Joint Strategic Needs Assessment: Health Profile for Lancashire North

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1 Joint Strategic Needs Assessment: Health Profile for Lancashire North Introduction This health profile forms part of a Joint Strategic Needs Assessment process for NHS Lancashire North CCG. Specifically it: describes the health of the population served by Lancashire North Clinical Commissioning Group (CCG) and identifies local health priorities recommends the strategic direction for Lancashire North CCG to improve health and wellbeing in the local resident population Dr Karen Slade Consultant in Public Health NHS North Lancashire Christine Graham Public Health Analyst NHS North Lancashire Donald Read Specialist Registrar in Public Health The information in this report has been assembled by the Public Health Intelligence Team in NHS North Lancashire. The development and maintenance of comprehensive intelligence on the health and wellbeing of the local population is supported by joint working between various partners across Lancashire including Public Health Intelligence teams in each of the three Lancashire PCT s, Lancashire County Council s Joint Health Unit, and the Lancaster District Health and Wellbeing Partnership. This report draws on existing knowledge about local priorities, set out in strategy documents and resources, which relate specifically to the area covered by Lancashire North CCG, or a wider area, of which the area covered by Lancashire North CCG is a part. These include: Lancashire Joint Strategic Needs Assessment Draft Lancashire Health and Wellbeing Strategy (2012) CCG Data Profile (NHS Commissioning Board, 2012) Health Profile for Lancaster (2012) NHS North Lancashire Commissioning Strategic Plan (published 2008) Lancaster Sustainable Communities Strategy ( ) NHS North Lancashire Public Health Annual Report (2009) Lancashire Public Health Report (2011) Draft

2 Where possible, this report presents data at the level of the CCG. In some circumstances, a CCG value has been derived by aggregating data available at practice level. In situations where data is not routinely available at CCG level, a proxy geographical area has been used (e.g. Lancaster District Council). This health profile sets out the overarching health priorities for NHS Lancashire North CCG based on routinely available health information. It should be used in conjunction with the knowledge of local stakeholders on what is currently being done to improve health outcomes and what more needs to be done. This triangulation approach will direct the efforts of the CCG and its local health partners to review commissioning plans and care pathways which relate to these priorities. Draft

3 The Health of the Resident Population of Lancashire North CCG Demography Figure 1: Lancashire North CCG footprint NHS Lancashire North CCG is the overarching consortium that oversees the 13 GP practices, 11 of which are within the local authority district of Lancaster (Figure 1). The remaining two practices are situated in Garstang in the borough of Wyre. The CCG covers an area of approximately 780 sq km of coast and countryside with registered patients living as far south as Broughton, near Preston and as far north as Burton in Kendal, Cumbria. Figure 2: Registered population of Lancashire North CCG Lancashire North CCG is responsible for a population of around 160,000 people. The majority of the population live in the urban towns of Lancaster, Morecambe, Heysham, Carnforth and Garstang but a significant proportion live in rural locations. Figure 2 shows the spread and density of the registered population across the CCG area. Draft

4 Age Distribution The population is generally characterised by a larger proportion of young adults than the England average as it includes the student population at the University of Lancaster. The CCG also has a slightly greater proportion of people aged 65 years and over (18%) compared to the national average (16.5%) and a smaller proportion of children aged less than 15 years (14.5% compared to 17.6% nationally). Figure 3 compares the population structure of Lancashire North CCG with England. Population Projection Estimated population projections suggest that over the next ten years the population of Lancashire North CCG will increase by over 7,000 people to approximately 167,800. The largest increase will occur in the over 70 age group which will increase by 30% from 20,200 to 26,300. This is in line with the national average. Conversely the young adult population (15-24 years) is projected to fall significantly more than the Draft

5 national average. By 2022 the CCG will have 3,000 less young adults, a fall of 12% compared to a fall of only 7% nationally for this age group. Figures 1.4 and 1.5 show the predicted population change for each age group between 2012 and Ethnicity The population of Lancashire North CCG is considerably less ethnically diverse than the population of England. Black and minority ethnic groups account for only 8% of the population compared to 16% nationally. Of these 3% are non-british White and 2% are Asian. Immigration The numbers of new immigrant registrations in Lancaster district has been declining since 2007/08. In 2010/11 there were 730 new registrations in Lancaster district, 230 (32%) of which were from Eastern European countries of Poland and Bulgaria. There were also 110 (15%) registrations from India. There may be cultural barriers to accessing health services in these communities. Intelligence on traveller populations is more difficult to ascertain. Records show that Lancaster district does have one official traveller site at Mellishaw Lane in Morecambe which has 20 residential pitches. Draft

6 Geo-demographic Profile (Figure 1.6) Based on the Mosaic Public Sector 2009 Citizen Classification, almost half (42%) of the population of Lancashire North CCG is made up of Groups B, E G and J (see table 1) - middle income working class, educated young adults and home-owners in small towns. Very few of the population are classified as Groups C, H and N (3%) which includes the wealthiest and also some of the most disadvantaged. The consortium has far fewer residents in the lowest social groups than the national average (6.7% compared to 13.4% nationally) though a higher proportion of active elderly in pleasant retirement locations, owner occupiers in older style housing and small town residents with strong local roots. Table 1: Mosaic categories and proportion of population in each Group UK LN CCG Ratio % No. % A Residents of isolated rural communities , B Residents of small and mid-sized towns with strong local roots , C Wealthy people living in the most sought after neighbourhoods , D Successful professionals living in suburban or semi-rural homes , E Middle income families living in moderate suburban semis , F Couples with young children in comfortable modern housing , G Young, well-educated city dwellers , H Couples and young singles in small modern starter homes , I Lower income workers in urban terraces in often diverse areas , J Owner occupiers in older-style housing in ex-industrial areas , K Residents with sufficient incomes in right-to-buy social houses , L Active elderly people living in pleasant retirement locations 3.1 6, M Elderly people reliant on state support , N Young people renting flats in high density social housing , O Families in low-rise social housing with high levels of benefit need , U Unclassified 13, Draft

7 Deprivation Figure 7: Indices of Multiple Deprivation 2010 Deprivation is a significant indicator of adverse health conditions. The 2010 Indices of Multiple Deprivation combines a number of indicators; including economic, health, housing, crime and social issues, into a single deprivation score for each small area in England. It allows areas to be ranked and compared according to five levels of deprivation across the country. Within Lancashire North CCG, the proportion of the population living in the most disadvantaged areas (18%) is less than the national average. However parts of Morecambe, Heysham and central Lancaster are classified as being amongst the fifth most disadvantaged areas in England and over 29,000 residents within Lancashire North live in these areas. Figure 7 maps deprivation across the CCG and figure 8 shows the proportion of the population living within each deprivation quintile. Within the CCG one practice has almost half its population (44%, patients) in the most deprived quintile while there are three practices with no registered patients in the most deprived quintile. This gives commissioners significant challenges in selecting the correct strategies for the diverse communities in the Draft

8 CCG. Life Expectancy Life expectancy has increased in Lancaster district over the last 20 years (figure 9). Although female life expectancy remains greater than male life expectancy at both national and district level, the difference has reduced over this period. In Lancaster district, both male and female life expectancies are just over one year lower than the national average. However life expectancy varies widely within the locality. There is an 11.6 year difference in male life expectancy between the most and least deprived areas (figure 10). For female life expectancy this difference is 8.5 years. This internal difference has also been increasing over the last few years, especially for males where the difference is now 2 years greater than it was 5 years ago. Draft

9 Figure 11 indicates the years of life that would be gained if disease-specific mortality rates for the most deprived quintile were reduced to the levels in the least deprived quintile. In Lancaster district tackling coronary heart disease, chronic obstructive pulmonary disease, chronic cirrhosis of the liver, cancer and suicides and accidents in males would make the largest contribution to reducing the gap in life expectancy. Although all-cause mortality rates in Lancaster district have fallen over the last 10 years, local death rates from cancer, heart disease and stroke in people aged under 75 years are still significantly worse than the England average. Draft

10 Figure 11: Life expectancy years gained if the Most Deprived Quintile had the same mortality rate as the least deprived in the local authority for each cause of death Draft

11 Burden of Disease Prevalence is a good indicator of the burden of disease in the population. Health service activity data such as QOF data does not necessarily present an accurate picture of disease burden, as disease prevalence reported as low could be explained by under-recording or unmet need within the practice population. The Association of Public Health Observatories has published estimates of disease prevalence at practice level to reflect the true burden of disease. In table 2, the available practice data has been aggregated to provide a summary of disease burden for Lancashire North CCG. (Where data is not available at CCG level, data for Lancaster District is used as a proxy). In Lancashire North CCG, disease prevalence largely reflects the national rates. The higher than average predicted increase in the proportion of older people in Lancashire North expected over the next ten years is likely to result in a higher than average rate of increase in the prevalence of diseases affecting older people (including dementia, circulatory disease, diabetes, COPD, osteoarthritis and cancers). Lancashire North CCG will need to develop commissioning strategies to tackle this. The prevalence of mental health conditions in Lancashire North is slightly higher than the national average and this is likely to increase in the current climate of economic recession. Table 2: Expected disease prevalence (APHO modelled estimates) England Lancashire North Lancaster CCG District No. % No. % No. % CHD (16+) 2,442, , Stroke 16+ 1,083, , Hypertension ,860, , COPD 16+ 1,530, , CVD16+ 4,950, , Diabetes 3,099, , CKD 18+ 3,547, , Dementia , , Any neurotic disorder 6,114, , Source: APHO Modelled Disease Prevalence, 2011 Draft

12 Investment and health outcomes Programme budgeting is a well-established technique for assessing investment in health programmes. The spine chart for Lancashire North CCG (figure 13) summarises the cost and outcome data for each programme budgeting category, and provides comparisons with the national average, the Strategic Health Authority and other similarly classified areas (ONS Cluster). NHS Lancashire North CCG has no areas where it is a significant (>2 SD) outlier on spend or outcome compared to other CCGs in England. Relative to the national average NHS Lancashire North has better outcomes for elective hip surgery, mortality from epilepsy and birth weight. However in NHS Lancashire North, outcomes for mental health (indicated by mortality from suicide and undetermined injury), circulatory disease (indicated by mortality from circulatory disease under 75 years), cancer (indicated by mortality from cancer under 75 years) and respiratory disease (indicated by mortality from bronchitis, emphysema and COPD under 75 years) are worse despite spend being equal to or higher than the national, SHA and ONS cluster comparators. NHS Lancashire North spends relatively less on gastrointestinal disease than the national, SHA and ONS cluster averages and this correlates with its relatively high mortality from gastrointestinal disease. These findings may be related to the high levels of binge drinking and hazardous drinking Draft

13 and increasing admission rates due to alcohol-related conditions in NHS Lancashire North (figure 17). Greater investment in the prevention and management of alcohol related diseases may be required. Efficiency gains may be possible in musculoskeletal disease and neurological conditions as NHS Lancashire North has both good outcomes and high spend for these conditions. Figure 13: Spend and outcome spine chart Draft

14 Service Utilisation and Activity Non elective (emergency and other non-elective) admission rates are slightly lower in Lancashire North CCG compared to the England average. This suggests urgent care provision in the community is good and/or admission thresholds are high. First outpatient attendance rates following a GP referral and elective admission rates are similar to the national average. Prescribing Activity Figure 15 shows the range of spend rates per 1,000 for the 4 biggest prescribing programmes in primary care: circulation, respiratory, endocrinology and mental health. In 2010/11 Lancashire North CCG spent 89,268 per 1,000 population compared to 79,662 nationally. This value has not been standardised for age so is likely to be due to the higher proportion of elderly patients living in the area. Draft

15 Figure 15: Prescribing spend rates (biggest programme) in primary care Patient Experience The GP Patient Survey indicated that patients in Lancashire North CCG have significantly greater levels of dissatisfaction with their ease of booking an appointment at their GP practice compared to the national average. Respondents expressed significantly higher levels of satisfaction with the quality of nursing care in their GP practice, and greater confidence in managing their own health compared to the national average. The self-reported health of respondents to the survey in Lancashire North CCG was significantly worse than the national average in terms of functional ability and anxiety and a significantly higher proportion were smokers. Draft

16 Figure 16: Spine chart of selected questions from the 2011/12 GP Patient Survey Draft

17 Risk Factors and Child Health Figure 17 Modelled estimates and recorded data on lifestyle behaviours, risk factors and child health Smoking Smoking is the most significant contributor to premature mortality and ill health through heart disease, stroke, pulmonary disease and cancer. Continued smoking is independently associated with readmissions for COPD, heart disease, vascular disease and nearly all surgical complications. The estimated prevalence of smoking across Lancashire North CCG is 23%, rising to 34% in routine and Draft

18 manual groups. Rates of smoking attributable hospital admissions in Lancashire North CCG are significantly higher than the national average (1,836 per 100,000 population, compared to 1,417 nationally) - this equates to over 1,400 admissions per year in Lancashire North CCG. Mortality rates from smoking-attributable diseases in Lancashire North CCG are significantly higher than the national average (259 per 100,000 population, compared to 211 nationally). In there were 862 deaths attributable to smoking in Lancashire North CCG. Smoking in pregnancy is linked to poor pregnancy outcomes and exposure of infants to second-hand smoke is associated with death in infancy. Smoking rates in pregnancy in NHS North Lancashire are reducing but remain significantly higher than the national average. CCG level data is not available but PCT level data indicates that 20.5% of new mothers in North Lancashire smoke at the time of delivery compared to 13.7% nationally. Alcohol Over recent years there has been an increase in the level of harm related to the consumption of alcohol both nationally and within Lancashire North CCG, and this is placing a huge burden on communities, health services, the criminal justice system and social and economic development. In Lancashire North CCG, binge drinking levels are significantly above the national average. 26% of the CCG population are estimated to be higher risk and increasing risk drinkers compared to the England average of 23%. Although the rate of alcohol-related hospital admissions for Lancashire North CCG is similar to the England rate (1,895 per 100,000 population), alcohol-specific hospital stays in people aged under 18 years are significantly higher than the national average (89.9 per 100,000 compared to 61.8 in England). Alcohol-specific and alcohol-attributable mortality in Lancaster district is higher than the national average for both males and females, though not significantly so. In 2009, the alcohol-attributable mortality rate for males was 40.2 per 100,000 compared to 35.9 nationally. For females this figure was 18.6 compared to a national average of Alcohol problems in Lancashire North are not confined to younger people. Recent research suggests a third of men and a fifth of women aged 65 years and over drink more than the guideline amounts. Trends in alcohol-related falls and hospital admissions suggest that increasing numbers of older people are at risk from alcohol-related problems. With a high proportion of older people this is a health priority for Lancashire North CCG. Draft

19 Obesity, Physical Activity and Nutrition Overall, rates of obesity, healthy eating and physical exercise in Lancashire North CCG appear to be better than national average. However this masks higher rates in the most deprived areas, for example where 26% of adults are obese (compared to 20% for the CCG overall and 24% nationally). Similarly, whilst childhood obesity rates for the CCG as a whole are similar to the national average for children aged 4-5 years and better than the national average for children aged years, in the most deprived areas of the CCG, childhood obesity rates are as high as 22%. Child Health Children and young people aged up to 19 years comprise more than a fifth (22%) of Lancashire North CCG s population. This equates to more than 35,000 children and young people. Inequalities in the health and wellbeing of children and young people have been identified as one of the top ten health inequalities across Lancashire. Outcomes in Lancashire North CCG are significantly better than the national average for child poverty, childhood obesity, low birth weight and immunisation. However child health in Lancashire North CCG could be improved through addressing poor outcomes for smoking in pregnancy, breastfeeding initiation and continuation, particularly in the most disadvantaged areas. Local analysis for Lancaster district shows that, of the mothers who did begin breastfeeding, 65% of mothers in the most affluent areas are still breastfeeding at 6-8 weeks compared to only 26% in the most disadvantaged areas. Accident and Injury In Lancashire North CCG, there are a large number of rural roads and the M6 motorway crosses through the centre of the patch. Between 2008 and 2010 there were 293 injuries and deaths from road accidents in this area. Road injuries and deaths in Lancashire North CCG are significantly higher than the national average (69.9 per 100,000 population compared to 44.3 nationally). Hospital stays for self-harm continue to be significantly higher than average, therefore improving mental health and wellbeing is a priority for Lancashire North CCG. Despite a high proportion of elderly people, hip fractures in people aged over 65 years and excess winter deaths in Lancaster district are similar to national averages. Draft

20 Challenges and Recommendations Challenge 1 The predicted increase in both the number and proportion of older people in Lancashire North CCG presents a challenge ahead. The CCG needs to focus on commissioning services to prevent ill-health and/or the complications of ill-health in younger adults so that the expanding older population is a healthier population. The CCG also needs to ensure it commissions efficient and effective care pathways for managing diseases which affect older people, with an emphasis on self-care, maintaining independence and end of life care. Challenge 2 The inequalities in health across the area present a challenge in Lancashire North CCG. Existing small area variations can be masked in large area analyses. The CCG needs to ensure that services to prevent, diagnose and manage ill-health are accessible to and utilised by those in its most disadvantaged groups (i.e people living in Morecambe, Heysham and Central Lancaster; people living in rural locations; ethnic minority groups; immigrant populations; homeless people). Challenge 3 The CCG faces the challenge of rising healthcare costs, for example due the ageing population, increased demand for healthcare and new technologies. Its commissioning plans should place emphasis on the prevention of disease, in particular through measures to reduce smoking prevalence, reduce binge and higher risk drinking, reduce smoking in pregnancy and increase breastfeeding. Challenge 4 - The existence of poor outcomes and low spend in gastrointestinal disease warrants further investigation as greater investment may be required to meet the health needs of the population. High levels of binge drinking and hazardous drinking and increasing admission rates due to alcohol related conditions in young people will contribute to these poor outcomes and should be addressed as a priority. Draft

21 Challenge 5 The existence of poor outcomes despite high spend in mental health, circulatory disease, cancer and respiratory disease warrants further investigation to gain a greater understanding of local need and how it can be effectively addressed to improve outcomes and efficiency. Challenge 6 The CCG s prevalence of mental illness and the rate of hospital admissions due to self-harm is likely to further increase during the current economic recession and the CCG should ensure its commissioning plans prioritise investment in prevention, early detection and treatment of mental illness. Challenge 7 The area has a high need for Trauma and Orthopaedics services, with high rates of road injuries (all persons) and emergency admissions for injury (children and young people), as well as a large and expanding elderly population (who are at greater risk of falls and have a higher prevalence of osteoarthritis) and high levels of binge drinking (which is associated with an increased risk of falls). The CCG should contribute to partnership work on accident prevention and tackling binge drinking to reduce service demand. The CCG s expenditure on musculoskeletal disease is relatively high and outcomes are relatively better than the national average. Therefore there may be scope to improve the efficiency of musculoskeletal care pathways. Draft