The Seven Wards: A Focus on

Author: Simon Collins (Public Health Knowledge and Intelligence analyst) Contributors: Dr Angela Tucker (Public Health Registrar) , Dr Farha Abbas (Public Health Knowledge and Intelligence analyst)

Project sponsor: Karen Thompson (Public Health Consultant)

Date: March 2015

The seven wards

Map of the West Wards (seven wards in Skelmersdale highlighted)

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The seven wards

Contents

Introduction ...... 3 Summary ...... 4 MOSAIC Profiling ...... 5 Population breakdown ...... 6 Rural/urban classification and deprivation...... 6 Rural/urban classification ...... 6 Income Deprivation (%) ...... 7 Children 0–15 living in income-deprived households (%) ...... 8 Older People in Deprivation (%) ...... 8 Burden of disease ...... 9 QOF Registers ...... 9 Recorded versus estimated prevalence ...... 9 Cancer incidence ...... 11 Mental Health ...... 11 Urgent care attendances ...... 11 Children and young people ...... 11 All ages ...... 11 Emergency hospital admissions ...... 12 Emergency hospital admissions for all causes (SAR) ...... 12 Emergency hospital admissions for Chronic Obstructive Pulmonary Disease (COPD) (SAR) ...... 12 Lifestyle indicators ...... 13 Obesity ...... 13 Healthy eating ...... 15 Alcohol ...... 15 Tobacco ...... 16 Adult smoking ...... 16 Childhood smoking ...... 17 Drug misuse ...... 17 Mortality indicators ...... 18 All cause premature mortality ...... 18 Premature cancer mortality ...... 19 Premature mortality from circulatory disease ...... 19 Respiratory disease mortality ...... 20 Infant mortality ...... 20 Underlying cause of mortality ...... 21 Diseases of the circulatory system ...... 22 Neoplasms ...... 24 Diseases of the respiratory system...... 25 Mortality from causes considered amenable to health care ...... 26 Conclusions ...... 27 Appendix A: district life expectancy at ward level – 2009-13 ...... 28 Appendix B: Population breakdown (percentage of population in each age band) by ward ...... 29 Appendix C: Practices by ward ...... 30 Appendix D: Recorded prevalence as a percentage of expected prevalence ...... 31

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The seven wards

Introduction

This report provides an insight into the health of the population of the seven most deprived wards of the West Lancashire district, these being Ashurst, Birch Green, Digmoor, Moorside, Skelmersdale North, Skelmersdale South and Tanhouse. The aim of this report is to identify the key health issues and needs of the seven wards, which can then be used to guide local interventions and policies to improve the health and wellbeing of the people living within these wards.

These seven wards are not only the most deprived wards within the West Lancashire district, they are amongst the most deprived wards of the whole Lancashire-141 area and in . Six of the wards fall into the most deprived 20% nationally and four of these within the most deprived 5% nationally.2 Furthermore these seven wards were found to have the highest proportions of children aged 0–15 living in income-deprived households and the highest proportions of adults aged 60 or over living in pension credit (guarantee) households in West Lancashire.

The link between deprivation and poor health is well established with those living in the more affluent areas of England estimated to live almost 20 more years of healthy life than those in the most disadvantaged areas3. Despite efforts to reduce health inequalities through policies and interventions since the 1980 Black Report (DHSS, 1980), a large and persistent gap has remained4.

Using the ONS mid-year population estimates 2009-2013 and the Open Exeter mortality files for the same period, we were able to calculate the estimated life expectancy at birth for males and females within the various wards of West Lancashire. For males, life expectancy at birth ranged from 83 in Derby to 73.6 in Tanhouse: a difference of 9.4 years. For females, life expectancy at birth ranged from 87.6 in to 76.1 in Birch Green: a difference of 11.5 years. We also looked at life expectancy at 75 to fit in with the premature mortality analysis found later on in this report. For males, life expectancy at 75 ranged from 14.3 in Knowsley to 8.1 in Birch Green: a difference of 6.2 years. For females, life expectancy at 75 ranged from 19.4 in Moorside to 7.8 in Tanhouse: a difference of 11.6 years (Appendix A).

1 The Lancashire-14 refers to the area covered by the Lancashire county along with the with and unitary authorities. 2 Based on IMD:2010 : The percentage of the population living in low income families reliant on means tested benefits. 3 Public Health England. (2014). Reducing health inequalities – key resources. Available: https://publichealthmatters.blog.gov.uk/2014/10/03/reducing-health-inequalities-key-resources/. Last accessed 26/01/2014. 4 Office for National Statistics. (2014). Inequality in Healthy Life Expectancy at Birth by National Deciles of Area Deprivation: England, 2009- 11. Statistical Bulletin. p1-2. 3

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Summary

The population of the seven wards is younger than elsewhere in West Lancashire, with a greater proportion of children under the age of 15. Life within the seven wards seems much harder than elsewhere, with higher levels of deprivation at all stages of life. There are poorer levels of healthy eating and high levels of obesity amongst both the adults and children of the seven wards and they also have higher levels of hospital admissions due to alcohol-related harm than their neighbours from elsewhere within West Lancashire. There are higher levels of premature morality from cancer and circulatory disease and higher infant mortality. Within the 7 wards, the majority of fatalities between 2006 and 2013 were from persons aged 65-89, whilst outside of the seven wards the majority of fatalities came from persons aged 70-94.

In contrast to accepted evidence that links deprivation to chronic illness, the burden of disease within the seven wards was found, in many cases, to be similar to that in the other parts of the district. However our analysis was limited to the general practice disease registers and all-cancer incidence rates. Perhaps this finding suggests that work needs to be done to identify and diagnose more individuals from the seven wards; whilst this would increase the QoF disease prevalence amongst the practices of these wards, it would be a positive move which could result in better outcomes for the residents of these areas and in time potentially bring down the premature mortality rates of the seven wards.

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The seven wards

MOSAIC Profiling

Using Experian's MOSAIC profiler tool and the latest population estimates (Mid-year 2013) we are able to obtain a more detailed picture of the kind of people living in the seven wards. In the Birch Green, Digmoor, Moorside, Skelmersdale North and Tanhouse wards the main population group was 'Family basics' which refers to households containing families with limited resources who have to budget to make ends meet, the key features of this grouping breakdown as follows:

 Families with children  Aged 25 to 40  Limited resources  Some own low cost homes  Some rent from social landlords  Squeezed budgets

The next biggest population group within these five wards was households classed as 'Municipal Challenge' and this refers to households considered to be urban renters of social housing facing an array of challenges, the key features of which are:

 Social renters  Low cost housing  Challenged neighbourhoods  Few employment options  Low income

In Ashurst the main population group was 'Domestic success' made up of households containing thriving families who are busy bringing up children and following careers with the key features:

 Families with children  Upmarket suburban homes  Owned with a mortgage  3 or 4 bedrooms  High Internet use  Own new technology

This is in contrast to next biggest population group within the ward, which was found to be the 'Family basics' grouping, which we have seen in other areas of the district.

Finally, analysis of the Skelmersdale South population found the biggest population group to be those households considered 'Modest Traditions', which refers to mature homeowners of value homes enjoying stable lifestyles. The key features of this group are:

 Mature age  Homeowners  Affordable housing  Kids are grown up  Suburban locations  Modest income

The next biggest population grouping in Skelmersdale South was made up of households classed as 'Transient Renters' defined as 'single people privately renting low cost homes for the short term' the key features of this group are:

 Private renters  Low length of residence  Low cost housing  Singles and sharers  Older terraces  Few landline telephones

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Population breakdown

Figure one shows the population pyramid for the seven wards and also for the other 18 West Lancashire wards. The population distributions differ significantly between the two groups. The pyramid for the seven wards has a wide base and a narrow top representing large proportions of young children and small proportions of older age groups respectively. On the other hand, the pyramid for the other 18 West Lancashire wards has a narrower base and a less narrow top representing the lower proportions of young children and higher proportions of older people relative to the seven wards pyramid. Appendix B provides a more detailed breakdown of the population.

Figure 1: Population pyramid – The seven wards compared to other West Lancashire wards

Rural/urban classification and deprivation

Rural/urban classification

Using the 2009 Urban/Rural Classification system5 we are able to obtain an insight into the kind of setting these seven wards present. The West Lancashire district as a whole falls under the Rural-50 (R50) classification, referring to districts with at least 50 per cent, but less than 80 per cent of their population living in rural settlements and larger market towns.

The ward level classifications are slightly more simplistic with areas being defined as either Urban > 10k, Town and Fringe or Village Hamlet & Isolated Dwellings. All of the seven wards fall under the Urban > 10k classification, along with the wards of Aughton and , Aughton Park, Derby, Knowsley, Scott and . However, these six areas all have much lower levels of deprivation than the seven wards.

5 2009 Rural Classification http://www.ons.gov.uk/ons/guide-method/geography/products/area-classifications/rural-urban-definition-and-la/rural-urban-local- authority--la--classification--england-/index.html 6

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Figure 2: West Lancashire ward level Urban / Rural classification Area Name Urban/Rural Classification IMD score

Ashurst Urban > 10k 16.5

Aughton and Downholland Urban > 10k 6.1 Aughton Park Urban > 10k 5.3 Village Hamlet & Isolated Dwellings 6.8 Birch Green Urban > 10k 32.2 East Town and Fringe 9.9

Burscough West Town and Fringe 9.9 Derby Urban > 10k 9.4 Digmoor Urban > 10k 34.7 Village Hamlet & Isolated Dwellings 9.2 Hesketh-with-Becconsall Town and Fringe 7.1

Knowsley Urban > 10k 9

Moorside Urban > 10k 37.1 Newburgh Village Hamlet & Isolated Dwellings 6.8 Town and Fringe 9.6 Town and Fringe 5.9 Rufford Village Hamlet & Isolated Dwellings 9.6

Scarisbrick Village Hamlet & Isolated Dwellings 9.2

Scott Urban > 10k 9 Skelmersdale North Urban > 10k 26.2 Skelmersdale South Urban > 10k 18.5 Tanhouse Urban > 10k 28.7 Tarleton Town and Fringe 7.6

Up Holland Urban > 10k 11.6

Wrightington Village Hamlet & Isolated Dwellings 7.6

Income Deprivation (%)

The income deprivation indicator comes from the Index of multiple deprivation 2010 (IMD2010) and is based on the percentage of the population of an area living in low income families reliant on means tested benefits. With all seven wards found to be significantly worse than the England average, it is no surprise to find that all seven areas also have the highest proportions of families reliant on means tested benefits within West Lancashire. Further analysis shows that they are the only wards from the district to have recorded levels significantly above the England average, with the other West Lancashire wards recording levels significantly below the England average.

Figure 3: Income Deprivation (%) - The percentage of the population living in low income families reliant on means tested benefits, IMD2010

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The seven wards

Children 0–15 living in income-deprived households (%)

This indicator is a measure of children living in poverty. Growing up in poverty damages children’s health and well-being, adversely affecting their future health and life chances as adults. Ensuring a good environment in childhood, especially early childhood, is important. A considerable body of evidence links adverse childhood circumstances to poor child health outcomes and future adult ill health. These figures indicate that the seven wards all have the highest proportion of children living in poverty within the district with five of the wards (Moorside, Digmoor, Birch Green, Tanhouse and Skelmersadale North) all recording levels significantly higher than the England national average.

Figure 4: Proportion of Children 0–15 living in income-deprived households (%)

Older People in Deprivation (%)

The older people in deprivation indicator comes from the IMD2010 and is based on the proportion of adults aged 60 or over living in pension credit (guarantee) households. The data presents a very similar picture to the income deprivation indicator with the seven wards all having the highest proportions within the district and again being the only wards within the district to record levels significantly above the England national average.

Nationally, all seven wards fall within the top 11% of wards across England and within Lancashire they all fall within the top 15%.

Figure 5: Proportion of Adults aged 60 or over living in pension credit (guarantee) households as a percentage of all adults aged 60 or over

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Burden of disease

QOF Registers

Whilst not an exact measure, we have used the Quality and Outcomes Framework (QOF) to get a feel for burden of disease within the seven wards based on the GP practices that sit within them. It is important to remember with QOF analysis that having a high prevalence can be either a positive or a negative. Positive in that it could be an indication of effective screening and detection methods and/or it could be an indication of a more engaged or educated/informed population. Negative as it could be a sign that a practice population has particularly high levels of certain diseases. It is also known that many of the disease registers are in fact under-reporting the true scale of the problem. This includes areas such as depression and obesity where patients may not wish to seek help due to the stigma around these conditions and undiagnosed cases of illnesses such as dementia and cardiovascular disease.

Going forward it would be advisable that the CCG obtain an extract of the disease registers for each of the West Lancashire practices including patient post code or LSOA of usual residence. This can then be used to determine a truer burden of disease within the seven wards. Additionally, this further work could also help the CCG to identify those individuals who are on more than one disease register.

22 practices from West Lancashire submitted data to the QOF programme for 2013/14, of these eight are located within four of the seven wards (Ashurst, Moorside, Skelmersdale South and Tanhouse). The remaining 14 practices are split up over nine different wards (Appendix C). A total of 39,717 people are registered to the eight practices which sit within the seven wards, this equates to 35% of the CCGs registered population. Of these 26,932 sit on one of the 22 disease registers of the practices from the seven wards. This accounts for 68% of the total registered population, although as stated previously it is possible for patients to be on more than one register and it is highly likely that this figure will include such patients. There are 72,229 persons registered to the 14 practices outside of the seven wards and 49,538 are on one of the disease registers (again this will include patients who sit on more than one disease register) accounting for 69% of the registered population, so a very similar figure to the seven wards despite the fact the seven wards have higher levels of deprivation and as such should, going off accepted evidence base, have a higher disease burden.

Examining the different disease registers in more detail we made the following observations:

 26% of the registered patients from the practices within the seven wards are on one of the cardiovascular disease registers, compared to 29% of patients registered to practices from within other wards  9% are on one of the respiratory disease registers compared with 8% from the other areas  12% are on the adult (16+) obesity register, compared with 8% from the other areas  13% are on one of the high dependency and other long term conditions registers, compared to 15% from the other areas. This includes 7% of persons from the seven wards aged 17+ who are on the diabetes mellitus register and 4% of persons aged 18+ who are on the chronic kidney disease register  9% are on one of the mental health and neurology group registers, compared with 2% in other areas. This includes 10% of persons aged 18+ from the seven wards who are on one of the following registers: Depression (9%), Epilepsy (1%) and Learning Disabilities (1%)  1% are on one of the musculoskeletal registers, which is equal to the other areas where 1% of the registered population are also on one of the musculoskeletal registers. The includes 1% of persons aged 50+ from the seven wards on the osteoporosis register and 1% aged 16+ who are on the rheumatoid arthritis register.

In total there are around 27,000 people from the practices of Skelmersdale on the disease registers, and around 50,000 from the practices elsewhere and whilst these figures will include people on multiple disease registers, this equates to 68% of the registered population of Skelmersdale and 69% of the registered population of the rest of West Lancashire, and when we look at a crude rate per 1,000 there are 678 Per 1,000 on the disease registers from the practices of the seven wards and 686 per 1,000 from the rest of West Lancashire.

Recorded versus estimated prevalence

For several conditions, there exists a disparity between the number of patients diagnosed and reported through the QoF and prevalence estimates from large surveys. An estimation model was therefore developed with the aim of giving a more accurate estimate of the true prevalence of certain diseases at local authority and general practice level. The estimation model was developed by Imperial College and uses data from the 2003-2004 Health Surveys for England.

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We therefore looked at recorded QoF prevalence as a percentage of estimated (modelled) prevalence by GP practice in West Lancashire for 4 conditions (hypertension, COPD, coronary heart disease and stroke) in order to determine whether there was any evidence of significant underdiagnosis within the 7 wards.

The results suggest that hypertension is the most underdiagnosed condition of the 4, with recorded prevalence at 50% of estimated prevalence for England. None of the practices within the 7 wards had a percentage lower than the England average for hypertension. This pattern was also seen for COPD with all Skelmersdale practices having a recorded prevalence at over 80% of estimated prevalence (See Appendix D for graphs).

For coronary heart disease and stroke however, a number of GP practices within the 7 wards have a percentage recorded versus estimated prevalence lower than the England average (figures 6 and 7). Practices within the 7 wards are displayed in red. There is therefore evidence for room for improvement in diagnosis and recording in all for conditions but in particular for hypertension, coronary heart disease and stroke.

Figure 6: Recorded prevalence as a percentage of estimated prevalence 2010/11 (coronary heart disease)

Figure 7: Recorded prevalence as a percentage of estimated prevalence 2010/11 (stroke)

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Cancer incidence

The Local Health tool provides ward level breakdown of incidence of all-cancers, breast cancer, colorectal cancer, lung cancer and prostate cancer. But for this report we have focused purely on the incidence of all-cancers data, to gain a general overview of the current situation within West Lancashire. The figures cover the period 2007-2011 and are presented as a Standardised incidence ratio. Analysis of the figures found that whilst four of the seven wards (Tanhouse, Birch Green, Skelmersdale North and Digmoor) have recorded the highest rates within the district no ward has recorded a rate significantly above the England average. The district as a whole recorded a SIR of 96.7 with the wards recording an SIR ranging from 119.3 (19% higher than the England average) in Tanhouse to 88.2 (12% lower than the England average) in Derby.

Mental Health

There is a strong body of evidence that living in poverty brings with it poorer mental health, and that the stresses of living in poverty increase the risk of developing mental health problems. In addition living with a mental health problem brings with it increased social disadvantage, such as higher levels of unemployment6.

Mental health can be a data poor area, particularly at ward level, however the Local Health tool provides us with data on hospital stays for self-harm at ward level allowing us to see that between 2008 and 2013 there were 1,103 hospital stays for self-harm from the West Lancashire district with 51% of these admissions coming from the seven wards. Using the standardised admission ratio and benchmarking the West Lancashire wards against the England national rate shows us that six of the seven wards have recorded rates significantly worse than the England national average, with the Ashurst ward recording a rate in line with the England average.

Figure 8: Hospital stays for intentional self-harm

Urgent care attendances

Earlier this year Lancashire County Council conducted an analysis of urgent care attendances recorded by the registered population of the West Lancashire CCG between April 1st 2011 and March 31st 2014. Copies of this work are available upon request and some of the key findings are outlined below:

 Children and young people  Urgent care attendance rates in children and young people under the age of 25 in West Lancashire vary considerably by GP practice, from 441 per 1000 in Tarleton Group Practice to 1216 per 1000 in Ashurst Primary Care. The seven practices with the highest rates of urgent care attendances are all located in and around Skelmersdale.7  All ages  The 8 practices located within the seven wards have notably higher proportions of walk-in-centre attendances compared to practices in other areas. This is likely to be at least in part connected to the proximity of patients registered with these practices to the Skelmersdale walk-in centre.8

6 The Mental Health Foundation . (2013). Starting today : Background Paper 3: Mental Health and Inequalities. 7 Please refer to "Population-based analysis of urgent care attendances in children and young people in West Lancashire" December 2014 8 Please refer to "Analysis of urgent care attendances by patients registered in the West Lancashire CCG footprint" September 2014 11

The seven wards

Emergency hospital admissions

The Local Health tool provides ward level data for emergency admissions for a number of different areas and as discussed at the beginning of this report the seven wards have all performed poorly against the England national average for admissions for all-causes and for chronic obstructive pulmonary disease (COPD) and we will now look at these two areas in more detail.

Emergency hospital admissions for all causes (SAR)

The emergency admissions for all causes data covers the time period 2008-13 and comparisons are done using a Standardised Admission Ratio (SAR). Examining this data shows us that once more the seven wards have recorded the highest rates within the West Lancashire district and all seven have recorded rates significantly above the England average.

Figure 9: Emergency hospital admissions for all causes (SAR) 2008-13

Emergency hospital admissions for Chronic Obstructive Pulmonary Disease (COPD) (SAR)

The Emergency admissions for COPD indicator is based on hospital activity recorded 2008-13 and once again we find the seven wards have recorded the highest rates within West Lancashire and again all seven have recorded rates significantly above the England national average. Benchmarking against all wards across the Lancashire-14 shows that these seven wards fall within the top 12% and nationally all seven fall within the top 5%.

Figure 10: Emergency hospital admissions for Chronic Obstructive Pulmonary Disease (COPD) (SAR)

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Lifestyle indicators

The ward level lifestyle indicators cover alcohol, obesity (adult / children's), healthy eating adults, childhood smoking and children's admissions for injury. For this report children's admissions for injury data has not been analysed in detail at this point in time, however it is an area that six of the seven wards recorded rates significantly above the England average, so going forward it may be an area of interest to the CCG.

Obesity

The data on the Local Health tool currently displays adult obesity data based on the Health Survey for England 2006-08 and more up to date district level adult obesity estimates are available from Sport England as part of their Active People survey. Furthermore, an update of the Health Survey for England was recently published and as such we expect the ward level figures on the Local Health tool to be updated in the near future. Comparing the estimated adult obesity prevalence for West Lancashire, from the Health Survey for England 2006-08 (22.7%) and the Active People Survey 2012/13 (22.5%), shows that they are almost identical and as such we felt that it would be acceptable to continue to use the ward level estimates from the Local Health tool until they are updated. The Health Survey for England 2006-08 ward level, adult obesity estimates suggest that there are some wide variances across West Lancashire. With prevalence levels ranging from 17% in Derby, to 29% in Moorside and comparing the West Lancashire wards shows that once more the seven wards of Ashurst (24.6%), Birch Green (28.2%), Digmoor (28.9%), Moorside (29.3%), Skelmersdale North (26.7%), Skelmersdale South (28.8%) and Tanhouse (27.8%) have the highest rates in the district.

The childhood obesity data comes from the National Child Measurement Programme (NCMP) and at a district level is a far more robust dataset when compared to the adult obesity estimates due to the way in which the data is collected. It focuses on two age groups, those in reception year (ages 4-5) and those in year six (ages 10-11) and has been updated annually since 2006. At a ward level the sample size used is much smaller, with an average of 75 children measured for each NCMP age group. As with all smaller area analysis the sample may be affected by small number variation and may therefore not provide a reliable estimate of the true value in the underlying population. However there is a demand for small area and population level NCMP data in order to target interventions at the most at risk communities within a local area, or to monitor change over time. In addition, this data can be used to evaluate whether schemes to encourage healthy eating or physical activity that have been implemented in certain areas or schools have led to a change in obesity prevalence. In many cases NCMP data may be able to fulfil these requirements9.

At a district level the NCMP figures are available for the years 2006/07 and 2013/14 allowing us to produce an eight year trend line as well as examining what happened to the 2006/07 and 2007/08 reception age population as they moved into year 6 in 2012/13 and 2013/14. This shows us that whilst the reception age obesity levels have remained fairly consistent over this period, the year six prevalence has consistently shifted to and from a high of 21% down to 19%. We can also see the 2006/07 reception age sample (highlighted in purple) had an obesity prevalence of 11.7%, then moving forward to 2012/13, now in year six the same population was estimated to have an obesity prevalence of 21.6%, an increase of 9.9%. Similarly the 2007/08 reception age sample (highlighted in green) went from having an estimated obesity prevalence of 10.2%, to a prevalence of 18.8% when it reached year six in 2013/14 an increase of 8.6%. Whilst this shows that the obesity situation got worse for these two populations and although we cannot draw any conclusions based on just two periods, this reduction in the increase (10% vs 9%) could be an encouraging sign and it will be interesting to see the difference between the 2008/09 reception age population and 2014/15 year six population when the figures are published.

9 National Child Measurement Programme. (2011). Guidance for small area analysis. NCMP. p4-5. 13

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Figure 11: West Lancashire NCMP reception and year six age obesity estimates trend line – 2006/07 to 2013/14

The Local Health tool provides the NCMP ward level childhood obesity figures for the pooled financial years 2010/11, 2011/12, and 2012/13. Looking at the figures we find the Skelmersdale South ward has significantly higher estimated obesity levels for both reception age and year six children than the national average. The Digmoor has a significantly higher year six obesity prevalence while Aughton Park is estimated to have a significantly lower level of year six obesity than the national average.

Figure 12: NCMP childhood obesity prevalence 2010/11 – 2012/13

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Healthy eating

The healthy eating adults' data is also an estimate based on the Health Survey for England 2006-08 and at this point in time we cannot confirm whether or not this dataset will be included within the latest update. These figures indicate that in the West Lancashire district just 27% of people are estimated to be eating the recommended five portions of fruit and vegetables a day, which is below the England average of 29%. Breaking this down by ward, shows us that the seven wards are all estimated to have healthy eating levels significantly below the England average; Ashurst (22.5%), Birch Green (17.5%), Digmoor (17.2%), Moorside (16.3%), Skelmersdale North (19.6%), Skelmersdale South (20.4%) and Tanhouse (19.2%).

The results of the Pupil Attitude Questionnaire, which gives us an insight into the eating habits of primary school age children, were examined as part of the Healthy Behaviours JSNA. The latest figures covering 2012/13 indicate that 80% of responders10 from West Lancashire would choose a health food option for lunch. Whilst this is a fairly positive finding, it does however indicate that 20% of responders would not choose a healthy lunch option.

Alcohol

Alcohol is England’s second biggest cause of premature deaths behind tobacco11. The 2011 General Lifestyle Survey found that 34 per cent of men and 28 per cent of women reported that they exceeded the current alcohol consumption guidelines on at least one day in the last week.

The hospital stays for alcohol related harm indicator from the Local Health Tool, refers to hospital admissions where the primary diagnosis or any of the secondary diagnoses contain an alcohol-attributable condition and covers the time period 2008-13. These figures indicate that again the seven wards have recorded the highest rates within West Lancashire and are again all significantly above the England national average.

Figure 13: Hospital stays for alcohol related harm (SAR) 2008-13

Alcohol features as one of the theme areas of the Lancashire healthy behaviours JSNA project, which should be published later this year (The target is April 2015). Findings from the secondary data analysis process of the project, show that West Lancashire as a whole recorded significantly more alcohol-specific attendances than the England average (2012/13) and that 87% of people who died from chronic liver disease including cirrhosis (2010-12), from West Lancashire, were under the age of 75.

10 There were 1,961 responders to the Pupil Attitude Questionnaire from the West Lancashire district in 2012/13 11 Public Health England, (2012), Longer Lives, Available: http://longerlives.phe.org.uk 15

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Tobacco

The tobacco epidemic is one of the biggest public health threats the world has ever faced, killing nearly six million people a year and up to half of all current users will eventually die of a tobacco-related disease12. Studies suggest that Nicotine, a psychoactive component of tobacco, plays a major role in tobacco dependence and is highly addictive. However, it is primarily the toxins and carcinogens in tobacco smoke that cause illness and death13. Smoking continues to be a public health concern, with an ongoing focus on the protection of children and young people from its harmful effects14.

The White Paper Healthy lives, healthy people: a tobacco control plan for England, published in 2011, set out a strategy for reducing tobacco use in the next five years, with the stated aim ‘to reshape social norms to make smoking less desirable, less acceptable, and less accessible’.6 The plan acknowledged that tobacco use amongst adults must be addressed in order to reduce the number of young people who take up smoking. It identified three national ambitions to reach by the end of 2015:

 to reduce smoking prevalence amongst adults in England to 18.5% or less;  to reduce the proportion of 15 year olds who are regular smokers to 12% or less; and  to reduce rates of smoking throughout pregnancy to 11% or less.

Adult smoking

2013 Integrated Household Survey (IHS) suggests that 17% of the West Lancashire population aged 18+ smoke, which is in line with the national average of 18%. Data from QoF and from the GP patient survey shows that smoking prevalence varies significantly by practice. This variation can be seen in figure 13 which also shows that the Skelmersdale practices (in bold) have the highest smoking prevalence rates within West Lancashire.

Of the 28,605 people on the West Lancashire GP QoF 2013/14 smoking register, 34% (9,606) come from the eight practices based within Skelmersdale, accounting for 30% of their 15+ population as per QoF 2013/14.

Figure 14: Recorded and estimated smoking prevalence 2013/14

12 World Health Organization. (2014). Tobacco Factsheet. Available: http://www.who.int/mediacentre/factsheets/fs339/en/. Last accessed 05/06/2014 13 Public health guidance, PH45 - Issued: June 2013, smoking tobacco harm reduction approaches pathway 14 Health and Social Care Information Centre (HSCIC). (2012). Smoking, Drinking and Drug Use Among Young People in England. 16

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Childhood smoking

According to findings from work carried out by the Department of Geography, University of Portsmouth and Geography and Environment, University of Southampton an average of 3.5% of young people across the 25 wards of West Lancashire, aged 11-15 are regular smokers, with the figures ranging from 6.3% in Birch Green to 2.4% in Aughton Park and Hesketh-with- Becconsall. These figures differ from the 2013 Trading Standards Alcohol and Tobacco survey which found that across the Lancashire County 16% of young people aged 14-17 claimed to be regular smokers. However, the work on the Local Health tool was based on modelled estimates and looked at a different population group than the Trading Standards survey.

Figure 15: PHE Local Health Tool – West Lancashire district Regular smoker (modelled prevalence, age 11-15)

Drug misuse

Drug misuse is a complicated, cross-cutting issues that continues to present significant challenges both locally and nationally. Drug-related harms do not only vary according to the different types of drugs being used but also the way a drug is used, the way it is used in combination with other substances and the social context in which they are used. Drugs do not only impact on those involved in misuse but on society as a whole. From crime to families affected by drug dependency and the corrupting effect of drug dealing and internationally organised crime. Drugs have a profound and negative effect on communities, families and individuals15. Data from the Public Health Outcomes Framework Tool suggests that in 2010/11 3.1per 100,000 people aged 15-64 from West Lancashire were opiate and/or crack cocaine users, significantly below the England average of 8.6.

Unfortunately ward level drugs misuse data isn’t readily available, however data from the Multi Agency Data Exchange (MADE) does suggest that for 2013/14 period there were 239 ambulance call outs to West Lancashire for reasons relating to Overdoses, Ingestion and Poisoning. Breaking this activity down by ward showed us that 43% of these call outs were to the seven wards.

As part of the research conducted by Lancashire Drug and Alcohol Action Team (LDAAT) and Lancaster University, 66% of a small focus group of young adults in Lancashire-14 (data only available at Lancashire-14 level) reported that they had tried an illicit drug at least once in their lifetime. In 2011/12 there were 258 young people (aged 15-17) in drug treatment services from the Central Lancashire locality.

15 Lancashire County Council (2012), Alcohol, Drugs and Tobacco in Lancashire Section 2: Drugs, Intelligence for Healthy Lancashire (JSNA) 17

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Mortality indicators

Thousands of people in England could avoid an early death from one of the five most common killers:

 Cancer  Heart disease  Liver disease  Respiratory disease  Stroke

Early diagnosis and better treatment could help tackle these potentially avoidable illnesses, but a few key lifestyle changes could also help you reduce your risk of getting them in the first place16.

For this section of the report we have focussed on premature mortality, initially looking at the picture as a whole then examining the data for three key areas, all of which can be affected by the lifestyle of a population, these being premature cancer mortality, premature mortality from circulatory disease and finally respiratory disease mortality which unfortunately at the time of publication we were unable to obtain the premature mortality rates for.

The latest figures cover the period 2008-12, and refer to mortality of persons aged 74 and under and in each case we have focussed on the current situation. Additionally readers should note that this data is based on the resident population of West Lancashire

All cause premature mortality

Six of the seven wards have recorded all cause premature mortality rates significantly above the England national rate, with the Ashurst ward recording a rate in line with the national average. This could be a sign of the impact of Ashurt's less deprived population in comparison to other six wards, based on the IMD2010 and the MOSAIC profiling.

The six wards of Birch Green, Digmoor, Moorside, Skelmersdale North, Skelmersdale South and Tanhouse all fall within the top 23% of wards in the Lancashire-14 for premature mortality, whereas Ashurst sits in the bottom 45%.

Figure 16: Premature mortality from all causes 2008-12

16 NHS Choices. (2014). The top 5 causes of premature death. Available: http://www.nhs.uk/LiveWell/over60s/Pages/The-top-five-causes- of-premature-death.aspx. Last accessed 27/01/2014. 18

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Premature cancer mortality

With the premature cancer mortality figures, we again see the Ashurst ward move away from other six wards that this report focuses on, recording a much lower premature cancer mortality rate than its neighbours. Unlike with the other indicators we have examined in this report, only two of the seven wards have recorded a rate significantly above the England national rate, these being the Digmoor and Skelmersdale South wards.

Figure 17: Premature mortality from cancer 2008-12

Whilst the cancer data may have been updated since the publication of the West Lancashire Cancer Health Needs Assessment (HNA) the document still holds value for the CCG. Identifying that West Lancashire had the highest all-age cancer mortality rate and second highest premature mortality rate (2008-10), when compared to its ONS peers of the Prospering Smaller Towns – A group.

Premature mortality from circulatory disease

Circulatory disease covers illnesses such as coronary heart disease, hypertension and stroke. The latest figures show that the seven wards have become more removed from one another and once more only two areas have recorded rates significantly above the England national average these being the Birch Green and Tanhouse wards.

Figure 18: Premature mortality from circulatory disease 2008-12

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Respiratory disease mortality

Due to low numbers there are no premature mortality data from respiratory disease indicators. However, we have been able to obtain the all age respiratory disease rates. From which we can see that four of the seven wards have recorded rates significantly above the England national average. Further digging reveals that six of the seven wards fall within the top 30% in the Lancashire-14 with Ashurst ward recording a lower rate than its neighbours.

Figure 19: Respiratory disease mortality

Infant mortality

Infant mortality refers to the death of an infant before their first birthday and does not include termination, miscarriage or stillbirth. It is a sensitive measure of the overall health of a population and provides an important measure of the wellbeing of infants, children and pregnant women with high infant mortality rates linked to social factors such as education, work, income and the environment. It is a known health inequality with the less deprived areas tending to have lower infant mortality rates and it was identified a key target of the National health inequalities Public Service Agreement (PSA) in 2001, the 2010 white paper Healthy Lives, Healthy People and the 2010 Marmot Review.

The latest CCG level infant mortality rates are available via Public Health England's 'Infant Mortality and Stillbirths Profiles' and cover the time frame 2011-13. Using this tool, we identified that the West Lancashire district has an overall infant mortality rate of 5.0per 1,000, which is below the North West region rate of 5.2, but significantly above the England national average of 4.1.

Due to small numbers and data confidentiality rules, for the ward level data we needed to examine the data over a longer time period to ensure that no individuals can be identified and for this analysis we used the time frame 2003-2012. Over the time period examined there were 59 infant deaths in the West Lancashire district, however only four wards recorded more than five deaths; these being : Ashurst (8), Birch Green (6), Moorside (6) and Digmoor (5).

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Underlying cause of mortality

In this next section of the report we have moved away from the national indicators, to make use of Open Exeter mortality data files the council holds, to conduct a more detailed analysis of the main causes of mortality within the seven wards. Due to information governance restrictions we are unable to use this data to provide comparisons against the England national rate, however we are able to build up a more detailed picture about the people behind the numbers than we could from the national indicators. The County Council currently holds mortality data for the period January 1st 2006 and December 31st 2013, although we do expect to have the full 2014 period in the near future. For the purpose of consistency we have extracted records with a usual place of residence post code which falls within the West Lancashire district boundaries.

In total 8,812 deaths were recorded for West Lancashire between January 1st 2006 and December 31st 2013, 27% (2,377) of which came from the seven wards. A mortality pyramid created from this data and comparing the seven wards against the remaining wards of West Lancashire, shows us that the residents of the seven wards are dying earlier than those in the other parts of West Lancashire. This fits in with our earlier findings when we examined the population estimates and life expectancy data.

Figure 20: All-cause mortality pyramid, proportion of mortality by five year age bands – 2006-2013

Analysis of the split between over and under 75 mortality, we found that found whilst 53% of those who lived in Skelmersadle and died between the years of 2006 and 2013 were aged 75 or over. In the remaining wards of West Lancashire the number rises to 71% a difference of 18%. With a total of 4,580 people dying aged 75 or over from outside of Skelmersdale and 1,251 from within Skelmersdale. Ratio wise for every 1 person that died aged 75+ from Skelmersdale, 3.7 people died from outside of Skelmersdale.

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Looking at the individual International Classification of Disease (ICD-10) chapters, revealed that biggest difference between the seven wards and the rest of the district was under the External causes of morbidity and mortality chapter were 78% of deaths from Skelmersdale were from people under the age of 75, compared to 46% elsewhere. However when you look at the actual total number of deaths it can be seen that more deaths coded to this chapter have occurred outside of the seven wards. This chapter is used for coding those illnesses or mortalities relating to environmental events and circumstances as the cause of injury, poisoning and other adverse effects. Such as traffic accidents, exposure to smoke, fire and flames as well as intentional self-harm. A calculated crude rate shows that the seven wards have a higher under 75 mortality rate, than the remaining wards of West Lancashire for nearly every ICD-10 chapter. Appendix E, provides a full breakdown of the main ICD-10 chapters examined, detailing the proportion split between over and over 75 mortality, the actual recorded number of deaths and a crude rate per 1,000.

In terms of total deaths for the district as a whole 31% of deaths were classed under diseases of the circulatory system, 29% neoplasms and 15% diseases of the respiratory system. Whilst these same three areas have accounted for the majority of deaths in the seven wards, we find that it is neoplasms (31%) which have accounted for the majority of deaths as opposed to diseases of the circulatory system (28%). Figure 20 below provides an ICD-10 chapter breakdown of the proportion of mortality for West Lancashire as a whole, the seven wards and the remaining wards of West Lancashire. For the purpose of data confidentiality we have grouped together the ICD-10 chapters that individually accounted for less than 1% of the total actual mortality count.

Figure 21: Proportion of mortality by ICD-10 Chapter – 2006 – 2013

With just three of the ICD-10 chapters accounting for 75% of all deaths within the seven wards the rest of this section of the report will be dedicated to understanding those areas in more detail.

Diseases of the circulatory system

As we know from our earlier analysis the seven wards all recorded fairly high premature mortality (2008-12) from diseases of the circulatory system, with two wards recording rates considered to be significantly above the England national average. To gain a better understand of this we broke the data from Open Exeter up by five year age bands and found that whilst in West Lancashire as a whole, 27% of deaths came from residents aged 74 or under, in the seven wards the proportion increases to 40%, whilst across the remaining wards the number drops to 22%.

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Figure 22: Proportion of mortality from diseases of the circulatory system by ages under 75 and 75+- 2006-201317

Next we looked at the data by gender finding that whilst in West Lancashire as a whole and in the wards outside of the seven wards, females have made up the greater proportion of deaths. In the seven wards males have accounted for the majority of deaths although the difference between the genders is just 4%.

Figure 23: Proportion of mortality from diseases of the circulatory system by gender- 2006-2013

Looking at when these deaths occurred we find that the seven wards and the other West Lancashire wards all have the same seasonal pattern with the greatest proportion (30%) of deaths occurring November to January and drop in mortality from June through to September which fits in with evidence that identifies those with circulatory disease as being at a greater risk of mortality during the colder months18,19. Interestingly the seven wards also seem to experience increase in mortality in May with 11% of all deaths from the seven wards (2006-2013) occurring during this month. Analysis of the underlying figures found that rather than a spike of deaths in one particularly year, for the month of May, there was in fact a jump in the total deaths during May, in 2006, 2009, 2011 and 2012 with an average of 11.75 deaths in May over these years. Whilst the remaining four years have an average of 7.25 deaths in May.

Figure 24: Proportion of mortality from diseases of the circulatory system by month and season – 2006-2013

17 "Other areas" refers to West Lancashire excluding the 7 Skelmersdale wards ie. The remaining 18 wards. "West Lancashire" refers to the whole of the district ie. All 25 wards 18 Public Health England and the Local Government Association . (2013). Reducing harm from cold weather. Local government’s new public health role 19 The Eurowinter Group. (1997). Cold exposure and winter mortality from ischaemic heart disease, cerebrovascular disease, respiratory disease, and all causes in warm and cold regions of Europe. The Lancet. 349, p1341–1346 23

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Finally breaking the mortality from diseases of the circulatory system figures by both the ICD-10 sub-chapter and underlying cause of death we are able to get a clearer picture of the kind of circulatory diseases affecting people in West Lancashire. At a sub-chapter level 75% of all deaths from diseases of the circulatory system fall under either ischaemic heart diseases (46%) or cerebrovascular diseases (29%). In comparison the seven wards have seen a greater proportion of deaths recorded under ischaemic heart diseases (53%).

Figure 25: Proportion of mortality from diseases of the circulatory system by ICD-10 chapter- 2006-2013 Other West ICD-10 sub-chapter Seven wards % of total % of total % of total areas Lancashire Ischaemic heart diseases 350 53% 904 44% 1254 46% Cerebrovascular diseases 163 25% 624 30% 787 29% Other forms of heart disease 55 8% 246 12% 301 11% Diseases of arteries, arterioles and capillaries 53 8% 136 7% 189 7% Hypertensive diseases 18 3% 59 3% 77 3% Pulmonary heart disease and diseases of pulmonary circulation 12 2% 42 2% 54 2% Diseases of veins, lymphatic vessels and lymph nodes, not elsewhere classified 10 2% 31 2% 41 2% Chronic rheumatic heart diseases 3 0% 16 1% 19 1% Grand Total 664 24% 2058 76% 2722

Looking at the underlying primary cause of death we found that 42% of deaths from the seven wards under ischaemic heart diseases were caused by atherosclerotic heart disease which is a condition where the arteries become clogged up by fatty substances with risk factors including smoking, lack of exercise and a high fat diet20. The World Health Organizations Global Atlas on cardiovascular disease prevention and control states that atherosclerotic disease is the underlying disease process in the blood vessels that results in coronary heart disease (heart attack) and cerebrovascular disease (stroke). It also states that this condition is linked with aging and deprivation and that there is strong scientific evidence that behavioural and metabolic risk factors play a key role in the aetiology of atherosclerosis.

53% of deaths from cerebrovascular diseases had an underlying cause of death of Stroke, not specified as haemorrhage or infarction.

Neoplasms

Neoplasms (cancer) accounted for 31% of all deaths from the seven wards between 2006 and 2013

Earlier analysis looking at the premature mortality from cancer (2008-2012) indicator from the local health tool showed us that six of the seven wards recorded the highest rates within the district with two areas recording rates significantly above the England national average. Breaking the Open Exeter down by age group allows us to further highlight this issues with 60% of cancer deaths from the seven wards coming from patients aged 74 and under, whilst in rest of West Lancashire 46% of fatalities from cancer are from patients aged under 75.

Figure 26: Proportion of mortality from neoplasms by ages under 75 and 75+ - 2006-2013

Looking at the data by gender shows us that at a district level 55% of fatalities related to males and 45% to females, but in the seven wards the gap between the genders is reduced with 53% of fatalities relating to males and 47% relating to females.

20 NHS Choices. (2013). Atherosclerosis . Available: http://www.nhs.uk/conditions/atherosclerosis/Pages/Introduction.aspx. Last accessed 02/03/15. 24

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Figure 27: Proportion of mortality from neoplasms by gender- 2006-2013

Looking at the data by months and season shows that unlike with the circulatory disease data, there does not appear to be any obvious trends with the levels of mortality staying fairly consistent. However, there was a spike in deaths for December from the seven which on further analysis was found to be most due to 17 (21%) of the total 81 December deaths occurring in 2010.

Diseases of the respiratory system

With respiratory disease there was no national under 75 indicator due to small numbers and from our Open Exeter data extract we can see that between 2006 and 2013 there were only 293 deaths over the eight year period, from West Lancashire. Breaking the data down by age, it was found that as with circulatory diseases and neoplasms a greater proportion of fatalities from the seven wards are from people under the age of 75 than across the rest of the district.

Figure 28: Proportion of mortality from diseases of the respiratory system by ages under 75 and 75+ - 2006-2013

Looking at the data by gender shows us that across the district there is a fairly consistent lean towards female deaths, although the seven wards do have a slightly larger split between the genders than the rest of West Lancashire.

Figure 29: Proportion of mortality from diseases of the respiratory system by gender- 2006-2013

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As with circulatory disease, mortality from respiratory disease increases during the colder months so it was no surprise to find that when we examined the West Lancashire data by season and month that a very obvious increase in mortality levels can be seen during the winter months. What we did not expect to see was a large spike in mortality, from the seven wards, during the month of March which has accounted for 13% of all mortality between 2006 and 2013. Looking at the underlying data it was found that 48 deaths were recorded for the seven wards with the month of March, 11 (23%) of which occurred in March 2007. Unfortunately the MET Office do not provide detailed data on past weather, however within the summary of their March 2007 report we were able to establish that a cold snap featuring snow, frost and cold showers did occur21 and looking at data available from the North West's Newton Rigg weather station we found that March 2007 had a mean daily maximum of 9.9 and a mean daily minimum temperature of 2.2, which was the same minimum temperature as recorded in January 2007 and colder than the minimum temperature recorded in November 200622.

Figure 30: Proportion of mortality from diseases of the respiratory system by month and season – 2006-2013

Mortality from causes considered amenable to health care

A death is amenable (treatable) if, in the light of medical knowledge and technology at the time of death, all or most deaths from that cause (subject to age limits if appropriate) could have been avoided through good quality healthcare. Studies have shown that mortality from causes considered amenable to healthcare are declining at a much faster rate than those from non-amenable causes and that this decline has coincided with the introduction of specific improvements in healthcare. Mackenbach et al., (1990) noted that geographical variations were strongly linked to socioeconomic factors which may in turn reflect the differences in timely access to healthcare and that geographical variations may also simply be a result of random variations in disease incidence23. Additionally a 2009 study produced by the UK Centre for the Measurement of Government Activity for the Office for National statistics, noted that amenable mortality rates had been falling between 1993 and 2005 and asked the question 'How much, if any, of the observed decline in amenable mortality can be attributed to the healthcare system?' The study concluded that there is no obvious answer to this question as there are a wide range of outcome influencing factors such lifestyle and socio-economic and that there was no clear evidence that the decline in amenable mortality can be attributed entirely to the NHS24.

21 MET Office. (2013 ). March 2007. Available: http://www.metoffice.gov.uk/climate/uk/summaries/2007/march. Last accessed 03/03/2015. 22 MET Office. UK climate - Historic station data. Available: http://www.metoffice.gov.uk/public/weather/climate- historic/#?tab=climateHistoric. Last accessed 03/03/2015. 23 Office for National Statistics. (2014). Avoidable Mortality in England and , 2012. Statistical Bulletin. p3-4. 24 Sophia Kamarudeen. (2009). Amenable Mortality as an Indicator of Healthcare Quality – A Literature Review. UK Centre for the Measurement of Government Activity 26

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The latest district level figures cover the period 2011-13 and the Health and Social Care Information Centre guidance on which conditions are included in the measure can be accessed via the below link :

Indicator specification document : Mortality from causes considered amenable to health care

The latest all-person under 75 figures indicate that between 2011 and 2013, 381 people from West Lancashire died from causes considered amenable to health care. This gave the district a directly standardised rate of 122.69 per 100,000, which whilst one of the lowest rates across the Lancashire-14 area is above the England national rate of 113.97, although the difference was not found to be significant.

From a data extract of the Open Exeter mortality data files we identified 386 records (2011-2013) which matched the criteria used for mortality amenable to health care for 2011 onwards. The difference of five from the national indicator dataset will likely be down to data updates. When we divided up the activity by ward we found that 37% of the fatalities had come from the seven wards, with 25% having come from Skelmersdale South (27), Ashurst (24), Tanhouse (24) and Digmoor (23).

Conclusions

The main conclusion that can be taken from this report is that the data backs up the evidence base that those living in more deprived areas die younger than their neighbours from the less deprived areas. What does not separate the more deprived wards of West Lancashire from its neighbours are the reasons for mortality. With cancer, circulatory disease and respiratory disease being the biggest killers right across the district. Lifestyle and age can play a big part in a person's chances of contracting an illness from one of these areas and along with stage of diagnosis can also play a part in a person's outcome. Clearly we cannot prevent people becoming older, but we can improve early diagnosis rates and through public health interventions we can attempt to change lifestyles' and general attitudes to health and wellbeing.

Going forward the findings of this report could be used to set achievable targets that the Clinical Commissioning Group and its partners can use to try and improve the health and health outcomes of the people of seven wards and reduce the inequalities which exist within the district.

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Appendix A: West Lancashire district life expectancy at ward level – 2009-13 Female life expectancy 2009-13 Male life expectancy 2009-13 Life Expectancy 95% Confidence Interval Life Expectancy 95% Confidence Interval Life Expectancy 95% Confidence Interval Life Expectancy 95% Confidence Interval Area Name Area Name at birth Lower Upper at 75 Lower Upper at birth Lower Upper at 75 Lower Upper England 82.97 82.95 82.99 13.21 13.20 13.20 England 79.41 79.38 79.44 11.52 11.50 11.54 Ashurst 83.04 80.49 85.58 13.50 11.07 15.94 Ashurst 78.31 75.20 81.42 11.23 7.96 14.50 Aughton and Downholland 81.75 80.07 83.44 10.94 10.02 11.87 Aughton and Downholland 81.60 80.19 83.01 10.44 9.43 11.45 Aughton Park 83.62 80.93 86.31 13.07 11.80 14.33 Aughton Park 79.22 75.87 82.56 10.63 9.36 11.90 Bickerstaffe 83.68 77.31 90.05 14.42 11.37 17.48 Bickerstaffe 82.91 80.01 85.81 12.20 9.63 14.77 Birch Green 76.14 73.62 78.67 9.37 7.74 10.99 Birch Green 73.69 71.28 76.10 8.08 6.65 9.50 Burscough East 83.05 81.23 84.88 11.41 10.15 12.67 Burscough East 79.95 77.70 82.19 10.81 9.13 12.48 Burscough West 82.41 80.33 84.48 11.83 10.40 13.27 Burscough West 79.85 77.65 82.05 10.69 9.28 12.11 Derby 83.01 80.84 85.18 12.79 11.44 14.13 Derby 82.99 80.61 85.37 12.60 10.82 14.38 Digmoor 78.91 76.66 81.17 9.81 8.00 11.61 Digmoor 75.20 72.50 77.89 10.17 8.07 12.26 Halsall 82.06 77.99 86.13 12.69 10.73 14.65 Halsall 80.30 76.55 84.06 11.01 9.46 12.56 Hesketh-with-Becconsall 84.19 81.90 86.48 13.72 11.89 15.56 Hesketh-with-Becconsall 81.14 79.05 83.23 11.12 9.27 12.97 Knowsley 87.51 84.28 90.74 17.27 14.62 19.93 Knowsley 82.69 80.32 85.05 14.28 12.43 16.12 Moorside 82.69 76.03 89.34 19.42 10.47 28.37 Moorside 74.72 71.59 77.85 9.84 7.57 12.10 Newburgh 85.84 81.66 90.02 15.44 11.63 19.24 Newburgh 80.13 75.19 85.06 11.13 9.16 13.10 North Meols 84.10 82.00 86.19 13.28 11.38 15.18 North Meols 79.26 77.21 81.30 10.85 9.40 12.29 Parbold 78.74 74.98 82.51 11.38 9.99 12.77 Parbold 78.20 74.50 81.91 11.54 9.56 13.52 Rufford 81.57 76.30 86.84 13.23 11.34 15.12 Rufford 78.32 73.29 83.36 11.05 9.12 12.99 80.77 77.71 83.83 11.43 10.12 12.74 Scarisbrick 79.92 77.70 82.13 9.68 8.51 10.85 Scott 81.61 78.94 84.27 13.63 12.24 15.01 Scott 76.52 74.26 78.77 9.48 8.53 10.42 Skelmersdale North 77.67 74.86 80.47 10.52 9.24 11.79 Skelmersdale North 76.78 73.93 79.63 12.45 10.08 14.82 Skelmersdale South 80.90 78.85 82.95 12.28 11.01 13.55 Skelmersdale South 73.89 71.55 76.24 9.23 7.97 10.50 Tanhouse 76.99 75.10 78.87 7.83 6.73 8.94 Tanhouse 73.62 71.21 76.03 9.19 7.82 10.55 Tarleton 87.65 84.84 90.46 16.67 14.20 19.13 Tarleton 82.13 79.52 84.75 13.75 11.50 16.00 Up Holland 84.75 82.60 86.91 13.95 12.34 15.57 Up Holland 79.40 77.32 81.48 11.28 9.99 12.57 82.59 80.67 84.52 11.24 10.21 12.27 Wrightington 80.48 78.86 82.11 9.36 8.07 10.65

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Appendix B: Population breakdown (percentage of population in each age band) by ward

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Appendix C: Practices by ward

Practice code Practice name Wards P81014 Dr Bishop-Cornet & Partners Scott P81039 Manor Primary Care Tanhouse P81041 Parkgate Surgery Derby P81045 The Elms Scott P81084 Hall Green Surgery Up Holland P81096 Parbold Surgery Parbold P81112 Dr S Biswas & Partners Skelmersdale South P81121 Dr J L Jain Moorside P81136 Dr A K Bisarya & Partners Skelmersdale South P81138 Burscough Family Practice Burscough East P81177 Dr V Gulati & Dr M J Hindle Tarleton P81201 Ashurst Primary Care Ashurst P81208 Dr S K Sur & Partners Moorside P81646 House Surgery Burscough East P81674 Stanley Court Surgery BurscoughAughton and East P81695 Aughton Surgery Downholland P81710 Tarleton Group Practice Tarleton P81727 The County Road Surgery Scott P81758 Matthew Ryder Clinic Wrightington P81764 Dr J S Modha & Partner Skelmersdale South P81772 Dr W H Alwan North Meols P81774 Dr A D Littler Skelmersdale South

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Appendix D: Recorded prevalence as a percentage of expected prevalence

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Appendix E : Mortality by ICD-10 chapter, showing the proportional split by under and over 75, the total actuals under and over 75 and a crude rate per 1,000 for under and over 75 mortality.

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