.1 per 1000 (2002-2004). Applying the rate of 10.1 per 1000 females aged 13 to 15 years to the ONS mid year population estimates for Torfaen, this means that there are approximately 19 babies per year being born to mothers aged under 16 years, which is just four more per year than if the Welsh rate were applied to the Torfaen population.

Unintended pregnancy and parenthood however are associated with a range of negative consequences. Hence this issue requires urgent focus by the community and statutory services to work with young people to change behaviours, thus reducing conception rates and also provide adequate support to young parents.

Between 2003 and 2004 there was an increase in the number of new cases of HIV/AIDS, gonorrhoea, anogenital chlamydia, herpes and warts diagnosed in GUM clinics in Wales.

Surveillance systems need to be developed to obtain specific data for Torfaen; however, given the general increase in incidence across Wales, lack of locality specific data should not delay urgent action in this area as health improvement actions to reduce STIs are also likely to reduce teenage conceptions.

x Physical activity Physical activity is widely acknowledged as the BEST buy in public health today.

The evidence shows that the health impact of inactivity on coronary heart disease is comparable to that of smoking and almost as great as high cholesterol levels.

Among children, about 30 per cent of boys and 40 per cent of girls are still not meeting the recommended activity guidelines of one hour per day and 20 per cent of boys and girls do less than 30 minutes physical activity a day.

Among adults, results from the latest Welsh Health Survey show 29 per cent achieving the recommended minimum (men 36 per cent but women only 23 per cent).

In Torfaen, the age standardised proportion of adults who reported meeting the target for healthy physical activity is just 22 to 27 per cent; lower than the Welsh average and seventh lowest for participation in healthy physical activity of the 22 LHB/LA areas.

Early indications from the Torfaen Health and Environment follow-up Study (2007) show that overall there was a drop in those taking NO physical activity in Torfaen from the baseline (2002) and that five per cent of adults increased their frequency of physical activity.

Physical INactivity is reported to be twice as common for residents of the most deprived Wards compared to the least deprived fifth of Wards in Torfaen – a third of Torfaen residents live in wards within the most deprived fifth in Wales.

The challenge of the Physical Activity Collaboration in Torfaen (PACT) group is to have the right delegation from the diversity of policy areas whilst identifying the appropriate mechanisms by which to influence the social ecological determinants of behaviour change related to physical activity, whilst influencing existing schemes to become more evidence-based in their delivery.

xi Substance misuse Substance misuse does not only seriously affect individuals’ health and wellbeing, but can also have a significant impact on family, friends and the wider community.

Alcohol is the most commonly misused substance in the UK. Alcohol misuse amongst young people is a worrying trend and one that is on the rise.

Data from the Health Behaviour in School Aged Children (HBSC) Survey indicates that 7 per cent of 11-year old girls and 12 per cent of 11-year old boys in Wales reported drinking any alcohol on a weekly basis, This figure rose to a quarter and a third respectively for 13-year olds. Data for 15-year olds shows that Wales has the highest proportion of young people in this age group reporting to drink on a weekly basis, of all the countries participating in the HBSC survey.

The Communities That Care (CTC) report (2006), which surveyed young people in Torfaen aged between 11-15 years old, found that 29 per cent had been seriously drunk (22% nationally). In addition, 14 per cent said they started drinking alcohol regularly aged 13 or younger. In the same study, 30 per cent thought that it was ‘only a bit wrong’ or ‘not wrong at all’ to drink alcohol regularly.

A local alcohol study with young people by Torfaen Youth Access amongst 14-15 year old attendees of Youth Access, found 86 per cent reporting that they drank alcohol at least once a week. Of these, 26 per cent reported drinking 7-10 drinks in one go, 25 per cent 10-14 drinks in one go and, 12 per cent reporting drinking more than 14 drinks in one go.

Among adults, (Welsh health survey 2003/05) 20 per cent of adults in Torfaen reported binge drinking in the past week. Torfaen ranked the seventh highest in Wales for adults whose average alcohol consumption was above the recommended guidelines.

Of those referred ‘drug misusers’ in Torfaen, where the main problem is specified, alcohol accounts for almost double all other drugs misused.

Analysis of hospital admissions for alcohol related conditions at LHB level show an age standardised (EASR) Welsh average of 309 per 100,000 population, with Torfaen slightly but not significantly higher, being ranked 12th out of the 22 authorities.

The UK has a higher prevalence of drug misuse than any other country in Europe (Morgan et al, 2006). Data at the all-Wales level between 2002 and 2004 shows 114 deaths resulting from drug related conditions. In Torfaen, recent research indicated that illegal drug misuse rates amongst school aged children currently reflect the national average (CTC, 2005).

With the opening of the Pontypool multi-agency substance misuse base imminent, services will be more accessible locally and it is anticipated that there will be more accurate data on prevalence of substance misuse being reported in Torfaen in the near future.

xii

Local action plans are needed to respond to the patterns and issues identified in Torfaen, with substance misuse prevention among young people being high on the list of priorities.

Focus should be placed on the substances most prevalent in Torfaen, identified in local reports as, alcohol, cannabis and volatile substances.

Best practice for substance misuse education and prevention needs to be agreed locally, and resources refocused on interventions that have the evidence for greatest impact.

xiii Nutrition and Food for Health A varied and balanced diet providing sufficient energy and an adequate supply of essential nutrients can enhance health and wellbeing. Obesity and overweight create a considerable health and economic burden.

Regrettably, there is a scarcity of ‘nutritional intake’ data in Wales and even less data on nutrition and healthy weight for young people locally.

The proportion of new-borns breastfeeding in Torfaen is increasing; however it remains 20 per cent below the all-Wales average and 30 per cent below the English average. Whilst there has been a rise in breastfeeding rates between 2004-2005, less than half the babies receive any breast milk at all, almost a third at 2 weeks and, as little as 5 per cent at 9 months are breastfed.

In Wales, there is a decrease of over 20 per cent in the eating of a daily breakfast in girls from age 11 to 15 years, and a drop of 8 per cent for boys. Data for young people engaged in dieting and weight control show a 24 per cent increase in those dieting for girls aged between 11 and 15 years.

In both the 13 and 15 year old age groups Wales has a higher proportion of pre- obese children than England and Scotland.

In Torfaen the proportion of adults eating the recommended amount of fruit and vegetables is 36.3 per cent (Wales average: 40 per cent). The proportion of Torfaen residents eating fruit and vegetables on most days of the week has shown a slight increase from 2002 to 2007. So although some work has already been done to address this issue it still remains a high priority of work.

Torfaen has a proportion of 55.9 per cent of adults who are overweight or obese, and this is higher than the Welsh average of 54.1 per cent.

Initial indications from the Torfaen Health and Environment Survey follow-up (2007) illustrate that there has been an increase in the proportion of Torfaen residents classified as overweight or obese throughout the borough compared to the initial survey (2002).

The Torfaen Action on Food for Health (TAFfH) Strategy group works to map current activity in Torfaen, identify specific needs and gaps, provide focus for action. The actions identified as a result of the work of this group need to be supported by the HSCWB Strategy.

xiv Risk factors and disease: Population Attributable Fractions The ‘population attributable fraction’ of a disease or condition is a measure of the proportion of cases that can be attributed to a risk factor. It is best described as the proportion of cases of that disease that would be eliminated if the specific risk factor alone were eliminated from the population, while the magnitude of other risk factors in the population remain unchanged.

For every 1,000 males quitting smoking, overall 40 of these quitters will be spared a diagnosis of Acute myocardial infarction, COPD, lung cancer and stroke in the first ten years following quitting, with an estimated saving of 47 life-years and 75 QALYs.4

In the UK, IMPACT modelling has examined the effect of reduction in mortality by the reduction of three risk factors i.e. smoking cessation, control of high blood pressure and high cholesterol. The study demonstrated that compared to secondary prevention (among CHD patients), primary prevention (i.e. interventions aimed at apparently healthy people) achieved a fourfold larger reduction in deaths5.

Increase in physical activity has been demonstrated to reduce all-cause mortality rates in both sexes across most age groups. Minimal adherence to current physical activity guidelines, which yield an energy expenditure of about 1000 kcal per week is associated with a significant 20-30% reduction in risk of all-cause mortality.6

Analysis of seven cohort studies with a total population size of more than 230,000 has shown that the risk of stroke was decreased by 11% for each additional portion per day of fruit, by 5% for fruit and vegetables, and by 3% for vegetables7. Similarly, nine studies including 220,000 people has demonstrated that the risk of CHD was decreased by 4% for each additional portion per day of fruit and vegetable intake and by 7% for fruit intake.8

The concept of PAF is key to prioritising and investing in interventions which can result in the reduction of risk factors and poor lifestyle choices across the population.

xv Health Outcomes In Torfaen LA/LHB area, life expectancy for males is 76 years of age and for females is 81 years neither being significantly different to the Welsh average.

Total mortality rates in Torfaen are similar to the Welsh average, but show variation across the area, with the highest rates seen in the north and urban areas in the south of the borough.

Nearly 25% of the population of Torfaen have a limiting long term illness.

Just over ten per cent of those aged 16 and over resident in Torfaen reported receiving treatment for a mental health issue; however, Torfaen is ranked fourth lowest for numbers of patients with mental illness resident in hospital. The EASMR for suicides in Torfaen is 11.5 per 100,000 of the population lower than the Welsh average of 13.7. Trend data indicate no significant differences in suicide between 1996 and 2005.

Death due to circulatory diseases is lower in Torfaen, compared to Wales, and the trend in reduction of the same has followed the all-Wales trend over the last decade exhibiting a more marked reduction. There are significant variations between the constituent geographic areas within the borough in terms of mortality, with four MSOAs among the highest fifth for death from circulatory disease in Wales. Mortality due to coronary heart disease also follow a similar pattern, being lower in Torfaen than in Wales. Torfaen has the lowest stroke-related mortality in all of Wales.

The EASMR for respiratory disease in Torfaen is 74 per 100,000 population. Torfaen is ranked ninth out of the 22 LHB/LA areas in Wales. Torfaen has an age standardised prevalence of asthma of 10.6 per cent, similar to the Welsh average.

In Torfaen the annual death rate (EASMR, 2002 – 2004) where the underlying cause is injury, is 24.7 per 100,000 of the population, statistically significantly lower than the Welsh average (30.9).

The Welsh Health Survey (2003/2005) age standardised (‘lifetime’) prevalence, those who reported having been treated for cancer, in Torfaen is 4.4 per cent of the population (0.2 per cent higher than the Welsh average). The WCISU have calculated that Torfaen LHB/LA area is ranked eighth lowest out of the 22 areas in Wales with an EASR of 384 for cancer registrations. Cancer mortality appears to be higher in the south Wales valleys with the EASMR for Torfaen being 197 (Wales, 189.3). In Torfaen four MSOAs are amongst the highest fifth in Wales for death from cancer.

Lung cancer incidence (EASR) in Torfaen is 60.4 per 100,000, which is nearly 67 per cent higher than the LHB/LA area with the lowest rate.

xvi The annual incidence (EASR for registration, 1995 - 2004) of breast cancer in females in Torfaen is 111.7 per 100,000 of the population (Wales, 114.2)

Data from QoF, Welsh health survey and the PBS model indicate that the prevalence of diabetes in the Torfaen population is between 4 and 6 per cent.

Reported prevalence (age standardised for persons aged 16+) for arthritis in Torfaen to be 13.9, higher than the Welsh average of 12.2 and eighth highest of the 22 LHB/LA areas in Wales.

QoF data identifies 14,062 people with high blood pressure in Torfaen, of whom 9,554 are well controlled; however there are likely to be more than 8000 people in Torfaen with hitherto undiagnosed hypertension.

xvii Service provision and uptake Analysis of Welsh Health Survey (2003/2005) data by LHB/LA area shows that nearly 50 per cent of Torfaen residents had used an optician in the last 12 months, third highest in area in Wales, however behind Merthyr Tydfil and Blaenau Gwent, Torfaen residents receive the least regular dental treatment in Wales almost 40 percent have not visited their dentist in the last year.

General practice consultations for Torfaen residents annually are similar to the Welsh average.

Torfaen has the ninth highest proportion for flu immunisation uptake amongst people aged 65 and older, of the 22 LHB/LA areas in Wales. The proportion is just below 70 per cent, higher than the Welsh average. Torfaen is third highest for childhood immunisation uptake of the 22 areas in Wales. There is a small degree of variation, for all immunisations except MMR; Torfaen has the second highest rate of all LHB/LA areas for uptake of MMR immunisation at 89 per cent.

Visits to A&E due to injuries shows a reducing trend.

Torfaen has statistically significantly lower rate of hospital admission for all causes in children and young people than the Welsh average; with below 8,000 admissions per year Torfaen is eighth lowest LHB/LA area in Wales

Welsh Health Survey shows whilst the all-Wales average for people reporting being in hospital in the last 12 months is 10.1 per cent, analysis of the data by LHB area shows higher age standardised rates in the South Wales Valleys with Torfaen being the highest in Wales. For patients with chronic disease, the rates of admission for the people of Torfaen are similar to the Welsh rates for 20005/06.

In contrast to the elective admissions, the emergency admissions rate in 2005 amongst people aged 65 and older in Torfaen (15,413) is statistically significantly higher than the Welsh average (14,796). Torfaen has the eighth highest rate of the 22 LHB/LA areas.

At the practice level, there is variation in the rates of emergency admissions and referrals to various secondary care specialties. The reasons for this variation are unclear, and there is a need to explore this further with clinical engagement between primary and secondary care.

The local secondary care health system, which covers Torfaen, among other boroughs in Gwent, is able to match or better the all-Wales average in several areas. However, there are still many important efficiency and productivity targets to achieve.

In the social care arena, there is a need to strengthen the provision of care for elderly at home and in the community to reflect the high rate of assessments at present; the same is true for community care for people with disabilities.

Delayed transfers of care are a major source of concern in the health and social care community, and need effective co-ordinated action across the health and social care

xviii pathway by the local authority, local health board, primary and community care, voluntary sector and the acute NHS trust hospitals.

Torfaen performs consistently better in the national strategic indicators for children and the social care indicators for looked after children.

xix Qualitative needs summary

Consultations/engagements summarised in this report include

• An assessment of Health and Social Wellbeing Need of the Thornhill Population • An assessment of Health and Social Wellbeing Need of the Blaenavon and Abersychan Population • An assessment of Health and Social Wellbeing Need of the St Cadocs Penygarn and Pontypool Population • Vox Pop • Community Open Spaces Events More information on the diversity of community consultations to understand need/demand carried out by the Local Authority can be found on Webster (http://www.webster.uk.net/Council%20Services/CommunityStrategy/Consultation.as px)

There are other consultations with the different communities in Torfaen which have not been included in this analysis for a variety of reasons. Where this needs assessment process has uncovered robustly conducted citizen engagement exercises leading to a greater understanding of need for HSCWB, that are not included in this report, they have been signposted in the main document. These will also be contained in the knowledge repository within the HSCWB pages on the Webster Internet site.

Topics are grouped under the structure of the needs assessment: Life Circumstances, Lifestyles, Health Outcomes and, Service Provision.

Life Circumstances Employment issues High Unemployment was highlighted as a big issue in all areas. In addition, there is the perception of a lack of well paid jobs, that people are not earning enough to pay for child care in order to work, and a culture of “not working at all” in some areas of the borough.

Poverty/deprivation was raised as an issue in all areas.

xx education regarding health promotion issues, IT training, young people and ecological awareness (local and global)

There were a range of alternative methods of delivery suggested throughout the consultation: enhance curriculum with community settings, more outreach education programmes, work with parents and children together, more adult education needed with more work on increasing uptake, integrate education with youth clubs, increase after school activities for primary age children and, the use of some of the existing open spaces for structured play.

Two facilitators to improve uptake and interest in education were mentioned in more than one area. Crèche facilities at college, for use by learners, were mentioned in several areas. Young people view lack of ‘facilities’ in school as a problem.

The closure of community schools is a highly contentious issue for local communities.

Community safety Interestingly a strong theme was need for greater or more visible police presence, along with the acknowledgement that the fear of crime is greater than actual crime.

Observations of crime were different for different areas: the list involved motorbike or cars ‘racing’ in residential areas and other inappropriate areas and driving recklessly.

Anti-social behaviour from young people was a theme and this was linked to ‘drugs problems’, vandalism and graffiti.

Housing Housing was expressed as an issue particularly for young people for a variety of reasons including access to affordable housing and housing for homeless young people.

Concern was expressed that some foster homes were overcrowded. There was also concern regarding suitable housing/accommodation at the age of 16 for young people leaving Looked After Care provision.

The other issue with housing was related to quality, with areas describing housing as “overcrowded”, “poor”, or “in need of updating”.

Physical Environment The main needs raised by citizens varied by area but in general the top themes were graffiti, litter and dog fowling.

A lack of safe places for young children to play was also cited.

Inadequate lighting and a lack of/or uneven pavements/pedestrian areas, suggested to be wheelchair- and older people- unfriendly, was a recurrent theme.

Road systems and inadequate parking were also raised at separate consultation events.

xxi

Transport With respect to transport, the main issues raised by citizens were with bus services. The biggest themes were that bus service should run more frequently, be accessible at evening and weekends and a service should run to Nevill Hall. The need for improved access for people with disabilities was also raised.

The problem of traffic at Blaendare road in mornings and evenings was described as “horrendous”.

Lifestyles The issue of health problems caused by poor lifestyles was raised in relation to a variety of themes and populations and the need for “health promotion/ lifestyle advice” was raised. Smoking, drug misuse and alcohol were the key themes with obesity getting one mention.

Young people felt that they needed better access to information regarding drugs, sex, alcohol and smoking in the form of posters and leaflets. The issue of teenage pregnancy and STI’s was concerning.

Health Outcomes People’s mental health was the strong theme running through these consultations. Depression and low morale, low aspirations and, emotional wellbeing were key themes. People expressed the need for more/better mental health provision and access to counselling services.

Other physical health conditions raised by Torfaen citizens as requiring more attention include multiple sclerosis, diabetes, coronary heart disease and mobility problems.

Service Provision Health The Carers Consultation (report forthcoming) indicates that there are a variety of specific differences in the way services are delivered and promoted based on outcomes.

Issues relating to primary health care were mixed. Whilst some said that GP services were good others suggested that there is a need for improved access and a greater range of services.

Lack of knowledge of services/clinic for young mothers and a perceived lack of Sure Start provision were mentioned.

Citizens indicated improved access to dental treatment in one area; however oral health of children remains a concern.

The need for better A&E services, and improved hospital access was highlighted, and Blaenavon residents of mentioned the possibility of closure of the health care unit in Blaenavon as a significant issue.

xxii Leisure/recreation Better access to a greater range of exercise, activities and facilities were felt to be very important. This was expressed for a range of different sports, clubs and facilities in different areas: football facilities, cricket facilities, bowls facilities, skateboard facilities. One suggestion was that schools with good facilities should be more integrated to community particularly at evenings, weekends and holiday periods.

Children (under 10 years) felt that there was no access to recreational activities such as mountain biking, Go Carting, paintballing or the chance to learn specific outdoor sports. There is need for a Youth Club provision where “under 10s” could take part in activities.

There was an expressed need for better socialisation opportunities for the 59+ age group. In addition it was raised that specific recreational facilities are also needed.

xxiii Conclusion This needs assessment exercise has brought out several important insights into the current state of health, social care and well being in Torfaen. It shows us that whereas we are clearly close to all-Wales average in population structure and life expectancy, we are not so well placed in several of the life circumstances and lifestyle indicators. Service provision is skewed towards the acute sector, with evident gaps in community level services. This, coupled with the potential to improve efficiencies in the acute services, indicates that development of safe and cost effective community services funded by service efficiencies in the secondary care sector should be a key priority for Torfaen.

Adverse life circumstances and poor lifestyle choices go hand in hand in a relatively deprived population. Education and employment opportunities are key to sustained improvement in the social and environmental determinants of health, and the profile of Torfaen indicates that there needs to be transformational changes in these arenas.

The population attributable fractions of the common major diseases, related to specific risk factors, should be considered in prioritising action to reduce the prevalence of these risk factors and poor lifestyle choices. The risk factor aggregation that is evident in certain geographical areas of the borough highlight that specific, targeted action is required to modify upstream risk factors. However, this should not deter our focus from borough-wide cross sectoral activity to reduce the risk factor prevalence across the population. As a responsible partnership, we need to acknowledge that the results of many of the health improvement interventions and adequate investment in prevention will lead to health as well as economic gains, albeit in the longer term. As a community, we need to explore ways to make healthy options also the easy ones.

Further Reading The full section reports are available on Health Social Care and Wellbeing pages on the Webster Internet site, along with the data and documents received from stakeholders. It is planned that in the medium term a new website will be commissioned to which all this information will be migrated; this knowledge resource will allow searching for contextually relevant data, documents and knowledge. It is here that the needs assessment ‘process’ can be continued and have biggest impact in planning, commissioning and delivery of local services tailored to the need of local citizens.

References The full references for this section are presented as a separate section within the needs assessment documents on the Health Social Care and Wellbeing pages of the Webster Internet site.

Glossary of abbreviations A & E Accident and Emergency CHD Coronary Heart Disease COPD Chronic Obstructive Pulmonary Disease CTC Communities That Care EASMR European Age Standardised Mortality Rate xxiv EASR European Age Standardised Rate GFR General Fertility Rate GUM Genito Urinary Medicine HBSC Health Behaviour in School-aged Children HIAT Health Information Analysis Team HSC WB Health, Social Care and Well Being MCS Mental component summary score MMR Measles Mumps and Rubella MSOA Middle Super Output Area MYE Mid Year Estimate NPHS National Public Health Service ONS Office for National Statistics PACT Physical Activity Collaboration in Torfaen PAF Population Attributable Fractions QOF Quality and Outcomes Framework SEW South East Wales STI Sexually Transmitted Infection TAFfH Torfaen Action on Food for Health TCBC Torfaen County Borough Council TFR Total Fertility Rate WAG Welsh Assembly Government WCISU Welsh Cancer Intelligence and Surveillance Unit WHO World Health Organisation WIMD Welsh Index of Multiple Deprivation

xxv Acknowledgements

Authors Jonathan West, Torfaen Local Public Health Team, National Public Health Service for Wales (NPHS) Dr S Subramonia-Iyer, Consultant in Public Health/Local Public Health Director, National Public Health Service for Wales (NPHS)

Contributors Project board The Authors wish to acknowledge the contribution of the Needs Assessment Project Board in it’s direction and leadership of the project and commissioning research to enrich the outcomes to understanding HSCWB need in Torfaen. In particular: David Congreve, Strategic Director Health and Wellbeing, TCBC Sue Evans, Head of Integrated Services, LHB/TCBC Jane Gray, Gwent Healthcare NHS Trust Gill Williams, Health Social Care and Well-being Co-ordinator, TCBC Catherine Gregory, Planning and Commissioning, Torfaen Local Health Board Maria Evans, Social Care and Housing, TCBC Deyolden Stroud, TCBC Linda Taylor, Gwent Community Health Council Nina Finnegan (Pat Powell), Torfaen Voluntary Alliance Lyn Cadwallader, TCBC Jon West, Torfaen Local Public Health Team, NPHS Dr S Subramonia-Iyer, Director of Public Health, NPHS Dr Hugo van Woerden, Director of Public Health, NPHS

Information, analysis and knowledge Members of the Health Information Analysis Team (HIAT) at the National Public Health Service for Wales (NPHS) for their comprehensive comparative needs assessments (http://www.wales.nhs.uk/sites3/page.cfm?orgid=719&pid=23339) which formed the basis for this needs assessment. In particular the Authors wish to thank: Nathan Lester, Margaret Webber, Hugo Cosh, Julie Jones, Tracy Price, Lisa Williams, Anna Childs, Martin Heaven, Gareth Davies and, Dr Judith Greenacre. The authors wish to acknowledge the wider contributors to the above documents acknowledged therein. Mark Piper, Business Services Centre; for provision of data and information on health service provision and performance Staff within Torfaen Local Public Health Team for their collation and collection of local data on the Lifestyles section of this report, in particular: Kathryn Cross, Jackie Williams, Virginia Morgan, Stuart Lawrence, Teresa Filipponi and Lorna Coombes The Authors wish to acknowledge the contributions from those Torfaen-local departments and organisations, too numerous to mention, who supplied local information and data to this needs assessment process.

Typography and presentation Rachel Jones, Torfaen Local Public Health Team, Torfaen Local Health Board. Pam Harris-Murton, Torfaen Local Public Health Team, NPHS

Torfaen Health, Social Care and Wellbeing Needs Assessment 2007

Supporting the Health Social Care and Wellbeing Partnership for Torfaen

Chapter 1 Introduction

Table of Contents

The County Borough of Torfaen 2 Background 2 Definition of Needs Assessment 4 Aims of this work 5 Scope 6 Process and methods 7 Determinants of health, social care and well-being 10

1 The County Borough of Torfaen Torfaen County Borough covers an area of around 12,500 hectares (31,000 acres) with a population of 90,300 persons according to the 2005 Mid Year estimates from the Office for National Statistics. Of the total population 51.6 per cent are female and 48.4 per cent are male. Torfaen has a similar population structure to that of Wales, with persons aged under 25 years representing 31.3 per cent of the local population and, those aged 65 and older contributing 17.5 per cent of the Torfaen total.

Torfaen is the eastern most valley of the South Wales coalfield, now characterised by a great variety of landscape types and a sharp diversity of rural and urban environments comprising 20 per cent built up areas, 50 per cent mixed agriculture, 5 per cent woodland, 10 per cent open moorland and common land, and, 15 per cent post industrial land.

In the north there are numerous redundant buildings, many of which are of great historic importance, particularly those which lie within the Blaenavon Industrial Landscape, a World Heritage Site. These are set in large areas of derelict land and spoil heaps, the legacy of a bygone era. The eastern side of the valley in Mid Torfaen has a medieval field system and ancient semi natural woodland. The southern landscape is characterised by being largely low lying with more gentle relief and dominated by more traditional agricultural fields and hedgerows.

The development of the valley was based on the exploitation of coal and iron; Pontypool and Blaenavon were founded on these industries, developing as they flourished. The population of Torfaen grew during the industrial revolution in the eighteenth and nineteenth centuries but experienced out-migration of the valley communities in the twentieth century, echoing the decline of the coal and iron industries. The south of the borough was largely underdeveloped until the designation of the Cwmbran New Town in 1949 and has been the focus of large- scale housing development ever since.

With the demise of the traditional industrial base during the post-war period, a new economic base is being established in Torfaen. With a relatively active economy, unemployment is broadly in line with but lower than the national average (5.6 per cent), most jobs today are in service related industries. Pontypool and Cwmbran today provide most of the employment options in Torfaen, being close to the M4 motorway and with good trunk road access. Opportunities elsewhere within the borough are more limited.

Background The Welsh Assembly Government, through the National Health Service (Wales) Act 2006 (the 2006 Act), has asked Local Health Boards (LHB) and Local Authorities (LA) in Wales to jointly formulate and implement the second Health Social Care and Well-being (HSCWB) strategies; for a three-year period, 2008-2011. The first draft strategies were developed by the end of March 2004, and following public consultation were adopted by Local Authorities, Local Health Boards and many local partners by the end of December 2004. The strategies became operational from 1 April 2005 to cover the 3 year period 2005-2008.

There has been much work in Torfaen since the last needs assessment to supplement our understanding of the need for health social care and wellbeing. Quantitative and qualitative information/data have been gathered by a range of organisations and planning groups locally for different purposes.

This work includes: • the ongoing action of the patient and public involvement (PPI) group • health needs assessments for areas within the North, Mid and South of the Borough and • many service or population specific assessments of need such as: o Supporting People Gwent Needs Mapping Exercise, o Sainsbury Centre for Mental Health Service review of adult mental health services, o Children and Young Persons Partnership Needs Assessment, and, o Torfaen Community Nursing Needs Assessment.

Whilst it is recognised that many of the reports have used existing data sources, including the 2003 HSC&WB needs assessment, some have included rapid participatory appraisal in consultation with the local population, and others have been new studies generating fresh information. This encompasses the qualitative information generated during Vox Pop and the preparation of the Torfaen Community Strategy. The Scope of this needs assessment (below) explains how this local proliferation of information has been utilised within this work and organised to support the Strategy development.

As well as the amount of work undertaken in assessing need outlined above there has been a wealth of national and local strategy documents since the last HSCWB Strategy in 2003. Emerging strategic developments being driven by WAG policy and impacting organisational direction include Designed for Life, Fulfilled Lives Supportive Communities, Gwent Clinical Futures, The Route to Health Improvement, Regional Case for Change, Making the Connections – Beyond Boundaries, and, the Community Strategy. The broader policy environment also includes developments relating to equality mainstreaming, economic development, transport, sport, culture, the environment, climate change and other areas, within an overall commitment to sustainable development.

A comprehensive list of policy and strategy developments that might affect the development and implementation of the 2008 HSCWB strategy are listed in the revised guidance (WAG, 2007).

The LHB’s corporate objectives refer to the development and delivery of the HSCWB Strategy, and, health improvement (universally, but particularly for specific populations) is a Corporate Plan commitment for TCBC.

The Welsh Assembly Government healthcare strategy Designed for Life (2005) is clear that reconfiguration is essential to achieve sustainability and improvement. Some of the key features of this reconfiguration are: • greater emphasis on health promotion and prevention; • developing self-care; • increased primary and social care capability, characterised by increased skills and technology and increased flexibility in roles;

These key features of reconfiguration are exemplified by Health, Social Care and Well-being (HSCWB) strategies and partnerships, the aims of which are to improve: • health, social care and well-being at the local level whilst addressing the broader public health agenda; • services in terms of provision, delivery and access and also provide an opportunity to integrate the strategic and operational responses of individual bodies; and • collaborative planning and investment to support more effective prioritising and joint investment decisions.

Definition of Needs Assessment Needs Assessment (NA) is a systematic method of identifying the health and social care needs of a population and, making recommendations for changes to meet these needs (Wright, 2001). In this context need is defined as the ability to benefit from an intervention. This definition has been expanded to: HNA is a systematic method for reviewing the health needs and issues facing a given population, leading to agreed priorities and resource allocation that will improve health and reduce inequalities (HDA, 2005). The intervention may result in provision of care, or removal of a risk factor at the individual or population level, thus improving the longer term health and well being experience.

The practice of HNA became relatively widespread in the early 1990s, at the time of the introduction of the NHS internal market. HNA was used to improve efficiency, aiming to identify which cost-effective services should be provided to meet population health needs, and which ineffective services should not. The strategic aim of contemporary HSCWB NA is to maximise the appropriate delivery of effective healthcare and minimise both the provision of ineffective care and the existence of unmet need for healthcare. HNA provides a systematic framework for undertaking this complex and important task in an evidence-based fashion.

The common approaches to assessing population needs for health care have been discussed elsewhere (Stevens and Rafferty, 1994); these approaches are characterised as the Corporate, Comparative and Epidemiological approaches to HNA.

4 The Corporate approach involves the structured collection of the knowledge and views of informants (stakeholders) on health care services and needs. Advantages of this approach include making the needs assessment responsive to local concerns and fostering local ownership of the issues. Disadvantages of this approach (if carried out in isolation) are that it determines demands rather than needs and stakeholder concerns may be influenced by political agendas.

The Comparative approach involves the comparison of levels of service provision between different localities. These could be cross-national comparisons of the levels of service provision (e.g. comparing England with other countries in Western Europe), or could be at a more local level (e.g. comparing the service provision in one town with another that has a similar demography).

The Epidemiological approach to HNA has three elements: (i) determining the incidence and/or prevalence of the health problem; (ii) identifying the effectiveness of existing interventions for the problem; and (iii) identifying the current level of service provision.

This combination of epidemiology (health status assessments) and evidence (effectiveness) has also been described as the evidence-based approach to HNA. While this is a systematic and objective approach, its disadvantages lie in the frequent lack of existing local epidemiological data, and the lack of evidence for certain interventions particularly for population subgroups such as older people. Carrying out new epidemiological work is costly and time consuming, so judicious extrapolations of evidence may be required.

Aims of this work The reviewed Strategy Guidance (WAG 2007) states, “In preparing the strategy and especially at the needs assessment stage, there must be a wide-ranging look at the factors that affect health and well-being and opportunities for improvement”. However, the process must lead to clear choices and the final strategy must focus tightly on delivery of real improvement.

This needs assessment then will provide many of the priorities for attention in the new Strategy 2008 to 2011 and through that, will eventually clarify the boundaries for the ownership and leadership of work by the Health Social Care and Wellbeing Partnership. The needs assessment will also contain valuable information that the HSCWB Partnership might use for measuring performance throughout the lifespan of the strategy.

The process of development of the needs assessment and strategy can strengthen collaboration and integration between local partners, with the shared aim of improving the health and social wellbeing of local citizens.

This work aims to identify local needs in relation to health social care and well-being, including the wider determinants, and provide access to evidence of effective interventions. This will support the development of a Strategy that leads to a balanced set of more fully integrated services that shift the focus towards health promotion, prevention and early intervention.

5 This needs assessment will provide a next step in the development of needs-based service planning, investment, commissioning and delivery. An up-to-date and comprehensive understanding of the availability and/or paucity of local data can provide can provide the direction for coordinated collaborative citizen engagement (patients, carers, employees and residents in Torfaen). This, in turn, through coordinated community engagement and information gathering, will allow services to be built around genuine and open engagement with citizens. Furthermore, the improvements in health and well-being resulting from reoriented, streamlined and more effective health and social care services can be measured more precisely. This will allow the strategy to deliver demonstrable outcomes through the accountability, ownership and leadership of the HSCWB Partnership.

Needs assessment should reflect the developing equality agenda including specific linguistic needs. This will require a more careful analysis of the diverse needs of different groups defined by demographic, health status and/or geographical differences to the overall population. Such an approach, requiring coordinated continuing needs assessment through citizen engagement and information, could allow fuller understanding of associated physical health inequalities, and issues of exclusion regarding opportunities to participate in family, parenting, work and community life and issues of choice, control, freedom and dignity.

Despite the vast permutations for categorising special populations, the time/cost implications in attempting to assess all populations’ needs profiles, and, the paucity of reliable data for smaller distinct groups, these issues must be fully taken into consideration as a priority, paying due attention to the statutory obligations of the local bodies. The Welsh Assembly Government is currently working to mainstream the equality and diversity agenda, and promote an integrated approach to all equality strands including race, disability, gender, age, sexual orientation, religion/belief and language, and will expect local bodies to do the same.

Scope No single document can capture the complete detail of ‘need’ for the vast permutations of all populations, organisations and services, from their variety of perspectives and purposes. For this reason, the Revised Guidance (WAG, 2007) states “Needs assessment should be viewed as part of an ongoing process, not as a one-off exercise”.

In addition to the huge scope, there is a variety of information (service reviews, needs assessments, mapping exercises, etc) generated by local (and often regional and national) stakeholders, that is available at present. Hence this needs assessment will utilise the relevant and appropriate information collected therein and provide reference and/or link to a locally hosted electronic version of the document or data. In the medium term, through the more coordinated approach to knowledge provision (as recommended in the Geography and Demography section) all locally produced documents and data (that are appropriate to share) relevant to the needs of the local population will be in an easy-to-use searchable Internet site. This report forms (and includes) part of this body of work which must be an ongoing process and which needs to be coordinated between organisations for appropriate inclusion and presentation for all local stakeholders needs.

For example, following a plan rationalisation exercise at WAG, reviewing the statutory plans that Local Authorities and partners are required to produce, only four remain including the Children and Young People’s Plan (CYPP). The Children and Young People’s Plan will be the defining statement of strategic planning intent and priorities for all children and young people’s services locally and thus acts as the reference point for all other locally plans/strategies. The CYPP needs assessment (2006) therefore will be referred to in this needs assessment and links published to the existing (and future) edition rather than this document containing a specific section for CYP reproducing information from the CYP Needs Assessment.

This strategic needs assessment is just the first step in achieving service transformation which requires collective focus on key issues for long periods of time. This document will inform the HSCWB strategy and undoubtedly, will lead to the development of action plans which will enable the achievement of better health for the population of Torfaen over the next three years. It will also act as the reference point for more detailed, dynamic and real-time service-specific or population-specific needs assessments over the life of the strategy and beyond.

Statutory partners will be expected by WAG/WLGA to produce a brief public annual report on progress following the implementation of HSCWB Strategies in 2008. Therefore the next steps of the ongoing needs assessment process must include the coordination of the data collection (both qualitative and quantitative), analyses and presentation, in addition to performance monitoring. This is essential for conducting the more detailed narrow focus needs assessments within specific services or special populations.

The National Public Health Service can play a supportive role in reviewing progress across Wales on a common basis and in addition, Local Public Health Directors will be re-required to publish an annual report, especially highlighting progress in tackling inequalities in health and the social determinants of health.

Process and methods The approach to this needs assessment, as well as using accepted methods, was essentially about inclusivity; inclusivity of the diversity of stakeholders in health social care and wellbeing in Torfaen and inclusivity of the work undertaken locally in establishing need for HSCWB since the 2003 needs assessment.

Using PRINCE2 methodology a Project Board (PB) was set up comprising senior users from the Local Authority, the Local health Board, Gwent Healthcare NHS Trust, Torfaen Voluntary Alliance, Gwent Community Health Council, the senior supplier was the Local Public Health Director, National Public Health Service for Wales, and the project executive was the Strategic Director of Health and Wellbeing with Torfaen County Borough Council (TCBC). The project was managed and delivered by Torfaen Local Public Health Team.

The approach consisted of a combination of the established needs assessment methods.

7 Comparative A vast amount of comparative information has been gathered by NPHS Health Information Analysis Team (HIAT) and has been condensed and collated locally for consideration with service performance data, Quality Outcomes Framework (QoF) data, and Business Service Centre analyses of Patient Episode Database Wales. This work is combined with the locally available data.

Comparative data on the diversity of determinants of health are, where possible, age standardised and focused on LHB/LA area level including the comparison between Torfaen, other LHB/LA areas, and the Welsh national average. Analysis at a sub- LHB/LA area level is crucial to the identification of need locally to be able to inform most appropriate commissioning. Whenever possible, data have been presented at the sub-LHB level so that comparisons can be drawn between geographical areas within Torfaen as well as identifying sub-LHB/LA areas which are among the extreme fifths of sub-LHB/LA areas in Wales. A fuller explanation of the geographies used in this report can be found in the section Geography and Demography.

The sources used for the comparative collection of data include:

o ONS, Mortality data (Annual District Death Extract), o Government Actuary’s Department (population projections), o Health Solutions Wales (PEDW), o Health Behaviour in School aged Children, o Health of Wales Information Service (Deprivation and Health, o Welsh Health Survey, o All Wales Injury Surveillance System ((AWISS) o Accident and Emergency (A&E) department data), o Comparative Analysis System for Prescribing Audit (CASPA), o Road traffic accident statistics (STATS19), o Welsh National Database for Substance Misuse, o Cancer incidence data, o CARIS (congenital anomalies), o Psychiatric census.

This list is not exhaustive but shows the range of data sources manipulated by NPHS in the comparative analyses included in this report.

Corporate The Project Board directed that the amount of work undertaken locally in assessing need for HSCWB since the last HSCWNA could provide a comprehensive picture of corporate need and that additional corporate needs gathering should be limited. Limited that is for the purposes of this document; the large amount of community consultation locally and the relative lack of coordination within or between agencies has lead to a hiatus which could not be within the scope of this work but, as mentioned, should be addressed in the future.

The major documents engaging with Torfaen citizens to understand need since the publication with the 2003 needs assessment were the Community Strategy Consultation and Vox Pop. Both these exercises were undertaken by TCBC. Other corporate assessments of need referred to in this document include: • Rapid participatory appraisals from three needs assessments carried out in o Trevethin, Penygarn and St Cadocs, o Thornhill, and, o Blaenavon and Abersychan; • the Torfaen Carers Consultation; • Gwent Needs Mapping Exercise for Supporting People; • Torfaen Community Nursing Needs Assessment; and, • Sainsbury Centre for Mental Health Review of Adult Mental Health Services.

This list is not intended to be definitive, rather, it is intended to show the range of appropriate and timely sources of ‘consultation’ with Torfaen citizens which are used and/or signposted in this document.

To identify the local work in assessing need questionnaires were designed and sent, following an introduction from the appropriate senior user, to the diversity of local HSCWB stakeholders. It was felt this approach early in the process, as well as providing an important source of local information, would improve partnership and ownership of this needs assessment and ultimately the HSCWB Strategy. The documents and data received are placed on the interim Website.

In addition to the existing work the Project Board, through Local Authority funding, commissioned a survey amongst Torfaen residents; the survey is a follow-up of the Torfaen Health and Environment Survey carried out by Gwent Health Authority in 2001. The report of the findings, to be produced by Cardiff University, of this robust longitudinal study will follow this document adding valuable information from the local population towards the HSCWB strategy. Early analyses from the survey are included in this report where available.

Epidemiological The above methodological approaches to needs assessment, combined with other local data including Quality and Outcomes Framework (QOF) data, provide the incidence and or prevalence of specific health outcomes or their determinants which are included in this report.

This needs assessment document will contain links to appropriate sources of evidence of effectiveness for interventions to address specific issues highlighted as areas for focus/investment. In time, this process will lead to the building of a knowledge management web-page/site which will contain reports on evidence-based practice in specific thematic areas for use by policy makers and practitioners.

This needs assessment document provides a good first step but it is vital that continued clear direction from the HSCWB Partnership is taken up by an appropriate group to provide data, examining service provision and performance within specific areas of interest. This information will also be included on the knowledge sharing web-page/site.

Determinants of health, social care and well-being In examining data relating to health status and key determinants of health and social wellbeing in Wales it is important to reinforce that many of the factors affecting health lie beyond the National Health Service and Social Care and Housing Departments. The model developed by Dahlgren and Whitehead (1991) and amended by Barton and Grant (2006) and the UKPHA Strategic Interest Group (2006), shown in the figure below, summarises the determinants of health. The Barton and Grant model, show how these determinants can be understood at different levels, from lifestyle choices, the community and local economy, to the built and natural environment and wider macro-economic and global forces, including climate change.

10 Based on the Dahlgren and Whitehead (1991) diagram as amended by Barton and Grant (2006)

Using this model it becomes clear that initiatives aimed at improving health and social wellbeing must involve multi-organisational input and, importantly, have multi- level reach, from the ability to work on delivery with individuals, groups and communities, to informing local, regional and national policy to create the society and environment which is conducive to the promotion and sustenance of health and wellbeing. The Ottawa Charter (1986) for action on promoting good health [including social wellbeing] fits with this model and illustrates the way in which we might influence change in the population. The five areas/levels suggested in the Ottawa Charter are: building healthy public policy; creating supportive environments; strengthening community action; developing personal skills; re-orientating services.

The three approaches to needs assessment combined provide a comprehensive picture of need for HSCWB in Torfaen and in so doing highlight thematic areas for investment and the evidence of effective practices to address the identified need. This strategic needs assessment document provides the first strides in informing the HSCWB Strategy priorities for 2008 to 2011, which together with continued wider consultation and engagement between the diversity of stakeholders will shape shared investment and the service transformation, enabling the achievement of better health for the population of Torfaen. It will also act as the reference point for more detailed, dynamic and real- time service specific needs assessments over the life of the strategy.

Torfaen Health, Social Care and Wellbeing Needs Assessment 2007

Supporting the Health Social Care and Wellbeing Partnership for Torfaen

Chapter 2 Geography and Demography of Torfaen

Table of Contents

Geography ______14

Demography______16 Population ______16 Population Structure ______16 Population aged 65 years and over______17 Population aged under 25 years ______19 Population Density (LHB/LA level) ______21 Population projections and life expectancy ______21 Fertility and Births ______22

Special populations______24 Ethnicity______25 Carers ______27 Young People ______29 Older people ______30

Needs assessment – an ongoing process ______30

13 Geography Traditionally, small area statistics have been reported at electoral division (or ward) level; the advantage of using this geography is that it is understood at local level and, of course, delineates the areas represented by councillors. There are, however, disadvantages which make electoral divisions less suitable for presenting some types of data, particularly health and social wellbeing data at a population level.

Firstly, since electoral divisions are an administrative geography, the Boundary Commission for Wales frequently alter boundaries to ensure fair democratic representation. This makes the presentation of data covering a number of years difficult and prone to error.

Secondly, and most importantly, electoral divisions are heterogeneous in terms of their population size. In Wales there are just under 900 electoral divisions and their populations range from less than a thousand persons to over 15 thousand. It is impossible to present reliable data for very small populations because the number of events, for example deaths, occurring in such areas will be relatively small and hence the numbers tend to fluctuate considerably over time making it very difficult to determine whether the pattern exhibited is genuine or merely a chance occurrence.

In order to try to overcome some of these problems the Office for National Statistics (ONS) has created two new statistical geographies called Lower and Middle Super Output Areas (SOAs) which are based on 2001 Census geography. Middle SOAs (MSOAs) have a mean population of 7,500 and a minimum of 5,000. The third layer of Upper SOAs is yet to be delineated. SOA geographies are designed not to straddle local authority boundaries. The ONS have stated that SOA geographies will be fixed for at least 10 years.

So, the advantage of using these new statistical geographies is stability and homogeneity. However, the main drawback is that they do not relate to local democracy and, at present, they do not have names. This makes them less amenable to the public and local government. The NPHS has concluded that the MSOA geography represents the best compromise between the need for small area data whilst at the same time ensuring that the data, and hence any conclusions drawn, are robust. In this document, where data exist at the sub-LHB/LA area level, they are presented at MSOA level or electoral division level (where MSOA analysis is unavailable).

The maps below show the electoral division geography and middle super output area geography (MSOA) of Torfaen LHB/LA area. There are 24 electoral divisions and 13 MSOAs in Torfaen LHB.

Crown copyright material is reproduced with the permission of the Controller of HMSO and the Queen’s Printer for Scotland

Currently there are very small differences in the boundaries between electoral division and MSOA geography. The data in this needs assessment, as mentioned, are presented at electoral division or MSOA level depending on their availability. At a national policy, increasingly the data are made available at MSOA level. It may be possible to judge ward-level determinants by either aggregating MSOAs to obtain a ward-level picture or identifying overlaps between MSOAs and ward areas of interest.

15 Demography

Population Any attempt to assess the health, or the health needs, of a given population must begin by gaining an understanding of the size, structure, distribution and development of that population.

This section shows population projections and life expectancy, which are important indicators when considering the health needs of a population, and fertility. In addition to providing basic data, this approach provides a projection of the likely need in a given area in future years. Birth and all-cause mortality (covered in more detail in the Health Outcomes section) rates, and, where available, trends are also included.

Certain groups among the citizens of Torfaen, who could also be counted as special populations, may have a different profile of health social care and wellbeing needs. One size does not always fit all. This should be considered when planning services. Special populations can be categorised in a variety of different ways which include demographic indicators or/and health status; for example: age, gender, ethnicity, caring status, people with mental health issues, or people with other specific health conditions. The differences in health and care needs in special populations compared to the total Torfaen population might arise from age or cultural differences in the prevalence of certain illnesses or determinants of health amongst these groups. It may also be due to differences in equity of provision or access to services and initiatives aimed at improving health, social care and wellbeing.

Population Structure The Mid-Year Estimates (2005) produced by the Office for National Statistics (ONS) shows that Wales has less people in the 20-39 age group than the other nations and more persons aged 60 and over.

Torfaen LHB/LA area has an estimated population of 90,300 persons (ONS; MYE, 2005) of which 46,600 (51.6 per cent) are female and 43,700 (48.4 per cent) are male. The population pyramid below shows the proportion of persons in Wales and Torfaen LHB/LA area by five-year age bands. The charts show that Torfaen has a similar population structure to that of Wales, with persons aged under 25 years in Torfaen representing 31.3 per cent of the local population (Wales 31%) and, those aged 65 and older in contributing 17.5 per cent (Wales 17.6%) of the Torfaen total.

16 Proportion (%) of population by age and sex, Wales Proportion (%) of population by age and sex, Torfaen Source: ONSMYE 2005 Source: ONSMYE 2005 Males Females 90+ Males Females90+ 85-89 85-89 80-84 80-84 75-79 75-79 70-74 70-74 65-69 65-69 60-64 60-64 55-59 55-59 50-54 50-54 45-49 45-49 40-44 40-44 35-39 35-39 30-34 30-34 25-29 25-29 20-24 20-24 15-19 15-19 10-14 10-14 5-9 5-9 0-4 0-4

10864202468101086420246810 % Population % Population

Population aged 65 years and over As mentioned previously the proportion of the population aged over 65 in Torfaen is similar to but slightly lower than the proportion of the all-Wales population of the same age group. Torfaen is the LHB/LA area closest to the all-Wales population structure for those aged 65 and older of all 22 LHB areas; 65 to 74 year olds representing 9.1 per cent of the Torfaen population (Wales 9.2%), 75 to 84 year olds 6.4 per cent (Wales 9.2%), and, those aged 85 and over two per cent (Wales 2.1%).

Proportion of population aged 65 and over, ranked Wales LHBs, 2005 Data source: ONS

65-74 75-84 85+ 25

10 Proportion (%)

0 Wales Powys Cardiff Conwy Torfaen Newport Bridgend Flintshire Swansea Gwynedd Wrexham Caerphilly Ceredigion Denbighshire Merthyr Tydfil Pembrokeshire Blaenau Gwent Monmouthshire Isle of AngleseyIsle of Carmarthenshire NeathTalbot Port Rhondda Cynon Taff The Vale of Glamorgan

17 Proportion of population aged 65 and over by middle super output area (MSOA): 2003

Crown copyright material is reproduced with the permission of the Controller of HMSO and the Queen’s Printer for Scotland

The above map shows the geographical distribution of MSOAs in Torfaen ranked by highest proportion of their constituent population that are aged 65 and older across Wales and then grouped in to fifths. The area shaded darkest is amongst the fifth of MSOAs with the highest proportion of people aged 65 and older in Wales (25 to 36.3%). The two areas to the south of that MSOA are amongst the second highest fifth of MSOAs in Wales with between 20 -25% of their resident populations being aged 65 and older. Planning of services for older people will need to take account of the distribution and numbers of older people in different areas of the borough.

18 Population aged under 25 years It is thought that the 20-24 age group is one of the most undercounted, having had the lowest response rate of all age groups in the 2001 Census. Compared to Wales (31%) the proportion of the total population aged under 25 years in Torfaen is slightly higher but very similar at 31.3 per cent. The proportion of the population aged 0 to four years in Torfaen is 5.4 per cent (Wales 5.4%), those aged five to nine years make up 6.1 per cent (Wales 5.9%), the 10 to 14 year age group 7.1 per cent (Wales 6.5%), 15 to 19 years 7.1 per cent (Wales 6.7%), and, the 20 to 24 year age group contribute 5.6 per cent to the total population in Torfaen (Wales 6.4%).

Proportion of population aged 0 - 24, ranked Wales LHBs 2005 Data source: ONS

0-4 5-9 10-14 15-19 20-24 40

20 Proportion (%)

0 Wales Powys Cardiff Conwy Torfaen Newport Bridgend Flintshire Swansea Gwynedd Wrexham Caerphilly Ceredigion Denbighshire Merthyr Tydfil Pembrokeshire Blaenau Gwent Blaenau Monmouthshire Isle of Anglesey Carmarthenshire Neath Talbot Port Rhondda Cynon Taff Cynon Rhondda The Vale of Glamorgan of Vale The

19 Proportion of population aged 0-24 by middle super output area (MSOA): 2003

Crown copyright material is reproduced with the permission of the Controller of HMSO and the Queen’s Printer for Scotland

The above map shows the geographical distribution of MSOAs in Torfaen ranked by highest proportion of their constituent population that are aged under 25 years and then grouped in to fifths for Wales. The area shaded darkest is amongst the fifth of MSOAs for the highest proportion of people aged under 25 years in Wales (over 40 %). In the two populations in the MSOAs with the next darkest shade, the proportion of those aged under 25 are between 35 and 40 per cent. This geographical variation in population will have implications for the focus of planning in HSCWB for children and young people.

20 Population Density (LHB/LA level) Census data (2001) shows the population density (population divided by area measured in hectares) in Torfaen is the third most densely populated LHB/LA area in Wales behind Cardiff and Newport, at a density of 7.2 people per hectare it is above the Welsh average of 1.4. However analysis of the 2001 census data shows us that although Torfaen is relatively dense at a LHB/LA area, this might be a reflection of the comparative rurality of large parts of the other LHB/LA areas.

Analysis of the 2001 Census data by Lower SOA (there are 60 LSOAs in Torfaen) provides a clearer picture for the population density at the sub-LHB/LA area level. Although Torfaen as a whole has the third highest population density, there are no LSOAs amongst the fifth most dense in Wales. There are 15 LSOAs in Torfaen among the second most dense fifth in Wales; they are spread across the borough with two in the north, three in mid-Torfaen and the rest in the south. Torfaen also has six LSOAs in the least dense fifth of Welsh LSOAs.

A relatively dense population would make it possible to provide health and care facilities in a more efficient manner than in a rural community, where there would be a trade-off between efficiency and accessibility.

Population projections and life expectancy Sub-national projections have been derived by the Government Actuary's Department. The chart below shows population projections at Welsh Assembly Government Regional Level for South East Wales.

2003-Based Population Projections: South East Wales Source: National Assembly for Wales Males Females 800 780 760 740 720 700 680 660 Population (Thousands) Population 640 620 2003 2008 2013 2018 2023 2028 Note: y axis has been truncated

21 The population of Torfaen in 2005 was estimated to be 1.1 per cent lower than it was 10-years earlier in 1996. This equates to an average annual decrease of 100 people across all age groups.

Mid-year population estimates, persons, Torfaen: 1996-2005 Source: ONS MYE, reproduced by Welsh Assembly Government 30,000 00-24 25,000

20,000 25-44

15,000 45-64

Population 10,000 65-84 5,000 85+ 0 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

The trends within the age groups show variation:

• 0 to 24: an annual average decrease of 90 persons was experienced in this age group, which equates to3.1 per cent.

• 25 to 44: a decrease of 11.2 per cent from 1996 to 2005; an annual average decrease of 290 persons.

• 45 to 64: an increase of this age group population of 8.8 per cent in 2005 compared to 1996; an average annual increase of 190 persons.

• 65 to 84: an increase of 3.7 per cent from 1996 to 2005; an average annual increase of 50 persons.

• 85+: the largest relative increase in proportion is in this age group that was 38.5 per cent higher in 2005 than in 1996. However, this only equates to an average annual increase of 50 persons.

Fertility and Births Total Fertility Rate (TFR) The TFR is the average number of children that would be born per woman if all women lived to the end of their childbearing years and bore children according to the age-specific fertility rates exhibited in Wales over the period shown. The TFR is an important measure of fertility, providing the most accurate answer to the question, "How many children do women have, on average?"

The TFR trend in Wales, from estimates of the number of children women had on average for the period 1997 to 2004, shows that between 1997 and 2002 the TFR declined from 1.8 to just below 1.65 however between 2002 and 2004 the rate rose more steeply to just over 1.75, almost back to the 1997 rate in just two years.

TFR for the Torfaen LHB/LA area in 2004 is 1.91, above the Welsh average of 1.76 and is eighth highest of the LHB/LA areas in Wales.

Total fertility rate, LHBs, 2004 Source: ONS 2.0 1.9 .. Welsh average = 1.76 1.8 1.7 1.6 1.5 1.4 1.3 1.2

Average number of children 1.1 1.0 Cardiff Powys Conwy Torfaen Newport Bridgend Swansea Flintshire Gwynedd Wrexham Caerphilly Ceredigion Denbighshire Merthyr Tydfil Pembrokeshire Blaenau Gwent Monmouthshire Isle of Anglesey Carmarthenshire Neath PortTalbot Rhondda CynonRhondda Taff

Note: truncated y axis The Vale of Glamorgan

General Fertility Rate (GFR) The general fertility rate is calculated as the number of live births divided by the number of women of child bearing age (15-44) multiplied by one thousand.

The GFR trend for Wales from 1995 to 2004 shows a decrease between 1996 (61.0) and 2002 (52.3), followed by a slight increase in 2003 and 2004 (55.7) similar to that of TFR.

Analysis of GFR at LHB/LA area level shows that Torfaen has a GFR of 58.1, which is above the Welsh average of 55.7; Torfaen is ranked seventh highest of the 22 LHB/LA areas in Wales.

23 General fertility rate, LHBs, 2004 Source: ONS

60 Welsh average = 55.7

10 Rate perRate 1000 women aged 15-44 0 Cardiff Powys Conwy Torfaen Newport Bridgend Swansea Flintshire Gwynedd Wrexham Caerphilly Ceredigion Denbighshire Merthyr Tydfil Pembrokeshire Blaenau Gwent Monmouthshire Isle ofAnglesey Carmarthenshire Neath Port Talbot Rhondda CynonRhondda Taff The Vale ofGlamorgan

The size of the population born in Wales is set gradually to reduce in years to come. The Total Fertility Rate in Wales has increased slightly to 1.76 children per woman aged 15-44 years, but is still below 2.08 which is the rate needed to replace the current population.

Special populations This section comprises a selection of special populations, and briefly outlines some of the guidance about how their needs might be met or incorporated in to planning and commissioning of HSCWB services. Where information and data at a local level relating to the other sections of this report are routinely available, those data are reported there. The following sub-section Needs assessment – an ongoing process provides the rationale for this approach.

Special populations may have a different profile of HSCWB needs compared to the total Torfaen population these differences may result in inequalities of health or care. The differences in health and care needs in special populations compared to the total population might arise from age or cultural differences in prevalence of certain illnesses or determinants of health amongst specific demographic or health-condition

24 groups. It may also be due to differences in equity of provision or access to services and initiatives aimed at improving health, social care and wellbeing which are often designed with the majority in mind.

For example, people living with Multiple Sclerosis (MS) are estimated to number between 100 and 120 per 100,000 of the population, equivalent to 52,000 to 62,400 people in total in England and Wales with an annual incidence of 3.5 to 6.6 people per 100,000 (RCP, 2004). On average, large resources are needed to help people with MS a total cost per patient of £17,000 per year has been estimated, however, direct medical cost to the NHS contribute only 16 per cent of this total with the remainder being borne by patients and their families and carers (RCP, 2004). Despite this, several studies have highlighted the poor provision of services to people with MS in the UK; the studies show many people with significant disability failed to receive services, a large extent of disorganisation, and many problems faced by individual patients (RCP, 2004). There are many specific needs published in the Royal College of Physicians (RCP) NICE Guidance (2004) referred to in this paragraph, many of which could be seen as different to the total population, and several recommendations are made for service provision to meet those specific needs of people living with MS. There is actually some information from two forums in Torfaen about perceived inadequate availability of and access to public transport for people with MS. Despite this, this needs assessment could not gain definitive information about the numbers of people with MS in Torfaen; the demographics of this special population are unknown and there has been no specific consultation to understand their needs for local services.

Using this example it is clear that no one document can capture all the information necessary to understand how health inequalities between special populations can be best attenuated, and, the need for coordination of multi-agency data gathering and in some cases generation through consultation (please see sub-section Needs Assessment – an on-going process) is also clear.

Ethnicity There is a range of evidence that poorer migrants and ethnic minorities have different health outcomes to those of the general population of the society in which they are living (Shaw 1999).

The Welsh Assembly Government’s Service Development and Commissioning Guidance for Selected Minority Groups (asylum seekers, Gypsies and Travellers, homeless people and the minority ethnic community) (2006) should be used to help tackle the health needs of these groups.

Details of homelessness and related housing support needs are provided in the Life Circumstances section; however the above document should be referred to for health and care needs.

There are no asylum seeker groups in Torfaen. The proportion of persons who reported being non-white (Census 2001) in Torfaen LHB/LA area is less than one per cent (see table below).

Breakdown of ethnicity in Torfaen; ONS, Census, 2001 Ethnicity Persons Mixed 343 Asian or Asian British 238 Black or Black British 84 Chinese 143 Other Ethnic Group 44 Total described as non-white 852

There has been consultation amongst BME communities in Torfaen, through the Public and Patient Involvement group and the LHB and partners. The Torfaen Race Equality Scheme (2005 to 2008) is prepared by the LHB and is presented on their website. http://www.wales.nhs.uk/sites3/docmetadata.cfm?orgId=284&id=61705

This is intended to be a live document accommodating changes in legislation and understanding of needs. There are annual reports reflecting progress of the objectives of the scheme, the latest from 2006 is also available on the LHB website. http://www.wales.nhs.uk/sites3/docmetadata.cfm?orgid=284&id=61323

These documents and the others included in the webpage are more about reflecting statutory requirements and provide less focus on the specific health needs of the Torfaen BME community, though the LHB clearly state that reducing health inequalities through reorientation of services is a priority.

Furthermore, these documents are based on evidence from consultation with the local community about priorities for focus. Again, this work isn’t specifically focussed on gaining a robust understanding of HSCWB need, more a consultation on the proposed scheme, however the findings do indicate areas of need which should be considered when planning HSCWB services locally. This report is also available from the LHB website. http://www.wales.nhs.uk/sites3/docmetadata.cfm?orgid=284&id=61330

There has been a second consultation with BME groups in Torfaen in 2006 which aimed to more closely understand their health social care and wellbeing needs and signpost primary care amongst the community. The report of this work is will be available on the needs assessment webpage in future.

Health Social Care and Wellbeing Partnerships must address the needs of their whole population including the needs of selected minority groups and services should be commissioned to meet these needs. The examples of good practice in the guidance cited above (WAG, 2006) are intended to illustrate existing good practice in addressing the healthcare needs of those included groups with respect to provision and promotion of services.

26 Carers This subsection is about provision of unpaid care. According to ONS, (Census, 2001) the definition of a provider of unpaid care is “if they give any help or support to family members, friends, neighbours or others because of long-term physical or mental health or disability, or problems related to old age”.

Torfaen is in the process of renewing the previous carers’ strategy and has completed a carers consultation in 2006 to inform strategy development. The consultation was planned through the Carers Strategy Group which has an inclusive and diverse membership. The event aimed to understand the needs of carers for health and care in Torfaen and was based around the eight key themes of Carers Compass (Kings Fund, 1998) including, improving information, recognising and assessing carers needs, quality services, opportunities for a break, emotional support, training and advice for carers, financial security and carers in employment, ensuring carers have a voice, and, equity of access to services and information. The final report is as yet unpublished however there are a range of issues relating to each theme which, as with the Service Development and Commissioning Guidance for Selected Minority Groups (WAG, 2006) report above, will require adjustments or enhancements to health and care services.

Planning and commissioning of services should consider this consultation document in the absence of a current strategy for carers. Once published, this document will be available on the needs assessment webpage

The table below shows the numbers of people in Torfaen who provide unpaid care and for how many hours a week they provide that care. There is no specific reference to whether this care is provided within the household or outside the household.

Persons providing unpaid care in Torfaen; ONS, Census, 2001 Provision of unpaid care Persons Provides 1 to 19 hours a week 7060 Provides 20 to 49 hours a week 1495 Provides 50 or more hours a week 2949 Total persons providing 20 hours or more a week 4444 Total persons providing any unpaid care a week 11504

Crude proportions calculated from 2001 Census data show that Torfaen is not very different to the other LHB/LA areas in Gwent, and similar also to the Wales crude proportion of the population providing unpaid care.

Crude proportion of persons providing unpaid care LHB/LA area; ONS, Census, 2001 Area 1 to 19 hours a 20 to 49 hours a 50 or more hours

27 week (%) week (%) a week (%) Torfaen 7.8 1.6 3.2 Blaenau Gwent 6.8 2.0 3.8 Caerphilly 7.1 1.7 3.6 Monmouthshire 7.8 1.2 2.4 Newport 6.9 1.4 2.9 Wales 7.2 1.5 3.1

Analysis of 2001 Census data at ward level shows the areas where there are most carers and the areas where carers make up the highest proportion (Not age standardised) of the total population. St Cadocs and Penygarn has the highest proportion of carers providing 20 hours or more of unpaid care per week at 8 per cent of the population whereas although Blaenavon has a proportion of 5.6 per cent providing 20 or more hours of unpaid care a week that translates to 433 people compared to 128 in St Cadocs and Penygarn.

Numbers and crude proportion providing 20 hours or more unpaid care per week by Ward; ONS, Census, 2001 Persons Persons providing providing 50 Proportion (%) 20 to 49 or more providing 20 or hours care hours care a more hours care a Ward a week week week St. Cadocs and Penygarn 45 83 8.0 Abersychan 152 281 6.3 Cwmyniscoy 33 45 6.1 Brynwern 35 72 5.9 Trevethin 71 139 5.7 Blaenavon 105 218 5.6 St. Dials 69 139 5.5 Pontnewydd 110 220 5.4 Llantarnam 68 184 5.4 Upper Cwmbran 91 210 5.3 Pontnewynydd 23 54 5.0 Snatchwood 32 57 4.6 Greenmeadow 68 137 4.6 Croesyceiliog North 48 109 4.6 Croesyceiliog South 31 50 4.5

28 Persons Persons providing providing 50 Proportion (%) 20 to 49 or more providing 20 or hours care hours care a more hours care a Ward a week week week Two Locks 111 179 4.4 Fairwater 82 158 4.3 Wainfelin 48 55 4.3

Pontypool 22 46 4.0 Llanyrafon North 25 55 4.0 Panteg 81 190 3.9 New Inn 92 152 3.8 Llanyrafon South 30 62 3.5

Coed Eva 23 54 3.2

Young People The publication of service standards in the National Service Framework for Children Young People and Maternity Services (Children’s NSF) and documents from the Children and Young Peoples Specialised Services Project, as well as the Torfaen Children and Young Peoples Partnership Needs Assessment (2006) means that there is agreement on what needs to be done. The challenge now is to make it happen by implementing the service changes needed to meet the standards set and to use these identified needs to seek funding, plan, and commission to improve the health of children and young people in Torfaen.

There is a clear association between adverse health outcomes and poverty. The reasons for this association are multi-factorial and therefore co-ordinated multiple interventions are needed to have any effect. Strong coordinated partnership between agencies in Torfaen provides the opportunity for co-ordination of services to be better than it has been in the past.

The Torfaen CYPP has the lead for planning and commissioning services for this special population locally. A needs assessment was produced by the Partnership in 2006 which is to be updated in 2007/2008 to inform the next CYPP Plan; this needs assessment therefore provides available data and information about the HSCWB of children and young people in the relevant sections with the recommendation that HSCWB planning to meet identified HSCWB need for children and young people is directed through that partnership structure.

29 Older people The proportion of older people in the Welsh population has been steadily rising over the past 25 years and, with a steadily decreasing birth rate, is likely to continue rising in the future (National Assembly for Wales, 2004). The proportion of the population aged 60 and over now accounts for nearly one in four people in Wales. Over the next 20 years, the overall population is projected to grow by just three per cent, but the number of people of retirement age will increase by 11 per cent. The number of very old people, aged 85 and over, is projected to increase by over a third to 82,000. These demographic changes will alter the overall balance of the population.

Increasing age is generally associated with increasing disability and loss of independence, and function impairments such as loss of mobility, sight and hearing. The 2001 Census shows that the proportion of individuals with a limiting long term illness (LLTI) increases markedly with age. Where local information and data are available by age group, allowing the separation of older groups for analysis, those data are presented in the relevant thematic sections of this report.

The policy agenda for Older People’s service development is driven by the Older Persons National Service Framework (NSF). The NSF for Older People in Wales sets national standards designed to ensure that as individuals grow older they are enabled to maintain health, wellbeing and independence for as long as possible, and receive prompt, seamless, quality treatment and support when required. Other important documents providing information for needs, standards and actions in planning and commissioning of services for older people include the Older Persons Strategy for Wales (2003) and the Health promotion Action Plan for Older People in Wales (2004).

Needs assessment – an ongoing process As mentioned previously there are many special populations which may have a different profile of HSCWB needs compared to the total Torfaen population, these differences may result in inequalities of health.

Designed for Life Vision 2015 aims, where possible, to eliminate inequalities in health. There are therefore a variety of issues related health and wellbeing including equity of provision or access which might require services to be planned, delivered or promoted in slightly different ways to more fully meet the needs of these populations. One size does not usually fit all.

The revised WAG Guidance on preparation of HSCWB Strategies provides and example list of populations “groups whose needs, or some of whose needs, are sometimes neglected by mainstream services” these are:

• carers • minority ethnic communities • people who are homeless or insecurely housed • disabled people • juvenile offenders, young adult offenders and adult offenders in the • criminal justice system

30 • those having completed a custodial or community sentence who need continuing care in the community • Welsh speakers and others who need to access services in a language other than English, including those who rely on signing and lip-reading • asylum seeking and refugee adults and children • Gypsy and Traveller communities • migrant communities • carers groups • Regional Protection of Vulnerable Adults Forums • substance misusers • people with mental health problems • students • people with serious but not common illnesses • those suffering from domestic abuse • people living in rural areas • children whose needs alter as they make the transition from • children’s services to adult services • vulnerable older people

Data relating to the needs of special populations, where available, have been included in the relevant sections of this needs assessment. This is, in general, where local information relating to need has been previously collected for special populations, such as the Torfaen Children and Young Persons Needs Assessment or the Sainsbury Centre for Mental Health Review of Adult Mental Health Services. Those reports are referred to in this document and are included on the web-resource. National and international information on needs or inequalities in specific population groups, which may be less relevant locally, where identified, will also be included on the needs assessment web-page.

In addition to the list (above) from the Revised Guidance (WAG, 2007) there have been other suggestions for populations which might provide focus for assessment, which further highlights the scale and complexity of a comprehensive needs analysis covering the whole population and all minority groups who may have a different profile of need:

The Disability Rights Commission has suggested that the following analysis framework be used in the case of impairment groups: physical impairment; visual impairment; hearing impairment; mental health condition; learning disability (such as

31 Down’s syndrome or dyslexia) or cognitive impairment (such as autistic spectrum disorder); and long-standing illness or health condition such as cancer, HIV, diabetes, chronic heart disease, or epilepsy.

The Welsh Assembly Government’s Service Development and Commissioning Guidance for Selected Minority Groups (WAG and NPHS, 2006) includes recommendations for the identification and addressing of needs within the populations of asylum seekers, Gypsies and Travellers, homeless people and minority ethnic communities.

Despite the vast permutations for categorising special populations, the time/cost implications in attempting to assess all populations’ needs profiles, and, the paucity of reliable data for smaller distinct groups, WAG Revised Guidance (2007) state, “these issues must be fully taken into consideration as a priority, paying due attention to the statutory obligations of the local bodies.” “The Welsh Assembly Government is currently working to mainstream the equality and diversity agenda, and promote an integrated approach to all equality strands including race, disability, gender, age, sexual orientation, religion/belief and language, and will expect local bodies to do the same”.

In many ways, this needs assessment is a stock-taking exercise. It is clear that locally available data and evidence are not of a quality comparable to nationally available data. The scale of the task, against the national expectation and local preparedness, is particularly evident in the case of special population groups. Awaiting complete, rather than adequate information before action can inadvertently lead to organisational inertia and delay in addressing the need for inevitable change. Hence a manageable middle way would be to acknowledge that this HSCWB needs assessment, like any strategic assessment, is an ongoing process.

This acknowledgement also supports the need for undertaking more appropriate local quantitative and qualitative analyses of need in Torfaen, in view of work underway within local stakeholder organisations. The work of the separate departments of the TCBC in citizen engagement and research is in the process of being coordinated through a central point. The ‘Torfaen Patient and Public Involvement Strategy’ is due for renewal in 2008. The Organizational Development Pace Setters work stream for developing user and carer involvement, and the willingness of other partners to be involved in sharing data, through Community Safety Partnership and the Children and Young Peoples Partnership, should be viewed as opportunities for change. It is suggested that the HSCWB Partnership, through the Strategy, provide the leadership and direction to take this urgently needed work forward.

A single partnership approach to coordinate citizen engagement for needs assessment and the identification, analysis, and presentation of routinely available quantitative information across all statutory and voluntary partners in Torfaen is a priority. This will have the potential to enhance the information provided in the following chapters on specific themes about lifestyle, life circumstances, disease prevalence, health and social care services.

32 Torfaen Health, Social Care and Wellbeing Needs Assessment 2007

Supporting the Health Social Care and Wellbeing Partnership for Torfaen

Chapter 3 Life Circumstances

Table of Contents

Deprivation 35 Economic activity and benefits 37 Education 40 Lone parent families 43 Child poverty 44 Older people and dependency 45 Housing 45 Injuries 47

34 Life circumstances are important factors that impact directly on the health social care and wellbeing (HSCWB) of both individuals and communities. The circumstances in which people live, impact directly on both mental and physical health and wellbeing. Other factors include physical environment, economy, community wellbeing, housing and social environment amongst others (see Introduction section for a model of wider determinants of health).

Deprivation

Townsend deprivation score fifth by WIMD score fifth by lower super electoral division: 2001 output area (LSOA): 2001

Crown copyright material is reproduced with the permission of the Controller of HMSO and the Queen’s Printer for Scotland

Townsend and WIMD include slightly different indicators, hence some of the differences may be related to the method of measurement; however, looking at information at the LSOA level is similar to the effect of a magnifying glass – more detail can be deciphered at smaller geographical levels, thus providing the evidence about where more targeted action is required, to improve health.

In 2004 the Health Information Analysis Team (HIAT) at the NPHS analysed Townsend deprivation by ward across Wales. Following ranking all Welsh wards by Townsend deprivation score from most deprived to least deprived and then grouping them in to fifths it can be seen that 8 of the 24 wards in Torfaen are amongst the most deprived fifth of all wards in Wales – 31 per cent of the total population of Torfaen live in Wards amongst the most deprived fifth in Wales (HIAT, 2004).

The HIAT calculated ‘rate ratios’ for a range of health outcomes and determinants to compare health of the most deprived fifth with the least deprived fifth; for example, a rate ratio of 2 means that the rate for the wards in the most deprived group is twice as high as that of the wards amongst the least deprived group.

The following are the ten highest rate ratios related to health outcomes: • Hearing problems (rate ratio 2.60) • Eyesight problems (2.26) • Pedestrian injury (2.15) • Deaths from chronic obstructive pulmonary disease (2.11) • Mental illness (1.90) • Deaths from lung cancer (1.80) • Diabetes (1.78) • Infant mortality (1.61) • Respiratory disease (1.52) • Suicide (1.51)

It is also clear that major risk factors affecting health are significantly more prevalent in the most deprived fifth across Wales: • Physical inactivity (2.08) • Smoking (1.64) • Obesity (1.47) • Healthy diet (0.65)

Table of Torfaen electoral divisions by fifth of deprivation in Wales:

12345 (most deprived) (least deprived)

1. Trevethin 9. Snatchwood 13. Llantarnam 18. Pontnewynydd 23. New Inn 2. St. Cadocs and Penygarn 10. Blaenavon 14. Fairwater 19. Llanyrafon North 24. Llanyrafon South 3. St. Dials 11. Abersychan 15. Croesyceiliog North 20. Panteg 4. Upper Cwmbran 12. Pontypool 16. Two Locks 21. Wainfelin 5. Brynwern 17. Coed Eva 22. Croesyceiliog South 6. Greenmeadow 7. Cwmyniscoy 8. Pontnewydd

Although these statistics are based on an analysis by fifth of deprivation for the whole of Wales, it can be reasonably expected that people living in areas such as Trevethin, St. Dials and Upper Cwmbran to have statistically significantly higher

36 levels of ill-health and a greater exposure to the major risk factors affecting HSCWB compared to those living in Llanyrafon South or New Inn Wards.

In the WAG revision of Welsh Index of Multiple Deprivation (2005) the patterns is very similar at LSOA level to the map above from the 2001 Census. The LSOAs in Trevethin and Blaenavon shaded darkest green are ranked 91 and 146 respectively out of 1896 in the whole of Wales and are in the 10 per cent most deprived category in Wales.

Economic activity and benefits Wales has a higher proportion (5.7%) than England (5.0%) and Scotland (5.2%) of unemployment amongst people of working age who are able to/available for work (e.g. do not have a disability or not in full-time education). However, this proportion is considerably lower than the proportion reported for Northern Ireland (6.6%).

LHB/LA level analysis of 2001 census data reveal large variation between the 22 areas; Torfaen is ninth lowest of the 22 LHB/LA areas for unemployment and has a slightly lower proportion unemployed (5.6%) than the Welsh average of 5.7 per cent. It should be noted however that this difference may be more indicative of higher proportion of people who are classed as economically inactive; this will be discussed later.

Job-Seekers' Allowance claimants (% of working age); ONS; 2006 Torfaen South East Wales Wales Persons 5.4 5.8 4.9 Males 3.7 4.2 3.5 Females 1.7 1.6 1.4

At the MSOA level within Torfaen the map below shows the distribution of the proportions of persons economically active and unemployed. There are no MSOAs in Torfaen amongst the highest range for Wales’ MSOAs.

37 Percentage economically active unemployed by MSOA: 2001

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Economic activity (% of the working age); 2005/06 Torfaen South East Wales Wales In Employment 68.5 69.2 71.1 Economically inactive, excluding 25.4 23.8 21.5 students

Over half of all benefits received (57%) in Torfaen however comprise Incapacity Benefit which represents 13 per cent of the working age population (ONS, 2004), compared to Jobseekers Allowance which makes up 5.6 per cent. The table below shows that Torfaen has higher levels of Incapacity benefits and Disability Living Allowance claimants compared to Wales but on the whole are similar to the South East Wales Region.

38 Other benefits 2006 Torfaen South East Wales Wales Incapacity benefit and severe 12.9 13.4 11.6 disablement allowance (% working age)

Disability living allowance 11.5 10.7 9.4 claimants (% under 65s)

The table below shows occupational socio-economic classification in Torfaen compared to South East Wales (SEW) and all-Wales. Torfaen has lower proportion of the population who have never worked than SEW and all-Wales but has less residents classified as managerial and professional or intermediate compared to SEW and all-Wales. There are more Torfaen residents with occupations classified as Routine and Manual compared with SEW and all-Wales.

Occupational Socio-economic Classification (% of those aged 16-74); 2001 Torfaen South East Wales Wales Managerial and professional 19.4 21.0 22.0 Intermediate 12.8 13.4 15 Routine and Manual 36.7 32.9 30.0 Never worked and long-term 3.6 4.2 3.8 unemployed Not classifiable 27.5 28.4 29.1

39 Education Education is a key determinant of health. People with low levels of educational achievement are more likely to have poor health as adults (Department of Health, 1999). The data in this subsection show the proportion of people aged 16-24 who have no educational, vocational or professional qualifications.

Compared with the rest of the UK, Wales has a higher proportion of young people with no educational qualifications. Analysis at LHB/LA area level reveals large variation between areas; the South Wales Valleys areas all have a higher proportion of young people with no educational qualifications than the Welsh average of 19.9 per cent. Torfaen is the best of these with just under 23 per cent of 16 to 24 year olds with no educational, vocational or professional qualifications.

Percentage of persons aged 16-24 with no qualifications by electoral division: 2001

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40 The following tables provide more information about performance in education in Torfaen and are taken from http://www.wales.gov.uk/keypubmrs/content/07-042.pdf produced by the Statistical Directorate at WAG.

GCSE Examination / equivalent achievements (% 15 year olds); 2005/2006

Torfaen SE Wales Wales

5+ GCSE Grades A*-C 48.6 48.5 53.8

5+ GCSE Grades A*-G 85.2 84.9 86.0

A*-C in each of the core subjects 29.1 34.3 39.7

Average GCSE / GNVQ points 38.3 38.4 41.2 score

Leaving full time education 3.3 2.8 2.1 without a recognised qualification

The proportion (per cent) of 15-16 year olds achieving at GCSE (or equivalent) in Torfaen are similar to Wales and South East Wales (SEW) proportions. Notable exceptions include the proportion of young people in school in Torfaen achieving A* to C grades in each of the core subjects is almost five per cent lower than SEW and more than 10 per cent lower than the all-Wales proportion.

Achievements in teacher assessments in each of the core subjects (%); 2005/06

Torfaen SE Wales Wales

Level 2 at Key Stage 1 76.4 81.6 80.6

Level 4 at Key Stage 2 67.6 74.6 74.2

Level 5 at Key Stage 3 50.0 58.3 58.2

Achievements in teacher assessments in each of the core subjects show proportions in Torfaen are lower for Level Two at Key Stage One, Level Four at Key Stage Two and Level Five at Key Stage Three compared to SEW and all-Wales proportions.

41 Pupil teacher ratios (Ratio); 2005/2006

Torfaen SE Wales Wales Primary schools 21.3 20.9 19.8 Secondary schools 17.2 17.0 16.6

Average class sizes (Number of pupils); 2005/2006

Torfaen SE Wales Wales Primary Key Stage 1 25.7 25.4 24.4

Primary Key Stage 2 26.6 26.2 25.0

Primary Key Stage 3 23.6 24.3 23.7

Secondary Years 7-11 22.2 23.0 22.4

Secondary Years 12-13 15.6 11.4 11.0

Pupil teacher ratios and average class sizes in Torfaen schools are similar to SEW and all-Wales.

42 Lone parent families Lone parent households tend to have lower incomes and a greater need for health and social care. In Wales, a quarter of dependent children live in lone parent households; this is relatively high compared with most other areas of the UK. Torfaen has a similar, slightly lower proportion of children living in lone parent families to the Welsh average at just under 24 per cent. The map below, based on 2001 census data, shows the electoral divisions of Greenmeadow, Brynwern and Trevethin have highest proportions of children living in lone parent families within Torfaen and these Wards have levels above the Welsh average. However, in Torfaen, there are no electoral divisions ranked amongst the fifth with the highest proportion of dependent children in lone parent families.

Percentage of dependent children in lone parent families by electoral division: 2001

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43 Child poverty In Torfaen LHB/LA area 26.3 per cent of children and young people aged 0 to 15 years live in households dependent on worklessness benefits, this is higher than the Welsh average of 25 per cent. Out of the 22 LHB/LA areas in Wales, Torfaen is ranked ninth highest for 0 to 15 year olds living in households dependent on worklessness benefits.

Sub LHB/LA area analysis of children aged under 16 years in households dependent on worklessness benefits in Torfaen shows that Cwmyniscoy, Penygarn/St Cadocs, and Trevethin have proportions amongst the highest fifth of wards in Wales; between 40 and 60 per cent.

Percentage of children aged under 16 living in households dependent on worklessness benefits by electoral division: 2005

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44 Older people and dependency Living arrangements are important because older people living alone may place a greater demand on personal social services compared to older people with other living arrangements. Greater financial independence, improvements in health and attitudes towards living in communal establishments contribute to the increasing proportion of older people living independently (Tomassini, 2005b). This is particularly important in the context of recent demographic trends such as the increase in the proportion of older divorced people. Such trends are associated with an increasing need for care facilities outside the family (Tomassini, 2005b).

Older people living alone The proportion of people aged 75 and over who live alone in Wales is 43 per cent; lower than the proportion of older people living alone in Scotland, England and most English regions. It is important to note that women are more likely than men to live alone, especially at older ages. Twice as many women live alone in the over 75 age group compared to men (Tomassini, 2005b), this is possibly due to the greater life expectancy for women.

Analysis at the LHB/LA area level shows that Torfaen is the eight highest of the 22 areas in Wales for people aged 75 and older living alone. The proportion is slightly higher than the Welsh average of 43 per cent.

Housing Housing is of particular importance in ensuring positive life circumstances for individuals and communities. Information obtained from the Supporting People Planning Inclusive Forum (and the Gwent Needs Mapping Exercise) outlines the housing needs for identified groups of people within Torfaen. The housing support needs of specific groups have been investigated in relation to: Vulnerable Single/Two Parent Families, Domestic Abuse, Ex-Offenders/Criminal Justice System, Homeless/Potentially Homeless, Vulnerable Young People/Care Leavers, Alcohol/Drug Dependency, People with Learning Disabilities, Mental Health, Black & Minority Ethnic Groups including Refugees and Travellers, Physical Disabilities and Sensory Impairments, Older Persons/Frail Elderly, Chronic Illness/HIV & AIDS.

Homeless/Potentially Homeless 519 people in Gwent expressed the need of Homeless/Potentially homeless; 379 as a Lead Need for their housing requirements. Of those who expressed homelessness as a lead need for supported housing, those aged 16 to 24 years were most prevalent (43%), with less than 1 per cent of this population coming from those aged 60 years and older. There were no differences between males (47%) and females (53%).

Of those who expressed lead need as homelessness 11 per cent reported “sleeping rough” and three per cent using a hostel. The other living arrangements were living with parents/partner (25%), ordinary accommodation (22%), staying with friends or “sofa surfing” (22%), Bed and Breakfast (11%) and, 1 percent were living in a refuge.

There are a variety of reasons for homelessness recorded in the GNME the largest

45 being “relationship breakdown” (34%), have to leave parental home (22%) and eviction (14%). Domestic violence contributed to 7 per cent of homelessness or potential homelessness whilst “money problems” contributed the least (9%) to homelessness or potential homelessness according to GNME. In terms of risk factors, 12 per cent had a probation officer; eight per cent were previously in care and just one per cent reported having a social worker.

The table and graph below show the decisions taken with homeless people in Torfaen from 2002 to 2007. There appears to be a decreasing trend, however these data should be treated with caution.

Summary of homelessness; decisions taken, Torfaen 2002-2007 (a) Year Ineligible Eligible, Eligible, Eligible, Eligible, All household but not homeless homeless unintentio Househol homeless but not in and in nally ds priority priority homeless need need but and in intentional priority ly so need 2002-03 0 372 261 27 397 1,057 2003-04 1 294 240 31 400 966 2004-05 1 332 178 28 386 925 2005-06 2 296 128 27 341 794 2006-07 (b) 0 98 13 17 81 209 (a) Under Part VII of the Housing Act 1996. (b) 2006-07 only includes data for April-September 2006

Homelessness in Torfaen: 2002 -2006

1,200

1,000

800 2002-03 2003-04 600 2004-05 400 2005-06 200 Number of Households of Number 0 Eligible, but not Eligible, Eligible, All Households homeless homeless but unintentionally not in priority homeless and need in priority need

46 Reported need for support from this group of people in priority order included: finding other accommodation, set up/maintain home, budgeting/managing finances, benefit claims and, advice and advocacy.

GNME conclusions and recommendations for focus amongst those reporting homelessness or potential homelessness as their lead need for support included: • Housing and support for homeless young people • Ref. new hostel in Osborne Road need for move-on floating support – young persons set up to fail without continuation of support • Need for supported accommodation and housing related support for ex-offenders, most specifically those at risk of harm • Housing related support services and accommodation for homeless persons with multi needs: offending/mental health /substance misuse/domestic abuse issues • Lack of affordable housing impinges upon homelessness • Floating support to assist all vulnerable client groups regards sustaining homes • Partnership working to address homelessness • Housing support services for all vulnerable people that focus on prevention of homelessness • Gwent-wide provision and partnership approach to housing with support of homeless ex-offenders, as particularly difficult to accommodate.

Injuries Injuries and their consequences produce a heavy burden on society in terms of short and long term disability, mortality, economic loss and health care costs. Whilst injuries account for only about three per cent of total deaths in Wales, the distribution of the age of death in those dying is very different from most other causes of death with a high proportion of deaths occurring in the young. After the age of one injury is the first or second leading cause of death in most European countries, including Wales. When a different measure of counting the impact of death is used, potential years of life lost (PYLL) before age 75 injuries account for around 15 per cent of all premature mortality in Wales.

Age group The age groups that visit hospital accident and emergency departments in Wales are typically children, young adults and the elderly. Injury rates are highest amongst those aged 10 to 14 years with the rate of injury resulting in hospital attendance dropping with age to the age group with the lowest rate, 65 to 69 years. From age 70 years the rate of injury rises steeply by five year age bands, with those aged 85 years and older having the highest rate of injury resulting in attendance to A&E for all age groups older than 24 years. More information on A&E attendances for injuries is included in the section Service Provision and mortality data are included in the section Health Status.

Main diagnoses The most common types of injuries resulting in accident and emergency attendances in 2004 were sprains, fractures, bruise / abrasion and laceration / wound.

47 Older children and young adults were the age groups more likely to attend accident and emergency departments in Wales with a main diagnosis of ‘sprain’ in 2004. The age-specific rates for persons attending accident and emergency departments with a major diagnosis of fractures is similar to that seen for sprains for the younger age bands i.e. it peaks at 10-14 year-olds. However, unlike sprains there is a sharp increase in the age-specific rate for persons aged 80 and over attending accident and emergency departments with a main diagnosis of ‘fracture’.

Rates for people attending accident and emergency departments in Wales in 2004 with a main diagnosis of either bruise/abrasion or laceration/wound show that lacerations/wounds were more common amongst children under 5 years of age whereas children aged 10-19 years had higher rates for bruise/abrasions.

Age-specific rates for accident and emergency attendances at hospitals in Wales in 2004 reveal the most vulnerable groups for poisoning/overdose to be young children and the elderly. The rates for children aged 0-4, with almost five per cent of children in this age group attending an accident and emergency department as the result of poisoning/overdose.

Whilst burns and scalds form a relatively low proportion of all injuries they are often quite severe injuries and may result in residual disfigurement and disability. Scalds are a particular problem in young children and most hospital admissions in those aged 0-4 years from thermal injuries are due to scalds. Half of these injuries are due to spilling hot drinks on the child and a quarter are due to excessively hot tap water.

Main location Data relating to the location of injuries shows that most people are injured at home. Age-specific rates for all injuries for 2004 show that the most vulnerable age groups for injuries occurring at home are the very young and older persons. Rates for people injured in road traffic incidents peak in the 15-24 age group, whilst rates for people injured in public places peak in the early teenage years.

Children and young people The following analysis also uses PEDW data to report on persons admitted either as inpatients or daycases. The data do not include A&E attendances. Once again the analysis based on counts of individuals, rather than activity. Injury and poisoning accounts for around 15 per cent of all person-based admissions in the 0 to 24 age group in Wales.

Hospital admissions for injury and poisoning vary with age in Wales. Rates are highest in under 5s and lowest in the 5 to 9 age group. The person based standardised emergency admission rate for 0-24 year olds where the principal diagnosis is injury and poisoning for Wales between 1999 and 2005 has remained stable over that period.

The person based standardised emergency admission rate for 0-24 year olds where the principal diagnosis is injury and poisoning for LHB/LA areas in 2005 shows considerable variation in the rate, ranging from 811 per 100,000 of the population in

48 the Vale of Glamorgan up to 1807 in Merthyr Tydfil. Torfaen is slightly lower than the Welsh average of 1209 and is ranked eighth lowest of all 22 LHB/LA areas in Wales.

Attendances at A&E by children and young people The table below shows that attendance at A&E following injury is highest amongst those aged 15 to 19 years. The attendance increased between 2003 and 2004 for those aged 0 to four and five to nine years old.

Injury attendances at A&E by age band, Torfaen residents aged 0-19 years, 2003-2004 Age band 2003 2004 0-4 394 512 5-9 586 578 10-14 897 878 15-19 954 925

The breakdown of diagnosis of injury for Torfaen residents visiting A&E by age band shows that although sprain is the leading diagnosis for those aged 0 to 19 years, the most frequent diagnosis changes with age band. In those aged 0 to four years head injury is most often the reason for a visit to A&E; this might be due to parental anxiety about head injury in infancy. In those aged five to nine years laceration/wound and fracture are the leading diagnoses following visit to A&E in 2004. In those aged 10 to 14 and 15 to 19 years the rank of leading diagnoses following visits to A&E are the same; the most frequent three diagnoses are sprain, fracture, bruise/abrasion. The increase in visits to A&E in the 10 to 14 year age band (and subsequently 15 to 19) is large, three times the number for sprains, and possibly relates to decreased supervision in unstructured play.

Injury attendances at A&E, age band by diagnosis, Torfaen residents, 0-19 years, 2004 Diagnosis 0 to 4 5 to 9 10 to 14 15 to 19 0 to 19

Sprain 42 85 258 274 659 Fracture 43 105 199 163 510 Bruise / Abrasion 57 90 188 181 516 Laceration / Wound 91 118 100 127 436 Head Injury 174 98 65 58 395 Foreign Body 35 37 18 25 115 Poisoning / OD 23 6 11 36 76 Burn 27 12 11 13 63 Bite 12 16 15 10 53 Dislocation 8 <5 6 22 36 Other Injury 0 9 7 16 32

The place where injuries resulting in visits to A&E occur amongst Torfaen residents aged 0 to 19 years is most frequently the home (excluding category other); the

49 second most frequent setting is educational establishment. Road traffic accidents account for the lowest setting of injury resulting in a visit to A&E. These settings possibly reflect the places where this age group spend most time but also provide an indication of which settings might provide the most important for interventions to reduce unintentional injury.

Injury attendances at A&E, by setting, Torfaen residents, 0-19 years, 2004 Setting 2004 Home 664 Educational Establishment 194 RTA 52 Sport 130 Public Place 123 Other 1730 Total 2893

Deprivation and Health (NPHS, 2004) includes data on hospital admissions stratified by fifth of deprivation. The chart below shows the admission rate for pedestrians aged 5 to 14 years injured in road traffic accidents by deprivation fifth (see appendix table 42). The admission rate for children in the most deprived fifth of electoral divisions is more than twice that of those in the least deprived fifth.

Pedestrian injury hospital inpatient episodes, children aged 5-14 years, Wales by 5th of deprivation, 1997-2002 Sour ce : PEDW / NPHS 50 45 40 35 30 25 20 15 Rate per 100,000Rate 10 5 0 1 (least 2345 (most deprived) deprived) Electoral division deprivation fifth

Road traffic injuries There were more than nine and a half thousand (9,535) road traffic collisions recorded on the STATS19 system by the police services in Wales in 2004; this figure is likely to be an underestimate of the true figure. Crude rates of road accidents per

50 100,000 population show considerable variation across the 22 Local Health Boards areas. These data show Torfaen had the lowest rate in Wales in 2004 at less than 200 per 100,000 of the population, lower than the Welsh average of 323 and less than half the rate of the LHB/LA area with the highest rate. Numbers of casualties occurring as the result of road traffic collisions in Wales in 2004 were in excess of thirteen and a half thousand (13,687 casualties). The pattern of casualties resulting from road traffic collisions by LHB/LA area is very similar to that seen for all road traffic collisions as might be expected with Torfaen having the lowest rate in Wales.

Inequalities The Deprivation and Health (NPHS, 2004) report includes data from police records of attendance at road traffic crashes as reported by the Collaboration for Accident Prevention and Injury Control (CAPIC, 2004). Deprivation scores for road traffic injuries recorded by the police depend on the place of injury occurrence (NPHS, 2004). The chart below shows that child pedestrian injuries in the most deprived fifth of areas occurred at 2.5 (based on place of injury occurrence) times the rate in the least deprived fifth (NPHS, 2004).

Pedestrian injuries reported to Pedestrian injuries reported to police, children aged 4-16 years: police, adults aged 65+ years: 1995−2000 1995−2000

Data source: STATS19, CAPIC

The ratio of 2.7 for older people, based on place of injury occurrence, also suggests a higher relative risk (NPHS, 2004) for pedestrian injuries in more deprived areas.

Workplace injuries This section looks at injuries to employees reported to the Health and Safety Executive by industry type and location.

51 The chart below shows the numbers of injuries to employees by industry type and LHB/LA area. It is important to note that figures for Cardiff are high because there are more people working in the city and not necessarily because the injury rate there is high. It is not possible to calculate population based rates with these data. The Services Industry accounted for 63 per cent of all injuries to employees in Wales in 2004/05.

Injuries to employees reported to Health and Safety Executive in Wales by industry type and Local Health Board: 2004/05 Source: Health and Safety Executive, 2005 1000 Agriculture Extraction & Utility Manufacturing Construction Services 900

800

700 oyees l

600 o emp t es es

i 500 ur j n i

f 400 er o

b 300 um N 200

100

0 Cardiff Conwy Powys Torfaen Newport Bridgend Swansea Flintshire Gwynedd Wrexham Caerphilly Ceredigion Denbighshire Merthyr Tydfil Pembrokeshire Blaenau Gwent Monmouthshire Isle of Anglesey Carmarthenshire Neath Port Talbot Rhondda,Cynon,Taff The Valeof Glamorgan

Summary

Life circumstances are important factors that impact directly on the health of both individuals and communities. The higher the deprivation, higher the prevalence of risk factors such as physical inactivity, smoking, obesity and lack of a healthy diet; in turn these are linked to poor health outcomes as well. Eight of the 24 wards in Torfaen are amongst the most deprived fifth of all wards in Wales – 31 per cent of the total population of Torfaen live in these 8 Wards. Two areas in Torfaen are amongst the highest 10 per cent of deprived areas in Wales according to the Welsh Index of Multiple Deprivation (2005).

Torfaen is the eight highest of the 22 areas in Wales for people aged 75 and older living alone.

Torfaen has a similar but slightly lower proportion of children living in lone parent families to the Welsh average at just under 24 per cent.

26.3 per cent of children and young people aged 0 to 15 years in Torfaen live in households dependent on worklessness benefits.

Homelessness seems to be becoming less prevalent in Torfaen however there are still several priority needs for support within this group.

53 age group spend most time but also provide an indication of which settings might provide the most important for interventions to reduce unintentional injury

54 Torfaen Health, Social Care and Wellbeing Needs Assessment 2007

Supporting the Health Social Care and Wellbeing Partnership for Torfaen

Chapter 4.1 Nutrition Table of Contents

Background 57 Breast Feeding 58 Young people 59 Adults 63 Local qualitative information 66

56 Background A varied and balanced diet providing sufficient (but not excess) energy and an adequate supply of essential nutrients can enhance health and wellbeing. In contrast, a poor diet can predispose to a variety of serious illnesses mentioned above, and is a significant factor in many premature deaths. Yet it is in fact one of the most modifiable lifestyle determinants of human health. Changing our dietary habits for the better will have a major impact in reducing rates of the chronic diseases.

Research evidence on the benefits of healthy eating include:

• Obese persons who lose just 10kg of weight would benefit from a 20-25 per cent fall in overall mortality (Jung, 1997). • An estimated third of cancers could be prevented by changes in diet (DoH, 1998). Around 40 per cent of endometrial cancer, 25 per cent of kidney cancer and 10 per cent of breast and colon cancers would be avoided by maintaining a healthy weight with a body mass index (BMI) of under 25 (Bianchini et al, 2002). • Poor nutrition contributes to at least 30 per cent of coronary heart disease deaths (Peterson and Rayner, 2003). Eating a portion of fruit and vegetables a day decreases the risk of coronary heart disease by 4 per cent and stroke by 6 per cent (Joshipura et al, 2001). • The links between low birth weight and poor maternal nutritional status are complex but significant (Bull et al, 2003).

People who develop healthy eating habits early in life are more likely to maintain them in adulthood and have reduced risk of obesity, cardiovascular disease, cancer, non-insulin dependant diabetes and osteoporosis (Mendelson & White, 1982: WHO, 2004).

Obesity and being overweight create a considerable health and economic burden. The House of Commons Select Committee on Health estimated that in England in 2002 (House of Commons Health Committee, 2004) the direct cost of treating obesity was £46-49 million; the cost of treating the consequences of obesity was £945-1075 million, the indirect costs of obesity was £1-1.1 billion for premature mortality and £1.3-1.45 billion for sickness absence and the direct plus indirect costs of overweight and obesity was £6.6-7.4 billion.

Over half of women and about two thirds of men are either overweight or obese. Less data is available about the prevalence of obesity in children, however data from the survey of Health Behaviour in School age Children in Wales, suggests that in the 13 year old age group, 18 per cent of boys and 15 per cent of girls are pre-obese, and 2 per cent of girls and 4 per cent of boys are obese (WAG, 2004)

Regrettably, there is a scarcity of ‘nutritional intake’ data in Wales. In terms of the British diet, surveyed in 2000 and 2001, it identified both positive and negative attributes including:

• The average intake of fat is close to that recommended, however the average intake of saturated fatty acids were higher (~13 per cent vs ~11 per cent).

57 • Mean intake of non-milk extrinsic sugars higher than recommended (~13 per cent vs ~11 per cent). • Mean salt intake was 9.5g/day – well above the 6g/day recommendation. • The recent Welsh Health Survey (NAfW, 2004) also identified similar nutritional trends: • 54 per cent of adults in Wales are currently overweight or obese. • 40 per cent of adults in Wales said that they had eaten 5 or more portions of fruits and vegetables the previous day. However, 5 per cent of adults said they had not eaten any fruits and vegetables the previous day

Breast Feeding Breast milk is the best possible nutrition for babies. It affords improved health outcomes in a number of key public health priority areas; diabetes, cancer, obesity and coronary heart disease. The health inequalities gap evident for infants born into disadvantaged families can be reduced markedly by receiving human milk and can be both life-saving and life- enhancing for those born prematurely (Kramer & Kakuma, 2002).

By reducing infections in the first year of life, significantly fewer breastfed babies are treated in primary and secondary care for ear, urinary, gastro-intestinal and respiratory infections. As well as this, breastfeeding also markedly reduces the incidence of asthma and eczema and therefore reduces the discomfort and cost of treating such conditions. The greatest improvements in health and nutrition are gained from exclusive breastfeeding to 6 months and the introduction of appropriate complementary foods thereafter, for a minimum of a year and ideally, two years and beyond (Kramer & Kakuma, 2002).

Breastfeeding Initiation Figures 2005

0 Engand 78% Scotland 70% Wales 67% Ireland 63% Torfaen 45.5% Torfaen 40.6% (2004)

The chart above shows the latest available breastfeeding initiation proportions. These data highlight that proportion of people breastfeeding in Torfaen is increasing, however it remains 20 per cent below the all-Wales average and 30 per cent below the English average.

Torfaen Breastfeeding Duration FiguresShowing Increase From 2004-2005

50.00%

45.00%

40.00%

35.00%

30.00%

2004 25.00% 2005

20.00%

15.00% Percentage Of Children Breastfeeding 10.00%

5.00%

0.00% Birth 2 weeks 6 weeks 6 months 9 months Period That Breastfeeding Is Continued

In Torfaen, whilst there has been a rise in breastfeeding rates between 2004-2005 less than half the babies receive any breast milk at all, and this falls to almost a third at 2 weeks and to as little as 5 per cent at 9 months (see graph above). It is unknown how many babies are exclusively breastfed in the UK or in Wales, but observations by Health Visitors suggest supplementation with formula is the cultural norm in Torfaen and so it is estimated to be small.

Young people This subsection shows data taken from the Health Behaviour of School aged Children (HSBC) report of 2001/02. Data for children aged 11, 13 and 15 years of age are shown.

Proportion of young people who eat breakfast every school day There is a decrease of over 20 per cent in the eating of a daily breakfast in girls aged between 11 and 15 years, and a drop of 8 per cent for boys. This is probably linked to the increase in dissatisfaction with body weight and dieting but may also be due to perceived time and increasing choice.

At age 11 the proportion of girls in Wales who eat breakfast daily is comparable with England and Scotland, this proportion drops below these countries as age increases. For boys aged 11 the proportion remains comparable with England but less than Scotland. At age 15 the proportion eating breakfast daily drops below both countries.

59 Daily eating habits of young people in Wales (HBSC, 2001/2)

70 60 Aged 11 Girls 50 Aged 13 Girls 40 Aged 15 Girls 30 Aged 11 Boys Aged 13 Boys

Proportion (%) Proportion 20 Aged 15 Boys 10 0 Eat Eat fruit Eat Drink soft Eat sweets breakfast vegetables drinks

Proportion of young people who eat fruit every school day The data show a decrease of daily fruit intake with increasing age. This is possibly due to an increase in autonomy shown by an increase in the consumption of soft drinks and sweets.

The proportion of children aged 11 eating fruit daily is comparable with England but lower than Scotland. As age increases the proportion of children eating fruit drops below both of these countries.

Proportion of young people who eat vegetables daily The data in this section show an increase of daily vegetable intake with an increase in age. This is possibly due to a change of taste as age increases.

The proportion of children in all age groups eating vegetables daily in Wales is consistently lower than in England and Scotland.

Proportion of young people drinking soft drinks daily The data in this section show an increase with age of soft drink consumption, especially in boys. This is possibly due to increased freedom to choose and purchase snacks as age increases.

The proportion of 11 year olds drinking soft drinks daily in Wales is lower than in England and Wales for both girls and boys. This remains the pattern as age increases except in girls aged 13 who consume slightly more than girls of the same age in England.

60 Proportion of young people who eat sweets daily The data in this section show an increase in daily sweet consumption with an increase in age. Again, this is possibly due to a greater autonomy as age increases. The proportion of in all age groups eating sweets daily in Wales is lower than in England and Wales for both girls and boys; this pattern remains as age increases.

Proportion of young people dissatisfied with their body weight and engaged in weight control behaviour The data in this sub-section show that girls become much more dissatisfied with their bodyweight as they get older i.e. from 33 per cent of 11-year olds to 52 per cent of 15-year olds. For boys this increase is much less. The increase is possibly due to an awareness of how young people think they should look linked to peer pressure. The media plays an ever increasing role in this area.

The proportion of 11 year old girls in Wales who are dissatisfied with their bodies is higher than England but lower than Scotland. For boys the proportion is higher than Scotland and lower for Wales. By age 13 the proportion of boys dissatisfied with their bodies is higher than both England and Scotland but for girls lower than both England and Scotland. By the age of 15 the proportion of boys dissatisfied with their bodies is higher than both England and Scotland but for girls Wales is comparable with Scotland and higher than England.

Young people in Wales' dissatisfaction with body weight and engaged in weight control

50 Aged 11 Girls 40 Aged 13 Girls Aged 15 Girls 30 Aged 11 Boys 20 Aged 13 Boys

Proportion (%) Aged 15 Boys 10

0 Dissatisfied with weight Engaged in weight control behaviour

The data for young people engaged in dieting and weight control show a 24 per cent increase in those dieting for girls aged between 11 and 15 years. This is possibly due to the pressure to fit a certain body image and might be linked to a decrease in girls eating breakfast as they get older. For boys, those involved in dieting decreases with age this could be due to the age related onset of the adolescent growth spurt in boys where relative fatness is decreasing. In the younger age group parental control

61 to keep to a sensible diet and exercise pattern is still appears to be influential. It may be that as boys get older this control lessens and weight watching decreases.

The proportion of boys aged 11 in Wales engaged in dieting is higher than in England but lower than Scotland. For girls the proportion is higher than both countries. By the age of 13 the proportion of boys dieting in Wales is higher than both England and Scotland and for girls the data are comparable. By the age of 15 the proportion for both girls and boys in Wales is higher than in England and Scotland

Proportion of young people who are classified pre-obese and obese The data in this section show the proportion of children aged 13 and 15 who are pre- obese (overweight) with a BMI between 25 and 30 and obese (BMI>30) (WHO, 2004a). These data need to be interpreted in the knowledge that the adolescent growth spurt for girls starts about two years before boys; one might expect to see a higher proportion of relative fatness prior to the adolescent growth spurt and relative leanness during this phase of normal growth. Comparing girls and boys at a population level, of the same chronological age to examine gender differences in relative fatness is not usually appropriate.

The data show that the proportion of overweight (pre-obese) children decreases as age increases. In both the 13 and 15 year old age groups Wales has a higher proportion of pre-obese children than England and Scotland.

The proportion of obese children increases with age, especially for boys. The proportion of 13 year old boys in Wales who are obese is comparable with England and Scotland. For girls the proportion is lower than both England and Scotland. By age 15 the proportion of girls and boys in Wales classed as obese is higher than that of England and Scotland.

Young people in Wales who are classified as pre-obese and obese 20

15 Aged 13 Girls Aged 15 Girls 10 Aged 13 Boys Aged 15 Boys Proportion (%) Proportion 5

0 Pre-obese Obese

62 Adults Consumption of the recommended daily quantity of fruit and vegetables The data in this section are taken from the Welsh Health Survey 2003/05 and show the proportion of adults who eat the recommended daily quantity of fruit and vegetables. Only 40 per cent of adults living in Wales reported eating the recommended daily quantity of fruit and vegetables. In Torfaen the proportion of adults eating the recommended amount of fruit and vegetables is 36.3 per cent. This is below the Welsh average and Torfaen ranks fourth lowest of the 22 LHB/LA areas in Wales. The LHB/LA area with the highest proportion consuming five portions of fruit and vegetables per day stands at 46 per cent.

Adults who reported eating five or more portions of fruit and vegetables the previous day, Wales LHBS, 2003/05 Source: Welsh Health Survey, 2003/05 50 45 Welsh average = 40 40

.. 35 30 25

15 Age standardised % 10 5

Cardiff Conwy Powys Torfaen Newport Bridgend Flintshire Swansea Gwynedd Wrexham Caerphilly

Ceredigion Denbighshire Merthyr Tydfil Pembrokeshire Blaenau Gwent Monmouthshire Isle of Anglesey Carmarthenshire

Neath Port Talbot

Rhondda Cynon Taff

The Valeof Glamorgan

In Torfaen although some work has already been done to address this issue it still remains a high priority of work as shown in the result of the needs assessment stakeholder exercise carried out in Torfaen in November 2006. A fruit and vegetable box scheme is functioning in the north of the borough mainly covering Garndiffaith and Abersychan areas but the need for more fruit and vegetables box schemes/co- operatives was highlighted in the nutrition needs assessment especially in the more deprived, isolated areas in the borough. This work will be continued as objectives of the Torfaen Action on Food for Health (TAFfH) group.

Initial indications from Torfaen Health and Environment Survey follow-up (2007) illustrate that there has been a positive change in the number of people eating fruit

63 and vegetables throughout the borough compared to the initial survey that was undertaken in 2002 using the same respondents.

53.6 per cent of respondents stated that they ate potatoes on most days of the week, compared with 40.5 per cent in the follow up, whilst 53.6 per cent of respondents to the original survey were eating vegetables and salad on most days of the week, compared to 55.4 per cent in the follow up and 61 per cent of respondents to the original survey stated that they ate fruit on most days of the week compared to 62 per cent in the follow up. Overall, 41.6 per cent of respondents to the original survey state they were eating fruit and vegetable on most days of the week compared to 43.1 per cent in the follow up.

Overweight and obesity The data in this section show the proportion of adults (aged 16+) who were overweight or obese when surveyed for the 2003/5 Welsh Health Survey. Adults overweight or obese are defined as having a body mass index (BMI) of 25 or more (BMI = weight (kg)/height (m2)).

More than half (54%) of adults living in Wales are reported as being overweight or obese. The variation between LHB/LA areas in Wales is quite small, between 50 and 60 per cent. Torfaen has a proportion of 55.9 per cent which is higher than the Welsh average and the borough is ranked eighth highest of the 22 LA/LHB areas in Wales.

Adults who were overweight or obese 2003/05 Source: Welsh Health Survey, 2003/05

Welsh average = 54.1 60

% 50

Age standardisedAge 20

Cardiff Conwy Powys Torfaen

Newport Bridgend Swansea Flintshire Gwynedd Wrexham Caerphilly Ceredigion Denbighshire Merthyr Tydfil Pembrokeshire Blaenau Gwent Monmouthshire Isle of Anglesey Carmarthenshire Neath Port Talbot Rhondda CynonRhondda Taff The Vale of Glamorgan

64 Initial indications from the Torfaen Health and Environment Survey follow-up (2007) illustrate that there has been an increase in the proportion of Torfaen residents classified as overweight or obese throughout the borough compared to the initial survey (2002). 41.1 per cent of respondents were classified as having BMI within the ‘normal’ range during the original survey this figure fell to 29.8 per cent in the update survey, 48.2 per cent of respondents were classified as overweight or obese in the original survey compared to 55.7 per cent in the follow up.

7.7 per cent had a lower BMI between the two surveys compared with 15.2 per cent moving into the overweight or obese category. However due to 18.6 per cent of respondents failing to provide complete data, BMI could not be calculated. It is therefore possible that the true proportion moving in a negative direction is even higher than the figures shown.

Inequalities Factors influencing food choice are complex. People living in poverty often replace fresh food by cheaper processed foods. Low income households have restricted choices because local choice may be limited, especially to healthier foods, and healthier food items may be difficult to access and perceived as more expensive. At all ages, people in poorer households have lower healthy food intakes than people in more affluent households and the gap between them has widened over the last 20 years (Dowler, 2001).

Cultural and social factors mean that social groups also have different priorities and ideas regarding food consumption and what constitutes healthy eating; this can contribute to nutritional and health inequalities. We know that access to affordable healthy food has a greater potential to impact on diet than health education alone.

Residents consuming a healthy diet by fifth of deprivation These data, taken from the Welsh Health Survey 1998, show those aged 18 and over eating a healthy diet by fifth of deprivation. A healthy diet is defined as green vegetables or salad consumed six or seven days per week. The data show that those living in deprived areas eat a less healthy diet.

Residents consuming a healthy diet Source: Welsh Health Survey 1998

140 120

o 100 80

40 Standardised rati 20

0 1 (least 2345 (most deprived) deprived)

Residents classified as obese by fifth of deprivation These data, taken from the Welsh Health Survey 1998, show those aged 18 and over who are classified as obese. Obesity is defined here as body mass index (BMI) greater than 30. The data have been age standardised to account for variation in the age structure across deprivation fifths and show that levels of obesity are higher in the most deprived areas of Wales.

Residents defined as obese (BMI>30) Source: Welsh Health Survey 1998

140

120 o 100

80 60

40 Standardised rati 20

0 1 (least 2345 (most deprived) deprived)

Local qualitative information The NPHS Framework for Action on Nutrition has recommended that local HSCWB partnerships develop a comprehensive approach to improving nutrition through the establishment of nutrition working groups/forums to coordinate the following activities:

• Identification/mapping of current activities and gaps in provision/activities. • Development, review and monitoring of local nutrition strategies/action plans. • Act as exemplars in terms of nutrition policies within workplaces and similar settings. • Working in partnership with local stakeholders and community groups.

In response to this the Torfaen Action on Food for Health (TAFfH) Strategy group was set up. The purpose of TAFfH is to map current activity in Torfaen, identify specific needs and gaps, provide focus for action and avoid duplication of work. It will also provide further opportunities for organisations to plan joint initiatives and projects, promote and disseminate evidence-based practice and in the future work towards pooling multi-organisational resources for food for health.

66 This represents the first step to promote a more strategic approach to public health nutrition in Torfaen, providing the different agencies in the borough with a clear focus in promoting good nutrition for health. The TAFfH group will produce the strategic framework in which the Action Plan for the borough will be developed.

The TAFfH group carried out a needs assessment with stakeholders from the public and professionals using the Kings Fund Community Oriented Primary Care (COPC) Model. The main priorities identified are as follows:

Priority of need Proposed action

Affordable fresh Fruit and Vegetables box scheme operating since 2004, products – E.g. based in Garndiffaith (Garnsychan Partnership) – doubled fruit and the orders in the last year vegetables co- Fruit and Vegetables box scheme in Cwmyniscoy (linked ops with the Garnsychan box scheme) operating since February 2007 Fruit and Vegetables box scheme in Cwmbran (CoStar - linked with the Garnsychan box scheme) launched in April 2007 Fruit and Vegetables Co-op to be launched in Thornhill in May 2007 Fruit and Vegetables Co-ops to be launched in September 2007 based in two primary schools in the Wainfelin area (linked with the Garnsychan box scheme)

Increase promotion of current activities The TAFfH is currently working on the directory which will be in nutrition – e.g. available on line in September 2007 directory www.communityinfo.torfaen.gov.uk/

Improve food Meals on The Older Adults sub group has been established in March wheals – Older 2007 working closely with the Gwent dieticians to look at adults Meals on Wheels, Nursing Home and Lunch clubs

[More] mobile shop providing healthy options – Co-op

Employ More operational Community Dieticians – Community Food Community Co-ordinators employed on long term and linked with the Dieticians Nutrition Forum is greatly needed

Healthy versus WAG proposal’s “Appetite for Life” to review school meals unhealthy and all food consumption throughout schools will be closely menus in school monitored by the Healthy Schools Steering group and the

67 Priority of need Proposed action – alter balance Torfaen County Borough Council – Primary School Meal Service

Community cooking classes More mobile Sure Start cooking classes (Food for Health and Much, shops with Much More & Mamma’s Cooking). Further initiatives healthy options “Serving up Champions” – co-ops In4Fun Youth project in the Thornhill area

Workplace healthy eating initiatives

Breakfast clubs in secondary 15 Breakfast Clubs operating in primary schools at present, schools but none in secondary schools

Poor food in some local shops

Increase awareness of healthy foods – range & taster After school Cooking Clubs are currently running in two Healthy cooking Secondary Schools Cookery classes linked with the fruit and classes in vegetable co-operatives are planned to take place in schools September 2007 based in two primary schools in Wainfelin. The PSE strategy manager is carrying out the mapping of the food/nutrition activities currently taking place in the primary schools in Torfaen. The TAFfH Group has been set up and will continue to Improved review membership to strive towards the diversity of local partnership stakeholders. working to improve priority As a response to the Nutrition Needs Assessment the for resource Nutrition Forum – TAFFH - has already responded allocation establishing new links and creating new initiatives. Better/increased knowledge of healthy foods in Torfaen Potential increased roll out of Food for Health and Much population Much More initiative targeting families.

The initiatives listed above have been identified through TAFFH to meet the needs identified as shown. This work will need to be updated in the light of the other

68 comparative evidence in this section and the action plan formalised. There is the need to identify the appropriate mechanisms by which to meet the gaps in the above table as some are unlikely to be within the operational capability of the group. Furthermore, with the uncertainty over continuation of the Torfaen Healthy Living Initiative’s nutritional components it must be stressed that a significant risk to the effective working of the actions identified if operational posts are reduced.

Other issues for consideration were identified as lack of kitchens/cookery places, especially during day time and, a lack of locally collected data on obesity (e.g. BMI or waste circumference) particularly for young people and in the work place.

Summary

A varied and balanced diet providing sufficient energy and an adequate supply of essential nutrients can enhance health and wellbeing. Obesity and overweight create a considerable health and economic burden.

Regrettably, there is a scarcity of ‘nutritional intake’ data in Wales and even less data on nutrition and healthy weight for young people locally.

In both the 13 and 15 year old age groups Wales has a higher proportion of pre- obese children than England and Scotland.

Torfaen has a proportion of 55.9 per cent of adults who are overweight or obese, and this is higher than the Welsh average of 54.1 per cent.

70 Torfaen Health, Social Care and Wellbeing Needs Assessment 2007

Supporting the Health Social Care and Wellbeing Partnership for Torfaen

Chapter 4.2 Physical Activity

Table of Contents

Background 73 Children and Young People 73 Adults 76 Inequalities 78 Effective intervention 78

72 Background Regular physical activity can make a huge contribution to improving longevity and quality of life for adults i.e. both physical and psychological (WHO, 2004). Physical activity not only contributes to well being but is also essential for good health (DoH, 2004).

People who have a physically active lifestyle have approximately 50 per cent less risk of developing coronary heart disease (CHD), stroke and type-2 diabetes compared to those who have a sedentary lifestyle, and can reduce their risk of premature death by about 20-30per cent (DoH, 2004). The evidence shows that the health impact of inactivity on coronary heart disease is at least comparable to that of smoking and almost as great as high cholesterol levels (DoH, 2004).

Regular physical activity is also associated with reduced risk of obesity, osteoporosis and colon cancer and with improved mental health and increased functional capacity in older adults (DoH, 2004).

The cost of physical inactivity in England, including direct costs of treatment for the major lifestyle related diseases, and the indirect costs caused through sickness absence, has been estimated at approximately £8.2 billion every year (DoH, 2004).

The National target for increasing population physical activity is one per cent of the population per year (WAG, 2006).

Children and Young People There are very little reliable and comparable lifestyle data available for children and young people in Wales at the LHB level. However, the Health Behaviour in School- aged Children (HBSC) study gives a useful indication of how children at the all Wales level compare to 34 other countries.

Current guidelines state that children should engage in 60 minutes or more physical activity on 5 or more days a week; where physical activity is described as any activity that increases heart rate and makes one get out of breath some of the time (WHO, 2004).

Despite an increase in obesity amongst children and young people, recent trends in physical activity offer some hope. Whilst there appear to have been no major changes between 1997 and 2002 in the recommended amount of physical activity, there was an increase for young people who did at least 30 minutes activity each day, improving from 64 per cent to 73 per cent for boys and from 51 per cent to 65 per cent in girls. In Wales between 1996 and 2000 there was an increase in young people participating in activity on four or more occasions a week, and in the percentage of those participating in activity for four hours or more a week (WAG, 2005b). It should be noted, however, that about 30 per cent of boys and 40 per cent of girls are still not meeting the recommended activity guidelines and 20 per cent of boys and girls do less than 30 minutes physical activity a day (BHF, 2004).

73 Children aged 11 years living in Wales in 2001/2 were less likely to be achieving the recommended guidelines for physical activity than children living in England, Scotland and Ireland. However, the development of initiatives specifically aimed at targeting sport and physical activity in young people have attempted to redress this situation. In particular, Dragon Sport has developed extra curricular sport in Primary schools and has enabled school- and community-club links that has helped to promote participation in physical activity, through sport, in the wider community. Other initiatives funded through Wanless investments have developed a Fit Kids programme throughout the borough in order to target children with specific needs.

Proportion of young people aged 11 years meeting guidelines for physical activity: 2001/2 Data source: HBSC survey

70 Girls Boys 60

Proportion (%) Proportion 20

10 0 Lowest: France Wales England Scotland Highest: Ireland

Children that were aged 13 and living in Wales in 2001/2 were also less likely to be achieving the guidelines for physical activity than children living in England and Ireland. However, the proportion of 13 year old girls in Wales achieving the guidelines for physical activity was marginally above that reported for Scotland. This particular age group exhibit a major drop in physical activity (PA) levels after initial participation in Primary schools. There are a number of national initiatives aimed at improving PA in this age group supported through WAG and the Sports Council for Wales. The PE in Secondary School (PESS) and the 5 x 60 projects are two examples aiming to improve standards of teaching in the PE discipline and also offering non traditional sports that may be more appealing to these individuals.

Proportion of young people aged 13 years meeting guidelines for physical activity: 2001/2 Data source: HBSC survey 70 Girls Boys 60

50 40

Proportion (%) 20

0 Lowest: Scotland Wales England Highest: Belgium Ireland (Flemish)

By the age of 15, only 17.6 per cent (less than one in five) of girls in Wales were meeting the guidelines for physical activity in 2001/2, compared to 39.2 per cent of boys. This figure is also below those reported for Scotland and England.

Proportion of young people aged 15 years meeting guidelines for physical activity: 2001/2 Data source: HBSC survey 70 Girls Boys 60

Proportion (%) Proportion 20

0 Lowest: Wales Scotland England Highest: USA Portugal

Overall the survey shows that the proportion of children meeting the guidelines for physical activity in Wales decreases with age, most noticeably in girls where it more than halves, from 37.4 to 17.6 per cent, between the ages of 11 and 15.

75 This information allows inference about targeting interventions in all young people of all ages but with particular attention on girls aged between 11 and 15 years. However there are no data available at the LHB/LA area or sub-LHB/LA area allowing comparisons between Torfaen and the Welsh average or between Torfaen and other localities within Wales. If planning of physical activity interventions are to be based on evidence of need, work to identify physical activity participation levels is needed locally, preferably at small area level.

This document also provides a wealth of evidence-based programmes and projects which it is recommended are built in to existing initiatives as a priority and are used to inform funding proposals and re-orientation of resources lead by the CYPP in conjunction with the Physical Activity Collaboration in Torfaen (PACT).

Adults Guidelines recommend adults undertake 30 minutes or more of at least moderate intensity physical activity on five or more days a week.

The Welsh Health Survey in 1998 reported that only 28 per cent achieved the recommended minimum of 30 minutes moderate activity on five or more days of the week (NAfW, 1999). Results from the latest survey show 29 per cent achieving the recommended minimum (men 36 per cent but women only 23 per cent) (NAfW, 2006a). Prevalence of inactivity increases with age in both men and women. The strong correlation between social class and physical activity levels (DoH, 2004), is supported by results from the Welsh Health Survey (NAfW, 1999). Low educational attainment is also a strong predictor of high inactivity levels (DoH, 2004).

In Torfaen, the age standardised proportion of adults who reported meeting the target for healthy physical activity, based on Welsh Health Survey (2003/05) data is just 27.1 per cent, lower than the Welsh average and seventh lowest for participation in healthy physical activity of the 22 LHB/LA areas.

76 Adults who reported meeting physical activity guidelines in the past week: 2003/05 Source: Welsh Health Survey, 2003/05 40

35 Welsh average = 29 30

15 Age standardised% 10

0 Cardiff Powys Conwy Torfaen Newport Bridgend Swansea Flintshire Gwynedd Wrexham Caerphilly Ceredigion Denbighshire Merthyr Tydfil Pembrokeshire Blaenau Gwent Monmouthshire Isle of Anglesey Carmarthenshire Neath Port Talbot Rhondda Cynon Taff The Vale of Glamorgan

A number of schemes have been developed to encourage Physical Activity in adults and older people which include the Walking the Way to Health, Fit Swim and Exercise for Life projects. The Exercise for Life referral scheme, in accordance with NICE guidance is now part of a national research programme examining effectiveness. These are targeting specific individuals who may be in particular need of physical activity for health related issues. This work is also being supplemented through the Community Chest scheme, helping to fund exercise classes in the community including sheltered housing and community groups.

The analysis from the Adult Participation Survey (SCW, 2004/05) that was carried out for Torfaen illustrated that 53 per cent of adults (60% of men and 47% of women) had participated in ‘any activity’, slightly below the Welsh average. Participation levels in outdoor games and outdoor pursuits are fairly similar to national averages and compare favourably with other valleys authorities however proportions amongst females are less than a fifth those of males.

Importantly, less than a quarter 22 per cent of adults undertake a sufficient amount of physical activity exercise the national average is 34 per cent; these data are similar to the Welsh health Survey of 27.1 per cent. The Adult Participation Survey also shows that 56 per cent of Torfaen residents are inactive.

Initial indications from the Torfaen Health and Environment Survey follow-up (2007) illustrate that there has been a positive change in the number of people taking

77 regular physical activity throughout the borough compared to the baseline survey (2002).

There was a drop in those reporting taking NO vigorous intensity physical activity from 47.2 per cent to 45 per cent. In line with current recommendations there is a decrease in those reporting taking NO moderate intensity PA from 23.9 to 22.7 percent. There was an increase in the proportion of people reporting taking NO light intensity PA. Despite no change in those reporting taking NO PA between baseline and follow-up, five per cent of the respondents increased their exercise frequency from 2002 to 2007.

Inequalities In 2004, the Health Information Analysis Team of the National Public Health Service produced a report entitled “Deprivation and Health” (NPHS, 2004) highlighting the relationship between small area deprivation and health in Wales. The report overcomes issues associated with small numbers by looking at deprivation at electoral ward level and combining wards across Wales by fifth of deprivation having been ranked in order of Townsend score.

Data from the 1998 Welsh Health Survey are included in this report, where physical inactivity is defined as taking no weekly exercise. Physical inactivity was reported to be twice as common for residents of the most deprived than the least deprived fifth of Wards in Torfaen.

The Physical Activity Collaboration in Torfaen is a newly formed multi-agency group aiming to establish a coordinated strategic approach to Physical Activity and to help identify duplication of work and possible gaps and in the future move towards pooling budgets and commissioning evidence-based solutions. A mapping exercise has been carried out of physical activity initiatives in Torfaen and work has commenced in writing a strategy for action.

Effective intervention Changes in work patterns, increasing automation, the litigation culture, proliferation of media-based entertainment, town planning, diminishing green space, changing school curriculum and increasing reliance on the car have combined to provide what has been called the ‘obesogenic environment’ (HoC, 2004).

There is little evidence to support the longer-term effectiveness of the traditional model of facility-based exercise referral schemes. That is not to suggest that there is no evidence to support interventions that concentrate on ‘developing personal skills’ i.e. working directly with individuals or groups to help increase physical activity behaviour, however, this type of intervention must focus on changing the processes of behaviour change in relation to physical activity. Initiatives such as these however, whilst potentially helpful to the individuals engaged are unlikely to have significant population effects.

78 Physical activity behaviour is influenced by a range of external factors or determinants hence the coordinated approach should, as mentioned have a multi- agency and multi-level influence.

Those activities that are easy to incorporate into people’s daily lives are much more likely to offer long-term sustainability (Hillsdon et al, 2004). Regular brisk walking, for example, can confer huge health benefits for an otherwise sedentary individual, and there are a number of high profile programmes designed to promote this (Bird & Reynolds, 2002). However in many areas it is perceived as unsafe to walk, for a whole range of reasons, and, in many instances, street design and traffic flow priorities deliberately deter walking.

Consequently the focus for public health intervention in this field is now moving toward a social ecological model built on the five principles of the Ottawa Charter, but with rather less emphasis on ‘developing personal skills’ and rather more on ‘creating supportive environments’ (Sallis & Owen, 1997). Improved social determinants of physical activity and an environment that enables building physical activity in to people’s lives as well as opportunistic PA will have biggest impact.

It is the challenge of the PACT group in Torfaen is to have the right delegation from the diversity of policy areas whilst identifying the appropriate mechanisms by which to influence the social ecological determinants of physical activity behaviour change whilst influencing existing schemes to become more evidence-based in their delivery.

Summary

Physical activity is widely acknowledged as the BEST buy in public health today.

The evidence shows that the health impact of inactivity on coronary heart disease is comparable to that of smoking and almost as great as high cholesterol levels.

Among children, about 30 per cent of boys and 40 per cent of girls are still not meeting the recommended activity guidelines and 20 per cent of boys and girls do less than 30 minutes physical activity a day.

Among adults, results from the latest Welsh Health Survey show 29 per cent achieving the recommended minimum (men 36 per cent but women only 23 per cent).

The challenge of the Physical Activity Collaboration in Torfaen (PACT) group is to have the right delegation from the diversity of policy areas whilst identifying the appropriate mechanisms by which to influence the social ecological determinants of physical activity behaviour change whilst influencing existing schemes to become more evidence-based in their delivery.

Torfaen Health, Social Care and Wellbeing Needs Assessment 2007

Supporting the Health Social Care and Wellbeing Partnership for Torfaen

Chapter 4.3 Sexual Health

Table of Contents

Background 83 Teenage conceptions 83 Sexually Transmitted Infections (STIs) 87 Sexual Health Services 90

82 Background

The Strategic Framework for Promoting Sexual Health in Wales (NAfW, 2000) outlined the following objectives:-

• Ensure that all young people in Wales receive effective education about sex and relationships as part of their personal and social development • Ensure that all sexually active people in Wales have access to good quality sexual health advice and services • Reduce rates of teenage pregnancy in Wales • Reduce incidence and prevalence of sexually transmitted infections in Wales • Promote a more supportive environment which encourages openness, knowledge and understanding about sexual issues and fosters good sexual health • Strengthen monitoring, surveillance and research to support future planning of sexual health services and interventions.

The resulting action plan recommended that all health Authorities and Local Health Groups have written strategies and service specifications for sexual health services - ensuring that appropriate arrangements are made for the following issues:-

• Accessibility of services • Confidentiality of services • Publicising services • User friendly services for young men • Out of hours access to emergency contraception • Policy on availability of free condoms • Integration of sexual health services where appropriate • Referral protocols with key partners • Targeted interventions for vulnerable/at risk groups • Psychosexual services • Training and accreditation programmes for staff involved in delivering sexual health services, particularly key workers for young people.

Also, to encourage the development of services geared specifically to the needs of young people and to increase awareness and availability of emergency contraception.

Since the launch of the Framework and action plan sexual health has continued to be a matter of concern in Torfaen, as in Wales as a whole. Teenage conceptions in Torfaen are the highest in Europe. There has also been a considerable increase in new diagnosis of sexually transmitted infections throughout Wales, an important cause of morbidity and mortality.

Teenage conceptions Pregnancy and parenthood are positive choices for some young people with some teenage pregnancies being planned and others, although unplanned, resulting in wanted babies (NPHS 2004). Unintended pregnancy and parenthood however are associated with a range of negative consequences 83 which have been well documented. Generally, teenage mothers and their children suffer poor social, economic and health outcomes. Lack of education and training reduces the long term potential among teenage mothers to improve their socio-economic conditions (Botting et al, 1998). Higher rates tend to be found in areas of greatest deprivation, and the risk of becoming a teenage mother for girls whose families are in social class V is almost ten times higher compared with girls whose families are in social class I (Botting et al, 1998). In addition, children of teenage parents have a much higher chance of becoming teenage parents themselves.

Official data on conceptions are collated by the Office for National Statistics, and is defined as maternities (i.e. pregnancies that result in one or more live or stillbirths) and legal abortions under the 1967 Abortion Act (NPHS, 2004a). They do not include miscarriages or illegal abortions (ONS, 2003).

Under 16s In the mid to late nineties, the teenage conception rate for females aged under 16 in Wales was above that for England. The chart below shows that the rate in Wales has reduced in recent years to 7.8 per 1,000 females aged 13-15, which is marginally above the average for English residents of 8.0 per 1,000 females aged 13-15.

Teenage conception rates, females aged <16, Wales and England, 1996 - 2004 Data s our ce : Office for National Statistics 12 Wales England 10

Rate per 1,000Rate females 2

0 1996-1998 1999-2001 2002-2004

The rate in Torfaen however, as illustrated in the chart below, has continued to rise from 6.8 per1000 (1999-2001) to 10.1 per 1000 (2002-2004). Applying the rate of 10.1 per 1000 females aged 13 to 15 years to the ONS mid year population estimates for Torfaen, this means that there are approximately 19 babies per year being born to mothers aged under 16 years, which is just four more per year than if the Welsh rate were applied to the Torfaen population.

84 Crude rate of conceptions in women aged less than 16 years old, 1999 - 2001 and 2002 - 2004 Source: ONS Torfaen Wales England

10.1 9.0 8.2 8.0 7.8 6.8 Rate per 1000 women aged 13-15

1999-2001 2002-2004

Under 20s The chart below shows that the teenage conceptions rate in Wales and England for under 20s has remained stable during the period shown. The rate for Wales is consistently slightly higher than for England.

Teenage conception rates, females aged <20, Wales and England, 2000-2004 Data source: Office for National Statistics 80 Wales England 70 60 50 40 30 20

Rate per 1,000 females 10 0 2000 2001 2002 2003 2004

As illustrated in the charts below however, the conception rate of under 20s in Torfaen is 89.6 per 1000, considerably higher than the all Wales rate of 64.3 per 1000. Torfaen has the highest conception rate in this age group of all twenty two LHB/LA areas in Wales. Applying the rate of 89.6 per 1000 females aged 16 to 19 years to the ONS mid year population estimates for Torfaen, this means that there are approximately 218 babies per year being born to mothers aged under 20 years, which is 62 more per year than if the Welsh rate were applied to the Torfaen population.

Conception rates by age and area of usual residence: 2004 Source: Office for National Statistics

England Wales Torfaen

100 90 80 70 60 50 40 30 20 rate)and 15-19 (under 20rate) 10 0 Rates 18 15-17 (under per 1,000aged women Under 18 Under 20 Age of woman at conception

Conception rates in women aged 15-19 ('under 20') by area of usual residence: 2004 Source: Office for National Statistics

100.0

90.0

80.0

70.0

60.0

50.0

40.0

30.0

20.0 Rate per 1,000 women aged 15-19 10.0

0.0 Cardiff Wales Powys Conwy Torfaen Newport England Bridgend Flintshire Swansea Anglesey Gwynedd Wrexham Caerphilly Ceredigion MerthyrTydfil Denbighshire BlaenauGwent Pembrokeshire Monmouthshire NeathPortTalbot Carmarthenshire ValeofGlamorgan RhonddaCynonTaff

Termination of pregnancy In 2005 the rate of termination of pregnancy in Torfaen was 20 per 1000 women aged 15-44 years. Again, this was the highest rate of all LHB/LA areas in Wales.

Figure 4 Legal abortions by LHB, 2005

4 Rate per 1000 women Rate residentper 1000 women areas 15-44

s e e ff e ff n rt n ey y ea r r re ir a illy a hire bot ent h T h g es s nedd al shi w ardi shi s fae y T ow ans eshi h n onwy edigion P C gh C ewpo ngl w w lint ok i no N Tor er A G thyr Tydfil S Bridgend F out y lamor Wrexham C r nau G Caerp e e enb G M la D da C of Pembr B Monm d Carmarthen Neath Port ale hon V R

Sexually Transmitted Infections (STIs) Barriers exist to effective surveillance of STI in Wales. KC60 data are not timely and neither laboratory nor KC60 data can provide data on the incidence of STI in Local Health Board resident populations. Data provided is therefore at an all Wales level though is likely to reflect the situation as regards Torfaen. As part of the sexual health modernisation programme being led by the Welsh Assembly Government an initiative is underway to improve surveillance of STIs in Wales, through the collection of more timely, person-based, residence-based incidence data.

Data from genitourinary medicine (GUM) clinics in Wales indicate that rates of STIs are continuing to increase. Between 2003 and 2004 there was an increase in the number of new cases of HIV/AIDS, gonorrhoea, anogenital chlamydia, herpes and warts diagnosed in GUM clinics in Wales. This trend is confirmed by data on laboratory diagnoses of STI. The consequences of some of these infections may be devastating; immune dysfunction, cancer, systemic illness, infertility, ectopic pregnancy, pregnancy loss, congenital malformation and social stigmatisation. The causal link between untreated genital chlamydia infection and ectopic pregnancy and infertility has significant implications for increasing demand on gynaecology and infertility services. STIs are communicable infections – and if infected individuals are not treated in a timely fashion the epidemic will not be halted (NPHS 2004) (National Public Health Service Communicable Disease Surveillance Centre. HIV and STI trends in Wales: 2005 Annual Report. Cardiff: National Public Health Service. 2006).

HIV HIV continues to be one of the most important communicable diseases in the UK. It is an infection associated with serious morbidity, high costs of treatment and care, significant mortality and high number of potential years of life lost.

104 cases of newly diagnosed HIV infection were reported to HPA by clinicians in Wales in 2004. This continues an increasing trend in reporting. By contrast, the number of new reports of AIDS has decreased steadily since the mid-1990s due to advances in treatment. In recent years, a notable feature in the epidemiology has been the shift in newly diagnosed infections from men who reported sex with other men (MSM) to patients reporting sex between men and women as their most likely source of infection. Of the 101 new positives diagnosed by laboratories in Wales in 2004, 36 were women. This compares to 44 in 2003, 31 in 2002, 17 in 2001 and 13 in 2000.

The best indication of the number of people living with HIV/AIDS in Wales, as opposed to the number newly diagnosed, is provided by the Health Protection Agency SOPHID (Survey of prevalent HIV infection diagnosed) scheme which counts the number of people receiving HIV-related care. SOPHID data for Wales show a steady increase in the number of people living with HIV, from 332 in 2000 to 677 in 2004. This increase reflects an increase in new diagnoses but also improved survival of cases due to better treatment. In 2004, SOPHID data for Wales indicated a prevalence of HIV in Torfaen at a rate of between 10 and 19 per 100,000 population.

Of HIV cases seen for treatment in Wales in 2004, the majority of cases (46%) were aged 25 to 39 years.

Syphilis After increasing in recent years, new cases of infectious syphilis seen in GUM decreased slightly, from 50 in 2003 to 39 in 2004. Cases are still predominantly in men who have sex with men, although around a quarter of all cases are reported in heterosexual men and women. The condition is especially significant in women in pregnancy where infection can cause miscarriage, still birth or foetal abnormality.

Genital Chlamydia Genital chlamydia infection is an important reproductive health problem, because 10-30% of untreated infected women develop pelvic inflammatory disease (PID). A significant proportion of cases, particularly amongst women, are asymptomatic and so, are liable to remain undetected, putting women at risk of developing PID.

In 2004, there was a 13% increase of uncomplicated chlamydia infection from 3126 episodes in 2003, to 3541 episodes in 2004. This is likely to be a combination of true increase in the incidence of and also increased awareness and improved diagnostic techniques.

In 2004 there were a total of 4293 reports of anogenital chlamydia infection received from laboratories in Wales. This is equivalent to a rate of 145.4 per 100 000 population. Rates were highest in 15-24 year old males and females. The charts below show the infection rate for Chlamydia in females aged 13-15 88 and 15-19 years respectively between 1996 and 2004. It is clear that in both age groups, but especially in the 16-19 age group, there has been a dramatic increase in the rate over the nine year period shown in the charts. In addition to the consequences of Chlamydia outlined, the increase of Chlamydia infection is also of concern as it suggests increasing numbers of young people are having unsafe sex and exposing themselves to the risk of sexually transmitted infections including HIV infection.

Genital chlamydia diagnosed in females aged 13-15 years, rate per 100,000 population, Wales, 1996-2004 Source: KC60 90

20 Rate per 100,000 population 100,000 per Rate 10

0 1996 1997 1998 1999 2000 2001 2002 2003 2004

Genital chlamydia diagnosed in females aged 16-19 years, rate per 100,000 population, Wales, 1996-2004 Source: KC60 1000 900 800 700 600 500 400 300 200 Rate per 100,000 population 100,000 per Rate 100 0 1996 1997 1998 1999 2000 2001 2002 2003 2004

Gonorrhoea After genital Chlamydia, gonorrhoea is the second most common bacterial sexually transmitted infection in the UK. As in previous years, reported rates are highest in 15-24 year old male and females. In 2004, 24 new cases of gonorrhoea were seen in GUM clinics in Wales per 100,000 population, compared to 42 per 100,000 in England. The rate for England outside London for 2004 is 31 per 100,000.

Other infections Anogenital warts are caused by the human papillomavirus (HPV). Warts are the most common viral STI diagnosed in the UK, with highest rates of new cases in 20-24 year old men and 16-19 year old women. Certain HPV types have been associated with cervical cancer. .

The number of new episodes of anogenital warts continues to increase steadily. In 2004, there were 3501 episodes of anogenital warts - first attack reported by GUM clinics in Wales compared to 3379 episodes reported in 2003. Episodes were most frequently reported in 20-24 year old males and females.

Genital herpes simplex virus (HSV) infection is the most common ulcerative sexually transmitted disease in the UK. In 2004, there were 617 episodes of anogenital herpes simplex - first attack reported by GUM clinics in Wales compared to 610 episodes reported in 2003. Episodes were most frequently reported in 25-34 year old males and females.

Sexual Health Services A review of NHS sexual health services in Wales (NPHS 2004) concluded that services are not equipped to deal with the sexual health needs of the population. The review identified problems regarding service provision as being a consequence of a number of factors. Though the review discusses Wales as a whole, the issues are pertinent to Torfaen Issues include long waiting times for those with symptoms of a STI or who suspect they have been exposed to an STI. Waiting times in Torfaen are currently 2-3 weeks for females and 2 weeks for males. Waiting times for HIV testing and no same day testing available in Wales is also a problem. Access to abortion services and access to psychosexual services are of concern. The average waiting time for a termination in Torfaen is 2 weeks, though this does depend on how many weeks the pregnancy has progressed.

Chlamydia testing and partner notification has been improved by the appointment of a community based nurse with this remit. Though funding was secured, initiatives to extend testing by other professionals were unable to be implemented due to lack of laboratory facilities.

External Factors: • Lack of central direction to suggest that this is a key priority for Wales • Lack of strategic leadership to develop sexual health services • Failure of NHS organisations, both providers and commissioners to prioritise and deal with this major health problem

90 • Inadequate information; on STIs (absence of a person based surveillance system); on contraceptive services and on psychosexual need and service delivery • Lack of national standards and absence of performance management • No accountability for services provided to the public, compounded by the fact that the service users do not have a voice.

Internal factors: • Failure of services to modernise practice • Failure to develop meaningful partnerships with other NHS providers of sexual health services and non-statutory organisations • Reluctance of the services to rebalance sexual health care provision • Lack of resources, IT, Gold standard tests, administrative support and clinical staff • Poor management.

The review also concluded that in order to deal with these issues and provide a sexual health service responsive to the needs of the population, the following is necessary: • Leadership • Realignment of service provision with modernisation and improved performance • Refocusing on the priorities and the contribution of the services at all levels with roles and accountabilities clearly defined • Investment in premises, people (particularly training and development), IT, surveillance systems and gold standard tests.

Published guidance for good practice and an evidence base for models of service delivery are outlined in the review of sexual Health services in Wales undertaken by the NPHS (2004).

A number of initiatives have been implemented in Torfaen to address the recommendations in the Welsh action plan, but many are hindered by short term or non recurring funding. This is particularly true as regards the prevention agenda.

Accessibility of services has been addressed to a large extent, with clinic times extended to both day and evening sessions. Young people’s clinics are also provided outside school hours, including a three hour service on a Saturday afternoon.

Access to emergency contraception and the provision of condoms has been improved due to the implementation of the Torfaen C-CARD and EHC schemes. These were evaluated in 2006, demonstrating positive outcomes, and a key recommendation was that the funding of both schemes be extended.

Evidence suggests that sex and relationships education is more effective before the onset of sexual activity. In Torfaen, the Sexual Health Educator, funded as part of the healthy Living Initiative and but is specifically for older young people, plays a key part in the delivery of Torfaen’s Sexual Health Action Plan. The need for a similar post to work with those professionals involved with primary school aged children has been highlighted. Given the 91 high rates of teenage conceptions in Torfaen it is of considerable concern that the continuation of currently available funding for sexual health educator work is uncertain, and transition arrangements are an urgent need.

Summary

Teenage conceptions and sexually transmitted infections continue to be a matter of concern in Torfaen.

Although most recent data on teenage conceptions are for the year 2004–05, these demonstrate that contrary to the trend in England and in Wales in general, the rate of pregnancies and terminations in the under 20 age group in Torfaen have increased over the last few years, and are now the highest among all LHB/LA areas in Wales. There are approximately 218 babies per year being born to mothers aged under 20 years, which is 62 more per year than if the Welsh rate were applied to the Torfaen population.

The rate in Torfaen for conceptions in those aged under 16 years has continued to rise from 6.8 per 1000 (1999-2001) to 10.1 per 1000 (2002- 2004). Applying the rate of 10.1 per 1000 females aged 13 to 15 years to the ONS mid year population estimates for Torfaen, this means that there are approximately 19 babies per year being born to mothers aged under 16 years, which is just four more per year than if the Welsh rate were applied to the Torfaen population.

Between 2003 and 2004 there was an increase in the number of new cases of HIV/AIDS, gonorrhoea, anogenital chlamydia, herpes and warts diagnosed in GUM clinics in Wales. Surveillance systems need to be developed to obtain specific data for Torfaen; however, given the general increase in incidence across Wales, lack of locality specific data should not delay urgent action in this area as health improvement actions to reduce STIs are also likely to reduce teenage conceptions.

93 Torfaen Health, Social Care and Wellbeing Needs Assessment 2007

Supporting the Health Social Care and Wellbeing Partnership for Torfaen

Chapter 4.4 Smoking

Table of Contents

Background 95 Children and Young People 95 Adults 98 Inequalities 101

94 Background

Smoking is the single biggest avoidable cause of disease and early death in Wales. It kills around 114,000 people in the UK each year (Peto, et al, 2003). Smoking is an important risk factor for coronary heart disease, stroke, respiratory diseases, many cancers, and is often implicated in fire related deaths. Exposure to environmental tobacco smoke is a major risk factor for conditions such as sudden infant death syndrome and respiratory childhood diseases (NPHS, 2004b).

In Wales, 23 per cent of adults (aged 16+) reported smoking compared to 25 per cent in Great Britain in the 2004 General Household Survey (ONS, 2005). The patterns of behaviour we establish early in life are often continued into adulthood (WHO, 2004). Behaviour that compromises health in childhood and adolescence (i.e. poor lifestyle choices) is predictive of morbidity and increased health service use (WHO, 2004).

Children and Young People There are few routinely available reliable and comparable lifestyle data available for children and young people in Wales at the LHB level. However, the Health Behaviour in School-aged Children (HBSC) study gives a useful indication of how children in Wales compare to 34 other countries.

In Torfaen research carried out by Communities That Care (CTC) (2005) illustrated that Torfaen secondary school pupils when surveyed about their smoking habits responded as follows: • 38% had smoked a cigarette • 35% had smoked a cigarette by the age of 13 or younger (19% by the age of 11) • 7% described themselves as regular smokers • 5% smoked now and then • 9% stated that they used to smoke but had now given up • 16% had just tried smoking once or twice.

Breakdown of the Communities That Care (CTC) report illustrates how there is geographical variation in the onset of smoking and smoking prevalence amongst young people. These data suggest that the Communities First electoral divisions of Thornhill and Trevethin have the largest percentage of young people starting to smoke and becoming regular smokers.

95 Smoking daily (HBSC) The proportion of children smoking daily rises substantially with age (WHO, 2004). In Wales, the same proportion of boys and girls aged 11 smoke daily i.e. less than 1 per cent.

Proportion of young people aged 11 years who smoke every day: 2001/2 Data s our ce : HBSC survey Girls Boys 2.5

2.0 )

1.5

1.0 Proportion (%

0.5

0.0 Lowest: Scotland Wales England Highest: Sweden Greenland

However by the age of 13, girls in Wales are almost twice as likely as boys to be smoking daily and have the second highest proportion, when compared to the other 33 countries that took part in the survey.

The CTC report illustrated a difference between those responses given by Torfaen sample and those given by the national sample. Pupils from Torfaen were more likely to report that they smoked cigarettes regularly (7% compared to 6% nationally).

Proportion of young people aged 13 years who smoke every day: 2001/2 Dat a s our ce : HBSC survey Girls Boys 30

25 ) 20 15

10 Proportion (% 5

0 Lowest: TFYR Scotland England Wales Highest: Macedonia Greenland 96

More than one in five girls in Wales aged 15 reported to be smoking daily in 2001/2, compared to around one in eight boys.

Proportion of young people aged 15 years who smoke every day, 2001/2 Data source: HBSC survey Girls Boys 60

) 40

Proportion (% 20

0 Lowest: Malta Scotland Wales England Highest: Greenland

Onset of smoking The frequency of smoking for 15-year-olds appears to be associated to the age at which they first smoked (WHO, 2004). The older an individual is when they first smoke, the less likely they are to become addicted (WHO, 2004). The average age at which children aged 15 in 2001/2 started smoking was 12.5 for girls and 12.6 for boys. These figures are comparable to those for Scotland and England.

CTC data suggest that 35 per cent of secondary school pupils in Torfaen stated that they had smoked a cigarette by the age of 13 or younger with 19 per cent by the age of 11 years. When broken down into geographical areas there was a significant difference in the percentage of pupils in the Communities First areas 43 per cent in Trevethin and 47 per cent in Thornhill compared to 35 per cent in Torfaen as a whole.

Adolescent Smoking Cessation An identified need set out in the Torfaen Wanless Local Action Plan was to address health and wellbeing issues including establishing a provision to provide adolescents with support to help them quit smoking. Much work has been done to meet this need locally including:

• The development of a course of workshops specifically designed in consultation with young people

97 • The development of a training course to provide professionals and volunteers working with young people with the most up to date knowledge and appropriate evidence-based activities and resources to support young people to quit.

To date many local professionals and volunteers have been trained to facilitate smoking cessation workshops including teachers youth access workers, social workers and community youth workers.

Despite recognition of the need for this work and a very positive response to the quality of materials and training, there have been a number of challenges to effective implementation. Most of the barriers are around perceived lack of capacity particularly in the school setting, the ad hoc nature of youth clubs do not suit a sustained course, lack of appropriate slots in school timetable for smoking cessation workshops and a lack of buy-in at school senior management. Solutions should be targeted at the implementation end of adolescent smoking cessation initiatives and address the above issues.

There is a wealth of evidence to illustrate the need for a provision to address smoking in a school setting targeting teenage girls particularly. The smoking cessation project as so far had a good result in one secondary school in Torfaen however as already identified the majority of secondary schools have not implemented projects despite smoking being a CYPP priority.

Smoking Prevention The greatest intervention in combating smoking related diseases is preventing young people from taking up smoking.

There are a number of initiatives coordinated by the Welsh Assembly Government to address this issue including Smoke Bugs and Smoke Free Class that are being implemented in schools throughout Torfaen. As a result of local Wanless funding and local NPHS provision smoking prevention training has been accessed by a number of schools in order for teachers to address smoking across the curriculum. However there is a need for more work to be undertaken to address smoking prevention targeted in the areas outlined above and specifically in young people aged below 13 years.

Adults Analysis of the Welsh Health Survey (2003/5) data show that 27.1 per cent, more than a quarter, of adults (aged 16+) reported being a current smoker with proportions varying considerably across LHB/LA areas. The prevalence of smoking in Torfaen is reported to be 28.8 per cent, higher than the Welsh average and fourth highest of the 22 LHB/LA areas in Wales.

98 Adults who reported being a current smoker: 2003/05 Source: Welsh Health Survey, 2003/05 35 Welsh average = 27.1 30

Age standardisedAge % 10

0 Cardiff Powys Conwy Torfaen Newport Bridgend Flintshire Swansea Gwynedd Wrexham Caerphilly Ceredigion Denbighshire Merthyr Tydfil Pembrokeshire Blaenau Gwent Monmouthshire Isle of Anglesey Carmarthenshire Neath Port Talbot Rhondda Cynon TaffRhondda The Vale of Glamorgan

The initial indications from the Torfaen Health and Environment follow-up Survey illustrate that there has been a positive change in the number of people smoking throughout the borough compared to the baseline survey (2002). 27.6 per cent of Torfaen residents reported that they were ex smokers in the original survey, compared with 31.3 per cent in the update survey indicating more people giving up. Reinforcing that, 42.2 per cent of respondents reported that they were smokers, compared with 33.2 per cent in the update survey, this represents a reduction of almost 10 per cent between 2002 and 2007, however, the proportion of smokers in Torfaen is still above the Welsh and UK average. Combining data from the Welsh Health Survey (2003/2005) with the Torfaen Health and Environment Survey (2007) the proportion of smokers in Torfaen is between 29 and 33 per cent.

The All Wales Smoking Cessation Service (AWSCS) is a dedicated resource to help smokers in Torfaen quit smoking with one WTE specialist. Figures from the AWSCS illustrate a number of adults throughout Torfaen access the service in a variety of community and primary care settings for support to quit smoking, with 75 per cent of those followed up successfully quitting at 4 weeks.

However the numbers accessing the service are relatively low compared to access in other boroughs in the valleys area. More effort from all healthcare professionals in Torfaen is required to motivate and refer smokers, to join the smoking cessation service. General practitioners and practice nurses have a big role to play in this area.

As well as promoting the service within large workplaces, community venues and primary care, the AWSCS has also held a number of training sessions for health care professionals across Torfaen in Brief Intervention for people who want to quit. To date 112 professionals including Practice Nurses have been trained.

The AWSCS are currently in the process of establishing a specialist service for smokers undergoing elective surgery. The target has two phases:

Phase 1: For the All Wales Smoking Cessation Service to negotiate the delivery of a smoking cessation service within each Trust by 31/03/08.

Phase 2: All smokers undergoing elective surgery to be referred to a smoking cessation counsellor prior to surgery by 31/03/09.

Although there is a significant amount of work being carried out within Torfaen to support smokers to quit, statistics show that there are a large amount of residents in Torfaen who smoke and many people suffer from diseases that are attributable to smoking. Evidence contained within the Health Outcomes section of this report illustrates that registration for cancer of the trachea, bronchus and lung for all age groups between 1995 and 2004 is higher in Torfaen compared to the Welsh average.

It is important to remember that the leading cause of lung cancer is tobacco smoking. However, many decades may follow the exposure before the development of the disease. Therefore any specific tobacco control programs will not demonstrate success in reducing lung cancer incidence for decades. The best measure of tobacco control programs is their effectiveness in terms of lowering smoking prevalence whether that is through enabling existing smokers to quit or through preventing potential smokers from taking up the habit.

Generally, incidence of lung cancer in men has been falling over the last decade (see Health Outcomes section), mirroring the trends in cigarette smoking habits (NPHS, 2006c). Whilst the overall rate for male lung cancers in Torfaen has been consistently higher than the Welsh rate.

Incidence of lung cancer in females has been rising, again mirroring the trends in cigarette smoking habits (NPHS, 2006c). The incidence for female lung cancer in Torfaen has been higher than, the Welsh average, but not significantly so.

100

Inequalities In 2004, the Health Information Analysis Team of the National Public Health Service produced a report (Deprivation and Health, NPHS, 2004) highlighting the relationship between small area deprivation and health in Wales. Smoking prevalence was reported as two-thirds higher among residents of electoral divisions within the most deprived fifth in Wales compared to the least deprived (see section Life Circumstances) – a third of Torfaen residents live in Wards classified as being in the most deprived fifth in Wales

Tobacco Control forum In order to achieve a uniformed approach to tackling the needs of Torfaen residents in relation to tobacco/smoking related issues a Tobacco Control Forum has been established. Initially the Forum had a number of successes and supported the implementation of the Health Bill (2007) banning smoking in enclosed public places and No Smoking Day 2007. However, since this time, as with many multi-agency groups, attendance at the forum has been low and inconsistent which has made it difficult to establish a work plan and take forward agreed work priorities. Buy in from partners is essential to the success of the Forum and an appropriate strategic approach to tobacco control in Torfaen. As these data show, there is still much to do.

Summary

Smoking is the single biggest avoidable cause of disease and early death in Wales.

Local data suggest that 35 per cent of secondary school pupils in Torfaen stated that they had smoked a cigarette by the age of 13 or younger with 19 per cent by the age of 11 years.

The prevalence of smoking in Torfaen is reported to be 28.8 per cent (Wales, 27.1 %) in the Welsh Health Survey (2003/ 05) however the Torfaen Health

101 and Environment Survey (2007) shows that smoking prevalence in Torfaen is 33 per cent.

Encouragingly, the above study indicates that smoking prevalence in Torfaen has dropped from 42 to 33 percent between 2002 and 2007, however, it must be remembered that this is still above the Welsh average.

102 Torfaen Health, Social Care and Wellbeing Needs Assessment 2007

Supporting the Health Social Care and Wellbeing Partnership for Torfaen

Chapter 4.5 Substance Misuse

Table of Contents

Background 105 Alcohol 106 Young People 107 Adults 109 Drug Misuse 113 Mortality 113 Suggested priorities 114

104 Background

Evidence suggests that the majority of people who use substances, do so without harming themselves or others (RSA, 2006). However, all substances carry risks, and the problem use of alcohol, use of volatile substances, illicit and/or prescription drugs is associated with significant, physical health, social and psychological risks. Substance misuse does not only affect individuals, but can also have a significant impact on family, friends and the wider community.

The illicit nature of some drugs means it is very difficult to ascertain the true extent of substance misuse. It should be noted that the client group and not always willing or able to provide accurate demographic information. Additionally, household and school based surveys are unlikely to reach for example, those problematic drug users whose lives are so busy that they are hardly ever at home.

Anecdotal evidence suggests that local prevalence of substance misuse is underreported. With the opening of the Pontypool multi-agency substance misuse base imminent, services will be more accessible locally and it is anticipated that there will be more accurate data on prevalence of substance misuse being reported in Torfaen in the near future. This is likely to be higher than that currently reported.

Setting the Scene • Substance misuse in the Welsh context refers to the problem use of illicit or prescribed drugs and or alcohol.

• Within Wales the strategic leads from the WAG now rests with the Minister for Social Inclusion - not Health and Social Care. The Strategy for substance misuse was produced in 2001 and has been followed by an ongoing programme of good practice guidance on specific issue e.g. prescribing and needle exchange. The agenda has had a focus on crime and disorder.

• From a public health perspective three of the major issues are:

a) co-morbidity i.e. the co-existence of a mental health problem along with substance misuse; b) the impact of alcohol misuse on the physical and mental health of the population in Wales; c) the maintenance and development of effective needle exchange schemes.

Policy guidance produced by the NPHS on a) and c) above was produced in 2003 and NPHS good practice guidance will be available in 2007.

General data issues It is difficult to assess the exact levels of substance misuse both in the general population and in those with mental health problems. Data on incidence and

105 prevalence of those with co-morbidity is not routinely available in Wales, though prevalence rates may be estimated from data collected separately on mental illness and substance misuse. Prevalence is thought to be rising.

• Treatment agencies routinely collect data on those in receipt of treatment but this does not identify co-morbid presentations.

• Statistics collected by local agencies are submitted to Health Solutions Wales who coordinate the Welsh National Database for Substance Misuse. The database started in April 2005, and Health Solutions Wales acknowledge a number of teething problems particularly with the comprehensiveness and quality of data collected. Information produced from this source must therefore be treated with caution. Statistics collected in the first year, up until March 2006, reported that alcohol was specified as the main substance misused, in just over 50% of cases.

• For intelligence led approach to planning and commissioning of services, compatible databases and the collection of comparable data is imperative.

• Different types of users and misusers – whether a person is an experimental, moderate social and/or heavy chaotic user is difficult to extrapolate from statistics.

Alcohol Alcohol is the most commonly misused substance in the UK (Cabinet Office Strategy Unit, 2003). Its misuse has become an increasing concern nationally and locally. The use of alcohol is embedded within British culture. However, for some people, social drinking can lead to heavier drinking, leading to excessive, hazardous or harmful alcohol consumption and sometimes dependence (collectively known as problem use of alcohol).

Problem use of alcohol can cause serious social, psychological and health problems, affecting work, social and personal relationships. Health risks associated with heavy drinking include: • liver disease (cirrhosis of the liver), • alcohol-related anaemia and nutritional disease, • chronic calcifying pancreatitis, • heart muscle damage (cardiomyopathy), • alcoholic dementia, and • psychiatric disorders.

Around 40 per cent of patients admitted to A&E are diagnosed with alcohol- related injuries or illnesses (Sussex Partnership NHS Trust, 2006). Alcohol has recently been identified as the third highest risk to health in developed countries (Alcohol Concern, 2006).

Alcohol misuse amongst young people is a worrying trend and one that is on the rise. Research indicates that young people are experimenting with alcohol at an earlier age, are drinking more frequently and more heavily.

106 Adverse health outcomes resulting from alcohol use are common among young people and many alcohol-related deaths occur relatively early in life. They also include intentional and unintentional injuries, both of which are related to patterns of drinking. The negative social consequences include missing school, falling behind in schoolwork, unplanned and unprotected sexual activity, arguments with friends, destructive behaviour and trouble with the police (WHO, 2004).

Of all drugs, the use of alcohol has shown the greatest recent growth and causes the most widespread problems among young people in the UK today (ACMD, 2006)

Patterns of alcohol misuse Recommended Guidelines The recommended guidelines indicate that no more than four units of alcohol a day for men and no more than three units of alcohol per day for women.

Data from the Welsh Health Survey shows that in response to a question relating to the average units consumed a day of alcohol, 40 per cent of adults reported that their alcohol consumption was above these recommended guidelines. Torfaen ranked the seventh highest in Wales for adults whose average alcohol consumption was above the recommended guidelines (Welsh Health Survey, 2003/05).

Initial indications from the Torfaen Health and Environment follow-up Study (2007) illustrate that there has been an overall decrease in the number of people drinking under the recommended limits, compared to the baseline survey (2002).

Young People Data from the Health Behaviour in School Aged Children (HBSC) Survey indicates that 7per cent of 11-year old girls and 12 per cent of 11-year old boys in Wales reported drinking any alcohol on a weekly basis. For 13-year olds nearly a quarter of girls and a third of boys in Wales reported drinking any alcoholic drink weekly. Data for 15-year olds shows that Wales has the highest proportion of young people in this age group reporting to drink on a weekly basis, of all the countries participating in the HBSC survey. Over 50 per cent of girls and almost 60 per cent of boys reported drinking alcohol on a weekly basis.

The Communities That Care (CTC) report (2006), which surveyed young people in Torfaen aged between 11-15 years old, found that the rate of reported underage drinking and its misuse were higher than the national average; reporting that: • 80% had taken more than a sip or two of alcohol (compared to 74% nationally) • 55% had drunk alcohol at least once in the past four weeks (51% nationally) • 29% had been seriously drunk (22% nationally)

107 • 18% drank regularly The CTC survey reported significant differences at ward level. Pupils living in Abersychan/Garndiffaith were significantly less likely than Torfaen as a whole to say that they had ever had a sip of alcohol. Significant differences by gender and age were also reported. Girls were significantly more likely than boys to say that they had ever had more than a sip or two of alcohol, had drunk alcohol in the past four weeks and had ever been seriously drunk. Reporting of frequency and quantity of alcohol use increased with age.

In addition the CTC study established that: • 55% of the young people reported that it would be easy or very easy to get hold of alcohol; • 30% thought that it was ‘only a bit wrong’ or ‘not wrong at all’ to drink alcohol regularly; • 14% said they started drinking alcohol regularly aged 13 or younger; • 52% had best friends who had tried alcohol without their parents’ knowledge.

With the study indicating that underage drinking in Torfaen young people appears to be higher than the national average, increased attention has been placed on this issue by the Torfaen Children and Young People’s Partnership and the SMAT.

Baseline data from a local pilot project exploring drama as an intervention for alcohol education conducted in three local secondary schools, with young people aged 11-15, found that:

• 61% had drunk alcohol at least once in the past four weeks – which ranged from 49-68% in the three schools ( compared with 55% Torfaen, 51% nationally); • 8% of year 7s (11-12 year olds), 27% of year 8’s (12-13 year olds), 39% of year 9’s (13-14 year olds) and 50% of 10’s (14-15 year olds) reported being drunk at least once in the past four weeks.

With vulnerable young people reporting higher than average alcohol misuse there has been a local alcohol initiative with young people from Torfaen Youth Access. A self-reporting questionnaire administered to 14-15 year old attendees of Youth Access, found 86% reporting that they drank alcohol at least once a week. Of these 26% reported drinking 7-10 drinks in one go, 25% 10-14 drinks in one go, and 12% reporting drinking more than 14 drinks in one go.

Binge Drinking Binge drinking is defined as drinking eight or more units of alcohol in one session for men, and more than six units in one session for women.

Binge drinking is common in young people in the UK, with 56% of 15-16 year olds having drunk more than 5 drinks on a single occasion in the last 30 days and 30% of this age group reporting having done so on three or more times in the last 30 days (Hibell, 2000).

108

The Torfaen Communities that Care Survey (CTC, 2005) reported that 29 per cent of 11-15 year olds had binge drank in the past four weeks (compared to 23 per cent nationally). CTC also reported that pupils from Trevethin were more likely than Torfaen as a whole to say that they had drunk five or more drinks in one session in the past four weeks and the same pupils were also significantly more likely than Torfaen as a whole to say that they had been seriously drunk

Adults Data from the Welsh Health Survey showing the age standardised proportion of adults who reported binge drinking on at least one day in the past week, shows that 19 per cent of adults report binge drinking in the past week. Torfaen is slightly higher than the national average, with 20 per cent of adults reporting binge drinking on at least one day in the past week, ranking 10th highest in Wales.

Referrals for treatment for alcohol misuse The Welsh National Database for Substance Misuse contains details relating to people referred for drug and alcohol problems to treatment agencies within Wales since 1st April 2005. Data are presented within this subsection for the first full year of the database (1st April 2005 to 31st March 2006). The data are classified as experimental and the results should be interpreted with caution.

Of those referred drug misusers in Torfaen, where the main problem is specified, alcohol accounts for almost double all other drugs. It is important to note that in addition to the data quality issues highlighted earlier the interpretation of data at this level is complicated by the proportion of cases referred to treatment agencies for unspecified problems.

Hospital activity Of persons admitted to hospital for alcohol-related conditions, Torfaen has high rates compared with Wales’s figures, being ranked 12th out of the 22 authorities. When the figures are separated, men are ranked 14th and women eighth for admission to hospital for alcohol-related conditions. Both are above the Welsh average.

Age and sex specific crude rates for people admitted to hospital with alcohol related conditions are higher for men compared with women. Admissions peak for men in the 45-54 age group and for women in the 35-44 age group.

Analysis of hospital admissions for alcohol related conditions at LHB level show an age standardised (EASR) Welsh average of 309 per 100,000 population with Torfaen slightly but not significantly higher.

These data are presented separately for men and women in the following figures. The all-Wales EASR of 405.4 for men is almost double the rate for women (218.2 per 100,000 population).

109 Trend data for hospital admission for alcohol related conditions are shown in the following chart. For both men and women an increase in the number of people admitted for alcohol related conditions can be seen.

All persons admitted to hospital for alcohol-related conditions, EASR per 100,000, Wales 1999-2005 Data source: PEDW

450 400 350 300 250 200 150 EASR per 100,000 100 Persons Males Females 50 0 1999 2000 2001 2002 2003 2004 2005

Mortality This section presents alcohol related mortality data, using the recently revised definition of alcohol related deaths, based on those causes regarded as most directly due to alcohol consumption (ONS, 2006). It is important to note that this definition differs from that used previously in analyses undertaken by the NPHS for Wales.

The following figure shows an age and sex breakdown for the average annual number of deaths resulting from alcohol related conditions for Wales. Between 2002 and 2004 there were on average 398 deaths resulting from alcohol related conditions. The number of deaths can be seen to peak for both men and women, in the 50-54 age group.

110 Deaths resulting from alcohol related conditions by age and sex, Wales: 2002-2004 Data s our ce : Annual District Death Extract (ADDE), ONS 70 Males Females 60

10 Average number of deaths per year per deaths of number Average

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

The following figure presents data showing three-year rolling average EASMRs for alcohol related mortality between 1996 and 2004. The all-Wales EASMR can be seen to increase from 10.2 per 100,000 population in 1996- 1998 to 14.0 per 100,000 population in 2002-2004. It is, however, important to note that caution needs to be applied when comparing deaths coded using ICD-9 (pre 2001) and ICD-10 (2001 onwards).

111 Alcohol-related deaths, 3-year rolling average European age standardised mortality rate (EASMRs) , Wales, 1996-2004 Source: Annual District Death Extract (ADDE), ONS

2 EASMR (per 100,000 population)

0 1996-1998 1997-1999 1998-2000 1999-2001 2000-2002 2001-2003 2002-2004

112 Drug Misuse

The UK has a higher prevalence of drug misuse than any other country in Europe (Morgan, et al, 2006). Different countries use different methods of collecting data, and comparisons should be treated cautiously (RSA, 2006). Drug misuse is important because the problem use of illicit OR prescription drugs carry many serious health risks, often because they are not controlled or supervised by medical professionals. Street drugs are often mixed with many other substances, which can be more harmful than the drugs themselves.

As well as having immediate health risks, some drugs can cause physical or psychological dependency, with the result that larger amounts are needed to get the same effect often leading to long-term damage to the body. Heavy or long-term use of some illegal drugs may cause the user to overdose, which may cause permanent damage to the body and can be fatal.

Patterns of drug misuse “Sweeping statements about drug use are also fraught with danger because different people take different drugs for different reasons and in different ways” (RSA, 2006, p55)

Drug misuse is a complex issue. Although its prevalence appears to be stabilising in the UK, figures disguise the fact that some substances are becoming more prevalent whilst others are in decline. New substances are constantly emerging and existing substances may change in their make up, and potency, which can result in them being more dangerous.

The most commonly used illegal drug in the UK is cannabis (ACMD, 2006). A recent study of 15 year olds found that cannabis use, regular and heavy, was lower in Wales than England of Scotland (HSBC). In Torfaen, recent research indicated that illegal drug misuse rates amongst school aged children currently reflect the national average (CTC, 2005).

There is anecdotal evidence that other substances currently being misused locally include prescribed drugs and steroids, yet there is little research into their prevalence even nationally. Volatile substances are legally available and easily accessible even to very young children, yet they get the fraction of attention of illegal drugs. National research indicates that glue sniffing in the 11-15 year age group has increased seven fold in the last year (RSA, 2006). This is an issue which needs to be kept on the local agenda.

Mortality Data relating to drug related mortality are shown below. The definition of drug related deaths used within this report are those specified by the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) The EMCDDA definition gives a fewer number of deaths than the broader ONS definition. This definition was applied to mortality data using the underlying cause of

113 death only. The codes included cover accidents and suicides involving drug poisoning as well as poisoning due to drug misuse and dependence but not other adverse effects of drugs. The range of substances includes legal and illegal drugs, prescriptions drugs and over-the-counter medications.

The age and sex breakdown for the average annual number of deaths resulting from drug related conditions at the all-Wales level between 2002 and 2004 shows 114 deaths resulting from drug related conditions. Overall for every woman who died from drug related conditions three men died. The number of deaths can be seen to peak in the 20-34 year olds

Deaths resulting from drug related conditions by age and sex, Wales: 2002-2004 Data source: Annual District Death Extract (ADDE), ONS 25 Males Females

5 Average number of deaths per year per number deaths of Average

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

National drugs and alcohol helpline Wales’ first free and bilingual drugs and alcohol helpline became fully operational on 1st September 2006 (Welsh Assembly Government, 2006). DAN 24/7 is a national confidential service providing advice to drugs and alcohol users and anyone wanting information on substance misuse 24 hours a day, 7 days a week. The helpline number is 0800 6 33 55 88. All calls from land lines are free, although some mobile phone networks may charge. This service should be promoted locally.

Suggested priorities • Focus should be placed on the substances most prevalent in Torfaen, identified in local reports as, alcohol, cannabis and volatile substances. • Increased focus and resource allocation from the SMAT and other partners to be directed towards preventative work.

114 • Best practice for substance misuse education and prevention needs to be agreed locally, and resources refocused on interventions that have the evidence for greatest impact. • Ensure that local resources are focussed on high risks groups, ie. School excluded young people, looked after young people. • Patterns of prevalence of substance misuse to be recorded across wards to provide a better focus for investment.

Summary

Substance misuse does not only seriously affect individuals’ health and wellbeing, but can also have a significant impact on family, friends and the wider community.

Alcohol is the most commonly misused substance in the UK. Alcohol misuse amongst young people is a worrying trend and one that is on the rise.

Data from the Health Behaviour in School Aged Children (HBSC) Survey indicates that 7per cent of 11-year old girls and 12 per cent of 11-year old boys in Wales reported drinking any alcohol on a weekly basis this figure rose to a quarter and a third respectively for 13-year olds. Data for 15-year olds shows that Wales has the highest proportion of young people in this age group reporting to drink on a weekly basis, of all the countries participating in the HBSC survey.

Among adults, (Welsh health survey 2003/ 05) 20 per cent of adults in Torfaen reported binge drinking in the past week. Torfaen ranked the seventh highest in Wales for adults whose average alcohol consumption was above the recommended guidelines.

Of those referred ‘drug misusers’ in Torfaen, where the main problem is specified, alcohol accounts for almost double all other drugs.

Analysis of hospital admissions for alcohol related conditions at LHB level show an age standardised (EASR) Welsh average of 309 per 100,000

115 population with Torfaen slightly but not significantly higher being ranked 12th out of the 22 authorities.

The UK has a higher prevalence of drug misuse than any other country in Europe (Morgan et al, 2006). At the all-Wales level between 2002 and 2004 shows 114 deaths resulting from drug related conditions. In Torfaen, recent research indicated that illegal drug misuse rates amongst school aged children currently reflect the national average (CTC, 2005).

Local action plans are needed to respond to the patterns and issues identified in Torfaen, with substance misuse prevention among young people being high on the list of priorities.

Focus should be placed on the substances most prevalent in Torfaen, identified in local reports as, alcohol, cannabis and volatile substances.

Best practice for substance misuse education and prevention needs to be agreed locally, and resources refocused on interventions that have the evidence for greatest impact

116 Torfaen Health, Social Care and Wellbeing Needs Assessment 2007

Chapter 4.6 Population Attributable Fractions

Population Attributable Fractions The ‘population attributable fraction’ of a disease or condition is a measure of the proportion of cases that can be attributed to a risk factor. It is best described as the proportion of cases of that disease that would be eliminated if the specific risk factor alone were eliminated from the population, while the magnitude of other risk factors in the population remain unchanged.

Table

Population attributable fractions of diseases in relation to modifiable risk factors (% DALYs for each disease-risk factor pair) Disease Modifiable risk Disease burden* (% of total**) factor attributable to the risk factor1,2 Males Females Ischemic heart disease Tobacco use 32 10 High blood 59 55 pressure High cholesterol 63 63 Nutrition –low fruit 29 27 & vegetable intake Excessive salt 22 22 intake3 Physical inactivity 23 22

Stroke Overweight 34 35 High blood 72 72 pressure High Cholesterol 39 41 Nutrition – low fruit 18 18 & vegetable intake Excessive salt 16 16 intake3 Physical inactivity 12 13

High blood pressure Overweight 57 59 (BP) Excessive salt - - intake3

Diabetes Mellitus Overweight 75 83 Physical inactivity 15 15

COPD Tobacco use 79 57

Lung Cancer Tobacco use 90 69

Motor vehicle accidents Alcohol 45 18

118

Liver Cirrhosis Alcohol 63 49

DALY: ‘Disability adjusted life year’, a measure of years of lives lost due to premature mortality and disability. *Attributable burden, estimated by W.H.O. for ‘Developed’ regions of the world, including UK (data for the year 2000). **May add up to more than 100 because most chronic diseases have multi- factorial causation, and different risk factors interact in the same individual to influence the disease process.

The percentages cited in table relate to average values in populations across the ‘Developed’ regions of the world, as estimated by W.H.O. The corresponding local figures would vary based on relative prevalence of risk factors and population structures, but are unlikely to vary by large values within component populations. Many chronic diseases are multi-factorial: hence some individuals with more than one risk factor can have disease prevented in more than one way, and the prevented cases of these individuals could be counted more than once, thus resulting in an apparent (total) attributable proportion of more than 100%.

Effects of Risk Factor Modification For every 1,000 males quitting smoking, overall 40 of these quitters will be spared a diagnosis of Acute myocardial infarction, COPD, lung cancer and stroke in the first ten years following quitting, with an estimated saving of 47 life-years and 75 QALYs.4

Reduction in salt intake, across the population, by 3g/ day will result in 5-7 mm Hg reduction in systolic BP and half as much in diastolic BP. This in turn, will lead to 22% reduction in the incidence of ischemic heart disease and 16% reduction in the incidence of stroke.3

119 demonstrated that the risk of CHD was decreased by 4% for each additional portion per day of fruit and vegetable intake and by 7% for fruit intake.8

References 1. World Health Organisation. Chronic disease risk factors. W.H.O. Geneva. url: http://www.who.int/dietphysicalactivity/publications/facts/riskfactors/en/index.ht ml accessed 21 March 2007

2. The World Health Report 2002. Annex 2. pp 220-3. World Health Organisation. Geneva. url: http://www.who.int/whr/2002/annex/en/index.html Accessed 21 March 2007

3. Frost CD, Law MR, Wald NJ. By how much does dietary salt reduction lower blood pressure? II—Analysis of observational data within populations. BMJ 1991; 302: 815–818.

4. Hurley SF, Matthews C. The Quit Benefits Model: a Markov model for assessing the health benefits and health care cost savings of quitting smoking. Cost Eff Resour Alloc. 2007; 5: 2. url: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1796848 Accessed 21 March 2007

5. Unal B, Critchley JA, Capewell S. Modelling the decline in coronary heart disease deaths in England and Wales, 1981-2000: comparing contributions from primary prevention and secondary prevention. BMJ. 2005 Sep 17; 331(7517): 614. url: http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=12 15556 Accessed 21 March 2007

6. Physical activity and all-cause mortality: what is the dose-response relation?, Medicine and Science in Sports and Exercise, I. Lee and P. Skerret, 2001

7. Dauchet L, Amouyel P, Dallongeville J. Fruit and vegetable consumption and risk of stroke: a meta-analysis of cohort studies. Neurology. 2005 Oct 25; 65(8): 1193-7.

8. Dauchet L, Amouyel P, Hercberg S, Dallongeville J. Fruit and vegetable consumption and risk of coronary heart disease: a meta-analysis of cohort studies. The Journal of Nutrition 2006 Oct; 136(10): 2588-93.

120 Torfaen Health, Social Care and Wellbeing Needs Assessment 2007

Supporting the Health Social Care and Wellbeing Partnership for Torfaen

Chapter 5 Health Outcomes

Table of Contents

Health status of older people 123 General health 123 Sensory disabilities 123 Older people and mortality 124 Excess winter mortality 125 Adults health outcomes 126 Limiting long-term illness 127 Physical component summary score 129 Mental health 130 Mental component summary score 130 Anxiety and depression 131 People receiving treatment for mental illness 131 People resident in mental health units 132 Eating Disorders 133 Low birth weight babies 136 Congenital anomalies 138 Mortality 139 Childhood mortality 140 Neonatal mortality 142 Infant mortality 142 Morbidity and mortality for selected poor health outcomes 145 Circulatory disease 145 Coronary Heart Disease 149 Cerebrovascular disease (stroke) 154 Males 154 Males 155 Respiratory disease 158 All respiratory diseases 158 Injuries 162 Cancers 165 All malignancies (excluding other skin) 165 Trachea, bronchus and lung 170 Skin cancer 178 Diabetes 181 Arthritis 184 Back pain 185 Hypertension 187 Quality and Outcomes Framework: long term conditions and risk factors 190

122 Health status of older people

General health Health status in older people is examined within this subsection using data on limiting long-term illness (LLTI) from the 2001 Census and data relating to the Physical Component Summary Score (PCS) from the Welsh Health Survey. Both of these indicators provide useful proxies for the prevalence of chronic conditions. It is however, important to note that even when symptoms are unremitting, they may not necessarily be perceived as limiting if the person has adapted their life to cope.

Limiting long-term illness LLTI is a self-reported measure of long-term illness, rather than officially diagnosed ill-health, and are a measure of health problems or disability that are perceived to limit a person’s daily activities or the work they can do including problems related to advancing/older age.

Compared to UK Nations and English Regions, Wales has the highest proportion of people aged 65 years and over reporting LLTI (Census, 2001). Analysis at LHB/LA area level shows Torfaen is ranked sixth highest of the 22 areas in Wales for people aged 65 years and older reporting a limiting long-term illness; at just over 60 per cent, the proportion is higher than the Welsh average but lower than Gwent as a whole.

Average physical component summary score The Welsh Health Survey (WHS) included a standard set of health status questions known as the SF-36 (version 2). The SF-36 questions ask respondents about their own perceptions of their physical and mental health and the impact it has on their daily lives. Physical Component Summary (PCS) scores are presented within this report. In general terms, a score of 50 represents the general population; scores above 50 can be interpreted as above the general population norm. Higher scores indicate better health and WHS data show that the PCS score decreases steeply with age from age group 35 to 44 years. More information on PCS is presented further on in this subsection.

Sensory disabilities Disability or impairment of function is an indicator of population health at all ages (NPHS, 2004b). Most people aged over 65 years of age report at least one chronic condition, and the number of conditions reported increases with age. The most common problems relate to movement vision and hearing (DoH, 2001).

Eyesight difficulties Analysis of the Welsh Health Survey shows the proportion of people reporting eyesight difficulties. The results are presented for the proportion of respondents reporting that they could not see the face of someone across a room without difficulty, with glasses or contact lenses if they usually wore them. Overall six per cent of adults (four per cent of men and seven per cent of women) reported eyesight difficulties. For all age groups, but particularly the older age groups, women were more likely than men to report difficulties with their eyesight (NAfW, 2006a). These data show that there is a three-fold increase with age in the proportion of both men and women reporting eyesight difficulties.

123

Hearing difficulties Analysis of the Welsh Health Survey, shows the proportion of adults reporting hearing difficulties. Respondents were asked whether they had any difficulty with their hearing, without a hearing aid if they usually wore one. Overall 14 per cent of adults (16 per cent of men and 12 per cent of women) reported having difficulty with their hearing (NAfW, 2006a). These data suggest that men’s hearing deteriorates at a younger age than women’s and shows that more men reported having difficulty with their hearing (NAfW, 2006a). Almost half of women and a third of men aged 75 years of age and over reported hearing difficulties.

Older people and mortality In 2004, 26,885 deaths occurred in Welsh residents aged 65 years and over. In this age group, male deaths totalled 12,009 and female deaths 14,876. This corresponds to 78 per cent of deaths in men and 88 per cent of deaths in women of all ages. The higher proportion of deaths amongst older women reflects their longer life expectancy.

The main causes of death amongst adults aged 65 years and over in 2004 are shown in the graph below. Circulatory diseases, including coronary heart disease and stroke, accounted for 41 per cent of deaths, cancers accounted for 24 per cent and respiratory disease 15 per cent of deaths in this age group.

Major causes of deaths for persons aged 65 and over, Wales: 2004 Data source: Annual district death extract, ONS 50 65-69 70-74 75-79 80-84 85+

20 Proportion (%)

0 Circulatory All malignant Respiratory Injuries Other disease neoplasms disease

Analysis of age standardised mortality data (EASMR) for adults aged 65 and over at LHB/LA area level shows that Torfaen is slightly lower but not statistically significantly different to the Welsh average of 4,568 deaths per 100,000 of the population; .

124

All cause European age standardised mortality rates (EASMRs) for residents aged 65+, by Local Health Board: 2002-2004 Source: Annual District Death Extract (ADDE), ONS Compared with Wales Significantly higher Higher Significantly lower Lower 6000

Welsh average = 4,568 5000

4000

3000

2000

1000

EASMR (per 100,000 population) 100,000 EASMR (per 0

Cardiff Powys Conwy Torfaen Newport Bridgend Flintshire Swansea Gwynedd Wrexham Caerphilly Ceredigion Denbighshire Merthyr Tydfil Pembrokeshire Blaenau Gwent Monmouthshire

Isle of Anglesey Carmarthenshire Neath PortNeath Talbot Rhondda Cynon Cynon Taff Rhondda he Vale ofGlamorgan

Excess winter mortality Excess winter mortality is a measure of additional deaths seen in winter months (deaths occurring in December to March) compared to non-winter months (April to July of the current year and August to November of the previous year). The Excess Winter Deaths (EWD) Index is calculated as excess winter deaths divided by the average non-winter deaths, expressed as a percentage (ONS, 2005b).

Older people are more susceptible to low temperatures than other age groups. The chart below shows the EWD index for persons aged 65 and over by LHB/LA area; three years’ data have been combined to account for variations which may occur in the climate from year to year. The EWD in Torfaen is slightly higher but very similar to the Welsh average of 16.4 ranking 11 out of the 22 LHB areas for excess winter mortality.

125 Excess winter deaths (EWD) index for persons aged 65+ by Local Health Board: August 2001 - July 2004 Source: Annual District Death Extract (ADDE), ONS 25

20 Welsh average = 16.4

10 Percentage (%) 5

0 Cardiff Powys Conwy Torfaen Newport Bridgend Flintshire Swansea Gwynedd Wrexham Caerphilly Ceredigion Denbighshire Merthyr Tydfil Pembrokeshire Blaenau Gwent Monmouthshire Isle of Anglesey of Isle Carmarthenshire Neath Port Talbot Rhondda Cynon TaffRhondda The Vale of Glamorgan

Adults health outcomes

Life expectancy at birth 2002-2004 These data are obtained from ONS. Data are averages, produced by aggregating deaths and population estimates for a three year period, 2002-2004. Life expectancy at birth for an area in each time period is an estimate of the average number of years a newborn baby would survive if he or she experienced the particular area’s age- specific mortality rates for that time period throughout his or her life. The figure reflects mortality among those living in the area in each time period, rather than mortality among those born in each area. It is not therefore the number of years a baby born in the area in each time period could actually expect to live, both because the death rates of the area are likely to change in the future and because many of those born in the area will live elsewhere for at least some part of their lives.

In Torfaen LA/LHB area, life expectancy for males is 73 years of age and for females is 78 years neither being significantly different to the Welsh average.

126 Limiting long-term illness LLTI data from the 2001 Census shows substantial variation between LHBs, with the highest reported proportion of LLTI occurring in the south Wales valleys with Torfaen being ranked eighth highest in Wales having nearly 25 per cent of the population reporting a limiting long term illness, slightly above the Welsh average of 23 per cent.

Persons1 with limiting long term illness Data source: Census 2001 35

25 Welsh average = 23.3

15 Proportion (%) 10

Powys Cardiff Conwy Torfaen Newport Bridgend Flintshire Swansea Gwynedd Wrexham Caerphilly Ceredigion

Denbighshire Merthyr Tydfil Merthyr Pembrokeshire Blaenau Gwent Monmouthshire Isle of Anglesey

Carmarthenshire Neath Port Talbot Rhondda CynonTaff

The Vale of Glamorgan Vale The

1 Persons in households

Analysis of people in households reporting having a limiting long term illness in Wales at MSOA level shows that there is variation across Torfaen with seven areas higher than the Welsh average, four areas similar to the Welsh average and two areas lower. There are no MSOAs in Torfaen within the highest range for MSOAs in Wales.

127 Percentage of persons in households with limiting long term illness by MSOA: 2001

Crown copyright material is reproduced with the permission of the Controller of HMSO and the Queen’s Printer for Scotland

128 Analysis of Welsh Health Survey data has revealed that the levels of LLTI are statistically significantly higher in more deprived areas.

Residents who reported having limiting long term illness (LLTI), by deprivation fifth, 1998 Data source: Welsh Health Survey 1998 120

100

40 Age standardised ratio 20

0 12345 Electoral division deprivation fifth (1=least deprived, 5=most deprived)

Physical component summary score A higher Physical Component Summary (PCS) score indicates better physical health. Analysis at LHB/LA area level shows that in contrast to self reported LLTI, the physical component summary scores do not vary markedly between areas in Wales (46 to 51). Torfaen is ranked 17 out of 22 for best physical health, and at a score of 48 is not significantly lower than the Welsh average of 48.7.

SF36 Physical Component Summary Score: 2003/05 Source: Welsh Health Survey, 2003/05 55 Welsh average = 48.7 50 45

40 35

30 25

Age standardised mean 15 10

5 0

Powys Cardiff Conwy Torfaen

Newport Bridgend Flintshire Swansea Gwynedd Wrexham Caerphilly Ceredigion Denbighshire Merthyr Tydfil Merthyr Pembrokeshire Blaenau Gwent Monmouthshire Isle of AngleseyIsle of Carmarthenshire Neath Port Talbot Port Neath Rhondda Cynon Taff Rhondda Cynon

The Vale of Glamorgan 129 Analysis of data from the 1998 Welsh Health Survey reveals that the PCS scores are statistically significantly lower in more deprived areas (NPHS, 2004b).

Mental health Figures from the Office for National Statistics suggest that one in six of adults in the UK experience “significant mental health problems” at any one time (ONS, 2000)., with half experiencing a mixed anxiety and depressive disorder, a quarter generalised anxiety disorders and the remaining quarter experiencing episodes of depression, phobia, obsessive compulsive behaviour or panic.

Data issues • The majority of information on mental health that is currently available within Wales (and UK) is activity focused; very little is collected on outcomes. • Although the agenda for mental health has moved from an institutional to a community focused model of care there are very little data collected or available that reflect these changes in a robust manner or that can be used to support any changes or benefits that are brought.

Mental component summary score A higher MCS score indicates better health; scores above or below 50 can be interpreted as above or below the general population norm. It should of course be remembered that different people’s perceptions of what constitutes good or poor mental health may vary considerably; in addition, individuals’ perceptions of their mental health may vary from day to day.

At LHB level, average MCS scores vary considerably between LHB/LA areas; the five south Wales valleys areas have the lowest scores with Torfaen ranked fifth lowest with an average score of 48.5 and below the Welsh average (49.7).

Mental component summary score by LHB Source: WHS 2003/05

52 51

Wales average = 49.7 50 49

47 Age standardised mean

Cardiff Powys Conwy Torfaen Newport Bridgend Swansea Flintshire Gwynedd Wrexham Caerphilly Ceredigion Denbighshire Merthyr Tydfil Pembrokeshire Blaenau Gwent Monmouthshire Isle of Anglesey Carmarthenshire Neath PortTalbot Rhondda Cynon Taff

130 The Vale of Glamorgan Note: truncated y axis

Anxiety and depression Whilst MCS shows a statistically significant relationship with the geographical pattern of deprivation the relationship is not strong. Analysis of the Welsh Health Survey (1998) however shows the proportion of adults reporting anxiety or depression (for at least three months) is strongly related to deprivation; it is apparent that as deprivation increases, levels of self-reported anxiety and depression also increase steadily. See the section Life Circumstances for more information on deprivation and mental health.

People receiving treatment for mental illness The Welsh Health Survey also asked respondents if they were currently being treated for certain illnesses including depression, anxiety or ‘another mental illness’. These data indicate that the proportion of men receiving treatment for mental health issues is less than women at all ages (ten year age bands). In women the proportion rises from six per cent in the 16 to 24 year age group up to 16 per cent amongst those aged 45 to 54 dropping to 12 per cent for those aged 75 and over. In males the pattern with age is similar but less pronounced; the proportion rises from three up to nine per cent in those aged 55 to 64 and then drops to around three per cent in those aged 75 and over.

Analysis at LHB/LA area level of Welsh Health Survey data shows that just over ten per cent of those aged 16 and over resident in Torfaen reported receiving treatment for a mental health issue; Torfaen are ranked sixth highest in Wales, higher than the Welsh average of 9.3 per cent.

Adults who reported currently being treated for a mental illness Source: WHS 2003/05

10 Wales average = 9.3

Age standardised % 4

Cardiff Powys Conwy Torfaen Newport Bridgend Flintshire Swansea Gwynedd Wrexham Caerphilly Ceredigion Denbighshire Merthyr Tydfil Merthyr Pembrokeshire Blaenau Gwent Monmouthshire Isle of Anglesey Carmarthenshire Neath PortTalbot Rhondda CynonRhondda Taff The Valeof Glamorgan

131

People resident in mental health units The Psychiatric Census carried out by NAfW (2005b) shows that the majority of patients resident in units for people with a mental illness are from LHB/LA areas in south Wales. This may of course be influenced by the placement of the largest service providers, which are Whitchurch Hospital (Cardiff), Cefn Coed Hospital (Swansea) and Glanrhyd Hospital (Bridgend); together these three facilities account for nearly a third of all resident patients with a mental illness in Wales.

Resident patients in hospitals and units for people with a mental illness in Wales Source: National Assembly for Wales Psychiatric Census 31st March 2005 300 Under 25 25-44 45-64 65 and over 250

200

150

100 Number of patients of Number

0 Cardiff Conwy Powys Torfaen Newport Bridgend Swansea Flintshire Gwynedd Wrexham Caerphilly Ceredigion Denbighshire Merthyr Tydfil Pembrokeshire Blaenau Gwent Monmouthshire Isle of Anglesey No FixedNo Abode Carmarthenshire Neath Port Talbot Rhondda CynonRhondda Taff The Vale of Glamorgan LHB of residence

Torfaen is ranked fourth lowest for numbers of patients resident in hospital this is against the context of spare capacity of beds in Torfaen. This might suggest that mental health services in Torfaen are more community focussed compared to most other LHB/LA areas in Wales.

In their review of Torfaen Adult Mental Health Services, the Sainsbury Centre for Mental Health (SCMH) provides a detailed account of a modern, multi-disciplinary mental health system and service, including the role and function of its core elements. In identifying the local priority service developments, the SCMH carried out quantitative analysis of acute In-patient Admission and Finished Consultant Episodes (FCE). This report is available on the needs assessment website. Analysis was carried out on:

132 • Length of Stay • FCEs by diagnosis • Single and Multiple Admissions

These data were then compared against 2003/04 Hospital Episode Statistics (HES) data for England provided by the Department of Health to enable comparisons to be made.

The main findings from SCMH in relation to mental health needs can be summarized as follows:

• Torfaen has much higher levels of multiple admissions than the English national average. This may indicate that community services need to be strengthened further to enable them to meet patients’ needs adequately and thus avoid multiple admissions to the acute in-patient service.

• Torfaen has slightly higher levels of clients diagnosed with psychosis than the English average. Diagnosis of anxiety and depression are much higher, almost double, than that of England. This may highlight an issue of service users being admitted to hospital that could more appropriately be supported by intensive support in the community.

• Compared to the national average Length of Stay for England, Torfaen has low average Length of Stay. When this is broken down further to show Length of Stay by diagnostic grouping, psychosis admissions have very similar levels to those in the HES data. However, for those admitted for non-SMI diagnoses the picture is very different, a much higher percentage being discharged in the 0 to 30 days Length of Stay (50%). Again this data may indicate the number of admissions for a relatively short period and raises the issues of inappropriate admission which could more appropriately be supported by intensive support in the community.

Three years of in-patient Finished Consultant Episode (FCE) data (April 2003 to April 2006) were also provided. These data were analysed in terms of numbers of admissions and lengths of stay; analysis of diagnoses was used to assess the susceptibility of the client group to alternatives to admission. These data show a reduction of admissions, a reduction in the length of stay, a substantial reduction in the admission of people with a non-psychotic illness but a slight increase in the number of people admitted with serious mental illness.

Eating Disorders The NICE guidelines suggest that "about one in 250 females will experience anorexia nervosa and five times that number will experience bulimia nervosa".

National surveys indicate that the annual incidence of anorexia nervosa, detected by all services is likely to be between 4 & 10 per 100,000 total population. It is

133 estimated that approximately one third of these people will require an inpatient admission. Annual incidence of bulimia, estimated from those presenting in Primary Care, range from 10 -15 per 100,000 per year (Hoek et al, 1995; Turnbull et al 1996). In reality however the majority of sufferers, particularly those with bulimia go undetected, as they do not seek help. Taken with other evidence, these figures translate into an overall estimated point prevalence of between 10 and 30 per 100,000 total population for anorexia and approximately 100 per 100,000 for bulimia. It must be noted that there are no figures for atypical eating disorders due to the lack of research into the distribution of this group. In clinical practice however, atypical eating disorders are often the most common diagnostic category and it is recommended that they are treated according to which diagnosis they most closely resemble (NICE 2000). This group must also be taken into account when planning services and are likely to double the Eating Disorders figures overall.

Using the above figures to predict demand and plan service is a complicated and imprecise exercise. Secrecy, ambivalence and treatment resistance are dominant clinical feature of these disorders, not all those estimated within the prevalence data will present or be identified at primary care and secondary services. The table below shows the prevalence for all eating disorders within mental health services across the age range in Gwent from January 2005 to April 2006. The Eating Disorders Association suggest that 1-2 adults per 100,000 population will present with severe anorexia nervosa requiring intensive care/emergency admission.

Newport Torfaen M’shire BG C’philly Totals

Adult CMHT 57 31 36 22 47 193 Admissions MH 4 1 NH 4 1 4 14 Units Out of Area 2 3 1 1 Treatment CAMHS 23 21 18 4 15 81 Paediatric 4 1 2 1 1 9 admissions T4 admissions 2 1 1 Totals 80 52 54 26 63 274

134 Suicide Suicide prevention is a key action identified within the Adult Mental Health National Service Framework for Wales (WAG, 2005).

For males, the European age-standardised rate (EASMR) for suicide in Wales is higher than the UK rate. The EASR for females in Wales is much lower that the rate for males, and is equal to the UK rate for females.

One of the national level health gain targets set by WAG is to reduce the EASMR for suicide mortality in Wales to 11.1 per 100,000 for all persons by 2012; the EASMR for suicide mortality in 2002-2004 is 14 per 100,000 for all persons. The rate for males, however, is approximately four times higher than the rate for females over this time period.

There is significant variation in the EASR for suicide at LHB/LA area level. The EASMR for Torfaen is 11.5 per 100,000 of the population (95%CI, 9.5 to 13.9) lower than the Welsh average of 13.7 and ranked fifth lowest LHB/LA area in Wales. .

European age standardised mortality rates (EASMRs), suicide or event of undetermined intent, persons, by

Local Health Board: 1996-2004 Source: Annual District Death Extract (ADDE), ONS 20 18 16 Welsh average = 13.7 14

population) 12 10 8 6

EASMR (per 100,000 2 0 Cardiff Powys Conwy Torfaen Newport Bridgend Swansea Flintshire Gwynedd Wrexham Caerphilly Ceredigion Denbighshire Merthyr Tydfil Pembrokeshire Blaenau Gwent Monmouthshire Isle of Anglesey Carmarthenshire Neath Port Talbot Rhondda Cynon Taff The Vale ofGlamorgan

135 The chart below shows the trend in deaths from suicide for Torfaen LHB residents from 1996-2005. The average annual number of deaths in Torfaen LHB residents due to suicides ranged from eight to 10 over the period 1996 - 2005. There are no significant differences between annual deaths from suicide between years.

All suicides & events of undetermined intent mortality European age standardised rate (EASR), persons: 1996-2005 Sources: ONS, StatsWales (WAG) Torfaen Wales 30

5 EASR per 100,000 population 100,000 per EASR 0 1996-98 1997-99 1998-00 1999-01 2000-02 2001-03 2002-04 2003-05

Low birth weight babies Low birth weight babies (weighing less than 2500 g) are at greater risk of problems occurring during and after birth placing additional demand on secondary care and health visiting services. In addition, there is a growing body of evidence pointing to the link between low birth weight and chronic diseases such as diabetes and CHD in adulthood. Numerous papers and reviews have been published citing the link between poor in utero development and chronic disease in adulthood (Barker et al, 2003).

The evidence of the link between singleton live low birth weight and poor lifestyle during pregnancy is strong. Specifically, low birth weight is associated with poor maternal general health, a low level of education, poor nutrition, alcohol consumption and smoking both pre-conceptually and during pregnancy.

Data are shown for all births and for singleton live births. This is because stillbirths and multiple births are more likely to be of low birth weight without necessarily being linked to the lifestyle factors mentioned above.

The proportion of singleton live low birth weight babies at LHB/LA area level the highest low birth weight rate is almost twice that of the lowest and there is a clear association with socio-economic deprivation. In Torfaen the rate is slightly higher but not significantly different to the Welsh average of 5.9 per cent.

The map below shows the percentage of singleton live born babies weighing less than 2500g at middle super output area level. The map below shows that there is one

136 MSOA ranked amongst the highest range in Wales, this observation may be because this area also has the highest proportion of young people in Torfaen.

Percentage of singleton live born babies with low birth weight by middle super output area (MSOA): Torfaen; 2002-2004

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The chart below is taken from Deprivation and Health (NPHS, 2004) and shows the association between low birth weight babies and socio-economic deprivation fifth in Wales (as measured by the Townsend index). It is clear that there is a strong relationship and the confidence limits indicate that it is likely to be statistically significant. The rate ratio between the most and least deprived fifth is 1.37 or, in other words, 37 per cent higher in the most deprived fifth compared with the least deprived. However whilst this may have implications for planning interventions such as Sure Start and Flying Start, this relationship between low birth-weight and deprivation does not seem to be present geographically within Torfaen.

137

Low birth weight babies (<2500g),

Wales by 5th of deprivation, 1998-2002 Source: ONS/ NPHS 10 9 8 7 6

Proportion (%) Proportion 3

1 0 1 (least 2345 (most deprived) deprived) Electoral division deprivation fifth

Congenital anomalies Information on congenital anomalies in Wales is held by the Congenital Anomaly Register & Information Service for Wales – CARIS. CARIS collects information about any foetus or baby who has or is suspected of having a congenital anomaly and whose mother is normally resident in Wales at time of birth. It covers babies in whom anomalies are diagnosed at any time from conception to the end of the first year of life. Data collection commenced on 1st January 1998 and includes any baby where pregnancy ended after this date.

Analysis of gross congenital anomaly cases at LHB/LA area level (CARIS, 2006) expressed as a rate per 10,000 total births shows that Torfaen has a rate that is below the Welsh average of 451 anomalies. The gross rate includes still born babies, foetal losses and terminations. It is important to note that often the number of congenital anomalies per case is greater than one. It is also noteworthy that the completeness of this data set is variable between LHB/LA areas.

138 Mortality This section shows the European age standardised mortality rates (EASMRs) for all causes of death for all persons at all-Wales, LHB and MSOA level.

All cause mortality 3-year rolling average EASMRs for all causes of death for all persons in Wales suggests that the standardised mortality rate is falling, highlighting the fact that people are living longer.

Analysis at LHB/LA area level show that the age standardised mortality rate for all causes is significantly higher in the South Wales Valleys compared with Wales but that Torfaen is not significantly different to the Welsh average and is ranked 11 out of the 22. Analysis at the sub LHB/LA area level show there is variation across Torfaen with three areas amongst the highest in Wales.

European age standardised mortality rates (EASMRs) for all causes (persons, all ages) by middle super output area (MSOA): 2000-2004

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139 Childhood mortality Childhood mortality rates in Wales are an important indicator for several reasons. Firstly they are known to be influenced by socio-economic factors and this subsection, along with the subsection on deprivation within the section Life Circumstances, contains evidence of this association in Wales. In addition, childhood mortality is directly linked with maternal health and lifestyle during pregnancy. Data on childhood mortality also provide an indication of the quality of healthcare both during pregnancy and following birth. The majority of childhood deaths occur in the first year of life and this section focuses on stillbirths and deaths in children aged under one year.

Stillbirths The stillbirth rate is the number of stillbirths expressed as a rate per 1,000 total births (live and still) occurring after 24 weeks’ gestation. The causes of many stillbirths are not well understood. Causes of death recorded in notifications to the Office for National Statistics were recently reviewed and showed about three quarters of stillbirths in England and Wales in 2002 were due to death before rather than during birth. In a further 14 per cent of cases, congenital anomalies were the main cause of death (NPHS, 2004b).

There has been an overall downward trend in stillbirth in England and Wales over the second half of the 20th Century. The stillbirth rate in Wales is slightly lower than in England and Scotland. The trend in the stillbirth rate for Wales over the past nine years (1996 to 2004) has remained fairly stable; however there has been a slight increase since 1999-2001.

Analysis at LHB/LA area level reveals considerable variation in the rate; however, much of the pattern shown may be the result of random variation due to the small numbers of stillbirths. However for the whole of Wales, the average annual number of neonatal deaths was 160, meaning that in most LHB/LA areas the average annual number of deaths over the five year period shown was in single figures. The rate for Torfaen LHB/LA area is shown in the graph below; the rate is above the Welsh average and ranked seventh highest of the 22 LHBs in Wales.

140

Stillbirths, rate per 1000, Wales LHBs, 2000-2004 (ICD10: all causes) Dat a s our ce : ONS ADBE

8 7

6 Welsh average = 5.1 5

4 3 Stillbirth rate Stillbirth 2 (per 1000 live and stillbirths) and live 1000 (per 1

Cardiff Conwy Powys

Torfaen Newport Bridgend Flintshire Swansea Gwynedd Wrexham Caerphilly

Ceredigion Denbighshire Merthyr Tydfil Pembrokeshire Blaenau Gwent Monmouthshire Isle of Anglesey Carmarthenshire

Neath PortTalbot Rhondda Cynon TaffRhondda The Vale of Glamorgan

Perinatal mortality The perinatal mortality rate is the number of deaths in babies who are stillborn or liveborn but die before the end of the 7th day of life, expressed as deaths per 1,000 live and stillbirths in the same year. The perinatal mortality rate is influenced by the proportion of low birth weight babies, the proportion of babies with serious congenital anomalies or other medical problems and the quality of maternity and neonatal healthcare services. Improvements in perinatal mortality are likely to reflect improvements in antenatal, intra-partum and early postnatal care (NPHS, 2004b). Wales has the lowest perinatal mortality rate in the UK remaining stable over the period 1996 to 2004.

At LHB/LA area level there is a considerable degree of variation, however, much of the pattern shown may be the result of random variation due to the small numbers of perinatal deaths. For the whole of Wales, the average annual number of neonatal deaths was around 240, meaning that in more than half of LHBs the average annual number of deaths over the five year period shown was in single figures. Torfaen perinatal mortality rate for 2000 to 2004 is shown in the graph below; the rate is higher than the Welsh average and raked fourth highest of the 22 LHB areas in Wales.

141 Perinatal mortality rate, Wales LHBs, 2000-2004 (ICD10: All causes) Data source: ONS annual birth and death extracts

10 9 8 Welsh average = 7.6 7 6 5 4 3

Perinatal Mortality rate 2

(per 1000 live and still births) 1 0 Cardiff Powys Conwy Torfaen Newport Bridgend Flintshire Swansea Gwynedd Wrexham Caerphilly Ceredigion Denbighshire Merthyr Tydfil Pembrokeshire Blaenau Gwent Monmouthshire Isle of Anglesey Carmarthenshire Neath Port Talbot Rhondda CynonRhondda Taff The Vale of Glamorgan

Neonatal mortality The neonatal mortality rate is expressed as the number of deaths in infants in the first 28 completed days of life per 1,000 live births in the same year. Causes of death recorded in notifications to the Office for National Statistics were recently reviewed and showed that over one half (58 per cent) of neonatal deaths in England and Wales in 2002 were due to prematurity and a quarter were due to congenital anomalies (NPHS, 2004b). Wales has the lowest neonatal mortality rate in the UK with a downward trend in the neonatal mortality rate in Wales between 1996 and 2004.

There is great variation in the rate at LHB level, however, much of the pattern shown may be the result of random variation due to the very small numbers of neonatal deaths. For the whole of Wales, the average annual number of neonatal deaths was around 100, meaning that in more than half of LHBs the average annual number of deaths over the five year period shown was less than five. The neonatal mortality rate in Torfaen is similar to that of the Welsh average of 3.3 per cent.

Infant mortality The infant mortality rate is the number of deaths in children aged less than one year per 1,000 live births in the same year. It is considered to be an important indicator of the level of health in a community and is associated with socio economic deprivation.

142

Causes of death recorded in notifications to the Office for National Statistics were recently reviewed and showed that premature birth is still the largest cause of death (46 per cent), followed by deaths due to congenital anomalies (28 per cent). In previous years, sudden infant deaths (previously known as “cot deaths”) would have comprised the largest single cause of death, however sudden infant deaths (SIDS) now account for only 5 per cent of deaths in this age group. This can be attributed to the reduction in SIDS following advice not to lay babies to sleep on their stomachs. Improved investigation of SIDS cases may also have led to an apparent reduction as other causes of death are identified (NPHS, 2004b). Wales has the lowest infant mortality rate in the UK with a downward trend between 1996 and 2004.

There is some variation in the infant mortality rate at LHB level. However, much of the pattern shown may be the result of random variation due to small numbers. For the whole of Wales, the average annual number of infant deaths was around 150, meaning that for most LHBs the average annual number of deaths over the 5 year period shown was in single figures. Torfaen has an infant mortality rate of 5 per 1000 live births, which is similar to the Welsh average.

Infant mortality rate, Wales LHBs, 2000-2004 (ICD10: All causes) Data source: ONS annual birth and death extracts 8

6 Welsh average = 4.9 5

3 Infant Mortalityrate

(per 1000 live births) 2

0 Cardiff Powys Conwy Torfaen Newport Bridgend Flintshire Swansea Gwynedd Wrexham Caerphilly Ceredigion Denbighshire Merthyr Tydfil Merthyr Pembrokeshire Blaenau Gwent Monmouthshire Isle of Anglesey Carmarthenshire Neath PortTalbot Rhondda Cynon Taff The Vale of Glamorgan

Deprivation and Health (NPHS, 2004) report includes data relating to infant mortality. The chart below shows there is a clear association between socio-economic deprivation and infant mortality. During the period shown the infant mortality rate in the most deprived 20 percent of electoral divisions was more than 60 per cent higher

143 than in the least deprived. One must remember the small numbers we are talking about locally however.

Infant mortality rate, Wales by 5th of deprivation, 1998-2001 Source: ONS / NPHS

7 6

5 4

Rate perRate 1,000 live births 1

0 1 (least deprived) 2 3 4 5 (most deprived) Electoral division deprivation fifth

144 Morbidity and mortality for selected poor health outcomes

Circulatory disease All circulatory diseases The most common types of circulatory disease are coronary heart disease and cerebrovascular disease (stroke). These are described in more detail in this section. Risk factors Risk factors for circulatory disease include high blood pressure, high blood cholesterol, tobacco use, unhealthy diet, physical inactivity, diabetes, advancing age and inherited (genetic) disposition, poverty, low educational status, poor mental health (depression), inflammation and blood clotting disorders, long periods of immobility e.g. while travelling, alcohol consumption and use of oral contraceptive (WHO, 2006b).

Morbidity The Welsh Health Survey asked adult respondents if they were being treated for a heart condition. Analysis of data for 2003/05 by LHB area revealed higher prevalence (for persons aged 16 and older) in the south Wales valleys, with the proportion in Torfaen being 10 per cent, slightly higher than the all-Wales average of 9.7 per cent and ranked 15 out of the 22 LHB/LA areas. More information from primary care is included later. Further detailed morbidity data are currently unavailable, and efforts need to be directed towards linking up practice level data with information from secondary care.

Adults who reported currently being treated

for a heart condition: 2003/05 Source: Welsh Health Survey, 2003/05

12 Welsh average = 9.7 10

Age standardised % 4

Cardiff Powys Conwy Torfaen Newport Bridgend Flintshire Swansea Gwynedd Wrexham Caerphilly Ceredigion

Denbighshire Merthyr Tydfil Pembrokeshire Blaenau Gwent Monmouthshire Isle ofAnglesey

Carmarthenshire Neath PortTalbot

Rhondda Cynon Taff

The ValeThe of Glamorgan

145

Mortality Circulatory disease accounts on average for more than 13,000 deaths per year in Wales and as expected the average annual number of deaths increases rapidly with age. In 2004, deaths from circulatory disease accounted for just under 38 percent of all deaths in Wales, however, the circulatory disease death rate in Wales has been falling continuously for a number of years.

Within Wales, the circulatory disease EASMR varies considerably between LHB/LA areas with the south Wales valleys having the highest rates, statistically significantly higher than the Welsh average. Torfaen is ranked the eighth lowest LHB/LA area in Wales with an EASMR for all circulatory diseases of 241.3 (95%CI, 226.5 to 257.1) not statistically significantly lower than the Welsh average of 256.

European age standardised mortality rates (EASMRs) Compared with Wales

for residents with an underlying cause of death of Significantly higher Higher

circulatory disease, by Local Health Board: 2002-2004 Significantly lower Lower Source: Annual District Death Extract (ADDE), ONS 350

300 Welsh average = 256 250

200

150

100

EASMR population) 100,000 (per 50

Cardiff Powys Conwy Torfaen

Newport Bridgend Swansea Flintshire Gwynedd Wrexham Caerphilly Ceredigion Denbighshire Merthyr Tydfil Pembrokeshire Blaenau Gwent

Monmouthshire Isle ofAnglesey Carmarthenshire Neath Port Talbot Rhondda CynonRhondda Taff The Vale of Glamorgan

146

The chart below shows the trend in deaths from all circulatory diseases for Torfaen LHB residents from 1996-2005 (HIAT, 2007).

All circulatory disease mortality European age standardised rate (EASR), persons: 1996-2005 Sources: ONS, StatsWales (WAG) Torfaen Wales 450 400 350 300 250 200

150

100

EASR per 100,000 population 100,000 per EASR 50 0 1996-98 1997-99 1998-00 1999-01 2000-02 2001-03 2002-04 2003-05

The average annual number of deaths in Torfaen LHB residents due to all circulatory diseases has decreased by 26 per cent from 467 in 1996-98 to 346 in 2003-05. Over the same period the equivalent number of deaths in Wales decreased by just over 15 per cent.

The European age standardised mortality rate (EASR) in Torfaen LHB residents due to all circulatory diseases decreased by 35 per cent from 349 in 1996-98 to 227 in 2003-05. Over the same period the equivalent EASR for Wales fell by almost 23 per cent.

Analysis of circulatory disease EASMR at small area level in Torfaen (MSOA) grouped into fifths across Wales and placed in rank order, shows that there is considerable variation across the borough. There are four areas, shaded darkest green in the map below, that are among the highest fifth for death from circulatory disease in Wales. Whilst in the south of the borough there are areas which are amongst the lowest in Wales for circulatory disease related mortality.

147

European age-standardised mortality rates (EASMR) for Torfaen residents of underlying cause of death of circulatory disease by MSOA; 2000 to 2004

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148 Coronary Heart Disease Risk factors Major risk factors for CHD include high blood pressure, high blood cholesterol, tobacco use, unhealthy diet, physical inactivity, diabetes, advancing age and inherited (genetic) disposition (WHO, 2006b). Other risk factors or ‘determinants’ are poverty, low educational status, poor mental health (depression), inflammation and blood clotting disorders (WHO, 2006b). Analysis of 1998 Welsh Health Survey data revealed that heart disease is statistically significantly higher in the more deprived areas compared with the least deprived (NPHS, 2004b).

Heart disease, persons aged 18 and over, 1998 Data source: Welsh Health Survey 1998

Health service utilisation Analysis of health service utilisation by LHB/LA area show the person based hospital admission rate where the primary diagnosis is CHD (ICD-10, I20 to I25) between 2003 and 2005. There is considerable variation between LHB/LA areas in Wales, the rate for the area with the highest (1,329) being more than double that of the lowest (609). The EASMR for Torfaen (878.4) is statistically significantly lower than the Wales average (914.5); Torfaen is ranked 11th out of 22.

149

People admitted to hospital for CHD, Compared with Wales EASMR per 100,000, LHBs 2003-2005 Significantly Higher Low er Higher Significantly Low er Dat a s our ce : PEDW 1400

1200 Wales rate = 914.5 1000

800

600

EASR per 100,000 400 200 0

Rhondda CynonTaff

TheVale of Glamorgan

Mortality The average annual number of deaths for both men and women in Wales, as with all circulatory disease (above), shows a sharp increase with age. In 2004, deaths from CHD accounted for just under 19 per cent of all deaths in Wales. The CHD death rate in Wales has been falling continuously for a number of years. The European age standardised mortality rate (EASMR) for coronary heart disease however in Wales is above the UK average in 2002-2004.

Analysis at the LHB/LA area level shows variation between areas, ranging from 105 per to 155 per 100,000. The areas with the highest rates are mainly in the south Wales valleys whilst the annual rate (2002 – 2004) for Torfaen (131.9) is similar to and slightly below the Welsh average (133.1).

150 European age standardised mortality rates (EASMRs) for Compared with Wales residents with an underlying cause of death of Significantly higher Higher coronary heart disease by Local Health Board: 2002-2004 Significantly lower Lower Source: Annual District Death Extract (ADDE), ONS 180

160 Welsh average = 133.1 140

120 population) 100

40 EASMR (per 100,000 20

0 Cardiff Conwy Powys Torfaen Newport Bridgend Flintshire Swansea Gwynedd Wrexham Caerphilly Ceredigion Denbighshire Merthyr Tydfil Pembrokeshire Blaenau Gwent Monmouthshire Isle of Anglesey Carmarthenshire Neath PortTalbot Rhondda CynonRhondda Taff The Vale of Glamorgan

The chart below shows the trend in deaths from coronary heart disease for Torfaen LHB male residents from 1996-2005.

Coronary heart disease mortality European age standardised rate (EASR), males: 1996-2005 Sources: ONS, StatsWales (WAG)

Torfaen Wales 350

300 250

200

150 100

50 EASR per 100,000 population 100,000 per EASR

0 1996-98 1997-99 1998-00 1999-01 2000-02 2001-03 2002-04 2003-05

151 The average annual number of deaths in Torfaen LHB male residents due to coronary heart disease has decreased by 34 per cent from 146 in 1996-98 to 96 in 2003-05. Over the same period the equivalent number of deaths in Wales decreased by 21 per cent.

The European age standardised mortality rate (EASR) in Torfaen LHB male residents due to coronary heart disease decreased by 43 per cent from 288 in 1996- 98 to 164 in 2003-05. Over the same period the equivalent EASR for Wales fell by almost 30 per cent.

Over the 10-year period, the EASR in Torfaen has fluctuated, though has been generally similar to the Welsh rate.

The chart below shows the trend in deaths from coronary heart disease for Torfaen LHB female residents from 1996-2005.

Coronary heart disease mortality European age standardised rate (EASR), females: 1996-2005 Sources: ONS, StatsWales (WAG) Torfaen Wales 350

300

250

200

150

100

50 EASR per 100,000 population

0 1996-98 1997-99 1998-00 1999-01 2000-02 2001-03 2002-04 2003-05

The average annual number of deaths in Torfaen LHB female residents due to coronary heart disease has decreased by 25 per cent from 114 in 1996-98 to 85 in 2003-05. Over the same period the equivalent number of deaths in Wales decreased by almost 21 per cent.

The European age standardised mortality rate (EASR) in Torfaen LHB female residents due to coronary heart disease decreased by 33 per cent from 133 in 1996- 98 to 87 in 2003-05. Over the same period the equivalent European age standardised mortality rate for Wales fell by over 27 per cent.

Over the 10-year period, the EASR in Torfaen has been higher than, but similar to, the Welsh rate. Importantly, the trend towards lower mortality rates from CHD is more pronounced in Torfaen compared to Wales.

152 Analysis at the sub-LHB/LA level (MSOA) within Torfaen for CHD EASMR ranked for Wales and grouped into fifths, shows that there are two areas in Torfaen, both in the North of the borough, which are amongst the highest in Wales. As with all circulatory diseases, there are areas in the south of the borough with rates amongst the lowest in Wales.

European age standardised mortality rates (EASMRs) for coronary heart disease (persons, all ages) by MSOA: 2000-2004

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153 Cerebrovascular disease (stroke) Strokes are caused by disruption of the blood supply to the brain. This may result from either blockage (ischaemic stroke) or rupture of a blood vessel (haemorrhagic stroke) (WHO, 2006b).

Risk factors Major risk factors for strokes include high blood pressure, high blood cholesterol, tobacco use, unhealthy diet, physical inactivity, diabetes and advancing age (WHO, 2006b).

Mortality The average annual number of deaths from strokes occurring between 2002 and 2004 shows a sharp increase with age. The following chart shows that the stroke death rate in Wales has been falling, although not as markedly as the trend for coronary heart disease. The European age standardised mortality rate (EASMR) for cerebrovascular disease in Wales can be seen to be above the UK average in 2002- 2004, but lower than the rate for Scotland

Within Wales, at LHB level, the European Age Standardised Mortality Rate (EASMR) for stroke varies considerably from 73 per 100,000 in Rhondda Cynon Taff to 52 per 100,000 in Torfaen. Torfaen is ranked 1st out of the 22 LHB/LA areas in wales for the lowest rate of death from stroke, statistically significantly lower than the Welsh average (66.1%).

European age standardised mortality rates (EASMRs) for Compared with Wales residents with an underlying cause of death of Significantly higher Higher cerebrovascular disease (stroke) Significantly lower Lower by Local Health Board: 2002-2004 Source: Annual District Death Extract (ADDE), ONS 80 Welsh average = 66.1 70 )

20 EASMR (per 100,000 population 10

154 Males The chart below shows the trend in deaths from cerebrovascular disease for Torfaen LHB male residents from 1996-2005.

Cerebrovascular disease mortality European age standardised rate (EASR), males: 1996-2005 Sources: ONS, StatsWales (WAG) Torfaen Wales 140

120

100

20 EASRper 100,000 population

0 1996-98 1997-99 1998-00 1999-01 2000-02 2001-03 2002-04 2003-05

The average annual number of deaths in Torfaen LHB male residents due to cerebrovascular disease has decreased by over 23 per cent from 41 in 1996-98 to 31 in 2003-05. Over the same period the equivalent number of deaths in Wales decreased by just over six per cent.

The European age standardised mortality rate (EASR) in Torfaen LHB male residents due to cerebrovascular disease decreased by almost 33 per cent from 79 in 1996-98 to 53 in 2003-05. Over the same period the equivalent EASR for Wales fell by almost 18 per cent.

Over the 10-year period, the EASR in Torfaen has fluctuated as one might expect, due to the relatively small numbers involved. Although the trend has been generally similar to the Welsh rate, the reduction in mortality following stroke is more marked.

155 Females The chart below shows the trend in deaths from cerebrovascular disease for Torfaen LHB female residents from 1996-2005.

Cerebrovascular disease mortality European age standardised rate (EASR), females: 1996-2005 Sources: ONS, StatsWales (WAG) Torfaen Wales 140

120

100

20 EASRper 100,000 population

0 1996-98 1997-99 1998-00 1999-01 2000-02 2001-03 2002-04 2003-05

The average annual number of deaths in Torfaen LHB female residents due to cerebrovascular disease has decreased by 26 per cent from 66 in 1996-98 to 49 in 2003-05. Over the same period the equivalent number of deaths in Wales decreased by almost 10 per cent.

The European age standardised mortality rate (EASR) in Torfaen LHB female residents due to cerebrovascular disease decreased by almost 35 per cent from 72 in 1996-98 to 47 in 2003-05. Over the same period the equivalent EASR for Wales fell by just over 16 per cent.

Over the 10-year period, the EASR in Torfaen has been lower than, but similar to, the Welsh rate. Once more, the mortality rate has fallen more steeply in Torfaen compared to the Welsh average, again the small numbers must be considered however for the last three time-points in the graph above, the Torfaen EASMR for stroke in females is statistically significantly lower than the Welsh average.

Analysis at the sub-LHB/LA level (MSOA) within Torfaen for stroke EASMR ranked for Wales and grouped into fifths shows considerable variation between areas. Despite Torfaen LHB/LA area having the lowest rate of death from stroke, and as expected several (six) areas within the lowest fifth of stroke mortality in Wales, there are pockets where death from stroke are amongst the highest and second highest fifth in Wales; see map below.

156 European age standardised mortality rates (EASMRs) for cerebrovascular disease (persons, all ages) by MSOA: 2000-2004

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157 Respiratory disease Respiratory diseases are a very common cause of ill health, hospitalisation and death. This section covers the respiratory diseases included in chapter J of the International Classification of Diseases including, influenza and pneumonia, lung diseases due to external agents e.g. pneumoconiosis, chronic lower respiratory diseases e.g. emphysema, asthma, chronic obstructive pulmonary disease, and, acute upper and lower respiratory tract infections e.g. common cold, acute bronchitis, etc.

All respiratory diseases Morbidity The latest Welsh Health Survey (2003/05) asked adults whether they were currently being treated for any respiratory illness. Analysis at LHB/LA area level shows that Torfaen has an age standardised prevalence for adults currently being treated for a respiratory illness at 14.6 per cent; this is higher than the Welsh average (13.6%) and Torfaen is ranked sixth highest of the 22 LHB/LA areas.

Adults who reported currently being treated for a respiratory illness: 2003/05 Source: Welsh Health Survey, 2003/05 18 16 14 Welsh average = 13.6

10 8 6

Age Standardised % 4

2 0

Powys Cardiff Conwy Torfaen Newport Bridgend Flintshire Swansea Gwynedd Wrexham Caerphilly Ceredigion Denbighshire Merthyr Tydfil Merthyr Pembrokeshire Blaenau Gwent Monmouthshire Isle of Anglesey Carmarthenshire Neath Port Talbot Rhondda Cynon Taff

The Vale of Glamorgan

158 Mortality Respiratory diseases were reported as the underlying cause of death in 13 per cent of all deaths in Wales between 2002 and 2004. The age standardised mortality rate for deaths due to respiratory diseases is lower in Wales than in Northern Ireland and Scotland.

Analysis at LHB/LA area shows the EASMR for respiratory disease in Torfaen is 74 per 100,000 population. Torfaen is ranked ninth out of the 22 LHB/LA areas in Wales and the rate of death from respiratory disease is statistically significantly lower than the Welsh average (83/100,000).

European age standardised mortality rates, underlying cause of death: respiratory disease, by Local Health Board: 2002-2004 Source: Annual District Death Extract (ADDE), ONS

120

100 Welsh average = 82.8

EASMR (per 100,000 population) (per EASMR

Powys Cardiff Conwy Torfaen Newport Bridgend Flintshire Swansea

Gwynedd Wrexham Caerphilly Ceredigion Denbighshire Merthyr Tydfil Pembrokeshire Blaenau Gwent

Monmouthshire Isle of Anglesey Carmarthenshire Neath Port Talbot

Rhondda Cynon Taff Cynon Rhondda The Vale of Glamorgan The

Analysis at the sub-LHB/LA level (MSOA) within Torfaen for deaths (EASMR) where the underlying cause is respiratory disease ranked for Wales and grouped into fifths shows that Torfaen has no areas amongst the highest fifth in Wales but the two areas where this mortality rate is among the MSOAs in the second highest fifth in Wales.

159 European age standardised mortality rates (EASMRs) for respiratory disease (persons, all ages) by MSOA: 2000-2004

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Asthma Morbidity Asthma UK claim that asthma prevalence in Wales is amongst the highest in the world, with 260,000 people estimated to be living with the disease (Asthma UK, 2005). The latest Welsh Health Survey (2003/05) asked adults whether they were currently being treated for asthma; analysis of these data at LHB/LA level shows that Torfaen has an age standardised prevalence of 10.6 per cent, similar to the Welsh average, and is ranked eighth out of the 22 areas in Wales for prevalence of people being treated for asthma (one being the area with the highest prevalence).

160

Adults who reported currently being treated for asthma: 2003/05 Source: Welsh Health Survey, 2003/05 14

12 Welsh average = 10.1 10

4 Age Standardised (%)

Powys Cardiff Conwy

Torfaen Newport Bridgend Flintshire Swansea Gwynedd Wrexham Caerphilly

Ceredigion Denbighshire Merthyr Tydfil Pembrokeshire Blaenau Gwent Blaenau Monmouthshire Isle of Anglesey of Isle Carmarthenshire

Neath Port Talbot Port Neath

Rhondda Cynon Taff Cynon Rhondda The Vale of of The Vale Glamorgan

161 Injuries Injuries are caused by predicable interactions between individuals and the environment in which they live and work. The term ‘accident’ is rarely used in contemporary parlance as it tends to suggest that injuries are random events and not amenable to prevention when, as mentioned, they usually follow a predictable pattern of exposure and are largely preventable. This needs assessment will therefore present data for the pattern of injury and it’s ‘determinants’ under the section Life Circumstances; the information provided in this section relates to the impact of injury on health status and there are more data in the section on Service Provision.

Mortality Whilst injuries account for only about three per cent of total deaths in Wales, the distribution of the age of death in those dying is very different from most other causes of death with a high proportion of deaths occurring in children and young people. After the age of one, injury is the first or second leading cause of death in Wales for young people. When a different measure of counting the impact of death is used, potential years of life lost (PYLL) before age 75 injuries account for around 15 per cent of all premature mortality in Wales.

Age and sex There are in the region of one thousand deaths registered for Welsh residents each year where the underlying cause of death is injury. An analysis of the age/sex distribution for injury deaths registered in 2002-2004, shows that on average higher numbers of deaths occur in older people. Males in their 20’s and 30’s accounted for more than 20 per cent (235 on average) of injury death registrations each year.

Deaths resulting from injuries by age and sex, Wales: 2002-2004 Data source: A nnual Dis trict Death Extract (A DDE), ONS 220 Males Females 200

180

160

140

120

100

40 Average number of deaths per year 20

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

162 In Torfaen the annual death rate (EASMR, 2002 – 2004) where the underlying cause is injury, is 24.7 per 100,000 of the population, statistically significantly lower than the Welsh average (30.9). Torfaen is ranked third lowest of the 22 LHB/LA areas in Wales for death from injury.

European age standardised mortality rates (EASMRs) Compared with Wales for residents with an underlying cause of Significantly higher Higher death of injury, by Local Health Board: 2002-2004 Significantly lower Lower Source: Annual District Death Extract (ADDE), ONS 45

40 )

35 Welsh average = 30.9 30 opulation

10 EASMR (per 100,000p 5

Analysis at sub-LHB/LA area (MSOA) for mortality following injury shows that there are seven areas amongst the lowest fifth of death rates following injury in Wales, with no areas amongst the highest fifth.

163 European age standardised mortality rates (EASMRs) for injuries (persons, all ages) by middle super output area (MSOA): 1996-2004

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164 Cancers Cancer Research UK estimates that one in three people in England & Wales will develop some form of cancer during their lifetime (CRUK, 2003a). The chances of developing any specific form of cancer vary, though the chances of developing almost all forms increase with age. Aside from gender specific cancers the risks of developing each type of cancer are often different for men than for women.

Whilst many forms of cancer, especially if detected early enough, can be treated successfully, about one in four of all annual deaths have been attributed to cancer in England & Wales (Coleman et al, 1999). In Wales, between 2002 and 2004, the average annual number of cancer related deaths was 8422 out of a total of 33147 deaths from all causes.

Therefore cancer and its control constitute major public health issues. Whilst the exact causes of many types of cancer remain uncertain, contributing factors for some cancers are no longer in question. For example, the causal link between tobacco smoking and lung cancer is well known. Given the long time many cancers take to develop, any control measures (such as smoking cessation) are unlikely to impact on disease incidence rates in the short term and hence can only really be viewed over a much longer period than can be reported here. Analyses of all malignancies, as well as analyses relating to the number of new cases of three of the most common cancers for each of the sexes are presented here.

All malignancies (excluding other skin) It is common practice to exclude certain skin cancers (ICD10: C44 Other malignant neoplasms of skin) from all malignancies tabulations. This is because of known inconsistency over the completeness of their registration and their exclusion therefore avoids a known potential bias. Therefore they are generally excluded from the incidence and mortality figures shown below but are probably included in the self reported Welsh Health Survey responses.

Morbidity The most recent Welsh Health Survey (WHS) asked respondents whether they had “ever been treated for cancer”. It is important to note when interpreting these results that there was no time limit specified, i.e. it is more akin to a lifetime prevalence, nor were any specific details as to the type of cancer, i.e. whether it was malignant, benign or in situ.

The findings of the WHS are somewhat at odds with the cancer incidence analyses from WCISU that follow, though the differences in what is being measured by the two analyses must be borne in mind. The self-reported WHS is more open to bias than the highly validated WCISU data. It is generally accepted that cancer incidence figures derived from national registries, such as WCISU, are the most accurate measure of the level of new cancers and therefore of the burden of cancer in any given community.

The Welsh Health Survey (2003/2005) age standardised (‘lifetime’) prevalence, those who reported having been treated for cancer, in Torfaen is 4.4 per cent of the

165 population. Whilst this is the eighth highest LHB/LA area of the 22 in Wales, it must be borne in mind that this is just 0.2 per cent higher than the Welsh average.

Adults who reported ever having been treated for cancer: 2003/05 Source: Welsh Health Survey, 2003/05 6

5 Welsh average = 4.2 4

2 Age standardised % standardised Age

Powys Cardiff Conwy Torfaen

Newport Bridgend Flintshire Swansea Gwynedd Wrexham Caerphilly Neath Port Ceredigion The Vale of Denbighshire Merthyr Tydfil Merthyr Pembrokeshire Blaenau Gwent Monmouthshire Isle of Anglesey Rhondda Cynon Carmarthenshire

The difference between the WHS and WCISU data could also in part be related to the interpretation of the word “treatment” in the WHS question. For some this could be taken to include investigations into suspected malignancies which may have turned out to be benign or in situ, although it is not clear how this may have particularly affected some LHBs relative to others.

The annual European age standardised rates (1995 – 2004) calculated from the registration data were subjected to a significance test to evaluate whether they were any different from the all Wales rate (Woodward, 1999). The WCISU analysis of their data show the age standardised difference in cancer registrations between LHB/LA areas, ranging from 356.4 to 410.9 registrations per 100,000. Torfaen LHB/LA area is ranked eighth lowest out of the 22 areas in Wales with an EASR of 384.

166 Cancer registrations for all malignancies excluding other skin (ICD10: C44), all persons, all ages by area of residence: 1995-2004 Data source: Welsh Cancer Intelligence and Surveillance Unit

450

Welsh average = 390.2 400

350

Compared with Wales 300 Significantly higher Higher 250 Significantly lower Lower 200

150 (per 100,000 population) 100,000 (per

Europeanage standardised rate 100

0 Powys Cardiff Conwy Torfaen Newport Bridgend Flintshire Swansea Gwynedd Wrexham Caerphilly Ceredigion Denbighshire Merthyr Tydfil Merthyr Pembrokeshire Blaenau Gwent Monmouthshire Isle of Anglesey Carmarthenshire Neath Port Talbot Port Neath Rhondda CynonTaff The Vale of Glamorgan of Vale The

Mortality It is important to note that mortality has limitations in its use for evaluating cancer trends. It is highly dependent on not just those patients diagnosed recently but the numbers diagnosed some time before and the success of any treatment they have received. It is estimated that around a quarter of people with cancer die from other causes and therefore do not figure in any cancer mortality analysis (Coleman et al, 1999).

The age standardised mortality rates for all malignant neoplasms in the four constituent countries of the United Kingdom shows that the Welsh rate of 190 is slightly higher than the rates in England, Northern Ireland and the UK as a whole. In Wales the European age standardised mortality rate for all malignancies has dropped by over five per cent between 1996-98 and 2002-04. However the actual number of cancer deaths has remained constant over the same period. This may be related to many of the more common cancers such as lung cancer having a relatively poor outcome with treatment, hence the increased relative importance of prevention

167

The same methods that were applied to the age standardised LHB registration analyses were applied to the age standardised mortality analyses. Cancer mortality appears to be higher in the south Wales valleys with the EASMR for Torfaen being 197 per 100,000 0f the population, which is higher but not statistically significantly different to the Welsh average.

European age standardised mortality rates (EASMRs) for residents with an underlying cause of death of malignant neoplasm (excl. other skin), by Local Health Board: 2002-2004 Source: Annual District Death Extract (ADDE), ONS

250

Welsh average = 189.3 200

150 Compared with Wales

Significantly higher Higher 100 Significantly lower Lower

50 EASMR (per 100,000 population)(per 100,000 EASMR

0 Powys Cardiff Conwy Torfaen Newport Bridgend Flintshire Swansea Gwynedd Wrexham Caerphilly Ceredigion Denbighshire Merthyr Tydfil Merthyr Pembrokeshire Blaenau Gwent Blaenau Monmouthshire Isle Anglesey of Carmarthenshire Neath Port Port Talbot Neath Rhondda Cynon Taff Cynon Rhondda The Vale of Glamorgan of Vale The

Analysis of cancer mortality at Middle Super Output Area (MSOA) level suggests that pockets of high age-standardised rates of cancer mortality can be found in LHBs with an overall lower standardised rate. In Torfaen four areas are amongst the highest fifth in Wales for death from cancer.

168 European age standardised mortality rates (EASMRs) for all malignancies excluding other skin (persons, all ages) by middle super output area (MSOA): Torfaen: 2000-2004

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169 Trachea, bronchus and lung Lung cancer is the most common cancer in the world yet is caused in at least 90 per cent of cases by tobacco smoking. In the UK, lung cancer accounts for about one in four of all cancers. Tobacco smoking is a risk factor for many other cancers hence tobacco control must remain high on the Health Social Care and Wellbeing agenda. Nicotine is highly addictive and smoking cessation is a worthy but difficult cause. Work based around preventing the development of a smoking habit must continue, especially in groups where smoking uptake is known to be rising such as in young women. Generally, incidence of lung cancer in men has been falling whilst incidence in females has been rising, mirroring the trends in cigarette smoking habits. Survival rates are very poor with around 1 in 16 diagnosed with the disease surviving for more than five years (Coleman, 1999). As such, lung cancer is one of the few cancers where incidence and mortality figures are usually very similar.

Morbidity Data from WCISU shown in the following chart and map suggest that lung cancer incidence is highest in the south Wales valleys and in the north east of Wales.

Analysis at LHB/LA area level shows the variation between these areas and the Welsh average. The annual European age standardised rate for lung cancer incidence (registrations) in Torfaen is 60.4 this is statistically significantly higher than the Welsh average (51.7) and is fourth highest of all the LHB/LA areas’ annual rates in Wales. There is considerable variation between the areas from just over 36 per 100,000 of the population per year to just over 65; the annual incidence in Torfaen is nearly 67 per cent higher than the LHB/LA area with the lowest rate.

170 Registrations for cancer of the trachea, bronchus and lung, persons, all ages by area of residence: 1995-2004 (ICD10: C33-C34) Data source: Welsh Cancer Intelligence and Surveillance Unit

Welsh average = 51.6 50 Compared with Wales

40 Significantly higher Higher

Significantly lower Lower 30 (per 100,000 population) 20 European age standardisedrate

0 Powys Cardiff Conwy Torfaen Newport Bridgend Flintshire Swansea Gwynedd Wrexham Caerphilly Ceredigion Denbighshire Merthyr Tydfil Pembrokeshire Blaenau GwentBlaenau Monmouthshire Isle Anglesey of Carmarthenshire Neath Port Talbot Rhondda Cynon TaffRhondda Cynon The Vale of Glamorgan

171 The chart below shows the trend in cancer registrations for cancers of the trachea, bronchus and lung for Torfaen male residents from 1996-2005.

Registrations for cancers of the trachea, bronchus and lung, 3-year rolling European Age Standardised Rate (EASR), males 1996-2005 Source: Welsh Cancer Intelligence and Surveillance Unit

Torfaen Wales

xxx 120

100

80 60

EASR per 100,000 population population 100,000 per EASR 0 1996-98 1997-99 1998-00 1999-01 2000-02 2001-03 2002-04 2003-05

Generally, incidence of lung cancer in men has been falling, mirroring the trends in cigarette smoking habits (NPHS, 2006c). The overall rate for male lung cancers in Torfaen has been consistently higher than the Welsh rate.

The chart below shows the trend in cancer registrations for cancers of the trachea, bronchus and lung for Torfaen female residents from 1996-2005.

Registrations for cancers of the trachea, bronchus and lung, 3-year rolling European Age Standardised

Rate (EASR), females 1996-2005 Source: Welsh Cancer Intelligence and Surveillance Unit Torfaen Wales xxx 120

100 80

40 20

EASR per 100,000 population 0 1996-98 1997-99 1998-00 1999-01 2000-02 2001-03 2002-04 2003-05

172 Generally, incidence of lung cancer in females has been rising, again mirroring the trends in cigarette smoking habits (NPHS, 2006c). The rate for female lung cancer in Torfaen has been very slightly higher than, but not statistically different to, the Welsh rate.

Survival rates for this cancer are very poor with around 1 in 16 diagnosed with the disease surviving for more than five years (Coleman et al., 1999). As such, lung cancer is one of the few cancers where incidence and mortality figures are usually very similar (NPHS, 2006c). This underlines the need for focussing on preventive measures, specifically smoking cessation and prevention of smoking initiation.

Colon Cancers of the colon account for around 1 in 11 of all cancers and the incidence in males has increased constantly since the mid 1970s. Incidence rates in males are 50 per cent higher than in females though more women develop the disease due to greater life expectancy. Over 80 per cent of cases are diagnosed in persons aged over 60.

Whilst the causes are less clear than for lung cancer there is some evidence to suggest that diet and lifestyle factors may affect the chances of an individual developing colon cancer. Increased physical activity levels probably decrease the risk whilst obesity probably increases the risk (see sections on Physical activity and Nutrition/obesity for further information on these risk factors).

Morbidity Analysis at the LHB/LA area reveals that the annual incidence (EASR for registration, 1995 - 2004) of colon cancer in Torfaen is 29.5 per 100,000 of the population, similar to the Welsh average of 29.4.

173 Registrations for cancer of the colon, persons, all ages by area of residence: 1995-2004 (ICD10: C18) Data source: Welsh Cancer Intelligence and Surveillance Unit

35 Welsh average = 29.4

30 Compared with Wales

Significantly higher Higher 25 Significantly lower Lower 20

15 (per 100,000 population) 10 Europeanage standardised rate

0 Powys Cardiff Conwy Torfaen Newport Bridgend Flintshire Swansea Gwynedd Wrexham Caerphilly Ceredigion Denbighshire Merthyr Tydfil Pembrokeshire Blaenau Gwent Monmouthshire Isle of Anglesey Carmarthenshire Neath Port Talbot Rhondda Cynon Taff TheGlamorgan Vale of

Again the causes of colon cancer do not lend themselves to short term targets to reduce incidence. Wholesale dietary and lifestyle changes, if possible, would not be reflected in these figures for many years. However, they remain essential to general public health improvement and, in addition, the promotion of awareness and early detection of colon cancer is important.

Breast (female) Breast cancer can occur in both sexes, though whilst it is rare in males it is the most common form of cancer in females, accounting for about 20 per cent of all cancers. The risk of a female developing breast cancer changes rapidly with age and the overall lifetime risk is 1 in 9. There are many known and/or suspected risk factors, some of which relate to reproductive history, exogenous and endogenous hormones, overweight and obesity, diet, physical activity and alcohol intake.

The chart below shows the trend in registrations for female breast cancers for Torfaen residents from 1996-2005.

174 Female breast cancer registrations, 3-year rolling European Age Standardised Rate (EASR), females: 1996-2005 Source: Welsh Cancer Intelligence and Surveillance Unit

Torfaen Wales xxx 180 160 140 120

100

60 40 20

EASR per 100,000 population 0 1996-98 1997-99 1998-00 1999-01 2000-02 2001-03 2002-04 2003-05

The incidence of female breast cancer for Wales is seen to be steadily increasing throughout the 10-year study period. The rate in Torfaen has fluctuated, though has been generally similar to the Welsh rate.

Morbidity As the vast majority of breast cancer cases occur in females the incidence analysis presented here is for females only. Incidence in the UK as a whole has increased constantly since the 1970s. Early detection, often through the breast cancer screening programme or other self awareness programmes, can lead to a significant improvement in the chance of successful treatment.

In Torfaen the annual incidence (EASR for registration, 1995 - 2004) of breast cancer in females is 111.7 per 100,000 of the population this is slightly lower but not significantly different to the welsh average of 114.2.

175 Registrations for cancer of the breast, females, all ages by area of residence: 1995-2004 (ICD10: C50) Data source: Welsh Cancer Intelligence and Surveillance Unit

140

Welsh average = 114.2 120

100

80 Compared with Wales

Significantly higher Higher 60 Significantly lower Lower

(per 100,000 population)(per 100,000 40 European age standardisedrate

Prostate Prostate cancer is the most common gender specific cancer in men, accounting for around 1 in 8 of all male cancers. Incidence has been observed to have been increasing in England & Wales by 10-15 per cent every five years (Coleman et al, 1999). The exact causes of prostate cancer are unclear but, like many cancers, it is strongly related to age, with the disease being rare in males under 50 and with half of all cases occurring after the age of 75.

The increase in cases is thought in part to relate to the common presence of latent prostatic carcinoma being increasingly diagnosed incidentally to treatment for benign prostatic hypertrophy. Therefore, some variations in incidence rates may be due to variations in the conduct of prostatectomy for benign prostatic disease.

176 Morbidity Analysis at the LHB/LA area level shows that Torfaen has the lowest annual rate (EASR for registrations, 1995 – 2004) of all 22 areas in Wales at 70.5 per 100,000 population, significantly lower than the Welsh average of 87.3.

Registrations for cancer of the prostate, males, all ages by area of residence: 1995-2004 (ICD10: C61) Data source: Welsh Cancer Intelligence and Surveillance Unit

120

100 Welsh average = 87.3

80 Compared with Wales

Significantly higher Higher 60 Significantly lower Lower

40 (per 100,000 population) European age standardisedrate

0 Powys Cardiff Conwy Torfaen Newport Bridgend Flintshire Swansea Gwynedd Wrexham Caerphilly Ceredigion Denbighshire Merthyr Tydfil Merthyr Pembrokeshire Blaenau Gwent Monmouthshire Isle ofAnglesey Carmarthenshire Neath Port Talbot Neath Rhondda Cynon Taff The Vale of Glamorgan

The chart below shows the trend in registrations for prostate cancers for Torfaen male residents from 1996-2005.

177

Prostate cancer registrations, 3-year rolling European Age Standardised Rate (EASR), males: 1996-2005 Source: Welsh Cancer Intelligence and Surveillance Unit Torfaen Wales 180 xxx 160 140 120 100

80 60 40

EASR per 100,000 population population 100,000 per EASR 20

1996-98 1997-99 1998-00 1999-01 2000-02 2001-03 2002-04 2003-05

Incidence of prostate cancer has been observed to have been increasing in England & Wales by 10-15 per cent every five years (Coleman et al., 1999). The rate in Torfaen has been rising since 1998 – 2000 and continues to rise up to 2005. The rate for prostate cancer was consistently lower than the Welsh rate until 2002-2004 when it increased to a similar rate to Wales. Despite Torfaen having the lowest incidence of all 22 LHB/LA areas in Wales, the trend of increasing incidence might be a reflection of greater public awareness of men’s health and prostate cancer leading to increased screening in primary care and greater detection and registration rates rather than an increase in prostate cancer in Torfaen.

Skin cancer Solar radiation (exposure to the sun) is the main known risk factor for three of the four main types of skin cancer (Detels et al, 2002). However, of those three, only malignant melanoma is considered here. The other two, squamous cell and basal cell carcinoma, are often diagnosed and treated without pathological confirmation and are therefore incompletely and inconsistently registered.

Morbidity As solar radiation is the main causation of melanoma, its avoidance must be the only main preventative measure that can be promoted, given that there is mixed evidence as to the effectiveness of sunscreens in preventing melanoma (Gore & Russell, 2003).

People with blond or red hair colour are at higher risk of developing malignant melanoma, as are people with fair and/or very photo-reactive skin. In addition, malignant melanoma has been observed to be more common in indoor workers and in the higher socioeconomic classes (Gore & Russell, 2003). These associations may be due to less awareness/compliance with solar avoidance which is counter-

178 intuitive to other associations of health behaviour awareness with occupational social class. It is suggested that this might reflect greater exposure to extreme solar radiation, through foreign holidays though one still might expect Manual Unskilled to have more prolonged exposure to the sun through occupation. It is accepted that extreme exposure in childhood is the most significant risk factor which might support the foreign travel hypothesis. There is little overall difference in risk between males and females.

Whilst malignant melanoma is rare in those aged less than twenty, its linear relationship with age makes it one of the more common tumours in young adulthood (Detels et al, 2002). This linear relationship with age is strongest for melanomas on the face and, in fact, the incidence of melanomas on other parts of the body increases to middle age but declines thereafter.

Analysis of cancer registrations for malignant melanoma (1995 to 2004) at LHB/LA area level show that Torfaen has a slightly lower incidence of malignant melanoma than the Welsh average of 9.6 per 100,000 of the population. Torfaen has the fourth lowest incidence of malignant melanoma of the 22 LHB/LA areas in Wales.

Cancer registrations for malignant melanoma, persons, all ages by area of residence: 1995-2004 (ICD10: C43) Data s our ce : Welsh Cancer Intelligence and Surveillance Unit Compared with Wales Significantly Higher Low er Higher Significantly Low er 16

14 12 Welsh average = 9.6 10

8 6

4 (per 100,000 population)

European age standardised rate 2 0

Cardiff Powys Conwy Torfaen Newport

Bridgend Swansea Flintshire Gwynedd Wrexham Caerphilly Ceredigion Denbighshire Merthyr Tydfil Merthyr Pembrokeshire Blaenau Gwent Monmouthshire Isle of Anglesey Carmarthenshire Neath Port Talbot CynonRhondda Taff The Vale of Glamorgan

Mortality Whilst the number of deaths is still relatively small, across Wales, the age standardised rate increased substantially between 1996 and 2004. The direct relationship between mortality from malignant melanoma and advancing age is

179 steep; mortality doubles from those aged 50 to 59 years to those aged 60 to 69 years, and the rate in those age 80 years and older is almost double that. However, the numbers are very small ranging from less than one per 100,000 per year in those aged 20 to 29 to just over 5 per 100,000 per year in those aged 80 years and older.

180 Diabetes Diabetes is a chronic condition that occurs when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces. There are two main types of diabetes mellitus:

• Type 1: people with this type of diabetes produce very little or no insulin. • Type 2: people with this type of diabetes cannot use insulin effectively. Most people with diabetes have type 2. A third type of diabetes, gestational diabetes mellitus, develops during some cases of pregnancy but often disappears after pregnancy (WHO, 2006).

The 2003/5 Welsh Health Survey asked adult respondents if they were currently being treated for diabetes (by injection, tablets or diet). Analysis of the data by LHB/LA area shows reported prevalence (age standardised for persons aged 16+) in Torfaen to be 5.9 per cent, slightly higher than the all-Wales average of 5.3 per cent and sixth highest of the 22 authorities in Wales.

Adults who reported currently being treated for diabetes: 2003/05 Source: Welsh Health Survey, 2003/05 7

6 Welsh average = 5.3 5

Age standardised % 2

0 Cardiff Conwy Powys Torfaen Newport Bridgend Flintshire Swansea Gwynedd Wrexham Caerphilly Ceredigion Denbighshire Merthyr Tydfil Pembrokeshire Blaenau Gwent Monmouthshire Isle of Anglesey Carmarthenshire Neath Port Talbot Rhondda CynonRhondda Taff The Vale of Glamorgan

181 The below graphs show estimates for diabetes prevalence, diagnosed and undiagnosed, LHB/LA area level using a model created by Yorkshire and Humber Public Health Observatory (http://www.yhpho.org.uk/). The estimates were derived using the PBS Diabetes Population Prevalence Model - Phase 2 combined with data from the 2001 Census and the Welsh Index of Multiple Deprivation. The model applies age/sex/ethnic group-specific estimates of diabetes prevalence rates, derived from epidemiological population studies, to 2001 Census resident populations. The model also allows estimates to be generated for user-defined populations.

Estimated prevalence of type 1 and 2 diabetes Source: Yorks and Humber PHO 6

Estimated (%) prevalence 1

n e e t re f m n rt n d d lly o fil i hir io o e i ea wy nt h s ha g fa ed en s hir yd n x r ph s n Tafflesey T th o n idg r Ta lb lints Cardif redi Powysewp T r e ke o g rt yr Co F N B wan ro u Gwe Wre Gwy Ca S b yn h a Ce C Po a Denbighshireth en a Mert la le of GlamorgaMonmou Pem B Isle of An CarmarthenshireNe Va he Rhondd T LHB

It may be reasonably to expect the WHS prevalence to be lower than the PBS estimate because the WHS asks about current treatment for diabetes whilst the PBS model estimates the prevalence of those diagnosed and undiagnosed. Contrary to this logic, the prevalence for Torfaen calculated from WHS data is 5.9 per cent with Torfaen being sixth highest in Wales, whilst the estimated prevalence from the PBS model above is 4.3 per cent showing Torfaen LHB/LA area as 14th highest out of the 22; a difference of 1.6 per cent comprising 1,445 people in Torfaen.

The QoF data for Torfaen indicates diabetes prevalence varies between practices from 3 to nearly 6 per cent with a mean of 5 per cent. The three different data sources are comparable and suggest that the prevalence of diabetes in the Torfaen population is between 4 and 6 per cent.

182 Analysis of Welsh Health Survey data has revealed that the incidence of diabetes is statistically significantly higher in more deprived areas (NPHS, 2004b).

Diabetes, persons aged 18 and over, 1998 Data source: Welsh Health Survey 1998

At a sub LHB/LA population level this might give an indication of where geographically in Torfaen the prevalence of diabetes might be highest (see section Life Circumstances for maps of deprivation in Torfaen.

183 Arthritis Arthritis is one of the most prevalent chronic health problems and it limits everyday activities such as walking, dressing and bathing. Arthritis affects people in all age groups and is more common in females than males (Arthritis Foundation, 2006).

The 2003/5 Welsh Health Survey asked adult respondents if they were currently being treated for arthritis. Analysis of the data by LHB/LA area shows reported prevalence (age standardised for persons aged 16+) for Torfaen to be 15.1 per cent, higher than the Welsh average of 13.9 per cent and seventh highest prevalence of the 22 LHB/LA areas in Wales.

Adults who reported currently being treated for arthritis: 2003/05 Source: Welsh Health Survey, 2003/05 25

Welsh average = 13.9 15

Age StandardisedAge % 5

Cardiff Conwy Powys Torfaen Newport

Bridgend Flintshire Swansea Gwynedd Wrexham Caerphilly Ceredigion Denbighshire Merthyr Tydfil Pembrokeshire Blaenau Gwent Monmouthshire Isle ofAnglesey Carmarthenshire Neath Port Talbot Rhondda CynonTaff

The Valeof Glamorgan

184

Analysis of Welsh Health Survey data has revealed that the prevalence of arthritis is more common in deprived areas (NPHS, 2004b).

Arthritis, persons aged 18 and over, 1998 Data source: Welsh Health Survey 1998

Back pain Back pain is relatively common and one of the main reasons for sickness absence from work in the United Kingdom. Although painful, back pain is normally not serious, that is in most cases the pain lasts from a few days to a few weeks and usually clears up after about six weeks (NHS Direct Online, 2006).

Back pain can affect people of any age but is more common between the ages of 35–55 years (NHS Direct Online, 2006). Also, females are more likely to need treatment for back pain than men (WAG, 2006).

The 2003/5 Welsh Health Survey asked adult respondents if they were currently being treated for back pain. Analysis of the data by LHB/LA area shows reported prevalence (age standardised for persons aged 16+) for Torfaen to be 13.9 per cent, higher than the Welsh average of 12.2 and eighth highest of the 22 LHB/LA areas in Wales.

185 Adults who reported currently being

treated for back pain: 2003/05 Source: Welsh Health Survey, 2003/05

16 14 Welsh average = 12.2 12 10 8

Age standardised% 4

Cardiff Conwy Powys Torfaen Newport Bridgend Swansea Flintshire Gwynedd Wrexham Caerphilly Ceredigion Denbighshire Merthyr Tydfil Pembrokeshire Blaenau Gwent Monmouthshire Isle of Anglesey Carmarthenshire

Neath Port Talbot Rhondda Cynon Taff The Vale of Glamorgan

Analysis of Welsh Health Survey data has revealed that the prevalence of back pain is more common in deprived areas (NPHS, 2004b).

Back pain, persons aged 18 and over, 1998 Data source: Welsh Health Survey 1998

186 Hypertension The three tables below show estimation of hypertension: prevalence, treatment and unmet need using the Faculty of Public Health Toolkit. The toolkit uses Health Survey for England (2003) data and provides a calculation template which was populated with the Torfaen population by age and sex yielding the following results:

Estimated number of persons with hypertension:

Age band Male Female Persons 15-24 320 100 420 25-34 570 280 850 35-44 1310 740 2050 45-54 2120 1420 3540 55-64 2720 2480 5200 65-74 2330 2890 5220 75 plus 1720 3390 5110 All ages 11090 11300 22390

Of those estimated to have hypertension, numbers estimated to be receiving treatment:

Male Female Persons Estimated number receiving treatment 4100 5200 9300 Estimated number not receiving treatment 6990 6100 13090

Of those estimated to be receiving treatment, numbers estimated to have hypertension controlled:

Male Female Persons Estimated number controlled 1890 2290 4180

Estimated number uncontrolled 2220 2910 5130

187 To obtain a better understanding of the prevalence and control of hypertension in Torfaen comparison is made with Estimates of Hypertension from QOF data in the tables below:

Patients on the Hypertension register by general practice; QoF; 2005/06

Practice Numerator Denominator Proportion (%) 1 1155 6280 18.4 2 1879 11003 17.1 3 1436 8683 16.5 4 679 4191 16.2 5 1856 11527 16.1 6 898 5778 15.5 7 970 6378 15.2 8 1035 7135 14.5 9 905 6457 14.0 10 818 5932 13.8 11 626 4688 13.4 12 1116 9323 12.0 13 689 5913 11.7 All persons 14062 93288 15.1

FPH Toolkit estimate of total persons with hypertension in Torfaen is 22,390 and the estimate of those receiving treatment is 9,300. QoF data however identifies 14,062 people; assuming all those identified are being treated, this is better than the expected/estimated average from the FPH Toolkit.

However, assuming comparability in the prevalence of hypertension in England and Wales, estimates from the FPH model also indicate, there are over 8,000 persons in Torfaen with undiagnosed hypertension,

Comparison of control of hypertension from QoF data of those with blood pressure of 150/90 or less with those estimated as controlled from the FPH toolkit, reveals interesting findings.

Control of hypertension BP 150/90 or less; by general practice; QoF; 2005/06 Practice Numerator Denominator Proportion (%) 1 983 1080 91.0 2 680 860 79.1 3 623 793 78.6 4 605 778 77.8 5 484 625 77.4 6 1306 1804 72.4 7 695 971 71.6 8 459 644 71.3 9 783 1117 70.1 10 430 620 69.4

188 Practice Numerator Denominator Proportion (%) 11 1108 1683 65.8 12 835 1271 65.7 13 563 862 65.3 All persons 9554 13108 72.9

The estimate of those whose hypertension is controlled is 4,180 however, the QoF data above suggest that in Torfaen the actual number is 9,554 controlled, which indicates much better outcomes. The actual number of persons with treated but uncontrolled hypertension in Torfaen, based on QoF data, is 3554 which is considerably less than the FPH estimate of 5,130.

Hypertension is an important risk factor in the development of coronary artery disease, stroke, and kidney disease; early identification and treatment leads to benefits by avoidance of complications in the long term. Hence more efforts should be directed in the improvement of care provision for high blood pressure.

189 Quality and Outcomes Framework: long term conditions and risk factors This subsection contains a review of data that help us to estimate the prevalence of risk factors and long-term conditions across the various primary care practices in Torfaen. This information is drawn from the Quality and Outcomes Framework (QOF) data collected as part of primary care information. The practices have been anonymised, and are arranged in the order of increasing prevalence of high blood pressure in the practice population.

Prevalence of Diabetes Mellitus and High Blood Pressure (QoF Data 2005-06)

20 BP (%)

18 DM (%)

8 Prevalence (%) Prevalence

0 1 2 3 4 5 6 Mean 7 8 9 10 11 12 13 Practice No

The prevalence of high blood pressure varies between 11 – 19% among practices, with a mean value of 16%. Diabetes prevalence varies between 3 to nearly 6% with a mean of 5%.

190 Prevalence of Coronary Heart Disease and Stroke (QoF Data 2005-06)

6.00 CHD (%) STROKE (%) 5.00

4.00

3.00 Prevalence (%) Prevalence 2.00

1.00

0.00 1 2 3 4 5 6 Mean 7 8 9 10 11 12 13 Practice No

The prevalence of coronary heart disease varies from 3 – 5%, with a mean of 4.8% For stroke, the range of prevalence is 1 – 2% (mean: 1.8%). Both these conditions are related to the risk factors of smoking, high blood pressure and diabetes mellitus.

Prevalence of COPD and Cancer (QoF Data 2005-06) 2.50 COPD (%) CANCER (%)

2.00

1.50

1.00 Prevalence (%) Prevalence

0.50

0.00 1 2 3 4 5 6Mean7 8 9 10111213 Practice No.

The common risk factor for COPD and Cancer, especially lung cancer, is tobacco smoke. The prevalence of COPD varies from 0.7 – 2.1% (mean: 1.8%) and that of cancer is in the range of 0.5 -1.2% (mean: 0.8%).

191 Prevalence of Epilepsy and Severe Mental Illness (QoF Data 2005-06)

1.20 EPILEPSY (%) Severe Mental Illness (%) 1.00

0.80

0.60 Prevalence (%) Prevalence 0.40

0.20

0.00 123456Mean78910111213 Practice No.

The prevalence of epilepsy in the practice populations varies between 0.6 – 1% (mean: 0.8%).

The term severe mental illness includes schizophrenia, bipolar disorders, psychoses and severe depression. The total prevalence of these conditions is 0.02 – 1.1% (mean: 0.4%). These numbers do not include the more common conditions of mild/ moderate depression and anxiety disorder which are more widely prevalent particularly relevant to Torfaen.

Prevalence of Asthma and Thyroid Disease (QoF data 2005-06) 9.00 Thyroid disease (%) Asthma (%) 8.00

7.00

6.00

5.00

4.00 Prevalence (%) 3.00

2.00

1.00

0.00 123456Mean78910111213 Practice No.

192 The prevalence of asthma varies from 4.2 -8.4 % (mean: 6.5%). The range for thyroid disease is from 2.5 -4.6% with a mean of 3.8%.

It can be seen that there is a wide range of variation in the prevalence of the diseases analysed, among the practices. There are many reasons which could account for the variation – including the age and sex composition of the population, variations in case ascertainment, as well as prevalence of more proximate risk factors such as smoking, obesity and levels of physical activity.

The nature of data available (counts of people, but no age/ sex information) means that only crude rates can be determined at present, and this is likely to account for some of the variation in the rates. It is also possible that the rules about the clinical indicators and their coding may be being interpreted in different ways, thus again leading to some variation.

It is also not possible, at present, to identify the numbers of people who have co- morbidities from QOF information. Besides several of the proximate risk factors also do not lend themselves to appropriate ascertainment through this mechanism, although there are further indicators being proposed nationally, which should make this information available in future.

The quality of data from primary care is continuously improving, and this information may be useful for practices for self assessment of case ascertainment and for planning services to support patients with long term conditions.

Summary

In Torfaen LA/LHB area, life expectancy for males is 76 years of age and for females is 81 years neither being significantly different to the Welsh average.

Total mortality rates in Torfaen are similar to the Welsh average, but show variation across the area, with the highest rates seen in the north and urban areas in the south of the borough.

Nearly 25% of the population of Torfaen have a limiting long term illness.

Torfaen is ranked fifth lowest among the LHB/ LA areas in the mental component summary score (MCS), an indicator of mental well being, with an average score of 48.5 and below the Welsh average (49.7). Just over ten per cent of those aged 16 and over resident in Torfaen reported receiving treatment for a mental health issue; however, Torfaen is ranked fourth lowest for numbers of patients with mental illness resident in hospital. The EASMR for suicides in Torfaen is 11.5 per 100,000 of the population (95%CI, 9.5 to 13.9) lower than the Welsh average of 13.7. Trend data indicate no significant differences in suicide between 1996 and 2005.

193 MSOAs among the highest fifth for death from circulatory disease in Wales. Mortality due to coronary heart disease also follows a similar pattern, being lower in Torfaen than in Wales. Torfaen has the lowest stroke-related mortality in all of Wales.

In Torfaen the annual death rate (EASMR, 2002 – 2004) where the underlying cause is injury, is 24.7 per 100,000 of the population, statistically significantly lower than the Welsh average (30.9).

The Welsh Health Survey (2003/2005) age standardised (‘lifetime’) prevalence, those who reported having been treated for cancer, in Torfaen is 4.4 per cent of the population (0.2 per cent higher than the Welsh average). The WCISU have calculated that Torfaen LHB/LA area is ranked eighth lowest out of the 22 areas in Wales with an EASR of 384 for cancer registrations. Cancer mortality appears to be higher in the south Wales valleys with the EASMR for Torfaen being 197 (Wales =189.3). In Torfaen four MSOAs are amongst the highest fifth in Wales for death from cancer.

Lung cancer incidence (EASR) in Torfaen is 60.4 per 100,000, which is nearly 67 per cent higher than the LHB/LA area with the lowest rate.

The annual incidence (EASR for registration, 1995 - 2004) of breast cancer in females in Torfaen is 111.7 per 100,000 of the population (Wales= 114.2)

Data from QoF, Welsh health survey and the PBS model indicate that the prevalence of diabetes in the Torfaen population is between 4 and 6 per cent.

Reported prevalence (age standardised for persons aged 16+) for arthritis in Torfaen to be 13.9, higher than the Welsh average of 12.2 and eighth highest of the 22 LHB/LA areas in Wales.

194 Torfaen Health, Social Care and Wellbeing Needs Assessment 2007

Supporting the Health Social Care and Wellbeing Partnership for Torfaen

Chapter 6 Service Provision

Table of Contents

Primary care 198 Dentist 198 Optician 198 Family doctor / general practitioner (GP) 198 Flu immunisation 65 years and older 198 Secondary care 201 A&E attendance 201 Hospital inpatients 204 Emergency Medical Admissions 209 Referrals to secondary care 214 Health Service Performance 217 Social Services Performance 219

196 GP services Secondary care services

Blaenavon Blaenavon Health Care Unit

Pontypool

County Hospital

Cwmbran

Llanfrechfa Grange

Crown copyright material is reproduced with the permission of the Controller of HMSO and the Queen’s Printer for Scotland

197 Primary care

Dentist As with hospital inpatients, use of dental services is known to be influenced by factors other than need, such as supply, demand and accessibility factors (NPHS, 2004b). Analysis of data from the Welsh Health Survey has also revealed that dental consultations are significantly less common in deprived areas, which is important when one considers that over 30 percent of Torfaen citizens reside in electoral divisions among the most deprived fifth in Wales.

The 2003/5 Welsh Health Survey asked adult respondents (16+) if they had visited a dentist in the last 12 months. Analysis of the data by LHB area shows rates ranging from 60.3 per cent to 71.7 per cent with an all-Wales average of 66.6 per cent. Therefore, on average across Wales one in three residents is not receiving regular dental treatment. The LHB/LA areas with lowest rates for yearly visits to the dentist are in the South Wales Valleys; behind Merthyr Tydfil and Blaenau Gwent, Torfaen residents receive the least regular dental treatment in Wales almost 40 percent have not visited their dentist in the last year.

Optician The 2003/5 Welsh Health Survey asked adult respondents (16+) if they had used an optician in the last 12 months. Analysis of the data by LHB/LA area shows that nearly 50 per cent of Torfaen residents had used an optician in the last 12 months, higher than the all-Wales average of 46.1 per cent and third highest in Wales.

Family doctor / general practitioner (GP) Analysis of the WHS data by LHB area shows that over 17 per cent of Torfaen residents had consulted with the GP in the past two weeks which is above but not significantly different to the Welsh average of 16.6 per cent.

Details of disease prevalence identified in primary care through Quality and Outcomes Framework are provided in the section Health Status of this report within the relevant health outcome.

Flu immunisation 65 years and older Influenza (or flu) is a highly infectious acute viral infection, affecting people of all ages, mainly during the winter months (Department of Health, 2006). Influenza remains one of the most serious vaccine preventable diseases in the UK today, claiming on average more than 500 lives each year in Wales, mainly among older populations. Uptake of seasonal flu vaccine in Wales amongst older people increased to 68 per cent in 2005, with over half the General Practices in Wales meeting the 70 per cent target.

Analysis of the Infection and Communicable Disease Service (NPHS) data show that Torfaen has the ninth highest proportion for flu immunisation uptake amongst people aged 65 and older, of the 22 LHB/LA areas in Wales. The proportion is just below 70 per cent which is higher than the Welsh average of 68.2.

198 Childhood Immunisation uptake There may be number of factors affecting immunisation uptake, these include socio- economic factors, lay beliefs about immunisation, the media, religious and moral beliefs and advice received from health professionals.

Because the various immunisation jabs are administered at or around the same time, uptake shows very similar, if not identical patterns. The exception to this rule is the MMR vaccination. Initially, the uptake rate was similar to the others included in the childhood immunisation program but, following adverse publicity in the media, based upon a study which has now been shown to have been flawed, uptake fell from around 92 per cent to a low of around 78 per cent at the beginning of 2003. Following intensive efforts to recover the damage caused by the adverse publicity the uptake rate had recovered to just over 85 per cent by the end of 2005. The chart below shows uptake of immunisations in Wales between 1996 and 2005.

Immunisation uptake for children aged <24 months resident in Wales, 1996 - 2005 Souce: Infection and Communicable Disease Service, NPHS 100 Diphtheria Pertussis Hib MMR Meningitis C

Uptake (%) 80

Q1 Q2 Q3 Q4 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 Note: y axis is truncated

Analysis of the latest uptake rates for immunisations at the LHB/LA area level (2005/2006) shows that Torfaen is third highest for immunisation uptake of the 22 areas in Wales. There is a small degree of variation, for all immunisations except MMR; Torfaen has the second highest rate of all LHB/LA areas for uptake of MMR immunisation at 89 per cent (Wales, 85%).

199

Immunisation uptake for MMR, children <24 months, Wales LHBs, 2005/06 Source: Infection and communicable disease service, NPHS 100

90 Wales = 85.3% 85

Uptake (%) 80

Cardiff Powys Conwy Torfaen Newport Bridgend Swansea Flintshire

Gwynedd Wrexham Caerphilly Ceredigion Denbighshire Merthyr Tydfil Pembrokeshire Blaenau Gwent Monmouthshire

Isle ofAnglesey Carmarthenshire Neath Port Talbot Note: y axis is truncated Rhondda Cynon Taff The ValeThe of Glamorgan

200 Secondary care

A&E attendance Age group The age groups that visit hospital accident and emergency departments in Wales are typically children, young adults and the elderly. The section Life Circumstances has more detail about injury in younger and older age groups, whilst the section Health Status provides data on mortality where underlying cause is injury.

Estimated injury rate, persons by age, Wales, 2004 Source: AWISS

300

250

200

150

100

Rate per 1,000 population 1,000 per Rate 50

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

Main diagnoses The most common types of injuries resulting in accident and emergency attendances in 2004 were sprains, fractures, bruise/abrasion and laceration/wound.

201

All injuries by main diagnosis, persons, Wales: 2004 Source: AWISS 35

Rate per 1,000 population 10

0 Bite Burn

Head Tendon Sprains Fracture Dislocation Other injury Foreign body

Other soft tissue soft Other Bruise /abrasion

Laceration / wound Poisoning / overdose

Fractures – age distribution The age-specific rates for persons attending accident and emergency departments with a major diagnosis of fractures is similar to that seen for sprains for the younger age bands i.e. it peaks at 10-14 year-olds. However, there is a sharp increase in the age-specific rate for persons aged 80 and over attending accident and emergency departments with a main diagnosis of ‘fracture’.

Bruise/abrasion and laceration/wound – age distribution The age-specific rates for people attending accident and emergency departments in Wales in 2004 with a main diagnosis of either bruise/abrasion or laceration/wound were very similar for persons aged 20 and over.

Poisoning/overdose – age distribution Age-specific rates for accident and emergency attendances at hospitals in Wales in 2004 reveal the most vulnerable groups for this type of injury to be young children and the elderly. The rates for children aged 0-4 are alarmingly high, with almost five per cent of children in this age group in Wales attending an accident and emergency department as the result of poisoning/overdose.

Childhood burns and scalds Whilst burns and scalds form a relatively low proportion of all injuries they are often quite severe injuries and may result in residual disfigurement and disability. Scalds

202 are a particular problem in young children and most hospital admissions in those aged 0-4 years from thermal injuries are due to scalds. Half of these injuries are due to spilling hot drinks on the child and a quarter are due to excessively hot tap water.

A&E and minor casualty visits; Torfaen residents Visits to secondary care A&E and minor casualty amongst Torfaen residents are less in 2006/2007 compared to 2005/2006; the number of attendances has more than halved for A&E visits. The larger numbers visiting minor casualty might suggest their perceived importance to Torfaen residents; these data may also indicate that reasons for casualty visits are relatively minor injuries which could provide focus for investigation in to reorientation. It is difficult to be conclusive because there are no data available at this time to understand how many patients are admitted from minor casualty or indeed how many re-attend. The numbers in the table below are provided by the Business Service Centre and are total visits, they do not represent total persons visiting casualty.

Visits to secondary care A&E and minor casualty departments 2005/2006 and 2006/2007:

2005/2006 2006/2007 All Specialties 6730 5998 Accident and Emergency 306 133 Minor Casualty 6424 5865

203 Hospital inpatients Admission to hospital is dependant on a variety of factors, including:

• Distance from home, ability to cope if living alone and bed availability (CAPIC, 2005) • Socio-economic deprivation • Analysis of hospital data has revealed that treatment in hospital for all causes is significantly greater among residents of deprived areas.

The 2003/5 Welsh Health Survey asked adult respondents (16+) if they had been in hospital as an inpatient in the last 12 months. Whilst the All-Wales average is 10.1 per cent, analysis of the data by LHB area shows higher age standardised rates in the South Wales Valleys with Torfaen being the highest in Wales. This highlights the need for improving health, better preventive care, and increasing support services in intermediate care and the community to help people get better without having to get admitted to hospital.

Adults who reported being in hospital as an inpatient in the past twelve months: 2003/05 Source: Welsh Health Survey, 2003/05 12 Welsh average = 10.1 10

4 Age standardisedAge %

The Vale of Glamorgan

204

The Welsh Audit Office (WAO) Baseline Review for Chronic Disease, recently completed (but unpublished), in Torfaen suggests that there were 25,186 admissions to hospital from Torfaen residents in 2005/2006. There are no important differences in the rates of admission across the age bands between Torfaen and Wales and as expected the rates increase with age. The table below shows the age-related rate of admission to hospital for Torfaen and Wales residents; these data are taken from the WAO baseline review mentioned above, it is unclear if these rates are standardised or crude.

Total admissions to hospital; Torfaen residents 2005/2006

Age bands Torfaen (%) Wales (%) 0 to 15 yrs 9.50 11.00 16 to 24 yrs 8.30 8.20 25 to 34 yrs 8.90 9.90

35 to 44 yrs 10.00 9.50 45 to 54 yrs 11.70 9.70 55 to 64 yrs 14.80 14.30 65 to 74 yrs 15.10 16.10

75 yrs and over 21.60 21.30

Total admissions 25,186 756,616 (number)

Source: WAO; Health Solution Wales, Inpatient Episode Data for Wales, 2005/2006

Children and Young People The following information is sourced from the Patient Episode Database for Wales (PEDW). This is a database of all inpatient and daycase activity in Welsh NHS Trusts and activity related to residents of Wales carried out in the rest of the UK. The analysis in this section is based upon persons admitted rather than the traditional approach of using finished consultant episodes or provider spells. Therefore analysis in this section only counts individuals once per calendar year since it is believed that this provides a more meaningful picture for intervention.

All causes The chart below shows the person based hospital utilisation rate for all diagnoses (excluding ICD-10 U500 – newborn infants requiring normal level of care and Z38 – live born infants). The rates have been age standardised to take account of demographic variation at LHB/LA area level. These data show considerable variation.

205 People aged 0-24 admitted to hospital, EASR per 100,000, Wales LHBs, 2005 Compared with Wales Data s our ce : PEDW Signif icantly Higher Low er Higher Significantly Low er 14000

12000

10000

8000

6000

EASR per 100,000 4000

2000

0 Cardiff Powys Conwy Torfaen Newport Bridgend Flintshire Swansea Gwynedd Wrexham Caerphilly Ceredigion Denbighshire Merthyr TydfilMerthyr Pembrokeshire Blaenau Gwent Monmouthshire Isle of Anglesey Carmarthenshire Neath Port Talbot Rhondda Cynon Taff The Vale of Glamorgan

Older people The Welsh Health Survey asked respondents whether they had been in hospital for treatment as a day patient (admitted to a hospital bed or day ward but not remaining overnight) or inpatient (overnight or longer) in the past twelve months. Analysis on an all-Wales (there are no age breakdown at LHB Level) level show that amongst older adults a higher proportion of men compared to women report being admitted to hospital as an inpatient or day patient. This is in contrast to the pattern for younger adults.

Analysis of the Patient Episode Database Wales (PEDW, 2005) for elective admissions for inpatients and daycases combined, in those aged 65 years and older show that the rate in Torfaen is not significantly different to the Welsh EASR of 12705 per 100,000 of the population, ranked twelfth out of the 22 LHB areas.

206

People aged 65+ admitted to hospital on an elective basis, EASR per 100,000, LHBs, 2005 Compared with Wales Data source: PEDW Significantly Higher Lower Higher Significantly Lower 16000

14000 Wales rate = 12705 12000

10000

8000

6000 EASR per 100,000 4000

2000

0 Powys Cardiff Conwy Torfaen Newport Bridgend Flintshire Swansea Gwynedd Wrexham Caerphilly Ceredigion Denbighshire Merthyr Tydfil Merthyr Pembrokeshire Blaenau Gwent Monmouthshire Isle of Anglesey Carmarthenshire Neath Port Talbot Rhondda, Cynon, Taff Rhondda, The Vale of Glamorgan

In contrast to the elective admissions above, the EASR for emergency admissions in 2005 amongst people aged 65 and older in Torfaen (15,413) is statistically significantly higher than the Welsh average (14,796). Torfaen has the eighth highest rate of the 22 LHB/LA areas.

207 People aged 65+ admitted to hospital on an emergency basis, EASR per 100,000, LHBs, 2005 Data source: PEDW Compared with Wales Significantly Higher Lower Higher Significantly Lower 20000 18000

16000 Wales rate = 14796 14000 12000 10000 8000

EASR per 100,000 6000 4000 2000 0 Powys Cardiff Conwy Torfaen Newport Bridgend Flintshire Swansea Gwynedd Wrexham Caerphilly Ceredigion Denbighshire Merthyr Tydfil Pembrokeshire Blaenau Gwent Monmouthshire Isle of Anglesey Carmarthenshire Neath Port TalbotNeath Port Rhondda, Cynon, TaffRhondda, Cynon, The Vale of Glamorgan

Emergency admissions in those Torfaen residents aged 65 and older, expressed as a proportion of all admissions in that age group is 57.1 per cent, higher than the Welsh average of 56 per cent and the area is ranked seventh of the 22. It must be noted that the variation across Wales is not large (less than 10% total), and importantly, these data are from 2005 – much work around intermediate care and admission avoidance has been undertaken locally.

People aged 65+ admitted to hospital on an emergency basis, as a proportion of all admissions, ranked LHBs 2005 Data source: PEDW

65%

The y axis has been truncated

60%

55% Percentage (%) 50%

45% Cardiff Wales Powys Conwy Torfaen Newport Bridgend Flintshire Swansea Gwynedd Wrexham Caerphilly Ceredigion Denbighshire Merthyr Tydfil Pembrokeshire Blaenau Gwent Monmouthshire Isle of Anglesey Carmarthenshire Neath Port Talbot Rhondda Cynon Taff The Vale of Glamorgan

208 Emergency Medical Admissions Seasonal variation in emergency admissions; Wales Peoples health profile often changes throughout the year (WAG, 2006a), this may be particularly important for older people.

Very hot or prolonged high temperature and humid weather can seriously damage a person’s health; heat exhaustion and dehydration are examples and can be life threatening. Cases of skin cancer have increased steadily over recent years, with exposure to sunlight being the main cause of the disease (WAG, 2006c); though the risk is indicated to be severe or repeated sunburn in children and young people the population experiencing skin cancer tend to be older people.

Older persons are particularly vulnerable in the winter months, with higher risks of hypothermia, trips and falls and developing influenza. Analyses relating to seasonal changes in hospital admissions for a range of conditions are presented below.

Overall average daily emergency admissions in Wales for all causes (1999 to 2005) show a general trend of being lowest in August (787) and highest in December (854). This trend, with admissions declining month on month from January to August and climbing thereafter actually represents very little variation in the daily emergency admission rates by month across the seasons.

Average daily emergency admissions resulting from infectious diseases peak in March (37), having risen steadily from September (24) to December and then more sharply in January and February. From March they more or less decline month on month, except for a very slight rise in July to the lowest points of the year in August.

Average daily emergency admissions resulting from respiratory diseases show the greatest variation with the seasons, peaking in December (152), having risen constantly from less than half that in August (67) to November and then rapidly to December. They decline slightly in January and then decline more or less constantly back to the low point of August.

Average daily Circulatory disease emergency admissions (1999 to 2005) in Wales show less variation throughout the season than is seen for some other diseases. The lowest number occur in August (98) and the greatest number in April (105) with higher levels seen in the months from January to April.

Average daily emergency admissions resulting from injury and external causes (1999 to 2005) in Wales peak in August (133), having risen constantly between January (108) and May then tail off steadily back to the low point in January.

Variation by General Practice There is variation in rate of emergency admissions between general practices in Torfaen. This may be due to a combination of several factors such as variations in clinical practice, accessibility to hospital, availability (or lack of) diagnostic services, and importantly, patient self-referral.

209

Age standardised emergency medical admission rates by general practice; Torfaen; 2005/2006

14000

12000

10000

8000

6000

4000

2000 Per 100,000 of the population population of the 100,000 Per

0 12345678910111213

Source: BSC; PEDW, 2005/2006

Analysis of PEDW data show that the number of emergency admissions from Torfaen residents are much higher to general medicine, than all the other specialties; general surgery and paediatrics also have high admissions. This reflects the position of general medicine as the ‘front door’ to hospital services, especially in relation to non- trauma emergencies.

Number of emergency medical admissions; Torfaen residents; top three specialties; 2005/2006

6000

5000

4000

3000

2000

1000

0 General Medicine General Surgery Paediatrics

Source: BSC; PEDW, 2005/2006

210 Number of emergency medical admissions; Torfaen residents; next highest ten Specialties; 2005/2006

800 700 600 500 400 300 200 100 0 s ic gy cy gy ss NT gy try py ry ne ed lo n lo ne E lo ia ra ge ici a co ge ro Ill to ch he ur ed op ae er U al a y iot S M rth n m nt em Ps d ic ic O Gy E e Ha e Ra st tr d t & M l Ag la ria an n ica d P e a ide in Ol s & G m c Cl rn au Ac u Tr B Source: BSC; PEDW, 2005/2006

Long-term conditions The term chronic disease refers to a disease or disorder that continues over a long period of time, causing continuous or episodic periods of incapacity (NPHS, 2006). Often referred to as long-term conditions, chronic conditions, chronic diseases, lifelong illnesses/diseases/conditions, examples include diabetes mellitus, chronic obstructive pulmonary disease, asthma, arthritis, epilepsy and heart disease. Existing evidence confirms that people with chronic conditions are high-frequency users of health services.

With the current policy flow through Wanless, Designed for Life and Gwent Clinical Futures more patients with long-term conditions will be treated in intermediate care and closer to their usual residence. In addition, advances in detection and treatment for people with long-term conditions will result in increasing prevalence in the future.

Together these will place and increasing demand on primary and intermediate health and social care services and will require improved capacity from a greater range of initiatives designed to proactively case find and ‘case manage’ patients at risk of emergency admission to hospital, probably using existing resources but with reoriented and integrated working. This work, in part, is being planned locally through the Community Nursing Strategy Group, the Demand Management Group and Clinical Futures Level One Steering Group.

The WAO baseline review in Torfaen suggests that emergency admissions for long- term conditions are falling, a trend mirroring the Welsh EMA for LTC. Whilst the emergency admissions component of the total admissions are decreasing, which may be related to intermediate care admission avoidance schemes, elective admissions are increasing. The raw data are presented in the table below.

211 Emergency admissions attributed to chronic diseases; Torfaen residents, 2005/2006

Year Number 2003/2004 2,834 2004/2005 2,731 2005/2006 2,692 Source: WAO; Health Solution Wales, Inpatient Episode Data for Wales

Analysis of PEDW data (2005/2006) for the selected long-term conditions of COPD, Diabetes and CHD shows the number of emergency admissions for Torfaen residents registered with general practices in Torfaen.

Numbers emergency medical admissions long-term conditions; Torfaen residents registered with Torfaen general practices; 2005/2006

900 800

700 600

500 400

300

200

100

0 COPD Coronary Heart Disease Diabetes LTC Total Source BSC; PEDW, 2005/2006

The graph below shows emergency admissions rate for the selected long-term conditions by general practice in Torfaen. There is considerable variation in the rate of emergency admission between general practices. QoF data (2006/7) suggest the prevalence of CHD varies by general practice by approximately 2 per cent (3% to 5%), the emergency admissions rate below shows a variation of 0.75 per cent (i.e. 7.5 per 1000). This may be an indication of relatively good control of CHD in the majority of patients, related to high quality primary care performance, despite a high prevalence of disease, and supports the need to continue investing in early identification and treatment of CHD.

212 Emergency medical admissions for long term conditions; general practice; 2005/2006

6 Crude rate (per 1000) (per Cruderate 4

0 COPD Coronary Heart Disease Diabetes LTC Total

End of Life Care and long-term conditions Given the higher mortality rate from these chronic diseases compared to that from Cancer and when one considers the current policy stream towards providing more care closer to home, along side more people living longer with a complexity of long- term conditions, end of life care needs a clear focus. Although traditionally thought of as care for people with end stage cancer, in 2005/2006 13 per cent of patients who received end of life care through St David’s Foundation (StDF) were non-cancer patients. The table below shows the activity of the StDF Clinical Nurse Specialists in Torfaen. The Service structure is explained in the Community Nursing Needs Assessment (2007), in brief it is multi-disciplinary and community focussed with a 24- hour Hospice at Home service. If appropriate reduction of emergency admissions for end stage non-cancer chronic disease is to be realised, the role of this service is vital.

St David’s Hospice Foundation, Clinical Nurse Specialist activity in Torfaen

CNS TEAM 2004/05 2005/06

Number of patients 412 427

New Referrals 297 307

Discharges 63 69

Patients started on 18 6 care pathway Deaths 204 157 Deaths at Home 64 57 Per cent died at home 30 36

213 Referrals to secondary care This sub-section displays information about practice-specific, standardised referral rates to various specialties. As with emergency admissions, various factors may influence referral rates, including, disease prevalence, clinical practice variations, patient perception of illness, co-morbidities, and clinical feedback. It must also be kept in mind that at the practitioner level, the annual number of referrals to any particular specialty may be relatively low, and wide fluctuations may occur year on year.

As such no firm conclusions can be drawn at present about the causes of variations of referral rates among practices in Torfaen; however, given the presence of these variations, it is important to develop a mechanism to facilitate peer-led clinical discussions between clinicians across care settings, about improving referral quality and ensuring that referrals to secondary care continue to be appropriate.

Age/Sex Standardised Referral Rates and Annual Referrals, General Surgery, Torfaen; 2005/2006

45 500 40 450 35 400 30 350 300 25 250 20 200 15

150 Annual Referrals 10

ReferralRate (per '000) 100 5 50 0 0 12345678910111213

Rate Annual Referrals SEW Av Rate

Age/Sex Standardised Referral Rates and Annual Referrals, General Medicine, Torfaen; 2005/2006

35 450

30 400 350 25 300 20 250

15 200 150

10 Annual Referrals 100 Referral Rate (per '000) 5 50 0 0 12345678910111213

Rate Annual Referrals SEW Av Rate

214 Age/Sex Standardised Referral Rates and Annual Referrals, Trauma & Orthopaedics, Torfaen; 2005/2006

35 350

30 300

25 250

20 200

15 150

10 100 Annual Referrals

Referral Rate (per '000) 5 50

0 0 12345678910111213

Rate Annual Referrals SEW Av Rate

Age/Sex Standardised Referral Rates and Annual Referrals, Ophthalmology, Torfaen; 2005/2006

30.0 400 350 25.0 300 20.0 250 15.0 200 150 10.0

100 Referrals Annual

ReferralRate (per '000) 5.0 50 0.0 0 12345678910111213

Rate Annual Referrals SEW Av Rate

215 Age/Sex Standardised Referral Rates and Annual Referrals, Gynaecology, Torfaen; 2005/2006

25.0 250

20.0 200

15.0 150

10.0 100 Annual Referrals

Referral Rate (per '000) 5.0 50

0.0 0 1 2 3 4 5 6 7 8 9 10 11 12 13

Rate Annual Referrals SEW Av Rate

Age/Sex Standardised Referral Rates and Annual Referrals, Dermatology, Torfaen; 2005/2006

35.0 350

30.0 300

25.0 250

20.0 200

15.0 150

10.0 100 Annual Referrals

Referral Rate (per '000) 5.0 50

0.0 0 12345678910111213

Rate Annual Referrals SEW Av Rate

216 Health Service Performance Delivery of services geared to meet population health needs requires targeted investment to address gaps in services. The ability of a health care system to justify new investment is based on the demonstration of efficient use of available resources. Hence monitoring the performance of health services in terms of efficiency and productivity are key components of planning information.

This section is based on the data related to the core measures developed for the measurement of NHS efficiency and productivity in Wales. Detailed definitions of the measures are available at: http://howis.wales.nhs.uk/sites3/Documents/407/Detailed%20Definitions%2Edoc

Specific targets and timetables for achievement have been set for each of the core measures of performance indicated in the table below.

Royal Gwent NHS Trust/ Torfaen performance against core measures 2006-’07

Core Measure Royal All Wales Potential Savings in Gwent NHS Average Gwent/ Torfaen Trust Average Length of Stay – 4.2 days 4.8 days 6459 bed days elective Average Length of Stay – 5.4 days 5.2 days 43492 bed days emergency AC Basket Day Case Rates 64 % 67 % 1939 bed days (Single day stay) 75% Day Case Rates 56 % 54 % 5178 bed days Operations on Day of 24.3 % 41.3 % 3234 bed days Admission Electives with No Procedure - 2.9 % 3.2 % 32 bed days inpatients Electives with No Procedure - 5.7 % 4.4 % 374 bed days daycases Short Stay Admissions 29.6 % 30.6 % 914 bed days Long Stay Patients 7.8 % 15.3 % 0 bed days Outpatient Follow Up (FU) 2.3 2.5 39190 FU Ratios Outpatient DNA Rates –new 7.3 % 7.8 % 3102 appts appts Outpatient DNA Rates –FU 11.2 % 10.2 % 13955 appts appts Cancelled Outpatient Clinics 5.5% 7.1 % 5260 appts GP Referral Management 1206 36607 3442 referrals (LHB) Cancelled Operations 12 % 6.8 % 2655 operations Theatre Utilisation – late starts 28.9 % 32.1 % 399 hours Theatre Utilisation – 34.5 % 32.6 % 516 hours early finishes

217 A&E Follow Up Rates – Major 11.3 % 4.1 % 4715 appts A& E depts A&E Follow Up Rates 26.2 % 18.6 % 9268 appts - Minor injury & casualty Sickness & Absence Rates – 5.2 % 5.2 % 1 % hours lost Agency Spend 2.9 % 1.5% £ 6,529,000 (as % of total pay expenditure) Medicines Management 84 % 82 % -- Indicators

These data indicate that the local secondary care health system, which covers Torfaen, among other boroughs in Gwent, is able to match or better the all-Wales average in several areas. However, there are still many important efficiency and productivity targets to achieve, on an all-Wales basis, which in turn, may result in the availability of resources to rectify service gaps with a view to addressing priority needs identified in this report.

218 Social Services Performance This section provides an overview of the social care services delivered to residents of Torfaen.

In Torfaen, there are more older people receiving assessment than the Wales average. Care provision in Torfaen, evidenced by these data, appears to be delivered more through residential homes than via community services. Nursing home care rates are relatively equal for Torfaen and Wales. These data indicate a need to strengthen the provision of care in the community to reflect the high rate of assessments at present. This is also important in view of the changing demography as outlined in the Demography section of this report which indicates that there is likely to be an increase in the population of the elderly population in Torfaen.

Older people proportions receiving social care assessment and intervention; 2004 to 2005

180 150 120 Torfaen 90 Wales 60 30 0

Per 1000, aged and 65 older assessment community residential care nursing home based services care

People with physical or sensory disability receiving social care assessment and intervention; 2004 to 2005 40

older Torfaen 10 Wales

0 Per 1000, aged 1000, 18 and Per assessment community residential nursing home based care care services

There is a similar gap between the assessment and community services rates among residents of Torfaen, compared to all Wales rates. Consequently, this indicates a need for improving the capacity for community based care in Torfaen for people with physical and sensory disability.

219 People with a learning disability receiving social care assessment and intervention; 2004 to 2005

2 Torfaen Wales 1

0 Per 1000, aged 18 and older assessment community residential care nursing home based services care (/10,000)

Care for people with learning disability in Torfaen presents a picture similar to the Welsh average, with the notable exception of high levels of nursing home care. This may be a reflection of the historic fact of provision of long term care in the borough in a nursing home setting.

people with a mental health issue receiving social care assessment and intervention; 2004 to 2005 6 5 4 3 Torfaen 2 Wales 1 0 assessment community residential nursing home Per 1000, aged 1000, 18 and older Per based care care services

There are fewer people with mental health issues in Torfaen receiving social care assessment and intervention, however, despite the rate of community-based services being lower than the Welsh rate it is closer to it than the other areas of social care provision. This issue is addressed more fully in section Health Status.

The table below shows all of the social services performance indicators contained in the set of National Strategic and Core Set Performance Indicators as defined by the Statistical Directorate in WAG. These indicators are part of the Performance Measurement Framework for Local Authorities in Wales; more detailed information on performance can be obtained from the Local Government Data Unit Website http://www.lgdu-wales.gov.uk/eng/Project.asp?nc=UKTE&id=2847

220 Social Care Performance Indicators 2005/2006 Torfaen Wales

National Strategic Indicators - Adults

The rate of delayed transfers of care (DTOC) for 15 8 social care reasons per 1,000 population aged 75 or over

The rate of older people (aged 65 or over): Helped 75 86 to live at home per 1,000 population aged 65 or over

The rate of older people (aged 65 or over): Whom 28 27 the authority supports in care homes per 1,000 population aged 65 or over

Core Set Indicators - Adults

The percentage of clients who are supported in the 87 91 community during the year, Aged 18-64

The percentage of clients who are supported in the 71 79 community during the year, who are: Aged 65+

National Strategic Indicators - Children

The percentage of first placements of looked after 98 86 children during the year that began with a care plan in place

For those children looked after whose second 100 85 review (due at 4 months) was due in the year, the percentage with a plan for permanence at the due date

The percentage of children looked after at 31 8 14 March who have experienced one or more changes of school, during a period or periods of being looked after, which were not due to transitional arrangements, in the 12 months to 31 March

Core Set Indicators - Children

Gross weekly expenditure per looked after child in 262 391 foster care

Gross weekly expenditure per looked after child in 11,066 3,186 children's homes

221 Social Care Performance Indicators 2005/2006 Torfaen Wales

The percentage of children looked after on 31 9 10 March who have had three or more placements during the year

The percentage of children looked after on their 100 95 16th birthday who have a care plan

The percentage of 'eligible' children looked after 92 51 on their 16th birthday who have a pathway plan for their continuing care

Staffing

Registered social care professionals (whole time 6 4 equivalent) rate per 10,000 population

Total social care staff (whole time equivalent) rate 55 67 per 10,000 population

Finance (£s)

Expenditure on all social services per person 325 394

Expenditure on social services for children per 267 491 child aged under 18

Expenditure on social services for older people per 842 854 person aged 65+

In Torfaen, approximately 15 per cent fewer people (75 per 1000 vs. 96 per 1000 in Wales) aged above 65 are provided support to live at home; this may be one of the reasons contributing to the high proportion of delayed transfers of care (15 vs. 8 per 1000 in Wales) that occur in Torfaen. Delayed transfers of care are a major source of concern in the health and social care community, and may be precipitated by a wide range of causes in a care environment that is not geared up to cope well with substantial pressures that arise from time to time. The multi-factorial nature of the issue clearly points to the need for effective co-ordinated action across the health and social care pathway by the local authority, local health board, primary and community care, voluntary sector and the acute NHS trust hospitals. In view of the suspected demographic changes and the proposed care pathway developments related to the change in acute service configuration, a robust response to DTOCs is essential to ensure that the health and social care community are able to continue delivering high quality services.

222 Torfaen performs consistently better in the national strategic indicators for children and the social care indicators for looked after children, relative to the all Wales picture.

Summary

Analysis of Welsh Health Survey (2003/2005) data by LHB/LA area shows that nearly 50 per cent of Torfaen residents had used an optician in the last 12 months, third highest in area in Wales, however, behind Merthyr Tydfil and Blaenau Gwent, Torfaen residents receive the least regular dental treatment in Wales almost 40 percent have not visited their dentist in the last year.

General practice consultations for Torfaen residents annually are similar to the Welsh average.

Visits to A&E due to injuries show a reducing trend.

223 In the social care arena, there is a need to strengthen the provision of care for elderly at home and in the community to reflect the high rate of assessments at present; the same is true for community care for people with disabilities.

Delayed transfers of care are a major source of concern in the health and social care community, and need effective co-ordinated action across the health and social care pathway by the local authority, local health board, primary and community care, voluntary sector and the acute NHS trust hospitals.

Torfaen performs consistently better in the national strategic indicators for children and the social care indicators for looked after children.

224 Torfaen Health, Social Care and Wellbeing Needs Assessment 2007

Supporting the Health Social Care and Wellbeing Partnership for Torfaen

Chapter 7 Qualitative Information

Table of Contents

Background 226 Definition 226 Why consult 226 Barriers to conducting and using consultation 227 How have we consulted? 228 Results 229 Life Circumstances 229 Lifestyles 230 Health Outcomes 230 Service Provision 231

225 Background

Definition Often referred to as ‘consultation’, this section outlines the perceived needs for health social care and wellbeing identified by citizens of Torfaen in a selection of consultation events over the last three years.

The term ‘consultation’ can mean different things in contemporary health social care and wellbeing parlance. Commonly, among other things, it can be about a process of guided stakeholder (users, carers and the wider public) discovery of emerging policy, strategy or series of options and the subsequent incorporation of their reaction and views as with the Gwent Clinical Futures Programme. It could be about building stakeholder views from the very beginning of a development plan, as with the Integrated Impact Assessment conducted for the North Torfaen Health Social Care and Housing Reconfiguration Project. In the context of needs assessment the term ‘consultation’ is not about stakeholder discovery and comment on a set of results, rather, it relates to the process of engaging local citizens to contribute to the overall understanding of health, social care and wellbeing need.

Qualitative information can be gathered in a variety of ways many of which can be meaningful; however just as with quantitative ‘research’ there are well accepted, robust and valid approaches which, if followed appropriately, help the consumers of the results (HSCWB decision makers) know that they are basing decisions on sound/valid evidence of what is needed. The vital point here is adopting, and being explicit about, valid and robust qualitative methodology.

Why consult

Not all that is ‘measurable’ is of value, and not all that is of value can be ‘measured’ – Bradley and Field (1995), Evidence Based Medicine, Lancet.

It has been suggested that the persistence of health and social inequalities in society has led researchers to look for new ways of considering the relationship between the social and physical environment, individual behaviour and health (Popay and Williams, 1994). For example, if we consider the challenge long-term conditions pose to traditional epidemiological methods. The large variation between individuals in the nature and severity of health problems, in changes in the nature of problems over time, and the degree of benefits gained from intervention tells us that simply using the incidence and prevalence of various diseases does not go far enough in identifying needs for health and social care. The value of qualitative research methods in HSCWB is that it allows for exploration of the meaning and significance of illness and disability in the context of people’s lives.

226 As well as the above weaknesses in traditional needs assessment approaches, quantitative methods can not provide complete answers to all questions about HSCWB. Consider quality or user experience issues for example, it would be difficult to obtain understanding of HSCWB needs around say, opening times, staff attitudes, empowerment or continuity of care using quantitative approaches. Finding out from people what matters to them will lead to better quality services since they will be responsive to what people say they need.

The principles of PPI or Citizen Engagement for qualitative understanding of health need, as is consistent with the message from the rest of this needs assessment, must be coordinated, of robust method, and ongoing. Collective involvement tends to be more closely associated with democratic models of empowerment, which emphasise the benefits to be gained from active participation, such as: increased confidence and skills, individuals gaining more control over their lives, more effective use of resources, greater accountability of authorities and, significant health gain (HEA, 1999).

Barriers to conducting and using consultation The acceptance and use of methodologies which reflect lay perspectives in mainstream HSCWB research is often hindered by a continued emphasis on ‘science’ and a mistrust of ‘softer’ data in influencing decision-making. This translates to the concern, which in some cases might be legitimate, that stakeholder consultation to understand need may actually reflect something else, demand.

The notion of need is essentially contested. During the 1970s, an influential ‘typology of need’ was devised, this categorised need into: • Normative need as defined by experts, professionals, doctors, policy makers, etc. Often a desirable standard is laid down and compared with the standard that actually exists; • Felt need; want or subjective views of need which may or may not become expressed need; • Expressed need; felt need turned into action, as a demand; • Comparative need; the measure of difference between service levels or epidemiology in two (or more) similar populations.

Which sort of need should HSCBW Partnerships be assessing? How do we know that ‘consultations’ are measuring the right need and not demand? Given a historical pattern of services, there is likely to be a temptation to rely on ‘expressed need’ or demand for services as a measure of local need. The concerns are that this might perpetuate current biases in service provision, for example, the skewing towards acute services, and, work against the aim of the current strategy to shift the emphasis towards services closer to the user and responsive to genuine need.

The Issue of the legitimacy of consultation is sometimes used as a reason for not involving local people, particularly if outputs from the engagements are not deemed to be ‘representative’. As with evidence-based decision making in

227 HSCWB, the decision makers at all levels must understand the benefits of appropriate use of explicit appropriately conducted qualitative evidence both in their practice and to the appropriate provision and use of HSCWB services locally.

How have we consulted? As mentioned in the introduction much work has been undertaken to find out about the views around needs for health social care and wellbeing services in Torfaen since the last needs assessment in 2003. The work has taken place in a variety of settings and populations, commissioned or conducted by a diversity of local organisations and departments and, importantly using a range of approaches. Many of these works have been used or cited in the 2007 needs assessment chapters.

The 2007 HSCWB Needs Assessment Project Board directed that: to be congruent with the Community Strategy, to make best use of existing resources and, in recognition of the amount of ad hoc ‘consultations’ being carried out locally, this document should use existing resources and recommend that a coordinated structure for robust qualitative needs gathering through community consultation be developed in future.

The selection used in this report are from the following sources: • LHB/NPHS community needs assessments (currently available in the knowledge repository on Webster) o North Torfaen (Blaenavon and Abersychan) o Trevethin and Penygarn & St Cadoc’s o Thornhill • TCBC “open book” consultations which contributed to the Community Strategy (currently available on Webster at: http://www.webster.uk.net/Council%20Services/CommunityStrategy/Co nsultation.aspx) o Vox Pop Video Project o The Big Vision o Community based Open Space events o Young Peoples Forum

A more coordinated, consistent and evidence-based approach to citizen engagement is needed between the agencies in Torfaen if the needs assessment is to continue to add valid information to service planning, commissioning and delivery. It must be remembered that disadvantages of this corporate approach to needs assessment (if carried out in isolation or in an un-validated format) are that it determines demands rather than needs and stakeholder concerns may be influenced by immediate political agendas. As seen in the Evidence-based Decision Making chapter, providing less-than robust, valid, comprehensive and concise information, whether qualitative or quantitative, will turn decision makers away from using evidence in practice.

228 Themes from the above ‘consultations’ are grouped by topic, following the structure of the needs assessment chapters: Life Circumstances, Lifestyles, Health Outcomes and, Service Provision.

Results

Life Circumstances Employment High Unemployment was highlighted as a big issue in all areas. Also, perception of a lack of well paid jobs and that people are not earning enough to pay for child care in order to work. Reported perception of a culture of “not working at all” in some areas of the borough.

Poverty/deprivation was raised as an issue in all areas.

Education There were a range of subjects/themes which citizens felt should be taken on in education in traditional and non-traditional settings amongst all ages. These themes included: arts and culture, neighbourhood renewal, improved self-esteem, access to education regarding health promotion issues, IT training, young people and ecological awareness (local and global)

There were a range of alternative methods of delivery suggested throughout the consultation: enhance curriculum with community settings, more outreach education programmes, work with parents and children together, more adult education needed with more work on increasing uptake, integrate education with youth clubs, increase after school activities for primary age children and, some of the existing open spaces could possibly be used for structured play.

Two facilitators to improved uptake and interest in education were mentioned in more than one area: Crèche facilities at college for use by learners were mentioned in different areas. Young people view lack of ‘facilities’ in school as a problem.

The closure of community schools is a highly contentious issue for local communities.

Community safety Interestingly a strong theme was need for greater or more visible police presence with the acknowledgement that the fear of crime is greater than actual crime.

Observations of crime were different for different areas; the list involved motorbike or cars ‘racing’ in residential areas and other inappropriate areas and driving recklessly.

Anti-social behaviour from young people was a theme and this was linked to “drugs problems”. Vandalism and graffiti.

229 Housing Housing was expressed as an issue particularly for young people for a variety of reasons including access to affordable housing and housing for homeless young people.

Concern was expressed that some foster homes were overcrowded. There was also concern regarding suitable housing/accommodation at the age of 16 for young people leaving Looked After Care provision.

The other issue with housing was related to quality, with areas describing housing as “overcrowded”, “poor”, or “in need of updating”.

Physical Environment The main needs raised by citizens varied by area but in general the top themes were graffiti, litter and dog fowling.

A lack of safe places for young children to play

Inadequate lighting, and a lack of or uneven pavements/pedestrian areas, suggested to be wheelchair and older people unfriendly, was a recurrent theme.

Road systems and inadequate parking were also raised at separate consultation events.

Transport With respect to transport, people’s main issues were with bus services. The biggest themes were that bus service should run more frequently, be accessible at evening and weekends and a service should run to Nevill Hall. The need for improved access for people with disabilities was also raised.

The problem of traffic at Blaendare road in mornings and evenings was described as “horrendous”.

Lifestyles The issue of health problems caused by poor lifestyles was raised in relation to a variety of themes and populations and the need for “health promotion/lifestyle advice” was raised. Smoking, drug misuse and alcohol were the key themes with obesity getting one mention.

230 Other physical health conditions raised by Torfaen citizens as requiring more attention include multiple sclerosis, diabetes, coronary heart disease and mobility problems.

Service Provision Health See the Carers consultation, there are a variety of specific differences in the way services are delivered and promoted based on those outcomes (report not yet published).

Issues relating to primary health care were mixed. Whilst some said that GP services were good others suggested there needed to be improved access and a greater range of services.

Lack of knowledge of services/clinic for young mothers and a perceived lack of Sure Start provision.

Citizens indicated improved access to dental treatment in one area and that oral health a concern amongst children.

A need for better A&E services, and improved hospital access was highlighted. Whilst the threat of closure of the health care unit at Blaenavon is significant to residents.

Leisure/recreation Greater access to a greater range of exercise, activities and facilities were felt to be very important. This was expressed for a range of different sports, clubs and facilities in different areas: football facilities, cricket facilities, bowls facilities, skateboard facilities. One suggestion was that schools with good facilities should be more integrated to community particularly at evenings, weekends and holiday periods.

Children (under 10 years) felt that there was no access to recreational activities such as mountain biking, Go Carting, paintballing or the chance to learn specific outdoor sports. A need for a Youth Club provision where “under 10s” could take part in activities

There was an expressed need for better socialisation opportunities for the 59- 65+ age group. In addition it was raised that specific recreational facilities.

231 Torfaen Health, Social Care and Wellbeing Needs Assessment 2007

Supporting the Health Social Care and Wellbeing Partnership for Torfaen

Chapter 8 Evidence-based Decision Making Table of Contents

Background ...... 234 Why do EBDM...... 234 Barriers to EBDM...... 234 Summary...... 235 Evidence of effective interventions...... 237 Children & Young people...... 237 Inequalities...... 237 Mental Health ...... 238 Nutrition / Obesity ...... 239 Older People ...... 254 Physical activity ...... 255 Smoking ...... 261 Substance misuse...... 267 Transport...... 268 Environment ...... 269 Housing...... 269 Climate change...... 271 Dental health...... 273 Infections ...... 274 Seasonal safety ...... 276 Evidence-based digests ...... 278 Databases and electronic sources of evidence ...... 279

233 Background

Why do EBDM “When we intervene in the lives of others we should do so on the basis of the best evidence available regarding the likely consequences of that intervention.” – (MacDonald, G., 1998)

"Evidence-based healthcare is the conscientious use of current “best” evidence in making decisions about the care of individual patients or the delivery of health services.” – (National Institute of Public Health, Oslo, Norway, 1996).

The ultimate goal of the work of the Health Social Care and Wellbeing Partnership is the improvement in health status and quality of life at the level of both the population and the individual. The acid test then is whether services, programs and policies can improve health and wellbeing beyond what could be achieved by doing something else with the same resources - or by doing nothing at all (British Columbia Provincial Health Officer, 1996). To achieve this, along with the information and data provided in the other needs assessment chapters, one also needs to explore the availability and accessibility of reliable knowledge that identifies how interventions, practices and programs affect health, social care and wellbeing outcomes.

It is known that spending more money on health care does not necessarily lead to better health. The mission to balance budgets and reduce indebtedness at all levels of government has accelerated the speed of change in the health and social care sector. Accordingly, with greater fiscal pressures on our health and social care budget(s), we must use best evidence to help us allocate the finite resources to improve health care services and health status. This is fundamental to improving efficiency and effectiveness.

Decisions about health social care and wellbeing are made every day by patients, health care providers, managers, planners, commissioners and policy makers. The aim of evidence-based decision making (EBDM) is to ensure that these decisions about health and health care are based on the best available knowledge. Thus providing the most effective and cost effective service to the citizens. However, to achieve effective and efficient health social care and wellbeing system, evidence- based decision making must be universally and consistently adopted by providers, planners, commissioners, strategists and policy makers.

Barriers to EBDM “Where high quality evidence is lacking, experience, anecdotes, hypotheses or "gut reaction" have masqueraded as evidence. Myths and misinformation often camouflage, substitute for and sabotage the use of high quality evidence in decision making.” – (Canadian National Forum on Health, 1997)

Barriers to using good evidence exist for all decision makers. For some decisions, high-quality evidence simply does not exist, especially when new concepts are

234 involved, or is not useful because it is not relevant, accessible or timely enough for operational needs. Tools, guidelines or care management strategies to assist in daily decision making have yet to be fully developed in many areas. Often, decisions are influenced by the values and interests of decision makers, as well as the situation or context in which the decision is being made. In some instances, decisions are made on evidence directed toward a non-health outcome but which has an impact on health or health care that could be maximised by subtle adjustments using appropriate evidence.

It is helpful to understand what this section on evidence-based decision making is not. It is not tyranny over providers; it is not value free; it is certainly not a suggestion that evidence is not being used now; it is not a methodological strait-jacket; and it is not a reason for inaction. Nor is evidence-based decision making based solely on evidence. It is influenced by individual values, interests and judgments as well as external pressures and conditions. It is simply getting the best information in place so that people can make the best decision which is consistent with their values and circumstances.

The need to make decisions based on a diversity of factors including evidence is accepted, but it is the degree to which appropriate evidence is used in decision making and practice which is crucial. The Canadian National Forum on Health (1997) reported that “several strongly held beliefs and myths still exist in health and social care systems: it is better to do something than nothing or to wait; more is better; it is better if it is more expensive or more specialized and high tech; and better sooner than later”. As a result many decisions have been, and continue to be, made disregarding available evidence. Individual self-interest, values, beliefs, emotions and other factors often drive the process, and the lack of shared interests and values results in poor decisions and outcomes (Canadian National Forum on Health, 1997).

Economic conditions and financial factors can be strong barriers to the uptake and use of evidence. Alternatively, they may be powerful incentives for the use of evidence. Some forms of remuneration work better than others in encouraging the most cost-effective interventions. Therefore, funding and remuneration systems should be matched with services and programs to enable and facilitate practice and policy changes if indicated by best available information. The opportunity of the new WAG guidance (2007) relating to financial scheduling to achieve the priorities for action contained in the new strategy must include evidence of need and of effectiveness.

Summary Evidence-based decision making (EBDM) is vital to maximise health social care and wellbeing for Torfaen citizens and, to ensure services and programmes are providing best value for money.

There is a vast and diverse body of evidence for effective practice, of variable methodological quality, which is available to decision makers in health social care and wellbeing.

235 The extent to which evidence is used in HSCWB decision making is variable; there are many barriers to using evidence to inform decisions. Understanding the importance of EBDM and recognising the alternative basis for decision making, along with easy access to evidence and, the knowledge and skills allowing quick appraisal of the quality and usefulness of evidence are important barriers which can be influenced locally.

This chapter provides evidence and evidence sources for effective decision making in policy, planning, commissioning and practice. The ‘evidence’ provided here is split in to three sections; the first section provides links to specific documents containing evidence of effective interventions for specific topic areas; the second section contains digest sources (i.e. collections of primary research, consensus, guidelines, etc), websites one can search to find evidence of effectiveness without having to appraise primary literature; and, the third section comprises a list of sources where one can find evidence of effective practice from primary research. These lists are not definitive and particularly the first section will require addition and updating on a regular basis as part of the ongoing needs assessment process alluded to in earlier chapters.

236 Evidence of effective interventions

Children & Young people

Childhood disadvantage and adult health: a lifecourse framework; Health Development Agency. Available at: http://www.publichealth.nice.org.uk/page.aspx?o=507885

HEN: Health Evidence Network, World Health Organization Recent questions include What is the evidence on school health promotion: How can injuries in children and young people be prevented Available at: http://www.euro.who.int/HEN

Promoting emotional health and wellbeing through the National Healthy School Standard (NHSS); Health Development Agency Available at: http://www.nice.org.uk/page.aspx?o=502723

Research bulletin - schools and young people issue 1; Welsh Assembly Government Health Promotion Division's bulletin containing work about health issues affecting children and young people. The aim of this bulletin is to inform and strengthen the evidence base for good practice. To highlight research and policy developments and also to support further professional knowledge. Covers a number of topic areas including smoking, emotional health, sexual health and education, healthy schools, substance abuse, dental health, safety and health promoting schools. The review is not intended as a systematic review on these topics. Available at: http://www.cmo.wales.gov.uk/content/publications/research/bulletin- schools-and-young-people-mar06-e.pdf

Research bulletin. Schools and young people. Issue 2. Nutrition, obesity and physical activity; Welsh Assembly Government; Public Health Improvement Division's Research Bulletin on Schools and Young People. This second issue provides literature on nutrition, obesity and physical activity, to support the launch of the Welsh Assembly Government's post-consultation action plan on Food and Fitness for Children and Young People and the consultation document on Food in Schools. Available at: http://www.cmo.wales.gov.uk/content/publications/research/bulletin- schools%20and%20young%20people-jun06-e.pdf

Inequalities Childhood disadvantage and adult health: a lifecourse framework; Health Development Agency Available at: http://www.publichealth.nice.org.uk/page.aspx?o=507885

Evidence of health inequalities; Healthcare Commission. Key issues and evidence, trends and causes and examples Available at: http://www.chai.org.uk/_db/_documents/04017601.pdf

237

Health inequalities: concept, framework and policy; Health Development Agency Available at: http://www.nice.org.uk/download.aspx?o=507959

Tackling health inequalities: Turning policy into practice. Health Development Agency -Includes Theory-based evaluation of complex community-based health initiatives -What contributions might ideas of social capital make to policy implementation for reducing health inequalities? - Regeneration and neighbourhood change - What is known about effective approaches to managing strategic systems change and what are the implications for mainstreaming inequalities? - Implementing neighbourhood renewal: experience and lessons so far - Reducing health inequalities: primary care organisations and public health - Decision-making processes for effective policy implementation - Systems governance: towards effective partnership working Available at: http://www.nice.org.uk/page.aspx?o=508295

Mental Health Effectiveness of mental health promotion interventions: a review; Health Education Authority Available at: http://www.nice.org.uk/page.aspx?o=502207

Evidence from systematic reviews of research relevant to implementing the "wider public health" agenda; NHS Centre for Reviews and Dissemination Includes - A national contract on accidents, mental health, Coronary heart disease, cancer; Education Social care and welfare and Crime, Drugs and Alcohol Available at: http://www.york.ac.uk/inst/crd/wph.htm

Health evidence bulletins Wales. Mental health; National Public Health Service for Wales A bulletin of research evidence to support the implementation of "Raising the Standard. The Revised Adult Mental Health National Service Framework and an Action Plan for Wales. Available at: http://www.hebw.cf.ac.uk/mental/intro.htm

Mental Health and behavioural conditions; National Institute for Health and Clinical Excellence Completed guidelines include Anxiety Bipolar disorder Depression, Depression in children and young people, Eating disorders Available at: http://www.nice.org.uk/page.aspx?o=mental

Mental health and young people; National Institute for Health and Clinical Excellence Public health intervention guidance: in progress, due December 2007 Available at: http://www.nice.org.uk/page.aspx?o=350205&c=mental

238 Research bulletin. Mental health issue 1; Welsh Assembly Government Available at: http://new.wales.gov.uk/docrepos/40382/40382311111/library/research/2004/mental- september-e?lang=en

Research bulletin. Mental health issue 2; Welsh Assembly Government Includes-mental illness and stigma, social skills, social network, housing, employment, suicide and prevention, community and social integration.

Youth suicide prevention: evidence briefing; Health Development Agency Available at: http://www.nice.org.uk/page.aspx?o=503368

Promoting emotional health and wellbeing through the National Healthy School Standard (NHSS) Health Development Agency Available at: http://www.nice.org.uk/page.aspx?o=502723

Nutrition / Obesity Breastfeeding: Library and Knowledge Management Service; National Public Health Service for Wales This is a rapid overview of recent major information sources. These BIS aim to summarise the knowledge base, to support guidance and briefings prepared by NPHS and to act as a 'launch pad' or signpost to more in-depth material. The scope for this BIS is: Breastfeeding - evidence of effectiveness of interventions. Available at: http://www2.nphs.wales.nhs.uk:8080/LKMSDocs.nsf

Evaluation resources for community food projects; Health Development Agency Available at: http://www.publichealth.nice.org.uk/page.aspx?o=503365

Healthy Eating: Breastfeeding - Background Information Sources [BIS no. 2a] Reviews: The effectiveness of public health interventions to promote the duration of breastfeeding. Systematic review part 1. Additional appendices part 2. NICE, 2005. This is a systematic review of the literature on public health interventions to promote the duration of breastfeeding. It is a follow-up to work begun by the HDA when it published an evidence briefing on the promotion of breastfeeding in 2003(see 2). It became apparent when reviewing the literature on breastfeeding that there was a considerable gap in the review-level evidence about the duration of breastfeeding. This systematic review was commissioned to fill this gap. Available at: http://www.nice.org.uk/page.aspx?o=511622

Breastfeeding for longer – what works? Summary report. NICE, 2005. This paper summarises the findings of a systematic review of interventions to enable women to continue breastfeeding, with special reference to women from disadvantaged groups where rates are lowest. Available at: http://www.nice.org.uk/page.aspx?o=511615

The effectiveness of public health interventions to promote the initiation of breastfeeding. Evidence briefing. Health Development Agency, 2003. This briefing presents the current evidence from selected good quality systematic reviews and meta-analyses published since 1996.

239 Available at: http://www.hda.nhs.uk/documents/breastfeeding_evidencebriefing.pdf

Consolidation and updating the evidence base for the promotion of breastfeeding. Stockley, L. National Assembly for Wales, 2001. There are considerable variations in breastfeeding rates, with older, better educated, and higher social class women being more likely to breastfeed. Analysing the data using demographic variables is a useful indicator to begin to try to understand some of the differences. However, factors which influence breastfeeding are complex. They include social, cultural, and attitudinal determinants, as well as practical issues including the quality of support provided in the health care service, and whether a woman is returning to employment or not. Because of this complexity, a sound evidence base is an essential prerequisite for developing a strategy to promote breastfeeding. In the time available it has not been possible to carry out a full systematic review. Fortunately several high quality systematic reviews have been carried out relatively recently. Thus, the approach used here is to consolidate and update the evidence base. Available at: http://www.wales.gov.uk/subihealth/content/keypubs/breast/promotionofBreastfeedin g.pdf

Promoting the initiation of breastfeeding. In: Effective Health Care: bulletin on effectiveness of health service interventions for decision makers 2000; 6(2). This bulletin reviews the evidence for the effectiveness of interventions to increase the initiation of breastfeeding. Available at: http://www.york.ac.uk/inst/crd/ehc62.pdf

Enabling women to breastfeed: a review of the practices which promote or inhibit breastfeeding - with evidence-based guidance for practice. Renfrew, M.; Woolridge, M.W.; MCGill, H.R. The Stationery Office, 2000. The aim of this structured literature review was to identify and review research studies in which interventions that enable women to continue to breastfeed or which interfere with the continuation of breastfeeding have been examined. On the basis of this information, the aim was both to produce a set of practice recommendations which are evidence-based and to identify questions for future research. Available at:

EU Project on Promotion of Breastfeeding in Europe. Protection, promotion and support of breastfeeding in Europe: a blueprint for action. European Commission: Directorate Public Health and Risk Assessment, 2004. This Blueprint for Action, written by breastfeeding experts representing all EU and associated countries and the relevant stakeholder groups, including mothers, is a model plan that outlines the actions that a national or regional plan should contain and implement. It incorporates specific interventions and sets of interventions for which there is an evidence base of effectiveness. It is hoped that the application of the Blueprint will achieve a Europewide improvement in breastfeeding practices and rates (initiation, exclusivity and duration); more parents who are confident, empowered and satisfied with their breastfeeding experience; and health workers with improved skills and greater job satisfaction.

240 Available at: http://ec.europa.eu/health/ph_projects/2002/promotion/fp_promotion_2002_frep_18_ en.pdf

Investing in a better start: promoting breastfeeding in Wales. National Assembly for Wales, 2001. Good nutrition starts from birth and Wales has low rates of breastfeeding in comparison with many other developed countries. The national breastfeeding strategy for Wales provides short, medium and long term priorities for action to increase both the uptake and the continuation of breastfeeding. Available at: http://www.wales.gov.uk/subihealth/content/keypubs/breast/betterstart- e.pdf

Healthy eating; Library and Knowledge Management Service; National Public Health Service for Wales This is rapid overview of recent major information sources. These BIS aim to summarise the knowledge base, to support guidance and briefings prepared by NPHS and to act as a 'launch pad' or signpost to more in-depth material. The scope of this BIS is: Healthy eating, diet and nutrition - all ages - as a lifestyle issue, evidence of effectiveness of interventions. Available at: http://www2.nphs.wales.nhs.uk:8080/LKMSDocs.nsf

Healthy eating: nutrition and the elderly; Library and Knowledge Management Service; National Public Health Service for Wales This is rapid overview of recent major information sources. These BIS aim to summarise the knowledge base, to support guidance and briefings prepared by NPHS and to act as a 'launch pad' or signpost to more in-depth material. The scope for this BIS is: Nutrition + elderly - health education, non-disease specific, focusing on the well elderly. Available at: http://www2.nphs.wales.nhs.uk:8080/LKMSDocs.nsf

Healthy eating: Salt; Library and Knowledge Management Service; National Public Health Service for Wales This is rapid overview of recent major information sources. These BIS aim to summarise the knowledge base, to support guidance and briefings prepared by NPHS and to act as a 'launch pad' or signpost to more in-depth material. The scope for this BIS is: Salt (dietary sodium chloride) inclusion in food, evidence of detrimental effect on health. Available at: http://www2.nphs.wales.nhs.uk:8080/LKMSDocs.nsf

The management of obesity and overweight; An analysis of reviews of diet, physical activity and behavioural approaches; Health Development Agency This review aims to identify diet, physical activity and behavioural interventions shown to be effective in the management of obesity and overweight, and is intended to inform policy and decision makers, NHS providers, public health physicians and other public health practitioners in the widest sense. Available at: http://www.hda-online.org.uk/documents/obesity_evidence_briefing.pdf

Maternal and child nutrition; National Institute for Clinical Excellence Guidance for midwives, health visitors, pharmacists and other primary care services concerning maternal and child nutrition. Seeks to improve the nutrition of

241 pregnant and breastfeeding mothers and children in low income households. Available at: http://www.nice.org.uk/page.aspx?o=MaternalandChildNutritionMain

Research bulletin; Schools and young people Issue 2; Nutrition, obesity and physical activity; Welsh Assembly Government Public Health Improvement Division's Research Bulletin on Schools and Young People. This second issue provides literature on nutrition, obesity and physical activity, to support the launch of the Welsh Assembly Government's post- consultation action plan on Food and Fitness for Children and Young People and the consultation document on Food in Schools. Available at: http://www.cmo.wales.gov.uk/content/publications/research/bulletin- schools%20and%20young%20people-jun06-e.pdf

Review of research on the effects of food promotion to children Final report; Executive summary and management summary; University of Strathclyde This review was commissioned by the Food Standards Agency to examine the current research evidence on: the extent and nature of food promotion to children, the effect, if any, that this promotion has on their food knowledge, and preferences and behaviour. Available at: http://www.foodstandards.gov.uk/healthiereating/promotion/readreview/

A systematic review of the effect of nutrition, diet and dietary change on learning, education and performance of children of relevance to UK schools; University of Teeside A systematic review covering empirical research that has been undertaken to evaluate the effect of nutrition, diet and dietary change on learning, education and performance in school aged children (4-18years) from the UK and other developed countries. Available at: http://www.food.gov.uk/multimedia/pdfs/systemreview.pdf

Scoping; Healthy eating, diet and nutrition – all ages – as a lifestyle issue – evidence of effectiveness of interventions. Excludes Public perception/attitudes and media reports

The evidence of effectiveness of public health interventions – and implications. Briefing paper. Health Development Agency, 2004 Abstract: Obesity and nutrition – brief sections on national, local and school interventions. Available at: http://www.hda-online.org.uk/html/research/effectiveness.html

Lifestyle - Health Evidence Bulletins Wales: Coronary Heart Disease. National Public Health Service, 2004; Chapter 1. Available at: http://hebw.cf.ac.uk/coronary/chapter1.htm

Review of research on the effects of food promotion to children. Final report. Executive summary and management summary. G Hastings, University of Strathclyde: Centre for Social Marketing. Food Standards Agency, 2003 This review was commissioned by the Food Standards Agency to examine the current research evidence on: the extent and nature of food promotion to children, the effect, if any, that this promotion has on their food knowledge, and preferences and behaviour.

242 Available at: http://www.foodstandards.gov.uk/healthiereating/promotion/readreview

Prevention of low birth weight: assessing the effectiveness of smoking cessation and nutritional interventions. Evidence briefing. Health Development Agency, 2003. This briefing aims to identify smoking cessation and nutrition interventions shown to be effective in preventing low birth weight and is intended to inform policy and decision-makers, NHS providers, public health physicians and other public health practitioners in the widest sense. Available at: http://www.hda.nhs.uk/documents/low_birth_weight_evidence_briefing.pdf

A systematic review of the effectiveness of interventions based on stages-of-change approach to promote individual behaviour change. Health Technology Assessment, 2002; 6(24). The objective of this review is to systematically assess the effectiveness of interventions using a stage-based approach in bringing about positive changes in health-related behaviour. Randomised controlled trials (RCTs) evaluating interventions that aimed to influence individual health behaviour, used within a stages-of-change approach were eligible for inclusion. Only studies that reported health-related behaviour change such as smoking cessation, increased physical activity, reduced alcohol consumption or dietary intake were included. The target population included individuals whose behaviour could be modified, primarily in order to prevent the onset, or progression, of disease. Available at: http://www.ncchta.org/fullmono/mon624.pdf

Food and health (including obesity and overweight) - Health Evidence Bulletins Wales: Healthy Living. National Assembly for Wales, 2000; Chapter 3. Available at: http://hebw.cf.ac.uk/healthyliving/chapter3.html

Evidence from systematic reviews of research relevant to implementing the “wider public health” agenda. NHS Centre for Reviews and Dissemination, 2000. Abstract: The Report is a source document containing brief summaries of and references to the results of research relevant to the wider public health agenda. Available at: http://www.york.ac.uk/inst/crd/wph.htm

Food and fitness – promoting healthy eating and physical activity for children and young people in Wales. Welsh Assembly Government, 2006. Abstract: The plan sets out some ways in which the Assembly Government is helping children and young people to eat well, stay fit and achieve the highest standard of health possible. Available at: http://new.wales.gov.uk/topics/health/improvement/food/action/?lang=en

Appetite for health. Consultation document. Welsh Assembly Government, 2006. Abstract: This consultation is to give information and seek views on the Food in Schools Working Group’s report on the extent to which more stringent nutritional standards are introduced; with the aim of delivering a reduction in pupils’ consumption of saturated fats, salt and sugar and an increase in the consumption of fruit, vegetables and other foods

243 containing essential nutrients. Available at: http://new.wales.gov.uk/docrepos/40382/4038232/403829/consultations/2006/appetit e_for_life_final_e.pdf?lang=en

Choosing a better diet: a food and health action plan. Department of Health, 2005. This action plan sets out the Government’s plans to encourage and co-ordinate the action of a range of organisations to improve nutrition and health in England. It is a summary of how it will deliver the commitments on nutrition presented in the public health white paper Choosing Health: making healthier choices easier. Available at: http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/document s/digitalasset/dh_4105709.pdf http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAnd Guidance/DH_4094550

School meals in secondary schools in England. Food Standards Agency, 2004. Following concern about the quality of children’s diets and the contribution of school meals, statutory National Nutritional Standards were reintroduced in April 2001. These standards set out the frequency with which school caterers must provide items from the main food groups (starchy foods, milk and dairy, fruit and vegetables, meat, fish and alternative sources of protein). They apply to all maintained schools in England. The Department for Education and Skills (DfES) and the Food Standards Agency (FSA) commissioned a survey to assess compliance with the standards and to measure food consumption in secondary school pupils. This report presents the findings from a nationally representative sample survey of 79 secondary schools in England which provided information about catering practice and food provision at lunchtime, and information on the food selections of 5 695 secondary school pupils age 11-18 years. Available at: http://www.food.gov.uk/multimedia/pdfs/secondaryschoolmeals.pdf

Concept testing of alternative labeling of healthy/less healthy foods. Food Standards Agency, 2004. The Food Standards Agency is currently considering a number of ways of making it easier for consumers to choose a healthy diet. In particular, the White Paper: Choosing Health and the Agency’s Action Plan on Food Promotions and Children’s Diets include a plan to implement a system of front of pack ‘signpost’ labelling for foods. The intention of the system is to make it easier for consumers to choose a healthy diet by providing ‘at a glance’ information about the nutritional content of foods. The purpose of this research, which was carried out for the Agency by independent researchers, was to test a range of concepts for how this signposting information might be presented to the consumer. Available at: http://www.food.gov.uk/multimedia/pdfs/navigatorsignposting.pdf

Starting early: food and nutrition education of young children. Food Standards Agency, 2004. In the autumn term 2003 and the spring term 2004, childcare inspectors and Her Majesty’s Inspectors from Ofsted, accompanied by nutritionists commissioned by the Food Standards Agency, visited 25 settings, including 19 nursery, infant and primary schools, and 6 maintained and private day nurseries. The inspection focused on:

244 *evaluating the appropriateness and quality of the work with food that the children undertake *assessing the extent to which the environment in which the children work and eat is supportive of promoting good health and nutrition *identifying the factors that support or impede food and nutrition education. Available at: http://www.food.gov.uk/multimedia/pdfs/ofstedearly.pdf

"Food for thought” - a new approach to public sector food procurement. Welsh Assembly Government, [2004]. This is a general guidance on the issues involved in public sector food procurement, including practical recommendations on how to carry out procurement in a way that will generate the most benefit to all. Available at: http://www.wales.gov.uk/subieconomics/content/bettervalue/food- thought-doc-e.pdf

Food and wellbeing – reducing inequalities through a nutrition strategy for Wales. Food Standard Agency for Wales, 2003. The strategy, ‘Food and Well Being’, outlines the actions required by key players to improve the diet of people in Wales. The key players include: policy and decision makers; health, nutrition and catering professionals; practitioners and educators at national and local levels, and the food production and retail industries. Available at: http://www.food.gov.uk/multimedia/pdfs/foodandwellbeing.pdf

Going hungry: the struggle to eat healthily on a low income. NCH Children’s Charity, 2004. NCH decided to research the diets of children and families living on low incomes in the UK today. NCH’s aim is ‘to improve the quality of life of the most vulnerable children’ and they believe these children’s views and those of their parents should inform the current debate about what we do eat and what we should eat. Available at: http://www.nch.org.uk/downloads/going_hungrymainreport2.pdf

Nutrition + food poverty toolkit. National Heart Forum, 2004. The toolkit: • Outlines the barriers to healthy eating and the scientific evidence on the role of poor nutrition in the major public health problems in the UK • Details key messages for healthy eating and includes practical tips on how people on low incomes can achieve a better diet • Demonstrates how nutrition and food poverty strategies can help to achieve local targets and how they are central to the government's health and inequalities agenda • Shows how nutrition and food poverty strategies inter-relate with the government's environment, social and education policies and programmes • Provides background information on how to write and implement a local strategy • Provides a comprehensive list of examples of good practice and further sources of guidance to assist with strategy development. Available at: http://www.heartforum.org.uk/pdfs/Nut_TkitAll.pdf

Healthy eating: eating for life Chief Medical Officer –Welsh Assembly Government. Public information resource giving practical advice on how to have a healthy diet. Available at: http://www.cmo.wales.gov.uk/content/work/healthyeating/eating-for- life/index-e.htm

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Lifestyle - Health Evidence Bulletins Wales: Coronary Heart Disease. National Public Health Service, 2004; Chapter 1. Available at: http://hebw.cf.ac.uk/coronary/chapter1.htm

Protein and energy supplementation in elderly people at risk from malnutrition. Milne AC, Potter J, Avenell A. The Cochrane Database of Systematic Reviews 2005, Issue 3. This review was carried out because evidence for the effectiveness of nutritional supplements containing protein and energy, which are often prescribed for elderly people, is limited. Furthermore malnutrition is more common in this age group and deterioration of nutritional status can occur during a stay in hospital. It is important to establish whether supplementing the diet with protein and energy is an effective way of improving outcomes for older people at risk from malnutrition. This review examines the evidence from trials for improvement in nutritional status and clinical outcomes when extra protein and energy food were provided, usually in the form of commercial 'sip-feeds'. Available at: http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD003288/pdf_fs.h tml

Keep fit for life: meeting the nutritional needs of older persons. World Health Organisation, 2002. Given the impact that good nutrition and keeping fit have on health and well being in later life, WHO organised a consultation to review the scientific evidence linking diet and other factors affecting nutritional status, disease prevention and health promotion for older persons. The consultation focused primarily on practical issues including the establishment of explicit recommendations to improve the health and nutritional status of older persons in a wide variety of socio-economic and cultural settings. The combined results presented here are intended as an authoritative source of information for nutritionists, general practitioners, gerontologists, medical faculties, nurses, care providers, schools of public health and social workers. The specific recommendations concerning nutrient intakes, food-based dietary guidelines, and exercise and physical activity should also interest a larger audience, including the general reader. The main body discusses the epidemiological and social aspects of ageing, health and functional changes experienced with ageing, the impact of physical activity, assessment of the nutritional status of older persons, and nutritional guidelines for healthy ageing. Additional material covers food-based dietary guidelines for older adults - with particular emphasis on healthy ageing and prevention of chronic non-communicable diseases - and guidelines for promoting physical activity among older persons. Link to Annex Available at: http://www.who.int/nut/documents/nut_older_persons_1.pdf http://www.who.int/nut/ documents/nut_older_persons_2.pdf

Food and health. Health Evidence Bulletins Wales: Healthy living. National Assembly for Wales, 1999; Chapter 3. Available at: http://hebw.cf.ac.uk/healthyliving/chapter3.html

246 Injury prevention – older people. Health Evidence Bulletins Wales: Injury prevention. National Assembly for Wales, 1998; Chapter2. Available at: http://hebw.cf.ac.uk/injury/chapter2.html

Primary prevention of cardiovascular disease. Health Evidence Bulletins Wales: Cardiovascular diseases. National Assembly for Wales, 1998; Chapter1. Available at: http://hebw.uwcm.ac.uk/cardio/chapter1.html

Effectiveness of interventions to promote healthy eating in elderly people living in the community: a review. Health Education Authority, 1998. The growing number of elderly people in the UK highlights the need to identify interventions and strategies to maintain and enhance their health. This report reviews the studies of interventions to promote healthy eating in elderly people living in the community. Interventions in settings such as long stay care or provision of meals programmes were not included. Available at: http://www.hda-online.org.uk/Documents/effective_eating_elderly.pdf

Opportunities for and barriers to change in the dietary behaviour of elderly people. Health Education Authority, 1997. This review reveals the barriers to the adoption of health promotion strategies in older people. The review sites a total of 53 reports, which examine nutritional status, the reduction of saturated fats, and nutrition among hospital in-patients or those in care. Other issues such as diet-related disease (overweight and underweight status), fat intake, cholesterol levels and dental health are also discussed. Cooking and shopping and fruit and vegetable consumption are issues addressed. Available at: http://www.hda-online.org.uk/Documents/nuthealth_elderly.pdf

Health promotion action plan for older people in Wales: A response to health Challenge Wales. Welsh Assembly Government, 2004. The purpose of the Action Plan is to: Bring together, in one document, existing and proposed health promotion initiatives for older people. Provide guidance for use at local level on key evidence based health promotion interventions with older people. As such, it provides the major implementation tool for the health promotion and ill health prevention elements of the developing National Service Framework for Older People in Wales. Outline responsibilities of the Welsh Assembly Government and its partners. Introduce new Assembly led initiatives as part of the Welsh Assembly Government response to Health Challenge Wales. (See Chapter 6(iii) Healthy eating.) Available at: http://www.cmo.wales.gov.uk/content/publications/consultations/action- plan-consultation-e.pdf

Nutrition for physically frail older people: best practice statement. Nursing & Midwifery Practice Development Unit, NHS Scotland, 2002. This document has been produced as part of a series of best practice statements. It offers guidance on meeting the nutritional needs of physically frail people within continuing care facilities and covers: assessment and care planning; promoting a nutritious diet; the environment of care; the managerial role of the nurse and education and training of staff.

247 NHS Health Scotland is currently developing a specific programme "Health in Later Life", tailor-made to the health education needs of older people. Available at: http://www.nhshealthquality.org/nhsqis/files/BPSNutrition_frail_elderlyMay02.pdf

Recommendations for a national food and nutrition policy for older people. Food Safety Authority of Ireland, 2000. This report sets out to facilitate the development and maintenance of good health for older people through appropriate food consumption. The objectives are to: • Attempt to ensure adequate food and nutrient intake • Prevent poor nutritional status • Avoid excessive food and nutrient intake which may predispose to several chronic diseases Reports from professional bodies The British Nutrition Foundation is currently working on a Task Force Report on nutrition and healthy ageing which should be published in 2006/7. Available at: http://www.fsai.ie/publications/reports/recommendations_nutrition_older_people.pdf

Food served to older people in residential care Food Standards Agency, 2006. There are approximately 410,000 older people in residential and nursing homes across the UK. The Food Standard Agency’s advice for food served to older people in residential care aims to support the wider care standards and provide the basis of assessment for residents, their family, care home staff and those responsible for commissioning and monitoring standards. Available at: http://www.food.gov.uk/multimedia/pdfs/residentialcarea.pdf

Nutritional Care for Older People - a guide to good practice. Age Concern, 1999. Written by an experienced nutritionist, this book stresses throughout the importance of good nutrition to health. Staff involved in food planning and management in care homes, day centres and other community settings will find this book a vital source of guidance and support. Drawing on national guidelines, accepted practice and the latest scientific knowledge, this book will help staff develop and maintain the very best standards in all aspects of food management.

Dietary advice for reducing cardiovascular risk. Brunner EJ, Thorogood M, Rees K, Hewitt G. The Cochrane Database of Systematic Reviews 2005, Issue 4. Changes in population diet are likely to reduce cardiovascular disease and cancer, but the effect of dietary advice is uncertain. The review’s objective was to assess the effects of providing dietary advice to achieve sustained dietary changes or improved cardiovascular risk profile among healthy adults. The dietary improvements recommended to the people in the intervention groups centred largely on the reduction of salt and fat intake and an increase in the intake of fruits, vegetables, and fibre. Available at: http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD002128/frame.h tml

Lifestyle - Health Evidence Bulletins Wales : Coronary Heart Disease. National Public Health Service, 2004; Chapter 1.

248 Available at: http://hebw.cf.ac.uk/coronary/chapter1.htm

High risk and CHD diagnosed - Health Evidence Bulletins Wales: Coronary Heart Disease. National Public Health Service, 2004; Chapter 2. Available at: http://hebw.cf.ac.uk/coronary/pdf/coron-heart-01-04-ch2.pdf

Dietary salt reduction or exclusion for allergic asthma. Ram FSF, Ardern KD. The Cochrane Database of Systematic Reviews 2004, Issue 2. There is a wide geographical variation in asthma prevalence and one explanation may be in dietary salt consumption. The objective of this review was to assess the effect of dietary sodium reduction in patients with asthma. Available at: http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD000436/frame.h tml

Advice to reduce dietary salt for prevention of cardiovascular disease. Hooper L, Bartlett C, Davey Smith G, Ebrahim S. The Cochrane Database of Systematic Reviews 2004, Issue 1. Restricting sodium intake in elevated blood pressure over short periods of time reduces blood pressure. Long term effects (on mortality, morbidity or blood pressure) of advice to reduce salt in patients with elevated or normal blood pressure are unclear. The objective of this review was to assess in adults the long term effects (mortality, cardiovascular events, blood pressure, quality of life, weight, urinary sodium excretion, other nutrients and use of anti-hypertensive medications) of advice to restrict dietary sodium using all relevant randomised controlled trials. Available at: http://www.wales.nhs.uk/page.cfm?orgid=1&pid=1836

Effect of longer-term modest salt reduction on blood pressure. He FJ, MacGregor GA. The Cochrane Database of Systematic Reviews 2004, Issue 1. Many randomised trials assessing the effect of salt reduction on blood pressure show reduction in blood pressure in individuals with high blood pressure. However, there is controversy about the magnitude and the clinical significance of the fall in blood pressure in individuals with normal blood pressure. The objectives of this review were to assess the effect of the currently recommended modest reduction in salt intake on blood pressure in individuals with normal and elevated blood pressure and to assess whether the magnitude of the reduction in blood pressure is dependent on the magnitude of the reduction in salt intake. Available at: http://www.wales.nhs.uk/page.cfm?orgid=1&pid=1836

Effects of low sodium diet versus high sodium diet on blood pressure, renin, aldosterone, catecholamines, cholesterols, and triglyceride. Jürgens G, Graudal NA. The Cochrane Database of Systematic Reviews 2004, Issue 1. One of the controversies in preventive medicine is, whether a general reduction in sodium intake can decrease the blood pressure of a population and thereby reduce cardiovascular mortality and morbidity. In recent years the debate has been extended by studies indicating that reducing sodium intake has effects on the hormone and lipid profile. The objective of this review was to estimate the effects of low sodium versus high sodium intake on systolic and diastolic blood pressure (SBP and DBP), plasma or serum levels of renin, aldosterone, catecholamines, cholesterol and triglycerides.

249 Available at: http://www.wales.nhs.uk/page.cfm?orgid=1&pid=1836

Salt and health report. Scientific Advisory Committee on Nutrition, 2003. The relationship between salt and blood pressure was previously considered in 1994 by the Committee on Medical Aspects of Food and Nutrition Policy (COMA) as part of their report on Nutritional Aspects of Cardiovascular Disease. The Scientific Advisory Committee on Nutrition (SACN) was asked by the Food Standards Agency and the Chief Medical Officer of Wales to review the evidence since the 1994 and to consider making recommendations for children. Available at: http://www.sacn.gov.uk/pdfs/sacn_salt_final.pdf

Lowering blood pressure to prevent myocardial infarction and stroke: a new preventive strategy. Health Technology Assessment, 2003; 7(31). The objective of this review was to investigate the screening performance of measuring blood pressure and other variables in identifying those who will develop, or die from, ischaemic heart disease and stroke. Link to Summary Available at: http://www.ncchta.org/fullmono/mon731.pdf http://www.ncchta.org/pdfexecs/summ731.pdf

Reduced salt intake compared to normal dietary salt, or high intake, in pregnancy. Duley L , Henderson-Smart D. The Cochrane Database of Systematic Reviews 1999, Issue 3. In the past women have been advised that lowering their salt intake might reduce their risk of pre-eclampsia. Although this practice has largely ceased, it remains important to assess the evidence about possible effects of advice to alter dietary salt intake during pregnancy. The objective of this review was to assess the effects of dietary advice to alter salt intake compared to continuing a normal diet, on the risk of pre-eclampsia and its consequences. Available at: http://www.wales.nhs.uk/page.cfm?orgid=1&pid=1836

Hypertensive disorders of pregnancy. Health Evidence Bulletins Wales: Maternal and child health. National Assembly for Wales, 1998; Chapter2. Available at: http://hebw.uwcm.ac.uk/maternal/chapter2.html

Understanding and perceptions of heart disease and stroke. Food Standards Agency, 2004. In June 2004 the Agency commissioned some research as it wished to develop a deeper understanding of public perceptions of heart disease and stroke and the factors that trigger these conditions (including salt). Key objectives for the research were: to explore general understanding and perceptions of heart disease and stroke to explore the perceived role of salt as a contributing cause of these conditions and broadly, to understand levels of receptivity to health messages and motivation to act in response to health messages. Available at: http://www.food.gov.uk/multimedia/pdfs/saltperceptions.pdf

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Salt – position statement. Faculty of Public Health, 2006. There is widespread recognition that daily salt intake levels in the population need to be reduced. However, continued pressure is needed to ensure industry (and government) meet the target of an average 6g/day for those aged 11 and over by 2010. The Faculty's Position Statement outlines what organisations and individual health professionals should advocate and lobby for around this issue, and how to do it. Available at: http://www.fphm.org.uk/policy_communication/downloads/policy_statements/salt_stat ement.pdf

Easing the pressure: tackling hypertension toolkit. (online resource). Faculty of Public Health [Accessed 30th June 2006] Available at: http://www.fphm.org.uk/policy_communication/publications/toolkits/hypertension/defa ult.asp

Guidelines for management of hypertension: report of the fourth working party of the British Hypertension Society, 2004—BHS IV. B Williams, NR Poulter, MJ Brown, M Davis, GT McInnes5, JF Potter, PS Sever and S McG Thom. Journal of Human Hypertension, 2004; 18: 139–185. These guidelines update previous reports by working parties of the British Hypertension Society. Updating these guidelines is appropriate because, since 1999, there has been much new evidence in key areas that has allowed BHS to reinforce and extend previous recommendations. Lists excess salt intake as a contributory factor in hypertension. Available at: http://www.bhsoc.org/default.stm Blood pressure, lifestyle & treatment (This site takes a look at things that raise blood pressure, especially salt, and how changing lifestyle can reduce your blood pressure.) Available at: http://www.jr2.ox.ac.uk/bandolier/booth/booths/bpsalt.html

The evidence of effectiveness of public health interventions – and implications. Briefing paper. Health Development Agency, 2004 Obesity and nutrition – brief sections on national, local and school interventions. Available at: http://www.hda-online.org.uk/html/research/effectiveness.html

The management of obesity and overweight. An analysis of reviews of diet, physical activity and behavioural approaches. Evidence briefing. Health Development Agency 2003 This review aims to identify diet, physical activity and behavioural interventions shown to be effective in the management of obesity and overweight, and is intended to inform policy and decision makers, NHS providers, public health physicians and other public health practitioners in the widest sense.Summary of Briefing Available at: http://www.hda-online.org.uk/documents/obesity_evidence_briefing.pdf http://www.hda-online.org.uk/documents/obesity_evidence_briefing_summary.pdf

Obesity – Health Evidence Bulletins Wales : Coronary Heart Disease. National Public Health Service, 2004 p6, 17-19, 42, 86.

251 Available at: http://hebw.cf.ac.uk/coronary/index.htm

The clinical effectiveness and cost effectiveness of sibutramine in the management of obesity: a technology assessment. The National Co-ordinating Centre for Health technology Assessment. Health Technology Assessment 2002; 6(6) To assess systematically the clinical effectiveness and cost effectiveness of sibutramine in the management of obesity. Conclusion: Although many trials demonstrated statistically significant differences between groups in terms of weight loss in favour of sibutramine versus placebo, the difference may not always be of clinical significance. The clinical significance of between- group differences for secondary outcomes may also be debatable. Possible adverse effects should be taken into account when subscribing sibutramine. Recommendations: Further research is required to determine the effects of sibutramine in different patient groups according to gender, age, ethnicity and social class. Available at: http://www.ncchta.org/execsumm/summ606.htm

The clinical effectiveness and cost effectiveness of surgery for people with morbid obesity: a systematic review and economic evaluation. Health Technology Assessment 2002; 6(12) To systematically review the clinical effectiveness and cost effectiveness of surgery for the management of morbid obesity and to develop a cost effectiveness model using the best evidence available to determine cost effectiveness in a UK setting. Recommendations: Although surgery appears to be effective in terms of weight change, there is limited evidence addressing the long term consequences and its influence on the QoL of patients. In addition, there have been few economic evaluations comparing the different surgical interventions and the availability of costing and resource use appears limited. Available at: http://www.ncchta.org/execsumm/summ612.htm

Systematic review of the long term effects and economic consequences of treatments for obesity and implications for health improvement Health Technology Assessment 2004; 8(21) To review systematically obesity treatments in adults to identify therapies that impact by achieving weight reduction, risk factor modification or improved clinical outcomes. Based on a systematic review of epidemiological data, to model the impact of moderate weight reduction on reducing the burden of obesity-associated disease. To review systematically health economic evaluations of obesity treatments and assess costs to the NHS of these treatments. Conclusion: Orlistat, sibutramine and metformin appear beneficial for the treatment of adults with obesity. Exercise and/or behaviour therapy appear to improve weight loss when added to diet. Low-fat diets with exercise, with or without behaviour therapy, are associated with the prevention of type 2 diabetes and hypertension. Long-term weight loss in epidemiological studies was also associated with reduced risk of developing diabetes, and may be beneficial for cardiovascular disease. Low-fat diet and exercise interventions in individuals at risk of obesity-related illness, such as diabetes, are of comparable cost to drug treatments. Available at: http://www.ncchta.org/execsumm/summ821.htm

252 A rapid and systematic review of the clinical effectiveness and cost effectiveness of orlistat in the management of obesity. Health technology Assessment 2001; 5 (18) To systematically assess the clinical effectiveness and cost-effectiveness of orlistat in the management of obesity. Conclusion: Although many trials have demonstrated statistically significant differences between groups in terms of weight loss in favour of orlistat versus placebo, the differences may not always be of clinical significance. The clinical significance of between-group differences for secondary outcomes may also be debatable. Possible adverse effects should be taken into account when prescribing orlistat, particularly gastrointestinal effects. Available at: http://www.ncchta.org/execsumm/summ518.htm

House of Commons Health Committee 3rd Report, HCP 23-1, 10 May 2004

Available at: http://www.parliament.the-stationery- office.co.uk/pa/cm200304/cmselect/cmhealth/23/2302.htm

Tackling Obesity in England. National Audit Office HCP 220, 15 February 2001

This is the first authoritative estimates of the costs and consequences of obesity in England, reports that obesity accounted for 18 million days of sickness absence and 30,000 premature deaths in 1998. Treating obesity costs the NHS at least £½ billion a year. The wider costs to the economy in lower productivity and lost output could be a further £2 billion each year.

Available at: http://www.nao.org.uk/pn/00-01/0001220.htm

Obesity , WHO internet pages Includes Obesity and overweight – WHO Global Strategy on diet, physical activity and health Available at: http://www.who.int/topics/obesity/en/

Obesity : Health Care Needs Assessment : the epidemiologically based needs assessment reviews. 3rd series. A Stevens, J Rafferty. University of Birmingham. Project funded by Department of Health and NICE. Sections include 3. Subcategories and risk4. Prevalence and Incidence , 5. Services Available and their Cost , 6. Effectiveness of Services and their Interventions, 7. Quantified Models of Care / Recommendations , 8. Outcome Measures and Audit Methods. Available at: http://hcna.radcliffe-oxford.com/obframe.html

Storing up problems. The medical case for a slimmer nation. Royal College of Physicians, 2004. Although over half the UK population are now either overweight or obese, many are unaware of the health problems it causes. This report sets out clearly the serious health consequences of excess body weight, citing the latest international research evidence to support its assertions. Link to Recommendations: Available at: http://www.rcplondon.ac.uk/pubs/books/SUP/obesityRecommendations.pdf

253 Tackling obesity. A toolbox for local partnership action. Faculty of Public Health Medicine; 2000. Aimed at all those working together at local level to tackle the problem of obesity. The Toolbox gives a brief overview of the size of the obesity problem and outlines the evidence base for key interventions at community, group and individual level. It provides a practical framework for developing a local action plan to prevent and control obesity and overweight, with an emphasis on a partnership approach targeting those at greatest need. It also lists the most useful current background documents and websites. Available at: Healthy eating: eating for life Chief Medical Officer –Welsh Assembly Government. Public information resource giving practical advice on how to have a healthy diet. Available at: http://www.cmo.wales.gov.uk/content/work/healthy-eating/eating-for- life/index-e.htm

Food and weight Food Standards Agency Includes an online Body Mass Index calculator Available at: http://www.foodstandards.org.uk/healthiereating/are_you_healthyweight

Older People

Measuring impact: improving the health and wellbeing of people in mid-life and beyond; National Institute for Health and Clinical Excellence Measuring impact is the third in a series of publications commissioned by the Health Development Agency from the mid-life programme of work, which seeks to improve the health and wellbeing of people in the mid-life age group and reduce inequalities. The publications Making the case (HDA, 2003) and Taking action (HDA, 2004), and now Measuring impact, aim to support practitioners and policy makers at a local level in implementing and using the evidence of what works to develop mainstream practice and influence policy formulation in this population group. Available at: http://www.publichealth.nice.org.uk/page.aspx?o=518183

Research bulletin: older people; Welsh Assembly Government The bulletin includes literature on general health issues, alcohol, healthy eating and nutrition, housing, influenza immunisation, emotional health and wellbeing, physical activity, sexual health and smoking. Available at: http://new.wales.gov.uk/docrepos/40382/40382311111/library/research/2006/older- people-e?lang=en

254

Physical activity Effectiveness of physical activity promotion schemes in primary care; Health Development Agency Available at: http://www.publichealth.nice.org.uk/page.aspx?o=502255

The effectiveness of public health interventions for increasing physical activity among adults: a review of reviews; Health Development Agency Available at: http://www.nice.org.uk/download.aspx?o=503377

Exercise referral - a guide to developing high quality schemes; Welsh Assembly Government The aim of this document is to help contribute towards the development of high quality exercise referral schemes across Wales. The information contained in this guide has been developed from contributions by a wide range of professionals working in research, training and delivery of exercise referral schemes across Wales and beyond. The guide has specific advice on setting up, running and evaluating schemes, with separate sections for all partners involved in their delivery. Available at: http://www.cmo.wales.gov.uk/content/work/physical-activity/exercise- referral-guide-e.pdf

Four commonly used methods to increase physical activity: brief interventions in primary care, exercise referral schemes, pedometers and community-based exercise programmes for walking and cycling; National Institute for Health and Clinical Excellence Available at: http://www.nice.org.uk/download.aspx?o=299528

Interventions that use the environment to encourage physical activity. Evidence review National Institute for Clinical Excellence A review presenting the current evidence derived from the published literature on environmental interventions. Primary studies and systematic reviews are examined. How the environment affects health, evidence concerning interventions, gaps in the evidence base and recommendations for research are included. Conclusions are drawn. Available at: http://www.nice.org.uk/page.aspx?o=366133

Making the case: improving health through transport; Health Development Agency Available at: http://www.publichealth.nice.org.uk/page.aspx?o=503415

Promotion of Physical Activity among adults. Evidence into practice briefing; National Institute for Health and Clinical Excellence A briefing commissioned by the Public Health Collaborating centre on Physical Activity. It examines suggested physical activity interventions in healthcare and community settings, the workplace, amongst ethnic groups, the disabled and older people. Available at: http://www.nice.org.uk/page.aspx?o=299207

255 Research bulletin. Schools and young people. Issue 2. Nutrition, obesity and physical activity; Welsh Assembly Government Public Health Improvement Division's Research Bulletin on Schools and Young People. This second issue provides literature on nutrition, obesity and physical activity, to support the launch of the Welsh Assembly Government's post- consultation action plan on Food and Fitness for Children and Young People and the consultation document on Food in Schools. Available at: http://www.cmo.wales.gov.uk/content/publications/research/bulletin- schools%20and%20young%20people-jun06-e.pdf

Promotion of physical activity among adults. Evidence into practice briefing. National Institute for Health and Clinical Excellence, 2006. This evidence into practice briefing represents the culmination of work commissioned by the former Health Development Agency (HDA). It presents a series of evidence- based actions for promoting physical activity among adults. These have been formulated through the integration of published scientific literature with practitioner expertise and experience. The briefing includes characteristics of effective programmes for specific settings and population sub-groups, barriers to implementation and suggestions for action. Available at: http://nww.nwales- ha.wales.nhs.uk/wahims/news/2006marchphysicalactivityadults.pdf

Physical activity public health intervention guidance. National Institute for Health and Clinical Excellence, 2006. This guidance covers four common methods used to increase the population's physical activity levels: brief interventions in primary care; exercise referral schemes; pedometers; community-based walking and cycling programmes. Available at: http://www.nice.org.uk/page.aspx?o=300202

Interventions that use the environment to encourage physical activity. Evidence review. National Institute for Health and Clinical Excellence, 2006. This review presents the current evidence derived from the published literature on environmental interventions, and includes both systematic reviews and primary studies from the earliest records to May 2005. Available at: http://www.nice.org.uk/download.aspx?o=366133

The effectiveness of public health interventions for increasing physical activity among adults: a review of reviews. (2nd edition) Evidence briefing. Health Development Agency, 2005. This evidence briefing collates review-level evidence about the effectiveness of interventions to increase physical activity among adults. It focuses on individual- centred interventions and discusses the potential generalisation of the results to UK settings. This evidence briefing updates the edition published in February 2004. Link to summary Available at: http://www.nice.org.uk/page.aspx?o=505281 http://www.nice.org.uk/page.aspx?o=503374

256 The evidence of effectiveness of public health interventions – and implications. Briefing paper. Health Development Agency, 2004 Physical activity – brief sections on national, local and school interventions. Available at: http://www.hda-online.org.uk/html/research/effectiveness.html

Lifestyle - Health Evidence Bulletins Wales: Coronary Heart Disease. National Public Health Service, 2004; Chapter 1. Available at: http://hebw.uwcm.ac.uk/coronary/index.htm

Clinical Evidence. BMJ Publishing Group [Accessed online 30th October 2006]. Numerous references to exercise/physical activity as a preventive and/or therapeutic measure with particular reference to the sections cardiovascular disease, musculoskeletal disorders and women’s health. Available at: http://www.clinicalevidence.com/ceweb/SearchServlet?searchTerm=exercise

Prevention and reduction of accidental injuries in children and older people. Health Development Agency, 2003. Includes references to physical activity as a preventive measure. Available at: http://www.hda-online.org.uk/documents/prev_accidental_injury.pdf

The management of obesity and overweight. An analysis of reviews of diet, physical activity and behavioural approaches. Evidence briefing. Health Development Agency, 2003. This review aims to identify diet, physical activity and behavioural interventions shown to be effective in the management of obesity and overweight, and is intended to inform policy and decision makers, NHS providers, public health physicians and other public health practitioners in the widest sense. Link to Summary of Briefing Available at: http://www.hda-online.org.uk/documents/obesity_evidence_briefing.pdf http://www.hda-online.org.uk/documents/obesity_evidence_briefing_summary.pdf

Health Evidence Bulletins Wales: Osteoporosis. National Assembly for Wales, 2001. Available at: http://hebw.cf.ac.uk/osteoporosis/index.htm

257 Children and young people –the importance of physical activity. European Heart Health Initiative, 2001. This paper is the fruit of the joint work of the national coordinators and their national alliances as well as experts in the area of physical activity. Evidence has been reviewed by experts and discussed in depth by the national coordinators. The paper is published in the context of the EHHI with the intention of promoting physical activity measures as a way to reduce the burden of CVD. Available at: http://ec.europa.eu/health/ph_projects/2000/promotion/fp_promotion_2000_frep_11_ en.pdf

Evidence from systematic reviews of research relevant to implementing the “wider public health” agenda. NHS Centre for Reviews and Dissemination, 2000. The Report is a source document containing brief summaries of and references to the results of research relevant to the wider public health agenda. Available at: http://www.york.ac.uk/inst/crd/wph.htm

Guidelines for health-enhancing physical activity promotion programmes. European Network for HEPA, UKK Institute: Tampere, Finland, 2000. Link to final report Available at: http://ec.europa.eu/health/ph_projects/2000/promotion/fp_promotion_2000_frep_09_ en.pdf

Food and fitness – promoting healthy eating and physical activity for children and young people in Wales. Welsh Assembly Government, 2006. The plan sets out some ways in which the Assembly Government is helping children and young people to eat well, stay fit and achieve the highest standard of health possible. Available at: http://new.wales.gov.uk/topics/health/improvement/food/action/?lang=en

Climbing higher: next steps. Welsh Assembly Government, 2006. The Climbing Higher Strategy is the Welsh Assembly Government’s twenty year vision for sport and physical activity. It recognises that increasing levels of physical activity and engaging local communities in more active lifestyles will also make very important contributions to other strategic priorities of the Welsh Assembly Government. Available at: http://new.wales.gov.uk/docrepos/40382/403822/403822131/4038221333/CH-NS- final-e.pdf?lang=en See also Climbing higher – sport and active recreation in Wales . Available at: http://new.wales.gov.uk/subiculture/content/sport/sports-active-e.pdf

Exercise referral - a guide to developing high quality schemes. Welsh Assembly Government, 2006.

258 The aim of this document is to help contribute towards the development of high quality exercise referral schemes across Wales. The information contained in this guide has been developed from contributions by a wide range of professionals working in research, training and delivery of exercise referral schemes across Wales and beyond. The guide has specific advice on setting up, running and evaluating schemes, with separate sections for all partners involved in their delivery. Available at: http://www.cmo.wales.gov.uk/content/work.physical-activity/exercise- referal-guide-e.pdf

Choosing activity: a physical activity action plan. Department of Health, 2005. This action plan sets out the Government’s plans to encourage and co-ordinate the action of a range of departments and organisations to promote increased participation in physical activity across England. It is a summary of how it will deliver the commitments on physical activity presented in the public health white paper Choosing Health: making healthier choices easier. Available at: http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/document s/digitalasset/dh_4105710.pdf http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAnd Guidance/DH_4094550

Climbing higher – sport and active recreation in Wales Welsh Assembly Government, 2005. This is the Welsh Assembly Government’s long-term strategy for sport and physical activity, setting out its strategic direction in Wales for the next twenty years. The purpose of this strategy, which complements other Welsh Assembly Government actions and policies, is that within 20 years sport and physical activity will be at the heart of Welsh life and at the heart of Government policy. Available at: http://www.wales.gov.uk/subiculture/content/sport/sports-active-e.pdf

At least five a week. Evidence on the impact of physical activity and its relationship to health. Department of Health, 2004. This report sets out the available evidence from around the world for the impact that physical activity has on public health. The evidence clearly demonstrates that an inactive lifestyle has a substantial, negative impact on both individual and public health – specifically, that physical inactivity is a primary contributor to a broad range of chronic diseases such as coronary heart disease, stroke, diabetes and some cancers. Available at: http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/document s/digitalasset/dh_4080981.pdf

Healthy and active lifestyles in Wales: a framework for action. Welsh Assembly Government, 2003. This Action Plan sets out a programme of action to encourage more active daily living among the most sedentary sectors of the population of Wales. It is designed to complement the Sports Council for Wales’ initiatives focusing on organised and competitive sport, as well as related Welsh Assembly Government documents including the Physical Education and School Sport Action Plan, the Walking and

259 Cycling Strategy and the Strategy on Sport and Active Recreation which is currently being issued for consultation. Available at: http://www.wales.gov.uk/subihealth/content/keypubs/pdf/healthy-active- lifestyle-e.pdf

Walking and cycling strategy for Wales. Welsh Assembly Government, 2003. The Welsh Assembly Government is committed to improving the health of the people of Wales. Walking and cycling can bring about tremendous health benefits to individuals, as well as wider community benefits from reduced vehicle emissions. More walking and cycling means less car use. Available at: http://www.wales.gov.uk/subitransport/content/walking-cycling-e.pdf

Exercise referral systems: A national quality assurance framework. Department of Health, 2001. This framework provides guidelines for exercise referral systems, with the aim of improving standards among existing exercise referral schemes, and helping the development of new ones. The framework focuses primarily on the most common model of exercise referral system, where the GP or practice nurse refers patients to facilities such as leisure centres or gyms for supervised exercise programmes. Guidance covers issues including patient selection, evaluation and long-term follow up. Available at: http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/document s/digitalasset/dh_4079009.pdf

Saving lives, saving money: physical activity – the best buy in public health. Central Council of Physical Recreation, [2003]. In April 2001, Health Authorities were required to put in place plans for physical activity promotion within their general Health Improvement Programmes. As Government looks to review the effectiveness of these plans after their first year, the CCPR has carried out a review of the measures drawn up by Health Authorities. The majority of plans included measures on physical activity and there were numerous examples of good work. However, there were wide differences between authorities and an identified need to improve consistency by spreading best practice. The review should be seen in the context of reports that only one in ten GPs were aware of the recommendations on minimum physical activity levels. Available at: http://www.ccpr.org.uk/dyncat.cfm?catid=5602

Let’s get moving – a physical activity handbook for developing local programmes. Faculty of Public Health; National Heart Forum, 2001. Abstract: A resource to help in the development of local policies, strategies and programmes to promote physical activity. Available free of charge from FPH or on loan from NPHS LKMS. British Heart Foundation Available at: http://www.bhf.org.uk/index.asp

HEPA - European network for the promotion of health-enhancing physical activity Available at: http://www.euro.who.int/hepa

Local Exercise Action Pilots (LEAP)

260 Available at: http://www.dh.gov.uk/PolicyAndGuidance/HealthAndSocialCareTopics/HealthyLiving/ LocalExerciseActionPilots/fs/en

Smoking

An assessment of brief interventions and referral for smoking cessation in primary care National Institute for Clinical Excellence Consultation on draft recommendations for Smoking interventions guidance: 25 January - 21 February 2006. Available at: http://www.publichealth.nice.org.uk/page.aspx?o=518522

Brief interventions and referral for smoking cessation in primary care and other settings National Institute for Clinical Excellence Public health intervention guidance concerning brief interventions and referral for smoking cessation in primary care and other settings. Available at: http://www.nice.org.uk/guidance/PHI1

Evaluation of specialist smoking cessation services in Wales; Welsh Assembly Government This Circular outlined the financial framework for service development, and gave initial advice on setting up the services, based on the 1998 White Paper Smoking Kills and the 1998 Thorax guidelines. It stated that services should be targeted, particularly at disadvantaged groups and pregnant women, and take both self- referred clients and those referred from GPs. The Circular also stated that services should be responsive to local needs. Health Authorities were encouraged to test and develop a range of services and innovative approaches to delivering smoking cessation advice and help. Available at: http://www.cmo.wales.gov.uk/content/work/tobacco/cessation-evaluation-report- e.htm

Public health interventions for the prevention and reduction of exposure to second-hand smoke. A review of reviews Evidence briefing National Institute for Clinical Excellence Available at: http://www.publichealth.nice.org.uk/page.aspx?o=513311

Research bulletin: Adolescent smoking cessation: a review Welsh Assembly Government The aims of the review were as follows: To examine the literature on youth smoking behaviour and the process of youth smoking cessation. To examine evidence on the potential for specialist cessation interventions targeted at young people and the appropriateness of alternative methods such as Nicotine Replacement Therapy (NRT) and non-NRT products, helplines, brief interventions, one-to-one counselling and clinics, computer-based services, group sessions and self-help materials. To identify, investigate and review current initiatives in the UK and internationally which aim to encourage and support smoking cessation in young people.

261 Available at: http://www.cmo.wales.gov.uk/content/work/tobacco/research-summary- 3-e.pdf

Smoking and public health: a review of reviews of interventions to increase smoking cessation, reduce smoking initiation and prevent further uptake of smoking; Health Development Agency This evidence briefing collates review-level evidence of interventions to increase smoking cessation, reduce smoking initiation and prevent further uptake of smoking. It also examines interventions targeted at pregnant women and evidence for tackling health inequalities in smoking. Available at: http://www.publichealth.nice.org.uk/page.aspx?o=502729

Tobacco Control Library and Knowledge Management Service National Public Health Service for Wales This is rapid overview of recent major information sources. These BIS aim to summarise the knowledge base, to support guidance and briefings prepared by NPHS and to act as a 'launch pad' or signpost to more in-depth material. The scope for this BIS is: Tobacco control, smoking cessation - all ages - as a lifestyle issue, evidence of effectiveness of interventions. Available at: http://www2.nphs.wales.nhs.uk:8080/LKMSDocs.nsf

Tobacco: Research Bulletin; Welsh Assembly Government This updates the first Tobacco Research Bulletin published in November 2001. Focus is on smoking cessation. Available at: http://www.cmo.wales.gov.uk/content/publications/research/bulletin-tobacco-aug03- e.pdf

Tobacco smoke pollution & health; Faculty of Public Health This briefing statement was produced by the Faculty to help those in public health access accurate and relevant information on this issue. It is based on the best available evidence and contains the essence of what a reasonable public health approach might include. It also signposts readers to other sources of more detailed information. Available at: http://www.fphm.org.uk/publications_press_and_communications/Publications/briefin g%20statements/briefing_statement_tobacco%20-%20final.pdf

The evidence of effectiveness of public health interventions – and implications. Briefing paper. Health Development Agency, 2004 Tobacco – brief sections on national, local and community interventions. Available at: http://www.hda-online.org.uk/html/research/effectiveness.html

Smoking and public health: a review of reviews of interventions to increase smoking cessation, reduce smoking initiation and prevent further uptake of smoking. Evidence briefing. Health Development Agency, 2004. This briefing (a review of reviews) aims to identify all relevant systematic reviews and meta- analyses, review these papers and highlight ‘what works’ to reduce smoking initiation and/or the further uptake of smoking, and to increase smoking cessation for all population groups, but with particular reference to disadvantaged and vulnerable

262 groups. Also, to highlight conflicting evidence, gaps in the evidence and provide a steer for future policy and research commissioning. Available at: http://www.hda- online.org.uk/documents/smoking_evidence_briefing.pdf

Lifestyle - Health Evidence Bulletins Wales: Coronary Heart Disease. National Public Health Service, 2004; Chapter 1. Available at: http://hebw.cf.ac.uk/coronary/index.htm

Clinical Evidence. BMJ Publishing Group, 11; 2004. Numerous references to smoking and smoking cessation with particular reference to the sections cardiovascular disease and COPD. Available at: http://www.clinicalevidence.com/ceweb/SearchServlet?searchTerm=smoking

The clinical effectiveness and cost-effectiveness of bupropion and nicotine replacement therapy for smoking cessation: a systematic review and economic evaluation. Health Technology Assessment, 2002; 6(16). The aim of this review was to assess the clinical effectiveness, cost-effectiveness and adverse effects of bupropion SR and NRT for smoking cessation. The effects of therapy in assisting long-term reduction in the amount smoked by smokers who are unwilling or unable to quit were not assessed. Link to Summary Available at: http://www.hda.ncchta.org/fullmono/mon616.pdf http://www.hda.ncchta.org/pdfexecs/sum616.pdf

263 Smoking - Health Evidence Bulletins Wales: Healthy Living. National Assembly for Wales, 2000; Chapter 1. Available at: http://hebw.cf.ac.uk/healthyliving/chapter1.html

Lung cancer - Health Evidence Bulletins Wales: Cancers. National Assembly for Wales, 1998; Chapter 1. Available at: http://hebw.cf.ac.uk/cancers/chapter1.html

Tobacco Smoking (Public Places & Workplaces) Bill. House of Lords, 2004. Available at: http://www.publications.parliament.uk/pa/ld200304/ldbills/042/2004042.pdf

Smoking in Public Places (Wales) Bill. House of Lords, 2004. Available at: http://www.parliament.the-stationery-office.co.uk/pa/ld200304/ldbills/012/2004012.pdf

Evaluation of specialist smoking cessation services in Wales. Executive summary and recommendations. Welsh Assembly Government, 2003. Since 1999, SCS have been established in each of the 5 Health Authority Areas in Wales, and the National Assembly has required each SCS to collect a minimum data set, to feed into evaluation of the services. However, there have been inconsistencies in how these data have been collected, and little use has been made of the data for local or national evaluation purposes. A team led by Laurence Moore of the Cardiff University School of Social Sciences was commissioned in April 2002 to conduct the national evaluation of Smoking Cessation Services in Wales, utilising and building upon the data collected by the SCS. The evaluation was completed in July 2003, and consisted of three components, a process evaluation, an outcome evaluation, and an economic evaluation. Available at: http://www.cmo.wales.gov.uk/content/work/tobacco/cessation-evaluation-report- e.htm

A breath of fresh air for Scotland. Tobacco control action plan. Scottish Executive, 2004. This document is the first ever action plan on tobacco control designed specifically for Scotland. It builds upon and responds to an excellent report by NHS Health Scotland and ASH Scotland and offers a programme of action covering prevention and education, protection and controls and the expansion of high quality cessation services. It also addresses the issue of passive smoking and offers everybody the opportunity to learn more about the risks involved and contribute to a national debate about the steps we might take to reduce such risks. Link to Summary of points Available at: http://www.scotland.gov.uk/Publications/2004/01/18736/31540 http://www.scotland.gov.uk/Publications/2004/01/18736/31543

264

A five year tobacco action plan 2003-2008. Department of Health, Social Services and Public Safety for Northern Ireland, 2003. This document seeks to combine an overview of the background, scale and nature of the problem with a comprehensive programme of action to reduce the harm caused by tobacco use. Available at: http://www.dhsspsni.gov.uk/publications/2003/tobaccoplan.pdf

Report of the Scientific Committee on Tobacco and Health. (Poswillo report);Department of Health; Department of Health and Social Services, Northern Ireland; Scottish Department of Health; Welsh Office; 1998. Much is known about the harmful effects of tobacco on health: overall about half of all persisting regular cigarette smokers are killed by tobacco. Even so many people continue to smoke and in 1996 in England 28% of adults were regular cigarette smokers1 and still about 30% of all deaths in middle age are caused by the habit. To ensure progress in the area of tobacco control and to inform future action, there is a need to keep under review up to date medical, scientific and behavioural information in this area, and therefore, in 1994, the Department of Health (DH) established the Scientific Committee on Tobacco and Health (SCOTH). SCOTH, assisted by the Technical Advisory Group (TAG), embarked on a programme of scientific review and appraisal of a range of important issues related to tobacco and health. This Report to the Chief Medical Officer describes the matters considered by the Committee. The topics addressed were diverse and wide-ranging, and they consequently vary in their implications for public health. Available at: http://www.archive.official-documents.co.uk/document/doh/tobacco/contents.htm

Smoking kills - a White Paper on tobacco. Department of Health, 1998. This White Paper announces the government's concerted plan of action to stop people smoking. It notes action already taken by the government on tobacco advertising and taxation and goes on to present a series of measures for reducing smoking among young people, new cessation services for adults, and action on smoking among pregnant women. Proposals for abolishing tobacco advertising and promotion, altering public attitudes, preventing tobacco smuggling, and supporting research are outlined together with further proposals for working in partnership with businesses to restrict smoking in public places, places of work, and government offices, and for working with other governments at European and global levels. Link to Summary Available at: http://www.archive.official-documents.co.uk/document/cm41/4177/contents.htm http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/document s/digitalasset/dh_4041684.pdf

WHO framework convention on tobacco control. Fifty-sixth World Health Assembly. World Health Organization, 2003. The objective of this Convention and its protocols is to protect present and future generations from the devastating health, social, environmental and economic consequences of tobacco consumption and exposure to tobacco smoke by providing a framework for tobacco control measures to be implemented by the Parties at the

265 national, regional and international levels in order to reduce continually and substantially the prevalence of tobacco use and exposure to tobacco smoke. Available at: http://www.who.int/gb/ebwha/pdf_files/WHA56/ea56r1.pdf

Tobacco smoke and health. Briefing statement. Faculty of Public Health, 2004. This briefing statement was produced by the Faculty to help those in public health access accurate and relevant information on this issue. It is based on the best available evidence and contains the essence of what a reasonable public health approach might include. It also signposts readers to other sources of more detailed information. Available at: http://www.fphm.org.uk/publications/briefing_statements/briefing_statement_tobacco - final.pdf

Smoking and reproductive life. British Medical Association, 2004. This report presents the first focused overview of the impact of smoking on sexual, reproductive and child health in the United Kingdom. It considers active and passive smoking by both men and women, and summarises the impact on sexual health, conception and pregnancy, as well as effects on the reproductive system. Available at: http://www.bma.org.uk/ap.nsf/650f3eec0dfb990fca25692100069854/00d17ddcf09d5c c080256e30004b8841/$FILE/ATTCeL93/smoking.pdf

Achieving smoke freedom toolkit. Chartered Institute of Environmental Health, 2004. This guide is intended to help local decision makers in England, Wales and Northern Ireland, and particularly Councillors and Council Officers, to frame tobacco control policies for their areas within existing legislation. The toolkit contains the latest expert advice on key issues including the law relating to second-hand tobacco pollution and the case for making use of the control measures currently available, as well as examples of action already being taken by local authorities throughout England and Wales. Available at: http://www.cieh.org/research/smokefree/

Tobacco smoke pollution: the hard facts. Royal College of Physicians London, 2003. Cites 10 reasons to make all enclosed public places and work places smoke-free and states that legislation to this effect would be popular, would improve quality of life and would save lives. Available at: http://www.rcplondon.ac.uk/pubs/books/smokefree/smokefree.pdf

Nicotine addiction in Britain. A report of the Tobacco Advisory Group of the Royal College of Physicians. Royal College of Physicians London, 2000. Brief summary and conclusion: Cigarette smoking is the single largest avoidable cause of premature death and disability in Britain, and thus presents both the greatest challenge and the greatest opportunity for all involved in improving public health. The eradication of smoking from Britain would realise massive health gains, particularly for the most disadvantaged sectors of society. The prevalence of smoking in Britain has fallen substantially since the health risks of cigarette smoking first began to be publicised, but now appears to be stabilising at approximately one in four

266 British adults. To achieve further significant reductions in smoking prevalence it is necessary to look more radically at the causes, treatment and ultimate prevention of smoking behaviour. The central conclusion of this report is that cigarette smoking should be understood as a manifestation of nicotine addiction, and that the extent to which smokers are addicted to nicotine is comparable with addiction to 'hard' drugs such as heroin or cocaine. This conclusion has fundamental implications for the design and implementation of public health policy on the control and prevention of cigarette smoking. Available at: http://www.rcplondon.ac.uk/pubs/books/nicotine/index.htm

Substance misuse

Alcohol and violence: briefing statement; Faculty of Public Health Covers types of violence, settings for effective interventions, using health data Available at: http://www.fph.org.uk/policy_communication/downloads/publications/briefing_statem ents/alcohol%20and%20violence%20-%20final%20pdf.pdf

Drug use prevention among young people: a review of reviews. Evidence briefing update National Institute for Clinical Excellence Update of an evidence briefing concerning illicit drug use among young people aged between 7 and 25 years old, reviewing tertiary-level evidence published between January 2002 and September 2004. Available at: http://www.publichealth.nice.org.uk/page.aspx?o=529849

Evidence from systematic reviews of research relevant to implementing the "wider public health" agenda; NHS Centre for Reviews and Dissemination Includes A national contract on accidents, mental health, Coronary heart disease, cancer Education Social care and welfare and Crime, Drugs and Alcohol Available at: http://www.york.ac.uk/inst/crd/wph.htm

Prevention and reduction of alcohol misuse: Evidence Briefing; National Institute for Health and Clinical Excellence Available at: http://www.nice.org.uk/page.aspx?o=503439

Prevention of alcohol misuse; Health Development Agency Paper setting out provisional findings and a summary of the work in progress on the topic of prevention and reduction of alcohol misuse. Available at: http://www.nice.org.uk/page.aspx?o=502745

Review of grey literature on drug prevention among young people; National Institute for Clinical Excellence A review which aims to complement the evidence base built by mainstream literature on the subject of drug prevention among young people. Examines research on interventions, advice and attempts to identify gaps and inconsistencies in the evidence base. Available at: http://www.nice.org.uk/download.aspx?o=316428

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Transport Health effects and risks of transport systems: the HEARTS project; World Health Organization Health effects and risks of transport systems. This report highlights how assessments of the effects of urban transport on health can be carried out. Includes the effects of air pollution, noise and road traffic accidents. Available at: http://www.euro.who.int/document/E88772.pdf

Health update: Environment and health - road transport; Health Development Agency Part of a subset on environment and health, this update summarises existing statistics, research and debate on road transport as a broader determinant of health. Available at: http://www.nice.org.uk/page.aspx?o=502053

Impact of transport and road traffic speed on health; Health Development Agency This paper begins by looking at the impact of transport on health specifically, accidents, physical activity and social interaction/quality of life and considers what part speed plays. It also considers the implications for health inequalities. It then looks at the evidence of effectiveness of interventions. Finally, it highlights some common elements of approaches that have made progress in tackling the health impacts of transport and speed. Available at: http://www.nice.org.uk/page.aspx?o=502321

Making the case: improving health through transport; Health Development Agency Available at: http://www.publichealth.nice.org.uk/page.aspx?o=503415

The NHS and local transport planning: a briefing; Health Development Agency Available at: http://www.publichealth.nice.org.uk/page.aspx?o=317670

Settlements, services and access. The development of policies to promote accessibility in rural areas in Great Britain; University of Aberdeen, Cardiff University, University of Sheffield Available at: http://www.wales.gov.uk/subitransport/content/settlements-services-access-e.pdf

Transport interventions promoting safe cycling and walking. Evidence briefing; National Institute for Health and Clinical Excellence An evidence briefing originally commissioned by the Health Development Agency. Explores the issues involved around transport and health and examines a working model concerned with transport, health and physical activity. Also looks at the policy context and reviews the evidence concerning transport interventions and draws conclusions from this evidence. Available at: http://www.nice.org.uk/page.aspx?o=346196

The benefits of providing transport to healthcare in rural areas; CAG Consultants TAS Partnership Countryside Agency Available at: http://www.countryside.gov.uk/Images/Transport%20to%20health%20(M)_tcm2-

268 20864.pdf

Cross-sector funding on road transport and health; Health Development Agency This study looks at current cross-sector collaboration on road transport and health, in particular current or planned funding over the next twelve months. It includes the analysis of a postal questionnaire survey of public health directorates in England. Some evidence is presented showing that during the latter part of the 1990s collaboration between road transport and health professionals has increased. In some cases this has involved joint funding a post to promote walking and cycling, or to provide funds to help the local highway authority install speed reduction measures. Available at: http://www.nice.org.uk/page.aspx?o=501955

Environment

Interventions that use the environment to encourage physical activity. Evidence review; National Institute for Health and Clinical Excellence A review presenting the current evidence derived from the published literature on environmental interventions. Primary studies and systematic reviews are examined. How the environment affects health, evidence concerning interventions, gaps in the evidence base and recommendations for research are included. Conclusions are drawn. Available at: http://www.nice.org.uk/page.aspx?o=366133

Considerations in evaluating the cost-effectiveness of environmental health interventions; World Health Organization This report looks at the economic evaluation of environmental health interventions, particularly where this may differ from other health intervention evaluations. Available at: http://www.who.int/quantifying_ehimpacts/cost_effectiveness/wsh0010/en/index.html

Housing

Fuel poverty and health: briefing statement, Faculty of Public Health Available at: http://www.fphm.org.uk/policy_communication/downloads/publications/briefing_state ments/briefing_statement_fuel_poverty.pdf

Homelessness in rural Wales; Wales Rural Observatory The research on which this report is based was commissioned to provide a

269 comprehensive evidence-base of homelessness in rural Wales. Two main areas of work were undertaken within the research project. First, an examination was made of the scale, nature and geography of homelessness in rural Wales. Second, attention was given to agency responses to rural homelessness and the identification of good practice for dealing with this problem. Available at: http://www.walesruralobservatory.org.uk/reports/english/Rural%20Homelessness%2 0Report.pdf

Housing and public health. A review of reviews of interventions for improving health. Evidence briefing; National Institute for Clinical Excellence Housing and public health. A review of reviews of interventions for improving health. Its aims are to: Identify all relevant systematic reviews, syntheses, meta-analyses and review- level papers on public health interventions relating to housing Review these papers and highlight what housing-related interventions work to promote health for all population groups, but with particular reference to disadvantaged and vulnerable groups Identify cost-effectiveness data for housing-related interventions to promote health for all population groups Highlight any gaps in the evidence and provide recommendations for future research. Available at: http://www.publichealth.nice.org.uk/page.aspx?o=526671

Housing need in rural Wales: towards sustainable solutions; Wales Rural Observatory The report presents a research project that sought to identify the nature, scale and geography of housing need. In addition, the research project examined current policy responses to the issues surrounding rural housing need. The report attempts to develop solutions to housing need in rural Wales. Available at: http://www.walesruralobservatory.org.uk/reports/english/10_Housing%20Needs%20 Report.pdf

The impact of overcrowding on health and education: a review of the evidence and literature; De Montfort University Office of the Deputy Prime Minister Review commissioned by the Office of the Deputy Prime Minister in 2003 to identify the known impacts of overcrowded housing on people’s health and education. The review identified, and critically assessed the research evidence in relation to physical health, mental health, childhood growth, development and education, and other impacts including personal safety and accidents. Available at: http://www.communities.gov.uk/pub/907/TheImpactofOvercrowdingonHealthandEduc ationMainreportPDF292Kb_id1152907.pdf

Is housing improvement a potential health improvement strategy? World Health Organization This is a Health Evidence Network (HEN) synthesis report on housing improvements and health. The reduction of exposure to specific hazards may lead to health improvements for current residents and prevent harmful exposure

270 by future generations. Improvements in mental health are reported consistently following housing improvements, and the degree of mental health improvement may be linked to the extent of the housing improvements. General housing improvements may also result in improvements in physical health and general well-being. Available at: http://www.euro.who.int/document/E85725.pdf

LARES: Large Analysis and Review of European housing and health Status: Preliminary overview; World Health Organization. A Pan-European housing and health survey has been undertaken from 2002 to 2003 was designed to achieve the following objectives: - To improve knowledge of the impacts of existing housing conditions on health and mental and physical wellbeing; - To assess the quality of the housing stock in a holistic way and to identify housing priorities in each of the surveyed cities, and possibly common trends; - To develop an 'easy to use' tool to assess the impact of housing on health in any city or region in Europe; - To prepare the 4th Ministerial Conference on Environment and Health (June 2004, Hungary). Available at: http://www.euro.who.int/Document/HOH/LARES_results.pdf

Climate change

This is one of a series of source lists, which have been compiled to accompany the HIAT topic reports. These include links to relevant NPHS reports, key policies and strategies, data sources and selected examples of the evidence base of effective interventions.

Environment strategy for Wales; Welsh Assembly Government The Environment Strategy is the Assembly Government’s long term strategy for the environment of Wales, setting the strategic direction for the next 20 years. It provides the framework within which to achieve our vision for the environment of Wales. The Strategy has five main environmental themes: Addressing climate change - covers climate change mitigation and adaptation Available at: http://new.wales.gov.uk/topics/environmentcountryside/epq/Environment_strategy_fo r_wales/About_the_strategy/?lang=en

A living and working environment for Wales; Environment Agency Reports on climate change and energy supply; wildlife, pollution, land use and resources. Available at: http://www.environment- agency.gov.uk/regions/wales/426317/573672/?version=1&lang=_e

Climate change and adaptation Strategies for Human health; World Health Organization This website looks at the way the health of European populations will be affected

271 by global climate change. The cCASHh project is a combination of impact and adaptation assessment for four climate-related health outcomes: health effects of heat and cold; health effects of extreme weather events; infectious diseases transmitted by insects and ticks, infectious diseases transmitted in the water supply or through food (waterborne and foodborne diseases).cCASHh investigates some of the many ways in which climate change affects health. Floods and heat-waves have direct effects on health. Foodborne and vectorborne diseases are indirect effects of climate change through change in seasonal patterns of diseases. Available at: http://www.who.dk/ccashh

Climate change and human health: risks and responses. World Health Organization This book seeks to describe the context and process of global climate change, its actual or likely impacts on health, and how human societies and their governments should respond with particular focus on the health sector. Contents include: Looking to the future: challenges for scientists studying climate change and health; Impacts on health of climate extremes; Climate change and infectious diseases; National assessments of health impacts of climate change; Monitoring the health effects of climate change; Adaptation and adaptive capacity in the public health context; From science to policy: developing responses to climate change Available at: http://www.who.int/globalchange/publications/cchhbook/en/index.html

Climate change: the UK programme 2006.Presented to Parliament by the Secretary of State for the Environment, Food and Rural Affairs by Command of Her Majesty Presented to the Scottish Parliament by the Scottish Ministers: Presented to the Northern Ireland Assembly: Placed with the Welsh Assembly library. March 2006; HM Government Defines climate change and what the Government policy to limit and alleviate the situation. Contains a chapter on action by the devolved governments. Available at: http://www.publications.parliament.uk/pa/cm/cmenvaud.htm#evid

Health effects of climate change in the UK; Department of Health Main sections include: Public perception of the health impacts of climate change; Methods to assess the effects of climate change on health; Overview of climate change impacts on human health in the UK; Secondary impacts of mitigation. Available at: http://www.dh.gov.uk/PublicationsAndStatistics/Publications/PublicationsPolicyAndG uidance/PublicationsPolicyAndGuidanceArticle/fs/en?CONTENT_ID=4007935&chk= aPZEuj

Heatwave plan for England: protecting health and reducing harm from extreme heat and heatwaves; Department of Health Outlines arrangements which should be made by Health and social care workers in advance of a heatwave and when a heatwave has been forecast. Available at: http://www.dh.gov.uk/PublicationsAndStatistics/Publications/PublicationsPolicyAndG uidance/PublicationsPolicyAndGuidanceArticle/fs/en?CONTENT_ID=4135296&chk= kQeY65

272 Preventing harmful health effects of heat-waves; World Health Organization Available at: http://www.euro.who.int/Document/Gch/Harm_Heatwaves.pdf

The Stern Review: the economics of climate change; Cabinet Office HM Treasury The review examines the evidence on the economic impacts of climate change and the policy challenges of a transition to a low-carbon economy. The review takes an international perspective. Sections titles: Contents 1. Climate change: our approach; 2. Impacts of climate change on growth and development; 3. The economics of stabilisation; 4. Policy responses for mitigation; 5. Policy responses for adaptation; 6. International collective action. Available at: http://www.hm- treasury.gov.uk/independent_reviews/stern_review_economics_climate_change/ster n_review_report.cfm

UK health impacts of climate change; Parliamentary Office of Science and Technology This document outlines the potential impacts of climate change on health in the UK and examines options open to public policy makers Available at: http://www.parliament.uk/documents/upload/POSTpn232.pdf

Dental health

BDA policy on tackling oral health inequalities; British Dental Association Brief sections on children, fluoridation, health promotion and health education, access and dental public health Available at: http://www.bda.org/about/policy.cfm?ContentID=135

Chief Dental Officer for Wales; Welsh Assembly Government Includes information about the Inequalities in Health fund's "Fissure sealant programme" and Dental access sessions; Available at: http://new.wales.gov.uk/topics/health/professionals/dental/?lang=en

Children's dental health in the United Kingdom 2003; Office for National Statistics The survey provides information on the dental health of children in the United Kingdom, measures changes in oral health since previous surveys in 1983 and 1993, and provides information on children's experiences of dental care and treatment, and their oral hygiene. Available at: http://www.statistics.gov.uk/children/dentalhealth/

Children's Dental Health in Wales 2003; Office for National Statistics; All Wales surveys, some regional tables are included. Available at: http://www.statistics.gov.uk/CHILDREN/dentalhealth/downloads/cdh_Wales.pdf

Oral Health Specialist Library Includes links to the evidence base for dental caries - causes and prevention, treatment and management and fluoridation Available at: http://www.library.nhs.uk/oralhealth/

273

Young people's health in context. Health Behaviour in School-aged Children (HBSC) study: international report from the 2001/2002 survey. World Health Organization The Health Behaviour in School-aged Children (HBSC) study provides unique insight into the health and behaviour of young people. It gives information about a much-neglected segment of society but one that has the greatest potential to benefit from policies and health initiatives based on sound research and information. Available at: http://www.euro.who.int/eprise/main/who/informationsources/publications/catalogue/2 0040518_1

Infections

Infection and Communicable Disease Service [ICDS]; Infection and Communicable Disease Service /National Public Health Service for Wales Includes CDSC surveillance reports - All Wales surveillance of Laboratory Confirmed Infections and Notifiable Communicable Diseases [Monthly]; Vaccination uptake - [Quarterly] by Welsh Vaccination District; HIV and STI trends in Wales and Influenza Vaccination Uptake. Available at: http://www2.nphs.wales.nhs.uk/icds/

Welsh Healthcare Acquired Infection Programme; National Public Health Service for Wales Includes statistics on NHS trust level - Surveillance of Blood Stream Infections, Top ten Blood stream infections, Clostridium difficile and Staphylococcus aureus. Available at: http://www.wales.nhs.uk/sites3/home.cfm?orgid=379

Blood Borne Viral Hepatitis Action Plan for Wales; Infection and Communicable Disease Service/ National Public Health Service for Wales A collection of reports to inform a Blood Borne Viral Hepatitis Action Plan for Wales being developed with the help of the Welsh Assembly Government. The main aims are to reduce transmission, improve the provision of treatment and increase diagnosis. Includes reports on prevalence of serious and injecting drug use, community drug teams Available at: http://www2.nphs.wales.nhs.uk/ICDS/page.cfm?pid=519

Sexual health in Wales: service review; National Public Health Service for Wales Sexual health has become a matter of great concern in Wales with dramatic increases in new diagnoses of sexually transmitted infections. In recognition of the need to address this and to ensure that quality accessible and integrated services are available to address the needs of all individuals the Minister for Health and Social Services commissioned a review of sexual health services in

274 Wales. Available at: http://www.wales.nhs.uk/sites3/documents/281/Sexual%20Health%20Services%20in %20Wales.pdf

Healthcare associated infections - a strategy for hospitals in Wales. Heintiau sy'n gysylltiedig a gofal iechyd - strategaeth ar gyfer ysbytai yng Nghymru; Welsh Assembly Government Healthcare Associated Infection will always be an issue, since some patients will become infected as a consequence of another illness. Nevertheless, there is good evidence that a proportion of this infection may be prevented through careful attention to infection control procedures. It is incumbent upon all healthcare staff to be aware of their personal responsibilities towards the prevention and control of healthcare associated infection. The strategy focuses on the personal responsibility outlined above and proposes the development of Trusts infection control infrastructure to emphasise these responsibilities at directorate level. Available at: http://www.cmo.wales.gov.uk/content/publications/strategies/healthcare-associated- infections-e.pdf

Wales framework for managing major infectious disease emergencies; Welsh Assembly Government The Framework sets out national arrangements for managing major infectious disease emergencies, including national co-ordination, operational responsibilities of NHS organisations and the role of partner agencies. Available at: http://www.cmo.wales.gov.uk/content/work/pandemic-flu/framework- e.pdf

A framework for the control of communicable disease in Wales. Fframwaith ar gyfer rheoli clefydau heintus yng Nghymru. Welsh Assembly Government

Getting ahead of the curve. A strategy for combating infectious diseases (including other aspects of health protection). Department of Health Available at: http://www.doh.gov.uk/cmo/idstrategy/index.htm

Fighting infection. 4th report of the Select Committee on Science and Technology. House of Lords: Select Committee on Science & Technology Available at: http://www.publications.parliament.uk/pa/ld200203/ldselect/ldsctech/138/138.pdf

Health protection in the 21st century - Understanding the burden of disease; preparing for the future; Health Protection Agency; Part 4: Infectious diseases. Available at: http://www.hpa.org.uk/publications/2005/burden_disease/default.htm

Improving patient care by reducing the risk of hospital acquired infection. A progress report. National Audit Office Available at: http://www.nao.org.uk/publications/nao_reports/03-04/0304876.pdf

275 Give us useful information: what the public want to know about Healthcare associated infections in Wales: a report for the Welsh Assembly Government; Welsh Institute for Health and Social Care Available at: http://www.cmo.wales.gov.uk/content/work/communicable-disease/give-us-useful- information-w.pdf

HEN: Health Evidence Network; World Health Organization; Public health decision-makers need a trustworthy source of evidence on which to build health policy. WHO/Europe meets this need with HEN, which gives rapid access to reliable health information and evidence. HEN provides: answers to policy questions in the form of evidence-based reports and summaries; How effective would antiviral vaccination and antiviral drug prevention and treatment strategies be for reducing the impact of the next influenza pandemic? Available at: http://www.euro.who.int/HEN

Interventions to change the wider determinants of health: What works? Briefings based on systematic reviews and health evidence bulletins Wales. Sexually transmitted infection (STI); Wider Determinants and Inequalities Team National Public Health Service for Wales Available at: http://www2.nphs.wales.nhs.uk:8080/widerdeterminantsdocs.nsf/1f8687d8da976509 80256fa30051b0be/6c644b6a763108788025708900316371/$FILE/STI.doc

National Resource for Infection Control; Links to the National electronic Library of Infection (NeLI) Contents include infection control settings, clinical practice, transmission, diseases and organisms. It includes comprehensive list with links to key policies, strategies and evidence Available at: http://www.nric.org.uk/IntegratedCRD.nsf/NRIC_Home1?OpenForm

Seasonal safety This is one of a series of source lists, which have been compiled to accompany the HIAT topic reports. These include links to relevant NPHS reports, key policies and strategies, data sources and selected examples of the evidence base of effective interventions.

Keep well this winter 2005/6 campaign - NPHS evaluation report; National Public Health Service for Wales This report provides an evaluation of the involvement of the local National Public Health Service (NPHS) local public health teams in the implementation of the Keep Well This Winter (KWTW) campaign commissioned by the Welsh Assembly Government (WAG). It also makes recommendations for the 2006/07 programme, based upon an evaluation of the scheme conducted at a Local Public Health Team (LPHT) level. Available at: http://www2.nphs.wales.nhs.uk:8080/vulnerableadultsdocs.nsf/61c1e930f9121fd0802

276 56f2a004937ed/bc521cb12b34617b802571d50040ee44?OpenDocument

Keep warm this winter; NHS Direct Available at: http://www.nhsdirect.nhs.uk/articles/article.aspx?articleId=2048

Keep well this winter; Welsh Assembly Government Available at: http://new.wales.gov.uk/topics/health/improvement/seasonal/sun/?lang=en

Cancer atlas of the United Kingdom and Ireland; Office for National Statistics; Chapter 14. Melanoma of skin Available at: http://www.statistics.gov.uk/statbase/Product.asp?vlnk=14059

Heatwave; Welsh Assembly Government; OCMO - providing advice on dealing with the dangers the seasons can bring Available at: http://new.wales.gov.uk/topics/health/improvement/seasonal/sun/?lang=en

Research bulletin: Skin cancer prevention. Welsh Assembly Government General public attitudes, awareness and behaviour; Young children, Teenagers and young adults; Effectiveness of sunscreens; Sunbeds / Artificial tanning Available at: http://www.cmo.wales.gov.uk/content/publications/research/skin-cancer-e.pdf

Saving our skins toolkit: raising awareness of the risk of skin cancer; Chartered Institute of Environmental Health Available at: http://www.cieh.org/library/Knowledge/Public_health/Skin_cancer/Saving%20our%20 Skins%20Toolkit.pdf

Sun awareness: skin cancer prevention; Welsh Assembly Government Available at: http://new.wales.gov.uk/topics/health/improvement/seasonal/sun/?lang=en

Sun protection and skin cancer: public knowledge, attitudes and behaviours; Welsh Assembly Government To inform future planning for SunSmart campaigns, baseline data - giving an insight into people's knowledge, attitudes and behaviours concerning sun protection and skin cancer prior to the launch of the UK-wide SunSmart campaign - were collected through the Welsh Omnibus Survey, carried out by Beaufort Research. The baseline questions used in the 2003 Welsh Omnibus Survey were repeated in 2005 to monitor changes in knowledge, attitudes and behaviours. The questions were developed as part of a study looking at skin cancer knowledge and preventive behaviours prior to the launch of the UK's SunSmart campaign. Available at: http://new.wales.gov.uk/docrepos/40382/40382311111/reports/2006/skin-cancer- e?lang=en

277 Evidence-based digests This subsection contains the main evidence-based sources that have been reviewed and the health knowledge ‘digested’ so you don't have to search the thousands of primary sources. The evidence is critically appraised and summarised.

NICE technology appraisals Subject scope: Interventions prioritised by wide consultation with the NHS. http://guidance.nice.org.uk/PHI http://guidance.nice.org.uk/PHP

Health Evidence Bulletins Subject scope: Best evidence for 12 health gain areas established as priorities for NHS Wales: cancers, cardiovascular disease, healthy environments, healthy living, injury prevention, learning disabilities, maternal & early child health, mental health, oral health, pain discomfort and palliative care, physical disability & discomfort, respiratory diseases. http://nww.wales.nhs.uk/hebw/

Wider Public Health Centre for Reviews and Dissemination, University of York. Subject scope: Evidence from systematic reviews of the research relevant to implementing the 'wider public health' agenda. Research relevant to implementing the wider public health agenda: cancer, CHD, accidents/injuries, mental health, education, social care and social welfare, crime drugs and alcohol. http://www.york.ac.uk/inst/crd/wph.htm

Health Evidence Network (HEN): WHO Regional Office for Europe Subject scope: Questions covered include effectiveness of old age mental health services, suicide prevention, screening for prostate cancer, disease management programmes. Information service primarily for public health and health care decision-makers in the WHO European Region. It comprises two services: Answers to questions and Easy access to sources of evidence such as databases, documents and networks of experts http://www.euro.who.int/HEN

Cochrane Subject scope: Systematic reviews and meta-analyses. All areas.

ARIF Aggressive Research Intelligence Facility. http://www.arif.bham.ac.uk/

ATTRACT Subject scope: Cancer, Cardiovascular , Child Health, Complementary Medicine, Dermatology, ENT, Endocrinology, Gastrointestinal, General Practice, Genitourinary, Gerontology, Haematology, Infectious Diseases, Mental health, Musculoskeletal, Neurology, Non-clinical, Nutrition, Ophthalmology, Pregnancy and Childbirth, Respiratory Care, Women's Health. http://www.attract.wales.nhs.uk/

278 Databases and electronic sources of evidence If you still haven’t found what you’re looking for this section is a list of known relevant sources available on the Internet, which can be searched for primary, secondary and tertiary evidence relating to HSCWB for decision making and practice. As with the previous sections there are links to the sites although in some cases access may be restricted. If you find you can’t get access to a particular site you wish to search then your local librarian will be able to help you, alternatively please contact Torfaen Local Public Health Team.

Agency for Healthcare Research and Quality (AHRQ) US The AHRQ is charged with improving the quality, safety, efficiency, and effectiveness of health care for all Americans. As one of 12 agencies within the Department of Health and Human Services, AHRQ supports health services research that will improve the quality of health care and promote evidence-based decision making Resource Type: Web site Available at: http://www.ahrq.gov/

American Public Health Association (APHA) The APHA is concerned with a broad set of issues affecting personal and environmental health, including federal and state funding for health programmes, pollution control, programmes and policies related to chronic and infectious diseases, a smoke-free society, and professional education in public health Resource Type: Web site Available at: http://www.apha.org/

Association of Public Health Observatories The APHO has been established since June 2000, and has a main focus of facilitating collaborative working of the Public Health Observatories (PHOs) and their equivalents in England, Wales, Scotland and Ireland Resource Type: Web site Available at: http://www.apho.org.uk/apho/

British Nursing Index (BNI) BNI is a comprehensive index covering all aspects of nursing, midwifery and community healthcare from 1985 to the present Resource Type: Database Available at: Cardiff University / HOWIS

Campbell Collaboration (C2) C2 is a non-profit organisation that aims to help people make well-informed decisions about the effects of interventions in the social, behavioural and educational arenas Resource Type: Web site Available at: http://www.campbellcollaboration.org/index.asp

CDC WONDER (Center’s for Disease Control and Prevention) US CDC WONDER is the CDC’s single point of access to a wide variety of reports and numeric public health data. CDC WONDER furthers CDC's mission of health promotion and disease prevention by speeding and simplifying access to public

279 health information for state and local health departments, the Public Health Service, and the academic public health community Resource Type: Web site Available at: http://wonder.cdc.gov/welcome.html

Centre for Public Health Excellence (CPHE) National Institute for Health and Clinical Excellence (NICE) The CPHE develops guidance on the promotion of good health and the prevention of ill health. Its guidance is for those working in the NHS, local authorities and the wider public, private and voluntary sectors Resource Type: Web site Available at: http://www.nice.org.uk/

Centre for Reviews and Dissemination (CRD) CRD aims to provide research-based information about the effects of interventions used in health and social care. Open access to the Database of Abstracts of Reviews of Effects (DARE) Resource Type: Web site Available at: http://www.york.ac.uk/inst/crd/index.htm

Cochrane Health Promotion and Public Health Field (CHPPHF) The Cochrane Health Promotion and Public Health Field, an entity of the Cochrane Collaboration, seeks to represent the needs and concerns of health promotion and public health practitioners in the Collaboration's work Resource Type: Web site Available at: http://www.vichealth.vic.gov.au/cochrane/

Cochrane Library The Cochrane Library is a collection of databases that contain high–quality, independent evidence to inform healthcare decision–making. In addition to Cochrane reviews, The Cochrane Library provides other sources of reliable information, from other systematic review abstracts, technology assessments, economic evaluations and individual clinical trials Resource: Database / Web site Available at: Cardiff University/HOWIS/Internet http://www3.interscience.wiley.com/cgi-bin/mrwhome/106568753/HOME

Cumulative Index to Nursing & Allied Health Literature (CINAHL) CINAHL provides coverage of virtually all English-language nursing and allied health publications along with the publications of the American Nurses Association and the National League for nursing Resource Type: Database Available at: Cardiff University/HOWIS

Department of Health The Department of Health manages the health and social care system at a national level Resource Type: Database / Web site Available at: HOWIS/Internet http://www.dh.gov.uk/Home/fs/en

280

Dissertation Abstracts Abstracts of doctoral and masters dissertations, primarily from North America, in all subject areas Resource Type: Database Available at: Cardiff University

Effective Public Health Practice Group (EPHPP) Canada The EPHPP is a key initiative of the Public Health Research, Education and Development Program (PHRED). EPHPP conducts systematic reviews on the effectiveness of public health interventions, and summarises recent, high quality reviews produced by others. The range of review topics is broad Resource Type: Web site Available at: http://www.myhamilton.ca/myhamilton/CityandGovernment/HealthandSocialServices/ Research/EPHPP

PHRED http://www.phred-redsp.on.ca/

EMBASE EMBASE is a biomedical and pharmacological database. Coverage includes research, pharmacology, pharmacy, pharmaceutics, toxicology, human medicine (clinical and experimental), basic biological research, health policy and management, public occupational and environmental health, substance dependence and abuse, psychiatry, forensic science and biomedical engineering and instrumentation Resource Type: Database Available at: Cardiff University / HOWIS

Evidence for Policy and Practice Information and Co-ordinating Centre EPPI-Centre The EPPI-Centre is part of the Social Science Research Unit (SSRU), Institute of Education, University of London. The EPPI-Centre was established in 1993 to address the need for a systematic approach to the organisation and review of evidence-based work on social interventions. Public access databases for public health research and public health and health promotion interventions are available (Bibliomap, DoPHER, TroPHI) Resource Type: Web site Available at: http://eppi.ioe.ac.uk/EPPIWeb/home.aspx

Evidence Network The Evidence Network, based at the School of Social Science and Public Policy, King's College London aims to provide a focal point for those who are interested in evidence based policy and practice (EBPP) to access useful information and resources Resource Type: Web site Available at: http://evidencenetwork.org/index.html/

Health Evidence Network (HEN) HEN provides rapid access to reliable health information and evidence by providing answers to policy questions in the form of evidence-based reports and summaries

281 Resource Type: Web site Available at: http://www.euro.who.int/HEN

Health Management Information Consortium (HMIC) UK focus on health management and services, community care; planning and design of health service buildings; people with disabilities and elderly people Resource Type: Database Available at: Cardiff University / HOWIS

Index to Theses Index to Theses provides bibliographic information on theses accepted for higher degrees by universities in Great Britain and Ireland. The Web database covers theses accepted from 1970 to date Resource Type: Database / Web site Available at: Cardiff University/Internet http://www.theses.com/

Joseph Rowntree Foundation (JRF) The JRF is one of the largest social policy research and development charities in the UK. Current research themes include housing and neighbourhoods, poverty and disadvantage, drugs and alcohol, governance, immigration and inclusion, independent living and parenting Resource Type: Web site Available at: http://www.jrf.org.uk/default.asp

King’s Fund The King's Fund is an independent charitable foundation working for better health. Their goals are to help develop: informed policy, by undertaking original research and providing objective analysis; effective services, by fostering innovation and helping put ideas into action; and skilled people, by building understanding, capacity and leadership Resource Type: Web site Available at: http://www.kingsfund.org.uk/

MRC Social and Public Health Sciences Unit The MRC Social and Public Health Sciences Unit was created on 1 October 1998 as a merger of the Medical Research Council's Medical Sociology Unit and the Public Health Research Unit. The aim of the Unit is to promote human health via the study of social and environmental influences on health Resource Type: Web site Available at: http://www.msoc-mrc.gla.ac.uk/

MEDLINE MEDLINE is the US National Library of Medicine's bibliographic database covering the fields of medicine, nursing, dentistry, veterinary medicine, the health care system, and the preclinical sciences Resource Type: Database Available at: Cardiff University / HOWIS

NHS Health Technology Assessment Programme (HTA)

282 The purpose of the HTA programme is to ensure that high quality research information on the costs, effectiveness and broader impact of health technologies is produced in the most effective way for those who use, manage and provide care in the NHS Resource Type: Web site Available at: http://www.hta.nhsweb.nhs.uk/

National Research Register (NRR) The NRR is the most comprehensive register of current research in the NHS Resource Type: Database / Web site Available at: Cardiff University/Internet http://www.nrr.nhs.uk

PsycInfo PsycInfo indexes abstracts for journal articles, book chapters, books, dissertations and technical reports in psychology and the psychological aspects of other fields Resource Type: Database Available at: Cardiff University / HOWIS

Public Health electronic Library (PHeL) The PHeL is a specialist branch library of the National electronic Library for Health (NeLH). It is no longer being updated or maintained as a new National Library for Public Health (NLPH) will be commissioned as part of the National Library for Health (NLH). The PHel website will remain accessible to users while the new NLPH is being developed Resource Type: Web site Available at: http://www.phel.gov.uk/

Research Findings Electronic Register (ReFer) ReFeR is a freely available database, providing 'prompt sight' of quality assured information on research findings that emerge from completed projects funded by the Department of Health including the NHS Executive Resource Type: Web site Available at: http://www.info.doh.gov.uk/doh/refr_web.nsf/Home?OpenForm/

Royal Institute of Public Health The Royal Institute of Public Health is a leading independent body with an international reputation dedicated to the promotion, practice and protection of the highest standards of public health Resource Type: Web site Available at: http://www.riph.org.uk/

Scirus Scirus is the most comprehensive science-specific search engine on the Internet. Driven by the latest search engine technology, Scirus searches over 250 million science-specific Web pages Resource Type: Web site Available at: http://www.scirus.com/srsapp/

Scopus

283 Scopus includes over 14,000 scholarly journals in scientific, medical, technical, and social science disciplines. Coverage goes back selectively to 1966 Resource Type: Database Available at: Cardiff University

SIGLE (System for Information on Grey Literature in Europe Archive) SIGLE provides details of reports and other grey literature produced in Europe. Indexed literature includes technical or research reports, doctoral dissertations, some conference papers and pre-prints, some official publications, discussion and policy papers Resource Type: Database Available at: Cardiff University (1980 – 03/2005)

Turning Research into Practice (TRIP+) The TRIP database aims to answer clinical questions in a clinically relevant time frame by allowing health professionals to easily find the highest-quality material available on the web Resource Type: Web site Available at: http://www.tripdatabase.com/index.html

Wales Centre for Health (WCfH) The WCfH aims to develop and maintain arrangements for making information about matters related to the protection and improvement of health available to the public in Wales, to undertake and commission research into such matters and to contribute to the development and provision of training Resource Type: Web site Available at: http://www.wales.nhs.uk/sites3/home.cfm?OrgID=568

Web of Knowledge Service This service provides access to the Web of Science databases: Arts & Humanities Citation Index, Social Science Citation Index, and Science Citation Index Resource Type: Database Available at: Cardiff University

World Health Organisation (WHO) WHO is the United Nations specialised agency for health. WHO's objective is the attainment by all peoples of the highest possible level of health Resource Type: Web site Available at: http://www.who.int/en/

WHOLIS (Library & Information Networks for Knowledge Database) The World Health Organisation’s open access library catalogue Resource Type: Web site Available at: http://dosei.who.int/uhtbin/cgisirsi/Thu+Jun+29+10:49:49+MEST+2006/0/49

ZETOC Zetoc provides access to the British Library's electronic table of contents of around 20,000 current journals and around 16,000 conference proceedings published per year

284 Resource Type: Web site Available at: http://zetoc.mimas.ac.uk/

285 Torfaen Health, Social Care and Wellbeing Needs Assessment 2007

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Areas in Need

A geographical represenatation of aggregation of risk factors/determinants of HSCWB: A supplement to the 2007 HSCWB Needs Assessment

Torfaen Local Public Health Team

October 2007

Reproduced from Ordnance Survey with permission of the Controller of Her Majesty's Stationary Office (C) Crown copyright. Unauthorised reproduction infringes Crown copyright and may lead to prosecution/civil proceedings. LICENCE No LA 100023426. 2007 1. Background to this supplement The 2007 needs assessment exercise has brought out several important insights into the current state of health, social care and well being (HSCWB) in Torfaen.

Adverse life circumstances and poor lifestyle choices go hand in hand in a relatively deprived population; 31 per cent of the Torfaen population live in Wards ranked amongst the most deprived fifth in Wales (ONS, 2001) and two Lower Super Output Areas (LSOA) amongst the most deprived ten per cent of LSOAs in Wales (WIMD, 2005).

Whilst the needs assessment states that focus should be on borough-wide cross-sectoral activity to reduce the risk factor prevalence across the Torfaen population as a whole, this report raises two important points relating to the focus of work at a sub-torfaen “community” level. Firstly, whilst much of the data and information for Torfaen as a whole are not too dissimilar to the Welsh average, there are several geographical areas in Torfaen where health and wellbeing experience remains significantly lower than the national average and in these areas there is an aggregation of risk factors, unhealthy lifestyles, less than optimal life circumstances and poor health. This suggests that specific, targeted action may be required to modify risk factors for the wider determinants of HSCWB. Secondly, the 2007 needs assessment states that as part of the ongoing process of needs assessment in Torfaen, much work is needed to identify HSCWB needs of special populations or communities which might be experiencing health inequalities. This report highlights the paradigm that "community" should be at the heart of service planning and delivery particularly for health improvement initiatives, but that there are very little data at the "community" level.

This report summarises the needs assessment data held at a geographical level which breaks Torfaen down in to smaller areas enabling us to identify those areas/communities of increased need which may require a special focus in HSCWB planning and provision. This report recommends that the PPI group and TCBC Research and Engagement work with the newly established Data and Information Group in engaging citizens to identify "communities" and assess their HSCWB needs as part of the ongoing needs assessment process.

2. Geographies used in this report Traditionally, small area statistics have been reported at electoral division (or ward) level; the advantage of using this geography is that it is understood at local level and, of course, defines the areas represented by councillors. There are, however, disadvantages which make electoral divisions less suitable for presenting some types of data, particularly health and social wellbeing data at a population level. These problems are discussed in the Geography and Demography section of the 2007 Torfaen needs assessment document which can be accessed at:

1 http://www.webster.uk.net/HealthAndWellbeing/HealthSocialCareAndWellbein g/HealthSocialCareandWellBeingNeedsAssessm.aspx

In order to try to overcome some of the problems the Office for National Statistics (ONS) has created new statistical geographies called Super Output Areas (SOA). More information about how SOA overcomes the disadvantages of analysing and presenting data at ward-level are explained in the needs assessment. Of course, the drawback with analysing and presenting data at SOA levels is that they do not relate to local communities or wards and, at present, they do not have names. This makes them less amenable to the public and local government and, makes it more difficult for HSCWB decision makers (the consumers of these data) to interpret and translate for direction of service resources. In this document, where data exist at the sub-LHB/LA area level, they are presented at Medium Super Output Area (MSOA) level or electoral division level depending on the availability of the most recent data.

The maps and table overleaf show Torfaen broken down in to Wards and MSOAs and describe the relationship between the two geographical areas.

Map 2.1: Electoral division and MSOA Geography in Torfaen

Electoral Divisions Medium Super Output Areas

Crown copyright material is reproduced with the permission of the Controller of HMSO and the Queen’s Printer for Scotland

2 Table 2.1: Matching electoral divisions/wards to MSOA geography

Electoral Division MSOA Blaenavon W02000323 Abersychan W02000324 Trevethin, Snatchwood, St C&P W02000325 Pontnewynydd, Wainfelin, Cwmyniscopy, Brynwern, Pontypool W02000326 New Inn W02000327 Panteg W02000328 Croesyceiliog North, Croesyceiliog South, Llanyrafon North W02000330 Llanyrafon South, Part of Llantarnam W02000335 Part of Llantarnam, St Dials, Part of Two Locks W02000332 Part of Two Locks, Coed eva W02000334 Part of Greenmeadow, Fairwater W02000333 Part of Greenmneadow, Part of Upper Cwmbran W02000331 Part of Upper Cwmbran, Pontnewydd W02000329

It can be seen from Map 2.1 and Table 2.1that the MSOA boundaries are not always co-terminous with ward/electoral division boundaries which makes interpreting the data more difficult and, that MSOAs in Torfaen are generally geographically larger than wards, which has the effect of lumping even more local “communities” together than electoral divisions (EDivs) did. This approach may lead to an interpretation bias in planning for sustainable health improvement at the “community” level for the reasons stated and hence are often crude and incomplete proxies for the characteristics of communities that affect HSCWB.

Public health programs and policy are often defined at electoral, regional and even national levels, but it is the community where prevention and intervention take place. Community involvement, particularly the involvement of socially and economically disadvantaged groups, is key to the success of national strategies to promote health and wellbeing and to reduce health inequalities (NICE, 2007). Involving communities could also help make policy initiatives more sustainable (NICE, 2007). The Ottawa Charter for Health Promotion (1986) sets out five areas for health promotion action including, “Creating supportive environments” and “Strengthening community action” which implicitly require identification of real communities and assessment of HSCWB needs thereof.

Recognition of these facts has led to increased calls for community collaboration as an important strategy for successful public health research and programs. It is essential therefore that we provide information about needs of communities that relate specifically to the perceived geographical communities in Torfaen.

However there are many potential obstacles to measuring need (and targeting appropriate investment at a ‘community level’) and, involving/engaging and

3 mobilising communities for effective action, mainly because ‘community’ has been defined in many ambiguous and contradictory ways. Geographical community means different things to different people and several research studies have explored the different explicit elements of community cited by people living in a diverse range of life circumstances and geographical areas, these include: sharing, joint action, social ties, social interaction, social and political responsibility, geographic area, locus, common institutions, membership, influence, integration, fulfilment of needs, shared emotional connection, common ties, personal community networks, and, people with common ties residing in a common geographic area (MacQueen, et al, 2001). To reinforce the complexity, other authors suggest that “communities are rarely, if ever, a homogeneous whole and that this represents a major challenge for successful community participation in setting health policy” (MacQueen, et al, 2001).

This supplement recommends that the work of identifying Torfaen communities from the citizens’ perspective is discussed by the data and information group and the LHB Patient and Public Involvement group with a view to obtaining a better understanding of HSCWB need at the community level and to build on current work aimed at effective community empowerment and participation.

4 3. Small area need in Torfaen This section discusses need at MSOA and related electoral division (EDiv) level, showing a selection of data including demography, life circumstances and health outcomes within these areas and their composite electoral divisions.

3.2 A picture of relative affluence and good health This Medium Super Output Area (W02000335), containing the whole of the EDiv of Llanyrafon South and part of the EDiv of Llantarnam, has the second highest proportion of people aged 65 years and older in Torfaen and a relatively low proportion of people aged less than 25 years. On the whole there are relatively few carers here compared to other parts of the Borough.

This area is amongst the least deprived fifth of MOSAs in the whole of Wales, has the second lowest unemployment rate in Torfaen well below the Welsh average, contains the lowest proportions of dependent children in lone parent families and, the lowest proportions of 16 to 24 year olds with NO educational qualifications in Torfaen.

This MSOA is amongst the lowest fifth in Wales for rates of death from all causes and death from injury, coronary heart disease (CHD), circulatory diseases and stroke. This area is in the second lowest fifth in wales for the proportion of people dying from respiratory disease and the middle fifth malignancies. Despite this picture of relative affluence and good health it must be noted that there remain almost a quarter of this population who report experiencing limiting long-term illness.

On the whole though it is this picture, whilst very positive and exemplary, that distorts the data for the Torfaen population when taken as a whole pulling us close to the national average. There are other notable examples including MSOA W02000330 (Croesyceiliog North, Croesyceiliog South and Llanyrafon North) and MSOA W02000334 (part of Two Locks and Coed Eva) (see Appendix 1).

3.3 Areas in Need Starting in the North of the Borough, the MSOA W02000323 and the electoral division of Blaenavon are coterminous (see map 2.1 and table 2.1). Whilst Blaenavon has the Borough’s fourth highest proportion of people aged 65 and older (18.8%) it still has almost 30 per cent of it’s population aged under 25 years. Blaenavon has the highest number of carers in Torfaen (323), who report providing 20 or more hours of care every week.

Crown copyright material is reproduced with the permission of the Controller of HMSO and the Queen’s Printer In terms of socio-economic determinants of HSCWB, Blaenavon is by no means amongst the worst in the Borough but it is amongst the second most deprived fifth of wards in Wales and is amongst the top five areas in torfaen for unemployment rate. Almost a quarter of dependent children live in lone parent families and 23 per cent of children with NO educational qualifications. In terms of health outcomes however, Blaenavon has some of the highest rates of ill health being amongst the highest fifth of MSOAs in the whole of Wales for death from all causes, circulatory disease, heart disease and cancer. It is also amongst the top three areas in Torfaen for long-term limiting illness and low-birthweight babies.

Travelling further South, the MSOA W02000325 includes, and is coterminous with, the electoral division boundaries for Trevethin, Snatchwood and St Cadocks and Penygarn (see map 1 and table 1). This MSOA has the second highest proportion of people aged under 25 years (35%) and relatively low proportion of those age 65 and older. Two of the composite EDivs are amongst the highest five MSOAs in the Borough for the proportion of the population who are carers with St Cadocs and Penygarn having the highest proportion in the borough.

In the introduction we mention that 33 per cent of the Torfaen population are reported to live in areas amongst the most deprived in Wales. This MSOA and two of the composite EDivs are amongst the most deprived fifth in Wales with Snatchwood being in the second most deprived fifth. Trevethin has the highest proportion of dependent children in lone parent families in the Borough along with the highest proportion of 16 to 24 year olds with NO educational qualifications. The MSOA as a whole has the second highest level of unemployment in the borough well above the Welsh average and more than double the lowest in the Borough.

This area is amongst the highest fifth of areas in Wales for deaths from coronary heart disease, circulatory disease and cancer, and, is amongst the second highest fifth for all causes and from injuries.

Moving in to mid-Torfaen highlights some of the issues of measuring need using data at MSOA level. For example, the MSOA W02000326 includes, and is coterminous with, the electoral division boundaries of Pontnewynydd, Wainfelin, Cwmynyscoy, Brynwern and Pontypool. Amongst these, Cwmynyscoy and Brynwern are amongst the most deprived fifth of Wards in Wales and amongst the top three of the borough for children in lone parent families and young people with no educational qualifications, whereas Wainfelin and Pontnewynydd are amongst the second least-deprived fifth in Wales.

Crown copyright material is reproduced with the permission of the Controller of HMSO and the Queen’s Printer Continuing to travel further to the South of Torfaen, MSOA W02000331 containing part of Greenmeadow and Part of Upper Cwmbran, has the highest proportion of the population aged under 25 years in the Borough, this is amongst the highest range for MSOAs in the whole of Wales. In contrast to the 41 per cent of under 25s in this area only 11 percent of the population are aged 65 and older. There are relatively few carers in this area.

This area would appear to be the most deprived in the Borough with both composite EDivs amongst the most deprived fifth in Wales. The MSOA also has the highest rate of unemployment in Torfaen at over nine per cent. Greenmeadow and Upper Cwmbran have the second and fifth highest proportions of children in lone parent families in the Borough.

Health outcomes in this area are also among the worst in the Borough and some of the worst in Wales with the proportion of low birth weight babies being the highest in Torfaen at 8 per cent. This area is amongst the highest fifth in Wales for deaths from all causes, for deaths from circulatory diseases and for death from cancer. This area is also among the second worst fifth in Wales for deaths from CHD, stroke and respiratory disease.

Immediately South East, the MSOA W02000332, comprising St Dials, part of Two Locks and part of Llantarnam has the third highest population proportion aged 65 and older in the Borough at just over 20 per cent.

Despite the older population proportion, like it’s neighbour there are still a high proportion of those aged under 25 (30%) and along with that this area has the third highest unemployment rate in the Borough. There is a big difference in the socio-economic determinants of HSCWB between the Wards making up this MSOA with St Dials appearing to have a greater aggregation of risk factors for poorer health and wellbeing to it’s neighbours; St Dials is amongst the fifth of most deprived wards in Wales and amongst the five wards with the highest proportions of dependent children in lone parent families and those aged 16 to 24 with no qualifications.

In terms of health outcomes, as a whole this MSOA is the highest in the Borough for the proportion of people reporting limiting long term illness and the second highest in the Borough for the proportion of babies born with a low birth weight. This area is amongst the highest fifth in Wales for death from all causes, for deaths from circulatory diseases, death from cancer and death from stroke.

4 Conclusion This report does not pick out all the needs in all the areas; this information can be found in Appendix 1 and in the 2007 needs assessment, and there are inequalities in the other Torfaen areas listed. There are also other data which

7 Crown copyright material is reproduced with the permission of the Controller of HMSO and the Queen’s Printer are not available at small area level which we might expect to be unevenly distributed across the communities of Torfaen. This report picks out areas with aggregation of risk factors and indicators of greatest HSCWB need in the Borough.

As a whole, the picture of health social care and wellbeing in Torfaen looks ok, not too dissimilar to the Welsh average, about in the middle of the other LHB/LA areas in Wales and a bit better in many respects than some of the other South Wales Valleys areas. However, analysis at a smaller area level tells us that there are large health inequalities in Torfaen with some areas experiencing amongst the best health outcomes and lowest levels of determinants of ill health in the whole of wales whilst several areas are experiencing amongst the worst deprivation, and poorest health in the Country.

To influence these indicators, improving outcomes for those experiencing the worst health and well being in Torfaen, this report suggests we must widen and strengthen the work of the existing community collaborations starting with involving local people to identify the real communities within the Borough and, through evidence-based methods, involve those communities in identifying real need and in the development and delivery of services to their community.

8 References

Health Information Analysis Team, NPHS (2006) Deprivation and Health: Torfaen: http://www2.nphs.wales.nhs.uk:8080/HIATDocs.nsf/Main%20Frameset?Open FrameSet&Frame=Right&Src=%2FHIATDocs.nsf%2FPublic%2Fd353ba7675 e0a2b88025717300505558%3FOpenDocument%26AutoFramed [accessed October 2007]

Health information Analysis Team, NPHS (2007) Health Needs Assessment: Torfaen Specific Information: http://nww2.nphs.wales.nhs.uk:8080/hiatdocs.nsf/61c1e930f9121fd080256f2a 004937ed/4573f91b5a39d71f80257274005ad8e9/$FILE/20070116_HNATorf aenLHBSpecificInformationDocument_V2a_compressed.doc [Accessed October 2007]

MacQueen et al. Community-Based Participatory Research, American Journal of Public Health, 2001, 91(12).

NICE (2007) Community engagement and community development methods and approaches to health improvement. NICE public health programme guidance(5).

Welsh Assembly Government (2005) Welsh Index of Multiple Deprivation (Revised 8 December 2005): Local Authority Analysis: http://new.wales.gov.uk/docrepos/40382/40382313/statistics/wimd- 2005/4038211011/wimd2005-analysis-r1-e.pdf?lang=en [accessed October 2007]

9 Appendix one: indicators of HSCWB need at MSOA and related EDiv level in Torfaen

1 Blaenavon The MSOA W02000323 and the electoral division of Blaenavon are coterminous (see map 2.1 and table 2.1).

Percentage population 0-24 29.3 (9) Percentage population 65+ 18.8 (4) Number of persons providing 20 or more hours of unpaid care a week 323 Proportion (%) providing 20 or more hours of unpaid care a week 5.6 (6) Non-white (%) 0.4

Townsend deprivation rank fifth in Wales 2 Economically active unemployed % 5.9 (5) % 0-15 in households dependent on Worklessness benefits 0.3 % dependent children in LP families 24.3 (10) %16-24 No quals 22.9 (11)

% singleton live births <2500g 7.2 (3) LLTI (%) 27.8 (3) Rank fifth in Wales for all cause death 1 Rank fifth in Wales for death from malignancies 1 Rank fifth in Wales for death from circulatory disease 1 Rank fifth in Wales for death from CHD 1 Rank fifth in Wales for death from respiratory disease 3 Rank fifth in Wales for death from stroke 3 Rank fifth in Wales for death from injury 5

x 2 Abersychan The MSOA W02000324 and the electoral division of Abersychan are coterminous (see map 2.1 and table 2.1).

Proportion population 0-24 (ONS) 32.0 (5) Proportion population 65+ (ONS) 16.4 (8) Number of persons providing 20 or more hours of unpaid care a week 433 Proportion (%) providing 20 or more hours of unpaid care a week 6.3 (2) Non-white (%) 0.4 (13)

Townsend deprivation rank fifth in Wales 2 Economically active unemployed % 5.5 (7) % 0-15 in households dependent on Worklessness benefits 0.3 % dependent children in LP families 25.1 (8) %16-24 No quals 25.0 (8)

% singleton live births <2500g 6.3 (5) LLTI (%) 27.7 (4) Rank fifth in Wales for all cause mortality 4 Rank fifth in Wales for death from injury 5 Rank fifth in Wales for death from malignancies 3 Rank fifth in Wales for death from respiratory disease 3 Rank fifth in Wales for death from circulatory disease 2 Rank fifth in Wales for death from CHD 2 Rank fifth in Wales for death from stroke 5

xi 3 Trevethin, Snatchwood and St Caddocks and Penygarn

The MSOA W02000325 includes, and is coterminous with, the electoral division boundaries for Trevethin, Snatchwood and St Caddocks and Penygarn (see map 1 and table 1).

St Cadocs & MSOA Trevethin Snatchwood Penygarn Proportion population 0-24 (ONS) 35.1 (2) Proportion population 65+ (ONS) 14.8 (10) Number of persons providing 20 or more hours of unpaid care a week 210 89 128 Proportion (%) providing 20 or more hours of unpaid care a week 5.7 (5) 4.6 (12) 8 (1) Non-white (%) 1.0 (6)

St Cadocs & MSOA Trevethin Snatchwood Penygarn Townsend fifth 1 2 1 Economically active unemployed % 8.8 (2) % 0-15 in households dependent on Worklessness benefits 0.4 0.3 0.5 % dependent children in LP families 35.4 (1) 20.5 (18) 25.1 (9) %16-24 No quals 36.1 (1) 22.6 (12) 30.6 (2)

MSOA % singleton live births <2500g 5.6 (8) LLTI (%) 28.7 (2) Rank fifth in Wales for all cause mortality 2 Rank fifth in Wales for death from injury 2 Rank fifth in Wales for death from malignancies 1 Rank fifth in Wales for death from respiratory disease 3 Rank fifth in Wales for death from circulatory disease 1 Rank fifth in Wales for death from CHD 1 Rank fifth in Wales for death from stroke 3

xii 4 Pontnewynydd, Wainfelin, Cwmynyscoy, Brynwern, Pontypool The boundaries are coterminous with the MSOA. MSOA Pontnewynydd Wainfelin Cwmynyscoy Brynwern Pontypool Proportion aged 0-24 (ONS) 30.3 (7) Proportion aged 65+ (ONS) 16.4 (9) Number providing 20+ hours unpaid care a week 77 103 78 107 68 Proportion (%) providing 20+ hours unpaid care a week 5 (11) 4.3 (18) 6.1 (3) 5.9 (4) 4 (19) Non-white (%) 0.6 (11)

MSOA Pontnewynydd Wainfelin Cwmynyscoy Brynwern Pontypool Townsend fifth 4 4 1 1 2 Economically active unemployed 6.0 (4) % % 0-15 in households dependent on Worklessness benefits 0.2 0.3 0.5 0.3 0.2 % dependent children in LP families 20.1 (19) 21.1 (15) 21.7 (13) 30.6 (3) 20.8 (16) %16-24 No quals 19.3 (18) 25.2 (7) 30.5 (3) 27.4 (5) 24.3 (9)

MSOA % singleton live births <2500g 4.7 (12) LLTI (%) 26.4 (6) Rank fifth in Wales for all cause mortality 3 Rank fifth in Wales for death from injury 3 Rank fifth in Wales for death from malignancies 2 Rank fifth in Wales for death from respiratory disease 2 Rank fifth in Wales for death from circulatory disease 4 Rank fifth in Wales for death from CHD 2 Rank fifth in Wales for death from stroke 5

xiii 5 New Inn

Proportion population 0-24 (ONS) 26.8 (12)

Proportion population 65+ (ONS) 18.5 (5) Number of persons providing 20 or more hours of unpaid care a week 244 Proportion (%) providing 20 or more hours of unpaid care a week 3.8 (22) Non-white (%) 0.7 (9)

Townsend fifth 5

Economically active unemployed % 3.1 (13)

% 0-15 in households dependent on Worklessness benefits 0.1

% dependent children in LP families 15.6 (23) %16-24 No quals 17.8 (21)

% singleton live births <2500g 4.4 (13) LLTI (%) 21.1 (11) Rank fifth in Wales for all cause mortality 4 Rank fifth in Wales for death from injury 5 Rank fifth in Wales for death from malignancies 3 Rank fifth in Wales for death from respiratory disease 3 Rank fifth in Wales for death from circulatory disease 4 Rank fifth in Wales for death from CHD 4 Rank fifth in Wales for death from stroke 4

xiv 6 Panteg The MSOA W02000328 is coterminous with the electoral division boundary of Panteg.

Proportion population 0-24 (ONS) 28.7 (10) Proportion population 65+ (ONS) 18.3 (6)

Number of persons providing 20 or more hours of unpaid care a week 271

Proportion (%) providing 20 or more hours of unpaid care a week 3.9 (21)

Non-white (%) 0.7 (10)

Townsend fifth 4

Economically active unemployed % 4.1 (11)

% 0-15 in households dependent on Worklessness benefits 0.2

% dependent children in LP families 15.9 (22) %16-24 No quals 13.2 (23)

% singleton live births <2500g 6.8 (4) LLTI (%) 24.6 (9) Rank fifth in Wales for all cause mortality 2 Rank fifth in Wales for death from injury 5 Rank fifth in Wales for death from malignancies 2 Rank fifth in Wales for death from respiratory disease 3 Rank fifth in Wales for death from circulatory disease 3 Rank fifth in Wales for death from CHD 3 Rank fifth in Wales for death from stroke 2

xv 7 MSOA W02000329 - part of Upper Cwmbran and Pontnewydd The MSOA W02000329 includes part of the electoral division of Upper Cwmbran and Pontnewydd.

Upper MSOA Pontnewydd Cwmbran Proportion population 0-24 (ONS) 31.3 (6)

Proportion population 65+ (ONS) 18.0 (7) Number of persons providing 20 or more hours of unpaid care a week 330 301 Proportion (%) providing 20 or more hours of unpaid care a week 5.4 (8) 5.3 (10) Non-white (%) 1.2 (3)

Upper MSOA Pontnewydd Cwmbran Townsend fifth 1 1 Economically active unemployed % 5.5 (6) % 0-15 in households dependent on Worklessness benefits 0.3 0.4 % dependent children in LP families 26.5 (6) 29.2 (5) %16-24 No quals 23.3 (10) 20.4 (14)

Electoral Division MSOA % singleton live births <2500g 6.2 (6) LLTI (%) 25.7 (7) Rank fifth in Wales for all cause mortality 4 Rank fifth in Wales for death from injury 4 Rank fifth in Wales for death from malignancies 2 Rank fifth in Wales for death from respiratory disease 5 Rank fifth in Wales for death from circulatory disease 4 Rank fifth in Wales for death from CHD 3 Rank fifth in Wales for death from stroke 5

xvi 8 Croesyceiliog North, Croesyceiliog South and Llanyrafon North The MSOA W02000330 includes and is coterminous with the electoral divisions of Croesyceiliog North and South and Llanyrafon North.

Croesyceiliog Croesyceiliog Llanyrafon MSOA North South North Proportion population 0- 24 (ONS) 25.8 (13) Proportion population 65+ (ONS) 27.1 (1) Number of persons providing 20 or more hours of unpaid care a week 157 81 80 Proportion (%) providing 20 or more hours of unpaid care a week 4.6 (14) 4.5 (15) 4 (20) Non-white (%) 1.0 (7)

Croesyceiliog Croesyceiliog Llanyrafon MSOA North South North Townsend fifth 3 4 4 Economically active unemployed % 5.0 (8) % 0-15 in households dependent on Worklessness benefits 0.2 0.1 0.2 % dependent children in LP families 23.3 (12) 16.9 (21) 20.8 (17) %16-24 No quals 18.3 (20) 14.5 (22) 19.0 (19)

MSOA % singleton live births <2500g 5.4 (10) LLTI (%) 27.3 (5) Rank fifth in Wales for all cause mortality 5 Rank fifth in Wales for death from injury 5 Rank fifth in Wales for death from malignancies 3 Rank fifth in Wales for death from respiratory disease 4 Rank fifth in Wales for death from circulatory disease 5 Rank fifth in Wales for death from CHD 4 Rank fifth in Wales for death from stroke 5

xvii 9 MSOA W02000331 Part of Greenmeadow and Part of Upper Cwmbran This MSOA contains part of the electoral divisions of Greenmeadow and part of Upper Cwmbran. Map 1 and 2 shows the locations of the EDivs within the MSOA.

Upper MSOA Greenmeadow Cwmbran Proportion population 0-24 (ONS) 41.1 (1) Proportion population 65+ (ONS) 10.9 (11) Number of persons providing 20 or more hours of unpaid care a week 205 301 Proportion (%) providing 20 or more hours of unpaid care a week 4.6 (13) 5.3 (10) Non-white (%) 1.3 (2)

Upper MSOA Greenmeadow Cwmbran Townsend fifth 1 1 Economically active unemployed % 9.1 (1) % 0-15 in households dependent on Worklessness benefits 0.3 0.4 % dependent children in LP families 32.9 (2) 29.2 (5) %16-24 No quals 27.2 (6) 20.4 (14)

MSOA % singleton live births <2500g 8.0 (1) LLTI (%) 22.5 (10) Rank fifth in Wales for all cause mortality 1 Rank fifth in Wales for death from injury 3 Rank fifth in Wales for death from malignancies 1 Rank fifth in Wales for death from respiratory disease 2 Rank fifth in Wales for death from circulatory disease 1 Rank fifth in Wales for death from CHD 2 Rank fifth in Wales for death from stroke 2

xviii 10 MSOA W02000332, St Dials, Part of Two Locks and Part of Llantarnam

Two MSOA Llantarnam St Dials Locks Proportion population 0-24 (ONS) 29.7 (8) Proportion population 65+ (ONS) 20.4 (3) Number of persons providing 20 or more hours of unpaid care a week 252 208 290 Proportion (%) providing 20 or more hours of unpaid care a week 5.4 (9) 5.5 (7) 4.4 (16) Non-white (%) 0.9 (8)

Two MSOA Llantarnam St Dials Locks Townsend fifth 3 1 3 Economically active unemployed % 7.8 (3) % 0-15 in households dependent on Worklessness benefits 0.2 0.3 0.2 % dependent children in LP 23.4 families 20.0 (20) 29.7 (4) (11) 19.9 %16-24 No quals 19.6 (16) 28.5 (4) (15)

MSOA % singleton live births <2500g 7.2 (2) LLTI (%) 29.4 (1) Rank fifth in Wales for all cause mortality 1 Rank fifth in Wales for death from injury 3 Rank fifth in Wales for death from malignancies 1 Rank fifth in Wales for death from respiratory disease 3 Rank fifth in Wales for death from circulatory disease 1 Rank fifth in Wales for death from CHD 2 Rank fifth in Wales for death from stroke 1

xix 11 MSOA W02000333, Part of Greenmeadow and Fairwater

Electoral Division MSOA Greenmeadow Fairwater Proportion population 0- 24 (ONS) 35.1 (3) Proportion population 65+ (ONS) 10.8 (12) Number of persons providing 20 or more hours of unpaid care a week 205 240 Proportion (%) providing 20 or more hours of unpaid care a week 4.6 (13) 4.3 (17) Non-white (%) 1.2 (4)

Electoral Division MSOA Greenmeadow Fairwater Townsend fifth 1 3 Economically active unemployed % 4.4 (10) % 0-15 in households dependent on Worklessness benefits 0.3 0.2 % dependent children in LP families 32.9 (2) 25.7 (7) %16-24 No quals 27.2 (6) 22.2 (13)

Electoral Division MSOA % singleton live births <2500g 6.0 (7) LLTI (%) 19.9 (12) Rank fifth in Wales for all cause mortality 3 Rank fifth in Wales for death from injury 4 Rank fifth in Wales for death from malignancies 3 Rank fifth in Wales for death from respiratory disease 4 Rank fifth in Wales for death from circulatory disease 4 Rank fifth in Wales for death from CHD 5 Rank fifth in Wales for death from stroke 4

xx 12 MSOA W02000334, Part of Two Locks and Coed eva

MSOA Coed Eva Two Locks Proportion population 0-24 (ONS) 33.3 (4) Proportion population 65+ (ONS) 9.6 (13) Number of persons providing 20 or more hours of unpaid care a week 77 290 Proportion (%) providing 20 or more hours of unpaid care a week 3.2 (24) 4.4 (16) Non-white (%) 1.4 (1)

MSOA Coed Eva Two Locks Townsend fifth 3 3 Economically active unemployed % 4.6 (9) % 0-15 in households dependent on Worklessness benefits 0.3 0.2 % dependent children in LP families 21.4 (14) 23.4 (11) %16-24 No quals 19.3 (17) 19.9 (15)

Electoral Division MSOA % singleton live births <2500g 5.0 (11) LLTI (%) 16.8 (13) Rank fifth in Wales for all cause mortality 5 Rank fifth in Wales for death from injury 5 Rank fifth in Wales for death from malignancies 5 Rank fifth in Wales for death from respiratory disease 3 Rank fifth in Wales for death from circulatory disease 5 Rank fifth in Wales for death from CHD 5 Rank fifth in Wales for death from stroke 5

xxi 13 MSOA W02000335, Llanyrafon South and Part of Llantarnam

Llanyrafon MSOA South Llantarnam

Proportion population 0-24 (ONS) 27.5 (11)

Proportion population 65+ (ONS) 23.0 (2)

Number of persons providing 20 or more hours of unpaid care a week 92 252

Proportion (%) providing 20 or more hours of unpaid care a week 3.5 (23) 5.4 (9) Non-white (%) 1.1 (5)

Llanyrafon MSOA South Llantarnam Townsend fifth 5 3 Economically active unemployed % 3.8 (12)

% 0-15 in households dependent on Worklessness benefits 0.1 0.2 % dependent children in LP families 10.6 (24) 20.0 (20) %16-24 No quals 10.8 (24) 19.6 (16)

MSOA % singleton live births <2500g 5.4 (9) LLTI (%) 24.9 (8) Rank fifth in Wales for all cause mortality 5 Rank fifth in Wales for death from injury 5 Rank fifth in Wales for death from malignancies 3 Rank fifth in Wales for death from respiratory disease 4 Rank fifth in Wales for death from circulatory disease 5 Rank fifth in Wales for death from CHD 5 Rank fifth in Wales for death from stroke 5

xxii