Time for Change NHS West Hertfordshire by NHS Herts Valleys CCG

West Hertfordshire

2009

foreword

Chapter 1:

Healthy weight, healthy lives for children in west Hertfordshire

Chapter 2:

Eating well in west Hertfordshire

Chapter 3:

be active, be healthy in west Hertfordshire

Chapter 4:

live longer in west Hertfordshire

Chapter 5:

Tobacco control

Chapter 6:

change4life through partnership, reducing inequalities in health

appendix 1: west hertfordshire hospital Trust actions

Foreword Dr Jane Halpin, Director of Public Health and Deputy Chief Executive I have based this yearâ&#x20AC;&#x2122;s report around the national Change4Life strategy. This focuses on key actions we can all take to improve health: eat well, move more, live longer. This report examines some of these areas in more detail, explains why they are so key and what is being done across Hertfordshire to improve health for local people. Most of the work is actually carried out by others - not by the PCT Public Health team! This report is an opportunity to raise the profile of this work carried out by general practitioners, pharmacists, nurses, teachers, police, staff in local authorities, the voluntary sector and many others. It is the quiet but systematic efforts of this wide range of people, many of whom are in jobs not thought of as part of health, that are leading to the improvements we can see. Last yearâ&#x20AC;&#x2122;s report focused on a number of key themes and I want to start by briefly reviewing progress on them.

Reducing rates of childhood obesity Reviewed in detail in chapter 1. More children are being measured each year, so we have better data. Obesity rates in Reception aged children fell slightly whilst rates in Year 6 children rose. Multiagency strategy agreed and being implemented. More services for overweight children have been commissioned.

Promoting good mental health Work to implement the agreed strategy has continued. Some service changes have taken place to support people better outside of hospital based care - in both community and primary care settings. However, rates of suicide are increasing locally as nationally, and more work is being focused on groups at risk - including those with serious mental health problems, and older people with chronic illness or following bereavement.

Older people A specific falls prevention plan has been agreed. Linked to this, a specific project has been set up to identify people who are at risk and rapidly provide them with support or care to avoid future harm (First Contact Screening tool checklist). Services for hip fracture have been improved across Hertfordshire. Flu immunisation rates are improving.

Working in Partnership to improve health Reviewed in detail in Chapter 6. The PCT continues to fund health improvement work in every local authority area. All local “sustainable community” strategies include actions to improve health and target local needs. Good progress has been made on meeting targets set in the “Local Area Agreement” which will mean the county will share additional reward funding.

Sexual Health GUM services continue to meet national targets - meaning more people can be seen and much more rapidly. Chlamydia screening is now better established - last year almost 12% of the population aged 15-24 was screened. Further work is needed to meet the national target level. Extra family planning services have been provided where rates of teenage pregnancy indicate extra need. The cervical cancer vaccination programme started successfully - with high levels of uptake in girls across Hertfordshire.

Looking forward This report unashamedly focuses on key areas where certain behaviours greatly increase risk of premature illness and death: particularly obesity (reflecting both a healthy diet and physical activity) and smoking. Higher levels of these risk factors lead to reduced life expectancy - mainly through deaths from preventable causes such as heart disease and cancer. However, action to reduce these levels is only effective if carried out across communities and often over sustained time periods. For example, whether a teenager starts to smoke reflects many factors - including whether his or her parents smoke, whether friends and role models smoke, how easy and/or cheap it is to buy cigarettes, how confident they are in resisting “peer pressure” and so on. These days, it is not a lack of knowledge of the health impact that is the problem! There is little that typical “health staff” can do to affect these wider factors - other than helping parents to quit. However, there is a key role for schools, colleges and workplaces, for Trading Standards and for Environmental Health Officers. This type of joint working is built on a variety of “partnership” groups - focused on a community or around a particular problem. It is not high profile, often takes time to demonstrate an impact and rarely attracts much attention from those not directly involved. However, it leads to major gains in health. As ever with Public Health, priority areas tend to be similar over several years. Appendix 1 details the response of West Hertfordshire Hospitals Trust to current public health challenges.

Additional areas of work in the coming year will include: • improving access to, and where necessary performance of, a variety of screening programmes • a review of the PCT immunisation and vaccination programmes • introducing new programmes such as “NHS Health checks” - to identify those at risk of serious illness before problems are evident • implementing an integrated approach to “Intermediate Care” - for older people who need help from both health and social care to help them maintain as much independence as possible and avoid unnecessary hospital admissions • improving care for those with chronic illnesses (such as heart or lung disease or diabetes), to provide integrated care based as close to home as possible

Chapter 1: Healthy weight, healthy lives for children in west Hertfordshire Anka Johnston, Children’s Healthy Weight Manager Childhood obesity is a growing public health problem. There are fears that this will lead to obesity-related diseases, such as diabetes, occurring at a much younger age than at present. Health Survey of England data shows that childhood obesity has been rising by 0.5–1% per year. Over 50% of obese 6-9 year olds and nearly 80% of obese 10-14 year olds become obese adults. In 2010 it is estimated that obesity and its consequences will cost West Hertfordshire PCT at least £73 million. Unlike most adults, children cannot choose the environment in which they live or the food they eat. They also have a limited ability to understand the long-term consequences of their behaviour. Therefore, children require special attention when fighting the obesity epidemic. Due to the complexity of this problem, we need a national and local commitment to change our environment, both physical and social. The key to tackling obesity locally is a multi-agency approach.

Local picture During the academic year 2006-2007, Hertfordshire took part in the National Child Measurement Programme for the first time. More than 10,000 children in Reception (age 4-5 years) and Year 6 (age 10-11 years) were weighed and measured in the infant, primary and middle schools in West Hertfordshire. This was 85% of the total number of children in those years. In 2007-2008, the programme continued with a participation rate of more than 86%.

A child’s body mass index (BMI) is calculated using the same method as for adults. However, a child’s BMI needs to be assessed differently because children are still growing. Therefore, age, height and gender have to be taken into account and checked against child growth reference charts. To make this task quicker for health professionals, we have developed a simpler tool set to assess a child’s weight status, which has been made available for every health professional who needs to do this assessment. We also provided them with an internet link to a similar online tool: www.hpherts.nhs.uk/childbmi Table 1 Percentage of overweight and obese children, 2006 to 2007 and 2007 to 2008, reception year and year 6 by gender, West Hertfordshire PCT SCHOOL YEAR AND GENDER Year R Girls Boys Year 6 Girls Boys

NHS WEST HERTFORDSHIRE (%) 2006/7 2007/8

ENGLAND AVERAGE (%) 2006/7 2007/8

22.5 27.3

20.2 24.1

21.5 24.3

21.09 24.03

25.2 29.8

29.5 32.5

30.0 33.2

30.74 34.33

Comparing 2007-2008 with the previous year, there was an improvement in the Reception Year results, which we also found in all five West Hertfordshire district councils (Figure 1). Unfortunately, this improvement is not seen in Year 6. More children are overweight or obese in Year 6 than in Reception and there was a greater yearly increase in the proportion of children in this category compared with the national picture for both girls and boys. Local data is in line with the national picture: boys are more likely to be overweight or obese than girls in Reception and Year 6. It is very important to concentrate our efforts in the local areas, which have the highest proportion of children who are overweight or obese. The most recent figures show that the highest levels of overweight and obese children in Year 6 were in Watford and Hertsmere (Figure 1). National data shows that obesity is not equal across all sections of the population. A strong relationship exists between deprivation and obesity prevalence in children in both Reception and Year 6. Nationally, the prevalence of obese children is about two thirds higher in the most deprived families compared with the least deprived. Our local data shows a similar pattern. Therefore, special efforts are needed to tackle Hertfordshire areas of deprivation as part of a drive to overcome health inequalities.

Risk factors The main cause of children gaining too much weight is an imbalance between calories eaten and calories spent. This is due to a diet which is energy-dense, mainly too high in fat and sugars. Children do not do enough physical activity because of the increasing use of computers and watching television and more use of cars for travel. Parents and parental behaviour have a very strong influence on child behaviour so to make change a whole family approach is needed. Overweight and obesity, as well as their related diseases, are largely preventable. The main factors for children being obese by the age of 7 are parental obesity and higher birth weight, sometimes due to maternal obesity during pregnancy. The risk for a child becoming obese is even higher when both parents are obese. There are also other risk factors relating to the parenting style e.g. insufficient sleep and too much watching TV in preschool children which are linked to obesity at primary school age.

Figure 1 Overweight and obese children in West Hertfordshire Local Authorities, National Child Measurement Programme 2006 to 2008, Reception class and Year 6 35.00%

30.00%

25.00%

20.00%

15.00%

10.00%

5.00%

0.00% 06/07 07/08 06/07 07/08 Yr R

Yr 6 Dacorum

06/07 07/08 06/07 07/08 Yr R

Yr 6

06/07 07/08 06/07 07/08 Yr R

Hertsmere

Yr 6

06/07 07/08 06/07 07/08 Yr R

St Albans

Overweight

Yr 6 Three Rivers

Obese

06/07 07/08 06/07 07/08 Yr R

Yr 6

Watford

Strategic approach In 2009, a childhood obesity strategy was written in co-operation with all relevant partners. It outlines the key local issues and actions to halt the year-on-year rise in obesity amongst children in Hertfordshire. It also aims to reduce the negative impact of obesity on children’s physical and emotional well being. The main areas and action points of the strategy are shown in Table 2. The strategy sets out measures to prevent further weight increase in overweight children. It also offers a best practice approach to help families manage obesity in children effectively. The strategy is designed to enable consistent and effective practice. It will form a structure to co-ordinate interventions to tackle the problem in Hertfordshire. This will mark an important shift in the focus to support children and their families in making the healthy choices, which will reduce obesity. As can be seen from Table 2, key actions include changes to the way we already work as well as actions that need additional resource.

Overcoming barriers Lifestyle change is often seen by parents as being difficult. Barriers to change need to be identified from the outset and steps taken to overcome them. This has to start with helping make parents more aware of obesity and overweight in their children. We produced a special leaflet titled Health & Weight: you and your child, explaining the link between a healthy weight and its importance for the future health of children. With the help of Health Promotion Hertfordshire, 55,000 copies went out to parents of primary school children all over Hertfordshire. Earlier this year, the Department of Health started a nationwide media campaign Change4Life, which together with the National School Measurement Programme will raise awareness of childhood obesity in the population. Due to this campaign, GPs, health visitors and school nurses requested more information and simpler resources to assess children’s weight correctly and quickly. To support health professionals who are advising families with overweight children of primary school age, Hertfordshire’s NHS Community Nutrition Education Service has developed a range of leaflets targeting all areas of lifestyle change. They are available to all practitioners to emphasise personal advice given to parents who want to tackle their children’s obesity problem.

Table 2 Action points from the Hertfordshire PCTs Childhood Obesity Strategy HEALTHY GROWTH AND HEALTH WEIGHT Preconception Overweight and obese women are more likely to have overweight children when aged 2-3 years - to give appropriate support to these women before conception and to develop care pathways to facilitate this. Antenatal Midwives to identify women who are overweight early in pregnancy and refer to a dietician as appropriate. Breast feeding Breast feeding provides protection against excess weight in later life - to develop an action plan to increase breast feeding exclusively for the first six months of life. Early years To review activities of Children’s Centres in helping children achieve a healthy lifestyle and weight. Schools To increase the proportion of proportion of accredited schools in the Healthy Schools programme and support the Healthy Schools co-ordinator in achieving healthy eating activities. PROMOTING HEALTHIER FOOD CHOICES To provide training for health visitors regarding healthy diets for children; the children’s Healthy Weight Manager to develop nutritional standards for food provision in preschool settings; Children, Schools and Families and District Children’s Trust Partnerships to ensure healthy food opportunities in all areas; Hertfordshire School Food Group to regularly monitor school meal uptake; Healthy Schools and Community Nutrition Service to develop more healthy eating leaflets for families; PCT and Local Strategic Partnerships (LSPs) to promote healthier food in local environments and review vending machine policies in leisure centres. BUILDING PHYSICAL ACTIVITY INTO CHILDREN’S LIVES PCTs through LSPs to ensure implementation of play strategies; Healthy Schools Steering Group to work with the School Travel Team to increase the number of pupils walking or cycling to school; Healthy Schools Sports co-ordinator to ensure two hours a week of physical education; LSPs to ensure relevant information about local opportunities for physical activity on council website and in libraries.

Resourcing the strategy To ensure the best possible outcome, measures recommended in our strategy need to be effectively commissioned and implemented across all sectors. Increased funding over the next three years will be required to support some new measures to prevent childhood obesity as well as offering personalised weight management services. To deliver this we need to reinforce the workforce and an increase in training programmes for health professionals, equipping them with the right skills to deliver obesity prevention or treatment. As can be seen from Table 2, key actions include changes to the way we already work, as well as actions that need additional resources. A complementary strategy to help prevent and, where necessary, reduce unhealthy levels of weight aiming at adults has also been developed (Chapter 3).

Chapter 2: Eating well in west hertfordshire Hertfordshire Robin Trevillion, Health Improvement Manager Hertfordshire, in common with the rest of the country, has an increasing number of adults who are overweight or obese. Consequently Hertfordshire also has an increasing number of the health problems associated with overweight and obesity such as type 2 diabetes, heart disease and cancer. The estimated prevalence of obesity in Hertfordshire is 24.6%, compared to an average for England of 23.6%. Hertfordshire prevalence rates range from 25.9% in Stevenage (and are also higher than average in Broxbourne and Watford) to 18.3% in St Albans. The estimated annual financial cost to the NHS in Hertfordshire by 2010 of overweight and obesity is expected to be ÂŁ275 million (anticipated to rise to ÂŁ295 million by 2015), because obesity leads to more ill health and early death from diseases such as diabetes. The cause of overweight and obesity in most people is the result of a complex inter-relationship between genetics, psychological factors, access to a large variety of low cost high calorific foods, and the physical environment at home, at work and for travel. An effective comprehensive obesity strategy therefore needs to take all these factors into account. The current Hertfordshire strategy follows current NICE guidance and recommends that services directed towards reducing obesity should provide access to individual and group weight management services that must include advice and support in three areas: diet/nutrition, physical activity and behavioural change. It also recommends that all partnerships work together to support access to weight management services and changes to the physical environment and travel which improve physical activity and healthy eating.

A variety of service gaps exist across Hertfordshire in terms of prevention and early intervention. Access to weight management information, advice and support is patchy, with variation in the services offered within primary care, and no formal services available between primary care and the specialist clinics for the morbidly obese (where the option of bariatric surgery is available). For established obesity, services need to be established that mainly target people with a BMI of 30 or over. These services should be integrated with other local services to be effective and avoid duplication. It is also vital that access to appropriate services is consistent and equitable across the county and so supports a reduction in health inequalities.

Key recommendations: Prevention a) Raise public awareness, via a communications strategy, of the importance of a healthy weight for a healthy life, opportunities for greater physical activity and a healthier diet, and where to look for help. b) Each local strategic partnership should have an integrated plan to: â&#x20AC;˘ promote greater physical activity â&#x20AC;˘ encourage healthier food choices

Early intervention (Level 1 and 2 Services) a) With the support of the Quality and Outcomes Framework and where appropriate Local Enhanced Schemes, the primary care team is asked to systematically assess obesity (through calculating BMI) and offer advice and signpost patients to other services when necessary. b) Where people are identified as overweight (BMI of 25 or over), basic advice on weight management and monitoring should be offered systematically. c) For people who are not able to achieve or maintain a healthy weight with level 1 support, signposting to local level 2 services (with staff who support behaviour change) may help.

General a) Services provided need to agree pathways that integrate support for people to achieve a healthy weight.

How will we know if we are succeeding? The ultimate measure of success for this strategy will be whether the prevalence in obesity in Hertfordshire can be reduced. Measurement of this success can be mapped through: â&#x20AC;˘ an increasing level of physical activity measured by percentage of adult population in general and within areas of greatest inequality doing at least 30 minutes of moderate physical activity 5 times a week. â&#x20AC;˘ an increasing consumption of fruit and vegetables measured by percentage of adult population in general and within areas of greatest inequality areas consuming at least 5 portions of fruit and vegetables a day. â&#x20AC;˘ the prevalence of obesity measured through Body Mass Index.

Services and gaps Describing the service we want Obesity services - Level 1 Level 1 services will be the starting point for most people who are assessed as being overweight or obese. Advice and information will be provided on the benefits of a healthy weight and how to approach making the necessary lifestyle change to healthy eating and increased physical activity. There will also be appropriate sign-posting into local weight management, healthy eating and physical activity opportunities. This level of service may be provided by a variety of health care professionals such as GPs, nurses and community pharmacists who are able to maintain a relationship to monitor progress. Obesity services - Level 2 Level 2 services are primary care/community interventions for patients who try a Level 1 service but fail to lose the desired weight in 6-9 months of trying and who may benefit from behaviour modification or other support. This level of service can be delivered across clusters of GP practices including across a PBC1 area. It requires access to increased support from people trained in behavioural change and to someone able to discuss, prescribe and monitor drug therapy options. Some of the components of this level of service could be delivered from non-NHS providers, for example commercial weight loss support groups.

PBC group - primary care focused commissioning group.

Obesity services - Level 3 Level 3 services are more specialised intermediate services for patients who have failed to lose and maintain weight reduction at previous levels, who have a BMI of more than 35 with co-morbidities or a BMI of 40 and above (with or without co-morbidities2). At this level anti-obesity medication, specialist weight management dietetics, psychological services, physical activity options, endocrinology assessment and genetic screening should be available if appropriate and in line with NICE guidelines. This level of service is likely to be provided across a PBC group, clusters of PBC groups, a PCT or across Hertfordshire as it requires access to more specialised behavioural change support. After level 3 services, the next option available would be referral to a morbid obesity clinic to discuss options for bariatric surgery. Some of the components of this level of service could be delivered from non-NHS providers.

Service gaps Gaps exist in the service available in Hertfordshire. Level 1 and Level 2 services are not consistent across Hertfordshire. Level 3 services are not available and therefore people failing with a Level 2 service only have the option of a Level 4 (morbid obesity) service. This is summarised in Table 1. Table 1 Identification of Service Gaps within West Hertfordshire PCT LEVEL 1 Generally available but not well monitored Greater use could be made of local partnerships, including NHS providers such as community pharmacists to provide physical activity, healthy eating and behavioural change support Obesity Management Group established in West Hertfordshire Hospital NHS Trust Recommendation Ensure a clear map of comprehensive level 1 services is in place across all primary care based commissioning areas LEVEL 2 Available in some GP practices but no PBC minimum service specification agreed “Your Choice” Lottery funded support in some GP practices Obesity LES currently being discussed in STAHCOM Recommendation Access to comprehensive Level 2 services need to be established in all PBC Group areas LEVEL 3 Not available Recommendation Access to comprehensive Level 3 services need to be established for all PBC Group areas

• • • •

• • • • • • 2 3

Co-morbidities are those health problems in addition to the weight eg. diabetes, chronic bronchitis, alcohol dependency. LES - Local Enhanced Service - a service provided by GPs in addition to the standard general medical services.

Other supporting components of the Service Healthy eating policies Every employer with a restaurant, shop or vending machine should adopt a healthy eating policy to provide healthy eating and drinking choices to their employees.

Patient and public involvement Patient and Public involvement is now a core part of health service development and decision-making. Without it truly responsive services cannot be delivered. It is therefore recommended that this strategy is regularly tested and developed through one or more of the following options: • individual feedback and patient surveys • consultation and formal evaluation of services • focus groups for feeding back thoughts and feelings on services • planning and project working groups (e.g. where a new service is developed) • Patient Forums and Expert Patients Programme • Patient Advocacy and Liaison Service • Patient and Public Involvement Forums • Voluntary and Charity Organisations • Independent Local Authority Forums

Eight tips for eating well 1. Base your meals on starchy foods Starchy foods such as bread, cereals, rice, pasta and potatoes are an important part of a healthy diet. Try to choose wholegrain varieties of starchy foods whenever you can. Starchy foods should make up about a third of the food we eat. They are a good source of energy and the main source of a range of nutrients in our diet. As well as starch, these foods contain fibre, calcium, iron and B vitamins. Most of us should eat more starchy foods, try to include at least one starchy food with each of your main meals. So you could start the day with a wholegrain breakfast cereal, have a sandwich for lunch, and potatoes, pasta or rice with your evening meal. Some people think starchy foods are fattening, but gram for gram they contain less than half the calories of fat. You just need to watch the fats you add when cooking and serving these foods, because this is what increases the calorie content. Why choose wholegrain foods? Wholegrain foods contain more fibre and other nutrients than white or refined starchy foods. We also digest wholegrain foods more slowly so they can help make us feel full for longer. Wholegrain foods include: • wholemeal and wholegrain bread, pitta and chapatti • wholewheat pasta and brown rice • wholegrain breakfast cereals

2. Eat lots of fruit and vegetables Most people know we should be eating more fruit and vegetables, but most of us still are not eating enough. Try to eat at least 5 portions of a variety of fruit and vegetables every day. It might be easier than you think. You could try adding up your portions during the day. For example, you could have: • a glass of juice and a sliced banana with your cereal at breakfast • a side salad at lunch • a pear as an afternoon snack • a portion of peas or other vegetables with your evening meal You can choose from fresh, frozen, tinned, dried or juiced, but remember potatoes count as a starchy food, not as portions of fruit and vegetables.

3. Eat more fish Most of us should be eating more fish - including a portion of oily fish each week. It is an excellent source of protein and contains many vitamins and minerals. Aim for at least two portions of fish a week, including a portion of oily fish. You can choose from fresh, frozen or canned - but remember that canned and smoked fish can be high in salt. What are oily fish? Some fish are called oily fish because they are rich in certain types of fats, called omega 3 fatty acids, which can help keep our hearts healthy. How much oily fish? Although most of us should be eating more oily fish, women who are planning to become or who are currently pregnant should have a maximum of 2 portions of oily fish a week (a portion is about 140g). Four is the recommended maximum number of portions for other adults. Examples of oily fish Salmon, mackerel, trout, herring, fresh tuna, sardines, pilchards, eel.

4. Cut down on saturated fat and sugar Fats To stay healthy we need some fat in our diets. What is important is the kind of fat we are eating. There are two main types of fat: • saturated fat - having too much can increase the amount of cholesterol in the blood, which increases the chance of developing heart disease • unsaturated fat - having unsaturated fat instead of saturated fat lowers blood cholesterol Try to cut down on food that is high in saturated fat and have foods that are rich in unsaturated fat instead, such as vegetable oils (including sunflower, rapeseed and olive oil), oily fish, avocados, nuts and seeds. Foods high in saturated fat Try to eat these sorts of foods less often or in small amounts: • meat pies, sausages, meat with visible white fat • hard cheese • butter and lard • pastry • cakes and biscuits • cream, soured cream and creme fraiche • coconut oil, coconut cream or palm oil For a healthy choice, use just a small amount of vegetable oil or a reduced-fat spread instead of butter, lard or ghee. And when you are having meat, try to choose lean cuts and cut off any visible fat. How do I know if a food is high in fat? Look at the label to see how much fat a food contains. Generally the label will say how many grams (g) of fat there are in 100g of the food. Some foods also give a figure for saturated fat, or ‘saturates’. HIGH is more than 20g of Total fat per 100g or is more than 5g of Saturated fat per 100g LOW is 3g or less of Total fat per 100g or is 1.5g or less of Saturated fat per 100g Remember that the amount you eat of a particular food affects how much fat you will get from it. Try to choose more foods that are low in fat and cut down on foods that are high in fat.

Sugar Most people in the UK eat too much sugar. We should all be trying to eat fewer foods containing added sugar, such as sweets, cakes and biscuits, and drinking fewer sugary soft and fizzy drinks. Having sugary foods and drinks too often can cause tooth decay, especially if you have them between meals. Many foods that contain added sugar can also be high in calories, so cutting down could help you control your weight. How do I know if a food is high in added sugar? Take a look at the label. The ingredients list always starts with the biggest ingredient first. But watch out for other words used to describe added sugars, such as sucrose, glucose, fructose, maltose, hydrolysed starch and invert sugar, corn syrup and honey. If you see one of these near the top of the list, you know the food is likely to be high in added sugars! Another way to get an idea of how much sugar is in a food is to have a look for the ‘Carbohydrates (of which sugars)’ figure on the label. But this figure can’t tell you how much is from added sugars, which is the type we should try to cut down on. HIGH is more than 15g of sugars per 100g LOW is 5g of sugars or less per 100g If the amount of sugars per 100g is in between these figures, then that is a medium level of sugars. Remember that the amount you eat of a particular food affects how much sugars you will get from it. Sometimes you will only see a figure for total ‘Carbohydrates’, not for ‘Carbohydrates (of which sugars)’, which means the figure also includes the carbohydrate from starchy foods.

5. Try to eat less salt - no more than 6g a day Lots of people think they don’t eat much salt, especially if they don’t add it to their food. But don’t be so sure! Every day in the UK, 85% men and 69% women eat too much salt. Adults - and children over 11 - should have no more than 6g salt a day. Younger children should have even less. Three-quarters (75%) of the salt we eat is already in the food we buy, such as breakfast cereals, soups, sauces and ready meals. So you could easily be eating too much salt without realising it. Eating too much salt can raise your blood pressure. And people with high blood pressure are three times more likely to develop heart disease or have a stroke than people with normal blood pressure. How do I know if a food is high in salt? Check the label to find out the figure for salt per 100g. HIGH is more than 1.5g salt per 100g or is more than 0.6g sodium per 100g LOW is 0.3g salt or less per 100g or is 0.1g sodium or less per 100g If the amount of salt per 100g is in between these figures, then that is a medium level of salt. Remember that the amount you eat of a particular food affects how much salt you will get from it.

6. Get active and try to be a healthy weight It’s not a good idea to be either underweight or overweight. Being overweight can lead to health conditions such as heart disease, high blood pressure or diabetes. Being underweight could also affect your health. You can check if you are the right weight for your height by using the BMI calculator on the NHS Choices website: www.nhs.uk Information on how you can lose weight and maintain a healthy lifestyle is also available. If you are worried about your weight, ask your GP or a dietitian for advice. But if you think you just need to lose a little weight, the main things to remember are: • only eat as much food as you need • make healthy choices - it’s a good idea to choose low fat and low sugar varieties, eat plenty of fruit and vegetables and wholegrains • get more active It’s also important to eat a variety of types of food so you get all the nutrients your body needs. Physical activity is a good way of using up extra calories, and helps control our weight. But this doesn’t mean you need to join a gym. Just try to get active every day and build up the amount you do. For example, you could try to fit in as much walking as you can into your daily routine. Try to walk at a good pace. Whenever we eat more than our body needs, we put on weight. This is because we store any energy we don’t use up - usually as fat. Even small amounts of extra energy each day can lead to weight gain. But crash diets aren’t good for your health and they don’t work in the longer term. The way to reach a healthy weight and stay there is to change your lifestyle gradually. Aim to lose about 0.5 to 1kg (about 1 to 2lbs) a week, until you reach a healthy weight for your height.

7. Drink plenty of water We should be drinking about 6 to 8 glasses (1.2 litres) of water, or other fluids, every day to stop us getting dehydrated. When the weather is warm or when we get active, our bodies need more than this. But avoid drinking soft and fizzy drinks that are high in added sugar. Alcohol There is nothing wrong with the occasional drink. But drinking too much can cause problems. Alcohol is also high in calories, so cutting down could help you control your weight. Women can drink up to 2 to 3 units of alcohol a day and men up to 3 to 4 units a day, without significant risk to their health. A unit is half a pint of standard strength beer, lager or cider, or a pub measure of spirit. A glass of wine is about 2 units and alcopops are about 1.5 units. More precise unit calculation can be obtained by visiting the DrinkAware website: www.drinkaware.co.uk For good health, it’s a good idea to spread your drinking throughout the week and avoid binge drinking. Drinking heavily over a long period of time can damage the liver.

8. Don’t skip breakfast Breakfast can help give us the energy we need to face the day, as well as some of the vitamins and minerals we need for good health. Some people skip breakfast because they think it will help them lose weight. But missing meals doesn’t help us lose weight and it isn’t good for us, because we can miss out on essential nutrients. There is some evidence to suggest that eating breakfast can actually help people control their weight.

Co-morbidities are those health problems in addition to the weight eg. diabetes, chronic bronchitis, alcohol dependency.

Chapter 3: be active, be healthy in west hertfordshire Tom May, Health Improvement Advanced Practitioner The health benefits from being physically active are clear. Those who are active can enjoy the following: • reduced risk of coronary heart disease • reach and stay at a healthy weight • better mental health • less risk of getting diabetes • lower blood pressure • reduced risk of cancer • better immune function • more stamina, flexibility and energy levels for everyday life • healthier bones and joints • a longer life

How much physical activity do we need? The Chief Medical Officer advises adults aim to get 30 minutes of moderate physical activity on five or more days of the week. This does not have to done during one period in a day, three bouts of ten minutes a day would count. Moderate intensity means the activity is enough to cause a faster breathing and heart rate together with a sensation of warmth. People do not necessarily need to join a gym or start taking part in a sport. Examples of everyday moderate intensity activities include brisk walking, gardening, do-it-yourself, dancing, swimming or bicycling. Simple steps could involve walking instead of driving for short journeys, walking up stairs instead of using a lift or doing housework at a brisk pace. The most common form of exercise nationally is walking, with over a third of adults saying they walked for over 20 minutes or more three times a week.

The activity recommendation for children and young people is 60 minutes every day which can be made up of both formal and informal physical activity. In February 2009, the government launched its plan for getting the nation moving. Be Active, Be Healthy aims to get 2 million people more active by 2012 and using the London 2012 Olympic Games to help inspire this. This will be supported by promoting physical activity through the Change4Life national campaign, increased provision of Health Walks and the free swimming programme for children and young people below the age of 16 and older adults over the age of 60. Free swimming is currently provided in Hertsmere, Three Rivers and St Albans Local Authorities. Be Active, Be Healthy predominately concentrates on adults as there are many other government initiatives focusing on increasing physical activity in children and young people. In public health terms, the greatest reduction in the risk of health problems arising from a lack of exercise will arise from getting people from an inactive level to any active level of physical activity.

Figure 1 Participation in moderate exercise activity in Hertfordshire 2005-2006 by age range.

Source: Active People Survey 2005-2006, Sports England.

How physically active are people in West Hertfordshire? The majority of people do not exercise at recommended levels and in West Hertfordshire fewer than 1 in 4 men and 1 in 5 women exercise at or better than recommended levels. However, the 2007 Health Survey for England has revealed that since 1957 both men and women are engaging in more physical activity. The survey showed that boys younger than 16 years have a higher level of activity compared with girls in the same age group (around 70% compared with around 60% achieving physical activity guidelines at 9 years of age). The Active People Survey takes place every twelve months. It monitors Sport Englandâ&#x20AC;&#x2122;s commitment to increase the number of people taking part in sport by one million by 2012-2013. It does not include recreational walking or cycling if less than a period of 30 minutes a day. Figure 1 shows that in the 16-24 year old age group over 30% of adults meet the recommended activity levels but from the age of 45 years less than 20% do not exercise at recommended levels. In the age group 75-84 years less than 6% meet the recommended activity level. However, surveys show that only 1 in 20 of the population consider themselves to be not at all physically active. There is a marked gender difference in physical activity between men and women and overall higher levels of physical activity in people living in the county of Hertfordshire compared with the East of England average (Figure 2). The survey shows what types of physical activity people engage. The most popular are walking, swimming, using a gym and cycling (Figure 3).

Figure 2 Participation in exercise by gender in Hertfordshire

Source: Active People Survey 2005-2006, Sports England.

Figure 3 The top 15 most popular activity in Hertfordshire (% population participating in at least one activity in the previous four weeks)

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Variation in exercise levels in West Hertfordshire Table 1 shows the latest figures for the council areas in West Hertfordshire. There has been no increase in the percentage of people undertaking moderate intensity exercise three times a week compared with the previous year and most areas register a slight decrease although there has been no statistically significant change. The council area with the least participation in sport is Watford. Nationally, there has been a significant increase only in participation in table tennis. Swimming, football, rugby, dancing and sailing have all registered a decrease. Table 1 Results of Active People Survey in West Hertfordshire. People aged 16 years and over: adult participation in 30 minutes of moderate intensity sport and/or physical activity for three sessions a week APRIL 2008 TO APRIL 2009 Hertfordshire Dacorum Hertsmere St Albans Three Rivers Watford

% 22 22 21 24 24 19

Source: Active People Survey 2008-2009, Sports England.

The cost to West Hertfordshire PCT of health problems related to inactivity has been estimated to be around ÂŁ6.2 million a year.

What is being done to increase physical activity in West Hertfordshire? There are many initiatives to help people become more active in West Hertfordshire. For children and young people of school age there are opportunities within the school sports partnerships to become more active. Some of these are within the curriculum during school hours but increasingly more opportunities are being offered outside the curriculum as part of the Sport Unlimited programme. Part of this involves schools making links with local sports clubs where children and young people can take advantage of a range of opportunities across a variety of sports. More traditional sports such as football, cricket and hockey are offered along with multi-activity sessions with a range of sports from kayaking, skateboarding to emerging urban sports such as free running.

77% of schools in Hertfordshire have achieved Healthy School Status in the Hertfordshire Healthy Schools programme. These schools meet nationally agreed criteria in the areas of healthy eating, physical activity, emotional health and wellbeing, personal and social health education. The majority of the remaining schools are working towards Healthy School Status. From September 2009 schools who have reached this status can achieve enhanced status by working closely with key partners towards achieving locally agreed health and well-being outcomes. These will reflect both school-based and local priorities as outlined in Local Area Agreements, Children and Young Peopleâ&#x20AC;&#x2122;s plans and PCT operational plans. In addition, the Saracens Foundation has a number of programmes including Sport For Health and the Community Dance Programme. Watford FC Community Trust had the On Side and Extra Time community projects aimed at getting people more active in West Hertfordshire across a variety of age ranges. Each district has a community sports network which is a collaboration of sports clubs providing opportunities for both children and adults to participate in a diverse range of sports and physical activities. Increasing participation in sport and physical activity is a county priority and a target within the Local Area Agreement. The PCT and the Hertfordshire Sports Partnership co-lead this work and a delivery plan has been developed to help more people become more active. The delivery has been implemented in partnership with local authority leisure providers. An example of this is the Nordic Walking programme. Sessions have been set up in the Dacorum and the Three Districts council areas. In Watford and St Albans a project was delivered to encourage women from black and minority ethnic groups to become more physically active as this group is underrepresented in physical activity participation. To achieve this members of the community have been trained as exercise instructors to deliver sessions to the rest of their local community. The ongoing development of projects is being guided using the Active People Survey market segmentation tool. This aims to target initiatives to areas of greatest need and ensure that the interventions are specific to the population preferences in a particular locality.

Another part of the delivery plan has involved working with the Countryside Management Service to develop the Hertfordshire Health Walks programme. This has been successful in increasing walk attendances over the last year by almost 25%. A health walk is led by a trained leader and is between one and three miles. The walks provide a venue for meeting other people as well as maintaining and improving an active lifestyle. The PCT aims to be an exemplar employer by encouraging its staff to be active. Recently, over 600 staff took part in the workplace pedometer challenge to help increase walking levels. Furthermore, activity taster sessions have been provided and the PCT has implemented a cycle to work scheme which supports staff in purchasing new cycles at reduced cost to promote active transport. Workplace activity guidelines have been developed to highlight what the employer and employee can do to promote physical activity in the workplace. Some leisure providers work in partnership with their local General Practices to provide Exercise on Referral schemes. These schemes involve eligible people being referred to the leisure provider by healthcare professionals. Schemes typically last between 10 and 24 weeks. Participants are assessed and supported by accredited exercise professionals. Motivational interviewing techniques are used to negotiate behavioural goals and the ways to achieve these goals. Currently, there are established schemes in St Albans and Hertsmere districts together with a pilot scheme in the Dacorum area. There are plans to develop a scheme in Three Rivers in the future. Three Rivers district council has taken the innovative step of installing two outdoor gyms. These offer people the opportunity to be physically active outside in local parks. Equipment ranges from a chest press machine to a static cycle and is free for young people and adults to use alongside other facilities in the park area. People often say cost and access are barriers to activity. It is hoped that initiatives like this which remove these barriers will encourage more people to be more active, more often.

There are many opportunities throughout West Hertfordshire to be more active and many projects are delivering on this important agenda. Nevertheless, there is much we can do which does not involve formal physical activity provision and cost. The physical activity pathway will be published by the Department of Health in the autumn and will help embed the promotion of physical activity into everyday clinical practice. In addition, people between the ages of 40 and 74 years will be offered health checks which will involve an assessment of physical activity.

Chapter 4: live longer in west hertfordshire Richard Garlick, Consultant in Public Health Life expectancy reflects death rates for people living in a specific area at a particular time. They do not predict how long any individual person can actually be expected to live as death rates change over time and people move. It is also likely, sadly, that the final years of life will be in states of increasing levels of ill health and disability for many. However, life expectancy is widely used as a headline measure to compare the mortality experience between different areas. The main illnesses leading to early death are heart disease and stroke, cancers and lung problems. The major risk factors for these illnesses include smoking, physical inactivity, being overweight and having a family history of these illnesses. Lifestyle changes such as stopping smoking, getting more active and losing weight will help people live longer and healthier lives. Further detail on these risk factors and the ways in which they are addressed in West Hertfordshire is found in other chapters. Life expectancy in the different local authority areas comprising West Hertfordshire is generally at least as good as life expectancy in England for both men and women. In the Three Rivers local authority area men can expect to live three years longer and women one year more than men and women in England (Table 1). Men living in Three Rivers local authority area in 2005-2007 had the 9th highest life expectancy at birth of all the local areas in the United Kingdom - 6.9 years longer than men living in North Ayrshire, Scotland.

Table 1 Life expectancy for local authority areas in West Hertfordshire, Hertfordshire, East of England and England for men and women, 2005-2007 in years LOCAL AUTHORITY Dacorum Hertsmere St Albans Three Rivers Watford Hertfordshire East of England England

MEN 79.2 78.7 80.0 80.6 77.5 79.1 78.7 77.5

WOMEN 82.9 82.2 83.3 82.9 81.1 82.6 82.6 81.7

The health of people in Hertfordshire and in the East of England Region is generally better than the England average. Within Hertfordshire, Watford has the lowest life expectancy for both men and women. In the period between 1991-1992 and 2005-2007 life expectancy at birth has improved by an average of 3.8 years in men and 2.4 years in women in West Hertfordshire (Figs 1 and 2). This compares with the biggest improvements in the UK in this period which were in London which saw an increase of 4.6 years for men and 3.1 years for women. Figure 1 82.0 81.0 80.0 79.0 78.0 77.0 76.0 75.0 74.0 73.0 72.0 71.0

Dacorum Hertsmere St Albans Three Rivers

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95 95 19

93 -

19 19

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number of years

Life expectancy at birth for males West Hertfordshire2

year

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number of years

Life expectancy at birth for females West Hertfordshire

year

Figure 3 number of years

Life expectancy for males West Hertfordshire at 65 years age 20.0 19.0 18.0 17.0 16.0 15.0 14.0

Dacorum Hertsmere St Albans 20002002

20012003

20022004

20032005

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Three Rivers Watford

year

Figure 4 number of years

Life expectancy for females West Hertfordshire at 65 years age 22.0 21.0 20.0 19.0 18.0 17.0

Dacorum Hertsmere St Albans Three Rivers

2000- 2001- 2002- 2003- 2004- 20052002 2003 2004 2005 2006 2007 year

Watford

The gender gap in life expectancy has narrowed. The gap between female and male life expectancy at birth has reduced from 4.7 years to 3.3 years between 1991-1993 and 2005-2007. Over the period from 2000-2002 to 2005-2007, average life expectancy for men aged 65 in West Hertfordshire increased by 1.5 years and by 2.9 years for women. (Figs 3 and 4). Over the last 16 years Watford has consistently had the lowest life expectancy for both men and women. The gap between Watford and the local authority in West Hertfordshire with the highest life expectancy has widened from 1.2 years in 1991-1993 for men to 3.1 years in 2005-2007; and from 1 year in 1991-1993 in women to 2.1 years in 2005-2007. In the late 1990s the difference in life expectancy between the highest and the lowest social class was 7.3 years for men and 7 years for women. Watford is the most deprived local authority in West Hertfordshire with the highest value for the Index of Multiple Deprivation as shown in Table 2. It ranks 203rd out of the 354 districts in England. Table 2 IMD 2007 and ranking in England LOCAL AUTHORITY Dacorum Hertsmere St Albans Three Rivers Watford

IMD 20073

Ranking in England

10.7 13.0 8.9 10.7 15.8

288 250 317 287 203

The PCT Director of Public Health updated the PCT Board in January 2009 on the PCT 2008 health inequalities action plan which underpins the Eastern Region pledge to halve the difference in life expectancy between the poorest 20% of our communities and the rest of the east of England: www.wherts-pct.nhs.uk/Documents/getinvolved/Board/2009/ january/E%20Health%20Inequalities%20Board%20update%20.pdf

Life expectancy is one of two national health inequalities targets, the other target is related to infant mortality. There are strong arguments that life expectancy is the best summary measure of health outcome reflecting a broad range of activities both within and outside the NHS. The PCT has agreed with the Eastern Region Strategic Health authority that life expectancy and all age all cause mortality rates for cancer, circulatory disease and respiratory disease will be monitored for the 16% most deprived areas of the population (equivalent to 25 MSOAs1) and compared with the average for the PCT. This list has been further enlarged by the PCT to include the most deprived MSOAs from the primary care based commissioning localities that did not have an MSOA in the 16% most deprived and also HMP The Mount, the only prison in Hertfordshire (see 30 priority areas map in Partnership chapter). Based on an analysis of data in the mid 1980s it has been estimated that complete elimination of the following causes would result in additional years of life as shown in Table 3. Table 3 Years of life gained with elimination of major causes of death CAUSE OF DEATH Circulatory system Cancers Respiratory system Accidents/suicides

MEN 7.4 3.3 1.2 1.0

WOMEN 8.3 3.6 1.1 0.5

Extrapolation of recent trends suggests for that both men and women there is a widening of the gap between the bottom 20% and the population as a whole - the target therefore is challenging in that it requires that by 2010 the (relative) gap narrows by 10%.

Conclusion West Hertfordshire local authority areas have a life expectancy in general at least as good as the figure for England. But there are differences in life expectancy and the PCT is committed to work with partners to focus health inequalities work programmes on the 30 priority areas in which the poorest groups of people live. This will focus on improving smoking cessation rates, reducing childhood obesity and seeking to reduce mortality from the major causes of death. General Practices that register patients from these areas have been identified. The primary health care team has an important role in monitoring and managing their patient population with chronic diseases such as diabetes, heart disease and chronic lung problems such as bronchitis and emphysema. The recent government focus on earlier access to cancer treatment is aimed at improving survival. Local Strategic Partnerships are a powerful means of providing the environment to make healthier lifestyle choices easier. Further work is being directed specifically at marginalized groups. A health promotion programme is being developed for HMP The Mount. In July 2009 a prisoner engagement programme at The Mount won an East of England Health and Social Care award. Other marginalized groups include the homeless, travellers, people with learning disabilities and those with long term mental health problems. The availability of affordable warmth using the grants for this purpose is being targeted at older people living in deprived areas; influenza vaccination in this group of people should be at least as good as the rest of the population. Watford stands out as an area where increased attention should be paid to lifestyle change programmes to address the life expectancy inequality within West Hertfordshire.

MSOA refers to a middle layer super output area - an area with a stable boundary and an average population of 7600 (minimum 5000). Life expectancy at birth is the number of years a baby can be expected to live if it experienced the current age specific mortality rate of that particular area or population throughout its life. 3 IMD 2007 The Index of Multiple Deprivation (IMD) has components measuring income, employment, health and disability, education, skills and training, barriers to housing and services, crime and disorder, living environment; a higher value corresponds to more deprivation. 2

Chapter 5: Tobacco control Robin Trevillion, Health Improvement Manager Smoking and the use of tobacco products is still the biggest cause of avoidable ill health and death in Hertfordshire. It causes a number of health problems such as heart disease and stroke, cancers and respiratory illness. To meet this important public health challenge requires all of us to work together to reduce the demand for tobacco products, help people to stop smoking, prevent young people starting to smoke, and reduce the supply of cheap, illicit and counterfeit tobacco products. Tobacco consumption is also a major cause of health inequalities in Hertfordshire. Smoking levels are highest in the most deprived sections of our communities. Reducing health inequalities means reducing these levels. Although smoking rates in Hertfordshire are less than the national average and falling, they are still too high. There are a number of key areas being targeted in Hertfordshire to support further reductions in the prevalence of people smoking.

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What is tobacco control? Tobacco control includes anything that affects either the demand for or the supply of tobacco products. At a national level this includes: • price measures including high rates of tax • non-price measures such as advertising restrictions, smoke free workplace laws, health warnings • controlling illicit trade • restricting access to minors In Hertfordshire the PCT works with local partners to ensure that these national themes are supported by: • gathering and using data to inform tobacco control • ensuring an integrated approach to delivering ‘Stop Smoking’ services • helping young people to not take up the habit • tackling cheap and illicit tobacco • influencing change through advocacy • maintaining and promoting smoke free environments

Supporting people to stop smoking One key priority is to support people who want to stop smoking. The majority of people who smoke want to stop. Our challenge is to ensure we provide the right sort of stop smoking services, in the right place and at the right time to help smokers quit.

Smoking cessation targets West Hertfordshire PCT is set a target number of “quitters” each year by the East of England Strategic Health Authority. The PCT did not achieve the target for the year 2008-2009. While a total of 1347 people were helped to quit by the Stop Smoking Services in Hertfordshire, this was less than half the target number we should reach. The PCT now has a target of 2944 quitters for the year 2009 -2010. In order to ensure that this target is met, the Stop Smoking team has been restructured to increase the capacity and flexibility of the service.

Services are widely available from GP surgeries, community pharmacies, health clinics and workplaces. To help reduce health inequalities we are trying to ensure these services are available in the PCT determined 30 priority areas. In addition, the team can support people with mental health problems and women who are pregnant who wish to quit.

A focus on young people Helping young people to avoid becoming smokers is also a high priority in Hertfordshire. Over two thirds of adult smokers started the habit as teenagers and very few people who are non-smokers at the start of their 20s will take up smoking. The evidence also indicates that people who start smoking at a younger age can find it more difficult to stop. Work is taking place to better target prevention work aimed at young people in those parts of Hertfordshire where the prevalence of smoking in young people is highest. In particular, the work will also be used to better understand how to build resilience into young people to withstand peer and role model pressure to start smoking. The role model effect of parents is very important. It is known that children and young people are more likely to smoke in homes where at least one adult is a smoker. Supporting parents to stop smoking will also therefore help children and young people to avoid becoming smokers. In addition, non-smoking â&#x20AC;&#x2DC;celebrityâ&#x20AC;&#x2122; role models and sporting personalities can help to promote the message that it is both normal and desirable not to smoke. Locally Watford Football Club promotes the smokefree message. The run up to the 2012 Olympics provides an opportunity to remind young people that successful athletes donâ&#x20AC;&#x2122;t smoke!

For anyone wanting to quit smoking the Hertfordshire Stop Smoking Service can be contacted through the freephone number 0800 389 3 998; alternatively your GP and Community Pharmacist will be able to discuss services available. Other information can be found at www.smokefree.nhs.uk and www.hpherts.nhs.uk

Supporting the work with children and young people will be close partnership working with Children Schools and Families, schools and colleges, childrenâ&#x20AC;&#x2122;s centres, youth services, voluntary sector organisations working with children and young people, and parenting groups. The service is already running clinics at colleges within the county.

Reducing the number of pregnant women who are smoking The health of both mother and baby is affected by smoking during pregnancy, for example by raising the risk of miscarriage. Significant numbers of women still smoke through their pregnancy; the rate for Hertfordshire as a whole is 14.0% compared to an average for the East of England of 14.7% and for England of 14.4% (2007-2008 data). It is important to continue to offer support and Stop Smoking services in Hertfordshire that meet the needs of pregnant women who smoke. This includes making sure that the importance and benefits of stopping smoking is stressed by all midwives and other professionals involved in maternal health care. A lead is being taken by the Hertfordshire Stop Smoking Service Pregnancy Adviser working closely with local midwifery services. Clinics are already running in some childrenâ&#x20AC;&#x2122;s centres in the county, to support women with young children who want to give up before a future pregnancy.

Smoke free buildings and sites in Hertfordshire The recent legislation preventing smoking in public buildings has made a substantial improvement to the air quality within buildings such as pubs, clubs and restaurants. This has improved the environment in particular for people working in these building who previously were exposed to second-hand smoke for long periods of their working day. Compliance is high in Hertfordshire but this is a continued focus of attention for enforcement officers in District/Borough Councils. The NHS also has a policy of no smoking on any part of its premises, including all outside areas. However, compliance is often patchy, with some people still smoking on acute hospital sites.

It is recommended that there should be a renewed focus by the PCT and local NHS Trusts to ensure that staff working on NHS sites, patients using NHS services and their family, carers and visitors are all aware of the need to refrain from smoking anywhere on the site and of the support available.

Reducing illicit and counterfeit sales of tobacco Reducing the supply of smuggled and counterfeit cigarettes in Hertfordshire is ongoing work and is led by Trading Standards. Not only do counterfeit cigarettes increase the consumption of cigarettes because they tend to be priced more cheaply than other cigarettes but it also brings into Hertfordshire products which have had no quality control in their production and could contain chemicals not normally found in cigarettes. The Trading Standards Service now has a dedicated Tobacco Control Officer in place. Partnership working with the PCT is a clear remit of the post, alongside the control of illicit and counterfeit tobacco products. Trading Standards have a tobacco reader which can detect illicit or counterfeit tobacco. Over 9000 products were tested during the course of last year at retail outlets. No counterfeit or illicit products were detected during the course of the visits. Two hundred premises were visited to examine their compliance with regard to labelling and advertising of tobacco products and other aspects of tobacco control. Protocols exist to enforce regulations if illicit or counterfeit tobacco is found. Trading Standards have an Intelligence Officer who is currently forging stronger links with the PCT, police, the Borders Agency and HMRC to enable a detailed profile and threat assessment to be compiled.

Looking ahead A Health Bill will be taken through parliament in 2009 that may introduce new restrictions on how tobacco products are displayed and access to cigarettes from vending machines (to reduce the sale of tobacco products to under-aged young people). These restrictions will be welcomed in Hertfordshire as a useful addition to the work the Tobacco Strategy group is leading to create smoke free as the normal environment in Hertfordshire.

Chapter 6: change4life through partnership, reducing inequalities in health Patsy Temple, Partnership Manager The PCT recognises that reducing health inequalities can only be tackled effectively through partnerships. In West Hertfordshire we are fortunate that there is a firm foundation to build on to take our plans forward. Our Practice Based Commissioning groups have developed a good understanding of their local health needs and are committed to ensuring that knowledge of differential health experience drives their commissioning decisions. Equally, primary care providers - GPs, dentists, pharmacists, optometrists and the wide range of support staff, such as practice nurses, dental nurses, therapists, etc. are well placed to reduce inequalities by identifying and delivering services to those people in most need. Our community services also have an important role to play and through our commissioned services we will be prioritising health improvement and the implementation of our action plans. We also have strong multi-agency partnerships which are critical to delivery. There are 11 formal partnerships in Hertfordshire: the ten District/Borough Local Strategic Partnerships (LSPs), and the county-wide LSP â&#x20AC;&#x153;Hertfordshire Forwardâ&#x20AC;? which link with the ten borough/district LSPs, local voluntary sector, third sector organisations, tertiary education, police and chambers of commerce. To ensure alignment and consistency of approach our plans contain a number of outputs which are also contained in the county-wide Local Area Agreement (LAA).This can be accessed through the following link: www.hertslink.org/hertfordshireforward/content/items/13843271/ 13843307/13843322/LAA2ActionPlanningYr1

All 10 district LSPs have a ‘Health Partnerships’ sub group to mirror the county’s Healthier People and Older People’s group. The PCT is well represented in the membership of these groups by senior public health staff as well as Practice Based Commissioning managers. The County-wide Sustainable Community Strategy Hertfordshire 2021: A Brighter Future was developed in consultation with a range of partners and members of the public and launched in June 2008. It identified a number of areas for improvement, including several which will impact on health and the PCT commitment to reduce health inequalities. The PCT key public health priorities to tackle health inequality are: • reduce smoking • reduce childhood obesity • reduce alcohol consumption • improve sexual health • improve screening • improve immunisation • improve falls prevention These priorities are well represented in the sustainable community strategies of every district Local Strategic Partnership. These have been re-visited and many were refreshed in 2008- 2009 to ensure they reflect the current issues and needs of the local communities. The PCT public health team have played a key role in this process. The long and short term priorities of all 10 district strategies reflect local need, prioritising reducing health inequalities and reducing smoking, obesity and alcohol consumption levels accordingly. In 2008-2009 the PCT allocated £10,000 to each district LSP to spend on projects which will potentially reduce health inequalities. These projects are in line with the public health and local sustainable community strategy priorities for health and wellbeing and address a wide range of issues. Some examples are listed on the next page.

Dacorum District Council Back to basics cookery Sessions run through Home start helping mums to learn the basics of cooking and healthy eating. Health improvement sessions for elderly Asians Indian Society: introducing regular half an hour health sessions to older and unemployed Asians.

Hertsmere District Council Multi activity sports sessions for mid-life and older people An activity programme for the 45+ age groups to increase their physical activity levels and promote a sustainable lifestyle change run by Hertsmere Leisure Trust and Hertsmere Borough Council. Community Healthy Eating project Taster family cooking sessions provided as part of the Potters Bar Extended Schools Consortium will work with groups of families to teach them how to cook healthy food on a budget and provide them with recipe cards to take home.

Watford District Council Exercise classes specifically tailored for women to be held in the multicultural community centre Women-only exercise classes to encourage women from black and minority ethnic communities to participate. Extended schools smoking prevention workshop Smoking prevention theatre workshops to be held in schools with Years 5 and 8.

Three Rivers District Council Extended schools smoking prevention project To reduce the number of children starting to smoke and reduce current smokers by delivering a programme of activities: 1) Drama workshops - Deliver a drama based series of workshops to families of Year 5 pupils in South Oxhey, Maple Cross and Mill End. 2) Curriculum based delivery - Promoting smoking cessation literature and curriculum based activities for Year 9 pupils in March 2009. Physical activity project for people with learning difficulties Programme which aims to increase levels of physical activity in adults with a learning disability over the age of 45 years.

St Albans District Council BME Healthy Lifestyle Support Group Establishment of a support group for ladies over the age of 45 from the BME group offering gentle exercise, a support session on diet, nutrition, general health issues. Safer Living for the 60+ sessions Sessions in a day centre setting covering a range of issues such as falls prevention, exercises, Tai Chi, etc. Young Carers Pilot Project To establish a new support group for young carers at Fleetville Junior School to run for one hour once a week during lunchtime and offer guidance and support.

Areas of deprivation The upward trend in life expectancy in Hertfordshire masks pockets of deprivation across the county. Equally our marginalised groups tend to be concentrated in the parts of the county with greatest deprivation. All 10 Local Authority areas and 12 Practice Based Commissioning groups have areas of social deprivation within their boundaries as defined by the index of multiple deprivation (IMD). People living in these areas of deprivation experience poor health, have worse health outcomes and shorter life expectancy. This is illustrated when we look at the 16% most deprived Medium Super Output Areas (MSOAs1) and compare their life expectancy to the rest of the population. • there is a 2 year difference in life expectancy for males and 1.4 years difference in life expectancy for females between those living in the 16% most deprived (25 MSOAs) and the average life expectancy of the PCTs as a whole • there is a 2.3 years for males and 1.6 years difference for females between those living in the 16% most deprived (25 MSOAs) and the life expectancy of those living in the rest of the PCTs (remaining 84%) • there is a 4.2 years difference in life expectancy for males and 3.3 years difference for females between those living in the 16% most deprived (25 MSOAs) and the 16% least deprived MSOAs

MSOA refers to middle layer super output area - an area with stable boundary and an average population of 7600 (minimum 5000)

The three wards in West Hertfordshire with the greatest social deprivation are: • Northwick and Ashridge (Three Rivers) • Central (Watford) • Borehamwood, Cowley Hill (Hertsmere). We also plan to focus our health improvement programmes on the 25 most deprived MSOAs according to the IMD. These represent the 16% most deprived MSOAs in Hertfordshire. To this list we have added HMP The Mount which contains people with significant health problems and higher rates of smoking. We have also added the most deprived MSOA in primary care commissioning group areas that do not have an MSOA in the 16% most deprived in Hertfordshire. The map shows these 30 target areas in Hertfordshire. The following issues are of concern and have been identified as priority areas of work for these geographical areas.

Figure 1 The 30 top priority areas in Hertfordshire

North Hertfordshire

Stevenage East Hertfordshire

Dacorum District

St. Albans Welwyn Hatfield

Legend

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HMP Prison The Mount Local Authorities in Hertfordshire

! (

Prison

Broxbourne

MSOAs in Hertfordshire Other MSOAs 4 Extra Priority MSOAs for PBC Groups 25 (16%) Most Deprived MSOAs

Watford Hertsmere Three Rivers 10

10 Kilometers

Statistically higher than county averages were: • adult GP recorded obesity and smoking • obesity in 10 to 11 year olds (Year 6) • estimated adult smoking, obesity and binge drinking prevalences Statistically lower than county averages were: • 65+ year old influenza vaccination • 2 year old MMR vaccination • adult fruit and vegetable consumption and physical activity Much of this difference in life expectancy (in the short term) can be addressed by a number of simple interventions as set out in the action plan such anti-hypertensive and statin prescribing, lifestyle changes such as weight loss, alcohol reduction and smoking cessation, intensive targeting of high risk groups and promoting early uptake of services, for example early antenatal booking (see also chapter 4, Live Longer in West Hertfordshire).

appendix 1: West Hertfordshire Hospital Trust action West Hertfordshire PCT Priority 2007-2008

West Hertfordshire Hospital Trust Action and evidence 2007-2008

Improving smoking cessation services and making sure the range of services reflects the needs of areas where smoking is most common.

Smoking cessation referral letter and literature disseminated to: • Orthopaedic / # clinic • Endocrinology • Vascular • General Surgery • Chest Medicine • Ante Natal • ENT • AAU - levels 1 and 3 • Breast Surgery • A&E WGH • Pre Operative Assessment • Breast Surgery • Renal Units -WGH/SACH • Cardiology; CCU and Cardiac Rehabilitation. Recording of referrals to the Smoking Cessation Service available. Medical Staff Committee minutes reflect request to consultant body to encourage patients to quit smoking and refer them to the Smoking Cessation Service (May 2008). Awareness training regularly provided to FY1s and FY2s through the Postgraduate Medical Centre supported by the Associate Medical Director for Medical Education. Awareness presentation given to the A&E department. On-line discharge summary including a box to confirm the doctor discussed quitting smoking with the patient/referral to the Smoking Cessation Service. Increase signage around the hospital sites. Organise smoking cessation counsellors to hold a 3 hour clinic on the Watford site - on-going. Work between primary and secondary care to support staff wishing to quit smoking; train OH nurses to support colleagues and provide NRT - first tranche free of charge. Trust-wide No Smoking Policy for patients, visitors and staff being produced. NRT audit for inpatients on-going with the Chief Pharmacist - awaiting outcome. Trust supported 11 March 2009 “No Smoking Day”

Ensuring that effective strategies are in place to encourage young people not to start smoking.

Awareness training through a half day session to the Paediatric service - literature provided to the OP department at Watford. Referrals and literature specific for young pregnant women given to all midwives including the community midwives.

Developing GUM services - including introducing Chlamydia screening and prompt access to treatment.

To work with the Clinical Director of Genitourinary Medicine to support the PCT “Sexual Health Strategy”. Meeting with the GUM doctors next week to discuss the Trust’s work with the National Chlamydia Screening Programme. Sexual Health Week, 3-9 August 2009 supported by the Trust. Together with Turning Point to highlight, with literature and posters, the risks of dirty needles and Hepatitis B - screening and awareness raising. Hepatitis B vaccine offered to identified high-risk patients/on-going high-risk. For staff with a risk of Hep B or C/HIV advice - work with Occupational Health. Encourage GUM doctors to give talks to Turning Point clients. Other GUM services available: • All patients/clients attending the service are offered a baseline full screening for ST infection - symptomatic or not • HIV opportunistic screening offered • HIV post exposure prophylaxis offered • Health promotion - health advisers, outreach services, school education, “train the trainers”, school nurses, police - close links /on-going • Prevent conception services • Consultant guest speaker at a transgender trainees World’s Aid Day conference • Staff with needle stick injuries through A&E and OH - self referral • Sexual Assault - work on-going with Ante Natal midwives • On-going need for funding support to expand the outreach services, i.e. sexual education in schools Links with a number of external organisations including The Crescent and Herts Aid.

Introducing a routine and regular child health measurement programme along with improvements to screening for some childhood diseases.

Paediatric Service; All patients are weighed and measured to calculate medication. Outpatient appointments every 2-6 months so any changes would be picked up in that period. Links with health visitors and school nurses are a vital part of collaborative working. To explore a Trust-wide “children’s pathway” separate to the draft adult pathway currently being approved to work between primary and secondary care.

Increasing the number of people receiving routine and specialised interventions for alcohol misuse.

Trust works alongside Turning Point - main advisor is based in the A&E department at Watford and another located in the Urgent Care Centre at Hemel. Document entitled “Acute Medical Care Division Healthcare Commission (HCC) Target Risk Assessment Drug mis-users: information, screening and referral is available in the A&E department. The adviser works with Heronsgate ward - the Discharge Co-ordinator, Aldenham ward and Cassio ward - sisters - who will contact him if there is a patient on the ward who needs his help. Working with Turning Point to write a Alcohol and Substance Misuse Policy and review the PCT strategy - to include a referral from A&E, outpatients and inpatient services. To work with Turning Point to co-ordinate “relapse prevention groups” within the Trust.

Improving care pathways for common accidents such as hip fracture which currently lead to considerable levels of illness and death among older people.

To work with the Lead Clinician in Care of the Elderly to support the pathway within secondary work and work alongside primary care to support this group of patients.

With a particular focus on children and older people, work effectively with partner agencies to promote good health and ensure high quality services are delivered.

Representatives from the Trust attend regular meetings of the various Partnership group meetings held throughout Hertfordshire. Bi-monthly meetings of the Public Health Forum with membership from the PCT. Meetings with PCT colleagues to ensure collaborative working across all areas of the Public Health agenda.

To work with external organisations i.e. Hertfordshire Partnership Foundation Trust, Hertfordshire County Council and the PCT to support and take forward the strategy. Close on-going relationship with specialties within the Trust - Care of the Elderly - Vulnerable Adults Lead Nurse, Maternity Service and the Child Protection Named Doctor and Named Nurse appointed within the Trust. Mental Health Act 2007 Policy, draft written. Trust supports the “Mindful Employer”. Mental Health Awareness Week, “fear”, supported within the Trust, 12 to 18 April 2009 Work with a large number of colleagues within the organisation to support service improvements for patients, visitors and staff: • Macmillan Patient Information Manager • Bowel Cancer Awareness Nurse Practitioner • Lead Consultant Physician - Stroke • Clinical Director - Genitourinary Medicine • Cardiac and Stroke Rehabilitation Teams. Bowel Cancer Awareness Month - April 2009 supported Trust-wide. Stroke Awareness Day, 12 May, supported by the Trust. Help a Heart Campaign month, June 2009, recognised Trust-wide. A number of cancer awareness months and days throughout the year supported by the Trust.

n Produced by Health Promotion Hertfordshire First published December 2009 The text of this document may be reproduced without formal permission or charge for personal or in-house use. West Hertfordshire PCT Charter House Parkway Welwyn Garden City AL8 6JL Telephone: 01707 390855 Fax: 01707 390864 www.wherts-pct.nhs.uk