FOR THE PEOPLE OF ATTENTION BRIGHTON OF THE & HOVE R Annual Report ROF THE DIRECTOR Rof PUBLIC HEALTH R FOR THE YEAR 2009

1 Copyright ©2010 NHS Brighton and Hove

2 R CONTENTS

Foreword R Executive Summary Chapter 1 Introduction ...... 15 Chapter 2 Public Health in Brighton and Hove ...... 21 2.1 The rush to the sea for thalassotherapy ...... 23 2.2 Public health in 19th century Brighton ...... 26 2.3 Public health in 20th century Brighton ...... 30 2.4 Public health in the latter part of the 20th century in Brighton and early 21st century in Brighton... and Hove ...... 36 Chapter 3 The population of Brighton and Hove ...... 41 3.1 The growth of population of Brighton and Hove ...... 43 3.2 Age profile through the ages ...... 44 3.3 Population density ...... 49 Chapter 4 Wider Determinants of Health in Brighton and Hove ...... 53 4.1 Housing and urban development ...... 55 4.2 The recession and unemployment ...... 67 4.3 Transport ...... 72 4.4 Environment ...... 76 Chapter 5 Lifestyle Determinants of Health in Brighton and Hove ...... 83 5.1 Alcohol ...... 85 5.2 Drug use ...... 94 5.3 Smoking ...... 97 5.4 Obesity ...... 101 5.5 Sexual behaviour ...... 110 Chapter 6 Ill Health in Brighton and Hove ...... 123 6.1 Coronary heart disease ...... 125 6.2 Cancer ...... 130 6.3 Mental health & suicide ...... 137 6.4 Infectious diseases ...... 145 Chapter 7 Health Inequalities ...... 157 7.1 National policy on health inequalities ...... 159 7.2 Deprivation, health and coastal resorts ...... 161 7.3 Infant mortality Mortality ...... 162 7.4 Mortality rates and health inequalities ...... 164 7.5 Life expectancy and health inequalities ...... 166 References Appendices

3 List of contributers Annie Alexander Kate Lawson Justin Pursaill Public Health Programme Manager Head of Health Promotion Graphic Design Team, Brighton & Hove City Council Kevin Claxton Barbara Hardcastle Resilience Manager Public Health Specialist Martin Reid Head of Housing Strategy Kerry Clarke Susie Haworth Commissioner for Teenage Pregnancy and School meals manager Andrew Renaut Substance Misuse Principal Transport Planning Officer Alistair Hill Kate Gilchrist Consultant in Public Health Samuel Rouse Head of Public Health Research and Analysis Senior Technical Officer, Air Quality Kerry Hone Thurston Crocket Graphic Design Team, Jo Sage Head of Sustainability and Environmental Brighton & Hove City Council Independent Consultant Policy Anna-Marie Jones Miranda Scambler Dr Katie Cuming Performance Analyst, Children and Young Public Health Information Specialist Specialist Registrar in Public Health and People’s Trust General Practitioner Annie Sparks Michelle Kane Divisional Environmental Health Officer Michelle Doll Health Promotion Specialist Public Health Administrator Graham Stevens Lydie Lawrence Drug and Alcohol Action Team Coordinator Chris Dorling Public Health Programme Manager Public Health Information Specialist Carolyn Syversen Dr Geoff Mead Health Promotion Specialist David Earls Convenor for Local History and Landscape Graphic Design Team, short courses CCE University of Sussex Andy Staniford Brighton & Hove City Council Housing Strategy Manager Dr Anjum Memon Dr Olu Elegbe Consultant in Public Health Liz Tucker Public Health Practitioner Drug and Alcohol Action Team Analyst Clare Mitchison Anna Fairhurst Clinical Assurance & Audit Manager Angeline Walker Smoking Cessation Team Manager Public Health Specialist Tim Nichols Rob Fraser Head of Environmental Health, Licensing & Dr Peter Wilkinson Head of Planning Strategy Public Safety Consultant in Public Health Betty Gillett Stephen Nicholson Yolande Watson Brighton Resident Lead Commissioner HIV & Sexual Health Health Promotion Specialist Doreen Harrison Martina Pickin Becky Woodiwiss PA to Director of Public Health Public Health Improvement Principal Health Promotion Specialist Susie Haworth Brenda Packham And other local residents... School Meals Manager Brighton Resident Liz Hegarty Maurice Packham Public Health Administrator Brighton Resident Tim Earthey Graham Osborne Public Health Administrator Housing Sustainability Project Manager Kirsty Hewitt Mita Patel Specialist Trainee in public health Sustainability Co-ordinator

4 R FOREWORDR

Welcome to the Annual Report of the Director of Public Health for 2009.This year my Report is slightly unusual in that it takes a very long term view of health in Brighton and Hove and makes frequent reference to the Annual Reports of previous Medical Officers of Dr Tom Scanlon Health and Directors of Public Health in Brighton, and in Brighton and Hove. The Report covers the history of Public Health in Brighton and Hove and some of the long-term wider determinants of health: housing, transport, environment and employment – including the potential health effects of the current recession. The main lifestyle factors that contribute to health in Brighton and Hove are discussed: smoking, alcohol, drugs, sexual behaviour, diet and exercise; as are the main causes of ill health in Brighton and Hove: coronary heart disease, cancer and mental health. The year 2009 has been an unusual year for infections and so there is a section covering the effects of the global flu pandemic in Brighton and Hove, and the depressing recent measles outbreak. I would like to be remembered as the last Director of Public Health to have a measles outbreak in Brighton and Hove, but as things stand that is by no means certain. And, of course there is a section on health inequalities with some in-depth discussion on whether or not inequalities are increasing or decreasing. A list of contributors is included opposite and I would like to thank them all. These include, unusually, members of the public and colleagues from Brighton University who have help give this Report its distinctive style. Any mistakes or inaccuracies are, however, entirely down to me.

Dr Tom Scanlon Director of Public Health NHS Brighton and Hove Brighton & Hove City Council

5 Photograph courtesy of The Royal Pavilion and Museums, Brighton & Hove City Council Brighton & Hove and Museums, Pavilion The Royal courtesy of Photograph 6 R EXECUTIVE SummaryR

The population of Brighton and Hove The wider determinants of health in Brighton and Hove Lifestyle determinants of health in Brighton and Hove Ill health in Brighton and Hove Health inequalities in Brighton and Hove

7 8 Executive Summary

The population of decent, affordable homes. Houses of Multiple Occupation bring service and social tensions, Brighton and Hove vulnerable people are sometimes placed in less than adequate housing and homelessness Brighton is historically renowned for being figures remain worryingly higher than average. densely populated and overcrowded. In contemporary Brighton, we can find evidence of this in the narrow streets of Hanover, lined The recession and with densely packed Victorian mews cottages unemployment now housing a mixture of families, students and The relationship between individual and older people living cheek-by-jowl. In recent years population health and the economy is complex. the population of Brighton and Hove has been The relationship between unemployment characterised by a relatively large proportion and health has been extensively studied and of young, working-age people. Many health is clearer than that between an economic and quality of life issues today reflect these recession and health. characteristics. We find evidence of this in A recession that results in a moderate housing pressures; environmental health issues increase in unemployment will see a mixed such as difficulties in storing and disposing of picture with regard to health in Brighton and refuse; pressures on green spaces and local Hove. Adverse effects are likely to be increased services; as well as health and wellbeing issues if there is a significant impact of the recession related to behaviour and lifestyle. on housing. Young people and men over the age of 50 years are likely to be most at risk of adverse health effects, mainly as a result of The wider being more likely to be unemployed. determinants of Transport health in Brighton In the South East, car use, including ownership and Hove of two cars or more, is higher than in the rest of England. Transport has important effects on Housing health. Car use brings problems of noise, air Housing has been, and remains, a key pollution with resultant respiratory problems, determinant of health for the residents of injuries from road traffic accidents, and obesity Brighton and Hove. We have come a long from reduced physical activity. Cycling and way from the desperate lives of the slum walking are on the increase in Brighton and dwellers of the 19th and early 20th centuries. Hove although there is considerable scope for However, modern day population and housing improvement. pressures mean that there still is a lack of The effects of the free bus pass for people aged over 60 years has been to increase

9 EXECUTIVE SUMMARY

the numbers of older people travelling by and Hove die or fall ill as a result of alcohol public transport. It is likely that this has had consumption, while the lives of many others are considerable beneficial effects on their wellbeing disrupted and in some cases ruined. although this has not been assessed. Data on Public services such as the Police, the City accidents in Brighton and Hove do not provide Council and the NHS have been working in any firm evidence of any trends consequent of partnership, and several initiatives have been the introduction of the free bus pass. introduced. However, given the scale of the problem, it would be wrong to suggest that Environment we are succeeding in reducing alcohol misuse In Brighton and Hove, air and seawater quality in Brighton and Hove. Also, the provision of have both improved in recent years. Levels of some alcohol-related services, such as specific nitrogen dioxide in 2008 were close to the general practice services, may not be quite in mean annual objective, and seawater has tune with need. been consistently found to be either of ‘good’ There is a wider question about whether or ‘excellent’ quality since 1995. There are we are, on the one hand, promoting or at least further improvements that could be made condoning the easy consumption of alcohol, and measures which reduce car usage and while on the other we lament its consequences. encourage alternative means of transport in The sale and provision of alcohol has a huge the city will help us to reach a stage where air impact on public health but national legislation quality targets are never breached – as well on licensing was not passed on the basis of as improving the health of individuals. The public health. While that remains the case, it is impact of climate change is assuming a greater up to us to find local ways of taking action on prominence in the public sector and Brighton alcohol, based on the principle of protecting and Hove has demonstrated a commitment and promoting public health. to reducing carbon emissions in line with national targets. The NHS has communicated Drugs a particularly strong message in this regard Substance misuse has been a persistent by forging a reduction strategy exceeding problem in Brighton and Hove for some time. government expectations. There are two reporting systems, and while one has shown a reduction in deaths in recent years, the other suggests that the number of Lifestyle determinants drug-related deaths has changed little. It is important to establish a common approach of health in Brighton to data collection. It is also important that an and Hove Action Plan which covers the wider aspects of the harm that result from substance misuse is Alcohol established and agreed soon. A host of alcohol indicators suggest that the city is performing worse than similar areas across Smoking the UK. Health data suggest that the problem Smoking as a habit is on the decrease and the of excessive alcohol consumption does not main diseases most associated with it - heart stop with acute intoxication in younger people disease and lung cancer, are behaving but that it continues throughout people’s lives. accordingly. There have been great efforts to There is also evidence that residents from more reach the smoking cessation targets in Brighton deprived groups are more adversely affected. and Hove over several years, mostly with Put simply, in awful lot of people in Brighton success, but this will be increasingly difficult as

10 EXECUTIVE SUMMARY the group of smokers who remain are likely to range of sexual health services has been be the most resistant to quitting. established, including in primary care. The There is an increasing deprivation profile current picture of rising sexually transmitted associated with smoking and this is where the infection rates suggests that these levels of real challenge lies. The danger of the target investment will be required for some time, and approach, and the perverse incentives that a that the public health message about safe sex target-driven culture brings, is that by focusing is falling on deaf ears. In Brighton and Hove, on a single number, performance may be this may be due to the particular characteristics seen to be good while in reality health of our local population. The high prevalence inequalities increase. of alcohol consumption in the city is also an important factor. Obesity Teenage pregnancy is associated with In a relatively short space of time we have poor educational, social and health outcomes moved from a state of under-nutrition to for mother and baby alike. Indeed it might be malnutrition through the excessive consumption argued that teenage pregnancy is really just a of the wrong foods. In Brighton and Hove marker of low expectations and the failure of however, there are relatively low levels of adult education, employment and training systems to and child obesity compared to national figures engage a section of the population. and we may be on the verge of reducing The figures suggest that Brighton has obesity levels in children. However, there is a historically had higher numbers of teenage national and local upward trend of obesity in mothers compared to national figures and this adults with all the potential health implications: may in part explain the difficulties in reducing coronary heart disease, diabetes and cancers. rates. Furthermore, compared to Office for As with many health issues, obesity is National Statistics’ comparator cities, when more pronounced in the more deprived parts weighted for deprivation, local rates appear of the city and in particular social groups. Any relatively favourable. strategy to deal with obesity then has to be In recent years, and in particular with the able to target these groups. Planners, school new Sexual Health Strategy in 2009, there has meal providers, the leisure industry and health been an expansion of approach from a focus services all have a role to play providing more on accessible contraceptive services to wider opportunities for a better diet and increased measures to tackle cultural and behavioural physical activity. patterns. It may be that this is at last beginning to have some effect, but it is too early to say whether this approach will have lasting success Sexual Behaviour in turning the tide on teenage pregnancy. Brighton has a long history of risk-taking The city needs to have a long and hard sexual activity although the pattern of sexually think about the issue of sexual health, about transmitted infections has changed over the related health and social costs, about the recent years, and now a different range of links to behaviour patterns and about the viral infections predominate. Treatments have important role played by alcohol consumption. improved, and there have been changes in perceptions with regard to how being infected with a sexually transmitted infection is viewed, both by the infected individual and by wider society. The costs to local health services are considerable and in the last few years a greater

11 EXECUTIVE SUMMARY

Ill Health in targeting of risk groups, improvements in breast screening facilities, and in particular, the Brighton and Hove focus on initiatives to improve early diagnosis and treatment offer the potential to turn the Coronary Heart Disease adverse cancer trends around relatively quickly. Coronary heart disease emerged as the major This will not be at the expense of longer term cause of death in the 20th century though it programmes, in particular smoking cessation, was some time before the links to lifestyle were whose purpose is to prevent cancer from ever made. In the last 20 years or so, the mortality occurring. In the end, the prevention of cancer news on coronary heart disease has been good, must remain the primary public health objective. with a sustained decline in deaths. There are lifestyle choices we can all make to reduce the risk of heart disease. These Mental health Suicide rates in Brighton and Hove have include diet, exercise, weight control, as well historically been higher than national rates. as not smoking and not drinking to excess. The reasons for this are various and the pattern Most people are aware of all these lifestyle of suicide has changed over the years. Suicide risk factors but we still consistently find higher rates in Brighton and Hove have reduced by rates of adverse lifestyle factors in lower income only 4% from the baseline target, and not at all groups. It is not enough simply to tell people over the past 50 years. There would need to be the facts and then sit back and expect them a dramatic improvement therefore to meet the to change. This was the approach taken with 2010 target of a 20% reduction on 1995/6/7 obesity in the 1980s and it failed. We have to figures. History suggests that this is unlikely. make it as easy and as rewarding as possible for This should not deter us of course from people to change. We also have to provide the making a continued effort to address what is the encouragement and incentives for those whose most important cause of premature mortality in role it is to deliver healthcare – both preventive young men. Information from Coroner’s records and treatment - to do so preferentially for those suggests that prevention efforts should focus on most at risk. The challenge now in coronary men aged over 40 years, men aged 18-44 years heart disease is stopping relative inequalities in with a history of substance and alcohol misuse, coronary heart disease from increasing. and those with pre-existing mental health issues. These efforts need to include better treatment, Cancer monitoring and follow-up, health education, There have been some worrying local trends in rehabilitation, and crisis management. cancer in recent years, though the last set of figures represented a return to improvement. The breast screening service has been unable to Infections Infectious diseases today may not present the provide screening for all eligible women within same risk they did 100 or even 20 years ago the recommended three-year timeframe, and in Brighton, but they have not gone away. younger women (aged 25-29 years) have not Measles is a preventable disease with a safe and taken up cervical screening as they should. effective vaccine and it is disheartening that However, these problems are being tackled and in the 21st century in a developed country an were not of sufficient degree in themselves to outbreak should have occurred and that several push up mortality rates. children were unnecessarily very ill. A number of initiatives point to potential Research with mothers in Brighton has improvements in cancer mortality. The new shown how vaccination decisions were shaped bowel cancer screening programme, better by personal and family health histories, birth

12 EXECUTIVE SUMMARY and health service experiences, related feelings Some progress has been made nationally, of control, and conversations and friendships with reductions in the absolute inequality gap with others. This complex set of influences in coronary heart disease and cancer mortality. raises questions about the cost effectiveness of Within Brighton and Hove, progress has been media campaigns. Nevertheless, parents are key less certain. It looks like the gap in infant to vaccine uptake and need to have accurate mortality may have reduced over the 20th information and the chance to discuss this in an century. Data on all age, all cause mortality open way. within the city is comparatively recent and while The social inequalities in vaccine uptake it is not particularly encouraging, it would be suggest that a range of interventions may foolish to read too much into it. be required. For some parents who do not The evidence base for how inequalities immunise their child, reminders of immunisation can be best tackled is expanding all the time. appointments and more accessible opportunities In 2007, the Department of Health identified such as vaccination in the home will be a number of health interventions which have successful. For others the process is likely to be been proven effective in reducing health more protracted and a decision will have to be inequalities. However, the NHS contribution to reached as to whether further discussion is a reducing health inequalities has been estimated waste of time and resources. at just 8%: the rest comes from action on the wider determinants of health. Much more important than providing more cholesterol Health Inequalities lowering drugs are the measures we take on the economy, on jobs, on housing and on in Brighton and Hove building strong communities. Many of these measures are not easy to put Progress in reducing health inequalities has in place, particularly at a time of recession, but been slow. Even over a period of over 100 in the end this is the relatively straightforward years, and with the establishment of a Welfare part. For while we may discuss how best to State and National Health Service, inequalities measure health inequalities, what tools to use, in health persist. That is not to say that we what population groups to examine, and while should simply give up and accept them. For we may argue about whether or not inequalities there is good evidence that, as measured by have reduced or not, and if so by how much, we deprivation, inequalities are an important do actually know what we need to do to tackle determinant not just of the health of those least them, and we should do it. well off, but of the population as whole.

The Stopp family enjoy a day out on Brighton beach shortly before the outbreak of war in 1939. Image courtesy of Brenda Packham

13 Photograph courtesy of The Royal Pavilion and Museums, Brighton & Hove City Council Brighton & Hove and Museums, Pavilion The Royal courtesy of Photograph 14 R CHAPTER OneR Introduction

15 16 Chapter 1 Introduction

Prior to the recent swine flu pandemic, I took on a range of personal tragedies and how the myself to the Brighton Reference Library to look day-to-day lives of ordinary people in Brighton at what historical material there was regarding were affected. There was also useful material the great Spanish Flu pandemic of 1918 and on the smaller pandemics of 1957 and 1968 1919. I was keen to find out what the specific whose impact was less severe. In short, there impact had been in Brighton and Hove. was a wealth of fascinating material. I was able to see the recorded mortality What caught my attention most, however, figures for Brighton by age and sex, reports of was the vast amount of historical material not how local services coped with large numbers just on flu, but on a whole range of public of sick people, troop movements in and out of health issues – many of which are still current the city which may have affected transmission, today. There was information on cancer, heart pronouncements and edicts to the local disease, alcohol, suicide, smoking, pregnancy population from local worthies on how to avoid and fertility, child health and of course the flu (which included not eating), and articles infectious diseases. There was also a wealth of

A traditional donkey ride in the 1960s Courtesy of Brighton & Hove City Council

17 CHAPTER 1 INTRODUCTION

material on some of the wider determinants of predecessors and the excellent work that many health most notably housing, water quality and of them undertook in a lifetime of service to sewerage. This got me thinking. If there were the local community. I have therefore included a lessons to learn from looking back at previous chapter the history of public health in Brighton flu pandemics, then there were likely to lessons and Hove which includes some information on to be learned from looking back at other long who the Medical Officers were and what they established public health problems. achieved during their tenure. Most impressive of all the resources were This Report does contain considerable the Annual Public Health Reports from Medical health data, but in Brighton and Hove we have Officers of Health for Brighton, which went been most active in trying to get our health back to the 1880s. These contained a lot of statistics on line so that local residents can see public health information, but in between the them whenever they want. Our Joint Strategic facts and figures Medical Officers didn’t shy Needs Assessment contains an up-to-date away from giving an opinion, be it on local or record of the current health needs of the local national policy, and sometimes they were ahead population and is available to the public on the of the game in their thoughts. Brighton Medical local web-based information service – BHLIS. Officers were very forward thinking with regard The Joint Strategic Needs Assessment will to diet, smallpox vaccination, measles control, replace much of the routine health information cervical screening and cardiac resuscitation. covered in previous reports. What also left an impression on me was This Annual Report of the Director of the local knowledge and understanding that Public Health is then in the style of earlier these Medical Officers built up over long Medical Officer Annual Reports, and is a review periods of time in office. In a 90 year period with commentary on the public health events of between 1888 and 1977 there were just four 2009. So it comes a little later than in previous different full-time medical officers in Brighton. years, in order that a full calendar year can be Contrast that with the 7 year period between examined. This has allowed me to present a 1993 and 2000 when there were five different fuller picture on the impact of pandemic flu. Directors of Public Health – albeit that three of Although written from a personal them were in an acting capacity. perspective I have, as ever, relied upon So, I decided to use this information to colleagues to furnish me with information, take a much longer term view of health in and at times write contributions. Jo Sage, a Brighton and Hove. It also provided me with former Council employee helped me bring an opportunity to pay a little homage to my it all together and I am very grateful to her. More than anyone however, I have relied on my public health colleague Chris Dorling, who shares my interest in local history. Without Chris’s expertise in collating, analysing and presenting data and without his skills and detective work finding out fascinating facts and figures from the distant past, this Report would have ground to a halt. I also made use of information that was provided to me by members of the public. With the support of the Brighton Argus and the A post-war victory celebration in Brighton Council’s publication – City News I advertised Courtesy of Brighton & Hove City Council for interesting health-related tales and

18 experiences from members of the public. I am very grateful to all those who took the trouble to contact me with their reminiscences and I have included some of these where relevant. I would not like anyone to think that this Report was some sort of indulgence, by people who should know better. There is much that we can learn about why we experience our current public health problems from looking at how Brighton and Hove grew and developed. This includes issues such as suicide, homelessness, teenage pregnancy and alcohol misuse which seem to feature so prominently and so persistently in our lives, despite the best efforts of the community to tackle them. I hope that in taking this long term view, this Report lends the insight that I set out to find. I know there will be some gaps, and the Report, although lengthy, is constrained in length. One of my predecessors, Dr Duncan Forbes, once cautioned the general reader not to attempt to read his dreary Report from cover to cover, stating that his target audience comprised strictly dusty Whitehall bureaucrats who obliged him to collect dry statistics. He didn’t realise what treasures he was setting down, not just with the health statistics, but with his insightful commentary. I hope that the general reader, as much as my public sector colleagues will find this Report a fascinating and useful read and I have modified the style of writing in an effort to make this Report more accessible to all. I also hope that by looking back as far as I have, we will be able to look forward with more understanding, more confidence and better equipped to tackle the apparently intractable public health problems that it behoves public servants like me to do something about. (My eloquent predecessors of course, would never have finished a sentence with a preposition...)

19 ‘Cases of smallpox, of typhus, and of others of the ordinary epidemics, occur in the greatest proportion, in common conditions of foul air from stagnant putrefaction, from bad house drainage, from sewers of deposit, from excrement-sodden sites, from filthy street surfaces, from impure water, and from overcrowding in private houses and in public institutions. The entire removal of such conditions by complete sanitation and by improved dwellings is the effectual preventive of disease of these species, and of ordinary as well as extraordinary epidemic visitations.’ Sir Edwin Chadwick, speaking at the Brighton Health Congress on 14 December 1881 Photograph courtesy of The Royal Pavilion and Museums, Brighton & Hove City Council Brighton & Hove and Museums, Pavilion The Royal courtesy of Photograph 20 R CHAPTER RTwo Public health in Brighton and Hove

2.1 The rush to the sea for thalassotherapy 2.2 Public health in 19th century Brighton 2.3 Public health in 20th century Brighton 2.4 Public health in the latter part of the 20th century in Brighton and early 21st century in Brighton... and Hove

21 22 Chapter 2 Public health in Brighton and Hove

This section of the Report explores the 2.1 The rush to the sea development of public health in the city, including how Brighton was virtually founded for thalassotherapy and developed in the 18th century on the premise of improving public health. Dr Richard Russell In 1750 Brighton, or rather Dr Richard Russell is considered to be a key Brighthelmstone, was a fishing village with a founder of Brighton’s prosperity. Born in population of 2,000. Prior to this, apart from South Malling near Lewes in 1687, the son fishermen, most people shunned living by the of a surgeon and apothecary, he later studied sea as it was deemed unhealthy and there medicine at the University of Leyden. On his was a fear of hostile raids in times of war. The return he expansion of the town owes a considerable published debt to public health. First, the town flourished in 1750 his as a spa centre, for in the middle of the 18th famous De century the so-called ‘rush to the sea’ began Tabe Glandulari and by 1850 the population had swelled to Sive De Usu 65,000. Later, as the town continued to grow Aquae Marinae and the urban problems that were prevalent in In Morbis many other large towns in the 19th and early Glandularum 20th century became ever more evident, it was Dissertatio or strong public health leadership which paved the Dissertation on the Use of Sea way in tackling the health problems associated Dr Russell. Courtesy of Brighton with housing, poor sanitation, poor diet and Water in the & Hove City Council Portrait by Benjamin Wilson c1755 alcohol consumption. Many of the public Diseases of health problems that exist in the city today have the Glands. their origins in the manner in which the town Dr Russell considered sea bathing a developed, and in the behaviours and culture therapeutic intervention and he prescribed it for of the residents, many of which have passed many patients. He went as far as to recommend through generations. drinking sea water, writing how internal and external administration of sea water had cured many of his patients. ‘The omniscient creator of all things’ he declared, ‘designed the sea to be a kind of common defence against the corruption and putrefaction of bodies.’ Dr Russell was not unique among English doctors in his belief in the benefits of thalassotherapy (sea water therapy) and even 70 years after his death it was observed that ‘many of the first

23 CHAPTER 2 PUBLIC HEALTH IN BRIGHTON AND HOVE

This engraving shows the bathing place at Brighthelmstone with wealthy people descending stairs cut into the cliff. They would then enter bathing machines, from which they could be bathed or dipped by characters such as John “Smoaker” Miles or Martha Gunn. On the right, members of the village’s fishing community sit in or beside boats, repairing fishing nets. A windmill can be seen the top of the cliff. This engraving is reputedly by Rowlandson, a satirical cartoonist of the time. Image reproduced with kind permission from Brighton and Hove in Pictures by Brighton & Hove City Council

families in Sussex still preserve his prescriptions Dr Anthony Relhan and with veneration, and often apply them with Dr John Awsiter the happiest effect.’ He was also a firm Dr Russell’s practice was secured by an Irishman believer in the value of fresh air which he also named Dr Anthony Relhan. Dr Relhan was prescribed with rigour. Indeed some writers also an early proponent of the benefits of considered that the virtue of his care lay in the vaccination, something that has a certain ‘dietetic and hygiene routine and discipline’ resonance in the city in the 21st century, that accompanied his administrations in ‘the and wrote a pamphlet ‘Reflections against attractive surroundings of Brighton’ (Brighton, inoculation’. More famously he penned ‘A Old Ocean’s Bauble).Dr Russell enjoyed a Short History of Brighthelmstone, with Remarks great reputation, corresponding with leading on its Air and an Analysis of its Waters’. This physicians of the day, and people from all over was really the first guide book to Brighton England came to Brighton for his treatments. and in it he laid new emphasis on the health- This put considerable pressure on the then giving properties of the town’s soil and climate. available accommodation in the town and Brighton he considered to be singularly several inns were enlarged to cope with healthy because of the absence of a river and the visitors. its freedom from ‘the insalutary vapour of Dr Russell himself built a large house that stagnant water’. had direct access to the seafront, lying just Dr Relhan was also one of the early where the Royal Albion Hotel now stands. Dr pioneers of data analysis. In London in 1761, Russell also prescribed waters from a spring he said, there was one death per annum for known as St Ann’s Well just outside the Parish every 32 persons compared with Brighton of Brighton. A pump room was erected around where there was just one death for every 62½ the spring but demolished by Hove Corporation persons. Death rates deteriorated in both cities in 1935. Dr Russell died in London on 19th in the 19th century before improving in the December 1759 while visiting a friend and 20th century. While death rates are now much was buried in South Malling Church where improved in both cities, today’s statistics do not a tablet dedicated to his memory lies. A compare Brighton so favourably with London. commemorative plaque also sits on the wall of Although number of deaths per resident is not the Royal Albion Hotel and in the words of Sir a statistic that is used now; in 2007, there was Christopher Wren’s epitaph invites the reader ‘If one death for every 150 persons in London, you seek his monument look around’. whereas in Brighton and Hove there was one

24 CHAPTER 2 PUBLIC HEALTH IN BRIGHTON AND HOVE death for every 107 persons (Table 2.1). At first the business was not a success. After Drs Russell and Relhan, Dr John However, after some cures business improved. Awsiter is probably the third in a line of famous Dr John Gibney, an Edinburgh graduate and spa doctors in Brighton. In 1769 he began the Senior Physician at the Sussex County Hospital construction of hot and cold baths, using sea and General Sea-Bathing Infirmary at Brighton, water, in Pool Valley. Dr Awsiter also advised referred several patients to Mahomed. Business that sea water should be taken internally, but prospered to the extent that Mahomed received mixed with milk and cream of tartar (potassium the appointment of ‘Shampooing Surgeon hydrogen tartrate) prior to ingestion. to George IV’ and later to William IV. His visitors’ book in Brighton Public Library records Sake Deen Mahomed many famous names of the day. Mahomed In 1786, perhaps the most colourful of all the died in 1851 of uncertain age although his proponents of Brighton as a health resort, an tombstone in St Nicholas Church records that Indian by the name of Sake Deen Mahomed, he was a centenarian. His Brighton baths were arrived in the town. Born demolished in1870 to make way for Markwell’s in Patna, capital of Bihar, Hotel, which later became part of the adjoining Mahomed had served Queen’s Hotel. as an officer in the East Mahomed’s lasting legacy is not bathing India Company and but more curiously, curry. For with his received some training as shampooing business flourishing, Mohamed, a surgeon. After coming ever the entrepreneur, opened the Hindoostane Sake Deen Mahomed to England he visited Cork Coffee House in Portman Square – an upmarket Courtesy of Brighton area of London popular with colonial returnees. & Hove City Council and where he is reported to have ‘run away with a An 1809 newspaper advert boasted that pretty Irish girl’. They returned to England and diners could enjoy ‘Indian dishes of the highest in Brighton opened a vapour and shampoo perfection’ as they sat in bamboo-cane sofas bath business. Mahomed’s Indian Medicated and finished off their spicy fare with a few puffs Vapour Baths were more akin with today’s from a hookah pipe. Turkish baths, and bathers after being subjected to great heat, were then vigorously massaged (shampooed) by an attendant through flannel sleeves in a tent cover.

Table 2.1: Mortality in Brighton / Brighton and Hove compared with London at periods since 1761 LoremYear ipsum dolor sit amet,Number of personsamet per accumsan death in quamresident quam population ac sapien. consectetur adipiscing Brighton elit. / Brighton Duisand cursusHove# malesuada neque,London sed Pellentesque a sapien orci. Vivamus faucibus urna aliquam id. Donec ut tincidunt1761 metus vel jvel jvel jvel justo62.5 libero sem, a tristique quam. Proin32.0 ut luctus1884 blandit. Phasellus venenatis 5.6 ante ipsum. Nulla suscipit tincidunt4.9 sapien1931 at neque consequat tempor.73.9 eleifend. Vestibulum id quam 83.0velit, Vestibulum nec mi id est lobortis venenatis sodales eros. Praesent ultricies2001# in vitae lectus. 90.4 blandit rutrum odio, a accumsan125.0 2007# 107.1 ipsum malesuada vel. Aliquam150.3 Suspendisse suscipit, tellus a varius augue est, dictum ut tincidunt vitae, Source: Public Health Directorate, NHS Brighton and Hove, 2009 gravida, neque velit facilisis orci, sit gravida ut lorem. Vestibulum ante

25 CHAPTER 2 PUBLIC HEALTH IN BRIGHTON AND HOVE

Dr F.A.A. Struve As visitors to the town increased, so did the spa facilities to accommodate them. In 1803 the Royal Baths, described as scarcely without equal in Europe, were opened. These were demolished in 1856 to make way for the Lion Mansion. The Artillery Baths were built in 1813 and later rebuilt in 1865 adjoining the newly erected Grand Hotel. Lamprell’s swimming baths were built in 1823 on the site of the old battery at the bottom of East Street and ladies’ Old German Spa facade in Queens Park. sea water swimming baths were erected on the Courtesy of MyBrighton&Hove site of Dr John Awsiter’s original baths in 1861. A fresh water spa was opened in 1825 by Dr F.A.A. Struve, a chemist from Dresden Dr Rickard Patrick Burke Taaffe who reproduced the characteristics of mineral In the intervening period between Dr water using chemicals. The spa was built Richardson’s two reports the town had in what is now Queens Park in the style of appointed its first Medical Officer for public continental spas and it became known as the health; Dr Rickard Patrick Royal German Spa, Like Sake Deen Mahomed, Burke Taaffe, an Irishman Dr Struve enjoyed royal patronage, this time in who achieved considerable the persons of King William IV, Queen Adelaide local renown. Described and the Duchess of Kent. The building’s facade by one of his successors, survives today housing a nursery school. Dr Forbes, as ‘enthusiastic and with a loveable Dr Taaffe Courtesy of Brighton personality’, Dr R.P.B. & Hove City Council Taaffe was appointed on 2.2 Public health in a part-time basis in 1874 19th century Brighton at a time when Brighton’s population was Three public health inspections attest to the 95,000, with an infant mortality rate of 141 state of public health in Brighton in the 19th per 1000 births. In fact the infant mortality rate century. In 1849, a formal inspection of public was unusually low that year and in the two health in Brighton was undertaken by Mr following years it was 177 and 152. Prior to his Edward Cresey, Superintending Inspector of the appointment as Medical Officer he had been Board of Health. Two similar inspections were in partnership and then independent practice undertaken by Dr Richardson, first in 1864 and in the town, and later was appointed as again, at the request of his Worship the Mayor, Assistant-Surgeon to the Brighton and Sussex in 1882. The 1864 report was published in ‘The Eye Infirmary where he remained a Consulting Medical History of Brighton’ in the Medical Physician until his death. Times and Gazette (June 11th, 18th and 25th As medical officer, Dr Taaffe set to work 1864). The 1882 Report received greater improving sewerage drainage and removing prominence still, being published in the Lancet cesspools. In common with thinking at the (Lancet November 4th 1882). time, Dr Taaffe was of the view that the entrance of sewer air into houses was a cause of ill health. While the mechanism of disease spread may have been erroneous, the treatment was quite accurate. His 1877 Report urged

26 CHAPTER 2 PUBLIC HEALTH IN BRIGHTON AND HOVE for slum clearance, much of which was only in infants from diarrhoea and in 1876 called for completed some 80 years later. an infectious diseases hospital to be established. In several of his reports he noted the need for more public toilets. In his 1877 report he asked that bicycle riders be compelled R to attach bells to their machines to give Outbreaks of infectious disease warning to people driving or walking in the streets. Some 130 years later there persists a were not uncommon: in 1881 certain frisson between cyclist, pedestrian and there was a serious outbreak of motorist. Outbreaks of infectious disease were typhoid associated with milk. not uncommon: in 1881 there was a serious outbreak of typhoid associated with milk and the sanatorium opened for the reception of cases of infectious disease. R Dr Taaffe worked until his death in his 60th With an eye to the influence of the year on the 3rd March 1888. It is recorded that environment on health, Dr Taaffe is described by the Royal Alexandra Hospital for Sick Children a successor, Dr Parker as having ‘an enthusiasm owed its existence to his efforts and it was Dr for planting trees in every available spot in Taaffe who greeted the Prince and Princess of the town’. He also ensured the establishment Wales along with their daughters, to present of a public mortuary, post-mortem room and them with a gold key when they arrived to chemical laboratory. He noted in his 1875 formally open the new children’s hospital on report the influence of bottle feeding on deaths July 21st 1881. A painting of this event survives.

The newly built Royal Alexandra Children’s Hospital in 1881. Inset the new Royal Alexandra, opened in 2007. Courtesy of The Royal Pavilion and Museums, Brighton & Hove City Council

27 CHAPTER 2 PUBLIC HEALTH IN BRIGHTON AND HOVE

Dr Frederick Akbar Mahomed Comparing his findings to his previous Report It is worth mentioning another of Brighton’s of 1864 Dr Richardson records, “In that day medical sons of the time at this point. Dr I found eleven miles of streets supplied with Frederick Akbar Mahomed MB FRCP (1849- sewers, now sixty miles of streets are supplied. 1884), a descendent of Sake Deen Mahomed, In that day cesspools abounded everywhere, also achieved some fame and might have now they are quite exceptional, and where merited more still were it not for his untimely they exist, have no connexion with the death. A graduate of Guys, Dr Mahomed, water-supply.” described in an anonymous British Medical The new Royal Alexandra Hospital for Sick Journal obituary (British Medical Journal, Children comes in for Dr Richardson’s praise November 29, 1884) as ‘tall, dark, noble, brave “... a newly built hospital on a site admirably and with a commanding presence’ was an selected. The building has been fitted up early pioneer of what today would be called with every consideration for health... The evidence-based practice and epidemiology. ventilation, the warming, the arrangement of In contrast to the style of his more the waterclosets and offices, and the modes of illustrious ancestor he advocated looking for cleansing leave nothing to be practically desired.” ‘no golden treasures, no startling discoveries, The relatively new workhouse in Elm Grove, now no new revelations as to the manifestations the site of Brighton General Hospital, is described of disease or the methods of treatment’ but as, “a really model workhouse.” rather ‘careful tilling of the ground by many Dr Richardson speaks equally highly of the hands and better husbandry’ by which ‘better health and wellbeing standards in the town’s crops [were] sure to follow’ (British Medical education facilities. Journal, January 3, 1880). Dr Mahomed argued that general practitioners rather than hospital doctors were ideally placed to shed new light on diseases, including their incubation periods, R their modes of transmission and their periods “The educational institutions of of communicability. He advocated a system for Brighton exhibited a freedom recording and registering such within primary care. Dr Mahomed died, aged just 35 years from all disease that was quite from typhoid fever, probably contracted as a exceptional in my experience. result of his physician duties at the London I should further remark that the Fever Hospital. scholars in every instance bore the Dr Richardson’s Reports appearance of excellent health.” The considerable problems with poverty, housing, sewerage and water supply that existed in Brighton in the 19th century are R evident from Dr Taaffe’s Reports. Even so, an 1882 Report (Richardson, 1882) commissioned In describing the 1881 outbreak of by the town’s authorities from a Dr Richardson, typhoid fever, Dr Richardson writes that it speaks glowingly of the progress being made “was accidental in respect to distribution, in public health in the town and the efforts [and was] soon under the observation of your of those charged with improving it. “The medical officer of health, Dr Taaffe, and of authorities have evidently been incessant your analyst, Mr Moore. Milk taken from the in their efforts to better the sanitation.” Lewes Road Dairy had in it 20 per cent of

28 CHAPTER 2 PUBLIC HEALTH IN BRIGHTON AND HOVE

Table 2.2: Mortality in Brighton compared to collective mortality in 20 similar towns (1871-80) LoremDisease ipsum dolor sit amet, amet accumsan quam20 quam Towns ac sapien. Brighton consecteturSmallpox adipiscing elit. Duis cursus malesuada neque,0.42 sed 0.09 Pellentesque a sapien orci. Vivamus faucibus urna aliquam id. Donec ut Measles 0.51 0.27 tincidunt metus vel jvel jvel jvel justo libero sem, a tristique quam. Proin ut luctusScarlet blandit. Fever Phasellus venenatis ante ipsum. Nulla suscipit0.80 tincidunt 0.39 sapienDiphtheria at neque consequat tempor. eleifend. Vestibulum id quam0.11 velit, 0.08 Vestibulum nec mi id est lobortis venenatis sodales eros. Praesent Whooping-cough 0.76 0.45 ultricies in vitae lectus. blandit rutrum odio, a accumsan Typhoid fever ipsum malesuada vel. Aliquam0.50 0.24 SuspendisseDiarrhoea suscipit, tellus a varius augue est, dictum ut tincidunt1.22 vitae, 1.00 gravida, neque velit facilisis orci, sit gravida ut lorem. Vestibulum ante The Seven above mentioned diseases 4.32 2.52 All causes 21.8 20.4 Source: 1882 Report on the Sanitary Conditions of the Borough of Brighton (Lancet November 4th 1882) water that had been added, the water was growth of a very large population susceptible to foul or contaminated, the milk unfitted for the diseases, in whom an outbreak, if it begins, consumption. Of the 91 families who drank the will spread, and will include unusually large milk 26, or 1 in 3.5 were attacked by typhoid. numbers in one epidemical attack.” Of the 6,969 families in the neighbourhood In a rare allusion to the stark health supplied from other dairies, only 27 (1 in 25.7) inequalities that existed at the time, Dr were attacked.” Richardson explains that with regard to; Dr Richardson’s comments do seem a “measles, scarlet fever and whooping-cough, bit partial and in some cases a little over the the mortality was chiefly amongst the poor, top, however he does present some objective and, indeed, hardly reached any other class. In evidence that health in Brighton had indeed this there is no reason for surprise, for in many improved and was better compared to other cases three or four families of the infected lived parts of the country (Table 2.2). He writes that “it in one house. They were badly clad, and some is recorded that Brighton, during the years 1871- actually had no bed.” 80, showed a mortality [rate] below the collective Dr Richardson concludes, “The health average mortality of twenty large towns in of the town, considering its size, the special England, all causes of death being included.“ dangers to which it is exposed as the However, Dr Richardson’s Report came just convalescent resort and sanatorium of London, a little too late for the town and the unstable and its position as a refuge from London of nature of these relatively better mortality rates vast numbers of unhealthy poor itinerants, who (1871-80) was demonstrated by their reversal in come to minister to the service and amusement 1881-82 (Table 2.3). This change in fortune Dr of visitors, is unusually good.” Richardson attributed to four diseases: typhoid, Reading Dr Richardson’s Report, it is hard measles, scarlet fever and whooping cough. He not to reach the conclusion that he is, by and writes sympathetically, “If in any town a long large, talking about the health and wellbeing interval elapses in which the zymotic diseases of the better off, and that there is an unspoken are absent, time is allowed for the birth and assumption that the poor will naturally

29 CHAPTER 2 PUBLIC HEALTH IN BRIGHTON AND HOVE

Table 2.3: Mortality from infectious disease in Brighton compared to the collective mortality from the same in 28 similar towns (first and second quarters of 1882) Lorem ipsum dolor sit amet, First Quarteramet accumsan quam quam Second ac sapien.Quarter consectetur adipiscing elit. 1882Duis cursus malesuada neque, 1882sed Pellentesque a sapien orci. Vivamus faucibus urna aliquam id. Donec ut tincidunt metus vel jvel jvel jvel 28 justoTowns libero Brighton sem, a tristique 28 quam. Towns Proin ut Brighton luctusSmallpox blandit. Phasellus venenatis 0.13 ante ipsum.0.15 Nulla suscipit0.10 tincidunt 0.00 sapienMeasles at neque consequat tempor.0.85 eleifend.3.04 Vestibulum id 0.86quam velit, 2.01 Vestibulum nec mi id est lobortis venenatis sodales eros. Praesent ultriciesScarlet Fever in vitae lectus. 0.56 blandit1.76 rutrum odio, a accumsan0.44 1.10 Diphtheria 0.18 ipsum0.07 malesuada vel. Aliquam0.15 0.15 SuspendisseWhooping-cough suscipit, tellus a varius1.47 augue2.89 est, dictum ut tincidunt1.13 vitae, 1.25 gravida, neque velit facilisis orci, sit gravida ut lorem. Vestibulum ante Typhoid fever 0.33 0.15 0.29 0.15 Diarrhoea 0.24 0.11 0.34 0.21 The Seven above mentioned diseases 3.76 8.17 3.31 4.87 All causes 24.7 29.2 20.9 21.8 Source: 1882 Report on the Sanitary Conditions of the Borough of Brighton (Lancet November 4th 1882)

experience poorer health and nothing much field of 74 applicants, the final choice came can be done about it. This may be unfair, but down to Dr Newsholme and a 36 year old what is clear is that a focus on the poor and the and more experienced Dr Henry Tomkins. Age diseases of poverty was to come in a big way featured as an important attribute and it is with the appointment of the town’s first full- recorded that elected members favouring his time Medical Officer, and an early pioneer of appointment noted that he “may be younger public health, Arthur Newsholme. but if he is 32 years think where he will be in 36 years.” Personal appearance and characteristics also seem to have been considerations, and 2.3 Public health in it is recorded that councillors had “seldom seen a better looking man” and that he was 20th century Brighton “gentlemanly and kindly in his manner.” The gentlemanly, kind, good looking and Dr (Sir) Arthur Newsholme young Arthur Newsholme won the day and the The most famous of all of Brighton’s Medical next 21 years saw improvements in housing, Officers is undoubtedly Dr Arthur Newsholme, infectious disease and nutrition. He persuaded later Sir Arthur Newsholme. Sir Arthur published the Council to remove all cesspools by 1900, 21 Annual Reports on the State of Public Health introduced metal rubbish bins, established a within the town between1888 and 1907. The public abattoir and through tough inspections, earliest surviving report dates from 1893. forced butchers to sell only healthy meat. He A graduate of St Thomas’ Hospital, Sir took a particular interest in the health and care Arthur, then aged 32 years, came to the town of infants and children and developed a public with a strong academic record. From an initial education programme in infant welfare as well

30 CHAPTER 2 PUBLIC HEALTH IN BRIGHTON AND HOVE as introducing what effectively was the first these houses, and by ever health visitor when he appointed a Lady letting them at a rental just Inspector in 1892. sufficient to cover these Like Dr Taaffe, Dr Newsholme observed expenses, this evil can that the best way to prevent diarrhoea in be avoided.” babies and reduce infant mortality was to Sir Arthur A devout Methodist, Newsholme encourage breast-feeding of babies. In his Courtesy of Arthur Newsholme 1905 Report he wrote, “The best food for the Brighton & Hove frequently highlighted the City Council baby is mother’s breast milk alone without any adverse consequences of other food whatever. Death from diarrhoea alcohol misuse among local is very common in hand-fed, rare in breast- residents, making a strong connection between fed babies. In the first nine or ten months poverty and alcohol use, but citing alcohol of the baby’s life nothing forms an efficient as a cause rather than a consequence of, or substitute for the mother’s breast. Never use coping strategy for poverty. In 1903 he wrote, a dummy teat or comforter. Comforters are “Alcoholism is the one social evil which, more always getting dirty. Never give a baby soothing than any other, prevents improvement among syrups or teething powder. Never give a baby a large section of the population. It is the main tea.” The infant mortality rates of the times of reason for children being insufficiently fed and Dr Newsholme and his successor Dr Forbes, unfit for school work. The housing problem and and the gradient between rich and poor are social problems generally are inextricably bound compared with today’s rates in the chapter on up with the drinking habits of the population.” health inequalities. Dr Newsholme’s achievements, especially in infant welfare brought him to national prominence and he was appointed as R the ‘Principal Medical Officer to the Local Arthur Newsholme frequently Government Board’ (equivalent to today’s Chief Medical Officer). He was a key voice in highlighted the adverse arguing for changes to the Poor Law and the consequences of alcohol misuse introduction of a National Insurance Health among local residents, making a Bill. He introduced a national system of disease notification and registration of illness and his strong connection between last major role was to oversee the influenza poverty and alcohol use. pandemic of 1918-1919. One admirer wrote of him that “No one contributed more in modern England to the growth of preventive R medicine and to the improvement in the quality of life for the working classes.” As Sir Arthur Arthur Newsholme worked to improve Newsholme, he held many honorary positions housing in the town and encouraged a public and was much travelled examining and writing building programme. In his 1903 report he on health systems across Europe and the USA wrote, “The problem of dealing with the – where he praised prohibition, arguing for insanitary central houses remains. Such houses similar measures in the United Kingdom. His will always be occupied by the very poor. The 1333 book ‘Red Medicine’ describes his journey houses put into repair will be let at increased across the Soviet Union examining the benefits rentals which the poor cannot afford. Hence and costs of ‘socialized’ health care. must follow overcrowding to an increased extent. By purchasing, repairing and owning

31 CHAPTER 2 PUBLIC HEALTH IN BRIGHTON AND HOVE

Dr Duncan Forbes were so ‘dreary’, and ‘of little interest to the Appointed in 1908, Scotsman and Edinburgh casual reader’. Indeed he warned the unwitting graduate Dr Duncan Forbes was the longest reader against trying to read his report from serving Medical Officer for Brighton, retiring front to back cover. In 1937, while commenting in 1939 and dying just two on a typhoid outbreak in Croydon he lamented years later. His tenure saw the behaviour of the local general practitioners, the introduction of school describing them as “interfering busybodies” inspections in 1908, the with “no expertise in the field”. commencement of a school His 1920 Report described the work of dental service in 1912, a Mr Watters, the newly appointed Organizer of Physical Training. “Several schools have adopted Dr Forbes school exercise programme Courtesy of the in 1920 and the opening of the daily period of 20 minutes suggested Argus the town’s first contraceptive by the Board of Education. A number of clinic in the early 1930s. He lessons are too formal with consequent slow had to cope with the strains on public service progress. More time should be devoted to that resulted from the First World War and later general activity exercises and games, and the Great Depression. Despite this, he oversaw a spirit of keenness and rivalry should be the most intense programme of slum clearance, encouraged by the team system. There is as first proposed by Dr Taaffe. His 1937 Report a lack of suitable accommodation, in three documents an extensive programme of schools there is neither hall nor playground. disinfestations of houses and the eradication There are five playing fields available for thirty of bed bugs with Cescone (sulphur gas). It was schools. During the months of May to October under the scrutinising gaze of Dr Duncan Forbes swimming is taught and two baths are utilised that new estates such as Moulsecoomb and for the purpose. Free admission tickets to Whitehawk sprung up on outskirts of the town. baths are granted by the Committee to all children gaining certificates for swimming 100 yards and 50 yards for boys and girls R respectively.” The availability of school playing field accommodation is still one that provokes In 1934 Dr Forbes noted that, debate nowadays. It was my own privilege to be despite improvements in midwife part of the reintroduction of free swimming for training, there had been no the children in Brighton and Hove in 2008, an initiative funded in partnership by the Primary corresponding improvement in Care Trust, the City Council and DC Leisure. maternal mortality in the previous In 1936, Dr Forbes commented that “It is satisfactory to note that in common with most 30 years and that over four other areas, the children of Brighton show mothers still died for every an increase in height and weight.” With the 1000 children born. re-introduction of national height and weight measurement programme for (5 year olds and 11 year olds), it is now possible to make some comparisons of the body mass index of children R in Brighton growing up in the early 20th Not someone to mince his words or to century with their counterparts of the early 21st refrain from criticising the Ministry, Dr Forbes century and these are illustrated in the chapter lamented that, as a result of having to report on obesity. on various health statistics, his Annual Reports

32 CHAPTER 2 PUBLIC HEALTH IN BRIGHTON AND HOVE

In 1934, Dr Forbes noted that despite Dr Forbes encouraged slum clearance and improvements in midwife training, there the building of “commodious houses with had been no corresponding improvement in large gardens to provide a useful supply of maternal mortality in the previous 30 years, and fresh vegetables”. However, he disapproved that over four mothers still died for every 1000 of the selection of the east of the town for the children born. Set against today’s maternal extensive building programme of new working- mortality in the city, when deaths occurring class housing estates, which he felt was at “the over a period of ten years can still be counted greatest possible distance from the industrial on one hand, this figure is striking. However, area.” To address this problem, he argued for it was housing, food and employment which cheaper public transport. Dr Forbes considered his main public health The contraceptive service which he opened priorities. In 1936, he spoke out against at the Royal York Buildings in the early 1930s national curtailed food imports which were was limited in its availability, being open on forcing up food prices, “No doubt if mothers the second Tuesday of every month for those had the money to expend, their children would whom the recommending doctor was of the get more milk, more eggs, more butter, all first opinion that further pregnancies would be class but expensive foods.” In the absence of detrimental to the health of the mother. In such funds, Dr Forbes encouraged the use of keeping with prevailing moral views of the time separated (skimmed) milk, “great for puddings, Dr Forbes wrote, “It is in no way a clinic for all soups, drinking raw or in tea or coffee”, and and sundry.” the use of margarine, “equal to the best butters He argued for the cessation of a in vitamin content.” “pseudo-compulsory system of vaccination”

Smallpox outbreak diagram Courtesy of Brighton & Hove City Council

33 CHAPTER 2 PUBLIC HEALTH IN BRIGHTON AND HOVE

[against smallpox] and for its replacement name stands alongside that of Dr Charles with a voluntary system of free vaccination. Chapin of Providence, USA. He commented that there had been three deaths in 1936 from “post [smallpox]-vaccinal encephalitis” and called for Medical Officers to Dr. Rutherford Cramb Dr Rutherford Cramb appears to have kept be given “surveillance over contacts and control a lower profile than Dr Forbes for whom he of the movements of vagrant contacts.” He served as deputy for 20 years, although he was was not to live to see the panic that gripped in post during two momentous events with a Brighton following the smallpox outbreak of significant impact on health: 1950-51. In his final Report of 1938, in one last the Second World War and dig at central government, he lamented, with the founding of the National words that have some resonance today, the Health Service. increasing amount of time spent in paperwork Another Scot, Dr Cramb that stopped people getting on with their jobs... was born in 1886 and Shortly after retirement and with the graduated from Glasgow outbreak of war, Dr Forbes once again was in Dr Cramb Courtesy of the University in 1909. He worked the public eye when his forthright views on Argus as a bacteriologist and then how the country should cope were reported in medical officer in Scotland the local Argus. He suggested that all persons before moving to school medical work in Essex aged over 65 years not engaged in essential and then in Leeds. During the First World War work (a total UK population of some 3 million he worked as a Territorial Army Medical Officer, people) should be shipped to Canada and the experiencing ambulance field work and was United States, that all “useless animals” (he mentioned in dispatches. It was on war duty in made it clear that he meant dogs) should be France that he met his wife, who was working destroyed and that people who fed pigeons as a nurse. with grain should be prosecuted. Cargoes of In 1919, he took up the post of Senior meat, oranges and tobacco should not be School Medical Officer and Deputy Medical imported, and cabbages and sprouts (which Officer in Brighton. He took over from his old he asserted had more vitamin C than oranges) chief as Medical Officer in 1939 and one of his should be used in salads. White bread should first tasks was to organise civil defence medical be replaced with wholemeal bread, and cheese services in Brighton. After the war was over, it and milk could serve as effective substitutes was Dr Cramb who had to oversee locally the for meat. Condemned meat, he contended, greatest-ever organisational change in United if sterilised, could be safely consumed. His Kingdom health care with the introduction of final suggestion was that it was better for a the NHS in 1947, though in characteristic style housewife to have sugar for jam than for her he did not make a song and dance about it. husband to get it in the form of alcohol at the The public health challenge however, for public house. which he is best remembered, took place a few Dr Forbes died a few years before his weeks before his retirement in 1951, when an predecessor, Sir Arthur Newsholme who outbreak of smallpox took place in Brighton, penned a handsome tribute as a postscript then full of Christmas visitors. The disease was to Duncan Forbes’ obituary, writing that Dr introduced into the area by a member of the Forbes was one of the earliest sanitarians in Royal Air Force who had become infected in the country who realized that it was persons India and had flown back to England during and not things that carried infection. In this the smallpox incubation period. In total there discovery, wrote Sir Arthur, Dr Duncan Forbes’ were thirty confirmed cases and ten deaths

34 CHAPTER 2 PUBLIC HEALTH IN BRIGHTON AND HOVE but it was thanks to Dr Cramb’s leadership Dr William Sheppard Parker and an effective six week campaign that no- The colourful but professional Dr William Parker one was infected after the first two days of was appointed Medical Officer in 1951 and the outbreak and that the disease remained continued in post until his retirement twenty-six confined to the town. The main foci of years later in 1977. As well infection were Bevendean hospital, a laundry as the smallpox outbreak of and a telephone exchange. All contacts were 1951, the 1950s also saw placed in quarantine and had to be visited daily several outbreaks of other for a period of 16 days. Public Health Inspectors infectious diseases, including made a total of 65,352 visits and 89,730 polio and paratyphoid. people were vaccinated during the outbreak. It Dr Parker was however, Dr Parker is recorded that Public Health Inspectors in the Courtesy of the the first local Medical Officer town worked over 16 hours a day for a month. Argus to grapple with the public After a well deserved retirement, Dr health problems that persist Rutherford Cramb is recorded as living quietly today such as smoking, obesity and cancer with his devoted wife in the town that he had screening, and in many respects he was ahead served so long and so well. He died in 1964. of national policy. He was an early pioneer of cervical cytology long before the establishment of a national cervical cancer screening programme and introduced a local screening programme in 1965, which he had run by a charity.

Mods and rockers throwing deckchairs on seafront, 1964 Courtesy of Brighton & Hove City Council

35 CHAPTER 2 PUBLIC HEALTH IN BRIGHTON AND HOVE

Dr Parker was also Medical Officer at a and the need for legislation that provided for time when the link between smoking and lung action to be taken on the basis of noise and cancer emerged. He drew attention to this disruption, and not just food hygiene. This was many times and even had 150 coffin-shaped introduced in the Public Health Act of 1961. ashtrays made and distributed throughout the Water fluoridation was a dividing issue town, one for each person who had died from fifty years ago, just as it is today. Dr Parker the disease in the previous year. was a frequent and strong supporter of The rise of circulatory disease as the main water fluoridation and expressed regret that cause of mortality saw Dr Parker, along with a “following the receipt of an avalanche of local cardiologist Dr (later Professor) Douglas anti-fluoride propaganda the Council had Chamberlain, launch heart ambulances in 1969 considered the matter without medical advice”. based on a Dublin model. This pilot scheme, It is interesting to reflect that a similar motion later adopted throughout the country is was passed in Brighton and Hove the early 21st described more fully in the chapter on coronary century, again without recourse to available heart disease. public health advice. Considerable dental Housing remained an issue of public health health inequalities exist in Brighton and Hove concern and in 1961 Dr. Parker bemoaned and improvements in dental health inequalities the persistence of slum houses that “should would almost undoubtedly occur if fluoridation long ago have been swept away” noting that were introduced. in 1955 he had presented a list of 1,650 unfit Numerous anecdotes abound about Dr houses requiring demolition to the Ministry but Parker; among my favourites are those of him that just 671 had been demolished. He also pouring wine over the head of a councillor for commented on the multi-storey developments showing disrespect to the monarchy, and also that were taking place and noted with concern slapping a council employee on the backside problems of emergency access, refuse disposal, as he was about to slip out of a queue for ventilation and dampness. ‘recommended’ vaccination. These were With an eye for the dramatic, 1961 saw Dr different times and while it appears that he Parker order the seizure of seaside confectionary did not suffer fools gladly, Dr Parker is best when it was discovered that a prohibited and remembered for public health initiatives he led potentially cancer-producing food colouring in the town and indeed in his honour a bus was being used to tint Brighton Rock and candy (Number 915) carries his name. He retired in floss. A year later he personally intervened to 1977 and died in 2000. reconnect gas and electricity to a house of multiple-occupation after they had been severed by an absent London-based landlord. Then, after 2.4 Public health in “two strong-arm men” broke in and “ripped out floorboards, tore out windows and destroyed the latter part of the electrical fittings”, Dr Parker assumed “official 20th century in personal and private financial responsibility” in Brighton and early order to get the electricity reconnected. He did this to right an “outrage committed against 21st century in ordinary decent citizens”. Brighton… and Hove The 1960s was also a time of considerable unrest among the youth of the town, both In recent times, the restructuring of how resident and visiting, and Dr Parker drew services are organised has meant that continuity attention to the problems of the coffee bars in post is a thing of the past, and the local knowledge and expertise early Medical Officers

36 CHAPTER 2 PUBLIC HEALTH IN BRIGHTON AND HOVE built up over many years no longer occurs. Williams came out of retirement in an acting role After a short hiatus, the role of Medical however, in 1995 as East Sussex Health Authority Officer was replaced with the post of Director merged with the Family Health Services Authority of Public Health and following the abolishment (responsible for primary care organisation) to of Area Health Authorities in 1982, ‘Brighton become East Sussex, Brighton and Hove Health Health District’ was established covering Authority, and in 1996 Dr Graham Bickler was the towns of Brighton, Newick, Lewes and appointed substantively as Director of Public Newhaven, so the links with local authorities Health for the new Health Authority. became more diffuse. The requirement for an But the lack of a local focus was perceived Independent Annual Public Health Report to as a loss and so Primary Care Groups, including be published was re-introduced in 1989 on the one covering Brighton and Hove were formed advice of the Chief Medical Officer, Sir Donald in 2000. These Primary Care Groups then Acheson who sadly died in 2009. became independent Primary Care Trusts in Dr Glen Williams, a cheerful Welshman 2002 and Health Authorities were abolished. who originally wanted to be an engineer but was headhunted by a London Medical School because of his rugby playing skills, was R appointed to the role of Director of Public Health for the District of Brighton. The subject Even during my time as Director matter in Dr William’s 1989 Report is very much of Public Health, mortality rates one which we would recognise today: wider from the major killers of coronary determinants of health, lifestyle factors and major disease areas – which have not changed heart disease and cancer have greatly in the past 20 years. decreased considerably, and life His fourth Annual Report of 1992 was to be his last as in April 1993 new Commissioning expectancy has improved. Health Authorities were created with a ‘purchaser’ role, holding health budgets and ‘buying’ care from ‘providers’ such as hospitals R and fund-holding general practitioners. This I took over as Director of Public Health was the new language of the ‘purchaser- in 2003, first in an acting role and then provider split’, an attempt to hold down ever substantively. As I write, discussions are taking increasing healthcare costs by creating an place to establish larger Commissioning Support ‘internal (health) market’. The success of this Units and what that will mean for individual split, both in holding down costs and more Primary Care Trusts remains to be seen. During importantly in providing better services is still my time as Director of Public Health, the role of very much disputed, although all major political ‘health’ within the Local Authority has grown parties remain supportive of it and indeed a stronger once more. As in the days of the similar purchaser-provider split is now being Medical Officers of Health, staff from the Public taken forward in local government. Health team sit in Council buildings and meet Dr Williams retirement in 1993 saw Dr with officers and elected members to discuss Angela Iversen take over in an acting role the public health contribution to housing, as Director of Public Health for East Sussex transport, employment, urban planning, the Health Authority which now covered Brighton, environment as well as the health of specific Eastbourne and Hastings; a year later, Dr groups like children, older people and people Brendan O’Connor was formally appointed. Dr with disabilities. Elected members once more

37 CHAPTER 2 PUBLIC HEALTH IN BRIGHTON AND HOVE

Dr Williams Dr Iversen Dr O’Connor Dr Bickler Dr Scanlon Courtesy of Courtesy of Courtesy of NHS Courtesy of NHS Courtesy of NHS Health Protection Dr Iverson Brighton and Brighton and Brighton and Agency Hove Hove Hove

take a keen interest in health, through scrutiny are several recommendations (including water panels and formal lead responsibilities. This joint fluoridation) although it is fair to say that the working to improve health and reduce health Report, like the national literature, is stronger inequalities is all to the good. when describing inequalities than it is when The 1993 Report of Dr Iversen records addressing them. This situation persists today. a new national Public Health Strategy, The The main health challenges for Brighton Health of the Nation, which included targets and Hove are detailed throughout this for the main disease areas, coronary heart Report and in the city’s Joint Strategic Needs disease, stroke and cancer, as well as targets Assessment. It will be obvious to the reader for reducing smoking, obesity, fatty food that the health of the population of Brighton consumption and alcohol consumption. The and Hove today is much better than it was in national emphasis was on providing knowledge the times of the Medical Officers of Health. so that people could take personal responsibility Even during my time as Director of Public for their health. It is not too unfair to say that in Health, mortality rates from the major killers terms of improving lifestyles, the strategy was a resounding failure. For example, obesity levels which were then at 8% for men and 12% for Medical Officers of Health women (1986/87 baseline) were to fall by the and Directors of Public year 2005 to 6% for men and 8% for women. Health for Brighton / Instead, obesity levels trebled in men and Brighton and Hove doubled in women so that nationally, by 2005, 23% of men and 24% of women were obese. Post Holder Tenure The second Report of Dr. Bickler in 1998, Dr. Richard Taaffe 1874 – 1888 entitled ‘Inequalities in Health’, was in response Sir Arthur Newsholme 1888 – 1908 to a switch in national public health strategic Dr. Duncan Forbes 1908 – 1939 direction from personal responsibility to a focus on addressing health inequalities. Rather Dr. Rutherford Cramb 1939 – 1951 than simply explaining to people what they Dr. William Parker 1951 – 1977 should do and expecting them to change, a Dr. Glen Williams 1981 – 1993 burgeoning public health literature sought to explain the differences in the health of different Dr. Angela Iversen 1993 (acting) populations and, less successfully, come up with Dr. Brendan O’Connor 1994 some measures for reducing these differences Dr. Glen Williams 1995 (acting) in health. The 1998 Report is a thorough Dr. Graham Bickler 1996 - 2003 exposition of the health inequalities that existed across East Sussex, Brighton and Hove. There Dr. Thomas Scanlon 2003 – present day

38 CHAPTER 2 PUBLIC HEALTH IN BRIGHTON AND HOVE

of coronary heart disease and cancer have decreased considerably, and life expectancy has improved. The prevalence of smoking has also reduced. There are several health areas where improvements have however yet to be seen. These include alcohol consumption, sexual health and obesity. Whether health inequalities have reduced or not is a matter of some debate, particularly when a longer term view is taken as is the case in this Report. The Medical Officer Reports considered in compiling this Report detail how the health and wellbeing of the local population have changed over time. The health challenges we face today however, are the same as those we have faced for the last 30 years and are likely to be the same for the foreseeable future. We are making progress: the public health investments we have made in tackling smoking are beginning to bear fruit. We are also beginning to see some impact on the wider determinants of health through health impact assessment and there is scope for building on this. Other areas are more difficult; alcohol and drug use, suicide and sexual health have been resistant to efforts to address them, and housing remains a problem in the city. We should however persist and not shrink from these difficult tasks; just as our forerunner Medical Officers did not shrink from theirs.

Sake Deen Mahomed in formal costume Courtesy of Brighton & Hove City Council

39 ‘Brighton is naturally a place of resort for expectants, and a shifty ugly-looking swarm is, of course, assembled here. Some of the fellows, who had endeavoured to disturb our harmony at the dinner at Lewes, were parading, amongst this swarm, on the cliff. You may always know them by their lank jaws, the stiffeners round their necks, their hidden or no shirts, their stays, their false shoulders, hips and haunches, their half-whiskers, and by their skins, colour of veal kidney-suet, warmed a little, and then powdered with dirty dust. These vermin excepted, the people at Brighton make a very fine figure. (‘Expectant’ refers to a stance of non-treatment adopted for an illness for which the benefit of therapy is uncertain) William Cobbett in his Sussex Journal: through Croydon, Godstone, East Grinstead, Uckfield, Lewes and Brighton returning by Cuckfield, Worth and Redhill. Thursday, January 10th, 1822. Photograph courtesy of The Royal Pavilion and Museums, Brighton & Hove City Council Brighton & Hove and Museums, Pavilion The Royal courtesy of Photograph 40 R CHAPTER ThreeR The population of Brighton and Hove

3.1 The growth of population of Brighton and Hove 3.2 Age profile through the ages 3.3 Population density

41 42 Chapter 3 The population of Brighton and Hove

The population we see in Brighton and Hove today is the result of a web of ever-changing social and cultural factors. Brighton and Hove has been historically a place of inward migration although recently certain groups have begun to leave the city. There have also been important boundary changes reflecting administrative and political shifts through the ages. This section of the Report traces how Brighton’s population profile has changed over West pier 1912 Reproduced from a post-card the years. Many of the public health problems that exist in the city today have their origins in Ovingdean and Rottingdean, and social rented the manner in which the city and its population housing was built in parts of Woodingdean developed. after the Second World War.

3.1 The growth of R the population of It was with the arrival of the Brighton and Hove railway in Brighton in 1841 that It was the arrival of the railway in Brighton the town was brought within in 1841 that brought the town to within the the reach of day-trippers reach of day-trippers from London, and the from London. population grew from around 7,000 in 1801, to 65,000 in 1850, to over 120,000 by 1901. The Victorian era saw the building of many major attractions including the Grand Hotel R (1864), the West Pier (1866) and the Palace Pier In the 1970s and 1980s, Brighton (1899). Boundary changes meant that the land witnessed a transformation to a laid- area of Brighton increased from 1,640 acres (7 back, alternative culture for which the city km²) in 1854 to 14,347 acres (58 km²) in 1952. is renowned today. More recent landmark Between the 1920s and 1940s new housing changes, which may have bypassed some estates were established in Moulsecoomb, of the more chilled residents, include the Bevendean, Coldean and Whitehawk promising administrative fusion of the towns of Brighton an end to slum life. The major expansion of and Hove to form the Unitary Authority of 1928 incorporated the villages of Patcham, Brighton and Hove in 1997, the award of city status by Queen Elizabeth II as part of

43 CHAPTER 3 THE POPULATION OF BRIGHTON AND HOVE

the millennium celebrations in 2000 and the course of the 20th century. Brighton’s wage establishment of the city as a World Health earning population (the proportion of 15-64 Organisation Health City in 2004. year olds) also changed; latterly this was less in tune with the national trends. Between the years 1875 and 2000, the working age 3.2 Age profile population has varied from between 56 to 73% of the city’s total population. In the early THROUGH THE AGES 21st century we find that, as a result of inward migration, the working population comprises Between 1877 and 2000, the percentage of one of the highest proportions in the country. children (aged under 15 years) in Brighton fell, Just as significant, and again latterly in echoing changes occurring across the nation. contrast with national trends, census records This reflected the decreasing birth-rate in the since 1881 tell a tale of expansion of the UK and across much of Europe during the proportion of older (aged 65 years and above).

Figure 3.2.1: Percentage population by age band, Brighton and England, 1901 to 2001

Under 15 ageband 15 to 64 ageband

35% 35% 75% 75%

30% 30% 70% 70%

25% 25% 65% 65%

20% 20% 60% 60%

15% 15% 55% 55% England England

Brighton Brighton 10% 10% 50% 50%

5% 5% 45% 45% 1901 1911 1921 1931 1951 1961 1971 1981 1991 2001 1901 1911 1921 1931 1951 1961 1971 1981 1991 2001

65+ ageband

30% 30%

25% 25%

20% 20%

15% 15%

10% 10%

Brighton

5% England 5%

0% 0% 1901 1911 1921 1931 1951 1961 1971 1981 1991 2001

Souce: Registrar General, Annual Reports Note: As less data are available, Hove data has been excluded. However, for the years where they are available, the proportions by age band are very similar to those for Brighton alone.

44

Chris Dorling K:\Public Health\AR\AR2009\Data\pops BH Eng agebands.xls 3.2.1 12/02/2010 14:50 Public Health, Brighton and Hove City PCT CHAPTER 3 THE POPULATION OF BRIGHTON AND HOVE

Figure 3.2.2: Changes in the population of Brighton over the 20th century

85+ 85+ Female 80-84 Female 80-84 75-79 75-79 Male 70-74 Male 70-74 65-69 65-69 60-64 60-64 55-59 55-59 50-54 50-54 45-49 45-49 40-44 40-44 35-39 35-39 30-34 30-34 25-29 25-29 20-24 20-24 15-19 15-19 10-14 10-14 5-9 5-9 0-4 0-4

864202468 864202468

Brighton population, 1000s, 1911 Brighton population, 1000s, 1931

85+ Female Female 80-84 75-79 75+ Male Male 70-74 70-74 65-69 65-69 60-64 60-64 55-59 55-59 50-54 50-54 45-49 45-49 40-44 40-44 35-39 35-39 30-34 30-34 25-29 25-29 20-24 20-24 15-19 15-19 10-14 10-14 5-9 5-9 0-4 0-4

864202468 864202468

Brighton population, 1000s, 1951 Brighton population, 1000s, 1971

85+ 85+ Female 80-84 Female 80-84 75-79 75-79 Male 70-74 Male 70-74 65-69 65-69 60-64 60-64 55-59 55-59 50-54 50-54 45-49 45-49 40-44 40-44 35-39 35-39 30-34 30-34 25-29 25-29 20-24 20-24 15-19 15-19 10-14 10-14 5-9 5-9 0-4 0-4

864202468 864202468

Brighton population, 1000s, 1991 Brighton population, 1000s, 2001

Souce: Registrar General, Annual Reports

45 CHAPTER 3 THE POPULATION OF BRIGHTON AND HOVE

Nationally, the proportion of the population of 65 years swell at a rate far greater than the comprising older people had remained at national increase. Then, in the 1990s, there was around 5% between 1851 and 1911. With falls a sudden reversal of this historical trend, with in birth rates and improved life expectancy this the proportion of over 65 year olds in Brighton proportion swelled by three-fold in the second and Hove realigning itself with the national half of the 20th century (Figure 3.2.1). pattern so that by the turn of the new century In the nineteenth century, the elderly were it represents 16% of the total population. This concentrated mostly in rural areas, as younger fall is in part due to less inward migration of people increasingly migrated to towns and the elderly but also due to more young people cities in search of employment. By 1951, a new moving to Brighton and Hove. Many of these pattern had emerged. Older people began young people came seeking the cosmopolitan to enjoy longer retirements and with greater way of life that the town offered, or had relative wealth compared to their predecessors. arrived as students and stayed on hoping to These changes resulted in shifting expectations, fill jobs in the developing new media industry and the elderly themselves became migrants, that has been a feature of Brighton and Hove’s moving for example, to seaside resorts such economic development in recent years. as Brighton. We can follow the ever changing shape of The attraction of our coastal townscape Brighton and Hove’s population distribution in saw the proportion of residents over the age Figures 3.2.2 and 3.2.3, which show population

Figure 3.2.3: Brighton and Hove population pyramid, projected 2011

85+

Female 80-84 75-79 Male 70-74 65-69 60-64 55-59 50-54 45-49 40-44 35-39 30-34 25-29 20-24 15-19 10-14 5-9 0-4

14 12 10 8 6 4 2 0 2 4 6 8 10 12 14

Brighton and Hove population, 1000s, projected 2011

Souce: Office of National Statistics

46 CHAPTER 3 THE POPULATION OF BRIGHTON AND HOVE pyramids for the city over the century between now relatively large numbers of young people 1911 and 2011. The classic pyramidal shape aged 20 to 44 years, with Brighton and Hove from 1911. with its broad base and steady boasting one of the highest proportions of upwards narrowing, demonstrates the high 18-24 year olds outside of London Boroughs. birth rates and high mortality rates of the early Hand-in-hand with this change we can see that 20th century. In this respect Brighton is typical there are now relatively fewer young children of late 19th and early 20th century settlements. and older people living in the city. By 1951, there is evidence of significant Part of this growth has been the increase social and economic development with in student numbers. The term ‘studentification’ decreasing birth and death rates reflecting has been used to describe increasing numbers improved healthcare, more use of birth control of student residents moving into established and greater social and economic aspirations. residential communities, and displacing families The proportion of young dependents has and older people. The Adult Social Care and decreased, mirroring regional and national Housing Scrutiny Committee reported in 2009 trends at this time. The post-war baby boom (BHCC and BHCPCT, 2009) the effects of softens this trend somewhat. studentification on communities in Bevendean, Projections to 2011, as shown in Figure Moulsecoomb and Hanover and Elm Grove. 3.2.3 suggest a very unusual contemporary This dramatic increase in student numbers population in Brighton and Hove compared nationally over the last decade has reflected the to regional and national trends. There are government’s pledge to increase the number

Figure 3.2.4: Increase in higher education students in Brighton and Hove, 1998-2008

25

2.4

23 The University of Sussex The University of Brighton 2.2 England

20 2.0

1.8 18

1.6

15

1.4 Numbers of students, England, millions England, students, of Numbers 13 1.2 Numbers of students, Brighton and Hove, thousands Hove, and Brighton students, of Numbers

10 1.0 1997/98 1998/99 1999/00 2000/01 2001/02 2002/03 2003/04 2004/05 2005/06 2006/07 2007/08

Academic year

Source: Higher Education Statistics Authority (HESA), number of students

47 CHAPTER 3 THE POPULATION OF BRIGHTON AND HOVE

of 18-30 year olds attending university to 50% with the caveat that there is an unusually large by 2010. In Brighton and Hove we have seen a proportion of very elderly people aged 85 24% increase in the number of students living years and over. This group accounts for 2.6% here between 1998 and 2008 (now totalling of our total population in Brighton and Hove, 33,360; accounting for approximately 13% of compared to just 2.1% in the UK as a whole. the total population of the city), as shown in Three quarters of this very elderly group are Figure 3.2.4. This increase in student numbers female and projected population estimates is now considered to be levelling off, as higher for 2031 suggests that the proportion of very education funding comes under pressure elderly will increase further as people live longer, during times of economic hardship. However, to almost 9% of the city’s total population. This the recession has also seen more young people is approximately three times the projection for seeking university places as jobs become more the UK as a whole. Therefore, while the public difficult to secure. health issues that residents witness every day The student population is by nature a might reflect a relatively young working age transient one, generally only settling in shared population, there is an imperative to provide housing or halls of residence for between 1-3 relatively higher levels of health and social care years. As such, students are less likely to register for our very aged population. with a local GP, and more likely to use open- access health services. The current relatively small proportion of retired people in Brighton and Hove comes

Figure 3.2.5: The expansion of Brighton and Hove from 1873     

Added 1952

Added 1923 Hove Added 1997

Brighton Boundary Changes

Added From 1997 1894 to 1908 1972 1928 to 1952 Pre 1873 boundary   Dotted Eyes © Crown copyright and/or database right 2009. All rights reserved. Licence number 100019918  Source: Encyclopaedia of Brighton

48 CHAPTER 3 THE POPULATION OF BRIGHTON AND HOVE

3.3 Population density Regency, which is dominated by retail outlets). Towards the peripheries we find more dispersed Brighthelmstone, unlike today, remained populations, reflecting the nature of housing confined within the area bordered by North, provision across the city area. West and East Streets. The late 18th and 19th Figure 3.2.7 shows contemporary centuries were a time of growth. The separate population densities at smaller spatial units, settlements of Brighton and Hove, began to known as super output areas. Introduced spread towards one another. Overcrowding by the Office for National Statistics in 2001, brought with it numerous problems for the these super output areas allow us to look at health and wellbeing of residents. population features at a small scale. This map Figure 3.2.5 illustrates how administrative shows how parts of Hanover and Elm Grove, boundaries expanded between 1873 and 1997. Queens Park, Regency and St Peters and North The increasing population density of Brighton Laine are particularly crowded residentially with and Hove outpaced many towns and cities in densities of between 200 and 300 persons the 19th and 20th century. per hectare. This is still of course much less Figure 3.2.6 and Figure 3.2.7 show than the crowding that occurred in the central how the density of Brighton and Hove has slums of 1901 illustrated in Figure 3.2.6 where changed over one hundred years from 1901 population density was between 301 and 408 and 2001, respectively. We can see that in people per hectare in much of the town. 2001, the central wards of the city have denser Current population densities are linked, in populations (save for the most central parts of part, to the movement of young people into

Figure 3.2.6: Brighton population density per hectare, 1901



D

i t

c

h

l i n

g

e u R d n o a e a o v d  R  A s d r o we f e P n L r a es t to S n D R y o k a e d R o a d

d oa R  n re ar W Elm Grove

   

D

y

k

e

R  o a Population per hectare d   W estern Road 36 - 50 No rth St   reet 51 - 120    King 's Ro  121 - 200 ad  E ast ern Ro 201 - 408 M ad arin e Pa rade Representation of roads

1 square mile = 259 hectares, 1 square kilometre = 100 hectares

Dotted Eyes © Crown copyright and/or database right 2009. All rights reserved. Licence number 100019918

Source: Annual Reports of Medical Officer of Health for Brighton; Registrar General, Annual Reports

49 CHAPTER 3 THE POPULATION OF BRIGHTON AND HOVE

the city. Younger people, particularly those aged with densely packed Victorian mews cottages 18 to 30 years, often settle in shared, private- housing a mixture of families, students and rented accommodation. Indeed, residents in older people living cheek-by-jowl. Many quality Hanover and Queens Park have watched the of life issues are tied to this population density buy-to-let housing market become particularly and endure in Brighton and Hove today. buoyant in recent years, as more and more We find evidence of this in residential and students and young professionals have commercial noise complaints; environmental joined these communities. The availability of health issues such as difficulties in storing privately rented flats and conversion of family and disposing of domestic refuse; pressures housing into Houses of Multiple Occupation on green spaces and local services and the (HMO) to accommodate students and young infrastructure of the city; and the efforts of the professionals has intensified population density authorities to reduce car traffic. in these communities. The cultural influences of the city have brought about artistic and creative renown, but also pressures on health and social care 3.4 Summary services in the city. These include the service pressures associated with the lifestyle traits of Brighton is historically renowned for being young people - no longer the sorts of problems densely populated and overcrowded. In that might be dealt with using spa services and contemporary Brighton, we can find evidence thalassotherapy. Instead these public health of this in the narrow streets of Hanover, lined issues mean a greater need for sexual and

Figure 3.2.7: Brighton and Hove population density per hectare, 2001

Wards 1 Brunswick & Adelaide 2 Central Hove  3 East Brighton 4 Goldsmid 5 Hangleton & Knoll 6 Hanover & Elm Grove 7 Hollingbury & Stanmer 8 Moulsecoomb & Bevendean 10 9 North Portslade 10 Patcham 20 11 7 Preston Park 9 12 Queen's Park 13 Regency 14 Rottingdean 5 Coastal 8 15 St. Peter's & North Laine 17 16 South Portslade 17 Stanford 11 18 Westbourne 16 21 19 Wish 4 6 20 Withdean 19 18 15 21 Woodingdean 2 3 1 13 Population per hectare 12 3 - 50 1931 Brighton Boundary 51 - 120 1901 Brighton Boundary 14 121 - 160 161 - 200 201 - 296

1 square mile = 259 hectares, 1 square kilometre = 100 hectares Dotted Eyes © Crown copyright and/or database right 2009. All rights reserved. Licence number 100019918

Source: Office of National Statistics

50 CHAPTER 3 THE POPULATION OF BRIGHTON AND HOVE mental health services, alcohol and substance misuse services, obstetric and paediatric services (Brighton and Hove JSNA Summary, 2009). Local historian Arscott (2009) sums up present-day Brighton: “How...to characterise Brighton? A bit of a chancer...not too comfortable to live with, but full of energy and with a wicked sense of humour. Definitely not the sort to introduce to your prim and proper maiden aunt without due warning, but immensely popular with the younger, wilder members of the family. Rather loud, up all hours of the night and warmly generous without caring too much whether you return the affection – but you most certainly will.”

In 2009, after a year-long restoration project the bandstand on the seafront was returned to its Victorian splendour. Image courtesy of Richard Rowlands

51 “Brighthelmstone is a country so truly desolate, that if one had a mind to hang one’s self for desperation at being obliged to live there, it would be difficult to find a tree on which to fasten the rope.” Samuel Johnson, (who detested Brighthelmstone Downs [Brighton]). Photograph courtesy of The Royal Pavilion and Museums, Brighton & Hove City Council Brighton & Hove and Museums, Pavilion The Royal courtesy of Photograph 52

R CHAPTER FourR The wider determinants of health

4.1 Housing and urban development 4.2 The recession and unemployment 4.3 Transport 4.4 Environment

53 54 Chapter 4 The wider determinants of health

This section of the Report considers some of the 4.1.1 Housing development in wider determinants of health, namely: housing, Brighton and Hove in the 19th transport, environment and the potential effects of the current recession with particular regard century to unemployment. Housing is discussed in some By 1840, the seaside town of Brighton had detail, as it has been by previous Medical Officers been Britain’s largest resort for about 70 years. of Health, for it remains an issue of substantial The town itself was confined to a small area public health concern in Brighton and Hove. and most of today’s city was short turf rural farmland grazed by sheep. The presence of large farms resulted in a structure of land ownership dominated by several estates with a 4.1 Housing and urban few small holdings. Large farms were vulnerable development to urban development as unprofitable farmland was sold off in large plots. From the slums of the 19th century to the The opening of the London to Brighton council estates and flats of the 20th century railway line in 1841 further boosted the town’s to present day aspirations of sustainable position ahead of rival resorts such as Worthing, development, Medical Officers and Directors Eastbourne and Hastings. Both visitors and of Public Health in Brighton and Hove have residents influenced the growth of Brighton consistently drawn attention to the effects of and Hove. Typically, a small group of socialites poor housing on health. In its recent review rented a house for a month over Christmas; this of health inequalities in the city the Audit then attracted middle class professionals and Commission praised the Primary Care Trust business men. As office employment increased and Local Authority for working closely on in London, clerks and white-collar workers housing through health impact assessments were able to afford a holiday stay in a boarding for example; but it criticised the dearth of house. By the late 19th century, large numbers commissioning intentions that would improve of day-trippers came during the summer – what health via housing. Reflecting the large was then the ‘off-season’, when few middle proportion of homes not meeting decent class or wealthy visitors were present. housing standards, the only red flag given Many residents originated from a middle to the city in the 2009 Comprehensive Area class background having migrated to the sea Assessment was for housing. So this chapter from London and the Home Counties, with is unapologetically full as it seeks to tell a others from the colonies. Resident unskilled comprehensive story of housing in Brighton and and semi-skilled workers migrated from the Hove, and the significant impact it has on the surrounding areas although the number of health and wellbeing of our residents. skilled workers from further afield increased with the decision to locate railway works in Brighton.

55 CHAPTER 4 THE WIDER DETERMINANTS OF HEALTH

By the 1860s, the rapid growth had slowed the middle was always filled with sludge or because of a shortage of land suitable for middle filth, and the single-roomed tenements were class resort clientele and a failure to absorb Hove. often flooded as rainwater could not run away Brighton had attempted and failed to claim the easily. The 1861 census recorded that in Orange Parish of Hove in 1844, 1853, 1875 and 1897 Row occupancy per house, typically tiny two- as Hove’s middle class residents successfully roomed terraced houses, was 7.65 persons. protected their assets of select housing, privacy, lower rates and absence of cheaper housing developments associated with urban R development. By the late 19th century, the age structure of Hove’s population was already older “Go along there any night, and than Brighton’s, and the dominance of servants you will see hideous old women, confirmed its relative affluence. drunken old men, young men, and Just as elegant seafront housing developed, so behind the beautiful facades sometimes mere boys, hopelessly grew several areas of slum housing. Two main intoxicated, reeling and areas of slums were established in the town: staggering in the road. There is Church Street with the top of North Street and West Street, built mostly between 1770 also, of course, the usual amount and 1800; and a second area to the north of of cursing and blaspheming, which St. James’s Street around Edward Street and is sometimes varied by an Carlton Hill. Church Street, considered to house many petty criminals, often made the news. occasional fight” (Bishop, 1860). The courts and alleys to the north of Church Street, which contained Pimlico, Orange Row and Pym’s Gardens, were described as very R narrow and badly ventilated, with very poor Little planning control existed in Brighton cramped dwellings. The surface gutter down before the 1860s and these slums had been

A row of houses in the Carlton Hill area built in c.1790 of flint and cobble-stones (left), and terraced properties on Richmond Hill (right). These were both demolished in the 1930s as part of the slum-clearance programme. Image from Brighton and Hove in Pictures; Brighton & Hove City Council.

56 CHAPTER 4 THE WIDER DETERMINANTS OF HEALTH constructed at speed with poor building repair and alteration, or failing that, demolition. materials. Houses sat amidst dung-holes, pig The Council began a building scheme of sties, open pools and privies. There was no its own in the early 1900s when terraced underground drainage, leaving the slurry to sit housing in May Street and St Helen’s Road on the surface of the street. Pigs were bred in was completed. These houses were expensive the courts and streets, and waste animal and to rent however, and only affordable for vegetable matter was not regularly removed. artisans. In addition, many tenants were forced Slaughter houses were common in this area, to sub-let – a problem also encountered in with dung collecting on the street. Moulsecoomb later. Housing conditions and Mr. Cresey’s 1849 Report (Cresey, 1849) unemployment were becoming national identified ill-drained and over-crowded slums political issues and in 1908 in Brighton, there and a lack of effective sewerage with several were organised demonstrations by unemployed thousand cesspits cut into the chalk soil. He people on the occasion of a visit from the King. found many people dependent upon wells A striking feature of the growth of the near the cess pits for fresh water, which posed town up until 1914 was the lack of open spaces serious health risks. Limited improvements in artisan areas. This is partly because much by 1864 gave Brighton 11 miles of sewers, development took place on two enormous principally along the London and Lewes open fields running north to south sold Roads. Only 4,000 houses were connected to profitably for terraced housing. The narrowness the sewerage system, however, with 11,000 of the London and Lewes road valleys were having cesspits instead. Mortality in Brighton further constraints. was comparable with larger industrial towns, A 1918 Report on the design of housing although some of that may have reflected a for the working classes, chaired by Sir John trend for invalids to come to Victorian resorts. Tudor Walters, recommended low density By the 1880s however, the message was housing (12 to an acre) with a range of sizes getting through and Brighton had started to and layouts and a mixture of social classes – a invest more in essential services. portent of similar recommendations for mixed Church Street slums were demolished in housing development some 90 years later. the 1860s and replaced with better housing. The growth of Brighton and Hove as a This attracted higher rents however, which regional centre and commuter town increased many residents could not afford, so they moved demand for housing, and precipitated the to other slum areas of the town. The 1890 suburban development of 1918 – 1939 with Houses of the Working Classes Act enabled new council housing estates and private councils to condemn and buy houses deemed housing developments for office workers. unfit for human habitation. Brighton had By 1918, some villages such as Patcham become one of the most densely populated and Rottingdean were regarded as worth boroughs in the country, and rents were high in retaining and cottages and farm buildings were relation to wages; a feature that has a familiar adapted to middle class houses. More typically, ring 120 years later. however, development was large scale and homogeneous. The West Brighton Estate in 4.1.2 Housing development in Hove and the Boer War streets in Bear Road are examples of this. The 1920s and 1930s saw Brighton and Hove in the first large council developments in Moulsecoomb, half of the 20th century Queens Park and Whitehawk. Simultaneous In his 1904 Annual Report the town’s first full- private development in Woodingdean, time Medical Officer, Dr Arthur Newsholme, Rottingdean and to the north and west of urged the Council to buy more houses for

57 CHAPTER 4 THE WIDER DETERMINANTS OF HEALTH

4.1.3 Housing development in Brighton and Hove in the second half of the 20th century Kemptown is a good example of post-war change in Brighton, some of it by necessity. In Edward Street, just past White Street a line of Victorian terraces stops short of the main road where they are replaced by more modern houses. This marks the route ploughed by a German bomber when it was shot down and Newly developed council housing in Moulsecoomb, crashed here (Kemptownhistory.org, 2009). The 1920s Image from Brighton and Hove in Pictures; Second World War saw 56 air raids demolish Brighton & Hove City Council 200 houses and damage 15,000 more. Since the Second World War, the town has seen further development with more modern Brighton meant that the social mix envisaged housing estates and the conversion of the by the 1918 Tudor Walters Report did not many Regency buildings into flats. The North materialise. By 1939 over half of the 21,300 Laine area, like Kemptown, is notable for its acres in the 11 Parishes of the boroughs of reinvention. Once characterised by the squalor Brighton and Hove had been built upon or were and stench of inner-city slums, it has been ready for development. Carlton Hill was finally transformed into a colourful ‘Bohemian quarter’ demolished in 1933. (Carter, 1996). The move from slums to new council Post Second World War British housing was a time of great promise for many governments sought to replace both residents. Maurice Packham recalls the move, as bomb-damaged and slum housing through a 13 year old, from Kemptown to Whitehawk programmes promising new dwellings of better opposite. design and quality. These began in the mid- In 1929, Brighton’s Medical Officer Dr 1940s and continued in some areas, including Duncan Forbes reported on the extent and Brighton, several decades beyond. The latter quality of housing development since the end stages of the 1950s saw a rapid acceleration of the First World War. Some of his findings are of slum clearance, with a total of 2,445 people summarised in Tables 4.1.1 and 4.1.2. Although re-housed from homes demolished or closed he found that housing was improving, in several between 1955 and 1959. cases the conditions were still deplorable, with The provision of new housing could not five or six people living and sleeping in one however keep up with demand, and, like room. There was still the slum problem and his predecessors, Medical Officer Dr Parker Dr Forbes was concerned that building new expressed exasperation at the prolonged houses on the outskirts would mean that many impact of poor housing on the health of some slum dwellers would not be able to leave the residents living in areas which should long centre of town and their place of work. ago have been swept away. The response At the same time there was extensive was the development of high-rise blocks building of private dwellings, many of which of flats, such as the Swanborough flats in were flats, which peaked in the 1930s. The Whitehawk, built in 1967. In his Report of availability of private buildings for rent is evident 1962, Dr. Parker commented on the changing today: much of the city’s rental sector is owned skyline of Brighton, and the new public health privately. challenges bought about by the high-rise

58 CHAPTER 4 THE WIDER DETERMINANTS OF HEALTH

Expectations on moving from a Kemp Town mews to a proper house in Whitehawk – Maurice Packham In the summer of 1938 a woman from the Housing Department visited our flat in Marine Terrace Mews, Kemp Town to find out if we were suitable tenants of a council house in Whitehawk. Her report was favourable, and my mother was delighted by the prospect of a house with a garden. Her recurring but never to be realised dream had always been a cottage in the country with hollyhocks and wallflowers and surrounded by fields of cows and sheep. “It’s right on the edge of the Downs!” she declared joyfully which sounded idyllic; but the reality was somewhat different. Just over the garden fence was a small holding which was periodically manured with rotting fish; and a little further still, in Sheepcote Valley, was the municipal dump. Whitehawk estate was sited in a valley beyond the town proper. It felt a little as though the City Fathers had successfully dealt with a social problem, and smugly satisfied with their success, could wash their hands of it. This is probably unfair but I for one always felt a bit of a second class citizen in Whitehawk. I remember the remark of a boy in my class when he heard another had moved to Whitehawk. “Cor – that’s worse Young Maurice Packham than Moulsecoomb!” he exclaimed. Courtesy of Maurice Packham development boom such as “...refuse disposal 4.1.4 Housing in 21st century and the provision of adequate sized lifts to take Brighton and Hove stretchers horizontally as well as wheel chairs” Today, compared to the national average, in (Dr. Parker, Medical Officer’s Annual Report, Brighton and Hove, fewer people own their 1962). The problem of social isolation, now own houses (62% compared to 71% for connected with high-rise living, was not yet England). Instead, residents are heavily reliant evident. Figure 4.1.1 shows main sites where on private rented housing; 23% of households slum clearance took place in Brighton. rent from a private landlord, more than double the national figure of 11% (Brighton & Hove City Council, 2008b). The city’s private rented sector is the 6th largest in the country, with 104,100 dwellings as of April 2009. The number of converted flats is seven times the national average (accounting for almost one-third of privately rented housing stock in Brighton and Hove, compared to 3.3% nationally), with far fewer semi-detached (17.5%) and detached houses (6.5%) suitable for families than typically found in the country as a whole (29.1% and 21% respectively). The city’s distinctive housing profile is illustrated by Winston Road party, Whitehawk Courtesy of MyBrightonandHove Figure 4.1.2.

59 CHAPTER 4 THE WIDER DETERMINANTS OF HEALTH

Brighton and Hove has comparatively More than half of the Council’s social housing old housing stock, particularly in the private stock fails to meet the decent home standard rented sector. Almost 40% of privately rented (Brighton & Hove City Council, 2008b), along housing was built before 1919, and a further with 35% of private sector stock (Brighton 25% during the inter-war period. This has & Hove City Council, 2008). As illustrated in implications for the quality of these dwellings. Figure 4.1.3, the highest rates of non-decent ‘Decent homes’ are a big issue for our city. homes are found in high and low rise purpose

Table 4.1.1: Number of houses built by the Brighton Corporation during the period 1918-1929 May Road 14 Elm Grove 14 Natal Road (Flats) 20 Moulsecoomb (including flats and shops) 530 Queens Park 450 Loder Road and Balfour Road (flats) 56 Nesbit Road 28 Hereford Street 40 North Moulsecoomb (including flats) 394 Freshfield Road 28 Whitehawk Valley 144 Crescent Cottages (flats) 8

Source – Dr Duncan Forbes, Annual Report of the Medical Officer for Health, Brighton, 1929

Table 4.1.2: Average number of persons per household and the number of households kept cleanly, 1929 Ave. No. No. houses Persons per house not kept cleanly Moulsecoomb estate 4.45 4 North Moulsecoomb Estate 5.32 65 Queens Park Estate 5.76 42 Whitehawk Valley Estate 5.62 14 Balfour Road Flats 3.81 No data St Helen’s Road 4.06 No data Tillstone Street 3.75 1 Nesbit Road 6.00 3 May road 4.69 1 Elm Grove Hereford Street 5.62 4 Dewe Road 4.03 No data

Source – Dr Duncan Forbes, Annual Report of the Medical Officer for Health, Brighton, 1929

60 CHAPTER 4 THE WIDER DETERMINANTS OF HEALTH built flats that were constructed relatively to meet the 2006/7 target of 65% of vulnerable recently (Brighton & Hove City Council, 2008). households living in a decent home. The South The reliance on the private sector rentals East England Development Agency’s Framework tells a story of the affordability of housing in for Action (2007) sets out a target of 11,400 Brighton and Hove. Figures from the 2008 new units of housing to be provided by 2026; Strategic Housing Market Assessment show this amounts to an annual requirement of 567 that a first time buyer would need a household new dwellings between 2010 and 2026, 230 income of £40-45,000 to buy an entry-level of which must be ‘affordable’ (Brighton & Hove flat or maisonette in the city (SHMA, cited by City Council, 2009c). Brighton & Hove City Council, 2009b). And the These housing needs are rendered more Health Inequalities Report by Oxford Consultants acute at a time of economic recession when for Social Inclusion (2007) states that a 2008/9 saw a large reduction in the number of household income of £88,000 is needed to buy housing units proposed and approved compared an average terraced house in the city. to previous years. Developers do not currently The dependence on renting from have ready capital to invest. Just four of the 196 the private sector means less security, and approved development projects in 2008/9 will sometimes this affects the most vulnerable in provide more than 10 housing units, and only the city. The loss of privately rented housing is two of these have commenced to date. the reason given for homelessness by one third So in 2009, we see cautious small scale of homeless people in Brighton and Hove. As development, high property prices and the of April 2009, 10,609 households in the city natural restrictions on development imposed by were waiting to be housed; of these, 42% the city’s geographical position compounded by had medical priority and 14% were living in an economic recession. Health problems that overcrowded housing. stem from poor or insufficient housing persist. An extra 1,600 homes need to be upgraded Paradoxically, some of these are found in

Betty Gillett’s memories of the bombing of St Cuthman’s Church, 16th August, 1943.

My most vivid memory of the war was in August, 1941. We were all in bed, and before the siren or the pips went a bomb fell on the local church. The church was completely demolished by the bomb. It was a moonlit night and the church was a white building in its own grounds, which probably made it more visible from the air. I remember standing on the landing with my family Young Betty Gillett being absolutely petrified. The house Courtesy of Betty Gillett shook from the explosion, slates came off the roof and windows were shattered but we were all uninjured. A friend of mine, however, lost her father who was fire-watching in the crypt of the church that night. The local men, who were in the Home Guard, took it The ruins of St Cuthman’s Church, in turns to be on duty there. My father was on the rota, but Whitehawk, following its destruction by a German bomb on 16th August, 1943. off-duty that night. Image from Brighton and Hove in Pictures; Brighton & Hove City Council

61 CHAPTER 4 THE WIDER DETERMINANTS OF HEALTH

4.1.5 The health impact of housing in Brighton and Hove Figure 4.1.4 illustrates the links between poor housing and health. Housing quality is a key determinant of health, or a result of issues such as lack of warmth, damp, mould and dangerous structures. In 2004, Brighton and Hove became a World Health Organisation Healthy City. The city pledged to assess the health impact of Council Planning Committee reviews the plans for the different developments and policies. During new marina development in 1964 Courtesy of Brighton & Hove City Council 2009, the Primary Care Trust and City Council worked together to assess the health impact of the new housing strategy 2009-2014 (BHCC locations that were once felt to be the solution and BHCPCT, 2009). This assessment stressed to housing problems, while other areas that the importance of addressing homelessness, once comprised slums, now prosper. overcrowding, and winter fuel poverty.

Figure 4.1.1: Map showing areas of slum clearance in central Brighton during the 19th and 20th centuries

Source: Libraries and museums, Brighton and Hove

62 CHAPTER 4 THE WIDER DETERMINANTS OF HEALTH

Homelessness the loss of privately rented accommodation “In comparison to the South East, residents in (31.2%). Providing housing advice and support Brighton and Hove remain nearly twice as likely to homeless people is now a key part of the city’s to be in a position where they need to make plan to tackle homelessness (Brighton & Hove a homeless application, and are more than City Council Homelessness Strategy 2008-2013). twice as likely to be homeless and in priority Local research has found that 17% of all need.”(Brighton & Hove City Council, 2008) rough sleepers describe themselves as being In years gone by, homeless people in unwell, and 70% report mental health or Brighton and Hove received an unsympathetic substance misuse problems (Brighton & Hove hearing from the locals. Among the Carlton City Council, 2007). A 2009 Health Equity Audit Hill and Edward Street slum areas of the 19th by the Mental Health Homeless Team found century several common lodging houses served that the main health-related issues for homeless as shelter for itinerant workers; hawkers, street people in Brighton and Hove were mental musicians, labourers and their families as well health including alcohol and substance misuse, as so-called ‘tramps and vagrants’. There are physical disability and having a dependent child. several reports of these people being described Poor housing can be associated with as an annoyance and being brought before serious consequences. A 2007 audit of drug- ‘the Bench’. related deaths in Brighton and Hove found that Today, the most commonly cited causes of the 41 drug-related deaths that year, 20% for homelessness in the city are eviction by did not live in settled accommodation. This parents, family or friends (39%), followed by corresponds to the findings of a local suicide

Figure 4.1.2: Brighton and Hove dwelling type profile

30

25 Brighton and Hove

20 England and Wales

15 Percentage 10

5

0 Converted Medium/large Semi Low rise Bungalow High rise Detached Small flats terraced detached purpose built purpose built house terraced house house flats flats house

Dwelling type

Source: 2007 Brighton and Hove Housing Condition Survey and 2005 English Housing Condition Survey

63 CHAPTER 4 THE WIDER DETERMINANTS OF HEALTH

audit (carried out across 2003/4/5 and based Despite these improvements, Brighton on 119 deaths) which reported that 11% of and Hove is still among the 10% of Local suicides were in people who were homeless, Authorities in England with the highest number or living in unsettled accommodation, for of homeless households, with the number example in unsupervised hostels, long-term bed of rough sleepers among the highest in the and breakfast, or sheltered accommodation country. So homeless people experience (Memon and Walker, 2009). multiple health issues, some of them very Recent efforts by statutory and voluntary serious and compounded by a lack of secure, agencies to address homelessness in Brighton decent accommodation (BHCPCT, 2009). and Hove appear to be having some effect. There has been a 78% reduction in new Fuel poverty and winter deaths homelessness applications since 2000/1 and The winter of 2009 brought prolonged an 82% reduction in rough sleeping over the snowfalls in Brighton and Hove. Emergency same time period. Between March 2003 and measures saw the city’s gardeners, street March 2009, the number of households living cleaners, refuse collectors and even much in temporary accommodation decreased from loved traffic wardens drafted in to help grit 559 to 366. Of these, the number in bed roads and pavements. Cars were abandoned, and breakfast accommodation fell from 240 buses suspended, and the Royal Sussex County households to 57 households (Brighton & Hove Hospital pressed to bursting point with patients City Council, 2009). who had slipped and fallen in the treacherous conditions.

Figure 4.1.3: Non-decent private rented sector dwellings by date of construction

60

50

40

30

Percentage unfit 20

10

0 Pre 1919 1919-1944 1945-1964 1965-1980 Post 1980

Construction date

Source: 2007 Brighton and Hove Housing Condition Survey

64 CHAPTER 4 THE WIDER DETERMINANTS OF HEALTH

Less immediately apparent than a full months. Increasing fuel prices in recent years accident and emergency waiting room, a have compounded this problem (BHCPCT, 2008). number of vulnerable residents will have Figure 4.1.5 shows the excess winter death suffered the effects of extreme cold, in trend in Brighton and Hove and England and particular homeless people, and those who Wales over the last decade. This trend varies struggle to find the means to heat their home according to the average winter temperature. sufficiently. Almost half (48%) of the 8,000 Over the last decade, Brighton and Hove has private sector non-decent homes in Brighton suffered a greater excess winter death score and Hove have what is technically referred to than the South East region and the country as as ‘a poor degree of thermal comfort’ (BHCC, a whole. This pattern may in part reflect the 2008b). This is more than twice the national city’s relatively large proportion of very elderly figure of 20%. people (aged 85 years and over), and the The ‘fuel poor’ are defined as people who quality of housing. It remains to be seen if this need to spend 10% or more of their income on will continue given the recent severe winter heating to maintain a comfortable temperature weather across the country. in their home. They comprise mainly older people, who are more susceptible to higher Overcrowding death rates in winter, and who are often on In 1880, Brighton was said to be one of the most relatively low incomes. In Brighton and Hove densely populated towns in the country (Farrant, up to 28% more deaths occur in the very aged 1987) and in a visit to a Health Congress population (aged 85 and over) during the winter in Brighton in 1881, Sir Edwin Chadwick

Figure 4.1.4: The links between Public Health and housing

Healthcare Community costs stability

Suicide Loneliness Falls & Stress Depression Drugs/Alcohol Sleep Deprivation Lack of Isolation Stress Acess Employment Dangerous Access to Worry Problems Stairs Burglars Lack of Lack of Money Excess Over Educational Cold Crowding Achievement Rubbish Trip Damp & Dumping Hazards Mould Burglaries Pneumonia Heart Attacks Colds Absence Asthma from Work Anti-Social Behaviour Death Bullying Vandalism Graffiti Truancy

Environmental Crime disorder Environmental

targets CO2 costs cleanup costs costs

Source: Chartered Institute of Environmental Health, 2008

65

Chris Dorling \\5lqfs001\5lq-uhf$\cdorling\Public Health\AR\AR2009\Data\Cha4\4.1.4#.xls 4.1.4 18/03/2Public Health,010 11:34 Brighton and Hove City PCT CHAPTER 4 THE WIDER DETERMINANTS OF HEALTH

Snow in Whippingham Road, Brighton, December 2009 Image courtesy of Brighton & Hove City Council

deplored the appalling local consequences housing: ‘Student Housing Strategy 2009-2014’ citing “excrement sodden sites... stagnant (Brighton & Hove City Council 2009a). putrefaction... and filthy street surfaces”. There has been considerable effort applied The 2001 census ranked Brighton and to housing in recent years, both from the City Hove the 53rd most densely populated Council Housing Department and colleagues in Local Authority (of 376) in the country, with the Directorate of Public Health. New legislation overcrowding affecting more than 1 in 8 means that up to 40% of new developments households. Overcrowding is a particular of 10 or more homes must comprise affordable problem for people living in privately housing, and all new homes must be to a rented housing where 28% of homes are Lifetime Homes Standard. As well as the health overcrowded, compared to 20% of houses impact assessment work, over the last two years in the social rented sector, and 5% of owner- 321 empty homes have been brought back occupied homes (Brighton & Hove City Council, into use and 3,000 grants and loans for home 2008a). This is in part a consequence of the improvements (adaptations, repairs and energy definition of overcrowding. Houses with less efficiency measures) have been allocated. There than a minimum of 2 habitable rooms, even are plans to incorporate assessments of housing in a 1 person household, are automatically into the assessments conducted by health classed as overcrowded. The large number of professionals visiting patients in their homes. studio flats and bedsits in Brighton and Hove contribute to these high figures. Nevertheless, 4.1.6 Summary shared housing tends to be particularly crowded We have come a long way from the desperate and houses in multiple occupation (HMOs) lives of the slum dwellers of the 19th and comprise 10% of the city’s housing stock early 20th centuries. However, modern day (Brighton & Hove City Council, 2009). population and housing pressures in the Today, overcrowding brings increased city mean that there still is a lack of decent, noise nuisance complaints, lifestyle conflicts, affordable homes. Houses of multiple social cohesion tensions, and pressures on occupation bring service and social tensions, street parking and domestic refuse disposal vulnerable people are often placed in less than services. In an effort to respond to this, the new adequate housing and homelessness figures housing strategy for the city addresses student remain worryingly higher than average.

66 CHAPTER 4 THE WIDER DETERMINANTS OF HEALTH

Following on from the health impact to ensure that the adverse health effects of assessment, the year 2009 saw local strategy- poor housing are reduced or eliminated. makers draft a raft of plans that address these issues. These included the new core Housing Strategy 2009-2014; and housing 4.2 The recession and strategies to support older people, students, homeless people, single homeless people and unemployment the Lesbian, Gay, Bisexual and Trans (LGBT) population. The next few years will be decisive 4.2.1 A brief history in determining whether, in the face of an of recessions economic recession, Brighton and Hove can The main global news of the year, was without emerge as a place where housing is not a doubt, the deepening of the recession that continuing and irresolvable problem, but an started in 2008. The economy has implications asset that all residents can enjoy in fair measure. for health, though these are not always straightforward. Recessions are of course, not Recommendations new. The first major recession of the 20th Housing and health colleagues should work century started in 1919 and lasted three years. closely together to develop practical initiatives It was triggered by the end of the First World

Figure 4.1.5: Excess winter deaths in Brighton and Hove and England, 1996/97-2007/8

35 8 C .

30 7 ort,

6 25

5 20

4

15 3

10 2 Excess Winter Death (EWD) Index (EWD) Death Winter Excess

5 1

0 0 Airp Shoreham at temperature winter average Monthly 1996/97 1997/98 1998/99 1999/00 2000/01 2001/02 2002/03 2003/04 2004/05 2005/06 2006/07 2007/08

Brighton & Hove EWD Index England & Wales EWD Index Avg Brighton & Hove winter temperature

Source: Annual Mortality File, Office for National Statistics “1) Excess winter deaths are defined by the Office of National Statistics as the difference between the number of deaths during the four winter months (Dec to Mar) and the average number of deaths during the preceding autumn (Aug to Nov) and the following summer (Apr to Jul). 2) 2007/8 data for Brighton and Hove is provisional.”

67 CHAPTER 4 THE WIDER DETERMINANTS OF HEALTH

War as European economies recovered from the war effort. In Britain, Gross Domestic Product fell by 10.9% in 1919, 6% the following year R and 8% in 1920. The city’s varied retail provision The Great Depression of 1930-1931 was the world’s most famous recession. The Wall makes an important contribution Street crash of 1929 caused a global crisis. By to the “sense of place” that 1932, the US economy had declined by half makes the city distinctive. and 90% had been wiped off the value of US shares. It took 25 years before the Dow Jones industrial average recovered to its 1929 level. Between 1973 and 1975, UK Gross R Domestic Product fell by 3.9% as OPEC In May 2009 there were an estimated launched an oil embargo on the West. Soaring 12,000 unemployed working age people living inflation, widespread strikes and a ‘Winter of in Brighton and Hove (based on the Office Discontent’ hit the country. Even Liverpool’s for National Statistics mid-year population gravediggers went on strike. estimate and 7.6% unemployment rate). A The 1980s were marked by long dole large proportion of the Brighton and Hove queues as unemployment rose from 5.3% workforce is employed in the increasingly in August 1979 to 11.9% in 1984 and the vulnerable business and financial services. Government struggled to control inflation by The Confederation of British Industry and cutting spending and raising interest rates. PricewaterhouseCoopers have estimated that up There was more discontent as riots broke out in to 60,000 jobs were lost in the financial services London, Liverpool and the Midlands. sector in 2009, almost double the number cut in The early 1990s saw another brief the previous year. Locally, however, the city has recession but it was in the first three months escaped the huge job losses that have been seen of 2009 that the British economy shrank at the in the financial sector in London, with no major fastest rate in 30 years. Gross domestic product job losses reported from companies based in fell by 1.9% between January and March 2009 Brighton and Hove. - a fall greater than the 1.5% decline forecast Construction companies in Brighton and by City economists. The International Monetary Hove, in common with the rest of the UK, Fund predicted that the economy would have suffered. In a report published in October continue to shrink into 2010 forecasting falls of 4.1% in output in 2009, and 0.4% in 2010. Council Planning Committee reviews the plans for the new marina development in 1964 4.2.2 The recession and Brighton Courtesy of Brighton & Hove City Council and Hove Local research has already been undertaken on the effects of the current recession. Brighton & Hove City Council commissioned the Centre for Cities to compare the impact of the recession in Leeds, Brighton and Bristol (Larkin and Cooper, 2009). This was followed by a second report from the same organisation, ‘Sustaining City Rationing in the 1940s – An orderly queue forms Growth’ (Webber, 2009). outside Davies and Cowley Bakers in Dyke Road Courtesy of Brighton & Hove City Council

68 CHAPTER 4 THE WIDER DETERMINANTS OF HEALTH

2009, the Construction Products Association So far, employment in Brighton and Hove estimated that it will take until 2021 for is holding up well, relatively speaking. However, construction output to reach the levels last the city starts from a relatively poor base. With enjoyed in 2007. The Association warned that just under 25,000 people in Brighton and the flagging construction sector will suffer a Hove on unemployment benefits of one kind drop in output of 15% in 2009 and 2% in or another, we have entered recession with a 2010 before beginning a slow recovery in 2011. higher level of unemployment than many other In Brighton and Hove, local company similar cities. Integra collapsed in October with the loss The Centre for Cities Report (Larkin and of 40 permanent jobs and many more sub- Cooper, 2009), comparing the likely impact of contractors. Adenstar – a company with an the recession on three cities including Brighton annual turnover of £4 million reported at the and Hove, estimated that job losses would be in end of 2008 that it had only £400,000 worth the region of 2,400 if the recession is short, and of contracts in the pipeline for 2009. 7,400 if it is long. The report also suggested The city’s varied retail provision makes an that most of losses in Brighton and Hove would important contribution to distinctive “sense of be from the retail and hospitality sectors. place”. While the independent retail sector is These sectors rely to varying degrees on probably more vulnerable in the longer term, visitors coming to Brighton and Hove and it is national chains like Woolworths, The Pier, spending their money in local shops and at Envy, Zavvi, USC and Roseby’s that have gone visitor attractions. Latest figures suggest footfall into administration and with the loss of around numbers are holding up very well compared 240 local jobs. to both last year and the national benchmark.

Unemployment and health in the 1930s – Memories from a local resident

Mum met dad when she nursed him as a wounded soldier in the Brighton General Hospital. He lived in Derby and on leaving hospital they corresponded and finally married in 1928. Dad had worked on a farm at home but this was the difficult years in the 1930s with a lot of unemployment, and in those days there was no help. He was unable to find work in Brighton and therefore signed on for unemployment benefit. Mum went back to the hospital to work after I was born but she could not cope, especially as she was now expecting my brother. Then at last my dad got a job doing manual work, helping to build a sea wall at Saltdean. But their joy was short-lived because one day a policeman knocked on the door and told my Mum that dad had fallen off the wall. She was later told that he had a pickaxe in his hand at the time and his workmates did not expect to find him alive. He was seriously injured, and when he came out of hospital he had to wear a special corset as he had spinal injuries. Now we were in trouble, with no money coming in and a sick husband. For nine years my dad was out of work. He was a chain smoker and when he could not afford cigarettes he became aggressive and thought nothing of lashing out at anything or anybody. Mum would end up with black eyes and my brother and I would have the buckle end of the belt around the back of our legs. On one occasion I came home from school to find his waistcoat ripped, and he had gone missing threatening to commit suicide. This has a lasting effect on children in later life and I sometimes relive those memories.

69 CHAPTER 4 THE WIDER DETERMINANTS OF HEALTH

Over 15 million shoppers were recorded in the mortgage or rent payments has increased. The ‘Prime Pitch’ (the stretch of Western Road from number of households approaching Brighton the Clock Tower to Crown Street, and Churchill & Hove City Council for homeless assessment Square) in 2008. Retail sales in the city centre has also risen from 1,885 in 2007/8 to 2,607 in 2008 declined compared to 2007, however. in 2008/9 (Housing Strategy Team, Brighton This suggests that while consumers are still & Hove City Council, 2009). However, the coming to the city, they are spending less in the number of homeless households in the city has current financial climate. continued to drop as many people are helped to stay in their existing homes, or to secure 4.2.3 The relationship between alternative accommodation. the economy and other A number of voluntary sector agencies determinants of health provide debt advice to residents with financial The economy interacts with many other wider problems. A ‘toolkit’ has been launched to help determinants of health. These include transport people to act early to prevent homelessness and family support. But perhaps the wider because of mortgage arrears. Local agencies are determinant of health most closely linked to the taking joint responsibility and have formed the economy is housing. ‘Recession Impact Working Group’. The cost of housing in Brighton and Hove The overall decline of mortgage has been high in relation to household income repossession orders in Brighton and Hove for a long time and house prices have tripled in reflects national trends with more, and better, the city since 1998. So an economic downturn investment in debt and housing advice, and could mean that houses become more government pressure on lenders through affordable. Average house prices have fallen in mortgage support schemes. There is also, the last two years but are still more than 25% however the possibility that some lenders and higher than the national average (Brighton & landlords are ‘sitting tight’ as they are unlikely Hove City Council, 2009d). to recover sufficient equity. The number of people coming to the Housing pressures in a recession bring Housing Options team at Brighton & Hove City additional burdens on health. Housing payment Council because they cannot maintain problems have adverse mental health consequences.

Woolworths London Road – An old High Street friend says farewell in 2009

70 CHAPTER 4 THE WIDER DETERMINANTS OF HEALTH

with economic hardship. For example, some mortality rates may decrease. These may R include traffic accidents as rising unemployment The cumulative effects of job means fewer people commuting to work, and more using public transport. Drug-related loss, housing problems, financial deaths have also been found to decrease during worries and associated health times of economic hardship. Diabetes (perhaps problems may put a severe strain related to less overeating) and more puzzlingly Alzheimer’s disease, influenza and pneumonia on relationships within have also all been shown to decrease during a household. times of unemployment (Stuckler et al, 2009). Although the picture is not fully clear, some research even goes as far as to suggest that an economic recession may improve overall R mortality with reductions in smoking, excessive 4.2.4 The health impact alcohol consumption and overeating as people of recession try to save money (Bezruchna, 2009). It has The first health impact of recession results from even been suggested that in some cases mental job insecurity and unemployment. Research into wellbeing may improve as people have more UK unemployment has shown that people in time for friends and family and ‘social capital’ secure employment recover more quickly from increases. Overall, the literature suggests that the illness. Conversely, unemployment increases the net effect of moderate unemployment is that all chances of being ill (Bartley et al, 2004). age all cause mortality rates remain the same. Studies of the impact of unemployment have reported increased rates of mental health 4.2.5 Summary problems, including depression, particularly The recession hit the UK hard in 2009 although among young people. This is because they the effects to date in Brighton and Hove have form the majority of the group who have never not been as bad as in some other parts of the worked, and also because they are least likely country. The local economy however, remains to secure employment when jobs are few. precarious, as the service and hospitality Higher suicide rates have been reported. In industries are vulnerable to consumer spending the UK, rates of attempted suicide in young, and there is local evidence that consumer unemployed men are 10-25 times higher spending is reducing. than in young, employed men (Dorling, The relationship between health and 2009). Homicide rates also rise in times of the economy is complex and there may be hardship. Deaths from alcohol, falls, cancers, associated, though independent, adverse health cardiovascular disease and cirrhosis of the liver effects from housing pressures. The relationship have also been shown to rise during periods of between unemployment and health has been sustained unemployment (Stuckler et al, 2009). extensively studied and is clearer. Young people (18-24 years), are most The effects on smoking, alcohol and drug at risk of joblessness, and people over that misuse, diet and exercise are hard to predict. The age of 50 years may experience age-related relatively small population of Brighton and Hove discrimination when they seek re-employment. means that it may be impossible to detect any It is not, however, easy to predict or even changes, and some of the changes that do occur assess the local impact of a recession, for there may simply reflect random variation in small may also be positive health effects associated numbers rather than any meaningful occurrence.

71 CHAPTER 4 THE WIDER DETERMINANTS OF HEALTH

The effects of the recession on the health 4.3 Transport of the population of Brighton and Hove will therefore depend on job losses, for how long 4.3.1 The development of people remain unemployed and wider effects on people’s lives such as how it affects their transport in Brighton and Hove marriage, and whether or not they lose Brighton and Hove has seen a variety of public their home. transport services since Brighton railway station first opened in 1841: suburban electric railways, trams, trolley buses, car clubs and even auto- R rickshaw and hydrofoil services. The Volk’s electric railway, running along the inland edge Efforts to sustain and improve the of the beach from the Palace Pier to Black Rock health of the population should was built in 1883 and is the world’s oldest focus on measures to minimise job operating electric railway. Between 1894 and 1901, another electric railway was created by losses and support people in Magnus Volk, called the ‘Daddy Longlegs’. This their own homes. used tracks laid under the sea. The carriage had tall iron legs and would carry thrill-seeking tourists out across the waves in the summer R months. It was never able to withstand the punishment of winter storms however, and Recommendations after several collapses and reconstructions The Directorate of Public Health should was finally abandoned to the sea. Modern work closely with colleagues in Economic transportation needs have not seen the end Development to monitor the effects of the of a sense of ‘being different’ in Brighton recession in Brighton and Hove and take and Hove. In recent years, a network of auto- prompt action to address any associated rickshaws known as Tuc-Tucs has operated in health problems. the city during the summer months, offering a quirky alternative to the buses and taxis between Brighton Marina and Hove Town Hall. Transport played a major role in the city’s development with easy connections to Britain’s capital city contributing considerably to Brighton and Hove’s success. By 1910 the London rail link had a journey time of just one

Daddy Long Legs Brighton Corporation Tram No. 75 Tuc Tuc Courtesy of Brighton & Hove City Council at the Lewes Tram Depot, c.1905 Courtesy of MyBrightonandHove

72 CHAPTER 4 THE WIDER DETERMINANTS OF HEALTH hour, which compares well with today’s travel Brighton behind, as costs of extending the time of 51 minutes today. tramways were prohibitive and it was the Intra-urban transport development motorbuses that followed the progress of the brought opportunities to move out of the builders. By 31st August 1939 the trams had all densely populated centre to lower density been withdrawn. peripheral developments. In Brighton and Hove, The first motorbus was introduced in suburban railway services had little influence 1904 on the Castle Square Western Road in shaping the town’s urban growth. A horse- route. By 1918 it seems all horse-drawn buses drawn bus service developed rapidly after 1879 in the town had ceased to operate and over with a network initially similar to the urban the next 20 years motorbus services expanded rail network then further inland. The steep considerably. gradients in Brighton limited development It is buses that continue to provide although horse-drawn services persisted into the key part of the city’s public transport the period of the Great War. system. In 1997, Brighton & Hove Bus and The earliest tramway opened in 1884 Coach Company, operating a service with along the route from Westbourne Villas, approximately 300 buses, absorbed the former Hove to Swiss Gardens, Shoreham. The municipal operator, Brighton Blue Buses. Recent Aldrington tramway, as it is referred to in times have seen improvements in the operation some early omnibus timetables, was notorious of services with raised level bus stops that allow for derailments and poor speeds. Motorbus better disabled access and real time information competition deterred extension of this tramway at bus stops. In 2007, Brighton & Hove City route which finally closed in 1912. Council approved a Bus Rapid Transport System. If implemented, this £12 million transport project could cut journey times across Brighton R and Hove by up to a third. In the South East, we travel further The first motorbus was introduced than people in other regions (The South East in 1904 on the Castle Square Public Health Observatory, 2008). Despite the Western Road route. By 1918 it availability of public transport, most of this additional travel is by car. In 2005, 16% of all the seems all horse-drawn buses in the UK’s road traffic was in the South East - where town had ceased to operate and 14% of the population resided. In the South East over the next 20 years motorbus we also own more cars than other parts of the nation. In 2005, 39% of households had two services expanded considerably. or more cars, compared to 32% in England. As we become more reliant on our cars, we spend less time walking and cycling. In this region only R 38% of men and 27% of women are active at Brighton Corporation motorised trams the recommended levels. opened up the hillier parts of the town to In recent times considerable effort has public transport. Although only one small gone into encouraging more use of public addition to the track was made after the basic transport, walking and cycling and shared network was completed in 1904, the number car ownership and usage. Automatic and of tramcars steadily increased and apart from manual counts and surveys show that cycling is a brief period in the 1920s fares were highly increasing with adult cycling (any time during competitive. However, further development the previous week) increasing from 24.7% in on the new housing estates left the trams in

73 CHAPTER 4 THE WIDER DETERMINANTS OF HEALTH

2006 to 26.4% in 2009, and the proportion of children cycling to school increasing from 1.5% Council Planning Committee reviews the plans for the new marina development in 1964 in 2006/07 to 1.8% in 2007/08. Courtesy of Brighton & Hove City Council The South East Plan (GOSE, 2009) sets out key regional policy on transport, and the South East England Health Strategy (GOSE, 2008) expresses determination to promote more active lifestyles. In Brighton and Hove, a Transport Partnership was established in October 2009. This group is contributing to the update of the city’s Sustainable Community Strategy which will be published in 2010. A victory bus party on the Downs, 1945 Courtesy of Brighton & Hove City Council 4.3.2 Transport and health Transport has positive and negative effects on two age groups are particularly at risk. These health (World Health Organisation, 2009). are young people aged 12-19 years, and older The positive effects of transport include: people aged 70 years and over (SEPHO, 2008). • Improving health through walking There are also health implications from or cycling; noise pollution which may reduce sleep quality, • Enabling access to health; impair hearing, increase fatigue, and decrease employment and other services; cognitive performance. It is estimated that • Keeping in touch with friends and upwards of 10% of us living in the South East family, facilitating strong are exposed to unacceptable levels of noise social networks. (SEPHO 2008). The main negative effects of transport are: The effects of air pollution, particularly • Obesity due to reduced on respiratory and cardiovascular health are physical activity; considered in more detail in Section 4.4 • Stress from noise pollution; on Environment. • Injuries from road traffic accidents; • Respiratory problems due to air 4.3.3 Older people and pollution. transport Approximately 30% of children aged 10 A recent transport development associated with to 11 years (Year 6 pupils) in Brighton and Hove potential health consequences has been the are overweight or obese. One of the clearest provision of free bus travel. This has enabled evidence of decreasing physical activity in the many people aged 60 years and over to travel last 20-30 years is demonstrated by the greater further and more frequently. In 2006, free reliance on cars. Together, a lack of physical local off-peak travel was introduced across the activity and smoking account for the largest country; then in April 2008 this was extended number of deaths and ‘years of life lost’ in so that people with a principal residence in developed countries. England, aged 60 years and over, or disabled, With improvements in vaccination and were entitled to free off-peak bus travel infectious disease control, road traffic injuries anywhere in England. are now the leading cause of death among In Brighton and Hove the number of bus children and young people. The South East has passes issued to older people at the end of the highest level of 17-24 year olds killed or February 2009 was 38,552. The mid-year 2007 seriously injured on the road. Pedestrians from population estimates of residents aged 60 years

74 CHAPTER 4 THE WIDER DETERMINANTS OF HEALTH and over is 47,900 (ONS website). This suggests There are a range of publicised bus walks and that locally the take-up rate is in the order of ‘Breeze up to the Downs’ buses which are very 80%. The cost of this concessionary travel to popular with older people. Brighton & Hove City Council for 2009-10 is estimated to be £8.9 million. 4.3.4 Summary The free bus pass has liberated many older The housing development on the hills of people, many of whom cannot afford, or prefer Brighton was accompanied by transport not, to drive. Research (Knight et al, 2007) developments, principally the motorbus. Data suggests that older people give up driving for on car use is for the South East of England four main reasons: declining health (particularly as a whole and in this area car use, including eyesight), general effects of ageing, loss of ownership of two cars or more, is higher than enjoyment of driving and financial concerns. in the rest of England. Cycling and walking are Accessible, free public transport can be a on the increase in Brighton and Hove although lifeline with the potential to reduce boredom, there is considerable scope for improvement. loneliness and isolation, and to promote social Transport has important effects on health; inclusion. from noise, air pollution and reduced physical Table 4.3.1 shows the changes in activity. The effects of the free bus pass for passenger casualties that accompanied free people aged over 60 years, which comes at a bus travel in Brighton and Hove. These figures significant cost to local authorities, has been to suggest that the availability of free bus passes increase the numbers of older people travelling may have been accompanied by a slight by public transport. It is likely that this has had reduction in car-related casualties, but a slight considerable beneficial effects on older people’s increase in passenger-related casualties in those wellbeing, although this has not been assessed. people aged 60 years and over. The trends are Data on accidents in Brighton and Hove do not not dramatic however, and these figures should provide firm evidence of any trends consequent be interpreted with some caution as many of of the free bus pass. the casualties are of estimated age and no A Transport Partnership has been postcode is recorded. established in the city which will oversee Both the Council and Primary Care Trust transport strategy within the city as part of the encourage older people to combine bus use Sustainable Community Strategy. with social interaction and physical activity.

Table 4.3.1: Casualties and transport in Brighton and Hove, 2005-2008 Lorem ipsumTotal dolor Car sit amet,Total Travelamet accumsanPassenger quam Carquam ac sapien.Total consecteturCasualties adipiscing elit.Passenger CasualtiesDuis cursus Casualties malesuada Casualties neque, sed Travel Pellentesque a sapien orci.Casualties Vivamus agedfaucibus urnaaged aliquam agedid. Donec ut Casualties tincidunt metus vel jvel jvel jvel justo 60+ liberoyears sem,60+ a tristiqueyears quam.60+ years Proin ut luctus blandit. Phasellus venenatis ante ipsum. Nulla suscipit tincidunt 2005 726 230 162 63 86 1288 sapien at neque consequat tempor. eleifend. Vestibulum id quam velit, Vestibulum2006 nec614 mi id est lobortis266 176venenatis sodales87 eros. Praesent73 1213 ultricies2007 in vitae677 lectus. 302 194blandit rutrum100 odio, a accumsan71 1296 2008 616 279 186ipsum malesuada95 vel. Aliquam69 1208 Suspendisse suscipit, tellus a varius augue est, dictum ut tincidunt vitae, Source: Scambler M. The Impact of concessionary bus passes for older people in Brighton and Hove, Directorate of Public Health,gravida, Brighton neque and velitHove, facilisisJuly 2009 orci, sit gravida ut lorem. Vestibulum ante

75 CHAPTER 4 THE WIDER DETERMINANTS OF HEALTH

Recommendations expectancy would increase by up to 11 months Council and NHS colleagues should continue (UK Government Committee on the Medical to work together to encourage more people Effects of Air Pollution, 2000). to walk and cycle to reduce potential serious The type of air pollution encountered health problems such as obesity, diabetes and to nowadays in Brighton and Hove is quite cardio-vascular disease. different to the type experienced before the Employers in the city should be Clean Air Act of 1956. This Act was introduced encouraged to develop transport plans. These after the ‘Great Smog’ of 1952, which engulfed should include initiatives to reduce air and London for 4 days in December as a result of noise pollution by discouraging car use and windless, cold weather conditions and the encouraging people to walk, cycle and use collection of airborne pollutants, mainly from public transport. the domestic coal for use. It is estimated that 12,000 people died prematurely as a result of the Great Smog (Bell et al., 2004). The Clean Air Act (1956) introduced a 4.4 Environment number of measures, such as smoke control zones within which households were allowed Following the launch of ‘Sustainable to burn only smokeless fuels, and the adoption communities: building for the future’ in 2003, of cleaner fuels such as gas and electricity. In fostering sustainable communities became the his Report of 1968, Dr William Parker talks of mainstay of urban policy in the UK. The concept the application of the Clean Air Act in Brighton of a sustainable community is wide ranging, to control the effects of smoke emission on air covering housing and the built environment; quality in the city. The monitoring of smoke social and cultural aspects of communities; and sulphur dioxide levels between 1964 and transport; local services; the economy; and the 1967 is discussed. Dr Parker reports that the natural environment. This chapter provides winter peak in smoke levels from coal-fired an overview of the environmental factors that heating decreased markedly from over 200 affect our health in Brighton and Hove, in microgrammes per cubic metre in January particular air quality, water quality and climate 1964 to 110 microgrammes per cubic metre in change, and reviews the progress the city has January 1967. This improvement in air quality made in these areas in recent times. resullted from a reduction in coal burning, and the enforcement of minimum chimney heights 4.4.1 Air quality in Brighton via planning regulations. and Hove The increasing problem of air pollution Air pollution has short and long-term damaging from road traffic is also discussed, with Dr effects on health. These include worsening Parker noting that “during the year, much the health of people who have heart or lung has been said about pollution from traffic disease, including asthma, and reducing life and considerable research into this problem expectancy. The numbers of hospital admissions is taking place” (Dr Parker, Medical Officer’s and deaths in people with the above conditions Report 1968). Diesel engines were singled out increase when air pollution levels are high; this as a particular problem, and Dr Parker talks is particularly so in the elderly. Although the of the possibility of “electric propulsion” as an full extent of the health effects of air pollution alternative to fuel-burning engines. are hard to quantify, if lifelong exposure Today, the majority of pollutants in air to pollution from ‘fine particles’ (see Table originate from road traffic (see Table 4.4.1), 4.4.1) was cut in half, it is estimated that life as our reliance on cars has increased over the

76 CHAPTER 4 THE WIDER DETERMINANTS OF HEALTH decades and “electric propulsion” has not objectives, the Local Authority must declare an materialised on any scale. Air Quality Management Area (AQMA). The The 1995 Environment Act places an air quality management area for Brighton and obligation on all Local Authorities to regularly Hove was extended in 2008 (Figure 4.4.1). review and assess air quality in their areas with An Air Quality Action Plan has been regard to a number of air quality objectives. declared for nitrogen dioxide, and sets out the Where the levels of pollutants exceed these measures intended to improve air quality as

Table 4.4.1: UK air pollutants and health effects LoremPollutant ipsum dolorMain sit sources amet, %amet in UK accumsan Effect quam on healthquam ac sapien. consectetur adipiscing elit. fromDuis cursusroad malesuada neque, sed Pellentesque a sapien orci. Vivamus transportfaucibus urna aliquam id. Donec ut tincidunt metus vel jvel jvel jvel justo libero sem, a tristique quam. Proin ut Benzene Combustion and 67% Genotoxic carcinogen causes luctus blandit. Phasellus venenatis ante ipsum. Nulla suscipit tincidunt distribution of petrol. leukaemia. sapien at neque consequat tempor. eleifend. Vestibulum id quam velit, Vestibulum nec mi id est lobortis venenatis sodales eros. Praesent ultricies1,3- in vitaeCombustion lectus. of 80%blandit rutrumGenotoxic odio, a carcinogenaccumsan causes Butadiene petrol. ipsum malesuadalymphomas vel. Aliquam and leukaemia. Suspendisse suscipit, tellus a varius augue est, dictum ut tincidunt vitae, gravida,Carbon neque Incompletevelit facilisis orci, sit 91%gravida ut lorem.Increased Vestibulum deaths and ante cardiovascular monoxide combustion. disease-related hospital admissions.

Nitrogen Combustion in air: 46-61% Long term: affects lung function, dioxide road transport, enhanced responses to allergens. electrical supply, industry and commerce.

Ozone Sunlight acting on NO, Respiratory symptoms and lung and VOCs. – function. Pollutant

Particles 1: Combustion 25% Shortens lives, increases (road traffic) hospital admissions from respiratory 2: Chemical reactions and cardiovascular disease. in air. Increased asthma symptoms. Coarse e.g. dust, soil, salt, pollen, tyres, construction.

Sulphur Combustion of sulphur 2% Respiratory and cardiovascular dioxide containing fuel. disease and deaths, and respiratory hospital admissions.

Source: Cave et al., 2004 Footnote: NO = Nitrous Oxide VOCs = Volatile Organic Compounds

77 CHAPTER 4 THE WIDER DETERMINANTS OF HEALTH

set out in the Environment Act (1995). Over in 2010 to establish exactly where any problems 80% of nitrogen dioxide monitors (diffusion may be. Unfortunately, it is not possible to tubes) in Brighton and Hove showed an directly compare the particulate matter and improvement in nitrogen dioxide between nitrogen dioxide levels of today with the smoke 2007 and 2008, and the hotspots exceeding and sulphur dioxide levels of Dr Parker’s time. the annual average for nitrogen dioxide have reduced from previous years. Figure 4.4.2 shows nitrogen dioxide trends, as recorded 4.4.2 Water quality in Brighton by two continuous analysers, in two specific and Hove points in Brighton and Hove between 2000 and 2008. Overall, in Brighton, nitrogen dioxide Drinking water levels have fluctuated around the mean annual In July 1872, under the terms of the Brighton target, showing no real trend. Levels in Hove Corporation Waterworks Act, the corporation have been consistently below the mean annual purchased the Constant Service Water average objective, and have decreased over Company, which supplied around 18,000 this period. homes in Brighton with 2.6 million gallons per With regard to particulate matter, when day. The new service covered Brighton, Falmer, natural sea salt is deducted from the total Hangleton, Ovingdean, Patcham, Preston and particulate measure, concentrations in areas Rottingdean, and supplied both constant and where people live show compliance with the intermittent services at different tariffs. target levels for the protection of human health. By the turn of the century, three other local New particulate matter monitoring equipment water companies had been acquired. These will be connected at roadside level in Brighton were the West Brighton in 1876; Shoreham

Figure 4.4.1: 2008 Air Quality Management Area (AQMA)

Source: Brighton & Hove City Council

78 CHAPTER 4 THE WIDER DETERMINANTS OF HEALTH and District in 1896; and Aldrington in 1897. in 1903 and demolished when it was found to The purchase of the West Brighton Waterworks be contaminated. The Brighton Corporation Company included a supply of piped sea water took great steps over the following years to serving one hundred houses from tanks filled prevent further pollution of the water supply. at high tide under Hove Western Lawns, which These included the acquisition of vast areas of was maintained until 1939 (Carder, 1990). downland to prevent turf-breaking, cultivation In his 1882 Report commissioned by or development, and monthly monitoring of the town’s authorities, Dr Richardson spoke the quality of all sources (Carder, 1990). In his glowingly of the water supply. “The water Report of 1919, Dr Duncan Parker discusses the supply has been so perfected that no town in ‘absolute organic purity and great palatability’ the world can boast a freer, a more distinct or a of the water, which resulted from a high level of purer water supply.” aeration. He describes the monitoring of water As demand for mains water increased, quality via sampling at each of the five supply several new sources and pumping-stations were sites, which were examined for bacteria on a established. These were located at Patcham in monthly basis. 1889; Mile Oak in 1900; Falmer in 1904; and In 1937, ozone treatment (discontinued the first electric station at Balsdean in 1936. in 1954) was introduced at the Goldstone This was the largest station of its kind, and pumping station, and during the Second World remains Brighton’s largest water station today War chlorination of all supplies was introduced (Carder, 1990). for disinfection purposes. In his 1963 Medical Lewes Road pumping station was closed Officer’s Report, Dr Parker supported the

Figure 4.4.2: Annual Mean Level of Nitrogen Dioxide in Brighton and Hove 2000-2008, with the Annual Mean Objective

45

40

3 35

30

25 Nitrogen dioxide µg/m dioxide Nitrogen

Brighton roadside

Hove roadside 20 Annual mean objective

15 2000 2001 2002 2003 2004 2005 2006 2007 2008

Year

Source: Brighton & Hove City Council

79 CHAPTER 4 THE WIDER DETERMINANTS OF HEALTH

fluoridation of the local water but 47 years Faecal Coliforms – specific coliform later, this has still not taken place. bacteria found only in the gut of warm-blooded Water quality is now monitored in animals. Their presence can indicate waters accordance with the Water Supply Regulations recently contaminated with sewage. (2000). It is pumped from underground Faecal Streptococci – also found in the sources in Sompting, Southover, Newmarket, gut of warm blooded animals and an indicator Falmer, Patcham, Shoreham, Goldstone Hove, of sewage contamination. High numbers Housedean, Mossy Bottom and Stanhope may be present in waters contaminated with Lodge. According to reports from the Water agricultural pollution. Quality Inspectorate, of seven recently reported The quality of sea water at Saltdean has incidents regarding water quality, none were in been ‘good’ or ‘excellent’ since 1988, and Brighton and Hove. consistently ‘excellent’ since 1995. The quality of seawater in Kemptown and Central Brighton Sea water has improved since the late 1980s / early 1990s, The Environment Agency has tested sea water when it was found to be ‘poor’ on 4 occasions, at Saltdean, Kemptown or Central Brighton, the last of these being in 1994. Since 1995, and Hove on a weekly basis since 1988. Tests the quality has been found to be either ‘good’ are carried out for the following three bacteria: or ‘excellent’. Finally, seawater in Hove was Coliforms – bacterial organisms which reported as consistently ‘poor’ until 1994 but inhabit the gut of warm blooded animals, but since 1995 has been either ‘good’ or ‘excellent’. can also be present in vegetation and soils. Overall then, there has been a considerable Whilst not necessarily harmful themselves, improvement in the quality of sea water along coliforms can indicate the presence of more the Brighton and Hove coast over the last harmful bacteria. 20 years.

Figure 4.4.3: National carbon reduction targets with 1990 and 2007 baselines

Source: NHS Sustainable Development Unit, 2009

80 CHAPTER 4 THE WIDER DETERMINANTS OF HEALTH

4.4.3 Climate change and Agreement (LAA) commits the city to reduce per carbon reduction capita carbon dioxide in the city by 12%’, and to increase the number of households living in ‘Climate change’ refers to changes in the energy efficient properties. climate as a consequence of human actions, The NHS has adopted more vigorous for example, the release of carbon dioxide efforts in a bid to lead the country in reducing and chlorofluorocarbons (CFCs) and other carbon emissions. The NHS carbon reduction gases. Recent press coverage of an exchange strategy, released in January 2009, recommends of scientific correspondence has dented public that the NHS reduces its carbon footprint by confidence in the objectivity of scientific advice 10% from 1990 levels by 2015. Figure 4.4.3 in this area. Nevertheless, the scientific world shows the NHS reduction carbon dioxide remains at a virtual consensus on this issue. reduction targets, with the projected trend The predicted changes in the global climate required to meet these. could have a huge impact on global public health. This includes mortality from extremes of temperature (natural disasters); and changing 4.4.4 Summary patterns of infectious diseases. The latter of The quality of the environment, including air, these was exemplified in 2007, when the first water and climate, plays an important role case of ‘blue tongue virus’ was diagnosed in in health and wellbeing; this is increasingly the UK in Suffolk. This virus is normally seen recognised at a global level. In Brighton and in Mediterranean climates, and the detection Hove, air and seawater quality have both of it in the UK suggests a temperature shift. improved in the city in recent years. Levels of Intense, short term fluctuations in temperature nitrogen dioxide in 2008 were close to the mean – a recognised effect of climate change, can annual objective, and seawater consistently seriously affect health, with stress resulting from found to be either of ‘good’ or ‘excellent’ quality very hot temperatures (hyperthermia) or extreme since 1995. There are further improvements that cold (hypothermia). could be made, and measures which reduce There are benefits to public health therefore car usage and encourage alternative means of from efforts to reduce carbon emissions in the transport will help in ensuring air quality targets short, medium and long-term. In addition to are never breached – as well as improving the reducing the risks of ill health such as those health of individuals. outlined above, reducing carbon emissions Climate change is assuming a greater through increased use of active transport such prominence in the public sector and Brighton as walking, cycling and car sharing encourages and Hove has demonstrated a commitment to active lifestyles, reduces obesity and will reducing carbon emissions in line with national ultimately reduce illness and mortality. targets. The NHS has communicated a strong In 2008, the UK government signed the message in this regard by forging a reduction Climate Change Act, which legally binds the strategy exceeding government expectations. UK to reduce its net carbon account by at least 80% by 2050, from levels recorded in Recommendations 1990. In the shorter term, there is a target to The City Council, NHS and the private sector reduce carbon emissions by 26% by 2020. should work together to reduce car usage Locally, the City Council signed the Nottingham and encourage alternative healthier means declaration on climate change in 2004, and in of transport in the city in order to improve air 2006 a Sustainability Strategy for the city was quality as well improve the health of individuals. developed. Included within this strategy is a draft climate change action plan. The Local Area

81 Many men were initially drawn to Brighton by the enormous numbers of soldiers garrisoned here during the Napoleonic Wars. In August 1822, George Wilson, a servant from Newcastle-upon-Tyne, was accused by a guardsman he had met in the Duke of Wellington public house in Pool Valley of having offered him a sovereign and two shillings to go with him onto the beach to commit an unnatural crime. www.brightonourstory.co.uk Photograph courtesy of The Royal Pavilion and Museums, Brighton & Hove City Council Brighton & Hove and Museums, Pavilion The Royal courtesy of Photograph 82 R CHAPTER RFive The lifestyle determinants of health

5.1 Alcohol 5.2 Drugs use 5.3 Smoking 5.4 Obsesity 5.5 Sexual behaviour

83 84 Chapter 5 The lifestyle determinants of health

This section of the Report considers some of my Annual Report of 2007 called for additional the lifestyle determinants of health, namely: measures to better identify and tackle alcohol alcohol, drugs, smoking, sexual behaviour, diet problems in the city, especially where there and exercise. The sections on alcohol and sexual were significant service pressures, such as behaviour are discussed in some detail, as both accident and emergency services. That Report are issues of substantial public health concern in also recommended that a health impact Brighton and Hove. assessment be undertaken of the effects of 24 hour licensing - introduced in November 2005 as a consequence of the 2003 Licensing Act. 5.1 Alcohol

Alcohol misuse is a major cause of ill health R in both England and Brighton and Hove. A Alcohol misuse has been plethora of national policy documents; Safe, recognised as a major problem in Sensible, Social: The next steps in the National Alcohol Strategy (Department of Health, 2007); the city for some time. Reducing Alcohol Harm (National Audit Office, 2008); High Impact Actions to Reduce the Rate of Alcohol-related Admissions (Department of R Health, 2008) and the Chief Medical Officer’s Within Brighton and Hove, the Alcohol Annual Report (Chief Medical Officer for Strategy 2008-11 and the Community Safety, England, 2008) bear testament to its public Crime Reduction and Drugs Strategy 2005- health importance, and perhaps also to the 08 both include actions to prevent and lack of progress that has been made in tackling reduce alcohol misuse. The year 2009 saw alcohol misuse in recent years. the publication of three new local strategic The Chief Medical Officer for England has alcohol-related documents. A Joint Strategic recently proposed a minimum price for a unit of Alcohol Needs Assessment (Brighton and Hove alcohol. However, while this proposal has found PCT, 2009a) was published alongside a Young some political support in Scotland, there are People’s Specialist Substance Misuse Treatment currently no plans to adopt such an approach Needs Assessment (Brighton and Hove PCT, in England. Instead, policy in England and 2009b). Both describe the health needs of Wales makes frequent reference to the need for adults and young people relating to alcohol. partnership working to tackle alcohol misuse. The third document was the Health Impact Alcohol misuse has been a substantial Assessment of the effects of 24 Hour Licensing problem in the city for some time, although Legislation in Brighton and Hove. The Children it has been overshadowed by a longstanding and Young People’s Partnership Trust will drug misuse problem. In recognition of this, also shortly publish a Young People’s Alcohol

85 CHAPTER 5 THE LIFESTYLE DETERMINANTS OF HEALTH

Mods and Rockers fighting in 1969 Courtesy of Brighton & Hove City Council

Strategy. So there is no shortage of national and that 15% of the average family’s and local strategic thinking to inform efforts to expenditure was on alcohol. (Cresey 1849) deal with alcohol problems; and it’s easy to see Brighton’s first full time Medical Officer why - for alcohol has taken a considerable toll (1888-1908), Arthur Newsholme, was an active within the city for a long time. campaigner against alcohol, and made frequent references to its links with deprivation, citing 5.1.1 Alcohol misuse in it as a cause rather than a consequence of poverty. Today, the relationship between alcohol Brighton and Hove misuse, income and health is considered to be As far back as 1800 there were 41 inns and more complex. However, if he were to walk taverns in Brighton, equivalent to 1 inn for down West Street and along the seafront on a every 30 houses. The number of pubs and beer Saturday evening today, Sir Arthur would see a shops in the town grew rapidly during the 19th picture of alcohol consumption that would still century. By 1860 there were 479 pubs and give him cause for reflection. beer-shops in Brighton, more than all the local butchers, bakers, grocers and greengrocers Alcohol consumption combined. Many of the larger properties in the Hazardous drinking is currently defined as Carlton Hill area were used as shops or pubs 22-50 units per week for men and 15-35 units (mybrightonandhove.org, 2009a). per week for women. It is estimated that there Mr. Cresey estimated in his 1849 report, are 53,000 hazardous drinkers in the city, that avarage alcohol consumption was two representing just over 24% of the population thirds of a pint per day per head of population,

86 CHAPTER 5 THE LIFESTYLE DETERMINANTS OF HEALTH aged 16 years or over. Brighton and Hove is Another local survey: the November 2007 ranked as the sixth worst Primary Care Trust Tell Us 3 Survey of 10-15 year olds in Brighton in the country for hazardous drinking. Binge and Hove found that children in the city were drinking is currently defined as the consumption more likely to have tried alcohol than their of eight or more units of alcohol for men and national counterparts. In Brighton and Hove, six or more units for women during a single 58% of 10-15 year olds said they had tried session. There are an estimated 40,181 binge alcohol compared to 48% nationally, and 13% drinkers in Brighton and Hove, representing reported drinking to the point of drunkenness 19% of those aged 18 years and over (North once or twice in the last month, compared West Public Health Observatory, 2009). to 12% nationally. Heavy drinking was most The Brighton and Hove Health Counts common in East Brighton and girls were more Survey (CHSS, 2003) included questions on likely to get drunk than boys (Health Counts self-reported drinking. As is illustrated in Survey 2003). Figure 5.1.1, it found that Hanover and Elm During 2007/8 there were 49 exclusions Grove (19%), followed by Queens Park (15%), from schools as a result of incidents relating Hollingbury and Stanmer, Preston Park and to drugs or alcohol. Most of 420 respondents Moulsecoomb and Bevendean (13%) had to the 2007 Drugs Alcohol and Sexual Health the highest proportion of self-reported binge Survey of young people (aged 13 to 19 years) drinkers in the city. reported that their parents were aware of them

Figure 5.1.1: Binge Drinking in Brighton and Hove

% Binge drinkers 1.7 - 5.1 5.2 - 9.2 9.3 - 11.9 12.0 - 15.1 15.2 - 18.8 Patcham

Withdean Hollingbury North & Stanmer Portslade Hangleton & Knoll

Moulsecoomb & Bevendean Stanford Preston South Park Portslade Hanover Woodingdean Goldsmid & Elm Wish Grove Central East Hove Brighton Queen's Regency Park Westbourne Brunswick & Adelaide Rottingdean St. Peter's Coastal & North  Laine

Dotted Eyes © Crown copyright and/or database right 2009. All rights reserved. Licence number 100019918

Source: Health Counts Survey 2003 Note: ‘Binge drinking’ in the Health Counts Survey was defined as consumption of an average of nine or more units of alcohol when a person drinks, and, drinking ten or more units in the seven days prior to responding to the survey.

87 CHAPTER 5 THE LIFESTYLE DETERMINANTS OF HEALTH

drinking alcohol at least some of the time. The specific hospital admissions, hazardous drinking three most common drinks were spirits, wine and proportion of employees working in bars. and beer/lager. The most common reasons for drinking were to have a laugh, to be sociable Hospital attendances and admissions and to get drunk. Nationally, it is estimated that 40% of accident and emergency attendances are alcohol-related, rising to 70% at busy times. Just over half of R those who attend accident and emergency at the Royal Sussex County Hospital because of The problem of excessive alcohol and assault are recorded as Brighton drinking is more visible among and Hove residents. Most are young men aged young people, but not confined less than 30 years and they typically end up in at accident and emergency between the hours to this group. of 6pm and 6am. Of equal concern is the apparent rising local trend in alcohol-related hospital R admissions and alcohol-related assault. Drinking to excess brings with it a host of Recorded alcohol-related hospital admissions other dangers, including physical and sexual rose from 855 per 100,000 in 2003/4, to abuse. A local 2007 report found that of 43 1,870 per 100,000 in 2008/9. Men account reported young victims of sexual exploitation, for two-thirds of these admissions. Admissions 25 were misusing drugs and/or alcohol. These resulting from the acute effects of alcohol are young people are also at risk of becoming most frequent in the less than 15 years, and victims of crime, physical injury via accidents 16-24 years age groups. Admissions due to or assault, or being exposed to other harmful mental and behavioural disorders as a result of substances, such as illicit drugs (Harris and alcohol are most frequent in the 25-44 years Robinson, 2007). age group, and admissions as a result of the The problem of excessive drinking is more chronic effects of alcohol are most frequent in visible among young people, but not confined the 45-75 years and 75 years + age groups. In to this group. other words, the misuse of alcohol is not just a ‘phase’ that young people ‘go through and then grow out of’. Instead, alcohol features 5.1.2 Alcohol and health in adversely in the lives of many residents for Brighton and Hove many years. The impact of alcohol in Brighton and Hove is This assertion is supported by other significantly worse than most in Primary Care signs that the long-term impact of alcohol Trusts and Local Authorities. This is important in on the health of Brighton and Hove residents itself, but it is also important to consider how is increasing. The number of local residents the city compares with similar areas. admitted to hospital for alcohol dependence Brighton and Hove as a Local Authority syndrome has doubled since 2006. An performs worse than most of its Office for estimated 17 residents of Brighton and Hove National Statistics comparator Local Authorities received a liver transplant for alcohol-related (Appendix 1) though could be said to be on diagnoses during the last ten years. During the a par with Southampton (Figure 5.1.2). The same period there were 44 kidney transplants indicators which stand out adversely are: male and seven heart transplants. mortality from chronic liver disease, female alcohol-specific mortality, female alcohol-

88 CHAPTER 5 THE LIFESTYLE DETERMINANTS OF HEALTH

Alcohol-related collisions disease including cirrhosis in Brighton and Younger and older people are most likely to be Hove is higher than the regional average at 21 involved in drink-driving collisions, especially deaths per 100,000, and double the average students and the group referred to as ‘active for England. It is also higher than in comparator older people’. Between 2005 and 2007, there Local Authorities. were 149 alcohol-related collisions in Brighton Female mortality from chronic liver disease and Hove that involved drink-drivers. Most including cirrhosis is in line with the average of the drivers were men aged 18 to 30 years across Brighton’s comparator cities and is lower who lived in Brighton and Hove. As with than it is in men at six deaths per 100,000 violent alcohol-related crime (see below), most (average across 2004/6). alcohol-related collisions occurred on weekend Alcohol-specific mortality and mortality evenings. from chronic liver disease in older people are particularly marked in the most deprived parts Mortality of the city. Mortality from chronic liver disease Brighton and Hove also has a higher level including cirrhosis in both males and females of male alcohol-specific mortality than its has recently started to decline. comparator Primary Care Trusts or Local Around 60% of drug-related deaths in Authorities except for Bournemouth and Brighton and Hove (in total around 40 per year) Blackpool. Male mortality from chronic liver also involve alcohol.

Figure 5.1.2: Alcohol indicators for Brighton and Hove and comparator Local Authorities 1 1 Average Higher than 0 0 average 4 Local Authority Lower than Average 1 1 - - Months of life lost Females Females lost Months of life Months of life lost Males # # Males lost Months of life Violent crimes, alcohol-related # alcohol-related # Violent crimes, Sexual offences, alcohol-related # Mortality, alcohol-specific Females Mortality, alcohol-specific Males # alcohol-specific# Mortality, Males Crimes, alcohol-related recorded # Binge drinking (synthetic estimate) Employees in bars % of all employees employees of all % in Employees bars Mortality, chronic liver disease Females Females chronicMortality, disease liver Mortality, alcohol-attributable Females Mortality, chronic liver disease Males # # Males chronicMortality, disease liver Hospital admission, alcohol-specificHospital F # Mortality, alcohol-attributable Males # # alcohol-attributable Males Mortality, Mortality from land transport accidents Harmful drinking (synthetic estimate) # # drinking Harmful (synthetic estimate) Hospital admission, alcohol-specificHospital # M Hospital admission, alcohol-specific,Hospital u18s Hospital admission, alcohol-related harm admission, alcohol-related harm Hospital Hospital admission, alcohol-attributable F Hazardous drinking (synthetic estimate) # Hospital admission, alcohol-attributable M # For these indicators, Brighton & Hove & Brighton indicators, these For # . England in quintile worst the in is Claimants, incapacity benefit, working age # # incapacityworking age Claimants, benefit,

Source: Public Health Directorate, data from North West Public Health Observatory

89 CHAPTER 5 THE LIFESTYLE DETERMINANTS OF HEALTH

5.1.3 The wider consequences Recent alcohol-specific mortality data, of alcohol in Brighton and hove illustrated in Figure 5.1.3, show that there is a 5 to 7 fold difference between the most and least deprived groups in the city. However, discerning Alcohol and crime any recent trend in this is more difficult. (See Brighton and Hove has almost double the Appendix 2 for definitions of alcohol-specific regional rate of alcohol-related violent crime and alcohol-related conditions) (North West Public Health Observatory, 2009). Further examination of this most deprived A large proportion of local crime (37%) is group can shed more light on the effects considered by the police to be alcohol-related. of alcohol consumption. Using the Mosaic Alcohol-related crime figures are not consistently classification (See Appendix 3) the most recorded across the country, so comparisons common social groups found in the most need to be treated with some caution. They are deprived quintile are the ‘Under 15s’, ‘Twilight more reliable as an indicator of local trends. In Subsistence’ (older poor people), ‘Welfare Brighton and Hove the figures are increasing Borderline’ and ‘Blue Collar Enterprise’. although the rate of increase has fallen slightly Analysis of the recorded alcohol-related since 2006. accident and emergency attendances by young There is also an upward trend in the people aged 13-18 years from January 1st 2006 proportion of sexual offences committed to October 30th 2008, showed that 149 out of under the influence of alcohol. Most violent 483 (31%) attendances were made of people crime occurs in central Brighton on Saturday from the most deprived quintile, compared night and Sunday morning, which coincides to 18% from the most affluent quintile. The with weekend drinking habits. Residents of electoral wards with the highest number of both the city centre and several relatively attendances were East Brighton, Moulsecoomb deprived outlying areas report that they feel and Bevenden and Queens Park. there is an alcohol problem in the city (Brighton The Primary Care Trust developed an & Hove City Council and NHS Brighton and Alcohol Local Enhanced Service for General Hove, 2009). Practice with the aim of better identification A needs assessment of Lewes Prison and treatment of people with alcohol problems. showed that 63% of male prisoners were In 2008, 20 out of 47 GP Practices signed up hazardous or harmful drinkers in the year leading but only two practices were from areas where up to their imprisonment. Brighton and Hove the most deprived groups live. Probation Service assessments of offenders show The local Count Me in Too Survey of 2007 that 59% had alcohol misuse problems and suggests that alcohol misuse is one and a of these, 21% were perpetrators of domestic half times more common in the Lesbian, Gay, violence. Just over 60% of perpetrators of Bisexual and Trans (LGBT) Community than domestic violence were males aged 31-50 years. in the general population. That survey also reported that a relative lack of alcohol-free 5.1.4 Alcohol and health social settings was a particular problem. inequalities The connection that Sir Arthur Newsholme 5.1.5 The effect of 24-hour made in 1903 between alcohol abuse and poverty in Brighton remains. The Brighton and licensing on alcohol misuse Licensing hours were first introduced in the Hove Health Counts Survey of 2003 recorded UK around the time of the Great War. The that a third of male heavy drinkers were Licensing Act (2003) allows for flexibility in the employed, a third unemployed and 20% had a times that premises are allowed to sell alcohol. long term disability/illness.

90 CHAPTER 5 THE LIFESTYLE DETERMINANTS OF HEALTH

These changes, supported by the alcohol retail alcohol off the premises. This means that industry, were heralded as a way of changing there is one on-licensed premise for every 290 the binge drinking culture in the UK. Since the residents. The total number of alcohol sales implimentation of the Licensing Act in 2005, premises is probably the highest figure per there has also been a smoking ban in enclosed person ever, even when compared to the high public spaces. These two policy initiatives have figures from 1800 and 1890 (Lowerson and resulted in changes in drinking patterns around Myerscough, 1977). the country. Brighton and Hove has a high proportion of employees working in bars compared to the R national average, and our nearest statistical neighbours. The sale and consumption of The sale of and consumption of alcohol have been and continues to constitute a alcohol has been and continues to very important part of the local economy. constitute a very important part A total of 321 new licensed premises have opened in the city since the introduction of the local economy. of the Licensing Act 2003, so that there are now 1,329 premises serving a population of 256,600. Of these, 447 are licensed for off R sales, meaning customers must consume their

Figure 5.1.3: Alcohol-specific mortality by deprivation quintile, 2001/3 – 2006/8

45

40

35

30

25

20

15

10

Directly standardised mortality rate 100,000 / 5

0 2001-03 2002-04 2003-05 2004-06 2005-07 2006-08

Quintile 1 (most deprived) Quintile 2 Quintile 3

Quintile 4 Quintile 5 (least deprived) All BH

Source: Office for National Statistics Mid Year Population Estimates; Exeter patient registration system

91 CHAPTER 5 THE LIFESTYLE DETERMINANTS OF HEALTH

Mr Cresey in his 1849 Report stated that home safely thereby reducing the potential the average estimated alcohol consumption impact on the public services. A new Alcohol in Brighton was two thirds of a pint of ale per Liaison Service has also been established in day per head of population. Ale was roughly Accident and Emergency so that people who equivalent in strength to modern strong lager are injured while drunk can be referred on to (2.8 units of alcohol per pint). The General community support services. Lifestyle Survey (ONS, 2008) reports that ‘Operation Park’ is a local initiative average alcohol consumption nationally is whereby Police Officers and Anti-social equivalent to two thirds of a pint of strong lager Behaviour Workers patrol public spaces on per day – the same as average consumption Thursday, Friday and Saturday nights. Between in Brighton in 1849. Consumption in Brighton June 2008 and December 2009, 575 young is higher than in the rest of the country. So people were stopped and of these, 530 were average consumption in Brighton and Hove found to be under the influence of alcohol and has increased since the time of Sir Arthur 320 had alcohol seized. Seventy young people Newsholme. The price of some types of alcohol have been stopped twice and eleven young has decreased in recent years relative to income. people three times or more. As of April 2008 in Brighton and Hove, there were 78 premises with 24 hour licences. There was also a 30% increase in the rate of R alcohol-related admissions in the city between 2005/6 and 2006/7: this compares to only a The Beacon award made to 7% increase for England over the same period. the city for its handling of the Data provided by Sussex Police show a night-time economy was in part sharp increase in violent crimes committed under the influence of alcohol immediately awarded on the basis of how many after the introduction of flexible licensing. These partners across Brighton and Hove increased from 2,996 in 2005 to 3,698 in 2006, were engaged in trying to tackle though these have now reduced from their high point. alcohol-related problems. Residents in the central areas of the city reported significant impacts on their health and wellbeing. These include disturbed sleep R and experiences of threatening, abusive and In March 2008 a Cumulative Impact Area antisocial behaviour (Brighton & Hove City (CIA) was introduced in Brighton and Hove. This Council, 2009e). means that new applicants for licensing are also judged on whether or not the granting of such 5.1.6 Recent efforts to tackle a license would have an adverse cumulative alcohol in Brighton and Hove impact on the area. A Controlled Drinking Zone Alcohol as a public health issue has received has also been introduced; this allows police to much greater prominence and reducing hospital confiscate alcohol from anyone who is drinking admissions related to alcohol has been agreed not on licensed premises. More recently, the as a Local Area Agreement target. Several large Licensing Committee, considered the merits of employers in Brighton and Hove now have establishing an Alcohol Disorder Zone which workplace alcohol policies. would allow the local authority to impose The Safe Space project in West Street helps charges on licensed premised to pay for the people under the influence of alcohol to get costs of addressing alcohol-related problems.

92 CHAPTER 5 THE LIFESTYLE DETERMINANTS OF HEALTH

Brighton and Hove an awful lot of people die or fall ill as a result of alcohol consumption, while the lives of many others are disrupted and in some cases ruined. Sir Arthur Newsholme would have recognised that picture. Public services such as the Police, the City Council, the NHS and some retailers have been working in partnership however, it would be wrong to suggest that we are getting on top of the alcohol misuse in Brighton and Hove. In some respects the answers need to come from central government with legislation Safe Space helps reduce alcohol related A&E admissions on pricing and on licensing. But it is too easy to blame those further up the line, and it is not enough to put in place safety-net initiatives to These charges could then be used to provide catch people who already have a problem. additional support measures. To date no Nor is it enough to simply put out a message Alcohol Disorder Zone has been established. that informs people of the adverse effects of A White Night event took place in 2008 alcohol consumption and expect them to modify and in 2009 in an effort to open up the city, their behaviour. through the night, for activities that were not There is a wider question about whether necessarily alcohol-related. The Beacon award we are, on the one hand, promoting or at least made to the city for its handling of the night- condoning the easy consumption of alcohol, time economy was, in part, awarded on the while on the other we lament its consequences. basis of how many partners across Brighton and The sale and provision of alcohol has a huge Hove were engaged in trying to tackle alcohol- impact on public health but national legislation related problems. on licensing was not passed on the basis of public health. While that remains the case, it is 5.1.7 Summary up to us to find local ways of taking action on Brighton has long been a destination for alcohol, based on the principle of protecting pleasure-seekers and to a large degree, this and promoting public health. sustains the city economically. Alcohol has historically been an important part of that good time. Recommendations Measures to tackle alcohol problems should Taken in excess, alcohol has significant be better targeted so the right group gets the adverse effects not just on the health and right message. wellbeing of the consumer, but also on the There should be improved identification family and the community. and follow-up of particular risk groups, such as A host of alcohol indicators bear testimony recently released offenders. its consequences in Brighton and Hove and Services introduced for people with alcohol suggest that the city is performing worse problems, such as local enhanced schemes, than similar areas across the UK. Excessive should be targetted to reduce health inequalities. alcohol consumption does not stop with acute There should be more effort to, develop intoxication in younger people, but continues and promote activities that encourage people of throughout people’s lives. Residents from more all ages to have a good time, in public spaces, deprived groups are more adversely affected. Put without having to consume alcohol. simply, it is not overstating the case to say that in

93 CHAPTER 5 THE LIFESTYLE DETERMINANTS OF HEALTH

The public health aspects of licensing the dangers from the spread of addiction decisions should be fully scrutinised with continued throughout the 20th century. reference to established powers under the Cumulative Impact Area legislation, and there should be regular consideration of the benefits R of implementing an Alcohol Disorder Zone. “The addict is a sick person and... addiction is a disease which 5.2 Drug use (if allowed to spread unchecked) will become a menace I have discussed substance misuse extensively in recent reports. Substance misuse is included, to the community” in order to update on progress with regard to (Interdepartmental Committee on reducing drug-related deaths, which remain an Drug Addiction, 1965). important public health problem in Brighton and Hove. 5.2.1 A brief history of R The 1960s saw a a rapid rise in the number substance misuse of drug users. The number of heroin addicts In the UK, opium was freely available until rose from 68 to 342 in total from the late 1950s the late 1860s, when qualified pharmacists to the mid 1960s. Cocaine use also increased, were required to dispense such medication. and drug use spread, users began to develop The ‘Society for the Study of Inebriety’, which addiction at a younger age. Amphetamines and included among its members Brighton’s Arthur cannabis were also heavily used. Newsholme, set up a network of publicly In the 1980s, the threat of HIV spread funded ‘inebriate asylums’ where ‘inebriates’ through illicit drug use, brought about a could be committed compulsorily. public health response targeting drug abusers. (Berridge, 2005). This included the prescription of substitute By World War One the term inebriety was drugs, such as methadone, and the provision replaced by addiction. This signalled a change of sterile equipment. At the same time in focus in the 1920s. The typical addict’s profile there developed an increasing focus on the of the time was a prevention of diseases associated with injecting middle class one, drug use, principally tuberculosis and blood typified by young borne viruses such as Hepatitis B and C. More wealthy socialites recently there have been concerns about the – ‘The Beautiful spread of bacteria such as methicillin resistant and the Damned’. staphylococcus aureus (MRSA) as a result of the Psychiatrists, injecting drug use. expanded their profession from beyond the confines of the asylum to a middle The Beautiful and the Damned From a book cover class clientele. Public health warnings about

94 CHAPTER 5 THE LIFESTYLE DETERMINANTS OF HEALTH

Table 5.2.1: Drugs implicated in drug-related deaths in Brighton and Hove in 1997 Drugs implicated and frequency of use Frequency of contact with services in the Lorem ipsum dolor sit amet, amet pastaccumsan month quam quam ac sapien. consectetur adipiscing elit. Duis cursus malesuada neque, sed PellentesqueHeroin a sapien 73%orci. Vivamus faucibusGP urna aliquam id. Donec ut 47% tinciduntMethadone metus vel jvel20% jvel (8% jvel prescribed)justo liberoAccident sem, a tristique and Emergency quam. Proin ut 12% luctusOther opiatesblandit. Phasellus25% venenatis (18% prescribed) ante ipsum.Drug services Nulla suscipit tincidunt 12% sapienBenzodiazepines at neque consequat67% (43% tempor. prescribed) eleifend.Psychiatry Vestibulum id quam velit, 10% VestibulumAlcohol nec mi id est47% lobortis venenatisPolice sodales eros. Praesent 8% ultriciesCrack / cocaine in vitae lectus. 6% blanditVoluntary rutrum Organisationsodio, a accumsan 8% Amphetamines 4% ipsum malesuada vel. Aliquam SuspendisseMajor tranquillisers suscipit, tellus4% a varius augue est, dictum ut tincidunt vitae, gravida,Volatile substances neque velit facilisis2% orci, sit gravida ut lorem. Vestibulum ante

Source: HM Coroner’s Office, Brighton and Hove, January – December 1997

Figure 5.2.1: Number and rate of drug related deaths reported to np-SAD in Brighton and Hove, 1999 - 2008

80 35

70 30

60 25

50 20

40

15 30 Number of deaths 10 20

10 5 Rate per 100,000 population, aged 16 & over

0 0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

Number of Deaths, Brighton & Hove Rate per 100,000, Brighton & Hove

Source: np-SAD, 2009

95 CHAPTER 5 THE LIFESTYLE DETERMINANTS OF HEALTH

5.2.2. Substance misuse in 5.2.3 Drug-related deaths in Brighton and Hove Brighton and Hove The early Reports of the Medical Officers for In terms of the time spans examined in this Brighton make no reference to the use of other Report, drug-related deaths are a relatively substances. It is only in the 1990s that it begins recent phenomenon, but have become an to feature with some prominence.Although drug established and significant problem. In an early use is high locally, the city sits, in a region with attempt to address the problem of drug-related relatively low problematic drug use and there is deaths, in 1997 a working group reviewed all some evidence that drug use is decreasing in the the drug-related deaths in the city. The results South East. The estimated prevalence rate for of this are shown in Table 5.2.1. Twelve years problematic drug use (defined as crack/opiate ago, heroin was the drug most frequently users) in the South East in 2008 was 3.4 per implicated in drug-related deaths in Brighton 1000 population, compared to 6.5 per 1000 in and Hove (involved in 73% of deaths) and this England. remains the case today. Local data on self-reported use of One of the difficulties in monitoring substances dates from a survey previously drug-related deaths is the presence of two undertaken in 2003. The merits and limitations systems for reporting: one used by the Office of the various local surveys of school children of National Statistics across the whole country, were discussed in my Report in 2008. and a voluntary reporting system run by the National Programme of Substance Abuse

Figure 5.2.2: The number of np-SAD and ONS drug related deaths in Brighton and Hove, 2001 - 2008

70

60

50

40

30

20 Number of drug related deaths related drug of Number

10 ONS NP-SAD

0 2001 2002 2003 2004 2005 2006 2007 2008

Year

Source: Office of National Statistics and np-SAD 2009

96 CHAPTER 5 THE LIFESTYLE DETERMINANTS OF HEALTH

Deaths (np-SAD) based at St. George’s hospital (Department of Health, 2001) and the Updated in London. Both use slightly different definitions Drugs Strategy (Home Office, 2002). Measures of drug related death. include the provision of the opiate antidote drug Brighton and Hove is usually the coroner’s naloxone and relevant training to people who jurisdiction reporting the highest rate in the misuse substances and their partners. country. This was the case in 2009, when 44 The targets in Government documents are drug-related deaths were reported in Brighton based on the identification of cases according and Hove between January and December 2008, to the ONS definition. An action plan will be giving a rate of 22.73 per 100,000 population drawn up in 2010 by a new Harm-reduction (Figure 5.2.1). Strategy Group. As is currently the case with Unilke np-SAD the Office of National regard to suicide, the goals of the action plan Statistics (ONS) definition excludes deaths will be regularly monitored. involving drugs listed under the Misuse of Drugs Act which form part of an analgesic or cold 5.2.4 Summary remedy (e.g. co-proxamol); deaths caused by Substance misuse has been a persistent secondary infections; and deaths from road problem in Brighton and Hove in recent years. traffic accidents and other accidents which There are two reporting systems and while one occurred while under the influence of drugs. has shown a reduction in deaths in recent years, These figures are therefore generally lower than the other suggests that the number of drug- np-SAD figures (Figure 5.2.2). related deaths has changed little. Figure 5.2.2 shows that the number of deaths reported by np-SAD was higher, but fell between 2001 and 2008. By contrast, the Recommendations From April 2010 the Office of National Statistics number of drug-related deaths classified by definition of drug-related deaths should be ONS has remained consistent low at around 20 adopted as the marker of progress in reducing deaths per year during the same time period. drug-related deaths. The Np-SAD observed Using ONS data would narrow the numbers and rates should continue to be definition of drug-related deaths but might also monitored for comparative purposes. help in developing and monitoring the effects All drug-related deaths should be of targeted preventive measures. It would also investigated to better understand the allow the separate identification of drug-related circumstances surrounding each death. deaths that are also recorded as suicides, An action plan should be produced by such as poisoning by drugs, medicaments the Harm-Reduction Strategy Group and and biological substances, and deaths from monitored regularly. undetermined intent. One of the key issues in Brighton and Hove in measuring these deaths has been the degree of overlap between drug- related deaths were suicides: in 2008 around 5.3 Smoking 17% of drug-related deaths were suicides as measured by np-SAD. In 2007, there were 82,900 smoking-related All drug-related deaths are investigated by deaths among adults aged over 35 years, the Primary Care Trust after the coroner’s inquest 18% of all deaths in England. Smoking has has concluded. Many of the measures currently for many years been the single biggest cause identified to reduce drug-related deaths are of preventable deaths in the country and it based on the Department of Health Action Plan remains so; it would therefore be remiss not to mention it in a public health Annual Report.

97 CHAPTER 5 THE LIFESTYLE DETERMINANTS OF HEALTH

Figure 5.3.1: Smoking and lung cancer deaths in England and Wales since 1948

70 140 ettes

60 120

50 100

40 80

30 60

20 40 Smoking prevalence, rate per 100,000 per rate prevalence, Smoking

10 20

% of adult population who smoked manufactured cigar manufactured smoked who population adult of % 0 0 1948 1952 1956 1960 1964 1968 1975 1979 1983 1987 1991 1995 1999 2003 2007

Male smoking prevalence Female smoking prevalence Male lung cancer incidence Female lung cancer incidence

General household survey; Office for National Statistics; Actual lung cancer incidence data 1975-2006 from CR-UK (Cancer Research UK)

5.3.1 A brief history of smoking smoked cigarettes. As illustrated in Figure 5.3.1, in the United Kingdom smoking prevalence decreased slowly in men and by contrast increased gradually in women Tobacco was introduced into Britain in the 16th until the 1970s when it began to fall more century and was smoked in pipes, then taken as rapidly in both groups. In the 1990s the rate of snuff and later still in the form of cigars. But it decline slowed so that by 2007, 20% of women was the invention of cigarette-making machines and 22% of men smoked. The incidence of in the nineteenth century that led to a large lung cancer, a disease irrevocably bound up increase in tobacco consumption and by the with smoking, has followed the gender trends end of the Great War more tobacco was sold in smoking. Lung cancer in men started to fall in as cigarettes than any other form. It was mainly the 1980s and has continued to decline while in men who smoked and consumption peaked women the incidence of lung cancer continues at an average of 12 cigarettes per adult male to rise (Cancer Research UK, 2009). per day in 1945. After the Second World War With regard to age groups, currently more women began to smoke, and smoking in the highest prevalence of smoking is among women peaked at an average of 7 cigarettes 20-24 year olds (31%), and the lowest among per adult female per day in 1974. those aged 60 and over (Information Centre Surveys of smoking prevalence began in for Health and Social Care, 2008). As smoking Britain in 1948 at which time 82% of men becomes less common it is increasingly an issue smoked some form of tobacco and 65% of inequality. It is now the largest single cause

98 CHAPTER 5 THE LIFESTYLE DETERMINANTS OF HEALTH

Figure 5.3.2: Brighton and Hove smoking cessation clinic ratio of smoking quitters 2005-2009, by deprivation quintile

1.13

1.10

1.08

1.05

1.03

1.00

0.98

Quitters (as a % of referrals) Ratio, 0.95 2005/06 2006/07

standardised against Brighton and Hove (1.00) Hove and Brighton against standardised 2007/08 2008/09 0.93

0.90 1 2 3 4 5 Most deprived Least deprived Index of Deprivation Quintile

Source: South Downs NHS Trust and Index of Multiple Deprivation 2007 of health inequality between higher and lower requested a total budget of £150 (equivalent to income groups: in 2006 17% of people in non- £2,600 today) to implement this. manual occupation groups smoked compared Smoking, particularly in men, was of with 28% in manual groups. course the norm and in his Report the following year, Dr Parker lamented that two Corporation 5.3.2 Smoking in Brighton Committees had declined to provide him facilities to implement the relevant Council and Hove Resolution, and that the only preventive In Brighton, the first mention of smoking as measures that met with general Council a public health issue appears in the Medical approval were those to ‘check the onset of Officer’s Annual Report for 1957. It followed the smoking habit among children’. He also a ministerial statement published in June that recorded that one member of the Council had year linking smoking to lung cancer. Dr William died of lung cancer during the previous year. Parker proposed a series of actions including Undeterred, Dr Parker continued to highlight a public campaign with posters, use of the lung cancer and its link to smoking and later press, short cinema films, voluntary bans on had 150 coffin shaped ash-trays made and smoking (some cinemas, he wrote, had already distributed around the town – one for every implemented this), the setting of a public lung cancer death in the previous year. example by Council members not smoking There was little information on the extent when on official business and measures to of smoking in Brighton then and there is not prevent children from smoking. Dr. Parker much now. Surveys of smoking do not take

99 CHAPTER 5 THE LIFESTYLE DETERMINANTS OF HEALTH

place on an annual basis so it is not possible at how referral to quitter ratios compare across to comment on annual trends. Instead, we different deprivation groups. As expected, monitor progress by looking at local smoking between 2000 and 2005, that the chances cessation services. We also monitor referral of quitting smoking following referral to local and smoking quitter data from the clinics to smoking cessation clinics were consistently make sure that services do not lead to more highest in the most affluent group. The rest of inequalities by concentrating on residents the picture is somewhat mixed and it is difficult from more affluent parts of the city, who to reach any firm conclusions about trends. might find it easier to quit. This could occur as It should also be noted that there were some the performance of the Primary Care Trust in data issues, (in some cases a postcode was not tackling smoking is only monitored on absolute recorded) and during this period data coverage quit rates. So if we were struggling to meet our was extended to include smoking quitter data target, which currently is set at around 2029 from so-called intermediate services (non- smoking quitters (as measured at four weeks specialist) such as GP practice nurses trained after stopping smoking) per annum, it would be in smoking cessation. Changes in the sources tempting to concentrate on those areas where of data collection render discussion of trends quitting comes easier. problematic. Figure 5.3.2 illustrates what we call referral Figure 5.3.3 shows the referrals to smoking to quitter ratios. We take the average referral cessation clinics by deprivation scores per ward to quitter ratio (in this case represented by the for the period of April 2008 to March 2009. horizontal line 1.0 on the figure) then we look This confirms that relatively more people from

Figure 5.3.3: Smoking cessation referrals by ward, plotted against deprivation score 2008/09

35 16-74 30

25 Trendline R2 = 0.75 20

15

10

5

0 Smoking cessation clinic referrals per 1000 popln aged popln 1000 per referrals clinic cessation Smoking 10 15 20 25 30 35 40 45 50

Less More deprived Index of Deprivation Average Ward Score deprived

Source: South Downs NHS Trust, and Index of Multiple Deprivation 2007

100 CHAPTER 5 THE LIFESTYLE DETERMINANTS OF HEALTH more deprived parts of the city attend smoking Recommendations cessation clinics. Now that the data sources The Primary Care Trust and City Council should have settled, it will be interesting to see if the ensure that there is proper co-ordination of the slope of this graph steepens or flattens as we new wider approach to tobacco control in order face the ‘challenge’ of registering another 2020 to get the best out of all available services. smoking quitters by March 2010 and a further Smoking cessation adviser services should 2030 by March 2011. continuously monitor how well they perform The focus on smoking quitters – many in getting people into the service, and provide of whom might quit, then restart, and be services in a way that engages the greatest counted in the figures many years running is number of residents, and in particular, residents very narrow. The approach needs to be broader from more deprived areas in the city. and include other aspects such as discouraging The public health team should monitor young people from taking up smoking, and closely the tobacco control services to ensure that working with colleagues in environmental they are reducing inequalities, and, irrespective health on enforcement of trading standards. of any national requirements (there are none on Following a review by the Regional Tobacco this aspect), should report regularly on progress Control Support Team in 2009, it was agreed in reducing health inequalities that result from that we could take a fresh approach and there smoking. are plans afoot to do this. Of course the overall target of smoking quitters has not gone away, nor has it been refined in any way to ensure that health inequalities do not widen. 5.4 Obesity Obesity is an increasing concern both for adults 5.3.3 In summary and children in the UK. Being overweight Smoking as a habit is on the decrease and the or obese increases the risk of diabetes, diseases most associated with it, in particular hypertension, heart disease and cancer, heart disease and lung cancer, are behaving amongst other diseases. ‘Healthy Weight, accordingly. There have been great efforts to Healthy Lives: A Cross-Government Strategy reach the smoking cessation targets in Brighton for England’ was published in January 2008, and Hove over the past several years, mostly and was yet another nationwide attempt to with success, but this will be increasingly combat obesity. The ambition of the strategy difficult as the group of smokers who remain was for the UK to be the first developed nation are likely to be the most resistant to quitting. There is an increasing deprivation profile associated with smoking and this is where the real challenge lies. A new direction with a broader approach is most welcome, but it will require more partnership working across different sectors. While the smoking cessation target remains, smoking cessation advisers will have to be flexible and deliver services in ways that are most likely to engage increasingly hardened smokers. Philbrock’s Butchers, 1922 Courtesy of Hove Library, Brighton and Hove City Council

101 CHAPTER 5 THE LIFESTYLE DETERMINANTS OF HEALTH

The arrival of the first bananas for seven long years in New England Street in 1946 Courtesy of Brighton & Hove City Council

to reverse the rising tide of obesity. The initial 5.4.1 Obesity in the UK focus of the strategy is on children, and by The concept of a balanced diet is relatively 2020, the target is to reduce the proportion recent. In the past, the key to eating well was of overweight and obese children to the levels thought to be about quantity rather than they were at in 2000. quality (Mayhew, 1988). The first quarter of the In Brighton and Hove, there are two 20th Century saw the discovery of vitamins, ‘Vital Signs’ indicators that have been agreed amino acids and mineral elements. Scientific to measure success or otherwise in reducing experiments showed that diseases such as childhood obesity. These are obesity prevalence rickets, beriberi and scurvy were caused by in Reception Year (children of 4-5 years old) and poor diet. obesity prevalence in Year Six (children aged 10- In the post-war years, the new science 11 years). In addition to the national stratergy of ‘nutrition’ was born. Today, we know that target, there is also a joint Primary Care Trust a balanced diet is imortant in maintaining a and City Council Local Area Agreement target healthy weight, and that it decreases the risk of to halt obesity among primary school children heart disease, diabetes and a number of cancers. in Year 6 at a maximum of 17.5% by 2010/11. In the past 50 years we have also seen a shift This chapter then looks at the changing away from concerns about malnutrition and height and weight profile of the local underweight to malnutrition and overweight. population through the 20th and 21st In 2008, the Health Survey for England centuries, focusing in particular on children. found that almost a quarter of adults (24% of men and 25% of women) were obese, and 66% of men and 57% of women were overweight

102 CHAPTER 5 THE LIFESTYLE DETERMINANTS OF HEALTH

Figure 5.4.1: Average weight of 4-5 year olds (1909-2009), and 12-13 year olds in Brighton (1901-1936) and 11-12 year olds in Brighton and Hove# (2009)

4 and 5 year olds 12 and 13 year olds 20 42

19 Boys Girls 40 Boys Girls

18 38

17 36

16 34

15 32 Average weight, kg weight, Average Average weight, kg weight, Average 14 30

13 28

12 26 0 0 1909 1919 1923 1936 2009# 1909 1919 1923 1936 2009#

Source: Medical Officer of Health Reports and NCMP data

(including obese). Just 33% of men and 41% women by 2015, and an astonishing 57% and of women had a body mass index (BMI) in the 36% of men and women respectively by 2025 normal range. (The Government Office for Science, 2007). The most recent data from the National Lifestyle habits, principally poor diet and lack Child Measurement Programme (NCMP) for of exercise are thought to be the dominant 2008/9 (NHS Information Centre, 2009) and influences on obesity (NHS Information Centre, from the Health Survey for England (NHS 2009b). Other risk factors include being an Information Centre, 2009a) suggest that ex-cigarette smoker, and moderate alcohol nationally we may be on the cusp of halting consumption in females. Socio-economic the rise in obesity in children. However, many deprivation has an important relationship with children are still overweight or obese, and adult obesity in women, with 28% of women in obesity rates are still and rising. the most deprived groups obese, compared to Obesity brings with it a higher risk of 20% of those in the least deprived groups (NHS hospital admission. The number of hospital Information Centre, 2009a). admissions in NHS hospitals with a primary diagnosis of obesity among adults and children was 5,018 in 2007/8. This was 30% higher than 5.4.2 Obesity in Brighton 2006/7 (3,862), and almost seven times higher and Hove than the figure for 1996/7 (738). In 2007, 1.23 Today, Reception (4-5 year olds) and Year million prescription items were dispensed for the Six pupils (10-11 year olds) are weighed and treatment of obesity compared to 0.13 million measured each year. Recent figures show that items in 1999. Between 2006 and 2007, the in the 2007/8 academic year, 17% of Year Six number of items dispensed for the treatment pupils in Brighton and Hove were recorded as of obesity increased by 16% (NHS Information obese. This was lower than the national figure. Centre for Health, 2009b). In the 2008/9 academic year, 89% of Year Six If current trends continue, obesity is pupils were measured and 16% were recorded estimated to affect 36% of men, and 28% of as obese. We should be cautious of interpreting any real change in obesity levels because of

103 CHAPTER 5 THE LIFESTYLE DETERMINANTS OF HEALTH

Box 5.4.1: Weekly menu for school meals in Brighton, 1908

School meals in Brighton, 1908

“In 1908 each child was medically examined before acceptance to the school canteen: 2,006 such examinations were made. The menu was calculated on a scientific basis and supplied one third of the total food requirements of the day (calculated as calories) for children of 14 years of age.

Monday: 1 pint of pea soup (1/4 lb peas), ½ lb bread. Tuesday: Irish stew (large plateful), 4oz. Bread and 2 oz. Cheese. Wednesday: 1 pint lentil soup (1/4 lb lentils), ½ lb bread. Thursday: Suet pudding (with raisins or currants), 4oz. Bread and 1 oz. margarine. Friday: 1 pint of haricot bean soup, 4 oz. bread. Saturday: ½ lb bread with 1 oz. margarine, 1 pint sweetened cocoa.

The cost of the actual food material in the above meals averaged ¾d. to 1d. The total number of school meals granted from October 5th to December 1st 1908 was 23,921. The total number of individual children who received free meals up until December 1st was 890.”

Source: Review of 100 years of Medical Officer’s Reports, 1960

Figure 5.4.2: Average height of 4-5 year olds (1909-2009), and 12-13 year olds in Brighton (1901-1936) and 11-12 year olds in Brighton and Hove# (2009)

4 and 5 year olds 12 and 13 year olds 1.10 1.46 1.08 Boys Girls Boys Girls 1.44 1.05 1.42 1.03 1.40 1.00 1.38

0.98 1.36 Average height, m height, Average Average height, m height, Average

0.95 1.34

0.93 1.32

0.90 1.30 0 0 1909 1919 1923 1936 2009# 1909 1919 1923 1936 2009#

Source: Medical Officer of Health Reports and NCMP data

104 CHAPTER 5 THE LIFESTYLE DETERMINANTS OF HEALTH

Box 5.4.2: One of four weekly menus for school meals in Brighton and Hove, 2009

Monday Tuesday Wednesday Thursday Friday

Dish of the day Jacket potato Salmon fish Roast chicken Lamb kofta Beef burger with cheese, fingers with fillets with pitta pocket in a bun beans or tomato Yorkshire veggie ketchup pudding bolognaise and gravy

Optional Choice Tuna and Gammon or Hot chicken Jacket potato Ham or cheese wrap cheese baguette with chicken cheese ploughman’s mayonnaise ploughman’s

Dish of the day 2 Tomato Vegetarian Veggie toad Pizza slice Quorn hot and cheese lasagne in the hole dog pasta bake with gravy

Accompaniment Garlic bread Creamed Roast or Oven baked Chunky potatoes parsley jacket chips or potatoes wedges potato salad

Vegetables Fresh broccoli Baked beans Carrots and/or Vegetable Crunchy and/or carrots and/or peas seasonal sticks and/ coleslaw and/ cabbage or peas or sweetcorn

Salad bar and wholemeal bread available daily

Desserts Fresh orange Fruity Ice cream Dorset apple Chocolate sponge and shortbread with fruit cake and and fair-trade custard and custard banana chocolate muffin sauce

Additional daily choice of fresh fruit or yoghurt

Source: Brighton & Hove City Council the wide confidence intervals (95% confidence The results for older children should be interval 14%-18%). interpreted with more caution. For the data This National Child Measurement from 2009 actually relate to 11-12 year olds Programme was introduced in 2005, but there while the earlier data refer to 12-13 year olds. is a long history of taking such measurements Nevertheless, it can be seen that 11-12 year old in schools, including Brighton and Hove and boys and girls in 2009 are considerably heavier especially in the earlier parts of the 20th century. Figures 5.4.1 and 5.4.2 show an increase in Victorian child being the weight of 4-5 year old children from 1909 weighed Courtesy of to 2008/9, with 4-5 year old boys and girls in healthyweight4children.org 2008/9 weighing approximately 4 kgs more than their counterparts in 1909. There has also been a corresponding increase in height of around 12 cms.

105 CHAPTER 5 THE LIFESTYLE DETERMINANTS OF HEALTH

Figure 5.4.3: Body Mass Index for 4-5 year olds (1909-2009), and 12-13 year olds in Brighton (1901-1936) and 11-12 year olds in Brighton and Hove# (2009)

4 and 5 year olds 12 and 13 year olds 17 19

Boys Girls Boys Girls

18 16

17 Body Mass Index Mass Body 15 Index Mass Body 16

140 150 1909 1919 1923 1936 2009# 1909 1919 1923 1936 2009# Source: Medical Officer of Health Reports and NCMP data

than 12-13 year olds in previous years. The association between overweight or obese and same cannot be consistently said for height. deprivation. The children’s centres in the more This suggests that older children in Brighton deprived areas of Moulsecoomb, Bevendean and Hove today are much heavier than their and Coldean report higher levels of obese and counterparts in previous years, but that height overweight children than do the children’s has not increased to the same degree. centres in Preston Park, and Knoll and Stanford. These data can be used to calculate the Further analysis by MOSAIC population groups average body mass index of children as is (Appendix 3) shows that the groups described shown in Figure 5.4.3. For 4-5 year olds, these as “Ties of Community” and “Blue Collar figures probably raise more questions than Enterprise” have higher rates of overweight they provide answers. The apparent higher and obese children. ‘Ties of Community’ is a average body mass index of 4-5 year old group described as families living in close-knit boys and particularly girls in Brighton in 1909 inner city communities, leading underactive compared to their Brighton and Hove in 2009 lives with limited educational attainment. ‘Blue is likely to reflect the relatively higher level of Collar Enterprise’ groups have similar health stunting of the height of children from chronic characteristics, with typically poor diets and under-nutrition, compared to levels of being inactive lifestyles. underweight. The complex and changing The link between deprivation and poor relationship between stunting of height and diet in Brighton and Hove permeates many of being underweight depending on levels of the Reports of the Medical Officers of Health in nutrition, is reflected in the particularly mixed Brighton in the 20th century. picture for 4-5 year olds. “Unfortunately it is true in many The results for 10-11 year olds in Brighton households that God provides good food, and Hove 2008/9 compared to 13-14 year but the devil sends the cook,” Dr Rutherford olds in Brighton in previous years are more Cramb, Medical Officer’s Annual Report for straightforward and confirm the higher levels of Brighton, 1939. obesity we see in older children today. Dr Cramb observed that there were “many Analysis of height and weight data instances of families found to be living on for childrenChris Dorling in K:\Public 2008/9 Health\AR\AR2009\Data\popln also shows age bands sepia.xlsa clear 5.4.3 15/02/2010 17:21 levels of food intake wellPublic below Health, Brighton those and Hove City generally PCT

106 CHAPTER 5 THE LIFESTYLE DETERMINANTS OF HEALTH thought essential for health”. In particular, a large proportion of the UK’s non-car-owning residents proportion of low paid and unemployed peoples (one-quarter) who live in what are termed ‘food could not afford sufficient quantities of what deserts’ - areas in walking distance of fast food were described as ‘protective foods’, namely milk, outlets, but with scarce provision of fresh fruit fresh vegetables, meat, fish and fruit. and vegetables. The city’s Public Health team We live in an age where we have moved now undertake Health Impact Assessment of from a lack of the right type of food to a surfeit major developments in an effort to maximise of the wrong type of food. Encouragingly, in their contribution to good health. Brighton and Hove the latest Health Related Behaviour Survey (2007) and Health Counts School meals Survey (2003) found, for the first time, that School meals form a valuable means of the eating habits of children aged 10-14 years promoting healthy eating habits in children, are improving as are the levels of physical particularly for children living in deprived areas activity in both children and adults. However with comparatively poor diets. Good nutrition the figures are still depressingly low. The 2003 is essential for concentration and so increasing Health Counts Survey reported that just 15% the uptake of school meals may improve the of residents took the recommended minimum health and education of pupils across the city. level of 30 minutes physical activity a day. When compulsory education began in More men (19%) than women (12%) took the Britain in 1880, school dinners were provided recommended level of physical activity, and by volunteers. Later, it became compulsory a greater proportion of unemployed people for local authorities to provide school dinners reported infrequent exercise (54%) compared of a specific nutritional standard for all school to employed people (31%). The number of children who wanted them. In Brighton, Dr. residents in Brighton and Hove walking and Duncan Forbes published the weekly school cycling has increased in recent years; however dinner menu (see Box 5.4.1) in 1908. Box 45% of workers who use a car to get to work 5.4.2 shows a 2009 menu for the purposes of drive less than three miles (Brighton & Hove comparison. The primary aim in 1908 was to City Council 2006). provide bulk through large quantities of soups comprising pulses, with little meat and relatively 5.4.3 Tackling obesity in low fat by today’s standards. Through-out the 20th century Medical Brighton and Hove Officers of Health in Brighton, worked to The ‘Promoting healthy weight and healthy improve nutrition and improve school meal lives in children in Brighton and Hove, 2008/09- provision and uptake. Today it is no different. 2011/12’ Strategy explains how the city is The uptake of school meals in Brighton and working to reduce childhood obesity. A ‘Healthy Hove primary schools is currently only 34%. In Weight for Children and Young People Delivery secondary schools just 21% of children have Plan’ has been put in place with a combination a school meal. The figure for primary schools of weight management and physical activity is higher than the average for the South East initiatives. (28%), but below the national average of 47%. At secondary school level, the uptake is Urban Planning considerably lower than the South East average In 2009, the National Institute for Health and (30%), and the national figure of 38%. Clinical Excellence (NICE) produced guidance A drop in school meals uptake took place on urban towns to encourage physical activity. in 2005, following Jamie Oliver’s television NICE also highlighted links between planning series. Subsequently, the government and health inequalities, illustrated by the high

107 CHAPTER 5 THE LIFESTYLE DETERMINANTS OF HEALTH

introduced prescribed nutritional standards 29% of women) and most adults (69% of men for school dinners. Nationally and locally, the and 68% of women) either underestimated cost of producing school meals has increased or did not know how much physical activity through the introduction of more fresh adults should undertake. Among men, the most ingredients, and fewer processed foods. common barrier to doing more physical activity The selling price of a primary school meal was work commitments (45%), followed by lack was £2 in September 2009. This is subsidised of leisure time (38%). Women were most likely by approximately 12-13p per meal by the to report a lack of leisure time (37%), with work School Lunch Grant. In Brighton and Hove this commitments almost as frequently mentioned amounts to a cost of around £150-200,000 (34%) (NHS Information Centre, 2009b). annually. A number of initiatives are underway Across Brighton and Hove there are a to encourage school meal uptake. These are number of programmes aimed at improving not simply concerned with the price of a meal health through exercise. These include free as the aim is also to increase free school meal swimming for all children aged 16 years of uptake. age or below in Brighton and Hove swimming The top three factors influencing the pools. As of the end of December 2009 11,712 likelihood of children choosing a school meal children and young people under 16 years old are: whether they like the food that is on offer had registered and the pools were used 44,528 or not; whether or not they recognise the times by those who registered. Other physical food (and are they confident they will enjoy activity initiatives include ‘health walks’ led by it); and the price. So schools face the tough trained volunteer leaders, and ‘Green Gym’ challenge in providing attractive, nutritious groups involving conservation or gardening work food at affordable prices. Furthermore, as with a trained leader. is shown in Figure 5.4.4, the uptake of free Weight management sessions for 5-7 and school meals varies considerably, and the 13-18 year olds are being delivered in schools relation with deprivation, if there is one, is by a sports teacher and dietician over 6-8 not straightforward. Current measures to weeks, including special needs schools. Food increase school meal uptake include a reward growing, dietary advice, cookery training, play scheme for fruit and vegetable consumption and physical activity opportunities are being in association with ‘Albion in the Community’, provided for all children aged 2-11 years in seven an initiative to improve the dining environment primary schools and one children’s centre in (access to water, reduced queuing, electronic east Brighton. Other initiatives, such as Weight payment) as well as improved menus. Management clinics, will start early 2010. In 2008, a new initiative was launched via Physical activity and diet local businesses to help staff members adapt Physical activity recommendations are for to healthier lifestyles and improve fitness. This adults to get at least 30 minutes of moderate initiative includes workplace health MOTs, intensity physical activity, on five or more days targeted at men. a week. These may comprise bouts of 10 There is however, a relatively weak minutes or more throughout the day. Moderate evidence base for the effectiveness of measures activity includes activities like walking, cycling, to reduce weight and increase exercise so gardening and housework, as well as various impact evaluations are built into all of the sports and exercise. above initiatives. In 2007, approximately one third of adults in the UK had not heard of the government guidelines for physical activity (34% of men and

108 CHAPTER 5 THE LIFESTYLE DETERMINANTS OF HEALTH

Figure 5.4.4: Percentage take-up of free school meals 2008/9 in primary schools and the index of multiple deprivation 2007

Wards 1 Brunswick Free school meal & Adelaide take up (% by school) 2 Central Hove 3 East Brighton 43.4 - 53.4 4 Goldsmid 53.5 - 65.2 5 Hangleton & Knoll 65.3 - 74.3 6 Hanover & Elm Grove 74.4 - 86.8 7 Hollingbury 10 & Stanmer 8 Moulsecoomb 20 86.9 - 100 & Bevendean 9 North Portslade 9 7 10 Patcham 11 Preston Park 12 Queen's Park 5 13 Regency 8 14 Rottingdean Coastal 17 15 St. Peter's 11 & North Laine 16 16 South Portslade 17 Stanford 4 6 21 18 19 15 Westbourne 18 2 19 Wish 3 20 Withdean 1 21 Woodingdean 13 12

14 IMD Quintile 2007 1 (most deprived) 2 3 4 5 (least deprived) 

Dotted Eyes © Crown copyright and/or database right 2009. All rights reserved. Licence number 100019918

Source: School Food Trust: First annual survey of take up of school meals in England

5.4.4 Summary caution. The city’s Healthy Weight for Children In a relatively short space of time we have moved and Young People Delivery Plan, which followed from a state of under-nutrition to malnutrition my Annual Report of 2008, is still within its first through the excessive consumption of the wrong twelve months. It will be key to establishing and foods. In Brighton and Hove there are relatively improving eating patterns, nutritional awareness low levels of adult and child obesity compared to and activity levels in young people. The scale of national figures. However, there is a national and the task should not be underestimated. local upward trend of obesity in adults with all the secondary health implications: coronary heart Recommendations disease, diabetes and cancers. The Primary Care Trust and City Council Obesity is more pronounced in the more should continue to address obesity on a wide deprived parts of the city. Any strategy has to range of fronts, including working with the be able to target these groups. Planners, school private sector. meal providers, the leisure industry and health There should be close monitoring of services all have a role to play. public health initiatives to ensure that sufficient The picture in children is a little more numbers of those most in need take part, and encouraging. However, the National Child that there are positive effects from participation. Measurement Programme is still in its infancy, and we should interpret results with some

109 CHAPTER 5 THE LIFESTYLE DETERMINANTS OF HEALTH

Table 5.5.1: All persons treated at the Venereal Disease Treatment Centre, Brighton, 1919

Syphilis Soft Chancre Gonorrhoea Total

males females males females males females males females

New cases 191 139 32 5 248 79 471 223

Total 2579 2255 No data No data No data No data n/a n/a attendances

Number of 301 365 8 19 62 186 371 570 inpatient days of treatment

Source: Annual Report of the Medical Officer of Health, Brighton, 1915

5.5 Sexual Behaviour (Governor of the Westminster Infirmary, 1738; quoted in Siena, 2004) This chapter is split into two main sections, the In the 19th century, public health first deals with sexually transmitted infections, measures were introduced, principally aimed the second with teenage pregnancy. at prostitutes, with the aim of preventing the spread of sexually transmitted infections. The SECTION A: 1866 Contagious Disease Acts of Great Britain legalised the compulsory incarceration and SEXUALLY TRANSMITTED examination of infected women. Women’s INFECTIONS groups, civil rights activists and members of the medical profession mounted campaigns 5.5.1 A brief history of sexually however, and the Acts were repealed in 1886. In the late 19th century, the micro- transmitted infections organisms causing infectious diseases began Sexually transmitted infections have been to be identified, and the 20th century saw the documented since the earliest Egyptian development of antibacterial drugs. However, civilisations but it was during the Middle Ages it became clear that antimicrobial treatment in that syphilis and gonorrhoea started to spread, itself was not enough, and that public health fuelled by war, travel, and the rise of city slums. measures were required. Treatment was largely ineffective up until the Sexually transmitted diseases are not middle of the 20th century, and sufferers were equally distributed across society. Today, young often subject to considerable disapproval and people, black minority communities and discrimination. men who have sex with men are consistently “The admission of venereal patients is a identified as most affected (LHO and HPA, subversion of the charity, or a misapplication 2008). These groups are often referred to as of the money given in trust for the poor... ‘at risk populations’. In Brighton and Hove, the Society has constantly rejected venereal the young population profile, high student patients for the very reason of being venereal”

110 CHAPTER 5 THE LIFESTYLE DETERMINANTS OF HEALTH

Figure 5.5.1: Cases of the top five STIs seen at the GUM clinic in Brighton and Hove, 2003 to 2008

1,400 400

1,200 350

300 1,000 250 800 200 600 150 Numbercases of Numbercases of 400 100

200 50

0 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2000 2001 2002 2003 2004 2005 2006 2007 2008

Uncomplicated chlamydia Uncomplicated gonorrhoea Genital herpes (first attack) Genital warts (first attack) Primary & secondary syphilis

Source: Brighton and Hove Genitourinary Medicine Clinic KC60 returns, 2009

Table 5.5.2: Deaths from syphilitic disease in Brighton, 1962-1971 Year Males Females Total Comment on

age data

1962 2 2 4 No age breakdown 1963 2 2 4 No age breakdown 1964 3 2 5 No age breakdown 1965 4 1 5 No age breakdown 1966 3 0 3 All over 75 years old 1967 No data available No data available No data available No data available 1968 0 0 0 n/a 1969 0 3 3 All over 55 years old 1970 2 1 3 F aged 55 – 64 M both 75+ 1971 0 0 0 n/a

Source: Annual Reports of the Medical Officer of Health, Brighton, 1962 – 1971 population, and large gay community present al, 2006); drug and alcohol abuse (Patton et particular challenges. al, 2008; Crawford et al, 2004); and sexual Attitudes and associated behaviour are liaisons while travelling abroad (Rogstad, 2004) important influences on sexual health. For all exacerbate the risk of contracting a sexually example, multiple partnerships (Mercer et al, transmitted infection. There is some evidence 2008); inconsistent condom use (Cassell et to suggest that in contrast to the behaviours

111 CHAPTER 5 THE LIFESTYLE DETERMINANTS OF HEALTH

Figure 5.5.2: Percentage of live births to mothers aged 15-19 years, England and Wales, 1941-2004

12

10

8

6 Percentage

4

2

0 1940 1945 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2004

Year

Source: Registrar General, Annual Reports; Office of National Statistics

that followed the AIDS campaign of the 1980s, attendances at the Centre for the treatment of recent years have seen high risk behaviours syphilis, gonorrhoea and soft chancre (a disease increase once more. now most commonly encountered in tropical countries). Table 5.5.1 shows that in 1919 that 5.5.2 Sexually transmitted the total number of recorded cases of sexually transmitted infections was 694, with men infections in Brighton and Hove accounting for more than twice the number of In keeping with its reputation as a place to have cases as women. These numbers are substantial a good time, sexually transmitted infections and equivalent to a crude population rate of have, at various times, figured prominently in approximately 5.8 per 1000 population. the lives of the residents of Brighton. This is well The collection of detailed sexual health documented in the Reports of local Medical data, like other health data, was unsurprisingly Officers. Between 1901 and 1918, Medical interrupted by the Second World War. Nevertheless, Officers; Dr Arthur Newsholme and Dr Duncan the necessarily brief reports of Medical Officer Dr Forbes reported deaths from syphilis. The total Rutherford Cramb still make frequent reference number of deaths reported annually during to “the black spot of venereal disease” in the those years did not exceed 16, and they were town. In January 1943, national legislation typically all infants under the age of 1 year. in the form of Defence (General) Regulation In 1919, Dr Forbes established a Venereal 33B enabled the compulsory examination and Disease Treatment Centre in Brighton. In his treatment of a person, named as a venereal Report of that year, he published figures for

112 CHAPTER 5 THE LIFESTYLE DETERMINANTS OF HEALTH disease contact by two separate sources. with more infections in younger residents. The recorded numbers of infected persons Certainly, chlamydia infection is most common in the 1940s are, surprisingly, fewer than those in those less than 25 years of age. from the earlier part of the 20th century. This Figure 5.5.1 shows that chlamydia, genital may in part be due to the fact that many young warts and genital herpes have all increased men were away on active duty. Between 1942 in recent years. After a fall in 2005, syphilis and 1946, the numbers of those with a Brighton rates have risen again. Apart from one year of address attending the Treatment Centre rose decrease in gonorrhoea figures (from 2007 to steadily, from 106 (51 males, 65 females) in 1942 2008), all of these top five sexually transmitted to 301 (190 males and 111 females) in 1946. infections have risen year in recent years. These Then, from 1947, the numbers start to fall, and figures do not include HIV infections, which are by 1949 had fallen to 179. illustrated in Table 5.5.3. In 2008 there were In the 1950s, data collection began to a reported 1,306 people with HIV infection in recover and the population began to grow once the city. more. By the start of ‘Swinging Sixties’ there 441 Taking the long-term view we can see new cases (gonorrhoea and syphilis and ‘other that in 1919 there were 694 recorded cases conditions’). So in 1960, in contrast perhaps to of sexually transmitted infections in Brighton, popular perception, sexually transmitted infection mostly syphilis and gonorrhoea. Perhaps rates in Brighton were actually lower than they somewhat surprisingly, forty years later (1959) had been 40 years previously. this had fallen to 387 recorded cases. By 2009 In the 1960s and 1970s, Medical Officer however, the figures had increased dramatically Dr William Parker returned to reporting deaths and there were well over 4,000 infections from syphilitic diseases. Table 5.5.2 shows how (including concurrent HIV). Most of these are these had decreased from the annual figures newer viral infections and the number of syphilis of 12 to 16 reported in the 1920s. Also, in and gonorrhoea cases is actually less than it was contrast to the infant deaths from syphilis of the 50, and even 90 years ago. early 20th century, deaths from syphilis were There have of course been important now mainly in people aged over 55 years. population changes in this time with a much Today, all Genitourinary Medicine (GUM) larger population and a current predominance of clinics submit data on the number of cases of young adults. There have also been important sexually transmitted infections (referred to as changes in disease occurrence with the KC 60 returns) to the Health Protection Agency. emergence of new infections, as well as new These data do not include patients with sexually curative and disease-suppressing treatments. An transmitted infections that are managed outside equally significant change has been the change of these clinics (e.g. in primary care, young in the sexual behaviour of the population. It people’s services or contraceptive services). The might be argued that this is not actually a shift profile of sexually transmitted infections has in the local mind-set. For as can been seen changed. There are still substantial numbers of from early 20th century sexually transmitted bacterial infections like syphilis and gonorrhoea infection rates, and as will be seen when we and the new bacterial infection – chlamydia. consider historical teenage pregnancy rates, But, there have been huge increases in viral Brighton has a long tradition of sexual activity infections such as warts, herpes and of outside of marriage – certainly more so than the course HIV infection. Many of these newer national average. What seems to have changed sexually transmitted infections have come to is the degree to which these behaviours take prominence in the last 30 years. It is also likely place: more and younger people appear to be that the age profile of sufferers has changed, engaging in sexual activity with more partners.

113 CHAPTER 5 THE LIFESTYLE DETERMINANTS OF HEALTH

National rates of sexually transmitted they are infected with chlamydia, and so a infections have also been increasing for a national screening campaign has been started. decade. Some commentators have suggested So, paradoxically, it would be a good thing if that the latest national data give a little more cases of chlamydia and HIV infection were scope for optimism. The total number of detected and numbers rose. It will take a few new sexually transmitted infections reported years before we can say that the public health (including chlamydia, gonorrhoea, herpes, message of safe sex is being taken seriously and warts and syphilis) rose by only 0.5% between that high risk sexual behaviour across the city 2007 and 2008 (397,909 to 399,738). This is decreasing. rise was mainly due to increased diagnoses of viral sexually transmitted infections. Over the 5.5.3 At-risk groups same period, diagnoses of bacterial sexually Some groups are more at risk of poor transmitted diseases (syphilis, gonorrhoea) sexual health. We have a distinctively young either stabilised or declined (HPA, 2009). population structure in Brighton and Hove, and Cautious optimism in Brighton and Hove a large Lesbian, Gay, Bisexual and Trans (LGBT) may, as yet be a little unwarranted. There is no community. Trends in sexually transmitted firm evidence that sexually transmitted infection infections and HIV vary considerably in these rates are falling or even stabilising. Gonorrhoea different populations, as do attitudes to sexual infections did fall in 2008 (Figure 5.5.1) and health, and the ways that these groups use the rise in HIV infected residents in 2008 in sexual health services. Some of these variations Brighton and Hove (Table 5.5.3) was the lowest are teased out below. for many years, but it is too early to say that these are trends. It is well established from Young people unlinked anonymous HIV testing in Brighton Young people are disproportionately affected by that many infected men are unaware that they most STIs, in particular chlamydia. The highest are infected with HIV. It is also well established rates of chlamydia in UK women are in 16 to that many young people are unaware that 19 year olds (2,002 per 100,000) whilst in men,

Table 5.5.3: Number of HIV infected patients in Brighton and Hove by probable route of exposure and total percentage change, 2004 - 2008

Probable route of exposure 2004 2005 2006 2007 2008

Sex between men 758 819 930 1,037 1,083 Sex between men and women 131 145 157 181 188 Injecting drug use 19 22 20 22 19 Other, including mother to 7 7 10 10 10 child transmission, blood / blood products recipient and not known Total 915 993 1,117 1,258 1,306 Percentage change from n/a 8.5 12.5 12.6 3.8 previous year

Source: SOPHID, 2009

114 CHAPTER 5 THE LIFESTYLE DETERMINANTS OF HEALTH the highest rates are found in those aged 20 to 2005). The total number of cases of syphilis in 24 years old (1,338 per 100,000). Similar trends Brighton and Hove in 2008 was 58. Of the 58 can be identified in gonorrhoea diagnoses. cases reported in 2008, 56 were in men. (LHO and HPA, 2008). Nationally it has been reported that apart from genital herpes, all sexually transmitted Lesbian, Gay, Bi-sexual and Trans people infections have increased in men who have sex (LGBT), and Men who have Sex with Men with men over the last five years. (MSM) The local Count Me in Too Survey in 2007 Men who have sex with men are particularly reported a lack of knowledge and information affected by HIV. This is reflected in the very about sexual health despite the fact that almost high number of males in Brighton and Hove the entire sample (94%) had had sex in the past living with diagnosed HIV infection, which was three years. Many of the people surveyed felt reported as over 600 per 100,000 in 2007. This that although available sexual health literature is the highest rate outside of London. was clear and understandable, it didn’t cater HIV is not the only sexually transmitted for the diversity within the community including infection which particularly affects men who people with disabilities. However, some have sex with other men disproportionately. subsequent service developments, such as the There has been an ongoing outbreak of syphilis dedicated clinic for deaf gay men (with signers) in Brighton and Hove since 1999 (Lambert et al, were discontinued when no-one attended.

Figure 5.5.3: Fertility rates in Brighton compared to national fertility rates

120

100

80

60 Fertility rate

40

20 England & Wales

Brighton (Brighton & Hove, 2008)

0 1911 1921 1931 1941 1951 1961 1971 1981 1991 2001 2008

Year

Source: Annual Reports of Medical Officer of Health for Brighton Registrar General, Annual Reports Note: The fertility rate includes as a numerator the number of live births to females aged 11 – 49 years although the denominator is the female population aged 15 – 44 years.

115 CHAPTER 5 THE LIFESTYLE DETERMINANTS OF HEALTH

Figure 5.5.4: Illegitimate birth rates in Brighton compared to national illegitimate birth rates

18

16

14

12

10

8

Illegitimate births, % births, Illegitimate 6

4

2 England Brighton

0 1911 1921 1931 1941 1951 1961 1971

Year

Source: Annual Reports of Medical Officer of Health for Brighton Registrar General, Annual Reports Note: Data are not available between 1958 and 1962

Drug and alcohol abuse evidence that some sexual assaults in Brighton Alcohol misuse, in particular binge drinking, and Hove related to drink promotion nights in is closely connected with sexually transmitted clubs and bars. infection rates, particularly in young people (McEwan et al., 2006). An association has also Travel abroad been found between the use of crack cocaine Overseas travel has become a regular part of and sexually transmitted diseases (Marx et al life for many people. Sexual encounters during 1991). One study reported that 62% of drug foreign travel have been identified as a factor users in treatment had tested positive for at influencing the increasing prevalence of sexually least one sexually transmitted disease. (Hwang transmitted diseases in the UK (HPA, 2009). et al, 2000). Another that 23% of women in Between 2000 and 2002, 69% of UK born short-term drug abuse treatment had a sexually men with heterosexually acquired HIV (235/342) transmitted infection (Lally et al, 2002). were infected through sex while abroad, as The misuse of alcohol is a substantial public were a quarter (75/316) of women. Of these health problem in our city. There is considerable men, 22% were probably infected in Thailand. anecdotal evidence from youth workers that in Brighton and Hove, many young girls’ first 5.5.4 Summary sexual encounter is experienced under the Brighton has a long history of risk-taking sexual influence of alcohol. There is also anecdotal activity – greater than is the case nationally.

116 CHAPTER 5 THE LIFESTYLE DETERMINANTS OF HEALTH

Figure 5.5.5: Trend in under-18 conception rate during 1997-2007, with projected trend required to meet 2010 reduction target

60

50

40

30

20

Under 18 conception rate per 1000 per rate conception 18 Under England South East 10 Brighton & Hove UA

0 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Year

Source: Teenage Pregnancy Unit, 2009

This was actually more prominent at the start these levels of investment will be required for of the 20th century than it was at the start of some time. the so called ‘permissive society’. The pattern But what cries out from this section is the of sexually transmitted infections has changed apparent failure of the public health message. over recent years and viral infections present This may be due to the particular characteristics more frequently. Treatments have improved, of our local population which contains many and there have been changes in perceptions groups known to be at greater risk. The high with regard to how being infected with a prevalence of alcohol consumption in the city sexually transmitted disease is viewed, both by is also an important factor. Whether recent the infected individual and by wider society. findings in terms of gonorrhoea and HIV The costs to the local health services are represent a turning point remains to be seen. considerable and in the last few years the We could simply accept that this is just a Primary Care Trust has made efforts to establish fact of local life, that this is how it is in Brighton a greater range of sexual health services across and Hove – and to a degree, it has always been the city, developing in particular primary care the case. People make choices in their lives, services. There are also year-on-year rising costs and there are benefits – artistic, creative and of drugs, and anti-HIV drugs cost now form no doubt economic from living like we do. a significant part of the Primary Care Trust’s We could also react and invest considerable Health budget. The current picture of rising public money in public health messages. There sexually transmitted disease rates suggests that is an evidence base on how best to present

117 CHAPTER 5 THE LIFESTYLE DETERMINANTS OF HEALTH

Figure 5.5.6: Under-18 conception rate plotted against deprivation score, 2007, with nearest statistical neighbours highlighted

100

90 Brighton & Hove UA

80 Statistical neighbours

70

60

50

40

30 Under 18 conception rate 2004-06 rate conception 18 Under

20

10

0 0 5 10 15 20 25 30 35 40 45 50

Index of deprivation 2007

Source: Teenage Pregnancy Unit, 2009 Note: Under 18’s conception data are provisional

these messages, but our recent track record SECTION B: suggests that while these might be heard, they TEENAGE PREGNANCY may not necessarily be listened to. I am not recommending any such new investment. We need a long and hard think about the 5.5.6 A brief history of teenage issue of sexual health, about the related health pregnancy and social costs, about the links to behaviour Historically, in the UK, teenage pregnancies patterns and about the important role played have fluctuated. They increased during the by alcohol consumption. We have somewhat post-war period, through the 1950s and 1960s shied away from that in recent years, perhaps to a peak of around 11% of all live births in from fear or making moral judgements, or 1975 (Figure 5.5.2). The trend then reversed, being caught up in a mire of arguments about falling to 6.5% of all live births in 1996. personal responsibility and lifestyle choices. This Between 1996 and 2002, the percentage of is a report on public health and not a report births in 15-19 year olds rose again, reaching on morality. Sexually transmitted infections 8% in 2002. Then a downwards trajectory was are an issue of public health. We need to talk resumed, and continued until 2006. openly about them, and find a more successful Today, England and Wales has the highest approach. teenage pregnancy rates in Western Europe. Furthermore, recent data show that teenage conception rates increased in 2007 for the

118 CHAPTER 5 THE LIFESTYLE DETERMINANTS OF HEALTH

Figure 5.5.7: Termination rates in Brighton and Hove and England and Wales per 1000 female population aged 15-19 years

40

35

30

25

20

15

10 Brighton & Hove

England & Wales Rate per 1000 women aged 15-19 years 15-19 aged women 1000 per Rate 5

0 1971 1976 1981 1986 1991 1996 2001 2006

Year

Source:Termination counts from DCSF, population denominators from Office for National Statistics first time since 2002 in England and Wales. North East, with 66.8 per 1,000 and 66.7 per The rate in 2007 was 41.9 conceptions per 1,000 respectively. 1000 females aged 15-17 years, compared to 40.9 the previous year. The national target is 5.5.7 Teenage pregnancy in to reduce the under-18 conception rates by 50% from a 1998 baseline by 2010. By 2007 Brighton and Hove While teenage pregnancy figures were not however, conception rates had reduced by reported in the Annual Reports of local Medical just 11.1%. In total, there were an estimated Officers, there was information on fertility rates, 42,900 conceptions in females aged less and what were referred to as illegitimate birth rates. than 18 years in 2007. The under-16 years These are illustrated in Figures 5.5.3 and 5.5.4. conception rates also increased from 7.9 per Fertility rates in Brighton have consistently 1,000 in 2001-2003 to 8.0 per 1,000 in 2005- been lower than national equivalents. 2007. Overall, the proportion of conceptions Interestingly, this was most marked in the leading to termination has been increasing earlier part of the 20th century. By contrast the while the rate of births has been declining. proportion of births recorded as ‘illegitimate’ Teenage girls in the North East are the has consistently been higher than nationally. most likely in England to become pregnant, Illegitimate births, both national and local, with 52.9 pregnancies per 1000 girls aged 15- increased dramatically in both war periods after 17 years. Hartlepool and Middlesbrough have which they decreased once more. The equally the highest rates of teenage pregnancy in the dramatic rise seen in the 1960s and 1970s

119 CHAPTER 5 THE LIFESTYLE DETERMINANTS OF HEALTH

was not followed by a large decrease. The The recent quarterly data must however term illegitimate birth is now of course almost be interpreted with caution and meeting the irrelevant as attitudes to marriage, to birth national target remains, unsurprisingly, a tough outside of marriage and to single parenthood challenge. This is demonstrated in Figure 5.5.5 have changed enormously. Medical Officer Dr which shows by just how much this trajectory Parker’s remark in the late 1960s that it was of change must accelerate beyond 2007 to “shocking that 1 in 3 of the girls who walk achieve the local target. down the aisle in Brighton does so pregnant”, When we compare our teenage pregnancy now seems rather quaint. rate with similar towns, and when we account These figures suggest that Brighton for relative levels of deprivation in Brighton and has long been a place where birth rates are Hove however, the picture is less bleak and lower than national equivalents, but where there are similar patterns. In fact, given our illegitimate births, which might be considered, level of deprivation, and teenage pregnancy to a degree, to be a proxy for today’s teenage is closely related to deprivation, levels of pregnancy rates, have always been higher than teenage pregnancy in the city are as might be nationally. Targets to reduce teenage pregnancy anticipated (Figure 5.5.6). over what, by comparison, is a relatively short time period, need to be considered in the 5.5.8 Abortions in Brighton context of much longer, established cultural and behaviour patterns. and Hove Abortion was legalised in 1967, and the first In 2007, the under-18 years’ conception abortion clinic in Brighton and Hove opened in rate in Brighton and Hove was 43 per 1000 1970. Over the last 40 years the rate of teenage females aged 15-17 years, slightly higher than pregnancies leading to abortion in England and the national rate, and the rate for the South Wales, and in Brighton and Hove, has increased. East. Statistics on teenage pregnancy are now The local trend presents something of a puzzle. also reported on a quarterly basis. The latest As is shown in Figure 5.5.7, terminations in quarterly statistics (Quarter 3 of 2008) from women aged 15-19 years in Brighton and Hove the Office for National Statistics show that the increased dramatically; more than three-fold, under-18 conception rate is 38.0 per 1000 during the decade 1971-1981, from 10.4 to which is equivalent to a 21.6% decrease on the 34.6 terminations per 1,000 female population 1998 baseline. aged 15-19 years. This rapid increase was Although the national target was a 50% much greater than in the country as whole. The reduction, locally a 45% reduction from 1998 rate then slowed in Brighton and Hove to 26 to 2010 was agreed. In addition, a key target terminations per 1,000 between 1981 and 1996 relating to teenage pregnancy was set out in before it started to increase, in line with national the 2008/11 Local Area Agreement for Brighton trends this time. and Hove. This sets a local goal to reduce the The reasons for this local pattern are not under-18 years’ conception rate of 43 per 1000 entirely clear, but it may simply be a feature of by 45% to 26.4 per 1000 by 2011. having a large centre locally where abortions The ‘Teenage Pregnancy Action Plan were being carried out. This would make it more 2009/11’ (BHPCT, 2009c) reports that there has likely that local teenagers would be referred for been improvement against the shorter-term abortion. Anecdotal evidence also suggests that targets set. Between April and September 2008 people came to Brighton and Hove, to stay with the local target of reducing the number of friends and family, sometimes from afar, in order births to teenage mothers by 24 was exceeded to procure an abortion. As more centres opened by 14 (with an overall reduction of 38). across the country this local phenomenon

120 CHAPTER 5 THE LIFESTYLE DETERMINANTS OF HEALTH diminished. Whether this factor in itself explains measures to tackle cultural and behavioural the dramatic rise is not clear, but it is likely to patterns. It may be that this is at last beginning have had some influence. to have some effect, but it is too early to say Today, abortion rates continue to increase, whether this approach will have lasting success and while teenage births have recently decreased in turning the tide on teenage pregnancy. slightly in Brighton and Hove, abortions in Sadly, it seems almost certain that recent teenagers have not. In 2002, 48% of teenage progress will insufficient for the city to meet pregnancies resulted in abortion: by 2007, this the 2010 teenage pregnancy target. Perhaps had risen to 63%. The percentage of teenage if there had been an opportunity for more pregnancies ending in abortion in England and reflection on the past history and profile of the Wales in 2007 was 50%, and the South East it city, such an ambitious target might not have was 53%. Furthermore, in 2008 repeat abortions been set for Brighton and Hove. in females aged less than 19 years in Brighton As is the case with sexually transmitted and Hove stood at 15.2% compared to 10.5% infections, there is an important question in the South East and 11.0.0% in England. that we should ask ourselves. As well as the There has been, and continues to be considerable and commendable efforts being considerable local investment in teenage taken to reduce teenage pregnancy in the pregnancy services – both support services for city, are we also taking decisions which might teenage mothers and also prevention services. promote unwanted teenage pregnancy? The In recent years, these services have moved from most obvious area is alcohol. a focus entirely on contraceptive and abortion services, to measures to improve education, Recommendations employment and training opportunities as Investment to reduce sexually transmitted well as measures to tackle excessive alcohol infection rates and unwanted teenage consumption. This is in keeping with what is pregnancy rates should be based on clearly a need to tackle long established cultural consideration of local cultural and behaviour and behavioural patterns that underpin teenage patterns, and the best available evidence of pregnancy. what works. In compiling strategic approaches 5.5.9 Summary to improving sexual health in the city, Teenage pregnancy is associated with poor consideration should be given to wider policy educational, social and health outcomes for initiatives within the city which might help in mother and baby alike. Indeed, it might be discouraging unsafe sexual behaviour. argued that teenage pregnancy is really just an outcome of low expectations and the failure of education, employment and training systems to engage a section of the population. The figures suggest that Brighton has historically had higher numbers of teenage mothers compared to national figures and this may in part explain the difficulties in reducing rates. Although, when weighted for deprivation, local rates appear more favourable. In recent years, there has been an expansion of approach from a focus on accessible contraceptive services, to wider Miss Brighton, 1965

121 ‘Because of its high number of visitors, few towns are more exposed to the introduction of infectious diseases than Brighton. In the previous year’s epidemic I supplied 800 doses of vaccine in a month. I have been vaccinating an average of 1,000 children a year for 12 years, nearly nine-tenths of them gratuitously: a great proportion of them being decent mechanics, unable to pay the usual fee, but unwilling to apply as paupers to the parish surgeons’. From a letter by John Badcock to The Medical Times, September 1853. Photograph courtesy of The Royal Pavilion and Museums, Brighton & Hove City Council Brighton & Hove and Museums, Pavilion The Royal courtesy of Photograph 122 R CHAPTER RSix Ill health in Brighton and Hove

6.1 Coronary heart disease 6.2 Cancer 6.3 Mental health & suicide 6.4 Infectious diseases

123 124 Chapter 6 Ill health in Brighton and Hove

This section of the Report considers the main than one in five men and one in six women will causes of ill health in Brighton and Hove. This die from the disease. Around 146,000 people includes the two main causes of death; coronary have a heart attack every year. Mortality from heart disease and cancer. Mental health and coronary heart disease varies geographically, wellbeing is also discussed with a particular with higher rates in the north of the UK focus on suicide which has been a problem in compared to the south. the city for many years. Finally, there is a section on infections as 2009 has been a year of some 6.1.1 Coronary heart disease unusual infectious disease activity in the city. in Brighton and Hove It is in the 1960s, in the Reports of Dr William 6.1 Coronary heart Parker that we start to read about public disease health efforts to tackle coronary heart disease in Brighton. However, even in the reports of Although mortality from coronary heart disease the 19th century there is reference to coronary (CHD) in the UK is declining, it continues to be heart disease. As shown in Table 6.1.1, in 1893, the single most common cause of death. More Dr Arthur Newsholme recorded that there were

Table 6.1.1: Illustrative causes of death (numbers) as recorded in Annual Reports of Medical Officers of Health in Brighton 1893 1968 2008* Total Population 116,032 164,680 256,600 Respiratory Diseases 343 279 283 Tuberculosis 300 2 0 Infectious Diseases 258 6 32 (includes parasitic diseases) Circulatory Diseases 190 Ischaemic Heart Disease: 643 311 Hypertensive disease: 47 30 Other Heart Disease: 155 109 Other Circulatory Disease: 98 269 Cancer 92 593 580 Influenza 33 102 1

Total Deaths 2165 2737 2,206 Source: Annual Reports of Medical Officers of Health, Brighton * Brighton and Hove

125 CHAPTER 6 ILL HEALTH IN BRIGHTON AND HOVE

190 deaths from ‘circulatory diseases’ (out of influenza. What is most remarkable when a total 2,165 deaths in Brighton) spread evenly comparing the 1968 Report with previous between the two sexes. Disease coding was Report is how the deaths from coronary heart different at the time and it is likely that this disease had emerged as the most common did not include people dying from stroke. At cause of death. Out of a total of 2,737 deaths the top of the mortality table sat respiratory in that year, there were 943 deaths from diseases (343 deaths), tuberculosis (300 deaths), circulatory disease (again this does not appear other infectious diseases (291 deaths) and then to have included stroke which was coded circulatory diseases. Cancer, which now along separately) and 593 deaths from cancer. with coronary heart disease accounts for most By 1970, the scale of coronary heart deaths was recorded as causing just 92 deaths. disease was apparent to the extent that By 1968 the profile of mortality had a national pilot Resuscitation Ambulance changed dramatically in the town. The year Service was started in Brighton by Dr Parker 1968 was the first year of a new Registrar in conjunction with the Medical Commission General’s Classification of Death which eases on Accident Prevention and a local consultant comparison with today. However, 1968 was cardiologist, Dr Douglas Chamberlain. The idea a slightly unusual year in that there were over was to deliver prompt D.C. shock therapy to 100 deaths from pandemic influenza – the patients who had suffered a heart attack. The last pandemic influenza prior to 2009. In scheme was based on an initiative from Dublin. 1967, there were just 13 recorded deaths from After a few teething problems, the resuscitation

Figure 6.1.1: Age-standardised mortality rate per 100,000 population from all circulatory diseases in under 75s, 1987/89-2006/08

180

England baseline, 141.3 160

140

120 England target, 84.8 100 Brighton & Hove baseline, 128.8 80

60 Brighton & Hove target, 77.3

Age standardised rate per 100,000 40 England Brighton & Hove 20 Brighton & Hove trendline

0

9 1 6 0 5 6 9 0 8 90 /9 93 94 97 98 99 0 02 0 0 07 0 1 / / / / / 9/ 8/ 90 6/ 01 5 6/ 8 /89/ 93 /94/95 /95/9 99/ / /02/03 /04 /0 0 /08/ 0 09/10/11 87/ 88 89/ 90/91/9291/92/ 92/ 93 94 95/9 96/97/ 97/98 98/ 99/00/0100 01 02/03/0403 04 05/ 06/07/0807 08/

3 year average

Source: Office for National Statistics Vital Statistics and Office for National Statistics Mid Year Population Estimates

126 CHAPTER 6 ILL HEALTH IN BRIGHTON AND HOVE ambulances began to have some success. This all circulatory diseases (this includes stroke) in led Dr Parker to claim in his Report for 1971 people aged less than 75 years has decreased that Brighton was the safest town in England in in Brighton and Hove since 1988. During which to have a coronary attack. this time, age-standardised mortality has In recent times mortality from coronary decreased from over 150 per 100,000 to less heart disease has been decreasing. The rate of than 80 per 100,000, with a projected further decline however, has been more marked among reduction to 53 by 2009/11. The downward more affluent groups increasing inequalities in trend in Brighton and Hove mirrors regional health. Nationally, mortality from coronary heart and national decreases, although the pace of disease began to level off in ‘professional men’ improvement has been slower. in the 1960s (Rose and Marmot, 1981) whereas More important now than the decrease in for working men it continued to rise. Over the overall mortality rates, is the inequality gap in last 40 years, although mortality from coronary coronary heart disease mortality. Figure 6.1.2 heart disease has decreased dramatically, the illustrates that the relative inequality gap in relative gap in coronary heart disease mortality circulatory disease mortality has not decreased between the most disadvantaged and least in Brighton and Hove and the relative gap is disadvantaged groups has widened. projected to increase. This is discussed more fully Figure 6.1.1 illustrates how mortality from in the Inequalities chapter.

Figure 6.1.2: Circulatory disease mortality in people aged under-75, absolute and relative inequality gap between the least and most deprived quintiles in Brighton and Hove. Brighton and Hove 1999-2001 to 2006-08, with trajectories to 2009-11

180 250%

Most deprived Progress 1999-2001 to 2006-08: quintile A fall of 10.4% in the absolute gap 160 An increase in relative gap from 105% to 164%

200% ion under 140

120 78.2 150% 100 75 years 80 70.0

100% Relative inequality gap 67.5 60 Least deprived quintile

40 Absolute inequality gap 50%

Age standardised mortality rate per 100,000 populat 20 Relative inequality gap

Actual Data Projected Data 0 0% 1999-01 2000-02 2001-03 2002-04 2003-05 2004-06 2005-07 2006-08 2007-09 2008-10 2009-11

3 year average

Source: Office for National Statistics Vital Statistics and Office for National Statistics Mid Year Population Estimates

127 CHAPTER 6 ILL HEALTH IN BRIGHTON AND HOVE

The Sussex Resuscitation Ambulance Service Inside a Sussex Resuscitation Ambulance

Both sourced from previous Medical Officer Annual Reports

6.1.2 Measures to tackle lifestyle determinants coronary heart disease. coronary heart disease in The Annual Reports of Dr Glen Williams in the late 1980s and 1990s are strong on lifestyle Brighton and Hove measures to curb mortality from coronary heart The work of Dr Parker and his colleagues on disease and similar measures have featured improving ambulance services for residents was prominently in subsequent reports – including laudable, but there are few details in Medical this one. Officer Reports with regard to measures that There is a national target to reduce might prevent heart disease; notably smoking, coronary heart disease mortality rate by 40% diet and exercise - for this evidence was just by 2010 (based on Health of the Nation starting to emerge in the 1970s. baseline figures from 1999) (see Figure 6.1.1). It is only really in the 1980s that we see In Brighton and Hove we met this target five public health measures being taken to tackle the years early, though in this respect we were by

Figure 6.2.1: Area covered by Sussex Cancer Network

Source: Sussex Cancer Network, 2009

128 CHAPTER 6 ILL HEALTH IN BRIGHTON AND HOVE no means unique. Coronary heart disease and for general practitioners for treating different cancer remain the two most important causes of income groups or particular groups who may be premature mortality (under 75 years) across the at an increased risk from coronary heart disease, country. So, there is still plenty to do. and who may be least likely of all to come Recently, there have been efforts to forward to take part in such initiatives. improve the diagnosis and management of hypertension, diabetes and hyperlipidaemia 6.1.3 Summary (high levels of fat in the blood) – all of which are Coronary heart disease emerged as a major known to be associated with premature death cause of death in the 20th century though it from coronary heart disease. These efforts are was some time before any links to lifestyle were organised through what is called the national made. In the last 20 years or so, there has been Quality and Outcomes Framework (QOF) for a sustained decline in deaths. general practice, whereby GPs are rewarded Most people are aware of most if not all for reaching certain diagnosis and treatment of the lifestyle risk factors but there are still targets. There are other local Primary Care Trust consistently higher rates of adverse lifestyle initiatives including Local Enhanced Services factors in lower income groups. It is not enough (LES) which seek to do the same. Compared to simply to tell people the facts and then sit longer term lifestyle measures, these efforts to back and expect them to change. This was improve the take up of preventive treatments the approach taken with obesity in the 1980s may yield results sooner. and it failed miserably. We have to make it as There are plans to introduce a new national easy and as rewarding as possible for people programme called NHS Health Checks by 2013. to change. We also have to provide the Adults aged 40 to 74 years will be invited to encouragement and incentives for those whose attend for a check every five years with the aim role it is to deliver healthcare – both preventive of identifying their risk of coronary heart disease and treatment - to do so preferentially for those as well as stroke, diabetes and chronic kidney most at risk. The real challenge now in coronary disease. They will then be offered advice and heart disease is stopping relative inequalities in support to reduce any risk. Those found to be coronary heart disease from increasing. at high risk will be offered appropriate medical therapies, for example ‘Statin’ drugs, which reduce the level of cholesterol in the blood. Recommendations The Primary Care Trust should continue to In Brighton and Hove, a ‘Health, Work and monitor closely the progress with mortality from Wellbeing’ programme is aimed particularly at coronary heart disease with a particular focus on men aged over 40 years in manual occupations health inequalities. in more deprived parts of the city. Currently The Primary Care Trust should explore however, there is no differential remuneration

Table 6.2.1: Breast screening uptake in East Sussex, South East Coast Strategic Health Authority and England between 1998/99 and 2008/09 98/9 99/00 00/1 01/2 02/3 03/4 04/5 05/6 06/7 07/8 08/9 East Sussex 77 77 78 77 77 79 76 77 78 71 68 SECSHA 78 76 76 76 76 77 77 77 75 74 75

England 76 76 75 76 75 76 75 75 74 74 74 Source: NHS Information Centre, 2009

129 CHAPTER 6 ILL HEALTH IN BRIGHTON AND HOVE

ways of targeting health inequalities in local Early in the 20th century, radium came enhanced schemes, including those that aim to to be used for some ‘inoperable’ cancers. The reduce coronary heart disease. Medical Research Council in the UK had a strong interest and the Manchester System of dosage was developed at the Christie Hospital 6.2. Cancer and Holt Radium Institute in Manchester (Wellcome Trust, 2009). In Nazi Germany there were campaigns 6.2.1 A brief history of cancer to stop people smoking as it was thought that It was the French gynaecologist Recamier who tobacco was linked to lung cancer, but this had first described the invasion of the bloodstream little impact outside Germany. Later studies in by cancer cells in 1839, coining the word the 1950s and 1960s left little doubt (Wellcome ‘metastasis’ to describe the spread of cancer Trust, 2009). (Cancer Research UK, 2009a). The story of When Francis Crick and James Watson modern cancer treatment begins in the 19th cracked the DNA code in 1953 it became century as the introduction of anaesthetics, possible to better understand the causes of and then of antiseptics which made surgery cancer at a molecular level, and to devise new possible.

Figure 6.2.2: The incidence of cancer in Brighton and Hove, the Sussex Cancer Network and England

Brighton and Hove Sussex Cancer Network

Gynaecology Gynaecology

Female Thyroid Female Thyroid Breast Breast Male Male Pancreas Pancreas CNS CNS Skin Skin Urological Urological Haematology Haematology Colorectal Colorectal Lung Lung Prostate Prostate

125 75 25 25 75 125 125 75 25 25 75 125

Incidence per 100,000 Incidence per 100,000

England

Gynaecology

Female Thyroid Breast Male Pancreas CNS Skin Urological Haematology Colorectal Lung Prostate

125 75 25 25 75 125

Incidence per 100,000

Source: National Cancer Information Service

130 CHAPTER 6 ILL HEALTH IN BRIGHTON AND HOVE treatments. The last fifty years have seen an 6.2.3 Cancer in Sussex, and in explosion in understanding of cancer, with Brighton and Hove many new drugs (Cancer Research UK, 2009a). In Brighton, cancer first emerges as a concern Cancer itself remained something of in the Medical Officer’s Annual Report for 1957 a taboo subject for many years and health when Dr William Parker reflected on national campaigns about cancer were unusual in the lung cancer figures and a ministerial statement UK in the 1950s. Specialists and policy makers published in June 1957 linking cigarette smoking were wary of generating fear and panic and to lung cancer. “That so many can be allowed overloading the NHS. to die of a preventable disease is a lamentable It was in the 1980s that the profile of reflection on the cigarette habit. There is no breast cancer was raised as intimate accounts doubt that the figures bare correct and that by people who had suffered were published, cigarette smoking is linked with lung cancer”. paving the way for today’s openess (Wellcome Dr. Parker’s proposal to tackle smoking did Trust, 2009). not find support in the Council. Undeterred, he continued to highlight the links between 6.2.2 Cancer in the UK cigarette smoking and lung cancer and in 1970 In 2009, nationally, one in three people can reiterated his frustration urging the population expect to develop cancer at some point in their to reduce tobacco consumption if not through lives. Cancer rates increase with age and as abstinence, then “by shifting from cigarette life expectancy increases so will the incidence smoking to the pipe”. of cancer. As premature deaths from other Fifty years ago, in 1959, out of a total diseases become less common, so more people population of 160,000 in Brighton there were will develop cancer later in life. There are more 469 recorded cancer deaths of which 81 were than 200 different types of cancer, but four of lung cancer deaths in men (36% of all male them - breast, lung, large bowel (colorectal) cancer deaths) and 16 were lung cancer deaths and prostate - account for over half (54%) of all in females (7% of all cancer deaths in women). new cases. Breast cancer is the most common Today, there are around 650 deaths per year cancer in the UK. Treatment for breast cancer is from all cancers in Brighton and Hove of which among the most successful however, and cancer around 310 are in people aged less than 75 mortality is higher in men compared to women. years. There are around 79 lung cancer deaths Nationally, in the 30-year period between per year in men of which around 40 are in men 1977 and 2006, adjusting for our ageing aged less than 75 years. There are around 50 population, the incidence rate for cancer lung cancer deaths per year in women of which increased by 25%, with a 14% increase in men around 26 are in women aged less than 75 years and a 32% increase in women (Cancer Research (NCHOD, ICD10 C33-C34, 2006/7/8 data). UK, 2009b). UK cancer incidence trends over There are 31 cancer networks across the the last ten years have leveled off however, with UK and their geographical configuration is a slight decrease in men (by 1%) and a slight based upon acute hospital trust population increase in women (by around 2%). The highest coverage, rather than primary care trust or increases have been in people aged 15-34 years. local authority coverage. The Sussex Cancer However, the relatively poor performance of the network area is illustrated in Figure 6.2.1. One UK against many of its European neighbours of 31 Cancer Networks in the UK, it serves a in terms of cancer survival has led to a push to population of 1.1 million people. Of the 31 improve cancer detection and care in the UK. Cancer Networks nationally, Sussex has the 4th lowest incidence of cancer behind Surrey, West Sussex (Western part) and Hampshire (SWSH),

131 CHAPTER 6 ILL HEALTH IN BRIGHTON AND HOVE

Mount Vernon and West London Cancer for all cancers in 2006 was 361 per 100,000 Networks. persons. This is lower than the national When the data are adjusted to account for incidence rate of 383 per 100,000 persons; our ageing population in Sussex, the incidence of however it is the highest of the Sussex Cancer cancer has been falling steadily since 1998/2000. Network group, the average incidence rate The number of actual cases seen has actually across these being 347 per 100,000 persons. remained constant, however, because our Figure 6.2.2 compares cancer incidence population has increased in size and has aged. rates in Brighton and Hove with incidence rates Compared to the 30 other cancer networks in the Sussex Cancer Network and England. Sussex has good 5-year overall survival rates: The incidence of breast cancer, a cancer of 45% for men, and 54% for women, - about 5% relative affluence, is lower in Brighton and Hove higher than the national average. Survival data than in the Sussex Cancer Network area and are not adjusted for age, and Sussex does have nationally. The incidence rate of skin cancers the most elderly population of all the networks. (including malignant melanoma) is higher. The poorest survival rates across the Sussex The incidence rates for all other cancers are Cancer Network area are in pancreatic, lung, roughly comparable with those for England but stomach and oesophageal cancer, all of which generally worse than they are for the Sussex have a 1-year survival rate of less than 42% Cancer Network area. This is the result of the (Sussex Cancer Network, 2009a). relative affluence of our region compared to In Brighton and Hove, the incidence rate Brighton and Hove and the country as a whole

Figure 6.2.3: Age-standardised mortality rate per 100,000 population from cancer in under 75s, 1987/89-2006/08

180 England baseline, 141.4 160 England target, 113.0 140

120

100 Brighton & Hove baseline, 130.6 80 Brighton & Hove target, 104.5 60

England

Age standardised rate per 100,000 40 Brighton & Hove

20 Brighton & Hove trendline

0

9 1 6 0 5 6 9 0 8 90 /9 93 94 97 98 99 0 02 0 0 07 0 1 / / / / / 9/ 8/ 90 6/ 01 5 6/ 8 /89/ 93 /94/95 /95/9 99/ / /02/03 /04 /0 0 /08/ 0 09/10/11 87/ 88 89/ 90/91/9291/92/ 92/ 93 94 95/9 96/97/ 97/98 98/ 99/00/0100 01 02/03/0403 04 05/ 06/07/0807 08/

3 year average

Source: Office for National Statistics Vital Statistics and Office for National Statistics Mid Year Population Estimates

132 CHAPTER 6 ILL HEALTH IN BRIGHTON AND HOVE

(Sussex Cancer Network, 2009a). 6.2.4 Screening for cancer in The mortality rate for ‘all cancers’ in Brighton and Hove people aged less than 75 years is higher in Brighton and Hove than in England. In fact, as Breast Cancer is shown in Figure 6.2.3, the cancer mortality There is a 35% reduction in mortality from rate in Brighton and Hove had actually been breast cancer among screened women aged increasing over the past few years although the 50 - 69 years old. It has been estimated that latest figures show a return to a decline. This is the national breast screening programme saves despite meeting national waiting time targets 1,400 lives each year. Women aged between and complying with National Institute of Clinical 50 and 70 years are invited for a mammogram Excellence (NICE) Guidance on Improving every three years although this is to be Outcomes. The poor recent mortality rates extended to women between 47 and 73 years mean that we may fail to reach the national with full implementation by the end of 2016. target agreed in the 1990s of “Reducing Locally, the breast screening programme is mortality from cancer by at least 20% in people East Sussex wide. In November 2008, the unit aged under 75 years by 2010”. moved to new premises with modern digital technology. Brighton and Hove women are

Figure 6.2.4: Cancer mortality in people aged under-75, absolute and relative inequality gap between the least and most deprived quintiles in Brighton and Hove. Brighton and Hove 1999-2001 to 2006-08, with trajectories 2006-08 to 2009-11

180 100% Most deprived quintile 160 90%

80% ion under under ion 140 59.6 66.3 70% 120 69.7

60% 100

50%

75 years 75 80 Least deprived

quintile 40% gap inequality Relative

60 30%

40 Absolute inequality gap Progress 1999-2001 to 2006-08: An increase of 16.8% in the absolute gap 20% Relative inequality gap An increase in relative gap from 60% to 79%

Age standardised mortality rate per 100,000 populat 100,000 per rate mortality standardised Age 20 10%

Actual Data Projected Data 0 0% 1999-01 2000-02 2001-03 2002-04 2003-05 2004-06 2005-07 2006-08 2007-09 2008-10 2009-11

3 year average

Source:Office for National Statistics Vital Statistics and Office for National Statistics Mid Year Population Estimates

133 CHAPTER 6 ILL HEALTH IN BRIGHTON AND HOVE

screened on this site. Historically, the service invited every five years until their 65th birthday. has had high uptake and above average clinical It is estimated that the cervical screening performance. However, coverage has fallen in programme saves approximately 4,500 lives per recent years with the result that the screening year in England. interval has increased. The main reason for this The national target is for 80% of women has been difficulty in recruiting and retaining to be screened but uptake has fallen in recent staff, combined with the need to incorporate years. Uptake is particularly low for the 25-34 two mammograms for each woman. year age-group. Uptake in Brighton and Hove Nationally, screening performance by at March 2009 was 75.4% - a slight increase Primary Care Trust is reported on an annual from 75.1% in March 2008 but much down basis. The visiting pattern of the mobile units from the high of 82.8% in 2002. determines the sequence in which women Uptake is also lower among lower socio- are invited for screening. The data therefore economic groups. In 2005, the uptake among need careful interpretation, as the date of last of women living in the most deprived quintile screening will depend on when the mobile of the city was 71.3% compared to 80.3% in units last operated in a particular area. The the most affluent quintile. breast screening coverage (the percentage of The national Cancer Reform Strategy set eligible women screened within the previous 36 a target of reporting results back to women months) for the year ending 31st March 2009 to two weeks by 2010. Local data show that for women aged 53 to 70 years in Brighton and in August 2008 approximately one third of Hove was 68%. women received their results within two weeks, However, by the end of November 2009 and the remainder received their results within the screening programme had offered screening four weeks. This compares with only 5.4% to all eligible women in Brighton and Hove in of women receiving their results within two the previous three years. The current screening weeks in August 2007. The main reason for round length for the remainder of the women in this dramatic improvement was introduction of the East Sussex programme however, is still more Liquid Based Cytology as the sampling method. than 36 months, but set to decrease soon. It is also worth mentioning the Human Table 6.2.1 shows breast screening uptake Papillomavirus (HPV) vaccination programme for across the entire East Sussex, Brighton and school girls aged 12 to 13 years, which began Hove, the South East Coast Strategic Health locally in September 2008. The aim of this Authority and nationally over the last 10 years. vaccination programme is to prevent cervical A number of actions have been taken to cancer by preventing infection with Human improve coverage. These include; new premises, Papillomavirus – the virus responsible for most new Saturday morning screening sessions, cervical cancers in this country. It will, however, extra radiologist sessions, recruitment of new be several years before the programme begins staff (although the unit still remains 2.75 whole to have an impact on women’s health so the time equivalent (WTE) radiographers below cervical screening programme remains of prime recommended levels) and a programme of importance. promotion of the service. In both cervical and breast cancer there is an active health promotion campaign in the city Cervical Cancer to reduce health inequalities by encouraging All women aged between 25 and 49 years uptake by younger women, women from lower registered with a GP are routinely invited to income groups, the black and minority ethnic have a cervical cytology screening test every community, the lesbian community and people three years. Women aged 50 are routinely with disabilities.

134 CHAPTER 6 ILL HEALTH IN BRIGHTON AND HOVE

Bowel cancer 6.2.5 Cancer and health The bowel cancer screening programme currently offers screening every two years, to inequalities Lung, head and neck, stomach, oesophageal men and women aged 60-69 years. Screening and bladder cancers are more common in test kits are posted to eligible people and more deprived groups (Sussex Cancer Network, those with screen-positive results are referred 2009a). These cancers have all been linked for endoscopy. From November 2010, the to smoking. Alcohol is also thought to be a programme will be extended to people aged factor in head and neck, oesophageal and liver less than 75 years. It is estimated that the cancer. Other possible mechanisms for the bowel cancer screening programme will reduce association between cancer and deprivation mortality from bowel cancer by 15%. include patients presenting with symptoms at a Bowel cancer screening began in Brighton later stage; poorer uptake of cancer screening, and Hove in November 2008. There are poorer access to diagnostic and treatment approximately 30,000 people aged 60-74 years services; and the presence of multiple health in Brighton and Hove, 21,000 of whom are issues (co-morbidities) that make survival less aged 60-69 years. As of June 2009 the uptake likely (Hughes et al 2006). of the programme was 50%. Some cancers are found more commonly in more affluent groups. These include malignant melanoma, breast cancer, prostate cancer, testicular cancer, male brain cancer,

Figure 6.2.5: Cervical screening uptake in Brighton and Hove by deprivation quintile and age group, 2005

100%

90%

80%

70% Percentage uptake 60% Quintile 1: MoreMost deprived

Quintile 2

Quintile3 50% Quintile 4

Quintile 5: Least deprived

40% 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64

Age band

Source: Primary Care Support Services and Index of Multiple Deprivation 2007

135 CHAPTER 6 ILL HEALTH IN BRIGHTON AND HOVE

male non-Hodgkin’s lymphoma and male Through the astute work of some of the myeloma. For melanoma this may be a result Public Health Team, Brighton and Hove received of increased exposure to the sun. The link “National Awareness and Early Diagnosis between affluence and breast cancer may Initiative” (NAEDI) funding to implement a local reflect different reproductive behaviour, such project with a number of initiatives aimed at the as late first pregnancies, and higher uptake of prompt recognition of cancer symptoms and mammograms leading to more detection. signs. Improving early diagnosis and treatment Overall however, it is estimated that if the offers the opportunity, if not to prevent cancer, entire Sussex Cancer Network population had at least to minimise its consequences. the incidence rates of the most affluent group, One notable feature of cancer care in there would be approximately 14,300 fewer recent times, including 2009, has been the cancers each year (6.2% of the total). (Sussex rising number of requests for life extending Cancer Network, 2009a). Whatever the cancer, drugs for patients with terminal cancer. These survival among those who fall ill is always poorer treatments typically extend life by a short in more deprived groups. period. The requests usually concern new Figure 6.2.4 shows a rather depressing drugs, that have not been fully researched, picture of poor progress both the absolute and often they concern patients with very rare and relative inequality gap in the total cancer cancers for which conclusive research might mortality rate in Brighton and Hove. This is in take many, many years. contrast to a national reduction in the absolute The National Institute of Clinical Excellence gap although the national relative gap has assigns a guide threshold figure of £30,000 increased, (See Chapter 7). per Quality Adjusted Life Year (QALY) although The suggestion that higher cancer death whether this figure should be raised is subject rates in more deprived areas may in part reflect to some debate (Towse and Raftery, BMJ 2009). poorer uptake of screening services is backed What this means is that if a treatment can up by local cervical cancer data. As is shown in extend life, at good quality, for one year, then Figure 6.2.5 approximately 10% fewer women the cost of that treatment should be no more in the most deprived group were screened for than £30,000. Some interventions, like smoking cervical cancer in 2005, compared to the most advice and treatment actually have negative affluent group. This difference is most marked QALY scores. What that means, is that by in the 50-54 years age group where the gap giving the advice to stop smoking, the general is 14%. practitioner is saving the NHS money. The National Institute for Clinical Excellence 6.2.6 Tackling cancer in has recommended that local committees give consideration to extending the QALY threshold Brighton and Hove beyond £30,000 for patients requiring end-of- Over the past three years, a Primary Care Trust life treatments. However, it often comes down funded Health Promotion specialist has worked to a matter of judgement, and not just with with particular communities to encourage regard to the individual patient, but also with screening uptake. Because of the time between regard to what treatments will not be funded as screening rounds, it is not been possible to say a result of spending health funds on relatively whether or not this post has been successful unproven end-of-life treatments. in encouraging screening uptake. To this end Given this uncertainty, it is important that the Primary Care Trust has taken a different wherever possible, there is consistency across approach focusing on certain groups and the region and wider country. There have been specific cancers such as young women and many attempts to do this; nationally with the cervical cancer.

136 CHAPTER 6 ILL HEALTH IN BRIGHTON AND HOVE creation of the National Institute of Clinical efforts to promote services are having a Excellence and Cancer Networks and locally positive effect. with advisory bodies such as the South East Coast Health Policy Support Unit. This work remains to some degree ‘work in progress’. 6.3 Mental health and suicide 6.2.7 Summary There is now an understanding of cancer that One in four people will experience a mental did not exist not so very long ago. Cancer health problem during their lives, and at any incidence and mortality rates in Brighton and one point one in six people is living with a Hove, although generally better than nationally, common mental disorder. Rates of mental ill do not compare favourably with the rest of the health have historically been high in Brighton South East Coast region. and Hove and this situation sadly persists to There have been some worrying local this day. This chapter has a particular focus on trends in cancer in recent years though the suicide - a devastating event with emotional last set of figures represented a return to and practical consequences for the family, improvement. The recent rise in mortality was friends and community. In Brighton and Hove examined in detail and it was not possible suicide rates have been high for most of the to pin this down to any one or few cancers. 20th and 21st centuries. In keeping with the Inequalities in cancer mortality, both absolute theme of this report then, there are lessons to and relative show little change. be learned in looking forward, by first taking a A number of initiatives point to potential good look back. improvements in cancer mortality. The new bowel cancer screening programme, better targeting of risk groups, improvements in breast 6.3.1 A brief history of mental screening facilities, and in particular the focus illness services in Brighton on initiatives to improve early diagnosis and and Hove treatment. This will not be at the expense of Historical accounts of changing mental health longer term programmes, in particular smoking treatment in 19th and 20th century England cessation programmes, whose purpose is to focus on London-based facilities such the prevent cancer from ever occurring. In the Tavistock clinic and the Maudsley Hospital. end, the prevention of cancer must remain the These facilities introduced new ways of treating primary public health objective. mental ill health. They rejected the ‘English Lunacy Laws’ in relation to ‘pauper patients’. Recommendations In Brighton, the pioneering work of Dr Cancer mortality trends should be monitored Helen Boyle saw the establishment of a unique closely to ensure that the recent improvement in-patient facility that preceded the Maudsley by continues. almost 20 years. The Lady Chichester Hospital New initiatives introduced to improve early opened in 1905, and offered charitable care for recognition, referral and diagnosis of cancer ‘nervous disorders in women and girls’. Dr Boyle should be evaluated at the earliest possible set out to care for people with recoverable stage to make sure that they are having the conditions outside of the asylum system. desired impact. Lady Chichester Hospital remained in Hove The breast and cervical screening until the 1980s when it was converted into a programmes should remain under review to Community Mental Health Centre and renamed ensure that improvements are continuing and Aldrington House, which still stands today.

137 CHAPTER 6 ILL HEALTH IN BRIGHTON AND HOVE

Dr Parker, Medical Officer for Brighton services included: the Downs View Training and and Hove during the 1950s and 1960s, was Occupation Centre; Coldean, which opened the first local Medical Officer to emphasise its doors to 40 adults and 60 children suffering the importance of mental health. He promised with mental health issues in 1962; a mixed the Mental Health Act of 1950 with its shift 20-bed day hospital for elderly mental health to “prevention and home treatment... treated patients which opened in Bevendean in 1968; in the future the same way as physical illness” and the development of day and inpatient He also recognised just how common mental provision at Brighton General Hospital in illness is. “It cannot be forgotten that one in 1978. Other new services included hostels for fifteen of the population will at some time the temporary care of former mental health need care from the Mental Health Service. patients, and rehabilitation centres. It has been The situation is in our midst today: it cannot suggested that these developments may have be coped with ostrich fashion by attempting had a significant effect in reducing the high to disregard it.” (Dr. Parker, Medical Officer of suicide rates in Brighton during the early to Health, 1960) mid-1960s (Jacobson and Jacobson, 1972). With this support, Brighton Corporation set out in the 1960s to move from traditional institutional care to community care. New

Figure 6.3.1: National and local trends in age standardised mortality rate from suicide and injury of undetermined intent 1901-2008

25

20

15

10 Age standardised rate per 100,000 5 Brighton / Brighton & Hove

National

0 1901 1906 1911 1916 1920 1926 1930 1936 1941 1946 1950 1955 1962 1966 1970 1975 1980 1987 1990 1990 2000 2004 2006 | | | | | | | | | | | | | | | | | | | 03 10 15 19 22 30 32 38 45 50 64 68 72 89 92 92 02 06 08

Period (years)

Source: Office for National Statistics Vital Statistics and Office for National Statistics Mid Year Population Estimates and Public Health Directorate Note: National data pre 1950 are for England and Wales, post 1950 for the UK; local data pre 1987 are for Brighton, post 1987 for Brighton and Hove.

138 CHAPTER 6 ILL HEALTH IN BRIGHTON AND HOVE

6.3.2 Suicide in Brighton and almost 20% in the previous 24 hours. Mental Hove in the 20th century health services, then, are in a position to help reduce the rate of suicide in Brighton and Although South East England as a whole has Hove – just as is suggested they did in the past a low suicide rate, Brighton and Hove has the (Jacobson and Jacobson, 1972). second highest suicide rate in England at 14.6 Although not consistently reported, suicide per 100,000 population (2006/7/8) just behind mortality data can be found dating back to the Blackpool at 15.4 per 100,000. Among men, early 1900s. Figure 6.3.1 shows that between Brighton and Hove has the third highest rate 1901 and 2008 the age-standardised mortality (18.9 per 100,000 men), behind Blackpool and rate from suicide fluctuated, although it was Torbay. Among women, it has the highest rate almost always higher locally when compared in England at 10.2 per 100,000 women. to the national rate. The first half of the 1960’s The city has been working towards a saw the suicide rate in Brighton peak at 22.6 national target to reducing the rate of death per 100,000 population. from suicide by 20% (from a baseline set in Throughout the century, there have been 1996/7/8 of 15.1 per 100,000 population) changing patterns to the age, sex and method to a mortality rate no greater than 12.1 per of suicides in Brighton. At the beginning of the 100,000 in 2009/10/11. This target was set 20th century there were on average 12 suicides in the National Suicide Prevention Strategy per year. The male: female ratio at this time (Department of Health, 2002): This was one of was 4:1, with highest rates in the age groups a number of national policy initiatives aimed at 25-35 years and 45-54 years. Women of this tackling of suicide. era commonly used poison or hanging, and Only a quarter of people who complete men used drowning, throat cutting or jumping suicide in Brighton and Hove are current or (referred to as ‘crushing’). recent patients of mental health services. In the 1920s, the number of suicides However, a recent local study of suicide victims increased, more than doubling between 1920 found that almost half of these had been in and 1929 from 13 to 30. Figure 6.3.2 shows touch with services in the previous week, and

Figure 6.3.2: Number of suicides in Males and in Females in Brighton during the 1920s

22 22 20 20 males females 18 18 16 16 14 14 12 12 10 10 8 8 6 6 4 4 Number of completed suicides Number of completed suicides 2 2 0 0 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929

Year Year

Source: Annual Reports of Medical Officer of Health for Brighton

139 CHAPTER 6 ILL HEALTH IN BRIGHTON AND HOVE

the 1990s, when suicide rates in young men started to increased. Jacobson and Jacobson (1972) report that a significantly high number of these 1960s suicides occurred in people from higher socio-economic classes. They also report that the most common method of suicide at the time, particularly in females, was toxic poisoning from drugs, barbiturates and other poisons (Figure 6.3.4). It is likely that the increased availability of illicit drugs during the 1960s influenced the suicide trend in Brighton. Jacobson and Jacobson (1972) also suggest that the isolation sometimes associated with retirement by the sea may have been a contributory factor. A newly erected sign on a known site of suicides “Brighton is a popular seaside resort for in Brighton the retired and semi-retired. Retirement brings Courtesy of Brighton & Hove City Council boredom, isolation and a declining élan for living. The rate of suicide in retirement areas how suicide increased dramatically in the 1920s must be high, when comparison is made with in Brighton. It was most common in men aged suicides classified as ‘retired’ in Brighton (32%) 45-55 years, and women aged 35-55 years. and Bristol (20.9%)” (Jacobson and Jacobson, The most common method among women 1972) was carbon monoxide poisoning resulting from The suicide rate fell and stabilised at the inhalation of coal gas. Coal gas, or ‘town around 12 per 100,000 in the early 1970s. gas’ as it was known, was used for heating. This decrease was reflected nationally (Ashford Unlike today’s natural gas, it contained carbon and Lawrence, 1976). Jacobson and Jacobson monoxide. As coal gas was phased out, the (1972) cite the development of mental health rise of the motor car saw carbon monoxide services as significant factors during this time, poisoning as a common ‘passive’ method of and the establishment of the first Samaritans suicide via the inhalation of car exhaust fumes. service in 1969. Figure 6.3.3 shows methods of suicides used Nationally, in the latter part of the 20th during the 1920s. century suicide rates began to rise once more in The collation of local data on suicide young men. During the 1990s, rates in young declined during the Second World War and only men aged 15-24 years were at their highest recovered in the 1960s when exceptionally high ever, and rates in men aged 25-34 years at their age-sex-standardised mortality rates occurred. A highest since the 1920s. Suicide accounted for new gender pattern emerged with higher rates about a fifth of all deaths in young men, and of suicide among females. In 1962, twice as led to suicide becoming a major contributor to many women completed suicide than men, and premature mortality. More broadly this trend in 1963, five times as many women completed is thought to indicate deteriorating mental suicide as men. It should be remembered that wellbeing in younger people. there were relatively high numbers of older This national pattern was mirrored in people, especially women, living in Brighton Brighton. A 1989 medical audit of suicide in at this time as is illustrated in Chapter 3. This Brighton found that 40% of suicides during this contrasts with today’s population structure and year had been carried out by men aged 21-40 the familiar suicide pattern which emerged in

140 CHAPTER 6 ILL HEALTH IN BRIGHTON AND HOVE years. Only 20% of suicides were completed by Fortunate as we are in Brighton and Hove women. The most common method for suicide to be able to look back a bit further, data from among men had shifted back to hanging. the last 40 years (Figure 6.3.1) would suggest The most common method of female suicide that the suicide reduction target will remain in 1989 was jumping. The Coroner’s records ‘challenging’. Based on an average of 38 people in 1989 show that of the 20 people who completing suicide in Brighton and Hove each completed suicide, 70% were unemployed. year, preventing 8 of these deaths for three This aligns with findings from studies of suicide consecutive years, would enable the target of rates in England which define the risk factors as 12.1 per 100,000 to be met by the year 2010 unemployment, divorce, substance misuse, and (Figure 6.3.5). There is no evidence to date that income inequality (Biddle, 2008). this is going to happen. Ten years later, Director of Public Health This is not due to lack of effort either in for East Sussex, Brighton and Hove, Dr Graham analysing trends, or in undertaking campaigns Bickler described how suicides and were and initiatives. The Brighton and Hove Suicide distributed within Brighton and Hove (Annual Audit (2003/4/5) analysed 119 suicides during Report of the Director of Public Health, 1998). this period. It showed that over half (51%) of The lowest standardised mortality rates were suicides were in people aged 18-44 years, and found in residents of Falmer and Moulsecoomb 67% were men. Almost one third were men (Bickler, 1998). The highest rates were recorded aged 44 to 60 years, which is relatively unusual in residents of the central and sea-front wards of compared to national trends which show that Pier, Montpelier, Queens Park and Regency. suicide in middle-aged men has decreased over The typical characteristics of coastal the last 20 years. towns and populations, discussed earlier in the Forty-one percent of people who took their Housing chapter, are likely to be contributory own lives in Brighton and Hove during 2003/4/5 factors. These include transient populations were unemployed, which compared to the often living in more socially excluded situations 70% found in the suicide audit of 1989. The (such as Houses in Multiple Occupation), current recession, if it results in high levels of relatively high levels of homelessness and unemployment, may see an increase in suicide. rough sleeping, drug abuse and alcoholism. It Residents who completed suicide were is sometimes suggested that people intent on more likely to; live alone (58%), be single, suicide come to the south coast – the Beachy divorced, separated or widowed (76%), and Head effect - and that this increases local have a primary diagnosis of mental illness suicide figures. In fact, suicides are assigned (87%; of these 45% had depression). Over one by residence status and not place of death: third also had histories of drug (30%) or alcohol a person would have to be registered as a (34%) dependencies. Figure 6.3.6 shows that resident of Brighton and Hove (typically this in the 21st century the dominant method involves having lived locally for 6 months or of suicide in men in Brighton and Hove was more) to be included in local figures. hanging, and in women drug overdose. These are also the most common methods nationally. 6.3.3 Suicide in Brighton and Brighton and Hove has a large lesbian, gay, bisexual and trans (LGBT) community. Hove in the 21st century While there is no conclusive evidence of higher The overall suicide death rate in England has suicide rates among the local LGBT community, been falling since the early 1980s and is now the National Suicide Prevention Strategy for the lowest on record. This is not the case, England now includes this group as a specific sadly in Brighton and Hove (14.6 per 100,000 group who require a targeted approach to population in 2006/7/8).

141 CHAPTER 6 ILL HEALTH IN BRIGHTON AND HOVE

promoting mental wellbeing. assessing suicide risk and the identification of In 2009, a complete review of the Suicide suicide hotspots with measures to adapt these Prevention Strategy was undertaken in Brighton (fencing, signposting) to discourage suicide and Hove and an action plan developed. is reviewed regularly. The local newspaper, Progress against planned measures such as the Argus, has also played a part and agreed publicity campaigns, support for primary care in to report suicides in line with Samaritans’

Figure 6.3.3: Percentage of suicides in Males and in Females in Brighton by method during the 1920s

Source: Annual Reports of Medical Officer of Health for Brighton

142 CHAPTER 6 ILL HEALTH IN BRIGHTON AND HOVE guidelines in order to reduce the risk of rates in Brighton and Hove have reduced by copy-cat suicides. only 4% from the baseline target, and not at all over the past 50 years. There would need to be 6.3.4 Summary a dramatic improvement therefore to meet the Suicide rates in Brighton and Hove have 2010 target of a 20% reduction on 1995/6/7 historically been higher than the national rates. figures. History suggests that this is unlikely. The reasons for this are various and the pattern This should not deter us of course from of suicide has changed over the years. Suicide making a continued effort to address what

Figure 6.3.4: Percentage of suicides in Males and Females in Brighton by method, 1965

Source: H.M. Coroner for Brighton’s records cited in Jacobson and Jacobson, 1972 Note: ‘Precipitation’ can be interpeted as jumping from a high place.

143 CHAPTER 6 ILL HEALTH IN BRIGHTON AND HOVE

is the most important cause of premature noted by the Royal College Psychiatrists (2009), mortality in young men. Data suggests that is yet to be fully understood. prevention efforts should focus on men aged over 40 years, men aged 18-44 years with a Recommendations history of substance and alcohol misuse, and A newly revised suicide prevention strategy those with pre-existing mental health issues. is now in place with a multi-agency group The prevention and treatment of alcohol overseeing its implementation. The strategy and substance misuse can reduce suicide rates. group should continue to monitor rates and The high numbers of residents living in Houses discuss lessons learned from individual cases. in Multiple Occupation present an addittional The strategy group should review funded suicide risk. Continuing to reduce homelessness initiatives and endeavour to assess the impact and rough sleeping in the city is important to of these. improving mental health and may help reduce The effects of the recession, and in suicide rates. particular changing employment patterns, Finally, the economic recession, if should be monitored closely to determine the accompanied by high levels of unemployment local impact on health. could increase in suicide rates, although the extent of the impact, as has been recently

Figure 6.3.5: Trends in age-standardised mortality from suicide and injury of undetermined intent in Brighton and Hove, 1987/89 – 2006/08 with projection until 2009/11

18

16

14 Brighton & Hove baseline, 15.1 12

10 Brighton & Hove target, 12.1 8 England baseline, 9.2 6 England target, 7.3

Age standardised rate per 100,000 4 England Brighton & Hove 2 Brighton & Hove trendline

0

9 1 6 0 5 6 9 0 8 90 /9 93 94 97 98 99 0 02 0 0 07 0 1 / / / / / 9/ 8/ 6/ 01 5 6/ 8 /89/ 90 93 /94/95 /95/9 99/ / /02/03 /04 /0 0 /08/ 0 09/10/11 87/ 88 89/ 90/91/9291/92/ 92/ 93 94 95/9 96/97/ 97/98 98/ 99/00/0100 01 02/03/0403 04 05/ 06/07/0807 08/

3 year average

Source: Office for National Statistics Vital Statistics and Office for National Statistics Mid Year Population Estimates

144 CHAPTER 6 ILL HEALTH IN BRIGHTON AND HOVE

6.4 Infectious diseases is on its way to being eliminated worldwide. In England, the recently introduced meningococcal When the NHS was established in 1948 several C infection vaccination programme has been vaccines were already in use. Smallpox vaccine remarkably successful. Prior to the vaccine’s had its origins in the 1700s. BCG (tuberculosis), introduction in November 1999 around 1000 and vaccines against cholera and typhoid cases of Group C meningitis and septicaemia developed in the early 1900s, and diphtheria were recorded in England and Wales every year. vaccine was introduced in 1942. These resulted in over 100 deaths per year. The national vaccine programme has Latest figures show that there were only 13 continued to expand and in a few decades cases of Meningitis C in 2008/09 compared to we have moved from a country where every 955 in 1998/99 - a decline of 99% largely due year, deaths and permanent disability from to the use of meningococcal C vaccine (Health a wider range of infectious diseases were Protection Agency Press Release 23 November commonplace, to one where such diseases have 2009). almost disappeared (Table 6.4.1). The year 2009 was an unusual year for Vaccination is undoubtedly one of the infectious disease outbreaks in Brighton and most cost-effective public health interventions. Hove. For the first time in 40 years there was a Smallpox has been eradicated and poliomyelitis pandemic flu outbreak. More discreetly, but in

A case of diphtheria in Brighton in 1932 In1932, aged seven, I was collected by a kindly man who carried me downstairs and took me off in an Isolation Ambulance, known as the Tin Lizzie to Brighton Borough Hospital. He wore a dark uniform, a cap and leather leggings. My mother was crying and I asked why – she told me she was really crying tears of laughter. On arrival I was put into a bed and I saw a couple arrive carrying a small child and then leave in tears. You started off with one pillow, then two and finally three when you had recovered sufficiently. I remember one injection with a very large needle Young Maurice which went into my thigh. I was the youngest on the ward and was bullied as Packham Courtesy of Maurice a result. The food was dreadful and I remember a nurse feeding me bits of fish Packham mixed with potato and butter. Every night we had a black draught and were given a sweet afterwards. When I was mobile, I was given jam and tea along with another boy but I was so hungry that I stole one of his slices. “Packham has stolen a bread and jam!” went up the cry. You were always called by your surname. I found myself in disgrace though no Mr. Bumble appeared to mete out justice. Visiting time was Sunday afternoon and my mother would appear, sometimes with my brother George on the balcony outside. The window wasn’t opened and we had to shout. On the other side of the ward the window overlooked the cemetery. I remember the last meal I had there. I thought it had been given to me by mistake as it was so much better than the usual fare. Even so, when I arrived home I ate a cake my mother had Brighton Borough Hospital, later baked specially for me ravenously. Oddly, when I drank some Bevendean Hospital, milk, it came back through my nose.

145 CHAPTER 6 ILL HEALTH IN BRIGHTON AND HOVE

many ways more disheartening, for it is entirely The benefits of improved living standards preventable, was the first measles outbreak in combined with vaccination means that most of the city for over 20 years. This section of the the illnesses that threatened the likes of young Report focuses on these two infections and is Maurice Packham and his mother in the past split into two corresponding sections. can now be eliminated. Measles is one of the most contagious infectious diseases and can have severe SECTION A: MEASLES consequences. Across the globe, in the 21st century, measles is estimated to kill 540 children every day. Outbreaks were common in Brighton 6.4.1 Measles in Brighton in the 19th and 20th century (Figure 6.4.1). and Hove Even as late as 1967 there were 2,564 recorded There are certain features of the population cases of measles in Brighton and it was not of Brighton and Hove which help define the unusual for a measles death to be recorded. characteristics of disease seen in the city. Not Following the measles vaccine introduction commonly documented, but certainly important in the UK in 1968 numbers fell although there in the spread of infection, is the significant continued to be several hundred cases every proportion of residents in the city who are year in Brighton due to inadequate vaccine sceptical about the value of vaccination - in uptake. The combined measles, mumps and particular with regard to the measles, mumps rubella (MMR) vaccine was introduced in 1988, and rubella vaccine. and cases of measles in Brighton Health District, Infections feature heavily in the Reports of which then covered Brighton, Hove and Lewes, former Medical Officers of Health and in the fell from 279 recorded cases in 1989 to just 39 past outbreaks were common and mortality cases in 1990. high. The local residents lived in fear of the consequences of certain infections.

Figure 6.3.6: Method of suicide in Brighton and Hove according to coroner’s verdict during 2003/4/5, based on 119 suicides

35 35

30 30 Males Females 25 25

20 20

15 15

10 10

5 5 Number of completed suicides Number of completed suicides 0 0 1 2 3 4 5 6 7 8 9 10 11 12 13 1 2 3 4 5 6 7 8 9 10 11 12 13

Source: Brighton and Hove Suicide Prevention Strategy 2008-2011 (data from Brighton and Hove Suicide Audit, 2003/4/5)

146 CHAPTER 6 ILL HEALTH IN BRIGHTON AND HOVE

6.4.2 MMR vaccination Vaccine scares are not uncommon and a Prior to the introduction of measles similar event took place with regard to pertussis immunisation in the late 1960s, there were vaccine in the 1970s. It took many years for regular measles epidemics and measles deaths vaccine coverage to recover. (Figure 6.4.2). This is not a picture typical of all infectious diseases. For example, in the case of 6.4.3 A 21st century measles tuberculosis, improved living standards have outbreak probably played a much greater role in reducing Measles is very contagious and requires a infection rates than has the introduction of the population immunity of over 90% to halt BCG vaccine (McKeown, 1988). disease spread. A slight increase in measles Following the publication of a paper in cases in 2007 and 2008 was followed by a 1998 in the Lancet by Dr Andrew Wakefield dramatic increase in March 2009. With the suggesting a link between measles vaccine and proportion of the local eligible population autism, and subsequent press coverage, where who had completed two doses of MMR Dr Wakefield implicated the combined measles, immunisation at 62% in 2007/8 and a mumps and rubella (MMR) vaccine, uptake of large cohort of children and young people the vaccine fell dramatically. Subsequently, these unprotected it was only a matter of time before limited findings have been disproven many an outbreak occurred (Figure 6.4.4). times over, and Dr Wakefield himself personally Among those who fell ill, were some very discredited. Nevertheless, the damage was young children aged less than 12 months. done and vaccination levels across the country Very young children rely entirely upon plummeted including in Brighton and Hove immunity passed from mother to infant and (Figure 6.4.3). on population immunity levels. Most of the

Table 6.4.1: The effect of vaccinations on the incidence of infectious diseases in the UK Disease Before vaccination Baseline year After vaccination (number of (number of annual cases) annual cases in 2008)

Diphtheria 46,281 1940 6 Hib 655 1989 67 Measles 409,521 1940 1,445 Mumps 20,713 1989 2,625 Pertussis 53,607 1940 1,028 Polio 1066 1940 0 Rubella 24,570 1989 31 Congenital Rubella Syndrome 73 1971 2 Tetanus 19 1969 5

Source: Health Protection Agency Centre for Infections, 2009

147 CHAPTER 6 ILL HEALTH IN BRIGHTON AND HOVE

children who contracted measles however Informal reports since the outbreak were older and even some young adults suggest that vaccination levels are improving, were affected reflecting the poor vaccination however it is more than unfortunate that coverage for many years. is seems to have taken the outbreak of a Several schools were affected with the serious disease, and the admission of several ill highest numbers in Stanford Infant, Stanford children to hospital to convince some parents Junior, Varndean and St Bartholomew’s and of the merits of vaccination. In some respects Balfour Junior schools. Whilst there were vaccination is a victim of its own success. For 69 cases confirmed by serology, there were as these diseases have begun to disappear and a similar number of probable cases. It is stories like those of Maurice Packham become estimated that over 100 children and young more and more unusual, the ill effects (and risks people contracted measles. Twelve children – real or imagined) of vaccine administration were ill enough to be admitted to hospital become bigger factors in parents’ decision and some required intensive support; two making. Some people make the erroneous children remained in hospital for over 10 days, assumption that good nutrition and healthy confirming if it needed to be, that measles is a living are sufficient protection. Others question serious illness. Just one of the confirmed cases how ‘natural’ it is to vaccinate children. had completed the two dose regime of MMR The publication of scare stories may sell vaccine (Figure 6.4.5). newspapers, but just adds fuel to the flames.

Figure 6.4.1: Death rate per 100,000 population from measles, Brighton, 1869-1904

160

140

120

100

80

60

40 Measles deaths per 100.000 population 100.000 per deaths Measles 20

0 1870 1874 1879 1883 1888 1892 1896 1900 1904

Year

Source: Medical Officer’s Report, Brighton and Hove, 1904

148 CHAPTER 6 ILL HEALTH IN BRIGHTON AND HOVE

6.4.4 Improving vaccine uptake You cannot reason someone out of a A host of measures have been undertaken in position they have not reasoned themselves recent years in an attempt to improve local into (Ben Goldacre, 2008) and it may be that, vaccination rates. Over the last two years the for some parents, the concept of vaccination Primary Care Trust employed an MMR Nurse means something much more than simply whose role has been to support fellow health protecting their children from harmful infectious professionals and also offer advice directly to disease. While a few may be convinced by families whose children did not come forward sound scientific argument, and others reverse for vaccination. This post has had some success, their decision when faced with actual evidence but not to the extent that an outbreak of harm such as an outbreak, some will never was avoided. change their mind. In fact, some parents Research funded by the Primary Care Trust whose children were seriously ill with measles and conducted by the University of Sussex in Brighton and Hove in 2009 still insisted to Anthropology Department (Cassell et al., staff that this was somehow better than the 2006) has shown that the reasons why some alternative of vaccination. parents do not support vaccination stem from Single dose vaccinations are not available longstanding and ingrained attitudes to a through the NHS for parents who would accept number of health issues - which are not this option but who will not accept the MMR easily reversed. vaccine. There are several reasons for this. It would expose children to six injections as

Figure 6.4.2: Notifications and deaths from measles in England and Wales, 1940-2008

800 1,400

700 1,200 Measles Notifications vaccine Total Deaths 600 1,000

500 800

400 MMR vaccine 600 300 Number of deaths MR Number of notifications of Number catch-up 400 200

200 100

0 0 1940 1945 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005

Year Source: Office of National Statistics Note: Measles vaccine first became available in 1963, with an improved vaccine in 1968

149 CHAPTER 6 ILL HEALTH IN BRIGHTON AND HOVE

opposed to two with the higher risk of default. that in the 21st century in a developed country Six injections would mean that children were an outbreak should have occurred, and that exposed to potential infection over a longer several children were unnecessarily very ill. period. In addition, there is concern about The complex set of influences on whether the efficacy of some single vaccines. Even in or not to vaccinate raises questions of the cost Brighton and Hove, where some GPs have effectiveness of media campaigns. Nevertheless, privately offered single vaccination, there have parents need to have accurate information been instances where the single vaccines have and the chance to discuss this in an open way been incorrectly stored and transported. In one (Hilton et al., 2007). current case, a further investigation is being We know very little about the local uptake considered because of concerns that patients of unlicensed single antigen vaccines. There is had been vaccinated with an ineffective single some national evidence that children receiving antigen vaccine as a result of poor storage. single vaccines do not receive all three antigens (Pearce et al., 2008) and some local evidence of 6.4.5 Summary poor vaccine storage. Vaccine preventable infectious diseases may The social inequalities in vaccine uptake not present the same risk today as they did 100 suggest that a range of interventions may or even 20 years ago, but they have not gone be required. For some parents who do not away. Measles is a preventable disease with a immunise their child at all, reminders of safe and effective vaccine and it is disheartening immunisation appointments and more accessible opportunities such as vaccination in the home

Figure 6.4.3: Uptake of 1st MMR dose by second birthday in Brighton and Hove (*includes Lewes)

100

90

80

70

60

50

40

30

20 First MMR coverage by second birthday (%) birthday second by coverage MMR First 10

0 2002/03 2003/04 2006/07 2007/08 2004/05 2005/06 2008/09 1991/92* 1990/91* 1992/93* 2001/02* 1993/94* 1997/98* 1998/99* 1999/00* 1989/90*

Year Source: NHS Information Centre, 2009

150 CHAPTER 6 ILL HEALTH IN BRIGHTON AND HOVE will be successful. For others, the process is SECTION B: PANDEMIC FLU likely to be more protracted and a decision will have to be reached as to whether or not further discussion is a waste of time and resources. 6.4.6 Pandemic flu in Brighton in the 20th century Recommendations The year 2009 saw the first flu pandemic for There should be more exploration of vaccination over 40 years. There were three flu pandemics champions. This could include school governors in the 20th century; in 1918-19, in 1957 and and teachers. The opportunities to work more in 1968. Pandemics are characterised both by closely with schools consequent of the measles the number and groups of people affected with outbreak should be followed up. young people the most vulnerable. There should be more work – such as The Spanish Flu of 1918-1919, which general practice surveys, to determine the actually appears to have emerged in the United extent of single vaccine use in the city. States, surpassed the death toll of the First World War, killing somewhere between 20 and 40 million people. The pandemic also took its toll in Brighton and Hove and local services sought to contain the effects, not always with the right measures. The Mayor of Brighton at this time, Alderman Herbert Carden J.P., offered some advice to

Figure 6.4.4: Number of confirmed measles cases (cumulative), Brighton and Hove, 2009

80

70

60

50

40

30

20 Number of confirmed cases (cummulative) 10

0 01- 11- 21- 31- 10- 20- 02- 12- 22- 01- 11- 21- 01- 11- 21- 31- 10- 20- 30- 10- 20- Jan Jan Jan Jan Feb Feb Mar Mar Mar Apr Apr Apr May May May May Jun Jun Jun Jul Jul

Date

Source: Health Protection Agency, 2009

151 CHAPTER 6 ILL HEALTH IN BRIGHTON AND HOVE

Brightonians in the Argus, on 17th July 1918: of very thorough washing-up at present. “It is a disgrace for anyone to be ill. All Thorough rinsing will remove the [flu] infection colds are caused by overeating. If you have a but plenty of water must be used.’ cold or ‘the flu’ all you have to do is stop eating However, it was reported that of 413 and drink hot water. If you will only fast you will licensed houses, 115 were without water get well very quickly.” supply and 123 had no fixed sinks. Well intentioned as he may have been, The 1957 ‘Asian’ flu pandemic which and responsible as he was for many positive emerged in February of that year in the Far East developments in Brighton, His Worshipful spread more quickly although the effects were Mayor Alderman Herbert Carden was not in less severe. As with the Spanish flu, infection tune with medical thinking of the day and got rates were highest among school children, it quite wrong. Medical Officer for Brighton, Dr young adults and pregnant women although Duncan Forbes documented the death toll in death rates were higher in the elderly people. Brighton totalling 367 flu deaths in 1918, and One million people were killed worldwide, a further 167 in 1919. Figure 6.4.6 shows that including 30,000 in the UK. The pandemic hit one quarter of flu deaths in Brighton were in Brighton over the Christmas break in 1957 and the 25-35 year old age group. on 27th December 1957 the Argus headline The influenza pandemic was a tragic event read: “Full Scale Asian Flu Epidemic hits in the lives of many of the residents of Brighton Brighton and Hove over Christmas”. Services and Hove including ‘Blind’ Harry Vowles. were affected, and in hospitals some 20% of Emergency measures were put in place to staff were off sick. Medical Officer for Brighton, combat the spread of Spanish flu. Dr Duncan Dr William Parker appealed to the population Forbes was exercised by a lack of hygiene to practise “home care and kitchen medicine” measures which were facilitating spread and (Parker, 1957). targeted publicans with advice: “With simple attention most people will ‘I am asking all publicans to give their be all right. They should go to bed, keep warm employees instructions as to the importance and take hot drinks and aspirin. They should

Figure 6.4.5: Vaccination status of confirmed measles cases, Brighton and Hove, as of 10th July 2009

Not entered 1 x MMR 7% 4% Not vaccinated Other 83% 17%

2 x MMR 2% Unsure 4%

Source: NHS Brighton and Hove Public Health Directorate, 2009

152 CHAPTER 6 ILL HEALTH IN BRIGHTON AND HOVE not trouble their doctor unnecessarily’ (Dr incidence was highest in children and young Parker, Medical Officer for Brighton and Hove, adults, although children aged less than 5 years 1957). Dr Parker also made a point of thanking were most likely to be admitted to hospital the local press for their “calm advice” in with complications. The outbreak peaked in the contrast to the “welter of near panic headlines” UK at Week 28 (October 2009) at 150 cases in the national press. per 100,000 population. This is actually much The 1968 pandemic gets little discussion in less than some seasonal flu outbreaks such as the Medical Officer Report of the time although the one which occurred in the winter of 1999 it is recorded that 102 people died in Brighton which peaked at 220 cases per 100,000 at from flu that year compared with just 13 the Week 52. previous year. A national awareness campaign was started, and a programme of antiviral medication distribution commenced in July 6.4.7 Pandemic flu in Brighton 2009. With great staff collaboration and a and Hove in 2009 sharing of costs between the Primary Care The flu pandemic of 2009 emerged from the Trust, City Council and Southdowns Health NHS Americas in early 2009. The first UK cases were Trust, Hove Town Hall opened as an Antiviral diagnosed on April 27th. Following a worryingly Distribution Centre. A national web-based high level of reported deaths in Mexico, the self-assessment tool allowed members of the relatively mild nature of the infection for most public to self-assess and present for receipt of people became apparent. medication without any medical consultation. As with other pandemic flu viruses, the Attendance for antiviral treatment peaked

Figure 6.4.6: Flu deaths in Brighton and Hove during the Spanish Flu pandemic of 1918-1919, compared with mean annual flu deaths 1890-99

100

100 90

90 80 1918 80 70 19191918

70 1919 60 1890-1899 average

60 1890-1899 average 50

50 40

Number of flu deaths flu of Number 40 30 Number of flu deaths flu of Number 30 20

20 10

10 0 0-5 5-15 15-25 25-35 35-45 45-55 55-65 65-75 75 0 0-5 5-15 15-25 25-35 35-45 45-55 55-65 65-75 75 Age band

Source: Medical Officer’s Report, Brighton and Hove 1919Age band

153 CHAPTER 6 ILL HEALTH IN BRIGHTON AND HOVE

in July with another much smaller peak in Hall. By the time a pandemic flu vaccine late October. In early December, the Antiviral offering 90% protection arrived the media Distribution Centre was stood down. and public were much less concerned and By January 2010 there had been 279 uptake of the vaccine has been low across the deaths across the country including one in country. The death of a local young child who Brighton and Hove. These figures were much was previously completely well was however, lower than was predicted at the start of the a reminder of the random nature of the H1N1 pandemic. The mild nature of the illness for swine flu virus. the vast majority of people, coupled with the sometimes tragic effects for a handful made for 6.4.8 Summary difficult planning for international organisations Flu pandemics occur at uncertain intervals such as the World Health Organisation, for and the course they run is unpredictable. The central governments, local planners and the terrible toll taken by the pandemic of 1918/19 media. As is shown in Figure 6.4.7, in Brighton has left us with an understanding of how and Hove, the volume of people presenting for deadly they can be. However, the last three antiviral treatment in July reflected the concerns pandemics of 1957, 1968 and now 2009 have being expressed across the country at the times been, by comparison, very mild. but these worries quickly dissipated. The very intensive approach taken in this During 2009, there were 9154 attendances pandemic is considered by some to have been a at the Antiviral Collection Point in Hove Town costly over-reaction. However, the low numbers

Figure 6.4.7: Number of courses of anti-viral issued per week at Hove Town Hall Anti-Viral Collection Point July 6th to December 6th 2009

1800 1800

1600 1600

1400 1400

1200 1200

1000 1000

800 800

600 600

400

Number of courses of antivirals issued 400 Number of courses of antivirals issued 200 200

0 0 28- 05- 12- 19- 26- 02- 09- 16- 23- 30- 06- 13- 20- 27- 04- 11- 18- 25- 01- 08- 15- 22- 29- 06- 13- Jun28- 05-Jul Jul12- 19-Jul 26-Jul Aug02- Aug09- Aug16- Aug23- Aug30- Sep06- Sep13- Sep20- Sep27- Oct04- Oct11- Oct18- Oct25- Nov01- Nov08- Nov15- Nov22- Nov29- Dec06- Dec13- Jun Jul Jul Jul Jul Aug Aug Aug Aug Aug Sep Sep Sep Sep Oct Oct Oct Oct Nov Nov Nov Nov Nov Dec Dec Week Ending Week Ending Source: NHS Brighton and Hove Public Health Directorate, 2009

154 CHAPTER 6 ILL HEALTH IN BRIGHTON AND HOVE of deaths that took place is undoubtedly partly attributable to the vast effort that was mobilised across the country, and many people would have been rightly upset if no treatment or vaccine had been made available and there had been avoidable deaths as a consequence. The pandemic is likely to remain a matter of debate for some time. Recommendations The population of Brighton and Hove should continue to receive balanced and informed medical advice regarding swine flu.

Blind Harry Vowles Source: MyBrightonandHove 2009

The influenza pandemic was a tragic event in the lives of many of the residents of Brighton and Hove including ‘Blind’ Harry Vowles, father of nine children and popular music hall and street musician singer with a reported fine tenor voice. He had a pitch where the Angel of Peace statue now stands. Harry spent a lot of time entertaining the troops stationed in Brighton but died from Spanish flu in 1919.

155 Photograph courtesy of The Royal Pavilion and Museums, Brighton & Hove City Council Brighton & Hove and Museums, Pavilion The Royal courtesy of Photograph 156 R CHAPTER SevenR Health Inequalities

7.1 National policy on health inequalities 7.2 Deprivation, health and coastal resorts 7.3 Infant mortality and health inequalities 7.4 Mortality rates and health inequalities 7.5 Life expectancy and health inequalities 7.6 Summary

157 158 Chapter 7 Health Inequalities

Reducing health inequalities is not a new these inequalities we must take urgent and concern, the crusading social and public health coordinated action – globally, nationally and reformers of the 19th and early 20th century locally – and we must build on the progress were fully aware of the impact of poverty on we have made so far” (The Prime Minister health, in particular the effects of housing, speaking at the ‘Closing the Gap Conference’, overcrowding and poor sanitary conditions. In November 2008). Brighton too, local Medical Officers recognised The rousing words of the Prime Minister all too well the health effects of socio-economic hark back to the birth of the Welfare State and conditions. In his 1905 Annual Report, Dr National Health Service when William Beveridge Arthur Newsholme, wrote “Poverty is at the pledged to defeat the Five Great Evils of Want, back of many of our sanitary difficulties... Ignorance, Squalor, Idleness and Disease and children suffer as a consequence of this fact.” Nye Bevin envisaged an NHS that in a few As has been seen throughout this Report, decades would make people so healthy, that while health has improved immeasurably there would be little need for doctors. The throughout the tenure of the city’s Medical holy grail of health, and health for all in equal Officers and Directors of Public Health, the measure, was almost a foundation stone of the problem of health inequalities has remained persistent. This final chapter looks at the history of health inequalities in Brighton and Hove, and examines how much these have changed over the last 150 years. This chapter also includes discussion on progress against national heath inequality targets and, in keeping with the style of early Medical Officers, some personal reflections on what it all might mean.

7.1 National policy on health inequalities

“To advance the cause of health for all, and to end these inequalities, these injustices, within a generation…that is the task we have set ourselves, and we must not bend in our resolve to see it through. It is an enormous challenge, Housing and health inequalities in Brighton but the prize is great: a healthier, more Courtesy of The Royal Pavilion and Museums, Brighton & Hove prosperous and fairer world… So to tackle City Council

159 CHAPTER 7 HEALTH INEQUALITIES

NHS and, judging by recent policy, it remains programme of action (DH, 2003), the Wanless very important. Report: Securing Good Health for the Whole The health of people in England has Population (Wanless, 2004), the Health and improved markedly over the last 150 years. Social Care Standards and Planning Framework: However, there are persisting health inequalities National Standards, Local Action (DH, 2004), that relate to gender, race, social status and the Public Health White Paper - Choosing geography. In 2006, a girl born in Glasgow Health: making healthier choices easier, (DH, could expect to 77 years of age while a girl 2004a), Commissioning a Patient Led NHS, (DH, born in Kensington and Chelsea could expect 2005), Our Health, Our Say, Our Care, (DH, to live to 88 years. Geographical inequalities 2006) and most recently with a focus on using such as these exist in Brighton and Hove where commissioning to reduce health inequalities - we find pockets of inequalities right down to World Class Commissioning (DH, 2008a). The street level. volume of policy initiatives perhaps reflects the A raft of policy initiatives underline the fact that inequalities haven’t reduced. government’s commitment to reducing health Along with policy initiatives have come inequalities: the Acheson Report (Acheson, targets: 1998), Saving Lives: Our Healthier Nation • ‘By 2010 to reduce by at least 10% the (DH, 1999c), the NHS Plan (DH, 2000), the gap between the fifth of local authority Cross-Cutting Review on Health inequalities areas with the lowest life expectancy at (DH, 2002), Tackling Health Inequalities: a birth and the population as a whole’.

Figure 7.1: Infant mortality rate in Brighton and Hove, 1901-2008

200

Brighton (Brighton and Hove in 2001) 180

e births) England 160

140 14 12 120 10 8 6 100 4 2 80 0 1981 1991 2001 2008

60

40

20 Infant mortality (number of infant deaths per 1000 liv 1000 per deaths infant of (number mortality Infant 0 1901 1911 1921 1931 1941 1951 1961 1971 1981 1991 2001 2008

Year Source: Registrar General, Annual Reports; Office for National Statistics Vital Statistics and Office for National Statistics Mid Year Population Estimates Note: More recent data involves small numbers of infant deaths; the average number per year for the last 10 years is 17, 2001 was the lowest with 8.

160 CHAPTER 7 HEALTH INEQUALITIES

• ‘To reduce the gap in all age all cause (IMD, 2007). If we compare Brighton and Hove mortality by 1% per annum over the with other large urban centres around the UK, five year period 2005-7 to our near neighbours – in deprivation terms 2009 to 2011’. include Huddersfield and Leicester. Policy initiatives to tackle coastal 7.2 Deprivation, health deprivation highlight the importance of promoting economic growth. and coastal resorts Deprivation has important effects on health, and not just for those who are most The health of people living in coastal towns deprived. The adverse effects impact even on the and cities is often worse compared to those better off. (Marmot and Wilkinson, 2006) High living inland. There are several reasons for this. differentials in wealth contribute to community- Seaside towns often share similar characteristics wide higher levels of premature death rates from such as geographical isolation, higher levels of cancer, stroke and heart disease as well poorer deprivation, a less diverse economy and lower health outcomes as measured by life expectancy quality housing (Donaldson, 2007). and infant mortality. The Index of Multiple Deprivation (IMD) positioned Brighton and Hove as the UK’s 28th most deprived city (out of 56) in 2004 (IMD, 2004), and the 29th most deprived in 2007

Figure 7.2: Infant mortality and health inequalities in Brighton and Hove in the last 100 years

Gp IV (remainder Group II Group III Group I includes families of Illegitimate (unskilled workers (artisans and their (poorest families) traders, business and their families) families) men & well-to-do) 200 8 1901-1912 180 2002-2007 7 ths Trendline, 1901-1912 160 Trendline, 2002-2007 6 140

5 120

100 4

80 3

60 2 40

1 births live 1,000 / 2001-2007 Rate Mortality Infant Infantile Mortality Rate 1901-1912 / 1,000 live bir live 1,000 / 1901-1912 Rate Mortality Infantile 20

0 0 1 2 3 4 5 IMD Quintile 1 IMD Quintile 5 IMD Quintile 2 IMD Quintile 3 IMD Quintile 4 (most deprived) (least deprived)

Source: Annual Reports of Medical Officer of Health for Brighton; Office for National Statistics Vital Statistics and Office for National Statistics Mid Year Population Estimates

161 CHAPTER 7 HEALTH INEQUALITIES

7.3 Infant mortality were some fluctuations and the economic depression of the late 1920s and the Second and health inequalities World War both caused short-term increases; the trend was however, relentlessly downwards. The key marker of the health impact of poverty As illustrated in Figure 7.1 infant mortality in Britain in the 19th and early 20th century decreased from 160 infant deaths per 1000 was infant mortality. Writing in 1924, Brighton live births in 1901, to 5 per 1000 in 2008. Medical Officer Dr Duncan Forbes asserted, Until recently Brighton and Hove has always “Many people take it for granted that the fall in maintained a lower infant mortality rate infantile mortality is due almost entirely to infant than England. welfare schemes. As a matter of fact... We know Figure 7.1 illustrates well by just how that general sanitation and standards of health much infant mortality has reduced over the last and social conditions have improved greatly, century with typically now less than 15 deaths and played a greater part in reducing infantile per year across the whole of the city. Happily, mortality than the intensive ad hoc work.” analysis of infant mortality on an annual basis From the mid 18th century, the life with a population the size of Brighton and Hove expectancy of children began to increase. The is no longer a very useful means of monitoring infant mortality rate continued to fall into the local population health inequalities as the 20th century with large reductions particularly numbers are so small, although collating data in the early third of the 20th century. There from several years can be helpful.

Figure 7.3: Circulatory disease mortality in people aged under-75, Absolute inequality gap in England 1993 – 2007 with projections to 2011

210

Spearhead group 200 1 Inequality gap in rate Actual data Target 190 1 The absolute gap between rate for England and rate for 180 Spearhead Group in deaths per 100,000 population. Target reduction for Spearhead Group (ie to achieve 170 ion under 75 years 75 under ion target reduction in gap given observed/ projected England rate). 160 36.7 Projection of CVD mortality for England (exponential 150 projection based on data for the 10 years 1999/2008).

140 England

130

120

110

100

90 Target: 40% minimum reduction in absolute gap, from 22.6 80 1995-97 baseline. 22.0 70

60 Age standardised mortality rate per 100,000 populat 100,000 per rate mortality standardised Age Baseline Target 500 1993- 1995- 1997- 1999- 2001- 2003- 2005- 2007- 2009- 95 97 99 01 03 05 07 09 11

3 year average

Source: Office for National Statistics Vital Statistics and Office for National Statistics Mid Year Population Estimates

162 CHAPTER 7 HEALTH INEQUALITIES

So, have local health inequalities, as figure), but even within those very high rates measured by infant mortality, decreased over there was a clear gradient of health inequality. the last 100 years? In 1913 Dr Duncan Forbes, Just as striking as the huge reductions in Medical Officer for Brighton, published a infant mortality across all social groups is the comparison of infant mortality during the clear gradient of health inequality that still period 1901 – 1912 across different social persists today. The population groups used then groups in the town. The findings of this analysis and now are not comparable, so it is impossible when compared to an analysis of infant to accurately calculate a precise change in mortality across similar social groups in the city the health inequality gradient: it may have today make for interesting reflection. These are diminished but a health inequality gradient illustrated in Figure 7.2. clearly remains. It should also be remembered In the first decade of the 20th century, too that if this small change is real, then it has for every 1000 children born in Brighton been over a timeframe of a century. Health to the most vulnerable group (illegitimate inequalities don’t vanish overnight and the mothers) 188 died before their first birthday: Prime Minister’s desire to vanquish them in a that is equivalent to nearly one in five children. generation is ambitious. This compared to an infant mortality rate of 67 per 1000 births in the so-called ‘well-to- do’ families. Both rates are huge by today’s standards (shown in the right-hand axis of the

Figure 7.4: Cancer mortality in people aged under-75, Absolute inequality gap in England 1993 – 2007 with projections to 2011

180

1 Actual data Spearhead group Inequality gap in rate Target 170 1 The absolute gap between rate for England and rate for Spearhead Group in deaths per 100,000 population. Target reduction for Spearhead Group (ie to achieve 160 ion under 75 years 75 under ion target reduction in gap given observed/ projected England rate).

Projection of Cancer mortality for England (exponential 20.7 150 projection based on data for the 10 years 1999/2008).

140 England

130

18.6 120 Target: 6% minimum reduction in absolute gap, from 1995-97 baseline. 19.5

110 Age standardised mortality rate per 100,000 populat 100,000 per rate mortality standardised Age Baseline Target 1000 1993- 1995- 1997- 1999- 2001- 2003- 2005- 2007- 2009- 95 97 99 01 03 05 07 09 11

3 year average

Source: Office for National Statistics Vital Statistics and Office for National Statistics Mid Year Population Estimates

163 CHAPTER 7 HEALTH INEQUALITIES

7.4 Mortality so we could see it levelling off. Other commentators would argue that it rates and health is the relative gap between the most affluent inequalities and most deprived groups that is important. Figures 7.5 and 7.6 illustrate what the previous One of the problems with health inequalities two graphs would look like if the measure of is proving whether or not they are actually inequalities was the relative gap rather than the decreasing. Figures 7.3 and 7.4 show the trend absolute gap. in the absolute inequality gap with regard to Nationally, the relative gap has not shown deaths in people aged less than 75 years from the same improvement as has the absolute gap. coronary heart disease and cancer respectively. Other academics would argue that the best In fact, nationally we are on target to meet measure is the slope of the line that measures the coronary heart disease target of a 40% the difference across the many different social reduction in the absolute gap by 2010. With groups (as shown in Figure 7.2) and not just the regards to cancer, we have already met the absolute or relative difference between those at inequality target of a 6% reduction with a fall the top and bottom of income scale. of 10.5% in the absolute gap two years before Irrespective of the dispute over whether or the target date. It should be noted however not we have reduced inequalities, we should not that this absolute inequality gap in cancer lose sight of the huge progress that has been deaths increased over the last three year period made at a total population level. In the UK, the

Figure 7.5: Circulatory disease mortality in people aged under-75, Relative inequality gap in England 1995 – 2007

17%

16%

15%

14%

13% Relative gap

12%

11%

10%0% 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 | | | | | | | | | | | 96 98 99 00 01 02 03 04 05 06 07 (Baseline) (Milestone period) 3 year average Source: Directly age-standardised mortality rates calculated by DH from Office for National Statistics death registrations and mid-year population estimates

164 CHAPTER 7 HEALTH INEQUALITIES age-standardised mortality rates for males and Comparisons with other parts of the country females in 2008, at 700 and 499 deaths per were not unusual in early public health 100,000 population respectively, were the lowest reports. Brighton Medical Officers and elected rates ever recorded (ONS, 2009). councillors were keen to demonstrate that People are healthier, both men and their town was a healthier place to live when women, and no matter where they live in the compared to other towns. In fact Dr Arthur country, they are living longer. Most academics Newsholme laments in his 1883 report that would probably argue that health inequalities he is disallowed from including better-heeled have not however, reduced. But by focusing on Hove residents when calculating local mortality a reduction on the ratio between the poorest statistics, commenting “The artificial separation and the most affluent, we may be setting of West Brighton from participation in the ourselves up for failure. This is because (for Registrar-General’s official figures renders the example) a theoretical ratio of 2000 infectious Brighton statistics only very partially comparable disease deaths in the poorest group and 1000 with those of other great towns who have the infectious disease deaths in the most affluent good fortune to include their suburbs within the group in the year 1809 would actually be more scope of their municipal boundaries.” ‘health equal’ than a ratio of three infectious In 1884, the first recorded mortality figures disease deaths in the poorest group and one in published by the Office for National Statistics the most affluent group in 2009. compared Brighton very favourably with other So where does Brighton and Hove sit? UK cities with the lowest crude mortality rate

Figure 7.6: Cancer mortality in people aged under-75, Relative inequality gap in England 1995 – 2007

35%

30%

25%

20% Relative gap

15%

10%0% 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 | | | | | | | | | | | 96 98 99 00 01 02 03 04 05 06 07 (Baseline) (Milestone period) 3 year average Source: Directly age-standardised mortality rates calculated by DH from Office for National Statistics death registrations and mid-year population estimates

165 CHAPTER 7 HEALTH INEQUALITIES

among the selected cities at 9,000 deaths per been developed so that the causes of death 100,000 population (Figure 7.7). Today, Brighton which contribute most to the inequalities gap and Hove sits in 12th position among the cities can be determined. In Brighton and Hove these shown in Figure 7.7, with a crude mortality rate are coronary heart disease; lung cancer; chronic comparable to Halifax and Derby. Across the cirrhosis of the liver; suicide and undetermined country there appears to have been a reduction injury (BHCC and BHCPCT, 2009). in inequalities over the last 125 years. In recent years, Public Health Annual Reports have monitored progress in addressing 7.5 Life Expectancy and health inequalities as measured by all age all health inequalities cause mortality within the city. Within the city recent progress has been indecisive, and as The last 100 years have seen considerable shown in Figure 7.8, although the overall all age, improvements in life expectancy. In Brighton all cause mortality rate is decreasing, the relative and Hove, life expectancy for men now stands gap between the most and least deprived in the at 75 years and for women at 81 years. The 21st century has not reduced. If, however, the gap between men and women is gradually review in this Report teaches us anything, it is narrowing. that 10 years is nothing in terms of inequalities. Sadly however, Brighton and Hove has the A National Health Inequalities Tool has second worst male life expectancy among its

Figure 7.7: Crude mortality rate, Brighton, Brighton and Hove and other UK cities, 1884 and 2007

28,00018,000 17,000 26,00016,000 15,000 2007 1884 24,00014,000 13,000 22,00012,000 11,000

20,00010,000 9,000 18,0008,000 7,000 16,0006,000 5,000

14,0004,000 Crude mortality rate per 100,000 3,000

2,0002,000 1,000 00

l y h d ll e x l r n o b t rd n ch m er d l d a n rn n ds e n to st u el o o u i a am n f to u to am t to i er fi ead f d H w h ford fiel h la i l ee h poo s h r s h n r g cest g cast al o L d es e ig B D mo n ad o mouth o n al ef er B er r er r L y ei S h in d H ackb Ol v ch Pr B rts d ke B N L S tt ew n hamp l Li d ir Pl rmi N u B an Po u B i o S er M H B N lv Wo

Source: Office for National Statistics Vital Statistics and Office for National Statistics Mid Year Population Estimates. Medical Officer’s Report, Brighton and Hove, 1884 Note: Town labels are as at 1884; as some administrative areas were different in 2007, data for Kirklees was used for Huddersfield, Wirral for Birkenhead, City of London for London and Calderdale for Halifax.

166 CHAPTER 7 HEALTH INEQUALITIES comparator towns and cities. Life expectancy equivalent figures for males are 70.4 years and 80.3 has increased in all five comparator locations years respectively. (BHCC and BHCPCT, 2009). over the past 15 years but with very little change in gaps between comparator towns 7.6 Summary and cities. Health Inequalities are hard to define, hard to Within the city mortality data from 2006-8 measure and harder still to reverse. Progress is suggest that Stanford, Withdean and Brunswick slow and even over a period of over 100 years, and Adelaide have the highest life expectancies and with the establishment of a Welfare State at 82 years, 84 years and 85 years, respectively and National Health Service, inequalities persist. (Figure 7.9). Queens Park, Westbourne and East That is not to say that we should simply give Brighton wards have the lowest life expectancies up and accept them, for there is good evidence at 76 years, 76 years and 77 years, respectively. that inequalities are an important determinant The combined male and female average life not just of the health of those least well off, but expectancy for Brighton and Hove 2006-8 is of the population as whole. 76.5 years. Some progress has been made nationally. For females in the most deprived 10% More locally, within Brighton and Hove, of Super Output Areas (SOAs) in the city, life progress has been less certain. It looks like the expectancy is 78.6 years compared with 83.6 gap in infant mortality may have reduced over years in the least deprived 10% of SOAs. The the 20th century. Data on all age, all cause

Figure 7.8: All age, all cause mortality in Brighton and Hove, 2001/3 to 2009/11 by Index of deprivation quintile

850

750

650

550

450

Quintile 1 (most deprived) Quintile 2 Quintile 3 Quintile 4

Directly standardised mortality rate 100,000 / 350 Quintile 5 (least deprived) All Brighton & Hove

Actual data Trajectory 250 2001-03 2002-04 2003-05 2004-06 2005-07 2006-08 2007-09 2008-10 2009-11

3 year period

Source: Office for National Statistics mortality files and Office for National Statistics Mid Year Population Estimates; Index of Multiple Deprivation 2007

167 CHAPTER 7 HEALTH INEQUALITIES

mortality within the city is not encouraging, but focus on the inequalities associated with alcohol these data are relatively recent and it would be misuse. In addition, the Primary Care Trust foolish to read too much into them. and City Council will together launch a revised The question of why health inequalities are Health Inequalities Strategy in 2010. hard to reverse may be more a philosophical The evidence base for how inequalities one than a health one. What is clear, is that can be best tackled is expanding all the time. there is a strong and persistent link between In 2007, the Department of Health identified deprivation (poverty as it was termed in the a number of health interventions which have past) and ill health. This was true in 1900 and been proven effective in reducing health it remains true today. Some progress has been inequalities (DH, 2007). These are listed below. made although the extent of this progress However, the NHS contribution to reducing depends to a degree on how you choose to health inequalities is probably just 8%: the rest measure it. comes from action on the wider determinants. The Department of Health has long shown Much more important than providing more a keen interest in health inequalities and 2010 cholesterol lowering drugs are the measures we sees the latest policy launch, based on a review take on the economy, on jobs, on housing and by the team headed by Sir Michael Marmot. on building strong communities. Local research Brighton and Hove has signed up to a national has identified a number of actions on the wider initiative, based on the Marmot Review, to determinants of health that would also reduce tackle inequalities more effectively and will inequalities. These too are also listed opposite.

Figure 7.9: Life expectancy, ward level for Brighton and Hove, 2006-2008

85

84.5

83.8 83 All females - 82.5

82.1 81.6 81.4 81 81.2 80.8 80.6 All people ,Brighton and Hove - 79.5 80.3 79.9 79 79.5 79.1

Age 78.9 78.6 78.2 78.2 All males - 76.5 77.8 77 77.5 77.1

76.2 75.8 75

73

k e n n r e e id h y e k ll e e al n m d n e ar rn o a e d in is nc v ar o v d st a a or a id P u ht e m la a sm W e o P n ro la a de h f de la s o g nd an ts L d g l H n K G ts o g tc n h e n' b ri e t r h ol e a o & r C n a ta it d e st B v S Po rt G R tr st n lm Po n di P S A e e st Be & h o n e o E h a o W & u W a y t N e Pr et & t e o k Q E & ur u & C l r or gd W c b b So s ng e N n i m g r' a ov ti sw o in te H n ot n co ll e a R ru se o . P H B l H St ou M

Source: Office for National Statistics mortality files and Office for National Statistics Mid Year Population Estimates Note: The local distribution of care homes can have a significant effect on small area life expectancy figures:- approx 40% of over 65 deaths allocated to Westbourne lived at a postcode where there was a care home, the next highest was Goldsmid with 23%.

168 CHAPTER 7 HEALTH INEQUALITIES

Department of Health interventions • Improve literacy and numeracy and to reduce health inequalities: reduce the number of young people • Greatly increasing the capacity of not in education, employment and smoking cessation clinics; training; • Increasing the coverage of effective • Reduce the number of working-age therapies for secondary prevention of people on out-of-work benefits. cardiovascular diseases in people aged less than 75 years; At a time of recession and potential cuts • Improving the primary prevention of in public funding, some of these measures may cardiovascular disease in people of not be easy put in place, but in the end this is all ages with hypertension through the relatively straightforward part. For while treatment with antihypertensive and we may discuss how best to measure health cholesterol lowering drugs; inequalities, what tools to use, what population • Increasing the early detection of cancer; groups to examine, and while we may argue • Increasing the use of interventions about whether or not inequalities have reduced aimed at reducing mortality from and if so by how much, we do actually know respiratory diseases and alcohol- what we need to do to tackle ill health and the related diseases, and reducing infant people it affects, and we should do it. mortality.

Measures identified locally to reduce health inequalities • Increase the amount of affordable housing – rented and low cost ownership;

Hove’s best parade on the lawns, c 1906. Courtesy of Hove Library, Brighton and Hove City Council

169 R REFERENCESR Acheson D (1998) ‘Independent enquiry into inequalities in Brighton & Hove City Council (2008) ‘Brighton & Hove health’, accessed 12th February 2010. http://www.archive. Homelessness Strategy 2008 – 2013’, accessed 8th official-documents.co.uk/document/doh/ih/ih.htm February 2010. http://www.brighton-hove.gov.uk/index. cfm?request=c306 Ashford J R and Lawrence P A (1976) ‘Aspects of the epidemiology of suicide in England and Wales’ International Brighton & Hove City Council (2008a) ‘Development Plan Journal of Epidemiology, Vol. 5, No. 2, pp.133-144. Document, Core Strategy - revised preferred options’. Arscott D (2009) ‘A Century of Brighton and Hove’, Brighton & Hove City Council (2008b) ‘Private Sector The History Press. House Condition Survey 2008’. Association of Public Health Observatories (2009) ‘Indications Brighton & Hove City Council (2008/11) ‘Local Area of public health in English Regions 10: Drug Use’. Agreement’ accessed 12th February 2010. http://www. brighton-hove.gov.uk/index.cfm?request=c1113627 Bartley M, Sacker A, Clarke P (2004) ‘Employment status, employment conditions, and limiting illness: prospective Brighton & Hove City Council (2009) ‘Brighton and evidence from the British Household Panel Survey 1991- Hove City Housing Strategy 2009-14’, accessed 8th 2001’ Journal of Epidemiology and Community Health, vol. February 2010 http://www.brighton-hove.gov.uk/index. 58, pp.501-506. cfm?request=c1188834 Bell ML, Davis DL, Fletcher T (2004) ‘A retrospective Brighton & Hove City Council (2009a) ‘Student housing assessment of mortality from the London smog episode of strategy 2009-2014’, accessed 9/1/2010. http://www. 1950: the role of influenza and pollution’ Environmental brighton-hove.gov.uk/downloads/bhcc/Brighton_and_ Health Perspectives, vol. 112, no. 1. Hove_Student_Housing_Strategy_051109.pdf Berridge V. (2005) ‘Illicit drugs, infectious disease and public Brighton & Hove City Council (2009b) ‘Draft Brighton health: a historical perspective’ Canadian Journal of & Hove Core Strategy: Development Plan Document – Infectious Diseases, Medicine and Microbiology, vol. 16, no. proposed submission’. 3, p.193. Brighton & Hove City Council (2009c) ‘Local Development Bezruchna S. (2009) ‘The effect of economic recession on Framework Core Strategy’, accessed 8th February, population health’ Canadian Medical Association Journal, 2010. http://www.brighton-hove.gov.uk/index. vol. 181, issue 5, pp.281-285. cfm?request=c1148443 Brandt, AM. (1993). Sexually transmitted diseases. In Brighton & Hove City Council (2009d) ‘Draft Brighton Companion encyclopaedia of the history of medicine, (ed. & Hove Core Strategy: Development Plan Document – W. F. Bynum and R. Porter), Vol. 1. Routledge, London. proposed submission’. Brem WV, Bolling GE, Casper E J (1918) ‘Pandemic Brighton & Hove City Council (2009e) ‘Flexible Alcohol influenza and secondary pneumonia at Camp Fremont, Licensing Hours in Brighton and Hove: Rapid Health Impact California’ Journal of the American Medical Association, Assessment’ prepared by Ben Cave Associates Limited. vol. 71, no. 26 pp.2138-2144. Brighton & Hove City Council (2009f), Cycling Bickler G. (1998) ‘Inequalities in Health: Annual Report of Demonstration Town Annual Report. the Director of Public Health, East Sussex, Brighton and Brighton and Hove Economic Partnership (2009) ‘Economic Hove Health Authority’. downturn, the local picture’. Bishop JG (1860) ‘Brighton as it is’. Brighton and Hove City Primary Care Trust (2008) ‘Older people’s health and needs. Joint strategic needs assessment’. Biddle L J (2008) ‘Suicide rates in young men in England in the 21st Century: time trend study’ British Medical Journal, Brighton and Hove City Primary Care Trust (2009) ‘Draft vol. 336(7643) pp. 539–542. health equity audit: mental health homes team’. Brighton as it is (1860). Brighton and Hove Reference Library. Brighton and Hove City Primary Care Trust (2009a) ‘Joint Strategic Alcohol Needs Assessment’. Brighton & Hove City Council (2007) ‘Brighton and Hove Homelessness Strategy Consultation Pack’. Brighton and Hove City Primary Care Trust (2009b) ‘Young

170 People’s Specialist Substance Misuse Treatment Needs Chief Medical Officer for England (2008) ‘Chief Medical Assessment’. Officer’s Annual Report 2008’. Brighton and Hove City Primary Care Trust (2009c) Cramb R (1939) ‘Medical Officer’s Annual Report ‘Teenage Pregnancy Action Plan 2009/11’. for Brighton’. Brighton & Hove City Council and Brighton and Hove City Cresey E (1849) ‘Report to the General Board of Health’. Primary Care Trust (2009a) ‘Brighton and Hove Health Crawford M, Lowe PC, Greene L, Brookings C (2004) Impact Assessment of the new housing strategy 2009- 2014: health homes, healthy lives, healthy city’, accessed ‘The prevalence of excessive alcohol consumption and the 9/1/2010. http://www.brighton-hove.gov.uk/downloads/ acceptability of brief advice in a sexual health clinic: cross bhcc/HIA_Housing_Strategy_Report_(Final).pdf sectional survey.’ Sexually Transmitted Infection, vol. 80, pp.416–7. Brighton & Hove City Council and NHS Brighton and Hove (2009) ‘Brighton and Hove Health Impact Assessment of 24 Department for Education and Skills (2006) ‘Teenage hour Licensing ‘. Pregnancy Next Steps: Guidance for Local Authorities and Primary Care Trusts on Effective Delivery of Local Brighton, Old Ocean’s Bauble by Edmund W Gilbert. Strategies’, accessed on 11th February 2010, www. Published by Methuen and Co. Ltd, London. commissioningsupport.org.uk/idoc.ashx?docid...5ef1 British Heart Foundation Statistics (2009) ‘Heart and Department of Health (1999) ‘National service framework circulatory disease is the UKs biggest killer’. Accessed for mental health’, accessed 11th February 2010 http:// 24th January 2010. http://www.heartstats.org/datapage. www.dh.gov.uk/en/Publicationsandstatistics/Publications/ asp?id=39 PublicationsPolicyAndGuidance/DH_4009598 British Medical Journal, November 29, 1884. Obituary to Department of Health (1999a) ‘Saving lives: our healthier Frederick Akbar Mahomed MB FRCP, Assistant Physician to nation’, accessed 11th February 2010. http://www. Guy’s Hospital. dh.gov.uk/en/Publicationsandstatistics/Publications/ PublicationsPolicyAndGuidance/DH_4118614 British Urban Regeneration Agency (2009) Notes from ‘Actions for housing in coastal towns: a BURA seaside Department of Health (1999b) ‘Saving Lives: Our Healthier network reception’, 27th January 2009, Westminster. Nation’, accessed 12th February 2010. http://www.dh.gov. uk/en/Publicationsandstatistics/Lettersandcirculars/ Cancer Research UK (2009) ‘Smoking – statistics’, accessed Healthservicecirculars/DH_4004289 11th February 2010 http://info.cancerresearchuk.org/ cancerstats/types/lung/smoking/index.htm Department of Health (2000) ‘The NHS Plan’. Cancer Research UK (2009a) ‘A brief history of cancer’. Department of Health (2001) ‘Reducing drug-related harm: http://info.cancerresearchuk.org/cancerandresearch/ an action plan’. learnaboutcancer/whatiscancer/historyofcancer/index.htm Department of Health (2002) ‘National suicide prevention Cancer Research UK (2009b) ‘Cancer incidence: trends strategy for England’, accessed 11th February 2010. http:// statistics’. http://info.cancerresearchuk.org/cancerstats/ www.dh.gov.uk/en/Publicationsandstatistics/Publications/ incidence/trends/index.htm, accessed 11/12010 PublicationsPolicyAndGuidance/DH_4009474 Cancer Research UK (2009c) ‘Cancer survival and Department of Health (2002a) ‘Tackling Health inequalities: deprivation statistics’, accessed 11th February 2010, 2002 Cross-Cutting Review’, accessed 12th February 2010. http://info.cancerresearchuk.org/cancerstats/survival/ http://www.dh.gov.uk/en/Publicationsandstatistics/ survivaldeprivation/index.htm Publications/PublicationsPolicyAndGuidance/ DH_4098280 Carder T (1990) ‘The Encyclopaedia of Brighton’. Department of Health (2003) ‘Tackling Health Inequalities: Carter T (1996) ‘Neighbourhood change in the North Laine, a programme of action’, accessed 12th February 2010. Brighton: a case of the marginal gentrifier?’ University of http://www.dh.gov.uk/en/Publicationsandstatistics/ Sussex geography research paper. Accessed 8th February, Publications/PublicationsPolicyAndGuidance/ 2010 http://www.geog.sussex.ac.uk/grc/ResearchPapers/ DH_4008268 Paper29.pdf Department of Health (2004) ‘National Standards, Cassell J A, Leach M, Poltorak M S, Mercer C H, Iversen Local Action: health and social care standards planning A, Fairhead J R (2006) ‘Is the cultural context of MMR framework’, accessed 12th February 2010. http://www. rejection a key to an effective public health discourse?’ dh.gov.uk/en/PublicationsAndStatistics/Publications/ Public Health, vol. 120, Issue 9, pp. 783-794. PublicationsPolicyAndGuidance/DH_4086057 Cave B, Molyneux P, Coutts A (2004) ‘Healthy sustainable Department of Health (2004a) ‘Choosing Health: making communities: what works?’ Milton Keynes and South healthier choices easier’, accessed 12th February 2010. Midlands Health and Social Care Group. http://www.dh.gov.uk/en/Publicationsandstatistics/ Publications/PublicationsPolicyAndGuidance/ Centre for Health Services Studies (CHSS) (2003) ‘Health DH_4094550 Counts Survey of people in Brighton and Hove’.

171 REFERENCES

Department of Health (2005) ‘Commissioning a Patient 2008 update: trends in diagnoses of sexually transmitted Led NHS’, accessed 12th February 2010. http://www. infections in the UK’ http://www.hpa.org.uk/HPA/ dh.gov.uk/en/Publicationsandstatistics/Publications/ Topics/InfectiousDiseases/InfectionsAZ/1203439654589/ PublicationsPolicyAndGuidance/DH_4116716 Higher Education Statistics Agency (2009) Higher Department of Health (2006) ‘Our Health, Our Say, Our education students by institution, accessed 8th February, Care’, accessed 12th February 2010. http://www.dh.gov. 2010. http://www.hesa.ac.uk/index.php/component/ uk/en/Healthcare/Ourhealthourcareoursay/DH_6608 option,com_datatables/Itemid,121/task,show_category/ catdex,3/ Department of Health (2007) ‘Safe. Sensible. Social. The next steps in the National Alcohol Strategy’. Hilton S, Pettigrew, M and Hunt K (2007) ‘Parents’ champions vs. vested interests: Who do parents believe Department of Health (2008) ‘High Impact Actions to about MMR? A qualitative study’ BMC Public Health, vol. Reduce the Rate of Alcohol-related Admission’. 7, No. 42.

Department of Health (2008a) ‘World Class House of Commons Communities and Local Government Commissioning’, accessed 12th February 2010. http:// Committee (2007) ‘Coastal Towns’, accessed 12th February www.dh.gov.uk/en/managingyourorganisation/ 2010. http://www.publications.parliament.uk/pa/ commissioning/worldclasscommissioning/index.htm cm200607/cmselect/cmcomloc/351/351.pdf

Department of Health (2009) ‘Joint strategic needs Housing Options Team (2009) Brighton & Hove City assessment: report of a study based on the South East Council. region’. Housing, Learning and Improvement network. Home Office (2002) ‘Updated Drugs Strategy 2002’ Donaldson L (2007) ‘Chief Medical Officer’s Report 2007’. accessed 12th February 2010 http://www.crimereduction. homeoffice.gov.uk/drugsalcohol/drugsalcohol60.htm Dorling D (2009) ‘Unemployment and health’ British Medical Journal, vol. 338. Home Office (2009), British Crime Survey, England and Wales (July). HM Stationers. Farrant S (1987) ‘London by the sea: Resort development on the South Coast of England, 1880-1939’ Journal of Huff NC and Gray D (2001) ‘Coronary heart disease Contemporary History, vol. 22, no. 1, pp.140. inequalities: deaths and the socioeconomic environment in Nottingham, England’ Health and Place, vol. 7, pp.57-61. Forbes D (1913) ‘Medical Officer’s Annual Report for Brighton’. Hwang LY, Ross MW, Zack C, Bull L, Rickman K, Forbes D (1924) ‘Medical Officer’s Annual Report for Holleman M (2000) ‘Prevalence of sexually transmitted Brighton’. infections and associated risk factors among populations of drug abusers.’ Clinical Infectious Diseases, vol. 31, Forbes D (1929) ‘Medical Officer’s Annual Report for pp.920–6. Brighton’. Information Centre for Health and Social Care (2008) Goldacre B (2008) ‘Bad Science’ Fourth Estate, London. ‘Statistics on smoking in England 2008’, accessed 11th Government Office for the South East (2008) ‘South February 2010 http://www.ic.nhs.uk/pubs/smoking08 East England Health Strategy’, accessed 12th February 2010. http://www.gos.gov.uk/497648/docs/289820/ Jacobson and Jacobson (1972) ‘Suicide in Brighton’ The SouthEastEnglandHealthStrat1.pdf British Journal of Psychiatry, vol. 121, pp. 369-377. Government Office for the South East (2009) ‘South East Jeffries J (2005) ‘The UK population: past present and Plan’, accessed 14th February 2010. http://www.gos.gov. future’, accessed 5/1/2010. http://www.statistics.gov. uk/gose/planning/regionalPlanning/815640/ uk/downloads/theme_compendia/fom2005/01_FOPM_ Population.pdf Gregory I (2009) ‘comparisons between geographies of mortality and deprivation from the 1900’s and 2001: spatial Kemptown history.org (2009) http://www.kemptown. analysis of census and mortality statistics’ British Medical org/history/history.htm, accessed 9th January 2010. Journal, vol. 339. Knight T, Dixon J, Warrener M and Webster S (2007) Harris J and Robinson B (2007) ‘Tipping the iceberg: a pan- Understanding the travel needs, behaviour and aspirations Sussex study of young people at risk of sexual exploitation of people in later life. Prepared for the Department for and trafficking: a final report’, Barnardo’s, Ilford. Transport January 2007. Health Protection Agency (2002) ‘Renewing the focus. Lally MA, Alvarez S, MacNevin R, Cenedella C, HIV and other sexually transmitted infections in the United Dispigno M, Harwell JI, Pugatch D, Flannigan TP (2002) Kingdom in 2002’. ‘Acceptability of sexually transmitted infection screening among women in short-term substance abuse treatment.’ Health Protection Agency (2008) ‘Unlinked anonymous Sexually Transmitted Diseases, Vol. 29, pp.752–5. survey of salivary antibodies to HIV, Hepatitis B, and Hepatitis C in injecting drug users’, Centre for Infections. Lambert NL, Fisher M, Imrie J, Watson R, Mercer Health Protection Agency (2009) ‘Health Protection Report CH, Parry JV, Phillips A, Iversen A, Perry N, Dean GL

172 REFERENCES

(2005) ‘Community based syphilis screening: feasibility, Office of National Statistics (2007) ‘2007 mid-year acceptability, and effectiveness in case finding’. Sexually population estimates’, accessed 12th February 2010 http:// Transmitted Infections, vol. 81, pp.213-316. www.statistics.gov.uk/statbase/product.asp?vlnk=601 Larkin K and Cooper M (2009) ‘Vulnerability and resilience Newsholme A (1893) ‘Medical Officer’s Annual Report for in Leeds, Brighton and Bristol’ Centre for Cities. Brighton’. London Health Observatory and Health Protection Newsholme A (1905) ‘Annual Report on the Health and Agency (November, 2008) ‘London Sexual Health Needs Sanitary Conditions of Brighton’. Assessment and Service Mapping: Project Report 1’. http://www.lho.org.uk/Download/Public/14198/1/ NHS Brighton and Hove and Brighton & Hove City Council Sexual_Health_Report.pdf (2009) ‘Joint Strategic Needs Assessment (JSNA)’. Lowersen J and Myerscough J (1977) ‘Time to spare in NHS information centre (2008) ‘Drug use, smoking Victorian England’ Harvester. and drinking among young people’. Accessed 12th February 2010. http://www.ic.nhs.uk/webfiles/ Mahomed FA. Suggestions concerning the scientific work of publications/sdd07/SDD%20Main%20report%2007%20 the Association, British Medical Journal, January 3, 1880. %2808%29-Standard.pdf Marmot M and Wilkinson R (eds). Social Determinants of NHS information Centre (2009) ‘National Child Health, 2nd Edition. Oxford University Press, 2006. Measurement Programme’, accessed 12th February 2010. http://www.ncmp.ic.nhs.uk/ Mayhew M (1984) ‘The 1930s Nutrition Controversy’ Journal of Contemporary History, vol. 23, pp.445-464. NHS Information Centre (2009a) ‘Health Survey for England’, accessed 12th February 2010. http://www. Marx R, Aral SO, Rolfs RT, Sterk CE, Kahn JG (1991) ic.nhs.uk/statistics-and-data-collections/health-and- ‘Crack, sex and STD.’ Sexually Transmitted Infection, vol. lifestyles-related-surveys/health-survey-for-england 18, pp.92–101. NHS Information Centre (2009b) ‘Statistics on obesity, McEwan et al (2006) ‘Sex and the risk of HIV: the physical activity and diet: England, February 2009’. role of alcohol’ Addiction, vol. 87, issue 4 http:// Accessed 4th February 2010. http://www.ic.nhs.uk/ www3.interscience.wiley.com/journal/119335452/ webfiles/publications/opan09/OPAD%20Feb%20 abstract?CRETRY=1&SRETRY=0 2009%20final.pdf McKeown T (1988) ‘The Origins of Human Disease’ Basil North West Public Health Observatory Data (2009) ‘Local Blackwell, Oxford. alcohol profile: Brighton and Hove’. http://www.nwph. net/alcohol/lape/LAProfile.aspx?reg=j Memon A and Walker A (2009) ‘Brighton and Hove suicide prevention strategy 2008-2011’ Brighton and Hove City Office of National Statistics (2008) ‘Summary Quality Teaching Primary Care Trust. Report for General Lifestyle Survey (GFL)’ accessed 15/2/2010. http://www.ons.gov.uk/about-statistics/ Mercer CH, Copas AJ, Sonnenberg P, Johnson AM, methodology-and-quality/quality/qual-info-economic- McManus S, Erens B, Cassell JA (2008) ‘Who has sex social-and-bus-stats/quality-reports-for-social-statistics/ with whom? Characteristics of heterosexual partnerships summary-quality-report-for-general-lifestyle-survey.pdf reported in a national probability survey and implications for STI risk’ International Journal of Epidemiology. Office of National Statistics (2009) ‘UK mortality lowest ever recorded’ accessed 5/1/2010. http://www.statistics. Mybrightonandhove.org. (2009) ‘Disease and slum gov.uk/cci/nugget.asp?id=2271 clearance’ accessed 8th February 2010. http:// www.mybrightonandhove.org.uk/page_id__9109_ Parker W (1957) ‘Medical Officer’s Report for Brighton’. path__0p116p171p408p.aspx Parker W (1958) ‘Medical Officer’s Annual Report for Mybrightonandhove.org (2009) accessed 11th February Brighton’. 2010. http://www.mybrightonandhove.org.uk/category_ id__1364.aspx Parker W (1960) ‘Medical Officer’s Annual Report for Brighton’. National Audit Office (2008) ‘Reducing Alcohol Harm’, accessed 11th February 2010. http://www.nao.org.uk/ Parker W (1963) ‘Medical Officer’s Annual Report for publications/0708/reducing_alcohol_harm.aspx Brighton’. National Health Service (2009) ‘NHS Carbon Reduction Strategy’ accessed 12th February 2010 http://www.sdu. Parker W (1968) ‘Medical Officer’s Annual Report for nhs.uk/ Brighton’. National Institute of Mental Health in England (2008) Parker W (1970) ‘Medical Officer’s Annual Report for ‘Mental disorders, suicide and deliberate self harm in Brighton’. lesbian, gay and bisexual people: a systematic review’. National Programme on Substance Abuse Deaths (2009) Parker W (1971) ‘Medical Officer’s Annual Report for ‘Annual Report 2009’. Brighton’.

173 REFERENCES

Patton R, Keaney F, Brady M (2008) ‘Drugs, alcohol and ‘The public health effect of economic crises and alternative sexual health: opportunities to influence risk behaviour’ policy responses in Europe: an empirical analysis’ The BMC Research Notes 2008, vol. 1, no. 27. Lancet, vol. 374, pp. 315-323. Pearce A, Law C, Elliman D, Cole T J, Bedford H (2008) Sussex Cancer Network (2009) ‘Sussex Cancer Network ‘Factors associated with uptake of measles, mumps, and Annual Report 2008/09’. http://www.sussexcancer.net/ rubella vaccine (MMR) and use of single antigen vaccines documents/annualreport2008-09.pdf in a contemporary UK cohort: prospective cohort study’ British Medical Journal, vol. 336, pp. 754-757. Sussex Cancer Network (2009a) ‘National Awareness and Early Diagnosis Initiative Baseline Assessment’. Poltorak M, Leach M, Fairhead J, Cassell J (2005) ‘MMR talk and vaccination choices: an ethnographic study in Tansey EM (2001) ‘Sexually transmitted diseases: a brief Brighton’ Social Science and Medicine, vol. 61, pp. 709- history’ In ‘The Oxford Companion to the Body’. 719. Teenage Pregnancy Unit (2009) ‘Under 18 conception data Prime Minister Gordon Brown (November, 2008) speaking for top tier local authorities, 1998-2007’. at the ‘Closing the Gap Conference’. The Argus, 17th July, 1918. Redlan A. A Short History of Brighthelmstone, with Remarks on its Air and an Analysis of its Waters’ (1761) The Argus 27th December, 1957. reprinted in 1829 with an introduction by JC Mitchell. The Argus (9/11/2007) ‘It’s not safe to breathe’. Richardson (1882) ‘Dr. Richardson’s report of the sanitary condition of the borough of Brighton’ The Lancet, vol. 120, The Argus (15/5/2009) ‘Warning: our air is a hazard’. no. 3088, pp. 747-763. The Government Office for Science (2007) ‘Foresight Rogstad KE (2004) ‘Sex, sun, sea and STIs: sexually – tackling obesities: future choices’, accessed 12th transmitted infections acquired on holiday’ British Medical February 2010. http://www.foresight.gov.uk/OurWork/ Journal vol. 329, pp.214-217. ActiveProjects/Obesity/KeyInfo/Index.asp Rose G and Marmot MG (1981) ‘Social class and coronary The Wellcome Trust (2009) ‘Constructing cancer: a history heart disease’ British Heart Journal, vol. 45, pp.13-19. of cancer in the UK’. http://www.wellcome.ac.uk/ News/2009/Features/WTX055643.htm Royal College of Psychiatrists (2009) ‘Mental health and the economic downturn’ http://www.lse.ac.uk/collections/ UK Government Committee on the Medical Effects of PSSRU/pdf/mental_health_downturn121109.pdf. Air Pollution (2000) ‘The health effects of air pollutants: COMEAP advice’. Siena K P (2004) ‘Venereal disease, hospitals and the urban poor. London’s ‘Foul Wards’ 1600-1800’. University of Wakefield A J, Murch S H, and Anthony A (1998). ‘Ileal- Rochester Press. lymphoid-nodular hyperplasia, non-specific colitis, and pervasive developmental disorder in children’. Lancet, vol. South East England Development Agency (2006) The 351, no. 9103, pp. 637–41. Coastal South East Strategy’, accessed 12th February 2010. http://www.seeda.org.uk/sustainable_prosperity/ Wanless D (2004) ‘The Wanless Report: Securing sustainable_developments/coastal_strategy/ Good Health for the Whole Population’, accessed 12th February 2010. http://www.dh.gov.uk/en/Publichealth/ South East England Development Agency (2007) ‘Coastal Healthinequalities/Healthinequalitiesguidancepublications/ South East Strategy: Framework for Action’, accessed DH_066213 12th February 2010. http://www.seeda.co.uk/_ documentbank/coastalSE_framework_March2008.pdf Webber C (2009) ‘Brighton and Hove: sustaining city growth’ Centre for Cities. South East England Development Agency (2009) ‘South East Plan’, accessed 12th February 2010. http://www.gos.gov. Wilkinson R, Pickett K. The Spirit Level – Why More Equal uk/gose/planning/regionalPlanning/815640/ Societies Almost Always Do Better. Published by Allen Lane, 2009. South East Public Health Observatory (2008) ‘Choosing health in the South East: road transport and health’. World Health Organisation (2005) ‘Air quality and health’. http://www.who.int/mediacentre/factsheets/fs313/en/ South East Regional Public Health Group (2009) ‘South index.html East England Health Strategy’, accessed 12th February 2010. http://www.gos.gov.uk/497648/docs/289820/ World Health Organisation (2007) ‘International Statistical SouthEastEnglandHealthStrat1.pdf Classification of Diseases and Related Health Problems, 10th Revision’, accessed 12th February 2010l http://apps. Southern Water (2009) ‘Fluoridation’, accessed 12th who.int/classifications/apps/icd/icd10online/ February 2010. http://www.southernwater.co.uk/ homeAndLeisure/drinkingWater/Fluoridation.asp World Health Organisation (2009) ‘Health effects of transport’. http://www.euro.who.int/transport/ Stuckler D, Basu S, Suhrcke M, Coutts A, McKee M (2009) hia/20021009_2

174 REFERENCES

175 REFERENCES R APPENDICESR

Appendix 1 Comparator Areas

Appendix 2 Definitions

Appendix 3 Mosaic Groups

Appendix 4 Maps

176 Appendix 1: COMPARATOR AREAS

There are different sets of comparator areas for local authorities and for primary care trusts, and then subsets within these of the most similar areas.

For Brighton and Hove Teaching Primary Care Trust (PCT), or as it is now known NHS Brighton and Hove, the comparator primary care trusts are:

Newcastle PCT, Plymouth Teaching PCT, Salford PCT, Portsmouth City Teaching PCT, Southampton City PCT, Leeds PCT, Sheffield PCT, Liverpool PCT and Bristol PCT.

For Brighton & Hove City Council, the comparator local authorities are: Bournemouth, Cheltenham, Bristol, Hastings, Eastbourne, Southampton, Portsmouth and Blackpool.

Appendix 2: DEFINITIONS

Alcohol-specific: Conditions that are wholly related to alcohol (e.g. alcoholic liver disease or alcohol overdose).

Alcohol-attributable: Alcohol-specific conditions plus conditions that are caused by alcohol in some, but not all, cases (e.g. stomach cancer and unintentional injury). For these latter conditions, different attributable fractions are used to determine the proportion related to alcohol for males and females.

A list of alcohol-attributable conditions with their ICD-10 codes can be found at: www.nwph.net/nwpho/publications/AlcoholAttributableFractions.pdf

177 APPENDICES

Appendix 3: mosaic groups Brighton & Hove Mosaic Profile

percentage of

Group Group description households key features Middle-aged; successful; rewarding careers; high incomes; high educated, young people living in net worth; choicest housing; good diet; drink alcohol daily; concern single people living a career professionals living in sought after locations 6.4 for the environment social housing with in areas of uncertain Young couples; good education; corporate careers; low transient employment living unemployment; good prospects; modern homes; internet; enjoy populations 34.2 in deprived areas b younger families living in newer homes 2.6 exercise; care for environment 10.1 Married Couples; Older Children; white collar workers; low income hardworking; self-reliant; comfortable homes; plan for retirement; families living in c older families living in suburbia 12.7 good place to live; environmental charities estate based social Young couples; children; family close by; older houses; small housing 3.3 industrial towns; traditional; close knit communities; working family d close-knit inner city and manufacturing town communities 6.3 tax credit ; inactive lifestyles Young singles; few children; well educated; full time students; close-knit inner city upwardly mobile educated, young single people living in areas of transient professionals; open-minded; cosmopolitan tastes; good diet and and manufacturing families living in town communities e populations 34.2 health; cultural variety homes bought 6.3 from social Families; many young children; low incomes; free school meals; landlords 7.0 people living in social housing with uncertain employment high deprivation; council housing; public transport; heavy watchers f living in deprived areas 10.1 of TV; Heavy drinkers / smokers Families; low incomes; income support; free school meals; older families living terraces and semis; large council estates; outer suburbs; bad in suburbia 12.7 g low income families living in estate based social housing 3.3 place to live; heavy TV viewers older people living middle aged couples; mostly poorly educated; council estates; in social housing upwardly mobile families living in homes bought from small towns; exercised right to buy; self reliant and capable; poor with high care younger families needs 2.5 h social landlords 7.0 diet; heavy smokers; heavy viewers of TV living in newer Older people; low incomes; low savings; pension credit; some homes 2.6 small bungalows; some sheltered homes; TV popular; Bingo; i older people living in social housing with high care needs 2.5 dominoes; cards; HESS emergencies career Pensioners; relocated on retirement; own their homes; index linked professionals living in sought after pensions; significant capital; active; good health and diet; HES independent older locations 6.4 people living in j independent older people with relatively active lifestyles 14.9 emergencies; prefer face to face service rural areas far from people with Older people; small communities; neighbourly; distinct rural life; urbanization 0.02 relatively active lifestyles 14.9 farming; agro-tourism; good diet and lifestyle; work long hours; k people living in rural areas far from urbanization 0.02 cars important Brighton & Hove Mosaic Profile percentage of

Group Group description households key features Middle-aged; successful; rewarding careers; high incomes; high educated, young people living in net worth; choicest housing; good diet; drink alcohol daily; concern single people living a career professionals living in sought after locations 6.4 for the environment social housing with in areas of uncertain Young couples; good education; corporate careers; low transient employment living unemployment; good prospects; modern homes; internet; enjoy populations 34.2 in deprived areas b younger families living in newer homes 2.6 exercise; care for environment 10.1 Married Couples; Older Children; white collar workers; low income hardworking; self-reliant; comfortable homes; plan for retirement; families living in c older families living in suburbia 12.7 good place to live; environmental charities estate based social Young couples; children; family close by; older houses; small housing 3.3 industrial towns; traditional; close knit communities; working family d close-knit inner city and manufacturing town communities 6.3 tax credit ; inactive lifestyles Young singles; few children; well educated; full time students; close-knit inner city upwardly mobile educated, young single people living in areas of transient professionals; open-minded; cosmopolitan tastes; good diet and and manufacturing families living in town communities e populations 34.2 health; cultural variety homes bought 6.3 from social Families; many young children; low incomes; free school meals; landlords 7.0 people living in social housing with uncertain employment high deprivation; council housing; public transport; heavy watchers f living in deprived areas 10.1 of TV; Heavy drinkers / smokers Families; low incomes; income support; free school meals; older families living terraces and semis; large council estates; outer suburbs; bad in suburbia 12.7 g low income families living in estate based social housing 3.3 place to live; heavy TV viewers older people living middle aged couples; mostly poorly educated; council estates; in social housing upwardly mobile families living in homes bought from small towns; exercised right to buy; self reliant and capable; poor with high care younger families needs 2.5 h social landlords 7.0 diet; heavy smokers; heavy viewers of TV living in newer Older people; low incomes; low savings; pension credit; some homes 2.6 small bungalows; some sheltered homes; TV popular; Bingo; i older people living in social housing with high care needs 2.5 dominoes; cards; HESS emergencies career Pensioners; relocated on retirement; own their homes; index linked professionals living in sought after pensions; significant capital; active; good health and diet; HES independent older locations 6.4 people living in j independent older people with relatively active lifestyles 14.9 emergencies; prefer face to face service rural areas far from people with Older people; small communities; neighbourly; distinct rural life; urbanization 0.02 relatively active lifestyles 14.9 farming; agro-tourism; good diet and lifestyle; work long hours; k people living in rural areas far from urbanization 0.02 cars important 178 APPENDICES

Appendix 4: birth rates, BRIGHTON 1901 

D

i t

c

h

l i e n

u g

n e R v d o A a oa d d  R  r o s f e n a w t e Pr S L es to n D R y o k a e d R o a d

ad Ro  n re ar W Elm Grove

   

D Crude Birth Rate y ke

 (No of births / 1,000 popln) R o  a W d estern 6.2 - 6.4 Road No rth Str  6.5 - 13.0  eet Edwa  rd Str  eet  13.1 - 20.0 Ki ng's  Road  East er 20.1 - 34.2 n R oa M d arin Representation of roads e Pa  rade

Dotted Eyes © Crown copyright and/or database right 2009. All rights reserved. Licence number 100019918 birth rates, BRIGHTON 1931   Wards 1 West  2 Regency 3 Pavilion 4 Pier 5 Queen's Park

L 6 Hanover o n d o 7 St John's n R o 8 St Nicholas' a d D 9 St Peter's y k e 10 Montpelier R o a 11 Lewes Road d 19 12 Elm Grove 13 King's Cliff

d 14 Rottingdean a o R

15 Moulsecoomb s e

w 16 Hollingbury e L 17 Preston 18 Preston Park 15 19 Patcham 16 18 17

oad 11 12 n R rre Crude Birth Rate W a

(No of births / 1,000 popln) 9 6 10 6.4 8 7 14 1 5 2 13 6.5 - 13.0 3 4

F 13.1 - 20.0 a l m

e r

20.1 - 34.0 M R ari o ne a D d 1901 Boundary rive Representation of roads  Note:- The 20.1-34.0 band is shown for comparison purposes with maps from other periods. The highest rate in 1901 was for Lewes Road (18.7).  Dotted Eyes © Crown copyright and/or database right 2009. All rights reserved. Licence number 100019918  179 APPENDICES

BIRTH RATES, BRIGHTON 2001

Wards 1 Brunswick & Adelaide 2 Central Hove  3 East Brighton 4 Goldsmid 5 Hangleton & Knoll 6 Hanover & Elm Grove 7 Hollingbury & Stanmer 8 Moulsecoomb & Bevendean 10 9 North Portslade 10 Patcham 20 11 Preston Park 7 12 Queen's Park 9 13 Regency 14 Rottingdean 5 Coastal 15 St. Peter's 8 & North Laine 17 16 South Portslade 17 Stanford 11 18 Westbourne 16 21 19 Wish 4 6 20 Withdean 19 15 21 Woodingdean 18 2 3 1 13 Crude Birth Rate 12 (No of births / 1,000 popln) 14 3.1 - 6.4 6.5 - 13.0 13.1 - 20.0 20.1 - 22.7 1931 Brighton Boundary  1901 Brighton Boundary Dotted Eyes © Crown copyright and/or database right 2009. All rights reserved. Licence number 100019918

DEATH rates, BRIGHTON 1901



D

i t

c

h

l i e n

u g

n e R v d o a A a o d d  R  or s f e n a w t e Pr S L es to n D R y o k a e d R o a d  ad Ro n re ar Elm Grove W Crude Death Rate   (No of deaths / 1,000 popln)   1,165

D y 1,166 - 1,500 k  e 

R

o W a 1,501 - 2,250 ester d n Road  No rth 2,251 - 4,275 Str   eet Edw  ard S treet  Representation of roads Ki ng's  Road  Eas ter n R oa M d arin Note:- The 2,251-4,275 band is e Pa rade shown for comparison purposes with maps from other periods. The highest rate for 1901 was for St Peter's (2,195).

Dotted Eyes © Crown copyright and/or database right 2009. All rights reserved. Licence number 100019918 t 180 S h APPENDICES

DEATH rates, BRIGHTON 1931   Wards 1 West  2 Regency 3 Pavilion 4 Pier 5 Queen's Park

L 6 Hanover o n d o 7 St John's n R o 8 St Nicholas' a d D 9 St Peter's y k e 10 Montpelier R o a 11 Lewes Road d 19 12 Elm Grove 13 King's Cliff

d 14 Rottingdean a o R

15 Moulsecoomb s e

w 16 Hollingbury e L 17 Preston 18 Preston Park 15 16 19 Patcham 18 17

11 12 oad Crude Death Rate n R rre (No of deaths / 100,000 popln) W a 9 6 10 820 - 1,000 8 7 14 1,001 - 1,500 5 1 2 3 4 13 1,501 - 2,250

F a l 2,251 - 4,275 m e r

M R ari o 1901 Boundary ne a D d rive Representation of roads  Note:- The 2,251-4,275 band is shown for comparison purposes with maps from other periods. The highest rate for 1931 was for West (1,830).  Dotted Eyes © Crown copyright and/or database right 2009. All rights reserved. Licence number 100019918 

DEATH rates, BRIGHTON 2001

Wards 1 Brunswick & Adelaide 2 Central Hove  3 East Brighton 4 Goldsmid 5 Hangleton & Knoll 6 Hanover & Elm Grove 7 Hollingbury & Stanmer 8 Moulsecoomb & Bevendean 10 9 North Portslade 10 Patcham 20 11 Preston Park 7 12 Queen's Park 9 13 Regency 14 Rottingdean 5 Coastal 15 St. Peter's 8 & North Laine 17 16 South Portslade 17 Stanford 11 18 Westbourne 16 21 19 Wish 4 6 20 Withdean 19 15 21 Woodingdean 18 2 3 1 13 Crude Death Rate 12 (No of deaths / 100,000 popln) 14 134 - 1,000 1,001 - 1,500 1,501 - 2,250 2,251 - 4,275 1931 Brighton Boundary  1901 Brighton Boundary Dotted Eyes © Crown copyright and/or database right 2009. All rights reserved. Licence number 100019918

181 APPENDICES

INFANT MORTALITY, BRIGHTON 1901



D

i t

c

h

l i e n

g

nu e R v d o a A a o d d  R  r o s e nf a w t e Pre S L s to D n y Ro k a e d R o a d  ad Ro n re ar Elm Grove W

    Infant Mortality D

y k  (No of under 1 deaths e 

R o / 1000 births) W a ester d n Road N  or th S 105 tre E   et dwar  d Stre et  106 - 130 Ki ng's  Road  Eas ter 131 - 176 n R oa M d arin e Pa rade 177 - 248 Representation of roads

Dotted Eyes © Crown copyright and/or database right 2009. All rights reserved. Licence number 100019918

INFANT MORTALITY, BRIGHTON 1931

  Wards 1 West  2 Regency 3 Pavilion 4 Pier 5 Queen's Park

L 6 Hanover o n d o 7 St John's n R o 8 St Nicholas' a d D 9 St Peter's y k e R 10 Montpelier o a 11 Lewes Road d 19 12 Elm Grove 13 King's Cliff

d 14 Rottingdean a o R

15 Moulsecoomb s e

w 16 Hollingbury e L 17 Preston 18 Preston Park 15 16 19 Patcham 18 17

11 12 oad n R Infant Mortality rre W a (No of under 1 deaths /1000 births) 9 6 10 0 - 62 8 7 14 5 63 - 130 1 2 3 4 13 131 - 176

F a l 177 - 248 m e r

M R ari o ne a 1901 Boundary D d rive Representation of roads 

Note:- The 177-248 band is shown for comparison purposes with maps from other periods. The highest rate in 1931 was for Hollingbury (137).  Dotted Eyes © Crown copyright and/or database right 2009. All rights reserved. Licence number 100019918  182 APPENDICES

INFANT MORTALITY, BRIGHTON 2001

Wards 1 Brunswick & Adelaide 2 Central Hove  3 East Brighton 4 Goldsmid 5 Hangleton & Knoll 6 Hanover & Elm Grove 7 Hollingbury & Stanmer 8 Moulsecoomb & Bevendean 10 9 North Portslade 10 Patcham 20 11 Preston Park 7 12 Queen's Park 9 13 Regency 14 Rottingdean 5 Coastal 15 St. Peter's 8 & North Laine 17 16 South Portslade 17 Stanford 11 18 Westbourne 16 21 19 Wish 4 6 20 Withdean 19 15 21 Woodingdean 18 2 3 1 13 Infant Mortality 12 (No of under 1 deaths /1000 births) 14 0 1931 Brighton Boundary 1 - 55 1901 Brighton Boundary 56 - 176 177 - 248

Note:- The 177-248 band is shown for comparison  purposes with maps from other periods. The highest rate in 2001 was for a part of Withdean (10 0). Dotted Eyes © Crown copyright and/or database right 2009. All rights reserved. Licence number 100019918

POPULATION DENSITY, BRIGHTON 1901



D

i t

c

h

l i n

g

e u R d n o a e a o v d  R  A s d r o we f e P n L r a es t to S n D R y o k a e d R o a d

d oa R  n re ar W Elm Grove

   

D

y

k

e

R  o a Population per hectare d   W estern Road 36 - 50 No rth St   reet 51 - 120    King 's Ro  121 - 200 ad  E ast ern Ro 201 - 408 M ad arin e Pa rade Representation of roads

1 square mile = 259 hectares, 1 square kilometre = 100 hectares

Dotted Eyes © Crown copyright and/or database right 2009. All rights reserved. Licence number 100019918

183 APPENDICES

POPULATION DENSITY, BRIGHTON 1931   Wards 1 West  2 Regency 3 Pavilion 4 Pier 5 Queen's Park L o 6 Hanover n d o 7 St John's n R o 8 St Nicholas' a d D y 9 St Peter's k e R 10 Montpelier o a 11 Lewes Road d 19 12 Elm Grove 13 King's Cliff

d 14 Rottingdean a o R

15 Moulsecoomb s e

w 16 Hollingbury e L 17 Preston 18 Preston Park 15 16 19 Patcham 18 17

11 12 oad Population per hectare n R rre W a 2 - 50 9 6 10 51 - 120 8 7 14 121 - 160 1 5 2 13 3 4 161 - 200 F a l m

201 - 336 e r

M R ari o ne a 1901 Boundary D d rive Representation of roads  1 square mile = 259 hectares, 1 square kilometre = 100 hectares  Dotted Eyes © Crown copyright and/or database right 2009. All rights reserved. Licence number 100019918 

POPULATION DENSITY, BRIGHTON 1961

Wards 1 Regency  2 Montpelier 3 St Nicholas 4 Pier 5 Queen's Park 6 Kings Cliff 7 Preston Park 13 8 St Peters 9 Hanover 10 Lewes Road 14 11 Elm Grove 12 Moulsecoomb 13 Patcham 14 Stanmer 15 Falmer 16 Warren 19 15 17 Rottingdean 7 18 18 Preston 19 Hollingbury 12

8 10 Population per hectare 16 11 3 - 15 2 9  3 16 - 28 1 4 29 - 40 5 6 41 - 79 17 1901 Boundary Representation of roads

 Dotted Eyes © Crown copyright and/or database right 2009. All rights reserved. Licence number 100019918 184 APPENDICES

POPULATION DENSITY, BRIGHTON 2001

Wards 1 Brunswick & Adelaide 2 Central Hove  3 East Brighton 4 Goldsmid 5 Hangleton & Knoll 6 Hanover & Elm Grove 7 Hollingbury & Stanmer 8 Moulsecoomb & Bevendean 10 9 North Portslade 10 Patcham 20 11 7 Preston Park 9 12 Queen's Park 13 Regency 14 Rottingdean 5 Coastal 8 15 St. Peter's & North Laine 17 16 South Portslade 17 Stanford 11 18 Westbourne 16 21 19 Wish 4 6 20 Withdean 19 18 15 21 Woodingdean 2 3 1 13 Population per hectare 12 3 - 50 1931 Brighton Boundary 51 - 120 1901 Brighton Boundary 14 121 - 160 161 - 200 201 - 296

1 square mile = 259 hectares, 1 square kilometre = 100 hectares Dotted Eyes © Crown copyright and/or database right 2009. All rights reserved. Licence number 100019918

185

NOTES

186 187 Finding out more about us: Brighton and Hove City Teaching Primary Care Trust Prestamex House 171-173 Preston Road Brighton BN1 6AG

Telephone: 01273 295490 Fax: 01273 295461 Minicom: 01273 545499 Email: [email protected] Website: www.brightonhovecitypct.nhs.uk

If you would like a large print version or taped version of this report, please call Communications on 01273 545322

2871 design by www.graphicdesignteam.org.uk