Sandwell Public Health Annual Report 2010-11 by Alex Hawley

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c Health

r of Publi to c e ir D e th f o rt Annual Repo /11 for Sandwell 2010

Public Health - a new asset

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Acknowledgements Editorial Team: Dr John Middleton, Director of Public Health Jyoti Atri, Deputy Director of Public Health Andrew Hood, Specialist Registrar in Public Health Shaukat Ali, Public Health Business Manager Dr Alexis Macherianakis, Consultant in Public Health Medicine Anna Hunt, Consultant in Dental Public Health Paul Southon, Public Health Development Manager Dr Patrick Saunders, Consultant in Public Health Sandwell Metropolitan Borough Council: Wendy Dale, Interim Divisional Manager - Personalisation and Service Development Ross Bailey, Senior Performance Analyst and Researcher Sandwell Primary Care Trust: Ralph Smith, Deputy Head of Information and Intelligence Enderjit Aujla, Information and Contracting Manager Greg Barbosa, Public Health Intelligence Analyst Thomas Grainger, Public Health Apprentice Nicola Howe, Public Health Analyst Trainee Nathan Lauder, Business Administration Apprentice

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Contents 4-9

1. Back where we belong - Public Health in the Local Authority

10-15

2. Are we reducing the inequalities gap?

16-21

3. Tackling inequalities is everyoneâ&#x20AC;&#x2122;s business

22-32

4. Lifestyle services for people in social care - improving health and managing demand

33-41

5. Understanding winter pressures - across health and social care boundaries

6. Building on the tradition of improving health through housing

42-51 52-56

7. Health proďŹ les for Sandwell Clinical Commissioning Groups

57-71

References/Achievements

72-74

CD and contents list

Sandwell - Director of Public Health Annual Report 2010/11

Introduction and recommendations by Dr John Middleton, Director of Public Health

Pages

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The highest law

The Victorians came to recognise the vital importance of public health, of clean water and sanitation, of housing, education and social care; despite their overriding commitment to free enterprise, they recognised that there could not be a safe and coherent society without collective provision and a safety net for the most vulnerable. Violence, squalor and disease would spill over and aﬀect the whole society in the absence of societal provision. Want, idleness, ignorance, squalor and disease were the giant evils which Beveridge later sought to tackle in his vision for the welfare state. Much later still, in the Blair years, these became recast as the ‘wicked issues’.

The health

of the

“

his quote from Cicero in the 4th century BC appears above the entrance to a Southwark council health centre building which in 1937 was one of the symbols of civic pride in health. Local authorities provided safety net cover for health before the NHS. By the same score - the picture shown below of the West Bromwich volunteer ambulance service shows how people had to organise their health services before the NHS. Public health had grown up in local authorities in the Victorian era and has a long and as distinguished a history as the institution of the local authority itself.

people is the

highest law.

Dr John Middleton Director of Public Health 4

Photo: West Bromwich Volunteer Ambulance Service (from 'Memories of the Black Country by Alton Douglas’, www.altondouglas.co.uk)

In 1989 in the first line of my first annual report I wrote, ‘It’s not who your doctor is, it’s who you vote for that most affects your health’. This was the era in which the new public health movement was being invented. The Black report had shown that despite 30 years of the NHS, inequalities in health experience and inequalities in use of health services were getting bigger between rich and poor, between the north and south of England and between social groups. The arrival of AIDS suggested that infectious disease had not been conquered. Prevention is better than cure, when there is no cure. This mantra we now know applies also to all long term illness. In 1989 there was then a local authoritys health network and a Public Health Alliance and a renewed interest in health as ‘everybody’s business’.

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Public health in the NHS

We have seen new public health workforces develop in smoking cessation and the health trainers and we have developed new tools for data management to stratify population health risks, to measure health impact and health inequalities impact, to measure illness and treatment responses in primary care. Public bodies have been performance managed on their achievements in reducing health burdens and reducing health inequalities - lay members of health service boards and local authority scrutiny committees have become as exercised by their local rates for smoking quitters and teenage pregnancy as they always have been by hospital waiting lists. Public health principles about being ‘needs led, and evidence based’ have gathered pace and been applied through all areas of the health service. And arguments about aﬀordability and eﬀectiveness are generally applied in processes of priority setting.

Bringing it all back home Most people have welcomed the move of public health back to the local authorities - or at least, not opposed it - the extent to which it would be necessary if it were not for the planned break up of the NHS is glossed over. There is much work that can be done better from a local authority base - the impact of all council policies - housing, education, economic development, environmental improvement and community safety should all be steered towards ones with maximum health beneﬁt. The old public health problems of squalor and insanitary conditions still exist. Idleness, ignorance, want are all best fought from a local authority base. Disease can best be prevented through education, environmental and economic means. Poverty is still our biggest killer. The new manifestations of the public illhealth include problems of inactivity and over consumption, of addiction, of loneliness, isolation; unhappiness and exclusion lend themselves to local authority solutions. The move to the local authority comes at a terrible time – Sandwell council is planning a 30% cut in public services by 2014. Across the country local authority budgets are being hammered, jobs axed and a new local authority culture of commissioning and outsourcing, safety net and do minimum is replacing local provision for the collective good.

Sandwell - Director of Public Health Annual Report 2010/11

After 40 years of public health in the NHS, public health is now destined to a return to the local authority. Public health has enjoyed an accelerated development during the last ten years including the work of the national support teams in helping primary care trusts and local authorities to address inequalities in their areas and increased dedicated investment through the ‘Choosing Health’ Public Health White Paper of 2004.

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A new burden? It is diﬃcult for councils to welcome public health as a new service and a new responsibility; to them, it is a ‘new burden’. ‘New burden’ is a term coined by the last government and its new burdens principles still apply. They were designed to ensure that local authorities are fully funded for new responsibilities devolved or transferred by government. There is understandable concern by councils about whether or not they will be fully funded for the public health function and on what terms and conditions public health staﬀ will transfer. It is fully understandable that councils might see public health as a new burden. But after 21 years as Director of Public Health in Sandwell I can report:

P P P P P P P P P P

rt Over 350 fewer deaths per year from hea disease cer Over 180 fewer deaths per year from can period Life expectancy for men increasing in the 2007-09 after a period of levelling g faster Life expectancy for women now increasin than nationally Epidemic measles doesn’t happen matically: Healthcare acquired infections down dra 2006-07 The MRSA super bug down – 86% since 7-08 Clostridium diﬃcile down 53% since 200 s in Increased achievement of smoking quitter iﬀ based 2010-11 following introduction of the tar provision. 6-75 Teenage pregnancy down 28% since 199 lity with fewer births per year- reducing our inequa the national rate. sed since Drug treatment access massively increa domestic 2004 with corresponding massive falls in burglary since then. the Excess winter deaths have reduced from l average in highest in region in 2006 to the nationa 2010.

Sandwell council has played a key role in achieving many of these health gains.

Civic pride In my 1995 annual public health report on crime and public health, I observed that in community surveys, people generally say the major concerns that they want something doing about are “dog shit” and “crime”. They all know someone of course who has died from cancer or a heart attack - but somehow these major health concerns never really make it on to the radar of local authority and citizen priorities. In the new public health system we will need to raise the proﬁle of health as a matter of civic pride. In the ﬁrst meeting of the new Health and Wellbeing Board, Councillor Bob Badham eloquently raised the questions of why life expectancy was better in some electoral wards than others. I welcome this and would like to see all councillors asking the questions: what is life expectancy in my ward and if it is less than Sandwell in general what are we doing about it? All Sandwell councillors should also ask: why is life expectancy less in Sandwell than for England as a whole?

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But we also have to recognise that health services can do good but they can also do harm - hospitals are more dangerous places than roads these days - health care acquired infections, treatment errors, deep vein thrombosis, pulmonary emboli, osteoporosis, bed sores – there are many major harmful effects of health services which need to be measured using population health methods, and effective methods for control and prevention need to be applied. The health service also needs to fulfil its obligations as a public health promoting body – making every contact count for lifestyle health referrals, getting people to stop smoking before their operations, incorporating lifestyle interventions into all clinical pathways and service redesigns. The NHS must have a powerful voice and resource for public health improvement.

The Oﬃce of Public Health

The government has recognised that as well as health protection and health improvement, there is a third domain of public health namely; health and social care related public health. We have been required to identify the funding committed to public health function for the health services like the ones above but also including screening management and immunisation. The local authority public health service is required to supply back to the Clinical commissioning groups public health expertise and nationally a ‘core offer’ is being worked up. What is unclear is where the government sees screening management and coordination of immunisation being done from - all the current programmes are managed by public health staff and there is no prospect of a new workforce being created. It may be beneficial for us to pursue the idea of an Office of Public Health or a Public health agency which is capable of offering public health services to the clinical commissioning groups, the proposed NHS commissioning board and the local authority.

A new asset So are we a ‘new burden’? I would urge the council to see public health as a ‘new asset’. Gro Harlem Brundtland, former Director general of the World Health Organisation attributed the South East Asian Tiger economic development to improvements in health. In the UK, Dame Carol Black’s report showed the benefits of health gain for more productive employment and for economic development. In these terrible economic times health will be an asset for: g Better learning g Better opportunities for young people g Better performance in work g Enrichment of our local economy g Enrichment of our local environment g Better social support networks and personal care Public health will be an asset for better decision making in: g Priority setting g In risk stratification - target setting g In health impact assessment/impact assessment g Health inequalities impact assessment g In intelligent use of information g In intelligent interpretation of research These are really difficult times for Sandwell in the local authority and in the health system. The public health directorate will seek to maintain the gains that have been made for the health of Sandwell people and to find ways to continue that improvement even in times where the threats to their health are being made worse. For Sandwell Council, we intend to be a New Asset. John Middleton Director of Public Health Sandwell Primary Care Trust and Sandwell Metropolitan Borough Council September 2011

Sandwell - Director of Public Health Annual Report 2010/11

A National service for health?

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Summary and recommendations by chapter:

For 6 1. Back where we belong – Public health in the local authority g

The ring-fenced budget for public health must be protected and applied to public health services which deliver maximum gains for the health of Sandwell people and most contribute to reducing health inequalities.

g g The 4% allocation should be seen as the minimum spend on health improvement, not the only spend g – further investment from local authorities and clinical commissioning groups is required to ensure people in Sandwell achieve the healthy life expectancy that other people in England enjoy.

g g Sandwell needs an Oﬃce or an Agency for Public Health, housed in the council, but capable of meeting g the needs of both the council’s People and Place themes and the clinical commissioning groups.

g g Sandwell needs to sustain its dedicated specialist public health resource to develop policy, commission g and provide services for the local community throughout the period of full transition to local authority management. A clear and early decision to move to a Sandwell based public health service will enable staﬀ to concentrate on improving public health in Sandwell. g g We will need full access to local authority and health data to inform NHS commissioning and to fulﬁl g g our obligations for the Joint Strategic Needs Assessment (JSNA) .

g g As an overall commitment to the people of Sandwell, Sandwell public health services will continue to deliver the services they provide until told to transfer them to some alternative services in the NHS or local authority or in the NHS Commissioning Board. We will not ‘drop the ball until there is someone else to pick it up’.

For 6 2. Are we reducing the inequalities gap?

g g Disability Free Life Expectancy (DFLE) information should be utilised to target social research activity in communities with the poorest DFLE to further understand their behaviour in relation to healthy lifestyles and identify strategies for promoting change. For 6 3. Tackling inequalities is everyone’s business

g g Develop evidence based parenting programmes g

Bring educational attainment in Sandwell up to the national average

Support employers with ensuring that they have a healthy workforce through lifestyle programmes and the prevention of physical and mental health problems at work

g g Ensure schools continue to take a ‘whole child’ approach including working with families in the community

g g

Provide support to people at risk of unemployment through ill health

Provide lifestyle support and health care to help people return to work after ill health

g g Ensure all partners are engaged in the development and delivery of the Friends and Neighbours g g project aim at increasing support in the community.

g g Prioritise policies that tackle both health inequalities and climate change including, increasing active travel (walking and cycling) and increasing accessibility to green spaces g g Improve the food environment for communities, including community agriculture, controlling the introduction of fast food outlets and improving the quality of fast food g

Improve energy eﬃciency of housing

g g Ensure additional funding for preventative interventions above the 4% ring-fenced budget for public g health g g Work with the NHS Commissioning Board and Clinical Commissioning Groups to identify those most g at risk of ill-health and ensure they receive appropriate preventative care g 8

Ensure that every contact with the public is used as an opportunity for health promotion

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For 6 4. Lifestyle services for people in social care – improving health and managing demand

g g g g g g

Further develop our understanding of social care clients who might beneﬁt from lifestyle interventions and how they might beneﬁt, including telephone interventions

Survey community social care clients to explore the needs/demand for lifestyle services and how and where they should be deployed Undertake a needs assessment for peripatetic postural instruction

Ensure that lifestyle assessment is a core part of the initial social services assessment

Social care staﬀ should be trained in addressing lifestyle issues with clients through the ‘Every Contact Counts’ programme The range of lifestyle services oﬀered to people in social care settings and to vulnerable adults, such as those with mental health problems or learning disabilities, should be expanded.

For 6 5. Understanding winter pressures – across the health and social care boundaries

g g Preventative interventions to reduce seasonal variations in admissions should focus on respiratory g disease and should include ensuring adequate ﬂu vaccination uptake and investment in winter warmth g g A detailed retrospective audit of case notes, tracking people across the health and social care systems is required to fully understand the reasons for the delays

g g Investigate the reasons why there is a higher proportion on women aged 85 plus using social care, than men in the same age group For 6 6. Building on the tradition of improving health through housing

g g Sandwell MBC Housing and public health should work more closely to identify those at higher risk of housing relating ill health by incorporating evidence based approaches to housing improvements CCGs should prioritise housing interventions and programmes to help reduce hospital activity and health inequalities

For 6 7. Health proﬁles for Sandwell Clinical Commissioning Groups

g g Improve recording of ethnicity and lifestyle factors such as obesity and smoking prevalence g

Further investigate estimated under recording by examining the relationship with hospital admissions, deaths and socio-demographic characteristics

g g Implement a local data sharing agreement which enables public health to present data by g practice, by electoral ward, by neighbourhoods, and by commissioning groups as well as on the Sandwell-wide basis KEY - Recommendations for:

Director of Public Health Sandwell Public Health Directorate Public Health with employers * Public Health and Adult Social Care Primary Care Black Country Cluster Strategic Health Authority Clinical Commissioning Consortia

*especially public sector employers

NHS Commissioning Boards Sandwell Metropolitan Borough Council Sandwell MBC, Housing and Partners Sandwell MBC, Education All partners, especially SWBH & SMBC Voluntary Sector Businesses SHUDU

Sandwell - Director of Public Health Annual Report 2010/11

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Introduction As part of the current reforms to the National Health Service (NHS) in England, the delivery of public health is changing dramatically1. The reforms herald a return of public health to local authorities, which many regard as ‘going home’ and as the place where the greatest impacts on health outcomes can be made. Yet public health departments have been outside of local authorities for over 30 years and the roles and responsibilities of both entities have changed signiﬁcantly in that time. In this chapter we consider some of the challenges and opportunities and how we can make the best of this move to improve and protect health and reduce inequalities.

The nominal national ring-fenced budget for public health stands at 4%. Is this enough? A previous Sandwell Director of Public Health Annual Report2 argues this should be at least 5%. We will need to invest considerably more than other areas if we are to reduce the life expectancy gap within Sandwell and between Sandwell and England. The ring-fenced budget for public health must be protected and applied to public health services which deliver maximum gains for the health of Sandwell people and most contribute to reducing health inequalities. There is concern that much of this budget will be eroded, even before it reaches the local authority. Funding for Public Health England (the proposed national organisation for public health) including the current functions of the Health Protection Agency (HPA), National Treatment Agency (NTA), Public Health Observatories (PHO) and cancer registries will be drawn from this budget. There were two previous occasions when money was handed back from local health authorities to national organisations both the HPA and the NTA collected national budgets – the amounts which then became available for local services never quite matched the amounts we had previously held locally.

We have a particular issue in Sandwell where we have a robust health protection service which has delivered massive reductions in healthcare acquired infections, reductions in tuberculosis (TB) incidence, better immunisations, better standards of decontamination, reduced genitourinary medicine (GUM) waiting times, better responses to blood borne viruses and a leading environmental public health tracking facility. We are concerned that the only health protection visible to ministers is the high profile work on national disasters like the Buncefield Fire and the Litvenyenko affair. Local accountability for health protection will remain and as such will need resourcing at a local level.

Sandwell - Director of Public Health Annual Report 2010/11

Making the best use of resources to improve health

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Sandwell MBC, as well as other local authorities all over England, will be taking on responsibility for improving health. Local authorities are currently facing unprecedented levels of cuts and there has been talk of using public health budgets to underpin council deficits. Yet the ring-fenced budget is a demonstration of the Government’s commitment to improving life expectancy and Sandwell MBC also regards this as a high level priority, as reflected in the council scorecard (a set of measures reflecting the council’s priorities). As we set out in ‘5% for health’, current public health spend is a tiny proportion of the total health service spendSandwell’s share on the latest evidence is just over £30 million. Of course we need to spend it most wisely and efficiently. The 4% allocation should be seen as the minimum spend on health improvement, not the only spend – further investment from local authorities and clinical commissioning groups is required to ensure people in Sandwell achieve the healthy life expectancy that other people in England enjoy.

With public health located in the council, efficiencies will be made through a more integrated approach. There are many areas of connection and overlap between public health and current council functions. Integration will lead to reduced duplication of effort and synergies in areas such as research and intelligence; physical activity, food and trading standards and community development. The public health department will bring to the council new expertise and experience in population measurement of risk, risk stratification, impact assessment from health and health inequalities that can be applied more widely. Our experience in carbon management and good corporate citizenship can also be of benefit to the council and our work on occupational health, knowledge management and information governance could also be applied within the council as a whole.

Increases in investment for prevention of ill health reap dividends for the commissioners as money is released from reduced hospital activity. More importantly small increments in public health spend save lives and improve health. Councils will need to decide which is more important - saving money, or saving lives? The public health department can help them to do both.

The Director of Public Health must have a strong and independent voice National interest has focussed on the independence of the Director of Public Health (DPH) to exercise judgements in the cause of achieving the best health for local people. Fulfilling this role in the interests of the people may create conflicts with other local economic and political opinions and interests. In practice, the Director of Public Health needs to exercise judgements and balance political imperatives to find the most effective approaches to improving health. The DPH has to be a corporate chief officer in order that the best advice is heard and acted upon by the council and lives are saved. This has always been the case in Sandwell and therefore national preoccupations should not be of major concern here. 12

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The distinction drawn between corporate themes of People and Place in the local authority requires public health to operate across both theme areas. The interconnections between the wider determinants of health - housing, economic development, town planning, transport, crime prevention, environmental protection and improvement, all lie in the council’s new Place Theme. Individual lifestyle choices and health services interventions lie more with the Council’s People Theme. For example, we know that an individual’s educational status will impact on where they live and the type of housing they can afford. It will also influence their lifestyle choices and both will impact on their health outcomes. In recognition of this and as recommended by the Healthy Lives, Healthy People Update paper, the DPH should report directly to the Council Chief Executive, alongside the Corporate Directors of People and Place. Sandwell needs an Office or an Agency for Public Health, housed in the council, but capable of meeting both the needs of the council’s People and Place themes and the clinical commissioning groups. There will also be a major hole if the NHS Commissioning Board is to take on screening and immunisation programmes the people who coordinate and lead this work are currently in local public health and they need to be able to continue to do this on behalf of the NHSCB. This would then be a third area of strategic relationship for the Sandwell Public Health Agency/Office of Public Health. Sandwell needs to sustain its dedicated and specialist public health resource to develop policy, commission and provide services for the local community throughout the period of full transition to local authority management. A clear and early decision to move to a Sandwell based public health service will enable staff to concentrate on improving public health in Sandwell.

Sandwell - Director of Public Health Annual Report 2010/11

An Oﬃce of Public Health

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Leaving the NHS The biggest influences on our health are outside the NHS – these include environment, education and economics - so called ‘wider determinants of health’. Addressing these wider determinants will bring the largest benefits to health outcomes, and there will be many opportunities to do this in the local authority. Yet health services, particularly primary care (GPs, dentists, pharmacists, and opticians and community health services) but also secondary care (hospitals) can bring added value. The Healthy Lives, Healthy People update paper made it clear that public health in the local authority will have a role informing healthcare commissioning. This service to Clinical Commissioning Groups (CCG) will be a ‘mandated’ (or ‘required’) service from local authority public health teams. There is a risk that being placed outside the NHS may result in a disconnection between public health and the NHS, and we will seek to ensure this does not happen in Sandwell. This is an exciting time for developing our understanding of needs in our population. We are rapidly developing our access to primary care records through the use of technology, which for the first time, opens up the potential to understanding patterns of illness within our population and not just of hospital use. We will also be able to match these records with hospital records and track patients’ journeys through the entire healthcare system. Public health in the local authority should have access to data on preventative activities, such as smoking cessation or physical activity, which can be added to these data sets and this will allow us to track the impact of participation on reducing the risk of 14

disease and hospitalisation. We could also add in social service use information, as well as other data sets currently only available in the local authority, such as housing conditions or educational attainment. The potential of these combined data sets to develop our understanding of health needs, the impact of the broader determinants on health and on which interventions work, is huge. Public health, located in the local authority, will be in a unique position to develop this understanding and inform broad strategies to improve health. We will need full access to local authority and health data to inform NHS commissioning and to fulﬁl our obligations for the Joint Strategic Needs Assessment (JSNA).

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Departure from the NHS also poses a risk to the public health workforce. We have already seen a number of public health staff with nursing qualifications return to a career in health visiting. The potential loss of NHS terms and conditions may lead to other members of the public health workforce leaving the specialty in order to retain their terms and conditions, resulting in a loss of specialist skills. Careful management of the transition and effective workforce planning will help to mitigate against these potential losses.

g The ring-fenced budget for public health must be protected and applied to public health services which deliver maximum gains for the health of Sandwell people and most contribute to reducing health inequalities.

g g g The 4% allocation should be seen as the minimum spend on health improvement, not the only spend – further investment from local authorities and clinical commissioning groups is required to ensure people in Sandwell achieve the healthy life expectancy that other people in England enjoy.

g g g Sandwell needs an Oﬃce or an Agency for Public Health, housed in the council, but capable of meeting the needs of both the council’s People and Place themes and the clinical commissioning groups. g g g Sandwell needs to sustain its dedicated specialist public health resource to develop policy, commission and provide services for the local community throughout the period of full transition to local authority management. A clear and early decision to move to a Sandwell based public health service will enable staﬀ to concentrate on improving public health in Sandwell.

g g g g We will need full access to local authority and health data to inform NHS commissioning and to fulﬁl our obligations for the Joint Strategic Needs Assessment (JSNA).

g g

Sandwell MBC

Strategic Health Authority

g g

Clinical Commissioning Consortia Director of Public Health

g g

NHS Commissioning Boards

Sandwell Public Health Directorate

Black Country Cluster

Sandwell - Director of Public Health Annual Report 2010/11

As an overall commitment to the people of Sandwell, Sandwell public health services will continue to deliver the services they provide until told to transfer them to some alternative services in the NHS, local authority or the NHS Commissioning Board. We will not ‘drop the ball until there is someone else to pick it up’.

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Are we reducing the inequalities gap? Authors: Hamira Sultan, Shamil Haroon and Andrew Hood (Specialist Registrars in Public Health) Jyoti Atri (Deputy Director of Public Health)

“

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“

Poverty remains the chief cause of disease, and it is a factor which is beyond the immediate control of medicine Henry Sigerist Social inequalities lead to health inequalities

Since the 1970s, there has been an increasing acknowledgement of the limitations of healthcare to address inequalities in health and wellbeing. The Black Report3 of the 1980s, established the relationship between social, economic and demographic characteristics and inequalities in health, subsequently corroborated by Whitehead’s report of 19874 and the Acheson report of 19985. All demonstrated that while health outcomes have improved since the introduction of the NHS and welfare beneﬁts - inequalities in health, between the most and least well oﬀ in society, have widened. The Marmot Review ‘Fair Society, Healthy Lives’6, published last year, adds to this body of evidence, demonstrating that inequalities in health are still prevalent in our society, with those living in the poorest areas, dying seven years earlier, on average, than those in the richest areas. The report places high priority on reducing this social gradient in health. These reports are particularly pertinent to Sandwell, the 12th most deprived local council area in England7, where men live nearly three and a half years less than England as a whole. In this report, we consider a set of ten indicators recommended by the Marmot review, for local authorities and health services to measure their progress on reducing health inequalities.

Sandwell - Director of Public Health Annual Report 2010/11

Health inequalities can be deﬁned as: “avoidable diﬀerences in health, wellbeing and length of life“.

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There are multiple inequalities between Sandwell and England Figure 1 shows the baseline position for Sandwell against the 10 inequality indicators selected by the Marmot team and how these compare to England as a whole. The indicators are separated into two broad categories, health outcomes and social determinants. Sandwell is signiďŹ cantly worse than England for the majority of indicators. Figure 1. The ten Marmot indicators for Sandwell compared to the rest of England (Source: London Health Observatory)

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Men and women in Sandwell still live shorter lives

Figure 2. Life expectancy at birth for males and females, Sandwell compared to England, 01-03 to 07-09 (Source: NCHOD)

Inequalities within Sandwell The Marmot Review also considers inequality in life expectancy; this reflects the difference in life expectancy between the most and least deprived areas in the borough. Based on data from 2005-2009, inequality in life expectancy remains similar for Sandwell compared to England, for both males and females. This may reflect the fact that Sandwell is fairly uniformly deprived, demonstrated by the fact that 17 of 24 electoral wards are amongst the 255 most deprived in the country. Conversely, it may reflect the fact that England as a whole is an unequal society. Nevertheless the key challenge for Sandwell is reducing inequalities between Sandwell and England.

Sandwell - Director of Public Health Annual Report 2010/11

Life expectancy provides a good summary measure for all deaths from all causes and can be used to reflect the overall health outcomes in a given area. Figures 1 and 2 illustrate that while life expectancy has improved in both England and Sandwell, life expectancy in Sandwell remains significantly lower than the national average. The gap between Sandwell and England has remained fairly stable for females (with a welcome narrowing in 2007-2009) but has actually widened for males, from 2.5 year in 2003-2005 to 3.4 years in 2007-2009. Figure 2 shows the levelling of life expectancy for men between 2003-2008. We have previously commented on this. We believe it reflects the experience of a generation of men who lost their jobs in the eighties and spent most of their lives in low paid jobs or unemployment, drinking, eating and smoking too much and developing heart disease and cancer at a premature age. The welcome increase in life expectancy in the years 2007-08 may reflect our cardiac risk management programme and better organised primary care for young men between the ages of 45-65.

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Inequalities in disability-free life expectancy within Sandwell While life expectancy provides a good summary measure for health outcomes for a population, it does not necessarily reflect quality of life. ‘Disability-free life expectancy’ (DFLE) provides a measure for how long people live without suffering any disability. It allows us to account for chronic diseases and disability within a population by measuring self-reported limitations in day to day activities, such as work, school and social activities. The level of inequality in disability-free life expectancy (1999-2003) for females in Sandwell, is not significantly different to England. However, for males, the data suggests that there is less inequality in Sandwell than for England. Again this is likely to be a reflection of universally low disability-free life expectancy across Sandwell.

This shows that Sandwell has an even spread of inequality in income,deprivation and life expectancy compared with national. But it is uniformly poor. There aren’t vast inequalities across the borough for this measure. As such, disability-free life expectancy, although a more sensitive overall indicator of quality of life, is of limited value to us. This information however could be utilised to target social research activity in communities with the poorest DFLE to further understand their behaviour in relation to healthy lifestyles and identify strategies for promoting long-term change.

Figure 3 shows Sandwell neighbourhoods (Medium Super Output Areas – MSOAs) cluster around the worse end of the spectrum for income deprivation as well as for life expectancy and disability-free life expectancy. Figure 3. Life expectancy and disability-free life expectancy at birth, by neighbourhood income level, England and Sandwell, 1999-2003 (Source for data: Marmot Review Team and ONS) (5 Sandwell MSOAs)

Sandwell demonstrates that social determinants are related to health outcomes Sandwell performs signiﬁcantly worse than England for the key social determinants deemed by the review team to have the largest impact on health inequalities (Figure 1). Sandwell’s poor life expectancy coupled with these poor outcomes on the social determinants, adds credence to the Marmot Review Team’s views on the relationship between these determinants and life expectancy in Sandwell. This is further demonstrated in Figure 4, showing the

relationship between these social determinants and life expectancy at the local authority level. For instance, we see that life expectancy increases with the percentage of children achieving a good level of development by age ﬁve and decreases with low levels of young people not in education, employment or training. It also decreases as the percentage of people on beneﬁts increases. This clearly shows how social determinants are related to health, such as life expectancy.

Public Health Annual Report 2010/11_Prt1 26/01/2012 15:09 Page 21

In the next chapter we explore the evidence base for addressing the social determinants of health and reducing inequalities, we report on actions we have already taken in Sandwell and make recommendations for future actions.

g g Disability Free Life Expectancy information should be utilised to target social research activity in communities with the poorest DFLE to further understand their behaviour in relation to healthy lifestyles and identify strategies for promoting change. g

Sandwell Public Health Directorate

Sandwell MBC

Sandwell - Director of Public Health Annual Report 2010/11

Figure 4 Scatter plots showing the relationship between life expectancy and the social determinants of health for all local authorities in England (Source for data: Marmot Review Team)

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Moving public health to the local authority will provide us with the opportunity to address the issues that can make the biggest difference to tackling inequalities. Whilst the PCT has an active programme to address the inequalities in life expectancy between Sandwell and England through the strategic plan10, and this will indeed result in improvements to life expectancy, they are largely a health service response to tackling these inequalities. In order to make a real and sustained impact on inequalities in life expectancy, we must also reduce the gap in the social determinants. We will need to do things differently and we now have that opportunity. We will be working alongside our colleagues who shape: the towns and buildings we shop, live, work and spend our leisure time in; who ensure the education of our children; who help us to find work and look after us in times of need. These are the things that will make the difference to how long and well we live. Working alongside our colleagues, public health can identify those in greatest need, we can provide the evidence for the best interventions and we can help to measure their impact. The potential to reduce inequalities is real. However this will require commitment across health, wider public services, voluntary and community groups and the commercial sector. Tackling inequality is everyone’s business. In this chapter we explore how we can make reducing inequalities a reality.

How are we addressing these inequalities in Sandwell? In addition to making recommendations on the ten inequalities indicators, as reported in the last chapter, the Marmot Teview team also recommend six key policy objectives to address inequalities: • 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 • 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 Each of the six policy objectives will now be explored in more detail, providing the evidence from the Marmot Review, progress we have already made against them and further actions we need to take. 24

Public Health Annual Report 2010/11_Prt1 26/01/2012 15:09 Page 25

Give every child the best start in life

An important factor that inﬂuences how well a child does in their education is their ability to learn, their cognitive ability. Evidence from the Marmot Review shows that those children with a high cognitive ability at 22 months but with parents of low socio economic status do less well (in terms of subsequent cognitive development) than children with low initial ability but with parents of high socioeconomic status. This is shown in Figure 1; Q refers to the child’s cognitive ability.

A child with a lower cognitive ability at 22 months but born to wealthy parents can overtake a child with a higher cognitive ability born to worse oﬀ parents. Addressing this inequality is reliant on families having access to high quality early years education. The responsibility for this sits within the local authority. Public health can provide support for local authorities to ensure that provision is evidence based, eﬀective and reaches the most vulnerable families.

Figure 1. Inequality in early cognitive development of children in the 1970 British Cohort Study, at ages 22 months to 10 years (Source: Fair Society, Healthy Lives (2010))

Sandwell - Director of Public Health Annual Report 2010/11

There is a growing body of evidence showing the importance of the first years of a child’s life. For example, a lack of appropriate stimulation and experiences during the first year can influence a child’s brain development and their subsequent cognitive development. A child from a disadvantaged family is less likely to be read to regularly, less likely to have a regular bed time and more likely to have a mother who is depressed.

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Sandwell achievements to date • The Good Start to Life programme is a partnership based programme to give all children and families the best start in life. This addresses both the health determinants such as breast feeding and maternity services and the social determinants of health such as housing. • Sandwell Council is leading an Early Intervention and Family Support programme. This provides coordinated support for the most vulnerable families. This has been identiﬁed as a partnership priority by the Health and Wellbeing Board. • A Family Nurse Partnership initiative led by health services is supporting over 100 vulnerable families with coordinated partnership support. • Developing a coordinated approach to early intervention with families with complex needs has been identiﬁed as a key priority by the new Health and Wellbeing Board.

g g Develop evidence based parenting programmes g

Sandwell Public Health Directorate

Sandwell MBC, Education

Enable all children, young people and adults to maximise their capabilities and have control over their lives Research has shown that an individual’s educational achievement is one of the best predictors of their long-term health and life expectancy11. A good education helps people to achieve their potential in life. Without this they are far less likely to have a good job, they are likely to earn less, have a shorter lifespan and spend more of their life ill or in disability. Inequalities in educational achievement mirror the inequalities in health and have proved to be as diﬃcult to tackle. 26

Figure 2. Life limiting illness rates at ages 16-74 by education level (2001) (Source: Fair Society, Healthy Lives)

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It is important to recognise that a child is part of a family and that the family has a signiﬁcant inﬂuence on educational attainment. Schools need to work with families and communities in an extended school approach if they are to contribute to tackling the social determinants of health. Education should not stop when a young person leaves full time education. Life-long learning enhances people’s ability to secure employment opportunities and improve personal well-being. This needs to be available across the social gradient, however there also needs to be targeted action to support vulnerable groups to gain literacy and other basic skills. Learning in older age is also important, it can help people stay independent for longer and improve their ability to care for their own needs.

For people of all ages, including people with long term conditions, disabilities and those who care for others, to have control over their lives they need to have the knowledge, skills and capacity to manage their own lives and their health. A good quality education will provide the basis for developing these. Local services must also be designed to support people in managing their own lives rather than creating dependence. This is a ‘self care’ based approach which builds on people’s and communities’ strengths12. This ﬁts well with the personalisation approach and individual budgets, providing people with the means to have real choice over the services they use to maintain independence and well-being.

Sandwell achievements

• There have been real successes in improving educational achievement for young people in Sandwell. There has been an improvement in the proportion of pupils who gained 5 or more A* to C GCSEs including english and maths. In 2005/06 this was 29.7%, by 2009/10 this had increased to 43.6%. This reduced the gap between Sandwell and national levels from 15.9% to 9.8%13. • A self care approach is central to Sandwell Council’s prevention strategy. Self care is being developed across council, health and third sector organisations through the Right Care Right Here programme. • Sandwell council and health services have demonstrated a joint commitment to supporting carers with joint strategy and funding for carers support programmes. Carer support is included within the council scorecard for measuring excellent council performance.

g Bring educational attainment in Sandwell up to the national average

g g Ensure schools continue to take a ‘whole child’ approach including working with families in the community

Sandwell Public Health Directorate

Sandwell MBC, Education

Sandwell - Director of Public Health Annual Report 2010/11

• Sandwell schools are working in Core Oﬀer Partnerships (CoOPs) which provide access to a wide range of services for Sandwell families.

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Create fair employment and good work for all Working is good for you; the benefits arise from the income that employment provides and from the psychological benefits that a job can bring. These include the social interactions, structure to daily life and sense of purpose that a job provides. However, having a low paid, insecure job where an individual has little control over their work can cause stress and have a detrimental effect on health14. Conversely the consequences of unemployment on health are significant. A person who is unemployed for more than a few months is more likely to experience depression. They are also more likely to have unhealthier lifestyles and are more prone to physical illness. Being unemployed can lead to poor health and poor health can lead to unemployment15. Figure 3 shows the proportion of the working age population claiming Jobseeker’s Allowance in Sandwell compared with the West Midlands and Great Britain. This shows that unemployment in Sandwell follows the national and sub-national trends but Sandwell has significantly higher levels of unemployment.

Figure 3: Job Seekers Allowance claimants 2008 to 2011 (Source: Sandwell Trends)

Sandwell achievements

• The regeneration of West Bromwich and the development of a new supermarket will provide local jobs. This regeneration has been awarded £4.2 million from the European Regional Development Fund. This includes a new British Telecom call centre which will provide 450 jobs. • Route ways to NHS and Social Care Careers, with public health in a key role, has helped 114 people into employment in the NHS and other public sector employers. • Find It In Sandwell is a council supported business development community. This provides support to local businesses in ﬁnding suppliers and customers within the local area. • Think Local is a council provided service which places more than 80 young people into work based training and 200 local people in employment in the construction industry each year. • 38 young people who were long term unemployed are now in apprenticeships in the health service. • Public Health has worked with Sandwell Council to develop the Fit for Work Pilot that provided early intervention with working people at risk of unemployment due to ill health.

g * Support employers with ensuring that they have a healthy workforce through lifestyle programmes and the prevention of physical and mental health problems at work

g Provide support to people at risk of unemployment through ill health

g Provide lifestyle support and health care to help people return to work after ill health

g 28

Public Health with employers *especially public sector employers

“

Public Health Annual Report 2010/11_Prt1 26/01/2012 15:09 Page 29

Professor Peter Townsend deﬁned poverty as;

Having resources that are so seriously below those commanded by the average individual or family that they are, in eﬀect, excluded from ordinary living patterns, customs and activities16.

Figure 4: Average weekly pay in Sandwell for all full time workers compared to the West Midlands and Great Britain (Source: ONS)

Poverty is closely linked to employment status and health. More than two ﬁfths of adults aged 45 to 64 on below average incomes have a limiting long standing illness or disability, this is more than twice the rate for those on above average income. Having a low income and debts is also related to an increase in depression and anxiety and other mental health problems17. It is possible to be in employment and still be in poverty. This can be due to a low income or from extra pressures on this income. Figure 4 shows the average pay for people in Sandwell between 2000 and 2010 compared to the West Midlands and Great Britain. This shows that the average weekly pay in Sandwell has been consistently lower than both the West Midlands and Great Britain. Since 2008 the gap has been widening with the pay in Sandwell decreasing against continued increases in other areas.

Sandwell achievements • The Welfare Rights service has helped local people claim over £40 million in additional beneﬁts over two years. • Sandwell Council and partners, including public health, have developed the Friends and Neighbours project. A community based project that builds on existing community involvement to support vulnerable residents and improve the capacity in the community to improve the neighbourhood and improve health and wellbeing.

g g g g Ensure all partners are engaged in the development and delivery of the Friends and Neighbours project Primary Care

Sandwell MBC

Voluntary Sector

Businesses

Sandwell - Director of Public Health Annual Report 2010/11

There are groups within society that are more at risk of experiencing poverty. These include disabled adults, people with mental health problems, carers, lone parents and young people. Ethnicity can also be a factor, 40% of Bangladeshi and Pakistani working couples with children are on means-tested beneﬁts compared with 8% of white families.

“

Ensure a healthy standard of living for all

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Create and develop healthy and sustainable places and communities The environment in which people are born and live, affects their health and wellbeing. Poor urban design, with poor air quality, environmental contamination and noise pollution, can affect how people feel about their area and can have an adverse effect on mental and physical health18, 19. Climate change is one of most significant public health challenges for the future and will have a disproportionate impact on the poor and vulnerable. The measures needed to minimise climate change are entirely compatible with the measures required to reduce health inequalities. These two challenges must be seen as inextricably linked and the approaches taken to tackle them together coordinated. People living in a deprived area are more likely to experience poor environmental quality. There is also growing evidence that they can be more susceptible to its effects. This is particularly relevant for Sandwell which experiences significant deprivation and has over half of its population living close to an industrial process. This was discussed in more detail in the Sandwell Annual Public Health Report for 2009/10. There is strong and developing evidence for the health benefits of green spaces. Having access to a green space is associated with lower health inequalities20. It can also play a part in tackling obesity, cardiovascular disease, mental health and antisocial behaviour21. Within Sandwell 24% of the area is green space and Sandwell Council has developed a green space strategy to make the most of these assets22.

The living environment, people’s houses, can also affect health. A cold and damp house can lead to an increase in respiratory disease and increase the risk of heart attacks and strokes. Overcrowding and poor quality housing can have a negative impact on mental health23. An individual on a low income is more likely to live in poor housing which is also energy inefficient and expensive to heat. People with a low income are therefore at a greater risk of being in fuel poverty. Alongside these direct effects, the environment can also have an indirect health impact through its influence on behaviour. The lifestyle choices people make have a major influence on their health, for example, choices about smoking, levels of physical activity and healthy eating. Over the past decade there has been considerable focus in national health policy on helping people to make healthier choices as a way to improve population health. Sandwell Healthy Urban Development Unit (SHUDU) is a partnership group with a membership that includes public health and council departments such as urban planning, transport, environmental health and community agriculture. SHUDU provides an example of how public health can engage with a wide range of council services to tackle the social determinants of health and to create environments that make healthy lifestyle choices easier.

Sandwell achievements

• Sandwell council has invested in improving the green space within the borough. Seven of Sandwell’s parks now have the Green Flag award, including the ﬁrst cemetery in the West Midlands to receive this award.

• SHUDU has been recognised nationally as an example of good practice in joint working on the social determinants of health by the Marmot Review group24, the Local Government Group25 and the Royal Town Planning Institute26.

gImprove energy eﬃciency of housing

g 30

SHUDU

Sandwell MBC

Businesses

Sandwell MBC, Housing & Partners

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Strengthen the role and impact of illhealth prevention

This role of the public sector as a major employer must also be recognised. All public sector organisations must commit to introducing policies and initiatives to improve the health of their workforce. This can include initiatives to encourage staﬀ to increase physical activity, to stop smoking and to eat a healthy diet. Examples include programmes to support staﬀ in adopting cycling and walking and to use the stairs instead of lifts. Existing programmes working with other employers from the private and voluntary sectors need to be developed. These programmes need to help these employers to ensure they have a healthy workforce.

Local residents Adrian and Patricia who featured in our “United we quit smoking” campaign December 2010.

Sandwell achievements • Through screening, 2,000 people have received treatment to reduce their risk from cardiovascular disease (CVD), 1,000 from diabetes, 500 from heart failure and 1,000 from chronic obstructive pulmonary disease (COPD). • Smoking cessations services have helped 5741 people to quit over the last 3 years • Lifestyle services have helped 19,000 people to get or keep active and 7,000 eat healthily

g g g Ensure additional funding for preventative interventions above the 4% ringfenced budget for public health

g g g Work with the NHS Commissioning Board and Clinical Commissioning Groups to identify those most at risk of ill-health and ensure they receive appropriate preventative care

g Ensure that every contact with the public is used as an opportunity for health promotion

g g Sandwell MBC g All partners, especially SWBH & SMBC

Clinical Commissioning Consortia

g NHS Commissioning Boards

Sandwell Public Health Directorate

Sandwell - Director of Public Health Annual Report 2010/11

It is important to continue to work with people to prevent ill health, to help people choose and maintain healthier lifestyles. The focus on this to date has been on health services providing health promotion and lifestyle services and this has been led by, and will continue to be led by public health. However, for this to have the largest possible impact it needs to ensure that every front line contact with the public is seen as an opportunity for ill-health prevention and health promotion. The largest number of such contacts is within local authority services. The movement of public health into the local authority therefore provides excellent opportunities to develop ill-health prevention across all relevant services.

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Discussion It is the social determinants of health that have the greatest influence on the health inequalities that exist within Sandwell and between Sandwell and the rest of England. The inter-relationships between these determinants are complex, for example the relationships between education, employment, poverty and their effects on health. These determinants act across the whole life course. What happens in the first few years of life affects an individual’s life chances through education, into employment and for the rest of their life. This has a direct impact on their physical and mental health and their life expectancy. A key message is that deprivation and poverty constrain people’s choices and opportunities. For example, the physical environment can limit the choices available for a healthy lifestyle. Choice has been a recurrent theme across national health policy for the past few years. However, having a choice is meaningless if this does not come with the opportunities to exercise it. The evidence for what will make a difference to the social determinants of health is comprehensively explored in the Marmot Review of Health Inequalities. This review shows what needs to be done at a national policy level down to local areas and communities. What is clear from this evidence is that the health service on its own can only have a very limited influence. Within the public sector it is the local authority that can have the greatest impact on the social determinants of health. Another key message is that many of the changes will take time and consistent efforts and investment across the public, voluntary and community People with higher socioeconomic position in and commercial sectors. society have a greater array of life chances and Tackling health more opportunities to lead a flourishing life. They inequalities is everyone’s business. also have better health. The two are linked: the more

“

In conclusion, a ﬁnal quote from Professor Sir Michael Marmot, author of the Marmot Review.

“

favoured people are, socially and economically, the better their health. This link between social conditions and health is not a footnote to the ‘real’ concerns with health – health care and unhealthy behaviours – it should become the main focus. Professor Sir Michael Marmot, Author of the Marmot Review, December 2010

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Lifestyle services for people in social care â&#x20AC;&#x201C; improving health and managing demand

Sandwell - Director of Public Health Annual Report 2010/11

Author: Susan Roberts (Specialist Registrar in Public Health)

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Introduction Local authority adult social services aim to support vulnerable adults. Vulnerable adults can be broadly categorised into those with learning or physical disability and those with mental health issues or drug and alcohol addictions27. There were 1.8 million social care clients in England in 2007/828. Many social service users (although not all) have long term conditions29. Long term conditions can be the cause of the disability that has lead to social service involvement or as a result of being a vulnerable adult (as described above) an individual may be at higher risk of developing long term conditions30. The relationship between social need and long term condition development can potentially lead to a downward spiral of ever increasing social and health care requirements. Conversely, a reduction in social need through intervention or proactive management of a long term condition can lead to reduced disability and social and health care requirements. Lifestyle intervention for those in social care is a potentially cost eďŹ&#x20AC;ective way of achieving this. In this chapter we aim:

1. To establish the number of people receiving social care that might beneďŹ t from lifestyle services. 2. To discuss approaches to increase uptake of lifestyle services by people receiving social care.

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Table 1 - Lifestyle services oﬀered by Sandwell Primary Care Trust

Universal 6

Domain: Physical Activity Sandwell stride

Cycling Development Walkwell (Walk Beijing to London): Walking based programme Active lifestyle*: neighbourhood activities during evenings and weekends in open spaces

Domain: Healthy Eating

Targeted Primary Prevention 6

Secondary Prevention 6

Active Sandwell: gentle exercise classes

Cardiac rehabilitation: Physical activity referral: 12 week program Includes holistic assessment (as well as physical activity) with (Exercise on Prescription) for those with signposting to other specific modifiable risk factors lifestyle interventions Physical activity referral (mental health)*: 16 week programme and one-one support Pulmonary rehabilitation: in mainstream sessions. CPN referrals Includes holistic assessment (as well as physical activity) with Walk from home: Small scale home-based signposting to other specific bespoke programme of walking for people lifestyle interventions who are housebound and at risk of falling

Grow well*: occasional sessions based on allotments and encouraging healthy eating Shop well*: tours aimed at increasing understanding of healthy eating Cook well*: 6 week health cooking course. Some clinical exclusions

Domain: Smoking Cessation Stop smoking: one-one and group interventions

Aquarius: one-one, telephone and group interventions

Domain: Integrated Multiple Intervention Services Slimwell: 20 week programme including weight management, food awareness and physical activity + ongoing advice on completion

Domain: Mental Health

Conﬁdence and well-being programme: One to one and group interventions designed to improve conﬁdence and well-being

Fab tots

Well ﬁt: Child weight management

Health trainers CVD prevention and screening: one to one assessments for those with a medium risk of developing cardiovascular risk, who have been identiﬁed by GPs, primary care CVD screening, workplaces or other community assessments

Expert patient programme

Sandwell - Director of Public Health Annual Report 2010/11

Domain: Alcohol

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There are potentially 4,000 adult social care clients who might beneďŹ t from lifestyle interventions Sandwell Council is responsible for the social well-being of its resident population. This comprises of a population of 292,800 people, of whom 234,600 are over the age of 15 years old31. Each year, approximately 5% of those aged 15 years and over require input from Sandwell Adult Social Services. In the 2009/10 ďŹ nancial year, 11,630 clients received social services provided or commissioned by Sandwell Adult Services. The majority of adults requiring social services had a physical disability (Figure 1).

Figure 1. Indications for accessing adult social care, 2009/10 (Source: SWIFT database, Sandwell MBC) N.B.Mental health ďŹ gures included in the graph are of people with mental health issues supported by social services commissioned by the Mental Health Trust and not the local authority.

Social services can be categorised into community based service and residential and nursing care. The majority of clients received community based services (Figure 2). (Source: SWIFT database, Sandwell MBC)

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Clients receiving community based services are the most likely to benefit from PCT lifestyle services as they are likely to be relatively mobile and independent. There were 10,050 Sandwell residents who received community based services during the 2009/10 financial year. Clients in a 24 hour nursing care setting are unlikely to be suitable for lifestyle intervention as their requirement for 24 hour nursing care implies a level of dependence that would make them unlikely to be able to undertake such intervention. However, they might potentially benefit from peripatetic lifestyle services in the future or from physical activity intervention provided by the home. There were 1,205 people in residential care in Sandwell during the 2009/10 financial year. There are a wide range of community based services offered by the local authorities (Figure

3). Many clients may have received more than one type of service and therefore may be doublecounted in the information displayed in Figure 4. Many clients receiving equipment or adaptations may receive more than one item of equipment and they have only been counted once as shown in Figure 4. The number of clients that may potentially be able to engage in lifestyle interventions is not clear from this information alone. Some clients that received equipment might have severe disabilities that prevent them to engage in lifestyle interventions (for example, those that are chair bound and have received hoists). However, someone that has only received a small item of equipment might beneﬁt greatly. Furthermore, a patient receiving help cleaning the house once a week is more likely to be able to engage in lifestyle intervention than a client receiving three carer visits a day to assist in all activities of daily living32.

Sandwell - Director of Public Health Annual Report 2010/11

Figure 3 Types of social care received by community - based clients in Sandwell, 2009-10 (Source: SWIFT database, Sandwell MBC)

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Of the clients receiving equipment in 2009/10, 4000 people received only one item of equipment and no further input from social services. These people might be considered to be the most able to benefit from receiving social services in Sandwell and the most likely to undertake lifestyle interventions. The 950 people that attended day care may also be suitable candidates for lifestyle interventions, however, they may well have already been accounted for by one of the other categories. In addition, some clients receiving homecare might be suitable for lifestyle interventions depending on the intensity of care they are receiving (Figure 4). Of the clients receiving home care, 241 received up to five visits of up to 2 hours duration, these clients might be considered most suitable for lifestyle intervention. Again, however, these clients might have also ordered equipment and therefore might have already been accounted for within the ‘equipment and adaptation’ numbers. We are therefore perhaps best to estimate that 4000 people receiving community based social services might benefit from lifestyle interventions. This accounts for approximately a third of those receiving adult social services in Sandwell. Figure 4. Breakdown of Sandwell adult services home care by frequency and length of visits (Source: SWIFT database, Sandwell MBC)

How can we increase the uptake of lifestyle services amongst adult social service clients? There are many potential opportunities for lifestyle interventions during a person’s progression through social services.

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Figure 5. Potential opportunities for lifestyle interventions for social service users

Client progression through social services Opportunities for lifestyle intervention

Opportunities for lifestyle intervention

24 hour nursing care 24 hour residential care Home care

Physical activity; smoking cessation

Physical activity; smoking cessation alcohol

Physical activity; smoking cessation, healthy eating, alcohol

Day care

Meals Equipment/ adaptations Physical activity; smoking cessation (healthy eating, alcohol)

Physical activity; smoking cessation (healthy eating, alcohol)

1. A person applies to social services for seat raisers to improve mobility whilst standing from a chair. Part of the application process could involve a questionnaire regarding lifestyle such as smoking/alcohol (perhaps in association with the explanation that smoking and alcohol consumption increase risk of fall-related injury). This person could be signposted to existing lifestyle services such as physical activity programmes (EXTEND/Walk from Home), stop smoking and Aquarius. 2. A person attending a day centre could perhaps be asked regarding their lifestyle on registering at the day centre for the first time. There could be posters up in the day centre advertising existing services. Physical activity interventions could be arranged in the day centre. 3. A person applying for homecare could be asked regarding their lifestyle. They might be housebound and still smoking. Smoking will be putting them at increased risk of osteoporosis and may be worsening a long term condition. They can’t attend a clinic, but they might be able to receive support over the telephone and have any necessary prescriptions sent in the post. In addition they might be overweight and healthy eating support over the telephone might also be of benefit. 4. A residential home client might have moved into a home as they are no longer able to cook for themselves and they have had previous falls. These people might be able to benefit from postural stability exercises to prevent more falls in the future.

Sandwell - Director of Public Health Annual Report 2010/11

Possible scenarios

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PCT lifestyle services cannot currently cater for those who are housebound, although they can cater for those who are sufficiently mobile to attend day centres. The use of local authority venues might increase uptake of lifestyle services by people in social care. In some cases, specific lifestyle services might not be appropriate in particular social circumstances. For example, does a person who receives meals from social services require healthy eating advice? The answer in particular cases might be yes, depending on the number of meals a day they are receiving and the reasons behind why they are unable to cook for themselves. Of the people who are housebound, some might be able to benefit from healthy eating, smoking cessation or alcohol consumption advice by telephone. People who live in residential care might be able to benefit from physical activity programmes (and to a lesser extent, smoking and alcohol advice) if they were held at their residence, but again this would depend on the specific physical or learning disability or mental health issue that lead them to require residential care. It might therefore be beneficial to contact residential care settings in order to establish an estimate of the number of residents that might benefit from a peripatetic lifestyle intervention. Sandwell PCT has a falls and bone health strategy, which calls upon a multidisciplinary effort to reduce falls and fall related injuries and has involved liaison with residential homes. Through this work, it was ascertained that although some care homes have activity coordinators, they will generally arrange seated exercise interventions, if any at all. Homes were reluctant to provide more active forms of exercise due to lack of staff members being available to prevent falls during the intervention and therefore the evidence of overall benefit is lacking. However, postural instability instruction has been a validated intervention for falls prevention. Currently there are no care homes in Sandwell that have postural instability instructors and funding into this area might be worth exploring. There are over 40 homes in Sandwell, so a peripatetic postural instructor service might not be viable. However, it might be possible to fund the training of specific members of care home staff to become postural instability instructors as an alternative33, 34.

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Finally, even more people would be able to benefit from lifestyle services if there were services that specifically catered for either physical or learning disabilities or mental health issues. Indeed Sandwell PCT already offers an integrated lifestyle intervention for people with mental health issues and this category of specialist lifestyle intervention could be expanded (Table 1). g Further develop our understanding of social care clients who might benefit from lifestyle interventions and how they might benefit, including telephone interventions

g Survey community social care clients to explore the needs/demand for lifestyle services and how and where they should be deployed g Undertake a needs assessment for peripatetic postural instruction

g Ensure that lifestyle assessment is a core part of the initial social services assessment

g Social care staﬀ should be trained in addressing lifestyle issues with clients through the ‘Every Contact Counts’ programme g The range of lifestyle services oﬀered to people in social care settings and to vulnerable adults, such as those with mental health problems or learning disabilities, should be expanded g

Public Health and Adult Social Care

Sandwell Public Health Directorate

Sandwell - Director of Public Health Annual Report 2010/11

In addition, it is imperative that cases are assessed on an individual basis, perhaps as part of a personalised care plan (personalised care plans are being actively encouraged by the Department of Health for people with long term conditions). The professionals responsible for compiling the personalised care plans therefore need to be aware of the lifestyle interventions available within the PCT and the activities they involve. There also needs to be a clear referral pathway into lifestyle services from social care in order for social services staff to be confident in signposting to lifestyle interventions. Sandwell PCT has already developed a ‘one number’ system, through which people can self-refer or be referred by their GPs to the lifestyle services and can be triaged to the most appropriate lifestyle service. This number needs to be systematically circulated amongst social service staff as well as mental health and rehabilitation (occupational therapy and physiotherapy) professionals if this is not already the case. Social care staff might not currently feel confident in addressing lifestyle issues. Indeed the NHS ‘Making Every Contact Count’ initiative is aimed at encouraging both NHS and non-NHS staff to be more confident in addressing lifestyle issues and has provided an e-training tool that might be useful for encouraging social service staff to address these issues during social service assessments35.

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Understanding winter pressures - across the health and social care boundaries Author: Jyoti Atri (Deputy Director of Public Health)

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The burden of winter Almost as predictably as the changing of the seasons, each year we see an increase in the number of deaths during the winter months (December to March), accompanied by a corresponding increase in illness manifested by increased attendance at GP surgeries and a rise in emergency admissions to hospital. Research has suggested that for every excess winter death there are 8 hospital admissions and 100 consultations with the GP36. This in turn places a burden on our social care services which provide essential support to health care services and facilitate people in staying out of, or leaving hospital at an appropriate time.

Sandwell - Director of Public Health Annual Report 2010/11

For the first time we have reviewed social care data alongside health care data for 2010/11, to better understand these seasonal changes and to highlight potential areas of collaborative action to reduce these winter burdens. This is the first step in understanding what happens across the health and social care boundaries. There is more to know and to increase our understanding we need to be able to track people across health and social care through data linkage and ideally the use of a unique identifier. This will allow us: to take stock of the range of services an individual benefits from; identify those at greatest risk of dying or needing unplanned hospital or social care services during winter and offer them preventative services and to evaluate the impact of any interventions.

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The causes of these seasonal increases are multiple and complex

In the West Midlands the largest contributors in disease terms are circulatory diseases, accounting for 1,100 excess winter deaths across the region between 2002 and 2007, followed by 927 respiratory deaths during the same period37. Influenza also plays a part in increasing winter mortality; however it is not usually recorded as the primary cause of death. The external temperature is a risk factor for excess winter deaths38, however the relationship is not straightforward, as countries with warmer winters (Portugal and Spain), have higher excess winter deaths and Scandinavian countries, with colder winters, have lower excess winter deaths. The authors of the Eurowinter study put forward potential explanations for this which include: the colder the country the more houses are designed to withstand cold and people dress more appropriately for the cold in colder countries. Demographic characteristics also have a role to play in winter deaths with female gender, older age, increasing risk of dying in winter. Lone pensioners are also at increased risk of unexpected death during the winter months39,40. No relationship between socioeconomic status and excess winters deaths has been demonstrated41. This may be because people from lower socioeconomic groups are more likely to occupy social housing which tends to be warmer than private sector or owner occupied housing. Fuel poverty (defined as more than 10% of the household income being required to maintain a comfortable level of warmth) may affect those who may be from higher socio-economic groups during retirement, as they may occupy larger, older homes that may not be energy efficient. The key role that housing has to play in excess winter deaths and morbidity, has been well documented and is summarised in the recent Marmot review commissioned by Friends of the Earth and entitled The Health Impacts of Cold Homes and Fuel Poverty42. Further to the risk factors noted above, this report also highlights the impact of cold homes: on children, who are also more likely to suffer from respiratory problems; on mental health at all ages and on existing conditions such as arthritis and rheumatism. The report also makes note of the indirect impacts of cold homes and fuel poverty including dietary opportunities and increased risk of accidents in the home. Locally we are exploring the link between improved housing conditions and health and this work is described in Chapter 6.

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Increasing pressure on health and social care services Additional to these seasonal variations, there are factors that may lead to further pressures on both health and social services, which will impact through out the year but may peak at winter time. People in Sandwell are living longer than before and this trend is predicted to continue. There are currently estimated to be 46,300 people aged 65 and over in Sandwell and this is predicted to rise to more than 58,000 people by 203043. The percentage growth in the very elderly, those aged 85 and over, is even starker. This group is predicted to increase from 6,100 in 2010 to more than 10,000 in 2030. The worsening economic environment will also impact on need during winter, rising unemployment together with forthcoming beneﬁts changes and fuel price increases will impact on people’s ability to heat their homes to an adequate standard and this will in turn lead to more illness and deaths during winter. In addition health and social care services are faced with meeting these increasing needs, with reducing budgets.

Winter deaths 2010/11

The chart below shows the number of Sandwell residents who died per month during the period where excess winter mortality is recorded (also a 5 year monthly average). The chart also shows the monthly temperature; for the months of 2010/11 and the monthly 5 year average.

Figure 1. Monthly deaths and temperature, winter 2010/11 for Sandwell PCT (Source: ONS Monthly deaths).

Sandwell - Director of Public Health Annual Report 2010/11

Despite unusually cold months in November and December, corresponding increases in monthly winter mortality were not witnessed in December and January (based on preliminary data, oﬃcial statistics are released in autumn 2012). This may be due to investment in ‘Sandwell Homes’, Sandwell’s largest social housing provider, bringing all ‘Sandwell Homes’ up to the ‘Decent Home’ standards44. The work described in Chapter 6 will explore this further.

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Seasonal variations in emergency admissions Data on emergency admissions is presented in the next series of graphs. Average admissions per day are presented to adjust for variations in the number of days in each month. Monthly breakdowns of emergency admissions to hospital show an increase in admissions, particularly in February. In line with the lower than average temperatures in the winter of 2010/11, there is a corresponding higher than average number of admissions. Figure 2. Average emergency admissions per day (Source: Provider data received via SUS)

Examinations of admissions by ICD 10 chapter groupings (a way of categorising diseases) shows more seasonal variations for certain disease groups. A breakdown of the individual diseases in the ICD -10 classiﬁcation can be found on the accompanying CD. Unsurprisingly diseases of the respiratory system show the biggest increase in the December to March period, these too were higher in 2010/11 compared to the previous 4 years. Diseases such as inﬂuenza, pneumonia, acute and chronic lower respiratory diseases and lung disease due to external agents, are included in the respiratory category. Figure 3. Average emergency admissions per day – J00-J99 diseases of the respiratory system, 2010/11 (Source: Provider data received via SUS)

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Diseases of the circulatory system (this includes heart disease and strokes) did not show a peak in the winter months and this winter, admissions were slightly lower than last 4 winters. This may be due to a downward trend in admissions for circulatory diseases. Seasonal variations in admissions for fractured femur are also expected due to the higher likelihood of falls in icy conditions. There was a peak in emergency admissions for fractured femurs in December and these were higher than the average for the last four Decembers.

Figure 4. Average emergency admissions per day â&#x20AC;&#x201C; I00-I99 Diseases of the circulatory system, 2010/11 (Source: Provider data received via SUS)

Seasonal variations in delayed transfers of care The relationship between winter pressures and delayed transfers of care is complicated. Due to the increased pressure on acute services there is an imperative need to ensure that people are discharged appropriately and in a timely fashion. However due to the increased pressure on social care services, there may not be appropriate places available to discharge people to. The data on delayed transfers of care shows an increase during late November and early December, due to delays attributable to social services, although numbers are small.

Figure 6. Delayed transfers of care for acute admissions, Sandwell and West Birmingham Hospitals NHS Trust (Source: Sandwell and West Birmingham NHS Trust)

Sandwell - Director of Public Health Annual Report 2010/11

Figure 5. Average emergency admissions per day â&#x20AC;&#x201C; S72 Fractured Femur (Source: Provider data received via SUS)

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Understanding social care use The social care data used in this report is drawn from the ‘SWIFT’ database which is used for both operational management and performance monitoring. The database does not include data on equipments used nor does it contain data relating to acute mental health activity for 1864 year olds. During the year 2010/11, there were 2536 people that started a social care service. Some of these people were already receiving social care support at the time of the new service. A number of people received more than one new service during the year and a total of 3597 services began. Analysis of referrals to social care shows that secondary care (hospitals) is the second highest source for referrals.

Seasonal variations in social service use

In line with rising demand for acute health care services during winter and the increase in delayed discharges attributable to social services during November and Figure 7. Number of social care contacts by source of referral, 2009/10 (Source: December, a corresponding ‘SWIFT’ database, Sandwell MBC) rise in new services starters might be expected. Instead the increase in new starters corresponds more with the end and start of the ﬁnancial year. A potential explanation for this is that people leaving hospital may ﬁrst go into intermediate care for several weeks and then go into social care and hence those leaving hospital in December or January, may not enter social care until March or April. Examination of new service started to facilitate hospital discharge also do not show an increase in the winter months but there is a rise in new services started to prevent hospital admission in January, February and March. There are Figure 8. Number of social care services started by month (Source: ‘SWIFT’ however small numbers in database, Sandwell MBC) these categories. 48

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Figure 9. Number of social care services started by month, to facilitate hospital discharge or prevent hospital admission

Demographic analysis of social care use and unplanned admissions

Sandwell - Director of Public Health Annual Report 2010/11

There were 6,426 people that received a care managed social care service during 2010/11 (this does not include equipment or services provided by the Mental Health Trust), accounting for 9,077 services received. Older people account for the largest client group, with numbers increasing with age. Those aged 85 plus, account for the majority of service use although they make up the smallest proportion of the population. Females outnumber male service users and this increases with age with a ratio of more than 3 to 1 in the over 85’s age groups. Whilst there are diﬀerences in the age structure between males and females in the population, with more females in the 75-84 and 85 plus categories, this does not fully account for the diﬀerences, as a higher proportion of women aged 85 plus are services users than men in the same age group. One possible explanation for this is that elderly women are more likely to be living alone as they are more likely to outlive their male partners. This requires further investigation.

Figure 10. Percentage of population that are service users by age and sex (Source: ‘SWIFT’ database, Sandwell MBC)

In total 48% of unplanned admissions in those aged 65-74, 52% in those aged 75-84 and 64% in those aged 85 and above, are attributable to women. This variation in unplanned admissions by gender is a reflection of gender differences in these age groups in the population. There are large gender differences, which increase with age, in the rate of admissions for respiratory and circulatory diseases, with males showing much higher rates. With males having lower numbers but higher rates of admissions at older age, the full reasons for the large gap between males and females in social care, remain unclear. 49

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Table 1. Rates (percent) of age sex speciﬁc non elective admissions by cause, 2010/2011

A00-B99

ICD Chapter name Certain infectious and parasitic diseases

D50-D89

Diseases of the blood and blood-forming organs …

C00-D48 E00-E90 F00-F99

G00-G99 H00-H59 H60-H95 I00-I99

J00-J99

K00-K93 L00-L99

Neoplasms

Endocrine, nutritional and metabolic diseases Mental and behavioural disorders Diseases of the nervous system

Diseases of the eye and adnexa

Diseases of the ear and mastoid process Diseases of the circulatory system

Diseases of the respiratory system Diseases of the digestive system

Diseases of the skin and subcutaneous tissue

Females

65-74 75-84 85+ 0.2 0.3 0.7 0.4

0.7

0.8

0.5

0.9

1.3

0.3 0.3 0.3 0.1 0.1 2.2 2.3 1.8 0.5

M00-M99 Diseases of the musculoskeletal system and connective 1.0 tissue

0.3 0.7 0.7 0.1 0.0 4.2 4.5 2.6 0.9 1.5

0.7 1.2 0.7 0.0 0.0 8.7 8.4 5.8 1.6 2.7

Males

65-74 75-84 85+ 0.2 0.4 0.8 0.7

1.3

0.6

0.9

1.2

0.3 0.3 0.5 0.1 0.0 3.2 2.8 1.9 0.4 0.7

0.4 0.8 1.0 0.2 0.0 6.2 6.5 3.6 0.8 1.7

0.8 1.2 1.1 0.2 0.0

10.0 12.8 4.8 1.2 2.6

N00-N99

Diseases of the genitourinary system

0.9

2.1

5.2

1.0

2.4

7.4

S00-T98

Injury, poisoning and certain other consequences of external causes

1.7

3.7

9.2

1.7

3.4

7.7

0.0

(blank)

0.0

0.1

0.0

0.1

0.3

R00-R99

Z00-Z99 (blank)

Symptoms, signs and abnormal clinical and laboratory 4.0 ﬁndings… Factors inﬂuencing health status and contact with health services

6.4

12.2

4.7

10.1

14.8

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Conclusions This year there has been low excess winter mortality, despite a harsh winter. However we see a higher rate of admission, compared with the average for the last four year. This may have resulted in a higher burden on social care last winter. Contrary to historical, regional evidence, in Sandwell for 2010/11, diseases of the respiratory system are the biggest cause of seasonal variations in emergency admissions, and circulatory diseases did not show seasonal variation. Although the numbers are smaller the rate of admissions in those over 85 is much higher for men. Preventative interventions to reduce seasonal variations in admissions should focus on respiratory disease and should include ensuring adequate ﬂu vaccination uptake and winter warmth for those as high risk of winter admissions and death. Secondary care is one of the largest sources of referral to social services. Facilitating hospital discharge and preventing hospital admission form a large part of the reasons for why people start receiving social care services. Whilst there was a winter increase in the number of delayed transfers of care attributable to social care, there was no corresponding increase in the number of new starters to social care. This requires further investigation and a detailed retrospective audit of case notes, tracking people across the health and social care systems.

Sharing of data at the individual level data is required in order to develop our understanding of ﬂows across health and social care boundaries.

g g g Preventative interventions to reduce seasonal variations in admissions should focus on respiratory disease and should include ensuring adequate ﬂu vaccination uptake and investment in winter warmth g g A detailed retrospective audit of case notes, tracking people across the health and social care systems is required to fully understand the reasons for the delays g g Investigate the reasons why there is a higher proportion on women aged 85 plus using social care, than men in the same age group g g

Sandwell MBC

Sandwell Public Health Directorate

Primary Care

Sandwell MBC Housing & Partners g Public Health and Adult Social Care

Sandwell - Director of Public Health Annual Report 2010/11

Demographic analysis of social care use shows an in increase in service use with age, and a disproportionate number of female service users, particularly in the 85 plus age group. This cannot fully be accounted for by structural age diﬀerences between males and females or by variations in unplanned admissions by gender. This may be due to the fact that elderly women are more likely to be living alone as they are more likely to outlive their male partners. This warrants further investigation and may lead to recommendations for preventative actions.

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Building on the tradition of improving health through housing Author: Dr Carl GriďŹ&#x192;n (Consultant in Public Health)

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A home is more than just a building or a dwelling with walls, windows and a roof. It provides shelter, security, provides an opportunity to build and support a family; provides a link with and is embedded within a community, and is a place for friends and family to visit. Unfortunately, as well as being protective and health promoting, a home and neighbourhood can have a detrimental impact on physical health and mental wellbeing. Recent National Institute for Health and Clinical Excellence guidance on Housing and Public Health (2005 p1) summarised the way poor housing can lead to poor health into four areas. These are: • Indoor environment including indoor pollutants (eg. asbestos, carbon monoxide, radon, lead, moulds and volatile organic chemicals). • Cold and damp, housing design or layout, infestation, hazardous internal structures or ﬁxtures, noise • Overcrowding, sleep deprivation, neighbourhood quality, infrastructure deprivation including availability and access to services, neighbourhood safety, and social cohesion • Access to housing (homelessness), housing tenure, housing investment, and urban planning. This review also pointed to the lack of good quality research evidence demonstrating causal pathways between housing investment and health improvement (NICE 2005). This problem has been highlighted before (see Thomson et al 2001) and a reason for this can be found in the methods used to evaluate housing improvements on health outcomes. In this chapter we will explore and describe some of the ways that health and housing colleagues can work together to provide more robust local evidence highlighting the value of decent housing and how this evidence can help inform housing policy in Sandwell.

The current state of our homes In order to fully understand the impact of housing on health we need to understand the condition of the housing stock in Sandwell. One useful source of Local Authority commissioned information comes from the Housing Stock Condition survey. This can be used to estimate and describe housing by tenure (e.g. privately owned, Sandwell Homes or housing association), age, construction and household. In terms of households, the most recent survey (2009) estimates that: • 40% (n=35,805) households classed as vulnerable elderly, children, long term sick or disabled • 24% (n=21,591) households have a disabled occupant • 67% (n=60,276) of households had income <£15,000 pa • 15% (n=13,494) households in fuel poverty (spending more than 10% of the household income on heating) • 30% (n=26,989) of households from Black and Minority Ethnic background • 31% (n≈27,917) householders are aged over 65 These data are important as they enable housing colleagues to prioritise investment and identify those groups of people who are in greatest need of home improvements. However, while these data can provide very useful information in their own right, there are opportunities to begin to link housing and health data together to maximise their utility. In Sandwell we are part of the Collaborations for Leadership in Applied Health Research and Care (CLAHRC) programme. This is a signiﬁcant national research programme and the Sandwell’s Director of Public Health is leading on one research theme which aims to quantify the impact of housing improvement on health outcomes.

Sandwell - Director of Public Health Annual Report 2010/11

A safe place

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Linking housing and health information One key element of the CLAHRC research programme has been to develop a method of linking local authority housing data with NHS health outcomes data in order to understand the impact on housing on the health of residents. The first worked example of this method, using infant mortality as a health indicator is described below. This first example uses housing datasets provided by Sandwell MBC and health datasets on birth and deaths in Sandwell from the Office of National Statistics. The housing datasets contain information on housing tenure and address. The latter is very important as it is used to identify the geography of each home and the unique property reference number (UPRN) which is the key to linking housing tenure and health data. Table 1 shows birth data 2005-7 for the six towns in Sandwell.

Table 1 – Births by Town – 2005-2007 Town

Number of Births

% Births

Rowley Regis

2138

Tipton

West Bromwich Oldbury

Wednesbury Smethwick

Not known

Total Births

1803 3040

1907

1371

2843

643

13745

Table 2 Table 2 provides Tenure Number of Births % Births preliminary data on housing tenure and infant births and deaths in Sandwell. The data indicates Private home 8775 64 that rates of infant Council home 2767 20 mortality vary by RSL home 353 3 housing tenure. We believe that the rates Tenure not known 1850 13 in council homes are Total Number of live births 13745 100 low partly because of the good condition of RSL=Residential social landlord, Council=Sandwell Homes ‘Sandwell Homes’. The high rates observed in RSL homes are diﬃcult to interpret because the numbers of births and deaths are small and because of other factors that increase risk of infant mortality such as smoking, ethnicity and poverty. This data is provisional and further work is required but they do indicate how housing and health data can be combined to help plan and prioritise access in health services. Using a UPRN to link information across housing and health datasets provides a real opportunity to analyse the impact of housing on health. The success of this approach is based on sharing accurate address information and in the future it is crucial that we maintain access to health and housing data for us to build detailed proﬁles on key housing and health indicators. 54

100

Infant mortality rate (per 1000) 7.6 6.1

14.2 -

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Does improving housing, improve health? As well as working with housing colleagues from Sandwell Metropolitan Borough Council we are working in partnership with colleagues from Sandwell Homes to evaluate the impact of implementing the Decent Homes investment and improvement programme. In Sandwell an estimated 29% (n=26,373) homes are non-decent (Stock Condition survey 2009). Figures 1 and 2 show the reasons for homes failing the Decent Standard (e.g. standard of general repair - external walls, roof structure and covering, windows and doors, chimneys, central heating boilers, gas ﬁres, storage heaters, electrics) and also the most common type of conditions that residents will experience (eg cold). Figure 1: Reasons for failing the Decent Homes Standard

The project with Sandwell Homes is looking at the impact of housing improvements and investment undertaken since 2004 to bring all social housing up to the Decent Standard. This project will involve academic partners as part of our CLAHRC research programme and will provide evidence on the effectiveness and costeffectiveness of the programme. The benefits of this are two fold. Firstly we will be able to provide evidence on the impact of all of the independent components of the Decent Homes programme on the health of tenants and secondly we will be able to help Sandwell Homes identify how future investment can be targeted to ensure it has the maximum benefit to the most vulnerable residents. This is only a brief description of some of the areas of joint working. There are other priority areas such as reducing fuel poverty or winter deaths that also require data sharing, setting joint priorities for commissioning services and evaluation that cut across both housing and health boundaries. It is programmes like this that require strong and secure collaboration between both the NHS and the Local Authority in order to ensure they have the most impact for residents in Sandwell.

Sandwell - Director of Public Health Annual Report 2010/11

Figure 2: Health and Housing safety rating failures Source: Housing Health and Safety Rating System

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Building on this for the future In Sandwell, we have a long and successful history of effective joint working with housing professionals within the Local Authority. The changes in the NHS and the plan to reconfigure health organisations, health services and in particular, transferring NHS public health to SMBC will offer both opportunities and risks to successful joint working in the future. It is clear that the relationship between poor housing and health is a complex one and it is very difficult to disentangle the impact of housing from other forms of deprivation and inequality (NICE 2005). This is precisely why health professionals must not only continue to work with housing colleagues but also maintain and secure links within the NHS. Finally, we have described some projects and highlighted the value and the contribution that working together can offer. We believe that targeted housing investment will contribute to health improvement but we need to work systematically together to build the evidence to support investment in priority areas such as fuel poverty or reducing excess winter deaths. Clearly, there is still a long way to go and while transferring NHS public health to the Local Authority will provide opportunities, this transfer also presents risks that need to be acknowledged and addressed.

g g Sandwell MBC Housing and public health should work more closely to identify those at higher risk of housing relating ill health by incorporating evidence based approaches to housing improvements

g CCGs should prioritise housing interventions and programmes to help reduce hospital activity and health inequalities g 56

Clinical Commissioning Consortia

Sandwell Public Health Directorate

Sandwell MBC Housing & Partners

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Health proďŹ les for Sandwell Clinical Commissioning Groups

Authors: Andrew Hood (Specialty Registrar in Public Health) Dr Alexis Macherianakis (Consultant in Public Health Medicine)

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Introduction and Background

There is a wealth of data and information on populations within primary care, their sociodemographic circumstances and their health status and lifestyle behaviours. However, this information is often hard to retrieve, is held within diﬀerent local and national systems and is not commonly collated in order to provide an overall picture of health at practice level. Given the future requirement of general practices to collaborate as Clinical Commissioning Groups (CCGs) to commission services for their combined populations, there is a need for baseline measurement of the characteristics and health status of their populations.

Sources of data used and methods

Data used in the production of the full profiles was taken from both local and national sources. Local data from primary care records extracted from the MSDi system and Open Exeter (NHAIS) was used to describe the key demographic characteristics. Information from the national QOF returns and published by the NHS information centre45 was used to review the recorded prevalence of long-term conditions, and both of these were drawn upon for lifestyle information. Data was aggregated up from practice level to CCG level using of-the-time practice to CCG reference tables. The membership of CCGs has yet to be formally agreed by the NHS Commissioning Board and Department of Health and is liable to change; therefore the information contained within the profiles may need revising and updating as necessary. Here we provide a summary of the profiles for the three main consortia in Sandwell:

• HealthWorks CCG • Sandwell Health Alliance CCG • Black Country CCG 58

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Sandwell - Director of Public Health Annual Report 2010/11

Figure 1. Map showing geographical distribution of practices by CCG

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Key Messages for HealthWorks CCG • With over 150,000 patients, HealthWorks is the largest of Sandwell CCGs although 30% of patients are registered to GPs currently commissioned by Heart of Birmingham PCT. • There are larger numbers of younger adults (aged 20-44) being served by the practices than average, having resource implications on child health and maternity services. • Above Sandwell average levels of patients within the CCG smoke or are obese, increasing their likelihood of developing heart disease or other long-term conditions in the future. • The most disproportionately high disease registers at CCG practices are those for mental health, dementia and learning disabilities.

Key Messages for Black Country CCG: • The smallest of the Sandwell CCGs, the group is responsible for just under 110,000 patients and has 19 practice members. • Given the demographic shift to an older population, there is likely to be an increase over time in the prevalence of age-related long-term conditions such as heart failure, cancer, stroke, dementia and also the increased need for palliative care. • Above Sandwell average levels of patients within the CCG smoke or are obese, increasing their likelihood of developing heart disease or other long-term conditions in the future. • Patients in the Black Country CCG on the whole experience higher levels of COPD, Cancer, Heart Failure, CKD, Atrial Fibrillation and Obesity than patients in the borough as a whole.

Key Messages for Sandwell Health Alliance CCG: • Sandwell Health Alliance (SHA) and its 29 constituent practices are responsible for 112,000 patients. • On the whole, the population is younger than average for both males and females and has the most ethnic diversity of the Sandwell CCGs. • Above Sandwell average levels of patients within the CCG smoke or are obese, increasing their likelihood of developing heart disease or other long-term conditions in the future. • Due in part to the younger population, but also perhaps to “under-diagnosis”, the patients registered to SHA practices generally have lower prevalence of most long-term conditions than average for Sandwell.

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Opportunities for case-ﬁnding of people with long-term conditions Predictive modelling of disease prevalence based on population factors (age, gender, ethnicity and deprivation) and prevalence studies can be a useful way of indicating where there are potential gaps in identifying patients with conditions that have not yet been diagnosed. People with genuine but undiagnosed disease may be missing out on preventative care and treatment.

Figure 2. Number and % of “missed” patients in Sandwell by disease group, 2008/09 (Source: NHS comparators, NHS information Centre).

This information suggests that in Sandwell (2008/09 data) in absolute terms there may be tens of thousands of obese, hypertensive or obese and hypertensive patients who have not yet been formally classified or diagnosed. There are also substantial numbers of people with potential kidney disease, asthma, COPD and CHD who fit the same definition.

Sandwell - Director of Public Health Annual Report 2010/11

NHS comparators (NHS information Centre) use models produced by several research units46,47,48,49 to estimate the number of potential “missed” patients for every practice and PCT. Despite their robust design and input of detailed local data, there are still questions about the accuracy and reliability of the underlying prevalence data that these models are based on, thus the output. Some data is selfreported by patients, therefore subject to recall bias and other data is taken from out-of-date studies or studies that are not really applicable to the general population. Never the less, they provide us with a good starting point to investigate potential gaps. The following ﬁgure shows the position for Sandwell PCT as a whole.

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HealthWorks CCG health proďŹ le

Commissioning group structure

As at February 2011, the commissioning group was made up of 23 practices. 14 of these were within the Sandwell PCT boundary, and 9 were within the Heart of Birmingham (HoB) PCT area. In total, the group is responsible for 151,181 patients.

Demographics

Patients registered to the Sandwell practices in this CCG have a fairly even spread of population by gender and across the age groups, however patients at the HoB practices predominate in the younger working-age and child-rearing age groups (between 20 and 39 years). This may have implications for maternity and child-health services. Ethnicity is recorded for around 65% of patients registered to HealthWorks CCG practices. Although there are slight variations across ethnic groups between Sandwell and HoB practices, overall the white population forms a minority of patients (47%) compared to a majority (77%) for Sandwell as a whole. The Black and Minority Ethnic (BME) patients are largely of Indian, Black Caribbean and Pakistani origin.

Table 1: Health Works patient ethnicity

Ethnicity White

Indian Other

Pakistani

Black Caribbean Black African Mixed

Bangladeshi

Total recorded Not recorded

Figure 3. Age distribution of HealthWorks patients by PCT area (Source: Exeter System and PAR data, 2010).

Health Works Number*

HealthWorks % (of recorded)

Sandwell PCT % ** HoB PCT % (of recorded)*

16,519

46,286 4,232 6,502 8,646 4,134 3,037 2,303

98,504 52,677

47 11 7 9 4 3 2

3 3 1 2 1

13 21 9 3 4 6

*Source: MSDi and Graphnet extraction, March 2011 ** Source: ONS 2006 mid-year estimate 62

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Lifestyles Data completeness is an issue again with regard to capturing lifestyle information. Only 54% of patients registered to a Health Works practice have their smoking status recorded, meaning wide margins of error when measuring the prevalence. Of those adults (aged 16 and over) that have been asked whether they smoke, 26% conďŹ rmed they do. If this were true for the entire population of the CCG, then around 31,000 adults would smoke and would therefore be candidates for brief interventions around smoking cessation or referral to specialist stop smoking advisors. The prevalence is markedly higher than comparable estimates for England as a whole with only 5/23 practices having lower than average levels.

According to records submitted for the Quality Outcomes Framework (QOF) almost 15,000 (11.3%) Health Works patients are clinically obese i.e. have BMI of over 30. Many of these are likely to have existing additional long-term conditions. This compares to 10% nationally and both are likely to be underestimates of the true prevalence. Modelled estimates for obesity, suggest there may be an additional 7,000 people at Health Works practices that might be obese but have not yet been measured for BMI.

Disease prevalence

Health Works CCG, on the whole, has higher recorded levels of mental health, dementia and learning disabilities than patients in the borough as a whole, but lower recorded levels of COPD, heart failure and atrial ďŹ brillation. Ascertainment of COPD may be an issue given the much lower than expected prevalence in practices in Health Works.

Sandwell - Director of Public Health Annual Report 2010/11

Obesity

Public Health Annual Report 2010/11_Prt3 26/01/2012 15:52 Page 12

Table 2. Recorded prevalence of long-term conditions in HealthWorks patients, 2009/10

Disease

Coronary Heart Disease Stroke or TIA Hypertension Diabetes (Type 2) COPD Epilepsy Hypothyroidism Cancer Mental Health Asthma Heart Failure Heart Failure (due to LVD) Palliative Care Dementia Depression Chronic Kidney Disease Atrial Fibrillation Obesity Learning Disabilities Smoking

HealthWorks CCG patients on register 4356 2169 19791 7312 1954 834 4594 1520 1347 8560 1081 647 198 690 10394 4394 1618 14919 572 32061

HealthWorks CCG Prevalence 3.29 1.64 14.94 5.52 1.47 0.63 3.47 1.15 1.02 6.46 0.82 0.49 0.15 0.52 7.84 3.32 1.22 11.26 0.43 24.20

Sandwell PCT Prevalence 3.63 1.64 15.25 5.16 1.73 0.63 3.52 1.17 0.76 6.31 0.91 0.48 0.14 0.45 7.85 3.57 1.34 10.81 0.34 24.61

Figure 4. DiďŹ&#x20AC;erence in expected and observed disease prevalence, selected diseases, 2009/10 (Source: NHS Information Centre, QMAS, QOF, 2009/10).

Public Health Annual Report 2010/11_Prt3 26/01/2012 15:52 Page 13

Black Country CCG health proﬁle

Commissioning group structure As at February 2011 the commissioning group was made up of 19 practices and were responsible for 109,000 patients. The group is the smallest of Sandwell’s 3 CCG’s.

Demographics

Ethnicity is recorded for around 69% of patients registered to Black Country CCG practices. With over 8 in every 10 patients, the population is predominantly white. Only the Indian and Pakistani population are represented in large numbers (>1000) in this commissioning group. This ethnic composition may be reﬂected in the proﬁle of long-term conditions, some of which, such as Diabetes, are more prevalent in minority ethnic groups than in the white population50.

Figure 5. Age distribution of Black Country CCG patients by PCT area (Source: Exeter System and PAR data, 2010).

Table 3: Black Country CCG patient ethnicity

Ethnicity

BC CCG Number

BC CCG %

BC CCG wards* %

Sandwell** %

White 50930 83.3 86.1 77.4 Indian 2807 4.6 5.8 9.4 Pakistani 2335 3.8 2.3 3.4 Other 1711 2.8 1.1 2.3 Bangladeshi 1075 1.8 0.8 1.4 Mixed 980 1.6 1.5 2.1 Black Caribbean 693 1.1 2.2 3.4 Black African 594 1.0 0.1 0.6 Total recorded 61,125 Not recorded 39468 * This percentage represents the wards that BC CCG patients reside in – Source: 2001 Census ** Source: ONS 2006 mid-year estimate

Sandwell - Director of Public Health Annual Report 2010/11

Patients registered to GPs in this CCG have a fairly even spread of population by gender and across the age groups. As expected from national patterns, there are a larger proportion of older females than males. Given the demographic shift to an older population, there is likely to be an increase in the prevalence of age-related long-term conditions such as heart failure, cancer, stroke, dementia and also the increased need for palliative care.

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Lifestyles Data completeness is an issue with regard to capturing lifestyle information. Fewer than 50% of patients registered to a BC CCG practice have their smoking status recorded, meaning wide margins of error when measuring the prevalence. Of those adults (aged 16 and over) that have been asked whether they smoke, 28% conďŹ rmed they do. If this were true for the entire population of the CCG, then around 23,000 adults would smoke and therefore be candidates for brief interventions around smoking cessation or referral to specialist stop smoking advisors. The prevalence, although marginally lower than the Sandwell average, is markedly higher than comparable estimates for England as a whole with no practices having lower than national average levels.

Obesity

According to records submitted for the Quality Outcomes Framework (QOF) almost 13,000 (12.6%) of Black Country CCG patients are clinically obese i.e. have BMI of over 30. Many of these are likely to have existing additional longterm conditions. This compares to 10% nationally and both are likely to be underestimates of true prevalence. Modelled estimates for obesity, suggest there may be an additional 6,000 people at Black Country CCG practices who might be obese but have not yet been routinely measured or had an adverse health event that meant they were measured for BMI.

Disease prevalence

Black Country CCG on the whole has higher levels of recorded COPD, cancer, heart failure, CKD, atrial ďŹ brillation and obesity than patients in the borough as a whole, but lower levels of hypertension, mental health and palliative care. Overall BC CCG has a smaller estimated under recording of disease when compared to Sandwell and England, except for stroke and dementia. 66

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Table 4. Recorded prevalence of long-term conditions in Black Country CCG patients, 2009/10

Coronary Heart Disease Stroke or TIA

Hypertension

Diabetes (Type 2) COPD

Epilepsy

Hypothyroidism Cancer

Mental Health Asthma

Heart Failure

Black Country CCG patients on register

Black Country CCG Prevalence

Sandwell PCT Prevalence

1879

1.78

1.64

4038

15659 5395 2187 713

3781 1369 686

7005 1118

Heart Failure (due to LVD) 587 Palliative Care

136

Depression

8461

Dementia

Chronic Kidney Disease Atrial Fibrillation Obesity

Learning Disabilities Smoking

461

4220 1639

13307 368

26364

3.82

3.63

14.80

15.25

5.10 2.07 0.67 3.57 1.29 0.65 6.62 1.06 0.55 0.13 0.44 8.00 3.99 1.55

12.58 0.35

24.92

5.16 1.73 0.63 3.52 1.17 0.76 6.31 0.91 0.48 0.14 0.45 7.85 3.57 1.34

10.81 0.34

24.61

Sandwell - Director of Public Health Annual Report 2010/11

Disease

Figure 6. DiďŹ&#x20AC;erence in prevalence of CCG and Sandwell PCT patients, 2009/10 (Source: NHS Information Centre, QMAS, QOF, 2009/10)

Public Health Annual Report 2010/11_Prt3 26/01/2012 15:52 Page 16

Sandwell Health Alliance CCG health proﬁle Commissioning group structure

As at February 2011, the commissioning group was made up of 29 practices. With a relatively small overall population (112,000) this CCG has the lowest average list size per practice in Sandwell of fewer than 3,900.

Demographics

Patients registered to the practices in this CCG have a fairly even spread of population by gender and across the age groups. On the whole though, the CCG population is slightly younger than average for the borough for both males and females. This may have implications for maternity and child-health services, and given current unemployment trends the same patients and families may be accessing welfare and social care support. Ethnicity is recorded for relatively few (43%) of patients registered to the SHA CCG practices leading to wide margins of error in estimating population %’s. Of those recorded for ethnicity, just under 2/3 of the CCG registered population is of ‘white’ origin compared to almost 80% for Sandwell as a whole. The CCG has signiﬁcant numbers of Indian patients, and also large populations from the other BME groups – Pakistani, Black Caribbean, Bangladeshi and Black African. SHA is probably the most ethnically diverse CCG in Sandwell. Figure 7. Age distribution of Sandwell Health Alliance patients and Sandwell PCT (Source: Exeter System and PAR data 2010).

Table 5: Sandwell Health Alliance patient ethnicity

Ethnicity SHA Number* SHA % White 96566 63.7 Indian 21268 14.0 Other 9687 6.4 Pakistani 8503 5.6 Black Caribbean 4811 3.2 Bangladeshi 3827 2.5 Black African 3589 2.4 Mixed 3310 2.2 Total recorded 151561 100 Not recorded *Source: MSDi extraction February 2011 ** Source: ONS 2006 mid year estimate

Sandwell** % 77.40 9.44 2.31 3.35 3.36 1.42 0.61 2.11 100

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Lifestyles Data completeness is an issue with regard to capturing lifestyle information. Only 47% of patients registered to a SHA practice have their smoking status recorded, meaning wide margins of error when measuring the prevalence. Of those adults (aged 16 and over) that have been asked whether they smoke, 28% conďŹ rmed they do. If this were true for the entire population of the CCG, then around 26,000 adults would smoke, therefore be candidates for brief interventions around smoking cessation or referral to specialist stop smoking advisors. The prevalence is markedly higher than comparable estimates for England as a whole with only 3/29 practices having lower than average levels.

Obesity

Modelled estimates for obesity, suggest there may be an additional 7,000 people at Health Works practices that might be obese but have not yet been routinely measured or had an adverse health event that meant they were measured for BMI.

Disease prevalence

Patients in the Sandwell Health Alliance CCG on the whole experience lower levels or recording for most long-term conditions than the borough as a whole, in part likely to be related to the younger population. Only diabetes, mental health and palliative care registers appear to be higher than average. Estimates of disease prevalence indicate a high level of under recording of COPD and stroke. As the risk of these diseases increases at older ages, these statistics may also be distorted by the younger population of this consortium.

Sandwell - Director of Public Health Annual Report 2010/11

According to records submitted for the Quality Outcomes Framework (QOF) almost 11,000 (9.5%) SHA patients are clinically obese i.e. have BMI of over 30. Many of these are likely to have existing additional long-term conditions. This compares favourably to national levels of 10% although both are likely to be underestimates of true prevalence.

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Table 6. Recorded prevalence of long-term conditions in SHA patients, 2009/10

Disease Coronary Heart Disease Stroke or TIA

Hypertension

Diabetes (Type 2) COPD

Epilepsy

Hypothyroidism Cancer

Mental Health Asthma

Heart Failure

Health Works CCG patients on register

Health Works CCG Prevalence

Sandwell PCT Prevalence

1499

1.33

1.64

3960

17242 5892 1714 647

3623 1057 911

6628 891

Heart Failure (due to LVD) 427 Palliative Care

164

Depression

8793

Dementia

Chronic Kidney Disease Atrial Fibrillation Obesity

Learning Disabilities Smoking

397

3702 1177

10696 359

27162

3.50

3.63

15.26

15.25

5.21 1.52 0.57 3.21 0.94 0.81 5.87 0.79 0.38 0.15 0.35 7.78 3.28 1.04 9.47 0.32

24.04

Figure 8. DiďŹ&#x20AC;erence in prevalence of CCG and Sandwell PCT patients, 2009/10 (Source: NHS Information Centre, QMAS, QOF, 2009/10)

5.16 1.73 0.63 3.52 1.17 0.76 6.31 0.91 0.48 0.14 0.45 7.85 3.57 1.34

10.81 0.34

24.61

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Next steps These proďŹ les represent the ďŹ rst steps in describing CCG populations and their needs. Our understanding of needs at the CCG level could be further developed through improved recording of ethnicity and of lifestyle measures.

g g Improve recording of ethnicity and lifestyle factors such as obesity and smoking prevalence

g Further investigate estimated under recording by examining the relationship with hospital admissions, deaths and socio-demographic characteristics

g g g Implement a local data sharing agreement which enables public health to present data by practice, by electoral ward, by neighbourhoods, and by commissioning groups as well as on the Sandwellwide basis

Clinical Commissioning Consortia

Sandwell Public Health Directorate

NHS Commissioning Boards

Sandwell MBC

Sandwell - Director of Public Health Annual Report 2010/11

The estimated under recording of disease presented here requires further investigation. We can compare the estimated under recording, at a practice level, with admissions to hospital and deaths for under recorded diseases. This can help us to test whether the estimated under recording is real and to understand the impact this is having. We also need to test the relationship between estimated under recording and socio-demographic characteristics such as ethnicity and deprivation.

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References Chapter 1: 1. Department of Health, Equity and Excellence: Liberating the NHS, July 2010 http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_117794.pdf 2. http://www.sandwell.nhs.uk/documents/publications/Public%20health%20annual%20report%20200809%20lowres.pdf Chapter 2: 3. The Black Report (1980) Inequalities in Health: Report of a research working group, London DHSS 4. Whitehead, M (1987) The Health Divide, London 5. Acheson Report (1998) Report of the independent inquiry into inequalities in health. London: Stationery Office, 1998 ISBN: 0113221738 6. Marmot, M (2010) Fair Society, Healthy Lives, The Marmot Review 7. The English Indices of Deprivation (2010). Communities and Local Government. Available at URL: http://www.communities.gov.uk/documents/statistics/xls/1871689.xls Last accessed 20.05.2011. Chapter 3: 8. World Health Organisation. Closing the gap in a generation: Health equity through action on the social determinants of health. 2008. 9. Barton, H. and Grant, M. A health map for the local human habitat, Journal of the Royal Society for the Promotion of Public Health, 126 (6) pp252-261. 10. Sandwell Primary Care Trust, Invest well – Priorities for Health, Strategic Plan, 2008/09-2012/13 11. Lin CC, Rogot E, Johnson NJ, Sorlie PD, Arias E. A further study of life expectancy by socioeconomic factors in the National Longitudinal Mortality Study. Ethnicity & Disease [2003, 13(2):240-7] 12. De Silva, D. Helping people help themselves. 2011. The Health Foundation. London 13. Sandwell Trends. 2011. http://www.sandwelltrends.info/lisv2/navigation/home.asp [Accessed 10 July 2011] 14. Doyle, C., Kavanagh, P., Metcalfe, O., Lavin, T. Health impacts of employment: a review. 2005. Institute of Public Health in Ireland. http://www.publichealth.ie/publications/healthimpactsofemploymentareview 15. Shuildrick, T., MacDonald, R., Webster, C., Garthwaite, K. The low-pay, no-pay cycle: understanding recurrent poverty. 2010. The Joseph Rowntree Foundation: York 16. Townsend, P. The meaning of poverty. The British Journal of Sociology, 1962, 13(3). 17. Department for Energy and Climate Change. Fuel poverty statistics. http://www.decc.gov.uk/en/content/cms/statistics/fuelpov_stats/fuelpov_stats.aspx [accessed 4 July 2011] 18. Kings Fund. The health impacts of spatial planning decisions. Kings Fund. 2009: London 19. The Marmot Review: Implications for spatial planning. The Marmot Review. 2011: London 20. Mitchell, R., Popham, F. Effect of exposure to natural environment on health inequalities: and observational population study. 2008. The Lancet 372(9650) pp1655-1660 21. Faculty of Public Health. Great outdoors: how our natural health service uses green space to improve wellbeing. 2010. Faculty of Public Health. London. 22. Sandwell Metropolitan Borough Council. Sandwell Green Space Strategy 2010-2020. http://cmis.sandwell.gov.uk/CMISWebPublic/Binary.ashx?Document=35677 [Accessed 25 July 2011] 23. World Health Organisation. Environmental burden of disease associated with inadequate housing. World Health Organisation. 2011. Copenhagen, Denmark 24. Marmot Review. 2011. http://www.marmotreview.org/implementation/other-local-examples.aspx [Accessed 11 July 2011] 25. Local Government Improvement and Development. http://www.idea.gov.uk/idk/core/page.do?pageId=23289114 [Accessed 10 July 2011] 26. Royal Town Planning Institute. www.rtpi.org.uk/download/10642/Paul-Southon.pdf [Accessed 14 July 2011] Chapter 4: 27. Sandwell Adult Services. RAP returns, 2009-10.Number of clients receiving services during 2009-10, provided or commissioned by Sandwell Adult Services, by primary client type, service type, and age group. 28. Social Care Clients, England, 2007/8. http://www.statistics.gov.uk/hub/health-social-care/social-care/social-care-clients 29. Department of Health, 2005. Supporting people with long term conditions. http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4122574.pdf 30. NHS Evidence: Learning Disabilities. Health inequalities and People with Learning Disabilities in the UK: 2010 http://www.library.nhs.uk/LEARNINGDISABILITIES/ViewResource.aspx?resID=389204&tabID=290 31. Office for National Statistics, Mid-year Local Authority quinary population estimates (table 9), 2010, http://www.statistics.gov.uk/statbase/product.asp?vlnk=15106 32. Discussion with Ross Bailey Senior Performance Analyst and Researcher, Adult and Community Services, Sandwell. 33. Electronic correspondence with Sarah Knight, Falls Management Lead, Sandwell PCT, 9th January 2011. 34. Care Quality Commission: Care Directory Search, 15/02/11. http://caredirectory.cqc.org.uk/caredirectory/searchthecaredirectory.cfm 35. NHS Local. Making Every Contact Count. http://nhslocal.nhs.uk/story/inside-nhs/every-contact-counts

Public Health Annual Report 2010/11_Prt3 26/01/2012 15:52 Page 21

Chapter 5: 36. Department of Health, Health Inequalities Nation Support Team, How to reduce the risk of seasonal excess deaths systematically in vulnerable older people to impact at population level, 2010 37. Smith, R., & Fowajuh, G., Excess Winter Deaths in West Midlands. Sandwell Primary Care Trust, West Midlands Public Health Observatory and NHS West Midlands, 38. The Eurowinter Group, Cold Exposure and winter mortality from ischaemic heart disease, cerebrovascular disease, respiratory disease and all causes in warm and cold regions in Europe. The Lancet 349, 1341-1346. 1997 39. Rudge & Gilchrist, Excess winter morbidity among older people at risk of cold homes: a population-based study in a London borough, Journal of Public Health 2005 27(4):353-358. http://jpubhealth.oxfordjournals.org/content/27/4/353.full 40. ONS, Excess Winter Mortality Statistical Bulletin – November 2010 www.statistics.gov.uk/pdfdir/deaths1110.pdf 41. Wilkinson P., et al Vulnerability to winter mortality in elderly people in Britain: population based study. BMJ 329, 644-649. 2004 42. Marmot Review Team. The health impacts of cold homes and fuel poverty. Written by the Marmot Review Team for Friends of the Earth. 2011 43. ONS, PCOs and SHAs within England; 2008-2033 population projections by sex and quinary age. http://www.statistics.gov.uk/downloads/theme_population/snpp-2008/InteractivePDF_2008-basedSNPP.pdf 44. Department for Communities and Local Government, A decent home: deﬁnition and guidance for implementation, 2006 http://www.communities.gov.uk/documents/housing/pdf/138355.pdf Chapter 6: 45. NHS Information Centre, http://www.ic.nhs.uk/qof, accessed 16th September 2011 46. http://www.erpho.org.uk/viewResource.aspx?id=17922 47. http://www.doncaster.nhs.uk/about-us/our-roles-directories/public-health/public-health-intelligence-evaluationteam/tools-resources/qof-benchmarking-tool/ 48. http://www.yhpho.org.uk/default.aspx?RID=81090 49. Knapp, M. & Prince, M. (2007) Dementia UK. London: Alzheimer's Society) 50. http://www.nhs.uk/Conditions/Diabetes-type2/Pages/Causes.aspx

Achievements 2010/11 Awards

g Finalists British Medical Journal (BMJ) Group Awards in the Sustainable Health Care category, 2011. g Dr Ishraga Awad Achieved a Postgraduate Award (PGA) in Public Mental Health and Wellbeing, Warwick University g Sharon Grant Short listed for Emergency Planning Society National Resilience Planner of the Year g Dr Patrick Saunders Elected Fellow of the Faculty of Public Health Achieved Deﬁned Specialist Registration on the UK Voluntary Register for Public Health Specialists Short listed for the Association of Directors of Public Health, UK, Annual Public Health Report competition, 2010.

Sandwell - Director of Public Health Annual Report 2010/11

g Shaukat Ali and Dene Stevens Winners Health Service Journal (HSJ) Awards 2010 in the Good Corporate Citizenship category.

Public Health Annual Report 2010/11_Prt3 26/01/2012 15:52 Page 22

Publications

g Ali S, Stevens D. Good corporate citizenship and carbon management. Health Service Journal (HSJ) Awards Best Practice Report, 2010. g Ali S, Stevens D. Good corporate citizenship and carbon management. Health Service Journal (HSJ) Awards supplement, 2010. g Haroon SM, Barbosa GP and Saunders PJ. The determinants of health-seeking behaviour during the A/H1N1 inﬂuenza pandemic: an ecological study. J Public Health (2011) PMID 21460370 (epub ahead of print). g Middleton J, Saunders PJ, Haroon SM. European Terrorism and Public Health. In Terrorism and Public Health, 2nd Edition (Sidel and Levy B, Eds). Oxford University Press (in press). g Middleton J, ed. 5% for health. The 20th Annual Public Health Report for Sandwell. West Bromwich: Sandwell Primary Care Trust, 2010. g Middleton J. Labour’s chimera. Health Service Journal (HSJ), letter (re NHS reorganisations), April 2010. g Middleton J. Managing public health - health dividends and good corporate citizenship. International Journal of Management Concepts and Philosophy, vol. 4 no 2: 154-176. g Middleton J. Gimme 5: why its 5% for health improvement. Health Service Journal (HSJ), June 2010. g Middleton J. Public health is a long haul. Health Service Journal (HSJ), September 2010. g Middleton J. The new public health service, Health Service Journal (HSJ), November 2010. g Middleton J. Public health and local authorities. Municipal Journal, November 2010. g Middleton J. Public health reforms in England lessons for Europe or lessons to avoid? Gesundheit, December 2010. g Middleton J. Public health can’t survive on £4 billion. Health Service Journal (HSJ), April 2011. And Local Government Chronicle website March 2011. g Grainger D, Time 2 Trade case study (commissioned by DoH). Institute for Volunteering Research. g Grainger D, Time 2 Trade case study, Governance International. g Saunders PJ. Use of routine public health nuisance complaint data to map and address environmental health inequalities. European Journal of Public Health. 2010; 20 (suppl 1): 47. g Saunders PJ, Kibble, AJ, Burls, A. Investigating alleged clusters. In Oxford Handbook of Public Health Practice, 2nd edition. (Pencheon D, Melzer D, Gray M, Guest C, Eds). Oxford University Press, Oxford (In press).

Presentations

g Dr John Middleton Young people’s health in Sandwell. Major launch of adolescent health strategy, CAP Centre, Smethwick, February 2010.

Three dividends for a healthier world. UK Public Health Association, March 2010. Healthy town planning and resilience. UK Public Health Association, March 2010

Crunchtime for health, poster presentation. UK Public Health Association, March 2010. Terrorism and public health. Open University international health masters course, Birmingham University, June 9th 2010.

Is Sandwell getting any better? 21 years of health improvement in Sandwell. Sandwell Health’s other Economic Summit (SHOES), June 2010.

Is Sandwell getting better in 21 years? University of the 3rd age Sandwell, September 2010.

NICE work if you can get it: implementing comprehensive and eﬀective public health programmes. 2nd International congress on health promotion and preventive medicine. Zagreb, Croatia, October 2010. Public Health in local authorities. West Midlands Teaching Public Health Network, Wolverhampton, November 2010.

g Dr Shamil Haroon The determinants of health-seeking behaviour during the A/H1N1 inﬂuenza pandemic. Poster presentation, HPA Pandemic Inﬂuenza conference, July 2010. An evaluation of breastfeeding peer support. Annual Faculty of Public Health conference, July 2011.

g Dr Patrick Saunders Use of routine public health nuisance complaint data to map and address environmental health inequalities. European Public Health Association Annual Conference, Amsterdam, November 2010. Use of Sub-National Indicators to Improve Public Health in Europe (UNIPHE) Conference Bucharest September 2010. Development of Sub National Children’s Environmental Health Indicators

g Dene Stevens Lessons for Planning & Public Health. New Partnerships for Health & Well-being event, Birmingham, May 2011.

Exploring the sustainability agenda and its role in the future of public health. National Public Health Congress, Botanical Gardens, Birmingham, May 2011.

Conferences organised

g Shaukat Ali and Dr John Middleton

Sandwell Health’s Other Economic Summit (SHOES), A climate for health? Global, local, health and health services – taking the temperature. The Public, West Bromwich, July 2011.

g Health Protection Team

World hepatitis Day conference, The Public, West Bromwich, July 2011.

Public Health Annual Report 2010/11_Prt3 26/01/2012 15:52 Page 23

CD and contents 1. Cancer Key Cancer Incidence Data & Mortality Data 2009 Sandwell Cancer Strategy 2010-2011 Executive Summary Sandwell Cancer Strategy 2010 Where do cancer patients die 2011 2. CLAHRC CLAHRC Newsletter October 2011 Housing Data Presentation Telecare Presentation

3. Clinical Commissioning Consortia proﬁles Black Country CCG Healthworks CCG Sandwell Health Alliance CCG

4. Community development Community Development Team Annual Report 2009-10

5. Healthy start to life 36 month Rolling Average Infant Mortality CDOP Report Child Health Profile Summary Leaflet February 2011 NI 116 2008 Briefing

6. JSNA BME Health Needs Assessment September 2010 JSNA Alcohol Report 2010 JSNA Coronary Heart Disease Report JSNA Obesity Report 2011 JSNA Pan Birmingham Cancers Needs Assessment Summary 2010 Sandwell JSNA Report V6

9. Older People National Falls & Bone Health Audit Report 2010 Sandwell Falls & Bone Health Audit Report 2011 Sandwell Falls & Bone Health Strategy 2011 10. Programme Budgeting Comparative Spend Sandwell PCT Health Investment Pack 2010 11. Public Annual Report 2010 – 11 12. Sandwell Health Proﬁle Sandwell Health Proﬁle 2011

13. Sexual Health PASH Group Data Presentation Outline PASH Sexual Health Data Report

14. SHUDU Green Space and Psychological Distress

15. Stroke National Sentinel Stroke Audit 2010 – Sandwell Results Performance against the NICE Quality Standard for Stroke Stroke Health Needs Assessment August 2011 16. Tobacco Control Sandwell PCT Smoking Proﬁle Tobacco Control Annual Report 2010 – 2011

Detailed reports that make up Sandwell’s Public Health Annual Report 2010/11 are contained on the attached CD.

If the CD is not attached, you can request a copy by telephoning 0845 155 0500. This document is also available for download on Sandwell Primary Care Trust’s website at www.sandwell.nhs.uk and click on ‘Publications’. Responsibility for the opinions expressed in this report rest with the Editor, Dr John Middleton, Director of Public Health for Sandwell PCT. Any errors or points of clariﬁcation that need to be further addressed should be forwarded to him at john.middleton@sandwell-pct.nhs.uk

Sandwell - Director of Public Health Annual Report 2010/11

7. Life Expectancy Life Expectancy Gap in Sandwell 8. Obesity Bariatric Surgery Policy Review Sandwell Obesity Strategy 2011 Triple S Programme Results

Public Health Annual Report 2010/11_Prt3 26/01/2012 15:52 Page 24

Sandwell Primary Care Trust 438 High Street West Bromwich West Midlands B70 9LD

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