Joint Director of Public Health Annual Report & Joint Strategic Needs Assessment

2010/11

Doncaster

> www.doncastertogether.org.uk > www.doncaster.nhs.uk > www.doncaster.gov.uk Joint Director of Public Health Annual Report & Joint Strategic Needs Assessment 2010/11

Joint Strategic Needs Assessment & Joint Director of Public Health Annual report 2010/11

> Contributors

Laurie Mott NHS Doncaster Jim Drake Doncaster MBC Jon Briggs NHS Doncaster Nick Germain NHS Doncaster Heather Coleman NHS Doncaster Ian Bates NHS Doncaster Alan Wiltshire Doncaster MBC Matthew Redden NHS Doncaster

Joint Director of Public Health Annual Report & Joint Strategic Needs Assessment 2010/11

2 Joint Director of Public Health Annual Report & Joint Strategic Needs Assessment 2010/11

> Contents

> List of figures...... 5 > Joint Director of Public Health Annual Report...... 9 > Foreword ...... 10 > Executive Summary...... 11 > Progress against recommendations ...... 13 > Challenges & Recommendations – 2010/11...... 17 > Joint Strategic Needs Assessment ...... 19 > Introduction ...... 20 > Living Well: a Doncaster overview ...... 23 > Summary - Living Well ...... 25 > Demography ...... 26 > Lifestyle & risk factors...... 40 > Ill-health & disability...... 42 > Signposts...... 45 > Starting Well: Early Years (0-4)...... 47 > Summary – Starting Well (0-4)...... 49 > Demography ...... 50 > Social and environmental context...... 52 > Lifestyle and risk factors ...... 53 > Ill-health and disability ...... 58 > Signposts...... 60 > Developing Well: School Years (5-19) ...... 61 > Summary – Developing Well (5-19) ...... 63 > Demography ...... 64 > Social & Environmental Context...... 66 > Lifestyle & risk factors...... 68 > Ill-health & Disability...... 74 > Signposts...... 78 > Developing Well: Training (15-24) ...... 79 > Summary – Developing Well (15-24) ...... 81 > Demography ...... 82 > Social & environmental context ...... 84 > Ill-health and disability ...... 87 > Signposts...... 88 > Working Well: Employment (25-64)...... 89 > Summary – Working well (25-64) ...... 91 > Demography ...... 92 > Social and environmental context...... 94 > Lifestyle & risk factors...... 98 > Ill-health and disability ...... 102 > Signposts...... 107 > Ageing Well: Retirement (65+)...... 109 > Summary – Ageing Well (65+) ...... 111 > Demography ...... 112 > Social and Environmental Context ...... 114 > Lifestyle and risk factors ...... 118 > Ill health and disability ...... 120 > Signposts...... 136 > Abbreviations ...... 137 > Appendix 1: All age all cause mortality...... 139 > Appendix 2: Policy Objectives ...... 149

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4 Joint Director of Public Health Annual Report & Joint Strategic Needs Assessment 2010/11

> List of figures

Figure 1: Areas of action across the life course...... 21 Figure 2: Total mid-year population estimates with projections for Doncaster, 1991- 2020 ...... 26 Figure 3: Changes in population by age group in Doncaster, 2009-20...... 27 Figure 4: Mid year population estimates for Doncaster by age group, 2009...... 27 Figure 5: Population estimates by ethnicity (excluding White British) in Doncaster and England, 2007...... 28 Figure 6: Changes in Doncaster’s ethnic populations (excluding White British), 2001-07 ...... 29 Figure 7: Migration into Doncaster and England & Wales, 2000/01-2007/08 ...... 29 Figure 8: Population density by community, 2009 ...... 30 Figure 9: The proportion of the Doncaster population in the most deprived 10% and 20% of England’s LSOAs according to the IMD 2007 and its domains...... 32 Figure 10: Index of Multiple Deprivation in Doncaster, 2007...... 33 Figure 11: Deprivation by Community in Doncaster, 2001...... 33 Figure 12: Economic Development Index (EDI) for Doncaster, 1999-2005...... 34 Figure 13: Weekly earnings in Doncaster and England & Wales, 1998-2009 ...... 35 Figure 14: Employment by occupation aged 16+, 2010 ...... 35 Figure 15: Urban rural map ...... 36 Figure 16: Housing by Tenure, 2008/09 ...... 37 Figure 17: The living environment domain of the IMD, 2007 ...... 38 Figure 18: CO2 emissions in Doncaster and the United Kingdom, 2005-08 ...... 38 Figure 19: Area classification by population in Doncaster, 2008 ...... 39 Figure 20: Lifestyle risk factors in Doncaster and England, 2006-08 ...... 40 Figure 21: Slope Index of Inequality in Doncaster and the England Median, 2001/05 – 2004/08 ...... 42 Figure 22: All age all cause standardised mortality rates in males with forecast (1993- 2020)...... 43 Figure 23: All age all cause standardised mortality rates in females with forecast (1993- 2020)...... 43 Figure 24: All age all cause standardised mortality rates in persons with forecast (1993- 2020)...... 44 Figure 25: Numbers of children aged 0-4 in Doncaster with forecast...... 50 Figure 26: Live birth rates in Doncaster and England & Wales, 1993-2009...... 51 Figure 27: 0-4 year olds in Doncaster’s communities, 2008 ...... 51 Figure 28: Household over-crowding in Doncaster and England & Wales (2001)...... 52 Figure 29: Women smoking at delivery in Doncaster (2006-09) ...... 53 Figure 30: Breastfeeding initiation in Doncaster, manufacturing towns and England, 2008-10...... 54 Figure 31: Breastfeeding at 6-8 weeks in Doncaster, manufacturing towns and England, 2008-10 ...... 55 Figure 32: Breastfeeding drop-off between initiation and 6-8 weeks in Doncaster, manufacturing towns and England, 2008-10...... 55 Figure 33: Children’s immunisation programmes in Doncaster and England, 2009/10.56 Figure 34: Children who have received their 1st and 2nd dose MMR immunisation by their 5th birthday in Doncaster and England, 2005/06-2009/10...... 57 Figure 35: Map of children aged 5 who have completed MMR vaccinations ...... 57 Figure 36: Stillbirth rates in Doncaster And England &Wales, 1993-2025 ...... 58 Figure 37: Infant mortality rates in Doncaster and England & Wales, 1993-2025...... 59 Figure 38: Low birth weight rates in Doncaster and England & Wales (1993-2009) ...... 59 Figure 39: Numbers of Children and young people aged 5-19 in Doncaster with projection...... 64 Figure 40: Changes in the 5-19 population by age group in Doncaster, 2009-20...... 65

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Figure 41: Changes in ethnicity in 0-15 year olds, 2001-07 ...... 65 Figure 42: Children in Poverty by LSOA in Doncaster, 2008...... 66 Figure 43: Child wellbeing index, 2009 ...... 67 Figure 44: Children and young people health index, 2010...... 67 Figure 45: GCSE attainment in Doncaster and England, 1997/98-2008/09...... 68 Figure 46: 5-16 year old Doncaster school children participating in 2 hours physical activity ...... 70 Figure 47: Obese and overweight children reception year ...... 71 Figure 48: Obese and overweight children in Year 6...... 71 Figure 49: Conception rates amongst females aged under 18...... 72 Figure 50: Risk factors associated with an increased prevalence of mental health disorders in children and young people...... 74 Figure 51: Changes in children (under 16) killed or seriously injured on the raod in Doncaster and England, 1998/00 – 2007/09 ...... 75 Figure 52: Mortality rates from accidents in children 0-14 in Doncaster, Manufacturing Towns, and England & Wales, 1993-2015...... 75 Figure 53: Age standardised mortality rates amongst males aged 0-14 in Doncaster, manufacturing towns and England & Wales...... 76 Figure 54: Age standardised mortality rates amongst females aged 0-14 in Doncaster, manufacturing towns and England & Wales...... 77 Figure 55: Age standardised mortality rates amongst persons aged 0-14 in Doncaster, manufacturing towns and England & Wales...... 77 Figure 56: Population of 15-24 years olds with projection in Doncaster, 1991-2020 ...... 82 Figure 57: Population by 5 year age group in Doncaster and England & Wales, 2009 83 Figure 58: Doncaster’s sentenced and remanded prison population compared to the resident population...... 83 Figure 59: 16-18 year olds not in Education, employment or training, 2005-10...... 84 Figure 60: IMD training and education domain ...... 85 Figure 61: Unemployment in 18-24 year olds, 2006 -10 ...... 85 Figure 62: The crime domain from the IMD ...... 86 Figure 63: Estimated numbers of problem drug users by age group in the Doncaster DAT Area, 2008/09...... 87 Figure 64: Rates of selected Sexually Transmitted Infections in Doncaster and England, 2009 ...... 87 Figure 65: Numbers of people aged 25-64 in Doncaster with projection ...... 92 Figure 66: Changes in ethnicity in 16-64/59 year olds, 2001-07 ...... 93 Figure 67: New national insurance registrations in Doncaster, 2004-08...... 93 Figure 68: Economic inactivity, 16-64 ...... 94 Figure 69: IMD employment domain ...... 95 Figure 70: JSA recipients, 16-64 ...... 95 Figure 71: Local authority-owned non-decent dwellings, 2001/02-2009/10...... 96 Figure 72: Age standardised mortality rates from chronic liver disease (including cirrhosis) in Doncaster, Manufacturing Towns, and England & Wales, 1993-2015...... 98 Figure 73: Adult participation in 30 minutes, moderate intensity sport, 2007-2010...... 99 Figure 74: Breast screening coverge rates in Doncaster and England, 2002-2009 ..... 100 Figure 75: Cervical cancer screening coverage rates in Doncaster and England, 2002/03 – 2009/10...... 101 Figure 76: All cause mortality in males (15-64)in Doncaster, Manufacturing Towns, and England & Wales, 1993-2020 ...... 102 Figure 77: All cause mortality in females (15-64) in Doncaster, Manufacturing Towns, and England & Wales, 1993-2020...... 103 Figure 78: All cause mortality in persons (15-64) in Doncaster, Manufacturing Towns, and England & Wales, 1993-2020...... 103 Figure 79: People aged 18-64 predicted to have a learning disability in Doncaster, 2010-2030 ...... 104

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Figure 80: People aged 18-64 predicted to have a mental health problem by condition in Doncaster, 2010-2030...... 104 Figure 81: Age standardised suicide & undetermined injury mortality rates (all ages) in Doncaster, manufacturing towns and England & Wales with forecasts, 1993-2015 .. 105 Figure 82: People aged 18-64 predicted to have a moderate or serious physical disability in Doncaster, 2010-2030...... 106 Figure 83: Numbers of older people aged 65+ with projection ...... 112 Figure 84: Numbers of older people aged 65-79 and 80+ with projection...... 113 Figure 85: Changes in ethnicity in 65/60+ year olds, 2001-07 ...... 113 Figure 86: Fuel poverty by LSOA ...... 114 Figure 87: Excess winter mortality in Doncaster and England, 2004/05-09/10...... 115 Figure 88: Excess winter deaths by Community, 2004-08 ...... 115 Figure 89: Income deprivation affecting older people index (IDAOPI), 2007...... 116 Figure 90: Estimated numbers of people living alone in Doncaster by age and gender, 2010-30...... 117 Figure 91: Estimated numbers of people resident in nursing homes (with or without local authority nursing) in Doncaster by age, 2010-30 ...... 117 Figure 92: Carers allowance recipients of pensionable age in Doncaster and England & Wales, 2003-10...... 118 Figure 93: Estimated numbers of people providing unpaid care by age, 2010-30..... 118 Figure 94: Uptake of Flu vaccinations in people aged 65+ in Doncaster and England, 2005/06 – 2009/10...... 119 Figure 95: Estimated numbers of people with depression in Doncaster by age, 2010-30 ...... 120 Figure 96: Estimated numbers of people with dementia in Doncaster by age, 2010-30 ...... 120 Figure 97: All cancer registrations (all ages) in Doncaster, Manufacturing Towns, and England & Wales with forecasts, 1993-2015 ...... 122 Figure 98: Breast cancer registrations (all ages) in Doncaster, Manufacturing Towns and England & Wales with forecasts, 1993-2015...... 123 Figure 99: Colorectal cancer registrations (all ages) in Doncaster, Manufacturing Towns and England & Wales with forecasts, 1993-2015 ...... 123 Figure 100: Lung cancer registrations (all ages) in Doncaster, Manufacturing Towns and England & Wales with forecasts, 1993-2015...... 124 Figure 101: Prostate cancer registrations (all ages) in Doncaster, Manufacturing Towns and England & Wales with forecasts, 1993-2015...... 124 Figure 102: Stomach cancer registrations (all ages) in Doncaster, Manufacturing Towns and England & Wales with forecasts, 1993-2015 ...... 125 Figure 103: All cause mortality in males aged 65-74 in Doncaster, Manufacturing towns, and England & Wales with forecasts, 1993-2020...... 126 Figure 104: All cause mortality in females aged 65-74 in Doncaster, Manufacturing Towns, and England & Wales with forecasts, 1993-2020 ...... 127 Figure 105: All cause mortality in persons aged 65-74, in Doncaster, Manufacturing Towns, and England & Wales with forecasts, 1993-2020 ...... 127 Figure 106: Age standardised circulatory disease mortality rates (under 75) in Doncaster, Manufacturing Towns, and England & Wales with forecasts, 1993-2015 . 128 Figure 107: Age standardised coronary heart disease mortality (under 75) in Doncaster, Manufacturing Towns, and England & Wales with forecasts, 1993-2015 . 128 Figure 108: Age standardised mortality rates from stroke (under 75) in Doncaster, Manufacturing Towns, and England & Wales with forecasts, 1993-2015 ...... 129 Figure 109: Age standardised mortality rates from all cancers (under 75) in Doncaster, Manufacturing Towns, and England & Wales with forecasts, 1993-2015 ...... 130 Figure 110: Age standardised mortality rates from colorectal cancer (all ages) in Doncaster, Manufacturing Towns, and England & Wales with forecasts, 1993-2015 . 130 Figure 111: Age standardised mortality rates from lung cancer (under 75) in Doncaster, Manufacturing Towns, and England & Wales with forecasts, 1993-2015 . 131

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Figure 112: Age standardised mortality rates from stomach cancer (all age) in Doncaster, Manufacturing Towns, and England & Wales with forecasts, 1993-2015 . 131 Figure 113: Age standardised mortality rates from breast cancer in Doncaster, Manufacturing Towns, and England & Wales with forecasts, 1993-2015 ...... 132 Figure 114: Age standardised mortality rates from respiratory disease in Doncaster, Manufacturing Towns, and England & Wales with forecasts, 1993-2015 ...... 133 Figure 115: Estimated numbers of falls in Doncasterby age, 2010-30 ...... 134 Figure 116: Age standardised mortality rates from accidental falls in Doncaster, Manufacturing Towns, and England & Wales with forecasts, 1993-2015 ...... 134 Figure 117: Age standardised mortality rates from accidents (all ages) in Doncaster, Manufacturing Towns, and England & Wales with forecasts, 1993-2015 ...... 135 Figure 118: Forecast rates and numbers of deaths ...... 139 Figure 119: Male all age mortality by underlying cause, 2006-08...... 140 Figure 120: Female all age mortality by underlying cause (2006-08)...... 141 Figure 121: Age standardised mortality rates from causes considered amenable to healthcare in Doncaster, manufacturing towns and England & Wales, 1993-2015... 142 Figure 122: Causes of deaths amenable to healthcare, 2006-08...... 143 Figure 123: Age standardised mortality rates amongst males aged 0-14 in Doncaster, manufacturing towns and England & Wales...... 143 Figure 124: Age standardised mortality rates amongst females aged 0-14 in Doncaster, manufacturing towns and England & Wales...... 144 Figure 125: Age standardised mortality rates amongst males aged 15-64 in Doncaster, manufacturing towns and England & Wales...... 144 Figure 126: Age standardised mortality rates amongst females aged 15-64 in Doncaster, manufacturing towns and England & Wales...... 145 Figure 127: Age standardised mortality rates amongst males aged 65-74 in Doncaster, manufacturing towns and England & Wales...... 145 Figure 128: Age standardised mortality rates amongst females aged 65-74 in Doncaster, manufacturing towns and England & Wales...... 146 Figure 129: 15-64 AAACM rates ...... 147 Figure 130: Component causes of AAACM in 15-64 men...... 147

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> Joint Director of Public Health Annual Report

9 Joint Director of Public Health Annual Report & Joint Strategic Needs Assessment 2010/11

> Foreword

I am pleased to present a combined Director of Public Health (DPH) Annual Report and Joint Strategic Needs Assessment (JSNA) as Joint Director of Public Health for NHS Doncaster and Doncaster Metropolitan Borough Council (MBC).

This report is very different from my previous annual reports. The Coalition Government through the White Papers and Bills for the NHS, Public Health, Social Care and Local Government has signalled sweeping reforms in the NHS and local government. This will lead to a changed architecture for the planning and delivery of services to improve health and wellbeing in Doncaster and across the country.

Central to the planning of services in each locality will be a JSNA process. The JSNA for 2010/11 is embedded in this combined report and an explanation of how it was developed, why it is presented in a different format this year and how to read it to get the best out of it is explained in the introductory paragraphs of this document.

I have read the tables and graphs in the JSNA and have tried to summarise the key messages on each page in a single sentence. This I hope will provide you with some of the most important headline messages in an accessible way. These headline messages are collated in an executive summary and form the main body of my brief report.

This report also > Describes progress against recommendations made in my last annual report > Makes recommendations for decision makers locally which I hope will contribute to the improvement of health and wellbeing in Doncaster people.

In compiling this report I am grateful for the help of a number of colleagues within the NHS and Local Authority. In particular I would like to thank Laurie Mott, Victor Joseph, Dr Rupert Suckling, Jacqui Wiltschinsky, Martha Mayhew and Jim Drake. I am also indebted to all of the Public Health Directorate team and colleagues in NHS Doncaster, Doncaster MBC and partner organisations who have worked so hard over the past 12 months.

I hope you enjoy reading this report as well as finding it of interest and value. Please try and play your individual part in addressing the issues raised as well as trying to interest others in them.

Dr Tony Baxter Joint Director of Public Health NHS Doncaster & Doncaster MBC

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> Executive Summary

The following bullet points are the key messages from the Joint Strategic Needs Assessment. They are repeated at the beginning of each relevant section of the JSNA report.

Living well

> There are over 290,000 people living in the borough and this number will increase over the next 10 years. > There will be a greater proportion of older people living in the borough over the next 10 years. > Doncaster is becoming more ethnically diverse. > Parts of the borough are very densely populated. > People are generally less well-off than the rest of England. > Some parts of Doncaster are less well-off then others. > Wages are lower and more jobs are less skilled than England. > The carbon footprint in Doncaster is better than the UK average. > Doncaster is in a group of similar local authorities called the ‘manufacturing towns’. > Death rates for men and women are similar to other manufacturing towns; although rates are reducing they remain higher than the national average. > People’s lifestyles are less healthy than in England.

Starting well

> There are over 18,000 children aged under 5 years in Doncaster. > Some communities have more 0-4 year olds than others. > Children have poorer health and wellbeing than many parts of England. > Fewer children live in overcrowded conditions compared to nationally. > A quarter of women are still smoking when they are about to have a baby. > Breastfeeding rates are improving. > Immunisation rates are slightly better than the national rate. > Deaths in children aged under 1 are rare but the rate remains higher than the national rate.

Developing well (School)

> There are over 52,000 young people aged 5-19 in the borough. > In some parts of Doncaster the health and wellbeing of children is poorer than others. > Children’s educational performance is improving. > Increasing numbers of young people are taking part in physical activity. > More children are obese and overweight than the national average. > Teenage conceptions are higher than the national rate. > The numbers of children killed or seriously injured on the roads are reducing. > Although numbers are low and reducing, slightly more young people die each year compared to other manufacturing towns.

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Developing well (Training)

> There are over 30,000 young people in the borough aged 15-24. > There are around 3,000 prisoners in Doncaster. > The numbers of young people not in employment, education or training is reducing but is still higher than the national rate. > Youth unemployment rates are higher than in England & Wales. > Crime is focused in hot spots across the borough. > We think there are around 3,000 problem drug users in the borough.

Working well

> There are over 150,000 adults aged 25-64 in the borough. > The population is becoming more diverse – the biggest rises in new residents in recent years come from Latvia and Poland. > More working age people than the national average are economically inactive. > The numbers of job seekers allowance claimants has climbed faster than the national average during the recession. > A greater proportion of local authority housing stock is in poor repair compared to other parts of England. > Death rates from alcohol related liver disease are increasing across the country but faster in Doncaster. > More women go for breast and cervical screening than the national average. > Fewer adults take part in moderate physical activity sport in all age groups than in other parts of the country. > Death rates in people of working age are improving, among women the gap is closing but not in men. > The number of suicides is small and not significantly different from the national average. > The number of people who have physical disabilities, learning disabilities or mental health problems will stay roughly the same over the next 20 years.

Ageing well

> There are about 50,000 people aged over 64 living in the borough, but over the next 10 years this number will increase to over 60,000. > The number of extra deaths in the winter vary from year to year. > Some communities in Doncaster have high rates of winter mortality. > Some parts of Doncaster have large numbers of older people living on low incomes. > The borough will have increasing numbers of older people living alone and also resident in care homes. > Older people not only need care they are also increasingly providing care as well. > With an increasingly older population Doncaster will have greater numbers of people with dementia and other mental health problems associated with old age. > More people in Doncaster are diagnosed with lung cancer compared to similar areas. > Deaths from circulatory diseases are lower in Doncaster compared to similar areas. > Deaths from respiratory disease remain very high in Doncaster. > The numbers of fall amongst older people are set to increase.

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> Progress against recommendations from my last Annual Report

Recommendations Actions For partners in Progress has been made on all aspects of the strategy. Doncaster to continue External scrutiny from the National Support Team for Health the implementation Inequalities has highlighted a number of areas of good and evaluation of the practice including improved quality of primary care, ‘Achieving Sustained significant improvements in reducing infant mortality and Change Strategy’. increasing the early diagnosis of lung cancer.

Evaluation is ongoing and will be subsumed by the new national public health outcomes framework.

For partners in A core evaluation steering group has been set up to Doncaster to evaluate oversee the evaluation process for the EPHP, this is led by the impact of the the PCT evaluation unit. Two members of the Public Health Enhanced Public Development Worker (PHDW) team have assisted by Health Programme. collecting qualitative data from a sample of some of the contracted organisations. A triangulation method has been used for collating data, this has included collecting data during a speed networking event that was attended by a variety of organisations from private, statutory and voluntary sectors.

For partners in The Healthy Weight Healthy Lives Strategic Group provides Doncaster to continue overall co-ordination of the obesity agenda. This multi- to implement the agency group is chaired by the Director of Public Health, ‘Healthy Weight, and is made up of professionals from both commissioner Healthy Lives’ strategy and provider organisations. locally and actively promote services and One of the main aims of Healthy Weight Healthy Lives support available to Agenda is to maximise public awareness of the main Doncaster people to preventable obesity risk factors through training and health help you work towards promotion to support individuals and families in achieving and maintain a and maintaining a healthy weight. healthy weight. A co-ordinated approach to prevention, assessment and treatment services around the management of overweight and obesity ensures continuous service improvement.

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Recommendations Actions For partners in A part of last year’s JSNA was the publication of community Doncaster to underpin profiles for all of Doncaster’s 88 communities (a joint project commissioning between NHS Doncaster and Doncaster MBC). The profiles decisions with a robust have been used extensively by the local authority and NHS Joint Strategic Needs Doncaster; they are also available for the public to use1 2. Assessment which Data from these reports have been used to support takes into account planning; the development of a local child health index current and future (detailed in this report), and have provided the basis for local health needs health profiles for all of Doncaster’s schools. and requirements and informs local action The JSNA has continued to use forecasting and projections related to the to identify potential health and wellbeing challenges in the Department of Health, future. The report identified the continuing increases in Quality, Innovation, deaths from alcohol related causes. Productivity and Prevention Programme (QIPP).

For partners in The ‘Health Protection Strategy’ has been updated and Doncaster and South assigned individuals have sent updates as requested to the Yorkshire Health Public Health Partnership Board, particularly regarding food Protection Unit to regulations via environmental health and vaccination & implement the health immunisation uptakes. This included the flu vaccine. protection strategy.

For partners in Local partners worked closely during the swine flu (H1N1) Doncaster, South pandemic to implement successfully national policy in Yorkshire Health relation to antiviral distribution, vaccine distribution and Protection Unit and uptake. The H1N1 vaccine component has now been South Yorkshire to incorporated into the seasonal flu programme. minimize and manage the impact of the swine flu pandemic on people and services in Doncaster.

1 www.doncaster.nhs.uk/upload_files/Community_Profile_Links_2010.pdf 2 www.doncastertogether.org.uk/about_doncaster/Your_Community.asp

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Recommendations Actions For partners to work Over the past three years NHS Doncaster has been able to within a common significantly reduce the usage of utilities and therefore framework for reduced its carbon footprint. It has done this by corporate social implementing a number of initiatives that monitor all utility responsibility and bills across the estate, something that has not happened in carbon reduction that the past. will support all partners in delivering the As a result we have been able to identify any increase that benefits of sustainable may occur in any NHS Doncaster building and address the development. problem, it has also been used to make an accurate ERIC3 return, again something that has not happened in the past.

A ‘Green Champions’ initiative has brought together staff from across NHS Doncaster to work together in their various locations and departments to reduce usage of electricity by “turning off” lights and PC monitors when not in use.

Across the borough we have given advice to numerous GP practices and health centre managers in relation to heating controls and how to adapt to meet seasonal heating demands and the needs of their particular building.

As part of the CRC Energy Efficiency Scheme DMBC have established a CRC Energy Efficiency Board at Director level and as a decision making forum for service level actions. The first issue was to unify energy efficiencies across the council and this has been done by setting a minimum 3% reduction in carbon emissions year on year for the next 5 years. DMBC have introduced Automatic Meter Reading (AMR) across its building portfolio including schools. This has led to more accurate billing and accuracy for the associate monitoring and target and measurement of the 3% target.

Having achieved Carbon Trust Standard in November 2010 a Carbon Management Programme is being developed; DMBC are looking at sustainable procurement, fleet management and resource efficiencies as part of this process. Working with Barnsley, Rotherham and Sheffield councils and having attracted considerable investment into the region DMBC provide energy efficiency advice to home owners and have targets for households in fuel poverty as well as privately owned households wishing to evaluate their carbon footprint.

3 ERIC: Estates Returns Information Collection. The ERIC return is information provided by all NHS trusts and PCTs about the status of their buildings and estate.

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Recommendations Actions For partners to The impact of the economic recession is a key part of the continue to work work of the ‘Enterprising Doncaster’ economic partnership. together to minimize The current economic climate has also informed the the impacts of the development of the new Borough Strategy4. global economic downturn the on health and wellbeing of local people.

4 The Borough Strategy is a local plan to improve quality of life for Doncaster’s residents and visitors. www.doncastertogether.org.uk/what_are_we_going_to_do/borough_strategy.asp

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> Challenges & Recommendations – 2010/11

Joint Strategic Needs Assessment

Challenge Recommendations How can we ensure That partners in Doncaster use the information in the JSNA to that the JSNA is used inform service commissioning and identify priorities for and further developed partnership action to further promote the health and well- to contribute to being of Doncaster people. positive health and wellbeing impacts for That the Health and Well-being Board use the JSNA to local people? inform the development of the borough’s first joint health and well-being strategy.

That the new partnership data observatory further develops the JSNA process to support an improved understanding of the health and well-being challenges we face in the future.

Living Well

Challenge Recommendation Some parts of That partners act on the priorities identified in the first Doncaster are less well Partnership Stocktake of Doncaster in Summer 2011. off than others.

Starting Well

Challenge Recommendation A quarter of women That all pregnant women are screened for their smoking are still smoking when status, and those who smoke, and their families, are offered they are about to intensive treatment and support through the pregnancy. have a baby.

Developing Well (School)

Challenge Recommendation More children are That partners maintain concerted action on a range of obese and overweight initiatives to ensure that services support children and young than the national people’s healthy weight from preconception to adulthood. average.

Developing Well (Training)

Challenge Recommendation We think there are That partners work together to increase the accessibility of around 3,000 problem outcome based treatment pathways with ‘wrap around’ drug users in the support to prevent relapse. borough.

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Working Well

Challenge Recommendation Death rates from That partnerships review factors contributing to the misuse of alcohol related liver alcohol in the borough and agree joint action. disease are increasing across the country but faster in Doncaster.

Ageing Well

Challenge Recommendation With an increasingly That partners focus activity on early diagnosis and better older population care at home, in care homes and in acute hospitals for Doncaster will have people suffering with dementia and their families. greater numbers of people with dementia and other mental health problems associated with old age.

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> Joint Strategic Needs Assessment

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> Introduction

The White Paper

This is the third Doncaster Joint Strategic Needs Assessment (JSNA) report. Since the publication of the last report the landscape in which the health service, local authorities and the third sector operate has changed dramatically. The new coalition government’s health white paper Equity and Excellence: Liberating the NHS5 has announced significant changes to both the commissioning of health and social services and the delivery of health improvement. The white paper proposes that Primary Care Trust (PCT) responsibilities for health improvement and public health are moved to local authorities, and the commissioning of health services should move to groups of GP practices (GP commissioning consortia). The PCTs will then be abolished in 2013.

Directors of Public Health, who are responsible for leading the delivery of health improvement for local populations, will integrate with local authorities; they will be jointly appointed by the local authority and a newly created national public health service to be called ‘Public Health England’. Another proposal is the creation of ‘Health and Wellbeing Boards’. These boards will promote collaboration across the NHS, local authorities and other interested sectors and will endeavour to promote health and reduce inequalities in the local area. Future JSNAs will need to evolve to support this new local strategic body. In the past delivery of the JSNA has been the responsibility of the PCT, in the future this requirement will move to the local authority. All of these changes are currently part of a national consultation and some of the details might be subject to change, nevertheless the main building blocks of the health and social care reforms will almost certainly remain.

Marmot review

While the white paper has proposed large scale structural changes to the way health services will be commissioned and health improvement delivered, it does appear to continue the previous government’s commitment to reducing health inequalities. The coalition’s public health white paper Healthy Lives, Healthy People6 emphasises the importance of addressing the root causes of ill-health and inequalities and describes itself as a reply to the Marmot review. The review7, published a few months before the white paper, is intended to “assemble the evidence and advise on the development of a health inequalities strategy in England.” Central to this review is the ‘life course approach’. This means that “disadvantage starts before birth and accumulates throughout life”. Hence policies and strategies to reduce inequalities in health and wellbeing must start before birth and continue through the early years, on into adolescence and adulthood and then into old age. The review identifies six key policy objectives which reflect this developmental model8: > Give every child the best start in life > Enable all children young people and adults to maximise their capabilities and have control over their lives > Create fair employment and good work for all

5 Equity and excellence: Liberating the NHS, July 2010, www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_117 794.pdf 6 Healthy Live, Healthy People: Our Strategy for Public Health in England, November 2010, www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_122 347.pdf 7 Fair Society, Healthy Lives: Strategic Review of Health Inequalities post 2010, Feb 2010, www.marmotreview.org 8 All of the Marmot review policy objectives are recommendations are outlined in Appendix 2

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> Ensure a healthy standard of living for all > Create and develop healthy and sustainable places and communities > Strengthen the role and impact of ill-health prevention

As well as the key objectives the review breaks the life course down into key age groups: > Pre-birth and early years (0-4) > Children and young people in full-time education (ages 5–16) > Early adulthood (ages 17–24) > Adults of working age (ages 25–64) > Adults of retirement age (65+) Figure 1 show how these policy objectives and age groups relate and provides a conceptual representation of how the life course model works.

Figure 1: Areas of action across the life course

Source: Fair Society, Healthy Lives: The Marmot Review

Joint Strategic Needs Assessment

Joint Strategic Needs Assessment is a process that will identify current and future health and wellbeing needs of a local population…9 As in past years this report will summarise some of the current challenges as well as outlining some of the issues which may be emerging in the future. This year the Doncaster JSNA report is structured using the age groups suggested by the Marmot review. The intention is that the data presented in this report will provide a foundation on which to build a comprehensive picture of the health and wellbeing needs of Doncaster. The report

9 Guidance on Joint Strategic Needs Assessment, 2007, www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_081267.p df

21 Joint Director of Public Health Annual Report & Joint Strategic Needs Assessment 2010/11 can also be used to help a nascent Health and Wellbeing Board define its priorities and work programmes for the future.

In last years report an early draft of a joint community profile was used for illustrative purposes. Since the publication of that report community profiles have been produced for all 88 of Doncaster communities. In this report a number of maps of Doncaster’s communities are shown, and most are drawn from the data in these profiles. These profiles and the data they contain are available from NHS Doncaster10 and the office of Doncaster Together11 (the strategic partnership).

How to read this report

This report has placed a number of the important issues affecting health and wellbeing in specific age groups; crime is addressed in the Developing Well section. The report acknowledges that many of the issues it deals with can affect people across all parts of the life course; people of any age are affected by crime and criminality. However to adopt a life course approach means that resources and actions should be focused on areas where the greatest benefits can be accrued. Most people engaged in crime are young people.

This report presents large amounts of data; it has over 100 graphs, tables and maps to illustrate just a small selection of the challenges facing the borough. Each section of the report is divided into five sub-sections. These are the same in each section (summary, demography, social and environmental context, lifestyle & risk factors, ill- health & disability, and signposts). The summary provides a list of the relevant policy recommendations from the Marmot review as well as a summary of the key messages from that section of the report. The signposts sub-section provides a list of key data sources, national and local strategies, and relevant public health guidance issued by the National Institute for Health and Clinical Excellence (NICE)12.

Finally this report includes references and resources available on the World Wide Web. These links may change after the publication of this report.

10 www.doncaster.nhs.uk/upload_files/Community_Profile_Links_2010.pdf 11 www.doncastertogether.org.uk/about_doncaster/Your_Community.asp 12 www.nice.org.uk

22 Joint Director of Public Health Annual Report & Joint Strategic Needs Assessment 2010/11

> Living Well: a Doncaster overview

Communities are important for physical and mental health and well-being. The physical and social characteristics of communities, and the degree to which they enable and promote healthy behaviours, all make a contribution to social inequalities in health. However, there is a clear social gradient in ‘healthy’ community characteristics.

The Marmot Review – page 30

23 Joint Director of Public Health Annual Report & Joint Strategic Needs Assessment 2010/11

24 Joint Director of Public Health Annual Report & Joint Strategic Needs Assessment 2010/11

> Summary - Living Well

Marmot review: objectives and recommendations Objectives > Develop common policies to reduce the scale and impact of climate change and health inequalities. > Improve community capital and reduce social isolation across the social gradient.

Recommendations > E1: Prioritise policies and interventions that both reduce health inequalities and mitigate climate change. > E2: Fully integrate the planning, transport, housing, environmental and health systems to address the social determinants of health in each locality. > E3: Support locally developed and evidence-based community regeneration programmes.

Key points for Doncaster > There are over 290,000 people living in the borough and this number will increase over the next 10 years. > There will be a greater proportion of older people living in the borough over the next 10 years. > Doncaster is becoming more ethnically diverse. > Parts of the borough are very densely populated. > People are generally less well-off than the rest of England. > Some parts of Doncaster are less well-off then others. > Wages are lower and more jobs are less skilled than England. > The carbon footprint in Doncaster is better than the UK average. > Doncaster is in a group of similar local authorities called the ‘manufacturing towns’. > Death rates for men and women are similar to other manufacturing towns; although rates are reducing they remain higher than the national average. > People’s lifestyles are less healthy than in England.

25 Joint Director of Public Health Annual Report & Joint Strategic Needs Assessment 2010/11

> Demography

Population

In 1991, at the time of the census, Doncaster had a resident population of 291,700. Since that time the numbers of residents appeared to decline gradually until 1999 when it reached just under 287,000. Since then the population has been increasing and in 2008 it was back at the 1991 level. Office of National Statistics (ONS) population projections show that these population increases will continue (see Figure 2) and by 2015 the population will be around 295,200 and will pass 300,000 by 202113.

Doncaster had an estimated resident population of 290,100 in 2009. These are the latest population estimates available. About 49.2% of residents are men and 51.8% women (see Figure 4). Doncaster’s population in common with the country as a whole will get, on average, older. Figure 3 illustrates these changes: currently 24.4% of the population are under 20 years old; by 2020 this will have fallen to 23.6%. People aged over 64 will have increased from 17.2% to 20.3%.

Figure 2: Total mid-year population estimates with projections for Doncaster, 1991- 2020

350,000

300,000

250,000

200,000 Number 150,000

100,000

50,000

0 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 All ages Projection Source: Office for National Statistics (ONS) Projections based on the 2008 based population projections

13 These population projections are based on ONS 2008 sub-national projections. Previous JSNA reports have used the older 2004 projections.

26 Joint Director of Public Health Annual Report & Joint Strategic Needs Assessment 2010/11

Figure 3: Changes in population by age group in Doncaster, 2009-20

8.0

7.0

6.0

5.0

% 4.0

3.0

2.0

1.0

0.0 0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+ 2009 2020 Source: Office for National Statistics (ONS) Projections based on the 2008 based population projections

Figure 4: Mid year population estimates for Doncaster by age group, 2009 Number % Age group Males Females Males Females 0-4 9,200 8,900 6.4 6.0 5-9 8,300 8,000 5.8 5.4 10-14 8,800 8,600 6.2 5.8 15-19 10,100 8,900 7.1 6.0 20-24 9,700 8,800 6.8 6.0 25-29 9,000 8,400 6.3 5.7 30-34 7,600 7,600 5.3 5.2 35-39 9,100 9,600 6.4 6.5 40-44 10,500 11,100 7.3 7.5 45-49 11,200 11,000 7.8 7.5 50-54 9,800 9,800 6.9 6.7 55-59 8,700 9,000 6.1 6.1 60-64 9,000 9,500 6.3 6.5 65-69 6,800 7,300 4.8 5.0 70-74 5,700 6,800 4.0 4.6 75-79 4,400 5,700 3.1 3.9 80-84 3,100 4,400 2.2 3.0 85+ 1,900 4,000 1.3 2.7 All Ages 143,000 147,200 100.0 100.0 Source: Office for National Statistics Rounded to nearest 100

27 Joint Director of Public Health Annual Report & Joint Strategic Needs Assessment 2010/11

Ethnicity and migration

Compared to England & Wales Doncaster has a small minority ethic population. Nationally just under 12% are from ‘non-white’ ethnic groups, in Doncaster this figure is 4.4% (see Figure 5). These estimates are from 2007 and have not been updated by ONS for several years.

In 2001 around 6,800 people in the borough were from ‘non-white’ groups, in 2007 this had increased to 12,700 (see Figure 6). The largest numerical change has been in the ‘white – other category’ that has increased from 2,000 to 3,500. This reflects the increased numbers of residents from Eastern European countries.

Immigration has been rising in Doncaster (see Figure 7) but has remained lower than nationally. A more detailed picture is available from the Yorkshire and Humber regional migration partnership14. Doncaster MBC commissioned a study of the Eastern European population in Doncaster15. The report estimates that between 5,000 and 10,000 people have come to the borough between 2004 and 2009. The majority are between 25 and 44 and many have young children. Seventy four percent of these eastern European migrants were from Poland.

Figure 5: Population estimates by ethnicity (excluding White British) in Doncaster and England, 2007

White: Irish

White: Other White

Mixed: White and Black Caribbean

Mixed: White and Black African

Mixed: White and Asian

Mixed: Other Mixed

Asian or Asian British: Indian

Asian or Asian British: Pakistani

Asian or Asian British: Bangladeshi

Asian or Asian British: Other Asian

Black or Black British: Black Caribbean

Black or Black British: Black African

Black or Black British: Other Black

Chinese or Other Ethnic Group: Chinese

Chinese or Other Ethnic Group: Other

0 0.5 1 1.5 2 2.5 3 3.5 4 % Doncaster England Source: Office for National Statistics Experimental statistics

14 Doncaster: Local Migration Profile (Spring 2010), Yorkshire & Humber Regional Migration Partnership www.migrationyorkshire.org.uk 15 Migration Impact Fund Profile of East Europeans in Doncaster, D Sporton, University of Sheffield, 2010

28 Joint Director of Public Health Annual Report & Joint Strategic Needs Assessment 2010/11

Figure 6: Changes in Doncaster’s ethnic populations (excluding White British), 2001-07

White: Irish

White: Other White

Mixed: White and Black Caribbean

Mixed: White and Black African

Mixed: White and Asian

Mixed: Other Mixed

Asian or Asian British: Indian

Asian or Asian British: Pakistani

Asian or Asian British: Bangladeshi

Asian or Asian British: Other Asian

Black or Black British: Black Caribbean

Black or Black British: Black African

Black or Black British: Other Black

Chinese or Other Ethnic Group: Chinese

Chinese or Other Ethnic Group: Other

0 0.5 1 1.5 2 2.5 3 3.5 4 '000s Mid 2001 Mid 2007 Source: Office for National Statistics Experimental statistics

Figure 7: Migration into Doncaster and England & Wales, 2000/01-2007/08

12.0

10.0

8.0

6.0 Rateper1,000

4.0

2.0

0.0 Mid 2000 - Mid Mid 2001 - Mid Mid 2002 - Mid Mid 2003 - Mid Mid 2004 - Mid Mid 2005 - Mid Mid 2006 - Mid Mid 2007 - Mid 2001 2002 2003 2004 2005 2006 2007 2008 England & Wales Doncaster Source: Patient Data Registration Service, Office of National Statistics Migration is measured using newly registered patients who have previously lived overseas for at least 3 months (Flag4).

29 Joint Director of Public Health Annual Report & Joint Strategic Needs Assessment 2010/11

Other populations

Doncaster is home to a number of different population groups. There are estimated to be between 4,000 and 6,000 gypsy/travellers resident at any time in the borough, a more recent assessment has counted 3,90416. There are also thought to be in the region of 600 asylum seekers living in various parts of Doncaster.

Doncaster has 4 prisons and an Immigration Removal Centre (IRC). More details about this population and their health and wellbeing can be found in the ‘Developing Well: Training’ section of this report.

Population density

The borough covers an area just under 57,000 hectares, at the time of the 2001 census it was the least densely populated borough in south Yorkshire with 5.05 people per hectare. Within the borough population density varies, with some communities with over 70 people per hectare down to communities with 0.1 per hectare (see Figure 8). The most densely populated communities in Doncaster are; Hexthorpe. Hyde Park, Town Moor, and Lower Wheatley.

Figure 8: Population density by community, 2009

Source: NHS Doncaster Darker colours indicate higher density populations

16 A Study and Assessment of the Accommodation Needs of Gypsies and Travellers in South Yorkshire (2007)

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31 Joint Director of Public Health Annual Report & Joint Strategic Needs Assessment 2010/11

> Social & environmental context

Deprivation

Deprivation is closely related to poverty and describes a lack of services, facilities and resources which are considered necessary or customary in everyday life. The Index of Multiple Deprivation (IMD) 200717 captures deprivation as a community experience with seven domains: income, employment, health & disability, education, barriers to housing & services, crime, and the living environment (Figure 9).

The latest IMD score for Doncaster is 30.84 and this places Doncaster as the 41st most deprived borough in England. There are 345 boroughs in total. Twenty one percent of the population of Doncaster reside in areas that are considered to be part of the 10% most deprived areas in the country. The map in Figure 10 shows the most deprived areas of Doncaster.

Doncaster has been divided into 88 communities. These communities are intended to reflect ‘natural’ communities18. Using census data, deprivation levels have been calculated for these communities. The most deprived communities in Doncaster are: Denaby Main, Clay Lane, Highfields, Stainforth, Carcroft, Askern, Hyde Park, New Rossington, Toll Barr, Woodlands, and Mexborough. These communities are all Enhanced Public Health Programme areas (see Figure 11).

Figure 9: The proportion of the Doncaster population in the most deprived 10% and 20% of England’s LSOAs according to the IMD 2007 and its domains 10% most deprived 20% most deprived Population % Population % IMD 61,797 21.4 107,658 37.3 Income 38,622 13.4 82,362 28.5 Employment 38,187 22.8 69,573 41.6 IDACI 4,242 7.4 12,855 22.4 IDAOPI 6,966 10.9 17,391 27.3 Health Deprivation & Disability 63,144 21.9 119,235 41.3 Education, Skills & Training 102,093 35.4 138,528 48.0 Barriers to Housing & Services 23,034 8.0 50,796 17.6 Crime & Disorder 66,735 23.1 107,670 37.3 Living Environment 14,985 5.2 31,212 10.8 Source: Department of Communities & Local Government IDACI: Income Deprivation Affecting Children Index; IDAOPI: Income Deprivation Affecting Older People Index LSOA: Lower Super Output Area – a small area geography with around 1,500 residents in each. Doncaster is divided into 193 LSOAs. Each domain relates to the whole population with the exceptions of: Employment (16-59/64); ICACI (0-15); IDAOPI (60+) Populations as at 2005, excluding prisoners

17 The English Indices of Deprivation, www.communities.gov.uk/documents/communities/pdf/733520.pdf 18 Natural communities are geographically defined areas that correspond to where people consider that they live as opposed to administrative boundaries such as electoral wards or service delivery areas.

32 Joint Director of Public Health Annual Report & Joint Strategic Needs Assessment 2010/11

Figure 10: Index of Multiple Deprivation in Doncaster, 2007

Source: Department of Communities & Local Government

Figure 11: Deprivation by Community in Doncaster, 2001

Source: Office of National Statistics, NHS Doncaster

33 Joint Director of Public Health Annual Report & Joint Strategic Needs Assessment 2010/11

Economy

Most deprivation indicators only provide a snapshot in time. They do not reflect changes in the social and economic circumstances of the borough. Partly to address this problem the Department for Communities and Local Government (DCLG) produced the Economic Deprivation Index (EDI)19. The EDI measured annual changes in income and employment in the borough between 1999 and 2005. Annually the EDI score in Doncaster reduced over that time. Doncaster’s relative rank also got better from 37th most deprived area to 53rd (see Figure 12).

Earnings in Doncaster remain slightly below the national average (Figure 13). However these data are based on estimates from the Annual Survey of Hours and Earnings (ASHE). The ASHE is based on a 1% sample of employees and excludes absence and arrears payments. Self employed earnings are also not included. This measure does not take into account the cost of living in Doncaster.

Types of employment are categorised by ONS into different classes (see Figure 14)20. Unsurprisingly given the boroughs manufacturing and industrial history Doncaster has more people employed in the ‘Process plant & machine operatives’ group compared to England & Wales. It also has proportionally fewer in the ‘managerial and professional groups’.

Figure 12: Economic Development Index (EDI) for Doncaster, 1999-2005 1999 2000 2001 2002 2003 2004 2005 Population-weighted average EDI score 34.35 33.69 33.60 32.32 31.42 30.48 30.39 Population-weighted average EDI rank 37 40 42 44 46 55 53 Source: Department of Communities and Local Government High score indicates greater levels of economic deprivation The EDI focuses on employment and income deprivation

19 Tracking Neighbourhoods: The Economic Deprivation Index 2008, Department for Communities and Local Government 20 www.ons.gov.uk/about-statistics/classifications/current/index.html

34 Joint Director of Public Health Annual Report & Joint Strategic Needs Assessment 2010/11

Figure 13: Weekly earnings in Doncaster and England & Wales, 1998-2009

600

500

400

£ 300

200

100

0 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Doncaster England and Wales Source: ONS annual survey of hours and earnings - workplace analysis Median earnings in pounds for employees working in the area. Results for 2003 and earlier exclude supplementary surveys. In 2006 there were a number of methodological changes made.

Figure 14: Employment by occupation aged 16+, 2010 England & Doncaster Doncaster Wales (numbers) (%) (%) SOC 2000 major group 1-3 41,500 33.8 44.7 1 Managers and senior officials 15,100 12.2 16.0 2 Professional occupations 11,500 9.3 13.8 3 Associate professional & technical 14,900 12.1 14.7 SOC 2000 major group 4-5 25,900 21.1 21.6 4 Administrative & secretarial 14,100 11.4 11.2 5 Skilled trades occupations 11,800 9.6 10.3 SOC 2000 major group 6-7 25,100 20.4 16.0 6 Personal service occupations 13,600 11.0 8.7 7 Sales and customer service occs. 11,500 9.3 7.3 SOC 2000 major group 8-9 30,300 24.7 17.8 8 Process plant & machine operatives 14,200 11.5 6.6 9 Elementary occupations 16,100 13.0 11.1 Source: ONS annual population survey % is a proportion of all persons in employment SOC 2000: Standard Occupational Classification 2000

35 Joint Director of Public Health Annual Report & Joint Strategic Needs Assessment 2010/11

Living arrangements

Doncaster is a metropolitan borough and has around 83% of the population living areas classified as urban. In England this figure is 73%. However this means that 17% of the Doncaster population reside in rural areas. Figure 15 shows the rural and urban areas of Doncaster.

Housing plays an important part in the health of the population and this is explored further in the ‘Working well’ section of this report. As a whole Doncaster has around 126,500 households21 and it has almost twice as many households in local authority accommodation as nationally (Figure 16).

Figure 15: Urban rural map

Source: Office of National Statistics More information of Urban rural definitions is available from Office of National Statistics and DEFRA (Department for Environment, Food and Rural Affairs)

21 A household was defined in the 2001 census as one person living alone or a group of people (not necessarily related) living at the same address with common housekeeping – sharing either a living room or sitting room, or at least one meal a day.

36 Joint Director of Public Health Annual Report & Joint Strategic Needs Assessment 2010/11

Figure 16: Housing by Tenure, 2008/09 Doncaster Doncaster England (Number) (%) (%) Local Authority (incl. owned by other LAs) 20,963 16.6 8.1 Registered social landlords* 2,955 2.3 9.7 Other public sector 2 0.0 0.3 Private sector* 102,659 81.1 81.9 Total* 126,579 100.0 100.0 Source: Department of Communities and Local Government * ONS recommend these figures be regarded as provisional

37 Joint Director of Public Health Annual Report & Joint Strategic Needs Assessment 2010/11

Environment

The IMD includes data relating to the living environment. This index combined measures of the quality of the indoor and outdoor environments, and is the best performing domain in Doncaster with only 5.2% of the population resident in the nationally defined 10% most deprived areas (Figure 17).

Global warming has important implications for the future health and wellbeing of people across the globe. Recently estimates for carbon emissions have been calculated for local authority areas. These data show Doncaster was producing 8.8 kt CO2 per capita in Doncaster compared to 8.2 nationally in 2008. However Doncaster has been achieving reductions year on year (Figure 18).

Figure 17: The living environment domain of the IMD, 2007

Source: Department of Communities & Local Government

Figure 18: CO2 emissions in Doncaster and the United Kingdom, 2005-08 2005 2006 2007 2008 Doncaster 9.2 9.1 8.9 8.8 United Kingdom 8.8 8.7 8.5 8.2

38 Joint Director of Public Health Annual Report & Joint Strategic Needs Assessment 2010/11

Geo-demography

Geo-demography is the application of population characteristics to geographical communities. These characteristics may relate to the types of housing people live in, the types of media they use, or their educational qualifications. A number of different types are used by commercial organisations to help them focus their efforts at specific populations. The Office of National Statistics has produced a geo- demographic taxonomy of local authorities and the smaller communities within them. Doncaster has been grouped with similar areas in a group titled ‘Manufacturing Towns’22 (How this classification system has been used is explored in Appendix 1). Figure 19 shows the numbers of people in each category in Doncaster. More details of the characteristic of these groups is available from the ONS and Output area classification user group websites23 24.

Figure 19: Area classification by population in Doncaster, 2008 OA area classification (Super- group) OA area classification (Group) Population % Blue collar communities Older blue collar 39,037 13.4 Terraced blue collar 21,162 7.3 Younger blue collar 52,271 17.9 City living Settled in the city 1,772 0.6 Constrained by circumstances Older workers 19,814 6.8 Public housing 4,469 1.5 Senior communities 2,401 0.8 Countryside Accessible countryside 5,923 2.0 Agricultural 4,693 1.6 Village life 9,158 3.1 Multicultural Asian communities 5,758 2.0 Prospering suburbs Prospering older families 27,810 9.5 Prospering semis 37,942 13.0 Prospering younger families 12,720 4.4 Thriving suburbs 6,549 2.2 Typical traits Aspiring households 3,271 1.1 Least divergent 9,082 3.1 Settled households 15,837 5.4 Young families in terraced homes 11,930 4.1 Source: Office for National Statistics OA: Output Area, Doncaster is divided into 960 output areas each with about 300 residents.

22 Manufacturing towns are local authority areas with similar characteristics across the following dimensions: demographics, household composition, housing, socio-economic status, employment and industrial sector. The following local authorities are in this group: Wigan, Barnsley, Doncaster, Rotherham, Dudley, Wakefield, Stockton-on-Tees, North East Lincolnshire, North Lincolnshire, Telford & Wrekin, Ellesmere Port & Neston, Amber Valley, Bolsover, Chesterfield, Erewash, North East Derbyshire, Chester-le-Street, Havant, Swale, Rossendale, Corby, Blyth Valley, Ashfield, Bassetlaw, Mansfield, Cannock Chase, East Staffordshire, Newcastle-under-Lyme, Tamworth, Nuneaton & Bedworth, and Reditch. The following PCTs are also within the manufacturing towns group: North East Lincolnshire, North Tees, North Lincolnshire, Bassetlaw, Rotherham, Ashton, Leigh & Wigan, Barnsley, Telford & Wrekin, Wakefield District, Doncaster, Derby County, Nottinghamshire County Teaching, Dudley, and North Staffordshire. 23 areaclassification.org.uk 24 www.statistics.gov.uk/about/methodology_by_theme/area_classification/oa/default.asp

39 Joint Director of Public Health Annual Report & Joint Strategic Needs Assessment 2010/11

> Lifestyle & risk factors

Lifestyle is considered to be those aspects of behaviour over which people have some voluntary control. It relates to the choices they make about smoking, alcohol consumption, physical activity, as well as the quality of their diet. However these choices take place within cultural and economic circumstances that influence these decisions25.

Levels of smoking are estimated to be higher in Doncaster compared to England as a whole. The Association of Public Health Observatories (APHO) has produced updated estimates for Doncaster. The borough has around 28% of the adult population regularly smoking, which is significantly higher than the national rate of 22%. As with levels of smoking in the adult population, calculations from APHO show Doncaster to have significantly high binge drinking26 rates. In Doncaster around 24% of adults have taken part in binge drinking compared to 22% nationally. A similar story emerges with levels of obesity in Doncaster. Twenty eight percent of adults are estimated to be obese in the borough compared to 24% nationally (see Figure 20).

All these data are available from the 2010 health profile27.

Figure 20: Lifestyle risk factors in Doncaster and England, 2006-08

35.0

30.0

25.0

20.0 %

15.0

10.0

5.0

0.0 England Doncaster England Doncaster England Doncaster England Doncaster

Adults who smoke Binge drinking adults Obese adults Healthy eating adults

Source: Association of Public Health Observatories Based on modelled data

25 M Blaxter, Health & Lifestyle, 1990, Routledge, London 26 Binge drinking in adults is defined separately for men and women. Men are defined as having indulged in binge drinking if they had consumed 8 or more units of alcohol on the heaviest drinking day in the previous seven days; for women the cut-off was 6 or more units of alcohol. 27 http://www.apho.org.uk/default.aspx?QN=P_HEALTH_PROFILES

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41 Joint Director of Public Health Annual Report & Joint Strategic Needs Assessment 2010/11

> Ill-health & disability

Health inequalities

Health inequalities are reflected in the differences in health, wellbeing and mortality between Doncaster and England & Wales. A more reasonable comparison could be between Doncaster and similar ‘manufacturing towns’. A further way to measure inequalities is to chart the differences within the borough. The Slope Index of inequality (SII)28, developed by APHO (Association of Public Health Observatories)29, measures inequalities within the borough. The SII for men in Doncaster was 9.7 (2004- 08) and for women was 6.8, the higher the score the greater the levels of internal inequalities. Nationally the median scores were 8.6 and 5.8 respectively. The differences between Doncaster and the national picture are not significantly different (see the confidence intervals in Figure 21). More extensive use of the SII methodology can be found in the ‘Wider determinates of health profile’ for Doncaster from the Yorkshire & Humber PHO30.

Figure 22, Figure 23, and Figure 24 illustrate the differences in all age all cause mortality (AAACM) rates between Doncaster and England & Wales and the manufacturing towns. The rates in Doncaster amongst both men and women remain higher than the national and comparable with manufacturing towns. In the case of male mortality the rate is forecast to remain significantly higher than the national rate.

Figure 21: Slope Index of Inequality in Doncaster and the England Median, 2001/05 – 2004/08 2001-05 2002-06 2003-07 2004-08 Males Doncaster PCT 9.2 (7.6, 10.8) 9.2 (7.2, 11.1) 9.0 (7.2, 10.9) 9.7 (8.2, 11.3) England 8.4 8.3 8.7 8.6

Females Doncaster PCT 6.0 (4.0, 8.0) 6.0 (4.4, 7.6) 6.8 (5.0, 8.6) 6.8 (4.6, 9.0) England 5.6 5.5 5.6 5.8 Source: APHO England: median value Figures in parentheses are 95% confidence intervals.

28 The Slope Index of Inequalities is calculated by grouping LSOAs into deciles based on the IMD. The life expectancy (at birth) is then calculated for each decile and the difference between the most and least deprived is calculated. This difference is the SII. 29 www.apho.org.uk 30 www.yhpho.org.uk/resource/item.aspx?RID=94826

42 Joint Director of Public Health Annual Report & Joint Strategic Needs Assessment 2010/11

Figure 22: All age all cause standardised mortality rates in males with forecast (1993- 2020)

1200.0

1000.0

800.0

600.0 Rate per100,000 Rate

400.0

200.0

0.0 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020

Doncaster Doncaster Forecast 95% Confidence Intervals Manufacturing Towns Manufacturing Towns Forecast England & Wales England & Wales Forecast Source: National Clinical and Health Outcomes Knowledge Base (NCHOD)

Figure 23: All age all cause standardised mortality rates in females with forecast (1993- 2020)

800.0

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500.0

400.0 Rate per100,000 Rate 300.0

200.0

100.0

0.0 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020

Doncaster Doncaster Forecast 95% Confidence Intervals Manufacturing Towns Manufacturing Towns Forecast England & Wales England & Wales Forecast Source: National Clinical and Health Outcomes Knowledge Base (NCHOD)

43 Joint Director of Public Health Annual Report & Joint Strategic Needs Assessment 2010/11

Figure 24: All age all cause standardised mortality rates in persons with forecast (1993- 2020)

900.0

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400.0 Rate per100,000 Rate

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0.0 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020

Doncaster Doncaster Forecast 95% Confidence Intervals Manufacturing Towns Manufacturing Towns Forecast England & Wales England & Wales Forecast Source: National Clinical and Health Outcomes Knowledge Base (NCHOD)

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> Signposts

Information sources > Health Inequalities Dashboard: Doncaster PCT – www.yhpho.org.uk > Doncaster: Health Profile 2010 – www.apho.org.uk > Health Intelligence Practice Profiles: PCT Summary – www.yhpho.org.uk > Mapping the wider determinates of Health: Doncaster Profile – www.yhpho.org.uk > Health Profile of England 2009 – www.dh.gov.uk > Yorkshire and Humber Local Authority Population Projections: Doncaster – www.yhpho.org.uk > Doncaster: Local Migration Profile #1 – www.migrationyorkshire.org.uk > Pharmacy Needs Assessment 2011-2014 – www.doncasterpct.nhs.uk > Beyond Barriers: The Physical Disability and Sensory Impairment Strategy (2008 Refresh) – www.doncasterpct.nhs.uk

Policy context National > Equality and Excellence: Liberating the NHS – www.dh.gov.uk > Fair Society, Healthy Lives: Strategic Review of Health Inequalities post 2010 – www.marmotreview.org Local > A Plan for Doncaster: Doncaster’s Borough Strategy 2010-15 – www.doncastertogether.org.uk > Corporate Plan 2009-11: Achieving Excellence in Service Delivery & Community Leadership – www.doncaster.gov.uk

NICE guidance > PH3 Prevention of sexually transmitted infections and under 18 conceptions > PH4 Interventions to reduce substance misuse among vulnerable young people > PH7 School-based interventions on alcohol > PH12 Social and emotional wellbeing in primary education > PH14 Preventing the uptake of smoking by children and young people > PH17 Promoting physical activity for children and young people > PH20 Social and emotional wellbeing in secondary education > PH23 School-based interventions to prevent smoking > PH28 Looked-after children and young people > PH29 Strategies to prevent unintentional injuries among under-15s > PH30 Preventing unintentional injuries among under-15s in the home > PH31 Preventing unintentional road injuries among under-15s: road design

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> Starting Well: Early Years (0-4)

Giving every child the best start in life is crucial to reducing health inequalities across the life course. The foundations for virtually every aspect of human development – physical, intellectual and emotional – are laid in early childhood. What happens during these early years (starting in the womb) has lifelong effects on many aspects of health and well-being– from obesity, heart disease and mental health, to educational achievement and economic status. To have an impact on health inequalities we need to address the social gradient in children’s access to positive early experiences. Later interventions, although important, are considerably less effective where good early foundations are lacking.

The Marmot Review – page 22

47 Joint Director of Public Health Annual Report & Joint Strategic Needs Assessment 2010/11

48 Joint Director of Public Health Annual Report & Joint Strategic Needs Assessment 2010/11

> Summary – Starting Well (0-4)

Marmot review: objectives and recommendations Objectives > Reduce inequalities in the early development of physical and emotional health, and cognitive, linguistic, and social skills. > Ensure high quality maternity services, parenting programmes, childcare and early years education to meet need across the social gradient. > Build the resilience and well-being of young children across the social gradient.

Recommendations > A1: Increase the proportion of overall expenditure allocated to the early years, and ensure expenditure on early years development is focused progressively across the social gradient. > A2: Support families to achieve progressive improvements in early years development > A3: Provide good quality early years education and childcare proportionately across the gradient.

Key points for Doncaster > There are over 18,000 children aged under 5 years in Doncaster. > Some communities have more 0-4 year olds than others. > Children have poorer health and wellbeing than many parts of England. > Fewer children live in overcrowded conditions compared to nationally. > A quarter of women are still smoking when they are about to have a baby. > Breastfeeding rates are improving. > Immunisation rates are slightly better than the national rate. > Deaths in children aged under 1 are rare but the rate remains higher than the national rate.

49 Joint Director of Public Health Annual Report & Joint Strategic Needs Assessment 2010/11

> Demography

Population and births

The latest population estimates from ONS estimate there are around 18,100 children aged under 5 years resident in the borough. This accounts for 6.2% of the total population. Current projections from ONS expect this age group to increase slightly to around 18,300 by 2015 and thereafter remain fairly static until 2020 (Figure 25).

On average Doncaster has about 3,600 live births each year. Birth rates in Doncaster had been falling during the 1990s but since 2002 rates have been increasing. In 2009 there were 3,841 live births in Doncaster the second highest number since 1993 (see Figure 26). The map in Figure 27 shows which communities have higher numbers of 0-4 year olds.

Figure 25: Numbers of children aged 0-4 in Doncaster with forecast

25,000

20,000

15,000 Number

10,000

5,000

0 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 0-4 Projection Source: Office of National Statistics

50 Joint Director of Public Health Annual Report & Joint Strategic Needs Assessment 2010/11

Figure 26: Live birth rates in Doncaster and England & Wales, 1993-2009

16.0

14.0

12.0

10.0

8.0

6.0 Rate per1,000 Rate population

4.0

2.0

0.0 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Doncaster England & Wales Source: Office of National Statistics Live birth rates: Live births per 1,000 population

Figure 27: 0-4 year olds in Doncaster’s communities, 2008

Source: NHS Doncaster

51 Joint Director of Public Health Annual Report & Joint Strategic Needs Assessment 2010/11

> Social and environmental context

Child Wellbeing Index

In January 2009 DCLG published the Child Wellbeing Index (CWI)31. This index, unlike the IMD, was intended to measure wellbeing rather than deprivation. Like the IMD it was built up from a set of seven domains (Material Well-being, Health, Education, Crime, Housing, Environment, Children in Need). Doncaster has a score of 190.32 and is ranked 69th worst out of 354 local authorities. More details of the social and economic circumstances of children in the borough are outlined in the next section (Developing well: school years (5-19)).

Overcrowding

Overcrowding in the home is related to a number of health and education problems in children32. Overcrowded housing is linked to an increase in respiratory conditions, meningitis and accidents. Living in overcrowded conditions can also lead to further health complications in adulthood. Overcrowding in households in Doncaster appears to be lower compared to England & Wales (Figure 28). These data are based on the 2001 census and so are out of data.

Figure 28: Household over-crowding in Doncaster and England & Wales (2001) Doncaster England & Wales Households % Households % Very under occupied 62,659 52.8 10,731,961 49.5 Under occupied 33,603 28.3 5,522,859 25.5 Average 17,853 15.0 3,895,233 18.0 Over crowded 3,619 3.0 1,066,822 4.9 Very Over crowded 965 0.8 443,600 2.0 Total 118,699 100.0 21,660,475 100.0 Source: Census 2001 Overcrowding is measured as the number of ‘common’ rooms (excluding bathroom) per member of the household. An overcrowded household has 1 room less than ‘required’ a very overcrowded one has 2 or more room less than required.

31 Local Index of Child Well-being, January 2009, Department for Communities and Local Government 32 The impact of overcrowding on heath and education: a review of evidence and literature, May 2004, Office of the Deputy Prime Minister

52 Joint Director of Public Health Annual Report & Joint Strategic Needs Assessment 2010/11

> Lifestyle and risk factors

Smoking in pregnancy

Maternal lifestyle, including drug and alcohol misuse, and smoking can have adverse effects on the early development of both the brain and the developing body of the foetus. Smoking in pregnancy increases the risk of complications during labour, miscarriage, still birth and low birth weight. It also increases the risk of infant death by a possible 40%33. In Doncaster the rate of women smoking at the time of delivery has remained relatively unchanged at around 25% (Figure 29).

Figure 29: Women smoking at delivery in Doncaster (2006-09)

35.0

30.0

25.0

20.0 %

15.0

10.0

5.0

0.0 Apr-06 Jun-06 Apr-07 Jun-07 Apr-08 Jun-08 Apr-09 Jun-09 Feb-07 Feb-08 Feb-09 Oct-06 Oct-07 Oct-08 Aug-06 Aug-07 Aug-08 Dec-06 Dec-07 Dec-08 Source: Performance and Information Directorate, NHS Doncaster The rate is calculated using confinements at Doncaster hospitals

33 How to stop smoking in pregnancy and following childbirth, National Institute for Health and Clinical Excellence, June 2010.

53 Joint Director of Public Health Annual Report & Joint Strategic Needs Assessment 2010/11

Breastfeeding

Breast milk is the best form of nutrition for at least the first 6 months of life. Evidence shows that breastfeeding reduces the risk of infections especially respiratory and gastro-intestinal. Breastfed children are also less likely to be obese in later life and may therefore be at less risk of type 2 diabetes. Mothers’ also benefit from breastfeeding as they reduce their risks of developing cervical and breast cancer34. Breastfeeding initiation35 in Doncaster has increased recently and is now only a little lower than the national rate. This improvement has not been reflected in the breastfeeding rates at 6-8 weeks after birth (Figure 30 and Figure 31), these are much lower in Doncaster. Figure 32 shows that drop-off rates in Doncaster remain high.

Figure 30: Breastfeeding initiation in Doncaster, manufacturing towns and England, 2008-10

80.0

70.0

60.0

50.0

% 40.0

30.0

20.0

10.0

0.0 2008/09 Q1 2008/09 Q2 2008/09 Q3 2008/09 Q4 2009/10 Q1 2009/10 Q2 2009/10 Q3 2009/10 Q4 2010/11 Q1 2010/11 Q2 Doncaster Manufacturing towns England Source: Department of Health; Performance and Information Directorate, NHS Doncaster Breastfeeding initiation is putting the child to the breast or receiving mothers milk within the first 48 hours after birth

34 Improving the nutrition of pregnant and breastfeeding mothers and children in low income households, National Institute for Health and Clinical Excellence, March 2008 35 A mother is defined as having initiated breastfeeding if, within the first 48 hours of birth, either she puts the baby to the breast or the baby is given any of the mothers breast milk.

54 Joint Director of Public Health Annual Report & Joint Strategic Needs Assessment 2010/11

Figure 31: Breastfeeding at 6-8 weeks in Doncaster, manufacturing towns and England, 2008-10

50.0

45.0

40.0

35.0

30.0

% 25.0

20.0

15.0

10.0

5.0

0.0 2009/10 Q1 2009/10 Q2 2009/10 Q3 2009/10 Q4 2010/11 Q1 2010/11 Q2 Doncaster Manufacturing towns England Source: Department of Health; Performance and Information Directorate, NHS Doncaster

Figure 32: Breastfeeding drop-off between initiation and 6-8 weeks in Doncaster, manufacturing towns and England, 2008-10

70.0

60.0

50.0

40.0 %

30.0

20.0

10.0

0.0 2009/10 Q1 2009/10 Q2 2009/10 Q3 2009/10 Q4 2010/11 Q1 2010/11 Q2 Doncaster Manufacturing towns England Source: Department of Health; Performance and Information Directorate, NHS Doncaster

55 Joint Director of Public Health Annual Report & Joint Strategic Needs Assessment 2010/11

Immunisations and vaccinations

Vaccinations protect children and adults against a range of diseases. The NHS vaccination programme provides protection from: polio, diphtheria, whooping cough, and measles (amongst others). If these programmes do not achieve adequate coverage in the population then these diseases can begin to spread within communities36.

Doncaster has performed above national rates on almost all measures of performance of the immunisation programme (Figure 33). Uptake of the MMR (Measles, Mumps & Rubella) immunisation has improved in recent years (see Figure 34 and Figure 35) but was still below the Doncaster target of 85%. More recent data from the ‘Annual report: immunisations in Doncaster 2009/10’ show that the very latest uptake rates have passed this target37.

Figure 33: Children’s immunisation programmes in Doncaster and England, 2009/10 Age Programme Abbreviation England Doncaster (%) PCT (%) Diphtheria, Tetanus, Polio, Pertussis, Hib DTaP/IPV/Hib 93.6 94.0 12 Mennigitis C group MenC 92.7 93.6 months Pneumococcal Conjugate Vaccine PCV 92.9 93.5 Diphtheria, Tetanus, Polio, Pertussis, Hib DTaP/IPV/Hib 95.3 96.2 Measles Mumps Rubella MMR 88.2 87.8 24 Mennigitis C group MenC 94.2 97.6 months Heamophilus Influenza / Mennigitis C group Hib/MenC 90.0 93.6 Pneumococcal Conjugate Vaccine PCV 87.6 88.6 Diphtheria, Tetanus, Polio (Primary) DTaP (Primary) 94.0 95.1 Heamophilus Influenza Hib 93.1 94.5 Diphtheria, Tetanus, Polio, DTaP/IPV 5 years Pertussis (Booster) (Booster) 84.8 85.9 Measles Mumps Rubella (First MMR (First dose) dose) 91.0 91.5 Measles Mumps Rubella (First & MMR (First & second dose) second dose) 82.7 83.6 Source: NHS Immunisation Statistics, Information Centre for Health and Social Care

36 www.dh.gov.uk/en/Publichealth/Immunisation/Keyvaccineinformation/index.htm 37 Annual report: Immunisations in Doncaster 2009/10, NHS Doncaster

56 Joint Director of Public Health Annual Report & Joint Strategic Needs Assessment 2010/11

Figure 34: Children who have received their 1st and 2nd dose MMR immunisation by their 5th birthday in Doncaster and England, 2005/06-2009/10

100.0

90.0

80.0

70.0

60.0

% 50.0

40.0

30.0

20.0

10.0

0.0 2005/06 2006/07 2007/08 2008/09 2009/10 Doncaster England Source: NHS Information Centre MMR: Measles, mumps & rubella

Figure 35: Map of children aged 5 who have completed MMR vaccinations

Source: NHS Doncaster MMR: Measles, mumps & rubella

57 Joint Director of Public Health Annual Report & Joint Strategic Needs Assessment 2010/11

> Ill-health and disability

Stillbirths

The CEMACH (Confidential Enquiry into Maternal and Child Health) has identified a number of risk factors for stillbirths38. Mothers aged over 40 and under 20 tend to have a higher risk of stillbirth. Obesity in the mother and deprivation also increase the risk. While around half of stillbirths are the result of congenital problems and complications of pregnancy around half remain unexplained. Stillbirths39 are relatively rare events, in 2009 there were 19 stillbirths (a rate of 4.9 per 1,000 births) (Figure 36).

Low Birth weight and infant mortality

Low birth weight40 is associated with longer term health problems and with poorer educational outcomes in later life41. Low birth weight babies are also more likely to die in their first year. Figure 38 shows that in Doncaster this rate has been gradually increasing since the early 1990s but nationally the rate has remained constant.

Infant mortality42 rates are falling in Doncaster but they have, with some annual exceptions, remained higher than the national rate (see Figure 37). It is regarded as a good measure of overall health in a population and is closely related to social deprivation43. The latest mortality rates for 2009 show that Doncaster had the lowest infant mortality rates since the early 1990’s.

Figure 36: Stillbirth rates in Doncaster And England &Wales, 1993-2025

8.0

7.0

6.0

5.0

4.0 per1,000 births 3.0

2.0

1.0

0.0 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 Doncaster Doncaster Forecast 95% Confidence Intervals England & Wales England & Wales Forecast Source: Office of National Statistics; Public Health Intelligence, NHS Doncaster

38 Perinatal mortality 2005, Confidential Enquiry into Maternal and Child Health, April 2007 39 Stillbirth: deaths in babies that have achieved 24 weeks gestation 40 Low birth weight: less than 2,500g 41 Prevention of low birth weight: assessing the effectiveness of smoking cessation and nutritional interventions, Health Development Agency, July 2003 42 Infant mortality: deaths in first year of life 43 Tackling health inequalities in infant and maternal health outcomes, Report of the Infant Mortality National Support Team, December 2010

58 Joint Director of Public Health Annual Report & Joint Strategic Needs Assessment 2010/11

Figure 37: Infant mortality rates in Doncaster and England & Wales, 1993-2025

9.0

8.0

7.0

6.0

5.0

4.0 Per Per 1,000live births

3.0

2.0

1.0

0.0 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 Doncaster Doncaster Forecast 95% Confidence Intervals England & Wales England & Wales Forecast Source: Office of National Statistics; Public Health Intelligence, NHS Doncaster

Figure 38: Low birth weight rates in Doncaster and England & Wales (1993-2009)

10.0

9.0

8.0

7.0

6.0

% 5.0

4.0

3.0

2.0

1.0

0.0 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Doncaster England & Wales Source: Office of National Statistics; Public Health Intelligence, NHS Doncaster Low birth weight: percentage of all births weighing less than 2,500g

59 Joint Director of Public Health Annual Report & Joint Strategic Needs Assessment 2010/11

> Signposts

Marmot review objectives & recommendations Objectives > Reduce inequalities in the early development of physical and emotional health, and cognitive, linguistic, and social skills. > Ensure high quality maternity services, parenting programmes, childcare and early years education to meet need across the social gradient. > Build the resilience and well-being of young children across the social gradient.

Recommendations > A1: Increase the proportion of overall expenditure allocated to the early years, and ensure expenditure on early years development is focused progressively across the social gradient. > A2: Support families to achieve progressive improvements in early years development > A3: Provide good quality early years education and childcare proportionately across the gradient.

Information sources > Child Health Profile: Doncaster – www.chimat.org.uk > Annual Report Immunisations in Doncaster 2009/10 – www.doncasterpct.nhs.uk > Children & Young People’s Plan 2011- 2016: Needs Assessment 2010 Document B – Engagement – www.doncaster.gov.uk > Children & Young People’s Plan 2011- 2016: Needs Assessment 2010 Document A – Data – www.doncaster.gov.uk

Policy context National > The Children’s Plan: Building Brighter Futures - www.education.gov.uk

Local > Accident Prevention Amongst Children and Young People: A priority Review – www.education.gov.uk

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> Developing Well: School Years (5-19)

Inequalities in educational outcomes affect physical and mental health, as well as income, employment and quality of life. The graded relationship between socioeconomic position and educational outcome has significant implications for subsequent employment, income, living standards, behaviours, and mental and physical health.

The Marmot Review – page 24

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62 Joint Director of Public Health Annual Report & Joint Strategic Needs Assessment 2010/11

> Summary – Developing Well (5-19)

Marmot review objectives & recommendations Objectives > Reduce the social gradient in skills and qualifications. > Ensure that schools, families and communities work in partnership to reduce the gradient in health, well-being and resilience of children and young people.

Recommendations > B1: Ensure that reducing social inequalities in pupils’ educational outcomes is a sustained priority. > B2: Prioritise reducing social inequalities in life skills.

Key points for Doncaster > There are over 52,000 young people aged 5-19 in the borough. > In some parts of Doncaster the health and wellbeing of children is poorer than others. > Children’s educational performance is improving. > Increasing numbers of young people are taking part in physical activity. > More children are obese and overweight than the national average. > Teenage conceptions are higher than the national rate. > The numbers of children killed or seriously injured on the roads are reducing. > Although numbers are low and reducing, slightly more young people die each year compared to other manufacturing towns.

63 Joint Director of Public Health Annual Report & Joint Strategic Needs Assessment 2010/11

> Demography

Population

Of the 290,200 people resident in the borough, 52,700 (18.2%) are aged between 5 and 19 years old44. The number of individuals in this age group has fallen recently but is forecast to increase a little from 2015 onwards (see Figure 39). Figure 40 illustrates the changes that are predicted to take by 5-year age band.

The Office for National Statistics (ONS) have produced estimates45 for minority ethic populations resident in Doncaster who are aged 0-15. Around 5.3% (3,000) of the population in this age group are from non-white populations. This is compared to 4.4% for the total population. The minority ethic population is slightly younger than the white population as a whole (Figure 41).

Figure 39: Numbers of Children and young people aged 5-19 in Doncaster with projection

70,000

60,000

50,000

40,000 Number 30,000

20,000

10,000

0 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 5-19 Projection Source: Office of National Statistics

44 Based on 2009 population mid year estimates 45 hwww.statistics.gov.uk/StatBase/Product.asp?vlnk=14238

64 Joint Director of Public Health Annual Report & Joint Strategic Needs Assessment 2010/11

Figure 40: Changes in the 5-19 population by age group in Doncaster, 2009-20

20.0

18.0

16.0

14.0

12.0

10.0 '000

8.0

6.0

4.0

2.0

0.0 5-9 10-14 15-19 2009 2020 Source: Office for National Statistics Projections based on the 2008 based population projections

Figure 41: Changes in ethnicity in 0-15 year olds, 2001-07 2001 2007 All 59,800 56,100 White British 57,400 52,500 Irish 100 100 Other White 300 500 Mixed White and Black Caribbean 500 500 White and Black African 100 100 White and Asian 200 300 Other Mixed 100 200 Asian or Asian British Indian 300 400 Pakistani 500 700 Bangladeshi 0 100 Other Asian 0 100 Black or Black British Black Caribbean 100 100 Black African 0 300 Other Black 0 0 Chinese or other ethnic group Chinese 100 100 Other 0 100 Source: Office of National Statistics Experimental statistics

65 Joint Director of Public Health Annual Report & Joint Strategic Needs Assessment 2010/11

> Social & Environmental Context

Child wellbeing index

A priority of the previous government was to reduce levels of child poverty46. It can lead to poor educational outcomes, and reduced economic circumstances in adulthood47. Child poverty levels are higher in Doncaster with 22.7% of children living in families in poverty compared to the national level of 20.9%. This equates to 6,500 children aged 5-15 and just under 15,000 children of any age (see Figure 42). More recent figure from the child and Maternal health observatory has calculated that just under a quarter of 1-15 year olds live in poverty in the borough48.

In 2009 the Index of child well-being was published (CWI). These data provide a snapshot of young people’s well-being in Doncaster across a number of domains49. More detail of what these data say about Doncaster is available from the Joint Director of Public Health’s Annual report 200950. To address some of the short comings of the CWI Doncaster has produced a local child health index51. This uses locally available data and because of its greater sensitivity it can more accurately reflect the needs of the 88 geographical communities of Doncaster (Figure 43 and Figure 44).

Figure 42: Children in Poverty by LSOA in Doncaster, 2008

Source: Department of Work & Pensions (DWP) LSOA: Lower level super output area Children living in families in receipt of Child Tax Credit whose reported income is less than 60 per cent of the median income or in receipt of IS or (Income-Based) JSA

46 The definition of child poverty is children resident in households whose income is below 60% of the national median. 47 Every Child Matters, September 2003, www.education.gov.uk/consultations/downloadableDocs/EveryChildMatters.pdf 48 Child Health Profile: Doncaster, April 2010, ChiMat, 49 www.communities.gov.uk/publications/communities/childwellbeing2009 50 www.doncaster.nhs.uk 51 Further Information about the Child Health Index is available from the Public Health Intelligence and Evaluation team at NHS Doncaster.

66 Joint Director of Public Health Annual Report & Joint Strategic Needs Assessment 2010/11

Figure 43: Child wellbeing index, 2009

Source: Department of Communities and Local Government

Figure 44: Children and young people health index, 2010

Source: NHS Doncaster

67 Joint Director of Public Health Annual Report & Joint Strategic Needs Assessment 2010/11

> Lifestyle & risk factors

Education

The exact relationship between educational performance and health is complex, the Marmot review points out that maternal depression and low birth weight can predict poorer educational attainment and poorer attainment is linked to health in latter life52. At the end of the foundation year pupils are assessed against 7 criteria. These early years foundation stage profiles (EYFSP) show that in Doncaster around 54% of children aged 5 had gained a good level of achievement53. Nationally this rate is 52%. Doncaster’s children appear to be starting with similar levels of educational advantage to England as a whole.

Exclusion rates in Doncaster’s schools are a little lower than the national rate according to estimates from the Department for Education (Doncaster: 0.09%; England 0.05%)54. Pupils with Special Education Needs55 (SEN) have remained at around 2.5% over the last 5 years a little below the national rate of 2.9%. This equates to around 1,200 pupils in Doncaster. Figure 45 shows the improving attainment rates achieved by Doncaster’s school children.

Figure 45: GCSE attainment in Doncaster and England, 1997/98-2008/09

80.0

70.0

60.0

50.0

% 40.0

30.0

20.0

10.0

0.0 1997/98 1998/99 1999/00 2000/01 2001/02 2002/03 2003/04 2004/05 2005/06 2006/07 2007/08 2008/09

Doncaster - 5+ GCSEs grades A*-C England - 5+ GCSEs grades A*-C Doncaster - 5+ GCSEs grades A*-C (Inc. English & Maths) England - 5+ GCSEs grades A*-C (Inc. English & Maths) Source: Department of Community & Local Government Attainment is the proportion of 16 year olds achieving 5 or more GCSE grades A*-C

52 Fair Society, Healthy Lives: Strategic Review of Health Inequalities post 2010, Feb 2010, www.marmotreview.org 53 The percentage of pupils achieving 6 or more points in each of the 7 scales of Personal, Social and Emotional development (PSE), Communication, Language and Literacy areas of learning. 54 www.dcsf.gov.uk/rsgateway/DB/SFR/s000942/index.shtml 55 These data count only pupils with statements of special educational need.

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Obesity and physical activity

Across the country rates of obesity56 have been increasing, the implications of increasing levels of obesity amongst children are of particular concern. Long term obesity is associated with premature mortality, heart disease and diabetes. Children who are obese can also face stigma and bullying affecting their mental well-being57. Child obesity has been monitored over the last few years through the National Child Measurement Programme (NCMP). The programme measures obesity in school children in Reception (aged 4-5) and Year 6 (aged 10-11). Figure 47 and Figure 48 show the changes in the rates of obese and overweight children over the course of the programme.

Children and young people’s participation in sport and physical activity has an impact on later life. Highly active young people are protected from chronic conditions such as obesity as well as increasing strength flexibility and stamina. Physical activity can also increase bone strength58. The School Sports Survey assesses levels of physical activity in school age children. Around 41% of Doncaster children take part in high quality sport or PE for at least 3 hours (this counts both school and non-school activity) and in England this figure is 49%59. Figure 46 illustrates the increasing numbers of children participating in 2 or more hours of physical activity per day in Doncaster.

Figure 46: 5-16 year old Doncaster school children participating in 2 hours physical activity

70.0

60.0

50.0

40.0 %

30.0

20.0

10.0

0.0 2004/05 2005/06 2006/07 2007/08 2008/09

Source: School Sports Survey, Department for Children, Schools and Families (DCSF)

56 BMI used to measure adult obesity but in children their weight is more variable so, in England, child obesity is measured in relation to the 1990 growth reference charts. 57 www.noo.org.uk/NOO_about_obesity/obesity_and_health/health_risk_child 58 Promoting physical activity, active play and sport for pre-school and school-age children and young people in family, pre-school, school and community settings, January 2009, National Institute for Health and Clinical Excellence (NICE) 59 School Sports Survey 2008/09, DCSF

70 Joint Director of Public Health Annual Report & Joint Strategic Needs Assessment 2010/11

Figure 47: Obese and overweight children reception year

18.0

16.0

14.0

12.0

10.0 %

8.0

6.0

4.0

2.0

0.0 2006/07 2007/08 2008/09 2009/10 Doncaster - Obese England - Obese Doncaster - Overweight England - Overweight Source: National Child Measurement Programme, Health & Social Care Information Centre

Figure 48: Obese and overweight children in Year 6

25.0

20.0

15.0 %

10.0

5.0

0.0 2006/07 2007/08 2008/09 2009/10 Doncaster - Obese England - Obese Doncaster - Overweight England - Overweight Source: National Child Measurement Programme, Health & Social Care Information Centre

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Teenage conceptions

Most teenage conceptions do not result in a birth. However teenage conceptions are both a consequence and cause of disadvantage for young women60. Teenage mothers and their children suffer higher levels of ill-health and social and economic disadvantage; the children of teenage mothers are also more likely to be teenage parents themselves and so perpetuate disadvantage. Teenage conception rates have remained stubbornly high in Doncaster since at least the early 1990’s (Figure 49).

Figure 49: Conception rates amongst females aged under 18

80.0

70.0

60.0

50.0

40.0

30.0 Rate per1,000 Rate 15-17aged women 20.0

10.0

0.0 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Doncaster Doncaster Forecast 95% Confidence Intervals England England Forecast Source: Department for Children, Schools and Families (DCSF) Under 18 conceptions are calculated as the number of births, stillbirths, and abortions amongst females aged under 18 as a rate per 1,000 females aged 15-17

60 Teenage Pregnancy Strategy: Beyond 2010, www.education.gov.uk/publications/eOrderingDownload/00224-2010DOM-EN.pdf

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> Ill-health & Disability

Mental health

Mental health in children and adolescents (CAMHs) has an important impact on the well-being of children. It is influenced by personal factors such as genetics, gender, and self-esteem; and wider social and environmental factors such as: housing, financial security, crime, and societal attitudes. A detailed CAMHs needs assessment is available from NHS Doncaster61. Figure 50 outlines risk factors associated with increasing mental health problems in children.

Accidents

Accidents are a leading cause of death and illness in children. Falls tend to predominate in children aged under 16, and transport accidents are more common in 16 year olds and above62. Boys and children from disadvantaged backgrounds are the groups most at risk. Figure 51 shows that the numbers of children killed or seriously injured in road traffic accidents has been falling in Doncaster compared to England as a whole63. Figure 52 details the deaths from accidents in children aged under 15.

Tooth decay

Poor oral health can lead to pain, sleeplessness, and poor nutrition as well as having social consequences. The Doncaster Health profile 201064 shows that Doncaster’s 5 year olds have significantly higher levels of decayed and lost teeth than nationally (DMFT65 scores Doncaster 1.8; England 1.1).

Figure 50: Risk factors associated with an increased prevalence of mental health disorders in children and young people > Lone parent families > Reconstituted families > Parent with no qualification > Parents not working > Receipt of disability benefit > Household reference person in routine occupational group > Living in social or privately rented accommodation > Living in ‘hard-pressed areas’ Source: CAMHs Mental Health Needs Assessment, NHS Doncaster (Green, H et al. Mental Health of Children and Young People in Great Britain, 2004. ONS)

61 CAHMS Mental Health Needs Assessment, 2010, NHS Doncaster 62 Accident Prevention amongst Children and Young People a Priority Review, 2009 63 The scale in Figure 51 has been reversed, so reductions in the numbers of deaths and injuries are illustrated by an increase. If the line goes up the number of deaths and injuries falls, 64 www.apho.org.uk/default.aspx?QN=HP_DATATABLES 65 DMFT: Decayed, Missing, Filled Teeth

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Figure 51: Changes in children (under 16) killed or seriously injured on the raod in Doncaster and England, 1998/00 – 2007/09

25

20

15

10

5

0 1998-00 1999-01 2000-02 2001-03 2002-04 2003-05 2004-06 2005-07 2006-08 2007-09 % Change %

-5

-10

-15

-20

-25 Doncaster England Source: Department of Communities and Local Government % change: a positive change is a reduction in the rate NI 48: Children killed or seriously injured in road traffic accidents

Figure 52: Mortality rates from accidents in children 0-14 in Doncaster, Manufacturing Towns, and England & Wales, 1993-2015

25.0

20.0

15.0

Rate per100,000 Rate 10.0

5.0

0.0 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Doncaster Doncaster Forecast 95% Confidence Interval 95% Confidence Interval England & Wales England & Wales Forecast Manufacturing Towns Manufacturing Towns Forecast Source: National Clinical and Health Outcomes Knowledge Base (NCHOD) Accidents: ICD9 E800-E928 exc. E870-E879, ICD10 V01-X59

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Mortality

The numbers of deaths amongst children in the 5-19 year old age group are much lower than in other age groups. Each year around 30 children die in Doncaster aged under 15 (this includes infant deaths). Figure 53, Figure 54 and Figure 55 show the changes in the mortality rates of males, females and persons. As the numbers of deaths are comparatively low the rates tend to vary dramatically from year to year, however the trend seems to be downwards.

Figure 53: Age standardised mortality rates amongst males aged 0-14 in Doncaster, manufacturing towns and England & Wales

120.0

100.0

80.0

60.0 Rate perRate 100,000

40.0

20.0

0.0 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020

Doncaster Doncaster Forecast 95% Confidence Intervals Manufacturing Towns Manufacturing Towns Forecast England & Wales England & Wales Forecast Source: National Clinical and Health Outcomes Knowledge Base (NCHOD)

76 Joint Director of Public Health Annual Report & Joint Strategic Needs Assessment 2010/11

Figure 54: Age standardised mortality rates amongst females aged 0-14 in Doncaster, manufacturing towns and England & Wales

140.0

120.0

100.0

80.0

60.0 Rate perRate 100,000

40.0

20.0

0.0 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020

Doncaster Doncaster Forecast 95% Confidence Intervals Manufacturing Towns Manufacturing Towns Forecast England & Wales England & Wales Forecast Source: National Clinical and Health Outcomes Knowledge Base (NCHOD)

Figure 55: Age standardised mortality rates amongst persons aged 0-14 in Doncaster, manufacturing towns and England & Wales

90.0

80.0

70.0

60.0

50.0

40.0 Rate per per 100,000 Rate

30.0

20.0

10.0

0.0 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020

Doncaster Doncaster Forecast 95% Confidence Intervals Manufacturing Towns Manufacturing Towns Forecast England & Wales England & Wales Forecast Source: National Clinical and Health Outcomes Knowledge Base (NCHOD)

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> Signposts

Information sources > Child Health Profile: Doncaster – www.chimat.org.uk > National Obesity Observatory - www.noo.org.uk > National Child Measurement Programme - www.ic.nhs.uk > Needs Assessment for Children and Young People Substance Misuse 2009/20010 – www.doncasterpct.nhs.uk

Policy context National > Teenage Pregnancy Strategy: Beyond 2010 – www.education.gov.uk > Choosing Activity: a physical activity action plan – www.dh.gov.uk > Youth Alcohol Action Plan - www.dh.gov.uk

Local > Doncaster Obesity Action Plan – www.doncasterpct.nhs.uk

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> Developing Well: Training (15-24)

Central to our vision is the full development of people’s capabilities across the social gradient. Without life skills and readiness for work, as well as educational achievement, young people will not be able to fulfil their full potential, to flourish and take control over their lives.

The Marmot Review – page 25

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80 Joint Director of Public Health Annual Report & Joint Strategic Needs Assessment 2010/11

> Summary – Developing Well (15-24)

Marmot review objectives & recommendations Objectives > Improve the access and use of quality lifelong learning across the social gradient.

Recommendations > B2: Prioritise reducing social inequalities in life skills > B3: Increase access to and use of quality lifelong learning opportunities across the social gradient.

Key points for Doncaster > There are over 30,000 young people in the borough aged 15-24. > There are around 3,000 prisoners in Doncaster. > The numbers of young people not in employment, education or training is reducing but is still higher than the national rate. > Youth unemployment rates are higher than in England & Wales. > Crime is focused in hot spots across the borough. > We think there are around 3,000 problem drug users in the borough.

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> Demography

Demography

This age group (15-24 year olds) over laps with the previous (5-19), and is intended to reflect the period of transition between school and work. This age group constituted around 37,500 people (13%) in 2009. By 2020 this will have fallen to 30,900 (10%) (Figure 56). The data displayed in Figure 57 show that Doncaster has a smaller proportion of its population in the 15-39 year old age bracket. This is probably a combination of the greater mobility of young people and the numbers departing for university.

Prisons

Doncaster has 4 prisons and an Immigration Removal Centre (IRC). The prison population is varied both in age and ethnicity, but is generally a young one. In Doncaster, the prisons are all-male institutions. Doncaster has around 3,000 prisoners (including those on remand); this number will vary as prisoners are moved around the prison system66. At Lindholme, as well as the prison there is an IRC. This facility has accommodation for just over 100 people and is looking to increase its capacity to 365. At the time of the last needs assessment there were 122 residents whose average length-of-stay had been 103 days. The health and welfare issue of both prisoners remand prisoners, and the residents of the IRC are detailed in the annual needs assessments undertaken by NHS Doncaster.

Figure 56: Population of 15-24 years olds with projection in Doncaster, 1991-2020

45,000

40,000

35,000

30,000

25,000

Number 20,000

15,000

10,000

5,000

0 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 15-24 Projection Source: Office of National Statistics

66 HMP Doncaster &YOI Health Care Needs Assessment 2010/11; HMP Lindholme Health Care Needs Assessment 2009/10; Moorland Closed Health needs assessment 2010

82 Joint Director of Public Health Annual Report & Joint Strategic Needs Assessment 2010/11

Figure 57: Population by 5 year age group in Doncaster and England & Wales, 2009

8.00

7.00

6.00

5.00

% 4.00

3.00

2.00

1.00

0.00 0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+ Doncaster England & Wales Source: Office of National Statistics

Figure 58: Doncaster’s sentenced and remanded prison population compared to the resident population

50.0

45.0

40.0

35.0

30.0

% 25.0

20.0

15.0

10.0

5.0

0.0 18-19 20-24 25-29 30-34 35-39 40-44 45-49 50+ Sentenced and remanded prisoners General population Source: NHS Doncaster

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> Social & environmental context

Training and unemployment

The Marmot review notes that people with low level qualifications or no skills have lower incomes and poorer health outcomes67. Young people between the ages of 16 and 18 who are not engaged in employment, education or training (NEET) face an increased risk of long term unemployment, low income and poorer mental and physical health68. In Doncaster the rates of young people classed as NEET have reduced but remain higher than the England rate (Figure 59). Figure 60 shows areas within the borough with higher levels of deprivation in the skills and education domain from the IMD69. Unemployment rates in 18-24 year olds (Figure 61) have remained consistently higher in Doncaster compared to England & Wales.

Figure 59: 16-18 year olds not in Education, employment or training, 2005-10

14.0

12.0

10.0

8.0 %

6.0

4.0

2.0

0.0 2005 2006 2007 2008 2009 Doncaster England Source: Department for Children Schools and Families

67 Fair Society, Healthy Lives: Strategic Review of Health Inequalities post 2010, Feb 2010, www.marmotreview.org 68 www.dcsf.gov.uk/everychildmatters/Youth/ypnieet/neet/ 69 The English Indices of Deprivation, www.communities.gov.uk/documents/communities/pdf/733520.pdf

84 Joint Director of Public Health Annual Report & Joint Strategic Needs Assessment 2010/11

Figure 60: IMD training and education domain

Source: Department for Children Schools and Families

Figure 61: Unemployment in 18-24 year olds, 2006 -10

40.0

35.0

30.0

25.0

% 20.0

15.0

10.0

5.0

0.0 Jul-06 Jul-07 Jul-08 Jul-09 Jul-10 Jan-06 Jan-07 Jan-08 Jan-09 Jan-10 Sep-06 Sep-07 Sep-08 Sep-09 Sep-10 Mar-06 Mar-07 Mar-08 Mar-09 Mar-10 Nov-06 Nov-07 Nov-08 Nov-09 May-06 May-07 May-08 May-09 May-10 Doncaster England and Wales Source: NOMIS, ONS

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Crime

Crime is often cited by members of the public as one of the most important factors affecting wellbeing70. Crime has an impact on health; from the direct effects of assault and violence to the more indirect impacts of fear of crime. Alcohol consumption and drug misuse exacerbate crime rates and the types and severity of the crimes committed71. Figure 62 shows the distribution of crime deprivation from the 2007 Indices of Multiple Deprivation.

Figure 62: The crime domain from the IMD

Source: Department for Children Schools and Families

70 www.lho.org.uk/LHO_Topics/Health_Topics/Determinants_of_Health/Crime.aspx#contacts 71 Alcohol Related Crime and Disorder: IAS Fact sheet, Institute of Alcohol Studies, www.ias.org.uk

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> Ill-health and disability

Drug misuse

The effects of drug misuse are wide-ranging, with implications for public health, health services and the criminal justice system. Drug misuse can lead to poisoning as well as chronic health problems; it is also linked to acquisitive crime. Drug misuse and its consequences not only affect individuals but whole communities72. Figure 63 shows the estimated numbers of problem drug users in Doncaster73.

Sexual Health

Sexual health problems have been growing in recent years; HIV infections and sexually transmitted infections have been increasing nationally74. In Doncaster rates of sexually transmitted infections are higher than national rates, and this is particularly noticeable in Chlamydia infections in 15-24 year olds (Figure 64). Chlamydia can have important implications for reproductive health for women and is associated with pelvic inflammatory disease, ectopic pregnancy and infertility75.

Figure 63: Estimated numbers of problem drug users by age group in the Doncaster DAT Area, 2008/09 Age group Type Number 95% CI 15-64 Problem drug users 3,079 2,685 3,491 Opiate users 2,621 2,342 2,919 Crack users 1,241 884 1,644 15-24 Problem drug users 570 459 728 25-34 Problem drug users 1,545 1,320 1,765 35-64 Problem drug users 964 823 1,135 Source: National Treatment Agency for Drug Misuse (NTA) Problem drug users: users of opiates and /or crack cocaine, it dose not include cocaine (powder), amphetamines, ecstasy or cannabis DAT: Drug Action Team 95%CL: 95% confidence Intervals

Figure 64: Rates of selected Sexually Transmitted Infections in Doncaster and England, 2009 Doncaster England Chlamydia (15-24) 2,972.4 2,180.6 Chlamydia (25+) 87.6 94.4 Gonorrhoea 17.5 28.5 Syphilis 2.7 5.2 Herpes 54.9 49.6 Warts 191.0 141.2 Acute STIs 914.3 774.6 Source: Health Protection Agency Rates per 100,000 population

72 Indications of Public Health in the English Regions 10: Drug Misuse, APHO 73 Estimates of the Prevalence of opiate use and/or crack use (2008/09): Yorkshire & Humber Region, www.nta.nhs.uk/facts-prevalence.aspx 74 Better prevention, Better services, Better sexual health: The national strategy for sexual health and HIV, July 2001, Department of Health 75 www.hpa.org.uk

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> Signposts

Information sources > Estimates of the prevalence of opiate use and/or crack cocaine use (2008/09): Yorkshire and Humber Region – www.nta.nhs.uk > Prison needs assessments – www.doncasterpct.nhs.uk

Policy context National > Drug Strategy 2010 Reducing Demand, Restricting Supply, Building Recovery: Supporting People to Live a Drug Free Life - www.homeoffice.gov.uk

Local

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> Working Well: Employment (25-64)

Being in good employment is protective of health. Conversely, unemployment contributes to poor health. Getting people into work is therefore of critical importance for reducing health inequalities.

The Marmot Review – page 26

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90 Joint Director of Public Health Annual Report & Joint Strategic Needs Assessment 2010/11

> Summary – Working well (25-64)

Marmot review objectives & recommendations Objectives > Improve access to good jobs and reduce long-term unemployment across the social gradient. > Make it easier for people who are disadvantaged in the labour market to obtain and keep work. > Improve quality of jobs across the social gradient.

Recommendations > C1: Prioritise active labour market programmes to achieve timely interventions to reduce long-term unemployment. > C2: Encourage, incentivise and, where appropriate, enforce the implementation of measures to improve the quality of work across the social gradient. > C3: Develop greater security and flexibility in employment.

Key points for Doncaster > There are over 150,000 adults aged 25-64 in the borough. > The population is becoming more diverse – the biggest rises in new residents in recent years come from Latvia and Poland. > More working age people than the national average are economically inactive. > The numbers of job seekers allowance claimants has climbed faster than the national average during the recession. > A greater proportion of local authority housing stock is in poor repair compared to other parts of England. > Death rates from alcohol related liver disease are increasing across the country but faster in Doncaster. > More women go for breast and cervical screening than the national average. > Fewer adults take part in moderate physical activity sport in all age groups than in other parts of the country. > Death rates in people of working age are improving, among women the gap is closing but not in men. > The number of suicides is small and not significantly different from the national average. > The number of people who have physical disabilities, learning disabilities or mental health problems will stay roughly the same over the next 20 years.

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> Demography

Population

The 25-64 age range accounted for about 150,800 residents in Doncaster in 2009. This is around 52% of the total population. Current population projects expect this to increase to 152,600 by 2020, this low rate of increase means that this group will fall to around 51% of the population (Figure 65) by 2020.

Ethnicity

Figure 66 shows the estimated changes to ethnic populations of working age. There have been small increases in most of the non-white populations. The main increases have been in the ‘white other’ category. This reflects the increasing numbers of people of working age from Eastern Europe. A report from the Yorkshire and Humber Regional Migration Partnership76 shows that while migration in Doncaster has been slightly lower than other areas in the region significant numbers of migrants have arrived in Doncaster and more have arrived from Poland and Latvia compared to other areas of the region (Figure 67).

Figure 65: Numbers of people aged 25-64 in Doncaster with projection

180,000

160,000

140,000

120,000

100,000

Number 80,000

60,000

40,000

20,000

0 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 25-64 Projection Source: Office of National Statistics

76 Doncaster: local migration profile 1 (Spring 2010)

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Figure 66: Changes in ethnicity in 16-64/59 year olds, 2001-07 2001 2007 All 172,400 177,400 White British 166,100 165,200 Irish 900 800 Other White 1,200 2,400 Mixed White and Black Caribbean 300 500 White and Black African 100 200 White and Asian 200 400 Other Mixed 100 300 Asian or Asian British Indian 900 1,700 Pakistani 900 1,600 Bangladeshi 0 100 Other Asian 200 600 Black or Black British Black Caribbean 500 600 Black African 200 1,200 Other Black 100 100 Chinese or other ethnic group Chinese 400 900 Other 200 700 Source: Office of National Statistics Experimental statistics 16-64 for males; 16-59 for females

Figure 67: New national insurance registrations in Doncaster, 2004-08

3,000

2,500

2,000

1,500 Number

1,000

500

0 2004 2005 2006 2007 2008 All registrations Eastern European Source: Migration Impact Fund Profile of Eastern Europeans in Doncaster, University of Sheffield, Department of Work and Pensions

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> Social and environmental context

Work and economic inactivity

The recent downturn in the economy has refocused attention on the relationship between work, unemployment, and economic inactivity. The Marmot review draws attention to the importance of healthy work and the close relationship between ill- health and unemployment. Economic inactivity levels reflect the proportion of the population who are unemployed as well as people not actively seeking work77. Figure 68 shows that Doncaster has persistently higher levels of economic inactivity compared to England & Wales. Job Seekers Allowance (JSA) is an indicator of unemployment78, and in the borough the claimant count has climbed (faster than nationally) with the economic recession (Figure 70). Figure 69 illustrates how employment deprivation is distributed across the borough.

Figure 68: Economic inactivity, 16-64

30.0

25.0

20.0

% 15.0

10.0

5.0

0.0 Jul 08-Jun 0908-Jun Jul Jul 07-Jun 0807-Jun Jul Jul 06-Jun 0706-Jun Jul Jul 05-Jun 0605-Jun Jul Jul 04-Jun 0504-Jun Jul Apr 09-Mar Apr 10 Apr 08-Mar Apr 09 Apr 07-Mar Apr 08 Apr 06-Mar Apr 07 Apr 05-Mar Apr 06 Apr 04-Mar Apr 05 Oct 08-Sep 09 Oct 07-Sep 08 Oct 06-Sep 07 Oct 05-Sep 06 Oct 04-Sep 05 Jan 0909-Dec Jan 0808-Dec Jan 0707-Dec Jan 0606-Dec Jan 0505-Dec Jan 0404-Dec Doncaster England and Wales Source: ONS annual population survey Economically inactive: People who are neither in employment nor unemployed. This group includes, for example, all those who were looking after a home or retired.

77 For example the retired, full time carers or people who are long term sick. 78 Some unemployed people are more likely to be missed by the claimant count than others; these include women, young people and those living in higher income households. This largely reflects the eligibility criteria for JSA

94 Joint Director of Public Health Annual Report & Joint Strategic Needs Assessment 2010/11

Figure 69: IMD employment domain

Source: NHS Doncaster

Figure 70: JSA recipients, 16-64

7.0

6.0

5.0

4.0 %

3.0

2.0

1.0

0.0 Jul-06 Jul-07 Jul-08 Jul-09 Jul-10 Jan-06 Jan-07 Jan-08 Jan-09 Jan-10 Sep-06 Sep-07 Sep-08 Sep-09 Sep-10 Mar-06 Mar-07 Mar-08 Mar-09 Mar-10 Nov-06 Nov-07 Nov-08 Nov-09 May-06 May-07 May-08 May-09 May-10 Doncaster England and Wales Source: ONS annual population survey

95 Joint Director of Public Health Annual Report & Joint Strategic Needs Assessment 2010/11

Housing

Housing and the quality of people’s homes are an important component of health and wellbeing; it also plays an important role in mental health79. Poor housing can expose people to dangerous pollutants such as asbestos, and houses can be poorly designed exposing the residents to cold and damp. The design of housing and neighbourhoods can affect people’s access to services and exposure to social stresses such as crime and over-crowding. Finally a lack of housing is very important for individuals and families who are unable to access housing at all. Figure 71 shows the percentage of local authority housing stock in poor repair. The rate is higher than the national rate but has improved recently.

Figure 71: Local authority-owned non-decent dwellings, 2001/02-2009/10

70.0

60.0

50.0

40.0 %

30.0

20.0

10.0

0.0 2001/02 2002/03 2003/04 2004/05 2005/06 2006/07 2007/08 2008/09 2009/10 Doncaster England Source: DCLG NI 158: Percentage of local authority-owned non-decent dwellings (%)

79 Housing and public health: a review of reviews of interventions for improving health (Evidence briefing), December 2005, National Institute for Health and Clinical Excellence (NICE)

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97 Joint Director of Public Health Annual Report & Joint Strategic Needs Assessment 2010/11

> Lifestyle & risk factors

Alcohol

The majority (70%) of adults in this country regularly consume alcohol. However alcohol has impacts on both individuals and communities80. Nationally evidence indicates that consumption has been increasing and around 31% of adults are now consuming above recommended levels81 82. Mortality and hospital admissions related to alcohol consumption are significantly higher in Doncaster83. Figure 72 shows the increasing chronic liver disease mortality rates in Doncaster compared to benchmarks.

Physical activity

After the age of 35 levels of physical activity tend to fall off, however high levels of physical activity contribute to reducing the risks of cardio-vascular disease, reducing obesity and improving mental health84. Taking part in exercise is governed by personal characteristic (personality, class), levels of familial and institutional support and the environment (weather, access to facilities)85. Figure 73 shows levels of participation in physical activity to be slightly lower in Doncaster compared to the national picture.

Figure 72: Age standardised mortality rates from chronic liver disease (including cirrhosis) in Doncaster, Manufacturing Towns, and England & Wales, 1993-2015

60.0

50.0

40.0

30.0 Rate per100,000 Rate

20.0

10.0

0.0 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Doncaster Doncaster Forecast 95% Confidence Interval 95% Confidence Interval England & Wales England & Wales Forecast Manufacturing Towns Manufacturing Towns Forecast Source: National Clinical and Health Outcomes Knowledge Base (NCHOD) Chronic liver disease: ICD9 571 adjusted, ICD10 K70, K73-K74

80 Alcohol-attributable fractions for England: Alcohol-attributable mortality and hospital admissions, June 2008, North West Public Health Observatory 81 Men should not regularly drink more than 3-4 units of alcohol per day and women should not regularly drink more than 2-3 units of alcohol per day (1 unit = 8g or 10ml alcohol) 82 Safe. Sensible. Social: The next steps in the national alcohol strategy, June 2007, Department of Health 83 Local Alcohol Profiles for England (LAPE), www.nwph.net/alcohol/lape/LAProfile.aspx?reg=d 84 Choosing Activity: a physical activity action plan, March 2005, Department of Health 85 Promotion of physical activity among adults Evidence into practice briefing, March 2006, National Institute for Health and Clinical Excellence (NICE)

98 Joint Director of Public Health Annual Report & Joint Strategic Needs Assessment 2010/11

Figure 73: Adult participation in 30 minutes, moderate intensity sport, 2007-2010

18.0

16.0

14.0

12.0

10.0 %

8.0

6.0

4.0

2.0

0.0 Oct 2007-Oct 2008 Oct 2008-Oct 2009 Oct 2009-Oct 2010 England Doncaster Source: Sport England’s Active People Survey

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Cancer screening

Generally, the earlier a cancer is detected the better the outcome for the individual86. Screening is one way to detect cancer early. The NHS has 3 cancer screening programmes; the cervical screening programme87 is available to all women aged between 25 and 64. Breast screening is available every 3 years for women aged 50 and over. Bowel cancer screening is for men and women aged 60- 69 and is available every 2 years. Screening rates in Doncaster are generally higher than national rates. The falls in cervical screening rates seems to have been arrested (Figure 74 and Figure 75).

Figure 74: Breast screening coverge rates in Doncaster and England, 2002-2009

86.0

84.0

82.0

80.0

78.0

% 76.0

74.0

72.0

70.0

68.0

66.0 March 2002 March 2003 March 2004 March 2005 March 2006 March 2007 March 2008 March 2009 Doncaster England Source: The Information Centre for Health and Social Care % of eligible women aged 53-64 screened within the previous 3 years

86 Cancer Reform Strategy, December 2007, Department of Health 87 Cervical screening is not a test for cancer. It is a method of preventing cancer by detecting and treating early abnormalities which, if left untreated, could lead to cancer

100 Joint Director of Public Health Annual Report & Joint Strategic Needs Assessment 2010/11

Figure 75: Cervical cancer screening coverage rates in Doncaster and England, 2002/03 – 2009/10

86.0

85.0

84.0

83.0

82.0

81.0 % 80.0

79.0

78.0

77.0

76.0

75.0 2002-03 2003-04 2004-05 2005-06 2006-07 2007-08 2008-09 2009-10 Doncaster England Source: The Information Centre for Health and Social Care % of eligible women aged 25-64 screened within previous 5 years

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> Ill-health and disability

Mortality

Deaths in the age group 15-64 account for about 18% of all deaths (22% males; 13% females) in Doncaster. Reductions in premature mortality will make an important contribution to increasing life expectancy and reducing health inequalities in overall death rates88. Figure 76, Figure 77 and Figure 78 show premature mortality rates in men and women and in all persons. The rates for working age men appear not to have fallen for the last 4 years and are significantly higher than comparative populations.

Figure 76: All cause mortality in males (15-64)in Doncaster, Manufacturing Towns, and England & Wales, 1993-2020

450.0

400.0

350.0

300.0

250.0

200.0 Rate perRate 100,000

150.0

100.0

50.0

0.0 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020

Doncaster Doncaster Forecast 95% Confidence Intervals Manufacturing Towns Manufacturing Towns Forecast England & Wales England & Wales Forecast Source: National Clinical and Health Outcomes Knowledge Base (NCHOD)

88 Geographical Variations in Premature Mortality in England and Wales, 1981-2006, Health Statistics Quarterly 38, pp6-22, Summer 2008

102 Joint Director of Public Health Annual Report & Joint Strategic Needs Assessment 2010/11

Figure 77: All cause mortality in females (15-64) in Doncaster, Manufacturing Towns, and England & Wales, 1993-2020

300.0

250.0

200.0

150.0 Rate perRate 100,000

100.0

50.0

0.0 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020

Doncaster Doncaster Forecast 95% Confidence Intervals Manufacturing Towns Manufacturing Towns Forecast England & Wales England & Wales Forecast Source: National Clinical and Health Outcomes Knowledge Base (NCHOD)

Figure 78: All cause mortality in persons (15-64) in Doncaster, Manufacturing Towns, and England & Wales, 1993-2020

350.0

300.0

250.0

200.0

150.0 Rate perRate 100,000

100.0

50.0

0.0 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020

Doncaster Doncaster Forecast 95% Confidence Intervals Manufacturing Towns Manufacturing Towns Forecast England & Wales England & Wales Forecast Source: National Clinical and Health Outcomes Knowledge Base (NCHOD)

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Learning disabilities

The government’s strategy to improve the health and wellbeing of people with learning disabilities recognises that people with learning disabilities are more likely to have health problems, are more likely to die at a young age and have greater challenges accessing services89. Figure 79 shows that it is predicted that Doncaster will have just over 4,000 people (aged 18-64) with learning disabilities.

Mental health

It is thought that around 1 person in 4 will experience a mental health problem at some point in their life and for those with longer term problems around ¾ find their symptoms have emerged in their early 20s90. Figure 80 shows some estimates of the prevalence of some mental illnesses. Doncaster had 26 deaths from suicide and undetermined injury91 in 2008, most were in the 35-64 age group (see Figure 81). With such relatively small numbers of deaths the rate in Doncaster tends to vary from year to year, but in the last 6 years the rate in Doncaster has been higher than both England & Wales and manufacturing towns.

Figure 79: People aged 18-64 predicted to have a learning disability in Doncaster, 2010-2030 2010 2015 2020 2025 2030 18-24 692 631 567 563 612 25-34 834 959 979 916 859 35-44 957 830 847 973 1004 45-54 984 1,004 912 798 820 55-64 817 827 911 931 850 18-64 4,284 4,251 4,216 4,182 4,145 Source: Projecting Adult Needs and Services Information System (PANSI) Estimates

Figure 80: People aged 18-64 predicted to have a mental health problem by condition in Doncaster, 2010-2030 2010 2015 2020 2025 2030 Common mental disorder 28,397 28,103 27,869 27,511 27,185 Borderline personality disorder 793 785 778 767 758 Antisocial personality disorder 621 618 615 610 606 Psychotic disorder 705 698 692 683 675 Common mental disorder 28,397 28,103 27,869 27,511 27,185 Borderline personality disorder 793 785 778 767 758 2 or more psychiatric disorders 12,712 12,594 12,498 12,351 4,112 Source: Projecting Adult Needs and Services Information System (PANSI) Estimates

89 Valuing People Now: a new three-year strategy for people with learning disabilities ‘Making it happen for everyone’ – Department of Health, January 2009 - www.valuingpeoplenow.dh.gov.uk/ 90 McManus s, Meltzer h, Brugha T et al. (2009) Adult Psychiatric Morbidity in England, 2007: Results of a household survey. NHS Information Centre for Health and Social Care 91 Undetermined injury deaths are included in the definition of the suicide to control for the different criteria used by coroners when reaching a verdict of suicide.

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Figure 81: Age standardised suicide & undetermined injury mortality rates (all ages) in Doncaster, manufacturing towns and England & Wales with forecasts, 1993-2015

16.0

14.0

12.0

10.0

8.0

Rateper100,000 6.0

4.0

2.0

0.0 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Doncaster Doncaster Forecast 95% Confidence Interval 95% Confidence Interval England & Wales England & Wales Forecast Manufacturing Towns Manufacturing Towns Forecast Source: National Clinical and Health Outcomes Knowledge Base (NCHOD) Suicide & undetermined injury: ICD-10 X60-X84, Y10-Y34 exc. Y33.3; ICD-9 E950-E980-E989 exc. E988.8

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Physical disability

Physical disability can be defined as a physical impairment that has a substantial and long term adverse effect on a persons ability to carry out normal day-to-day activities92. This is just one type of disability. The new Equality Act 2010 will place duties on public services to deliver equitable services across all dimensions of disability93. The estimated numbers of people with physical disabilities in Doncaster are in Figure 82.

Figure 82: People aged 18-64 predicted to have a moderate or serious physical disability in Doncaster, 2010-2030 2010 2015 2020 2025 2030 moderate 18-24 1,045 955 861 857 935 physical 25-34 1,407 1,617 1,651 1,546 1,449 disability 35-44 2,190 1,893 1,926 2,206 2,268 45-54 4,113 4,171 3,764 3,279 3,356 55-64 5,379 5,424 5,975 6,109 5,573 18-64 14,134 14,060 14,176 13,996 13,581 serious 18-24 204 186 168 167 182 physical 25-34 134 154 157 147 138 disability 35-44 665 575 585 670 689 45-54 1,145 1,161 1,048 913 934 55-64 2,094 2,111 2,326 2,378 2,169 18-64 4,241 4,187 4,283 4,275 4,112 Source: Projecting Adult Needs and Services Information System (PANSI) Estimates

92webarchive.nationalarchives.gov.uk/+/www.direct.gov.uk/en/disabledpeople/rightsandobligations/disa bilityrights/dg_4001069 93 www.equalities.gov.uk/equality_act_2010.aspx

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> Signposts

Information sources > Adult Alcohol Treatment Health Needs Assessment Report 2008-2009 (Draft) – www.doncasterpct.nhs.uk > Labour Market Profile: Doncaster – www.nomisweb.co.uk > Profile of Alcohol Related Harm: Doncaster (Local Alcohol Profiles for England – www.nwph.net > Local and Regional CO2 Emissions Estimates for 2005 – 2008 for the UK – www.decc.gov.uk > Doncaster PCT Tobacco Control Profile (Local tobacco control profiles for England) – www.lho.org.uk > Doncaster: local migration profile 1 (Spring 2010) - www.migrationyorkshire.org.uk > Adult Alcohol Treatment Health Needs Assessment Report, 2008-2009 (Feb 2010) – NHS Doncaster

Policy context National > Safe. Sensible. Social: the Next Steps in the National Alcohol strategy – www.dh.gov.uk Local > Doncaster Alcohol Strategy 2010-13 – www.doncasterpct.nhs.uk > Being Valuable, Being Valued: A strategy for people with learning disabilities in Doncaster 2010 – 2013 – www.doncaster.gov.uk > Better Homes, Better Places: Doncaster Housing Strategy 2011-14, DMBC - www.doncaster.gov.uk

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> Ageing Well: Retirement (65+)

Prevention of ill health has traditionally been the responsibility of the NHS, but we put prevention in the context of the social determinants of health. Hence, all our recommendations require involvement of a range of stakeholders.

The Marmot Review – page 30

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> Summary – Ageing Well (65+)

Marmot review objectives & recommendations Objectives > Prioritise prevention and early detection of those conditions most strongly related to health inequalities. > Increase availability of long-term and sustainable funding in ill health prevention across the social gradient.

Recommendations > F1: Prioritise investment in ill health prevention and health promotion. > F2: Implement evidence-based programme of ill health preventive interventions that are effective across the social gradient. > F3: Focus core efforts of public health departments on interventions related to the social determinants of health, proportionately across the gradient.

Key points for Doncaster > There are about 50,000 people aged over 64 living in the borough, but over the next 10 years this number will increase to over 60,000. > The number of extra deaths in the winter vary from year to year. > Some communities in Doncaster have high rates of winter mortality. > Some parts of Doncaster have large numbers of older people living on low incomes. > The borough will have increasing numbers of older people living alone and also resident in care homes. > Older people not only need care they are also increasingly providing care as well. > With an increasingly older population Doncaster will have greater numbers of people with dementia and other mental health problems associated with old age. > More people in Doncaster are diagnosed with lung cancer compared to similar areas. > Deaths from circulatory diseases are lower in Doncaster compared to similar areas. > Deaths from respiratory disease remain very high in Doncaster. > The number of falls amongst older people are set to increase.

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> Demography

Population

In 2009 the estimated population aged over 64 was just under 50,000 in Doncaster. In common with most other parts of the country this age group has been increasing94 and will, by 2020 have reached 60,800 (Figure 83). This equates to 1,000 more people aged 65+ living in the borough each year. These increases are more marked in the 65-74 group (Figure 84).

Ethnicity

Figure 85 shows the estimated numbers of people from different ethnic groups aged over 60/65. In Doncaster the older population is predominantly white.

Figure 83: Numbers of older people aged 65+ with projection

70,000

60,000

50,000

40,000 Number 30,000

20,000

10,000

0 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 65+ Projection Source: Office for National Statistics

94 www.statistics.gov.uk/pdfdir/pproj1009.pdf

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Figure 84: Numbers of older people aged 65-79 and 80+ with projection

50,000

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15,000

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0 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 65-79 Projection (65-79) 80+ Projection (80+) Source: Office for National Statistics

Figure 85: Changes in ethnicity in 65/60+ year olds, 2001-07 2001 2007 All 54,700 57,500 White British 53,200 55,700 Irish 500 600 Other White 500 500 Mixed White and Black Caribbean 0 0 White and Black African 0 0 White and Asian 0 0 Other Mixed 0 0 Asian or Asian British Indian 100 200 Pakistani 100 100 Bangladeshi 0 0 Other Asian 0 0 Black or Black British Black Caribbean 200 200 Black African 0 0 Other Black 0 0 Chinese or other ethnic group Chinese 100 100 Other 0 0 Source: Office of National Statistics Experimental statistics 65+ for males; 60+ for females

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> Social and Environmental Context

Fuel poverty and excess winter mortality

Households are in fuel poverty if they have to spend more than 10% of their income to keep their home satisfactorily heated95. In Doncaster the latest estimates reveal that over 9,000 households are in fuel poverty96. More recent regional estimates propose that around 17% of Doncaster households are in fact in fuel poverty this is around 20,000 households97. These differences may be explained by different methods of calculation. Fuel Poverty impacts on some of the most vulnerable groups, particularly the poor and the elderly. It is linked to cold and damp housing which in turn exacerbate conditions such as cardio-vascular illnesses, respiratory diseases and excess winter mortality98. Figure 86 shows how fuel poverty is estimated to be distributed across the borough. Figure 87 shows how excess winter mortality has changed in Doncaster compared to England as a whole, and Figure 88 shows how excess winter mortality varies across different communities.

Figure 86: Fuel poverty by LSOA

Source: Office of National Statistics LSOA: Lower Super Output Area, LSOAs are a small-area geography with around 1,500 residents. Doncaster has 193 LSOAs

95 Fuel Poverty: Fifth Report of Session 2009-10 (House of Commons Energy and Climate Change Committee), March 2010 96 www.fuelpovertyindicator.org.uk 97 Awaiting refernce from DMBC 98 Alleviating Fuel Poverty in Order to Improve Health in the North East: Final Report for the Economy, Culture and Environment Regional Advisory Group of Public Health North East, October 2009, NEA

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Figure 87: Excess winter mortality in Doncaster and England, 2004/05-09/10

40.0

35.0

30.0

25.0

% 20.0

15.0

10.0

5.0

0.0 2004/05 2005/06 2006/07 2007/08 2008/09 2009/10 Doncaster England Source: National Energy Action and NHS Doncaster The ratio of extra deaths from all causes that occur in the winter months compared to the average of the number of non-winter deaths of the same period. Winter is December to March

Figure 88: Excess winter deaths by Community, 2004-08

Source: NHS Doncaster Communities in white mean the data has been suppressed.

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Poverty

Nationally the income of pensioners has improved, in real terms, over the last 10 years. The numbers of pensioners living in poverty99 has reduced from 2.8 million in 1999/2000 to 1.8 million in 2008/09. However there is considerable variation in income between different groups. Older pensioners (over 74) tend to have lower incomes and spend a greater portion of their income on food, energy, housing, and council tax. Single women aged over 75 tended to have the lowest income of all100. Figure 89 is a map of Income Deprivation Affecting Older People (IDAOPI)101. This highlights the differences in income across the borough102.

Living alone and living in care homes

With an increasing ageing population the numbers of older people living alone is set to increase as are the numbers of people resident in care homes. Figure 90 and Figure 91 show the latest estimates for these populations from POPPI103.

Figure 89: Income deprivation affecting older people index (IDAOPI), 2007

Source: Department of Communities and Local Government IDAOPI is a based on a subset of data from the IMD 2007 and measures income deprivation in people aged 65+

99 An income of less than 60% of the median income after housing costs. 100 Statistical Bulletin: Older People’s Day 2010, September 2010, ONS 101 The English Indices of Deprivation 2007, March 2008, DCLG, www.communities.gov.uk 102 IDAOPI: adults 60 or over living in pension credit (guarantee) households as a proportion of all those 60 or over 103 POPPI: Projecting Older People Population Information System, www.poppi.org.uk

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Figure 90: Estimated numbers of people living alone in Doncaster by age and gender, 2010-30 2010 2015 2020 2025 2030 Males 65-74 2,540 2,940 3,040 3,120 3,500 75+ 3,264 3,638 4,182 5,100 5,576 Females 65-74 4,290 4,830 5,040 5,100 5,580 75+ 8,601 9,211 10,065 11,712 12,871 Total 65-74 6,830 7,770 8,080 8,220 9,080 75+ 11,865 12,849 14,247 16,812 18,447 Source: POPPI Modelled data with rounding

Figure 91: Estimated numbers of people resident in nursing homes (with or without local authority nursing) in Doncaster by age, 2010-30 2010 2015 2020 2025 2030 LA care 65-74 34 39 41 41 46 home 75-84 68 73 79 93 98 85+ 111 129 150 185 221 Non LA 65-74 152 173 181 183 204 care 75-84 509 544 593 694 732 home 85+ 944 1,099 1284 1,579 1,888 Total 65+ 11,865 12,849 14,247 16,812 3,188 Source: POPPI Modelled data with rounding LA: Local Authority

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> Lifestyle and risk factors

Carers

People of any age can become a carer. Nevertheless many are over 65 or caring for older people. They can face isolation, loss of income and can be coping with health problems of their own. Many may not even consider themselves to be carers104. Carers allowance is a benefit available for people who look after those with mental or physical disabilities who need help with their care105. Figure 92 shows that the numbers of people of pension-able age receiving this benefit has been climbing. The numbers of people providing unpaid care aged over 64 is also projected to increase (Figure 93).

Figure 92: Carers allowance recipients of pensionable age in Doncaster and England & Wales, 2003-10

35,000 250

30,000

200

25,000

150 20,000

15,000

100 Doncaster(No.) Englnd & Wales & (No.) Englnd

10,000

50

5,000

0 0 Feb-04 Feb-05 Feb-06 Feb-07 Feb-08 Feb-09 Feb-10 Nov-03 Nov-04 Nov-05 Nov-06 Nov-07 Nov-08 Nov-09 Aug-03 Aug-04 Aug-05 Aug-06 Aug-07 Aug-08 Aug-09 May-04 May-05 May-06 May-07 May-08 May-09 May-10 England & Wales Doncaster Source: NOMIS Pension age: Males aged 65+ and females aged 60+

Figure 93: Estimated numbers of people providing unpaid care by age, 2010-30 2010 2015 2020 2025 2030 65-74 3,943 4,486 4,691 4,764 5,292 75-84 1,668 1,782 1,943 2,274 2,398 85+ 203 236 276 339 406 Total 65+ 5,814 6,503 6,910 7,378 8,095 Source: POPPI Modelled data with rounding

104 Recognised, valued and Supported: Next Steps for the Carers Strategy, November 2010, Department of Health 105 www.direct.gov.uk/en/disabledpeople/financialsupport/dg_10012425

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Flu vaccinations

Seasonal flu vaccination is offered to all people aged over 64 with relevant long-term health conditions106. Rates have fallen very slightly over the last 5 years but in Doncaster they have remained comparable with national rates (see Figure 94).

Figure 94: Uptake of Flu vaccinations in people aged 65+ in Doncaster and England, 2005/06 – 2009/10

80.0

70.0

60.0

50.0

% 40.0

30.0

20.0

10.0

0.0 October 2005 - January October 2006 - January October 2007 - January October 2008 - January October 2009 - January 2006 2007 2008 2009 2010 England Doncaster Source: The Information Centre for Health & Social Care

106 NHS Immunisation Statistics: England 2009-10, November 2010, IC

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> Ill health and disability

Mental health

Mental health problems affect all ages and communities. There is a close relationship with deprivation; more severe mental illness is present in the most deprived households. Not all of this can be explained by a downward social drift by people with mental illness107. Mental health is an important aspect of life in people aged over 64. Nationally around 1 in 10 people aged 60-74 have significant neurotic symptoms. Around 1 in 5 has some form of cognitive impairment108. It is estimated that there are around 700,000 people with dementia in England & Wales and this number is set to increase109. The disease can also have serious implications for the families, friends and carers of people with the disease. The Mental Health Observatory110 (MHO) and POPPI111 (Projecting Older People Population Information System) have produced estimated prevalence calculations for local authorities. (See Figure 95 and Figure 96)

Figure 95: Estimated numbers of people with depression in Doncaster by age, 2010-30 2010 2015 2020 2025 2030 65-69 1224 1479 1346 1491 1647 70-74 1039 1100 1332 1234 1362 75-79 875 925 993 1219 1130 80-84 696 744 829 905 1131 85+ 557 638 735 892 1060 Total 65+ 4392 4886 5234 5740 6330 Source: POPPI Modelled data with rounding

Figure 96: Estimated numbers of people with dementia in Doncaster by age, 2010-30 2010 2015 2020 2025 2030 65-69 180 217 197 220 244 70-74 340 363 440 407 451 75-79 600 635 685 842 779 80-84 888 945 1,053 1,144 1,429 85-89 872 944 1,061 1,256 1,411 90+ 539 717 893 1,158 1,513 Total 65+ 3,419 3,822 4,328 5,026 5,827 Source: POPPI Modelled data with rounding

107 Fair Society, Healthy Lives: the Marmot Review, February 2010. 108 The Mental Health of Older People, 2003, Office of National Statistics 109 Living Well with Dementia: A National Dementia Strategy, Department of Health, 2009 110 Mental Health Observatory Briefs: Estimating the future number of cases of dementia in PCTs and upper tier local authorities in England 111 www.poppi.org.uk

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Cancer morbidity

About 1,500 cancers are diagnosed each year in Doncaster. However nationally and locally survival rates are below the levels achieved in other countries in Europe112. The following figures show cancer registration rates for major types of cancer (see Figure 97 to Figure 102). Lung cancer incidence is significantly higher in Doncaster compared to both the manufacturing towns and England & Wales (Figure 100).

Figure 97: All cancer registrations (all ages) in Doncaster, Manufacturing Towns, and England & Wales with forecasts, 1993-2015

500.0

450.0

400.0

350.0

300.0

250.0

Rateper100,000 200.0

150.0

100.0

50.0

0.0 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Doncaster Doncaster Forecast 95% Confidence Interval 95% Confidence Interval England & Wales England & Wales Forecast Manufacturing Towns Manufacturing Towns Forecast Source: National Clinical and Health Outcomes Knowledge Base (NCHOD) Incidence of all cancers ICD9 140-208 exc. 173, ICD10 C00-C99 exc. C44

112 Improving Outcomes: A Strategy for Cancer, January 2011, Department of Health

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Figure 98: Breast cancer registrations (all ages) in Doncaster, Manufacturing Towns and England & Wales with forecasts, 1993-2015

250.0

200.0

150.0

Rate per Rate 100,000 100.0

50.0

0.0 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Doncaster Doncaster Forecast 95% Confidence Interval 95% Confidence Interval England & Wales England & Wales Forecast Manufacturing Towns Manufacturing Towns Forecast Source: National Clinical and Health Outcomes Knowledge Base (NCHOD) Incidence of breast cancer ICD9 174, ICD10 C50)

Figure 99: Colorectal cancer registrations (all ages) in Doncaster, Manufacturing Towns and England & Wales with forecasts, 1993-2015

70.0

60.0

50.0

40.0

30.0 Rate per Rate 100,000

20.0

10.0

0.0 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Doncaster Doncaster Forecast 95% Confidence Interval 95% Confidence Interval England & Wales England & Wales Forecast Manufacturing Towns Manufacturing Towns Forecast Source: National Clinical and Health Outcomes Knowledge Base (NCHOD) Incidence of colorectal cancer ICD9 152-154, ICD10 C17-C21

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Figure 100: Lung cancer registrations (all ages) in Doncaster, Manufacturing Towns and England & Wales with forecasts, 1993-2015

80.0

70.0

60.0

50.0

40.0 Rate per Rate 100,000 30.0

20.0

10.0

0.0 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Doncaster Doncaster Forecast 95% Confidence Interval 95% Confidence Interval England & Wales England & Wales Forecast Manufacturing Towns Maufacturing Towns Forecast Source: National Clinical and Health Outcomes Knowledge Base (NCHOD) Incidence of lung cancer ICD9 162, ICD10 C33-C34

Figure 101: Prostate cancer registrations (all ages) in Doncaster, Manufacturing Towns and England & Wales with forecasts, 1993-2015

140.0

120.0

100.0

80.0

60.0 Rate per Rate 100,000

40.0

20.0

0.0 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Doncaster Doncaster Forecast 95% Confidence Interval 95% Confidence Interval England & Wales England & Wales Forecast Manufacturing Towns Manufacturing Towns Forecast Source: National Clinical and Health Outcomes Knowledge Base (NCHOD) Incidence of prostate cancer ICD9 185, ICD10 C61

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Figure 102: Stomach cancer registrations (all ages) in Doncaster, Manufacturing Towns and England & Wales with forecasts, 1993-2015

25.0

20.0

15.0

Rate per Rate 100,000 10.0

5.0

0.0 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Doncaster Doncaster Forecast 95% Confidence Interval 95% Confidence Interval England & Wales England & Wales Forecast Manufacturing Towns Manufacturing Towns Forecast Source: National Clinical and Health Outcomes Knowledge Base (NCHOD) Incidence of stomach cancer ICD9 151, ICD10 C16)

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Mortality

Figure 103 to Figure 114 show mortality rates for a range of causes. Appendix 1 looks at the causes of death which are higher in Doncaster compared to manufacturing towns. As these areas are broadly similar in terms of deprivation, demography, social and economic make-up, Doncaster would be ‘expected’ to have similar mortality rates. This analysis has identified where Doncaster has causes of mortality that are higher than ‘expected’ and has identified the numbers of ‘delayed deaths’ that could be achieved if Doncaster moved the average rate for its cluster. Amongst men: stomach cancer, colorectal cancer, lung cancer, coronary heart disease, chronic respiratory disease and chronic liver disease are the key causes of excess deaths, and if they were reduced to manufacturing town rates could result in more than 50 fewer deaths. Amongst women the principle causes are lung cancer, chronic respiratory disease, and chronic liver disease. From this analysis more than 30 deaths a year could be delayed in Doncaster.

Figure 103: All cause mortality in males aged 65-74 in Doncaster, Manufacturing towns, and England & Wales with forecasts, 1993-2020

4500.0

4000.0

3500.0

3000.0

2500.0

2000.0 Rate perRate 100,000

1500.0

1000.0

500.0

0.0 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020

Doncaster Doncaster Forecast 95% Confidence Intervals Manufacturing Towns Manufacturing Towns Forecast England & Wales England & Wales Forecast Source: National Clinical and Health Outcomes Knowledge Base (NCHOD)

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Figure 104: All cause mortality in females aged 65-74 in Doncaster, Manufacturing Towns, and England & Wales with forecasts, 1993-2020

3000.0

2500.0

2000.0

1500.0 Rate perRate 100,000

1000.0

500.0

0.0 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020

Doncaster Doncaster Forecast 95% Confidence Intervals Manufacturing Towns Manufacturing Towns Forecast England & Wales England & Wales Forecast Source: National Clinical and Health Outcomes Knowledge Base (NCHOD)

Figure 105: All cause mortality in persons aged 65-74, in Doncaster, Manufacturing Towns, and England & Wales with forecasts, 1993-2020

3500.0

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2500.0

2000.0

1500.0 Rate perRate 100,000

1000.0

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0.0 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020

Doncaster Doncaster Forecast 95% Confidence Intervals Manufacturing Towns Manufacturing Towns Forecast England & Wales England & Wales Forecast Source: National Clinical and Health Outcomes Knowledge Base (NCHOD)

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Circulatory diseases mortality

Figure 106: Age standardised circulatory disease mortality rates (under 75) in Doncaster, Manufacturing Towns, and England & Wales with forecasts, 1993-2015

200.0

180.0

160.0

140.0

120.0

100.0

Rate per100,000 Rate 80.0

60.0

40.0

20.0

0.0 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Doncaster Doncaster Forecast 95% Confidence Interval 95% Confidence Interval England & Wales England & Wales Forecast Manufacturing Towns Manufacturing Towns Forecast Source: National Clinical and Health Outcomes Knowledge Base (NCHOD) Circulatory diseases ICD10 I00-I99, ICD9 390-459

Figure 107: Age standardised coronary heart disease mortality (under 75) in Doncaster, Manufacturing Towns, and England & Wales with forecasts, 1993-2015

140.0

120.0

100.0

80.0

60.0 Rate per100,000 Rate

40.0

20.0

0.0 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Doncaster Doncaster Forecast 95% Confidence Interval 95% Confidence Interval England & Wales England & Wales Forecast Manufacturing Towns Manufacturing Towns Source: National Clinical and Health Outcomes Knowledge Base (NCHOD) Coronary heart disease ICD10 I20-I25, ICD9 410-414

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Figure 108: Age standardised mortality rates from stroke (under 75) in Doncaster, Manufacturing Towns, and England & Wales with forecasts, 1993-2015

40.0

35.0

30.0

25.0

20.0

Rateper100,000 15.0

10.0

5.0

0.0 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Doncaster Doncaster Forecast 95% Confidence Interval 95% Confidence Interval England & Wales England & Wales Forecast Manufacturing Towns Manufacturing Towns Forecast Source: National Clinical and Health Outcomes Knowledge Base (NCHOD) Stroke ICD10 I60-I69, ICD9 430-438

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Cancer

Figure 109: Age standardised mortality rates from all cancers (under 75) in Doncaster, Manufacturing Towns, and England & Wales with forecasts, 1993-2015

180.0

160.0

140.0

120.0

100.0

80.0 Rate per100,000 Rate

60.0

40.0

20.0

0.0 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Doncaster Doncaster Forecast 95% Confidence Interval 95% Confidence Interval England & Wales England & Wales Forecast Manufacturing Towns Manufacturing Towns Forecast Source: National Clinical and Health Outcomes Knowledge Base (NCHOD) All cancers ICD10 C00-C97, ICD9 140-208

Figure 110: Age standardised mortality rates from colorectal cancer (all ages) in Doncaster, Manufacturing Towns, and England & Wales with forecasts, 1993-2015

35.0

30.0

25.0

20.0

15.0 Rate per100,000 Rate

10.0

5.0

0.0 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Doncaster Doncaster Forecast 95% Confidence Interval 95% Confidence Interval England & Wales England & Wales Forecast Manufacturing Towns Manufacturing Towns Forecast Source: National Clinical and Health Outcomes Knowledge Base (NCHOD) Colorectal cancer ICD10 C17-C21, ICD9 152-154

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Figure 111: Age standardised mortality rates from lung cancer (under 75) in Doncaster, Manufacturing Towns, and England & Wales with forecasts, 1993-2015

60.0

50.0

40.0

30.0 Rate per100,000 Rate

20.0

10.0

0.0 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Doncaster Doncaster Forecast 95% Confidence Interval 95% Confidence Interval England & Wales England & Wales Forecast Manufacturing Towns Manufacturing Towns Forecast Source: National Clinical and Health Outcomes Knowledge Base (NCHOD) Lung cancer ICD10 C33-C34, ICD9 162

Figure 112: Age standardised mortality rates from stomach cancer (all age) in Doncaster, Manufacturing Towns, and England & Wales with forecasts, 1993-2015

18.0

16.0

14.0

12.0

10.0

8.0 Rateper100,000

6.0

4.0

2.0

0.0 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Doncaster Doncaster Forecast 95% Confidence Interval 95% Confidence Interval England & Wales England & Wales Forecast Manufacturing Towns Manufacturing Towns Forecast Source: National Clinical and Health Outcomes Knowledge Base (NCHOD) Stomach cancer ICD9 151, ICD10 C16

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Figure 113: Age standardised mortality rates from breast cancer in Doncaster, Manufacturing Towns, and England & Wales with forecasts, 1993-2015

60.0

50.0

40.0

30.0 Rate per100,000 Rate

20.0

10.0

0.0 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Doncaster Doncaster Forecast 95% Confidence Interval 95% Confidence Interval England & Wales England & Wales Forecast Manufacturing Towns Manufacturing Towns Forecast Source: National Clinical and Health Outcomes Knowledge Base (NCHOD) Breast cancer ICD10 C50, ICD9 174

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Respiratory disease

Figure 114: Age standardised mortality rates from respiratory disease in Doncaster, Manufacturing Towns, and England & Wales with forecasts, 1993-2015

60.0

50.0

40.0

30.0 Rate per100,000 Rate

20.0

10.0

0.0 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Doncaster Doncaster Forecast 95% Confidence Interval 95% Confidence Interval England & Wales England & Wales Forecast Manufacturing Towns Manufacturing Towns Forecast Source: National Clinical and Health Outcomes Knowledge Base (NCHOD) Respiratory disease ICD10 J40-J44, ICD9 490-492, 496

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Falls and accidents

Falls are a major cause of morbidity and mortality amongst older people. The risk of falling and the attendant complications increases with age, nevertheless falls are largely preventable113. Figure 115 shows the potential increases than Doncaster can expect in falls amongst older people, and Figure 116 and Figure 117 show the mortality rates for accidental falls and accident generally.

Figure 115: Estimated numbers of falls in Doncasterby age, 2010-30 2010 2015 2020 2025 2030 65-69 2,985 3,605 3,277 3,641 4,028 70-74 2,976 3,150 3,815 3,533 3,902 75-79 2,394 2,532 2,727 3,352 3,103 80-84 2,423 2,584 2,878 3,135 3,918 85+ 2,623 3,053 3,569 4,386 5,246 Total 65+ 13,401 14,924 16,266 18,047 20,197 Source: POPPI Modelled data with rounding

Figure 116: Age standardised mortality rates from accidental falls in Doncaster, Manufacturing Towns, and England & Wales with forecasts, 1993-2015

8.0

7.0

6.0

5.0

4.0

Rateper100,000 3.0

2.0

1.0

0.0 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Doncaster Doncaster Forecast 95% Confidence Interval 95% Confidence Interval England & Wales England & Wales Forecast Manufacturing Towns Manufacturing Towns Forecast Source: National Clinical and Health Outcomes Knowledge Base (NCHOD) Accidental falls ICD9 E880-E888, ICD10 W00-W19

113 Clinical practice guideline for the assessment and prevention of falls in older people, November 2004, NICE

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Figure 117: Age standardised mortality rates from accidents (all ages) in Doncaster, Manufacturing Towns, and England & Wales with forecasts, 1993-2015

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Doncaster Doncaster Forecast 95% Confidence Interval 95% Confidence Interval England & Wales England & Wales Forecast Manufacturing Towns Manufacturing Towns Forecast Source: National Clinical and Health Outcomes Knowledge Base (NCHOD) Accidents ICD9 E800-E928 exc. E870-E879, ICD10 V01-X59

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> Signposts

Information sources > Estimating the future number of cases of dementia in PCTs and upper tier local authorities in England – www.mentalhealthobservatory.org.uk

Policy context National > Improving Outcomes: A Strategy for Cancer – www.dh.gov.uk > Living well with dementia: A National Dementia Strategy – www.dh.gov.uk > Improving care and saving money: Learning the lessons on prevention and early intervention for older people – www.dh.gov.uk Local > Long Term Conditions Strategy: April 2010 – March 2013 – www.doncasterpct.nhs.uk

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> Abbreviations

AAACM All age all cause mortality APHO Association of Public Health Observatories BMI Body Mass Index CAMHS Child & Adolescent Mental Health Service CEMACH Confidential Enquiry into Maternal and Child Health CHIMAT Child & Maternal Health Observatory CWI Child Wellbeing Index DCLG Department for Communities and Local Government DAT Drug Action Team DMFT Decayed, Missing, Filled Teeth DPH Director of Public Health EDI Economic Deprivation Index ERIC Estates Returns Information Collection EYFSP Early Years Foundation Stage Profile IMD Index of Multiple Deprivation IRC Immigration Removal Centre JSA Job Seekers Allowance LA Local Authority LSOA Lower Super Output Area MBC Metropolitan Borough Council MHO Mental Health Observatory MMR Measles, mumps & rubella NCHOD National Clinical and Health Outcomes Knowledge Base NCMP National Child Measurement Programme NEET Not in Education, Employment or Training NICE National Institute for Health & Clinical Excellence NOMIS National Online Manpower Information Service OAC Output Area Classification ONS Office for National Statistics PANSI Projecting Adult Needs and Service Information System PCT Primary Care Trust PHO Public Health Observatory POPPI Projecting Older People Population Information System SEN Special Educational Needs SII Slope Index of Inequality

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> Appendix 1: All age all cause mortality

All age all cause mortality (AAACM) rates are one of the key measures of success for both NHS Doncaster and Doncaster MBC. All age all cause mortality and life expectancy (a similar measure) have formed part of the National Indicators (NI120), the Vital Signs (VSB01) and World Class Commissioning. In the Doncaster overview chapter of this report, the reductions in AAACM rates that have already been achieved are illustrated, however mortality rates in Doncaster remain significantly higher than England & Wales. This difference is particularly marked in men.

Doncaster is part of the manufacturing towns group. Manufacturing towns are one of a number of clusters of local authorities and PCTs defined as having significant characteristics in common. This geo-demographic taxonomy was created by ONS. The area classification system placed Doncaster in the ‘manufacturing towns’ group. Manufacturing towns are areas that are similar across a range of variables, from the proportion of the population with educational qualifications, to the types of housing available to the population. This means that comparing Doncaster with other manufacturing towns is potentially more informative than comparing it to national or regional averages. The following analysis will compare mortality rates in Doncaster with manufacturing town rates, to identify causes of mortality that are higher than ‘expected’ and so are, arguably, more amenable to improvement.

Figure 118 shows the rolling 3 year average AAACM rates for men and women with current targets and numbers of deaths. The male target for 2009-11 is 684 per 100,000. Current forecasts predict that the mortality rate will be 752 per 100,000. To achieve the 2009-11 target for men Doncaster will have to achieve 117 fewer deaths than is forecast. For women Doncaster will need to acheive 56 fewer deaths over the 3 year period.

Figure 118: Forecast rates and numbers of deaths Males 2006-08 2009-11 2009-11 Delayed (Actual) (Expected) (Target) deaths Rate 793.7 751.5 684.3 Number 4,447 4,331 4,215 117 Annual average 1,482 1,444 1,405 39

Females 2006-08 2009-11 2009-11 Delayed (Actual) (Expected) (Target) deaths Rate 539.7 520.3 499.0 Number 4,518 4,475 4,418 56 Annual average 1,506 1,492 1,473 19 Source: Public Health Intelligence, NHS Doncaster

To identify where Doncaster could potentially achieve these kinds of reductions the AAACM has been broken down into specific causes and these have been compared with the rates for manufacturing towns. The following two figures (Figure 119 & Figure 120) compare Doncaster with the manufacturing towns rates and the numbers of potential delayed deaths have been calculated.

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Figure 119: Male all age mortality by underlying cause, 2006-08 Deaths if Doncaster Manufacturing Doncaster achieve MT Cause Rate Towns (MT) rate deaths rate Difference Oesophageal cancer 13.72 14.34 77 77 0 Stomach cancer 11.82 10.04 70 59 11 Colorectal cancer 25.9 23.62 151 138 13 Lung cancer 64.39 58.42 364 330 34 Malignant melanoma 2.49 2.88 13 13 0 Prostate cancer 25.19 24.88 152 150 2 Bladder cancer 8.98 9.08 53 53 0 Diabetes 7.82 8.08 46 46 0 Chronic rheumatic heart disease 0.98 1.02 6 6 0 Hypertensive disease 2.56 5.13 14 14 0 CHD 147.89 143.47 843 818 25 Stroke 48.8 52.94 296 296 0 Pneumonia 32.88 32.74 190 189 1 COPD 49.45 40.49 297 243 54 Asthma 1.59 1.17 8 6 2 Chronic liver disease (inc. cirrhosis) 19.37 15.25 89 70 19 Chronic renal failure 2.42 2.3 13 12 1 Accidents 24.46 25.66 112 112 0 Suicide and injury undetermined 14.18 12 59 50 9 Sum of main causes 2853 2683 Other causes 1594 1594 Total deaths 4447 4277 170

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Figure 120: Female all age mortality by underlying cause (2006-08) Cause Deaths if Doncaster Manufacturing Doncaster achieve MT Rate Towns (MT) rate deaths rate Difference Oesophageal cancer 4.42 4.74 35 35 0 Stomach cancer 3.9 4.16 32 32 0 Colorectal cancer 13.31 14.23 112 112 0 Lung cancer 36.11 34.07 262 247 15 Malignant melanoma 1.83 1.68 12 11 1 Breast cancer 27.95 27.04 181 175 6 Cervical cancer 3.02 2.61 20 17 3 Bladder cancer 2.45 3.3 20 20 0 Diabetes 4.77 5.93 44 44 0 Chronic rheumatic heart disease 1.08 1.31 10 10 0 Hypertensive disease 3.29 4.5 34 34 0 Coronary heart disease 68.23 67.41 617 610 7 Stroke 45.95 48.23 437 437 0 Pneumonia 27 27.36 264 264 0 COPD 31.27 26.78 257 220 37 Asthma 2.09 1.81 16 14 2 Chronic liver disease (inc. cirrhosis) 12.11 8.75 62 45 17 Chronic renal failure 1.23 1.3 13 13 0 Accidents 6.76 11.42 50 50 0 Suicide and injury undetermined 3.82 3.09 17 14 3 Sum of main causes 2495 2404 Other causes 2023 2023 Total deaths 4518 4427 91

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Deaths from causes amenable to healthcare

Deaths form causes amenable to health care are a selection of causes that evidence suggests can be reduced by good quality healthcare, delivered in a timely way. Mortality rates from this range of causes has remained broadly in line with rates in the manufacturing towns as a whole. (Figure 121). This is confirmed when the 2006- 08 data are pooled. The numbers of delayed deaths for men would number 10 and for women this would be just 1 (Figure 122)

Figure 121: Age standardised mortality rates from causes considered amenable to healthcare in Doncaster, manufacturing towns and England & Wales, 1993-2015

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Doncaster Doncaster Forecast 95% Confidence Intervals England & Wales England Forecast Manufacturing Towns Manufacturing Towns Source: National Clinical and Health Outcomes Knowledge Base (NCHOD) Causes considered amenable to healthcare: Intestinal infections (ICD-10 A00-A09, ICD-9 001-009, ages 0- 14 years; Tuberculosis (ICD-10 A15-A19, B90; ICD-9 010-018, 137), ages 0-74 years; Other infectious diseases (diphtheria, tetanus, poliomyelitis) (ICD-10 A36, A35, A80; ICD-9 032, 037, 045), ages 0-74 years; Whooping cough (ICD-10 A37, ICD-9 033), ages 0-14 years; Septicaemia (ICD-10 A40-A41, ICD-9 038), ages 0-74 years; Measles (ICD-10 B05, ICD-9 055), ages 1-14 years; Malignant neoplasm of colon and rectum (ICD-10 C18- C21, ICD-9 153-154), ages 0-74 years; Malignant neoplasm of skin (ICD-10 C44, ICD-9 173), ages 0-74 years; Malignant neoplasm of female breast (ICD-10 C50, ICD-9 174), ages 0-74 years; Malignant neoplasm of cervix uteri (ICD-10 C53, ICD-9 180), ages 0-74 years; Malignant neoplasm of unspecified part of the uterus and body of the uterus (ICD-10 C54-C55, ICD-9 179, 182), ages 0-44 years; Malignant neoplasm of testis (ICD-10 C62, ICD-9 186), 0-74 years; Hodgkin’s disease (ICD-10 C81, ICD-9 201), ages 0-74 years; Leukaemia (ICD-10 C91-C95, ICD-9 204-208), ages 0-44 years; Diseases of the thyroid (ICD-10 E00-E07, ICD-9 240-246), ages 0-74 years; Diabetes mellitus (ICD-10 E10-E14, ICD-9 250), ages 0-49 years; Epilepsy (ICD-10 G40-G41, ICD-9 345), 0-74 years; Chronic rheumatic heart disease (ICD-10 I05-I09, ICD-9 393-398), ages 0-74 years; Hypertensive disease (ICD-10 I10-I13, I15; ICD-9 401-405), ages 0-74 years; Ischaemic heart disease (ICD-10 I20-I25, ICD-9 410-414), ages 0-74 years; Cerebrovascular disease (ICD-10 I60-I69, ICD-9 430-438), ages 0-74 years; All respiratory diseases (excl. pneumonia, influenza and asthma) (ICD-10 J00-J09, J20-J44, J47-J99; ICD-9 460-479, 488-492, 494-519), ages 1-14 years; Influenza (ICD-10 J10-J11, ICD-9 487), ages 0-74 years; Pneumonia (ICD-10 J12-J18, ICD-9 480-486), ages 0-74 years; Asthma (ICD-10 J45-J46, ICD-9 493), ages 0-44 years; Peptic ulcer (ICD-10 K25-K27, ICD-9 531-533), ages 0-74 years; Appendicitis (ICD-10 K35-K38, ICD-9 540-543), ages 0-74 years; Abdominal hernia (ICD-10 K40-K46, ICD-9 550-553), ages 0-74 years; Cholelithiasis & cholecystitis (ICD-10 K80-K81, ICD-9 574-575.1), ages 0-74 years; Nephritis and nephrosis (ICD-10 N00-N07, N17-N19, N25-N27; ICD-9 580-589), ages 0-74 years; Benign prostatic hyperplasia (ICD-10 N40, ICD-9 600), ages 0-74 years; Maternal deaths (ICD-10 O00-O99, ICD-9 630-676), ages 0-74 years; Congenital cardiovascular anomalies (ICD-10 Q20-Q28, ICD-9 745-747), ages 0-74 years; Perinatal deaths (all causes excl. stillbirths), ages 0-6 days; Misadventures to patients during surgical and medical care (ICD-10 Y60-Y69, Y83-Y84; ICD-9 E870-E876, E878-E879), ages 0-74 years

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Figure 122: Causes of deaths amenable to healthcare, 2006-08 Males Females Manufacturing towns 135.37 90.29 Doncaster 137.43 90.46 Deaths 641 447 Deaths if MT rate 631 446 Difference 10 1 Source: NHS Doncaster

Age groups

All age all cause mortality can also analysed by deaths in different age groups. The following figures illustrate the differences in men and women in different age groups (0-14, 15-64, 65-74). The group of particular concern are men of working age (15-64). Figure 125 shows that mortality rates have not declined since 2004.

Figure 123: Age standardised mortality rates amongst males aged 0-14 in Doncaster, manufacturing towns and England & Wales

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Doncaster Doncaster Forecast 95% Confidence Intervals Manufacturing Towns Manufacturing Towns Forecast England & Wales England & Wales Forecast Source: National Clinical and Health Outcomes Knowledge Base (NCHOD)

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Figure 124: Age standardised mortality rates amongst females aged 0-14 in Doncaster, manufacturing towns and England & Wales

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Doncaster Doncaster Forecast 95% Confidence Intervals Manufacturing Towns Manufacturing Towns Forecast England & Wales England & Wales Forecast Source: National Clinical and Health Outcomes Knowledge Base (NCHOD)

Figure 125: Age standardised mortality rates amongst males aged 15-64 in Doncaster, manufacturing towns and England & Wales

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Doncaster Doncaster Forecast 95% Confidence Intervals Manufacturing Towns Manufacturing Towns Forecast England & Wales England & Wales Forecast Source: National Clinical and Health Outcomes Knowledge Base (NCHOD)

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Figure 126: Age standardised mortality rates amongst females aged 15-64 in Doncaster, manufacturing towns and England & Wales

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Doncaster Doncaster Forecast 95% Confidence Intervals Manufacturing Towns Manufacturing Towns Forecast England & Wales England & Wales Forecast Source: National Clinical and Health Outcomes Knowledge Base (NCHOD)

Figure 127: Age standardised mortality rates amongst males aged 65-74 in Doncaster, manufacturing towns and England & Wales

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Doncaster Doncaster Forecast 95% Confidence Intervals Manufacturing Towns Manufacturing Towns Forecast England & Wales England & Wales Forecast Source: National Clinical and Health Outcomes Knowledge Base (NCHOD)

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Figure 128: Age standardised mortality rates amongst females aged 65-74 in Doncaster, manufacturing towns and England & Wales

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Doncaster Doncaster Forecast 95% Confidence Intervals Manufacturing Towns Manufacturing Towns Forecast England & Wales England & Wales Forecast Source: National Clinical and Health Outcomes Knowledge Base (NCHOD)

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Males aged 15-64

Using pooled data from 2006-08 the numbers of delayed deaths that could be achieved if men in this age group had the same mortality rates as the manufacturing towns is around 95. For women this figure is 4.

Figure 129: 15-64 AAACM rates Males Females Manufacturing towns 299.68 186.27 Doncaster 331.27 187.5 Deaths 999 586 Deaths if MT rate 904 582 Difference 95 4

Benchmarking data is not routinely available for specific conditions for this age group. The following information is based on comparisons with national data adjusted to reflect the ‘estimated’ manufacturing town’s rates (mortality rates in the manufacturing towns are around 8% higher than national). In men in this age group the areas of most concern are: accidents, chronic liver, CHD, lung cancer, suicide, and colorectal cancer (See Figure 130).

Figure 130: Component causes of AAACM in 15-64 men Potential delayed Doncast deaths Males 15-64 (2006-08) er rate Deaths (3ys) Annual All deaths 330.3 999 145 48 Other causes 111.8 336 11 4 Accidents 27.3 79 16 5 Asthma 1.0 3 1 0 Bladder cancer 2.2 7 1 0 Chronic liver disease (inc_ cirrhosis) 22.2 66 15 5 Chronic Obstructive Pulmonary Disease 8.6 27 5 2 Chronic renal failure 0.6 2 1 0 Chronic rheumatic heart disease 0.3 1 0 0 Colorectal cancer 9.8 30 12 4 Coronary Heart Disease 60.1 187 35 12 Diabetes 1.5 5 0 0 Hypertensive disease 1.2 4 0 0 Lung cancer 30.5 95 28 9 Malignant melanoma 0.9 3 0 0 Oesophageal cancer 6.5 20 0 0 Other malignant neoplasms of skin 0.0 0 0 0 Pneumonia 5.8 18 2 1 Prostate cancer 3.4 11 0 0 Stomach cancer 4.3 14 4 1 Stroke 9.5 29 6 2 Suicide & injury undetermined 22.6 62 16 5

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> Appendix 2: Policy Objectives

The objectives below are taken copied directly from the Marmot review.

Policy Objective A - Give every child the best start in life

1. Reduce inequalities in the early development of physical and emotional health, and cognitive, linguistic, and social skills. 2. Ensure high quality maternity services, parenting programmes, childcare and early years education to meet need across the social gradient. 3. Build the resilience and well-being of young children across the social gradient.

Policy recommendations

A1: Increase the proportion of overall expenditure allocated to the early years and ensure expenditure on early years development is focused progressively across the social gradient.

A2: Support families to achieve progressive improvements in early years development, including: I. Giving priority to pre and postnatal interventions, such as intensive home-visiting programmes, that reduce adverse outcomes of pregnancy and infancy II. Providing paid parental leave in the first year of life with a minimum income for healthy living III. Providing routine support to families through parenting programmes, children’s centres and key workers, delivered to meet social need via outreach to families IV. Developing programmes for the transition to school.

A3: Provide good quality early years education and childcare proportionately across the gradient. This provision should be: I. Combined with outreach 1 to increase the take-up by children from disadvantaged families II. Provided on the basis of evaluated models and must meet quality standards.

Policy Objective B - Enable all children, young people and adults to maximise their capabilities and have control over their lives

1. Reduce the social gradient in skills and qualifications. 2. Ensure that schools, families and communities work in partnership to reduce the gradient in health, well-being and resilience of children and young people. 3. Improve the access and use of quality lifelong learning across the social gradient.

Policy recommendations

B1: Ensure that reducing social inequalities in pupils’ educational outcomes is a sustained priority.

B2: Prioritise reducing social inequalities in life skills by: I. Extending the role of schools in supporting families and communities and taking a ‘whole child’ approach to education II. Consistent implementation of the full range of extended services in and around schools

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III. Developing the school-based workforce to build their skills in working across school– home boundaries and addressing social and emotional development, physical and mental health and well-being.

B3: Increase access to and use of quality lifelong learning opportunities across the social gradient by: I. Providing easily accessible support and advice for 16–25 year olds on life skills, training and employment opportunities II. Providing work-based learning, including apprenticeships, for young people and those changing jobs/careers III. Increasing availability of non-vocational lifelong learning across the life course.

Policy Objective C - Create fair employment and good work for all

1. Improve access to good jobs and reduce long-term unemployment across the social gradient. 2. Make it easier for people who are disadvantaged in the labour market to obtain and keep work. 3. Improve quality of jobs across the social gradient.

Policy recommendations

C1: Prioritise active labour market programmes to achieve timely interventions to reduce long-term unemployment.

C2: Encourage, incentivise and, where appropriate, enforce the implementation of measures to improve the quality of work across the social gradient by: I. Ensuring public and private sector employers adhere to equality guidance and legislation II. Implementing guidance on stress management and the effective promotion of well-being and physical and mental health at work.

C3: Develop greater security and flexibility in employment, by: I. Prioritising greater flexibility of retirement age II. Encouraging and incentivising employers to create or adapt jobs that are suitable for lone parents, carers and people with mental and physical health problems.

Policy Objective D - Ensure healthy standard of living for all

1. Establish a minimum income for healthy living for people of all ages. 2. Reduce the social gradient in the standard of living through progressive taxation and other fiscal policies. 3. Reduce the cliff edges114 faced by people moving between benefits and work.

Policy recommendations

D1: Develop and implement standards for minimum income for healthy living.

114 The Marmot review describes the ‘cliff edge’ as follows ‘Living standards initially fall as income first begins to rise, due to a loss of state benefits, creating a U-shaped profile between income and other measures of living standards; this is what is called the ‘cliff edge’…’ (Page 76)

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D2: Review and implement systems of taxation, benefits, pensions and tax credits to provide a minimum income for healthy living standards and facilitate upward pathways

D3: Remove ‘cliff edges’ for those moving in and out of work and improve flexibility of employment.

Policy Objective E - Create and develop healthy and sustainable places and communities

1. Develop common policies to reduce the scale and impact of climate change and health inequalities. 2. Improve community capital and reduce social isolation across the social gradient.

Policy recommendations

E1: Prioritise policies and interventions that both reduce health inequalities and mitigate climate change by: I. Improving active travel across the social gradient II. Improving good quality spaces available across the social gradient III. Improving the food environment in local areas across the social gradient IV. Improving energy efficiency in housing across the social gradient.

E2: Fully integrate the planning, transport, housing, environmental and health systems to address the social determinants of health in each locality.

E3: Support locally developed and evidence-based community regeneration programmes that: I. Remove barriers to community participation and action II. Reduce social isolation.

Policy Objective F Strengthen the role and impact of ill health prevention

1. Prioritise prevention and early detection of those conditions most strongly related to health inequalities. 2. Increase availability of long-term and sustainable funding in ill health prevention across the social gradient.

Policy recommendations

F1: Prioritise investment in ill health prevention and health promotion across government departments to reduce the social gradient.

F2: Implement evidence-based programme of ill health preventive interventions that are effective across the social gradient by: I. Increasing and improving the scale and quality of drug treatment programmes, diverting problem drug users from the criminal justice system II. Focusing public health interventions such as smoking cessation programmes and alcohol reduction on reducing the social gradient III. Improving programmes to address the causes of obesity across the social gradient.

F3: Core efforts of public health departments should be focused on interventions related to the social determinants of health, proportionately across the gradient.

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NHS Doncaster White Rose House Ten Pound Walk Doncaster DN4 5DJ

Telephone: 01302 565656 www.doncaster.nhs.uk

Doncaster Council Council House College Road Doncaster DN1 1BR

Telephone: 01302 7360000 www.doncaster.gov.uk