Gloucestershire ICS Population Profile
Gloucester City
Draft v5 August 2019
Table of Contents Air Quality ...... 25 Foreword ...... 4 Lifestyle and Prevention ...... 26 Locality Data ...... 6 Obesity ...... 26 Summary, issues and potential areas for investigation ...... 7 Physical Activity ...... 26 People and Place ...... 10 Smoking ...... 27 Age ...... 10 Alcohol ...... 30 Deprivation ...... 11 Screening ...... 31 Access to the Natural Environment ...... 14 Breast Cancer Screening ...... 31 Loneliness and Social Isolation ...... 14 Bowel Cancer Screening ...... 32 Housing ...... 15 Cervical Cancer Screening ...... 34 Caring Responsibilities ...... 15 Immunisations ...... 35 Health Inequalities ...... 17 Seasonal Flu ...... 35 Life Expectancy at Birth ...... 17 Childhood Vaccinations ...... 36 Healthy Life Expectancy at Birth ...... 17 Long Term Conditions ...... 38 Inequality in Life Expectancy ...... 18 MSK ...... 40 Infant Mortality ...... 19 Frailty...... 40 Anxiety and Depression ...... 19 Mental Health and Neurology ...... 41 Unemployment ...... 20 Learning Disabilities ...... 41 Child Development...... 21 Dementia: ...... 42 Birth Weight ...... 22 Respiratory Disease Supplement ...... 45 School Readiness ...... 22 CVD Supplement ...... 50 Self Reported Wellbeing for Year 10 Pupils ...... 22 Chronic Kidney Disease ...... 54 Personal Wellbeing ...... 23 Diabetes ...... 54 Violent Crime ...... 24 High Intensity Users...... 55 2
Health Services ...... 56 Urgent Care ...... 56 Referrals ...... 56 Outpatient Attendances...... 57 Prescribing ...... 58 Mortality ...... 59 Glossary ...... 60 Appendix 1: Health Summary ...... 64 Appendix 2: Diabetes Enhanced Service Clinical Audit Q4 2017/18 Summary ..... 68 Appendix 3: Local Authority Definitions and Data Sources ...... 74
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Foreword In 2016 Gloucestershire County Council and Gloucestershire CCG came together to form a Sustainability and Transformation Partnership (STP) in order to improve health and social care for the people of Gloucestershire. Our STP is now working even more closely together and has evolved into an Integrated Care System (ICS) which takes collective responsibility for managing resources, delivering NHS standards, and improving the health of the population it serves1.
The long term ambition of the Gloucestershire ICS is to have a population, that is:
Healthy and well – taking personal responsibility for their health and care, reaping the personal benefits that this can bring Living in healthy, active communities and benefitting from strong networks of community services and support Able to access consistently high quality, safe care when needed in the right place, at the right time. ICS’s are central to the delivery of the NHS Long Term Plan2. As the Gloucestershire system develops into working as an ICS, through ‘Integrated Locality Partnerships’ (ILPs) and ‘Primary Care Networks’ (PCNs), the need for comprehensive, joined up informatics is essential to help determine how best to meet the needs of its population, identify areas for improvement, highlight inequalities and reduce unwarranted clinical variation and outcomes.
This report-based Locality Profile is part of a number of data tools developed to support ILPs and PCNs in their new role. It gives a ‘snapshot’ summary of population health indicators taken from a regularly updated online operational dataset and also includes some wider determinants of health and health behaviour data.
The profile should be seen in the context of wider system efforts to address health and social care issues within the county. This includes partnership plans such as the Joint Health and Wellbeing Strategy (JHWS), the Prevention and Self Care Plan, the Children, Young People and Families Partnership Framework and the Mental Health and Wellbeing Strategy; and plans and strategies from District Councils, Gloucestershire Constabulary, the Police and Crime Commissioner and wider public sector and voluntary services.
Current priorities in the system include (but are not limited to): (see over)
1 https://www.england.nhs.uk/integratedcare/integrated-care-systems/ 2 https://www.longtermplan.nhs.uk/online-version/ 4
Key Gloucestershire ICS priorities and milestone for place based working Pathway integration with a focus on: Diabetes, Respiratory, Increased focus on cross-cutting requirements of vulnerable groups, Cardiovascular and Frailty & Dementia including those with Learning Disabilities Improving population health through a focus on wellbeing, Improving the use and application of population health management prevention & self-care. Increasingly influencing the wider Improving Mental Health e.g. through peri-natal mental health services determinants of health such as loneliness and isolation and delivery of the Children’s and Young people Mental Health Focusing on proactive care in partnership with local Trailblazer project communities: including building capacity in primary, community Supporting Urgent & Emergency Care and VCSE care, reducing demand for acute services and improving end of life care. NHS Long Term Plan priority areas Smoking Learning disability and/or autism Obesity Rough sleepers Alcohol Carers Air pollution Gambling Antimicrobial resistance Workplace (mental health) Health inequalities UNICEF Baby Friendly Initiative Screening and immunisation NHS Health Checks Maternity Suicide prevention Smoking in pregnancy Annual health check in primary care for people aged over 14 years Physical health needs of people with severe mental health problems with a learning disability Seven service specifications for Primary Care Network (PCN) delivery Structured Medication Review and Optimisation Personalised care Enhanced Health in Care Homes Supporting Early Cancer Diagnosis (April 2020) Anticipatory Care CVD Prevention and Diagnosis (2020) [DRAFT] Joint Health and Wellbeing Strategy 2019 (subject to public consultation) ACEs (Adverse Childhood Experiences) Housing and health Early Years / Best Start in Life Social isolation and loneliness Physical Activity Mental wellbeing Healthy lifestyles – focusing initially on healthy weight The Health and Wellbeing Board will also develop position statements on economic development and transport.
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Locality Data
Information on the health of the Gloucester population has been drawn from a range of sources including the county’s Joint Strategic Needs Assessment, intelligence from the county’s Data Analyst Teams and indicators contained in the Public Health Outcomes Framework and the national General Practice Profiles.
GP practice populations are based on practice boundaries, rather than geographical or council boundaries. Please note that at the current time, not all data is collected or available at PCN or Locality level and the report includes both County and District level data. There is a difference of 45,388 between the GP practice population in Gloucester Locality 174,471 (January 2019) and the population of Gloucester City 129,083 (ONS mid year 2017). It should also be noted that the complex landscape of PCNs, Localities and Districts means that some practice populations may live within a particular ‘Place’ or District but fall within a PCN attached to a different Locality. Wherever possible we have tried to show the data for each variation and the geography at which the data is available will be clearly indicated throughout the report.
Confidence intervals are shown where they are available. In some cases, such as for Office of National Statistics (ONS) data (air quality and housing) and Oxford Consultants for Social Inclusion (OCSI) data (for the Indices of Multiple Deprivation (IMD)) they do not provide denominators in order to calculate confidence intervals.
This Locality Profile does not seek to reproduce all data held within the Integrated Locality Reporting (ILR) tool available from Gloucestershire CCG Data and Analysis team as this includes data that is refreshed on a more regular basis than is possible with a report based profile. The following data is not included but can be found on the operational monthly dashboard that is distributed to PCNs by the CCG.
Primary care quality metrics, patient experience and appointment data A narrative summary of the key findings is included below and this is followed by the relevant tables and graphs and a more detailed analysis.
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Summary, issues and potential areas for investigation Gloucester City covers a mostly urban patient population of around 174,471 in total and includes four Primary Care Networks (PCNs);
HQR PCN Inner City PCN North and South Gloucester (NSG) Aspen PCN PCN Rosebank Bartongate, The Alney Practice, Aspen Medical Practice Hadwen Gloucester City Health Brockworth,
Quedgeley Practice Centre, Churchdown, Patient population of 29,763. Gloucester Health Access Hucclecote Patient population of 48,466; Centre, Longlevens Practice Partners in Health Patient population of 53,492; Kingsholm Practice Patient population of 42,756; .
People and Place The percentage of children in Gloucester achieving a good level of The health of people in Gloucester is varied compared with the development by the end of reception (67%) is lower than in the England average. Life expectancy for both men and women is lower county as a whole (69.2%). than the county and England average. For those eligible for free school meals, the percentage of those 10 out of 13 of Gloucestershire’s top 10% most deprived LSOAs achieving a good level of development is even lower at 48.3%. nationally are located in Gloucester district and Gloucester has the highest proportion of all districts living in the most deprived areas Long term conditions (23% of district). About 16% (4,100) of children live in low income Prevalence in lifestyle related conditions are notably above the overall families. CCG rate; Smoking prevalence is 3.5% higher in Gloucester City, than 27% of the district population are living within 22 LSOAs that fall into in the CCG population as a whole, with Inner City practices also having the most deprived national quintile for “Education Skills and Training” some of the highest rates of COPD. Obesity and Diabetes are also Second highest rate of unemployment in the county significantly above CCG prevalence for all PCNs, most notably for 0.2% of social and private homes failed to meet the decent homes Aspen. standard which is slightly lower than the county average and the 10.3% of older adults across the locality have a Long Term Condition lowest of the six districts. but this varies considerably by PCN and Practice. Hospital admissions for violent crime (rate per 100,000) is almost The Locality has a higher than county prevalence for depression, double the county rate diabetes, obesity and smoking 7
Of those patients who have been diagnosed with Atrial Fibrillation - Nationally it is estimated that PR has only been offered to 13% of eligible (AF), 90.5% of patients have been risk assessed for stroke compared COPD patients, with a focus on those with more severe COPD. with 92.2% CCG average and 93.6% England average. City Health Centre (27.6%), the Health Access Centre (30.2%) and the High-intensity users Alney Practice (30.6%) all have significantly higher prevalence of smoking compared with the county (15.9%) High Intensity Users have been defined as patients above a certain Approximately 1129 people recorded as having a learning disability in activity level threshold in a 12 month period, this varies by service. primary care in 2018/19. 61% of health-checks were completed (692 Overall, the CCG has just over 1 patient per 1000 that meet this people). This is slightly lower than the 65% target. definition, however, for Gloucester City that level is more than Screening uptake for people with a learning disabilities is lower than doubled at 2.13 the county average across the four screening programmes (bowel, Mortality breast, cervical and Retinal) (which are in themselves lower than the Neoplasms, cardiovascular disease, respiratory disease and uptake for people without a learning disability). unintentional injuries are the biggest causes of avoidable mortality in The average completion of 7 care processes for Gloucestershire CCG is the locality for both men and women. at 71.48% (eye examination and Albumin excluded*). In Gloucester City there was 67.4% completion of the 7 care processes, although Lifestyle and Prevention practice completion varied from 34.5% to 89.7%. * GCCG audit team Childhood obesity for Year 6 children is significantly higher than the identified a national problem in the extraction of Albumin data, hence county rate. the additional indicator of 7 Care processes to reflect this problem. The number of adults in Gloucester District doing the recommended Completion of various elements of respiratory care processes are level of physical activity remained the same between 2015/16 and lower in Gloucester City including; 2016/17 at 64.4%. This is the lowest activity level in the county. Confirmation of COPD by post bronchodilator spirometry In 2017/18 91% of patients with coronary heart disease, PAD, stroke Proportion of patients with COPD received an annual review or TIA, hypertension, diabetes, COPD, CKD, asthma, schizophrenia, Proportion of patients with COPD who were recording as having had their bipolar affective disorder or other psychoses had their smoking status recorded compared with 93% in the county. influenza immunisation Smoking prevalence is around 21% which is much higher than the Proportion of patients with Asthma having their diagnosis confirmed and county average of 14%. receiving an annual review The percentage of patients aged 15 years or over who are recorded as The rate of Asthma and COPD admissions (primary causes) for current smokers who have a record of an offer of support and Gloucester City registered patients is considerably above the rate per treatment within the preceding 24 months was 82% which is 1000 population for the CCG as a whole. significantly lower than the county rate of 89%.
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Screening and Immunisations Prescribing Overall levels of screening coverage and uptake are below the county rate for breast, bowel and cervical cancer. As at the end of Mach 2019 (latest position available), Gloucester City Seasonal Flu vaccinations for 2-4 year olds and ‘at risk’ individuals are are not achieving the target for 3 out of the 5 KPIs in prescribing. Most lower than the county rate. notably, the COPD triple therapy inhaler (40.4% of the 50% target). Childhood vaccinations for DTaP/IPV and MMR are lower than the Within Gloucester City, both Aspen and North/South Gloucester PCN county rate. are less than 40% compliant (rated Red) with the above definition. When comparing the rates of Opioid use by PCN, both Aspen and Health services North/South Gloucester are above the CCG level. Recent local analysis The increase in the registered list size for Gloucester City has been has shown a correlation between deprivation and the proportion of a consistent with the overall CCG trend. However, by PCN, all have seen population prescribed Opioids. Work is still under way to try to considerable growth above that of the CCG, except Aspen, when there understand causation and the relationship between chronic pain and has been a notable reduction. other multi-morbidities. The Standardised Admission Ratio (SAR) is a summary estimate of
admission rates relative to the national pattern of admissions and takes into account differences in a population's age, sex and socioeconomic deprivation. Standardised Admission ratio at 120 is higher than the countywide SAR value and 20% above expected. Although almost all places or network analysis of emergency
admissions shows significant change in the rate per 1000 from around June 2018, for Gloucester City this position is more pronounced, and even further still when looking at working age adults only. The observed increase in the county aligns with the introduction of the assessment setting in GHFT. When comparing first outpatient appointment rates for the Gloucester City population, by specialty and indexed to the CCG rate, it appears that for all specialties apart from Paediatrics, the levels are below the county position. Although the highest in absolute terms, the referral rate to Social Prescribing services per 1000 population for Gloucester City is one of the lowest. Given the high levels of high intensity users, prevalence of life style related conditions and multi-morbidity it could suggest there is still considerable opportunity in this area. 9
People and Place The health of people in Gloucester is varied compared with the England average and Life expectancy for both men and women is lower than the England average. Around 5.5% of the District population are from an ethnic minority group.
Age Gloucester Locality has a younger age profile than the other localities in the county. 22.8% of the practice populations are under 18 and 16.7% are over 65 years of age.
Figure 2: NHS Digital: Age Structure Population Pyramid, Gloucester Locality PCN
You can see from the following graphs that there is some variation between PCNs in age structure but all have a younger profile than the county.
Figure 1: ONS Mid-year population estimate 2016 for Gloucester District Figure 3: NHS Digital: Age Structure Population Pyramid, Aspen PCN
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Figure 7: NHS Digital Age Structure Population Pyramid SEGG PCN Figure 4: NHS Digital Age Structure Population Pyramid, Inner City PCN Deprivation The burden of ill health falls disproportionately on individuals, families and communities in Gloucestershire that have lower incomes and lower educational levels. The people that are most likely to have the very worst health and wellbeing outcomes in our county include those living in the most deprived geographical areas and people who may be vulnerable to experiencing inequalities because of: race, disability, age, religion or belief, gender, sexual orientation and gender identity. Some vulnerable groups, for example people
Figure 5: NHS Digital Age Structure Population Pyramid, HQR PCN with learning disabilities, or the homeless, have significantly poorer life expectancy than would be expected based on their socioeconomic status alone.
Since the 1970s the Department of Communities and Local Government has calculated local measures of deprivation in England. The Indices of Multiple Deprivation (IMD) is an overall measure of multiple deprivation experienced by people living in an area.3 It uses 37 separate indicators, organised across seven distinct domains of deprivation which can be combined, using appropriate weights, to calculate the IMD 2015.
Figure 6: NHS Digital Age Structure Population Pyramid, NEG PCN
3 GP Practice Profiles, PHE 11
Gloucester is the district in Gloucestershire that displays the most even spread of population across the national deprivation quintiles. However, 10 out of 13 of Gloucestershire’s top 10% most deprived LSOAs nationally are located in Gloucester district and Gloucester has the highest proportion of all districts living in the most deprived areas (23% of district). The areas of high deprivation that exist tend to be in the more densely populated central parts of the district.
Figure 8: LSOAs shown by IMD national quintile, 2015
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To see a more detailed picture of how deprivation is measured in the district, Figure 9 shows the individual domains of deprivation that make up the total IMD 2015 together with supplementary indices, including a comparison with IMD 2010. The chart again shows the proportion of population in the district to enable a comparison between years.
Figure 9: Gloucester Indices of Deprivation Domains by National Quintile, 2015 compared with 2010
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The domain that shows the highest levels of deprivation in the district in 2015 is Loneliness and Social Isolation “Education Skills and Training” with 33,756 people (27% of district population) Loneliness and isolation is not the same thing. Social isolation is defined as ‘an living within 22 LSOAs that fall into the most deprived national quintile. objective state determined by the quantity of social relationships and contacts “Education Skills and Training” is weighted at 13.5% of the total IMD, and includes between individuals, across groups and communities.’ Meanwhile loneliness is indicators such as: (for Children & Young People) Key stage 2 attainment: average defined as ‘a subjective state based on a person’s emotional perception of the points score, Key stage 4 attainment: average points score, Secondary school number and/or quality of social connections they need compared to what is absence, Staying on in education post 16, Entry to higher education; (for Adult currently being experienced’. Therefore, it is possible for an individual to be skills) Adults with no or low qualifications (aged 25-59/64), English language socially isolated without feeling lonely, or conversely feel lonely without being proficiency (aged 25-59/64). Gloucester has the most deprived LSOA in the socially isolated. county for this domain – Podsmead 1 which ranks 109th nationally. Loneliness and social isolation affects the physical and emotional wellbeing of Another domain, “Health Deprivation and Disability” slipped significantly in the large numbers of people in the county, especially the elderly. Both are important national rankings since 2010. In 2015 25% of Gloucester’s population were living but there is evidence that social isolation has a greater impact on physical health in areas within the most deprived national quintile for this domain. This compares than loneliness.4 There is an increasing recognition that reducing social isolation to 7% in 2010. There is also a large change within the least deprived national not only improves the lives of those affected but leads to savings in health and quintile – in 2010 it encompassed 32% of the district’s population, but this has social care spending. Every year the County Council carries out a survey of a now decreased to 5%. Gloucester has the most deprived LSOA in the county for sample of adults receiving adult social care services. One of the questions asks this domain – Kingsholm and Wotton 3 which ranks 487th nationally. whether service users have as much social contact as they would like and in 2016/17 only 49.2% of service users responded that they did. .This issue has been Access to the Natural Environment identified as a priority for the Gloucestershire Health and Wellbeing Board There is strong evidence to suggest that green spaces have a beneficial impact on (GHWB) in the new Joint Health and Wellbeing Strategy (2019 – 2030) and will be physical and mental wellbeing and cognitive function through both physical taken forward by GHWB together with ‘Safer Gloucestershire’. access and usage. When the weighted estimate of the proportion of residents in each area taking a visit to the natural environment for health or exercise purposes The following links to resources may be able to help over the previous seven days is calculated at County level it was found to be people experiencing loneliness and isolation: lower than both the regional and national levels (although not statistically Your Circle significantly so). Given the rural nature of the county there is potential to increase the number of people accessing the natural environment but factors Gloucestershire Community Wellbeing Service such as access to transport will need to be considered.
4 Parsons, E. Loneliness and Social Isolation in Gloucestershire, 2016 14
Housing Caring Responsibilities Housing provision has a direct impact on health, educational achievement, Caring responsibilities can have an adverse impact on the physical and mental economic prosperity and community safety - all of which are important to the health, education and employment potential of those who care, which can result success and wellbeing of communities within Gloucester. Poor housing in significantly poorer health and quality of life outcomes. Many carers are conditions including cold, damp and mouldy housing, overcrowding and themselves older people living with complex and multiple long-term conditions. temporary accommodation can have a negative effect on health and wellbeing5. The latest available data for poor housing in Gloucester is taken from the IMD Through GP patient survey data we are able to get an idea of the number of 2015. At that time 0.2% of social and private homes failed to meet the decent people in the Locality who have caring responsibilities. People were asked "Do you look after, or give any help or support to family members, friends, neighbours homes standard, which is the lowest of the six districts. or others because of either: long-term physical or mental ill health / disability, or problems related to old age?" Figure 11 below indicates the percentage of patients who answered this question with "Yes" from all respondents to the question. Gloucester has a similar number of patients with caring responsibilities (17.2%) as both the England (16.7%) and Gloucestershire (17.2) average.
Figure 10: The proportion of social and private homes that fail to meet the decent homes standard, IMD 2015
The Warm and Well team give free energy efficiency advice to help people stay warmer and healthier in their home. Figure 11: % of Patients with Caring Responsibilities 2018 http://www.warmandwell.co.uk/ Gloucester City Council: https://www.gloucester.gov.uk/housing/ 6 Homeseeker Plus: All social housing in Gloucestershire and West The NHS Long Term Plan (2019) has undertaken to improve how unpaid carers Oxfordshire is let through Homeseeker Plus: are identified, and strengthen support for them to address their individual health https://www.homeseekerplus.co.uk/choice/ needs. NHS England is introducing best-practice Quality Markers for primary care that highlight best practice in carer identification and support. Healthcare staff, including those in Primary Care, are in a position to identify those in a caring role 5The Marmot Review – Fair Society Healthy Lives http://www.instituteofhealthequity.org/Content/FileManager/pdf/fairsocietyhealthylives. 6 pdf https://www.longtermplan.nhs.uk/wp-content/uploads/2019/01/nhs-long-term-plan.pdf 15
and direct them to support as well as offering them an NHS Health Check and immunisations such as a flu jab.
PeoplePlus are the new provider of carers services in Gloucestershire: https://gloucestershirecarershub.co.uk/carers/#support
Age UK Gloucestershire: https://www.ageuk.org.uk/gloucestershire/
Practical Guide to Healthy Ageing: https://www.england.nhs.uk/publication/practical- guide-to-healthy-ageing/
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Health Inequalities Health inequalities are the preventable, unfair and unjust differences in health status between groups, populations or individuals that arise from the unequal distribution of social, environmental and economic conditions within societies, which determine the risk of people getting ill, their ability to prevent sickness, or opportunities to take action and access treatment when ill health occurs7. Health inequalities are described and measured by comparing the health outcomes (such as life expectancy, healthy life expectancy and rate of disease) of different groups.
Life Expectancy at Birth Life expectancy at birth is the average number of years a person would expect to live based on contemporary mortality rates. Life expectancy in Gloucester District is significantly lower than the Gloucestershire average for both men and women. For men it is 77.6 years compared with 80.2 years for the county and for women, it is 82.7 compared with 83.7 for the county.
Figure 12: Life Expectancy at Birth, Gloucester District
Healthy Life Expectancy at Birth Healthy life expectancy at birth is the average number of years a person would expect to live in good health based on contemporary mortality rates and prevalence of self- reported good health. With increasing life expectancy the question of whether the additional years of life gained are spent in good health or poor health is increasingly
7 https://www.england.nhs.uk/about/equality/equality-hub/resources/ 17
relevant because of the potential policy implications, such as health-care provisions and extending retirement ages. For some people, a large proportion of the additional years gained from increases in life expectancy are spent in poor health. The burden of disabling conditions has implications for health system planning and health-related expenditures. This data is not available at lower geographies but Gloucestershire is significantly better than the England average for both men and women. This of course masks pockets of deprivation and resultant variation. .
South Key: Gloucestershire England 2015-17 West Significantly better Value Lower CI Upper CI than England average Not significantly different Male 66.0 64.4 67.6 64.7 63.4 to England average Female 65.9 64.2 67.6 65.1 63.8 Significantly worse than England average Table 1: Healthy Life Expectancy in Gloucestershire 2015-2017
Figure 14: Healthy Life Expectancy at birth (Female)
Figure 13 and 14 show the time trend for male and female healthy life expectancy between 2009-11 and 2015-17. For men healthy life expectancy has improved but for women there has been a downward trend.
Inequality in Life Expectancy The charts below show the range of years of life expectancy across the social gradient within Gloucestershire, from most to least deprived. This is taken from
Figure 13: Healthy Life Expectancy at birth (Male) the Slope Index of Inequality in Life Expectancy at Birth within English Local Authorities, based on local deprivation deciles. For the period 2015 – 2017 there was an 8.4 year difference for men and a 5.7 year difference for women in life expectancy between the least and most deprived.
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newborn.8 In Gloucester, the rate of infant deaths under one year of age per
10 1000 live births is 4.2 95% CI [2.6, 6.4] which is significantly higher than the 9 8 Gloucestershire rate of 3.3 95% CI [2.5,4.1]. 7 6 5 4 Anxiety and Depression 3 2 Depression and anxiety are very common. The vast majority (up to 90%) of 1 0 depressive and anxiety disorders that are diagnosed are treated in primary care.
Range in years life expectancy However, many individuals do not seek treatment, and both anxiety and Period depression often go undiagnosed. Around 30 per cent of all people with a long- Gloucestershire term physical health condition also have a mental health problem, most Figure 15: Inequality in life expectancy at birth (male) commonly depression/anxiety9.
Data from the GP Patient Survey gives an indication of the prevalence of anxiety and depression as reported by respondents to the survey. We know that a significant proportion of people that have depression are not diagnosed. Knowledge of how many people state that they have depression contributes to building up the local picture of prevalence of depression. It may also highlight gaps between diagnosed and undiagnosed prevalence in a local area. The self reported prevalence of anxiety and depression in Gloucester District (14%) is similar to Gloucestershire (12.2%) and the South West (13.1%).
Across the Locality, Prevalence of Depression (February 2019) is 16.3%. Across Figure 16: Inequality in life expectancy at birth (female) the four PCNs there is wide variation between practices as you might expect. Infant Mortality Some Practices such as Rosebank and Aspen have significantly higher prevalence Infant mortality is an indicator of the general health of an entire population. It of depression than both the Locality and county rate and others such as reflects the relationship between causes of infant mortality and upstream Bartongate and Partners in Health have a significantly lower prevalence. determinants of population health such as economic, social and environmental conditions. Deaths occurring during the first 28 days of life (the neonatal period) in particular, are considered to reflect the health and care of both mother and 8 https://fingertips.phe.org.uk/profile/public-health-outcomes- framework/data#page/4/gid/1000044/pat/6/par/E12000009/ati/101/are/E06000022/iid/92196/ag e/2/sex/4 9 https://www.kingsfund.org.uk/projects/time-think-differently/trends-disease-and- disability-mental-physical-health 19
Figure 17: HQR PCN: Prevalence of Depression February 2019 Figure 20: Aspen PCN Prevalence of Depression February 2019
Unemployment Wider determinants, also known as social determinants, impact on people’s health and in fact can have a greater impact on health and wellbeing than services delivered by the NHS10. These include a diverse range of social, economic and environmental factors. One of these factors is whether or not a person is employed. Gloucester has the second highest unemployment rate in the county at 3.4%.
Figure 18: Inner City PCN: Prevalence of Depression February 2019
Figure 21: The unemployment count as a percentage of the economically active population aged 16+
Figure 19: NSG PCN Prevalence of Depression February 2019) 10 Marmot et al (2010) Fair Society Healthy Lives (The Marmot Review) - IHE 20
We know that those with long term conditions are more likely to be unemployed and we can see in figure 22 that for Gloucester there is a 4.5% gap in employment rate between those with long term health conditions (LTCs) and the overall employment rate. We also know that psychosocial risk factors such as loneliness, isolation and depression are all more common in those with LTCs and may impact on people’s ability to work.
Figure 24: Gap in the employment rate between those in contact with secondary mental health services and the overall employment rate
Child Development There is compelling evidence that a child’s experiences in the early years (0–4) 11 Figure 22: Gap in employment rate between those with long term health conditions and the have a major impact on their health and life chances, as children and adults . overall employment rate The Gloucestershire Children, Young People and Families Needs Assessment (2018)12 points to emerging evidence that Gloucestershire is becoming a county The gap in employment rate is significantly higher for those with a learning of two parts: with some children having the best of times and some the worst of disability or those in contact with secondary mental health services. times. It highlights the Harvard three principles to improve outcomes for children (Support responsive relationships; Strengthen core life skills; Reduce sources of stress) and points to evidence around adverse childhood experiences (ACES) and how the adversity we experience as children can affect us into adulthood.
‘Action on ACES’ is a partnership of statutory and VCS organisations working to prevent, intervene early and overcome the impact of ACEs, and build resilience: https://www.actionaces.org/who-we-are/
11https://www.kingsfund.org.uk/projects/improving-publics-health/best-start-life 12 Figure 23: Gap in the employment rate between those with a learning disability and the overall https://inform.gloucestershire.gov.uk/media/2082189/cyp_and_families_needs_assessm employment rate ent_2018-2.pdf 21
Birth Weight National Healthy Schools criteria, such as healthy eating, physical activity, Low birth weight increases the risk of childhood mortality and of developmental relationships and mental and emotional wellbeing. The survey runs every two problems for the child and is associated with poorer health in later life. It can be years and in 2016 for example was completed online by over 30,000 students looked at in the context of addressing issues of premature mortality, avoidable ill from 271 schools and other education settings. Figure 27 shows the self reported health, and inequalities in health, particularly in relation to child poverty. The wellbeing scores for Year 10 pupils across Gloucestershire (2018) and as you can percentage of term babies born below 2500g in Gloucester is low (2.3% in 2016) see, they were very similar across the County. and very similar to the county value (2.2% in 2016).
School Readiness School readiness is a key measure of early years development across a wide range of developmental areas. Children from poorer backgrounds are more at risk of poor development and evidence shows that differences by social background emerge early in life. The percentage of children in Gloucester achieving a good level of development by the end of reception (67%) is lower than in the county as a whole (69.2%). If we look at those eligible for free school meals, the percentage of those achieving a good level of development is even lower at 48.3%.
Figure 26: Self-reported wellbeing score (Year 10, 2018)
It is interesting to note the WEMWBS13 scores across school phases with those with excellent mental health dropping from 29% in primary school to just 13% in Year 12. Just 12% of primary school children had poor mental health and this rose to 27% in Year 12 and even higher at 33% in further education.
The Association of Young People’s Health work to improve the health and wellbeing of 10 to 24 year olds. They have produced a free GP Champions Toolkit for Primary Care (endorsed by the Royal College of General Practitioners (RCGP)).
It contains actions all GPs could carry out to improve primary care services for Figure 25: The % of children achieving a good level of development at the end of reception young people: http://www.youngpeopleshealth.org.uk/our-work/practice/gp- Self Reported Wellbeing for Year 10 Pupils champions. Gloucestershire’s Online Pupil Survey has been operating since 2006 and is made up of over 200 age appropriate questions across a range of topics in line with the 13 https://warwick.ac.uk/fac/sci/med/research/platform/wemwbs/ 22
Figure 27: WEMWBS scores compared across school phases - Primary (OPS 2018). Figure 29: WEMWBS scores compared across the school phases – FE (OPS 2018)
Teens in Crisis: TIC+ provides face-to-face and online counselling services for young people, family counselling, parent support and psycho-educational workshops. https://ticplus.org.uk/
Personal Wellbeing Research shows that many factors influence our quality of life and well-being. Through their ‘Measures of National Wellbeing’ dashboard, the ONS14 monitor and report on how the UK is doing in terms of wellbeing. They describe well- being as “how we are doing” as individuals, as communities and as a nation, and how sustainable this is for the future. The full set of headline measures of Figure 28: WEMWBS scores compared across school phases - Secondary (OPS 2018) national well-being used in the dashboard are organised into 10 areas, such as
14 https://www.ons.gov.uk/peoplepopulationandcommunity/wellbeing/articles/measuresof nationalwellbeingdashboard/2018-09-26 23
health, where we live, what we do and our relationships. The measures include Violent Crime both objective data and subjective data. People with higher well-being have The number of emergency hospital admissions for violence in Gloucester is the lower rates of illness, recover more quickly and for longer, and generally have highest in the county at 43.3 per 100,000 compared with 23.6 per 100,000 for better physical and mental health. Gloucestershire.
Personal wellbeing Includes individual's feelings of satisfaction with life, whether they feel the things they do in their life are worthwhile and their positive and negative emotions. The personal wellbeing scores for people in Gloucester District are very similar to the county as a whole.
Figure 32: The number of emergency hospital admissions for violence (per 100,000 population) Figure 30: Average Happiness Weightings of adults 16+ (out of 10 where 10 is completely happy) Domestic abuse related offences and incidents are defined as threatening behaviour, violence or abuse (psychological, physical, sexual, financial or emotional) between adults, aged 16 and over, who are or have been intimate partners or family members, regardless of gender or sexuality. The crude rate per 1000 population in Gloucestershire has fallen overall since 2015/16 but appears to be rising again and is now 18.9 per 1000.
It is difficult to obtain reliable information on the extent of domestic abuse as there is a degree of under-reporting of these incidents. Changes in the level of domestic abuse incidents reported to the police are particularly likely to be Figure 31: Average Anxiety Weightings of adults 16+ (out of 10 where 10 is completely anxious) affected by changes in recording practices. These kinds of changes may in part be due to greater encouragement by the police to victims to come forward and
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improvements in police recording, rather than an increase in the level of and in particular in cardiopulmonary mortality15. Figure 35 shows an estimate of victimisation. the concentration of the four pollutants nitrogen dioxide, benzene, sulphur dioxide and particulates in the six Districts. A higher score for the indicator represents a higher level of deprivation. Gloucester has the highest rate per Gloucestershire Domestic Abuse Support Service (GDASS): 100,000 population which you might expect given the urban nature of the operates in all districts offering a variety of support locality. programmes for women and men over 16 years old experiencing domestic abuse across all levels of risk and need. Website: http://www.gdass.org.uk Email: [email protected] / Secure: [email protected] Helpdesk line: 01452 726570 Professionals line: 01452 726561
Figure 34: Air Quality (concentration of nitrogen dioxide, benzene, sulphur dioxide and particulates)
Figure 33: Domestic abuse related incidents and crimes in Gloucestershire (rate per 1000 population)
Air Quality Poor air quality is a significant public health issue. There is clear evidence that particulate matter has a significant contributory role in human all-cause mortality 15 https://fingertips.phe.org.uk/search/air%20quality#page/6/gid/1/pat/6/par/E12000009/ati/102/are/E10000013 /iid/92924/age/-1/sex/-1 25
Lifestyle and Prevention
Obesity There is concern about the rise of childhood obesity and the implications of such obesity persisting into adulthood. The health consequences of childhood obesity include: increased blood lipids, glucose intolerance, Type 2 diabetes, hypertension, increases in liver enzymes associated with fatty liver, exacerbation of conditions such as asthma and psychological problems such as social isolation, low self-esteem, teasing and bullying16.
Low incomes, living in social deprivation and ethnicity have an impact on the likelihood of becoming obese. Children from low income areas have double the risk of developing obesity than those from high income areas in Gloucestershire. Figure 35: Reception: Prevalence of obesity (including severe obesity) Evidence suggests that people from black, Asian and other minority ethnic groups are at an equivalent risk of diabetes and other health conditions at a lower body mass index (BMI) than white populations.
Prevalence of obesity in reception age children in Gloucester District is currently higher (10.7%) than for the county (9.9%) but not significantly. Prevalence of obesity in Year 6 children is significantly higher (21.5%) than the county prevalence (17.8%) and has been so since 2010/11.
Across the GP Practice population there is variation in obesity prevalence but for the locality as a whole, prevalence across all ages is currently 11.9% compared with a county rate of 10.1%. For older adults in the locality, prevalence of obesity is 20.8% compared with 16.4% for the county.
Figure 36: Year 6: Prevalence of obesity (including severe obesity)
Physical Activity Physical inactivity is the 4th leading risk factor for global mortality accounting for 16 6% of deaths globally. People who have a physically active lifestyle have a 20-35% https://fingertips.phe.org.uk/search/childhoood%20obesity#page/6/gid/1/pat/6/par/E12 lower risk of cardiovascular disease, coronary heart disease and stroke compared 000009/ati/201/are/E07000079/iid/20601/age/200/sex/4 26
to those who have a sedentary lifestyle. Regular physical activity is also associated with a reduced risk of diabetes, obesity, osteoporosis and colon/breast cancer Healthy Lifestyles Service Gloucestershire: and with improved mental health. In older adults physical activity is associated The service provides stop smoking, weight with increased functional capacities17. Public Health England note that the Chief management, alcohol reduction and physical activity support through one integrated Medical Officer currently recommends that adults undertake a minimum of 150 service. They take a flexible, person-centred minutes (2.5 hours) of moderate physical activity per week, or 75 minutes of approach, empowering people to adopt vigorous physical activity per week or an equivalent combination of the two healthier lifestyle behaviours to improve their (MVPA), in bouts of 10 minutes or more. The overall amount of activity is more overall long-term health and wellbeing. important than the type, intensity or frequency18. People can self refer or are referred by a professional using the online referral form. The number of adults in Gloucester District doing the recommended level of https://hlsglos.org/ physical activity remained the same between 2015/16 and 2016/17 at 64.4% and Tel: 0800 122 3788 this is the lowest activity level in the county. Interestingly, the percentage of adults in the District walking for travel at least three days a week is similar (19.6%) to both the South West (20.7%) and England (22.9%) rates (PHE 2016/17). Smoking Smoking is the most important cause of preventable ill health and premature mortality in the UK and is a major risk factor for many diseases, such as lung cancer, chronic obstructive pulmonary disease (COPD) and heart disease. It is also associated with cancers in other organs, including lip, mouth, throat, bladder, kidney, stomach, liver and cervix.
Prevalence Using self reported data from the Online Pupil Survey, prevalence of smoking amongst young people aged 14 to 15 in Gloucester District has seen a steady decline since 2010 (16.2% to 5.8% in 2018) and prevalence is currently the lowest in the county. Figure 37: Percentage of physically active adults 2015 - 2017
17 https://fingertips.phe.org.uk/profile/physical-activity 18 Department of Health, 2011. Start Active, Stay Active: A report on physical activity for health from the four home countries’ Chief Medical Officers see: http://www.gov.uk/government/uploads/system/uploads/attachment_data/file/152108/ dh_128210.pdf 27
birth-weight and sudden unexpected death in infancy. The Tobacco Control Plan19 contains a national ambition to reduce the rate of smoking throughout pregnancy to 6% or less by the end of 2022 (measured at time of giving birth).
Smoking status at time of delivery is measured at a county level and whilst there has been a general downward trend over the past few years in the percentage smoking at time of delivery, since 2016/17 the numbers have been rising.
Figure 38: Smoking prevalence ages 14/15 by District (2018)
For adults, using self reported data from the Annual Population Survey, we can see that prevalence has fluctuated over the past 7 years but in 2017 was at 21.3% which is the highest prevalence in the county and significantly higher than the county rate of 14.3%
Figure 40: Smoking status at time of delivery 2010/11 – 2017/18
Cessation In terms of smoking cessation, the combination of various pharmacotherapies with intensive behavioural support (similar to the treatment offered by Stop Smoking Services) is among the most cost-effective interventions available in the health care sector. There is evidence that when doctors and other health professionals advise on smoking cessation, and particularly when they offer support and treatment, that people are more likely to quit. Around four per cent Figure 39: Smoking Prevalence ages 18+ by District (2017) of patients who quit without using either pharmacotherapy or behavioural support will remain abstinent at 12 months. With pharmacotherapy and brief Smoking in pregnancy has well known detrimental effects for the growth and development of the baby and health of the mother. These include complications 19 during labour and an increased risk of miscarriage, premature birth, stillbirth, low https://www.gov.uk/government/publications/towards-a-smoke-free-generation- tobacco-control-plan-for-england 28
supervision from a GP or other clinician, this would be about eight per cent. If a patient takes up the offer of referral to an NHS Stop Smoking Service or a specially trained member of practice staff, such as a practice nurse, providing regular weekly support, the 1-year continuous abstinence rate doubles to about 15 per cent.20
Figure 42: Cessation support and treatment offered 2017/18
For this same cohort of patients, 93% were offered cessation support and treatment in 2017/18 which was slightly lower than the county rate of 95%.
Figure 41: Smoking status recorded in the last 12 months (certain conditions) 2017/18
Primary Care records the percentage of patients with any or any combination of the following conditions: coronary heart disease, PAD, stroke or TIA, hypertension, diabetes, COPD, CKD, asthma, schizophrenia, bipolar affective disorder or other psychoses whose notes record smoking status in the preceding 12 months. In 2017/18 91% of patients with these conditions had their smoking status recorded in Gloucester Locality compared with 93% in the county.
Figure 43: Cessation and support offered 15+
The percentage of patients aged 15 years or over who are recorded as current
20 PHE Fingertips indicator definitions: https://fingertips.phe.org.uk/profile/general- smokers who have a record of an offer of support and treatment within the practice/data#page/6/gid/3000010/pat/152/par/E38000062/ati/7/are/L84073/iid/90619 /age/188/sex/4 29
preceding 24 months was 82% which is significantly lower than the county rate of 89%.
Alcohol Alcohol consumption is a contributing factor to hospital admissions and deaths from a diverse range of conditions. Alcohol misuse is estimated to cost the NHS about £3.5 billion per year and society as a whole £21 billion annually21.
Alcohol misuse is strongly associated with both areas of deprivation but is also linked to income and affluence. At a population / universal level alcohol consumption is linked to cost and affordability i.e. people with more money can drink more and in ways that are socially acceptable. Therefore in Gloucestershire we see both high levels of harm from alcohol in poorer areas but alcohol Figure 44: Young People (Year 10) drinking alcohol (2018) consumption affects residents with higher incomes. These harms are sometimes hidden due to shame and stigma but also due to alcohol’s social and cultural acceptability. Problem consumption of alcohol can also be missed or ignored by CGL Gloucestershire is a free and confidential drug communities and other professionals. and alcohol service for adults (including offenders), families, and carers and affected others. In 2017/18 the directly age standardised rate of admission episodes for alcohol Imperial Chambers, 41-43 Longsmith specific conditions in Gloucester District was higher (at 629 per 100,000 Street, Gloucester population compared to 578) than the region and England. Alcohol specific Bramery House, Alstone Lane, Cheltenham mortality in the period 2015 – 2017 was similar to the England average (10.3% Bankfield House, 13 Wallbridge, Bath Road, compared with 10.6%). Stroud You can call them on 01452 223014 or email them on Self reported data from the Online Pupil Survey tells us that the percentage of [email protected]. young people (year 10's when asked "Do you drink alcohol?” who answered: "Sometimes (e.g. monthly)", "Quite often (e.g. weekly)", "Most days") drinking alcohol in Gloucester District has fallen since 2010 from 48.6% to 27%. Gloucester has the lowest percentage of young people drinking alcohol in the county.
21https://fingertips.phe.org.uk/search/alcohol#page/6/gid/1/pat/6/par/E12000009/ati/10 1/are/E07000079/iid/92906/age/1/sex/4 30
Screening Breast Cancer Screening Breast screening supports early detection of cancer and is estimated to save 1,400 lives in England each year. Screening rates in Gloucester Locality have been falling since 2015/16 and are significantly lower than the CCG rate (72.6% compared with 75.5%) but similar to the England rate. Coverage across the PCNs is similar with the exception of Inner City PCN which is significantly lower at 64.3%. Figure 47: Females, 50 – 70, screened for breast cancer in last 36 months (3 year coverage, %), HQR PCN There are a number of categories of women in the eligible age range who are not registered with a GP and subsequently not called for screening as they are not on the Breast Screening Select (BS-Select) database. Improvements in coverage would mean more breast cancers are detected at earlier, more treatable stages.
Figure 48 Females, 50 – 70, screened for breast cancer in last 36 months (3 year coverage, %), NSG PCN
Figure 45: Females, 50-70, screened for breast cancer in last 36 months (3 year coverage, %), Gloucester Locality
Figure 49 Females, 50 – 70, screened for breast cancer in last 36 months (3 year coverage, %), Inner City PCN
Figure 46: Females, 50 – 70, screened for breast cancer in last 36 months (3 year coverage, %), Aspen PCN 31
Bowel Cancer Screening Bowel cancer screening supports early detection of cancer and polyps which are not cancers but may develop into cancers over time. About one in 20 people in the UK will develop bowel cancer during their lifetime. Improvements in coverage would mean more bowel cancers are detected at earlier, more treatable stages, and more polyps are detected and removed - reducing the risk of bowel cancer developing. Screening coverage in Gloucester (59.7%) is higher than in England (57.3%) but significantly lower than the county rate 62.2%). Coverage is Figure 52: Persons, 60-69, screened for bowel cancer in last 30 months (2.5 year coverage, %), HQR significantly lower than the CCG in Inner City PCN (50.7%). PCN
Figure 50: Persons, 60-69, screened for bowel cancer in last 30 months (2.5 year coverage, %), Figure 53: Persons, 60-69, screened for bowel cancer in last 30 months (2.5 year coverage, %), NSG Gloucester Locality PCN
Figure 51: Persons, 60-69, screened for bowel cancer in last 30 months (2.5 year coverage, %), Figure 54: Persons, 60-69, screened for bowel cancer in last 30 months (2.5 year coverage, %), Aspen PCN Inner City PCN
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Screening uptake in Gloucester (58.5%) is significantly higher than England (56.1%) but significantly lower than the county (61.4%). It might be worth taking a more in depth look at this to see if there is anything that could be done to improve uptake. Uptake in both Aspen (58.2%) and Inner City (50.8%) PCN is significantly lower than the county and uptake in NSG is significantly higher (66.8%).
Figure 57: Persons, 60-69, screened for bowel cancer within 6 months of invitation (Uptake, %), HQR PCN
Figure 55: Persons, 60-69, screened for bowel cancer within 6 months of invitation (Uptake, %), Gloucester Locality
Figure 58: Persons, 60-69, screened for bowel cancer within 6 months of invitation (Uptake, %), NSG PCN
Figure 56: Persons, 60-69, screened for bowel cancer within 6 months of invitation (Uptake, %), Aspen PCN
Figure 59: Persons, 60-69, screened for bowel cancer within 6 months of invitation (Uptake, %), Inner City PCN
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Cervical Cancer Screening This indicator looks at the number of women registered at the practice who are screened adequately in the previous 42 months (if aged 24-49) or 66 months (if aged 50-64) divided by the number of eligible women on the last day of review period. The overall cervical screening coverage in Gloucester is significantly lower (73.3%) than the county rate (76%). Across the PCNs there is a similar picture as there was for coverage with Aspen and Inner City both significantly lower for uptake than the county and NHSG significantly higher. Figure 62: Females, 25-64, attending cervical screening within target period (3.5 or 5.5 Overall, levels of screening in Gloucester Locality are below the county rate and year coverage, %), HQR PCN there is potential across the Locality to improve these.
Figure 63: Females, 25-64, attending cervical screening within target period (3.5 or 5.5 Figure 60: Females, 25-64, attending cervical screening within target period (3.5 or 5.5 year coverage, %), NSG PCN year coverage, %), Gloucester Locality
Figure 64: Females, 25-64, attending cervical screening within target period (3.5 or 5.5 Figure 61: Females, 25-64, attending cervical screening within target period (3.5 or 5.5 year coverage, %), Inner City PCN year coverage, %), Aspen PCN
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Immunisations Seasonal Flu Vaccination coverage is the best indicator of the level of protection a population will have against vaccine preventable communicable diseases. Immunisation is one of the most effective healthcare interventions available and flu vaccines can prevent illness and hospital admissions among vulnerable groups of people. Increasing the uptake of flu vaccine among high risk groups should also contribute to easing winter pressure on primary care services and hospital admissions. The flu vaccination is offered to people who are at greater risk of developing serious complications if they catch flu. Figure 66: Seasonal flu vaccinations for at risk groups aged 6 months - 65 by locality
For those over 65 years of age coverage in Gloucester rose slightly between 2016/17 and 2017/18 from 75% to 76.2% which is higher than the Gloucestershire average (74.7%).
Figure 65: Seasonal flu vaccinations for 2-4 year olds by locality
Uptake for 2-4 year olds in Gloucester Locality fell in 2017/18 from 40.5% (2016/17) to 38.5% and is below the county rate of 42.9%.
For at risk groups between the ages of 6 months and 65 years uptake also fell Figure 67: Seasonal flu vaccinations for ages 65+ by locality from 52.2% to 51.1% although this is still slightly higher than the county rate of 50.9% for at risk groups. Seasonal flu vaccination coverage for pregnant women in Gloucester has increased from 46.3% in 2016/17 to 51.5% in 2017/18. This is higher than the county average of 49.4%.
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(encephalitis) and deafness. They can also lead to complications in pregnancy that affect the unborn baby and can lead to miscarriage. In Gloucester coverage for MMR was 89.8% which is slightly lower than the county average of 90.9% (2017/18).
Figure 68: Seasonal flu vaccinations for pregnant women by locality
Across the PCNs, there is wide variation in coverage and uptake of seasonal flu vaccinations. Of note, in Aspen PCN vaccinations for pregnant women have increased from 48.5% in 2016/17 to 61.4% in 2017/18 but for all other groups the levels have fallen slightly. For Inner City PCN, flu vaccinations for 2 – 4 year olds fell from 33.6% in 2016/17 to 25.8% in 2017/18. The only increase in vaccination levels was for the 65+ age group. For HQR PCN levels of vaccinations increased Figure 69: MMR 2 doses at age 5 (Gloucester Localitys) for all groups except the ‘at risk’ group which saw a 1.3% fall. It was a similar picture in NEG PCN where vaccinations increased for all groups except the at risk The combined DTaP/IPV/Hib is the first in a course of vaccines offered to babies group which saw a fall of 1.6%. Finally, for SEG PCN flu vaccinations for pregnant to protect them against diphtheria, pertussis (whooping cough), tetanus, women rose by 11% but for 2-4 year olds fell by 2.3% Haemophilus influenzae type b (an important cause of childhood meningitis and pneumonia) and polio. In Gloucester coverage was similar to the county rate Childhood Vaccinations (97%) at 96.5%. Vaccination coverage is the best indicator of the level of protection a population will have against vaccine preventable communicable diseases. Coverage is closely correlated with levels of disease and monitoring coverage identifies possible drops in immunity before levels of disease rise. Evidence shows that highlighting vaccination programmes encourages improvements in uptake levels.
MMR is the combined vaccine that protects against measles, mumps and rubella. Measles, mumps and rubella are highly infectious, common conditions that can have serious complications, including meningitis, swelling of the brain 36
Figure 70: DTAP/IPV/Hib at 24 months Gloucester Locality
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Long Term Conditions HQR PCN A long term condition (LTC) is defined as a condition that cannot, at present be In the Rosebank, Hadwen & Quedgeley PCN the average number of LTCs is 1.1 cured but can be controlled by medication and/or other therapies. Examples of compared with 1 for the county. Rosebank and Hadwen have a higher than LTC are diabetes, heart disease and chronic obstructive pulmonary disease county prevalence for smoking (20% and 17.2% compared with 15.9% for the (COPD). Nationally, people with LTCs account for 50% of all GP appointments; county), depression (20.7% and 19.3% compared with 15.5%) and obesity (12.7% 64% of all outpatient appointments and over 70% of all inpatient bed days22. and 12.2% compared with 10.1%). Quedgeley has lower than county prevalence for all the conditions other than obesity which is slightly higher at 10.4%. LTCs are more prevalent in older people and in more deprived groups and the number of people with multiple LTCs appears to be rising. Multi-morbidity is It’s useful to look at different segments of the population to see how the burden associated with reduced quality of life, higher mortality, polypharmacy and high of disease differs. 8.6% of children in HQR have LTCs with the highest prevalence treatment burden, higher rates of adverse drug events, and much greater health being for depression (0.4%) and smoking (0.7%). services use (including unplanned or emergency care). For working age adults, 61.7% have LTCs compared with 55.9% at county level. In Gloucester City ‘place’ prevalence in lifestyle related conditions are notably There is higher than county prevalence for COPD, diabetes, depression, obesity above the overall CCG rate (see figure 55). Smoking prevalence is 3.5% higher and smoking. than in the CCG population as a whole, with Inner City practices also having some We know that the prevalence of LTCs increases with age and older adults (65 of the highest rates of COPD. Obesity and Diabetes are also significantly above years and over) in HQR PCN have an average of 2.5 LTCs with 62.3% of this CCG prevalence for all PCNs, most notably for Aspen. segment having an LTC. Older adults have higher than county prevalence for all the listed LTCs apart from cancer.
Rosebank Gloucester RHQ Hadwen Quedgley RHQ PCN CCG average City Place Cancer 2.9 3.1 2.4 2.8 3 3.9 CHD 2.5 2.7 1.7 2.5 2.8 3.2 COPD 2 1.3 0.7 1.5 1.9 1.8 Dementia 0.7 0.9 0.3 0.7 0.7 0.9 20.7 Depression 19.3 14.6 19.2 16.5 15.3 5.5 Diabetes 6.5 0.5 5.7 6.2 5.5 Figure 71: QOF reporting long-term conditions, Gloucestershire CCG Obesity 12.7 12.2 10.4 12.8 13 10.1 20 Smoking 17.2 14.8 18.3 20.3 15.9 22 http://www.kingsfund.org.uk/time-to-think-differently/trends/disease-and- Table 2: Prevalence of LTCs across HQR PCN Practices (%) February 2019 disability/long-term-conditions-multi-morbidity. Accessed 11th April 2019 38
Inner City PCN 67.1% of older adults have a LTC and each patient has on average 2.3 LTCs. 23.5% Across the practices, prevalence of smoking in particular stands out with all of older adults smoke in NEG PCN compared with 12.1% at county level. Older practices having much higher than county rate. Prevalence of obesity and adults also have higher than county prevalence for CHD, COPD, diabetes and diabetes are also high. obesity. The PCN has 8.9% of children with LTCs with the highest prevalence for depression (0.3%), diabetes (0.3%) and smoking (1%). For working age adults, Children in Inner City PCN have higher than county prevalence of obesity (0.8% 57.1% have LTCs with prevalence of all listed conditions lower than the county compared to 0.6%). 11.5% have LTCs compared to 9.9% in the county. For rate apart from smoking (25.8% compared with 22.5% for the county). working age adults the highest prevalence rates are for diabetes, obesity and The Alney smoking which mirrors the picture in the Locality as a whole. Older adults have Gloucester NSG Practice Brockworth Churchdown Hucclecote Longlevens NSG PCN CCG average on average 2.5 LTCs per patient and have higher than county prevalence for all City Place conditions apart from cancer and depression. Cancer 4.2 3.4 4.3 5.7 3.3 4.1 3 3.9 CHD 3.6 2.8 3.7 3.9 3.1 3.5 2.8 3.2 2.1 Bartongate City COPD 1.8 1.6 2 1.9 1.8 1.9 1.8 Partners Inner Gloucester CCG Inner City Health GHAC Kingsholm Dementia 0.8 1.1 0.9 1.2 1 0.9 0.7 in Health City PCN City Place average 0.9 Centre 11.8 Cancer 2 2.8 1.3 2.7 3.3 2.4 3 3.9 Depression 14.6 16.4 12 17 14.3 16.5 15.3 CHD 2.6 3.4 1.2 2.3 3.1 2.5 2.8 3.2 Diabetes 6 6.1 6 7 5.3 6 6.2 5.5 COPD 2.5 2.5 1.5 1.7 3.1 2.1 1.9 1.8 Obesity 10.5 10.1 9.4 11.1 13.5 11.5 13 10.1 Dementia 0.5 0.9 0.5 0.8 1.3 0.7 0.7 0.9 Smoking 30.6 18.4 16.6 10.7 11.6 18.4 20.3 15.9 Depression 10.4 15.3 11.9 10.2 16.4 12 16.5 15.3 Table 4: Prevalence of LTCs across NEG PCN Practices (%) February 2019 Diabetes 8.4 7.5 3.7 5.6 7.8 6.4 6.2 5.5 Obesity 10.9 11.8 10.4 12.3 14.8 12.4 13 10.1 Aspen PCN Smoking 20.7 27.6 30.3 16.8 21 22.6 20.3 15.9 Table 3: Prevalence of LTCs across Inner City PCN Practices (%) February 2019 In Aspen PCN the prevalence of depression (20.3%), Diabetes (7.1%), obesity (14.4%) and smoking (18.6%) are all higher than the county rate NSG PCN
For North/South Gloucester PCN the average number of LTCs is slightly higher than the county rate at 1.1. Prevalence of smoking at the Alney Practice is 30.6 compared with 19.4 for the Locality and 15.9 for the county. Three out of five practices have higher than county prevalence for obesity. Hucclecote has higher than county prevalence for all conditions apart from depression and smoking.
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Aspen PCN Gloucester Gloucestershi Aspen Frailty City Place re Frailty is a medical syndrome with many causes. Lots of medical conditions may Cancer 3.8 3 3.9 contribute to frailty causing people who have it to have a loss of strength, CHD 3.4 2.8 3.2 stamina and reduced physical function. There are different degrees of frailty; COPD 2 1.9 1.8 mild, moderate and severe. Frailty is often associated with ageing, but becoming Dementia 0.8 0.7 0.9 frail is not necessarily a consequence of getting older. It can also affect younger 20.3 Depression 16.5 15.3 people, particularly those living with an ongoing health condition. Appropriate 7.1 Diabetes 6.2 5.5 exercise and nutrition can reduce a person’s degree of frailty and increase their 14.4 Obesity 13 10.1 level of independence24. Smoking 18.6 20.3 15.9 Table 5: Prevalence of LTCs across Aspen PCN (%) February 2019 Using population projections we can see the current and future estimated prevalence of frailty by locality. In all localities prevalence is predicted to grow in There are 10.2% of children with LTCs compared with a county rate of 9.9%. As in all age bands above 60 by 2028. the other PCNs, prevalence is highest for depression, diabetes, and obesity and smoking. For working age adults, 62.2% have LTCs with higher than county Mild Moderate Severe All Fit prevalence for all listed conditions apart from cancer and COPD. 2.2% in this District Frailty Frailty Frailty frailty segment are classified as ‘frail’ compared with 0.6% for the county. Only 12% of Cheltenham 89.1% 8.1% 2.4% 0.4% 10.9% older people are classified as ‘healthy’. Cotswold 85.7% 10.5% 3.2% 0.7% 14.3% Forest of Dean 84.8% 11.5% 3.2% 0.5% 15.2% MSK Gloucester 85.6% 10.5% 3.3% 0.7% 14.4% Musculoskeletal disorders (back and neck pain, osteoarthritis and rheumatoid Stroud 87.5% 9.3% 2.7% 0.5% 12.5% arthritis) account for about a quarter of the years lived with disability in England. Tewkesbury 85.5% 10.6% 3.3% 0.6% 14.5% They result in pain and physical inactivity which are recognised risk factors for Gloucestershire 86.6% 9.9% 3.0% 0.6% 13.4% developing other long-term conditions such as depression, cardiovascular total Table 6: Prevalence of Frailty by District (2018) conditions and some cancers. They also cause a considerable burden to social and informal care as both the prevalence and severity of these disorders increase with age.23
Further data and analysis will be included in the next iteration of the profile.
23 https://www.england.nhs.uk/rightcare/products/ccg-data-packs/focus-packs/focus- packs-for-cancer-mental-health-and-dementia-msk-and-trauma-may-2016/ 24 Living with Frailty – a Gloucestershire needs assessment - 2018 40
problems represent the largest single cause of disability in the UK. The cost to the economy is estimated at £105 billion a year – roughly the cost of the entire NHS25.
It is intended that a more detailed supplement on Mental Health will be developed in 2019/2020.
Learning Disabilities We know that the proportion of emergency admissions to general hospitals is substantially larger for people with learning disabilities than for those who do not have learning disabilities (50% versus 31%).For people with learning disabilities, about 8 out of every 100 admissions are emergencies that might be preventable (compared to 5 in every 100 for those without). Annual health checks are designed to promote the early detection and treatment of physical and mental health problems, which can lead to better health outcomes and wellbeing, as well Figure 72: Source: ELSA (and private correspondence with Professor C. Gale, University of as reducing avoidable admissions26.27. Southampton), https://inform.gloucestershire.gov.uk/population/population-projections/ Annual health-checks are aimed at those people with a learning disability thought Table 19 shows prevalence broken down by District and by level of frailty. Using to have the greatest need and are offered to people whose GP has registered this method, 85.6% of Gloucester patients would be categorised as ‘fit’; 10.5% as then as having learning disability. The number of people with a learning disability mildly frail; 3.3% as moderately frail and 0.7% as severely frail with overall on GP registers is much smaller than the likely true number of people with a prevalence of frailty 14.4%, slightly higher than the county average. learning disability, although it should include those with the highest need. NHS England recommends targeted case-finding, risk stratification and electronic Based on local audit data, in 2018/19 there were approximately 1129 people assessment tools in primary care and the community to identify frailty. It is recorded by primary care as having a learning disability in Gloucester City. For important to have a consistent approach across all organisations involved in the those on the learning disabilities GP register; care pathway. 61% had received an annual health-check (692 people) Mental Health and Neurology Mental health problems are widespread yet often hidden. One in four adults 25 The Five Year Forward View for Mental Health, 2016. https://www.england.nhs.uk/wp- experiences at least one diagnosable mental health problem in any given year. content/uploads/2016/02/Mental-Health-Taskforce-FYFV-final.pdf 26 People in all walks of life can be affected and at any point in their lives, including Perry, J., Kerr, M., Felce, D., Bartley, S. and Tomlinson, J. (2010) Monitoring the Public Health Impact of Health Checks for Adults with a Learning Disability in Wales. new mothers, children, teenagers, adults and older people. Mental health 27 Hampson, C. et al. Addressing Health Inequalities in People with Learning Disabilities 2017/18 41
This is slightly lower than the 65% target for Gloucestershire Table 21 - Uptake of screening programmes for those with a Learning Disability (2018/19, PCAG audit GCCG) Sum of LD Sum of Patients with LD Locality % Health Check What can partners do? Gloucester City 1129 692 61% Recognise potential barriers to equitable healthcare The Forest of Dean 633 499 79% (table 22) Stroud and Berkeley 678 449 66% Make reasonable adjustments Vale Use the LD toolkit and easy read, accessible information Cheltenham 574 287 50% available on G Care for people with a learning disability Tewkesbury Newent 213 139 65% Undertake locally available training on supporting and Staunton people with a learning disability North Cotswolds 80 55 69%
South Cotswolds 119 46 39% Grand Total 3426 2167 63% A lack of accessible Failure to recognise that a Lack of joint working from transport links person with a learning different care providers Table 20: Age 14+ PCCAG Learning Disabilities Audit Q4 2018/19, split by Locality disability is unwell Patients not being Failure to make a correct Not enough involvement Uptake of all screening programmes in Gloucestershire was lower for people with identified as having a diagnosis allowed from carers a learning disability compared to the population without a learning disability. learning disability Uptake in Gloucester City was lower than the county average for all four Staff having little Anxiety or a lack of Inadequate aftercare or screening programmes (cervical, breast, bowel and retinal). understanding about confidence for people with follow-up care. learning disability a learning disability Cervical Breast Bowel Retinal screening screening screening screening Table 22 - Potential Barriers to equitable healthcare (Source: Heslop et al. 2013; Tuffrey- coverage coverage coverage coverage Wijnes et al. 2013; Allerton and Emerson 2012) Cheltenham 37.7% 35.5% 37.5% 52.2% Forest 26.4% 49.4% 22.8% 71.4% Gloucester City 25.1% 34.5% 20.2% 57.5% North Cotswold 26.9% 66.7% 77.8% 66.7% Dementia: South Cotswold 35.3% 57.1% 35.7% 56.3% Dementia is a broad category of brain diseases that cause a long-term and often Stroud and BV 23.7% 55.9% 64.4% 56.9% gradual decrease in the ability to think and remember that is great enough to Tewkesbury 21.4% 44.4% 90.5% 71.4% Gloucestershire 27.4% 44.8% 39.5% 59.6% affect a person's daily functioning. Other common symptoms include emotional problems, difficulties with language, and a decrease in motivation.
The recorded dementia prevalence provides an indication of the concentration, within a population, of the number of people aged 65 or older who have been 42
diagnosed and who are now living with the condition. This data can be used to The figure below shows that our records of ethnicity in the dementia patient inform local service planning as to the scale of services required to provide cohort are incomplete as ethnicity is not recorded in more than half of cases. treatment, care and support as needed, so those with dementia can live well with the condition.
Overall the county is achieving the Dementia Diagnosis target of 66.7%. The Estimated Dementia Rate for over 65's is based on the national figure, this is split to GP practices based on the over 65 population.
Figure 75: Dementia cohort by ethnicity and gender
You can see below a breakdown of the dementia cohort by electronic frailty index Figure 73: Dementia Diagnosis rate (Gloucestershire, April 2019) category (eFI). Dementia patients with moderate frailty are the largest group for females and mild frailty is the largest group for males. You can see in the figure below that recorded dementia prevalence is higher for females than for males with the greatest prevalence is in the 85 to 89 age group. For men the highest prevalence is in the 80 to 84 age group.
Figure 76: Dementia cohort by eFI category
If we look at the utilisation of secondary care by the dementia cohort we can see that 42.1% of patients had an ED attendance at least once in the previous 12 Figure 74: Dementia cohort by 5 year age band and gender months (April 2019) and many had more than one.
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Figure 77: Dementia Cohort Multiple ED Attendances (April 2019)
73.2% of attendances at ED resulted in admission for dementia patients and the average length of stay was 7.6 days.
Figure 78: Dementia Cohort Multiple Emergency Admissions (April 2019)
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Respiratory Disease This further underlines the importance of smoking cessation interventions during It is estimated that around 21% of the population of Gloucester City smoke 28 pregnancy (and in parents of infants and young children); and encouraging all which is much higher than the county average of 14%. Smoking status at time of those involved in the care of pregnant women or in contact with parents, to delivery has been in decline in Gloucestershire but increased in 2017/18 to 10.9% signpost or refer to appropriate sources of local support. Exposure to poor air (comparable to the England average). quality, primarily Particulate Matter (PM) and Nitrogen Dioxide;
Increases risk of developing respiratory diseases Smoking cessation Increases risk of respiratory exacerbations and acute admissions to services Around 3 to 4 in 100 people remain non-smokers after a year when they Is a source of inequality (where those who are most deprived are also the choose to make an unassisted quit attempt. most likely to live in areas with the highest level of exposure)
Around 16 in 100 people remain non-smokers a year later when they Air quality levels for PM2.5 and PM10 in Gloucestershire are in line with regional choose to quit with support from a trained stop smoking advisor and use a averages. Estimated levels are highest in Tewkesbury and Cheltenham, which are stop smoking aid. both higher than regional averages29.
What can partners do?
1. ASK and record smoking status: is the patient a smoker, ex-smoker or a non-smoker? 2. ADVISE on the best way of quitting: the best way of stopping smoking is with a combination of medication and specialist support. 3. ACT by offering referral to specialist support and prescribing medication if appropriate: smokers who get expert support are up to 4 times as likely to quit successfully.
To refer to Gloucestershire Healthy Lifestyle Service www.hlsglos.org/health- professional-referral/
Smoking and exposure to second-hand smoke is one of the leading modifiable risk factors for childhood asthma and other respiratory conditions in childhood.
Infants whose parents smoke are also more likely to be admitted to hospital for Figure 79: Modelled estimate of particulate matter (Gloucestershire County Council, bronchitis and pneumonia during the first year of life. 2018)
28 PHOF (2019) Adult smoking prevalence 29 CDRC https://data.cdrc.ac.uk/dataset/access-to-healthy-assets-and-hazards-ahah 45
What can partners do? Management Promote clean and accessible public transport and It is recommended by NICE31 that patients with COPD are reviewed annually (bi- active travel annually for those with very severe COPD). The annual review offers an Strengthen air quality, health and active transport opportunity to; review medication, discuss management strategies for in planning breathlessness, refer to pulmonary rehabilitation, develop individual care plans, Engage and educate the public on air quality and monitor disease status and to promote preventative interventions such as health Improve monitoring and information sharing of air smoking cessation and immunisations. In 2017/18; quality in Gloucestershire. Review their own fleet and to reduce emissions. 75.5% of patients with COPD had received a review in the preceding 12 months (including an assessment of breathlessness) COPD diagnosis and management This is lower than the county average of 78.6%, In Gloucester City the prevalence of people with COPD is 1.8% (comparable to the This is consistent across all four PCN’s county average of 1.8%). This equates to 2565 people. CCG Gloucester Aspen Inner RQH PCN NSG PCN Early detection and diagnosis average City Place PCN City PCN Nationally around a third of people with a first hospital admission for a COPD 78.6% 75.5% 77.5% 72.1% 72.8% 74.0% exacerbation have not been previously diagnosed30. Diagnosis requires access to Table 8: % of COPD patients who have had a review, undertaken by a healthcare professional, including an assessment of breathlessness using the Medical Research Council dyspnoea scale in high quality spirometry testing across the county. In 2017/18; the preceding 12 months (QOF published data 2017/18) 75.2% of patients had had their diagnosis of COPD confirmed by post People living with COPD are more at risk of serious complications from bronchodilator spirometry within the recommended timeframe contracting Influenza and as such are eligible for a free annual flu immunisation. This is lower than the county average In 2017/18 This is consistent across all four PCNs The percentage of patients with COPD who were recording as having had their influenza immunisation was 80.4%,, CCG Gloucester Inner City average City Place Aspen PCN PCN RQH PCN NSG PCN This is lower than the county average of 82.6% (figure X). However there was variation across PCN’s with higher uptake in Aspen 82.0% 75.2% 74.1% 72.5% 78.3% 78.3% Table 7: % of COPD patients where the diagnosis has been confirmed by post bronchodilator and N&S Gloucester PCN’s spirometry between 3 months before and 12 months after entering on to the register (QOF published data 2017/8)
30 NHS (2019) Long Term Plan. 31 NICE (2018 ) Chronic Obstructive Pulmonary Disease NG115 46
CCG Gloucester Aspen Inner City This is consistent across all four PCN’s RQH PCN NSG PCN average City Place PCN PCN CCG Gloucester Inner City Aspen PCN RQH PCN NSG PCN 82.6% 80.4% 82.5% 78.1% 79.0% 85.6% average City Place PCN Table 9: The percentage of patients with COPD who have had influenza immunisation in the 83.0% 77.4% 77.5% 79.2% 73.4% 78.6% preceding 1 August to 31 March (QOF published data 2017/18) Table 10: % of patients aged 8 or over with asthma (diagnosed on or after 1 April 2006), on the register, with measures of variability or reversibility recorded between 3 months Pulmonary Rehabilitation (PR) before or any time after diagnosis (QOF published data 2017/18) Nationally it is estimated that PR has only been offered to 13% of eligible COPD patients, with a focus on those with more severe COPD. Increasing the number of Management eligible individuals being referred onto PR is important to reduce and prevent NICE recommend that all asthma patients have a written personalised action exacerbations and admissions and increase the quality of life of those living with plan, which identifies potential triggers for the patient33. Research cited within COPD. It is recommended that practices identify those patients that are eligible this guidance highlights that without an action plan children with asthma are four for PR but have not been referred. times more likely to have an asthma attack needing emergency hospital care. In 2017/18; Co-morbidities Co-morbidities are common in the case of COPD. This is partly due to shared risk Completion of a 12 month review for patients with asthma was 64.6% in factors, such as older age and smoking. Research suggests that the most common Gloucester City co-morbidities with COPD are cardiovascular conditions and lung cancer. Studies This was lower than the county average of 70.0% have also reported higher prevalence of osteoporosis and depression among This was consistent across all four PCN’s COPD patients32 (local data on co-morbidities for specific PCN populations with COPD can be found in the ILR). CCG Gloucester Inner City Asthma diagnosis and management Aspen PCN RQH PCN NSG PCN average City Place PCN Prevalence of Gloucester City is 6.0%, lower than the county average of 6.6%. 70.0% 64.6% 61.7% 59.2% 67.5% 65.5% There are 8578 people on the asthma register in this locality. Table 11: % of asthma patients, on the register, who have had an asthma review in the preceding 12 months that includes an assessment of asthma control using the 3 RCP Confirmation of diagnosis is lower than the county average (77.4% V questions (QOF published data 2017/18) 82.9%
32 Cavailles et al (2013) Comorbidities of COPD, European Respiratory Review, 22(130); Franssen and Rochester (2014) Comorbidities in patients with COPD and pulmonary rehabilitation: do they matter? European Respiratory Review, 23(131) 33 NICE quality standard (QS25) Asthma. 47
Admissions The rate of Asthma Admissions by age band for Gloucester City is considerably above the rate per 1000 population for the CCG (these are emergency admissions where the primary diagnosis is coded as Asthma) (figure 64). However, the rate calculated is per 1000 total population (not just the asthma population). Further work is needed to refine this measure as the variation could, at least in part, be explained by prevalence.
As with Asthma, the rates of COPD admissions for Gloucester City are higher than the CCG position (figure 65). This is particularly evident in the over 75s, however, this will need to be adjusted for the COPD population, to remove the impact of prevalence on the findings.
Figure 81: Respiratory admissions (COPD) per 1000 population (2018/19, 5 year age bands)
What can partners do? ASK, ADVISE and ACT to increase smoking cessation for people at all stages of disease severity in all settings Increasing uptake of annual reviews, this may require delivering the review differently to target different populations Encourage everyone with COPD to have the annual flu jab and the one- off pneumococcal vaccination Identify those eligible for pulmonary rehabilitation that have not been referred to Pulmonary Rehabilitation from COPD registers and refer Figure 80: Respiratory admissions (asthma) per 1000 population (2018/19 5 year age Encourage the use of supported self-management tools including bands) MyCOPD Increase the number of staff in primary care trained and accredited to interpret spirometry results to ensure that testing is available within 2-4 weeks (consider pooling resource within PCNs)
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Adopt a preventative approach to respiratory exacerbations or acute illness through; - Timely access to swallowing assessments and interventions - Increasing uptake of flu immunisations for those at risk and - Raising awareness of the impact of damp and cold housing on health - Home Self-Management plans and Home Rescue Medications Consider a multi-disciplinary approach and personalised care planning for people living with severe or poorly controlled respiratory conditions, and those living with multi-morbidity. Apply a consistent risk scoring tool for deteriorating patients with pneumonia (e.g. NEWS score) Discuss end of life planning with those living with severe illness (As of April 2020 PCNs will be expected to address medicine optimisation for Asthma and COPD through the ‘structured medications reviews and optimisation’ national service specification)
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CVD Prevention As the leading cause of death worldwide, Cardiovascular Disease (CVD) accounts There are a number of different physiological and behavioural risk factors for for 17.9 million lives each year, which is 31% of all global deaths. Poor CVD, including smoking, high cholesterol, high blood pressure, poor diet, harmful cardiovascular health can cause heart attacks, strokes, heart failure, chronic drinking and physical inactivity. It is also linked to a range of environmental and kidney disease, peripheral arterial disease, and the onset of vascular dementia. social factors. Premature death rates from CVD in the most deprived 10% of the According to PHE’s Health Profile for England, falling mortality rates from heart population are almost twice as high in the least deprived 10%. disease were the biggest cause of increases in life expectancy between 2001 and 2016 in England. However, since 2011 the rate of increase in life expectancy has slowed for both sexes as improvements in heart disease mortality have plateaued. This highlights the need for a renewed drive to prevent CVD deaths, which still account for one in four of all deaths in England; the equivalent to one death every four minutes34.
CVD is one of the conditions most strongly associated with health inequalities. If you live in England’s most deprived areas, you are almost four times as likely to die prematurely as those in the least deprived. CVD is also more common where a person is male, older, has a severe mental illness, or ethnicity is South Asian or African Caribbean.
High quality primary care is key to improving CVD outcomes as a large proportion of prevention, diagnosis and treatment is delivered in a primary care setting. PHE’s CVD Primary Care Intelligence Pack notes that some practices are more effective than others at reaching their whole population. Looking at variation across Practices and benchmarking exception reporting can help to generate Healthcare professionals can make every contact count to encourage behaviour questions which will drive quality improvement such as: ‘how many people would change to reduce the risk of CVD, with focus on poor diet, physical inactivity, benefit if average performers improved to the level of best performers?’ and smoking and excess alcohol. ‘what are the better performers doing differently in the way that they provide services in order to achieve better outcomes?’.
34 https://publichealthmatters.blog.gov.uk/2019/02/14/health-matters-preventing- cardiovascular-disease/ 50
What can partners do? AF by two thirds however despite this; AF is underdiagnosed and under-treated. Social prescribing and wellbeing hubs offer models for supporting Nationally, only half of all individuals with known AF who suffer a stroke have behaviour change while reducing burden on general practice. been anticoagulated. The NHS Health Check is a systematic approach to identifying local people at high risk of CVD, offering behaviour change PHE estimate that there are 3076 people with undiagnosed AF in NHS support and early detection of the high risk but often Gloucestershire CCG with the range of observed to expected AF prevalence across undiagnosed conditions such as hypertension, atrial fibrillation, GPs 0.62 to 1.10. Of those patients who have been diagnosed with AF in the chronic kidney disease (CKD), diabetes and prediabetes. county, 90.5% of patients have been risk assessed for stroke compared with
QUESTION: What proportion of our local population is receiving the NHS 92.3% for the CCG average and 93.6% for England. Health Check and how effective is the follow-up management of their England CCG Glouceste Inner Aspen 35 NSG PCN RHQ PCN clinical risk factors in primary care? Indicator average Average r City City PCN PCN The percentage of patients with atrial fibrillation in whom stroke risk has been assessed using the CHA2DS2-VASc score risk stratification 93.6 92.3 91.1 97.7 87.9 89.3 89.6 NHS Health Check: scoring system in the preceding 12 months (excluding those patients with a previous CHADS2 or CHA2DS2-VASc score of 2 or more) The NHS Health Check offers an opportunity to assess the top 7 risk factors Table 12: % of patients with AF who have been stroke risk assessed driving premature death and disability in England among 15 million people in midlife. This includes pulse rhythm, BP and cholesterol. They are also supported The percentage of patients with AF who are currently treated with anti- to understand their risk of CVD and make positive behavioural changes that can coagulation drug therapy is 85.7% which is slightly below the CCG average prevent and delay the onset of CVD. (85.9%). There is variation between the PCNs with Inner City PCN much lower than the other PCNs and the CCG average at 82.8%. The percentage of the eligible population invited for an NHS Health Check in Q4 2017/18 in Gloucester Locality is 3.4% compared with 2.7% for the CCG. The England CCG Gloucester Inner City Aspen NSG PCN RHQ PCN percentage uptake is 57% compared with 62.2% for the CCG and the number of Indicator average Average City Place PCN PCN completed Health Checks is 709. It should be noted that this data is derived from In those patients with atrial fibrillation with a record of a CHA2DS2-VASc score of 2 or more, the percentage of patients who are currently treated 84.0 85.9 86.2 86.9 82.8 87.5 86.1 PCCAG and may differ from GP claims data. with anti-coagulation drug therapy Atrial Fibrillation Table 13: AF patients treated with anti-coagulation drug therapy Atrial fibrillation (AF) is a heart condition that causes an irregular and often Blood Pressure and Hypertension: abnormally fast heart rate. Atrial Fibrillation increases the risk of stroke by a High blood pressure is common, it affects around a quarter of all adults and costs factor of 5, and strokes caused by AF are often more severe, with higher mortality the NHS around £2 billion per year with costs for social care considerably higher. and greater disability. Anticoagulation reduces the risk of stroke in people with We know that at least half of all heart attacks and strokes are caused by high blood pressure and it is a major risk factor for chronic kidney disease and 35 PHE, CVD Primary Care Intelligence Pack for NHS Gloucestershire CCG, February 2019 51
England CCG Gloucester Inner City cognitive decline. NSG PCN RHQ PCN Aspen Indicator average Average City Place PCN There are 90,010 people with diagnosed hypertension in NHS Gloucestershire The percentage of patients aged 79 years or under with hypertension in whom the last blood pressure reading (measured in the preceding 12 79.1 79.2 77.0 82.8 75.6 79.5 70.2 CCG and of these, 71,162 (79.1%) people have blood pressure which is less than months) is 140/90 mmHg or less or equal to 150/90. This means that 18,795 (20.9%) have blood pressure that is Table 16: % patients <79yrs with hypertension treated to target. not below 150/90 and this presents an opportunity for improvement. For those patients over 80 years with hypertension, the percentage treated to England CCG Gloucester Inner City Aspen NSG PCN RHQ PCN Indicator average Average City Place PCN PCN target is 84.6% compared with 85% for the CCG. The percentage of patients aged 45 or over who have a record of England CCG Gloucester Inner City 90.5 90.2 89.8 91.8 89.8 88.4 92.1 NSG PCN RHQ PCN Aspen blood pressure in the preceding 5 years Indicator average Average City Place PCN The percentage of patients aged 80 years and over with hypertension in Table 14: % patients 45+ with a record of blood pressure in preceding 5 years whom the last blood pressure reading (measured in the preceding 12 83.4 85.0 83.2 80.5 85.8 79.8 93.2 The percentage of patients over 45 years who have a record of blood pressure in months) is 150/90 mmHg or less the preceding five years is 89.7% compared with 90.2% CCG average. Table 17: % patients >80yrs with hypertension treated to target
In those patients who have a new diagnosis of hypertension, the percentage in the Locality who are currently treated with statins is 71.8% which is significantly What can partners do? higher than the CCG (65.7%) and England averages (66.8%). In two of the PCNs, Support practices to share audit data and HQR and Aspen, this data was not available. systematically identify gaps and opportunities for improved detection and management of hypertension England CCG Gloucester Inner City NSG PCN RHQ PCN Aspen Indicator average Average City Place PCN Work with practices and local authorities to maximise In those patients with a new diagnosis of hypertension aged 30 or uptake and follow up in the NHS Health Check over and who have not attained the age of 75, recorded between the programme. preceding 1 April to 31 March (excluding those with pre-existing Support access to self-test blood pressure stations in CHD, diabetes, stroke and/or TIA), who have a recorded CVD risk 66.8 65.7 68.1 71.4 72.7 n/a n/a assessment score (using an assessment tool agreed with the NHS waiting rooms and to ambulatory blood pressure CB) of ≥20% in the preceding 12 months: the percentage who are monitoring. currently treated with statins Commission community pharmacists to offer blood Table 15: % patients <79yrs with hypertension treated to target. pressure measurement, diagnosis and management support, including support for adherence to medication. The percentage of patients aged 79 years and under with hypertension that are treated to target is 77.6% which is lower than the CCG average of 79.2%. Inner QUESTION: How can we support practices who are average and City PCN and Aspen PCN are the lowest performers in this area. below average to perform as well as the best in detection and management of hypertension?
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England CCG Gloucester Inner City NSG PCN HQR PCN Aspen Stroke and TIA: Indicator average Average Place PCN The percentage of patients with a stroke or TIA (diagnosed on or after 1 Stroke is the third most common cause of death in the developed world. One April 2014) who have a record of a referral for further investigation quarter of stroke deaths occur under the age of 65. There is evidence that between 3 months before or 1 month after the date of the latest 83.4 84.6 83.2 80.8 85.8 79.8 86.3 appropriate diagnosis and management can improve outcomes. recorded stroke or the first TIA Table 19: % patients with stroke or TIA who have record of referral A transient ischaemic attack (TIA) or "mini stroke" is caused by a temporary disruption in the blood supply to part of the brain. The disruption in blood supply results in a lack of oxygen to the brain. This can cause sudden symptoms similar What can partners do? to a stroke, such as speech and visual disturbance, and numbness or weakness in Increase opportunistic pulse checking especially in over the face, arms and legs. However, a TIA doesn't last as long as a stroke. The 65s. effects often only last for a few minutes or hours and fully resolve within 24 Support practices to share audit data and systematically identify gaps and opportunities for improved detection hours. The occurrence of a TIA is a warning that the person may be at risk of a and management of AF – e.g. GRASP-AF. more serious stroke. Promote systematic use of CHADS-VASC and HASBLED to ensure those at high risk are offered stroke prevention. The QOF prevalence of stroke (all ages) in the Locality is 1.6% which is lower than Promote systematic use of Warfarin Patient Safety Audit the CCG average of 2%, perhaps reflecting the age profile of the population. Tool to ensure optimal time in therapeutic range for people on warfarin. England CCG Gloucester Inner City Develop local consensus statement on risk balance for NSG PCN RHQ PCN Aspen anticoagulants. Indicator average Average City Place PCN Work with practices and local authorities to maximise Stroke: QOF prevalence (all ages) 1.8 2.0 1.6 2.1 1.5 1.4 2.0 uptake and clinical follow up in the NHS Health Check Table 18: Stroke QOF prevalence (all ages) programme. Commission community pharmacists to offer pulse check, The percentage of patients with stroke or TIA who have a record of referral is anticoagulant monitoring, and support for adherence to 83.2% which is lower than the CCG average of 84.6%. Again, there is variation medication. between the PCNs. The aim of rapid referral is to allow swift identification, QUESTION? How can we support practices who are average and assessment and start of treatment for the secondary prevention of vascular below average to perform as well as the best in detection of atrial fibrillation and stroke prevention with anticoagulation. events.
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Chronic Kidney Disease 67.4% completion of the 7 care processes, although practice completion varied Chronic kidney disease (CKD) is a long-term condition where the kidneys don't from 34.5% to 89.7%. work as well as they should. It's a common condition often associated with * The audit team identified a national problem in the extraction of Albumin data, getting older (around a third of people over 75 are affected). Anyone can get it, hence the additional indicator of 7 Care processes to reflect this problem. although it's more common in black people and people of south Asian origin. Approximately 7,000 excess strokes and 12,000 excess heart attacks occur each It is interesting to note that the number of patients with type 1 diabetes newly year in people with CKD compared to those without. diagnosed between January 2016 to March 2018 in Gloucestershire who were offered structured education was only 33.2% and of those, only 0.9% (or 2 out of It is intended that more detailed analysis on CKD will be included in the profile in 75) completed structured education between January 2016 to March 2018. 75.5% 2019/2020. of newly diagnosed type 2 diabetics were offered structured education but the
completion rate was still only 2.9%. These results warrant further investigation Diabetes and suggest potential to improve data collection, identification of eligible Type 2 diabetes is often preventable. People at high risk of developing Type 2 individuals, referral rates and to explore different methods to improve diabetes can be identified through the NHS Health Check Programme and completion. identification and assessment of patients that might be at increased risk. In many cases the disease can be prevented or delayed through positive behaviour It is intended that a more detailed supplement on Diabetes will be developed in changes and support. Diabetes is a major cause of premature death and 2019/2020. increases the risk of heart disease, stroke, kidney failure, amputations and blindness.
For those diagnosed with Diabetes maintaining good blood glucose control and general health is important to reduce the risk of complications. There are 8 essential care processes, in addition to retinal screening, that together substantially reduce complication rates. However, despite this there is widespread variation between GP practices in levels of achievement of these.
In 2017/18 a clinical audit of the diabetes enhanced service with Primary care showed that diabetes prevalence is 5.4% for Gloucestershire for all types of Diabetes. The average completion of 8 care processes for Gloucestershire CCG is 56.35% (eye examination excluded). This is below the 70% Enhanced Service standard. The average completion of 7 care processes for Gloucestershire CCG is at 71.5% (eye examination and Albumin excluded*). In Gloucester City there was 54
High Intensity Users
High Intensity Users have been defined as patients above a certain activity level threshold in a 12 month period, this varies by service. Overall, the CCG has just over 1 patient per 1000 that meet this definition, however, for Gloucester City that level is more than doubled at 2.13
The HIU rate per 1000 population in Gloucester Locality is 1.46 compared with 1.05 for the county and this equates to 237 high intensity users in the Locality. The rate varies at PCN level: Aspen is 2.13; HQR is 1.04; NSG is 0.77 and Inner City is 2.18 per 1000 population.
Figure 82: High Intensity User Rate per 1000 Gloucester Locality (2018)
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Health Services standardised admission ratio for emergency admissions (SAR) The change in the registered list size for Gloucester City has been consistent with 160 the overall CCG position, showing slightly higher levels of month-on-month 140 growth, but nothing significant. However, by PCN, all have seen considerable 120 growth above that of the CCG, except Aspen, when there has been a notable 100 Selection 80 reduction (figure 83). County 60 SAR 100 Marker Urgent Care 40 The Standardised Admission Ratio (SAR) is a summary estimate of admission rates 20 relative to the national pattern of admissions and takes into account differences 0 in a population's age, sex and socioeconomic deprivation. Standardised Actual Rate/1000 Expected Rate/1000 SAR
Admission ratio at 120 is higher than the countywide SAR value and 20% above Figure 84: Standardised admissions ratio for emergency admissions, Gloucester City registered expected (figure 84). population (Dr Foster, 2018/19)
Almost all place or network analysis of emergency admissions shows significant emergency admissions per 1000 population change in the rate per 1000 from around June 2018 (figure 85). However, for 9 Gloucester City this position is more pronounced, and even further still when 8 7 looking at working age adults only (18-64 years). This observation aligns with the 6 introduction of the assessment setting in GHFT and therefore could be partly due 5 4 to local policy change. 3 2 1
0
Jul-17 Jul-18
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Apr-18 Apr-17
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May-17 May-18 Countywide Mean Figure 85: Emergency admissions trend, Gloucester City registered population (2017-2019)
Referrals Although the highest in absolute terms, the referral rate to Social Prescribing services per 1000 population for Gloucester City is one of the lowest. Given the high levels of high intensity users, prevalence of life style related conditions and
Figure 83: Trend in registered list size, Gloucester City place (2017-2019) multi-morbidity it could suggest there is still considerable opportunity in this area.
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first outpatient attendances - specialty distribution vs CCG norm of 100
Audiology Urology 120 Cardiology 100 T & O 80 Dermatology 60 Rheumatology 40 Ent 20 0 Respiratory Medicine Gastroenterology
Figure 86: Referrals to the Community Wellbeing Service by GP locality (2019) Pain Management Gynaecology
Paediatrics Neurology Other Ophthalmology Outpatient Attendances When comparing first outpatient appointment rates for the Gloucester City CCG average Selection population (by specialty and indexed to the CCG rate) it appears that for all Figure 87: First Outpatient Attendances – Specialty Distribution vs CCG norm of 100 specialties apart from Paediatrics, the levels are below the county position.
Analysis has been carried out to understand the link between deprivation and access; this analysis showed that there is a strong correlation between deprivation and elective access, with the opposite relationship noted for unscheduled activity. It is therefore plausible that the above observation is related to equality and accessibility, not necessarily need.
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Prescribing Percentage of the Population Prescribed opiods in the Last 12 months
As at the end of Mach 2019 (latest position available), Gloucester City are not 9% achieving the target for 3 out of the 5 KPIs in prescribing. Most notably, the COPD 8% Indicator, which is defined as follows: 7% 6% 5% ‘At least 50% of COPD patients that obtain significant benefit from ICS and are % theof population 4% also taking LAMA & LABA should be prescribed ICS/LAMA/LABA as a formulary 3% recommended triple therapy inhaler.’ 2%
1% Within Gloucester City, both Aspen and North/South Gloucester PCN are less than 0% Aspen Gloucester Inner City Hadwen, Quedgeley and North and South 40% compliant (rated Red) with the above definition. Rosebank Gloucester
PCN CCG
Figure 89: Percentage of registered population prescribed opioids in the last 12 months (2019)
Figure 88: Prescribing Performance Against Target, April 2019
Recent analysis has shown a correlation between deprivation and the proportion of a population prescribed Opioids. Work is still under way to try to understand causation and the relationship between chronic pain and other multi-morbidities. However, when comparing the rates of Opioid use by PCN, both Aspen and North/South Gloucester are above the CCG level (figure 69).
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Mortality Average of Value Year of death 2018 Female Male Mortality rates look at the number of people who die relative to the size and age Cardiovascular diseases 839 1371 of the population at any one time, and give a general measure of the health of Digestive disorders 42 113 that population. Avoidable mortality is deaths from causes that are considered Drug use disorders 125 252 avoidable in the presence of timely and effective healthcare or public health Genitourinary disorders 0 0 36 interventions . Infections 34 91 Intentional injuries 62 168 The three biggest killers in Gloucestershire (and nationally) are malignant Maternal and infant 91 0 cancers, circulatory diseases and respiratory diseases. Neoplasms 1851 1470 Table 23 shows an overview of mortality rates by gender for each of these disease Neurological disorders 0 0 areas. Differences in mortality rates are likely to reflect true differences in the Nutritional, endocrine and metabolic prevalence of relevant risk factors, diseases and outcomes. 0 0 Respiratory diseases 717 563 Neoplasms continue to be the leading cause of avoidable mortality for women Unintentional injuries 356 807 in Gloucester locality followed by cardiovascular disease and respiratory Grand Total 343 403 disease. Table 23: Avoidable mortality by gender (Gloucester Locality) 2018
For men in Gloucester, the leading cause of avoidable mortality is neoplasms followed by cardiovascular disease and unintentional injuries.
36 https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/causesofdeath/bulletins/avoida blemortalityinenglandandwales/previousReleases 59
Glossary Grade 5, Too breathless to leave the house B G Bronchodilator Spirometry GHWB – Gloucestershire Health and Wellbeing Board Bronchodilator means the test is carried out after you have had a Gloucestershire Health and Wellbeing Board leads on improving the co- bronchodilator inhaler or nebuliser, which open your airways and ordination of commissioning across Health, Social Care and Public Health Spirometry is a breathing test that can help to diagnose and monitor lung services and brings together elected members, leaders from the NHS, conditions such as asthma and chronic obstructive pulmonary disease social care, Police and the voluntary and community sector to work (COPD). together and support one another to improve the health and wellbeing of C the local population and reduce health inequalities.
Cardiopulmonary Mortality I Cardiopulmonary death is the irreversible loss of function in the heart and ICS – Integrated Care System lungs and also this is a formal, legal definition of death. "In 2016, NHS organisations and local councils came together to form 44 D sustainability and transformation partnerships (STPs) covering the whole of England, and set out their proposals to improve health and care for Dyspnoea Scale patients. In some areas, a partnership will evolve to form an integrated The dyspnoea scale is a questionnaire that consists of five statements care system, a new type of even closer collaboration. In an integrated care about perceived breathlessness: system, NHS organisations, in partnership with local councils and others, take collective responsibility for managing resources, delivering NHS Grade 1, Breathless only with strenuous exercise standards, and improving the health of the population they serve. "
Grade 2, Short of breath when hurrying on the level or up a slight hill ILP – Integrated Locality Partnership Grade 3, Slower than most people of the same age on a level surface or Have to stop when walking at my own pace on the level. ILP’s will have a key role in bringing together health and social care at a district level. Initially they will be an Operational and Strategic partnership Grade 4, Stop for breath walking 100 meters or after walking a few of senior leaders of health and social care providers and local government, minutes at my own pace on the level supporting the integration of services and teams at PCN level. Their role 60
will be to unlock issues for PCNs and share responsibility, working with depression. Lithium also helps prevent future manic and depressive PCNs, for finding local solutions to delivering ICS priorities and tackling episodes issues which arise locally which can only be resolved collectively. LSOA In time the ambition is to see the membership of ILPs broaden to include LSOA was introduced as the smallest units of output for the 2001 Census partners whose work impacts on health and wellbeing and the wider and to avoid the frequently changing geography of electoral wards. It determinants of health, for example social prescribing, education and allows for data to be presented in a range of different sizes of area. They employment and working alongside a range of other partners and local cover England and Wales and have a minimum size of 1000 residents and communities. 400 households. "
IMD – Indices of Multiple Deprivation M The Index/indices of Multiple Deprivation is designed primarily to be a small-area measure of deprivation. But the Indices are commonly used to Mental Health and Wellbeing Strategy describe deprivation for higher- level geographies including local authority The Mental Health & Wellbeing Strategy outlines Gloucestershire's districts response to No Health without Mental Health and supports the county's Joint Health & Wellbeing Strategy Fit for the Future and Your Health. This J plans to improve outcomes relating to the mental health and wellbeing of children and young people. JHWS – Joint Health and Wellbeing Strategy Joint Health and Wellbeing Strategy (JHWS) is a plan that will aim to O improve the health and wellbeing of people in Gloucestershire. Part of the strategy will contain advice to local organisations and communities about ONS what they can do to improve health and wellbeing. Office for national statistics
L P
Lithium Therapy PAD Lithium (Eskalith, Lithobid) is one of the most widely used and studied Peripheral arterial disease (PAD) is a common condition, in which a build- medications for treating bipolar disorder. Lithium helps reduce the severity up of fatty deposits in the arteries restricts blood supply to leg muscles. It's and frequency of mania. It may also help relieve or prevent bipolar also known as peripheral vascular disease (PVD). PCNs - Primary Care Networks 61
PCNs consist of a grouping of GP practices within a coherent geographical physical development; and communication and language) and the early learning area, typically covering a population of 30-50,000 patients. goals in the specific areas of mathematics and literacy.
Pharmacotherapy Screening Pharmacotherapy is the treatment of disease and especially mental illness Screening is a way of identifying apparently healthy people who may have with drugs an increased risk of a particular condition. The NHS offers a range of Prevalence screening tests to different sections of the population. The aim is to offer Prevalence in epidemiology is the proportion of a particular population screening to the people who are most likely to benefit from it found to be affected by a medical condition (typically a disease or a risk Social Gradient factor such as smoking or seat-belt use). It is derived by comparing the The social gradient in health is a term used to describe the phenomenon number of people found to have the condition with the total number of whereby people who are less advantaged in terms of socioeconomic people studied, and is usually expressed as a fraction, as a percentage, or position have worse health (and shorter lives) than those who are more as the number of cases per 10,000 or 100,000 people.. advantaged. Q STP – Sustainability and Transformation Partnership QOF STP stands for sustainability and transformation partnership. These are The QOF is a voluntary reward and incentive programme. It rewards GP practices, areas covering all of England, where local NHS organisations and councils in England for the quality of care they provide to their patients and helps drew up shared proposals to improve health and care in the areas they standardise improvements in the delivery of primary care. The results are serve. STPs were created to bring local health and care leaders together to plan around the long-term needs of local communities. Each STP has to published every year. produce a five-year local plan covering 2016 to 2021. The purpose is to S build services around the needs of local areas rather than around existing organisations, and to work out how to meet people’s growing need for School Readiness care within limited resources.
All children defined as having reached a good level of development at the end of the EYFS by local authority. Children are defined as having reached a good level of development if they achieve at least the expected level in the early learning goals in the prime areas of learning (personal, social and emotional development;
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W
Wider Determinants Wider determinants, also known as social determinants, are a diverse range of social, economic and environment factors which impact on people’s health. Such factors are influenced by the local, national, and international distribution of power and resources which shape the condition of daily life.
WEMWBS The Warwick-Edinburgh Mental Well-being Scale (WEMWBS) is a scale of 14 positively worded items for assessing a population's mental wellbeing.
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Appendix 1: Health Summary Key: Value boxes are graded by colour depending on their position against the other Localities with pale yellow being low and deep orange being high. The values are coloured red if they are significantly higher than the county and green if they are significantly lower than the county.
Gloucestershire Gloucester
Theme Indicator Name Geography Year Age Value Value Utilisation of outdoor space for exercise County 2014/15 n/a 15.3
Housing in Poor condition (The proportion of social and private homes that fail District 2015 n/a 0.25 0.20 Place to meet the Decent Homes standard) Social Isolation: adult social care users who County 2016/17 Adult 49.2 have as much social contact as they would like Percentage with Caring Responsibilities ILP Place 2018 All Ages 17.2% 17.2% Healthy life expectancy at birth (male) County 2015 - 2017 All Ages 66.0 Individual Health Healthy life expectancy at birth (female) County 2015 - 2017 All Ages 65.9
Infant mortality (rate per 1000) District 2015 - 2017 n/a 3.3 4.2 Unemployment District 2017/18 16+ 2.9% 3.4% Gap in employment rate between those with a long term condition and overall employment District 2017/18 16+ 10.5% 4.5% Wider Gap in employment rate between those with a Determinants of County 2017/18 16-64 74.7% learning disability and overall employment Health Gap in employment rate for those in contact with secondary mental health services and County 2016/17 16-64 68.1% overall employment Low birth weight of term babies District 2016 n/a 2.2% 2.3% Children Good Level of Development at the end of reception District 2016/17 5 69.2% 67.0% 64
Good level of development at the end of reception - free school meals District 2014/15 5 48.9% 48.3% Children's wellbeing (score out of a maximum of 70) District 2018 14/15 47.2 46.7 Average Happiness Score (10 = completely happy) District 2017/18 16+ 7.4 7.2 Average life satisfaction score District 2017/18 16+ 7.8 7.8 Personal (10 = completely satisfied) Wellbeing Average worthwhile score (10 = feel what you do is worthwhile) District 2017/18 16+ 7.9 7.8 Average anxiety score (10 = completely anxious) District 2017/18 16+ 2.8 2.8 Violent crime - hospital admissions for violence 2015/16 - District All Ages 23.6 43.3 (rate per 100,000) 2017/18 Violent Crime Domestic abuse-related incidents and crimes County 2017/18 16+ 18.9 (rate per 1,000) Air Quality (concentration of nitrogen dioxide, Air Quality benzene, sulphur dioxide and particulates) District 2015 n/a 0.84 0.97 Cardiovascular Disease (male) ILP Place 2018 All Ages 66.5 84.7 Cardiovascular Disease (female) ILP Place 2018 All Ages 29.3 43.3 Digestive Disorders (male) ILP Place 2018 All Ages 3.0 5.2 Digestive Disorders (female) ILP Place 2018 All Ages 2.9 1.7 Drug use disorders (male) ILP Place 2018 All Ages 12.6 12.6 Avoidable Drug use disorders (female) ILP Place 2018 All Ages 8.9 7.9 mortality (rate Genitourinary disorders (male) ILP Place 2018 All Ages 0.3 - per 100,000) Genitourinary disorders (female) ILP Place 2018 All Ages 0.3 - Infections (male) ILP Place 2018 All Ages 2.3 4.6 Infections (female) ILP Place 2018 All Ages 0.9 1.5 Intentional injuries (male) ILP Place 2018 All Ages 11.7 15.6 Intentional injuries (female) ILP Place 2018 All Ages 3.4 4.2 Maternal and Infant (male) ILP Place 2018 All Ages 4.2 1.3 65
Maternal and Infant (female) ILP Place 2018 All Ages 4.2 4.6 Neoplasms (male) ILP Place 2018 All Ages 61.6 79.3 Neoplasms (female) ILP Place 2018 All Ages 65.0 85.9 Neurological disorders (male) ILP Place 2018 All Ages 0.7 - Neurological disorders (female) ILP Place 2018 All Ages 0.3 - Nutritional, endocrine and metabolic (male) ILP Place 2018 All Ages 0.4 - Nutritional, endocrine and metabolic (female) ILP Place 2018 All Ages 0.3 - Respiratory diseases (male) ILP Place 2018 All Ages 25.0 29.1 Respiratory diseases (female) ILP Place 2018 All Ages 18.7 32.1 Unintentional injuries (male) ILP Place 2018 All Ages 31.3 41.7 Unintentional injuries (female) ILP Place 2018 All Ages 18.7 17.8 Cancer screening programmes (breast) – coverage (screened in last 3 years) ILP Place 2017/18 50-70 75.5% 71.6% Cancer screening programmes (bowel) – coverage (screened in last 2.5 years) ILP Place 2017/18 60-69 62.2% 58.6% Screening Bowel: 60-69 uptake of invitation to screen in year (screened within 6 months) ILP Place 2017/18 60-69 61.4% 58.5% Cancer screening programmes (cervical) - coverage (screened in last 3.5 or 5 years) ILP Place 2017/18 25-64 76.0% 73.3% Seasonal flu vaccination programme (2-4 yr olds) ILP Place 2017/18 2-4 42.9% 37.4% Immunisations: Seasonal flu vaccination programme (at risk ILP Place 2017/18 6m-65 50.9% 50.3% Flu individuals) Seasonal flu 65+ ILP Place 2017/18 65+ 74.7% 75.2% Seasonal flu pregnant women ILP Place 2017/18 All Ages 49.4% 50.6% Childhood vaccinations - Dtap/IPV ILP Place 2017/18 0-2 97.1% 96.0% Immunisations: Childhood vaccinations - MMR vaccinations (2 dose pre-school boosters) ILP Place 2017/18 5 91.0% 89.3% Childhood obesity - reception District 2017/18 5 9.9% 10.7% Obesity Childhood obesity - Year 6 District 2017/18 11 17.8% 21.5%
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Physical activity % adults doing 150 + mins Physical activity moderate exercise per week District 2016/17 19+ 69.2% 64.4% % Y10 children who, when asked "Do you drink alcohol?", answered: "Sometimes (eg Alcohol District 2018 14/15 34.8% 27.0% monthly)", "Quite often (eg weekly)", "Most days". Smoking prevalence - adults District 2017 18+ 14.3% 21.3% Smoking: Smoking prevalence - young people District 2018 14/15 9.2% 5.8% Prevalence Smoking in pregnancy County 2017/18 All Ages 10.9%
The percentage of patients whose notes record smoking status in the preceding 12 months with any or any combination of the following conditions: CHD, PAD, stroke or TIA, ILP Place 2017/18 All Ages 93.4% 91.4% hypertension, diabetes, COPD, CKD, asthma, schizophrenia, bipolar affective disorder or other psychoses The percentage of patients who are recorded as current smokers who have a record of an Smoking: offer of support and treatment within the Cessation preceding 12 months with any or any ILP Place 2017/18 All Ages 94.6% 92.6% combination of the following conditions: CHD, PAD, stroke or TIA, hypertension, diabetes, COPD, CKD, asthma, schizophrenia, bipolar affective disorder or other psychoses The percentage of patients aged 15 or over who are recorded as current smokers who have a record of an offer of support and treatment ILP Place 2017/18 All Ages 88.9% 82.4% within the preceding 24 months
Health Checks Health checks completed as a percentage of ILP Place 2017/18 All Ages 60.1% 54.8% health checks offered
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Appendix 2: Diabetes Enhanced Service Clinical Audit Q4 2017/18 Summary
Gloucestershire CCG Diabetes Enhanced Service Clinical Audit Q4 2017/18 Summary
Introduction
This clinical audit has been continued in 2018 to support evaluation of the Diabetes Enhanced Service for primary care, and extracted data up to end March 2018. The overall countywide results showed that:
Diabetes prevalence is 5.40% for Gloucestershire for all types of Diabetes The average completion of 8 care processes for Gloucestershire CCG is at 56.35% (eye examination excluded). This is below the 70% standard set by the ES. The average completion of 7 care processes for Gloucestershire CCG is at 71.48% (eye examination and Albumin excluded)
There is wide practice variation and many outstanding achievements, so we encouraged practices to view their results. We believe there may still be a national problem in the extraction of Albumin, hence the additional indicator of 7 Care processes to reflect this problem (Indicator 15).
All figures are an average for the CCG as a whole, so practice variation should be taken into account when looking at these results. Individual results for each GP practice are available. Audit results are being distributed to each GP Practice for review prior to the extraction of the National Diabetes Audit to allow practices to review and enhance their patient records prior to the national extraction.
Methodology 79 out of 80 Gloucestershire CCG practices undertook the audit using the MIQUEST audit method within the GP clinical systems in April 2018. GP Practices returned data securely to the CCG and data has been analysed based on the agreed audit criteria. The CCG information team has provided the figures, with checks done by PCCAG to assure accuracy.
Participation 79 out of 80 practices submitted data to PCCAG for the clinical audit achieving % participation.
Please note that Upper Thames Medical Centre, L84010 (Previously Park surgery – L84010 and Lechlade MC – L84055) were unable to upload their data due to Firewall issues, currently being investigated by IT.
Results Overall NHS GCCG results are found below. Percentages are provided. These results will be discussed within the Clinical Programmes Group for Diabetes, and this report will help inform assurance and evaluation of the enhanced service.
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Glos CCG Glos CCG Glos CCG Indicator Diabetes Enhanced Service clinical audit April 2018 Jan 2017 Jan 2016 number criteria (Averages) (Averages) (Averages)
Participating GP Practices 98.7 % 100% 100%
(79) (79) (79)
Participating GP practices registered patients (Total of 633,165 635,509 629,835 practice list sizes) 1 Number of patients coded with diabetes and 5.40% 5.35% 5.15% diabetes prevalence (%) (34,171) (33,997) (32,467) (% prevalence based on total practice list size for NHS Gloucestershire CCG)
2 Number of diabetic patients with all 9 care 45.92% 46.29% 45.48% processes recorded in the preceding 15 months (% based on no. of Read coded Diabetic pts) (15,691)
3 Number of diabetic patients with 8 care processes 56.35% 55.67% 55.65% recorded in the preceding 15 months (excluding eye examination) (19,254) (% based on number of Read coded diabetic patients)
4 Number of diabetic patients with "Diabetes 2.16% 1.57% 1.47% Resolved" Read code ever recorded. (% based on no. of Read coded Diabetic pts) (739) (534)
5 Number of diabetic patients that have a valid "QoF" 99.97% 99.98% 99.89% Diabetic Diagnosis Read code recorded? (% based on no. of Read coded Diabetic pts) 11 patients 7 patients identified identified 6 Number of diabetic patients with HbA1c recorded in 94.48% without94.80% a QOF 93.59% diagnosis the preceding 15 months? (% based on no. of Read coded Diabetic pts) (32,284) 7 Number of diabetic patients with albumin recorded 66.70% 67.06% 69.32% in the preceding 15 months? (% based on no. of Read coded Diabetic pts) (22,791)
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Glos CCG Glos CCG Glos CCG Indicator Diabetes Enhanced Service clinical audit April 2018 Jan 2017 Jan 2016 number criteria (Averages) (Averages) (Averages) 8 Number of diabetic patients with creatinine recorded 94.57% 95.10% 93.96% in the preceding 15 months? (32,317) (% based on no. of Read coded Diabetic pts) 9 Number of diabetic patients with eye examination 71.07% 73.36% 70.57% recorded in the preceding 15 months? (24,284) (% based on no. of Read coded Diabetic pts) 10 Number of diabetic patients with cholesterol 90.55% 90.94% 90.50% recorded in the preceding 15 months? (30,943) (% based on no. of Read coded Diabetic pts) 11 Number of diabetic patients with foot examination 85.19% 83.50% 82.28% recorded in the preceding 15 months? (29,110) (% based on no. of Read coded Diabetic pts) 12 Number of diabetic patients with smoking status 93.87% 93.27% 83.87% recorded in the preceding 15 months? (32,077) (% based on no. of Read coded Diabetic pts) 13 Number of diabetic patients with BMI recorded in the 84.7% 84.43% 82.90% preceding 15 months? (28,927) (% based on no. of Read coded Diabetic pts) 14 Number of diabetic patients with Blood pressure 95.07% 94.48% 92.45% recorded in the preceding 15 months? (32,486) (% based on no. of Read coded Diabetic pts) 15 Number of diabetic patients with 7 care processes 71.48% 70.17% 68.14% recorded in the preceding 15 months? (Excluding Eye examination and albumin due to data extraction (24,425) problems) (% based on no. of Read coded Diabetic pts)
Patients coded with Pre-Diabetes or non-diabetic 16 3.20% 1.11% New hyperglycaemia (excluding patients diagnosed with indicator (%Diabetes)? based on no. of Read coded Diabetic pts) (20,665) (7,036) (% based on total practice list size) 70
Glos CCG Glos CCG Glos CCG Indicator Diabetes Enhanced Service clinical audit April 2018 Jan 2017 Jan 2016 number criteria (Averages) (Averages) (Averages) 17 Type 1 Diabetic patients with 8 care processes 32.32% 30.95% New recorded in the preceding 15 months? indicator (% based on no of type 1 Read coded Diabetic pts) (767/2,373) (700)
18 Type 2 Diabetic patients with 8 care processes 58.21% 56.79% New recorded in the preceding 15 months? indicator (% based on no. of type 2 Read coded Diabetic pts) (15740/27039) (14,972) 19 Unknown type diabetic patients 13.80% 15.71% New (% based on no. of Read coded Diabetic pts) indicator (4714) (5,342)
20 "Other" type diabetic patients with 8 care processes 55.56% 33.33% New recorded in the preceding 15 months. indicator (% based on no. of Read coded "Other" type Diabetic pts) (5/9) (1)
21 "Pancreas Dysfunctional" type diabetic patients with 6.67% 25.00% New 8 care processes recorded in the preceding 15 indicator months. (1/15) (3) (% based on no. of Read coded Pancreas Dysfunctional Diabetic pts)
22 "Medication induced" type diabetic patients with 8 12.50% 5.88% New care processes recorded in the preceding 15 indicator months. (% based on no. of Read coded Medication induced Diabetic pts) (2/16) (1)
23 Number of diabetic patients who also have Learning 35.5% New New Disabilities with all 9 care processes recorded in the indicator for indicator preceding 15 months (98/276) 2017/18 for 2017/18 (% based on number of patients with Diabetes and Learning Disabilities)
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Glos CCG Glos CCG Glos CCG Indicator Diabetes Enhanced Service clinical audit April 2018 Jan 2017 Jan 2016 number criteria (Averages) (Averages) (Averages) 24 Number of diabetic patients who also have Learning 46.7% New New Disabilities with 8 care processes recorded in the indicator for indicator preceding 15 months? Excluding Eye Examination (129/276) 2017/18 for 2017/18 (% based on number of patients with Diabetes and Learning Disabilities) 25. Number of patients with type 1 diabetes newly 0.9% New New diagnosed between: January 2016 to March 2018 indicator for indicator *completed structured education between: January (2/226) 2017/18 for 2016 to March 2018. 2017/18 * Please note that this only includes the completed Read codes and not the attended Read codes.
(% based on number of Patients with type 1 diabetes newly diagnosed between: January 2016 to March 2018 )
26 Number of patients with type 2 diabetes newly 2.9% New New diagnosed between: January 2016 to March 2018 indicator for indicator *completed structured education between: January (136/4747) 2017/18 for 2016 to March 2018. 2017/18 * Please note that this only includes the completed Read codes and not the attended Read codes.
(% based on number of Patients with type 2 diabetes newly diagnosed between: January 2016 to March 2018 )
27 Number of patients with type 1 diabetes newly 33.2% New New diagnosed between: January 2016 to March 2018 indicator for indicator offered (referred for) structured education between: (75/226) 2017/18 for January 2016 to March 2018. 2017/18
(% based on number of Patients with type 1 diabetes newly diagnosed between: January 2016 to March 2018 )
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Glos CCG Glos CCG Glos CCG Indicator Diabetes Enhanced Service clinical audit April 2018 Jan 2017 Jan 2016 number criteria (Averages) (Averages) (Averages) 28 28. Number of patients with type 2 diabetes newly 70.5% New New diagnosed between: January 2016 to March 2018 indicator for indicator offered (referred for) structured education between: (3347/4747) 2017/18 for January 2016 to March 2018. 2017/18
(% based on number of Patients with type 2 diabetes newly diagnosed between: January 2016 to March 2018 )
Vicky Smith (Primary Care Clinical Audit Advisor) PCCAG, NHS Gloucestershire Clinical Commissioning Group June 2018 Information analysed and provided by; Ziyad Patel (Information Analyst) CCG Information| NHS Gloucestershire Clinical Commissioning Group
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Appendix 3: Local Authority Definitions and Data Sources
Topic Indicator Name Definition Source Housing in Poor condition (The proportion Modelled estimate of the proportion of social and Indices of Deprivation (2015) Place of social and private homes that fail private homes that fail to meet the Decent Homes underlying indicators to meet the Decent Homes standard) standard. Percentage with Caring Responsibilities Question 59. People were asked: "Do you look after, or give any help or support to family members, friends, neighbours or others because of either: long-term physical or mental ill health / disability, or problems GP Practice Profile related to old age?". The indicator value is the Individual Health percentage of people who answered this question with "Yes" (various ranges of hours per week) from all respondents to this question. Infant mortality (rate per 1000) Infant mortality - Rate of deaths in infants aged under 1 PHOF year per 1,000 live births. Unemployment The unemployment count as a percentage of the Annual Population Survey economically active population aged 16+. Gap in employment rate between those The percentage point gap between the percentage of Wider with a long term condition and overall respondents in the Labour Force Survey who have a Determinants of employment long-term condition who are classified as employed Health PHOF (aged 16-64) and the percentage of all respondents in the Labour Force Survey classed as employed (aged 16- 64) Low birth weight of term babies Live births with a recorded birth weight under 2500g and a gestational age of at least 37 complete weeks as a PHOF percentage of all live births with recorded birth weight and a gestational age of at least 37 complete weeks. Children Good Level of Development at the end of Children defined as having reached a good level of Department for Education (DfE), EYFS reception development at the end of the Early Years Foundation Profile: EYFS Profile statistical series Stage (EYFS) as a percentage of all eligible children Good level of development at the end of Children with free school meal status defined as having Department for Education (DfE), EYFS 74
reception - free school meals reached a good level of development at the end of the Profile: EYFS Profile statistical series EYFS as a percentage of all eligible children with free school meal status Children's wellbeing (score out of a Self reported wellbeing of Year 10 pupils (70 = perfect Online Pupil Survey maximum of 70) score) Average Happiness Score (10 = completely Average Happiness Weightings of adults 16+ (out of 10 Office for National Statistics, Wellbeing happy) where 10 is completely happy) data Average life satisfaction score (10 = Average Life Satisfaction Weightings of adults 16+ (out of Office for National Statistics, Wellbeing Personal completely satisfied) 10 where 10 is completely satisfied) data Wellbeing Average worthwhile score (10 = feel what Average Worthwhile Weightings of adults 16+ (out of 10 Office for National Statistics, Wellbeing you do is worthwhile) where 10 is completely worthwhile) data Average anxiety score (10 = completely Average Anxiety Weightings of adults 16+ (out of 10 Office for National Statistics, Wellbeing anxious) where 10 is completely anxious) data Violent crime - hospital admissions for The number of emergency hospital admissions for Violent Crime violence (rate per 100,000) violence (external causes: ICD-10 codes X85 to Y09). PHOF Directly age standardised rate per 100,000 population. Air Quality (concentration of nitrogen Estimate of the concentration of the four pollutants dioxide, benzene, sulphur dioxide and nitrogen dioxide, benzene, sulphur dioxide and Indices of Deprivation (2015) Air Quality particulates) particulates. A higher score for the indicator represents a underlying indicators higher level of deprivation. Cardiovascular Disease (male) avoidable deaths are all those defined as preventable, amenable (treatable) or both, where each death is Avoidable counted only once; where a cause of death is both mortality (rate per PCMD preventable and amenable, all deaths from that cause 100,000) are counted in both categories when they are presented separately Cancer screening programmes (breast) – % of eligible women screened adequately within the GP Practice Profile coverage (screened in last 3 years) previous 3 years on 31st March Cancer screening programmes (bowel) – % of people eligible for bowel screening who were GP Practice Profile coverage (screened in last 2.5 years) screened Screening Bowel: 60-69 uptake of invitation to screen Screening uptake %: the number of persons aged 60-74 in year (screened within 6 months) invited for screening in the previous 12 months who were screened adequately following an initial response GP Practice Profile within 6 months of invitation divided by the total number of persons aged 60-74 invited for screening in 75
the previous 12 months
Cancer screening programmes (cervical) - % of eligible women screened adequately within the coverage (screened in last 3.5 or 5 years) previous 3.5 or 5.5 years (according to age) on 31st GP Practice Profile March Seasonal flu vaccination programme (2-4 GP practice population vaccination coverage – Flu (2-3 Immform yr. olds) years old) Seasonal flu vaccination programme (at risk GP practice flu vaccination coverage (at risk individuals individuals) from age six months to under 65 years, excluding Immform otherwise ‘healthy’ pregnant women and carers) Seasonal flu 65+ GP practice flu vaccination coverage of people aged 65+ Immform Immunisations Seasonal flu pregnant women GP practice flu vaccination coverage of pregnant women Immform Childhood vaccinations - Dtap/IPV % of eligible children who received 3 doses of Dtap / IPV Childhood Vaccination Coverage / Hib vaccine at any time by their 2nd birthday Statistics Childhood vaccinations - MMR (2 dose pre- % of eligible children who have received two doses of Childhood Vaccination Coverage school boosters) MMR vaccine on or after their 1st birthday and at any Statistics time up to their 5th birthday Childhood obesity - reception Prevalence of obesity among children in Reception (age NCMP Childhood Obesity Profile 4-5 years). Obesity Childhood obesity - Yr. 6 Prevalence of obesity among children in Year 6 (age 10- NCMP Childhood Obesity Profile 11 years). Physical activity % adults doing 150 + mins The number of respondents aged 19 and over, with valid moderate exercise per week responses to questions on physical activity, doing at least 150 moderate intensity equivalent (MIE) minutes PHOF, (Public Health England (based on Physical activity physical activity per week in bouts of 10 minutes or Active Lives, Sport England)) more in the previous 28 days expressed as a percentage of the total number of respondents aged 19 and over. Alcohol - young people % Y10 children who, when asked "Do you drink alcohol?", answered: "Sometimes (e.g. monthly)", "Quite Online Pupil Survey often (egg weekly)", "Most days". Alcohol Admission episodes for alcohol-related Admissions to hospital where the primary diagnosis is an conditions - narrow definition alcohol-attributable code or a secondary diagnosis is an PHOF alcohol-attributable external cause code. Directly age 76
standardised rate per 100,000 population (standardised to the European standard population).
Smoking prevalence - adults Smoking Prevalence in adults - current smokers (APS). PHOF Smoking prevalence - young people Do you smoke cigarettes Online Pupil Survey The percentage of patients whose notes record smoking status in the preceding 12 The percentage of patients whose notes record smoking months with any or any combination of the status in the preceding 12 months with any or any following conditions: CHD, PAD, stroke or combination of the following conditions: CHD, PAD, GP Practice Profile TIA, hypertension, diabetes, COPD, CKD, stroke or TIA, hypertension, diabetes, COPD, CKD, asthma, schizophrenia, bipolar affective asthma, schizophrenia, bipolar affective disorder or disorder or other psychoses other psychoses The percentage of patients who are Smoking recorded as current smokers who have a record of an offer of support and treatment The percentage of patients who are recorded as current within the preceding 12 months with any or smokers who have a record of an offer of support and any combination of the following treatment within the preceding 12 months with any or GP Practice Profile conditions: CHD, PAD, stroke or TIA, any combination of the following conditions: CHD, PAD, hypertension, diabetes, COPD, CKD, stroke or TIA, hypertension, diabetes, COPD, CKD, asthma, schizophrenia, bipolar affective asthma, schizophrenia, bipolar affective disorder or disorder or other psychoses other psychoses The percentage of patients aged 15 or over The percentage of patients aged 15 or over who are who are recorded as current smokers who recorded as current smokers who have a record of an GP Practice Profile have a record of an offer of support and offer of support and treatment within the preceding 24 treatment within the preceding 24 months months % eligible patients offered a health check The percentage of eligible patients offered a health PCCAG check Health checks % patients accepting a health check The percentage of invited patients accepting a health PCCAG check
77