RISK FACTORS FOR HEALTH & WELLBEING by WJQQY8G

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									       DRAFT
   EVIDENCE BASE
      FOR THE
  ESSEX HEALTH &
WELL BEING STRATEGY

      A product developed from the
 Essex Joint Strategic Needs Assessment




            28 February 2012
                          DRAFT as at 28 February 2012


JSNA CONTENTS
FOREWORD                                                       2
KEY ISSUES                                                     3

CHAPTER 1: ESSEX POPULATION & HEALTH DETERMINANTS              5
1.1 POPULATION OF ESSEX                                   5
1.2 DEPRIVATION                                           6
1.3 EMPLOYMENT & ASPIRATIONS                              7
1.4 ACCESS TO SERVICES & TRANSPORT                        8
1.5 CRIME & COMMUNITY SAFETY                              9
1.6 POVERTY AND SOCIAL CLASS                              11
1.7 HOUSING & ENVIRONMENT                                 12
1.8 COMMUNITY COHESION                                    13
1.9 RECOMMENDATIONS TO THE HEALTH & WELLBEING BOARD       13
1.10 SUPPORTING RESOURCES                                 14
CHAPTER 2: HEALTH & COMMUNITY WELL-BEING & INEQUALITIES        14
2.1   LIFE EXPECTANCY & QUALITY OF LIFE                   14
2.2   MORBIDITY & TRENDS                                  15
2.3   DISEASE BURDEN & TRENDS                             18
2.4   LIFESTYLE BEHAVIOURS                                21
2.5   INTERVENTIONS TO REDUCE HEALTH INEQUALITIES         25
2.6   POPULATION PROTECTION                               26
2.7   RECOMMENDATIONS TO THE HEALTH & WELLBEING BOARD     27
2.8   SUPPORTING RESOURCES                                28
CHAPTER 3: CHILDREN, YOUNG PEOPLE & FAMILIES                   30
3.1   MATERNAL & INFANT HEALTH & WELLBEING                30
3.2   CHILDREN & YOUNG PEOPLE                             31
3.3   CHILDREN AT RISK & SAFEGUARDING ISSUES              37
3.4   RECOMMENDATIONS TO THE HEALTH & WELLBEING BOARD     38
3.5   SUPPORTING RESOURCES                                39
CHAPTER 4: ADULTS & VULNERABLE GROUPS                          40
4.1 WORKING AGE POPULATION                                40
4.2 SOCIAL CARE PROVISION IN ESSEX                        41
4.3 LEARNING DISABILITIES                                 41
4.4 PHYSICAL AND SENSORY IMPAIRMENT                       41
4.5 CARERS                                                42
4.6 OLDER PEOPLE                                          42
4.7 VULNERABLE ADULTS                                     44
4.8 TRAVELLING FAMILIES                                   45
4.9 RECOMMENDATIONS TO THE HEALTH & WELLBEING BOARD       45
4.10 SUPPORTING RESOURCES                                 46
CHAPTER 5: PUBLIC OPINION & SERVICE USER VIEWS             46
5.1   PUBLIC PRIORITIES OF ADULTS                         46
5.2   RESULTS FROM ENGAGING CHILDREN & YOUNG PEOPLE       47
5.3   RESULTS FROM HEALTH SERVICE ENGAGEMENT              47
5.4   RESULTS FROM ADULT SOCIAL CARE ENGAGEMENT           48
5.5   SUPPORTING RESOURCES                                51




                                                                    1
                                DRAFT as at 28 February 2012


Foreword

“We envisage Health and Wellbeing Boards developing a joint health and wellbeing strategy
based on the assessment of need outlined in their JSNA…”

This document is the latest in the suite of Essex JSNA products being produced to generate
meaningful information for commissioners and policy makers.

It will be used to produce a short, easily readable and high-level account of what the issues
are for Essex over the next three years. Together the detailed evidence and summary will
help the Health and Well Being Board make comprehensive judgements about priorities for
the Health and Well Being Strategy.

The summary of key issues at the beginning of the document picks out a number of topics
that are likely, given emerging trends, to have a major impact on the work of the Board.

This document has been developed, in partnership, by the NHS Public Health Intelligence
Team, the ECC Research & Analysis Unit, the ECC Children & Young People Involvement
Team, the ECC Adult Social Care Informatics Team and Essex DAAT. The contributions of
other colleagues are also gratefully acknowledged.




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                                    DRAFT as at 28 February 2012


KEY ISSUES


SOCIAL AND ECONOMIC FACTORS

Population growth
By 2031, Essex will have to absorb an extra 324,000 residents. By 2031, the number of people aged
85 or over in Essex will more than double, from about 31,000 to 77,000. These extra years of life will
often involve poor health, dementia or disability. The number of people with learning disabilities may
also continue to grow with further advances in medical technology. All of this will have an impact on
housing needs – including specialised housing- as well as on health and social care.

Deprivation
A wide range of problems, from poor health to crime to low educational attainment are associated
with deprivation or low income. Deprivation even reduces the ability to die of a terminal illness in
one’s own home rather than in hospital. Children from the lowest social class are five times more
likely to die in road accidents than those from the highest. Effective targeting of action to tackle
clusters of issues for deprived communities will be important.

Impact of economic downturn
The recession that arrived in 2008 is still pushing UK GDP about 4% points below its pre-2008 trend
value. A long period of low growth is expected. Rising unemployment and less secure part time jobs
with low real income can be a source of stress affecting health. The impact of these changes is more
likely to be felt by women and young people in particular. Long term investment in skills would help
to counteract this.

Stresses on family life
About 13% of pupils aged 7 to 16 in Essex have poor emotional well-being. This can affect their
social and emotional development and educational attainment. Children and young people say that
their safety, especially from bullying, is their biggest concern. The percentage of children in poverty
in Essex is lower than in England but is rising more rapidly – especially in Tendring. Being a carer
can adversely affect the wellbeing of both children and adults.

Stresses on communities
‘Sense of belonging’ and of ‘people getting on well together’ as measured by surveys are high in
Essex. However, communities can be disrupted by high house prices forcing younger people to
move. Commuting long distances to work is common in Essex. Crime is generally low but people say
that keeping it low is important. Some minority groups, such as those by ethnicity, sexuality and
disability, experience prejudice or hate crime.


LIFE EXPECTANCY GAP

The gap in life expectancy between the best and worst wards in Essex is nearly 20 years. For men,
the immediate causes of the gap are coronary heart disease, lung cancer and stroke. For women, it
is breast cancer, lung cancer and coronary heart disease. Life expectancy is shaped by social and
economic factors, mediated through individual behaviours.


BEHAVIOURAL FACTORS

Smoking
This is the single biggest cause of preventable illness and early death. Braintree, Tendring and
Basildon have the highest prevalence. Variation in smoking habits in pregnancy between socio-
economic groups accounts for about one-third of the difference in stillbirth rates and infant mortality
rates. Asthma is 50% more likely in children whose parents smoke.

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                                    DRAFT as at 28 February 2012
Diet and exercise
Nearly 25% of people in Essex are obese. Harlow, Castle Point and Braintree have highest
prevalence. Breastfeeding can reduce obesity in later life but only West Essex has an initiation rate
higher than the national average. A good diet can reduce risks of several illnesses. Over the last 25
years there has been a big drop in physical activity as part of daily routines but a small rise in it for
leisure.

Alcohol
Over 21% of adults in Essex are taking part in increasing and higher risk drinking. There has been
an increase in hospital admissions due to alcohol-related harm over the last few years. Harlow had a
significantly higher rate of admissions in 2009/10 than the England average. There has been a
marginal increase in mortality rates from liver disease since 2004-06 across most of Essex.

Safeguarding
Domestic abuse impacts on both adults and children, with women most likely to be the victims. It is
estimated that in 2010 for females aged 16-59 years, over 35,000 people may have been the victim
of domestic abuse. Over half of the 9, 248 children identified as in need in Essex in March 2011 had
abuse or neglect as the primary reason. The three biggest reasons for 1,110 children having a child
protection plan were neglect, multiple abuse and emotional abuse.

Immunisation

Poor media reporting around the effect of some immunisation programmes had a negative impact on
uptake for MMR and the flu jab over recent years. With some innovative campaigns, we are seeing
an improvement in uptake with MMR vaccination alone showing a 5-6% increase over the past 2
years. It will be important to sustain this.


SERVICES

Access to services
Physical access to services depends on transport. This is a high priority for residents. Poorer people
may not be able to run a car or afford train or bus fares. Satisfaction with bus services nowhere
exceeds 66% and is lowest in rural districts like Uttlesford, Maldon and Braintree. Use of health and
social care services by some groups, eg, BMEs for social care, is disproportionately lower than
expected.

Satisfaction with services
Overall 87% of people surveyed said they were satisfied with social care services. Clients ask for
better signposting to existing information, advice and support, and improved standards following
assessment. 82% of people eligible for personal budgets receive them. Satisfaction with GP support
for long term health conditions is in line with the national average but low in Basildon. Patient ratings
of hospital maternity services in Essex are quite low. Only 63% reported being treated with kindness
and understanding in hospital after birth.

Integrating the health and social care systems
Health conditions are major drivers of the demand for social care, and appropriate housing and
social care can help to prevent acute health episodes. Citizens recognise the issues and want a
single approach to their care. Failure to integrate the systems, eg, through delayed discharges from
hospital or poor reablement, can be wasteful of public resources.

Getting the balance right between community and secondary services
A major challenge will be to meet people’s needs in the community through universal public services,
community-based social care and primary health care. This can prevent escalation of need through
psychological dependency on care systems. It is usually preferred by citizens as a better outcome. It
is also usually a more effective use of scarce public resources.


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                                   DRAFT as at 28 February 2012


1. ESSEX POPULATION & HEALTH DETERMINANTS
Understanding local demographics and the wider determinants of health provides a
sound basis on which to improve quality of life, raise aspirations and secure better
health outcomes.

1.1 POPULATION OF ESSEX
Profile
Essex has a population of 1.738 million residing in its twelve district/borough councils (making up
Essex County Council; pop. 1.413m) and the two unitary authorities of Southend-on-sea (pop.
165,300) and Thurrock (pop. 159,600). Colchester (181,000) and Basildon (175,200) have the
largest population and Brentwood (74,800) and Maldon (63,200) the smallest. The biggest towns in
Essex are Chelmsford and Colchester.

In comparison with the population of England, Essex has a similar proportion of children (19% of 0-
15 yrs) but more older-aged people (18% are 65yrs+). There are fewer 15-44 year olds, which may
reflect the migration outwards, primarily as people seek work elsewhere. Tendring is the only district
with a marked difference in population structure – 16% are <16yrs; 27% are 65yrs+.

The districts of Harlow (2,674 people per km2), Castle Point (2,191) and Basildon (1,592) are most
densely populated. Conversely, Braintree (236), Maldon (177) and Uttlesford (121) are the least.
Areas with high population density, are most likely to have pockets of high deprivation and poor
housing.

Projections
Between 2008 and 2033 the population projection for Essex is expected to show a decrease in the
working age group (from 60% to 55%) and an increasing older population (21% increasing to 28%).
Significant difference at district level is expected for Maldon with the largest decrease in children
(3%) and second largest decrease in working age adults (8%) after Castle Point (9%) In terms of
older people, both these areas will also see the largest increase with an 11% increase in Maldon and
10% in Castle Point.

In the future it is predicted that the balance between those of working age and the ‘dependent’
population is likely to shift, changing the proportion of economically active people in relation to the
proportion supported by the state. The increase in the older age group will not only impact on all
public services (this is explored further down in this document), but will also mean an increasing
demand on care homes places, more unpaid carers and the need for better community networking to
support independent living.

Ethnicity & Sexual Orientation
People from differing ethnic grouping (including travelling families) and those who have are not
heterosexuals are at greater risk of discrimination and social exclusion, which can lead to poor
health and social care outcomes. National reports suggests that they are less likely to be considered
to provide an adoption and less likely to seek support from statutory agencies.

The ONS (2009) population estimates suggests that Essex is home to 173,900 residents from black
and minority ethnic (BME) groups (including Irish and other white). There are 114,600 residents from
ethnic groups other than white and 59,300 from white minority groups. The BME groups made up
12.4% of Essex residents, which is less than the England average (17.2%).

Essex has become more diverse with the areas closest to London and the largest towns having the
highest concentrations of people from BME groups. The highest proportions reside in Epping Forest
(17.6%) and Harlow (15.6%) compared to the lowest in Rochford (8.3%) and Maldon (8.6%).

It is becoming more customary for Gypsy and travelling families to live in more formal style of
housing. People living in caravans, mostly are on authorised public or private sites but around 20%
                                                                                                      5
                                   DRAFT as at 28 February 2012
of these are on unauthorised sites. Whilst the trend in unauthorised encampments and trespass has
diminished over recent times, the trend in unauthorised developments has been increasing. In Essex
(Jan. 2011), there were 1,142 caravans, of which 30% were not on authorised sites.


1.2 DEPRIVATION & WIDER IMPACT ON POPULATION
Although quality of life for most Essex residents is good, some areas of Essex are very deprived. An
area located in Golf Green ward in Tendring (locally known as Jaywick), has been identified as the
most deprived small area in England. Essex has some of the most affluent and some of the most
deprived areas in the country. The least deprived areas are in Uttlesford, Brentwood and
Chelmsford. The most deprived areas in Essex tend to be more focussed in and around the larger
towns, in condensed pockets (hot spots) and these are reflected in Tendring and Basildon.

Many of the most deprived areas also experience the lowest levels of life expectancy, poor
educational achievements, higher levels of teenage pregnancy, poor housing (including fuel poverty)
and generally higher levels of social and health care needs. There is a high eligibility level for free
school meals in the more deprived areas, which is a proxy measure of childhood poverty. Many
children from these disadvantaged communities tend to experience poor parenting support, have
poor aspirations and end up generally bereft of essential life skills. Children Centres have been set
up in the areas of most need to help redress these inequalities and improve life opportunities.




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                                        DRAFT as at 28 February 2012

1.3 EMPLOYMENT & ASPIRATIONS


Nationally, Gross Domestic Product is currently estimated to be about four percentage points below
what it would have been now on pre-recession growth trends. Given issues around the scale of both
public and private debt, consequent falls in the level of aggregate demand, and liquidity problems in
the financial sector, many commentators expect a long period of low growth ahead.


Labour Market
Recent national analysis of labour market conditions1 indicates that during the recession, the level of
employment fell by less than might be expected from the drop in output. Whereas output fell by more
than 7% from its pre-recession peak, employment fell only by about 2% and total hours worked by
just under 4%. Full time and permanent jobs reduced in number, and the number of part-time and
temporary jobs rose correspondingly. During the subsequent recovery, the labour market has shown
only a modest recovery, with employment rising by less than in previous recoveries from recession.
The labour market has also adjusted to the recession through slower earnings growth. Earnings
have been growing more slowly than price inflation for much of the past four years. Earnings growth
in December 2011 was 2% compared with 4.2% price inflation. However, consumer price inflation
fell to 3.6% in January 2012 as the impact of VAT rises in January 2011 dropped out of the equation.
The Bank of England’s inflation forecasts for the next three years, based on market interest rate
expectations, show a probability of CPI inflation remaining above 2% ranging from 99% for 2012 Q1
to 38% for 2013 Q1 and then rising again to 47% by 2015 Q1.2 These changes in the structure of
the labour market if they persist over a period of sluggish economic growth may create some
stresses for households in Essex in terms of lower earnings and job instability.


Unemployment Level
Unemployment is strongly correlated with health and wellbeing. Where unemployment is highest,
we tend to have a lower rating in children’s wellbeing3. Educational qualifications, both as part of
secondary education and adult learning, are a determinant of an individual's labour market position,
which in turn influences income, housing and other material resources and has an impact on health
and health inequalities.

Unemployment rates have risen sharply since the end of 2008 as the UK economy has gone into
recession. The rate in Essex (7.1%) was above the average for the Eastern region (6.6%), but was
below the UK average (7.6%), in 2010-11.

Within Essex 73.1% of the working age population are employed, compared to the national average
of 70.4%. Unemployment rate varies across the county with high rates in Harlow (11.9%), Epping
Forest (11.2%) and Tendring (10.9%). Lowest unemployment rates are seen in Castle Point (4.1%),
Uttlesford (4.5%) and Colchester (4.8%). In September 2011, the number of male (3.7%) Job
Seekers Allowance (JSA) claimants was much higher than female (2.3%).

In 2011, there was an increase of 0.2% over 2 years, across Essex CC (0.5%) in the working-age
resident population (aged 16-64) claiming job seekers allowance for over 12 months – this was
similar to the national increase.

The Office of Budget Responsibility expects that nationally 710,000 jobs in the public sector will
disappear over the next five years. The Institute of Public Policy has suggested that this, combined
with rising childcare costs, is likely to have a disproportionate impact on female employment.4


1
  ONS, ‘GDP and the Labour Market – 2011 Q4 – February GDP update’
2
  http://www.bankofengland.co.uk/publications/inflationreport/irprobab.htm
3
  Child Well-being Index
4
  http://www.ippr.org/press-releases/111/8387/female-unemployment-set-to-rise
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                                        DRAFT as at 28 February 2012
Qualifications & Skills
The workforce in Essex tends to be slightly older than across England, and older people tend to
have fewer qualifications. Essex is also a net exporter of 16-24 year olds who are more likely to hold
qualifications. As a result, skills in Essex (23%)5 tend to be lower than elsewhere, with higher skills
levels (NVQ4+) being much lower than the national average (31.1%). Rochford (15.3%), Castle
Point (15.2%) and Tendring (15.1%) have the highest proportion of residents without any
qualifications. Conversely, Uttlesford (73.0%), Chelmsford (72.6%) and Brentwood (70.1%) have
higher proportions of people with a minimum qualification of NVQ level 2.

Prior to the recent recession, the number of NEET young people in Essex was comparatively low,
but has risen since the start of the credit crunch. Essex performs slightly worse then England and
our comparative LA peers although the gap between Essex and peers has reduced between 2009
and 2010. The level of NEET (3-month average in 2009/10) in Essex (6.9%) was higher than the
national average (6.2%) and the East of England average (5.7%). Tendring and Basildon (the most
deprived areas in Essex) had levels of NEET that were nearly twice the county average, whilst levels
in Braintree, Rochford and Maldon were all over 10%. Uttlesford, Epping Forest and Chelmsford all
had levels under 4%.

Mental Health & Employment
In 2009, Essex CC had 10.1% adults who were receiving secondary mental health services and
known to be in employment at the time of their most recent assessment, formal review or multi-
disciplinary care planning meeting – this was higher than the England average (7.9%) and an
increase on 2008 (6.3%). Improved data collection would provide a better picture in this area.

NICE guidance supports the provision of Increasing Access to Psychological Therapies (IAPT)
service, to help those with mental health problems get back into work and this is now operating
across a few key areas in Essex.

Migration
The advent of economic migration, associated with the expansion of the European Union, has led to
significant inward migration into Essex, especially as Harwich Port provide an easier gateway into
the county. A cumulative total of 15,430 migrants registered to work in Greater Essex between May
2004 and December 2009. Anecdotal evidence suggests that many of these migrant workers suffer
from poor living conditions and lack the knowledge and support required to ensure they remain safe
and well.

Employment has a high weighting (22.5%) in the computation of the deprivation score. People with
little and/or no qualifications are lest likely to find jobs or earn a decent income and have poorer
health-related outcomes. Whilst acknowledging the challenge posed by the economic downturn, the
proportion of young people likely to end up as NEET will require a focused and coordinated
approach to minimise economic inactivity.


1.4 ACCESS TO SERVICES & TRANSPORT
Access to services, regardless of the purposes (e.g. to work, hospital, educational establishment,
recreational activities), is intrinsically linked to transportation. The chosen modes of travel (walking,
cycling, or motorised) can vary according to people’s means (can they afford a car or bus fare), their
personal mobility (are they able to walk or cycle) and the availability of public or alternative transport.
It is also important to note that lack of transport may not always be a factor in addressing inequity in
access to services, as issues such as homelessness and lack of information also have an effect.


Impact on Community Health and Wellbeing
With motorised transport comes the challenge of traffic congestion, pollution, accidents and physical
inactivity. People have become more dependent on the use of private cars for their journeys,

5
    ONS Annual Population Survey, Jan-Dec 2010
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                                                 DRAFT as at 28 February 2012
including short ones, instead of walking or cycling to their chosen destination, thus contributing
significantly to a reduction in physical activity.

This over-dependence has increased the volume of traffic by 6.2% over the last 10 years, causing
long delays and impacting on air quality with an increase in carbon dioxide emission, which can have
a detrimental effect on people who have respiratory problems.

Children from the lowest social classes are five times more likely to die in road accidents than those
from the highest social class. More than 1 in 4 of child pedestrian/cyclist casualties happen in the
10% most deprived wards6. Good accidents prevention work must be sustained if we are to reassure
parents and encourage young people to walk and cycle more regularly.

Utilisation & Satisfaction with Public Transport
Local residents’ tracker survey (2010) reported that residents from Chelmsford (61.6%), Castle Point
(59%) and Tendring (56.4%) were the most satisfied with local transport information. Epping
(38.8%), Uttlesford 39.6%) and Maldon (42.2%) were least satisfied.

Colchester (40.3%), Brentwood (38.8%) and Castle Point (33.2%) were the districts which access
local transport information more frequently, whilst residents from Uttlesford (21.8%), Braintree
(25.5%) and Harlow (24.9%) were the least likely.

Residents from Colchester (65.9%), Rochford (59.4%) and Tendring (58.6%) were the most satisfied
with local bus services whilst those from Uttlesford (39.3%), Maldon (41.2%) and Braintree (44.7%)
were the least satisfied.

Colchester (56.6%), Chelmsford (45.9%) and Tendring residents (43%) are most likely to use bus
services at least monthly. Residents from Uttlesford (22.5%), Braintree (31.8%) and Brentwood
(32.4%) are least likely to use bus service on monthly basis.


1.5 CRIME & COMMUNITY SAFETY
Crime Rates
Crime is associated with social disorganisation, dysfunctional communities, deprivation and
inequalities. In addition to the human and emotional costs, crime has a direct impact on housing,
employment and health. Recent Essex’s Place surveys have highlighted criminality as an area that
requires high priority despite continued increased in crime detection rates and a reduction in
criminality. Drug and alcohol-related crime, anti-social behaviour (including damage to property),
violence against the person and domestic violence are the key areas where the law needs to
intervene the most to protect the population and property. There is also a high inter-relationship
between these elements of crime and disorder.

Overall since 2007, crime rates have been decreasing, from 67 per 1,000 to 60 per 1,000 in 2010-
11. The latest position is lower than the national average (75 per 1,000). Crime rates vary
considerably across Essex, with the highest rates recorded in Harlow (95 per 1,000) and Basildon
(71 per 1,000) and the lowest rates in Maldon (36 per1,000) and Rochford (29 per 1,000).

Hate crime
The term ‘hate crime’ covers crimes that are driven by hostility or personal hatred because of race,
religion, sexuality or disability. Nationally, the number of such crimes referred by police to the Crown
Prosecution Service for decision rose from 14,133 in 2006/07 to 15,519 in 2010/11, ie, by nearly
10%. In the Essex CPS Area in 2010/11, there were 298 prosecutions, of which 86.9% were
successful. Of these prosecutions, 263 involved race or religious hatred, 25 homophobic or
transphobic hatred, and 10 hatred of people with disabilities.7


6
    Social Exclusion Unit (2003)- Making the connections: Transport and Social Exclusion.
7
    http://www.cps.gov.uk/publications/docs/cps_hate_crime_report_2011.pdf
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                                   DRAFT as at 28 February 2012
Crimes against older people
The Crown Prosecution Service collects data on crimes which are targeted at or take advantage of
older people or involve abuse of trust or hostility towards them. Nationally, the number of such cases
referred to the CPS doubled to 2,978 between 2008/09 and 2010/11. In the Essex CPS Area in
2010/11, there were 54 such prosecutions, nearly 91% of which led to a conviction.

Fear of crime
A standard perception measure of the fear of crime is feeling safe after dark. The percentage of
people feeling safe after dark in Essex increased significantly between the 2008 Place Survey and
the 2010 Tracker 9 Survey, from 56% to 65%. However, provisional results from Tracker 10 in 2012
indicate that the % feeling safe after dark has dropped down to 58%.

Tracker 9 shows that this varies across the districts in Essex. Whilst a high proportion of people
living in the Maldon district feel safe after dark (80%) this is not the case for Harlow (47%), Basildon
(55%), Colchester (56%), Castle Point (58%) and Tendring (63%) who all fall below the Essex
average (65%). Additionally, analysis shows there is a relationship between fear of crime and actual
crime, suggesting that people are aware of the levels of crime in their area. At smaller geographical
areas, however, there was more variance with some area showing high fear and high crime rates
whilst people in other areas had fairly high crime rates but had fairly low fear of crime.

An analysis of which type of anti-social behaviour has a impact on the fear of crime was undertaken
and shows that different types of behaviour has a significant impact on the fear of crime. An
example of this is Harlow district where ‘Teenagers hanging around on the street’, ‘Rubbish or litter
lying around’, ‘Vandalism or graffiti’ and ‘People using or dealing drugs’ have an impact whilst in
Braintree it is ‘People being drunk or rowdy in public places’.

Drug & Alcohol-related Criminality
The is a strong link between alcohol and drug use and the level of crime, in particular where violence
and anti-social behaviour are involved but also correlated with a high level of burglaries. Nationally,
the impact of alcohol misuse alone, on health, crime and society, is estimated to cost nearly £20bn a
year. Harlow (10.5/1,000) had the highest alcohol-related crime rate in 2010-11, with Basildon (7.2)
and Epping Forest (7.1) also above the regional average (6.2). Rochford (2.7/1,000 ranked 10th
lowest nationally), Maldon (3.6) and Uttlesford (4.2) were the districts with the lowest recorded
alcohol-related crime rates.

Uttlesford (68.2%), Chelmsford (64.6%) and Maldon (63.0%) residents reported the greatest feeling
of safety after dark, whilst Harlow (40.4%) and Basildon (42.0%) were the lowest. There is a clear
upward trend in Essex residents’ feeling of safety.

Domestic Incidents and Young People
Domestic abuse impacts on both adults and children, with women most likely to be the victims. It is
estimated that in 2010 for females aged 16-59 years, over 35,000 people may have been the victim
of domestic abuse with a further 11,000 victims of a sexual assault in Essex. The financial impact of
these incidents is estimated at £133m with one fifth spent on health-related interventions.

One of the indicators in recent years, has looked at ‘first time’ young people who have engaged in
criminal activities. Changes in policing policies and better crime detection rates, seem to have
deterred youths from committing crimes as there has been a 50% reduction over the last 10 years in
England and Wales of first and further offences resulting in a reprimand, warning or conviction by
those aged 10-17. Within Essex, there has been a 32% decrease in the rate of youths receiving their
first reprimand, warning or conviction over the same time period. With continued prevention work,
young people can be channelled to more meaningful activities and learning to develop their civic
skills.

Preventing young people from becoming offenders and promoting a value-based society (e.g. civil
responsibilities) can help improve community health and well-being through better educational
attainment (enhancing aspirations), improved employability and a reduction in crime against the
person and property.
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                                    DRAFT as at 28 February 2012



1.6 POVERTY & SOCIAL CLASS
All the evidence suggests that social class inequalities persist throughout life and post retirement.
Life expectancy at birth differs by three years for women and five for men between social classes I/II
and IV/V. Other than occupation, a number of proxy indicators can indicate the level of poverty
including housing tenure, income deprivation index, entitlement to free school meal, take-up of
means-tested benefits and level of fuel poverty.


Home Ownership
A high proportion of Essex residents (75%) own their own homes compared to England (69%),
although commuting pattern into London is also suggesting that Essex’s residents are benefitting
from higher salaries. Castle Point (88%) has the highest proportion of households owning their
accommodation while Harlow (60%) has the lowest. Basildon (11,596) has the highest number of
local authority dwellings and Braintree (17%) the highest proportion of registered social landlord
stock – also known as housing association.

Childhood Poverty
Despite the relative affluence of Essex, nearly 16% of children (around 51,000) live in poverty. In
four districts (Harlow, Basildon, Tendring and Colchester) the percentage of children living in child
poverty is higher than the regional average for the East of England. Socially disadvantaged groups
suffer poorer physical health and lower life-expectancy than the more advantaged, have higher
incidence and prevalence of acute and chronic illness, and are more likely to smoke and have a poor
diet. Children from poorer backgrounds suffer higher rates of accidental injury, infections, failure to
thrive, general ill health, anaemia, dental caries and teenage pregnancy. In addition, poorer families
are less likely to have access to, and make appropriate use of, health services than those from more
advantaged circumstances, and they are less likely to benefit from health promotion services and
advice. Collaborative intensive support for families and children with the most need can prevent a
decline in their quality of life.
Although the attainment of children living in poverty is improving (as it is nationally), there remains a
significant gap between the performance of children receiving free school meals and those who do
not. On average, pupils on free school meals have lower attainment than all pupils, and the gap
tends to increase with age. The gap in attainment at key stage 4 in those children achieving 5+ A*- C
grade in 2009-10 is especially pronounced in Uttlesford (37%), Brentwood (35%) and Epping Forest
(34%). Where local interventions can raise young people’s aspirations, this can lead to improvement
in educational attainment, reduction in ‘planned’ teenage pregnancy and better job prospects.

Low Income & Poor Housing
Low income and the rising cost of heating can contribute to high levels of fuel poverty. The
consequences of fuel poverty include cold and damp homes, reduced quality of life, poor health and
debt. People with existing health problems and living poorly heated dwellings are more likely to need
health interventions and suffer from health complications and even death. People already struggling
financially may find themselves in even more serious debt problems if they cannot pay their fuel bills
and even resort to borrowing money from unscrupulous lenders. It may also lead to a move into
temporary accommodation, which is mostly preventable.

Low income families cannot readily afford childcare, which makes it difficult for them to penetrate the
job market or develop their skills. The evidence also points to the lack of information and/or support
to parents, especially lone parents, in accessing their full benefit entitlement.


1.7 HOUSING & ENVIRONMENT
Over recent years, central government plans has brought about significant housing development to
ECC. As population growth and housing development accelerate, the need for inward investment
and local job growth will intensify. House prices in the East of England fell by 0.3% over the year to
                                                                                                      11
                                               DRAFT as at 28 February 2012
December 2011 although over England as a whole they rose by 0.5%. Most commentators expect
prices to level out over the next twelve months.

Average house prices in September 2011, are marginally higher in Essex (£186,800) than our
comparator neighbour of Kent (£182,250). However, high house prices can have a detrimental effect
on the sustainability of communities, leading to increased levels of homelessness and forcing people
on low income to seek housing in poorer condition to facilitate their access to work – this is a
concern in areas like Epping Forest and Brentwood. Developing affordable housing for first-time
buyers and low income families will continue to be critical for both urban and rural communities.

The housing provision should cater for the increasing number of people who are becoming
homeless, those who are victims of domestic violence, the increase in migrant workers and/or those
who have become teenage parents.

Ageing population & Supported Living
The growth in our ageing population and the increasing levels of disability, together with shifts in
national and local policy towards independence and choice, will impact on the availability of
adequate housing.

For the majority of older people, staying in their own home, being cared for by members of their
family and dying in their own home, are their preferred options. In Essex, 74% are owner-occupiers
but many cannot afford to adapt their home or keep it in good repair.

We will need to make better use of technology, develop a wider range of supported housing options
and give people greater control over the support they receive. Existing planning guidance places an
obligation on local developers to provide new houses that meet the Lifetime Homes Standard policy
for Essex8. The development of sustainable housing reduces the utilisation of natural resources
during construction and subsequently and ensures that these dwellings are easily adaptable to meet
future needs.

Fuel Poverty
Fuel poverty occurs when a household needs to spend more than 10% of its income on fuel to
maintain satisfactory heating and other energy services. The consequences of fuel poverty include
cold and damp homes, reduced quality of life, poor health and debt. Fuel poverty is particularly an
issue in rural areas, for instance the north of Uttlesford and Braintree districts and the east of
Rochford and Maldon. This is generally because homes in these areas are detached and may offer
poor heat insulation, meaning high heating costs.

Waste Management & Recycling
90.8% of Essex’s residents indicated in the 2010 tracker survey, that they already recycle as much
as possible. The districts where this is highest are Braintree (96.1%), Castle Point (94%) and
Harlow (92.9%). The following three areas have rates below 88% - Colchester (87.3%), Maldon
(87.5%) and Chelmsford (87.9%). Better education and continued work around raising awareness,
especially among children and young people, will provide Essex with a better outlook on recycling.

Carbon Footprint
Although Essex has a relatively low carbon footprint, road transport emissions are high due to the
M11 and M25 passing through Uttlesford, Epping Forest and Brentwood. Essex produces 8.5 tonnes
of carbon dioxide per person although this is one tonne per person less annually than the UK
average. With almost 99% of the energy consumption in Essex coming from unsustainable source,
realising opportunities in environmental technology is seen as key to improving both the local
economy and the environment.

Air Quality
Air quality is measured on a scale where the national average is 1 and areas are given a score
against that scale, with lower scores being better than high scores. In Essex CC, air quality is best

8
    Guidance note: Lifetime Homes Standard – Essex Planning Officers Association (March 2008)
                                                                                                       12
                                   DRAFT as at 28 February 2012
in Maldon (1.02), Uttlesford (1.02) and Tendring (1.04) and worst in Basildon (1.29), Epping Forest
(1.26) and Castle Point (1.25). All areas in Essex had scores above the national average. Pollution
measured includes nitrogen dioxide, sulphur dioxide, particles and benzene. Poor levels of air quality
can have a direct detrimental effect on health, exacerbating existing health conditions but with good
local surveillance and management, this can be minimised.




1.8 COMMUNITY COHESION
Analysis of community cohesion data (‘people getting on well together’) in 2007 highlighted how
important a driver this is for residents’ overall satisfaction with the local area. Communities in
Basildon (73.6%), Colchester (76.3%) and Harlow (69.2%) were the least cohesive – the same three
reported the least ‘sense of belonging’. Brentwood (85.1%), Chelmsford (83.4%) and Rochford
(88.4%) reported a stronger sense of community cohesion.

Across Essex, the trend since the summer of 2007 in ‘people getting on well together’ has been
slightly positive. The Place survey (2008) reported that more people in Essex (79.9%) believed that
‘people got on well together’, which was higher than both East of England (78.2%) and England
(76.4%).

Socio-economic well-being, covering labour market, immigration, housing policy and the economy,
all play a significant role in defining the interaction in a given community which can promote
community participation (e.g. in crime prevention or volunteering), life ambitions (e.g. valuing
education and civic responsibilities) and promoting equality (e.g. race relations, access to services).


1.9 RECOMMENDATIONS TO THE HEALTH & WELLBEING BOARD

POPULATION
 Continue with the development of strategies aimed at preparing Essex to cope with the growing
   ageing population and people with disability, all of which will have significant impact on
   infrastructure (e.g. housing needs) and services (e.g. care needs).
DEPRIVATION & WIDER DETERMINANTS
 Focus on tackling health inequalities with identified priority groups and families in areas with high
   levels of deprivation.
   Through the continued development of the Children’s Centres, we must ensure all children get a
    good start in life so that this can have a lifelong impact.
EMPLOYMENT & ASPIRATIONS
 Concerted effort is required to improve the workforce competencies (qualification and skills) and
  promote the creation of jobs in Essex. Consideration should be given to the creation of
  apprenticeships and volunteering schemes to support the overall strategy.
   Ensure integration of work around benefit take-up, unemployment and health & well-being
    promotion (e.g. mental health intervention), which can also support a reduction in NEET.
ACCESS TO SERVICES & TRANSPORT
 Engaging with relevant groups, including young people and parents is essential to address
  specific transport barriers, support change in travel behaviour and improve travel information.
   Strategy to ensure physical activity is embedded in policy (e.g. Transport Planning), encouraging
    walking and cycling and promoting road safety.
   Consider the challenges faced by hard-to-reach groups, e.g. homeless people, in accessing
    services that can improve their health and wellbeing.
POVERTY & SOCIAL CLASS
 Active collaboration between agencies can help create social capital in the most deprived
   communities, by developing strong social networks, civic engagement and volunteering.

                                                                                                      13
                                    DRAFT as at 28 February 2012
   Engaging people in the planning and design of the built environment to generate a sense of
    belonging, especially for young people, with further extension of the ‘early years’ programme.
HOUSING & ENVIRONMENT
 Agencies should work in collaboration to ensure that people live in decent, affordable houses and
  promote the development of a housing stock fit for purpose in supporting independent living.
   It is important to shift the focus of housing related support towards early recognition of issues,
    prevention and intervention in order to reduce the need for more costly longer term services.
   Essex needs to implement measures aimed at improving the environmental factors, such as
    reduction in waste, air pollution, increase sustainable development and reduce its dependency on
    non-renewable energy.
COMMUNITY COHESION
 Ensure policies actively promote community engagement and participation and promote equality.



1.10 SUPPORTING RESOURCES
   Geography & Demographics Chapter (September 2010)
   District profile reports (2010)
   JSNA Local Economy (August 2010)
   JSNA Mental Health (May 2010)
   JSNA Children (May 2011)
   JSNA Crime (September 2010)
   Public Health Outcomes – Evidence-based Practice (September 2011)




2. HEALTH, COMMUNITY WELLBEING AND INEQUALITIES
Measures of population mortality and morbidity are indicative of the health care
needs and the overall disease burden on the population. The burden of ill-health and
life expectancy can be improved by reducing the population's risk (behavioural or
inherited), by earlier detection of disease and through more effective interventions to
reduce health-related inequalities.


2.1 LIFE EXPECTANCY & QUALITY OF LIFE
Causes in Life Expectancy Gap
Data on years of life lost show that for males the main causes are coronary heart disease, lung
cancer and stroke and for females it is breast cancer, lung cancer and coronary heart disease.

Trends in Life Expectancy
In Essex, the trend in life expectancy for both males and females is upward, with male life
expectancy currently at 79.6 years and at 83.1 years for women (2007-09). However, in our most
deprived fifth of the population, the average male life expectancy is much lower at 76.8yrs – a gap of
2.8yrs. Although the gap is not as big as it is in males, the same pattern is seen in females (gap of
1.9yrs), with life expectancy amongst the most deprived fifth at 81.2yrs.

At a district level, males in Harlow (78.0), Maldon (78.9) and Basildon (79.1) have the lowest life
expectancy. Those men living in Rochford (80.3), Uttlesford (80.6) and Brentwood (80.7) have the
highest life expectancy – this is a gap of 2.7 years between males in Harlow and Brentwood.


                                                                                                         14
                                    DRAFT as at 28 February 2012
For women, Basildon (82.3), Epping Forest (82.5) and Tendring (82.6) have the lowest life
expectancy with women in Brentwood (83.9), Rochford (84.0) and Chelmsford (84.3) having the
longest life expectancy – a gap of two years between the highest and lowest districts.

Quality of Life
The overarching quality of life measure used within the UK is the percentage of people who feel
satisfied with their local area overall. This quality of life measure is influenced by a number of other
factors, such as community cohesion, feeling of safety, and a high satisfaction score indicates a
cohesive and functioning community.

In 2012, the districts with the lowest satisfaction are Basildon and Tendring (both 74%), Castle Point
(73%) and Harlow (72%) – Basildon, Tendring Harlow are also the most deprived districts in Essex
with lower life expectancy. The four districts with the highest satisfaction are Brentwood (86%),
Rochford (88%) and Chelmsford and Uttlesford (both 89%) – these are among the least deprived
districts in Essex with higher life expectancy.

There is a striking difference in overall satisfaction with area between owner occupiers (84%) and
social tenants (69%). People with a disability give a satisfaction score of 79% compared with 84% for
those without a disabiliuty.

Satisfaction rating in Essex saw a small upward trend between 2006 and 2010 (rising from 80% to
85% overall) but in 2012 has fallen back to 82%. In 2008, Essex’s (85.5%) satisfaction rating was
above that of the East of England (83.3%) and England (79.7%).


2.2 MORTALITY & TRENDS

Across Essex, overall mortality rates have steadily improved over the last ten years (from 662 per
100,000 to 491 in 2009). Circulatory diseases remain the most common cause of death followed by
cancer. During 2007-09, the infant mortality rate in Essex (3.9 per 1,000 live births) was lower than
England (4.7). Brentwood (1.3) and Castle Point (2.1) had the lowest rates, while Colchester (5.2)
had the highest rate. All other districts had rates lower than England.

Cancer
Despite a downward trend, cancer remains a major contributor to mortality and health inequalities,
with high NHS treatment costs. It is estimated that 21% of the gap between the national average life
expectancy and the areas with the lowest life expectancy is attributable to cancer mortality. Total
number of cancer-related deaths was 10,819 (2007-09) in Essex CC.

While there have been marked reductions in cancer mortality rates across Essex, from 133.2 per
100,000 (1995-97) to 106.2 (2007-09), these have been far less compared to heart disease. Higher
mortality rates are associated with deprivation with Harlow (129.7) and Basildon (116.4) having the
highest rates. Uttlesford (94.1) and Brentwood (95.8) and Rochford (97.3) all had the lowest mortality
rates from cancer.

Across Essex, the highest mortality rates (2007-09), are in cancers associated with the lungs (34 per
100,000), colo-rectal area (16.4), breast (26.3) and the cervix (2.3). The lung cancer rate in men
(43.6) is nearly twice that of women (26.6). Early detection of these conditions through national
screening programmes as well as the prevention programmes (e.g. smoking cessation) including
HPV vaccination, are key to a reduction in associated morbidity and mortality.

Moreover, despite most people’s wish to die at home, there is a wide variance in the proportion who
can experience this wish across Essex – Cancer patients living in Uttlesford (33.5%) and Rochford
(32.2%) are more likely to die at home while those least likely reside in Epping Forest (22.2%) and
Harlow (21.7%).

Cardiovascular Diseases

                                                                                                       15
                                   DRAFT as at 28 February 2012
Cardiovascular disease (CVD) describes the group of diseases that includes coronary heart disease
and stroke. Essex’s all age mortality rate (157 per 100,000) is much lower than England (175)
though Epping Forest (182), Basildon (169) and Harlow (167) have rates higher than the East of
England (162). CVD is the second biggest cause of premature mortality in Essex (2,814 deaths in
the under 75 age group, 2007-09), despite a steady annual decrease, and is strongly associated
with inequalities in health. Total number of CVD-related deaths was 12,451 (2007-09) in Essex CC.

Broad public health interventions of heart disease have contributed to a significant reduction in
associated mortality – Essex from 121.6 per 100,000 (1995-97) to 57.9 (2007-09). Higher mortality
rates are associated with deprivation with Harlow (78.3), Tendring (66.6) and Basildon (66.2) all
recording higher mortality rates.

Respiratory Diseases
Chronic Obstructive Pulmonary Disease (COPD) is the collective term for a range of conditions
(including bronchitis and emphysema) that result in long term damage to the lungs and is largely
preventable (e.g. smoking). Levels of COPD deaths (people under 75yrs) reduced marginally across
Essex from 10.01 per 100,000 in 2003-05 to 9.90 in 2007-09. Harlow (21.73) and Maldon (10.41)
had the largest increases, although Basildon (12.59) and Castle Point (11.98) also had a high
mortality rate in 2007-09. Uttlesford (5.06), Brentwood (6.67) and Chelmsford (6.88) had the lowest
mortality rates in 2007-09.

Asthma is a more common condition than COPD and affects many children (most chronic condition)
as well as adults. Although many patients have mild to moderate levels of asthma, in some the
effects of asthma can be severe resulting in hospitalisation and some to death. Although the number
of deaths is small for Essex CC (73 between 2007-09), Castle Point (2.67/100,000) and Maldon
(2.18) had the highest mortality rates, with the lowest rates in Tendring (0.6) and Uttlesford (0.77) –
the Essex average was 1.26/100,000 and England’s was 1.24/ 100,000.

Liver Disease
There has been a marginal increase in mortality rates (people under 75yrs) from liver disease since
2004-06 across most of Essex (the latter had increased from 6.33 per 100,000 to 6.25 per 100,000
over 2007-09). Total number of deaths was 327 (2007-09) in Essex CC.

Colchester (9.06) and Brentwood (7.81) had the largest increases, although Basildon (8.19) also had
a high mortality rate in 2007-09.Castle Point (3.08), Uttlesford (4.27), Chelmsford (4.39) and
Rochford (4.59) had the lowest mortality rates in 2007-09.

Diabetes
Diabetes is a chronic and progressive disease that is associated with an increased risk of certain
complications including heart disease and chronic kidney disease. At least two thirds of Type 2
diabetes (almost 90% of all diabetes) is preventable impacting significantly (c.10 years) on life
expectancy. Braintree (133) and Maldon (127) had the highest mortality rates from diabetes in Essex
(2007-09) and both were higher than England (100). Uttlesford (63) and Rochford (58) had the
lowest mortality rates.

Diabetes is much more common in some ethnic minority groups and lower socio economic groups.
Around 5% of total NHS spend (and up to 10% of hospital inpatient spend) is used for the care of
people with diabetes.

Chronic Kidney Disease (Renal Failure)
Chronic kidney disease (CKD) is often caused by diabetes and people with hypertension. There has
been a small increase in mortality rates (people under 75yrs) from chronic liver disease since 2004-
06 in Essex. Between 2007-09, Essex has seen 23 deaths from chronic renal failure but numbers
are too small at district level for any meaningful comparison. With smoking being a key risk factor, it
is likely that the high prevalence of this condition persists in the more deprived communities.

Accidents & Suicides

                                                                                                     16
                                    DRAFT as at 28 February 2012
Accidental injury is one of the main causes of death for children aged 1-15 years and is closely
linked to deprivation. Home remains the most common site for accidents, particularly for young
children and older people, followed by the road. In Essex we had 2,987 hospital admissions from
people aged 0-17 with accidental injuries in 2009-10.

Local road traffic casualties resulted in 658 people being seriously injured or killed on the Essex
roads in 2009, although there has been a decrease over the last three years. Alcohol and/or use of
illegal substances are often linked to accidents, especially road traffic accidents amongst young
adults (16-29 year olds).

Falls can result in a loss of independence and can also lead to complications and death. In Essex,
there were 100 deaths from accidental falls in 2007-09. All the local districts had rates lower than
England (3.79 per 100,000) with higher rates recorded in Brentwood (3.19) and Braintree (1.68).
Epping Forest (1.09) and Tendring (1.03) had the lowest mortality rates.

During 2007-09, the mortality rate from suicides in Essex (4.3 per 100,000) was lower than England
(5.7). Harlow (2.2) and Epping Forest (2.9) had the lowest rates, while Castle Point (6.2) had the
highest rate. All other districts had rates lower than England, although Brentwood and Colchester
had rates over 5 deaths per 100,000.

Mortality from serious mental illness is often linked with unintentional (e.g. substance misuse,
communicable diseases and infections) and intentional injuries (suicide). We do not have definitive
estimates for our local population and it is not possible to extrapolate from existing information on the
level of suicides, the proportion of who had a serious mental health condition.

Excess Seasonal Mortality
Excess seasonal death is an important public health concern which sees an increase in mortality
among people with cardiovascular diseases, respiratory diseases and amongst older people, mostly
during winter but also during heat waves.

Links between poor quality housing, fuel poverty and health are widely recognized. Lower/ higher
temperatures, people’s lowered resistance to illnesses (due to disease), safety in the home and the
incidence and intensity of influenza outbreaks, all contribute to a higher mortality rate during winter.

With the exception of Colchester (17.9%), Harlow (13.2%), Maldon, (10.1%) Rochford (14.2%) and
Tendring (15.5%), all other districts in Essex had higher excess winter deaths (2006-09) than
England (18.1%).

The level of excess winter deaths had dropped marginally in recent years (between 2005-7 & 2007-
09) in Essex (from 19.1 per 100,000 to 18.8). Maldon (10.2) has seen a significant drop (-20.1), in
excess winter mortality, which was also the lowest rate in Essex. In 2007-09, with the exception of
Harlow (13.2), Rochford (14.2) and (Tendring 15.5), all the other districts had higher (or equal)
mortality rate than England (18.1).

Communicable Diseases
Because the number of deaths is small, we can only draw conclusions with caution. Essex (5 deaths
per 100,000) and most local districts had lower rates than the England average (7.6 per 100,000).
Maldon (2.8) and Rochford (3.5) had the lowest mortality rates while Harlow (9.0), Epping Forest
(6.7) and Tendring (6.6) had the highest rates. Overall there has been a gradual increase in mortality
rates but in the last reported years (2007-09), there has been a reduction across most of Essex CC,
possibly as a result of better surveillance and increase in immunisation rates.


2.3 DISEASE BURDEN – Prevalence & Hospitalisation
Essex has similar levels of disease prevalence, on the GP disease registers, compared to England;
except for hypertension (higher by 1.1%), depression (lower by 2.8%), kidney disease (higher by
0.4%) and thyroid problems (higher by 0.8%). Early identification of at risk patients and better
                                                                                                       17
                                               DRAFT as at 28 February 2012
management of chronic/long-term conditions will enhance and improve quality of life, increase life
expectancy and reduce costs by preventing hospital admissions.

Long-term condition and chronic illness (formerly referred to as Limiting Long Term Illness) include
conditions that people have to live with over a period of time such as cancer, COPD, diabetes, heart
disease and dementia. Additionally, physical & sensory impairments as well as learning difficulties
can affect people’s ability to carry out day to day activities, so causing disability, dependency and/or
having a reduced capacity to learn.

Cancers Incidence and Prevalence
There are more than 200 types of cancer but breast (most common cancer in women), lung, skin,
bowel (colon) and prostate (most common cancer in men) accounted for most new cases (incidence)
in recent years. Risk factors for lung and bowel cancers in men are strongly linked to lower income.
However, the opposite is true with breast, prostate and skin cancers, being more common in higher
income groups9.

Each year in Essex, there are approximately 1,100 new cases of breast cancer, 50 cases of cervical
cancer, 800 cases of lung cancer, 900 cases of prostate cancer and 950 cases of colorectal cancer.
Colorectal cancer incidence has been increasing and this may be due to the implementation of
national bowel cancer screening campaign which has enabled earlier detection.

In 2009-10 the prevalence of all cancers in England was 1.41%, the regional prevalence was slightly
higher at 1.46%. Locally South West Essex had the lowest prevalence at 1.16% with North East
having the highest with 1.56% - although this may be reflective of the large older population that is
resident here.

Survival rates are improving but this can be better enhanced with early diagnosis and management
of cancer patients. With over 27,900 people on the GP cancer registers across Essex (QOF 2010-
11), it is also important to ensure good provision of end-of-life care.

A substantial proportion of cancers could be avoided mainly through a combination of reducing
smoking rates (lung cancer is increasing amongst women due an increase in smoking), improving
diet and increasing physical activity. People also underestimate the rate of occurrence of skin cancer
and the danger of excessive sun or sun-bed exposure.

Cardiovascular diseases (CVD)
NE Essex has higher prevalence and ill-health from CVD than other areas in Essex. The prevalence
of hypertension in NE Essex (15.2%) and SE Essex (15.6%) are higher than the England average
(13.4%). It is estimated that 29% of people in Essex are undiagnosed with CHD, and a further 20%
undiagnosed with stroke which will culminate in poorer health outcomes.

A number of chronic illnesses associated with CVD can prevent people from retaining employment
and claiming incapacity benefit due to severity of illness (which can lead to disability) and/or poor
management of their conditions. It is also recognised that with improved disease ascertainment and
an ageing population, Essex will have more people with CVD on the GP’s disease registers and will
lead to increasing demand on health and social care services in years to come.

Lifestyle behaviours such as smoking, obesity and physical inactivity, all contribute to increased risks
of CVD and related health inequalities. Tackling these risk factors from an earlier age will reduce
demand on services and increase life expectancy. This is discussed in more details in section 2.4
below.

The prevalence of stroke is high in some areas of Essex, (NE Essex - 1.9% vs England 1.7%), which
is particularly linked with age and area with higher deprivation. With the growth in an ageing
population and poor lifestyle choices, we will continue to face a challenge in reducing the incidence
of stroke and provide adequate rehabilitation. There are 29,242 people on the stroke registers

9
    Cancer Incidence UK and National Cancer Intelligence Network (2009): www.ncin.org.uk
                                                                                                      18
                                   DRAFT as at 28 February 2012
across Essex, and in 2009-10 there were just under 2,000 hospital admissions across Essex for this
condition.

Diabetes
Diabetes is one of the biggest health challenges facing people living in the UK (nearly 4%). By 2030
up to 1 in 10 of the population will have the condition with obesity, age and ethnicity being key risk
factors. The poor management of diabetes can lead to serious complications including heart
disease, stroke, blindness, kidney disease and amputations which in turn lead to disability and
earlier death.

Across Essex, some 78,300 people are on the GP diabetic registers - a prevalence of 5.5%. Many
diabetic people are overweight and have poor diets and can improve their condition by becoming
more physically active and making healthier dietary choices.

Over the last 3 years, Essex has seen a year on year increase in the number of emergency
admissions related to diabetic ketoacidosis from 328 in 2007-08 to 391 in 2009-10. In terms of
diabetic admissions in those aged under 19 years, both NE Essex (95.4 per 100,000) and West
Essex (75.5) had admission rates higher than the regional average (70.9).

Chronic Kidney Disease (CKD)
Although seen as a serious condition, CKD if identified and managed well, can be prevented from
causing further renal damage. People with CKD are at increased risk of heart attack or stroke,
especially if they smoke or are overweight and people from some ethnic groups are at higher risk of
developing CKD. People with these co-morbidities and ethnic backgrounds, are more likely to
progress to the severe form of end stage renal disease.

Across Essex, there are over 65,500 people registered on the chronic kidney disease registers – a
local prevalence of 4.7%, this is compared to a national prevalence of 4.3%. At a PCT level
prevalence is highest in NE Essex (6%) and lowest in West Essex (3.6%).

Respiratory Diseases
Chronic Obstructive Pulmonary Disease (COPD) is the collective term for a range of conditions
(including bronchitis and emphysema) that result in long term damage to the lungs and is largely
preventable (e.g. smoking). The estimated prevalence of COPD for England is 4.7%. However, only
a proportion of those with COPD are on the local GP registers, with the highest prevalence in NE
Essex (1.9%) and lowest in Mid Essex (1.2%). In total there are 28,248 people on the GP registers
across Essex. Overall prevalence is projected to continue falling especially as we continue to see a
reduction in smoking prevalence.

Across Essex (2008-09), approximately 13% of patients on the COPD registers are admitted to
hospital as an emergency admission related to their condition – this compares to 13.2% in England
but only 11.6% across the East of England.

Asthma is a more common condition than COPD, but mostly preventable, and affects many children
(most chronic condition) as well as adults. Triggers for asthma attacks can be very different for each
person, with cigarette smoke, housing conditions, allergies (e.g. to pet hair) and air quality the most
common triggers. Children whose parents smoke are 50% more likely to develop asthma and
women who smoke during pregnancy are at risk of giving birth to babies with low-birth weight, who
are at increased risk of developing asthma.

Although many patients have mild to moderate levels of asthma, in some the effects of asthma can
be severe resulting in hospitalisation. Asthma admission rates in those aged under 19s, were
exceptionally high in NE Essex (213 per 100,000) in 2009-10 and were far higher than the regional
(171) average. Mid Essex had the lowest rate (92.5) – almost 2.5 times lower than NE Essex.

In 2009-10 the rate of emergency admissions for children with LRTI in Essex (229 per 100,000), was
lower than both the regional (316) and national (383) rates. At a district level, there is a threefold

                                                                                                     19
                                    DRAFT as at 28 February 2012
difference between the lowest district of Rochford (131) and the highest of Colchester (411).
Colchester has seen a 1.7 times increase on their previous rate of 241 in 2008-09.

The asthma prevalence across Essex (6.0-6.2%) is higher than England’s (5.9%) – Essex has
107,960 people diagnosed and on the GP registers for asthma.

Liver Disease
Regular drinking above recommended daily limits increases the risk of a wide range of health
problems including liver damage, such as cirrhosis and liver cancer. There is an increasing trend of
people who are regular social drinkers becoming dependent drinkers. The availability of cheaply-
priced alcohol, especially through main supermarkets, is contributing to this growing concern.

Hospital admissions related to alcohol are seeing a year on year increase both at a national level
(average yearly increase of 9%) and at a regional level (average yearly increase of 10%). The same
is also true at a local level and all districts in Essex, have a yearly average increase in hospital
admissions ranging from 7% in Brentwood to 15% in Harlow.

It is estimated that Harlow, Basildon and the central areas of Chelmsford and Colchester have the
biggest problems related to binge drinking.

Mental Health
Mental illness is common with one in six adults afflicted at any one time and for half of these people,
the problem will last longer than a year, which suggests that almost 150,000 people across Essex
are experiencing mental illness. Furthermore, over half of all adults with mental illness will have
developed their conditions by the time they were 14 years old.

Mental health disorders include a wide range of disorders that can impact on everyday living,
including anxiety and depression, eating disorders and dementia and are a common cause of short-
term and long-term impairment to health and wellbeing. In 2011, Essex had 14,060 people claiming
incapacity benefit / severe disablement for a mental health-related disorder, which is a decrease on
previous years. Colchester (49%) had the highest proportion and Castle Point (35%) the lowest.

The association between rates of mental illness and certain population characteristics, notably
poverty unemployment and social isolation is well established. Mental ill-health can and does affect
anyone (in childhood, working age, older age) and impacts on society as a whole.

Recent data shows that of those who are receiving secondary mental health services and are in the
care programme approach (CPA) programme, only between 7.3% (SE Essex) and 13.6% (Mid
Essex) are in employment. In the same period, the labour force survey showed that nationally 14.2%
of those with mental illness were in employment.

Dementia accounts for more years of disability than any other condition, including stroke,
cardiovascular disease and cancer. Cases of dementia are expected to double by 2030 and
increase rapidly with age. There are nearly 8,700 people on the GP registers with dementia across
Essex. The variation in GP registers across Essex (0.4% to 0.6%) may be due to the fact that
dementia is difficult to diagnose in the early stages. By 2021, the projected increase in prevalence is
expected to reach 38% .

In 2009-10, Harlow (55.7 per 1,000), Tendring (47.5) and Epping Forest (43.9) had higher
proportions of adults, than England (38.7), accessing specialist mental health services in Essex CC.
Rochford (22.8) and Castle Point (28.1) had the lowest rates.

Prevalence rates are higher amongst boys than girls and amongst 11-15 year olds when compared
to younger children. Mental health difficulties are particularly prevalent among young prisoners,
homeless young adults and young adults leaving care. Poor mental health in childhood affects
educational attainment, social skills and physical health. It also increases the likelihood of smoking,
alcohol and drug use. There are also wider consequences for later in life as it increases the risk of
poorer physical health, unemployment, reduced earnings and criminal activity.
                                                                                                      20
                                           DRAFT as at 28 February 2012


Satisfaction with Primary Care & Hospital Services
The latest GP patient survey (2010-11) indicated that across Essex 53.1% of people felt there was
support from local services to manage their long-term health conditions – this was in line with the
national average (53.7%). At a district level, Basildon (50.7%) had the lowest level of support
indicated and both Castle Point and Colchester the highest with 55.4%.

Across Essex, the hospitals performance ranged from 63% in Colchester University Foundation
Trust to 66% in both Basildon & Thurrock University Hospital Trust and Princess Alexandra Hospital.


2.4 LIFESTYLE BEHAVIOURS


Physical & Recreational Activities
Physical activity can contribute significantly to people’s general physical health and well-being,
reducing the risk of premature death, reducing the risk of falls and protecting people from becoming
overweight and obese. Over the last 25 years there has been a significant reduction in physical
activity as a part of daily routines, and a small increase in the proportion of people taking physical
activity for leisure in the UK. The total cost of physical inactivity for Essex PCTs in 2007 was £22.6m
(£7m/100,000)10 – The cost in North east Essex (£2m) and West Essex (£1.54m) were above the
national average of £1.5m/100,000.

Recent data11 suggests that 47.9% of the Essex population fail to do any session of moderate
intensity activity for 30 minutes, which is slightly higher than the national average (47.7%). Females
are less likely to partake in physical activity then men, and the rate of inactivity has not significantly
changed over the last few years.

The proportion of adults in Essex (10.4%) who do 30 minutes of moderate intensity physical activity
on five or more days of the week is lower than England (11.5%). Harlow (7.8%), Tendring (8.1%)
and Brentwood (8.8%) have the lowest proportion of the population completing the recommended
level of physical activity, whilst Colchester (14.6%), Uttlesford (14.2%) and Maldon (13.2%) have the
highest proportion.

A recent survey12 of school pupils aged 7 to 18 years in Essex highlighted that only a third of primary
pupils had exercised to the right intensity, five or more times in a week, but just under a quarter of
secondary pupils reported a similar level of activity. Primary pupils in Rochford (38%), Epping Forest
(37%) and Uttlesford (36%) were more likely to exercise five times or more while those in Brentwood
(27%), Harlow (30%) and Basildon (32%) were less likely. Maldon (29%), Brentwood (28%) and
Colchester (27%) had higher percentages of secondary pupils saying they had exercised five times
or more in the past week, whilst Epping Forest (14%), Basildon (20%) and Castle Point (20%) had
lower proportions.

Across the districts, policy-makers have driven the need to ensure the allocation of green space
within new developments as part of the Local Development Plans. The provision of green space
including parks, playgrounds, allotments, is an essential part of the socio-environmental fabric to
help promote moderate and recreational physical activity.

It is still encouraging that at least half of secondary pupils usually walk to school with fewer travel to
school by car/van and a quarter take the bus. Less encouraging is that just 5% of primary and 4% of
secondary pupils cycle to school in Essex. However, in Essex, more people cycle at least once for
approximately 30 minutes at moderate intensity per week - males 12.8% (an increase of 2.6%) and
females 6.9% (an increase of 1.2%), over 3 years to 2008-09. It should be noted that areas with the
highest level of deprivation, such as Tendring and Harlow, have seen no increase or very little

10
   Be Active Be Healthy, DH (2009)
11
   Active People’s Survey, Sport England
12
   SHEU Survey, 2011
                                                                                                         21
                                         DRAFT as at 28 February 2012
increase. Generally more men are taking up cycling than women, especially in Colchester (19.6%),
Braintree (15.9%) and Maldon (15.7%).

The ability to keep active and independent depends greatly on mobility. Mobility can be seriously
limited as a consequence of age, by the effects of falls and physical inactivity. In Essex, more falls
leading to a hospital admission, were recorded in Castle Point (add data) and Epping Forest (add
data).

Work sickness absence is a significant cost to the UK economy in terms or working days lost.
Although the key causes of sickness absence relate to mental health problems and alcohol related
sickness, the promotion of physical activity in this setting will improve health and wellbeing.

Diet & Obesity
Diet and nutrition are key contributors to the prevention of chronic ill-health and to some extent social
exclusion. The challenge of tackling obesity (an increasing prevalence) and associated chronic
diseases means looking at this issue before the child is born right through old age. A diet that does
include a good range (5-a-day campaign) of fruits and vegetables, can contribute to reducing the risk
of cardiovascular diseases, obesity and some cancers.

According to 2006-2008 modelled estimates on obesity prevalence, 24.6% of people in the Essex
CC area are obese. This is higher than both the East of England average of 23.6% and the national
average which is 24.2%. Out of the districts in the Essex CC area, the estimates suggest that Harlow
(31.1%), Castle Point (27.3%) and Braintree (26.7%) have the highest prevalence. The lowest
prevalence’s are in Brentwood (19.4%), Uttlesford (21.7%) and Epping Forest (22.4%).

The 2010/11 Quality and Outcomes Framework (QOF in primary care) data indicates there are
146,586 identified obese adults registered with general practices in Essex- however only around a
third of the GP-registered population have had their BMI measured, an indication that many people
are going undiagnosed.

The prevalence of obesity amongst children attending schools in Essex in 2009-10, is 8.8% for
Reception Year (children aged 4 – 5 years) and 16.1% for Year 6 (aged 10 – 11 years), both below
the national averages of 9.8% and 18.7% respectively. In reception year, Uttlesford (16%) had the
highest proportion of children considered overweight and Tendring had the highest proportion of
obese children (10.7%). Overall Uttlesford (26.6%) had the highest proportion of overweight and
obese children in reception year.

For year 6, in 2009-10, Harlow (19.2%) had the highest proportion of children classified as
overweight but for obese children, Epping Forest (20.7%) had the highest proportion in Essex.
Harlow (38.6%) had the highest proportion of children classified as both overweight and obese. We
now have several years’ worth of data but there are no clear trends in prevalence at local level.

Encouraging breastfeeding can promote good parenting skills and reduce the risk of obesity in later
life. Only West Essex (76.8%) had a breastfeeding initiation rate higher than the national and
regional averages (both 73.9%) at quarter 4 in 2010-11. SW Essex (67%) had the lowest rate. Over
the past two years the initiation rate across the PCTs has remained fairly stable at around 70%.

The data recording for the prevalence of breastfeeding at 6 - 8 weeks following birth has been
problematic and is still being developed and improved, this has led to data quality and reporting
issues for a number of PCTs. Over the past two years the north Essex PCTs have experienced 6-8
week breastfeeding prevalence proportions of around 40%.

Smoking & Tobacco Control
Smoking is the UK’s single greatest cause of preventable illness and early death. Nationally, the
prevalence of cigarette smoking in the adult population was estimated at 21% in 2009/10.13


13
     Integrated Household Survey (ONS)
                                                                                                         22
                                                   DRAFT as at 28 February 2012
Data from the 2010-11 integrated household survey, indicates that Essex (19.1%) has a smoking
prevalence lower than both regional (19.9%) and national (21%) estimates. In Essex, Braintree
(24%) has the highest estimated prevalence followed by Tendring (23.5%) and Basildon (22.5%).
The districts with the lowest smoking prevalence are Rochford (10.4%), Uttlesford (12.8%) and
Castle Point (14.6%).

Overall in Essex it is estimated that 25.1% of the 20% most deprived communities smoke compared
to only 17.5% in the remaining 80% of the population14. The prevalence is estimated to be as high as
33.6% in the most deprived communities of Tendring. Younger men and women in routine and
manual groups as well as teenagers are most likely to smoke and this is estimated to be 26.9% in
Essex.

In 2009/10, 4.8% of all secondary school pupils in Essex say that they smoke regularly or every
day15. There is very little difference in smoking behaviours between males and females but there is a
significant difference by age. While over nine out of ten Year 7 pupils have never smoked, this
proportion falls to under half of those in Year 12 and 13.

Smoking in pregnancy is associated with poor pregnancy outcomes, and exposure of infants to
second-hand smoke is associated with death in infancy. Smoking is more common in more deprived
women. The variation in smoking habits in pregnancy between socioeconomic groups accounts for
about one third of the difference in stillbirth rates and infant mortality rates. In 2009/10, most of
Essex had a rate lower than the national (6.6%) and regional (13.8%) averages, except NE Essex
(20.8%) which was considerably higher.

Excessive Alcohol Consumption
Recent estimates (2008)16 suggests that 21.1% of adults in Essex are taking part in increasing and
higher risk drinking which is lower than the East of England (21.4%) and England average (27.9%).
This behaviour increases their risk of cardiovascular disease, cirrhosis, poor mental health,
unemployment, accidental injury and death. Factors which can trigger hazardous drinking amongst
adults include bereavement, mental stress, physical ill health, loneliness, isolation and loss.

Women who regularly drink more than 6 units of alcohol a day (or more than 35 units a week) and
men who regularly drink more than 8 units a day (or 50 units a week) are at the highest risk of
alcohol-related harm. Women who drink heavily during pregnancy put their baby at risk and
consequential disorders can lead to lifelong intellectual and behavioural problems for the child.

In Essex, people over 15 years reported engaging in hazardous (18.4%) and harmful drinking (4.5%)
– this is higher in the south of the County at 4.9% (2009-10). The data also suggests that there are
over 34,000 (3.6%) dependant drinkers across Essex.

This increase in alcohol abuse coincides with an increase in hospital admissions due alcohol-related
harm over the last few years and in 2009/10 Harlow (1,900 per 100,000) had a significantly higher
rate of admissions then the England average (1,743) and all other areas in Essex CC (1,383) – the
lowest rates were in Brentwood (1,091) and Colchester (1,175). Intoxication also increases the risk
of accidental injuries, including road traffic incidents (e.g. drink-driving related).

There has also been an increase in alcoholic liver disease which does not usually cause any
symptoms until the liver has been extensively damaged. There has been a marginal increase in
mortality rates (people under 75yrs) from liver disease since 2004-06 across most of Essex (the
latter had increased from 6.33 per 100,000 to 6.25 per 100,000 over 2007-09). Colchester (9.06) and
Brentwood (7.81) had the largest increases, although Basildon (8.19) also had a high mortality rate
in 2007-09.Castle Point (3.08), Uttlesford (4.27), Chelmsford (4.39) and Rochford (4.59) had the
lowest mortality rates in 2007-09.


14
     East of England Lifestyle survey 2008
15
     Schools Health Education Unit Survey 2009/2010. Primary & Secondary Schools Detailed Findings. SHEU, 2010
16
     Local Alcohol Profiles for England, Increased & Higher Risk Drinking Estimates 2008
                                                                                                                 23
                                              DRAFT as at 28 February 2012
Alcohol misuse can also contribute to an increase in criminal behaviour. Harlow (10.5 per 1,000) had
the highest alcohol-related crime rate in 2010-11, with Basildon (7.2) and Epping Forest (7.1) also
above the regional average (6.2). Rochford (2.7 per 1,000 was ranked 10th lowest nationally),
Maldon (3.6) and Uttlesford (4.2) were the districts with the lowest recorded alcohol-related crime
rates. It is also important to take note of the effect of alcohol abuse on families, with the risk of
domestic violence and abuse.

Early identification and referral of people with a drinking problem is important if we are to slow down
these gradual increases in morbidity, especially as it is estimated that only 5.6% of these people
access an alcohol treatment programme annually.

Drug Misuse
People with substance misuse problems are more likely to live in and be from more deprived
communities and are likely to concentrate (especially for illicit substance users) in conurbations (e.g.
Clacton, Basildon) where substances and the means to pay for them are more readily available.

They are also more likely to be experiencing a range of health and social care related issues and will
be linked to a number of services such as Mental Health, Primary Care and other non medical
service provision and are frequently also known to the Criminal Justice services due to offending
behaviour often associated with this client group.

The most recent Problem Drug Use - PDU (now defined as Opiate and Crack Users – OCUs)
prevalence estimate17 for Essex is 4,668 people in 2009-10. Basildon (OCUs 323; others 95) and
Tendring (OCUs 224; others 82) had the larger proportion of drug users engaged in treatment, whilst
Maldon (OCUs 43; others 22) and Uttlesford (OCUs 45; others 18) had the lowest proportion of
users in treatment.

For many young people drug and alcohol use is a part of growing up, but for a small proportion of
young people experimental and recreational use becomes problematic. Recent trends show an
increase in problematic alcohol use with a corresponding drop in the use of illicit substances among
young people18. In Essex we have seen a steady increase over the past 3 years (25.6%) in under
18s accessing structured treatment for substance misuse – from 218 in 2008-09 to 353 in 2010-11.

Sexual Health
Unprotected sex can lead to sexually transmitted infections (STIs), unwanted pregnancy and
preventable terminations. The health and social consequences associated with contracting STIs,
such as HIV, are enormous to the individual, their relatives and the health economy. HIV sufferers
can feel excluded and people are often so worried about stigmatisation that they avoid checking
whether they may have accidentally contracted a STI following unprotected sex.

Recent figures from the HPA reveal that of those dying of HIV-related illnesses, 73% were
diagnosed late. A number of recent models have suggested that the majority of HIV transmissions
are from those who are undiagnosed. It is not possible to report on local data, due to confidentiality,
as the numbers are too small at locality level.

Certain groups such as young people and men who have sex with men are at a higher risk of STIs
then others. The rate of acute STIs vary between districts in Essex, with Harlow (1,003 per 1,000)
and Colchester (860) having rates higher than England (779) in 2010. Uttlesford (333), Brentwood
(381) and Rochford (414) had the lowest rates. This is suggestive of the need to better engage with
the more disadvantaged communities in the developing and improving access to sexual health
services.

Good contraceptive services can keep the demand for abortions low and reduce the risk of teenage
pregnancy. Based on information gathered through the Chlamydia screening programme, it is


17
     National Drug Treatment Monitoring System
18
     Drug Use, Smoking and Drinking among young people in England, NHS Information Centre 2007
                                                                                                      24
                                   DRAFT as at 28 February 2012
evident that poor sexual health practices prevails in the younger age groups (people <25yrs), across
Essex.

There is a strong association between teenage conception rates, low educational attainment, low
aspirations, and poor employment prospects at 16-18 years. Teenage parents often have poor
parenting skills and end up living in ‘poverty’. There has been a decrease in the under 18s
conception rate in Essex between the rolling three average in 1998-2000 (35.4 per 1,000) and that of
2007-09 (31.8 per 1,000) which mirrored the overall 11% reduction in England. Basildon (43.8),
Harlow (41.6) and Tendring (41.5) had higher rates than England (40.2) in 2007-09, with Brentwood
(16.8), Uttlesford (20.4) and Maldon (25.5) with the lowest rates.


2.5 INTERVENTIONS TO REDUCE HEALTH INEQUALITIES
Tackling health inequalities has been on the local agenda, following a plethora of government
policies introduced since 2003, culminating in Essex’s publication of its Health Inequalities Strategy
in 2009. There are some signs of progress (reported in this section) but much remains to be done
including improving joint working, ensuring appropriate measures of performance/progress, and
rolling out more evidence based interventions that would help achieve the QIPP (Quality,
Improvement, Prevention and Productivity) agenda.

Early Years & Children
Our local emphasis on early years’ interventions is consistent with the life-course approach to
tackling inequalities. The enhancement of the Sure Start program has brought about the creation of
the much broader-based Children’s Centres, which are also focusing on reducing the impact of child
poverty.

Although we do not yet have specific information, the anecdotal evidence suggests progress is being
made, especially with the targeting of disadvantaged communities, raising welfare benefit levels (e.g.
through the Reach Out scheme) and the provision of support to low-paid workers (e.g. subsidized
child care).

Targeted lifestyle interventions have also been introduced with early indications of some success.
These include tackling childhood obesity (e.g. the MEND scheme – Mind, Exercise, Nutrition, Do It!),
teenage pregnancy (e.g. access to free contraception and emergency hormonal contraception) and
improving educational attainment for children being looked after. There has also been an
improvement in the proportion of children being breastfed at 6-8 weeks, following the roll-out of the
peer-led support programme.

Early Identification
A number of national screening and assessment programmes are in place to support the early
identification of health and social care needs. In the past 2-3 years a number of new schemes have
been implemented across Essex which will specifically target risk factors associated with health
inequalities. Some of these include Health Checks, the use of assistive technology and the
introduction of the alcohol IBA (Identification & Brief Advice) scheme.

All PCTs in Essex have now introduced a local Health Check programme, primarily through GP
services. This programme will help identify people at risk of some conditions, such as diabetes but
will also help identify those who need to be encouraged to lead a healthier lifestyle. In areas, where
uptake to the checks has been low, especially with hard-to-reach groups, external providers have
been commissioned. A senior health check scheme is also being piloted in NE Essex to identified
patients at higher risk of health-related complications.

A more comprehensive alcohol pathway is being developed across Essex to ensure that we can
identify people who are dependent drinkers as well as consuming harmful levels of alcohol and
signpost them onto services to help them. The IBA scheme in primary care has been rolled out
across Essex, with additional liaison nurses based in A&E departments to provide an early
assessment of people at risk of alcohol abuse.
                                                                                                     25
                                    DRAFT as at 28 February 2012


Community-based Interventions
Implementing broad lifestyle interventions aimed at supporting people to make healthier choices is
paramount in tackling the gap in health inequalities. We continue to roll out innovative and evidence-
based schemes aimed at tackling obesity, drug and alcohol misuse and a comprehensive smoking
cessation service operates across Essex. We also have plans in place targeting the health and
wellbeing of vulnerable groups, such as travelling families, people with learning disabilities, prisoners
and people who are homeless.

We continue to make use of targeted social marketing to improve health and social wellbeing and
reduce stigma (e.g. promoting the uptake of Chlamydia screening is helping to de-stigmatise
perceptions about sexually transmitted infections). The use of marketing has helped improve flu and
MMR immunisation rates. We have also launched an Essex-wide website, via Facebook, to promote
health and wellbeing and to signpost young people to relevant services.

Improving Disease Management in Primary Care
The introduction of the Quality Outcomes Framework in primary care was intended to help improve
the quality of primary care services and improve the care of people with chronic conditions. In some
areas of Essex, additional Local Enhanced Services (LES) have been introduced to help identify and
treat people at higher risk of complications.


2.6 POPULATION PROTECTION
Infectious Diseases
A number of well-established national public health strategies are in place for the surveillance,
prevention and control of infectious diseases. Currently of particular interest in infectious disease
control, are the threat of pandemics (Influenza - swine flu and bird flu), hospital-acquired infections
(such as MRSA), the increase in blood-borne (BBV) diseases (such as Hepatitis B/C & HIV) and the
increase of certain infections (for example, TB & measles).

Preventing the spread of these diseases is of paramount importance as the outcome of contracting
many of them is fatal or likely to lead to an eventual death. To this effect the surveillance work
undertaken by the Health Protection team can contribute to minimise potential serious outbreaks and
minimise spread and harm.

A number of immunisation programmes are in place to ensure that the population can acquire a
good level of immunity from childhood into older age. Poor media reporting around the effect of
some of these programmes had a negative impact on uptake for MMR and the flu jab over recent
years. With some innovative and evidence-based public health interventions, we are seeing an
improvement in uptake with MMR vaccination alone showing a 5-6% increase over the past 2 years.

In 2010-11, MRSA infection rates in England were 2.9 per 100,000 – NHS West Essex had a rate
above this at 3.5. The other PCTs in Essex had rates below this and the regional rate (2.1). All the
PCTs in Essex had seen a decrease in their rate from 2009-10 except Mid Essex which saw an
increase on the previous year. All the Essex PCTs had a C.Difficile infection rate below both the
regional (31.7 per 100,000) and national (43) rates. Over the last 3 years, Mid Essex, NE Essex and
SE Essex have seen a year on year decrease in infection rates.

The rolling out of targeted BBV services, hepatitis B/C vaccination (e.g. drug users) and the needle
exchange programme, is helping to prevent the spread of blood borne viruses and HIV.

Other Major Incidents
Agencies continue to collaborate to ensure that Essex is fully prepared for the effects of flooding as
some of the county is within high risk flood zones.

The Essex Resilience forum has a comprehensive strategy to help deal with other major incidents
such as the risk of terrorism, outbreak of a pandemic flu and large scale incidents.
                                                                                                      26
                                    DRAFT as at 28 February 2012



2.7 RECOMMENDATIONS TO THE HEALTH & WELLBEING BOARD

LIFE EXPECTANCY & QUALITY OF LIFE
 Need to ensure that strategy is in place to reduce the inequalities in life expectancy and that there
   is a collaborative undertaking to tackle the wider determinants of life, implement targeted
   interventions where necessary and engage with local communities to improve overall quality of
   life.
CANCERS
 Ensure regular campaigns for the public to be aware of risks and also symptoms that can indicate
  cancer and know when to seek medical advice.
   Ensure increasing number of people are attending for national cancer screening programmes and
    that patients are diagnosed without unnecessary delay.
   Effective strategies to reduce the risk factors – tobacco consumption, alcohol misuse, unhealthy
    diets, physical inactivity, obesity and excessive sun/sun-bed exposure.
CARDIOVASCULAR DISEASES
 Need to ensure a robust strategy to improve prevention, provide better management of patients
  and provide effective evidence-based interventions.
   Prevention strategy needs to focus on inequalities associated with lifestyle risk factors and
    personal responsibility for health (e.g. physical inactivity).
RESPIRATORY DISEASES
 Collaborative working to improve housing conditions for people with asthma.
   Ensure stop smoking and physical activity programmes target people with asthma and COPD and
    those with children.
 Early identification and better management of people with respiratory illnesses in primary care.
LIVER DISEASE
 More concerted support for the development of work around earlier identification and support for
   alcohol misuse within primary care, hospitals and other settings.
   Develop a systematic alcohol strategy, with a focus on preventing alcohol abuse amongst young
    people.
DIABETES
 Prevention strategy needs to be tailored and focus on inequalities associated with lifestyle risk
   factors and personal responsibility for health (e.g. physical inactivity).
   Early identification and optimal management are paramount to enable good diabetes control and
    avoid unnecessary complications.
CHRONIC KIDNEY DISEASE
 More CKD care, including renal replacement therapy, should take place closer to home, especially
   for those patients requiring end of life care.
   Early identification and better management of people with CKD in primary care.
ACCIDENTS & SUICIDES
 Continue to develop a more co-ordinated safety enforcement, promotion and education
   programme across key agencies, especially with children (e.g. home safety equipment), young
   people (e.g. through PSHE) and older people (e.g. home minor adaptations).
   Strategy to improve the population’s mental wellbeing should address the broader factors affecting
    mental health which could lead to suicidal intent (e.g. people in debt, being bullied or prisoners).
EXCESS SEASONAL MORTALITY
 Improve referral system for high risks residents and assessments using the Common Assessment
   Framework (CAF) which can include identification of at-risk residents.
   Effective falls prevention programme with community-based support services, effective public
    health interventions (e.g. fuel poverty payment) and better management of chronic conditions.
MENTAL HEALTH
 Work with partners to ensure focus on positive emotional and social wellbeing across services and

                                                                                                       27
                                    DRAFT as at 28 February 2012
    implement/ rollout initiatives for children and families (e.g. parenting programmes).
   Develop a strategy to improve the population’s mental wellbeing whilst addressing the broader
    factors affecting mental health and not just treating mental ill-health.
   Focus on earlier diagnosis of dementia, improving the provision of intermediate care and
    rehabilitation and increasing the range of accommodation choices for people with dementia with
    good quality residential and nursing care places.
   Consistent signposting to opportunities for support in the wider factors such as support to
    maintain/seek employment (e.g. skills development, volunteering) and managing income and debt
    (e.g. to minimise accommodation issues).
PHYSICAL & RECREATIONAL ACTIVITIES
 Strategy to ensure physical activity is embedded in policy (e.g. Planning, Sports Development) with
   a need to protect green space for formal and informal active recreation.
   Sustainable and tailored support for individual (e.g. Health Trainers) and families (e.g. MEND)
    through setting-based interventions (e.g. workplaces, schools).
DIET & OBESITY
 Better identification and referral of people at risk of being overweight is required at primary care
   (GP) level and in schools, with more effective community-based prevention and support
   programmes.
   Continue to develop new initiatives and embrace new approaches to improve breastfeeding rates.
SMOKING PREVALENCE
 As a major cause of ill-health and mortality, strategy must tackle prevention among young people,
  increase smoking cessation services in areas of high prevalence and ensure robust tobacco
  control measures are in place and enforced.
ALCOHOL MISUSE
 Co-ordinated approach to focus on problems drinkers, where domestic violence is a known risk
   with support for perpetrators and victims.
   Investment in alcohol misuse prevention (including setting-based) and treatment services needs to
    increase to improve access to detoxification programmes. Early identification and referral of
    problem drinkers can further impact on morbidity.
   Strategy must also focus on the health and social impact of alcohol misuse among young people.
DRUG MISUSE
 Increase the penetration rate to ensure drug users are engaged in effective drug treatment and
  supported to live independently.
   Life-course approach to prevention to tackle societal adversity by implementing comprehensive
    intervention programmes in adolescence and early adulthood and restricting supply.
SEXUAL HEALTH
 Ensure sexual health services are configured to provide an effective prevention programme, a
   broad range of contraception and promote STI screening (esp. Chlamydia) in core services.
   Strategy should also focus on the link between alcohol misuse, sexuality and personal safety.
INTERVENTIONS TO REDUCE HEALTH INEQUALITIES
 Strategy should embrace the wider social and economic determinants of health, including skills,
   jobs and good neighbourhoods in which families can thrive. A shared focus by public sector
   agencies on children is an investment in the future of our communities. Community based
   interventions to promote healthier lifestyle choices will also help reduce inequalities.
POPULATION PROTECTION
 Strategy should continue to promote immunisation and vigilance against outbreaks of infectious
   diseases.


2.8 SUPPORTING RESOURCES

a. JSNA Local Economy (August 2010)
b. JSNA Crime (September 2010)
c. Geography & Demographics Chapter (September 2010)
                                                                                                         28
                                  DRAFT as at 28 February 2012
d.   JSNA Health (August 2010)
e.   JSNA Substance Misuse (August 2010)
f.   JSNA Children (May 2011)
g.   Public Health Outcomes – Evidence-based Practice (September 2011)




                                                                         29
                                              DRAFT as at 28 February 2012


3. CHILDREN, YOUNG PEOPLE & FAMILIES
3.1 MATERNAL & INFANT HEALTH & WELLBEING

There is widespread consensus that the early years in a child’s life (aged 0-5 and especially the first
22 months) have a strong impact on future health, attainment and social/emotional development.
The factors that affect children’s health generally are social disadvantage, poverty and poor access
to education and other services. Socially disadvantaged groups suffer poorer physical health and
lower life-expectancy than the more advantaged, have higher incidence and prevalence of acute and
chronic illness, and are more likely to smoke and have a poor diet. Children from poorer
backgrounds suffer higher rates of accidental injury, infections, failure to thrive, general ill health,
anaemia, dental caries and teenage pregnancy. In addition, poorer families are less likely to have
access to, and make appropriate use of, health services than those from more advantaged
circumstances, and they are less likely to benefit from health promotion services and advice.

The majority of women are judged to be at low risk of developing complications during pregnancy or
childbirth, with around 20-25% at higher risk. These risks may also include factors such as smoking,
diet and substance misuse all of which can contribute to low birth weight and infant mortality. These
factors are more prevalent amongst younger pregnant women, especially teenagers.

To minimise other risks to both mothers and the unborn children, a number of antenatal screening
programmes have been introduced and it is crucial that expectant mothers are provided with expert
guidance to take up these tests.

In the Essex CC area in 2009, there were 16,264 (61.4 per 1,000 females aged 15-44yrs) live births
to females aged 11-49 years old. This is below the national average (63.7) and the regional average
(63.9). The highest birth rate in Essex was in Harlow (75.8) and the lowest in Castle Point (52.7)19.

Low birth weight is an enduring aspect of childhood morbidity, a major factor in infant mortality and
has serious consequences for health in later life. In Essex CC (6.7%) of live and still births were
under 2500grams in weight in 2009, which was lower that England (7.5%) and East of England
(7.1%). Maldon (7.5%) had the highest proportion of low birth weight babies in Essex and Uttlesford
(5.1%) had the lowest.

The infant mortality rate (<1yr) is a useful indicator of the overall health of a population. There are
significant differences in infant mortality rates between different population groups. Whilst neonatal
deaths (within 28 days of birth) are particularly associated with the circumstances of pregnancy/
childbirth, post-neonatal deaths are more associated with parental circumstances.

The infant mortality rates in Essex districts were not significantly higher to the national rate in 2007-
09. Overall the mortality rate for Essex CC (3.9 per 1,000 live births) was lower than England (4.7).

Breastfeeding is an important part of maternal and child health and provides the best start in life for a
new born child as well as offering many benefits for mothers. Breastfeeding has an essential role to
play in improving the public’s health and reducing health inequalities; by preventing disease in both
the short and long term, for mother and child. It also supports the development of an intimate and
affectionate bond between mother and child.

Children who are not breastfed are at increased risk of a number of poor health outcomes.
Breastfeeding protects babies from infections including gastroenteritis and urinary tract infection and
childhood diseases, including juvenile-onset insulin-dependent diabetes mellitus and respiratory
disease. Breastfeeding can also positively influence maternal health and can protect women against



19
  Office for National Statistics. Compendium of Clinical and Health Indicators / Clinical and Health Outcomes Knowledge Base
(www.nchod.nhs.uk or nww.nchod.nhs.uk)
                                                                                                                               30
                                               DRAFT as at 28 February 2012
certain forms of cancer, including breast cancer and epithelial ovarian, thereby reducing the burden
of ill health on the women.


Data at PCT-level indicates that there has been an increase in breastfeeding initiation rates except
for North East Essex (-4.5%) between 2009-10 and 2010-11. The Essex average (71.7%) is lower
than England (73.9%) – nationally the best performing PCT reported 95.6%. The breastfeeding
(totally or partially breastfed) prevalence at 6-8 weeks after birth is low in Essex (41.1%), compared
to England (47.8%). Essex’s prevalence in the south (38.3%) was lower than in the north (42.9%).

The provision of immunisations programmes is aimed at reducing the risks associated with
communicable diseases (such as measles, mumps, rubella, flu & polio) all of which are diseases
with serious complications. The childhood immunisation programme targets children under the age
of 5 years. None of the areas (PCT level data) in Essex are achieving the 95% required for herd
immunity but there has been an increasing trend in recent years – e.g. MMR at year 5 has increased
from 83.7% (2006-07) to 88.9% (2009-10).

Good parenting skills can contribute significantly to improved outcomes in later life for all children.
Supporting parents to make healthier choices, provide a safe learning environment (including
discipline) and have aspirations, will prevent poor outcomes (e.g. criminality, poor lifestyle choices)
in life.

A recent survey20 of maternity services highlighted some areas of concern, including lack of
information about new mothers’ emotional health (21%), about their physical health (17%) and about
infant feeding (13%). Hospital-level patient ratings across Essex were poor (between 5.8 to 6.5 out
of 10) in comparison to the rest of England. Only 74% of patients felt they were involved in decisions
about their care and only 63% reported being treated with ‘kindness’ and understanding in hospital
after birth.


3.2 CHILDREN & YOUNG PEOPLE

Family environment
While the influence of parents is greatest when children are very young, parents matter at every
stage in a child’s life. Parenting in the home has a far more significant impact on children’s
achievement than parents’ social class or level of education. From the very earliest years, the
mother’s nutritional intake, consumption of alcohol or drugs, even levels of stress during pregnancy
can have a substantial impact on the health and well-being of the foetus and baby. For children of
primary school age, parental involvement – particularly in the form of good parenting in the home –
has the biggest impact on their achievement and adjustment, an effect that is greater than that of the
school itself. A child that has not had the benefit of a positive, caring relationship with their parents is
likely to have low self-esteem and be vulnerable to mental health problems which can seriously
impair their ability to achieve, enjoy and learn. Parents continue to have a significant impact through
secondary school years, as shown in staying on rates and educational aspirations, and also in the
way that aspects of parenting also appear to be a reliable predictor of childhood obesity, offending
and anti-social behaviour, substance misuse and teenage pregnancy. Parental support is also an
important factor for young people making a successful transition to adulthood and independent
living.
An estimated 2% of families experience multiple problems, which puts children at a higher risk of
adverse outcomes. There is a greater concentration of families with multiple problems in deprived
areas, although even in the most deprived areas only one in twenty families experiences five or more
of the basket of disadvantages. Families living in social housing, families where the mother’s main
language is not English, lone parent families and families with a young mother all face a higher than
average risk of experiencing multiple problems.


20
     Maternity Services survey 2010, Care Quality Commission
                                                                                                         31
                                    DRAFT as at 28 February 2012
There are an estimated 1,000 teenage parents under 20 in Essex. Children of teenage mothers are
generally at increased risk of poverty, low educational attainment, poor housing and poor health, and
have lower rates of economic activity in adult life. The health risks to the children of teenage parents
include a much higher infant mortality rate (60% higher than older mothers) and the fact that teenage
mothers are more likely to smoke during pregnancy and are less likely to breastfeed.

There are four groups of children and young people who are at particular risk of poor outcomes
resulting from homelessness: 16 and 17 year olds who are homeless or at risk of homelessness;
care leavers aged 18 to 21; children of families living in temporary accommodation; and children of
families who have been, or are at risk of being, found intentionally homeless by a housing authority.
Homelessness can significantly increase child vulnerability and it increases the risk of a child being
on the Child Protection Register from 1% to 12%. Homeless young people are more likely to sleep in
dangerous places, travel longer distances and have mental health, drug and alcohol problems. Up to
half of single homeless youth have experienced being looked after. Children who have been
excluded from school are 90 times more likely to end up living on the streets than those who stay on
and pass exams. More than a quarter of all those living rough have been excluded from school and
62% have no educational qualifications.

Education
Supporting children and parents during a child’s early years of development is a key for children’s
health and wellbeing. Educational attainment is influenced by both the quality of education children
receive and their family’s socio-economic circumstances. Educational qualifications are a
determinant of an individual's labour market position, which in turn influences income, housing and
other material resources and has an impact on health and health inequalities. The factors associated
with low achievement are eligibility for free school meals, levels of unemployment, single-parent
households, having parents with low educational qualifications and being persistent truants.

Attainment across Essex is improving at each key stage, but in many areas remains behind the
national average. A quarter of pupils did not achieve the expected Level 4 in both English and maths
at Key Stage 2. Almost one in five did not progress by two levels between Key Stages 1 and 2 in
English and maths. 45% of pupils did not achieve the target five A*-C grades at GCSE (including
English and maths), slightly better than the national average of 46%. However, there is wide
variation across Essex with pupils in Basildon, Braintree, Castle Point, Harlow, Maldon and Tendring
performing below the county average. Across Essex, only 1.2% of pupils left school without a GCSE
or equivalent qualification – similar to the England figure of 1.0%.

Poor attendance is a strong predictor of poor attainment. Several initiatives are aimed at improving
attendance, directly or indirectly through increasing general engagement/ enjoyment. Persistent
secondary school absence has fallen over the last few years, to 5.0% in 2008/09 and in line with the
national figure although still in the third quartile.

While the attainment of children looked after in Essex has improved over the last few years, it is still
significantly below that of their peers. There is also a significant gap in attainment levels between
boys and girls (as there is nationally), between pupils having free school meals and those who do
not, and between pupils with special needs and all pupils. The picture amongst the BME community
is mixed, with some communities outperforming the Essex average.

Assessment of children with special educational needs (SEN) is a national requirement. If a child’s
needs cannot be met through an agreed plan (e.g. Statement, School Action Plus), ECC may
consider the need for a statutory assessment and, if appropriate, makes a multi-disciplinary
assessment. Most children with special educational needs require support with behavioural,
emotional and social development and cognitive skills. Significantly fewer pupils with special needs
achieve the expected level of attainment at each key stage. The gap in attainment for pupils with
SEN compared to all pupils is higher at Key Stage 2 than at Foundation or GCSE. Young people
with statements of SEN are considerably more likely to move into positive outcomes than those on
School Action Plus and more likely to do so than those on School Action.


                                                                                                      32
                                                 DRAFT as at 28 February 2012



NEET
National statistics show that young people who are NEET, are more likely to have parents with
qualifications below that of ‘A’ Levels, parents who are in routine or lower supervisory jobs, and to
have been eligible for free school meals. 27% of persistent truants and 11% of occasional truants
are NEET, compared to 5% of young people who have not truanted. 36% of young people with no
reported qualifications and 28% with lower grades at GCSE are NEET, compared to 2% who have
received 5+ A*-C grades at GCSE. Young people who report risky behaviours in Year 9 (such as
smoking cigarettes or cannabis, vandalism, graffiti and shop lifting) are twice as likely to end up
NEET after Year 11. In 2010/11 NEET rates were particularly high in Tendring (16.2%), Basildon
(13.2%) and Braintree (11.4%), compared to a county average of 6.3% and national average of
6.0%.

Lifestyle Issues
Many of the risk factors associated with the key causes of ill-health and mortality are lifestyle based.
These include alcohol and drug misuse, smoking, poor diet, physical inactivity and poor sexual
health practices.

The consumption of alcohol by young people is a growing area of concern. It causes a wide range of
problems including increased risk of injury, accidents, risk taking behaviour, cognitive problems and
a long term risk to health. Under the influence of alcohol, young people are more likely to indulge in
unprotected sex (which can lead to unwanted pregnancies and contracting sexually transmitted
infections) but may also be subject to unwanted sexual advances or worse abuse/rape. Adolescent
binge drinking is a risk behaviour associated with significant later adversity and social exclusion. By
the time the teenage binge drinkers reach 30 they are 60% more likely to be an alcoholic, nearly
twice as likely to have a criminal conviction, 40% more likely to use illegal drugs, 40% more likely to
suffer mental health problems and 60% more likely to be homeless. They are also 40% more likely to
have suffered accidents, almost four times as likely to have been excluded from school and 30%
more likely to have gained no qualifications.

In Essex nearly two in ten secondary pupils21 say that they have been drunk at least once in the last
four weeks: 8% once, 6% twice and 4% three times or more – this is slightly more females than
males and a rate that increases significantly with age, from just 4% of Year 7 pupils to half of Year
12 and 13 pupils.
There is evidence to suggest that young people who use recreational drugs run the risk of damage
to mental health including suicide, depression and disruptive behaviour disorders. Regular use of
cannabis or other drugs may also lead to dependence. When asked if they have ever taken drugs
(not prescribed by a doctor), 9.1% of secondary pupils in Essex22 say that they have – fewer females
than males and age again having a significant impact on behaviour with 3% of Year 7 pupils saying
they have taken drugs compared to over 20% of Year 11 pupils. A third of pupils who say that they
have been drunk in the last month also say they have taken drugs while half of those who have
taken drugs also say they have been drunk in the last month.

5.7% of all secondary pupils in Essex23 say that they smoke regularly. While 93% of Year 7 pupils
have never smoked, this proportion falls to just 41% of those in Year 12 and 13. Local interventions,
aimed at reducing the numbers of children and young people, have targeted the access to tobacco
for this age group.

The percentage of pupils smoking, drinking and taking drugs have all fallen over the last five years,
with the percentage drinking regularly nearly halving. The percentage of pupils who have been drunk

21
     Schools Health Education Unit survey 2011
22
     Schools Health Education Unit survey 2011

23
     Schools Health Education Unit survey 2011
                                                                                                        33
                                                 DRAFT as at 28 February 2012
at least once in the last month has also fallen since 2009 from 29% to 18%. Pupils with poor
emotional wellbeing and those who have had a Police warning are all significantly more likely to say
that they smoke/drink regularly, have been drunk at least once in the last month or have taken drugs
than their peers, as are LGBT pupils and children not living with their parents. Pupils who are bullied
are significantly more likely to say that they have behaved in this way, except for drinking regularly.

The issue of overweight children continue to pose a challenge with a gradual rise in obesity rate
across the county. Childhood obesity is a complex public health issue that is a growing threat to
children’s health. Being overweight or obese increase the risk of a wide range of diseases and
illnesses, including coronary heart disease and stroke, type 2 diabetes, high blood pressure,
metabolic syndrome, osteoarthritis and cancer. Obesity reduces life expectancy on average by 11
years. Essex has fewer obese school children than in England or the Eastern region but there are
pockets of concern. In terms of Year 6 children, Tendring and the West quadrant have a far higher
proportion measured as obese. For those in reception, the North East and West quadrants have
proportionally more obese children than other areas. Although, Essex has lower rates compared with
the national average, more can be done to improve their diet and increase physical activity with a
view to reduce morbidity and premature mortality. Children who are overweight can also succumb to
mental health issues, through low self-esteem, bullying and general lack of motivation. These in turn
can impact negatively on their future aspirations and contribute to more chronic mental health
conditions.

The Chlamydia diagnostic rate in people aged 15-24 years vary considerably across Essex. In 2010,
Brentwood (940 per 100,000) and Uttlesford (1,000 per 100,000) had lower rates, whilst screening
services in Harlow (2,674), Tendring (1,892) and Colchester (1,883) detected higher rates – the
national rate was 2,219. It is likely the levels were as much influenced by service availability as by
levels of actual disease. Despite the access to free condoms across Essex and the apparent
reduction in teenage pregnancy, the ‘safe sex’ message may still be falling on deaf ears also due to
alcohol-fuelled risk taking behaviours.

The national evidence highlights the interplay between good parenting, education achievement and
lifestyle choices, where we have a wealth of local information to focus our interventions. However,
there is a lack of robust data on the prevalence of mental health issues in children and young people
as well as a clear understanding of complex needs.

Mental Health & Wellbeing
In evidence collected as part of the national ‘Good childhood Inquiry’ positive well-being for children
was held to depend on good relationships, especially within the family; on a sense of purpose and
achievement; on freedom and autonomy; and on a positive sense of self. Support for parents,
valuing all the professions charged with the care of children, and the role of schools, were all felt to
be important. Young people highlighted the importance of being free from stress, pressure and
worry. Some children and young people explicitly linked pressure to school, the influence of peers,
bullying, family expectations and their looks.

Primary pupils in Essex report a higher level of overall well-being than secondary pupils24, with an
index score (out of 20) of 16.0 compared to 14.3, which appears to be a little higher than the national
average. Mirroring the national findings, the level of well-being is stable during primary years but
declines for secondary pupils as they get older and secondary school girls are less happy with life as
a whole. There are no significant differences in the well-being of primary pupils by district, but
secondary pupils in Epping, Rochford, Brentwood and Castle Point have higher average scores than
all pupils while secondary pupils in Harlow and Basildon are the least happy.

The issue of most concern for young people in Essex (YEA 2010) is about feeling safe - particularly
bullying but also personal safety, road safety and racism. 9% of primary and 4.5% of secondary
pupils25 say they feel afraid to go to school because of bullying either ‘very often’ or ‘often’, similar to

24
     Data comes from the 2011 SHEU survey using the well-being index developed by the Children’s Society.
25
     Schools Health Education Unit survey 2011
                                                                                                            34
                                                DRAFT as at 28 February 2012
national levels. However, whilst the percentage of primary pupils feeling afraid to go to school
because of bullying has shown a decline over the last five years, the percentage for secondary
pupils showed a significant increase in 2011.

Many of the above-mentioned lifestyle risk factors can impact negatively on children and young
people’s emotional wellbeing. As highlighted throughout this document, people pre-disposed with a
mental health condition are likely to have poorer health-related outcomes as well as poor
educational achievement and job prospects.

Young people’s emotional health and well-being is important, both for the impact that it has on their
present quality of life, and also for the implications it has for their future social and emotional
development, academic experience and achievement. It is estimated26 that 13% of pupils (aged 7-
16) in Essex, or nearly 26,000, have poor emotional well-being. There is little difference between
genders at primary school, but secondary school girls are ten percentage points more likely than
boys to have poor emotional well-being. Pupils who have been bullied often are between four and
five times as likely while children at secondary school who are not living with their parents are also
significantly more likely to have poor emotional well-being. LGBT young people also appear more
likely to have poor emotional well-being. Pupils with poor emotional well-being have significantly less
positive views about their lives than all pupils.

An estimated 10% of children aged 5-19 years have a diagnosable mental health condition (equating
to 25,000 children in Essex) and a further 10% have an emotional or behavioural problem requiring
targeted support. These children have a wide range of conditions including clinically significant
conduct disorders, self harm, depression, hyperactivity and less common disorders such autistic
disorders and eating disorders. Many young people suffer from multiple problems such as bullying
and learning difficulties. Prevalence rates are higher among boys than girls and amongst 11-5 year
olds compared to younger children. Mental health difficulties are particularly prevalent among young
prisoners, homeless young adults and young adults leaving care. Over half of adults with a mental
illness will have begun to develop this by the time they were aged 14 years.

An estimated 10,000 young people had interventions by CAMHS Tier 2 services in 2010/11 while
13,000 young people received CAMHS Tier 3 treatment and just under 200 received Tier 4
treatment. Initial data shows that the main reasons for referral to Tier 2 services were conduct
problems and emotional problems. Data from South Essex shows that the main reasons for young
people being referred to Tier 3 services were significant parental factors, anxiety and behavioural
problems. It is paramount that the provision of Tiers 1 and 2 Child and Adolescent MH services are
reviewed in line with local requirements.

Children with Disabilities
There is a rising population of children with disabilities nationally, with two main elements: a growing
number of children with profound learning disabilities and/or multiple complex health needs; and a
growing number of children with autistic spectrum disorders, some of whom have very challenging
behaviour.

Families of disabled children commonly experience exclusion from ordinary child and family
activities, as well as some mainstream and community services, including education, healthcare,
leisure activities, transport and housing. Families with disabled children often face high levels of day-
to-day stress, and many have high levels of unmet need for support services, which can lead to
higher levels of stress and ill health than those experienced by other parents. In particular, families of
children with learning disabilities show greater levels of unmet need than those with children who are
not disabled. Lowering stress levels in families is important for the well-being of the whole family,
and is also likely to reduce the number of children who require residential placements or who are
looked after. Disabled children and their families face challenging times in coping with their physical
and/or learning disability, which can increase the risk of experiencing further ill health, unless we
gear up universal services and provide additional specialist services to support them. Their needs
are unique to them, often complex, and change over time.

26
     Based on data from the 2011 SHEU survey.
                                                                                                       35
                                              DRAFT as at 28 February 2012



It is difficult to establish the exact number of children with special needs who are known to children’s
services in Essex since the information is held in separate Health, Social Care and Schools
databases that are not linked up. SENCAN estimates27 there are 4,000 children with severe
disabilities aged 0 -19 in Essex, but only 1,200 receive a service from social care. There are 5,560
pupils in Essex who have a Statement of Educational Needs. Just over 650 pupils with a Statement
have a physical or sensory impairment, a similar number have behavioural and emotional support
needs (BESD) and just over 700 have speech and language communication needs. Around 1,000
have autistic spectrum disorders and just under 3,000 have learning disabilities.

It is important to ensure that the educational and skills-development needs of children and young
people living with a disability are carefully considered, to ensure that they can integrate better and
have similar opportunities as others with no disabilities.

Young people with disability often do not access health and social care services as readily and we
need to better understand why this is the case. For epilepsy admissions in under 19 year olds, NE
Essex had the highest rate (81 per 100,000) in the county, although this was more in line with
regional admission rates (78), West Essex had the lowest rate of admission (51). Better
management of their conditions can minimise the need for hospital admissions.

Accidental Injuries
Accidental injury is one of the main causes of death for children aged 1-15 years and is closely
linked to deprivation. Home remains the most common site for accidents, particularly for young
children, followed by the road.

Essex (100.2 per 10,000) has a lower hospital admission rate caused by unintentional and deliberate
injuries to people aged 0-17years, compared to England (123.3) in 2009-10. Harlow (132.1) and
Chelmsford (116.9) had the highest rate and largest increases since 2007-08. Brentwood (97.6) and
Uttlesford (94.2) have experienced the largest reductions (11.6), while Rochford (81.2) and Tendring
(85.3) had the lowest rates in Essex.

Young Carers
Another area of concern in Essex is the issue of young carers. Caring can be a positive experience,
helping to foster maturity and independence and strengthen family ties. However, extensive or
inappropriate caring can be damaging, constraining young people’s time and contributing to poor
outcomes. 27% of all young carers of secondary school age are experiencing some educational
problems. Many miss school and fail to attain any educational qualifications. This, combined with
ongoing caring responsibilities, serves to exclude some young carers from the labour market.

Substantial numbers of young carers report stress, anxiety, low self-esteem and depression and
many report feeling isolated from their peers. They also feel that they lack the time and opportunity
to socialise, and can also be reluctant to do so. Young carers also report bullying and anxiety about
bullying. Young carers are often reluctant to disclose their situation to practitioners or other young
people. There are an estimated 11,000 young carers aged 11-18 in Essex who provide care every
day to someone28, the majority of whom provide more than two hours of care per day. However, just
1,100 are supported by young carer groups across the county.

A recent Carers’ Needs Assessment29 in North East Essex predicated that this group made up 2.4%
of the carer’s population. Nationally it is estimated that of the young carers known to support
services, 66% care for parents/step-parents (especially in one parent families) while 31% care for
their siblings. Notably, 12% of young carers are caring for more than one person. Most of the care
provided is in the form of emotional support, domestic support (e.g. cooking, ironing and general

27
   This is based on 1.2% of the total child population in 2010, the percentage recommended nationally by Together for Disabled Children
to estimate the number of disabled children and young people.
28
   Estimate based on data from the Schools Health Education Unit survey 2011
29
     NE Essex Carers’ Needs Assessment July 2011
                                                                                                                                     36
                                    DRAFT as at 28 February 2012
support (e.g. administering medicines, assisting with mobility, etc), with a relatively small group
(18%) involved in providing intimate care (i.e. washing, dressing, toileting).

Crime & Young People
A number of factors can contribute to the likelihood of young people (8-17yrs) becoming known to
the local police and entering the youth justice system. This range from acting under the influence of
drugs or alcohol, being subject to abuse and/or neglect, being mentally and cognitively challenged to
young people displaced due to family breakdown and/or being looked after.

Up to a third of young offenders have mental health problems while a large minority, particularly
women, have low self-esteem. The prevalence of drug and alcohol use in the cohort is extremely
high, although few young offenders report dependence and only 15% are rated as at high risk of
substance abuse problems (but this is about 10 times the prevalence of all young people). Over 40%
feel there is a relationship between their substance use and their offending.

In Essex, the Police force, under the umbrella of the Youth Justice Service (YJS) has developed
plans to stop young people getting sucked into the system too early (e.g. after anti-social behaviour
or minor offences), while still offering them the help and support they need to stop offending. There
were some 18,500 offences by young people in Essex in 2010/11 – meaning that some 85 out of
every 1,000 young people aged 10-19 had offended in some way. Around 77% of all offences
committed by 10-19 year olds were repeat offences and 77% were committed by males.

The Youth Offending Service caseload was 1,220 young people in 2010/11, of whom 78% were
males and 93% were White. 23% were 14 or under at the time of referral, 22% were 15, 23% were
16 and 31% were 17/18. The number of first-time entrants continued to fall in 2010/11, 40% lower in
the first half of 2010/11 than a year earlier. 30% were female, down from 36% a year earlier. Harlow
was the only district to see an increase – all other districts saw a fall. The re-offending rate has risen
over the last three years: of 648 young people in the 2010/11 cohort, 80 re-offended within three
months.


3.3 CHILDREN AT RISK & SAFEGUARDING ISSUES

Although of rare occurrence, the abuse and neglect of children is intolerable. Safeguarding is
everyone’s responsibility, parents, relatives, the public and staff. All staff who, during the course of
their employment, have direct or indirect contact with children, or who have access to information
about them, have a responsibility to safeguard and promote their welfare. Furthermore, children
looked after (CLA), also need to receive better support to ensure they can maximise their potential.

Many of the issues highlighted in this document, such as social deprivation, parenting history, poor
education, parental mental health, drug and/or alcohol misuse, can all contribute to impacting on
child neglect and abuse. The Essex Drug & Alcohol Partnership (DAP) estimates there are 5,240
families in the county with four or more vulnerabilities, with a greater concentration of these families
in deprived areas. Children in families displaying ‘chaotic life styles’ are at high risk of being or
becoming children in need or looked after, and often such families have been receiving attention
from a range of social care and other organisations. The DAP estimates that there are 57,902
children in Essex with at least one parent abusing alcohol, 7,300 children with at least one parent
who is a dependent drug user, 46,636 children with at least one parent with a mental health problem
and 26,200 children experiencing parental domestic abuse. Most of the children looked after by ECC
have parents with two or more of these vulnerabilities.

Domestic abuse is a common risk factor leading to children being taken into care and becoming
subject to a child protection plan (CPP). Conservative estimates indicate that 30% of children living
with domestic violence are themselves physically abused by the perpetrator, and also use domestic
violence against their mothers. Other studies estimate that up to 66% of children suffer direct abuse
when living with domestic violence.


                                                                                                        37
                                      DRAFT as at 28 February 2012
It is estimated that just over 1,000 children were present in households where a domestic violence
offence took place in 2011 (although this does not necessarily mean that they were present in the
same room at the time). However, these figures are significantly lower than the estimates from the
DAP that there are 26,200 children in Essex who experience parental domestic abuse, i.e. one in ten
children. The difference is likely to be due to the fact that the Police data covers offences30
committed only (of which there were 2,500 in 2011) rather than incidents31 (of which there were
nearly 19,000 in 2011). The DAP also estimate that of the 1,500 children looked after in Essex, at
least 36% have parents involved in domestic violence.

Over half of the 9,000 children identified as Children in Need in Essex had the primary reason32 of
abuse or neglect at initial assessment. Half of the 1,100 children with a Child Protection Plan in
Essex had an initial category of abuse33 as neglect. A fifth had multiple categories and just under a
fifth had emotional abuse as the initial category.

The number of children looked after in Essex has increased by 20% since 2009 due to a
combination of increasing placement stability; higher rates of children becoming looked after; and
reduced rates of children leaving the care system, e.g. through slower adoption processes. However,
since January 2011 the total number has stabilised at around 1,550 and is predicted to fall over the
coming year. Nearly a quarter of all CLA in Essex are aged 16-17, although a large number are in
the 0-5 age group (but with a shorter average period of care).

National research shows that children looked after are seven times more likely than their peers in the
wider population to suffer from mental health problems and also seven times more likely to misuse
alcohol or drugs. 20% have a statement of special educational need (compared with 3% of the
general population). Young people who were looked after at one point are twice as likely to become
teenage parents: 17% of young women leaving care are pregnant or already mothers while 50% of
looked after girls are pregnant within two years of leaving care. Looked after young people are over-
represented in the youth justice system (9% are cautioned for, or convicted of, an offence, three
times higher than other young people) while about a quarter of adults in prison were looked after as
a child. Between a quarter and a third of rough sleepers were looked after at one point in their lives.
It is therefore vital that children in care or with a CPP have their needs adequately assessed to
ensure the best placement (including fostering) and to provide stability. This would ensure the best
outcome for them as well as represent better value for the council.

Although Essex has improved the schools attendance of CLAs considerably, their performance
remains substantially below that of their peers at every key stage. The gap for CLA increases with
age, in all areas. It is especially large at GCSE, when only one in six CLA achieved 5 A*-C grades
(including English & Maths).



3.4 RECOMMENDATIONS TO THE HEALTH & WELLBEING BOARD

MATERNAL & INFANT HEALTH
 Implement a life course perspective to health promotion, independent living, disease prevention
  and good parenting to address disparities in maternal, infant and child health.
    Develop preconception health initiatives, aimed at improving the health of a woman before she
     becomes pregnant and supporting young and vulnerable mothers-to-be.
    Need to improve hospital care in maternity services in relation to the provision of information,
     patient engagement and satisfaction.


30
   An incident is where police are called to a household but no offence is necessarily recorded.
31
   An offence is where police are called to a household and an offence has been committed such as breach of
the peace or actual bodily harm etc.
32
   Primary need indicates the main reason why a child started to receive services. It should not be left blank
and only one reason should be recorded.
33
   Category of abuse as assessed when the child protection plan commenced.
                                                                                                            38
                                    DRAFT as at 28 February 2012
    Need to ensure that there is a high uptake of the national childhood immunisation programmes
     across the County to ensure maximum protection for the population.
EDUCATION & NEET
 Action to reduce the disparities in educational achievement at an early stage will support efforts to
   reduce health inequalities, by improving individual’s employment prospects as well as their ability
   to make informed healthy choices.
LIFESTYLE ISSUES
 Action
MENTAL HEALTH & BULLYING
 There is a need for early identification and intervention in regards to children’s mental health and
   emotional wellbeing, including improved access to Tiers 1 & 2 as well as specialist services.
    High quality, jointly commissioned children’s mental health services are not only a safeguard for
     children and families but also a cost-effective investment over the medium to long term.
    The Essex strategy must place a significant emphasis on prevention including better health
     promotion for children and young people, as well as supporting people who are already afflicted.
CHILDREN WITH DISABILITIES
 A more detailed needs assessment is required to ensure we can better plan for the level and types
   of services that people with disabilities and their families feel better supported.
    Children’s Services and the NHS need to work to support parents whose have children with
     learning disabilities to improve their health and wellbeing.
    Provision of personalised and integrated care to encompass better management of health
     conditions (e.g. epilepsy), minimise crisis management and delayed transfer of care.
ACCIDENTAL INJURIES
 Need to ensure effective risk-reduction strategies, including training for front-line staff, and
  prevention schemes (including development of parenting skills) are in place. Community and
  setting-based interventions are most effective.
YOUNG CARER’S HEALTH
 Strategy to improve young carer’s assessment process, adopting a person-centred approach in
  addressing the needs of young carers.
CRIME & YOUNG PEOPLE
 It is important to recognise the correlational link between vulnerability on young people, substance
   misuse and offending and adopt corresponding interventions to reduce misuse of rug and alcohol.
    There is a need to reduce the level of NEETs, exclusions from school and have effective actions in
     place to tackle truancy in a bid to avert young people entering the Youth Justice system.
CHILDREN AT RISK & SAFEGUARDING
 Develop joint commissioning strategy enabling Children’s and Adult services, along with partner
   agencies, to co-ordinate their work to ensure that the family as a whole is supported to achieve the
   best possible outcomes for children at risk.
    Co-ordinated services to focus on working with perpetrators of domestic violence and children
     who are victims.



3.5 SUPPORTING RESOURCES

a.   JSNA Health (August 2010)
b.   JSNA Substance Misuse (August 2010)
c.   JSNA Children (May 2011)
d.   JSNA Crime (September 2010)
e.   Geography & Demographics Chapter (September 2010)
f.   Public Health Outcomes – Evidence-based Practice (September 2011)




                                                                                                         39
                                    DRAFT as at 28 February 2012


4 ADULTS & VULNERABLE GROUPS

4.1      WORKING AGE POPULATION


Overall in many areas in Essex, residents experience greater prosperity and less socio-economic
deprivation compared to other areas which have high unemployment rates and higher levels of
deprivation. Being employed plays a key role in mental and physical wellbeing. However, jobs that
are insecure, low paid and that fail to protect employees from stress and danger can contribute to ill-
health. The number of people likely to become unemployed in coming months will rise, with more
people aged over 60 years and who are unlikely to work again.

Work & Health
The impact of poor health or disability on a person’s likelihood of finding and keeping a job is
significant. Prevalence estimates suggest that in Essex, about 162,000 people of working age have
a disability of some sort. Nationally only 46% of people with a disability are in work compared to 76%
of those without a disability – this would equate to 66,700 numbers being unemployed in Essex.
This effect can be mitigated by educational qualifications.

Essex Adult Community Learning Service provides a CV writing course regularly to improve
employability. Additionally, EssexCares is providing employment opportunities for adults with a
learning disability and there were 385 adults in employment in March 2011 which is a 3% increase
on the previous year. The mental health trusts supported 600 services users in 2010-11 into
education and employment and greatly exceeded the target of 222.

Nationally, it is estimated that 1 in 5 adults have health conditions caused by or made worse by
work. In 2010-11 the East of England saw over 2,000 working days lost linked to either injury or
illness. Nationally, the biggest causes of work related ill-health were:

     Mental ill-health caused half of all sickness absence – local data shows that the proportion of
      incapacity benefits claimants ranges from 11% in Uttlesford up to 32% in Tendring (2008)
     Musculo-skeletal problems caused about a third of all working days lost in England in 2010-11
      but in the Eastern region this figure was higher at about 40%. Regional figures suggest that in
      2010/11 there were 54,000 cases (1770 rate per 100,000 population), which is a decrease on the
      previous year (59,000 cases).

Disability
Disability is an important issue for public health for a number of reasons. First, with more effective
health promotion measures, a reduction in the proportion of people who develop disability can be
achieved by addressing the underlying causes. Secondly, adequate treatment and rehabilitation
directed at restoring function in people who are already ill or injured can minimise disability. Thirdly,
disabled people have special needs and require personalised, tailored care.

Supported Housing
There are currently 803 specialist housing units to support adults with Learning disabilities in Essex
and approximately 32% (254) are self-contained units and 549 are shared units. It is estimated that
the requirement for units is 989 which is a shortfall of 186 units across Essex. Braintree (-54),
Chelmsford (-42) and Colchester (-41) are showing the greatest deficits. The demand for specialist
housing units is expected to increase as young people move from children’s to adult services and
move away from their family home.




                                                                                                        40
                                    DRAFT as at 28 February 2012


4.2    SOCIAL CARE PROVISION IN ESSEX

In order to obtain social care provision from Essex, people are assessed against the ‘Fair Access to
Care’ (FACS) criteria. FACS is a national eligibility framework that classifies a person’s needs as
either low, moderate, substantial or critical. In Essex, the council funds services for people who are
assessed as having ‘Critical or Substantial’ needs. In 2010-11 approximately 27,500 adults in Essex
were provided with social care support, a quarter of which (6,600) were residential services and the
remaining 20,850 people were given access to community services to support their needs. 79%
(5,250) of all residential services were provided to adults over the age of 65 compared with 53%
(11,250) of all community services. Although a lack of suitable housing for people with a physical
impairment can lead to admissions into residential care, adults with mental health (4,100) or physical
impairments (3,050) were more likely to receive community based services than residential services,
helping people to maintain their independence for longer.

During 2010-11 approximately 3000 people, a 22% increase compared with previous year, received
support from the reablement service, which aims to support people to regain skills with a view to the
risk of reducing longer term care. Of those people that received support 53% left the reablement
service and either received smaller packages of support inline with their new level of need or went
onto self-care.

4.3    LEARNING DISABILITIES

As of 2010, there is estimated to be 20,875 adults across Essex with a learning disability, which is
2.4% of the adult population. 16% are estimated to have a moderate learning disability and 6% a
severe or complex learning disability. Predicted demographic change, increased survival rates,
reduced mortality rates, improved diagnostic techniques and improved health care will lead to an
increase in the number with learning disabilities. Estimates suggest that the number of adults with a
moderate or severe learning disability could increase by 17% over the next 20 years. Additionally,
longer life expectancies will mean that support will be required for a longer period of time and may
need to support more complex needs.

The highest rates of people with a learning disability can be found in Tendring, Colchester and
Braintree, where former long stay hospital were located. People have since moved out of these into
areas of the local community. 33% of adults with a learning disability are living at home with
relatives or other family. One third of people caring for a person with a learning disability is over the
age of 65, this equate to 770 carers known to Essex social care. These are people who most at risk
of needed intensive support from social care in the future.


4.4 PHYSICAL & SENSORY IMPAIRMENT

Physical disability has far reaching implications not only a persons own circumstances in terms of
healthy living but depending on the level of disability there are implications in terms of health and
social care resources. Across Essex, there are estimated to be just over 69,000 people of working
age with a moderate disability which is estimated to rise to just under 78,000 by 2030. In terms of
serious physical disability it is estimated almost 21,000 suffer with this figure expected to rise to over
23,000 by 2030. 47% of adults with moderate or serious physical disabilities require personal care
assistance which includes getting in and out of bed or a chair, dressing, washing, feeding or use of a
toilet.

Almost two million people in the UK are living with sight loss (vision less than 6/12). By 2020 this
number is predicted to increase by 22%. It will double to four million people by the year 2050.
These increases are mainly due to the demographics of the population and eye health will be
particularly subject to this because over 80% of sight loss occurs in people over 60 years. Visual
impairment is another serious debilitating condition that can have implications for a person’s health
and ability to stay independent. For those with visual impairment, the likelihood of having a fall is
                                                                                                       41
                                     DRAFT as at 28 February 2012
greatly increased. It is estimated that currently across Essex there are approximately 600 adults with
a serious visual impairment, however in the over 65s this figure is estimated to be over 23,000.
By 2030, it is estimated that there will be almost 38,000 people with a visual impairment. The
estimated numbers of people with a hearing impairment are also significant – in Essex it is estimated
that approximately 150,000 people have impairment with this figure rising to almost 234,000 by
2030.

The rate of adults with physical disabilities who are supported in Essex in terms of receiving either
community or residential/nursing home care has seen an increase year on year since 2006/07 (577
per 100,000) and is now at a rate (620) that is higher than the East of England (594) – conversely
East of England has seen a year on year decrease in the rate of adults receiving support. The
highest rate can be found in Colchester, Basildon and Tendring.



4.5       CARERS

Almost 10% of our residents provide informal care to relatives, friends or neighbours, ie, about
139,300 as of 2010. Carers are people looking after or giving help or support to family members,
friends, neighbours or others because of long term physical or mental ill health or disability, or
problems related to old age. It is estimated tat 72% of people are providing unpaid care of less than
19 hours per week. 9% are estimated to be providing between 20-49 hrs and 19% are providing 50
or more hours a week. These people are likely to be providing help and support with domestic and
personal care tasks.

Research suggests that the economic value of the contribution made by carers in Essex is £2.4
billion per year which is £45.4 million per week.34

Two thirds of adult carers are economically active but are more likely to be in part time employment.
50,480 carers are likely to be economically inactive. Carers are more likely to describe their health
are not good or fairly good compared to non carers.


Older Carers
Over half of the people providing unpaid care are people aged over 50, which is of particular concern
as they are more likely to be suffering from ill health themselves. It is estimated that 83,850 people
aged 65 years and older (1 in 6 people) provided unpaid care for others in Essex (2010), It is
estimated that two-third of people with dementia are looked after by unpaid carers.

Approximately one third receive no support from either social services or the voluntary sector and
just over a third are not satisfied with the support they get. Fewer people of working age will be
available to care for and support older people; the 2008 sub national population projections suggest
that Braintree will see the biggest decrease in this ratio from just over 3:1 to drop to under 2:1 over
the next 25 years.

Essex assessed or reviewed 13,250 carers needs during 2010/11, of which 3,728 received a carers
assessment in their own right. 43% of these assessments were for older carers aged 65+.


4.6 OLDER PEOPLE

Social Care Needs & Social Capital
It is estimated that 80,600 older people with social care needs live in Essex - defined as people who
are having difficulty with or unable to perform personal care or domestic tasks without help. This is
31% of the older population aged 65+, which is slightly lower than the England estimate of 33%.

34
     ‘University of Leeds Valuing carers, 2011’
                                                                                                     42
                                             DRAFT as at 28 February 2012
There is a projected 15% increase in older people with care needs over the next 5 years, which is
higher than the anticipated increase in England (12%).

Harlow (37%), Basildon (36%) and Castle Point (34%) have the highest percentage of the population
with social care needs and Brentwood (27%), Uttlesford (29%) and Chelmsford (29%) have the
lowest proportion. Harlow and Basildon also have the fewer number of charitable organisations who
provide local support. This may be an indication that local investments (e.g. grants to voluntary
sector) to encourage grass-root community activity, is contributing to the building of valuable social
capital which in turn may reduce social isolation and improve community networking. There is
estimated to be 57,000 older people in Essex with care needs that are either unsupported or
privately funded. 65% of these people have either low or moderate needs.

The living circumstances of older people and people with mental health issues affect both
opportunities for social interaction and the need for additional support from formal and informal
services. It is estimated that the number of people aged 65+ living on their own will have increased
by around 48% by 2025. Loneliness can damage both physical and mental health and can be further
exacerbated by lack of transport and poor mobility.

As of May 2010, there are 293,720 people in Essex of pensionable age - 91,400 (31%) are receiving
state pension plus at least one other state benefit. These are people who are more likely to require
support from statutory services. The proportion is lower in Essex compared to England (36%).

Areas where there is a higher proportion of the population receiving more than one benefit include
Harlow (37.7%), Tendring (37.2%) and Basildon (35.8%). Areas where there is a lower proportion
include more affluent areas of Uttlesford (25.1%), Brentwood (25.3%) and Chelmsford (25.4%).

Mobility & Falls
The ability to keep active and independent depends greatly on mobility. Mobility can be seriously
limited as a consequence of age and by the effects of falls which may have lead to a fractured neck
of femur. Falls are a major cause of illness and disability amongst those aged over 65 years, and
one in three experiences one or more falls in a year. Falls can result in a loss of independence and
may impact on both physical and mental health.

The rate of hospital admission from all accidental falls varied significantly across Essex – the lowest
rates are 978 per 100,000 (Tendring) and 1,004 (Colchester) to 1,578 per 100,000 (Castle Point)
and 1,504 (Epping Forest). The latter two districts had higher rates than England (1,495).

Mental Health
Mental health and dementia account for more years of disability than any other condition, including
stroke, cardiovascular disease and cancer. Cases of dementia are expected to double by 2030 and
increase rapidly with age. There are nearly 8,700 people on the GP registers with dementia across
Essex. The variation in GP registers across Essex (0.4% to 0.6%) may be due to the fact that
dementia is difficult to diagnose in the early stages. By 2021, the projected increase in prevalence is
expected to reach 38%35.

Excess Seasonal Deaths & Flu Immunisation
Excess seasonal deaths is an important public health concern which sees an increase in mortality
among people with cardiovascular diseases, from respiratory diseases and amongst older people,
mostly during winter but also during heat waves. Links between poor quality housing, fuel poverty
and health are widely recognized. Lower/ higher temperatures, people’s lowered resistance to
illnesses (due to disease), safety in the home and the incidence and intensity of influenza outbreaks,
all contribute to a higher mortality rate during winter.

With the exception of Colchester (17.9%), Harlow (13.2%), Maldon, (10.1%) Rochford (14.2%) and
Tendring (15.5%), all other districts in Essex had higher excess winter deaths (2006-09) than
England (18.1%).

35
     Dementia UK, Alzheimer’s Society 2007
                                                                                                     43
                                                  DRAFT as at 28 February 2012


People aged over 65 years and those who are at risks (e.g. due to chronic illness) are eligible to an
annual flu jab. Although at PCT-level, all had achieved the target of 70% immunised among the older
age group, this has been lower in recent years. With new strains of viruses emerging and the risk of
a flu pandemic, the uptake of flu immunisation must be kept at a high level to ensure better
protection for our population.

End of Life Care
Across Essex, end of life care programmes are in place to support people to enable them to make
decisions about their palliative care packages and also their preferred place of death. The majority of
deaths occur in hospital but the vast majority of people would choose to die at home in their own
surroundings. End of life care aims to support these people and to increase the proportion of people
that are able to fulfil this wish. Data from 2008-10 showed that 20% of Essex deaths were at home,
with local authority figures ranging from almost 24% in Uttlesford down to 18% in both Brentwood
and Epping Forest.

Nursing and Residential Care
As people are living longer and the proportion of older people increases, the use of residential and
nursing homes will become more vital as there will be fewer younger relatives to support and look
after older people in their own homes and the demand for live in care and support is likely to
increase over the next decade- I’m not sure this is right to say as we are not necessarily encouraging
more registered care provision to be developed. Despite the significant increase in older people with
care needs this has not been matched by increase use of registered care, as people are being cared
for via alternatives in the community . The rate of adults in permanent nursing care in Essex in 2009-
10 was 59 per 100,000 – significantly lower than both the regional (97) and national rate (139).
However in terms of adults in permanent residential care in Essex (400 per 100,000), the rates are
not significantly different from regional (406) rates but are higher than national (373).

Special housing needs
It is estimated36 that there should be 21,960 specialist housing units available to the over 75
population in Essex whilst 16,226 are currently provided, which is a shortfall of 5,734 units. It is
estimated that Tendring (1140), Castle Point (1030) and Colchester (980) have the largest deficits in
terms of supported housing requirements. The over 75 years population in Essex is expected to
increase significantly over the next 20 years and if the need for supported housing units follows this
trend is estimated to increase to 35,300 units in 2020 and 39,100 in 2030 with a potential deficit of
22,874 units by 2030.

Premature Mortality
Premature mortality is considered to be when a person dies under the age of 75 and early death can
be associated with levels of inequality. Premature mortality rates from cancer vary across Essex
from a low in Uttlesford (94 per 100,000) to a high in Harlow (130) and Basildon (116), which are the
only 2 districts in Essex that are above the national rate (112). In circulatory disease, Harlow is the
only district (78) in Essex that has a rate above the national (70) premature mortality rate.


4.7 VULNERABLE ADULTS

The older population in Essex is growing faster than average for the UK and presents one of our
most significant challenges. The likelihood of developing a chronic disease or long-term condition
increases with age and, as our population ages, levels of disability will increase sharply. Patterns of
disability are also being affected as more premature babies survive and more children with complex
and multiple disabilities live on into adulthood. However, the changes are not expected to occur
uniformly across Essex as there are already considerable differences.




36
     Benchmarks from More Choice, Greater voice
                                                                                                     44
                                    DRAFT as at 28 February 2012
People who are pre-disposed to suffer from chronic ill-health, unable to work, homeless, who are in
the older age group and those adults who rely on people to care for them are at high risk of neglect,
isolation and poor health. As people age, the frequency of ill health and disability tends to increase.

As of May 2011, in Essex there were 43,500 people receiving employment and support allowance or
incapacity benefit.(of working age) and over 57,000 people receiving disability living allowance.
There are 37,475 people of working age in Essex, who are permanently sick or disabled.

Another group of vulnerable people are those who are made homeless, as of Dec 2009, there were
903 households that were in temporary accommodation and of those 67% of households either had
dependent children or pregnant women in Essex. It is imperative that those households that have
become homerless and have dependent children recover a sense of stability as the outcomes for
these children in later life can be very much shaped by childhood experiences and their living
environment.

There has been a decrease in the number of people from black and minority ethnic groups who have
been accessed for social care in 2010-11 compared with the previous year’s data, although
proportionally this increased in Q1 2011-12. The proportion of black and minority ethnic people
assessed is less than the overall percentage of BME groups in the wider population and the situation
will be monitored on-going.



4.8 TRAVELLING FAMILIES

Travelling families have low life expectancy, are unaware or unwilling to access statutory services
and therefore tend to have poorer health outcomes. There are 11 permanent sites across Essex for
the gypsy and traveller community, however at the last caravan count there were several
unauthorised encampments across Essex. There are currently in place a range of services available
to the gypsy and traveller community to include both adult and child education services and local
health services; however it has long been recognised that engagement with these communities is
challenging and more work is needed to promote better health and social care outcomes.




4.9 RECOMMENDATIONS TO THE HEALTH & WELLBEING BOARD

WORK & HEALTH
 Development an implement an effective workplace health and wellbeing programme based on the
  recommendations of the Boorman review, starting with the whole of the public sector, which can
  lead by example.
EXCESS SEASONAL MORTALITY
 Clear identification of vulnerable groups for targeted interventions (e.g. reducing fuel poverty,
   increasing flu jabs) is key to the prevention of excess seasonal mortality.
MENTAL HEALTH & DEMENTIA
 Age, injury to the brain and vascular diseases are the main risk factors to tackle in addressing
  dementia. Early identification can help improve quality of life.
   There is a need for early identification and intervention of mental health conditions, improved
    access to specialist services.

ACCOMMODATION & WELLBEING
 Develop joint commissioning strategy for health and social care that promotes healthy living,
   independence and quality of life.
   Need to ensure that there is adequate provision of care homes/ supported accommodation and

                                                                                                      45
                                      DRAFT as at 28 February 2012
      better support for carers.
SOCIAL CAPITAL
 Support the development of the minimum infrastructure necessary to build social capital, working
  with the Third Sector and communities.
VULNERABLE ADULTS
 Safeguarding Adults strategy to support early intervention, reablement, information/support and
   promote healthy lifestyles for vulnerable groups so as to maintain independence and healthy lives.
CARERS HEALTH
 Develop integrated commissioning strategy to improve the carer’s assessment process, adopting a
  person-centred approach, including respite care and emergency support.


PHYSICAL & SENSORY IMPAIRMENT
 Need to ensure that individuals with physical and sensory impairment are receiving adequate level
   of support from health and social services, including community-based services and welfare
   support. The aim should be to enable disabled people to be fully integrated within society.



4.10 SUPPORTING RESOURCES

a.    JSNA Health (August 2010)
b.    JSNA Mental Health (May 2010)
c.    JSNA Children (May 2011)
d.    Public Health Outcomes – Evidence-based Practice (September 2011)




5        PUBLIC OPINION & SERVICE USER VIEWS

Engagement with service users and the general public already takes place in health,
social care and other services. Local Healthwatch, a new consumer champion taking
a single view across not just health and social care but the wider determinants of our
health, creates an opportunity to join this work up more thoroughly.


5.1      PUBLIC PRIORITIES OF ADULTS

In June 2011, Essex County Council commissioned four focus groups in different parts of the county
to sound adult residents out about their views on priorities for the future.

In describing Essex, residents highlighted the variety, vibrancy, work ethic and natural beauty of the county.
There was a sense that Essex is under-sold to the rest of the country.

On national priorities, some residents questioned the short term nature of budget and strategy
planning and called for a longer view. Education was a priority for all of the groups: not simply
educational attainment, but its significance in, for example, tackling childhood obesity. Health issues,
particularly around changes to the NHS and the ageing population, were the most commonly
identified national priorities with ramifications at county and local level.

On Essex priorities, transport issues were important for all groups. These issues ranged from the need for
road improvements to better public transport, and were seen as an area for Essex CC to show leadership.
Similarly, housing developments were seen as an area where councils should focus for the benefit of
                                                                                                                 46
                                      DRAFT as at 28 February 2012
residents. Issues here included affordable housing and providing the type of housing people actually wanted,
eg, more houses and fewer flats. School standards and the need to improve run-down town centres were
also discussed.

On more local issues, residents raised a number of things, including difficulty of parking in town centres, cost
of using leisure centres, insufficient further education provision, frequency of refuse collection and lack of
police coverage after dark.



5.2      RESULTS FROM ENGAGING CHILDREN & YOUNG PEOPLE


Various consultations took place across Essex from September to December 2010 with a total of
103 children and young people from a diverse range of schools and groups. The question posed
was 'What is most important to me?’ For children, the top five issues were: family, playing, leisure
activities, friends and school. For young people, the top five were: smoking, drugs and alcohol; crime
and feeling safe; school; bullying; and child welfare and children's rights.

In the Future Essex consultation in 2011, 75 young people highlighted public health, educational
attainment and places to go or things to do as the most important issues for them in the future. All of
the groups involved mentioned public health and exercise, educational achievement, unemployment
and jobs, families, and places to go or things to do as important. Children in the care of the local
authority stressed the importance of families.

According to the Young Essex Assembly in 2010, the issue of most concern for young people in
Essex (YEA 2010) is about feeling safe - particularly bullying but also personal safety, road safety
and racism. As reported in Chapter 4 above, 9% of primary and 4.5% of secondary pupils say they
feel afraid to go to school because of bullying either ‘very often’ or ‘often’, similar to national levels.
While the percentage of primary pupils feeling afraid to go to school because of bullying has shown
a decline over the last five years, the percentage for secondary pupils showed a significant increase
in 2011.

In November 2011, the Essex Children in Care Council identified a number of issues about health
assessments for children looked after by the local authority. Areas of concern included the questions
on the form, seeing what is written up by the nurse, and not feeling safe opening up when the nurse
doing the assessment was not known to them. Members of this group identified the following ways of
improving the process:

     Young people being given a say about where and when the assessment takes place
     A pre-assessment form being sent to young people, so they can raise in writing any issues they
      find it hard to talk about
     Young people helping to redesign the health assessment form
     Opportunities for the children and young people to meet with the nurses more than one a year,
      thus helping to build relationships and make the experience easier
     Looked after children and young people training their nurses in how to work with and
      communicate with them appropriately
     Lobbying the Government to change the law on health assessments.




5.3      RESULTS FROM HEALTH SERVICE ENGAGEMENT

Engagement with the public around the Primary Care Trusts’ QUIPP (Quality, Improvement
Productivity and Prevention) plans in late 2011 yielded the following points.



                                                                                                              47
                                  DRAFT as at 28 February 2012
Services for older people
    Improving care and treatment provided at home is seen as a priority as is better co-ordination
      and integration of health and social care services was welcomed
    The vital role of carers and the need to ensure they have more support, respite and training
      was highlighted
    The development of ‘virtual wards’ was welcomed
    The importance of providing empowering education and training for patients was highlighted
    Suggestions for supporting older people’s health and well being included IT training to help
      reduce isolation and raise awareness of local services, and closer links between health and
      utility companies

Services for people with long term conditions
    There was support to provide more services in the community.
    Better communications between professionals and integration of care was highlighted as a
      priority.
    Further developing links with voluntary services to support people holistically was highlighted
      several times.
    The vital role of supporting carers was a common theme. It was suggested that more
      specialist advocates are needed to represent and support patients, carers and the wider
      family.
    Telehealth (eg remote monitoring of health conditions so people can stay at home rather be
      admitted to hospital) is welcomed and participants stressed the importance of making sure
      patients and their carers are fully trained to use IT equipment

Urgent care
    Discussions on urgent care covered GP and out of hours services. A number of
      improvements for GP services were suggested such as
          o streamlined appointment systems
          o different opening times to reflect people’s working patterns
          o setting a up a patient referent group in every practice
          o increasing the length of appointments for more complex conditions
          o Giving every household an urgent care check list with information about who to phone
              and when was suggested
          o The flexibility of walk in centres was welcomed and some people called for more of
              these facilities or more services provided in GP surgeries.
    A number of people felt that out of hours care is needed even more locally (eg run by local
      practices) and it is important that staff have strong communication/English language skills
    The rural nature of north Essex and consequent difficulties in accessing local service
      services was raised

Preventing ill health/Maintaining good health
    Recommendations for improving the health and well being of local people include
          o Targeting education at young people
          o Joining up services eg health and leisure facilities to tackle health problems such as
               obesity, working in partnership with schools or using Meals on Wheels as care eyes
               and ears
          o Looking at the needs of the whole family rather than just the individual
          o Further promotion of health living schemes
          o Promote the role of community pharmacists in promoting health
          o Supporting self care and empowering patients to feel better able to cope with their
               condition
          o Better information about where to go to get support and help

End of life care
    Developments and further plans to improve care at the end of life as welcomed.


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                                    DRAFT as at 28 February 2012
         Feedback highlighted the importance of training for GPs and other staff, and also ensuring
          patients and their families have information about available support.
         A survey of the bereaved (could your experience have been improved?) and changing NHS
          language from saying DNR to say “allow natural death” was also suggested

Maternity services
People said more promotion about birthing options is needed.

Hospital services
    Several people felt that care at home following discharge from hospital needs to be
      significantly improved
    The whole care of a patient and looking at a range of issues whilst in hospital was seen to be
      important
    The importance of training for hospital cleaning staff was raised

Patient and public involvement
    There was strong interest in proposals to develop patient and public engagement for clinical
       commissioning groups. People sought reassurance that new arrangements would really
       ensure that the patient voice is heard and the diversity of patients and voluntary groups
       would be reflected in arrangements
    Other suggestions for patient and public engagement in the transformation and reform
       programme included:
          o Ensuring full information about local services is available on line
          o A newsletter about updates
          o Easy to use feedback processes
          o Removing NHS jargon from communications with the public

What else needs to be considered in the transformation of services?
   The development of integrated multi-disciplinary teams which are able to deliver individual,
      specialist care in the community was welcomed. However, there was concern that people
      may fall between the gaps for the care and treatment net
   Several people talked about the need to break down traditional barriers between
      professionals and services to ensure service transformation takes place
   The vital role of carers and ensuring they have good support was highlighted
   Another common theme was the need for clear referral and patient pathways,

Reform programme
Themes about the NHS reform programme included:
    Ensuring that GPs clinical time is protected
    Ensuring the Health and Wellbeing Board works as effectively as possible. Suggestions to
      support this included ensuring there is a strong relationship with clinical commissioning
      groups, district/borough councils and the voluntary sector.




5.4       RESULTS FROM ADULT SOCIAL CARE ENGAGEMENT

The Adult Social Care user survey
The results from user surveys in 2010-11 suggest that generally people are experiencing decent
services and are able to live reasonable lives. Key areas for improvement include better signposting
to existing sources of information, advice and support (market research in Essex suggests that most
people would not think to contact the Council and that they tend to rely on their acquaintances and
neighbours or ring their GP for advice); and improved standards following the assessment process.

A high proportion (87%) of respondents report that they have a good quality of life and around half
(53%) say that the way they are helped and treated makes them think and feel better about
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                                    DRAFT as at 28 February 2012
themselves. 79% have as much social contact as they want with people they like and 63% are able
to spend enough of their time doing things they value or enjoy. However, just over two thirds (69%)
of respondents said they could not get to all the places in their local area that they wanted to and
some respondents highlighted difficulties in participating as active and equal citizens.

As regards safeguarding vulnerable adults, the majority (94%) of respondents reported feeling safe.
The majority of respondents (96%) also felt clean and presentable and said that their home was
clean and comfortable. A high proportion of respondents report that good standards are achieved
during the social care assessment but that the standards they would expect following the
assessment – such as being given a written record and knowing what will happen next and who to
contact with concerns - were not always adhered to.

Once services are in place, 73% of respondents say they have as much control over their life
as they want, and 85% report they are able to have the food and drink they like. Respondents
continue to report the positive experiences of managing their own personal budget.

Overall 87% of respondents reported their satisfaction with services. Generally participants are
reporting they are able to live free from abuse, they feel safe in their own home, and services enable
them to continue living there.


Engagement with service user groups
Essex County Council engages with service users through several forums. These include the five
Planning Groups for client specialisms, Options for Independent Living (OIL) Transport group, Essex
Participation Advisory Group (E-PAG), the Learning Disability People’s Parliament, the Participation
Networks Forum and the Local Involvement Network (LINks). Two members of the Participation
Networks Forum participate in Directorate Leadership Team meetings.

By April 2013, Local Involvement Networks will be superseded by Local HealthWatch which is a new
‘consumer champion’ for health and social care services. Local Healthwatch will have a seat on the
new Health & Wellbeing Board whose function is to integrate health and social care locally. Essex is
a Pathfinder for HealthWatch and an executive board was formed in January 2012. A major task for
the Pathfinder will be to drive that integration by presenting the single view of health, social care and
other related services that the public and service users have. Healthwatch must also reach out into
local communities so that it hears and adequately re-presents a wide range of experiences to both
health and social care commissioners.


Complaints
During 2010-11, the social care complaints team dealt with just over 500 complaints and over 300
representations from councillors, MPs and other officials. The team also received over 200
compliments. The highest single reasons for complaints are: assessment delay 11.9%; quality of
social work support 11.3%; conduct of staff 6.8%; quality of external domiciliary care 6.6%; charging:
invoice 5.8%; and delay in service provision 5.8%.


Developments
Feedback about the need for better information and advice is being addressed via a substantial
Council-wide transformation programme which commenced in 2010-11 and is called ‘Customers
First’. This will change how services are delivered by designing them from the customer’s
perspective. This includes a Single Point of Access portal that will provide customers with advice,
guidance and information to help resolve their issues. The project will also streamline how the
Council deals with enquiries and requests for social care support. Essex Social Care Direct, the first
point of contact for people who need a social care service, have already delivered improvements by
moving from a ‘call back’ service to dealing with as many issues as possible during the initial ‘live’
telephone call. The new contract for domiciliary care has an emphasis on quality as well as price.
This will also help to reduce delays in service provision because providers are encouraged to
respond quickly to requests for care and support and to deliver good quality services.
                                                                                                      50
                                   DRAFT as at 28 February 2012


Staff who undertake assessments and reviews are monitored on an annual basis to ensure they
meet the standards agreed in partnership with service users and local citizens. A comprehensive
training programme is delivered to ensure workers are kept up to date with best practice. Guidance
material is also available on the Council’s intranet, ensuring staff can view the latest policies and
practice guidelines.


5.5    FURTHER RESOURCES

See www.engageessex.org.uk




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