Gloucestershire County Health Profile The Annual Report of the Director of Public Health June 2010 gloucestershire healthy living
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1 Introduction
The 2010 Area health Profile provides information on the main health issues for the county. It includes data at district level, and makes comparisons with the English national average where possible.
Many factors impact on health and wellbeing in a population. In addition to health care services, socio-economic factors such as education, housing, employment and income have a significant influence. The 2010 Area Health Profile contains information on socio-economic determinants not covered in the 2009 Area Health Profile - employment, income and living environment. It also contains information about some of the typical health and lifestyle behaviours of children and young people, taken from the Gloucestershire Pupil Online Survey. This gives an important insight into the challenges we need to address in our young people today to ensure they become healthy adults. An update on some of the current partnership and project work is also included, and finally some recommendations for future work are made.
This document is divided into the following sections: • Demographics – now and in the future • How Healthy is Gloucestershire – key issues • The burden of disease • What we are doing now • What else we need to do
2 Demographics – now and in the future Gloucestershire is a diverse county with a population of approximately 601,405 residents. It is mainly rural, with two major urban centres of Gloucester and Cheltenham at its heart. Nearly 40% of the county’s population live in Gloucester and Cheltenham. The age structure of the population varies within the county, with the more urban of the six districts tending to have a ‘younger’ profile than the others. Gloucestershire already has a greater proportion of people aged 65 and over than England and Wales. Based on 2005 mid-year estimates, this age group makes up 18.2% of the total population compared with 16.1% nationally.
By 2025, the number of older people in Gloucestershire aged over 65 is expected to rise by 44%, compared to an increase of 8.8% for all ages. The number of 0 to 19 year olds is expected to fall by 2.8% based on current projections.
The latest estimates suggest that the county’s resident population will increase by about 9% in 2025 to around 654,340 (Figure 1). The latest projections have been updated on the basis of a trend based model with the anticipated effects of the Regional Spatial Strategy removed. This has implications at a local level which are considered within each district profile.
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Figure 1
Gloucestershire Population 2009 vs. 2025
90+ 85-89 80-84 75-79 70-74 65-69 60-64 55-59 50-54 45-49 40-44 35-39
Age Band Age 30-34 25-29 20-24 15-19 10-14 5-9 0-4
30000 20000 10000 0 10000 20000 30000 Population
Female 2009 Male 2009 Female 2025 Male 2025
Source: eJSNA
Figure 2 illustrates the projected shift in numbers and proportions of children, adults and older people over the next 16 years.
Figure 2
Resident Population by age group in Gloucestershire 2009 and 2025
2025 136,262 362,570 155,507 Year 2009 140,251 353,337 107,819
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Percentage of total population
Gloucestershire 0‐19 Gloucestershire 20‐64 Gloucestershire 65+
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Ethnicity
Gloucestershire has a small black and ethnic minority population (4.9%) compared to England (11.8%) although there is considerable inter-district variation with Gloucester city having the highest black and ethnic population (8.6%).
The black and minority ethnic groups represented in Gloucester are shown in Figure 3.
Figure 3
Ethnic minority population 2007
6.00%
5.00%
4.00%
3.00%
2.00%
1.00%
Percentage of total population 0.00% Asian or Asian Black or Black Chinese or Other Mixed British British Ethnic Group Gloucestershire 1.30% 1.70% 1.00% 0.90% England 1.70% 5.70% 2.80% 1.50%
Source: eJSNA
The proportion of school age children (aged 5-16 years) from BME backgrounds is higher than for the population as a whole (12.5%). The percentage of children in the county whose first language is not English is low at (3.1%) compared to England (13.2%).
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2. How healthy is Gloucestershire – key issues
Data taken from a survey of the local population in April 2009 indicates that 79.5% of respondents in the county reported overall good health and well being. This data is supported by the information from the Joint Strategic Needs Assessment (JSNA) which shows that the health of people in Gloucestershire is generally good with life expectancy being better than the England average. The three main causes of death and serious illness, like the rest of the country are:
• Circulatory diseases ( heart disease and strokes) • Cancers • Respiratory diseases such as asthma and chronic obstructive pulmonary disease (COPD)
Further data taken from the JSNA shows that in most areas Gloucestershire is doing better compared to England as a whole with just a couple of health indicators where Gloucestershire rates are worse than nationally. The areas where the county is either doing better or worse are shown respectively in the green and red boxes below.
Better than the England Average • At county level Gloucestershire has a similar or better than average for all health and wellbeing indicators except for those listed below However there is considerable intra county variation which will be examined both here and within the individual area health profiles.
Worse than England • Breast Cancer • Malignant Melanoma
In addition to the above depression and dementia rates may be higher than nationally, but the figures currently available are estimates.
The amber box below contains a number of lifestyle factors that influence the health and well-being of people but for which the data are not robust, making comparisons against national data less valid, or where there is no nationally agreed population target. Whilst it is encouraging that the county is performing well in certain areas, it is important that continued efforts are made to improve performance in all the key lifestyle behaviours that impact on ill-health if further health gains are to be made and inequalities reduced.
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• Physical activity in adults • Physical activity in children • Healthy eating in adults • Healthy eating in children • Obesity in adults • Obesity in children • Smoking and tobacco control • Alcohol misuse
3. Burden of disease
3.1 Introduction
The three main causes of illness and death are circulatory diseases, cancers and respiratory diseases. These and other important conditions are examined in this section.
Data for this section comes from a variety of sources as outlined below:
• Disease Registers in General Practice As part of the Quality and Outcome Framework (QOF) General Practitioners (GPs) keep registers of patients with long term conditions. The number of patients on the register gives us some indication of the prevalence1 of the disease (i.e. the number of people living with the condition). These registers may under-estimate the true burden of disease as the rates are lower than expected prevalence rates calculated from national studies and extrapolated to Gloucestershire. Nevertheless they do provide a proxy of the prevalence of long term conditions such as CHD, stroke, chronic obstructive pulmonary disease (COPD), diabetes and cancer in the community.
The rates calculated from these registers are crude rates which mean that they do not take into account the age and gender profile of the district. Inter-district variation could be the result of different age/gender population distributions in each district.
• Cancer Registry
The National Cancer Registry keeps a register of all new cancers. Each new diagnosis of cancer is notified to them and entered onto a national database. This therefore provides a robust indication of the incidence2 (new cases) of cancer. These data are made available directly from the Cancer Registry and also via other databases such as the Compendium of Clinical and Health Indicators (the source used here).
1 Prevalence is the total number of cases of a disease. 2 Incidence is the number of new cases of a disease.
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• Estimates of incidence and prevalence
In some areas disease registers are less well-developed. This is particularly so for mental health problems where there is little local incidence or prevalence information. In such cases the best available data are provided by estimates which are based on age and gender specific rates from studies extrapolated to the local population.
Mortality (Death) data
Information on deaths is collected from death certificates. This is analysed and made available via the Compendium of Clinical Indicators.
Standardisation of data
Some data presented throughout this document are Directly Standardised Rates (DSR). This means that the data are gender and age-standardized by using a standard European population profile. Standardised rates are used because death and disease rates are influenced by the age and gender distribution of a population. For example, two populations with the same age-specific mortality rates for coronary heart disease will have different overall rates if the age distributions of their populations are different. Where data are not standardised (such as QOF data), variation between districts may be due to differences in the population’s age- distribution.
3.2 Cardiovascular disease
Cardiovascular disease refers to conditions involving the heart or blood vessels and comprises of coronary heart disease and stroke. CHD disease occurs when the blood supply to the heart is reduced to such an extent that it cannot function normally, resulting in either a heart attack or angina. A stroke or TIA (often referred to as a mini-stroke) occurs when the blood supply to the brain is reduced either as a result of a blocked artery or a bleed which occurs as a result of a burst blood vessel.
Overall premature mortality (deaths in people under 75 years old), from CHD and stroke, is declining steadily as shown in Figure 4 below.
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Figure 4
Mortality from CHD for people under 75 years old, Trend 1993-2008 120 100 80 60 40 20
Standard population Standard 0
Rate per 100,000Rate European 2 4 0 0 0 0 1993 1994 1995 1996 1997 1998 1999 2000 2001 2 2003 2 2005 2006 2007 2008
England Gloucestershire
Figure 5
Mortality from stroke for people under 75 years old, Trend 1993 - 2008 30
25
20
15
10 Standard population Standard
Rate per 100,000 European 5
93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 08 19 19 19 19 19 19 19 20 20 20 20 20 20 20 20 20 England Gloucestershire
Source:NCHOD
However there is considerable variation between the districts. The district with the highest rate of premature death from CHD (Gloucester) being 50% higher than the lowest rate in Tewkesbury (Figure 6). For stroke, the district with the highest rate of premature deaths is the Forest of Dean
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Figure 6
Premature Deaths (<75) from CHD 2006-2008 pooled 50 40 30 20 10 DSR per 100,000 0 Forest of Tew kesbur Cheltenham Cotsw old Gloucester Stroud Dean y
District 30.6 29.4 40.1 43.9 37.5 28.0 Gloucestershire PCT 35.1 35.1 35.1 35.1 35.1 35.1 England 42.3 42.3 42.3 42.3 42.3 42.3
Source: NCHOD
Figure 7
Premature deaths (<75) from stroke 2006-2008 pooled 20
15
10
5
0 DSR per 100,000 Forest of Cheltenham Cotsw old Gloucester Stroud Tew kesbury Dean
District 13.1 11.3 15.5 13.8 12.6 10.6 Gloucestershire PCT 12.9 12.9 12.9 12.9 12.9 12.9 England 13.7 13.7 13.7 13.7 13.7 13.7
Source: NCHOD
There is a strong association between levels of deprivation and premature deaths from heart disease as shown in Figure 8
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Figure 8
Circulatory Disease Mortality (<75) by Deprivation 2006-2008
180 160 140 120 100 80 60 DSR per 100,000 40 20 0 Q1 (most Q5 Q4 Q3 Q2 deprived) Quintiles of Deprivation 63.4 68.1 88.5 129.5 163.2 County 83 83 83 83 83
Given the high mortality rates in Gloucester City and the association seen with deprivation, the prevalence of CHD, as measured by the GP CHD registers, should also be high. However as Figure 9 below shows this is not the case and Gloucester City would appear to have the second lowest prevalence rate of CHD in the county.
Figure 9
Prevalence of CHD as recorded on GP registers as at March 2009 40
35
30
25 registered 20 patient population Rate per thousand thousand per Rate Forest of Cheltenham Cotswold Gloucester Stroud Tewkesbury Dean District 29.3 32.1 31.6 30.2 31.8 33.4 NHS Gloucestershire 31.2 31.2 31.2 31.2 31.2 31.2 England (QOF) 35.0 35.0 35.0 35.0 35.0 35.0
Source: eJSNA
This could be for a range of reasons: • People in Gloucester City are not presenting to their GP with their symptoms • People in Gloucester City are presenting to their GP with symptoms of Coronary Heart Disease, but are not being recorded on the register
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• People in Gloucester City are presenting to their GP with their symptoms, being recorded on the register, but are more likely to die from their disease than in other parts of the county.
KEY POINTS about cardio- • Premature mortality rates from heart disease and vascular disease stroke are decreasing year on year. • However there is almost a three fold difference in CHD mortality between the least and the most deprived communities. • There is a lower rate of registration on GP registers in Gloucester which has the highest rate of premature deaths from CHD compared with other districts
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3.3 Chronic Obstructive Pulmonary Disease (COPD)
Chronic Obstructive Pulmonary Disease (COPD) is an 'umbrella' term for people with chronic bronchitis, emphysema, or both. With COPD the airflow to the lungs is restricted (obstructed). COPD is usually caused by smoking. Symptoms include cough and breathlessness.
It can be seen in the graph below that mortality from respiratory conditions is falling in keeping with the national trend.
Figure 10
Mortality from Respiratory conditions for all ages, Trend 1993 - 2008 40 35 30
25 20 Standard population Standard 15 Rate perEuropean 100,000
6 7 8 9 0 6 7 8 9 9 9 9 0 0 0 0 9 9 9 9 0 0 0 0 1993 1994 1995 1 1 1 1 2 2001 2002 2003 2004 2005 2 2 2
ENGLA ND Gloucestershire CC
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However this masks some variation at district level. The rate in Gloucester city exceeds both the county and the national rates. Cheltenham and the Forest of Dean have rates slightly higher than the county average. (Figure 11)
Figure 11
Premature deaths (<75) from respiratory diseases 2006-2008 pooled
15
10
5
DSR per 100,000 per DSR 0 Cheltenh Forest of Gloucest Tewkesb Cotswold Stroud am Dean er ury District 11.0 6.1 10.5 13.2 9.6 7.7 Gloucestershire PCT 9.7 9.7 9.7 9.7 9.7 9.7 England 12.1 12.1 12.1 12.1 12.1 12.1
Key points about COPD • mortality is decreasing in the county as a whole • the districts with the highest mortality rates are Gloucester, Cheltenham and the Forest of Dean.
3.4 Diabetes
Diabetes mellitus, often simply referred to as diabetes—is a condition in which a person has high blood sugar either because the body does not produce enough insulin, or because cells do not respond to the insulin that is produced. There are two main types of diabetes:
• Type 1 diabetes results from the body's failure to produce insulin, and presently requires the person to inject insulin. • Type 2 diabetes results from insulin resistance, and is commonly associated with obesity and therefore is to a degree preventable.
Nationally and locally the prevalence of diabetes is on the increase. The increase in the last four years has been faster in Gloucestershire than in England as a whole. In March 2009 there were 25% more people diagnosed with diabetes in the county than there were four years previously. This may partly be due to the fact that detection and recording of diabetes has improved more rapidly in Gloucestershire than
12 DRAFT consequently and also may represent true population need. For example we know that in Gloucester City there is a significant Asian population who are at high risk of developing diabetes.
Figure 12
Prevalence of diabetes (Type 1 and Type 2) in people aged 17 years and over as recorded on GP registers Trend 2005/6 - 2008/9 60
55
50
45
40 Reported prevalence prevalence Reported 35 per 1,000 registered population registered 1,000 per 30 2005/2006 2006/2007 2007/2008 2008/2009 NHS Gloucestershire 41.4 44.8 48.0 51.0 England 44.4 45.6 48.2 50.8
Diabetes register requirement : Type (1 or 2) must be specified
Source: NHS Comparators: Quality and Outcomes Framework data
There is some variation at district level with the highest prevalence in Gloucester City being just under one and a half times the rate of the district with the lowest prevalence (Cotswold).
Figure 13
Prevalence of Diabetes (Type 1 or Type 2) in people aged 17 years & over as recorded on the GP register at March 2009 70 60 50 40 30 20
population population 10 aged over 17 & 0 Rate per thousand thousand per Rate registered resident resident registered Forest of Cheltenham Cotsw old Gloucester Stroud Tew kesbury Dean
District 43.51 43.02 57.19 59.89 47.78 54.59 NHS Gloucestershire 50.81 50.81 50.81 50.81 50.81 50.81
Source: eJSNA
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Further analysis of JSNA data shows an association between diabetes and deprivation with people in the most deprived 20% of the population experiencing just under one and a half times the rate of diabetes as those in the least deprived fifth.
Key points about Diabetes • The prevalence of diabetes is increasing • There is a strong association with deprivation with those in the most deprived quintile higher rates of diabetes • There are considerable differences between the rates of diabetes in the highest (Gloucester) and lowest district (Cotswold)
3.5 Cancer
The Cancer Registry holds data for registrations by cancer site. Data for all cancers give an overview of the burden of disease. Malignant melanoma (a form of skin cancer) and breast cancer, are examined here because they are the only common cancer sites in which the rates are significantly higher in Gloucestershire than nationally and also because they are amenable to lifestyle interventions.
Figure 14 shows that the incidence of cancer throughout the county is generally lower compared with the national rate. However the incidence in Gloucester is notably higher when compared with the rate in Cotswold which has the lowest rate.
Figure 14
Incidence of All Cancers 2004-06 (Pooled)
400
380
360
340
320 Forest of Standard Population Standard Cheltenham Cotsw old Gloucester Stroud Tew kesbury Dean Rate per 100,000 European European 100,000 per Rate District 376.5 346.6 365.4 395.1 370.5 368.7 NHS Gloucestershire 370.9 370.9 370.9 370.9 370.9 370.9 England 372.4 372.4 372.4 372.4 372.4 372.4
Source: Compendium of Clinical and Health Indicators (NCHOD 2009)
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Premature mortality is also noted to be higher in Gloucester and the Forest of Dean.
Figure 15
Premature deaths (<75) from stroke 2006-2008 pooled 20
15
10
5
0 DSR per 100,000 Forest of Cheltenham Cotsw old Gloucester Stroud Tew kesbury Dean
District 13.1 11.3 15.5 13.8 12.6 10.6 NHS Gloucestershire 12.9 12.9 12.9 12.9 12.9 12.9 England 13.7 13.7 13.7 13.7 13.7 13.7
Source: Compendium of Clinical and Health Indicators (NCHOD)
Malignant Melanoma
Malignant melanoma is the most serious cancer of all skin cancers and the 6th most common cancer in the South West. In England, the incidence rate has increased faster than any other common cancer over the past 25 years. The incidence rate in Gloucestershire is significantly higher than national rates while death rates are similar to national rates. It is of concern that the county rate has been increasing faster than the national rate, as can be seen in Figure 28
Figure 16
Incidence of Melanoma All Ages Trend 1993-2006
20
15
10
5
standard population standard 0
rate perrate 100,000 European 3 4 5 6 7 8 9 0 1 2 3 4 5 9 9 9 0 0 00 199 199 19 19 19 199 199 200 200 20 20 2 200 2006
England Gloucestershire
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Within the county there is considerable variation in the incidence between districts with the highest rate (Gloucester and Stroud) being 25% higher than the district with the lowest rate (Cotswold).
Figure 17
Incidence of Malignant Melanoma 2004-06 (Pooled) 25 20 15 10 5 0 Forest of Standard Population Standard Cheltenham Cotsw old Gloucester Stroud Tew kesbury Dean Rate perRate 100,000 European District 16.7 14.3 17.2 20.2 19.6 12.6 NHS Gloucestershire 17.0 17.0 17.0 17.0 17.0 17.0 England 13.9 13.9 13.9 13.9 13.9 13.9
Source: Compendium of Clinical and Health Indicators (NCHOD)
Malignant melanoma, although potentially fatal if left untreated, has a low mortality rate so figures have been provided only for the incidence of this disease. The main risk factor for developing melanoma is exposure to sun – a behaviour which should be amenable to change.
Breast Cancer
Breast cancer is the most common female cancer with 1 in 9 women are expected to develop it at some time in their life. The incidence (new cases) rate for Gloucestershire is significantly higher than the national rate, while death rates are similar to national values.
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Figure 18
Incidence of Breast cancer for women of all ages, Trend 1993 - 2006 160
140
120
100
80
Standard population Standard 60
Rate per 100,000Rate European 1 0 0 1993 1994 1995 1996 1997 1998 1999 2000 2 2002 2003 2004 2005 2006
ENGLA ND Gloucestershire CC
There is also considerable variation between the districts as noted below. Stroud District has a 20% higher incidence compared with Gloucester which has the lowest rates. This is probably explained by the fact that breast cancer appears to be more common in more affluent, higher socio economic groups compared with less affluent groups.
Figure 19
Incidence of Breast Cancer 2004-06 (Pooled)
150
140
130
120
110 Forest of Standard Population Standard Cheltenham Cotsw old Gloucester Stroud Tew kesbury Dean Rate per 100,000 European District 129.77 124.56 128.46 121.70 143.45 139.98 Gloucestershire 131.48 131.48 131.48 131.48 131.48 131.48 England 122.81 122.81 122.81 122.81 122.81 122.81
Source: Compendium of Clinical and Health Indicators (NCHOD)
It is of note that whilst Stroud and Tewkesbury have the highest incidence rates of breast cancer, they appear to have the lowest premature mortality rates. This might suggest that there is higher awareness and earlier health seeking behaviour compared, for example, with the Forest of Dean and Cotswold.
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Figure 20
Premature deaths (<75) from breast cancer 2006-2008 pooled 25
20
15 DSR per 100,000 Forest of Cheltenham Cotsw old Gloucester Stroud Tew kesbury Dean
District 20.3 22.4 22.5 18.5 16.6 16.1 Gloucestershire PCT 19.2 19.2 19.2 19.2 19.2 19.2 England 20.6 20.6 20.6 20.6 20.6 20.6
Despite the increase in breast cancer incidence, the mortality rates continue to decline and are in keeping with the national rate.
Figure 21
Mortality from Breast Cancer 50-69 years old, Trend 1993 - 2008 100 90
80 70 60 50 Standard population Standard 40 Rate per 100,000 European
4 5 6 8 9 0 2 3 4 6 7 8 9 9 9 9 0 0 0 0 993 9 9 9 9 001 0 0 0 0 1 1 1 199 1997 1 1 200 2 2 2 200 2005 2 2 200
England Gloucestershire
Key points about Cancer • The incidence of melanoma is higher than nationally and is increasing • The incidence of breast cancer is higher than nationally and is increasing • Mortality from breast cancer remains low and is decreasing.
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3.6 Mental health
Figure 22 provides data on the estimated prevalence of neurotic disorders for the adult population (under 75’s). The term neurotic disorder is used to group together mental illnesses characterised by symptoms such as anxiety and depression.
Figure 22
Estimated prevalence of neurotic disorders (<75)
250
200
150
100
population 50
0 Forest of
Rate per 1,000 resident resident 1,000 per Rate Cheltenham Cotsw old Gloucester Stroud Tew kesbury Dean
District 203.0 139.6 145.2 195.8 145.6 142.8 Gloucestershire PCT 165.21 165.21 165.21 165.21 165.21 165.21 England 164.00 164.00 164.00 164.00 164.00 164.00
Source: Mental Health Observatory (NEPHO)
3.7 Older people’s Health
Falls Falls are a major contributor to ill health in Gloucestershire. A fall can be a life changing, and in many cases life threatening, event for older people with far reaching consequences for the person involved, their family and carers, and the organisations responsible for delivering services.
Evidence suggests that loss of self-confidence as well as social withdrawal, confusion and loneliness can occur even when there has been no injury. Depression, fear of falling and other psychological problems are common effects of repeated falls. Recurrent falls also lead to increased likelihood of early admission to nursing care.
The annual cost to health and social care services in the county from fractures sustained in falls by people 65+ is approximately £35 million. This does not include the personal costs to the faller in terms of their overall health and well being, and the impact on their families and carers.
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Figure 23 shows that the Cotswolds have a particularly high rate of emergency hospital admissions following a fall.
Figure 23
Admissions to hospital following a fall (aged 75+) 70 60 50 40 30 20 10 0 Cheltenh Forest of Gloucest Tewkesb Cotswold Stroud am Dean er ury Rate per 1,000 resident population resident 1,000 per Rate District 38.5 57.8 35.2 31.4 40.6 34.0 Gloucestershire PCT 39.78 39.78 39.78 39.78 39.78 39.78
Source: eJSNA
Depression Depression in older people is often not recognised. However it can lead to increasing social exclusion and impact on physical as well as mental health. Predicted rates suggest that overall the county rate is similar to the national rate but there may variation between districts.
Dementia Similarly figures for dementia are currently not available, however this is being addressed at a local level as part of the implementation of the National Dementia Strategy,
Falls prevention interventions need to be targeted at those most at risk. These interventions include healthy ageing advice with an emphasis on maintaining or increasing physical activity levels and raising awareness of the risks associated with alcohol consumption and other lifestyle behaviours in older age.
Excess Winter Deaths
Excess winter deaths (EWD) are defined by the Office for National Statistics as the difference between the number of deaths during the four winter months (December to March) and the average number of deaths during the preceding autumn (August to November) and the following summer (April to July).
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Figure 24 shows the average excess death rate over a three year period.
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Figure 24
Excess winter deaths August 2005 - July 2008 30 000 20
10
0 Rate per 100, Rate Forest of Cheltenham Cotsw old Gloucester Stroud Tew kesbury Dean
District 8.1 24.0 17.5 12.3 18.2 22.2 Gloucestershire PCT 16.5 16.5 16.5 16.5 16.5 16.5 England 15.6 15.6 15.6 15.6 15.6 15.6
Source: eJSNA
Levels of excess winter mortality are higher in Britain than many other European countries, including those with lower winter temperatures such as in Scandinavia. Coronary heart disease, strokes and respiratory diseases are responsible for the majority of excess winter deaths. There is little change in the number of deaths from most causes between the summer and winter, with the notable exception of respiratory disease (+41% in winter) and circulatory disease (+32% in winter) The main cause of excess winter mortality is therefore not hypothermia, but respiratory and circulatory problems such as asthma, influenza, bronchitis, pneumonia, heart conditions and mental health problems. The increase in winter deaths is associated with damp and cold conditions at home which are made worse by inefficient heating and insulation. The most vulnerable groups affected are; the elderly, children, those with ischemic diseases (mainly heart disease and stroke), and people with chronic respiratory diseases or asthma. Excess winter mortality is largely preventable by keeping warm indoors with adequate heating, appropriate insulation and ventilation and by wearing warm clothing and being physically active.
People over 60 are most at risk during the winter period, with the highest levels of excess winter mortality in the over 85 age band. The high rates in Cotswold and Tewkesbury are partially explained by the age profile of their populations, and by some of the issues relating to housing stock.
4. Factors affecting the burden of disease
If we are to reduce the burden of disease and ill-health it is important that we understand the factors that influence this and how best they can be modified. In February 2010, Professor Sir Michael Marmot published a review on health inequalities, Fair Society, Healthy Lives. The review proposed an evidence based strategy to address the social determinants of health - the conditions in which people are born, grow, live, work and age and which can lead to health inequalities. Together with lifestyle factors such as smoking, physical activity, alcohol intake and diet these can significantly influence the risk of developing disease or disability and
22 DRAFT dying prematurely. These factors tend to be concentrated among the same people, and their effects on health are cumulative. These together with the lifestyle ‘choices’ people make have a powerful influence on health within the population. Those who are better off live longer and experience fewer illnesses than those in disadvantaged groups.
Therefore, attempts to reduce health inequalities should focus on addressing the wider social and economic determinants of health as well as lifestyle factors. In section 4.1 we will use information from the Index of Multiple Deprivation to assess where some of these inequalities exist. The Index of Multiple Deprivation (IMD) 2007 is a Lower Super Output Area (LSOA) level of multiple deprivation, and is made up of seven LSOA level domain indices. In this section, in addition to the health deprivation and disability domain, we examine three of the remaining domains: employment deprivation, income deprivation and living environment deprivation, as they have significant impact on health and well-being. It is possible to examine indices of deprivation at national and county levels. This year we are examining intra- county variation by using the total county’s LSOAs and dividing them into 5 equal groups or quintiles.
Section 4.2 will explore in greater detail the data on lifestyle ‘choices’ such as smoking status, physical activity, healthy eating and alcohol.
4.1 – Social and economic factors
Employment Unemployment can have a significant impact on health with unemployed people suffering from a variety of health related issues. The experience of unemployment has consistently been associated with an increase in overall mortality, and in particular with suicide. The most deprived communities experience higher rates of unemployment than the least deprived communities.
Unemployment can have both short and long term effects on health. However, long term unemployment has the most adverse effects through; financial problems which may result in lower living standards, reduced social integration and lower self- esteem; increased anxiety and depression and increased smoking, alcohol consumption and decreased physical activity.
The employment deprivation domain measures employment deprivation conceptualised as involuntary exclusion of the working age population from the labour market. The information used to calculate the employment deprivation score is:
• Recipients of Job Seekers Allowance (JSA) (both contribution based and income based), Incapacity Benefit and Severe Disablement Benefit for men aged 18-64 and women aged 18-59. • Participants in the New Deal for the 18-24s and the 25+ who are not in receipt of JSA.
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• Participants in the New Deal for lone parents (after initial interview).
Figure 25 shows the distribution of unemployment deprivation across the county as measured in the IMD 2007.
Figure 25
Source: MAIDeN
IMD 2007 data pre-dates the current economic recession.
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Figure 26 shows the current employment trend since July 2008 and a series of possible trend projections. The red and blue lines with data points are projections based on what happened during the last recession. The linear trend line is derived by extrapolating from current data. Latest figures for May 2010 suggest that the linear trend best represents the current trend for unemployment in the county.
Figure 26: Unemployment projections for Gloucestershire from July 2008 to February 2011
Source: Research Team, (Economics) Chief Executives Support Unit, Gloucestershire County Council, May 2010
Income Deprivation Income is the most important modifiable determinant of health and is strongly related to health and well-being. People on low incomes are more likely to refrain from purchasing goods and services which maintain or improve health and more likely to purchase goods and services that increase health risks. In addition, those on low incomes are more likely to suffer from mental ill health and social isolation and experience the highest rates of illness and premature death.
There is also evidence that particular social groups are at risk of low income. Some groups have significantly reduced employment opportunities they include; disabled adults, people with mental health problems, those with caring responsibilities, lone parents and young people.
The purpose of the income deprivation domain is to capture the proportion of the population experiencing income deprivation and is calculated using:
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• Adults and children in Income Support Households, Income Based JSA households and Pension Credit households. • Adults and children in those Working Tax Credit households where there are children in receipt of Child Tax Credit whose equivalised3 income (excluding housing benefits) is below 60% of the median before housing costs. • Adults and children in Child Tax Credit households (who are not eligible for IS, Income-Based JSA, Pension Credit or Working Tax Credit) whose equivalised income (excluding housing benefits) is below 60% of the median before housing costs. • National Asylum Support Service (NASS) supported asylum seekers in England in receipt of subsistence support, accommodation support, or both. Figure 2927 shows the distribution of income deprivation derived from IMD 2007, with the red areas being the most deprived.
Figure 27:
Source: MAIDeN
Income Deprivation Affecting Children Index (IDACI)
This is one of the indicators used to calculate the income deprivation score. Although Gloucestershire is a relatively affluent county, there are nevertheless nearly 16,000 chil d ren living in poverty. Growing up in poverty damages children’s health and well- being, adversely affecting their future health and life chances as adults. Ensuring a good environment in childhood, especially early childhood, is important. A
3 "Equivalisation" means adjusting a household's income for size and composition so that incomes of all households can be compared.
26 DRAFT considerable body of evidence links adverse childhood circumstances to poor child health outcomes and future adult ill health. Adverse outcomes include higher rates of: fatal accidents, poor dental health, child mortality, low educational attainment, low birth weight, childhood obesity, school exclusions, infant mortality, teenage pregnancy, some infections, substance misuse, and mental ill health. As shown in Figure 28 Gloucester and Cheltenham have higher rates whilst Stroud and Cotswold districts have lower rates of children in poverty than the county.
Figure 28
Children Living in Poverty, 2005
25 20 15 10 5
years 0 Forest of Cheltenham Cotsw old Gloucester Stroud Tew kesbury Dean
District 17.1 9.8 14.4 20.0 11.1 13.0 Gloucestershire PCT 14.6 14.6 14.6 14.6 14.6 14.6 Percentage of children under 16 16 children under of Percentage England 22.4 22.4 22.4 22.4 22.4 22.4
Living Environment Poor housing conditions are associated with a wide range of health conditions, including respiratory conditions (including, asthma), lead poisoning, injuries, and mental health. The highest risks to health in housing are attached to cold, damp and mouldy conditions. Anxiety and depression also increase with the level and type of housing problems people experience.
Exposure to air pollutants may lead to short term effects such as reduced visibility, headaches, allergic reactions, irritation to the eyes, nose and throat, and longer term effects such as breathing difficulties, asthma and various chronic respiratory illnesses such as lung cancer and heart disease. In infants and young children, the effects can be far worse as their respiratory defences have not been fully formed, affecting their lung development and breathing capacities.
This domain focuses on deprivation with respect to the characteristics of the living environment. It comprises two sub-domains: the ‘indoors’ living environment which measures the quality of housing, and the ‘outdoors’ living environment which contains two measures about air quality and road traffic accidents.
The ‘indoors’ living environment • Social and private housing in poor condition and houses without central heating. The ‘outdoors’ living environment • Air quality and road traffic accidents involving injury to pedestrians and cyclists
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Figure 29 maps the living environment domain in Gloucestershire.
Figure 29
Source: MAIDeN
Housing is a key determinant of health in its own right, having a particular impact on excess winter deaths. The housing condition surveys from the six district councils in Gloucestershire suggest there are significant housing issues to be overcome to ensure that people can enjoy affordable warmth. The average Standard Assessment Procedure (SAP a measure of energy efficiency) rating for the county of Gloucestershire is 55, below the government’s recommended minimum of 65, and there are significant variations within the districts. Based on pooled data from across the 6 District Council household surveys it has been estimated that there are 58,206 private dwellings within the county that fail to meet the Government’s Decent Homes standard, with an estimated 29,289 failing to provide reasonable thermal comfort and/or effective heating. District Surveys are carried out during a 5 year period and consequently some of the scoring for the more recent ones may be better. (Excess Winter Mortality Task Group, GCC (2009).
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Table 1 Year District Average SAP Rating 2004 Forest of Dean 46 2005 Gloucester City 61 2005 Cheltenham 60 2006 Stroud 48 2008 Tewkesbury 62 2008 Cotswold 55 National Minimum, 65 Source: Excess Winter Mortality Task Group, GCC (2009)
4.2 Lifestyle Factors
4.2.1 Adults
Introduction
The lifestyle data presented below comes from the following data sources:
• The Health Survey for England is an annual survey designed to measure health and health related behaviours in adults and children living in private households in England. It has been undertaken since 1991. Sample data is available to Strategic Health Authority (SHA) level. This data is not sufficiently robust to measure geographical boundaries smaller than SHA. This is currently the most robust data source to monitor trends in adult obesity in England. • The Active People Survey (APS) is a large telephone survey of sport and active recreation, commissioned by Sport England. The survey began in October 2005, and is planned to run continuously until 2010. In the first year the sample was 363,724 adults in England (aged 16 plus), with a minimum of 1,000 interviews completed in each Local Authority in England. While the indicator includes recreational and sport walking and cycling it does not include cycling or walking as a mode of travel. Nor does it include other physical activity such as housework, DIY or work related activity. The APS also relies on self-reported physical activity levels and are likely to be an overestimate.
Data from these and other sources (such as the Census) are then used to model prevalence at a local level. It is important to note that these estimates are modelled and published as ‘experimental data’ and should be used and interpreted with caution.
Physical Activity
Recommendation The Government recommendation for physical activity in adults is 30 minutes of moderate intensity activity (e.g. brisk walking) on at least 5 days a week.
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The data reported here from the eJSNA are modelled estimates based on samples of people reported within the Active People’s Survey.
Figure 30
Modelled data on self-reported achievement of recommended physical activity levels (aged 16 and over) 2008/9 20
ge 15
10 rcen 5 Pe ta 0 Forest of Cheltenham Cotsw old Gloucester Stroud Tew kesbury Dean
District 10.5 15.5 13.6 11.8 11 10.7 Gloucestershire PCT 12.3 12.3 12.3 12.3 12.3 12.3 England 11.20 11.20 11.20 11.20 11.20 11.20
Source: eJSNA
The data indicates that Gloucestershire has a higher percentage of physically active people over the age of 16 than the average for England, although some districts may have slightly lower levels. However due to the relatively small sample size, the data at district level needs to be interpreted with caution. There seems to have been a slight increase in the number of physically active adults in Gloucestershire, in line with the trend reported for England as a whole, between 2007/08 and 2008/09. However, in view of the wealth of evidence for the benefits of physical activity we still have a long way to go before we can say that a significant proportion of our population are active enough to experience benefits to their health and wellbeing.
Healthy Eating
Recommendation The Government recommendation for healthy eating in children and adults is to eat at least five portions of fruit and vegetables a day.
A further recommendation is to eat breakfast each day. Not only does breakfast provide an important source of essential nutrients (e.g. iron and calcium) but evidence also suggests skipping breakfast can affect concentration at work or school during the morning, and can increase the likelihood of snacking on high fat / sugar foods later in the day.
Data on fruit and vegetable intake have been consistently collected by the Health Survey for England (HSE) since 2001. This provides useful trend data but is not necessarily indicative of wider dietary patterns and furthermore is based on self- reported data from samples of the population. Therefore the data should be used with caution. Research has not yet identified which elements of dietary intake overall
30 DRAFT provide the most robust indicators of a healthy diet and this is currently the most robust data source to monitor trends in healthy eating in England.
Nationally people in higher income groups are more likely to meet the ‘5 a Day’ target. Women tend to eat more fruit and vegetables than men. This is reflected both in the proportion meeting the ‘five a day’ target (25% of men and 29% of women) and in the average number of portions consumed (3.5 portions for men, 3.8 portions for women). The number of people meeting ‘five a day’ also increases with age up to 55-64 years and then it starts to decline.
The data reported in Table 2 are modelled estimates based on the HSE 2006/08.
Table 2: Adults who report that they eat five of more portions of fruit or vegetables a day. % of adults reporting % of adults reporting that they eat ‘five a that they eat ‘five a day’ 2003/05 day’ 2006/07 Gloucestershire 19.4 31.0 England average 26.3 28.7 Source: e-JSNA /Association of Public Health Observatories
This data suggests that the number of adults in Gloucestershire who achieve the recommended five portions of fruit and vegetables a day is higher than the average for England in 2006/07 and has increased significantly since the 2003/05 survey. However, it should be reiterated that this is modelled data based on self-reported intakes of small samples of the population and therefore should be interpreted with caution.
Obesity
Obesity in adults is classified as Body Mass Index (BMI) of 30 or more. BMI is calculated as a ratio of weight to height.
The data below is modelled data taken from the Health Survey and therefore should be used and interpreted with caution. We do not currently collect sufficient data on adult obesity locally to provide a more robust picture. The quality of local data collected should improve as the NHS health checks are rolled out across the county.
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Figure 31
Modelled Obesity levels in adults (aged 18 and over) 2008 40
30
20
10 Percentage 0 Forest of Cheltenham Cotsw old Gloucester Stroud Tew kesbury Dean
District 24.9 23.2 28.9 28.3 25.3 26.7 Gloucestershire PCT 24.9 24.9 24.9 24.9 24.9 24.9 England 26.2 26.2 26.2 26.2 26.2 26.2
Smoking
Cigarette smoking is the greatest single cause of illness and premature death in the UK. Smoking causes almost 90% of deaths from lung cancer, around 80% of deaths from bronchitis and emphysema, and around 17% of deaths from heart disease. About one third of all cancer deaths can be attributed to smoking. These include cancer of the lung, mouth, lip, throat, bladder, kidney, stomach, liver and cervix. People who smoke between 1 and 14 cigarettes a day have eight times the risk of dying from lung cancer compared to non-smokers. In addition, smokers under the age of 40 have five times greater risk of a heart attack than non-smokers. Teenage smokers experience more asthma and respiratory symptoms, suffer poorer health, have more school absences and are less fit.
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Figure 32 shows the percentage of people aged 16 and over that were recorded by their GP as being a smoker in the previous months 15 months. Gloucester is the highest of the districts and Cotswold the lowest.
Figure 32 Smoking: Number of people aged 16 and over recorded as being a smoker in previous 15 months March 2009 20
15
10 recorded 5
0 Forest of
percentge patients with status Cheltenham Cotsw old Gloucester Stroud Tew kesbury Dean
District 15.2 12.2 15.6 18.8 13.8 13.3 Gloucestershire PCT 15.0 15.0 15.0 15.0 15.0 15.0
Source: eJSNA
Smoking when pregnant increases the risk of: miscarriage and can slow the growth of the baby leading to a low birth weight, premature labour or stillbirth. Even after the birth, children of smoking parents have an increased risk of developing chest infections, asthma, 'glue ear', and sudden infant death syndrome (cot death). Smoking in pregnancy remains a challenge, particularly in Gloucester and the Forest of Dean.
Figure 33 Mothers who are smokers at time of booking
250
200
150
100
50
per 1,000 live births 0 Forest of Cheltenham Cotsw old Gloucester Stroud Tew kesbury Dean
District 135.7 110.2 217.0 212.3 113.9 156.0 Gloucestershire PCT 161.9 161.9 161.9 161.9 161.9 161.9
Source: eJSNA
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Deaths attributable to smoking are, not surprisingly, distributed variably across the districts with Gloucester experiencing the highest rates as shown in the graph below.
Figure 34
Deaths from Smoking ged ged
250 tion a tion
a 200
150 popul 35+ 100
50
0 Forest of Cheltenham Cotsw old Gloucester Stroud Tew kesbury Dean
Rate per 100,000 per Rate District 185.3 149.2 181.3 210.6 176.2 163.7 Gloucestershire PCT 177.9 177.9 177.9 177.9 177.9 177.9
Alcohol misuse
In the absence of robust survey data at Local Authority level, data on alcohol-related hospital admissions is presented as it is considered to be sensitive to a range of alcohol misuse prevention and treatment interventions. Figure 35 shows Gloucester and Cheltenham to be higher whilst the Forest of Dean and Stroud are lower than the county rate.
Figure 35
Hospital Stays for Alcohol Related Harm 2008/09
2000
1500
1000
500
0 Forest of Cheltenham Cotsw old Gloucester Stroud Tew kesbury
Rate per 100,000 population 100,000 per Rate Dean
District 1670.0 1390.0 1300.0 1730.0 1200.0 1490.0 Gloucestershire PCT 1480.0 1480.0 1480.0 1480.0 1480.0 1480.0
Source e JSNA
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Children
Introduction
The lifestyle data presented below comes from the following data sources:
National Child Measurement Programme (NCMP) The NCMP annually weighs and measures children in reception year and year six in maintained schools in England. The programme began in 2005 and now provides the most robust source of childhood obesity data in England. The local (Gloucestershire) data should be treated with caution until the 2008/09 schools year as the coverage (percentage of eligible children who took part) was too low to produce reliable data. The 2008/09 coverage level was sufficient to produce reliable data on local children’s weight status.
Gloucestershire Online Pupil Survey (OPS) Owing to the lack of actual public health data relating to healthy lifestyles in children the Public Health Directorate (NHS Gloucestershire) with the Children and Young People’s Directorate at Gloucestershire County Council designed and commissioned an on-line pupil health survey to find out about local school children’s lifestyle behaviours, needs and attitudes. The first survey was conducted in 2006 and has been carried out every two years. The survey is a total sample with every school invited to take part and it is carried out across years 4, 6, 8 and 10. In 2010 it was introduced into year 12. This year 220 (88%) mainstream schools participated plus 26 Special Schools and Short Stay Schools (formally known as Pupil Referral Units). The results this year are based on a total of 18,867 children and young people, whilst the 2010 one was based on 17,801 and the 2008 on 12,227. This provides a rich source of data at a local level not available anywhere else in the country.
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Obesity in Children
Obesity in children is assessed using BMI percentile charts rather than weight to height ratio. This is to allow for a child’s gender and developmental age. The Forest of dean has the highest levels of obesity in the County, whilst Cotswold District has the lowest.
Figure 36
Obesity levels in reception year 20 08/9
15
10
centage 5 Per 0 Forest of Cheltenham Cotsw old Gloucester Stroud Tew kesbury Dean
District 7.3 5.4 9.2 8.5 8.0 7.9 Gloucestershire PCT 7.8 7.8 7.8 7.8 7.8 7.8 England 9.6 9.6 9.6 9.6 9.6 9.6
Source: eJSNA
Breastfeeding Evidence suggests that breast feeding saves lives and protects the health of mothers and babies both in the short and long term. Figure 37 shows that there are higher rates in Cotswold district and Cheltenham but low rates the Forest of Dean and particularly Gloucester City compared to county rates.
Figure 37
Breast Feeding Initiation 2008/09
ths 800
700
600
500 per 1,000 live bir 400 Forest of
Rate Cheltenham Cotsw old Gloucester Stroud Tew kesbury Dean
District 724.3 757.3 644.9 605.6 678.9 676.5 Gloucestershire PCT 672.3 672.3 672.3 672.3 672.3 672.3
Source: eJSNA
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Table 3 – Healthy Eating Healthy Eating Those who eat Eat 5 or more Average number Indicator breakfast most portions of of unhealthy days (%) fruit/veg per day snacks Year Group (%) (50 is equivalent to 1 per day) 4 88.2 30.4 53.3 6 84.5 24.3 53.1 8 70.4 18.4 55.6 10 61.8 16.1 58.3 12 60.6 17.1 59.5 Source: OPS
Key findings:
• Even at a young age not all children eat breakfast on most days and this decreases steadily with age. By year ten almost four in ten children usually skip breakfast. This has implications for their intake of key minerals (e.g. calcium and iron) at a time of rapid growth when nutrient needs are at their highest. It could also affect concentration levels during morning school and lead to snacking on high fat high sugar foods later on in the day.
• The highest rate of children eating 5 or more portions of fruit and vegetables a day is in year 4 and decreases with age until year 10
• All children and young people have at least 1 unhealthy snack per day and this increases with age
Table 4 Physical Activity Indicator Do more less 2 hours Never take part in physical activity per day physical activity not Year Group (%) linked to school (%) 4 not available 20.2 6 20.5 16.6 8 15.8 21.3 10 19.9 25.9 12 39.1 22.2
• Around one in five children in years 6, 8 and 10 do less than 2 hours physical activity a week. Furthermore this figure almost doubles between year 10 and year 12 with almost 40% of children in year 12 reporting that they do less then 2 hours of physical activity per week.
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• Between one in four and one in six children never take part in physical activities that are not linked to school. Furthermore the data suggests that secondary school pupils are less likely to take part in physical activities not linked to school than primary school pupils
Table 5 Risk Behaviours Indicator Smoke regularly - weekly Drink Alcohol - monthly, or daily (%) weekly or daily (%) Year Group 6 0.9 7.3 8 3.1 21.9 10 11.8 52.4 12 11.7 77.1
Source: OPS
Key Findings
• The majority of young people start smoking between years 8 and 10.
• About 1 in 10 children and young people in years 10 and 12 say that they smoke weekly or daily.
• Around 1 in 5 children and young people in year 8 say that they drink alcohol at least monthly, weekly or daily and this rises to 77% in year 12.
Correlation between lifestyle factors in Gloucestershire schoolchildren
Further analysis of the 2010 online pupil survey data, illustrated in Table 6 below highlights some interesting correlations between reported lifestyle behaviours, emotional health and wellbeing and deprivation. A positive correlation is where there is an increase in both variables (e.g. smoking and deprivation), a negative correlation is where there is an increase in one variable and a corresponding decrease in the other (e.g. fruit and vegetable intake and high fat/high sugar snacks). However, although the correlations reported here are statistically significant, it should be stressed that these do not infer causality.
The following relationships are of particular interest:
Healthy Eating and Emotional Health and Wellbeing 1. Both indicators of healthy eating (eating breakfast and eating 5 portions of fruit or vegetables) are significantly positively correlated with being happy, satisfied, ambitious and confident, and negatively correlated with being bullied.
2. Consumption of high fat, high sugar snacks and drinks is significantly positively correlated with being bullied and negatively correlated with being ambitious but is not significantly correlated with other indicators of emotional health and wellbeing.
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Breakfast, fruit and vegetable intake and snacking on high fat, high sugar foods and drinks 1. Th ere is a signific ant negative correlation between both eating breakfast, and eating 5 o r more p ortions of fruit or vegetables a day, and consumption of high fat, high s ugar sn acks and drinks
Healthy Eating and D eprivation 1. Th ere is a signific ant negative correlation between deprivation (classified as being elig ible for fre e school meals) and both eating breakfast and eating 5 or more port ions of fru it or vegetables a day
2. Th ere is a significant positive correlation between deprivation and consumption of high fa t, high su gar snacks and drinks
Physic al Activ ity and Emotional Health and Wellbeing 1. Re ported physica l activity levels are significantly negatively correlated with bullying and signi ficantly negatively correlated with being happy, satisfied, ambitious and con fident
2. Ch ildren w ho nev er take part in physical activities that are not linked to school are signific antly more likely to report being bullied and significantly less likely to report feeli ng happy, satisfied, ambitious and confident
Physic al Activi ty and Deprivation 1. Th ere is a signific ant positive correlation between reporting never taking part in physical activ ities that are not linked to schools and deprivation
Risky B ehaviours and Emotional Health and Wellbeing 1. Sm oking is significantly positively correlated with being bullied and significantly negatively correlate d with feel ing happy, satisfied, ambitions and confident
2. Alcohol consumption, on the other hand, is not significantly correlated with bullying but is significantly negatively correlated with feeling happy, satisfied, ambitions and conf ident
Risky B ehavio urs and Deprivation 1. Smoking is significantly correlated with deprivation.
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Table 6 + Significantly Positively Correlated - Significantly Negatively Correlated Blank is Not Significantly Correlated
Physical Risk Healthy eating Emotional H ealth and Wellbeing Deprivation activity behaviours Physical Free School 5 a Unhealthy Physical Activity Satisfied Variables Breakfast Smoking Alcohol Bullied Happy Ambition Confident Meals day snacks Activity Outside with life (eligible) School Breakfast + - + + - - - + + + + - Healthy 5 a day eating + - + + - - - + + + + - Unhealthy snacks - - - + + + - + In school + + + - - + + + + Physically active Outside of school + + - + - - + + + +
Risk Smoking - - + - - + + - - - - + behaviour Alcohol - - + - - + - - - - Bullied - - + - + - - - - + Happy Emotional + + + - - - - + + + health and Satisfied + + + - - - - + + + - well being Ambition + + - + - - - - + + + - Confident + + + - - - - + + + Free school Deprivation meals - - + + + - - (eligible) 40 DRAFT
Teenage Pregnancies
Teenage pregnancies carry extra health risks to the mother and the baby. Teenage mothers are more likely to suffer health, social, and emotional problems as well as having an increased risk for complications, such as high blood pressure and premature labour. Risks for the baby include premature birth and a low birth weight.
Forest of Dean has the highest rate for all teenage pregnancies and the Forest Dean has particularly high rates of under 16 teenage pregnancies in the county. All of these rates are at the same level or higher than the rates for England which is considerably higher than for Gloucestershire overall.
Figure 38
Teenage Pregnancies under 16, average number per year 2005-2007 10 8 e per 1,000 1,000 per e
ed 15-17 6 at g 4 2 0
females a Forest of Cheltenham Cotsw old Gloucester Stroud Tew kesbury Dean Conception r Conception
District 4.1 1.8 9.5 9.1 5.3 6.6 Gloucestershire PCT 6.1 6.1 6.1 6.1 6.1 6.1 England 7.9 7.9 7.9 7.9 7.9 7.9
Source: eJSNA
Figure 39
Teenage Pregnancies under 18, average number per year 2005-2007 17
1,000 1,000 50
er 40 15- e p e
ed 30 20 10 0
ception rat Forest of Tew kesbur females ag females Cheltenham Cotsw old Gloucester Stroud Dean y Con District 24.1 19.1 33.5 42.2 25.4 27.8 Gloucestershire PCT 31.2 31.2 31.2 31.2 31.2 31.2 England 41.70 41.70 41.70 41.70 41.70 41.70
Source: eJSNA
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What are we doing now?
Last year’s DPH Annual Report recommended actions to sustain and improve the health and wellbeing of the population of Gloucestershire via partnership working to improve health and reduce health inequalities:
Promoting increased physical activity Get Up Get Out Get Active Get Up Get Out Get Active is a social marketing programme designed to support the most inactive local people to adopt more active lifestyles.
This includes a local radio campaign, enhanced website signposting people to local opportunities, according to their needs and preferences, and links with Gloucestershire Dance who provide opportunities for different groups to enjoy anything from street dance and salsa to ballroom dancing.
The programme links with local partners via a network of district based Community Sport and Physical Networks (CSPANs) who deliver a range of physical activity opportunities. Training is provided for community workers to raise the issue of physical activity with local people and help them to consider ways they could build more activity into their daily lives.
Get Up Get Out Get Active is being delivered by Active Gloucestershire (County Sports and Physical Activity Partnership)
NICE Guidance and the Built Environment: Toolkit for Planners NHS Gloucestershire, Gloucestershire County Council and other partners are working to implement NICE guidance on physical activity and the built environment and have commissioned a toolkit to support planners and architects to consider the importance of promoting and enabling physical activity in all their plans. The toolkit will be complete by autumn 2010.
Active Start Active Start is a programme of active play for the under 5’s which is delivered in Children’s Centres across the county. It aims to help children have the confidence to be physically active and develop their motor skills. It also supports parents to encourage their families to adopt a more active family lifestyle.
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Promoting Healthy Eating
Promoting breastfeeding in the Community NHS Gloucestershire is commissioning a Breastfeeding Peer Support Service which provides breastfeeding peer support on a 1:1 basis to those women who are least likely to initiate or continue to breastfeed in order to increase rates of breastfeeding in Gloucestershire.
Peer supporters are local women who have had a positive experience of breastfeeding and have undertaken training to enable them to support other local women to breastfeed. They work alongside community midwives, health visitors and family centre workers in 12 children’s centres which have been identified to in those areas where breastfeeding initiation rates are the lowest in the county.
First Food Programme Gloucestershire Food Vision has been working in partnership with The Wiggly Worm Charity on the implementation of the First Food Programme. The objectives of the programme are to: - Develop a training day for those responsible for the production of meals in Early Years (EY) settings - Deliver 2 hour food skills training sessions across the county in settings to staff and parents - Develop a Pre School Food Leaders Pack 25 settings with a particular focus on Children’s Centres, and those settings in locations of higher deprivation, have benefited from the programme. The programme encourages staff, within the target settings, to value the importance of developing food policy. It also aims to increase the knowledge of staff and parents of key food and nutrition messages required for their own and their children’s health. An ‘Early Years Food Award’ scheme has been developed.
Promoting healthy lifestyles and reducing inequalities
Healthy Schools Plus NHS Gloucestershire and Gloucestershire County Council together support “Healthy Schools Plus” .The programme, which has been built on the previous Healthy Schools programme, ensures an outcome focused approach aimed at bringing about changes in health behaviour. It targets health inequalities using the Free School Meals indicator of deprivation and also focuses on school priorities, specific priority groups and the key local priorities as outlined in the Children and Young People’s Plan.
All schools taking part in Healthy Schools Plus are required to have a focus on healthy weight. Schools have been actively encouraged to design bespoke programmes to meet the needs of their children. Examples include; • smoking cessation work with the support of the public health nurse at Wyedean school
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• increased participation in physical activity, curriculum time spent on the benefits of healthy breakfasts and setting up of a breakfast club at Pittville school
Gloucestershire Community Health Trainer Programme There are currently six Community Health Trainers working with individuals in identified areas of deprivation in Gloucestershire: four in Gloucester (focusing on Barton and Tredworth, Matson and Robinswood and Podsmead), one in Cheltenham (focusing on Hesters Way, Springbank and Oakley) and one in Tewkesbury (focusing on Priors Park and Northway).
The Community Health Trainer Programme went ‘live’ in February 2010, following the successful completion by all Health Trainers of the Level 3 City and Guilds Training. Currently the Community Health Trainers have a total of 65 clients, and there are over 20 clients who are waiting to be seen in the next few weeks.
From initial analysis of data collected via the Health Trainer Data Collection and Recording System (DCRS) we have found that:
• Most clients heard about the Community Health Trainers through a promotional event or by word of mouth. • The issues that most clients want to address are weight management, healthy eating and increasing physical activity. • The majority of clients are from the two most deprived quintiles of deprivation.
The Community Health Trainer Programme is expanding this year by recruiting 3 new Community Health Trainers and training approximately 100 volunteer ‘Health Trainer Champions’. The Champions will be able to engage with clients, giving basic health messages to people in their community or workplace and signposting to the Community Health Trainers or other services such as the Stop Smoking Service.
One Community Health Trainer works in Rycroft Probation Approved Premises in Gloucester. He is an ex-offender, and is able to engage with the residents on a one- to-one basis. The Community Health Trainer has recently undertaken the Smoking Cessation Advisor training, and to date 4 residents have given up smoking with his support.
Two out of the four Community Health Trainers in Gloucester are from BME communities. One speaks five languages (English, Bengali, Gujurati, Urdu, Punjabi) and one speaks two languages (English and Gujurati). One has supported a recent Pacesetters Project for south Asian women at risk of developing diabetes. The Community Health Trainers have strong links with local BME groups and organisations at the community level and to date 20% of the clients are from this target group.
Work with black and minority ethnic groups
NHS Gloucestershire has been working with the Linking Communities network to provide a comprehensive list of health professionals who are able to provide Health Talks to three lunch clubs in Gloucester which target people aged 50 and over from
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BME communities in central Gloucester. Linking Communities are developing an annual programme for these groups involving health topics, art, music, and various forms of physical activity.
NHS Gloucestershire’s Healthy Ageing Coordinator has also been working closely with the Chinese Women’s Guild in to coordinate a Healthy Ageing Awareness Day within their community
Reducing smoking prevalence
The Gloucestershire NHS Stop Smoking Service was one of the first services to establish stop smoking support in leisure centres and has extended this over the years to offer support to smokers who wish to quit in a range of settings such as supermarkets, Quit Shop, pharmacies, HM Prison Gloucester, local community venues and Neighbourhood Projects.
The Gloucestershire Smoking Advice Service (GSAS) delivers stop smoking support to clients either individually or in a group setting.
Services include;
A community pharmacy scheme - developed for smokers to access help locally within targeted areas in Gloucestershire. Of 105 Pharmacies, 21 are signed up to the scheme.
GP practices - 75 GPs practices are commissioned to provide help for smokers throughout the county.
Smoking in pregnancy. A specialist Midwife provides smoking cessation advice and support to all pregnant smokers and their families and continues to supports them in their quit attempts throughout their pregnancy. GSAS have developed an antenatal smoking cessation pathway which promotes the identification and referral by midwives of all pregnant smokers on an ‘opt out’ basis to a stop smoking specialist advisor.
Smoke free families. - GSAS works with public health nurses and children’s centre workers throughout the county and has trained local champions to ensure the continued promotion of smokefree homes and cars. In addition, a ‘smoking in the home’ page has been developed within the Parent Held Child Health Record (Red Book) to raise the subject of smoking after birth and refer a smoker for support.
Smoking and mental health GSAS works in partnership with the 2gether Trust to offer all staff brief intervention training to be able to signpost clients for support. Current support for mental health inpatients is provided by the specialist in secondary care.
Smoking within HMP Gloucester GSAS has a trained smoking cessation adviser within the prison who carries out smoking cessation support. In addition, a specialist from GSAS also provides weekly groups and support within the prison.
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Routine and manual workers GSAS is working with employers to encourage the uptake of Stop Smoking Services and smoking cessation advice for employees
Young people - GSAS supports and trains school nurses and has trained other professionals such as youth workers who act as role models and have continued contact with young people. The Tobacco Control Smokefree Co-ordinator continues to work with school and colleges raising the profile on the impact of smoking and how to access services.
ASSIST Introduced in six schools in Gloucestershire. This is a peer led programme for children in Year 8. Peer supporters undertake a day of information and training. On return to school pupils support their friends to reduce the uptake of smoking.
Toxic Truth This is a learning tool, developed by the Smoke free Co-Ordinator, used in Personal, Social and Health Education (PSHE) in schools
Smoking in secondary care - A Specialist for Secondary Care works in the hospitals offering staff, patients and visitors advice and support on giving up smoking. The specialist works in partnership with medical, nursing and pharmacy colleagues in order to increase the provision and effectiveness of smoking cessation within the secondary care setting. A StopB4theOp Policy has been implemented to include all smokers who are inpatients or outpatients within the Gloucestershire Hospitals NHS Foundation Trust.
Training- GSAS facilitates the training of other service providers to deliver stop smoking support as part of their role e.g. practice nurses, community workers, school nurses. This includes Brief Intervention training to ensure robust referrals are made from a range of partners to GSAS.
Tobacco control alliance – The multi-agency Smokefree Gloucestershire Alliance has been convened to take forward actions outlined in the new National Tobacco Control
Reducing alcohol misuse
NHS Gloucestershire is working with partners to reduce alcohol misuse through;
• Providing training and support to raise awareness on the harm of alcohol for front line staff working with adults and children. The number of front line staff, skilled to make interventions following early identification, is being increased, limiting progression to hazardous and harmful alcohol use and ultimately, hospital admissions.
• Adopting a social marketing approach to alcohol awareness campaigns, through improving information and ensuring advice is easily accessible, especially to those vulnerable groups who are not in contact with services.
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• Supporting initiatives, such as PSHE, Family Packages, screening and early targeted interventions with young people in order to reduce early use of alcohol and progression to hazardous and harmful alcohol use in adulthood. • Reducing alcohol related offending by providing an intervention for people arrested in circumstances where alcohol is a contributory factor. (Alcohol Arrest Referral Scheme). This scheme improves awareness of the harm associated with alcohol misuse and has resulted in sustained and improved working practices and partnerships with the police. • Commissioning a range of treatment services for Gloucestershire residents concerned about their drinking. There are different treatment tiers depending on the level of need identified through the AUDIT tool, these include: Brief and extended brief interventions for alcohol treatment in bases across the county for people referred by Primary care/GPs/accident and emergency departments and via the Alcohol Arrest referral Scheme. Specialist alcohol service for over 18’s with alcohol dependence or co- morbidity (including mental illness, physical illness and pregnancy). This specialist service is offered to those who suffer with severe or moderately severe dependence on alcohol, have binge alcohol disorder or have less severe alcohol dependence complicated by other illnesses Community integration service. This programme concentrates on Health and Wellbeing issues through the provision of practically based life and social skills. These include alcohol reduction, social skills, lifestyle management, nutrition, IT, literacy and numeracy, money management and work preparation to re-enter the job market. Emergency Department Scheme. This is available to problematic alcohol users referred from the Emergency Departments (ED) and is available to adults and young people whose attendance at ED is alcohol-related. All prisoners in HMP Gloucester are screened for problem drinking and have access to a range of interventions
Improving sexual health and tackling teenage pregnancy
Improving access to reliable forms of contraception to reduce unintended pregnancies and sexually transmitted infections is being addressed through a range of actions: Implementing ‘You’re Welcome’ (2007) quality criteria to make services more young people friendly. Improving information via web and communications campaign Widening access to free condoms (through the C-Card condom distribution scheme) and to LARC’s (long acting reversible contraception). Increasing Chlamydia screening to test and treat young people Ensuring rapid access to Genito Urinary Medicine Services
Increasing sexual health and advice services for adults and young people in community settings by: Expanding provision in FE colleges, schools and youth settings. Developing young people’s sexual health services in GP practices
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Supporting the provision of good quality sex and relationship education (SRE) in all schools and FE Settings.
Introducing community based rapid testing and support for people living with HIV has resulted in earlier identification, diagnosis and access to treatment.
Chlamydia Gloucestershire has a Chlamydia screening programme for all sexually active 15-24 year olds. This is a free, confidential and easy test and treatment service through: Community Hospitals and Acute Hospitals (including antenatal clinics)
Community Pharmacies and GPs
Youth Services and Connexions
Education settings - FE colleges, extended nurse drop-in services within schools
Employment - linking with businesses to offer Chlamydia screening for employees (targeting young people and parents of young people to encourage their children to test)
Targeted outreach settings, such as festivals and other key events
Teenage Pregnancy Many of the initiatives described above have an impact on reducing the rates of teenage pregnancy. In addition, a teenage pregnancy midwife service was established in July 2009. Teenage parents are referred to Connexions for support they need to return to education, training or employment, after their babies are born. Young parents are also put in touch with their local children’s centre to enable them to benefit from support and information as well as assessing whether additional input is needed. This service also aims to improve health outcomes for mother and baby.
Promoting awareness of cancer, heart disease and stroke
Gloucestershire Breast Screening Programme
One of the Cancer Reform Strategy commitments is to develop targeted programmes that increase breast screening uptake in deprived and Black and Minority Ethnic (BME) communities. The minimum required uptake nationally is 70% whilst the South West ambition is for 80% uptake by 2013. Gloucestershire has good breast screening uptake (77.34% in 2008/09 above the national average of 74% and the SW average of 76.74%).
Local analysis of Gloucestershire’s breast screening uptake conducted at GP practice level indicated six communities in the top 20% most deprived Local Super Output Areas; (Barton and Tredworth, Moreland and Tuffley, Podsmead, Westgate, Kingholm and Wotton, and Matson and Robinswood) with persistent low breast screening uptake.
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NHS Gloucestershire commissioned an independent agency to carry out a social marketing assessment in the above target areas of Gloucester and examine the issues impacting on uptake. This qualitative research was carried out with service users, service providers and other related stakeholders. The qualitative insight generated by the research has informed breast cancer promotional initiatives to focus on: Primary Care, Breast Screening Service and Community Outreach.
NHS Health Check Programme (NHS HCP) in Gloucestershire
The NHS HCP is a Department of Health initiative launched in 2008. The overall aim of the programme is to reduce mortality and morbidity from cardiovascular disease (Stroke, Transient Ischemic Attack, Myocardial Infarction, Chronic Kidney Disease and Diabetes Mellitus Type 2), by assessing the risk of developing cardiovascular disease and managing this risk in community settings. The NHS Health Check programme is being offered to people 40 -74 years old who are not currently in any disease register.
NHS Gloucestershire commenced the delivery of the NHS HCP in 2009 based on the burden of cardiovascular disease on communities and their level of deprivation. The first stage of the programme implementation targeted the Gloucester City residents in early 2010 as the area with highest mortality from cardiovascular disease in Gloucestershire. During this stage of the programme over 750 residents of Gloucester were invited to attend the NHS HCP in the new Gloucester Health Access Centre.
NHS Gloucestershire has invited all primary care services to join the NHS HCP to enable all residents to have access to NHS Health Checks in 2010.
Promoting Healthy Lifestyles for Older People
Healthy Ageing Coordinator
In December 2009, the post of Healthy Ageing Coordinator was commissioned to lead on health improvement programmes for older people and advise on the development and implementation of specialist local health improvement programmes in all aspects healthy ageing.
This has involved working in partnership to, provide specialist advice to multi agency groups on the planning and implementation of specialist programmes countywide, focusing on improving healthy ageing in targeted settings and groups, such as care homes and projects involving the BME community. Projects include;
Library Service - working with libraries across the county to;
• deliver healthy ageing talks to 25 library clubs across the county • have Chi Gong books and DVDs available to borrow in 8 libraries across the county, supported with short demonstrations of the exercises by the author via library clubs across the county.
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Living Books - Living Books are real people who may have a Long Term Condition or Life Experience of a life changing event that they are willing to share objectively with another person who borrows them for a pre-arranged period, i.e. 20 -30 minutes, in a virtual library session.
NHS Gloucestershire recruited volunteer living books in May from members of the public library clubs, the Expert Patient Programme and Look after your Legs Clinics.
ANT Project (Ageing Naturally Together) - The purpose of this project is to deliver healthy ageing messages in a creative way, drawing together older people from sheltered housing schemes and care homes. The messages have been put into a short light hearted play with optional music to support it. The aim is for older people themselves to be empowered to develop the play locally in their own community.
Independent clubs and groups throughout Gloucestershire - Healthy Ageing talks are delivered to various over 50s groups across the county, with audience sizes varying from 10 -35.
Health Exec TV Health Exec TV are an independent television company who invite health professionals to showcase their innovative work via a short cameo DVD film which is published nationally to Health Trusts and other Health networks . The films rely on PCT funding or external sponsorship. Two films have been produced for NHS Gloucestershire, through external sponsorship, as sequels to a film made in 2008 showcasing the ‘Look After Your Legs’ model of leg ulcer management.
Reducing falls in older people NHS Gloucestershire has worked with partners to develop a pathway of services across the whole spectrum of prevention and early intervention, with the aim of reducing the number of older people who fall and sustain a fracture. Services which have been put in place to contribute to this success have included; • the countywide Bone Health (fragility fracture) service, • positive engagement with primary care in case finding those at risk of osteoporosis, • care home community pharmacy pilot, • care home support team and activity coordinators network ensuring that falls prevention advice and exercise is available as widely as possible in care homes, • falls coordinator post (in the two main hospital sites) ensuring linkages across Emergency Departments, Consultants, falls clinics and Bone Health service, • falls and healthy ageing publicity and education programme for older people in the community • Countywide roll out of evidence based falls prevention and postural stability instructor training to ensure we have a wide range of evidence based exercise classes in the community and evidence based active balance classes linked to Falls Clinics.
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Promoting good mental health and wellbeing
The Rethink Gloucestershire Self-Harm Helpline is a telephone support service for people affected by self-harm. The Helpline can provide support and information for individuals who are coping with self harm or supporting someone who self-harms, emotional support, and support for individuals during a crisis. It offers a safe, supportive, non-judgemental and informative space for people who self-harm, their families, friends or carers.
The project was developed in partnership with NHS Gloucestershire in response to national and local evidence relating to the prevalence of self-harm and it being one of a number of predisposing factors that could lead to an increased rate of suicide. It is usually an indicator of mental distress.
Art on Referral (Gloucestershire Art Lift)
Art-Lift is an NHS Gloucestershire funded primary care project offering adult patients the opportunity to improve their health and well being by working with an artist. Currently operating within 8 GP settings across the county, Art-Lift is available to a variety of patients including people experiencing:
• Anxiety and depression • Loss such as bereavement, relationship break up or redundancy • Chronic pain or long term health conditions • Behaviour related problems such as weight management issues, substance abuse • Low self esteem • Caring for a relative
Referrals can be made by any healthcare professional, including GPs, public health nurses, district nurses, and primary mental health workers. Participating surgeries are open to receiving referrals for patients from other surgeries if they have capacity. The current evaluation, conducted by The University of Gloucestershire, will measure improvements in well being as well as looking at a range of outcomes including where people move on to following the project.
Improving mental wellbeing through physical activity
There is good evidence to support the connection between physical and mental health, and recent evidence from Rethink (2008) showed that people with severe mental illness are at risk of higher mortality rates due to poor physical health.
Physical activity Referral schemes (PARS) run in each district within Gloucestershire. Delivered by district councils, activities on offer include health walks, tailored gym based exercise programmes and dance sessions. NHS Gloucestershire contributes to this service through partnership working, funding, and staff resources.
Some Practice Based Commissioning (PBC) clusters have commissioned specific services, such as the ‘Salsa on Prescription’ scheme available in Berkeley Vale.
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Evaluation of the Stroud referral scheme shows that mental health was a reason for referral in 33.2% of patients referred between July 2008 and February 2010.
Physical activity is beneficial as a preventative measure for patients experiencing mild to moderate symptoms, as well as for people with severe and enduring mental health problems. In Gloucestershire the Occupational Health Department has been working with leisure staff in district councils to improve access to PARS schemes and leisure facilities, by providing mental health awareness training to front line staff.
Promoting awareness of mental health with men
‘Know yer Balls’ - MENtalk is an initiative developed by Cheltenham Town Football Club’s Football in the Community Team, in partnership with specialists in men’s health and sexual health from NHS Gloucestershire and Gloucestershire County Council. It provides a gender-sensitive approach to health work with young men in schools (year 11 plus) via the medium of football.
‘Know yer Balls’ – MENtalk is relevant for all young men, delivering mental health promoting messages which are credible to young men, discussing acceptable/accessible support around emotional health concerns - and dispelling myths around mental health, discussing confidentiality concerns and entrenched masculine coping – that whether it’s football, or mental health concerns – men can talk!
The programme consists of a five session course, each session lasting one hour covering mental wellbeing and emotional health topics relevant to young men in schools and other educational settings; of particular significance to young men facing GCSEs and career/education choices! All sessions are delivered by football coaches trained in the gender-sensitive delivery of health work with young men.
Promoting positive mental health and support for people with dementia and their carers.
NHS Gloucestershire has been engaging with carers through regular carer events and bespoke carer groups. Some examples of new initiatives include:
The Managing Memory Together service was developed following feedback from carers. It aims to support carers with information through group sessions, which are delivered close to surgeries
Within the Expert Patient Programme, there is now a programme specific to carers – Looking after Carers.
Caring with Confidence provides support to carers of people with long term conditions.
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Addressing excess winter deaths and fuel poverty - Gloucestershire Warm and Well
During 09/10 the scheme improved the energy efficiency of 5,374 properties, installing 6,257 measures throughout 7 local authority areas. The local authorities in Gloucestershire and South Gloucestershire made more than £1.2 million available to householders in the form of grants to improve heating and insulation and, together with fuel supplier funding, almost £3.5 million worth of measures were installed. Gloucestershire Warm and Well continues to work closely with local authorities, NHS Gloucestershire and members of the Affordable Warmth Partnership as well as other community groups.
In addition to having access to grants and offering energy efficiency advice to all householders, the scheme now offers clients the option of being referred onto some of its relevant partner organisations such as Village Agents, Age Concern and the Fire Service. Its new signposting service involves a partnership referral form which can further assist the client in moving out of fuel poverty and into a more comfortable and manageable lifestyle.
7. What else do we need to do?
Data from the Joint Strategic Needs Assessment has identified the following areas for action in Gloucestershire:
• Breast Cancer • Malignant Melanoma • Smoking • Healthy Eating • Physical Activity • Obesity • Alcohol misuse • Mental Health
It has also identified variations in health status and factors influencing health status across the six districts. More detailed information on intra-district variation can be found in the six district area profiles.
Data from the IMD 2007 and data on lifestyles in adults and children helps to identify where and with whom initiatives should be targeted for maximum impact. Analysis of the Online Pupil Survey shows some strong correlations between less healthy behaviours and a range of factors such as self-esteem, bullying and poorer households. This demonstrates the complexity in achieving behaviour change that leads to healthier lifestyles, given the multiple factors that may be at play at any one time. However, much can be achieved, as demonstrated by some of the examples provided in the section on what we are already doing. Further information on what else we could do is provided in an accompanying commissioning briefing ‘Promoting Healthy Lifestyles – what works?’.
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It is anticipated that this health profile will be circulated widely and will be used to assist in deciding priorities for action across partner agencies. It will need to be considered by the Gloucestershire Strategic Partnership, its constituent organisations and thematic partnerships, including the Health and Community Wellbeing Partnership, in order to inform current and future work programmes.
For further information contact the Director of Public Health, NHS Gloucestershire/Gloucestershire County Council
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NHS Gloucestershire, Sanger House, 5220 Court, Valiant Gloucester Business Park, Brockworth, Gloucester GL3 4FE Further copies can be downloaded at www.gloucestershirehlp.nhs.uk Published by NHS Gloucestershire 2010