Health and Community. Directorate Health Health and and Wellbeing Community in Halton

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1 Health and Community Directorate Health Health and and Wellbeing Community in Halton Directorate HeaHealth and Wellbeing in Halton Joint Strategic Needs Assessment for Halton 2008

2 Contents Tables... 5 Charts... 9 Maps Executive Summary Introduction Methodology Boundaries for Analysis General Population Demographic profile Population Ethnicity Migration Religion Disability Social and Environmental context Deprivation Living Arrangements Transport Halton Residents Access to Services Economic Overall Employment Rate (NI 151) Unemployment Rate Working age people on out-of-work benefits (NI 152) Working age people on out-of-work benefits in the worst performing neighbourhoods (NI 153) Income Environment Urban/Rural Classification Lifestyle and risk factors Smoking Eating habits Alcohol Obesity Hypertension Burden of Ill health All causes Life Expectancy All age all cause mortality a Geographical variation of all age all cause mortality i Hospital admissions Elective admissions Non Elective Admissions Mortality from causes amenable to healthcare Diabetes

3 Circulatory Disease a.i Mortality from all circulatory diseases under i CHD c Stroke Cancer All Cancers Breast Cancer a Colorectal Cancer Cervical Cancer Prostate Cancer Chronic Obstructive Pulmonary Disease a Sexually transmitted infections Road accidents Disability Services Sexual health services Voice: Consumer Views and Access to Services Equitable Access to Primary Medical Care Programme Patients Survey Dental Health Children and Young People Demography Ethnicity Social and Environmental Context Deprivation Educational attainment Education measures by ward Economic Well-being Lifestyle and risk factors Low birth weight Breastfeeding Smoking in Pregnancy Sexual behaviour Obesity among primary school age children Burden of ill-health and disability Infant mortality Chlamydia in the under 25 s Dental decay Road accidents Injuries Services Measles, Mumps and Rubella vaccination Adult Social Care Demography, Social and Environmental Context Older People Extra Care Housing Forecasting the Impact of Projected Population Change on Demand 179 3

4 Contracted Domiciliary Care Services In-house Services People with a Learning Disability (LD) People with Mental Health Issues People with a Physical, Sensory Disability/Limiting Long Term Illness (LLTI) Carers Burden of Ill Health and Disability Healthy Life Expectancy Fractured Neck of Femur Hip and Knee Replacements Dementia Influenza Vaccination HIV and AIDS Service Provision Commissioning Priorities Older People Adult with Learning Disabilities Mental Health Physical and Sensory Disabilities Substance Misuse Carers Children and Young People NHS Halton & St Helens Appendix 1 - List of ICD10 Chapters and Categories Appendix 2 Map of Top Ten Causes of Elective and Non-elective admissions Appendix 3 Joint Strategic Needs Assessment for Halton Feedback Form 233 4

5 Tables Table 1: Percentile of SOA deprivation by Ward Table 2: Health Deprivation Rank in Halton Table 3: Mid 2006 Population Estimates, Halton, North West and England Table 4: Halton population growth Table 5: Halton Age Distribution 2006 vs Table 6: Halton Age Distribution 2006 vs Table 7: Percentage of the population by age group Table 8: Percentage Age Distribution of Ethnic Groups Table 9: White Population % By Ward Table 10: National Insurance Number Registrations in respect of non-uk Nationals in 2006/07 by Local Authority and country of origin Table 11: Halton Population by Religious Group Table 12: Limiting Long Term Illness for Halton Table 13: Number of households claiming disability allowance by age group and ward Table 14: Number of households whose home has been built or adapted to meet the needs of a disabled person Table15: Incapacity Benefit Claimants Table 16: Wards Ranked within the IMD Table 17: Housing tenure Table 18: Dwelling Stock by Council Tax Band Table 19: Property types by Ward Table 20: Access to Car or Van Table 21: Access to Car or Van per Household by Ward Table 22: Access to Services Table 23: Working Age People on Out of Work Benefits in the Worst Performing Neigbourhoods Table 24: Average Household Income by Ward Table 25: List of ICD10 codes used for alcohol conditions Table 26: Predicted/Expected numbers with Hypertension based on ONS population predictions and expected numbers based on prevalence model Table 27: Number in Treatment Year to Date Table 28: Retention > 12 Weeks Table 29: Trends in Life Expectancy, 3 Year Rolling Averages

6 Table 30: Top 10 Causes of Elective Admissions for Residents Registered with a Halton G.P. Practice Table 31: Top 10 causes for elective admissions split by electoral ward Table 32: Top 10 Causes of Non-Elective Admissions for Residents Registered with a Halton G.P. Practice Table 33: Top 10 causes for non-elective admissions split by electoral ward Table 34: Predicted prevalence of Diabetes in Halton (3 different scenarios) Table 35: Prevalence of Coronary Heart Disease in Halton and St Helens Table 36: QMAS Coronary Heart Disease Data Table 37: MI Rate of admission per 100, /07, Halton all ages Table 38: Myocardial infarctions admission rate per 100, / Table 39: Admissions by PCT for Cardiac Revascularisation, Table 40: Incidence: Top three most common types of cancers for males, Halton 114 Table 41: Incidence: Top three most common types of cancers for females, Halton Table 42: Mortality: Top three most common types of cancers for males, Halton Table 43: Mortality: Top three most common types of cancers for females, Halton116 Table 44: Top types of cancer in the wards with the highest mortality rates, All Ages Table 45: Top types of cancer in the wards with the highest mortality rates, Ages less than Table 46: Chronic Obstructive Pulmonary Disease Prevalence, Halton & St Helens Table 47: Quality Outcomes Framework data prevalence Table 48:Sexually transmitted infections diagnosed at Halton GUM department, Table 49: Long term illness and disability Table 50: Percentage of abortions performed under 10 weeks gestation funded by the NHS Table 51: Halton Children and Deprivation levels Table 52: Ethnic mix of Halton school pupils Table 53: Attainment and further education by socio-economic favours Table 54: Economic well being of young people Table 55: Proxy for social inclusion by location (ranked by deprivation) Table 56: Library Membership Table 57: Proxy for social inclusion by location children vs adults Table 58: 1998 to 2006 under 18 conception rates

7 Table 59: Number of Pupils with Heights and Weights Recorded Table 60: PCT NCMP Summary Table 61: Percentage of Reception Children Overweight & Obese Table 62: Percentage of Year 6 Children Overweight & Obese Table 63: Total Child Measurement data by People and Places Tree Table 64: Percentage of the year old population opportunistically screened for Chlamydia infection in Halton and St Helens Table 65: No. of Children (<16) Killed or Seriously Injured in Accidents Table 67: Halton Older People and Deprivation levels Table 68: Older People (OP) Living Alone - Distribution by Ward Table 69: Living arrangements of people aged 65 and over by age bands (65-74, and 75 and over) and gender and numbers living alone, projected to Table 70: People aged 65 and over by age (65-74, 75-84, 85 and over) living in a dwelling with no central heating, year Table 71: Comparison of extra care units with other Boroughs Table 72: Quantified Need for Extra Care Provision Table 73: External Provider Service: Number of Service Users per 1000 Population - Adults and Over 65s Table 74: External Provider Service: Forecast Level of Demand for Domiciliary Care Adults Table 75: External Provider Service: Forecast Level of Demand for Domiciliary Care Table 76: External Provider Service: Forecast Level of Demand for Domiciliary Care - Adults and Table 77: External Provider Service: Impact on Annual Cost of Home Care Services of Forecast Changes in Demand (at 2007 prices and using average cost p.a. figures) Table 78: In-house Service: Number of Service Users per 1000 Population Table 79: In-house Service: Forecast Level of Demand for Domiciliary Care - Adults and Table 80: People with a Learning Difficulty (Age 16+) Table 81: Weekly Prevalence of Common Mental Health problems in Halton & St Helens Table 82: Limiting Long Term Illness for Halton Table 83: People with a Sensory/Physical Disability by Ward Table 84: Number of households claiming disability allowance by age group and ward Table 85: Prevalence of disability between age groups Table 86: Number of Informal Carers within Halton

8 Table 87: National Top 4 illnesses reported by Carers Table 88: Life Expectancy at age 65 ( ) Table 89: People aged 65 and over predicted to have dementia, by age band (65-69, 70-74, 75-79, and 85 and over) and gender, projected to Table 90: Service usage by Primary Service Type Table 91: Service Type by Number and % of Total Services Table 92: Number of clients receiving services during period provided (1 April 2007 st to 31 March 2008) or commissioned by prime Table 93: Number of clients on the books to receive community based services on 31st March 2008 provided or commissioned by the CSSR by prime Table 94: Number of Older people aged 65 and over receiving community-based services projected to Table 95: Older people aged 65 and over in local authority residential care, independent sector residential care, and nursing care st 8

9 Charts Chart 1: Halton Population Pyramid Chart 2: Halton growth by age band Chart 3: Overall Employment Rate Chart 4: Working Age People on Out of Work Benefits Chart 5: Prevalence of all smokers in Halton practices Chart 6: Percentage of People with 2 or more poor Diet Behaviours Chart 7: Prevalence of Unsafe Drinkers (Halton Practices) Chart 8: All Alcohol Admissions, 2006/07 by Ward Chart 9: Alcohol admissions per 1,000 by age (2006/07) Chart 10: Alcohol related admissions per 100,000 (EASR) (2005/06 and 2006/07).64 Chart 11: Prevalence of Overweight (BMI 25+), Halton Practices Chart 12: Percentage of Hypertension recorded in GP s Chart 13: Number in Treatment Year to Date Chart 14: Retention > 12 Weeks Chart 15: Trends in life expectancy, 3 year rolling averages Chart 16: All Age All Cause Mortality Chart 17: All Age All Cause Mortality to , males Chart 18: Trends in mortality from all causes, females, to Chart 19: All Age All Cause Mortality by ward, persons, Chart 20: Elective admissions rate to hospital from Halton GP practices by age, 2006/ Chart 21: Number of Elective admissions from Halton GP practices, 2006/ Chart 22:Rate of elective admission (DSR) by ward in Halton, Persons, 2006/ Chart 23: Rate of elective admission (DSR) by ward in Halton, Males, 2006/ Chart 24: Rate of elective admission (DSR) by ward in Halton, Females, 2006/ Chart 25: Elective admissions future trend based on ONS population projections Chart 26: Non-Elective admissions rate to hospital from Halton GP practices, 2006/ Chart 27: Number of Non-Elective admissions to hospitals from Halton GP practices, 2006/ Chart 28: Future trends Non-Elective admissions to hospitals from Halton GP practices Chart 29: Rate of non-elective admissions (per 100,000), All Persons Chart 30: Rate of non-elective admissions (per 100,000), Females

10 Chart 31: Rate of non-elective admissions (per 100,000), Males Chart 32: Predicted prevalence of Diabetes from 2001 to Chart 33: Predicted prevalence of Diabetes from 2001 to Chart 34:Diabetes Related Mortality All Persons 1993/95 to 2004/ Chart 35: Diabetes Related Mortality Males and Females 1993/95 to 2004/ Chart 36: Rate of mortality from all circulatory diseases (DSR) Ages less than 75, 2004/ Chart 37: Mortality from all circulatory diseases All Persons Under 75 Years, 1993/95 to 2004/ Chart 38: Mortality from Coronary Heart Disease 1993/95 to 2004/ Chart 39: All Admissions for Myocardial Infarction Halton All Persons by Ward 2006/ Chart 40: MI Rate of admission per 1, /07, Halton Chart 41: MI Rate of admission per 100, /07, Halton all ages Chart 42: Myocardial infarctions admission rate per 100, /07, Persons, all ages Chart 43: Admissions by PCT for Cardiac Revascularisation, Chart 44: Mortality from Stroke All Persons 1993/95 to 2004/ Chart 45: All Admissions Stroke Halton All Persons by Ward 2006/ Chart 46: Stroke, Rate of admission per 100,000, 2006/07, Persons, all ages Chart 47: Stroke, Rate of admission per 100,000, 2006/07, Halton, all ages Chart 48: Percentage of GP Registered Population Recorded with a Stroke Chart 49: Incidence of all cancers, DSR, all ages, males, 1993/95 to 2002/ Chart 50: Incidence of all cancers, DSR, all ages, females, 1993/95 to 2002/ Chart 51: Mortality from all cancers, DSR, all ages, males, 1993/95 to 2004/ Chart 52: Mortality from all cancers, DSR, all ages, females, 1993/95 to 2004/ Chart 53: Incidence of Breast Cancer, DSR, all ages, 1993/05 to 2002/ Chart 54: Mortality from Breast Cancer, DSR, all ages, 1993/05 to 2004/ Chart 55: Incidence of colorectal cancer, DSR, all ages, 1993/95 to 2002/ Chart 56: Mortality from colorectal cancer, DSR, all ages, 1993/95 to 2004/ Chart 57: Incidence of Cervical Cancer, DSR, all ages, 1993/95 to 2003/ Chart 58: Mortality from Cervical Cancer, DSR, all ages, 1993/95 to 2004/ Chart 59: Incidence of Prostate cancer, DSR, all ages Chart 60: Mortality from Prostate Cancer DSR all ages Chart 61: Incidence of lung cancer, DSR, all ages, 1993/95 to 2002/ Chart 62: Mortality from lung cancer, DSR, all ages, 1993/95 to 2004/

11 Chart 63: Mortality from Chronic Obstructive Pulmonary Disease persons, Chart 64: Mortality from Bronchitis, Emphysema and other Chronic Obstructive Pulmonary Disease - All Persons 1993/95 to 2004/ Chart 65: Mortality from Land Transport Accidents All Persons, 1996/98 to 2004/ Chart 66: GUM Clinic Activity- North Cheshire Trust Chart 67: Births for period 2000/ Chart 68: Mid-year population estimates, under 19 s, Halton, Chart 69: Mid-year population estimates and population projections, under 19 s, Halton, Chart 71: 5 A*-C GCSE (Y axis) vs % Children living in Income Deprived households (X axis) Chart 72: Percentage staying on in Education (Y axis) vs % Children living in Lone Parent households (X axis) Chart 73: Percentage staying on in Education (Y axis) vs % Children living in Income Deprived households (X axis) Chart 74: Proxy for social inclusion by location children vs adults Chart 75: Trend in Low Birth Weight Births 1998 to Chart 76: Under 18 conception rates (single years) Chart 77: Under 18 conceptions rates (3 year rolling averages) Chart 78: Under 16 conception rates (3 year rolling averages) Chart 79: Under 18 conception rates 2002/04 (3 year rolling averages) Chart 80: Percentage of Overweight & Obese Reception Children by National Deprivation Quintile 2006/ Chart 81: Percentage of Overweight & Obese Year 6 Children by National Deprivation Quintile, 2006/ Chart 82: Halton CYPAN Percentage of Overweight & Obese Reception and Year 6 Children Chart 83: Total Child Measurement data by People and Places Tree Chart 84: Decayed, Missing and Filled Teeth for Children Aged 5 Years Chart 85: Serious and Untoward Incidents in Children and Young Persons 0-19 Years Halton All Persons by Ward 2006/ Chart 86: Serious and Untoward Incidents in Children and Young Persons, Halton by Age-band / Chart 87: Impact on Annual Cost of Domiciliary Care Service of Forecast Changes in Demand Chart 88: All Admissions for Fractured Neck of Femur Halton by Ward, All Persons 2006/

12 Chart 89: Fractured Neck of Femur, Rate of admission per 100,000, 2006/07, Halton all ages Chart 90: Fractured Neck of Femur, Rate of admission per 100,000, 2006/07, Persons, all ages Chart 91: Halton All Persons Hip & Knee Replacements by Ward for 2006/ Chart 92: Halton Males Hip & Knee Replacements by Ward for 2006/ Chart 93: Halton Females Hip & Knee Replacements by Ward for 2006/

13 Maps Map 1: Halton Ward and Super Output Area Boundaries Map 2: Deprivation levels relative to England Map 3: IMD 2007, Distribution of Deprivation in Halton (National Quintiles) Map 4: SOAs in Top 20% Nationally for Health Deprivation Map 5: Working Age People on Out of Work Benefits in the Worst Performing Neigbourhoods Map 6: Population Density Map 7: Urban/Rural Classification Map 8: All Alcohol Admissions Halton All Persons 2006/07 by Ward Map 9: All Age All Cause Mortality, females, Map 10: All Age All Cause Mortality, male, Map 11: Rate of elective admission (DSR) by ward in Halton, All People, 2006/07.83 Map 12: Rate of elective admission (DSR) by ward in Halton, Males, 2006/ Map 13: Rate of elective admission (DSR) by ward in Halton, Females, 2006/ Map 14: Rate of non-elective admissions (per 100,000), All Persons Map 15: Rate of non-elective admissions (per 100,000), Females Map 16: Rate of non-elective admissions (per 100,000), Males Map 17: All Admissions for Myocardial Infarction Halton All Persons by Ward 2006/ Map 18: All Admissions Stroke Halton All Persons 2006/ Map 19: Geographic Spread of Population (by age) under 5 s Map 20: Geographic Spread of Population (by age) 14 and Under Map 21: Geographic Spread of Population (by age 19 and Under) Map 22: Proxy for social inclusion by location (ranked by deprivation) Map 23: Indices of Deprivation 2004: Rank of ID Overall Score by National Quintile Map 24: Halton Proposed Children & Young People s Area Network Map 25: Halton & St Helens P2 People and Places Classification Map 26: Prevalence of Decayed Teeth in 5 year old children, 2005/06, Halton and St Helens PCT Map 27: Serious and Untoward Incidents towards Children and Young People Halton 2006/ Map 28: Geographic Spread of Population (by age 60 and Over) Map 29: Halton Admission Due to Fractured Neck of Femur 2006/ Map 30: Halton Elective Admissions for Neoplasms, 2006/

14 Map 31: Halton Elective Admissions for Genitourinary Infections, 2006/ Map 32 Halton Elective Admissions for Digestive Conditions 2006/ Map 33: Halton Elective Admissions for Musculoskeletal Conditions, 2006/ Map 34: Halton Elective Admissions for Conditions Affecting the Eye, 2006/ Map 35: Halton Elective Admissions for Circulatory Conditions, 2006/ Map 36: Halton Elective Admissions for Factors Influencing Health Status and contact with Health Services, 2006/ Map 37: Halton Elective Admissions for Symptoms, Signs and Abnormal Clinical and Laboratory Findings Not Elsewhere Classified, 2006/ Map 38: Halton Elective Admissions for Respiratory Conditions, 2006/ Map 39: Halton Elective Admissions for Skin Conditions, 2006/ Map 40: Halton Non-Elective Admissions for Symptoms, Signs and Abnormal Clinical and Laboratory Finding Not Elsewhere Classified Map 41: Non-Elective Admissions Due to Injury, Poisoning and Other External Causes, 2006/ Map 42: Non-Elective Admissions for Respiratory Conditions, 2006/ Map 43: Non-Elective Admissions for Circulatory Conditions, 2006/ Map 44: Non-Elective Admissions for Digestive Disorders, 2006/ Map 45: Non-Elective Admissions for Genitourinary Conditions, 2006/ Map 46: Non-Elective Admissions for Musculoskeletal Conditions, 2006/ Map 47: Non-Elective Admissions for Neoplasms, 2006/ Map 48: Non-Elective Admissions for Certain Infections and Parasitic Diseases, 2006/ Map 49: Non-Elective Admissions for Mental and Behaviour Disorders, 2006/

15 Executive Summary Halton s resident population is 119,500 (ONS mid year estimate 2006) Overall, the population has decreased by 2% since 1996, but has been rising since At present, Halton has a younger population than the national and regional averages. However, Halton mirrors the national picture of an ageing population, with projections indicating that the population of the borough will age at a faster rate than the national average. In % of the total population were aged 65 and over, by 2006 this had increased to nearly 14% and by 2015 this is projected to have increased to 17%, which could have a significant impact on the need for health and social care. The population is predominantly white (98.8%) with relatively little variation between wards. However, in recent years, it has seen a small influx of Eastern European (Polish & Slovakian) migrants. In recent years Halton has seen increases in life expectancy for both men and women and declining all cause mortality, predominantly due to drops in deaths from coronary heart disease and cancer. Whilst this is good news, the England figures have decreased at a greater rate so the gap between Halton and England has widened for all cause mortality and for both genders. Halton now has the 3 rd worst life expectancy in England for women and the 6 th worst life expectancy for men. Within Halton there are also geographical variations in life expectancy. Men in the most deprived areas of Halton live 7.7 years less than men in the least deprived areas. For women in Halton the average life expectancy at birth is 5.8 years less in the most deprived areas than in the least deprived areas. Deprivation is a major determinant of health. Lower income levels often lead to poor levels of nutrition, poor housing conditions, and inequitable access to healthcare and other services. Deprivation, measured using the English Index of Multiple Deprivation (IMD) 2007, ranks Halton as the 30 th most deprived authority in England (compared to 21 st in 2004). The 2007 IMD shows that deprivation in Halton is widespread with 57,958 people (48% of the population) in Halton living in Super Output Areas (SOA s) that are ranked within the most deprived 20% of areas in England. In terms of Health and Disability, the IMD identifies 53 SOA s that fall within the top 20% most health deprived nationally and that approximately 40,000 people (33% of the population) live in the top 4% most health deprived areas in England. At ward level, Windmill Hill is the most deprived area in terms of health. However, health deprivation is highest in an SOA within Castlefields, ranked 32 nd most deprived nationally. 15

16 Key Issues and Findings Specific Populations Older People Projections indicate a significant and substantial increase in the numbers of older people between 2006 and 2015, at a rate that is higher than the national and regional trends. Currently 14% of the population is over 65. This is set to rise to 17% by One of the largest growths (up by 19%) will be seen in potentially the most frail and dependent group of over-85s, bringing key implications for planning future service provision for this group. In 2000/01 the NHS spent 41% of its budget ( 12.4 billion) on people over 65. On average older people are more likely than younger people to report lifestyle-limiting illness, to live alone, live in poverty and to rely on public services and informal cares. Advancing age also carries some increased risk of dementia and depressive illness and in Halton levels of people with dementia are rising. Just under half of Halton s 65+ population live with limiting long-term illness and the rate of fractured neck of femur (hip fracture) is the 5 th worst in the country. In 2006/07 there were 123 hip fractures in the over 65s in Halton. The wards with the highest proportions of the population that are older people are seen in Castlefields, Halton and Ditton. People with Disabilities or a Limiting Long Term Illness (LLTI) Nationally, 18% of people (over 16 years) have at least one dimension of a limiting long-term illness i.e. about 20,300 people in Halton. In Halton the number of adults living with a long term limiting illness is higher than the national average at 22% (2001 census). Whilst there is no evidence to suggest dramatic increases in the number of adults aged with physical/sensory impairments, as the proportion of the population over 45 increases, later onset conditions such as Parkinson s Disease, sensory impairment, arthritis, etc, will rise. In addition, significant increases in the levels of obesity in Halton are predicted to lead to an increase in the prevalence of diabetes and incidence of heart disease. People with Learning Disabilities It is predicted that the population of people with learning disabilities will grow by 6% by Of further significance is that people with learning disabilities are living longer. Adults with learning disabilities have poorer general health than the wider population and can struggle to access mainstream health services. The wards showing the highest prevalence of learning difficulty are Castlefields, Hough Green, Grange and Halton Lea respectively. The overall pattern shows a strong relationship between levels of learning difficulty with areas of deprivation, in that these 4 wards also have a high percentage of the population living in the top 10% most deprived areas nationally. Numbers of people (known to social services) in Halton with a learning disability have remained fairly constant in recent years (between ). However, since 16

17 2002 there has been a significant shift in the way in which services are delivered to people with a learning disability. Halton now performs well in respect to helping people with learning disabilities to live in the community with approximately 82% of people now receiving services in their own home. However, access to general needs social housing remains limited and levels of owner occupation remain extremely low. Few adults with learning disabilities in Halton are in paid employment (less than 1% compared to 10% nationally), even though employment is key to sustaining wellbeing and enabling people to maximize independence. Children Population estimates indicate that Halton has a younger population than the regional and national average. However, overall the 0-19 population is decreasing. Windmill Hill is ranked the most deprived ward in the borough across all domains and is ranked the most deprived ward in terms of health. Over 50% of Halton s children live in the 20% most deprived areas nationally and a further 15.5% live in the 40% most deprived areas nationally, with only 8% of children living in the 20% least deprived areas nationally. A number of major health issues relevant to children and young people in Halton have been identified through the JSNA and the Children and Young Peoples Plan. Key issues include, higher rates of infant mortality and low birth weight, high rates of teenage pregnancy, high rates of obesity for both reception and year 6 children. In Halton, 24% of reception age children are overweight and 11.6% are obese, and 36.3% of Year 6 children are overweight and 22.3% are obese. All of these levels are above the England average. Pregnant Women & Newborns The health of the child starts with the health of their mothers before and during pregnancy. Locally, 1 in 4 were still smoking at the birth of their child, and just 4 in 10 are breastfeeding on delivery (half the national average and 4 th worst in the country). Therefore programmes around stopping smoking (particularly before and during pregnancy), increasing levels of physical activity, developing healthier eating habits and dramatically increasing the number of women who breastfeed are a priority. Incidence of teenage pregnancy remains an issue in Halton, despite falling for several years; rates are now above the 1998 baseline level. There is also a correlation between deprivation and incidence of teenage pregnancy with the most deprived areas in Halton experiencing the highest levels of teenage conception rates. Carers Carers provide a significant proportion of community care as services target provision on those with highest need. There are as many as 13,531 carers in Halton and 3,696 provide over 50 hours unpaid care a week. Research by the equal opportunities Commission suggests that caring can have a detrimental impact on health and employment. Approximately 14% of carers in Halton state that they are in poor health. As the ageing population in Halton increases there is also predicted to 17

18 be a steady increase in the number of carers, including those carers aged over 85 and an increase in older carers with poor health. All factors indicate an increased demand for services to support carers in Halton. Conditions Mental Health and Emotional Well-being About 1 in 6 adults in Halton suffer from depression (or chronic anxiety, which effects 1 in 3 families). This rises to 1 in 4 older people having symptoms of depression that are severe enough to warrant intervention. Of other mental health problems, anxiety and phobias are the most common. People with mental health problems are less likely to be in paid employment and carers are twice as likely to have mental health problems. 40% of people on incapacity benefit are claiming for mental health problems (nationally more than the total number of people claiming benefits for unemployment). In Halton s Housing Needs Survey 2005, 96% of people with a mental health problem (who reported their household income) had an income below the national average and 65% of people with a mental health problem indicated that the problem was serious enough for them to need care and support. In addition, the range and number of supported housing available for people with mental health problems in Halton remains low compared to national and regional averages. Emotional well-being is a concern for all members of the community and we should be focusing on preserving it. Improving people s relationships, self-image, selfesteem and levels of worry, which all impact on emotional well-being will give people the ability to cope with life. Supporting adults to remain in or return to employment will pay dividends in terms of mental health and we need to improve our performance in this area. We also need to support people with mental health problems to improve their wellbeing by increasing access to services such as housing support, creative arts and leisure, physical activities and talking therapies. It is estimated that 2000 children and young people in Halton have moderately severe problems requiring attention from professionals trained in mental health, and approximately 500 children and young people with severe and complex health problems requiring a multi-disciplinary approach. The establishment of a continuum of emotional health and mental well being services that can intervene early where appropriate, is critical to meeting the needs of the these vulnerable children, who will soon face the challenge of adulthood. The transition to adult services is a critical point for this group of young people. Promoting the emotional well being and mental health of children and young people is everyone's business in Halton and will have a major impact on a number of other health and socio-economic factors. 18

19 Dementia Dementia is most common in older people, with prevalence rising sharply amongst people over 65 years. It is also one of the main causes of disability in later life. Locally 5% of the population has dementia. This translates to 1,061 people over 65 with dementia living in the community with dementia and is predicted to rise to an estimated 1,613 by Early diagnosis of, and intervention for, dementia are the keys to delaying admission to long-term care and to help people remain independent for longer. Promoting healthy ageing, for example by keeping people active and tackling social isolation, is important in delaying the onset of dementia. Accommodation choices including extra care housing, residential and nursing care for older people with dementia must also be balanced to meet future aspirations in respect to choice of service and be sufficient in numbers to meet future needs. Obesity in Adults Obesity is one of the most significant threats to the long-term health of our population as it leads to an increased risk of a wide range of health problems including type 2 diabetes, heart disease and some cancers. Nationally the levels of overweight and obesity are increasing and this pattern is reflected in Halton. Between 20% to 25% of adults in Halton are obese and these figures have increased in recent years. Considered alongside the increased levels of obesity in children this is a key priority, which can only be addressed by a wide range of strategies to be delivered through partnership working across all sectors. Cancer Cancer is the second biggest cause of premature death in Halton but its rate makes Halton the worst area in the country for cancer deaths. Incidence (the number of new cancers per year) of all cancers in men has decreased over the past decade but remains above the national rate. The incidence rate for women has risen over the same period both nationally and locally although in Halton the rates are now falling. Levels of mortality vary across Halton, with the highest rates being in Norton South, for both all ages and under 75s. Other areas with high rates are Farnworth, Castlefields and Grange. There has been a steady increase in the number of women developing breast cancer in Halton and death rates for the disease have increased recently. Nationally the rate has improved but this remains the second largest cause of cancer death in Halton. The Incidence of colorectal (bowel) cancer in Halton has slowed since However, the rate remains significantly above the North West and the national average. Mortality rates, which had been falling since their peak in , have begun to rise in , widening the gap between Halton and England. A fall in the Incidence of lung cancer in Halton was mirroring the falling rates nationally. However, from the rate began rising. Similarly, the rate of mortality from lung cancer has improved both nationally and locally, but an increase between 2001 and 2003 in Halton, even though it has fallen since, widened the gap between the Halton and England rates. Lung cancer remains the leading cause of cancer death in Halton for both men and women. 19

20 Prostate cancer has the highest observed incidence rates of any cancer for men in Halton and is in the top 3 causes of cancer mortality. An increase in preventative services which support lifestyle change will reduce incidence levels whilst increased emphasis on early detection and treatment will improve health outcomes and mortality rates. Heart disease and stroke Heart disease is the single biggest cause of premature death in Halton. Locally more people have heart disease than nationally and, for those under 75, men are more likely to have it than women. However, there has been a reduction in the number of deaths from heart disease over recent years. Stroke is a significant cause of UK morbidity and mortality, the most important cause of adult disability, and the third leading cause of death. Halton has lower rates of death from stroke than the North West but slightly higher rates than England as a whole. When looking at admissions to hospital for stroke Kingsway and Halton View have significantly higher rates compared to Halton as a whole. It is estimated that just under 1 in 4 (23.9%) people locally have high blood pressure (hypertension) which can lead to stroke and heart disease and numbers are set to increase. However, the number of patients identified as having hypertension at GP practices is much lower than the estimated levels, suggesting many people are going unidentified and therefore untreated. Promoting and enabling people to adopt healthy personal behaviors, such as not smoking, being physically active and eating healthily can help to reduce high blood pressure, reduce the risk of stroke and prevent the development or worsening of heart disease. Diabetes Diabetes is a very disabling and potentially fatal condition if not well managed. Diabetes increases the risk of other conditions such as heart disease and stroke, and magnifies the ill effects of other risk factors such as smoking, high cholesterol levels and obesity. The severity of impact of the disease is linked to how soon it is identified and how well managed it is. Type 2 Diabetes is the most common form, with obesity the primary modifiable risk factor for it. The risk of developing Type 2 Diabetes increases with age. As the older population in Halton is increasing, as are levels of obesity, more and more people in Halton will be affected by diabetes. If the current rates of obesity continue, by % of the adult population will have type 2 diabetes which will rise to an estimated 6.16%, or 6,700, GP registered patients by Chronic Obstructive Pulmonary Disease (COPD) This is an umbrella term for chronic bronchitis, emphysema or both. The PCT has the 10 th highest level in England, whilst levels in Halton are lower than experienced in St Helens, the rate remains higher than the North West and the national rate. As the main risk factor for these diseases is smoking, promoting healthy personal lifestyle choices will be key to reducing incidence levels. 20

21 Personal Behaviours Substance Misuse Illegal drugs cause damage and ruin to individuals, families and communities. And the most vulnerable and deprived among us are often the hardest hit. For individuals, drug misuse means wasted potential, broken relationships and, for some, a life of crime to feed their drug habit. For the wider community, our efforts to lift children out of poverty, promote equality of opportunity and reduce crime are held back when families and communities are in the grip of drug use. Over the past few years, increasing numbers of adults have entered and successfully left drug treatment. waiting times have consistently been within national targets and service users have expressed high satisfaction with the treatment they have received. however, attracting those in their 20s into drug treatment, and improving the uptake of services around blood borne viruses continues to present a challenge. these issues, together with seeking to support service users into employment, addressing the causes of some individuals offending, and improving the help available to those families affected by drug misuse, will continue to be the focus of future work. Alcohol Drinking alcohol to excess is a major cause of disease and injury, increasing the risks of heart disease, liver disease and cancer. Heavy drinking has a severe risk of cardiovascular disease as well as addiction. Binge drinking is linked to significantly increased blood pressure. Consuming alcohol in pregnancy increases the risk of foetal abnormality. People have low levels of awareness of the amount of alcohol they drink and the harmful effects it can have. Halton has the 8 th highest hospital admissions for alcohol-related conditions in England for 2006/07, showing that alcohol consumption is an issue of major concern locally. Alcohol admissions appear linked to deprivation, gender and age, with men in their 40s, and those from deprived wards, more likely to be admitted. Furthermore, estimates suggest that approximately 24% of adult residents binge drink. Whilst twice as many men than women drink above safe limits the number of women doing so has increased significantly from 6.9% in 2001 to 12.4% in The rate has decreased slightly for men during the same period (24.8% in 2001 to 22.5% in 2006). Smoking Smoking causes more avoidable and early deaths than any other personal lifestyle factor, killing more than 106,000 people in the UK annually; 17% of all deaths. Most die from lung cancer, chronic obstructive lung disease (bronchitis and emphysema) and coronary heart disease. It is a cause of a wide range of diseases, not just those resulting in death. Second-hand smoke is a major risk to the health of non-smokers. Locally smoking rates remain high with over 1 in 4 adults still smoking. Overall, prevalence is highest in males aged but in the younger age groups, a higher 21

22 percentage of women smoke than men. The results of a Halton survey of year olds highlighted that the smoking rates of year olds match that of adults, although there is a significant difference in smoking take up rates -18% male and 29% female. Food and Nutrition Nutrition with physical activity is second only to smoking tobacco in its influence on a wide range of health issues, not just obesity. Locally we estimate that only 20% of adults eat 5 portions of fruit and vegetables a day although this has improved since the 2001 lifestyle survey when only 12% did so. Males in the age group have the poorest diet, with lower intake of fruit and vegetables, and more poor diet habits. Decaying teeth is another sign of poor nutrition and the rate in Halton for 5-year-olds is higher than the national average. Within Halton the areas with the highest prevalence of decayed teeth are Kingsway, Riverside and Halton Lea. Sexually Transmitted Infections Over the period , there has been a general rise in the numbers of Sexually Transmitted Infections (STIs) recorded in Halton, rising from 150 in 1996 to 518 in Whilst some increase may be due to greater awareness and willingness to seek treatment this alone cannot account for this level of rise. Chlamydia Screening in Halton identified that 10.6% of cases were positive, which is higher than the national rate. In addition, the number of young people diagnosed with sexually transmitted infections is increasing. Wider Factors Employment Worklessness remains a key challenge in Halton, particularly in certain deprived areas and in respect to residents with physical and learning disabilities and mental health problems. Work provides status, purpose, social support, structure to life and income, so it is important not just for the working person but also their family. Being out of work has a huge negative impact on the health and well-being of the person and their family and is often a consequence of ill-health or disability. 25 of Halton s super output areas have over a third of their working age population (approximately 7,000 people) claiming out-of-work benefits. Nearly 68% of Halton s residents are in employment that makes it the 9 th worst in the North West and 34 th worst nationally. Levels of unemployment impacts on the levels of household income and in Halton average household incomes vary from a high of 54,060 in Birchfield (the least deprived ward in respect of health) to a low of 23,260 in Windmill Hill (the most deprived ward in respect to health). Halton s latest State of the Borough report was produced at the beginning of In terms of employment, it found the low skills base to be a causal effect of 22

23 unemployment that needs to be addressed in order to reduce levels of unemployment in Halton. Housing Condition and Options Decent housing is a pre-requisite for health and has a significant influence on people with many health conditions such as asthma and depression. Birchfield, where 99% of households are owner-occupiers and 0% of properties are socially rented scores well in terms of health deprivation, whilst in Windmill Hill where owner occupation is 22% and 62% of properties are socially rented has the highest level of health deprivation, at ward level, in the borough. When housing tenure is compared to health deprivation, it becomes clear that there is a strong correlation. The eight most deprived wards in terms of health have the lowest proportion of owner occupation in Halton, whereas the eight wards with the lowest health deprivation have the highest levels of owner occupancy. Educational Attainment Educational attainment is an important indicator of the future life chances for children and young people. There is also a direct correlation between levels of educational attainment and deprivation and health inequalities. Halton has made significant progress in improving GCSE results of young people in the borough, and for the last two years the percentage of young people achieving 5 A*-C has increased from 52.6% to 71.3%, taking us well above the national average. Over the same period the percentage of young people achieving 5 A*-C including English & Maths, a key indicator of future employability, has risen by 15.9% to 49.2%. The main priority for Children s Services now is to focus on narrowing the gap and reducing educational inequalities for vulnerable groups based on locality and other factors. Over half of Halton s children live in the 20% most deprived areas nationally and this has an effect on their attainment. Performance at ward level ranges from 93.3% in Beechwood to 40% in Windmill Hill and this impacts on levels of NEET (not in Employment, Education or Training) and future worklessness. Young women with poor educational attainment are more likely to be teenage parents. Therefore narrowing the gap in education attainment will be a major factor in improving the health and well-being of our communities. Isolation and Social Networks Isolation has a significant effect on general well-being and increases the risk of a range of health issues such as depression. Strong social networks are particularly important for vulnerable people. In Halton, almost 6,000 adults over 65 live alone. As the older population grows, the numbers living alone will increase and by 2025 it is projected that over 8,500 pensioners will be living alone. Social isolation needs to be tackled by all partners to ensure that there are adequate activities and support networks available within local communities. The voluntary and community sector can play an increasing role in developing community-based services that alleviate the effects of social isolation. 23

24 Introduction The aim of the Joint Strategic Needs Assessment (JSNA) is to provide a top level, holistic view of need within the borough. The JSNA has been driven by the Local Government White Paper; Our Health, Our Care, Our Say. In December 2006 guidance was produced on what data items should be included in a JSNA. This JSNA incorporates the majority of these suggested data items, in addition to providing a detailed analysis of other data, which seeks to describe fully the current health and social care issues experienced within the borough. The purpose of this document is to provide a comprehensive overview of the health needs of local populations, and to inform and guide decision makers in the commissioning of services, which adequately address the needs of local residents. The JSNA should inform prioritisation processes and the results of the analyses presented in this document should help to guide decisions about priorities areas to be included in revised Local Area Agreements (LAAs). 1.1 Methodology Boundaries for Analysis There are numerous ways in which the borough of Halton can be sub divided. The boundaries used for analyses can greatly influence the results obtained, thus it is important to ensure that the geographical level chosen is large enough to allow robust analyses whilst at the same time being small enough to ensure that very local areas experiencing real need are not masked by more affluent surrounding areas. Spatial analysis has been used, where appropriate, throughout this profile to present disease rates and other statistics, by geographical area, and thus highlight any local variations in the factors that influence health. There are a number of maps included within this report. They are useful, in that they can help analyse and visualise data at a given geographical level. The boundaries used for the aggregation, analyses and dissemination of data depend both on the availability of data and the likely robustness of analyses at any given level. Some data is only from Primary Care, thus this data is presented here at either GP Practice or Consortia level. The vast majority of data included in this report is available on a geographic level. Different geographic boundaries have been used within this report. The appendix provides a full description of the different boundary sets used. The lowest geographical boundary used here for the dissemination of statistical information is the Super Output Area (SOA). SOAs were introduced as part of a layered geography, with the aim of improving the consistency of small area information. The SOAs nest within the latest ward boundaries. Map 1 below shows Halton s 79 lower level SOAs in relation to the latest ward boundaries. 24

25 Map 1: Halton Ward and Super Output Area Boundaries Source: Halton & St Helens PCT Map 2 below demonstrates the variance of deprivation, across Halton and within Wards. Map 2: Deprivation levels relative to England Source: Index of Multiple Deprivation

26 Taking Castlefields as an example, it can be seen in Table 1 that whilst a very deprived ward this is not equally spread. 47% of the population lives in the 0-10 most deprived decile and 53% of the population lives in the most deprived decile. Table 1: Percentile of SOA deprivation by Ward Appleton 23% 26% 51% Beechwood % 31% Birchfield % - Broadheath - 52% 23% % Castlefields 47% 53% Daresbury % 39% - Ditton 26% 47% % Farnworth % % 54% - - Grange 44% 21% 35% Hale % Halton Brook 48% % Halton Lea 77% 23% Halton View - 42% - 21% 18% - 18% Heath % - 27% 27% 23% Hough Green 61% % - 19% - - Kingsway 30% 25% 24% - 21% Mersey 24% 28% 22% 26% Norton North - 26% - 22% - 24% - 28% - - Norton South 17% 62% % Riverside 74% - 26% Windmill Hill 100% Overall 27% 22% 10% 7% 8% 7% 6% 8% 6% 0% Source: Index of Multiple Deprivation 2007 Hence when reviewing this report, ward trends should not be applied across all SOAs within that ward. This may go some way to explaining any anomalies within the ward analysis contained within this report and hence serve as a signpost for further detailed analysis within certain wards. Further information on the Index of Multiple Deprivation (IMD) 2007 can be found in section (Deprivation) but below is a list of Halton s wards ranked by Health Deprivation, with Windmill Hill, ranked at 1, the most health deprived ward in Halton and Birchfield the least health deprived ward and so ranked 21 st. This Health Deprivation information is used throughout the forthcoming sections of this document to show the amount of correlation between Health Deprivation and various indicators. Table 2: Health Deprivation Rank in Halton Health Deprivation IMD 2007 Rank within Halton 1 Windmill Hill 2 Castlefields 3 Halton Lea 4 Riverside 5 Norton South 26

27 6 Halton Brook 7 Kingsway 8 Grange 9 Appleton 10 Ditton 11 Mersey 12 Hough Green 13 Broadheath 14 Halton View 15 Norton North 16 Heath 17 Farnworth 18 Hale 19 Beechwood 20 Daresbury 21 Birchfield Source: Index of Multiple Deprivation

28 General Population 2.1 Demographic profile Population Halton has a total resident population of 119,500 (Office for National Statistics (ONS) mid 2006 estimates). The population of the borough has decreased over the past ten years by approximately 2%, from 121,700 in 1996, although this figure has risen slowly again since The age of the local population inevitably has an impact on health experience and the level of health services likely to be required. Populations with a higher percentage of over 65 s are likely to have a higher level of need. Current estimates highlight that Halton has a younger population than the national and regional averages. The population pyramid below shows the structure of the population. In developing countries the population structure in the younger age groups is bigger and older age groups are a lot smaller. However, in most developed countries this has changed whereby the population in middle and older age groups is growing and in younger age groups declining and therefore the pyramid is less like a traditional pyramid and with similar numbers across the age groups until the older age groups. Table 2 presents the percentage of the population with broad age bands, comparing local, regional and national figures. As Table 3 and Chart 1 illustrate, a greater proportion of Halton residents are children, compared with both national and regional figures. Halton has a smaller proportion of residents aged between 65 and 74 than nationally and regionally, and far fewer residents aged 75+. Table 3: Mid 2006 Population Estimates, Halton, North West and England Difference Age Band England North West Halton Halton & England % 17.9% 18.9% 1.2% % 19.7% 19.7% 0.1% % 21.2% 21.2% -0.9% % 25.0% 26.4% 1.8% % 8.6% 7.7% -0.5% % 7.6% 6.0% -1.7% Source: 2006 Mid Year Estimates, ONS 28

29 Chart 1: Halton Population Pyramid 2006 Population Pyramid, Halton, 2006 mid year estimates Source of data: National Statistics, Compendium of Clinical and Health Indicators / Clinical and Health Outcomes Knowledge Base Crown Copyright Source: ONS Mid 2006 Estimates males females 5,000 4,000 3,000 2,000 1,000 Source : ONS Mid 2008 Estimates 0 1,000 2,000 3,000 4,000 5,000 Changing Population Structures The age structure of the Halton population has changed considerably over the past ten years. In 1996, 12.9% percent of the total population were aged over 65, by 2006 this had increased to almost 14%. In the same period there was a 0.1% increase in proportion of over 65 s in England as a whole. The ageing population is set to continue, with projections suggesting that the population of the borough will continue to age at a faster rate than national averages. Population projections are available from the Office for National Statistics (ONS) at local authority level, by age band and gender. However the projected population figures outlined below must be treated with caution although it is expected that the trend of an ageing population will continue. Also these projections assume recent population trends continue and so do not reflect the impact of future development policies on the population of the local areas. Table 4: Halton population growth Year Population Count Population Growth (over 2006) , , % , % Source: 2006 Mid Year Estimates, 2004 Population Projections (Revised), ONS 29

30 Chart 2: Halton growth by age band Broad Age Group Distribution of Halton Residents 2006, 2012 and 2022 M F M F M F % 19.8% 17.3% 19.2% 16.8% 18.9% 19.2% 20.3% 18.9% 20.0% 16.7% 17.7% 21.6% 21.2% 19.2% 18.7% 19.1% 19.4% 26.3% 26.2% 27.9% 27.3% 26.5% 25.6% 15.1% 12.4% 16.5% 14.5% 20.6% 18.5% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Source: 2006 Mid Year Estimates, 2004 Population Projections (Revised), ONS Between 2006 and 2012 the population in Halton is predicted to decrease under age groups under 45 but increase in older age groups. Looking further ahead by 15 years the trends described above continue and become even starker, as follows: The age groups and show the greatest difference between the current year and The 65 year olds and above will increase by 43.3%. The 75 year olds and above will increase by 41.7%. The 85 year olds and above will increase by 62.5%. The tables below illustrate that the population is projected to decrease in the younger age groups and increase in the older age groups over time. It must be noted however that predicting populations is thwart with difficulties and government policies on immigration can greatly influence the data. New data for 2006 is currently being consulted upon and may show a different story as some influences from migration may start to be shown through this data. Table 5: Halton Age Distribution 2006 vs 2012 Age Variance Change ,600 21, ,600 23, ,300 22,800-2, ,500 33,100 1,600 5 All > 65 Years 16,400 18,400 2, All > 75 Years 7,200 7, All > 85 Years 1,700 1,

31 Source: ONS Mid year population estimates 2006 and ONS 2004 revised population projections Table 6: Halton Age Distribution 2006 vs 2022 Age Variance Change ,800 21,400-1, ,100 20,600-2, ,700 23,200-2, ,100 31, All > 65 Years 16,400 23,500 7, All > 75 Years 7,200 10,200 3, All > 85 Years 1,600 2,600 1, Source: ONS Mid year population estimates 2006 Table 7 below shows Halton is predicted to have a higher proportion of their population in the 0 14 age group and the age groups than the national average at each future projection point. Although the population of Halton is predicted to get older the proportion of adults in the oldest age group over 75 is less than national predictions. It should be noted that accurate population projections were not available when this document was being put together beyond 2015 for England to do a comparison over a greater time period. Table 7: Percentage of the population by age group Halton England Halton England Halton England Source : (ONS Mid Year population estimates 2006) Ethnicity Halton has a relatively small Black and Minority Ethnic (BME) population. Despite a small increase in the proportion of non-white population between 2001 and 2005 from 1.2 to 1.85%, the proportion has increased at a quicker rate in other areas. The national average is 9.9% and the North West average 7.1%. Whilst the ethnic distribution varies between children and those age over 65 years, the differences are insignificant. Table 8: Percentage Age Distribution of Ethnic Groups Ethnic Group All people White 98.2 Mixed 0.8 Asian or Asian British 0.5 Black or Black British 0.3 Chinese or other ethnic group 0.4 Source: 2005 ONS ethnicity estimates 31

32 The latest breakdown of ethnicity by ward is from 2001 census data. This shows that there is relatively little ethnic diversity across all wards in Halton, each having a predominantly white population. This varies from 98.06% in Birchfield, to 100% in Hale. The full breakdown is given below in Table 8. In terms of correlation to Health Deprivation ranking based on the IMD 2007 (See Deprivation), there does not appear to be a correlation between the white population % and level of health deprivation overall. It is perhaps surprising that the least deprived in terms of Health (Birchfield) has the lowest proportion of its population classified as White but the figures for each ward are too similar to place too much emphasis on this. Table 9: White Population % By Ward Ward White Population % Health Deprivation Ranking Birchfield Mersey Norton North Halton Lea Castlefields Hough Green Grange Kingsway Daresbury Norton South Appleton Beechwood Halton Brook Broadheath Windmill Hill Halton View Farnworth Riverside Heath Ditton Hale Source: 2001 Census Migration Urban policy in Britain has focused on area-based regeneration, targeting resources at selected neighbourhoods with high levels of multiple deprivation. The aim has been to create areas of upwardly mobile populations who use their newly-acquired skills to secure more secure employment. Frequently the beneficiaries of such policies may also choose to move to more affluent residential areas either in the same city/town or beyond. Migrants moving in may have different expectations and needs. Those who stay may be less able to secure employment, may have long-term limiting disabilities or be retired. 32

33 Table 10 shows the number of national insurance number registrations to non-uk nationals within the Borough in 2006/07. A total of 280 people were registered of which the majority came from Poland or the Slovak Republic. The actual number of people who come to live here that are non-uk nationals may be larger as some will not register and those that do register may have also have partners of other family members. The exact number between censuses is hard to determine. Table 10: National Insurance Number Registrations in respect of non-uk Nationals in 2006/07 by Local Authority and country of origin Country of origin Number All 280 Poland 130 Slovak Republic 30 Australia 10 France 10 China People s Republic 10 Republic of Latvia 10 USA 10 Republic of Ireland 10 Philippines 10 Thailand 10 Source: ONS Revised Estimates Religion Table 11 shows the Halton population split by religious group. Halton has a significantly higher proportion of people that state their religion to be Christian (84%) than in the North West (78%) or in England overall (72%). A smaller proportion of the Halton population (9%) state that they have no religion than in the North West (10%) or in England (15%). Table 11: Halton Population by Religious Group Halton North West England All People 118,204 6,729,764 49,138,831 Christian 99,096 (84%) 5,249,686 (78%) 35,251,244 (72%) Buddhist 114 (0%) 11,794 (0%) 139,046 (0%) Hindu 98 (0%) 27,211 (0%) 546,982 (1%) Jewish 41 (0%) 27,974 (0%) 257,671 (1%) Muslim 150 (0%) 204,261 (3%) 1,524,887 (3%) Sikh 32 (0%) 6,487 (0%) 327,343 (1%) Any other religion 123 (0%) 10,625 (0%) 143,811 (0%) No religion 10,273 (9%) 705,045 (10%) 7,171,332 (15%) Religion not stated 8,277 (7%) 486,681 (7%) 3,776,515 (8%) Source: 2001 Census 33

34 2.1.5 Disability The percentage of people that described themselves as having a limiting long term illness in Halton varied from high levels in Castlefield, Windmill Hill, Halton Lea, Ditton and Appleton to low levels of 15% or less are seen in Beechwood, Daresbury and Birchfield. Mapping this against health deprivation ranking shows a strong correlation, with the three wards with the highest percentage of people with a limiting long-term illness being the three most deprived wards in terms of Health, and conversely, the three wards with the lowest percentage are the three least health deprived wards. Table 12 shows this correlation in more detail and this should be considered strongly in future health commissioning. Table 12: Limiting Long Term Illness for Halton Ward Percentage of people with a long term illness % Health Deprivation Ranking Castlefields Windmill Hill Halton Lea Appleton Ditton Grange Riverside Halton View Halton Brook Broadheath Kingsway Mersey Hough Green Heath Norton South Hale Farnworth Norton North Beechwood Daresbury Birchfield Source: Neighbourhood Statistics, 2001 Census As would be expected there is very strong relationship between the proportion of households claiming disability allowance and levels of deprivation with Castlefields, Windmill Hill and Halton Lea the three most health deprived wards and these are the three wards with the highest proportions of households where disability allowance is claimed. On the other hand, Birchfield is the least deprived ward in terms of health and has the lowest percentage of households that claim disability allowance. 34

35 It is interesting to note that all 36 households where disability is claimed and the head of the household is below 25 fall within two wards Windmill Hill and Riverside. Castlefields has the highest number of households where disability allowance is claimed in the two age bands between 25 and 59 for the head of household but has fewer than wards such as Ditton, Halton Lea and Mersey in the older age bands, indicating a younger population found in Castlefields than these latter three wards. Table 13 sets out the proportion of households claiming disability allowance by age group and by ward. 35

36 Table 13: Number of households claiming disability allowance by age group and ward Head of Head of Head of Head of Household Household Household Household Head of % of Health Total Aged 16 - Aged 25 - Aged 45 - Aged 60 - Household households Deprivation Ward households Aged 75+ Total in ward Ranking Castlefields Windmill Hill Halton Lea Kingsway Broadheath Appleton Riverside Grange Norton South Halton Brook Hough Green Mersey Norton North Ditton Daresbury Halton View Heath Hale Beechwood Farnworth Birchfield TOTAL Source: Neighbourhood Statistics, 2001 Census The wards with the highest proportion of adapted households are Appleton, Castlefields, Grange and Riverside respectively. There is not an exact correlation to the wards with the highest levels of limiting long-term illness (Table 12), showing that not all people with a physical disability require an adaptation to their property but it would be reasonable to expect a relationship. There some anomalies where this relationship is inversed, such as Ditton, which has a relatively high number of adaptations compared to the number of people with a disability, and Kingsway where the reverse of this is the case, but overall there is a general trend that wards with a higher health deprivation ranking tend to have a higher proportion of households with adaptations. 36

37 Table 14: Number of households whose home has been built or adapted to meet the needs of a disabled person Health Deprivation Ward Total Adaptations - number Adaptations % Ranking Appleton Castlefields Grange Riverside Hough Green Windmill Hill Ditton Broadheath Halton Lea Norton South Birchfield Kingsway Mersey Farnworth Heath Hale Daresbury Norton North Halton Brook Halton View Beechwood TOTAL % Source: Neighbourhood Statistics, 2001 Census Table 15 indicates the percentage of benefit claimants on incapacity benefit by ward areas in Halton. Overall of Halton 53% of benefit claims are for incapacity benefits, which indicates inability to work due to a disability. This varies from 60.93% in Halton View to 45.89% in Norton South. In terms of correlation to Health Deprivation ranking, there appears to be no clear links between a high health deprivation ranking and having the highest proportion of claimants on incapacity benefits. Table15: Incapacity Benefit Claimants 2003 CAS ward % of Claimants on Incapacity Benefit Halton View Castlefields Farnworth Beechwood Broadheath Hale Norton North Ditton Halton Lea Daresbury Riverside Health Deprivation Ranking 37

38 Halton Brook Birchfield Hough Green Appleton Heath Kingsway Windmill Hill Mersey Grange Norton South Source: Nomis, Social and Environmental context Deprivation In January 2008 a State of the Borough report for Halton was published following research commissioned through the Halton Data Observatory. This report compares Halton with other districts, both on a regional and national scale. One of the main findings of this report was that health inequality remains of great concern in Halton. Shortly before this the latest national Index of Multiple Deprivation (IMD) was published. This Index ranks each local authority in England in terms of deprivation across seven different domains. Overall, the IMD 2007 ranked Halton as the 30 th most deprived local authority in England, an improvement from 21 st at the time of the last IMD in Within Halton, the 21 wards were ranked as follows across each domain overall, with Windmill Hill the most deprived ward, and Birchfield the least deprived. Table 16: Wards Ranked within the IMD 2007 Rank within IMD 2007 Halton 1 Windmill Hill 2 Halton Lea 3 Castlefields 4 Riverside 5 Norton South 6 Kingsway 7 Appleton 8 Halton Brook 9 Grange 10 Mersey 11 Ditton 12 Hough Green 13 Broadheath 14 Halton View 15 Norton North 38

39 16 Hale 17 Heath 18 Farnworth 19 Beechwood 20 Daresbury 21 Birchfield Deprivation is a major determinant of health. Lower income levels often lead to poor levels of nutrition, poor housing conditions, and inequitable access to healthcare and other services. There are a range of deprivation indicators that have been developed to assist in assessing and comparing deprivation, or poverty, at the neighbourhood, local area, regional or national level. Deprivation indicators can be used to identify local populations at health risk, enabling action and resources to be better targeted at specific groups. The IMD is based on 32,482 Super Output Areas (SOAs) across the country. SOAs are a small geographical unit of around 1,500 people. Map 4 illustrates the distribution of deprivation in Halton SOAs (of which there are 79), grouped according to the national ranking. SOAs in Quintile 1 are within the most deprived 20% of areas in England, SOAs grouped in Quintile 5 are within the 20% least deprived in England. The map shows that deprivation within Halton is quite widespread, and there are a high number of Halton SOAs ranked within the most deprived quintile nationally. Map 3: IMD 2007, Distribution of Deprivation in Halton (National Quintiles) 39

40 More specifically in terms of Health, the results of the Health Domain shown in the map below make for interesting reading. Overall, 53 out of Halton s 79 SOAs are in the top quintile indicating that this domain is still the one giving Halton its highest deprivation rankings. However this is down from 57 in 2004, showing the overall position has slightly improved. Having said that, the number of SOAs in the worst 4% nationally in Halton has increased from 24 to 27, showing the gap between the healthiest part of Halton and the least healthy is widening despite this improvement overall. 33% of Halton s population lives within this top 4% nationally, up from 30% in Despite Windmill Hill being the ward with the highest deprivation levels overall, the SOA with the greatest health deprivation is still in Castlefields, ranked as the 32nd most deprived SOA nationally in terms of Health. This is an improvement from 2004, when this SOA was ranked as 27 th worst nationally. Map 4: SOAs in Top 20% Nationally for Health Deprivation 40

41 Social Marketing ACORN is a consumer profiling tool that combines geography with demographics and lifestyle information, places where people live with their underlying characteristics and behaviour, to create a tool for understanding the different types of people in different areas throughout the borough. The study shows that a similar proportion of people in Halton are comfortably off as in the UK population at large, but a much lower proportion of Halton residents are classed as wealthy achievers or living in urban prosperity when compared to the UK average. People in Halton are more likely to be hard pressed and more live in moderate means than in the UK overall. Wealthy Achievers 40% 35% 30% 25% 20% Hard Pressed 15% 10% 5% 0% Urban Prosperity Halton UK Moderate Means Comfortably off Source: ACORN Living Arrangements Types of housing tenure are a reflection not just of the individual householder but of the surrounding environment, including availability of social and leisure amenities, cleanliness and crime. This may relate to the level of commitment people feel to the area including levels of migration. Table 15 shows the great variation in housing tenure in Halton. Owner occupancy varies from 99% of households in Birchfield to 6% of households in Windmill Hill, which has the greatest percentage of social rented dwellings. Birchfield on the other hand, contains no social rented dwellings. A significant proportion of social rented housing is located in the New Town estates in Runcorn. 41

42 The greatest proportion of privately rented accommodation is in Appleton, where 9% of households are privately rented compared with only 1% in Birchfield and Windmill Hill. Overall in Halton, 66% of households are owner occupied, 28% are socially rented and 4% privately rented, with the remainder being shared ownership dwellings, tied to employment tenancies or households living rent free. When housing tenure is compared to health deprivation, it becomes clear that there is a strong correlation. The eight most deprived wards in terms of health have the lowest proportion of owner occupation in Halton, whereas the eight wards with the lowest health deprivation have the highest levels of owner occupancy. Table 17: Housing tenure Ward Owner - Health Social Private occupancy Other % Deprivation Rented % rented % % Ranking Windmill Hill 6% 92% 1% 1% 1 Castlefields 34% 61% 2% 3% 2 Halton Lea 40% 53% 3% 4% 3 Norton South 49% 47% 3% 2% 5 Riverside 51% 37% 7% 5% 4 Grange 55% 40% 2% 3% 8 Kingsway 60% 33% 3% 4% 7 Halton Brook 62% 32% 5% 1% 6 Broadheath 65% 28% 4% 4% 13 Mersey 65% 24% 8% 3% 11 Hough Green 65% 27% 4% 4% 12 Appleton 68% 18% 9% 4% 9 Ditton 70% 24% 2% 3% 10 Norton North 70% 22% 3% 5% 15 Halton View 77% 16% 4% 2% 14 Heath 86% 6% 6% 2% 16 Farnworth 89% 7% 5% 0% 17 Hale 92% 2% 6% 0% 18 Daresbury 94% 2% 3% 2% 20 Beechwood 95% 2% 3% 0% 19 Birchfield 99% 0% 1% 1% 21 Halton overall 66% 28% 4% 3% Source: Halton Housing Needs Survey 2006 Despite the high volume of low value property, the Halton Housing Needs Survey undertaken in 2006 pointed to an affordability issue in the Borough arising from the relationship between average incomes and the cheapest housing available. This, coupled with the current economic climate making it increasingly difficult for first time buyers to access a mortgage, is likely to impact on the profile of the housing stock. The number of households applying for social housing is on the increase, while the number of vacancies in the social rented sector is declining as a result of restricted 42

43 mobility between social renting and owner occupation. It is inevitable that those unable to access either tenure will look to the private rented sector to meet their housing needs. While figures collected in late 2005 revealed a relatively low proportion of private rented housing in the Borough, it is likely that this level is now significantly higher. As the economic situation continues, it is likely to put greater pressure on Council resources which could have an adverse impact on the health of households in private rented housing Table 18 shows that Halton has a significantly higher proportion of Band A dwellings, which are the lowest rated for Council Tax housing stock than the North West or England. Each band represents a higher valuation of housing (based on April 2001 prices) and from Band C onwards, Halton has a lower proportion of its housing stock within these bands than found regionally or nationally, which will impact on the level of money generated through Council Tax. Table 18: Dwelling Stock by Council Tax Band Band A Band B Band C Band D Band E Band F Band G Band H Band I Halton 48% 20% 15% 8% 6% 2% 1% 0% 0% North West 43% 19% 17% 10% 6% 3% 2% 0% 0% England 25% 19% 22% 15% 9% 5% 4% 4% 0% Source: Council Tax Band, 2006 The April 1991 Council Tax Bandings for England are as follows: Band A - up to 40,000 Band B - 40,001-52,000 Band C - 52,001-68,000 Band D - 68,001-88,000 Band E - 88, ,000 Band F - 120, ,000 Band G - 160, ,000 Band H - 320,001 and above Housing type illustrates the type of accommodation people live in. Overall, in 2006, 90.3% of households in Halton were living in a house or bungalow, varying from 69.6% in Castlefields to 98.9% in Hale. Castlefields had the highest proportion of flats, maisonettes or apartments at 30.4%. The percentage of households living in caravan, mobiles or other temporary structures was low at 0.2%. Table 19: Property types by Ward Ward % House or Bungalow % Flat, maisonette or apartment Appleton Beechwood Birchfield Broadheath % Caravan or other mobile or temporary structure 43

44 Castlefields Daresbury Ditton Farnworth Grange Hale Halton Brook Halton Lea Halton View Heath Hough Green Kingsway Mersey Norton North Norton South Riverside Windmill Hill Halton Source: Halton Housing Needs Survey Transport The data shows similar levels of car and van ownership in Halton as found regionally and nationally. Halton has a greater proportion of households with no cars or vans than England overall, (29% compared to 27%), but fewer than the North West average (30%). Table 20: Access to Car or Van Total No Car Households or Van Halton 47, ,082 (29%) North 2,812, ,769 West (30%) England 20,451,427 5,488,386 (27%) Source: 2001 Census 1 Car or Van 21,287 (44%) 1,224,554 (44%) 8,935,718 (44%) 2 Cars or Vans 10,428 (22%) 605,586 (22%) 4,818,581 (24%) 3 Cars or Vans 4 or more Cars or Vans 1,724 (4%) 430 (1%) 104,120 (4%) 924,289 (5%) 28,760 (1%) 284,453 (1%) When breaking down the Halton data by ward, the following headlines can be highlighted: The two most deprived wards in terms of health deprivation (Windmill Hill and Castlefields) have the greatest proportion of households with no cars or vans The least health deprived ward (Birchfield) has the lowest proportion of households with no cars or vans. Access to cars or vans will have a significant impact on ability to access health services and employment. 44

45 Birchfield and Daresbury have the lowest proportion of households with 1 car or van, but this is because over 60% of households in both wards have at least 2 cars or vans. Beechwood has the highest proportion of households with 4 or more cars or vans. Table 21: Access to Car or Van per Household by Ward Ward No Car or Van Health Deprivation Ranking Windmill Hill 48.3% 1 Castlefields 45.1% 2 Appleton 42.7% 9 Riverside 38.1% 4 Halton Lea 37.3% 3 Grange 37.3% 8 Kingsway 35.6% 7 Mersey 35.6% 11 Norton South 34.3% 5 Hough Green 33% 12 Broadheath 32% 13 Halton Brook 29.8% 6 Ditton 29.1% 10 Halton View 26.1% 14 Heath 17.9% 16 Norton North 17.5% 15 Farnworth 15% 17 Hale 11.6% 18 Beechwood 6% 19 Daresbury 4.8% 20 Birchfield 3.5% 21 Source: 2001 Census Halton Residents Access to Services The data below shows that overall there is good access to services across each sector in Halton, in particular around access to employment and supermarkets or convenience stores. Access to education provision should be further improved through Building Schools for the Future and Primary Capital Programme (secondary and primary provision respectively) developments in Halton within the next few years. It is important to note that there could be implications around health for residents who are not within 15 or 30 minutes of a GP or hospital. The residents affected will mostly be in the most health deprived wards, 45

46 Table 22: Access to Services Health Proportion of Households within 15 minutes of a GP by public 93.6% transport or walking Proportion of Households within 30 minutes of a GP by public 99.2% transport or walking Proportion of Households within 30 minutes of a hospital by 97.1% public transport or walking Proportion of Households within 60 minutes of a hospital by 100% public transport or walking Employment Population of Employment Age (16-74) 87,516 Jobseekers 2,272 Proportion of Employment Age Population within 20 minutes of 100% at least 500 jobs by public transport, walking or cycling Proportion of Employment Age Population within 40 minutes of 100% at least 500 jobs by public transport, walking or cycling Jobseekers within 20 minutes of at least 500 jobs by public 100% transport, walking or cycling Jobseekers within 40 minutes of at least 500 jobs by public 100% transport, walking or cycling Education Population Aged ,953 Free School Meals Population Aged ,895 (21.2%) Proportion within 15 minutes of primary school by public 91.1% transport or walking Proportion within 30 minutes of primary school by public 100% transport or walking Population Aged ,467 Free School Meals Population Aged ,539 (18.2%) Proportion within 20 minutes of primary school by public 89.6% transport or walking Proportion within 40 minutes of primary school by public 99.5% transport or walking Population Aged , Year Olds within 30 minutes of a Further Education 91.9% College by public transport, walking or cycling Year Olds within 60 minutes of a Further Education 98% College by public transport, walking or cycling Supermarket or Convenience Store Indicator Proportion of Households within 15 minutes of a Supermarket or 99.98% Convenience Store by public transport or walking Proportion of Households within 30 minutes of a Supermarket or 100% Convenience Store by public transport or walking Source: Department of Transport 46

47 2.2.5 Economic The State of the Borough report 2008 for Halton highlighted the following key economic findings: Halton is performing well in terms of its current economic performance and structure. However, the level of human capital and trends in economic growth may present problems for the future. This is particularly so given the district s poorer performance in terms of some social and environmental indicators, which may create difficulties attracting the best qualified people to the borough. Halton s performance on education and skills (although improving), and low levels of home ownership point to problems of inclusiveness, with some groups of residents not sharing in the current levels of economic prosperity. The evidence suggests that the gap in prosperity between the richest and poorest neighbourhoods is widening. The policy implications are that a broad based approach to regeneration is still needed to deal with the depth and breadth of challenges in Halton. However, poverty of place issues need to be urgently addressed in terms of narrowing the gap between areas within the borough Overall Employment Rate (NI 151) The graph below shows Halton s employment rate in relation to each local authority in the North West. Based on these figures from Quarter 2 of the , Halton s employment rate is 67.8%, which equates to over 50,000 Halton residents in employment. Halton s employment rate is the 9 th worst in the North West out of 43 local authorities, and the 34 th worst nationally. The national average employment rate is 74.3%. 47

48 Chart 3: Overall Employment Rate Ribble Valley Congleton Macclesfield Eden Wyre Stockport Carlisle Warrington South Ribble Fylde South Lakeland Trafford Lancaster Allerdale Chorley Ellesmere Port and Chester Vale Royal Crewe and Nantwich Tameside Bury West Lancashire Barrow-in-Furness Bolton Wigan Salford Sefton Hyndburn Rochdale St. Helens Wirral Oldham Rossendale Preston Halton Blackpool Blackburn with Darwen Pendle Manchester Burnley Knowsley Copeland Liverpool 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% Unemployment Rate In 2007 the Halton unemployment figure was 6.9%. This was significantly higher than the overall North West rate of 5.6% and the national average of 5.2%. Halton s rate of 6.9% equated to 4,100 working age residents Working age people on out-of-work benefits (NI 152) The graph below shows that in Quarter 2 of 2007 Halton had the 7 th highest percentage of working age people claiming out-of-work benefits (18%) in the North West. This equates to over 13,000 people from Halton. Nationally, 11% of working age people are claiming out of work benefits, much lower than the rate in Halton. Indeed, Halton has the 21 st highest rate nationally. 48

49 Chart 4: Working Age People on Out of Work Benefits Eden Ribble Valley South Lakeland Macclesfield Congleton South Ribble Fylde Chester Chorley Crewe and Nantwich Vale Royal Stockport Warrington Wyre Trafford Lancaster Ellesmere Port and Neston Carlisle Bury Allerdale Rossendale West Lancashire Preston Copeland Pendle Bolton Sefton Wigan Tameside Oldham Hyndburn St. Helens Rochdale Blackburn with Darwen Wirral Burnley Halton Barrow-in-Furness Salford Manchester Blackpool Knowsley Liverpool 0% 5% 10% 15% 20% 25% Working age people on out-of-work benefits in the worst performing neighbourhoods (NI 153) The term worst performing neighbourhoods is defined as SOAs with over 25% of the working age population claiming out of work benefits. In Halton, Government Office for the North West (GONW) have identified 25 SOAs as the worst performing neighbourhoods. Of these, 20 fall within the top 10% most deprived areas nationally (IMD 2007). These are shown in red on the map below, with the remaining 5 as orange. These SOAs fall within the following 15 of Halton s wards: Table 23: Working Age People on Out of Work Benefits in the Worst Performing Neigbourhoods Ward Health Deprivation Ranking Windmill Hill 1 Castlefields 2 Halton Lea 3 Riverside 4 Norton South 5 Halton Brook 6 Kingsway 7 Grange 8 Appleton 9 Ditton 10 Mersey 11 49

50 Hough Green 12 Broadheath 13 Halton View 14 Norton North 15 Source: Index of Multiple Deprivation 2007 The 15 wards within which Halton s 20 SOA s are located that fall within the top 10% most deprived areas nationally are the 15 most health deprived wards in Halton. In these areas, 31.6% of working age people were claiming out of work benefits during Quarter 2 of This is around 7,000 Halton residents claiming out of work benefits. Nationally the figure is 31.2%. Map 5: Working Age People on Out of Work Benefits in the Worst Performing Neigbourhoods Income The average household income in each ward in Halton in early 2008 was as shown in the table below. Overall, the average household income was 32,256.19, ranging from 54,060 in Birchfield to 23,260 in Windmill Hill. The table shows that there is a close correlation between household income and deprivation, with the lowest income seen in the two most health deprived wards, and the eight highest average household incomes found in the eight wards with the best health deprivation ranking. 50

51 Table 24: Average Household Income by Ward Ward Average Household Income Health Deprivation Ranking Windmill Hill 23,260 1 Castlefields 25,440 2 Grange 25,890 8 Halton Lea 25,970 3 Norton South 27,080 5 Mersey 27, Appleton 27,250 9 Riverside 27,520 4 Broadheath 28, Halton Brook 28,840 6 Kingsway 29,060 7 Ditton 29, Hough Green 29, Halton View 31, Heath 32, Hale 35, Farnworth 38, Norton North 39, Beechwood 40, Daresbury 51, Birchfield 54, Source: Halton SMART Observatory; CACI Information Solutions 2.3 Environment A healthy environment should be of concern to everyone, as the quality of human life depends fundamentally on the quality of the environment. The natural environment is a subjective topic which makes benchmarking problematic; nevertheless it is an important consideration in any attempt to carry out a comprehensive audit of conditions in an area. An area s natural environment can be an important consideration in economic development. The natural environment is important to Halton, which aims to create an attractive borough with quality accessible open space that is valued by the local community, and strategic routes through the borough which are well landscaped and create an image which will be attractive to new investors and potential new residents. As a result of its heritage in the chemical industry, Halton has inherited a number of environmental problems. Gaining unitary status in 1998 has helped to co-ordinate more activity over a wider front and increased the resources the Council and its strategic partners have been able to invest in Halton. However, there still remains much to be done. 51

52 Research from the Halton Data Observatory gives Halton a score of 72 as an index where the English average is 100, ranking it 249th out of 354 districts in England for the quality of its natural environment. Halton scores for natural beauty, and 68.2 for tranquillity, both indexed against England. How we feel about where we live and the environment in which we will in has an impact on our health. One indicator of our environment is spread of the population. Highly populated areas could mean that there is little green space and more congestion in relation to traffic, both could have an impact on the ability to have space for activities and the local air pollution. Conversely populations of low density may have less access to services and people may have to rely on personal transport if good public transport is not available. The IMD 2007 shows some links between living environment deprivation and health deprivation. This is shown in terms of some of the least health deprived wards, such as Birchfield and Daresbury, also having the best living environment ranking. However, the two most deprived wards for health, Windmill Hill and Castlefields, are mid-ranking in terms of their living environment, so a correlation between the two is not exact Population Spread The majority of Halton is of low population. For both Runcorn and Widnes it is areas towards their respective town centres that are the most densely populated. In relation to geographic spread of the population the Electoral Wards of Hough Green, Broadheath, Halton Brook and Grange have the highest population densities. The least dense areas are towards the peripheries of Halton, in Hale and Daresbury, with Riverside, Heath and Ditton (due to their industrial area)s. There is not a strong correlation between population density and levels of deprivation, which is perhaps surprising. Map 5 looks at population density in terms of SOAs, while Map 6 looks at broader ward-level population density. 52

53 Map 6: Population Density Urban/Rural Classification The map below shows that just 2 of the 21 wards within Halton have any Rural classification these being Hale and Daresbury. The entire ward of Hale is classified as Rural, with the majority, but not all, of Daresbury also Rural. The rest of Halton, including the remaining areas of Daresbury, are Urban. 53

54 Map 7: Urban/Rural Classification Source: ONS, August 2008 Key Messages for Health and Social Care Windmill Hill, Castlefields and Halton Lea are the three most deprived wards in Halton in terms of Health. Birchfield, Daresbury and Beechwood are the three least deprived. Halton currently has a younger population than seen overall nationally but there is expected to be a sharp increase in Halton s older population in the next 15 years, which will have significant cost implications for Health and Social Care if preventative measures are not taken. Overall, the IMD 2007 shows that there has been a slight improvement in Health Deprivation in Halton since 2004, but the gap has widened between the most and least deprived. 33% of Halton s population live in the top 4% most health deprived areas of the country. There is a strong correlation between Health deprivation and the following indicators when looking at Halton on a ward-by-ward basis: o Proportion of the population with a limiting long-term illness o Proportion of households claiming incapacity benefits o Housing tenure o Proportion of the population without access to cars or vans o Household income 54

55 2.4 Lifestyle and risk factors It is important to understand the lifestyles of the local population in order to commission targeted preventative services. However, these should not be seen in isolation but as part of an integrated care pathway. Derek Wanless in his 2004 report Securing Good Health for the whole population stated that: if current targets for smoking cessation, teenage pregnancy, obesity and physical activity and diet are met, by 2022 we would see 10% fewer hospital admissions, GP visits and prescriptions related to coronary heart disease and stroke for year olds, 5% reduction in all other hospital admissions, GP visits and prescriptions for year olds. 5% fewer births requiring special or intensive care due to reductions in teenage pregnancy and reduced levels of smoking in pregnancy. There is a need for: a re-alignment of incentives in the system to focus on reducing the burden of disease and tackling the key lifestyle and environmental risks. Individual lifestyle represents just one of the many determinants of health, and health inequalities. Research illustrates that there are variations in individual risk behaviours across socio-economic classes. Understanding these variations and the trend in health-related behaviour overall is crucial in order to inform the commissioning and targeting of health improvement and prevention services. Information on lifestyle is not routinely collected through any standard data source. To gain an understanding of individual health related behaviour it is necessary to conduct an in-depth survey or undertake an additional data collection exercise. In 2000/01 Halton commissioned a comprehensive health and lifestyle surveys to better understand local health need and health-related behaviour. The survey was repeated in 2006, a summary of key results is presented here, and full results have been reported elsewhere.* Also this information is added to by data provided in the Annual Patients Survey Listening to Patients published in May 2008 (see Voice Section for further information on this survey) Smoking In the Lifestyle Survey 2006, overall, 25.6% of Halton residents responded that they currently smoke; this suggests that there are approximately 24,500 adult smokers in the borough. These figures suggest a reduction in smoking prevalence within Halton since 2001, when prevalence was estimated to be 29.2%. As in 2001, current estimates suggest that there is a slightly higher proportion of male smokers overall 26.1% compared with 25% of females. * Halton Health and Lifestyle Survey 2006 Summary of Initial Results 55

56 Smoking prevalence is higher in Runcorn, with 26.5% of residents reporting that they currently smoke, compared with 24.7% in Widnes. Prevalence varies considerably across age bands and by gender, with Runcorn males aged years reporting highest prevalence (32.1%). Amongst the younger age groups, a higher percentage of females; smoke 27.7% compared with 24.4%. The results of a Halton survey of 15-16's year old undertaken by the Consumer Protection Service highlighted that the smoking rates of year olds match the adults with although there is a significant difference in smoking take up rates 18% male and 29% female. 31% of year olds stated they bought cigarettes from street sellers, neighbours, private houses or vans a stark difference to the Northwest average of 16%. As such it is unsurprising that 60% have bought cigarettes with health warnings in a different language and 30% think they have bought fake cigarettes Chart 5: Prevalence of all smokers in Halton practices Smoking data is also recorded in General Practice as part of the Quality and Outcomes Framework and although this shows a lower percentage of smokers than the above survey results (22% - chart 5) this may be due to recording, however there is evidence that smoking rates have decreased since Further implications of smoke free legislation are yet to be seen within smoking prevalence results, all evidence from other countries that have introduced smoke free legislation indicate that prevalence will decrease yet further. A short survey is being undertaken by the Primary Care Trust of all GP s registered population, which may help to indicate current smoking prevalence within the borough. 56

57 The PCT Patient s Survey shows that of those who responded 52% had not smoked in the last 12 months, 8% had been given some advice from their GP/health centre to give up smoking, 2% would have liked advice but didn t receive it and 38% were not given advice but didn t want any. This indicates that at least 10% definitely smoked because they received advice or wanted advice in how to stop smoking. 38% did not want advice but we can not assume all of these smoked, some may not have wanted advice because they did not smoke Eating habits Lifestyle Survey (2006) respondents were asked questions about their usual diet. Almost 80% of Halton residents indicated that they ate less than the recommended 5 portions of fruit and/or vegetables a day, this is consistent with data from the PCT Patient s Survey where only 21% definitely ate 5 portions of fruit and vegetables a day and in line with modeled estimates produced nationally by the Association of Public Health Observatories and the Department of Health. Whilst this is a very large proportion of residents, there has been a marked improvement since the last survey, when 88% of residents reported eating less than the recommended 5 a day, and suggests that the health promotion message about the benefits of fruit and vegetables may be getting through. Lifestyle Survey (2006) results were further analysed to look at overall diet behaviour. Where residents indicated in two or more responses that fruit and/or vegetables were eaten less than three times a week, and that fried food was eaten more than twice a week, the respondent was classified as having a poor' diet behaviour. Overall, 17.8% of residents indicated that they had a poor diet. Again, this is an improvement on previous results, which indicated that 21% of residents consumed an unhealthy diet. Within the patients survey 28% ate 5 portions of fruit or vegetables on 1-3 days a week and 12% less than 1 day a week. The two surveys together indicate that there is still a lot more health promotion and interventions to help a greater proportion of our residents to eat 5 portions of fruit and vegetables daily. Males in the age group have the poorest diet, with lower intake of fruit and vegetables, and more poor diet habits. From September 2008 Halton and St Helens PCT was rebranded NHS Halton and St Helens to reflect its role/responsibilities in commissioning and service provision 57

58 Chart 6: Percentage of People with 2 or more poor Diet Behaviours Alcohol Lifestyle Survey (2006) respondents were asked four questions regarding their drinking habits. From these responses, it was possible to determine unsafe drinking levels. For men risk categories are defined as: 21 units or less per week ( low ), between 21 and 50 units ( medium ), and more than 50 units per week is deemed high risk. For women the equivalent figures are: 14 units or less ( low ), between 14 and 35 units ( medium ) and 35+ units per week high. Overall, 17.5% of Halton respondents indicated that they drank more units per week than considered safe under these guidelines. This represents an increase on the 2001 figure of 15.7%. Whilst a greater proportion of males drink to unsafe levels, (22.5% compared with 12.4% of females) the proportion of women drinking unsafely has increased considerably from the 6.9% figure reported in 2001, whereas the proportion of males drinking unsafely has decreased from 24.8% in Highest rates amongst males are in the age band, and in the age band amongst females. As may be expected, the younger age group reports highest rates of binge drinking, with 54.1% of males, and 33.2% of females aged reporting that they drank more than the recommended number of units per day in the last week. Binge drinking is more prevalent in Widnes, 36.5%, compared with 28.7% in Runcorn. 58

59 The patients survey also asked questions regarding alcohol consumption but the data was not split by male and female and so results are difficult to assess the true percentage drinking above recommended alcohol units. However, 13% of respondents were drinking more than 21 units (the limit for males) per week, an increase from previous surveys (9%). This information indicates that alcohol consumption is increasing and as yet there is no evidence that the health messages have affected consumption levels. The results of a Halton survey of 15-16's year old undertaken by the Consumer Protection Service highlighted that 47% of Halton yr olds drink alcohol at least once a week with 34% binge drinking (5 drinks or more on one occasion) at least once a week which is 5% higher than the Northwest average for this age group and 10% higher than the adult binge drinking rate. Nearly a third of girls and a quarter of boys aged yr olds claimed to drink more than the recommended weekly alcohol units. 13% of drinkers said they drank more than 30 units per week (Recommended limits are 14 for women and 21 for men per week). 78% say they drink because their friends do however 68% worry that their drinks may be spiked. Whilst these statistics are mirrored across the NW the following statistic is significantly higher for Halton, 59% say they drink alcohol because there is nothing else to do is compared with NW 28% and a whole of Cheshire comparison of 35%. The health effects and crime and disorder issues associated with excessive alcohol consumption are well documented. For Halton, 28% of year olds who drank alcohol admitted to having been violent whilst drunk. 15% had been in a car with a person who had been drinking and 13% indicated they had regretted sex after drinking alcohol. 59

60 Chart 7: Prevalence of Unsafe Drinkers (Halton Practices) Modelled estimates have been used nationally to ascertain the level of binge drinking. These have been developed by using Health Survey for England and extrapolating the results to local areas. Halton is estimated to have 23.9% of adults binge drinking. This varies from 28.4% in Norton to 20.5% in Farnworth. Halton has similar rates of binge drinking estimated in the North West but higher than the national rate of 18%. Data from hospital episode statistics has been extracted for all patients registered with a GP in Halton for all alcohol related admissions. International Classification of Disease (ICD 10) Codes were used to select the criteria for admission with a summary of the codes presented in table 25. (see also Appendix 1) Table 25: List of ICD10 codes used for alcohol conditions ICD10 Code Condition E244 Alcohol pseudo-induced Cushing s syndrome F10 Mental and behavioural disorders due to use of alcohol G312 Degeneration of nervous system due to alcohol G621 Alcoholic polyneuropathy G721 Alcoholic myopathy I426 Alcohol cardiomyopathy K292 Alcoholic gastritis K70 Alcoholic liver disease T510 Ethanol poisoning T511 Methanol poisoning X45 Accidental poisoning by and exposure to alcohol 60

61 Crude electoral ward rates have been calculated and based on this information it can be seen that Riverside and Broadheath electoral wards have higher rates of alcohol related admissions than the overall Halton rate (but not significant) rest of Halton and Daresbury, Beechwood, Hale, Birchfield, Farnworth and Heath have lower admissions than Halton as a whole. The number of alcohol related admissions by ward varies from 1 to 21 in a year and so the numbers are small therefore hard to make judgment about geographical variation. Chart 8: All Alcohol Admissions, 2006/07 by Ward Alcohol admisssions by electoral ward - April 2006 to March 2007, persons Source: Oracle Discoverer Rate per 1, Daresbury Beechwood Hale Birchfield Farnworth Heath Halton Brook Hough Green Kingsway Windmill Hill Grange Norton North Ditton Norton South Castlefields Halton View Mersey Appleton Halton Lea Broadheath Riverside When looking at the data for males and females separately the numbers are even smaller and so confidence intervals are wider. But males in Riverside and Broadheath have higher rates of admissions relating to alcohol than the rest of Halton (not significant) and males generally have higher rates of admissions for alcohol related problems The map below shows all admissions for alcohol related problems during the period The rate is per 1,000 of the population and as can be seen; the more deprived areas of Halton present higher rates of admissions for alcohol related conditions. Areas such as Halton Lea, Riverside, Broadhealth and Appleton indicate alcohol problem hotspots but the rates for these areas are not significant as highlighted in the chart above. 61

62 Map 8: All Alcohol Admissions Halton All Persons 2006/07 by Ward Source: Oracle

63 Chart 9: Alcohol admissions per 1,000 by age (2006/07) ALCOHOL ADMISSIONS: Rate of admission per 1,000, 2006/07, Halton Rate per 1, Age band Source: Oracle 2008 Males Females The ICD codes used to look at alcohol related hospital admissions in this section are more likely to show variations in chronic and acute drinkers rather than hospital admissions related to alcohol consumption. This may be the reason why the age of people especially men are highest in middle age. There is a marked difference between males and females but the variance for females is less marked than males and females have higher admissions in the under 20 s. The national indicator for alcohol related admissions assumes a number of admissions in many categories will be alcohol related, for example it is assumed from this that 34% of drowning would be alcohol related. Chart 15 shows quarter by quarter rates of alcohol related admissions (EASR European age standardised rates per 100,000) for 2005/06 and 2006/07. This data shows that the rates of alcohol related admissions in Halton are consistently higher than the North West and England rate and higher than our neighbouring borough St Helens. th Halton has the 8 worst hospital admissions in the country relating directly to alcohol. 63

64 Chart 10: Alcohol related admissions per 100,000 (EASR) (2005/06 and 2006/07) Alcohol related hospital admissions (EASR) Rate per 100,000 population Halton St Helens North West England Q1 2005/06 Q2 2005/06 Q3 2005/06 Q4 2005/06 Q1 2006/07 Q2 2006/07 Q3 2006/07 Q4 2006/07 Time In early 2008 a Community Safety Joint Strategic Needs Assessment was undertaken for Halton and the key points for Halton based on its alcohol profile were as follows: Halton had the fifth highest estimated prevalence of binge drinking in the North West (23.8%) to Between 2003/04 and 2004/05, Halton experienced the fifth largest decrease in the prevalence of alcohol specific hospitalised admission amongst males in the North West (by 0.17 per 1,000 population). For the prevalence of hospital admission for all conditions attributable to alcohol, Halton had the fourth highest rate in the North West for males and the third highest for females in 2004/05 (13.68 and 7.56 per 1,000 population respectively). Both males and females in Halton experienced some of the highest average numbers of months of life lost attributable to alcohol in the North West in 2004 (13.46 and months respectively; both have increased overall since 1995 by 6.61 and 6.69 months). In 2004/05, Halton had the highest rate of less serious violence attributable to alcohol in the North West at 4.36 per 1,000 population, and this has more than doubled since 2002/03 (from 2.10 per 1,000 population the second largest increase in the region). 64

65 2.4.4 Obesity The Lifestyle Survey (2006) asked respondents to state their weight and height. From this data, a measure of obesity could be derived. Those with a body mass index (BMI) of 25 or over are considered overweight. A body mass index of 30 plus indicates obesity. The percentage of overweight residents has increased from 52% in 2001 to 56.6% in This prevalence of almost 57% suggests that approximately 54,200 adults in Halton are overweight. A higher proportion of Widnes residents are overweight, 58.4% compared with 54.9% in Runcorn. A higher proportion of males are overweight, (63% compared with 50% of females) with highest prevalence amongst males in the age band (71%). Obesity within Halton has also increased quite substantially since 2001; with 20.2% of residents currently measuring as obese, this compares with 15.1% at the time of the last survey. The figures from Halton Health Survey are lower than the Modelled Estimates used nationally where it is predicted that 26.8% of Halton s population are obese, higher than the figure for the North West and England (24.5% and 23.6% respectively). BMI monitoring is also part of the GP Quality & Outcomes Framework (QOF). Figures lower than the survey and modeled estimates data may reflect difference across the borough but may equally be due to under recording. 65

66 Chart 11: Prevalence of Overweight (BMI 25+), Halton Practices Hypertension Hypertension, or high blood pressure, is defined as a persistently elevated blood pressure exceeding 140 systolic over 90 diastolic mmhg. Chronic hypertension is known as the silent killer as it is often symptomless on its own. Hypertension is arguably the most important modifiable risk factor for coronary heart disease (the leading cause of premature death in the UK) and stroke (the third leading cause). It is also an important cause of congestive heart failure (heart strain), chronic kidney disease, and peripheral vascular disease (diseased arteries in the limbs). Unfortunately, it is one of the most common conditions in the UK. It is therefore important to prevent if possible, or at the very least to diagnose promptly and put lifestyle and/or medication treatments in place to prevent the kinds of diseases described above from developing. Prevalence of Hypertension The expected prevalence of hypertension in the PCT using synthetic estimates derived from the 2004 health Survey for England was 23.90%. Using the November 2007 QMAS data for GPs the actual rates of hypertension recorded are 13.3% for Halton. Chart 12 however shows that despite the low levels of recording of hypertension in Halton the prevalence is a lot higher than the national rate. Based on the information from national prevalence models this suggests that just over 11,500 people in Halton may be at risk of hypertension but have not been diagnosed. 66

67 Chart 12: Percentage of Hypertension recorded in GP s Table 26: Predicted/Expected numbers with Hypertension based on ONS population predictions and expected numbers based on prevalence model Nov 2007 QMAS data ,897 28,464 28,512 28,512 By 2015 based on ONS population projections, which indicates an increasing population, it is expected that the number with hypertension in the district will increase to over 28,500. This does not account for the ageing population, nor any changes to planning policy or interventions that decrease risks Substance Misuse Based on the headline measures throughout 2007/08 the drug treatment system has continued to make significant progress. As of October 2007, the number in treatment (YTD) was 907, compared to 744 in October An increase of 22% and in excess of the year-end target of 750 by 21% (129). The actual number of women entering treatment also improved by 54% between Q1 2006/07 and Q2 2007/08. However whilst Halton had a higher percentage of under 25 year olds in treatment than the regional average in 2006/07, relatively few were identified as problematic drug users (PDUs). Only 20% of the total cohort of 15 to 24 year old PDUs was known to treatment services in 2006/07, a decline from the previous year. Retention in treatment as of October 2007 was 93% and has consistently been above the year s planned target of 85%. Planned discharges have risen from 50% in Q1 2006/07 to 75% in Q2 2007/08. Between April and October 2007, 45 individuals were taken on to the DIP caseload at an average of 6.4 per month compared to an average of 4.3 per month in 2006/07. The actual number of DRR commencements in 67

68 2006/07 was 25, 66% of the target. DRR completions and commencements for 2007/08 are on target. Waiting times across all modalities are consistently well within national targets. In a growing number of cases service users experience a same day service. Service users have also expressed a high level of satisfaction. A local survey of service users new to treatment shows that 73% agreed or strongly agreed that the service was friendly and welcoming and 94% that the staff treated them with respect. There are constraints on the current data that do not allow for analysis of patterns of drug use by geographical location. Anecdotally service providers do not report differences in patterns of drug use between Widnes and Runcorn. Aged 25 and upward, the highest self reported primary problematic substance is heroin. Between 25 and 34 the next highest self reported problematic substance is cocaine. Under the age of 25 the highest self reported primary problematic substance is cannabis. There has been a sharp rise in the numbers of individuals in this age group presenting to services whose primary problematic substance is cannabis. There is strong regional evidence showing that in nearly half of cases this is associated with supplementary alcohol use. Halton has the highest number of individuals in the region in treatment that state alcohol as a supplementary problematic substance. Currently 67% of the total population of PDUs are either in treatment or have been in treatment over the past two years. Of women PDUs, 75% are known to treatment services. The current gap is around 15 to 24 year olds where the number known to services has reduced slightly between 2005/06 and 2006/07. However, this may be because of changing patterns of drug use amongst this cohort. Of the individuals presenting to the Agency Syringe Exchange the majority were steroid users, outnumbering PDUs by some 3 to 1. These steroid users were always male and usually between the ages of 19 and 24. Of the opiate and stimulant injectors, the largest cohort, nearly half of all injectors, was between the ages of 35 and 44. Two thirds of those new to treatment reported never injecting, and of the remainder only 13% were currently injecting. A large number of individuals new to service are accepting and commencing hepatitis B vaccinations but acceptance and take up of hepatitis C screening is low. Between April 2006 and March 2007 there were 267 drug related admissions to hospital. 90% (240) of these were emergency admissions. 60% of admissions were male. The highest age band for emergency admission was 35 39, followed by 30 34, and then During 2006/07 there was one report of a drug related death. From the limited data available it seems that of the current in treatment population, around 300 service users are parents and that there are approximately 500 to 600 children identified on drug service s databases. In 2006/07 there were 60 new registrations on the Child Protection Register. In 8 drugs were a factor, in 10 it was alcohol and in 6 both drugs and alcohol. Overall in 40% of new registrations substance misuse was identified as a factor. Between October 2006 and November 2007 there were also 66 referrals of Children in Need where substance misuse was a presenting issue. Of these 41 were as a result of drug use and 25 due to alcohol use. 68

69 Chart 13: Number in Treatment Year to Date Number in treatment year to date Apr-04 Jun-04 Aug-04 Oct-04 Dec-04 Feb-05 Apr-05 Jun-05 Aug-05 Oct-05 Dec-05 Feb-06 Apr-06 Jun-06 Aug-06 Oct-06 Dec-06 Feb-07 Apr-07 Jun-07 Aug-07 Oct-07 Dec-07 Feb-08 Apr-08 Number in Treatment YTD Target Benchmark Linear Trendline 3 month forecast Table 27: Number in Treatment Year to Date Fiscal Target Monthly Target Q4 Total Q3 Total Q2 Total Q1 Total Fiscal Total Projected Year End 2007/08 Title Per 1,000 population 03/04 baseline target /08 Target Performance 06/ Source : Safer Halton Partnership Joint Strategic Needs Assessment 69

70 Chart 14: Retention > 12 Weeks Retention > 12 weeks 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Apr-04 Jun-04 Aug-04 Oct-04 Dec-04 Feb-05 Apr-05 Jun-05 Aug-05 Oct-05 Dec-05 Feb-06 Apr-06 Jun-06 Aug-06 Oct-06 Dec-06 Feb-07 Apr-07 Jun-07 Aug-07 Oct-07 Dec-07 Feb-08 Retention % Target Linear Trendline 3 month forecast Source: Safer Halton Partnership Joint Strategic Needs Assessment Table 28: Retention > 12 Weeks Fiscal Target Monthly Target Q4 Total Q3 Total Q2 Total Q1 Total Fiscal Total Projected Year End 2007/08 Retention > 12 weeks % 85% 85% 92% 93% 94% 92% 93% Per 1,000 population 05/06 baseline target N/A N/A N/A N/A N/A N/A N/A N/A 2007/08 Target 85% 85% +7% +8% +9% +8 +8% Performance 06/07 82% 82% 0% +5% +6% 3% +3% 70

71 2.5 Burden of Ill health All causes Life Expectancy Life expectancy at birth is a major indicator of overall health and whether the local population die younger than England as a whole. Life Expectancy is a key Government target: The national Public Service Agreement (PSA) for improving the health of the population aims: To increase the life expectancy at birth in England to 78.6 years for men and to 82.5 years for women by 2010 and; Reduce the inequalities in life expectancy at birth by 10% between the lowest fifth of local authority districts and the average for England by Halton is a Local Authority district that experiences some of the poorest health, and thus are required to meet differential stretched mortality targets to narrow the inequalities gap. An indicator of whether we are achieving this is to look at the gap between local life expectancy at birth and national figures. Life expectancy for both Males and Females has improved in Halton between and with Males living on average an extra 2.4 years and females living an extra 0.6 years. The gap between England life expectancy and local life expectancy in shows a different picture with neither males nor females closing the gap (3.02 years and 3.15 years difference between Halton and England life expectancy respectively for males and females). Halton females have the third worst life expectancy in the country and males have the 6 th worst life expectancy in the country. 71

72 Chart 15: Trends in life expectancy, 3 year rolling averages Table 29: Trends in Life Expectancy, 3 Year Rolling Averages Males Females Halton St Helens National All age all cause mortality The decline in all cause mortality has been predominantly brought about by reductions in death rates for coronary heart disease and cancers. However, inequalities exist in both of these conditions across social class gradients and are reflected in a similar pattern of differential all cause. All age all cause mortality rates (persons) have been reducing in Halton, chart 12 shows that reduction since 1993 to 2006 based on 3 year rolling averages. As a PCT and within the Local Area Agreement the all age all cause mortality statistic is used to analyse the contribution to health inequalities especially life expectancy. The baseline year of is used to assess our performance against this target. Halton overall has made a 14.81% reduction in mortality since , however England has made a 17.92% reduction which means that we have not narrowed the gap between England. 72

73 Chart 16: All Age All Cause Mortality 73

74 Chart 17: All Age All Cause Mortality to , males Mortality from all causes, DSR (per 100,000), all ages, to , Males Source of data: National Statistics, Compendium of Clinical and Health Indicators / Clinical and Health Outcomes Knowledge Base, Crown Copyright DSR England North West Halton St Helens Halton and St Helens PCT Death rates for males in Halton have remained higher than the national and North West rate since , however there have been big reductions in death rates. A slight upward turn in deaths is apparent in Chart 18: Trends in mortality from all causes, females, to Mortality from all causes, DSR (per 100,000), all ages, to , Females Source of data: National Statistics, Compendium of Clinical and Health Indicators / Clinical and Health Outcomes Knowledge Base, Crown Copyright DSR England North West Halton St Helens Halton and St Helens PCT. 74

75 Death rates for females have remained high and not reduced as fast as males. In recent years the gap between the North West, England and Halton female deaths has widened a Geographical variation of all age all cause mortality When looking at geographical variations in all causes of mortality within Halton ( ) there are seven wards with significantly higher mortality rates than Halton as a whole. These are Halton Brook, Grange, Heath, Halton Lea, Broadheath, Appleton and Norton South. Wards with significantly lower rates than Halton as a whole in are Broadheath, Norton North, Daresbury, Birchfield, Halton View and Hough Green. Chart 19: All Age All Cause Mortality by ward, persons, All age all cause mortality, persons, Source: Public Health Mortality File Directly age-standardised rate per 100, Beechwood Norton North Daresbury Birchfield Halton View Hale Hough Green Windmill Hill Kingsway Mersey Ditton Castlefields Farnworth Halton Brook Riverside Grange Heath Halton Lea Broadheath Appleton Norton South Ward Despite some areas in Halton having significantly lower rates than the rest of Halton It should be noted that as a whole Halton has significantly higher rates of mortality than England and the North West as a whole (see chart 16). 75

76 When looking at all age all cause mortality by gender, , significantly high rates for females are in the wards of Appleton, Norton South, Broadheath, Halton Lea and Riverside. Significantly low rates of deaths are found in the wards of Birchfield, Norton North, Daresbury and Beechwood. Map 9: All Age All Cause Mortality, females, For males significantly high rates of mortality are found in the wards of Norton South, Broadheath, Appleton, Heath, Halton Lea and Grange. With low rate wards in Daresbury, Birchfield, Beechwood and Norton North. 76

77 Map 10: All Age All Cause Mortality, male, i Hospital admissions There were a total of 30,746 admissions to hospital in for people in Halton registered with a GP in the borough. There are two broad categories of admissions those that have been planned for (elective admissions) and those that are emergencies (non-elective admissions). In order to ensure that people get appropriate care when they need it generally we would need to see a reduction in emergency admissions especially for health conditions that could be prevented through primary or secondary interventions in the community and within general practice. Also some interventions that are being undertaken in hospital could be undertaken safely in a primary care or community setting closer to people s homes, therefore reducing the burden on the patient and hospital services. Understanding the top ten causes for hospital admissions will allow the local health commissioners to plan services to meet the needs of the population in the most appropriate setting. 77

78 Elective admissions Elective admissions to hospital are where an admission has been planned and are not an emergency. From there were elective admissions. The top ten causes of admissions are shown in the table 15. Table 30: Top 10 Causes of Elective Admissions for Residents Registered with a Halton G.P. Practice ICD Chapter Total Percent Neoplasms 1, Diseases of the Gemito-Urinary System 1, Diseases of the Digestive System 1, Diseases of the Musculoskeletal system and Connective Tissue 1, Diseases of the eye and adnexa 1, Diseases of the Circulatory system 1, Factors Influencing Health Status and Contact with Health Services Symptoms and Signs Diseases of the Respiratory System Diseases of the Skin and Subcutaneous Tissue Other categories 1, Total 11,

79 Table 31: Top 10 causes for elective admissions split by electoral ward In red top three wards and in green bottom three wards Neoplasms Genito-Urinary System Digestive System Musculoskeletal system and Connective Tissue Eye and adnexa Circulatory system Influencing Health Status and Contact with Health Services Symptoms and Signs Respiratory System Skin and Subcutaneous Tissue Windmill Hill Norton South Castlefields Ditton Heath Grange Halton Lea Hough Green Broadheath Halton Brook Riverside Kingsway Appleton Halton View Mersey Farnworth Beechwood Norton North Birchfield Daresbury Hale Grand Total Windmill Hill has the highest crude rates in 4 of the top ten categories and Castlefields, Ditton, Heath, Halton Lea and Hough Green have the highest crude rates in 3 of the top ten categories. By contrast, Hale has the lowest crude rates in all top ten categories and Daresbury in nine of the top ten categories. 79

80 The age-sex specific rates for elective admissions have been calculated from GP populations, chart 37 shows the variation in age-sex specific rates. The highest rates of elective admissions were seen in the Male population, an age specific rate of per 1000 population. The lowest rates of elective admissions were also seen in Females aged with an age specific rate of 29 per Chart 20: Elective admissions rate to hospital from Halton GP practices by age, 2006/07 Source: Oracle, 2008 Although the highest rates of admissions are seen in the age group the highest numbers are seen in and age group and again there are more males than females. The percentage of elective admissions by male and females was evenly split 50:50. 80

81 Chart 21: Number of Elective admissions from Halton GP practices, 2006/07 Source: Oracle, 2008 The distribution of high and low rates of admissions rates by ward for females and males is similar to all persons with only a few variations. We can therefore assume that in order to help to prevent these admissions we can target interventions within wards with the highest rates for both males and females alike. 81

82 Chart 22:Rate of elective admission (DSR) by ward in Halton, Persons, 2006/07 Rate of elective admission (DSR) by electoral ward in Halton, Persons, 2006/07 Source: Oracle, Rate per 100, Hale Daresbury Birchfield Norton North Halton View Mersey Beechwood Kingsway Appleton Farnworth Riverside Halton Brook Hough Green Ditton Halton Lea Grange Broadheath Castlefields Heath Windmill Hill Norton South The wards with the significantly highest rates of elective admissions for all persons in are Norton South, Windmill Hill, Heath, Castlefields, Broadheath, Grange, Halton Lea and Ditton. Low rate wards were Hale, Daresbury, Birchfield and Norton North. 82

83 Map 11: Rate of elective admission (DSR) by ward in Halton, All People, 2006/07 Source: Oracle, 2008 Although there are some similarities between male and females elective admissions, there are also some note able differences. Windmill Hill has significantly high admissions for females but relatively low for males. Conversely Ditton has significantly high admissions for males and relatively low for females. 83

84 Chart 23: Rate of elective admission (DSR) by ward in Halton, Males, 2006/07 Rate of elective admission (DSR) by electoral ward in Halton, Males, 2006/07 Source: Oracle, Rate per 100, Hale Daresbury Norton North Windmill Hill Beechwood Birchfield Kingsway Mersey Halton View Hough Green Farnworth Appleton Halton Brook Grange Halton Lea Castlefields Norton South Broadheath Heath Ditton Riverside Chart 24: Rate of elective admission (DSR) by ward in Halton, Females, 2006/07 Rate of elective admission (DSR) by electoral ward in Halton, Females, 2006/07 Source: Oracle, Rate per 100, Hale Daresbury Birchfield Halton View Ditton Norton North Appleton Mersey Kingsway Farnworth Beechwood Halton Brook Hough Green Broadheath Heath Riverside Halton Lea Castlefields Grange Windmill Hill Norton South 84

85 Map 12: Rate of elective admission (DSR) by ward in Halton, Males, 2006/07 Source: Oracle, 2008 Map 13: Rate of elective admission (DSR) by ward in Halton, Females, 2006/07 Source: Oracle,

86 In order to predict future demand for elective admissions to hospital age sex rates from the data these have been applied to the population projections from ONS to derive what will happen to elective admissions based on changes to the population profile. Overall it is estimated that by 2029 Halton will see just under 1500 more elective admissions, this is due to the ageing population which currently have high rates of admissions. There is a steady increase between 2010 and These predictions do not account for any changes to health service policy or new local and national government policies which may impact on the population structure in the future, or utilisation of acute hospital services. Chart 25: Elective admissions future trend based on ONS population projections 86

87 Non Elective Admissions Non-elective hospital admissions are classed as emergency admissions as they were not planned prior to the admission. The reason it is good to differentiate between elective and non-elective is that many non-elective admissions maybe prevented with the right intervention in the community earlier and so reduce unnecessary admissions to hospital. The total number of non-elective admissions otherwise called emergency admissions to hospital was which are greater than the number of planned admissions. Table 32: Top 10 Causes of Non-Elective Admissions for Residents Registered with a Halton G.P. Practice Chapter Number Percent Symptoms, signs and abnormal clinical and laboratory findings, not 4, elsewhere classified Injury, poisoning and certain other consequences of external 2, causes Diseases of the respiratory system 2, Diseases of the circulatory system 1, Diseases of the digestive system 1, Diseases of the genitourinary system Diseases of the musculoskeletal system and connective tissue Neoplasms Certain infectious & parasitic diseases Mental & behavioural disorders 4, Other categories 2, Grand Total 19,

88 Table 33: Top 10 causes for non-elective admissions split by electoral ward In red top three wards and in green bottom three wards Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified Injury, poisoning and certain other consequences of external causes Diseases of the respiratory system Diseases of the circulatory system Diseases of the digestive system Diseases of the genitourinary system Diseases of the musculoskeletal system and connective tissue Appleton Beechwood Birchfield Broadheath Castlefields Daresbury Ditton Farnworth Grange Hale Halton Brook Halton Lea Halton View Heath Hough Green Kingsway Mersey Norton North Norton South Riverside Windmill Hill Halton Borough Neoplasms Certain infectious & parasitic diseases Mental & behavioural disorders Castlefields ward has the highest crude rate of non-elective hospital admissions in 6 of the top ten categories. Riverside and Halton Lea has the highest crude rate of non-elective hospital admissions in 5 of the top ten categories. Hale and Daresbury have the lowest crude rate of non-elective hospital admissions in all of the top ten categories. Beechwood ward has the lowest crude rate of nonelective hospital admissions in 5 of the top ten categories. 88

89 Castlefields ward has the highest crude rate of non-elective hospital admissions in 6 of the top ten categories. Riverside and Halton Lea has the highest crude rate of non-elective hospital admissions in 5 of the top ten categories. Hale and Daresbury have the lowest crude rate of non-elective hospital admissions in all of the top ten categories. Beechwood ward has the lowest crude rate of nonelective hospital admissions in 5 of the top ten categories. Age-specific data shows us that generally admission rates go up with age, apart from in the early years. This is true for both males and females but in the very young and older age groups males have higher rates of admissions than females and only in the age groups do women have slightly higher rates of admissions. Chart 26: Non-Elective admissions rate to hospital from Halton GP practices, 2006/ Non-elective admissions from General Practice in Halton Age specific admission rates per 1000 population Source: Oracle, Age specific rate per To 4 5 To 9 10 To To To To To To To To 49 Age group 50 To To To To To To To And Over Male rate per 1000 Female rate per 1000 The highest numbers of admissions are seen in those over 75 particularly females followed by the 0-4 males and females. 89

90 Chart 27: Number of Non-Elective admissions to hospitals from Halton GP practices, 2006/ Number of non-elective admissions from General Practice in Halton Source: Oracle, 2008 Male Female Number To 4 5 To 9 10 To To To To To To To To To To To To To To To 84 Age group If rates of emergency admissions were to stay at the same based on ONS population predictions we would see an increase in the total number of emergency admissions due to the ageing population. Older people are more likely to be admitted to hospital in an emergency, however by 2029 the number of admissions is likely to increase by a further 3500 per year. 90

91 Chart 28: Future trends Non-Elective admissions to hospitals from Halton GP practices Number of future annual non-elective admissions based on projected population changes, Halton Source: Oracle Discoverer, 2008 ONS 2004 revised population projections Number Year Map 14: Rate of non-elective admissions (per 100,000), All Persons Source: Oracle,

92 High rates of non-elective admissions are seen within the wards of Mersey, Appleton, Riverside, Broadheath, Halton Brook, Castlefields, Grange, Halton Lea, Windmill Hill and Norton South. These levels are closely associated with areas that have high levels of deprivation and therefore high levels of health and social care need. This also indicates that these populations with higher than the Halton rate of admissions may be seeking health care late and not accessing services to prevent ill-health. Low levels of non-elective admissions are also seen in areas with relative low levels of deprivation, this is with the exception of Kingsway. This may be unusual for this year and further analysis would be needed to clarify if this is a trend. Chart 29: Rate of non-elective admissions (per 100,000), All Persons Rate of non-elective admission (DSR) by electoral ward in Halton, Persons, 2006/07 Source: Oracle, Rate per 100, Hale Daresbury Beechwood Birchfield Farnworth Norton North Kingsway Heath Halton View Hough Green Ditton Mersey Appleton Riverside Broadheath Halton Brook Castlefields Grange Halton Lea Windmill Hill Norton South The distribution of high and low rates of admissions rates by ward for females and males is similar to all persons with only a few variations. We can therefore assume that in order to help to prevent these admissions we can target interventions within wards with the highest rates for both males and females alike. 92

93 Map 15: Rate of non-elective admissions (per 100,000), Females Source: Oracle,

94 Chart 30: Rate of non-elective admissions (per 100,000), Females Rate of non-elective admission (DSR) by electoral ward in Halton, Females, 2006/07 Source: Oracle, Rate per 100, Hale Daresbury Beechwood Birchfield Farnworth Heath Norton North Halton View Kingsway Ditton Hough Green Broadheath Appleton Mersey Riverside Castlefields Halton Brook Grange Halton Lea Windmill Hill Norton South Map 16: Rate of non-elective admissions (per 100,000), Males 94

95 Source: Oracle, 2008 Chart 31: Rate of non-elective admissions (per 100,000), Males Rate of non-elective admission (DSR) by electoral ward in Halton, Males, 2006/07 Source: Oracle, Rate per 100, Hale Daresbury Beechwood Birchfield Farnworth Norton North Kingsway Hough Green Halton View Heath Riverside Mersey Ditton Halton Brook Grange Appleton Castlefields Halton Lea Broadheath Norton South Windmill Hill 95

96 When looking at the distribution of both elective and non-elective hospital admission rates there are a lot of similarities with a 0.88 correlation between the ward rates. The one ward that shows a degree of difference between elective and non-elective rates is Heath which has the third highest elective hospital admissions but relatively low levels of non-elective admissions. Heath does have higher than average deprivation levels compared to national rates, it falls within the 21-40% most deprived area nationally, however there are areas within Halton which have higher levels of deprivation so these rates can not be explained by deprivation alone Mortality from causes amenable to healthcare Mortality that is defined as amenable to healthcare is deaths that can theoretically avoided due to timely interventions. In this section the conditions listed can be either prevented due to identifying risk factors early and changing behaviour, can be detected early and appropriate interventions can be put in place or can be treated effectively therefore increasing years lived with the condition and improving quality of life Diabetes Diabetes mellitus is a condition in which the amount of glucose (sugar) in the blood is too high because the body cannot use it properly. Insulin helps glucose to enter the cells and therefore many people with Diabetes either can not produce insulin, do not produce enough insulin or when the insulin produced does not work properly There are two main types of diabetes. These are: Type 1 diabetes - usually appears before the age of 40 accounts for around 5-15% of all people with Diabetes Type 2 diabetes in most cases this is linked with being overweight and often appears over the age of 40, in ethnic groups such as South Asian and African-Caribbean it can appear after the age of 25. Some children are being diagnosed as young as 7 with this type of Diabetes. This accounts for between 85-95% of all people with Diabetes It is estimated nationally that over 2 million people may have Diabetes without being diagnosed, therefore it is important for us to understand locally what that may mean for St Helens population. To estimate prevalence some national models have been developed and one of these for Diabetes is called the PBS model. This model predicts diabetes actual numbers and prevalence using three different scenarios relating to population change, i.e. ageing population, and obesity levels. Obesity is included as, together with age (a non-modifiable risk factor), it is a primary risk factor for diabetes type 2, the most common type. An increase of 1 kilo in weight can increase the risk of diabetes by 4.5%. Whilst a weight loss of 5% is sufficient to prevent most obese individuals with impaired glucose tolerance of developing diabetes type 2.. We have used this model to predict 3 different scenarios relating to Diabetes. The first is based on population projections alone, the second is based on population 96

97 projections and an increase in obesity and the third is based on population predictions but obesity levels will decrease to 1995 levels. Table 34: Predicted prevalence of Diabetes in Halton (3 different scenarios) Scenario 1 Population change obesity static Scenario 2 Population change obesity rates are increasing Scenario 3 Population change but obesity rates decreasing to 1995 levels No % No % No % England 2,377, % 2,595, % 2,176, % North West 334, % 365, % 306, % Halton 5, % 6, % 5, % (ONS data) Halton (registered practice data QMAS Nov 07) 6, % 6, % 5, % The best case scenario of Halton in relation to Diabetes prevalence would be a rate of 4.40% by 2010 based on obesity levels returning to 1995 levels. In terms of numbers the three scenarios suggest that the number of Diabetics in Halton will be anywhere between 5,199 and 6,655 depending on whether we look at resident or registered populations. Chart 32: Predicted prevalence of Diabetes from 2001 to 2010 The PBS Model currently only forecasts till An extrapolation over a longer time frame, using scenario 2, till 2020 is attempted below. The assumption is made that 97

98 demographic, deprivation etc remain as before. Therefore caution should be exercised in drawing conclusions. Chart 33: Predicted prevalence of Diabetes from 2001 to 2020 This would imply with an increasing obesity trend, prevalence rates between 2001 and 2020, for Halton would increase from 4.43 to 6.16 In terms of absolute numbers, using population projections for 2020 and applying the above rates, we can derive the expected numbers Table 35: Projected rates applied to 2020 population projections AREA POPULATION PREVALENCE EXPECTED RATE NUMBERS Halton ONS data Halton QMAS data GP registered Nov Providing the assumptions made as above are valid, the implication is a substantial increase in demand and highlights the need for early intervention to tackle obesity. An invest to save approach would be far more cost effective in the longer run, than simply increasing expensive treatment services to cope with increasing demand. 98

99 Chart 34:Diabetes Related Mortality All Persons 1993/95 to 2004/06 Chart 34 shows mortality relating to Diabetes. Generally mortality rates for Diabetes are low as people often die of other conditions associated with diabetes such as heart disease. The chart above shows than mortality rates since 1993 have been erratic. Chart 35 shows the males and female mortality trends and show a similar picture to all persons with erratic trends. The low number of deaths mean that small changes may result in large increases and decreases in the rates so therefore difficult to ascertain the trend. 99

100 Chart 35: Diabetes Related Mortality Males and Females 1993/95 to 2004/ Circulatory Disease a.i Mortality from all circulatory diseases under 75 All Circulatory disease is a term for diseases relating to the circulatory system such as hypertensive disease, heart disease, pulmonary disease and stroke. Circulatory diseases have been the most common cause of death in England and Wales for 90 years for both males and females (apart from 1918 and 1919 WW1). It is the most significant cause of early death in Halton. Mortality from all circulatory diseases in Halton under the age of 75 is significantly higher than the England and Wales rate for both Males and Females. Males have a higher rate of circulatory mortality under 75 than females. This will contribute to the overall life expectancy figures for Halton. 100

101 Chart 36: Rate of mortality from all circulatory diseases (DSR) Ages less than 75, 2004/06 Chart 37: Mortality from all circulatory diseases All Persons Under 75 Years, 1993/95 to 2004/06 101

102 Mortality trend in circulatory diseases have decreases in Halton since as shown in the chart above since The gap between Halton and England has narrowed but a slight upturn in deaths in has meant the decrease in deaths has slowed i CHD Coronary Heart Disease (CHD) is a significant circulatory disease and cause of death. There are many primary and secondary interventions that can help to reduce the risk of heart disease and prevent serious ill health due to existing heart disease. In attempt to better manage Coronary Heart Disease and prevent acute episodes a range of measures have been introduced within primary care. However, these rely on the identification of people at risk of developing Coronary Heart Disease or with a current condition. It is therefore important to have a way of benchmarking the numbers actually identified on practice registers with the number we would expect to find in a particular population. The Coronary Heart Disease model developed by the Association of Public Health Observatories (APHO), Yorkshire & Humber division, enables us to do this. Prevalence of Coronary Heart Disease The expected prevalence of Coronary Heart Disease, based on the Coronary Heart Disease Model developed by the APHO, in Halton and St Helens is 4.92% (Table 35). This would mean that there would be persons (9278 males and 6285 females) have CHD. The known prevalence of CHD using Quality and Outcomes Framework data from general practice (QMAS November 07) for Halton is 4.52%, This is lower than the expected rate by 0.4% but a lot higher than national rates which currently stand at 3.53%. Table 35: Prevalence of Coronary Heart Disease in Halton and St Helens Synthetic Practice Expected Expected Prevalence estimates Population Males Females Total 99.8% Percentage C.I. CHD LL UL % Table 36: QMAS Coronary Heart Disease Data Percentage of CHD Modelled Prevalence of CHD 4.92 Halton QMAS data 4.52 Halton and St Helens PCT - QMAS data 4.75 National prevalence - QMAS data 3.53 Population predictions for Halton show an increasing percentage of people in older age groups. However without an age-specific breakdown of CHD the overall population trends to 2015 do not show an increasing number of people with CHD. 102

103 QMAS data does not break the information by age it is likely to be higher than the figures quoted below as Halton has an ageing population who have age associated risk factors for CHD. Chart 38: Mortality from Coronary Heart Disease 1993/95 to 2004/ Mortality from Coronary Heart Disease, (DSR), all ages, to Source: National Statistics, Compendium of Clinical and Health Indicators/ Clinical and Health Outcomes Knowledge Base, Crown Copyright Rate per 100, England - Males North West - Males Halton - Males St Helens - Males Halton & St Helens - Males England - Females North West - Females Halton - Females St Helens - Females Halton & St Helens - Females The above chart shows mortality from Coronary Heart Disease (CHD) for both males and females of all ages, as expected females have lower rates of CHD. Both males and females are narrowing the gap with England rates. Hospital admission rate for Myocardial Infarction Myocardial infarction (MI) means that part of the heart muscle suddenly loses its blood supply. Without prompt treatment, this can lead to damage to the affected part of the heart. An MI is sometimes called a heart attack or a coronary thrombosis. Therefore hospital admissions for MI is an indicator of heart problems in the community. The total number of hospital admissions from Myocardial Infarction in was 340 a crude rate of 2.9 admissions per 1000 population, when analysed by ward Castlefields and Grange ward were significantly higher than the Halton rate and Windmill Hill, Kingsway, Hale and Daresbury had significantly lower rates of admissions. 103

104 Map 17: All Admissions for Myocardial Infarction Halton All Persons by Ward 2006/07 Source: Nomis, 2008 Chart 39: All Admissions for Myocardial Infarction Halton All Persons by Ward 2006/07 As expected the rate of hospital admission for MI significantly increases with age with the highest rates seen in the over 85 year old males. 104

105 Chart 40: MI Rate of admission per 1, /07, Halton MI: Rate of admission per 1, /07, Halton Males Females Rate per 1, Age band There is a significantly higher rate of MI admissions in males than there are in females this would be as expected as heart problems normally affect men at a younger age but will impact on women post menopause. Chart 41: MI Rate of admission per 100, /07, Halton all ages MI: Rate of admission per 100,000, 2006/07, Halton, all ages Rate per 100, Males Gender Females Table 37: MI Rate of admission per 100, /07, Halton all ages Rate per 100,000 LL UL Males Females

106 Chart 42: Myocardial infarctions admission rate per 100, /07, Persons, all ages MI: Rate of admission per 100,000, 2006/07, Persons, all ages Rate per 100, Halton St Helens Halton & St Helens Area Table 38: Myocardial infarctions admission rate per 100, /07 Rate per 100,000 LL UL Halton St Helens Halton & St Helens When compared to our borough neighbours Halton has a significantly higher rate of MI admissions. The rates quoted are crude rates and do not account for age, but as Halton has a younger population than St Helens the age adjusted rate is likely to be higher. Admission for cardiac revascularisation Cardiac revascularisation or heart bypass are treatments for heart disease when the arteries are blocked or severely narrowed hence reducing blood flow to the heart. With high levels of heart disease it would be expected that there would be high levels of cardiac revascularisation locally. In relation to admissions for cardiac revascularisation Halton the PCT as a whole has lower rates for all revascularisations than expected (10% lower). With high rates of heart disease this suggests an inequality in healthcare access (source Dr. Foster). 106

107 Chart 43: Admissions by PCT for Cardiac Revascularisation, 2007 Admissions by PCT for Cardiac Revascularisation - All Persons 2007 Source: Dr Foster 2008 Standardised Admission Ratio PTCA CABG (isolated first time) CABG (complex, combined and repeat) CABG (including valve ops) Table 39: Admissions by PCT for Cardiac Revascularisation, 2007 Group SAR ALL 90 PTCA 78.8 CABG (isolated first time) CABG (complex, combined and repeat) CABG (including valve ops) c Stroke Stroke is a significant cause of UK morbidity and mortality the most important cause of adult disability, and the third leading cause of death. Hypertension (see section ) is the most prevalent modifiable risk factor for primary and secondary prevention. In the UK it represents 4.4% of NHS costs, notwithstanding costs to social services and individual patients and carers. Halton has maintained consistently low rates for mortality from Stroke compared to the North West for the past several years almost matching the England average in with Halton s average being compared to the England average of However levels have risen marginally to for the period reducing the gap between Halton and the North West. Stroke is the sudden death of some brain cells due to lack of oxygen when the blood flow to the brain is impaired by blockage or rupture of an artery in the brain. A stroke is also called a cerebrovascluar accident or CVA for short. 107

108 Chart 44: Mortality from Stroke All Persons 1993/95 to 2004/ Mortality from Stroke, DSR, Persons, to Source of data: National Statistics, Compendium of Clinical and Health Indicators / Clinical and Health Outcomes Knowledge Base, Crown Copyright Rate per 100, England North West Halton St Helens Halton & St Helens PCT Although death rates from stroke for Halton are higher than the England rate they have reduced and have generally been lower than the North West rate. There were a total of 342 admissions for Stroke in 2006/07 the crude rate of admissions varies from 0.2 per 1000 population in Daresbury to 5.3 per 1000 in Halton View. Halton View and Kingsway are areas with significantly higher rates of admissions from stroke than the overall Halton rate. 108

109 Map 18: All Admissions Stroke Halton All Persons 2006/07 Source: Nomis, 2008 Map 18 shows the rate of admissions per 1,000 population for individuals suffering a Stroke during the year Although four areas are highlighted in red; Kingsway, Halton View, Appleton and Mersey indicating high rates of stroke admissions for Halton only two areas, Kingsway and Halton View present significantly high admission rates. This can be further seen through chart

110 Chart 45: All Admissions Stroke Halton All Persons by Ward 2006/07 Compared to our neighbouring borough Halton has significantly higher rates of admissions to hospital due to stroke. Chart 46: Stroke, Rate of admission per 100,000, 2006/07, Persons, all ages In relation to the difference in all admissions for stroke based on gender there is very little difference. 110

111 Chart 47: Stroke, Rate of admission per 100,000, 2006/07, Halton, all ages STROKE: Rate of admission per 100,000, 2006/07, Halton, all ages Rate per 100, Males Gender Females Based on Quality and Outcomes framework data from GP practices, 1.76% of Halton s GP registered population have been recorded with stroke compared with a national prevalence of just under 1.65%. 111

112 Chart 48: Percentage of GP Registered Population Recorded with a Stroke Percentage of GP Registered Population Recorded as having had a Stroke Source: QMAS November % 1.80% Perentage of GP registered population 1.75% 1.70% 1.65% 1.60% 1.55% National Prevalence Halton Borough St Helens Borough Halton and St Helens PCT Cancer Cancer is not a single disease, there are many types of cancers and hence treatments. The similarity between cancers is that all cancers involve abnormal growth of cells. Some cancers form into tumours (lumps) but they are benign in that they will not invade other cells, cancerous lumps are those that are invasive and will spread to other cells. Cancer is more common in older people and during our lifetimes one in three of us will be diagnosed with cancer. However over half of cancers can be prevented through lifestyle and the single biggest preventable lifestyle risk relating to cancer is smoking. Halton has the worst rates of premature cancer deaths in the country. Cancer deaths increased substantially in 2004 and remained high in 2005, although they have decreased slightly in 2006, the 3 year rolling average still shows high rates, in fact Halton has the worst cancer mortality rates in the country based on data All Cancers Incidence Incidence is the number of new cases of a disease in a time frame. It is good to examine incidence, prevalence and mortality separately. Incidence can tell us if a disease or in this case type of cancer is growing, prevalence can tell us the full burden of the disease locally and mortality can indicate how effective health care interventions are especially if there are treatments and or risk factors that can modify the affect of the disease or even prevent individuals getting the disease. Up to 50% of all diseases can be prevented and reducing the numbers who smoke will have the biggest impact on cancer incidence, prevalence and mortality. 112

113 Chart 49: Incidence of all cancers, DSR, all ages, males, 1993/95 to 2002/04. Incidence of male cancers have decreased steadily and although Halton has higher rates than England and the North West the gap has narrowed. Chart 50: Incidence of all cancers, DSR, all ages, females, 1993/95 to 2002/ Incidence of all cancers, DSR, all ages, females, to Source of data: Regional Cancer Registries and the National Statistics, Compendium of Clinical and Health Indicators / Clinical and Health Outcomes Knowledge Base, Crown Copyright Rate per 100, England North West Halton The chart above shows that overall there has been an increase in the rate of incidence all cancers in females, although the increase in the rates seems to have leveled off for England and the North West. After a peak in the incidence rate for Halton in there was a reduction in numbers for

114 Table 40: Incidence: Top three most common types of cancers for males, Halton Males OBS % of Total Cancers Malignant neoplasm of prostate Malignant neoplasm of bronchus and lung Malignant neoplasm of colon Total number of top 3 1, Total all cancers 2,244 Table 41: Incidence: Top three most common types of cancers for females, Halton Females OBS % of Total Cancers Malignant neoplasm of breast Malignant neoplasm of bronchus and lung Malignant neoplasm of colon Total number of top 3 1, Total all cancers 2,265 Tables 40 and 41 above show the three types of cancers with the highest number of incidences throughout Halton for 2003 to Mortality The chart below shows the trend in mortality from all cancers in males, it shows that overall for England, the North West and Halton the rate has been reducing at a steady pace, although Halton s rate has increased between and Chart 51: Mortality from all cancers, DSR, all ages, males, 1993/95 to 2004/ Mortality from all cancers, DSR, all ages, males, to Source of data: National Statistics, Compendium of Clinical and Health Indicators / Clinical and Health Outcomes Knowledge Base, Crown Copyright Rate per 100, England North West Halton 114

115 Chart 52: Mortality from all cancers, DSR, all ages, females, 1993/95 to 2004/ Mortality from all cancers, DSR, all ages, females, to Source of data: National Statistics, Compendium of Clinical and Health Indicators / Clinical and Health Outcomes Knowledge Base, Crown Copyright Rate per 100, England North West Halton The chart above shows the rate of mortality from all cancers in females between the years to Overall, for England, the North West and Halton, the trend has seen a reduction in the rate of mortality, although Halton s rate increased significantly in the period but another decline for Table 42: Mortality: Top three most common types of cancers for males, Halton Males OBS % of Total Cancers Bronchus & Lung *Prostate Oesophagus Total number of top Total all cancers 534 * Malignant neoplasm without specification of site had the second highest number of deaths 115

116 Table 43: Mortality: Top three most common types of cancers for females, Halton Females OBS % of Total Cancers Bronchus & Lung Breast *Colon Total number of top Total all cancers 518 * Malignant neoplasm without specification of site had the third highest number of deaths Tables 42 and 43 above show the three types of cancers with the highest number of deaths throughout Halton for 2004 to As can be seen from the previous ten tables, the top three cancers accounted for approximately 43% of all cancer incidences throughout the PCT in both males and females during 2004 to Table 44: Top types of cancer in the wards with the highest mortality rates, All Ages Norton South Farnworth Grange 1 Bronchus & Lung 2 Breast 3 Stomach 1 Bronchus & Lung 2 Non specified site 3 Colon 1 Bronchus & Lung 2 Colon 3 Breast Table 45: Top types of cancer in the wards with the highest mortality rates, Ages less than 75 Norton South Castlefields Farnworth 1 Bronchus & Lung 2 Breast 3 Stomach 1 Bronchus & Lung 2 Oesophagus =3 Breast =3 Leukaemia 1 Non specified site =2 Bronchus & Lung =2 Brain =2 Bladder 116

117 Breast Cancer Breast cancer is a significant cause of female death and the second largest cause of cancer death to women in Halton. 1 in 9 women will develop breast cancer in their lifetime. Early detection and treatment of breast cancer will improve health outcomes and reduce deaths. The chart below shows the trend in the incidence of breast cancer both nationally and locally. The chart shows that there has been a steady increase in the rate of incidence (directly age-standardised registration rates per 100,000 population) of breast cancer for England and the North West. However, the rate of incidence peaked in for Halton and then the rate declined in to slightly higher rates than England and the North West. Chart 53: Incidence of Breast Cancer, DSR, all ages, 1993/05 to 2002/ Incidence of Breast Cancer, DSR, all ages, to Source of data: Regional Cancer Registries and the National Statistics, Compendium of Clinical and Health Indicators / Clinical and Health Outcomes Knowledge Base, Crown Copyright Rate per 100, England North West Halton 117

118 Chart 54: Mortality from Breast Cancer, DSR, all ages, 1993/05 to 2004/ Mortality from Breast Cancer, DSR, all ages, to Source of data: National Statistics, Compendium of Clinical and Health Indicators / Clinical and Health Outcomes Knowledge Base, Crown Copyright Rate per 100, England North West Halton The chart above shows the rate (Directly age-standardised rate) per 100,000 of mortality from breast cancer. The chart shows that there has been a steady decrease in the rate of mortality for both England and the North West. Locally the trend has not been as consistent. The overall trend for Halton shows a gradual decrease from till but then increases again till before beginning a slight decrease for a Colorectal Cancer Colorectal cancer or bowel cancer is the third most common cancer in the UK (excluding non-melanoma skin cancer). In Halton it is the second biggest cancer death for males and the third biggest for females. This cancer is common in older people and so a new screening programme has been rolled out across Cheshire and Mersey, this screening programme is likely to identify more bowel cancers but effective treatment will mean that health outcomes will be improved. 118

119 Chart 55: Incidence of colorectal cancer, DSR, all ages, 1993/95 to 2002/ Incidence of colorectal cancer, DSR, all ages, to Source of data: Regional Cancer Registries and the National Statistics, Compendium of Clinical and Health Indicators / Clinical and Health Outcomes Knowledge Base, Crown Copyright Rate per 100, England North West Halton The chart above shows that for England the overall trend in the rate of incidence of colorectal cancer has not changed very much, with the rate for being virtually identical to the rate for The same relationship can be seen for the North West, except the rate was slightly higher than England. The overall rate for Halton shows an increase in the incidence of colorectal cancer between the years to , resulting in a significantly higher rate than England. The rate has however started to decrease leveling off in although is still above the regional and national average. 119

120 Chart 56: Mortality from colorectal cancer, DSR, all ages, 1993/95 to 2004/ Mortality from colorectal cancer, DSR, all ages, to Source of data: National Statistics, Compendium of Clinical and Health Indicators / Clinical and Health Outcomes Knowledge Base, Crown Copyright 26.0 Rate per 100, England North West Halton The chart above shows that for both England and the North West, the rate of mortality from colorectal cancer has been reducing. The trend for Halton has been slightly erratic, but overall the rate has been reducing since it peaked in In the rate for Halton began to rise again widening the gap further between England and the North West Cervical Cancer Cervical cancer is the second most common cancer in women under the age of 35. Early detection and treatment are essential to improve health outcomes. A screening programme for women has been operating for many years and the roll out of the Human Papiloma Virus vaccine for 13 year old girls will help to reduce some of the cervical cancers in young women. 120

121 Chart 57: Incidence of Cervical Cancer, DSR, all ages, 1993/95 to 2003/04 Incidence of Cervical Cancer, DSR, all ages, to Source of data: Regional Cancer Registries and the National Statistics, Compendium of Clinical and Health Indicators / Clinical and Health Outcomes Knowledge Base, Crown Copyright Rate per 100, England North West Halton The overall trend in the incidence of cervical cancer for England and the North West has been a reduction between the years to Halton was also showing a reduction in rates but began to rise again from before peaking at In however the rate changed direction again with rates rising further widening the gap between the regional and national average for the period Chart 58: Mortality from Cervical Cancer, DSR, all ages, 1993/95 to 2004/ Mortality from Cervical Cancer, DSR, all ages, to Source of data: National Statistics, Compendium of Clinical and Health Indicators / Clinical and Health Outcomes Knowledge Base, Crown Copyright Rate per 100, England North West Halton The rate of mortality from cervical cancer has shown a downward trend for England and the North West between the years to The trend for Halton however has been much more erratic rising between and

122 before dipping then rising sharply to peak in At this point the rate starts to decline closing the gap between Halton and the North West. It should be noted that the numbers of females who died from this cause of mortality were very small which is indicated in the erratic nature of the chart Prostate Cancer Prostate cancer is one of the most common forms of cancer in males. It is fairly rare up to the age of 50 after which it becomes a significant form of cancer. There is no screening programme for it. Nationally, 1 in 14 men will be diagnosed with prostate cancer during their lifetime. It is the most common cancer in men. Locally, this is not the case but it is in the top 3 causes for both incidence and mortality (see chart 42). It generally occurs in older men with 4 out of every 5 prostate cancers are diagnosed in men over the age of 65. Chart 59: Incidence of Prostate cancer, DSR, all ages Incidence of Prostate Cancer, DSR, all ages, to Source of data: Regional Cancer Registeries and the National Statistics Compendium of Clinical Indicators/ Clinical and Health Outcomes Knowledge Base, Crown Copyright Rate per 100, Year England North West Halton St Helens The incidence of prostate cancer dropped between to before beginning to rise steadily during each reporting phase from to This follows the pattern in England and the North West but the drop in Halton during the earlier parts of this reporting phase mean Halton s rates are below the regional and national averages. 122

123 Chart 60: Mortality from Prostate Cancer DSR all ages 40.0 Mortality from Prostate Cancer, DSR, all ages, to Source of data: Regional Cancer Registeries and the National Statistics Compendium of Clinical Indicators/ Clinical and Health Outcomes Knowledge Base, Crown Copyright Rate per 100, Year England North West Halton St Helens After a period of rise to the mortality rate fell during to and since then has remained fairly steady with only minor fluctuations. As with incidence Halton s rates are slightly below the regional and national averages. Lung Cancer Lung cancer is the second most common cancer in the UK (excluding nonmelanoma skin cancer). In Halton it is the leading cause of cancer death for both males and females. Reducing the prevalence of smoking will have a big impact on lung cancer prevalence and mortality. 123

124 Chart 61: Incidence of lung cancer, DSR, all ages, 1993/95 to 2002/ Incidence of lung cancer, DSR, all ages, to Source of data: Regional Cancer Registries and the National Statistics, Compendium of Clinical and Health Indicators / Clinical and Health Outcomes Knowledge Base, Crown Copyright DSR England North West Halton The chart above shows the rate of incidence of lung cancer, as the chart shows there has been a steady decline in the rate for England and for the North West, but at a significantly higher rate. The overall trend for Halton was a reduction in the rate however, the rate rose in , continuing to rise for the following time period. The rate for Halton in was significantly higher than the rate for England. Chart 62: Mortality from lung cancer, DSR, all ages, 1993/95 to 2004/ Mortality from lung cancer, DSR, all ages, to Source of data: National Statistics, Compendium of Clinical and Health Indicators / Clinical and Health Outcomes Knowledge Base, Crown Copyright Rate per 100, England North West Halton The chart above shows that there has been a steady decrease in the rate of mortality from lung cancer for both England and the North West, however, the mortality rate for the North West was significantly higher than the rate for England. The rate of mortality for Halton shows a downward trend but increased in and has remained higher than the rate for the North West and England. Although 124

125 the mortality gap between Halton, England and the North West has reduced since the gap is wider now than in Chronic Obstructive Pulmonary Disease Chronic obstructive pulmonary disease is a general term which describes diseases where airflow is restricted and includes chronic bronchitis, emphysema, or both. There are about 1 million adults in the UK affected by chronic obstructive pulmonary disease and it mainly affects people over the age of 40. The biggest risk factor relating to these diseases is smoking. In order to understand the size of the problem locally a prevalence model developed by Eastern Region Public Health Observatory has been used. This model allows us to estimate the expected or predicted prevalence. Table 24 shows the results for the PCT and for the two boroughs. At the PCT level, Halton and St Helens has the 10 th highest level in England at 5.3%. Blackpool had the highest at 5.9% whilst Berkshire West had the lowest at 2.0%. The PCT therefore has a substantial burden of Chronic Obstructive Pulmonary Disease. Males have a much higher prevalence then females. At the borough level St Helens has a higher level than Halton. Table 46: Chronic Obstructive Pulmonary Disease Prevalence, Halton & St Helens Percentage Percentage Percentage All Female Male 15+ Persons Halton and St 6.3% 4.4% 5.3% Helens PCT Halton Borough 6.1% 4.2% 5.1% St Helens Borough 6.5% 4.5% 5.4% Actual Prevalence using Quality Outcomes Framework data We can see that the quality outcomes framework data prevalence is less than half the expected prevalence which indicates significant under recording, under diagnosis and probably a combination of both. Table 47: Quality Outcomes Framework data prevalence QOF Nov 07 Percentage Numbers Halton 2.06% 2612 St Helens 2.47% 4721 Halton and St Helens PCT 2.31% 7334 National 1.48 % Not Available 125

126 Chart 63: Mortality from Chronic Obstructive Pulmonary Disease persons, Mortality from bronchitis, emphysema and other COPD, DSR, Persons, Source of data: National Statistics, Compendium of Clinical and Health Indicators / Clinical and Health Outcomes Knowledge Base, Crown Copyright Rate per 100, England North West Halton St Helens Halton & St Helens PCT Halton has significantly higher levels of Chronic Obstructive Pulmonary Disease deaths than the North West as a while and England. Chart 64: Mortality from Bronchitis, Emphysema and other Chronic Obstructive Pulmonary Disease - All Persons 1993/95 to 2004/ Mortality from bronchitis, emphysema and other COPD, DSR, Persons, to Source of data: National Statistics, Compendium of Clinical and Health Indicators / Clinical and Health Outcomes Knowledge Base, Crown Copyright Rate per 100, England North West Halton St Helens Halton & St Helens PCT Although mortality rates from Chronic Obstructive Pulmonary Disease have reduced in recent years, there is a substantial gap between the rate for Halton and the rates for the North West and England. 126

127 2.5.4.a Sexually transmitted infections Sexually transmitted infections have been rising in the UK over the past decade due to personal behaviours relating to sexual risk taking, greater awareness of infections and better diagnosis. Although not all sexually transmitted diseases will impact on mortality they can have an impact on fertility and quality of life. Many sexually transmitted infections can be present without any symptoms and so seeking advice on reducing the risk of infections is an important factor in reducing the spread of these infections. Most sexually transmitted infections can be prevented through interventions and effectively treated, therefore reducing the burden of sexual ill health. The table below shows the numbers of diagnosed sexually transmitted infections for the Halton area from As can be seen the number of cases of Gonorrhoea, Anogenital Warts and Uncomplicated Chlamydia have increased whilst Primary and Secondary Syphilis and Anogenital Herpes has seen a marginal decline in the numbers. Table 48:Sexually transmitted infections diagnosed at Halton GUM department, Primary and secondary syphilis Uncomplicated Gonorrhoea Anogenital Herpes simplex - first attack Anogenital warts - first attack Uncomplicated Chlamydia Total infections Primary and secondary syphilis Uncomplicated Gonorrhoea Anogenital Herpes simplex - first attack Anogenital warts - first attack Uncomplicated Chlamydia Total infections Road accidents Latest figures from the National Statistics Health Outcomes Centre indicates that in 2005 a total of 7 people lost there lives due to road traffic accidents, this accounts for 2% of the North West total for that year. The low number of deaths due to transport means that the mortality rates show erratic trends (see chart below), overall the rates do not show higher trends than those of England as a whole. 127

128 Chart 65: Mortality from Land Transport Accidents All Persons, 1996/98 to 2004/ Mortality from Land Transport Accidents, DSR, Persons, to Source of data: National Statistics, Compendium of Clinical and Health Indicators / Clinical and Health Outcomes Knowledge Base, Crown Copyright Rate per 100, England North West Halton Halton & St Helens Disability Limiting long term illness The Census 2001 asked a question about whether people had a limiting long term illness. The percentage of people that stated they had such an illness is strongly correlated with the deprivation of the area. The Index of Multiple Deprivation 2004 also produced an index of disability and illness standardised by gender and age. This is similarly correlated with the deprivation of the area. Section outlines details of the level of service provision delivered to people with a limiting long-term illness Table 49: Long term illness and disability Location % with self-defined Limiting Long Term Illness Poor Health (%) Appleton 25 (3) 14 (4) 3 Beechwood 15 (19) 8 (18) 19 Birchfield 7 (21) 3 (21) 21 Broadheath 23 (7) 12 (9) 8 Castlefields 31 (1) 17 (2) 1 Daresbury 11 (20) 6 (20) 20 Ditton 21 (11) 11 (14) 13 Farnworth 17 (17) 8 (19) 18 Overall Rank of Disability and Illness 128

129 Grange 24 (4) 13 (5) 5 Hale 20 (16) 10 (16) 16 Halton Brook 23 (8) 13 (7) 7 Halton Lea 23 (5) 14 (3) 4 Halton View 22 (9) 11 (12) 10 Heath 20 (15) 11 (15) 15 Hough Green 22 (10) 12 (11) 11 Kingsway 21 (12) 12 (8) 9 Mersey 21 (14) 11 (13) 14 Norton North 16 (18) 9 (17) 17 Norton South 21 (13) 12 (10) 12 Riverside 23 (6) 13 (6) 6 Windmill Hill 28 (2) 18 (1) 2 Overall 21% 11% - Source: 2001 Census 129

130 2.6 Services Sexual health services Genito-urinary Medicine (GUM) Genito-urinary Medicine Departments (GUM) are normally based in hospitals and provide a range of sexual health services relating to sexually transmitted infections. Due to national rises in the number of people with sexually transmitted infections the government set targets to ensure that patients have quick access to sexually health advice through GUM departments. The national target was to ensure that all people who contact a GUM department can be offered an appointment with 2 working days. The majority of Halton residents will access their local GUM department at Halton hospital for issues relating to sexually transmitted infections. Access to services at North Cheshire Trust which includes both Halton GUM and Warrington GUM has improved greatly between April 2007 and June 2008 with 100% of people contacting GUM was offered an appointment within 48 hours. As well as people being able to get an appointment quicker 86% are also being seen for treatment within 2 working days of contacting the service, therefore quick treatments means that the likelihood of passing the infection on decreases. Chart 66: GUM Clinic Activity- North Cheshire Trust Access to GUM at North Cheshire Trust Percentage Apr-07 May-07 Jun-07 Jul-07 Aug-07 Sep-07 Oct-07 Nov-07 Dec-07 Jan-08 Feb-08 Mar-08 Apr-08 May-08 Jun-08 Month %seen in 48 hours %offered in 48 hours 130

131 Termination of Pregnancy In order that patients receive the best options of care possible another government target for sexual health is to increase the percentage of abortions undertaken at under 10 weeks gestation. The aim is to improve health outcomes for women choosing this intervention. Table 50: Percentage of abortions performed under 10 weeks gestation funded by the NHS England North West Halton & St Helens PCT Source: Department of Health, 2007 Across the PCT there has been a large increase in percentage of abortions under 10 weeks performed by the NHS. Between 2002 and 2006 there has been an increase of 48% (in 2002 the percentage was 43% and in 2006 it had increased to 63%), increases in percentages were also seen for the North West (49% in 2002 to 61% in 2006) and England (51% in 2002 and 65% in 2006). The outcomes for women accessing abortion services early in their gestation are better than a later gestation. It is therefore a target to increase the percentage of abortions that are carried out under 10 weeks. Community Sexual Health Services The PCT delivers community sexual health services in a number of locations across the 2 boroughs. The community sexual health services provide a range of services but particularly access to a full range of contraceptive methods. Being able to access a range of contraceptive methods allows women of reproductive age to regulate their fertility and both men and women to access barrier methods to control pregnancy and help prevent sexually transmitted infections. Recent guidance from the National Institute of Clinical Excellence recommended greater use of Long Acting Reversible Contraception or LARC as being effective for women of reproductive age and whilst not suitable for all women these methods should be offered where appropriate. There is a move to increase the uptake of LARC methods of contraception in order to help to reduce the number of unintended pregnancies. In Halton and St Helens these methods are available in community sexual health clinics. In % of women who first contacted the local service choose long acting reversible contraceptive as their contraceptive method. This is higher than the national percentage of 15% and the regional figure of 17% Voice: Consumer Views and Access to Services Equitable Access to Primary Medical Care Programme The NHS Next Stage Review Interim Report (October 2007) carried out by Lord Darzi (the Report), reported that, despite sustained investment and improvement in 131

132 the NHS over the past ten years, access to primary medical care services and the quality of those services, continues to vary significantly across the country. The Equitable Access to Primary Medical Care programme will play a significant role in achieving more personalised care set out by Lord Darzi. The focus of the programme will be on achieving the visions of a fair and personalised NHS (whilst upholding the values of safe and effective primary care services). It was agreed that 100 new GP Practices would be established across the country, sited in the PCTs assessed to have the poorest primary care provision. In addition all PCTs will now be required to open a GP Access Centre The PCT falls within the 25% of PCT assessed to have the poorest primary care provision and as a result we will be funded to open 3 GP Practices and a GP Access Centre. The ranking has been calculated using 3 factors: 1. 60% is based on the GP and practice nurse to population ratio. The BMA recommended ratio is approximately patients per full time GP, whereas our current ratio is 1978 (Halton borough 1806; St Helens 2106) 2. 30% is based on deprivation % GP access survey. The contract will be under the provisions of APMS (Alternative Provider of Medical Services), which opens up the market to the private sector. Also extended hours will be provided including Saturdays, and the practice will be required to become a training practice. The GP led Access Centre which will provide services to registered and nonregistered patients from 8am to 8 pm 7 days a week. Under this scheme there will be a new GP practice in Windmill Hill, Runcorn and an Access Centre in Widnes Patients Survey A national patients survey is undertaken every year asking a variety of questions about patients experience of health services locally. The 2008 survey published in May 2008 and provides information for the PCT on health service experience within general practice/health centres, about medicines, dental care and health promotion. 189 males (45%) and 230 females (55%) completed questionnaires and 4 had no details on gender. The most common age group to respond was in the age group, the ethnic group most apparent was White British in line with the local communities. Generally feedback in all areas was very positive. The following summary highlights positive aspects of patient feedback and areas for improvement Making an appointment with a doctor from GP practice or health centre Overall 358 patients (85%) had made an appointment in the last year, 75% of those thought they were seen in the necessary time, 18% thought they should have been seen a bit sooner and 7% a lot sooner. Twenty eight percent of patients trying to make advance appointments more than 3 days ahead could not do this. 132

133 Visiting the GP practice/health Centre 363 patients (87%) visited the GP practice of health centre in the last 12 months, 86% rated the courtesy of receptionists either, good, very good or excellent. 11% rated the courtesy of receptionists fair, and 3% poor or very poor. 67% were seen either on time, before time or waited up to 15 minutes, whilst 22% waited over 15 minutes up to 30 minutes and 6% waited longer than 30 minutes Seeing a doctor 352 people (84%) have seen a doctor in the last 12 months, overall people thought the doctor listened to them carefully (86%) and people had enough time to discuss their problem (79%), thought they were involved in decisions about care and treatment (71%), understood answers to any questions posed (70%), had an explanation of reasons for treatment (76%), trusted the doctor (80%) and were treated with respect and dignity (94%). Medicines 222 people (53%) had new medicines prescribed over the last 2 months. Only 51% of people felt they were involved as much as they wanted to be about the best medicines for them, 14% were not involved. Only 53% of people thought they were given enough information about the side effects the medicines may have, however 85% thought they were given enough information about how to take the medicine. Twenty four percent of people had their medication reviewed in the past 12 months. Referrals Thirty seven percent of people had been referred to a specialist in the last 12 months. Of those only 55% were offered a choice of hospital for their first appointment and only 16% received all the letters from the specialist and GP. Seeing another professional Fifty percent of people had seen another professional in the last 12 months in their GP practice/health centre, the most common professional seen was the practice nurse/nurse practitioner (86%). The majority saw the professional within a timescale they thought acceptable (86%). Overall satisfaction of GP/Health Centre Seventy four percent of people were satisfied with how the main reason for their visit to the GP/Health Centre was dealt with. 72% thought the practice/health centre was very clean. 65% of patients had sometimes or always experienced difficulty getting through to their GP on the phone and 33% were put off going to their GP sometimes or often because of inconvenient opening times. Dental care Fifty five percent of people had visited their NHS dentist in the last 2 years and 14% visited a non NHS dentist. Thirty percent had not visited their dentist. 77% of people would like to receive dental care as an NHS patient. 133

134 Health Promotion Sixty six percent of people in the survey had their blood pressure taken by their GP in the last 12 months. 31% had been given advice about their weight but 11% had not but would have liked advice, 58% were not given advice and did not want advice about their weight. 26% had been given advice about their diet, 15% were not given advice but would have liked advice and again 59% were not given advice but did not want advice about their diet. Twenty two percent of people were given advice about exercise, 15% were not given advice and wanted advice and 63% were not given advice but did not want advice about exercise. 23% were given advice about alcohol intake and 4% were not given advice/help but wanted and again 73% were not given advice/help but did not want it. 55% of patients did not have a long standing medical condition but of those that did the following conditions were highlighted Deafness or severe hearing impairment 10% Blindness or partially sighted 2% A long standing physical condition 22% A learning disability 1% A mental health condition 3% A long standing illness such as cancer, HIV, diabetes, chronic heart disease or epilepsy 15% Of those with the above condition 48% had difficulty with everyday activities that people of their age could normally do. 15% had difficulty at work or in education/training, 13% had difficulty accessing buildings, streets or vehicles, 6% reading or writing, 8% with people s attitude because of the condition, 18% communicating missing or socialising and 11% with other activities. Summary Overall people were satisfied with the care they received from their GP practice/health centre. The main issues were found in relation to advance booking to GP practices, involvement in decisions about medication, being offered choice of hospital on first appointment and receiving copies of letters between specialists and the GP. There were also some issues with GP opening times that had sometimes put people off visiting the GP. Within dental care there was a large percentage of people that had not visited a dentist in the last 2 years and yet a high proportion would like to be treated by an NHS dentist. The health promotion section illustrates that generally people did not want health advice/help regarding diet, exercise, weight, smoking and alcohol intake from their GP/health centre. This poses a challenge for public health and how these messages are delivered and how health interventions link with GP practices and what other referral mechanisms there should be for these types of health interventions Dental Health A national survey undertaken for the Department of Health in summer 2008 reported that 94% of patients in Halton (and the neighbouring borough of St Helens) were satisfied with the NHS dentistry they had received and 88% were happy with the time they had to wait for an appointment. 134

135 Between March 2006 and March 2008, over 5000 new patients were treated by dentists in Halton and St Helens. Within the borough of Halton, and in line with the objectives of the local dental commissioning strategy, new, extended NHS dental services will be developed in This will further improve access to dental care for those residents wishing to attend an NHS dentist. The strategy has four key aims and 28 objectives each with defined outcomes against which performance will be judged over a 5 year period. In year one , the PCT has focussed on 6 objectives, which if delivered can be expected to improve both oral health and dental services for the local population. There are four key aims that need to be addressed in the strategy: Reducing population prevalence of dental disease; Reducing inequalities in dental caries prevalence; Ensuring access to NHS services Ensuring evidence based services according to need. Within the Oral Health Commissioning Strategy a number of initiatives have been identified: All children aged 3-16 years attending their dentist (70% of the 3-16 year population) will be offered fluoride varnish. This evidence based intervention, supported by the Department of Health, is a simple way of preventing the development of decay. Dentists will be given incentives to encourage them to participate in this programme. Ongoing fluoride toothpaste schemes, based in schools, are expected to enhance further the drive towards dental prevention. It is anticipated that The PCT, along with all other 23 PCTs in Northwest region will be invited in 2008 to consider whether or not it wishes to consult on the possibility of a water fluoridation scheme. At this stage we do not know if such a scheme is feasible locally, but should water fluoridation be possible, the PCT will follow Department of Health Guidance (Feb 2008) subsequent to the Water Act 2003, Section 58, in any consultation process. The PCT is currently considering the detailed implications of the study on children with a Statement of Special Educational Needs, and is focussing particularly on ways in which recruitment to such studies can be optimised. It is important that the PCT has robust data on dental health needs if it is to plan future services effectively. (see also Children & Young People chapter Dental Decay) The PCT is currently considering the implications of the DAC study in relation whether they are the optimal setting for the delivery of dental care to poorly motivated patients with high levels of dental need. The new NHS dental contract offers PCTs the opportunity to shift the responsibility for the care of DAC patients to the mainstream NHS dental service, where the long term needs of these patients may be better addressed. 135

136 Dental Access Centres (DACs) were set up in the late 1990s for patients that were reluctant to commit to long term dental care within the High Street primary dental care service. Little is known of the attitudes and dental health of those using them compared to patients of High Street dentists. A study of local Dental Access Centres was conducted in It revealed patients: Were younger and from a more disadvantaged background than patients attending High Street practices Had worse oral health than High Street dental patients Experienced more frequent episodes of dental pain than High Street dental patients Had poorer attitudes to dental health than their High Street counterparts Are often prepared to attend High Street dental practice for treatment. 136

137 3. Children and Young People This part of the Joint Strategic Needs Assessment provides a profile of the health of children and young people living in Halton. It is based mainly on routinely available data, collated into one section. Where possible, statistics are provided at a local level and comparisons are made with regional and national averages. This section aims to provide information on factors known to impact on child health, and includes sections on fertility, and information on the health behaviours of pregnant women. Further sections relate to health of babies and to the health of children and young people. Information is also included on educational attainment, school exclusions economic well-being, oral health, childhood immunisations, teenage pregnancy and youth offending. 3.1 Demography There were approximately 1627 births to Halton women in The overall birth rate per 1000 population has increased from the year 2000 from to in It is generally accepted that we expect to see birth rates increase in future years which has been partially attributed to government policy and more especially related to migrant populations particularly for this area Polish migrants. Chart 67: Births for period 2000/

138 Chart 68: Mid-year population estimates, under 19 s, Halton, Mid-year population estimates and population projections, Persons, Halton Source: National Statistics, Crown Copyright and 2004-based SNPP; population projections by sex and quinary age groups Population The chart above shows that there has been an increase in the numbers in the 0-4 year olds, the 5-9 and year old populations have remained static over the past few years but the year old population has decreased. Population projections shown in the chart below indicate that the and population is predicted to decrease in the next few years. The 0-4 will remain static and the 5-9 population will rise slightly. 138

139 Chart 69: Mid-year population estimates and population projections, under 19 s, Halton, Mid-year population estimates and population projections, Persons, Halton Source: National Statistics, Crown Copyright and 2004-based SNPP; population projections by sex and quinary age groups Population Projected 1-4 Projected 5-9 Projected Projected Maps show the relative number of children under 5, 14 and under, and 19 and under by electoral ward. In addition to being a useful indicator to future needs this map also shows that whilst a number of the more deprived wards such as Windmill Hill, Riverside and Halton Lea show higher than average number of children under five other deprived wards such as Castlefields show a lower concentration. 139

140 Map 19: Geographic Spread of Population (by age) under 5 s Source: 2005 Mid Year Estimates, ONS Map 20: Geographic Spread of Population (by age) 14 and Under Source: 2005 Mid Year Estimates, ONS The under 15 s show high levels in Windmill Hill, Halton Lea and Norton South. Where the highest concentration of young people live are not necessarily the wards with the highest population densities. 140

141 Map 21: Geographic Spread of Population (by age 19 and Under) Source: 2005 Mid Year Estimates, ONS For the under 19 s the highest concentrations are seen in Windmill Hill and Norton South Ethnicity Whilst children from BME groups form a small proportion of the 0-15 year olds, the 2001 Census data shows that children who are mixed race are significantly greater than the overall population (3.30% against 1.4%). 3.2 Social and Environmental Context Deprivation In relation to deprivation over 50% of Halton s children live in the 20% most deprived areas nationally and a further 15.5% in the 40% most deprived areas nationally. Only 7.6% of children live in the 20% least deprived areas nationally. 141

142 Table 51: Halton Children and Deprivation levels IMD Deprivation % of Children 20% most Deprived 52.5% 21-40% most Deprived 15.5% 41-60% most Deprived 12.6% 61-80% most Deprived 11.8% 20% least Deprived 7.6% Source: Index of Multiple Deprivation 2007 The ethnicity section of the first section of this report indicated that generally over 98% of the population in Halton that are classed white, whereas information from the school census indicates this is lower for school age children and there is a higher proportion of children classed as mixed ethnicity. However, generally the proportion of ethnic population other than white is still low. Table 52: Ethnic mix of Halton school pupils Ethnic Group Percentage White 97.62% Mixed 1.21% Asian 0.24% Black 0.22% Chinese 0.16% Other 0.10% Source: HBC School Census Educational attainment Educational attainment is an important indicator of the future life chances for children and young people. There is also a direct correlation between levels of educational attainment and deprivation and health inequalities. Halton has made significant progress in improving GCSE results of young people in the borough, and for the last two years the percentage of young people achieving 5 A*-C has increased from 52.6% to 71.3%, taking us well above the national average. Over the same period the percentage of young people achieving 5 A*-C including English & Maths, a key indicator of future employability, has risen by 15.9% to 49.2%. The main priority for Children s Services now is to focus on narrowing the gap and reducing educational inequalities for vulnerable groups based on locality and other factors. Over half of Halton s children live in the 20% most deprived areas nationally and this has an effect on their attainment. Performance at ward level ranges from 93.3% in Beechwood to 40% in Windmill Hill and this impacts on levels of NEET (not in Employment, Education or Training) and future worklessness. Young women with 142

143 poor educational attainment are more likely to be teenage parents. Therefore narrowing the gap in education attainment will be a major factor in improving the health and well-being of our communities Education measures by ward The table below enables an assessment of the wider determinants of low educational attainment. The strength of these relationships is more easily analysed by looking at the charts below. Table 53: Attainment and further education by socio-economic favours % attaining 5 or more GCSEs % year olds in education % Lone Parent % Children in income deprived households Appleton 59 (8) 80 (12) 25 (8) 23 (10) Beechwood 93 (21) 95 (19) 10 (19) 24 (19) Birchfield 90 (20) 92 (18) 7 (21) 11 (21) Broadheath 57 (7) 70 (4) 21 (12) 22 (13) Castlefields 50 (2) 73 (8) 26 (7) 49 (3) Daresbury 77 (16) 98 (20) 7 (20) 21 (20) Ditton 59 (9) 71 (7) 19 (14) 20 (11) Farnworth 83 (18) 91 (17) 11 (18) 35 (18) Grange 55 (5) 63 (2) 26 (6) 30 (7) Hale 83 (19) 99 (21) 12 (16) 65 (16) Halton Brook 50 (3) 81 (13) 25 (10) 30 (12) Halton Lea 61 (12) 71 (6) 31 (2) 19 (6) Halton View 59 (10) 82 (14) 19 (13) 36 (1) Heath 80 (17) 87 (16) 11 (17) 15 (15) Hough Green 66 (15) 79 (9) 24 (11) 36 (17) Kingsway 62 (13) 56 (1) 26 (5) 15 (8) Mersey 59 (11) 70 (5) 25 (9) 10 (5) Norton North 62 (14) 83 (15) 16 (15) 31 (9) Norton South 55 (6) 70 (3) 30 (3) 33 (14) Riverside 52 (4) 79 (10) 29 (4) 35 (4) Windmill Hill 42 (1) 80 (11) 39 (1) 40 (2) Sources: HBC School Census, 2001 Census, Index of Multiple Deprivation 2007 The charts below plot the correlation between GCSE attainment, and staying on in education with the socio-economic factors, % lone parents and % children living in income deprived households at Ward level, as captured in the above table. Whilst both deprivation and living in a lone parent household are significantly correlated with educational attainment, this relationship is stronger for the percentage gaining 5 or more GCSEs compared to those staying on in education compared to the. It is worth noting that the severity of this effect is slightly greater for those achieving 5 GCSEs or more. 143

144 Chart 70: Percentage Children living in Lone Parent households (Y axis) vs 5 A*-C GCSE (X axis) Source: HBC School Census Chart 71: 5 A*-C GCSE (Y axis) vs % Children living in Income Deprived households (X axis) Source: HBC School Census, Index of Multiple Deprivation

145 Chart 72: Percentage staying on in Education (Y axis) vs % Children living in Lone Parent households (X axis) Source: HBC School Census, 2001 Census Chart 73: Percentage staying on in Education (Y axis) vs % Children living in Income Deprived households (X axis) Source: HBC School Census, Index of Multiple Deprivation

146 3.2.4 Economic Well-being Table 54: Economic well being of young people % Children in income deprived households % NEET Working Age Unemployment Working Age Long Term (over 12 months) Unemployment % attaining 5 or more GCSEs Appleton 23 (10) 20 (11) 3.3 (11) 0.6 (1) 59 (8) Beechwood 24 (19) 5 (19) 1.2 (18) 0.1 (16) 93 (21) Birchfield 11 (21) 8 (18) 1.3 (17) 0 (21) 90 (20) Broadheath 22 (13) 30 (3) 3.1 (13) 0.4 (5) 57 (7) Castlefields 49 (3) 27 (8) 4.8 (2) 0.5 (4) 50 (2) Daresbury 21 (20) 2 (20) 0.5 (21) 0.1 (17) 77 (16) Ditton 20 (11) 29 (6) 3.8 (6) 0.6 (2) 59 (9) Farnworth 35 (18) 9 (17) 1.1 (19) 0.1 (18) 83 (18) Grange 30 (7) 37 (2) 4.5 (3) 0.4 (6) 55 (5) Hale 65 (16) 1 (21) 1.1 (20) 0.1 (19) 83 (19) Halton Brook 30 (12) 19 (13) 3.6 (8) 0.3 (10) 50 (3) Halton Lea 19 (6) 29 (7) 4.4 (4) 0.3 (11) 61 (12) Halton View 36 (1) 18 (14) 2.3 (14) 0.2 (14) 59 (10) Heath 15 (15) 13 (16) 1.6 (16) 0.2 (15) 80 (17) Hough Green 36 (17) 21 (9) 3.6 (9) 0.4 (7) 66 (15) Kingsway 15 (8) 44 (1) 3.5 (10) 0.4 (8) 62 (13) Mersey 10 (5) 30 (4) 3.8 (7) 0.3 (12) 59 (11) Norton North 31 (9) 17 (15) 1.9 (15) 0.1 (20) 62 (14) Norton South 33 (14) 30 (5) 3.2 (12) 0.3 (13) 55 (6) Riverside 35 (4) 21 (10) 4.4 (5) 0.6 (3) 52 (4) Windmill Hill 40 (2) 20 (12) 5.7 (1) 0.4 (9) 42 (1) Sources: Index of Multiple Deprivation 2007, HBC School Census, Claimant Count December

147 Table 55: Proxy for social inclusion by location (ranked by deprivation) Library Membership Rate / 1000 Adult Learning Rate / 1000 % Car Ownership of households Access to Supermarkets Average Distance (KM) Access to Post Office Average Distance (KM) % Unemployment Rate % Young People not in education, employment or training Do not feel safe at night (%) Appleton 193 (7) 57 (19) 0.6 (20) 0.5 (21) 3.3 (11) 20 (11) 50.8 (2) 91 (20) Beechwood 161 (17) 94 (3) 2 (9) 2 (2) 1.2 (18) 5 (19) 39.9 (4) 72 (11) Birchfield 200 (4) 97 (1) 1.8 (10) 1.3 (5) 1.3 (17) 8 (18) 33.9 (6) 61 (6) Broadheath 164 (16) 68 (11) 2.2 (7) 0.6 (20) 3.1 (13) 30 (3) 43.5 (3) 73 (13) Castlefields 225 (1) 55 (20) 1 (16) 1.1 (7) 4.8 (2) 27 (8) 39.5 (5) 59 (5) Daresbury 138 (19) 95 (2) 3 (3) 1.4 (4) 0.5 (21) 2 (20) 20.4 (7) 76 (15) Ditton 185 (11) 71 (9) 2 (8) 0.9 (11) 3.8 (6) 29 (6) 43.5 (3) 54 (4) Farnworth 199 (5) 85 (5) 1 (17) 0.8 (14) 1.1 (19) 9 (17) 33.9 (6) 83 (18) Grange 166 (15) 63 (17) 0.6 (21) 0.7 (18) 4.5 (3) 37 (2) 51.8 (1) 77 (16) Hale 130 (21) 89 (4) 1.2 (14) 0.7 (17) 1.1 (20) 1 (21) 43.5 (3) 100 (21) Halton Brook 173 (12) 70 (10) 0.7 (18) 0.8 (12) 3.6 (8) 19 (13) 51.8 (1) 74 (14) Halton Lea 215 (2) 63 (16) 2.2 (6) 2 (1) 4.4 (4) 29 (7) 39.9 (4) 40 (1) Halton View 139 (18) 74 (8) 1.6 (11) 0.7 (16) 2.3 (14) 18 (14) 33.9 (6) 87 (19) Heath 173 (13) 82 (7) 1.2 (12) 1.3 (6) 1.6 (16) 13 (16) 51.8 (1) 71 (10) Hough Green 133 (20) 67 (12) 1 (15) 1 (10) 3.6 (9) 21 (9) 43.5 (3) 78 (17) Kingsway 206 (3) 64 (15) 1.2 (13) 1 (9) 3.5 (10) 44 (1) 50.8 (2) 53 (3) Mersey 186 (9) 64 (14) 0.6 (19) 0.7 (19) 3.8 (7) 30 (4) 51.8 (1) 73 (12) Norton North 167 (14) 82 (6) 3.3 (1) 1.1 (8) 1.9 (15) 17 (15) 39.5 (5) 64 (8) Norton South 196 (6) 66 (13) 3 (4) 1.5 (3) 3.2 (12) 30 (5) 39.5 (5) 48 (2) Riverside 186 (10) 62 (18) 2.3 (5) 0.8 (13) 4.4 (5) 21 (10) 50.8 (2) 63 (7) Windmill Hill 193 (8) 52 (21) 3.1 (2) 0.7 (15) 5.7 (1) 20 (12) 39.5 (6) 65 (9) Sources: HBC Libraries, 2001 Census, Department for Communities and Local Government, Claimant Count December 2007, HBC School Census, Consulting the Communities Survey Sum of Ranking Table 56: Library Membership Source: HBC Libraries Library Membership No. Rate/1000 Junior Adult Old

148 Map 22: Proxy for social inclusion by location (ranked by deprivation) 148

149 Table 57: Proxy for social inclusion by location children vs adults Library Membership Unemployment / Young People Neet Child Adult Adult Child rank rank rank rank Appleton Beechwood Birchfield Broadheath Castlefields Daresbury Ditton Farnworth Grange Hale Halton Brook Halton Lea Halton View Heath Hough Green Kingsway Mersey Norton North Norton South Riverside Windmill Hill Sources: HBC Libraries, HBC School Census, Claimant Count December

150 Chart 74: Proxy for social inclusion by location children vs adults Explanatory Note Higher ranking depicts low unemployment/neet Lower ranking depicts high unemployment/neet 150

151 3.3 Lifestyle and risk factors Low birth weight The birth weight of a baby is considered to be low when the weight is below 2500 grams. Low birth weight is predictive of increased risk of ill health and the incidence is linked to socio-economic and lifestyle (e.g. smoking) factors. Information on all births to Halton women is available locally from the annual Public Health Birth File. From this data source the birth weight can be obtained along with the area of residence at time of birth. Chart 75 illustrates the trend in percentage low birth weights. Within England as a whole the percentage has remained fairly constant. Within Halton, however, there has been a substantial increase over the time period. Chart 75: Trend in Low Birth Weight Births 1998 to 2006 Source: National Centre for Health Outcomes Development (NCHOD), Breastfeeding The positive health benefits for breast fed children are well documented. In 2003, as a proxy indicator for infant health, the government set a target to increase the number of women starting to breastfeed by 2% a year. Breast milk contains the right amount of nutrients, in the right proportions, for the growing baby. Evidence shows that breast milk has antibodies, which protect against infection including gastroenteritis, respiratory illness, urinary infections, and ear infections. In addition, it reduces the risk of childhood diabetes and leukemia, and of allergic conditions, such as asthma and eczema. Research suggests that infants who are not breastfed are much more likely to be admitted to hospital in their first year of life. The government target set for the NHS relates to increasing the percentage of mothers initiating breastfeeding, as yet there are no national targets set to increase continuation rates. Information on breastfeeding initiation is reported and monitored 151

152 through the Local Delivery Plan (LDP) process, and is available in aggregate form for comparative purposes from the Department of Health. The average proportion of women breastfeeding on delivery in Halton had increased slightly from 41.7% in 2003/04 to 42.8% for 2005/06. Recent figures however indicate that the number of women known to be initiating breastfeeding has dropped to 37.1% for the period 2006/07. The England average for 2005/06 was 77%** Smoking in Pregnancy The proportion of women continuing to smoke during pregnancy is reported as part of the LDP for the PCT. Figures for 2006/2007 indicate that the number of women choosing to smoke during pregnancy has declined to 24.1% creating a 2.7% reduction on the previous year (2005/2006) in which 26.8% of women within the PCT smoked during pregnancy Sexual behaviour The national target for teenage conceptions is a reduction of 50% in the rate of conception amongst girls aged under 18. Differential stretched targets apply to boroughs with the highest rates of teenage conceptions. Thus, Halton borough has to achieve a reduction of 55% from the 1998 baseline. The most recent published data shows that Halton has not reduced teenage conceptions from the baseline and in fact has had a small 1.9% increase. When looking at the rates using 3 year rolling averages which will smooth out any unusual low and high rates and are a useful way to examine trends Halton has reduced it s rates by 5.4% from average rates to average rates Table 58: 1998 to 2006 under 18 conception rates % diff between 1998 and 200 Halton UA St Helens MCD Halton and St Helens PCT North West England ** Infant feeding survey 2005 Data for the PCT has been calculated by aggregating borough data to PCT to establish population base. There may be small rounding differences to the actual figure 152

153 Chart 76: Under 18 conception rates (single years) Rate of teenage conceptions per year old females, 1998 to 2006 Source: Office of National Statistics 60 Rate per 1,000 females aged 15 to 17 years Year England North West GOR Halton UA Chart 77: Under 18 conceptions rates (3 year rolling averages) 55.0 Rate of teenage conceptions per year old females (3 year rolling averages) Source: Calculated from Office of National Statistic single year data Rate per 1000 females (3 year averages) Year England North West GOR Halton UA Under 16 conception rates for Halton in average were 8.5 per 1000 females year old which is comparable to the England rate of 8.4 and had reduced in line with national trends to 7.9 in Although there are variations in this over time as the numbers are small. 153

154 Chart 78: Under 16 conception rates (3 year rolling averages) Chart 79: Under 18 conception rates 2002/04 (3 year rolling averages) 120 Under 18 conception rates (females aged 15 to 17 years) by ward, , Halton Source: Teenage Pregancy Unit, Rate per 1, Daresbury Hale Birchfield Beechwood Farnworth Heath Norton North Halton View Hough Green Riverside Broadheath Kingsway Appleton Norton South Windmill Hill Ditton Halton Brook Halton Lea Castlefields Mersey Grange Wards 154

155 There are local areas within the borough that experience teenage conception rates, which are significantly higher than the borough average. In keeping with national trends there is a significant correlation between areas of deprivation and areas with highest rates of teenage pregnancy. 7 out of 21 wards have teenage conceptions amongst the highest 20% in England (6 being in Runcorn) Wards indicated in red are classified as hotspot wards with a rate among the highest 20% in England (rate over 54.3 per 1000 females aged 15-17). Hot spot wards (over 3 years include Mersey, Castlefields, Norton South, Riverside, Kingsway and Halton Lea). Identified hotspots provide the focus for targeted interventions. There is a direct correlation between levels of attainment and the rate of conceptions in wards. Hotspot wards have a lower percentage of girls and boys achieving 5 + GCSE A*- C. The first 2 quarters of 2007 indicate a rise in the number of teenage pregnancies. Live births in deprived wards have risen. The majority of teen mothers are 17 years of age. Hot spot months for conceptions in Halton are December, May and August Obesity among primary school age children Halton & St Helens Childhood Obesity Summary: Academic Year 2006/07. Childhood obesity is a Public Service Agreement (PSA) target set in July 2004, which aims to halt the year on year rise in obesity among children under 11 by 2010 in England. In the summer of 2007 the heights and weights of all Halton & St Helens primary school children in Reception (aged 4 and 5) and Year 6 (aged 10 and 11) were measured and collated. These data were made anonymous and uploaded onto the National Childhood Measurement Programme Database (NCMP). NCMP automatically calculates the BMI for each record. The 85th and 95th Centile cut-offs from the British Growth Reference 1990 were selected by the Department of Health as public health definitions of overweight and obese children in the population respectively. Aggregation of these data into different clusters and geographies will provide prevalence rates. This should be used for indicative purposes only, as due to the relatively small numbers prevalence figures calculated may not be statistically robust. This report will present the data in a number of different ways to enable service providers to evaluate the most appropriate level to address childhood obesity in their area. National data, due to be reported at the end of 2007, will enable comparisons with local rates. Table 38 shows the percentage of pupils who had their heights and weights recorded during 2006/

156 Table 59: Number of Pupils with Heights and Weights Recorded Numbers on Roll Number measured Percentage Measured St Helens - Reception % St Helens - St Year % Halton - Reception % Halton - Year % Halton & St Helens PCT % Reception Halton & St Helens PCT - Year % Halton & St Helens PCT Overall % Table 60 shows the provisional summary provided by the NCMP for the PCT. The summary has separated overweight (85th 94th Centile cut off) and obese (>=95th Centile cut-off) children. This report will calculate the prevalence of overweight and obese children (>=85th Centile cut-off) and obese children (>=95th Centile cut-off). Table 60: PCT NCMP Summary 1. Percentage of pupils with a BMI p- score: Halton & St Helens Reception England Average Reception Halton & St Helens Year 6 England Average Year 6 >=0.85 (defined as overweight) 15.80% 13.00% 15.32% 14.20% >=0.95 (defined as obese) 12.95% 9.90% 21.56% 17.50% Office for the Deputy Prime Minister produced The Indices of Deprivation 2004 (ID2004), this provides a measure of multiple deprivation for all Lower Super Output Analysis of the National Childhood Database : A Report for the Department of Health by the South East Public Health Observatory on behalf of the Association of Public Health Observatories. 156

157 Map 23: Indices of Deprivation 2004: Rank of ID Overall Score by National Quintile. Using the children s residential postcode the heights and weights data were ranked by national quintile. Halton and St Helens pupils who live in the 20% most deprived LSOAs nationally were ranked in Quintile 1. Charts and tables in this report are based on children who live within the borough of Halton & St Helens only. They therefore exclude children who reside out of the two boroughs but attend a school in Halton or St Helens. Chart 80 shows the percentage of Reception children by national deprivation quintile who were overweight and obese (BMI >=25) and those who are obese (BMI >=30). Table 61 shows the proportion of overweight & obese and obese children by borough and national deprivation quintile. 157

158 Chart 80: Percentage of Overweight & Obese Reception Children by National Deprivation Quintile 2006/ % Percentage of Overweight & Obese Reception Children by National Deprivation Quintile. Academic Year 2006/ % 20.0% Percentage 15.0% 10.0% 5.0% 0.0% Quintile 1 - Most Deprived Quintile 2 Quintile 3 Quintile 4 Quintile 5 - Least Deprived Halton Overweight & Obese Halton Obese Chart 81: Percentage of Overweight & Obese Year 6 Children by National Deprivation Quintile, 2006/ % Percentage of Overweight & Obese Year 6 Children by National Deprivation Quintile. Academic Year 2006/ % 35.0% 30.0% Percentage 25.0% 20.0% 15.0% 10.0% 5.0% 0.0% Quintile 1 - Most Deprived Quintile 2 Quintile 3 Quintile 4 Quintile 5 - Least Deprived Halton Overweight & Obese Halton Obese The percentage of overweight and obese children in St Helens and Halton appears to be comparable across all the deprivation quintiles except quintile 5. As shown in Map 22 the majority of the LSOAs in Halton & St Helens (84%) are ranked in national quintile 1 to 3. Only 3 LSOAs (1 in St Helens, 2 in Halton) are in the least deprived quintile 5. As previously mentioned these prevalence rates are based on small numbers therefore care must be taken when interpretating data. 158

159 Table 61: Percentage of Reception Children Overweight & Obese Table 62: Percentage of Year 6 Children Overweight & Obese Chart 81 and table 61 shows the percentage of overweight & obese Year 6 children in Halton & Helens. Overall there appears to be a greater proportion of overweight and obese children in Year 6 compared to reception year. Similar to the reception data, the proportion of overweight children appears to be comparable across the deprivation quintiles. In Halton the data were amalgamated and analysed by Children and Young People Area Networks (CYPAN). Chart 82 shows the prevalence of overweight and obesity by CYPAN areas. Children & Young People s Area Networks, (CYPANs) build upon initial developments around Children s Centres and Extended Schools. Work with Head teachers, PCT, Voluntary Sector and CYPD colleagues led to this model of developing integrated service delivery within discrete, manageable geographic areas that focus services on specific SOAs, allow groups of Extended Schools and Children s Centres to work together and utilise local knowledge of community preferences in accessing By working in this way across local communities, opportunities to provide not only all of the core service entitlement but allows the deeper local need to be identified by demographics, current service provision and consultation findings. Each network is defined on a ward basis and as the map below shows; there are 3 in Widnes and 2 in Runcorn. 159

160 Each CYPAN has a flexible workforce to meet the needs of its area, with a core workforce who are primarily area network based and by definition work to meet the needs of a defined geographical area. In addition, there are also a range of professionals who provide support in the form of challenge, scrutiny, and administrative support. This second band of virtual practitioners work across Halton, working specifically within any specific CYPAN only when the need arises. Map 24: Halton Proposed Children & Young People s Area Network 160

161 Chart 82: Halton CYPAN Percentage of Overweight & Obese Reception and Year 6 Children 50.0% Halton CYPAN Percentage of Overweight & Obese Reception and Year 6 Children. Academic Year 2006/ % 40.0% 35.0% 30.0% 25.0% 20.0% 15.0% 10.0% 5.0% 0.0% CYPAN 1 CYPAN 2 CYPAN 3 CYPAN 4 CYPAN 5 Reception:Overweight & Obese Reception: Obese Year 6: Overweight & Obese Year 6: Obese Geodemographic Distribution of Childhood Obesity Geodemographic classifications are widely utilised in the commercial sector. The classifications cluster together local areas where resident populations have similar characteristics. They are based primarily on data derived from the 2001 Census. These groupings offer an alternative method of segmenting the population. There are various geodemographic classification systems currently in use. The data presented utilises the P2 People and Places product. P2 People & Places is built in a hierarchical structure, with three types of clusters: the top level of 14 Trees, subdivided into 41 Branches, with a lower level made up of 157 Leaves. The Trees, Branches and Leaves are ranked in order of affluence, with Mature Oaks being the most affluent group and Urban Challenge the least affluent. The PCT has access to the People and Places product at Tree level. This classification groups certain types of people at different stages of their life together and provides summaries for each tree based on their lifestyle, socio economic group and age. Consequently, certain trees such as Senior Neighbourhoods will only have a very small number of children as characteristically these consist more of older people. Care must therefore be taken on interpretation of this data due to potentially small numbers. Map 24 illustrates the spatial distribution across the boroughs. Chart 83 presents the 2006/07 child measurements aggregated into People and Places Classifications. 161

162 Map 25: Halton & St Helens P2 People and Places Classification. Chart 83 shows that obesity levels are comparable across the different classifications ( trees ). This indicates obesity has become universally spread across social classes. 162

163 Chart 83: Total Child Measurement data by People and Places Tree Chart 83 shows that obesity levels seem comparable across the different trees. Table 63 shows the distribution of the Reception and Year 6 children across the classifications. The table shows that the majority of the children measured across Halton & St Helens live within 3 trees; Urban Producers, Rooted Households and Suburban Stability. Table 63: Total Child Measurement data by People and Places Tree 163

164 In order to target these groups during a campaign P2 provide summaries for each tree based on their lifestyle, socio economic group, age. Urban Producers Reception; 28.8% are overweight & obese, 12.6% are obese. Year 6; 38.3% are overweight & obese, 23.5% are obese. Urban producers are adults aged between 16 and 34 years, many have children. Single parent families are common in this classification. Council housing is the dominant tenure in this group and they may have one small car. Urban producers tend to do their grocery shopping at Asda and are very likely to be smokers. They tend to read tabloid papers. They are the 4th most deprived group in the people and places classification. Income falls into the fourth quintile, 0 to 12,999, with many unemployed. The jobs tend to be skilled manual, unskilled labour or routine/semi routine occupations Rooted Households Reception; 29.8% are overweight & obese, 13% are obese Year 6; 37.6% are overweight and obese, 21.8% are obese. Rooted Households are made up of older adults and young families, where the parents are aged 25 to 34 years. Semi detached properties are the dominant housing tenure with generally two or more cars. The adults are skilled manual workers on fairly high wages. Income falls into the second quintile, 23,000-36,999. Rooted Households tend to do their shopping at Tesco and read newspapers such as the Express and the Mail. Suburban Stability Reception; 28.1% are overweight & obese, 12.6% are obese Year 6; 36.2% are overweight & obese, 12.9% are obese People and Places describe this classification as the average group of British society; families are common in this group with parents aged between 25 and 34. The homes are mainly semi detached or terraced and are a mixture of rented, owner occupied with a mortgage, council and housing association. They are likely to own a car. Grocery shopping is done in a number of supermarkets, Asda, Aldi, Lidl, Morrisons, Safeway and Somerfield. Their income falls into the third quintile ( 13,000-22,999) and are employed in routine, semi routine and skilled manual work. 164

165 3.4 Burden of ill-health and disability Infant mortality Infant mortality, that is the death rate amongst babies less than one year old, is used as an indicator of population health, in that it reflects socio-economic factors and maternal health it can be used to compare the health and well-being of populations across and within countries. Infant mortality forms part of the governments plan to tackle health inequalities, with a 10% reduction in the gap between rates in routine and manual socio-economic groups and England as a whole required by Infant mortality is the second aspect of the health inequalities PSA target and is a mandatory indicator for both PCT and local government. The number of infant deaths per year is very small. In 2006 there were 10 deaths amongst babies aged less than one year within Halton; this gave a rate of 6.1 per 1,000 live births. The rate in the borough is higher than the rate for England (5.0 per 1,000 births) and the North West region (5.6). As with other health indicators, there is variation within Halton, however the very small number of deaths means it is not feasible to calculate robust SOA or ward level rates, as even aggregating a number of years will still result in very small numbers at this level. In view of these issues, in order to monitor the health inequalities target at a local level, it is necessary to look at other indicators of infant health. Low birth weight is a useful indicator, and the Government has proposed two further indicators, which can be used as interim measures for the infant mortality indicator; breastfeeding initiation and smoking in pregnancy Chlamydia in the under 25 s Chlamydia is the most common bacterial sexually transmitted infection and there has been a rise nationally in the number of infections diagnosed particularly in the under 25 s. Chlamydia is often present without any symptoms and can affect future fertility. As a result a national programme of opportunistically screening year olds for Chlamydia has been rolled out nationally. Within Halton and St Helens the programme started screening in the third week of September 2007 and had screened 3.6% of the year old cohort by March Regionally 10% of the cohort has been screened and nationally 6.3%. Although local screening figures look small with a full year affect it is expected that Halton and St Helens will exceed the national rates and work towards the very challenging target of screening 17% of the year old population. Of the 3.6% screened for Chlamydia 10.6% were positive by which is higher than the national average which is just over 7% in As the screening becomes embedded and more young people are screened we expect the positive rates to eventually fall as the pool of infection is reduced through treatment and good health promotion. 165

166 Table 64: Percentage of the year old population opportunistically screened for Chlamydia infection in Halton and St Helens Area (15-24 years) % of sexually % of total active N* population population Halton and St Helens 1, Strategic Health Authority TOTAL 72, ENGLAND TOTAL 319, Dental decay Decayed, missing and filled teeth is an indicator of dental health, there are national programmes, which examine the dental health of school aged children and therefore give an indication of the picture locally. Good dental hygiene and diet will have an impact on dental health and so can prevent poor dental health which is an important factor relating to an individuals quality of life. Chart 82 below shows the mean number of decayed, missing and filled teeth in children aged 5 years for the years 2001/02 and 2004/05. The chart shows that the mean number is higher in Halton for 2004/05 when compared to the England and Cheshire and Merseyside values.. Chart 84: Decayed, Missing and Filled Teeth for Children Aged 5 Years 2.5 Decayed, Missing and Filled Teeth for Children Aged 5 Years Source of data: Department of Health, West Midlands Public Health Group,Compendium of Clinical and Health Indicators / Clinical and Health Outcomes Knowledge Base 2 Mean Percentage England Cheshire and Merseyside SHA Halton PCT St Helens PCT 2001/ /05 166

167 Map 26: Prevalence of Decayed Teeth in 5 year old children, 2005/06, Halton and St Helens PCT. A local epidemiological survey across Halton & St Helens, Warrington, Western Cheshire and Knowsley Primary Care Trusts of children with a Statement of Special Educational Needs found the levels of dental health to be broadly similar to the wider same age population in the North West. The survey was carried out as little is known of the dental health of this population; data is not routinely collected in a way that allows identification of children with learning difficulties. Unfortunately positive consent from parents was low resulting in a 34% participation rate. Whilst dental health is similar there is evidence from elsewhere that access to and the type of care received differs. It is not known why the response rate was so low as this has not been the case with other research and merits further investigation Road accidents Children killed or seriously injured on roads The first part of Table 65 shows there has been a year-on-year decrease in the numbers of children killed or seriously injured in road traffic accidents. Experience would suggest that the figure of 4 for 2006 is particularly low and unlikely to be repeated in the years immediately following. The second part of the table has calculated the percentage change in number of children killed or seriously injured during the calendar year compared to the previous year. Figures are based on 3-year rolling averages. The resultant percentage changes show that until 2009/10 the actual and targeted figures show an improvement. Whilst the figure for 2010/11 suggests a decrease in performance it is 167

168 only when the actual figure for 2007 is known that determine whether the current targets need to be revised. This is because the 2011 target has been distorted by the 2006 actual figure dropping out of the 3-year rolling average. Table 65: No. of Children (<16) Killed or Seriously Injured in Accidents Actual Actual Actual Actual Target Target Target Comparison of 3 year rolling averages by reporting year. Actual Target Target Target 2007/8 2008/9 2009/ /11 a b a-b a-b* a-b*100/a or % change Injuries The Government s vision over the 2007 Comprehensive Spending Review period is to improve child safety, so that children and young people are better protected from deliberate and unintentional harm. Hospital admissions nationally due to unintended and deliberate injuries to children and young people under 19 have been increasing in recent years. There were a total of 664 hospital admissions caused by unintended and deliberate injuries in children and young people in 2006/07. This varied from 4.9 per 1000 in Hale to 35.1 per 1000 in Windmill Hill. Windmill Hill has significantly higher rate of admissions than the Halton rate. 168

169 Chart 85: Serious and Untoward Incidents in Children and Young Persons 0-19 Years Halton All Persons by Ward 2006/07 The age groups that had significantly high rates of admissions for and deliberate injuries in children and young people in 2006/07 were the 0-4 s and the 15 to 19 s. Chart 86: Serious and Untoward Incidents in Children and Young Persons, Halton by Age-band /07 169

170 Map 27: Serious and Untoward Incidents towards Children and Young People Halton 2006/07 The wards with the highest percentage of admissions were Windmill Hill, Mersey, Hough Green and Broadheath 3.5 Services Measles, Mumps and Rubella vaccination Measles, mumps and rubella (MMR) vaccination programme for children is a national programme aimed at protecting children from these infectious diseases that can lead to serious disability and or death. Rates for the MMR uptake are presented at PCT level for the year 2006/07. In this period 87% of children received their first dose whilst 76% received both their first and second dose of the vaccine by their 5th Birthday. These figures beat the England percentage with 86% and 73% being immunised. Additionally for the same period 85% of children within Halton & St Helens PCT received their initial dose by the age of 2 matching the England average of 85% for the same period. 170

171 4 Adult Social Care 4.1 Demography, Social and Environmental Context Older People The age of a local population inevitably has an impact on health experience and the level of health services likely to be required. Populations with a higher percentage of over 65 s are likely to have a higher level of need. Current estimates highlight that Halton has a much younger population than the national and regional averages. A greater proportion of Halton residents are children, compared with both national and regional figures. Halton has a smaller proportion of residents aged between 65 and 74 than nationally and regionally, and far fewer residents aged 75+. The age structure of the Halton population has changed considerably over the past ten years. In 1996, 12.9% percent of the total population was aged over 65; by 2006 this had increased to almost 14%. This compares with a 0.1% increase in proportion of over 65 s in England as a whole. The ageing population is set to continue, with projections suggesting that the population of the Borough will continue to age at a faster rate than national and Northwest averages. The most significant of these increases are from 2011 onwards and most will be female. The health and well being of older people in the borough is comparatively poor. Being the 30 th most deprived area nationally means that deprivation is widespread and not just confined to hotpots. On average, older people are more likely than younger people to report lifestylelimiting illness, to live alone, live in poverty and to rely on public services and informal carers. People are also living longer with chronic long-term conditions (respiratory, heart, and diabetic etc). Advancing age carries some increased risk of dementia and depressive illness, often linked to bereavement. Additionally sight and hearing loss can become more significant with age. Falls are also a common feature where prevalence increases with age and Halton has a high prevalence of respiratory illness. This shift to an older population will have a large effect on demand for social care, health and other public services. Unless outcomes are improved through effective, adequate prevention and health promotion, this increased demand will lead to significantly increased costs for health and social care provision. Between 2006 and 2012 the population in Halton is predicted to decrease in each age group under 45 but increase in older age groups. By 2025, this trend will see a far greater number of Halton residents aged 75 and over and so to reduce future costs preventative work should focus on the current population within the age range with a view to maintain good health and prevent pressures on the system when this population reaches

172 Table 66: Older People Population Projections People aged ,200 5,400 7,200 6,900 7,000 People aged ,300 4,400 4,800 6,500 6,200 People aged ,400 3,400 3,700 4,100 5,500 People aged ,200 2,400 2,500 2,800 3,100 People aged 85 and over 1,700 1,800 2,100 2,400 2,900 Total population 65 and over 16,800 17,400 20,300 22,700 24,700 Source : POPPI Tool The following map indicates that the highest concentration of older people can be found in Castlefields (ranked 2 nd highest for health deprivation in Halton), Halton View and Ditton. Map 28: Geographic Spread of Population (by age 60 and Over) Source: 2005 Mid Year Estimates, ONS Nearly 50% of over 65 s and 53% of over 75 s live in the 20% most deprived areas nationally, compared with 4% and 3.3% of the same age groups living in the 20% least deprived nationally (this analysis has been drawn from a combination of ONS and IMD statistics which can be found at and respectively). 172

173 Table 67: Halton Older People and Deprivation levels IMD Deprivation % over 65 % over 75 20% most Deprived 49.5% 53.4% 21-40% most Deprived 17.0% 15.8% 41-60% most Deprived 15.4% 15.2% 61-80% most Deprived 14.2% 12.4% 20% least Deprived 4.0% 3.3% Source: Index of Multiple Deprivation 2007 Findings from the Housing Needs Survey 2005, suggest that there are 24,739 people aged 60 and over living in the Borough with 17,498 people aged between 60 and 74 and 7,241 people aged 75 and over. Over 18,000 households contain at least one person who is aged 60 or over with 8,305 older people living alone and 5,470 older couple households with the remainder living in larger households. Almost half of people aged 75 and over live alone (3,551 households) with 27% of people aged 60 to 74 forming single person households (4,754 households). With respect to the age range, the top 20% of wards for people living alone are Appleton, Kingsway, Ditton, and Broadheath. For the 75+ age group it is Mersey, Grange, Broadheath and Riverside. All of these areas are also areas of deprivation. This is cause for concern because of potential combined effect of deprivation and social isolation. Given there is strong research evidence to suggest the detrimental effect deprivation combined with social isolation can have on health and well-being, this is an important indicator for targeting initiatives. These implications are consolidated by the projected ageing population in that by 2025 there will be sharp increases in the numbers of people living alone. Whilst all age male and female groups are projected to increase by 33% or more, the most significant increase is for men aged 75 and over at 73%. Table 68: Older People (OP) Living Alone - Distribution by Ward OP Living Alone Numbers OP Living Alone - Proportion of ward population Ward population Total Total Ward Appleton Beechwood Birchfield Broadheath Castlefields Daresbury Ditton Farnworth Grange Hale Halton Brook Halton Lea Halton View

174 Heath Hough Green Kingsway Mersey Norton North Norton South Riverside Windmill Hill TOTAL Source : Housing Needs Survey 2005 Table 69: Living arrangements of people aged 65 and over by age bands (65-74, and 75 and over) and gender and numbers living alone, projected to 2025 Males aged predicted to live alone Males aged 75 and over predicted to live alone Females aged predicted to live alone Females aged 75 and over predicted to live alone Total population aged predicted to live alone Total population aged 75 and over predicted to live alone Source : POPPI Tool ,071 1, ,008 1,176 1,456 1,650 1,716 2,079 2,310 2,343 2,537 2,655 2,773 3,068 3,776 2,415 2,515 3,048 3,381 3,363 3,377 3,523 3,781 4,244 5,232 The survey also found that 48% of older person households contained a household member with a disability or limiting long term illness. Couple households were more likely to contain someone with a disability/limiting long term illness (57%) than single person older households (43%). Not only is there a correlation between disability and limiting long-term illness with deprivation but this relationship is stronger than for social isolation. There is thus an emerging picture of multiple negative effects on an older people s health and well-being combined with deprivation. This means that the individuals capacity to improve their health and well being is mitigated by the lack of economic and social resources to draw upon. In the 2001 Census, 12.48% of people in Halton aged 65 and over were without central heating. The age group with the highest percentage are people aged 85 and over at 15.25%. These percentages are of particular concern given the concentration of people without central heating in areas of deprivation. The specific wards in question are also those with the greatest deprivation in the top 20%. It will be important for older people to be targeted as part of wider fuel poverty strategy given the combined effect of this age group being highly susceptible to the cold with rising fuels and limited financial resources. 174

175 Table 70: People aged 65 and over by age (65-74, 75-84, 85 and over) living in a dwelling with no central heating, year 2001 People aged People aged People aged 85 and over Total population aged 65 and over Source : POPPI Tool Total 65 and over population 2001 Number of 65 and over population with no central heating 2001 Percentage of 65 and over population with no central heating ,085 1, % 5, % 1, % 16,000 1, % Older person households are more likely to be owner occupiers with over half of all older person households owning their property outright, with over a third being social housing tenants. Social housing currently makes up 26% of the overall housing stock in Halton so this latter statistic demonstrates an over concentration of older people in the social rented sector. Whilst there are high numbers of people without a mortgage this is not complimented by the level of savings as seen below. Overall, 10% of older person households indicated that their current accommodation was not adequate for their needs, lower than the general population who found their accommodation inadequate (15%). The major reason given for inadequacy by both singles and couples was that the accommodation needs improvements or repairs, although single households were more likely to give this as a reason than couples. Over a fifth of single households who found their accommodation inadequate indicated that it was too large while couples are more likely to find their accommodation too small and too costly to heat. Given the current high percentage of under occupancy and projected significant increase, there is a need to target initiatives to address rising fuel costs. Whilst the Housing Needs Survey collated information on household income, savings and benefits received, not all respondents were willing to answer questions relating to finances. Over half (58%) of older person households have less than 5,000 savings, rising to 67% of singles and falling to 46% of couples. Almost a fifth of couples and only 8% of singles have significant savings of over 30,000. Given the correlation between older people living in areas of deprivation and faced with increased risks to their health, this means they are also less likely to cope with unplanned events. Again early intervention, which prevents a problem escalating, will be key. 175

176 Respondents who were owner occupiers were asked to indicate approximately how much equity value was in their property. A quarter of older person owner occupied households did not answer the question but the findings from those that did show the extent of high level equity tied up in property as a result of house price increases as three quarters have spare equity of over 75,000 and a quarter with equity of over 150,000. A high proportion (41%) of older person households did not answer the income question. The responses from those that did show that on the whole older people have very low annual incomes with 93% receiving less than the annual income of 27,500 and 58% less than 10,000. As perhaps expected, a much greater proportion (74%) of single older person households have total household incomes of less than 10,000 than couples (38%). With respect to claiming means tested benefits, almost a third claim Housing Benefit, 28% receive pension credits and a quarter claim disability allowances and Council Tax Benefit. Single older person households are more likely to claim benefits than couple, with the exception of Disability Allowance Extra Care Housing The aspirations of older people have changed and there has been a move towards enabling greater independence and choice. Older people are more mobile than previous generations, in terms of employment and accommodation. Historically choice in housing as people aged meant staying in their long term home (possibly with this becoming difficult to maintain and increasingly inaccessible), moving to sheltered housing or moving to a care home. Recent changes have included an increase in support to people in their own homes, through assistive technology and domiciliary care and in the development of specialist housing providing for health and care needs. Extra care housing is one of the options becoming available to people in response to changing needs and by 2006 nationally there were 25,000 extra care housing units Halton currently has one extra care housing scheme providing 40 flats (37 one bed flats and three two beds) for a range of needs; the targets set for the service are 30% low dependency, 40% moderate dependency and 30% high dependency residents. The scheme has a lounge, restaurant, buggy store, therapy space, laundry, assisted bathing facilities and hairdressing room. It is owned by ECHG and managed by Halton Adult Services. Halton Adult Services also provide the care services. The scheme has been operating for 18 months. In the last 12 months there have been eight voids. There is currently a waiting list of 11 people for the service and no more people are being accepted for referral to the panel for decision about acceptance for inclusion on the waiting list. The model is seen as successful by the service manager and by other stakeholders. 176

177 Comparison of extra care units with other Boroughs In comparing the number of extra care units with a sample of local authorities in the North West (using the same comparator authorities used in developing the Halton domiciliary care strategy), Halton has a similar number of units in proportion to the older population as Blackpool, but a significantly lower number than Warrington and Blackburn. See the table below. Information in this table includes extra care villages. It does not break down the figures into high, medium or low support needs or tenure. Table 71: Comparison of extra care units with other Boroughs Authority Extra Care Units Population (65+)* Population (all) % of people 65+ % of all people Warrington , , % 0.25% Blackpool 59 27, , % 0.04% Blackburn , , % 0.15% St Helens , , % 0.18% Halton 40 16, , % 0.03% Quantified need for extra care provision In quantifying the core need for extra care provision we have used the following assumptions, which were arrived at through consultation with stakeholders: 25% of the number of older people currently in residential care who could otherwise be housed in extra care, plus 50% of the number of older people in receipt of intensive domiciliary care support (over 10 hours a week)with data based on PAF indicator of intensive home care = 11.1 per 1,000 population. The current estimated need has then been applied to future population projections of older people in Halton to determine future need. On this basis, the core need for extra care housing for older people is 166 units (25% of older people in residential care (298) = 74.5) + (50% of people currently in receipt of intensive domiciliary care (183.15) = 91.5). The table below shows the projected need for extra care based on the projected future population growth of the population of people aged 65 and over. Table 72: Quantified Need for Extra Care Provision Future Need Projected population 65+ Projected 1.01% 1.01% 1.01% 1.01% 1.01% 1.01% 1.01% 1.01% 1.01% 1.01% 177

178 percentage in need Identified need for extra care This needs analysis is based on data from older people who currently access services (domiciliary care and residential care). This has produced a baseline need. However, there may be additional need in the older population that has not been quantified and the baseline assessment needs to be viewed in this context. This may include some older people who have not accessed domiciliary or residential services but may also benefit from extra care housing. In addition stakeholders identified possible future need amongst the current younger population of Halton in the 55 to 65 age range who have significantly higher long term conditions than the national average. This age band was not included in the assumptions used for the needs assessment, but as this group ages they are likely to require higher levels of care and support and may add to the estimated need for extra care housing. Older people with learning disabilities The overall need for extra care for older people identified above excludes the needs of older people with learning disabilities who may benefit from extra care housing. Total need can be adjusted to take account of those people age 65+ with learning disabilities who currently receive a service. Older people aged 65+ with learning disabilities are a fixed population as diagnosis is made at birth and not acquired. Whilst numbers aged 65+ currently are low at 23 people, there are a further 58 people in the age group who are likely to develop age related conditions which will become their primary need, rather than their learning disability. An additional factor to consider is that people with learning disabilities develop presenile (early onset) dementia on average 15 years earlier than the general population at age 54 but onset for some can occur in their 30 s particularly for those with Downs syndrome. Examination of the 23 people aged 65+, currently receiving a service shows: - 19 living in their own home with intensive support - 3 in residential care two recent admissions as older people and one discharged from long stay hospital in the 1980 s - 1 out of area specialist placement Based on for this information about older people with leaning disabilities it is estimated that need for extra care housing for this group equates to 11units. The assumption resulting in this estimate is that the two people in older people s residential care plus 50% of the people living in their own homes with intensive support would benefit from extra care accommodation. An examination of the age profile of people with learning disabilities aged 65+ over the next ten years shows 178

179 that the level of need for extra care housing during the years 2010 to 2015 will double to 22 units and then stabilise. In summary, the current core need for extra care is 166 units. This will increase to 214 units by 2017.In addition there is a current need for an eleven units of extra care provision for older people with learning disabilities. The initial need could be met through the development of four additional extra care housing schemes providing forty to fifty units by Forecasting the Impact of Projected Population Change on Demand Contracted Domiciliary Care Services In order to forecast future demand for the externally provided service, the relationship between the number of service users and the population needs to be understood. If the total adult and the total 65+ populations are divided by the number of service users, a ratio (or strike rate as it is sometimes called) can be established that can then be applied to future projected levels of population. This is illustrated in Table 3 below. This should (if all other variables remain the same) provide a sound basis for estimating demand. Other variables will of course be unlikely to remain constant, however the application of this ratio will provide an initial estimate which can then be varied as appropriate, as predicted changes to other variables are factored in. (Note: The figures in Table 3 relate only to the contracted services) Table 73: External Provider Service: Number of Service Users per 1000 Population - Adults and Over 65s Adult 65+ Adult and 65+ Population in 2007 (ONS data) 71,700 16,600 88,300 Number of service users Ratio of service 1 per per 31 1 per 133 users to population The ratio for older people that the analysis reveals - 1 person receiving domiciliary care for every 31 older people in the population - is 17 times greater than the ratio for adults. This indicates that changes to the population of older people will have a much greater impact on the level of demand for domiciliary care than similar changes to the adult population. Applying the adult ratio to the projected adult population for 2008, 2010, 2012 and 2015 the demand for domiciliary care for adults can be forecast. As can be seen, Table 74 shows only a small change from the current level, a change which only becomes apparent from 2012: 179

180 Table 74: External Provider Service: Forecast Level of Demand for Domiciliary Care Adults Year Projected adult population 71,700 71,800 71,300 70,300 Forecast level of demand (-1) 127 (-3) for domiciliary care for adults When the ratio for older people is applied to the projected population of older people the changes to the level of demand observed are both immediate and substantial. As shown in Table 75, by 2010 there would be a forecast growth in demand of 25 additional service users, and by 2015 this would increase to 119, which is a 22% increase in the demand for domiciliary care for older people. Table 75: External Provider Service: Forecast Level of Demand for Domiciliary Care 65+ Year Projected 65+ population 16,800 17,400 18,400 20,300 Forecast level of demand 542 (+6) 561 (+25) 594 (+58) 655 (+119) for domiciliary care for 65+ If the forecast changes in the adult and older person populations are combined, this gives us the forecast change to the demand for all contracted domiciliary care. As shown in Table 6, this indicates a growth in the number of service users overall; of 6 by 2008, 25 by 2010, 57 by 2012 and 116 by This would represent a 17% increase by 2015 in the number of all service users receiving a contracted package of domiciliary care. 180

181 Table 76: External Provider Service: Forecast Level of Demand for Domiciliary Care - Adults and 65+ Year Projected adult and over 65s 88,500 89,200 89,700 90,600 population Forecast level of demand for domiciliary care for adults and (+6) 691 (+25) 723 (+57) 781 (+116) If the changes are costed (at 2007 prices) using the separate annual average costs for adults and for older persons, we can derive the figures shown in Table 77. This shows a consistently upward and accelerating trend costs would be forecast to exceed 2007 costs by 32,459; the two years 2008 to 2010 show an increase of 135,225, i.e. an average of over 67,000 p.a. By 2012 the additional costs would be forecast to rise to 301,773 above the current level, and by 2015 the additional cost would rise to 607,824. Table 77: External Provider Service: Impact on Annual Cost of Home Care Services of Forecast Changes in Demand (at 2007 prices and using average cost p.a. figures) Year Adults No change No change , , , , ,444 Total + 32, , , ,

182 The same data can also be shown as a graph: Chart 87: Impact on Annual Cost of Domiciliary Care Service of Forecast Changes in Demand In-house Services Applying the same analysis to the in-house service we get a ratio of 1 service user for every 932 people in the combined adult and older person s population: Table 78: In-house Service: Number of Service Users per 1000 Population Adult and 65+ Population in ,700 Number of service users 94 Service users per 1000 population 1 per 932 As the proportion of in-house service users in the population is much smaller than that for the externally provided services the impact of population change is considerably reduced. This can be seen in Table 79 which suggests that the increases in demand for in-house domiciliary care would only increase by 4 people in the period to 2015 i.e. just over 4%. 182

183 Table 79: In-house Service: Forecast Level of Demand for Domiciliary Care - Adults and 65+ Year Projected adult and ,500 89,200 89,700 90,600 population Change from 2007 (= ) , ,700 +3,600 Forecast level of demand for 95 (+1) 96 (+2) 97 (+3) 98 (+4) domiciliary care for adults and 65+ However there may be greater upward pressure on demand for the in-house service than is suggested by the above calculation, based as it is, simply on the increase in the combined adult and 65+ population. The in-house service does not have a significant adult client base and is therefore more likely to be affected by the increase in the over 65s. Furthermore it provides a number of specialist services that may be particularly affected by the increasing proportion of over 80s, in the longer term, who will have greater need for the services for complex needs that it provides such as the end of life, complex physical needs and dementia services In summary forecast changes to the population in Halton will result in a steadily accelerating increase in the number of older people who are likely to have care needs arising from high levels of chronic ill health and disability. The increase in the population of adult and over 65s that is anticipated between 2008 and 2015 is 2,100. This represents an increase in the over 65s of 3,500 and a decrease in the under 65s of 1,400. The future demand for domiciliary care services, both external and inhouse, has been estimated by multiplying the forecast population by the relevant strike rates, taking appropriate account of the differing population trends for adults and over 65s. The analysis in relation to externally provided services suggests that there will be a slight decline in the demand for adult services by 3 service users by 2015 and a significant increase of 119 service users in the over 65s. The combined effect represents 116 additional service users, an increase of 17%. The impact in additional costs for externally provided services would be approximately 300k by 2012 and 600k by 2015, at current prices. The in-house provider serves a relatively separate and fairly specialist area of the market, and currently meets about 11% of the overall demand. It has a much lower strike rate and could expect to see a much lower increase in demand, of the order of 4 more service users by However there is a possibility that this is an underestimate given the focus of their services toward certain groups with high level needs. 183

184 The forecast bulge in the proportion of over 80s within the population of over 65s appears likely to appear somewhat later in Halton than our analysis period up to The period to 2015 will in fact see particular growth in the younger age-bands of older people. However there will be a need at a later date to take account of the likely increase in levels of ill-health and disability, and in particular dementia, that is likely to accompany this bulge People with a Learning Disability (LD) Nationally the numbers of adults with a learning disability is rising, by at least 6% and for the older population (65+) a 41% increase is predicted for those aged between and a 56% increase for those aged 80+ in the period to According to Care First and finance data, there are 437 (Numbers of people, known to social services in Halton with a learning disability have remained fairly constant in recent years, between ) Adults with Learning Disability (ALD) users and 102 carers in Halton. By analysing their postcodes, we know users and carers of ALD service are almost equally split geographically between both sides of the river. There are currently 27 people aged 65+ with a learning disability in Halton and their combined care packages total 560, Work has been done to assess the levels of need of all ALD service users according to their support needs based on their disability on their worst days. The results show that 27 (5.72%) have low needs and 172 (39.59%) severe needs. For 23 (5.26%) their needs are unknown either because the person died during the year, is placed in Halton from out of the area or is Section 64. Prevalence data shows we can expect a significant increase in older ALD users and Halton data shows we have an age range bulge in the middle years that will travel in time to older age groups. We therefore need to make sure there is adequate budgetary provision for ALD users and carers 65+ and plan for the expected rise in numbers and needs. People with Down s Syndrome who do not receive sufficient stimulation in their daytime activities are more likely to develop mental health problems and experience an early onset of dementia. Insufficient care and meaningful day time activity will increase challenging behaviour, cause mental health problems and put intolerable strain on the carers of people with learning disabilities. This will increase costs in the medium to long term. In Halton there are currently 45 people with Down s Syndrome who are aged 35+ and dementia can onset in the 30 s age range. There are six young people who have statements and attend local schools who will reach age 18 at various times up to People with mild LD are less likely to acquire Early Onset dementia than those in the severe LD groups and the prevalence of dementia increases with age up to 60 then drops from 32% to 26%. As only five of the 45 people with Down s Syndrome have either high or medium severity needs then the future demand might not be high. Nevertheless, it will call for specialist support and needs planning into future commissioning. Information from Transition Services also shows that there are six young people with Down s in schools currently who will present to the ALD as adults in the next eight years. 184

185 There are clear pressure points surrounding the provision of services to people with learning difficulties, as follows: Older people with learning difficulties. Younger people with learning difficulties who develop early dementia. These pressures will be all the greater unless prevention and early intervention become an integral part of service provision. For example, significant savings can be made from delaying the onset of early dementia and research suggests increased mental and physical activity as well as an improved diet can have beneficial effects. Since 2002 there has been a significant shift in the way in which services are delivered to people with a learning disability. Halton now performs well in respect to helping people with learning disabilities to live in the community with approximately 82% of people now receiving services in their own home. However, access to general needs social housing remains limited and levels of owner occupation remain extremely low. Few adults with learning disabilities in Halton are in paid employment (Less than 1% compared to 10% nationally), even though employment is key to sustaining peoples well-being and enabling people to maximize independence. The top 20% wards showing the highest prevalence of learning difficulty Castlefields, Hough Green, Grange and Halton Lea respectively. The overall pattern is a strong relationship between levels of learning difficulty with areas of deprivation/health deprivation in that these 4 wards also have a high percentage of the population living in the top 10% most deprived areas nationally. An anomaly in this respect, is that inspite of the very high levels of deprivation/health deprivation in Windmill Hill, the levels of people with a learning difficulty are not as high as one might otherwise expect. The total number of adults with a learning difficulty (636) reflects only part of the picture in terms of commissioning implications. There are another 392 children and young people thought to have a learning difficulty, which in transitional terms represents a significant cost pressure to adult services. Furthermore, the shift to prevention and early intervention means that clients currently not meeting the eligibility criteria or not known to social services, will in the future need to be targeted to ensure sustainability and independence are maximized. This policy shift alone could result in up to a 45% increase in adults being supported. Table 80: People with a Learning Difficulty (Age 16+) Ward Ward population Learning difficulty - numbers As proportion of ward population Appleton Beechwood Birchfield Broadheath Castlefields

186 Daresbury Ditton Farnworth Grange Hale Halton Brook Halton Lea Halton View Heath Hough Green Kingsway Mersey Norton North Norton South Riverside Windmill Hill TOTAL Source : Housing Needs Survey People with Mental Health Issues Using the Improving Access to Psychological therapies workforce tool, this provides an estimation of mental health morbidity for each PCT locality. It applies national data to establish the weekly prevalence of common mental health problems in Halton and St Helens. Using these figures the tools applies a number of assumptions concerning the impact of deprivation and the likely presentation and detection of common mental illnesses and provides an adjusted weekly prevalence for a number of disorders. The assumptions are: Only 50% of people suffering from depression and/or anxiety will actually present in Primary Care. Only 50% of people presenting in Primary Care will actually be detected as having depression and/or anxiety The index of deprivation applied is specific to those with common mental health problems. Mixed anxiety and depression consists of 4 groups: - Those treated as though they have depression Those treated as though they have an anxiety disorder. Those treated as though they have both anxiety and depression Those with Post Traumatic Stress Disorder (PTSD) who form 22% of total with Mixed Anxiety and Depression The proportions of severity of depression are: - Mild 20% Moderate 40% Severe 40% 186

187 Table 81: Weekly Prevalence of Common Mental Health problems in Halton & St Helens AGE Total Pop Mixed Anxiety & Depression Generalise d Anxiety Disorder Depressive episode All Phobi a Obsessive Compulsive Disorder Panic Disorder Any Neurotic Disorder , , , , , , , , , , , , Total 216,104 18,728 9,600 5,583 3,753 2,419 1,544 35,259 Once the assumptions of deprivation, presentation and detection are applied the totals are as follows All Ages 216,104 5,431 2,784 1,619 1, ,225 Source : Improving Access to Psychological therapies workforce tool From the data given in the above table we can conclude that the incidence of mixed anxiety and depression increases year on year until the age group. The incidence is already high in the age group but drops significantly from 65 years onwards. Generalised anxiety disorder, panic disorder and any neurotic disorder follow a similar pattern with peaks at 45-49, and year age groups respectively. For other conditions the prevalence is more spread out. In the case of depressive episodes, the peak is at but remains high until the year age group. Similarly, all phobias show a high prevalence across most of the age groups but particularly between years of age. Finally, only obsessive compulsive disorders show an erratic pattern with high prevalence in most age groups except for 65 years plus. To show the numbers of people who indicated that they or someone within their household has a mental health need within Halton, data has been drawn from the Housing Needs Survey 2005 but in some cases the actual number of responses on 187

188 which the data is based will be low and hence the results should be treated with some caution. According to the findings some 1,858 people have a mental health problem to some degree, contained within 1,777 households (81 households contain more than one person with a mental health problem) The majority of people (67%) with a mental health need are aged between 25 and 59 with 17% over 59 and 11% are under % (1,211 people) of people with a mental health need indicated that the problem was serious enough for them to require care or support but currently 18% (220 people) of these were not receiving sufficient care or support. The main type of care or support required was in personal care (43%), establishing social contact/activities (41%) and looking after the home (32%). Households containing someone with a mental health problem are more likely (56%) to live in social rented housing. A large proportion (35%) of households containing someone with a mental health need did not indicate their household income. Of those that did respond, over 96% reported an income below the national average of 27,500 and 66% earned under 10,000. The Housing Needs Survey indicates that a high proportion (almost 91%) of households containing someone with a mental health are claiming some form of financial support. Disability Allowance is the most commonly claimed benefit (claimed by 65% of households containing someone with a mental health need) followed by Housing Benefit (55%) and Council Tax Benefit (46%). About 1 in 6 adults in Halton suffer from depression at any one time. This rises to 1 in 4 older people having symptoms of depression that are severe enough to warrant intervention. Of other mental health problems, anxiety and phobias are the most common. Emotional well-being is a concern for all members of the community and we should be focusing on preserving it. Improving people s relationships, self-image, selfesteem and levels of worry, which all impact on emotional well-being will give people the ability to cope with life. Supporting adults to remain in or return to employment will pay dividends in terms of mental health and we need to improve our performance in this area. We also need to support people with mental health problems to improve their well-being by increasing access to services such as housing support, creative arts and leisure, physical activities and talking therapies People with a Physical, Sensory Disability/Limiting Long Term Illness (LLTI) For the various categories described in the table below, the wards showing the highest prevalence are as follows: - People with a limiting long-term illness are most likely to live in Castlefields, Windmill Hill, Halton Lea and Appleton respectively. People with a sensory difficulty are most likely to live in Norton North, Appleton, Halton Lea and Norton South respectively. 188

189 People with a physical disability are most likely to live in Riverside, Kingsway, Appleton and Broadheath respectively. The overall pattern is a strong relationship between levels of limiting long term illness with areas of deprivation. Whilst the strength of this relationship varies the only area in which this relationship is reversed is Norton North which has high levels of sensory difficulty, but relatively low in terms of deprivation. Another anomaly is that inspite of the very high levels of deprivation in Windmill Hill, there are not particularly high levels of people with a Sensory or Physical disability. Table 82: Limiting Long Term Illness for Halton Ward Percentage of people with a long term illness % Health Deprivation Ranking Castlefields Windmill Hill Halton Lea Appleton Ditton Grange Riverside Halton View Halton Brook Broadheath Kingsway Mersey Hough Green Heath Norton South Hale Farnworth Norton North Beechwood Daresbury Birchfield Source: Neighbourhood Statistics, 2001 Census Table 83: People with a Sensory/Physical Disability by Ward Sensory difficulty - numbers As proportion of ward population Physical disability - numbers As proportion of ward population Ward Ward population Appleton Beechwood Birchfield Broadheath Castlefields

190 Daresbury Ditton Farnworth Grange Hale Halton Brook Halton Lea Halton View Heath Hough Green Kingsway Mersey Norton North Norton South Riverside Windmill Hill TOTAL Source : Housing Needs Survey 2005 Table 84: Number of households claiming disability allowance by age group and ward Head of Head of Head of Head of Household Household Household Household Head of % of Health Total Aged 16 - Aged 25 - Aged 45 - Aged 60 - Household householdsdeprivation Ward households Aged 75+ Total in ward Ranking Castlefields Windmill Hill Halton Lea Kingsway Broadheath Appleton Riverside Grange Norton South Halton Brook Hough Green Mersey Norton North Ditton Daresbury Halton View Heath Hale Beechwood Farnworth Birchfield TOTAL

191 The table below shows that 5,031 people between the ages of 16 and 59 have a physical and/or sensory disability. The majority of these (72%) are aged between 45 and 59 with 23% aged between 25 and 44 and 5% between 16 and 24. The majority (88% equating to 4,438 people) have a physical disability only with 71% of these having a walking difficulty, 9% in a wheelchair and the remaining 20% with another physical disability. 343 people have a sensory but no physical disability and 250 have both a physical and a sensory disability. The table below shows the type of disability for each age group and also indicates the number of responses on which the borough wide data is based. Respondents were asked to indicate whether the household member with the disability required care or support and whether they are currently receiving sufficient care or support. In total 12% are not receiving the care or support they need and wheelchair users are least likely to be receiving the care or support they need with 25% indicating insufficient care or support. Where sufficient care or support is provided this is most likely to come from family, neighbours or friends rather than Social Services or a voluntary body. Table 85: Prevalence of disability between age groups Total Weighted data Weighted data Weighted data Weighted data Physical disability only Wheelchair user Walking difficulty (not in wheelchair) Other physical disability Total physical disability only Sensory disability only Physical and sensory disability Wheelchair user with a sensory disability Walking difficulty with a sensory disability Other physical disability with a sensory disability Total physical and sensory disability Total people with a physical and/or sensory disability Source: Housing Needs Survey 2005 As has been evidenced, of all users, people with chronic conditions place the highest pressures on health and social care services and many off these are preventable. Whilst there is no evidence to suggest dramatic increases in the number of adults aged with physical/sensory disabilities, as the proportion of the population over 45 increases, later onset conditions such as Parkinson s Disease, sensory 191

192 impairment, arthritis, etc, will rise. In addition, significant increases in the levels of obesity in Halton are predicted to lead to an increase in the prevalence of diabetes and incidence of heart disease. Note The term LLTI, comes from the 2001 Census. Limiting long-term illness or disability which restricts daily activities is calculated from a 'Yes' response to the question in the 2001 Census: 'Do you have any long-term illness, health problem or disability which limits your activities or the work you can do?'. The definition therefore seems to be used interchangeably with disability. For the 2011 census the term is being replaced by a term more consistent with the DDA Carers The Health of Carers is a major influencing factor upon the health and welfare of the people receiving care, upon the carers themselves, and on the cost and shape of public services provided. The changes in demography indicates that the cared for are living longer and that carers within Halton will have to care for much longer periods than in previous years often experiencing health problems as they get older themselves. To alleviate these pressures, the level of support provided to carers needs to be enhanced and improved as well as greater recognition being given to the pressures they face. Data from this census shows that 13,531 people in Halton provide formal or informal care, over 11% of the Halton population. National data (2001 Census) suggests that 11% of informal carers consider themselves to be in poor health, whilst in Halton the proportion appears to be higher, with 14% of all carers having felt that they were in poor health. Currently 10.85% of carers are receiving needs assessment or review and a specific carer s service, or advice and information. This clearly needs to be improved if threats to health and well being are to be averted. Table 86: Number of Informal Carers within Halton 1 to 19 hours - Provides care 20 to 49 hours - Provides care 50 or more hours - Provides care All People Good Health Fairly Good Health Not Health Good 192

193 Total Source: 2001 census Table 87: National Top 4 illnesses reported by Carers Mental Health of Carers Physical Health of Carers 1. Anxiety 1. Stress 2. Depression 2. High Blood Pressure 3. Loss of Confidence 3. Heart Problems 4. Loss of Self Esteem 4. Strains 4.2 Burden of Ill Health and Disability Although the following areas have been selected for analysis, this list is not exhaustive and further details of conditions that have a burden on ill health can be found in Section 2.4 of this document Healthy Life Expectancy An indication of healthy life at age 65 is the average number of years that people are expected to live in an area. In Halton males are expected to live an average of 15.5 years after the age 65, this is compared to just over 17 years in England as a whole. For females, life expectancy at age of 65 is 17.9 years compared with the England average of years. Table 88: Life Expectancy at age 65 ( ) Males Females Years Rank* Years Rank* England North West Halton St Helens Source: Health Statistics Quarterly 36, National Statistics, Fractured Neck of Femur Fractured neck of femur is a fracture to the bone at the top of the leg and this is common in elderly frail people but there are different preventions that can help to reduce the number and rate of admissions due to fractures. Hospital admissions for fractured neck of femur or hip fracture are often preventable due to early prevention and ensuring that the environment for people at risk of falling is as safe as possible. Hospital admission rates for fractured neck of femur show high rates in Castlefields, Grange and Appleton. Emergency hospital admissions in 193

194 the over 65 s in Halton for fractured neck of femur are one of the highest in the country and significantly higher than the national rate (5 th highest rate). The rate of admissions for females is significantly higher than males; there is a greater risk of breaking of bones in postmenopausal women particularly in women after the age of 75. Map 29: Halton Admission Due to Fractured Neck of Femur 2006/07 Source: Oracle,

195 Chart 88: All Admissions for Fractured Neck of Femur Halton by Ward, All Persons 2006/07 All Admissions for Fractured Neck of Femur - Halton - All Persons Rates per 1, Daresbury Hale Beechwood Hough Green Halton View Windmill Hill Birchfield Kingsway Ditton Broadheath Halton Brook Mersey Norton South Farnworth Norton North Riverside Halton Lea Heath Grange Appleton Castlefields Chart 89: Fractured Neck of Femur, Rate of admission per 100,000, 2006/07, Halton all ages 195

196 Chart 90: Fractured Neck of Femur, Rate of admission per 100,000, 2006/07, Persons, all ages Hip and Knee Replacements Hip and knee replacements are common in elderly people but access to these operations can improve mobility, relief from pain and quality of life. Chart 91 shows the variation of hip and knee replacements conducted for each ward. Based on the Halton average no ward has significantly high levels of hip and knee replacements but Daresbury for all persons and males and Halton Brook for females have significantly low numbers of admissions for hip and knee replacements. The level of operations may well impact on the levels of adaptations, which may need to be made to properties. 196

197 Chart 91: Halton All Persons Hip & Knee Replacements by Ward for 2006/ Halton All Persons Hip & Knee Replacements by Ward for Source: Oracle, Rate per 1, Daresbury Beechwood Hale Mersey Halton Brook Halton Lea Norton North Kingsway Birchfield Norton South Appleton Windmill Hill Riverside Castlefields Grange Halton View Hough Green Farnworth Ditton Broadheath Heath Chart 92: Halton Males Hip & Knee Replacements by Ward for 2006/ Halton Males Hip & Knee Replacements by Ward for Source: Oracle, Rate per 1, Daresbury Beechwood Castlefields Hale Norton North Hough Green Kingsway Riverside Halton Lea Mersey Appleton Norton South Halton Brook Windmill Hill Birchfield Halton View Heath Ditton Grange Farnworth Broadheath 197

198 Chart 93: Halton Females Hip & Knee Replacements by Ward for 2006/ Halton Females Hip & Knee Replacements by Ward for Source: Oracle, Rate per 1, Halton Brook Mersey Daresbury Beechwood Birchfield Hale Halton Lea Norton South Kingsway Windmill Hill Grange Norton North Appleton Halton View Riverside Farnworth Broadheath Ditton Castlefields Heath Hough Green Dementia Dementia is most common in older people, with prevalence rising sharply amongst people over 65 years. It is also one of the main causes of disability in later life. Locally 5% of the population has dementia and this is predicted to rise by 52% between 2008 and This translates to 1,061 people over 65 with dementia living in the community with dementia in 2008, rising to an estimated 1,613 by This increase is not evenly spread across the population or in terms of time however. For all age groups the projected increase is minimal for the next two years but from 2010 and beyond there are marked increases. Between 2010 and 2015 the increases are greatest for men aged and over 85 whereas between 2010 and 2025 all age groups show an increase of 40% or more except for men aged and women aged Of particular note, are the increases men aged (72%) and 85 and over (100%) and women aged (67%). Early diagnosis of, and intervention for, dementia are the keys to delaying admission to long-term care and to help people remain independent for longer. Promoting healthy ageing, for example by keeping people active and tackling social isolation, is important in delaying the onset of dementia. Accommodation choices including extra care housing, residential and nursing care for older people with dementia must also be balanced to meet future aspirations in respect to choice of service and be sufficient in numbers to meet future needs. From the information currently available it is not possible to identify specific projections, financially or in terms of demand, for future service provision. There are, 198

199 however, indicators to justify the need for this issue to be given greater attention. At a national level the number of people with dementia will double in the next 30 years and as dementia is the strongest determinant of entry into residential and nursing care in over 65s, this is cause for particular concern. In addition, problems in the current system, such as two-thirds of people with dementia not receiving a formal diagnosis, are likely to result in additional pressures; especially given when diagnoses is given it is often late in the illness and when the person with dementia is in crisis. As part of addressing these systemic weaknesses, drivers for change emanate from Dementia care being given an increased profile and specifically with the plan to produce a national dementia care strategy in the autumn of The resultant consultation document has four key themes all of which have associated cost pressures: Raising awareness Early diagnosis and interventions Improving the quality of care Delivering the National Dementia Strategy Table 89: People aged 65 and over predicted to have dementia, by age band (65-69, 70-74, 75-79, and 85 and over) and gender, projected to Males aged predicted to have dementia Males aged predicted to have dementia Males aged predicted to have dementia Males aged predicted to have dementia Males aged 85 and over predicted to have dementia Total males aged 65 and over predicted to have dementia Females aged predicted to have dementia Females aged predicted to have dementia Females aged predicted to have dementia Females aged predicted to have dementia Females aged 85 and over predicted to have dementia Total females aged 65 and over predicted to have dementia Total population aged 65 and over predicted to have dementia Source : POPPI Tool ,061 1,099 1,220 1,397 1,

200 4.2.5 Influenza Vaccination The vaccination of older people is a national programme aimed at reducing the morbidity and mortality due to the impact of influenza. The aim of this programme is to ensure that 70% of older people are vaccinated. The uptake rate of the Influenza vaccine for the period in Halton was 71.5%, this is higher than the national average for the same period in which the target is 70%; however the rate has fallen for the past two years with a drop of 4.5% from the period The figure is also down on the rate by a further 1% HIV and AIDS HIV and AIDS is now considered to be a chronic health condition and due to better treatments people can live with HIV for many years without any need for support and so would not consider themselves to be vulnerable. However, late diagnosis of HIV can lead to poorer health outcomes and the greater need for support systems to be in place for the individual. In Halton there are 22 males and 8 females (30 total) people that have been diagnosed with HIV/AIDS. Seven (23.3%) have AIDS, 16 have no symptoms and 5 have symptoms but not AIDS. There has been 1 AIDS related death. In 2007 there were 4 new cases of HIV/AIDS of which one already had AIDS. Although number of cases of HIV and AIDS are still low locally there has been a steady increase year on year. Those diagnosed late are more likely to have greater social care needs. 200

201 4.3 Service Provision With respect to service provision as a whole over the course of last year, older people comprised of 70% of all service users and the greatest uptake is from people with a physical and sensory disability. The table below shows that there is a much greater uptake of people over 65 years with a physical and sensory disability. With respect to other services, vulnerable people shows a significant increase especially above 65 years of age, though the numbers are far lower where as in the case of learning difficulty the numbers of users drops dramatically above 65 years of age. From the data of known services users, overall service users are primarily those with a physical & sensory disability (77%). This is followed by people with mental health problems who comprise 13% of the users. Table 90: Service usage by Primary Service Type Primary Category Number Learning Disability 61 Mental Health 554 Other Vulnerable People 55 Physical & Sensory Disability And Frailty 4266 Substance Misuse 7 Unknown 571 Source: Carefirst. There are significant variations in the usage of services over time. In the case of users categorised as having a physical & sensory disability or mental health problem there is a broadly similar pattern of a drop-in activity over the course of the year whereas substance misuse and learning disability and other vulnerable people all show constant activity over the course of the year. By far the majority of activity is around PSD, with a significantly higher proportion of users being female. With respect to the type of service provided the vast majority of activity is absorbed by home care (33%). There is a significant drop in activity for professional support (12%) and even more so for client payments, short term resident, supporting people and lifeline all show a similar level of activity of around 6% with the other remaining services showing significantly less. Table 91: Service Type by Number and % of Total Services Service Type Number % of Total Services Transport/Support (Supp) to Carer Unplanned Respite Supporting People/Supp to Carer Community Meal/Supp to Carer Homecare/ Supp to Carer Transport Day Care / Supp to Care

202 Respite Care Respite / Supp to Carer Direct Payments Placements For Child Aids & Adaptations Direct Payment/Supp to Carer Residential (Adult) Carers Break / Supp to Carer Day Care Professional Supp/ Carer Supp Keysafe Community Meals Client Payments Short Term Resident Supporting People Lifeline Professional Support Home Care Total Source: Carefirst From this overview we can conclude that the current and projected pressure points are as follows: People with a physical and sensory disability in terms of numbers. This is expected to increase as a consequence of the ageing population. Home care is the predominant intervention. This is expected to increase as a consequence of the emphasis on intervention and early intervention but demand is also likely to become more unpredictable as people choose alternative provision as a consequence of direct payment flexibilities. Table 92: Number of clients receiving services during period provided (1 st April 2007 to 31 st March 2008) or commissioned by prime Total Physical and Sensory Disabilities Mental Health Vulnerable People Learning Difficulty Substance Misuse Total Source : Carefirst 202

203 Table 93: Number of clients on the books to receive community based services on 31st March 2008 provided or commissioned by the CSSR by prime Total Physical and Sensory Disabilities Mental Health Vulnerable People Learning Difficulty Substance Misuse Source : Carefirst The tables below show only a 3.5% increase in older people using services over the next 2 years, whereas the percentage increase up to 2025 is 52% when compared against 2008 figures. A more useful analysis is provided by breaking down the increases into 5-year intervals. In this instance, the greatest increase is from 2010 to 2015 at 17.8% dropping to 10.3% from 2020 to For both tables below, the percentage increase is the same suggesting that demographic changes will have the same impact that they do today. Prevention and early intervention initiatives are, however, likely to result in greater pressures on community based provision than the tables would suggest. Table 94: Number of Older people aged 65 and over receiving communitybased services projected to Number of older people receiving community-based services provided or 2,879 2,981 3,513 3,958 4,369 commissioned by the CSSR. Source : (POPPI Tool) Table 95: Older people aged 65 and over in local authority residential care, independent sector residential care, and nursing care Total number of older people in residential and nursing care during the year, purchased or provided by the CSSR Source : (POPPI Tool) The timeliness of social care assessments and timeliness of social care packages following assessment are both important indicators of the quality of service provision. The current performance of the local authority currently stands at 76.94% and 87.37% respectively. An important proxy for quality of life is the number of people supported to live independently through social services. Currently 2111 are supported in this way. 203

204 5 Commissioning Priorities The challenges and opportunities facing Halton has led to the identification of a number of priorities for the Borough (outlined in the Community Strategy ) over the medium term with the overall aim of making it a better place to live and work. These include: - Improving health Improving the skills base in the borough Improving educational attainment across the borough Creating employment opportunities for all Tackling worklessness Tackling the low wage economy Improving environmental assets and how the borough looks Creating prosperity and equality of opportunity Reducing crime and anti-social behaviour Improving amenities for all age groups Furthering economic and urban regeneration Tackling contaminated land Creating opportunities/facilities/amenities for children and young people Supporting an ageing population Minimising waste/increasing recycling/bringing efficiencies in waste disposal Increasing focus on community engagement Running services efficiently The Community Strategy provides an overarching framework through which the corporate, strategic and operational plans of all the partners can contribute. Halton s Local Area Agreement (LAA) builds on this overarching framework and provides a mechanism by which key elements of the strategy can be delivered over the next three years. It is an agreement between Central Government and the local authority and its partners about the priorities for the local area, expressed in a set of targets taken from an over National Indicator set of 198 targets. The purpose of the LAA is to take the joint thinking of the Partnership enshrined in the Community Strategy, and make it happen through joint planning and delivery. Hence the five strategic themes detailed in the Community Strategy are mirrored in the LAA. The key overarching issues for Halton that were highlighted by the work leading to the finalising of Halton s LAA were: Health inequalities, with a particular focus on alcohol Worklessness and skills Community safety, with a particular focus on anti-social behaviour 204

205 In particular, the focus will be on narrowing the gap between areas within Halton around these. A central commissioning pot of 5.4 million has been ring-fenced from Halton s Working Neighbourhoods Fund allocation over the next three years to focus on these three areas and all partnerships are expected to direct funding towards the priorities agreed in the LAA. The LAA will also seek to address the following issues: The physical, environmental and social problems resulting from Halton s industrial legacy, particularly from the chemical industries. Halton shares many of the social and economic problems more associated with its urban neighbours on Merseyside. The latest Index of Multiple of Deprivation (IMD) for 2006, shows that whilst the level of deprivation is improving Halton is still ranked 30th nationally. Health problems through a more discriminating approach in how services are delivered. We need to better concentrate on the wider determinants of health. We also need to target specific initiatives both geographically and demographically, especially recognising the needs of an increasingly ageing population. Social exclusion through a focus on responding to their full range of needs. The level of human capital and trends in economic growth may present problems for the future. This is particularly so given the district s poor performance in terms of social and environmental indicators, which may create difficulties attracting the best qualified people to the borough. Halton s performance on education and skills, and low levels of home ownership point to problems of inclusiveness, with groups of residents not sharing in the current levels of economic prosperity. Given the above priorities, a key measure of whether service delivery has been transformed will be how far and how fast we can narrow the gap in outcomes for the most disadvantaged in Halton, as measured by comparison with both Halton and national averages. In order to focus on closing the gaps we need to identify a coherent set of priority geographic areas. 5.1 Older People The overriding issue facing the development of services for older people is the large increase in numbers due to people living longer. As reflected in the statistics whilst the next 5 years will see an increase in numbers, it is the next 15 years, which are cause for greatest concern. The key priorities, which arise from this demographic change, are as follows: A direct effect will be increased demand for domiciliary contracts. Increased demand for appropriate supported housing for the elderly, such as extra care housing. Increased demand for aids and adaptations, which will lead to increased budgetary pressures as local authorities are expected to fund 40% of Disabled Facilities Grant. 205

206 Whilst the large increase in older people will lead to an increase in residential contracts, this will to some extent be offset by a decrease in the percentage of people requesting residential care. There will be a large increase in the number of people experiencing dementia or EMI. Low-level mental health problems such as anxiety and depression will increase. Interventions to help mitigate this effect are likely to include befriending, counselling and bereavement services. Individual Budgets (IB) is likely to impact on the current model of health and social care provision. This will mean a change to the way, which services are configured as well as which services are provided. Largely due to IB but not entirely there will be an increased demand for advocacy. Currently provision is capped where as in future it will be consumer driven. Given the cumulative effect of the above changes, the health funding of domiciliary care and residential services needs to be addressed. 5.2 Adult with Learning Disabilities The numbers of adults with learning difficulties is rising and will continue to do so but not significantly. There is concern, however, in relation to the pattern of need especially with respect to profound and multiple learning difficulties; largely due to people living longer. The number of people presenting profound learning difficulties is expected to rise by 60% over the next 15 years. The government White Paper Valuing People A New Strategy for Learning Disability for the 21st Century (2001) set out the vision for people with learning disability based on four main principles of: Legal and civil rights Independence Choice and Inclusion Valuing People Now From Progress to Transformation sets out the next steps for the Valuing people policy and its delivery priorities for the next three years. It identifies the following key priorities for : Personalisation. What people do during the day helping people to be properly included in their communities, with a particular focus on paid work. Better Health ensuring that the NHS provides full and equal access to good quality healthcare Access to housing A policy development which will have a significant impact on the way services are delivered will be the increased emphasis being given to carers support being a positive experience for the service user. 206

207 The numbers are also increasing for autistic spectrum disorder. This is cause for particular concern as there is a lack of specialised services locally. From 2009 NHS monies for social care activities will transfer to the local authority. 5.3 Mental Health With respect to the pattern of expected need dual diagnosis (especially mental health and substance misuse including alcohol) is rising dramatically whereas schizophrenia and bi-polar disorders are broadly staying the same. Depression is currently very high at 1 in 6 of the population. Whilst it is important to improve equity and ease of access to services, a key policy development is to decrease the number of referrals to secondary care. This will be achieved through the prevention of the development of mental health problems or their progression. Other key policy priorities are as follows: Treatment will be as close to home as possible through primary and secondary care home treatment. The need to map need around primary care provision. Promotion of social inclusion through services such as supported accommodation and supported employment. The development of mental health initiatives in the Local Area Agreement. 5.4 Physical and Sensory Disabilities As with other areas of social care, a key development is the promotion of preventative services and early intervention. There are difficulties in forecasting the incidence of physical and sensory disabilities (PSD) for a specific age group, however, as in many cases it is a time-limited episode. Whilst the PSD strategy covers the age band, the services provided are from cradle to grave. This will impact heavily on services as the numbers of people older than 65 years is set to increase disproportionately in the medium term. Other areas for concern are follows: Neuro-rehabilitation appears to be underutilised. Rehabilitation finishes after 6 weeks with no follow-up. The health and social care review of commissioning needs to address current gaps in provision (e.g. therapy, rehabilitation and psychological services). Future provision will increasingly be based on a self-assessment process for equipment. 207

208 5.5 Substance Misuse The Home Office has directed that all Crime and Disorder Reduction Partnerships conduct a Strategic Assessment and develop a Partnership Plan for The purpose of the strategic assessment is to provide knowledge and understanding of community safety problems; as a consequence the following priorities have been identified: To improve the integration of service users, their children & carers into the community. To reduce the crime committed by problematic drug users. To develop a workforce with the appropriate skills, knowledge & expertise to improve the outcomes of drug treatment. To reduce the physical, dental, sexual and mental health risks associated with problematic drug use. To work with the Children & Young Peoples Directorate and the Safeguarding Children Board to improve the outcomes for the children of drug using parents. To improve the involvement of service users in the decisions about their treatment. To undertake a planned audit of clinical governance arrangements and prescribing practice together with the 5 Boroughs Partnership NHS Trust. 5.6 Carers The Government's new national strategy for Carers published on 10 June 2008 sets out their vision for supporting Carers over the next decade. It includes short-term commitments and identifies longer-term priorities. There is additional investment, primarily for extending planned breaks for carers and to help carers into work. There is also an increased emphasis on joint agency working, and on the need for the NHS to more effectively engage with carers. The national strategy stresses the essential contribution of GPs in supporting carers and how this needs to be developed. A survey of carers' health, released for the launch of this year's Carers Week, revealed that more than two-thirds of carers had been unable to find an opportunity to visit a GP about their own health due to time constraints and a general lack of flexibility to leave the house to attend appointments. Over two thirds said they felt that their health is worse because of their caring role, with 95 per cent of the 2,000 carers questioned saying that they regularly disguise the fact that their health is suffering in order to continue their caring responsibilities. All carers need more support to be able to continue caring and to lead active lives as well. The new strategy is encouraging there is additional investment; and a clear vision set out, which if delivered, would mean carers are treated with respect, have a degree of financial security; and receive quality advice and support from health, 208

209 social care and other agencies. Carers would be treated as expert partners and there would be more choice and control over how they receive support. 5.7 Children and Young People The key policy drivers for children and young peoples services in Halton came out of the 2004 Children Act which established the Every Child Matter s (ECM) programme. A raft of national guidance has driven the implementation of the ECM agenda based on an Outcomes Framework for Children to improve outcomes across five areas; Be Healthy Stay Safe Enjoy and Achieve Make a Positive Contribution Achieve Economic Well-Being A central component of the Children Act was the establishment of Children s Trust to bring together all partners within a locality to jointly plan and deliver service for children and young people. The partnership was required to produce a Children and Young People s plan (CYPP) based on a strategic needs analysis and in consultation with children, young people and their families by April In Halton this plan was refreshed and resubmitted to DCSF and Ofsted in June 2007 and established the commissioning priorities for the Children s Trust. 19 priorities have been set within the CYPP based on the findings of the needs analysis and the following 8 identified as the key priorities in consultation with GONW and Ofsted; Reduce Health Inequalities Improve Sexual Health Emotional Health and Well Being Placement Choice and Quality of Care for Children in Care Educational Outcomes for all Children School Attendance of all Children Narrowing the Gap in Educational Attainment Participation Post-16 and Reducing NEET 5.8 NHS Halton & St Helens NHS Halton & St Helens has recently set out its commissioning strategy. As the local NHS organisation responsible for the planning and securing of health it recognises the need to work closely with partners, patients and the public to deliver better, more responsive health services and improve the health of local people. To ensure the PCT is investing in line with local health needs, it is developing an investment plan which will link to the ambitions identified below. These ambitions have come from an understanding of the needs of the local population, and a desire to ensure the deliver of two critical outcomes. Outcome 1: Improving health and tackling inequalities in health Outcome 2: Delivering effective and efficient health and related services To work with partners and local To provide effective and efficient people to promote a positive health care services that place the experience of good health and needs of the patient at their core equal opportunities for health, not simply an absence of disease. 209

210 The PCT has identified 6 priorities each with a number of specific ambitions. 1. To support a healthy start in life by: Enabling all pre-school children to have a healthy start in life Reducing the number of unintended teenage pregnancies, by providing good access to contraceptive services and advice Providing timely, good quality services to young people when they need them 2. To reduce poor health that results from preventable causes by: Helping people to stop smoking and reduce tobacco-related harm Supporting people in managing their weight and to live an active life Reducing harm from alcohol and encourage sensible drinking Reducing harm from substance misuse and ensure effective treatment when needed Improving the numbers of people benefiting from a healthy, balanced, diet Preventing and controlling the spread of infectious diseases Ensuring that all children have good dental health 3. To ensure that when people do fall ill from some of the major diseases, they get the best care and support by: Reducing the burden of cancer and cancer related deaths by improving access & availability of prevention and early detection services for local people Reducing the burden of ill health and premature death caused by Cardiovascular Disease by improving information, access and provision of preventative and treatment services Reducing the burden of ill health and premature death caused by Diabetes by improving information, access and provision of preventative and treatment service. Reducing the burden of mental illness by providing effective prevention and treatment services and to work with partners to address the wider causes of mental illness by providing a better social, physical and economic environment. Reducing the levels of poor sexual health Reducing the number of deaths from respiratory ill health and reduce the burden of illness caused by respiratory ill health by providing appropriate prevention and treatment services 4. To provide services which meet the needs of vulnerable people by: Ensuring that no-one experiences barriers to accessing good quality care and support because of their culture, ethnicity or sexuality. Supporting the needs of Carers, not only helping to support those they are caring for, but also their own needs for support Enabling all people with learning disabilities to be treated as full citizens Ensuring that all older people have the opportunity to enjoy a good quality of life People with physical and sensory disability will be supported to have a good quality of life and to be able to participate fully and constructively in the life of the local community. 210

211 5. To make sure people have excellent access to services and facilities by: Providing state of the art health and social care facilities, built to enhance user experience, which will assist in the improvement of the health and wellbeing of local communities. Creating a no-wait health economy, in which there is fast, safe and high quality care at all levels of the service. Supporting communities to be engaged in the design and delivery of public services and solutions to improve the health and wellbeing of all our residents. 6. To play our part in strengthening disadvantaged communities by: Contributing to creating vibrant, healthy and economically stable local communities. 211

212 Appendix 1 - List of ICD10 Chapters and Categories ICD-10 was endorsed by the Forty-third World Health Assembly in May 1990 and came into use in WHO Member States as from The classification is the latest in a series which has its origins in the 1850s. The ICD is the international standard diagnostic classification for epidemiological, health management and clinical use. These include the analysis of the general health situation of population groups and monitoring of the incidence and prevalence of diseases and other health problems in relation to other variables such as the characteristics and circumstances of the individuals affected, reimbursement, resource allocation, quality and guidelines. It also provides the basis for the compilation of national mortality and morbidity statistics by WHO Member States. A full list of codes and there detailed explanations are available at: The following table is a full list of all chapters (broad classifications) and individual groups of disease types (categories) for the top 10 causes of elective and non-elective admissions in Halton. 212

213 Chapter I Certain infectious and parasitic diseases A00-B99 Intestinal infectious diseases A00-A09 Tuberculosis A15-A19 Certain zoonotic bacterial diseases A20-A28 Other bacterial diseases A30-A49 Infections with a predominantly sexual mode of transmission A50-A64 Other spirochaetal diseases A65-A69 Other diseases caused by Chlamydiae A70-A74 Rickettsioses A75-A79 Viral infections of the central nervous system A80-A89 Arthropod-borne viral fevers and viral haemorrhagic fevers A90-A99 Viral infections characterised by skin and mucous membrane lesions B00-B09 Viral hepatitis B15-B19 Human immunodeficiency virus (HIV) disease B20-B24 Other viral diseases B25-B34 Mycoses B35-B49 Protozoal diseases B50-B64 Helminthiases B65-B83 Pediculosis, acariasis and other infestations B85-B89 Sequelae of infections and parasitic diseases B90-B94 Bacterial, viral and other infectious agents B95-B97 Other infectious diseases B99 213

214 Chapter II Neoplasms C00-D48 Malignant neoplasms C00-C97 In situ neoplasms D00-D09 Benign neoplasms D10-D36 Neoplasms of uncertain or unknown behaviour D37-D48 Chapter V Mental and behavioural disorders F00-F99 Organic, including symptomatic, mental disorders F00-F09 Mental and behavioural disorders due to psychoactive substance F10-F19 use Schizophrenia, schizotypal and delusional disorders F20-F29 Mood (affective) disorders F30-F39 Neurotic, stress-related and somatoform disorders F40-F48 Behavioural syndromes associated with physiological disturbances F50-F59 and physical factors Disorders of adult personality and behaviour F60-F69 Mental retardation F70-F79 Disorders of psychological development F80-F89 Behavioural and emotional disorders with onset usually occurring in F90-F98 childhood and adolescence Unspecified mental disorder F99 Chapter VII Diseases of the eye and adnexa H00-H59 Disorders of the eyelid, lacrimal system and orbit H00-H06 Disorders of conjunctiva H10-H13 Disorders of sclera, cornea, iris and ciliary body H15-H22 Disorders of lens H25-H28 Disorders of choroid and retina H30-H36 glaucoma H40-H42 Disorders of vitreous body and globe H43-H45 Disorders of optic nerve and visual pathways H46-H48 Disorders of ocular muscles, binocular movement, accommodation H49-H52 and refraction Visual disturbances and blindness H53-H54 Other disorders of eye and adnexa H55-H59 Chapter IX Diseases of the circulatory system I00-I99 Acute rheumatic fever I00-I02 Chronic rheumatic heart diseases I05-I09 Hypertensive diseases I10-I15 Ischaemic heart diseases I20-I25 Pulmonary heart disease and diseases of pulmonary circulation I26-I28 Other forms of heart disease I30-I52 Cerebrovascular diseases I60-I69 Diseases of arteries, arterioles and capillaries I70-I79 Diseases of veins, lymphatic vessels and lymph nodes, not I80-I89 elsewhere classified Other and unspecified disorders of the circulatory system I95-I99 Chapter X Diseases of the respiratory system J00-J99 Acute upper respiratory infections J00-J06 Influenza and pneumonia J10-J18 Other acute lower respiratory infections J20-J22 Other diseases of upper respiratory tract J30-J39 Chronic lower respiratory diseases J40-J47 Lung diseases due to external agents J60-J70 214

215 Other respiratory diseases principally affecting the interstitium J80-J84 Suppurative and necrotic conditions of lower respiratory tract J85-J86 Other diseases of pleura J90-J94 Other diseases of the respiratory system J95-J99 Chapter XI Diseases of the Digestive System K00-K93 Disease of the oral cavity, salivary glands and jaws K00-K14 Diseases of the oesophagus, stomach and duodenum K20-K31 Diseases of the appendix K35-K38 Hernia K40-K46 Non-infective enteritis and colitis K50-K52 Other diseases of the intestines K55-K63 Diseases of the peritoneum K65-K67 Diseases of the Liver K70-K77 Disorders of gallbladder, biliary tract and pancreas K80-K87 Other diseases of the digestive system K90-K93 Chapter XII Diseases of the Skin and Subcutaneous Tissue L00-L99 Infections of the skin and subcutaneous tissue L00-L08 Bullous Disorders L10-L14 Dermatitis and eczema L20-L30 Papulosquamous disorders L40-L45 Urticaria and erythema L50-L54 Radiation-related disorders of the skin and subcutaneous tissue L55-L59 Disorders of the skin appendages L60-L75 Other disorders of the skin and subcutaneous tissue L80-L99 Chapter XIII Diseases of the musculoskeletal system and connective tissue M00-M99 Arthropathies M00-M25 Systemic connective tissue disorders M20-M36 Dorsopathies M40-M54 Soft tissue disorders M60-M79 Osteopathies and chondropathies M80-M94 Other disorders of musculoskeletal system and connective tissue M95-M99 Chapter Diseases of the genitourinary system N00-N99 XIV Glomerular Diseases N00-N08 Renal tubulo-interstitial diseases N10-N16 Renal failure N17-N19 Urolithiasis N20-N23 Other disorders of the kidney and ureter N25-N29 Other diseases of the urinary system N30-N39 Diseases of the male genital organs N40-N51 Disorders of breast N60-N64 Inflammatory diseases of female pelvic organs N70-N77 Non-inflammatory disorders of female genital tract N80-N98 Other disorders of the genitourinary system N99 Chapter Symptoms, Signs and Abnormal Clinical and Laboratory R00-R99 XVIII Findings, not elsewhere classified Symptoms and signs involving the circulatory and respiratory R00-R09 systems Symptoms and signs involving the digestive system and abdomen R10-R19 Symptoms and signs involving the skin and subcutaneous tissue R20-R23 215

216 Chapter XIX Symptoms and signs involving the nervous and musculoskeletal systems Symptoms and signs involving the urinary systems Symptoms and signs involving cognition, perception, emotional state and behaviour Symptoms and signs involving speech and voice General symptoms and signs Abnormal findings on examination of blood, without diagnosis Abnormal findings on examination of urine, without diagnosis Abnormal findings on examination of other body fluids, substances and tissues, without diagnosis Abnormal findings on diagnostic imaging and in function studies, without diagnosis Ill-defined and unknown causes of mortality Injury, poisoning and Certain other consequences of external causes Injuries to the head Injuries to the neck Injuries to the thorax Injuries to the abdomen, lower back, lumbar spine and pelvis Injuries to the shoulder and upper arm Injuries to the elbow and forearm Injuries to the wrist and hand Injuries to the hip and thigh Injuries to the knee and lower leg Injuries to the ankle and foot Injuries involving multiple body regions Injuries to unspecified part of trunk, limb or body region Effects of foreign body entering through natural orifice Burns and corrosions Frostbite Poisoning by drugs, medicaments and biological substances Toxic effects of substances chiefly nonmedical as to source Other and unspecified effects of external causes Certain early complications of trauma Complications of surgical and medical care, not elsewhere classified1 Sequelae of injuries, of poisonings and other consequences of external causes R25-R29 R30-R39 R40-R46 R47-R49 R50-R69 R70-R79 R80-R82 R83-R89 R90-R94 R95-R99 SOO-T98 S00-S09 S10-S19 S20-S29 S30-S39 S40-S49 S50-S59 S60-S69 S70-S79 S80-S89 S90-S99 T00-T07 T08-T14 T15-T19 T20-T32 T33-T35 T36-T50 T51-T65 T66-T78 T79 T80-T88 T90-T98 216

217 Chapter XXI Factors Influencing Health Status and Contact with Health Services Persons encountering health services for examination and investigation Persons with potential health hazards related to communicable diseases Persons encountering health services in circumstances related to reproduction Persons encountering health services for specific procedures and health care Persons with potential health hazards related to socioeconomic and psychosocial circumstances Persons encountering health services in other circumstances Persons with potential health hazards related to family and personal history and certain conditions influencing health status Z00-Z99 Z00-Z13 Z20-Z29 Z30-Z39 Z40-Z54 Z55-Z65 Z70-Z76 Z80-Z99 217

218 Appendix 2 Map of Top Ten Causes of Elective and Nonelective admissions Map 30: Halton Elective Admissions for Neoplasms, 2006/07 Source: Oracle, 2008 Cancers (neoplasms) have the greatest number of elective admissions in 2006/07, the percentage breakdown by ward shows that Heath, Castlefields, Windmill Hill and Halton View have the highest numbers, where as Daresbury, Norton North, Hale, Riverside, Farnworth and Birchfield have the lowest numbers. In relation to reducing numbers of cancers then interventions need to be concentrated in areas of high numbers to have the greatest impact, however a cancer equity audit is currently underway and will examine if there are inequalities and which areas have the highest rates of cancers. 218

219 Map 31: Halton Elective Admissions for Genitourinary Infections, 2006/07 Source: Oracle, 2008 There are high proportion of admissions in these categories in the wards of Health, Norton South, Windmill Hill and Ditton. For a full breakdown of conditions covered within genitourinary infections see appendix one. The highest number of admissions in this category fell within Other diseases of the urinary system. 219

220 Map 32 Halton Elective Admissions for Digestive Conditions 2006/07 Source: Oracle, 2008 For digestive conditions the wards with the highest rates were Halton Brook, Grange and Halton Lea, whereas Musculoskeletal Conditions high rates were seen in Ditton, Hough Green, Halton View and Halton Lea. Map 33: Halton Elective Admissions for Musculoskeletal Conditions, 2006/07 220

221 Source: Oracle, 2008 Map 34: Halton Elective Admissions for Conditions Affecting the Eye, 2006/07 Source: Oracle, 2008 High rates of admissions for eye conditions were seen in Windmill Hill, Hough Green and Broadheath. The rates represented here are crude rates and have not been 221

222 adjusted for age. Eye related problems maybe more likely in the young and older populations. 222

223 Map 35: Halton Elective Admissions for Circulatory Conditions, 2006/07 Source: Oracle, 2008 High admission rates for circulatory conditions were seen in Castlefields, Grange, Windmill Hill and Heath. 223

224 Map 36: Halton Elective Admissions for Factors Influencing Health Status and contact with Health Services, 2006/07 Source: Oracle,

225 Map 37: Halton Elective Admissions for Symptoms, Signs and Abnormal Clinical and Laboratory Findings Not Elsewhere Classified, 2006/07 Source: Oracle, 2008 Map 38: Halton Elective Admissions for Respiratory Conditions, 2006/07 Source: Oracle,

226 Riverside, Hough Green and Windmill Hill had high elective admission rates for respiratory conditions. Map 39: Halton Elective Admissions for Skin Conditions, 2006/07 Source: Oracle,

227 Map 40: Halton Non-Elective Admissions for Symptoms, Signs and Abnormal Clinical and Laboratory Finding Not Elsewhere Classified Source: Oracle,

228 Map 41: Non-Elective Admissions Due to Injury, Poisoning and Other External Causes, 2006/07 Source: Oracle, 2008 High rates of non-elective admissions for Injury, poisonings and other external factors were found in Mersey, Castlefields, Windmill Hill and Appleton 228

229 Map 42: Non-Elective Admissions for Respiratory Conditions, 2006/07 Source: Oracle, 2008 Map 43: Non-Elective Admissions for Circulatory Conditions, 2006/07 Source: Oracle,

230 Map 44: Non-Elective Admissions for Digestive Disorders, 2006/07 Source: Oracle, 2008 Map 45: Non-Elective Admissions for Genitourinary Conditions, 2006/07 Source: Oracle,