Hinckley and Bosworth Primary Care Trust

Public Health Annual Report 2002-2003

Mary Gee Director of Public Health November 2003 Hinckley and Bosworth Public Health Report 2002/03 Acknowledgements

Hannah Blackledge Di Spalding, Director of LNDS, Public Health Analyst, Leicester & and Alison Scott, Primary Care, Rutland Health Informatics Service Leicestershire Nutrition and Dietetics Services Sue Read Specialist in Public Health, Peter Wilson Eastern Leicester PCT Public Health Specialist, Hinckley and Bosworth PCT Mandy Wardle Assistant Director of Public Mark Braham Health, Hinckley and Bosworth Resolution Manager, PCT Smoking Cessation Services

Jama Warsame Michele Carruthers Trainee Specialist Registrar, PA, Hinckley and Bosworth PCT Public Health Mary Fitzgerald Ginny Copley PA, Hinckley and Bosworth PCT Public Health Specialist, Hinckley and Bosworth PCT

Contents Mission Statement 1 Coronary Heart Disease 13

Introduction 2 Diabetes Care 17

The Way Forward 3 Smoking Prevention and Cessation 21

The Population of Hinckley and Bosworth 5 Food and Health 23

Inequalities in Health 6 Physical Activity 25

Addressing Health Inequalities 8 1 Hinckley and Bosworth Public Health Report: 2002/03

Public Health aims to improve the physical, social, mental and environmental health of the people of Hinckley and Bosworth. By working in partnership with and empowering individuals, communities and organisations, we aim to reduce the health inequalities between different groups within the community.

We would like to hear from you. Our address is:

Hinckley and Bosworth PCT Swan House Business Centre The Park Market Bosworth CV13 0LJ

Telephone: 01455 293200 Fax: 01455 290700

Alternatively, please visit our website at:

www.hinckleybosworthpct.nhs.uk 2 Hinckley and Bosworth Public Health Report 2002/03 Introduction: Tackling Health Inequalities THE EXISTENCE OF INEQUALITIES IN HEALTH across England is well known, with the life expectancy of a child born in some parts of the north of England being up to 10 years shorter than that of a child born in parts of the south. Inequalities in health can also be seen locally. The important point about health inequalities is that they are both unjust and very often avoidable.

“Everyone has a part to At the end of each section of this As the Director of Public Health play, from the individual report are suggested ways forward. for Hinckley and Bosworth, I am looking after his or her own These will become the basis for required to write an annual report health through to statutory our Public Health Strategy, and are on the health of the residents of and voluntary organisations aimed not only at the health the PCT. Each year I will aim to working with communities, community but at our partners and explore certain aspects of health, a the importance of whose individuals living within Hinckley particular group of people or a role as public health and Bosworth. serious preventable illness. Although the report will describe practitioners cannot be The role of the Public Health the disease or disorder and the stressed too much.” Department of Hinckley and prevalence of the problem, I want Bosworth PCT is to recognise such to focus on the positive aspects of inequalities and, together with what can be done, and is being partner agencies, to address them. done, to improve matters. I shall Our partners are vital, because also suggest ways forward. they are often the key to preventing ill health in the first This year, my focus is on health place. The NHS can go on forever inequalities and how they are improving services, but this will measured, and on coronary heart never stem the tide of ill health. disease, diabetes, obesity and their prevention and management. The Everyone has a part to play, from “This year, my focus is on directions for us to work in, along the individual looking after his or health inequalities and how with specific recommendations, are her own health through to they are measured, and on highlighted at the beginning of the statutory and voluntary coronary heart disease, document. diabetes, obesity and their organisations working with prevention and communities, the importance of management. The whose role as public health directions for us to work practitioners cannot be stressed Mary Gee in, along with specific too much. Director of Public Health recommendations, are highlighted at the beginning Two words of caution: At the local level the numbers referred to are small. Care of the document.” must be taken in interpreting such statistics. They should therefore be interpreted relative to one another and not as absolute values.

The Primary Care Trust is almost, though not completely, coterminous with Hinckley and Bosworth Borough Council. There are areas outside the Council’s boundaries (Stanton and Broughton) which are part of the PCT, while Markfield is outside the PCT boundaries but is part of the Borough Council. It has not always been possible to obtain information which reflects the PCT’s boundaries exactly, so some information has been included (especially maps and nationally available data) which refers to the local authority. No offence to those living in these areas was meant, and I hope, none taken. 3 The Way Forward - Priorities for Action Health Improvement address primary prevention as well as clinical intervention, and Inequalities which is arguably not currently The Public Health Strategy will address adequately actioned or resourced. health improvement and inequalities in Hinckley and Bosworth by: l There is a need for continued investment in physical activity and l providing a framework to co-ordinate the development of further development of smoking public health skills and capacity, cessation/tobacco control both inside and outside the NHS; initiatives and food and health programmes. l addressing the key public health issues identified in this report and l The PCT needs to improve the ensuring that reduction of quality and volume of locally inequalities is specifically specific data to inform action, targeted for action. especially between primary, secondary care and the community The Primary Care Trust and its Public services. This should improve the Health team should: effectiveness of its use, in turn ensuring that patients are provided l develop robust partnerships with more appropriate support and “The Public Health Strategy with other organisations, information. will address health communities and individuals improvement and l The PCT should support the (This will also enable clear inequalities in Hinckley and understanding of the variety of implementation of the Bosworth by developing contributions necessary to address Leicestershire-wide strategies for this agenda); heart failure, cardiac rehabilitation, robust partnerships with including Phase 4 (community other organisations, l support the development and based rehabilitation) and communities and implementation of relevant local revascularisation. individuals.” strategies, (e.g., the Leicestershire County Plan); Diabetes l support implementation of the l The quality and volume of local Homelessness Strategy and services for diabetes need to be Community Plan. raised so that the health care needs of increasing numbers of The Public Health team should: patients with diabetes can be met l lead a co-ordinated approach to at all levels. the development of community l The PCT should review the nurses’ public health role; baseline assessment of diabetes l carry out a local health equity services in primary care and from audit and develop and agree an it develop a future action plan. action plan. (This should improve l Approved ways or models should the targeting of health service be identified and adopted to detect provision at all stages - primary and treat patients with care, secondary care and in the undiagnosed diabetes as early as community); possible. l support a review of the role of l the Hinckley and Bosworth Mechanisms need to be developed and implemented which provide Health Forum and the PCT/Public appropriate education and Health contribution. support for patients with diabetes, making sure that patients Coronary Heart Disease gain the knowledge and skills they l The PCT needs to invest in and need for effectively controlling 4 Hinckley and Bosworth Public Health Report 2002/03 their condition and minimising Food and Health potential diabetes complications. The PCT should work with its l The training and development partners to: needs of all staff, including those in l develop an action plan for the primary care, should be assessed, prevention and management of and the necessary action taken to overweight and obesity within the ensure that professionals have local population; the skills and confidence to l expand local initiatives to support patient management of promote food and health issues; diabetes. l continue to promote and develop l Service development should include an effective education and effective preventive interventions training programme for for reducing the incidence of community workers and diabetes, including tackling obesity healthcare professionals involved and overweight and promoting in the prevention and management healthy eating and physical activity. of overweight and obesity, and l Primary care should offer all other nutrition-related issues, patients with known diabetes an alongside local dieticians; annual review to assess the risk l develop referral pathways for of diabetes complications and weight management, with follow their prevention or mitigation, and up and on-going monitoring; to offer patients advice and education about their condition. l develop new ways of working, using consumer consultation to Smoking redesign service provision (e.g., The PCT should ensure that: homeless groups, breastfeeding). l smoking cessation services run by accredited advisors will be Physical Activity available in every GP practice The PCT should work with its across the PCT (or, alternatively, partners to: nearby community venues such as l implement the Leicester, pharmacies) in order to improve Leicestershire and Rutland access to high quality support for physical activity strategy; those seeking to quit; l continue to support the Exercise l the public will have improved Alliance as the main partnership access to effective stop smoking mechanism for joint working in products on prescription, such as physical activity and for ensuring Nicotine Replacement Therapy an evidence-based approach; (NRT) and Zyban; l develop a range of local l there will be increased levels of interventions, involving both adults support for pregnant smokers and children, which will meet the and their friends and family, needs of the local population (e.g., including home visits by a smoking chair-based exercise classes, green cessation specialist, to help them gyms, walking initiatives); quit; l re-launch, support and publicise the l there will be an increase in exercise on referral scheme, and referrals to smoking cessation develop a programme for an services. exercise referral outreach scheme in local communities; l highlight the role of physical activity in addressing a range of health issues (e.g., obesity, cardiac rehabilitation). 5 The Population of Hinckley and Bosworth The population of Hinckley and middle-aged and young adults: more Bosworth was counted at the last 50-54 year olds, and fewer 20 year census in 2001. Below is a diagram of olds. There has been a 5.0% rise in the local population in five-year age the size of the population in England bands, outlined against the average over the past 20 years. The increase population for the UK. It can be seen was greater in the East Midlands that it closely matches that of the UK, (8.3%), whereas in Hinckley and but with slight variation among the Bosworth it has been just 3.6%.

Figure 1 90 and over Men 85-89 Women 80-84 75-79 UK Average 70-74 65-69 60-64 55-59 50-54 45-49 40-44 35-39 30-34 25-29 20-24 15-19 10-14 The population of Hinckley 5-9 and Bosworth has more 0-4 50-54 year olds and fewer 10% 8% 6% 4% 2% 0% 2% 4% 6% 8% 10% 20-year olds than the national average. Source: National Statistics website: www.statistics.gov.uk Crown copyright material is reproduced with the permission of the Controller of HMSO

Age Range Total Males Females 0 - 4 5536 2833 2703 5 - 9 5912 3009 2903 10 - 14 6426 3219 3207 15 - 19 5843 3035 2808 20 - 24 4888 2517 2371 25 - 29 5707 2734 2973 30 - 34 7526 3735 3791 35 - 39 7837 3977 3860 40 - 44 7260 3602 3658 45 - 49 7150 3551 3599 50 - 54 8348 4219 4129 55 - 59 6520 3226 3294 60 - 64 5146 2596 2550 65 - 69 4534 2227 2307 70 - 74 4079 1876 2203 75 - 79 3414 1415 1999 80 - 84 2132 815 1317 85 - 89 1280 412 868 90 and over 603 168 435 Totals 100141 49166 50975

Source: National Statistics website: www.statistics.gov.uk Crown copyright material is reproduced with the permission of the Controller of HMSO 6 Hinckley and Bosworth Public Health Report 2002/03 Inequalities in Health

HEALTH INEQUALITIES ARE STUBBORN, PERSISTENT AND DIFFICULT TO CHANGE. They are also widening and will continue to do so unless we do things differently. This means addressing not only the short-term consequences of avoidable ill health, but also the longer- term causes. “Though the difference in life expectancy between Poorer health and reduced life ward level. In the map below, it can those with better and expectancy are related to childhood be seen that people living in Bagworth worse health has been poverty and social circumstances. are admitted to hospital more often known for some years, this Worse still, though the difference in than those living in areas such as life expectancy between those with Market Bosworth and Cadeby. The gap is still widening.” better and worse health has been standardised admission rate in known for some years, this gap is still Hinckley and Bosworth (for all causes) widening. averages 98.3, which is significantly Differences in health can be lower than the rate for Leicestershire measured in a variety of ways, both (where the average is taken as 100). directly, such as by asking people, and The range is 75.2 to 133.0. The five indirectly by proxies such as wards with rates significantly higher admissions to hospital. When asked than that for Leicestershire are: to assess their health, 69.4% of the Hinckley and Bosworth population Bagworth 133.0 considered their health to be good, Barwell 104.9 22.7% fairly good, and 7.9% poor. Castle 103.8 Within Hinckley and Bosworth Newbold Verdon 110.2 differences in health can be found at a Trinity 105.7

Bagworth Groby Barlestone, Twycross & Shackerstone Nailstone, Ratby & Osbaston Newbold Verdon Cadeby, Carlton & Market Bosworth Desford & Peckleton Sheepy & Witherley “When asked to assess their health, Normanton

69.4% of the Hinckley Ambien Earl Shilton and Bosworth Barwell Croft Hill population considered Trinity Stanton their health to be De Montfort good, 22.7% fairly Standardised Admission Rates Clarendon Castle All causes, 1998-2001 Broughton good, and 7.9% poor.” Flamville 125 to 210 (1) 105 to 125 (2) Burbage 95 to 105 (10) 75 to 95 (9) 52 to 75 (0) Statistical Significance Significantly higher than Leicestershire (5)

Source: Leicestershire Health Informatics

Figure 2: Standardised admission ratios to hospital – all causes 7 In a similar way, for mortality rates of one ward has a significantly higher those under 75 years of age, the ratio: Castle, with a ratio of 131.1. Hinckley and Bosworth average is The range across the PCT is 64.4 to significantly lower than that of 131.1. Leicestershire (92.7: 100). However,

Bagworth Groby Barlestone, Twycross & Shackerstone Nailstone, Ratby & Osbaston Newbold Verdon Cadeby, Carlton & Market Bosworth Desford & Peckleton Sheepy & Witherley

Normanton Ambien Earl Shilton Barwell Croft Hill Trinity Stanton De Montfort

SMR All Causes Clarendon Castle in under 75 yr olds, 1996-2000 Flamville Broughton 150 to 216 Burbage 105 to 150 95 to 105 75 to 95 37 to 75 Statistical Significance Significantly higher than Leics (4)

Source: Leicestershire Health Informatics

Figure 3: Standardised mortality ratio – under 75 years, all causes

Inequalities in health are not simply issues will be discussed in later annual “Affluence is generally geographical. They also occur among reports. A common factor affecting related to better health, different groups of people, such as all these groups is that affluence is and vice versa. Health those with disabilities or different generally related to better health, and inequalities can also pass ethnic communities within the same vice versa. Health inequalities can also down the generations.” geographical area. Some of these pass down the generations. 8 Hinckley and Bosworth Public Health Report 2002/03 Addressing Health Inequalities

ADDRESSING HEALTH INEQUALITIES IS NOT EASY, PARTICULARLY AT A LOCAL LEVEL. Many actions have long-term consequences rather than immediate impact and are only one of the many complex factors affecting people’s lives simultaneously. This does not mean we should wait: targeted actions to reduce the so-called wider determinants of health can and must be taken. “Targeted actions to reduce the so-called ‘wider The wider determinants include social, Deprivation determinants of health’ can economic and environmental factors. The Index of Multiple Deprivation and must be taken.” Very often these determinants co-exist (IMD) 2000 (figure 3) is a ward level in deprived areas, which experience measure based on six separate factors high unemployment and poorer quality associated with deprivation: of housing, as well as fewer health and other services. l Income This means, therefore, that action to l Employment address health inequalities needs to be l Health deprivation and disability based on partnership working across a l Education, skills and training range of organisations including the l Housing NHS, local authorities, communities l Access to services and the voluntary and business communities. The higher the score, the higher the level of deprivation. The range in Hinckley and Bosworth is 4.42 to 30.3. No wards within the PCT appear in the lowest 20% nationally.

Hinckley and Bosworth Primary Care Trust

Bagworth (30.3) Groby (4.42) Barlestone, Twycross & Shackerstone (11.32) Nailstone, Ratby (10.91) & Osbaston (14.09)

Newbold Verdon (10.99) “The wider determinants Cadeby, Carlton & include social, economic Market Bosworth (6.87) and environmental factors. Desford & Sheepy & Witherley (10.71) Very often these Peckleton (12.03) determinants co-exist in Normanton (7.07) Ambien (8.1) deprived areas, which Earl Shilton (20.2) experience high Barwell (16.71) Croft Hill (11.17) unemployment and poorer Stanton (7.32) quality of housing, as well Trinity (20.66) as fewer health and other De Montfort (7.86) Broughton (4.79) Flamville (10.74) services.” Clarendon (18.41) Burbage (5.16) Index of Multiple Deprivation 2000 Scaled using 20% intervals (quintiles) across the national data Castle (16.4) 32.9 to 83.8 21 to 32.8 13.9 to 20.9 10 to 13.8 1.1 to 9.9

Source: Leicestershire Health Informatics

Figure 4: Deprivation in Hinckley and Bosworth (IMD scores) 9 Income and Employment Education, summarised the issue 3.5% of the population is either effectively in an address to the Faculty disabled or has long-term illness. More of Public Health, 2003, quoting than two-thirds of the population is Professor Amartya Sen, Master of employed (67.7%), 2.5% unemployed Trinity College, Cambridge: and 0.6% long-term unemployed. The “The death rate from coronary heart unemployment rate is approximately disease is three times higher among half that of Leicester City, and similar unskilled manual men of working age than among professional men. to that of other local authorities in Recent analysis of the birth cohort studies the county such as Charnwood and shows that graduates are generally less North-West Leicestershire. depressed and report a higher sense of However, such statistics refer only well-being than people with lower to those receiving unemployment qualification levels. benefit and mask the ‘hidden Levels of obesity – particularly among unemployed’ who are in receipt of women – are lower among the graduate incapacity benefit, etc. population. From the 2001 census, among those Women with very low literacy skills are of working age (16-74 yrs) almost more likely to suffer from depression than “The death rate from equal proportions of men and women either men or women with good literacy coronary heart disease is (3.58% male:3.42% female) were skills. permanently sick, preventing them So, the case for working hard to raise three times higher among from working. As a proportion of the educational standards in our schools and unskilled manual men of adult population of working age, this is colleges, powerful in its own terms, should working age than among significant in terms of ill health. be strongly reinforced by the desire to raise professional men.” standards of health across our population.“ Limiting long-term illness The importance of a good general (LLI) education cannot be stressed too Within Leicestershire and Rutland, much. Among the adult working-age Hinckley and Bosworth has the population (16-74 years) of Hinckley highest percentage of residents with and Bosworth, almost one third have limiting long-term illness (16.3%). no qualifications. Schools are working In the East Midlands, the percentage hard to rectify this. So, for example, of people with limiting long-term two local secondary schools in the illness ranged between 25.8% and PCT achieved 86% and 93% of 15 year 12.9%. This is a rise from 10.4% ten olds with at least 5 GCSEs, A-G. ii years previously . Again, approximately (Level 2). This is encouraging evidence equal proportions of men and women of improvement in the overall level of had such problems. education as young people become the working age population. The 2011 Education census data should begin to reflect Charles Clarke, Secretary for State for these changes.

All people No Highest Highest Highest Highest Other “Two local secondary aged qualifications qualification qualification qualification qualification qualifications 16 - 74 (%) attained level attained attained attained / level schools in the PCT achieved 1*(%) level 2**(%) level level unknown (%) 86% and 93% of 15 year 3***(%) 4/5#(%) olds with at least 5 GCSEs, 73,622 30.86 19.55 19.18 6.59 15.77 8.04 A-G. (Level 2). This is encouraging evidence of Level 1 = 1+ O level/GCSE/NVQ level 1 improvement in the overall Level 2 = 5+ O levels/GCSEs/NVQ level 2 level of education as young Level 3 = 2+ A levels/4+ AS levels/Higher School Certificate/NVQ level 3 people become the working Level 4/5 = 1st or higher degree/NVQ levels 4+5/HND etc. age population.” Source: National Statistics Census 2001 Figure 5: Education levels across Hinckley and Bosworth Borough 10 Hinckley and Bosworth Public Health Report 2002/03 Access to services showed that 28% of unfit dwellings Measurement of access is based solely were from the private rented sector. on those claiming benefit who, it is The Council has an active programme assumed, will find it more difficult to of support and grants to bring private get to the services they need because sector housing up to the decent home they lack their own method of standard. The energy efficiency of the transport. Taken into account is the housing stock improved by 10% from distance to a large food shop, GP or 1996 to 2002. Over 50 healthcare post office and, for 5 to 8 year olds, workers have received training in the distance to a primary school. basic energy efficiency. Twycross and Shackerstone, Sheepy Homelessness is bad for your health. and Witherley and Bagworth are all Homeless children have high rates of ranked within the top 2,000 (out of infectious disease, sickness and 8,414) wards in England with the most diarrhoea, increased hospital serious access problems. admissions and greater risks of accidents. Behavioural and developmental problems are common Housing and often associated with maternal There are about 40,000 households in stress and depression. Skin disorders “Living in a decent home Hinckley and Bosworth. Most people are common and few homeless people does not mean that you live in good quality, warm and secure sleep well. are well, but living in poor homes. However, some live in homes Very few rough sleepers are housing can adversely which they cannot afford to heat, reported in Hinckley and Bosworth. affect your health.” whilst others are overcrowded and For many, homelessness is hidden, some people have temporary living with people living with family or arrangements or are homeless. Living friends, both long and short term. In in a decent home does not mean that rural areas, people often remain in the you are well, but living in poor family house because there is no housing can adversely affect your affordable housing available locally. In health. more urban areas, people may move The underlying cause of 80% of from friend to friend, sleeping on excess winter deaths is the cold. For floors. every 1°C fall in the outdoor In 2001/2, 105 people applied to the temperature, mortality rates rise by Council as homeless and 162 in 2.8% for those living in the coldest 2002/3. In both years, 68% were 10% of homes, compared with a rise accepted as homeless. In 2002/3, a of just 0.9% in the warmest 10% of quarter of those accepted as homeless homes. had parents who were unable to Much colder countries than the UK continue accommodating them. have much lower levels of excess Another quarter were homeless winter mortality. Compared with because of a partner’s violent colder countries, at the same outdoor behaviour. The majority (70%) of temperature living rooms in the UK those accepted as homeless had are colder and bedrooms are less children. likely to be heated. When we go A health visitor is employed outside, we are less likely to wear specifically to work with these warm clothing and more likely to be families. A resource pack describing less active. health and support services in the Hinckley and Bosworth Borough Borough has been produced. The “The underlying cause of Council is very proactive in Council has been able to house 80% of excess winter encouraging all residents to achieve homeless people in temporary deaths is the cold. For energy efficiency in their homes and in accommodation, without resorting to every 1°C fall in the ensuring that affordable warmth is the use of bed and breakfast, since outdoor temperature, available to all. Few of the Council’s 1992. However, the increase in mortality rates rise by 2.8% dwellings, which accommodate 11% of demand may mean that existing for those living in the households, fall below the decent home resources are insufficient. coldest 10% of homes.” standard. A private sector house Some people choose not to live in condition survey, undertaken in 1998, houses. The number of travellers in 11 the Borough varies over time as March, reflecting both the number of people move. Many travellers wish to travellers present and the number of “Homelessness is bad for travel from town to town, staying on available staff. Where possible, a your health. Homeless temporary sites, but are unable to do health needs assessment is undertaken children have high rates of so because of the lack of site on the site by the team and care infectious disease, sickness provision. They are forced to encamp initiated where appropriate. and diarrhoea, increased illegally, making it difficult for them to The service enables travellers to hospital admissions and access health and other services. For access GPs in a variety of ways. It greater risks of accidents.” example, there were four groups of identifies GPs who are available to see travellers illegally camped in July 2003, patients at short notice, arranging but none in August. appointments and follow-ups and The nomadic lifestyle of many taking families to practices for travellers reduces access to traditional registration, particularly where there healthcare systems. Poor sanitation at are problems associated with literacy. inadequate sites and roadside The service also provides a recall locations is common. Studies of system and contact address. travelling families have identified levels Visits to mobile groups are a priority of morbidity and mortality even for the overstretched service. greater than those of the lowest social Nursing staff are flexible in the classes of the settled population. services which they provide. For Traveller children are between one example, they may find themselves and a half and two times more likely helping travellers to sort out benefit to die in the first year of life than problems at the same time as trying to children of settled communities. Half ensure that children have completed of travellers are under the age of 16. vaccination schedules. The Travelling Families Health Service Evidence of the link between aims to make contact with all deprivation and ill health is clearly travellers. It undertakes vaccination shown in Figure 6. The scatterplot of and immunisation of children, provides mortality from all causes against the maternity care and other health care average Index of Multiple Deprivation and liaises with other health services. score for East Midlands local The number of contacts with authorities shows a clear, proportional travellers in Hinckley & Bosworth relationship between them. Ill health varied from 17 in June 2003 to 58 in increases with increasing deprivation.

Relationship between Mortality from All Causes All Ages (DSR 1999 and 2001 pooled) and Deprivation (IMD2000) for Local Authorities in the East Midlands e

t 900.00

a “Traveller children are r d

e between one and a half s

i 850.00 d r

a and two times more likely d n a

t 800.00 to die in the first year of s n e o g i life than children of settled t a a l y

l 750.00 u t

p communities.” c o e r p i d 0 700.00 0 s 0 n 0 o 0 s r 1 e r p 650.00 e s p e g a l l 600.00 a , s e s u

a 550.00 c l l A 500.00 0.00 5.00 10.00 15.00 20.00 25.00 30.00 35.00 40.00 45.00 50.00 Deprivation (IMD2000) average of ward scores per local authority)

Source: East Midlands Public Health Observatory Figure 6: Relationship between mortality from all causes, all ages and deprivation for local authorities in the East Midlands 12 Hinckley and Bosworth Public Health Report 2002/03 Conclusion The Primary Care Trust and its Public The link between deprivation and ill Health team should: health means that Public Health needs l develop robust partnerships “Increasing the capacity of to address the wider determinants of with other organisations, this public health workforce health described previously. In the communities and individuals by increasing their skills process, we need carefully to target (This will also enable clear and knowledge, and by activities in order to reduce local understanding of the variety of supporting health inequalities. contributions necessary to address promoting activities, will be The vital component is the public this agenda); the main thrust of public health workforce. Many people from a health work for the wide variety of professions and l support the development and foreseeable future.” communities, along with individuals implementation of relevant local themselves who have a responsibility strategies, (e.g., the Leicestershire for their own health, have a role to County Plan); play. Increasing the capacity of this public health workforce by increasing l support implementation of the their skills and knowledge, and by local Homelessness Strategy and supporting health promoting activities, Community Plan. will be the main thrust of public health work for the foreseeable future. The Public Health team should: l lead a co-ordinated approach to The Way Forward the development of community The Public Health Strategy will address nurses’ public health role; health improvement and inequalities in Hinckley and Bosworth by: l carry out a local health equity audit and develop and agree an l providing a framework to action plan. (This should improve co-ordinate the development of the targeting of health service public health skills and capacity, provision at all stages - primary both inside and outside the NHS; care, secondary care and in the community); l addressing the key public health issues identified in this report and l support a review of the role of ensuring that reduction of the Hinckley and Bosworth inequalities is specifically Health Forum and the PCT/Public targeted for action. Health contribution. 13 Coronary Heart Disease

THE RANGE OF NATIONAL AND LOCAL TARGETS AND DRIVERS FOR “Annual trends show a CHANGE which focus on coronary heart disease reflects its impact on life and reduction in mortality from health. The Government Strategy Saving Lives Our Healthier Nationiii (SLOHN) CHD locally, in line with highlighted coronary heart disease (CHD) and stroke as one of four target Leicestershire and England areas to be prioritised. and Wales.” The National Service Framework for CHDiv built on this by outlining a 10-year programme aimed at reducing the death rate from CHD and stroke by 40% by the year 2010. The NHS Planv, which followed in 2002, reiterated the need to focus on this area, stating that the NHS should make improved services and outcomes in CHD an ongoing priority. These national imperatives are reflected in the recent East Midlands Public Health Strategyvi. Reducing the incidence of CHD, and improving the outcomes of CHD and stroke, are included as key objectives.

Regional Action Plan

l Update practice-based registers in primary care so that patients with CHD and diabetes continue to receive appropriate advice and treatment in line with the CHD National Service Frameworkiv. l Improve the management of heart failure in line with clinical guidelines. l By April 2004 all general hospitals caring for people with stroke to have a specialised stroke service. l Deliver a 10% increase per year in the proportion of people suffering from a heart attack who receive thrombolysis within 60 minutes of calling for professional help.

(East Midlands Public Health Strategy 2002vi)

Locally, in Leicester, Leicestershire Improvement (CHI) has recently and Rutland, the former Health carried out a review of the Authority’s Health Improvement implementation of the CHD NSF in Programme for 2001-4vii recommended Leicestershire. Recommendations local action to achieve these national from this review will provide a useful targets. insight into further development of Subsequent NHS reorganisations work to address CHD. have led to the formation of a Strategic Health Authority which The Size of the Problem – covers Leicestershire, Northampton Mortality and Ill-Health and Rutland, and to the development of PCTs which have the ‘local lead’ for delivering national and regional Mortality targets. Annual trends show a reduction in Hinckley and Bosworth PCT, mortality from CHD locally, in line therefore, has responsibility for with Leicestershire and England and “Hinckley & Bosworth PCT working with its NHS and other Wales. has responsibility not only partners to deliver the targets in its Mortality is probably best expressed for local action to reduce area. Moreover, within these new in terms of the number of years of life the incidence of CHD and NHS structures, Hinckley & Bosworth lost (YLL) per head of population. In improve outcomes for Hinckley and Bosworth there are 55 PCT has responsibility not only for patients but also for local action to reduce the incidence of YLL per 10,000 population. This is the providing the strategic lead CHD and improve outcomes for lowest figure among all Leicestershire patients but also for providing the PCTs (average of 79 YLL). The on behalf of all the strategic lead on behalf of all the national average for England and Leicestershire PCTs.” Leicestershire PCTs. Wales is of 80 YLL. Notably, the Commission for Health On the basis of these figures, the 14 Hinckley and Bosworth Public Health Report 2002/03 overall burden of mortality due to section that follows highlights the “Smoking is the largest CHD in Hinckley and Bosworth is progress made locally. single risk factor; but relatively low compared with both physical inactivity, poor diet regional and national levels. However, Prevalence of CHD and a high level of alcohol it is still a major cause of mortality Prevalence is currently difficult to consumption also increase and morbidity. With better survival in estimate, though general practice an individual’s risk.” acute forms of CHD, more patients based registers under development go on to develop congestive heart will help address this. However, proxy failure. National targets require measures can be used to obtain a improvements in the delivery of a picture of the level of disease: range of medical interventions. The

CHD Cases Percentage of population Number of residents who have had any hospital admissions with CHD diagnosis in the past 8 years. 2,200 2.2%

Community Diagnosis of CHD – Estimated number of patients with CHD never previously admitted with that diagnosis. 1,300 1.3%

Total 3,500 3.5% Source: Leicestershire Health Informatics Figure 8 CHD Risk Factors difficult for individuals to adopt a There are a variety of risk factors for healthy lifestyle, such as a low income CHD, including family history, gender, or lack of access to an affordable age and ethnicity. A number of lifestyle healthy diet. factors can also increase the risk that It is suggested, therefore, that in someone will suffer from CHD. addition to addressing lifestyle risk Smoking is the single largest risk factors overall, the particular needs of factor; but physical inactivity, poor those who are more ‘at risk’ will need diet and a high level of alcohol to be a focus for action. consumption also increase an Service Provision and individual’s risk. In addition, people suffering from Action certain conditions, such as high blood As is evident from the section on the pressure or diabetes, and those who prevalence of mortality, illness from are obese, are at increased risk. It has CHD and its related conditions, much been estimated that locally in 2002 of the treatment received is delivered there were 21,000 obese adults and within a hospital setting. However, 36,000 people overweight. By the GPs and primary care also play a key “By the year 2010 it is year 2010 it is estimated that there role. All Hinckley and Bosworth PCT estimated that there will be will be 26,000 obese adults in practices have established CHD 26,000 obese adults in Hinckley and Bosworth. registers. Hinckley and Bosworth.” Inequalities in health are also evident The PCT’s Quality Framework in CHD. Being male, older or South highlights standards of practice to be Asian are all factors which increase achieved, including an annual review of the risk of developing this disease or the CHD register; CHD and heart its related illnesses. Investment for failure ‘audits’ and risk registers. Healthvi, the East Midlands Public It is possible that, as the registers Health strategy, highlights the fact that become more effective, the number of men in the region from social class 5 people diagnosed with CHD might who are aged between 20 and 64 rise. This will need to be monitored “Men from social class 5 years are twice as likely to die from and individuals will need to be who are aged between 20 CHD as those in social class I. appropriately supported. Annual and 64 are twice as likely This fact reflects the way that CHD audits will also be used to to die from CHD as those predisposing factors, such as being male, develop action plans to support this in social class 1.” can be added to if there are work. circumstances which make it more 15 The PCT is also working with its HEART ATTACKS AND OTHER NHS partners, including University ACUTE SYNDROMES Hospitals of Leicester (UHL) and East Assuming everyone who has a heart Midlands Ambulance Service (EMAS), attack is admitted as an in-patient, to ensure that the door to needle rates in Hinckley and Bosworth are standards for thrombolysis are met. relatively low – 18 per 10,000 A key target is that patients who population over 40 years of age when need it should receive thrombolytic compared with 20/10,000 in therapy within 60 minutes of calling Leicestershire and Rutland overall. for professional help. There is One-month case fatality after acute “The PCT is working with therefore also a need for education on heart attack is the same as for the its NHS partners, including the early recognition of symptoms, so whole of Leicestershire – 18% of all University Hospitals of that help is called for as early as patients with a heart attack die within Leicester and East possible. one month of admission. Midlands Ambulance The PCT is supporting and Service, to ensure that the undertaking a range of measures to CHRONIC CHD door to needle standards deliver improved heart health. These Among PCTs in Leicester, for thrombolysis are met.” include: Leicestershire and Rutland, Hinckley and Bosworth PCT has the third l appointment of a lead GP, and highest rate of admission to a Rapid training for nurses in CHD Access Chest Pain Clinic (RACPC), and management, in GP practices in below average emergency admissions order to continue to improve the for chest pain or angina. quality of care and support offered; Admission to RACPCs should reduce emergency admissions for l a protocol for the systematic chest pain or angina. This correlation assessment, treatment and largely holds for Hinckley and follow up of people with CHD Bosworth. and heart failure aimed at ensuring a consistent approach to INTERVENTION RATES good practice; The provision of revascularisations1 was in line with the rest of l consolidation and further Leicestershire and Rutland. Rates of development of the work of a percutaneous coronary interventions local CHD programme group in (e.g., angioplasty) have increased by order to reflect local need and 82% from 382 per million population implement action to deliver the (pmp) in 1998/9 to 696 pmp in National Service Framework; 2002/3. This is still short of the target of 750 pmp but characteristic of the l expansion and development of shift from coronary artery bypass graft smoking cessation clinics, (CABG) to PCI interventions walking groups and an exercise recommended nationally. on referral scheme to ensure that Although rates of diagnostic they have the maximum positive catheterisations were slightly lower impact. (but not significantly so) than the Leicestershire average, there has been a significant (74%) increase in catheterisation rates between 1998/9 and 2002/3. 1 Interventions to improve the blood supply to the heart. 16 Hinckley and Bosworth Public Health Report 2002/03 HEART FAILURE heart failure cases in Leicestershire It is difficult to give precise numbers and Rutland. It is important to note of heart failure cases in the that there is an overall trend towards “There is an overall trend community. However, reasonably increasing hospitalisation rates for towards increasing robust estimates - based on heart failure in Leicestershire (rates of hospitalisation rates for hospitalisation and epidemiological admissions, incidence and prevalence heart failure in data - do exist. of heart failure in the community). Leicestershire.” Hinckley and Bosworth has the The burden of this disease is lowest rates of previously hospitalised increasing.

2002-3 Cases Percentage of H&B Population

Prevalence of hospitalised heart failure (patients previously admitted with that condition in population over 40 years of age). 700 1.2% (population > Hospital incidence – annual number of new heart failure cases 40 years) diagnosed in hospital. 180

Cases annually treated for heart failure in hospital. 330

Source: Leicestershire Health Informatics Figure 9 The Way Forward especially between primary, l The PCT needs to invest in and secondary care and the community address primary prevention as services. This should improve the well as clinical intervention, effectiveness of its use, in turn which is arguably not currently ensuring that patients are provided adequately actioned or resourced. with more appropriate support and There is a need for continued information. investment in physical activity and further development of smoking l The PCT should support the cessation/tobacco control implementation of the initiatives and food and health Leicestershire-wide strategies for programmes. heart failure, cardiac rehabilitation, including Phase 4 (community l The PCT needs to improve the based rehabilitation) and quality and volume of locally revascularisation. specific data to inform action, 17 Diabetes Care

Targets and Drivers for Change IN 2001 THE DEPARTMENT OF HEALTH SET NEW TARGETS AND STANDARDS FOR DIABETES SERVICES, (the National Service Framework for Diabetesviii (NSF) (see figure 10)). Further advice to support the implementation of the NSF for Diabetes was given in the Delivery Strategyix along with specific standards and recommendations for appropriate service provision.

Targets for Diabetes

l By 2006, a minimum of 80% of people with diabetes should be offered screening (and treatment if needed) for diabetic retinopathy and, by the end of 2007, 100% of those at risk of retinopathy.

l In primary care, - practice-based registers should be updated to facilitate patients with CHD and diabetes receiving appropriate advice and treatment in line with NSF standards, and - by March 2006, practice-based registers should be supporting systematic treatment regimens, including appropriate advice on diet, physical activity and smoking, and also should be covering the majority of patients at high risk of CHD.

Figure 10 Primary Care Trusts in England, The prevalence of diabetes increases including Hinckley and Bosworth, are 4 to 6-fold among people of South “The prevalence of required to implement the NSF, Asian origin, and up to 3 times in diabetes increases 4 to beginning with the undertaking of a people of African or Afro-Caribbean 6-fold in people of South baseline local service needs descentxi. Asian origin, and up to 3 assessment. Such an assessment has Type 1 diabetes or IDDM is mainly a times in people of African been completed for Leicestershire and disease beginning in childhood. or Afro-Caribbean descent.” Rutlandx. However, type 2 diabetes occurs predominantly in adults over 40 years, with prevalence increasing up to 20% Diabetes in Hinckley and in people aged 85 years and over. Bosworth Obesity and overweight increase the Diabetes is a common condition and is risk of type 2 diabetes significantly. becoming more common. Overall, in Sedentary lifestyle and high-calorie the UK, there are about 1.3 million diets may also increase the risk of people of all ages diagnosed with developing type 2 diabetes because of diabetes, with an estimated prevalence the link with obesity/overweight. of 2-3% (about 15% with insulin- Diabetes shortens life (by dependent diabetes mellitus (IDDM) approximately 20 years for people “In Leicestershire, 3% of and 85% with non-insulin-dependent with IDDM, and 10 years for people the population - or 29,000 diabetes mellitus). In Leicestershire, with NIDDM). It increases the risk of people - are estimated to 3% of the population - or 29,000 developing and dying from conditions have diabetes mellitus at people - are estimated to have such as coronary heart disease, stroke any point in time.” diabetes mellitus at any point in time. and renal failure.

(1) Definition of Diabetes Diabetes mellitus comprises a group of clinical disorders characterised by raised blood glucose including insulin-dependent diabetes mellitus (IDDM or type 1), non-insulin—dependent diabetes mellitus (NIDDM or type 2) and the gestational diabetes (diabetes from pregnancy). Current accepted definition (and diagnosis) is based either on fasting blood glucose of > of 7.0 mmol/l or > or 11.0 mmol/l taken 2 hrs after an oral glucose load of 75g. Treatment is aimed at controlling blood glucose levels so that the risk of complication is minimised, and includes education/counselling, monitoring, self-management and drug therapy (oral tablets or insulin injections). 18 Hinckley and Bosworth Public Health Report 2002/03 (table 1). This means a potentially Diabetes causes serious greater proportion of people with complications; it is a leading cause of diabetes mellitus, assuming everything lower limb amputations and visual else is equal. impairment in people of working age. As shown in table 2, the risk of Approximately 5% of NHS resources diabetes associated with are used for diabetes care and it is unemployment, ethnicity and multiple estimated that it costs patients £800 deprivation is lower for Hinckley and plus per year in lost earningsxii. Bosworth compared with the whole There are fewer younger adults of Leicestershire. (15-44 years) and more older people National figures suggest a worryingly (45-64 years) in the population of high and increasing prevalence in Hinckley and Bosworth than in the overweight and obesity, especially Leicestershire population as a whole among children and young people.

Table 1. Age distribution of the population in Hinckley & Bosworth, 2002

Area Age (years)

<15 15-44 45-64 56+ Total population

Hinckley and Bosworth 18% 41% 26% 15% 101,000

Leicestershire 18% 44% 23% 15% 960,000

Source: Leicestershire Health Informatics Service, 2001

Table 2. Prevalence of some relevant risk factors

Hinckley & Bosworth Leicestershire England County Body Mass Index (BMI) ‡30 Not known Not known 21% - women 17% - men Body Mass Index (BMI) >25 Not known Not known 50 % - women 67% - men Ethnic proportion * 1% 5.3% 9.1% - overall Deprivation (IMD 2000) average score 12.1 21.5 Not applicable Unemployed (based on claimants) * 2.5% 2.35% 3.35%

“Approximately 5% of NHS * source 2001 census, Crown Copyright resources are used for Scale and impact of diabetes diabetes care and it is estimated that it costs Table 3 compares estimated prevalence of diabetes for Hinckley and Bosworth patients £800 plus per district with that of other PCTs in Leicestershire. year in lost earnings.” Table 3. Estimated prevalence of diabetes in Leicestershire by PCT

PCT Prevalence based Prevalence based Prevalence based on previous study on Trent model on practice data in Leicestershire Hinckley & Bosworth 3.1 2.7 2.3 S Leicester 3.3 3.0 2.8 Melton Rutland Harborough 3.3 2.8 2.8 Charnwood & NW Leicester 3.1 2.7 2.7 Eastern Leicester 2.8 3.7 4.3 Leicester City West 2.7 2.6 3.2 Leicestershire average 3.0 3.0 3.1 19 Estimates were derived using Primary care different sources, including general practice data and previous studies. For Nationally, around 75% of care for the population of Hinckley and patients with diabetes is provided in Bosworth PCT, the prevalence varies primary carexii by a range of health from 2.3% to 3.1%. professionals. Locally, they include According to mortality statistics, GPs, podiatrists and dieticians. deaths with diabetes as the underlying A full picture is expected to be cause have declined over the last available when PCTs conclude the decade both locally and nationally. baseline assessment for diabetes in However, the overall contribution to primary care, which is currently under mortality may be higher. way. For Hinckley and Bosworth, there At present, local figures show that were approximately 5 deaths with 37% of known diabetics in Leicester diabetes as the underlying cause per receive care solely via their general “All practices are expected 100,000 population, compared with an practitioners. The rest receive either to develop or enhance their average of 8 per 100,000 for the shared care or hospital care only. whole of Leicestershire (1993 to Although the majority of care is diabetes registers and 2001, standardised for age and sex). provided through routine conduct an audit of For patients with a primary diagnosis appointments, a significant number of diabetes.” of diabetes, approximately 80 patients GP practices have developed proactive per 100,000 from Hinckley and approaches to delivering care to their Bosworth are admitted to hospital patients. annually compared with 100 per For example, some practices run 100,000 for Leicestershire. regular diabetes clinics providing a For diabetic patients, approximately range of services, including treatment, 15 per 100,000 population of Hinckley education, patient follow-up and and Bosworth are admitted to hospital surveillance of diabetes complications. annually with acute complications Most practices have a diabetes (keto-acidosis and coma) compared register. However, the proportion of with 20 per 100,000 annually in patients in the register and quality of Leicestershire. recorded data varies widely across This suggests that while the scale of practices. the problem might be lower in some In Hinckley and Bosworth PCT, ways than the average, it is still a there are 14 practices (13 group significant health burden. practices and one single GP practice) Moreover, increased detection, and around 51 general practitioners. demographic changes (e.g., an All practices are expected to develop increasing number of older people or enhance their diabetes registers and/or people of South Asian or other and conduct an audit of diabetes. So ethnic background) and increased far, three practices have completed levels of obesity/overweight are likely the electronic diabetes auditxiii. “The county was the first to lead to increased levels of diabetes. place in the UK to Hospital and Specialised introduce diabetes specialist Current Service Provision nurses. There is an active Overall, services for diabetes in Services Leicestershire Diabetes Leicestershire are well established. Services Advisory Group.” The county was the first place in the Services provided at the UK to introduce diabetes specialist University Hospitals Leicester nurses. There is an active Secondary care services for diabetes Leicestershire Diabetes Services are based in all three sites of the Advisory Group (LDSAG). Good University Hospitals Leicester (UHL) working relationships between NHS Trust. However, the majority of primary and specialist care are care is provided at Leicester Royal supported by an active research Infirmary (LRI) and the Leicester programme. General Hospital (LGH). About 60% of the care from these two sites is 20 Hinckley and Bosworth Public Health Report 2002/03 provided at the LRI and 40% at the The Way Forward LGH. At LRI, there are general out-patient l The quality and volume of sessions as well as specialised clinics, services for diabetes need to be including a foot clinic, an antenatal raised so that the health care clinic and an erectile dysfunction clinic. needs of increasing numbers of ‘Outreach’ consultant support clinics patients with diabetes can be met are held in peripheral areas, including at all levels. Hinckley. Both general out-patient sessions and specialised clinics are l The PCT should review the held at LGH. baseline assessment of diabetes services in primary care and from Specialised Services for Hinckley it develop a future action plan. and Bosworth A specialist from LRI holds weekly l Approved ways or models should out-patient clinics at Hinckley & be identified and adopted to detect District Hospital. Patients with and treat patients with diabetes in Hinckley and Bosworth are undiagnosed diabetes as early as referred to a clinic run by a consultant possible. diabetologist. A diabetes specialist nurse (DSN) l Mechanisms need to be developed supports the diabetes services in this and implemented which provide “Patients with diabetes area. The DSN provides education, appropriate education and should be offered retinal advice and support to staff caring for support for patients with screening annually. This people with diabetes and to patients diabetes, making sure that patients can be organised locally by themselves. gain the knowledge and skills they GPs supported by Leicester A county-wide nutrition and dietetic need for effectively controlling Royal Infirmary or via service is available for patients with their condition and minimising referrals directly to diabetes. A clinic is held at Hinckley potential diabetes complications. Hospital on the same day as the Leicester Royal Infirmary or consultant-run diabetes clinic. local optometrists.” l The training and development However, there is a waiting time of up needs of all staff, including those in to 16 weeks. primary care, should be assessed, A podiatry department based at and the necessary action taken to Hinckley Hospital runs a daily clinic ensure that professionals have providing foot care as well as the skills and confidence to education and advice for patients. support patient management of Patients with diabetes should be diabetes. offered retinal screening annually. This can be organised locally by GPs l Service development should include supported by Leicester Royal effective preventive interventions Infirmary or via referrals directly to for reducing the incidence of Leicester Royal Infirmary or local diabetes, including tackling obesity optometrists. and overweight and promoting healthy eating and physical activity.

l Primary care should offer all patients with known diabetes an annual review to assess the risk of diabetes complications and their prevention or mitigation, and to offer patients advice and education about their condition. 21 Smoking Prevention and Cessation

Targets and Drivers for Change

“The burden of premature mortality and morbidity caused by smoking is massive. No other single avoidable cause of disease accounts for such a high proportion of deaths, hospital admissions or GP consultations. Cigarette smoking is the single most important public health problem in Britain.” Royal College of Physicians, 2000xiv

“Smoking is the principal cause of the inequalities in death rates between rich and poor. Put simply, smoking is a public health disaster.” Alan Milburn, Secretary of State for Health, 2000xv

Given the enormous scale of the In Britain, one third of adults smoke. problem, the Government has given Half of them will die from their habit. PCTs some very tough targets to The proportional impact of smoking is reduce the rate of smoking in England. greatest in younger age groups and in “Smoking is the greatest Nationally, 800,000 smokers must quit men, accounting for one in three single preventable cause of smoking at the 4-week stage by 2006. deaths in the 35-64 age groupxiv. premature death and This translates locally for Hinckley and illness in Hinckley and Bosworth as 1,326 smokers in the Smoking increases Bosworth. Despite this, same period. inequalities in health… smoking prevalence rates The PCT must also demonstrate that People in lower social classes are remain relatively high, with it is focusing smoking cessation more likely to die early. This is due to approximately 27% of the support on those who need it most. a variety of factors. In men, the population smoking. This means achieving tough targets for dominant factor is smoking, which reducing smoking among manual regularly.” accounts for over half of the workers and those who smoke during difference in the risk of premature pregnancyxvi. death between the social classesxvii. Although just as motivated to stop The size of the problem smoking as people in professional Smoking is the greatest single groups, people in lower socio- preventable cause of premature death economic groups are much less likely and illness in Hinckley and Bosworth. to succeedxvii. Whilst the overall “Smoking causes one in Despite this, smoking prevalence rates prevalence of smoking in the UK over three cancers, and one in remain relatively high, with the past 30 years has decreased, there seven deaths from heart approximately 27% of the population has been little change in smoking rates disease, stroke and smoking regularly. among those living on low incomes circulatory diseases.” In all, twenty-five diseases are known and those who are most to increase in incidence because of disadvantagedxv. smoking. However, most smokers die In the most disadvantaged from one of three main diseases: communities, smoking rates can be cancers, chronic obstructive lung over 70%xviii. The most disadvantaged disease (bronchitis and emphysema) spend a disproportionately larger xiv and coronary heart disease . share of household income on Smoking causes one in three cancers, cigarettes. Over 70% of two-parent and one in seven deaths from heart households on income support buy disease, stroke and circulatory cigarettes, spending around 15% of diseases. In addition, smoking is weekly income. This compares with associated with a large number of an average of 2% of household income non-fatal diseases which may cause spent on cigarettes xviii. long-term illness, disability and dependence on medication, often impacting severely on quality of life xiv. 22 Hinckley and Bosworth Public Health Report 2002/03 Service Provision: with Melton Rutland & Harborough Performance in 2002-2003 PCT and South Leicestershire PCT. This new service will build upon the In 2002-03, smoking cessation services excellent infrastructure already in for Hinckley and Bosworth PCT were place by significantly increasing the delivered by the Resolution Stop number of local stop smoking clinics Smoking Service, which operates across and developing services which focus Leicestershire and Rutland. particularly on the needs of our rural A total of 185 Hinckley & Bosworth and disadvantaged communitiesxix. PCT residents made a commitment to stop smoking with Resolution. Of these, 113 (61%) had successfully The Way Forward stopped smoking after a 5-week The PCT should ensure that: intervention, which is well above the national average of 54%. l smoking cessation services run by Resolution follows up all clients after accredited advisors will be one year. Its findings show that available in every GP practice approximately 25% remain non- across the PCT (or, alternatively, smokers. These are excellent results - nearby community venues such as comparable with those achieved pharmacies) in order to improve anywhere in the world by smoking access to high quality support for cessation services. However, it must those seeking to quit; not be forgotten that the targets which the PCT has to meet are even l the public will have improved tougher for 2003/4. access to effective stop smoking “Resolution follows up all products on prescription, such as Actions: Past and Current Nicotine Replacement Therapy clients after one year. Its Given the scale of smoking in the (NRT) and Zyban; findings show that PCT, helping people to stop smoking approximately 25% remain is high on the public health agenda. l there will be increased levels of non-smokers. These are Hinckley and Bosworth is the only support for pregnant smokers excellent results - area in the county where stop and their friends and family, comparable with those smoking clinics are held at the local including home visits by a smoking achieved anywhere in the Leisure Centre as well as other cessation specialist, to help them world by smoking cessation venues. quit; services.” In September 2003, the PCT enhanced the existing county-wide l there will be an increase in NHS specialist stop smoking service referrals to smoking cessation offered by Resolution by creating a new services. service - Resolution (County) - jointly 23 Food and Health

National, Regional and Local Targets

A KEY FEATURE OF THE GOVERNMENT’S STRATEGY TO REDUCE EARLY DEATHS FROM CANCER AND CORONARY HEART DISEASE (CHD) is action to improve diet and nutrition. Current recommendations are that everyone eats at least five portions of fruit and vegetables daily. The introduction of the national school fruit scheme to supply a piece of fruit to each 4-6 year old per school day has helped address this. The NHS Planv, NHS Cancer Plan, and the National Service Frameworks for CHDiv, Diabetesviii and Older People xxall highlight diet and nutrition as key areas for action.

The National Audit Office’s (NAO) 20% reduction in deaths from chronic report Tackling Obesity in Englandxxi has diseasesvi. called for local authorities to put into Besides a health cost, there is a place effective strategies for the considerable financial cost - both in prevention and management of direct costs and in treating the obesity. A strategyxxii for tackling diseases attributable to obesity – from overweight and obesity in primary care through to out-patient “Overweight and obesity Leicestershire has been developed and and in-patient treatment, prescription increases the risk of ill a local PCT action plan to implement costs and community services. health and significantly the strategy is currently being In 1998, the direct costs in England increases the risk of early developed. were estimated to be £9.4 million. death. In 2001, a fifth of This was considered to be an under- the population were obese, Size of problem estimate, as the data were for 1991/2, with East Midland region Overweight and obesity increases the the prevalence of obesity had grown figures indicating that 25% risk of ill health and significantly considerably since then, and the figure of men and 32% of women increases the risk of early death. In did not include the costs of were obese. These are consultations with nurse and dietitians 2001, a fifth of the population were among the highest levels in xxiii in primary care. obese with East Midland region the country.” figures indicating that 25% of men and The cost of treating the 32% of women were obese. These consequences of obesity was are among the highest levels in the estimated at almost £470 million. The country. indirect costs include 18 million The trend for increasing obesity and working days lost, loss of earnings overweight has been rising steeply estimated at £1,322 million, and days over the last 20 years: in 1980 eight lost through shortened working lives. per cent of women in the UK were (On average, people with obesity live obese, and six per cent of men. 9 years less than those who are not Likely explanations are changes in obese, and in 1998 9,000 people in eating patterns and increasingly England died before the age of 65 sedentary lifestyles. Reducing years.) overweight and obesity could lead to a BENEFITS OF 10KG WEIGHT LOSS

Mortality: l Fall of > 20% total mortality l Fall of > 30% diabetes related deaths l Fall of > 40% obesity related cancer deaths Blood Pressure: l Fall of 10mmHg systolic l Fall of 20mmHg diastolic Diabetes: l Fall of 50% in fasting glucose Lipids: l Fall of 10% total cholesterol l Fall of 15% LDL l Fall of 30% triglycerides l Rise of 8% HDL

Source: Obesity in Scotlandxxiv 24 Hinckley and Bosworth Public Health Report 2002/03 Risk factors Shilton and Barwell on cooking The NAO report states that ‘virtually healthily on a budget. They have also all obese people develop some increased the numbers of local “Obesity is well known to associated physical symptoms by the mothers breastfeeding by supporting and giving knowledge to local families. increase the risk of age of 40, and the majority will require medical intervention for Physical activity can also contribute developing diseases such as to obesity prevention. Hinckley and CHD, stroke, and some diseases that develop as a result of obesity before they are 60’. Bosworth has some of the most cancers. It contributes to Obesity is well known to increase successful ‘walking for health’ groups conditions such as diabetes the risk of developing diseases such as in the country. Patients who are not and is associated with CHD, stroke, and some cancers. It active, or who are obese or respiratory diseases, contributes to conditions such as overweight, can be referred to a local reproductive disorders diabetes and is associated with exercise scheme for individually (including complications respiratory diseases, reproductive prescribed programmes of physical during pregnancy), disorders (including complications activity. osteoarthritis, social stigma during pregnancy), osteoarthritis, Local primary care teams can refer patients to dietitians at Hinckley and poor quality of life.” social stigma and poor quality of life. Obese people are more likely to Health Centre and other dietetic suffer from problems such as binge clinics for one-to-one consultations eating, poor self-image and feelings of and advice. isolation. The Way Forward Service provision The PCT should work with its On a daily basis all local primary partners to: schools now receive fruit for children through the Fruit in School scheme. l develop an action plan for the prevention and management of Fruit is not only a good source of overweight and obesity within the vitamins and minerals, but also has a local population; protective effect against some chronic diseases, including coronary heart l expand local initiatives to disease and cancer. Increasing fruit promote food and health issues; and vegetable consumption is even regarded by experts as the second l continue to promote and develop most important strategy for cancer an effective education and prevention after reducing smoking. training programme for Many local schools are also involved community workers and in the National Healthy Schools healthcare professionals involved Standard, a scheme which supports in the prevention and management schools in making pupils and staff of overweight and obesity, and healthier, physically and mentally. To other nutrition-related issues, date, six schools have chosen healthy alongside local dieticians; eating as their focus. This involves offering more healthy food and l develop referral pathways for educating children about healthy weight management, with follow eating. up and on-going monitoring; Local health visitors give advice and support to families on weaning and l develop new ways of working, nutritious food for children and have using consumer consultation to worked with Community Adult redesign service provision (e.g., Education to provide sessions in Earl homeless groups, breastfeeding). 25 Physical Activity

THE HEALTH BENEFITS OF SPORT AND PHYSICAL ACTIVITY ARE NOW PROVEN AND WIDELY ACCEPTED. Physical activity is considered to be one of the best buys in public health, providing physical, social and mental health benefits. It also promotes an overall improvement in quality of life for people of all agesxxv.

National, Regional and not exercise enough to improve their Local Targets health. l 37% of Coronary Heart Disease There are a number of overarching deaths can be attributed to national plans which provide the inactivity, compared to just under framework for promoting physical 20% from smokingxxxi. activity: l 63% of men and 75% of women are not physically active enough to gain l NHS Plan: A plan for investment, a health benefits. plan for reformv l 9% of all Coronary Heart Disease l Saving Lives: Our Healthier Nationiii could be avoided if there was an l xxvi The NHS Cancer Plan increase in physical activityxxxi. l Young people who are physically In addition, there are a number of active are more likely to be active National Service Framework targets as adults, thus decreasing the risk which are specifically aimed at of coronary heart disease and activity: obesity in later years. l National Service Framework for Mental Healthxxxii Risk Factors l Coronary Heart Disease National Increasing physical activity is included Service Frameworkiv in the National Service Frameworks for Coronary Heart Disease, Mental xxxii There are also a number of key Health , Diabetes and Older People. “Exercise on Referral documents that provide guidance on This is because there has been an schemes within a primary promoting physical activity: unnecessary increase in the prevalence care setting are one of the of conditions such as coronary heart activities highlighted by the l Exercise Referral Systems, a disease and cancer, which have been Primary Care Trust to National Quality Assurance described by the Department of iv promote physical activity.” Frameworkxxvii Health as the “major killers” in our l Physical activity and inequalities, a country. A sedentary lifestyle is one of briefing paperxxviii the major contributing factors in the development of these conditions along l Tackling obesity in Englandxxi with smoking, obesity, poor diet and l Encouraging Walking: Advice to local authoritiesxxix nutrition.

In response, a strategy for promoting Service Provision/Actions physical activity in Leicestershire has Exercise on Referral schemes within a been published for 2003/2008. This primary care setting are one of the makes recommendations for taking activities highlighted by the Primary forward a physical activity programme Care Trust to promote physical for the regionxxx. activity. The local scheme currently runs from Hinckley Leisure Centre. Size of the Problem Those taking part in the programme The extent to which low levels of can attend sessions where they are physical activity constitute a risk to carefully monitored, or they can be health cannot be over-estimated. referred to walking or gardening groups, forming a partnership approach to health. l Over 70% of people in the UK do 26 Hinckley and Bosworth Public Health Report 2002/03 Hinckley and Bosworth has one of l continue to support the Exercise the most successful “Walking for Alliance as the main partnership Health” groups in the country: the mechanism for joint working in Let’s Walk Hinckley scheme has an physical activity and for ensuring average of 70 walkers meeting on a an evidence-based approach; weekly basis. Support and training for l develop a range of local walk leaders has been exceptionally interventions, involving both adults successful with nine volunteers trained and children, which will meet the as walk leaders since January 2002. needs of the local population (e.g., With support from local health chair-based exercise classes, green visitors this year will see new groups gyms, walking initiatives); starting up in Barwell, Earl Shilton and Market Bosworth. l re-launch, support and publicise the exercise on referral scheme, and The Way Forward develop a programme for an exercise referral outreach scheme The PCT should work with its in local communities; partners to: l highlight the role of physical l implement the Leicester, activity in addressing a range of Leicestershire and Rutland health issues (e.g., obesity, cardiac physical activity strategy; rehabilitation). 27 References i Department of Health. 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