Director of Public Health Annual Report Heywood, Middleton and Rochdale Primary Care Trust (HMRPCT)

Director of Public Health Annual Report Heywood, Middleton and Rochdale Primary Care Trust (HMRPCT) June 2007 Baseline Assessment of Health Inequalities in the Borough

CONTENTS CONTENTS page FOREWORD 4 AN INTRODUCTION TO HEALTH INEQUALITIES 5 The wider determinants of Health MEASURING HEALTH INEQUALITIES 6-11 Deprivation Life expectancy Infant Mortality TOP 10 KEY 5 APPROACH TO CLOSING 12-14 THE GAP IN LIFE EXPECTANCY TOP 5 CONTRIBUTORS TO THE HEALTH GAP 15-16 SMOKING 17 CANCER 18 CARDIO-VASCULAR DISEASE (CVD) 19-20 OBESITY 21 MENTAL HEALTH 22-23 CLOSING THE GAP BY ADDRESSING 24-26 THE PUBLIC HEALTH INFORMATION AND DATA SOURCES 27 3

FOREWORD FOREWORD T he purpose of this annual report is to provide a baseline audit of health inequalities by painting a broad picture of health and it s determinants in the Borough, for use by the new Heywood, Middleton and Rochdale Primary Care Trust (HMRPCT) and partners. This will serve as the baseline Health Equity Audit for the PCT by identifying the major contributors to the health gap and identifying the key determinants to be tackled when developing the relevant strategies It should also act as a guide for the new Practice Based Commissioning (PBC) clusters when determining their commissioning strategy by ensuring that their activities serve to close the health gap in the borough as well as ensuring access to high quality health care. Equitable access to high quality care must go alongside actions designed to prevent ill health supported by partnership working if we are to change the currently negative impact of the determinants of health locally into positive ones. When these three strands of activity come together the health inequalities currently seen in the Borough can be effectively addressed and reduced. The Local Strategic Partnership is already doing a lot of work in this area but we must build on these foundations to address all of the factors that influence health if we are to close, not only the gap between Rochdale Borough and the rest of the country but also the gaps seen between the best and the worst off groups within the Borough. The communities themselves are key partners in achieving this and every individual in the Borough needs to be aware of their own responsibilities in relation to their health, be aware of what they can do to improve their health and be supported in accessing the means to take control of their health and wellbeing whatever their abilities. There are a number of projects underway to ensure that this happens but we need to expand these to ensure that we reach as many people as possible. This Annual Report provides high level information on the main contributors to the life expectancy gap locally; it identifies the key areas for interventions to achieve the biggest impact on that gap and is intended to inform the development of future strategies. This report will be followed later in the year by the annual report for 2007/8 that will include the detail behind each of the key areas. That report will include an assessment of current interventions and recommendations for additional future action. To supplement the annual reports the specialist Public Health team will be producing topic based reports on key areas throughout the year which will incorporate the relevant needs assessment and recommendations for action. I present this report in the hope that it will ensure that everyone with a responsibility for any aspect of the public health will find it useful in identifying the areas that will bring about the biggest improvements to health and wellbeing locally. 4

AN INTRODUCTION TO HEALTH INEQUALITIES AN INTRODUCTION TO HEALTH INEQUALITIES H ealth inequalities are differences in the levels of good health and well being experienced by sections of the population, which occur as a consequence of differences in life experience across the determinants of health. Human health is determined by the complex interaction of Biology, Lifestyle and the Environment. These are often referred to as the determinants, of health. We all as individuals have a unique set of health determinants however many of these are shared within families and communities. Inequalities in a person s health experience often reflect the inequalities in the distribution of the positive and negative effects of these health determinants. Different groups of people have very different experiences of the determinants of health, resulting in marked differences in patterns of health and illness. Some of the groups are well known and include: gender, class, ethnic group, age and geographical area; others might be less obvious such as disability or single parent status. Many groups and individuals are adversely affected by more than one of these factors, worsening their health experience and widening inequalities within communities. The wider determinants of Health Many of the policies that have the greatest potential impact on health have traditionally 5 been outside the influence of the health and social care sector. To tackle health inequalities successfully, a concerted effort is needed from a wide range of individuals and organisations so that inequalities in health are reduced not only by improving access to health care provision but also by reducing the impact of the other determinants of poor health within neighbourhoods such as housing, education, access to transport, exposure to pollutants and low levels of nutrition and income. By working together in partnership all agencies within the Borough of Rochdale, especially those who make up the Health and Wellbeing Partnership, can ensure that the residents of the Borough experience a higher quality of life and better health. The primary goal is to reduce the currently detrimental differences experienced by our residents within the Borough as well as the differences between the Borough of Rochdale and other, more affluent, areas of the U.K.

MEASURING HEALTH INEQUALITIES MEASURING HEALTH INEQUALITIES T he National Public Service Agreement (PSA) targets aimed at reducing Health Inequalities are: By 2010 to reduce by at least 10% the gap between areas with the lowest life expectancy at birth and the population as a whole. By 2010 to reduce inequalities in health outcomes by 10% as measured by infant mortality and life expectancy at birth Life expectancy in Rochdale is lower than the National average. Table 1: Gaps in life expectancy in Rochdale. Gender Life expectancy Life expectancy Gap HMRPCT Nationally men 74.4 76.9-2.5 women 78.8 81.1-2.3 Map 1: Index of Multiple deprivation Index of Multiple Deprivation 2004 - Rochdale Borough Lower Levels SOAs Deprivation Economic status has a big impact on the health experienced by members of the population. The index of multiple deprivation for Rochdale is shown in the map. In the recently published health profile data Rochdale ranked 315th in terms of Income Deprivation (where 1 was the best off and 352 the worst off local authority in England). It is 8th out of 10 for Income Deprivation in Greater Manchester. Source of Data ODPM 2004 6

Table 2: Comparing Income in Rochdale with the rest of Greater Manchester: Local Authority Income deprivation rank (1= best off; 10 = Worst off) Value =% of residents dependant on means tested benefits (2003 data) Stockport 1-10.4 Trafford 2 11.0 Bury 3 12.5 Wigan 4 13.8 Bolton 5 16.1 Tameside 5 16.1 Oldham 7 17.0 Rochdale 8 18.6 Salford 9 20.5 Manchester 10 27.5 The influence of economics on health means that when adverse health experience is mapped we would expect to see a similar picture. This influence is greatest on the health of children. The Child Poverty Index is shown in the next map. When Local Authorities are ranked for Child Poverty Rochdale is ranked 306th out of 352 with 28% of local children living in low income households (2001 data) Map 2: Child Poverty index Child Poverty Index 2000 - Rochdale and Heywood and Middleton PCTs It is no surprise that this map shows a similar distribution to the Index of Multiple Deprivation. 7 Source of Data Government Office North West

Life expectancy The cumulative effects on the determinants of life are seen when life expectancy is mapped for the Borough. Map 3: Life Expectancy Health Inequalities - Life Expectancy Whilst there is a gap in life expectancy between the Borough and England as a whole there has still been an underlying increase in life, however, in addressing the determinants of health we should be able to close the gap between Rochdale and England as a whole. The PCT needs to work in partnership with other local agencies to increase the speed of this improvement and close the gap. Graph 1: Trend in Female life expectancy Graph 2: Trends in Male life Expectancy Life Expectancy at Birth - Female 1991 to 2005 Life Expectancy at Birth - Male 1991 to 2005 8

Rate per 1000 Live Births The Health Profile ranking for Male and Female life expectancy is shown in Table 3 below. The Borough was ranked 340 th for female life expectancy and 337 th for male life expectancy out of 352. Life expectancy is ranked lower than income deprivation this is the case for all of the local authorities in Greater Manchester. The most likely explanation for this is the high rate of deaths attributable to smoking related diseases. Smoking is the single most significant adverse influence on health in the Borough. Table 3: Male and female Life expectancy in Greater Manchester: Local Authority (ranked by income deprivation) Female life expectancy (1= best; 10 = Worst) Value in years (for 2003-2005) Male life expectancy (1= best; 10 = Worst) Value in years (for 2003-2005) Stockport 1-81.3 2 76.8 Trafford 2 81.1 1 77.3 Bury 3 80.3 3 75.8 Wigan 4 79.4 4 75.1 Bolton 5 79.0 5 = 74.6 Tameside 5 79.5 5 = 74.6 Oldham 7 79.2 8 74.2 Rochdale 8 78.8 7 74.4 Salford 9 78.4 9 73.8 Manchester 10 78.3 10 72.5 Infant Mortality rates are higher in Rochdale than nationally, but again the trend shows an improvement and this time the gap is closing. However we know that some factors which have an effect on infant mortality e.g. smoking in pregnancy and the initiation and maintenance of breast feeding are not as good as they should be locally. Graph 3: Trends in Infant Mortality: Infant Mortality Rates (Age Under 1 Year) 1994 to 2005 9 Year

Infant Mortality The figure below is taken from the recent review of Infant Mortality and shows the actions that need to be taken to reduce the current gap by 10% This shows that Lifestyles intervention aimed at stopping women smoking and reducing obesity levels would contribute a 4.8% reduction in the gap. These interventions will also contribute to reducing the local life expectancy gap. 10

Infant Mortality is closely associated with teenage pregnancy so reducing numbers of teenage pregnancies will impact on infant mortality (reducing the gap by up to 1%) High teenage pregnancy rates and high infant mortality rates are higher in areas of Income Deprivation. Rochdale has seen a marked improvement in teenage pregnancy rates in recent years and is currently ranked 286th out of 352 (cf. 315th for Income Deprivation). Table 4: Teenage Pregnancy in Greater Manchester Local Authority (ranked by income deprivation) Teenage Pregnancy Rates (1= best, 10 = Worst) Crude rate births under 18 / 1,000 female population aged 15-17 (2002-2004) Stockport 2 81.3 Trafford 1 81.1 Bury 3 80.3 Wigan 6 79.4 Bolton 5 79.0 Tameside 7 79.5 Oldham 9 79.2 Rochdale 4 78.8 Salford 8 78.4 Manchester 10 78.3 11

TOP 10 KEY 5 APPROACH TO CLOSING THE GAP IN LIFE EXPECTANCY TOP 10 KEY 5 APPROACH TO CLOSING THE GAP IN LIFE EXPECTANCY Table 5: Top ten contributors to lower life expectancy in Rochdale Male Top 10 Female Top 10 Coronary Heart Disease Stroke Infant Mortality Overdose and poisoning / Self Harm Lung cancer Other cancers (especially Lip, oral and oesophagus cancer Bronchitis, COPD and other respiratory disease Digestive disease (including cirrhosis) Diabetes Accidents Coronary Heart Disease Stroke and other circulatory disease Lung cancer Breast cancer Other cancer (esp. Colorectal cancer) Bronchitis, COPD and other respiratory disease Self Harm / Overdose and poisoning Infant mortality Diabetes Violence Table 6: Key 5 Determinants of lower life expectancy in Rochdale Key 5 Contributory determinants Smoking Diet Physical Activity Deprivation Uptake of Screening Areas with a high proportion of adults who smoke have populations with significantly lower life expectancy Poor diet leads to higher levels of Heart Disease, Diabetes and Cancer the indicator for poor diets at a community level is the proportion of adults overweight or obese Reduced physical activity leads to higher levels of Heart Disease and Diabetes Income deprivation is linked to a wide range of other negative determinants of health. It is linked with the other 4 key determinants in this table as well as poor housing, poor educational attainment, poor mental health etc. Where the uptake of screening programmes aimed at ensuring early intervention for some cancers, diabetes and other conditions is low, life expectancy is reduced. Uptake is commonly low in areas of income deprivation 12

Table 7: Barriers Top 10 Barriers to Healthy Lifestyles Awareness Acceptability Obesogenic environment Availability of the right foodstuffs Accessibility Affordability Low self esteem Low aspirations Lack of empowerment Social norms Individuals, groups and communities need to be aware of the actions they can take to improve their health and life expectancy. Actions to improve health need to be culturally and socially acceptable and to fit in with peoples daily lives. The environment in which we live means that the easier choices relating to lifestyle are the ones that lead to weight gain - the environment needs to be changed to support healthy living. Local suppliers including shops, school meals and restaurants need to stock / offer healthy options. Accessibility to the support needed to adopt a healthy lifestyle is key to closing the life expectancy gap: Access to affordable exercise, weight management, cookery and parenting skills etc. Healthy choices need to be affordable if they are to be adopted, especially in areas of Income Deprivation. Individuals with low self esteem will not make healthy choices in their lives. This is especially relevant to young adults. Low aspiration lead to low educational attainment and often then to low earning capacity. Often individuals, groups and communities are aware of the health messages but are not able to act on them. Giving them the skills to do so is key to closing the gap. Social norms on the acceptability of poor health behaviours e.g. smoking need to be changed to make them socially unacceptable. This leads to peer pressure to change behaviours. 13

Table 8: Actions to Close the Gap Top 10 interventions Stop smoking services Reduce salt and fat intake Target statin prescribing Increase fruit and vegetable consumption Increase physical activity Improve uptake of screening programmes Increase educational attainment Improve environmental factors e.g. air quality / obesigenicity Increase opportunities for social interaction Improve access to high quality health care Smoking is the single biggest contributor to poor health and lower life expectancy in Rochdale.* These factors are known to increase the risk of heart attack and stroke both major contributors to the local gap in life expectancy.* In increasing the levels of Statin prescribing to the expected amount we need to target those groups at highest risk of developing heart disease. Consumption of at least 5 portions of fruit and vegetables a day has been shown to improve health, reduce the risk of certain diseases and increase life expectancy.* Increased activity is associated with both better physical and mental health.* The borough has good overall uptake of screening programmes but there are specific groups / areas where uptake is low and we need to increase uptake specifically in those areas. This is linked to higher earning capacity and therefore increased income across the community reversing the impact of deprivation on health. Improving the quality of the environment improves mental health, increases physical activity, social interaction and reduce levels of obesity. Social interaction leads to better mental health and in older people reduces the prevalence of dementia. The Inverse Care Law means that often those who need health the most access it the lease. In improving standards of care we need to ensure equity of access. * See the Lifestyle Strategy details Equity = distribution based on need i.e. those who need services most, get more care. 14

TOP 5 CONTRIBUTORS TO THE HEALTH GAP TOP 5 CONTRIBUTORS TO THE HEALTH GAP T he top contributors to Health Inequalities locally are: Smoking Cancer CHD Obesity (as a measure of an unhealthy lifestyles) Poor Mental Health (incl. suicide) The graphs below show more detail in relation to all of the contributors to the health gap - including those listed above. Graph 4: Main health problems that contribute to the gap in life expectancy Rochdale Injury and poisoning (f) Injury and poisoning (m) Coronary heart disease (f) Coronary heart disease (m) Stroke (f) Stroke (m) Other circulatory disease (f) Other circulatory disease (m) Chest disease (f) Chest disease (m) Digestive disease (f) Digestive disease (m) Lung cancer (f) Lung cancer (m) Colorectal cancer (f) Colorectal cancer (m) Other digestive cancer (f) Other digestive cancer (m) Breast cancer (f) Other cancer (f) Other cancer (m) Infants under 1 year (f) Infants under 1 year (m) Other all causes (f) Other all causes (m) Months of life lost 15

Using this information broken down for men and women we can begin to identify the issues we need to concentrate on to improve life expectancy in the Borough: Graph 5: Main contributors to the gap in Female Life Expectancy In Rochdale Graph 6: Main Contributors to the gap in Male Life Expectancy In Rochdale 16

SMOKING SMOKING T he recent National Health Profiles modelled the percentage of adults who smoked in Rochdale based on the Health Survey for England, which is generally accepted as an underestimate, at 28.7% of adults compared to 26% for England as a whole and 27.4% in the North West. This is reflected in the smoking related, Coronary Vascular disease and the Cancer death rates. Table 9: Smoking related death rates in Greater Manchester Local Authority (ranked by income deprivation) Deaths from Smoking (1= best, 10 = Worst ) Directly age standardised rates / I00,000 population aged 35 or over (2003-5) Stockport 1 237.8 Trafford 2 250.4 Bury 3 271.6 Wigan 4 291.6 Bolton 5 291.4 Tameside 6 311.8 Oldham 7 305.1 Rochdale 8 322.2 Salford 9 340.6 Manchester 10 359.6 Rochdale ranks 341 st out of 352 with 322.2 deaths per 100,000 of the population over 35 from smoking attributable causes compared to a rate of 234.4 for England as a whole and 279.3 for the North West. The population of Rochdale Borough aged 35 and over in 2003 was 110,300; in 2004 was 110,700 and in 2005 was 110,300. Applying the death rate attributable to smoking to these population figures gives us an annual number of deaths in the over 35s attributable to smoking of 358 (on average) per year. 17

Rate per 100,000 CANCER CANCER T his chart shows that the death rate from cancer in Rochdale is significantly higher than in England as a whole. Graph 7: Trends in cancer death rates Deaths per 100,000 for All Cancers (Age Under 75) 1993 to 2010 (Projected) Rochdale Borough England and Wales Linear (Rochdale Borough) Year The biggest contributors to this higher rate are the smoking related cancers, see graphs 4,5 & 6 above. Actions to address smoking prevalence, unhealthy lifestyles and increase screening are in place to try to reduce this gap. In Rochdale the time taken from referral to diagnosis and treatment is good and there is a system in place to monitor this to ensure targets continue to be met. The Borough as a whole meets its targets for all screening programmes but these high uptake rates are not universal across the Borough. We are currently auditing the uptake of cervical screening to address areas where uptake is lower that target. 18

Rate per 100,000 CARDIO-VASCULAR DISEASE (CVD) CARDIO-VASCULAR DISEASE (CVD) Graph 8: Trends in CVD death rates Deaths per 100,000 for All Circulatory Disease (Age Under 75) 1993 to 2010 (Projected) Rochdale Borough No Stretch Rochdale Borough Stretch (actual data to 2006) England and Wales Linear (Rochdale Borough Stretch (actual data to 2006)) Year P revious targets set for the Borough in relation to CVD have been stretched recently - that means they have been raised (by comparison to the national improvement) and more challenging targets have been set in the above chart the figures to 2005 are actual figures, those after that day show projections based on the old target (no stretch) and the new ones (with the stretch). The doted line shows our current trend (This is where the data is adjusted to smooth out year on year variations in the data and shows the general direction of change). If this target is achieved it will have a significant impact on life expectancy in the Borough. Local activity has focused both on treatment services (e.g. call to needle times, thrombolysis therapy and statin prescribing) and on prevention (healthy eating, physical activity, stop smoking etc). 19

The reasons for taking both the improved access to treatment and the lifestyles approach can be seen in the table below which shows that changes to modifiable risk factors such as smoking, cholesterol and blood pressure have made a greater contribution (71%) to reducing mortality than medical treatments over a 19 year period. Some of this impact, however, has been reduced by increases in obesity, diabetes and physical inactivity although 58% of the reductions in mortality remain due to these risk factor changes. Table 10: Explaining the fall in CHD Fall in Coronary Heart Disease Deaths in England and Wales (1981-2000) Risk Factors worse +13% Obesity (increase) +3.5% Diabetes (increase) +5% Physical activity (less) +4.5% Risk Factors better -71% Smoking -48% Cholesterol -9% Population BP fall -9% Deprivation -3% Other factors -8% Treatments -42% AMI Treatments -8% Secondary prevention -11% Heart failure -12% Angina: CABG & PTCA -4% Angina: Aspirin etc -5% Hypertension therapies -3% 20

OBESITY OBESITY T he emphasis locally is on promoting healthy lifestyles where the individuals eats healthily, exercises regularly and doesn t smoke. Further information in relation to this activity is in the health lifestyles strategy and is being implemented locally using the Do you feel good? brand. The lifestyles work will help to prevent weight gain and to support people who have lost weight; in addition we are putting measures in place to support people with weight management. The Aim is: To provide appropriate services to help adults & children who are overweight or obese reach a healthy weight. 1. Evidence-based care pathway for adults 2. Family-orientated programme for children Locally we are using two main strategies to achieve this: Rochdale pilot programme working with commercial slimming groups: Weight watchers and Slimming world. MEND Programme-mind, exercise, nutrition, DO IT!! 21

Rate per 100,000 MENTAL HEALTH MENTAL HEALTH T he headline measure for mental health and inequalities is the suicide rate. Graph 9: Trends in Suicide death rates Deaths per 100,000 from Suicide and Injury Undetermined (All Ages) 1993 to 2010 (Projected) Rochdale Borough England and Wales Year The problem with this as a population measure is that it is based on very small numbers where one or two additional deaths can have a significant impact on the rates. The data it is drawn from also included death from injuries (undetermined) so, for example, one or more deaths in a house fire will be included in this measure and will show as a significant increase in the rate. In the above chart the difference in rate between Rochdale and England and Wales as a whole for 2003 to 2005 (the last year with actual data) was 8.064-7.367 = 0.697 per 100,000 of the population. Other measures of mental health including wellbeing are very subjective. 22

Promoting good mental health requires: Clear strategies for The well population Those at risk Those with mental health problems Raising awareness Reducing discrimination Improving knowledge and skills Preventing suicide Tips for staying (mentally) healthy* Talk about it Keep active Eat well Sleep well Drink sensibly Stay in touch with family and friends Sunlight (sensibly done) Get involved Look beyond the drug therapies Get the knowledge take control Get professional help A change of scene Avoid caffeine Go for green Learn to relax Set realistic goals *based on information on the Wellscotland.info website 23

CLOSING THE GAP BY ADDRESSING THE PUBLIC HEALTH CLOSING THE GAP BY ADDRESSING THE PUBLIC HEALTH The Public Health T he public health is the health of all the individuals and communities that make up the population of the Borough of Rochdale and it is everyone s responsibility. At a general level the individuals who make up the population have a responsibility to maintain their own health. As a result of the impact of the determinants of health on these individuals and groups some will need more support than others to achieve this. The nature of the help needed varies greatly and ranges from the provision of health information, through improved access to prevention and treatment services to additional support from teams based in the community e.g. Health trainers. General Public Health All individuals who work in the Borough have a responsibility for protecting the Public Health. The extent of this responsibility will vary depending on the nature of their employment and the effect that employment has on the determinants on health. This ranges from a general responsibility to protect the environment through minimising the pollutant effects of their work place (ranging from adhering to pollutant prevention regulations to work based green transport plans). Through more specific actions e.g. improved housing, accident prevention etc to delivering wellbeing interventions as part of a role within the delivery of Health and social care ranging from screening and immunisation programmes to the delivery of lifestyle advice and other brief interventions during consultations. Specialist Public Health The Functions of a specialist Public Health services are: Health Protection Health Equity Public Health Intelligence 24

Health Protection includes: Emergency Preparedness including Major Incident and Outbreak planning (including Pandemic Flu) Screening and Immunisation programmes Environmental contamination and health Planning and Health Programmes for Health Improvement Health Equity includes: Leading on action aimed at improving life expectancy closing the gap between the borough as a whole and the National average plus close the gaps seen between populations in the borough Reducing deaths from CVD and Cancer Reducing the prevalence of smoking Promoting healthy lifestyles Improving mental health and wellbeing Developing non-specialist Public Health Capacity (including Community Health Development and Health Trainers) Working in partnership to influence the determinants of Health Ensuring equitable access to health care Undertaking Health Needs Assessment, Impact Assessments and Equity Audits Informing effective commissioning Leading on action aimed at reducing Infant Mortality rates Ensuring high quality health care Promoting Breast Feeding Reducing the prevalence of smoking in pregnancy Improving child care including weaning Public Health Intelligence includes: 25 Developing and using models for Needs Assessment, Impact Assessment and Audit Define and set goals for the population and monitor our progress in achieving them Identify and develop effective Interventions, reconsider these if they are not working

Ensure mainstreaming of these interventions outside of Public Health Performance Improvement in Public Health Public Health Priorities 2007 to 2010 Based on the Information contained in this report and other local data the priorities for specialist public health action for 2007 onwards have been identified, these will be reviewed annually based on the health needs of the population and NHS and other relevant priorities. For 2007/8 these priorities have been identified as the following areas which are expected to make the biggest contribution to a reduction in Health Inequalities in Rochdale: Reducing mortality from CVD Reducing Smoking prevalence Tackling Obesity (Adult and Childhood) Reducing Infant Mortality Targeted increases in the uptake of screening and vaccination programmes Promoting mental health and wellbeing and reducing suicides Developing non-specialist Public Health capacity Ensuring the PCT has robust health protection systems in place Developing Public Health Intelligence Reducing the adverse impact of alcohol on health Improving sexual health 26

INFORMATION AND DATA SOURCES Information and Data sources: 1. Socio-economic Determinants of Health; Dalgreen and Whitehead (1991) 2 Health Profile for Rochdale, North West Public Health Observatory 2007 3 Health Profile for Rochdale, North West Public Health Observatory 2006 4 ONS - National Census data 2001 5 Government Office North West Child Poverty index 6 Review of the Infant Mortality PSA target 2007. 7 WellScotland information website 8 Rochdale Borough Healthy Lifestyles Strategy 9 Public Health 3 year plan Web links: www.nwph.net/nwpho www.statistics.gov.uk www.dh.gov.uk www.wellscotland.info www.hmrpct.nhs.uk/your_health/do_you_feel_good.asp?pm=40 27