Glossary of terms

Public Health Report 2007 Are we missing something? 1 Contents Contents Introduction Section One: The missing patients Coronary Heart Disease Diabetes Chronic Obstructive Pulmonary Disease Section Two: A closer look at… Coronary Heart Disease Smoking Obesity Mental health Alcohol Working together to deliver better health Glossary of terms 2 Introduction Health: “… a state of complete physical, social and mental well-being and not merely the absence of disease or infirmity. The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being, without distinction of race, religion, political beliefs or economic and social conditions” (World Health Organisation, 1948) On average, people are living longer than ever before in the recorded history of our nation. A trend that was initially a bi-product of peace and prosperity in Europe since 1945, and technological developments, has been strengthen by government health strategies, in particular those to reduce deaths from heart disease and cancer and the systematic application of interventions of proven effectiveness. Lifestyles also play an important part and people who follow public health advice, such as the advice to stop smoking and take more exercise, live healthier as well as longer lives. The systematic application of interventions of proven effectiveness has reached many, but not everybody. Nor is everybody choosing to adopt a healthy lifestyle. The result is that some communities have not experienced the same increased life expectancy as others and in relative terms are falling behind. This is considered unfair and there is a determination to address such inequalities in measurable health outcomes. There are two things that have to happen to reduce health inequalities: (i) we have to ensure that everybody has access to interventions of proven effectiveness and (ii) we have to do more to engage with more people with regard to their health and support everybody to life a healthy lifestyle. Health inequalities are determined by education, opportunities in life and the basic make up of people: factors that cannot be affected by health service interventions. There is a strong case for the NHS to invest time and energy in alerting other public sector agencies to the costs associated with ill health and the work that needs to be done across society to tackle the determinants of ill health. Life expectancy is the measure that drives policy at the moment. As public services connect with people, as we are asked to do, the issues may change. The variations in health, rather than life expectancy, may prove to be of greater concern - in particular inequalities of mental health. The challenges faced by the health service to address inequalities in health as measured by life expectancy may be eclipsed by new challenges that will take those of us concerned to improve health further into the heart and soul of our society. 3 South Birmingham PCT Public Health Annual Report This Public Health report may well prove to be a defining moment for South Birmingham PCT. It looks at disease prevalence (how many people are known to suffer from a disease) for some of the medical conditions that are major contributors to premature death, where we know that good medical care can make a real difference. This has been made possible thanks to the effective “Quality and Outcomes Framework” (QOF) that has been in place in our general practices for three years. From this we receive summary data from GP practices telling us the number of people with key disease who have been diagnosed by them and entered onto a practice register. We also receive some information about how well managed these patients are. The missing patients Along with the prevalence data from primary care we have used a model recommended by the Department of Health, of how many people would be expected to have a disease. Taking the number of people with a disease condition in each GP practice and the number of people who would be expected to have that disease condition, we have calculated the number of people likely to have a disease condition, who are not currently known to a practice: the “missing prevalence”. A key task for South Birmingham PCT is to reduce inequalities in health. It is now clear that one of the most important things we can do is encourage and incentivise GP practices to undertake risk assessments of patients who have not presented to the surgery, but who may be at risk (chiefly due to age, but sex, ethnicity and socio-economic status are factors that also need to be taken into account). The concept of missing patients has been embraced by patient advocacy groups:  The British Heart Foundation estimates there are 3,000 people in South Birmingham with undiagnosed heart disease, who would benefit from diagnosis and treatment. Diabetes UK estimates that there are approximately 4,500 people in South Birmingham with undiagnosed diabetes who could benefit from diagnosis and treatment. The British Lung foundation estimates there are 12,000 people in South Birmingham with chronic obstructive pulmonary disease (COPD) that have not been diagnosed, who would benefit from diagnosis and treatment.   4 Estimating the number of missing patients There is no established, validated method for calculating expected prevalence. We have used a method first applied by Doncaster PCT, developed with funding from the Department of Health and now recommended by DH. The data are presented on statistical process control charts. The numbers of expected patients with the disease, based on the modeling, are plotted on the x axis and the number observed as having the disease on the register over the number expected is plotted on the y axis. The central line, along 0 represents the position of no difference between the observed and the expected (i.e. no missing prevalence). The curved dotted lines represent 99.8% confidence limits. Practices that fall above the upper curved, dotted line have a, statistically significant, higher observed number of patients than expected and those that fall below the lower curved, dotted line have a, statistically significant, lower observed number of patients than expected. The missing patients: CORONARY HEART DISEASE According to our QOF data there are 12,281 people (3.2% of the population) living in South Birmingham who have been entered on their GP practice‟s database as having Coronary Heart Disease (CHD). This compares with 3.6% of the population across the West Midlands and 3.5% across England. The expected number of cases is nearly 16,000 CHD cases – giving an estimated missing prevalence of 3,719, higher than the British Heart Foundation estimate of 3,000. The graph below shows that there are many practices with fewer recorded prevalence than would be expected from the modelling. Figure 1: Doncaster model, Patient reported, doctor diagnosed CHD Observed relative to expected (%) 40 20 0 -20 -40 -60 0 200 400 600 Expected No. of Patients 800 1000 5 The missing patients: DIABETES We have 14,609 people (4.8% of population) recorded on GP systems as having diabetes. This compares with 4.2% across the West Midlands and 3.9% across England. Based on the Doncaster model there should be 14,479. Whilst overall there are more people recorded as having diabetes than would be expected across the PCT, when this is examined by practice there are some practices that have more than expected and some that have fewer than expected. The model uses an estimate of prevalence based on Health Survey for England 2004 and 2004. We know that age specific prevalence of diabetes is growing due to rising levels of obesity. It is therefore possible that the model is under estimating prevalence. Figure 2: Doncaster model, Diabetes Mellitus Observed relative to expected (%) 80 60 40 20 0 -20 -40 -60 0 200 400 Expected No. of Patients 600 800 1000 6 The missing patients: CHRONIC OBSTRUCTIVE PULMONARY DISEASE There are 5,932 people (1.6%) recorded as living with Chronic Obstructive Pulmonary Disease (COPD), which is close to both the West Midlands and national prevalence of 1.5%, as well as the Doncaster model estimate of 6,063 patients. When these data are analysed by practice there are several practices that have a, statistically significant, lower prevalence than expected and 5 practices that have a higher number recorded than would be expected. Our recorded prevalence is in line with national and regional comparators and the modelled prevalence. The British Lung Foundation estimates of COPD, based on smoking rates, suggest that there are significantly more COPD patients, though the difference may well be a difference of definition. Figure 3: Doncaster model, Chronic Obstructive Pulmonary Disease Observed relative to expected (%) 125 100 75 50 25 0 -25 -50 -75 -100 0 50 100 150 200 250 Expected No. of Patients 300 350 400 450 7 Finding missing patients It is safe to assume that all GP practices will engage with the idea of finding “missing patients”. We do not start from the point of view that it is a GP practice‟s fault that there are missing patients, though the best organised practices will have fewer. Finding the body of missing patients represents a change in culture of General Practice. In the past the job of a GP practice was to respond to the demands made by attending patients. The call now is for practices to become proactive. The job of the PCT is not just to highlight the need, but to facilitate this change in culture. There are a number of things that the PCT will be doing to support practices in identifying their missing patients:    We can indicate the number of patients we would expect to be on any disease register; We can provide funding to practices, to call patients in for assessment; We can ensure that no practice suffers financially from identifying and treating patients appropriately (these actions are highly cost-effective and meet all the criteria for health service investment); We can fund marketing exercises, that increase the awareness of “at risk” groups and increase the likelihood that more people will take up their GPs‟ offer of a risk assessment.  Our responsibility as a PCT is to secure health improvement for our population. As well as making support for GP practices to identify missing cases, we have to accept consider what we would do if a GP practice were not to engage with this agenda. This may turn out to be a Clinical Governance issue of considerable significance, in a few cases. Recommendations To systematically save lives we have to deliver a quality assured programme: 1. We need to secure the widespread take up of the Cardiovascular Disease (CVD) Local Enhanced Service (LES) that was agreed during 2007 (this provides funding for the risk assessment of patients at possible risk of Coronary Heart Disease and Diabetes); 2. We need to review the incentives in place to identifying people with COPD 3. We need the support of our acute and community providers to ensure that all patients are on GP registers; 4. We need to increase awareness in the population of our local schemes to identify potentially damaging disease in its earliest stages. 8 A closer look at… CORONARY HEART DISEASE Coronary Heart Disease (CHD) is common and largely preventable. Despite huge progress in reducing death rates over the past 15 years it remains the leading cause of premature mortality for South Birmingham residents. The major risk factors of CHD are: smoking, lack of regular physical activity and a diet high in saturated fat. Conditions strongly associated with heart disease are: diabetes (type 2), high blood pressure and high blood cholesterol. CHD lies at the heart of measurable inequalities in health outcome, as it is most prevalent in lower socio-economic groups, mainly due to higher smoking rates and the general lack of a healthy lifestyle. People whose ethnic origin lies in the Asian subcontinent are at higher risk of CHD. National target: to substantially reduce mortality rates by 2010: from heart disease and stroke and related diseases by at least 40% in people under 75, with at least a 40% reduction in the inequalities gap between the fifth of areas with the worst health and deprivation indicators and the population as a whole. The local picture The good news is that the number of people dying from CHD, under 75 years, has been decreasing. In the last 10 years, the rate in South Birmingham has dropped from 107 deaths per 100,000 population (directly standardised rate) per annum in 1995 - 97 to 54.95 per 100,000 in 2005 – 2007: a nearly 50% reduction. 9 Figure 4: Standardised mortality ratios under 75 years by ward, 2003-5 Excess Deaths 0 0 0 0 0 0 0 1 1 2 2 2 3 3 14 Lower Confidence Interval 78 74.8 66.4 72.9 79.8 73.8 68.4 89.3 82.4 102 103.3 119.3 137.7 127.6 97.2 Upper Confidence Interval 142.3 142.7 142.6 138 159.5 140.8 131.7 158.8 177.1 177.4 181.5 203.2 224.9 220.6 155.2 Ward Billesley Bournville Edgbaston Hall Green Harborne Quinton Weoley Northfield Selly Oak Brandwood Kings Norton Longbridge Bartley Green Moseley & Kings Heath South B‟ham Actual Expected 5 4 3 5 4 4 4 6 3 6 6 6 8 6 71 5 4 3 4 3 4 5 5 3 4 4 4 4 4 57 SMR 106.6 104.7 99.2 101.6 114.6 103.3 96.3 120.4 123.1 135.9 138.3 157.1 177.3 169.4 124.5 Five wards in South Birmingham have significantly high Standardised Mortality (in bold) 10 Action to prevent death from Coronary Heart Disease We already have actions in place, including a Local Enhanced Service (LES) that has been designed with our GP clinical leader to ensure that GP practices will have an incentive to search their records for patients who may have Cardiovascular Disease (CVD) risk factors, to call them in and undertake a risk assessment. This scheme is designed to identify and deal with missing prevalence from CVD and is the basis for ensuring that all South Birmingham patients at significant risk have been risk assessed and offered appropriate treatment, including lifestyle support. Lifestyle support is not well developed. A key strand of our work is our Stop Smoking service. Smoking causes premature death from cardiovascular disease and cancer and is particularly damaging for diabetics. Smoking also causes COPD and it accounts for approximately 50% of health inequalities, with smoking rates significantly higher in routine and manual workers. Our Stop Smoking service audits uptake and adjusts provision to ensure that its effort is greatest in areas of greatest deprivation. The service aims to achieve highest quit rates in our most deprived communities and most resources, particularly marketing resources, are focused in these areas. We are fortunate to have funding from Kings Norton New Deal for Communities for a intensive cessation campaign in that are know as „Stop & Quit‟. This work is currently being evaluated and the expectation is that effective elements will be “mainstreamed”. South Birmingham now has more than a dozen “Health Trainers” who are deployed in practices with high levels of social deprivation. When people are identified as “at risk” this work force supports lifestyle change that can significantly reduce individual risk, particularly through increasing levels of daily physical activity. This builds on two new initiatives already developed in the Northfield locality, initially using Neighbourhood Renewal Funding. The first is the offer of a walk-in „Heart MOT‟ at pharmacies, which is shortly to be rolled out across the more deprived areas of South Birmingham. The second is „Fit4Life‟, a programme of community engagement that supports people to make healthy choices. We have seen the recent introduction of a cohort of „Health Trainers‟, who will offer their services to GP practices serving our most deprived communities. Patients with identified risk factors will be offered support in lifestyle change to reduce risk and patients who may be at risk due to age, will be offered a risk assessment if they have not already had one. Our plans for the future We know that the rising trend in obesity is likely to impact on coronary heart disease risk, both directly and by increasing diabetes risk. Actions to address this are outlined in the obesity section of this report. 11 A closer look at… DIABETES Diabetes is a lifelong disease that can impact both on the quality of life and the life expectancy of those affected. Although it cannot be cured, it can be prevented through lifestyle measures and for those who do develop it, there is the potential to manage and treat them successfully once they are diagnosed. There are different types of diabetes, but type 2 is the most prevalent, accounting for more than 90% of identified cases. Type 2 diabetes is strongly linked to obesity and just as obesity levels have increased, the prevalence of diabetes in England has almost doubled since 1994 and is predicted to continue to increase due to rising levels of obesity, the ageing population and the growing and ageing Asian population. National target: Whilst there is no national target relating specifically to diabetes, it is a major risk factor for both heart disease and stroke. Addressing the rising trends in diabetes will be essential to sustain reductions in heart disease and stroke mortality and in achieving the required 40% reduction in deaths attributable to these diseases. Figure 5: Standardised mortality ratios by ward, 2003-5 Lower Excess Deaths -1 -1 0 0 1 1 1 2 2 2 Confidence Interval 12.8 25 51.7 53 71.8 56.8 71.8 82.7 95.2 101.9 Upper Confidence Interval 126.9 152.4 200.3 222.7 302.1 220.2 301.7 281.7 282.2 314.8 Ward Brandwood Northfield Bournville Weoley Edgbaston Quinton Selly Oak Kings Norton Billesley Bartley Green Actual Expected 1 2 3 3 3 3 3 4 5 5 3 3 3 3 2 3 2 2 3 2 SMR 49.1 69.6 108.5 116.8 158.5 119.3 158.3 160.8 170.7 187.1 12 Longbridge Hall Green Harborne Moseley & Kings Heath South B’ham 5 5 6 2 3 3 2 3 4 200.9 196.6 236.6 109.4 112.1 142.1 337.9 320 370.1 7 56 2 36 4 20 277.9 155.6 169.5 117.2 430 198.8 13 Figure 6: Death rate for diabetes by age & sex, 2002-2006 35 30 25 Rate per 10,000 20 15 10 5 0 Action to prevent death from diabetes Diabetes is a disease that results in premature death if it goes undiagnosed and untreated. The key to good outcomes for diabetics is early detection and application of evidence-based care, most of which can be provided in primary care. There are three things that need to be carefully managed in primary care: (i) blood sugar levels, as monitored by HbA1c (a measure of glucose levels in the blood); (ii) blood pressure (which needs to be kept within set limits) and (iii) blood cholesterol levels. If all these three factors are well controlled then a diabetic can expect to remain healthy; good control depends on good quality support from doctors and nurses but also good concordance between doctor and patient. It is very important that diabetics do not smoke, as both diabetes and smoking damage blood vessels and in combination the damage is very great. Good management of HbA1c, blood pressure and cholesterol in diabetics are all rewarded under the QOF. Since its introduction there has been a measurable drop in the number of poorly controlled diabetics. This will reduce deaths, both those directly attributable to diabetes, and from CVD. Our plans for the future The major modifiable risk factor for diabetes is obesity. Actions to address this are outlined in the obesity section of this report. -1 15 9 -2 20 4 -2 25 9 -3 30 4 -3 35 9 -4 40 4 Males -4 45 9 -5 50 4 Females -5 55 9 -6 60 4 -6 65 9 -7 70 4 -7 75 9 -8 80 4 + 85 14 A closer look at… SMOKING Smoking is the main cause of premature and avoidable death in the United Kingdom and reducing prevalence of smoking remains the number one public health priority. It is estimated that 2,400 smokers in South Birmingham PCT die each year, and approximately a further 240 people die as a result of exposure to second-hand smoke. We know that smoking significantly increases the risk of developing heart and circulatory disease, cancer and chronic obstructive pulmonary disease amongst other illnesses. Of all cancers, 30% can be attributed to smoking, this increases to 84% of lung cancer. In addition 25% of all deaths from CHD can be attributed to smoking. It follows that reducing smoking prevalence will have a dramatic effect on improving the health of our population. National target: Through the 1998 White Paper Smoking Kills the Government set out its intention to reduce the prevalence of smoking by 2010 from 28% to 24%, and to reduce smoking in pregnancy from 23% to 15%, with greater reductions for manual socioeconomic groups. To contribute to this the Department of Health sets annual targets for smoking quitters and smoking during pregnancy, as part of the wider strategy to reduce the prevalence of smoking. The local picture Population survey data estimates that adult smoking prevalence in South Birmingham is 23%. This puts the number of adult smokers across the PCT at approximately 71,674. Data recorded by our general practices supports this estimate but also demonstrates that this varies considerably across the PCT. 15 Figure 7: Smoking prevalence (%), 2006-07 The highest prevalence of smoking, reported from GP records, is in Hall Green, Billesley, Kings Norton and Quinton. The wards with the lowest prevalence are Harborne, Edgbaston, Selly Oak and Moseley and Kings Heath. Smoking is increasingly linked with deprivation. In 1961 there was no difference in lung cancer mortality between social groups, by the 1980s a man in an unskilled manual occupation was more than four times as likely to die of lung cancer as a professional and twice as likely to die from coronary heart disease; for women there is a threefold difference for lung cancer and a fourfold difference for heart disease. This reflects the way in which more people in higher socioeconomic groups have stopped smoking than people in lower socio-economic groups. We estimate that around half of the reduced life expectancy in areas of high deprivation can be attributed to tobacco use, and that as a proportion of their total expenditure, low income households spend over five times more on tobacco than the high income households. 16 Action to prevent death from smoking On July 1st 2007 England became “Smoke Free”. The legislation was designed to protect non-smokers from tobacco smoke and this will lead to a reduction in deaths from “second hand” tobacco. It will also have helped smokers to cut down their consumption of tobacco and help them to quit. It was anticipated that smoking prevalence would fall by 1.5 - 2% and early indications suggest this has been exceeded. It is a huge Public Health success story. The continuing fall in smoking prevalence remains inconsistent across socioeconomic groups. The current efforts to reach out to promote smoking cessation in deprived areas need to be intensified, and there is a clear case for resources to be focused increasingly on routine and manual workers. Plans are being formulated under the auspices of the Birmingham Health & Wellbeing Partnership (Health Inequalities theme group). We know that 7 out of 10 smokers would like to quit and the development of an offer of support, with Nicotine Replacement Therapy (NRT) and other therapeutic tools has been fundamental in the government strategy to tackle health inequalities. Sadly, the performance indicator for PCTs remains the number of four week quitters. To attain this target our Stop Smoking service needs to attract 5,000 smokers during the period. This means that resources have to be used to bring in numbers, rather than in support of innovation to meet the needs of deprived communities. Plans are being developed to redesign the smoking in pregnancy services which will introduce greater choice and consistency in access for pregnant women who want to give up smoking. Our plans for the future In South Birmingham, we are committed not only to providing local services for people who want to give up smoking but also to addressing the wider issues of tobacco control. We will be targeting groups with higher smoking prevalence such as manual workers and will develop further our services within secondary care with a particular focus on „stop before your op‟ and on increasing access to services for mental health service users. Consideration will be given to people who are not ready or able to quit and we will continue to work in collaboration with our research partners on developing evidence-based strategies for harm reduction. There are also plans to include service users in the development of services. In the future we will be working more closely with families and children to promote initiatives such as smoke free homes. We will also be working with our partners in tackling underage sales and engaging with schools and the community in preventing smoking uptake including wider implementation of „Face Facts‟ and „Buzz In‟. This will form the basis of our future 17 Smoking Cessation and Tobacco Control strategy working in conjunction with the city wide strategy. A closer look at… OBESITY The growth in the number of people in the population who are overweight and obese is of increasing concern in most developed countries of the World. So much so that obesity has been termed a 'global epidemic'. It is well recognised that overweight and obesity increases the risk or coronary heart disease and cancer - as well as diabetes, high blood pressure and osteoarthritis. Obesity is a result of a habitual imbalance between the amount of energy consumed and the amount used in daily life. It is commonly assessed through the Body Mass Index (BMI) calculation which is derived by dividing a person's weight in kilograms by their height in metres squared (kg/m2). In England, an individual is considered to be 'overweight' if their BMI is between 25 and 30, and „obese‟ if over 30. Based on these definitions, around 21% of adult men and 24% of adult women are now obese. A further 47% of men and 33% of women are overweight. The prevalence of obesity in England has trebled in the last 20 years. This worrying trend is evidenced when considering children. Figure 8 shows how dramatically obesity in children has increased over the past 15 years. Figure 8: Prevalence of overweight children in the UK National target: There is a Public Service Agreement (PSA) target which is jointly owned by the Department of Health, the Department for Education and Skills and the Department for Culture Media and Sport recognising that delivery 18 will depend on a concerted, joined up effort across government and at local level. The target is to: halt the year-on-year rise in obesity among children aged under 11 by 2010 in the context of a broader strategy to tackle obesity in the population as a whole. It focuses upon preventing and managing obesity in children, but also recognises that wider action to tackle obesity at a population level will be critical to achieving this. The local picture Since 2006 general practices have started to routinely record the BMI of all patients over 16 years of age. Although data is not yet complete we are beginning to get a more accurate picture of our local population. These data show that nearly one in four adults is recorded as being obese. This is consistent with national data. Figure 19 shows that this varies considerable across the PCT. Figure 9: Prevalence of Adult obesity in SBPCT 2006/07 The areas of the PCT with higher obesity rates are Kings Norton, Bartley Green and Northfield. The wards with the lowest obesity rates are Harborne, Edgbaston and Selly Oak. 19 Action to prevent disease and death associated with obesity: adults The NHS is now comfortable about investing in personal support for people who recognise the need for lifestyle change. “Health Trainers” are now being introduced across the NHS. Their key task is to promote more physical activity, while also promoting a healthier diet. For adults we have recently commissioned a range of services that support personal weight management, such as “Weight Watchers” and “Size Down” (called Level 2 Services). Together with our general practices we are testing new ways of encouraging participation in such programmes through the development of a „call centre‟ which will help keep in touch with, and motivate, people as they try to change elements of their lifestyle behaviour. This new service will also put participants in contact with other lifestyle services, such as the Stop Smoking Service and Health Trainers if requested. Physical activity is well recognised as critical in tackling obesity. There is considerable evidence that regular physical activity reduces the chance of weight gain, whereas being inactive at home (e.g. watching television), and particularly at work (e.g. Office jobs) can have the opposite effect. We are therefore continuing with and developing our local “Exercise on Prescription” scheme. In addition, we are exploring, in partnership with Birmingham City Council and through the voluntary sector, ways of encouraging people to be more active. We hope to make physical activity part of everyday life rather than something people have to think about or consciously make effort to do. For adults who require more specialist support we have started on the process of commissioning “level 3” obesity services. These services will be based in primary care and are designed for patients with a BMI over 40 made up of a team that includes a physician, dietician and cognitive behavioural therapist. These services compliment our recent implementation of national guidance on use of surgery for the morbidly obese (level 4 services), along with other PCTs in the region. As a member of the Birmingham Health & Wellbeing Partnership we are seeking to influence the “obesogenic” environment that we now live in, hoping to shift transport priorities away from motor vehicles in favour of pedestrians and cyclists and the use of public transport. (Such measures are referred to as “level 1” obesity measures.) Our plans for the future    Further development of the “Health Trainer” service; Support general practices developing their own local schemes; Expanding of the Level 2 provision to meet local demand; 20    Following up all Level 2 service contacts to help, encourage and maintain their weight loss Establish a Level 3 specialist weight management service in primary care; Improve the Exercise on Prescription scheme and develop further community based schemes that help promote physical activity. Obesity in Children As part of the PSA shared target between the Department for Education and Skills and the Department of Health, the government introduced a new annual requirement to measure the height and weight of all children in Reception (ages four/ five) and Year 6 (ages ten/ eleven) attending state maintained primary schools within the PCT area. The first data from initial measurements were taken in Birmingham in 2006/07. In South Birmingham the wards with the highest proportion (>21%) of obese children are Brandwood, Bournville, Bartley Green and Billesley (Figures 10 & 11). Figure 10: Percentage of Obese Children, Year 6, 2006 Figure 11: Percentage of Overweight Children, Year 6, 2006 21 Action to prevent disease and death associated with obesity: children There are two large scale community based programmes to tackle obesity in children: the “WATCH IT” and “MEND” programmes. The Watch It programme has been developed to address the needs of overweight or obese children in disadvantaged communities. It encourages overweight 8 to 15-year olds to lead healthier lifestyles, through group activity sessions and oneon-one meetings which are focused on eating behaviours, physical activity and confidence building. The MEND programme is a 10 week programme which combines all of the elements known to be useful in treating and preventing obesity in children, with an emphasis on family involvement and practical, fun learning. Both these programmes have been undergone evaluation and been found to be effective, though definitive research findings are not yet available. Both programmes are in their early stages locally and will need to be built up to meet the considerable need that exists. The PCT also supports the delivery of the National “Healthy Schools Programme” which requires schools to equip children and young people with the skills and knowledge to make informed health and life choices, as part of the national curriculum. 53% of all schools in South Birmingham PCT have now achieved National Healthy Schools Status, a further 44% of schools are currently working towards achieving this status. Our plans for the future The PCT is planning to considerably increase investment in the overall programme for managing obesity. Plans for the future focus on bolstering current provision for children‟s and family services:     Increasing access to Watch It and MEND childhood obesity services; Training for Health Visiting teams, particularly in relation to weaning and childhood nutrition; Providing additional support for schools to build on their Healthy School Status and promote healthy eating; Funding the Villa Vitality programme: the scheme is aimed at giving all children in year 5 two days tuition outside the school environment (at Aston Villa Football Club) concerning a healthy lifestyle, diet and nutrition, exercise and anti smoking. Weight management training for health visitors and primary health care professionals enabling them to deliver treatment programmes to children and families Dietician led weight management groups for children and families 22         Food Net „cook and taste‟ courses in our most deprived areas working with schools, nurseries and the community Commissioning a number of ICE gyms with equipment designed specifically for under 16‟s Development of a children‟s exercise on referral scheme Commissioning a „level three‟ specialist weight management service for children Working with colleagues in commissioning and secondary care in developing screening pathways for children at risk of type two diabetes Commissioning a range of free exercise programmes ensuring children and their families have the opportunity to be more physically active 23 A closer look at… ALCOHOL Although most people use alcohol at levels that do not cause harm, its misuse is becoming a significant public health problem. The misuse of alcohol, characterised by chronic heavy drinking, binge-drinking or even inappropriate moderate drinking (eg. operating machinery) not only poses a threat to the health and wellbeing of the drinker, but also affects family, friends and communities through such problems as crime and anti-social behaviour. Alcohol is also directly linked to many health issues such as high blood pressure, liver disease, cancer, obesity, accidental injury, violence, mental ill-health, unwanted pregnancy and sexually transmitted infection. National target: Through the governments National Alcohol Harm Reduction Strategy a target has been agreed to reduce the rate of Hospital Admissions per 100,000 for Alcohol Related Harm. The local picture In South Birmingham alcohol is now directly responsible for 37 deaths each year and contributes to a further 33 deaths. This makes alcohol responsible for 2.1% of all deaths and the third most common cause of preventable death. Figure 21: Mortality rates by age, 2005/6 25.0 20.0 % of deaths by age 15.0 10.0 5.0 0.0 4 -2 20 9 -2 25 4 -3 30 9 -3 35 4 -4 40 9 -4 45 4 -5 50 9 -5 55 4 -6 60 9 -6 65 4 -7 70 9 -7 75 4 -8 80 20 -1 85 Alcohol is responsible for more than 1 in 5 deaths for 40-49 year olds and for more than 1 in 20 deaths in everybody under the age of 75. It is responsible for the death of twice as many men (44 deaths) as women (23 deaths). This pattern was reflected in the 1,063 hospital admissions in 2005/06. 24 Figure 22: Admissions to hospital, rates by age and sex, 2005/6 120.0 Rate per 10,000 population 100.0 80.0 60.0 40.0 20.0 0.0 10- 15- 20- 25- 30- 35- 40- 45- 50- 55- 60- 65- 70- 75- 80- 85+ 14 19 24 29 34 39 44 49 54 59 64 69 74 79 84 Males Females There is a wide range of admission rates across the different PCT localities. The highest admission rate was in Edgbaston (49 admissions per 10,000 population). Excess alcohol consumption affects all socio-economic groups, though there is a rise in admissions in line with increasing deprivation. Figure 23: Admissions by ward, 2005/6 50.0 rate per 10,000 population 45.0 40.0 35.0 30.0 25.0 20.0 15.0 10.0 5.0 0.0 Bartley Green Billesley Bournville Brandwood Edgbaston Hall Green Harborne Kings Norton Longbridge Moseley & Kings Northfield Quinton Elect ive Selly Oak Emergency Weoley 25 Action to prevent death and distress as a result of alcohol misuse The National Alcohol Strategy for England was published in June 2007 and outlines measures to address the issues of alcohol misuse. The national strategy has been built on locally with the key partners in Birmingham joining together to develop the Birmingham Alcohol Strategy, 'Reducing harm: Empowering change'. The strategy, launched in October 2007, sets out Birmingham‟s objectives for the next three years in tackling alcohol related harm. The strategy has a number of key aims which are to:    Challenge and change the idea that drunken anti-social behaviour is acceptable or normal Implement and action measures to reduce alcohol related crime and disorder Target support and treatment to those most at risk of harm including the family harms that are associated with alcohol misuse through domestic violence and child abuse Provide readily accessible information and advice for all citizens of all ages about the health risks of harmful drinking Ensure that business and industry reinforce responsible drinking messages Develop robust infrastructures to support both delivery of effective alcohol interventions and the measurement of outcomes that clearly demonstrate progress.    Our plans for the future Working with our partners we intend to raise the profile of alcohol related problems with key „front line‟ staff. This will be achieved by providing training that will help front line staff to identify and support people with alcohol related problems. We will be building on national campaigns designed to raise awareness of alcohol related harm issues. This will be undertaken through road shows and publicity campaigns. Plans will also be developed to work with our community pharmacists to help identify and advise people who may benefit from brief advice relating to alcohol consumption. Recommendations To reduce harm from alcohol the local NHS needs to: 1. Identify misuse of alcohol in patients; 2. Provide brief intervention therapy to motivate people who drink at levels that harm to consider cutting down; 3. Identify harmful drinking in staff and provide opportunities for harm reduction; 4. Support the city-wide alcohol strategy. 26 ADDRESSING HEALTH INEQUALITIES Health inequalities are rooted in the fact that many people from deprived communities have fewer skills and less of the resources needed to live a healthy lifestyle and minimise risks to health. There is also the issue of culture within communities and lack of opportunities to enhance life chances. In South Birmingham over 21% of our population lives in the bottom tenth of the most deprived communities in the UK. Health equity audits repeatedly show greater health resource usage by those from more deprived communities. It is in the interests of everybody that we work to reduce health inequalities by tackling the determinants of health. South Birmingham PCT has to be concerned about three determinants that we are wellplaced to address:    Primary care in deprived communities tends to be less well organised than in more affluent areas, which can lead to less proactive care, later diagnosis, treatment and referral; People with less understanding and / or investment in their own health are slower to come forward to seek help from doctors; There is more exposure to health risk in more deprived communities, and worse access to health enhancing activities and facilities. Individual lifestyle factors that can contribute to inequalities in health include:      Putting harmful substances into the body - alcohol, illegal drugs, processed foods; Failing to put enough beneficial stuff into the body - vitamins, fibre, proteins; Not taking enough physical activity; Putting oneself into harms way - driving while under the influence of alcohol or whist tired, driving too fast in dangerous road conditions, crossing the road without due care or attention; Insufficient sleep / relaxation. Strengthening partnership working is key to help tackle the wider determinants of health. Providing good employment and opportunities for people living in our most deprived communities, building social capital in these communities, improving diets, reducing the cost of public transport and improving levels of physical activity in children under 16 years. Joint commissioning with other public sector agencies, from specialist providers notably the third sector, is needed to address the unmet needs of the social excluded. Unless this group is reached, the gap in life expectancy between the best off and the worst off will not diminish. 27