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Public Health

THE CHANGING STATE OF THE SOUTH WEST 2012

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Public Health
This section details the latest statistics relevant to public health in the South West, before outlining the wide ranging changes to the public health system, and reform programme.
WHAT DO WE KNOW?

In 2008-10, the South West and South East had the joint highest life expectancy of all the English regions for women (83.5 years), and the South West had one of the highest for men (79.5 years). The comparable figures for England were 82.6 years for women and 78.6 years for men. (Source: Office for National Statistics).

However, these positive life expectancy statistics mask inequalities within the South West. People living in areas of greatest deprivation have shorter life expectancies than those in the least deprived areas. For example, men living in the most deprived areas of North Somerset die almost 10 years earlier than their neighbours in less deprived areas. Issues associated with reduced life expectancy include equality of access to education, employment and income, as well as differences in individual behaviour.

Moreover, geographical differences might in part be a consequence of internal migration, whereby healthier and wealthier individuals move to more affluent areas. (Source: Health Profiles Life expectancy by deprivation quintile 2005-09).

Mortality rates from major disease groups such as cancer and circulatory diseases are amongst the lowest in England (see Figure 8.1).


Figure 8.1: Number of Deaths and Age-standardised Mortality Ratios (SMRs) for Selected Causes of Death in the South West

Cause of death

Number of deaths aged 1+ in 2009

Age-standardised Mortality Ratio (England = 100, 2007-09 pooled)

Confidence interval

Comparison to England

All causes

51,870

93

93-93

Lower

Circulatory

17,202

94

93-94

Lower

All Cancers

14,479

94

93-95

Lower

Accidents

1,236

97

94-100

Similar

Asthma

97

81

72-91

Lower

Bronchitis and Emphysema

191

122

113-133

Higher

Suicide and injury undetermined

514

107

101-113

Higher

Land transport accidents

252

114

106-122

Higher

Malignant Melanoma

248

125

116-134

Higher

Prostate Cancer

1,130

104

100-107

Similar

Source: Number of Deaths (aged 1+): 2009; SMRs: 2007-09 pooled; National Statistics (NCHOD)

However, the rates of death from malignant melanoma, and bronchitis and emphysema in the South West are amongst the highest in England. (Source: NHS Information Centre).

Suicide rates in the South West, as across England, have increased since 2007, with an average of 460 suicides and undetermined deaths in the region per year (see Figure 8.2).

Hospital admissions for self-harm have also increased, with the South West experiencing a 73% rise between 2002/03 and 2008/09 - the second highest in England. (Source: South West Public Health Observatory)

Infant mortality is defined as death within the first year of life. Factors affecting infant mortality include extreme prematurity and congenital anomalies. Some of the risks related to these can be reduced through better diet, not smoking, and better antenatal and neonatal care.

Deaths under one year of age per 1,000 live births have been falling in England and in the South West. In the South West, the infant death rate has dropped to 3.2 in 2010 compared to 4.3 for England as a whole (Source: Office for National Statistics). While the South West’s infant mortality rate is lower than for England as a whole, there is variation by deprivation within the South West. Analysis by the SWPHO shows that the most deprived quintile has 25% of all births, but 35% of all infant deaths (Source: South West Public Health Observatory).


Figure 8.2: Trends in Numbers of Suicides and Undetermined Deaths, all ages, males and females, South West, 2001-2010

[ Zoom ]
Source: ONS Public Health Mortality File; Analysis: SWPHO; Definition: ICD-10 codes: X60-X84, Y10-Y34 (excluding Y33.9)
In 2009/10, 14.2% of women in the South West were current smokers at the time of delivery, similar to the England average of 14.0%. (Source: Health Profiles 2011).

The latest National Child Measurement Programme data for 2010/11 show that nearly one in ten children in Reception year in England were obese (9.4%), and more than double this proportion of children in Year 6 were obese (19.0%). The South West, however, had lower childhood obesity levels than England for both Reception year (8.8%) and Year 6 (16.6%). In contrast the percentage of children who were overweight in Reception year in the South West (14.3%) was higher than in England (13.2%). The percentage of Year 6 children who were overweight was similar in the South West (14.2%) to that of England (14.4%).

The measles-mumps-rubella vaccine (MMR) is a safe and highly effective vaccine that was introduced in 1988 with coverage of over 90% between the early 1990s and 1998. However, a fall in uptake was observed from 1997 (down to 81% in 2003/04) as a result of adverse publicity about the vaccine (Source:
Health Protection Agency). More recently in 2010/11, the uptake has increased significantly, reaching 90%. Within the South West there is wide variation in MMR uptake by Primary Care Trust (PCT) (see Figure 8.3). (Source: NHS Information Centre).

Latest data for 2007-09 show that there are, on average, 34.5 conceptions per 1,000 females aged 15-17 in the South West each year, which is lower than the England average of 40.2. (Source:
SWPHO)

Choices that adults make are key to improving the future health of the South West. While smoking rates have reduced in recent years, in 2009 it was estimated that almost one in five (18%) adults still
smoked, with the proportion slightly higher in men (19%) than in women (17%). Both groups have seen considerable reductions in prevalence since 2008 when it was estimated that 21% of men and 22% of women smoked. (Source: The General Lifestyle Survey 2009).

In 2009, 24% of women and 34% of men in the South West drank more than the recommended sensible daily limits (maximum of three units for women and four for men) on at least one day in the week prior to the survey. However, this is lower than the equivalent percentages for England as a whole, namely 29% of women and 37% of men. (Source:
The General Lifestyle Survey 2009).

Deaths from chronic liver disease and cirrhosis of the liver have increased since the early 1990s. However, the increase has not always been linear. And although the all age directly age-standardised mortality rate (8.72 per 100,000 European population, 95% CI: 8.29, 9.16) in 2008-10 is lower in the South West than in England as a whole (10.28 per 100,000 European population, 95% CI: 10.12, 10.43), the disease nonetheless costs many lives in the South West every year. In the years 2008-10, over a thousand men in the South West died from chronic liver disease (including cirrhosis of the liver); nearly double the number in 1996-98 (1,064 deaths compared to 588). As well as lower numbers amongst women, a much smaller increase in the number of deaths was seen for the equivalent period, approximately a one-third increase; 594 deaths in 2008-10, compared to 437 in 1996-98. (Source:
NHS Information Centre).

Figure 8.3: Uptake of MMR Vaccination by Second Birthday by Primary Care Trust in the South West, 2010-11

[ Zoom ]
Uptake of MMR vaccination by second birthday by PCT in the South West, 2010-11
Source: HPA COVER data. Note: Bournemouth & Poole and Torbay Care Trust experienced data quality issues as a result of recent migration to a new child health information system or problems with their existing child health information system
It is now estimated that over a quarter of adult men and women in the region are obese. Also, a further 40% of men and 30% of women are overweight. (Source: Health Survey for England 2010).

Although the age-standardised mortality ratio (SMR) for land transport accidents is higher for South West residents than for English residents (see Figure 8.1) as a whole, overall the South West has lower rates of serious injury and death from road transport incidents (based on location of the incident rather than area of residence): during the three year period 2007-09, in the South West there were 42 deaths per 100,000 population (crude rate) compared to England’s 48. However, this still equates to over 2,200 people, on average, being seriously injured or losing their lives on the South West’s roads each year. (Source: Health Profiles 2011).

In 2009/10 there were an estimated 2,830 excess winter deaths in the South West, of which 55% occurred in those aged 85 years and older. In 2010/11 there were 2,400 excess winter deaths in the South West, with a slightly lower proportion (50%) occurring in those aged 85 years and older than in 2009/10. (Source: ONS Excess Winter Mortality Table 2). Three year averages by region are shown in the ONS Excess Winter Mortality Statistical Bulletin.

Between 2011 and 2030 the population aged 65 years and over is projected to increase by over 547,000 with 156,600 of this increase projected to be in those aged 85 years and over. This is a doubling in number of the region’s oldest age group. While mature adults in the South West are healthier than those in the rest of England, a growing older population still presents many challenges for the region. (Source: POPPI).

A 2004 survey commissioned by the Marie Curie Cancer Care found that 64% of Britons would prefer to die at home. However, 54% of deaths in England in 2008-10 were in hospital and 20% occurred at home. In 2008-10, the South West had the lowest proportion of deaths in hospital (50%) when compared with other regions and 21% of deaths were at home. (Source: SWPHO).

The proportion of deaths in ‘usual place of residence’, which includes own home and care home, is a proxy marker for the quality of end of life care adopted on the basis that many people would, given the choice, prefer to die there. Latest data for 2008-10 indicates that the South West had the highest proportion of deaths at usual residence (44%) when compared to other regions and England (39%); see Figure 8.4 (Source: ONS).

Figure 8.4: Proportion of Deaths in Usual Place of Residence, by Primary Care Organisation in the South West, 2008 - 2010

[ Zoom ]
Proportion of deaths in usual place of residence by PCT in the South West 2008-10
Source: ONS Public Health Mortality File. Analysis: SWPHO

1- Place of death indicator is a percentage calculated as: deaths in usual place of residence/all deaths* 100
2 - Excluding al deaths from external causes defined by the International Classification of Diseases, Tenth Revision (ICD-10) codes V01-V98.
3 - Based on boundaries and communual establishment types as of May 2011
4 - Figures exclude deaths of non-England residents
5 - Figures are for deaths registered in calendar years
6 - Not all primary care organisations (PCOs) are entirely within the boundaries of the strategic health authorities (SHAs) to which they report, so the sum of the deaths in the PCOs included in an SHA do not always equal the total figure shown for the SHA.

WHAT'S THE POLICY CONTEXT? 
The changes to the Public Health system are wide ranging and include the establishment of new structures and changes to responsibility at all levels of the system. As set out in the Health and Social Care Bill, the changes introduced by the coalition government will be subject to Parliament’s approval.

‘Healthy Lives, Healthy People - Update and Way Forward’ outlines the new public health system, detailing how localism will be at the heart of the reforms, with responsibilities, decision making and financial responsibility devolved wherever possible. Enhanced central powers will only be taken where absolutely necessary, for example in areas such as emergency preparedness and health protection.

The Public Health reform programme has a range of elements to it. Key areas include:


The role of the Director of Public Health

Directors of Public Health will be the strategic leaders for public health and tackling health inequalities in local communities. They will work in partnership with the local NHS and across the public, private and voluntary sectors. As a core member of the local Health and Wellbeing Board the Director of Public Health will be the principle adviser on health to the Local Authority.

The Director of Public Health will be:

  • The principal adviser on health to elected members and officials;
  • The officer charged with delivering key new Public Health functions;
  • A statutory member of the Health and Wellbeing Board;
  • The author of an annual report on the health of the population.

Health and Wellbeing Boards

Maximising opportunities for integration between the NHS, public health and social care, Health and Wellbeing Boards will promote joint commissioning, driving improvements in the health and wellbeing of the local population. They will provide the vehicle for local government to work in partnership with commissioning groups to develop comprehensive Joint Strategic Needs Assessments and robust joint health and wellbeing strategies.

Ring Fenced Budgets

There will be ring-fenced public health funding from within the overall NHS budget. Although ring-fenced this will still be subject to the running-cost reductions and efficiency gains that will be required across the system. A new health premium will be introduced to reward Local Authorities for progress made against elements of the proposed public health outcomes framework, taking into account their local health inequalities.


Public Health England (PHE)

PHE will be established as an executive agency to the Department of Health. The service will drive delivery of improved outcomes in health and wellbeing and protect the population from threats to health. PHE will ensure access to expert advice, intelligence and evidence and will provide a focus for the development of new approaches including adopting insights from behavioural sciences; and provide an expert and resilient health protection service.


NHS Commissioning Board

The NHS will continue to play an important role in commissioning and providing Public Health services While local authorities will become the lead local body for many Public Health services, where appropriate the NHS Commissioning Board will be required to commission specific services funded from the Public Health budget. The NHS Commissioning Board will set incentives for clinical commissioning groups to encourage local GPs to play an active role in Public Health.


Clinical Commissioning Groups

Clinical Commissioning Groups (CCGs) will take responsibility for the majority of NHS commissioning. Led by GPs, their membership will ensure involvement of patients, carers, the public and a wide range of health professionals. They will be under a duty to promote integrated services and will be required to operate in an open and accountable manner.

Health and Wellbeing Boards will also be involved as CCGs develop their commissioning plans and there will be an expectation, set out in statutory guidance, for the plans to be in line with the Joint Health and Wellbeing Strategy.


HealthWatch

Based upon the current Local Involvement Networks (LINks), local branches of HealthWatch will provide the public with a single point of contact for local services. HealthWatch will give people real influence over decisions made about local services; it will support individuals as well as engaging communities; and HealthWatch England will ensure that consumer voice has influence not only locally but nationally also.


Leadership

The Secretary of State will be accountable for the NHS, exercising their responsibility through their relationship with the new bodies, such as the NHS Commissioning Board. The Chief Medical Officer will have a central role in providing independent advice to the Secretary of State for Health and the Government on the population’s health. They will be the leading advocate for public health within, across and beyond government, and will lead a professional network for all those responsible for commissioning or providing public health.

WHAT HAPPENS NEXT?
Subject to the passage of the Health and Social Care Bill, the Government plans to:

  • Enable the creation of Public Health England, including the formal transfer of functions and powers from the Health Protection Agency and the National Treatment Agency for Substance Misuse (NTA);
  • Transfer local health improvement functions to local government, with ring-fenced funding allocated to them from April 2013;
  • Give local government new functions to increase local  accountability and support integration and partnership working across social care, the NHS and Public Health.

The abolishment of Primary Care Trust and Strategic Health Authority clusters in April 2013 will coincide with the establishment of PHE and the NHS Commissioning Board, with full handover of responsibilities in early 2013.

Following the paper ‘Healthy Lives, Healthy People - Update and Way Forward’ a series of policy papers will outline the operating model for PHE, the public health outcomes framework and the role of local government in public health. Further documents will follow to define the funding allocations for public health in 2012/13 and a consultation will be issued on a public health workforce strategy
in early 2012.
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