Southend-On-Sea Localities Needs Profile

Southend-on-Sea Localities Needs Profile:

East

Authors Sally Watkins, Senior Public Health Intelligence Analyst

October 2017

Acknowledgements

The authors of this report wish to thank the following people who have contributed to this report:

Andrea Bann, NHS Southend CCG Chris Campos, NHS Southend CCG DACTeam, Southend-on-Sea Borough Council Gemma Robinson, Community Safety Officer, Southend-on-Sea Borough Council Lee Watson, Health Improvement Practitioner Advanced, Southend-on-Sea Borough Council Luke Wood, Business Intelligence Officer, Department for people, Southend-on-Sea Borough Council Pearl Ray, Health Checks Co-Ordinator, Southend-on-Sea Borough Council Samantha Reed, Adaptations Officer, Southend-on-Sea Borough Council Simon Ford, Senior Public Health Manager (Sexual Health), Southend-on-Sea Borough Council Tim Winters, Head of Public Health Information, Public Heath, Norfolk County Council Tony Mardle, Stop Smoking Service Manager, Southend-on-Sea Borough Council

With special thanks to Thurrock Council Public Health Information Team

Contents Acknowledgements 2 1. INTRODUCTION 6 2. BACKGROUND 7 PART 1: WHAT IS THE PROFILE OF OUR POPULATION? 8 3. DEMOGRAPHY 8 3.1 Age and sex distribution of the current population 8 3.2 Ethnicity 9 3.3 Fertility Rate 10 3.4 Pensioners living alone 11 3.5 Care Homes 12 3.6 Population projections 14 3.7 How can the new Primary Care Centre help? 14 4. WIDER DETERMINANTS OF HEALTH 15 4.1 Deprivation 15 4.1.1 How does deprivation impact on health? 15 4.1.2 Deprivation in East Locality 16 4.2 Housing 16 4.2.1 How does poor housing impact on health? 16 4.2.2 Persons per household 17 4.2.3 Overcrowded Households 17 4.2.4 Households with central heating 18 4.2.5 Needs of residents living in East Locality council homes 19 4.2.6 Future known housing developments 20 4.3 Employment 20 4.3.1 How does employment impact on health? 20 4.3.3 Benefits claimants 21 4.4 Education and skills 22 4.4.1 How do education and skills impact on health? 22 4.4.2 Good level of development 23 4.4.3 Residents with no qualifications 23 4.4.4 Digital skills 23 4.5 Air Quality 24 4.5.1 How does air quality impact on health? 24 4.5.2 Air quality in East Locality 24 4.6 Crime 25 4.6.1 How does crime impact on health? 25 4.6.2 Crime in East Locality 25 4.7 Access to Transport 26 4.7.1 How does accessing services impact on health? 26 4.7.2 Accessibility in East Locality 26

4.8 Summary of needs: Wider Determinants of Health; How can the new East Primary Care Centre help? 27 5 HEALTH LIFESTYLE BEHAVIOUR 29 5.1 Breastfeeding 29 5.1.1 How does breastfeeding impact on health? 29 5.1.2 Breastfeeding prevalence 29 5.2 Smoking 29 5.2.1 Smoking Prevalence 29 5.2.2 How does smoking impact on health? 31 5.2.3 The financial impact of smoking 31 5.2.4 Use of current commissioned stop smoking services 32 5.3 Obesity 33 5.3.1 How does obesity impact on health? 33 5.3.2 Child obesity Prevalence 34 5.3.3Adult Obesity Prevalence 36 5.3.4 Use of current services 36 5.4 Substance Misuse 37 5.4.1 Current service 38 5.4.2 How does substance misuse impact on health? 38 5.5 Sexual Health 39 5.5.1 Sexual Health in East locality 39 5.5.2 Teenage Pregnancy 40 5.5.3 Current Services 40 5.5.4 How does poor sexual health further impact on health? 41 5.5.5How does teenage pregnancy impact on health? 42 5.6 Summary of needs: Health Lifestyle Behaviour; How can the new East Primary Care Centre help? 42 6. EPIDEMIOLOGY – The Current Disease Burden Experienced by People in East Locality 44 6.1 Self-reported health 44 6.2 Life expectancy 45 6.2.1 Males 45 6.2.2 Females 46 6.2.3 Premature mortality 47 PART 2: WHAT DO WE CURRENTLY HAVE AND HOW DO WE USE IT? 48 7. PRIMARY CARE 48 7.1 General Practice 48 7.1.1 General Practice Workforce - 50 - 7.1.2 Practice Nurses - 51 - 7.2 Long Term Conditions Management Clinics - 52 - 7.3 Pharmacies - 53 - 7.4 Dentists - 54 - 7.4.1 Current Dental Provision - 54 -

7.4.2 Use of Current Provision - 55 - 7.5 Opticians - 56 - 7.6 Primary Care Out of Hours Service - 56 - 7.6.1 Current Service Provision - 56 - 7.6.2 Use of Current Service - 56 - 7.7 Summary of Current Primary Care Provision - 57 - 8. LONG TERM CONDITIONS AND THEIR MANAGEMENT - 58 - 8.1 Long term conditions in East Locality - 58 - 8.2 Non-diagnosed Long Term Conditions - 58 - 8.3 Quality Outcomes Framework (QOF) - 60 - 7.4 Clinical Management of Patients with Hypertension - 61 - 7.4.1 Summary of hypertension care. - 69 - 8.5 Clinical Management of patients with Heart Failure (HF) and Atrial Fibrillation (AF) - 69 - 8.5.1 Summary of HF and AF Care - 76 - 8.6 Clinical Management of Stroke, Transient Ischaemic Attack (TIA) - 76 - 8.6.1 Stroke care summary - 82 - 8.7 Clinical Management of Patients with Diabetes - 83 - 8.7.1 Summary of Diabetes Care - 90 - 8.8 Care of Patients with Respiratory Disease - 90 - 8.8.2 Summary of respiratory care - 97 - 9. MENTAL HEALTH AND WELLBEING - 98 - 9.1 Mental Ill Health prevalence - 98 - 9.1.1 Recorded Prevalence of Depression - 98 - 9.1.2 Prevalence of Serious Mental Ill Health (SMI) - 99 - 9.2 Referral of Patients with Depression to Talking Therapies - 99 - 9.3 Clinical Management of Patients with Mental Ill Health including depression and dementia in Primary Care - 100 - 9.4 Mental ill health and co-morbidities - 108 - 9.5 Mental health and wellbeing summary - 110 - 10. SECONDARY CARE - 111 - 10.1 Current Service Provision - 111 - 10.2 Outpatients Clinics - 111 - 10.3 A&E Attendance - 112 - 10.3.1 A&E Attendances that could have been treated elsewhere - 114 - 10.3.2 A&E Diagnoses (all HRG coded attendances) - 116 - 10.4 Unplanned Care Admissions - 117 - 10.5 Summary – Secondary Care - 119 - Bibliography - 120 - Appendix 1 – List of Figures - 122 - Appendix 2 – List of Tables - 126 - Appendix 3 - 127 -

1. INTRODUCTION This report was requested by NHS Southend Clinical Commissioning Group and Southend- on-Sea Borough Council to assess the health and wellbeing profile of the population of the East Locality.

The East Locality is comprised of the following wards:  Shoeburyness  Southchurch  Thorpe  West Shoebury

This report aims to examine the quality of the current primary care provision and the defined ‘blue print’ for a new Primary Care Centre which would encompass services and enhance primary care facility together with wellbeing services and potentially other clinical and social services traditionally provided in alternative settings.

It is divided into 3 parts:  Part one considers the profile of the population of East locality  Part two considers the current level of service provision and how it is being used  Part three attempts to define a possible future ‘blue print’ for a new Primary Care Centre.

2. BACKGROUND There are eight GP practices in the East Locality.

We know that under-doctoring and nursing is a huge issue and people are waiting for an unacceptable length of time in order to obtain a GP appointment. We also know that if people cannot get a GP appointment they are more likely to use more expensive parts of the system such as A&E, and that under-doctoring leads to a reduced ability of GP practices to care proactively for patients with long term conditions, increasing the risk of patients experiencing an adverse event.

In Southend-on-Sea we have a vision to provide more integrated health and social care services, and provide a more holistic population health approach to the way in which we commission services. In East our vision is to create a new Primary Care Centre which incorporates Primary Care, but also aspects of Secondary Care, and wellbeing services to address to underlying causes of ill-health.

Influences on health and wellbeing can be thought of as a chain of events set out in Figure 1. This report is structured to mirror this chain of events.

Figure 1: Influences on health and wellbeing chain of events

PART 1: WHAT IS THE PROFILE OF OUR POPULATION?

3. DEMOGRAPHY 3.1 Age and sex distribution of the current population Data from October 2016 shows that the practice registers for the GPs in East have a combined population of 36,381 (NHS Digital, October 2016). 49.5% are male and 50.5% are female. When looking at the age breakdown of this population, it can be seen there are some differences compared to the rest of the Southend-on-Sea population. East has a smaller proportion of male adults of working age, particularly between 30 and 44 and a higher population of people aged between 65 and 69.

Figure 2: East Locality GP Registered Population by Age and Sex, October 2016

Data Source: NHS Digital

When comparing the GP registered figures to the ONS population estimates of the four wards that are in East Locality, the GP registers have a lower number registered (36,381) compared to the ward population size (41,428 ONS Mid-Year Estimates, 2015). It should be noted that the ONS Mid-Year Estimates, 2015, may include patients registered with one of the largest practices within Southend-on-Sea aligned to neighbouring localities, located near the border of this locality (Queensway Surgery; 21,065).

Figure 3 shows the age breakdown of the wards within East Locality. Thorpe has the highest proportion of residents aged 65 years and over (22.4%) and the lowest proportion of persons aged under 25 years (26.2%). Shoeburyness has the highest proportion of people of working age (54.3%).

Figure 3: Population by age band, by ward, 2013

Data Source: ONS Mid-Year Population Estimates 3.2 Ethnicity Data from the 2011 Census indicates that 9.6% of the population in East are from a BME group. This is lower than the Southend-on-Sea average of 12.7%. All four of the wards in East Locality have a lower proportion than the Southend-on-Sea average; Shoeburyness has the lowest rate with 8.4% (1 in 12) classified as BME.

Figure 4: Proportion of residents classifying themselves as from a BME group, by ward, 2011

Data Source: 2011 Census 3.3 Fertility Rate The fertility rates in three of the four wards in East Locality have a lower fertility rate than the Southend-on-Sea average, with the highest being Southchurch ward and lowest being Thorpe ward, as shown in Figure 5. Whilst the rate for Southend-on-Sea is 66.4 per 1,000 women aged 15-44, the fertility rate in Southchurch is 67.0.

Figure 5: Crude fertility rate per 1,000 female population aged 15-44, by ward, 2010-2014

Data Source: ONS (Local Health) 3.4 Pensioners living alone Data from the 2011 Census indicates that 30.0% of the population aged 65 years and over in East are living alone. This is lower than the Southend-on-Sea average of 34.2%. One of the wards in East has a higher proportion than the Southend-on-Sea average; Shoeburyness ward (35.2%).

The ward with the lowest number of people aged 65 years and over in living alone in East is West Shoebury (25.7%). The second lowest, although it has the second highest proportion of residents aged over 65, is Southchurch. In contrast Southchurch, with the highest proportion of people aged 65 and over (22.4%) within the locality has the second lowest proportion of people aged 65 years and over living alone (29.0%).

Figure 6: Proportion of pensioners living alone, by ward, 2011

Data Source: Local Health Profiles (ONS 2011 Census) 3.5 Care Homes In Southend-on-Sea there are 98 care homes. Thirteen of these are located within the East Locality (13.3%) with six located in the ward of West Shoebury (6%) and none located in Shoebury. There are a total of 2,069 beds across Southend-on-Sea with 298 beds (14%) in East Locality and 270 (13%) located in both Southchurch and West Shoebury.

In November 2016 there were 1,299 care home residents registered with a NHS Southend CCG GP. This would suggest that nearly one third of residents are registered with GPs in neighbouring CCGs.

Figure 8 below shows the rate per 1,000 registered population of each GP practice in NHS Southend CCG. There are a total of 1,299 care home residents registered to GP practices in NHS Southend CCG. Of these, 112 are registered with GP practices in East with Dr Mario & Partners Surgery (39) and Irlam A C & Partner (36) having the majority of these. In contrast East Locality GP practices have 112 registered patients residing in care homes, whilst hosting only 13 of the 98 care homes found within Southend-on-Sea.

Figure 7: Number of care homes, by ward, Southend-on-Sea, November 2016

Data Source: People Department, Southend-on-Sea Borough Council

Figure 8: Rate of care home residents per 1,000 registered population with NHS Southend CCG practices, November 2016

Data Source: NHS Southend CCG

3.6 Population projections Population projections are an indication of the future trends in population by age and sex over the next 25 years. They are trend-based projections, which means assumptions for future levels of births, deaths and migration are based on observed levels mainly over the previous 5 years. They show what the population will be if recent trends continue.

The projected resident population of an area includes all people who usually live there, whatever their nationality. People moving into or out of the country are only included in the resident population if their total stay in that area is for 12 months or more, thus visitors and short-term migrants are not included.

As with national and borough populations, the population of East is set to increase in coming years. Applying the Southend-on-Sea rate of change to the East population generates 1,415 additional residents by 2019. The projections can be extended further, and enable an estimate of 2,794 additional residents by 2024 and 4,036 by 2029.

The projected rate of change for persons ages 75 years and older in Southend-on-Sea is much higher than for all persons (31.78% by 2029 compared to 11.09%). By applying the Southend-on-Sea rate of change for persons aged 75 years and older to the East population generates 199 additional residents by 2019. The projections can be extended further, and enable an estimate of 737 additional residents by 2024 and 989 by 2029. 3.7 How can the new Primary Care Centre help? The above information indicated that East Locality has a very mixed demography. Whilst it has a lower proportion of people of working age (Figure 2) and a low proportion of people who class themselves as from a BME group (Figure 4) it has a low fertility rate (Figure 5) and low proportion of older people living alone (Figure 6). However the population of East is set to increase, especially in older people compared to other localities in Southend-on-Sea. The Primary Care Centre should ensure it provides a range of services to support people of working age and older people and their families to stay healthy. The Primary Care Centre should be able to flexibly accommodate this future population increase.

4. WIDER DETERMINANTS OF HEALTH 4.1 Deprivation

4.1.1 How does deprivation impact on health? Deprivation is directly linked to life expectancy and the length of disability free life. This essentially means that those living in poorer areas do not only die sooner, but also they will spend more of their shorter lives with a disability. The consequences of poverty, higher levels of harmful behaviour and lower levels of protective behaviours are seen most clearly in the distribution of illnesses and health status. When compared to those living in more affluent communities, populations living in areas of high deprivation statistically have:  Higher levels of mental illness  Increased likelihood of developing a long-term condition, particularly chronic respiratory conditions, cardiovascular disease and arthritis  A higher prevalence of unhealthy lifestyle behaviours such as obesity, physical activity and smoking

Children living in areas of high deprivation:  Experience a higher risk of infant mortality  Are at higher risk of acute illnesses requiring hospital admissions  May be more likely to experience emotional and behavioural problems  Are less likely to maintain a healthy weight  Are more likely to experience problems with oral health  Are more likely to achieve lower levels of educational attainment

In addition, young people growing up in areas of high deprivation:  Are more likely to conceive and become teenage parents  Are more likely to enter the youth justice system  Are more likely to smoke  Are at higher risk of becoming NEET  May experience lower earnings and poorer qualifications in adulthood

This will impact accordingly on the use of health services – the inverse care law states that the availability of good medical care tends to vary inversely with the need for it in the population served. Research by (Mercer & Watt, 2007) found that access to care generally took longer, and satisfaction with access was significantly lower in the most deprived areas. Patients in the most deprived areas had more problems to discuss (especially psychological), yet clinical encounter length was generally shorter. GP stress was higher and patient enablement was lower in encounters dealing with psychological problems in the most deprived areas. Variation in patient enablement between GPs was related to both GP empathy and severity of deprivation. There is also the added complication of the larger demand on primary, secondary and community care due to the higher likelihood of patients exhibiting unhealthy lifestyle behaviours and earlier onset of long-term conditions.

4.1.2 Deprivation in East Locality According to the Index of Multiple Deprivation (IMD) 2015 Southend-on-Sea contains 13 Lowers Super Output Areas (LSOA) which are in the 10% most deprived areas in England. Five of these 13 LSOAs are within the East Locality wards. Thorpe Bay contains three of the 10% least deprived LSOAs in England.

Figure 9: 2015 IMD Score by LSOA's within East Locality

Data Source: ONS 4.2 Housing

4.2.1 How does poor housing impact on health? Housing is a massive driver of health inequalities – generally speaking, older people, children and those with long-term conditions are at greater risk of adverse health due to poor housing conditions. There is a large body of evidence to indicate that poor housing can impact on the following health conditions:  Respiratory problems – this is particularly linked to residents living in cold homes and houses with mould, although is also associated with general overcrowding. Research suggests that around 1 in 18 dwellings in England have appreciable dampness or mould. This can lead to increased development of conditions such as asthma and bronchitis, and worsening of existing respiratory conditions. In addition, insufficient ventilation in houses can lead to increased indoor pollutants such as radon, carbon monoxide and nitrogen dioxide.  Circulatory problems – cold homes are linked to an increased risk or hypertension and cardiovascular disease. Excess Winter Deaths due to circulatory disease are estimated to be between 40-50% (Marmot Review Team, 2011)  Mental Health – increased exposure to noise due to poor home insulation can result in increased stress and anxiety levels, and also lead to an increased risk of ischaemic

heart disease. Stress can also be exacerbated by feeling of overcrowding or fuel poverty. Depression and feelings of isolation could also develop as people feel they cannot escape their situation.  Falls and accidents – poor quality housing leads to an increased number of falls, due to an increased number of trip hazards or poor quality furnishings.  Mortality rates – The Marmot Review Team (2011) found that residents who live in the coldest homes have a 20% greater risk of Excess Winter Deaths than those in the warmest homes, simply due to the their houses being colder. The risk factors for respiratory problems might also contribute to a rise in mortality rates. It is also known that mortality rates increase during extreme hot weather; and although there is not conclusive evidence to link housing quality to this, houses should be adequately ventilated to reduce risk.

4.2.2 Persons per household The average number of persons per household in Southend-on-Sea is 2.34, which is lower than the national average of 2.36. West Shoebury has more persons per household than the Southend-on-Sea average, but is below the National average (2.35).

Figure 10: Average number of persons per household, by ward, Southend-on-Sea

Data Source: Calculated Using ONS & 2011 Census

4.2.3 Overcrowded Households A household can be classified to be overcrowded if it has fewer bedrooms than the notional number recommended by the bedroom standard (a recommended notional number of bedrooms for each household, based on the size of the household, age, sex, marital status and relationship among members of the household). An occupancy rating of -1 or fewer could indicate overcrowding within a household. Only Shoeburyness of the East wards has a higher proportion of households with an occupancy rating of -1 or fewer than the Southend- on-Sea (9.6%) and England (8.7%) averages.

Figure 11: Proportion of households with 1 or more rooms too few, by ward, 2011

Data Source: ONS Census 2011

4.2.4 Households with central heating Central heating can help maintain a warm home during cold weather. The Institute of Health Equity (IHE) has reported (Marmot Review Team, 2011) on the health impacts of cold homes:

Figure 12: Proportion of households without central heating, by ward, 2011

Data Source: Local Health (ONS Census 2011) The IHE reported findings included:  There is a strong relationship between cold temperatures and cardiovascular and respiratory diseases.  Children living in cold homes are more than twice as likely to suffer from a variety of respiratory problems than children living in warm homes.  Excess winter deaths are almost three times higher in the coldest quarter of housing than in the warmest quarter.

Shoeburyness ward has the highest proportion of homes without central heating1 in the East Locality, and is similar to Southend-on-Sea, as seen in Figure 12. This could mean that residents in these households are more susceptible to cardiovascular and respiratory diseases.

4.2.5 Needs of residents living in East Locality council homes Some residents living in Southend-on-Sea Borough Council accommodation have particular health needs which may require adaptations to the property they reside in. These adaptations may be required following an acute admission or deterioration of health. The adaptations are categorised into major or minor. Major adaptations include level access shower, stair lift, ramps, and adapted kitchen at an average cost £4,200. Minor adaptations include grab rails, stair rails, half steps, shower seats, door width alterations. Average cost £300.

Table 1 shows the number of adaptations, by ward, in East for 2014/15 and 2015/16. The total cost to the council for these years were £150.9k and £126.3k respectively.

1 Any type of central heating including gas, oil, solid fuel and electric (including storage heaters)

Table 1: Adaptations to council accommodation 2014/15 & 2015/16 2014/15 2015/16 Major Minor Major Minor Shoeburyness 5 13 7 18 Southchurch 17 18 11 14 Thorpe - - - - West Shoebury 11 10 9 11 Total 33 41 27 43 Data Source: Adaptations Team, Department for People, Southend-on-Sea Borough Council

4.2.6 Future known housing developments As with national and borough populations, the population of East is set to increase in coming years. Using information held by the Council on known developments in the locality and applying a ratio of 2.30 persons per new house (based on the current East ratio) is it estimated that this alone would result in an increase of 216 persons (94 new households) by 2021.

Table 2: Number of known developments in East Locality Wards 2016-2021 Ward 2016-17 2017-18 2018-19 2019-20 2020-21 Total Yield Shoeburyness 56 7 1 1 0 65 Southchurch 6 0 0 2 0 8 Thorpe 14 0 2 3 0 19 West Shoebury 0 0 0 2 0 2 Total 76 7 3 8 0 94 Data Source: Department for Place, Southend-on-Sea Borough Council 4.3 Employment

4.3.1 How does employment impact on health? There is a well-established link between employment and health – in general, having a job is better for health than having no job. Research by the (UCL Institute of Health Equity, 2015) have cited four ways in which work can however have an adverse effect on health: through adverse physical conditions of work; adverse psychological conditions at work; poor pay or insufficient hours; and temporary work, insecurity and the risk of redundancy or job loss.

Negative health impacts from unemployment and wordlessness include:  Higher mortality rates – evidence summarised by the World Health Organisation found that, even after allowing for other factors, unemployed people and their families suffer a substantially increased risk of premature death  Increased use of medical services – including higher numbers of medical consultations, increased consumption of medication, and higher hospital admission rates  Higher rates of depression and anxiety - (Catalano, et al., 2011) found that unemployment is associated with 15-30% increase in the reported symptoms of depression and anxiety

 Increased substance use and abuse – (Catalano, et al., 2011) found that unemployment is associated with a doubling of alcohol intake  Worse general health  Increased risk of cardiovascular disease

4.3.3 Benefits claimants Data from August 2016 indicates that 2,995 adults aged between 16-64 years from the four East Wards were claiming at least one benefit. East claimants accounted for around 22.3% of all Southend-on-Sea claimants (population of East aged 16-64 is 19.2% of Southend-on- Sea population aged 16-64). Figure 13 below depicts the proportion of adults aged 16-64 years from the four wards in East who claim a benefit and the Southend-on-Sea average. None of the four wards in the East Locality have higher than average proportion who claim a benefit.

Figure 13: Proportion of working aged adults claiming a benefit in East Wards, February 2016

Data Source: NOMIS

The figure below shows the rate of Employment Support Allowance claimants per 1,000 population aged 16-64 for the East wards. The rate in one of the four wards is higher than the Southend-on-Sea average. Southchurch ward has the fifth highest rate in Southend-on Sea.

Figure 14: Rate of ESA Claimants for East Wards, February 2016

Data Source: Nomis & ONS 2013 Population Estimates (calculated by PHI) 4.4 Education and skills

4.4.1 How do education and skills impact on health? Numerous outcomes in adult life are influenced by their early years. The quality of a child’s early life experience is shaped by a number of factors, including socio-economic status, access to high quality early education and care, and the influence of ‘good parenting’ (Ofsted, 2013). Research has found that vocabulary at age 5 is the best predictor of later social mobility for children from deprived backgrounds – those who start school as confident speakers with good language skills are more likely to become successful learners and achieve in life (Washbrook & Waldfogel, 2011). Educational attainment throughout school is lower in deprived areas, and this can affect future life choices – young people with fewer qualifications are more likely not to be in education, employment or training (NEET) after leaving school and find it more difficult to secure employment as thy get older. They may also have had poor childhood health or not had the support to fully comprehend the consequences of poor lifestyle behaviour choices (such as smoking).

Having few or no qualifications can make it more difficult to move into work and increase the likelihood of obtaining a lower paid or unsecure job. This could then lead to the adverse health impacts cited in the section above on employment. Digital skills are becoming more and more important in today’s society, with many services and employment opportunities accessed online. This is also true of health services, with resources such as NHS Choices becoming more frequently used as well as social networking, learning opportunities and other forms of communication. Those who are digitally excluded could be at risk of isolation and potentially find it harder to engage in services.

4.4.2 Good level of development Pupil attainment by the age of five can be measured by the achievement of a “Good Level of Development” at the Early Years Foundation Stage. This is a key measure of early year’s development across a wide range of developmental areas. Children from poorer backgrounds are more at risk of poorer development and the evidence shows that differences by social background emerge early in life.

Rates in Southend-on-Sea have continued to increase year on year. In 2015/16 school year 71% of pupils achieved a good level of development, which is similar to the England average of 69.3% (DfE).

4.4.3 Residents with no qualifications According to the 2011 Census data residents in two of the four wards in East have a higher proportion of people with no qualifications than the Southend-on-Sea average (24.6%). Two of the wards in East have a higher proportion than the England average of 18.2%.

Figure 15: Proportion of people aged 16 years and over with no qualifications, by ward, 2011

Data Source: Census 2011

4.4.4 Digital skills Go ON Local has combined various sources research into the use and experience of digital services within all UK local authorities into a combined indicator to estimate whether an area is at risk of “digital exclusion” (Doteveryone). Whilst the below statistics are only available at a Local Authority level, it is worth considering that some of these outcomes may be worse in areas in Southend-on-Sea, given the higher proportion of residents with no qualifications and high deprivation levels.

The quintile values shown are for the UK (quintile 1 = worst 20%, quintile 5 = best 20%).

In Southend-on-Sea:  1% of households do not receive broadband speeds of at least 10MBps (National Quintile 5)  15.2% of adults have never been online (National Quintile 2)  79% of adults have all 5 Basic Digital Skills (National Quintile 5)  39% of adults have used all 5 Basic Digital Skills in the last 3 months (National Quintile 2)

The Combined Digital Indicator estimates Southend-on-Sea to be at “Low” risk of digital exclusion (National Decile 2). 4.5 Air Quality

4.5.1 How does air quality impact on health? There is substantial evidence that air pollution has adverse effects on health. Adverse health effects from short and long term exposure to air pollution range from premature deaths caused by heart and lung disease to worsening of asthmatic conditions, and can lead to reduced quality of life and increased costs of hospital admissions. Research by the World Health Organisation’s (International Agency for Research on Cancer, 2013) concluded that outdoor air pollution is carcinogenic, with the particulate matter component of air pollution most closely associated with increased cancer incidence, especially cancer of the lung. An association was observed between outdoor air pollution and increase in cancer of the urinary tract/bladder. In their briefing, (Natural England, 2012) found that green spaces provided micro climates that aid particular removal for cleaner air helping to reduce respiratory conditions.

4.5.2 Air quality in East Locality The main source of air pollution in the borough is road traffic emissions from major roads, notably the A13, A127 and A1159. Southend-on-Sea Borough Council has one Air Quality Management Area (AQMA) at the junction of the A127, Hobleythick Lane, and Rochford Road. Other pollution sources, including commercial, industrial and domestic sources, also make a contribution to background pollution concentrations.

An AQMA is declared where the national ‘air quality objective’ set by the Government is exceeded. The ‘air quality objective’ for nitrogen dioxide is an Annual mean of 40μgm-3. However, the boundary of the AQMA has been extended to include areas where the air quality is actually 36μgm-3 (lower than the national ‘air quality objective’) and where a property is only partially within that boundary, it is still included within the AQMA. Work at The Bell junction will take place in 2017/18 and it is expected that this work, along with other measures will mean that the air quality objective for the Borough is achieved before 2020 (SBC).

4.6 Crime

4.6.1 How does crime impact on health? Research by North East Public Health Observatory (Bellis, Hughes, Perkins, & Bennett, 2012) found that the following consequences of crime on health:  Physical injury – potentially leading to disabilities or disfigurement, or in the case of sexual assault, pregnancy or disease  Relationship difficulties – reduced trust, intimacy and increased isolation  Self-harm and suicide – particularly stemming from youth violence and bullying  Post-traumatic stress/anxiety or aggression  Disruption to eating or sleeping patterns  Increase in alcohol or drug misuse as a form of self-medication or coping mechanism  Reduction or physical exercise in parks and public places – leading to a higher level of inactivity amongst the population and an increase in the associated long-term conditions

Indirect links with health were also found, with crime potentially impacting on educational or professional attainment and victims of violence potentially needing to leave their homes.

There is also a large economic cost associated with the effects of crime on health. Bellis et al (2012) indicated that violence is estimated to cost the NHS of £2.9 billion every year, with the total cost to society being estimated at £29.9 billion each year.

4.6.2 Crime in East Locality The Southend-on-Sea Community Safety Partnership (CSP) commissioned a Strategic Intelligence Assessment in order to identify the key threats and opportunities concerning the safety of Southend-on-Sea residents. One of those priorities included problem solving in high crime locations, by adopting a multi-agency approach to address the shared issues in high crime areas.

An example of this piece of work is Operation Stonegate conducted in the Milton Ward. The Southend-on-Sea CSP hosted several community days in the area. These community days are designed to encourage partner agencies (including health) to be visible in the area, engage with residents and discuss access to different types of service provisions.

Since the engagement within the area, a reduction of incidents has been recorded and surveys have been undertaken to gain an in-depth insight to the demographics, understand the challenges and to highlight any gaps in service provision.

Figure 16: Rate of crime per 1,000 population, by Ward, Southend-on Sea, April 2015 - March 2016

Data Source: Community Safety Team, Southend-on-Sea Borough Council

Figure 16 shows that the rate of crime in the four wards of the East Locality are lower than the Southend-on-Sea rate. 4.7 Access to Transport

4.7.1 How does accessing services impact on health? Being able to access services means people are more likely to be feeling better connected within their community and improve choice and therefore encourage them to feel more empowered. Conversely, those who have reduced access to services have a reduced choice which could result in poor quality of care because they have no other option. This could have a number of longer term impacts to both physical and mental health – that feeling of being “trapped” can have a negative impact on mental health and wellbeing, and also potentially lead to a greater risk of isolation if there are limited opportunities to interact with others.

4.7.2 Accessibility in East Locality Access to a car or van is a measure of accessibility to services. It can be seen from Figure 17 below that when compared to other parts of Southend-on-Sea, the wards within the East Locality have a lower proportion of people with no access to a car or van. Thorpe ward having nearly half the proportion of residents (15.7%) without access to transport compared to Southend-on-Sea (27.3%).

Figure 17: Proportion of households with no access to a car or van, by ward, 2011

Data Source: 2011 Census 4.8 Summary of needs: Wider Determinants of Health; How can the new East Primary Care Centre help? The information above indicates that East patients are already at risk of receiving poorer quality care that is unlikely to meet their needs. The personnel employed in the new health facility will have a key role in both treating current needs, but in anticipating future needs to avoid costly service use at a later date

Employment of a multi-skilled workforce in the health facility will enable patient needs to be assessed holistically, look to reduce stress/workload of GPs by filtering out inappropriate consultations (e.g. those that could be met by a pharmacist), and should aid the addressing of some of the poorer outcomes experienced by patients in deprived areas – e.g. public health preventative services should support people to maintain healthy lifestyle behaviours, a targeted sexual health service should help reduce potential numbers of unplanned pregnancy and teenage parents, co-location of IAPT mental health services could support children who might be at risk of emotional/behavioural problems etc.

There is also a possible role for the Primary Care Centre to host some of the wider community services that can support the place-based outcomes e.g. inclusion of an area to enable further education and learning opportunities would support people to improve their skills and lead to a greater likelihood of employment, thereby reducing the likelihood of health problems associated with unemployment (see later section on Employment for further detail) the multi-faceted approach of this facility will also improve inter-agency working relationships and ensure each professional is in a position to be able to advise/guide the person to the best avenue to meet their needs.

East has a slightly lower number of people per household (2.30), and a lower proportion of overcrowded households (6.2) than the Southend-on-Sea and national averages. Services could be designed to support those in overcrowded households, providing targeted advice and assistance to potentially help overcrowded families in social rented housing access relevant small capital grants to improve their homes. Part of the health centre could also provide a base to share information through training and briefing to other front line services. Advice should be available to residents regarding their needs and options for housing adaptations, potentially reducing falls and resulting in savings to the future healthcare bill.

Over a fifth of East households do not have access to a car or van means that there is likely to be a heavy reliance on public transport to access locations further afield and high use of local facilities. That danger is that if the current facilities/services are not meeting the needs of the populations and they are less able to access services elsewhere, there is a risk that residents may become more isolated, or access inadequate provision and therefore potentially compound issues in the future. This presents a strong case for providing a wide range of different health and other community services from the new Health facility, as residents can plan their journeys to one destination and have many of their needs met there, rather than having to make several different journeys. It can also encourage social inclusions, which may be particularly important for certain community groups.

As East residents currently have a range of poor public health outcomes and high usage of health services as a whole, consideration should be given as to how these can be collated. The new health facility would have numerous benefits to health: it would improve inter- agency working and knowledge of available services/resources to communicate to residents, it would raise the profile of isolation as a health issue by locating a service designed to reduce this alongside health services, and would assist in the identification of people who would benefit from the support.

5 HEALTH LIFESTYLE BEHAVIOUR 5.1 Breastfeeding

5.1.1 How does breastfeeding impact on health? There has been significant reliable evidence produced over recent years to show that breastfeeding is a major contributor to public health. Breast milk is the best form of nutrition for infants and exclusive breastfeeding is recommended for the first six months (26 weeks) of an infant’s life; additionally there is evidence that the longer the duration of breastfeeding, the greater the health benefits in later life.

According to a review undertaken by the World Health Organisation in 2007, the available evidence suggests that breastfeeding has long-term benefits such as lower blood pressure and lower total cholesterol for breastfed subjects, as well as reduced prevalence of overweight/obesity and type 2 diabetes. And better success in intelligence tests. Another review looked at evidence for health outcomes for breastfeeding mothers, and found lactation to be associated with reduced risk for type 2 diabetes, breast and ovarian cancer. Early cessation of breastfeeding or not breastfeeding was associated with an increased risk of maternal postpartum depression.

5.1.2 Breastfeeding prevalence The percentage of infants being breastfed at 6-8 weeks in Southend-on-Sea during 2015/16 ranges from 39.3% to 48.3% (Table 3 below). The target set for babies that are totally or partially breastfed in Southend-on-Sea is 40%. This target has been exceeded every month in 2015/16 with the exception of August 2015.

Table 3: Breastfeeding prevalence at 6-8 weeks, NHS Southend CCG, 2015-16 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 47.80% 44.10% 44.20% 48.10% 44.70% 39.30% 43.70% 42.90% 48.30% 44.80% 40.90% 42.90% Data Source: SEPT 5.2 Smoking

5.2.1 Smoking Prevalence Smoking prevalence can be ascertained by estimates based on survey data, or by recording of smoking status from GP registers. Figure 18 shows the estimated smoking population of all wards in Southend-on-Sea. This data is based on synthetic estimates of smoking prevalence which take into account the socioeconomic makeup of each ward and distribute local authority smoking populations accordingly.

When compared to other areas in Southend-on-Sea, Thorpe ward has the lowest estimated prevalence of smoking (17.9%) with Southchurch having the second lowest rate (19.2%) whilst remaining below the Southend-on-Sea average of 20.1%.

Figure 18: Estimated smoking prevalence of smoking in adults aged 18+

Data Source: ASH Ready Reckoner

Figure 19 shows the smoking prevalence recorded at GP practice population level for those aged 15 years and over for NHS Southend CCG with the East Locality GP practices highlights in Orange.

Figure 19: QOF recorded smoking prevalence, patients aged 15+, 2015/16

Data Source: Quality Outcomes Framework 2015/16

In total there were 6,551 smokers aged 15+ recorded in the four East locality practices which gives and overall 15+ prevalence for East of 17.0%. This is lower than the overall prevalence of NHS Southend CCG of 20.2%. However these figures are likely to be an underestimate of the true prevalence of smoking in Southend-on-Sea, partly because the smoking status of patients is generally not recorded for all patient records at GPO practice level, and secondly because some smokers may be reluctant to admit that they smoke to NHS Health professionals.

5.2.2 How does smoking impact on health? Adults There is a large body of evidence to demonstrate the causal links between smoking and a number of diseases, including cancers, circulatory and respiratory conditions, diabetes and rheumatoid arthritis. About 70% of lung cancer burden can be attributed to smoking alone. Second-hand smoke has been proven to cause lung cancer in non-smoking adults. Smokeless tobacco (also called oral tobacco, chewing tobacco or snuff) causes oral, oesophageal and pancreatic cancer. Smoking has also been shown to diminish general health status and have other adverse effects on the body, such as causing inflammation and impairing immune function. It is ultimately responsible for a large number of premature deaths every year.

Children Child and adolescent smoking causes serious risks to respiratory health in the short and long term. Children who smoke are two to six times more susceptible to coughs and increased phlegm, wheeziness and shortness of breath than those who do not smoke. They are also more likely to continue smoking during their adult lives and have a lower chance of quitting. Smokers who start smoking at an early age have a higher risk of developing lung cancer or heart disease. In addition, there are enormous economic costs to society associated with smoking. Research by Action on Smoking and health (ASH) estimated that smoking costs the UK economy £13.9 billion per year, including £2 billion in direct treatment costs to the NHS (ASH, 2015). Children and young people are more susceptible to the effects of passive smoking, particularly if there is a parent who smokes. They are at higher risk of respiratory infections, asthma, bacterial meningitis and cot death.

Smoking in Pregnancy Smoking during pregnancy can cause serious pregnancy-related health problems, complications during labour and an increased risk of miscarriage, premature birth, still birth, low birth-weight and sudden unexpected death in infancy. It has been found to increase the risk of infant mortality by 40% (NICE, 2010). Evidence has shown that smoking prevalence during pregnancy is much higher among lower socioeconomic groups (Gray, Headley, Oakley, Kurinczuk, Brocklehurst, & Hollowell, 2009) and teenage mothers.

5.2.3 The financial impact of smoking According to the ASH Ready Reckoner (ASH) 2016, the cost to the NHS of current and ex- smokers who require care as a result of smoking-related illnesses is £1.84m per year in East Locality. The annual cost to Adult Social Care is a further £566.2k per annum.

5.2.4 Use of current commissioned stop smoking services The Southend-on-Sea Stop Smoking Service is located with the Public Health Team of Southend-on-Sea Borough Council. It is an in-house service which provides a public telephone consultation service and manages the pharmacies and GP Practices within the brought for quality and performance and also provides these with clinical support.

Figure 20 shows the percentage of smokers setting a quit date in 2015/16 through an NHS Stop Smoking Service, by practice. Less than half of the GP practices in the East Locality have a higher proportion of their patients than the NHS Southend CCG average.

Figure 20: Percentage of patients aged 15+ recorded as setting quit date, NHS Southend CCG, 2015/16% setting quit date

Data Source: Quit Manage & Open Exeter

Out of 6,551 smokers in East Locality, only 293 set a quit date in 2015/16 (4.5%).

Figure 21 shows the percentage of smokers setting a quit date who successfully quit smoking at four week using an NHS Smoking Service in 2015/16.

Figure 21: Percentage of smokers successfully quitting at four weeks through an NHS Stop Smoking Service, NHS Southend CCG, 2015/16

Data Source: Quit Manager

Out of 6,551 smokers in East Locality, only 157 successfully quit smoking in 2015/16 (2.4%). Although this seems a relatively small number, this is 54% of those who set a quit date in the same period. 5.3 Obesity

5.3.1 How does obesity impact on health? The increasing prevalence of obesity amongst adults and children is a major public health challenge both nationally and internationally. There is a large body of evidence to indicate that being overweight or obese can increase the risk of developing a range of other health problems such as coronary heart disease (CHD), type 2 diabetes, some cancers and reduce life expectancy.

The consequences of obesity are not limited to the direct impact on health. Overweight and obesity also have adverse social consequences through discrimination, social exclusion and loos of or lower earnings, and adverse consequences on the wider economy.

There are numerous factors for obesity, as it is a very complex condition. Some of the known inequalities in obesity prevalence include:  Age – prevalence of overweight and obesity generally increase with age, although there is a decline in prevalence among those aged 75 years and over  Income – those living in low income households have the highest prevalence of obesity and those living in high income households have the lowest. These differences are particularly marked among women: women living in the lowest

income households have double the prevalence of obesity (31%) compared to those living in the highest income households (15%)  Ethnicity – there is some ethnic variation: women from Black African groups appear to have the highest prevalence of obesity and men from Chinese and Bangladeshi groups have the lowest  Poor diet – those who are malnourished in early years have a higher risk of obesity in later life  Household – having family members who are obese or overweight can increase the risk of obesity or overweight  Mental health issues – having a mental health condition can lead to different behaviour choices that can lead to overweight or obesity.

There are also environmental influences that can impact on behavioural choices (such as amount of physical activity undertaken or diet) which can lead to overweight or obesity.

5.3.2 Child obesity Prevalence In order to provide a robust an indicator as possible at small area level Public Health England aggregate three years of data from the National Child Measurement Programme and produce estimates of obesity and excess weight prevalence in Reception and Year 6-aged children. Figure 22and Figure 23 below show data for each ward in Southend-on-Sea for reception and year 6 respectively.

Thorpe ward has one of the lowest proportion of children classed as overweight or obese in reception class in the Southend-on-Sea area, with both Shoeburyness and Southchurch wards having a higher proportion than the Southend-on-Sea average.

The wards in the East Locality are in the lower proportion of children classed as overweight or obese in Year 6 in the Southend-on-Sea area.

All children measured in the National Childhood Measurement Programme whose results are on or above the 91st centile are analysed. For all those who are assessed as appropriate are referred to the MoreLife programme which has been successfully supporting young people who struggle to maintain a healthy weight and their families for many years.

The MoreLife team delivers gimmick-free programmes that help clients to make the changes so they can look and feel much healthier by making little steps that make big changes.

Figure 22: Proportion of children classed as overweight or obese in reception class, by ward, 2012/13-2014/15

Data Source: Local Health

Figure 23: Proportion of children classed as overweight or obese in Year 6, by ward, 2012/13- 2014/15

Data Source: Local Health

5.3.3Adult Obesity Prevalence Adult obesity levels in Southend-on-Sea can be estimated using survey data. Ward-level adult obesity prevalence estimated for those aged 16 year and over estimates that three East Locality wards have prevalence higher than the Southend-on-Sea average of 24.8% (Figure 24). The Southend-on-Sea average is slightly higher than England; 24.1%.

Figure 24: Percentage of population aged 16+ with a BMI of 30+, modelled estimate, By Ward, 2006-08

Data Source: Public Health England

5.3.4 Use of current services The Public Health team in Southend-on-Sea Borough Council commissions tier 2 Weight Management service. This is a 12 week programme, utilising three different providers/programmes that are available where individuals are supported by the Lifestyle Service to choose the programme that best suits their needs. All three programmes follow NICE guidelines for T2 weight management programmes and are multicomponent programmes including physical activity and diet support as well as behaviour change techniques and tools.

In 2016-17 there were 85 referrals to the weight management service from patients registered with East Locality GPs. When looking at the referrals against the number of people recorded on the QoF Obesity registers (Figure 25) the referral rate varies between practises. North Shoebury Surgery (F81684) has the highest rate of referrals from their list of obese patients (5.52 per 1,000) whilst Shaftesbury Avenue Practice (F81209) and The Thorpe Bay Surgery (F81121) have the lowest rates (1.03 and 1.49 per 1,000 respectively). When compared to the NHS Southend CCG average (1.7 per 1,000) only two of the East Locality GP practices have lower referral rates.

Figure 25: Referrals to Weight Management Service 2016/17

Data Source: SBC Public Health Team & NHS Quality Outcomes Framework

Active Southend offers the residents of Southend-on-Sea access to a range of physical activity opportunities including Walking Football, Diving Classes, Rounders and Cycling. It provides sport and fitness opportunities for adults who want to keep fit, meet new people and try something new. The activities are delivered at community venues across Southend- on-Sea. (Active Southend)

NHS Southend CCG Patients are also referred to a 12 week gym-based programme. This is available to patients with a Long Term Condition including, but no limited to diabetes, mild- moderate anxiety and depression, respiratory conditions and musculoskeletal conditions. This exercise referral programme is designed so that patients referred by a health professional can engage in physical activity which can help improve quality of life.

In 2016/17 336 NHS Southend CCG patients were referred through the exercise referral pathway with 206 (61%) being referred by their GP. There were 114 patients from East Practices referred in 2016/17 of which 75% of referrals were completed by the patients GP. 5.4 Substance Misuse Modelled estimates of the population aged 16 years and over who binge drink estimate that 17.7% of residents in East are binge drinkers. This is similar to the Southend-on-Sea average of 19.0%. Figure 26 shows the estimates by ward where it can be seen that there are other parts of Southend-on-Sea which have similar estimates.

Figure 26: Modelled estimates of binge drinking, by ward, 2006-08

Data Source: Local Health

There is national data available (PHE, 2015) shows that high deprivation is correlated with both alcohol related mortality and alcohol specific hospital admissions. As some of Southend-on-Sea’s LSOAs have high levels of deprivation, it is likely that East has higher rates of alcohol-related mortality and hospital admissions compared to other parts of the borough.

5.4.1 Current service Southend Drug and Alcohol Commissioning Team (DACT), on behalf of Southend-on-Sea Borough Council, currently contract with CGL (Change, Grow, Live) to deliver the Southend Treatment And Recovery Service (STARS) which provides specialist substance misuse for adults over the age of 18. STARS is located in the town centre so that it is accessible to all localities. Specialist substance misuse treatment for young people up to the age of 21 is currently delivered by Southend Borough-on-Sea Council through the Young People’s Drug and Alcohol Team (YPDAT). Although also located in the town centre, much of YPDAT’s work is conducted in schools and community venues across the Borough.

Southend DACT contract with 25 pharmacies across the Borough to deliver supervised consumption of opiate substitute medication for those STARS clients who require it, of which four are located in East. Southend DACT also contract with seven pharmacies to provide needle and syringe exchange programmes (none in East).

5.4.2 How does substance misuse impact on health? Substance misuse has a number of adverse effects on health: cardiovascular disease, mental health problems, liver disease and lung damage can all be caused or impacted on by an individual’s use of drugs. In particular, the prevalence of co-existing mental health and substance use problems (termed ‘dual diagnosis’) may affect between 30 and 70% of those

38 presenting to health and social acre settings. Not only does substance misuse cause physical and mental ill health, it can also cause homelessness, poverty and crime. They are associated with other social and physical problems that influence misuse, such as unemployment, low self-esteem, perceived failure, relationship problems and psychological problems.

Children and Young People The risk to children of substance misuse can come from their own use of drugs/alcohol, or parental use within the family home. The risk-harm profile identifies 10 key items to gauge the vulnerability of young people entering specialist substance misuse services – they are more likely to be NNET, have contracted an STI, have a child, be in contact with the youth justice system, be receiving benefits by the time they are 18, and half as likely to be in full- time employment. The vulnerabilities are:  Opiate and/or crack user  Alcohol users  Using 2 or more substances  Began using main problem substance under 15  No fixed abode / unsettled housing  Not in education, employment or training  Involved in self-harm  Involved in offending pregnant and/or parent  Looked after child

Children of parental users can be at risk in terms of:  Access to drugs or drugs paraphernalia within the home, e.g. tablets, needles etc.  Violence in the home  Exposure to a number of strangers within the home  Neglect of their own needs, potentially resulting in poorer health and educational attainment and poor mental health

Unborn Children Substance use during pregnancy may result in premature birth, low birth weight and potential chemical dependence of the child when s/he is born such as Foetal Alcohol; Spectrum Disorder. 5.5 Sexual Health Nationally there has been a 5% increase in the total number of new cases of STIs diagnosed nationally. In England, the most commonly diagnosed STIs were chlamydia, genital warts, genital herpes and gonorrhoea. The diagnoses for Southend-on-Sea followed a similar pattern to that nationally.

5.5.1 Sexual Health in East locality Due to small numbers involved, it is not possible to show how many new sexually transmitted infections (STIs) occur in East Locality compared to other parts of Southend-on- Sea.

5.5.2 Teenage Pregnancy Data on the rates of under 18 conceptions is released at ward level for aggregated 3 year periods. The latest data is for 2012-14. It can be seen from Figure 27 below that Shoeburyness and Thorpe wards have low teenage conception rates in Southend-on-Sea. Southchurch ward is higher than the Southend-on-Sea average.

Figure 27: Teenage Conception Rate, per 1,000, by ward, 2012/14

Data Source: ONS

Southend-on-Sea as a whole has a rate of under 18 conceptions that is significantly higher than England. The under 18s birth rate in Southend-on-Sea of 10.9 per 1,000 is significantly worse than England (6.3 per 1,000).

5.5.3 Current Services In Southend-on-Sea there are FREE to access, friendly, and confidential sexual health services available to anyone that wants to use them. This includes contraception and testing for sexually transmitted infections and HIV at specialist sexual health services as well as services provided at GP surgeries and community pharmacists.

The SHORE (Sexual Health, Outreach, Reproduction (and) Education) Integrated Sexual Health Service is delivered by Essex Partnership University NHS Foundation Trust (EPUT), Southend University Hospital NHS Foundation Trust and BROOK Young People’s Sexual Health Charity. SHORE provides the following services:  Testing and treatment for Sexually Transmitted Infections  HIV testing (with same day testing, Monday to Wednesday, at Southend Hospital)  All contraceptive methods including barrier protection  Emergency contraception

 Pregnancy testing  Quick check sexually transmitted infection screening (Testing for Chlamydia, Gonorrhoea, Syphilis and HIV)  Screening for Hepatitis A,B & C  Advice, support and reassurance on a range of contraceptive and sexual health matters

RU Clear is Southend-on-Sea’s Chlamydia Screening Programme for young people under 25. Chlamydia is the most common sexually transmitted infection and in most cases it has no obvious external symptoms. If left undetected or untreated in can cause serious complications in later life. RU Clear offers a free, simple and painless chlamydia test.

The Contraception Advisor website provides an onsite website tool to support people to find their best option for contraception. The website can help make the contraception choice easier, providing detailed tailored suggestions about the most appropriate form of contraception methods.

Primary Care A number of General Practice and Community Pharmacists in Southend-on-Sea provide some sexual health services, these include:  •Chlamydia testing for under 25s  •Chlamydia treatment  •Contraception advice on all methods  •Emergency contraception

HIV Home-Sampling Screening: People over the age of 16, if they are concerned about HIV, may be eligible to receive a free HIV home-sampling kit straight to their door. The test is small, discreet and easy to do.

5.5.4 How does poor sexual health further impact on health? Relationships and sexual practices can be influences by a number of factors including:  Social norms  Peer pressure  Religious beliefs  Culture  Confidence and self-esteem  Substance misuse  Coercion and abuse

Unsafe sex impacts on health services and the wider community in a number of ways. Untreated STIs can facilitate HIV transmission and increase susceptibility to HIV. Late diagnosis of STIs and HIV also make them more costly to treat, with gonorrhoea becoming particularly difficult as it can quickly develop resistance to antibiotics. Unintended pregnancies can also lead to abortions, which can in turn have detrimental effects both in terms of mental health and future fertility, potentially resulting in more costly interventions for future planned pregnancies. There are also impacts to health in dealing with the

41 consequences of rape or sexual assault, which can be substantial and have a long lasting duration.

5.5.5How does teenage pregnancy impact on health? Unwanted teenage pregnancy is a major underlying driver of health inequalities. Teenage mothers are at greater risk of experiencing a range of poor outcomes, which include:  Being less likely to finish their education, and more likely to bring up their child alone and in poverty  Experiencing an infant mortality rate that is 60% higher than for babies to older mothers  Experiencing a rate of post-natal depression that is three times that experienced by older mothers and a higher risk of poor mental health for three years after birth

Children of teenage mothers are generally at increased risk of poverty, low educational attainment, poor housing and poor health, and have lower rates of economic activity in adult life. Sons of teenage mothers are more likely to be imprisoned when compared to their peers born to older mothers.

A number of risk factors have been identified to be associated with teenage pregnancy:  Living in a deprived area  Limited knowledge regarding contraception and sexual health advice  Family structure – children living in care or those from lone parent backgrounds may be more likely to become teenage parents. Additionally, those whose mothers were teenage parents are also more likely to become teenage parents.  Educational attainment – on average, deprived wards with poor levels of educational attainment have under-18 conception rates twice as high as similarly deprived wards with better levels of educational attainment (Department for Education & Skills, 2006)  Disengagement from school – the Department for Education and Skills found that among the most deprived 20% of local authorities, areas with higher rates of absenteeism have higher under-18 conception rates  Participation in early and risky behaviours – including early onset of sexual activity and substance misuse  Mental health problems – particularly self-esteem and confidence levels, which can impact on their choices  Some ethnic groups are more likely to experience teenage pregnancy than others – however it is unclear whether this is an independent factor

Children of teenage parents are much more likely to become teenage parents themselves, meaning that if not addressed; teenage pregnancy perpetuates health inequality between generations. 5.6 Summary of needs: Health Lifestyle Behaviour; How can the new East Primary Care Centre help? Data indicates that the prevalence for breastfeeding for Southend-on-Sea generally exceeds the set target of 40%.There are currently a range of services being offered in Southend-on-

Sea, including breast feeding support at Southend-on-Sea children’s centres and some business are supportive of breastfeeding mothers, although this can be improved and encouraged to increase across the town. The new Primary Care Centre could provide support to breastfeeding mothers by providing private quiet areas if required and by hosting breastfeeding support groups. Targeted activities to improve breastfeeding support and awareness of the benefits of breastfeeding amongst demographics where take up is traditionally low (e.g. low income mothers) should also be implemented. An increased uptake of breastfeeding could have benefits to the future prevalence of long term conditions including post-partum depression, resulting in reduced demand on health services.

All GP practices in NHS Southend CCG are trained and contracted to deliver smoking cessation treatments. 31 out of 40 pharmacies, with one of the exceptions located in the East Locality, are trained and contracted to provide smoking cessation advice and treatments. From the data in Figure 20 the percentage of current smokers who set at quit date is relatively low. This could be due to smoking cessation not receiving the priority that clinical need suggests it should.

The information in this section shows that East Locality has a varied prevalence of adult obesity and a relatively low usage of commissioned weight management services. The new Primary Care Centre may have a role in hosting and coordinating these services, and providing accurate advice regarding healthy choices (particularly targeted towards low income families to help them to live well) and the adverse consequences of overweight and obesity in both children and adults. There is also the need for the promotion of NHS Health Checks and breastfeeding in early detection of associated diseases and prevention of compounding factors. The Facility can also look towards addressing some of the determinants of obesity, including hosting IAPT services and working closely with them to address underlying mental health issues associated with eating or physical activity behaviours. All health professionals should be MECC trained to enable them to identify and support individuals at risk of becoming overweight or obese.

In Southend-on-Sea there are already free to access, friendly, and confidential sexual health services available to anyone that wants to use them. The new Primary Care Centre could enhance the current service by increasing access and uptake to long acting reversible contraception. In addition to the suite of questions asked around health lifestyle behaviours at a new patient registration (e.g. smoking status, weight management), sexual health intervention could be added, offering screening for STIs and contraceptive advice.

6. EPIDEMIOLOGY – The Current Disease Burden Experienced by People in East Locality 6.1 Self-reported health The 2011 Census asked people to report their own perceived views on their health and wellbeing. In 2011 7.65% of the residents in East locality wards felt that their day to day activities were limited “a lot”, which is lower than the Southend-on-Sea average of 8.8% and lower than the England average of 8.3%.

Figure 28: Proportion of persons whose day-to-day activities are limited "a lot", East Locality wards, 2011

Data Source: Census 2011

Residents are also asked about their health in the GP patient survey. In the 2015 release it can be seen that there is a wide variation at practice level for those who consider themselves as having a long standing health condition. However it should be noted that due to the relatively low sample size, the confidence intervals are fairly wide. Dr Dhillon’s Surgery (F81688) has the lowest proportion of those with longstanding health conditions (50.6%) whilst North Shoebury Surgery (F81684) has the highest proportion (59.5%). This can be seen below benchmarked against the NHS Southend CCG and England average.

Figure 29: Proportion of survey respondents who had a long-standing health condition, East practices, July 2016

Data Source: GP Patient Survey, July 2016 6.2 Life expectancy Life expectancy is a measure indicating the number of years that a person can expect to live.

Nationally, life expectancy has been improving year on year over the past decade. However, the health of the most disadvantaged has not improved as quickly as that of the better off and, in some cases the gap in life expectancy between these groups has widened. The life expectancy average for Southend-on-Sea in both males (79.1) and females (82.6) is similar to the England averages (males 79.1, females 83.0)

6.2.1 Males Data for 2009-13 shows that the life expectancy for males in all wards in the East locality (80.3) is higher than Southend-on-Sea (79.2) and England (79.1).

Figure 30: Life expectancy in Southend-on-Sea for males, by ward, 2009-13

Data Source: ONS

6.2.2 Females Data for 2009-13 shows that the life expectancy for females in all four wards in the East locality (84.6) is higher than Southend-on-Sea (82.6) and England (83.0).

Figure 31: Life expectancy in Southend-on-Sea for females, by ward, 2009-13

Data Source: ONS

6.2.3 Premature mortality The standardised mortality ratio (SMR) is a way of comparing death rates between populations and England (controlling for differences in age structure between different populations). The SMR for England is set at 100. An SMR above 100 indicates a mortality rate that is greater than England’s. Premature mortality rates in Southend-on-Sea are just above the England value for under 65’s (101.7) and under 75’s (100.1)

Three of the four wards in the East locality are lower than the Southend-on-Sea and England values, for both the under-65 and under-75 premature mortality.

Figure 32: Premature Mortality in East Wards (Under 65 and 75 Years) 2010-14

Data Source: Local Health (ONS)

PART 2: WHAT DO WE CURRENTLY HAVE AND HOW DO WE USE IT?

7. PRIMARY CARE 7.1 General Practice East Locality currently has eight GP practices:  Irlam A C & Partner – code F81086  The Thorpe Bay Surgery – code F81121  Shaftesbury Avenue Practice – code F81209  Dr Kumar's Surgery – code F81613  Dr Marasco Surgery – code F81622  Dr Mario & Partners Surgery – code F81649  North Shoebury Surgery – code F81684  Dr Dhillon's Surgery – code F81688

The map below shows the locations of these practices.

Figure 33: Map of GP Practices in East Locality MAP Data Source:

Table 4 shows further information on the eight GP practices within East Locality

Table 4: Information in the eight GP practices in East Locality Practice Net Internal opening Name/address Type Ownership details code Area M2 hours Dr Irlam & Partners, 27 Southchurch Blvd, Southend on Sea on Sea, F81086 GP practice 172.20 (NIA) Privately owned by GP 52.5 Essex, SS2 4UB

F81121 Dr Agha, 99 Tyrone Road, Thorpe Bay, Essex, GP practice 240 (NIA) Privately owned by GP 40

Dr Siddique, The Shaftesbury Avenue Surgery, 119 Shaftesbury F81209 GP practice 120 (NIA) Privately owned by GP 51.5 Avenue, Southend on Sea, Essex, SS1 3AN Dr Kumar, Shoebury Health Centre, Campfield Road, Shoebury, Part of NHSPS Building F81613 GP practice 264.38 (NIA) 56.5 Essex SS3 9BX (Shoebury Health Centre)

F81622 Dr Khan & Dr Marasco 101 West Road, Shoebury, Essex, SS3 9DT GP practice 110 (NIA) Privately owned by GP 53.75

F81622 1 Watkins Way, Shoeburyness, Essex SS3 9NX (Branch of Dr Khan) GP practice 58 (NIA) Privately owned by GP 18

Dr Schembri, Health Centre, Campfield Road, Shoeburyness, Essex Part of NHSPS Building F81649 GP practice 131.85 (NIA) 52.5 SS3 9BX (Shoebury Health Centre) Dr Moss, North Shoebury Surgery, Frobisher Way, Shoebury, Essex F81684 GP practice 246 (NIA) Privately owned by GP 47 SS3 8UT

F81688 Dr Dhillon, 129 Eagle Way, Shoeburyness, Essex, SS3 9YA GP practice 133 (NIA) Privately owned by GP 36.5

Data Source: NHS Southend CCG & NHS Choices

7.1.1 General Practice Workforce Figure 34 below shows each GP practice list size per Full Time Equivalent (FTE) GP in NHS Southend CCG with the East Locality GP practices highlights in orange compared to the CCG Average and England.

The average number of patients cared for by an FTE GP in England is 1,640. The mean for NHS Southend CCG is higher at 1,809 with the East mean being higher than NHS Southend CCG and England, at 1,926. The Thorpe Bay Surgery (F81121), North Shoebury Surgery (F81684) and Dr Marasco Surgery (F81622) have three of the highest values in the East locality of 3,931, 2,978 and 2,855 respectively.

Figure 34: Number of Patients per FTE GP in NHS Southend CCG 2015/16

Data Source: NHS Digital

Figure 35 below shows the association between GP Practice population deprivation and the number of patients per FTE GP in NHS Southend CCG. As the R2 score is 0.0015 (i.e. close to zero) there is no statistical correlation between the two. However when looking at the association between the GP Practice population deprivation and the number of patients per FTE GP in the practices in East (highlighted as  in Figure 35) the R2 scores is 0.5155 which is not high enough to demonstrate a strong correlation (see Figure 109).

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Figure 35: Association between deprivation and number of patients per FTE GP

Data Source: ONS & NHS Digital

7.1.2 Practice Nurses GP Practice nurses are a key part of the GP practice clinical workforce and deliver a number of essential clinical interventions to patients including well-being programmes such as smoking cessation, cervical screening, immunisations and long term condition management such as diabetes clinics or management of patients with high blood pressure.

The recommended ratio of patients to FTE practice nurse in England is a maximum of 4000:1 although the England average ratio is actually smaller than this at 3729:1

Figure 36: Ratio of patients to FTE Practice Nurses, East Practices 2015/16

Figure 36 shows the ratio of patients to FTE practice nurses in the East Locality practices compared to NHS Southend CCG and England mean ratios. Two practices (Dr Marasco Surgery and Dr Dhillon’s Surgery) are recorded as having no Practice Nurses in 2015/16.

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Figure 36: Ratio of patients to FTE Practice Nurses, East Practices 2015/16

Data Source: NHS Digital

The Family Healthcare Practice is significantly higher than the England recommended ratio of 4000:1. This is due to the recorded FTE PN is 0.19 for the registered population of 1,833. In total; five of the eight practices have a ratio higher than the England average. This could be constraining practices to offer good quality care to patients.

In 2015/16 East had a total of 6.91 FTE Practice Nurses. In order to increase capacity to the England mean, East would need 13.5 FTE Practice Nurses; nearly a 50% increase on current numbers.

Two of the East Locality GP practices (F81622 – Dr Marasco Surgery and F81688 – Dr Dhillon’s Surgery) have no data reported for the period. 7.2 Long Term Conditions Management Clinics Table 5 shows additional clinical services provided from within each of the eight GP surgeries in East Locality.

This demonstrates a wide variation in provision of clinical services between different practices within East. It is particularly concerning that flu vaccination, cervical screening health checks and maintenance of long term conditions are not uniformly provided to all patients locally from within each surgery given the needs previously identified.

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Table 5: Additional services provided with General Practice F81209: F81649: F81684: F81086: F81121: F81613: F81622: F81688: Shaftesbury Dr Mario & North Clinic/Health Service Irlam A C & The Thorpe Dr Kumar's Dr Marasco Dr Dhillon's Avenue Partners Shoebury Partner Bay Surgery Surgery Surgery Surgery Practice Surgery Surgery

24-hr BP Monitoring

Ante-natal & Post-natal Care

Asthma

Cervical Smear

Child Health & Development

Child Immunisations

COPD Clinic with Spirometry

Diabetes

Dressings

ECG

Flu & Pneumococcal Vaccinations

HRT

Learning Disability Health Check

Long-Acting Reversible Contraception (LARC - eg IUD or implant) Minor surgery (e.g. removal of moles and skin lesions) - provided in-house - Minor Surgery

NHS Health Check

Obesity management clinic

Pre-conceptual Advice & Family Planning

Primary care counselling service

Smoking cessation clinic

Travel health with yellow fever

Online Facilities:

Online appointment booking

Order or view repeat prescriptions online is available

Online access to view your record is available Data Source: NHS Choices

7.3 Pharmacies The four wards of East Locality contain nine pharmacies. When compared to Southend-on- Sea as a whole, one of the wards has a high density of pharmacies compared to their population size than Southend-on-Sea. Thorpe has 32.7 per 100,000 population. Conversely, West Shoebury has less than half of the Southend-on-Sea value of 22.9 per 100,000 population, with a value of 9.7.

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Figure 37: Pharmacies per 100,000 population in Southend-on-Sea, By Ward 2014

Data Source: ONS & Southend-on-Sea PNA 2014

Pharmacies in East Locality provide a range of services to patients, including:  Diabetes screening  Respiratory and Lung Check service  Minor Ailments  Substance misuse  Needle Exchange  Medicines Use Reviews  Waste Management  Weight Management  Social Prescribing  Incontinence products  Travel Vaccinations  NHS Health Checks They also have the potential to provide services such as Well Man clinics, New Medicines Service and Seasonal Immunisation where commissioned.

7.4 Dentists

7.4.1 Current Dental Provision There are 21 dentists in Southend-on-Sea, five of these are located within East:  Smiles on Broadway Dental Practice (Thorpe);  Thorpe Bay Dental Practice (Thorpe);  Advanced Dental Aesthetics (West Shoebury);  Cambridge Dental Practice (West Shoebury); and

- 54 -

 Ms J Haftbaradaran Mohammadi (West Shoebury).

7.4.2 Use of Current Provision Data from PHE East of England indicates that 73 different children aged 5 years from East wards attended a dentist between April 2014 and March 2015. This is 15% of all 5 year old in this locality and 22% of all attendances in Southend-on-Sea.

Figure 38: 5 year olds visiting a dentist, rate per 1,000, by ward, 2014-15

Data Source: ONS 2014 Mid-Year Population Estimate & PHE East of England

Figure 38 shows that three of the four wards in East have a lower rate than the Southend- on-Sea average of children aged 5 years attending a dentist. Only Shoeburyness is higher. However when looking at the average number of decayed, missing and filled teeth per child who visited a dentist (Figure 39) the children in Southchurch have a much lower number than the rest of the locality.

Of the children visiting a dentist in East Locality, children in Thorpe have the highest number of decayed, missing and filled teeth and it may be assumed the worst dental hygiene in the locality.

The average number of decayed, missing and filled teeth in Southend-on-Sea is 0.59 per child aged 5 years visiting a dentist. The East average is higher at 0.61.

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Figure 39: Average number of decayed, missing and filled teeth, by ward, 2014-15

Data Source: PHE East of England 7.5 Opticians There are 21 opticians in Southend-on-Sea, with only one of these located within East and is in the Thorpe ward:  S J More Opticians (Thorpe). 7.6 Primary Care Out of Hours Service

7.6.1 Current Service Provision Out of hours care is offered by IC24. It can be accessed between the hours of 6.30-8am Monday-Friday, and 24 hours over the weekend. Patients can either ring NHS 111 or visit the premises at Southend University Hospital Foundation Trust (SUHFT). Depending on need, patients will either receive a telephone call from a clinician, be invited to visit the premises for an appointment, or receive a home visit.

7.6.2 Use of Current Service Dr Kumar’s Surgery (F81613) had the highest proportion of patients contacting OOH services at 27.2% (Figure 40). Dr Dhillon’s Surgery (F81688) had the lowest proportion of patients contacting the OOH services at 18.7% (Error! Reference source not found.). The average across NHS Southend CCG was 20%.

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Figure 40: Proportion of patients who tried to contact an NHS service when GP surgery was closed in past 6 months, East GP practices 2015/16

Data Source: GP Patient Satisfaction Survey

7.7 Summary of Current Primary Care Provision East has some of the worst levels of under-doctoring in both Southend-on-Sea and England. It is estimated that almost four additional FTE GP’s and at least one additional FTE nurse is needed to be employed locally to meet the needs of the population.

According to the NHS Choices website (NHS Choices) there is significant variation in the services that different practice populations can access in their surgery. The latest data available on the NHS choices website, none of the GP practices in the East locality offer NHS health checks, yet all state Learning Disability Health Checks are offered. The information on the NHS Choices website is out of date as all practices are contracted to offer the NHS Health Check service.

As stated in the Digital Skills section of this document (page 23) residents of Southend-on- Sea are at low risk of digital exclusion so there should be efforts made to update the information recorded on the NHS choices website with what services are provided at each practice as this may be a resource regularly used by patients looking for certain services.

Provision of pharmacy and dental services in East is good, but there is only one optician located in the East ward.

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8. LONG TERM CONDITIONS AND THEIR MANAGEMENT 8.1 Long term conditions in East Locality In 1948 when the NHS was founded, almost half of the population died before their 65th birthday. In 2015 this figure dropped to 18%. However, although living longer, our population are increasingly doing so with long term conditions. Spend on patients with long term conditions accounts for over 70% of the entire NHS budget. Effective management of long term conditions in absolutely vital in order to prevent patients’ health, well-being and independence from deteriorating and to prevent them being admitted to hospital or requiring social care packages.

Figure 41 shows the prevalence of the most common long term conditions in East locality, NHS Southend CCG and England using GP QOF data. This estimates prevalence from the number of patients on GP disease registers who have already been diagnosed as having a long term condition.

Figure 41: Recorded prevalence of the most common long-term conditions in East locality, NHS Southend CCG and England 2015-16

Data Source: Quality Outcomes Framework, 2015-16

East has a greater percentage of patients diagnosed with COPD (Chronic Obstructive Pulmonary Disease), Coronary Heart Disease and Hypertension compared to NHS Southend CCG. 8.2 Non-diagnosed Long Term Conditions ERPHO (Eastern Region Public Health Observatory) produced modelled expected estimates of disease prevalence for certain long term conditions in GP practice populations based on the best published evidence and considering differences in demography and other risk

- 58 - factors known about a GP practice population. By comparing the variation between these modelled prevalence figures and the LTC prevalence in Figure 42 of patients already diagnosed we can estimate numbers of patients within a given practice population who are living with a long term condition that is not diagnosed, and therefore the completeness of GP long term condition QOF registers. A register that is significantly incomplete suggests poor case finding of patients with long term conditions, meaning that there may be a significant proportion of patients on a GP’s list have a long term condition and that are not being managed or treated. ERPHO generated estimated prevalence for Hypertension, Diabetes, Stroke, Atrial Fibrillation and COPD. When comparing the modelled estimates for each practice to the observed prevalence, for each condition, the condition with the largest gap between observed and the modelled estimate was Hypertension. The figure below shows the total estimated prevalence of hypertension by NHS Southend CCG GP practice, broken down by the diagnosed/observed prevalence and the estimated undiagnosed prevalence generated by the ERPHO estimates. It can be seen that Shaftesbury Avenue Practice has the highest difference between observed and estimated prevalence of Hypertension (22.13%). Dr Marasco Surgery has the smallest difference (13.06%) whilst having the second highest diagnosed prevalence. Dr Dhillon’s Surgery has the lowest total prevalence of Hypertension in East Locality. Shaftesbury Avenue Practice has the highest total prevalence of Hypertension (37.07%) with The Thorpe Bay Surgery, Dr Mario & Partners Surgery and Irlam A C & Partner having similar total values (35.16%, 33.51% and 32.33% respectively).

Figure 42: Diagnosed and non-diagnosed hypertension in East

Data Source: Quality Outcomes Framework 2015/16 & ERPHO Modelled Disease Estimates 2011

Using this it has been possible to calculate an estimate of how many cases may not be diagnosed. This can be seen in the table below by GP and condition. We have also indicated where the observed levels are higher than expected. Which could mean that diagnosis rates

- 59 - are good, or that diagnostic protocols have not been followed and the wrong people are on the register. An audit of diagnostic procedures is needed to asses this.

Table 6: Estimated number of undiagnosed LTC by practice, East Locality Practice Code Practice Name Hypertension Stroke & TIA COPD F81086 Irlam A C & Partner 742 36 121 F81121 The Thorpe Bay Surgery 674 48 174 F81209 Shaftesbury Avenue Practice 365 36 48 F81613 Dr Kumar's Surgery 691 43 61 F81622 Dr Marasco Surgery 136 1 19 F81649 Dr Mario & Partners Surgery 310 8 51 F81684 North Shoebury Surgery 215 -4 16 F81688 Dr Dhillon's Surgery 231 12 18

Total For East 3,364 180 508 Data Source: Quality Outcomes Framework 2015-16 & ERPHO Modelled Disease Estimates 2011

We estimate that in East there are 3,364 patients who have hypertension and 508 who have COPD who are not diagnosed and therefore not treated. Without good quality primary care and education on self-care these conditions will only worsen and result in high cost activity in secondary care and increased need of social care packages.

Evidence suggests (see QOF section below) that offering patients with LTC good quality care does reduce levels of non-elective activity for these conditions.

8.3 Quality Outcomes Framework (QOF) QOF records certain quality of care information on how patients who are diagnosed with diseases are treated in primary care. It was set up as an incentive system and GP practices get paid for the percentage of their “diseased population” that they offer certain tests, medication reviews and treatments for. The indicators are based on evidence of good quality care for the conditions.

There has been much debate over recent years whether QOF actually achieves good outcomes for patients in terms of reducing the risk of major events requiring hospitalisation. However a study published in the BMJ this year showed that nationally the introduction of QOF was in fact associated with a decrease in emergency admissions for these incentivised conditions. They also state that:

“Contemporaneous health service changes seem unlikely to have caused the sharp change in the trajectory of incentivised ACSC admissions immediately after the introduction of the Quality and Outcomes Framework. The decrease seems larger than would be expected from the changes in the process measures that were incentivised, suggesting that the pay for performance scheme may have had impacts on quality of care beyond the directly incentivised activities.”

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Figure 43: Effect of a national primary care pay for performance scheme on emergency hospital admissions for ambulatory care sensitive conditions

Data Source:

QOF scores can therefore be used as a proxy for the quality of care for patients with Long- Term Conditions. A sub-set of these indicators that are used by CQC to assess quality have been selected to give an indication of how the practiced within the locality are performing.

These are shown in the next section.

Note: All figures are for 2015/16 and labels are shortened versions of the full QOF indicator. A list of the full QOF indicators is available http://qofportal.uk/qof-read-codes/clinical- domain/

7.4 Clinical Management of Patients with Hypertension We estimate that there are 8,990 patients with hypertension in East including 3,364 who are not yet diagnosed.

Of those who are diagnosed the QOF tells us about the quality of their care and how well managed their condition is in general. Specifically for Hypertension it looks at the control of patients’ Blood Pressure, levels of physical activity (including brief interventions) and lifestyle advice, and treatment with statins for patients with a CVD risk score of 20% or higher. All of these indicators are aimed at reducing the risk of patients suffering from a CVD event in the future.

The QOF includes the concept of ‘exception reporting’ to ensure that practices are not penalised where, for example, patients do not attend for review, or where a medication

- 61 - cannot be prescribed due to a contraindication or side-effect. Patient exception reporting applies to those indicators in the clinical domains where level of achievement is determined by the percentage of patients receiving the designated level of care

Table 7 below shows the exception reporting rates, including the numbers of patients, for the practices in East locality. These are compared to the CCG and National rates. The CCG exception reporting overall for Hypertension is lower than the national average yet higher for primary prevention of cardiovascular disease.

Table 7: QOF Hypertension Exception reporting rates for East GP Practices 2015/16  Higher Hypertension Cardiovascular Primary Prevention  Same Value Compared to Value Compared to  Lower % (No.) CCG England % (No.) CCG England National 3.94 31.29 NHS Southend CCG 3.11  35.29  Irlam A C & Partner 2.76 (33)   80.00 (4)   The Thorpe Bay Surgery 2.16 (26)   : (0) No Data No Data Shaftesbury Avenue Practice 4.61 (16)   33.33 (1)   Dr Kumar's Surgery 2.82 (32)   33.33 (1)   Dr Marasco Surgery 3.41 (16)   50.00 (3)   Dr Mario & Partners Surgery 1.93 (10)   0.00 (0)   North Shoebury Surgery 4.65 (23)   0.00 (0)   Dr Dhillon's Surgery 0.76 (2)   0.00 (0)   Data Source: Quality Outcomes Framework 2015/16

Note: Indicators with an asterisk (*) were not reported in 2015/16 QOF as these indicators were retired in 2013/14. These have been included in this section as a guide to how each practice performs in hypertension care.

Radar charts show an overview of how practices LTC patients are being managed in terms of processes and clinical outcomes. Generally the larger the darker blue area the better that practice is at managing the condition as a whole. They also show where conditions may be well managed in one area and not in others. The radar charts also include figures for exception reporting with the lighter blue areas on the radar charts indicating how much better a practice could perform if all patients were included in the treatment.

Figure 44 to Figure 51 show the hypertension indicators for all practices within the East Locality.

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Figure 44: QOF indicators for Hypertension care 2015/16, F81086 (Irlam A C & Partner)

Data Source: Quality Outcome Framework 2015/16

Overall, Irlam A C & Partner practice performs well in terms of clinical management of hypertension with (Figure 44) 75% having a recorded blood pressure less than 150/90 mmHg at their latest reading and 70% of those who are under the age of 80 had their blood pressure measured as under 140/90. Process measures are mixed with, 79% of those aged 16-74 having their physical activity levels assessed. However, 88% of those found to be physically inactive have a brief intervention recorded. 80% of those diagnosed with hypertension were offered any level of Lifestyle advice. Of all new patients (aged 30-74) with a CVD risk assessment of 20% or more 100% are treated with statins. This may be down to patient choice or contraindications and given the practice is noted as having a lower exception reporting rate compared with both the CCG and national average may not be a cause for concern.

The Thorpe Bay Surgery (Figure 45) has 73% of its hypertension register noted as having a blood pressure under 150/90 mmHg and 78% of those who are under the age of 80 had their blood pressure measured as under 140/90. This may be indicative of the clinical case mix of the practice or may indicate there is scope to improve the clinical management of hypertension and coupled with an exception rate lower than that of the CCG and national average. Process measures are generally well performed with 84% of patients having their physical activity levels assessed and 89% of those found to be inactive are recorded as having a brief intervention. 77% were offered any level of Lifestyle advice. No new patients (aged 30-74) with a CVD risk assessment of 20% or more have been recorded at this surgery. This may be down to patient choice or contraindications and given the practice is noted as having a lower exception reporting rate compared with both the CCG and national average may not be a cause for concern.

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Figure 45: QOF indicators for Hypertension care 2015/16, F81121 (The Thorpe Bay Surgery)

Data Source: Quality Outcomes Framework 2015/16

Of all the patients diagnosed with hypertension on the practice list in Shaftesbury Avenue Practice (Figure 46) 83% had their blood pressure under 150/90 mmHg at their latest reading and 78% of those who are under the age of 80 had their blood pressure measured as under 140/90. However, exception reporting rates are greater than both the CCG and national average which warrants further investigation. Process measures perform well with 74% of patients aged 16-74 having their physical activity levels assessed and 89% who were inactive received a brief intervention and 78% of patients were offered lifestyle advice. Of all new patients (aged 30-74) with a CVD risk assessment of 20% or more 100% are treated with statins. This may be down to patient choice or contraindications but given the practice is noted as having a greater exception reporting rate compared with both the CCG and national average, this may warrant further investigation.

Of all the patients diagnosed with hypertension on the practice list in Dr Kumar’s Surgery (Figure 47) 78% had their blood pressure under 150/90 mmHg at their latest reading and 69% of those who are under the age of 80 had their blood pressure measured as under 140/90. This may be indicative of the clinical case mix of the practice or may indicate there is scope to improve the clinical management of hypertension and coupled with an exception rate lower than that of the CCG and national average. Lifestyle management is generally good with66% of patients aged 16-74 recorded as having their physical activity levels assessed and 84% who were inactive had a brief intervention). 75% were offered any level of Lifestyle advice. Of those with a CV risk assessment of greater than 20% there were 67% of patients treated with a statin. This may be down to patient choice or contraindications but given no patients are exception reported that would indicate such reasons there is no recorded explanation for performance at this level and so may warrant further investigation.

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Figure 46: QOF indicators for Hypertension care 2015/16, F81209 (Shaftesbury Avenue Practice)

Data Source: Quality Outcomes Framework 2015/16

Figure 47: QOF indicators for Hypertension care 2015/16, F81613 (Dr Kumar’s Surgery)

Data Source: Quality Outcome sFramework 2015/16

Of all the patients diagnosed with hypertension on the practice list in Dr Marasco Surgery (Figure 48) 81% had their blood pressure under 150/90 mmHg at their latest reading and 75% of those who are under the age of 80 had their blood pressure measured as under 140/90. Lifestyle management measures perform well with 89% having their physical

- 65 - activity levels assessed and 98% who were inactive are a brief intervention. 94% were offered any level of Lifestyle advice.

Figure 48: QOF indicators for Hypertension care 2015/16, F81622 (Dr Marasco Surgery)

Dat Source: Quality Outcomes Framework 2015/16

The data suggests that half of all new patients (aged 30-74) with a CVD risk assessment of 20% or more are treated with statins. This may warrant further investigation and should be considered in the context of how well the practice performs in recording of its CV risk assessments as low levels of risk assessment will affect the denominator of this measure.

Clinical management indicators perform well at Dr Mario & Partners Surgery (Figure 49). Of all the patients diagnosed with hypertension on the practice list in only 76% had their blood pressure under 150/90 mmHg at their latest reading and 80% of those who are under the age of 80 had their blood pressure measured as under 140/90. Measures around lifestyle are mixed with 87% of those aged 16-74 having their physical activity levels assessed, 99% who were inactive had a brief intervention and only 76% were offered any level of Lifestyle advice.

The data suggests that all new patients (aged 30-74) with a CVD risk assessment of 20% or more are treated with statins. Given no patients are exception reported it may indicate good management and patient compliance with medication or no new patients (aged 30-74) with a CVD risk assessment of 20% or more. However, this may warrant further investigation and should be considered in the context of how well the practice performs in recording of its CV risk assessments as low levels of risk assessment will affect the denominator of this measure.

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Figure 49: QOF indicators for Hypertension care 2015/16, F81649 (Dr Mario & Partners Surgery)

Data Source: Quality Outcomes Framework 2015/16

Figure 50: QOF indicators for Hypertension care 2015/16, F81684 (North Shoebury Surgery)

Data Source: Quality Outcomes Framework 2015/16

Of all the patients diagnosed with hypertension on the practice list in North Shoebury Surgery (Figure 50) clinical management indicators perform well with 82% had their blood pressure under 150/90 mmHg at their latest reading and 75% of those who are under the age of 80 had their blood pressure measured as under 140/90. Process and management

- 67 - measures around lifestyle also perform well with 85% are having their physical activity levels assessed, 88% who were inactive had a brief intervention and 72% were offered any level of Lifestyle advice. The data suggests that all new patients (aged 30-74) with a CVD risk assessment of 20% or more are treated with statins. Given no patients are exception reported it may indicate good management and patient compliance with medication or no new patients (aged 30-74) with a CVD risk assessment of 20% or more. However, this may warrant further investigation and should be considered in the context of how well the practice performs in recording of its CV risk assessments as low levels of risk assessment will affect the denominator of this measure.

Figure 51: QOF indicators for Hypertension care 2015/16, F81688 (Dr Dhillon’s Surgery)

Data Source: Quality Outcomes Framework 2015/16

Of all the patients diagnosed with hypertension on the practice list in Dr Dhillon’s Surgery (Figure 51) clinical management indicators perform well with 83% having a blood pressure under 150/90 mmHg at their latest reading and 73% of those who are under the age of 80 had their blood pressure measured as under 140/90. Lifestyle process and management measures perform well with 89% having their physical activity levels assessed, 96% who were inactive had a brief intervention and 82% were offered any level of Lifestyle advice.

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7.4.1 Summary of hypertension care. There is a great deal of clinical variation in the management of hypertension in primary care for the East locality. Practices such as Shaftesbury Avenue Practice, North Shoebury Surgery and Dr Marasco Surgery perform well in terms of clinical management of hypertension. Furthermore, Dr Marasco Surgery, Dr Dhillon’s Surgery and Dr Mario & Partners Surgery perform well in terms of lifestyle process and management indicators. However, there are some indicators with poor performance across East practice and exception reporting levels that warrant further investigation, particularly where they differ from the CCG and national averages.

When other practices in East are compared, management of patients with hypertension in 2015/16 was variable with a minority of patients experiencing an inadequate level of care on some QOF indicators. Controlling high blood pressure is usually relatively straight forward and inexpensive. Conversely uncontrolled hypertension places patients at significant increased risk of more serious cardio-vascular events such as strokes, and heart attacks. The impact of such events can have a catastrophic impact on the lives of the patients concerned and drive significant additional and preventable cost to CCG, hospital and council budgets. Improving both the diagnosis and clinical management of Hypertension in East Locality must be a key priority for the new Primary Care Centre. 8.5 Clinical Management of patients with Heart Failure (HF) and Atrial Fibrillation (AF) Of those who are diagnosed the QOF tells us about the quality of their care and how well managed their condition is in general. Specifically for AF and HF it looks at treatment with specific drugs, and for AF the inclusion of a CHADS2 score (with appropriate treatment). All of these indicators are aimed at reducing the risk of patients suffering from a further CVD event in the future. Care should be taken in interpreting some of the figures below, as absolute numbers of patients requiring each clinical intervention are relatively small.

Table 8 below shows the exception reporting rates, including the numbers of patients, for the practices in East locality. These are compared to the CCG and National rates. The CCG has a higher exception rate for Heart Failure and Atrial Fibrillation when compared with the national average.

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Table 8: Heart Failure & Atrial Fibrillation Exception reporting rates for East GP Practices 2015/16  Higher Atrial Fibrillation Heart Failure  Same Value Compared to Value Compared to  Lower % (No.) CCG England % (No.) CCG England National 6.62 9.18 NHS Southend CCG 6.86  10.31  Irlam A C & Partner 6.04 (9)   7.50 (9)   The Thorpe Bay Surgery 2.89 (7)   11.24 (10)   Shaftesbury Avenue Practice 6.25 (5)   15.00 (3)   Dr Kumar's Surgery 9.46 (21)   8.79 (8)   Dr Marasco Surgery 0.00 (0)   2.78 (1)   Dr Mario & Partners Surgery 5.10 (5)   4.26 (2)   North Shoebury Surgery 2.04 (2)   8.33 (3)   Dr Dhillon's Surgery 4.88 (2)   0.00 (0)   Data Source: Quality Outcomes Framework 2015/16

Figure 52 shows that 88% of patients registered with Dr Irlam & Partner who are on the HF register have had their diagnosis confirmed appropriately, using an ECG or specialist assessment. 92% of patients with LVD are being treated with an Ace Inhibitor or ARB. AF patients treated with anticoagulation therapy if greater or equal to two leaves some scope for improvement with 83% being antiocoagulated and 3% exception reported. The remaining 17% of patients with AF should either be reviewed in terms of suitability for anticoagulation or exception reported given their Stroke risk.

Figure 52: QOF indicators for HF and AF 2014/15, F81086 (Irlam A C & Partner)

Data Source: Quality Outcomes Framework 2015/16

Figure 53 shows that patients registered with The Thorpe Bay Surgery who are on the HF register are generally well diagnosed with 93% having had their diagnosis confirmed appropriately, using an ECG or specialist assessment. All patients with LVD are being treated

- 70 - with an Ace Inhibitor or ARB and beta blocker. 91% of patients with AF are anticoagulated and 3% are currently exception reported. The remaining 9% of patients with AF should either be reviewed in terms of suitability for anticoagulation therapy or exception reported given their Stroke risk.

Figure 54 shows that patients registered with the Shaftesbury Avenue Practice who are on the HF register are generally well diagnosed with 70% having had their diagnosis confirmed appropriately, using an ECG or specialist assessment. All patients with LVD are being treated with an Ace Inhibitor or ARB and beta blocker. 87% of patients with AF are anticoagulated and 5% are currently exception reported. The remaining 13% of patients with AF should either be reviewed in terms of suitability for anticoagulation therapy or exception reported given their Stroke risk.

Figure 53: QOF indicators for HF and AF 2015/16, F81121 (The Thorpe Bay Surgery)

Data Source: Quality Outcomes Framework 2015/16

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Figure 54: QOF indicators for HF and AF 2015/16, F81209 (Shaftesbury Avenue Practice)

Data Source: Quality Outcomes Framework 2015/16

Figure 55 shows that patients registered with the Dr Kumar’s Surgery who are on the HF register are generally well diagnosed with 96% having had their diagnosis confirmed appropriately, using an ECG or specialist assessment. All patients with LVD are being treated with an Ace Inhibitor or ARB and beta blocker. 90% of patients with AF are anticoagulated and 16% are currently exception reported. The remaining 10% of patients with AF should either be reviewed in terms of suitability for anticoagulation therapy or exception reported given their Stroke risk.

- 72 -

Figure 55: QOF indicators for HF and AF 2015/16, F81613 (Dr Kumar’s Surgery)

Data Source: Quality Outcomes Framework 2015/16

Figure 56 shows patients registered with Dr Marasco Surgery who are on the HF register with 94% having had their diagnosis confirmed appropriately, using an ECG or specialist assessment and the remaining 6% exception reported. 78% of patients with AF are anticoagulated . The remaining AF patients should either be reviewed in terms of suitability for anticoagulation therapy or exception reported given their Stroke risk.

Figure 57 shows patients registered with Dr Mario & Partners Surgery who are on the HF register with 89% having had their diagnosis confirmed appropriately, using an ECG or specialist assessment and 3% exception reported. 82% of patients with AF are anticoagulated and 7% are currently exception reported. The remaining 11% of patients with AF should either be reviewed in terms of suitability for anticoagulation therapy or exception reported given their Stroke risk.

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Figure 56: QOF indicators for HF and AF 2015/16, F81622 (Dr Marasco Surgery)

Data Source: Quality Outcomes Framework 2015/16

Figure 57: QOF indicators for HF and AF 2015/16, F81649 (Dr Mario & Partners Surgery)

Data Source: Quality Outcomes Framework 2015/16

Figure 58 shows patients registered with the North Shoebury Surgery who are on the HF register with all patients having had their diagnosis confirmed appropriately, using an ECG or specialist assessment. 88% of patients with AF are anticoagulated with 3% currently exception reported. The remaining patients with AF should either be reviewed in terms of suitability for anticoagulation therapy or exception reported given their Stroke risk.

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Figure 58: QOF indicators for HF and AF 2015/16, F81684 (North Shoebury Surgery)

Data Source: Quality Outcomes Framework 2015/16

Figure 59: QOF indicators for HF and AF 2015/16, F81688 (Dr Dhillon’s Surgery)

Data Source: Quality Outcomes Framework 2015/16

Figure 59 shows patients registered with the Dr Dhillon’s Surgery who are on the HF register all having had their diagnosis confirmed appropriately, using an ECG or specialist assessment. All patients with LVD are being treated with an Ace Inhibitor or ARB and beta

- 75 - blocker. Management of AF indicators is good with 94% of patients with a CHADS2 score of 2 or more anticoagulated and the remaining 6% currently exception reported.

8.5.1 Summary of HF and AF Care Overall, the management of Heart failure in general practice is good. Performance for AF management is generally good however; this should be considered in the wider context of how well practices are recording their CHADS2 scores in those with AF as this will affect the denominator to be considered for anticoagulation therapy. Almost every practice has scope to improve on considering patients suitability for anticoagulation in light of their stroke risk or exception reporting them appropriately. 8.6 Clinical Management of Stroke, Transient Ischaemic Attack (TIA) In 2015/16 there were 180 patients registered with a stroke or transient ischaemic attack. Of those diagnosed QoF tells about the quality of their care and how well managed their condition is in general. Specifically for stroke and TIA it looks at keeping blood pressure within a health range in order to reduce the risk of further strokes and other CVD events, and treatments with anti-platelets, anti-coagulants and aspirin, flu vaccination dis also included.

Table 9: Stroke & TIA and Peripheral Arterial Disease Exception reporting rates for East GP Practices 2015/16  Higher Stroke & TIA Peripheral Arterial Disease  Same Value Compared to Value Compared to  Lower % (No.) CCG England % (No.) CCG England National 10.13 5.78 NHS Southend CCG 10.43  5.67  Irlam A C & Partner 13.39 (51)   3.53 (3)   The Thorpe Bay Surgery 8.09 (25)   12.50 (3)   Shaftesbury Avenue Practice 6.67 (6)   0.00 (0)   Dr Kumar's Surgery 16.93 (53)   1.92 (1)   Dr Marasco Surgery 11.03 (15)   6.67 (2)   Dr Mario & Partners Surgery 10.34 (18)   4.17 (1)   North Shoebury Surgery 12.83 (24)   6.67 (1)   Dr Dhillon's Surgery 8.57 (6)   6.25 (1)   Data Source: Quality Outcomes Framework 2015/16

Table 9 above shows the exception reporting rates, including the numbers of patients, for the practices in East locality. These are compared to the CCG and National rates. The CCG has a higher exception rate for Stroke and Transient Ischaemic Attack and Peripheral Arterial Disease when compared with the national average.

Figure 60 shows patients registered with the Irlam A C & Partner who are on the Stroke/TIA or PAD register. Treatment with antiplatelet/anticoagulation therapy is good for both conditions with little exception reporting (3.5%). Blood pressure is well managed in those with PAD with 74% of patients having as reading of <=150/90mmHg in the last 12 months and some scope for improvement at 81% for Stroke/TIA with 4% being exception reported. Data would suggest there are 57% new patients with a Stroke requiring an onward referral for investigation.

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Figure 60 QOF indicators for stroke and TIA care 2015/16, F81086 (Irlam A C & Partner)

Data Source: Quality Outcomes Framework 2015/16

Figure 61 shows patients registered with The Thorpe Bay Surgery who are on the Stroke/TIA or PAD register. Treatment with antiplatelet/ anticoagulation therapy is good with Stroke/TIA patients having 93% treated with 3% exception reported and 83% of PAD patients treated with 17% exception reported. Blood pressure management leaves scope for improvements in PAD patients with 91% of patients (including 9% exception reported) having as reading of <=150/90mmHg in the last 12 months and 73% for Stroke/TIA with 2% being exception reported. Data would suggest there are some patients awaiting onward referral following a new or recent Stroke at 79% performance and 5% exception reported. Achievement for influenza immunisation is at 69% but this does include 13% of exception reporting. This may be down to contraindications or patient choice

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Figure 61: QOF indicators for stroke and TIA care 2015/16, F81121 (The Thorpe Bay Surgery)

Data Source: Quality Outcomes Framework 2015/16

Figure 62 shows patients registered with the Shaftesbury Avenue Practice who are on the Stroke/TIA or PAD register. Treatment with antiplatelet/ anticoagulation therapy is good with Stroke/TIA patients having 87% treated and 3% exception reported and 100% of PAD patients treated with no exception reporting. Blood pressure management is good in PAD patients with 100% of patients having as reading of <=150/90mmHg in the last 12 months, but only 73% for Stroke/TIA with 8% being exception reported. Data would suggest there are some patients awaiting onward referral following a new or recent Stroke at 85% performance and 15% exception reported. Achievement for influenza immunisation is at 90% and includes 3% of exception reporting. This may be down to contraindications or patient choice.

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Figure 62: QOF indicators for stroke and TIA care 2015/16, F81209 (Shaftesbury Avenue Practice)

Data Source: Quality Outcomes Framework 2015/16

Figure 63 shows patients registered with Dr Kumar’s Surgery who are on the Stroke/TIA or PAD register. Treatment with antiplatelet/ anticoagulation therapy leaves scope for improvement with Stroke/TIA patients having 91% treated with 8% exception reported and 92% of PAD patients treated with no exception reporting. Blood pressure management is good for PAD patients with 89% of patients having as reading of <=150/90mmHg in the last 12 months. There is potential to improve this for Stroke/TIA with 78% managed including 5% being exception reported. Data would suggest there are some patients awaiting onward referral following a new or recent Stroke at 80% performance and 20% exception reported. Achievement for influenza immunisation is fairly low at 65% but this does include 34% of exception reporting. This may be down to contraindications or patient choice

Figure 64 shows patients registered with Dr Marasco Surgery who are on the Stroke/TIA or PAD register. Treatment with antiplatelet/anticoagulation therapy is good for Stroke/TIA patients with 93% treated and 4% exception reported and 80% of PAD patients treated with 20% exception reported. Blood pressure management is good for PAD patients with 93% of patients having as reading of <=150/90mmHg in the last 12 months. There is minor potential improve this for Stroke/TIA with 83% managed and 5% exception reported. Data shows 100% of patients are awaiting onward referral following a new or recent Stroke. Achievement for influenza immunisation is fairly low at 77% but this does include 20% of exception reporting. This may be down to contraindications or patient choice.

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Figure 63: QOF indicators for stroke and TIA care 2015/16, F81613 (Dr Kumar’s Surgery)

Data Source: Quality Outcomes Framework 2015/16

Figure 64: QOF indicators for stroke and TIA care 2015/16, F81622 (Dr Marasco Surgery)

Data Source: Quality Outcomes Framework 2015/16

Figure 65 shows patients registered with Dr Mario & Partners Surgery who are on the Stroke/TIA or PAD register. Treatment with antiplatelet/ anticoagulation therapy is fairly good for Stroke/TIA patients with 87% treated including 2% exception reported. 82% of PAD patients are treated with 8% exception reported. Blood pressure management requires improvement for PAD patients with 85% of patients having as reading of <=150/90mmHg in

- 80 - the last 12 months and also for Stroke/TIA at 82% managed and 12% exception reporting. Data shows that no patients are awaiting onward referral following a new or recent Stroke. Achievement for influenza immunisation has scope to improve at 74% including 26% of exception reporting. This may be down to contraindications or patient choice

Figure 65: QOF indicators for stroke and TIA care 2015/16, F81649 (Dr Mario & Partners Surgery)

Data Source: Quality Outcomes Framework 2015/16

Figure 66: QOF indicators for stroke and TIA care 2015/16, F81684 (North Shoebury Surgery)

Data Source: Quality Outcomes Framework 2015/16

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Figure 66 shows patients registered with North Shoebury Surgery who are on the Stroke/TIA or PAD register. Treatment with antiplatelet/ anticoagulation therapy is fairly low for Stroke/TIA patients with 83% treated including 11% exception reported. 83% of PAD patients are treated with 17% exception reported. Blood pressure management is good for PAD patients with 100% of patients having as reading of <=150/90mmHg in the last 12 months. Stroke/TIA requires some improvement at 85% managed and 4% exception reporting. Data shows 8% of patients are awaiting onward referral following a new or recent Stroke. Achievement for influenza immunisation has scope to improve at 75% including 13% of exception reporting. This may be down to contraindications or patient choice.

Figure 67 shows patients registered with Dr Dhillon’s Surgery who are on the Stroke/TIA or PAD register. Treatment with antiplatelet/ anticoagulation therapy is good for Stroke/TIA patients with 100% treated and 85% of PAD patients are treated with 15% exception reported. Blood pressure management is good for PAD with 100% of patients having a reading of <=150/90mmHg in the last 12 months. Stroke/TIA requires some improvement at 79% managed with no exceptions reported. Data shows no patients are awaiting onward referral following a new or recent Stroke. Achievement for influenza immunisation is fairly low at 71% including 23% of exception reporting. This may be down to contraindications or patient choice.

Figure 67: QOF indicators for stroke and TIA care 2014/15, F81688 (Dr Dhillon’s Surgery)

Data Source: Quality Outcomes Framework 2015/16

8.6.1 Stroke care summary Clinical management of stroke in East is varied with patients registered at Dr Dhillon’s Surgery receiving the best levels of care. All practices have over 85% of patients with a record of anti-platelet or anti-coagulant is taken, with the exception of North Shoebury Surgery (83% net of exceptions). The percentages of Stroke & TIA patients with blood pressure being controlled could improve at The Thorpe Bay Surgery and Shaftesbury Avenue

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Practice. The figures for new patients being referred are high and may be due low number of new patients being diagnosed (less than 10 in most surgeries in 2015/16). 8.7 Clinical Management of Patients with Diabetes There are an estimated 1,551 people in East locality with diabetes. The QOF demonstrates the quality of care and how well managed the condition is in general for patients registered with a diagnosis of diabetes. Specifically for diabetes, its looks at keeping HbA1c, blood pressure and cholesterol within a healthy range, as well as testing and treatment for albuminuria, foot examination and risk classification, dietary reviews, referrals to education programmes and flu coverage. These care indicators are used to monitor, manage and prevent some of the complications of diabetes including diabetic coma and ketoacidosis, limb amputations, and blindness.

Table 10 shows the exception reporting rates for Diabetes Mellitus. NHS Southend CCG has a lower rate than England. Only three of the eight practices in East have a higher exception rate than the CCG, with only one of these being higher than England. North Shoebury Surgery has the highest rate of 14.62%, which is more than the CCG rate, with Irlam A C & Partner and Dr Marasco Surgery having the second and third highest rates at 10.82% and 10.79% respectively. Dr Mario & Partners Surgery has the lowest rate (5.64%).

Table 10: Diabetes Mellitus exception reporting rates for East GP Practices 2015/16  Higher Diabetes Mellitus  Same Value Compared to  Lower % (No.) CCG England National 11.57 NHS Southend CCG 9.93  Irlam A C & Partner 10.82 (325)   The Thorpe Bay Surgery 8.77 (245)   Shaftesbury Avenue Practice 9.21 (95)   Dr Kumar's Surgery 9.91 (345)   Dr Marasco Surgery 10.79 (152)  Dr Mario & Partners Surgery 5.64 (98)   North Shoebury Surgery 14.62 (232)   Dr Dhillon's Surgery 6.88 (59)   Data Source: Quality Outcomes Framework 2015/16

Figure 68 to Figure 75 show the Diabetes indicators for all practices within the East Locality.

Figure 68 shows patients registered with Irlam A C & Partner who are on the Diabetes register. Performance of clinical management indicators is mixed which can be indicative of the clinical case mix of the practice and/ or potential scope for improvement with 77% having a blood pressure of <=150/90mmHg in the last 12 months and 52% <=140/80mmHg. Only 64% have a cholesterol reading of 5 mmol/l or less. HbA1c management has potential room for improvement across all the HbA1c thresholds. Influenza immunisation performance is low at 66%. Process indicators and lifestyle management could be improved with 54% of patients having had a foot examination and classification of risk and 67% of Diabetics having no record of being referred or excepted for a structured education

- 83 - programme. The exception reporting rate of this practice for Diabetes is in line with the national average but is greater than that of the CCG. This may warrant further investigation.

Figure 68: QOF indicators for diabetes care 2015/16, F81086 (Irlam A C & Partner)

Data Source: Quality Outcomes Framework 2015/16

Figure 69 shows patients registered with The Thorpe Bay Surgery who are on the Diabetes register. Performance of clinical management indicators is mixed which can be indicative of the clinical case mix of the practice and/ or potential scope for improvement with 86% having a blood pressure of <=150/90mmHg in the last 12 months and 73% <=140/80mmHg. Management of cholesterol is fairly good at 74% having a reading of 5 mmol/l or less. HbA1c management has potential room for improvement across all the HbA1c thresholds. Influenza immunisation performance is at 66% yet has a 13% exception rate. Process indicators could be improved with 76% of patients having had a foot examination and classification of risk. However, 89% of Diabetics have been referred or excepted for a structured education programme. The exception reporting rate of this practice for Diabetes is greater than that of the CCG and national average. This may warrant further investigation.

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Figure 69: QOF indicators for diabetes care 2015/16, F81121 (The Thorpe Bay Surgery)

Data Source: Quality Outcomes Framework 2015/16

Figure 70: QOF indicators for diabetes care 2015/16, F81209 (Shaftesbury Avenue Practice)

Data Source: Quality Outcomes Framework 2015/16

Figure 70 shows patients registered with Shaftesbury Avenue Practice who are on the Diabetes register. Performance of clinical management indicators is mixed which can be indicative of the clinical case mix of the practice and/or potential scope for improvement with 91% including 4% exception reported having a blood pressure of <=150/90mmHg in the last 12 months and 66% <=140/80mmHg with 5% exception reported. Management of

- 85 - cholesterol is at 76% having a reading of 5 mmol/l or less with 5% exception reported. HbA1c management has potential room for improvement across all the HbA1c thresholds. Influenza immunisation performance is at 100% yet has a 24% exception rate. Process indicators warrant further investigation with 84% (including 9% exception reported) of patients having had a foot examination and classification of risk. 100% (60% exception reported) of Diabetics have been referred or excepted for a structured education programme. The exception reporting rate of this practice for Diabetes is greater than that of the CCG and national average. This may warrant further investigation.

Figure 71shows patients registered with Dr Kumar’s Surgery who are on the Diabetes register. Performance of clinical management indicators is mixed which can be indicative of the clinical case mix of the practice and/ or potential scope for improvement with 91% having a blood pressure of <=150/90mmHg in the last 12 months and 82% <=140/80mmHg. Management of cholesterol is at 71% having a reading of 5 mmol/l or less. HbA1c management has potential room for improvement across all the HbA1c thresholds. Influenza immunisation performance is at 97% with an 27% exception rate. Process indicators again are mixed as although 79% of patients had a foot examination and classification of risk, almost 93% of Diabetics have been exception reported for a structured education programme. The exception reporting rate of this practice for Diabetes is greater than that of the CCG and national average. This may warrant further investigation.

Figure 71: QOF indicators for diabetes care 2015/16 F81613 (Dr Kumar’s Surgery)

Data Source: Quality Outcomes Framework 2015/16

Figure 72shows patients registered with Dr Marasco Surgery who are on the Diabetes register. Performance of clinical management indicators is mixed which can be indicative of the clinical case mix of the practice and/ or potential scope for improvement with 93% (4% exception reported) having a blood pressure of <=150/90mmHg in the last 12 months and 80% (8% exception reported) <=140/80mmHg. Management of cholesterol is at 80% having

- 86 - a reading of 5 mmol/l or less. HbA1c management has potential room for improvement across all the HbA1c thresholds. Influenza immunisation performance is at 100% with a 27% exception rate. Process indicators again are mixed as although 93% of patients had a foot examination and classification of risk, almost 100% of Diabetics have been exception reported for a structured education programme. The exception reporting rate of this practice for Diabetes is greater than that of the CCG and national average. This may warrant further investigation.

Figure 72: QOF indicators for diabetes care, F81622 (Dr Marasco Surgery)

Data Source: Quality Outcomes Framework 2015/16

Figure 73 shows patients registered with Dr Mario & Partners Surgery who are on the Diabetes register. Performance of clinical management indicators is low which can be indicative of the clinical case mix of the practice and/ or potential scope for improvement with 86% having a blood pressure of <=150/90mmHg in the last 12 months and 77% <=140/80mmHg. Management of cholesterol is at 71% having a reading of 5 mmol/l or less. HbA1c management has potential room for improvement across all the HbA1c thresholds. Influenza immunisation performance is at 85% with a 14% exception rate. Process indicators again are mixed with only 76% patients having had a foot examination and classification of risk but 100% of Diabetics have been referred for a structured education programme. The exception reporting rate of this practice for Diabetes is in line with both the CCG and national average and so is not a cause for concern.

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Figure 73: QOF indicators for diabetes care F81649 (Dr Mario & Partners Surgery)

Data Source: Quality Outcomes Framework 2015/16

Figure 74 shows patients registered with North Shoebury Surgery who are on the Diabetes register. Performance of clinical management indicators is mixed which can be indicative of the clinical case mix of the practice and/ or potential scope for improvement with 92% having a blood pressure of <=150/90mmHg in the last 12 months and 82% <=140/80mmHg. Management of cholesterol is at 84% having a reading of 5 mmol/l or less but has 8% exception reported. HbA1c management has potential room for improvement across all the HbA1c thresholds. Influenza immunisation performance is at 98% with a 22% exception rate. Process indicators again are mixed with 98% patients having had a foot examination and classification of risk and 100% of Diabetics have been exception reported for referral to a structured education programme. The exception reporting rate of this practice for Diabetes is greater than both the CCG and national average and may warrant further investigation.

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Figure 74: QOF indicators for diabetes care F81684 (North Shoebury Surgery)

Data Source: Quality Outcomes Framework 2015/16

Figure 75 shows patients registered with Dr Dhillon’s Surgery who are on the Diabetes register. Performance of clinical management indicators is good with 92% having a blood pressure of <=150/90mmHg in the last 12 months and 73% <=140/80mmHg. Management of cholesterol is at 75% having a reading of 5 mmol/l or less. HbA1c management does have some room for improvement across all the HbA1c thresholds. Influenza immunisation performance is at 98% with a 20% exception rate. Process indicators are again good with 86% patients having had a foot examination and classification of risk and 100% of Diabetics having been referred to a structured education programme. The exception reporting rate of this practice for Diabetes is in line with the CCG and national average and is no cause for concern.

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Figure 75: QOF indicators for diabetes care F81688 (Dr Dhillon’s Surgery)

Data Source: Quality Outcomes Framework 2015/16

8.7.1 Summary of Diabetes Care Prevalence of diabetes in East practices is high, ranging from 5.64% to 14.82% in each of the East Practice’s lists of patients aged 17 and over. However, management of diabetes varies between the practices in East Locality with Dr Mario & Partners Surgery appearing to have diabetic patients who are well managed and have better outcomes than most of the other practices. 8.8 Care of Patients with Respiratory Disease In 2015-16 there are approximately 508 people in East Locality with a diagnosis of Chronic Obstructive Pulmonary Disorder (COPD) and 1,909 are diagnosed with asthma. It is anticipated that there are very few undiagnosed cases of COPD in the area.

There are 508 patients on the COPD register and 1,909 on the asthma register in East. The QOF tells us about the quality of their care and how well managed their condition is in general. Specifically for respiratory disease it looks at COPD patients having flu vaccination, FEV1 (Forced Expiratory Volume) recorded, assessment using MRC dyspnoea score and its results, and confirmation of the diagnosis using spirommetry test. For asthma it looks at measures of variability/reversibility, review, and smoking records. These care indicators are used to monitor, manage and prevent some exacerbations of the conditions which can result in unplanned care activity.

Table 11 shows the exception reporting rates for COPD and asthma. NHS Southend CCG has a lower rate than England. Only one of the eight practices in East has a higher exception rate than the CCG and England for COPD. Shaftesbury Avenue Practice has the highest rate of 13.36%, which is more than the CCG rate, with Dr Kumar’s Surgery having the second

- 90 - highest rate at 11.36%. The Thorpe Bay Surgery has the lowest rate (6.67%). Two of the eight practices in East have a higher exception rate than the CCG for asthma, with only one of these being lower than England. Irlam A C & Partner has the highest rate of 8.00%, which is nearly double the CCG rate, with Shaftesbury Avenue Practice having the second highest rate at 6.94%. Dr Mario & Partners Surgery has the lowest rate (0.58%).

Table 11: Respiratory Disease exception reporting rates for East GP Practices 2015/16  Higher COPD ASTHEMA  Same Value Compared to Value Compared to  Lower % (No.) CCG England % (No.) CCG England National 13.04 7.05 NHS Southend CCG 11.74  4.14  Irlam A C & Partner 8.38 (55)   8.00 (44)   The Thorpe Bay Surgery 6.67 (22)   1.86 (6)   Shaftesbury Avenue Practice 13.36 (33)   6.94 (10)   Dr Kumar's Surgery 11.36 (93)   4.09 (25)   Dr Marasco Surgery 7.38 (20)   1.29 (4)   Dr Mario & Partners Surgery 7.30 (20)   0.58 (2)   North Shoebury Surgery 9.01 (32)   0.86 (3)   Dr Dhillon's Surgery 7.04 (14)   0.74 (1)   Data Source: Quality Outcomes Framework 2015/16

Figure 76 to Figure 83 show the Respiratory Disease indicators for all practices within the East Locality.

Figure 76 shows patients registered with Irlam A C & Partner who are on a respiratory disease register. Performance of process management indicators for COPD is mixed with 84% of patients COPD confirmed by spirometry. 81% of patients are assessed using the MRC dyspnoea score and of those found to score 3 or more 92% have an oxygen saturation level recorded. Recording of a patient’s FEV1 is good at 78%. Immunisation for influenza is good at 73% however this does include 5% exception reported. Asthma performance shows scope for improvement with 15% of asthmatics aged 14-19 smoking status unknown. Review and assessment including 3 RCP questions performs well at 65% and recorded measures of variability/reversibility at 83%.

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Figure 76 QOF indicators for respiratory disease 2015/16, F81086 (Irlam A C & Partner)

Data Source: Quality Outcomes Framework 2015/16

Figure 77 shows patients registered with The Thorpe Bay Surgery who are on a respiratory disease register. Performance of process management indicators for COPD is mixed with 74% of patients COPD confirmed by spirometry with 1% exception reported. 94% (including 4% exception reporting) of patients are assessed using the MRC dyspnoea score and of those found to score 3 or more 87% have an oxygen saturation level recorded. Recording of a patient’s FEV1 is at 54% with 2% exception reported. Immunisation for influenza appears good at 89% however this does include 13% exception reported. Asthma performance shows scope for improvement with 25% of asthmatics aged 14-19 smoking status unknown. Review and assessment including 3 RCP questions performs well at 74% and recorded measures of variability/reversibility at 95%.

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Figure 77: QOF indicators for respiratory disease 2015/16, F81121 (The Thorpe Bay Surgery)

Data Source: Quality Outcomes Framework 2015/16

Figure 78: QOF indicators for respiratory disease 2015/16, F81209 (Shaftesbury Avenue Practice)

Data Source: Quality Outcomes Framework 2015/16

Figure 78 shows patients registered with Shaftesbury Avenue Practice who are on a respiratory disease register. Performance of process management indicators for COPD is mixed with 88% of patients COPD confirmed by spirometry. 85% (including 5% exception reporting) of patients are assessed using the MRC dyspnoea score and of those found to

- 93 - score 3 or more 90% have an oxygen saturation level recorded. Recording of a patient’s FEV1 is at 53% with 5% exception reported. Immunisation for influenza appears good at 98% however this does include 38% exception reported. Asthma performance is also mixed with 100% of asthmatics aged 14-19 smoking status known. Review and assessment including 3 RCP questions performs well at 80% and recorded measures of variability/reversibility at 92%.

Figure 79: QOF indicators for respiratory disease 2015/16, F81613 (Dr Kumar’s Surgery)

Data Source: Quality Outcomes Framework 2015/16

Figure 79 shows patients registered with Dr Kumar’s Surgery who are on a respiratory disease register. Performance of process management indicators for COPD is mixed with 97% of patients COPD confirmed by spirometry including 11% exception reported. 85% (including 9% exception reporting) of patients are assessed using the MRC dyspnoea score and of those found to score 3 or more 90% with no exception reported have an oxygen saturation level recorded. Recording of patients FEV1 is at 85% with 9% exception reported. Immunisation for influenza appears good at 100%, this does include 21% exception reported. Asthma performance is also mixed with 90% of asthmatics aged 14-19 smoking status known or exception reported (3%). Review and assessment including 3 RCP questions performs reasonably well at 73% and recorded measures of variability/reversibility at 99%.

Figure 80 shows patients registered with Dr Marasco Surgery who are on a respiratory disease register. Performance of process management indicators for COPD is good with 100% of patients COPD confirmed by spirometry and no exception reported. 94% (including 6% exception reporting) of patients are assessed using the MRC dyspnoea score and of those found to score 3 or more 100% are reported have an oxygen saturation level recorded. Recording of patients FEV1 is at 94% with 8% exception reported. Immunisation for influenza appears good at 98% but does include 10% exception reported. Asthma performance is good with 96% of asthmatics aged 14-19 smoking status known. Review and

- 94 - assessment including 3 RCP questions performs well at 100% and recorded measures of variability/reversibility at 79%.

Figure 80: QOF indicators for respiratory disease 2015/16, F81622 (Dr Marasco Surgery)

Data Source: Quality Outcomes Framework 2015/16

Figure 81 shows patients registered with Dr Mario & Partners Surgery who are on a respiratory disease register. Performance of process management indicators for COPD is mixed with 87% of patients COPD confirmed by spirometry with no exception reported. 92% (with no exception reporting) of patients are assessed using the MRC dyspnoea score and of those found to score 3 or more 93% are reported have an oxygen saturation level recorded. Recording of patients FEV1 is at 82% with 1% exception reported. Immunisation for influenza appears good at 100% but does include 25% exception reported. Asthma performance is good with 92% of asthmatics aged 14-19 smoking status known. Review and assessment including 3 RCP questions performs well at 73% and recorded measures of variability/reversibility at 96% (with no exception reported).

Figure 82 shows patients registered with North Shoebury Surgery who are on a respiratory disease register. Performance of process management indicators for COPD is mixed with 95% of patients COPD confirmed by spirometry including 7% exception reported. 93% (including 9% exception reporting) of patients are assessed using the MRC dyspnoea score and of those found to score 3 or more 100% are reported have an oxygen saturation level recorded. Recording of patients FEV1 is at 91% with 5% exception reported. Immunisation for influenza appears good at 99% but does include 18% exception reported. Asthma performance is fairly good with 87.5% of asthmatics aged 14-19 smoking status known. Review and assessment including 3 RCP questions performs well at 79% and recorded measures of variability/reversibility at 95%.

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Figure 81: QOF indicators for respiratory disease 2015/16, F81649 (Dr Mario & Partners Surgery)

Data Source: Quality Outcomes Framework 2015/16

Figure 82: QOF indicators for respiratory disease 2015/16, F81684 (North Shoebury Surgery)

Data Source: Quality Outcomes Framework 2015/16

Figure 83 shows patients registered with Dr Dhillon’s Surgery who are on a respiratory disease register. Performance of process management indicators for COPD is fairly good with 88% of patients COPD confirmed by spirometry. 92% of patients are assessed using the MRC dyspnoea score and of those found to score 3 or more 100% are reported have an

- 96 - oxygen saturation level recorded. Recording of patients FEV1 is at 91% with 4% exception reported. Immunisation for influenza appears good at 98% with 16% exception reported. Asthma performance is mixed with 100% of asthmatics aged 14-19 smoking status known. Review and assessment including 3 RCP questions performs well at 75% and recorded measures of variability/reversibility at 85%.

Figure 83: QOF indicators for respiratory disease 2015/16, F81688 (Dr Dhillon’s Surgery)

Data Source: Quality Outcomes Framework 2015/16

8.8.2 Summary of respiratory care Prevalence of COPD is fairly low ranging from 6.67% to 13.36% in each of the East Practice’s lists of patients aged 17 and over. Prevalence of asthma is low ranging from 0.58% to 8.00% in each of the East Practice’s lists of patients aged 17 and over. However, management of respiratory diseases varies between the practices in East Locality with The Thorpe Bay Surgery appearing to have patients with respiratory diseases who are well managed and have better outcomes than most of the other practices.

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9. MENTAL HEALTH AND WELLBEING 9.1 Mental Ill Health prevalence The prevalence of mental ill-health in the community can be assessed in part through demand from a given population for mental health treatment. QOF requires GP practices to place patients on registers for depression or more serious mental ill-health (SMI) such as schizophrenia, bi-polar disorder or other psychoses.

9.1.1 Recorded Prevalence of Depression Figure 84 shows the recorded prevalence of depression in patients aged 18+ for each GP practice in NHS Southend CCG with the East Locality GP practices highlights in orange. Depression prevalence in East Locality varies widely between GP practices. Four practices have prevalence above the Southend-on-Sea mean, with North Shoebury Surgery having the greatest prevalence. Conversely, The Thorpe Bay Surgery has the lowest prevalence.

Figure 84: QOF 2014/15 recorded depression prevalence in patients aged 18+, East practices

Data Source: Quality Outcomes Framework 2015/16

Figure 107 (found in appendix 3) shows three practices within East Locality have a depression prevalence which is significantly lower than Southend-on-Sea (Dr Mario & Partners Surgery, Shaftesbury Avenue Practice and The Thorpe Bay Surgery).

It is worth noting that QOF depression prevalence is a function of a number of factors including underlying prevalence of depression within a population, the population’s willingness to seek treatment from their GP and clinical practice used by the GP to make a diagnosis. Given that the eight practices serve the same population it seems unlikely that the underlying prevalence would be significantly different between different practice populations. As such, differences between practice populations in terms of willingness to

- 98 - access help from their GP and differences in clinical practice with regard to diagnosis or case finding explains the wide variation in Figure 84

However given nationally published evidence suggesting that a significant proportion of depression remains undiagnosed and treated, particularly in older people, the recorded prevalence may be an under-estimation of the true prevalence, suggesting that adult depression is a significant issue in Southend-on-Sea.

9.1.2 Prevalence of Serious Mental Ill Health (SMI) Figure 85 shows the percentage of patients aged 18+ diagnosed with a serious Mental Illness (SMI) such as schizophrenia, bi-polar disorder or other psychosis in each practice population in NHS Southend CCG with the East Locality GP practices highlighted in purple. Three practices in the East, Irlam A C & Partner, North Shoebury Surgery and Shaftesbury Avenue Practice, have higher levels of prevalence of SMI. Conversely Dr Mario & Partners Surgery and The Thorpe Bay Surgery have some of the lowest prevalence in NHS Southend CCG, with each of them being significantly lower (as seen in Figure 108).

Figure 85: GP practice prevalence of those aged 18+ diagnosed with a serious mental ill health, 2015/16

Data Source: Quality Outcomes Framework 2015/16

Given the distressing and often noticeable symptoms of SMI, it would seem less likely that recorded prevalence is a product of unwillingness to seek help when compared to depression, and more likely that East Locality has a greater underlying prevalence of SMI in its population. 9.2 Referral of Patients with Depression to Talking Therapies During 2013/14 there were 3,665 referrals to IAPT services in NHS Southend CCG (HSCIC/NHS Digital, 2014), which would equate to 17% of the 21,131 people estimated to

- 99 - have a common mental disorder. However, many of these referrals were from the 9,200 people on the GP register with depression over this period.

The number referred to IAPT is equivalent to 40% of the number on the GP register for depression, although it is not possible to say whether those referred were on the GP register or not.

Table 12: IAPT referrals Service Number Period IAPT coverage IAPT referrals 3,665 2013/14 n/a GP register for depression 9,197 2013/14 40% Estimated number of people with common mental disorders 21,131 2014/15 17% Source: HSCIC (2014)

The IAPT referral rate per 100,000 population in NHS Southend CCG (740) was higher than East of England (730) but lower than England (839) (Q4 2014/15) (HSCIC, 2015).

IAPT waiting times in NHS Southend CCG have significantly reduced in the last few months: In July 2014, proportion of people waiting less than 28 days to receive treatment in NHS Southend CCG (28.7%) was significantly below England (62.9%) (HSCIC, 2014) while this had risen to 98.4%, which was significantly above the England average (74.9%), in March 2015 (HSCIC, 2015).

Similarly, the proportion of people referred to IAPT waiting more than 90 days for the first treatment in NHS Southend CCG (3.3%) was lower than England (6.3%) (Jan 2015) (HSCIC, 2015) which represented a similar improvement from earlier in 2014.

During 2013/14, there were 3,665 IAPT referrals in NHS Southend CCG which means that 17% of the estimated number of people with common mental disorder were referred (HSCIC, 2014).

The proportion of referrals entering treatment in NHS Southend CCG (65% / 2,390 people) is similar to England (63%) (HSCIC, 2014). However, during Q4 2014/15, the rate per 100,000 population entering treatment in Southend-on-Sea (634) was higher than East of England (582) or England (564) (HSCIC, 2015). 9.3 Clinical Management of Patients with Mental Ill Health including depression and dementia in Primary Care Up to half of patients who have a serious mental illness are seen only in a primary care setting. For these patients, it is important that the primary care team takes responsibility for discussing and documenting their care in their primary care record.

Table 13 shows the exception reporting rates for dementia, depression and Mental Health NHS Southend CCG has a lower rate than England for dementia and Mental Health, and is higher for Depression. Four of the eight practices in East have a lower exception rate than NHS Southend CCG and England for dementia. Dr Kumar’s Surgery has the highest rate of 20.34%, which is almost double the CCG rate, with Dr Marasco Surgery having the second

- 100 - highest rate at 12.50%. Dr Mario & Partners Surgery has the lowest rate (4.35%), with two practices having a recorded rate of 0.00% (Shaftesbury Avenue Practice and Dr Dhillon’s Surgery).

Four of the eight practices in East have a higher exception rate than the CCG for depression, with none of these being lower than England. Dr Mario & Partners Surgery has the highest rate of 62.07%, which is nearly three times the CCG rate, with Dr Marasco Surgery having the second highest rate at 45.95%. North Shoebury Surgery and Dr Dhillon’s Surgery have the lowest rates in the East locality (8.33% and 6.67% respectively).

Three of the eight practices in East have a higher exception rate than the CCG for mental health, with one of these being lower than England. Dr Kumar’s Surgery has the highest rate of 18.47%, which is almost twice the CCG rate, with Dr Marasco Surgery having the second highest rate at 12.73%. Dr Dhillon’s Surgery has the lowest rate (1.67%).

Table 13: Mental Health exception reporting rates for East GP Practices 2015/16  Higher Dementia Depression Mental Health  Same Value Compared to Value Compared to Value Compared to  Lower % (No.) CCG England % (No.) CCG England % (No.) CCG England National 12.73 22.14 11.34 NHS Southend CCG 11.67  22.93  10.26  Irlam A C & Partner 9.86 (7)   27.36 (29)   8.65 (25)   The Thorpe Bay Surgery 11.29 (7)   22.45 (11)   7.92 (8)   Shaftesbury Avenue Practice 0.00 (0)   33.33 (11)   11.11 (7)   Dr Kumar's Surgery 20.34 (12)   22.45 (33)   18.47 (41)   Dr Marasco Surgery 12.50 (3)   45.95 (17)   12.73 (7)   Dr Mario & Partners Surgery 4.35 (2)   62.07 (18)   3.95 (3)   North Shoebury Surgery 8.00 (2)   8.33 (5)   4.70 (7)   Dr Dhillon's Surgery 0.00 (0)   6.67 (1)   1.67 (1)   Data Source: Quality Outcomes Framework 2015/16

Figure 86 to Figure 93 show the clinical management of patients with Depression, SMI and Dementia (including exceptions) in the GP practices within the East Locality. Figure 86 to Figure 93 below shows the exception rates for dementia, depression and mental health indicators for each practice.

Figure 86 shows patients registered with Irlam A C & Partner who are on a SMI/Depression/Dementia register. Mental health register management processes have a good performance with 84% of patients having a comprehensive care plan noted. 80% and 74% of patients have a blood pressure check and alcohol consumption recorded respectively. The percentage of newly diagnosed depression patients receiving a review in 10-56 days after diagnosis is high at 60%. Dementia care plans perform better with 68% of them being reviewed face to face in the last 12 months. However, blood tests in newly recorded patients to exclude a potentially reversible or modifying cause for the dementia and to help exclude other diagnoses is at 71% with 12% exception reported.

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Figure 86 QOF indicators for SMI/Depression/Dementia 2015/16, F81086 (Irlam A C & Partner)

Data Source: Quality Outcomes Framework 2015/16

Figure 87 shows patients registered with The Thorpe Bay Surgery who are on a SMI/Depression/Dementia register. Mental health register management processes have mixed performance with 86% of patients having a comprehensive care plan noted. 75% and 86% of patients have a blood pressure check and alcohol consumption recorded respectively. The percentage of newly diagnosed depression patients receiving a review in 10-56 days after diagnosis is 79% with 18% exception reported. There is scope to improve the delivery of dementia care plans with only 65% of patients being reviewed face to face in the last 12 months. Blood tests in newly recorded patients to exclude a potentially reversible or modifying cause for the dementia and to help exclude other diagnoses is at 69% with 12% exception reported.

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Figure 87: QOF indicators for SMI/Depression/Dementia 2015/16, F81121 (The Thorpe Bay Surgery)

Data Source: Quality Outcomes Framework 2015/16

Figure 88: QOF indicators for SMI/Depression/Dementia 2015/16, F81209 (Shaftesbury Avenue Practice)

Data Source: Quality Outcomes Framework 2015/16

Figure 88 shows patients registered with Shaftesbury Avenue Practice who are on a SMI/Depression/Dementia register. If all exception reporting is appropriate this practice performs well on mental health register management processes with 89% of patients having

- 103 - a comprehensive care plan noted. 71% (4% exception reported) and 95% (10% exception reported) of patients have a blood pressure check and alcohol consumption recorded respectively. The percentage of newly diagnosed depression patients receiving a review in 10-56 days after diagnosis is 73% with 25% noted exceptions. Dementia care plans perform well with 95% of them being reviewed face to face in the last 12 months. Data indicates there are no newly diagnosed patients requiring a blood test.

Figure 89 shows patients registered with Dr Kumar’s Surgery who are on a SMI/Depression/Dementia register. Mental health register management processes have mixed performance with 80% of patients having a comprehensive care plan noted. 98% (17% exception reported) and 92% (22% exception reported) of patients have a blood pressure check and alcohol consumption recorded respectively. The percentage of newly diagnosed depression patients receiving a review in 10-56 days after diagnosis is at 82% with 18% exception reported. Dementia care plans perform well with 88% of them being reviewed face to face in the last 12 months. Blood tests in newly recorded patients to exclude a potentially reversible or modifying cause for the dementia and to help exclude other diagnoses is at 67% but with 40% exception reported.

Figure 89: QOF indicators for SMI/Depression/Dementia 2015/16, F81613 (Dr Kumar’s Surgery)

Data Source: Quality Outcomes Framework 2015/16

Figure 90 shows patients registered with Dr Marasco Surgery who are on a SMI/Depression/Dementia register. If all exception reporting is appropriate this practice performs well on mental health register management processes with 100% of patients having a comprehensive care plan noted. 93% (12% exception reported) and 100% (12% exception reported) of patients have a blood pressure check and alcohol consumption recorded respectively. The percentage of newly diagnosed depression patients receiving a review in 10-56 days after diagnosis is 90% with 41 % noted exceptions. Dementia care

- 104 - plans perform better with 79% of them being reviewed face to face in the last 12 months. Blood tests in newly recorded patients to exclude a potentially reversible or modifying cause for the dementia and to help exclude other diagnoses is at 100% with 33% exception reported.

Figure 90: QOF indicators for SMI/Depression/Dementia 2015/16, F81622 (Dr Marasco Surgery)

Data Source: Quality Outcomes Framework 2015/16

Figure 91 shows patients registered with Dr Mario & Partners Surgery who are on a SMI/Depression/Dementia register. Mental health register management processes have mixed performance with 91% of patients having a comprehensive care plan noted. 91% (0% exception reported) and 91% (0% exception reported) of patients have a blood pressure check and alcohol consumption recorded respectively. The percentage of newly diagnosed depression patients receiving a review in 10-56 days after diagnosis is high at 90% but with 56% exception reported. Dementia care plans perform well with 92% of them being reviewed face to face in the last 12 months. Blood tests in newly recorded patients to exclude a potentially reversible or modifying cause for the dementia and to help exclude other diagnoses is at 100% with 0% exception reported.

- 105 -

Figure 91: QOF indicators for SMI/Depression/Dementia 2015/16, F81649 (Dr Mario & Partners Surgery)

Data Source: Quality Outcomes Framework 2015/16

Figure 92 shows patients registered with North Shoebury Surgery who are on a SMI/Depression/Dementia register. Mental health register management processes perform fairly well with 85% of patients having a comprehensive care plan noted. 88% (0% exception reported) and 95% (7% exception reported) of patients have a blood pressure check and alcohol consumption recorded respectively. The percentage of newly diagnosed depression patients receiving a review in 10-56 days after diagnosis is 80% with 7% exception reported. Dementia care plans perform well with 88% of them being reviewed face to face in the last 12 months. Blood tests in newly recorded patients to exclude a potentially reversible or modifying cause for the dementia and to help exclude other diagnoses is at 100% with no exception reported.

- 106 -

Figure 92: QOF indicators for SMI/Depression/Dementia 2015/16, F81684 (North Shoebury Surgery)

Data Source: Quality Outcomes Framework 2015/16

Figure 93 shows patients registered with Dr Dhillon’s Surgery who are on a SMI/Depression/Dementia register. If all exception reporting is appropriate this practice performs well on mental health register management processes with 94% of patients having a comprehensive care plan noted. 94% (0% exception reported) and 94% (0% exception reported) of patients have a blood pressure check and alcohol consumption recorded respectively. The percentage of newly diagnosed depression patients receiving a review in 10-56 days after diagnosis is 86% with 6% noted exceptions. Delivery of dementia care plans is good with 80% of patients being reviewed face to face in the last 12 months. Data indicates there are no newly diagnosed patients requiring a blood test.

- 107 -

Figure 93: QOF indicators for SMI/Depression/Dementia 2015/16, F81688 (Dr Dhillon’s Surgery)

Data Source: Quality Outcomes Framework 2015/16 9.4 Mental ill health and co-morbidities A report by the King’s Fund (2014) identified that at least 23.5% of the total population in England are currently living with a long-term condition (LTC). This high prevalence has increased the resource burden in both primary care and secondary care. The following have been attributed to LTCs:  50% of all GP appointments  64% of all outpatient appointments  over 70% of inpatient bed stays

In 2008 the King’s Fund estimated that 3.1% of people in England had multi-morbidity (three or more LTCs). Individuals with an LTC are more than twice as likely to suffer from depression as the rest of the population, (National Institute for Health and Clinical Excellence (NICE) 2011). NICE estimates 20% of the population in people with an LTC also suffer from depression.

Applying the above national prevalence estimates for multi-morbidities and comorbidity of one LTC + depression indicates there could be 1,085 people registered with NHS Southend CCG GPs with three or more LTCs and 1,643 people with one LTC and depression. However the true number of cases is likely to be higher than these modelled estimates.

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Figure 94: Modelled estimate of patients with 3 or more long-term conditions, East GP Practices

Data Source: Calculated using Kings Fund 2008, and Open Exeter October 2016

Figure 95: Modelled estimate of patients with long-term conditions and depression, East GP Practices

Data Source: Calculated using Kings Fund 2008, NICE 2011 and Open Exeter October 2016

The Kings Fund research clearly demonstrated that patients with a long term condition and comorbid depression were much more likely to have a greater level of mortality and

- 109 - morbidity and to cost the health and social care system significantly more. It is therefore imperative that this cohort of patients is identified and treated for their depression. 9.5 Mental health and wellbeing summary Prevalence of mental-ill health is high within the East locality. Figure 84 shows there are four practices that have a higher than average prevalence of depression whilst Figure 85 shows there are three practices with a higher than average serious mental ill health, the two highest values belonging to Irlam A C & Partner and North Shoebury Surgery.

Quality of care for patients is variable across the locality with too many exceptions resulting in in patients diagnosed with depression, dementia and serious mental ill health not receiving all of the interventions necessary to keep them well.

- 110 -

10. SECONDARY CARE 10.1 Current Service Provision East residents can currently access the location of Southend University Hospital Foundation Trust (SUHFT) for secondary care services including acute/inpatient care, A&E provision and non-acute care e.g. outpatient clinics. 10.2 Outpatients Clinics In 2015/16 there were 7,085 outpatient attendances by East patients.

The common speciality codes recorded for outpatients attendances were in Dermatology with 1,606 attendances and Gynaecology with 1,088 attendances.

Figure 96: Top 10 most commonly performed outpatient procedures, East Locality patients, 2015/16

Data Source: Secondary Users System (NELFT CSU)

Of the 7,085 outpatient attendances in 2015/16 there were 2,960 procedures recorded (Figure 97). The most common procedures performed in outpatient services for East Locality patients were Diagnostic Dermatoscopy of Skin (Dermatology), Other Specified Clearance of External Auditory Canal (ENT) and Other Specified Other Examination of Female Genital Tract.

- 111 -

Figure 97: Top 10 most commonly performed outpatient procedures, East Locality patients, 2015/16

Data Source: Secondary Users System (NELFT CSU)

When considering the main procedures undertaken during these appointments, it is envisaged that many could be addressed in primary care with correct resources. 10.3 A&E Attendance In 2015/16 there were 10,338A&E attendances from patients registered with East Locality GP practices. The average crude rate for NHS Southend CCG is 305 attendances per 1,000 patients. Five practices in East Locality have a higher than average rate of attendance with the exceptions of The Thorpe Bay Surgery (F81121), Dr Kumar’s Surgery (F81613) and Dr Mario & Partners Surgery (F81649).

The rate for North Shoebury Surgery (F81684) is higher at 338 admissions per 1,000 patients.

- 112 -

Figure 98: A&E attendances, East Locality GP practices crude rate 2015/16

Data Source: Hospital Episode Statistics (Norfolk County Council)

Average cost of A&E attendance in Southend-on-Sea in 2015/16 was £102.60. Of the eight GP practices in East Locality, six had higher costs per attendance (Figure 99); Irlam A C & Partner (F81086), The Thorpe Bay Surgery (F81121), Shaftesbury Avenue Practice (F81209), Dr Kumar's Surgery (F81613), Dr Mario & Partners Surgery (F81649) and Dr Dhillon's Surgery (F81688).

Figure 99: Average cost per A&E attendance, East Locality Practices, 2015/16

Data Source: Hospital Episode Statistics (Norfolk County Council)

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Figure 100 below shows the percentage of patient who visited A&E and were subsequently admitted to hospital. Of the four practices that have a higher than NHS Southend CCG average (24%), all four have the higher than CCG average cost (Figure 99).

Figure 100: Percentage of patients who visited A&E who were admitted, East Locality, 2015/16

Data Source: Hospital Episode Statistics (Norfolk County Council)

10.3.1 A&E Attendances that could have been treated elsewhere Attending A&E for clinical conditions that could have been a more local setting is both inconvenient for patients and put additional and unsustainable pressure and cost on the Southend-on-Sea health economy. When attending A&E, the clinical complexity and cost of a patient’s investigation and treatment is coded into ten categories. These are then used to charge the CCG under the Payments by Results (PbR) tariff system. Coding for investigation and treatment runs from zero (no significant investigation/treatment) to five (the most clinically serious/complex investigation and treatment). As such, HRG coding is a good method of ascertaining the severity of clinical case mix of patients attending A&E.

Of 10,338 attendances from East Locality Practices 7,307 (71%) were classified into the three least clinically serious categories:  Emergency Medicine, No Investigation with No Significant Treatment  Emergency Medicine, Category 2 Investigation with Category 1 Treatment (including arterial/capillary blood gas, bacteriology, biochemistry, blood culture, cardiac enzymes, clotting studies, electrocardiogram, urinalysis, haematology, x-ray plain film)  Emergency Medicine, Category 1 Investigation with Category 1-2 Treatment (including arterial/capillary blood gas, biochemistry, dental investigation, electrocardiogram, pregnancy test, urinalysis)

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Figure 101: Number of A&E attendances by time of day, HRG investigation and treatment categories, East Locality Patients, 2015/16

Data Source: Hospital Episode Statistics (Norfolk County Council)

Figure 101 shows the breakdown of HRG coding for East Locality patients attending A&E in 2015/16. It shows the vast majority of patients in East attended A&E for investigations that were coded in the least clinically serious HRG coding categories.

There are similar numbers of attendances for most investigation and treatment categories during the day and at night time with the exception of those requiring category one investigations with category one or two treatments which are higher during normal hours. This indicates that most people with these conditions would rather attend A&E in the day daytime.

Table 14: Modelled cost per A&E visit 2015/16 Modelled Cost/Visit Number of Attendances Total Cost No investigation with no significant treatment £ 56.00 982 £ 54,992.00 Category 1 investigation with category 1-2 treatment £ 79.00 3,848 £ 303,992.00 Category 2 investigation with category 1 treatment £ 113.00 2,477 £ 279,901.00 Category 2 investigation with category 2 treatment £ 125.00 1,281 £ 160,125.00 Category 1 investigation with category 3-4 treatment £ 100.00 263 £ 26,300.00 Category 2 investigation with category 3 treatment £ 143.00 242 £ 34,606.00 Category 2 investigation with category 4 treatment £ 165.00 874 £ 144,210.00 Category 3 investigation with category 1-3 treatment £ 187.00 251 £ 46,937.00 Category 3 investigation with category 4 treatment £ 220.00 76 £ 16,720.00 Any investigation with category 5 treatment £ 233.00 7 £ 1,631.00 Data Source: Hospital Episode Statistics (Norfolk County Council)

Figure 102 shows the investigations performed at avoidable A&E attendances for East Locality Patients in 2015/16. These can broadly be categorised as attendances that could have been dealt with elsewhere in a primary care setting. The total cost of these to NHS

- 115 -

Southend CCG was £1,069,414 (Table 14). If the 71% patients who attended A&E who were classified into the three least clinically serious categories, which had a total cost of £638,885 had visited their GP instead, a potential saving of £310,070 could have been made (by applying the national average GP appointment cost of £45).

Figure 102: Investigations performed at avoidable attendances, East Locality Patients, 2015/16

Data Source: Hospital Episode Statistics (Norfolk County Council)

The most common diagnostic investigations performed at A&E for East patients were Blood Culture and Arterial/Capillary Blood Gas. However, the most common investigation recoded was no investigation meaning patients did not require any investigations in A&E.

10.3.2 A&E Diagnoses (all HRG coded attendances) The most common cause for East Locality patients to attend A&E in 2015/16 (Figure 103) was soft tissue inflammation (650 attendances) followed by laceration (337 attendances) and Gastrointestinal conditions (283 attendances). Many of these causes could have been seen in primary care setting if capacity were available.

- 116 -

Figure 103: Top 10 Reasons for attending A&E, 2015/16

Data Source: Hospital Episode Statistics (Norfolk County Council) 10.4 Unplanned Care Admissions The DSR for East Locality emergency admissions is 9,697.4 per 100,000 registered population. This is similar to the NHS Southend CCG DSR of 10,233.6 per 100,000 registered population as seen in Figure 104.

Figure 104: Emergency Admissions by Locality, DSR per 100,000, 2015/16

Data Source: Hospital Episode Statistics (Norfolk County Council)

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Figure 105 shows the DSR per 100,000 population of emergency admissions by GP practice. Irlam A C & Partner (F81086) and Dr Dhillon's Surgery (F81688) have significantly higher rates of emergency admissions than the East locality and NHS Southend CCG.

The Thorpe Bay Surgery (F81121), Dr Mario & Partners Surgery (F81649) and Dr Kumar's Surgery (F81613) all have significantly lower emergency admission rates.

Figure 105: Emergency Admissions by GP Practice, East Locality, DSR per 100,000, 2015/16

Data Source: Hospital Episode Statistics (Norfolk County Council)

The most common reasons recorded as the primary diagnosis for unplanned care admissions for East Patients in 2015/16 were Pain localized to other parts of lower abdomen (99 admissions), Urinary tract infection, site not specified (96 admissions) Chest pain, unspecified (79 admissions) as seen in Figure 106.

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Figure 106: Top 10 primary diagnosis for unplanned care admissions, East Locality patients, 2015/16

Data Source: Hospital Episode Statistics (Norfolk County Council) 10.5 Summary – Secondary Care In 2015/16 there were 7.085 outpatient attendances by East Locality patients. The most common specialities were Dermatology, Gynaecology and Ophthalmology.

Five of the eight practice populations had an A&E attendance rate above the NHS Southend CCG mean. In total there were 10,338 A&E attendances from patients registered to the eight GP practices in East. Of those, half of all patients attended A&E from East needed no significant investigation or treatment and 72% were classified into the three least clinically serious HRG categories. This suggests huge potential to reduce avoidable A&E attendances.

By far the most common diagnosis of patients attending A&E where no investigation or treatment was required, was that no diagnosis of illness was made or that the diagnosis ‘was not classifiable’. Where a positive diagnosis was made within this cohort, soft tissue inflammation, lacerations and Gastrointestinal conditions were common.

Out of the eight GP practices in East Locality, four had a directly standardised rate of unplanned care admissions greater than the NHS Southend CCG mean, two statistically significantly greater. The most common reasons were Pain localized to other parts of lower abdomen, urinary tract infections and chest pain.

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Appendix 1 – List of Figures Figure 1: Influences on health and wellbeing chain of events 7 Figure 2: East Locality GP Registered Population by Age and Sex, October 2016 8 Figure 3: Population by age band, by ward, 2013 9 Figure 4: Proportion of residents classifying themselves as from a BME group, by ward, 2011 10 Figure 5: Crude fertility rate per 1,000 female population aged 15-44, by ward, 2010-2014 11 Figure 6: Proportion of pensioners living alone, by ward, 2011 12 Figure 7: Number of care homes, by ward, Southend-on-Sea, November 2016 13 Figure 8: Rate of care home residents per 1,000 registered population with NHS Southend CCG practices, November 2016 13 Figure 9: 2015 IMD Score by LSOA's within East Locality 16 Figure 10: Average number of persons per household, by ward, Southend-on-Sea 17 Figure 11: Proportion of households with 1 or more rooms too few, by ward, 2011 18 Figure 12: Proportion of households without central heating, by ward, 2011 19 Figure 13: Proportion of working aged adults claiming a benefit in East Wards, February 2016 21 Figure 14: Rate of ESA Claimants for East Wards, February 2016 22 Figure 15: Proportion of people aged 16 years and over with no qualifications, by ward, 2011 23 Figure 16: Rate of crime per 1,000 population, by Ward, Southend-on Sea, April 2015 - March 2016 26 Figure 17: Proportion of households with no access to a car or van, by ward, 2011 27 Figure 18: Estimated smoking prevalence of smoking in adults aged 18+ 30 Figure 19: QOF recorded smoking prevalence, patients aged 15+, 2015/16 30 Figure 20: Percentage of patients aged 15+ recorded as setting quit date, NHS Southend CCG, 2015/16% setting quit date 32 Figure 21: Percentage of smokers successfully quitting at four weeks through an NHS Stop Smoking Service, NHS Southend CCG, 2015/16 33 Figure 22: Proportion of children classed as overweight or obese in reception class, by ward, 2012/13-2014/15 35 Figure 23: Proportion of children classed as overweight or obese in Year 6, by ward, 2012/13-2014/15 35 Figure 24: Percentage of population aged 16+ with a BMI of 30+, modelled estimate, By Ward, 2006-08 36 Figure 25: Referrals to Weight Management Service 2016/17 37 Figure 26: Modelled estimates of binge drinking, by ward, 2006-08 38 Figure 27: Teenage Conception Rate, per 1,000, by ward, 2012/14 40 Figure 28: Proportion of persons whose day-to-day activities are limited "a lot", East Locality wards, 2011 44 Figure 29: Proportion of survey respondents who had a long-standing health condition, East practices, July 2016 45 Figure 30: Life expectancy in Southend-on-Sea for males, by ward, 2009-13 46 Figure 31: Life expectancy in Southend-on-Sea for females, by ward, 2009-13 46 Figure 32: Premature Mortality in East Wards (Under 65 and 75 Years) 2010-14 47 Figure 33: Map of GP Practices in East Locality 48

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Figure 34: Number of Patients per FTE GP in NHS Southend CCG 2015/16 - 50 - Figure 35: Association between deprivation and number of patients per FTE GP - 51 - Figure 36: Ratio of patients to FTE Practice Nurses, East Practices 2015/16 - 52 - Figure 37: Pharmacies per 100,000 population in Southend-on-Sea, By Ward 2014 - 54 - Figure 38: 5 year olds visiting a dentist, rate per 1,000, by ward, 2014-15 - 55 - Figure 39: Average number of decayed, missing and filled teeth, by ward, 2014-15 - 56 - Figure 40: Proportion of patients who tried to contact an NHS service when GP surgery was closed in past 6 months, East GP practices 2015/16 - 57 - Figure 41: Recorded prevalence of the most common long-term conditions in East locality, NHS Southend CCG and England 2015-16 - 58 - Figure 42: Diagnosed and non-diagnosed hypertension in West - 59 - Figure 43: Effect of a national primary care pay for performance scheme on emergency hospital admissions for ambulatory care sensitive conditions - 61 - Figure 44: QOF indicators for Hypertension care 2015/16, F81086 (Irlam A C & Partner) - 63 - Figure 45: QOF indicators for Hypertension care 2015/16, F81121 (The Thorpe Bay Surgery) - 64 - Figure 46: QOF indicators for Hypertension care 2015/16, F81209 (Shaftesbury Avenue Practice) - 65 - Figure 47: QOF indicators for Hypertension care 2015/16, F81613 (Dr Kumar’s Surgery) - 65 - Figure 48: QOF indicators for Hypertension care 2015/16, F81622 (Dr Marasco Surgery) - 66 - Figure 49: QOF indicators for Hypertension care 2015/16, F81649 (Dr Mario & Partners Surgery) - 67 - Figure 50: QOF indicators for Hypertension care 2015/16, F81684 (North Shoebury Surgery) - 67 - Figure 51: QOF indicators for Hypertension care 2015/16, F81688 (Dr Dhillon’s Surgery) - 68 - Figure 52: QOF indicators for HF and AF 2014/15, F81086 (Irlam A C & Partner) - 70 - Figure 53: QOF indicators for HF and AF 2015/16, F81121 (The Thorpe Bay Surgery) - 71 - Figure 54: QOF indicators for HF and AF 2015/16, F81209 (Shaftesbury Avenue Practice) - 72 - Figure 55: QOF indicators for HF and AF 2015/16, F81613 (Dr Kumar’s Surgery) - 73 - Figure 56: QOF indicators for HF and AF 2015/16, F81622 (Dr Marasco Surgery) - 74 - Figure 57: QOF indicators for HF and AF 2015/16, F81649 (Dr Mario & Partners Surgery)- 74 - Figure 58: QOF indicators for HF and AF 2015/16, F81684 (North Shoebury Surgery) - 75 - Figure 59: QOF indicators for HF and AF 2015/16, F81688 (Dr Dhillon’s Surgery) - 75 - Figure 60 QOF indicators for stroke and TIA care 2015/16, F81086 (Irlam A C & Partner) - 77 - Figure 61: QOF indicators for stroke and TIA care 2015/16, F81121 (The Thorpe Bay Surgery) - 78 - Figure 62: QOF indicators for stroke and TIA care 2015/16, F81209 (Shaftesbury Avenue Practice) - 79 - Figure 63: QOF indicators for stroke and TIA care 2015/16, F81613 (Dr Kumar’s Surgery) - 80 - Figure 64: QOF indicators for stroke and TIA care 2015/16, F81622 (Dr Marasco Surgery) - 80 - Figure 65: QOF indicators for stroke and TIA care 2015/16, F81649 (Dr Mario & Partners Surgery) - 81 - Figure 66: QOF indicators for stroke and TIA care 2015/16, F81684 (North Shoebury Surgery) - 81 -

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Figure 67: QOF indicators for stroke and TIA care 2014/15, F81688 (Dr Dhillon’s Surgery) - 82 - Figure 68: QOF indicators for diabetes care 2015/16, F81086 (Irlam A C & Partner) - 84 - Figure 69: QOF indicators for diabetes care 2015/16, F81121 (The Thorpe Bay Surgery) - 85 - Figure 70: QOF indicators for diabetes care 2015/16, F81209 (Shaftesbury Avenue Practice) - 85 - Figure 71: QOF indicators for diabetes care 2015/16 F81613 (Dr Kumar’s Surgery) - 86 - Figure 72: QOF indicators for diabetes care, F81622 (Dr Marasco Surgery) - 87 - Figure 73: QOF indicators for diabetes care F81649 (Dr Mario & Partners Surgery) - 88 - Figure 74: QOF indicators for diabetes care F81684 (North Shoebury Surgery) - 89 - Figure 75: QOF indicators for diabetes care F81688 (Dr Dhillon’s Surgery) - 90 - Figure 76 QOF indicators for respiratory disease 2015/16, F81086 (Irlam A C & Partner) - 92 - Figure 77: QOF indicators for respiratory disease 2015/16, F81121 (The Thorpe Bay Surgery)- 93 - Figure 78: QOF indicators for respiratory disease 2015/16, F81209 (Shaftesbury Avenue Practice) - 93 - Figure 79: QOF indicators for respiratory disease 2015/16, F81613 (Dr Kumar’s Surgery) - 94 - Figure 80: QOF indicators for respiratory disease 2015/16, F81622 (Dr Marasco Surgery) - 95 - Figure 81: QOF indicators for respiratory disease 2015/16, F81649 (Dr Mario & Partners Surgery) - 96 - Figure 82: QOF indicators for respiratory disease 2015/16, F81684 (North Shoebury Surgery) - 96 - Figure 83: QOF indicators for respiratory disease 2015/16, F81688 (Dr Dhillon’s Surgery) - 97 - Figure 84: QOF 2014/15 recorded depression prevalence in patients aged 18+, East practices - 98 - Figure 85: GP practice prevalence of those aged 18+ diagnosed with a serious mental ill health, 2015/16 - 99 - Figure 86 QOF indicators for SMI/Depression/Dementia 2015/16, F81086 (Irlam A C & Partner) - 102 - Figure 87: QOF indicators for SMI/Depression/Dementia 2015/16, F81121 (The Thorpe Bay Surgery) - 103 - Figure 88: QOF indicators for SMI/Depression/Dementia 2015/16, F81209 (Shaftesbury Avenue Practice) - 103 - Figure 89: QOF indicators for SMI/Depression/Dementia 2015/16, F81613 (Dr Kumar’s Surgery) - 104 - Figure 90: QOF indicators for SMI/Depression/Dementia 2015/16, F81622 (Dr Marasco Surgery) - 105 - Figure 91: QOF indicators for SMI/Depression/Dementia 2015/16, F81649 (Dr Mario & Partners Surgery) - 106 - Figure 92: QOF indicators for SMI/Depression/Dementia 2015/16, F81684 (North Shoebury Surgery) - 107 - Figure 93: QOF indicators for SMI/Depression/Dementia 2015/16, F81688 (Dr Dhillon’s Surgery) - 108 - Figure 94: Modelled estimate of patients with 3 or more long-term conditions, East GP Practices - 109 -

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Figure 95: Modelled estimate of patients with long-term conditions and depression, East GP Practices - 109 - Figure 96: Top 10 most commonly performed outpatient procedures, East Locality patients, 2015/16 - 111 - Figure 97: Top 10 most commonly performed outpatient procedures, East Locality patients, 2015/16 - 112 - Figure 98: A&E attendances, East Locality GP practices crude rate 2015/16 - 113 - Figure 99: Average cost per A&E attendance, East Locality Practices, 2015/16 - 113 - Figure 100: Percentage of patients who visited A&E who were admitted, East Locality, 2015/16 - 114 - Figure 101: Number of A&E attendances by time of day, HRG investigation and treatment categories, East Locality Patients, 2015/16 - 115 - Figure 102: Investigations performed at avoidable attendances, East Locality Patients, 2015/16 - 116 - Figure 103: Top 10 Reasons for attending A&E, 2015/16 - 117 - Figure 104: Emergency Admissions by Locality, DSR per 100,000, 2015/16 - 117 - Figure 105: Emergency Admissions by GP Practice, East Locality, DSR per 100,000, 2015/16 - 118 - Figure 106: Top 10 primary diagnosis for unplanned care admissions, East Locality patients, 2015/16 - 119 - Figure 107: GP Practice Recorded Depression Prevalence in those aged 18+, 2015/16, with CIs - 127 - Figure 108: GP Practice Prevalence of those aged 18+ diagnosed with a serious mental ill health, 2015/16, with CIs - 127 - Figure 109: Association between deprivation and number of patients per FTE GP, East Locality - 128 -

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Appendix 2 – List of Tables Table 1: Adaptations to council accommodation 2014/15 & 2015/16 20 Table 2: Number of known developments in East Locality Wards 2016-2021 20 Table 3: Breastfeeding prevalence at 6-8 weeks, NHS Southend CCG, 2015-16 29 Table 4: Information in the eight GP practices in East Locality 49 Table 5: Additional services provided with General Practice - 53 - Table 6: Estimated number of undiagnosed LTC by practice, East Locality - 60 - Table 7: QOF Hypertension Exception reporting rates for East GP Practices 2015/16 - 62 - Table 8: Heart Failure & Atrial Fibrillation Exception reporting rates for East GP Practices 2015/16 - 70 - Table 9: Stroke & TIA and Peripheral Arterial Disease Exception reporting rates for East GP Practices 2015/16 - 76 - Table 10: Diabetes Mellitus exception reporting rates for East GP Practices 2015/16 - 83 - Table 11: Respiratory Disease exception reporting rates for East GP Practices 2015/16 - 91 - Table 12: IAPT referrals - 100 - Table 13: Mental Health exception reporting rates for East GP Practices 2015/16 - 101 - Table 14: Modelled cost per A&E visit 2015/16 - 115 -

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Appendix 3

Figure 107: GP Practice Recorded Depression Prevalence in those aged 18+, 2015/16, with CIs

Data Source: Quality Outcomes Framework 2015/16

Figure 108: GP Practice Prevalence of those aged 18+ diagnosed with a serious mental ill health, 2015/16, with CIs

Data Source: Quality Outcomes Framework 2015/16

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Figure 109: Association between deprivation and number of patients per FTE GP, East Locality

Data Source: ONS & NHS digital

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