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WCC Submission 30.11.08

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  • 1. Barnet Joint Strategic Needs Assessment 2008/11 Subject to approval by Barnet PCT/Barnet Council Adult Strategy Group and Barnet PCT Board NHSBarnet Primary Care Trust NHSBarnet Primary Care Trust NHSBarnet Primary Care Trust NHSBarnet Primary Care Trust
  • 2. Barnet Joint Strategic Needs Assessment 2008/11 CONTENTS Summary i Acknowledgements iii 1 Introduction 1 2 Creating a health-supporting environment: First things first 2 Barnet: overview 2 2.1 Barnet’s population.................................................................................................2 2.2 Housing...................................................................................................................9 Improving access to quality health services 13 Reducing unscheduled care 13 2.3 The effect of deprivation and ethnicity on health...................................................15 2.4 Employment..........................................................................................................21 2.5 Crime....................................................................................................................24 2.6 The views of local residents..................................................................................25 3 Improving health and wellbeing: enabling healthy choices for a healthy life, and supporting independence and building resilience 31 3.1 Introduction...........................................................................................................31 3.2 Immunisation........................................................................................................34 3.3 Smoking cessation................................................................................................39 3.4 Coronary heart disease and stroke: preventing vascular disease.........................42 3.5 Cancers................................................................................................................52 3.6 Respiratory disease..............................................................................................58 3.7 Diabetes................................................................................................................62 3.8 Sexual health .......................................................................................................66 3.9 Mental health problems.........................................................................................75
  • 3. 3.10 Obesity................................................................................................................78 3.11 The views of local residents................................................................................82 3.11.1 Overview – Perception of health 82 4 Investing in independence 87 4.1 Overview...............................................................................................................87
  • 4. Barnet Joint Strategic Needs Assessment 2008/11 Summary Whilst Barnet is a prosperous and generally healthy borough, many of its residents are affected by health and social inequality. For example, there is a difference in life expectancy for males at birth of up to some seven years between those who live in the most affluent parts of the borough compared with those in the most deprived; for females this difference is up to seven years. Whilst women generally live longer than men, it is the life expectancy difference within the sexes of those living in different parts of the borough that is significant. Put another way, people living in the more deprived parts of the borough are more likely to experience poorer health and are more likely to die prematurely. It is also important to note that there is evidence that, overall, Barnet has become relatively more deprived in the last few years. If this trend continues, we can expect Barnet residents’ health to worsen unless we take action to reduce the risk factors for avoidable ill-health. A major cause of the geographical differences in life expectancy in Barnet, as elsewhere, is differences in lifestyle factors such as smoking and obesity. People living in moiré deprived areas are more likely to smoke and are more likely to be overweight and obese. The burden on the health and social care services caused by this is substantial and thus may be considered to be an issue that goes beyond personal choice as it impacts on service need and thus the PCT’s and the council’s ability to provide services for the whole population. Encouraging and enabling people to avoid unhealthy lifestyles is thus an important role for the PCT and the council. Barnet’s population is expected to grow substantially over the coming five years, with the largest increase occurring in people aged 45-64 years. This ‘middle aged spread’ is especially important: people of this age are more likely to develop avoidable risk factors for a number of diseases and screening for breast cancer, high blood pressure, high blood cholesterol, kidney disease and diabetes will need to become a more prominent and regular feature of health care if we are to detect and manage risk factors before significant damage occurs. With an increase in the borough’s population of possibly some 40,000 people, and a consequential rise in the proportion of children and of women of childbearing age over the next few years, it will also be necessary to review the capacity of education and maternity services to meet the population’s needs. The proportion of Barnet’s population who come from Black and minority ethnic groups is also expected to change. It has increased in recent years from about 25% to 31.5% and is likely to reach 35.7% by 2017. People from Black and minority ethnic groups often have different cultural, social and religious values and their health and social needs can only be met properly if our services are tailored to those differences. i
  • 5. Over the next few years, in terms of health services, Barnet needs to:  increase childhood immunisation rates;  increase breast and bowel cancer screening rates;  identify and adequately manage more people with risk factors for heart attack and stroke;  increase (despite the recent and current good performance) the number of people who quit smoking;  reduce the proportion of children who are overweight and obese;  reduce the proportion of adults who are overweight and obese;  increase the number of young people screened for genital Chlamydia infection;  further reduce the number of teenagers who have unplanned pregnancies. ii
  • 6. Barnet Joint Strategic Needs Assessment 2008/11 Acknowledgements The creation of this document would not have possible without the help of the following people: Annette Alcock Alison Blair Alice Bolton Andrew Burnett Mary Caporizzo Dadia Conti Christine Cornwall Steve Craker Diane Curbishley Eryl Davies Shindi Dhillon Julia Duke-MacRae Hester Fairgrieve Cynthia Folarin Alison Hardacre Chloe Horner Glynis Joffe Kanan Kannan Peter Keeble Kate Kennally Susan Otiti Lance Saker Vilish Shah Paul Shipway Jill Stansfield David Thomas Noreen Twomey Val White iii
  • 7. iv
  • 8. Barnet Joint Strategic Needs Assessment 2008/11 1 Introduction This joint strategic needs assessment identifies the ‘big picture’ in terms of health and well-beingi of the residents of Barnet and people registered with Barnet GP practices. Its purpose is to provide a basis for the development of health and social care services so that they can promote health and well-being more effectively and so that:  services are shaped more by local communities;  inequalities can be reduced; and  social inclusion can be increased. This version builds on the Barnet Health Profile 2007/08. It is a draft document that covers the main health service issues including a number of health improvement areas. Further work will be undertaken to add sections expanding on social care needs. This Barnet Joint Strategic Needs Assessment for 2008-11 has been drawn up by Barnet Council and Barnet PCT. It will inform future iterations of:  the Barnet Sustainable Community Strategy;  the Barnet Local Area Agreement;  the Children and Young People’s Plan;  the Commissioning Framework for Health and Wellbeing;  the Barnet PCT Commissioning Strategy Plan;  the Barnet PCT Local Delivery Plan; and  various strategies and polices, including – − housing, − regeneration, − community safety, − supporting people, − supporting carers, − community safety, − workforce planning, − practice-based commissioning initiatives, − community pharmaceutical services development. Joint strategic needs assessments draw on national, regional and local datasets as well as the outcomes of local consultations and views expressed by community representatives and individuals at meetings such as the Barnet Civic Network and formal groups such as the Barnet Local Strategic Partnership and the Barnet Adult Strategy Group. 1
  • 9. 2 Creating a health-supporting environment: First things first Barnet: overview Barnet is a prosperous and generally healthy borough. Its residents are more likely to be owner-occupiers than are others in London, with proportionately fewer living in the social rented sector. However, like many places, Barnet has areas of deprivation where there are above-average death rates in people aged under 75 years, and with others living in those areas experiencing generally poorer health. Generally, life-expectancy is greater in Barnet than in many other parts of London and the rest of the country but, as elsewhere, there are differences in life expectancy between different parts of the borough. Barnet is home to some 335,000 people, based on Office for National Statistics (ONS) projections. Some 350,000 people are registered with Barnet GPs. The difference between these figures is that some people who live just outside the borough choose to register with GPs whose practice areas lie mainly within it and thus are the responsibility of Barnet PCT. (Similarly, some Barnet residents register with GPs whose practice areas are mainly outside the borough.) A snapshot of Barnet:  covering 87 square kilometres, Barnet is London’s fourth largest borough in size;  28% of the land in Barnet is green belt (2,466 hectares) and 8% is metropolitan open land (690 hectares). There are also 200 parks and open spaces;  it is the second most religiously diverse borough in the country and with 31.5% of its population belonging to a black and minority community, the 20th most ethnically diverse;  results in our primary and secondary schools place Barnet in the top quartile nationally;  this high education attainment is also evident across the adult population; over 37% are qualified to at least HND, degree and higher degree level;  crime levels per head of population are lower in Barnet than the national average. Fear of crime, however, remains high;  71% of houses in Barnet are owner-occupied;  37% of Barnet working-age residents travel to work by public transport  Barnet has a large share of knowledge workers – those in managerial, professional and technical jobs – relative to the national average;  there were over 14,780 VAT-registered businesses at the end of 2006, the third largest in London;  each resident produces around 431kg of waste each year and Barnet as a whole produces 1892 tonnes of CO2 emissions per year. 2.1 Barnet’s population Barnet’s resident population has a similar age-structure to the rest of London, but there are some important differences. A common way of showing the age-sex structure of a population is with a population pyramid. Error: Reference source not found shows the age-sex structure of the populations of Barnet and London. 2
  • 10. Figure 1: Population pyramids for Barnet and London showing the numbers of people by age band (Source: Office for National Statistics 2006 mid-year estimate) However, because the populations of the two areas are different in size (note that the scales are different on the horizontal axis) it is difficult to tell what, if any, differences there are. Figure 2 therefore shows the populations of Barnet and London expressed as proportions of the total population in each age band and these are compared directly in . Figure 2: Population pyramids for Barnet and London showing the proportion of people in the total population by age band (Source: Office for National Statistics 2006 mid-year estimate) 3 15000 10000 5000 0 5000 10000 15000 0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85-89 90+ males females 400000 200000 0 200000 400000 0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85-89 90+ males females BARNET LONDON Agebands Number of people Number of people 15000 10000 5000 0 5000 10000 15000 0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85-89 90+ 0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85-89 90+ males females 400000 200000 0 200000 400000 0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85-89 90+ 0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85-89 90+ males females BARNET LONDON Agebands Number of people Number of people 6 4 2 0 2 4 6 0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85-89 90+ Agebands Proportion of total population (%) 6 4 2 0 2 4 6 0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85-89 90+ Agebands Proportion of total population (%) males females males females BARNET LONDON 6 4 2 0 2 4 6 0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85-89 90+ Agebands Proportion of total population (%) 6 4 2 0 2 4 6 0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85-89 90+ Agebands Proportion of total population (%) males females males females BARNET LONDON
  • 11. Figure 3: A direct comparison of the proportions of people in both Barnet and London in each age band (Source: Office for National Statistics 2006 mid-year estimate) shows that there are proportionately fewer men in the age band 20-44 years in Barnet than in London, and fewer women (age band 20-40 years). This is especially relevant in terms of maternity services provision: Barnet’s current population has proportionately fewer women of child-bearing age than the rest of London, although this is set to change, as described below. It is also relevant in terms of employment. Many employed people are in the age band 20-44 years. also shows that Barnet has proportionately more children of school-age and more middle-aged and older people than the rest of London. This has implications for school and health services. In the next few years, Barnet’s population is expected to increase through natural growth and because more people will move into the borough because of a substantial increase in the number of homes being built. Population projections made by the Office for National Statistics (ONS) take account of death and fertility rates, and make assumptions about internal migration (people moving from one part of the country to another), but do not include the anticipated population growth due to Barnet’s regeneration programme. Population projections made by the Greater London Authority (GLA) use a slightly different calculation method but do factor in the proposed regeneration growth. 4 6 4 2 0 2 4 6 0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85-89 90+Agebands Proportion of total population (%) males females LONDON and BARNET The grey dotted line shows the proportion of people in each age band in Barnet 6 4 2 0 2 4 6 0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85-89 90+Agebands Proportion of total population (%) males females LONDON and BARNET The grey dotted line shows the proportion of people in each age band in Barnet
  • 12. Table 1 shows the proportionate increase expected in Barnet’s population over the measured population in the 2001 census. Both ONS and GLA figures are shown. Table 1: The proportionate growth predicted in Barnet’s population Age band (years) 2001 Census 2013 (ONS) 2013 (GLA) Projected population change between 2001 & 2013 (%) ONS GLA 0-14 60,043 70,000 64,660 17 8 15-44 142,027 149,400 163,077 5 15 45-64 67,000 82,400 83,634 23 25 65-74 22,809 25,300 23,982 11 5 75+ 22,685 24,700 22,506 9 -1 Figure 4 shows these same figures graphically. The most striking feature is that whether the ONS or GLA projection method is used, we can expect the biggest increase in the population to be amongst people aged 45-64 years. This ‘middle-age spread’ is important because it is at this age that many significant risk factors for cardiovascular disease become apparent and when a number of cancers that be identified by screening become more likely. The main risk factors for cardiovascular disease, other than smoking, are raised blood pressure, raised blood cholesterol and diabetes, all of which are more likely in people who are obese. People should not be complacent about this; it is very easy to move from being overweight to being obese and this risk increases with overweight and obesity, it does not suddenly happen when someone reaches a certain weight for their height. Whilst smoking is a risk at any age, overweight and obesity become more common in middle age. If the health and social care services are to help people to reduce the risk of cardiovascular disease then there will be more work to do with more people in Barnet as the population gets bigger – in both senses of the word – especially in this age group. In addition, the risk of developing breast cancer and colorectal cancer starts to increase at this age. Thus, with the biggest increase in Barnet’s population over then next few years being in the middle-age group, services will need to be developed to cope with more people needing more lifestyle risk assessments and interventions if we are to reduce morbidity and mortality from a number of diseases. Figure 4: The proportionate growth predicted in Barnet’s population Source: Office for National Statistics and Greater London authority 5 -5% 0% 5% 10% 15% 20% 25% 30% 0-14 15-44 45-64 65-74 75+ Age Group (years) Projectedpopulationchange between2001and2013(%) Office for National Statistics projection Greater London Authority projection -5% 0% 5% 10% 15% 20% 25% 30% 0-14 15-44 45-64 65-74 75+ Age Group (years) Projectedpopulationchange between2001and2013(%) Office for National Statistics projection Greater London Authority projection Office for National Statistics projectionOffice for National Statistics projection Greater London Authority projectionGreater London Authority projection
  • 13. Figure 5: Planned regeneration projects in Barnet and projected consequential population growth (Source: Barnet Council Information Observatory) Figure 5 shows where the main regeneration projects are planned in the borough and how many additional people are expected to move into these areas. Barnet has the second highest number of people over 65 in Greater London. There has been a steady increase in the number of people who are living to the age of 75 years in Barnet, and this growth will be compounded when the post war generation (referred to as the baby boomers) will, by 2020, begin to reach 75 years old. Associated with this will be an increase in the number of older people from Black and minority ethnic groups, with the sharpest increase expected to occur in Indian, Chinese and Black African groupsii . 6
  • 14. At the same time, the number of people living beyond 85 years of age is set to increase. GLA projections for the years 2007 to 2017 shows an increase of approximately 1,100 people. Although this increase is small, in terms of overall population growth, there will be a significant impact on the demand for services, due to the higher number of complex high-dependency conditions more frequently found in this age group. However, this projected increase in older people aged 85+ years is expected to occur only in 11 out of 21 wards. The biggest absolute increase is expected in Colindale (131) and West Hendon (113). Figure 6 and Table 2 show the ONS projections for the 65, 75 and 85 + age groups for the years 2004 to 2029. Figure 6 Estimate of the population growth in the 65, 75 and 85+ year old age groups (000’s) 2004-2029 Source: Office for National Statistics Table 2: Estimate of the population growth in the 65, 75 and 85+ year old age groups (000’s) 2004-2029 Age 2004 2005 2006 2007 2008 2009 2014 2019 2024 2029 65+ 45.5 45.5 45.4 45.2 45.5 46.1 50.3 53.9 58.7 65.1 75+ 22.8 23.0 23.3 23.2 23.2 23.3 24.3 25.6 29.5 32.4 85+ 6.6 6.8 6.9 7.0 7.1 7.2 7.6 8.3 9.4 10.5 As the population for older people increases, so will the number of older people living on their own. Approximately 18,000 (31%) of older people in Barnet live alone and due to a higher rate of divorce in the 50+ age group the number of older people living alone is set to increase. Older people who live alone, and who are in poor health, are more likely to require help from sources other than their family. Social changes of this nature are very likely to increase the demand for social care and health services. However, there is strong evidence that social networks make a contribution to healthy ageing. Creating the opportunities for people to socialize and to become involved in local voluntary 7 0 10 20 30 40 50 60 70 2004 2005 2006 2007 2008 2009 2014 2019 2024 2029 65 years+ 75 years+ 85 years+ Projectedpopulation(thousands) ineachage-group 0 10 20 30 40 50 60 70 2004 2005 2006 2007 2008 2009 2014 2019 2024 2029 65 years+ 75 years+ 85 years+ 65 years+ 75 years+ 85 years+ Projectedpopulation(thousands) ineachage-group
  • 15. networks will be an important factor in prolonging the well-being and independence of older people who live alone. During 2005, the Office for National Statistics announced that life expectancy at the age of 65 was at its highest ever in the UK and that, on average, men aged 65 could expect to live a further 16.6 years, and women a further 19.4 years, if mortality rates remain the same as they were in 2003-05. Women will continue to live longer than men, but the gap has been closing in recent years. In 1983-85 there was a difference of 4 years between male and female life expectancy at age 65 in the UK (13.2 and 17.2 years respectively). By 2003-05 this had narrowed to 2.8 years. The implication of this is that historically women have spent a larger proportion of their final years in poor health. This difference in the number of years over which, older males and females experience poor health may become less obvious as life expectancy for men increases. On the other hand, as more people can be expected to live beyond 90 years of age, so an increase in the prevalence of limiting long-term conditions is also very likely to increase. Audit Commission data shows that 15% of residents aged over 60 years of age live in households that are income deprived. This is slightly higher than the national mean and is near the average for London, where the range is 23.1% (Brent) and 9.9% (Bromley)iii . A Joseph Rowntree Foundation study of the material resources of older people found that women, persons living alone, those that are widowed, divorced or separated, poorly educated are disproportionately represented in the lower socio-economic groups and to be in poor health.iv A recent analysis of the location of people aged 85+ shows there are pockets of older people at a variety of locations within the borough. This is significant in terms of the targeting of selected geographical areas to reduce the impact of undue poverty on the demand for social care and health services due to: social isolation, depression, poor nutrition or hypothermia. 2.1.1 What are the implications of these population changes? More people will require more services as Barnet’s population grows and they will need different services at different ages. For example, Figure 4 shows that Barnet is expected to have more children and women of childbearing age in the next few years. This means that there will be a need for more family planning and sexual health services; more maternity services; more pre-school provision; more school places; and more health and social care for children and families. To enable the increased number of adults in this age-group to be better able to support themselves and their families, the borough will also need to encourage and enable more employers to offer job opportunities. However, the biggest change in Barnet’s population will be in the number of people aged 45-64 years. This ‘middle-age spread’ will have particular significance for long-term conditions: these people are the most likely to develop obesity, raised cholesterol, high blood pressure, diabetes, stroke and heart disease. Addressing this issue is important if we are to use the resources available to the commissioners and providers of health and social care effectively. In his final report on the nation’s health in 2004, Derek Wanless predicted that the proportion of the country’s wealth required to fund the health system would rise inexorably unless both the population and the health and social care services became ‘fully engaged’ in health improvement: an additional £30bn would be required each year by 2022, for example.v 8
  • 16. Wanless described three ‘scenarios’, one being of ‘slow progress’ in both the general public and the NHS being involved in more health-improving behaviour. He predicted that such ‘slow progress’ will result in the NHS requiring an increasing proportion of the country’s wealth to deal with an increasing amount of illness. This is shown in Figure 7. But much of this illness is avoidable. Wanless’s second scenario, that of ‘solid progress’, showed that there would still be an increasing amount of the country’s wealth required to support health care but this would be much less after about 2012. However, significantly, Wanless predicted that with ‘full engagement’ by both the general public and the NHS in health-promoting behaviour, the proportion of the country’s wealth required to support the NHS would level off by 2017. Figure 7: The expenditure required for health care services as a proportion of gross domestic product in each of Wanless’s three scenariosvi Significantly, Wanless observed that “The more engaged [people are in improving their health], the more often people will use primary care and self care as opposed to secondary or acute care…”Error: Reference source not found So, the healthier we become as a result of our own actions and the encouragement and enablement of the health services and local authorities, the proportionately cheaper the NHS will be to provide health care for those who need it. This will reduce the need for higher taxation to support the NHS. 2.2 Housing In the 2001 Census, only 7.3% of Barnet residents described their health as ‘not good’ which is lower than that of both London (where 8.1% described their health as ‘not good’) and England (9.2%). However, there is a clear association between reported ill- health and housing tenure, as shown in Table 3, poorer health is more common amongst those living in social housing. 9 fully engagedslow uptake solid progress 1977-78 1982-83 1987-88 1992-93 1997-98 2002-03 2007-08 2012-13 2017-18 2022-23 5 6 7 8 9 10 11 12 13 ProportionofGDP(%) fully engagedslow uptake solid progress 1977-78 1982-83 1987-88 1992-93 1997-98 2002-03 2007-08 2012-13 2017-18 2022-231977-78 1982-83 1987-88 1992-93 1997-98 2002-03 2007-08 2012-13 2017-18 2022-23 5 6 7 8 9 10 11 12 13 5 6 7 8 9 10 11 12 13 ProportionofGDP(%)
  • 17. Table 3: Reported ill-health in relation to housing tenure Tenure Total households Households reporting ill-health Proportion of households reporting ill-health (%) Owner-occupied, no mortgage 40,576 301 0.74 Owner-occupied, with mortgage 48,434 1,207 2.49 Privately rented 20,371 1,567 7.69 Registered social landlord rented 6.035 536 10.64 Council-owned property rented 11,008 1,684 15.29 Source: London Borough of Barnet Housing Needs Assessment, Fordham Research, 2006 Barnet Council considers that a good quality and secure home provides the basis for good health, and there are a number of ways in which the housing services provided by the council and its partners contribute to this. For example, the council is landlord to some 15,000 tenants and leaseholders, many of whom are on low incomes and are vulnerable. In addition, the council provides about 2,500 temporary homes to homeless people and a housing benefits service to about 27,500 people on low incomes. It is likely that the clients that the council provide services to suffer from a higher incidence of poor health, and the circumstances that lead to poor health. Older people in Barnet make up 21% of the population as a whole and 75% of these households own their own property without a mortgage. Seventy-five per cent of older owner-occupiers live in three or four bedroom properties. Many of these households are asset rich, but cash poor, and struggle to maintain their homes. National research has shown that the majority of older people would prefer to either remain living in their home, or would prefer accommodation which is part of the ordinary housing stock but suitable to meet their needs through design. Older people increasingly expect a high standard of accommodation, with a spare room for visitors, a study and car parking facilities. Leasehold sheltered/retirement housing in Barnet is generally provided by the independent sector, where existing properties tend to be in the more affluent areas of the Borough. A number of new schemes are planned and this may be an indication that the supply is not yet sufficient to meet demand. People moving into such schemes are likely to be downsizing from larger properties, and therefore access to funding is not significant issue. What may be significant is the type of support and care that is based on site in the private schemes and a comparison with the type of product on offer for tenants in terms of care and support and where possible the strategy needs to refer to the research being carried out by the independent sector and /or commission A survey by Housing Needs Survey (HNS) found that 5.7% of single pensioner and 8.1% households were living in unsuitable housing. The main reasons for unsuitability were described as accommodation being too expensive, restricted mobility which may be due to health reasons and the accommodation being subject to major disrepair or unfitness 10
  • 18. these were some of the issues identified. Another issue which affected older people was they were experiencing difficulty maintaining their home. In 2006, the HNS survey data revealed that fewer than 5% of older people living in the borough had difficulty maintaining their home, and they defined this as a problem. In addition 0.48% indicated that this was a serious problem. A major concern for older people during the winter months is the ability for them to keep warm during the winter months. This is highlighted annually when the Department of Health campaign Keep Warm Keep Well is aimed at financially disadvantaged older people or disabled people and their carers. Nevertheless, it is worth noting the number of older person households without central heating. Table 4 indicates the figures collected at the last census. The proportion of such households was just over 7%. 1 Table 4: People aged 65 and over by age (65-74, 75-84, 85 and over) living in a dwelling with no central heating, year 2001 Total 65 and over population Number of 65 and over population with no central heating Percentage of 65 and over population with no central heating (%) People aged 65-74 22,809 1,392 3.06 People aged 75-84 15,626 1,207 2.65 People aged 85 and over 7,059 626 1.38 Total population aged 65 + 45,494 3,225 7.09 Figures may not sum due to rounding. Crown copyright 2007 Figures are taken from Office for National Statistics (ONS) 2001 Census, Standard Tables, Table SO54 Shared / unshared dwelling and central heating and occupancy rating by age. Figures in this table have not been projected forward as the figures would not be reliable. Barnet’s Sustainable Communities Plan recognises the council’s contribution to improving the health and well being of its residents needs and to focus on three areas:  health improvement;  improving access to quality health services; and  reducing unscheduled care. Table 5 sets out some of the existing contributions that Housing Services in Barnet make towards some of the borough’s health priorities and identifies areas for further work. 1 The number of council homes without central heating will have reduced through the decent homes programme. The private sector stock condition survey due late 2008 will provide an update. 11
  • 19. Table 5 Current and potential contributions by Housing Services in Barnet to improving health Health improvement Existing Activities Potential Tackle environmental factors underlying health and well being  Decent Homes Programme (includes HH&S legislation assessment on safety within the home)  Estate Regeneration Schemes  Improvements to thermal efficiency of council dwellings  Tackling decent homes in the private sector, inc. improvements to thermal efficiency  Housing Health and Safety Rating System to tackle poor housing conditions in the private sector  HMO registration scheme  Providing more suitable temporary accommodation for households with dependant children.  Reducing the use of temporary accommodation  Working with Housing Associations to provide high quality new affordable homes  Application of lifetime homes standard for new homes Health Promotion/Education  West Hendon Healthy living Day July 07  Barnet Homes Healthy eating programme  Fire safety campaigns (LPSA concluded March 06)  Barnet Homes Health and Safety Promotion (Nov 06)  Targeted campaigns/information using Barnet Homes tenant newsletter and other communications (inc. translations and interpreting as appropriate) Table 5 continued Health improvement 12
  • 20. Existing Activities Potential Supporting Healthier Life Styles  Barnet Homes Gardening Scheme  West Hendon healthy sports weeks in August 07 for under 11's  Barnet Homes Silver Surfers Scheme  Barnet Homes Youth Group Dancing  Analysis of correlation between poor health and social housing  Research into access to health services and physical activity Improving access to quality health services Champion the Needs of Local Communities  Older persons housing needs strategy group (includes representation from the PCT)  Tenant/Leaseholder consultation framework  Residents associations Use Planning policy to support PCT Community and Primary Care developments  Consultation with residents on regeneration estates on planned health facilities Targeted Client Groups  Falls prevention in sheltered housing  Exercise classes in sheltered housing  Nottingham University project on water softeners and eczema  Development of Sheltered Housing as community resource  Providing better information on local health services to homeless people and new tenants  Identify specific needs of BME communities Reducing unscheduled care Improved planned care  Adaptations Reduce unscheduled care  Lifeline and Telecare schemes  Housing Support Officers  Fire safety checks carried out 13
  • 21. by Barnet Homes 14
  • 22. 2.3 The effect of deprivation and ethnicity on health Data from the decennial census are used to construct an ‘index of multiple deprivation’. This includes factors such as employment status, the proportion of working age adults with no or low qualifications, household overcrowding, houses without central heating. The relative levels of deprivation in Barnet’s 21 electoral wards is shown in Error: Reference source not found. There is a close relationship between poor health and deprivation. This is shown clearly by death rates in people aged under 75 years, as shown in Figure 9. Figure 8 Relative deprivation levels in Barnet at an electoral ward level Source: Office for National Statistics data 15 Edgware Hale Burnt Oak Colindale West Hendon Golders Green Childs Hill Hendon Garden Suburb Finchley Church End East Finchley Mill Hill Totteridge West Finchley Woodhouse Coppetts Underhill Oakley Brunswick Park East Barnet High Barnet Index of Multiple Deprivation (2007) Very high High Moderate Low Very low Edgware Hale Burnt Oak Colindale West Hendon Golders Green Childs Hill Hendon Garden Suburb Finchley Church End East Finchley Mill Hill Totteridge West Finchley Woodhouse Coppetts Underhill Oakley Brunswick Park East Barnet High Barnet Edgware Hale Burnt Oak Colindale West Hendon Golders Green Childs Hill Hendon Garden Suburb Finchley Church End East Finchley Mill Hill Totteridge West Finchley West Finchley WoodhouseWoodhouse Coppetts Underhill Oakley Brunswick Park East Barnet High Barnet Index of Multiple Deprivation (2007) Very high High Moderate Low Very low Index of Multiple Deprivation (2007) Very high High Moderate Low Very low
  • 23. Figure 9: The relationship between death rates in people aged under 75 years and deprivation levels at an electoral ward level. Figure 9 shows that in areas with a higher deprivation score, death rates are correspondingly higher. However, these data have been compiled at an electoral ward level. If one looks at census ‘super output areas’, i.e. subdivisions of electoral wards, it is apparent that the borough is a patchwork of different levels of deprivation.2 This is shown in Figure 10. Many of the more deprived areas shown in Figure 10 coincide with housing estates and areas of social housing. As will be seen in section 3.4.6, focusing on these small areas of relatively high deprivation is more likely to enable commissioners of health and social care services to improve people’s health: it is here that, generally, more people with more poor health risk factors live, and many of these people are less likely to recognise any need to do anything to address these. Recently published government data shows that Barnet is more deprived in relation to other local authority areas than in 2004. It now has six census superoutput areas that are in the most deprived centile3 in the country; previously there were none. It is difficult to make exact comparisons in deprivation between different years because the precise way the government defines its index of multiple deprivation (IMD) changes, although these changes are not necessarily great. The IMD consists of a number of measures including some from the census; some from educational data (e.g. average 2 Census data is compiled from individual household returns. Much data is collated into electoral wards, but some is made available at sub-ward (‘census super output’) level. In Barnet, an electoral ward covers an average population of about 15,000 people. The average super output area covers some 1,500 people. Analysis at this scale shows that deprivation, for example, is not confined to large areas in limited parts of the borough but that there is a patchwork of deprivation and affluence of different degrees nestled together across the borough. That said, there is a greater preponderance of deprivation in certain areas and wards. Deprivation tends to be highest in certain estates, such as Grahame Park, Brunswick Park and Stone Grove. 3 A centile is a group of ten. Proportions can be expressed as percentages, i.e. as a number of one hundredths. The metrics being measured, e.g. people’s height, the proportion of children achieving 5 grade Cs in GSCE exams can be ranked in numerical order and then grouped in a number of ways, such as in tenths 16 400 500 600 700 800 900 1000 1100 1200 1300 10 15 20 25 30 35 Index of Multiple Deprivation (2007) Standardisedall-causemortalityinpeople agedunder75yearsper100,000 400 500 600 700 800 900 1000 1100 1200 1300 10 15 20 25 30 35 Index of Multiple Deprivation (2007) Standardisedall-causemortalityinpeople agedunder75yearsper100,000
  • 24. test scores at Key Stage 4 and GCSE results); data on road traffic accidents; modelling to estimate ‘difficulty of access to owner-occupation; measures of the proportion of households for whom a decision has been made on applications for homeless provision assistance; and health data including GP prescribing data, hospital episode statistics, and average distance from a GP surgery. The new figures show Barnet to be more deprived than in 2004 in relation to other boroughs in both London and England. This worsening is the largest such change nationally. Of 354 English local authorities, Barnet now ranks the 128th most deprived (65 more so than in 2004) and 21st out of the 33 London boroughs, three places worse than in 2004 (1 = most deprived). Barnet is thus more deprived than most local authorities in England but less deprived than most London ones. It is important to note that the change in Barnet’s position is relative because the measures used have been changed. It does not necessarily mean that Barnet has become more deprived in absolute terms; it is possible that Barnet is becoming less deprived but that other boroughs are improving at a greater rate. Figure 10: Relative deprivation levels in Barnet at census superoutput area level Source: Office for National Statistics data 17
  • 25. Whenever new data show something surprising it is necessary to question their accuracy and then to look for other possible causes. Possibly the most significant factor to consider is the actual population. As most measures are based on the actual number for each metric divided by the borough’s population, an artificially low denominator population will tend to increase the measure and an artificially high one will tend to decrease it. Any measure based on census returns will become increasingly inaccurate over time (e.g. the number of people living in overcrowded premises, the number of people with no or low qualifications), as will any modelling based on such data, e.g. the Table 6 shows the relative changes that occurred in the main measures of deprivation in Barnet between 2004 and 2007. Table 6 : Average ranks in different deprivations measures at superoutput level IMD measure Average rank of Barnet’s superoutput areas (out of 32,482 nationally) NOTE 1 = most deprived Change: 2004 to 2007 2004 2007* Barriers to housing and services (wider) [including the proportion of households for whom a decision has been made on applications for homeless provision assistance] 4,916 1,012 3,904 Living environment (outdoors) [incl. air quality, road traffic collisions] 7,963 7,449 514 Crime [burglary, violence, theft, criminal damage] 15,075 12,959 2,116 Income [recipients of means-tested benefits] 16,127 15,021 1,106 Living environment (indoors) [incl. social & private housing in poor condition, houses without central heating] 16,566 16,319 247 Employment [Jobseekers Allowance and Incapacity Benefits claimants, New Deal Scheme participants] 20,461 18,741 1,720 Barriers to housing and services (geographical) [incl. distance from services, e.g. GP surgery, post office] 19,217 18,787 430 Health and disability [incl. hospital statistics.] 23,767 23,193 573 Education (skills) [proportion of working-age adults with no or low qualifications] 26,684 26,703 + 19 Education (children and young people) [incl. Key Stage scores and staying-on rates] 23,419 31,350 + 7,931 Average rank (out of 32,284) 18,755 14,610 4,145 * Where the ranking for 2007 has become smaller this reflects a worsening of the position, i.e. a move towards higher deprivation. The data in Table 6 suggest that, over the last three years, deprivation in Barnet has increased especially, albeit not to a great extent, in terms of more applications for homeless provision, an increase in crime and fewer people being in employment. On the other hand, educational achievements have improved by a relatively large amount. 18
  • 26. These changes, which affect a number of superoutput areas rather than the whole borough, are unlikely to be especially significant in terms of the need for future health and social care services unless there are further changes in the same direction. 2.3.1 The effect of ethnicity on health Barnet is the twentieth most ethnically diverse borough in England with 31.5% of its residents belonging to Black and minority ethnic groups. This is an increase of 5.5% since 2001, a trend that is projected to continue, with 35.7% of the population belonging to a Black and ethnic minority group by 2017. Error: Reference source not found shows the relative proportions of people in Black and minority ethnic groups in different parts of the borough. Figure 11: The proportion of people from Black and minority ethnic groups as a proportion 19 Edgware Hale Burnt Oak Colindale West Hendon Golders Green Childs Hill Hendon Garden Suburb Finchley Church End East Finchley Mill Hill Totteridge West Finchley Woodhouse Coppetts Underhill Oakley Brunswick Park East Barnet High Barnet Proportion of ward population from Black and minority ethnic groups (%) >29 27 – 29 26 – 27 21 – 26 11 – 21 Edgware Hale Burnt Oak Colindale West Hendon Golders Green Childs Hill Hendon Garden Suburb Finchley Church End East Finchley Mill Hill Totteridge West Finchley West Finchley WoodhouseWoodhouse Coppetts Underhill Oakley Brunswick Park East Barnet High Barnet Proportion of ward population from Black and minority ethnic groups (%) >29 27 – 29 26 – 27 21 – 26 11 – 21 Proportion of ward population from Black and minority ethnic groups (%) >29 27 – 29 26 – 27 21 – 26 11 – 21
  • 27. People from Black and minority ethnic groups often have different health needs. There are several reasons for this. Some diseases are relatively specific to certain ethnic groups. For example, sickle cell disorder (a disease affecting the haemoglobin in red blood cells) occurs mainly in people in Black ethnic groups, whilst thalassaemia (a different condition affecting haemoglobin) mainly occurs in people from Asian and Mediterranean (especially Greek and Turkish) ethnic origin. Another example of a disease affecting people differently is diabetes. This is more common amongst people from Asian and African-Caribbean ethnic origin,vii and death rates from the disease and from its complications is higher in these people. Similarly, high blood pressure and one of its most important complications – stroke – is more common amongst people of Black ethnic origin.viii,ix Such people are also more likely to die if they have a stroke, making the control of high blood pressure all the more important,x but cultural differences also mean that different approaches are needed in addressing these issues in different groups.xi Two aspect of mental health, and thus the type of care that is needed, are especially noteworthy in the context of ethnic differences. Schizophrenia is diagnosed more commonly in people of African Caribbean origin than in people from other ethnic groups.xii And rates of suicide and of deliberate self-harm are higher among young Asian women than in the White population.xiii It is not clear why these differences occur, but they do reflect the need for services to be both flexible and culturally sensitive. Another reason that people from Black and minority ethnic groups have different health and social care needs is because, for many of them, their cultural values and religious beliefs are different from those of the indigenous population. A further aspect of this is the different incidence of certain diseases in their countries of origin. For example, breast cancer is relatively uncommon amongst Asian women in the sub-Asian continent but its incidence among them rises when they emigrate to the west. In addition to having different cultural values and beliefs about cancer, they may also consider themselves to be at low risk of breast cancer because it was an uncommon disease amongst their parents’ and grandparents’ contemporaries. This has implications for how breast screening services are organised and promoted. A number of other issues affect the health and social care needs of people from Black and minority ethnic groups. For many, English is not their first language, so they may not understand some of the nuances of English any more than those whose first language is English would understand theirs. And many refugees and asylum seekers are escaping repression and/or physical abuse or worse and are reluctant to seek help from ‘officials’, including people in the health and social care services. The effect of this is that a ‘traditional’ approach by health and social care services is unlikely to serve them in the best way. But a service that is better orientated towards their values can be. This means that services need to be developed at a local level – and to engage community leaders – if we are to provide care in a way that can be used effectively. In Barnet, the largest numbers of people from Black and minority ethnic groups are Asian and Black African. Whilst a proportionately small group, Barnet is home to the largest Chinese population in London. And, although a religious rather than an ethnic group, Barnet is home to the largest Jewish population in the country. 20
  • 28. 2.3.2 Other aspects of diversity There are six equality and diversity ‘strands’. These are:  age;  gender;  ethnicity;  disability;  religious belief; and  sexual orientation. There is legislation requiring those providing public services to take reasonable steps to avoid direct and indirect discrimination on the grounds of age, gender, ethnicity and disability. There is also an increasing expectation that those providing public services should also avoid direct and indirect discrimination on the grounds of religious belief and sexual orientation. Most people can imagine examples of direct discrimination, for example refusing to provide someone with a service because of their ethnic group, or refusing to employ someone (irrespective of their ability) because of their age. Indirect discrimination is less easy to understand but can be equally unfair. For example, providing information in leaflets in a small typeface could indirectly discriminate against people with visual disability: they may be unable to read it; placing lift controls high up could discriminate against wheelchair users: they may be unable to reach the higher buttons. Monitoring potential discrimination can, in part, be achieved by recording different factors about people, e.g. age, gender, ethnicity and then checking to see what proportion of people with these different factors are accessing services, or being offered jobs. There are several problems with this, however. the first is that such data have not been routinely collected in the past and, for some equality strands, are still not routinely collected, e.g. sexual orientation. In part this is because it has not been recognised as an issue, and in part it is because some people are embarrassed to ask. The second is that it is not always apparent what the relevance of such data might be. Whilst one may assume that the use of particular services should be the same for people in a proportion that is equal to their representation in the population is this always the case? Some diseases are more common in one gender, for example gallstones in women and abdominal aortic aneurysms in men. Some conditions are more common in some ethnic groups, e.g. diabetes in Asians and high blood pressure in African-Caribbeans. However, it is also more common, proportionately speaking, for Black Africans, and especially African-Carribeans to be compulsorily admitted to mental health units, yet it is unclear if people from these ethnic groups have a predisposition to severe mental illness or are more likely to be diagnosed with a severe mental illness perhaps because of some cultural difference. 2.4 Employment Nearly three-quarters (72.8%) of people aged 16 years and over in Barnet are economically active, which is slightly less than the London average (75.2%) and the national average (78.7%).xiv This may be a reflection of education in Barnet and more students staying on to take higher qualifications: in 2007, only 11.2% of Barnet’s 21
  • 29. population had no qualifications, whilst the London average was 12.8% and the national average was 13.1%xv . In 2006, 54.4% of Barnet’s working-age population was qualified to NVQ Level 3 or higher and 39.3% to Level 4 or above. Barnet Council is committed to increasing this still further and has included this as a target in the 2008-11 Barnet Local Area Agreement with the Government Office for London. It is also noteworthy that, on average, Barnet residents earn more than the national average, albeit less than the London average. This is shown in Table 7. Table 7: Gross weekly pay by residence (2007) Barnet (£) London (£) Great Britain (£) Full-time workers 548.90 553.30 459.00 Male full-time workers 626.10 596.00 500.70 Female full-time workers 479.10 506.00 394.80 Source: Office for National Statistics There are proportionately more male Barnet residents who are economically active than female (78.2% vs. 67.2%) and this also differs from the London average (82.1% vs. 67.7%) and the national average (83.3% vs. 73.7%). Again, as the definition of being economically active includes all people aged 16 and over, this is likely to be related to those still in education in Barnet, and the gender difference is likely to reflect a higher proportion of women being in child and adult carer roles. In 2001, 27% of people aged between 60 and 74 years were in work. Recent changes in employment legislation mean that people need not retire at 65, but the effect this will have remains to be seen. It is not unreasonable, however, to assume that older people on low incomes, or who have poor pension prospects, will work on and that the income will be used for essential expenses, rather than improved quality of life. However, in parts of Edgware, Colindale, Burnt Oak, Brunswick Park and East Finchley, more than 25% of the working-age population relies on state benefits. Barnet Council is committed to reducing this and has included this as a target in the 2008-11 Barnet Local Area Agreement. There is also a close relationship between deprivation and higher proportions of people being on state benefits. Barnet council aims to assist young people to access a broad range of education, training and employment opportunities through targeted support and improved access in order to develop and broaden their skills. ONS data for economic activity in Barnet shows that between April 2006 and March 2007 Barnet’s rate (75.8) was slightly higher than the rest of London (75.0), but lower than England (78.6). There is a similar trend for employment rate Barnet (71.2, London (69.3) and England (78.6). The unemployment rate in Barnet (6.2) is therefore lower than London (7.6), but higher than for England (5.5) 22
  • 30. Figure 12: Trend in people aged 16-24 years claiming Jobseekers Allowance in Barnet 0 200 400 600 800 1000 1200 1400 2001 2002 2003 2004 2005 2006 2007 Source: Office for National Statistics Figure 13: Trend in people aged 16-24 years claiming Jobseekers Allowance in London 0 5000 10000 15000 20000 25000 30000 35000 40000 45000 50000 2001 2002 2003 2004 2005 2006 2007 Source: Office for National Statistics Figure 14: Trend in people aged 16 -24 year old claiming jobseekers allowance in England 0 50000 100000 150000 200000 250000 300000 2001 2002 2003 2004 2005 2006 2007 Figure 12, Figure 13 and Figure 14 show trends people aged 16-24 years claiming Jobseekers Allowance in Barnet, London and nationally. It appears that Barnet is following a similar trend to London and that, at present, there is no real evidence that any relative increase in deprivation in Barnet (see section 2.3 and Table 6) in terms of unemployment amongst younger people. 23
  • 31. 2.5 Crime Crime has a harmful effect on communities both through its actual impact and fear of becoming a victim. Currently, fear of crime exceeds the chances of becoming a crime victim. Barnet council has prioritised activities to reduce crime and reassure the community that crime is being tackled. Crimes that cause the most concern in the community are: alcohol disorder; household burglaries; young people as offenders and victims of crime; robbery; motor vehicle crime; violent crime; and drugs. Figures 15 and 17 shows the crime trends in London, whilst figures 16 and 18 show the crime trends in Barnet. Most types of crime are reducing, although there is little change in burglary, and drug-related crime continues to increase. Figure 15 Crime trends in London Figure 16: Crime trends in Barnet from 2004 to 2008 0 1000 2000 3000 4000 5000 6000 7000 8000 Violence against Person Burgulary Offences against Vehicles Criminal Damage Drug Offences 2004/5 2005/6 2006/7 2007/8 24 0 50000 100000 150000 200000 250000 Violence against Person Burgulary Offences against Vehicles Criminal Damage Drugs 2004/5 2005/6 2006/7 2007/8
  • 32. 2.6 The views of local residents A wide range of consultations and Citizen’s Panel surveys are undertaken in Barnet. The Citizen’s Panel consists of a ‘core group’ of 1,000 residents aged 18 year s and over, and a ‘hard-to-reach group’, the latter being residents who are traditionally viewed as being less likely to take part in this type of consultation exercise. The core panel is intended to be representative of the adult population of the whole borough based on ward, age, gender, ethnicity, disability and socio-economic status and was recruited by rando selection across all wards from the Local Land and Property Gazetteer by telephone and by face-to-face approach on Barnet’s streets. Hard-to-reach groups consist of 150 people from Black and minority ethnic groups recruited via postal survey targeting ethnic groups within electoral wards (super output areas) and targeted face-to-face interviews, and 100 residents with long-term illnesses or disability recruited through postal surveys, targeted face-to-face interviews and through Barnet Voluntary Service Council, Barnet's umbrella group for voluntary organisations. The Citizens' Panel response rate to being surveyed is 42%, which is above the average for postal surveys. Barnet PCT has also undertaken consultations concerning proposals to develop clinical services at Barnet and Chase Farm hospitals and proposals for London-wide health services development. These surveys were undertaken in shopping malls and centres, special public meetings and at the Friern Barnet Show. Seven hundred and forty two residents also completed a Better Health for Barnet survey this year. More women responded than men (67% vs. 28% [note that the respondent’s gender was unrecorded in 5% of cases]) and this varies slightly from the proportion of men and women in Barnet’s population (52% vs. 48%). The proportion of people in different age groups, in comparison with the proportions in Barnet’s population, is shown in Table 8. Table 8: Ages of respondents to the Better Health for Barnet survey and the proportion in Barnet’s population Age group Under 25 25-34 35-44 45-54 55-64 65 and over Not stated Number of respondents 123 74 120 90 103 201 19 Proportion of all respondents 17% 10% 16% 12% 14% 28% 3% Number in Barnet’s population 105,400 53,600 54,000 42,000 33,600 46,000 - Proportion of population 31.5% 16% 16% 12.5% 10% 14% - Table 8 shows that there were proportionately fewer younger respondents and proportionately more older respondents than in Barnet’s population. 25
  • 33. The proportion of people in different ethnic groups, in comparison with the proportions in Barnet’s population, is shown in Table 8Table 9. Table 9: Ethnicity of respondents and the proportion in Barnet’s population Ethnic group White Black or Black British Asian or Asian British Mixed Chinese Other Not stated Number of respondents 473 81 107 17 9 18 37 Proportion of all respondents 64% 11% 15% 2% 1% 2% 5% Number in Barnet’s population 228,263 28,280 49,302 Not 8,606 20,150 - Proportion of population 68% 8% 15% Collected 3% 6% - Table 9 shows that respondents were reasonably representative of Barnet’s population in terms of ethnicity. Of those who answered the question, out of 742 respondents, 103 said that they were registered disabled and 533 said that they were not. An Ipsos MORI survey was also undertaken on proposals for developing London- wide health services following the publication of Lord Darzi’s report Healthcare for London: A Framework for Action. The report described changes to services from a patient’s view point to make them safer and more accessible. Again, and out of 140 respondents, more women than men responded (66% vs. 33%) but there was a different age distribution, as shown in Table 10: Ages of respondents to the Healthcare for London survey Age group Under 25 25-34 35-44 45-54 55-64 65 and over Number of respondents 5 18 29 26 29 34 Proportion of all respondents 4 13 21 18 21 24 There was a slight, relative under-representation of White people amongst respondents, but otherwise they were broadly representative of Barnet’s population from an ethnicity perspective. Twenty-three respondents stated that they were registered disabled. A health survey was also undertaken in Hendon, but as there were only 44 respondents, this cannot be considered to be representative of local residents in that area. 26
  • 34. 2.6.1 Travelling further for GP services Respondents were asked if they would be prepared to travel a little further to see a GP, if they were able to receive a wider range of services, including blood tests, outpatient clinics and other specialist clinics and a majority said that they would be or might be willing to do so, as shown in Table 11. Table 11: Willingness of respondents to travel further for a wider range of GP and specialist services Yes No Maybe No Response 316 247 146 33 43% 33% 20% 4% Specific comments from respondents who indicated that they are prepared to travel included:  To reduce waiting times for appointments e.g. blood tests, I don't mind travelling a little further  Most important that you receive the care you need even if it means travel  It should reduce the number of visits and time needed  As a diabetic pensioner, these services seem appealing  Having one visit rather than multiple  I would travel further if I knew I would receive a better service with more on offer  Providing I saw my same doctor each time and it was run on the lines of a good practice with added services Specific comments from respondents who indicated that they were NOT prepared to travel included:  Local should be better  Too difficult to get there, do not want to travel further  I have a good GP service, and wouldn't want to change it.  I do not want to lose the relationship I have with my GP who is aware of my illness and knows me.  Perfectly satisfied with current pattern of hospital services.  We are happy with the excellent service provided in our practice.  Too old to make travelling an option. 2.6.2 Respect and Dignity Respondents were asked who they would contact if they had a concern about health services. 27
  • 35. Table 12: Responses to the question ‘Who would you contact if you had a concern about health services? Other responses included: teacher, local medical committee, British Medical Association, Genera; Medical Council, receptionist, police, newspaper, NHS Direct. It is noteworthy that no one said that they would contact the Patient Advice and Liaison Service (PALS), which is present in every PCT, acute and mental health trust and which receives a large number of contacts from patients and relatives. It seems that there is still some way to go in helping people to understand how to engage with the health service. It is noteworthy that three respondents stated that they would not complain because they were afraid and felt vulnerable; this was because they still were required to see the health professional for their care. One stated “it might rebound on me (being punished).” Another stated that she would not know who to complain to and that “access to such contacts has proved very difficult in her experience.” Whilst one respondent said “I wouldn’t really mind how I was treated. I’m grateful to have them treat me anyway. The responses by people from Black and minority ethnic groups were generally the same as those from White ethnic groups. 2.6.3 Recent use of NHS services Respondents were asked if they had used particular NHS services in the preceding 12 months. The responses are shown in Table 13. 28 Manager Don’t know PCT Chief Exec GP or Doctor Matron / Ward Sister PALS Relative / Friend 128 82 78 77 71 66 35 17% 11% 11% 10% 10% 9% 5% MP Complaints Dept Wouldn’t Social Services Voluntary Organisation Other Did not answer 18 14 12 8 8 25 120 2% 2% 2% 1% 1% 3% 16%
  • 36. Table 13: Responses to the question ‘Have you or your family used any of the services below provided by the NHS within the last year?’ Ipsos MORI Better Health in Barnet Number of completed responses proportion of completed responses (%) Number of completed responses proportion of completed responses (%) None of these 40 28 - - Long-term conditions 39 28 109 15 Acute Care 36 26 - - Children and young people 21 15 75 10 Planned Care 16 11 55 7 Maternity and newborn care 16 11 79 11 Staying healthy (e.g. smoking cessation clinics) 13 9 33 4 Mental Health 11 8 50 7 Prefer not to say 9 6 61 8 End of life care 5 4 8 1 A&E - - 254 34 GP - - 584 79 Pharmacy - - 471 64 Dentist - - 307 41 Optician - - 303 41 Walk-in centre - - 222 30 Total sample size 141 742 - indicates that this category was not included in the survey. It is noteworthy that 79% of respondents said that hey had used GP services in the preceding year. This is consistent with research evidence: 80-90% of people have contact with their GP surgery every year. It is also noteworthy that about two-thirds of respondents used a community pharmacy. This is less in keeping with research evidence that shows that people use community pharmacies more frequently than GP surgeries. It is possible that respondents in this survey were referring to seeking health advice from pharmacists whilst other research has identified people using pharmacists for any purpose. However, the key point is that most people use primary care services rather than specialist secondary and mental health care services. 29
  • 37. 2.6.4 Maternity and Newborn Care The Healthcare for London survey found that a number of factors were important to users of maternity services. These are shown in Table 14. Table 14: Relative importance of different aspects of maternity services to service users Number of responses Proportion of all responses (%) Giving birth in a midwife-led unit with a doctor- led unit on the same hospital site 40 58 Having a senior doctor present on the unit where you will give birth 39 57 Being given a choice of home birth 29 42 Time taken to travel to the place where you will give birth 29 42 Giving birth in a doctor-led unit in a hospital 21 30 Giving birth in a midwife-led unit in the community 14 20 The survey also found that women preferred to see their midwives at home for an appointment after the birth of their baby 45 (65%) rather than travel to their GP or health clinic for an appointment 17 (25%), even if midwives could spend more time with them at the GP surgery or health clinic. Healthcare for London informed respondents that the majority of care for children, including urgent care would continue to be provided locally. However, it was proposed that specialist care for children would be concentrated in hospitals with specialist child care units, which would mean that they could be situated further away from some people’s homes. Table 15 shows the responses to this proposal, which seem to suggest that people’s views were split equally on this issue. Table 15: Views on the proposal to site some child care services in specialist units Number of responses Proportion of all responses (%) Strongly agree 11 12 Tend to agree 35 39 Neither agree nor disagree 11 12 Tend to disagree 17 19 Strongly disagree 12 13 Don’t know 4 4 30
  • 38. 3 Improving health and wellbeing: enabling healthy choices for a healthy life, and supporting independence and building resilience 3.1 Introduction In this section we look at how we can improve our health and wellbeing by focusing on our own responsibility to maintain good health. The determinants of health include lifestyle factors such as smoking, physical inactivity and obesity. Barnet Council and Barnet PCT believe that individuals and the community have a key role to play in improving their own health whilst influencing and encouraging the rest of the community to do so, using local networks. The foundations set out in the Government’s White Paper Our Health, Our Care, Our Sayxvi proposed helping people stay healthy and independent whilst providing choice in their care services and to tackle inequalities in health. As a result, Barnet Council and Barnet PCT seeking to commission care that encourages independence, promotes greater choice and that will help communities to develop local networks of support which can improve health and wellbeing, as well as encouraging people to live independently as long as possible. Barnet’s Community Strategyxvii outlines its vision on improving the social, economic and environmental well-being of the borough. It focuses on four key themes:  investing in children and young people  a safer, stronger and cleaner Barnet  growing successfully  a healthier Barnet (including sub theme: older people). The government continues to emphasise the importance of tackling ‘health inequalities’, i.e. significant differences in health and well-being and access to health care that still exist between different groups in our society. There are differences in life expectancy, hospital admission rates, the risk of serious accidents and the risk of death from illness in different parts of the borough. Differences in life expectancies in different parts of the borough are shown in Figure 17. 31
  • 39. Figure 17: Life expectancy at birth by gender and by electoral ward for Barnet Source: London Health Observatory 3.1.1 The main causes of ill-health death The main causes of ill-health and death have changed in the last 150 years from infections such as measles and TB, accidents and malnutrition, to diseases such as heart attack, stroke and cancers. This shift from infectious and respiratory disease deaths to circulatory (principally coronary heart disease and stroke) deaths is shown in Figure 18. 32 Edgware Hale Burnt Oak Colindale West Hendon Golders Green Childs Hill Hendon Garden Suburb Finchley Church End East Finchley Mill Hill Totteridge West Finchley Woodhouse Coppetts Underhill Oakley Brunswick Park East Barnet High Barnet Index of Multiple Deprivation (2007) Very high High Moderate Low Very low 81.5 82.6 83.1 78.9 82.5 75.6 83.8 77.7 82.7 77.8 81.4 76.5 76.0 78.8 82.1 76.7 83.1 79.4 78.2 83.383.3 79.7 81.5 77.3 79.0 84.3 81.0 77.6 82.0 76.0 85.2 82.7 81.0 78.7 84.7 81.4 81.4 75.7 79.7 82.9 79.3 83.4 Edgware Hale Burnt Oak Colindale West Hendon Golders Green Childs Hill Hendon Garden Suburb Finchley Church End East Finchley Mill Hill Totteridge West Finchley West Finchley WoodhouseWoodhouse Coppetts Underhill Oakley Brunswick Park East Barnet High Barnet Index of Multiple Deprivation (2007) Very high High Moderate Low Very low Index of Multiple Deprivation (2007) Very high High Moderate Low Very low 81.5 82.6 83.1 78.9 82.5 75.6 83.8 77.7 82.7 77.8 81.4 76.5 76.0 78.8 82.1 76.7 83.1 79.4 78.2 83.383.3 79.7 81.5 77.3 79.0 84.3 81.0 77.6 82.0 76.0 85.2 82.7 81.0 78.7 84.7 81.4 81.4 75.7 79.7 82.9 79.3 83.4
  • 40. Figure 18: Age-standardised mortality rates for selected broad disease groups, 1911-2003, England & Wales Source: Office for National Statisticsxviii These changes principally come about because of the widespread availability of a clean drinking water supply, the introduction of universal childhood immunisation, better housing and better food. But this has led to diseases related to lifestyle becoming more common. Many years ago, a doctor called Elliot Joslin said, “Genes load the gun, but it’s lifestyle that pulls the trigger”. In other words, many of us may have a genetic predisposition to certain diseases, but how we choose to live our lives will influence whether we develop those diseases or not and, if we do, how severely they will affect us. This is most apparent with smoking, which is the most important preventable risk factor for death from cancer and cardiovascular disease.xix,xx (It is also important to remember that, in addition to the unequivocal evidence that smoking damages the smoker’s health, there is also substantial evidence that exposure to second-hand tobacco smoke (e.g. smoke from other people’s cigarettes) harms non-smokers.xxi,xxii,xxiii,xxiv,xxv ) A further example of the way in which our own lifestyle can affect our health is overweight and obesity. In 2004, a House of Commons select committee noted that ‘On present trends, obesity will soon surpass smoking as the greatest cause of premature loss of life. It will bring levels of sickness that will put enormous strains on the health service, perhaps even making a publicly funded health service unsustainable.’xxvi Overweight and obesity increases the risk of developing diabetes and high blood pressure (itself a risk factor for stroke). Overweight and obesity increases the risk of developing arthritis, especially of the hip and knee. And obesity, a high fat diet and inactivity have also been shown to increase the risk of breast cancer.xxvii,xxviii Error: Reference source not found shows the ‘relative risk’ (i.e. how much more (or less) something is likely to occur) of 33 0 200 400 600 800 1911 1921 1931 1941 1951 1961 1971 1981 1991 2003 circulatory diseases cancers infections respiratory disease Age-standardiseddeathsper100,000 0 200 400 600 800 1911 1921 1931 1941 1951 1961 1971 1981 1991 2003 circulatory diseases cancers infections respiratory disease 0 200 400 600 800 1911 1921 1931 1941 1951 1961 1971 1981 1991 2003 0 200 400 600 800 1911 1921 1931 1941 1951 1961 1971 1981 1991 2003 circulatory diseases cancers infections respiratory disease Age-standardiseddeathsper100,000
  • 41. developing different diseases in people who are obese. For example, Table 16 shows that an obese woman is nearly 13 times as likely to develop diabetes as one who is not obese, and an obese man is three times as likely to develop bowel cancer as one who is not obese. Table 16: Relative risks of health problems associated with obesity in women and men Disease Relative risk (women) Relative risk (men) Non-insulin dependent diabetes 12.7 5.2 High blood pressure 4.2 2.8 Heart attack 3.2 1.5 Cancer of the bowel 2.7 3.0 Angina 1.8 1.8 Gallbladder disease 1.8 1.8 Cancer of the ovary 1.7 N/A Osteoarthritis 1.4 1.9 Stroke 1.4 1.3 Source National Audit Officexxix Another example of lifestyle issues affecting health is the misuse of alcohol. In addition to alcoholic liver disease, alcohol misuse can cause a variety of health and other problems. For example, driving under the influence of alcohol substantially increases the risk of having an accident. Excessive alcohol intake is associated with antisocial behaviour and street violence, as well as domestic violence. Alcohol is implicated in 78% of assaults and 88% of criminal damage.xxx Excessive alcohol intake also affects people’s ability to work and, when it becomes a significant problem, this can often lead to job loss.Error: Reference source not found 3.2 Immunisation 3.2.1 Overview Immunisation is second only to a clean drinking water supply as a way of improving and maintaining the health of the population. Whilst smallpox has been eradicated from the world, by immunisation, all other infectious diseases remain; the only way to protect children and adults from avoidable death and serious, often long-term, complications from such diseases is to maintain high levels of immunisation in the population.4 3.2.2 The risk we face Barnet, in common with all other London boroughs, now faces the likelihood of a measles epidemic. In the last year of so the number of children and adults catching measles – the most contagious disease that there is – has been much higher than in past years and there have been several outbreaks, as shown in Figure 19. 4 The main exception to this is TB. Whilst BCG vaccine is an important way to protect people most at risk the way this disease affects the population has changed. 34
  • 42. Figure 19: The number of reported cases of measles in Barnet in recent years The reason that so many people have caught measles and the fact that we now face the very real risk of a measles epidemic is because there are now so many children whose parents have refused consent for them to be immunised with measles, mumps and rubella vaccine. The ‘herd immunity’ of the population is now sufficiently low to enable each person with measles to infect more than one other person. The problem of measles is more widespread in other parts of London, as shown in Figure 20. Figure 20: Notified cases of measles in London by sector and district between 1 January and 5 July 2008 Source: Health Protection Agency. Measles and MMR uptake in London, 2008 Figure 21 shows how MMR immunisation rates have dropped, more so in London than in the rest of the country. Figure 21: MMR uptake at age 2 years for London and UK – January 1996 – March 2008* 35
  • 43. Source: Health Protection Agency. Measles and MMR uptake in London, 2008 Cover data and trends in vaccine uptake 2005-2008 Figure 22: Immunisation rates in Barnet by children’s fifth birthdays Figure 22 shows the current achievement in immunising children in Barnet for:  first course of diphtheria, tetanus, pertussis and polio;  first dose of Haemophilus influenzae B;  meningococcus C;  first dose of measles, mumps and rubella (MMR);  second dose of MMR; and  diphtheria, tetanus and pertussis and inactivated polio booster. 36 45.0 50.0 55.0 60.0 65.0 70.0 75.0 80.0 85.0 90.0 95.0 Q3 05/06 Q4 05/06 Q1 06/07 Q2 06/07 Q3 06/07 Q4 06/07 Q1 07/08 Q2 07/08 Q3 07/08 Q4 07/08 Q1 08/09 DTP/Polio primary MMR 1st dose Hib primary MMR 2nd dose MenC DTaP/IPV booster % Quarter in each year 45.0 50.0 55.0 60.0 65.0 70.0 75.0 80.0 85.0 90.0 95.0 Q3 05/06 Q4 05/06 Q1 06/07 Q2 06/07 Q3 06/07 Q4 06/07 Q1 07/08 Q2 07/08 Q3 07/08 Q4 07/08 Q1 08/09 DTP/Polio primary MMR 1st dose Hib primary MMR 2nd dose MenC DTaP/IPV booster DTP/Polio primary MMR 1st dose Hib primary MMR 2nd dose MenC DTaP/IPV booster % Quarter in each year
  • 44. This shows clearly that MMR immunisation rates in Barnet are very substantially below the level required for safety, i.e. to avoid measles outbreaks and to avoid a measles epidemic, although they are beginning to increase. 3.2.3 The relationship between diversity and deprivation and infectious disease Data on ethnicity and religious belief are not currently routinely recorded in the context of childhood immunisation. However, it is apparent that in the North East and North central London area, the majority of people affected by measles have been Jewish (see Figure 23). It is not clear why this should be and it is not apparent that this is the case in Barnet. Figure 23: The number of reported cases of measles in North East and North Central London in 2007/2008 by religious/ethnic group (Source: Health Protection Agency) 3.2.4 Local targets In common with other London PCTs, Barnet has agreed to increase all of its childhood immunisations to 90% by 2010/2011. Figure 24 shows the trajectory for MMR, which is the most challenging as all other childhood immunisation rates are currently in the high eighties and thus closer to the target. 37 0 50 100 150 200 250 300 Asian: Pakistani Black: Other Mixed: White & Asian Mixed: White & Black African Not known Chinese Asian: Other Asian: Indian Mixed: Other Mixed Black: Caribbean Asian: Bangladeshi White: Other Any Other ethnic group White: Irish Black: African White: Eastern European White: British Jewish Number of reported measles cases 0 50 100 150 200 250 300 Asian: Pakistani Black: Other Mixed: White & Asian Mixed: White & Black African Not known Chinese Asian: Other Asian: Indian Mixed: Other Mixed Black: Caribbean Asian: Bangladeshi White: Other Any Other ethnic group White: Irish Black: African White: Eastern European White: British Jewish Number of reported measles cases
  • 45. Figure 24: The trajectory for immunisation rates for MMR by the age of two years Source: Barnet PCT Operating Plan 3.2.5 Key things that need to be done The key activities required are:  ensuring the accuracy of immunisation records – it is apparent that a lot of children have been immunised but the fact has not been recorded on the PCT’s child health surveillance system;  bolstering the immunisation call system to ensure that all children who need immunisation (because it is due or have, apparently, been missed) are invited for immunisation;  providing immunisations in various sites, e.g. GP surgeries, community pharmacies, A&E departments, walk-in centres, children’s centres, children’s outpatient departments;  promoting immunisation widely, using social marketing techniques, to better ensure that the right message is received; and  working with local community and religious leaders, and in schools, pre-school facilities, children’s centres, NHS facilities and other places to promote immunisation. 38 73.9 74.5 75.6 76.4 77 80 90 2004_05 2005_06 2006_07 2007_08 2008_09 2009_10 2010_2011 0 10 20 30 40 50 60 70 80 90 100 Proportion(%)of2-yearoldswithfirstMMRimmunisation actual trajectoryestimate 73.9 74.5 75.6 76.4 77 80 90 2004_05 2005_06 2006_07 2007_08 2008_09 2009_10 2010_2011 0 10 20 30 40 50 60 70 80 90 100 Proportion(%)of2-yearoldswithfirstMMRimmunisation actual trajectoryestimate
  • 46. 3.3 Smoking cessation 3.3.1 Overview Whilst immunisation is one of the most significant primary disease prevention activities, smoking cessation is the most significant secondary preventive measure. It is best not to start smoking, but it is never too late to stop: giving up – at any age5 – will lead to health improvement and reduced risk of disease and premature death. Figure 25 shows the estimated prevalence in different London boroughs. Even though Barnet’s smoking prevalence overall is estimated to be only 17.9% and is one of the lowest in London, (see also section 3.4.6), this still means that there are some 60,000 smokers in the borough. Figure 25: The estimated prevalence of smoking in different parts of London Source: Health Surveys for England 2003-2005xxxi 3.3.2 The risk we face Tobacco use is the most important preventable risk factor for death from cancer and cardiovascular disease.xxxii,xxxiii About 2,600 people die in Barnet each year. Of these, about 440 die from smoking-related diseases.xxxiv This is more than from any other cause and these deaths are all preventable. Smoking tobacco causes diseases that affect nearly every part of the body. Smoking is especially damaging to the lining of blood vessels and leads to a reduced blood supply to various parts of the body. It is therefore a leading and avoidable cause of heart attack, 5 About the only exception to this is that if someone is terminally ill, i.e. they are likely to die in the next three months, then stopping smoking (always assuming that they are well enough to smoke) will not lead to any significant health gain. In everyone else, it can be expected to do so, if only by reducing the likelihood of a chest infection 39 0 5 10 15 20 25 30 35 Barking and DagenhamBarnetBexley BrentTeaching Brom leyCam den City and Hackney Teaching CroydonEalingEnfield G reenw ich Teaching Ham m ersm ith and Fulham Haringey TeachingHarrowHavering Hillingdon HounslowIslington Kensington and C helsea Kingston Lam beth Lew ishamNew ham Redbridge Richm ond and Tw ickenham Southw ark Sutton and M erton Tow erHam lets W altham Forest W andsw orth W estm inster Estimatedsmokingprevalence(%)
  • 47. kidney failure, intermittent claudication and impotence. For the same reason, people who are smokers when they have operations are more likely to suffer from wound breakdown and to have delayed bone healing. Among many other conditions caused by smoking are chronic obstructive pulmonary disease (COPD), coronary heart disease, osteoporosis, insulin resistance in diabetes, infertility, age-related macular degeneration (the most common cause of blindness in older people), premature menopause, Crohn’s disease, gastro-oesophageal reflux and peptic ulcers, bone resorbtion and tooth loss, multiple sclerosis, thyroid disease, hearing loss, and liver disease. Women who smoke when pregnant damage the placenta and this leads to a reduced blood supply to their baby. Smoking is also a cause of premature hair loss and premature skin ageing (so children are right: smoking does make you look older). In addition to the unequivocal evidence that smoking damages the smoker’s health, there is now substantial evidence that passive exposure to tobacco smoke harms non- smokers.xxxv,xxxvi,xxxvii,xxxviii,xxxix Second-hand smoke causes lung cancer, coronary heart disease, stroke, asthma attacks, reduced growth of babies in the womb and premature birth, and in children it causes cot death, middle ear diseases, respiratory infections, the development of asthma in those previously unaffected and asthma attacks in those already affected.xl 3.3.3 The relationship between diversity and deprivation and smoking-related disease There are differences in smoking habits between the sexes and between people in different ethnic groups. This is shown in Figure 26. Principally, this is important when planning smoking cessation services. It is important that promotion and provision of such services are culturally appropriate and that smokers see them as relevant to them and not just to others. Figure 26: Current cigarette smoking by ethnic group and sex in England in 1999 Source: Office for National Statisticsxli 40 General population White Irish Indian Pakistani Bangladeshi Black Caribbean Chinese 0 10 20 30 40 50 Proportion of smokers in different ethnic groups (%) Men Women General population White Irish Indian Pakistani Bangladeshi Black Caribbean Chinese 0 10 20 30 40 50 Proportion of smokers in different ethnic groups (%) General population White Irish Indian Pakistani Bangladeshi Black Caribbean Chinese 0 10 20 30 40 50 Proportion of smokers in different ethnic groups (%) Men Women
  • 48. Smoking is more prevalent amongst people who live in deprived areas. Figure 27 shows the differences in smoking habits between people from different social classes; people in routine and manual occupations (and those who are unemployed) are more likely to live in deprived areas than those in managerial and professional occupations. Figure 27: Cigarette smoking by sex and socio-economic classification, adults aged 16 and over, 2006, Great Britain Source: British Heart Foundationxlii As smoking is the cause of so many deaths, and it is more common amongst people living in more deprived areas, an important cause of the differences in death rates between affluent and deprived areas is likely to be smoking. Seeking to increase the proportion and the absolute number of smoking quitters in deprived areas will thus contribute to reducing health inequalities. Finally, deaths from COPD – principally a disease caused by smoking – in Barnet are now higher amongst women than men, and deaths from lung cancer in women will soon become more common than deaths from breast cancer. This is simply because an increasing number of women took up smoking in the 1940s and 1950s: they are now reaping the longer-term consequences of this. 3.3.4 Local targets Figure 28 shows how the number of people quitting smoking through NHS services has increased over the last few years. In 2005/06, Barnet PCT exceeded its target for smoking quitters for the first time and did so again last year. Currently, the PCT is ahead of our quarterly target and should exceed the target for 2008/09. The PCT also has a ‘stretch target’ to enable a higher proportion of smokers in the seven most deprived electoral wards in Barnet to quit smoking. This target was achieved last year and, again, the PCT is ahead of its quarterly target and should exceed the annual one. 41 0 5 10 15 20 25 30 35 Managerial & Professional Intermediate Routine & Manual Men Women 0 5 10 15 20 25 30 35 Managerial & Professional Intermediate Routine & Manual Men Women
  • 49. Figure 28: The number of people quitting smoking through NHS services in Barnet Source: Barnet PCT Stop Smoking Service data returns to Department of Health 3.3.5 Key things that need to be done The key activities required are:  maintaining current performance on smoking cessation;  identifying greater numbers of quitters in more deprived areas and enabling them to quit (see also section 3.4.6);  introducing techniques, such as measuring ‘lung age’ to increase quit rates; and  raising awareness amongst health and social care personnel and the public of the risks of being a smoker when a surgical procedure is required to encourage and facilitate more smokers to quit. 3.4 Coronary heart disease and stroke: preventing vascular disease 3.4.1 Overview Coronary heart disease (CHD) is caused by the progressive narrowing or by the blockage of one or more of the small arteries that supply the muscle of the heart. As less blood gets through these arteries the oxygen supply to the heart muscle is reduced. This causes pain on exertion (angina) and reduces the amount of work that the heart can do. If the narrowing gets too great or there is a sudden blockage caused by a small blood clot the blood supply to a portion of the heart is stopped completely. This is a ‘heart attack’ and, together with stroke, is still the most common cause of death in this country and in Barnet. For example, since 1993, the average number of deaths in Barnet, from all causes, has been 2,840 (it has dropped steadily from 3,130 in 1993 to 2,461 in 2006). The average number of deaths in Barnet each year from heart attack over this time has been 280 (it has dropped steadily from 326 in 1993 to 202 in 2006). Figure 29 shows comparative rates and trends in deaths from heart attack in England and Wales, London and Barnet. Rates are decreasing, but they are lower in Barnet and decreasing at a slightly higher rate. In part, this is due to a lower average prevalence of smoking in the borough and an above-average level of affluence. 42
  • 50. Figure 29: Age-standardised death rate from heart attack nationally, in London and Barnet Source: Office for National Statistics Stroke is caused by either a blockage of one of the blood vessels supplying the brain or, less commonly, by one of these blood vessels bursting and bleeding. In either event, the blood supply to a portion of the brain is suddenly stopped. This is a ‘stroke’ (also called a cerebro-vascular accident or ‘CVA’) and leads to a permanent loss of function of the part of the brain affected. Figure 30 shows comparative rates and trends in deaths from stroke in England and Wales, London and Barnet. Like heart attack, rates are decreasing, but they are lower in Barnet and decreasing at a slightly higher rate. Figure 30: Age-standardised death rate from stroke nationally, in L Like heart attack, London and Barnet These two diseases have similar origins: they are usually caused by progressive damage to the lining of blood vessels. This damage occurs in many parts of the body but the heart and the brain are more susceptible to a loss of blood supply than most other organs. CHD and stroke are often combined into one condition – cardio-vascular disease (CVD) for this reason. The most common causes of CVD are smoking, high blood pressure, raised blood cholesterol levels and diabetes. These last three risk factors are much more common amongst people who are obese. Put another way, the most common cause of death in 43 30 50 70 90 110 130 150 170 190 210 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Age-standardiseddeathrateper100,000 England and Wales London Barnet 30 50 70 90 110 130 150 170 190 210 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Age-standardiseddeathrateper100,000 England and Wales London Barnet 30 40 50 60 70 80 90 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 England and Wales London Barnet Age-standardiseddeathrateper100,000 30 40 50 60 70 80 90 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 England and Wales London Barnet Age-standardiseddeathrateper100,000
  • 51. Barnet is mainly caused by two things: smoking and obesity. If we wish to reduce the number of people who die each year from avoidable disease then we need to help people – in various different ways – to stop smoking and, if they are overweight or obese, to lose weight. 3.4.2 The risk we face Death rates from CVD have been dropping in recent years both in Barnet and nationally. There have been two main reasons for this: nationally, the prevalence of smoking has been dropping6 and treatment for both heart attack and stroke (especially for heart attack) is more effective now than it was.7 However, the ‘obesity epidemic’ and the projected change in Barnet’s population (see section 2.1 concerning Barnet’s impending ‘middle age spread’) mean that we can expect more people to be at risk of CVD than before. Unless we take active steps to help people to reduce lifestyle risks such as smoking and obesity, and take active steps to identify more people with established problems such as raised blood pressure, raised blood cholesterol and diabetes, then this downward trend in death rates is likely to reverse. 3.4.3 The relationship between diversity and deprivation and CVD The impact of deprivation on health is shown most starkly in terms of deaths from coronary heart disease, which, together with stroke, is the most common cause of death. Everyone will die of something, so we tend to look at ‘premature’ deaths and this is defined as death occurring under the age of 75 years. Figure 31 shows the trend in deaths in Barnet from coronary heart disease in recent years. This has been constructed by ranking superoutput areas in order of deprivation score (see Figure 10) and then dividing these into three groups of lowest, middle and highest deprivation. Figure 31 clearly shows that, in terms of coronary heart disease, people living in the most deprived parts of the borough are most likely to die prematurely. 6 In part, the reduction in smoking prevalence is attributable to NHS and other services enabling people to quit. Smoking cessation in Barnet is discussed in section 3.3. In part, the reduction in smoking prevalence is also due to taxation and smoke-free legislation and to a decreasing social acceptance of smoking. No one measure will work alone in helping people to quit (and preferably not to start) and it is necessary for the NHS, local government, employers, landlords and others to continue to discourage smoking as much as possible and to facilitate people to quit (for example, by actively encouraging people to attend smoking cessation services during working hours and not to have smoking breaks at work). 7 The Department of Health is looking to the NHS to provide immediate revascularisation services for everyone who has a heart attack, i.e. passing a small balloon on a catheter through an artery in groin into the affected blood vessel of the heart and expanding the narrowed area and then ‘splinting’ it with a stent to help keep it open. This requires specialist facilities and staff and thus, increasingly, people who have heart attacks will not be take to the nearest hospital but to one with these facilities. However, reducing deaths from CHD also requires the identification of people with risk factors such as high blood pressure and raised blood cholesterol and diabetes and managing these conditions aggressively to reduce risk. 44
  • 52. Figure 31: Age-standardised death rates from coronary heart disease in people aged under 75 years grouped by super-output areas ranked in order of deprivation Asian people are at higher risk of developing diabetes and consequently have a risk of developing coronary heart disease that is about 40% higher than amongst the White population in the UK,xliii principally because of the damage that diabetes does to the blood vessels. People from Black, and especially African-Caribbean, ethnic groups are also at higher risk of stroke, principally because of a genetic predisposition to developing high blood pressure. However, for reasons that are not clear, Black people are between 25% and 50% less likely to have coronary heart disease than the White population in the UK. Age is also a factor in death from CVD: death from a heart attack or a stroke is more likely to occur in an older person than a younger one. This may seem obvious, but the important point is that many people live to an old age before dying of a CVD-related event, as shown in and Figure 32 and Figure 33. Figure 32: The total number of deaths from cardiovascular disease in Barnet over the four- year period 2004-2007 by age group Source: Office for National Statistics Annual District Mortality Data 45 19 29 39 49 59 69 2004 2005 2006 2007 Age-standardiseddeathsper100,000 Low Deprivation SOAs Medium Deprivation SOAs High Deprivation SOAs PCT Average 19 29 39 49 59 69 2004 2005 2006 2007 Age-standardiseddeathsper100,000 Low Deprivation SOAs Medium Deprivation SOAs High Deprivation SOAs PCT Average Low Deprivation SOAsLow Deprivation SOAs Medium Deprivation SOAsMedium Deprivation SOAs High Deprivation SOAsHigh Deprivation SOAs PCT AveragePCT Average
  • 53. Figure 33: The total number of deaths from stroke in Barnet in 2007 by age group Source: Office for National Statistics Annual District Mortality Data 3.4.4 Local targets Figure 34 shows the current death rate in people aged under 75 years in Barnet and the trajectory for this that has been agreed as a target to achieve. This is especially challenging: the death rate from this disease cannot be expected to continue to drop until it reaches zero. However, it is also clear that death rates in the more deprived parts of the borough are higher than in the more affluent ones and if more effort is made with the people at special risk of CVD who live in these areas then overall CVD deaths should decrease. Figure 34: The trajectory for deaths from cardiovascular disease 46 0 10 20 30 40 50 60 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85-89 90+ Totalnumberofdeaths Age at death 0 10 20 30 40 50 60 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85-89 90+ Totalnumberofdeaths 0 10 20 30 40 50 60 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85-89 90+ 0 10 20 30 40 50 60 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85-89 90+ Totalnumberofdeaths Age at death
  • 54. 3.4.5 Key things that need to be done The key activities required are:  maintaining the current good performance on smoking cessation and, especially in the more deprived areas, to try to increase the number of people quitting smoking;  establishing ways for GP practices and acute and community sector providers to identify people with obesity and to refer them to specific services to enable them to lose weight which need to be of two types – − for people with ‘simple’ obesity and no other established medical problems, − for people with obesity and co-morbidity, e.g. conditions such as high blood pressure, raised blood cholesterol, diabetes, as helping these people to lose weight requires careful monitoring of the treatment they have for their other conditions;  working with employers to make it easier for their staff to (i) be healthier at work and (ii) identify any established health risks such as smoking, obesity, high blood pressure and for these risks to be properly dealt with;  working with schools to increase opportunities for healthy eating and taking exercise and to increase understanding amongst younger people of the importance of healthier lifestyles;  targeting people at special risk of CVD who, for various reasons, do not see themselves at such risk and encouraging and enabling them to reduce CVD risk factors. 3.4.6 The ‘Finding the 5000’ project In Barnet, some 20,000 households live in ‘social housing’, i.e. in council or housing association property or in temporary accommodation. CVD death rates are high in these areas. Using the full, seven-character post codes for 10,873 council tenant households and 2,457 homeless households in temporary accommodation (we do not have full post codes for people living in housing association properties) we have correlated these postcodes with GP practice-registered households (see Table 17 and Figure 35) and found that:  87% such households are registered with a GP close to a high deprivation area;  21 practices have 10-48% of their patients living in these households. Table 17: The GP practices where most people in social housing are registered Practice code (anonymised) List size No of households registered No of households in social housing Proportion of registered households in social housing E83444 5132 1475 708 48% E83555 7035 4034 1322 33% E83666 12149 2658 864 33% E83777 14260 3075 984 32% E83888 4412 1624 455 28% E83999 2424 756 173 23% 47
  • 55. Table 17 Continued Practice code (anonymised) List size No of households registered No of households in social housing Proportion of registered households in social housing E83000 1595 700 125 18% E83111 1659 654 112 17% E83222 3177 1235 211 17% E83333 7347 2237 356 16% E83121 4670 1643 228 14% E83212 3806 1977 261 13% E83313 6698 2208 290 13% E83414 3579 801 105 13% E83515 1192 239 28 12% E83616 3456 1161 128 11% E83717 7666 2941 316 11% E83818 5656 2209 237 11% E83919 7578 4204 434 10% E83010 2859 960 97 10% E83232 3610 1028 103 10% As part of the new general practice contract introduced in 2004, GPs are encouraged to reduce many CVD risk factors, for example by maintaining blood pressure below a certain level in people diagnosed with conditions such as coronary heart disease, stroke and diabetes. We therefore looked at the GP contract Quality and Outcomes Framework activity of these 21 practices. The results are shown in Table 18. Table 18 shows that there is little scope to improve the quality of care for those with a number of different diseases in terms of – in this example – blood pressure control. The GP contract reimburses practices in relation to the proportion of people on disease registers in whom a certain clinical parameter is achieved.8 The data in Table 18shows (i) that all these practices are achieving the expected care standard for the majority of patients, and (ii) that most are achieving or exceeding the highest expected level.9 GPs can exclude some patients from these results on clinical or other grounds. Table 18 also shows that few such exceptions are being made and even if they were included this would make only a minimal difference to the results. 8 This is assessed through the ‘Quality and Outcomes Framework’ (QoF). Data are collated and analysed to identify how many patients registered in each practice have received certain types of care within certain clinical parameters 9 Green = exceeding upper QoF limit, amber = close to upper QoF limit, red = below the upper QoF limit 48
  • 56. Figure 35: The location of GP practices with the highest proportion of registered patients living in social housing in relation to deprivation levels 49 Index of Multiple Deprivation (2007) Very high High Moderate Low Very low Index of Multiple Deprivation (2007) Very high High Moderate Low Very low Index of Multiple Deprivation (2007) Very high High Moderate Low Very low
  • 57. Table 18: Quality and Outcomes Framework activity for patients registered in the 21 practices for patients on specific disease registers Pfizer Limited has provided Barnet PCT with ‘Health Acorn’ data. This models various factors in the population in census superoutput areas. Making the assumption that each Health Acorn factor is homogenously distributed in each superoutput area, we transposed these data to 7-character post codes and attributed these to each of the 21 GP practices based on where their patients live. This work is still at an early stage, but initial findings are shown in Table 19 and Table 20. Note that on average in Barnet, 75% of the population are White, 12% Asian and 9% Black. About 18% smoke and 8% have been identified by Barnet GPs as being obese (i.e. having a body mass index (BMI) of 30 or greater. Table 19: Early outputs of modelling various characteristics against populations in the 21 GP practices with the highest proportion of households living in social housing 50
  • 58. Table 20: QoF-recorded obesity prevalence in the 21 practices and modelled prevalence of obesity Practice code (anonymised)10 List size Proportion of patients identified as obese (%) (BMI >30) Proportion who are obese based on Health Acorn data modelling (%) E83444 2424 3 - E83555 1192 4 - E83666 7578 5 17 E83777 7035 5 19 E83888 7347 6 15 E83999 3610 6 13 E83000 3579 6 14 E83111 7666 6 17 E83222 14260 6 17 E83333 1659 7 - E83121 12149 7 18 E83212 4670 7 13 E83313 6698 7 15 E83414 5656 7 15 E83515 2859 7 15 E83616 3177 7 - E83717 3806 8 - E83818 4412 9 15 E83919 1595 10 - E83010 3456 11 17 E83232 5132 11 17 The early results of modelling shown in Table 19 and Table 20 indicate that:  generally, a much higher proportion of people living in social housing smoke; and  there is an under-recognition of obesity and thus, probably of people with or at risk of developing high blood pressure, abnormal blood lipids and/or diabetes. It is also important to note that in some of these practices there are also very different proportions of people from different ethnic groups than in others. The significance of this is that people in different ethnic groups have different social, religious and health beliefs and values. We are planning bespoke approaches to facilitate the identification and management of CVD risk factors in these different groups. The discrepancy between, in this example, the proportion of people identified as obese and the proportion who are probably obese (based on modelling) does not imply that the 10 Data in the tables and figures in this paper are real but the GP practice identifies have been anonymised 51
  • 59. practices are failing to identify obesity patients attending their surgeries. It probably reflects that most of these people do not attend their doctor’s surgery. Next steps We need to undertake more data analysis and modelling, e.g. to identify the number of smokers known in each practice and the likely real number based on modelling. From this, and each practice’s current stop smoking activity, we can estimate how many additional people might be enabled to quit. This work should enable us to develop individual practice profiles of registered patients with CVD risk factors. We need to develop a ‘local enhanced service’ (a local addition to GPs’ NHS contracts) to enable:  the identification of individuals who have CVD risk factors; and  the management of these risk factors to pre-determined levels and their maintenance at these healthier levels (e.g. reduced blood pressure, reduced lipid levels, controlled diabetes). We need to develop social marketing packages and to provide training to practices to better-enable them to identify and work with the patients who rarely, if ever, attend their surgeries. This may include the development of teams to visit people in their homes and/or to provide services in places such as supermarket car parks. We need to work with other organisations, e.g. those in the voluntary sector, as well as in the statutory sector (e.g. housing, education) to enable the identification and management of CVD risk factors in places other than NHS facilities, including the probable provision of phone-call and text services. (We have found this latter service particularly effective in boosting smoking quit rates.) Barnet Council, in collaboration with the PCT, have recently run a half-day workshop to start this process. 3.5 Cancers 3.5.1 Overview Overall, cancer is the second most common cause of death in Barnet and across the country. However, unlike CHD (which only affects the heart) and stroke (which only affects the brain) there are many types of cancer and different ones affect different organs and their causes and effects are different.11 For example, in 2004-2007, the total numbers of people in Barnet dying from some of the more common cancers were as shown in Table 21. Table 21 The number of people dying from the more common cancers over the four-year period 2004-2007 11 Most cancers have similar characteristics, i.e. they are abnormalities of cell growth causing the affected tissue to grow in a relatively uncontrolled way. The majority of cancers spread locally by infiltrating adjacent tissues and spread distantly by ‘metastatic spread’ through the blood and lymphatic systems. The rate of growth, the degree of spread and the effect on other parts of the body differs with each type of cancer 52
  • 60. Organ Total number of deaths over 4-year period 2004-2007 Average number of deaths/year (rounded) Lung 575 144 Colon or rectum 293 73 Breast 234 59 Prostate 169 42 Bladder 49 12 Cervix 16 4 Source: Office for National Statistics Annual District Mortality Data 3.5.2 The risk we face As death rates from CVD drop so more people live long enough to develop a cancer: cancer is thus becoming more common. However, like CVD, death rates from cancer are also dropping. This is predominantly due to earlier diagnosis, in part because of screening, and because many (but not all) cancer treatments are now much more effective than they used to be. There are different risk factors for different cancers which independently or in combination, can increase an individual’s risk of developing a specific cancer.xliv,xlv Tobacco use, for example, increases the risk for pancreatic, kidney and urinary bladder cancers, as well as for the more familiar lung, colorectal, head and neck and cervical cancers. Higher-than moderate alcohol intake can increase the risk of breast, oesophageal and head and neck cancer. High dietary fat and being obese can increase the risk for colon and breast cancer. There is also an increased risk for colorectal, breast, prostate, ovarian, thyroid and melanoma cancers for people in whom a first- degree relative has had one of these types of cancer. 3.5.3 The relationship between diversity and deprivation and cancer There is little reliable data in this country to draw any firm conclusions about differences in cancer incidence or survival rates amongst people in Black and minority ethnic groups. However, there is some evidence from studies in the United States of America that some Asian American subgroups are more likely to develop and to die from some cancers than people in other ethnic groups.xlvi And, for example, whilst large bowel cancer is common in developed countries its incidence in India is low,xlvii yet the incidence and spread of breast cancer has been shown to be different in people from different ethnic groups in New Zealand.xlviii In terms of deprivation, there is evidence that women who live in more deprived communities tend to have poorer outcomes if they develop breast cancer.xlix,l There is also evidence to suggest that differences in breast cancer diagnosis, treatment and survival may be more related to economic differences than to ethnicity.li,lii Various factors have been reported that increase the risk of developing breast cancer. Some like gender (being female), age (being older), genes (having the BRCA 1 and 2 genes), ethnicity (being White), and having a family history of breast cancer all increase the risk but cannot be changed.liii However, lifestyle factors like never given birth, having the first child after the age of 30 years, which are commoner features amongst women 53
  • 61. living in more affluent areas, obesity, high fat diets and inactivity, also increase the risk of breast cancer but can be changed in many instances.liv,lv Research shows that cervical cancer and death from the disease is commoner amongst women living in more deprived areas.lvi There is also evidence that women from deprived backgrounds are less likely to attend for cervical screening, and this may be connected with reduced self-esteem, lower educational attainment and poorer literacy skills.lvii Women who smoke (smoking is also more prevalent amongst people in lower socio- economic groups) are less likely to attend for cervical screening.lviii There do not seem to be any specific associations between cervical cancer and women from Black and minority ethnic groups. However, there is some evidence that some women from these groups are likely to be screened more often than others and that others are likely to be screened less often. Error: Reference source not found The reasons for this are unclear. There is also an association between cervical cancer and early age of first sexual intercourse, having many different sexual partners, having a large number of pregnancies and with smoking.Error: Reference source not found Thus, the picture with cancer in terms of deprivation, ethnicity and other factors is complex and not easy to unravel. It is further complicated when examined at a local level because the numbers of people with different cancers (even the common ones) are relatively small. This means that year-to-year variations in the number of people developing cancer are not necessarily significant: it is the overall trend over several years that is more important. Figure 36, Figure 37 and Figure 38 show the trends in deaths from lung cancer, breast cancer and colorectal cancer (respectively) in relation to deprivation. This has been done by ranking all the census superoutput areas in Barnet by deprivation score and then dividing them into three groups (tertiles) of low, medium and high deprivation, and correlating the deaths occurring in each of these groupings. Figure 36: The trend in deaths from lung cancer in people aged under 75 years in Barnet in areas with different deprivation scores (derived from census superoutput areas) Source: Office for National Statistics Annual District Mortality Data 54 10.0 12.0 14.0 16.0 18.0 20.0 22.0 24.0 26.0 28.0 30.0 2004 2005 2006 2007 Age-standardiseddeathrateper100,000 Low Deprivation SOAs Medium Deprivation SOAs High Deprivation SOAs Barnet average 53 57 49 56Number of deaths 10.0 12.0 14.0 16.0 18.0 20.0 22.0 24.0 26.0 28.0 30.0 2004 2005 2006 2007 Age-standardiseddeathrateper100,000 Low Deprivation SOAsLow Deprivation SOAs Medium Deprivation SOAsMedium Deprivation SOAs High Deprivation SOAsHigh Deprivation SOAs Barnet averageBarnet average 53 57 49 56Number of deaths
  • 62. Figure 37: The trend in deaths from breast cancer in people aged under 75 years in Barnet in areas with different deprivation scores (derived from census superoutput areas) Source: Office for National Statistics Annual District Mortality Data Figure 38: The trend in deaths from colorectal cancer in people aged under 75 years in Barnet in areas with different deprivation scores (derived from census superoutput areas) Source: Office for National Statistics Annual District Mortality Data In Figure 36, there is a relatively clear trend: people living in the more deprived areas are more likely to die from lung cancer. In Figure 37 the pattern is less clear and the numbers are smaller, which can exaggerate year-to-year differences. However, women in higher socio-economic groups are more likely to develop breast cancer and this is reflected in these data to some extent. 55 0.0 5.0 10.0 15.0 20.0 25.0 30.0 2004 2005 2006 2007 Age-standardiseddeathrateper100,000 Low Deprivation SOAs Medium Deprivation SOAs High Deprivation SOAs Barnet average 43 29 19 26Number of deaths 0.0 5.0 10.0 15.0 20.0 25.0 30.0 2004 2005 2006 2007 Age-standardiseddeathrateper100,000 Low Deprivation SOAsLow Deprivation SOAs Medium Deprivation SOAsMedium Deprivation SOAs High Deprivation SOAsHigh Deprivation SOAs Barnet averageBarnet average 43 29 19 26Number of deaths 6.0 8.0 10.0 12.0 14.0 16.0 18.0 20.0 2004 2005 2006 2007 Age-standardiseddeathrateper100,000 Low Deprivation SOAs Medium Deprivation SOAs High Deprivation SOAs Barnet average 40 29 33 36Number of deaths 6.0 8.0 10.0 12.0 14.0 16.0 18.0 20.0 2004 2005 2006 2007 6.0 8.0 10.0 12.0 14.0 16.0 18.0 20.0 2004 2005 2006 2007 Age-standardiseddeathrateper100,000 Low Deprivation SOAsLow Deprivation SOAs Medium Deprivation SOAsMedium Deprivation SOAs High Deprivation SOAsHigh Deprivation SOAs Barnet averageBarnet average 40 29 33 36Number of deaths
  • 63. In Figure 38 it is not possible to discern an obvious trend other than the fact that overall the Barnet average death rate from colorectal cancer is relatively unchanged over the four years shown but there seems to be a trend of a decreasing rate amongst those living in the most affluent areas. 3.5.4 Local targets In common with other London PCTs, Barnet has agreed to reduce deaths from cancer by 2010/2011 and our trajectory for this is shown in Figure 39. Figure 39: The trajectory for cancer deaths in Barnet Source: Barnet PCT Operating Plan Like other targets, cancer deaths cannot continue to drop to zero, but, it is reasonable to expect the NHS to further reduce cancer deaths. This can be achieved through (i) encouraging and enabling more people to be screened so that some cancers to be diagnosed sooner (when treatment is likely to be more effective), and (ii) supporting, within the resources available, the use of more aggressive and effective treatments.12 3.5.5 Key things that need to be done The key activities required are:  improving the uptake of screening (see section 3.5.6) for breast and colorectal cancer screening – the two biggest cancer killers for which population screening is available;  work with local providers to improve access to services to ensure that people who may have cancer are investigated and, as necessary, treated, as soon as possible;  work with local providers to try to improve the availability of clinically and cost- effective treatments for cancer; and 12 It is important to recognise that many of the new drugs developed to treat cancer do not cure but can, in some instances, prolong survival times. However, not all prolong survival by much, and many are very expensive. A balance has to be struck between the wants of individual patients and their relatives and the needs of the wider population: sometimes the needs of the wider population conflict with the needs of individuals, and the NHS has a duty to use public money to the maximum advantage of the maximum number of patients 56 2003 2004 2005 2006 2007 2008 2009 2010 2011 80 85 90 95 100 105 110 Age-standardiseddeathrateper100,000 actual trajectoryestimates 2003 2004 2005 2006 2007 2008 2009 2010 2011 80 85 90 95 100 105 110 Age-standardiseddeathrateper100,000 actual trajectoryestimates
  • 64.  continue to encourage people to avoid starting smoking and, for those who do, to encourage and enable them to quit – whilst stopping smoking will take many years before there is a detectable drop in deaths from cancers caused by smoking, stopping smoking improves the effectiveness of many treatments and reduces potential complications of surgery and, by increasing health generally, contributes to prolonging life. 3.5.6 Screening Breast cancer screening Nearly all breast cancers can be treated successfully if detected early, and regular breast screening with mammography, an x-ray examination of the breast, is reported as the single most effective way to detect breast cancer at an early, curable stage.lix There has been a dramatic reduction in mortality since the late 1980s when over 15,000 women were dying each yearlx and the data in figure 44 show that this has occurred in Barnet as well. However, the latest available figures show that breast screening for Barnet PCT residents has fallen over recent years from 65% in 2005/06 (which was better than the pan-London rate of 62%). This is shown in Figure 40. Figure 40: The proportion of women invited for breast screening who attended for mammography Source: North London Breast Screening Service performance report The breast screening unit serving Barnet developed significant operational difficulties and was closed for a while in 2007. Whilst the service is running again and many of the problems have been dealt with, there is still some degree of backlog to overcome. This is not the only issue: the data in Figure 40 show the proportion of women who are invited to attend for screening and who subsequently do so. The service needs to become more accessible and there is an important need to enable people to understand the importance and benefit of breast screening and thus why they should attend. Put simply, breast screening increases the likelihood of a woman who has breast cancer being diagnosed at an earlier stage and thus being more likely to overcome the disease: earlier treatment is more likely to be successful. 57 Proportionofwomeninvited forscreeningwhoattend(%) 0 10 20 30 40 50 60 70 80 Oct-07 Nov-07 Dec-07 Jan-08 Feb-08 Mar-08 Apr-08 May-08 Jun-08 Jul-08 Aug-08 Proportionofwomeninvited forscreeningwhoattend(%) 0 10 20 30 40 50 60 70 80 Oct-07 Nov-07 Dec-07 Jan-08 Feb-08 Mar-08 Apr-08 May-08 Jun-08 Jul-08 Aug-08
  • 65. Colorectal cancer screening Bowel cancer is the second most common cause of cancer deaths in the UK, and has the fourth highest incidence of cancer in Barnet PCT.lxi It is predicted that deaths from bowel cancer could drop by as much as 15% as a result of screening.lxii Overall, deaths from bowel cancer in Barnet are declining (see also Figure 38) and this is likely to be due to early diagnoses being made and to treatment being more effective. Full implementation of the bowel screening programme in Barnet began in October 2007 and, as a consequence, bowel cancer’s contribution to the overall cancer mortality rate should start to reduce further. The bowel cancer screening programme invites men and women aged 60-69 (people aged 70 or over are provided with a testing kit on request) to be screened for bowel cancer every two years. Testing kits are sent direct to individuals to be used in their homes. 3.6 Respiratory disease 3.6.1 Overview Excluding cancers of the respiratory tract, respiratory disease is the third most common cause of death in Barnet. Respiratory disease includes infections (such as acute bronchitis and pneumonia), reversible airways obstruction in response to irritation or allergy (asthma), and permanent structural damage (chronic obstructive pulmonary disease (COPD) which includes both chronic bronchitis (repeated chest infections and inflammation) and emphysema). COPD is almost entirely due to smoking. 3.6.2 The risk we face COPD is the most significant risk that we face. There are over 900,000 people in the UK, diagnosed with COPD and half as many again are thought to be living with undiagnosed COPD.lxiii The true prevalence of COPD both nationally and locally is unknown, but it has been estimated at 1-10%.lxiv Rates are higher in men, although this is now beginning to equaliselxv as more women reach an age when smoking earlier in life is taking its toll. The change in smoking habits between the sexes is shown in Whilst COPD starts to affect lung function from the age of about 40 onwards (which is one reason why younger smokers do not think that the problem applies to them), death from COPD occurs much later in life. This is shown in Figure 42, which shows age of death from COPD in Barnet men and women between 2004 and 2007. With a 30-50-year lag between starting smoking and dying from COPD, and with an increasing number of women smoking until the mid-1970s, we can expect more women to die of COPD (if they do not die of another smoking-related disease first) over the next ten years or so in Barnet whilst the number of men dying from this unpleasant disease continues to drop.. Women took up smoking in increasing numbers after the First World War and smoked cigarettes in increasing numbers until the mid 1970s. In contrast, whilst men smoked more, they started to reduce the amount they smoked from the beginning of the 1950s, when consumption was near-static for 25 years and then stated to reduce cigarette smoking sooner and by a greater amount than women. Whilst COPD starts to affect lung function from the age of about 40 onwards (which is one reason why younger smokers do not think that the problem applies to them), death from COPD occurs much later in life. This is shown in Figure 42, which shows age of death from COPD in Barnet men and women between 2004 and 2007. With a 30-50- 58
  • 66. year lag between starting smoking and dying from COPD, and with an increasing number of women smoking until the mid-1970s, we can expect more women to die of COPD (if they do not die of another smoking-related disease first) over the next ten years or so in Barnet whilst the number of men dying from this unpleasant disease continues to drop. 59
  • 67. Figure 41: Annual consumption of manufactured cigarettes per person in the UK Source: Tobacco Advisory Council In Barnet, death rates from COPD are reducing faster in men than they are in women, as shown in Figure 42 and we can expect this gender difference to continue for some time. Figure 42: Trends in age-standardised death rates from COPD in Barnet in men and women Source: Office for National Statistics 60 0 500 1000 1500 2000 2500 3000 3500 4000 4500 1905 1910 1915 1920 1925 1930 1935 1940 1945 1950 1955 1960 1965 1970 1975 1980 1985 Numberofmanufacturedcigarettesperperson men women virtually no rise in cigarette consumption by men continued substantial rise in cigarette consumption by women proportionately greater reduction in cigarette consumption by men proportionately slower reduction in cigarette consumption by women 00 500 1000 1500 2000 2500 3000 3500 4000 4500 1905 1910 1915 1920 1925 1930 1935 1940 1945 1950 1955 1960 1965 1970 1975 1980 1985 Numberofmanufacturedcigarettesperperson men women virtually no rise in cigarette consumption by men continued substantial rise in cigarette consumption by women proportionately greater reduction in cigarette consumption by men proportionately slower reduction in cigarette consumption by women 10 15 20 25 30 35 40 45 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Age-standardiseddeathper100,000 Men Women 10 15 20 25 30 35 40 45 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Age-standardiseddeathper100,000 Men Women Men Women
  • 68. Figure 43 shows the total number of men and women dying from lung cancer in Barnet. This also indicates that 30-40 years ago, women were more likely to start smoking at an older age than men. As women now tend to take up smoking in their early teens, as men used to, we can expect women to die at a younger age from lung cancer than they do now. Figure 43: Total number of deaths from COPD in men and women in Barnet 2004-2007 Source: Office for National Statistics Stopping smoking is important whatever the degree of disability someone has because of COPD. This has two important effects: it prevents the damage getting worse and it reduces the risk of hospitalisation. Research has shown that stopping smoking more than halved the likelihood of hospital admission, but merely reducing smoking does not make any significant difference.lxvi The risk of people suffering and dying from other respiratory diseases can also be reduced by quitting smoking – it increases one’s likelihood of developing acute bronchitis – and, for those in at-risk groups, of having an annual influenza immunisation. Asthma is predominantly a cause of intermittent breathing difficulty and a relatively unusual cause of death. For most people, it can be wholly managed in a primary care setting with only a small number requiring hospital admission for severe attacks. 3.6.3 The relationship between diversity and deprivation and respiratory disease There is a relationship between respiratory disease and deprivation. Figure 44 shows the hospital admission rate for respiratory disease in 2006/07 for residents in each of Barnet’s electoral wards ranked in order of deprivation. In most instances, there is a close and increasing relationship between the two: people living in more deprived areas are more likely to have respiratory disease that is severe enough to require hospital admission. It is noteworthy that smoking is more prevalent in more deprived areas. There are insufficient data currently available to indicate any relationship between ethnicity or other aspects of diversity and respiratory disease. However, it is likely that different smoking habits in men and women in different ethnic groups is likely to have an effect on this. 61 0 5 10 15 20 25 30 35 40 45 50 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85-89 90+ Men Women 0 5 10 15 20 25 30 35 40 45 50 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85-89 90+ Men Women Men Women
  • 69. Figure 44: The relationship between hospital admission for respiratory disease and deprivation Source: Local hospital admission data 3.6.4 Local targets Currently, there is no formal target to reduce death rates from respiratory disease. However, reducing deaths from respiratory diseases of all types will contribute to reducing the all-age, all-cause death rate and, with appropriate targeting of activity, contribute to reducing health inequalities. 3.6.5 Key things that need to be done The key activities required are:  continuing to reduce the prevalence of smoking;  continuing to encourage and enable the uptake of influenza immunisation and pneumococcal immunisation;  the provision of services to manage acute exacerbations of COPD early and to provide pulmonary rehabilitation services. 3.7 Diabetes 3.7.1 Overview Diabetes occurs when the body either fails to make enough insulin or no longer responds to it as it should.13 There are two main types of diabetes: type 1 and type 2. Type 1 diabetes occurs when the body fails to make insulin in sufficient quantity. This is usually caused by an abnormality in the body’s immune system that leads to the destruction of the cells in the pancreas that make insulin. Type 2 diabetes occurs when the body fails to respond to insulin as it should. If inadequately controlled, diabetes can cause a variety of complications. Principally, these affect blood vessels and thus the blood supply to various organs in the body. The 13 Much of the food we eat is converted by the body into glucose. This is needed by body cells for them to function properly. Insulin is a hormone that enables glucose to transfer from the blood stream into cells 62 0 5 10 15 20 25 30 10 12 14 16 18 20 22 24 26 28 30 32 34 Index of Multiple Deprivation 2007 Admissionrateper1000population 0 5 10 15 20 25 30 10 12 14 16 18 20 22 24 26 28 30 32 34 Index of Multiple Deprivation 2007 Admissionrateper1000population
  • 70. complications of diabetes therefore include increased risk of heart attack, kidney failure, blindness, inadequate blood supply to the extremities (especially the feet) that can lead to ulceration and gangrene, and inadequate blood supply to nerves, especially in the extremities, leading to loss of touch and pain sensation. It is thus a potentially serious condition. 3.7.2 The risk we face Diabetes is a relatively common condition. Barnet GPs have identified some 14,000 people with this condition,14 although the actual number is likely to be higher. This is shown in Figure 45, which also shows that there is considerable variation throughout London in the burden of diabetes. This is predominantly because of differences in the Black and minority ethnic makeup in different areas. A major risk factor for type 2 diabetes is obesity: an obese woman is 12.7 times as likely to develop diabetes as a woman who is not obese and an obese man is 5.2 times as likely to do so as a man who is not.lxvii Unless we can curb the year-on-year rise in obesity in Barnet then the number of people with diabetes, and thus the number of people at risk of complications and death as a consequence, will continue to rise. Diabetes is not only associated closely with obesity. It becomes more common with age and is more likely to occur in someone if one or more of their close family has diabetes, and in women who developed glucose intolerance during pregnancy. Figure 45: The estimated prevalence of diabetes in London PCTs compared with the QoF- reported prevalence in March 2007 Source: Healthcare for London Report – Diabetes Care. July 2008 14 Source: Barnet PCT Quality and Outcomes Framework 2007 63 Newham Brent Harrow Redbridge Ealing WalthamForest TowerHamlets Hounslow Croydon Enfield Lewisham Barking&Dagenham Barnet Haringey City&Hackney Southwark Greenwich Lambeth Hillingdon Islington Havering Bexley Bromley Kensington&Chelsea Westminster Hammersmith Camden Sutton&Merton Kingston Wandsworth Richmond&Twickenham 0 1 2 3 4 5 6 Proportionofpeoplewithdiabetes(%) QoF-reported prevalence Estimated additional prevalence Newham Brent Harrow Redbridge Ealing WalthamForest TowerHamlets Hounslow Croydon Enfield Lewisham Barking&Dagenham Barnet Haringey City&Hackney Southwark Greenwich Lambeth Hillingdon Islington Havering Bexley Bromley Kensington&Chelsea Westminster Hammersmith Camden Sutton&Merton Kingston Wandsworth Richmond&Twickenham 0 1 2 3 4 5 6 Proportionofpeoplewithdiabetes(%) QoF-reported prevalenceQoF-reported prevalence Estimated additional prevalenceEstimated additional prevalence
  • 71. There is also a condition called ‘pre-diabetes’ (which is also referred to as ‘impaired glucose tolerance’ and ‘impaired fasting glucose’. This is an asymptomatic condition characterised by higher than normal blood glucose levels and insulin resistance. Without intervention and appropriate treatment, people with pre-diabetes are at risk of developing type 2 diabetes within10 years.lxviii The risk factors for pre-diabetes are similar to those for type 2 diabetes. There is evidence that by identifying and treating pre-diabetes with lifestyle change and – as necessary – drugs, type 2 diabetes can be prevented or delayed and the risk of complications associated with the condition, such as cardiovascular disease, can be reduced.lxix,lxx,lxxi 3.7.3 The relationship between diversity and deprivation and diabetes Diabetes is more common in Asians and Blacks, and amongst African Caribbeans it is more common in women than in than in men, as shown in Table 22. The average age at diagnosis of diabetes is also lower in people of African Caribbean origin, the risk of death from diabetes is between three and six times higher, there is a greater susceptibility to the cardiovascular and renal complications of diabetes amongst them.lxxiiTable 22 For example, Bangladeshi men are nearly six times more likely to develop diabetes than the general population and African Caribbean women four times as likely to do so (noting that this is an ethnicity and gender difference: African Caribbean men are only 2.5 times as likely to develop diabetes as the general population. The average age at diagnosis of diabetes is also lower in people of African Caribbean origin, the risk of death from diabetes is between three and six times higher, there is a greater susceptibility to the cardiovascular and renal complications of diabetes amongst them.lxxii Table 22: Standardised risk ratios for diabetes by ethnic group and gender in 1999 Men Women General population 1.0 1.0 Irish 1.4 1.0 Indian 3.0 2.9 Pakistani 5.4 5.6 Bangladeshi 5.8 5.8 Black Caribbean 2.5 4.2 Chinese 1.4 2.1 Source: Health Survey for England, 1999, Department of Health There may be an association between deprivation and diabetes, but this is more likely to be a reflection of the fact that obesity is more common amongst people who live in deprived areas. 64
  • 72. 3.7.4 Local targets There are no specific PCT performance targets for diabetes other than in relation to screening for diabetic retinopathy.15 However, in collaboration with a wide variety of experts on the subject, the Healthcare Commission has identified a number of measures that might be used to assess the quality of diabetes control in groups of patients. The glycosylated haemoglobin level is one such measure and reflects the level of diabetes control over the preceding few weeks. In contrast, testing for glucose in the urine or checking the level of glucose in the blood only shows what is happening at that point in time. Figure 46 shows the proportion of people with ‘tightly controlled’ diabetes as measured by their glycosylated haemoglobin level. In comparison with most other parts of London, Barnet GPs (who are the ones predominantly caring for people with diabetes) in collaboration with GP practice nurses, diabetes nurse specialists and hospital doctors are providing a good service. Figure 46 The proportion of patients with diabetes who have a record of HbA1c and in whom this is 7.5 or less in the previous 15 months Key things that need to be done The key activities required are:  continuing to identify people with diabetes and impaired glucose tolerance (‘pre- diabetes’) and to manage this effectively;  to increase the proportion of people with diabetes in whom the last HbA1c measurement in the last 15 months is 7.4% or less;  to enable people with diabetes to manage their own condition more effectively;  to maintain the current high coverage of diabetic retinopathy screening; and  to encourage and enable people to avoid and to address lifestyle risk factors that increase their likelihood of developing diabetes. 15 Diabetic retinopathy is the most common cause of acquired blindness in people of working age. The main damage caused by diabetes is to the lining of blood vessels (hence the increased risk of heart attack and stroke). This blood vessel damage affects many parts of the body, including the blood vessels supplying the retina. 65 45% 50% 55% 60% 65% 70% Brom leyEnfield W altham ForestBarnet R ichm ond & Tw ickenhamKingstonH aringeyIslington H averingH arrow Sutton & M erton Lew ishamLam bethC am den Southw ark H am m ersm ith & Fulham Kensington & C helsea London average H ounslow R edbridge W estm inster Brent W andsw orthC roydon Barking & D agenham H illingdon Tow erH am lets C ity & H ackney TeachingEalingN ew ham G reenw ich 45% 50% 55% 60% 65% 70% Brom leyEnfield W altham ForestBarnet R ichm ond & Tw ickenhamKingstonH aringeyIslington H averingH arrow Sutton & M erton Lew ishamLam bethC am den Southw ark H am m ersm ith & Fulham Kensington & C helsea London average H ounslow R edbridge W estm inster Brent W andsw orthC roydon Barking & D agenham H illingdon Tow erH am lets C ity & H ackney TeachingEalingN ew ham G reenw ich
  • 73. 3.8 Sexual health 3.8.1 Overview Sexual health is an important aspect of physical and mental well-being. Poor sexual health can have a long-lasting and severe impact on people’s lives, for example through unintended pregnancies and abortions causing physical disease and poor educational, social and economic opportunities; Sexually transmitted infections (STIs) and HIV/AIDS; ectopic pregnancies leading to infertility; cervical and other genital cancers; and hepatitis, chronic liver disease and liver cancer. 3.8.2 The risk we face Sexually transmitted infections Nationally, diagnoses of sexually transmitted infections (STIs) have been steadily rising in the UK since 2001. The most recent Health Protection Agency (HPA) data indicate that this trend is continuing: between 2005 and 2006 there was a 2% rise in both new diagnoses and total numbers of STIs (recurrent and follow-up presentations) in genito-urinary medicine (GUM) clinics. The overall increase in STIs masks a more complicated picture for specific infections and in specific age and other risk groups.lxxiii Genital Chlamydia infection remains the most commonly diagnosed STI in the UK and Gonorrhoea the second. Infection rates are highest in the younger age groups (40% per cent of infections in women were in teenagers) and in men who have sex with men (MSM). In contrast to Chlamydia, cases of gonorrhoea have been in decline since 2003, with an overall 1% drop in 2006. However, STIs in MSM have continued to increase, rising by 3% in 2006, suggesting that sexual risk-taking behaviour in this community is increasing. Diagnoses of first episodes of genital herpes have been rising nationally since the early 1990s, reaching 21,698 in 2006 (a 9% rise on 2005). This latest rise was particularly pronounced among young adults, with numbers of diagnoses increasing by 16% in 16- 19 year-old women and by 10% in 20-24 year-old men. Again, data suggest that sexual health risk taking may be increasing in younger age groups, but other factors, such as increasing numbers of diagnoses in people who have recently moved to the UK may also be important. Syphilis, a very common STI in the early 1900s, remains relatively uncommon and occurs mainly in MSM. The true incidence of STIs in Barnet is not known, since figures on the numbers of people with a STI are rarely presented on the basis of a person’s residence. Most data are reported at GUM clinic level, but since these clinics see people regardless of their place of residence, figures from clinics include diagnoses made on people living outside of the ‘host’ PCT area where the clinic is situated. Data can also be distorted when the place of residence of a patient attending a clinic is unknown and this varies between GUM clinics, as shown in Table 23, which shows the GUM clinics most likely to be attended by Barnet residents. 66
  • 74. Table 23 “Unassigned PCT” from Unify data, selected GUM clinics (2007) GUM clinic Proportion of attendances recorded as “Unknown PCT” (%) Claire Simpson Clinic (Barnet Hospital) 30.4 The Marlborough Clinic (Royal Free Hospital) 16.8 The Archway Sexual Health Clinic 14.6 Mortimer Market Centre 11.4 Jefferiss Wing St Mary’s Hospital 3.8 Northwick Park Hospital 12.4 Central Middlesex Hospital 2.1 The potentially distorting effect of clinic-based data and under-recording of PCT of residence is demonstrated in Table 24, which shows the number of cases of different infections that would be expected at the Claire Simpson Clinic Barnet’s main GUM provider) based on the extrapolation of national data and the number of cases actually reported. Table 24: Diagnoses of STIs in Barnet residents extrapolated from Unify data and reported by Claire Simpson Clinic in 2006 Syphilis Gonorrhoea Genital Herpes Genital warts Chlamydia Number expected annually: Unify data 25 136 166 343 476 Number of diagnoses reported 0† 43 128 218 222 Source: Claire Simpson Clinic and Health Protection Agency † The Claire Simpson Clinic believes that this number should be 6-9, i.e. that reported incidence is erroneous It is also important to note that data from different GUM clinics may not be equally accurate, complete or representative of attendance by Barnet residents. Also, it is assumed that the rates of STIs in Barnet residents visiting a GUM clinic are equal to those attending who live in other boroughs. However, people from inner city boroughs may be more likely to have a STI or, conversely, people from Barnet attending inner city GUM clinics may be more likely than local residents to have a STI; there is no obvious method for correcting for this limitation. Therefore, GUM clinic data can only provide an approximation of the numbers of STIs in Barnet residents. That said, whilst local GUM clinic data are a poor indication of the local incidence and prevalence of STI, they do give a reasonable idea of trends and these continue to rise in Barnet, as elsewhere. 67
  • 75. HIV/AIDS The number of people in Barnet known to have HIV infection has increased steadily since 2002. This is shown in Table 25. In 2006, there were 518 people known to have HIV infection living in Barnet. Table 25: HIV positive people in Barnet Survey year Male Female Total 2002 237 165 402 2003 250 193 443 2004 253 194 447 2005 281 223 504 2006 283 235 518 The ethnicity of Barnet residents known to have HIV infection is shown in Table 26 and the age distribution in shown in Table 27. Table 26: The ethnic groups of Barnet residents with HIV infection Survey Year White Black African / Caribbean Other Not known Total 2002 123 219 33 27 402 2003 142 239 37 25 443 2004 153 240 40 14 447 2005 154 268 69 13 504 2006 168 273 64 13 518 Table 27: The age distribution of Barnet residents with HIV infection Age band (years) 0-15 16-24 25-34 35-44 45-54 55+ Number of people with HIV 20 20 98 244 99 37 In common with many other areas, HIV is more common in people in Black African and African Caribbean ethnic groups. However, unlike most of the other PCTs in the north central part of London, especially the inner-city ones, HIV infection is becoming increasingly common in Black women in Barnet rather than in the Black MSM group. It is possible that the male partners of many of these women contract the infection abroad. But the important point is that it is heterosexual transmission of HIV that is becoming a larger issue that it is in MSM in Barnet. In 2005, 132/504 (26.2%) of known cases of HIV in Barnet were in MSM, 316/504 (62.7%) were in heterosexual men or women, 26/504 (5.2%) were acquired by mother-to-child transmission, and the remainder were acquired through other or unknown means. 68
  • 76. Teenage pregnancy Barnet has one of the lowest rates of teenage pregnancy (TP) in London, and this is also lower than similar boroughs (including those matched for deprivation) such as Merton, Hounslow and Enfield. Not only is it lower than the London average, but it is also lower than the national average. This is shown in Figure 47: The trend in teenage pregnancy in Barnet, London and England. Figure 47: The trend in teenage pregnancy in Barnet, London and England 69
  • 77. Source: Office for National Statistics Figure 48: The trend in teenage pregnancy in Barnet The dashed line in Figure 48 shows that the trend in teenage pregnancy in Barnet was increasing until the second quarter of 2004 but that is has decreased since then. Approximately 68% of teenagers who conceived in Barnet in 2006 had a termination of pregnancy (TOP), the remainder having had either a live or still birth. Data on the residential postcodes of all TOPs performed by Marie Stopes, the PCT’s main provider of abortion services, on women in Barnet aged under 18 years show that 15.2% of teenage abortions were performed on young women who had had at least one previous TOP. Teenagers who have had one TOP are a high risk group for further unplanned pregnancy. 70 0 10 20 30 40 50 60 March June Sept Dec March June Sept Dec March June Sept Dec March June Sept Dec March June Sept Dec March June Sept Dec March June Sept Dec March June Sept Dec March June Sept Dec March June 1999 2000 2001 2002 2003 2004 2005 2006 2007 Under18conceptionrateper1000 Barnet rolling average London England 1998 0 10 20 30 40 50 60 March June Sept Dec March June Sept Dec March June Sept Dec March June Sept Dec March June Sept Dec March June Sept Dec March June Sept Dec March June Sept Dec March June Sept Dec March June 1999 2000 2001 2002 2003 2004 2005 2006 2007 Under18conceptionrateper1000 Barnet rolling averageBarnet rolling average LondonLondon EnglandEngland 1998 0 5 10 15 20 25 30 35 40 45 March June Sept Dec March June Sept Dec March June Sept Dec March June Sept Dec March June Sept Dec March June Sept Dec March June Sept Dec March June Sept Dec March June Sept Dec March June 1999 2000 2001 2002 2003 2004 2005 2006 2007 Under18conceptionrateper1000 Quarterly rate Rolling average 1998 0 5 10 15 20 25 30 35 40 45 March June Sept Dec March June Sept Dec March June Sept Dec March June Sept Dec March June Sept Dec March June Sept Dec March June Sept Dec March June Sept Dec March June Sept Dec March June 1999 2000 2001 2002 2003 2004 2005 2006 2007 Under18conceptionrateper1000 Quarterly rate Rolling average 1998
  • 78. Abortion services In terms of access to abortion services for all women of child-bearing age, there were 2444 TOPs performed on Barnet residents in 2006. This is above the national average rate and probably reflects either better access to termination services or lack of access to contraception services. As Barnet has such a low number of teenage conceptions (which include abortions as well as births) relative to most other PCTs in London, this latter possible explanation is unlikely. Chlamydia trachomatis is the most common curable sexually transmitted infection in the UK. The infection can have serious long term consequences including pelvic inflammatory disease leading to infertility, ectopic pregnancy and chronic pain in some affected women, and neonatal ophthalmitis and pneumonitis in children born to infected women. Up to 70% of infected women and 50% of infected men are asymptomatic, a large number of cases are never diagnosed. For these reasons, Chlamydia screening is considered an effective way of reducing sexual ill-health at a population level. The group considered to be greatest risk of the long-term consequences of Chlamydia infection is young people, in this context defined as those aged 15-24 years old.Error: Reference source not found 3.8.3 The relationship between diversity and deprivation and sexual health problems There is a clear relationship between rates of sexual ill-health, poverty and social exclusion. Certain groups are particularly at risk of poor sexual health, including:  young people, especially those in, or leaving, care;  people from Black and ethnic minority groups;  gay and bisexual men;  injecting-drug users;  adults and children living with HIV and other people affected by HIV;  sex workers; and  people in prisons and youth offending establishment. People in these groups are not only more likely to engage in sexually risky behaviour, but will often make only poor use of existing services and are therefore hard to reach.lxxiv Ethnicity is relevant to the planning of sexual health services in several ways. First, certain communities are more likely to experience a high incidence of specific STIs, for example HIV is much more common in the Black African community, and the majority of women with HIV in Barnet are from this community. Secondly, services may need to be modified so that that can be made religiously and/or culturally acceptable to certain communities, for example sex and relationships education (SRE) programmes for young people from certain orthodox Jewish and Islamic communities. Thirdly, cultural values and ethnicity may affect health beliefs and behaviours and health-seeking activities and can be important influences on health and well-being. There is limited evidence on this issue, but for instance there is some indication that men from the Black African community are less likely to attend GUM clinics.lxxv,lxxvi,lxxvii An increasing number of women are becoming infected with HIV in Barnet, although the numbers involved remain relatively small. Figure 49 shows that whilst there is a small 71
  • 79. year-on-year increase in the number of HIV-infected people accessing services, the proportion of women doing so is increasing faster than that of men. Figure 49: The number of HIV-infected Barnet residents accessing care 72
  • 80. Source: Health Protection Agency Figure 50 shows the number of HIV-infected people accessing services by ethnic group. A small part of the year-on-year increase shown here may be attributed to a reduction in the number of people for whom their ethnic group is unknown. However, there is a clear picture: the groups most affected by HIV/AIDS in Barnet are the Black and African Caribbean and the White, and the numbers of people infected is increasing. Knowing people’s ethnicity is also important in terms of designing services: there is evidence that many people from the African community are uncomfortable visiting GUM clinics, and that in this community a different approach is needed. Since in general sexually active women of all communities are more likely to attend health services, increasing testing in these settings is an important method for increasing uptake of HIV screening in women, for example in antenatal or family planning clinics. For men, however, a more community-orientated approach is most likely to achieve results. 73 0 50 100 150 200 250 300 2002 2003 2004 2005 2006 Numberofpeopleaccessingcare Male Female 0 50 100 150 200 250 300 2002 2003 2004 2005 2006 Numberofpeopleaccessingcare Male Female Male Female
  • 81. Figure 50: The number of HIV-infected Barnet residents in different ethnic groups accessing care Source: Health Protection Agency In terms of age and general sexual health services, the greatest numbers of people seen in the main GUM clinics serving Barnet’s population are aged 15-35 years (77% of attendees) and 60% of attendees are women. 3.8.4 Local targets There are two main targets. The first is to screen people aged 15-24 years for genital Chlamydia infection. The target for 2008/09 is to screen 6,699 people. The other main target is to reduce the number of teenage pregnancies. The trajectory for this is shown in Figure 51. Figure 51: Teenage pregnancy rates in Barnet – current and future trajectory 74 0 50 100 150 200 250 300 2002 2003 2004 2005 2006 Numberaccessingcare White Black and African Caribbean Other Not known 0 50 100 150 200 250 300 2002 2003 2004 2005 2006 Numberaccessingcare WhiteWhite Black and African CaribbeanBlack and African Caribbean OtherOther Not knownNot known Conceptionrateper1,000femalesaged15-17 0 5 10 15 20 25 30 35 2005 2006 2007 2008 2009 2010 actual trajectoryestimate 167 168 149 131 107 84 Conceptionrateper1,000femalesaged15-17 0 5 10 15 20 25 30 35 Conceptionrateper1,000femalesaged15-17 0 5 10 15 20 25 30 35 0 5 10 15 20 25 30 35 2005 2006 2007 2008 2009 20102005 2006 2007 2008 2009 2010 actualactual trajectorytrajectoryestimateestimate 167 168 149167 168167 168 149 131 107 84131 107 84
  • 82. 3.8.5 Key things that need to be done The key activities required are:  increasing the provision of sexual health services in GP practices;  increasing the number of young people screened for genital Chlamydia infection; and  ensuring that all sexual health services (including sexual health promotion and sexual relationship education) are designed to enable access by people from different ethnic and religious backgrounds. 3.9 Mental health problems 3.9.1 Overview Mental health problems are common and are the commonest cause of death and years- of-life lost through disability.lxxviii At any time, one in six of adults can be expected to be experiencing mental health problemslxxix and require medical, psychiatric nursing or other therapist interventions. Nearly one third of GP consultations are related to mental health problems,lxxx and over 90% of people with mental health problems will receive care in a primary care setting.lxxxi 3.9.2 The risk we face Various different factors influence the development and course of mental illness, including deprivation, homelessness, unemployment, poor educational attainment, being a member of a Black and minority ethnic group and being a lone parent or teenage mother. Table 28: Estimated number of adults in Barnet suffering from mental health problems in Barnet shows the estimated prevalence, based on national prevalence data derived from the Office for National Statistics Psychiatric Morbidity Survey. ‘Neuroses’ are mental health conditions of all types that are less severe in as much as the person affected by them is aware of their problem and, despite their disability, has a good ‘grasp’ of reality. People who are psychotic are much more severely mentally ill and are unaware that they have a problem. They often have little or no grasp of reality, as the rest of the population would understand it. Table 28: Estimated number of adults in Barnet suffering from mental health problems in Barnet Source: London Health Observatory Mental health problem Prevalence (%) Number of adults affected in Barnet Mixed anxiety and depressive disorder 8.4 16,573 Generalised anxiety disorder 5.3 10,457 Depressive episode 3.6 7,103 All phobias 2.1 4,143 75
  • 83. Obsessive compulsive disorder 1.6 3,157 Panic disorder 0.9 1,776 Psychotic disorders 0.4 789 People aged 65 years and over experience the sort of mental health problems listed in Table 28 to a similar extent to that of younger people. However, dementia becomes a bigger issue as people get older. It affects some 6% of people aged 65 years and over and 20% of people aged over 80 years. Whilst it remains a significant problem, the proportion of people with dementia is unlikely to increase much in Barnet because of the likely change in the age structure of the population. Figure 52 shows that the all-age death rate from mental and behavioural disorder in Barnet is relatively low (the death rate from cardiovascular disease in people aged under 75 years in Barnet in 2007 was 75.7/100,000, for example). This includes deaths from all causes including suicide and dementia. shows deaths from suicides and injury of undetermined intent. The rates of both all mental and behavioural disorders and suicide vary from year to year because the overall numbers are small; small changes in numbers can lead to a relatively large change in rate. Figure 52: Age-standardised death rates from mental and behavioural disorders (all ages) in Barnet Source: Office for National Statistics annual mortality data population estimates Figure 53: Age-standardised mortality from suicide and injury of undetermined intent in people aged under 75 years in Barnet Source: Office for National Statistics annual mortality data population estimates 76 6 7 8 9 10 11 12 13 14 15 2004 2005 2006 2007 Age-standardisedmortality rateper100,000 6 7 8 9 10 11 12 13 14 15 2004 2005 2006 2007 Age-standardisedmortality rateper100,000 0 2 4 6 8 10 12 14 Male Female Person Age-standardiseddeathrateper100,000 0 2 4 6 8 10 12 14 Male Female Person Age-standardiseddeathrateper100,000
  • 84. What is probably more significant is the likely increase in the number of people suffering from dementia in the future. Dementia covers a range of progressive, terminal brain diseases that seriously affects a person’s ability to carry out daily activities. The most common form of dementia among older people is Alzheimer’s disease and involves the parts of the brain that control thoughts, memory, language and ability to carry out daily activities and loss of bodily functions.lxxxii dementia predominantly affects older people: about 5% of those aged 65 years and over will have dementia and some 20% of those aged 80 and over will do so. Dementia also affects younger people, but the main risk factor for dementia is age, with the prevalence rising as people get older. Other risk factors include cardiovascular disease and learning disability such as down’s syndrome. Dementia accounts for 3% of all deaths in England and Waleslxxxiii and the average time from diagnosis to death is 11-12 years, but people can live with dementia for as long as 20 years. Error: Reference source not found shows approximately how many people we can expect to have in Barnet with dementia in 2008 and in 2013. If we fail to address vascular disease risk factors in the expanding middles-age population, then we can expect proportionately more people with dementia in the years after 2013. Table 29 The current and projected numbers of people in Barnet aged 65 years and older No. of people aged 65-79 years No. of people aged 80 years and over No. of people aged 65- 69 years with dementia (prevalence 5%) No. of people aged 65- 69 years with dementia (prevalence 20%) 2008 31,500 14,300 1,575 2,860 2013 34,600 15,400 1,730 3,080 Source of population data: Office for National Statistics Another important risk that we face is that people with mental health problems tend to die earlier than others, even taking suicide into account. People with mental health problems have above-average rates of physical illnesslxxxiv and death from natural causes in people with severe mental health problems is 2.3 times higher than average – mainly due to disease of the circulatory, digestive, endocrine, nervous and respiratory systems.lxxxv Higher death rates in people with severe mental health problems reflect the greater prevalence of smoking and people with severe mental health illness who also smoke are more likely to die of respiratory disease (this risk is 10 times higher in people with schizophrenia.lxxxvi In addition to this, tobacco smoke induces certain enzymes (i.e. makes them more active) and increases the metabolism of a large number of drugs used in the treatment of mental health problems reducing their benefit and – if this effect is recognised – requiring higher doses.lxxxvii If we cannot enable people with mental health problems to quit smoking then this particular health inequality will persist. 3.9.3 The relationship between diversity and deprivation and mental health problems Disorders of mood (e.g. depression) and to a lesser extent thought disorders (e.g. schizophrenia) are usually extremes of normal feelings and thoughts that are out of keeping with the social norms of the sufferer’s society and culture. For example, most people experience both anxiety and depression to some extent in certain circumstances, but when such emotions significantly affect a person’s ability to function normally because of either or both their intensity or duration, then this might become a clinical problem. It is particularly noteworthy that schizophrenia is diagnosed more commonly in 77
  • 85. people of African Caribbean origin than in people from other ethnic groups,lxxxviii and that rates of suicide and of deliberate self-harm are higher among young Asian women than in the White population.lxxxix It is not clear if this is a genetic or a cultural issue. Some physical diseases are more common amongst people in different ethnic groups, so it is not unreasonable to expect that this may apply to some mental health issues. However, this may also be, in part, bound up in different cultural values and beliefs, and whilst, say, diabetes is easy to diagnose with a blood test, the assessment of someone’s mental health can be less clear-cut. 3.9.4 Local targets There is currently a local target to reduce deaths from suicide in Barnet. However, as the numbers of people killing themselves in an area as small as a London borough is quite small, this local target is likely to become a London-wide one. However, there is still a need to endeavour to reduce suicide and injury of undetermined intent, especially amongst people who are currently receiving or who have recently received care from mental health services. 3.9.5 Key things that need to be done The key activities required are:  enabling more people with mental health problems to give up smoking;  identifying and acting on any common factors that there may be in people who are currently receiving or who have recently received care from mental health services and who attempt or succeed in killing themselves;  recognising that there will be an increased need for services to care for people with dementia in the coming years. 3.10 Obesity 3.10.1 Overview Obese adults are at a greater risk of premature death and are more likely to suffer from conditions such as diabetes, heart disease, hypertension, stroke, cancers, musculoskeletal diseases, infertility and respiratory disorders. Overweight is defined as a body mass index (BMI) of 25 and over16 and obesity as a BMI of 30 and over. People with a BMI of 40 or more are referred to as being ‘morbidly obese’. 3.10.2 The risk we face Nationally, in 2002, some 43% of men and 34% of women are overweight, 22% of men and 23% of women are obese and 22% of boys and 28% of girls are overweight or obese.xc This is now an underestimate: it is expected that by 2010, there will be more than 12 million obese adults and 1 million obese children in the country if no action is taken to halt the rise of obesity. The upward trend of obesity is seen as the result of a combination of factors such as less active lifestyle and changes in eating patterns. 16 The body mass index (BMI) is calculated by dividing the weight (measured in kilograms) by the square of the height (measured in metres). Whilst waist circumference and skin-fold thickness are alternative ways of measuring overweight and obesity, the BMI is a simple and consistently reproducible way of doing so and thus is a more appropriate mechanism for screening and monitoring 78
  • 86. Being obese increases the risk of developing a number of conditions, such as diabetes, high blood pressure and high blood cholesterol that, in turn, increase the risk of life- threatening conditions such as heart disease and stroke. Obesity also increases the risk of developing some types of cancer, musculoskeletal disease, infertility and respiratory problems.xci Regardless of age, a person with a BMI of 30 or greater has a higher risk of premature death than someone with a healthy BMI (i.e.19-25). Figure 54 shows the effect that unchecked obesity will have on the incidence of three key conditions: diabetes, stroke and coronary heart disease. Obesity has been called ‘the new epidemic’ and likened in its risks to health to smoking. Whilst currently fewer people die in Barnet due to the direct and indirect effects of obesity, it is clear that without adequate action, morbidity and mortality will rise considerably over the coming years and will probably reverse the current downward trend in death rates. Childhood obesity is also an issue. PCTs are now required to measure the height and weight of children in reception classes and year 6 classes each year. The results for Barnet are shown in Figure 55. The fact that obesity levels dropped slightly in 2006/07 may be a reflection of natural variation and should not, at this stage, be regarded as an encouraging trend – we only have two years’ data so far and are currently awaiting confirmation of the data collected for 2007/08. Childhood overweight and obesity is a special problem. It is difficult enough for an adult to lose weight, as shown by the plethora of diet books and services available commercially. Childhood overweight and obesity is a family issue: young children have no real sense of overeating or taking insufficient exercise and are dependent upon adult family members and carers to help them avoid or address obesity. Figure 54: The proportionate increase expected in three diabetes, stroke and coronary heart disease due to obesity (age and sex standardised)xcii 79
  • 87. 80 0 10 20 30 40 50 60 70 80 2005 2010 2015 2020 2025 2030 2035 Proportionateincreaseoncurrentlevels(%) diabetes stroke coronary heart disease 0 10 20 30 40 50 60 70 80 2005 2010 2015 2020 2025 2030 2035 Proportionateincreaseoncurrentlevels(%) diabetes stroke coronary heart disease
  • 88. Figure 55: Current obesity levels in Barnet reception classes and Year 6 classes and trajectory 3.10.3 The relationship between diversity and deprivation and obesity Both men and women in lower socio-economic groups are more likely to be obese than those in professional occupations. In terms of differences between ethnic groups, Asian children more likely to be obese compared to White children, and Black Caribbean women have obesity levels much higher than the national average, as do Pakistani women, albeit to a lesser extent. As referred to in section 3.10.1, proportionately more men are overweight than women but the proportion of obese men and women is much the same. It is unclear why this should be so and it may simply be a statistical artifact. However, the relative risk of developing a number of diseases is greater in obese women than it is in obese men. 3.10.4 Local targets In common with other London PCTs, we are required to reduce the year-on-year rise in childhood obesity. The trajectory for this is shown in Figure 55 3.10.5 Key things that need to be done The key activities required are:  expanding services for families so that obese children can be better enabled to lose weight;  targeting groups more likely to be overweight or obese to identify and manage risk factors for cardiovascular disease; and  establishing services for GPs, practice nurses, community pharmacists, hospital doctors, nurses and allied health professionals, and social care workers can signpost and/or refer people to if they are obese. 81 2005/06 2006/07 2007/08 2008/09 2009/10 2010/11 0 2 4 6 8 10 12 14 16 18 20 Proportion(%)ofchildrenidentifiedasobese reception class year 6 actual trajectorydata being collected 10.5 17.7 9.21 17.3 10.1 10.5 10.9 18.2 18.6 19.0 2005/06 2006/07 2007/08 2008/09 2009/10 2010/11 0 2 4 6 8 10 12 14 16 18 20 Proportion(%)ofchildrenidentifiedasobese reception class year 6 actual trajectorydata being collected 10.5 17.7 9.21 17.3 10.1 10.5 10.9 18.2 18.6 19.0
  • 89. 3.11 The views of local residents 3.11.1 Overview – Perception of health The Citizens Panel Survey (2006), surveyed 1200 members and received 506 responses, thereby providing a 42% response rate. In 2007, 1155 Barnet residents were contacted and 536 responses were received (46% response rate). The respondents were asked how they rated their own health. Almost half of respondents (49%) said that their life has become less healthy in the last seven years. It was found that over two thirds (70%) of respondents had rated their own health as either good or very good; this was down from 79% in 2000. Indeed at the other end of the spectrum 6% of respondents rated their own health as (very) poor and this was compared to 3% in 2000. The survey also indicated that males in Barnet felt their health was poor (8%), slightly higher than compared to Barnet female respondents (6%), but this was comparable with the national average. Although 18-24 years old age group did not rate their health as very poor, it was 35-44 year age group who were most likely to rate their own health as very good (85%). Only 63% of 18-24 year age group indicated that their health was very good and 59% for those aged 55+. It was found that respondents of White ethnicity were more likely to rate their own health as very good (73%) than respondents of “Non White” origin (59%).17 In the TellUs 2 Survey 37% of pupils rated themselves as being ‘very healthy,’ this figure is higher than the national average of 31%. Furthermore, 9% of pupils said they were ‘not very healthy’; this is the same percentage as the national average. 3.11.1 Healthy lifestyle During the public consultation in 2008, the respondents were asked what were they likely to undertake in order to improve their health. The responses to this question are shown in Table 30 and Table 31. 17 London Borough of Barnet 2006– Citizens Panel Survey 82
  • 90. Table 30: What respondents said they would do in order to improve their health (Ipsos MORI and Better Health in Barnet surveys) Barnet PCT Consultation 2008 Improve Diet Increase level of exercise Reduce levels of stress Lose weight Reduce alcohol intake Give up smoking Improve sexual health Other 535 24% 515 23% 361 16% 343 15% 98 4% 76 3% 44 2% 23 1% Ipsos MORI Improve Diet Increase level of exercise Reduce levels of stress Lose weight Reduce alcohol intake Give up smoking Improve sexual health Other 54 42% 82 63% 51 39% 56 43% 12 9% 6 5% 5 4% 9 7% Table 31: The top 5 healthy lifestyles which respondents indicated they would do to improve their health Better Health in Barnet Healthcare for London Improve diet Increase level of exercise Reduce levels of stress Lose weight Reduce alcohol intake Increase level of exercise Lose weight Improve diet Reduce levels of stress Reduce alcohol intake 3.11.2 Alcohol consumption in Barnet The Citizens Panel survey 2006, revealed that 5% of respondents drunk alcoholic beverages every day, whilst 11% were drinking 4-6 times a week. Nevertheless, 20% of respondents indicated that they were drinking less than once a month and 17% never drunk alcoholic beverages. Barnet Council’s 2006 Citizens Panel Survey showed that, generally, younger people drink alcohol more frequently than older ones. This is shown in. It was found that White respondents were more likely to drink frequently (19%) compared to BME groups (6%). Respondents who indicated that they had a disability were less likely to drink alcohol (25%) compared to the general population of Barnet (15%). The data did not reveal any correlation between alcohol consumption and income. However, the highest alcohol consumption was in £10,000 -£19,000 income group. 83
  • 91. Figure 56: The number of people reporting drinking 5 or more units of alcohol and the frequency of doing so The results of the TellUs 2 surveyxciii indicates that alcohol consumption among young people in Barnet is lower than the national average. Table 32compares the results of this survey with national data. Table 32: Results regarding alcohol consumption in TellUs 2 survey Barnet National Never drink alcohol 61% 42% Get drunk once/twice a week 9% 12% Get drunk three or more times a week 4% 7% The Exeter surveyxciv found that there was a rise in the number of pupils who drunk at least one alcoholic drink in the last week which was 30% compared to 26% in 2001. Nevertheless, the number of female pupils indicated that they consumed over the recommended units of alcohol (14 per week) had decreased from 15% in 2001 to 13%. 3.11.3 Healthy eating The populations surveyed by both Barnet Council18 and Barnet PCT19 identified healthy eating as a factor for improving health. Barnet PCT’s survey found that 535 (24%) respondents wished to improve their diet. Furthermore, the Citizens Panel showed that respondents were eating more healthily: 26% said that they ate 5 or 18 London Borough of Barnet 2006 – Citizens Panel Survey 19 Barnet PCT Public Consultation Survey 2008– Delivering Better Health in Barnet – “Your NHS, Your Money, YOU help Decide” 84 0 10 20 30 40 50 60 70 80 90 100 18-24 25-34 35-44 45-54 55-64 65+ Numberofrespondents 0-1 per month 2-4 per month 2-3 per week 4-7 per week 0 10 20 30 40 50 60 70 80 90 100 18-24 25-34 35-44 45-54 55-64 65+ Numberofrespondents 0-1 per month 2-4 per month 2-3 per week 4-7 per week 0-1 per month 2-4 per month 2-3 per week 4-7 per week
  • 92. more pieces/portions of fruit and vegetables in a day. However, 2% stated that they did not eat even one portion of fruit or vegetables in a day. Women in Barnet appear to have healthier eating habits than men. 34% of women indicated that they ate “5 or more” fruit and vegetable portions as compared to only 17% of men. When Black and minority ethnic groups were compared to respondents from White ethnic origin, only 15% of them groups indicated that they ate five or more fruit and vegetables a day compared to 30%. Other areas that were highlighted by respondents in this survey included: reducing high blood pressure, reducing cholesterol levels, visiting the dentist, avoiding drug use and starting dancing. As well as identifying what respondents were more likely to do in order to improve their health, they were asked what the NHS could do to help them make the changes. The respondents indicated that they thought that the following would help:  stress reducing classes;  well-being classes;  leaflets on stress relief techniques;  get fit sessions (free) like stop smoking sessions;  crèche so parents can partake in exercise;  make gym use cheaper, particularly for people who are unable to afford it e.g. those on low incomes;  regular check-ups with GP or other health professional for advice and monitor progress;  more awareness for school children;  more information from radio / TV;  advertising, promotions in health centres, surgeries; and  greater access to dietitians. The Healthcare for London consultation found that 101 people (78%) strongly agreed or agreed that they would welcome advice on staying healthy when they came into contact with healthcare professionals. (e.g. advice on losing weight or stop smoking). It is worth noting that in the Citizens Panel Survey (2006), 49% of respondents gave a number of reasons why their health had become worse over the last seven years. These are summarised in Table 33. 85
  • 93. Table 33: Reasons given for people’s health deteriorating Reason Number of people citing this Taking less exercise 24 Increased pressure at work 14 Increase in stress levels generally 13 Weight increase/eating too much/wrong foods eaten 11 Onset of old age 10 Progressive worsening of existing condition 10 Air pollution/Smoking in public places/Cars 8 Mobility more difficult due to health problems 8 Increased household bills/Increased cost of living 6 One of the highest responses in both surveys was the recognition that exercise was required to improve health. Responses to PCT survey indicated that 23% of people wished to increase their level of exercise. Moreover, the Citizens Panel survey 2006, revealed that 29% of respondents stated that they took the recommended level of physical activity a week i.e. 30 minutes or more of physical activity a one day, five times or more a week. It was found that only 17% of respondents indicated that they exercised less than once a week to rarely or never. The responses from the Citizens Panel Survey 2006, indicated that Barnet residents who took the recommended level of exercise per week was below the national average Currently 120 out of a potential 700 adults with learning disability in Barnet are known to take regular sports and exercise activities more then once a week. Barnet Council is keen to increase the numbers participating in sport to three sessions which last for 30 minutes. However, barriers to participation in sport include:  a lack of clubs where people can learn a sports skill necessary to enable them to access mainstream;  no accessible list of inclusive activities;  a limited number of sessions to meet the increased participation; and  little promotion or awareness of the benefits of sport within this community. The evidence of specific health problems within the community of people with learning disability also makes concerning reading: Research for the Disability Rights Commission investigation Equal Treatment : Closing the Gap (September 2006), found that the rate of respiratory disease was significantly higher (20% more ) than in the remaining population (16%). It was found that 80% of people with learning disability engage in levels of physical activity below the minimum recommended by the Department of Health.. Furthermore, people who had lower ability and who live in more restrictive conditions are at risk of increased physical inactivity. The Citizens Panel Survey 2006 revealed a clear negative relationship between level of income level and level of physical activity. It was found that the recommended amount 86
  • 94. of physical activity was undertaken 38% of the time by respondents who were on incomes below £10,000, but only 17% by those on income of £100,000 – £150,000. However, 50% of those with an income in excess of £200,000 said that they undertook regular physical activity, whilst the least physically active were those on incomes between £40,000 to £200,000. the Barnet PCT consultation found that only 3% of those surveyed thought that giving up smoking was one of their first three priorities in order to improve their health. Nevertheless, the Citizens Panel survey showed that there were 14% of smokers in their survey population and 68% indicated that they wanted to quit smoking whilst 20% indicated that they had a strong desire to do so. Non-smokers made up the largest group of those surveyed (n=461, 62%), followed by those who had quit smoking for more than two years (n=148, 20%). As giving up smoking is the most significant thing that someone can do to impove their health (and it is better not to start), this is very encouraging. 4 Investing in independence 4.1 Overview The Government’s green paper Independence, Well-being and Choicexcv set out proposals for the future direction of social care for all adults of all age groups in England. A key priority area within the proposal is to provide services that help to maintain the independence of the individual by giving them greater choice and control over the way in which their needs are met. This grene paper identifies areas that Barnet PCT and Barnet Council need to take into account in commissioning services. The green paper states that many older people prefer to stay in their own homes in familiar surroundings with their family and friends, whilst remaining independent. Other wishes expressed by older people were for easy access to amenities and support, social activity and a sense of community, and:  improved health;  improved quality of life;  making a positive contribution;  exercise of choice and control;  freedom from discrimination or harassment;  economic well-being; and  personal dignity. Helping people stay at home for as long as they want to will require a fundamental shift from the focus on just treating disease to promoting health to reduce the risk of avoidable disease. Providing people with good information and advice on how to manage their condition, increasing investment in active rehabilitation and prevention and improving the way that services are delivered in terms of flexibility and quality will all help avoid the costly and distressing consequences of merely responding to health crises. 87
  • 95. Barnet Council and Barnet PCT need to work with local communities to develop support through easily accessible networks which will help promote health and well being and prevent isolation and loss of independence. Although people with physical disability make up the largest group who have support needs (74%), the frail and elderly are the second highest 24%. A comparison of the needs of owner-occupiers and those in other tenures has shown that owner-occupiers are more likely to have unmet needs. The Housing Needs Assessment 2006 indicated that 43% (1,947) households in Barnet were reported to receive no support. Following an assessment it was found that (5%) 97 households were assessed to need no support. Nevertheless, when comparing with older people living in other tenures only 11% (498) households were receiving no support and 1% (5) were assessed as needing no support. This indicates that older people who are owner-occupiers are more likely to have unmet needs than older people living in other tenures. 88
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