SOMERSET JOINT STRATEGIC NEEDS ASSESSMENT
October 2008
SOMERSET PRIMARY CARE TRUST AND SOMERSET COUNTY COUNCIL
JOINT STRATEGIC NEEDS ASSESSMENT
TABLE OF CONTENTS
PREFACE Page
1. INTRODUCTION ...... 1 Background and Somerset’s Approach
2. DEMOGRAPHY OVERVIEW ...... 7
3. SOCIAL AND ENVIRONMENTAL CONTEXT ...... 9
4. CURRENT HEALTH STATUS ...... 33 What the situation is like now How are we doing? What is working? Where are the gaps?
5. CURRENT MET NEED...... 119
6. “SOMERSET VOICE” ...... 133 Community Engagement Patient and Public Involvement
7. ANALYSIS OF HEALTH INEQUALITIES ...... 147
8. GOING FORWARD FOR SOMERSET ...... 169 Summary of key issues Recommendations for Action
9. USEFUL LINKS AND RESOURCES ...... 173 Web information Somerset Local Area Agreement 2008-2011 National Indicators chosen Access and Feedback Index
STATISTICAL COMPENDIUM (separate file electronically – ‘JSNA for Somerset - Core Data Set’)
October 2008
Welcome to the first Joint Strategic Needs Assessment (JSNA) for Somerset.
It is built on strong partnership working, already present in Somerset, and is underpinned by the Somerset Health and Social Needs Analysis data, which has been regularly updated since 1998 (latest publication HSNAG 2007).
The scope of our JSNA provides a firm foundation for commissioning to improve health and social care services and reduce health inequalities. It enables stronger partnerships between communities, local government and the NHS.
The document structure sets out a picture of Somerset that encompasses the county’s environmental attributes and challenges, the social context of our populations, our health status, how current needs are met, the ‘Voice’ of Somerset stakeholders and communities and where the health inequalities and gaps are to be found.
By its very nature, the JSNA is not a static document; it will change and develop to adapt to the needs of Somerset people and be a crucial tool in ensuring the services we provide are based on sound evidence and are value for money. We would welcome any comments you make wish to make on its content. Signposts for how to do this are included toward the end of the document.
Chapter 4 (‘Current Health Status’) highlights the current situation concerning children and young people, teenage pregnancy, sexual health, substance misuse, mental health, learning disabilities, obesity, smoking, diabetes, coronary heart disease and stroke, cancer and older people. At the end of each of these sections is a summary and an identification of gaps. A separate ‘Health Inequalities’ section (Chapter 7) goes into more detail about these gaps and where further work could be undertaken.
The JSNA is a large document; there have been over 45 contributors (many on behalf of multi-agency teams) bringing together their knowledge and expertise in specialist areas from Somerset County Council and Somerset Primary Care Trust. I would like to thank them all for the enthusiasm and rigour with which they approached the requirements of the JSNA.
There is much to be proud of in the work undertaken to help Somerset people stay healthy, enjoy their lives, be supported and informed; and looked after across the health and social care sectors when needs require.
We also think the Somerset JSNA is an interesting document in its own right. This has been an opportunity not just to look at how health and social care works together and to influence commissioning decisions but to share information with a host of organisations, communities and individuals who want to make a difference to the future of this vibrant and forward-looking county.
Joint Director of Public Corporate Director Corporate Director for Health Community Children’s Services
CHAPTER 1 - BACKGROUND
The Department of Health’s Draft Commissioning Framework for Health and Wellbeing (March 2007) proposed to establish a duty on upper tier Local Authorities and Primary Care Trusts (PCTs) to produce a Joint Strategic Needs Assessment (JSNA). The duty to undertake a JSNA was also described in Section 166 of the Local Government and Public Involvement Act (2007) and set out in the draft statutory guidance, Creating Strong, Safe and Prosperous Communities. The duty commenced on 1 April 2008.
What is a Joint Strategic Needs Assessment1 (JSNA)?
This is an ongoing process by which Somerset County Council and Somerset Primary Care Trust (SPCT) will describe the future health, care and wellbeing needs of our local population (over the short term – three to five years and long term - five to ten years) to inform the commissioning of services, the Local Area Agreement (LAA) and Sustainable Community Strategy.
It will be delivered by collaborative partnership working, including the involvement of District Councils, Local Strategic Partnerships (LSPs), patients, the public and voluntary sector. It will address evidence of effectiveness, identifying not only what works well, but highlight gaps in information where further work is required. This is why each JSNA will be unique; it will reflect local circumstances and what is really required to meet the needs of the Somerset population.
How does the JSNA add value to existing needs assessment?
The JSNA is a driver for change2. In creating an evidence base for the local populations of Somerset, it informs key levers for change in outcomes for health and wellbeing – public demand, partnership working, seamless provision and local commissioning. On one level, it is a tool, a methodology for strategic analysis of an area and an important one precisely because of its scope. On another, it captures the change of culture across health and social care. To do this, the JSNA needs to bring together diverse and often competing interests within both professional and public interest groups to shape local outcomes for health and wellbeing.
JSNA and the commissioning cycle – how does it work?
The Department of Health describes effective commissioning in terms of eight steps:
1. Putting people at the centre of commissioning 2. Understanding the needs of populations and individuals 3. Sharing and using information more effectively 4. Assuring high quality providers for all services 5. Recognising the interdependence of work, health and wellbeing 6. Developing incentives for commissioning for health and wellbeing 7. Making it happen: local accountability 8. Making it happen: capability and leadership
1 DoH JSNA Guidance document, February 2008 2 London CSIP Commissioning Learning Event 3 – 8th January 2008
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CHAPTER 1 - BACKGROUND
3 The Local Government and Public Involvement Act (2007) places the duty of JSNA on upper-tier local authorities and PCTs. In practice, the Director of Public Health, Corporate Director - Community and the Director of Children’s Services jointly undertake the JSNA, working closely with Commissioning and Finance to help set strategic priorities and make evidence based investment. A jointly appointed Director of Public Health, as we have in Somerset, can facilitate the process by working across health and local government. For PCTs, the World Class Commissioning assurance model will ensure PCT Boards take an active interest in the JSNA and that it is used and understood at senior governance level.
Our approach to developing the JSNA for Somerset
A steering group was established to drive the development of the JSNA. The group is made up of the Joint Director of Public Health, the Corporate Director – Community, Director of Children’s Services, Head of Environment and Regeneration for Somerset County Council and commissioners from the PCT, the Director of Primary Care Development and Director of Secondary Care Development. There is representation from the PCT Professional Executive Committee and a finance representative, as appropriate.
3 JSNA presentation – Renu Bindra (Public Health Development) DoH
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CHAPTER 1 - BACKGROUND
The function of the JSNA steering group is to:
agree and finalise the JSNA process and timeframe ensure involvement of key stakeholders in the JSNA working group and subgroups provide strategic support and advice ensure partner and public views are considered within the ongoing JSNA process agree content of the final document identify, highlight and explore key local health inequalities make recommendations through the JSNA and the Health and Wellbeing Group with regard to changes in commissioning and delivery of children’s and adult services
A technical working group was established to progress the data collation needed to support the written evidence in the JSNA and provide supplementary local level information to the core data set.
At the first meeting of the JSNA steering group a commissioner commented, “I welcome the JSNA, it will drive the health agenda and take commissioning further on. It will encourage joined-up working, tackling inequalities and improving the delivery of services”.
Figure 2
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CHAPTER 1 - BACKGROUND
The Local Area Agreement (LAA) and Sustainable Community Strategy (SCS)
What is an LAA?
Local Area Agreements4 set out the priorities for a local area agreed between central government and the local authority, the Local Strategic Partnerships and other key partners like PCTs, at the local level. LAAs simplify some central funding, help join up public services more effectively and allow greater flexibility for local solutions to local circumstances.
Through these means, LAAs are helping to devolve decision-making; the ideas behind them are to recognise that ‘one size does not fit all’ and that local services should reflect what local people want. They give more flexibility to local authorities, PCTs and other public sector organisations in the ways they deliver services for local people and make them more accountable to their population.
Somerset Joint Strategic Needs Assessment will identify areas for priority action through the Local Area Agreement. It will help commissioners, including practice- based commissioners, to specify outcomes that encourage local innovation and help providers to shape services to address needs.
Working together
Somerset County Council, with its partners in the Somerset Strategic Partnership (SSP) is developing the Sustainable Community Strategy. This will bring together a collective ‘Vision for Somerset’ for 2026, the challenges faced over the next fifteen years or so and the priorities to make sure these challenges are met. The Strategy, due to be published in January 2009, sets out a framework for service delivery.
Somerset County Council’s ‘Annual Plan 2008’ demonstrates how it will start to deliver its responsibilities in the Strategy and the LAA. The Council and each of its partners, including the PCT, will be judged by the Government on results. The judgement will be based, in part, on the views of local people. The Sustainable Community Strategy is based on outcome themes and these same themes have been used to group the LAA priorities and outcomes.
These outcome themes are:
Making a positive contribution Living sustainably Ensuring economic wellbeing Enjoying and achieving Staying safe Being healthy
4 Communities and Local Government website
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CHAPTER 1 - BACKGROUND
Both the Sustainable Community Strategy and the LAA have drawn on the refreshed ‘Somerset Story’; this is the evidence base drawn from demographic profiles and other statistical information, consultation with local people, key agencies and community and voluntary groups (further information is contained in Chapter 6 of this document, ‘Somerset Voice’). These results have been distilled in a series of challenges and priorities grouped under the outcome themes (based on ‘Every Child Matters’ outcomes) but are also relevant to every person and community in Somerset.
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CHAPTER 2 – DEMOGRAPHY OVERVIEW
The County
Somerset lies in south west England and covers an area of 3,450 square kilometres.
The resident population in 2006 was 518,600 with about 48.6% male and 51.4% female. This is about 10% of the population of the south west region. The settlement pattern is one of dispersal; only about a third of the population live in our four largest towns of Taunton (63,536), Yeovil (42,140), Bridgwater (36,892) and Frome (24,150).
Map 1
Our average population density is 144 persons per sq km, compared with a south west average of 207 persons and national average of 240 persons. The following map on page 8 illustrates the particularly sparse population densities on Exmoor, other upland areas and parts of the Somerset Levels. Low population density presents challenges for the provision of appropriate transport infrastructure, the viability and accessibility of local services, and employment opportunities.
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CHAPTER 2 – DEMOGRAPHY OVERVIEW
Somerset’s population is growing relatively quickly: 7.1% between 1991 and 2001, 36% higher than the south west region as a whole (5.2%) and over two and a half times the England and Wales average (2.6%).
We have an older age profile than the national average: 58.2% of our population is of working age compared with a national average of 62.2%.
Like the rest of the south west region, we have much higher levels of people aged 50 and over than the UK as a whole and a lower than average number of younger people. There are much fewer 20-24 year olds than would be expected; this is most likely due to outward migration for higher education.
According to the 2001 Census, within our county, 18% of people have a long-term limiting illness health problem or disability which limits their daily activities or work. This is a similar proportion of the population as the regional and national averages. West Somerset and Sedgemoor have the highest rates of long-term limiting illness at 21% and 18% respectively.
We have 210,587 households which are becoming smaller, with the average household size of 2.38 in 1991, reducing to 2.31 persons per dwelling in 2001. This means that the demand for new housing and accompanying services is increasing at a greater rate than the levels of population growth.
Map 2
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CHAPTER 3 – SOCIAL AND ENVIRONMENTAL CONTEXT
The health of people in Somerset is generally better than the England average. Most people can expect to live well into their 70s (and beyond) and do so with a relatively low risk of significant illness affecting their lives.
However, there are pockets of deprivation across the county, mainly in the towns, but also in rural West Somerset5, where around a fifth of children live in households dependent on benefits. Life expectancy is lowest within the most deprived areas.
Early death rates from heart disease and stroke are lower than the England average and have fallen over the last ten years.
The proportion of women who smoke during pregnancy is higher than for England and the south west. Levels of physical activity are high for both children and adults. In Mendip the level of reception age children who are classified as obese is less than for the south west and England6.
The estimated proportion of adults who smoke or binge drink is lower than for England. However, there are around 860 deaths due to smoking each year and around 1,200 admissions to hospital for alcohol-related conditions.
Deprivation
An important source of information for our evidence base is the Index of Multiple Deprivation (IMD), a national data set that enables important statistics about the county to be analysed and compared. The IMD takes into account seven forms of deprivation based on: income, employment, health and disability, education/skills and training, barriers to housing and services, living environment and crime. In order to fairly compare this (and other) data, England and Wales is divided into small geographical areas known as 'Super Output Areas' or SOAs which are based on population size.
The IMD ranks two SOAs in the county within the most deprived 10% in the country. One of these is in Bridgwater and the other in Taunton. Overall, Somerset is generally less deprived than many other parts of the country and the region, however, concentrated pockets of deprivation do exist, mainly confined to the urban areas of Taunton, Bridgwater, Glastonbury, Yeovil and Minehead. The following map illustrates the extent of deprivation across Somerset. The largely rural area of West Somerset is also ranked high on the IMD, but this relates more to services and housing.
5 Association of Public Health Observatories – Health Profile West Somerset 2008 6 Association of Public Health Observatories – Health Profile Mendip 2008
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Map 1
The IMD (2007) ranks 46 SOAs within the most deprived 10% nationally for barriers to housing and services - this includes the 10th nationally most deprived SOA on Exmoor, West Somerset.
Schools
The number of pupils of primary school age in Somerset has been decreasing annually from a peak in 1998. Forecasts issued in 2007 show a further fall equivalent to about 26 classes of 30 pupils by 2010. There are now signs of a modest recovery of primary aged pupils for 2011 and beyond.
Somerset School Population Forecast - 2007
All forecast figures have as their base the actual number on roll data for 2007 that was supplied by schools in October 2007 as part of the Department for Children Schools and Families (DCSF) collection of pupil data. For primary schools, the forecasts cover the period up to 2012, middle and secondary school forecasts are produced in most instances until 2016 or 2018. The forecast totals for each school will appear as part of the Somerset School Organisation Plan which is a key part of the planning of school places in the county. In addition, the forecast figures are supplied to the Schools Finance Team to help in the calculation of multi-year budgets for all schools geared to pupil numbers.
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LEVEL TRENDS
Calculation of County Forecasts
In line with DCSF guidance7 the forecasts at county level have been calculated independently rather than being based solely on the aggregate of individual school forecasts. This provides a means of validating individual forecasts to avoid serious over/under-estimating. There are no significant changes in overall trends from those that were reported in the 2006 forecasting exercise.
Primary Aged Pupils
The number of pupils of primary school age (i.e. aged four-10) in Somerset has been decreasing annually from a peak in 1998. Since that time, there has been a fall in total roll of 3,267 pupils (a fall of 8.0%), with a further drop in pupil numbers forecast to continue until 2010. The difference in the forecast total four-10 roll for 2010 from the 1998 roll is 4,035 – the equivalent of all the primary schools in Yeovil. There are now early signs of a modest recovery of primary aged pupil numbers beyond 2010 which is consistent with a slight national up-turn in the numbers expected nationally (as shown in figure 1 on page 13). The most significant factor behind the slight increases that are being seen is an increase in the birth rate that has occurred since 2001. The Office for National Statistics8 reports that nationally in 2006 the number of live births increased slightly for the fifth successive year. Nationally the number of births has been increasing since 2001 and has reached levels last seen in 1993.
The forecast fall in primary aged pupil numbers in Somerset is a reflection that the number of pupils leaving the primary sector aged 10 is more than the number of pupils joining at reception. The 2008 reception year intake to all Somerset primary schools is forecast at 5,174 which compares to 5,773 pupils leaving the primary age range at the end of the current academic year. For the next few years the number of pupils in the reception year in Somerset is forecast around 5,200, which is higher than the number in 2004 and 2005 although it is well below the peak year of first admissions (1992) when there were over 5,800 pupils in the reception year.
Secondary Aged Pupils
Throughout the 1990s, there was a significant increase each year in the number of secondary aged pupils (aged 11-17) in Somerset's secondary and middle schools. The increase in secondary aged pupils ended in September 2004, although the first really significant fall did not occur until September 2006. Secondary aged pupils are forecast to continue falling throughout the period of the forecasts, with a forecast fall of 1,269 pupils by 2012 (a forecast drop of 4.3% over a five year period). Further falls are forecast in the period up to 2016, when secondary aged pupil numbers are expected to be 2,342 lower than the current roll – a reduction of 7.9%. From Figure 1 it can be seen that the number of secondary aged pupils in Somerset generally follows national trends.
7 Department for Education and Skills “Pupil Projection Guide” 8 “Live Births” published by Office for National Statistics (24 September 2007)
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All Mainstream Pupils
In the period up to 2003 the increase in secondary aged pupils helped to offset the annual decrease in the primary school roll to produce an overall increase each year. Since 2003, the total roll of Somerset primary, middle and secondary schools has fallen by 3,225 – a fall of 4.6%. With secondary school numbers continuing to fall each year and no significant increase in the primary age ranges an annual decrease is forecast in the mainstream roll until at least 2012 (the period covered by current primary school forecasts). The forecast total for September 2012 is 1,799 lower than the 2007 roll – an average fall of 360 pupils per year.
As well as obvious implications for the local schools, there are wider implications of a smaller client base. This includes the County Council's annual financial settlement from Central Government, a key element of which is the number of school pupils. It is clear from the forecast figures that there will be an overall reduction in the total pupil roll each year until at least 2012 as can be seen from Figure 1.
Migration
At county level net gains from migration are not significant enough to change the overall trend which results from the increase/decrease in the birth rate. At a local level, gains or losses from migration can be quite significant and the forecasts include an allowance for migration to reflect such factors as gains from new housing, options out to non-Somerset LA schools etc.
By its very nature migration tends not to be consistent from one year to another. The migration included in the county level forecasts is based on an average level of migration of recent years. This would include some gains from pupils moving into new housing throughout the county. If the actual future migration is significantly different from the average of recent years then the county level forecasts are likely to be an over-estimate or underestimate as a result.
Longer Term Population Projections
The Office of National Statistics9 also indicate that there will a 20% growth in the population of Somerset as a whole from 2004-2029, although the most significant growth with be in people aged 60+. Nevertheless, there will be fluctuations in the number of primary and secondary age pupils as the natural cycle of births brings increases and decreases in the size of the cohorts entering and leaving school. Additionally, there will be specific pressures resulting from local factors such as new housing developments.
School Organisation Plan 2007-2011
The forecasts of pupil numbers feed into the Somerset School Organisation Plan – the latest version of which was published in July 2007. It includes the 2006 school population forecasts (i.e. covering the period 2007-2011), school net capacities as at 19 June 2007 and surplus places for all Somerset county schools divided into 20 geographical areas. A new version of these tables will be produced to incorporate the 2007 forecast figures.
9 2004-based sub-national population projections published by Office of National Statistics
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The July 2007 version is available from the link below: http://www.six.somerset.gov.uk/sixv3/content_view.asp?did=17286
ECONOMY AND EMPLOYMENT
There are 207,400 jobs in Somerset (2006). Businesses are smaller than the national average with 85% of workplaces having 10 or fewer employees and there are relatively few major employers, with only 95 workplaces having over 200 employees.
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Map 2
Map 2 shows that unemployment is generally concentrated in the major urban centres of Taunton, Yeovil and Bridgwater.
Somerset experienced a slower rate of economic growth between 1993 and 1998 than regional or national averages and estimates to 2011 suggest growth rates below the national average.
The employment sectors of manufacturing and distribution, hotels and catering are over-represented in Somerset compared with national and regional averages. Over one sixth of our employees work in the manufacturing of a wide range of goods from fruit juice to helicopters. Somerset has an established and regionally competitive advantage in food and drink, aerospace, advanced engineering and tourism.
Tourism is an important element of the south west’s economy and in Somerset is of particular importance in West Somerset and parts of Sedgemoor. An estimated 19,000 actual jobs (2006) are directly and indirectly supported by tourism expenditure, with day and staying visitors spending around £602 million in 2003.
We have 0.87 jobs per working age resident, which is comparable with the national average. However in Sedgemoor and West Somerset this falls to 0.7 reflecting their rural nature and higher levels of commuting out of these districts for work. The density of 1.0 in Taunton Deane reflects Taunton’s role as the largest town and administrative centre of Somerset.
Although we have a low unemployment rate compared with the national average, earnings in Somerset are below both the national and regional averages.
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Table 1: Average Gross Weekly Earnings (2007) Somerset South West National Full-time £427.1 £433.4 £459 Male £479.9 £480 £500.7 Female £348.8 £364.2 £394.8
The IMD (2007) ranks 17 SOAs in Somerset in the most deprived 10% nationally for education, skills and training. In Somerset, 10.3% of people of working age have no formal qualifications – higher than the regional average. The occupational profile shows a relative concentration of people in low level occupations (particularly personal service occupations and process, plant and machine operatives) reflecting the characteristics of the overall economy.
Migrant Workers
Migrant workers are a transient population and as such difficult to count – a nationally recognised problem. There are only estimates available for the number of migrant workers in any given area. These estimates are likely to be under-estimates because they do not account for families, only individuals who register for work.
Numbers of migrant workers are increasing significantly in Somerset in all areas (and in the whole of the south west region). In Somerset between 2003/04 and 2005/06 numbers increased from 1,255 to 3,175 (an increase of 153%), based on National Insurance registration data.
Mapping in South Somerset and Mendip indicated the main groups of migrant workers were Polish, Portuguese and Filipino with the majority (over 90%) aged between 18 and 44 years. Main occupations of migrant workers (based on South Somerset data) include – administration, business and management*; manufacturing, agriculture, hospitality and catering, health and medical services (*use of employment agencies may skew figures).
A number of community associations in Somerset have been established – including Portuguese and Polish communities.
Future Housing and Employment Growth
The Regional Spatial Strategy (RSS) (proposed changes July 2008) proposes the following new housing allocations between 2006 and 2026.
Table 2 New Dwellings 2006-2026 District (as per proposed changes July Comments 2008) Taunton Deane 21,800 Of which 18,000 in Taunton South Somerset 19,700 Of which 11,400 in Yeovil Sedgemoor 10,200 Of which 7,700 in Bridgwater Mendip 8,300 West Somerset 2,500 TOTAL 62,500
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The RSS suggests an economic growth rate of 2.8% would be a reasonable assumption for the plan period to 2026 and that the area would be expected to provide 18,500 new jobs in the Taunton/ Bridgwater travel to work area and 9,100 new jobs in the Yeovil travel to work area.
ENVIRONMENT
Biodiversity
Around 10,000 species of plants, animals and fungi have been recorded in Somerset and the county is known to be one of the richest in the UK for biodiversity. We have high levels of national and European protected species and therefore have a particular responsibility to conserve wildlife. Local trends in species population are generally downward, although strategies are being developed to reverse this trend. We have a great diversity of habitats, many of which are designated due to their special nature, including eight Special Areas of Conservation, two Special Protection Areas, two Ramsar sites, 126 Sites of Special Scientific Interest and 2,100 County Wildlife Sites.
Flooding
Much of Somerset is low lying and a significant proportion of the county is at risk from flooding. Amongst those areas where the risk is greatest are the Somerset Levels and low-lying moors and the urban areas of Taunton and Bridgwater (see also climate change in this section).
Landscape
The landscape of Somerset is extremely varied and much of it is considered to be of national importance, including Exmoor National Park and Areas of Outstanding Natural Beauty shown in Map 3. The Somerset Levels and Moors are an internationally recognised wetland and parts of the Somerset are designated as Heritage Coastline. The variety of landscape and natural features is impressive and includes unique features such as Glastonbury Tor, the Quantock Hills and the Levels often ringed by low hills.
Map 3
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Air Quality
In comparison to more densely populated areas in the UK, air quality is generally good in Somerset.
The highest pollutant levels are around major roads and urban areas as would be expected, however the following map clearly shows the widespread effect of the M5, A303 and part of the A358 particularly on carbon dioxide emissions.
Map 4
There are currently three Air Quality Management Areas (AQMAs) designated because of the impacts of traffic congestion: East Reach in Taunton, A358 at Henlade, and Central Yeovil. Taunton Deane Borough Council is now considering designating the whole of Taunton Town Centre as an AQMA to reflect the latest Air Quality Review and Assessment report (Faber Maunsell 2004), which identified further sites in Taunton where Government air quality thresholds are likely to be exceeded.
Climate Change
Climate change has implications for human health, the economy, biodiversity, fauna and flora, soils and our cultural heritage. The social, environmental and economic costs associated with change in the global climate could be immense. Scientific evidence is clear that greenhouse gas emissions are having a significant effect on the earth's climate. Locally, mean maximum and minimum temperatures recorded at Yeovilton have risen 1ºC between 1965 and 2003 (SERC analysis of Met Office data).
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Figures produced by the South West Climate Change Partnership and the Environment Agency suggest that average summer temperatures will have risen by 3.5ºC by 2050. Summers will become drier and winters will become wetter. Extreme sea levels could occur up to 20 times more frequently with a sea level rise up to 76cm by 2080. Increases in both the amount of winter rainfall and the intensity of storms could increase the risk of flooding which would have a serious impact on the extensive low-lying areas of Somerset.
Map 5 Areas at risk of combined coastal and fluvial flooding
There are currently about 32,500 properties in this flood risk zone.
TRAVEL AND TRANSPORT
Accessibility
A detailed analysis for access to a range of services has been undertaken, including access to healthcare, employment, learning and food shopping.
The table following assesses the level of accessibility to services for different areas of the County using a scoring system that considers:
local and national demographic data public transport journey times and links with local deprivation indices a review of community/accessible transport schemes in the county
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Table 3
The services identified to be the least accessible are highlighted as ‘high concern’ and ranked accordingly. Please note that the highest and worse possible score is 100.
Access to acute hospitals is an issue of concern across most zones and access from the Minehead and Bridgwater areas is of most concern.
A series of studies is underway considering in more detail the access issues in each zone according to the priority ranking shown above.
Key issues around access to healthcare are as follows:
28% of rural residents have either a minimum 30 minute travel time to their nearest GP or no service at all by public transport, compared with only 1% of urban residents 43% of residents have either over an hours travel time to their nearest general hospital or no service at all by public transport (51% from rural areas and 37% from urban areas) 24% of rural residents have either over an hours travel time to their nearest Community Hospital or no service at all by public transport; and around one in five residents have either a minimum 30 minute travel time to their nearest supermarket or no service at all by public transport
In line with national trends, our health services are experiencing a growing number of missed appointments for consultant led specialties. Data for 2007/08 shows a rate of 8.6% appointments missed, 6.7% for the first attendance and 9.5% for follow-ups, with the estimated cost being £188 for the first attendance and £95 for the follow-up attendance.
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Travel patterns
The travel to work data for Somerset has been analysed from the 2001 Census. About three out of four of our residents travel to work by car or van. This has a particular impact on people who are less mobile or do not have access to private transport and offers a challenge to both service providers and the Local Transport Plan (LTP). The proportion of people cycling to work is higher than the national average and is particularly high in our larger settlements. Public transport is poorly used in Somerset although patronage is now growing.
Figure 2
Of employed people, 28% travel over 10kms to work, slightly higher than the regional average of 25%.
Each of our Districts is relatively self-contained in terms of travel to work. Taunton Deane is the most self-contained with 82% of trips starting and finishing within the District. Mendip is the least self-contained: 69% of trips start and finish within the District, with the majority of other trips destined for nearby counties Bath and North East Somerset (BANES), Wiltshire, Bristol and North Somerset. Significant travel to work patterns are as follows:
the major travel to work movements are between the settlements on the M5 corridor, particularly between Taunton and Bridgwater, from Wellington to Taunton and to a lesser extent from Burnham-on-Sea to Bridgwater. This supports the Regional Spatial Strategy which has identified the Taunton/Bridgwater/Wellington corridor as a growth area due to the strong relationship between the towns significant numbers of people travel to work in Bristol from a number of Somerset towns other notable movements are in the Mendip area between Glastonbury and Street and from Glastonbury and Shepton Mallet to Wells the most self-contained towns are Minehead and Frome both with 69% of the working population living in the town there is a large travel to work movement between Frome and Bath
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The Growth in Road Traffic
Our population has grown by 6.3% in the last decade; however car ownership has increased by 29%. These changes have combined to produce increased delays and longer journey times on our congested routes during the peak hours. There is significant variation in car ownership across Somerset, with West Somerset and Taunton Deane having the largest proportion of the population who do not own a car.
Traffic has grown by 23.6% in our county over the last ten years which is far greater than the national growth of 18.3% as illustrated below. The increase of 1.6% between 2003 and 2004 is comparable with the national picture.
Figure 3
Figure 4
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Map 6 illustrates the Annual Average Daily Traffic Flows on Somerset roads. Many roads are close to, or are exceeding the vehicle numbers for which they were designed, particularly the A358 between Ilminster and Taunton, the A38 around Bridgwater, and the eastern approach to Yeovil, which are congested during peak periods.
Map 6
Performance in delivering targets - the main traffic targets are related to overall traffic mileage in the County, and congestion in Taunton and Yeovil, which are the most significantly congested towns with associated air quality management areas. The targets are set to limit the growth in mileage and congestion rather than achieve an absolute reduction. This reflects the reality of the situation in a rural area with towns that will be growing in size significantly and cars likely to be the main form of transport for some time to come. Current performance for these targets is set out below:
Table 4 Target 2004 2005 2006 2007 2008 2009 2010 Total growth in Actual 4132 4139 4192 4247 vehicle kilometres (mvkm) to not exceed Trajectory 7.29% between 4230 4280 4330 4380 4430 2004 and 2010. (mvkm) Actual 1334 1455 Congestion (Delay) (Car hrs) Taunton Trajectory 1754 1886 2018 2150 2282 2414 (Car hrs) Actual Congestion 1183 1190 (Car hrs) (Delay) Trajectory Yeovil 1440 1521 1602 1682 1763 1844 (Car hrs)
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Areas for Improvement
Table 4 (page 22) shows that mileage and congestion levels are currently well below our forecast targets and this is largely due to the fact that new housing areas have not been developed as quickly as had been predicted in these towns.
The Future
The Council’s transport strategy is to improve public transport infrastructure and services, promote more sustainable forms of transport such as walking and cycling, and undertake localised highway junction improvements where there are critical pinch- points on the road network.
Examples of successful initiatives are:
the Taunton Flyer park and ride service (www.tauntonflyer.co.uk) introduced to the west of Taunton now has passenger numbers way in excess of the original predictions, and is shortly to be supplemented with a second site to the east of Taunton
the ‘Moving Forward’ marketing campaign (www.movingsomersetforward.co.uk) is encouraging people to use their cars less
Road Traffic Collisions
Due to a lack of substantial improvement in casualty figures from 1994-2006 Somerset County Council made the decision to bring together individual road safety organisations in a coherent and targeted approach, to reduce the numbers of people being killed and injured on local roads. To achieve these goals, the Somerset Road Safety Partnership was formed.
Casualty data reveals that these are the following key areas for attention:
Drivers car occupants account for 90% of road casualties a third of driver and passenger casualties are under the age of 25 years
Riders riders of powered two-wheelers under 125cc, aged between 16-19 years, show a rise in casualties by 38% over the past five years riders of larger capacity two-wheelers shows those aged 30-44 years are the most vulnerable to being involved in collisions
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Children long-term road safety education is essential in preparation for when they become riders or drivers in the future
Casualty Reduction Targets
The figures below show the casualty statistics for Somerset and progress towards the Government’s road safety casualty reduction targets for 2010 compared with the average for 1994-98.
Figure 3
Figure 4
Figure 5
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Developing a new ‘Step Change’ Safer Roads Strategy
Delivering the LTP2 Objective: reducing traffic accidents, with a particular emphasis on child casualties and areas of disadvantage.
There is a need for a step change in intervention through the widest possible range of activities and processes, departments and external agencies, communities and businesses. This will require a prioritised sequential approach to achieve targeted and best value for money outputs in order to deliver most needed outcomes – a significant reduction in numbers of people killed and injured on roads in Somerset.
Cycling
Figure 6 below shows that our levels of cycle commuting are considerably higher than they are in the country as a whole and the south west region. Over half our cycle commuters live in the main urban areas of Taunton, Bridgwater and Yeovil, with almost a quarter (about 2,500 cyclists) living in Taunton.
Figure 6
The following figure shows the percentage change in cycling in each town between 1991 and 2001 in purple, together with the proportion of people cycling to work in each town (2001) in red. This shows for instance in Wellington that about 5% of people currently cycle to work, and there was about a 4% reduction in cycling to work between 1991 and 2001.
Many towns have suffered a reduction in cycling over this period although five have experienced growth. Cycle to work figures range from 1.2% in Crewkerne to 10.5% in Bridgwater, with 10 of our 16 towns currently higher than the national and regional average.
Figure 7
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Crime
Research carried out in 2007 by South Somerset District Council and as part of the LAA research, revealed that Somerset’s population is satisfied with their local area as a safe place to live. The majority feel safe outside their local area at night, although they would feel unsafe being outside alone at night. However, although most respondents to this survey did not feel any different toward crime than two years ago, a quarter felt more afraid of crime. Crime reduction and community safety is still a rising priority for Somerset’s residents: 60% felt that levels of crime were an important factor in making somewhere a good place to live and 38% that the levels of crime were a high priority.
The county has experienced an increase in anti social behaviour (ASB) reporting due to the set up of recording systems, demonstrating the confidence of Somerset residents to report incidents10. The proportion of people perceiving high levels of ASB in Somerset fell from 46% in 2003/04 to 27% in 2006/07 and is generally lower than the national average. However, ASB reports have increased by 5% between 2006 and 2007, with the biggest increase in Burnham-on-Sea (+20%), Wellington (+19%), Shepton Mallet (+16%) and Street (+15%). The fall in perception of anti-social behaviour might be linked to the increase in reporting due to a better disposition for reporting (even for lower levels of nuisance) and the perception that the authorities will take action.
Crime statistics for Somerset West11 (neighbourhood areas: Bridgwater, Burnham on Sea, Minehead and Taunton)
Figure 8
10 Somerset Community Safety Strategic Assessment printed February 2008 11 Avon and Somerset Police website
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Table 5
Crime category Number of crimes Change on same for financial year period last year 2008/2009 2007/2008 Homicide 0 0 Grievous Bodily Harm 42 +11 Actual Bodily Harm 654 -59 Common Assault 389 +18 Harassment 295 +66 Other Violence against the Person 137 -4 Robbery 31 +6 Sexual Offences 113 +20 Domestic Burglary 274 -5 Non-domestic Burglary 582 +57 Theft of Motor Vehicles 139 -51 Theft from Motor Vehicles 527 -151 Criminal Damage 1758 -122 Fraud / Forgery 217 +45 Other Crimes 2180 -215 Total Crime 7338 -384
Table 6 Detected Crime - % of crime where there has been some form of legal sanction against the offender (e.g. taken to court, cautioned or fined)
Area 2008/2009 (Year to date) 2007/2008 Somerset West district 28.7% 28.9% Avon and Somerset 25.9% 25.1%
Table 7 Force Average - How do local crime levels compare to the force average?
Area Total crime per 1000 population for financial year 2008/2009 Somerset West district 29.7 Avon and Somerset 40.6
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Crime statistics for Somerset East (neighbourhood areas: Frome, Mendip West, South Somerset Rural, Yeovil)
Figure 9
Table 8
Crime category Number of crimes Change on same for financial year period last year 2008/2009 2007/2008 Homicide 0 -1 Grievous Bodily Harm 18 +2 Actual Bodily Harm 555 -109 Common Assault 307 -78 Harassment 316 -12 Other Violence against the Person 114 +17 Robbery 18 -11 Sexual Offences 86 -7 Domestic Burglary 291 -7 Non-domestic Burglary 548 +12 Theft of Motor Vehicles 164 -25
Theft from Motor Vehicles 536 -67 Criminal Damage 1783 0 Fraud / Forgery 202 -11 Other Crimes 2777 +367 Total Crime 7715 +70
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Table 9 Detected crime - % of crime where there has been some form of legal sanction against the offender (e.g. taken to court, cautioned or fined)
Area 2008/2009 (Year to date) 2007/2008 Somerset East district 25.9% 26.9% Avon and Somerset 25.9% 25.1%
Table 10 Force Average – how do local crime levels compare to the force average? Please note that these figures are provisional and are subject to audit
Area Total crime per 1000 population for financial year 2008/2009 Somerset East district 30.1 Avon and Somerset 40.6
Community Safety Strategic Assessment 2007
The Somerset Community Safety Strategic Assessment is a yearly document published in December gathering countywide research, evidence and intelligence in order to identify and prioritise potential community safety issues and threats which the county may face in the coming year.
It is a joint partnership document and is designed to be a point of reference and guidance to resource community safety initiatives among all partner agencies across the county. The main aim of the assessment is to identify priorities to inform a joint strategy and action plans in order to tackle these priorities in a coordinated approach within Somerset.
Between publications, other pieces of work will be commissioned to fill any information gaps or identify new potential emerging threats in the course of the year and will then be integrated to the Strategic Assessment Process.
The Drug and Alcohol Action Team and Crime and Disorder Reduction Partnerships (DAAT/CDRP) group has agreed to adopt the process, which is summarised in Figure 10 on page 30. The third Community Safety Strategic Assessment involved a team of managers and analysts from:
Avon & Somerset Constabulary (A&SC): Somerset East & Somerset West District Devon & Somerset Fire and Rescue Service (D&SFRS) Somerset PCT and the Drug and Alcohol Action Team (DAAT) Somerset County Council Avon & Somerset Probation Service Mendip District Council and South Somerset District Council (M&SSDC) Sedgemoor District Council (SDC) Taunton Deane Borough Council (TDBC) West Somerset District Council (WSDC) Youth Offending Team (YOT)
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Figure 10
Community Safety Strategic Assessment – some issues of concern
Binge drinking - is a major contributor to the levels of crime relating to the night-time economy. The findings of a national Home Office survey12 revealed that, even after other factors were taken into account, frequency of drunkenness remained strongly associated with both general offending and criminal and/or disorderly behaviour during and after drinking with two thirds of ‘binge’ drinkers admitting to it. ‘Binge drinkers’, especially males, were more likely to offend than other young adults. In Somerset there are alcohol related ‘hotspots’ in town centres and to outlying estates ie: criminal damage.
Dwelling burglaries - have decreased across Somerset every year since 2002/03. During 2007/08 there were 2,087 fewer victims of dwelling burglary than in 2002/03 - a reduction of 62.3%. So far year to date there is a 2% reduction in the number of dwelling burglaries compared to the same period last year. It is expected that there will be a slight rise in the number of dwelling burglaries by the end of the year due to the worsening economic climate. A large number of dwelling burglaries in Somerset are committed by offenders with a drug dependency and will rise when a persistent offender is released. Offenders still target property that is easy to carry and/or easy to sell on: mainly cash, jewellery, mobile phones, computer equipment but also small electric tools (e.g. drills). 60% of offenders have admitted returning to a property they have previously burgled and taken items from it on a second occasion13.
12 www.homeoffice.gov.uk – alcohol related crime page – facts and figures from the BCS 2005/06 13 Home Office (2004) Decision making by house burglars: offenders’ perspective – Findings 249.www.homeoffice. gov.uk/rds/pdfs04/r249.pdf
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In Somerset, 10% of dwelling burglary victims have been repeat victims of the same offence within a year.
Distraction burglaries - targeting older and vulnerable people - are decreasing after a rise in the previous crime year (2007/08); elderly people (primarily females, 65 years and over) are still the main target for ‘distraction’ burglars due to their vulnerability. Various research studies, including interviews with offenders, indicate that distraction burglars (employing, for example, a water supply problem as an excuse to call in) use environmental factors such as neglected gardens, wheelchair ramps or grip handles to identify vulnerable victims.
Year to date, distraction burglaries in Somerset East have decreased by 69% and in Somerset West by 71%. The reasons for the decrease are closer working relationships between Trading Standards and the Police and positive action on reports of rogue traders in Somerset. Sharing information with other forces on targeted offenders has also proved effective.
Metal theft - commercial burglaries and shed/garage breaks are increasing across the county where offenders steal tools and metal due to the high value of the items. Year to date, non-dwelling burglaries have increased by 7% compared to the same period last year. Increasingly, thieves are specifically targeting metal due to the fact that metal prices have dramatically risen in the last year and tools, as they are easily resaleable and can be hard to identify14. Offenders are targeting builders’ yards/sites and buildings under renovation, specifically for metal, mostly overnight. Offences are concentrated in central Bridgwater, Taunton, Yeovil, and Frome.
Increased reporting of domestic abuse - a high proportion of victims become victims of domestic abuse during pregnancy; however the effect of domestic abuse on children is still a gap in knowledge. While domestic abuse is a crime which is perpetrated upon both men and women, statistically 80% of reported domestic abuse victims are women15. Somerset’s profile of victims of reported domestic abuse is similar to the national profile: the most prevalent victim age groups being 16-24 and 35-44 yrs old. The prevalence of reported domestic abuse was found to decrease relatively consistently with the victim’s age16. It has been estimated that as many as approximately half a million older people are being abused at any one time in the United Kingdom (UK). The majority of perpetrators of elder abuse are family members.
Somerset’s fourth Community Safety Strategic Assessment is currently being completed and will be finalised in December this year (2008).
14 Nationally, Copper prices have risen by133% and steel prices by 40% between 2001 and 2004, and Iron prices by 400% between 2004 and 2006. (www.lme.co.uk) 15 BCS 2005/06 16 Home Office (2006), Domestic violence, sexual assault and stalking: findings from the 2004/05 British Crime Survey. Home Office Online Report 12/06.
31
32 CHAPTER 4 - CURRENT HEALTH STATUS CHILDREN AND YOUNG PEOPLE
What the situation is like now
Children and young people in Somerset are generally healthy, and partners are committed to further improvement. The Somerset Children and Young People’s Partnership (SCYPP) is responsible for planning, commissioning and delivering services to children and young people. The priorities in the Somerset Children and Young People’s Plan were developed by the SCYPP following a detailed Needs Analysis. The plan is structured into the five Every Child Matters outcomes (Being Healthy, Staying Safe, Enjoying and Achieving, Making a Positive Contribution, and Economic Wellbeing) and identifies 22 priorities.
In general, children are among the healthiest members of the population with falling perinatal and infant death rates. However, there is increasing evidence of the effects of poor health status in infancy and their relationship to health outcomes later in life.
Ideally women should consider their health prior to pregnancy to ensure the best start for their baby. Steps that can be taken to improve outcomes include stopping smoking as this results in babies of lower birth weight and increasing intake of folic acid as this is known to reduce spina bifida. Women with specific health problems such as diabetes and epilepsy need careful monitoring to maximise the health of their unborn child. The NHS operating framework for 2008/09 sets out a target for women to attend antenatal care by the 12th week of pregnancy. Early booking is associated with better outcomes for babies and mothers as problems can be identified early and those at risk given extra support.
There are a range of ante natal and post natal tests undertaken routinely to ensure that the baby is protected from specific diseases, or if affected, can be identified early. These include ultra sound scans, screening for Down’s Syndrome, Hepatitis B and HIV. Post-natally a newborn physical examination is carried out along with a heel prick test for a collection of inherited conditions which can be screened for early in infancy and neonatal hearing screening.
Infant mortality in Somerset, with 4.3 deaths per 1,000 live births, is not significantly different from the south west average of 4.4 per 1,000 births and slightly better than the rate for England and Wales of 5.0 per 1,000 births.
There are 111,841 children aged under 18 living in Somerset and at any point in time, 3,250 children are assessed as being “in need”. Over the last year, there have been approximately 370 Children in Care (CiC). At any one time, 240 children are subject to a child protection plan. There are about 200 CIC in Somerset who are placed by other local authorities. 260 foster carer households care for 75% of children in care; thereafter nine children’s residential centres. The proportion of children with a limiting long-term illness at 4% is less than the national average.
The needs of children and young people feature throughout this JSNA, and issues such as Sexual Health, Teenage Pregnancy, Smoking, Substance Misuse and Obesity, are addressed within the relevant sections.
33 CHAPTER 4 - CURRENT HEALTH STATUS CHILDREN AND YOUNG PEOPLE
This Children and Young People section focuses on the following issues: Breastfeeding, Healthy Schools, CAMHS, Children in Care and Children with disabilities, Dental Health and other wider issues which have an impact on health inequalities, such as educational achievement and young people’s participation in education, employment and training.
How are we doing?
Breastfeeding
Breastfeeding has a major role to play in public health, promoting health and preventing disease, in both the short and the long term for baby and mother, yet breastfeeding initiation rates in the UK are the lowest in Europe. Women from disadvantaged or minority groups and teenage mothers are less likely to breastfeed.
Many mothers who do breastfeed but give up early would have continued if they had more support. Breastfeeding protects the baby against many illnesses including gastroenteritis and ear, respiratory and urinary infections and reduces the incidence of childhood obesity. Breastfeeding has also been shown to have a protective effect on the health of mothers, particularly in respect of pre-menopausal breast cancer and ovarian cancer. The breastfeeding initiation rate is good at 76% cent, higher than the national average of 69%. In 2008/09 the PCT has a new target, in addition to breastfeeding initiation, to measure the breastfeeding rate at six weeks (currently around 34%).
Multi agency breastfeeding training (including children’s centre staff) is now provided in partnership with the National Childbirth Trust.
Healthy schools
The Department for Children, Schools and Families (DCSF) runs the National Healthy Schools Standard which encourages partnership working between health service and schools to promote healthy lifestyles with the whole school community. This is achieved through the provision of accessible and relevant information, and by fostering skills and attitudes to promote informed decision making about health.
To satisfy the National Healthy Schools Standard, a school has to meet 41 criteria across four key themes – Personal, Social and Health Education (PSHE), Healthy Eating, Physical Activity and Emotional Health & Wellbeing.
Support for schools working toward the National Healthy Schools Standard has been provided in Somerset by the Healthy Schools Team, who are part of the Children and Young People’s Directorate of Somerset County Council. Somerset PCT has had a key role in their work through both the appointment of the Health Promotion Practitioner for Children and Young People, who works in partnership with the team, and through the work of School Health Advisors supporting individual schools. From April 2008, there has been a 12 month interim arrangement in place for the Healthy Schools Team with a view to wider integration with other posts currently supporting health promotion for children and young people from 2009 onwards.
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Somerset teachers and community nurses are able to participate in the DCSF and DoH National Personal, Social and Health Education Continuing Professional Development Programme. By the conclusion of the 2006/07 programme, a total of 47 teachers and 16 community nurses had gained national certification. A further seven nurses and 28 teachers have already been recruited to the coming year’s programme. The management of the community nurse programme is led by Somerset PCT and is run in collaboration with the Local Authority Healthy Schools Team which leads on the teacher's programme. This joint training of professionals further strengthens understanding and partnership working in support of the children and young people in our schools.
Somerset PCT support for health promotion in schools is already well developed. In future, this joint working can be further strengthened by greater strategic planning of work undertaken by school health advisers, Somerset Healthy Schools Team and the Health Promotion Practitioner for Children and Young People.
From July 2008, 71% of Somerset schools have achieved National Healthy Schools Status (NHSS), exceeding national targets and milestones. All schools are registered as engaged in the process and the team are confident of achieving 75% cent by 2009.
Each year, Ofsted undertake a survey of a sample of Children and Young People in Somerset. The ‘TellUs’ survey asks a number of questions about children and young people’s perception of their health and about the information and advice they receive. The results for Somerset for the 2007 survey were better than the national average and showed that:
only 7% of respondents in Somerset answered that they are “not very healthy” which is lower than the national average of 9% 86% of respondents were happy (“good enough”) with the information and advice they received in relation to eating healthy food, compared to national average of 80% 79% of respondents were happy (“good enough”) with the information and advice they received in relation to alcohol and smoking, compared to national average of 74% 75% of respondents were happy (“good enough”) with the information and advice they received in relation to drugs, compared to national average of 69%
CAMHS (Child and Adolescent Mental Health Services)
A needs assessment of Tier 3 and 4 CAMHS services has been carried out to inform future commissioning requirements and the development of the service specification. The annual CAMHS Mapping for 2007/08 illustrated good progress in the four key areas. In 2006, the percentage of new CAMHS cases with a length of wait under four weeks improved dramatically to 82.4 per cent compared with 57.6 per cent in 2005. This is significantly better than the national average of 39.8 per cent and has a RAG (Red; Amber; Green) rating of green (further information is contained in the Mental Health section of this chapter).
35 CHAPTER 4 - CURRENT HEALTH STATUS CHILDREN AND YOUNG PEOPLE
Children in Care (CiC)
There are a number of measures of ‘outcomes’ for children in care. There is one specific indicator for the health of looked after children and it measures the percentage who have had an annual health assessment and a dental check.
In Somerset for 2007/08 performance was 81.8%, which although is judged by Ofsted to be “very good” is not rising as fast as other authorities. Therefore, the Healthy Care Partnership has identified a range of initiatives and additional resources to further improve performance.
The percentage of CiC cases reviewed on time has risen from 92.1% in 2006/07 to 94.3% in 2007/08. There has also been a rise in the proportion of children in care expressing their opinions in their reviews, from 87.1% in 2006/07 to 92.3% this year.
Children with special education needs and disabilities
There is continued growth in the prevalence of children with severe and complex disabilities, and there are rising numbers of children with autistic spectrum disorders. Increased survival across the age range is the main reason for the growth - especially of very premature/extreme low birth weight infants.
Children with learning difficulties and/or disabilities are very well supported to ensure they can enjoy and maximise their educational potential. As a result of effective Early Years multi-agency assessment, intervention and funded support, 9.8% of Key Stage 1 (KS 1) children with Special Education Needs (SEN) entered mainstream schools last September; only eight required specialist provision. School action funding targets the most vulnerable pupils and is accessed through rigorous audits. Monitoring is through annual reviews and frequent multi-professional consultation meetings. As a result, specialist provision need is consequently low, with 99.2% of pupils (0.6% above the national figure) included within the mainstream.
As a result of the synergies created by integrating disability services, fewer children and young people with complex SEN and disabilities require independent specialist education and care placements. Of the school population of approximately 70,000, only 85 students in Somerset, annually, are placed in independent provision. An increasing number of children with autism at the highest level of School Action Plus (level 3) are able to have their needs met in mainstream rather than specialist provision (35% cent in April 2008). The Children and Young People’s Directorate (CYPD) is currently drawing up a service specification for Paediatric therapies with the PCT. This work will be jointly commissioned between Health and CYPD.
Half of Somerset’s primary schools are actively engaged with the local authority (LA) to develop the use of SEAL (Social and Emotional Aspects of Learning), and others are doing so independently. Monitoring visits show over 75 per cent of supported schools are developing good or excellent practice in the first two years of the programme.
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Staff report that pupils are calmer and better able to learn (further information is contained in the Learning Disabilities section of this chapter).
Dental health
The dental health of children and young people has improved over the past 30 years but research shows that the levels of decay in Somerset’s five year olds are increasing. Oral health is an integral element of general health. Good oral health enables individuals to communicate, eat and is important to overall quality of life, self- esteem and social confidence. Pain, discomfort, sleepless nights, functional limitation leading to poor nutrition, and time off work and school are common impacts of oral disease. Most oral disease is preventable.
Disadvantaged children continue to be disproportionately affected by dental decay. The 2003 Child Dental Health Survey found children from deprived backgrounds to be to be 50% more likely to have decayed primary (milk) teeth than the most affluent. The prevalence of dental decay in Somerset is approaching that of England, children having an average of 1.48 teeth with treated or untreated decay (2007 figures).
Average decay rates mask underlying inequalities in dental health, as decay is not evenly spread throughout the population. Most of the children who took part in the 2006 survey did not have dental decay; all of the decay was seen in 37% of the children. Amongst this group, each child had an average of four affected teeth. When analysed at school level, using the Wealth-Poverty index (an aggregate measure of social deprivation, derived from individual pupil data), dental decay prevalence was higher amongst deprived schools. The most disadvantaged children in Somerset are most likely to have experienced dental decay.
Distribution of Schools with High Level Dental Caries
Previous research on the economic effectiveness of water fluoridation has identified a mean “dmft” (decayed, missing or filled teeth) of two teeth per child as a community level of dental caries. The map overleaf illustrates the distribution of schools with dmft greater than two. The location of these schools has been mapped to provide a visual representation of community areas likely to have high levels of dental decay.
37 CHAPTER 4 - CURRENT HEALTH STATUS CHILDREN AND YOUNG PEOPLE
Map1: Distribution of schools with mean dmft of 2.0 or greater in Somerset
Education
There have been notable improvements in performance in Early Years Foundation Stage. At Key Stage 1, Somerset’s results are around national average at level 2 and level 3. Key Stage 2 results improved significantly in 2007, although Outcomes at Key Stage 3 dipped slightly, but still exceed the national outcomes and no schools were below the floor target. Good improvements were made at Key Stage 4 with the proportion of pupils achieving 5+ A*-C grades (including English and Maths) increasing by 2.5 percentage points.
Ofsted’s judgements in relation to Somerset’s schools show an overall improvement in the effectiveness of schools and the quality of provision. There has been a rise to 63% in the number of schools inspected and judged to be good or outstanding since April 2007. Currently, only 1.77% of schools are judged to be inadequate, better than both our statistical neighbours and the national average.
Attendance at primary school is particularly good with overall absence of 4.95% (2006/07) compared with the national average of 5.15%. Authorised absence in primary schools is low, placing Somerset in the top quartile of LAs; unauthorised absence remains at 0.5%. Overall absence in secondary schools is low and is reducing (7.58% in 2006/07) despite a slight increase in unauthorised absence as a result of the rigorous stance being taken by head-teachers in relation to holidays in term time.
38 CHAPTER 4 - CURRENT HEALTH STATUS CHILDREN AND YOUNG PEOPLE
In terms of exercise, 89% of 5-16 year olds are receiving two hours of PE/sport in schools compared to 86% nationally – largely due to the excellent work of our Somerset Activity and Sports Partnership. Moreover, 49% of 5-16 year olds compete in inter-school sport competitions compared with 35% nationally. Somerset is also a trailblazer county (one of nine in England) to receive funding to support the Five Hour Offer – an action plan is currently being rolled out to deliver this.
Participation in education, employment or training
Progress in improving participation in education, employment or training for those at risk of becoming Not in Education, Employment or Training (NEET) is very good. The Somerset NEET figure has continued to decline and is currently amongst the best in the country at 4.3%. However, the young people with the highest rate of NEET are young offenders, teenage parents and care leavers.
What is working?
Partnership working is strong. Relationships with schools are good; regular meetings of the Somerset Education Policy Team (SEPT), which includes the chairs of the head teachers’ groups, help to inform and shape policy. Senior officers regularly attend primary, middle, secondary and special school head teachers’ meetings. Relationships with other partners, such as the dioceses and Learning Skills Council, are good as are those with the teacher associations and UNISON, largely as a result of well-developed consultative arrangements.
Overall, children are safe in Somerset and tell us so from the Ofsted survey. In 2006/07, 90/96 (94%) and in 2007/08, 68/74 (92%) were good or outstanding in relation to pupils adopting safe practices. However, there are a number of issues including bullying, road safety, domestic violence, internet safety and some issues from Serious Case Reviews that need addressing.
A significant development in the last three years has been a focus on the effective use of data, drawn from a variety of sources and updated annually, to inform planning and performance management. Data is well-used to support the priorities in our children’s plan and is reviewed with partners at away days and through our 0-13 and 13-19 commissioning groups. The updated activity plans include actions arising from our Joint Area Review carried out in November 2006. Progress on implementing the Plan’s priorities is undertaken quarterly and shared with partners. Presentations to a range of staff and community groups were undertaken to publicise the revised activities. Senior officers and elected members meet with groups of young people on a regular basis to discuss their priorities and reflect their views in service planning.
Recent discussions with young people have informed the development of our internet safety policy and County Bus ticket.
39 CHAPTER 4 - CURRENT HEALTH STATUS CHILDREN AND YOUNG PEOPLE
In tandem, the top priorities, together with the priority areas agreed with the DCSF at the annual priority setting meeting in last December, were used to inform the selection of indicators for inclusion in Somerset’s LAA 2008-11. This has strengthened the understanding of county council officers in other directorates and members as well as other partners of the priorities for children and young people in Somerset.
Young people are involved at a strategic level in a variety of ways:
as members of the Somerset Strategic Partnership and C&YP Scrutiny Panel in the appointment of staff throughout the directorate in the effective distribution of Youth Opportunity and Youth Bank funds and in the priorities for projects to receive grant aid from Children’s Fund monies; the Somerset Youth Partnership allocates grants to voluntary organisations in their communities through the ‘Activ8tors’ training programme; 60 young people were involved in 2007, 23 of whom participated with elected members in the ‘Place Shaping’ agenda for Somerset providing advice on priorities for funding schools (as part of the recent fundamental review of the allocation of schools’ budgets) highlighting current issues of concern to young people through the Children’s Parliament for Year 6 pupils through consultations on the designs for new play provision in Yeovil and Taunton the provision of more sporting opportunities as a result of feedback from summer play schemes through feedback to corporate parents when members visit residential units as key contributors in the design process for BSF17 in Bridgwater
The Positive Activities database (AWSOM) was researched and designed by young people and detailed consultations with young people ensured customer-friendly content and design of the MovingonMovingup website providing information for all 14 - 19 courses. Connexions Service carried out a survey of 2,000 young people and 500 parents and held an ‘Involvement Week’ of consultations as part of their process of continuously developing the service.
Providers who take on the Flying Higher award are being asked to show they have taken the views of the children into consideration and, where possible, involved them in planning.
17 Building Schools for the Future
40 CHAPTER 4 - CURRENT HEALTH STATUS CHILDREN AND YOUNG PEOPLE
Children and Young People – summary
there are 111,841 children aged under 18 living in Somerset and at any point in time, 3,250 children are assessed as being “in need” the breastfeeding rate is 76% (national average 69%). In 2008/09 the PCT has a new target, in addition to breastfeeding initiation to measure the breastfeeding rate at six weeks (currently around 34%) 71% of Somerset schools have achieved National Healthy Schools status, exceeding national targets and milestones the prevalence of dental decay in Somerset is approaching that of England, each child having an average of 1.48 teeth with treated or untreated decay and marked inequalities exist 63% of Somerset schools are judged following inspection as good or outstanding since April 2007 the Somerset NEET (not in education, employment or training) figure is currently amongst the best in the country at 4.3%
Where are the gaps?
Wide inequalities exist between children born to the most affluent parents and those who are most deprived. For example, childhood accidents are five times more common in deprived children and they are twelve times more likely to die in a fire. Some specific projects focusing on inequalities are being undertaken such as the Family Nurse Partnership targeting young vulnerable mothers and consideration of health input to the Bridgwater “Building Schools for the future” project. The roll out of children’s centres and input from health staff will target children requiring extra support.
vulnerable groups - although children are generally healthy overall there are some specific groups who need special focus to ensure that health outcomes are improved. These include children who are looked after, children out of school, children with disabilities, children from minority ethnic groups and children known to the youth justice system approximately 60% of children who are looked after will have a mental health problem and one in seven girls leaving care either have been or are pregnant. Specific targets relating to immunisations, access to dentistry and regular health assessments are monitored for this group of children and young people
Work to reduce health inequalities is set out within this section and also in the obesity and teenage pregnancy sections (see also Chapter 7 - Health Inequalities – page 150-151)
41 CHAPTER 4 - CURRENT HEALTH STATUS TEENAGE PREGNANCY
What the situation is like now
Over the last two years there have been substantial changes within young people’s services within both Somerset County Council and the PCT. However, there have been positive developments and maintenance of services for young people during this change period.
The Teenage Pregnancy Partnership Board and the Sexual Health Implementation Team oversee and monitor the key areas of work. Teenage pregnancy is fully embedded into the Children and Young People’s Plan and the Sexual Health Strategy.
The Teenage Pregnancy Implementation Grant is no longer ring-fenced as from April 2008 and is now incorporated into the Area Based Grant.
There are a number of young people’s clinics based within the PCT, community and school based venues which enable young people to access a range of services, depending on what staff are able to offer. The majority of clinics have been assessed and awarded the Somerset quality assurance award, RESPECT. The RESPECT award has recently been evaluated which identified some areas for improvement but also highlighted that young people welcome such a scheme as RESPECT. Young people have been involved in ‘mystery shopping’ services. Work is underway to ensure that this area of work is mainstreamed within the PCT. The PCT is working towards developing a framework for setting up young people’s clinics as well as a service specification.
There has been an emphasis on the development and implementation of the C-Card across the county to enable young people to access free condoms from a range of venues. A more effective database has been implemented that will provide more accurate figures but approximately 3,500 young people have signed up to the C-Card. The C-Card was evaluated during 2007 which highlighted positive outcomes for young people and staff.
A care pathway for abortion services has been developed and has been opened up to NHS funded places with two private providers – Marie Stopes and British Pregnancy Advice Service (BPAS) for all Somerset residents. This will increase access and choice.
Multi-agency sexual health training has been delivered to a substantial number of workers with a comprehensive training programme in place for the period September 2008 – March 2009. The training focuses on basic awareness, delaying early sex, abortion awareness, Sex and Relationship Education (S&RE) delivering good practice, Lesbian, Gay, Bisexual and transgendered (LGBT), sexual health work with vulnerable young people and the C-Card. A multi-agency team will deliver the training with an aim of ensuring standardisation, quality assurance and sustainability.
Single gender work has been undertaken, with support from the Boys and Men’s Worker and Girl’s and Young Women’s Worker, with vulnerable young people, including those attending pupil referral units (PRUs) and mainstream schools, looked after children and in areas of high teenage pregnancy.
42 CHAPTER 4 - CURRENT HEALTH STATUS TEENAGE PREGNANCY
Young parents have been involved in delivering peer education programmes in a school setting in some parts for the county.
A Sex and Relationships Education (S&RE) Schools Adviser supports schools in their delivery of S&RE. A package of work is being developed based on the National Children’s Bureau audit tool and linked to local services. The 3 Tier Model for S&RE in Somerset was published in May 2007, which clearly outlines how S&RE should be delivered within schools and pupil referral units. Phase 5 of the Personal, Social, Health, Education Continuing Professional Development (PSHE CPD) programme saw 23 teachers and six nurses complete the programme (2007/08). In Somerset there is a higher retention rate compared to national figures. As of July 2008, 71% of Somerset schools have received Healthy School status.
A branding for young people’s sexual health services and information has been developed and will be used to inform young people about chlamydia screening, young people’s clinics, C-Card, pregnancy testing, abortion services and emergency contraception. A web site will be developed over the coming year using the branding. A promotional plan will be put together in order to maximize the best use of the resources produced and to raise awareness about local services.
The Family Nurse Partnership is one of only 10 pilot programmes in the country and is showing positive outcomes for young families already. 100 families were recruited by October 2007 with 72 families still on the programme in May 2008, which represents a 28% drop out rate. The average age of the young mothers involved is 17.9 years. 45% live with their partner/husband, 59% are not in work, 24% work part time, and 29 clients are at school.
The Targeted Youth Support Team for young people not in education, employment and training comprises of a designated team of additional support advisers based with the Youth Offending Team who have a role around supporting young people who are either young offenders, care leavers or teenage parents back in education, employment or training.
Taunton and Somerset NHS Foundation Trust have employed a specialist midwife for young mums. A multi-agency under 16s ante natal clinic runs at Musgrove Park Hospital once a month.
How are we doing?
Somerset’s target is to reduce the rate of under 18 conceptions by 50% by 2010 using the baseline figures for 1998. The target rate for 2010 is 19.4. Somerset has seen an upward trend in the 2006 under 18 conception rate.
The rate for 2006 is 33.0 with a change in rate from baseline (1998) of 15%. The 2006 rate for the south west is 32.9 (-16.6%) and the 2006 rate for England is 40.4 (-13.3%). The upward trend has meant that Somerset has gone from Green to Green/Amber (2005 data) to Red/Amber (2006 data). The 2006 data shows that we have made least progress in the Taunton Deane area (-5%) and the most progress in Sedgemoor (-28.5%) and West Somerset (-35.1%).
43 CHAPTER 4 - CURRENT HEALTH STATUS TEENAGE PREGNANCY
The comparisons with our statistical neighbours show that we are doing less well than Suffolk (-17.9%), Herefordshire (-29.6%) and better than Devon (-8.8%) and Shropshire (-4.6%). The Teenage Pregnancy Partnership Board has developed a local data set, which includes a range of data including local deliveries and abortion data and numbers accessing clinics (Figure 1).
Figure 1
1998 2010 50
Somerset 40 England
30 South West
20 LA 2004 target
10
Under 18 conception rate per 1000 per conceptionrate Under 18 0 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Year
From 2004 to 2006 the percentage of under 18 conceptions leading to legal abortion stayed at 49%. Nationally, the figures increased by 3% in the same period. The number of repeat abortions to females aged under 19 in Somerset decreased between 2005 and 2006 from 8.9% to 6.7%.
Between 2005/06 and 2007/08 the rate of under 18 deliveries across Somerset increased from 12.9 to 18.5 per 1,000 with the greatest increases occurring in West and South Somerset followed by Sedgemoor and Mendip.
Increases in South Somerset occurred in both South Somerset East and West (increases of 49.8% to 20.22 and 78.43% to 16.88).
Rates in West Somerset, Wellington and Wiveliscombe almost doubled to 20.50 per 1,000 2007/08. Rates in East Mendip increased by 91.8% to 19.08 per 1,000 whereas rates in West Mendip fell slightly by 1.48 per 1,000. Rates in South Sedgemoor increased from 15.55 to 23.05 and fell in North Sedgemoor by 1.48 per 1,000 to 8.88.
44 CHAPTER 4 - CURRENT HEALTH STATUS TEENAGE PREGNANCY
Table 1: Under 18 hospital deliveries estimated rates per 1000 District 2005/6 2006/7 2007/8 Mendip 12.2 11.3 17.0 Sedgemoor 13.3 13.3 17.7 South Somerset 11.0 16.3 18.6 Taunton Deane 17.5 16.2 18.6 West Somerset 8.5 13.6 26.1 SOMERSET 12.9 14.4 18.5
Local Service Team (LST) 2005/6 2006/7 2007/8 East Mendip 9.95 13.06 19.08 North Sedgemoor 10.36 9.94 8.88 South Sedgemoor 15.55 16.94 23.05 South Somerset (East) 13.50 20.21 20.22 South Somerset (West) 9.46 14.20 16.88 Taunton 20.35 18.06 20.41 West Mendip 15.85 11.52 14.82 West Somerset, Wellington & Wiveliscombe 10.81 14.59 20.50
During the same period the rate of under 16 hospital deliveries also increased. South Somerset experienced a significant increase from 1.6 to 3.4 per thousand followed by Sedgemoor, Taunton Deane and Mendip.
Rates in South Somerset West increased by 2.78 per thousand to 3.47, and in South Sedgemoor by 3.94 per thousand to 6.12. Rates in East Mendip increased to 4.05 but fell slightly in West Mendip to 3.81. Taunton Deane experienced little change. In West Somerset, Wellington and Wiveliscombe the rate of 1.71 in 2007/08 was a slight decrease on the previous year.
Table 2: Under 16 hospital deliveries estimated rates per 1000 District 2005/6 2006/7 2007/8 Mendip 3.1 2.6 3.9 Sedgemoor 1.4 0.9 3.8 South Somerset 1.6 2.2 3.6 Taunton Deane 1.9 1.8 2.8 West Somerset 0.0 1.8 0.0 SOMERSET 1.8 1.9 3.4
Local Service Team 2005/6 2006/7 2007/8 East Mendip 2.48 1.64 4.05 North Sedgemoor 0.00 1.24 0.00 South Sedgemoor 2.18 0.76 6.12 South Somerset (East) 2.43 1.89 3.80 South Somerset (West) 0.69 2.76 3.47 Taunton 2.63 1.94 2.65 West Mendip 4.05 4.05 3.81
45 CHAPTER 4 - CURRENT HEALTH STATUS TEENAGE PREGNANCY
What is working?
C-Card
The aim of the C-Card is to promote the use of condoms for safer sex, encourage access to sexual health information and develop a monitoring system to provide data for the PCT to ensure equitable access to condoms across Somerset. The C-Card is an excellent example of partnership working between not only the PCT and SCC but also the great range of agencies that operate the C-Card.
In September 2007 Evidence Base Ltd undertook an evaluation of the C-Card using online and telephone surveys. The evaluation demonstrated that the C-Card is a successful scheme for promoting condom use and safer sex for young people. The evaluation has demonstrated that, to a large extent, the scheme appears to be meeting the needs of stakeholders. Both young people and staff value the C-Card greatly. The evidence suggests that the C-Card will help to reduce the incidences of teenage pregnancy and sexually transmitted infections (STIs) among young people in Somerset.
Young people’s health clinics
There are a number of school based clinics in Somerset. The majority are based within Sedgemoor and West Somerset. The clinics that have been set up by running formal consultations with students, governors, parents and school staff are ‘owned’ by the school and are promoted openly and link with the schools SRE curriculum. The PCT is working towards developing a framework for setting up young people’s clinics in schools as well as a service specification.
The East Taunton Clinic for young people has been operating for a year now. Attendances have increased over the year with young people attending the clinic for chlamydia screening, C-Card and contraception from a doctor or a nurse. This area has the highest under 18 conception rate in Somerset and is an area of high deprivation and disadvantage.
Teenage Pregnancy and the Chlamydia Screening Programme are working together including a peer education project in Yeovil College.
Teenage Pregnancy – summary
Somerset needs to reduce its under 18 conception rate by 50% by 2010. The 2006 rate shows a reduction of only 15% under 18 conceptions are 4.7 times higher in the most deprived areas a Teenage Pregnancy Data Set has been developed but formal information sharing procedures need to be in place between key agencies a targeted, multi-agency approach needs to developed in teenage pregnancy hot spot areas, including the establishment of school based health clinics teenage deliveries are increasing
46 CHAPTER 4 - CURRENT HEALTH STATUS TEENAGE PREGNANCY
Where are the gaps?
there are areas in Somerset where young people have limited access to contraception and advice. In the Taunton area there are no school based clinics. In Taunton there is limited access to the C-Card. The RESPECT quality assurance scheme for young people’s clinics needs to be mainstreamed to ensure that the good work that was developed is sustained there is a need for more promotion of services setting out what they can offer including emergency contraception from pharmacists. Young women need to be offered the full range of contraception, including the Long Acting Reversible Contraception (LARC) full post code data is now provided by maternity services within NHS Trusts but there needs to be a formal agreement to provide names, with consent, so that appropriate support arrangements can be put into place
(see Chapter 7 – Health Inequalities – page 152-154)
47 CHAPTER 4 - CURRENT HEALTH STATUS SEXUAL HEALTH
What the situation is like now
Sexual health
Reporting from south west region sexual health profile November 2006:
there is continuing increase in HIV infection with 85% acquired through heterosexual route outside of the UK other sexually transmitted infections are continuing to increase in line with the rest of the UK with particular concern for chlamydia, which has seen an increase of 200% over the last two years particularly amongst young people
Teenage pregnancy (also see Chapter 4 - Teenage Pregnancy)
Whilst Somerset has low rates of teenage pregnancy compared to the national picture, following an initial downward trend from the 1998 baseline there has been an upward trend in the 2006 under 18 conception rate.
The rate for 2006 is 33 (per thousand) with a change in rate from the baseline 1998 of 15%. The 2006 rate for the south west is 32.9 (-16.6%) and the 2006 rate for England is 40.4 (-13.3%).
Termination of pregnancy
The number of terminations of pregnancy (TOP) in Somerset has remained fairly consistent year on year, with 1,186 terminations in 2007, compared to 1,193 in 2006. The majority of terminations are in women in their 20s. The number of women receiving a TOP under 10 weeks gestation in Somerset has consistently fallen below the target of 60%.
HIV
The numbers of people with HIV in Somerset remains relatively low in comparison to most other areas. However, these numbers continue to increase year on year, with increases being significant in relation to the low prevalence. HIV contracted through men who have sex with men remains the main route of transmission overall, but the largest increases have occurred through heterosexual sexual transmission. A sizeable proportion of newly diagnosed HIV in Somerset has been amongst immigrants from Sub-Saharan Africa and Eastern Europe.
How are we doing?
Teenage pregnancy
There is a Government and Local Area Agreement indicator (N112) of reducing the rate of under 18 conceptions by 50% by the year 2010 (data available 2012), from the 1998 baseline.
48 CHAPTER 4 - CURRENT HEALTH STATUS SEXUAL HEALTH
Whilst Somerset has low rates of teenage pregnancy compared to the national picture, there has been an upward trend in the 2006 under 18-conception rate.
The upward trend has meant that Somerset has gone from Green to Red/Amber on its performance against the target. The 2006 data shows that the least progress has been made in the Taunton Deane area (-5%) and South Somerset (-9.6%) and the most progress in Sedgemoor (-28.5%) and West Somerset (-35.1%).
GUM waiting times
The government’s 48-hour maximum waiting time target for genitourinary medicine (GUM) was achieved at Musgrove Park Hospital and Yeovil District Hospital for March 2008. However, the take up of offered appointments within 48 hours has not been achieved within target.
Chlamydia
The LDP target for the Somerset programme in 2007/08 was set at 15% of Somerset’s total GP registered 15-24 year olds (9,600) with an anticipated 10% positivity rate. The Somerset Chlamydia Screening Programme (SCSP) screened 4.4% (2287) with a 12.5% positivity rate; 98% of index cases identified through the SCSP received treatment.
The LDP target for 2008/09 sets a screen return at 17% or 10,200 but this volume can now be made up from both activity within the SCSP and from diagnostic tests from all clinical areas other than genito-urinary medicine. Reviewing this activity for the past year the work outside of SCSP and GU in relation to Chlamydia in the age range is around 6,500 screens. This leaves the SCSP the more achievable target of 4,000 screens in the coming year or 1,000 each quarter. At the close of Quarter1 SCSP had screened 1,051 and treated 98% of positive cases.
Figure 1 Reports of Chlamydia trachomatis from laboratories compared to reports received through KC60 returns 1400 16000 1200 2.49* 14000 2.56* 1000 12000 10000 800 1.92* 1.52* 8000 600 Locality 6000
West South 400 4000 200 2000 0 0 2002 2003 2004 2005 2006 *Rate per 1000 Year KC60 reports all ages, Taunton & Yeovil Laboratory reports, Taunton & Yeovil KC60 reports all ages SW Laboratory reports SW
49 CHAPTER 4 - CURRENT HEALTH STATUS SEXUAL HEALTH
Termination of Pregnancy
The data for under 18 year olds shows that Somerset has one of the lowest rates nationally, with a rate of 14 per 1,000 15-17 year olds, slightly less than 2006, which had 15 per 1,000. The national rate for under 18s in 2007 was 19.8, compared to 18.2 in 2006 (England and Wales).
In Somerset the percentage of previous abortions in women under 25 (repeat abortions) for 2007 was 18%, compared to 19% in 2006. The south west was 19% and national 23.4%. The percentage of NHS funded abortions under 10 weeks for 2007 was 43%, compared to 40% in 2006, and well below the target of 60%. The south west percentage was 62%, and the national percentage was 64.9%.
HIV
Somerset PCT commission Somerset Gay Health to work to reduce the rates of HIV infection amongst men who have sex with men in Somerset. Positive Action South West are commissioned to provide support, advice, advocacy and information to Somerset residents with confirmed HIV status and their carers. This year’s World Aids Day campaign in Somerset aims to focus particularly on ‘hard to reach’ communities including black, minority, ethnic (BME)/migrant workers. The planned HIV multi agency conference in November 2008 will have this focus and planning work involving Somerset Racial Equality Council is underway. Further work to address HIV infection locally will be informed by these events and by a planned regional HIV health needs assessment.
What is working?
The Teenage Pregnancy Partnership Board and the Sexual Health Implementation Team oversee and monitor the key areas of work. Teenage pregnancy is fully embedded into the Children and Young People’s Plan and the Sexual Health Strategy. The following joint initiatives all aim to address this work programme:
Somerset C-Card - there has been an emphasis on the development and implementation of the C-Card across the county to enable young people to access free condoms from a range of venues. A more effective database has been implemented that will provide more accurate figures but approximately 3,500 young people have signed up to the C-Card. The C-Card has been recently externally evaluated demonstrating very positive outcomes regarding the uptake and views of the scheme by both young people and practitioners local services - minimum quality standards: young people’s clinics have been set up in a number of schools and community venues in the county. Further clinics will be developed in areas of high teenage pregnancy. The majority of clinics have been quality assessed to local RESPECT standards, which are in line with the ‘You’re Welcome’ national quality standards. The RESPECT award has recently been externally evaluated. As a result, work is underway to ensure that this area of work is mainstreamed within the PCT and better promoted to local young people
50 CHAPTER 4 - CURRENT HEALTH STATUS SEXUAL HEALTH
workforce training - multi-agency sexual health training has been delivered to a substantial number of workers. The training has focused on basic awareness, delay, abortion awareness and the C-Card. All sexual health training has been brought together into one multi-agency sexual health training programme for 08/09. A multi-agency ‘team’ will deliver the training with an aim of ensuring standardisation, quality assurance and sustainability single gender work - has been undertaken with vulnerable young people, including those attending PRUs and mainstream schools, looked after children and in areas of high teenage pregnancy rebranding - work to bring together a number of different sexual health initiatives (Chlamydia screening, C-Card, RESPECT award, young people’s clinics) under a common ‘look’ or design identity is underway. Staff and young people have been consulted around a number of design concepts that aim to enable sexual health services and initiatives to be easily recognisable to young people in Somerset. This will result in posters, flyers and other promotional materials as well as a Somerset young people’s sexual health website
Chlamydia
During 2007/08 the SCSP developed a sustainable base of screening venues offering attractive and acceptable DIY screening kits in a variety of settings. With over 150 venues, there is a choice of both situation and approach to men and women under 25. All of Somerset’s GP practices have signed up to offer screens, and progress has been made in the routine offering of screens through the Contraceptive and Sexual Health Service and in colleges. Treatment centres in 25 locations, many with walk in options for care, are also offered ensuring ease of access for all clients. The development of on-line postal kits and parallel promotion on buses and local radio have helped to increase awareness and accessibility of the programme. From September 2008 there will be phased mail out to all 20-24 year olds inviting them to take part in the programme.
Termination of pregnancy
During 2007/08 Somerset PCT commissioned NHS funded TOP services from Marie Stopes International and the British Pregnancy Advisory Service. This has enabled more choice for women in Somerset, with the aim of reducing waiting times. Both services offer procedures within five days, and advise and provide a variety of contraceptive methods, including LARC (long acting reversible contraceptives).
Improving sexual health services
In 2007, Somerset PCT developed a service specification for sexual health services, with the aim of developing an Integrated Sexual Health Service in Somerset. This service will incorporate GUM and Contraceptive and Sexual Health Services, and the development of enhanced services in primary care, providing a more holistic and accessible service across Somerset.
51 CHAPTER 4 - CURRENT HEALTH STATUS SEXUAL HEALTH
Sexual health – summary
improved promotion of young people’s sexual health and contraceptive services will ensure an increase in uptake in some areas. New promotional materials and a young people’s website are in development termination of pregnancy services are now extended with an increase in service provision but there is a need to identify reasons why women are not having terminations within 10 weeks gestation and if waiting times for procedures are influencing this chlamydia; the Somerset Chlamydia Screening programme is a universal service and aims to screen 17% of 15 – 24 year olds in Somerset. More work is required to identify and target high-risk communities sexual health needs of BME/migrant worker communities; further work is needed to assess need and the uptake of services by local BME and migrant worker communities. This year’s World AIDS Day (1 December) and a Somerset HIV conference will be focusing on addressing the needs of hard to reach groups a new framework for young people’s sexual health services will be launched aiming to ensure consistency of services offered and quality of delivery in line with the standards identified in the RESPECT award for young people friendly services workforce development will continue to be a priority delivering a comprehensive sexual health training programme aimed at the young people’s workforce in Somerset
Where are the gaps?
promotion of services - there is a need to better promote local sexual health services to ensure increase in uptake in some areas. The new rebranding work aims to help this process ‘Hotspot’ areas - work is underway to identify the particular ‘hotspot’ areas in Somerset with high levels of teenage pregnancy. Somerset County Council and the PCT are working together to develop a Teenage Pregnancy Dataset that will provide a range of information related to risk factors for teenage pregnancy as well as more up-to-date data on hospital births. This targeted approach will enable more strategic planning of services and resources to focus on particular geographic areas and vulnerable groups access to services and information for young people in isolated rural communities - young people living in particularly remote communities experience difficulties in accessing sexual health services in the county towns. Work is underway to further develop school based health services and improve Sex and Relationship Education provision within schools to address this issue. Free pregnancy testing training for practice nurses and other clinical staff will be delivered across the county to increase ease of access to pregnancy testing for young people. This training will incorporate Chlamydia screening.
52 CHAPTER 4 - CURRENT HEALTH STATUS SEXUAL HEALTH
sexual health needs of BME/migrant worker communities - further work is needed to assess need and the uptake of services by local BME and migrant worker communities. The focus of the planned HIV conference and further joint work with Somerset Racial Equality Council and with the Somerset Black Development Agency will help inform this work chlamydia - the Somerset Chlamydia Screening Programme is a universal service. More work is required to identify and target high-risk communities. In addition, only 30% of screens come from males, so more targeted work is needed to increase uptake amongst young men termination of pregnancy – there is a need to identify reasons why women are not having TOPs within 10 weeks gestation, and if waiting times for procedures influence this. Large numbers of TOP are in women in their 20s who may not be receiving appropriate information on contraceptive services. Some work needs to be done to promote services to this age group, and improve the uptake of long acting reversible contraception (LARC) (see Chapter 7 – Health Inequalities – page 154)
53 CHAPTER 4 - CURRENT HEALTH STATUS SUBSTANCE MISUSE
What the situation is like now
In Somerset the work to tackle the harm associated with drugs and alcohol is co- ordinated through the Drug and Alcohol Action Team (DAAT) – a strategic partnership of public sector agencies namely Somerset PCT, Somerset County Council, Avon and Somerset Constabulary, Avon and Somerset Probation and District Councils. Together, these agencies are responsible for implementing, at a local level, the national drugs and alcohol strategies.18,19
There are three subgroups to the DAAT: adult treatment, children and young people and communities. Each undertakes a broad range of development work and/or commissions specific services to respond to local needs.
Adult treatment
The funding for adult treatment services comes from both agencies mainstream budgets and from central government through an allocation from the National Treatment Agency for Substance Misuse (NTA). These funds are pooled and partners commission services together to put in place services that will achieve health, social care and criminal justice/community safety gains.
Following extensive consultation with a wide range of stakeholders including service users, Somerset DAAT decided to tender for a single organisation to provide a new integrated Tier 2 and 3, drug and alcohol, treatment service for adults aged 18 years and over from 1 April 2008. The contract has been awarded to Turning Point (a large national voluntary sector organisation).
The new service incorporates all the community-based treatment services previously provided by three providers. The restructuring of services is intended to make better use of resources and improve the ability of the service provider to meet the needs of those affected by drug and alcohol problems.
Based on the outcomes from the consultation, improving access to treatment and reducing inequalities is at the heart of this new service model. It will achieve this by:
permitting self-referral to all Tier 2 and 3 treatment modalities simplifying care pathways and assessment by having interventions available under one roof extending opening hours to ensure that service users seeking or trying to remain in education, training and employment can do so without adversely affecting their opportunities or prospects increasing opening hours for needle exchange ensuring access to vaccination and testing of blood borne viruses for all at-risk service users
18 HM Government (February 2008) Drugs: protecting families and communities – The 2008 drug strategy 19 HM Government (June 2007) Safe Sensible Social – the next steps in the National Alcohol Strategy
54 CHAPTER 4 - CURRENT HEALTH STATUS SUBSTANCE MISUSE
reconfiguring services within particular areas such as Mendip to respond to the needs of users in Frome increasing the number of services available from primary care settings which will further improve access for people living in more rural locations. This in turn will facilitate improved attention to the physical health issues many service users face incorporating treatment for alcohol misuse which has previously been an under-developed area of service provision
The integrated service for adults has brought into sharper focus the need for clear pathways with other services to ensure that there is an effective interface between drugs and alcohol and for example mental health services, criminal justice system, housing and maternity services.
Children and Young People
This area of work is jointly overseen by the DAAT and Somerset Children and Young People’s Partnership (SCYPP).
Over the last two years partners have been reviewing the substance misuse services available in Somerset for young people to assess what is working and what could be done differently to achieve better outcomes for young people20. Funding arrangements have also changed significantly with specific substance misuse ring fenced grants coming to an end and the introduction of the Area Based Grant (which is not ring fenced) from April 2008. Funding for young people’s treatment comes from the NTA and the formula to determine each area’s allocation is currently being revised.
Partners jointly commission a dedicated substance misuse treatment service for young people – On the Level - provided by Somerset Partnership NHS Foundation Trust. This service provides a range of interventions through a small team working across the county. Nationally, young people’s treatment services are receiving more attention. This was reinforced in the 2008 national drugs strategy. Somerset is nearing completion of its revised specification for this service. Commissioners are changing to an outcome based specification so it is clear what we are seeking to achieve from investing in young people’s treatment.
Based on the outcomes from the review of substance misuse services, the need for a new service was identified to provide targeted interventions to vulnerable young people at an early point in their substance misuse. This service development is the major area of work for 2008/09 and will be linked closely to the locality teams of SCC and the PCT. This service will bridge the gap between the young people’s treatment service and generic young people’s services. It will work directly with young people but also support generic young people’s services by offering advice and information to support them to deliver effective interventions.
20 DAAT/SCYPP (July 2007) Confidential Review of Tier 2 Substance Misuse Services in Somerset; DAAT/SCYPP (January 2008) Young People’s Substance Misuse Needs Assessment
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As this service will be relatively small (four to six staff across the county), the programme of accredited competency based substance misuse training for staff working with young people has been commissioned again. This aims to ensure that staff working with young people are able to recognise substance use through the use of SUST (substance use screening tool), respond effectively to that use, reducing harm, and refer appropriately to more specialist services as required.
The focus on alcohol is increasing within the work with young people and a number of alcohol specific developments are in place. For example, schools and parents are being targeted with a Theatre in Education project called ‘Time in a Bottle’ which aims to raise awareness of alcohol and the risks associated with it; two Police Community Support Officers (PCSOs) have been seconded to work with Trading Standards to continue with under age test purchasing of alcohol on and off licensed premises, to restrict young people’s access to alcohol and enforce legal powers available.
Communities
This area of work focuses on increasing public awareness and education of drugs and alcohol issues and enabling community responses to those issues.
Working with Somerset Direct a system has been established to enable the general population to access information about drugs and alcohol and signposting to local and national sources of advice and help.
Fifteen community members and workers have been trained to deliver drug and alcohol awareness sessions within community settings.
Locally in response to the national alcohol strategy the Communities Group of the DAAT has, in the last year, focused on alcohol. Following a needs assessment a plan has been developed with three broad areas of work:
licensing - to include a range of activities that aim to enhance consistency in approach across the licensing authorities and the other partner agencies involved in this area of work i.e. police, trading standards etc. For example, over the last year the Somerset Tackling Alcohol Related Crime (STARC) project has been focusing on under age sales of alcohol. Through test purchasing operations they have seen the overall failure rate reduce to 17% compared to over 75% a year ago increasing public awareness - the needs assessment identified 16-24 year olds as the target audience for a multi-media campaign. The aims for this are to raise awareness about units contained in alcoholic drinks and raise awareness about harm reduction when consuming alcohol interventions - a number of activities are in the plan that will impact on Somerset including: o two day competency based training course for staff of non substance misuse agencies to deliver brief interventions for alcohol users i.e. to effectively recognise, respond and refer for alcohol use/misuse
56 CHAPTER 4 - CURRENT HEALTH STATUS SUBSTANCE MISUSE
o work specifically with Accident and Emergency (A&E) Departments by supporting A&E staff to respond to alcohol themselves with very brief interventions, pilot specialist alcohol workers within A&E at peak times; and improve understanding of the issues through comprehensive data collection o development of consistent alcohol (and drugs) work place policies in public sector agencies
How are we doing?
Ongoing assessment of needs and performance monitoring is part of the work the DAAT undertakes to ensure we have an up to date understanding of the drugs and alcohol situation in the area.
The adult needs assessment 21 reports that there are an estimated 2,137 problem adult drug users in Somerset based on those who use opiates (for example heroin) and crack. Comparing this to population data suggests that about one in 100 adults aged between 18 and 59 experience problems with these drugs or 0.042% of the population as a whole.
Of the 2,137 about 1,020 were reported as having engaged in ‘structured treatment’ with a specialist service, at Tier 3 level or above between April 2006 and September 2007. Local data suggests that about a further 500 drug users are engaging with services considered Tier 2. Therefore, in total about 1,500 or 70% of the estimated number of problem drug users are engaging with a treatment service at tiers 2 and above and of these 47% are engaging in structured treatment.
The ages of people engaging in structured treatment is similar to previous years and reflects the national profile, with 20 to 39 year olds accounting for 74.4% of the in treatment population. It is also worth noting that the proportion of those aged over 40 years is increasing.
Similarly the gender profile of adults who engage in treatment, 75% male to 25% female, reflect the national profile and in Somerset these proportions have remained constant over the last five years and are reflected by drug-treatment services at a national level. The ethnicity of adults engaging in treatment in Somerset is similar to the general population of Somerset. Almost all service users identify as White British, accounting for 93% of records over the last two years.
The main problem drug reported to treatment services by people engaging in structured treatment continues to be heroin (74%). In Somerset, injecting is common among drug users and 75% of people entering treatment each year report that they were currently injecting or had injected in the past.
Drug use occurs to some degree across most of the county. Although the greatest numbers are located in and around the larger towns, there are people living with drug problems in the smaller, more rural communities.
21 Somerset DAAT (March 2008) Adult Needs Assessment 2007/08
57 CHAPTER 4 - CURRENT HEALTH STATUS SUBSTANCE MISUSE
This presents a challenge for drug treatment services and service users, particularly as in some areas public transport is limited. This is also an important reason why the DAAT is planning to continue developing services for drug users which are available from primary care settings. Mapping the total estimated number of drug users against the residence of users in treatment and particular town’s population suggests that:
the numbers engaged in treatment are broadly in line with projected estimates and are similar per head of population in each town this shows again that drug problems are widespread across the county including within smaller towns and villages towns with the highest numbers of drug users accessing treatment services correspond with the areas of highest deprivation
This analysis has indicated the need to review the fixed sites of services in the Mendip area, as Frome ranks as 4th in terms of numbers of people accessing treatment and size of the population, but it does not have the permanent presence of a drug treatment service. Burnham-on-Sea, Highbridge and Wellington are also indicated as areas for potential service locations.
The young people’s substance misuse needs assessment22 provided a baseline for local understanding; however it also highlighted the gaps in our knowledge and areas where the quality of data needed to improve.
The target number of young people accessing a specialist substance misuse service has been set at a minimum of 7.1% of the estimated 2,137 problem adult drug users - this equates to approximately 150 young people.
2006/07 data from two different sources (national and local) on referrals to ‘On the Level’ (young people’s (YP) substance misuse treatment service) indicates that it receives between 120 and 180 referrals per year. The majority of referrals are related to problematic use of cannabis (28%) and alcohol (25%). Heroin accounted for 5% of referrals whilst solvents accounted for the 4th largest category at 12%, after not specified at 17%. This indicates a different picture of problem substance misuse when compared to adults. The peak age of young people referred was 16-17 years old.
This understanding of the significance of alcohol is reinforced by the findings from the DAAT Alcohol Needs Assessment.
Ofsted’s TellUs survey (October 2006) was a general survey on the views of young people aged 10-15 years completed by 529 individuals living in Somerset. One question was phrased, “How easy is it for you to get help, advice or information?” 229 young people said it was very easy, 236 thought it quite easy, and 53 said it was not very easy. Of the young people who found it quite and not very easy, the majority (172 individuals) chose “Having an adult I can talk to” as the category that would make the most difference in getting help, advice or information.
22 DAAT/SCYPP (January 2008) Young People’s Substance Misuse Needs Assessment
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Somerset’s policy of training generic professionals in the use of SUST is contributing towards the provision of such adults.
TellUs2 (November 2007) was completed by 584 young people in Somerset (aged 10- 15 years). 81% of respondents said they had never taken any drugs, compared with 37% who said they had never had an alcoholic drink. However, 20% of young people said they had ‘got drunk’ once or more times during the last four weeks. Also, 7% of respondents said they had used cannabis in the last four weeks, and 1% said they had used ‘other drugs’ (e.g. cocaine, LSD, ecstasy, heroin, etc). Although the sample is very small, 1% of 584 young people, projected across the 10-15 year old population as a whole, would indicate that over 400 individuals may have used ‘other drugs’ in the last month.
Tackling the harms caused by alcohol misuse has become increasingly high on the agenda for Somerset. In 2008, with support from the PCT, the DAAT set out to describe the use of alcohol in Somerset, identify inequalities in misuse and access to services, and determine priorities for reducing alcohol related harm in Somerset.23
This work estimated that up to 15% of the adult population in Somerset regularly binge drink (i.e. men regularly drinking eight or more units of alcohol, and women regularly drinking six or more units in a single session). Higher levels of binge drinking occur in and around town centres, with much lower levels of binge drinking in rural West Somerset.
It also concluded that although levels of harmful and hazardous drinking are estimated to be lower across Somerset than the south west average, around 19% of Somerset adults drink at levels considered harmful (between 22 and 50 units a week for men, and 15 and 35 units for women) and a further 4% at hazardous levels (50 units a week for men, 35 units a week for women).
24National prevalence rates for drinking behaviour applied to Somerset’s population suggest that there is an estimated 87,000 people aged 16 – 64 in Somerset that have an alcohol use disorder. Of these, approximately 12,000 people (3.6%) are dependent alcohol users.
Alcohol use has been shown to be a particular problem amongst vulnerable groups in the county: data collected by Supporting People, suggests more than half of service users in supported housing have identified alcohol related problems as a reason for those services; Ofsted’s TellUs2 Survey found that up to one fifth of young people in Somerset regularly get drunk, with one quarter of all referrals to On the Level, the county’s young people’s substance misuse service a result of alcohol use.
Consistent with national data, inequalities exist in alcohol related health in the south west. The rate of alcohol specific hospital admissions is five times higher among adults from the most deprived areas compared to the most affluent.
23 Silk L on behalf of Somerset DAAT (March 2008) Alcohol Needs Assessment for Somerset 24 Department of Health (2005), the National Alcohol Needs Assessment for England, research project (ANARP)
59 CHAPTER 4 - CURRENT HEALTH STATUS SUBSTANCE MISUSE
Over the past five years, Somerset has seen an upward trend in hospital admission rates for alcohol related conditions. Although admission rates across the county are below that of the regional average for females, males living in Taunton Deane and West Somerset have higher rates of hospital admission for alcohol specific conditions than the south west average, with a slightly older presentation among those from West Somerset. Between April 2002 and March 2007, 17% (4,469) of alcohol related hospital admissions in Somerset were the result of mental and behavioural disorders due to alcohol, a further 16% (4,200) were the result of falls or injuries.
Of the 431 people attending the Accident and Emergency department at Musgrove Park Hospital (between April 2006 and March 2007) because of acute conditions caused by alcohol consumption, 40% were under 25. Young women formed a higher proportion of this group (60%), compared with older groups where males formed a greater proportion of those attending (74%). The mortality rate for deaths caused by alcohol attributable conditions is significantly higher for both males and females in West Somerset than in the other District Local Authorities.
Whilst it is generally acknowledged that alcohol consumption might be a contributing factor in criminal and antisocial behaviour, it is difficult to determine which crimes occur as a result of alcohol consumption. Data from the Home Office recorded crime statistics suggest the rate of violent crime across Somerset is significantly lower than the south west average, although slightly higher in Taunton Deane than in the other District Local Authorities. The rate of sexual offences in Somerset is not significantly different to the south west average. Avon and Somerset Probation identified alcohol as a problem linked to offending in over half of their current caseload.
Data from the needs assessment provided the evidence base for developing a Somerset strategy to reduce alcohol related harm. In addition, gaps in our understanding of alcohol use in the county have been identified and improving data quality and collection is a priority to enhance local understanding of need and gaps in service provision.
Links with LAA
The work to tackle drug and alcohol is embedded within the LAA for Somerset with three substance misuse related indicators included with the county’s top 34.
These are:
NI 39: Reducing alcohol related admissions to hospital – from 2006/07 baseline of 1,389 to 1,697 in 2010/11. This is a challenging target which seeks to slow the increase down with a 1.3 percentage point reduction on the increase year on year NI 40: Increasing the number of drug users in effective treatment – from 2007/08 baseline of 908 to 936 in 2010/11. This is a cautious target of 1% increase year on year which we anticipate exceeding as a result of the new integrated adult treatment service
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NI 115: Substance misuse by young people. As this is a new indicator no baseline is currently available, however the TellUs survey is to be used to establish this which will be published annually by Ofsted in September of each year
What is working?
Substance misusers in supported housing
In April 2006 the DAAT and Somerset Supporting People published a forward strategy for responding to the housing and housing related support needs of substance misusers in Somerset. This was based on service user research conducted in 2005/06.
The recommendations highlighted a number of actions including:
reconfiguration of parts of existing services within the supported housing provision to create a ‘resettlement pathway’ the establishment of shared protocols, which define the roles of the different agencies within the network and clearly describe a ‘resettlement pathway’ that is the route through and access to the various types of accommodation training and development initiatives which include: the development and delivery of substance misuse training programmes for housing providers and local housing authority staff which are in line with both drugs and alcohol and housing National Occupational Standards; the development of screening and brief intervention work by housing providers; and consideration of the secondment of drugs workers to housing agencies and housing support workers to drug treatment agencies create routine systems and procedures to enable the ongoing collection of data with which to monitor need
Accredited competency based training has been commissioned now for two years, targeted at specific supported housing providers that work with single homeless, young people and offenders. This provides supported housing workers with the knowledge, understanding and confidence when responding to substance misuse and enables supported housing providers to develop a designated lead role in their organisation in responding to substance misuse that will act as a link between housing and specialist services.
With single providers for both the adult and young people’s substance misuse services, joint working guidelines are being developed with a clear housing (resettlement) pathway that appropriately matches people’s stages in their housing career with that of their stage in treatment.
Capital developments are underway to progress the remodelling of existing services (Taunton and Yeovil) and establish new homeless services – Mendip will be the first of these.
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Primary care services for drug users
The DAATs strategic plan is to develop substance misuse services in primary care. Key elements of this plan are as follows:
the Somerset Shared Care Scheme involves the joint treatment of people with problematic drug use by their GP, Pharmacist and a specialist drugs worker from Turning Point. Service users receive prescribed medication, vaccination and testing for blood bourne viruses (BBVs) as well as general health interventions. This has been in development for the last seven years, growing year on year. The Scheme started in Somerset in 2000 as a pilot in the South Somerset area with a 0.5WTE specialist drugs nurse covering three GP practices. At present there are 50 GP practices signed up to the scheme – 66% of all GP practices, managing 330 clients.
The success of the scheme has been recognised regionally by the National Treatment Agency for Substance Misuse as a model of good practice as it addresses the issue of access to drug treatment in a rural area.
The GPs signed up to the scheme are required to complete an e-learning package and attend a one day RCGP certificate course. Pharmacists and drug workers also attend this course which assists with effective multi-disciplinary working.
GP practices in the scheme are open to annual review which assesses and evaluates clinical governance, patient safety and service user involvement issues in relation to clients in the shared care scheme.
the Pharmacy Supervised Consumption Scheme involves people who are prescribed controlled drugs as part of their treatment consuming them initially under supervision. This supervision is carried out by a pharmacist ensuring the dose is taken regularly and safely whilst preventing leakage onto the streets.
Currently there are 86 pharmacies participating in the scheme – 93% of the total pharmacies.
A three way agreement between the pharmacy, drugs workers/GP and client governs the working of the scheme in terms of policy and guidance.
There are currently 24 Pharmacies in Somerset’s Pharmacy Needle Exchange Scheme. This is an essential element to the drugs treatment system and helps to ensure there is adequate provision of sterile injecting equipment and sharps boxes for safe disposal across the county.
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Substance misuse – summary
the work to tackle harm associated with drugs and alcohol is co-ordinated through a strategic partnership of public sector agencies known as Somerset Drug and Alcohol Action Team (DAAT) there is an estimated 2,137 problem adult drug users in Somerset. This equates to one in 100 adults aged between 18 and 59 or 0.042% of the population as a whole in comparison, alcohol is a significantly bigger issue for the county with an estimated 15% of the adult population in Somerset regularly binge drinking (for men that equates to regularly drinking eight or more units of alcohol and for women six or more unites of alcohol in a single session). Further, although levels of harmful and hazardous drinking are estimated to be lower across Somerset than the south west average, around 19% of Somerset adults drink at harmful levels (between 22 and 50 units a week for men and 15 – 35 units a week for women) and a further 4% at levels considered hazardous (50 units a week for men and 35 units a week for women). Approximately 12,000 people in Somerset aged between 16 – 64 years could be dependent alcohol users data from a range of sources indicates that alcohol and cannabis are the two substances Somerset young people aged 17 years and under are both more likely to have ‘ever tried’ and to experience problems with when that use continues there are major service developments in place to respond to the treatment needs of both adult and young people who need specialist treatment services for their drug and/or alcohol misuse. However, more attention needs to be given to assist people rebuild their lives and reintegrate into the Somerset community through developments which respond to the education, training, employment and housing needs of users to enable safe, sensible and social alcohol use in Somerset, changing societal attitudes to alcohol is a long term priority
Where are the gaps?
The DAAT has already flagged a number of issues needing attention:
better information to parents/carers to help them prevent young people (YP) getting involved substance misuse involving families where appropriate in treatment of YP and other family members additional support for families at risk – focus on parental substance misuse to prevent “intergenerational harm” for example: increasing parents access to treatment; parental skills; support to kin carers i.e. grandparents; protecting children – joint work between treatment and children's services ; pre-natal harms - joint work between treatment and maternity services
(see Chapter 7 – Health Inequalities – page 154-155)
63 CHAPTER 4 - CURRENT HEALTH STATUS MENTAL HEALTH
ADULTS
What the situation is like now
Mental health is the emotional wellbeing and resilience which enables us to enjoy life and to live it to its fullest. It enables us to make the most of opportunities, learn how to make the best decisions, to survive pain, disappointment and sadness and to be able to contribute back to society. It is a positive sense of wellbeing and an underlying belief in our own and others’ dignity and worth.
Mental health is affected by a wide range of factors which can protect from, or increase, the risk of mental illness. These include “lifestyle factors” such as taking sufficient physical activity, keeping alcohol consumption within sensible daily limits and eating a healthy diet with plenty of fruit and vegetables. Other factors such as employment, education and access to strong social networks also promote good mental health and wellbeing. Evidence shows that some black and minority ethnic groups have more mental health problems than other sections of society25.
Almost everyone will be affected by mental ill-health in their life, either directly or indirectly. It has been estimated that around 11.5% (or about one in 10) adults in the south west may have a mental health problem at any particular time and an estimated 7.4% (or about one in 14) adults will have a significant problem that is likely to require treatment. These percentages do not differ significantly from the England average (13.2% and 7.3% respectively)26. Little Somerset-specific data is available, although data collected via general practice provides an indication of service utilisation (see Table 1 following).
The amount of mental ill health presenting at a practice will be strongly linked with the general characteristics of the practice population. Indicators of social deprivation such as unemployment and homelessness are associated with higher levels of mental ill health. The burden of illness in a practice will therefore reflect the socio-demographics of the geographical area serviced by the practice.
25 Somerset Public Health Annual Report 2006/7 26 APHO (May 2007) Indications of public health in the English regions 7: Mental Health
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Table 1: Indication of service utilisation
Diagnosis Weekly Estimated number Quality prevalence per of patients aged Outcomes 1000 adults 15-64 on Somerset Framework aged 16-647 GP lists with Register mental health figures disorder Mixed anxiety and No prevalence 77 26,000 depression data
No prevalence Generalised anxiety 31 10,400 data No prevalence Depressive episode 21 7,000 data No prevalence All phobias 11 3,700 data No prevalence Obsessive Compulsive Disorder 12 4,000 data No prevalence Panic Disorder 8 2,700 data Total all neuroses 160 53,800
Functional Psychoses 4.4 1,500 2,886
No prevalence Eating disorders 10027 19-20,000 data
The number of new diagnoses of depression in Somerset in 2006/07 was 2,139.
Modelling using an index based on the 1993 National Psychiatric Morbidity Survey gives some indication of where in Somerset common mild to moderate mental illness may be more prevalent. Although the data is now fairly old, Table 2 following identifies the wards in Somerset which fall within the 6th decile and above for predicted rates of common mild to moderate mental health conditions which may require higher levels of input from primary care.
27 Prevalence in women in the general population reported to be up to 10% may be affected by some eating difficulties including anorexia, bulimia nervosa and binge eating disorder
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Table 2: wards in Somerset which fall within the 6th decile and above for predicted rates of common mild to moderate mental health conditions
Mendip Sedgemoor South Somerset Taunton Deane West Somerset Taunton Glastonbury St Bridgwater Chard Holyrood Blackbrook and Alcombe East Benedict's Eastover Holway Glastonbury St Bridgwater Taunton Yeovil Central Dunster Edmund's Hamp Eastgate Bridgwater Taunton Frome Keyford Yeovil East Minehead North Sydenham Fairwater Bridgwater Frome Welshmill Taunton Halcon Watchet Victoria Glastonbury St Taunton Highbridge John's Lyngford Shepton East Street North Wells Central Source: North West Public Health Observatory mental health needs indicators data.
CHILDREN AND YOUNG PEOPLE
Mental health disorders in children and young people can be considered under four broad categories:
conduct disorders; including oppositional defiant disorder, socialised conduct disorder, and unsocialised conduct disorder emotional disorders; including separation anxiety, specific phobia, social phobia, generalised anxiety disorder, and depression hyperkinetic disorder; including attention deficit hyperactivity disorder (ADHD) less common disorders; including autistic spectrum disorder, tics, eating disorders and elective mutism (Office for National Statistics 2005)
National prevalence of mental health disorders
Overall, one in 10 children and young people aged five to 15 are estimated to have a diagnosable mental health disorder that would benefit from specialist services at Tiers 3 and 4 (Office for National Statistics 2005). The National Service Framework (NSF) estimates that similar numbers of children and young people with less serious mental health problems need help from Tiers 1 and 2 services.
Somerset prevalence
Comprehensive local data on prevalence of mental health disorders among children and young people is not collected. Mapping conducted each year by Children and Adolescent Mental Health Services (CAMHS) identifies the numbers of patients receiving care from CAMHS, and breaks this data down by type of mental disorder.
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However, this data is limited to those receiving intervention within the NHS and does not provide an estimate of the overall prevalence of mental disorders among children and young people in Somerset.
We therefore have to consider national prevalence figures for the main categories of mental health disorders and apply them to Somerset with adjustments made for differences between the age and gender profile of the national and Somerset populations.
In 2007, a comprehensive needs assessment of CAMHS at Tiers 3 and 4 was produced. It estimated that 11,347 children and young people in Somerset would benefit from specialist CAMHS at Tiers 3 and 4, using national estimates from a survey by the Office for National Statistics set out in the NSF. However, the NSF’s definition of specialist CAMHS is not restricted to Tiers 3 and 4 but also includes some Tier 2 services. This makes it difficult to estimate the numbers in Somerset who would benefit from, but are not receiving, a specialist service given that the numbers receiving a specialist service at Tier 2 is not known.
However, we do know that at the time of the needs assessment, 1,374 were receiving a specialist service at Tiers 3 and 4. This means that 9,973 of the estimated 11,347 who would benefit from specialist CAMHS were not receiving Tiers 3 and 4 services, although a proportion of this number would be receiving Tier 2 services.
There is an absence of data on levels of mental health disorders among very young children (aged 0 to four). One study has estimated that prevalence among two to five year olds is as high as that for older children, with one in 10 experiencing mental health disorders, in particular ADHD, anxiety or depression (Mental Health Foundation 2006). This is probably an overestimate as it is unlikely that younger children have the same or higher levels of mental disorders as older children. However, research on younger children is limited to very few studies and it is difficult to estimate prevalence in this age group.
Table 3 sets out the prevalence of mental health disorders among five to 16 year olds from the survey:
Table 3 Prevalence (%) of mental health disorders among 5 to 16 year olds 5 to 10 year olds 11 to 16 year olds All children % % % Boys Girls All Boys Girls All Boys Girls All Any mental disorder 10.2 5.1 7.7 12.6 10.3 11.5 11.4 7.8 9.6 Conduct disorders 6.9 2.8 4.9 8.1 5.1 6.6 7.5 3.9 5.8 Emotional disorders 2.2 2.5 2.4 4.0 6.1 5.0 3.1 4.3 3.7 Hyperkinetic disorders 2.7 0.4 1.6 2.4 0.4 1.4 2.6 0.4 1.5 Less common disorders 2.2 0.4 1.3 1.6 1.1 1.4 1.9 0.8 1.3 (autistic spectrum, tics, mutism, eating disorders)
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The study found that around 20% of children with a mental health disorder were diagnosed with more than one of the four categories of disorder outlined previously, representing 1.9% of all children. The most common combinations were conduct and emotional disorder, and conduct and hyperkinetic disorder (0.7% of all children in each case).
Young adults aged 16 and above are included in the national adult psychiatric morbidity survey undertaken on a regular basis (Office for National Statistics 2000). This study uses different categories of mental health disorder to those used in the children’s survey and both studies include 16 year olds in their analysis. The adult survey does not provide an overall prevalence figure for mental health disorders unlike that for children and young people.
The adult survey provides data on 16 to 19 year olds with neurotic disorders (including depression, anxiety or phobias), personality disorders (including OCD and schizophrenia), probable psychotic disorders, hazardous drinking (an established pattern of drinking which brings the risk of physical and psychological harm now or in the future), alcohol dependence, and drug dependence.
The figures for each category are set out in Table 4:
Table 4 Prevalence (%) of mental health disorders among 16 to 19 year olds Men Women All Neurotic disorders 8.6 19.2 13.3 Personality disorders* 5.2 1.7 3.4 Probable psychotic disorders 0.0 0.5 0.2 Hazardous drinking 45 32 38.5 Alcohol dependence 11.9 2.9 7.4 Drug dependence 12.6 5.9 9.3 *Data on personality disorders uses a different age banding of 16 to 34
Overall, the survey found that around one in 25 adults of all ages had a personality disorder of some kind (4.4%) with a slightly higher prevalence among men compared to women. The most common type of personality disorder was obsessive compulsive disorder (1.9%), while avoidant, schizoid, paranoid, borderline and antisocial personality disorders each had a prevalence of less than 1%. The majority of adults with psychiatric morbidity had one disorder, with 3% having two disorders and 1% having more than two disorders.
Large inequalities in levels of mental health disorders exist between more deprived and less deprived groups, pointing to the importance of ensuring equitable access to CAMHS for all children and young people, with particular attention paid to the barriers that might be experienced by more deprived groups in accessing CAMHS.
Some groups of children in special circumstances are at greater risk of developing mental health problems, including looked after children, children with a learning disability, children with special educational needs, young offenders, children with a physical illness, and homeless children.
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How are we doing?
the annual CAMHS Mapping for 2007/08 illustrated good progress in the four key areas in 2006, the percentage of new CAMHS cases with a length of wait under four weeks improved dramatically to 82.4% compared with 57.6% in 2005. This is significantly better than the national average of 39.8% and has a RAG rating of green
LAA N51 - to improve access to an appropriate level of Child and Adolescent Mental Health Service (CAMHS) support
we are developing appropriate screening and assessment tools we are monitoring and evaluating referral data at a locality level we are progressively implementing clear referral pathways for access to emotional health and wellbeing workers based in locality teams and Specialist CAMHS
What is working?
a mental health promotion strategy has been developed for Somerset 7.5 Emotional Health Workers (EHWs) now deliver targeted and preventative work. Referrals to EHWs highlight the need for this role; issues include low self esteem, poor self image, peer relationships and friendships a resource pack has been developed containing information on depression, self- harm, bereavement, the effects of divorce and separation, domestic violence and eating disorders. A further 1.5 EHW are to be appointed the roles of CAMHS Link Workers have been reconfigured to bridge the gap between the EHWs and specialist CAMHS the development of the CHEW (Care leavers Health and Emotional Wellbeing) involving Specialist CAMHS and the SCC Leaving Care Team half of our primary schools are actively engaged with the Somerset County Council to develop the use of SEAL28 and others are doing so independently. Monitoring visits show over 75% of supported schools are developing good or excellent practice in the first two years of the programme. Staff report that pupils are calmer and better able to learn. A joint focus with social care, on behaviour, has ensured high cost behavioural, emotional and social development (BESD) placements (above £150K) remain very low (only two at April 2008). Children in receipt of medical tuition on the grounds of anxiety related conditions have reduced from 94 to 70 in the 12-month period ending April 2008. Attendance levels in primary schools have also improved in 2006/07 (see Enjoy and Achieve).
28 Social and emotional aspects of learning, integral to the national strategy work
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Mental health – summary
about one in ten adults in the south west may have a mental health problem at any particular time mental health is affected by many factors including ‘life-style’ factors such as taking sufficient physical activity, keeping alcohol consumption within sensible daily limits and eating a healthy diet with plenty of fruit and vegetables a mental health promotion strategy has been developed for Somerset to tackle some of the risk factors in Somerset, one in ten children and young people aged five to 15 (11,347) are estimated to have a diagnosable mental health disorder that would benefit from specialist mental health services in Somerset, one in 95 children and young people currently receive specialist mental health services Emotional Health Workers deliver targeted and preventative work in Local Service Teams Children and Adolescent Mental Health Services (CAMHS) Link Workers bridge the gap between Emotional Health Workers and specialist CAMHS further work is required to ensure access to high quality mental health care for people of different ethnic origin
Where are the gaps?
mental health care for people of different ethnic origin training, consultation and advice integrated service referral - the lack of a single point of entry and triage
(see Chapter 7 – Health Inequalities – page 156)
70 CHAPTER 4 - CURRENT HEALTH STATUS LEARNING DISABILITY
What the situation is like now
There are approximately 1,650 adults with learning disabilities supported by the Somerset Adult Learning Disability Service. About 950 people live independently from their families in either residential cares homes or sheltered housing. This includes a small number of former long stay hospital patients and a small group of people who receive care outside of Somerset as a result of their exceptional health needs and behavioural problems. The remaining 700 people remain at home with parents or carers.
In addition, 450-500 people with learning disabilities are known to be resident in Somerset based independent sector care homes, placed by other local authorities or PCTs. Some are placed with independent special needs colleges such as the Mencap facility at Lufton. Anecdotally, proximity to these facilities can have an impact on primary healthcare services.
National estimates of prevalence of severe learning disabilities in the general adult population range from 0.28% to 0.5% (source: Harker report to the Valuing People Support Team). Valuing People estimates prevalence of mild/moderate learning disabilities as 25 per 1,000 populations.
There is national evidence to suggest that the number of people with learning disabilities will increase. Emerson and Hatton in their 2004 report suggested that between 2001 and 2011 there will be:
6% increase in the number of adults with learning disabilities known to services 20% increase in the number of adults with learning disabilities aged 60+ who are known to services
and that between 2001 and 2021 there will be:
9% increase in the number of adults with learning disabilities known to services 36% increase in the number of adults with learning disabilities aged 60+ who are known to services
This is the result of several factors, including both changes to the demographic profile of the population and the effects of reduced mortality among people with learning disabilities. Within this increased number, the service is likely to be working with increased numbers of young people with profound and multiple learning disabilities (PMLD) who are surviving into adulthood, and an increasing number of people with Autistic Spectrum Disorder (ASD) and challenging behaviour.
Demand for services is exacerbated by the fact that a higher proportion of service users now live away from the family home, supported by health and social care services. This now approaches 60% of Somerset adults with learning disabilities.
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Particularly important is the need for services for those young people who are moving into adulthood. Table 1 shows numbers of young people who moved through the transitions pathway to adult services or are predicted to do so in future years. Numbers for future years include people with Aspergers Syndrome and Autistic Spectrum Disorder (ASD), as well as physical disability and mental health needs. Numbers are less certain the further into the future that is projected.
Table 1 Year No. Transitions 2008/9 30 2009/10 67 2010/11 100
Apart from the increase in profound and multiple learning disabilities (PMLD) and ASD, notice will need to be taken of the implications of ageing for people with Down’s syndrome. Research also shows early onset dementia as being an increasing problem. In Somerset this means about 100 people with learning disabilities at any one time living with dementia.
Health issues for people with learning disabilities
up to one third of people with learning disabilities have an associated physical disability, most often cerebral palsy. This may put them at risk of postural deformities, hip dislocation, chest infections, eating and swallowing problems, gastro-oesophageal reflux, constipation and incontinence people with learning disabilities experience a high rate of under-detection of visual and hearing problems. About one third of people with learning disabilities have poor eyesight. Over 40% have a problem with hearing and the prevalence of both visual and hearing loss increases with age epilepsy occurs in about one third of people with learning disabilities and the likelihood of seizures increases with the severity of the learning disability. Often seizures are complex and difficult to control and specialist input is required. Anti- epileptic drugs often have side effects, particularly with long-term use, and require regular review autistic disorders also occur very frequently with learning disability and this additional disability will have a considerable effect on the functioning and needs of the individual. People with autism have impairments in communication, social behaviour and imagination mental health problems, including challenging behaviour, occur in up to 50% of people with learning disabilities. Depression and withdrawal are frequently not diagnosed or treated. The prescription of psychotropic medication should be based on the advice of a psychiatrist with special knowledge of learning disabilities
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particular conditions, such as Down’s syndrome, carry an increased risk of certain health complications such as cardiac disorders, respiratory problems, thyroid disorders and hearing impairment older people with learning disability are particularly at risk of dementia, especially of Alzheimer’s disease if they have Down’s syndrome and also of other undetected health problems such as sensory impairments
What is working?
Public agencies in Somerset work in partnership to plan and deliver health and social support to people with learning disabilities. The work programme is monitored by the Learning Disability Partnership Board which has extensive user involvement and influence.
In 2007 a review of the health needs of people with learning disabilities was carried out. The review identified several areas where services could be improved.
Learning Disabilities – summary
approximately 2,200 people with a learning disability live in Somerset between 2001-2011 there will be a 20% increase in people with learning disabilities over 60 years of age people with learning disabilities experience a high rate of under-detection of visual and hearing problems mental health problems, including challenging behaviour occur in up to 50% of people with learning disabilities public agencies in Somerset work in partnership to plan and deliver health and social support to people with learning disabilities there is scope for further improvement in services for screening, vision and hearing, routine medical access and oral health
Where are the gaps?
arrangements for accessing mainstream primary medical services need to be strengthened despite high need, access to routine hearing and vision testing is limited a significant number of people with learning disabilities do not yet have access to a health action plan inadequate uptake of cervical screening increased risk of poor oral health, scope for more preventive support to reduce need for potentially hazardous general anaesthetics for simple dental procedures
(see Chapter 7 – Health Inequalities – page 157)
73 CHAPTER 4 - CURRENT HEALTH STATUS OBESITY
What the situation is like now
Levels of obesity are rising rapidly. If the current increases continue at the same rate, it is estimated that by 2020 one third of adults, one third of girls and one fifth of boys will be obese. Overweight and obesity are conditions whereby weight gain (which is predominantly fat) has reached the point of endangering an individual’s health. Overweight and obesity can have serious health consequences for children and adults.
The most common measurement of obesity is the Body Mass Index (BMI). It is defined as a person’s weight in kilograms divided by the square of their height in metres (kg/m2). Table 1 shows the classification of overweight and obesity using BMI according to the World Health Organisation.
Table 1: World Health Organisation BMI definitions
BMI score category definition 18.4 or lower underweight 18.5 – 24.9 normal 25.0 – 29.9 overweight 30.0 – 39.9 obese 40 or above severe (morbid) obesity Source: WHO
In Somerset, 34.7% of adults are overweight and 13.5% are obese29. The PCT takes part in the National Child Measurement Programme where children in Reception and Year 6 routinely have their height and weight measured and their BMI is calculated. The BMI for children takes into consideration their age and predicted eventual height. Using the values for all children the Department of Health (DH) assesses the heaviest 5% as ‘obese’ and the heaviest 15% as ‘overweight’. In 2006/07, 8.7% of children in Reception were obese and 15% of Year 6.
Rising obesity levels have been brought about by behavioural and environmental changes, resulting in the consumption of high calorific foods and a more sedentary way of life.
The Active People’s Survey (2006) showed that in Somerset 21.9% of adults took part in at least three sessions of activity per week. The majority (51.4%) of Somerset adults surveyed stated that they participated in no regular activity.
29 Dorset and Somerset Strategic Health Authority 2002 Lifestyle Survey
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Map 1
Map 1 shows activity levels across the county, and enables targeting of initiatives.
Figure 1
Figure 1 illustrates participation in moderate activity by household income.
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The work on obesity is being driven forward locally by the Somerset Obesity Forum, a multi-agency steering group comprising representatives from each PCT directorate and partner organisation responsible for the commissioning and delivery of the preventative and treatment aspects of obesity and overweight. Specific sub-groups focusing on children and young people, for example, have also been set up.
How are we doing?
Table 2 below sets out the current performance for obesity prevalence and recording levels in relation to the targets for 2008/09. Obesity has been identified as a designated target in the new Local Area Agreement, the target matches the vital signs target seen below.
Table 2
Current Performance Target 2008/09 2007/08 Reception Year Obesity: 8.7% Obesity: 8.67% Recording: 91.01% Recording: 91.05% Year 6 Obesity: 15.0% Obesity: 14.86% Recording: 85.01% Recording: 85.75%
Work is in progress to collate this year’s National Child Measurement Programme data with results submitted to the DH in early September 2008.
Breast feeding also has an impact on obesity levels in children in later life and therefore the current targets are included in Table 3 below:
Table 3
Baseline Vital Signs Local Target 2007/08 Trajectory for for 2008/09 SPCT 2008/09 Prevalence of breastfeeding at 6 -8 34.6% 35.6% 37.6% weeks Coverage: the percentage of children 68.4% 85% 95% with a breastfeeding status recorded as a percentage of all instances due for a six to eight week check during quarter 4
What is working?
Somerset PCT has recently revised its weight management care pathways for both adults and children and young people in line with NICE guidance; public health maps provide a framework for action at a local level. During 2008/09 a new Healthy Lifestyles strategy will be developed that incorporates both the previous food and health and physical activity strategies.
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County wide multi-agency groups such as the Somerset Physical Activity Group, Somerset Food and Health Alliance and the district Community Sports Networks support the work and provide a specific topic focus and expertise.
Work in Early Years settings is a key priority area for the PCT and the successful Energy for Life bid enabled the ‘Full of Beans’ and ‘Bosom Buddies’, Phase 1 to be developed. ‘Full of Beans’ sessions have taken place in seven children’s centres across Somerset focusing on active play and healthy eating for families. This reached 72 families. Training for children’s centre staff is planned for the autumn in collaboration with Somerset Activity and Sports Partnership (SASP). This will enable staff to continue providing the activity and food sessions themselves. A booklet to accompany the practical sessions was developed and given to the families. ‘Bosom Buddies’, our breastfeeding initiative, has ensured that 18 key health visitors across Somerset were trained on the UNICEF Baby Friendly Initiative and support their peers and families in a particular locality with advice and support around successful breastfeeding. They also help develop drop-in sessions and support groups across the county focusing on areas of deprivation.
Work with school age children and young people has focused on two key projects as well as routine support to the Healthy School Standard. The Do Activity Stay Healthy (DASH) programme is now available in 18 primary and middle schools across Somerset, with several more planning to start for Autumn Term 2008. Young people participate in three activity sessions before school each week as well as looking at healthy eating and have two family home visits. Funding for the project was enhanced by the Football Association who will be sponsoring the evaluation of the scheme as a whole.
MEND (Mind Exercise Nutrition Do it!) courses for children aged seven -13 have been taking place in Taunton since last October and it is hoped that this will roll-out further across Somerset in the future. The programme features 12 weeks of practical physical activity sessions and nutrition for children who have been referred from health professionals and other agencies primarily as a result of issues with weight. Family based sessions are an important part of this national programme which is evaluated in a standard way across the country.
Weight Management in Primary Care is supported by the Nutrition and Dietetics department who employ two staff to run weight management groups in selected localities. A voucher scheme for referral to three different commercial slimming clubs is being developed for implementation later this year.
Three multi-disciplinary weight management programmes for Tier 3 patients have been delivered. The evaluation is showing promising results and a commitment has been given to fund further courses this year.
Active Somerset is a Sport England-funded two year project to increase opportunities for physical activities in communities. The aim is to set up 300 new active recreation opportunities in Somerset, engage 300 volunteers and several thousand participants. It will run until March 2009 and is currently on track to achieve the targets.
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The ProActive Physical Activity Referral Scheme is a countywide scheme designed to provide a safe introduction to physical activity for people who have specific health problems and have previously led an inactive lifestyle. Referrals are taken for clients who would benefit from a structured approach to increasing their activity levels. The aim is to provide safe and effective exercise within the knowledge base and experience of the instructors, all of whom have been assessed by Somerset Physical Activity Group and achieved the national required standard to be working on the scheme.
ProActive is a scheme that has been developed to introduce people to a more active lifestyle within a friendly, supportive and enjoyable setting. People are able to join the scheme through referral from a medical practitioner, for example a GP or Practice Nurse, if it is considered beneficial to the individual’s health needs. Over 50% of referrals received are for overweight or obesity. Currently the scheme receives 2,000 referrals per annum.
Somerset PCT has been represented at local stakeholder meetings for the Local Transport Plan (LTP2) to raise awareness regarding cycling and walking opportunities. The PCT has also been consulted on the Rights of Way Improvement Plan for Somerset and is currently exploring joint working with the Smarter Choices Team at Somerset County Council.
Support for community food projects, including food co-ops, that increase access to affordable healthy food is ongoing. A two year Making Local Food Work project is being carried out across Somerset by the local charity Somerset Community Food (SCF).
Over the last few months, Somerset PCT has been developing the NHS Health Trainer Service as the first part of the Integrated Lifestyle Service. These seven part- time posts, based out in communities with the highest health need, can offer one-to- one support to individuals who are ready to make a lifestyle change or signpost them to the most relevant agency, activity or health professional. Referral into the service is currently via community groups, children’s centres or by self referral.
Workplace health is seen as a key priority for the PCT and a programme to offer support to PCT staff on health and wellbeing including healthy weight is in its infancy and will be introduced during 2008/09.
Somerset Community Food – Nourishing Capacity Project
This was a three year project, funded by the Big Lottery Fund, delivered by the educational charity Somerset Community Food and supported by Somerset PCT30. The project’s objectives were to work in four wards in Somerset each year to be selected by their high levels of deprivation (twelve in total) and food poverty. Local people were trained and supported to become fieldworkers, aiming to help communities to access healthier diets and to increase social capital at the same time
30 Nourishing Capacity Project – end of project report July 2008
78 CHAPTER 4 - CURRENT HEALTH STATUS OBESITY by bringing people together, assisting local groups and educating. The project aimed for changes in three areas:
healthier diets more networking between people local projects to become self-sustaining
The diversity of the local projects was greater than anticipated and reflected strong, grass-roots connections. Fieldworkers were recruited who had firm local connections and were trained and employed 50:50 to become Food Access Workers, setting up and supporting local projects in Somerset through their allocated year, in response to local demand. These projects were ultimately encouraged to become self-sustaining and independent.
Nourishing Capacity original targets for local projects:
Table 4 Talk about healthy food to 100 people in each of every year for Two food co-ops with 20 customers each four three years; to be One growing group with 7 members targeted self-sustaining One cookery class for 8 learners areas
In addition, the project continued Somerset Community Food’s core activities: holding annual county wide conferences and producing the newsletter, ‘BeansTalk’.
Other outcomes included:
103 local projects - in which 3,300 Somerset people participated. Over 70% of these participants came from households that had incomes of below £20K per annum. The project also worked with 28 Somerset schools, nurseries, family centres and youth groups and engaged with 1,700 children. Again, even though this was outside the original plan, it soon became clear that often children were the key to changing whole families’ diets. In one initial questionnaire created by the Monitoring and Evaluation Officer, one of the commonest reasons for not making healthier food at home was ‘the kids won’t eat it’.
“Thanks for educating my child in healthy food – he eats more vegetables now, he’s trying everything.”
140 volunteer placements - the experience was valuable to the individuals themselves; some used their experience to access paid work or take on positions of responsibility in their own communities. Many reported increased confidence and were able to overcome isolation. The project sometimes helped ailing groups to survive by supporting existing volunteers and this represents a signification injection of social capital into deprived areas.
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“I feel I have developed confidence and the ability to perform tasks that before I would not have considered. I have become Chairperson for a pre- school, catered for an event for 150 people and helped organise a live band event.”
1,900 learners - the Nourishing Capacity Project ran courses on growing, preparing and understanding food. Some were ‘one-offs’ like a workshop on bottling and preserving and others were specially tailored course for parents of small children. There were sessions on healthy lunchboxes for school children and focused nutrition workshops on salt intake.
Classes were run in Somerset schools, youth groups and centres for older people including some that paired up with children and their parents and grandparents.
Fielders workers were trained by a specially devised course called ‘Know Your Onions’ created by the Project Training Co-ordinator. This covered nutrition, food production and delivery systems; how to set up and run community projects, how to grow food and how to teach other people cooking, nutrition and growing. The course is Open College Accredited and runs over one year, with learners able to choose some or all modules.
Five county wide conferences - attended by a mix of young and old, professionals and volunteers who met, ate and learned together. 97% of participants said they have learned something new about how to identify, grow or prepare healthy food.
Working in partnership - the project worked with 51 voluntary sector or community groups, 33 statutory organisations and 12 commercial sector groups or businesses. The Nourishing Capacity Project has particularly added value to social care work; for example in special education, in homelessness projects and in drug or alcohol programmes.
“We’re finding healthy lunches deal with more problems that we thought…..dealing with anger and everything. Healthy eating changes people’s attitudes for the better. When they’d eaten a burger and chips it was all outside having a fag, no communication. When it was chicken salad they all sat around the table talking and everyone helped wash up.”
Pied Piper project for ex drug-users, Burnham on Sea 2007
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Obesity – summary
levels of obesity are rising rapidly. If the current increases continue at the same rate, it is estimated that by 2020 one third of adults, one third of girls and one fifth of boys will be obese in Somerset, 34.7% of adults are overweight and 13.5% are obese in 2006/07, 8.7% of children in Reception were obese and 15% of Year 6, figures for this year are currently being compiled as part of the annual National Child Measurement Programme the work on obesity is being driven forward locally by the Somerset Obesity Forum, a multi-agency steering group comprising representatives from each PCT directorate and partner organisation responsible for the commissioning and delivery of the preventative and treatment aspects of obesity and overweight Somerset PCT has recently revised its weight management care pathways for both adults and children and young people in line with NICE guidance; public health maps provide a framework for action at a local level key partnership groups have developed a range of successful initiatives and programmes that deliver work on physical activity, food and health in the heart of communities across Somerset
Where are the gaps?
inequalities in overweight and obesity exist between men and women as indicated by the predicted rates shown above for girls and boys. However, inequalities also exist between social groups, with obesity being more common in semi-routine households as compared to professional households; this association is particularly true for women and children
(see Chapter 7 – Health Inequalities – page 157-159)
81 CHAPTER 4 - CURRENT HEALTH STATUS SMOKING
Helping people to stop smoking remains the single most effective method of improving health. Smoking prevalence is highest in more deprived areas. Services supporting people to stop smoking have the opportunity to improve the health of many individuals and make a significant impact on health inequalities. At one year the risk of heart attack is half that of a smoker, although it requires being quit for 15 years before the risk reduces to the level of someone who has never smoked.
What the situation is like now
Within the Health Profiles for England 2008 Somerset is indicated to have 863 deaths per year from circumstances relating to smoking. That is 176.6 deaths per 100,000 population compared to the national death rate from smoking of 225.4 deaths per 100,000. These figures suggest that smoking has less impact in Somerset than for the country overall however, the impact is still considerable and needs to be addressed. Although smoking prevalence overall is lower in Somerset than for the country, the prevalence varies geographically and across population groups. The health profiles indicate that 20.2% of pregnant women are smoking at time of delivery which is 4% more than the national average. We also know that there are higher numbers of young smokers in the south west than in England overall. Map 1 below indicates the variation in prevalence of smokers across Somerset. The areas with higher smoking prevalence broadly relate to the communities where more people are classified as being within routine and manual working groups. This also relates to areas where people are likely to be living in relative deprivation.
Map 1
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Smoking cessation services are set up to be as convenient for people as possible. Behavioural change studies recommend that people should be supported when they are ready to quit. The most effective evidence based route to quitting is regular structured support by a trained professional with pharmacotherapy as appropriate. Support is available at the vast majority of the 75 general practices across the county, also in some pharmacies and in some work-based support groups. There is also a central team of specialists who will support people to quit in group settings or with individual support.
How are we doing?
One effective outcome-based measure of performance is numbers of deaths related to smoking. We know that numbers of deaths have been reducing, the 863 deaths related to smoking in the 2008 Health Profile is less than the 900 deaths reported in 2007. We also know that disease specific deaths rates, with a direct link to smoking, such as cancer and heart disease are reducing in line with government expectations.
In smoking cessation services there are specific targets for numbers of people supported through to being quit at four weeks. This measure is evidence based as once someone is past four weeks they are passed the initial craving.
The target number of people being recorded as quit at four weeks for Somerset in 2007/08 was 3,900. The actual number of people supported to quit was 4,166. Within the context of south west PCTs, the Somerset target is the third most challenging in terms of quitters per 100,000 population, and the two areas with higher targets are in smaller more urban PCTs where the co-ordination of services should be relatively straightforward. Somerset exceeded its target by the largest amount in the south west and has been viewed as the most successful service in 2007/08.
The point of supporting people to be quit at four weeks is that many of them stay quit. There is also a locally agreed target for number of people still quit at 52 weeks. Between 2006 and 2008 it was expected that services would know about 1,064 people still quit at 52 weeks, in that period the service could confirm that 1,132 people were still quit at that time.
What is working?
Support to Stop services working out of the majority of General Practice sites work well. Services are locally accessible and advisors are well trained and supported to ensure they offer an evidence-based effective service. This is complemented by the central specialist service that offers a network of group and one to one support clinics, and also takes on the more challenging aspects of the service. However, alongside providing services to support people to stop smoking it is essential that statutory and voluntary services and community groups work together to reduce smoking prevalence. It is important to create an environment where people do not make the choice to start smoking.
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Smokefree Somerset Alliance
This local alliance between a range of organisations was re-launched in October 2007. Health services, schools and colleges and all District Councils and the County Council are represented. The alliance brings together those with a statutory responsibility for enforcement with those who advise and support people to quit. Initial work was focused on supporting organisations to go smokefree. This was a mostly supportive and advisory role and was particularly focused on ensuring that local statutory organisations were effective leaders in smokefree work. Since the smokefree legislation has come into place work has moved on to support the enforcement of this and offer services to make the transition effective. The alliance helps ensure partner activities are supportive and complimentary. Age of sale legislation has also directed the work of the alliance.
In recent months the focus of the alliance has moved on, and joint working has reached the point where organisations are committing funds to jointly develop work streams. Two new posts have been created; one to focus on smokefree homes/prevention of uptake (Smokefree Families Adviser) and a second post to work in partnership with environmental health and trading standards (Smokefree Somerset Co-ordinator). A separate Smokefree Homes subgroup is now operating ensuring that the Smokefree Homes project work is well scoped and a number of routes to funding a social marketing aspect of the work is being pursued.
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Smoking – summary
helping people to stop smoking remains the single most effective method of improving health in 2007/08 the number of people in Somerset recorded by smoking cessation services as supported to quit quit at four weeks was 4,166 – exceeding the target of 3,900 the number of deaths is reducing; 900 deaths in the 2007 health profile and 863 recorded in the 2008 Health Profile produced by the South West Public Health Observatory 20.2% of pregnant women in Somerset are smoking at the time of delivery – 4% higher than the national average
Where are the gaps?
overall services are working well and partnerships to ensure smoking prevalence is reduced are strong. However, further progress is needed. Within the smoking cessation services there are some general practices who do not provide a service and refer smaller numbers of potential quitters to the central service. There are also practices that only support smaller numbers of smokers through to quitting there needs to be more focus on pregnant women and manual workers to stop smoking. Numbers of women choosing to smoking during pregnancy are too high. Increased effort to work with the acute sector and maternity services to increase the focus in this area is required. Nationally it is known that smoking prevalence is highest among the routine and manual working groups it is also the case that there are too many young smokers, cessation services aim to increase evidence based activity at targeting this and statutory services need to increase efforts to effectively implement age of sale legislation. Improved campaigns are needed to prevent young people from taking up smoking supporting people to quit through their local pharmacy is a scheme in its infancy in Somerset. This is a proven effective way to support people and offers the opportunity to provide services where there is service provision
(see Chapter 7 – Health Inequalities – page 159-161)
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What the situation is like now
The latest Health Profile for England 2007 (uses 2005/06 diabetes data) shows 3.6% of the Somerset population has diabetes. This is not significantly different to national rates. However, there are a significantly higher proportion of people with diabetes in the districts of Sedgemoor and West Somerset.
Of the known population with diabetes in Somerset 10.5% have Type 1 and 89.5% have Type 2. Type 1 generally occurs early in life, commonly during early teens through to mid to late twenties. Type 2 is generally diagnosed in those aged over 50.
Modelled estimates suggest that there may be up to 21% (almost 5,000 people) undiagnosed diabetes in the Somerset population. When applied to practice populations the model would suggest there may be 30 practices with more than 30% undiagnosed diabetes within their population. However, there are some reservations about applying the model to small populations particularly when there are larger numbers of people aged over 65.
ONS projections indicate that Somerset’s population is set to rise overall and the proportion aged over 65 will rise rapidly over the next 20 years. This being the case the number of people with diabetes is likely to increase significantly over the coming years.
How are we doing?
Few deaths in Somerset can be directly attributed to diabetes. Figure 1 below shows that in the region of five deaths per 100,000 population were attributed to diabetes in the three years 2004/06. Numbers of male deaths were below national and regional rates and female deaths were marginally higher than the regional figure.
What may be of note is that although the numbers of early deaths (indicated by years of life lost) in men is lower than the regional or national figures, for women they are higher. However figures are based on small numbers of deaths and are therefore may not be statistically significant.
Figure 1: Years of Life Lost due to Diabetes
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Figure 2 below, shows trend in deaths comparing Somerset with the south west and England and Wales. There is some fluctuation in the Somerset figures but overall there is a downwards trend. Standardised Mortality Ratio (SMR) is a comparison of observed and expected deaths. The national rate for 2006 is expressed as 100 and all other figures are shown as a ratio of that. By 2006 the Somerset figure had fallen to 80; this indicates that there are 20% fewer deaths due to diabetes in Somerset than you would expect if the local population characteristics matched those of the national.
Figure 2: Trend in Mortality
When using locally available death certification information it is possible to consider where diabetes has been recorded as a contributory factor to death. Table 1 below shows that although seldom the cause of death, diabetes is often recorded as a contributory factor. There is no obvious pattern within these years; there appears to be a general increase in the number of deaths in some way attributed to diabetes through to 2005 and then numbers reduce. There are currently some changes with local acute trust data as new systems have been brought into place and 2007 data may be incomplete.
Table 1: Contributory Cause of Death
Contributory Main Total 2002 203 4 207 2003 287 1 288 2004 260 1 261 2005 319 6 325 2006 249 3 252 2007 163 2 165 Total 1481 17 1498
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Table 2 shows the main cause for all recorded deaths where diabetes is included as a factor. Death due to circulatory disease is the single largest group; however, it is also the main cause of all deaths.
Table 2: Somerset Deaths with Diabetes as a Contributory Cause ICD 10 2002 2003 2004 2005 2006 2007 Total Circulatory Disease 97 46.9% 122 42.4% 104 39.8% 152 46.8% 106 42.1% 73 44.2% 654 43.7% Respiratory Disease 40 19.3% 78 27.1% 52 19.9% 59 18.2% 49 19.4% 31 18.8% 309 20.6% Neoplasms 23 11.1% 25 8.7% 33 12.6% 29 8.9% 28 11.1% 21 12.7% 159 10.6% Abnormal Findings 18 8.7% 19 6.6% 30 11.5% 31 9.5% 19 7.5% 11 6.7% 128 8.5% Genitourinary 11 5.3% 14 4.9% 17 6.5% 19 5.8% 10 4.0% 10 6.1% 81 5.4% Infectious Diseases 7 3.4% 14 4.9% 8 3.1% 14 4.3% 14 5.6% 5 3.0% 62 4.1% Other 11 5.3% 16 5.6% 17 6.5% 21 6.5% 26 10.3% 14 8.5% 105 7.0% Total 207 288 261 325 252 165 1498
Secondary Care
Figure 3 shows recent trend in elective admissions. Between 2003/04 and 2006/07 the pattern is consistent, steady low numbers of admissions for both main and main dual diagnosis and a rapid increase in the number of admissions with diabetes as a subsidiary condition. By 2006/07 there were more than 1,600 admissions with diabetes as a contributory factor.
Figure 3: Trend in Elective Admissions
Figure 4 following shows the emergency admissions for the same period. The pattern is consistent with elective admissions, between 2003/04 and 2006/07 there are steady and low numbers of admissions for both main and main dual diagnosis. Over the same period there is a rapid increase in the number of admissions with diabetes as a subsidiary condition which by 2006/07 has reached 6,000 admissions.
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Figure 4: Trend in Emergency Admissions
In 2007/08 both elective and emergency admissions showed a sudden decline where diabetes was recorded as a subsidiary condition and a possibly associated increase in the number of admissions with diabetes as main / dual diagnosis. This may in part be the result of coding changes in Acute Trusts. Rapid decrease in figures is often suggestive of an incomplete dataset. However, the rapid increase in Main / Dual diagnosis is worthy of further investigation as it may be indicative of the role that diabetes plays in reason for admission.
The available data included above is of limited value. There is a clear suggestion that the contributory nature of diabetes as a cause for admission is being increasingly recognised and may also relate to increasing numbers of admissions. However, as yet there has been no consideration of the impact of diabetes on length of stay once an admission has taken place. There is a clear need to add to this work.
What is working?
Glucose control
An indication of how well a patient with diabetes is managing glucose levels in their blood can be attained through measuring the level of HbA1c in the blood. A measure of 7.4% or below indicates a well managed patient. Practices aim to record HbA1c levels regularly and as of March 2008 records are up to date for 98.5% of patients that should have been offered the test and 64.3% of patients in Somerset have good control.
Blood pressure control
A further measure of effective structured care is good blood pressure control. 99% of practices in Somerset have checked blood pressure of patients with diabetes appropriately. However, effective control is indicated by a blood pressure reading of 145/88 mm Hg or less. According to data from March 2008 79.7% of patients across Somerset have their blood pressure this range.
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Cholesterol control
A final indicator of effective care of patients with diabetes is a total cholesterol measurement of five or less. In March 2008, 97.5% of patients had their cholesterol measured with 85% of patients with a score less than five.
Retinal screening
To avoid retinopathy all appropriate people with diabetes should have retinal screening annually. Figure 5 shows the latest figures that enables comparison of local data with regional and national figures. Screening rates in Somerset compare well, three of four areas have a higher rates than both regional and national rates.
More recent local data is available and this shows that overall in Somerset 95% of appropriate patients are offered retinal screening. The range between the four old PCT areas is 93.7 – 96.6% which suggests that there has been significant improvement in service provision in all areas since 2004/05.
Figure 5: Retinal Screening
Development of a new model of care for people with diabetes
The growth in numbers of people with diabetes has implications for a range of health, social and community services that support patients with diabetes, including dietetic, podiatry and psychology services, as well as specialist diabetes services.
Somerset PCT is developing a new model of service which will deliver integrated and accessible care, with an increased focus on prevention, early intervention and self management. The model of care will set out to:
improve the care and health outcomes of adult patients with diabetes in Somerset promote partnership working and a shared care approach between providers so patients experience appropriate care seamlessly and in a timely manner provide accessible services as close to patients’ home or work as possible
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improve the knowledge and skills of patients and health care professionals to manage diabetes care, through education, training and practice support support self care
To enable the above to work effectively identification of patients needs to be improved. The national prevalence model estimates that there may be up to 21% or almost 5,000 people with diabetes undiagnosed.
The PCT is about to undertake an exercise comparing practice data on known people with diabetes compared to likely estimates in order to help practices identify where there may be additional need.
Somerset is implementing a Year of Care project to develop partnership in care for people with diabetes and their clinicians with expected improved outcomes for the management of their diabetes and quality of life. This project will inform the development of a service specification for diabetes services in Somerset.
The PCT is also putting further funds and effort into the provision of retinopathy screening and the provision of structured education for adults and children with Type 1 and Type 2 diabetes.
Diabetes – summary
3.6% of the Somerset population has diabetes of the known population, 10.5% have Type 1 and 89.5% have Type 2 modelled estimates suggest there may be up to 21% (almost 5,000 people) undiagnosed overall, 95% of appropriate patients are offered retinal screening 99% of GP practices in Somerset have checked blood pressure of patients with diabetes appropriately; 79% of these patients have their blood pressure well managed
Where are the gaps?
location of more deprived communities does appear to have some association with diagnosed diabetes. However, there is no correlation with modelled diabetes prevalence. There is little evidence to suggest any correlation between deprivation and diabetes control or quality of care, however, this may be worthy of further investigation Somerset’s rural nature may impact on people’s ability to self care / self manage and may also impact on services abilities to support people to remain in their own home. This may become particularly apparent if the projected numbers of people with diabetes in rural areas are accurate
(see Chapter 7 – Health Inequalities – page 161-163)
91 CHAPTER 4 - CURRENT HEALTH STATUS CORONARY HEART DISEASE AND STROKE
Despite being a largely preventable condition Coronary Heart Disease (CHD) produces more deaths in England, and locally in Somerset, than any other disease. Risk factors include smoking, obesity, high cholesterol and high blood pressure.
Some people are particularly predisposed towards developing atherosclerosis, due to inherited genetic factors. They may have a family history of people dying at a young age from CHD.
A stroke (cerebrovascular disease) occurs when the blood supply to part of the brain is disrupted. As a result there is loss of function in the area of the body supplied by that part of the brain. Stroke has a major impact on individual lives leaving lasting damage, affecting mobility, cognition, sight or communication.
Stroke is the third most common cause of death in England and Wales and is the main cause of acquired disability in adults. Many strokes are preventable, most are treatable, and the harm done by stroke can be greatly reduced by acting quickly on important warning signs like transient ischaemic attacks or ‘minor strokes’, and ensuring patients can benefit from expert, multidisciplinary care. After stroke, individual recovery can be enhanced through specialist therapy and wider social support.
People need a better understanding of how to reduce their own risk of having a stroke. Risk factors are the same as for other vascular diseases such as coronary heart disease – for example smoking and high blood pressure.
What the situation is like now
In March 2000, the National Service Framework for CHD was launched as a comprehensive blueprint to tackle the burden of CHD. The Framework established 12 standards for prevention, diagnosis and treatment and introduced a ten-year programme to reduce premature deaths from CHD and promote faster, fairer access to high quality services.
Work to implement the National Service Framework has successfully reduced death rates from circulatory disease. The national target to “Reduce substantially the mortality rates by 2010 from heart disease by at least 40% in people under 75” is on schedule to be achieved locally.
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Figure 1
Somerset deaths 2004-6
4% Bronchitis, Emphysema and other COPD 8% Figure 1 shows the leading causes of 20% Other diseases of Respiratory System death in Somerset. Cancer, Ischaemic Cerebrovascular disease 11% Heart Disease and Stroke being among Ischaemic Heart Disease 1% the highest 3% Other diseases of Circulatory System Neoplasms
17% Diseases of the Nervous System Diabetes
27% Other deaths 9% Figure 2
Mortality rates for Coronary Heart Disease in those aged 65 - 74 550
500 ENGLAND Mortality rates from Coronary heart AND WALES Disease in those aged 65 – 74 years, 450 has gradually decreased over the 400 years. This is due to improved services South West SHA from both preventive and secondary 350
care 300
Somerset 250 PCT
200 2001 2002 2003 2004 2005
Figure 3
Admissions for Stroke - all ages
200 Admissions for stroke 180 overall have been rising 160 for some time. However, 140 Mendip 120 some reductions in 100 Somerset Coast admissions, particularly 80 South Somerset in South Somerset, have 60
rate per 100,000 per rate lead to a levelling off of 40 Taunton Deane 20 the position in the last SOMERSET 0 two years.
/6 /7 * 5 6 /8 00 00 7 2002/3 2003/4 2004/5 2 2 00 2
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As effective prevention programmes, self care programmes, and care provided by primary care take effect the rate of stroke and stroke deaths should reduce.
Figure 4
190 Mortality rate from stroke in those aged 65 - 74
170 ENGLAND Figure 4 shows that the mortality AND WALES rate of people aged 65 – 74 150 years from stroke is lower than 130 South West national and regional rates. SHA 110
90 Somerset 70 PCT
50 2001 2002 2003 2004 2005
Figure 5
Deaths from Stroke - all ages 90 Death rates due to 80 stroke have been 70 reducing for some time. Mendip 60 This suggests that care 50 Somerset Coast is effective and getting better. 40 South Somerset
30 Taunton Deane rate per 100,000 per rate 20 SOMERSET 10
0
2002 2003 2004 2005 2006
The Somerset Coast area shows a minor increase in recent years; effort is still required to maintain and improve a downward trend and plans are in place to make sure rates are monitored closely.
Stroke prevalence in Somerset is 2.1%. Stroke prevalence in the England population over all is 1.6% and in the south west it is 1.9%. Occurrence of stroke is more common among older people. We know there is a higher proportion of older people in the south west than nationally, and the proportion higher again in Somerset. The higher prevalence rates suggest that more services will be needed locally and planning services effectively needs to be a high priority.
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In the three years between 2004 and 2006, 1,103 women and 645 men in Somerset died from stroke. However, when viewing the numbers of deaths as a standardised rate (for age and sex) the figures show that lower deaths rates occur in Somerset than for the south west region or nationally. The age standardised rates per 100,000 population is 48.97 for Somerset, 50.82 for the south west and 53.55 for England. Lower death rates suggest a relatively healthy population and may also suggest effective health care is being provided. However, it should not be forgotten that because of the age structure in Somerset the overall comparative rate of stroke may be low, but the actual numbers are considerable.
How are we doing?
An equity audit conducted in 2006 revealed that death rates from CHD in Mendip had remained static between 2001 – 2004 whilst death rates in all other areas of Somerset had fallen. In 2004, death rates in the Mendip area from CHD were higher than the national rate whist all other areas in Somerset were lower. One issue particularly highlighted as the reason for this inequality was the inequity in access to services. The Mendip area was found to be underserved for both angiography and revascularisation compared to other districts in the county with East Mendip being particularly underserved. This has resulted in service investment to address this inequality.
Performance in stroke prevention can be measured through focused efforts on high risk groups. Primary among these groups are people who are obese and older people and there has been significant interventions for both groups developed in recent years. Health walks have been running for some time, exercise referral schemes are in place and the Obesity Care Pathway has recently been developed. Active Living Centres are a network of community centres aimed at providing people over 50 with the information they need to effectively care for themselves and access a range of initiatives, activities and interventions that will help keep them healthy. Currently 55 of these Centres have been developed in Somerset.
What is working?
Over the past three years significant progress has been made to address this inequality primarily through improving equity and timely access to specialist services for Mendip residents. Developments have included the opening of a new Catheterisation Laboratory in Bath which has significantly improved timely access to angiography. A review of the most recent data relating to death rates from CHD in Somerset shows significant improvements across districts with CHD deaths rates in Mendip reducing from 114 per 100,000 population in 2003 to 70 per 100,000 in 2006.
Rehabilitation and Recovery
Rehabilitation in Somerset provides a variety of services that support older people in improving confidence by providing the right information and support to continue living as normal and independent a life as possible. This can be through attending a six week course that covers both exercise and education on how to manage the condition.
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Much work is being undertaken nationally and locally to prevent or reduce the incidence of stroke, falls, heart disease and other diseases. In addition to this, there have been important advances in the provision of rehabilitation in Somerset.
Somerset PCT Rehabilitation Service - the rehabilitation service aims to provide rehabilitation to patients both in hospital and at home, to assess patient’s needs and provide therapy to allow patients to meet their greatest functional potential.
Its aim: to reduce unnecessary hospital admissions to reduce length of stay to facilitate safe, effective discharge from hospital or ‘stepup-stepdown’ beds to provide a service that is responsive to patient’s needs and a changing agenda to assist the patient with long term conditions to manage their condition at home
Currently there are different models of service delivery across 13 community hospital teams. The Occupational Therapists and Physiotherapists work closely together but with different paperwork, protocols and profession specific assistants. The aim in the immediate future is to integrate these services to ensure the patients receive the right treatment at the right time and place. It supports rehabilitation staff to work together in a flexible and responsive way and working smarter to utilise resources as effectively as possible.
Cardiac Rehabilitation
Heart disease causes distress and impairs quality of life. Cardiac rehabilitation is a multidisciplinary approach to improve short-term recovery and promote long-term changes in lifestyle which help to correct adverse risk factors. It is a process by which patients are restored to and maintained in optimal physical, emotional, social, vocational and economic state.
Cardiac rehabilitation services usually include exercise training, risk factor modification, education and counselling. The principal justification for rehabilitation is the encouragement of return to full activities and a reduction in well-documented convalescence problems of lack of confidence and sleep, anxiety, depression fatigue and worry about non-specific physical symptoms together with excessive caution about every day activities.
In the UK, cardiac rehabilitation is traditionally described in terms of phases of recovery; Phase I is the inpatient stage, Phase II the early discharge from hospital period, Phase III is a clinically supervised outpatient programme and Phase IV is the long term maintenance of physical activity and lifestyle change.
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The Phase III of cardiac rehabilitation traditionally took place in hospital with patients returning to the hospital setting for their sessions. This has now developed and many Phase III courses are held in community settings. The Phase III courses are taken by a cardiac nurse, a physiotherapist and a specially trained exercise instructor. These specially trained exercise instructors also offer the Phase IV courses across Somerset in a variety of community settings such as village halls, church halls and leisure centres.
Somerset Cardiac Rehabilitation Service - the Somerset Cardiac Rehabilitation Service offers support and advice for those living with Coronary Heart Disease across Somerset. This includes exercise, lifestyle education and psychosocial support following a Myocardial Infarction (MI), Angioplasties and Stents and Coronary Artery Bypass Surgery as well as angina, heart failure and valve replacement in some localities.
The service offers telephone contact, home visits and a structured cardiac rehabilitation programme, which is delivered by a multidisciplinary team of health care professionals working in partnership with local authorities, NHS organisations, voluntary and charitable organisations such as the British Heart Foundation. Prompt referrals back to GPs or hospitals are made for patients with unstable or worsening conditions.
Somerset Cardiac Rehabilitation Service is now coming into an exciting time of development and change in order to ensure that all patients within Somerset are offered the same good quality service. This is due to the amalgamation of the previous PCTs and the newly appointed Cardiac Services Manager.
Future Developments
Under the guidance of the Cardiac Services Manager we are currently in the process of developing a home based programme for those patients who are unable to attend the Phase III Cardiac Rehabilitation Exercise Programme, which can be due to many reasons such as lack of transport due to Somerset’s rural location.
Once the patient has been discharged from the service they are actively encouraged to participate in a Phase IV community structured exercise programme in their locality. Find your local cardiac rehab programme in Somerset http://www.cardiac-rehabilitation.net/
It is important to achieve a balance between improved quality of systematic care and care that informs, involves, engages and empowers individuals to manage their own conditions and live as full and independent lives as possible. It is important that a range of evidence based interventions are available in the areas of prevention, early detection, proactive and integrated care, self care, specialist care and rehabilitation.
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Stroke Rehabilitation
Stroke care is one of the top priorities for the Department of Health and is the top priority for NHS South West and Somerset PCT following the publication of the National Stroke Strategy in December 2007. Rehabilitation following stroke is about the process of achieving the best level of independence as possible by:
learning new skills relearning skills and abilities adapting to the physical, emotional and social consequences of the stroke
Stroke services in Somerset PCT
Over the last few years services have been developing in Somerset. There is now a 20 bedded stroke rehabilitation unit in Williton Hospital, an eight bedded stroke rehabilitation unit in Shepton Mallet Hospital and six stroke rehabilitation beds integrated onto a general rehabilitation ward in Verrington Hospital in Wincanton.
A team of professionals support the service and include a Consultant Nurse for Stroke, three Stroke Co-ordinators and a Clinical Specialist Physiotherapist, Occupational Therapist and Speech and Language Therapist, all based in the community.
Future Developments
Somerset PCT is part of the Avon, Gloucester, Wiltshire and Somerset Cardiac and Stroke Network. Our Local Implementation Team is currently developing a comprehensive action plan to ensure that within three years we will comply with all areas of the National Stroke Strategy.
A further new and exciting innovation is taking place in South Petherton with the development of a new Community Hospital and Long Term Conditions Centre. As part of this the PCT are developing a state of the art centre of excellence for stroke rehabilitation which should be open for its first patient in summer 2010.
For more information on Stroke visit: http://www.stroke.org.uk/information/stroke_rehabilitation/
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Coronary Heart Disease (CHD) and Stroke – summary
CHD produces more deaths in England and locally in Somerset than any other disease risk factors for heart disease and stroke include family history, smoking, obesity, high cholesterol and high blood pressure the national target to reduce mortality rates by 2010 from heart disease by at least 40% is on schedule to be achieved locally stroke prevalence in Somerset is 2.1% between 2004 and 2006 1,103 women and 645 men in Somerset died from stroke the Somerset Stroke Group is monitoring an agreed strategic plan to implement integrated stroke services
Where are the gaps?
data relating to deaths from cardiovascular disease under the age of 75 years in Somerset shows that for the period 2004 - 2006 there were a total of 1,243 deaths, a directly standardised rate of 66 deaths per 100,000 population. Whilst this figure is below the national average significant inequalities can be seen within Somerset. There is a strong association with income deprivation with the most deprived quintile of wards in Somerset experiencing deaths 47% higher when compared with wards in the rest of the county as already stated, the risk factors for stroke are common with other circulatory disease. These risk factors are more common among communities living in more deprived areas. Both admissions and death rates for stroke appear to be highest in the Mendip area, although it is generally in urban areas where there will be greater numbers
(see Chapter 7 – Health Inequalities – page 163-165)
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What the situation is like now
During the 1990s, survival rates for cancer improved in England but the gap between the UK and the best rates for European countries did not close. In December 2007 the government produced the Cancer Reform Strategy to support the ambition in England that by 2012 cancer services should not only be among the best in Europe but among the best in the world.
The incidence of cancer continues to rise due to the ageing population and this is predicted to increase by approximately one third between 2001 and 2020.
One in three people will be diagnosed with cancer at some time in their life and cancers account for around one quarter of deaths in Somerset. In 2005 there were a total of 1,452 deaths from cancer in Somerset. Of these deaths, 226 were from lung cancer, 198 from colorectal cancer and 132 from breast cancer. Targets to reduce mortality rates from cancer are included in the National Health Strategy, Saving Lives Our Healthier Nation, the priorities and planning framework and the Cancer Plan. During 2004-06 in Somerset the age standardised premature mortality rate from all cancers per 100,000 population was 106.4.
Figure 1: Death rate of those aged less than 75 from cancer: Somerset and England 1996-2005
220 200 180 160 140 120 100 80 60 40 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
ENGLAND Somerset PCT
Prevention
The causes of some cancers remain unknown however, over half of all cases of cancer could be prevented through changes of lifestyle such as quitting smoking, avoiding excessive ultraviolet exposure, maintaining a healthy weight and avoiding alcohol consumption.
Plans for a vaccination programme for young people against the human papillomavirus are in place which will prevent a large proportion of cases of cervical cancer. The programme will be fully implemented by 2010, resulting in all girls up to 18 years old being offered the vaccination course.
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Diagnosing Cancer
Evidence shows that later diagnosis of cancer has been a major factor in the poorer survival rates in the UK compared with some other countries in Europe. One of the aims of the Cancer Reform Strategy is to extend and widen existing programmes and to investigate other opportunities for new screening programmes for other cancers.
● the cervical screening programme will ensure that all women receive the results of their screening tests within two weeks by 2010 ● the age range for breast screening will be extended further to provide nine screening rounds between 47 and 73 years. Starting in 2008 this expansion will be completed by 2012. Direct digital mammography will be introduced over the same period ● the NHS Bowel Screening programme will be extended from 2010 to invite men and women aged 70-75 years ● the NHS Breast Screening programme will take responsibility for the management of surveillance for women at high familial risk of breast cancer ● a new National Awareness and Early Diagnosis initiative will be established ● campaigns to raise awareness of the signs and symptoms of common cancers are being piloted in 20 deprived areas of the country; and ● a national audit in primary care of all patients newly diagnosed with cancer will be established
How are we doing?
Somerset Breast Screening Programme
During 2006-07 in Somerset the breast screening coverage (the percentage of women aged 53-64 screened within three years of their last adequate test) was 82.6% compared to a target of 70.0%.
The most recent figures for Somerset show:
Round length 84% screened in 36 months Screen to normal result 82% within 2 weeks Screen to assessment 86% within 3 weeks
Somerset has historically always achieved over 90% round length but in 2007 there was a temporary problem due to the way in which women were invited at a large site three years ago. A recovery plan was implemented which put the programme back on track by summer 2008. The unit worked extended days from 8am until 8pm as well as Saturday mornings to achieve this. Extra investment has been identified to increase capacity and the future purchase of digital equipment will facilitate this.
Somerset Breast Screening has had major staffing problems in the last 18 months with two of its three Consultant Radiologists leaving and Consultant maternity leave.
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Despite some locum cover and successful recruitment of replacement radiologists, there have been long periods of significant staff shortages.
The recent Breast Screening QA visit highlighted the unit’s excellent results but recognised the issues of workload and staff pressures.
The PCT will be working closely with the Unit to keep the screening programme on track and ensure appropriate investment in resources and equipment.
Somerset Cervical Screening Programme
During 2006-07 in Somerset the cervical screening coverage (the percentage of women aged 25 – 64 that have been screened within 5 years since their last adequate test) was 82.6% compared to the target of 80.0%.
The cervical screening programme in Somerset continues to have good coverage of its target population.
Table 1: Cervical screening KC53 statistics % screened in last 5 years (25-64 age groups)
2004/5 2005/6 2006/7 Mendip PCT 83.2% 83.4% 82.4% Somerset Coast PCT 83.1% 83.6% 82.9% South Somerset PCT 83.1% 83.1% 82.5% Taunton Deane PCT 82.1% 82.7% 82.4%
Somerset 82.9% 83.2% 82.6% England 80.3% 79.5% 79.2%
Somerset is covered by laboratories from Taunton and Royal United Hospital Bath (for East Mendip residents).
The migration of younger women (25-49) to three yearly re-call is continuing. In 2006/07 just under 95% of women had their smear reported as normal, but over 1,800 women had an abnormal smear that required further investigation.
The underlying trend in death rates from cervical cancer continues to be downwards.
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Figure 2: Trends in three year rolling average age standardised mortality rate (ASMR) of cervical cancer in Somerset, 1981-83 to 2002-04. Rates are per 100,000 women per year.
8
7
6
5
4
3
2
1
Age standardised mortality rate (per 100,000 women per year) per women 100,000 (per rate mortality standardised Age 0
1981-1983 1982-1984 1983-1985 1984-1986 1985-1987 1986-1988 1987-1989 1988-1990 1989-1991 1990-1992 1991-1993 1992-1994 1993-1995 1994-1996 1995-1997 1996-1998 1997-1999 1998-2000 1999-2001 2000-2002 2001-2003 2002-2004
This figure shows that there is a downwards underlying trend in deaths due to cervical cancer since the cervical screening programme began in 1981. It is estimated that if coverage can be maintained at over 80% then there is the potential to reduce death rates to 95% of those prior to the introduction of the programme.
A visit by the Regional QA Team identified a small number of suggestions for further improvement of the programme that will help to improve performance beyond its current level.
Work is continuing on the development of a sample taker register and towards the implementation of a laboratory rejection policy. Somerset is participating in the 14 day turn around pilot project.
Somerset Bowel Screening Programme
One in 20 people will get colorectal cancer at some time in their life. Around 40% of people over 60 develop polyps, some of which remain benign, but may progress to cancer. The National Screening Committee has recommended a target screening programme. Somerset commenced screening for bowel cancer in March 2008. The programme aims to screen all people aged between 60 and 69 every two years.
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What is working?
Public awareness initiatives for different types of cancer have been delivered across Somerset including radio station slots, newspaper advertising, the smoking cessation bus (going to town centres and schools) and ‘Smokefree Somerset’ helping businesses to reduce smoking in the workplace.
Additional material raising awareness about cancer and providing information is available from Somerset PCT Health Promotion Resource Service on skin cancer, cervical screening, breast cancer and testicular cancer.
The implementation of the human papilloma virus (HPV) vaccination programme involves a media plan to promote public awareness of the vaccine. To date this has included an article in the July 2008 edition of ‘Your Somerset’, which is delivered to all households in Somerset, and in the Summer edition of the Healthy Schools Newsletter. Letters and information regarding the programme have been sent to all schools in the county.
From September 2008 there will be a national media campaign that will be supported in Somerset through targeted press releases and through local radio. In addition to this, information will be sent to all parents and guardians of Year 8 girls and all 17 and 18 year olds who are eligible for vaccination programme during 2008/09. Information and resources are also being sent to all GPs and relevant health services to help them in their response to public enquiries. The HPV vaccine protects against the two strains of HPV that cause 70% of all cervical cancer cases.
Cancer – summary
during 2006/07 in Somerset the breast screening coverage was 82.6% compared to a target of 70% during 2006/07 in Somerset the cervical screening coverage was 82.6% compared to the target of 80.0% a bowel screening programme commenced in March 2008; the programme aims to screen all people aged between 60 – 69 every two years the human papilloma virus (HPV) protects against the two strains of HPV that cause 70% of all cervical cancer cases. A targeted media campaign will commence in September 2008 nationally and locally through press releases and local radio Where are the gaps?
inequalities in cancer outcomes are experienced across a range of different groups and may vary according to the type of cancer as well as other factors such as location for example, the incidence of lung cancer among men and women are around twice that in the most affluent areas and death rates are twice as high
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although the uptake of cervical screening overall in Somerset meets the national target there is significant variation of coverage by GP practice and uptake of the screen is linked to socio-economic differences
(see also Chapter 5 “Current Met Need” – page 119 - and Chapter 7 “Health Inequalities” (smoking) – page 159-161)
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What the situation is like now
People aged 65 years and older make up approximately 20% of Somerset’s population. This is more than the south west regional proportion which is already the highest in the country. With increased age there is increased likelihood of normal life being limited through disability, long term illness or chronic disease. This implies that in areas with larger numbers of older people there is likely to be an increased call on services to support people with limiting long-term illness. The proportion of the population aged over 65 tends to be higher in the more rural areas.
Generally people living in rural areas are lower users of health and social care services. The Somerset situation where large numbers of older people reside in more rural areas may lead to large numbers wishing to be supported to remain in their own homes. Expressed opinion suggests that older people and their families want more services for strokes, falls, mental health, long term conditions and emergency care. Furthermore, those entering old age want to know how to maintain their health, independence and wellbeing.
As indicated in Figure 1, the population of Somerset is relatively healthy in terms of life expectancy and prosperous, although there are pockets of deprivation within some of the larger towns and in isolated rural areas.
Figure 1: Terms of Life Expectancy
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Map 1 shows that in Somerset it is mostly rural areas that have a high proportion of over 65s. In particular these are parts of West Somerset, but also areas within Sedgemoor, South Somerset and also the outskirts of Taunton.
Map 1: Percentage of population aged 65+ 2007
As Figure 2 below shows, Office for National Statistics (ONS) estimates suggest there will be a 14% rise in the total population in Somerset by 2025. The population aged 65 and above is set to grow by 55% over the same period, and the over 85s by 73%. This may place additional pressure on health and social care services. Over the same period the working age population will grow at a much lower rate and this will change the baseline of dependency within the population.
Figure 2: Population Increase Figure 3: Proportion of Population
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To understand likely population change Table 1 provides the numbers that sit alongside the percentage increase shown in Figure 3 (previous page). The number of older people is likely to grow by approximately 60,000 and increase to more than 160,000 in the next 17 years.
Table 1: Population Change (Numbers in ‘000)
AGE GROUP 2007 2015 2025 ALL AGES 525.7 558.6 601.1 50+ 214.1 249.9 292.5 65+ 105.3 133.1 163.6 85+ 15 19 26
Maps 2, and 3 show the geographical change in the over 65s population structure. The maps are presented at Super Output Area (SOA) level where the coloured shading reflects the proportion of the population that is aged over 65 years. This series of maps graphically illustrates the dramatic rise in population aged over 65, particularly in rural areas.
Map 2: Percentage of Population aged 65+ - 2017
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Map 3: Percentage of Population aged 65+ - 2027
Figure 4 shows that with increased age there is increased likelihood of normal life being limited through disability, long term or chronic disease. This implies that in areas with larger numbers of older people there is likely to be an increased call on services to support people with limiting long-term illness.
Figure 4: Limiting Long Term Illness
Limiting Long Term Illness by age group- 2001 80 Census 70 South West 60 England 50 40
30
How20 are we doing? 10 0 r 5 4 9 9 4 4 e 1 3 4 5 6 8 v o o o o o o o t t t t t t r 0 6 5 0 0 5 o 1 3 5 6 6 % 5 % % % % % 8 %
Life expectancy continues to rise in Somerset and early deaths due to major killers such as cancer and heart disease are reducing. There are a range of initiatives aimed at supporting older people to be physically active and to improve health and wellbeing. However there are areas where improvement is required.
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Falls are a major cause of disability and the leading cause of mortality due to injury in people aged over 75. A fall represents the most frequent and serious type of injury for anyone over the age of 65 years and 50% of people over 80yrs will fall every year.
Figure 5: admissions due to falls
Figure 5 shows that over recent years the number of admissions due to a fall have been regularly increasing. Despite a range of initiatives designed to improve physical activity rates and improve older people’s balance, admissions continue to increase. Work on falls has been a priority area for a number of years but need to continue to be a priority in coming years.
In Somerset 85% of deaths occur in those aged over 65. It is important that people are supported to die in the environment that they choose. End of life care is the support for those with advanced, progressive, incurable illness to live as well as possible until they die. Generally these are services that enable the supportive and end of life care needs of both patient and family to be identified and met throughout the last phase of life and into bereavement. The aim is to increase choice at the end of life for all adults irrespective of the condition they are suffering from, to live and die in the place of their choice. Although every individual may have a different idea about what would constitute a ‘good death’, for many this would involve:
being treated as an individual, with dignity and respect being without pain and other symptoms being in familiar surroundings; and being in the company of close family and/or friends
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Figure 6: trend in place of death
As the figure above shows, in Somerset we are not as effective as we would like to be in supporting people to die in their place of choice. Fewer people are dying in acute hospitals and slightly more people are dying at home. However, when considering cancer care considerably more progress has been made. Effort is required to replicate the work undertaken in cancer care for all palliative care episodes, everyone has the right to die in their place of choice regardless of diagnosis.
What is working?
Physical activity improves your physical, mental and social health. It is one of the most important factors in maintaining a good quality of life. Regular physical activity decreases the risk of coronary heart disease, stroke and diabetes, and the associated risk factors such as hypertension and obesity. Physical activity also has a role in preventing falls among older people.
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The ProActive Physical Activity Referral Scheme is a county wide scheme designed to provide a safe introduction to physical activity for people who have specific health problems and have previously led an inactive lifestyle.
The Walking the Way to Health Initiative has enjoyed considerable and continued success in Somerset. The project offers regular led walks close to where people live or work. It is aimed at people unused to regular activity, and everyone is encouraged to walk at their own pace.
The 'Active Somerset' project aims to increase opportunities for, and adult participation in, active recreation. It is developing Community Activists to promote local opportunities and support new people to become involved. Particular emphasis is given to increasing participation in women and people over the age of 50 years old in wards that fall into the most deprived quintile in Somerset. The project is supporting the start-up of 300 new active recreation opportunities across the county from March 2007 until April 2009.
Active Living Centres
Although there are undoubtedly challenges associated with the proportion of Somerset’s population who are aged over 65, it is important that we recognise that there are also significant benefits. Older people in Somerset are more likely to undertake regular volunteering than younger residents, and are often the mainstay of the many clubs, groups, associations and societies that contribute so much to the quality of life in Somerset.
In some cases older people are themselves designing and delivering the services they need to remain active and independent. A good example of this is the success of Somerset’s Partnership for Older People Project (POPP), which is mainly delivered through local volunteers (many of them aged over 65).
Somerset was one of only 19 local authorities nationwide to be successful in bidding for two year POPP funding. We received a total of £1.3m during 2006/07 and 2007/08 to develop services that would help older people to maintain their independence and reduce/delay their need for health and social care services. We set ourselves the ambitious task of developing 50 very local Active Living Centres, which would:
serve their local community operating from the church / village hall, sheltered housing scheme or other suitable local venue, with outreach facilities be a vibrant ‘hub’ providing a café style environment, and hosting a variety of activities, as well as being a source of information and referral to the full range of preventive services available locally be led by local volunteers help older people to identify ways in which their local communities might be enhanced, and support them in action to bring about improvements
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The Somerset POPP programme has been overseen by a multi-agency Partnership Board led by SCC and incorporating District Councils, Somerset PCT, a Voluntary / Community Sector representative and Age Concern Somerset (which hosted the project team). A much wider partnership of organisations has been involved in establishing and running Active Living Centres and providing preventive services through them. The members of the wider partnership range from very small community organisations (e.g. Norton Fitzwarren Village Hall Committee), to very large statutory organisations (e.g. Avon and Somerset Constabulary).
As at 31 March 2008, 52 Active Living Centres had been established throughout the county. The communities served range from those in larger urban centres to the very rural, with each centre reflecting the needs and wishes of the particular community it serves. In all, 93 additional volunteers have been recruited through the POPP programme, of which 41 have taken on formal leadership roles. In addition, a network of ‘time-banks’ has been established, which provide a vehicle for older people to exchange particular skills on a voluntary basis.
Approximately 6,000 older people have attended an Active Living Centre since the start of the project. This has contributed to a reduction in the number of low-level health and social care packages starting during the two years, as well as delays to the expected pattern of progression of those packages. There has also been a significant reduction in the number of older people who have suffered a fall during the lifetime of the project, due in part to the falls screening service that has been developed as part of POPP.
The resulting net savings to local health and social services are estimated at £0.6m over the two years, and the potential for on-going savings is approximately £0.5m per annum. This is coupled with many more qualitative outcomes. The initial (independent) evaluation of the Somerset POPP programme undertaken by Kent University demonstrates real gains in the quality of life experienced by older people using Active Living Centres. These include, a lessening of the effects of chronic health conditions, improved mobility, reduced social isolation and perhaps most importantly, a renewed sense of feeling independent, in control and being a part of the local community.
The challenge for the current and future years is to sustain and build upon what has been achieved through POPP so far. All key partners remain committed and have signed up to take forward the work in the form of a county wide Active Living Service. This reflects the priority and targets within the new LAA to increase the number of older people who say they receive the information, advice and guidance they need to maintain their independence, as well as targets to increase the number of volunteers and enhance the role of voluntary/community groups. The Active Living Service will be made up of local networks that link together and develop the range of opportunities available to older people. This will involve:
sustaining the Active Living Centres developed through POPP by providing community development support and helping them to achieve small grant funding
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modernising day care services previously provided through SCC’s Adult Social Care Service so that they are available to a wider range of older people and become more a part of local communities linking and supporting the many local clubs, groups and societies that contribute so much to older peoples’ quality of life improving the range of preventive services provided by statutory (and other) organisations, and making them more readily available through local networks further developing the falls screening service so that it is even more effective in identifying those at risk of falls and ensuring they receive an appropriate service developing an Active Living Service website that provides information about Active Living Centres and preventive services, and offers an interactive forum for older people
Older people – summary
20% of the Somerset population is over 65 the Office for National Statistics estimates there will be a 14% rise in the total population of Somerset by 2025; the population aged 65 and above is set to grow by 55% over the same period and the over 85s by 73% in Somerset the number of older people is likely to grow by approximately 60,000 and increase to more than 160,000 in the next 17 years in Somerset 85% of deaths occur in those aged over 65 a fall represents the most frequent and serious type of injury for anyone over the age of 65 years there are 55 Active Living groups in Somerset which promote keeping safe, well and preventing long term illness in older people
Where are the gaps?
inequality in the older population can be multi-factoral. In urban areas older people are more likely to be living alone, or with financial difficulties, or with a limiting long term illness. However in more rural areas older people often experience difficulty with accessing services, and although they may be relatively wealthy, it is often the case that they are asset rich but cash poor and therefore experience difficulties with heating their home and the health complications that go along side that. Inequalities among our older population can be tackled in a range of ways, important elements of this work might include: effective benefit advice to ensure people receive the income to which they are entitled, and targeted healthy living advice, chronic illness can be postponed or well managed through effective self care
(see Chapter 7 – Health Inequalities – page 165-168)
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What the situation is like now – emergency planning
Somerset PCT has dedicated plans for a major incident, heat wave and pandemic flu. Each of these plans is reviewed on an annual basis and tested throughout the year by internal specific and external multi agency exercises. The exercises take the form of either tabletop or physical scenario.
As a Category 1 responder, as identified in the Civil Contingencies Act 2004, the PCT operates in a multi agency format and contributes to the development of the Local Resilience Forum plans. These plans are tested through multi agency exercises and updated in accordance with emerging guidance and legislation.
Specific events such as Glastonbury Festival, sites such as Hinkley Point Nuclear Power Station or environmental issues such as flooding have dedicated multi agency plans produced by the PCT and its partners.
Somerset PCT works with the local branch of the Health Protection Agency, District Environmental Health Services and other partner agencies on issues relating to communicable diseases, chemicals and poisons, radiation, emergency response, environmental health hazards.
All employees of Somerset PCT receive training on the Major Incident Plan, its implementation and the role they may be expected to play in the event of an incident.
How are we doing?
All PCT specific plans are compliant with the responsibilities identified for a Category 1 responder in the Civil Contingencies Act 2004, the NHS Emergency Planning Guidance 2005 and Department of Health guidance as issued.
The Major Incident Plan was reviewed, amended and sanctioned by the Executive Board in November 2007. The Heat Wave Plan was issued in accordance with the Department of Health timeline at the end of May 2008 and a final draft of the Pandemic Flu Plan will be complete by December 2008 compliant with the NHS timeline. A self assessment audit of the Pandemic Flu Plan was conducted in March 2008 which allowed a gap analysis. A second self assessment audit will be conducted in October 2008.
The PCT regularly interacts with partner agencies and stakeholders to develop multi agency plans and is the lead organisation for producing a Mass Vaccination Plan for the Avon and Somerset Local Resilience Forum.
What is working?
A task and finish Influenza Planning Group was established by the PCT drawing together health and social care partners. This open forum allows the discussion and development of a response to a Flu pandemic with cross organisational working and realistic mutual aid arrangements. The pooling of resources, intelligence and
115 CHAPTER 4 – CURRENT HEALTH STATUS HEALTH PROTECTION experience is ensuring a robust and resilient Somerset-wide preparation with defined areas of responsibility and agreed guidelines.
The Avon and Somerset Local Resilience Forum is cited as the model for other local resilience forums to adopt by the Government Office for the South West.
Emergency planning – summary
Somerset PCT has dedicated plans for a major incident, heat wave and pandemic flu. Each of these plans is reviewed and tested on an annual basis all employees of Somerset PCT receive training on the Major Incident Plan, its implementation and affect all PCT specific plans are compliant with the Civil Contingencies Act 2004, the NHS Emergency Planning Guidance 2005 and Department of Health guidance the PCT regularly interacts with partner agencies and stakeholders to develop multi agency plans. all emergency plans are non discriminatory and provide a level of response to ensure the safety of the entire Somerset population ensuring that vulnerable people and hard to reach groups are fully included in all plans has resulted in each organisation, both statutory and voluntary, holding a list of recognised vulnerable people which can be shared in the event of an incident. Each organisation has the responsibility for maintaining and updating their records
Where are the gaps?
health inequalities - there are no identified health inequalities in any of Somerset PCTs emergency plans or any of the multi agency emergency plans
IMMUNISATION
What the situation is like now
Immunisation remains one of the greatest successes in protecting children’s health. The childhood immunisation course now consists of coverage for several illnesses including diphtheria, polio, tetanus, whooping cough, meningitis C, haemophilus influenzae, pneumococcal disease, measles, mumps and rubella.
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Figure 1
Percentage DTP vaccine uptake at 24 months 100
95
90
85
80
Percentage DTP uptake 75 2003/04 2004/05 2005/06 2006/07 Year Somerset PCT South West England
It is important that population coverage is maintained around 95% to ensure protection of very young children, pre-immunisation and the few children who are not able to receive vaccine such as those with childhood cancer. A new vaccine will be introduced for girls aged 12 to 13 from September 2008 to protect against human papilloma virus which is strongly linked to cervical cancer in later life.
MMR uptake rates at 24 months of age have been steadily increasing across Somerset over the past couple of years and reached about 87% for 2006/07. However, the last two quarters have seen a drop in vaccine uptake rates to below 85%. In light of the notifications of measles across the country, there is cause for concern if this trend continues. Adding MMR to the school leaver programme, raising awareness and some specific work with practices has been effective.
Figure 2
Percentage MMR vaccine uptake at 24 m onths 100
95
90
85
80
Percentage MMR uptake uptake MMR Percentage 75 2003/04 2004/05 2005/06 2006/07 Year Somerset PCT South West England
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Immunisation – summary
a new vaccine will be introduced for girls aged 12 to 13 from September 2008 to protect against human papilloma virus which is strongly linked to cervical cancer in later life MMR uptake rates at 24 months of age have been steadily increasing across Somerset over the past couple of years and reached about 87% for 2006/07. However, the last two quarters have seen a drop in vaccine uptake rates to below 85%
Where are the gaps?
the drop in MMR uptake rates in Somerset over the last two quarters has made the average for Somerset lower than the south west average
(see Chapter 7 – Health Inequalities – page 168)
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Health
This chapter sets out Somerset health and social care data relating to illness prevalence and admission rates, uptake of screening and immunisation rates. Further detailed analysis of health and social need including health data is set out in the 2007 Health and Social Need Analysis Group (HSNAG) report for Somerset.
Common Condition Prevalence
primary care data of crude rates per 1,000 list size from the Quality Outcome Framework (QOF) shows that, in general, rates in Somerset are more than the rates nationally; this is due in part to our older population Table 1 condition National Somerset Hypertension 124.9 150.1 Asthma 57.7 62.6 COPD 14.3 15.2 Mental Health 7.1 6.3 Thyroid 25.5 30.2 Cancer 9.1 12.1 Heart Failure 7.8 9.8 Stroke (TIA) 16.1 20.9 CHD 35.4 39.7 Atrial Fibrillation 12.9 17.9 Dementia 4.0 4.5 Epilepsy (18 yrs +) 6.0 8.0 Diabetes (17 yrs +) 36.5 45.1 Chronic Kidney Disease (18 yrs +) 23.8 40.2 Learning Disabilities (18 yrs +) 2.6 3.6 Obesity (16 yrs +) 74.1 84.7
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based on the current age/sex specific rates within Somerset and the projected population change it is predicted that the numbers will rise as shown in Table 2 below over the next 15 years
increases of over 50% are predicted in Dementia, Atrial Fibrillation, Heart Failure, Chronic Kidney Disease and Stroke
Table 2 – QOF condition prevalence data
predicted increase predicted increase number over number over condition number in 2013 2006/7 in 2023 2006/7 Hypertension 78,816 89,083 13% 108,887 38% Asthma 32,881 34,459 5% 38,076 16% COPD 7,976 9,186 15% 11,524 44% Mental Health 3,307 3,426 4% 3,861 17% Thyroid 15,876 17,651 11% 20,818 31% Heart Failure 5,149 5,929 15% 7,959 55% Stroke (TIA) 10,977 12,674 15% 16,526 51% CHD 20,853 24,065 15% 30,640 47% Atrial Fibrillation 9,421 11,556 23% 15,180 61% Dementia 2,337 2,775 19% 3,790 62% Epilepsy (18 yrs +) 3,379 3,596 6% 4,028 19% Diabetes (17 yrs +) 19,216 21,570 12% 26,049 36% Chronic Kidney Disease (18 yrs +) 16,891 19,842 17% 25,918 53% Learning Disabilities (18 yrs +) 1,527 1,585 4% 1,678 10% Obesity (16 yrs +) 36,586 37,559 3% 42,321 16%
Cancer data collected using MIQUEST is not comparable with QOF so it is not possible to use it to predict numbers in the future.
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some of the differences shown between practices arise from differing true prevalence and some arise from differing levels of detection and/or recording of disease Table 3 Lowest Median Highest condition practice practice practice rate rate rate Hypertension 104.4 149.5 210.6 Asthma 32.6 64.8 86.4 COPD 7.0 14.3 36.3 Mental Health 1.6 5.4 19.4 Thyroid 14.7 29.8 38.3 Heart Failure 2.3 9.6 20.2 Stroke (TIA) 8.9 21.1 41.6 CHD 25.9 39.3 61.9 Atrial Fibrillation 10.8 18.0 23.8 Dementia 0.7 4.1 13.7 Epilepsy (18 yrs +) 3.0 8.0 27.8 Diabetes (17 yrs +) 31.3 43.5 65.5 Chronic Kidney Disease (18 yrs +) 0.0 37.8 118.1 Learning Disabilities (18 yrs +) 0.0 2.6 19.4 Obesity (16 yrs +) 38.7 81.9 182.9
there is a suggestion of a gradient across the deprivation quintiles for most (but not all) conditions. The clearest gradients are for CHD and Diabetes Table 4 Quintile 1 Quintile 5 condition Most Quintile 2 Quintile 3 Quintile 4 Least deprived deprived Hypertension 147.4 157.2 151.5 149.7 141.4 Asthma 60.7 65.2 59.5 64.7 63.2 COPD 18.4 16.7 14.1 13.1 13.4 Mental Health 7.2 6.8 6.1 5.5 5.6 Thyroid 32.6 30.0 30.0 29.2 26.9 Heart Failure 10.0 11.3 8.9 9.1 10.2 Stroke (TIA) 21.7 21.7 21.6 20.5 18.6 CHD 44.5 40.9 39.3 37.6 36.2 Atrial Fibrillation 17.7 18.2 17.7 18.8 17.0 Dementia 3.9 5.3 4.7 3.9 4.4 Epilepsy (18 yrs +) 9.6 8.0 8.4 7.1 6.5 Diabetes (17 yrs +) 49.5 46.3 45.0 43.8 40.6 Chronic Kidney Disease (18 yrs +) 40.6 42.1 44.6 43.0 28.7 Learning Disabilities (18 yrs +) 4.4 5.1 2.3 2.5 2.9 Obesity (16 yrs +) 100.6 81.8 82.9 83.9 69.8
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First Outpatient Attendances the rate in Somerset is roughly similar to the national and regional rates first outpatient attendances decreased between 2005/06 and 2006/07 according to the analysis on the NHS indicators, but then increased again in the first quarter of 2007/08 Table 5 Rate per 1000 2005/6 2006/7 Q1 2007/8 Somerset 276.5 261.1 273.3 South West 272.0 274.9 279.1 National 272.1 273.6 283.8
based on the current age/sex specific rates it is predicted that the number of first outpatient attendances will rise 10% by 2013 and 25% by 2023
Table 6
Current 2013 2023 2005/6 – 2006/7 Number per year 158,846 174,008 198,734 % increase over current - 10% 25%
within Somerset in 2005/06-2006/07 Taunton Deane has much the highest rate and Mendip just the lowest of the settlements within Somerset Wellington has the highest rate and Wells the lowest the most income deprived 20% of wards has the highest rate, but there is a suggestion of a U-shaped distribution, with the most and least deprived having more first outpatient attendances than those in the middle deprived quintile. This fits with more need due to illness in the most deprived quintile but more demand and greater expectation from those least deprived Figure 1
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ward rates vary 3.4 fold. Those with the highest rates are Bishop’s Lydeard, Chard Avishayes, Ivelchester, Taunton Blackbrook & Holway and Norton Fitzwarren. These are not all deprived wards the breakdown by age and sex shows that in general, with the exception of the youngest age group, the older people get the more likely they are to have a first outpatient attendance. During the reproductive years women have higher rates than men, but in the elderly the situation is reversed
Table 7
male female Age group rate per 1000 per year rate per 1000 per year 0-4 249 209 5-14 187 160 15-24 169 256 25-34 182 377 35-44 190 310 45-54 234 313 55-64 328 366 65-74 484 463 75-84 609 536 85+ 546 430
Total admissions
the rate in Somerset has been lower than the national and regional rates, the Somerset rate for Q1 2007/08 shows a large increase, which may reflect process changes in coding admissions have been increasing
Table 8 Rate per 1000 2005/6 2006/7 Q1 2007/8 Somerset 200.7 202.0 209.7 South West 203.6 205.6 206.9 National 203.5 206.1 206.2
based on the current age/sex specific rates it is predicted that the number of admissions will rise 11% by 2013 and 30% by 2023 Table 9
Current 2013 2023 2005/6 – 2006/7 Number per year 129,209 143,519 167,380 % increase over current - 11% 30%
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within Somerset in 2005/06-2006/07, as with the first outpatient attendances, Taunton Deane has the highest rate and Mendip has the lowest of the settlements within Somerset, Wellington has the highest rate and Wells the lowest, as for the first outpatient attendances the most income deprived 20% of wards has the highest rate, and in general the higher the deprivation the higher the rate. The rate in the most deprived quintile is 25% higher than the rate in the least deprived quintile Figure 2
ward rates vary 3.6 fold. Those with the highest rates are Chard Avishayes, Bishop’s Lydeard, Ivelchester, Wellington Rockwell Green & West and Bridgwater Bower. These are not all deprived wards the breakdown by age and sex shows that in general, with the exception of the youngest age group, the older people get the more likely they are to have an admission. During the reproductive years women have higher rates than men, but in the elderly the situation is reversed Table 10
male female Age group rate per 1000 per year rate per 1000 per year 0-4 390 345 5-14 80 69 15-24 90 254 25-34 106 383 35-44 122 205 45-54 159 176 55-64 264 228 65-74 428 347 75-84 646 502 85+ 781 634
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Emergency Admissions
the rate in Somerset is lower than the national rate but similar to the regional rate in the final time period emergency admission rates stayed much the same between 2005/06 and 2006/07 according to the analysis on the NHS indicators, but then increased in the first quarter of 2007/08 Table 11 Rate per 1000 2005/6 2006/7 Q1 2007/8 Somerset 72.3 72.4 76.5 South West 77.5 76.4 76.0 National 81.3 81.8 81.6
based on the current age/sex specific rates it is predicted that the number of emergency admissions will rise 12% by 2013 and 34% by 2023 Table 12 Current 2013 2023 2005/6 – 2006/7 Number per year 43,716 48,925 58,526 % increase over current - 12% 34%
within Somerset in 2005/06-2006/07,as for all admissions, Taunton Deane has the highest rate and Mendip just the lowest, indeed the pattern across the districts is very similar of the settlements within Somerset Yeovil has the highest rate and Shepton Mallet the lowest. This might reflect the closeness to large hospitals or MIUs the most income deprived 20% of wards has the highest rate. The rate in the most deprived quintile is 40% higher than the rate in the least deprived quintile Figure 3
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ward rates vary 3.3 fold. Those with the highest rates are Chard Avishayes, Glastonbury St John’s, Bishop’s Lydeard, Taunton Halcon and Bridgwater Hamp. With the exception of Bishop’s Lydeard these wards are among the most deprived in Somerset the breakdown by age and sex shows that in general, with the exception of the youngest age group, the older people get the more likely they are to have an emergency admission. For most of the age groups males are more likely to have an emergency admission than females
Table 13
male female Age group rate per 1000 per year rate per 1000 per year 0-4 147 115 5-14 42 36 15-24 48 65 25-34 49 55 35-44 48 45 45-54 54 47 55-64 76 56 65-74 127 99 75-84 247 212 85+ 436 396
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Admissions by type of diagnosis
Table 14 below shows the current and projected admissions by disease group. Eye and Circulatory diseases are predicted to increase by over 40% by 2023
Table 14 – all inpatient admissions including day cases % % Figures change change 2005/6 over over and proportion 2013 2005/6- 2023 2005/6- 2006/7 of annual 2006/7 annual 2006/7 ICD group inclusive admissions predicted average predicted average Symptoms & signs 29,679 12% 16,483 11% 19,318 30% Digestive 28,500 11% 15,776 11% 18,278 28% Malignant Neoplasms 26,640 10% 15,232 14% 18,250 37% Pregnancy 21,098 8% 10,954 4% 11,533 9% Musculoskeletal 19,726 8% 10,960 11% 12,675 29% Other Factors 19,392 8% 10,695 10% 11,882 23% Circulatory 19,238 8% 11,026 15% 13,588 41% Injury & poisoning 18,494 7% 10,202 10% 12,029 30% Genitourinary 13,641 5% 7,534 10% 8,727 28% Respiratory 12,146 5% 6,801 12% 8,073 33% Eye 10,849 4% 6,250 15% 7,987 47% Other Neoplasms 5,764 2% 3,242 13% 3,782 34% Skin 5,670 2% 3,120 10% 3,626 28% Nervous 5,028 2% 2,755 10% 3,207 28% Blood 3,908 2% 2,207 13% 2,695 38% Mental 3,350 1% 1,813 8% 2,087 25% Endocrine 3,157 1% 1,747 11% 2,033 29% Perinatal period 3,121 1% 1,748 12% 1,843 18% Infections 2,505 1% 1,385 11% 1,577 26% Congenital malformations 1,673 1% 899 7% 965 15% Ear 1,571 1% 828 5% 908 16%
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for the top 10 groups the rates per 1,000 across deprivation quintiles are shown below. In general the highest rate is found in the most deprived quintile Table 15
Quintile 1 Quintile 5 Most Quintile 2 Quintile 3 Quintile 4 Least deprived deprived ICD group Symptoms & signs 31.0 24.5 21.4 21.5 21.5 Digestive 25.0 23.6 22.5 21.4 22.6 Malignant Neoplasms 19.9 20.4 16.6 21.3 18.6 Pregnancy 30.1 24.1 21.4 22.9 21.7 Musculoskeletal 17.0 16.2 14.3 13.3 15.3 Other Factors 24.3 21.2 20.5 20.9 21.5 Circulatory 15.0 12.8 11.2 11.1 11.5 Injury & poisoning 17.4 15.9 13.8 14.3 13.1 Genitourinary 12.3 11.5 9.9 10.9 10.8 Respiratory 14.0 10.9 9.4 9.7 9.7
Social Care Clients in 2007 there were 2,809 clients aged <18 and 14,042 aged 18 or over within Somerset for those aged <18 South Somerset has the highest rate and Mendip the lowest. For those aged 18 or over South Somerset has the highest rate and Sedgemoor just the lowest of the settlements within Somerset for those aged <18 Glastonbury has the highest rate and Wells the lowest. For those aged 18 or over Burnham/Highbridge has the highest rate and Shepton Mallet the lowest the most income deprived 20% of wards has the highest rate for those aged <18. The rate in the most deprived quintile is 160% higher than the rate in the least deprived quintile. There is little difference between the most and second most deprived 20% of wards for those aged 18 or over, the rates in each quintile being nearly 60% higher than the rate in the least deprived quintile (see figures 4 and 5 following)
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Figure 4
Figure 5
for those aged <18 ward rates vary nearly 14 fold, but numbers are small. Those with the highest rates are Glastonbury St John’s, Chard Avishayes, Curry Rivel, Taunton Halcon and Alcombe East. With the exception of Curry Rivel these wards are among the most deprived in Somerset for those aged 18 or over ward rates vary from 0 to 7.7 per 1,000. Those with the highest rates are Glastonbury St Benedict’s, Frome Park, Burnham North, Neroche (South Somerset) and Langport & Huish. These are not all deprived wards
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Cancer screening 2006/07 breast cancer screening appears to increase as deprivation decreases
Figure 6
cervical cancer screening also increases as deprivation decreases West Somerset appears to have a lower coverage than the other districts for the older age group
Figure 7
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Figure 8
Immunisations 2007
there is a suggestion that the uptake of Pertussis decreases as deprivation increases, but the uptake of MMR increases as deprivation increases
Figure 9 Figure 10
131
132 CHAPTER 6 – SOMERSET VOICE
In Somerset there is a long history of engagement with local people in the provision of health and social care services. Views of local people have been described as ‘ordinary wisdom’ – the only way that organisations can really know how a service is performing ‘on the ground’, what needs to change and just as importantly, what is working well. Local views build a picture of a local area - what it’s like to live there and what services need to be maintained, changed or delivered to ensure it remains a sustainable community.
CONSULTATION ON SHAPING THE FUTURE OF SOMERSET
Somerset Strategic Partnership’s long term plan for Somerset includes its vision for what the county will look like by 2026. This will be based on the aspirations of local people and what is special about the county. The new Local Area Agreement is the main delivery plan for the Sustainable Community Strategy and is based on its themes, translating its aspirations into targets to secure the improvements local people want to see over the next three years (2008 – 2011).
As part of the exercise of updating the long-term strategy for Somerset to be set out in the Sustainable Community Strategy (which will be published in January 2009), the Council completed its first round of consultations in January this year. All the partners of the Somerset Strategic Partnership were invited, together with representatives of statutory agencies (especially those with a statutory Living sustainably duty to deliver the Local Area Agreement) Achieving economic wellbeing and representatives from community Enjoying and achieving and special interest groups. Staying safe Being healthy The consultation was based on the six Making a positive contribution themes within the Strategy and LAA.
As a starting point, a series of storyboards telling ‘The Somerset Story’ were used – what the situation is like now and what might be done in the future.
The storyboards included the latest verifiable data relating to the position of Somerset. This information was displayed at each of the four consultation events, a meeting with the Somerset Economic Leaders Group and a meeting with the Community Cohesion Group.
A presentation was given on the key challenges for the future which was followed by a series of workshops led by those representing the lead bodies for each of the themes. The information from these sessions was captured to provide part of the feedback. Participants added further comments using notes they attached to the storyboards. These comments are being used to inform the new version of ‘The Somerset Story’ and the key challenges facing the county in the coming ten years. They will, in turn, be aligned with regional and national strategies and priorities.
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Some of the main concerns to emerge were ensuring the sustainability of local communities; responding to the effects of climate change; accommodating the predicted housing need; meeting the challenges of an ageing population and problems of housing affordability, whilst managing the impact of the unique landscape and the limitations of natural resources.
Highest scoring priorities from the consultations according to each theme are detailed below, with comments from the debates (relevant notes from storyboards, where given, are highlighted in italics). To read the full summary of this consultation please go to: www.somersetstrategicpartnership.org.uk
Living sustainably - highest priority points
Young people feel isolated in rural areas; access to public transport can cause difficulties for them. The County Ticket travel pass scheme for post 16 students has allowed greater access to learning and transport freedom Housing in Somerset is amongst the least affordable in the country – November 2007 the average house price was around eight times that of average earnings
Living sustainably – what we might do
Comments
Planning for change – tackling and adapting to climate change Working with partners and developers to provide the appropriate infrastructure to support delivery of our growth centre as sustainable communities Reducing carbon emissions from local authority buildings, from new developments and that caused by transport and waste Improving the efficiency and effectiveness of the transport network and ensuring it is well maintained Ensuring that new residential and commercial developments provide or fund appropriate improvements to the transport system Providing support to businesses to develop effective travel plans and encourage staff to ‘travel smarter’ The demand for affordable housing for existing and future Somerset residents of all ages is achieved by making more homes available Make sure new housing and other developments are environmentally friendly, including the adoption of challenging design and construction principles for sustainability Working with authorities and organisations to improve access to work, learning, healthcare, food shops and other services
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Living sustainably
Notes
Travel – create safer routes to school , encouraging children to cycle or walk to school Support for rural post offices Local post offices essential centre for communities
Achieving economic wellbeing – highest priority points
Creative industries – identified as potential growth industry sector
The Third Sector is very important to Somerset’s economy. It is a major employer providing paid employment for more than 4,000 people and attracts a large amount of funding into the county each year
Achieving economic wellbeing – what we might do
Comments
Provide economic growth that will more sustainable, resource efficient and resilient to climate change Take advantage of opportunities available for Somerset to strengthen its economy and ensure a sustainable future Develop a wider and stronger range of business and employment opportunities in rural areas and market towns Increase the opportunities for older people to remain in paid employment if they so wish Ensure that paid care is a desirable profession for those seeking employment in order to ensure a work force for the future Support people who want to get into paid employment Provide access to a wide range of high quality learning and development opportunities Increase the quality and availability of affordable housing for vulnerable young people
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Enjoying and achieving – what we might do
Comments
Support and develop the conditions in which organisations offering cultural opportunities can thrive Increase cultural and social interaction with organisations enabling them to work together to provide access to a range of cultural opportunities including arts, sport, heritage, learning and play Support and enable people over 65 to receive the information, assistance and support they need to exercise choice and control to live independently Improve support to schools in managing behaviour, improving attendance and reducing exclusions Further raise standards across all key stages in schools
Enjoying and achieving
Notes
Help teenagers access facilities – rural cycle paths
Staying safe – highest priority points
Heavy drinking amongst young people is increasing in Somerset and the likelihood of committing a crime increases with the frequency and regularity of under-age drinking. Nearly half (43%) of Somerset pupils in school years 7 – 11 (age 11 – 16) reported having drunk alcohol in the last week and 17% had illegally purchased alcohol in the last week
Staying safe – what we might do
Comments
Building respect in our communities including action to address racist, ageist and sexist discrimination and abuse Reducing public perceptions and fear of crime, particularly amongst older people Reducing anti-social behaviour including bullying Reducing drug misuse and concentrating on initiatives aimed at reducing drug dependency Working with offenders to reduce levels of re-offending Limiting the damage of alcohol on our communities Preventing young people from entering the criminal justice system Improving positive activities for young people Reducing youth offending
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Being healthy – highest priority points
Prevalence of obesity in adults has increased significantly in the last thirty years. It is estimated that in Somerset 24.0% of boys and 29.9% of girls aged two to 19 are overweight and a further 6.8% and 8.6% respectively are obese, 8.6% of children in reception classes and 15.1% of children in year 6 were found to be obese.
Being healthy - what we might do
Comments
Enable communities to access good quality, affordable health and social care Improve the physical, mental and emotional health and wellbeing of all residents Information/assistance is readily available through improved primary care and prevention services to maintain good health
Being healthy
Notes
We need good health facilities in market towns – community hospitals and maternity services. At present these are being run down/closed Ensure that carers’ emotional wellbeing is cared for by health services and they are ‘treated’ in their own right
Making a positive contribution - what we might do
Comments
Develop more parish/town plans and make best use of them To be more effective in engaging local communities in determining their priorities and how best to meet them Developing effective means through which local communities have an ongoing dialogue with District and County tiers of Local Government, the wider public sector and other partners, promoting opportunities for volunteering and community engagement Provide specific support to particular groups – younger people, older people, employed, carers
Making a positive contribution Notes
Older people are able to contribute to their communities and are regarded as an asset and a resource. They are able to use formal and informal networks to reduce their social isolation and to help them remain in their own homes
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SOMERSET PATIENT ADVICE AND LIAISON SERVICE (PALS)
The Patient Advice and Liaison Service provides the patient with someone to listen to them whilst providing an impartial perspective on situations. The service endeavours to provide enquirers with a choice of possible options to help resolve their concern. This could also involve suggesting the enquirer raises a formal complaint, and PALS would provide the enquirer with the information and advise on the process to help them to raise the formal complaint with an organisation.
PALS works towards seven national standards, which provide a framework for how the service is delivered. These are:
being identifiable and accessible to the community served by the Trust being seamless across health and social care, including the voluntary sector and other public sector services providing a confidential service that meets individuals needs having a system in place that make findings known in order to facilitate change enabling people to access information about NHS services and health and social care issues playing a key role in bringing cultural change within the NHS, placing patients at the heart of the service, planning and delivery to actively seek views from the public to ensure effective services
Patient Advice and Liaison Service issues and actions are consolidated within the Standards for Better Health submissions required by the Somerset Health Trusts.
Prior to 1 April 2007, the service was managed by four individual PALS Officers for the four PCTs across the county. The service is now administered by a PALS Lead and continues to be a popular source of contact by the public, staff, NHS Independent Contractors and other organisations to raise their concerns and enquiries.
From the 1 April 2007 to 31 March 2008, Somerset PCT PALS service dealt with a total of 1207 issues. Figure 1 following reflects the activity of the service between April 2007 to March 2008. This reflects a decrease in the number of issues raised when compared with the previous year’s total of 1,621 when the service was provided by four PCTs across the county. There is no identifiable reason for this decrease and it cannot be contributed to a single factor, however, dental enquiries reduced significantly.
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Figure 1 – Comparison of PALS issues raised in each quarter with formal complaints
Table 1 – PALS issues by quarter with comparison to formal complaints
Period Number of Number of PALS issues formal complaints Quarter 1 - April to June 2007 258 19 Quarter 2 - July to September 255 27 2007 Quarter 3 - October to December 33 2007 254 Quarter 4 - January to March 2008 440 37 Total 1207 116
Information is recorded on the Patient Advice and Liaison Service database. However it is anticipated that information will be recorded on the Datix Database when it is available.
PALS issues are categorised using five key dimensions identified as ‘Improving the Patient Experience’. Analysis of the issues raised through the Patient Advice and Liaison Service using the five key dimensions that are known as ‘Improving the Patient experience’ are identified in Figure 2 (following).
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Figure 2 – PALS issues by ‘Improving the Patient Experience’ theme
Table 2 (below) illustrates a comparison with the number of enquiries received for 2007/08 against the number of enquiries received in 2006/07 when the service was provided by four PCTs. The table shows a slight decrease in the four key themes of Access and Waiting, Better Information More Choice, Building Closer Relationships, and Clean Safe Comfortable Place to be whilst the key theme of Safe High Quality Co-ordinated Care remains on a par.
Table 2 – PALS issues by ‘Improving the Patient Experience’ Theme
April 2007 to April 2006 to Theme March 2008 Total March 2007
Access and Waiting 436 (36%) 559 (34%)
Better Information, more 628 (39%) 436 (36%) choice
Building closer relationships 120 (10%) 187 (12%) Clean, safe comfortable place to be 19 (2%) 52 (3%) Safe, high quality co-ordinated care 196 (16%) 195 (12%) 1621 Total 1207
Issues raised with the Patient Advice and Liaison Service may relate to any aspect of the NHS. The data collected can be further analysed by the service provider and this is demonstrated in the chart following (Figure 3). Table 3 (also following) compares the service provider data for the year of April 2007 to March 2008 to the previous year of April 2006 to March 2007.
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Figure 3 – PALS issues by service area for 1 April 2007 to 31 March 2008
Table 3 – PALS Enquiries by Service Area compared with the previous year
April 2007 to April 2006 to Service Area March 2008 March 2007 Accessing NHS transport 38 11 Acute Trusts 148 163 Advice and Support Enquiries – generalised 259 312 Air products 0 2 Ambulance service 7 12 Audiology 1 1 Choose and Book 34 38 Contraceptive and Sexual health 3 6 Community Hospitals 37 95 Community Nursing 15 17 Community Services 6 2 Dental Access centre 1 0 Dentists including general enquiries 176 307 Dorset and Somerset Security Management Services 1 0 Expert Patient Programme 5 0
/table continues...
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Table 3 continued – PALS Enquiries by Service Area compared with the previous year
April 2007 to April 2006 to Service Area March 2008 March 2007 GP Practice including general enquiries 266 304 ICAS 1 0 Independent Treatment Centre 0 17 Mental Health 13 27 Optician/Optometrist 3 10 Other Services 59 56 Out of Hours service 16 43 PCT Responsibility 35 67 Patient Transport Centre 2 0 Pharmacist 10 37 Podiatry 63 78 Referral Management Centre – transport 8 15 Wheelchair Services 0 1 Total 1207 1621
The data in Table 3 also shows that the Patient Advice and Liaison Service continues to be a prominent contact point for patients and members of the public to raise enquiries and concerns which relate to any aspect of the NHS.
There were 266 issues raised about GP services. This figure contains 49 general enquiries that did not relate to a named GP practice. We can also identify that there were 176 issues raised about dental services of which 53 general enquiries were not specific to a named dental practice.
The data also shows that there has been a significant reduction in the number of issues raised against the following service providers:
Acute Trusts advice/support enquiries community hospitals dental services GP services Independent Treatment Centre out of hours service pharmacy
PALS has experienced another busy year. In 2008/09 work will continue to develop and enhance a PALS service which can be accessed easily by all service users. PALS will continue to actively promote PALS awareness sessions with community groups, and frontline staff groups as many patients are still unaware of the PALS service.
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PALS awareness sessions teaches people how this advisory service can be of help and support to them as patients and also staff members who require assistance.
There is a need for PALS to work with the Children and Young People groups. It is anticipated that a training session with the National Children’s Bureau titled ‘PALS- Getting it right for children and young people training’ will be delivered through the Dorset & Somerset PALS network. PALS staff should attend this training because The Children’s Act (2004), Every Child Matters (2004) and UN Convention on the Rights of the Child place great emphasis on participation and it is the duty of services to ensure that children and young people are actively involved in service provision and improvement. This training will showcase examples from around the country of PALS engaging with children and young people and provide participants with the opportunity to discuss their challenges and develop a realistic action plan to increase the participation of children and young people in their service.
COMMUNITY ENGAGEMENT
Single Equalities Scheme
Earlier this year Somerset PCT commissioned the Forum for Equality And Diversity in Somerset (FEDS) to carry out a community engagement exercise in order to inform the Trust’s Equality and Diversity Strategy (Single Equalities Scheme).
The Forum is a network promoting equality and diversity in Somerset and provides consultation, monitoring and facilitation support to public, business and voluntary sector bodies. Each of the six diversity strands (known as religious belief, race, gender, age, sexual orientation and disability) has a representative on the Forum’s steering group.
It was agreed for FEDS to hold four focus group sessions across Somerset in accessible venues, to engage with a range of people who represent the six strands of diversity but specifically disability (including carers), gender, race and children and young people. Staff members were also invited to the events, and further consultation of staff took place via an online questionnaire. The events were advertised through the Forum for Equality and Diversity in Somerset and its constituent members, mainly Compass Disability Services (through their Somerset Access and Inclusion Network), Somerset Racial Equality Council, Somerset Rural Women’s Network and Somerset Gay Health.
The PCT was particularly keen to find the opinions of disabled children and their parents. The Forum for Equality and Diversity in Somerset approached Somerset Impact, Barnardo’s and four Special Schools to send invites and questionnaires to a total of 413 parents of disabled children. Those who could not attend the focus group meetings were requested to return the questionnaire.
Participants were invited to complete a short questionnaire during the meetings, along with monitoring information. The questionnaire used at the events was adapted into easy read language and Somerset Total Communication for attendees with learning disabilities. Attendees were asked to give advance warning of any specific needs they might have (access, care support, dietary, translation etc.) and given a Freepost
143 CHAPTER 6 – SOMERSET VOICE address to reply to. Participants were offered transport in order to attend the event and the re-imbursement of mileage for those wishing to make their own way to the meetings. Costs to allow for care support were also provided.
A presentation on the PCT and its Equality and Diversity Strategy (Single Equalities Scheme) was adapted to include Somerset Total Communication at the request of some of the event attendees. The presentation was then delivered by a facilitator at the start of each focus group. At each meeting the participants were divided into three small groups to allow for more confident discussion. Each group was facilitated by a Forum for Equality and Diversity in Somerset representative. Notes were taken of each discussion, which were combined to produce an extensive report to the PCT. No representative of the PCT attended any of the four groups so that participants could speak freely about their views of local healthcare services both as user and employee.
In summary through this process, engagement with a wide range of people within Somerset has thus taken place to inform a review of the Single Equality Scheme. A copy of the Forum’s full report on the engagement methodology, attendance and the feedback from the exercise is published separately along with the Equality and Diversity Action Plan are available from the Trust website www.somersetpct.nhs.uk
Involvement of diverse communities
Somerset PCT worked to enable the involvement of people from diverse communities including:
members from the Deaf Forum have made valuable contributions on the Patient and Public Involvement Steering Group and contributed to equality and diversity training for all staff the Trust is represented on a multi-agency working group including service users, which considers access to healthcare by people with learning disabilities the development of the Black and Minority Ethnic Community Development Workers project and ongoing work with Community Development Workers who help people from black and minority ethnic groups to access mental health services service planning groups such as local implementation teams, equality and diversity groups and consultations, which have involved all of the six equality and diversity strands information on how to access services and give feedback is available in a range of formats, including Braille, large print, and other languages the Trust meets with members of diverse communities, representatives and advocates and seeks feedback on their experience of using health services, what the barriers are and how they can be improved. This information is then passed on to staff through induction training, meetings to discuss methods of engagement or through awareness sessions
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Engagement with Gypsy and Traveller communities
The Trust has made significant progress in identifying the difficulties experienced by members of the Gypsy and Traveller community when accessing health services. The Trust’s Patient and Public Involvement Lead has developed a relationship with this community that is based on trust and a growing mutual understanding, which has led to meaningful engagement.
The Patient and Public Involvement Lead has worked with the Romany Advisory Group for Somerset and identified ten key health issues that affect them. These include:
access to prescriptions, collecting medications and understanding how to take them registering with a GP and sometimes poor experiences when they try obtaining an appointment with their GP continuity of care such as leg ulcers understanding health issues because of literacy difficulties earlier access to pregnancy advice and antenatal care better access to immunisations and understanding of their importance slow access to medical records by healthcare professionals when the patient moves from one area to another hospital food and environment that does not meet their cultural needs healthcare professionals not understanding the culture of Romany Gypsies and their need to visit patients who are ill in hospital and to see doctors of the same gender
These issues are being addressed by the Trust in partnership with representatives from the Romany Advisory Group for Somerset with significant improvements being anticipated for 2008/09.
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Generally, the more affluent people are, the better their health and wellbeing will be conversely, the poorer people are, the poorer their health will be, but there are wide differences among social groups31. The reasons for these differences are a consequence of differences in opportunity, in access to services, and material resources, as well as differences in the lifestyle choices of individuals. The effects can be passed on from generation to generation.
Defining Health Inequalities
The term “health inequalities” refers to differences in health status or outcomes between different groups within Somerset32. This is different from accepting that there will be a “natural” variation in the health of individuals as a result of interplay between their biological make-up and their environment. Tackling health inequalities is about working to ensure that everyone in Somerset has the best health that they can possibly have.
The World Health Organisation European Office released two reports in 2006 that sought to revisit the need for action on health inequalities and provide frameworks for effective action suitable for the 21st century. The significance of these reports is two- fold: firstly, that they update earlier work from the 1990s that was fundamental in mobilising action against health inequalities in that decade; and secondly, that they reiterate that health inequalities are largely socially derived. The second point is important because recent policy direction in England has been criticised as being too focused on the role of individual choices in driving health inequalities. It is important that we keep in mind the wider context in which individuals make choices or have choices imposed upon them. This wider context is reflected in the way in which the health and social care sectors in Somerset work in partnership with other public bodies, communities and other agencies towards the creation of a “healthy environment” - a Somerset where it is easy to have good health.
Why health inequalities are important
The World Health Organisation reports outline the crucial concepts behind health inequalities and the reason for the focus of action upon them. They state that health inequalities are:
Systematic – they show a consistent pattern across the population and do not arise by chance. An example of this is the link between wealth and health: within the population there is a clear link showing worsening health with decreasing socio- economic status. In simple terms, the poorer you are the more likely you are to be sick and to die young.
Socially produced – they arise as a result of the actions of society or the community on an individual and not as a result of the biological make up of an individual. This concept is important because it underpins the concept that action to tackle health inequalities is possible. It also means that effective action against health inequalities is action to modify the behaviour of society and communities and thus create an environment or setting that promotes the health of individuals. This is a reminder that
31 Strategy to Improve Health and Reduce Inequalities – Somerset PCT 32 Somerset PCT Public Health Annual Report 2006/7
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CHAPTER 7 – HEALTH INEQUALITIES effective actions tackling health inequalities cannot be delivered by the health service acting alone but are delivered through a partnership of all those organisations that in some way impact on health.
Unfair – they arise as a result of bias or discrimination (conscious or unconscious) in the way in which we as individuals have access to resources (including healthcare) that might impact on our health. Health inequalities prevent individuals within society from achieving their full potential in life and so are inextricably linked with concepts of social justice, fairness and human rights. This is particularly demonstrated in respect of health inequalities in children.
The principles behind tackling health inequalities from a multi-agency perspective are: that health inequalities are not inevitable; that tackling them requires concerted action from a wide range of organisations acting in partnership to create a ‘healthy environment’; and that individuals are capable of changing their behaviour.
CHILDREN AND YOUNG PEOPLE
Breastfeeding
Breastfeeding has a major role to play in promoting health and preventing disease, both in the short and long term for baby and mother, yet breastfeeding initiation and duration rates in the UK are the lowest in Europe. Women from disadvantaged or minority groups and teenage mothers are less likely to breastfeed. Many mothers who do breastfeed, but give up early, would have liked to have continued for longer if they had more support.
Somerset has introduced a range of initiatives to promote breastfeeding and key wards are targeted to increase rates through the training of health visitors, the development of peer support networks and the promotion of Breast-feeding Awareness Week (2008).
In 2006, the Somerset Maternity Services Liaison Committee produced the Somerset Breastfeeding Strategy and Implementation Framework. The aim of the strategy is to enable mothers to feel confident and competent to breastfeed, no matter who or where they are. It hopes to do this by encouraging a change in cultural norms regarding infant feeding and ensuring a coordinated network of professional and peer support available for mothers whenever they need it
Somerset PCT has a target to deliver a 2% per year increase in the breastfeeding initiation rate. The 2006/07 target was achieved, with just over 76% of new mothers initiating breastfeeding within 48 hours of their child’s birth. During 2008/09 the PCT will measure the number of new mothers who have continued breastfeeding at six - eight weeks and at four months as part of a national performance measure.
In its first year, the Family Nurse Partnership pilot (one of ten, nationally) has successfully supported 100 young, vulnerable women through pregnancy and childbirth. The project has demonstrable outcomes in terms of improved parent bonding, increased breastfeeding rates, larger spacing of second children and improved self-esteem.
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Children in Care (CiC)
As part of the range of measures put in place through the Healthy Care Partnership, health plans for CiC are agreed, implemented and regularly reviewed. The specialist CiC nurse offers flexible access to health advice and assessment when young people opt out of medical reviews. All CiC receive an information pack when they are first accommodated, and are provided with information and advice tailored to their individual needs through their assessments and reviews. The CiC website (www.lookedaftersomerset.org.uk) signposts to relevant health websites and there is an on-line contact facility for the Designated Nurse. Plans are in place to involve school nurses in health assessments for children in care to reduce stigma and improve uptake. The nurse for children in care is now based within the PCT provider service.
Training relating to health matters is available to foster carers and residential staff. Sexual health training courses have been completed by all residential social workers. An innovative and successful project supports birth parents in producing meaningful, acceptable information for their children placed in adoptive families. Following the mapping of our services against the Healthy Care Audit Tool, support was obtained to set up the Care Leavers Health and Emotional Wellbeing Project to improve the range of services and clinical support provided.
Dental Health
Somerset’s Oral Health Promotion Team, based at Bridgwater Dental Access Centre, have taken an evidence-based approach to improving the oral health of young children by delivering the objectives set out in the An Oral Health Improvement Strategy for Somerset. Somerset Smiles, a pack produced by the team as a resource for teachers to promote oral health to children within the curriculum, has been distributed to schools where children are most at risk of dental decay. More than 4,000 children have been involved in the scheme. The team are currently working with health visitors to implement a scheme to provide fluoride toothpaste and toothbrush packs to children in disadvantaged areas at the eight-month health check.
Participation in education, employment or training
The Local Authority wishes to improve outcomes for the most vulnerable (care leavers, young offenders and teenage parents) as part of the re-commissioning of Connexions. A targeted youth support team has been set up during the past year to provide a prompt response, intensive support and enhanced personal/ welfare support for vulnerable young people. The team will work over a prolonged period with those young people whose multiple and complex issues inhibit their entry into employment, further education or training and develop a clear strategy to motivate these young people to re-enter learning, employment or work-based training.
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TEENAGE PREGNANCY
Teenage pregnancy is strongly associated with the most deprived and socially excluded young people. Difficulties in young people’s lives such as poor family relationships, low self-esteem and unhappiness at school also put them at greater risk. Rates of teenage pregnancy are far higher among deprived communities, so the negative consequences of teenage pregnancy are disproportionately concentrated among those that are already disadvantaged.
The poorer outcomes associated with teenage motherhood also mean the effects of deprivation and social exclusion are passed from one generation to the next. Evidence shows that having children at a young age can damage young women’s health and wellbeing and severely limit their education and career prospects. Whilst young people can be competent parents, longitudinal studies show that children born to teenagers are more likely to experience a range of negative outcomes in later life, and are up to three times more likely to become a teenage parent themselves.
At age 30, teenage mothers are 22% more likely to be living in poverty than mothers giving birth aged 24 or over, much less likely to be employed or living with a partner and 20% are more likely to have no qualifications. Teenage mothers have three times the rate of post-natal depression of older mothers and a higher risk of poor mental health for three years after the birth. The infant mortality rate for babies born to teenage mothers is 60% higher than for babies born to older mothers.
There are very significant trends over the quintiles, with the rate in the most deprived quintile being about 4.7 times higher than the rate in the least deprived quintile for the under 18 indicator and about 4.1 times higher for the under 16 indicator. For both indicators the rate in the most deprived quintile is between 2.1 and 2.3 times the average rate in the county.
Figure 1
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Figure 2
The inequality in the under 18 delivery rate appears to be decreasing. The under 18 delivery rate in the most deprived quintile was 2.35 times the average in April 2000 - March 2003, and 2.32 times the average in April 2003 - March 2006 and 2.09 times the average in April 2006 - March 2008.
There is some indication that the inequality in the under 16 delivery rate has also decreased over time. The under 16 delivery rate in the most deprived quintile was 2.5 times the average in April 2000 - March 2003 and 2.1 times the average in April 2003 - March 2006 and 2.0 times the average in April 2006 - March 2008.
This probably overestimates the difference in conception rate because of the speculated differential in uptake of abortions between deprivation groups.
There is a need to formalise data sharing between maternity services, the Children and Young People’s Directorate (SCC) and Connexions in line with the Somerset Information Sharing Protocol. Names and contact details should be provided, with the young parents consent, to ensure that full support can be given.
FUTURE WORK
A teenage pregnancy data set has been developed but there is much work to be done to drill down into the data to ensure that services are placed in the correct area and targeted at young people most in need.
The PCT aims to ensure there is a young people’s health clinic in each locality. The PCT is also investing in school health advisors who will work closely with social care.
There will be targeted work in a number of hotspot areas by working with schools, ensuring access to quality contraception (GP, contraceptive and sexual health (CASH), Pharmacists) services.
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Capacity will be increased to deliver peer education across the county ensuring that this work is targeted at vulnerable young people including young people in PRUs and children in care.
A more comprehensive communications strategy will be developed, targeted at all young people, families and practitioners linked to the new branding to young people’s sexual health services and information.
The Contraceptive and Sexual Health Services and GPs need to offer the range of contraception that meets the needs of young people, this includes Long Acting Reversible Contraction (LARC).
SEXUAL HEALTH
Poor sexual health is linked to discrimination, poverty and deprivation. The most vulnerable groups in society experience the poorest sexual health. They are less likely to receive adequate information regarding sexual health and services, and the stigma surrounding sexual health can be a barrier to accessing information and services.
In addition to this, poor educational achievement and low expectations have all been identified as key factors contributing to high rates of teenage pregnancy (as highlighted on page 152). If teenage pregnancy rates are to be reduced there must be an open and accepting attitude towards teenage sexuality, appropriate sex and relationships education, widely available information and easy access to confidential contraceptive services. International research has found these factors to be present in countries with low rates of teenage pregnancy.
If left untreated, sexually transmitted infections (STi) will continue to be spread, increasing the pool of people infected. With the most common STI, chlamydia, there are often no symptoms and if left untreated this can lead to sub-fertility.
Current and future work is detailed in Chapter 4 – Sexual Health under the heading ‘What is working?’
SUBSTANCE MISUSE
Alcohol misuse is a priority issue across the whole agenda and an initial plan has been developed.
Somerset services for alcohol users are less developed than those for drug users. The new contract for the adult treatment service has integrated drugs and alcohol with only limited additional funding to take account of demand from alcohol users. Existing national funding from the National Treatment Agency for Substance Misuse (NTA) has restrictions on it which stipulate use for drugs services not alcohol. Turning Point has been asked to monitor the uptake of service for alcohol only users as this information will be required to evidence the unmet need for resources for alcohol users’ services.
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The new drugs strategy 2008 emphasises the need to work with families. It identifies a range of actions that includes:
better information to parents/carers to help them prevent young people (YP) getting involved in substance misuse involving families where appropriate in treatment of YP and other family members additional support for families at risk – focus on parental substance misuse to prevent “intergenerational harm” for example: increasing parents access to treatment; parental skills; support to kin carers i.e. grandparents; protecting children – joint work between treatment and children's services; pre-natal harms - joint work between treatment and maternity services
In 2007/08 Somerset DAAT commissioned Evidence Base Ltd to conduct a study of Hidden Harm research, policy and practice. The principal aim of this study was to gather sufficient evidence to enable Somerset DAAT to develop a local strategy to identify and tackle Hidden Harm within the county. The emphasis of the study would be on lessons learnt from other counties across the country (focusing on those with similar characteristics to Somerset), enabling Somerset DAAT to formulate an evidence-based strategy that draws on examples of good practice. This highlighted that Hidden Harm needed to take an increasing priority with partners particularly in terms of the services for both substance misusing parents and the children of substance misusing parents especially those who were non-using.
Additionally the needs of carers and family of substance misusers have been identified and further needs analysis will take place in 2008/09. However, the response to those family members for services is critical and a pressure on partners will be to act on the needs that the analysis will demonstrate. Locally the DAAT supports a carer led project – The ‘In Touch’ Project.
Again, the new drugs strategy 2008 emphasises social re-integration of substance misusers i.e. to support people through the treatment system to enter education, training and employment. Somerset has a contract with Turning Point to run the Community Access Programme. This is making a significant difference to people’s lives but capacity is limited as there are four staff covering the county. With the target to increase people in treatment the numbers who need support to exit treatment and move on will increase.
FUTURE WORK
A bid has been made to the Home Office to be one of the Alcohol Arrest Referral pilot sites. If successful this will be valuable in scoping unmet need because of the range of offences that it will impact on. It will also be critical that shared care for alcohol misusers is developed and resourced to ensure that appropriate services at a primary care level are in place to respond to people’s needs.
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MENTAL HEALTH
Mental Health care for people of different ethnic origin - although the numbers of people in Somerset of different ethnic origin are small, the numbers are growing. There is ample national evidence of mental health inequalities in these groups and further work will be required in Somerset.
The capacity to deliver mental health needs support for mild to moderate conditions in primary care is limited and inequitably distributed. Further investment and expansion is required to provide an equitable service across Somerset. This is currently being addressed through the development of a primary care based mental health service.
Training, consultation and advice – there is a need to further develop capacity at Tier 2 to provide a sufficient level of training, consultation and advice, for universal professionals, to assist them in identifying the emotional health needs of children and young people.
Integrated service - we need to develop a comprehensive community based CAMHS that can be more flexible to the needs of children, young people and their families and form part of a wider integrated system of children’s services. We should aspire to the development of integrated teams managed within a single health and social care structure with a single point of entry and triage.
FUTURE WORK
An Organisational Cultural Competence Self Assessment Tool (OCCA Tool) for CAMHS has been developed nationally which the Somerset CAMHS Partnership is monitoring itself against. It is underpinned by the National Service Framework for Children, Young People and Maternity Services; Every Child Matters; Delivering Race Equality – the five year action plan for reducing inequalities in Black and minority ethnic patients’ access to, experience of and outcomes from mental health services - and the Core Dimensions Framework. The Partnership is also monitoring provision for BME through the CAMHS Partnership Self Assessment Matrix (current rating from 0-3 is 1)
Somerset Racial Inclusion Project works with children aged 5 – 18 years and their families who are experiencing racial harassment either in school or in the community. The project offers support, advice and advocacy. The two caseworkers also work with schools to improve their racial equality practice.
National Indicator Set mapped against SCYPP Top Priorities:
NI 107 Key Stage 2 attainment for Black and minority ethnic groups NI 108 Key Stage 4 attainment for Black and minority ethnic groups
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LEARNING DISABILITIES
Health inequalities exist because this group of people have higher than average health needs but face barriers to accessing care. The impact of the health inequality is that individuals do not have the support to prevent illness and promote health and wellbeing. They are more likely to present to health services at a later stage of illness with associated increased complexity of care and in some case poorer outcomes.
FUTURE WORK
improve access to hearing and vision screening promote oral health quality assure cervical and breast screening services encourage use of personal health action plan through rollout of ‘my health book’ patient held health record
OBESITY
A review of obesity and inequalities by the Department of Health Public Health Research Consortium in 2007 identified several factors that influence this inequality. Notably as countries gain more wealth, there is a shift from infectious to chronic diseases, for example, diabetes, coronary heart disease both of which can be exacerbated by overweight and obesity. Obesity rates in the UK are in line with other high income countries and as the rates of obesity increase in children and adults, this has become associated with a change in the UK’s social profile.
Rates have increased most in children from poorer backgrounds particularly girls and adults in the lowest quintile of household income, with higher rates in women. Inequalities in obesity also vary according to ethnic grouping with Asian children more likely to be obese than white children, and for adults rates are higher in women from Black African, Black Caribbean and Pakistani backgrounds.
Research in this area can follow a life course approach which examines the cumulative influences over time on an individual’s obesity levels and inequality. For example, studies have found that an individual with overweight parents is more likely to be overweight themselves. There is also a tendency for fatter mothers to have heavier babies which is associated with obesity in later life. If children are overfed during foetal development and in early years this also seems to have a lasting effect on obesity rates later. This is an important consideration in planning any interventions to reduce obesity rates.
The second approach is an ecological one which explores the relationship that environment and society has on obesity rates and inequalities. As highlighted in the Foresight Tackling Obesities: Future Choices report (2007) the obesogenic environment in the UK is likely to have had a great effect on the rising obesity rates.
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There is evidence for the individual effect of diet and activity levels on an individual’s weight but little on how urbanisation and legislation such as banning unhealthy food advertising on children’s television has affected rates. This evidence will be forthcoming over time.
Impact on communities - the Government’s approach on tackling obesity is detailed in Healthy Weight: Healthy Lives (2008) and it has set a challenging ambition:
“Our ambition is to be the first major nation to reverse the rising tide of obesity and overweight in the population by ensuring that everyone is able to achieve and maintain a healthy weight. Our initial focus will be on children: by 2020, we aim to reduce the proportion of overweight and obese children to 2000 levels”
Our focus in Somerset must reflect this agenda and also target our work in areas of highest deprivation initially.
The National Childhood Measurement Programme data collected in 2008 will include postcode data, allowing precise identification of hotspots.
There are, however, more general factors to consider that affect certain communities in Somerset. If people live in an environment that is dangerous, either from traffic or crime, it is more challenging for people to take part in purposeful activity locally, such as walking to the shops. People in income-deprived areas are more likely to experience this problem.
People with less income are less likely to be able to afford to take part in sport. Whilst some activities such as walking are free, many have a cost, and this is a significant barrier to participation.
Physical activity levels drop dramatically in teenage girls and young women as a whole. Its impact in the community is that this section of the population is not participating in enough activity to benefit their health. Active Somerset has offered opportunities to address this in a small way with relevant activities such as the Hip Hop classes in Yeovil for young women.
Food that is calorie dense may be less expensive. For those on a limited income, this may restrict the range of food they can buy. Surveys suggest that as a population we are still not eating enough fruit and vegetables to reach our target of 5 A DAY. This is particularly true of lower income groups and children. Transport or lack of it at affordable prices also disadvantages people in communities where there is little choice of shops to buy food and the cost of a taxi has to be factored into the money available for food each week.
FUTURE WORK
Significant progress has been made during 2007/08 to develop and agree new care pathways for obesity and weight management. These act as a framework for the next pieces of work that will be forthcoming in 2008/09 and beyond. These include:
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local research into the views of teenagers on barriers to physical activity and healthy eating with the Arts and Health project REACH supporting the delivery of the Change 4 Life national social marketing approach to obesity projects with families and children from its rollout in September 2008 developing a training programme for health professionals and others to be able to raise the issue of a healthy weight support for community food projects such as cooking skills courses, food growing and food co-operatives support for community based physical activity opportunities focused work with Children’s Centres and Early years on healthy lifestyles further development of MEND and DASH programmes across Somerset development of a voucher scheme for referral to commercial slimming clubs
SMOKING
The first map in the Current Health Status section on smoking showed geographical variation in smoking prevalence. There is a strong association between high prevalence and deprivation.
As highlighted in the cancer section of Chapter 4, lung cancer among men and women is around twice that in the most affluent areas and death rates are twice as high.
Figure 1 Lung cancer <75 It is likely to be the case 2001,2,3,5 that for many people 40 living in these areas 35 159% smoking is an ingrained 30 behaviour, where habits 25 102% 100% held by parents are 20 89% 88% passed on to children 15 76% and where breaking the 10 habit is particularly 0 0 0 , 0 0 1 r e p e t a r 5 challenging. 0 1 2 3 4 5 all quintiles most deprived least deprived
Smoking cessation services have been shown to be less successful in supporting people from more deprived areas to quit. If these behaviours are retained in significant numbers then these populations will continue to live shorter, less healthy lives and it is likely that the economic circumstances will not improve.
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Map 1
Map 1 highlights relative success at quitting through to four weeks. It shows where in the county are the highest and lowest four week quit rates. This information in combination with mapped prevalence and also mapped use of services (not necessarily successful) enables an understanding of the communities that require further efforts.
The maps demonstrate where there are gaps in services, and enable a targeted approach to new service deployment. High prevalence, low uptake and knowledge that local services are weak suggest that alternative routes of service provision are required. High prevalence, high uptake but low quit rates suggest that services provided do not work well for the given population. This may be a function of service quality or possibly services appropriate to need; it certainly means further understanding is required to address the issues. High uptakes and relatively high quit rates demonstrate areas where services are working well.
FUTURE WORK
There is a range of work required around tackling the highlighted inequality. In the first instance variation in service availability needs to be addressed. The service is aware of the areas where general practice chooses not to provide in-house cessation support and also where the referral rate to central services are low. Either a route to GP provided services needs to be agreed or alternative providers need to be in place. Practices where uptake is poor or quit rates are low need to be worked with to identify if there are service quality issues or there are additional support options that can be put in place to make services more effective.
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The smoking cessation service has identified a priority list of 20 practices that provide primary care services to the most deprived populations in Somerset. The service wishes to work more closely with these practices and offer additional support in efforts to provide services where the greatest health benefits are to be gained.
DIABETES
Map 1 uses darker shading to show where in the county higher numbers of people with diabetes have been identified (using QOF data). Most brown and red shaded SOAs are in urban areas of Bridgwater, Taunton, Minehead, Highbridge and Chard. This ties in with deprivation being a risk but does not obviously reflect the risk associated with higher numbers of older people in more rural areas.
Map 1: Diagnosed Diabetes
Map 2 following is an estimate of diabetes prevalence in Somerset using the national model. The data used does not reflect the ethnicity breakdown of the population but does consider age and deprivation. The modelled prevalence shows some similarity to the diagnosed diabetes map, particularly around Minehead, Williton, Highbridge and parts of Bridgwater and Taunton. However there is a clear suggestion that there are likely to be more people with diabetes in rural Somerset, particularly West Somerset, than are identified currently.
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Map 2: Estimated Diabetes 2007
Map 3 below uses ONS projections of population data mapped at SOA level. If the Somerset population change is as expected there will be increasing numbers of older people and many of them will settle in rural areas. As old age is a significant risk factor for diabetes numbers with diabetes overall will increase and the areas where diabetes prevalence will increase most are shaded brown.
Map 3: Estimated Diabetes 2017
Map 4 following continues the process from Maps 2 and 3. If as projected, the Somerset population continues to grow, and the net inwards migration of older people continues, then it is likely that the numbers of people with diabetes will increase. It is very difficult to predict population patterns in 20 years time; however, if current projections do occur then there will be many areas with a diabetes prevalence of more than 6%.
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Map 4: Estimated Diabetes 2027
FUTURE WORK
From the Current Health Status section, the prevalence model has suggested sizeable undiagnosed diabetes within the Somerset population. It also indicates where in the county this is likely to be and enables the identification of General Practice where higher numbers of people with diabetes would be expected to be identified. The modelled estimates should be verified locally.
Available information allows limited conclusions to be drawn between quality of care, self care and deprivation. This may be worthy of further investigation.
Need for and utilisation of secondary care; this area requires further consideration particularly around length of stay and the nationally recognised increases associated with diabetes. A better understanding of outpatient activity is also required.
CORONARY HEART DISEASE AND STROKE
Detailed analysis of rates relating to deaths from cardiovascular disease shows seven wards with significantly higher rates of deaths for cardiovascular disease after adjusting for age and sex. These are as follows:
Axbridge Puriton Chard Jocelyn Beacon Taunton Halcon Bridgwater Sydenham Taunton Pyrland and Rowbarton
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There is commitment within the county to narrow the gap between areas that experience health and social inequalities and, as such, deaths from Cardiovascular Disease under the age of 75 years has been identified as one of thirty four priority areas within the Somerset Local Area Agreement 2008 – 2011.
Table 1: Coronary Heart Disease Mortality 2004/06. Directly Standardised rate per 100,000 population (all ages) Males Females ENGLAND 144.59 67.50 Somerset PCT 126.75 52.58 Mendip 130.93 56.03 Sedgemoor 148.55 59.97 South Somerset 114.87 48.33 Taunton Deane 121.83 51.19 West Somerset 114.48 44.83
Table 1a: Coronary Heart Disease Mortality 2004/06. Directly Standardised rate per 100,000 population (for those aged less than 75) Males Females ENGLAND 74.75 23.77 Somerset PCT 58.29 15.05 Mendip 63.79 16.67 Sedgemoor 67.39 19.34 South Somerset 52.40 13.50 Taunton Deane 56.42 13.30 West Somerset 46.05 10.40
Table 2a shows that although Somerset stroke mortality rates are lower than England the Mendip rate is considerably higher for both men and women for all ages but lower in those under 75. When considering small areas the impact of low numbers can reduce the certainty with which such statements are made and it is the case that significance tests do reduce the certainty of statements about Mendip. Death rates due to stroke are lower in West Somerset than the rest of the county, it must also be remembered that the proportion of older people in this district is by some way the highest in the county.
Table 2: Stroke Mortality 2004/06. Directly Standardised rate per 100,000 population (all ages) Males Females ENGLAND 55.33 51.30 Somerset PCT 50.60 47.00 Mendip 58.50 55.58 Sedgemoor 46.21 44.68 South Somerset 50.87 44.92 Taunton Deane 53.94 47.37 West Somerset 38.35 39.78
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Table 2a: Stroke Mortality 2004/06. Directly Standardised rate per 100,000 population (for those aged less than 75) Males Females ENGLAND 18.29 13.73 Somerset PCT 15.39 10.26 Mendip 17.47 12.46 Sedgemoor 16.83 8.63 South Somerset 14.18 10.17 Taunton Deane 17.39 9.91 West Somerset 7.91 9.21 Source: Clinical and Health Outcomes Knowledge Base, Crown Copyright, June 2008
FUTURE WORK
One area of work to be developed to help to address these inequalities is further development of early identification of higher risk individuals and developing intensive support packages tailored to the individual’s needs, including both medical and lifestyle intervention. This work will build on the NHS Health Trainer Programme recently initiated in Somerset and will be a forerunner of the systematic programme of vascular risk assessment and management for people aged 40-74 years proposed by the Department of Health in April 2008.
In South Petherton a new community hospital and Long Term Conditions Centre is being developed. As part of this the PCT are developing a centre of excellence for stroke rehabilitation which should be open for its first patient in summer 2010.
Somerset PCT is part of the Avon, Gloucester, Wiltshire and Somerset Cardiac and Stroke Network. Our Local Implementation Team is currently developing a comprehensive action plan to ensure that within three years we will comply with all areas of the National Stroke Strategy.
OLDER PEOPLE
Using age specific deprivation scores is a common approach to identifying vulnerable groups in the older population. Tables 1 and 2 following present the numbers/proportions of older people in each deprivation quintile. Deprivation is measured using the Indices of Deprivation 2007 based on a variety of indicators including health deprivation and disability, living environment, barriers to housing and services, crime and disorder, income, employment, education, skills and training; and an aggregated overall deprivation score calculated for each Census Super Output Area. The population in Quintile 1 is most deprived and comparable with the most deprived 20% SOAs when ranked nationally. Conversely, the population in Quintile 5 are least deprived and compare with the most affluent 20% of SOAs nationally.
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Table 1: Numbers of Older People by Deprivation Quintile (in thousands)
Q1 (most Q5 (least Age deprived) Q2 Q3 Q4 deprived) Total 65+ 3.2 17.5 33.4 35.3 17.3 106.6 75+ 1.7 9.2 16.5 17.1 8.6 53.1 85+ 0.5 2.8 4.8 4.8 2.4 15.2 All ages 21.4 88.3 162.0 170.8 85.3 527.6
Table 2: Proportion of Older People by Deprivation Quintile (%)
Q1 (most Q5 (least Age deprived) Q2 Q3 Q4 deprived) Total 65+ 3.0% 16.4% 31.3% 33.1% 16.2% 100.0% 75+ 3.1% 17.4% 31.1% 32.2% 16.2% 100.0% 85+ 3.3% 18.3% 31.2% 31.7% 15.5% 100.0% All ages 4.0% 16.7% 30.7% 32.4% 16.2% 100.0%
The tables above clearly show that there are small numbers and a low proportion of older people living in the most deprived areas of Somerset. This would be consistent with the view that there is shorter life expectancy in more deprived areas and also that the net inward migration of people aged 50 and over is drawn from more affluent populations.
Deprivation is not the only indicator of vulnerability in the older population, three other contributors are presented here. Older people living alone are known to be often more vulnerable. A variety of contributing factors such as the lack of close, personal companionship, an increased sense of isolation, depression and physical fragility can indicate these older people may greatly benefit from the support of a broader range of health and social care services.
Map 1: Older People Living Alone
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Map 1 (previous page) shows the location of the highest proportions of older people living alone. Darker shading highlights higher proportions, where the brown areas indicate where more than 35% of older people live alone.
It is interesting to note that although more rural areas have the highest proportion of older people overall, it is in urban areas where many of these people live alone.
Map 2: Older People’s Income Deprivation
Map 2 shows older people’s income deprivation. The darker the shading the greater the proportion of older people likely to be living with financial difficulty. Map 2 shows a close correlation with Map 1. Areas of Bridgwater, Highbridge, Taunton, Yeovil, Frome and Chard that stand out could indicate that income deprivation correlates to life expectancy in our older population and therefore higher numbers in urban areas are likely to have lost a partner.
Map 3: Fuel Poverty
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Map 3 (previous page) indicates where large numbers of people are experiencing fuel poverty. This measure is not specific to older people; however there is close correlation with high proportions of older people and it is well known that poorly heated property contributes to poor health in the older population. It is recognised that in Somerset there are large numbers of older people who are ‘asset rich but cash poor’. This may result in numbers of people who do not register as being among the more deprived population. They own their properties but in fact are unable to heat them, with the corresponding impact on heath that is associated with this.
FUTURE WORK
To meet the needs of increasing numbers of people aged over 65 now and in the future statutory and voluntary services need to plan and work together. Joint strategic needs assessment is a major vehicle to deliver this and those responsible for the planning and development of these services will grasp this opportunity.
There needs to be a clear focus on prevention. To develop and extend initiatives to continue to improve exercise, balance, medicines management and the environment for older people to reduce falls risk, we need to learn available lessons and in particular develop Active Living Centres and make good practice sustainable across Somerset.
In the coming years there is a clear opportunity to increase the number of older people taking part in physical activity. Funds are in place to work to improve physical fitness through encouraging and communicating the benefits of moderate regular exercise for older people. There will be a particular focus on older people within the Community Sports Network programme.
Joint planning of palliative care services needs to continue to develop a wider focus. End of life care services should be available regardless of diagnosis and meet people’s expressed preference to die in their place of choice. More detailed information can be found in the latest Somerset Annual Public Health Report 2007/08, the focus of which is the health of older people, www.somersetpct.nhs.uk
HEALTH PROTECTION
MMR immunisation
The drop in uptake rates in Somerset over the last two quarters has made the average for Somerset lower than the south west average. It is difficult to assess whether this is a temporary drop or whether the trend is likely to continue. Awareness remains a key issue for poor uptake rates.
Somerset has not yet had laboratory confirmed cases of measles although the notifications of possible clinical cases have been steadily increasing (the one lab confirmed case was in a London resident). However cases will occur if herd immunity levels drop. To ensure community protection, an immunisation rate of 95% should be achieved. Analysis of vaccine uptake rates by GP practice and geographical area/locality will help to identify further actions required.
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Summary of Key Issues
Somerset has a rich bio-diverse landscape; however, in low lying areas there is an increasing risk of flooding, due in part, to climate change.
The registered population of Somerset is 530,000 and will increase by 87,000 over the next 20 years:
9.9% aged over 75 2.6% aged over 85 4.4% Black and Ethnic minorities
Somerset is a predominantly rural and affluent county. There are pockets of deprivation, mainly in the towns, but also in some rural areas, particularly in West Somerset.
Good access to public transport, particularly for isolated and vulnerable groups, remains a challenge
Unemployment is low, but earnings are below the national and regional averages leading to issues in relation to affordable housing
On average, people in Somerset live longer than in England as a whole. Early death rates from heart disease and stroke and cancer are lower than the England average and falling.
Life expectancy, although higher than the England average, shows up to a nine year variation in the lowest and highest wards in Somerset, so significant inequalities exist.
9% of Somerset's residents are dependent on means-tested benefits, compared with 13% in England. One in seven of Somerset's children lives in benefit-dependent households.
Children are generally healthy however, inequalities remain in dental health, MMR uptake and mental health.
Teenage pregnancies are higher than expected given the demography of the local population, and not decreasing, 350 births to girls and young women under 18 each year in Somerset.
Rates of smoking and binge drinking are lower than the England average (these are estimates based on national surveys) however there are significant hospital admissions due to alcohol misuse, and these are rising.
Levels of physical activity are above average; however 15% of year 6 children are obese.
Although the death rate from smoking in Somerset is lower than the national average, smoking still kills around 900 people every year.
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The rate of road injuries and deaths is high and around 350 people die or are seriously injured on the roads of Somerset each year.
The rate of hip fracture in people aged over 65 in Somerset is higher than average.
Recommendations for Action
Each of the 34 chosen LAA indicators for Somerset (Chapter 9), reflect identified priorities from this JSNA and are underpinned by detailed action plans. These are summarised as follows:
increase the number of affordable homes (NI 155, NI 154, and NI 166)
improve employment opportunities (NI 171, NI 151, NI 152, NI 163, and NI 165)
improve access to public transport particularly for isolated and vulnerable groups (NI 175)
reduce the number of people killed or seriously injured in road traffic collisions (NI 47)
ensure tried and tested multiagency plans in place to tackle flooding and other major incidents (NI 185, NI 188)
Children
targeted improvements in dental health
increase uptake of MMR
reduce teenage pregnancy (NI 112) through peer education, increased communication, targeted work in high rate areas and increased uptake of long acting reversible contraception
improve access to CAMHS (NI 51)
improve uptake of medical assessments for Children in Care
All ages
improve Sexual Health through promotion of services, targeted work in high prevalence areas, improve uptake of Chlamydia screening and access to termination of pregnancy services (NI 112, NI 113)
reduce Substance Misuse (NI 115, NI 40, and NI 39) through implementation of the DAAT action plans
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improve Mental Health through provision of a community based service for less severe mental illness and roll out mental health promotion strategy
improve health assessments for those with Learning Disabilities through hearing, vision and targeted screening tests
halt the rise in obesity, particularly focusing on children (NI 56)
increase the number of people who stop smoking particularly pregnant women and those in manual groups by targeting areas of greatest need (NI 121)
improve the detection and management of Diabetes (NI 121, NI 137) Coronary Heart Disease (NI 121) and Stroke (NI 137) and ensure rapid access to appropriate care and treatment
Older People
improve information about services, volunteering, job opportunities and ways to improve health (NI 139, NI 137, and NI 6)
develop the Active Living Network (NI 137)
reduce falls and improve bone health (NI 137, Li 1)
improve detection and management of dementia (NI 139)
greater use of “telecare” technology to support older people in their own homes. (NI 137)
tackle fuel poverty (NI 187)
increase choice at the end of life for all adults, irrespective of the condition they are suffering from, to live and die in a place of their choice
171
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CHAPTER 9 – USEFUL LINKS AND RESOURCES www.somerset.gov.uk - Somerset County Council www.somersetpct.nhs.uk - Somerset PCT www.swpho.nhs.uk - South West Public Health Observatory www.dh.gov.uk - Department of Health www.defra.gov.uk - Department for Environment, Food and Rural Affairs www.dfes.gov.uk - Department for Children, Schools and families
Government Office for the South West Home Office
DFES (Department for Education & Skills) formerly DfEE (Department of Education and Employment) DTI (Department of Trade and Industry) www.immunisation.nhs.uk - comprehensive and accurate source of information on vaccines, disease and immunisation www.healthyschools.gov.uk - the national Healthy Schools programme
Info4Local - site provides the first one-stop portal for local authorities to get quick and easy access to information they need on the web sites of central government departments, agencies and public bodies Local Government Association - policy Information on Local Government from the national Local Government Association including links to local authority and other websites Local Government Information Unit (LGIU) UK govtalk - latest news and developments in the area of e-Government. E-Government Unit - 'Leading the drive to get the UK online'. Essential e- Government information including e-GIF, e-GMF, and Web standards www.equalityhumanrights.com - champions equality and human rights for all Environment Agency - (formerly the National Rivers Authority & Her Majesty's Inspectorate of Pollution) DirectGov – directory for the widest range of government information and services. Browse by audience groups such as 'Disabled people and carers' and 'Parents' or by topics including 'Employment', 'Learning' and 'Motoring and transport'. Office for National Statistics Office of Public Sector Information (formerly HMSO)
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OFSTED NHS local services page - find your local GP, pharmacy, dentist etc. www.CSCI.org.uk - the Commission for social care inspection NHS NHS Direct Health Protection Agency Avon & Somerset Police Hate Crimes Unit Citizen's Advice Bureau Connexions West of England - the advice, guidance and support service for all 13- 19 year olds Focus on Disability - a site with a wide range of general information for those disabled and their carers in the UK www.somerset.gov.uk/adultcare - Somerset Social care www.somerset.gov.uk/childrenandfamilies - Somerset Social care www.carehomesinsomerset.org.uk – information about moving into care and vacancies www.somerset.gov.uk/somerset/communityliving/popp/ - Older People Active Living www.accessiblessouthwest.co.uk – information about accessible accommodation, retailers and recreational activities www.avonandsomerset.police.uk/information/useful_links/ - Avon and Somerset Police information page with useful online links www.somerset.nhs.uk/sompar/ - Somerset Mental Health Trust www.southwest.nhs.uk/ - South West Strategic Health Authority www.southwest.csip.org.uk – Care Services Improvement Partnership South West www.nice.org.uk/ - the National Institute for Clinical Excellence Somerset District Councils www.sedgemoor.gov.uk www.mendip.gov.uk www.westsomersetonline.gov.uk www.southsomerset.gov.uk www.tauntondeane.gov.uk
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SOMERSET LOCAL AREA AGREEMENT 2008-2011 NATIONAL INDICATORS CHOSEN
National Indicator
NI 115 Substance misuse by young people
NI 51 Effectiveness of child and adolescent mental health (CAMHS) services
NI 56 Obesity in primary school age children in Year 6
NI 105 The Special Educational Needs (SEN)/non – SEN gap – achieving 5 A* - C GCSE inc English and Maths
NI 45 Young offenders’ engagement in suitable education, employment or training Supporting Tier: NI 148 Care Leavers in education, employment or training NI 117 16 to 18 year old who are not in education, training or employment (NEET)
NI 112 Under 18 conception rate Supporting Tier: NI 113 Prevalence of Chlamydia in under 25 year olds
NI 171 VAT registration rate per 10,000 adults of the resident population aged 16 and above (proxy target) Supporting Tier: NI 172 VAT registered businesses showing growth Local Indicator: Growth in Somerset‘s knowledge economy
NI 151 Overall employment rate (Somerset resident population of working age) NI 152 Working age people on out of work benefits in West Somerset and Sedgemoor Supporting Tier: NI 153 Working age people claiming out of work benefits in the worst performing neighbourhoods
NI 163 Working age population qualified to at least Level 2 (GCSE) or higher
NI 165 Working age population qualified to at least Level 4 (Degree) or higher
NI 166 Average earnings of employees (median weekly, gross pay for full time workers)
NI 185 CO2 reduction from LA operations
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NI 188 Adapting to Climate Change Supporting Tier: Health of the Natural Environment in Somerset NI 186 per capita CO2 emissions in the LA area
NI 191 Residual household waste per head
NI 175 Access to services and facilities by public transport, walking and cycling Supporting Tier: Accessibility in Somerset
NI 121 Mortality rate from all circulatory diseases at ages under 75 Supporting Tier: Existing Stretch Target for Smoking Cessation and Adult Exercising until March 2009
NI 137 Healthy life expectancy at age 65 PSA 17 Supporting Tier: LI 1 Reduce the prevalence of hip fracture in people over the age of 65 years DWP PSA 16 % of Pensioners on low income
NI 139 People over 65 who say that they receive the information, assistance and support needed to exercise choice and control to live independently Supporting Tier: NI 130 Social Care clients receiving Self Directed Support (Direct Payments and Individual Budgets) NI 136 People supported to live independently through social services (all ages) NI142 Number of vulnerable people who are supported to maintain independent living
NI 40 Drug users in effective treatment
NI 16 Serious acquisitive crime
NI 30 Re-offending rate of prolific and priority offenders
NI 39 Alcohol related hospital admission rates
NI 111 First time entrants to the Youth Justice System aged 10-17
NI 32 Repeat incidents of domestic violence
NI 24 Satisfaction with the way the Police and local council deal with anti- social behaviour
NI 47 People killed or seriously injured in road traffic accidents
NI 4 % of people who feel they can influence decisions in their locality
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NI 6 Participation in regular volunteering Supporting Tier: NI 7 Environment for a thriving third sector NI 11 Engagement in the Arts
NI 1 % of people who believe people from different backgrounds get on well together in their local area
NI 155 Number of affordable homes delivered (gross) Supporting Tier: NI 147 Care Leavers in suitable accommodation
NI 154 Net additional homes provided
NI 187 Tackling fuel poverty – people receiving income based benefits living in homes with low energy efficiency rating
NI 179 Value for Money
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Tel: 01935 385020
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Email: [email protected]
Address: Freepost RRKL-XKSC-ACSG, Equality and Diversity Lead Somerset Primary Care Trust Wynford House Lufton Way Yeovil BA22 8HR
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We would like to hear from you about what you think of the Joint Strategic Needs Assessment for Somerset. Have we got our priorities right? What are your views on how the JSNA could progress and develop?
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Or email: [email protected]
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INDEX
Page (s) A Active Living Centres 95, 112 – 114, 168 Active Somerset 77, 112, 158 Air quality 17, 22 Alcohol misuse 9, 30, 54 – 63, 68, 136, 154 – 155, 169, 176 Ante natal 33, 43,145
B Binge drinking 30, 59, 63, 169 Biodiversity 16 Blood pressure control (diabetes) 89 Body Mass Index (BMI) 74 Bowel cancer screening 103 Breastfeeding 34, 76 Breast screening 101, 102,130
C CAMHS (Child & Adolescent Mental Health Services) 35, 66 – 70, 156, 170, 175 Cancer 100 – 105, 111, 130, 131, 159, 168, 169 C Card 42, 46, 47, 50 Cervical Cancer screening 73, 101, 103, 105, 130, 131 Cervical Cancer vaccine 117, 118 Children and young people’s health status 33 – 41 Children – dental health 37, 38, 151, 169, 170 Children in Care 33, 36, 151, 170 Children and young people – mental health 35, 41, 66 – 70, 156, 169, 175 Children – special educational needs 36, 37, 68, 175 Chlamydia 49, 51 – 53, 154, 170, 175 Cholesterol control (diabetes) 90 Climate change 17, 18, 134, 135, 176 Common condition prevalence 119 – 121 Community engagement 143 – 145 Community food 78 – 80, 159 Community safety 26, 29 – 31 Consultation 5, 40, 54, 55, 133 – 137 Coronary heart disease (CHD) 92, 93, 95 – 97, 99, 163 – 165, 171 Crime 26 – 31, 176 Cycling 20, 25, 78, 176
D Demography 7, 8, 169 Dental health (children) 37, 38, 151, 169, 170 Deprivation 9, 18, 19, 37, 46, 58, 64, 78, 82, 99, 106, 121, 124, 128, 147 – 168
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INDEX
Diabetes 33, 86 – 91, 119, 120, 121, 161 – 163, 171 Diet 77 – 81, 157 - 159 Diversity 143, 144 Drugs 30, 54 – 63, 154 – 155
E Economy 13 – 17, 30, 135 Education 10 – 12, 34 – 41, 56, 80, 151, 175 Emergency admissions 88, 89, 125, 126 Emergency planning 115, 116 Employment 13 – 16, 39, 151, 169, 170, 175 Environment 16 – 18, 176
F Feedback 178 Flooding 16, 18, 115, 169, 170 Food 77 – 81, 157 – 159 Fuel poverty 167, 168, 171
G Glucose control (diabetes) 89 Gypsy and traveller communities 145 Health inequalities 41, 47, 52, 53, 63, 70, 73, 81, 85, 91, 99, 104, 105, 114, 118, 147 – 168 H Healthy schools 34, 35 Heart disease 92, 93, 96 – 97, 99, 163 – 165, 171 HIV 48, 50, 53 Hospital admissions 125 – 128 Housing 8 – 10, 15, 16, 134, 169
I Immunisation 116 – 118, 131, 168 Indicators (LAA) 175 – 177 Inpatients 125 – 128
J Joint Strategic Needs Assessment (definition) 1
K
L Landscape 16 Learning disabilities 71 – 73, 119 – 121, 157, 171 Links and resources 173 - 182
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INDEX
Local Area Agreement (LAA) 4, 5, 175 – 177
M Measles, mumps and rubella (MMR) 116 – 118, 131, 168 – 170 Mental health (adults) 64 – 66, 68, 70, 72, 119 – 121, 142, 156, 171 Mental health (children and young people) 35, 41, 66 – 70, 72, 73, 171, 175 Migrant workers 15 Migration (schools) 12, 162,166
N Nourishing Capacity Project 78 – 80
O Obesity 74 – 81, 95, 119 – 121, 157 – 159, 171, 175 Older people 94, 95, 106 – 114, 135 – 137, 165 – 168, 171 Outpatients 122 – 124
P Partnerships for Older People Project (POPP) 112, 113 Patient Advice and Liaison Service (PALS) 138 – 143 Population overview 7 – 9 Pregnancy 33, 127, 128, 150 Pregnancy (teenage) 42 – 52, 152 – 154, 170 Pregnancy (termination) 48, 50 – 53, 170 Primary aged pupils 10, 11 Physical activity 76 – 78, 110 – 112, 158, 159, 169
Q Quality Outcomes Framework data (QOF) 119, 120, 161
R Rehabilitation (CHD and stroke) 95 – 98, 165 RESPECT 42, 47, 50 – 52 Road traffic collisions 23, 24, 170
S Safer roads 25 School populations 10 – 13, 36 Secondary aged pupils 11, 12 Sexual health 42, 43, 46, 48 – 53, 141, 154, 170 Single Equalities Scheme 143, 144 Smoking 9, 82 – 85, 104, 159 - 161, 169, 171, 176 Social care clients 128, 129, 176
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INDEX
Somerset Community Food 78 - 80 Stroke 92 – 99, 119 – 121, 163 – 165 169, 171 Substance misuse 30, 54 – 63, 154, 155, 170, 175 Substance misuse (supported housing) 61 Sustainable Community Strategy consultation 133 – 137
T Teenage pregnancy 42 – 52, 152 – 154, 170 Traffic 17, 21 – 23 Transport 18 - 23, 134, 169, 170, 176 Travel patterns 20
U
V ‘Vision for Somerset’ 4, 5, 133 – 137
W Wellbeing 64, 149
Y Young people’s health status 33 – 41
Z
182