WCC Submission 30.11.08

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WCC Submission 30.11.08

  1. 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. 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. 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. 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. 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. 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. 7. iv
  8. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 21. by Barnet Homes 14
  22. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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

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