Cumbria 2011 The Annual Report of the Director of Public Health Allerdale / Carlisle / Copeland / Eden / Furness / South Lakeland / / Health in Numbers 2 Health Protection in Cumbria:

Health in Numbers

■ Cumbria is England’s ■ There are approximately ■ In 2008/09 the alcohol- second largest county, 15,000 children under 16 harm related hospital representing 48% of the years old (16% of the admissions rate was 1811.2 land mass in the North population), living in per 100,000 population, West, with an estimated income deprived which was higher than the population of 495,000 households. This is lower rate for England at 1582.4. ■ 51% of the total than the national average ■ The current conception population in Cumbria live of 21%. rate of 41 per 1,000 girls in rural communities, ■ 247 people were killed or under 18 years of age is compared with 19% in seriously injured in road above the national figure England traffic accidents in Cumbria of 40 girls per 1,000. ■ Cumbria has 24 specific during 2009. ■ The life expectancy at birth communities (super output ■ In October 2010, the rate for males is 78.1 years areas) that are in the 10% of unemployment in which is 0.2 years above most deprived in England Cumbria was 2.4% (7,525 the national average. For and Wales, of which seven claimants) compared to the females the life expectancy are in the worst 3%. This national rate of 3.9%. The is 81.7 years which is 0.3 means that approximately claimant count fell by 70 years less than the national 16% of the Cumbria between September and average. population lives in areas October 2010. ■ There were 21,006 patients which officially rate as ■ Around 10% of 4/5 year included on the GP among the most deprived olds and 19% of 10/11 year diabetes register in in the country. olds in Cumbria were 2008/09, accounting for ■ There were 5326 deaths classed as being obese in 4.9% of the Cumbria and 5080 live births in 2008/09. population. This is the 2009. ■ There were 1,516 deaths same as the national ■ In early 2010 the average from all causes of cancer in average. house price in Cumbria was 2009. This gives a rate of ■ In 2009 there were 18 £171,632 compared to the 306 deaths per 100,000 deaths under one year old national average of people. in Cumbria, an infant £214,003. ■ The mortality rate from mortality rate of 3.5 deaths ■ In 2009 the average suicide and injury of per 1,000 births compared household income in undetermined intent for to a national average of Cumbria was £30,637, 2006 to 2008 was 9.9 per 4.7 deaths. compared with the 100,000 population. This is ■ In 2008/09 there were national average of significantly higher than 3,114 people registered £34,884. the rate for England at 7.8. with a GP with a diagnosis of dementia. / Contents 3 Contents:

Foreword 4

Introduction 6

Section 1 Emergency Planning 10

Section 2 Infection Prevention 18

Section 3 Vaccination 32

Section 4 Screening Programmes 42

Section 5 Injury and Violence 50

Section 6 Healthy Workplace 58

Section 7 Health Protection and Hard to Reach Groups 62

Section 8 Sustainable Energy 68

Section 9 Review of Last Year’s Recommendations 76

Section 10 Conclusions and Recommendations 80 Acknowledgements & Contact Details 82 / Forword 4 Foreword:

This is my fourth annual If we are to see a real improvement in people’s health, we need to support our report on the health of people communities in their aspirations to lead in Cumbria. Given the series healthier, happier and longer lives by taking of serious and tragic incidents more control over lifestyle choices and self- management of long-term conditions. It is that have affected Cumbria also necessary to strive for comprehensive over the last year, I have uptake of public health screening and preventive medicine programmes. chosen the theme of Health Protection for my report this Improving the public’s health, resilience to year. illness and strengthening the community response to hazards to health is our priority, yet we need a strong and protected public Health Protection is the area of Public Health health system to tackle these priorities. practice that deals with external hazards and threats to health, as well as communicable The recently launched White Paper ‘Healthy diseases. Lives, Healthy People’ outlines plans to put the role of public health on a sound footing in We know that more lives could be improved if society, and sets out plans to ring-fence the there was a greater emphasis on helping public health budget so that it is used to people to stay healthier for longer and being tackle the key causes of preventable ill-health. equipped with the skills to make the right health choices. This White Paper spells out one of the biggest changes in the delivery of public health since There are many influences on our health, yet the inception of the NHS over fifty years ago, broadly they can be categorised as the three with plans to hand power back to a public pillars of health, which are the biology we health department which will sit alongside inherit from our parents, the environment in local authorities rather than within primary which we grow up and live and the care trusts. This follows the government’s behaviours which link the environment and previous announcements within the Health biology. All of these areas can be influenced White Paper in July that GP Consortia will take by effective health protection measures, over the commissioning and budgetary education and encouragement to make control of local health services, and primary behavioural change. care trusts will be closed down by 2013. However, the return of public health to its role in local government will only be one part of the organised efforts of society for health and well-being. / Foreward 5 “we need a strong and protected public health system”

Clinicians, whether based in the community or in hospital, have important opportunities to contribute to public health, as our experience in Cumbria over the past four years has demonstrated. We need to build on this through our local GP Consortia in the years ahead.

The establishment of Public Health England as a nationally accountable service with a remit for preventative programmes such as screening and vaccinations, as well as health emergency planning, will be the third arm of a robust set of arrangements which will be coordinated nationally and at a local level by the Board of Health and Wellbeing.

The wider determinants of health – economic status, education opportunities, employment, housing and environment – are integral to our efforts, therefore reforms will involve the public sector, NHS, social care, education, transport, environment and industry in ensuring that we have a unified approach to improving health.

The intention is for us all to become more focused on helping people to improve their With the new proposals and greater local own health and reduce the number of people flexibility, we will be able to move away from dying prematurely. The gross inequality in life a centralised focus, and further focus on the expectancy and ill health between different needs of our local communities, tackling areas and groups within the county is priority areas in Cumbria and using the best unacceptable to a society that places great insights of social psychology and health store on being fair. protection to make further inroads into improving the lives of people in Cumbria.

Dr John R Ashton CBE Director of Public Health & County Medical Officer, Cumbria / Introduction 6 Introduction:

Last year my annual report These changes mean that for Recent events including the focused on mental health, mental health services, the swine flu pandemic of 2009, from infancy to adulthood link between mental and Cumbria Floods – November and into old age. I outlined physical health will be 2009, the Keswick School bus what is known about mental strengthened. There will be crash – May 2010, devastating health and wellbeing in greater integration with GP shooting incident in Cumbria, what can affect a and other community health Whitehaven – June 2010, and person’s mental health and services – leading to better our coldest winter for 100 gave recommendations on access and seamless care years have left a lasting mark how support services could be between community services on our communities. In improved and enhanced. This and mental health, drug, addition we also saw the included a recommendation alcohol and learning disability failure of the breast screening for mental health services to support in the county. service in North Cumbria, be further embedded into which has emphasised the primary care to create a closer, The opportunities for importance of quality control more integrated and holistic integration of mental health in programmes such as this. health service. services are particularly important, given our ageing Each of these events has wide This recommendation now population in Cumbria and ranging implications for looks set to become a reality, increase in cases of dementia public health, both physical as health services provided by and other types of brain and psychological, and all NHS Cumbria will soon join failure. required a coordinated and forces with Cumbria multi agency response from Partnership NHS Foundation There is much to be done – organisation across the Trust – the provider of mental creating a holistic service county, yet it is the response health services for the county. cannot be achieved overnight, of our communities that has This change follows but it is the right approach if been a real testament to the announcements made in the we are to see real and long strength within Cumbria. government’s white paper term improvements in people These events, and the ‘Equality and Excellence: centred services. Further community response, have led Liberating the NHS’, that will information on progress to the development of this see NHS Cumbria joining regarding mental health report that focuses on the other primary care trusts in services can be found at the wide range of programmes separating their provider and end of this report. and health protection commissioning functions. methodologies that are used This year, the theme of my to protect, prevent and Knowledge of the link annual report is ‘Health prepare for external causes of between body and mind dates Protection’. ill-health. from Roman and Greek Cultures (“Mens sana in corpore sano” – A healthy mind in a healthy body). / Introduction 7

This report will introduce There are three domains of health protection and our What is Health public health: mechanisms to deal with Protection? ■ major incidents, infection Public Health is ‘the science Health protection - which prevention and our approach and art of preventing disease, focuses on protection of to ensuring downward trends prolonging life and the population’s health in Meticillin-resistant promoting health through the from communicable Staphylococcus aureus (MRSA) organised efforts of society.’ diseases and environmental and Clostridium difficile (C. (CEA Winslow, "The untilled hazards (Environment). difficile) and other infections, field of public health," ■ Health improvement - vaccination and screening Modern Medicine Vol. 2 which is concerned with programmes to protect and (1920), pp 183-191). reducing inequalities in the detect, the workplace role in health of populations by health protection and our This definition, which addressing the wider work to tackle our hard to originally comes from Charles determinants of health reach and disadvantaged Winslow, the Dean of Public such as lifestyles, housing groups. Health at Yale in 1920s, was and education (Society) revived by Chief Medical ■ Service improvement - This section introduces Health Officer Sir Donald Acheson in which is concerned with Protection as one of the three 1988 and has influenced our planning and effectiveness domains of Public Health. thinking about public health. of health services (Health and Social Care) Public Health services are concerned with the health of the populations they serve, While these areas of public recognising that prevention is health have distinct features, better than cure. they also overlap and integrate with each other.

The role of the Cumbria Public Health Protection team is to identify and implement appropriate interventions to protect health and reduce risk to our communities. This includes delivering programmes to protect health and wellbeing, and work to ensure adequate policies and procedures are in place to limit the risk of infectious and environmental hazard. / Introduction 8

Health protection works to In order to protect the health It is these areas, and the prepare, prevent and protect of our communities, a number public and professional against the following issues: of methods are used to response to threats to health, identify and protect against which provide the focus for ■ Infectious diseases hazards to health, spot risks this report. and trends, access hard to ■ Chemicals and poisons reach groups who have On account of the many ■ Radiation historically had limited untoward or major incidents ■ Emergency response contact with health services that Cumbria has experienced and monitor rates of over the last 12 months, I will ■ Environmental health infection, causes of mortality first introduce our approach ■ External threats to health, and access to services. to emergency preparedness, including fire and flood and the importance of a ■ Violence and injury A large focus of health planned, coordinated and protection is the monitoring multi agency response to limit of trends to help identify risk the health fallout of an The Cumbria Public Health areas and also to develop the emergency incident. Protection team works with a evidence base to identify wide range of partner priorities for action and organisations to ensure a develop new approaches to coordinated response from health protection. The team local authorities, the work also delivers programmes to done by the NHS, social care, raise awareness of health housing, environmental protection measures and health, leisure and transport encourage people to adopt services and third sector healthier behaviours. groups to protect the health of our population, using a The team works closely with number of methods including: the Health Protection Agency to protect the public and ■ Preparing for and manage and prepare for managing major incidents untoward incidents of any ■ Hazard identification nature – from outbreaks of disease, biological, chemical ■ Risk assessment and environmental threats, ■ Infection prevention and risks brought on by extreme control weather, illness outbreak or ■ Co-ordination of industry hazards, all of which immunisation programmes pose a threat in Cumbria. ■ The commissioning or coordination of a number of screening programmes / Introduction 9 / Section 1 10 / Section 1 11 Section 1: Emergency preparedness to mitigate risk and protect from harm

In this section I will give an In view of the potential threat Planning for a major overview of what we mean to public health that each of incident by emergency preparedness these incidents could cause, it is and planning, I will outline vital that we have well Over the last few years, NHS the challenges that Cumbria established and practised plans Cumbria has – in collaboration has experienced first hand in place to help to manage and with partner agencies – over the last year, and steps mitigate the threat to public developed a set of multi- that the community can safety and life. It is absolutely agency emergency plans. These take to prepare for an essential that all relevant include plans specific to emergency event. agencies, including the NHS, particular situations, for are fully prepared and work example flooding and Outbreaks of disease or together to deal quickly and pandemic influenza, and also a infection, environmental effectively with such incidents. general Major Incident Plan. hazards and other threats to the public's health are Emergency Planning is the In order to ensure that we are continually emerging and can process and management fully prepared to respond arise at any time. In certain structures put in place to appropriately to any incident, circumstances, and as we have reduce the impact of a major emergency planning also witnessed in Cumbria, incident on an organisation or involves training and exercising sometimes these hazards can community. It has four broad to simulate an emergency escalate into a major incident aims: situation, enabling us to test in just a matter of hours. our emergency plans, systems ■ to preserve life and and procedures and rehearse A major incident is any property. key staff roles. emergency that requires the ■ to mitigate the harmful implementation of special effects of the emergency on NHS Cumbria is involved in arrangements by one or more the environment. major incident exercises of the emergency services, the throughout the year and has ■ to bring about a swift return NHS or the local authority. participated in several multi- to normal life for agency major exercises during communities and the Major incidents could include: 2009-10 including Exercise environment. severe weather conditions (e.g. Coniston, a Pandemic exercise, flooding or heat wave), ■ to encourage all agencies and Exercise OSCAR 9 - a environmental pollution, and organisations to prepare regular test of emergency industrial or technical failures, for their role. arrangements at the Sellafield outbreaks of disease (e.g. nuclear site. The Swine Flu pandemic influenza), large- pandemic was also used to scale transport accidents and develop and test business terrorist attacks. continuity arrangements.

Civil Contingencies / Section 1 12

Act 2004 Category One Responders Category Two organisations are required under the Act to: include the utility and Following the floods and fuel transport companies, the crisis in 2000 and the foot and ■ Assess the risk of Health and Safety Executive mouth crisis in 2001, it was emergencies occurring and and Strategic Health recognised that there was an use this to inform Authorities. While these urgent need to review contingency planning organisations will be less likely to be involved in core emergency planning ■ Put in place emergency emergency planning work, arrangements in the United plans Kingdom. they will have an essential ■ Put in place business function during incidents that continuity arrangements Nationally, the UK affect their sector. Government is responsible for ■ Put in place arrangements emergency planning, with the to make information Cumbria Resilience Forum is Civil Contingencies Act 2004 available to the public the name given to our local identifying the roles and about civil protection resilience forum. It brings responsibilities of other lead matters together Category I and 2 responders to ensure effective agencies. The Act recognises ■ Maintain arrangements to delivery of the organisations’ that through effective warn, inform and advise duties outlined in the Act. coordination, cooperation the public in the event of and communication across an emergency organisations, the overall The Civil Contingencies Act ■ management of and recovery Share information with 2004 requires Cumbria from an incident will be other responders to Resilience Forum to compile a better than that of individual enhance co-ordination Community Risk Register. agencies operating ■ Co-operate with other Category 1 and 2 responders independently. responders to enhance come together to conduct a coordination and efficiency comprehensive assessment of The organisations at the core the risks facing our of the response to most communities. These risks are For a Primary Care Trust, this ranked in relation to the emergencies are the blue- not only includes those light services (i.e. Police, Fire likelihood of them occurring services it provides directly, and the impact that they will and Ambulance), the local such as district nursing and authorities, NHS bodies, the have on the community if health visitors, but the full they do occur. The Community Environment Agency, and the range of independent health Maritime and Coastguard Risk Register is then used to services including GPs, inform emergency planning. Agency. They are known as Dentists, Pharmacists and Category One Responders. Opticians. Independent In Cumbria our highest area contractors, especially GP of risk has been assessed as surgeries, are not classed as being from pandemic 'Category One' responders. influenza, followed by Thus, despite the fact that adverse weather and then they have a crucial role to flooding. play, there are no legal requirements - or indeed related resources - for GPs to plan for an emergency. / Section 1 13

Declaring an incident Major incidents Winter 2009/10 affecting Cumbria Any Category One Flu pandemic responder can declare an Over the last 18 months, During 2009 a new strain of the ‘Unusual’ or ‘Major’ Cumbria has experienced a H1NI influenza virus emerged incident. number of devastating which differed to that of the incidents, all of which required seasonal H1N1 virus. This new Unusual incident a multi-agency response, and strain originated from animal have left a lasting mark on our influenza virus. An ‘Unusual Incident’ is an communities. incident which because of its The NHS deals with unexpected On 11th June (Week 24 2009) nature or effects requires a and shocking events on a daily WHO declared an influenza limited multi-agency response. basis, though not often on the pandemic. Category 1 responders who scale of these events. The declare an unusual incident will response by NHS Cumbria Typically seasonal influenza open a control room to deal colleagues was truly affects people in the northern with the incident, and invite remarkable and characterised hemisphere during the colder selected agencies to attend. by a sense of calm and winter months. However professionalism that was all the Pandemic H1N1 caused high Major Incident more impressive given the levels of summer infections and unprecedented circumstances. then even higher levels of A major incident is any NHS Cumbria was instrumental infections during the colder emergency that requires the in managing the gold months in this part of the implementation of special command response for a world. arrangements by one or more number of these incidents. of the emergency services, the Pandemic H1N1 also differed NHS or the local authority. Communities in Cumbria are from seasonal flu in that most A major incident affecting the close knit, and these events of the deaths occurred in NHS is defined as: affected every individual in our younger people. Pregnant county in some way. women, young children and Any occurrence which people with underlying medical represents November 2009 conditions were seen to be at higher risk of severe illness. The 1. A serious threat to the health virus also caused many more of the community West Cumbrian Floods On 19th November 2009, cases of viral pneumonia. 2. Disruption to a service or following a long spell of wet 3. Causes (or is likely to cause) weather, there were major 24 May 2010 such numbers or types of floods affecting several parts of casualties as to require Cumbria, wiping out local Keswick school bus crash special arrangements to be medical services for over 15,000 On Monday May 24th 2010, a implemented by hospitals, people in Cockermouth, as well bus carrying children home ambulance trusts or primary as cutting off services for a from Keswick School was in care trusts whole community in collision with a car on the A66 Workington. Other towns at Braithwaite. The coach including Keswick, Kendal, overturned and two Ulverston, Egremont and schoolchildren were killed. The Crosby-on-Eden were also driver of the car also died at affected. the scene. 35 children were injured including 4 seriously. A total of six rescue helicopters / Section 1 14

were used to ferry the injured 12 people and injured another to hospital. A Reception 11 in West Cumbria during the The public health Centre was established morning of 2nd June 2010. response to the at Braithwaite School were a Bird’s twin brother, David, was Cumbria Floods, number of casualties were the first victim and was killed 2009 triaged before transfer to sometime in the early morning hospital. The ‘walking of the 2nd at Lamplugh. At On 19 November 2009, wounded’ were also treated at approx 10am Bird then went following a long spell of the School. on a 45 mile journey where he wet weather, there were shot people in Frizington, major floods affecting 2 June 2010 Whitehaven, Egremont, Wilton, several parts of Cumbria, Gosforth and Seascale. Bird’s wiping out local medical West Cumbria Shooting body was eventually discovered services for over 15,000 A 52 year old Whitehaven taxi by Police at 13.40hrs in people in Cockermouth, as driver, Derrick Bird, shot dead woodland near Boot. well as cutting off services for a whole community in Workington. Other towns including Keswick, Kendal, Coping with tragic Ulverston, Egremont and events Cumbria Partnership NHS Foundation Trusts ‘First Step’ Crosby-on-Eden were also affected. Following these events service also provided an enhanced service following which occurred in quick Cockermouth saw 885 succession, our county was the incident and in the months after the event. First homes flooded, Keswick left in shock and grief, with 240 and Workington 66. the emotional trauma Step helps large numbers of people deal with the effects leaving many in need of help Particular pressures for and support. NHS Cumbria mental health problems including anxiety, depression NHS Cumbria, as well as worked promptly with public health concerns, Cumbria Partnership NHS and dealing with the impact of traumatic events. People focussed on disruption to Foundation Trust to establish community services in a number of drop-in sessions are usually referred to this service by their GP but Cockermouth where two offering emotional support GP surgeries were flooded following the flooding and people in Copeland who were affected by recent out. All 14 doctors who West Cumbria shootings. were based in the two Literature on coping with events were invited to call First Step directly if they practices relocated to stress was also widely Cockermouth Cottage distributed to schools, require “face to face” psychological support. Hospital, moving from 29 libraries and community rooms into just four. As centres in the area. As a part of the emergency number of GPs and nursing Callers were able to arrange to speak to a trained response and staff were first on the scene reestablishment of services, to treat shooting victims, practitioner on the phone in the first instance, and if a suite of over 20 further specialist help was temporary buildings was also offered to these staff necessary arrange an appointment at a suitable quickly established at members, as well as other Cockermouth Hospital professionals who were time and place to provide specialist ongoing support. enabling normal involved in the emergency outpatient clinics and other response. services to begin again. / Section 1 15

Business continuity GP services were also business that also leads to to maintain essential affected in Workington, with financial worry, longer days services patients unable to access due to travel problems, or their usual services due to simply not being able to Business continuity is a process the collapse of the town’s access local amenities can that helps ensure that a service major bridges. Extra GP lead to a range of can continue to operate to the clinics were set up in Seaton psychological problems –such extent required in the event of for people who were unable as sleep problems, mild a disruption. It is closely linked to travel to their own GP depression, or panic attacks. to emergency planning and Surgery. Damage to a NHS Cumbria worked with continuity of service must be number of bridges in flood Cumbria Partnership NHS considered during the areas continues to cause Foundation Trust to boost implementation of a major disruption to travel. access to mental health incident plan. support services for those Flooding brings many public whose lives and businesses Business continuity at NHS health risks, not least the where affected by the floods. Cumbria looks at the critical threat of contaminated flood First Step, a service operated functions of the organisation water. Other issues include by Cumbria Partnership NHS and ranks them. If a disruption disruption to services and Foundation Trust received occurs, the critical functions access to medical supplies for 198 referrals for help will be managed so that the those with existing medical following the floods. organisation can continue to conditions, contamination of provide a viable service. property by flood water and A multi-agency recovery Business continuity processes sewage, as well as the coordinating group oversaw are most often implemented increased risk of spread of the recovery and restoration during periods of adverse disease and infection due to work, which is ongoing a weather, when resources such displaced communities. year after the event. as staffing are diverted to priority areas such as at-risk NHS Cumbria worked closely and vulnerable patients. with the police and local authorities to ensure a swift To ensure services are response to the Cumbria maintained and prioritised floods, quickly re-establishing during periods of high demand services and identifying at or during a major or unusual risk patients. Experience incident, all departments gained from the Carlisle within NHS Cumbria have a floods of 2005 also helped to responsibility to conduct a ensure that lessons were Business Impact Analysis (BIA) learnt and systems for and then to develop a recovery were quickly functional business continuity established. plan. This is to provide a set of documented procedures to The biggest problem facing deliver continuity of critical our communities was the functions in the event of a psychological effects of disruption. displacement and worry caused by the event. Anxiety over loss of property or / Section 1 16

Disaster preparedness Recent events in Cumbria have other parts of the world that and the role of the demonstrated the enormous experience natural disasters public community spirit and resilience such as hurricanes more in Cumbria. Our communities frequently. It is my hope that Emergencies happen. They can are close knit and support each we continue to develop this happen at any time, and to other, yet in order to save life, approach in Cumbria, and anybody. The emergency there are measures that towns equip our communities with services will always prioritise and villages can take to further resilience skills and a basic those in greatest need, prepare for the unexpected. understanding of what to do in especially where life is in We need to know how to help an emergency. Please also refer danger, yet there may be times ourselves and those around us. to my resilience guide on the when a whole community By becoming more resilient, back cover of this report. response to an incident is our community can required. complement the work of local emergency services and reduce Our experience in Cumbria has the impact of an emergency. shown us the invaluable contribution of ordinary We need to empower our citizens in sustaining each communities to utilise their other – particularly through assets to develop safer and support after the acute phase stronger communities. of an incident and while This is known as disaster moving into recovery. preparedness and is seen in

Local Area alongside councils and other Grasmere as a pilot area to Partnerships (LAPS) agencies in a co-ordinated develop their first Community way. They have identified the Emergency Plan. Learning LAPS are groups of parishes development of a Community from the experience of that have agreed to work Emergency Plan as one of developing this plan will help together on a range of their priorities. This plan will to guide other Partnership common issues, particularly assist to review the level of communities in developing the local response to threat following an incident, their own Community emergencies. They are made establish activation triggers to Emergency Plans in the up of councillors at parish, declare an ‘incident’, help future. district and county level, establish plans to determine resources needed and Central Lakes Local Area methods to communicate Partnership consists of the during an emergency, as well parishes of Skelwith, Lakes as steps needed to identify and Windermere in South the vulnerable and most at Lakeland District Council. need of support.

The Partnership recognises The Partnership has agreed that the area will be better that a single plan for the able to respond to future whole partnership area would emergencies if local residents be impractical; therefore they and businesses work have selected the village of / Section 1 17

Working with the Third Sector Cumbria’s First An example of how this can Responders work is provided by the Many important partners in our Keswick Flood Action Group. emergency response are in the Community First Responder The group has used funding voluntary sector. For example, volunteers are trained to from Cumbria Community colleagues in such as the Red attend emergency calls Foundation to appoint a Cross and Mountain Rescue received by the ambulance coordinator and there is a Teams have provided support in service and provide care until well-developed local network a number of recent incidents. the ambulance arrives. of responders. They are able to respond not only to floods Cumbria St John Ambulance Volunteers can arrive at an but to other adverse events provides a wide range of emergency scene in a matter and emergencies that may services throughout Cumbria, of minutes, as they are sent affect the community. including first aid training, first to calls in their local area. aid cover at public events and First Responders provide vital opportunities for youth care and reassurance, members to develop their life particularly in rural areas of saving and first aid skills. Cumbria. Having someone in the community who has been The Associate Director of trained in first aid and can Health Protection at NHS reach the patient quickly Cumbria has recently been makes all the difference. appointed as County Commander for Cumbria St John Ambulance, and will be working with the organisation Recommendations: ■ An increased focus on to increase the number of developing resilience at people in the community who Public sector organisation in community level - For are trained in first aid. Cumbria work extremely well effective and rapid response together in an emergency, yet to emergencies, especially in order to further strengthen in a rural area such as ours, emergency planning it is essential to build procedures in Cumbria, I community resilience and recommend: understand what action to take in an emergency. ■ Still closer collaboration between partner ■ Work with third sector agencies both during organisations to provide emergencies and in the basic first aid training to ongoing planning our communities - It is process - As agencies feel unacceptable that people the effects of reductions in die needlessly because no resources over the next few one could give them first years we need to work aid. If everyone was able to together even more closely learn some basic life saving to maintain a coordinated and resilience skills lives and effective response. could be saved. / Section 2 18 / Section 2 19 Section 2: Infection prevention and control to limit the spread of illness

In the previous section I potential to spread from one ■ Insertion of a medical device looked at our emergency person to another, and the e.g. urinary catheter, drip response and planning spread can happen quickly. ■ Surgery. As this usually procedures to prepare and involves cutting the skin, protect. This section looks Communications and public which is one of the body’s at Infection Prevention to awareness campaigns on most important defences help limit the spread of reducing the spread of against infection, thus infection and causes of ill infection are launched allowing micro-organisms health. throughout the year. (e.g. bacteria) to enter the Campaigns focus on hand body. The prevention and control of hygiene for health care staff, infection is a top priority across patients, visitors and the ■ Some medications can lower Cumbria. The Infection community, as well as self-care a patient’s resistance to Protection and Control team advice to reduce infections infection, for example works to reduce the risk of spreading and the importance steroids and treatment for patients acquiring a health care of vaccination to protect to cancer. associated infection and advises limit the spread of illnesses ■ The use of antibiotics, which on measure to reduce the such as flu. may allow an infection to spread of infection in other develop with resistant settings. Why do health care bacteria. associated infections Everyone carries large numbers happen? Stringent hygiene procedures of micro-organisms (germs) on are applied to reduce the risk their skin, hair and bodies. If people develop an infection of patients acquiring a health Most of the time these whilst receiving health care this care associated infection. The organisms don’t cause any is referred to as a ‘health care number of cases are going problems, but if they present in associated infection’. In an down year on year. the wrong place then they can environment where patients cause infections. are recovering from illness, injury or an operation, there is Infection or disease may be an increased risk of infection. caused by bacteria, viruses, Patients are more susceptible in fungi and parasites, and can these settings due to factors result in a wide variety of such as having a weakened illnesses. These include: urinary immune system and being in tract infections, wound the same environment as infections, respiratory another patient who may be infections, blood borne and suffering an infection. Sharing skin infections. Not all some facilities, as well as some infections can be passed on, procedures and treatment can but some such as Clostridium also increase the risk of difficile, influenza infection, for example: and norovirus have the / Section 2 20

Prevention and In a health care setting, it is Care in the use and control of health care particularly important that all disposal of sharps associated infection health and social care staff clean all parts of their hands. Some infections, including To help reduce the risk of Some parts, such as thumbs, hepatitis and HIV / AIDS, are infection, there are certain are often missed, so health carried in the blood and can precautions that are taken with care professionals need to use be transmitted by infected every patient, whether a particular series of actions blood being introduced, or receiving care and treatment in to make sure that the soap inoculated, into the a hospital, at home, at a health and water or alcohol reaches bloodstream of a susceptible centre or clinic, or anywhere every area of the hand. person. Strict procedures on else in the community. These Advice for staff and services the use and disposal of sharps are called standard precautions users is displayed in health are applied in all health care and consist of: and social care settings to settings. demonstrate a good hand Good hand hygiene washing technique. Educating staff, patients and their Appropriate use of The single most effective carers about infection thing anyone can do to gloves and aprons reduce the risk of infection is Providing suitable accurate to carry out good hand Sometimes even the best information on infections is hygiene preferably by hand washing isn’t going to extremely important, helping washing with soap and water, be enough, and there is a to educate and inform. or by disinfecting them with need to wear protective alcohol gel or hand rub. equipment such as gloves and It has been found especially Patients and the community an apron. effective for infection are reminded of the reduction if patients feel able importance of good hand Environmental to challenge clinicians who hygiene through awareness cleanliness are about to examine them campaigns and material without cleaning their hands. displayed in health care Making sure that premises settings. Alcohol gel is readily and equipment are clean Environment available for use by patients, plays a large part in giving visitors and staff in all NHS people confidence in the care The environment is also a Cumbria’s community that is provided, and is key to factor in the prevention of hospitals, health clinics and the reduction of the risk of infection. Designing and GP surgeries. health care-associated constructing surfaces in such a infection. way that they can be easily and effectively kept clean is an important contribution to infection prevention. / Section 2 21

Containing an The number of cases appears ■ Disinfect any surfaces or infection: Norovirus to be rising year on year. objects that could be Methodologies to help reduce contaminated with the Each winter, Norovirus the spread of norovirus virus. It is best to use a infection, commonly known include early detection and bleach-based household as winter vomiting bug, isolation of cases, reporting to cleaner, remembering to affects communities across the the Health Protection read the product country. Norovirus is a highly Team/Agency and good hand instructions. hygiene. infectious but short-lived ■ Wash any clothing or illness from which most bedding that could have To help limit the spread of people, including the frail and become contaminated with infection, outbreaks often elderly, will normally recover the virus. Wash the items result in the closure of an area in anything from 12 to 60 separately and on a hot such as a ward, hospital; care hours. wash to ensure that the home or school. As there is no virus is killed. Norovirus is the most common specific treatment for ■ Flush away any infected form of gastrointestinal illness norovirus infection, we faeces or vomit in the in the UK, affecting between strongly advise people with lavatory and keep the 600,000 and one million the infection to stay at home, surrounding lavatory area people every year. It can rest and take plenty of drinks clean. spread rapidly, particularly in to replace lost fluids. Steps to environments where people limit the spread of the virus ■ Avoid eating raw, live or work in close proximity, include: unwashed produce and such as hospitals, residential only eat seafood from a ■ care homes, cruise ships, Wash hands frequently reliable source. Oysters in schools and the workplace. and thoroughly, particular have been Norovirus is probably the particularly after using the known to carry the biggest example of how easy lavatory and before norovirus. it can be for infections in preparing food. health care settings to spread. ■ Households should not share towels and flannels. / Section 2 22

Reducing infection Our main aim now is to Trends in cases of in Cumbria continue the downward trend Clostridium difficile as even one case of infection is associated diarrhoea Health care associated one too many. in Cumbria infections have been tackled It is clear from investigation successfully in recent years Clostridium difficile causes mild work done on cases of MRSA across Cumbria. Figures show to moderate diarrhoea, fever Bacteraemia and Clostridium that the numbers of patients and stomach cramps. There has difficile associated diarrhoea suffering MRSA bacteraemia been a marked reduction of that many people who are (blood stream infections) and cases of in Cumbria, due in part affected have been in contact Clostridium difficile associated to improved awareness of hand with a number of health and diarrhoea (CDAD) have fallen hygiene measures and the social care services in the weeks on consecutive years. The introduction of hand gels in all leading up to their infection. In number of reports of patients health care settings as well as Cumbria, infection prevention suffering MRSA bacteraemia awareness around the teams therefore have an fell from 37 cases in 2007-08 to appropriate use of antibiotics. 14 cases in 2009-10. Similarly integrated approach to the prevention of health care the number of patients In 2008 it was not unusual to associated infections, working suffering Clostridium difficile see more than 70 patients closely with both NHS and the associated diarrhoea has fallen suffering Clostridium difficile social care sector alike. from 787 cases reported in associated diarrhoea each Effective evidence-based 2007-08 to 458 reports in 2009- month. Whereas since April interventions as described 10. Whilst this is good news 2010 fewer than 30 cases have earlier (hand hygiene, there is still a lot of work to be been reported each month. The appropriate clinical techniques, done to ensure the fall in figures are set out in the tables antibiotic stewardship) will numbers is sustained. Many on the right. initiatives have already been continue to be used to further launched across the health reduce risk. Audit, regular economy to effect this feedback and unannounced reduction including the visits to health and social care implementation of the “clean settings continue to be used to your hands campaign” and the provide assurance that the Saving Lives initiative which issue of health care associated focuses on things that are infection is being addressed known to make a difference, and applied correctly and such as good catheter care. consistently. / Section 2 23

Reports of Clostridium difficile associated diarrhoea cases in Cumbria 2007 – 2010

Clostridium Difficile - April 2007 to March 2010

100

90

80

70

60

50

40

30

20

10

0

- 07 - 07 - 08 - 08 - 08 - 09 - 09 - 09 - 10 g t - 07 c b g t - 08 c b g t - 09 c b un - 07Jul - 07 ep - 07 c an - 08 un - 08Jul - 08 ep - 08 c an - 09 un - 09Jul - 09 ep - 09 c an - 10 Apr - 07May - 07J Au S O Nov - 07De J Fe Mar - 08Apr - 08May - 08J Au S O Nov - 08De J Fe Mar - 09Apr - 09May - 09J Au S O Nov - 09De J Fe Mar - 10

Clostridium Difficile - April to December 2010

30

25

20

15

10

5

0

- 10 - 10 g t - 10 c un - 10 Jul - 10 ep - 10 c Apr - 10 May - 10 J Au S O Nov - 10 De / Section 2 24

Trends in cases of MRSA All NHS patients going into bacteraemia (blood stream bacteraemia in Cumbria hospital for a relevant planned infection) and from the MRSA stands for meticillin- procedure are screened for beginning of April 2010 to the resistant Staphylococcus MRSA beforehand. This helps end on November 2010, 8 aureus, which is a common skin the NHS reduce the chance of patients have been found to be bacterium that is resistant to a patients acquiring an MRSA suffering the infection. range of antibiotics. It can infection or passing MRSA on Although there has been a affect any part of the body, to another patient. marked reduction in the including blood, and can be The graphs below show that number of patients suffering fatal. from January to the end of the infection work continues to June 2008, 27 patients were ensure this reduction is found to be suffering an MRSA sustained.

Cases of MRSA bacteraemia (blood stream infections) in Cumbria 2007 – 2010

MRSA April 2007 to March 2010 7

6

5

4

3

2

1 0

- 07 - 07 - 08 - 08 - 08 - 09 - 09 - 09 - 10 g t - 07 c b g t - 08 c b g t - 09 c b un - 07Jul - 07 ep - 07 c an - 08 un - 08Jul - 08 ep - 08 c an - 09 un - 09Jul - 09 ep - 09 c an - 10 Apr - 07May - 07J Au S O Nov - 07De J Fe Mar - 08Apr - 08May - 08J Au S O Nov - 08De J Fe Mar - 09Apr - 09May - 09J Au S O Nov - 09De J Fe Mar - 10

MRSA April to December 2010

2.5

2

1.5

1

0.5

0

- 10 - 10 g t - 10 c un - 10 Jul - 10 ep - 10 c Apr - 10 May - 10 J Au S O Nov - 10 De / Section 2 25

How bacteria When bacteria are treated good bacteria. Therefore become resistant to with an antibiotic, such as people prescribed broad antibiotics penicillin, some of the spectrum antibiotics may ‘stronger’ bacteria may suffer from side effects such Antibiotics are important survive. This happens in as thrush, or suffer the effects medicines designed to treat particular when people do of a Clostridium difficile bacterial infections such as not finish their full course of Infection. meningitis, kidney infections antibiotics. Any surviving and pneumonia. bacteria are then able to It has also been widely mutate and develop a debated about the use of However in recent years, a resistance to the antibiotic. antibiotics in agriculture, number of factors have led to These bacteria then multiply particularly cattle, and the them becoming less effective and can infect others. This is suggestion that this is at treating infection. how MRSA bacteria have facilitating increased Shortly after antibiotics were become resistant to many antibiotic resistance in first mass produced for the antibiotics, and is how humans. general public, the microbes ‘superbugs’ that cannot be that they were designed to successfully treated with kill began to develop antibiotics are developing. resistence. Since that time, many pathogenic microbes Antibiotics are powerful (those that cause disease) drugs, but inappropriate use have become resistant to drug of broad spectrum antibiotics therapy. destroys all bugs – including

Keeping hands clean: School Nurses use glitter to School campaign demonstrate how germs can be transferred from one hand to another. Schools have an important role to play in teaching and The children put their encouraging hand washing hands in glitter and are from an early age. Hand then asked to touch desks, washing habits learnt at door handles and pick up school can last a lifetime. items so they can see just This message is reinforced how easily the glitter Each year School Nurses every year to teach primary ‘germs’ can spread. The run a programme of age children the children are then asked to awareness to teach importance of hand wash their hands to show youngsters about the hygiene and aids the how the “germs” can easily importance of washing prevention of the spread of be washed away by using hands after using the infection in schools and at soap and warm water. lavatory and before eating home, in particular colds as an important measure and flu and gastro- for reducing sickness rates intestinal illnesses. in all schools. / Section 2 26

Training and support Environmental Health water from untreated water to reduce infections and Protection supplies can also present a risk of infection. Mandatory training to promote Many infections in the good practice and ensure community are related to food. Food poisoning caused by E. continuing downward trends in According to the Health coli O157 has been associated rates of infection is provided to Protection Agency (HPA), up to with undercooked minced beef NHS staff across Cumbria. NHS one million cases of food-borne products such as burgers, Cumbria Infection Prevention illness and food poisoning are therefore it is important to Nurses have also been working reported each year in the UK. ensure all minced beef with both Cumbria Care Sector Approximately 20,000 people products are cooked Alliance and Cumbria Care, are hospitalised and 500 die thoroughly to ensure there are providing support to private from these diseases. no pink areas and the juices and voluntary care provider run clear. Extra care should be organisations on infection In the UK, and here in Cumbria, taken when cooking on prevention and control the majority of cases were barbeques because of the risk measures. caused by salmonella and of undercooking or campylobacter and there was a contaminating cooked food The Infection Prevention Team noticeable increase over the with bacteria from uncooked have been looking at ways of summer months. Some of this meat. using resources and good increase is likely to be as a practice from outside the result of poor food handling Infection may also result from health service to facilitate the practices in warm weather. contact with animals that carry prevention of health care E. coli O157 or from exposure associated infections. Examples Bacteria can grow faster if food to an environment from other industries may is left out of refrigeration in contaminated with animal bring useful solutions for the warmer temperatures, faeces, such as farms and preventing infection. Probiotics while eating food at barbecues similar premises which are are live bacteria given in food and picnics can present open to the public. It is supplements or some yogurt additional risks such as cross- therefore important to wash products which have been contamination and serving hands thoroughly with soap found to help reduce infection food that has not been cooked and water after contact with by improving the balance of properly. The most commonly animals and the farm good bacteria in the gut, thus reported food-borne infections environment. E. coli O157 can inhibiting the growth of toxic in the North West are: cause illness, ranging from mild producing bacteria. Interesting to severe bloody diarrhoea, it studies are currently being Escherichia coli can be particularly serious for carried out into the use and (E. coli) O157 young children and for some effectiveness of probiotic to can cause a condition known as haemolytic-uraemic syndrome reduce infection, as well as E. coli O157 can be found in (HUS) The number of E. coli other illnesses such as Chronic the gut of cattle, sheep, goats O157 reports decreased by 42% Obstructive Pulmonary Disease and a wide range of other in 2009 in Cumbria compared and Helicobacter pylori. animals. People can become to 2008, see Figure 1. There Interesting studies are currently infected by E. coli O157 if they was a national increase of 9% being carried out into the use consume food that has become over the same period. and effectiveness of probiotics. contaminated by infected animals and it is not washed or cooked properly, drinking / Section 2 27

Figure 1. E.coli O157 reports Campylobacter Salmonella Cumbria, 2008-2009 Campylobacter is the Salmonella bacteria cause food 60 commonest cause of food poisoning. Salmonella live in poisoning in the country. the gut of many farm animals 50 Campylobacter is found in most and so meat, poultry and eggs s raw poultry and is common in can be affected. People usually 40 raw meat, so it is possible to aquire salmonella by eating become infected by eating contaminated food that has 30 undercooked meat or cooked been undercooked. Salmonella er of Report b 20 and ready to eat foods that can also be spread from have been cross-contaminated human-to-human or from Num 10 with the bacteria from raw animal-to-human by poor meat. It is therefore important hygiene. Pet reptiles can carry 0 to take care to avoid cross salmonella and children have 2008 2009 contamination by keeping raw been infected from them as meat separate to cooked and they are particularly at risk ready to eat foods and ensure because they like to handle and Listeria hands are thoroughly washed stroke them. To reduce the risk after handling raw meat. You children should be supervised Another type of food can also catch campylobacter ensure that they do not put poisoning that has increased in from infected pets and other reptiles near their mouths and the UK in recent years is caused animals. The number of wash their hands thoroughly by Listeria. This can cause campylobacter reports with soap and water illness particularly among those increased by 8% in 2009 immediately after touching people who have weakened compared to 2008, see Figure 2. them. The number of immune systems, for example There was a national increase salmonella reports decreased the over 60s and those who of 16% over the same period. by 41% in 2009 compared to due to their medical condition, 2008, see Figure 3. There was such as those who have cancers national decrease of 8% over or had transplants, are the same period. particularly susceptible to infection. Pregnant women are also susceptible. Listeria can be Figure 2. Campylobacter Figure 3. Salmonella reports present in ready-to-eat foods reports Cumbria 08-09 Cumbria 08-09 such as pre-packed sandwiches, pate, smoked salmon, and soft 700 140 mould-ripened cheese such as 600 120 Camembert and Brie. To minimise the risk, chilled foods s 500 s 100 must be kept cold and eaten by 400 80 the ‘use by’ dates and use open foods within two days unless 300 60 er of Report er of Report the manufacturer’s instructions b b state otherwise. 200 40 Num Num 100 20

0 0 2008 2009 2008 2009 / Section 2 28

Cryptosporidium Figure 4. Cryptosporidium reports Cumbria 2008-2009

Cryptosporidium is a tiny 140 organism which can be transmitted through animal-to- 120 human or human-to-human s 100 contact. Cryptosporidiosis can be a water-borne infection; in 80 previous years there were large 60 outbreaks of cryptosporidosis er of Report b which were associated with 40 public water supplies. In 1999 Num there was a large outbreak of 20 cryptosporidium in the North 0 West which was traced to 2008 2009 contamination of the Thirlmere Aqueduct. This aqueduct Figure 5 - Gastro-Intestinal Infection in Cumbria January to carries water from the Lake September 2010 District to large conurbations in the North West of England. 0% 10% Cumbrians also used to be 0% Campylobacter - 76% exposed to risks from 3% 2% Cryptosporidium - 9% contaminated water from E.coli O157 - 2% reservoirs in the West of the 9% County which are now Giardia - 3% protected by filtration. Hepatitis A - 0% Listeria - 0% People may also be infected by Salmonella - 10% consuming contaminated water or food, or by swimming in 76% contaminated water, for example in lakes or rivers. Infection is frequently Figure 5 shows the proportion Standards Agency has associated with foreign travel. of gastro-intestinal infection in identified tackling There was a large increase Cumbria in 2010. The high campylobacter as a key priority (94%) in cryptosporidium proportion of campylobacter and is commissioning a range reports in 2009 compared to infection reflects the national of research to tackle the food 2008, see Figure 4. Some of this picture, that is, campylobacter poisoning bug campylobacter. increase can be accounted to a is the most common bacterial large outbreak of cause of food poisoning, It has been identified by the cryptosporidiosis in the Carlisle causing an estimated 300,000 Health Protection Agency that area in May 2009, this was cases of illness every year in there has been a dramatic associated with several primary England and Wales alone. A change in the age specific schools visiting a working farm recent survey carried out by the incidence of campylobacteriosis that had an open day. Food Standards Agency showed in England and Wales with However there was still a large that campylobacter was older people now being at overall increase in 2009 present in 65% of samples of greatest risk of infection. compared to 2008. chicken tested. The Food / Section 2 29

Top Tips: Keeping food safe 5) It’s especially important to Food-borne infections can be keep raw meat away from avoided if people follow a few ready-to-eat foods such as simple but essential rules for salad, fruit and bread. As the safe storage, preparation the ready-to-eat foods and cooking of food. The won’t be cooked before Health Protection Agency and being eaten, any bacterium the Food Standards Agency that is transferred from the (FSA) issue communication raw foods won’t be killed. throughout the year to remind people of food safety risks and 6) Always cover raw meat and the simple steps to be taken to store it on the bottom shelf avoid food poisoning. of the fridge where it can’t Ten top tips for food safety: touch other foods or drip on to them.

1) Wash hands thoroughly 7) Cook food thoroughly and with soap and hot water check that it’s piping hot all and dry them before the way through. Make handling food and after sure poultry, pork, burgers, handling raw meat, going sausages and kebabs are to the lavatory or touching cooked until steaming hot, animals (including pets). with no pink meat inside.

2) Wash worktops before and 8) Keep fridge temperatures after preparing food, between 0C and 5C. By particularly after they’ve keeping food cold, we can been touched by raw meat, stop food poisoning bugs including poultry or raw growing. eggs. Anti-bacterial sprays don’t need to be used. Hot 9) Cooked food that is not soapy water is fine. going to be eaten straight away should be cooled as 3) Wash dishcloths and tea quickly as possible (within towels regularly and let 90 minutes) and store it in them dry before you use the fridge or freezer. Use them again. Dirty, damp any leftovers from the cloths are the perfect place fridge within two days. for bacteria to breed. 10) Don’t eat food that’s past 4) Use separate chopping its “use by” date boards for raw meat and label. These are based on for ready-to-eat food. Raw scientific tests that show meat contains harmful how quickly harmful bugs bacteria that can spread can develop in the very easily to anything it packaged food. touches, including other foods, worktops, chopping boards and knives. / Section 2 30

Reduce infection risk: Public information ■ Take wellington boots to Petting farms for farm visits wear during the visit and a change of footwear to Visits to petting farms and What are the risks? travel home in. open farms are highly popular Illnesses can occur when germs with families and schools and from animals are transferred How can risks be minimised an important and enjoyable to the mouth. If hands are on the day? aspect of education for placed in or near the mouth Most importantly, children children. Farm visits need not after touching animals, fences, need to be supervised. be discouraged, but people footwear or other surfaces need to remember that a that may be contaminated by The following advice is range of infections can be animal droppings, it is possible applicable to everyone visiting passed on through contact to become unwell. Infection the farm, but particularly to with animals unless care is can also occur when food is children: taken to avoid them. eaten with unwashed, ■ Eat and drink in picnic contaminated hands, which areas only – never while All animals naturally carry a allows harmful bacteria or touching animals or while range of micro-organisms, viruses to be swallowed. walking around the farm. some of which can be This includes not eating transmitted to humans, and How should we prepare for sweets, crisps or chewing may cause ill health. E. coli a farm visit? gum. O157 may be contracted on ■ ■ farms. This organism has little If the farm is open to the Do not eat anything that or no effect on the health of public, check that the public may have fallen on the animals and they show no areas are as clean as ground. signs of illness or distress. E. possible (meaning no ■ If touching or feeding coli O157 however can cause animal faeces), and that animals, ensure that very serious illness, especially animals are not allowed children do not put their in children. Other organisms into picnic areas. Suitable faces close to the animals such as Salmonella, first aid arrangements or put their fingers in their Campylobacter and the should also be in place. own or anyone else’s parasite Cryptosporidium also ■ Check that washing mouths. abound, and there have been facilities are available to ■ Ensure hands are washed outbreaks linked to farm visitors. These should have and dried thoroughly with visits, as well as isolated cases running water, soap and soap and water of infection, in Cumbria and disposable towels or hand immediately after any the North West in recent driers. These should be contact with animals and years, including a large located near to places BEFORE eating and outbreak of Cryptosporidiosis where animals can be drinking. Young children, caused by the touched and also where in particular, should be Cryptosporidium parasite at a food is eaten. supervised while washing dairy farm in Carlisle in 2009 ■ If the visit is with a party of their hands. that led to 155 suspected children, they will need Cryptosporidium cases. The close supervision so it is outbreak highlighted the important to ensure there importance of open farms are enough adults in the providing adequate hand group. washing facilities. / Section 2 31

■ Alcohol hand gels SHOULD Recommendations ■ Priority should be given to NOT be used instead of ensuring that infection hand washing as they are Reducing the number of prevention services not effective against all reports of infections can only remain robust through infections that can be be achieved with everyone the current round of NHS picked up from animals. working together in our reorganisation. ■ Eating areas should be well hospitals and health care ■ Following on from the away from where animals settings and the wider implementation of are located. community. To further general practice consortia, continue downward trends ■ Keep away from sick this aspect of public in infection, I recommend: animals, manure and slurry health should become as these are particularly mainstream within hazardous. If anyone does primary care. come into contact with any of these, ensure hands are washed and dried immediately.

What should be done before leaving?

Ensure that everyone in the group has washed their hands thoroughly with soap and water. Footwear and pushchair wheels should be as free as possible from mud and droppings. Where possible, hose pushchair wheels and boots down with water and change into other footwear. Wash hands after removing and cleaning boots.

NOTE: Additional advice for women who are pregnant Pregnant women need to take particular care and specifically avoid direct contact with lambs and their droppings. / Section 3 32 / Section 3 33 Section 3: Vaccinate for health protection

As well as ensuring good that epidemics of most serious When a vaccination hygiene to reduce the infectious diseases are – owing programme against a disease spread of infection and largely to vaccination begins, the number of people illness, both at home and in programmes – a distant catching the disease goes health care settings, one of memory, have led to general down. But as the threat recedes the best methods to limit reductions in vaccine uptake in it’s important to keep the spread of illness is recent years. vaccinating, otherwise the vaccination. This section disease can start to spread focuses on the importance The updated Code of Practice again. Recent outbreaks of of vaccination for health for the prevention and control measles in London and other protection. of health care associated areas are examples of this, as infections (Health and Social was the outbreak of measles After clean water, vaccination is Care Act 2008) emphasises the over the summer in France; we the most effective public health need for NHS organisations to also saw a rise in cases of intervention in the world for ensure that health care workers Mumps recently in parts of saving lives and promoting are free of and protected from Cumbria. good health. Because of communicable infections (so far vaccination, we no longer see as is reasonably practicable), If enough people in a smallpox, and polio is heading and that all staff are community are vaccinated, it is towards eradication. appropriately educated in the harder for a disease to pass Vaccination has saved more lives prevention and control of between those who are not. and prevented more serious infections. On appointment and This is called herd immunity, diseases than any other medical at regular intervals, clinical and and provides some protection advance in recent history. support staff at NHS Cumbria to those who are not are offered vaccines against immunised, however it is The United Kingdom has an diseases to ensure high levels of important that as many people enviable record on achieving protection and limit the threat as possible accept offers of high uptake rates with some to patients. vaccination if we are to keep areas of Cumbria achieving diseases at bay. some of the best uptake rates in The importance of the country, but some good uptake rates It may be tempting to say ‘no’ geographical areas and some to vaccination and ‘leave it to harder-to-reach groups have Vaccines work by stimulating nature’ instead. seen lower uptake of some our immune system to produce However, deciding not to vaccines than would be ideal. antibodies which make us vaccinate puts us at risk of immune to a disease, without catching a range of potentially Vaccination provides one of the us actually becoming infected serious, even fatal, diseases. In safest and most effective means with it. Vaccination reality, having a vaccination is available for reducing the programmes aim to protect much safer than not having spread of communicapable people for life and have led to one. They are not 100% disease. However recent a drastic reduction in illness effective in every individual, controversies around vaccine and death from infectious but are the best defence safety, together with the fact diseases. against epidemics that used / Section 3 34

to kill or permanently As a result of hard work of our disable millions of children and health care professionals in Seasonal flu vaccine adults. promoting accurate and consistent information and Flu (influenza) is a highly Most people cannot remember allowing parents the time to infectious illness that spreads a time when these very serious discuss concerns fully, update rapidly through the coughs infections were common, so rates are slowly beginning to and sneezes of people who health professionals need to improve in Cumbria. are carrying the virus. remind parents just how dangerous infections such as Another potential obstacle to Each year NHS Cumbria diphtheria, polio and measles being vaccinated is worry over launches a campaign to are. side effects. Most side effects encourage staff and priority from vaccination are mild. It’s groups to come forward for Potential obstacles to quite usual for people to have their seasonal influenza good uptake rates redness or swelling in the place vaccine and get protected where they had the injection, against the virus which can In our country, vaccination is but this soon goes away. Other lead to serious health optional and there are a range reactions, including feeling ill complications such as of reasons why a small number or more severe allergic bronchitis and pneumonia. of people chose not to access reactions are very rare. The vaccination provides 70- vaccinations. It is unfortunate 80% protection, yet as that misinformation and different strains of flu misrepresentation in the media circulate each year, people has led to some public are advised to present for scepticism about the safety of annual jabs because the vaccination programmes. The viruses that cause flu are measles, mumps and rubella always changing. Changes in programme (MMR) in the virus are monitored to particular suffered from the help predict when outbreaks reckless claims made by Dr may occur, and to help Andrew Wakefield. This has led prepare for a pandemic. to the inevitable result that uptake rates declined. In 2009 there were 1144 cases of measles across the UK, with 79 of those in the North West. That’s compared with 70 cases across the whole UK during 2001. / Section 3 35

At-risk groups there were more than 100 vaccination those at particular confirmed cases in the UK and risk including those with It is recommended that on 11 June the World Health existing medical conditions, people have a flu jab if they: Organisation declared a children under 5 and pandemic. By early May cases pregnant women. ■ are 65 or over, had spread to the UK and on District nurses delivered swine 14 June the UK had its first ‘flu vaccinations to all ■ have a serious medical swine flu death. This outbreak housebound “at risk” patient condition such as Chronic demonstrated how quickly as well as those in residential Obstructive Pulmanory the flu virus can change and and nursing homes. Disease, chronic heart spread. disease or are HIV positive, A local public information ■ live in a residential or Antiviral medication for those campaign was provided nursing home, suspected of having the virus through the NHS Cumbria was supplied through a series Communications Team, ■ are the main carer for an of antiviral collection points. particularly in relation to the elderly or disabled person NHS Cumbria worked with the use of personal protective whose welfare may be at voluntary sector who equipment, hand hygiene, Flu risk if their carer falls ill, provided volunteers to act as Friends and the importance of ■ are a health care or social ‘Flu Friends’ for patients who vaccination. care professional directly needed someone to attend involved in patient care, or an antiviral collection point Although not officially ■ work with poultry on their behalf. declared over, pandemic flu Large stocks of gloves, gowns, cases are now very low across ■ Also, this winter (2010-11), goggles and masks were the UK. The experience has the seasonal flu vaccine provided by the Department been useful as a preparation was offered to all pregnant of Health and by the Primary for future pandemics, and has women. Care Trust. General Practices enabled us to work closely and care homes were given with all sectors of the health A pandemic is described by guidance on the procurement service and with partner the World Health of supplies and clear agencies to manage the Organisation as “the guidelines relating to their pandemic locally, rapidly worldwide spread of a new use. implement vaccination disease” programmes and implement There was a need to rapidly emergency plans. An influenza pandemic occurs introduce a new swine flu when a new type of flu virus vaccination programme to run develops and spreads around alongside the usual seasonal the world. The majority of flu programme and help keep people do not have immunity the pandemic under control. to this new strain of virus. NHS Cumbria responded to the pandemic in line with After years of planning for an guidelines drawn up by the influenza pandemic, April Department of Health. In 2009 saw the first cases of Cumbria, GPs and community H1N1 influenza or ‘swine flu’ staff worked closely together in North America. By mid May to bring in the extra swine flu / Section 3 36

Incidence of Cases of Rubella in Cumbria vaccination preventable diseases Cumbria 2005 2006 2007 2008 2009 in Cumbria Confirmed 0 0 1 0 0

Equivocal 0 0 0 0 0 Whilst most people feel the majority of these diseases are Negative 15 2 13 4 5 things of the past it is important to be aware of any Unknown 10 7 2 2 2 increasing trends in some of Total Number 25 9 16 6 7 these traditional infectious of Notifications diseases, for example, whilst there has been very few cases Cases of Measles in Cumbria of rubella (German measles) 2010 and measles in Cumbria in Cumbria 2005 2006 2007 2008 2009 to date recent years the same thing Confirmed 2 0 0 1 0 0 cannot be said of mumps, with 95 confirmed cases in 2009 and Equivocal 1 0 0 1 0 0 whooping cough with numbers Negative 6 6 9 13 4 5 of cases running into double figures in each of the past few Unknown 6 4 4 5 2 2 years. The following charts Total Number show cases year on year, and 15 10 13 20 6 7 of Notifications emphasise the importance of ongoing vaccination Cases of Mumps programmes. 2010 Cumbria 2005 2006 2007 2008 2009 to date Confirmed 68 17 7 29 95 8 Equivocal 0 0 0 1 0 1 Negative 25 15 19 20 38 25 Unknown 242 13 23 24 52 24

Total Number 335 45 43 74 185 58 of Notifications

Cases of Whooping Cough 2010 Cumbria 2005 2006 2007 2008 2009 to date Confirmed 3 0 28 15 14 31 Equivocal 0 0 0 0 0 0 Negative 0 0 0 0 1 0 Unknown 6 3 6 0 4 1

Total Number 9 3 34 15 19 32 of Notifications / Section 3 37

How well does Cumbria’s vaccine uptake rates compare to national rates? Latest available data From April 2010 –end of June 2010

Uptake Age of child Vaccinations Uptake for England for Cumbria 1 years Primary vaccines 93.5% 97.9%

2 years First MMR 88.3% 94.1%

5 years Preschool vaccine 85.7% 92.4%

MMR 1 [1st dose] 91.4% 94.3%

MMR 2 [2nd dose] 92.9% 90.6%

Although we have continued to achieve 95% uptake and over for Primary vaccinations throughout the year, we continue to strive to reach 95% for MMR uptake rates but progress has been maintained.

Flu vaccination programme Every year flu vaccination is offered to people over 65 and those over 6 months who have specific underlying health needs. This programme is run very successfully by GPs and sees large numbers of people receiving protection against the three most likely strains of flu expected to circulate in the winter months.

Over 65

2009/2010 Eligible Vaccinated % Vaccinated

NHS Cumbria 98912 73703 75%

Under 65 in ‘At Risk Categories’

2009/2010 Eligible Vaccinated % Vaccinated

NHS Cumbria 47102 25928 55%

Swine Flu Priority Groups

2009/2010 Eligible Vaccinated % Vaccinated

NHS Cumbria 102939 45403 44% / Section 3 38

Potential new Protecting against The HPV virus is passed vaccines cervical cancer through intimate sexual contact. Because it is so Currently there are no specific Nearly 12 thousand girls in common, most women will plans to introduce new Cumbria had the HPV vaccine become infected at some vaccinations in the UK, but the last year to protect against point in their lives. In most Department of Health are the human papilloma virus women the virus does not constantly reviewing new (HPV). The human papilloma cause cervical cancer, but vaccinations and exploring the virus (HPV) is the name given having the vaccination at a benefits of vaccines available in to a family of viruses that young age is important to other countries. There will be affect the skin and the moist ensure that they are as many more potentially life- membranes (mucosa) that protected as possible when saving vaccines in the years to line the body. There are over and if they do come in come. Research is thriving, with 100 types of HPV. Infection contact with the virus. more than 150 new vaccines with some high-risk types of currently being tested. HPV can cause abnormal The widespread uptake of tissue growth as well as other this vaccine alongside the One of these vaccines is cell changes that can lead to cervical screening Chickenpox vaccine which cervical cancer (cancer of the programme should mean could potential be given with cervix). that in the future the 11 or Measles Mumps and Rubella, as so women who die annually is currently done in other Since 2008, girls aged 12 to from cervical cancer in countries. The Department of 13 (in year 8 at school) have Cumbria can be significantly Health are keen to introduce a been offered the HPV vaccine reduced. Shingles vaccine for older in school each year, with people over the next few years parental consent. There has There is a controversy about but there are currently also been a catch up the most appropriate vaccine problems with the production campaign to give the vaccine to use in this programme. of this vaccine in large enough to older girls aged from 14 to The current vaccine is cervarix quantities. There is ongoing 17, this is due to finish before which protects against the research into vaccines to the next academic year. Up strains of the HPV virus. protect against Meningococcal until the end of August However an alternative diseases and it is possible that special arrangements have vaccine gardacil, which also there may be further vaccines been put in place to allow protects against genital warts available in the not too distant any girls born on or after 1st is being used in other future. of September 1990 to access European countries and there this vaccination via their GPs. is a strong body of clinical In 2009/10 a total of 11,987 opinion in this country girls in Cumbria aged from 12 suggecting switching to this to 18 had the vaccine vaccine. including those in the catch up programme, with over a 93 per cent uptake in the 12- 13 age group. / Section 3 39

Targeting hard to qualified as a Health Trainer. chose to use this to promote reach groups She is now able to promote vaccinations and were vaccinations amongst the welcomed by the Family In 2008 it was estimated that other Travellers in her Support workers who allowed there were at least 770 local community and has led by us use of their caravan for Gypsies and Travellers in example by ensuring that her two days. We were able to Cumbria. In 2009 a report was own children are vaccinated. meet travellers, offer published looking into their information on vaccinations, health needs and this Another issue that was hand out our new leaflet and highlighted, as anticipated, a highlighted was the fact that even offer on the spot low uptake rate for some Gypsies and Travellers vaccinations if requested. vaccinations. Only 42% of the have some issues around Gypsy and Traveller literacy and the standard At the end of July the DOH community parents surveyed immunisation leaflets are announced an outbreak of said their children were fully quite detailed. A new leaflet measles in Gypsy and vaccinated. There are a range has now been designed in Travellers communities so our of reasons for this low uptake consultation with the Gypsies actions were timely. To date and NHS Cumbria’s and Travellers to help to there have been no reported Vaccination Team chose to try address this. cases of measles within the and address some of the main Cumbrian Travellers issues. In the first week of June each community, although it is an year Cumbria hosts the ongoing challenge to Following a review, a number Appleby Horse fair, one of the continue to promote of recommendations were largest gatherings of Gypsies vaccinations to this hard-to- implemented, including a and Travellers from all over reach group. training programme that saw the county and abroad. NHS a local Traveller becoming Cumbria’s Vaccination Team / Section 3 40

Vaccination checklist A number of vaccines are routinely offered to everyone in the UK for free on the NHS.

Recommended Age Who is vaccinated Injection given to protect against

Babies identified as being Tuberculosis (TB) From birth particularly susceptible to these diseases. Hepatitis B (HB)

Tetanus, diphtheria, whooping cough, polio and 8 weeks All babies haemophilus influenza (one injection) Pneumococcal (one injection)

Tetanus, diphtheria, whooping cough, polio 12 Weeks All babies and haemophilus influenza (one injection) Meningitis C (one injection)

Tetanus, diphtheria, whooping cough, polio and 16 Weeks All babies haemophilus influenza (one injection) Pneumococcal (one injection) Meningitis C (one injection)

From 6 months “at risk” babies and children Influenza vaccination in the autumn annually All over 65 years

Booster dose of Pneumococcal (one injection) Hib/men C From 12 months All babies (one injection) Measles, Mumps and Rubella (MMR) first does (one injection)

Those who have other health From 2 years of needs that make them susceptible Pneumococcal vaccinations (adult vaccine) age and over and all those over 65 years of age

Tetanus, diphtheria, whooping cough and polio 3½ - 4 years All children (one injection) Measles, Mumps and Rubella (MMR) second dose (one injection)

HPV (human papilloma virus). Cervical cancer protection 12 - 13 years Girls only given in year 8. Three doses required.

Diphtheria, tetanus and polio booster usually given 14 - 15 years All children in year 10.

Range of vaccines. Book a GP appointment several months Travel vaccines Travellers all ages before travelling to discuss.

Occupational Range of vaccines, employees should be told by their Variety of occupations vaccines employer if they require vaccination.

People who fall into certain risk groups may be offered extra vaccines. These include vaccinations against diseases such as hepatitis B, tuberculosis (TB), seasonal flu and chickenpox. / Section 3 41

Recommendations

In order to continue to see a decline in preventable illness, and ensure a high uptake of available vaccines, I recommend that:

■ We continue to promote the importance of vaccinations, by ensuring our staff pass on accurate information on the importance of vaccinations at all appropriate opportunities. ■ We continue to ensure that all staff delivering vaccinations are trained to the highest level and regularly updated. ■ We endeavour to be as flexible as possible in our delivery of vaccination programmes to ensure they are accessible to all that require them ■ We continue to offer advise and support to anyone with concerns about vaccinations. ■ We continue to encourage good uptake in vaccinations in as many ways as we can, to enable us to reach the required levels of vaccine uptake to protect the population, [especially those who are not able to be vaccinated]. / Section 4 42 / Section 4 43 Section 4: Screening programmes for early detection

Previous sections have improve the quality of life for question or offered a test, to looked at the importance of those affected. The NHS Breast identify those individuals who prevention and protection Screening Programme, for are more likely to be helped against illness and infection. example, saves over 1,400 lives than harmed by further tests or In this section I will a year in England. treatment to reduce the risk of introduce the importance of Testing or case finding happens a disease or its complications’. screening for early detection on a GP’s recommendation to and to identify those identify the underlying causes It is important to recognise that members of the community once symptoms present. In the people who are being who may be at heightened diagnostic testing, offered screening do not risk of developing certain asymptomatic people are consider themselves to be ill. conditions and serious invited for further This makes screening services illness. investigation. Common tests unusual compared with many include: other health services which are Health checks can fall into two targeted towards people with different categories: ■ Height and weight known health problems. screening, which is a ■ Blood tests systematic process applied to The aim of screening is to ■ Urine tests to check good populations, and testing or identify those who are more kidney function case finding, which is carried likely to be helped than out on individual people who ■ Blood glucose test for harmed by further tests or are in contact with health diabetes treatment to reduce risk. So services. ■ Peak flow lung function screening does not aim to tests identify disease, but rather to Screening is a process whereby ‘sieve out’ those who may be at ■ a population is assessed for an Allergy tests increased risk. This statement increased risk of certain ■ DEXA bone scans for also introduces the idea that diseases before they present osteoporosis. screening and any follow up with symptoms, and helps to investigation or treatment has catch and treat serious the potential to cause harm conditions sooner. The What is screening? through worry or unnecessary intention being that illness can tests, as well as benefit, and be identified early and a The United Kingdom National that this must be taken into programme of treatment Screening Committee (UKNSC) consideration when developing started. Screening is an defines screening as ‘a public a screening service. important public health service, health service in which which has the potential to save members of a defined lives and reduce risk to health. population, who do not There are several major necessarily perceive they are at national screening programmes risk of, or are already affected available in England that save by a disease or its thousands of lives a year and complications, are asked a / Section 4 44

The history of develop in several countries. individuals, and have screening In the 20th century, employers successfully reduced deaths and life insurance companies from a number of life limiting It is over 150 years since the began to encourage regular conditions. concept of identifying future health checks for their health risks of individuals first employees and policy holders, Gray M, Raffle A (2007) came about. Dr Horace Dobell whilst in Japan in the 1950’s Screening Evidence and gave a series of lectures in senior business executives Practice OUP : Oxford p1 1861 suggesting that doctors were admitted to hospital for should perform periodic five days of health checks for checks on everyone regardless what was known as the of if they were ill. Slowly the ‘human dry dock’. Screening concept of regular and non programmes are now well specific health checks for established as an effective adults and children began to means of identifying at-risk

Types of screening Before birth and early Later childhood programmes childhood ■ Diabetic retinopathy In Cumbria we run a full range ■ Antenatal screening for screening for all people with of screening programmes pregnant women, including diabetes aged 12 and over. offered to people at different examinations for Down’s stages in their lives (See NHS syndrome, foetal Screening Timeline). Everyone abnormalities and some Adulthood registered with a GP will infectious diseases. ■ Cervical cancer screening for automatically receive ■ Newborn screening, which all women aged 25 and over. invitations for relevant includes a top-to-toe screening tests throughout physical examination, a ■ Breast cancer screening for their life. People don’t have to hearing test and a ‘heel all women aged 50 and take up these invitations, but it prick’ or ‘blood spot’ test to over (the age range of is strongly advised that they do. check for cystic fibrosis, women eligible for breast All screening tests are congenital hypothyroidism, screening will extend from scientifically proven to be phenylketonuria, medium age 47 by 2012). effective and could mean that a chain acyl CoA ■ Bowel cancer screening for serious condition is spotted dehydrogenase deficiency all men and women aged 60 early, when it may be easier to and sickle cell anaemia. and over. treat. Before birth and in early ■ life, the focus of screening is on Childhood screening: checks ■ Abdominal aortic aneurysm developmental, hereditary and for height, weight, vision (AAA) screening for men metabolic conditions. Later in and hearing, all grouped aged 65. life, there is an emphasis on the under what is known as the early detection of cancer. They school entry health check. include: NHS Screening Timeline

Age 80+

Age 75

AAA Screening Abdominal aortic aneurysm Age 70 Offered to all men in their 65th year. Men over this age are able to self-refer Age 65 Bowel Cancer Screening Offered to men and women aged 60 to 69 every 2 years Age 60

Breast Screening Offered to women aged Age 55 50 to 70 every 3 years. Women aged 70 or over can self-refer Age 50

Age 45

Age 40

Age 35

Cervical Screening Offered to women aged Age 30 25 to 49 every 3 years & to women aged 50 to 64 every 5 years Age 25

Age 20 Diabetic Retinopathy Screening Age 15 Offered annually to people with diabetes from the age of 12 Age 10

Age 5 Antenatal & Newborn Screening There are 6 antenatal and newborn screening Newborn programmes and these screening tests need to be carried out at set times.

Please see the antenatal and newborn timeline Week 27 for full details of the optimum times for testing. Visit: http://cpd.screening.nhs.uk/timeline

Week 18 • Sickle Cell and Thalassaemia • Infectious Diseases in Pregnancy • Down’s Syndrome and Fetal Anomaly Week 9 Ultrasound Screening • Newborn Hearing • Newborn and Infant Physical Examination • Newborn Blood Spot Conception

www.screening.nhs.uk/england

Source: UK National Screening Committee and NHS National Screening Programmes (www.screening.nhs.uk/nhs-timeline) / Section 4 46

Limitations of A balance must be struck every two years to all men and Screening Programmes between the cancer detection women aged 60 to 69. In the rate and having an acceptable third quarter of 2008, 9954 Screening has the potential to level of investigations carried invitation kits were issued to save lives or improve quality of out on people who are invited the target group, inviting life through early diagnosis of for screening and ultimately are individual to submit a sample serious conditions, but it is not found to have no abnormality. for screening. A further 83 test a fool-proof process. Screening As a result, programmes can kits were requested by people can reduce the risk of never deliver a 100% detection who were outside the age developing a condition or its rate, and during any one range where kits are complications but it cannot screening round, a proportion automatically sent. offer a guarantee of of very small cancers will not be protection. detected. This is true of any Polyps (like skin tags but inside screening programme. the bowel) and bowel cancers Medical tests are not perfect. In sometimes bleed, and the test any test, there is an irreducible Recent developments that individuals are invited to minimum of false positive in Screening in use is called a ‘faecal occult results (wrongly reported as Cumbria blood’ (FOB) test. This works by having the condition) and false detecting tiny amounts of blood negative results (wrongly Bowel Cancer Screening which cannot normally be seen reported as not having the in bowel motions. ‘Occult’ means hidden. The FOB test condition). The National In the UK, around one in 20 does not diagnose bowel Screening Committee is people will develop bowel cancer, but the results will increasingly presenting cancer during their lifetime. It indicate whether further screening as ‘risk reduction’ to is the third most common investigation (usually a emphasise this point. cancer in the UK, and the colonoscopy) is needed. second leading cause of cancer Because screening is offered to deaths, with over 16,000 The test is processed and the people who are essentially people dying from it each year. healthy, there is a limit to how results returned within two weeks. People who receive an extensive screening can be In Cumbria bowel cancer is the abnormal result will be invited while remaining acceptable. third greatest cause of cancer to an appointment with a Using the example of breast death in men after lung and specialist nurse. The nurse will screening, women aged 50 to prostate cancer, and the third explain what a colonoscopy 70 years are invited every three commonest in women after involves, assess the patient’s years for a mammogram (an X- lung and breast cancer. There fitness for the procedure, and Ray examination of the were 162 deaths in Cumbria on answer any questions. breasts). A small percentage of average between 2003 and these women will require 2005; in 2007 there were 161. Of the kits issued in Cumbria, further investigation and this Nationally the five year survival 6,310 were returned which will involve attending an rate is 52.1%. In Cumbria the means an uptake rate of around assessment clinic and position is similar at 52.9%. 63%. Of the returned kits 152 undergoing various further To help tackle the illness, bowel gave a positive result. The tests. There is a great deal of cancer screening was launched number of kits sent out in anxiety associated with this, in Cumbria in 2008 and is 2009/10 has risen steadily and but most of these women will delivered in partnership with overall the programme has an not to have any significant NHS North Lancashire. The NHS uptake rate of 68%, with 1.75% disease. Bowel Cancer Screening of these tests showing a positive Programme offers screening result. Overall the uptake rate / Section 4 47

in Cumbria is higher than the national target of 60%. Chlamydia: Know website. In addition, a However there is some variation Best to Test number of promotional in uptake between localities events were arranged around and amongst different Chlamydia is the most the county and in school and population groups. Such common sexually transmitted colleges to raise awareness of variation has the potential to infection in the United the importance of regular contribute to health inequalities Kingdom. The NHS National screening, especially when and presents an opportunity to Chlamydia Screening with a new sexual partner. improve performance overall. programme has been running National data indicates that since 2003, and targets In the summer of 2010, a regular bowel cancer screening people under 24. Uptake has team from NHS Cumbria has been shown to reduce the been variable, particularly for manned specially hired luxury risk of dying from bowel cancer those in the target group ‘Best Loos’ to raise awareness by 16 per cent. who are not in education. of the screening programme Between April and at the annual Kendal Calling September 2010 a total of music festival. 4,764 tests were carried out Some risk factors in Cumbria: 2,550 among In total, 765 tests were for bowel cancer those aged 15-19 years and collected – representing 2,214 among those aged 20- around 1 in 10 of all the Age - bowel cancer can festival goers. Freebies were occur in younger people 24 years – this is below the national average for testing. offered such as glow in the but 8 out of 10 people who dark condoms, sperm key are diagnosed with cancer 7.0% of young people tested positive for the infection in rings and sugar free heart of the bowel are over the shaped lollipops. In addition, age of 60 Cumbria compared with 7.1% in the North West and 5.6% all screens received over the A previous bowel polyp across England. three day event were entered Personal history of chronic into a prize draw to win high bowel inflammation The case for a Chlamydia street shopping vouchers. The test for chlamydia involves Diet – a diet that is high in screening programme is strong because not only is the collecting a small urine red meat and fat and low in sample which is then sent to vegetables, folate and fibre infection symptomless, if left untreated it can significantly a lab for testing. Participants may increase the risk of are then contacted discreetly bowel cancer damage a person’s future reproductive and long term via their chosen method with Lack of exercise - physical health; yet the their result. This is usually moderate exercise may help condition can be detected within a couple of weeks of prevent bowel cancer relatively easily through a taking the test. If someone’s Obesity - being overweight simple urine test. test is positive they are or obese may increase the In early 2010, a ‘Best 2 Know’ advised how to obtain risk of bowel cancer campaign was launched to treatment which is usually just one course of antibiotics. Smoking and alcohol - increase uptake of screening although not as strong a in Cumbria. Free, confidential Visit: risk factor as for other test kits are available in a www.best2know.co.uk cancers, smoking and variety of primary care for more information. drinking heavily may also locations. Young people can increase the risk of bowel also request a postal test kit cancer. by text or through the Best 2 / Section 4 48

Future plans for Abdominal Aortic Once fully implemented, the Screening in Cumbria Aneurysm Screening programme will invite all men for screening during the year Breast Cancer The NHS Abdominal Aortic that they turn 65. Men who age expansion Aneurysm (AAA) Screening have an aneurysm detected Programme has been gradually through screening will be offered treatment or The NHS Breast Screening introduced across England from monitoring depending on the Programme will extend the age Spring 2009. The aim of the size of the aneurysm. Cumbria range of women eligible for Programme is to reduce deaths is part of the Cumbria and breast screening to ages 47 to from abdominal aortic Lancashire AAA programme. 73 over time. The current age aneurysms (also called ‘AAAs’ The Cumbria and Lancashire range is 50 to 70. An extra or ‘Triple As’) through early Programme will offer AAA 200,000 women a year will be detection. An AAA is a screening for the population of screened in the UK. Future ballooning of the abdominal the six primary care trusts developments in the breast aorta, which is the largest covering a total population of screening programme will artery in the abdominal cavity. 1.9 million. include the introduction of The NHS AAA Screening digital mammography to Programme has been Other screening opportunities replace the traditional film introduced following research which might become available system currently used in most and analysis of data from nationally and across Cumbria places. existing local screening in the future include Alcohol programmes in England which A large national study is Screening and Prostate Cancer. underway investigating the show a reduction in mortality effectiveness of mammography from AAAs when men are in women who have a strong offered ultrasound screening in family history of breast cancer. their 65th year. The evidence Ten thousand women aged 40- was assessed by the UK 44 with a significant family National Screening Committee history are being recruited and (UK NSC) against a set of offered annual two-view internationally recognised mammography for five years. criteria which have confirmed The incidence by size, node that screening all men aged 65 status and histological grade can deliver benefits to men at a will be compared with a reasonable cost. contemporaneous comparison group and a historical comparison group. / Section 4 49

Recommendations each of the screening and encourage friends and programmes, as evidenced in relatives to do the same As we become older, we are the recent service failure of ■ People must always be more likely to develop a breast screening in North alert to changes in their range of conditions that are Cumbria. bodies that could rare in younger people. potentially be signs of Therefore it is vital that To continue to improve early illness, so women should people in Cumbria are aware detection rates and screening still be on the lookout for of the value of screening programme uptake in changes in their breasts programmes and take up the Cumbria, I recommend that: even if they have recently opportunity for screening had a screening test, and ■ when offered. Screening tests Communications specialists people should still report a are never 100% accurate and and health promotion change in bowel habit or it is important to be aware of practitioner’s work bleeding even if they have changes in our body, for together to deliver recently had a bowel example breast lumps, or a campaigns that highlight screen change in bowel habit, and the importance of seek medical advice if screening programmes for Further information on worried. targeted groups in the screening in Cumbria is region. available in my report, There are a number of ■ People in Cumbria take up “Health Screening in Cumbria: potential areas for the opportunity for a Public Health Service – improvement and greater screening when invited, January 2011”. assurance of quality across / Section 5 50 / Section 5 51 Section 5: Injury and violence

Each year in Cumbria there high likelihood of resulting in behaviours or difficulties in are a number of deaths and injury, death, psychological maintaining effective serious injuries resulting harm, maldevelopment, or relationships in adult life. from traffic accidents, deprivation”. drowning, poisoning, falls or burns - and violence - from Violence is among the leading Where can victims assault or self-inflicted causes of death for people get help? violence. These types of aged 15-44 years worldwide, accidents are often accounting for 14% of deaths Don’t wait for an categorised as ‘external among males and 7% of deaths emergency situation to seek causes of injury’. This among females. Violence covers help. Victims of any type of section features some many areas, from intimate domestic violence can: examples of external causes partner violence, male on male of injury that we see most violence, violence towards ■ talk to a doctor, or other often in Cumbria. I explore children and elder violence. health care professional measures to reduce mortality from road traffic Domestic violence is a ■ call 0808 2000 247, accidents and discuss particular distressing issue, the 24-hour National violence prevention, and accounting for nearly 25% of Domestic Violence introduce the recently all recorded violent crime in Helpline run in launched suicide prevention Cumbria despite being the partnership strategy. I also look at most under reported crime between Women’s Aid farming as a hazardous nationally. The abuse can be and Refuge (calls from a occupation in Cumbria. physical, mental or even landline are free) financial. One in four women ■ Visit www.notinmy Violence prevention (and one in six men) in the UK home.co.uk to report in Cumbria will be the victims of domestic domestic violence violence during their lifetime, ■ call Cumbria according to research In recent years, there has been Constabulary 0845 33 00 estimates. Two women a week major growth in the 247 understanding of how violence are killed by a current or ■ burdens communities and former male partner. in an emergency, call 999 contributes to a wide spectrum of health consequences and For every person who dies as a health risk behaviours in result of violence, many more children and adults. The World are injured and suffer from a Health Organisation describe range of physical, sexual, violence as “the intentional use reproductive and mental health of physical force or power, problems. There is also a wide threatened or actual, against body of research into the oneself, another person, or lasting effects on children who against a group or community, witness violent incidents and which either results in or has a then go on to display similar / Section 5 52

NHS Cumbria works in Cumbria Local Safeguarding The Cumbria Domestic Violence partnership with a number of Children Board has the lead Partnership was established in agencies to provide a responsibility to coordinate and 2003. Its main aim is to ensure coordinated approach to ensure the effectiveness of high quality domestic violence research, guidance and local work to safeguard and services are consistent support, staff training and promote the welfare of throughout the county. The education programmes on all children. Cumbria Local partnership brings together elements of violence and Safeguarding Children expertise, resources and aggression. This is coordinated Board has produced multi- commitment, with partners through Crime and Disorder agency Safeguarding from statutory, voluntary and Reduction Partnerships and the Procedures in accordance with private sectors to tackle Trauma and Injury Intelligence government guidance in ‘What domestic violence in Cumbria. Group which works to improve to do if you are worried a child data sharing and collection of is being abused’ and the injury statistics from emergency updated ‘Working Together to departments. Working groups Safeguard Children’ which was are also established to tackle published in March 2010. For safeguarding and domestic further information go violence. to www.cumbrialscb.com.

Alcohol and Violence midnight and 4am on Often these types of incidents Friday, Saturday and are not premeditated, but a There is a wide body of Sundays. result of tensions boiling over evidence that demonstrates and are fuelled by alcohol. In the link between drinking too Research also demonstrates these situations people often much alcohol and increases of increases of violence incidents reach out for the nearest violence and reckless or during public holidays such as weapon, which on our streets dangerous behaviour. Christmas, or large social and in pubs and clubs at the events. For example, assault weekend is glass. According to research carried attendances in Emergency out in Cumbria, the majority of Departments across Cumbria, Polycarbonate glasses are assaults occurring in the Lancashire and Merseyside already used by some bars and county happen in the early during the 2006 World Cup clubs for people drinking hours of the morning at the increased by an average of outside. They are made from weekends – a prime time for 33% on England match reinforced plastic which is very the consumption of alcohol. days. The NHS increasingly has difficult to break and are to deal with assault victims available in different styles, ■ Over 40 per cent of people who’ve been attacked where which look like existing glass who go to A&E or a primary alcohol is a contributing factor. tumblers. If we take away the care assessment service These are also increasingly by ability to use such a vessel as a because they’ve been someone using a glass as a weapon, by replacing glasses assaulted, do so between weapon. These types of with their polycarbonate midnight and 4am on injuries are not just complex to counterparts, then we have Friday, Saturday, Sundays. treat with many people essentially removed weapons requiring facial reconstruction, from the street. ■ Over 60 per cent of but there is also significant ambulance call outs due to psychological impact on the assaults also occur between victims. / Section 5 53

Safer Roads for Figure 6. shows the KSI (killed and seriously injured) road users in Cumbria Cumbria, on a year-by-year basis since 2005.

The two groups of people that Accidents In: 2005 2006 2007 2008 2009 2010 are most likely to become casualties on our roads are January 26 16 34 23 16 12 young people aged between 16 February 48 13 22 15 17 10 and 25 and motorcyclists. March 25 30 37 19 17 11 During 2009 young people April 36 26 56 32 19 29 were involved in 25% of road fatalities and 32% of serious May 31 24 16 25 22 44 injuries. Motorcyclists June 42 37 24 24 28 14 accounted for 13% of the fatalities and 29% of the July 39 36 20 32 18 17 serious injuries. August 37 43 26 28 29 28 For these reasons many of our September 33 36 23 16 31 17 initiatives to improve road safety are targeted at these October 39 22 23 16 25 15 two groups of people. November 37 36 23 21 14 8 December 34 25 15 30 11 20

Road safety focuses on a number of areas from speeding to road safety education in schools. / Section 5 54

Cumbria Road Safety Partnership (CRSP) was established in 2004. It has just one objective: to reduce the number of people who are killed or injured on Cumbria’s roads. The CRSP is made up of members from all the organisations that are concerned with road safety and ■ ■ includes representatives from Cumbrian Pass+ Scheme Local Campaigns NHS Cumbria, Cumbria The Cumbrian Pass Plus Scheme The Partnership runs a number Constabulary, Cumbria Fire and targets young drivers aged 17 – of campaigns each year using a Rescue Service, Cumbria Safety 20 who have recently passed range of media such as local TV Cameras and Cumbria Highways their driving test. The scheme and radio, buses and the local Agency. provides them with additional press to deliver messages across subsidised driving instruction to our target groups. We try to Outlined below are just some of and all people enrolled on the make these relevant to the programmes that have been course must also attend a Road Cumbrian people by giving the implemented in Cumbria during Awareness Training programme. messages a distinctly local the year. Pass+ teaches young people flavour. how to drive safely in a variety ■ Road Awareness Training of different road conditions While we are seeing a year on including rural roads, year reduction in the number This educational programme is motorways and night driving. of serious accidents on delivered by Cumbria Fire and Cumbria’s roads we want to see Rescue Service to children in Upon successful completion of this trend continue. their final year at school before Pass+ participants are eligible to they are able to learn to drive. receive a reduction in their Each year Cumbria strives to The programme is designed to insurance premiums. During reduce the number of road raise young peoples’ awareness 2009/10, 799 young Cumbrians accidents. We have targets to of dangers on the roads and the successfully completed Pass+ reduce the number of people outcomes to both themselves training. This represents 19.2% killed or seriously injured on and others if they cause or are of Cumbrians aged 17 – 20 who the roads. involved in a road traffic passed their driving test during collision. the same time period. The government target for 2010 is for the total number of ■ National Cycle Standard ■ Ride Safe Back Safe people killed or seriously This cycle training course has This initiative works with injured on Cumbria’s roads to replaced the previous cycling motorcycle, moped and scooter reach a maximum of 305. proficiency course. The new riders to highlight the benefits course teaches children to of voluntary rider training, to We have seen a steady become more aware of hazards promote the wearing of good reduction in the number of on the road. This year the quality protective clothing and people harmed on our roads Department for Transport to encourage all drivers to and continue to strive to awarded Cumbria Road Safety ‘THINK Bike and THINK Biker’. improve road safety in Partnership a record local Cumbria. authority cycle training grant of £160,000 to support National Cycle Standard training across Cumbria / Section 5 55

A Suicide Prevention areas, suicide accounts for Prevention Reference Group Strategy for Cumbria about 16% of inequality in whose aim is to prevent premature mortality, making avoidable loss of life through It is particularly poignant that suicide the second most suicide in Cumbria. in the most beautiful county in important contributor to the country where the social inequality in premature At the moment Cumbria will cohesion of its communities is mortality in Cumbria after fail to reach the Government so prized, the suicide rates circulatory disease. As in the set target for reducing the should are so much higher than rest of England, three times as numbers of these sad and when compared to the country many men die through suicide tragic events. Until now we as a whole. than women. Rurality and the have had no adequate farming profession are known framework and strategy to Around 50 people die through risks for suicide in Cumbria. ensure that our collective suicide each year in Cumbria. efforts achieve results in this Our suicide death rate is Many deaths through suicide area. However the recently significantly higher than the are preventable. Individuals launched Suicide Prevention average for England, with social and economic factors, as Strategy for Cumbria aims to about 10-15 more suicides a well as access to health and change this. It builds on the year in Cumbria than expected. other services can increase Suicide Prevention Local Suicide rates are also falling people’s vulnerability, or Implementation Framework more slowly in Cumbria than in conversely, increase their published by the Care Services the rest of England. resilience to adverse life events. Improvement Partnership in 2006 and draws heavily on the Although deaths through Because the reasons for suicide recent epidemiological review suicide represent only 1% of all are complex, its prevention of suicide in Cumbria. We now deaths in Cumbria, they requires concerted action at have the basis for making a account for about 6% of years many levels. This is why a wide real difference and saving the of life lost to premature death. range of agencies, as well as lives of people whose deaths This is because suicide rates are service users and carers, were are a waste in themselves and highest in younger people. In brought together in January so often blight the remainder addition, because suicide rates 2009 by Cumbria’s Mental of the lives of those affect disproportionately Health Care Stream Board to surrounding them. people living in more deprived form the Cumbria Suicide / Section 5 56

Farming in Cumbria: The most common causes of Recommendations A hazardous death are: occupation The subject of injury and ■ transport – being struck by violence covers a wide moving vehicles; Farming is a hazardous number of public health occupation. The industry ■ falls from a height; issues, and requires a coordinated, multi-agency represents approximately 1.8 ■ being struck by a moving effort to tackle some of the per cent of the workforce in or falling object, for prevailing issues. Great Britain but accounts example bales, trees etc; for about 19 per cent of the ■ reported fatal injuries each being trapped by I recommend that: year. something collapsing or overturning; ■ Work should continue to Farmers and farm workers ■ contact with machinery; improve our work with potentially understanding of injury ■ injury by an animal; dangerous machinery, and violence in Cumbria, vehicles, chemicals, livestock, ■ asphyxiation or drowning; and especially of threats at heights or near pits and ■ contact with electricity, to health in agricultural silos. They are exposed to the nearly two-thirds of which communities in order to effects of bad weather, noise involve overhead power produce a more and dust. lines. effective approach to prevention. Together, these factors can Agriculture is now the most make farms dangerous and dangerous industry in the often isolating places to country, based on accidents work, and there’s no doubt per worker. that many farming operations involve significant hazards that can result in injury or worse. The risks also include family members working at the farm and children living at the farm. Over the last ten years, 455 people have died in accidents on British farms and 1,700 were seriously injured. Some 38 of those deaths came last year. Sadly, provisional figures indicate that there have been a further 26 agriculture related deaths since those statistics were compiled, all with a tragic story which will have a real and lasting impact on the families and businesses involved. / Section 5 57 / Section 6 58 / Section 6 59 Section 6: Healthy workplace

We spend a large amount of The sheer scale of the numbers workplace. Many pieces of time in the workplace, of people on incapacity legislation that cover things therefore it is vital that benefits represents an historical such as working hours, rest employers take an active failure of health care and breaks and working conditions role in encouraging health employment support to address are in place to ensure that and well being and the needs of the working age employees are supported in the providing a safe population in Britain. The workplace. On July 1st 2007, environment. That is the problem is not just with the England introduced a new law focus for this section, which existing caseload. Each year, to make virtually all enclosed explores healthy workplace 600,000 people move onto public places and workplaces in initiatives and steps incapacity benefits. The system England smokefree. employees can take to is failing those with common promote wellbeing. health condition, who, with the A smokefree England ensures a right support, could instead healthier environment, so For most of us, work is good have maintained their job and everyone can socialise, relax, for our long-term health and progressed in the workplace. travel, shop and work free for a family’s well-being and is from secondhand smoke. an essential part of a happy Lack of appropriate and fulfilling life. Yet the information and advice is the benefits to both employers and most common barrier to employees of promoting health employers investing in the and wellbeing at work have health and well-being of their only recently been recognised. employees. This is particularly true for smaller organisations, The economic cost of sickness yet there are many initiatives absence and worklessness to support a healthy associated with working-age ill workplace, and many small health is over £100 billion a actions and signposting that year – greater than the entire can help. budget for the NHS and equivalent to the GDP of The economic benefits to Portugal. promoting a healthy workplace and workforce are With the publication of Dame unquestionable. Yet due to the Carol Black’s review, Working time many people spend in for a healthier tomorrow, in work, the benefits of March 2008, the issue of promoting good mental health, health, work and well-being exercise and healthy living in and the links between them the workplace is also vital for are now firmly on the the long-term health of the Government’s agenda. working population. National initiatives are helping to promote a healthier / Section 6 60

Many larger workplaces have Sick note to fit note possible with some help occupational health support, or – helping people from the employer. employee support through a stay in work HR department. A number of The doctor may include some initiatives can support a healthier workforce including On the 6 April 2010 the sick comments which will help programmes to address: note was replaced by the fit the employer understand note. how the employee is affected by the condition. If Stress – highlighting the issues and producing targeted advice Evidence shows that work is appropriate, they can also for employees and managers generally good for your suggest one or more on their role in managing it. health and that often going common ways to help back to work can actually aid facilitate a return to work. Bullying – highlighting the a person’s recovery. On the This could include: issues and producing targeted other hand, staying off work ■ advice for managers and staff, can lead to long-term a phased return to work - as well as promoting absence and job loss with the where the employee may improvements in working risk of isolation, loss of benefit from a gradual relationships, communications confidence, mental health increase in work duties or and dignity at work. issues, de-skilling and social working hours, for Violence and aggression – exclusion. example after an operation or after injury taking a no tolerance approach to violence and aggression in The new fit note can help. ■ the workplace, and increasing Doctors are able to advise altered hours - allowing the number of prosecutions people who are on sick leave the flexibility to start or against perpetrators. for over 7 days whether, with leave later, for example if extra support from their the employee struggles Manual handling – working employer, they could return travelling in the 'rush to reduce the number of back to work earlier. hour' injuries and to provide training ■ in effective manual handling. Understanding amended duties - to take into account the the fit note condition, for example Stop smoking support removing heavy lifting if services – complying with When a doctor provides a fit the employee has had a smoke free legislation and note they will advise on one back injury signposting to stop smoking of two options. Either the services. employee is 'not fit for work' ■ changes to the workplace or 'may be fit for work'. - to take into account Healthy canteen – larger 'Not fit for work' medical condition, for employers are encouraged to The doctor will choose this example allowing the provide healthy meals and option when they believe employee to work on the snacks in staff restaurant areas. that the health condition will ground floor if they have prevent a return to work for problems going up and a stated period of time. down stairs 'May be fit for work' the doctor will choose this Find more details online option when they believe atwww.dwp.gov.uk/fitnote that a return to work may be / Section 6 61

NHS Cumbria’s Stop Workplace Specialist Stop as time is not taken for Smoking Service Smoking Advisors role unscheduled smoking breaks involves approaching and overall the health of the NHS Cumbria’s Stop Smoking workplaces and providing on workforce is improved. Service offers a range of site support to workers to support services from one-to- stop smoking. The Specialist Advisor is one appointments with a stop currently working with smoking advisor, to telephone This approach offers benefits Cumbria Trades Union consultations and group to both employers and Congress to develop a joint support where clients can quit employees. approach to wellbeing in the together with family and workplace. friends. The service also For the employee they are provides specialist support for given a priority referral to the expectant mothers and their Stop Smoking Service. They families. provides healthy are seen on site during work workplace stop smoking time which saves both advise, and has a dedicated personal time and travel. resource to help organisations Nicotine Replacement reduce smoking within their Therapy is made available via workforce. prescription.

In 2009/10 the service helped On average, non smokers take 3,732 smokers across Cumbria fewer sick days than smokers. to quit, with a further 5,958 Therefore ultimately setting a quit date. employers will see reduced absenteeism. There is likely to be an increase in productivity

Recommendations being so substantial, there is a ■ NHS Cumbria should strong case for a county wide continue to develop its Individuals have a service in Cumbria. involvement in the fundamental personal provision of work-related responsibility to maintain their Ultimately, no efforts from health interventions and own health. employers or health care occupational health professionals will be effective services, to ensure a holistic Occupational health has unless individuals actively seek approach to occupational traditionally never been part to remain in or return to work health that supports both of the NHS, other than for its and do not assume that being those in work, and those own employees, yet with many signed off work with a health seeking work. employers to date having condition is always necessary failed to provide access to or beneficial, yet in order to adequate occupational health, ensure a coordinated effort to and the associated costs to the improve workplace health, I taxpayer and the economy recommend that: / Section 7 62 / Section 7 63 Section 7: Health protection and hard to reach groups

Reducing inequalities in Average life expectancy in Moss Smoking, excessive use of health and health provision Bay, Allerdale, is 72 whilst in alcohol, a bad diet and lack of is a key priority for the Greystoke, Eden, it is 91. The exercise all contribute to ill- Cumbria Public Health Team death rate for cancer in Barrow health. Concerns in Cumbria and NHS Cumbria. This is 11% higher than the England that have an implication on section explores health and Wales average, and in health protection include: inequalities in Cumbria, and Carlisle it is 7% higher. This in particular looks at compares markedly with the ■ Relatively large numbers of methods that have been death rate for cancer in South people living in housing that used to engage with hard to Lakeland which is 13% lower is in poor condition reach groups, particularly than England and Wales. It is ■ High levels of fuel poverty the Gypsy and Traveller clear to see the link between community in Cumbria. deprived areas and associated ■ A low proportion of the influences on health such as workforce educated to degree level or higher Cumbria is regarded as one of access to high-quality housing, the most scenic parts of employment, crime levels and ■ Low employment levels England, yet this beauty masks education all have an effect on amongst people with pockets of deprivation and health. disabilities inequality around the county. ■ On average men in Cumbria Carlisle and Barrow have been The Index of Multiple lose 10 months of life, and designated by the Department Deprivation ranks Cumbria as women 4.5 months, directly of Health as Spearhead areas, the 84th most deprived out of attributable to alcohol the 149 county councils in as they are in the most ■ 50-60 suicides each year England. deprived 20% of the English population. Of the 354 local authorities, NHS Cumbria is committed to when ranked in order of For the worst districts in reducing inequalities in the deprivation, four of Cumbria’s Cumbria to ‘level up’ with the health of our population. We six localities (Allerdale, Barrow, best, 270 premature deaths are also committed to ensuring Carlisle, Copeland, Eden, and need to be prevented annually. that all members of our South Lakeland) fall below the This includes: population have equal access national average: Barrow in to our services. This is a Furness is ranked as the 29th Accidents 8 deaths commitment in the Strategic most deprived district council in Plan, and will feature heavily in th Coronary Heart the country, Copeland the 84 , Disease 50 deaths developing plans for GP Allerdale 105 and Carlisle 108. consortia. Eden’s position at 200 and Stroke 16 deaths South Lakeland’s at 258, places Lung cancer 34 deaths them above average. Suicide 8 deaths Breast cancer 6 deaths All cancers 67 deaths / Section 7 64

Under the government’s Engaging with hard- Gypsies and Travellers changes, GP consortia (very to-reach groups similar to our current GP-led Cumbria has a relatively large localities) will take over Hard-to-reach patients are Gypsy and Traveller community responsibly for all local health often not in contact with any and is host to the annual care commissioning from the health and care services, as Appleby Horse Fair in the first primary care trust from April they are either unaware of week of June each year, one of 2012. Working closely with them or do not wish to access the largest gatherings of public health and other them, and are the most at-risk Gypsies and Travellers from all partners, GP consortia in of ill-health as a result. Services over the country and abroad. Cumbria will ensure that local often struggle to identify and health services are shaped by make contact with such The Cumbria Gypsy and the needs of their communities, individuals. Traveller Accommodation with streamlined care Assessment 2008 estimated pathways, better integration of Improved access, improved that there were at least 771 services, local health prevention and early local Gypsies and Travellers at programmes to address health intervention in primary care are the time of the study period, inequalities and greater clinical central to reducing inequalities yet it was acknowledged that leadership. Resources and in health. this was likely to be an under- health teams will be shaped estimate. In Cumbria there are around individual communities, Hard to reach groups are often four authorised Traveller leading to improved local those who suffer from social encampments, however those health outcomes. exclusion. They include living on unauthorised sites homeless people, Gypsies and and those living in bricks and It is also hoped that the Travellers, asylum seekers, mortar are largely unaccounted increased autonomy and refugees, people with for. This presents a large body flexibility afforded to GP disabilities, those living in of hard-to-reach individuals consortia will lead to the deprivation and prisoners. and family groups. development of closer Members of these groups tend relationships with the to suffer high levels of Evidence indicates that Gypsies voluntary sector, which are morbidity and premature and Travellers have significantly fundamental to developing death. Activities led by Public poorer health than other UK links and improving access for Health Cumbria to reach these residents. National data about hard-to-reach groups and groups have included: their health and health care communities. status is limited; however it is ■ vaccination programmes for widely acknowledged that the the Gypsy and Traveller Traveller community have community limited contact with health and care services. While there are ■ health needs assessment at no national morbidity statistics, Haverigg Prison it is acknowledged that the life expectancy of Gypsies is 10 -12 ■ special vaccination clinics for years below that of the settled children living in population. disadvantaged areas / Section 7 65

One in five Gypsy and Traveller The findings support the ■ Although the percentage of women has experienced the evidence that Gypsy Travellers Travellers registered with a death of their child compared have poorer health than the GP in Cumbria is relatively to less than 1% of the settled settled population. A number high (86 per cent) and population and the rate of of issues were raised, giving a relationships with health miscarriage is almost twice that further understanding of the care staff seem generally of the settled population. needs of this group. Research positive, over half (54 per established that: cent) of the Traveller sample To find out more about the was unwilling to identify health needs, beliefs and ■ The prevalence of mental themselves as Travellers to experiences of using health health and wellbeing their GP because of fear of services, as well as barriers to problems within the discrimination and negative accessing health services, NHS Travelling community in stereotyping. Cumbria conducted a health Cumbria appears to be needs assessment of the considerably higher than in ■ Furthermore, poor literacy Cumbrian Gypsy Traveller both the overall population may be an important factor population. of the North West Region in limiting Travellers access and in England as a whole. to health services.

■ Immunisation uptake in The research highlighted areas Travelling population is low. where improvements must be There is a particular made if we are realistically to resistance to the MMR reduce the inequalities in the vaccination amongst health of Cumbrian Travellers, Travellers. and provided a useful case study for addressing hard to ■ Barriers to health care access reach groups. were experienced, including: reluctance of some GP surgeries to register Travellers with no permanent address or postcode; practical problems of access whilst travelling; complex and variable appointment systems; mismatch of expectations between Travellers and health care staff; interruption of treatment as a consequence of travelling or being moved on/evicted. / Section 7 66

The following recommendations 3. The introduction of care 6. Ethnic monitoring - staff are currently being pathways for Travellers - it should record ethnicity on implemented in Cumbria: is proposed that the patient records to ensure development of multi- that more accurate data on 1. Identify appropriate health agency care pathways for minority groups can be workers with dedicated Travellers will improve collected in order to time to work with local health outcomes for mobile develop targeted health Travellers - families. programmes. dedicated/specialist health workers would play an 4. Immunisation programmes 7. Develop patient-held important role in raising - the introduction of records for adult Travellers - awareness amongst dedicated immunisation there is strong support for Travellers of existing health programmes for Travellers. this initiative from local provision and facilitating health professionals and equitable access to a range 5. Implement mandatory Travellers as a way of of health services, including cultural awareness training improving continuity of mental health services. for all staff that may care. interact or have contact 2. Health Trainers on each with Travellers or other 8. Support the development authorised site in Cumbria - vulnerable groups - this will of a county/regional the introduction of a NVQ enable the provision of network of good practice in qualified Health Trainer on more culturally sensitive primary care- develop a each of the authorised services for Travellers. regional network in order Traveller sites in Cumbria that mobile Travellers may would provide an be signposted to ‘culturally opportunity to deliver safe’ GP surgeries in other health promotion and areas. improve health literacy for Travellers.

Recommendations ■ Public Health Cumbria continues to devise In addition to the specific campaigns to reach hard recommendations for to reach groups and Gypsies and Travellers, the increase uptake of challenge for the NHS in screening and Cumbria is to eradicate the vaccinations. health divide and level out inequalities. Increasingly ■ We work with HMP Public Health Cumbria is Haverigg to implement working with partner the findings of the health agencies to tackle many of needs assessment and so the problems that impact on improve the health of health, yet in order to prisoners. Some of the further engage with hard-to- areas that require reach groups, I recommend attention are screening that programmes, smoking and diet. / Section 7 67 / Section 8 68 / Section 8 69 Section 8: Our changing climate

In this section I look at how increases in disease caused by Weather also causes problems climate can affect our allergies, respiratory problems, around travel and health. We have experienced and illnesses carried by insects infrastructure, and puts two of our coldest winters in or in water, particularly flood enormous pressure on NHS over 40 years, and studies water; and threats to the safety services. suggest that this is set to and availability of our food and continue. If we are to see water supplies. Weather How our changing more extreme weather, we conditions also have a climate is affecting will continue to see the measured impact an our health public health effects of this, individual’s overall mood and so need to ensure that extreme weather can cause less Recent data from the World public health programmes direct health problems such as Health Organisation (WHO) further focus on addressing worry and depression. suggest that annually issues linked to our approximately 5 million people changing climate. Extreme weather conditions suffer from a climate related have led to floods, famine and illness and there are 150,000 Weather has a profound effect drought throughout the world. deaths globally from the effects on health and well-being. This has been seen recently in of climate change. By the year Studies have been able to the failure of crops, leading to 2030 it is anticipated that this demonstrate that weather is food shortages and famine. may double. associated with changes in birth rates and sperm counts, Changes in weather and Increases in heart disease, and also leads to increased difficulties in growing crops obesity and other chronic outbreaks of pneumonia, will inevitably lead to a rise in diseases, as well as an influenza and bronchitis. the price of bread, milk and increasingly ageing population, meat, a trend that we are will mean that a greater Extreme weather brings many already beginning to see with number of people will be problems, particularly for the problems with the 2010 wheat susceptible to weather related very young or old, and the crop seeing prices increase deaths in the future. vulnerable. Heat waves cause a from £100 per tonne in 2009 to number of public health £160 in September 2010. Research published by NHS concerns, such as heatstroke, Cumbria earlier this year, shows heat exhaustion and sun burn, Our changing climate and that around 250 avoidable as does extreme cold weather extreme weather conditions deaths occur each winter in the and its associated problems are unquestionably leading to county. such as slips trips and falls and a further threat to public the aggravation of existing health and Cumbria has not medical conditions. escaped its share of extreme weather – with sub-zero winter Direct health effects of climate temperatures and devastating change can include injuries and floods affecting several parts of illnesses from severe weather, Cumbria in November 2009 and floods, and heat exposure; in Carlisle in January 2005. / Section 8 70

Excess Winter Deaths winter varies depending upon with the overall average for the temperature and level of Cumbria and for England Excess Winter Deaths are disease (particularly ‘flu) in during the period 2005 - 2008. defined as the difference the population as well as between the number of other factors. The elderly The chart shows that deaths during the four winter experience the greatest Copeland and Carlisle have months (December – March) increase in deaths each the highest ratio of excess and the average number of winter. winter deaths. However these deaths during the preceding findings were not significantly Autumn (August – November) Figure 7. shows the excess higher than the average for and the following Summer winter death ratio for each of England. (April – July). The number of the local authorities in extra deaths occurring in Cumbria and compares them

Figure 7. Excess Winter Death Ratio 25

20

15 22.2 10 18.1 Winter Death Ratio 15.6 ss 14.4 14.6 e 13.7 c 5 11.2

Ex 8.7

0 CopelandCarlisle Allerdale Eden South Barrow Cumbria England Lakeland

Local Authority

The elderly and vulnerable INDOOR TEMPERATURE EFFECT ON HEALTH suffer more in the winter months, with cold weather 21°C Recommended living room temperature aggravating a number of Minimum temperature with no health risk, health conditions. Colder 18°C weather can lead to some though may feel cold people suffering serious health Resistance to respiratory diseases may be Under 16°C problems such as heart attacks, diminished strokes or pneumonia. Increases blood pressure and risk of 9–12°C This table illustrates the effects cardiovascular disease of living in temperatures below 5°C High risk of hypothermia the recommended 16–21°C (or recommended 18°C and over in There are currently more than 33,000 pensioners who live alone in living areas): Cumbria. The number of older people in the county is expected to grow by 69,000 over the next twenty years, so we need to ensure we give support to our older population during cold weather. / Section 8 71

Problems we may Food shortages Infectious diseases experience due to extreme weather The price of food is likely to There is a clear link between increase due to increasing rises of cases of food poisoning Heat wave production and reduced raw and periods of warm weather. material costs. Fewer people The number of food poisoning Heat exhaustion can happen to will be able to afford cases are predicted to increase anyone in hot weather and if it manufactured food; this will up to 10,000 cases per year in isn’t treated it can lead to result in a greater need to the UK. changes in weather heatstroke, which can be grow crops. The deprived will conditions also lead to the dangerous and even fatal. The be the most vulnerable. In spread of communicable average temperature in 2010, the cost of wheat diseases such as coughs, could, Cumbria and the North West is increased from £100 a tonne in flu and norovirus. predicted to increase, leading 2009 to £160 a tonne in to an increase in episodes of September 2010. Cancer and cataracts heat waves. It is anticipated in the UK there will be an Coastal, River By 2050 in the UK, with additional 2,000 heat related and Flash Floods warmer, sunnier conditions, deaths a year by 2050. The cases of skin cancer are chronically ill, elderly, young, The risk of serious flooding is anticipated to increase by up to and deprived are most increasing in the UK, with 5,000 cases per year. susceptible to health problems metrological records being caused by heat, and an aging broken every year. The Ironically, in part this will come population in Cumbria could flooding in Cockermouth about as a result of our result in more fatalities during (November 2009) was the infatuation with sun tan, heat waves. greatest downpour in the UK in leading to the use of artificial a single 24 hour period since tanning methods. Water shortages records began. Increased flooding could cause In summer of 2010 many areas contamination of drinking in Cumbria were subject to water and waterborne water rationing measurers as a infections. This was clearly result of local reservoirs being shown in the devastating unsustainably low. Extremes of floods in Pakistan August / weather patterns in the future September 2010, when there will produce periods of little or were several outbreaks of no rain. Drought may increase Cholera due to the worst the risk of dehydration flooding in recent years, with especially in the elderly. An 21 million people being increase of infectious diseases’ displaced. Increased water due to reduced hygiene and temperatures in standing water increased risk of water such as reservoirs could contamination then follow. increase water blooming and Water shortages mean that bacterial infections. water is prioritised for human consumption with crops and industry having reduced supplies. / Section 8 72

Ultra Violet Light, provide a source of vitamin D used for medical purposes not Sunbeds and Skin – which is needed for healthy for tanning or cosmetic Cancer teeth and bones. We get most reasons. of your vitamin D from Each year in the United sunlight on our skin, yet the Only 20% of tanning salons Kingdom there are 10,400 effects on vitamin D synthesis are members of a voluntary new cases of melanoma and from sunbeds are limited and body, and salons and use are 81,500 new cases of non- better supplied largely uncontrolled. melanoma skin cancers. There pharmacologically if there is a Members are required to are around 2000 deaths from demonstrable need. work to a code of practice melanoma per year. which reduces the risk from Commercial outlets offering Excessive exposure to sunbeds UV radiation. sunbed sessions have been can cause skin aging, increasing rapidly in recent immunosuppression and Surveys carried out across the years. Sunbeds, sunlamps and cataracts in unprotected eyes. UK reveal that 19% of tanning booths give out the tanning salon users are less same type of harmful Emerging evidence also shows than 20 years old and girls radiation as sunlight: a substantially increased risk tend to use them more than of malignant melanoma boys. (75%) in those who have used ■ UVA rays make up about sunbeds in their first three The Sunbeds (Regulation) Act 95% of sunlight. They can decades of life. 2010 comes into force in April cause skin to age early, 2011 and prohibits persons making it look coarse, The risks of sunbed use are under 18 years of age from leathery and wrinkled. greatest for the young, fair using commercial sunbeds. skinned and those who use it This legislation allows further ■ UVB rays make up about excessively or produce skin controls on protective eye 5% and cause skin to burn. burning. UV light has a very wear to be brought into force limited therapeutic use in a at a later date. Local authority A tan is our body’s attempt to small number of medical environmental health staff protect itself from the conditions, although this is will be assessing compliance damaging effect of UV rays. carefully controlled under with this legislation during The effects of sunbed sessions medical guidance. The World health and safety inspections. are largely cosmetic and Health Organisation psychological. There is a recommends that UV perception that sunbeds radiation appliances only be

Why is our climate passionately believing in global electricity from coal-fired changing? warming and one that power plants, or heating our passionately denies its homes with oil or natural gas, Although a well-debated issue, existence. we release carbon dioxide and some believe that changes to other heat-trapping gases into our weather patterns are Human activities, and the atmosphere. caused by global warming. This particularly the generation of argument is sparking frank and power using fossil fuels, have It is claimed by pro global earnest debate in the scientific been attributed to global warning scientists that global world, with two camps, one warning. Driving cars, using warming is attributable to the / Section 8 73

melting of Glaciers and Arctic It cannot be denied that we are Ice caps. As a result of this experienced a changing melting it is claimed that sea climate, with more and more levels are rising. In the United examples of extreme weather. Kingdom, it would take an We must accept and plan for increase of sea level by 10 the fact that we will continue metres to start to have to suffer from hard winters, significant impact with the Fens increased flood risk and heat and Norfolk being the worst hit waves in Cumbria. The move to areas. Globally a rise of 1 integrate public health with metre would swamp most of local authority will help us to the US Eastern seaboard cities, further ensure that resources while 50% of the Maldives are targeted to help deal with would become submerged. climate pressures, such as flood defences and ensuring that our transport network can cope in extreme temperatures.

Are unfair heating The number of households To tackle this, Public Health bills a risk to public living in fuel poverty has been Cumbria advises that Ofgem health? rising steadily since 2003 and must look at ways of now stands at almost 5 million introducing a progressive Last winter saw 25,400 more according to government energy pricing policy which deaths in England and Wales, figures. The same figures makes sure the first energy compared with the average show that this has largely units used are not the most for the non-winter period. been caused by rising energy expensive. December 2010 was the prices, which have gone up by coldest in 100 years and one an average of 80 per cent As well as the benefits to of the coldest months ever between 2004 and 2008. public health by making it recorded in the UK, according cheaper for older people and to the Met Office. Energy companies currently those on low incomes to heat structure energy bills around their homes properly, a In Cumbria, latest figures primary and secondary units. progressive pricing structure from the county’s NHS public Households are billed more would also be more health team show that the for primary units, and move environmentally sustainable. second week of December (6- on to cheaper secondary units 12 Dec) saw 46 excess winter when these are used up. The Switching the practice of deaths in the county. energy market that has rewarding greater developed in the UK is too consumption with reduced Colder weather can lead to regressive and penalises those per-unit costs would make it people suffering serious on low incomes who use the easier for low income health problems such as heart least energy while rewarding households to heat their attacks, strokes or pneumonia households who can afford homes during freezing winter with poorly heated homes a greater energy consumption. temperatures and help to significant factor. reduce winter deaths. / Section 8 74

Using Sustainable nuclear reactors worldwide Wind Power Energy into re-useable uranium, plutonium, and highly Cumbria is home to 17 wind The human contribution to radioactive fission products farms with around 100 global warming can be that will have to be safely operational turbines with a mitigated by reducing the stored for thousands of years capacity of 78MW. A further greenhouse gasses, and and is a major employer in the 13 with a 27MW capacity are sustainable energy is one of the area. awaiting construction and 12 methods being adopted by a new generation of nuclear with 28.5MW capacity under society to mitigate global installation is under active consideration. They are mostly warming and climate change. consideration, yet the issues to sited around the coastline and do with the benefits and risks in a strip east of the M6 To have a real different of nuclear need to be more between Carlisle and Penrith. though, we would need to see widely debated. the dependence on energy to The ecological advantage of be reduced and the way energy As the discussion of the nuclear wind power is well recognised. is generated to be free from power option moves forward, Electricity is produced without expelling any carbon dioxide it is critically important to the emission of thousands of and other heat trapping gasses. consider what is now known harmful gasses. The electricity This can be achieved in part by about the public health and generated is piped into the the generation of energy environmental risks of the National Grid. A major through sustainable energy nuclear fuel cycle. There is now drawback is that it only production. a large body of knowledge generates electricity when the about the impact of uranium wind is blowing and its Cumbria is very well placed to mining and milling, effectiveness has been maximise on sustainable energy transportation of radioactive questioned. particually forms that rely on materials, power reactor wind or water. operations, and waste disposal Hydro Power and decommissioning of Nuclear commercial reactors, yet Cumbria and the Lake District literature on public health has used hydro power for Nuclear power produces aspects is comparatively thin hundreds of years to generate around 11% of the world’s considering the size of the power from its many mills that energy needs, and produces industry and the concerns provided the energy to turn huge amounts of energy from which are raised. There is a the machines that kept its small amounts of fuel. body of research on the human industry productive. About a mile north of Seascale health effects of low-level in Cumbria is the Sellafield radiation exposure on workers To produce electricity, Nuclear Site, which was the site exposed in the nuclear industry, significant volumes of moving of the world’s first commercial and research has been water are required. Water will nuclear power station, Calder undertaken on effects of need to be diverted from a Hall, and the Windscale Nuclear surrounding communities, yet stream or river through a Reactor (Piles) - Britain’s first the nuclear industry pros and turbine, which turns the energy attempt at a nuclear reactor to cons needs to be discussed into electricity by means of a produce plutonium for the war further. generator. Although many effort, which suffered a major thousands of mills or mill sites incident in 1957. This site is still exist, most operate on now home to Sellafield large, slow-moving bodies of Reprocessing Plant - a site that water, whereas it is easier to converts the spent fuel from generate electricity where / Section 8 75

there is a fast flow of water that can be channelled to hit a turbine at high pressure.

Solar power

Solar power is the conversion of sunlight into electricity. Solar installations in recent years have also largely begun to expand into residential areas, with governments offering incentive programs to make “green” energy a more economically viable option.

Energy efficient homes

To protect against extreme weather, as well as save energy, homes should be properly insulated: lofts should have at least 10 inches of insulation, and wall cavities should be insulated too. There are grants available to help make homes Recommendations To further prepare for more energy efficient. changes to our climate, I The interdependence of recommend that: human health and wellbeing on the environment is ■ Public Health Cumbria becoming clearer as we should seek to support grapple with the issues of increasing understanding sustainability and global of these issues so that it warming. How we use can play a full part in energy, and shape our shaping the policy options human habitats in the form in the years to come. of our towns and villages and how we live, work, play ■ We work with and move around within and communications experts between them is likely to to promote awareness become an increasing matter raising campaigns such as of concern as we progress ensuring homes are through this decade. prepared for winter, at- risk groups receive a seasonal flu vaccine, being a good-neighbour to ensure that our more vulnerable members of society are cared for. / Section 9 76 / Section 9 77 Section 9: Review of last year’s recommendations

Cumbria has had a difficult Below I provide a brief update Health and Wellbeing Strategic and traumatic year, yet the on the progress made to Framework, which will be challenges we have faced as achieve the recommendations accountable through the a county have demonstrated that were made in 2010. Health and Wellbeing Board, Cumbria’s enormous calls for joint action to tackle community spirit and 1. The Children’s Trust Board the root causes of population resilience in times of continues to provide the mental ill-health and adversity. Recent events strategic leadership of inequalities. have reinforced the value of commissioning services and community and the interventions to improve the 3. The commissioning process importance of communities wellbeing and mental health of for health services in Cumbria coming together to help and Children and Young People ensures that all opportunities support each other. Looking from birth to adulthood. are taken to maximise the after neighbours, offering Although the statutory basis of wellbeing and mental health of support and talking to each Children’s Trust Boards have children, especially across the other has helped the now ended, partner agencies range of universal, targeted recovery process, and in Cumbria remain committed and specialist services provided cemented community to a joint strategic approach to by the new Children’s Health relationships. Health and developing holistic services for Service Provider in Cumbria. support services have also children. This will be Emotional health and learnt from the resilience of coordinated through the new wellbeing of children and our communities and have Health and Wellbeing Board, young people is an integral been instrumental in which is part of government part of Cumbria’s Ways of providing support to health reforms. Working which underpin the improve the outcomes for new commissioning mental health and wellbeing 2. Strategic linkages should be arrangements for Children’s for the communities of made within the Cumbria Services in Cumbria Cumbria. Community Strategy between the improvement of the 4. Child and Adolescent Mental psychological wellbeing and Health Services should be mental health of Children and redesigned as a priority within Young People, and issues each locality, applying the relating to health inequalities, learning from the Furness in particular, the reduction of Transformation Project. child poverty, reducing social Mental health services are now isolation, improving set to become further educational attainment and integrated with community tackling unemployment. services, following changes Progress on Cumbria’s that will see NHS Cumbria’s Community Strategy awaits provider arm joining the clarity on new local county’s mental health government structures. provider, Cumbria Partnership Cumbria’s forthcoming Mental NHS Foundation Trust. / Section 9 78

5. Children and young people 7. The existing skills and 8. Health impact assessments of should have the best start in capabilities in our communities new developments in Cumbria life by developing an are developed to increase levels should include a mental health appropriate curriculum to of resilience in Cumbria (our impact assessment and the ensure that all children develop “resilience Capital”) for evaluation of mental health mental health coping skills. This example through development services should include equity is a priority. Parents should also of peer support networks, impacts. be supported in their parenting electronic resources and Public Health Cumbria is role and have access to services support through ‘new media’. working to ensure that any that meet their wellbeing and Community asset mapping future new developments mental health needs. should routinely be used involve patients and Public Health Cumbria alongside needs assessments to stakeholders in the initial continues to work closely with inform health and mental design and scoping stage, and schools, Targeted Adolescent health commissioning. that health impact assessments Mental Health Services, A number of successful briefing and equality impact children’s services and events were held during the assessments on the building children’s centres, health year to engage as many take into consideration the visitors and school nursing partners as possible in asset impact on mental health and teams to make sure children based working and celebrating access to mental health and young people get the best the work already undertaken services. possible start in life. within both voluntary and statutory sectors. 9. Further partnerships should 6. Work to be undertaken so be developed between health that the public becomes more As part of the work on the and other sectors to address aware of wellbeing issues and Cockermouth Centre for the the socio-economic problems is engaged in activities that Third Age, work has been that are the catalyst for mental increase individual and undertaken to create an ill-health. collective wellbeing, such as asset register for the Cumbria’s Health and the five ways to wellbeing community which will be Wellbeing Strategy, outlined in last year’s report. available online. underpinned by the Joint A wellbeing discussion kit has Strategic Needs Assessment been co-designed and piloted and accountable to the Health in Cumbria for use across the and Wellbeing Board, will play North West. Health and other a central role in co-ordinating statutory and voluntary sector action to address the social organisations, workplaces such determinants of health. as the NHS and Sellafield, service users and carers and the public are taking up the call for wellbeing across the county. For example, Eden Mental Health Group has produced a wellbeing pamphlet and Carlisle and Eden MIND has created a walk in wellbeing space in the centre of Penrith. / Section 9 79

10. A database of initiatives 12. Existing mental health and resources for mental services should be further health and wellbeing in developed, based on a model Cumbria should be created, for centred around the person, use by the general public and fully integrated into primary professionals. care and focused on mental Cumbria County Council has health promotion, public published six directories of mental health and recovery. services, one for each of the six In Cumbria, community district council areas of services will soon be jointed Cumbria. NHS Cumbria, with mental health services as Cumbria County Council and part of government reforms to the voluntary sector are the NHS. This will see NHS working together to produce Cumbria’s provider arm joining an electronic resource to Cumbria Partnership NHS showcase the full range of Foundation Trust. The new services and activities that partnership brings excellent support wellbeing and health. opportunities to develop a seamless mental and 11. Social marketing initiatives community health service, with about alcohol should include more mental health support messages about its potential delivered through GP surgeries, negative effects on mental which is where most people health. first access mental health NHS Cumbria has a strong support. communications and marketing team, who devise and deliver social marketing and public relations campaigns to raise awareness and lead to behaviour change in a number of public health areas, from smoking to screening. Alcohol messages have been developed on the potential negative effectives on mental health, weight and aggression. / Section 10 80 Section 10: Conclusions and recommendations

This year’s report has Summary of recommendations 3. Work with third sector concentrated on Health To improve health outcomes in organisations to provide Protection and the external Cumbria I recommend: basic first aid training to threats to health and our communities. It is wellbeing in Cumbria, a 1. Still closer collaboration unacceptable that people major domain of public between partner agencies die needlessly because no health that has been both during emergencies one could give them first especially important for us and in the ongoing aid. If everyone was able to over the past two years. I planning process. As learn some basic life saving hope that in bringing agencies feel the effects of and resilience skills lives together an overview of our reductions in resources over could be saved. current understanding of the the next few years we need relevant issues and of the to work together even 4. Priority should be given to arrangements that we have more closely to maintain a ensuring that infection to respond to them will put coordinated and effective prevention services remain us in a stronger position to response. robust through the current avoid the toll of avoidable ill round of NHS health in the coming years. 2. An increased focus on reorganisation. developing resilience at community level. For 5. Following on from the effective and rapid implementation of general response to emergencies, practice consortia, this especially in a rural area aspect of public health such as ours, it is essential should become mainstream to build community within primary care. resilience and understanding of the action to take in an 6. Communications specialists emergency. and health promotion practitioner’s work together to deliver campaigns that highlight the importance of screening programmes for targeted groups in the region. / Section 10 81

7. People in Cumbria take up 10. NHS Cumbria should 13. Public Health Cumbria the opportunity for continue to develop its should seek to support screening when invited, involvement in n the increasing understanding and encourage friends and provision of work-related of climate change issues so relatives to do the same. health interventions and that it can play a full part in occupational health shaping the policy options services, to ensure a holistic in the years to come. 8. People must always be alert approach to occupational to changes in their bodies health that supports both that could potentially be 14. We work with those in work, and those signs of illness, so women communications experts to seeking work. should still be on the promote awareness raising lookout for changes in their campaigns such as ensuring breasts even if they have 11. Public Health Cumbria homes are prepared for recently had a screening continues to devise winter, at-risk groups test, and people should still campaigns to reach hard to receive a seasonal flu report a change in bowel reach groups and increase vaccine and being a good- habit or bleeding even if uptake of screening and neighbour to ensure that they have recently had a vaccinations. our more vulnerable bowel screen. members of society are cared for. 12. We work with HMP 9. Work should continue to Haverigg to implement the improve our understanding findings of the health of injury and violence in needs assessment and so Cumbria, and especially of improve the health of threats to health in prisoners. Some of the agricultural communities in areas that require attention order to produce a more are screening programmes, effective approach to smoking and diet. prevention. / Acknowledgements 82 Acknowledgements & Contact Details

My thanks go the Cumbria Public Health Team for their contribution to this years annual report: Nigel Calvert, Fiona McCredie, Lyn Murphy, Steve McLachlan, Jane Morphet, Paula Smith, Nicky Holland and Tracey Wood of the Health Protection Agency.

Thanks also to Amy Clement of the Corporate Communications Team who has coordinated said project and managed the production of this report.

Design and artwork: G1 Creative Cumbria Photographs: NHS Photo Library and iStockphoto.com

Director of Public Health NHS Cumbria Trust Headquarters Penrith Hospital Bridge Lane Penrith CA11 8HX

T: 01768 245317 E: [email protected]

NHS Cumbria: www.cumbria.nhs.uk Cumbria County Council: www.cumbria.gov.uk Cumbria Intelligence Observatory: www.cumbriaobservatory.org.uk Vaccination Checklist

A number of vaccines are routinely offered to everyone in the UK for free on the NHS.

Recommended Age Who is vaccinated Injection given to protect against

Babies identified as being Tuberculosis (TB) From birth particularly susceptible to these diseases. Hepatitis B (HB)

Tetanus, diphtheria, whooping cough, polio and 8 weeks All babies haemophilus influenza (one injection) Pneumococcal (one injection)

Tetanus, diphtheria, whooping cough, polio 12 Weeks All babies and haemophilus influenza (one injection) Meningitis C (one injection)

Tetanus, diphtheria, whooping cough, polio and 16 Weeks All babies haemophilus influenza (one injection) Pneumococcal (one injection) Meningitis C (one injection)

From 6 months “at risk” babies and children Influenza vaccination in the autumn annually All over 65 years

Booster dose of Pneumococcal (one injection) Hib/men C From 12 months All babies (one injection) Measles, Mumps and Rubella (MMR) first does (one injection)

Those who have other health From 2 years of needs that make them Pneumococcal vaccinations (adult vaccine) age and over susceptible and all those over 65 years of age

Tetanus, diphtheria, whooping cough and polio 3½ - 4 years All children (one injection) Measles, Mumps and Rubella (MMR) second dose (one injection)

HPV (human papilloma virus). Cervical cancer protection 12 - 13 years Girls only given in year 8. Three doses required.

Diphtheria, tetanus and polio booster usually given 14 - 15 years All children in year 10.

Range of vaccines. Book a GP appointment several months Travel vaccines Travellers all ages before travelling to discuss.

Occupational Range of vaccines, employees should be told by their Variety of occupations vaccines employer if they require vaccination.

People who fall into certain risk groups may be offered extra vaccines. These include vaccinations against diseases such as hepatitis B, tuberculosis (TB), seasonal flu and chickenpox. Personal Resilience Guide Prepare for Basic First Aid an Emergency Knowing some basic first Severe bleeding To prepare for an emergency, you aid skills could help you Control severe bleeding by should take time to find out: deal with an emergency – applying firm pressure to the your relatives or friends ■ Where and how to turn off water, gas wound using a clean, dry and electricity supplies in your home could be the ones to dressing and raise it above benefit from your skills. ■ The emergency procedures for your the level of the heart. Lay the children at school and at your When there is more than one person down, reassure them, workplace injured person, go to the keep them warm and loosen ■ How your family will stay in contact in quietest one first. tight clothing. the event of an emergency They may be unconscious and Burns ■ need immediate attention. If any elderly or vulnerable For all burns, cool with water neighbours might need your help Learning first aid is easy so for at least 10 minutes. Wrap ■ How to tune in to your local radio why not take a few minutes the affected part in clingfilm, station. now to familiarise yourself do not apply dry dressings, ■ Fit and maintain smoke alarms in your with the first aid scenarios keep the patient warm and home and plan an escpare route below, or enrol on a basic call an ambulance. should a fire break out first aid course. Broken Bones ■ Be aware of important supplies you Unconscious may need in an emergency such as Try to cause as little prescribed medication, candles and If the casualty is not movement as possible. responding but is able to spare clothes Choking breathe normally, turn them onto their side to protect Encourage the casualty to their airway. If there are no cough if they are able to do What to do in signs of life, call 999 and ask so. If not, lean them forward an Emergency for an ambulance. Follow the and give up to five sharp call handlers advice on how blows between the shoulder to give chest compressions blades. If this fails, give up to If you find yourself in the middle of five thrusts in the stomach if an emergency, your common sense and mouth-to-mouth and instincts will usually tell you what resuscitations while you wait you or a bystander have the to do. However, it is important to: for the ambulance to arrive. skills to do this. ■ Make sure 999 has been called if people are injured or if there is a threat to life Emergency Contact Details ■ Not put yourself or others in danger ■ Follow the advice of the emergency Compile a list of useful emergency contact numbers services and keep them somewhere easily accessible to you – ■ Try to remain calm and think before on your fridge door for example. acting, and try to reassure others ■ Check for injuries - remember to help Emergency services: 999 yourself before attempting to help NHS Direct: 0845 46 47 others. Anti terrorist hotline: 0800 789 321 If you are not involved in the Cumbria Constabulary: Non Emergency Number - incident, but are close by or believe 0845 33 00 247 (available 24 you may be in danger, in most cases hours a day, 7 days a week). the advice is: Cumbria County Council: 01228 606060 ■ Go inside a safe building ■ Stay inside until you are advised to do Local District Council: otherwise ■ Tune in to local radio or TV for more Doctor: information. Work: Of course, there are always going to be Schools: particular occasions when you should not “go in” to a building, for example if Family contact 1: there is a fire. Otherwise: Family contact 2: GO IN, STAY IN, TUNE IN. Local Radio Station & Frequency: