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the health of the population 2001 - Avon

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					                  the
     health
              of the
population
  2001
REPORT OF THE DIRECTOR OF PUBLIC HEALTH
Prepared by:
Avon Health Authority
King Square House
King Square
Bristol
BS2 8EE

Telephone: 0117 976 6600
Fax:       0117 976 6601
Minicom:   0117 900 2675
www.avonhealth.org.uk




If you would like further copies of this report, please contact Gill Bealing on 0117 900 2630.
e-mail: Gill.Bealing@userm.avonhealth.swest.nhs.uk
                                                              2001
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                                Contents                           of the
                                                              population

    Introduction                                              2

Section
1   Developing Public Health Action in the Avon Area

          1.1   Public Health in Primary Care Trusts          5
          1.2   Developing Public Health Capacity             9


2   Health and Well Being

          2.1   General Indicators of Health and Well Being   12
          2.2   Saving Lives: Our Healthier Nation Targets    14
          2.3   Infant Health                                 17
          2.4   Health of Older People                        18


3   Tackling Inequalities in Health

          3.1   Action on Tackling Inequalities               20
          3.2   Regeneration and Neighbourhood Renewal        26
          3.3   Injury Prevention                             29
          3.4   Oral Health                                   34


4   Improving Health

          4.1   Diabetes                                      39
          4.2   Cancer                                        45
          4.3   Heart Disease                                 51


    Technical notes                                           54

    Jargon explained                                          55

    Your views on this report: feedback sheet                 63




                                                                            1
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     Introduction
     This is the tenth annual report on the health of the one million people served by Avon
     Health Authority.

     This report is for all those who play a part in improving the health of the population,
     including colleagues in the Health Authority, PCTs, PCGs, NHS Trusts, the four local
     authorities, and people in the voluntary sector, service users and carers, and indeed the
     wider public. It is a source of information on health and health needs, and a record of
     local trends in health. My aim is that it should provide a basis for action, tell people
     about what is being done and what needs to be done, and inform the Health Authority’s
     Health Improvement Programme.

     Earlier this year, two publications highlighted the role of public health and the annual
     public health report: the Department of Health published the Report of the Chief Medical
     Officer’s Project to Strengthen the Public Health Function and the House of Commons
     Health Committee published a report Public Heath: Report and Proceedings of the
     Committee 1.

     The first of these – the Chief Medical Officer’s report – confirmed the central importance
     of public health in implementing the government’s NHS Plan 2. I refer to the report’s
     conclusion that a larger, more skilled public health workforce is required in Section 1.2.

     The Health Committee Report recommended that the annual report of the Director of
     Public Health (a statutory requirement) should, among other things, “clearly distinguish
     between past trends in epidemiology and key present agenda concerns,” and that it
     “ought to be a critical document in the formulation of the joint Health Improvement
     Programme…” This year, I have included more information on health trends in Avon and
     discussed many current concerns about health and health services. I hope this means that
     it will be useful for PCGs, PCTs, local authorities and others when they review needs and
     priorities, and make plans for the future.

     The report covers the area of the four local authorities of Bath & North East Somerset
     (B&NES), Bristol, North Somerset and South Gloucestershire (see Map 1). In April 1999,
     this population was organised into twelve Primary Care Groups (PCGs - see Map 2). In
     April 2001 we saw further changes: the establishment of two Primary Care Trusts (PCTs) in
     B&NES and South Gloucestershire, mergers of the six Bristol PCGs into two (Bristol North
     and Bristol South & West) and the merger of the two PCGs in North Somerset into one
     (North Somerset PCG). This new configuration is shown in Map 3. Most data in this report
     refer to local authority populations or the latest PCG/PCT configuration, but some relate
     to previous PCGs.




     1
       Department of Health (2001) Report of the Chief Medical Officer’s Project to Strengthen the Public
       Health Function. London: Department of Health
       House of Commons Health Committee (2001) Second Report: Public Health. Volume 1: Report and
       Proceedings of the Committee. London: The Stationery Office
     2
       Secretary of State for Health (2000) The NHS Plan. London: The Stationery Office
2
                                                                                                                                          2001
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                                                                                  Introduction                                                   of the
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                                                                                                                                  Map 1
                                                                                                                                  Avon Health
             Local Authority                                                                    •Thornbury
             Urban Area
                                                                                 •Aust                                            Authority and Local
                                                                                  SOUTH GLOUCESTERSHIRE                           Authorities
                                                                                         •Patchway              •Yate

                                                         •Avonmouth
                                                                              •Downend
                                              •Portishead       BRISTOL
                                                                    •Bristol •Kingswood
                                      •Clevedon
                                                 •Nailsea                 •
                                                                 Brislington
                                     NORTH SOMERSET                                              •Keynsham
                                          •Yatton                                                                       •Bath
                                           •Congresbury                          •Chew Magna
                                                                                                     •Marksbury
                  •Weston-super-Mare
                      Banwell •                    •Patchway                    BATH AND NE SOMERSET
                                               0      2.5            5
                                                                                   Peasedown St. John          •
                                                     Miles                                           Radstocky
                                                                                                          •




                                                                                                                                  Map 2
                                                                                                                                  Avon Health
              Primary Care Group

Weston (13) PCG Name &
            Number of practices
            per PCG                                                              Severnvale (10)                                  Authority and
                                                                                                                                  Primary Care Groups
                                                                                                 South East Gloucestershire(20)
                                                                                                                                  1999/2000
                                                                     Bristol
                                                                 North West (19)
                                                                                            Bristol East (7)

                                                            Bristol West (7)           Bristol Inner City (9)
                                                                                           Bristol South East (13)
                                                           Bristol South (11)


                                     Woodspring (13)                                                                 Bath (15)



                                                                                       Greater Wansdyke (12)
               Weston (13)

                                           0         2.5         5

                                                    Miles




                                                                                                                                  Map 3
Bristol
               Primary Care Group/Trust

               PCG/T Name &
                                                                                                                                  Avon Health
North (13)     Number of practices
               per PCG/T                                                                                                          Authority, Primary
                                                                                         South Gloucestershire (30)
                                                                                                                                  Care Trusts and
                                                                                                                                  Primary Care Groups
                                                                           Bristol
                                                                         North ((35)                                              2001

                                                             Bristol South & West (31)




                               North Somerset (26)

                                                                                 Bath and NE Somerset (27)



                                           0         2.5         5

                                                    Miles


                                                                                                                                                          3
2001
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population

     This year’s significant developments in the way we organise health care mean changes for
     Avon Health Authority, which will have a more strategic role in future as new PCTs or
     possibly Care Trusts take on a larger role in commissioning health services. My Public
     Health Directorate is responding to these changes, and Section 1 Developing Public
     Health Action in the Avon Area sets out how we see public health work developing in
     PCTs, and how we can build up public health capacity and skills across the Avon area.

     Section 2 Health and Well Being draws on national and local sources of data to give a
     picture of the health and well being of the Avon Health Authority resident population. We
     focus particularly on indicators of the quality of life, premature death and life
     expectancy, our local progress towards targets set in the national strategy for health
     Saving Lives - Our Healthier Nation3, and the health of infants and older people. This year
     we have included information about whether health is getting better or worse.

     Section 3 Tackling Inequalities in Health focuses on progress in addressing inequalities
     across the Avon area. In last year’s report I set out our plans for tackling inequalities in
     health, and inequalities in access to health care, following the publication of our report
     Tackling Inequalities in Health 4. This year, we outline progress in implementing the
     report’s action plan. We also look at regeneration initiatives and their impact on health
     inequalities, and review action in injury prevention and oral health.

     Section 4 Improving Health looks at important disease areas where action is being taken
     to prevent illness and improve services: diabetes, cancer and heart disease.

     We have tried to avoid jargon as far as possible, but the nature of this report means that
     it contains technical and medical terms, as well as specialised language which describes
     health service work. We have included a comprehensive Jargon Explained section at the
     end of this report, along with some Technical Notes.

     I would like to thank my colleagues in Avon Health Authority and in Health Promotion
     Service Avon for their contributions to this report, especially Jackie Beavington, Karen
     Blowers, John Boyles, Angela Chung, David Evans, Natalie Field, Trevor Foster, Susan
     Hamilton, Stuart Harris, Chris Hine, Susan Laverty, Angela Raffle and Janette Treagust.
     I am also grateful to Linda Ewles (Headspring Consulting) and Julia Neidhold for editing,
     design and production.

     Finally, I would appreciate your views on this report. Your comments will help to ensure
     that future reports will be more useful to you, so please complete and return the
     Feedback Form at the end.




     Dr Kieran Morgan
     Director of Public Health
     July 2001


     3
         Secretary of State for Health (1999) Saving Lives: Our Healthier Nation. London: Stationery Office
     4
         Avon Health Authority (2000) Tackling Inequalities in Health: Final Report of the Project Steering
         Group on Tackling Inequalities in Health. Bristol: Avon Health Authority
4        Summary version: Avon Health Authority (2000) Tackling Inequalities in Health: a guide for action by
         the Avon health community.
                                                                                       2001
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Section 1
Developing Public Health Action in the Avon Area

In this report, we look at two aspects of public health work which have been important this
year: how we can take public health forward in the new framework of Primary Care Groups
(PCGs) and Primary Care Trusts (PCTs), and how we can build up the ability to respond and
develop public health across the Avon area to meet new needs and growing demands.

1.1: Developing Public Health in Primary Care Trusts

As we explained in the introduction to this report (Map 3), Avon’s population is now served by
five new health service organisations: two PCTs in Bath & North East Somerset and South
Gloucestershire, and three PCGs in Bristol South & West, Bristol North, and North Somerset.
The two Bristol PCGs are applying to become PCTs; North Somerset PCT is applying to become
a Care Trust. The purpose of PCTs is to improve health through commissioning and providing
health services.

People working in the field of public health have focused on how we can best work in the new
arrangement of PCTs. We have highlighted the main tasks that public health work must
address within PCTs and emphasised the importance of recognising the large number of
people who can contribute to this work. Within the Trusts, this includes public health
specialists, health promotion specialists, health visitors, nurses, GPs and managers.
It also includes many others working in other parts of the NHS (such as hospitals and specialist
mental health services), the voluntary sector, local authorities, and service users and carers.

      Improving public health is about preventing disease, prolonging life, and promoting,
      protecting and improving health and well being. This means tackling the root causes
      of health and disease as well as providing effective health care services. It also means
      basing developments on research evidence to ensure that our health services and
      programmes – whether for prevention, treatment or care – are effective, and give
      best value for money.
      It involves working in partnerships which cut across professional and organisational
      boundaries. 1

Public Health functions provided by Avon Health Authority

Not all public health functions are delegated to PCTs, although they will have a role to play
in local action plans. Some functions are currently best fulfilled on an Avon-wide basis;
this may change as the role of the Health Authority becomes more strategic in future.
Currently, these Avon-wide functions include:
•     health surveillance and communicable disease control;
•     planning and responding to major incidents, such as a major accident or a chemical
      spillage;
•     providing the lead on Avon-wide programmes on areas such as heart disease, mental
      health, cancer, diabetes and inequalities in health. The expertise of people taking a
      lead role will be available to all PCTs;
•     training public health specialists.

1
    Based on: Lessof L, Dumelow C & McPherson K (1999) Feasibility study of the case for national
    standards for specialist practice in public health, a report for the NHS Executive, Cancer and Public   5
    Health Unit. London School of Hygiene and Tropical Medicine
2001
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population

     Public health tasks that need to be addressed within a Primary Care Trust

     We have identified the public health tasks which PCTs need to address as follows; we are
     currently starting to tackle these.

     •         Executive committee membership
               National guidance on the establishment of PCTs sets out that there should be a
               public health specialist on the Executive Committee2.

               Avon Health Authority’s public health department has agreed that in the short term
               we will second a Public Health Specialist (a Consultant in Public Health Medicine) to
               the PCT for two days a week. This person will be the public health member of the
               Executive Committee providing leadership in public health issues: expertise on
               identifying and prioritising health needs, and developing and monitoring effective
               services and programmes to meet those needs.

               To use these skills most effectively we propose that the specialist will work largely in
               an advisory role, providing input to commissioners and work programmes (although
               the expertise of colleagues taking a lead in Avon wide programme will also be
               available) and working closely with PCT colleagues.

     •         Reducing inequalities
               One of the biggest challenges facing PCTs is to take strong action to reduce
               inequalities in health across its population. (See also Section 3 Tackling Inequalities
               in Health.) For the first time, national inequalities targets have been set 3. The NHS
               Plan 4 also sets a number of key actions to improve public health and reduce
               inequalities which include:
               • improving access to services for all patients by reducing inequalities in access;
               • reducing obesity and increasing physical activity;
               • increasing smoking cessation provision, especially for manual groups;
               • reducing drug misuse in young people;
               • increasing uptake of fruit and vegetables;
               • reducing conception in under 18s.

               A framework for reducing inequalities was endorsed by Avon Health Authority in
               20005. Considerable partnership work between PCTs, Health Promotion Service Avon
               and local authorities is already in progress including work on teenage pregnancy,
               smoking cessation services, regeneration and action to improve air quality. This is
               co-ordinated through the Health Improvement Programme.

     •         Advice to commissioners of services
               Public health specialists provide advice for commissioning managers in PCTs to
               ensure that decisions are based on assessments of a population’s needs and to
               establish the evidence (costs and benefits) for proposed services.


     2
         Department of Health (1999) HSC 1999/246: LAC (99)40. Primary care groups: taking the next
         steps. London: Department of Health
     3
         www.doh.gov.uk/healthinequalities/targets.pdf
     4
         Secretary of State for Health (2000) The NHS Plan. London: The Stationery Office
         www.doh.gov.uk/nhsplanimpprogramme/nhsplanimpprogramme.pdf
     5
         Avon Health Authority (2000) Tackling Inequalities in Health: a guide for action by the Avon Health
6        Community.
                                                                           2001
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•     Strategy development and implementation
      Public health specialists also advise PCTs on their local strategies and
      implementation plans (for example on heart disease, cancer or diabetes).

•     Collecting and sharing information
      If health programmes and services are to be truly based on local needs, we need to
      develop ways of collecting local knowledge about communities and their needs.
      Such information is known to health professionals who work directly with the
      community (such as health visitors, practice nurses and GPs) but it is not usually
      recorded in standard ways. Data which are routinely collected often do not give us
      the detailed knowledge we need. To address these problems, community profiles
      have been compiled in some areas such as North Bristol: Bradgate surgery, Lawrence
      Weston and Southmead. We need to learn from this work and consider how it can
      be used and developed across other areas.

•     Developing public health skills
      Many health professionals within PCTs have significant public health skills, and other
      staff may be interested in developing them. To enable the PCT to deliver public
      health improvements we need to ensure that these skills are developed and shared.
      (We say more about this in Section 1.2 Developing Public Health Capacity.)

Priorities
We need to consider how the public health specialist resource available to PCTs can be
used most effectively. We have established that priority should be given to:
•    fulfilling the role of the public health member of the Executive Committee;
•    developing and overseeing the implementation of a strategy to tackle inequalities;
•    acting in an advisory role to PCT staff;
•    co-ordinating access to wider public health support;
•    contributing to the development of public health skills within the PCT.

Action Plans
We are developing action plans to ensure that the broad approach we have described above
is turned into reality. PCTs are at different stages of development, but action plans can
include:
•      establishing a public health steering group within the PCT;
•      mapping local action against Avon’s framework to reduce inequalities, identifying
       specific points of action;
•      developing networks and forums to share and develop expertise in public health work;
•      planning and monitoring progress in priority service areas such as cancer, heart
       disease, diabetes, teenage pregnancy, drugs and alcohol, mental health and services
       for older people.




                                                                                               7
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        Examples of public health work in Primary Care Trusts
        Helping people to stop smoking
        Support to Stop Avon is scheme to help people stop smoking, which we outlined in
        last year’s report The Health of the Population 2000. The scheme has just
        completed its first year with outstanding results. Targets set in March 2000 were to
        have 1,600 people through the scheme with a quit rate (that is, the percentage who
        stopped smoking) of 15% after four weeks. We far exceeded this: 3,535 people
        went through the programme with a quit rate of 49% at four weeks. This is
        primarily due to the hard work of the 327 trained advisors working mostly in GP
        practices.

        Developments for the coming year include working with pregnant women who
        smoke to meet the government target to reduce pregnant smokers by 1% by March
        2002. This initiative includes training for midwives and health visitors in supporting
        pregnant smokers who want to quit.

        Extra support is also being offered to some practices in areas of high health need to
        reduce smoking rates among manual workers.

        For more information please contact Support to Stop Avon,
        telephone: 0117 959 5465, e-mail supporttostop@hpsa.org.uk



        Community profiles
        Community profiles of Southmead and Lawrence Weston have recently been
        completed by Health Promotion Service Avon. These provide social, environmental
        and economic descriptions of the areas and include the views of residents who were
        surveyed by local volunteers. Both profiles were funded by Bristol Regeneration
        Partnership’s Single Regeneration Budget Northern Arc Scheme Capacity Building
        Fund and are available from Alison Gibbons, HPSA, King Square House, Bristol BS2
        8EE.

        Profiles were launched in June 2001 to members of the community, local voluntary
        organisations and the health community at a conference in Southmead. They will
        be used as a baseline to develop plans for a Healthy Living Centre in Southmead and
        to strengthen links between local organisations.




8
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1.2: Developing Public Health Capacity

The government set out its strategy for improving health and reducing inequalities in the
White Paper Saving Lives: Our Healthier Nation 6 and in the NHS Plan 4. A key element of
the strategy is developing the multi-disciplinary public health workforce so that it is
skilled, staffed and resourced to deliver health improvement and the reduction of
inequalities in health.


        The Report of the Chief Medical Officer’s Project to Strengthen the Public Health
        Function7, published this year, concluded:

        We need to make sure that the public health workforce across all sectors is skilled,
        staffed and resourced to deal with the major task of delivering the Government’s
        health strategy. An increase in capacity and capabilities must be achieved.


Developing capacity means both increasing the number of people involved in public
health work and enhancing the skills which they bring to the job. With the establishment
of PCTs and the anticipated development of the new strategic health authorities, the
Avon health community faces the challenge of ensuring that people with the right public
health skills are available in appropriate numbers at the different levels of public health
activity: neighbourhood/community, PCT/local authority and strategic health authority.
For example, practitioners working at the neighbourhood level will need to have skills in
community development and the ability to access and utilise the evidence base on
effective interventions to tackle health inequalities.
In terms of people, the Chief Medical Officer’s report identifies three broad categories
within the public health workforce.
•        Most people, including managers, have a role in health improvement and reducing
         inequalities, although they may not recognise it. This is true, for example, of
         teachers, local business leaders, social workers, transport engineers, housing
         officers, other local government staff, the voluntary sector, as well as of health
         care professionals. They need to adopt a public health “mind set”, with greater
         appreciation of how their work can make a difference to health and well being and
         of where more specialist support can be obtained locally.
•        A smaller number of professionals spend a major part, or all, of their time in public
         health practice. These – sometimes called public health practitioners - include
         those who work with groups and communities as well as with individuals, such as
         health visitors, environmental health officers or community development workers.
         There are also those who use their research, information, public health science or
         health promotion skills in specific public health fields. These professionals have in-
         depth knowledge and skills and are a vital part of the workforce.
•        Public health consultants (medical) and specialists (non-medical) work at a
         strategic or senior management level, or at a senior level of scientific expertise such
         as in public health statistics. The ability to manage change, to lead public health
         programmes and to work across organisational boundaries is as crucial as technical
         skills in epidemiology, health promotion or health care evaluation.

6
    Secretary of State for Health (1999) Saving Lives: Our Healthier Nation. London: Stationery Office.
7
    Department of Health (2001) Report of the Chief Medical Officer’s Project to Strengthen the Public    9
    Health Function. London: Department of Health
2001
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population

      Specialists working in the NHS in future may come from a variety of professional
      backgrounds such as public health sciences, environmental health, social science,
      medicine, nursing, health promotion and dentistry. They will have a common core of
      knowledge, skills and experience acquired from postgraduate public health qualifications,
      successful completion of approved training and experience gained in practice. This may
      combine with more specialised expertise, usually based on their background discipline, to
      enable them to practice at comparable levels of responsibility in appropriate areas of
      expertise and practice to consultants in public health medicine.

      Progress so far
      Agencies in the Avon health community are already contributing to developing public
      health capacity.

      •         Regional public health specialist training scheme – the Public Health Directorate
                provides a training location and trainers for an increasing number of medical
                Specialist Registrars and non-medical trainees. In future, it is likely that trainees
                increasingly will work with PCTs. The Department of Social Medicine at the
                University of Bristol also provides academic training as part of this scheme.

      •         A new MSc in Public Health was introduced by the University of the West of England
                in 2000. Participation in the MSc by local public health practitioners has been
                supported by the Avon, Gloucestershire, Wiltshire and Dorset Workforce
                Development Confederation. Other public health related degrees are offered by the
                four higher education institutions in Avon.

      •         The Department of Social Medicine at the University of Bristol offers a short course
                and seminar programme on public health topics.

      •         Avon Health Authority supports local authority/Primary Care Trust partnership-
                based public health forums as well as an Avon-wide public health seminar
                programme.

      •         Health Promotion Service Avon offers a health promotion training programme.

      In addition, there have been a number of other professional development opportunities
      including funding from the Public Health Development Fund, the regional public health
      residential school and scientific conference and various bursary and secondment
      opportunities.

      PCGs and PCTs in Avon have already begun to consider their need to develop their public
      health workforces in order to deliver the NHS Plan and the Avon Health Improvement
      Programme 8. A new Local Workforce Development Group brings together the PCTs and
      PCGs, NHS Trusts, the Health Authority, local authorities, the voluntary sector and higher
      education institutions to work together for workforce planning. Local planning will be
      partly informed by the National Public Health Workforce Development Plan which we
      anticipate will be published later this year.


      8
          Avon Health Authority (2001) The Avon Health Improvement Programme 2001-04. Bristol: Avon
          Health Authority

10
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The challenge for the future
As we have already stressed, the public health workforce includes diverse professionals
located in a range of health, local authority and voluntary agencies. As the Chief Medical
Officer’s report indicates, many practitioners combine a broad public health role with
other more specific professional responsibilities. General practitioners and community
nurses, for example, may play public health roles as members of a PCT Board, in addition
to their usual clinical responsibilities.

There is no easy way to identify the number of practitioners or the skills development
they require to fulfil their public health potential. A key task for PCTs and their partners
will be to develop local workforce plans which address needs for building public health
capacity. The tasks to be done include:
•     defining who makes up the current public health workforce;
•     identifying what new public health jobs need to be done in the future;
•     identifying the public health skills and competencies people will need to do these
      jobs;
•     planning what action (including investing in professional development, education
      and training) is needed to prepare the future public health workforce.

Current national work on public health skills has focused largely on defining standards and
competencies for public health specialists 9. A key challenge for local partners will be to
build upon this work to define public health standards and competencies for the much
wider group of public health practitioners working at the neighbourhood/community or
PCT/local authority levels. Skills in community development and closer working with
communities will be an important component of these standards and competencies.

As PCTs develop and the role of the strategic health authority emerges, we need to co-
ordinate public health capacity building within a Managed Public Health Network. Such
a network will be essential to ensure that the scarce skills of public health specialists
(whether based in PCTs or the strategic health authority) are utilised across the whole
health community.

The Managed Public Health Network will provide the infrastructure to ensure that learning
is shared and professional development, education and training opportunities provided for
the wider group of public health practitioners who will be based at the PCT or local
authority level. The Network is likely to include a range of development opportunities
such as local public health forum events, secondments, mentors and learning sets. Close
links will need to be maintained and developed with local authority and education
colleagues. High quality information systems including a comprehensive public health
network web site will be essential for maintaining communication and information
exchange.




9
    Healthwork UK (2001) Standards for Specialist Practice in Public Health: Consultation Version
    January 2001. London: Healthwork UK

                                                                                                          11
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      Section 2                                           Health and Well Being
      (Please note that the Technical Notes and Jargon Explained sections at the end of the
      report are especially relevant to this section.)

      This section draws on national and local sources of data to give a picture of the health and
      well being of the Avon Health Authority resident population. We focus particularly on
      indicators of the quality of life, premature death and life expectancy, our local progress
      towards targets set in the national strategy for health Saving Lives - Our Healthier
      Nation1 , and the health of infants and older people.

      This year we have, where possible, identified trends so that we can get an idea about
      whether health is getting better or worse in specific respects.

      Avon Health Authority has developed a public health web site, which we will use to make
      basic public health information more easily available in future.
      (www.avonhealth.org.uk/phealth)

      2.1: General Indicators of Health and Well Being

      Indicators of quality of life
      There is a wide range of factors, such as housing conditions, crime and employment,
      which affect health status. Over the past few years, Bristol and South Gloucestershire
      local authorities have produced Quality of Life Indicators, which assess trends in a variety
      of indicators of health and well being. A selection of these is shown in Table 2.1. They
      show a mixed picture: some things are getting better, some worse and some unchanged.

      Table 2.1: Indicators of quality of life in Bristol and South Gloucestershire
          Indicator                                              Bristol               South Gloucestershire
          Road traffic accidents                                 Getting worse         Getting worse
          Days with air pollution                                Getting better        No change
          Household waste collected                              Getting worse         Getting worse
          Household waste recycled                               Getting better        Getting better
          Homelessness                                           Getting worse         No change
          Recorded crime                                         No change             Getting better
          Woodland projects                                      Getting better        Getting better
          Unemployment                                           Getting better        Getting better
      Source:
      Bristol City Council web site: www.bristol-city.gov.uk (under Quality of Life)
      South Gloucestershire Council web site: www.southglos.gov.uk




      1
          Secretary of State for Health (1999) Saving Lives: Our Healthier Nation. London: The Stationery
          Office

12
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    Premature death
    Premature death (death before the age of 65) has continued to fall over the last ten years
    in Avon in all local authority areas, approximately in line with that for England and Wales.
    Figure 2.1 shows how the premature death rate shows an overall downward trend, using
    the 1993 England and Wales rate as the baseline.

    Figure 2.1: Trends in premature death (age 15-64)
    in Avon and local authorities
                               120

                               110
standardised mortality ratio




                               100

                                90

                                80

                                70

                                60
                                                                              1989     1990       1991       1992       1993           1994   1995     1996      1997    1998     1999
                                                    Source: Compendium of Clinical Indicators 2000
                                                                                      England and Wales                                        Avon
                                                                                      Bath & North East Somerset                               Bristol
                                                                                      North Somerset                                           South Gloucestershire



    Cancers and diseases of the circulation (including heart disease and strokes) cause the
    majority of premature deaths. Figure 2.2 shows that rates for both causes in Avon show a
    downward trend similar to that for England and Wales. (Trends relating to specific
    cancers can be seen in Section 4.2.)

    Figure 2.2: Trends in death rates from cancer and circulatory diseases
    (age under 75)

                                                                                190
                                     directly standardised rate per 100,000




                                                                                180
                                                                                170
                                                                                160
                                                                                150
                                                                                140
                                                                                130
                                                                                120
                                                                                110
                                                                                100
                                                                                          1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999
                                                                                      Source: Compendium of Clinical Indicators 2000


                                                                                      England and Wales cancer                                       Avon cancer
                                                                                      England and Wales circulatory diseases                         Avon circulatory diseases
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      Life expectancy and deprivation
      Table 2.2 shows the average life expectancy in PCG or PCT areas by deprivation quintiles.
      (Quintiles divide areas into five equal groups according to common values, in this case
      deprivation scores. The most deprived quintile is therefore the fifth of enumeration
      districts with the worst deprivation scores. Enumeration districts are areas used in the
      census which contain approximately 250-500 people.)

      In all areas, life expectancy for men and women in the most deprived quintile is worse
      than life expectancy in the least deprived quintile. In Avon, men in the least deprived
      quintile live on average 5.4 years longer, and women 3 years longer, than those in the
      most deprived quintile.

      Table 2.2: Deprivation and variations in average life expectancy in PCGs
      and PCTs

                                         Men                               Women
                               Most                   Least      Most             Least
                               deprived               deprived   deprived         deprived
                               quintile Average       quintile   quintile Average quintile
       B&NES                   74.2       76.8        78.7       80.7        81.9      82.9
       Bristol North           73.2       75.0        77.8       79.7        80.8      81.9
       Bristol South & West    72.8       74.5        77.8       80.9        80.6      82.7
       North Somerset          72.5       76.2        79.2       78.8        81.4      82.4
       South Gloucestershire 75.5         77.4        78.7       79.8        81.4      82.6
       Avon                    73.1       76.0        78.5       79.3        81.2      82.3
      Source: ONS 1995-99




      2.2: Saving Lives: Our Healthier Nation Targets

      More data have become available since the baseline for Saving Lives: Our Healthier
      Nation targets were set. This allows some initial analysis of emerging trends; however, a
      longer timescale is needed to assess patterns accurately.

      Accidents
      Saving Lives: Our Healthier Nation national strategy for health sets two national targets
      for accidents:
      •       to reduce the death rate from accidents by at least a fifth by 2010;
      •       to reduce the rate of serious injury from accidents by at least a tenth by 2010.




14
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     Figure 2.3 shows that there has been an overall reduction in death rates from the 1995-97
     baseline in Avon. However, Figure 2.4 shows that the rate of serious injury from
     accidents in Avon has increased, but not significantly.(The link between serious injury
     from accidents and inequalities is discussed in Section 3.3 Injury Prevention.)

     Figure 2.3: Progress against Saving Lives target for reduction in deaths
     from accidents

                          25
standardised mortality




                          20
   rate per 100,000




                          15
                          10
                                5
                                0
                                           Avon                   B&NES                 Bristol         N.Somerset   S. Gloucestershire
                                       Source: Compendium of Clinical Indicators 2000


                            Baseline 1995-1997                            1996-1998                   1997-1999          2010 Target



     Figure 2.4: Progress against Saving Lives target for reduction in serious
     injury from accidents
                                     450
                                     400
           standardised admissions




                                     350
               rate per 100,000




                                     300
                                     250
                                     200
                                     150
                                     100
                                      50
                                       0
                                                  Avon                  B&NES               Bristol       N. Somerset    S. Gloucestershire
                                       Source: Avon Health Authority in-patient data




     Cancer
     Saving Lives: Our Healthier Nation sets a target to reduce the death rate from cancer in
     people under 75 by at least two fifths by 2010.

     There has been little change in the death rate in Avon since the baseline (Figure 2.5).
     None of the local authority death rates have changed significantly since the baseline,
     although there has been a consistent increase in Bristol and a consistent decrease in
     South Gloucestershire. (See Section 4.2 Cancer for more information about trends in
     death from cancer.)
                                                                                                                                                15
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     Figure 2.5: Progress against Saving Lives target for reduction in deaths
     from cancer (age under 75)
     standardised mortality rate per 100,000




                                                                     160
                                                                     140
                                                                     120
                                                                     100
                                                                      80
                                                                         60
                                                                         40
                                                                         20
                                                                          0
                                                                                  Avon         B&NES             Bristol         N.Somerset   S. Gloucestershire


                                                                         Baseline 1995-1997              1996-1998             1997-1999          2010 Target
               Source: Compendium of Clinical Indicators 2000




     Circulatory Diseases
     Saving Lives: Our Healthier Nation sets a target to reduce the death rate from coronary
     heart disease, stroke and related diseases in people under 75 by at least two fifths by
     2010.

     There has been a consistent decrease in the death rate in Avon as a whole and in all local
     authorities except North Somerset (Figure 2.6). However, none of the rates are
     significantly different from the baseline.

     Figure 2.6: Progress against Saving Lives target for reduction in
     circulatory diseases (age under 75)
                                                                         160
                               standardised mortality rate per 100,000




                                                                         140
                                                                         120
                                                                         100
                                                                          80
                                                                          60
                                                                          40
                                                                          20
                                                                              0
                                                                                   Avon        B&NES                 Bristol       N.Somerset S. Gloucestershire

                                                                          Baseline 1995-1997              1996-1998             1997-1999          2010 Target
                                                        Source: Compendium of Clinical Indicators 2000
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Suicide
The Saving Lives: Our Healthier Nation strategy sets a target to reduce the death rate
from suicide and undetermined injury by at least a fifth by 2010.

Figure 2.7 shows that there has been a decrease in the suicide rate in Avon since the
baseline. However, it should be noted that suicides are uncommon events so that numbers
are small for statistical purposes, and any trends should be interpreted with caution.

Figure 2.7: Progress against Saving Lives target for reduction in suicides

                                            12
  standardised mortality rate per 100,000




                                            10

                                            8

                                            6

                                            4

                                            2

                                            0
                                                 Avon             B&NES          Bristol   N.Somerset   S. Gloucestershire

                                             Baseline 1995-1997             1996-1998      1997-1999           2010 Target
                           Source: Compendium of Clinical Indicators 2000




2.3: Infant Health

Low birth weight is associated with increased developmental problems and poor health
later in life. Low birth weight and infant mortality rates (deaths of infants under one year
as a percentage of live births) are both linked with deprivation (see Section 3.1 Action on
Tackling Inequalities).

Table 2.3 shows that still births and infant mortality are highest in Bristol North. They are
lowest in B&NES with respect to low birth weight, and South Gloucestershire with respect
to still births.




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      Table 2.3: Births and infant deaths 1997-1999

                                                              Average             Infant mortality    % Stillbirths % Low birth
                                                              annual              rate per 1000                     weight babies
                                                              number of                                             (<2500g)
                                                              births
                B&NES                                         1745                3.63                0.59         6.14
                Bristol North                                 2879                6.48                0.70         8.73
                Bristol South & West                          2074                4.50                0.49         8.53
                North Somerset                                1927                6.40                0.50         6.71
                South Gloucestershire                         3012                4.43                0.45         6.72
                Avon                                          11682               5.14                0.54         7.51
      Source: ONS




      2.4: Health of Older People

      Older people are the largest group of users of NHS services. The number of older people
      is increasing, particularly people aged over 85 who will require more services appropriate
      to their needs.

      Hospital Admissions
      The emergency hospital admission rate for people over 75 has been steadily increasing in
      Avon, and in all local authorities except North Somerset (see Figure 2.8).



      Figure 2.8: Emergency admission rates for the over 75 resident
      population in Avon


                            300
                            250
      admissions per 1000




                            200
                            150
                            100
                             50
                              0
                                       B&NES         Bristol North Bristol South         N.Somerset    S. Glos      Avon
                                                                      & West
                                                        1997-1998                 1998-1999           1999-2000
                                  Source: Avon Health Authority in-patient data



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The top ten causes of emergency admission are shown in Table 2.4.

Table 2.4: Top ten emergency admissions for residents aged over 75 in
Avon in 99/00
   Cause                                                                              Number of               Admission Rate
                                                                                      admissions                per 1000
   Fracture of femur                                                                         974                        12.3
   Heart failure                                                                             845                        10.7
   Pneumonia, organism unspecified                                                           749                          9.5
   Angina pectoris                                                                           576                          7.3
   Unspecified acute lower respiratory infection                                             543                          6.9
   Other chronic obstructive pulmonary disease                                               535                          6.8
   Other disorders of urinary system                                                         503                          6.4
   Stroke, not specified as haemorrhage or infarction                                        484                          6.1
   Pain in throat and chest                                                                  461                          5.8
   Acute Myocardial Infarction                                                               457                          5.8
Source: Avon Health Authority in-patient data


Older people also have a wide range of conditions, such as diabetes and arthritis, which
rarely result in hospital admission. Dementia, which includes Alzheimer’s disease, is one
such condition. The proportion of the population with Alzheimer’s increases with age;
the number of people estimated to have dementia is shown in Table 2.5.


Table 2.5: Estimated numbers of people with dementia

                                             Age 75-79                   Age 80-84                   Age 85+                    Total
  B&NES                                      383                         584                         903                        1870
  Bristol                                    788                         1235                       2119                        4141
  North Somerset                             450                         701                         1280                       2431
  South Gloucestershire                      423                         585                         1013                       2021
  Avon                                       2043                        3105                        5315                       10463
Source: ONS 2001 population projections. Prevalence Estimates: Clegg A, Bryant J, Nicholson T, McIntyre L, De Broe S, Gerard K, et al.
Clinical and cost-effectiveness of donepezil, rivastigmine and galantamine for Alzheimer’s disease: a rapid and systematic review. Health
Technol Assess 2001; 5(1)




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      Section 3                             Tackling Inequalities in Health

      As in previous years, this report emphasises that health is not spread evenly through the
      population. In general, people who live in the most disadvantaged circumstances have
      more illness, more disability and shorter lives than those who are more affluent.

      This section focuses on progress in tackling inequalities in health across the Avon area.
      Last year’s report set out our plans for tackling inequalities in health, and inequalities in
      access to health care, following the publication of our report Tackling Inequalities in
      Health 1. This year, we outline progress in implementing the report’s action plan. We
      also look at regeneration initiatives and their impact on health inequalities, and review
      action in two specific areas: injury prevention and oral health.

      3.1: Action on Tackling Inequalities

      The national picture: widening health gap

      Standards of living and general health status are currently higher than ever before, both
      in Avon and across Britain as a whole. However, rising living standards and increasing life
      expectancy have been achieved at the cost of widening inequalities in these two
      fundamental dimensions of human welfare.

      The increasing gap in living standards is, at least in part, due to changing employment
      patterns across the whole of society. Throughout the 1980s and 1990s there was a shift
      away from households containing a mix of employed and non-employed adults, and a
      corresponding increase in two-earner and no-earner households. The changing
      distribution of work affects the distribution of income, as the incomes of working
      households rise and non-working households struggle to make ends meet. The result is an
      increase in poverty, particularly in households with children. One in three British children
      live in poverty, a rate far exceeding those elsewhere in the European Union.

      Along with the growth in inequalities in living standards comes a growth in inequalities in
      health. Between 1972 and 1996 nationally, life expectancy for men in social class I
      (‘professional’) increased by 5.7 years, while among men in social class IV (‘unskilled
      manual’) increased by only 1.7 years. In the 1970s, death rates were twice as high
      amongst unskilled manual workers as among professionals; by the 1990s, the death rate
      was three times higher.

      Of course, we want to see continued improvements in both living standards and health
      status across all sectors of the population. The challenge is to bring about a reduction in
      the health gap between affluent and deprived sections of the population, whilst
      maintaining the general improvement for all.


      1
          Avon Health Authority (2000) Tackling Inequalities in Health: Final Report of the Project Steering
          Group on Tackling Inequalities in Health. Bristol: Avon Health Authority
          Summary version: Avon Health Authority (2000) Tackling Inequalities in Health: a guide for action by
          the Avon health community


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Health inequalities in Avon

Nationally, Avon compares favourably across most economic and health related
indicators. Out of the 99 health authorities across England, Avon Health Authority is
ranked 36th for deprivation (Townsend Score – 1991 Census), 39th for unemployment
(1991 - various), 34th for morbidity (limiting long term illness – 1991 Census), and 16th for
mortality (ONS death registrations – 1996 to 1998).

However, despite its position in the national ‘league tables’ of health and prosperity,
considerable internal variations exist across the area covered by Avon Health Authority.
Table 3.1 gives some indication, at electoral ward level, of the extremes for selected
socio-economic and mortality indicators. It compares social and economic indicators with
the Avon average, and sets out death rates compared with a standardised Avon rate of
100.

Table 3.1: Indicators of socio-economic and health status: best and worst
wards in Avon
  Indicator                           Worst Ward                     Best Ward                  Avon Average
  Low income*                         Lawrence Hill (53%)            Bradley Stoke South (5%)       16%

  Unable to work*                     Lawrence Hill (29%)            Oldbury-on-Severn (2%)          8%

  Child poverty *                     Lawrence Hill (72%)            Clevedon Walton (1%)           23%


  All deaths**                        Weston-super-Mare West (139)   Wrington (69)                  100

  Deaths <75 years**                  Lawrence Hill (171)            Lyncombe (53)                  100

  CHD deaths**                        Filwood (151)                  Widcombe (49)                  100

  Cancer deaths**                     Filwood (139)                  Wrington (60)                  100
* DETR Deprivation Indicators, 2000
** ONS death registrations, 1995-1999. Age-standardised



As we know, there is a close association between deprivation and health status. Maps 4
and 5 show the DETR Index of Multiple Deprivation and the DETR Health Deprivation
Domain, which show general deprivation and health status respectively. They reveal
almost identical patterns across Avon’s electoral wards.




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      Map 4: Deprivation in Avon wards
      (DETR Index of multiple deprivation)



             Avon Ranking Quartile
                1st (Most Deprived)

                2nd

                3rd

                4th (Least Deprived)




      Map 5: Health in Avon wards
      (DETR Health deprivation domain)




      We do not yet fully understand the precise mechanisms through which socio-economic
      inequalities determine health inequalities. A wide variety of influences combine and
      interact to affect any individual’s health status at a given time, including genetics,
      education, lifestyle (such as smoking, diet and exercise) and access to services. Debate is
      currently in progress about whether we can best reduce health inequalities by evening out
      socio-economic inequalities, by targeting health interventions (such as health promotion
22    programmes) on disadvantaged populations, or by a combination of approaches.
                                                                                    2001
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Health inequalities targets


        In February 2001 two national health inequalities targets were introduced 2 :
        •   Infant Mortality:
            Starting with children under one year, by 2010 to reduce by at least 10% the
            gap in mortality between manual groups and the population as a whole.
        •   Expectation of Life
            Starting with health authority areas, by 2010 to reduce by at least 10% the
            gap between the quintile of areas with the lowest life expectancy at birth
            and the population as a whole.


Infant mortality in Avon.
In 1999 there were 56 infant deaths across Avon, resulting in an infant mortality rate of
4.9 deaths per 1,000 live births. (This compares favourably with the rate for England of
5.7.)
It is not possible to calculate a separate rate for the ‘manual’ population – which the
national target requires - in Avon as socio-economic group is not currently recorded in
routine birth statistics. However, it is possible to demonstrate a relationship between
level of material deprivation (as measured by the Townsend deprivation score) and infant
mortality rate.
Figure 3.1 shows the variation in infant mortality rate (deaths of infants under one year
old, based on data from 1995 to 1999) with deprivation levels in areas categorised
according to deprivation levels (Townsend score quintiles, calculated at enumeration
district level from 1991 census data). It shows a general increase in infant mortality rate
with increasing level of deprivation, with the least deprived quintile having the lowest
rate (4.2 deaths per 1,000 births) and the most deprived quintile the highest (7.9 deaths
per 1,000 births). If the whole of Avon could attain the level of infant mortality of the
lowest deprivation quintile, there would be approximately 16 (24%) fewer infant deaths
per year.

Figure 3.1: Infant mortality rates and deprivation in Avon

                 Infant mortality rate
            10

             8

             6

             4

             2

             0
                          I              II            III         IV         V
                                              Townsend deprivation
                 (Least Deprived)                score quintile         (Most Deprived)
                 Source: ONS

2
                                                                                                     23
    www.doh.gov.uk/healthinequalities/targets.pdf
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      Life expectancy in Avon
      Recent calculations for the Avon population (based on data from 1995 to 1999) indicate an
      average life expectancy of 78.7 years. Women’s average life expectancy, at 81.2 years, is
      over five years greater than that of men (76.0 years). These figures compare favourably
      with national life expectancies (based on data from 1997 to 1999) of 75.1 years for men
      and 79.8 years for women.

      Once again, variation across Avon can be demonstrated by calculating life expectancies
      for Townsend deprivation score quintiles – Figure 3.2

      Figure 3.2: Average life expectancy and deprivation in Avon

                   Average life expectancy (years)
              85



              80



              75



              70
                           I              II            III         IV         V
                                               Townsend deprivation
                   (Least Deprived)               score quintile         (Most Deprived)




      A consistent decrease in average life expectancy with increasing level of deprivation is
      apparent, with the least deprived quintile having the longest life expectancy (80.4 years)
      and the most deprived quintile the shortest (76.1 years).

      On average, a person living in an area lying within the least deprived Townsend score
      quintile will live 4.3 years longer than someone living in an area within the most deprived
      quintile. If the whole of Avon could attain the level of life expectancy currently
      experienced by the lowest deprivation quintile, average life expectancy would be 1.7
      years longer than at present, and reduce premature mortality in the population by about
      20,200 life years per annum. (See Section 2.1 General Indicators of Health and Well Being
      for more information on life expectancy and deprivation in Avon.)




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Progress in tackling health inequalities in Avon.
Despite the complexity of the health inequalities issue, and the uncertainties surrounding
the best methods to employ, significant progress has been made in this area since the
publication of last year’s report.

•    The report Tackling Inequalities in Health has been widely circulated and
     extensively discussed. Key partner organisations, in particular the emerging PCTs,
     have acknowledged the recommendations of the report as a useful starting point for
     addressing inequalities in health.

•    We launched an ‘Inequality Education and Training Bursary/Secondment Scheme’,
     offering grants for training and education related to health inequalities. Five
     projects were funded in the first round, all relating to inequalities in primary care.

•    We have developed and refined methods for allocating resources on the basis of
     need, particularly in the areas of heart disease and primary care access. We hope
     to develop and expand this approach so that it can be applied to a wider range of
     programmes.

•    We have produced health statistics and profiles to support applications for
     regeneration money and other sources of funding for deprived areas.

•    We have undertaken extensive work to increase understanding of the patterns and
     nature of health inequalities across Avon. Particular attention has been given to
     analysing inequalities across localities and population groups other than traditional
     ones such as wards; for example, we have looked at ‘neighbourhoods’ and GP
     practice populations, so that the results may support practical action across real
     functional units.

•    We have also begun work on compiling a compendium of evidence-based
     interventions which have been shown to be effective in reducing inequalities across
     a range of programme areas and in a variety of settings.

•    We plan to examine the wide range of quality, health status and performance
     indicators currently available for various NHS programme areas (such as Saving
     Lives: Our Healthier Nation targets, and National Service Framework milestones),
     and to derive specific inequalities indicators to complement them. Hopefully, this
     will enable inequalities work to be more closely incorporated into mainstream
     programme areas, rather than to be viewed as a fringe or separate issue, as is
     currently often the case.

•    PCTs will be required from 2002 to identify key health inequalities affecting the
     populations they serve, and to derive and implement programmes to reduce these
     inequalities. Quantitative and measurable targets will be set for inequality
     reduction, and the PCTs will be monitored on achieving these targets as part of their
     Health Improvement Programme performance management. Again, we see this as a
     valuable process for integrating health inequalities into mainstream work
     programmes.




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      3.2: Regeneration and Neighbourhood Renewal

      Neighbourhoods and health
      We now recognise that many factors determine the state of our health and our ability to
      improve it, including our education, the work we do, the state of our housing and the
      environment in which we live. In other words, the neighbourhood in which we reside has
      a significant effect upon our health.

      Reports from the Social Exclusion Unit have highlighted the disparity between England’s
      most deprived neighbourhoods and the rest of the country. In the 10% most deprived
      wards in England in 1998, 44% of people relied on means tested benefits, compared with a
      national average of 22%. In these same areas 19 % of all homes suffered from high levels
      of vacancy, disrepair, dereliction or vandalism, compared with 5% of homes elsewhere 3.

      In Avon there is a big gap in living standards between the most deprived neighbourhoods
      and those that are more well off. The poorest neighbourhoods often suffer from high
      rates of unemployment and crime, and poor standards of housing. The people who live in
      these areas are among the most socially excluded in society. They often have low
      incomes, few qualifications and poor health.

      It therefore follows that raising standards of living in deprived neighbourhoods through
      regeneration should lead to improvements in health and well being.

      What is “regeneration”?
      Regeneration is an umbrella term for a whole host of activities ranging from small locality
      based initiatives which may have very specific objectives, for example community based
      energy efficiency projects, to larger projects that involve land planning issues and
      complete redevelopments, for example the Harbourside development in Bristol.

      Regeneration initiatives rely on partnerships between all major sectors, including the
      public, private, business and voluntary sectors. The relative strength of each of these
      sectors shifts depending on the project but traditionally, the public and voluntary sectors
      have been most prominent. Key bodies in Bristol, for example, include Bristol City
      Council and the Bristol Regeneration Partnership, a body separate from the Council which
      incorporates a range of organisations from across the city, including Avon Health
      Authority.

      Since 1997 there has been a multiplicity of policy initiatives about regeneration. The New
      Deals for Employment, Employment and Education Action Zones, Health Action Zones, the
      New Deal for Communities, the Single Regeneration Budget (SRB) and the Neighbourhood
      Renewal Strategy are examples.




      3
      Social Exclusion Unit (1998) Bringing Britain Together: a national strategy for neighbourhood
      renewal. London: Social Exclusion Unit, Cabinet Office
      Social Exclusion Unit (2000) National Strategy for Neighbourhood Renewal: a framework for
      consultation. London: Social Exclusion Unit, Cabinet Office
26
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Funding
Funding for regeneration activity is secured either from UK or European sources.

In the UK there are several funding mechanisms. SRB is an allocation of government
money earmarked for regeneration activity and secured by bidding in a series of
competitive rounds. The most recent round was SRB6.

A further source of finance in England is the Neighbourhood Renewal Fund which provides
an extra £800 million over three years to 88 deprived local authority areas, including
some in Avon. The fund is dependent upon eligible authorities fulfilling certain
conditions, namely: working with a Local Strategic Partnership (LSP), agreeing a
Neighbourhood Renewal Strategy and delivering specific Public Service Agreement
Targets. Other UK based sources of funding include the New Opportunities Fund and New
Deal for Communities Funding.

There is also significant European funding available for regeneration activity. Allocations
are made under the auspices of the Objective and Urban programmes and managed at a
regional level.

Current regeneration projects
Currently, many regeneration projects are underway in the Avon area, funded from a
variety of sources. They include the following examples.

•    The Rough Sleepers Initiative, operational since 1996, offers a range of services to
     help homeless people back into housing.
•    The Norton Radstock Regeneration Scheme, started in 1996, is allocated £2.9
     million over six years for community projects in the Norton Radstock area of B&NES.
     The largest project is development of a largely vacant and partially derelict and
     contaminated site; other projects focus on young people and families, sports, and
     possible health facilities and drugs services.
•    An Education Action Zone brings twenty-two schools across Bristol into partnership
     with local community and business organisations in an attempt to raise educational
     achievement.
•    The Northern Arc SRB scheme, started in 1997, is a £5 million 7-year scheme in
     Bristol aimed at regenerating communities in Lawrence Weston, Henbury and
     Southmead. It addresses housing, projects to tackle crime and drugs and
     emphasises training and career guidance.
•    The Barton Hill New Deal for Communities in Bristol allocated £49.99 million over
     10 years, is one of seventeen countrywide initiatives. It was adopted by the
     government as a “National Pathfinder”; this scheme incorporated innovative
     community consultation processes and is managed by a partnership of local
     residents.

The new Neighbourhood Renewal Strategy
In January of this year the government announced its National Strategy for
Neighbourhood Renewal. Developed by the Social Exclusion Unit the strategy details the
government’s agenda for improving the most deprived neighbourhoods in England. With
delivery aimed over the next ten to twenty years the strategy sets specific targets (Public
Service Agreement Targets) for improvement across a spectrum of activity including
employment, housing, education, crime, health and the environment.


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            Public Service Agreement target for health
            Issue           Government Lead          Local Lead              Target
            Health          Department               Health                  To develop targets in 2001
                            of Health                Authorities             to narrow the health gap in
                                                                             childhood and throughout
                                                     PCT/PCGs                life between socio-
                                                                             economic groups and
                                                     Local Authorities       between the most deprived
                                                                             areas and the rest of the
                                                                             country. Targets will be
                                                                             developed in consultation
                                                                             with external stakeholders
                                                                             and experts early in 2001.

      An Avon-wide Local Strategic Partnership that brings together key local agencies from the
      public, private, voluntary and community sectors is being set up to coordinate the
      Neighbourhood Renewal Strategy. Avon Health Authority will play an active role within
      the partnership in an attempt to create healthier neighbourhoods.

      Questions and issues
      It is clear that regeneration activity of such breadth and extent will impact upon the
      health of the local population. But it also raises questions and issues which we need to
      address.

      •         How exactly do regeneration projects impact upon health? Our report Tackling
                Inequalities in Health included a framework for tackling inequalities in health based
                on the recommendations of the Acheson report 4. These recommendations include
                initiatives on, for example, increasing benefit uptake and developing pre-school
                education, which are commonly regarded as “regeneration activity”. The extent to
                which regeneration projects incorporate these evidence based recommendations is
                not currently known.

      •         The impact of regeneration projects may have a down side. Evaluation of certain
                schemes has revealed a mixed impact on health, with increased relative poverty and
                deleterious effects on local social cohesiveness. One factor has been private and
                public market forces with private landlords in regenerated areas increasing rents,
                and regenerated areas and properties becoming eligible for higher council tax
                banding.5

      •         We also need to be aware that regeneration activity is extensive, requiring
                performance at several levels from the strategic overview to the grass roots project
                management. We need to identify the most appropriate roles for health
                professionals and the levels at which their input would be most effective, in the
                context of limited human resources and the need to avoid duplication of effort.

      4
          Department of Health (1998) Independent Inquiry into Inequalities in Health Report (the Acheson
          Report). London: The Stationery Office
      5
          Ambrose P. Urban regeneration by Area Based Initiatives - how much health gain? Paper presented
          at UKPHA Conference, Bournemouth, April 2001
          Ward O. Report on the Bryson House Project. Presentation UKPHA Conference, Bournemouth,
28        April 2001
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•       In the past decade we have seen the emergence of many "partnerships" across the
        Avon area. We need to coordinate work on tackling inequalities with work on
        regeneration and neighbourhood renewal in order to pool resources and expertise
        and avoid duplication. The manner in which work on reducing inequalities in health
        may be incorporated into the mainstream regeneration agenda needs to be
        clarified.


       Tackling health inequalities through regeneration:
       • Our health is determined by many factors – genetic, social and environmental.
       • Regeneration initiatives are diverse – they include projects to tackle
          unemployment, crime, poor housing and poor education. All of these affect our
          health and inequalities in health.
       • More research is needed to evaluate the impact of regeneration on health.


Sources:
Social Exclusion Unit (2001) A New Commitment to Neighbourhood Renewal: National
Strategy Action Plan. London: Social Exclusion Unit, Cabinet Office
Social Exclusion Unit (2001) National Strategy for Neighbourhood Renewal: Policy Action
Team Audit. London: Social Exclusion Unit, Cabinet Office
Local Government Association (2000) Public Health and Regeneration. London: Local
Government Association Publication


3.3: Inequalities in Injury Prevention


       Accident prevention or injury prevention?
       For many years safety officials and public health authorities have discouraged use
       of the word “accident” when it refers to injuries or the events that produce them.
       So, for example, it is better to speak of “road traffic collisions” rather than “road
       traffic accidents”, “home injuries” rather than “home accidents” and
       “unintentional drug overdoses” rather than “accidental drug overdoses”.

       Why? Because an accident is often understood to be unpredictable – a chance
       occurrence or an “act of God” – and therefore unavoidable. But most injuries and
       the events that cause them are predictable and preventable.

       Using the correct terms consistently will help to improve our understanding that
       injuries of all kinds – in homes, schools, workplaces and vehicles – could usually be
       prevented.

       The British Medical Journal has decided to ban the word “accident” as far as is
       practically possible 6, and we are doing the same. Sometimes it is unavoidable – for
       example, “accident” is used in the International Classification of Diseases, and in
       some national documents which we quote from – but wherever possible we will use
       the correct terms.


6
    British Medical Journal Editorial 2 June 2001, 322: 1320-21
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      Deprivation and injury
      Unintentional injuries are responsible for 10,000 deaths a year across England. However,
      injuries do not affect all sectors of the community equally. Young people are more likely
      to be killed or injured in road traffic collisions while older people are more likely to be
      injured by falls.

      In addition, there are clear links between deprivation and unintentional injury or death.
      Deaths from injuries have a steeper class gradient than any other fatal condition and this
      inequality is widening 7. Injury in young children is more common among poorer families
      and in deprived areas 8. Among men, major injuries are more common in the manual
      classes for those aged under 55 9. A recent Department of Trade and Industry study found
      that residential areas with lower social class and lower income households have higher
      overall injury rates. This statistical relationship was most significant for children under
      sixteen, and particularly for the under-fives. For older people, however, there was no
      evidence for a statistical link between social class and overall injury rates.10

      National policy
      The White Paper Saving Lives: Our Healthier Nation11 set a national target:

      • to reduce the death rates from accidents by at least one fifth and to reduce the rate of
        serious injury from accidents by at least one tenth by 2010 – saving 12,000 lives in total.

      Although this target does not explicitly address inequalities, such a significant reduction
      in deaths and injuries is likely to disproportionately benefit deprived communities which
      are most affected by injuries. (Section 2.2 Saving Lives: Our Healthier Nation Targets
      gives information about our progress in meeting this target in Avon.)

      The Chief Medical Officer’s Our Healthier Nation Working Group concluded that the
      greatest gains towards reaching the target would result from reducing injury (or its
      severity) in:
      •     children up to 15 years (especially those from manual and unskilled households);
      •     young people aged 16-24 years involved in road traffic collisions;
      •     older people who are at risk of stumbling or falling.

      Action with the first two groups in particular should also contribute to reducing injury-
      related inequalities in health.




      7
           Roberts, I, Power, C (1996) Does the decline in child injury mortality vary by social class? A
           comparison of class specific mortality in 1981 and 1991. British Medical Journal 313: 784-86
      8
           Reading, R, Langford, I, Haynes, R, Lovett, A (1999) Accidents to preschool children: comparing
           family and neighbourhood risk factors. Social Science & Medicine 48: 321-30
      9
           Prescott-Clarke, P, Primatesta, P (1998) Health Survey for England ’96 London: The Stationery
           Office
      10
           Department of Trade and Industry (2001) Working for a Safer World: 23rd Annual Report of the
           Home and Leisure Accident Surveillance System – 1999 Data. London: Department of Trade and
           Industry
      11
           Secretary of State for Health (1999) Saving Lives: Our Healthier Nation London: The Stationery
           Office
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At a national level, the government is working across a range of departments to tackle
injury prevention.
•     The Department of the Environment, Transport and the Regions (DETR) is
      responsible for road safety. In March 2000 the DETR published a new road safety
      strategy, setting casualty reduction targets for 2010. The strategy sets local
      authorities targets including a 40% reduction in death and serious injuries and a 50%
      reduction in child deaths.
•     The Department of Trade and Industry is responsible for the prevention of home
      injuries, and publishes an annual report1 2 .
•     The Home Office is concerned with fire safety policy.
•     The Health and Safety Executive is responsible for ensuring that risks to people’s
      health and safety from work activities are properly controlled.
Many other policies such as the New Deal for Communities or the Sure Start programme
may play a significant part in reducing injury rates in deprived communities.

Evidence of what works
There is a large body of research evidence of effective interventions to reduce injuries1 3 .
For example, the NHS Centre for Reviews & Dissemination identified the following useful
evidence.
•     Community-wide campaigns which use local injury data have resulted in a reduction
      in the reported incidence of injuries in the home.
•     Area-wide traffic schemes in the UK (such as traffic calming) appear to have
      resulted in some reduction in pedestrian injuries and can reduce the total number of
      collisions by 10%.
•     Child resistant container closures have been shown to reduce home injuries.

However, there is little or no evidence on effective interventions to reduce the health gap
in injury between deprived and non-deprived populations. One of the few examples in
the NHS Centre for Reviews & Dissemination review was that there is some evidence that
injury prevention committees in high risk, deprived populations reduce injuries.

Deprivation and injury in Avon
Overall, Avon’s relatively prosperous population is reflected in rates of unintentional
injury and death from injuries which are slightly better than the national average.
Between 1997 and 1999, Avon had a lower death rate (17.2 per 100,000) than the average
for England and Wales (20.7 per 100,000).

There is some variation between the four local authorities in Avon as shown in Tables 3.2
and 3.3, which summarise Avon’s baseline position and targets in terms of the Saving
Lives targets. They show that rates of both deaths and hospital admissions from injuries
are highest in Bristol.


12
     Department of Trade and Industry (2001) Working for a Safer World: 23rd Annual Report of the
     Home and Leisure Accident Surveillance System – 1999 Data. London: Department of Trade and
     Industry
13
     Health Development Agency (2001) What Works in Preventing Unintentional Injuries in Children
     and Young Adults: An Updated Systematic Review. London: Health Development Agency
     NHS Centre for Reviews and Dissemination (2000) Evidence From Systematic Reviews of
     Research Relevant to Implementing the ‘Wider Public Health’ Agenda. York: NHS Centre for
     Reviews & Dissemination
     Towner, E et al (1996) Preventing unintentional injuries in children and young adolescents.
     Effective Health Care 2(5): 1-16                                                               31
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      Table 3.2: Deaths from unintentional injury (all ages) 1995-97

      Baseline rates/numbers and 2010 targets for Avon local authorities
                                   European standard rate/100,000 population*                            Number of deaths
       Local Authority            3 year average          2010            Target rate            3 year   2010 Reduction
                                     1995-97**            Target           reduction             average Targets in numbers
       Bath & North East
       Somerset                         16.35              13.08                                    32           28            4
       Bristol                          16.81              13.45                                    76           64            12
       North Somerset                   15.74              12.60                 20%                37           30            7
       South
       Gloucestershire                  13.20              10.56                                    34           33            1***
       Avon Health
       Authority                        15.56              12.44                                    179          155           24

      *          This column provides an age-standardised rate for injury deaths.
      **         Three year averages are used as the relatively small number of deaths for individual years will be more susceptible
                 to random variation.
      ***        Although the target reduction in the death rate for South Gloucestershire is the same as for the other local authority
                 areas (20%), because of the expected increase in the South Gloucestershire population, particularly amongst older
                 people, the absolute number of injuries will not show a significant decrease.
      Source: ONS


      Table 3.3: Admissions to hospital for unintentional injuries (all ages)
      1996/97
      Baseline rates/numbers and 2010 targets for Avon local authorities
                                   European standard rate/100,000 population*                            Number of deaths
       Local Authority                1996/97              2010           Target rate           1996/97 2010 Reduction
                                      base year           Target          reduction             base year Targets in numbers
       Bath & North East
       Somerset                         311.78            280.60                                     735        697              38
       Bristol                          359.15            323.23                                    1841       1748              93
       North Somerset                   300.12            270.11                 20%                 820        786              34
       South
       Gloucestershire                  343.43            309/09                                     912       1073            -161**
       Avon Health
       Authority                        333.51            300.16                                    4308       4304                4

      *          This column provides an age-standardised rate hospital admission for injury.
      ***        Although the target reduction in the rate of injuries for South Gloucestershire is the same as for the other local
                 authority areas (10%), because of the expected increase in the South Gloucestershire population, particularly
                 amongst older people, the absolute number of injuries is expected to increase.
      Source: Inpatient files, Avon Health Authority

      Rates of injury and death from injuries at a local authority level, however, mask even
      greater variation between more local neighbourhoods and communities. It is useful to
      identify inequality at the level of enumeration districts (areas containing approximately
      250-500 people used in the census). Figure 3.3 shows hospital admission rates for serious
      injuries (requiring a stay in hospital for at least three days) in Avon comparing the most
      and least deprived quintiles (fifths) of the Avon population. There is a consistent
      correlation between areas with higher levels of deprivation and higher rates of serious
      injury for all ages, including under 15s and young people aged 15-24.
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        Figure 3.3: Relationship between deprivation and admissions for serious
        injury between 97/98 and 99/00 in Avon

                                         300
directly standardised rate per 100,000




                                         250                                                             0-14

                                         200                                                             15-24

                                                                                                         All Ages
                                         150

                                         100

                                          50
                                               Most affluent         Average           Most deprived
                                                 quintile                                quintile

        Source: Inpatient files, Avon Health Authority.


        Action on reducing the health gap on injuries in Avon
        Action on reducing injuries in Avon is coordinated through Avonsafe – Action for Safety, a
        multi-agency injury prevention alliance. A range of injury prevention programmes and
        activities take place across Avon and within local authority partnership areas. Road safety
        schemes, for example, are integral to all the local authority Local Transport Plans.
        Specific work for children and young people includes:
        •     the development of low cost child safety equipment purchase schemes;
        •     support for the Lifeskills – Learning for Living Centre;
        •     promotion of safer routes/walk to school programmes;
        •     involvement in speed and drink driving campaigns;
        •     support for education courses aimed at developing young people’s knowledge and
              skills.
        Specific work for older people is focusing on:
        •     implementing the National Service Framework for Older People standard for
              reducing the number of falls;
        •     supplying accessible safety information;
        •     supporting and developing home environment check schemes;
        •     providing and fitting free smoke alarms;
        •     providing programmes for older people at the Lifeskills – Learning for Living Centre.

        What more do we need to do?
        The links between deprivation and injury are complex and deep-rooted. The most
        deprived communities in Avon, which are also the communities experiencing the worst
        injury rates, are well known and are currently the focus of a range of regeneration and
        health improvement initiatives (see Sections 3.1 Action on Tackling Inequalities and 3.2
        Regeneration and Neighbourhood Renewal). Many of these areas have also been
        specifically targeted for injury prevention initiatives (such as low cost safety equipment
        and subsidised access for schools to Lifeskills – Learning for Living Centre).
        There is little evidence on the relative value of broad based regeneration versus targeted
        injury prevention initiatives in deprived communities. Both are likely to be necessary. In
        any case, the need remains to identify, implement and evaluate evidence based
        interventions to reduce injury in deprived communities.                                                     33
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      3.4: Inequalities in Oral Health

      People need good oral health and a functioning set of teeth so that they can eat, speak
      and socialise without active disease, discomfort or embarrassment. Dramatic
      improvements in dental health have taken place in the past thirty years in both children
      and adults but inequalities exist in levels of oral health and in access to dental services.

      Inequalities in dental decay, gum disease and dental injury
      The need for dental treatment has changed, with most children and younger adults now
      requiring minimal treatment. Middle aged and older people who have experienced dental
      disease in younger life have damaged teeth that often require continuing and complex
      treatment to save or replace them. However, those living in areas of relative deprivation
      may have higher levels of dental decay, gum disease and dental injury and consequently
      need more treatment. This inequality of dental disease and injury is compounded by
      inequality of access to treatment services.

      There are socio-economic differences in the exposure to all the risk factors for dental
      disease, which are:
      •     the frequency of intake of sugars;
      •     oral cleanliness;
      •     smoking.

      Vitamins A and C may have some protective benefit from oral cancer.

      Oral health in adults
      Changes in oral health are well described nationally and locally through an ongoing
      programme of epidemiological surveys. These surveys show significant improvements in
      oral health with more adults keeping their own teeth with less untreated disease.

      Table 3.4 shows the changes in numbers of adults aged 55 to 64 years who have lost their
      teeth, usually through dental decay. However, the average number of restored teeth is
      more than twelve per person.

      Table 3.4: Percentage of 55 – 64 year-olds who have lost all of their
      natural teeth


                      1968                               1978         1988                1998

                      64%                                48%          37%                 20%

      Source: Adult Dental Health Survey 1998 ONS 2000


      But there are social class inequalities in decay experience and total loss of teeth – only 5%
      of men from non manual background compared to 27% women from unskilled backgrounds
      had lost all of their natural teeth.

      It also appears that people in professional classes receive more fillings whereas those in
      manual classes receive more extractions.


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Oral health in children
Surveys of children’s teeth also show dramatic improvements but unfortunately dental
decay is still prevalent. The latest survey – the National Diet and Nutrition Survey 1 4 of
young people published in 2000 – showed that 67% of fifteen to eighteen year olds had
some experience of dental decay although most of it had been treated.

Table 3.5 shows the overall reduction in dental decay in twelve year olds over the past
twenty years1 5 .

Table 3.5: Percentage of 12 year olds with dental decay experience


              1973                             1983                           1993

              93%                              79%                            50%



Although there have been significant reductions in dental decay in five year olds, the
decay mainly lies untreated. Decayed milk (baby) teeth, which can be painful and cause
infection, should be treated pending the eruption of permanent teeth by the age of
twelve. Only 12% of decay in milk teeth had been treated at the time of the survey dental
examination.

The widening oral health gap
Local dental surveys, which are co-ordinated nationally through the British Association for
the Study of Community Dentistry, have demonstrated similar improvements in oral
health. Although oral health in disadvantaged groups has also improved, they experience
a higher proportion of unmet need for treatment, more missing teeth and fewer filled
teeth. The health gap between the more and less disadvantaged groups appears to have
widened1 6 .

Figures 3.4 and 3.5 show the decay experience in two areas of Avon in 1999 following a
school dental screening exercise. One area – BS13 – is an area of relative deprivation in
south west Bristol which includes Hartcliffe, Withywood, Highridge and Bedminster Down.
The other area – BS20 – is a more affluent area in North Somerset which includes Pill,
Easton-in Gordano and Portishead. (The Index of Deprivation 2000 from National
Statistics Neighbourhood Statistics lists BS13 as 1,036 and BS20 as 6,310 of the total 8,414
wards - the lower the rank number, the more deprived the neighbourhood, so BS13 is
ranked as considerably more deprived than BS20).




14
     Walker A; Gregory J, Bradnock G, Nunn J, White D (2000) National Diet and Nutrition Survey;
     young people aged 4 to 18 years. Volume 2 Report of the oral health survey. London: The
     Stationery Office
15
     O’Brien M (1994) Children’s Dental Health in the United Kingdom 1993. London: HMSO.
16
     Watt R & Sheiham A (1999) Inequalities in oral health: a review of the evidence and
     recommendations for action. British Dental Journal Volume 187, No. 1.
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      Figure 3.4: Proportion of 5 year old children with decayed teeth in
      schools in postal district BS13


       100

           80

           60

           40

           20

            0
                  1       2        3        4     5    6        7       8       9       10
                                                School



      Figure 3.5: Proportion of 5 year old children with decayed teeth in
      schools in postal district BS20

       100
        90
        80
        70
        60
        50
        40
        30
        20
        10
         0
                      1        2            3        4         5            6       7
                                                 School

      There is some evidence that there are higher levels of dental decay in black and minority
      ethnic groups particularly in preschool children1 7 . However, the key issue seems to be
      socio-economic environments rather than ethnicity. Asian children appear to have
      relatively higher decay rates in their milk teeth and a relatively lower rate in their
      permanent teeth. This perhaps indicates an element of cultural and behavioural
      influences on oral health, probably related to snack-food choices and rewards. Access to
      dental services and dental registration of children in these groups is often lower than in
      white children.


      17
           Department of Health (2000) Modernising NHS Dentistry – Implementing the NHS Plan.
           www.doh.gov.uk/dental/strategy


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Inequalities of access to dental health services
The problem of poorer oral health is compounded by access to dental services. Many NHS
dental surgeries are not accessible for patients with disabilities.

It is noteworthy that NHS dentists are largely paid on a fee for item of service basis and
they have freedom to practice where the demand for their services is greatest – and
demand tends to come most from more affluent areas. For example, the postal district of
BS13 has two dental practices whereas BS20 has four.

Access to NHS dental services generally has deteriorated with dentists shifting towards
private work. The British Dental Association surveys show that in 1993 75% of dentists
who undertake NHS work said they received at least 75% of their earning from the NHS,
but by 1999 that figure had reduced to 58%. There is no doubt the figure is much lower in
southern England.

Improvements in oral health have largely occurred as a result of fluoride toothpaste and
changes in social and economic circumstances. As treatment services have little bearing
on the incidence of disease, we need to focus on prevention. Improving oral health and
reducing inequalities are only likely to be achieved through effective and appropriate oral
health promotion policies.

National policies
Reducing inequalities is currently one of the main health policy issues. The dental
strategy, Modernising NHS Dentistry – Implementing the NHS Plan includes the following
key elements:
•     targets to reduce the incidence of dental decay particularly in children;
•     acknowledgement that inequalities exist between more and less deprived areas;
•     encouragement to use Health Action Zones and Healthy Living Centres to promote
      oral health;
•     the need to address black and minority ethnic issues locally;
•     the need to improve access to dental services;
•     a promise to review fluoridation of water supplies;
•     a promise to review the dental workforce and its working patterns.

The Disability Discrimination Act contains new requirements for dentists to make their
surgeries more accessible to disabled people. The new strategy for people with learning
disabilities, Valuing people1 8 , emphasises the importance of good oral health and the
need to incorporate oral health in their personal action plans.




18
     Department of Health (2001) Valuing People: A New Strategy for Learning Disability for the 21st
     Century. DoH Cm 5086. www.doh.gov.uk/learningdisabilities/strategy.htm


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      Local action
      •    Better access to NHS dental services
           Avon Health Authority is improving access to dental services particularly in areas of
           greatest need. The current dental action plan agreed with the Department of
           Health (DoH) is to provide new surgeries in Bristol, Bath and Radstock under the
           Dental Access Centres/Personal Dental Services initiative. New proposals have been
           made to the DoH to expand current provision. Priority will be attached to use funds
           from the DoH to improve local service availability in areas of high need with few
           dentists and to improve access to surgeries for people with disabilities. We will
           agree new contractual arrangements with local general dental practitioners to
           reduce inequalities of access to NHS dental services.

      •         Primary care and community dental services
                Primary care dental services including the Community Dental Service will be
                reviewed to ensure they deliver a complementary service to the General Dental
                Service.

                Improving the service for people with learning disabilities will be an important part
                of the review. The Community Dental Service will need to work with local
                authorities on Joint Investment Plans emphasising the need for oral health
                promotion in developing personal action plans including the role of carers.
                Following a needs assessment, a more user-friendly service integrating the different
                branches of dental services should be developed. At ground level the service should
                work more closely with Community Learning Disabilities teams, social services and
                the voluntary sector.

      •         Oral health promotion
                The oral health promotion service will be reviewed to ensure that the delivery of
                this small service is in line with the principles of the Ottawa Charter (strengthening
                community action, building healthy public policies, creating supportive
                environments, developing personal skills and re-orienting service delivery). Our aim
                is to work with Health Promotion Service Avon, using a common risk factor approach
                focussing on diet, hygiene, smoking, injury prevention and developing personal
                skills. A key objective is to reduce inequalities.

      •         Moving from a demand-led to a needs-led service
                We will need to improve local oral health needs assessment information through
                local dental surveys ensuring that planning is based on sound needs assessment,
                encouraging a shift away from a purely demand-led service.




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Section 4                      Improving Health

This section focuses on three important common diseases: diabetes, cancer and heart
disease. Nationally and locally, attention has been given to prevention, reducing risks of
developing disease, detecting it early and improving services.

4.1 Diabetes


    Diabetes is a condition in which the body is unable to control the amount of sugar in
    the blood. There are three types:
    • type 1 diabetes (previously known as Insulin Dependent Diabetes Mellitus -
        IDDM) affects children and younger adults. They lack insulin;
    • type 2 diabetes (previously known as Non-Insulin Dependent Diabetes Mellitus -
        NIDDM) tends to affect people over 40. They may lack insulin, or their insulin
        may not work properly;
    • during pregnancy, some women develop temporary ‘gestational diabetes’.


Diabetes is a common condition which can have serious complications. People with
diabetes are at higher risk of damage to nerves and blood vessels. This can lead to heart
disease, stroke, loss of eyesight, foot ulceration (in some cases leading to amputation)
and kidney disease.

Diabetes appears to be increasing. GP reports suggest that in 1999/2000 over 1 in 50
people in Avon – 2.1% of GP patients - were known to have diabetes. This was an increase
from 1.6% in 1995. Nearly 75% of these people have type 2 diabetes.

However, these numbers are an underestimate because people can have diabetes for
years without realising it. Research suggests that there are as many people with
undiagnosed diabetes as there are with a known diagnosis. Delay in diagnosing diabetes is
serious because up to half of newly-diagnosed people already have evidence of organ or
tissue damage.

The growth in the registered diabetic population in Avon over recent years is greater than
the increase in the Avon population, and this trend is mirrored throughout the UK and
globally. This could reflect a real increase, migration, the fact that people with diabetes
are living longer, better diagnosis, improved recording, better statistical returns to Avon
Health Authority - or a combination of these. Most professionals feel that there is a real
increase in cases of both type 1 and type 2 diabetes throughout the country.

Impact of diabetes in Avon
Diabetes is not spread evenly across the population: prevalence varies between areas and
ethnic groups. GPs report considerable variation across the twelve former Primary Care
Groups (PCGs) in Avon. This is shown in Table 4.1, where in Bristol Inner City the
percentage of the population reported to have diabetes is about three times that for
Bristol West.




                                                                                              39
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        the
     health
     of the                                             Section 4 - Improving Health
population

      Table 4.1: Number of registered patients with diabetes reported by
      Avon GPs, year ending March 2000.

       Current Primary Care Groups                              People with                Total              % population with
       and Primary Care Trusts in Avon                           diabetes                Population               diabetes
       Bath & North East Somerset PCT                             3,883                     183,854                        2.1
       Bristol North PCG                                          5,492                     226,618                        2.4
       Bristol South & West PCG                                   4,088                     202,737                        2.0
       North Somerset PCG                                         3,901                     187,922                        2.1
       South Gloucestershire PCT                                  4,828                     237,265                        2.0

       Former Primary Care Groups                               People with                Total              % population with
                                                                 diabetes                Population               diabetes
       Bath PCG                                                   2,044                   102,213                          2.0
       Bristol East PCG                                           1,682                    70,400                          2.4
       Bristol Inner City PCG                                     1,584                    53,169                          3.0
       Bristol North West PCG                                     2,619                   119,783                          2.2
       Bristol South East PCG                                     1,503                    66,864                          2.2
       Bristol South PCG                                          2,032                    79,023                          2.6
       Bristol West PCG                                             553                    56,850                          1.0
       Greater Wansdyke PCG                                       1,839                    81,641                          2.3
       Severnvale PCG                                             1,217                    68,215                          1.8
       South East Gloucestershire PCG                             3,218                   152,316                          2.1
       Weston Super Mare PCG                                      1,660                    81,714                          2.0
       Woodspring PCG                                             2,241                   106,208                          2.1
       Avon                                                       22,192                1,038,396                          2.1

      Source: Avon GP reports for the Chronic Disease Management Scheme for diabetes. Avon Health Authority Information Department.

      Diabetes is commoner in the Inner City, partly due to the relatively high number of people
      from minority ethnic groups. Relatively greater levels of unemployment, lower income
      and educational attainment are an important consideration. Research has shown that
      poorer control of diabetes and death rates are higher amongst people with diabetes from
      lower social class groups and from those who are less well educated.

      About half of all deaths in people with diabetes are due to heart disease, for which
      diabetes is a risk factor. Diabetes shortens life expectancy, but improving heart disease
      risk factors (being physically active, stopping smoking and reducing blood pressure and
      blood lipids) can improve survival. The remainder of deaths are due to other
      complications of diabetes, including kidney failure and infection.

      Between 1995 and 1999, 487 deaths due to diabetes were recorded amongst Avon
      residents. Almost 90% of these deaths were in people aged over 65. Diabetes contributes
      to further deaths, but may not be registered as the main cause. Figure 4.1 only includes
      deaths where diabetes is stated as the main cause.

40
                                                                                                                                                           2001
                                                                                                                                                                           the
                                                                                                                                                                      health
                                                             Section 4 - Improving Health                                                                                 of the
                                                                                                                                                                     population

In Figure 4.1 the standardised mortality ratio compares the number of deaths from
diabetes in each PCG with the Avon population (allowing for differences in age and sex).
The ratios were significantly higher for Bristol Inner City, reflecting the higher number of
people with diabetes show in Table 4.1. The actual numbers of deaths due to diabetes in
Bristol Inner City during 1995 -1999 were nine in people aged 64 years or less, and 49 in
people aged 65 years or over.

Figure 4.1: Mortality from Diabetes in Avon
Numbers of deaths and standardised mortality ratios where diabetes was main cause of
death, Avon residents 1995 -1999.


                               800

                               700
                               600
standardised mortality ratio




                               500

                               400
                               300
                               200

                               100
                                 0
                                       th




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                                                            Persons aged 65 and over                          Persons aged 64 and under
Source: ONS death registrations


Diabetes complications
Diabetes can lead to serious complications.

•                                     1999 data from the UK Renal Registry reports diabetes as the commonest single
                                      cause of end stage renal (kidney) failure amongst adults starting on renal
                                      replacement therapy (accounting for 16% of the total).
•                                     We do not know how many people in Avon have lost their sight due to diabetes.
                                      But by implementing a programme of specific eye tests (retinal photography), we
                                      estimate that within ten years up to 300 people would have blindness prevented.
                                      Despite screening and treatment, a small number of people would still lose their
                                      sight, as this cannot be prevented in all cases.
•                                     Poor blood supply (‘peripheral vascular disease’ or PVD) and damage to the nerve
                                      supply (neuropathy) of the lower limbs are relatively common complications. An
                                      estimated 20% men and 25% women with type 2 diabetes have PVD; estimates for
                                      people with type 1 diabetes are lower. Peripheral neuropathy becomes commoner
                                      with age, rising from 5% of 20-29 year old, to 60% of 80-89 year old people with
                                      diabetes.
A survey of 40 practices in Avon and Somerset has shown that the risk of developing
diabetes eye disease is related to socio-economic factors. Lower levels of education and
income are associated with higher risks of eye and heart disease. Less advantaged
individuals have more ill health but appear to use specialist care less.

                                                                                                                                                                                   41
2001
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     of the                            Section 4 - Improving Health
population

      Diabetes and minority ethnic groups
      The prevalence of diabetes varies between different ethnic groups.
      •    A 1999 national survey of health of minority ethnic groups found that South Asian
           men and women had the highest rates of diabetes, with Pakistanis and Bangladeshis
           of both sexes being five times more likely to develop diabetes compared with the
           general population. Indian men and women were three times more likely, and Black
           Caribbean men and women were more than twice and four times more likely to have
           diabetes respectively.
      •    Rates amongst Chinese and Irish people were not significantly raised above the
           general population level.
      •    With the exception of Black Caribbean people, all groups were achieving physical
           activity levels below the general population.
      •    Central obesity (excess weight particularly around the waist) is associated with
           higher risk of diabetes. South Asian men were more likely to have central obesity
           than the general population. Central obesity in women was commoner than in the
           general population for all minority ethnic groups at higher risk of diabetes.
      •    A Bristol black and ethnic minority health survey ten years ago found that 8% of
           respondents aged 18 to 64 had diabetes. Two out of three of this group did not
           experience difficulty attending the surgery for care. Further investigation found
           that patients from different backgrounds received the same level of routine
           diabetes examinations, but that South Asian women faced particular barriers to
           achieving higher levels of physical activity.


          Inequalities issues and diabetes
          • The risk of developing diabetes varies between ethnic groups.
          • The risk of complications is associated with lower educational attainment and
              lower income.
          • Quality of care varies between practices and services, with different levels of
              access to annual review checks and specialist support.
          • A diabetic retinopathy screening programme is needed district wide. Only
              Weston and Bath have programmes at present.


      Improving health care for people with diabetes
      We expect the Department of Health to publish a National Service Framework for
      Diabetes later this year. Its goals will be to:
      •    decrease the incidence of type 2 diabetes;
      •    improve health outcomes for people with diabetes;
      •    reduce unacceptable variations in the quality of services for people with diabetes.

      Responding to user needs is particularly relevant to diabetes. Once developed, it is a life
      long condition where people have to learn about and manage their own diabetes; services
      can only assist. A study of user views was commissioned to inform the National Service
      Framework, involving people with diabetes from eight centres, including Bristol. The
      detailed report provides vivid insights into the challenge of learning to live with and
      manage diabetes. Three suggestions are based on user views and experiences:
      •     improving information and support, recognising the need for diversity and longer
            timescales in the way information is provided;



42
                                                                          2001
                                                                                     the
                                                                                  health
                    Section 4 - Improving Health                                   of the
                                                                               population

•    improving diabetes services: respondents wanted greater levels of expertise, more
     time with health professionals, more efficient and effective clinic organisation, and
     more supportive, friendly services;
•    improving access to repeat prescriptions, developing more user friendly services and
     reducing battles and barriers.

The main messages in the report are consistent with a local user survey in the 1990s.
People want improved quality of service: friendlier, working with rather than against the
patients’ own knowledge of diabetes, with more flexibility in the way that information
and repeat prescriptions are offered.

Improving prevention
There are some clear messages about preventing diabetes and preventing complications in
people who already have it.
•    Increasing physical activity and reducing obesity will help to prevent type 2 diabetes
     which is becoming more common.
•    Access to good advice and effective health care is a priority in order to reduce the
     risk of developing complications and to detect and treat complications at an early
     stage.
•    Particularly important are annual eye tests, special attention to feet to avoid foot
     ulcers, and reduction of raised blood pressure and blood sugar levels.

Local issues
As we anticipate the diabetes National Service Framework, we face increasing problems
of a growth in the population with diabetes, under-provision of services, inequalities in
health outcomes and access to services.

There are local strengths that we can build upon:
•    health promotion programmes involving NHS and local authorities to promote active
     living, for example through leisure services, education, transport planning and
     regeneration schemes;
•    high uptake of the national chronic disease management for diabetes by general
     practices – 99% of practices work within this scheme;
•    a good record of primary care audit of the quality of diabetes care;
•    local experience in surveying service user views, and enthusiasm to involve users in
     implementing the National Service Framework;
•    enthusiasm from primary and secondary care clinical staff keen to develop diabetes
     services;
•    experience in joint planning with local authorities which will be important in
     tackling National Service Framework requirements from primary health promotion
     to social care and rehabilitation.

The greatest challenges will include:
•    planning and funding service developments;
•    changing the way we offer services to be more responsive to users, through a
     combination of cultural change and achieving higher levels of expertise. In primary
     care, this has to be considered alongside the requirement to provide a full range of
     general medical services;
•    effective action on inequalities in diabetes outcomes and care.



                                                                                              43
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     health
     of the                            Section 4 - Improving Health
population

      Sources and further information
      Diabetes UK http://www.diabetes.org.uk/ or contact at:
      Diabetes UK Central Office
      10 Queen Anne Street, London W1G 9LH
      Tel: 020 7323 1531
      Fax: 020 7637 3644
      E-mail: info@diabetes.org.uk

      Chatuverdi N et al (1998) Socioeconomic gradient in morbidity and mortality in people
      with diabetes. BMJ 316:100-6

      Eachus J et al (1996) Deprivation and cause specific morbidity: evidence from the
      Somerset and Avon survey of health. BMJ 312:287-292 (Note: further research is in
      progress.)

      Erens B, Primatesta P, Prior G (editors) (2001) Health survey for England: the health of
      minority ethnic groups 99. Great Britain. Department of Health National Centre for Social
      Research Joint Health Surveys Unit. Royal Free and University College Medical School,
      London Department of Epidemiology and Public Health. ISBN 0113224486. The full
      national survey report is available via
      http://www.official-documents.co.uk/document/doh/survey99/hse99.htm

      Pilgrim S, Fenton S, Hughes AO, Hine C, Tibbs N (1993) The Bristol black and ethnic
      minorities health survey report. Bristol: University of Bristol Departments of Sociology
      and Epidemiology and Public Health Medicine

      Audit Commission (2000) Testing times: a review of diabetes services in England and
      Wales. London: Audit Commission http://www.audit-commission.gov.uk

      Ansell D, Feest T (editors). UK Renal Registry Report 2000.UK Renal Registry, Bristol, UK.
      ISSN 1471-3349. http://www.renalreg.com/

      For information on the forthcoming National Service Framework for Diabetes (including
      the report on the survey of people with diabetes), see
      http://www.doh.gov.uk/nsf/diabetes/index.htm

      For national recommendations on screening for diabetic retinopathy see the National
      Screening Committee’s advice at http://www.diabetic-retinopathy.screening.nhs.uk




44
                                                                                 2001
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                              Section 4 - Improving Health                                 of the
                                                                                        population

4.2 Cancer

Cancer prevalence and trends
Table 4.2 shows the average number of new cases of cancer expected for each PCG or PCT
in Avon. The nine most common cancers are listed, with all the rest grouped as ‘other’.

Table 4.2: Average number of new cases of cancer per year

Mean annual incidence (new cases) based on 96-98 average

                              B&NES         South           North      Bristol   Bristol    Avon
                                            Gloucestershire Somerset   South &   North
                                                                       West
 Breast                       160                138         147        112      127        683
 Lung                           91               125         107        124      137        585
 Colorectal(bowel) 116                           116         125         94      125        576
 Prostate                       83                 86         93         50        84       396
 Bladder                        61                 61         49         46        55       273
 Other lower
 gastro-intestinal              52                 42         47         40        42       222
 Lymphomas                      47                 52         38         32        42       211
 Stomach                        23                 34         23         30        40       150
 Head and Neck                  25                 25         26         27        33       135
 Other                        111                  97         93         62        95       459
 Total all cancers 1002                          970         939        768      1154      4833

Note: numbers may not add up exactly because of rounding.
Source: South West Cancer Intelligence Unit




We can expect an increase in the number of people with cancer even though the death
rate for many cancers is improving. Numbers increase because more people are living long
enough to develop cancer. Figures 4.2 and 4.3 show trends in death rates for selected
cancers in women and in men. Changes due to an ageing population are corrected for by
age-standardisation.




                                                                                                    45
2001
                   the
     health
     of the                                                                                       Section 4 - Improving Health
population

      Figure 4.2: Death rates from cancer for women in England and Wales
      1971 – 1999

      Rates are age-standardised and show deaths per 1,000,000 women


                                               45
                                               40
       mortality per 100,000




                                               35
                                               30
                                                0
                                               20

                                               10
                                               15
                                               10
                                                5
                                                0
                                                    71


                                                               73


                                                                        75


                                                                              77


                                                                                        79


                                                                                                81


                                                                                                        83


                                                                                                                      85


                                                                                                                                 87


                                                                                                                                         89


                                                                                                                                                   91


                                                                                                                                                            93


                                                                                                                                                                         95


                                                                                                                                                                               97


                                                                                                                                                                                       99
                                                19


                                                             19


                                                                       19


                                                                             19


                                                                                      19


                                                                                               19


                                                                                                       19


                                                                                                                    19


                                                                                                                             19


                                                                                                                                       19


                                                                                                                                                 19


                                                                                                                                                          19


                                                                                                                                                                      19


                                                                                                                                                                              19


                                                                                                                                                                                     19
                                                            Lung                  Stomach              Colorectal                     Melanoma of skin              Breast             Cervical


      Source: Quinn M et al (2001) Cancer Trends in England and Wales 1950-1999. London: Stationery Office


      This figure shows that deaths from all the main causes of cancer in women are decreasing,
      except deaths from lung cancer which are likely to become the leading cause of death
      from cancer in women, overtaking breast cancer. This is due to the rise in women
      smoking in the last century. The national breast screening programme began around 1989
      and would be expected to make a difference after some seven years. The fall in breast
      cancer deaths began before this. Cervical screening began in the 1960s and became an
      organised national programme from 1988. There is evidence that deaths from cervix
      cancer have declined more rapidly since then.

      Figure 4.3: Death rates from cancer for men in England and Wales
      1971 – 1999

      Rates are age-standardised and show deaths per 1000,000 men
                                               120
      directly standardised rate per 100,000




                                               100


                                                80


                                                60


                                                40


                                                20


                                                    0
                                                        1


                                                                   3


                                                                       75


                                                                               7


                                                                                        79


                                                                                                  81


                                                                                                         83


                                                                                                                  85


                                                                                                                               87


                                                                                                                                          9


                                                                                                                                                   91


                                                                                                                                                            93



                                                                                                                                                                         5


                                                                                                                                                                                7


                                                                                                                                                                                       99
                                                   7


                                                                7




                                                                                7




                                                                                                                                          8




                                                                                                                                                                         9


                                                                                                                                                                                 9
                                                19


                                                             19


                                                                       19


                                                                             19


                                                                                      19


                                                                                               19


                                                                                                       19


                                                                                                                19


                                                                                                                             19


                                                                                                                                       19


                                                                                                                                                 19


                                                                                                                                                          19


                                                                                                                                                                      19


                                                                                                                                                                              19


                                                                                                                                                                                     19




                                                            Lung                     Stomach                        Colorectal                   Melanoma of skin                    Prostate


      Source: Quinn M et al (2001) Cancer Trends in England and Wales 1950-1999. London: Stationery Office


46
                                                                         2001
                                                                                    the
                                                                                health
                    Section 4 - Improving Health                                  of the
                                                                              population

Figure 4.3 shows that deaths from lung cancer are decreasing, reflecting a decrease in
smoking. For many cancers the changes over time gives clues to the causes but cannot
yet be fully explained.

Overview of cancer work in Avon
What are we doing to prevent cancer and to help people with cancer? Figure 4.4 provides
an overview of cancer work in Avon, from primary prevention and screening through to
diagnosis, treatment and care.


                                  Primary prevention
Palliative care and               Education,                   Screening
support                           information and              Routine screening
For cancer patients who           help to reduce the           programmes for breast
die and their families.           risk of cancer, such         and cervical cancer in
Many NHS and other                as avoiding smoking,         women help to detect
agencies contribute.              eating plenty of             cancers at an early
About 2,500 Avon                  fruit and vegetables         stage when they are
residents die from                and taking care in           most easily treated.
cancer each year                  the sun.                     45,000 women in Avon
                                                               have a cervical
                                                               screening test each
                                          ➤
                           ➤




                                                          ➤
                                                               year, and 29,000 have
                                                               breast screening.

 Specialised
 haematology/oncology                CANCER
 treatment
 This includes
                                     WORK IN
                                                               Primary care
 chemotherapy,                        AVON                     Consultations and
 radiotherapy, bone
                                                               management for
 marrow or peripheral
                                                               patients with
 blood stem cell
                                                               symptoms, perhaps as
 transplant at Bristol
                           ➤




                                                               many as ten times the
                                                          ➤




 Haematology and
                                                               number who actually
 Oncology Centre or the
                                                               turn out to have cancer.
 Children’s Hospital.
                                                               We estimate that there
 About 3,000 Avon
                                                               are about 40,000
 residents are treated
                                                               suspected cancers a
 each year.
                                                               year in Avon.
                               ➤




                                                      ➤




 Definitive diagnosis and treatment by
 hospital cancer teams                          Support for people with cancer
 For people with new and recurrent              Primary and secondary NHS care, and
 cancers.                                       services from other agencies.
 Over 4,000 newly diagnosed cancers in          About 14,000 Avon residents have
 Avon residents (excluding non-melanoma         cancer.
 skin cancer) are treated by hospitals
 each year.
                                                                                           47
2001
          the
     health
     of the                                Section 4 - Improving Health
population

      Figure 4.4: Cancer work in Avon
      Commissioning cancer services
      In the past Avon Health Authority has been responsible for commissioning services and
      preventive programmes for cancer. This means agreeing the amount and quality of a
      service that a supplier (such as an NHS Trust) will provide for a specified sum of money.
      Commissioning also involves monitoring services and agreeing any changes with the
      provider.

      PCGs and PCTs are now taking on responsibility for commissioning cancer services along
      with all other services for their local populations. Bringing local GP and community health
      services into single organisations should mean that services can be organised in a more
      streamlined and efficient way. A close working relationship with social services, local
      voluntary agencies and patient support and self-help groups will enable better care for
      people with cancer.

      Commissioning cancer services involves many elements. First, we need an overall plan for
      improving cancer services. This has to incorporate the specialists’ views of how services
      should be delivered to achieve best outcomes for patients. It also must incorporate the
      patients’ views about the kind of support, treatment choices, and information they want
      from health and social services. In addition we must take into account the requirements
      for education and training, research, and for information systems to support and monitor
      the whole process.

      In order for this overall plan to become reality, we need to divide it into manageable parts
      and turn these into costed proposals for each of the different NHS organisations involved
      in cancer care. Funding then has to be secured and service agreements established. We
      also need a constant process of asking how services are doing in meeting the standards we
      would expect if it was our family or friend on the receiving end. Continued effort is
      needed to make sure that staff and different organisations always communicate well and
      work cooperatively together.

      The establishment of PCTs, coinciding with publication of the NHS Cancer Plan 1 and the
      national Manual of Cancer Services Standards 2, brings an ideal opportunity to combine all
      these elements into an integrated programme for improving the care and experience for
      patients with cancer, their families and carers.

      The Patient Pathway
      For any patient there can be many staff and many organisations contributing to their care.
      The case of Mr P shown in Figure 4.5 illustrates this. It is quite a task to ensure that all
      the services work constructively together, and communicate well with the patient and his
      or her family and with each other. At present many of our services are not fully accessible
      for patients whose first language is not English, or who have specific cultural needs. This
      needs to improve.




      1
          Department of Health (2000) The NHS Cancer Plan. www.doh.gov.uk/cancer/cancerplan.htm
      2
          National Cancer Programme (2000) Manual of Cancer Services Standards.
          www.doh.gov.uk/cancer/mcss.htm


48
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                                                                                                              health
                          Section 4 - Improving Health                                                         of the
                                                                                                         population

Figure 4.5: The Cancer Patient Pathway

                                   ➚           After two months, things are no




                                                                                 ➚
   Mr P, who has a number of                   better. The GP arranges a chest
  health problems, goes to his                        x-ray at Hospital A.
   GP with vague symptoms.

                                                                 ➚           The x-ray department telephones
                                                                              the practice. There is a possible
                                                                               cancer on the chest x-ray. The
                                                                               practice nurse gets a message
                     The GP telephones the patient at home                   straight to the GP who arranges a
                      that evening and suggests he comes to                 faxed referral to Hospital B fifteen
                    surgery with his wife the next morning. At               miles away where there is a Lung
                      that consultation the GP explains that                           Cancer Team.
                       cancer is a possibility, gives him his
                    appointment the following week with the
                    Lung Cancer Team, and suggests that Mr P
           ➚            comes back to see her after that.


                                                                  The Lung Consultant fixes for Mr P to see
                                                                  a surgeon at Hospital C thirty miles away,

                                                      ➚
       Mr P goes to Hospital B for his
  appointment, sees the consultant and a                           and an oncologist who he sees in a clinic
  specialist nurse. He has an appointment                            at Hospital B. Mr P and his wife have
      arranged for bronchoscopy. The                               many fears and questions, which the GP
   specialist nurse explains a lot of what                                 tries her best to answer.
   may happen, and gives Mr P her phone
                  number.                                ➚
          The surgeon advises Mr P that surgery is not
             the best option and instead a course of
          chemotherapy is arranged at the day-unit in
                                                            ➚           The GP visits Mr P at home. She asks
                                                                        the district nurses to visit and seeks
                                                                        advice from the Specialist Palliative
                                                                       Care Team based at Hospital B. They
          Hospital B. There is a wait of several weeks                    fix for a visit by an occupational
              before this can begin. Mr P finds the                    therapist, who arranges a wheelchair
           chemotherapy quite hard to cope with, he                      and the GP arranges home oxygen.
         has lost a lot of weight, and is troubled by his                This makes it much easier for Mr P
          cough and extreme tiredness. The transport                            and his wife to cope.
          to the hospital is almost as big a problem as
                the side-effects from the drugs.
                                                      ➚
                                                                         Mr P becomes bed-bound and


      For several months Mr P is still able to manage
         to go out of the house with his wife. He is
                                                            ➚            Mrs P looks after him with help from:
                                                                         • district nurses
                                                                         • home-care assistants
                                                                         • a Marie Curie nurse who comes at
       visited by many of his family and friends. He                        night time
     realises that his condition will soon deteriorate                   • a community specialist palliative
     and wants, if possible, to stay at home. The GP                        care nurse from the local hospice
      asks for Social Services and the District Nurses                   The Gp visits regularly and Mrs P finds
     to do a joint assessment to arrange the services                    this a source of encouragement
          that will help him and his wife to cope.

                                                      ➚
                                                                   Mrs P finds the months and years after
         After a particularly difficult night, Mr P                 Mr P’s death very difficult. She visits
        dies. The District Nurse and GP both visit
        and give practical advice to Mrs P about
           the arrangements she has to make.             ➚          the GP regularly and is supported by
                                                                   friends and by her local CRUSE group


                                                                                                                         49
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      Current issues
      Drug policy
      In the past few years there have been stories in the newspapers about “postcode prescribing”
      for cancer drugs. Patients living in one area have apparently been offered a new cancer
      drug, whilst patients living elsewhere received a different treatment. Some of these stories
      have been inaccurate but some have highlighted genuine differences in funding and decision
      making about cancer treatments. The pharmaceutical industry and the popular press tend to
      create the impression that new expensive drugs are the main issue on cancer care. A greater
      need is for the staffing and overall capacity within chemotherapy services and palliative care
      so that all patients receive tried and tested affordable drugs that improve their chance of
      survival and/or reduce their symptoms.
      Cancer specialists working throughout Avon, Somerset and Wiltshire have set up a process for
      agreeing the use of new cancer drugs across all three counties. This aims to ensure that all
      patients resident in Avon, Somerset and Wiltshire are treated fairly. The Avon, Somerset and
      Wiltshire Cancer Services drug policy forum produces reports for each type of cancer and
      each report has a plain English summary published on the Avon, Somerset and Wiltshire
      Cancer Services website 3. The reports are intended to guide funding decisions across Avon,
      Somerset and Wiltshire, and to provide information for patients and professionals.
      Improving palliative care
      Making sure that all patients with cancer receive good control of their symptoms and good
      support for themselves and their families is a formidable task. It requires staff from many
      different parts of the NHS and from social services to work together. The Palliative Care
      Strategy for Adults was published in January 2001 by the Avon Palliative Care Advisory Group
      and approved by Avon Health Authority in February 2001. It is designed to help all the
      relevant agencies in the Avon area to work together to improve services for patients and their
      carers and to meet the required national standards for palliative care. A summary version of
      this strategy is available on the Avon Health Authority website.4
      National Manual of Cancer Service Standards
      The Department of Health has produced a manual of cancer service standards aiming to
      improve the quality and consistency of cancer care. These standards cover ten topics which
      span the patient pathway and the organisation of cancer services. All NHS Trusts have to
      complete self-assessments saying how well they are managing to meet the standards. The
      NHS Executive Regional Offices are organising formal visits to each network of cancer services
      to see how well each network meets the standards.
      Planning for cancer surgery, radiotherapy and chemotherapy
      Some cancer treatment needs to be provided in centres covering a large catchment area,
      either because the equipment (such as linear accelerators for radiotherapy) is highly
      expensive and needs specialist medical physics support, or because procedures are rare and
      best results are produced by a dedicated team who have the experience of dealing with many
      cases.
      The way these services are configured has implications for many other related services.
      Planning ahead to ensure that high quality specialised surgery, radiotherapy and
      chemotherapy services are in place for all residents who need them is a challenge and these
      services are expensive. It is important to take a long-term view about what can and should
      be afforded as part of an overall balanced range of services that improves the quality of life
      for people with cancer. PCGs and PCTs need to be involved in these planning processes.
      3
          www.aswcs.nhs.uk
      4
          www.avonhealth.org.uk
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                                                                                         population

4.3 Heart Disease

This section focuses on a specific aspect of work on heart disease: the Health
Improvement Programme (HImP) Performance Scheme for Coronary Heart Disease (CHD).

This scheme is a three year project which started in November 2000 to address health
inequalities in coronary heart disease. The benefits of declining rates of CHD deaths in
England and Wales have not been experienced equally. Death rates of unskilled men from
CHD are now three times higher than those of professional men.

Avon Health Authority is one of three health authorities in the south west region which
gained funding in April 2000 from the Regional Office of the NHS Executive for work on the
National Service Framework for CHD 5. Avon Health Authority has been awarded £445,000
per year for three years, in recognition of Avon health community’s progress in tackling
entrenched problems of ill-health and deprivation.

The HImP Performance Scheme for Avon has four main areas of work, described below.

1. Improving access to effective secondary prevention of CHD
Fifty-four general practices in Avon have been selected on the basis of deprivation
indicators for additional support to improve access to effective secondary prevention of
CHD.

The support includes:
•    additional help with information and technology;
•    training practice staff;
•    practice payments for additional nursing hours to help practices meet the National
     Service Framework for CHD milestones.

In addition primary care co-ordinators in four PCGs and PCTs are supporting these
practices in their provision of CHD clinics for patients.

The majority of practices have achieved the April 2001 milestone of having a
systematically developed and maintained practice-based CHD register which will be used
to provide structured care to people with CHD. The next milestone, to be achieved by
April 2002, is for all practices to have a protocol describing the systematic assessment,
treatment and follow-up of people with CHD and to be using the protocol to provide
structured care to people with CHD.

2. Extension of programmes for primary prevention: physical activity and
breastfeeding
Physical activity
Since there is a high rate of inactivity in the population, the majority of the population
could benefit from increasing their activity. The attributable risk of physical inactivity for
CHD is considerable. In the US it has been estimated that 35% of CHD deaths could be
attributed to inactivity 6.
5
    Department of Health (1999) National Service Framework for Coronary Heart Disease. London:
    Department of Health
6
    Powell K & Blair S (1994) The public health burdens of sedentary living habits: theoretical but
    realistic estimates. Medicine and Science in Sports and Exercise, 26, 851-856
                                                                                                       51
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      The overall prevalence of physical activity in England is low. Data from the 1998 Health
      Survey for England showed that only 37% of men and 25% of women met the current
      guidelines for activity (30 minutes of activity per day on most days of the week).

      Interventions that encourage walking and do not require attendance at a special facility
      such as a leisure centre appear most likely to lead to sustained increases in physical
      activity 7. Others have found that promoting lifestyle physical activity such as walking
      leads to changes in behaviour and CHD risk factors similar to those produced by
      structured, facility-based interventions 8.

      Deprived groups are twice as likely to be sedentary as more affluent groups9. The HImP
      Performance Scheme physical activity project will target interventions in areas of high
      health need in Bristol. The work will involve partnerships with different organisations to
      support action on green transport policies to promote walking and cycling, for example.
      In addition, work will be done to co-ordinate a comprehensive strategy for physical
      activity in line with the National Service Framework for CHD.

      Breastfeeding
      There is evidence that breast feeding is preferable to bottle feeding because it gives
      protection against a range of adverse conditions often associated with adulthood,
      including obesity, CHD, insulin dependent diabetes and liver disease1 0 . Breast feeding
      rates in the UK are low compared to other countries. This project will provide practical
      support to enable more women, particularly in areas of high health need, to breast feed
      and to sustain doing so for longer.

      3. Community development
      The National Service Framework for CHD recognises the benefits of a community
      development approach for reducing health inequalities in CHD. Community development
      can be promoted by public bodies encouraging social advocacy, devolving decision-making
      and developing partnerships with the local community. Evidence suggests that
      encouraging autonomy and strengthening social networks are prerequisites for good
      health1 1 . It is essential that approaches are taken to engage with diverse and hard-to-
      reach groups.

      7
           Hillsdon M, Thorogood M & Foster C (1999) A systematic review of strategies to promote physical
           activity. In: D MacAuley (ed.) Benefits and hazards of exercise, Vol 1. London: British Medical
           Journal Publications
      8
           Dunn A, Marcus B, Kampert J, Garcia M, Kohl H & Blair S (1999) Comparison of lifestyle and
           structured interventions to promote physical activity and cardiorespiratory fitness: a randomised
           trial. Journal of the American Medical Association, 281, 327-334
      9
           Gordon D, Shaw M, Dorling D & Smith GD (eds) (1999) Inequalities in health: the evidence
           presented to the independent inquiry into inequalities in health, chaired by Sir Donald Acheson.
           Bristol: The Policy Press
      10
           Barker DJP & Osmond C (1986) Infant mortality, childhood nutrition and ischaemic heart disease.
           The Lancet 1077-1082
           Heinig J, Nommsen LA, Peerson JM, Lonnerdal B & Dewey KG. (1993) Energy and protein
           intakes of breastfed and formula fed infants during the first year of life and their association with
           growth velocity, the DARLING study. American Journal of Clinical Nutrition Vol.57 140-145
      11
           Cooper H, Arber S, Fee, L & Ginn J (1999) The influence of social support and social capital on
           health: a review and analysis of British data. London: Health Education Authority




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                                                                                      population

Community development projects do not usually focus on disease specific issues; however
it is rare for them not to address one or more important risk factors for CHD.

The HImP Performance Scheme funds a community development worker in South
Gloucestershire for two years and an extension of an existing community development
project in Lawrence Weston (Lawrence Weston Action on Health) in Bristol. These
projects are both managed by Health Promotion Service Avon.

The project worker for South Gloucestershire will work closely with colleagues in South
Gloucestershire Council. Work will continue to develop council initiatives such as the
Food Links Network and will focus on physical activity and food and health projects such
as community schemes for growing vegetables and fruit.

In Lawrence Weston the community identified concerns over a number of years about
transport, isolation, debt, lack of community resources and a need for opportunities for
volunteering. Physical activity and food were also perceived as important issues.
Lawrence Weston Action on Health project’s work reflects these needs and many
initiatives have been developed including community transport schemes, a healthy living
centre bid and support for the local credit union. The HImP performance scheme funding
will be used to develop creative food and health and physical activity projects such as
supporting the community farm, luncheon club, cooking clubs, community walks and
community food growing schemes.

4. Research to establish whether CHD interventions have the same benefits to people
of South Asian origin
South Asian groups are especially prone to CHD, with death rates from CHD at least 36%
higher in men and 46% higher in women compared to the majority white population1 2 .
The National Service Framework for CHD makes explicit the need to ensure that primary
care services for CHD patients are accessible to everyone who can benefit. This includes
ensuring that services are appropriate for the diverse cultural needs of different ethnic
communities.

This research is exploring South Asian and white patients’ knowledge, beliefs and
concerns about primary care services for CHD. It will also establish the views of primary
health care staff on CHD services for their South Asian and white patients, as well as
monitor secondary CHD prevention target measurements. The research will provide
valuable information about which approaches and interventions are most appropriate for
black and other minority ethnic patients with CHD or at high risk.




12
     Balarajan R (1991) Ethnic differences in mortality from ischaemic heart disease and
     cerebrovascular disease in England and Wales. British Medical Journal, 302: 560-564




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      Technical Notes
      Standardised Rates and Ratios
      Mortality and morbidity rates of different populations are standardised so that
      populations in different areas can be compared fairly, taking account of, for example,
      different percentages of older people or children living in areas we wish to compare.
      There are two ways of standardising mortality rates: direct standardisation and indirect
      standardisation.

      Directly standardised rates adjust for differences in age structure by applying local age
      specific rates to a standard population, which in this report is the European Standard
      Population. This way of standardisation allows direct comparison of weighted averages to
      be made between each area, and allows trends over time to be measured.

      Figure 2.2, for example, uses direct standardisation to monitor trends in death rates from
      cancer and circulatory diseases over time.

      Indirect standardisation compares actual numbers of deaths to expected numbers,
      expressed as a percentage. This is commonly called a standardised mortality ratio, or an
      SMR. The expected number of deaths are calculated from deaths rate for England and
      Wales as in Figure 2.1, or for Avon as in Figure 4.1.

      So in Figure 2.1, for example, we take 100 as the benchmark based on the England and
      Wales death rate in 1993, and show trends in premature death for Avon and the four local
      authority populations. If a value is higher than 100, there were more deaths than
      expected compared to the England and Wales death rate in 1993, and if the value is
      lower, there were fewer deaths than expected.

      Confidence limits
      We need a method of seeing whether fluctuations in figures reflect real changes, or just
      happen by chance. Figures are likely to vary a certain amount from year to year by
      chance, and confidence limits show the likely range of that variation. We have used them
      when we present figures where we cannot be absolutely certain that they show a real
      difference or trend.

      In Figures 2.3 and 2.4, for example, the line at the top of each bar – representing the
      confidence interval - shows the likely range of where the top of the bar could be. As we
      have set the line at 95% confidence limits, this means that we are 95% certain that the
      real figure lies between the range indicated by the line. But in no case is the bottom of
      the bar in one column higher than the top of the bar in the next column. This means that
      we cannot be certain that there is a real difference: it could simply be chance. This is
      why we say that the year-to-year changes are not significantly different. In Figure 3.3,
      however, we can see that the difference between the most affluent and the most
      deprived quintiles is real, because there is a wide gap between the range of the
      confidence interval bars.

      The following Figures all show confidence limits: 2.3, 2.4, 2.5, 2.6, 2.7, 3.3 and 4.1.




54
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Jargon Explained
Angina pectoris                Pain in the centre of the chest caused by heart disease.
Audit                          Systematic examination of a service in order to check
                               and if necessary improve its quality.

Avon, Somerset and Wiltshire   The principal cancer service network for people in
Cancer Services                Avon, Somerset and Wiltshire.
ASWCS

Avon health community          All NHS health organisations and workers within the
                               Avon Health Authority area, including Avon Health
                               Authority, NHS Trusts, Primary Care Groups, Primary
                               Care Trusts, GP practices, pharmacists and dentists.

Bath & North East Somerset     Bath and North East Somerset Council or geographic
B&NES                          area depending on context.

Blood lipids                   Fats in the bloodstream.

Bronchoscopy                   A procedure to look into the windpipe and bronchial
                               tubes.

Care Trust                     New NHS bodies which will provide health and social
                               care services. They will formed by the merger of local
                               authority social care services with NHS primary and
                               community health services. The first Care Trusts are
                               likely to be set up in 2002.

Carer                          A relative, neighbour, friend or anyone else who - on an
                               unpaid, regular basis - looks after a person who needs
                               support in their own home.

Chemotherapy                   Treatment of disease with chemicals such as cancer
                               destroying drugs.

Circulatory disease            Disease of the heart and blood vessels of the body,
                               causing problems in blood circulation.

Commissioning                  Acting on behalf an NHS body, such as a Health
                               Authority or a Primary Care Trust, to agree health
                               services (amount and quality) which a supplier (such as
                               an NHS Trust) will provide for a specified sum of
                               money. Commissioning also involves monitoring these
                               services and agreeing any changes with the provider.




                                                                                          55
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     of the                             Jargon Explained
population

      Community development       Working with people to identify their concerns, and
                                  support and facilitate them in collective action for the
                                  good of the community as whole.

      Community health services   Health services provided by NHS Trusts in people’s
                                  homes or from premises in the community such as GP
                                  surgeries, health centres, clinics and small community
                                  hospitals.

      Confidence limits           The range of values above and below a statistic (such
                                  as an average or percentage) within which the real
                                  value probably lies. Values outside these limits could
                                  have happened by chance. (See also Technical Notes
                                  above)

      Coronary heart disease      Heart disease caused by poor circulation of blood to
      CHD                         the heart muscle because the blood vessels have
                                  become blocked. This may show up as a heart attack
                                  or chest pain (angina).

      CRUSE                       A charity offering help to people who have been
                                  bereaved.

      Dementia                    A group of diseases of the brain when there is loss of
                                  memory and intellect.

      Department of the           A Government department concerned with the
      Environment, Transport      environment, transport and planning on a regional
      and the Regions             basis within the country.
      DETR

      Emergency admission         Admission to hospital because of sudden illness or
                                  injury, as opposed to admission for treatment or
                                  surgery which has been planned in advance (elective).

      Enumeration district        Small areas used in the census containing 250-500
                                  people.

      Epidemiology                The study of the distribution, determinants and control
                                  of ill health in populations.

      Evidence based              Based on research evidence that something works. For
                                  example, “evidence based medicine” means medical
                                  procedures based on research which shows that the
                                  treatments are likely to be successful.




56
                                                                        2001
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                            Jargon Explained                                     of the
                                                                             population

Femur                           Thigh bone.

Haematology                     The study of blood and blood disorders.

Health Action Zone              Area of high health need selected by government for
                                special funding and health programmes.
Health Authority                The statutory NHS organisation responsible for health
                                services for a defined population – Avon Health
                                Authority is responsible for the population of Bath &
                                North East Somerset, Bristol, North Somerset and South
                                Gloucestershire. It does not provide services itself, but
                                pays for them to be provided by NHS Trusts, Primary
                                Care Trusts and other organisations. It also manages
                                the contracts of local GPs, dentists, pharmacists and
                                opticians.

Health gap                      The gap between the health of the better off and worst
                                off communities.

Health Improvement              A three year rolling plan of action for the Avon Health
Programme                       Authority population to improve health and services for
HImP                            health and social care.

Health Promotion Service        Service managed by the North Bristol Trust which works
Avon                            across the Avon area, providing health promotion
HPSA                            programmes, resources and training.

Health Survey for England       A national survey which provides indications of the
                                level of health and ill health for the population.

Healthy Living Centres          Centres or networks of activity which aim to promote
                                good health, developed by partnerships with local
                                participation. They are funded from the national
                                lottery.

Incidence                       The number of new episodes of illness arising in a
                                population over a specified period of time.

Inequalities in health          The gap between the health of different population
                                groups, such as better off and more deprived
                                communities, or people with different ethnic
                                backgrounds.

Infant mortality rate           Deaths of infants under one year as a percentage of live
                                births.




                                                                                            57
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population

      Infarction                   Death of the whole or part of an organ when its blood
                                   supply is cut off e.g. myocardial infarction is the death
                                   of heart muscle (myocardium) when a blood clot
                                   obstructs the flow of blood to the heart muscle.

      Insulin                      A hormone produced by the pancreas which is
                                   important for regulating the levels of sugar in the
                                   blood.

      Jarman score                 A way of measuring deprivation in a population by
                                   looking at census data about social and economic
                                   conditions.

      Joint Investment Plan        Plan developed jointly between health and social
      JIP                          services showing investment in services for older
                                   people, mental health and learning difficulties.

      Low birth weight             The weight of a baby at birth of less than 2,500 grams.
                                   High rates of low birth weight babies in a population
                                   indicate poor health overall.

      Lymphoma                     A malignant tumour of the lymph nodes, which are
                                   small swellings, part of the lymphatic system which
                                   conveys fluids round the body.

      Morbidity                    Illness

      Mortality / mortality rate   Death / Incidence of death in a population in a given
                                   period.

      National Service Framework   National document which sets out the pattern and level
      NSF                          of service (standards) which should be provided for a
                                   major care area or disease group such as older people,
                                   mental health or heart disease.

      NHS Cancer Plan              National plan setting out priorities and standards for
                                   cancer services, including waiting times and
                                   treatments.

      NHS Executive                National top-level body responsible for running the
      NHSE                         NHS, directly accountable to the Secretary of State. It
                                   has branches and a Regional Office in each NHS region.
                                   For Avon, this is the NHS Executive South West which
                                   also covers Somerset, Devon, Cornwall, Wiltshire,
                                   Dorset and Gloucestershire.




58
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                            Jargon Explained                                     of the
                                                                             population

NHS Plan                         Government plan for the NHS published in July 2000.

NHS Trust                        An independent body within the NHS which provides
                                 health services in hospitals and in the community.
                                 Some NHS Trusts provide a range of services; other
                                 specialise in, for example, ambulance services or
                                 mental health services.

Office for National Statistics   National body which collects and publishes national
ONS                              data about, for example, population and health.

Oncology/oncologist              The study and practice of treating tumours/specialist
                                 in treating tumours.

Ottawa Charter                   A document launched in 1986 at an international World
                                 Health Organisation conference in Ottawa, Canada,
                                 which identified key themes for health promotion
                                 practice.

Palliative care                  Care which gives relief from symptoms but does not
                                 actually cure disease, such as care given to people who
                                 are terminally ill.

Patient pathway                  The process of diagnosis, treatment and care a patient
                                 goes through on a step-by-step basis.

Peripheral neuropathy            Disease affecting the parts of the nervous system lying
                                 outside the brain and spinal chord, usually causing
                                 weakness and numbness.

Peripheral vascular disease      Disease of blood vessels near the surface of the body,
                                 away from the main veins and arteries.

Premature death                  Death under 65 years of age. High rates of premature
                                 death in a population indicate poor health overall.

Prevalence                       Measure of how much illness there is in a population at
                                 a particular point in time or over a specified period of
                                 time.

Primary care                     Services which are people’s first point of contact with
                                 the NHS. They are provided by primary health care
                                 teams based in GP surgeries and by NHS Trust staff
                                 working in the community. Primary care workers
                                 include GPs, practice nurses, health visitors, district
                                 nurses and many others.




                                                                                            59
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     of the                           Jargon Explained
population

      Primary Care Group     An NHS body created from a group of GP practices,
      PCG                    which works with its local health authority. Members
                             include GPs, nurses, and representatives from social
                             services, the Health Authority and the lay public. The
                             main tasks are to assess local health needs, contribute
                             to the Health Improvement Programme, and develop
                             primary care and secondary services.

      Primary Care Trust     An NHS body developed from Primary Care Groups,
      PCT                    with additional responsibilities to commission primary,
                             community and secondary care services, and to provide
                             primary and community health services.

      Primary prevention     Stopping ill health arising in the first place, by, for
                             example, eating a healthy diet and not smoking.

      Protocol               An agreed written procedure for a specific task, which
                             ensures that everyone carrying out that task does so in
                             the same way.

      Pulmonary disease      Disease of the lungs.

      Quintile               Fifth.

      Risk factor            An attribute, such a habit (e.g. smoking) or exposure
                             to some environmental hazard, that leads to a greater
                             likelihood of developing an illness.

      Saving Lives:          National strategy for health in England, published in
      Our Healthier Nation   1999, which sets out priority areas (cancer; heart
                             disease and stroke; accidents; and mental health) and
                             sets national targets.

      Screening              The application of a special test for everyone at risk of
                             a particular disease to detect whether the disease is
                             present at an early stage. It is used for diseases where
                             early detection makes treatment more successful.

      Secondary care         Specialised care provided by hospital in patient and out
                             patient services.

      Secondary prevention   Catching ill health at an early stage so that further
                             damage can be prevented.




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                            Jargon Explained                                    of the
                                                                           population

Single Regeneration Budget      Government funding for economic and social
SRB                             development.

Standardised mortality          Death rates in which allowances have been made for
rates/ ratio                    different age structures of populations. This means
SMR                             that fair comparisons can be made between
                                populations with, for example, different proportions of
                                children or older people. (See also Technical Notes
                                above).

Sure Start                      Government schemes in areas of high health need,
                                which aim to support parents and children under four.

The Avon, Somerset and          Services working together to develop and implement
Wiltshire Cancer Services        common standards of cancer services across Avon,
network                          Somerset and Wiltshire.
ASWCS

Townsend score                  A way of measuring deprivation in a population using
                                data from the census about social and economic
                                conditions.

Vascular                        To do with blood vessels.

White Paper                     Government policy, often accompanied by legislation.
                                Usually follows a Green Paper.




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62
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    Dr Kieran Morgan, Director of Public Health, Avon Health Authority, King Square House, King Square, Bristol
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