‘A Picture of Health’ Lincolnshire and Boston

1. ‘A Picture of Health’ Lincolnshire and Boston Philip Garner Public Health and Partnerships

2. ‘A Picture of Health’ • The DPH annual report for 2007 • ‘Something old , something new something borrowed ….’ • Covers the county but will emphasize issues locally relevant • Focus on • Population needs • The response by the local NHS • Potential impacts – short and long term • Brief mention of Commissioning for outcomes • What are we comparing ourselves with – what is our aspiration?

3. DPH Annual Report for 2007 designed to support a: SHIFT towards services that are personal, sensitive to individual need maintaining independence and dignity STRATEGIC REORIENTATION towards promoting health and well-being, investing now to reduce future health costs STRONGER FOCUS on commissioning services/ interventions that will achieve better health across health and local government everyone working together to promote inclusion and tackle health inequalities .

4. The Population of Lincolnshire

5. Number of Births: 2000-2006 Boston – 8% increase in crude birth rates

6. Population: Projections by Cluster – 65yrs and Over • In many GP Clusters, by 2027, numbers aged over 65 yrs will approx. double, exceeding 30% of total residents. • These increasing numbers will increase the number of people living with a long term condition.

7. vi) Boston NUMBER PERCENTAGE Age Band 2007 2012 2017 2022 2027 Age Band 2007 2012 2017 2022 2027 00-04 3,786 4,736 5,676 6,616 7,556 00-04 4.9% 5.7% 6.2% 6.6% 6.9% 05-19 13,154 13,724 15,059 17,417 20,247 05-19 17.1% 16.4% 16.5% 17.4% 18.5% 20-39 18,732 20,898 23,286 24,718 25,684 20-39 24.4% 25.0% 25.5% 24.7% 23.4% 40-64 26,033 27,965 29,518 31,943 34,564 40-64 33.9% 33.4% 32.3% 31.9% 31.5% 65-69 7,891 8,992 10,241 10,583 11,323 65-69 10.3% 10.8% 11.2% 10.6% 10.3% 75-84 5,365 5,415 5,528 6,634 7,835 75-84 7.0% 6.5% 6.1% 6.6% 7.2% 85+ 1,750 1,903 2,056 2,209 2,363 85+ 2.3% 2.3% 2.3% 2.2% 2.2% Grand Total 76,711 83,634 91,364 100,122 109,572 Grand Total 100.0% 100.0% 100.0% 100.0% 100.0% Population Projections

8. Population: Age Standardised Premature Mortality (/100,000 pop.2004-06) (mortality rate based on deaths recorded on GP Clinical system from NSTS and is death rate for those registered with PCT and not Lincolnshire resident rate.) • Skegness & Coast cluster rate significantly above County rate. • East Lindsey and Welland cluster rate significantly below. • The different rates, as might expect, follow pattern of deprivation. • However, when deprivation accounted for, picture changes dramatically.

9. Population: Age Standardised Premature Mortality – Adjusted for Deprivation (2) Boston Cluster has a lower age standardised rate, when adjusted for deprivation – by 2.9%

10. Population: Main Causes of Premature Death

11. Some Potential Impacts

12. Summary Number of People Who May Have a LTC in Next 20 Years • Projections based on changes in population as earlier and assuming services in Lincolnshire remain same. • Increase in those living with a LTC could increase by nearly 60%. • The above increase will consume significant resources within the NHS which may well be beyond the financial means of the NHS in Lincolnshire.

13. Forecast Persons on GP Registers with CHD 2007-27 • County overall could see increase of 75% • % increase for Clusters ranges from 30.5% in Skegness & Coast to 133.8% in Mid Kesteven. • These figures would be reduced as a result of reduction in smoking and excess alcohol, and improvements in diet and amounts of physical activity undertaken.

14. Forecast Persons on GP Register with Diabetes, 2007-27 • Estimates based on numbers known to the NHS. However, not all diabetics are diagnosed, so these are likely to underestimate the actual numbers of diabetics in the County. Approx.4,300 diabetics could be undiagnosed in 2027. • Mid Kesteven cluster will again see greatest impact but also significant figures for East Lindsey • Again, lifestyle changes would impact on these numbers, most diabetics being Type 2.

15. The Cost of Acute Care For LTCs in Lincolnshire • The increase in the number of people living with a LTC was nearly 60%, however, the cost of acute care alone could rise by 227% from 2007 to 2027. • The greatest % increase in cost will be seen for treatment of COPD, though the greatest financial burden will be for Cancer and Diabetes.

16. Est.Cost Acute Hospital Admissions, Diabetes, 2007-07 • Shows the total cost of treatment for diabetic patients, almost £70 million (increase almost £48 million). These costs may, therefore, also be included in those for other long term conditions as patients with diabetes might also have had a primary diagnosis of CHD, stroke etc.

17. Response to NHS Service User Needs

18. Proportion of Patients on CHD Registers • The CHD Register is typical of all Registers and the relative position for each Cluster changes very little for each of the conditions reported (Hypertension, Stroke / TIA, Diabetes, COPD)

19. GP Response via Quality & Outcomes Framework (QOF) Proportion CHD Patients Whose Cholesterol is 5mmol/l or Less • National guidelines recommend patients with cholesterol level greater than 5 mmol/l should be offered lipid lowering therapy. • The fact that fewer patients in Skegness & Coast cluster have a cholesterol level of 5mmol/l or less does not necessarily mean that they have lower prescribing of Statins. • Patient self management will also play a part in the ability to control Cholesterol levels. • Statin prescribing in Skegness and Coast is in fact higher than both the County and national figures.

20. % Patients with History MI(Diagnosed after 1 April 2003) and currently treated with ACE Inhibitor/Angiotensin II Antagonist • In Skegness and Coast cluster fewer than 80% of MI patients appear to be prescribed the appropriate drug, while in Welland and Mid Kesteven the figure is above 90%.

21. CHD and BP 150/90mmHg or less • British Hypertension Society Guidelines proposes audit standard BP reading of 150/90 or less. • A reduction of 5 – 6 mmHg in blood pressure sustained over 5 years been shown to reduce coronary events by 20 – 25% in patients with CHD.

22. Stroke/TIA with BP 150/90 or Less A long term difference of 5 – 6 mm Hg in usual diastolic blood pressure has been shown to be associated with 36% - 40% less stroke over five years.

23. High BP and last BP 150/90mmHg or less Trials of HBP treatment have shown significant reduction in incidence of stroke and CHD in patients with treated hypertension.

24. Deaths Amenable to Intervention

25. Summary Deaths Amenable to Intervention • Circulatory diseases account for more than 22%, of total deaths under 75 years old, 60% of those amenable to healthcare • Some of these lives could be saved with statins, and other drugs, and with smoking cessation and therapeutic/surgical intervention • Cancers account for more than 7.3%, of premature deaths, 20% of those amenable to interventions, through awareness raising, screening, and smoking cessation • Lincs PCT 37% premature deaths amenable to intervention (range 33% E Lindsey cluster- 40% Welland). • Boston had 37% of deaths amenable to healthcare. • Costs for prescribing and Primary Care are needed to get complete picture along the care pathways, so not possible to draw any conclusions as to whether overall balance of spend by condition and geography is appropriate

26. 2010 Health Inequalities Target • Dept. of Health review of trends in life expectancy, 1995 – 2004, • Lincoln City: second slowest progress in England re. female LE. • progress for males assessed as being “just adequate”. • Need to focus on cancers, circulatory disease, respiratory disease, digestive disease for both men and women • National modelling highlights addressing smoking prevalence, primary and secondary prevention of circulatory diseases, improving blood pressure and cholesterol control, will make most significant contributions to narrowing the gap. • For longer term, these interventions need to be considered in the context of wider determinants of health and lifestyle issues.

27. Longer Term Implications: Lifestyles- Smoking • Biggest single- preventable cause of premature deaths • - cause of health inequalities • Synthetic Estimates- 21.1% adults smokers (Eng.26%) • Boston and Lincoln LAs’ rates significantly higher than national average. • 10% patients with LTC in Boston, East Lindsey and Skegness and Coast clusters smoking status not recorded • 20% & 15%,resp., patients where smoking status known in Boston and Skegness and Coast clusters not offered smoking cessation • Need to - increase awareness and referrals • - increase cessation services in Practices and Pharmacies • - address differences in prescribing NRT/drug treatments

28. Longer Term Implications: Lifestyles- Obesity(1) • Being obese - increases risk of wide range of diseases • - reduces life expectancy by 9 yrs on ave. • 30.8% adult pop. Obese (sig higher Eng. ave.21.8%) • Boston …… • Boston, E.Lindsey and Lincoln LAs sig. worse rates re. healthy eating (19.3%,21.6% & 18% resp. Eng 23.8%) • Active People Survey – Lincs one of least active counties in the Country • Boston and Sth.Holland LAs two of least active Districts

29. Longer Term Implications: Lifestyles- Obesity(2) • Data based on measurements 2007 for approx.half (7,676)children within the target group. • Overall 31% of children in Lincolnshire measured as overweight • Year Reception – 9% of children obese • Year 6 17% of children obese. • Nationally suggested that, as response rate increases the higher apparent prevalence of obesity, more closely approaching true prevalence. • Significant implication for all LAs on changing behaviour and recognition/acceptance by individuals and families that obesity is a problem! • (New national obesity strategy due)

30. Reflection on LincolnshireSummary of Key Points (1) By comparison to national and county averages – doing quite well… but no room for complacency : Boston • life expectancy for males is significantly worse than a national average • Premature deaths for males is significantly worse than national average • Lifestyle information – healthy eating and physical activity are the lowest

31. Reflection on LincolnshireSummary of Key Points (2) As well, remember: • Population growth and aging • Smoking and obesity and the impact of obesity • Maintaining progress on teenage pregnancy and improve STI service usage by highest risk groups • Preventive screening – infections, childhood immunisations • If nothing changes projected costs will be unaffordable in £ terms and unacceptable in health and well being terms • Reallocation of resource is improving local funding but coastal cluster is still underfunded

32. Commissioning for OutcomesSome key challenges • Tensions relate to need to balance: - Better outcomes and effectiveness - Equality and equity - Benefits to service users (personal health) and to population outcomes (population health) • Consideration also be given to : - Result longevity Need for ‘balanced portfolio’ also encompasses: • Different timescales, i.e. short term, often ‘fire-fighting’, and longer term, • The “bigger picture” with prevention and promotion • The traditional and innovative, with established and new providers. • Not only configured around the needs, but also the preferences, of the ‘citizen’. - Key part to play, in that outputs and outcomes influenced by their attitudes and behaviours knowledge,.