Joint Strategic Needs 2009 Assessment VolumeVolume 1 2
and Director of “Understanding Derby’s population, its health and its social care needs” Public Health’s Annual Report
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Volume 2
7. Burden of Ill-Health 98
7.1. Misc 98 7.1.1. All causes 98 7.1.2. Causes considered amenable to healthcare 105 7.1.3. Due to smoking 106
7.2. Diabetes 108 7.3. Circulatory 114 7.3.1. General 114 7.3.2. Coronary Heart Disease 115 7.3.3. Stroke 120
7.4. Cancer 126 7.4.1. General 126 7.4.2. By site 127
7.5. Respiratory 140 7.6. Infectious disease 145 7.6.1. TB 145 7.6.2. STIs & HIV 146
7.7. Dental health 150 7.8. Mental health 154 7.8.1. Dementia 154 7.8.2. Suicide 159 7.8.3. Mental Illness 162
7.9. Trauma 164 7.9.1. Falls 164 7.9.2. Road accidents 167 7.9.3. Injuries 169
7.10. Musculo-skeletal 171
8. Services 177
8.1. Social care 177 8.2. Health services 188 8.2.1. Maternity 188 8.2.2. Dental health 188 8.2.3. Preventative/Screening 189 8.2.4. Sexual Health 192 8.2.5. Mental Health 196 8.2.6. Long-term conditions 196
8.3. Voice 198 8.3.1. User perspective on health care 198
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7. Burden of Ill-Health
7.1 Misc
7.1.1 All causes
What is the problem?
By improving overall life expectancy and tackling health inequalities, we aim to achieve better health and well-being for everyone in Derby City.
All age all cause mortality in Derby is generally improving, however, in males the gap between the East Midland and England rates is wider than for females, and in the case of premature (less than 75 years of age) mortality from all causes, this gap has widened from 2006 to 2007.
Figure 91 All Age All Cause Mortality Rates 1100
1000
900
800 England Males East Midland Males Derby Males 700 England Females
Standardised Standardised Rate/100,000Population East Midland Females - Derby Females
600 Directly Age
500
400 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
Year
Source: ONS; National Centre for Health Outcomes Development (NCHOD)
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Figure 92 Premature All Cause Mortality Rates 650
600
550
500
450 England Males East Midland Males Derby Males 400 England Females
Standardised Standardised Rate/100,000Population East Midland Females - 350 Derby Females
Directly Age 300
250
200 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
Year
Source: ONS; National Centre for Health Outcomes Development (NCHOD)
It is evident that all age all cause mortality in Derby is directly related to deprivation. The city’s three most deprived wards according to the IMD 2007 – Arboretum, Normanton and Sinfin Wards – equally have the highest directly age-standardised rates of mortality by 100,000 population. This is highlighted in Figure 93. All three wards have significantly higher rates of mortality than is average in Derby City.
Figure 93 Directly Age Standardised Rate of All Age All Cause Mortality by Ward in Derby City (2003/07) DASR/100,000 Population LCL UCL Abbey 787.50 726.07 848.92 Allestree 393.28 359.06 427.50 Alvaston 635.22 582.48 687.95 Arboretum 949.37 879.43 1019.31 Blagreaves 439.83 397.75 481.90 Boulton 596.22 547.83 644.62 Chaddesden 594.61 545.47 643.74 Chellaston 420.02 379.44 460.60 Darley 738.80 681.58 796.02 Derwent 707.01 649.56 764.45 Littleover 427.24 383.39 471.09 Mackworth 594.90 541.53 648.27 Mickleover 459.74 420.66 498.83 Normanton 835.75 772.87 898.62 Oakwood 468.89 416.01 521.77 Sinfin 797.00 729.70 864.30 Spondon 657.67 607.59 707.75 DERBY CITY 604.23 592.04 616.41 Source: ONS Annual District Deaths files
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Figure 94 Infant Mortality (2005/07) 7.0
6.0
5.0
4.0
Infant age under 1 year Infant age under 28 days 3.0
Rate/1000BirthsLive Infant age under 7 days
2.0
1.0
0.0 ENGLAND EAST MIDLANDS Derby UA
Region
Source: ONS; National Centre for Health Outcomes Development (NCHOD)
Reducing the gap in infant mortality between the routine and manual socio-economic group and the England average is one of the key measures of the national health inequalities target, and tackling this will in turn contribute to the life expectancy target. In Derby, there is no significant difference in rate of mortality in infancy in those aged under 1 year (48 deaths), under 28 days (29 deaths) and in those aged less than 7 days (28 deaths), compared with the East Midlands and England where there is significant difference between each of them. Moreover, whilst the confidence intervals suggest that the rate of mortality in infants aged under 28 days could be as high as is the case nationally, the actual rate for the period 2005-2007 was much lower (Figure 94).
Figure 95 displays the current trend and forecast in infant mortality (under 1 year) to 2009/11 in Derby City compared with England and the East Midlands region. As is clear from the confidence intervals that have been applied to Derby’s figures; the rate of mortality is not significantly worse nor is it better than is seen in the East Midlands and nationally. However, it is apparent from the steeper trend that there has been much success in reducing mortality in infancy in Derby in recent years (despite the slight increase in 2005/07 from 2004/06) and as a result, the forecast of mortality in 2009/11 is far lower (though potentially not significantly compared to the national picture) than it is likely to be in the East Midlands and in England (based on their current trends).
Analysis undertaken of the rate of mortality in infancy in the wards of Derby has revealed that whilst rates are clearly linked to deprivation, there is no significance when applying confidence intervals to the overall Derby average, with one exception. Arboretum Ward for the period 2004/06 had an infant mortality rate of 11 per 1000 live births. This was very much higher than the average in Derby of 4.2 for the same period.
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Figure 95 Trend and Projection of Rate of Infant Mortality (under 1 year) in Derby City 10
9
8
7
6 ENGLAND EAST MIDLANDS 5 Derby UA Expon. (ENGLAND)
4 Expon. (EAST MIDLANDS)
CrudeRate/1000 Live Births Expon. (Derby UA)
3
2
1
0 1999/01 2000/02 2001/03 2002/04 2003/05 2004/06 2005/07 2006/08 2007/09 2008/10 2009/11
Source: ONS; NCHOD
Current life expectancy trends in males and females in Derby are very different, though are equally very positive in terms of overall life expectancy for people in the city. Figures 96 and 97 highlight that in males, the gap in life expectancy between Derby, the East Midland and England has been narrowing since 1991/93. In fact, the projection to 2009/11 suggests that male life expectancy in Derby could potentially be as good as it is in England as a whole (approximately 78.5 years). In females, life expectancy has fluctuated above and below the national and regional expectancies for the same duration. In recent years however, females in Derby are expected to live for longer than is the case nationally (approximately 82 years), and are set to continue this trend to the year 2009/11 and potentially beyond.
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Figure 96 Males 80
79
78
77
76
75
74
73
72
71
70
69
ENGLAND (non-resident deaths excluded) EAST MIDLANDS Derby UA Expon. (ENGLAND (non-resident deaths excluded)) Expon. (EAST MIDLANDS) Expon. (Derby UA)
Source: ONS; NCHOD
Figure 97 Females 83
82
81
80
79
78
77
76
ENGLAND (non-resident deaths excluded) EAST MIDLANDS Derby UA Expon. (ENGLAND (non-resident deaths excluded)) Expon. (EAST MIDLANDS) Expon. (Derby UA)
Source: ONS; NCHOD
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Current life expectancies in England are 77.7 years in males and 81.8 in females. In comparison, males in Derby can expect to live for 76.8 years and females for 81.5 years. Life expectancy though varies greatly between wards. As expected, the most deprived wards have the lowest life expectancies; females in Normanton for instance can expect to live on average only to 76.5 years. That is more than 5 years less than is expected nationally. Equally as stark are males in Arboretum who on average can expect to live only to their 70th birthday. This is more than 7 years less than nationally. Life expectancy can however, be far higher in the more affluent wards of Derby City. For instance, in Allestree females can expect to live to 87.5 years and males to 82.6. This is far higher than the national average.
Figure 98
Significance Significance Life expectancy females Life expectancy males City rank City rank Ward code Ward name (compared to (compared to (females) (males) (2003-2007) Derby City) (2003-2007) Derby City)
00FKNA Arboretum 76.7 Sig. low 70.6 Sig. low 16 17 00FKNL Normanton 76.5 Sig. low 74.2 Sig. low 17 15 00FKNN Sinfin 79.1 Sig. low 73.0 Sig. low 14 16 00FKNG Derwent 81.2 74.2 Sig. low 11 14 00FKMZ Alvaston 82.7 75.4 9 12 00FKMX Abbey 79.5 Sig. low 74.6 Sig. low 13 13 00FKNC Boulton 83.1 76.9 7 9 00FKNJ Mackworth 83.4 76.7 5 10 00FKND Chaddesden 82.2 77.8 10 7 00FKNF Darley 78.8 Sig. low 75.5 15 11 00FKNP Spondon 79.9 77.3 12 8 00FKNB Blagreaves 84.6 Sig. high 79.6 Sig. high 4 4 00FKNE Chellaston 82.8 79.3 Sig. high 8 6 00FKNH Littleover 84.7 Sig. high 81.0 Sig. high 3 2 00FKNM Oakwood 85.3 Sig. high 80.0 Sig. high 2 3 00FKMY Allestree 87.5 Sig. high 82.6 Sig. high 1 1 00FKNK Mickleover 83.3 Sig. high 79.4 Sig. high 6 5 DERBY CITY 2003-2007 81.5 76.8 Source: ONS Annual District Deaths files
Focussing on the main causes of death in Derby; all circulatory diseases and all cancers make up over 60% of all premature deaths in the city. Between 2007 and 2008, premature deaths from cancer rose by approximately 4%. Deaths from respiratory disease fell by almost half (62 deaths down to 34 deaths), as did suicides and deaths as a result of undetermined injuries which fell by 2%. Mortality from all circulatory diseases, all accidents and unknown causes remained similar.
Figure 99 Underlying causes of premature mortality in Derby City (all persons) 2007 2008 Underlying cause of death Total % of all Total % of all All circulatory diseases 194 26.4% 199 26.3% All cancers 270 36.7% 307 40.6% All respiratory diseases 62 8.4% 34 4.5% All accidents 21 2.9% 18 2.4% All suicides/undetermined injuries 27 3.7% 13 1.7% Other known causes 143 19.4% 168 22.2% Cause unknown 19 2.6% 18 2.4% Total 736 757 Source: Public Health Mortality File (PHMF)
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In terms of hospital admissions, these causes are directly linked. As is evident in Figure 100, diseases of the respiratory system made up 30% of the top 10 causes of hospital admission during 2008/09. Premature mortality from respiratory disease has shown one of the biggest decreases in recent years (by almost half between 2007 and 2008).
Figure 100 Top 10 causes of hospital admission during 2008/09 (by primary diagnosis) Diagnosis Chapter Primary Diagnosis Code Primary Diagnosis Name Total Diseases of the circulatory system I209 Angina pectoris, unspecified 422 J181 Lobar pneumonia, unspecified 677 Diseases of the respiratory system J22X Unspecified acute lower respiratory infection 479 J459 Asthma, unspecified 394 Diseases of the genitourinary system N390 Urinary tract infection, site not specified 654 R073 Other chest pain 410 R074 Chest pain, unspecified 788 Symptoms, signs and abnormal clinical and R103 Pain localized to other parts of lower abdomen 466 laboratory findings, notelsewhere classified R104 Other and unspecified abdominal pain 376 R55X Syncope and collapse 486 Total 5152 Source: Secondary Uses Service (SUS)1
Additional indicators of the overall health of the population of Derby are; National Indicator NI 119: Self-reported measure of overall health and wellbeing, and NI 137 (also Vital Sign VSC25): Healthy life expectancy at age 65. NI 119 is derived from Census, the last of which was undertaken in 2001, when 75.9% of the residents of Derby declared that they were in overall good health – this will next be updated in 2011. NI 137 equally comes from Census.
Life expectancies are calculated by constructing life tables, where life expectancy at age 65 in 2007 would be worked out using the mortality rate for age 65 in 2007, for age 66 in 2008, for age 67 in 2009, and so on. To obtain healthy life expectancy, a standard survey question on self-reported health is asked of those over 65. Results from this are then applied to life expectancy projections at 65 to show how many of the years to be expected will be spent in good health. The survey question has been used in the General Household Survey (GHS) for many years, and is also on the 2001 Census. On the 2011 Census the standard survey question on self-reported health will move from the original 3 category answer to a five category answer. ONS are currently undertaking work to ensure the series is consistent when the question changes.
All age all cause mortality is clearly a very broad subject. By changing our lifestyles for the better by way of cutting out smoking, reducing alcohol consumption, eating more healthily and taking regular exercise to combat obesity amongst other disease areas, the risk of developing conditions such as hypertension and diabetes, which would in turn put you at high risk of developing circulatory diseases and cancers, two of the UK population’s biggest killers, general mortality at any age would be greatly reduced.
1 The single source of NHS hospital activity data at a local level, directly fed from Acute Hospital Trust’s Patient Administration Systems (PAS)
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7.1.2 Causes considered amenable to healthcare
The purpose of this measure (Vital Sign VSC30) is to assess the impact of healthcare interventions on the mortality rate from causes which are amenable to treatment using those interventions2, and to give an indication of progress against tackling ‘premature’ and ‘preventable’ mortality. The difference between amenable and non-amenable causes in their trends over time may provide evidence of the increasing (or decreasing) effectiveness of health care.
Figure 101 Mortality from Causes Considered Amenable to Healthcare 250
200
150 Derby Amenable Derby Non-Amenable East Midlands Amenable East Midlands Non-Amenable 100
England Amenable DASR / 100,000DASR Population England Non-Amenable
50
0 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
Year
Source: ONS; NCHOD
As Figure 28 demonstrates, mortality from causes considered amenable to healthcare in Derby, the East Midlands and England, is decreasing in a far steeper trend than in those conditions considered not to be amenable to healthcare. The gap is clearly widening, suggesting that the effectiveness of healthcare is very apparent across the country.
2 The full list of these conditions can be found at www.nchod.nhs.uk
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7.1.3 Due to smoking
The latest Health Profile3 for Derby (2009) states that the number of deaths due to smoking in the city totalled 383 during 2005/07. This amounts to a directly age-standardised rate per 100,000 people aged over 35 of 221.8, which is higher than the England average for the period which was 210.2. It was however, by no means the worst in the country, which was a rate of 330.2 per 100,000 population aged 35+. The smallest rate in the country was 134.4. The top 10 smoking attributable deaths in both males and females in Derby are highlighted in Figures 102 and 103. Lung cancer unsurprisingly tops the list of smoking attributable deaths for both males and females, followed by Chronic Obstructive Pulmonary Disease (COPD) and Aortic Aneurysm.
Figure 102 Top 10 smoking attributable deaths in Males 70
60
50
40
30 Number
20 2004
10 2005 2006 0
Source: Secondary Uses Service
3 The Health Profiles, developed by the Association of Public Health Observatories (APHO) and funded by the Department of Health, are produced on an annual basis, and provide a profile of health in your area. They are designed to help Local Government and Primary Care Trusts tackle health inequalities and improve people’s health
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Figure 103 Top 10 smoking attributable deaths in Females 50 45 40 35 30 25
Number 20
15 2004 10 2005 5 2006 0
Source: SUS
Figure 104 demonstrates the crude rate per 1000 population smoking attributable hospital episodes. The general trend in recent years, whilst fluctuating and taking into account that there are only three data points, is an increasing one.
Figure 104 Smoking Attributable Hospital Episodes by Derby City PCT 43.0
42.5
42.0
41.5
41.0 CrudeRate/1000 Hospital Episodes 40.5
40.0
39.5 2005/06 2006/07 2007/08 2008/09 2009/10 2010/11 2011/12 2012/13 2013/14
Financial Year
Source: SUS
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7.2 Diabetes
What is the problem?
Diabetes is one of the greatest health challenges facing the UK today. It is a chronic and progressive disease affecting people of all ages, with a higher occurrence of cases being in people who are overweight or obese, physically inactive or with a family history of diabetes. People in black and ethnic minority groups are up to six times more likely to develop it than people of European origin (derived from recent Health Survey for England results). Diabetes is becoming more common and can affect many aspects of life. The majority of cases are of type 2 diabetes, two thirds of which could be prevented.
NHS Derby City currently has 12,742 people diagnosed with diabetes (types 1 and 2) and it is estimated that there are 700 newly diagnosed patients with type 2 diabetes per year. GP practice prevalence varies in the city from 2.67% to 7.69%. The health needs assessment undertaken by the PCT around diabetes shows that the highest prevalence is predominantly in the centre of the city where there is a high ethnic minority population as well as greater levels of social deprivation. Deprivation is strongly linked to smoking, obesity, physical inactivity and poor access to health care services.
Figure 105
Estimated Prevalence of Type I or II Diabetes by Age
16% 14% 12% 10% 0-29 8% 30-59 6% 60+ 4%
2% Percentage of each age group 0% Derby C ity P C T Derbys hire E as t Midlands E ngland C ounty P C T SHA
Source: NHS Derby City’s Diabetes Health Needs Assessment (2008)
Figure 105 demonstrates how the risk of diabetes increases with age. This shows that Derby city has a higher estimated prevalence in those aged over 30, compared to its neighbouring PCT, Derbyshire County, as well as the East Midlands Strategic Health Authority area and England. In these age ranges for Derby City, there must be other contributing risk factors which result in the estimated prevalence being higher than the other comparison areas.
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Figure 106
Total number of bed days for patients admitted with a primary diagnosis of diabetes (E10-E14) 10 27 10 16 113 Other R enal 137 C oma Neurological P eripheral C irculation 138 K etoacidos is Without C omplications 894 Ophthalmic
Source: SUS (Secondary User Service) hospital admissions dataset
Blood glucose and blood pressure are key areas which need to be managed well in order to prevent the development of diabetes related complications, such as coronary heart disease, retinopathy and kidney disease.
Diabetic Retinopathy
Retinopathy is the biggest single cause of blindness in the UK and if detected in time, treatment is very effective at preventing loss of vision in the majority of people. The Derbyshire Diabetic Retinopathy Screening Programme covers all people registered with a GP practice in the Derbyshire area. The programme was set up to detect changes in the eye using digital camera technology.
Retinopathy is an eye disease, where blood vessels supplying the retina are affected by diabetes. These blood vessels can sometimes leak and fluid then collects on the surface of the retina. In advanced stages, new blood vessels grow to try and improve blood supply to the eye. However, constant bleeding of these blood vessels can seriously affect sight. Early laser treatment is most effective in removing problematic areas and ultimately saving sight.
Diabetic retinopathy screening is a simple procedure, whereby drops are placed in the eye to dilate the pupils, and then two photographic images are taken of each eye. Trained graders/screeners then check the photographs of the retina for abnormalities which might suggest that the eye is affected by diabetic retinopathy. Other eye problems can also be identified, e.g. cataracts, and all patients are referred straight away to the Eye Clinic for treatment as required.
Derby hospitals together with NHS Derby City and Derbyshire County PCTs have always received an overwhelming response to their campaign to encourage people with diabetes to attend appointments for a sight saving service.
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Hospital admissions can give an insight into how local services are being used and where resources may want to be targeted in the future to meet further demand. Hospital admission data needs to be interpreted with some caution however, as it may be subject to recording and coding errors. Nevertheless, the data has been analysed where diabetes appears as a primary diagnosis and as such, cause of admission, in order to examine the impact of diabetes related complications in secondary care.
Figure 106 shows the number of admissions by NHS Derby City registered patients, with diabetes as a primary diagnosis. The largest proportion of admissions was from ophthalmic related conditions. Figure 107 on the other hand identifies the total number of bed days for patients admitted with diabetes, and it is those with peripheral circulation who actually stayed in hospital for the longest. Ophthalmic related procedures only used a very small number of the total bed days suggesting that these are likely to be day case procedures.
Figure 107
Total number of bed days for patients admitted with a primary diagnosis of diabetes (E10-E14)
112425 10 91 Other 206 Ophthalmic R enal C oma 222 Neurological K etoacidos is Without C omplications 1204 P eripheral C irculation
Source: SUS
It is known that people with diabetes have higher mortality rates than those without the disease. However, it is just as well known that when diabetes or a diabetes related complication are a contributory factor to death they are not necessarily recorded on the death certificate. This is ultimately as a result of clinical coding practice, but essentially means that it is not possible to get an accurate picture of the number of deaths attributable to diabetes from routine data sources. As such, the Yorkshire and Humber Public Health Observatory (YHPHO) have undertaken an analysis estimating the excess deaths among people with diabetes and diabetes attributable deaths using a combination of cohort studies and disease registers with routine population and mortality data.
In England, YHPHO estimate that in 2005, 26,300 deaths of people aged between 20 and 79 were attributable to diabetes. This equates to 11.6% of all deaths in that age group during 2005. During the same period, the East Midlands region saw 11.4% of deaths in the 20-79 age group attributable to diabetes, and in Derby this proportion was 12.3% (n= 131). If current trends in diabetes prevalence and mortality rates continue, it is likely that 12.2% of deaths between 20 and 79 years will be
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What works?
On the whole, type 1 diabetes cannot be prevented. It develops when the insulin-producing cells found in the pancreas have been destroyed. The most likely cause of this damage is an abnormal reaction of the body to the cells, which may be triggered by a viral or other infection, but nobody knows for sure. Type 2 diabetes on the other hand can, for some of the risk factors at least, be prevented. On the whole, the risk can be reduced by making changes in diet and increasing physical activity. Maintaining a healthy weight and exercising to nationally recommended standards i.e. 3 times moderate intensity activity for half an hour each week, can reduce the risk considerably.
What are we doing now?
Derby City PCT commissioned Surtal Asian Arts to produce and deliver a play about diabetes in March 2008 as a follow on from ‘All Shook Up’, a play about diabetes delivered by the Pyramid Theatre Company 18 months earlier. Although ‘All Shook Up’ was a huge success, it failed to attract South Asian audiences who are more likely than most to develop the disease. The reasons given for non attendance were predominantly due to language barriers – the theatre company was unable to deliver the play in Urdu and Panjabi. As such, a proposal was developed to fund a play with the following aims:
To work in partnership with a voluntary organisation – because of its networks in the community.
To use local people – rather than professional actors from elsewhere.
To use a community engagement and community development approach – the stories about diabetes would evolve as a result of undertaking community research by the selected cast members.
To have information in the play about prevention, signs and symptoms, risk factors, treatment, compliance and complications of diabetes.
To have the events hosted by local community centres.
Diabetes care is one of the corporate goals in NHS Derby City’s 5 year Strategic Plan and the PCT is committed to reducing the level of diabetic complications. So as well as risk factors, signs, and symptoms, the play also focussed on complications relating to chiropody, retinopathy and sexual health.
Representatives from Diabetes UK attended one of the performances and has been supportive of future developments. Diabetes UK is the largest organisation in the UK working for people with diabetes, funding research, campaigning and helping people live with diabetes. Diabetes UK was also involved in the marketing strategy.
Over 600 people received information about diabetes, the risk factors, signs and symptoms, the management and complications of diabetes. Comments from members of the audience included the following:
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“I attended Gurh Nalo Ishq Mitha (Love is Sweeter than Sugar) about Type 2 diabetes in the Hindu temple in Derby. The play was performed in Panjabi and in English. The actors were drawn from the community. It was excellent in raising awareness with sensitivity and humour. It is a great example of how we can convert our strategic priorities of awareness and education into action in communities that need it most.” Douglas Smallwood, Chief Executive of Diabetes UK
“Ground breaking regional work of a PCT commissioning a piece of community theatre for health promotion – model of good practice. The PCTs around the country should consider developing partnership with local arts organisations, not just BME, and use Surtal’s experience as the template….Diabetes UK can use this model to raise awareness of diabetes around the country” Utkarsha Joshi, (Diversity Officer) and Dom Jinks (Arts in Health, Officer) Arts Council of England, East Midlands
“A brilliant piece of community theatre where a serious health message was delivered in an innovative way …an effective piece of partnership work between Surtal and Derby PCT, well done!” Graham Marriet, Director of Derby Arts
“Script writers understood the sensitivity of the Asian culture, used words in a meaningful way…directing with tint of comedy was brilliant. Dominic Rai did a wonderful job” Dipak Joshi, Leicester Theatre Trust
“The production raised the issue of diabetes in a creative, powerful way. To see elderly Asian women leaning forward, gripped by the dialogue, nodding to each other and murmuring agreement was a vindication of the actors.” Gersh Subhra, University of Derby
“Thanks for a brilliant evening. We were so glad to see it all come together. We were also very impressed with the number of people who were there, which was a testament to all your hard work.” Philippa & Jeff, Directors of Pyramid Theatre Company
“I really enjoyed the play. It has encouraged me to take a test. My knowledge of the subject of diabetes has grown and I have been talking to family about it.” (audience member)
“A really engaging and interesting way to deal with a sensitive area. Really impressed." (audience member)
“An amazing performance, displaying awareness in this dramatic play. Would love to attend another play in the future.” (audience member)
“Good to be part of such an interesting approach to education.” (audience member)
“Great to see attentive audience enjoyed bilingual approach.” (audience member)
“The different scenarios really brings home the message in a way that Asian people can relate. Particularly diet and the use of ghee!” (audience member)
“An excellent way of engaging with people who may have difficulty in understanding written information.” (audience member)
“Very good, clear, succinct message to the right audience.” (audience member)
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What should we be doing?
By using the information in NHS Derby City’s practice profiles 2007/08, the practices that had a lower actual prevalence against their individual expected prevalence were reviewed, and common themes were identified. These themes were based around their risk factor control and outcomes i.e. admissions:
High admission ratio for primary diagnosis High admission ratio for circulatory conditions for diabetes High % of ineligibles for BP control Low risk factor controls for HbA1c <7.5, BP, and cholesterol
For the practices where the above factors were identified, the following actions were suggested and agreed as part of the individual practice action plans:
Admission audits to identify if the patients had been known to have CHD/ Diabetes before admission. Blood glucose to be done on patients having other blood tests on those over 40. Audits where risk factors were below average. Audits where numbers of ineligibles are high. Audit of statin prescribing for CHD, Stroke, and Diabetes. Identify % patients with risk factors (BMI> 30) who have not had fasting / random blood glucose. Increase BMI recording for patients with long term conditions but to look at them opportunistically for all adults.
Currently, the practice profiles 2008/09 are being produced and will continue to be used by the Public Health and wider commissioning teams of the PCT to measure progress in the Diabetes prevalence indicators, by GP Practice.
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7.3 Circulatory
7.3.1 General
Figure 108 below illustrates Derby City’s progress in tackling premature mortality from all circulatory diseases (detailed further in the forthcoming sections). Premature mortality from all such disease is monitored nationally as part of the local area agreement between NHS Derby City and Derby City Council (NI 121) and within the Primary Care Trust itself by way of Vital Sign VSB02. Evidently, there is a downward trend in the rate of mortality in Derby. However, it is fluctuating above both the national and regional trends. Projecting by way of linear trend line based on the actual rates of mortality seen in previous years, Derby appears to be on track to achieve the 2010/11 (based on 2009 actual data) target of 77 premature deaths per 100,000 population. Much needs to continue to be done though to ensure this achievement.
Figure 108 Premature Mortality from Circulatory Disease 200
180
160
140
120
ENGLAND 100 EAST MIDLANDS Derby City Actuals 80 Derby City Targets
DASR / 100,000DASR Population Linear (Derby City Actuals) 60
40
20
0 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Year
Source: ONS; National Centre for Health Outcomes Development (NCHOD)
Reducing deaths from circulatory disease will contribute significantly to reducing overall premature mortality and the strategic goal to save 2000 lives in 10 years. The population health goals paper for the PCT (a supporting document to the Healthy Derby strategy) sets our the milestones and progress to be achieved in relation to premature mortality from CVD in order to achieve the overall strategy target of ‘saving’ 2000 premature deaths by 2017. This is an ambitious but realisable target provided the action plans are funded and executed.
Performance against this target will be influenced by the lifestyle behaviours of Derby people, the wealth of the city, and the educational attainment of children in the city. National changes with regard to the taxation and advertising of unhealthy behaviours will influence the success of this indicator.
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7.3.2 Coronary Heart Disease
What is the problem?
Coronary Heart Disease (CHD) is the largest cause of death in the UK and in Derby. CHD together with Stroke (discussed next), account in the most part for what is collectively known as Cardio-Vascular Disease (CVD). This in turn makes up a large part of what are collectively known as Circulatory Diseases. In the city, there were 2451 deaths from circulatory diseases between 2005 and 2007, of which 732 were in people aged under 75 years and potentially preventable. Some of our population groups are at a greater risk than others and provide the focus for the CHD strategy. These include:
Those from South Asian and African Caribbean communities Those living in socially deprived areas Smokers People with a BMI (Body Mass Index) above 30 People with diabetes People with hypertension and People with disabilities
Figure 109 below shows that the overall trend in rate of premature mortality from CHD in Derby is following the national picture. Our aim though, is to reduce this even further to ultimately exceed the rate of mortality in England.
Figure 109 Premature Mortality from Coronary Heart Disease 120
100
80
60 ENGLAND EAST MIDLANDS
Derby UA DASR / 100,000DASR Population 40
20
0 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
Year
Source: ONS; NCHOD
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In England, 32% of men and 30% of women aged 16 years or over have hypertension or are being treated for high blood pressure. This means that, in terms of the average GP’s list of 2000 patients, about one quarter will have hypertension and there is substantial evidence that lowering blood pressure in people with hypertension is associated with a reduction in cardiovascular risk.
CVD kills 1 in 3 people every year4. Like with diabetes, while there are some contributing factors that cannot be altered there are others in our lifestyles that we can change to help prevent its onset. CHD itself is a major cause of morbidity and mortality in Derby, with significant disparities between areas of deprivation. Tackling the disease is a national priority and at a local level, our target is to avert 2000 premature deaths by 2017; 200 of these being through CVD prevention.
In 2008/09, over 10,000 patients in Derby were on the CHD register at their GP practices (QOF). The expected prevalence based on the QOF benchmarking tool developed by Doncaster PCT was closer to 12,500 people. One particular surgery is picking up only 50% of it’s expected CHD population. As such, work needs to be done with the practices, by way of the PCT’s practice profiles, to ensure that all patients are appropriately risk assessed and diagnosed at the earliest possible stage. Compared to England, the prevalence of CHD in NHS Derby City is greater, as it is compared with NHS Nottingham and Leicester Cities (Figure 110). This is expected only to rise to 2020.
Figure 110 Modelled estimates of prevalence of CHD, by PCT Eastern Region Public Health Observatory, November 2008 7%
6%
5%
4%
Derby City Nottingham City 3% Leicester City
ENGLAND Prevalence Hypertensionof
2%
1%
0% 2006 2007 2008 2009 2010 2015 2020
Year
Source: ERPHO
Hospital admissions with acute Myocardial Infarction (heart attack) can be used as a proxy for incidence of CHD where no other data is available. During 2008/09 there were 1050 admissions with heart attacks made by patients of NHS Derby City. The expected figure, when indirectly age- standardising to Derbyshire as a whole (hospital activity for Derby City and Derbyshire County PCTs combined), was 973 admissions. The indirectly age-standardised ratio of admissions to hospital for MI
4 bbc.co.uk/health
21 for Derby City was therefore 107.9 – where a ratio of 100 is average, and a ratio above 100 means that there were more admissions than the average and a ratio below 100 means that there were less than average.
The East Midlands Public Health Observatory (EMPHO) report in their document, Coronary Revascularisation: Need and Provision In the East Midlands (2008 update), that there has been a 90% increase in revascularisation5 rates across the East Midlands in the nine years since 1998/99 – from 718 to 1360 per million population (pmp). Despite this significant increase, the East Midlands as a whole is still short of the 1500 pmp target set by the CHD NSF6. In Derby City, there was a shortfall of 150 procedures, compared to 180 in Derbyshire, 190 in Lincolnshire and 200 in Nottingham.
On the whole though, revascularisation procedures have increased for both males and females registered to NHS Derby City. The highest rates of increase have been seen in the most deprived areas of the city, and for males the gap between the most deprived and the least deprived quintile has decreased for CHD Mortality, Cardiology Outpatient, CHD Inpatient, Angiography and Revascularisation since 2001/02. For females, the gap between the most deprived and the least deprived quintile has decreased for CHD Inpatient, but increased for CHD Mortality, Cardiology Outpatient, Angiography and Revascularisation between 2001/2 and 2005/6. Although the level of need has decreased, it is still much higher for men in the most deprived quintile and this is not reflected in the number of angiograms being performed7.
Figure 111
Directly Standardised Ratio for Persons CHD Events for Worst Compared w ith Least Deprived Quintile
2 1.75 1.51 1.28 1.25 1.15
1
0 CHD Mortality Cardiology CHD Inpatient Angiography Revascularisation Outpatient
Source: SUS
Age-specific rates of revascularisation in 2006/07 are presented in Figure 112. As is evident from the chart, rates are generally significantly higher in the older age groups in the combined Leicester, Leicestershire and Rutland, and Northamptonshire region, compared to the Trent region; comprised of Nottingham and Nottinghamshire, Bassetlaw, Lincolnshire, Derby and Derbyshire.
5 Revascularisation is a surgical procedure for the provision of a new, additional, or augmented blood supply to a body part of organ 6 National Service Framework for Coronary Heart Disease: Modern Standards & Service Models, Department of Health 2000 7 Review of Revascularisation uptake in Southern Derbyshire report held by NHS Derby City and Derbyshire County PCT
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Figure 112 Age-specific rates of revascularisation in the East Midlands in 2006/7
9,000 <50 50-59 60-69
70-79 80+ 8,000
7,000
6,000
5,000
4,000
rate per million population ratemillion per 3,000
2,000
1,000
0
LNR Derby TRENT Leicester Bassetlaw Derbyshire Nottingham Lincolnshire
Nottinghamshire EAST MIDLANDS Northamptonshire
Leicestershire and Rutland
Source: EMPHO
Figure 113 Age-specific rates of revascularisation in the East Midlands in 2006/7
Trends in revascularisation in the East Midlands
1800
LNR - CABG TRENT - CABG 1600 EM - CABG LNR - PCI TRENT - PCI EM - PCI TCN - PCI target LNR - PCI target 1,540
1400
1,280 Adjusted PCI target for TCN : 1200 pmp 1200 Adjusted PCI target for LNR : 1100 pmp 1,142
1000
800 rate per million per rate
600
400
200
0 1998/9 1999/0 2000/1 2001/2 2002/3 2003/4 2004/5 2005/6 2006/7 2007/8 2008/9 2009/0 2010/1
Source: EMPHO
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The work that EMPHO undertook in publishing their report also looked at forecasts and targets for revascularisations in the region. As if evident in Figure 113, the LNR region exceeded their target in 2005/06, while the Trent Cardiac Network are unlikely to reach theirs until 2010/11. This is based on the targets set in the NSF in 2000. However, higher national levels of revascularisation are now considered achievable such as 1850 by 2008 and 2500 by 2010.
What works?
The Department of Health in it’s July 2008 document, Economic Modelling for Vascular Checks, state that a systematic approach to CVD risk assessment has been shown to be both clinically and cost- effective. There is general agreement that the initial focus should be on people with greater than or equal to 20% risk of a CVD event in the next 10 years. GPs have been offering successful secondary CVD prevention for several years and are already offering opportunistic primary CVD risk prevention for some patients. Changes in lifestyle behaviours illustrated in previous chapters of this assessment will obviously also work in tackling CHD.
What are we doing now?
The PCT’s aim is to develop more systematic approaches to identify other high-risk groups with minimal administrative burden to GP practices. As such, a CVD Risk Assessment Programme LES (Locally Enhanced Service) has been developed in Derby which will be configured to ensure such patients are identified, risk assessed and managed appropriately.
The development of a co-ordinated programme of CVD risk assessment and primary prevention will require sustained action over a number of years. Therefore this initial LES will be offered from 01 July 2009 to 30th June 2010 when it will be reviewed and modified as appropriate according to local needs. In addition, the PCT may amend this LES depending on national guidance and in response to QOF or other GP contractual or clinical practice changes.
The LES aims to reduce levels of CVD risk and associated premature mortality in Derby through systematic and proactive primary care identification and management of patients with ≥20% risk of CVD event in the next 10 years (based on adjusted Framingham Heat Study risk equations identified via specified software).
The service objective is to deliver a preventive programme for vascular checks, which will consist of a system to identify the eligible population, plus a risk assessment and management service. This LES will be complimented by targeted, community-based activity.
The intended health outcomes are to:
1. Enable more people to be identified at an earlier stage of vascular change, with a better chance of putting in place positive ways to reduce the risk of premature death or disability; 2. Sustain the continuing increase in life expectancy and reduction in premature mortality that are under threat from the rise in obesity and sedentary living; 3. Offer a real opportunity to make significant inroads into health inequalities, including socio- economic, ethnic and gender inequalities.
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What should we be doing?
Alongside the LES, community endeavours should be developed to ensure our population have a better understanding of the condition, as well as of ways to improve lifestyles; such as quitting smoking if you are a smoker, to help prevent the diseases onset.
7.3.3 Stroke
What is the problem?
Stroke has a major impact on people’s lives. It starts as an acute medical emergency which has diagnostic implications; presents complex care needs (which may result in long-term disability) and can lead to admission for long-term care. Transient Ischaemic Attacks (TIAs) are described as mini- strokes, where symptoms and signs usually resolve within 24 hours. Having a TIA increases the subsequent chances of a stroke. It is estimated that, in the UK, 150,000 people will have a stroke each year. The majority of people who have a stroke are aged over 65 but it can occur at any age, even in childhood. Not only is stroke a major cause of death both nationally and in Derby City, it is also the leading cause of severe disability. After all this, stroke is recognised as a preventable and treatable disease.
According to the Health Survey for England (2003) prevalence of doctor-diagnosed stroke was similar in both sexes; 2.4% in men and 2.2% in women. Prevalence rose with age, ranging from 7.5% at age 65-74 to 13.3% aged over 75 in men and from 5.3% in women aged 65-74 to 8.8% in over 75s. This estimates 2236 men and 2138 women living in Derby City to have had a stroke, using 2007 population data. The evidence from the Quality and Outcomes Framework in 2008/09 is that there are 4759 people on the Primary Care stroke and TIA prevalence register. The overall proportion of prevalence in Primary Care is 1.65% of the population for Derby with a range of 0.6 to 2.6% in the practices.
TIAs affect new (incidence) patients at a rate of 0.42 per 1,000 per year. This would equate to around 100 people per year in Derby City. This shows an increase with age and with the main risks relating to hypertension and other markers of vascular disease. The number of new patients with a stroke or TIA identified in Primary Care in Derby in 2007/08 was 305 of whom 283 (92.8%) were referred for further investigation. In 2008/09 the number was 221 of whom 202 (91.4%) were referred for further investigation. The proportions of those referred by the practice were as little as 0% in one practice, however of the 32 practices showing incidence, 19 of them recorded 100% referred for further investigation in 2007/08. In 2008/09 all practices recorded at least 83% with again 19 of them recorded 100%. There will also be other patients in the community already experiencing TIAs, but the number will be unknown unless they visit the GP with symptoms.
What works?
NICE Guidance suggests that primary prevention is key in reducing instances of stroke. Reducing raised blood pressure in people with hypertension for instance, reduces the risk of a stroke by half in those aged between 40 and 80 years. This can only be done though if those with hypertension are found and treated. Also, treating those with Atrial Fibrilation by means of anticoagulation therapy, as well as other vascular prevention strategies such as reducing cholesterol and smoking cessation.
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The Royal College of Physician’s National Clinical Guidelines for stroke treatment and care, advise admission to a unit within 24 hours of the episode itself. Swift assessment for the cause of the stroke i.e. internal bleed or blood clot, must follow, including CT Scan imaging within 3 hours, and clot busting medication given where appropriate. Prior to the patients’ discharge, rehabilitation goals should be agreed as well as secondary preventative measures, such as being discharged on statins as well as blood pressure treatment if necessary.
What are we doing now?
Analysis by NICE shows that during 2006/07, 63,000 people were admitted to hospital nationally as an emergency with stroke. This works out at 120/100000 or 0.12% of the population. This is lower than the population wide estimate (110,000) because it does not include a significant proportion of strokes that result in death before admission can take place, or that occur in hospital. Coding issues could also be a factor.
In 2006/07 there were 461 admissions to hospital for Derby City registered patients, with the same primary diagnosis as those calculated above and in 2008/09 458. This is 0.16% of the population or 161/100000 population in 2007/08, higher than the national average. The table below shows the breakdown of admissions to hospital for stroke by provider. From the table we can see that almost without exception, when the stroke occurs within Derby City, patients are admitted to Derby Royal Hospital (Derby Hospitals NHS Foundation Trust).
Figure 114
Emergency admissions of NHS Derby City patients to hospital for stroke, by provider of care Provider 2006/07 2007/08 2008/09 Derby Hospitals NHS Trust 97.5% 96.9% 95.3% Other providers in East Midlands 1.7% 1.4% 2.6% Hospitals outside the East Midlands 0.8% 1.8% 0.4% Source: SUS (Secondary User Service) hospital admissions dataset
Derby Hospitals, when based at Derbyshire Royal Infirmary site (since closed and services moved to the new Derby Royal Hospital), had an acute stroke ward (Ward 9) with 26 beds and a rehabilitation ward (Ward 2a) with 21 beds. This service moved to the new hospital site in May 2009 where there are now 4 hyper-acute beds and 20 other acute beds on the acute stroke ward. The number of rehabilitation beds is not known. Derby Hospitals also provide a service to Derbyshire County PCT and East Staffs PCT for stroke treatment.
It is estimated that 85% of all strokes are ischaemic and 15% haemorrhagic. The following table shows numbers for Derby City patients by ICD-108 code, being treated for stroke at Derby Hospitals. The most common type of stroke admission is cerebral infarction (ischaemic) – I63. There is a significant proportion where the stroke is not specified as haemorrhagic or ischaemic (I64).
8 International Classification of Diseases, Version 10 – adopted by World Health Organisation (WHO) member states to clinically code patient diagnoses
26
Figure 115
Numbers and proportion of emergency admissions for stroke (primary diagnosis) at Derby Hospitals by ICD10 code, and year of admission Derby City Financial Broad ICD-10 year code No % 2005/06 I60 28 6.7% I61 60 14.4% I62 17 4.1% I63 246 60.0% I64 66 15.8% 2005/06 total 417 2006/07 I60 30 6.0% I61 89 18.5% I62 24 4.8% I63 272 54.0% I64 89 17.7% 2006/07 total 504 2007/08 I60 18 3.7% I61 81 16.8% I62 23 4.8% I63 255 52.9% I64 105 21.8% 2007/08 total 482 2008/09 I60 19 4.1% I61 59 12.6% I62 15 3.2% I63 297 63.6% I64 77 16.5% 2008/09 total 467 Source: SUS (Secondary User Service) hospital admissions dataset
Figure 116 below shows the age specific rates of admission to hospital for stroke by gender for each of the last three financial years. As expected, rates increased with age. In males, the graph shows a decrease over the time period in 75-84 age group, with an increase in 65-74. Females showed a decrease in 55-64 year olds and 65 to 74 year olds, with an increase in the 75-84 age group. The combined graph shows an increase in 45-54 age group with a decrease in 65-74 and 75-84 age groups. The numbers over the last three financial years have been similar with a 5% reduction in the last year from 2006/07. Twice as many men than women had a stroke in 55-64 age group, but by 75 onwards women overtake men. Those aged 75 and over saw mainly higher rates in women than men.
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Figure 116
Source: SUS (Secondary User Service) hospital admissions dataset
Figure 117 shows trends of national, regional and local emergency admissions to hospital on a resident basis. Both males and females show a downward trend locally, with a higher downward trend for males. The rate of emergency admissions locally for stroke are now slightly lower than regional and national admissions.
Figure 117
3-year rolling average of rate of emergency admissions to hos pital for s troke, (pers ons )
200
150
100 Derby
50 England 3-year rolling average Eas t Mids 0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Last financial year in 3-year period
Source: SUS (Secondary User Service) hospital admissions dataset
Local admissions to hospital were examined for people from minority ethnic groups. In 2006/07, 72.7% were from a white background with 3.9% Asian and only 0.8% from a black background (22.3%
28 had missing information about ethnic origin). In 2007/08, 72.2% were from a white background, 5.9% from an Asian background and 1.4% each from black background (20.4% had missing data in the ethnic origin field). In 2008/09 75.6% were from a white background, 5.7% Asian and only 0.2% black (18.3% had missing information about ethnic origin). It would appear from this that ethnic origin information could be improving in secondary care data, however the improvement needs to be sustained.
Admissions to hospital have also been analysed on a quintile basis. This involved assigning postcodes to lower layer super output areas9 (LLSOA) which were then divided into national quintiles based on the IMD 2007 score for each LLSOA. Quintile 1 is the most deprived with quintile 5 being the most affluent. Figure 118 below shows the numbers of emergency admissions by gender for stroke patients. 49%, almost half of all patients treated for stroke, live in the more deprived areas. These admissions are based on a registered PCT basis and thus include a number of patients living in Derbyshire County.
Figure 118 Number and proportions of emergency admissions for stroke (primary diagnosis) by gender, for Derby City registered patients by national quintile of deprivation – 2006/07 to 2008/09 Quintile Male Female Persons No % No % No % Quintile 1 141 23.6% 164 20.8% 305 22.0% Quintile 2 160 26.8% 225 28.6% 385 27.8% Quintile 3 99 16.6% 126 16.0% 225 16.2% Quintile 4 89 14.9% 122 15.5% 211 15.2% Quintile 5 109 18.2% 151 19.2% 260 18.8% Source: SUS (Secondary User Service) hospital admissions dataset
What should we be doing?
There is evidence to suggest that immediate treatment on an acute stroke ward followed by rehabilitation in a dedicated care setting gives the best possible outcome for patients who suffer stroke. In the National Sentinel Stroke Audit10 there are five key factors that contribute to optimum patient care. These are:
Consultant physician with responsibility for stroke Formal links with patient and carer organisations Multidisciplinary meetings at least weekly to plan patient care Provision of information to patients about stroke Continuing education programmes for staff
In the audit taken in 2006, 46% of patients of Derby Hospitals NHS Trust had all five key factors in their care compared with 54% nationally. Nationally in the 2008 audit, care has moved on and now 100% of hospitals have a consultant physician with responsibility for stroke. In 2006, only 33% of patients at the hospital received a brain scan within 24 hours. This almost doubled in 2008 to 64%. By 2008 average waiting times for CT scan on weekdays and weekends was 5-24 hours and for an MRI scan, 5- 24 hours on weekdays but more than 48 hours at the weekend. This shows an improvement since
9 Super Output Areas are a relatively new geography, introduced by the Office for National Statistics, designed to improve the reporting of small area statistics. The Lower Layer Super Output area has no fewer than 1000 residents, and a mean of 1500. 10 Royal College of Physicians of London. National Sentinel Stroke Audit, 2006 and 2008. London.
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2006 and enables further treatment such as thrombolysis to be given within 3-4 hours of onset of stroke, a challenging target to meet.
The population benchmark for receiving treatment for ischaemic stroke with alteplase (a thrombolytic agent given by means of injection to degrade blood clots) is 9% of patients meeting the criteria admitted to secondary care following a stroke. This equated to approximately 20 patients during 2007/08. A total of 6 patients at Derby Hospitals have received alteplase since September 2008. In April 2008 national monitoring indicators for stroke, part of the National Health Service’s Vital Signs performance monitoring agenda, were initiated to demonstrate performance against recommended guidelines. There are four lines of measurement on a quarterly basis:
Patients who spend at least 90% of their time on a stroke unit Number of people who were admitted to hospital following a stroke TIA cases with a higher risk of stroke who are treated within 24 hours Number of people who have a TIA who are at higher risk of stroke
In 2008/09 financial year, according to the indicator, there were 390 people admitted for stroke (if a patient has two episodes of admissions to hospital following a stroke they would be counted twice). Of these 215 (55%) people spent at least 90% of their time on a stroke unit. There were 161 people with high risk TIA and 114 (70%) of those were scanned within 24 hours.
For some patients surgery is necessary after stroke. Carotid angiography with or without duplex ultrasonography is estimated to be 33 per 100,000 per year equating to 79 per year for Derby City patients. It is not possible to determine the number of those patients having ultrasonography. The treatment of carotid endarterectomy for TIA and minor stroke is estimated at 16 per 100,000 per year, which would be 38 per year for Derby City. There were on average 14 Derby City patients per year having surgery following a stroke or TIA in the years 2005/6 to 2007/8 with 12 in 2008/09.
In the Sentinel Audit 2006, it was found that 46% of patients received a swallowing assessment within 24 hours of their admission to hospital with stroke; however by 2008 this had risen to 68%. Patients who do have difficulty swallowing will need speech and language therapy to work out whether it is safe to take food or drink by mouth. In severe cases a nasogastric feeding tube is used, or percutaneous endoscopic gastrostomy (PEG) is used where a feeding tube is put into the stomach directly through the abdominal wall. The local score of 46% in 2006 was compared with 66% nationally. The 2008 score of 68% compared with 73% nationally.
As stroke is a major cause of disability, all services such as physiotherapy, occupational therapy and speech therapy are vital to those with speech and mobility problems. Some patients recover fairly quickly, some recover slowly and others have significant levels of disability for the rest of their lives. This has an impact on those caring for them, and services required to facilitate independent living and quality of life. Information on aftercare and how to prevent further stroke is imperative for sufferers and carers. NICE Clinical Guideline No. 6811 is the guideline for initial diagnosis and treatment of stroke and TIA. Within this document are listed key priorities for implementation including details on rapid recognition of symptoms and diagnosis and specialist care for people with acute stroke. It recommends the use of validated tools such as FAST12 and ABCD13 for diagnosis with recommendations for early initial treatment, assessment and further investigation.
11 National Institute for Health and Clinical Excellence . (July 2008). Diagnosis and initial management of acute stroke and transient ischaemic attack (TIA) – NICE Clinical Guideline no 68. National Collaborating Centre for Chronic Conditions. 12 Facial weakness, Arm and Leg weakness, Speech problems, Time to call 999 13 Royal College of Physicians (2000) National Clinical Guidelines for Stroke, Intercollegiate Working Party for Stroke, RCP, London
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7.4 Cancer
7.4.1 General
Worldwide, there were around 11 million new cases of cancer in 2002 and a quarter of these were in Europe. Each year in the UK, around 293,600 cases of cancer are newly diagnosed14. This amounts to someone being diagnosed with cancer every two minutes. Moreover, 1 in 3 people will develop some form of cancer during their lifetime. Cancer is widely regarded to be the number one fear for the British public.
Figure 119 below illustrates Derby City’s progress in tackling premature mortality from all cancers (detailed further in the forthcoming section). Premature mortality from cancer is monitored nationally as part of the local area agreement between NHS Derby City and Derby City Council (NI 122) and within the Primary Care Trust itself by way of Vital Sign VSB03. On the whole, the rate of mortality is lower than that seen not only in the East Midlands but also nationally, and the trend is a downward one. However, based on the current trend alone we are not on target to achieve our 2010/11 (based on 2009 actual data) target of 96 premature deaths per 100,000 population.
Figure 119 Premature Mortality from Cancer 180
160
140
120
100 ENGLAND EAST MIDLANDS 80 Derby City Actuals Derby City Targets
DASR / 100,000DASR Population Linear (Derby City Actuals) 60
40
20
0 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Year
Source: ONS; National Centre for Health Outcomes Development (NCHOD)
Cancer causes one in four of all deaths in the UK. In 2007, this amounted to more than 155,000 cancer deaths in the UK. However, on a more positive note, half of people diagnosed with cancer now survive for more than five years, the average ten-year cancer survival rate has doubled over the last 30 years, and treatment for children is far more successful now than it ever was15
14 43 Cancer Research UK
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Progress in reducing premature cancer mortality in Derby in the last ten years has been limited, particularly for women. Derby has increasing numbers of deaths from lung cancer in women, a picture reflected in other deprived areas of the East Midlands, for example in Bolsover, but not in the East Midlands as a whole. Reducing cancer deaths below the age of 75 in women, and in particular lung cancer deaths will be a key, but difficult, challenge to achieve.
Evidence based action plans would suggest that the key challenge is undertaking a comprehensive programme of symptom recognition and early diagnosis, involving patients and professionals. The risk to this though, is the increasing lung cancer deaths in women. Analysis shows that this is likely to be related to smoking behaviour patterns in the past leading to current burden of disease i.e. those women who at a younger age during the 1950’s and 60s smoked considerably, are coming through now at an older age with serious health complaints, as is also evident in CHD. This trend may take time to reverse.
7.4.2 By site
What is the problem?
There are more than 200 different types of cancer, each with different causes, symptoms and treatments. The most common cancers by site are:
Bladder Cancer Bowel (Colorectal) Cancer Breast Cancer Lung Cancer Oesophageal Cancer Ovarian Cancer Pancreatic Cancer Prostate Cancer Skin Cancer Stomach Cancer
Breast, lung, bowel and prostate cancers together account for over half of all new cancers each year. Figures 120 through 123 on the following pages show the current, and forecasted trends in these particular cancers for Derby, compared to the East Midlands and England.
Derby City’s progress in tackling mortality from breast cancer is evident in Figure 121. On the whole the rate of mortality has been below not only the East midlands rate but also the rate seen nationally. With regard to mortality from lung cancer, since 2003 the rate of mortality has been below the national rate but has remained above the East midlands rate since 1993. However, Derby City’s rate is decreasing at a greater rate than that seen in the East midlands region. In terms of prostate cancer, Derby’s progress in tackling mortality associated with the cancer can be seen in Figure 123. As is the case with breast cancer, on the whole the rate of mortality has been below not only the East midlands rate but also the national rate. The trend in reduction of rate of mortality from bowel cancer would appear to be a far steadier one compared to the other three, and we in fact might reach a stage where the rate of mortality in Derby is greater than seen not only in the East Midlands, but across England.
In the 1993 – 2007 period, the rate of mortality within the East midlands and nationally has been decreasing steadily but Derby City’s rate has decreased at a far greater rate. The rate of mortality
32 from bowel cancer in Derby has on the other hand, been far more erratic. The general trend, whilst downward, is far flatter than is evident for the other cancers. This is of concern.
Figure 120 Mortality From Bowel Cancer 30.00
25.00
20.00
England East Midlands 15.00 Derby Expon. (England)
DASR / 100,000 Population 100,000 DASR / Expon. (East Midlands) 10.00 Expon. (Derby)
5.00
0.00 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Year Source: ONS; NCHOD
Figure 121 Mortality from Breast Cancer 60
50 ENGLAND
40 East Midlands
Derby 30 Expon. (East Midlands )
Expon. (East DASR / 100,000 Population / 100,000 DASR 20 Midlands ) Expon. (Derby)
10
0 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Year
Source: ONS; NCHOD
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Figure 122 Mortality From Lung Cancer 70
60
50 ENGLAND
East Midlands
40 Derby
Expon. 30 (ENGLAND) Expon. (East
DASR / 100,000 Population / 100,000 DASR Midlands) Expon. 20 (Derby)
10
0 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 year Source: ONS; NCHOD
Figure 123 Mortality From Prostate Cancer 45
40
35
30 England 25 East Midlands 20 Derby 15
Expon. (England) DASR / 100,000 Population 100,000 / DASR 10 Expon. (East Midlands) 5 Expon. (Derby) 0 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Year
Source: ONS; NCHOD
Cancers can develop at any age, but are most common in older people, particularly in those aged 60 or over who are likely to have three-quarters of all cases of cancer across age-groups. Around 1% of
34 cancers occur in children, teenagers and young adults. Cancer is widely regarded as the number one fear of the British public, and of particular concern at the moment in the UK are increases of potentially unavoidable cancers such as malignant melanoma (skin), uterine (womb) and kidney cancers. As Figure 124 demonstrates, the directly age-standardised registration rate of all cancers in Derby was not significantly different to the incidence of all cancers seen in England and the East Midlands during 2004/06.
Figure 124 Incidence of all cancers (ICD10 C00-C99 exc C44) 2004/06 330
320
310
300
ENGLAND EAST MIDLANDS 290 Derby UA
DAS RegistrationDAS Rate 100,000/ Population 280
270
260 MALES FEMALES PERSONS Source: ONS; NCHOD
However, the trend of registration of all cancers in Derby since 1993, and forecast to 2010 based on the period 1993 to 1996, highlights that whilst the incidence rate in Derby was once lower than that seen in the East Midlands and England overall, it has been increased at a steeper rate and by 2010, is expected to be approximately 12% greater than will be seen nationally (Figure 125).
Figure 125 Trend and Forecast in Incidence of All Cancers in Derby City LA 450
400
350
300
250 ENGLAND EAST MIDLANDS Derby UA 200 Expon. (ENGLAND) Expon. (EAST MIDLANDS)
150 Expon. (Derby UA) DAS RegistrationDAS Rates / 100,000Population
100
50
0 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Year
Source: ONS; NCHOD
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What works?
An individual’s risk of developing cancer depends on many factors. As discussed earlier, age is particularly significant, as is a person’s genetic make-up. However, unhealthy lifestyles are also likely to cause the development of cancer. Cancer Research UK estimates that up to half of all cancer cases diagnosed in the UK could be avoided if people made changes to their lifestyles; such as through stopping smoking, moderating alcohol intake, maintaining a healthy bodyweight and avoiding excessive sun exposure. Excessive exposure to UV radiation not only from the sun but from sun beds too, is the most important modifiable risk factor for skin (melanoma) cancers.
Smoking is evidently the single most important cause of preventable death in the UK, resulting in more than a quarter of all deaths from cancer. Smoking causes almost 90% of lung cancer deaths alone. Estimates suggest that, in the UK, up to 13,000 cases of cancer could be avoided if no-one exceeded a body mass index (BMI) of 25. In addition, research suggests that each of the following increase the risk of certain cancers:
Alcohol consumption A low fibre diet Low consumption of fruit and vegetables High consumption of red and processed meats High intake of salt and saturated fats
As such, changes in lifestyle alone will impact significantly on the risk of developing cancer.
What are we doing now?
The ‘Lifestyle and Risk Factors’ section of this needs assessments elaborates on the initiatives in place around helping the population of Derby City to modify the lifestyles for the healthier. Whilst such initiatives remain ongoing, we are concentrating on our screening programmes in Derby City; particularly for bowel, breast and cervical cancers.
The Derbyshire Bowel Cancer Screening Centre ‘went live’ on 12th March 2007, as the second stage roll out of the National Screening Programme was launched across Derbyshire County and Derby City. The East Midlands Hub manages call and recall services, processes FOBt kits and arranges Screening Nurse clinic appointments. The Screening Centres for Derbyshire and Derby City are based at Derby Hospitals NHS Foundation Trust and Chesterfield Royal Hospital NHS Foundation Trust and they provide Screening Nurse clinics and endoscopy services.
Activity and performance information for the programme is collected and collated by the national screening programme from all the regional hubs. The information gathered is used for quality assurance purposes and to monitor performance against national standards. These reports can be accessed online and programme centres use it to check and compare their performance with other centres. Local centres can now access and analyse their own raw data, allowing local monitoring of uptake. The reports generated by the National Centre are based on available data which is a couple of weeks behind the local centres activity.
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Figure 126
National Bowel Cancer Screening Data Sets
National Target Derbyshire National Target Derbyshire January- March Screening Centre April -June 2008 Screening Centre 2008 January -March April -June 2008 2008
Colonoscopies Performed 36.99 132 37.4 172 Completion rate to caecum, terminal 90% 94.70% 90% 94.77% ileum or anastamosis Average wait (in days) from +ve FOBt to 14 8.67 14 8.1 SSP clinic Average wait (in days) from SSP clinic 14 9.15 14 9.63 to colonoscopy Average wait (in days) from 21 14 21 14.44 colonoscopy to SSP result clinic Adenoma detection rate 35% 68.12% 35% 66.86% Cancer detection rate 11% 10.17% 11% 5.14% Polyp retrieval rate 90% N/A* 90% 93.05%
Source: National Screening Centre
The National Screening Centre quality assurance reports for the Derbyshire screening centres for the first two quarters of the year 2008, show that the centres were performing well. However, the cancer detection rate is shown to be lower than expected and the reasons for this are being investigated. The cancer registry has been contacted and is working with the local centres to examine reporting mechanisms. The local centres analysed their activity data for the period January – June 2008 and found uptake to be 54% in Derby City. The screening programme defines uptake as the percentage of initial invitations that were returned, and includes all those who may not be eligible for screening.
Figure 127
Proportion of screening kits returned in Derby City (January to June 2008)
Derby City PCT Number Percentage Target Difference Intial invitations 9782 Kits returned 5280 54% 60% -6% Positive Kits 96 1.82% 2% -0.18% Source: National Screening Centre
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Figures 128 and 129 show the uptake of bowel cancer screening by GP practice and by ward of residence respectively. Both the GP practice map and the ward of residence map indicate that areas of high deprivation have the low uptake rates. The maps help identify the areas in which targeted work may need to be focused in regard to addressing inequalities in uptake.
Figure 128
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Figure 129
The screening programme has had a number of challenges in the past year of which solutions have been found for most, but there are a few that still need to be resolved. Increasing the uptake rates in areas of high deprivation and in certain ethnic groups for example have been challenging. Initial screening uptake data from Derby City showed that areas of low uptake are those with the highest percentage of Black Minority Ethnic groups and high levels of deprivation.
Having access to timely data to prevent breaches at a local level can be sometimes difficult. This is due to a number of factors associated with collation, collection and interpretation of activity data. The lag in time between the kits being sent out and their return is a factor that has an impact on the interpretation of activity and uptake rates. As a result the National Screening Programme is not able to provide reports that are timely. However, local Screening Centres can now access raw activity data
39 via the web and can now use this to monitor progress and this should enable them to make the necessary adjustments.
Meeting the national wait targets of 14 days from positive FOBt to first offered Specialist Screening Practitioner (SSP) appointment, and 14 days from SSP appointment to first offered colonoscopy, has also proved challenging. The FOBt to SSP clinic wait has largely been achieved with breaches (3 in total of 1 day breach) due primarily to clinic capacity. To prevent any further breaches an additional nurse clinic in Derby has been established.
Achieving waiting times targets between attendance to Specialist Screening Practitioner clinic and colonoscopy is a further challenge. This a national problem, as the majority of established screening centres also struggle to meet this target. In Derbyshire there is Endoscopy unit capacity, however the availability of an Endoscopist is limited. The current consultant job-plans allow little in the way of cross cover opportunities. Plans to appoint a Nurse Colonoscopist to cross-cover screening lists between the two sites has not been possible. An additional screening Colonoscopist has been accredited in Chesterfield and there are plans for an additional consultant from Derby to also undertake accreditation.
The ongoing increase in the population eligible for screening, combined with proposed age limit for screening extensions to men and women up to 74 years old, present significant challenges in the future for planning of screening services. By widening the age range for screening alone, there is likely to be a 30% increase in workload. This equates to 2 additional screening rounds for subjects aged 69- 75 years. Continual monitoring of how these factors impact on the service across the five pilot sites will be essential.
The two national pilots have identified priority groups and actions to ensure the screening programme is successful and wide reaching. The information from the pilot studies and the analysis of local activity data will help to inform a health promotion action plan and future service development. The health promotion aims to increase awareness of the screening programme in Derby City. Focused health promotion approaches will be developed and used to increase uptake within areas of high deprivation and Black Minority Ethnic populations.
Cervical Screening
Cervical cancer is the 12th most common female cancer in the UK, and the 2nd worldwide. Cervical screening detects pre-cancerous abnormalities in the cervix at an early stage, when treatment can be given and prevent pre-invasive disease developing into invasive cancer. The Cervical Screening Programme in NHS Derby City (the same programme also covers Derbyshire County PCT), continues to work well, with recent, main findings being as follows:
Cancer registrations and mortality rates remain within acceptable levels Coverage, within the past 5 years, in 25-64 year olds remains high. Coverage within NHS Derby City is 80.7%, being above the national average of 78.6% Overall laboratory and colposcopy performance is satisfactory
However, national statistics show that there has been a slight decline in the number of women under 35 attending for routine screening, and coverage is closely monitored in this age group to try and understand why this is happening and how more eligible women can be encourage to attend.
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Figure 130
Number of Cervical Cancer Deaths in Derbyshire [25-64 year olds]-4 year cohorts
40 35 30 25 20 15
10 Number of Deaths Numberof 5 0 1996-99 2000-03 2004-07 4 year cohorts
Total Derbyshire
Derbyshire County PCT
NHS Derby City
Source: National Screening Centre
The National HPV Vaccination Programme
On 29th September 2008, young girls across Derby City were offered the brand new vaccine to protect them against cervical cancer, as part of the nationally-backed government vaccination programme. The vaccine, the human papillomavirus (HPV), protects girls against the commonest cause of cervical cancer and at the time had already been successfully introduced to thousands of girls and young women in America, Australia and Germany. In the UK, cervical cancer affects about 2,000 women every year, and this vaccine may potentially save up to 400 lives for each school year of girls receiving it.
The national vaccination programme was initially offered to girls aged 12 to 13 (school year 8) and girls aged 17 to 18, who have been invited for a course of vaccinations to protect them against cervical cancer. In the Autumn of this year, the programme widened to include girls aged 16 to 18 years, and from the Autumn 2010 this will be widened again to include those aged 15. By the end of this campaign, all girls under the age of 18 years will have been offered the HPV vaccine.
In April 2009, uptake figures released by the Health Protection Agency revealed a 90% uptake in the vaccine against a target of 60% for year 8 girls. This amounted to approximately 4,000 doses being administered to approximately 1,300 12 to 13 year old girls across the city. This figure was achieved by the specialist HPV vaccination team set up by NHS Derby City, who visited schools across the city to administer the vaccine to year 8 girls, whilst 17 and 18 year olds received vaccinations at their doctor’s surgery. The teams aim has been to continue to deliver the same effective service to 4,500 girls across three academic year groups. In May 2009, they took part in the year’s Race for Life at Darley Park in Derby, in aid of Cancer Research. Some of the charity’s funding goes towards ongoing research in to the long-term effects of the vaccine.
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Recent results on uptake of the vaccine in the UK reveal that NHS Derby City continues to have one of the best uptakes. In 2008/09 financial year, 89% of year 8 girls received their full course of three injections.
What should we be doing?
In terms of our various cancer screening programmes we should, and are, working with our GP Practices that have low uptake in order to uncover barriers to screening and to incorporate appropriate health promotion interventions to improve uptake. We will also continue strive to ensure that the Department of Health’s Cancer Reform Strategy16 (CRS) targets will be met.
As part of the recent Annual Health Check17, the East Midlands Strategic Health Authority released the latest rate of premature mortality from cancer for Derby, based on a three year rolling average 2006 – 2008. The annual mortality file 2008 (supplied by the Office for National Statistics) has not yet been received by the PCT. However, as the annual rate of mortality for 2006 and 2007 is known, the anticipated annual rate for 2008 was calculated based on the three year rolling average. As would appear to have been the case between the years 1999 and 2000, the rate of premature mortality from all cancers in 2008 is predicted to show a relatively steep increase from 2007 (Figure 131).
Figure 131 Trend and Forecast against Targets for Premature Mortality from Cancer in Derby City LA
170 Cancer <75 Mortality
150
130
110
90
70
50 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
1993-95 1994-96 1995-97 1996-98 1997-99 1998-00 1999-01 2000-02 2001-03 2002-04 2003-05 2004-06 2005-07 2006-08 2007-09 2008-10 2009-11 2010-12 2011-13 2012-14 2013-15 Target Single Year Projected Maximum Rate Allowed 3-year Average Projected Required
Analysis of the Public Health Mortality File (PHMF) received on a monthly basis from the ONS by the PCT, reveals that this increase will predominantly be due to ‘malignant neoplasms of ill-defined, secondary and unspecified sites’ (according to the ICD- 10 authority on clinical diagnosis coding). This is expected to increase by over 100% from 2007 to 2008 (Figure 132).
Analysis of 2009 reveals that the increase in rate in 2008 is likely to be inconsistent to the years directly either side of it. NHS Derby City receives monthly mortality extracts by way of the Public Health Mortality File (PHMF) from the ONS. Currently, data is available from January to the end of July 2008, and in predicting a full year based on these seven months of data, the rate of mortality is expected to fall again in 2009 with fewer deaths and a greater overall population (Figure 132). Work is ongoing looking into the potential reasons for this increase in rate in 2008.
16 The Cancer Reform Strategy builds on the progress made since the publication of the NHS Cancer Plan in 2000, and sets a clear direction for cancer services for the next five years. It shows how by 2012 our cancer services can and should become among the best in the world 17 The Annual Health Check is the Care Quality Commission’s (formerly Healthcare Commission) method for assessing the performance of NHS organisations
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Figure 132
Trend and Forecast against Targets for Premature Mortality from Cancer in Derby City LA Cancer Type 2007 2008 2009 (modelled) 2007-2008 % Change Bone <5 <5 <5 -50.0% Breast 19 22 17 15.8% Digestive 72 75 71 4.2% Eye, brain and Central Nervous System 11 9 <5 -18.2% Female genital 12 13 20 8.3% Male genital 10 <5 6 -40.0% Of Ill-defined, secondary and unspecified sites 17 35 13 105.9% Of Independent (primary) multiple sites <5 <5 <5 200.0% Stated or presumed to be primary, of lymphod, haematopoietic and related tissue 13 20 18 53.8% Oral 9 <5 6 -77.8% Respiratory 69 85 54 23.2% Skin <5 7 <5 133.3% Soft tissue 8 9 7 12.5% Thyroid & Endocrine <5 <5 <5 100.0% Urinary Tract 15 13 11 -13.3% Grand Total 262 302 235 15.3%
Reducing cancer mortality through better symptom recognition and earlier diagnosis is being done through a number of local projects as outlined in the DECREASED 2010 project (led by NHS Derby City and the Derby/Burton Cancer Network to aid cancer reduction by way of enhancing awareness, screening and early detection). A number of pieces of work have begun including:
CANCER AWARENESS ROADSHOWS
Working in partnership with Cancer Research UK, a series of road shows are taking place in four sites across the city. The road shows aim to promote awareness and encourage behaviour change through face to face interaction and distribution of health information. NHS Derby staff and Leisure Services staff will be working alongside the road show staff at these events.
BOWEL CANCER EARLY DETECTION SOCIAL MARKETING PROJECT
In partnership with Cancer Research UK, the target population will be men aged over 50 in selected wards in Derby City which include Sinfin, Alvaston, Boulton, Derwent, Mackworth, Darley and Chaddesden areas. The objectives of the project are:
To raise awareness of the signs and symptoms of bowel cancer over 50’s To promote positive attitudes towards benefits and importance of early presentation/diagnosis amongst over 50s To increase intention to present with/seek advice for symptoms potentially indicative of bowel cancer To increase presentations of appropriate bowel cancer symptoms with local GPs To engage local community with dissemination of key messages and encourage peer to peer dialogue around the importance of early detection To encourage more GP referrals for diagnostic tests for bowel cancer
The Cancer Awareness Measure will be used to evaluate activity against objectives
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NATURAL COMMUNITIES LINKING & AWARENESS through DRAMA
The target population will be Derby City’s South Asian communities. A community development and engagement approach will be used in working with local South Asian people in developing health messages about cancer with particular reference to bowel cancer. A range of methodologies will be used including one to one work, participatory workshops and forum theatre to collect information for the plays. The plays will be delivered in Urdu and Panjabi and shown in local venues.
NURSE LED PROGRAMME
This programme will target low uptake inner-city practices with the aim of raising the uptake of bowel cancer screening
PRIMARY CARE
This will be led by the GP and Nurse cancer Leads and will support all practices with peer education, training and development, improvement plans and practice audits to encourage more early cancer detection and GP referrals
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7.5 Respiratory
What is the problem?
Nationally and in NHS Derby City, chronic respiratory illness is the most important cause of morbidity and mortality (after CVD and Cancers) and is the third largest cause of inequalities in health outcomes and life expectancy – accounting for more than 15% of the inequalities gap. COPD and Asthma affect more patients than any other long term conditions (apart from CVD/hypertension), and the prevalence of pneumonia (especially in complicating chronic respiratory disease) and consequent non- elective admissions is considerably higher than expected levels in the city.
There is need to action changes required for fully implementing the principles identified by the regional and national Long Term Conditions Reviews implemented by Lord Darzi, as well as the county-wide Asthma and COPD care pathways. Additionally, already known evidence based elements for the anticipated COPD/respiratory National Service Framework (NSF) should be ideally planned for and initiated in developing services.
In Derby, there are high non-elective admission rates with significant variation/inequalities in care within NHS Derby City GP practices. The overall number of patients on the COPD register in NHS Derby City according to the QOF during 2008/09, was over 4,500. However, the expected for that period was closer to 3,700 individuals. This is more than 20% more cases of COPD than were expected based on the demographics of Derby’s population, but ranged from -40% to more than 160% within the GP practices themselves.
There is significant evidence of gaps and unmet need in services including evidence of high levels of non-elective readmissions and patient/users difficulty in accessing appropriate services at out-of hours and weekends. This can result in increased avoidable admissions. A recent review of ambulatory conditions (based on program budgeting and acute service utilisation metrics) revealed potential savings of up to £200,000 – with an additional £700,000 for associated influenza and pneumonia.
Figure 132
Admission rates per 100,000 population from Derby City residents for selected LTCs against selected comparators
Derby City 2007/8 admission rates compared to all PCTs
D39-D40 Chronic Obstructive Pulmonary Disease or Bronchitis
E11-E12, E28 Acute MI / Cardiac Arrest
E18-E19 Heart Failure or Shock HRG Group HRG
E22-E23 Ischaemic Heart Disease without intervention
E31-E32 Syncope or Collapse
0 50 100 150 200 All PCTs 75th percentile All PCTs average Derby City Admission rates per 100,000
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As Figure 132 reveals, NHS Derby City exceeds the 75th percentile figure taken as a “best practice” indicator by the NHS, across the major long-term conditions. NHS Derby City’s Programme Budgets indicate COPD is the highest spend long-term condition.
There is urgent need for an appropriate clinical assessment service for oxygen treatment which has significant impact on reducing high cost and unnecessary (and potentially unsafe) prescribing of medications. There is recognised need to integrate service strands seamlessly in the community setting and provide focus for patient centred easily accessible services. There is also recognised need to develop specialist capacity in the community with close links to primary care to facilitate continuing training and improvement of routine care. Moreover, there is recognised need to develop community services that promote, work with and support self help groups and in turn improve patient self care, empowerment, and engagement. It has also been acknowledged that there is a local requirement to build capacity to achieve targets for reduced emergency admissions, to promote/improve intermediate care, and LTC community care.
Figure 133 Premature Mortality from Bronchitis, Emphysema and other Chronic Obstructive Pulmonary Disease (COPD) 2005/07 18
16
14
12
10
Population ENGLAND 000 000 , EAST MIDLANDS
100 8
Derby UA DASR / DASR 6
4
2
0 MALES FEMALES PERSONS
Source: ONS; NCHOD
The latest premature mortality rates from COPD available for Derby City LA (2005/07) reveal that there is no significant difference in rate when compared to the East Midlands region and England. If anything, the actual rate in males in lower, as is the rate for males and females combined. In females on their own, the actual rate of mortality is higher than seen in the East Midlands, but lower than seen nationally, though as previously stated there is no significance in this.
What works?
The primary risk factor for COPD is chronic tobacco smoking, followed by occupational exposures i.e. intense and prolonged exposure to workplace dusts, air pollution, and genetics. There is no cure at
46 present for COPD, however, the disease is both a preventable and treatable disease. NICE guidelines for the management of COPD are available, as well as the Global Initiative for Chronic Obstructive Lung Disease (GOLD) which is a collaboration that includes the World Health Organisation. The biggest directions of COPD management are to assess and monitor the disease, reduce the risk factors, manage stable COPD, prevent and treat acute exacerbations, and manage co-morbidity.
Smoking cessation is obviously one of the most important factors in slowing down the progression of COPD. Even in the late stages of the disease it can significantly reduce the rate of further deterioration in lung function, and delay the onset of disability and death. It is the only standard intervention that can improve the rate of progression of COPD.
What are we doing now?
NHS Derby City’s Staying Well Programme (Expert Patient Programme) is a free course that supports people to manage their long-term health problems, such as COPD, on a day-to-day basis. The programme recognises that the patient has a lot of knowledge about their condition, and that this information can be used to improve their situation. The course is run over a six week period, with each session lasting two and a half hours.
The Adult Integrated Respiratory (AIR) Team are a specialised team of nurses, physiotherapists and practitioners who offer comprehensive assessment, advice, support and information on managing this condition, including self management plans for patients with respiratory disease. Patients may be seen at various outpatient clinics across Southern Derbyshire, or in their own home if they are ‘housebound’. Other services the AIR Team offers are:
Group education sessions for patients with COPD at a variety of venues throughout Southern Derbyshire Follow-up of respiratory patients discharged from hospital Home management scheme for GP selected acutely unwell COPD patients Providing specialist respiratory equipment Spirometry to confirm COPD diagnosis
Coaching is currently provided to approximately 400 patients by the COPD Team. This is provided through a single point of access phone number given to all patients with LTC for signposting to services. This service is based at Pentagon House and the telephone line is manned from 9:00am to 5:00pm. Patients are directed to services they request or are given information on their query. If the query is related to COPD they will be directed or put through to the COPD Team at Coleman Health Centre. Specific advice to support patients with COPD offered by the Respiratory Team and where the team cannot advise they may refer to another clinical or support service.
In addition to these initiatives, work is currently underway to produce local, condition-specific Information Prescriptions which will include COPD.
What should we be doing?
Nearly three million people in the UK have undiagnosed COPD, which is said to be costing the NHS a potential £3.2 billion a year. At diagnosis, COPD is a condition associated with many co-morbidities including; cardiovascular disorders (angina and myocardial infarction), bone disorders (osteoporosis
47 and fractures) and other smoking-related conditions or diseases of the aging population (respiratory infection and pneumonia). As such, smoking as a causative factor of co-morbidities in COPD has to be emphasised, and all respiratory patients should quit smoking, regardless of age. In order to achieve this, we should continue our active encouragement of people to access Derby’s smoking cessation service, Fresh Start.
One of the major winter hazards for individuals with respiratory problems is breathing cold air and for many people with COPD, this causes bronchospasm and increased breathlessness. Advising people at a primary care level on how to manage their symptoms and protect against breathing cold air in the winter can help to prevent serious breathing problems, like exacerbations which cause significant rise in COPD hospital admissions. For a person with COPD, it is important to make every effort to maintain a healthy lifestyle, even during the cold weather season. This should also be actively encouraged, as well as keeping warm.
Each year cold homes contribute significantly to excess winter deaths and wider health issues; this in turn puts pressure on the Social Care sector and the NHS who estimate that millions of pounds each year are spent treating preventable cold related illnesses. In 2009, a small booklet with information about saving energy in your home and keeping warm, published by Amber Valley Borough Council in partnership with the other Derbyshire County councils and Derbyshire County PCT as well as NHS Derby City and Derby City Council, was distributed to all households in Derbyshire. The aim of the Healthy and Warm in Derbyshire Public Health Pharmacy Campaign 2009 is to promote better health through addressing the issues people living in cold damp homes may face, by improving the energy efficiency and warmth in your home and offering advice and signposting to other services that may lead to financial support to carry out major works.
Figure 134 Excess Winter Deaths in Derby City (2004 - 2007) 40%
35%
30%
25%
20%
% Excess Excess Winter% Deaths 15%
10%
5%
0%
Ward
Source: ONS; Public Health Mortality Files
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Each winter there are an estimated 30-50,000 more deaths in England and Wales compared to levels in the non-winter period. In Derby, up to 34% of deaths during the winter period can be excess, by ward (Figure 134). Appropriate insulted winter clothing is a must, particularly for COPD patients.
Warm and Well in Derby18
The Warm and Well in Derby Project is funded by NHS Derby City and Derby City Council. The funding available to the Project was set for the six month period from January to June 2009, and primarily enabled the appointment of a dedicated home energy advisor until the end of June 2009, as well as also covered the costs of promoting the project to the target group – older people aged over 60. The aim of the project is to work with local organisations, groups and residents to make sure that older people in Derby get home energy advice and information so that they can keep warm and well, and can afford to heat their homes. The key objectives of the project are to:
Reduce health inequalities for older people in Derby by reducing fuel poverty and excess winter deaths, and by improving health through making homes warmer Improve well-being and quality of life – helping to reduce cold/illness/unnecessary admission to care homes, and also reduce anxiety Contribute to meeting targets set under National Indicator NI187: Tackling fuel poverty (% of people receiving income based benefits living in homes with a low and high energy efficiency rating
In order to assess whether the objectives are being met, a resident satisfaction survey was sent out to 177 people that made contact with the project during the period January to April 2009 – whilst only 76 people officially responded, many others received help through the project who did not return a questionnaire. The project is contributing to the council’s wider work on fuel poverty and addressing NI187 because it is reaching older, vulnerable people and helping them with their home fuel costs. This is illustrated by the mail-out sent to over 200 older people claiming Council Tax Benefit in February 2009 offering them help through the project, to which 32 people requested more information.
It is clear from a project evaluation that all the key project tasks have been met. For example, a Working Group has been established and a monthly email newsletter on the project has been created and is in circulation. A variety of promotional materials and literature has also been produced in order to raise awareness of the project and excellent working relationships have been established with, for example, Derby City Council’s Welfare Rights and Money Advice Teams, Social Services, the Warm Front Team, Spirita Home Improvement Agency, Age Concern/Help the Aged, Community Action Derby, and the British Red Cross. There has equally been good engagement with GP surgeries.
All key outputs were met by the end of June 2009. The outcomes were more difficult to measure. However, the survey conducted earlier in the year has shown that the project has improved home energy efficiency for a large number of vulnerable, older people. A significant number of people (32.9%) also stated that they noticed that their homes were now warmer and more comfortable. The findings from the survey also show that a number of people (9.2%) had reduced gas and electricity costs. Overall, the project has delivered a high quality service to older, vulnerable people in Derby, making sure that they are warmer in their homes, resulting in the likelihood of improved well-being and better health. There are plans to target any future agreed work towards those most vulnerable in terms of fuel poverty and long-term limiting illness over the coming months.
18 For more information contact Richard Murrell, Home Energy Advice Manager, Derby City Council
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7.6 Infectious disease
7.6.1 TB
What is the problem?
Infectious diseases are an important public health priority and due to the adverse health effects caused, preventable nature of some diseases and the inequalities in health produced through excess disease burden in at-risk groups of the population.
Tuberculosis (TB) is an infectious disease caused by a bacteria which is spread by a person inhaling respiratory droplets which have been coughed or sneezed out by someone with infectious TB. The disease may spread within the lungs (causing pulmonary TB) or to other parts of the body such as bones, lymph glands, or the brain. Due to the number of sites which may be affected, symptoms of pulmonary TB include chronic cough, weight loss, intermittent fever, night sweats and coughing blood whilst symptoms of extra-pulmonary disease will depend on the site infected. Latent TB infection may however occur where the disease lies dormant. The disease is however curable with treatment which must be taken for six months.
Before drug treatment was available nearly half of all infected persons with active TB died from it. A number of groups of people are at increased risk from contracting TB which includes close contacts of infected cases, those with links to regions of the world and ethnic communities where TB is prevalent, immunocompromised patients, those with chronic health problems and those living in poor and crowded housing conditions.
In 2007, 368 notifications (8.4 per 100,000) of TB were recorded across the East Midlands region which compares favourably to the 6780 notifications (13.1 per 100,000) recorded across England19. Recent data from the Health Protection Agency shows that 88 cases of TB from Derby (30.9 per 100,000) were notified in 200820. The greater incidence of TB notifications in Derby may however be explained by the ethnic diversity of the population who are at increased risk of contracting the disease, and the reporting of disease by hospital clinicians in patients who are not resident in the city. The former explanation has an important public health implication in terms of tackling health inequalities across Derby.
What works?
Co-ordinated TB services where respiratory or TB nurses provide rapid access to high quality diagnosis, treatment and preventive healthcare. Service models include those which are centralised, central with satellites, general hospital/community based, or a specialist hospital-based model.
What are we doing now?
Currently, we are offering vaccination against TB through BCG immunisation via a risk-based programme primarily designed to protect children most of risk of exposure to the disease. We are
19 The Information Centre for Health and Social Care. NCHOD National Centre for Health Outcomes Development. [Online]. Available from: http://www.nchod.nhs.uk [Accessed 15 October 2009] 20 East Midlands North Health Protection Unit. Derby City PCT Annual Report 2008 (draft). Pleasley Vale: Health Protection Agency; 2009
50 also providing identification, screening, education and support to patients who have contracted TB or are deemed to be at high risk through a fortnightly TB out-patient clinic.
What should we be doing?
NHS Derby City should be working toward providing an integrated TB service delivered by TB nurse specialists.
7.6.2 STIs & HIV
What is the problem?
Sexually transmitted infections (STIs) and human immunodeficiency virus (HIV) are predominantly transmitted by unprotected sexual intercourse. The methods for preventing sexual transmission of STIs and HIV are the same, and there is strong evidence that several biological mechanisms exist where STIs facilitate transmission of HIV by increasing infectiousness and susceptibility. STIs most commonly diagnosed in genitourinary medicine (GUM) clinics are Chlamydia, warts, herpes, gonorrhoea, and syphilis and symptoms may include increased discharge, pain or ulcers. Infected persons may not show symptoms, and STIs which are not diagnosed and treated may result in serious complications later in life such as infertility.
The groups at increased risk of contracting STIs include men who have sex with men, young men and women, those of black ethnic origin and those living in urban areas. HIV is associated with a significantly increased risk of morbidity, mortality, and high treatment cost. The virus causes severe immunosuppression which is associated with opportunistic infections, tumour growth and acquired immune deficiency syndrome (AIDS). Risk groups for contracting HIV include men who have sex with men, heterosexual people from black ethnic background, and injecting drug users. HIV may also be passed through vertical transmission (mother to child). Transmission of HIV infection by blood products no longer occurs in the UK following the introduction of donor screening and heat inactivation in 1985.
Data from the Health Protection Agency shows that the incidence of Chlamydia, warts, herpes, gonorrhoea, and syphilis from GUM clinic attendees is greater in Derby compared to the wider East Midlands region. There has been a general upward trend in the number of STIs diagnosed across Derby and the East Midlands since 2004, although the incidence of gonorrhoea has gone down across the region and syphilis has remained largely stable over this time. A similar trend is shown with HIV where the rate of new diagnoses in Derby is greater than the East Midlands region. It should however be noted that these data do not exclusively include patients who are both resident and registered in Derby since a number of patients who reside in other PCTs (e.g. Derbyshire County) will have been referred to hospital clinics for diagnosis and treatment in the city.
The County of Derbyshire (including the City of Derby) has around 120,000 resident young people between the ages of 15 and 24. There are a further 270,000 between 25 and 44 years of age. The main BME groups are found in the City, although there are some significant numbers in the County, particularly South Derbyshire. It is estimated that between 5% and 7% of the population are Lesbian, Bisexual, Gay or Transgender. Poor sexual health is linked to deprivation and drug and alcohol misuse. The main areas of deprivation are the City, North Eastern Derbyshire and communities along the Nottinghamshire border with some pockets amongst the rural West of the County.
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What works?
The National Strategy for Sexual Health and HIV was published by the Department of Health in 20012 with the clear aims of:
Reducing the transmission of HIV and STIs Reducing the prevalence of undiagnosed HIV and STIs Reducing unintended pregnancy rates Improve health and social care for people living with HIV Reducing the stigma associated with HIV and STIs
In order to achieve these aims the strategy proposed that we should work within an integrated model of delivering sexual health services using a managed network and sound evidence base for local interventions; prevention should be central to the delivery. A range of contraceptive services should be offered and equitable access to termination services provided. The detection and management of STIs should be improved through setting standards for their treatment, the setting up of a Chlamydia screening programme and open and improved access to GUM (Genito-Urinary Medicine) services. The detection of HIV should be improved by increasing testing and the development of standards for treatment, support and social care of people living with HIV; and there should be a focus on improving the skills of staff through training.
The action plan that followed from the strategy1 emphasised that the provision of sexual health care and the standard of that care varied between providers and areas. We should be moving towards a model of care in which an individual will receive consistent and quality care wherever they access services1. Services should be planned for communities to ensure that they have appropriate access to sexual health services through Primary Care, Community Sexual Health and specialist GUM clinics1. Education should be provided through Sex and Relationship Education in schools, Connexions, Further Education colleges and Young Offender institutes. The action plan also emphasises the need to have a local sexual health and HIV lead with public health expertise.
Other initiatives include:
Rapid detection and treatment of STIs through improved access to GUM clinics including targeted interventions to groups at risk of HIV infection Community-based HIV testing services STI and HIV health promotion, prevention and screening services such as the Chlamydia screening programme21 in young people aged 15 to 24 years (Figure 135) Increased provision of level 1 and 2 sexual health services in community settings, including services for young people
21 The Derbyshire programme had a reassuring visit from the National Support Team for Sexual Health, where future sustainability of the programme was commended. A GP LES and Pharmacy LES is in place and being reviewed to ensure effectiveness and in particular draw more people in through General Practice. In addition, a website is up and running, and local Social Marketing and media work is underway which will inform the targeted approach to be taken for the ongoing communication plan. The programme is seeing increased delivery through C&SH services, with a greater emphasis on activity reflecting the footfall of the service. The social marketing campaign/approach is crucial to the programme development (due to the way the national programme has been set up) and will continue to support embedding the programme in young people’s mindsets.
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Figure 135
Source: The National Screening Centre
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What are we doing now?
Nationally, there are concerns about the availability of information regarding services to the population. There is a wide range of services available in Derby City focusing on target groups, but there are currently no schools in the city providing extended, holistic sexual health services. In fact, there are areas of deprivation, for example Mackworth, where no local services are available. We are however, ensuring that awareness and prevention of sexually transmitted infections through sex and relationship education is being provided to school children.
In terms of primary care, there does not appear to be a particular General Practice in the city at present with a special interest in sexual health services. With regard GUM services, individuals must travel to Derby, Chesterfield or Buxton (or out of Derbyshire) to access these services, though we are ensuring that people who require GUM clinic appointments are given them within 48 hours of contacting the sexual health service. We are also ensuring that all sexually active young people aged 15 to 24 years are offered Chlamydia screening.
Whilst there are open access termination services available in Derby, those over 12 weeks cannot be seen. There are anecdotal reports of low levels of counselling by some non NHS termination providers. Individuals must travel to either Derby or Chesterfield for a psychosexual counselling service and there are anecdotal reports of unmet need.
Specialist psychosexual services are provided through two NHS centres, these are the GUM clinic in Derby in the south and the Contraceptive and Sexual Health Clinic in Chesterfield in the north. Provision is also available thorough ‘Relate’ which is available across the county but does have a cost for those using the service. There is no current estimate of the need or demand for these services although there is anecdotal evidence that there is a large unmet demand.
There is a specialist ‘Sexual Assault Referral Centre’ in Codnor, Amber Valley, Derbyshire County. This provides forensic sexual health services, for those who have been assaulted for examination, screening, emergency contraception and psychological support.
What should we be doing?
The Department of Health recently commissioned a review of ‘One Stop Shops for Sexual Health’20. This review evaluated three different models for delivering sexual health services from a single site (contraceptive and STI testing and treatment centres). Three models were assessed:
1. A young peoples service based in a youth service 2. A mainstream model with contraceptive clinic and GUM service housed at the same site 3. A specialist service delivered in General Practice
The services were run with staff that were dual trained in contraceptive and STI services. The young people’s model saw only small numbers but these were felt to be high risk individuals who may not have accessed other services. The mainstream model was considered to be the least cost effective as it was felt to duplicate services already locally available. The GP service was felt to be the most cost effective, reducing the use of the community and GUM services in the area.
In respect of both TB and sexual health, we should be developing culturally sensitive services which reflect the needs of people in Derby and aim to reduce the inequalities in health produced by infectious diseases.
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7.7 Dental health
What is the problem?
Despite dental and oral disease being largely preventable, the number of treatments delivered to patients is continuing to increase and inequalities in dental health persist in the general population. The Steele review stated that “the NHS in 2009 is still dealing with, and paying for, the consequences of disease that developed more than 50 years ago”22.
The increasing activity and cost of NHS dentistry was recently highlighted by The Information Centre for health and social care. Statistics from 2008-09 show that the number of courses of treatments and units of dental activity delivered in England increased by 4.0% and 5.7% on the previous year respectively.2 Similar same trends were reported locally in Derby, where these measures of treatment and activity increased by 7.9% and 9.3% respectively. However, poor oral health has a significant impact on individual and societal financial costs. Approximately £570 million was calculated as patient charges across England in 2008-09 which represents an increase of £40 million on the previous year23.
Dental health in adults has been steadily improving. Choosing Better Oral Health: an oral health plan for England shows that more adults keep their teeth for life, however, many still suffer tooth decay and the number with no teeth is high compared to other European countries. This presents challenges for dentistry in supporting people with an ageing dentition.
Figure 136
22 Steele J, Rooney E, Clarke J, Wilson T. NHS dental services in England. An independent review led by Professor Jimmy Steele. London: Crown copyright; 2009 23 The NHS Information Centre, Dental and Eye Care Team. NHS dental statistics for England: 2008/09. London: The NHS Information Centre for health and social care; 2009.
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Children in England have among the best oral health in Europe. The proportion of children starting school with no experience of tooth decay has increased from 30% in the early 1970s to 59% in 200324. There are however significant improvements in dental and oral health which remain to be realised. Inequalities in dental health are particularly apparent in children from deprived social backgrounds but also exist in other vulnerable groups. There are also variations related to other factors such as the use of fluoridated tooth paste and fluoridated water. The water supply Derby does not have fluoride added to it, although some areas receive levels between 0.3 and 0.7 mg/l due to natural fluoridation.
Figure 137
© Severn Trent Water Ltd. WU298522.
Source: Seven Trent Water Ltd
24 The Department of Health. Choosing Better Oral Health: an oral health plan for England. London: Crown copyright; 2005.
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Across England in 2005/06 the mean number of decayed, missing or filled teeth (d3mft) in 5 year old children following standardised examinations of clinical caries was 1.4725. Thirty-eight percent of children had at least one decayed, missing or filled teeth. These children had a mean dmft score of 3.86 which shows that this group experiences a significant proportion of the burden from poor dental health. The East Midlands compares marginally more favourably to England, where a mean d3mft score of 1.30 was recorded. Thirty-five percent of children had at least 1 dmft, where a mean dmft score of 3.69 was recorded.
Whilst local data from Derby City shows a mean d3mft score of 1.38 which is lower than the national average, it is greater than the regional average. Thirty-five percent of children had at least one dmft which matches the regional prevalence, however, children in Derby suffer poorer dental health compared to the East Midlands and England with a mean dmft score of 3.99. The number of child patients in Derby seen by NHS dentists has also fallen by 4.0% between June 2007 and June 2009 from 76.7% to 72.7%. A reduction was also shown nationally and regionally across the East Midlands, although less pronounced (1.2% and 0.8% respectively).
What works?
Accessing NHS dental services for high quality preventive and clinical oral healthcare Improving diet through increasing the quantity of fruit and vegetables consumed each day and reducing intake of sugar and promoting the use of sugar-free medicines Following child-specific advice as stated in Delivering Better Oral Health (2nd edition)5 such as promoting breast feeding, children not drinking from bottles past one year of age, not adding sugar to weaning foods, parents brush or supervise tooth brushing (up to seven years of age) with a smear of toothpaste containing no less than 1,000 ppm fluoride (increase quantity and fluoride concentration as child grows older), and brushing teeth as soon as they erupt into the mouth Adults should brush teeth last thing at night and on one other occasion daily using toothpaste with at least 1,350 ppm fluoride, and spit out after brushing and do not rinse. Some adults may benefit from using a fluoride mouthwash daily Adopting a preventive approach to dentistry through appropriate commissioning arrangements, the contractual framework for NHS dentistry, and transitioning from dental activity to oral health as the outcome of the NHS dental service Adding fluoride to public water supplies to prevent dental caries Reducing dental injuries through the use of safe play environments and mouth shields in contact sports Adopting measures to prevent periodontal disease include reducing smoking, using an appropriate toothbrush, consider using a toothpaste with triclosan with copolymer or zinc citrate, cleaning interdentally with brushes or floss Alcohol consumption should also be reduced to moderate (recommended) levels to prevent oral cancer
25 The British Association for the Study of Community Dentistry. BASCD: Documents. [Online]. Available from: http://www.bascd.org/viewdocpool.php?id=72#engwales [Accessed 11 October 2009].
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What are we doing now?
The Derbyshire Oral Health Plan (including Derbyshire County and Derby City PCTs) was produced in 2007 based on Choosing Better Oral Health: an oral health plan for England and supports the evidence-based approach described in the first edition of Delivering Better Oral Health. The Derbyshire plan has a number of key principles which include tackling inequalities in oral health, ensuring a prevention and common risk factor approach to oral health, working in partnership with other organisations and communities, providing accessible and high quality dental services, and ensuring the retention and development of an appropriate dental workforce.
An oral health promotion programme based on prevention and partnership working has been in place to support special care dentistry services aimed at vulnerable groups, and a new service specification is currently being developed by colleagues from the University of Sheffield. General dental services are commissioned across Derby and there are primary care-based specialist minor oral surgery and orthodontic services. Dental general anaesthetic services are delivered by salaried primary dental care services from a secondary care environment.
What should we be doing?
Ultimately, we should be strengthening the prevention agenda for oral health and locally support the transition of dental treatment to oral health as an outcome of NHS dental services. NHS Derby City’s position on fluoridation of the public water supply needs to be clarified in discussion with the East Midlands Strategic Health Authority as the regional lead, and we should continue to work with all our dental providers to deliver co-ordinated high quality services and develop a skilled workforce responsive to the needs of all people in Derby. Successful partnership working between NHS organisations and with other agencies is key to achieving this aim and should be developed further.
We should continue to tackle inequalities in dental and oral health through targeting services and programmes to communities which experience a disproportionate burden of poor dental and oral health. In addition, the PCT should consult with dental clinicians, commissioners, public health and other partners how to locally implement the recommendations made by the Steele review, and improve sustainable links with general health services with a shared agenda such as smoking cessation, cancer awareness, and screening through collaboration by public health colleagues in Derby and Derbyshire County
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7.8 Mental health
7.8.1 Dementia
What is the problem?
The term ‘dementia’ is used to describe a collection of symptoms, including a decline in memory, reasoning and communication skills, and a gradual loss of skills needed to carry out daily activities. These symptoms are caused by structural and chemical changes in the brain as a result of physical diseases such as Alzheimer’s disease. Dementia can affect people of any age, but is most common in older people. One in six people over the age of 80 has a form of dementia, as do one in 14 people over 65.
Ethnic minority populations will also be more susceptible to developing dementia. For instance, it is widely recognised that people of Southern Asian descent are more prone to diabetes and as a result, cardiovascular disease that is a complication. This can lead to vascular dementia. The African Caribbean population are as equally at greater risk of hypertension, which can also lead to vascular dementia.
Alzheimer’s disease is the most common type of dementia. It changes the chemistry and structure of the brain, causing brain cells to die. Vascular dementia is caused by strokes or small vessel disease which affect the supply of oxygen to the brain. Vascular dementia affects people in different ways. It can cause communication problems, stroke-like symptoms and acute confusion. Frontotemporal dementia is a rare form of dementia affecting the front of the brain; it includes Pick’s disease and often affects people under the age of 65. In the early stages, the memory may remain intact, while the person’s behaviours and personality change. Dementia with Lewy bodies is caused by tiny spherical protein deposits that develop inside nerve cells in the brain; these interrupt the brain’s normal functioning, affecting the person’s memory, concentration and language skills.
Recent predictive modelling undertaken by NHS Derby City suggests a rise of 13% in cases of early onset dementia by 2015, amounting to 77 individuals. Cases of late onset dementia are estimated to increase by 27% over the same period to 4045 individuals. This will amount to more than two and a half thousand cases of Alzheimer’s disease in the registered population of NHS Derby City in 2015 (Figure 138).
Figure 138 Dementia Type 2009 2015 % increase Early Onset 68 77 13% Mild 1755 2216 26% Late Onset Moderate 1017 1295 27% Severe 403 534 33% Late Onset Total 3175 4045 27% Early & Late Onset 3243 4122 27% In people with Down's Syndrome 8 8 0% Alzheimer's disease 2011 2556 Vascular dementa 551 701 Mixed dementia 324 412 Dementia sub-types Dementia with Lewy bodies 130 165 27% Fronto-temporal dementia 65 82 Parkinson's dementia 65 82 Other dementias 97 124
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Figure 139 below highlights on a thematic map, the prevalence of dementia by GP practice during 2008/09, according to the QOF. The total number of people registered in Derby City to have dementia on the QOF was 1,055 out of a total registered population at the time of 286,054. This suggests that for 2008/09, approximately 0.4% of Derby’s registered population has dementia, which is in line with the national QOF prevalence of dementia at the same figure. Out of the 34 GP practices serving the population of Derby, 9 had greater prevalence rates of dementia than the national average. None though, had a greater prevalence than the nationally expected of 1.1% that is documented by the Alzheimer’s Society.
Figure 139
One in four people may suffer from a mental health problem at some stage in their life. We know that good support from our communities and families can help to alleviate some of the worse effects, but early recognition and diagnosis is vital to ensure access to the many treatments which are now available.
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What works?
The National Dementia Strategy, Living well with Dementia, has three themes:
Improved public and professional awareness Early diagnosis and support Living well with dementia
This strategy provides a strategic framework within which local services can:
deliver quality improvements to dementia services and address health inequalities relating to dementia provide advice and guidance and support for health and social care commissioners and providers in the planning, development and monitoring of services provide a guide to the content of high-quality services for dementia
There are 17 objectives aimed at delivering the strategy26. Ideally, the aim is to have a system in place where people who are affected by dementia can; know where to go for help, know what services they can expect, seek help early for problems with memory, are encouraged to seek help early, get high- quality care and an equal quality of care, wherever they live; and are involved in decisions about their care.
What are we doing now?
NHS Derby City in collaboration with its partners are currently in the process of writing the Dementia Strategy for Derby. Modelling of future need has already taken place, as has analysis of current service provision, as well as best practice. We are now developing the services that need to be in place to meet what will be an increased demand due to population increase alone.
We recognise that equity of access to dementia services is an issue in Derby City. People living in the most deprived wards are likely to experience a lack of access to information, recognition and ultimately, early diagnosis, in order to obtain the support and treatment they require. Peer support (Dementia Cafés27) and carer support will therefore need to be targeted to those wards with greatest need, with a model of care based on the community development model that is already in place in the city. Taking our ethnic minority populations into account, we are also aware that primary prevention should be focused on the wards of Arboretum and Normanton, whereas ongoing treatment, care and support should be focussed on wards with greater numbers of older people, particularly in the Allestree area.
26 http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_0 94052.pdf 27 Dementia Cafés are a place to get advice, share experiences and make new friends in the city
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Figure 140
Recent analysis conducted by Social Services has highlighted that Derby City’s highest users of social care service are located in Chellaston, Arboretum and Abbey wards; some of our most deprived. The lowest users of social care service are located in Oakwood, Mickleover and Sinfin wards. Whilst Sinfin is quite a deprived area, Oakwood and more so, Mickleover, are relatively affluent. Mickleover particularly also has a large older adult population and so it is interesting that the uptake of social care is low. The over 75s generate the most demand for adult social care.
What should we be doing?
Figure 141 below illustrates the emerging model of service for Dementia in Derby City, while Figure 142 explains the emerging care pathways. These are models in development whilst the Dementia Strategy is being written.
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Figure 141 Emerging Model
Derby Dementia Service
Intermediate , Respite, Crisis Care, Specialist Localised Care Dementia Beds, Continuing Care Palliative Care
Primary Social & Community Care Home , Care Hospital Focus on Diagnosis & Early Intervention & Hospice Dementia Care Pathway Coordinator
General Hospital Memory Assessment Service Dementia Liaison Carers Support/IAPT Team Crisis and Emergency support Care Home Liaison
Public Health Initiatives EI Diagnosis EI Looking to the Future Ongoing Person and Carer Centred Care
Competent Workforce
Source: Dementia Strategy 2009 (draft)
The aim of the strategy is to help target resources in areas of highest dementia prevalence. It will also improve early diagnosis and support by improving the memory assessment service, as well as developing the roles of both a Dementia Advisor, and Dementia Care Pathway Coordinator. Improvements in intermediate care should also be made on the basis of the Dementia Strategy.
Figure 142 Emerging Care Pathways Derby Dementia Pathways
Public Health Primary Care EI Diagnosis EI Looking to Ongoing the future person and MemoryReferrals Clinic from Carer, GP MH carer, liaison, Acute care centred care BME communities •Tackling ageism & or 3rd sector services stigma Referral Continuous assessment and review • Awareness raising – •Integrated CMHT start in schools •Advocacy • dementias and GP screening & •Respite Care subsequent •Intermediate Care disease progression Multi-disc and agency until death; referral for specialist •Crisis Intervention assessment assessment. While Capable: includes, •Young Onset Dementia team • likelihood of prioritisation and Primary Care Liaison end of life care, benefits, •Outpatient/Community dementia and other onward referral long term conditions – workers. lasting power of attorney, Clinics the issues Dementia Register. living wills, advanced care •Hospital Liaison team • Info to be available Pre assessment planning, advocacy •Planned Inpatient Admission at different sources Counselling. requirements, driving, (assessment & using a variety of Multidisciplinary genetic counselling, etc Continuing Care) methods Specialists. •Social Services Diagnosis made by: •Palliative Care Old Age •Bereavement Psychiatrist; •End-of-Life care Geriatrician; •Carer Support Neurologist; GPwSI •Residential/Nursing care •Psychological Services Social Social Social •Long-termSocial Conditions Inclusion Inclusion Inclusion •End-ofInclusion-Life care
Source: Dementia Strategy 2009 (draft)
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7.8.2 Suicide
What is the problem?
Suicide can mark the extreme end point of poor mental health in a population, but whilst not all people who commit suicide have a diagnosed mental health problem, 25% of suicides take place in people who have been in contact with secondary care mental health services. Of the remaining 75% of people who die by suicide many, but not all of these people, are likely to have been in contact with a primary care service.
The Suicide Act of 1961 resulted in suicide no longer being a criminal act. However, the stigma attached to suicide remains and can result in significant burden and distress for families, friends and health care staff which can result in additional health problems that may persist across a lifetime.
Suicide and underdetermined injury account for a very small proportion of the total preventable deaths that occur in Derbyshire each year28 (n=61 in 2008). Although variations exist within Derbyshire’s constituent local authorities, the absolute numbers make interpretation difficult. Nonetheless, in Derby City the 1995/97 baseline of directly age-standardised rates of suicide and undetermined intent mortality was 8.11 per 100,000 population, which requires a reduction to 6.49 in order to meet the 2010 target put in place as part of Vital Sign performance monitoring within the NHS.
Figure 143
Performance against OHN Target for Derby City
Derby City 12 2010 Target
10
8
6 DSR
4
2
0 95-97 96-98 97-99 98-00 99-01 00-02 01-03 02-04 03-05 04-06 05-07 06-08 07-09 08-10 09-11 Year
28 Office of National Statistics 2007
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The continued rise in rates from 2003/05 to 10.23 per 100,000 population in 2005/07 put Derby City above what would be expected to reach in order to meet the OHN target, highlighted in Figure 143. It is difficult to predict whether 2005/07 rates are indicative of an increasing trend in terms of future progress towards the target. Moreover, caution should be excised in interpreting this trend due to the very small numbers involved.
For the purposes of trend analysis, rates are presented as rolling three-year averages in order to smooth the yearly fluctuations that can occur in rates when dealing with small numbers. The directly age standardised suicide rate for persons of all ages is also a target indicator in the Saving Lives: Our Healthier Nation (OHN) strategy. The overall target is a 20% reduction from the 1995/97 baseline by 2010.
What works?
NHS Derby City together with Derbyshire County PCT has formulated a Derbyshire wide Suicide Prevention Action Plan based on nationally recognised best practice in preventing suicides. There is no one thing that will prevent people from committing suicide, however, the following points are being undertaken at present:
Developing a robust information reporting and data collection mechanism Peninsular PCT audit produced annually o GP Practices also supported to carry out serious incident reviews Promoting Mental Health o Mental Health Promotion Strategy has been produced o Child and Adolescent Mental Health Service supported post being developed o Community Development and Mental Health workers in post o Health promoting schools o Work with the Samaritans o Develop a Self Harm Protocol o Loss & bereavement document circulated to schools Prescribing – Reducing Availability o Review and monitoring of prescribing across the city is ongoing o Ensuring national guidance is being followed Reducing risk in vulnerable groups o Homeless Health Needs Assessment29 has been undertaken Ensuring NICE guidance is being followed o Strategy for primary care is being led by GP Mental Health leads o GPs conducting improved risk assessments Reducing risk of individual self harm o Healthcare professionals assessing anyone who self harms for physical risk and emotional and mental state o Raising awareness of Practice Counsellor roles Communication with Coroners Office o It is now the PCTs responsibility to conduct audit working with the Coroners Office (was previously the responsibility of Derbyshire’s Mental Health Trust) Substance Misuse (Drugs Strategy and Alcohol Treatment Service) o Derby Alcohol Service new treatment model approved for roll-out o Bradshaw Clinic & Milestone House provision
29 The full document is available at NHS Derby City
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Promote responsible reporting of suicides to the media o Communication strategy developed to promote Mental Health within the media using Samaritans media guidelines Delivering Race Equality Mental Health Steering Group o Includes a counselling service for Asian women Evaluate and adhere to the national suicide prevention strategy Multi-Agency Hot Spots group
NHS Derby City’s aims for 2010 include; delivering Suicide Awareness training to all GPs and GP Practice staff across the city with the support of a Big Lottery Funded Post (18 hours) to provide awareness raising training to targeted communities in the city. The Support Survivors of Bereavement by Suicide (SOBS) Service is also to identify a base in Derby City by 2010.
What are we doing now?
Within the new GP Contract30 Education Indicator 7, GPs are able to undertake Significant Adverse Event Reviews, one of which should include a review on suicide if one has occurred over a 3-year period. Clinical audits at practice level offer an opportunity to improve clinical care and address governance issues in the context of a supportive learning environment. In addition, a suicide audit undertaken by Derby City and Derbyshire County PCTs in 2009, based on 2008 data, has enabled both PCTs to assess their performance against these plans.
What should we be doing?
The National Suicide Prevention Strategy in England31 reinforced the strategic aim to reduce suicides set out in Saving Lives: Our Healthier Nation32. As well as the national target set out above, PCTs are required to show trends in suicide rates for inclusion in Local Delivery Plans (now Local Operating Plans). To support this target all PCTs are required to have a local strategy and suicide prevention action plan to address the six goals for suicide prevention identified in the National Suicide Prevention Strategy. The 6 goals of the strategy are as follows:
Goal 1: To reduce risk in key high risk groups Goal 2: To promote mental well-being in the wider population Goal 3: To reduce the availability and lethality of suicide methods Goal 4: To improve reporting of suicidal behaviour in the media Goal 5: To promote research on suicide and suicide prevention Goal 6: To improve monitoring of progress towards the Saving Lives: Our Healthier Nation target to reduce suicides
30Standard Medical Services Contract (27.2.04) 31 DOH (2002) National Suicide Prevention Strategy in England. London The Stationary Office 32 DOH(1999) in Saving Lives: Our Healthier Nation. London The Stationary Office
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7.8.3 Mental Illness
Figure 144 Derby Common Mental Health Problems in Adults aged 16 – 64 years (based on 2007 Derby registered population of 187,896)
Figure 144 above was produced recently to better illustrate the common mental health problems that are likely to be affecting the population of Derby. At a recent Mental Health User Group meeting, it was commented that those with a mental health need in the city were probably at a big enough number to fill Derby County football team’s Pride Park Stadium. People do not necessarily understand the wider context of common mental health problems, but as a number of people will know what a packed Pride Park football stadium looks like, then this illustration might help them better understand how potentially big an issue common mental health problems are.
Figure 145
People aged 65 and over predicted to have depression, projected to 2025 2008 2010 2015 2020 2025
People aged 65 and over predicted to have depression: 827,980 858,420 971,450 1,056,300 1,158,760 lowest estimated level of prediction
People aged 65 and over predicted to have depression: 1,241,970 1,287,630 1,457,175 1,584,450 1,738,140 highest estimated level of prediction
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Figure 146
People aged 65 and over predicted to have severe depression, projected to 2025 2008 2010 2015 2020 2025 People aged 65 and over predicted to have severe 1,131 1,167 1,266 1,350 1,470 depression: lowest estimated level of prediction People aged 65 and over predicted to have severe 1,885 1,945 2,110 2,250 2,450 depression: highest estimated level of prediction Source: POPPI
Figures 145 and 146 demonstrate both the lowest and highest estimations of numbers of people aged 65 and over predicted to have depression and severe depression over the coming years. As is evident from the figures for Derby taken from the Projecting Older People Population Information System, this could be as many as 1,740,000 older people suffering from depression by 2025, while almost two and a half thousand are likely to be suffering from severe depression.
Child and Adolescent Mental Health Services
The CAMHS Partnership commissioned an independent assessment of the needs of children and young people in relation to mental health during July 2009. Input from a broad stakeholder group and the views of young people have supported the process which has also included consultation on the final documents. The final version provides information and evidence that will support and enhance the commissioning of services to children and young peoples mental health. The recommendations will be used to inform commissioning priorities and service review and development activity across the city. The documents have been shared with the PCT, Acute Trust and Derbyshire Mental Health Trust.
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7.9 Trauma
7.9.1 Falls
What is the problem?
A 2007 report by Professor Ian Philp ‘ A Recipe for Care – not a single ingredient’ focuses on early intervention and assessment benefits in terms of falls and fractures. It is assumed that those with brittle bones, who sustain a low-impact fall, may go on to fracture. The majority of the report translates into difficulties with walking, dressing, shopping, interrupted sleep because of pain and a potential lack of independence, rather than those fractures seen and treated by the NHS. However, information is available for those aged 65 and over, as below, in terms of hospital admissions as a result of a fall, and for those who sustain a fracture e.g. hip fracture as a result of a low-impact fall.
Figure 147
65s and over 2005 2006/7 2007/8 2008/9 DERBY CITY
had a fall, requiring a stay in hospital 821 855 1,127
had a fall, 353 395 492 351 requiring a stay >3 days
admitted with 273 247 277 247 #NOFemur
admitted with vertebral # 45 43
all of the above for DERBY City, available by GP practice, and by ward for 2007
A&E had a low impact fall 65s and 1,026 over
A&E had a # eg wrist 65s and over 825
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Figure 148 Admission numbers for 2008/2009 for Falls, Hip fractures, and Vertebral fractures for 65s and over and 75s and over, by Ward Admissions for Admissions for falls Admissions for Hip Admissions for falls any LoS LoS 3+ days fractures any LOS vertebral fractures any LOS 65 - 74 75+ 65+ 65 - 75+ 65+ 65 - 75+ 65+ 65 - 75+ 65+ 74 74 74 Abbey 11 45 56 <5 15 18 <5 8 9 0 <5 <5 Allestree 11 67 78 <5 27 30 <5 18 20 0 <5 <5 Alvaston 11 61 72 <5 16 19 <5 14 15 <5 <5 5 Arboretum 16 63 79 6 18 24 <5 14 17 <5 <5 <5 Blagreaves 15 65 80 5 23 28 <5 16 20 0 <5 <5 Boulton 8 50 58 5 13 18 <5 10 11 <5 <5 <5 Chaddesden 10 55 65 <5 18 21 <5 13 15 0 0 0 Chellaston 16 74 90 5 20 25 <5 8 10 <5 <5 <5 Darley 11 59 70 <5 23 26 <5 18 20 0 <5 <5 Derwent 7 51 58 <5 16 19 0 12 12 0 <5 <5 Littleover 8 53 61 <5 10 14 <5 5 9 <5 <5 <5 Mackworth 6 63 69 <5 19 23 <5 18 20 0 <5 <5 Mickleover 11 72 83 <5 26 30 <5 21 23 <5 <5 <5 Normanton 17 46 63 8 11 19 <5 13 17 0 <5 <5 Oakwood 7 23 30 <5 8 9 <5 5 6 0 0 0 Sinfin 8 33 41 <5 10 12 <5 5 6 0 <5 <5 Spondon 9 65 74 <5 15 16 <5 16 17 0 <5 <5 182 945 1127 63 288 351 33 214 247 7 36 43
Figure 149 Fall rates for 2008/2009 per 100 population for 65s and over and 75s and over, by Ward 65+ pop'n 75+ pop'n Fall Rate per 100 pop/65+ Fall Rate per 100 pop/75+ Abbey 1813 955 3.09 4.71 Allestree 3477 1707 2.24 3.93 Alvaston 2178 1118 3.31 5.46 Arboretum 1808 876 4.37 7.19 Blagreaves 2548 1166 3.14 5.57 Boulton 2450 1178 2.37 4.24 Chaddesden 2326 1075 2.79 5.12 Chellaston 2251 1173 4.00 6.31 Darley 2022 1155 3.46 5.11 Derwent 2035 968 2.85 5.27 Littleover 1836 946 3.32 5.60 Mackworth 2369 1406 2.91 4.48 Mickleover 2873 1392 2.89 5.17 Normanton 1988 1030 3.17 4.47 Oakwood 1547 579 1.94 3.97 Sinfin 1392 592 2.95 5.57 Spondon 2472 1132 2.99 5.74 Total 37385 18448 3.01 5.12
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What works?
There are assumptions that 30% to 40% of falls can be prevented, and that in those who do fall, less than one in 10 will fracture but in those who have sustained a previous fracture e.g. a fractured hip, they are more likely to fracture again. Clear guidance on both primary and secondary prevention of osteoporosis is encapsulated in NICE guidance, whilst specific falls prevention should include environmental modification (particularly for those with a history of falls (including the appropriate use of slippers and glasses etc), there is evidence to suggest that regular review of medication contributes to a decrease in falls, exercise preserves mobility but does not necessarily reduce falls, as does high intensity training.
What are we doing now?
Based on the above information regarding rates of falling, and in conjunction with demographic information which suggests that the majority of older people live in our suburban wards, in Allestree particularly, the following has been initiated:
A Falls Team which targets work to those GP practices in the appropriate wards Osteoporosis Guidelines have been agreed by the JAPC (Joint Area Prescribing Committee) for medication prescribing by GPs to older people to avoid brittle bones A PBC (Practice-based Commissioning) proposal for Derby City will ensure that work by the secondary care fracture liaison service (for people who have already sustained a hip fracture admission) will tie in seamlessly with the work of GPs. A recent GP audit found that many people sustaining a secondary fracture were nor continuing to take appropriate medication. This will ensure that systems are in place for accurate recording and follow-up. Telecare – a jointly funded project with the City Council is ensuring that, by the use of sensors, the independence of older people is maintained in their own homes. The initial evaluation finds that the target group is primarily ‘those who are at risk of falling’ Keep Warm, Keep Well – we know that the outcomes for those who fracture a hip are worst if they lie unattended and get cold prior to admission and operation Work with secondary care The Royal Derby in improving the hip pathway for those admitted – with an emphasis on early resuscitation and early mobilisation and discharge to home A Falls Team which works with care homes and GPs, and all primary care providers, to ensure that Falls assessments are completed Practice Pharmacists who ensure that medication reviews are carried out in primary care and in care homes Specialist Falls Team at The Royal Derby and geriatrician with specialist interest in assessment of falls
What should we be doing?
As well as the initiatives that are already in place, we should also be continuing to ensure that older people in contact with any professional/health trainer should be asked routinely about falling, and offered information orally and in writing about what measures can be taken to prevent further falls. We should also continue to develop all of the current initiatives, including offering dietary/lifestyle advice which ensures that people receiving treatment have an adequate intake of calcium. We should ensure that a communication plan is targeted at not only females, but our male population too as falling is not just a problem for elderly women (which it is often perceived to be).
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A service in our local A&E Department which addresses falling and issues for those who fracture e.g. fractured wrists and are not admitted should be developed, as should continued work with care homes, to ensure that environmental modifications are carried out. We should also think about re- auditing secondary prevention prescribing, and work on early supported discharge programmes which reduce both length of stay for our patients in hospital, and a higher rate of effective return to previous residential status.
7.9.2 Road accidents
Road accident statistics play a leading part in the Government's Road Safety Strategy, and monitoring its targets for the number of road deaths and injuries by 2010.
Figure 150
Source: Derby City Council
Figure 151
Source: Derby City Council
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Derby City, compared to the other major cities in the East Midlands region – namely Nottingham and Leicester – experienced 113 KSI casualties during 2008, which is a decrease of 26% based on the baseline figure of 153 KSI casualties during the 1994/98 period. Figure 153 details the same indicator, but for children. In 2007, there were 22 KSI casualties in Derby City, the highest number in the region. However, during 2008 there were 13 KSI casualties which alludes to an overall decrease of 57% in casualties from the baseline period.
The Government’s targets for casualty reduction, set out in the Department for Transport publication “Tomorrows Roads – safer for everyone” (March 2000), are:
To achieve a minimum reduction of 50% in the number of children killed or seriously injured on Derby’s roads by 2010 (NI 48) To achieve a minimum reduction of 40% in the total number of people killed or seriously injured on Derby’s roads by 2010 (NI 47)
Derby City is currently exceeding it’s target for children, but is not meeting the 40% target for people of all ages. Other targets have been introduced since then, but the 50% and 40% reduction targets have continued to be quoted and reported upon by many local authorities, perhaps because they are easily understood by the public.
Figure 152
Reported Killed and Seriously Injured (KSI) casualties in the East Midlands UAs
2008 percentage change on baseline
2008
Nottingham UA Leicester UA Derby UA 2007
1994 - 1998 baseline
-100 -50 0 50 100 150 200 250 300 350
% change Number of Cas ualties
Source: The Department for Transport
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Figure 153 Reported Child KSI casualties in the East Midlands UAs
2008 percentage change on baseline
2008
Nottingham UA Leicester UA Derby UA* 2007
1994 - 1998 baseline
-100 -80 -60 -40 -20 0 20 40 60 80
% change Number of Cas ualties
Source: The Department for Transport
7.9.3 Injuries
What is the problem?
In Derby, we are actively monitoring hospital admissions caused by unintentional and deliberate injuries to children and young people, by way of National Indicator NI70 and Vital Sign VSC29. Figure 154 below highlights the current trend in these hospital admissions in Derby, as well as a projection to the financial year 2010/11 based on the historical activity from 1996/97, and the targets set for the PCT against the NI and VS performance indicators. If the trend in activity continues, the PCT should achieve its targets in the years to come.
Activity is monitored using the HES statistical dataset, and 2008/09 years data is currently being analysed. The latest rate per 10,000 population aged under 18 years was 119.01 in 2007/08. This amounted to 632 individuals, and is down from a baseline rate of 156.14 per 10,000 in 1996/97 (n= 857 individuals).
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Figure 154 VSC29: Hospital admissions caused by unintentional and deliberate injuries to children and young people
180
160
140
120
100
80
60
40 Emergency admissions per 10,000 aged under 18
20
0 1996/97 1997/98 1998/99 1999/00 2000/01 2001/02 2002/03 2003/04 2004/05 2005/06 2006/07 2007/08 2008/09 2009/10 2010/11
Period
Target Actual Projection
Source: HES
In general, prior to the current year, there has been a downward trend in numbers admitted who fulfil the criteria for this measurement. However, when extrapolating 09/10 YTD for a full year using seasonality from previous years there seems to have been an upturn in this financial year.
The general trend in number of A&E attendances by under 18s has been flat for the last 3 years, with an apparent drop in the first couple of months of this year. This is in contrast to the percentage of those attendances that result in admission, which is evidently falling steadily over time. what is interesting to note is that with the exception of mid 2008/09 to date wherever attendances have risen the percentage of those not admitted rises as well, suggesting that the extra activity is generally not serious.
Figure 155 100 Actual admissions meeting criteria Actual Projected Trend 90
80
70
60
50
40
July July July July
May May May May
June June June June
April April April April
March March March March
August August August August
January January January January
October October October October
February February February February
December December December December
November November November November
September September September September Source: SUS
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Figure 156 88% 3300
Percentage Not Admitted 87% 3100 Total Attendances 86% Poly. (Percentage Not Admitted) 2900 Poly. (Total Attendances) 85% 2700
84% 2500 83% 2300 82%
2100 81%
1900 80%
79% 1700
78% 1500
July July July July
May May May May
June June June June
April April April April
March March March March
August August August August
January January January January
October October October October
February February February February
December December December December
November November November November
September September September September
2006/07 2007/08 2008/09 2009/10
Source: SUS
The Government’s vision over the 2007 Comprehensive Spending Review period was to improve, and continue to improve child safety so that children and young people are better protected from deliberate and unintentional harm. It is vital that we learn the lessons from inquiries such as that into the death of Victoria Climbié and Sir Michael Bichard’s report on Soham. Standard 5 of the National Service Framework for Children, Young People and Maternity Services refers to Safeguarding and Promoting the Welfare of Children and Young People.
Ultimately, we want to see children and young people safeguarded from harm (maltreatment) and able to achieve their optimal outcomes throughout childhood, their teenage years and into adulthood. They should be able to grow up in circumstances where they are safe and supported, and this will require all agencies working together to prevent children suffering harm and to promote their welfare, as well as provide them with the services they require to address their identified needs and safeguard children who are being or who are likely to be harmed.
7.10 Musculo-skeletal
What is the problem?
Admission rates for Trauma and Orthopaedics have shown a rising trend for the three years, 2005/06 to 2007/08. In October last year, a piece of work was undertaken focussing on the musculoskeletal services available to the population of Derby. At the time, a full 2008/09s worth of hospital activity was unavailable, however, projections based on a partial year were made, and further rises of the overall T&O activity were predicted for the full 2008/09 year (Figure 157). In terms of total activity and admissions: arthroscopy, intermediate pain procedures, hand procedures, minor procedures and soft tissue work account for the top 5 categories.
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Figure 157
Headline Orthopaedic Annual Admission Rates and Cost
30.00 £16,000,000.00 Admission Rate Total Spell Cost
£14,000,000.00 25.00
£12,000,000.00
20.00 £10,000,000.00
15.00 £8,000,000.00 Cost£'s
£6,000,000.00
10.00 Rate/ 000 registered population registered 000 Rate/
£4,000,000.00
5.00 £2,000,000.00
0.00 £0.00 05_06 06_07 07_08 08_09*
The cost of spells (from date of a persons admission to date of their discharge) under the T&O speciality have also risen in recent years. Despite small increases in elective and non-elective admissions, increases have been seen year on year in day case admissions. NHS Comparators33 data for the full 2008/09 year highlights the extent of the problem with T&O hospital activity in Derby City. Figure 158 illustrates where NHS Derby City sits (in blue), ranked against all other PCTs in the country. The black line is the national average, and it is clear that there are more people, at approximately 20 per 1000, being admitted to hospital electively than is seen nationally. Derby City has the highest elective crude admission rate in the East Midlands.
Figure 158 Total Elective (Inpatient + Day Case) Admissions per 1000 Population, under T&O Speciality
Source: NHS Comparators
33 NHS Comparators is a national resource and is part of the Secondary Uses Service (SUS), jointly delivered by the NHS Information Centre and NHS Connecting for Health. It provides comparator data for NHS commissioning and provider organisations, enabling users to investigate aspects of local activity, costs and outcomes
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A large number of these admissions, particularly during 2007/08, can be attributable to Derby City acting early in wanting to see and treat people who are referred under the T&O banner, within 18 weeks. However, despite this, we have not seen the activity under this speciality go down. In cost terms, large (cemented) joint (hip and knee) work accounts for the top 2 costs, followed by arthroscopy. Revisions to hips appear at number 4 – this requires further clinical investigation – followed by the category ‘complex elderly’ which should be considered further in terms of coding and costs. The total cost of elective T&O activity under the Programme Budget Category34 P15: Problems of the Musculo-skeletal system, was more than £7,700,000 in Derby during 2008/09, against an expected of closer to £6,200,000. This overspend of £1,500,000 in elective activity needs to be addressed.
With regard non-elective and so emergency admission under Trauma and Orthopaedic speciality, the top 5 HRG35 codes that appear more often than not, are; H37: Fractured pelvis or lower limb (in those aged less than 70), P15: Accidental injury, H36: Fractured pelvis or lower limb (in those aged 70+), H99: Complex elderly, and H39: Closed upper limb fractures. Figure 159 highlights that unlike with the elective activity, non-elective T&O activity in Derby (the blue bar) is comparable to not only the average of activity occurring in the East Midlands Strategic Health Authority region, but the rate of admissions that are occurring nationally (the black line on the chart highlights the national average, and the lighter blue line, the regional average).
Figure 159 Total Non-Elective (Emergency) Admissions per 1000 Population, under T&O Speciality
Source: NHS Comparators
Information is also available for referrals and admission at a GP practice level, and shows variation by practice across years. There is no consistent pattern seen.
34 The aim of the Department of Health’s Programme Budgeting Project is to forge a closer and more obvious link between the object of expenditure and the patient care it delivers with a view to influencing and tracking future expenditure in those same programmes to achieve the greatest health improvement per £ spent in the NHS. There are 23 programme budget categories. 35 A Healthcare Resource Group (HRG) is a group of clinically similar treatments and care that require similar levels of healthcare resource
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What works?
Musculo-skeletal disorders will include:
Ankle sprain Bunions Carpal tunnel syndrome Chronic fatigue syndrome Gout Herniated lumbar disc Hip fracture Leg cramps Low back pain (acute and chronic) Neck pain Osteoarthritis Planter heel pain and fasciitis Reynaud’s phenomenon Rheumatoid arthritis Shoulder pain Systemic lupus erythematosus Tennis elbow
One of the more commonly associated complaints though is arthritis, the most severe of cases of which impact heavily on admissions for hip and knee replacement. Osteoarthritis is the most common form of arthritis. Cartilage (connective tissue) between the bones gradually wastes away (degenerates), and this can lead to painful rubbing of bone on bone in the joints. It may also cause joints to fall out of their natural positions (misalignment). The most frequently affected joints are in the hands, spine, knees and hips.
Rheumatoid arthritis is a long-term disease in which joints in the body become inflamed, causing pain, swelling and stiffness. It is known as an ‘autoimmune disease’ because it is caused when the body’s immune system, which normally fights infection, starts to attack healthy joints. At times, it can be very painful and affect a person’s ability to carry out everyday tasks. It is not known why rheumatoid arthritis develops, and there is no cure. However, understanding of the disease has improved and there are now effective treatments that can help ease the pain and symptoms, and ultimately slow down the disease. It is very important that treatment is started early to minimise damage to joint.
The National Institute for Health and Clinical Excellence offers ‘Rheumatoid arthritis: the management of rheumatoid arthritis in adults’, which gives advice on the care of adults with this condition. The options available for treating arthritis include:
Medicines Physiotherapy Surgery Complementary therapy Exercise General joint care
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What are we doing now?
The treatment options listed above will vary depending on the type of arthritis. In general though, studies have shown that physical exercise of the affected joint can have noticeable improvement in terms of long-term pain relief. Furthermore, exercise of the arthritic joint is encouraged to maintain the health of the particular joint and the overall body of the person. This is actively encouraged by our GPs in the primary care setting at present.
In terms of managing orthopaedic surgery capacity for our patients; Barlborough NHS Treatment Centre opened in July 2005, providing PCTs in the Trent and South Yorkshire regions with additional orthopaedic capacity to help achieve shorter waiting times. It provides patients with the choice to receive their orthopaedic treatment sooner, at a one-stop facility which combines assessment and treatment on the one site. For a year prior Barlborough ISTCs opening, orthopaedic surgery was performed at co-located NHS facilities in Ilkeston and Bassetlaw.
In NHS Derby City, we are actively encouraging our GPs to refer their patients to Barlborough, to ease the services of our local acute hospitals trust and ensure a choice of where patients may wish to be treated. Figure 35 is one of a number of posters that are being placed in the GP practices of Derby City to promote the service, and GPs have been asked to enclose a leaflet about the facility with letters to patients. We are currently working with our practice consortia (of which there are two in NHS Derby City: First Commissioning Group, and FPC Consortium) to increase the uptake at Barlborough.
We have equally been actively seeking to engage with our local population, by identifying any patients who have received treatment at Barlborough to see if they can help us as a PCT raise the profile of the ISTC, and generate publicity.
Figure 160
Patient Satisfaction: Monitored daily in each department and on average over 97% of Referral Criteria: patients have consistently rated the service as The patient is over 18 years old. good or excellent. Barlborough were well The patients has a BMI of 39 or less. ahead of the local NHS trust and top 20% Patients requiring anaesthetic who NHS trusts in a patient experience survey meet the ASA classification of physical Travel Costs: status ASA1 (A normally healthy performed by DOH. Barlborough exceeds the Reimbursement of threshold score for the top 20% of NHS acute individual) ASA2 (A patient with mild travel costs for patients systematic disease) are generally trusts on all questions. and visitors by the PCT. accepted or ASA3 patients whose pre-
(One visit for each day existing co-morbidities are stable and of patient stay) well controlled, will be reviewed by the anaesthetist. Available Treatments: Hip and Knee replacements Knee arthroscopies Hand and foot procedures Why the ISTC Quality of Staff: Doctors, Soft tissue procedures Barlborough is a nurses and clinical staff are Anterior cruciate ligament fully qualified, experienced and reconstruction. viable option for your registered with appropriate Also provide diagnostic procedures and professional bodes within the after care. patients UK.
Efficiency: Ideal option as part Short Waiting time: In most cases Clinical Quality: To end of March 2008 of QuIP to improve quality & patients can be see within two Barlborough have performed 13,945 efficiency. Financially, better weeks for first appointment. If procedures, 7,605 Majors (Hip and knee utilisation of resources. patients need further treatment or Replacements & Revisions) and 6,340 surgery, Barlborough can offer a Minors (day case procedures), with an choice of date/time to suit them. overall complication rate of less than 1%. Not a single case of MRSA bacteraemia, to the end of April 2008. In 2008/09 Barlborough carried out 2,085 major procedures and 1,1658 minor operations.
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What should we be doing?
Arthritis can mean that previously simple tasks become difficult, but there is help and equipment available to those suffering from the condition from the likes of Social Services, Disabled Living Centres, family GPs and even Citizens Advice Bureaus in terms of counselling those who have become depressed as a result of living with the condition.
Medicines are essential, and sometimes life saving for serious inflammatory forms of arthritis. We should ensure that our patients are being prescribed medications as appropriate, and that clear advice is given as to why they are taking the medication and how often they should be taking it. Medications for arthritis must be taken conscientiously and regularly, and monitoring should be undertaken by GPs at specific intervals. Complementary medicines/therapies that are proven to work can also be prescribed by GPs on the NHS prescription service. However, patients should continue to be encouraged to try exercise and relaxation programmes rather than unproven herbal or other remedies. Some types of arthritis are associated with an increased risk of heart disease, so it is important to eat a properly balanced diet that is low in fat and includes plenty of vegetables.
Rheumatology and orthopaedics are the medical and surgical specialties that deal with complex arthritis and rheumatism. Physiotherapists, occupational therapists, nurses, orthotists, chiropodists and podiatrists help with exercise regimes, pain control, monitoring, education and foot care. Our patients should not be afraid to ask their GPs about specialised advice. Advances in treatment can have a big impact on the more serious forms of arthritis and early treatment is essential.
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8. Services
8.1 Social care
What is the problem?
As at 31st March 2009, numbers of people requiring social care in Derby City during 2008/09 were as follows:
Figure 161 Physical disability, Age Learning Mental Substance Vulnerable Numbers frailty and Total Group Disability Health Misuse People sensory impairment Clients 1535 598 620 15 63 2831 Clients receiving 18-64 community 1483 543 559 6 62 2653 based services Clients 5914 80 616 3 79 6692 Clients receiving 65+ community 5148 66 400 2 60 5676 based services Source: Derby City Council
As is clear, the number of clients aged over 65 years receiving community based services in the city is more than twice as many as in the 18 to 64 age group. The numbers of physical disability, frailty and sensory impairment clients are naturally much greater in the older age group, while learning disability and substance misuse clients are larger in the 18 to 64 year olds.
The figures for people helped to live at home will start to reduce during 2010/11 as the effects of early intervention and preventative services start to become apparent. In future more people will be supported to live at home independently without receiving on-going social services from the council.
Figure 162 shows the usage of adult social care related services by ward. The total rank column represents the ranking based on all services added together. This demonstrates comparative ward need, at a high level. For the services identified in the table the geographical location is linked to the address of the service user, but in the case of residential care it is linked to the last place of address before that admission. This better focuses the services on particular communities.
The table at Figure 162 shows that service usage varies quite considerably between wards and across the different services. The table suggests that the highest users of social care services are located in Arboretum, Blagreaves and Mackworth wards. The lowest users of social care services would appear to be in Oakwood, Mickleover and Sinfin wards. These areas generally rank mid to low across all
82 services. This is not surprising for Mickleover and Oakwood as these areas score low on the Index of Multiple Deprivation but Sinfin is not categorised in a similar bracket in relation to deprivation. However, it is notable the over 75 population is lowest in Sinfin - only some 5.3% - and this may explain the apparent low take up of social care services in Sinfin, as the over 75’s generate the most demand for adult social care.
Figure 162 All Adults with Open services as @ 2009 Usage per 10,000 75+ Pop The number in brackets is for usage rate ranking 1 being the highest All listed services Day Home Direct Total Total Ward Meals Care Care Residential Nursing Payments Usage Rank Abbey 25.5(6) 24.7(13) 89.7(8) 40.3(6) 31.3(6) 13.2(10) 224.6 8 Allestree 31.7(3) 20.2(16) 115.3(1) 13.2(17) 15.0(14) 12.3(12) 207.7 11 Alvaston 30.4(4) 41.0(6) 78.0(14) 32.0(11) 16.4(12) 9.8(14) 207.6 12 Arboretum 12.5(14) 28.2(11) 93.5(5) 51.4(1) 49.6(2) 32.0(1) 267.3 1 Blagreaves 32.7(2) 43.6(4) 85.2(9) 44.6(4) 20.8(9) 21.8(3) 248.7 2 Boulton 17.2(10) 52.6(1) 84.3(10) 35.3(10) 21.7(8) 15.4(7) 226.6 7 Chaddesden 25.8(5) 47.8(2) 89.8(7) 42.0(5) 20.1(10) 13.4(8) 238.8 4 Chellaston 23.2(7) 45.4(3) 93.5(4) 35.6(9) 16.9(11) 16.9(4) 231.5 5 Darley 12.4(15) 23.3(14) 75.2(16) 38.0(7) 51.2(1) 7.0(17) 206.9 13 Derwent 16.3(12) 31.7(9) 94.1(2) 46.2(3) 31.7(5) 7.2(16) 227.2 6 Littleover 17.5(8) 29.4(10) 93.7(3) 30.3(12) 14.7(15) 23.0(2) 208.6 10 Mackworth 17.4(9) 39.1(7) 92.2(6) 47.0(2) 28.7(7) 15.7(6) 240.0 3 Mickleover 17.2(11) 19.8(17) 78.2(13) 17.2(16) 8.6(16) 11.2(13) 152.1 16 Normanton 13.3(13) 26.7(12) 77.1(15) 37.1(8) 34.8(4) 16.3(5) 205.3 14 Oakwood 7.5(17) 22.6(15) 50.0(17) 24.5(13) 6.6(17) 8.5(15) 119.8 17 Sinfin 11.6(16) 42.8(5) 82.9(12) 21.4(15) 16.0(13) 13.4(9) 188.0 15 Spondon 34.0 (1) 33.0(8) 84.0(11) 23.0(14) 37.0(3) 13.0(11) 224.0 9 Source: Derby City Council
Service Response
The process of assessing clients and delivering services continues to be good. National Indicator NI132 which monitors assessments completed within 4 weeks for new adult service users; shows 91.6% for 2008/09, ahead of the year-end target of 90%. Similarly, waiting time for care packages for new service users aged 65 and over measured by NI133 shows 92.7% delivered within 4 weeks, ahead of our year-end target of 90%. Future targets for these indicators are detailed below in Figure 163:
Figure 163 Indicators 2008/9 2009/10 2010/11 2011/12 Assessment Waiting 90% 92% 93% 93% Time NI 132 Care Package Waiting 90% 92% 94% 96% Time NI 133 Source: Derby City Council
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Self Directed Support
NI130 - Self Directed Services including Direct Payments - measures the number of recipients of self directed services. It can be seen as a proxy for measuring the continuing transformation of adult social care services giving more choice, control and independence to service users directing and purchasing their own care. For 2008/09, the outturn in Derby was 208.75, expressed as a rate per 100,000 population. From 2009/10 onwards, NI130 will be expressed as a proportion of service users receiving self-directed services. The national target is 30% by March 2011. Derby City Council has set an interim target of 10% by March 2010.
Carers
An increasing number of us (one in ten) are likely to find ourselves providing care and support for a family member or friend at some point in our lives. Over recent years the needs of carers have been given an increasingly high profile on the national agenda. There is an expectation that local authorities and their partners will make continued and real progress in supporting carers, who play a vital role in meeting the community care needs of disabled and elderly people.
The national indicator for Carers Services including advice and information - NI135 - is included in the Derby City Local Area Agreement with stretch targets of 10% for 2008/09, 16% for 2009/10, and 25% for 2010/11. The outturn for 2008/09 was 11.2% and the forecast for 2009/10 is 20%.
The Derby Carers Strategy 2009/12 builds on the City Council's vision that the provision of accurate and timely information for carers, together with advice and support, will enable carers to feel recognised and valued and will help them to live full and healthy lives.
As part of developing services to better meet the needs of carers, Derby has been awarded Carer’s Break Demonstrator Site status. This will entail the development and implementation of new Carer’s Break services between 2009 and 2011, including new ways of working in partnership to identify and support a greater number of carers within Derby.
The following information (Figure 164) has been extracted from the last census conducted across Derby.
Figure 164 Total number of adults aged 18 years and older who were 22,769 13.7% of total adult providing unpaid care population of Derby Number of carers providing care up to 19 hours per week 15,299 67.2% of carers Number of carers providing care 20 to 49 hours per week 2,648 11.6% of carers Number of carers providing care 50+ hours per week 4,822 21.2% of carers Number of carers providing care 50+ hours per week who 1,094 4.8% of all carers stated they were not in good health Number of carers aged between 45 and 64 years 10,211 44.8% of all carers carers aged 85 and over 175 Number of such carers providing care for 50+ hours a week 87 Number of children aged between 5 and 17 years 856 providing care for family members Source: Derby Carers Strategy 2009/12
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As the proportion of older people in Derby increases, a similar increase in carer population is anticipated. Figure 165 depicts this level of growth and identifies an increase in the number of carers based on the adult population increase. We expect that the number of carers shall rise to 29,800 by the year 2026 (an increase of 31%).
This growth in carers in absolute terms due to population increase is expected to be reinforced by a change in the national system for care responsibility which shall seek to equalise the responsibility between the state, the family and the individual.
Services still need to be developed to support carers effectively. The Strategic themes for the support of carers are identified clearly in the Derby Carers Strategy 2009 – 2012.
Figure 165
Source: Derby City Council
Learning Disability & Autism
The expected growth in numbers of people with learning disability and autism in Derby are pictured in Figure 166.
The learning disability projections are based on the Emerson & Hatton research into prevalence of people with learning disabilities. The autism figures are based upon research undertaken by Baird, G et al and reproduced in the Department of Health good practice guidance for local authorities and primary care trusts, for services to people with Autism. The prevalence rate used to project numbers of people with autism concentrates on those people with complex needs as a result of autism who shall require services (0.16% of the population).
The learning disability projection shows a rise from 799 to 1063 adults, an increase of 33% over the period, while the autism figure grows from 286 to 380 – a similar proportional increase as people with learning disability. Emerson & Hatton’s study repeated the findings of the Baird study; that 50% of people with Autism Spectrum Disorders (ASD) also have a learning disability. These two projected populations therefore are not mutually exclusive, and overlap significantly according to research.
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Whilst these projections are informative and provide a base for planning services we also need to survey the local population to ensure there is no major mismatch between prevalence projections and our actual local population. This is particularly true of people with Autism as these are relatively small numbers and could be subject to significant local fluctuations. To illustrate this point, the information systems for social care only categorised fifty seven open service users with a primary Autism diagnosis as at March 2009.
Services for people with Autism are not well developed and people often fall through gaps in local services, particularly between mental health and learning disability services.
The increase in numbers is expected to occur because of advances in medical science which have led to more babies with complex conditions surviving birth and living into adulthood. The life expectancy of someone with moderate to complex learning disabilities has almost doubled since the 1970’s.
The need to provide a range of services for people with learning disabilities and Autism shall grow in line with the projections highlighted in the graph below. There is an increasing expectation of the need to integrate people with disabilities into mainstream society as far as is practicable in terms of education, employment, housing and other life opportunities36.
Figure 166
Source: Derby City Council
The challenge for social care in relation to people with learning disabilities is to modernise service delivery and make services sustainable for the future. We need to act on person centred plans to make services more personal and engage with carers and their support needs, some of whom are aged or disabled and have needs of their own. The wider task is to integrate people with learning disability and autism into every aspect of ordinary life.
36 Valuing People Now (2009) The Department of Health’s new three-year strategy for people with learning disabilities
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Deaf Blindness
There is no specific register in localities for people who are deaf and blind – often referred to as people with dual sensory loss. These people tend to be categorised with other physically disabled or sensory disabled people. Social Care in Derby in March 2009 had seventy seven open cases where the primary categorisation was dual sensory loss. However, currently we do not have intelligence about all the people that there might be in the city with if not total loss, then dual sensory impairment.
People with dual sensory loss or progressive impairment tend to have a significant functional impact on their ability to communicate, access information and their mobility. The services in these areas need to be tested against the needs of people with dual sensory loss.
What should we be doing?
Social care services are underpinned by the requirement to improve choice and control to maximise independence through the availability of a range of high quality services. In order to promote health, well-being and quality of life there is a need to ensure the whole community has access to information, advice and preventative services. Future developments need community views at the heart of the planning process. We must ensure that all vulnerable adults are treated with dignity and respect and safeguarded against poor practice in the care industry or other people in the community who may harm or restrict them.
There are a number of strategic priorities that are being driven either through the national agenda or through our local knowledge of existing services.
The grid below (Figure 167) highlights some of the specific development issues that local services need to tackle. These have been categorised into three distinct areas; service development need, quality improvement need, and fair access need. Requirements may feature across more than one category. The shaded area highlights development areas where Adult Social Care and Health Services need to work particularly closely to develop services which meet these needs.
Figure 167
Development Driver Requirement Service Quality Fair Development Improvement Access Increase choice and control through the use of Personal Budgets and Direct Payments. Improve information and advice services for the whole community. Actively support disabled people and those with mental health needs into employment. Provide a range of supported housing options for all client groups which maintain or return people to the community and promote their independence.
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Increase the range and level of support for carers across all client groups. Strengthen our service quality monitoring arrangements and safeguarding processes. Develop the local care market to make a wider range of services available to the public. Improve the quality of regulated services in the local market through the provision of incentives and workforce development opportunities. Better understand user experience and use this knowledge to improve the whole range of our activities. Ensure services cater for the needs of the whole community and are inclusive of minority communities. Develop Services for Deaf Blind people. With partners introduce Dementia specific services that support service users and carers in the community. Develop residential services for people with Dementia. Develop services for early intervention which promote good health, prevent social exclusion and deterioration. Develop cross cutting services for Intermediate Care, Falls Prevention, Stroke, Learning Disabilities, Autism and other Complex Conditions.
Social Care and information underpinning joint commissioning is currently being finalised.
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Children & Young People
During 2008/09 there were around 2,600 referrals relating to safeguarding and family support made to the city's Children's and Young People's Department. This equates to 82 children per 10,000 population which is below the national average. However, Derby's re-referral rate is good with only 17% of referrals occurring within 12 months of a previous referral. This is an improvement from 32% in the previous year and is now below the national average of 23%. The referrals made to children's social services last year were predominately from Schools and other Educational Organisations (19%), Primary and Secondary Health settings (18%), the Police (15%) and family or relatives (12%). Figure 168 below shows the primary reason for the referrals received during 2008/09:
Figure 168
Referral Reason Referral Reason Domestic Violence 15.2% Schedule 1 Offender 2.4% Neglect 14.7% Parenting Problems 2.4% Physical Abuse 14.6% Special Education Needs 2.3% Emotional/Behavioural 12.8% Children who abuse others 1.6% Difficulties Sexual Abuse 9.4% Behavioural Management 1.5% Parents Abusing 3.9% Emotional Abuse 1.4% Alcohol/Drugs Parent with Mental Ill Health 3.4% Learning Disability 1.3% Homelessness 2.6% Low income/Financial 1.0% Sensory or Physical Disability 2.5% Others 7.0%
Source: Swift (April 2009)
Child Protection
The number of children in Derby subject to a child protection plan at 31 March 2009 was 134, which equates to 25 per 10,000 population. This is Derby’s lowest figure since it became a Unitary Authority in 1997 (Figure 169). There are a number of national indicators relating to children with protection plans and it is important that they are looked at collectively. NI65 measures those children who become subject to a child protection plan for a second or subsequent time, and Derby performs in line with the national average at 12.4%. Derby also performs well against the review timescales for child protection plans with 100% completed on time.
An area where performance is significantly worse than the national average relates to NI64 which measures the proportion of children who ceased to be subject of a child protection plan that lasted 2 years or more. Derby’s figure for 2008/09 was 13% with the national average being just 6%. The indicator is being monitored closely and improvements have been seen during 2009/10.
89
Figure 169
Children and YP who were the subject of a Child Protection Plan rate per 10,000 population
80
70
60
50
40 CPP rate CPP 30
per 10,000 population 10,000 per 20
10
0 98/99 99/00 00/01 01/02 02/03 03/04 04/05 05/06 06/07 07/08 08/09
Derby UA 65 76 67 64 56 36 38 49 57 32 25 National 28 27 24 23 24 24 23 24 25 27 31 Statistical neighbours 38 34 30 33 33 32 32 29 31 29 34
Source: Derby City Council; Children & Young People’s Department
During 2008/09, 161 children required a new child protection plan of which 12.4% were subject to a plan for a second or subsequent time – NI65. This is in line with national averages and slightly better than statistical neighbours. The primary reasons for children requiring child protection plans are shown in Figure 170 below.
Figure 170
Neglect Physical Sexual Emotional Multiple Abuse Abuse Abuse Derby 22% 10% 14% 54% 0% Statistical Neighbour Average 46% 13% 8% 31% 2% National Average 46% 13% 6% 27% 8%
Source: DCSF First Statistical Release – Children Looked After in England Oct 09
Children Looked After
Children in the care of Local Authorities are one of the most vulnerable groups in society. The majority of children who remain in care are there because they have suffered abuse or neglect. At any one time around 60,000 children are looked after in England, although some 90,000 pass through the care system in any year. The number of children looked after in Derby at 31 March 2009 was 421, which represents the highest numbers since March 2000. There has been steady rise in the number of children in care for the past 4 years which mirrors the trend of statistical neighbours but remains substantially higher than national averages (Figure 171).
90
Figure 171 Children looked after at 31st March 2009
100 Number of Children Looked After aged under 18 per 10,000 Population 90
80
70
60
50
40
30 CLA per 10,000 Population 10,000 CLA per
20 10
0 97/98 98/99 99/00 00/01 01/02 02/03 03/04 04/05 05/06 06/07 07/08 08/09
Derby UA 89 83 81 75 75 74 74 69 71 74 77 80 England 50 52 52 53 54 55 55 55 55 55 54 55 Statistical Neighbours 56 60 65 64 67 70 71 73 70 73 73 74
Source: Derby City Council; Children & Young People’s Department
Around three quarters of looked after children from Derby are placed with foster carers, the vast majority of which are local authority carers living in Derby. However, there has been a steady increase in the number of children being placed with independent fostering agencies resulting in significant budget pressures. In response to this demand a number of initiatives have been implemented to retain local authority carers and also recruit new carers through various media and advertising campaigns.
There are a number of national indicators associated with children looked after, and for many Derby performs well compared to national averages. These include NI62 and N163; ‘Stability of Placements’, NI66 ‘Timeliness of Reviews’, and NI148 ‘Care Leavers in Education, Employment or Training’. The national indicator where Derby performs below national and statistical neighbours is NI61; ‘Adoption Timescales’, where only 56% of children were placed for adoption within 12 months of the decision that adoption was appropriate.
Outcomes for Children in Care
In 2007 the Government set out a vision to improve the lives of children in care which was underpinned by Public Service Agreements (PSA) and national indicators. The themes covered by the PSA were:
narrowing the gap between low income and disadvantaged children and their peers, which includes a focus on improving educational achievement of children in care at Key Stages 2 and 4 ; improving the health and wellbeing of children and young people, which includes a focus on improving the emotional health of children in care; improving the safety of children and young people, which includes a focus on reducing the proportion of children with three different care placements per year and on improving long term stability of care placements; and increasing the number of children and young people on the path to success, which includes a focus on improving the participation in education, employment and training by care leavers, and the suitability of their accommodation.
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Derby performs well against most of the outcome indicators used by the DSCF to measure progress against the PSA, notably:
The percentage of looked after children covered by a statement of special education needs in Derby was 24.5% in 2008, this is in line with the national average of 28% and the comparator authority average of 29% The percentage of looked after children missing at least 25 days from school in Derby is now at its lowest point – 9.3% in 2008. The comparator authority average was 13% and national average was 12%. Key Stage Two results for looked after children – Derby are now performing higher at Science (69%) than the national average (60%), the maths figure (44%) is in line with the national average (44%) however Derby is performing lower in English (31%) than the national average (46%) GCSE results – Derby’s looked after children performed above the national averages with 69% of looked after children achieving 1 GCSE A*-G, 54% achieving 5 GCSEs A*-G and 12% achieving 5 GCSEs A*-C. The percentage of children looked after aged 10 or over cautioned or convicted of a criminal offence was 8% in 2008; this is below the national average of 9% and the comparator average of 10%. The percentage of children looked after receiving health assessments, dental checks and immunisations is generally in line with national and comparator averages. The percentage of children looked after with a substance misuse issue was 3.7% in 2008, this compares to 4.9% nationally and 6.2% for the comparator authorities. Destinations for looked after school leavers were good in 2008 with 69% entering full time education which is in line with the national average In Derby, 8% of looked after school leavers were unemployed compared to 16% nationally and 22% for the comparator authorities.
Children with Disabilities
Based upon the 2008/09 Children in Need census, Derby was working with 262 children with a disability on the 31st March 2009. This includes children in care, children and families receiving respite services, family support and therapeutic services. Derby is well positioned to meet the needs of children with disabilities through the provision of integrated services at the Lighthouse and the new ‘Shine’ project which provides residential services for children with autism.
Furthermore, the Government is seeking a transformation in short break provision through the delivery of the Aim Higher for Disabled Children programme (AHDC). This is a jointly funded LA and PCT initiative in response to evidence that children who have the greatest need for these breaks are often unable to access provision because of the challenges posed by their disability. There is a targeted cohort of disabled children and young people that the initiative and grant will support which falls into two main groups:
Group A Children and young people with Autistic Spectrum Disorder, who have severe learning disabilities or behaviour which is challenging, or those children and young people whose challenging behaviour is associated with other impairments such as severe learning disabilities, and
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Group B Children and young people with complex health needs including those with disability and life limiting conditions and/or those who require palliative care and/or those with associated impairments such as cognitive or sensory impairments and/or have moving/handling needs and/or require special equipment/adaptations.
From national statistical data it is envisaged that this targeted cohort is equal to 1.2% of the child population and, for Derby City, has been calculated at just over 500 individuals. In partnership with the national monitoring organisation, 'Together for Disabled Children' (T4DC), the partnership will support at least 400 disabled children and young people between 2009 and 2011.
Further to initial consultation, with parents, carers, their disabled children and young people, some services have already been implemented to enabling access short break activities in more mainstream and universal settings. Further consultation and commissioning of short break services is planned for implementation and delivery in 2010/11. New services will be commissioned to meet the individual needs, to promote choice, improve quality, be flexible and will, of course, support them to achieve the five Every Child Matters outcomes.
8.2 Health services
8.2.1 Maternity
The PCT monitors access to maternity services on a quarterly basis to fulfil national performance indicator NI126 and Vital Sign VSB06: Early access for women to maternity services. During 2008/09, over 87% of women requiring a maternity service were able to at an early stage. In partnership with Derby Hospitals NHS Foundation Trust and Derbyshire County PCT, an engagement campaign promoting direct access to midwives is being developed through GP practices, pharmacies and other primary community services. This began in August 2009.
8.2.2 Dental health
As discussed earlier, the Derbyshire Oral Health Plan (including Derbyshire County PCT and NHS Derby City) was produced in 2007 based on Choosing Better Oral Health: an oral health plan for England, and supports the evidence-based approach described in the first edition of Delivering Better Oral Health. The Derbyshire plan has a number of key principles which include tackling inequalities in oral health, ensuring a prevention and common risk factor approach to oral health, working in partnership with other organisations and communities, providing accessible and high quality dental services, and ensuring the retention and development of an appropriate dental workforce.
An oral health promotion programme based on prevention and partnership working has been in place to support special care dentistry services aimed at vulnerable groups, and a new service specification is currently being developed by colleagues from the University of Sheffield. General dental services are commissioned across Derby and there are primary care-based specialist minor oral surgery and orthodontic services. Dental general anaesthetic services are delivered by salaried primary dental care services from a secondary care environment.
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8.2.3 Preventative/Screening
The Seasonal Flu Jab
The Department of Health recommends that the following people are at particular risk from the effects of seasonal flu and so should be vaccinated every year. A person is eligible for a free flu jab if they are over 65 years of age and/or are suffering from:
Chronic chest conditions including asthma Diabetes Chronic heart disease Chronic kidney disease Lowered immunity due to disease or treatment Main carer for elderly or disabled person whose welfare may be at risk if the carer falls ill
All adults over 65 and people at high risk of pneumococcal infection should receive the one-off pneumococcal polysaccharide vaccine. During 2008/09, NHS Derby City’s GP Practices achieved an average vaccination percentage of 76% in the total population aged over 65, compared to a 74% achievement seen nationally. During the same period, Derby achieved a 38% average vaccination percentage of the at risk population aged under 65, compared to a 47% achievement nationally. This varied widely between practices from 17% to 68% among the under 65s and 64% to 84% in the over 65s.
Figure 172
Over 65 % vaccinated 2008-09
90
National % 80
70
60
50
40
30
20
10
0
C81113 C81118
C81108 C81100
C81616 C81040 C81064 C81665 C81009 C81068 C81072 C81036 C81051 C81035 C81042 C81019 C81071 C81087 C81629 C81630 C81653 C81054 C81073 C81626 C81006 C81066 C81007 C81047 C81014 C81652 C81639 C81648 Source: Flu Vaccine Survey (GP) - January 2009 (1 Sep 08 to 31 Jan 09)
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Figure 173 % Under 65 at risk vaccinated 2008-09 90
80
70
60
% National 50
40
30
20
10
0
C81118 C81113
C81108 C81100
C81040 C81007 C81087 C81006 C81047 C81630 C81009 C81626 C81616 C81653 C81064 C81068 C81054 C81652 C81036 C81035 C81073 C81665 C81066 C81014 C81072 C81648 C81639 C81051 C81071 C81019 C81042 C81629
Source: Flu Vaccine Survey (GP) - January 2009 (1 Sep 08 to 31 Jan 09)
Childhood Immunisation
In line with current World Health Organisation (WHO) immunisation recommendations, at least 95% of children should receive three primary doses of diphtheria, tetanus, polio and pertussis in the first year of like, and at least 95% should receive a first dose of a measles, mumps and rubella containing vaccine by 2 years of age. In line with the WHO target, at least 90% should receive a booster dose of tetanus, diphtheria and polio between 13 to 18 years of age. England is not currently meeting these public health targets, which are in place to end the transmission of these vaccine-preventable life- threatening infectious diseases. As such, Vital Signs performance measure VSB10 was established: Proportion of children who complete immunisation by recommended ages.
Figure 174 demonstrates the percentage of children immunised by their 5th birthday during 2008/09 in NHS Derby City, with comparisons to the other PCTs in the East Midlands region, as well as England. In Derby, uptake of the primary Diphtheria, Tetanus and Polio vaccine was 95%, compared to England where it was 93%. Derby performed equally over all of the immunisations to be given by children’s 5th birthdays, compared to England.
95
Figure 174
Percentage of children immunised by their 5th birthday, by Primary Care Trust in the East Midlands 2008-09 120
100
80
60
40
Percentageimmunised theirby 5th birthday 20
0
Primary Diptheria, Tetanus & Polio Primary Hib Booster Diptheria, Tetanus & Polio MMR First dose MMR First & Second dose
Source: The Information Centre
Screening for Breast Cancer
The breast screening service in Derby City moved to its final solution home on the new Derby Royal Hospital site at the close of 2007, and during 2008 staff have strived to continue to improve it. Examples of these developments include; the commencement of family history screening in very high risk patients with annual MR, routine availability of day case wide local excision in suitable patients, progress onto an initial trial of 23 hour mastectomy discharge (for appropriate patients who chose this option). The reconstruction service is being developed following the appointment of a new breast surgeon with oncoplastic expertise. In Pathology, from 1st July 2008, the Derby and Burton departments merged.
The Derby Breast Unit was selected for 3 national pieces of work during 2007 – 2009, two of which are to trial new pieces of mammography equipment on behalf of the NHS Breast Screening Programme. The unit was also selected as one of five national pilot sites for the integration of NBSS/PACs (the development of the necessary interfaces for digital national breast screening to occur). The digital conversion of the screening service has been ongoing, but it will be one of the first fully integrated digital breast screening services in England.
During 2007/08, a total of 20,029 women were screened by the unit (a very similar number to the preceding year at 20,815. The uptake in the prevalent group (those called for screening for the first time) was 80.2% while in the incident group (those who were initially screened three years earlier) it was 90.1%. Of note, the invasive cancer detection rate at Derby’s unit was high at 7.4 per 1000 women in both prevalent and incident groups, compared to the national target levels of 3.6 and 4.0 respectively. The local small cancer detection rate was 2.8 and 4.4 per 1000 respectively compared to
96 targets of 2.0 and 2.2 per 1000 set nationally. The benign autopsy rate was 0 in the prevalent group and 0.1 per 1000 in the incident group, and the unit’s overall three year standardised detection ratio for all cancers is 1.54. These figures demonstrate excellent performance by Derby’s Breast Unit and screening programme.
Within the symptomatic service, the number of new GP referrals over the last five years appears to have remained static, although in the year 2007/08 3294 new GP referrals were seen compared to the previous year when 3107 were seen. The number of follow-ups was slightly lower with a total annual number of appointments of 5838 compared to 6145. Overall, 238 symptomatic cancers were diagnosed in 2007/08 compared to 233 in the previous year. There were 178 screen detected cancers and three family history screen detected cancers compared to a previous year’s total of 167. The total number of cancers diagnosed in 2007/08 was 420 compared to the previous total of 400. The two week wait target was met for all 1489 cases, and the 31 day wait and 62 day wait targets were met to 97% and 99.4%. During 2009, the unit is due its next Quality Assurance visit as well as a Trust Peer review.
8.2.4 Sexual health
The ‘Every Child Matters’37 Survey highlighted low levels of understanding about HIV, although better than average understanding about emergency contraception was evident. 80% of year 10 pupils surveyed believed that condoms were effective at preventing pregnancy, with 77% believing this for the contraceptive pill. 10% believed that the pill prevented the contracting of infections, with 69% believing this for condoms.
A southern Derbyshire County (including Derby City) service users survey found that young people tended to use their mum, friend or GP for advice on sexual health. Opening times and distance to services (over 1 mile) were barriers to access and they appreciated evening and weekend (Saturday afternoon) opening with a mix of walk-in and appointment sessions. Concerns were expressed regarding confidentiality and being seen using services. Figure 179 highlights the location of sexual health services in Derby City. Over the past few years there have been only a small number of complaints regarding contraceptive and sexual health services. These appear to have been mainly regarding individual experiences with no specific patterns.
With regard to specific sexual health services that are offered in Derby, the Genito-Urinary Medicine (GUM) Clinic is situated close to the city centre. 48 Hour Genitourinary Medicine Access Monthly Monitoring (GUMAMM) has been undertaken by the Department of Health – it was previously monitored by the Health Protection Agency. The offering of an appointment within 48 hours for GUM clinics was a target for March 2008 and is a current standard within the Operating Framework. Current achievement against this target is highlighted in Figure 175.
37 Every Child Matters is a shared programme of change to improve outcomes for all children and young people. It takes forward the Government’s vision of radical reform for children, young people and families
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Figure 175 GUM Access Monthly Monitoring as of July 2009/10 Genito-Urinary Genito-Urinary first Genito- Genito- Genito-Urinary Genito-Urinary first Genito-Urinary first appointments Urinary all Urinary first first attendances first attendances appointments appointments offered within 2 Org Code Organisation attendances attendances seen within 2 days seen after 10 days missed missed within 2 days days 5EM NOTTINGHAM CITY PCT 1284 1068 862 14 108 61 1068 5ET BASSETLAW PCT 440 289 272 3 31 27 289 5N6 DERBYSHIRE COUNTY PCT 1510 999 862 11 46 37 999 5N7 DERBY CITY PCT 954 668 643 13 1 1 668 5N8 NOTTINGHAMSHIRE COUNTY TEACHING PCT 1833 1281 981 19 173 91 1281 5N9 LINCOLNSHIRE TEACHING PCT 1783 1248 1021 19 125 107 1248 5PA LEICESTERSHIRE COUNTY AND RUTLAND PCT 1342 980 922 3 15 13 979 5PC LEICESTER CITY PCT 867 624 594 3 23 18 624 5PD NORTHAMPTONSHIRE TEACHING PCT 1770 1244 1032 11 71 68 1244 Source: The Department of Health
Primary care is only one channel for the provision of contraception, but data from community contraception clinics is not yet available broken down by PCT. The Medicines Management Pharmaceutical Team at NHS Derby City however, does collect contraceptive prescription data, which is held in the Prescribing Analysis and Cost Tool (PACT). Figure 174 details this data by the four subcategories of long-acting reversible methods of contraception (LARCs) given to women aged approximately 15-49 in Derby City over the years 2006/07, 2007/08 and 2008/09. Rates per 1000 women in this age group have been applied to the total items prescribed each year in each of the four subcategories.
As is clearly evident from the table, implants and IUS (Intra-Uterine Progestogen only System) LARCs have increased over the past 3 years, though this increase is more apparent in implants which are being recommended more in recent NICE guidance on LARCs. Prescriptions for IUCDs (Intra-Uterine Contraceptive Device) have not changed significantly, and injectable LARCs have been decreasing, though are by far the most prescribed method of LARC.
Figure 176 Quantity of prescriptions in NHS Derby City for long-acting reversible methods of contraception 2006/07 2007/08 2008/09 Total Total Items 7097 6540 6218 19855 Injectables Total Cost (£) 32745.96 35152.9 34584.78 102483.64 Rate/1000 women aged 15-49 103.08 93.76 87.95 94.86 Total Items 308 331 320 959 IUCD Total Cost (£) 3254.14 3571.48 3504.78 10330.4 Rate/1000 women aged 15-49 4.47 4.75 4.53 4.58 Total Items 224 454 725 1403 Implant Total Cost (£) 16855.39 33723.15 53821.47 104400.01 Rate/1000 women aged 15-49 3.25 6.51 10.25 6.70 Total Items 459 598 706 1763 IUS Total Cost (£) 35100.61 46168.44 54671.34 135940.39 Rate/1000 women aged 15-49 6.67 8.57 9.99 8.42 Source: NHS Derby City’s Medicines Management Team
In 2006, for women resident in England and Wales, the total number of abortions was 193,700, compared with 186,000 in 2005. This amounts to a rise of 3.9%. The age-standardised abortion rate was 18.3 per 1,000 resident women aged between 15 and 44 years old, compared with 17.8 in 2005. The abortion rate was highest at 35 per 1,000 women aged 19, while in under 16 year olds the abortion rate was 3.9 and in under 18 year olds it was 18.2, in 2006. 87% of abortions were funded by
98 the NHS and of these, just over half (55%) took place in the independent sector under NHS contract. 68% of these abortions were at under 10 weeks.
In Derby during 2006, the highest proportion of NHS funded abortions under 10 weeks took place in the East Midlands region, at 65%. This is compared to the East Midlands average of 58%. The total number of abortions though, was relatively small in comparison to some of the other PCTs in the region, at 504. In 2007, 37% of under-18 conceptions lead to abortion in Derby City (Figure 178).
Figure 177 Abortions during 2006, by PCT in the East Midlands 1,200 70
60 1,000
50 800
40
600
30 Number Abortionsof
400 Percentage of Abortions 20
200 10
- 0
NHS funded abortions at under 10 weeks Percentage of all NHS funded abortions at under 10 weeks
Source: EMPHO
Figure 178 Trends in Under-18 Conceptions in Derby, by Outcome 100%
90%
80%
70% 144 135 131 148 165 181 162 144 60%
50% 241 248
40% Proportion of Conceptions
30%
20% 77 77 87 97 71 76 70 78 For confidentiality reasons, ONS supressed the 2004 and 2005 10% abortion proportions for Derby
0% 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
Year
Proportion leading to abortion Proportion leading to birth
Source: Teenage Pregnancy Unit
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Figure 179
Source: EMPHO
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8.2.5 Mental health
Derby City commissions an integrated mental health service delivered via Derbyshire Mental Health Services NHS Trust and the City Council. This covers both community and inpatient services. Investment over recent years has seen the implementation of services as prescribed by the Mental Health National Service Framework. These include; Assertive Outreach Team, Crisis Resolution and Home Treatment and Early Intervention in Psychosis Team. These services compliment the Community Mental Health Teams. More recent investments have included the new Improving Access to Psychological Therapies Service provided by Derby PTS and the Day Services which is delivered by Derby Community Services.
Improving Access to Psychological Therapies (IAPT) is the government policy to ensure better access to taking therapies for those experiencing mild to moderate psychological distress. This policy is also aimed at implementing the National Institute of Clinical Excellence (NICE) guidance on Anxiety and Depression and wherever possible working with people to assist maintain their employment or assist them back into training, education or employment.
8.2.6 Long-term conditions
Available to our patients on the NHS Derby City website (as well as from our GP Practices), is an NHS Derby City Long Term Conditions Patient Prospectus38. We realise that living with a long-term condition can sometimes make daily life difficult, so it is important that information and local services are available to help patients, their relatives and/or carers deal with specific problems and assist with self care.
The prospectus is a directory of local health, social and voluntary services available to people with long term conditions. It has been designed to ensure that our patients are receiving the right kind of care and support for their condition, and to help them make choices to improve their care and lifestyle. The first section of the guide gives information about general services such as GP Practices, as well as healthier lifestyles and the services available locally. Further sections then cover each condition separately. As people’s needs vary so will the services that are required or available. The long-term conditions included in the document are:
Cardiovascular disease Respiratory disease Neurological conditions Diabetes Musculo-skeletal conditions Chronic Kidney Disease
To sit alongside this guide, the Service Improvement and Market Management Directorate of NHS Derby City have developed ‘Patient Prescriptions’. We have listened to our patients and carers who have said that they want to know how to find information they can trust and rely on. As such, these Information Prescriptions have been developed as a quick and easy way to provide information about specific long-term conditions and local services.
The information comes in a variety of forms and includes descriptions and details on how further information can be found through websites, leaflets and telephone number help/request lines, with
38 http://www.derbycitypct.nhs.uk/
101 specific details on how to get them. Patients, their family members, friends, or carer can look at the prescription either on-line or as a printed version.
Figure 180 highlights how by using Experian’s Mosaic Public Sector, we are able to better understand the whereabouts of our population suffering from a long term condition. This map of Normanton Ward highlights how we can target communities by as low as household level, to make them more aware of the services that are potentially available to them, that they may not realise are available.
Figure 180
Source: Experian
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8.3 Voice
8.3.1 User perspective on health care
Derby’s Community Dialogue Project39
NHS Derby City recognised that to be successful in the current agenda, they must engage with communities in a more systematic way and co-create rather than impose solutions (based on Papay: 2006). Derby’s Community Dialogue Project was to pilot co-production by working with two local communities. The initiative was part of the ongoing work in the Sinfin neighbourhood of Derby, which had already been identified as one of the priority areas of the city. The first part of the work resulted in a Fun Day in October 2008. Previous work identifying local health needs and further consultation at the Fun Day (Make a Difference activity) highlighted the two main issues for the community to be Young People and Families.
During the first three months of 2009, the process to design a new service to improve the health of local families was facilitated. 160 interviews with local people were carried out across four key venues, to attract people from old and new Sinfin. Care was taken to ensure a good mix of types of people from the young and old, single and married parents, and ethnic minorities. The key findings showed that lack of exercise, healthy eating, weight issues and drugs in the community were key factors in determining health in the Sinfin population. Participants raised the issue of mental health and self esteem as being a health issue, and a number of people talked about the lack of activities for young people being a significant concern. Participants suggested that in order to liver healthier lives, they would need support and encouragement.
Eight participants from the 160 interviewed were selected to go onto the next stage; workshops. The eight were chosen to ensure representation from the key groups across Sinfin. Five workshops were held where, together, NHS Derby City and those selected from the community considered responses
39 http://www.coproduction.org.uk/
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to the health issues raised, and explored options for a new service to improve health. The service specification proposal – to be demonstrated by way of an ‘umbrella’ programme of community health improvement activities within the Sinfin neighbourhood, and delivered through a team of workers and community partners – included:
1. Direct Delivery – development workers will deliver activity sessions
2. Training – development workers will provide training for local people to facilitate activities
3. Time Banking – a delivery mechanism; to allow people to exchange skills and pay for activities using time credit
4. Incentives – the programme will provide a range of incentives to help motivation
Figure 181
“Oomph!” Community Health Improvement Programme
Links to: Links to Coordination Role – Provide as part of Contract Management DCC Leisure GP Practices Possibility of Community Development & Health Worker role Sinfin Schools 0.5 day per fortnight – to oversee and coordinate – ensuring Counter-Weight Extended Schools Programme is meeting its commissioned objectives CVD Risk Ass C. Safety Partnership Fresh Start Derby CVS Health Trainer(s) Vol & Comm Groups
Health Improvement Health Improvement Health Improvement Development Worker Development Worker Development Worker (Exercise) (0.6 F/T) (Food) (0.4 F/T) (Time Broker)(0.8 F/T)
Community Partners Local People given training to provide delivery with groups
Exercise Activities Food Activities Time Bank – using credits to exchange for Individuals and Families: for Individuals & Families: skills with others (individuals/families) Dance, Exercise, Yoga, Outdoor Activities Cooking Groups/Demos, Recipes, F&V or ‘pay’ to attend groups/activities and Family Orientated or Childcare Available Family Orientated or Childcare Available earn credits by cascading info to others
Incentives to Motivate
Figure 181 explains the service (programme) model – named the “Oomph!” model – that was designed by the dialogue project group, in more detail. The next stage of this process will be to develop a service specification, and secure funding. The programme will then follow the NHS Derby City Commissioning cycle to secure one or more providers for delivery.
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95%
90%
85%
80%
75%
70%
65%
60% Ease of Seeing a GP Booking Seeing a Satisfaction England Overall getting fairly quickly ahead specific GP with opening NHSEM satisfaction through on (48hrs) (advance times NHSDC the phone booking)
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95%
90%
85%
80%
75%
70%
65% 06/07 07/08 08/09 Opening Hours - Plan 48 hour access to GP - Plan Advance booking - Plan Opening Hours - Actual 48 hour access to GP - Actual Advance booking - Actual
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Opening Hours Distribution Of Practice Results Against National Mean
Specific GP
Advanced
48 Hour
Telephone
0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1
107
100% Overall Satisfaction 90%
80%
70%
60%
50%
Y02216
C81019 C81064 C81007 C81639 C81072 C81009 C81108 C81630 C81100 C81665 C81648 C81626 C81040 C81073 C81653 C81042 C81068 C81014 C81051 C81071 C81006 C81047 C81112 C81087 C81036 C81113 C81652 C81066 C81035 C81118 C81107 C81616 C81054 C81629 Practice Result England Average SHA Average NHSDC Average
100%
90%
80%
70% VIDYA MEDICAL (UHUK) NORMANTON MEDICAL 60% (UHUK) Practice Actual National Mean 1 std lower 1 std upper 2 std lower 3 std lower
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109