Wolverhampton City Council OPEN DECISION ITEM

Agenda Item No. 6

Scrutiny Board / Panel

rd Originating Service Group(s) Public Health Date 23 September 2010

Contact Officer(s)/ Dr Adrian Phillips Telephone Number(s) 01902 444768

Title Joint Strategic Needs Assessment update

RECOMMENDATION

That the Health Scrutiny Panel notes the Joint Strategic Needs Assessment update.

OPEN DECISION ITEM SCRUTINY 1. PURPOSE

1.1 Joint Strategic Needs Assessment is a responsibility of Councils and PCTs through their Directors of Children Services, Adult Services and Public Health. It aims to inform strategy and planning.

1.2 The document has 5 chapters including updates to the nationally defined core dataset and analysis in areas recognised as needing further work in the original JSNA, namely Mental Health and Learning Disability.

1.3 The document has not been published in a printed version as it is available on-line.

2. BACKGROUND

2.1 The 2009 Joint Strategic Needs Assessment builds upon the comprehensive analysis performed in 2008. This can be accessed from the following link http://www.wolvespct.nhs.uk/JSNA/rootfolder/index.html

2.2 The broad thrust of the needs assessment has not changed. The main causes of our poor life expectancy remain the “big six” of Infant Mortality, Coronary Heart Disease, Stroke, Alcohol-related Liver Disease, Suicide and Cancer (particularly lung cancer). Obesity in children and adults remains a significant problem and teenage pregnancy rates are stubbornly high. 2.3 Deprivation and inequality feature heavily in our analysis and we confirm the persistent local link between socio-economic disadvantage and survival. We also show variation in access to services by ethnic group. This update examines how the ageing population and increased survival will impact upon one often neglected service area. 2.4 The first chapter provides updates to the nationally suggested core dataset wherever new information is available. It draws heavily upon “Window on Wolverhampton” which is led by the City Council in collaboration with partner agencies. It reaffirms that our total population will be relatively stable in the medium term; there will be a significant rise in the over 65 year population and this will lead to an increase in the number of single people. The analysis also shows that our most disadvantaged wards have a higher proportion of children, an important factor in our fight against child poverty. The rapid rise in unemployment in the city consequent upon the international financial crisis is documented. 2.5 Learning Disability was a gap noted in our original JSNA and is covered in chapter two. Comparative assessment suggests that there about 4 - 6000 people with learning disability in the city, of whom about 900 will have severe disability. This is in line with the number of people with moderate or severe disability known to live in the city and receive services. It predicts a small (less than 5%) rise in this group of people, mainly in the over 65 age group and due to ageing. Most people with learning disability are cared for by families and increasingly by old or frail carers. Local survey work shows that people with learning disability are three times more likely to be obese and twice as likely to have asthma. Girls with learning disability have a 40% chance of getting pregnant in the 18 months after leaving school. Learning disability accounts for two thirds of special school places, with approximately 60 per year entering adult services. 2.6 Chapter three explores Cardiovascular Disease (CVD) in more depth as it remains the single greatest cause of lost life years in Wolverhampton. Although we are improving in this area, mortality from CVD remains considerably higher than the national average. The chapter explores the factors which explain the high burden of CVD in the city. It identifies the non-modifiable and modifiable risk factors for CVD and the impact of these. OPEN DECISION ITEM SCRUTINY The potential to reduce the number of CVD events is examined in a model which uses these risk factors and the potential of better risk factor management. The model shows that if new services were focussed on the most disadvantaged groups then this may halve their excess in CVD events compared to the most advantaged in the city. 2.7 Mental Health is the last of the detailed analysis undertaken in this JSNA and like learning disability responds to gaps in the initial document. The chapter includes both quantitative and qualitative data relating to the burden of mental health problems and service configuration and productivity. It reviews the determinants of mental health problems especially poverty and unemployment. Encouragingly, suicide rates are falling in the city and the mortality gaps between disadvantaged and advantaged are closing. However the overall burden of mental ill health is high, with at least 14,000 people with depression although these are in line with other benchmarks. Approximately 3,000 people have dementia in the city and this will rise by at least 14% over the next decade. Differences in service use by ethnic group are described with higher rates in certain BME groups, especially the black population. Considerable information is given on the type of client in contact with services as well as comparative data on service productivity. Important qualitative data is given about the perception of services from stakeholders and service users. Finally financial information is provided which shows that the triangle of spend is opposed to the burden of need with a disproportionate amount spent on a small number of clients. 2.8 The last chapter describes how we have evolved the JSNA process in Wolverhampton to firmly support the Local Strategic Partnership in strategically assessing need. It shows the governance arrangements we have put in place which involve the whole partnership. We have identified three priorities for 2010/11:-

1 Children and Young People: This work will link to and support the new Children and Young People Plan. 2 The effects of the recession on the needs of Wolverhampton: This will have a particular emphasis on child poverty. 3 The effects of ageing on the needs of Wolverhampton

2.9 This JSNA refresh was developed by the Needs Analysis Governance Group of the Local Strategic Partnership. Representatives include:

Local Strategic Partnership

Voluntary Sector Council

City Council (Children and Young People Services)

City Council (Adults and Community Services)

City Council (Policy)

City Council (Regeneration)

PCT

Police

OPEN DECISION ITEM SCRUTINY 3. FINANCIAL IMPLICATIONS

3.1 There are no financial implications

4. LEGAL IMPLICATIONS

4.1 There are no direct legal implications.

5. EQUAL OPPORTUNITIES IMPLICATIONS

5.1 This report shows how opportunity by those who are disadvantaged could be improved.

6. ENVIRONMENTAL IMPLICATIONS

6.1 No environmental implications

7. SCHEDULE OF BACKGROUND PAPERS

7.1 JSNA final version attached.

OPEN DECISION ITEM SCRUTINY

WOLVERHAMPTON JOINT STRATEGIC NEEDS ASSESSMENT 2009

Update January 2010

Contents

Section Page

Executive Summary 3

Chapter 1: Core Intelligence 5

Chapter 2: Learning Disability 36

Chapter 3: Cardiovascular Disease 50 1.1 Introduction 50 1.2 Risk factors 50 1.3 Burden of ill-health 52 1.4 Health Services 54 1.5 Impact of service redesign 55 Chapter 4 - Mental Health 57 1.6 Determinants of Mental Illness 57 1.7 Prevalence of Mental Illness 58 1.8 Mental Health Services – Access and Productivity 61 1.9 Qualitative Data 66 1.10 Finance 69 1.11 Conclusion 70 Chapter 5: Infrastructure and next years priorities 72

Wolverhampton City March 2010

Executive Summary

The 2009 Joint Strategic Needs Assessment builds upon the comprehensive analysis performed in 2008. This can be accessed from the following link http://www.wolvespct.nhs.uk/JSNA/rootfolder/index.html.

The broad thrust of the needs assessment has not changed. The main causes of our poor life expectancy remain the “big six” of Infant Mortality, Coronary Heart Disease, Stroke, Alcohol-related Liver Disease, Suicide and Cancer (particularly lung cancer). Obesity in children and adults remains a significant problem and teenage pregnancy rates are stubbornly high.

Deprivation and inequality feature heavily in our analysis and we confirm the persistent local link between socio-economic disadvantage and survival. We also show variation in access to services by ethnic group. This update examines how the ageing population and increased survival will impact upon one often neglected service area.

The first chapter provides updates to the nationally suggested core dataset wherever new information is available. It draws heavily upon “Window on Wolverhampton” which is led by the City Council in collaboration with partner agencies. It reaffirms that our total population will be relatively stable in the medium term; there will be a significant rise in the over 65 year population and this will lead to an increase in the number of single people. The analysis also shows that our most disadvantaged wards have a higher proportion of children, an important factor in our fight against child poverty. The rapid rise in unemployment in the city consequent upon the international financial crisis is documented.

Learning Disability was a gap noted in our original JSNA and is covered in chapter two. Comparative assessment suggests that there about 4 - 6000 people with learning disability in the city, of whom about 900 will have severe disability. This is in line with the number of people with moderate or severe disability known to live in the city and receive services. It predicts a small (less than 5%) rise in this group of people, mainly in the over 65 age group and due to ageing. Most people with learning disability are cared for by families and increasingly by old or frail carers. Local survey work shows that people with learning disability are three times more likely to be obese and twice as likely to have asthma. Girls with learning disability have a 40% chance of getting pregnant in the 18 months after leaving school. Learning disability accounts for two thirds of special school places, with approximately 60 per year entering adult services.

Chapter three explores Cardiovascular Disease (CVD) in more depth as it remains the single greatest cause of lost life years in Wolverhampton. Although we are improving in this area, mortality from CVD remains considerably higher than the national average. The chapter explores the factors which explain the high burden of CVD in the city. It identifies the non-modifiable and modifiable risk factors for CVD and the impact of these. The potential to reduce the number of CVD events is examined in a model which uses these risk factors and the potential of better risk factor management. The model shows that if new services were focussed on the most disadvantaged groups then this may halve their excess in CVD events compared to the most advantaged in the city.

Mental Health is the last of the detailed analysis undertaken in this JSNA and like learning disability responds to gaps in the initial document. The chapter includes both quantitative and qualitative data relating to the burden of mental health Joint Strategic Needs Assessment Update

problems and service configuration and productivity. It reviews the determinants of mental health problems especially poverty and unemployment. Encouragingly, suicide rates are falling in the city and the mortality gaps between disadvantaged and advantaged are closing. However the overall burden of mental ill health is high, with at least 14,000 people with depression although these are in line with other benchmarks. Approximately 3,000 people have dementia in the city and this will rise by at least 14% over the next decade. Differences in service use by ethnic group are described with higher rates in certain BME groups, especially the black population. Considerable information is given on the type of client in contact with services as well as comparative data on service productivity. Important qualitative data is given about the perception of services from stakeholders and service users. Finally financial information is provided which shows that the triangle of spend is opposed to the burden of need with a disproportionate amount spent on a small number of clients.

The last chapter describes how we have evolved the JSNA process in Wolverhampton to firmly support the Local Strategic Partnership in strategically assessing need. It shows the governance arrangements we have put in place which involve the whole partnership. We have identified three priorities for 2010/11:

This JSNA refresh was developed by the Needs Analysis Governance Group of the Local Strategic Partnership. Representatives include:

Local Strategic Partnership

Voluntary Sector Council

City Council (Children and Young People Services)

City Council (Adults and Community Services)

City Council (Policy)

City Council (Regeneration)

PCT

Police

Wolverhampton City March 2010 Joint Strategic Needs Assessment Update

Chapter 1: Core Intelligence

This first chapter of the JSNA considers areas of the nationally recommended JSNA core data set where live data is available. This allows trends in these datasets over the last five or more years and the current position to be presented.

Some of the data included in the JSNA core dataset is based on Census data or modelling. These areas will be unchanged from 2008 and therefore are not presented in this 2009 refresh.

The following areas will be covered: • Demography: population numbers, births, ethnicity, religion, migration and social marketing categories. • Social and Environmental Context: poverty, living arrangements, employment, education, house prices, business and the green environment. • Lifestyle Risk Factors: smoking, alcohol, teenage pregnancy, hypertension, and obesity. • Burden of ill-health: All Cause mortality, Mortality from causes considered amenable to healthy care, Mortality attributable to smoking, Diabetes, Circulatory Disease, Cancer, Respiratory, Mental Health and Accidents.

The majority of this first chapter of the JSNA is based on Window on Wolverhampton 2009. Window on Wolverhampton is produced by the City Council in collaboration with partner agencies including the PCT and is a publicly available document. In 2010, the aim is to incorporate the JSNA core dataset into the cities Local Information System which will allow access to data in a number of ways, both online and for inclusion in the JSNA update.

Wolverhampton City March 2010 Joint Strategic Needs Assessment Update

Demography

Population Estimates The population of Wolverhampton has been on a steady decline, losing around 15% of residents from 1971 to 2001. The resident population at the 2001 Census was 236,582. Until the next Census in 2011, the most reliable source of information about population changes are the Mid-Year Estimates from the Office for National Statistics (ONS); these calculate approximately how the population is likely to have changed taking into account births, deaths and migration data.

The graph below shows that the population in Wolverhampton increased slightly in 2008 after a decline between 2005 and 2007. This is in line with national trends, where the population of the UK has seen its biggest growth in the last 50 years according to the latest mid year estimates.

Wolverhampton’s age profile broadly mirrors the age structure of the UK. The older population (those of pensionable age) continues to increase with a rise of 200 people in 2008. 2.2% of the population is aged 85 years or over with numbers increasing year on year.

The broadening of the base at the bottom of the pyramid and the bulge around ages 35-49 can be attributed to an increase in births from mid 2003 onwards and the baby boom years of the 1960s respectively. The sharp narrowing of the pyramid between the ages of 5-14 and 30-34 are more than likely due to the low fertility rates of the 1990’s.

Wolverhampton’s male population outnumber females by 2,900, levelling out just before 50 years of age. After 60, females outnumber males consistently, with the number of women over 90 being almost 40% greater than men. The effects of both the ageing population and recent increases in births will result in higher demands for public services.

Wolverhampton City March 2010 Joint Strategic Needs Assessment Update

Population Estimates by Age

Children & Young People in Wolverhampton The map below suggests there is a link between high levels of deprivation and areas with larger proportions of children. The two LSOAs with the largest proportion of children (two darkest areas) are also two of the most deprived areas in Wolverhampton.

Older People in Wolverhampton This map shows how there are larger concentrations of people aged 65 and over in the west and north east of the city. The distribution of older people within the city will influence future provision for this age group. 7

Wolverhampton City March 2010 Joint Strategic Needs Assessment Update

Population Projections ONS publishes the Sub National Population Projections (SNPP) to provide estimates of the future population. These are based on the ageing of the population from the previous year, and applying local fertility and mortality rates to calculate the projected number of births and deaths, then adjusting for migration into and out of an area.

According to the most recent projections (2006-based), the population of Wolverhampton will increase consistently over the next 20 years to 247,500 in 2031. This growth is in line with national trends, which predict that the population of England will reach 61 million by that year.

The chart below shows how, while the total population is increasing, this growth affects mainly the younger and older groups (below 20 and over 65 years of age). This means that the numbers of the dependant population are increasing, whereas the working population is decreasing.

Wolverhampton City March 2010 Joint Strategic Needs Assessment Update

Households In line with the expected growth of the population, the number of households in Wolverhampton is also projected to increase from approximately 99,000 in 2006 to 109,000 by 2029. Household composition is also going to change, as shown in the table below for the West Midlands Region.

Wolverhampton City March 2010 Joint Strategic Needs Assessment Update

Births by year in Wolverhampton 1986–2007

4000

3500

3000

2500

2000 Total births Total 1500

1000

500

0 1986-88 1987-89 1988-90 1989-91 1990-92 1991-93 1992-94 1993-95 1994-96 1995-97 1996-98 1997-99 1998-00 1999-01 2000-02 2001-03 2002-04 2003-05 2004-06 2005-07

Year (3 year rolling average)

Source: Vital statistics tables, ONS

The above graph shows births in Wolverhampton by year from the 1980’s up to 2007. Births declined year on year from the early 1990’s a trend that reversed in the early 2000’s. Births have risen year on year from 2000 with around 3,300 births on average a year by 2007.

Ethnicity One of Wolverhampton's most remarkable characteristics is its superdiversity. This means that within the city we find both high rates and broad range of peoples of diverse nationalities, religions and ethnic backgrounds.

The 2007 Mid Year Estimates (MYE) by ethnic group show that approximately 27% of the population in the city is of Black and Minority Ethnic origin (BME) (anyone not white British). This shows an increase in the BME population of 2.3% since the last Census (24.6% in 2001).

While this increase follows national trends, Wolverhampton still has a significantly higher proportion of BME population than the England average (16.4%). Wolverhampton is also the second most diverse city in the West Midlands, after Birmingham.

Wolverhampton City March 2010 Joint Strategic Needs Assessment Update

The estimates also show that the composition of the BME population in Wolverhampton is changing. The fastest growing BME groups in the city are those of Black African and Bangladeshi origin, whereas the white population is generally decreasing except for those born outside the British isles, who are mainly European migrants.

Religion The results of the 2001 Census show that two thirds of Wolverhampton's population identify themselves as Christian. 7.6% consider themselves to be Sikh giving Wolverhampton the fourth largest Sikh community in England.

Responses to the Census question reflect people's identification, not whether they practise their religion. This question was also the only non-compulsory question, which may explain why 8.4% of respondents did not answer the question. However, the Census is the only source of information available for tracking religion for the city.

Migration The free movement of workers across the European Union (EU) is one of the key factors affecting population change in recent years. In 2004 the EU expanded to include the A8 and A2 countries (see list at foot of page) making way for increased numbers of workers from the EU.

The existing methods of collecting and collating data on migration are not comprehensive or consistent. The two most commonly used sources are:

National insurance number registrations (NINo): All overseas workers are required to register for National Insurance. Registrations peaked in 2008 but by March 2009 had decreased by 6%. Applicants from the A8 countries account for 40.2% of all registrations, an increase of just over 10% since 2008. Workers from Asia and the Middle East account for 33.5% of registrations compared with 40% in 2008. This system does not record non- working spouses, asylum seekers and children.

Workers Registration Scheme (WRS): A8 workers are required to register on the WRS if they work in the UK for over one month. The WRS data shows that between April and June 2009, 57% of those registered were male and between the age of 18-24 (43%). The majority of workers came from Lithuania (50%) and Poland (29%). In the first quarter of 2008, Poland had the largest proportion of approved registrations (59%). Also, 71% of registered workers stated that they intended to stay in the UK for less than three months.

Wolverhampton City March 2010 Joint Strategic Needs Assessment Update

Social and Environmental Context

Poverty The English Indices of Deprivation are the Government’s official measure of multiple deprivation factors for local authorities in England. The information is collated by the Department of Communities and Local Government (DCLG) every three years. The latest available data set is the Index of Multiple Deprivation (IMD) 2007, which updates information provided in the IMD 2004.

The 2007 Index of Multiple Deprivation identifies levels of deprivation across England by bringing together 37 different indicators. The indicators cover specific aspects of dimensions of deprivation, also called domains, which are: • Income • Employment • Health and Disability • Education • Skills and Training • Barriers to Housing and Services

Wolverhampton City March 2010 Joint Strategic Needs Assessment Update

• Living Environment • Crime

These indicators are weighted and combined to create the overall IMD 2007. The majority of the data underpinning the IMD 2007 represents 2005 although some data covers a number of years, for example an average of 2003-2005. The data is then combined to produce a score. The scores are not an actual measure of deprivation, but the result of a formula that allows for geographical areas to be ranked according to their score (the most deprived area being the 1st ranked).

Geographies The IMD is released at different geographical levels. For Wolverhampton, the district and Lower Super Output Area (LSOA) geographies are used. LSOAs have between 1,000 and 3,000 people living in them with an average population of 1,500 people. Being smaller than wards, they allow the identification of small pockets of deprivation even in generally affluent areas. There are 32,482 LSOAs in England, of which 158 are in Wolverhampton.

The map on the next page shows the LSOAs in Wolverhampton coloured according to their rank (% of most deprived nationally).

We cannot aggregate the ranks, which are a comparative measure, to calculate deprivation at ward or Local Neighbourhood Partnership (LNP) level. However, the map identifies which wards have a higher concentration of the most deprived LSOAs in Wolverhampton, such as Bushbury South & Low Hill, St Peters, Bilston East and Ettingshall.

Wolverhampton’s overall ranking in the IMD 2007 is 28th nationally, which places the city in a relatively more deprived position than in 2004, when Wolverhampton was ranked 35th. There are 354 local authority districts in England, which means Wolverhampton falls now in the band of the 10% most deprived.

Nationally, the most deprived local authorities tend to be located in urban areas, with particular concentrations in the North of England and in London. Authorities in the South East are the least deprived, but even within affluent authorities there can be pockets of severe deprivation.

The overall index of deprivation is calculated by adding together all the other indices, weighted appropriately. The map to the right shows how deprivation is distributed in Wolverhampton according to the rank that each LSOA has respectively to the other areas in the country.

The map shows that the most deprived wards in Wolverhampton are Bushbury South & Low Hill, St Peters and Bilston East.

Wolverhampton has: • 2 LSOAs ranked within the 1% most deprived in England. • 15 LSOAs (9%) ranked within the 5% most deprived in England. • 37 LSOAs (23%) ranked within the 10% most deprived in England. • 77 LSOAs (49%) ranked within the 20% most deprived in England.

Wolverhampton City March 2010 Joint Strategic Needs Assessment Update

Economic Deprivation Index The Economic Deprivation Index (EDI) is an experimental index produced by the Department of Communities and Local Government (DCLG) and based on the structure and methodology of the Indices of Multiple Deprivation 2007 (IMD 2007). The EDI focuses on the economic components of the IMD (Income and Employment domains) and combines them to create a new dataset.

The map to the right shows how economic deprivation (as measured by the EDI) is distributed in Wolverhampton. The most deprived areas in the city can be found in the centre, north east and south east. Also, the Warstones area in Merry Hill is amongst the most deprived.

The table below shows how the number of Wolverhampton LSOAs ranked in the national list for deprivation has changed between 1999 and 2005. In 2005, Wolverhampton had an extra 14

Wolverhampton City March 2010 Joint Strategic Needs Assessment Update

6 LSOAs in the top 20% most deprived in England, meaning that 51% of all Wolverhampton LSOAs were included in this banding.

Additionally, in 2005 more LSOAs featured in the 5% and 10% most deprived categories respectively: this suggests that deprivation on this indicator has intensified in the city since 1999.

Child Poverty Ten years ago, the national Government made a historic commitment to eliminate child poverty. Each of the main UK political parties has now signed up to the 2020 goal to eradicate child poverty.

Child poverty is usually measured by the percentage of children living in households depending on workless benefits (e.g. jobseeker’s allowance). Wolverhampton has one of the 15

Wolverhampton City March 2010 Joint Strategic Needs Assessment Update higher rates of unemployment in the country and therefore the rate of children in poverty is higher than national and regional averages, as shown in the graph below. The current recession has worsened this situation, widening the gap with the UK rates.

The map on this page shows LSOAs in Wolverhampton with the ward boundaries superimposed. The different colours show the national ranking in terms of child well being, with the darkest colour being the most deprived. The wards where deprivation is more prevalent are Bushbury and Low Hill, St Peter’s, Ettingshall and Bilston East.

Unemployment

Wolverhampton City March 2010 Joint Strategic Needs Assessment Update

The recession has caused a significant increase in the number of people receiving out of work benefits in Wolverhampton. A lack of vacancies has meant that many people who have been made redundant, including skilled workers, have been unable to re-enter employment as competition for posts has become much greater.

By February 2009, redundancies had caused the proportion of claimants claiming for less than 3 months to swell, skewing all unemployment figures towards short term claimants. However, a continued lack of vacancies has caused people to remain unemployed for longer, and there is now a growing proportion of claimants who have been receiving benefits for 6-12 months.

While benefits such as Incapacity Benefit (IB) and lone parent benefits will not have changed significantly, the number of claimants receiving Jobseeker’s Allowance (JSA) increased by around 4,000 between September 2008 and September 2009. The claimant rate increased to 8.2%, the highest rate in the UK, and the highest rate Wolverhampton has experienced since September 1996.

While the recession has caused the majority of the increase in JSA claimants, changes in legislation have also had some impact. In November 2008 the introduction of Employment Support Allowance (ESA) made the testing process for new claimants more rigorous. Those who are unable to claim ESA are now given JSA meaning that they have to actively look for employment in order to receive their benefits. This will increase the number of claimants on JSA while decreasing the number of IB claimants.

If the recession had not occurred, the change in legislation would have caused the unemployment rate to increase, though the out of work benefit claimant rate would have remained the same.

Wolverhampton City March 2010 Joint Strategic Needs Assessment Update

The map on the next page shows the concentration of Jobseeker’s Allowance (JSA) claimants in Wolverhampton by LSOA. The picture is consistent with historical trends, areas with the highest number of claimants are in the centre and the east of the city, while the areas to the west have lower claimant numbers.

One area that has seen a significant increase in JSA claimants is in the centre of Merry Hill ward: the Warstones estate. Previous targets to reduce unemployment in Wolverhampton were based on priority wards, and only looked at unemployment at a ward level. With the rest of Merry Hill being more affluent than the Warstones area, the overall ward figures masked the fact that there was a deprived neighbourhood right in the middle of the ward.

Other areas of concern regarding unemployment rates are Heath Town and Low Hill. Some LSOAs in these wards have almost half of their working age populations in receipt of out of work benefits.

It should also be recognised that some of the wards with the highest unemployment rates are also the wards with high proportions of the city’s businesses and high numbers of employees, such as the Bilston North, Bilston East and St Peter’s ward. This suggests that people working in these locations are not necessary local to the wards, and therefore people must either be commuting to these locations from other parts of the city, or entering the city to work from other neighbouring local authorities.

The continuing recession is keeping the claimant numbers significantly above their normal levels, and it is anticipated that fewer temporary jobs will also be created over the Christmas 2009 period. This will result in the claimant numbers remaining high well into 2010.

Wolverhampton City March 2010 Joint Strategic Needs Assessment Update

Housing There are currently 104,776 dwellings in Wolverhampton, of which Wolverhampton City Council owns 22.7% (almost 24,000 dwellings). Currently 91.2% of city council housing stock is managed by Wolverhampton Homes, the remaining 8.8% is run by tenant management organisations (TMO).

Wolverhampton has a lower proportion of flats and maisonettes than other urban authorities, although levels are rising. There are also lower than average rates of terraced housing and a larger than average proportion of semi detached houses.

According to the latest projections by ONS, the population of Wolverhampton is due to rise by 3.6% up to 2026, a rise of 8,400 additional residents. To meet this rise it is estimated that approximately 14,600 affordable new dwellings will be needed in the city.

Also, it is estimated that the older population, particularly those aged over 85 years, will increase at a higher rate than other age groups. This will have implications for the provision of suitable housing for these people.

The new Housing Strategy for Wolverhampton (2009-2026) has been developed to meet the specific housing needs of the city and to support the delivery of wider strategic frameworks such as the Sustainable Communities Strategy.

Key elements in the strategy include affordable housing, quality of neighbourhoods, homelessness, accessibility, private rented sector, employment and skills, etc.

Wolverhampton City March 2010 Joint Strategic Needs Assessment Update

During the past year the council has worked with developers to ensure that quality new housing, including new affordable housing, is built in the city. A private sector leasing scheme has also been established and 199 empty properties were bought back into use.

The waiting list is the number of households (household is defined as each application for housing, whether it is an individual or a family) who are not currently living in council housing but who have applied for it. The bar chart below shows that the number of households on the waiting list has decreased by almost a third (32.7%) in the past five years.

This downward trend is also present in the housing register. The housing register is composed by the households in the waiting list, plus those current council tenants who wish to transfer between properties. The total number of households on the housing register at March 2009 was 6,524, compared to 7,244 at March 2008. This is a reduction of almost 10%. Additionally, there were 2,121 new council tenancies created over the same period, an increase of 298 from the previous year.

In 2008/09 there were 1,058 homeless applications received by the council, 422 of these were accepted as being statutorily homeless. In 2007/08 these figures were 1,242 and 416 respectively. If someone is accepted as being statutorily homeless this means that the local authority has a duty to house them.

The availability of social housing has been adversely affected by Right to Buy, which over the past 25 years has seen a significant number of council properties pass into private ownership. Right to Buy has been especially popular with tenants of 2 and 3 bedroom semi detached homes.

New social housing developments have not matched the rate at which houses have been sold as a result of Right to Buy, resulting in a net loss of social housing across the city. In some estates, such as parts of Ashmore Park, over 50% of dwellings are now owner occupied.

Housing Needs Study 2007 The Housing Needs Study 2007 examined housing need in both public and private sector housing across the city, looking at both current and future need. This study is available on the council’s website or on request from the council’s Housing Strategy Team (tel: 556999). Other housing needs studies which include Wolverhampton have also been produced at a

Wolverhampton City March 2010 Joint Strategic Needs Assessment Update regional level. Information about housing needs is used to develop strategies and to inform planning.

The 2007 Housing Needs Study found that there was a need for 702 new affordable housing units per year in the city. It also highlighted the need for housing provision to respond to the needs of an aging population and a preference for semi detached and detached properties from households moving within Wolverhampton.

Burden of Ill-Health

Tackling health inequalities continues to be a top priority both at a national and local level. Persistent inequalities in Wolverhampton have contributed to a significant gap not only within the city but also between the city and the country as a whole. Wolverhampton still finds itself in the bottom 20% of local authorities for life expectancy in England & Wales.

Despite continued improvement in life expectancy in Wolverhampton the gap between the national average remains the same in men and continues to widen for women. Currently men in Wolverhampton can expect to live to 75.7 years compared with 77.5 years for England & Wales. For women in Wolverhampton life expectancy is 80.3 years against 81.7 years for England & Wales. This gap is even more pronounced between the priority wards (higher index of deprivation) and non-priority wards. For men the gap ranges from 70.7 years in Bilston East to 78.0 years in Tettenhall Wightwick, and for women 76.5 years in Ettingshall to 81.9 in Tettenhall Wightwick.

Even though life expectancy across the city has improved in the last 3 years, if it continues to rise at the current rate it will not meet the 2010 target (for males and females), as shown in the charts below.

In order to tackle the main causes of health inequalities in the city, the Primary Care Trust (PCT) has outlined an ambitious Strategic Plan which seeks to radically transform services within Wolverhampton to tackle these persistent issues. The plan outlines a wide range of service improvement and innovation initiatives which will be implemented over the next 5 years.

Wolverhampton City March 2010 Joint Strategic Needs Assessment Update

Circulatory Disease Cardiovascular Disease (CVD) is one of the main causes of premature death in the UK. The main forms of CVD are Coronary Heart Disease (CHD) and stroke. The map on the next page shows how the incidence of the disease varies geographically across the city, with the most deprived areas in Wolverhampton having a much higher proportion of deaths. St Peter’s for instance, has a CVD mortality rate almost four times higher than Tettenhall Regis.

Statistics show that CHD is more prevalent in men than women and also in Black and Asian communities; additionally, men of working social class are 50% more likely to die from CHD than men in the population as a whole.

Approximately one in every five deaths from CVD is attributable to smoking, yet most of these are preventable. To try to tackle this issue, the PCT ensures that high quality of care is consistently available in general practices for patients with and at high risk of CHD. This includes smoking cessation, blood pressure control and cholesterol management.

Circulatory Disease will be discussed in more detail in chapter 3.

Wolverhampton City March 2010 Joint Strategic Needs Assessment Update

Lung Cancer Lung cancer is the second biggest killer of people in Wolverhampton who are aged less than 75, with smoking accounting for 90% of all cases. Estimates suggest that by reducing the lung cancer death rate in the city to national levels, 54 lives would be saved and 531 years of life gained over the next five years in Wolverhampton.

The graph below shows how the mortality due to lung cancer in Wolverhampton has declined by almost 5% in the last 10 years, even though the gap with England and Wales is not closing. In the priority wards, it is even wider than it was 5 years ago (13.5 higher). By contrast, in the non priority wards the rate has decreased to a level which is even lower than the England and Wales average.

Wolverhampton City March 2010 Joint Strategic Needs Assessment Update

Suicide Suicide is one of the top causes of Years of Life Lost (YLL) in the city; in other words, reasons for dying earlier than would be expected, after Coronary Heart Disease (CHD) and infant mortality.

The chart below shows how the suicide rate in Wolverhampton rose between 2000 and 2005 in all areas. This is against the national trend, which shows a steady decline. The most recent figures indicate that the suicide rates in Wolverhampton are starting to decrease; however, the gap with the England and Wales average is still bigger than other similarly deprived areas.

According to the Department of Health, 75 people committed suicide in Wolverhampton between 2005 and 2007. While suicide rates have fallen in older men and women, the majority of suicides now occur in young adult males, being the most common cause of death in men under the age of 35.

Wolverhampton City March 2010 Joint Strategic Needs Assessment Update

Infant Mortality Reducing infant mortality (death of children under 28 days old) is one of the highest public health priorities in Wolverhampton. Deaths in the young make most contribution to the amount of Years of Life Lost (YLL), tackling this issue would have the biggest potential of improving the life expectancy in the city. In Wolverhampton there were 116 infant deaths in 2001-2005, equivalent to nearly 9,000 years of life lost. If the rates of infant deaths could be reduced to match the national average, this would save about 600 life years each year.

There is a strong correlation between deprivation and infant mortality. St Peter’s and Fallings Park wards have the highest rates of infant mortality in the city, as well as being amongst the most deprived. In these wards 10 or more babies per 1,000 live births die before they are 1 year old. National research indicates that babies born to mothers from routine and manual occupations and those from the Indian sub-continent are at greater risk of still birth and infant mortality.

Source: Health Statistics, ONS 2009

Wolverhampton City March 2010 Joint Strategic Needs Assessment Update

Diabetes Diabetes prevalence is 5.1% for England and 6.4% for Wolverhampton. The Doncaster model predicts a prevalence of 15,221 (8%) compared with the 13,474(6.4%) reported prevalence for Wolverhampton. The control chart below shows that nearly half of Wolverhampton GP’s have lower prevalence than we would expect given their practice demography.

Diabetes prevalence by GP expected v. observed prevalence at March 2009 99.8% Hi 99.8% Lo Average Local Practices 95% Hi 95% Lo 80 Hi g 60 Lower than expected her than expected

-20

-40 Observed relativeObserved to expected (%) -60

-80 0 100 200 300 400 500 600 700 800 Expected No. of Patients Source: Doncaster QOF model 2008-09

Coronary Obstructive Pulmonary Disorder (COPD) COPD prevalence is currently 1.5% in Wolverhampton and 1.5% as well for England. Expected prevalence from the Doncaster model is 4,558 (1.8%) compared with an observed prevalence of 3,915 (1.5%). About 20 GP practices have lower prevalence than the model would expect. Overall recorded prevalence is not far from what we would expect using the Doncaster model.

COPD prevalence by GP expected v. observed prevalence at March 2009 99.8% Hi 99.8% Lo Average Local Practices 95% Hi 95% Lo Hi

100 g e hnepce Lower than expected her than expected

-25

-50

-75 Observed relative to expected (%) -100 0 50 100 150 200 250 Expected No. of Patients

Source: Doncaster QOF model 2008-09

Wolverhampton City March 2010 Joint Strategic Needs Assessment Update

Unintentional Deaths Wolverhampton has seen a dramatic fall in the number of people killed or seriously injured (KSI) in road traffic accidents (RTA’s). Since 1990 the number of people KSI in a RTA has more than halved. There has also been a halving in the number of children KSI in RTA’s; however there was an increase during 2007 and 2008.

People killed or seriously injured on the roads in Wolverhampton 1990 to 2008

Source: West Midlands Accident Review, Mott MacDonald

Wolverhampton is already ahead of its targets for reducing KSI’s from the 1994-1998 baseline by 40% (50% in children) by 2010. From 1998 to 2008 the biggest reductions in accidents has been amongst pedestrians (44% reduction), pedal cyclists (50% reduction), goods vehicles (50% reduction) and the car/taxi group (37% reduction). Reductions in accidents have been seen across all groups of road users except for P2W which includes motorbikes and other two wheeled powered vehicles. Young drivers under 30 continue to be a target for further improvement of road safety.

Number of accident emergency admissions for children aged under 15 in Wolverhampton from April 2003 to March 2009

40 Numbers 30

0 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 10 11 12 10 11 12 10 11 12 10 11 12 10 11 12 10 11 12 2004 2005 2006 2007 2008 2009 Time

Source: SUS hospital admissions data

Wolverhampton City March 2010 Joint Strategic Needs Assessment Update

This figure shows the number of accidents emergency admissions in children aged under 15 over a six year period. The underlying trend is fairly stable over the last 6 years with only a slight hint of a downwards trend from 2007 onwards. Accident admissions for children are strongly influenced by seasonal variation, with the highest numbers of admissions being over the summer period.

Lifestyle/Risk Factors

Child obesity National and local obesity rates are a major concern, particularly the impact this issue may have on future health services for several conditions like diabetes, CHD and bowel and breast cancer. Projections suggest that by 2025, 47% of men and 36% of women in the UK will be obese.

In Wolverhampton, childhood obesity is of particular concern. Given this, over the past two years, height and weight data of pupils has been collected at Reception (4 to 5 years of age) and Year 6 pupils (10 to 11 year olds). The results for 2007-08 show that obesity in the city is higher than the national average for these groups, with the gap between the national figure being biggest for those in Year 6. The biggest increases were found amongst Asian and mixed ethnic groups.

The maps below identify the rates of pupils classed as obese across the city, showing how this problem is more prevalent in priority wards, even though high percentages can also be found in the more affluent areas. A positive note is that the rates have decreased slightly from the 2006-7 figures.

Wolverhampton City March 2010 Joint Strategic Needs Assessment Update

Smoking The map below shows the rates of people quitting smoking after 4 weeks. Even though the priority wards show the highest rates of quitters, these wards also have the highest number of smokers and therefore of lung cancer-related deaths.

Wolverhampton City March 2010 Joint Strategic Needs Assessment Update

Under 18 Conception Wolverhampton’s teenage conception rate remains consistently above the England and West Midlands averages. Recent figures show that after a slight decrease between 2002 and 2006, the rates are going up, widening the gap even further.

The teenage conception rate for Wolverhampton in 2007 was 62.9 per 1000 women aged 15 -17, compared with a 41 rate for England as a whole. This is an increase of 1.2 from the previous year.

Babies born to young mothers are at a greater risk of dying in infancy (60% higher mortality rate), identifying a link between rates of teenage pregnancy and infant mortality. Teenage conceptions are more likely to occur among girls affected by poverty and social exclusion. These links can be seen in the map on the right, with the highest rates being in the priority wards (Ettingshall, Bilston East, East Park, and Heath Town).

Conception Rates per 1000 Women aged 15-17 in Wolverhampton (2008)

Source: Health Statistics,ONS 2009

Wolverhampton City March 2010 Joint Strategic Needs Assessment Update

Alcohol Wolverhampton has one of the highest rates of deaths arising from alcohol consumption in the country, and this number is growing. The increase is more pronounced in areas of deprivation, with the five highest rates belonging to priority wards. (see map below)

Alcohol intoxication is strongly associated with suicide, violent crime, domestic violence, accidents and risky sexual behaviour. It also has a major impact on the economy as it is one of the biggest causes for time off work. The key challenge is promoting a sensible drinking culture that reduces violence and improves health.

According to the Department of Health, chronic liver disease including cirrhosis was responsible for 159 deaths in the city between 2005 and 2007. This represents a gap with England of 16.8% for males and 10% for females. Wolverhampton also has significantly higher rates for alcohol-related crime, violence and sexual offences compared to national averages.

Source: Health Statistics, ONS 2009

Wolverhampton City March 2010 Joint Strategic Needs Assessment Update

Hypertension National hypertension prevalence is around 13% of the population in Wolverhampton prevalence is higher at 15%. However the Doncaster model predicts a prevalence of 21% in Wolverhampton. Wolverhampton is not unusual in having a lower recorded to expected prevalence this is also the case across the country. This difference between recorded and predicted prevalence is mainly due to the hidden nature of hypertension, many people will have hypertension without any visible symptoms, thus stressing the importance of regular blood pressure check ups for those who are at risk of developing hypertension.

Hypertension prevalence by GP expected v. observed prevalence at March 2009 99.8% Hi 99.8% Lo Average Local Practices 95% Hi 95% Lo 60 Hi g her than expected

0 Lower thanexpected

-20

-40

-60 Observed relative to expected (%) Observed

-80 0 500 1000 1500 2000 2500 3000 3500 Expected No. of Patients

Source: Doncaster QOF model 2008-09

Wolverhampton City March 2010 Joint Strategic Needs Assessment Update

Services

Mental Health Mental health services are provided by Wolverhampton PCT provider arm, the chart below shows the variation in inpatient admissions by ethnic group. We can see that admissions for the black and mixed rate groups are far higher than those of the population as a whole.

Mental health inpatient admission rates by ethnic group

DSR <75 Wolverhampton Rate

1.4

Mixed 1.2

Black 0.8

0.6 Asian

0.4

0.2 White

0 0 200 400 600 800 1000 1200 Rate per 100,000 population

Source: Mental Health Admissions data April 2006 – March 2009

Learning Difficulties General practices are required to keep a register of patients with learning difficulties under the Quality and Outcomes process. The chart below shows that prevalence in Wolverhampton is lower than expected prevalence using modelled estimates from the Doncaster model. Expected prevalence from the model is at 2% (4,496) compared with an actual prevalence of 0.3% (845). National prevalence as recorded from QOF is 0.4%. It is likely that prevalence of learning difficulties is underestimated by using the QOF data across the whole country.

Learning difficulties prevalence by GP expected v. observed prevalence at March 2009

99.8% Hi 99.8% Lo Average Local Practices 95% Hi 95% Lo

60 Hi g her than ex her than 40

20 p ected 0

-20 than expected Lower

-40

-60

-80 Observed relative to expected (%) to expected relative Observed -100 0 50 100 150 200 250 Expected No. of Patients

Source: Doncaster QOF model 2008-09 33

Wolverhampton City March 2010 Joint Strategic Needs Assessment Update

Maternity The chart below displays the percentage of pregnant women who book with a maternity department by 12 weeks. In Wolverhampton the number of women booking by 12 weeks has improved and is around 80%.

% of expectant mothers booking by 12 weeks in Wolverhampton (by month of delivery not month of booking)

Percentage 65

50 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 10 11 12 10 11 12 10 11 12 10 11 12 2005 2006 2007 2008

Vaccination Uptake Every winter all people aged 65 and over are offered immunisation against seasonal influenza. Below is the uptake for the vaccine by GP for the latest winter period 2008-09. Overall vaccine uptake rates are above the 70% target, however there is wide variation in performance between individual GP’s with some hitting uptake rates of 80% plus whilst several others have rates below 60%.

Flu Vaccination by GP Practice, Winter 2008-09

January Percentage 2008-09 Centre Line LL UL

100.0

90.0

80.0

70.0

60.0 Percentage Uptake

50.0

40.0 GP

Wolverhampton City March 2010 Joint Strategic Needs Assessment Update

MMR uptake is key marker of the overall child vaccination services. Due to negative publicity around the vaccine in recent years vaccine rates fell across the country. Recently vaccine rates have picked up again and currently at 88.4% compared with 84.5% nationally. In Wolverhampton there are 2 GP’s who have lower uptake than we would expect other than this uptake is within control limits.

MMR uptake at 2 years by GP practice in Wolverhampton June 2009 %mmr Mean centre line(CL) Upper control limit(UCL) Lower control limit(LCL)

120.0

110.0

100.0

90.0

80.0

70.0

60.0

50.0 Percentage 40.0

30.0

20.0

10.0

0.0 GP

Wolverhampton City March 2010 Joint Strategic Needs Assessment Update

Chapter 2: Learning Disability

A learning disability (LD) refers one of a variety of disorders that affect the acquisition, retention, understanding, organization or use of information. People with learning disability are intelligent and have abilities to learn despite difficulties in processing information.

The Diagnostic & Statistical Manual of Mental Disorders defines a LD as an Intellectual impairment (IQ of approximately 70 or below), social or adaptive dysfunction and early onset (before 18 years old).

Valuing People defines LD as a significantly reduced ability to understand new or complex information and to learn new skills (impaired intelligence), with a reduced ability to cope independently (impaired social functioning) which started before adulthood, with a lasting effect on development

Figures suggest that 1.5 million people in the United Kingdom have a LD (Mencap, 2008). Causes include complications before, during or after birth or genetics (Fragile X syndrome and Down’s syndrome). A learning disability may also be associated with other problems such as cerebral palsy, epilepsy, autism or Aspergers syndrome. People with LD experience a variety of health inequalities compared with the general population with a national study showing mortality rates are three times higher in this population than in the general population. A number of ongoing projects are examining the health and social service provision for people with LD in Wolverhampton.

Demographics Predictions based on the population of Wolverhampton and national data on prevalence of LD suggest we would expect 4000-6000 people with learning disabilities in the city, depending on the source used. This includes approximately 900-1000 people with moderate to severe LD [Table 1].

Wolverhampton City March 2010 Joint Strategic Needs Assessment Update

Wolverhampton LD services provide for approximately 900 adults with moderate to severe LD of whom 90% will require some form of support for most of their lives (sectorial review of learning disabilities, supporting people commissioning board). If we take the predictions from PANSI and POPPI, the Department of Health tool, as our reference, this suggests we are identifying and providing services for the majority of people with moderate-severe learning disabilities in the city. However, there are currently just 845 people on the Wolverhampton LD register. This should include those with mild to severe LD, so this suggests that not all people with LD are being identified in GP surgeries.

The number of people with LD is expected to increase over the next decade. Figure 1 shows projections for the total number of people with LD in the city up until 2025 [Figure 1]. This demonstrates that the modest rise in numbers is due to an increase in the older population with LD. Figure 2 shows projections for the numbers of people with moderate to severe LD in Wolverhampton [Figure 2]. Again total figures increase modestly and this is due to an increase in the over 65s.

Although the total numbers and those with moderate to severe LD are predicted to increase over time, the number of people with severe LD in the 18-64 year group, estimated to be currently just over 200, is predicted to remain approximately the same over the next 15 years [Figure 3]. Prevalence of Down’s syndrome, as well as the number of people with a LD

Wolverhampton City March 2010 Joint Strategic Needs Assessment Update displaying challenging behaviour, are predicted to remain stable over the next 15 years while the numbers with ASD are set to decrease [Figure 4]. We currently expect around 90 to have Down’s syndrome, 1500 to have an Autism Spectrum Disorder (of which 55% will have a LD) and approximately 35 to have a LD and challenging behaviour (PANSI, POPPI).

An audit of children aged 13-18, attending the five specialist needs schools within Wolverhampton highlighted that the majority of these children reside in the areas identified by the Index of Multiple Deprivation 2004 as being some of the most highly deprived areas in the city [Figure 5]. This data will include those whose disability is purely physical, as well as those with LD. It also excludes children who may be attending mainstream schools. However, it gives some indication that the burden of LD is unevenly spread around Wolverhampton with more occurring in deprived areas.

Wolverhampton City March 2010 Joint Strategic Needs Assessment Update

Health It is well established that people with LD experience significant health inequalities compared with the general population, including higher rates of obesity, coronary heart disease, and mental health difficulties (e.g. Treat me right! Mencap, 2004; Equal Treatment: Closing the Gap, Disability Rights Commission, 2006). Tyrer, Smith and McGrother (2007) performed a UK population-based study to measure the extent of excess mortality in people with LD compared with the general population. Both all-cause and disease-specific mortality were around three times higher in the LD population than in the general population. This varied considerably with age. The largest differences were observed in people in their twenties, where all-cause mortality was almost 9 times higher in men and more than 17 times higher in women. This suggests the health status of people with LD in the UK requires attention.

Locally, a strategic health facilitation post has been created and appointed to, which supports the implementation of a Local Enhanced Service within GP practices and the development of health actions plans. The aim of this enhanced service is to proactively identify and treat the physical and mental health needs of adults with a learning disability, through an annual health check. This will reduce inequalities in health service access, meet government objectives to improve health outcomes through increased participation in health promotion activities and health surveillance activities to ensure that people with LD live healthier lives. It will encourage an integrated approach to service delivery between GP practices, the specialist learning disability teams, carers and people with a LD (LES paperwork). Other current service development work includes an early onset dementia project, a health promotion project, access to dental services research project and bowel screening project (Valuing People Now 6th October 2009).

Obesity Obesity in people with LD is common. (Bhaumik, Watson, et al). Causes may be medical e.g.: some LD are the result of syndromes which also cause weight gain and many LD are associated with low basal metabolic rate, hypotonia and hyperthyroidism. Other reasons may include limited understanding about health risks, limited opportunities to gain appropriate knowledge, reliance on ready-meals, low levels of physical activity and possibly

Wolverhampton City March 2010 Joint Strategic Needs Assessment Update the use of food as an emotional tool. In addition LD may exist alongside lower income with associated increased risk for obesity.

An audit of GP notes found that GPs report obesity for 39% of those on the learning disability register but only 13% of the general population.

An audit of Body Mass Index across the three day centres for adults with learning disabilities in Wolverhampton (n = 132) revealed that 70% of men and 79% of women were overweight, with 36.9% of these men and 62.5% of women being obese. This means 74% were overweight and 46% were in the clinically obese range overall. This compares unfavourably with rates for the general population where 46% of men and 32% of women in England are overweight and 17% of men and 21% of women are obese (Department of Health) and confirms that obesity in people with LD is a problem in Wolverhampton [Figure 6].

Following this audit the healthy lifestyles project has been developed by a multi-disciplinary steering group comprising professionals from psychology, community nursing, and the day centre staff teams. This 12 month pilot intervention study aims to help and encourage people with learning disabilities to making healthier choices. This will include guidance and support in setting personally valued goals in the areas of diet, physical exercise and leisure activities.

The interim findings from this study demonstrate that a multi-disciplinary approach has ensured the success of the participant’s weight loss and maintenance of that weight loss. Participants have been in the program for 3 months and 56% (n=15) have lost weight with an average weight loss of 2kg (4.5lb) and 5.5kg being the highest reported weight loss. They have also demonstrated an increase in knowledge and awareness of making healthier lifestyle choices “I now know which foods are healthy and can ask the staff to support me to cook healthier meals”. Even where participants have not lost any weight, many have reported benefits “I like being in the group, especially using the Wii Fit”.

This Healthy Lifestyle project has also linked up with other health promotion projects that are happening in Wolverhampton such as Skills for Life healthy lifestyles project and the ‘Flourish2BU’ project (funded by Wolverhampton PCT and Wolverhampton City Council), which aims at helping disabled people to get more fit and active (Healthy Lifestyles Draft).

Pregnancy In 2005, Wolverhampton had an under 18 conception rate of 62.4 per 1000 females aged 15-17, which is 51% higher than the England average of 41.3 per 1000 (Office of National 40

Wolverhampton City March 2010 Joint Strategic Needs Assessment Update

Statistics). Wolverhampton has the highest rates of teenage conceptions when compared to neighbouring areas in the West Midlands and has the eighteenth highest rate of teenage conception in the country (Wolverhampton Partnership, 2007).

Data surrounding the prevalence of teenage pregnancy in girls with LD is limited and often restricted to specialist services. Much of the data available is based on estimates or population studies. According to Connexions Black Country approximately 28% of teenage mothers in Wolverhampton have some form of a LD. Data collected by the PCT from a specialist school in Wolverhampton (Westcroft) for pupils aged 4-16 with a range of moderate LD suggest that approximately 40% of their ex-pupils become teenage mothers within 18 months of leaving. (Heer, 2008 Journal of Health and Social Care Improvement).

There are a number of risk factors associated with teenage pregnancy in youth with disabilities which include a lack of sexual knowledge/skills, low expectations for post school outcomes, poor social skills and susceptibility to sexual abuse. Often teenagers learn about sex and relationships via their education, school and their peers. However teenagers with LD have limited opportunities for social interaction with peers, sex education taught in schools often fails to cater for the cognitive needs of children with learning disabilities. Furthermore parents can find it difficult to support the sexuality of children with LD (Heer, 2008).

Asthma Blackman and Gurka (2007) examined the prevalence of developmental and behavioural co- morbidities of asthma. Associations were examined between asthma and rates of developmental and behavioural problems. Children with asthma have higher rates of attention-deficit/hyperactivity disorder; diagnoses of depression, behavioural disorders, learning disabilities; and missed school days (all p < .0001) after adjustment for potential confounding effects of age, gender, race, income, and parent education on outcomes. More severe asthma correlates with higher the rates of these problems.

An audit of GP patient records found 13.4% of patients on the Wolverhampon LD register had asthma. This is compared to 5.84% of people without a LD. A significant difference between these figures suggests there are higher rates of asthma in the LD population of Wolverhampton.

Mental Health The literature suggests the prevalence of mental health problems is high in adults of all ages with learning disabilities (Torr and David, 2007). People with learning disabilities are more likely to experience social exclusion or isolation, as there are higher rates of unemployment and acquaintance may not extend beyond close family and care-givers. An inability to think through problems can make worries into more stressful and anxiety provoking crises.

In an audit of GP notes for patients on the Wolverhampton LD register, 8% of the sample were found to suffer Schizophrenia, 13% had other mental health problems like bipolar affective disorder, obsessive compulsive disorder, generalized anxiety, phobia or psychosis and 7% self-harmed. 16% suffered from depression. These figures were considered significantly higher than reported in the non-LD population (GP Audit). This confirms that the mental health of our LD population needs attention.

Dementia Dementia is common in Down’s Syndrome patients, and the age of onset is usually younger than in the non-Down’s syndrome populations. Autopsy and neuroimaging studies (Deb et al, 1992) show an almost universal presence of Alzheimer's neuropathology among adults with Down's syndrome over the age of 45 years.

Wolverhampton City March 2010 Joint Strategic Needs Assessment Update

Although data from an audit of GP notes did not suggest levels of dementia were higher in the population on the Wolverhampton LD register than in the general population, this data was not age standardised. This makes it likely that a lower life expectancy of people with LD may obscure a true difference.

Although nationwide the number of Down’s syndrome patients with dementia is set to increase, PANSI predicts that there are approximately 7 Down's syndrome patients with dementia in Wolverhampton and this number is not set to change over time [Figure 7].

Mortality/Hospital Admissions The findings surrounding obesity indicate a large number of LD service users have a significantly increased risk of experiencing type 2 diabetes, heart disease and cancer, and have a reduced life expectancy. Obesity, epilepsy, mental illness, diabetes and asthma were all highlighted after an audit of GP notes for patients on the LD register, as being more significant problems for the LD population than for the general population.

There were 42 hospital admissions in the last 5 years with a LD read-code attached. These almost certainly do not include all admissions of patients with a LD, as this may not have been coded reliably in the notes. 11 of these hospital admissions were related to epilepsy, 9 were related to mental health problems (schizoaffective disorder, bipolar affective disorder, somatoform disorder, and schizophrenia), 4 were related to diabetes and 3 to asthma [Figure 8]. This data supports the conclusions from other health research in highlighting epilepsy, mental illness, diabetes and asthma as problems for the population with a LD.

Wolverhampton City March 2010 Joint Strategic Needs Assessment Update

There are 13 deaths known to LD services over the last 18 months. These include 5 cancer deaths (3 abdominal cancers, 1 bone cancer, 1 oesophageal), 3 deaths from complications of dementia and 5 from respiratory illness including recurrent chest infections. 6 of these patients died in hospital, 4 in nursing homes and 1 died at home. There is no information about where the remaining 2 deaths occurred (Diane Webb personal communication).

SOCIAL CARE

Employment The Black Country Labour Market Information State of the region report in October 2009 report that there is an employment rate of 64.8% in Wolverhampton and the employment rate in Wolverhampton for people with LD is just 29.4% [Figure 9].

Figures from Connexions Black Country: analysis of October 2007 Active NEET Groups show that there were 636 young people not in education or training of which almost a quarter (147) had some form of LD during 2007.

Wolverhampton City March 2010 Joint Strategic Needs Assessment Update

In an audit of children aged between 13 and 18 attending special needs schools in Wolverhampton (and therefore including those with physical disabilities only as well as those with LD), the majority (87%) were indicated to be planning to pursue a place at college after finishing school. 51% of children were identified as possibly going into paid or voluntary work in the future, with support (Thomas, Carter, Thomas).

The Wolverhampton City Council, Employment Pathways Team based at Oxley Moor House can help people with a LD find out more about the world of work. This might include: • work experience or ‘tasters’

• training courses

• help with travel

• talking about how they can work but still keep their benefits. The team can help people decide what sort of work or training they would like to do and check that a prospective job site is suitable. The team then work with them while they are learning how to do the job, meeting regularly to talk about how they are doing.

The team currently provide support for 114 people, of whom 9 are over 65 years old and 37 are in paid employment. Figure 10 shows the type of employment that people supported by this service are in. Figure 11 shows the amount of support required by those with learning disabilities accessing the Employment Pathways services. Band 1 indicates that the person requires none to minimum support; Band 2 requires an annual review; Band 3, a quarterly review; Band 4, monthly support and Band 5 require support weekly.

Wolverhampton City March 2010 Joint Strategic Needs Assessment Update

Locally LD day services are being reconfigured to deliver a wider range and more appropriate activities for people. Albert Road is being developed into an employment academy that will support people either to gain sustainable employment or provide the skills to individuals to move into employment. Stowheath and Oxley are diversifying in the types of activities that they are delivering with more community engagement and educational and training activities. An older people’s service is being developed that will meet the needs of this group more effectively and deliver activities which are more appropriate and meaningful. (Meeting notes: Valuing People Now 6th October 2009)

Housing Supporting People is the programme through which types of support that enable people to live independently are delivered. Much of this support is delivered as ‘floating support’ to people living in their own homes, including both home owners and renters. It is the intention that floating support becomes the primary model for delivery, in line with the government’s transformation programme to make a shift to ‘personalisation’ and individual budgets. However, in some cases it is more appropriate to provide the support within specialized accommodation; either because of the particular support needs of the client or because their primary need is to have somewhere to live. The programme identifies needs and assesses certain accommodation requirements for people with a range of support needs. As of November 2007, Wolverhampton Council and housing partners have provided accommodation-based support to 62 people with LD. (Wolverhampton Housing Futures Plan).

Locally, the LD service has maintained a single referral forum (SRF) which co-ordinates available housing and matches this to identified individuals who are seeking housing. The SRF consists of social care, health care, and housing professionals to identify linkages between housing and people with learning disabilities. In addition two new supported housing schemes will open in 2009, one for adults with autism and one to support a re- provision project. Further work needs to be undertaken to develop further supported housing options and to promote supported living as a real alternative to residential care (Valuing People Now, 6th October 2009).

Wolverhampton City March 2010 Joint Strategic Needs Assessment Update

The vast majority of adults with a LD live with and are cared for by their families. In Wolverhampton, approximately 200 people live in residential care and about 100 people live in supported living arrangements. There are approximately 200 people living with elderly or frail carers and about 60 people are placed out of the city (sectorial review of learning disabilities, supporting people commissioning board).

PANSI predicts the number of people with moderate or severe learning disabilities living with a parent to be over 300. This is predicted to fall very slightly over time until 2025, this is mainly as a result of a fall in the number of 18-25 year olds living with their parents. However, more people in other age groups will be living with their parents, including (importantly) the eldest age group, who may be living with increasingly frail and elderly parents [Figure 12].

Wolverhampton City Council formally commissioned DCA in February 2007 to carry out a City-wide Local Housing Needs Study. A postal questionnaire to 12,420 households in 20 wards across the City was undertaken between 15th March 2007 and 11th April 2007, and face to face interviews with 500 households across 13 wards. In total 2,620 responses were received giving a statistical confidence at 95% level of ± 1.95%.

28.8% of households in the area contain somebody with a disability, suggesting 28,169 households in Wolverhampton were affected in some way. 8.5% of individuals with a disability responding had a LD and 14.6% of households responding had someone with a LD.

20 (9%) children currently studying at one of the 5 special schools in Wolverhampton were identified as potentially requiring future housing services (Thomas, Carter Thomas) [Figure 13]. This includes 6 who will potentially need a care home place. PANSI also has projections for people aged 18-64 with a learning disability helped to live at home and for people aged 18-64 with a learning disability in residential or nursing care provided by council’s with social 46

Wolverhampton City March 2010 Joint Strategic Needs Assessment Update services responsibilities these numbers stay pretty constant until 2025 suggesting no huge increase in need will occur in the next few years.

Figure 13

With the introduction of the revised Fair Access Criteria it is anticipated that the number of people eligible for services provided as a result of a community care assessment will be reduced by between 30-50 people during the next year (sectorial review of learning disabilities, supporting people commissioning board).

The sycamores block purchasing expenditure has doubled from 08/09 to 09/10 due to the purchase of the extra respite bed to meet demand for the service.

Transitions An evaluation of the health and social care needs of children with a disability who are approaching the transition between child and adult services was carried out in the five special needs schools within Wolverhampton. This was done using an audit tool that was completed for each pupil aged 13-18 and resident in Wolverhampton. This information includes data on those with a physical disability only, as well as those with LD. However the majority of children at the schools have a LD as their primary need [Figure 14]. Children with LD attending mainstream schools are not included in this data set.

Figure 14

The results indicate that a quarter of all children included in the audit require specialist equipment and aids. This gives some idea of how many young people will need these types of resources to be provided by adult services in the near future. It is not only the equipment itself which needs to be provided, but that staff working with these young people also need to be trained in how to use and maintain the equipment. This has further implications in terms of resources. Almost half (44%) of the children included in the audit require transport. The need for mobility aids was identified as being higher for older children.

Wolverhampton City March 2010 Joint Strategic Needs Assessment Update

114 (49%) children were highlighted as requiring assistance with social care. 123 (53%) children were highlighted as requiring assistance with personal care. Only 18% were said to be receiving assistance with social care. It may be that families are receiving this input but are not recognising it, perhaps because it is insufficient.

15% of children were said to be receiving respite. 15 of the 35 children receiving respite are receiving ‘in-house’ respite at Penn Hall School. However, there is no information on the intensity of this respite which could range from one night a month, to one weekend a fortnight.

2% of children in the audit were identified as being subject to a child protection plan. These young people may require further input around vulnerability from adult services.

Schools were identified as providing the majority of transition co-ordination. Schools are an important part of the transition plan but it is essential that health and social care needs are also taken into consideration (Thomas, Carter, Thomas et al).

Experience 11 complaints were received concerning services for people with LD in 2005-2006. This compares with 10 (IPF) and 16 (England average). 17 complaints were received concerning services for people with LD in 2006-2007. This compares with 12 (IPF) and 18 (England average).

The amount of money spent by Wolverhampton Council on advocacy services for people with LD has increased year on year [Table 2]. Through investment in services with Mencap, Issues Based advocacy and Empowerment Service (Our Shout) people have developed their skills to speak for themselves and influence future services. Empowerment Service enables people to attend and co-chair the Partnership Board. Empowerment Service was commissioned to deliver events in LD week, raising the profile in the city. Empowerment Service makes information accessible for external agencies e.g. Care and Repair UK.

Wolverhampton City March 2010 Joint Strategic Needs Assessment Update

Six self advocacy services run by the Voluntary Sector Council are influencing changes within day services, especially the transport service and new day service models. People with LD were involved in agreeing priorities for refreshed LD Housing Strategy and consultation on Valuing People Now and the future of Lea Castle.

Wolverhampton City March 2010 Joint Strategic Needs Assessment Update

Chapter 3: Cardiovascular Disease

Introduction There were over 2,500 deaths in under 75s in Wolverhampton between 2006-2008. Just over a quarter of these were related to Cardiovascular Disease (CVD) (the majority either Coronary Heart Disease (CHD) or Stroke) – leading to over 8,000 lost life years.

Age standardised mortality for circulatory disease in people aged under 75 in Wolverhampton

Wolverhampton West Midlands Centres with Industry England & Wales Linear (Wolverhampton)

200

180

160

140

120

100 Rate per 100,000 Rate 80

0 1994- 1995- 1996- 1997- 1998- 1999- 2000- 2001- 2002- 2003- 2004- 2005- 2006- 2007- 2008- 2009- 2010- 2011- 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 Year

These trend lines show that age standardised CVD mortality in under 75s is reducing in Wolverhampton. However Wolverhampton rates are still higher than England and Wales, and the West Midlands but lower than comparable areas (i.e. Centres of Industry).

Risk factors The non-modifiable risk factors for CVD include age, gender, ethnicity and family history.

Age and Gender Wolverhampton’s age and gender profile broadly mirrors the age and gender structure of the UK. The older population continues to increase with a rise of 200 people in 2008. It is the older age group that is at greatest risk of CVD.

Ethnicity The 2007 Mid Year Estimates (MYE) by ethnic group show that approximately 27% of the Wolverhampton population in the city is of Black and Minority Ethnic origin (BME). This compares to national proportions of 16.4%. This shows an increase in the BME population in Wolverhampton of 2.3% since the last census. 14.9% of the Wolverhampton population is Asian, the ethnic group who is at highest risk of CVD.

Family History Data to describe family history is difficult to access. However, the fact that CVD mortality is higher in Wolverhampton that for England and Wales would suggest that the proportion of people with a family history of CVD will also be higher.

The modifiable risk factors for CVD include smoking, diet, physical activity and alcohol consumption. The modifiable risk factors are all correlated to deprivation. 50

Wolverhampton City March 2010 Joint Strategic Needs Assessment Update

Smoking 81% of patients aged over 16 years on GP registers in Wolverhampton have their smoking status recorded. Of these 17.1% are smokers. Modelled estimates from 2003-2005 suggest smoking prevalence in Wolverhampton is 24.7%.

Diet There is no data about the population’s diet either from GP registers or local surveys Modelled estimates from 2003-2005 suggest that 23.0% of adults in Wolverhampton eat five or more portions of fruit and vegetables daily.

Physical Activity The annual Sport England “Active People” survey suggests low levels of physical activity undertaken by adults which has not increased recently. Data from APHO (2005-2006) suggests that 8.8% of adults in Wolverhampton participate in moderate physical activity an average of 5 times per week. This compares to 11.6% nationally.

Alcohol There is no data about the population’s alcohol consumption either from GP registers or local surveys. Modelled estimates from 2003-2005 suggest that 17.9% of adults in Wolverhampton binge drink. Wolverhampton has one of the highest rates of deaths arising from alcohol consumption in the country and this number is growing. This increase is more pronounced in areas of deprivation.

Together these risk factors can lead to high blood pressure, high cholesterol, impaired glucose and obesity.

High Blood Pressure 15.7% of patients on GP registers in Wolverhampton are diagnosed with Hypertension. 80% of these have had their BP recorded in the last 9 months. Of these: 63.5% have their BP controlled. 23.8% without drugs and 76.2% with one or more drug. 36.5% do not have their BP controlled. 26.8% of these have not had any drug in the last 7 months. A further 3.9% of patients have raised blood pressure or are on medication which suggest they likely to be hypertensive.

High Cholesterol 39% of patients on GP registers have had their Total Cholesterol measured in the last 5 years. 32.3% have a Total Cholesterol of over 5 mmol and are not on a statin 27.9% are on a statin and now have a Total Cholesterol of under 5mmol. 11.5% are on a statin but still have a Total Cholesterol of over 5mmol. 28.3% have a Total Cholesterol of under 5mmol and are not on a statin.

Impaired Glucose 5.5% of patients on the GP register have a diagnosis of Diabetes.

Obesity 40% of patients on GP registers aged over 16 years in Wolverhampton have their BMI recorded. Of these 32% have a BMI of over 30. Modelled estimates from 2003-2005 suggest that 28.6% of adults in Wolverhampton are obese.

There is a lot of evidence about how individual risk factors affect the population’s risk of CVD and in addition there are a number of validated risk calculators that compute an individuals 51

Wolverhampton City March 2010 Joint Strategic Needs Assessment Update risk from multiple risk factors. However, there is less understanding about how multiple risk factors affect the population’s risk of CVD. With the objective of understanding how the prevalence of risk factors in Wolverhampton described above will impact on Wolverhampton’s CVD events in the future a model was built to combine the evidence from individual risk factors and the individual risk calculator.

The model predicts risk of cardiovascular events. Local data is used to input population age, sex, ethnicity, deprivation and prevalence of smoking. National data was used to distribute of BMI and systolic blood pressure. The output of expected cardiovascular events over a ten year period is then calculated according to the Qrisk2 algorithm. The initial input into the model use census data for the age, sex and ethnicity. The last census was in 2001 and the QRisk2 algorithm predicts risk of CVD event over the next 10 years. Therefore the output was number of CVD events between 2001 and 2011. For the 2001 Wolverhampton population the model predicted 13443 events compared to 13952 events in the Wolverhampton GP responsible population in the last 5 years times 2. Therefore the model underestimated events by 509.

The model can now be used to explore the effect of altering risk factor levels and as a result the impact of introducing new services. This will be discussed further in the services section.

Burden of ill-health People who have previously survived a CVD event are at greatest risk of another CVD event.

Wolverhampton City March 2010 Joint Strategic Needs Assessment Update

10.2% of patients on GP registers have a diagnosis of CVD or related Condition (including CHD, Stroke, TIA, PVD, Heart Failure, Diabetes and Chronic Kidney Disease stage 5). 3.9% have a diagnosis of CHD 1.1% have a diagnosis of Stroke 0.9% have a diagnosis of TIA 1.1% have a diagnosis of PVD 1.0% have a diagnosis of Heart Failure 5.5% have a diagnosis of Diabetes 0.1% have a diagnosis of CKD stage 5.

Of patient with a diagnosis of CVD or related condition: 14.5% are recorded as smokers and 86.2% of these have been offered smoking cessation advice in the last 15 months. 41.9% have a BMI of over 30 and 76.3% have a BMI of over 25. 37.4% of these have been offered diet advice in the last 15 months 19.8% had had their physical activity recorded in the last 15 months. 79.2% are not undertaking moderate exercise. 78.7% had their BP recorded. 69% had their BP under control. 73.3% had their cholesterol recorded. 76.8% had their cholesterol under control.

Deprivation There is variation in CVD mortality across the three localities in Wolverhampton – with the South East having the highest age standardised mortality rates. These differences are not significant.

However, when mortality is considered at the ward level there are three wards with particularly high rates and none of these are in the South East. They are St. Peters and Graisely ward in the South West and Bushbury North and Low Hill in the North East. When mortality is considered at the locality level the need in these areas is hidden because of the lower mortality in neighbouring ward.

Wolverhampton City March 2010 Joint Strategic Needs Assessment Update

The figure below shows the difference between age standardised circulatory disease mortality in under 75s between the most people living in area in the most deprived quintile nationally and people living in the other quintiles.’

Age standardised circulatory disease mortality for people aged under 75 2006-2008

140

120

100

60 rate per 100,000 population 40

0 0-19.9 20.0-39.9 40.0-59.9 60.0-79.9 80.0-100 Deprivation quintile (0-19.9 = most deprived, 80.0-100 = least deprived)

Health Services In 2009-2010 a number of programmes around lifestyle risk management and CVD prevention have been developed

Smoking Cessation There is an established Stop Smoking Service in Wolverhampton. The service supported 1752 4-week quitters in 2008-2009.

Adult Weight Management A new adult weight management service started in June 2009. By October 2009, 730 interventions had been completed. At least 88 of these have been referred twice meaning they have lost at least 5% of their body weight.

Physical Activity There is an established Walking for Health service in Wolverhampton. Over the last year the service has supported 1393 people to have undertaken a led health walk with over 20% doing 25 or more walks. 50% of the walkers were from BME groups and 50% were from deprived areas.

Significant investment has been made in new physical activity equipment across the city including: 10 new young peoples gyms; 2 older peoples gyms; 2 gym upgrades; 1 gym in GP practice; 12 outdoor gyms;

Portable music systems for schools, children’s centres, neighbourhood management teams and community centres; and BMX track.

Wolverhampton City March 2010 Joint Strategic Needs Assessment Update

Alcohol This is the second year of the Wolverhampton Keep it Safe campaign. This is a harm reduction campaign which aims to reduce health, social and crime problems caused by excessive alcohol consumption. This is a 10 night campaign over Christmas and New Year.

An Alcohol Service to provide Motivational Enhancement Therapy to people with dependent drinking habits on targeted wards at the Royal Wolverhampton Hospital Trust is due to start early next year.

Plans to develop a community service offering treatment and prevention will be developed in 2010.

Health Trainers A new Health Trainer Service is due to start early in 2010. They will proved an intermediary service between primary care clinicians and specialist lifestyle risk management services, managing clients who are normally regarded as hard to reach, unmotivated, and/or non- compliant.

Links to mental health services Referral routes to Wolverhampton Healthy Minds (Talking Therapies) from all parts of the CVD pathway are under developments.

Health Checks – Primary Prevention Health Checks are offered to people with three of more risk factors through General Practice. 660 checks were provided in the first 4 months. This service will continue in 2010.

2250 Health Checks will be provided in 2010 targeting people with mental health problems, people with learning disabilities, people from BME groups and men from disadvantaged area. Health Checks will identify an individual’s risk of coronary heart disease, stroke, diabetes and kidney disease, to communicate this in a way that the individual understands, and for that risk to be managed by appropriate follow-up, including being recalled every five years for reassessment.

Secondary Prevention A project is underway to improve the management of patients who have had a CVD event. Prescribing pharmacists are supporting practices to improve their patient’s management through secondary prevention clinics.

Since this project started in September nearly 20% more patients are being managed optimally in four or more out of six areas.

Impact of service redesign The model discussed in the risk factor section has been used to consider the impact of introducing Health Checks.

Research from Sheffield considers the likely impact on risk factors due to Health Checks.1 It gives a best case scenario, as well as less optimistic targets from the literature.

1 Whitfield M, Gillett M, Holmes N and Ogden E (2006) Predicting the impact of population level risk reduction in Cardio-vascular disease and Stroke on acute hospital admission rates over a 5 year period – a pilot study. Public Health. 55

Wolverhampton City March 2010 Joint Strategic Needs Assessment Update

Risk Factor Optimistic Target Realistic Target Mean BMI -5% -2% Smoking -13% -10% Total cholesterol -6% -4% HDL +6% +4% SBP -5% -3% CKD prevalence -5% -3% Cholesterol/HDL -7.7% -1.3%

The changes in risk factors outlined in these two possible scenarios were fed into the model and this provided an outcome in terms of CVD events: For the Realistic targets of health checks the model predicted: 11885 CVD events (ie: 1535 events averted). For the Optimistic targets of health checks the model predicted: 11235 CVD events (ie: 2186 events averted).

It is also possible to use the model to consider the impact of targeting high risk populations. The table below shows the impact if just the population living in the most deprived quintile were targeted with health checks.

Most deprived quintile Other quintiles Number of people age 35- 48181 59108 74 Predicted number (rate) of 8783 (182 per 1000 6780 (115 per 1000 CVD events without population) population) Health Checks Predicted number (rate) of 7370 (153 per 1000 CVD events with Health population). Checks - optimistic

This demonstrates the targeting only the most deprived quintile could nearly halve the gap in CVD events rate from 67 to 38 per 1000 population.

Wolverhampton City March 2010 Joint Strategic Needs Assessment Update

Chapter 4 - Mental Health

Determinants of Mental Illness The association between rates of mental illness and certain population characteristics notably ethnicity, unemployment, poverty and deprivation is well established. In addition people with physical health problems are also shown to be at increased risk of mental health problems.

Ethnicity Around a quarter of Wolverhampton’s population are of BME origin. The population is projected to grow only slightly, however the composition is projected to change with an increase in BME groups and rise in older people. This will have implications for future configurations of mental health services in order to meet the needs of the changing population.

Unemployment The city has below average employment and wages are below the national average. JSA claimants are above the national average. Further, mental health referrals to social care are high. Generally, disadvantaged people are more likely to suffer mental health disorders, so areas of social deprivation are at increased risk/ need of mental health services. 8 priority wards have been identified in Wolverhampton and these need to be targeted to ensure better outcomes are achieved across the city.

Poverty and Deprivation Life expectancy in Wolverhampton is not improving. There is high deprivation in the city and many areas are among the most deprived fifth areas of England The figure below illustrates the ward level prevalence of more severe types of mental ill health across Wolverhampton. Areas of higher prevalence are consistent with wards with greater deprivation.

Figure 1 MINI index of need – all mental health causes (ages 16-59)

Wolverhampton City March 2010 Joint Strategic Needs Assessment Update

The Mental Illness Needs Index 2000 (MINI) was developed by the University of Durham as a “ready reckoner” to estimate ward level prevalence of more severe types of mental ill health using national data. It uses 1998 ward level population estimates and considers ward level deprivation.

Physical Health Problems The percentage of people with a long term limiting illness in Wolverhampton (21%) is slightly high compared to West Midlands (19%) and also above the England average (18%). People with long-term physical conditions are at increased risk of developing depression (Patton, 2001). Depression may be a cause or consequence of physical illness and may exacerbate severity of symptom and increase use and cost of services.23.

Medically unexplained physical symptoms (MUPS) These are physical symptoms that have no currently known physical pathological cause. MUPS are common, accounting for as many as one in five new consultations in primary care.4 It is estimated that this rises to an average of 52% in secondary care5. Evidence suggests that as many as 70% of people with MUPS also suffer from depression and anxiety disorders. The estimated costs of medically unexplained symptoms in secondary care for Wolverhampton. across specialties is over £7 million.6

Prevalence of Mental Illness

Severe and Enduring Stevens and Raftery (2007) estimate the prevalence of psychosis in the population to be (0.4%). The city’s QOF data of psychosis registers reports the prevalence to be higher than this at (0.7%). However this is consistent with national QOF registers.

QOF indicators for mental health were slightly below the national achievement levels (See table below).

Mental Health QOF Indicators 2007/08 Indicator Wolverhampton England MH4; Lithium who have had creatinine and TSH 95.3% 97.1% checked MH5; Lithium with recorded levels in correct range 81% 91.2% MH6; % of patients with care plan 80% 83.9% MH7; % or patients with psychoses who are followed 85.5% 88.8% up after DNA MH8; Register of people with psychoses 0.7% 0.7% MH9; % of patients with psychoses with a review in 91% 92.6% 15 months Source: ic.nhs.co.uk

2 Katon 2003; Hiller & Fichter 2004; Yates et al 2004 3 Long-term Conditions and Depression: Considerations for Best practice in Practice Based Commissioning, CSIP, 2006 4 Bridges, K.W. and Goldberg, D.P. (1985) Somatic Presentation of DSM-III Psychiatric Disorders in Primary Care. Journal of Psychosomatic Research, 29: 563–9 5 Nimnuan, C., Hotopf, M. and Wessely, S. (2001) Medically unexplained symptoms: an epidemiological study in seven specialities. Journal of Psychosomatic Research, 51: 361–7 6 CSIP Primary Care, Nottingham Medical School tool to identify people with medically unexplained symptoms.

Wolverhampton City March 2010 Joint Strategic Needs Assessment Update

The Mental Illness Needs Index 2000 (MINI) predicted Wolverhampton to have 2 % more severe mental illness than the national average. The level of schizophrenia inpatient admissions matched predictions. However, the admission rate for mood affective disorders was 30% lower than the MINI prediction.

Depression Katon and Schulberg (1992) estimate the prevalence of major depression in people seen in primary care to be between 5-10%. Wolverhampton’s QOF depression registers report a comparable prevalence at 5.5%. This approximates to 14,000 people. However, the equity audit report also reviewed GP Practices by practice size in each locality and found there was wide variation in the assembling of GP depression registers with 1 practice having no patients on the register. This is demonstrated in the figure below. Therefore a potential detection issue may indicate that prevalence estimates are too low.

GP Practice register for depression per 100,000 practice population, March 2009

rate per 100,000 pop Mean centre line(CL) Upper control limit(UCL) Lower control limit(LCL)

18,000 PEACOCK NEPCL SEPCL SWPCL

16,000 WALKER

14,000 BAGARY

BARRY MANDAL MITTAL RAVINDRAN MOHINDROO 12,000 HALL

SAINI

KAINTH MS COWEN LUCKRAFT NOBLE 10,000 WAGSTAFF DE ROSA BUSH

8,000 Rate per 100,000 KRISHAN TAYLOR 6,000 WARIYAR RANGEL SURYANI LAL GRANDHI KANCHAN FOWLER AGRAWAL PAHWA DHILLON TADROS VENKATARAMANAN 4,000 MUDIGONDA CHAKRABARTI RYAN CUTHBERT MAHAY WHITE PASSI 2,000 CURRIE KAINTH P GHOSH

0 13579111315171921232527293133353739414345474951535557 GP Source: QMAS

Low level depression is thought to be more prevalent among Wolverhampton adults since 2.4% of the population (5,615 people) claim incapacity benefit (IB) on the grounds of mental health, which equates to 42% of those claiming the benefit. This is slightly higher than the regional average (39.5%), and the national average (41%).

Patients with a new diagnosis of depression, recorded between the preceding 1st April to 31st March, the percentage of patients who have had an assessment of severity at the outset of treatment using a tool validated for primary care, March 2009

Achieved Percent Calculated Data Mean centre line(CL) Upper control limit(UCL) Lower control limit(LCL)

200 NEPCL SEPCL SWPCL 180

160

140

120 RAVINDRAN 100

Percentage 80 CHRISTOPHER BUSH 60 FOWLER GRANDHI RYAN 40

20 TAHERI CUTHBERT 0 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 GP Source: QMAS

Wolverhampton City March 2010 Joint Strategic Needs Assessment Update

Assessing prescribing of antidepressants as a proportion of the register indicates 4 GP practices were extreme outliers, meaning they prescribed higher than expected for the numbers recorded on their depression register. Patients with a new diagnosis of depression are also required under the new GP contract to have a severity assessment using a validated tool. 17 Practices said 100% of such patients were assessed with a further 9 Practices having lower than required assessments. This is demonstrated in the figure above.

Black ethnic groups were over represented in community services and in patient services. This needs to be examined in more detail.

Dementia Prevalence estimates indicate that there were 2,774 people over 65 with dementia in Wolverhampton in 2001. Population projections for 2011 indicate that the number of people with dementia will have risen over the 10 year period by a further 14% to 3,152.

Suicide In 2006, the average suicide rate in Wolverhampton was 11.6, compared with the national average of 8.3. There is a large discrepancy between different wards in Wolverhampton, which highlights the health inequality present when dealing with Suicide rates (see figure). These are areas of generally higher social deprivation and unemployment which highlights the strong social context of suicide, which cannot be divorced from other determinants like mental health.

Figure 2 Age Standardised Mortality Rates Due To Suicide Wolverhampton Priority Wards Non Priority Wards England & Wales NCHOD West Midlands NCHOD Wolverhampton NCHOD

16.0

14.0

12.0

10.0

8.0

6.0 Rate per 100,000

4.0

2.0

0.0 1994- 1995- 1996- 1997- 1998- 1999- 2000- 2001- 2002- 2003- 2004- 2005- 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Year

An audit of suicides in Wolverhampton between 2004 – 2008 found that 77% were male, the most common age of suicide is 35-44.This is consistent with national trends. Men are more than six times more likely to commit suicide in the younger age group (25-44). 58% of female suicides occur over the age of 55. Men are nearly twice as likely as women to commit suicide in this age group. Ethnicity was poorly recorded (not known in 20% of cases). Of the cases where ethnicity was recorded, suicide falls evenly across the ethnic makeup of the population, i.e. 9% white: 14% Asian: 4% Black and 2% Mixed. However, the 40-44 age group was disproportionally high for non white patients (50%), with most of these being Asian men. Suicide for Asian females in any age category is very low

Wolverhampton City March 2010 Joint Strategic Needs Assessment Update

The report also found that 30% of suicides were not known to be in contact with any primary or secondary services at the time of death: 30% were being managed in primary care, usually for depression which was not assessed with a validated tool; 40% had had some contact with specialist mental health services in the last 12 months of their life.

In order to address Wolverhampton’s suicide rate there is a need for better early identification, assessment and treatment of depression in primary care, using more robust risk assessment tools.

Mental Health Services – Access and Productivity

Community Mental Health Services (CMHS7) Black ethnic groups have the greatest representation in CMHS, followed by Asian groups, and then people with a White ethnic background, demonstrated in the table below. Interestingly, the Count me in Census 2008 indicates that referrals from GPs and community mental health teams were lower than average among some Black and White/Black groups.

Access rates to CMHS by Ethnic groups Ethnic Group Rate per 100,000 CI- CI+ White 518.4 485.5 551.2 Asian 714.5 624.8 804.2 Black 1011.6 823.5 1199.7 Mixed 310.5 174.6 446.4 Other 443.5 89.4 797.5 Total 933.7 895.0 972.5

The health equity audit also looked at where people using the CMHS’s lived and who their GP was. Use of CMHS by patient postcode was in keeping with the socio-demographic picture in Wolverhampton. Analysis of use by GP showed relatively higher use in the North East locality than the South East and lower in the South West.

In-patient The local mental health equity audit reported that black men had a four-fold over use of inpatient services compared to their Asian and White counterparts. The starkest difference was seen in the use of forensic services with a 20 times over-use compared to Asian men and 10 fold greater than White men. A similar pattern was also seen for Black women, with an increased use of all services compared to the other ethnic groups. However the “intensity” was not as great as that for men.

The overrepresentation of Black people in inpatient admissions is consistent with national data, however the ‘Count-me-in’ data suggested an admission rate of 15%, nearly double the 8% rate indicated by the routine audit collection. This would suggest further investigation is necessary to determine the accuracy of Black inpatient admissions, i.e. the locally reported numbers are high, but not as high as the national census would suggest.

Acute bed provision is in line with comparator norms. Overall admission levels and utilisation are in line with that bed provision and comparator norms. Bed utilisation against high priority acute psychotic illness is above comparator norms. There is pressure on length of stay for psychosis related admissions with length of stay outside of comparator norms which is not accounted for by the skewing affect of a few very long lengths of stay. There are an over

7 CMHS comprises the following adult service teams: 2 Crisis Resolution teams, 3 CMHTs, 3 forensic teams, 1 eating disorder team, 1 depot clinic, 1 assertive outreach team, 1 early intervention team; 1 Asian Link Adult 61

Wolverhampton City March 2010 Joint Strategic Needs Assessment Update representation of admissions from the BME community. Acute bed staffing is in line with comparator norms. PICU bed provision is higher than comparator norms

Community resourcing Community Mental Health Team (CMHT) staffing was above cluster average, below national average. CMHT caseloads very high; 75% above cluster average, 50% above national average.

Crisis Resolution and Home Treatment caseload was 38% above cluster average, although below national average, and staffing 22% above the cluster average

Assertive outreach team staffing 25% below national average and caseload 63% below national average. Caseload to staff ratio lowest in cluster and only 50% of national average

Wolverhampton City March 2010 Joint Strategic Needs Assessment Update

Early intervention team caseload is 22% below cluster average and 66% below national average. Early intervention team caseload to staffing ratio lowest in cluster.

This data demonstrates a high number of emergency admissions with a significant degree of complexity. Qualitative evidence suggests crisis assessment and intervention is too slow and earlier engagement opportunities are missed. The consequence is increased demand and increased length of stay. Opportunities for supporting earlier discharge is compromised by lack of capacity and skill/confidence within CMHTs. Staffing and caseloads across community teams support perceptions of pressure and concerns in different parts of the system, from high and static caseloads in the CMHTs, high caseloads in the Crisis team, low caseloads and functioning of the Assertive Outreach Team, and low caseloads in the Early Intervention Team.

Wolverhampton City March 2010 Joint Strategic Needs Assessment Update

Community Mental Health Team A detailed audit reviewed 13% of the caseload of CMHTs, Assertive Outreach Team, Early Intervention Team and Day Services using the Yorkshire Care pathway methodology.

Audit of CMHT Caseload - NAS Sample and number of completed forms Caseload on Per 100k Per 100k NAS Completed day of estimated total pop Sample forms census adult pop Assertive 47 29 18 11 11 (100%) Outreach Team CMHT North 883 1559 984 117 23 (20%) South East CMHT 812 1749 1105 104 30 (29%) South West 1008 1641 1036 127 59 (46%) CMHT Early Intervention 66 40 25 17 13 (76%) Service Brooklands Day 2 Service Not recorded 30 Grand Total 2816 376 168

This audit showed the majority of patients in the sample had a primary diagnosis of Schizophrenia, Psychosis and Bi-polar (75%), with smaller proportions suffering from Anxiety and Depression (13%), Eating Disorder/Personality Disorder /Obsessive Compulsive Disorder /Post Traumatic Stress Disorder (8%). 20% of patients had a marked disability.

The majority of the sample was White (63%), The African and Caribbean population were over-represented (22%). No Asylum Seekers were recorded in sample.

The majority of patients were single (58%) with no children (75%) and either living alone (45%) or with partner, family or friends (51%). Carers needs were only assessed in 17% of sample, Carers refused assessment in 5%.

Only 21% owned a property and 19% were in supported accommodation or a nursing home.

The average patient demonstrated serious impairment in social, occupation or school functioning demonstrated on the SOFAS8 with only 10% in paid work, voluntary work or training. However a high percentage had some form of social network/friends.

15% of sample on enhanced CPA (Care Programme Approach), 78% on standard CPA. 65% were not on Section, 22% were on Section 117 (of the Mental Health Act). The majority of the sample cases were seeing more than one professional for their care. Overall there were good levels of co-operation with treatment, with over 70% passive acceptance or active participation in attending appointments; accepting contact at home or in the community; and with medication.

70% of patients had between 1 and 6 contacts a month with only 23% at least once a week or more. Telephone contact was lower, with an average of 34% none/not known telephone

8 SOFAS - The higher the score (maximum 100) the better, the lower the score the greater the impairment from mental and physical problems

Wolverhampton City March 2010 Joint Strategic Needs Assessment Update contact. The DNA rate was 70% overall, but was lower in Assertive Outreach Team, Brooklands Day Service and Early Intervention Service. 8% of patients were perceived as having unmet need.

Assessment of current risk highlighted 30% at moderate or severe risk of suicide, 39% at moderate or severe risk of self-neglect, 28% at moderate or severe risk of being aggressive, 10% at moderate or severe risk of being exploitive, 305 at moderate or severe risk of being vulnerable to exploitation and 3% at severe risk or committing arson.

Qualitative Data

Complaints There were 55 complaints made about mental health services between April 2007 and April 2009. The most common complaint referred to the lack of access to mental health services and available support (18%). Other common complaints included: poor treatment and care in the community, the general inpatient environment including food and problems with medication

Complaints about Mental Health Services in Wolverhampton

Voluntary Sector Research Two projects have also recently been conducted to examine mental health services for both Asian men and women. Overall both studies found that mental health services were not meeting the needs of Asian people. This was because of a lack of understanding of Asian culture on the part of mainstream mental health services and front line workers, lack of support, lack of information about the mental health services available and language barriers. At the same time a significant number of Asian people were simply not aware of the existence of any mental health services in Wolverhampton. The reviews recommended a number of ways to improve mental health services including involving Asian people in developing services; both male and female service users stated that having someone to talk to who understands what they are going through would help, especially if this was done by Asian workers in their own language. There is also a need to make provide more information about the range of mental health services available to Asian communities in Wolverhampton, how to access them and to ensure that all services are more supportive. Additionally addressing the stigma and negative perceptions surrounding mental health issues is important.

Wolverhampton City March 2010 Joint Strategic Needs Assessment Update

Stakeholder Interviews Semi-structured interviews were held with a wide range of stakeholder by an independent organisation. This has provided a direct opportunity for people who work in the system or receive care and support from local services to comment in confidence about their experiences. A number of key strengths and issues were identified and described in the table below.

Strengths Stakeholders identified a skilled and dedicated workforce. However, there was also evidence of poor morale and issues with vacancies. There was evidence of individuals’ knowledge, commitment and dedication to try and improve the service and a real understanding of the challenges to be faced and the rich potential that is afforded by the current workforce and developing service model to successfully move forward. If harnessed through effective management and leadership this is one of the greatest assets Wolverhampton has.

Strong engagement and interest in mental health development amongst a number of GPs was highlighted and a well developed locality framework for practice based commissioning

There is an emerging care pathway (work on acute care pathway) and commitment to put in place key and well resourced NSF functional services - specifically assertive outreach, early interventions and crisis resolution home treatment. There are issues with some of the interfaces between services and some of the delivery of certain aspects of the service, but many of the building blocks of a modern and fit for purpose whole systems approach are in place.

There is an acknowledgement that Crisis Resolution Home Treatment service has evolved out of a number of previous teams and this has impacted on its compliance with Policy Implementation Guidance (PIG) standards. This has resulted in a clear strategic plan for imminent implementation that will fully integrate all staff under a single manager, see recruitment to vacant social work and occupational therapy posts, resolve 24 hour medical cover and utilise the full pooled staffing resource.

A number of innovative local approaches and service developments have been described. These include: the development of a Single Point of Access; a notably diverse, vibrant and forward thinking range of third sector organisations; a ‘beacon status’ and critically acclaimed local forensic initiative and model of working that has created a dedicated capacity located in community teams and interfaced with regional medium secure resources; successful second wave bid for the development of an IAPT service; the current review of day services that provides a real opportunity to remodel services in line with current national thinking and policy around personalisation and social inclusion; Current thinking on the development of approaches to support dual diagnosis and personality disorder, building upon the forensic services model; and some innovative practice and a generally well respected model of care within older people’s mental health such as home treatment that potentially provides potential shared learning and development.

A vision of a recovery based model of care was often articulated and an associated strategic ambition to develop and enhance primary care services in partnership with social care and the 3rd sector that supports a re-focus of community mental health services to support more complex mental health needs.

Wolverhampton City March 2010 Joint Strategic Needs Assessment Update

Coterminosity between health and social care and fully integrated and multi-disciplinary teams is a strength. Whilst many interviewed felt the full advantage of this had not been realised there was a genuine belief in a strong willingness to work together to realise the full potential of this opportunity.

Issues and Pressure Points Communications was often highlighted as a difficulty which resulted in people feeling they did not fully understand how the system worked, what the full range of opportunities, how they might contribute and be involved in change and development. What became clear through the process of engagement was that there was varied understanding of what services there were, how they operated and crucially how they could get the system to work properly and be more responsive especially in crisis situations.

Assertive outreach was identified as being too selective in its eligibility criteria leading to an under performance in overall caseload and a reluctance to develop skill and capacity in supporting dual diagnosis and wider definitions of vulnerability and complexity of need.

Single point of access was thought to be a very positive development that has the potential to simplify access into mental health services. However in practice many thought it was not working in a way that improved access. Two specific issues were often cited: no direct referral option with referrals having to come via GPs. Given the demographic and cultural diversity of the city early access to mental health services via a GP and then the SPA team may not promote timely intervention. Many spoke of observing missed opportunities to intervene at an earlier stage leading to crisis admissions to hospital or entry into the criminal justice area or forensic services; and no capacity within CMHTs to respond to assessed need.

A number of concerns were expressed about the role, function and resourcing of CMHTs. These have potentially significant implications for the overall provision of mental health services. Four specific concerns were regularly identified: Loss of identify and purpose following the development of key NSF services, which has affected morale and the effectiveness of the service. Issues of service user involvement, choice of treatment and more self determination in the care management and care planning process were consistently raised. These findings are in line with the findings of the ‘Heath Care Commission Follow Up Review 2008/9 on Adult Community Mental Health Services’; loss of focus and prioritisation of complex mental health needs. Whilst there is a strategic recognition that CMHTs should become more focused on meeting complex care needs, the service appears to many, to be supporting very high and static caseloads that prevents access of higher priority need at an earlier stage. There has been little development around New Ways of Working that might help prioritisation and management of complex need; level of resource within CMHTs being insufficient, having reduced over recent years to support NSF developments. This coupled with high sickness levels and vacancies has significantly impacted on the sustainability of a critical mass within the teams; and interface with crisis team and acute inpatient care. This may in part be linked to issues of levels of staffing and morale, however there was concern that CMHTs look for the crisis service to take on crisis support when perhaps the CMHT is best placed to meet that increased need as well as concerns about longer lengths of stay in acute inpatient settings caused by an inability to support earlier discharge back to community services.

Concerns were expressed about the operation of crisis resolution and home treatment. These included a lack of responsiveness to crisis assessment and gate keeping functions especially out of hours, leading to vulnerable people having to be taken to A&E for assessment; and the disjointedness of the service which for many people appears to operate 68

Wolverhampton City March 2010 Joint Strategic Needs Assessment Update as four separate elements; home treatment north and south, crisis assessment and single point of access; the crisis service subsuming the A&E liaison function and resource, but finding it difficult to provide consistency in responsiveness.

It was felt that the potential of NSF service developments had not been maximised due to a lack of focus on whole systems working. There was significant concern expressed about the degree of fragmentation across the system, with services being isolated and in some case defensive and overly protectionist in their response to referral and care pathway management. There was a sense that the various bits of the system did not work in the way that other parts of the system expected and therefore access into services and movement through services was compromised resulting in potentially high risk situations.

There was a perception of a very traditional and medical treatment orientated approach to providing care that is not in keeping with the diverse culture and need of the local population or a wider social inclusion evidence base. The social and economic determinants of poor mental health that are recognised by many GPs are not well reflected in the corresponding staffing, skill mix and philosophy of statutory provider services. There was reported to be a fear and suspicion of mental health services from the BME community which make up nearly 25% of the population. Issues of under representation of people from bme backgrounds in primary and community based services and over representation in inpatient and tertiary based services were thought to be the norm.

The system’s responsiveness to crisis situations and its management of risk was severely questioned on a number of occasions with particular concerns on vulnerable people having to be taken to hospital sometimes on public transport before an assessment could be undertaken.

Finance Total spend on adult mental health spend in Wolverhampton is £31,403,000. The total spend is split into direct costs of £27,605,000 and indirect, overhead and capital costs of £3,798,000. Investment weighted for population is less than for the SHA, England or the ONS cluster but only marginally (£173 cf. £178, £177 and £179 respectively).

The estimated need and total mental health direct costs for 2008-2009 is described in the figure below. This demonstrates the need to redress the balance of spend to reduce the emphasis on high cost low volume interventions at the higher steps of care and increase the emphasis on low cost high volume interventions at the lower steps of care.

Wolverhampton City March 2010 Joint Strategic Needs Assessment Update

Within this context, increasing access to mental health services in primary care, especially talking therapies is a key project requiring new investment in the short term that is needed to enable the wider objective to redress the balance of services to be achieved. As a result this has been chosen as strategic goal 4. This will be achieved through strategic initiative 4 – Talking therapies: early intervention mental health services. The budget for this is outlined in the table below.

Planned investment in Psychological Therapies 2008-09 2009-10 2010-11 2011-12 2012-13 Planned £300,000 £1,270,000 £1,500,000 £2,000,000 £2,680,000 Investment Planned number 200 2,352 2,800 3,800 5,000 of intervention Proportion of intervention 50% 50% 50% 50% 50% successful

Conclusion This needs assessment highlights four key areas that need to be addressed to improve mental health services in Wolverhampton.

A recovery approach needs to be supported through developing a stepped model of care. This can be achieved by building on the Healthy Minds (Improving Access to Psychological Therapies) initiative to develop a primary care or step 3 mental health service that affords alternatives to referral into secondary care services as well as providing an exit route for those currently in secondary care services.

Wolverhampton City March 2010 Joint Strategic Needs Assessment Update

This would in turn allow for the development of case management for people with stable severe mental illness as well as access into a wide range of mental health and wider community support services that support an alternative to entry into or prolonged presence in secondary care specialist services. This would be a crucial development in achieving a more balanced and effective model of care and care pathways which can more readily respond to the diversity of culture and need within the local population.

Community services for people with more complex and challenging mental health needs need to be strengthened and integrated. This will be achieved through refocusing current specialist secondary care services to develop community capacity and expertise thereby reducing reliance on in area acute care and out of area tertiary and forensic care.

The working hypothesis is that a significant proportion of current step 4 activity in CMHTs could be undertaken (according to level of need) either within a primary care mental health service at step 2-3 or within the currently under-performing specialist mental health service functions developed through the NSF – Crisis Resolution and Home Treatment Teams (CRHTs) and Early Intervention Teams (EITs) and Assertive Outreach (AOT).

Support and intensive treatment for people with long term and/or complex needs (including dual diagnosis and moderate personality disorder) could then be provided through a new complex and long term care team drawn from the existing resource in CMHTs and working closely with the AOTs and rehab services.

Access routes across the system need to be improved and clarified. The ability to respond rapidly to crisis situations at an earlier point in time and in a way that is acceptable and relevant to diverse cultures will afford opportunities to provide alternatives to admission or to presentation within criminal justice settings. This in turn will maximise the effectiveness of the whole systems care pathway and the specialist functional services within it.

Through the development of the local recovery house an increased number of individuals will be offered an alternative to hospital admission.

Reliance on forensic and other high cost individual placements needs to be reduced. This would free up significant resources to fund the redesign and refocus of community services in both primary and secondary care over the longer term.

These four elements are interdependent on each other. The current community secondary care services cannot create capacity and develop expertise without reducing its current activity. This current activity cannot be supported in an alternative way without the development of an enhanced primary care service and associated wider community support services. The whole systems working that promotes movement between and increased access and choice to the various service options within the care pathway cannot operate without addressing responsiveness to crisis situations and the deployment of gate keeping and effective single point of access. The investment that will be necessary to develop primary care and wider community support services is currently locked into forensic services and into low productivity within the status quo.

Wolverhampton City March 2010 Joint Strategic Needs Assessment Update

Chapter 5: Infrastructure and next years priorities

Infrastructure During the course of undertaking the review of the Joint Strategic Needs Assessment (JSNA), it was agreed by those involved in the JSNA process that it would be sensible to formalise the needs analysis governance arrangements in order that as a city, we can respond effectively not only to the needs identified in the JSNA but to a fuller range of needs analysis work.

The revised governance structure around needs analysis, enables a co-ordinated approach to collating, sharing and reporting needs data across the city to inform the strategy development and commissioning process for the following service areas across all ages: Social Care Children & Young People Health Housing Support & Social Inclusion Housing Education, Employment & Skills Safety & Crime Population Demographics

The revised processes will ensure delivery of key cross cutting needs analysis projects, including the annual Joint Strategic Needs Assessment. Key demographic trends and emerging needs will be reported across the city to appropriate groups, including those associated with the Wolverhampton Local Strategic Partnership.

The development of a Local Information System which will be accessible to a range of partners will help us to respond as a city in a timely and co-ordinated manner to any emerging needs.

The Local Strategic Partnership have approved the new processes and will oversee the needs analysis work being undertaken across the city in order to ensure ownership at the highest possible level.

The group will:

Identify needs information and analysis requirements for Wolverhampton Ensure delivery of key cross cutting needs analysis projects, including the annual Joint Strategic Needs Assessment Report key demographic trends and emerging needs to appropriate groups, including those associated with the LSP Oversee needs analysis activity in Wolverhampton to ensure it is co-ordinated, of good quality and shared with partners Ensure up to date needs information is used routinely as part of the commissioning process

Three priorities have been agreed for the JSNA 2010/11 Children and Young People - This work will link to and support the new Children and Young People Plan The effects of the recession on the needs of Wolverhampton - This will have a particular emphasis on child poverty The effects of ageing on the needs of Wolverhampton - This will look at how an ageing population will impact upon local services

Wolverhampton City March 2010