01 Health Overview and Scrutiny Agenda 15.1.08 by vev19514

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									                         COUNCIL OF THE ISLES OF SCILLY

                                                                         Town Hall
                                                                          St Mary's
                                                                 ISLES OF SCILLY
                                                                        TR21 OLW
                                                                    7 January 2008

To:   Councillors R H Banfield, J J Goddard, M Hicks, Mrs A J Martin,
      Mrs A I Oyler and D Pearson.

To:   All other Councillors by email for information.
      Dr T Dalton for Information

Dear Member

You are requested to attend a meeting in the Council Chamber, Old Wesleyan
Chapel as follows:-

Committee:          Health Overview and Scrutiny Committee
Date and Time:      Tuesday 15 January 2008 at 9.30am

Note:
At 10.30 am a Video Conference will be undertaken with a West Country Primary
Care Trust Representative to present the consultation paper at Item 9

The Agenda is set out below. If you have any questions please contact the
Committee Secretary, Peter Laverock.

                                     Yours sincerely



                                     P S HYGATE
                                     Clerk and Chief Executive

                                 A    G   E   N   D     A
1     Declarations of Interest
2     To confirm the Minutes of the meeting of the Health Overview and
      Scrutiny Committee held on 11 September 2007 (Min No’s 530/07 to
      540/07) as a correct record. (circulated with Council 11.12.07, please
      bring the document with you)
3     Any items the Chairman considers urgent.
PART 1 REPORTS REQUIRING A DECISION
4     National Blood Service Collection - Isles of Scilly (report of the Assistant
      Chief Technical Officer enclosed)
5     Single Issue Panel - Medical Launch Update (report of the Assistant
     Chief Technical Officer enclosed)
6    Establishment of a LINk (NHS Local Involvement Network) for the Isles of
     Scilly (verbal report of the Assistant Chief Technical Officer)
7    Budget Monitoring 2007/08 (report of the Assistant Chief Technical
     Officer to follow)
8    Annual Report of the Director of Public Health for Cornwall & Isles of
     Scilly (report and presentation by Julie Moseley, Associate Public Health
     Specialist and Jane Royle enclosed )
9    “Future Shape of Cancer Services in the Peninsular” consultation paper,
     presented by Video Conference by the Primary Care Trust
10   Health Fayre (verbal report of the Assistant Chief Technical Officer)
PART 2 REPORTS FOR INFORMATION ONLY
11   Star of Life Activity Report (report of South West Ambulance Trust to
     follow)
12   Smoke Free Policy update (verbal report of the Assistant Chief Technical
     Officer)
13   Joint Strategic Needs Assessment (report of the Director of Community
     Services enclosed)
14   Health and Wellbeing Strategy (verbal report of the Assistant Chief
     Technical Officer t).
COUNCIL OF THE             HEALTH OVERVIEW             15.01.08       PART 1 DECISION
ISLES OF SCILLY              AND SCRUTINY                             ITEM 4

Title                   National Blood Service Collection – Isles of Scilly
Author                            Assistant Chief Technical Officer

1        Introduction

1.1      At the Health Overview and Scrutiny Committee meeting on 11th September
         2007 members considered the response from the National Blood Service
         Regional Collection Manager to their request for information on why the
         collection service was being withdrawn from the Isles of Scilly. Members
         resolved to:
         ask the National Blood Service if anything can be done by the Community to
         restore the blood doning facility on the Isles of Scilly and to obtain details of
         the costs involved. (Minute 534/07).

2        Information

2.1      After some difficulty in making contact with the appropriate officer in the
         National Blood Service (NBS) the Assistant Chief Technical Officer received a
         phone call from the Acting Regional Collection Manager (SW Region) to
         answer the question raised by this Committee.

2.2      The NBS is part of the National Health Service and are under pressure to
         ensure that their Collection Service is cost effective. They estimate how
         many units of blood will be required annually throughout England and from
         that figure a price per unit of blood is calculated that must equate to the costs
         involved in the collection process.

2.3      In the past the Isles of Scilly Steamship Company have provided
         transportation on the Scillonian III free of charge and British International
         Helicopters have provided free transport for blood doning staff. The RAF
         have also flown the donated blood to Plymouth without charge.

2.4      The NBS have, however, reviewed the salary and accommodation costs
         involved in providing the Isles of Scilly collections and the volume of blood
         taken does not equate to the costs involved. The figures given exemplify that
         for the costs involved in collecting blood on Scilly double the amount could be
         achieved in Penzance.

2.5      The Collection Manager also raised concerns about having the staff and
         equipment stuck on the Islands during periods of fog, a hazard which would
         have little impact on mainland collections.

2.6      The Assistant Chief Technical Officer asked about options for continuing the
         Isles of Scilly collection in a different format and the Manager agreed to
                                                              HOS – 15.1.08 – Item 4

       consider the possibility of providing a smaller Collection Unit. This could
       involve 2 – 4 members of staff who would visit twice yearly (e.g. April and
       September) but would not be programmed before 2009.

3      Financial Implications

3.1    If the mini sessions were to be introduced there would be a need to provide a
       facility locally that would remove the requirement to transport bulky equipment
       (i.e. beds, tables and screens) and afford space and power for their computer.
       Transportation costs for the necessary equipment and staff would also be a
       significant factor in ensuring the collection service was meeting its cost
       effectiveness target.


4      Recommendations

4.1    Members are invited to consider if they wish to pursue the idea of introducing
       mini sessions on the Islands.

4.2    That Members decide how to provide the necessary support to ensure the
       continuation of this service.




Implications Environmental Impact                   None as a result of this report
            Community Health Implications           None as a result of this report
            Crime and Disorder Reduction            None as a result of this report
            Best Value Implications                 None as a result of this report
            Financial Implications                  See Paragraph 3
            Legal opinion Required/ Date            Yes/No: Date
WT/ 19 November 2007                -2-
COUNCIL OF THE          HEALTH OVERVIEW             15.1.08          PART 1 DECISION
ISLES OF SCILLY           AND SCRUTINY                               ITEM 5

Title                    Single Issue Panel - Medical Launch Update
Author                           Assistant Chief Technical Officer

1        Introduction

1.1      This report is submitted for the Committee to approve the recommendations
         of its Single Issue Panel following meetings with the Medical Launch
         Trustees (MLT), South West Ambulance Services Trust (SWAST) and the
         Cornwall & Isles of Scilly Primary Care Trust (CIOSPCT).

2        Information

2.1      As a result of the Star of Life (SOL) ambulance launch being out of
         commission for 6 months, the HOSC was asked to scrutinise the situation and
         a Single Issues Panel was formed. This lead to the publication of the Report
         on the Ambulance/ Medical Launch Services.             This report and its
         recommendations were reviewed at a meeting with CIOSPCT, HOSC,
         SWAST and MLT representatives, and agreement made to work together to
         look at the options for the ambulance and medical launch services.

2.2      SWAST confirmed they were keen to work with MLT and HOSC to review a
         long-term replacement of the Star of Life ambulance boat. In addition, the
         CIOSPCT agreed to continue its £25k annual funding of a Medical Launch,
         with the proviso that the Committee approves a specification for that service.
         The Committee agreed to work together with the MLT to develop the
         specification for the service ‘provided to meet the needs for health related
         inter-island transport other than that which is met by the 999 service.’

2.3      Members of the Committee’s Single Issue Panel held four very positive
         meetings with representatives from the interested parties and considered
         arrangements for mutual aid support between SWAST and the MLT, minimum
         requirements of the MLT vessel, crewing, callout and operating procedures,
         management, Insurance, health & safety, funding and sustainability
         arrangements.

2.4      SWAST agreed to ascertain minimum specifications for their requirements
         and to liaise directly with the MLT within 10 days of the last meeting. They
         also agreed to consider the management arrangements with the MLT within
         28 days.

2.5      Arrangements for business continuity and risk management have not been
         confirmed. The Council’s Business Continuity Assistant has offered to assist
         the MLT in developing these strategies
                                                          HOS – 15.1.08 - Item 5

2.6   Subsequent to the meetings CIOSPCT and MLT representatives have liaised
      to develop and expressions of interest advertisement that has now been
      published. (see attached at Appendix 1)

3     Financial Implications

3.1   Costs arising from the assistance of the Council’s Business Continuity
      Assistant will be met from the existing emergency planning budget for
      2007/08

4      Recommendations

4.1   That Members approve the recommendation of its single issue panel, namely:
      that the Committee is satisfied with service specification developed for a
      Medical Launch, with the expectation that SWAST provides back-up vessel
      requirements, for further negotiation with the MLT within 10 days.

4.2   That a further report on business continuity and risk management
      arrangements be brought to this Committee.

4.3   That the panel be appraised of the outstanding SWAST requirements through
      Cllr Mrs A J Martin the SWAST liaison member.




Implications   Environmental Impact             Procurement of a service attuned
                                                    to the local environment will
                                                    reduce the negative impact
               Community Health Implications    A more flexible service will greatly
                                                benefit off-island access to health
                                                services
               Crime and Disorder Reduction     None as a direct result of this
                                                report
               Best Value Implications          Mutual aid arrangements will
                                                provide best value for stakeholders
            Financial Implications              See Paragraph 3
            Legal opinion Required/ Date        No: Date/10.12.07
WT/HOSC/10.12.07                    -2-
                                                              HOS – 15.1.08 - Item 5
                                                                       Appendix 1


Medical Launch Expressions of Interest

Expressions of interest are sought from contractors to supply Medical Launch
facilities to the Isles of Scilly. The contractor will be responsible to the Medical
Launch Trust for providing:

   •   A properly registered and operated, fit for purpose launch to transport mainly
       but not exclusively essential staff (police etc) GP’s, community staff and
       patients, including those who are disabled and on stretchers.

   •   Coxswains with passenger carrying qualifications, who will be very familiar
       with the waters around the islands and preferably with the minimum of a
       Council of the Isles of Scilly ‘B’ licence.

This contract will require that the launch and a coxswain will be available for both
scheduled and non-scheduled work (seven days a week) and undertake emergency
medical transport for the South Western Ambulance Trust if the ambulance launch
was unavailable. Insurance cover for all risks and alternative provision for launch
unserviceability and Coxswain unavailability would be required in the contract.
Additionally, this contract must take absolute priority over any other work undertaken
by the Coxswain or with the launch; which must be at 10 minutes notice for
emergencies and 20 minutes for other work.

For further information and to express an interest, please contact Toby Dalton at St.
Mary’s Health Centre on 01720 422628 or toby.dalton@ioshc.cornwall.nhs.uk by
noon on the 1st January 2008.
                                                                                                                                                                     Date        03/01/2008
Profit & Loss Variance Report
                                                                                                                                                                     Time          13:58:11



All Values are shown in      Sterling          As at month        9                                      Current month is 9               ending 31/12/2007

                                              -----------------------------------------Year to Date----------------------------------------
                                                             Budget                                                      Actual                      Variance

      POLICY & RESOURCES COMMITTEE

      HEALTH SCRUTINY & OVERVIEW

      Travel & Subsistence                                 1500.00                                                     323.20                        1176.80
      Expenditure                                            500.00                                                    325.92                         174.08
      Prof.Tech. & Admin.                                  2060.00                                                   1600.00                          460.00
      Democratic,Rep. & Man.                               7090.00                                                                                   7090.00
                                                          11150.00                                                   2249.12                         8900.88
      RECHARGE

      Recharge - Dem.Rep. & Man.                           7090.00                                                                                   7090.00
                                                           7090.00                                                                                   7090.00


                NET EXPENDITURE                            4060.00                                                   2249.12                         1810.88




Report name           P&R - HEALTH SCRUTINY                                                                                                                     Cost centre from
Currency              0                                                                                                                                         Cost centre to

Department from
Department to

COUNCIL OF THE ISLES OF SCILLY                                                                                                                                                   Sage MMS
Profit & Loss Variance Report                                                                                                                                                    Page    1
                                   THE HEALTH
                                   OF THE
                                   POPULATION
                                   Tackling Inequalities Strategy
                                   Health Inequalities in Cornwall and
                                   the Isles of Scilly




                                   THE ANNUAL REPORT OF THE
            2007




                                   DIRECTOR OF PUBLIC HEALTH FOR
                                   CORNWALL AND ISLES OF SCILLY




                                   Part 1
Cornwall and Isles of Scilly PCT
                                   please turn over
                                   report for part 2
Staff and Contributors

Staff                                                     Contributors
James Bolt           Associate Public Health Specialist   Margaret Barlow         Public Health Specialist
Philip Brigham       Associate Public Health Specialist                           Cornwall and IoS Health
                                                                                  Protection Unit
Pat Carling          PA/Administrator
                                                          Philip Brigham          Associate Public Health Specialist
Denis Cronin         Associate Director of Public
                     Health                               Denis Cronin            Associate Director of Public
                                                                                  Health
Trish Davis          Public Health Manager
                     (until April 2007)                   David Miles             Deputy Director of Public
                                                                                  Health
Kirsty Edlin         Children and Young People
                     Project Manager                      Julie Moseley           Associate Public Health Specialist

Jo Erwin             Volunteer                            Marian O’Donnell        Public Health Consultant
                                                                                  (Screening)
Chantelle Grenfell   PA/Administrator
                     (until September 2006)               Brian O’Neill           Specialty Registrar, Public Health

Anne Hall            Head Health Visitor & School         Felicity Owen           Director of Public Health
                     Nurse (until April 2007)
                                                          Lindley Owen            Public Health Consultant
Nicky Houghton       Project Manager Children’s
                     Services (until April 2007)          Pat Owen                Public Health Consultant
                                                                                  (Information)
Melanie Jones        Specialty Registrar, Public Health
                                                          Lynda Quee              Stop Smoking Service
Ros Meagor           PA/Administrator                                             Co-ordinator

David Miles          Deputy Director of Public
                     Health (retired July 2007)

Julie Moseley        Associate Public Health Specialist

Marian O’Donnell     Public Health Consultant
                     (Screening)

Brian O’Neill        Specialty Registrar, Public Health

Felicity Owen        Director of Public Health

Lindley Owen         Public Health Consultant

Pat Owen             Public Health Consultant
                     (Information)

Sara Roberts         Associate Director of Public
                     Health

Karina Wilson        PA to Director of Public Health
                                                          Environmental Statement
                                                          Greencoat paper is manufactured exclusively for Howard
                                                          Smith Paper on the shores of Lake Garda in an area of
                                                          outstanding natural beauty. The mill has obtained both
                                                          ISO 9001 and ISO 14001 accreditations, which means all
                                                          responsibilities to the local environment and manufacturing
                                                          processes are strictly monitored.
                                                          FSC certification
                                                          10% TCF virgin fibre, 10% ECF fibre, NAPM recycled
                                                          certification, 80% recycled post-consumer fibre
                                                          Published by
                                                          Cornwall and Isles of Scilly Primary Care Trust
                                                          Designed and typeset by Reef Publishing
Introduction
Since last year’s annual public health report, much has      A health equity audit has been carried out on mental
changed in Cornwall and the Isles of Scilly. The three       health services, with others planned and underway.
previous primary care trusts (PCTs) merged on 1st            The Healthcare Commission visited Cornwall and the
October, with the Director of Public Health being a joint    Isles of Scilly to observe some of the leading edge work
appointment between the County Council, the Council          on reducing the carbon footprint of the NHS.
for the Isles of Scilly, and the PCT. The new PCT
                                                             Breast and cervical screening programmes have
conducted a strategic review with guidance from an
                                                             achieved great success in 2006/07, with a reduced rate
independent reference group, and produced the Healthy
                                                             of inadequate cervical smears, and reduced time to
Futures document. This document gives strategic
                                                             receive the results. Waiting times have been improved
direction for the PCT, and the acute and mental health
                                                             in the breast screening programme, and the PCT has
NHS trusts.
                                                             received a commendation from the Strategic Health
July 2007 saw a successful bid by Cornwall County            Authority. The neonatal hearing screening programme
Council for unitary status in Cornwall. One Cornwall:        has had a national inspection, and received an excellent
One Council plans to combine the district, borough           result.
and county local authorities, giving an unprecedented
                                                             The Health and Well Being Board has drafted a Health
opportunity for reducing bureaucracy and making a real
                                                             and Well Being Strategy, which comprises 13 high
difference to local people’s lives.
                                                             impact change cards. These will be consulted on, with
The Cornwall Local Area Agreement (LAA) is in its            the aim of launching them in January 2008.
second year and many of the targets have begun to
                                                             The third report by Sir Derek Wanless Our Future Health
have an impact. The Government requires that LAAs
                                                             Secured? has been produced. He notes that the current
are refreshed and rewritten, and a new set of 200
                                                             pace of change to the fully engaged scenario has not
indicators is due out in October 2007, of which locally
                                                             yet been sufficient, and in respect of obesity, the slowest
we have to select 35. The current stretch targets will
                                                             rate of change has not been achieved. Overall, people
remain and the new LAA will come into force in June
                                                             in Cornwall and the Isles of Scilly live longer than many
2008. The Isles of Scilly are currently developing an
                                                             other areas of the country. However, there remain
LAA to run from 2008/09.
                                                             differences in life expectancy between communities,
Practice-based commissioning is driving change in            with people from more deprived areas more likely to die
primary care and the community, bringing services closer     earlier. There can be no greater inequity. It is only by
to people’s homes.                                           working together that we can make a real difference and
                                                             tackle issues such as child poverty. The Public Health
July saw the introduction of the long-awaited smoking
                                                             Department will be looking to maximise effort with all its
ban in public places. In Cornwall and the Isles of Scilly
                                                             partners in tackling and reducing inequalities in health
the newly published Smoke Free Strategy, which forms
                                                             in Cornwall and the Isles of Scilly.
a chapter of this report, aims to discourage people
from starting smoking, assist those who want to quit,
and reduce the incidence of smoking. The ban, from
1st October 2007 on the sale of tobacco to under 18s
is warmly welcomed.
The public health team has seen the merger of three
teams, a new structure and increase in investment,
leading to an increase in posts of one consultant and        Felicity Owen,
one half-time analyst. The team has also been joined         Director of Public Health,
by two specialty registrars. Dr David Miles retired in       Cornwall County Council,
                                                             Cornwall and Isles of Scilly Primary Care Trust,
July after many years working to deliver the public
                                                             Council of the Isles of Scilly.
health agenda; in particular he stressed the importance
of stopping smoking, and also increasing immunisation
uptake.
2006/07 saw an increased focus on emergency planning
with strengthened plans for major incidents, pandemic
flu, avian flu, smallpox, and testing of the plans through
major exercises and real events.
The Health of the Population

                                                   Part 1

                         Health Inequalities

    Contents                                                                                                            Page
    Tackling Inequalities Strategy                      ......................................................................    3
        Health Inequalities in Cornwall and the Isles of Scilly                                                       ........    3
        Cornwall and Isles of Scilly                         .................................................................    5
               Age and size of population                       ..............................................................    5
               Deprivation       .............................................................................................    6
               Ethnicity    ...................................................................................................   7
        What we need to do to decrease inequalities                                                  ..........................   7
               Premature mortality                ............................................................................    7
               Life expectancy            ....................................................................................    7
               Infant mortality         ......................................................................................    9
               Work, income, benefits and housing                                 .......................................... 11

               Reduce smoking               ................................................................................ 12

               Healthy workplaces, leisure and recreation, and food                                                 ........ 13

               Sex, drugs and alcohol, and safe, strong communities                                                   ...... 14

               Emotional health and well being                            .................................................   16
               Improve access to services                        ..........................................................   16
        Sources     ......................................................................................................... 17
Tackling Inequalities Strategy
Health Inequalities in Cornwall                                    This approach does not exclude a whole population
                                                                   approach to improving health, but the intention is to
and the Isles of Scilly                                            improve the health of the poorest at a greater speed,
                                                                   thereby ‘levelling up’ or reducing the gap in health
Health inequalities can be seen in many forms; dying
                                                                   inequalities.
early or having a long term chronic illness at a younger
age being the most obvious. When looking at who                    Health and life expectancy are linked to social
these people are, it is frequently the same groups of              circumstances and childhood poverty. It cannot be
people that experience other inequalities. This section            solved by health organisations alone. The top five
of the annual report looks at the impact of these
                                                                   causes of premature death (i.e. before the age of 75)
inequalities and suggests how in Cornwall and the Isles
of Scilly (CIoS) we can work together to reduce them.              for women and men in CIoS relate to coronary heart
                                                                   disease, stroke, cancer, respiratory disease and
Health and life expectancy are linked to social                    alcohol related diseases. Actions can be taken to
circumstances and poverty. Whilst overall, the health              prevent many of these.
of our society has been improving for a century or
more, the rate of improvement in those from deprived               CIoS has some of the most deprived areas in the
backgrounds has been slower than for those who are                 country. Much deprivation in CIoS is hidden by the
better off.                                                        beauty of the land and seascape. Many inner city
                                                                   areas of England have the same deprivation scores
Following the Acheson’s report into inequalities in health         as parts of CIoS. All the local authorities in CIoS are
(Acheson 1998), the Government has prioritised the                 ranked in the lowest quintile in the country for gross
need to tackle the causes and consequences of health               domestic product (GDP), in the lower three quintiles
inequalities through a co-ordinated approach. This has             for income and bar one authority in the second lowest
been further reflected in the White Paper on Public                quintile for wealth. Incomes in CIoS fall well below the
Health Choosing Health – Making healthy choices                    national average. In 2004 average annual earnings in
easier (DH 2004) and more recently in the White Paper              CIoS were 20% below the average in Britain.
in health and social care Our health, our care, our say
(DH 2006). Causes of health inequalities can be                    A number of studies in recent years have highlighted
established by analysing the deviation from the wider              the financial problems associated with rural living.
determinants of health across the community. The most              These include the lack of transport, high costs of
recent paper by Wanless has shown that inequalities                shopping and fuel, lack of childcare facilities, and
are not decreasing.                                                housing that is energy inefficient. Social isolation and
                                                                   limited opportunities for employment and leisure close
Social economic trends indicate that there are wide                to home are important.
health status differences among social groups, which
may persist from generation to generation if not                   There is also a lack of access to information on
addressed. The more affluent enjoy better health                   available services including social welfare. In areas
than less well off people. Those from lower income                 such as North Cornwall and Caradon where the
households have significantly higher mortality rates               population is sparse and largely rural these problems
for nearly all major causes of death, particularly from            may be particularly acute.
coronary heart disease, strokes, and lung cancer; and              On the Isles of Scilly the main centre of population is
higher rates of morbidity, including mental health                 St Mary’s, but approximately one fifth of the population
problems. Babies born to poorer families are more                  live on the off-islands. People on the Isles of Scilly
likely to be born prematurely, be at greater risk of infant        have particular issues with regard to accessing
mortality, and suffer from poverty, impaired development           services, and off-islanders have the added expense of
and chronic disease later in life. The causes of these             inter-island travel. Boat links between the off-islands
differences can be remedied by improving opportunities             and St Mary’s are detrimentally affected by the absence
for increasing income, access to services and                      of tourists in winter as the economic viability of regular
supporting healthier lifestyle choices of individuals.             and low cost services is affected.
The gap in health status between the rich and the poor             Personal debt and financial exclusion impacts on both
is widening – there is a step gradient in health status            the individual and the community. The Social Exclusion
that relates principally to poverty. Tackling health               Unit identifies personal debt as affecting health,
inequalities requires us to close the ‘health gap’ and focus       employment, child poverty, housing and re-offending.
on improving the health of those people who fare worst.            It can affect efforts for neighbourhood renewal and



                                                               3
Tackling Inequalities Strategy

impact on the local economy and regeneration. The               The Health and Well Being Board identified key
stress and anxiety associated with debt can exacerbate          areas for intervention for partners to work together to
existing health problems and contribute to problems             decrease inequalities and improve well being.
such as domestic violence.                                      These are:
In CIoS, differences in life expectancy are as great as         G   Healthy workplaces
eight years, with people living in Penzance East having         G   Reducing smoking
a life expectancy of 75, compared to 83 in Feock or             G   Benefits
Kea.
                                                                G   Getting into work
Infant mortality rates in CIoS have been decreasing             G   Leisure and recreation
for over thirty years but over the last five years this
                                                                G   Warm, affordable, safe housing
decrease has stalled. It is important that we review the
figures carefully as some risk factors such as obesity          G   Food
are increasing.                                                 G   Emotional health and well being
Reducing health inequalities requires mainstream                G   Reducing infant deaths
action. It involves developing equitable and socially           G   Safe, strong communities
inclusive strategies, policies, programmes and services         G   Better access to services
across all agencies. This necessitates a wide                   G   Reducing problems caused by sex,
understanding and ownership by all agencies and
                                                                    drugs and alcohol
professionals at all levels of the rationale for tackling
                                                                G   Environment.
health inequalities, and a capacity to understand and
monitor the impact of their work. Key agents in taking          Throughout this report we show how we can reduce
this forward are the Cornwall Strategic Partnerships and        inequalities locally if we work together. The first section
the groups that feed into them. The Health and Well             shows the CIoS background which we need to work
Being Board is one of these groups.                             with to promote change. We then go into the aspects
                                                                where inequality is known to have its greatest effects.




                                                            4
Cornwall and the Isles of Scilly
Age and size of the population
Population pyramids allow comparison between age                                      85 and over in CIoS in 2005 is 2.7% compared with
and sex structures of the populations from two areas.                                 2.0% nationally and in 2029 is projected to be 4.9%
Figure 1 compares CIoS to England and Wales. For                                      compared with 3.5% nationally.
both sexes there are smaller numbers of people under
                                                                                      In CIoS these percentages equate to 14,200 people
45 years of age and greater numbers over the age of
                                                                                      over the age of 85 in 2005 and a larger increase to
50 in CIoS compared to England and Wales as a whole.
                                                                                      30,800 by 2029. People over the age of 85 are far
Comparing the projections shows an increasingly                                       more likely to require health and social care support
ageing population due to declining fertility rates and                                services and this projected growth in both numbers
declining mortality rates. Nationally there will be                                   and percentage terms will require planning for.
declining numbers of under 16s and an increasing
                                                                                      It is yet to be seen if the opening of the Combined
population aged 65 plus.
                                                                                      Universities in Cornwall helps young people to remain
In Cornwall over many years there has been an inward                                  in the county. House prices play a major role in
migration of people aged 50 and over and this is                                      preventing young people from remaining in CIoS as
expected to continue. The percentage of people aged                                   affordable housing is very scarce.




FIGURE 1. POPULATION       ESTIMATE   2005                                            POPULATION   ESTIMATE   2029
SOURCE: OFFICE   FOR   NATIONAL STATISTICS 2005   MID YEAR POPULATION ESTIMATES       SOURCE: OFFICE FOR NATIONAL STATISTICS 2005 MID YEAR POPULATION PROJECTIONS




                                                                                  5
Tackling Inequalities Strategy

Deprivation
Deprivation is frequently measured in England by the                                                          We need to help people to access
Indices of Multiple Deprivation (IMD2004). It combines                                                      the benefits to which they are entitled,
income, employment, education, barriers to housing                                                                 to help combat poverty.
and services, crime, living environment, and health and
disability into a measure that compares one geographical
area with another. The areas of deprivation include                                               CIoS has some of the most deprived areas in the
many of the people experiencing the greatest inequalities.                                        country, as predicted by the IMD2004 (figure 2). The
It is important to remember that the index is largely                                             indices of deprivation are mapped by super output area
driven by income and employment deprivation (these                                                (SOA); this is the smallest level at which deprivation
represent 45%). This is correct, as low income is a                                               can accurately be shown. Each district council in
good predictor for other inequalities. For both of these                                          Cornwall has some SOAs that are in the most deprived
indicators however, a person is only counted when they                                            quintile, but the west has the most. No SOA is in the
access welfare benefits or tax credits, and there is a                                            least deprived quintile for England. The Isles of Scilly’s
strong argument that in rural areas the take up of these                                          isolation gives rise to issues for health and well being
benefits is low, causing the deprivation to be hidden.                                            and access to services.
Elderly people are a group where benefit take-up is
often low. Government estimates reveal that each year                                             People who experience material disadvantage, poor
over £4 billion goes unclaimed in four benefits alone –                                           housing, lower educational attainment, insecure
Income Support, Job Seekers Allowance, Housing                                                    employment and homelessness are among those more
Benefit and Council Tax.                                                                          likely to suffer poorer health, have poorer access to
                                                                                                  health care and die prematurely.
Many of our older citizens are unaware of the welfare
benefits to which they may be entitled. Age Concern
estimates that about 1 million pensioners are entitled
to Minimum Income Guarantee but do not claim it.



         Indices of Deprivation by Super Output Area (Lower Layer)

                           LEGEND                                                                                                                       Bude

              Index of Multiple Deprivation (IMD) 2004
           Ranked in the top 20% nationally (most deprived)



           Least deprived 20% in the country

                                                                                                                                                                          Launceston
                                                                                                                                          Camelford




                                                                                                                         Wadebridge


                                                                                                                                      Bodmin
                                                                                                                                                               Liskeard

                                                                                                              Newquay
                                                                                                                                          Lostwithiel
                                                                                                                                                                                       Saltash

                                                                                                                                                                                        Torpoint
                                                                                                                            St Austell




                                                                                                                Truro
                                                                                                  Redruth
                                                                           St Ives

                                                                                     Hayle


                                                                                                              Falmouth
                                                                      Penzance

                                                                                             Helston




                                             0                 10        20
                                                              miles


FIGURE 2. INDICES   OF DEPRIVATION BY SUPER OUTPUT AREA FOR                CORNWALL



                                                                                             6
Ethnicity
The 2001 Census indicated that in CIoS 0.9% of the                     When looking at ways to decrease
resident population are from a minority ethnic group;                    inequalities we will need to:
by 2004 the estimate had increased to 2%. One
exceptional characteristic of ethnic mix of the
                                                                          Ensure that the services available
population is the continuing increase in the number
                                                                           are appropriate and available to
of migrant workers.
                                                                                all groups within CIoS.
It is widely known that some people from a black or
minority ethnic (BME) group experience poorer health
and have unequal access to health services compared
                                                                         Overcome barriers to health care for
to the general population. Diabetes, coronary heart                       migrant workers in the county and
disease, hypertension, stroke and osteoporosis are                           continue development of a
more common in some BME groups. There is much                             Migrant Workers Welcome Pack.
controversy over the reasons for these differences
but there is no doubt that relatively high levels of socio-
economic deprivation, cultural attitudes and
biological/genetic differences all play a part.                   What we need to do to
Refugees and asylum seekers                                       decrease inequalities
While many refugees are registered with GPs there are
still some who do not appear able to access primary               Premature mortality (early deaths)
care, whether GPs, dentists or opticians. Many suffer
from mental illness and stress, and have limited money,           Life expectancy
which restricts their diet. Children in particular are            To understand and reduce the inequality in life
prone to ill health. Although many do receive help,               expectancy across England money was targeted
there is still a lot of health and social care needed, as         towards areas with the greatest deprivation. Life
well as education and information on how the system               expectancy has been shown nationally to vary with
works.                                                            deprivation; the gap between the most deprived and
                                                                  the least being seven years in men and five years
Gypsies and travellers                                            in women. This gap widens to 13 and 12 years
The 2004 report on the health status of gypsies and               respectively when considering disease-free life
travellers in England commissioned by the Department              expectancy. Within wards in Cornwall the range is
of Health confirmed that gypsies and travellers                   about eight years, from 83 years for the highest life
experience health inequality that is even more                    expectancy and about 75 years where people are
pronounced than that experienced by other socially                dying youngest.
deprived or excluded groups or ethnic minorities.
                                                                  In addition to life expectancy we can compare death
The gypsies and travellers who took part in the                   rates adjusted for the different age structures within
research reported poorer health status over the past              local populations. This allows us to see in which parts
year than those in the housed population, and in terms            of the county people are dying younger than would
of their health on the day of the questionnaire, they had         be expected, and indicates where we should target
more problems with mobility, self care, undertaking               initiatives. These figures are easier to calculate locally
usual activities, pain or discomfort and anxiety or               than life expectancy as wards of similar deprivation can
depression.                                                       be combined, thus looking at larger numbers, and then
                                                                  compare them with the county as a whole. The highest
Regionally and nationally the number of gypsies and
                                                                  concentration of these wards and therefore people, is in
travellers has been growing. In Cornwall there has
                                                                  west Cornwall.
been an increase of 13% in caravan numbers between
2003 and 2005, largely on unauthorised sites. The                 Death rates, as with life expectancy show all people are
county has a lower proportion of private sites than               generally living longer, but those that live in deprived
elsewhere in the South West and the rest of England,              areas tend to die earlier than those that live in less
and a higher proportion of unauthorised encampments.              deprived areas. This is the greatest inequality in health.



                                                              7
Tackling Inequalities Strategy


                               750


                               700


                               650
                 DSR/100,000




                               600


                               550


                               500


                               450


                               400
                                         2000-2        2001-3          2002-4           2003-5       2004-6      2005-7          2006-8          2007-9

                                                      Cornwall most deprived quintile
                                                      Cornwall most dep quintile                              Cornwall least dep quintile
                                                                                                              Cornwall least deprived quintile


FIGURE 3. ALL AGE ALL CAUSES             MORTALITY RATES
DSR: DIRECTLY STANDARDISED           RATE (SEE   SOURCES   FOR DEFINITION)




Figure 3 shows the difference in death rates between
the most and least deprived communities in CIoS.
                                                                                                        The gap in the all cause all age
Although death rates can be seen to be decreasing in
both the least and most deprived communities, the gap
                                                                                                        mortality rate will mean that in a
between rich and poor is not decreasing. Two-thirds                                                  population of 100,000 as many as 100
of the gap in life expectancy is due to cardiovascular                                                 more people may die in a year in a
disease, cancer and respiratory disease. Smoking                                                     population of similar age structure but
causes 50% of this difference in longevity between the                                                     with greater deprivation.
most and least deprived communities, as the most
deprived communities have higher levels of smoking
and smoke greater numbers of cigarettes.                                                         Mortality can only provide part of the picture; it will be
Increasing services to reduce the number of smokers                                              important to look at primary care data such as smoking
and finding and managing high blood pressure and high                                            prevalence, smoking cessation services, cardiovascular
cholesterol are three key factors in reducing the gap in                                         disease, and alcohol related disease to determine
life expectancy. In addition, early detection of cancer,                                         priorities for each locality. These services must be
reducing infant mortality and alcohol related diseases                                           sited to help reduce inequalities ensuring accessibility
will also reduce health inequalities.                                                            for all groups.

Levels of obesity need to decrease as it increases the
risk from many of these conditions. Programmes such                                                  Actions can be taken to prevent most
as Health Trainers and increased smoking cessation                                                   premature deaths and they are similar
services can be useful in delivering these changes.
                                                                                                       for all: don’t smoke, or give up; eat
Although the work demonstrating differences is national,                                              healthily, including consuming less
the deaths in those under 75 years of age in CIoS
                                                                                                         salt; take more physical activity.
show similar patterns. The top five causes of death
                                                                                                     All these messages have been around
are the same as for England and Wales: coronary
heart disease, stroke, lung cancer and breast cancer                                                   for many years but they have been
(for women), respiratory disease and alcohol related                                                  accepted and used more by those in
diseases.                                                                                                    the most affluent groups.




                                                                                           8
Infant mortality                                                G   Immaturity related conditions

Infant mortality is one of the historically earliest
                                                                G   Congenital anomalies and
indicators used to show differences in deprivation.             G   Sudden unexpected death in infancy.
In the west rates of infant mortality are low but there         Additional risk factors are absence of breastfeeding,
are still marked differences between countries and              maternal smoking, and obesity of the mother.
groups of people within countries.
                                                                Some particularly disadvantaged groups are for births
A study by the Department of Health shows infant                where only mothers register the birth, the long-term
mortality is higher in people working in the routine and        unemployed, those who have never worked, and
manual (R&M) group, which includes those in lower               students. These are excluded from the target and are
supervisory and technical, semi-routine and routine             groups that are often people living in greatest poverty.
occupations. Typical examples of employment might               These groups must not be forgotten when trying to
be porters, cleaners, bar staff, waiters/waitresses,            reduce infant mortality.
sales assistants, catering assistants, train drivers,
people working in call centres, electricians and sewing         Measuring progress towards tackling health inequalities
machinists. The gap between this group and the rest             in infant mortality at a local level is complicated by the,
of the population has not reduced since the target was          thankfully small numbers of infant deaths in individual
set in 2000. The 2001 Census shows that CIoS has a              localities. To help investigate the local progress, the
slightly higher percentage of men employed in these             national review identified the 43 local authority areas
groups than England and Wales. National figures show            that faced the biggest challenge in reducing infant
that the gap in the baseline year, 1997 to 1999 was             mortality in the R&M group. These were areas with
13%; this has widened to 18% (figure 4).                        20 or more infant deaths in this group over a three-year
                                                                period, 2002–04.
For the infant mortality target, the three main causes of
death in infancy, and which also account for most of the        Breastfeeding has long been recognised as beneficial to
gap are:                                                        both the mother and her baby. Nutritionally, it provides




FIGURE 4. INFANT MORTALITY




                                                            9
Tackling Inequalities Strategy

everything for the first six months of a baby’s life.
Breastfeeding also reduces the risk of a baby being
admitted to hospital for gastro-intestinal or respiratory
infections. In addition, it promotes bonding between the
mother and her baby. There is some evidence that it
reduces the likelihood of that individual becoming obese
in later life. In CIoS in 2005/06 70.8% of mothers
initiated breastfeeding. The first three quarters of
2006/07 show that this figure had increased to 71.3%.

Five areas of good practice to reduce infant mortality
(high impact changes) have been identified:

G   knowing the target, knowing your gap;
G   making the target part of everyday business –                                                              SOURCE: BREAST FRIENDS
    integrate into commissioning plans and provider
    contracts;
G   taking responsibility and engaging communities;                            It is important that we review infant
                                                                              mortality rates carefully as some risk
G   matching resources to needs;
                                                                             factors such as obesity are increasing.
G   focusing on what can be done.

In CIoS the rate of deaths in those under one year of
age has halved since 1976 and the number decreased                      Although none of the districts in Cornwall fall into the
from 64 deaths in 1976 deaths to 22 in 2005 (figure 5).                 high rate group identified in the Department of Health’s
Infant mortality rates are decreasing in CIoS and are                   report, many of the conclusions from the national review
similar and usually below the rates in England and                      group would be applicable locally. To produce similar
Wales but over the last five years this decrease has                    information locally is difficult, as local data systems do
stalled.                                                                not link all births to the occupation of the father.




FIGURE 5. COMPARISON   OF INFANT MORTALITY IN   CIOS AND ENGLAND AND WALES




                                                                   10
In a year there are usually fewer than 30 deaths                   Work, income, benefits and housing
under one year in CIoS, of which about half would be
                                                                   Incomes are low and house prices are high causing
in the R&M group. Local data would be difficult to use
                                                                   affordable housing to be scarce. Incomes in CIoS fall
effectively as variation, even using the method of
                                                                   well below the national average. In 2004 average
smoothing over three years, would be too great.
                                                                   annual earnings in CIoS were 20% below the average
                                                                   in Britain. The majority of people in employment are in
                                                                   service industries. Unemployment is seasonal and
      If the gap in rates between the R&M                          part-time employment and multiple job holding are
        and all births had reduced to 3%,                          common. Levels of worklessness are high, with over
                                                                   37,000 jobless people in CIoS of working age claiming
       (the target for 2010) the number of
                                                                   benefits. Of these, 27,300 are claiming benefits due to
       deaths would be reduced by three
                                                                   ill-health. Worklessness is known to be a cause of ill
          deaths in a three year period.                           health. Debt, mental health problems and drug and
                                                                   alcohol misuse are reported as key barriers to work by
                                                                   employment advisers in CIoS. You are less likely to be
                                                                   in work if you are a lone parent, over 50, a member of
Locally the Health and Well Being Board translated
                                                                   a minority ethnic group or have a disability.
these changes into the desire to:
G   Reduce maternal smoking during pregnancy and
    afterwards.
G   Increase the numbers of women breastfeeding
    their babies.
G   Ensure advice and support is available to improve
    maternal and infant nutrition.
G   Continue to reduce unwanted teenage pregnancies.
G   Target work where we know rates are high.
G   Develop programmes to prevent sudden unexpected
    incidents and deaths of babies.
G   Carry out a health equity audit on infant mortality.
G   Encourage all women to receive care early in their
    pregnancy.


To make them happen CIoS will need to:
G   Increase the uptake of smoking cessation in                                                             Photograph: Karen Sawyer
    pregnant woman, and support them to remain
    non-smokers.
G   Increase the awareness of symptoms of infectious
    diseases, particularly meningitis.
G   Support and promote childhood immunisations.
G   Support the Invest to Save project, involving wider
    joint action between statutory and voluntary and
    community partners to tackle child poverty. The aim
    is to break the cycle of child poverty for families in
    CIoS by shifting efforts from treatment to prevention.
G   Support the introduction of fortification of flour with
    folic acid.




                                                                                                            Photograph: Karen Sawyer




                                                              11
Tackling Inequalities Strategy

House prices in CIoS have been rising rapidly in the                       Reduce smoking
last few years and are further inflated by second home
                                                                           Smoking is the single biggest preventable cause of ill
ownership. Thirty per cent of houses are of poor
                                                                           health and premature death in the UK. We consider
quality, with people over 75 years of age the most likely
                                                                           this in more detail in the smoking section of the report.
to be living in a non-decent home. As many as 45,000
(24%) households are estimated to live in fuel poverty.                    It is a major contributor to inequalities in health.
                                                                           Between1973 and 1996 the most affluent had more
CIoS will need to promote:
                                                                           than halved the percentage smoking, whereas for the
G   Closer working between health services and                             poorest there had been a slight increase as is shown
    Cornwall Works with schemes such as Health                             in figure 6.
    Trainers
G   Work with employers to help them understand the
    barriers to employment                                                                       Smoking kills
G   Returning people to the workplace through
    structured volunteering
G   Reducing the number of households in fuel poverty                      Around 1,000 premature deaths in CIoS are due to
    by contributing to the delivery and monitoring of the                  smoking every year. Smoking is responsible for 10%
    Fuel Poverty and Energy Efficiency Action Plan for                     of all deaths. In CIoS as many as 170 hospital
    Cornwall, and by increasing take up of sustainable                     admissions per year of children under the age of five
    energy advice services and grants                                      are due to their parents smoking. In 2001, 27% of
                                                                           Cornwall’s adults smoked. This ranged from about
G   Achieve the decent homes target for both social
                                                                           35% of 16 -34 year olds to 15% or less of the over 65s.
    and private sector housing. Increase the number of
    employers offering flexible working solutions.                         CIoS needs to:
                                                                           G   Continue to provide support for those who wish
                                                                               to stop smoking
                                                                           G   Increase the range of venues for support
                                                                           G   Ensure smoking legislation is enforced
                                                                           G   Work to decrease the number of people who
                                                                               take up smoking
                                                                           G   Ensure use of brief interventions by health and
                                                                               social care staff and volunteers to signpost
                                                                               potential quitters to support
                                                                           G   Ensure quitters have access to the
                                                                               pharmacotherapy they need.



                                           Photograph: Karen Sawyer




                                                                           FIGURE 6. VARIATION   OF SMOKING WITH AFFLUENCE IN   GREAT BRITAIN.
                                                                           SOURCE: WANLESS




                                                                      12
            Healthy workplaces, leisure and                                                       National research and surveys show that obesity is
                                                                                                  linked to social class, being more common among those
            recreation, and food                                                                  in the routine or semi-routine occupational groups than
            Reducing obesity will need contributions from all partners                            in the managerial and professional groups. Obesity
            and is achieved by the interaction of many strands of                                 trebled amongst adults between 1980 and 1998. If this
            work. It has been widely acknowledged that obesity                                    trend continues it is estimated that over one quarter of
            has been increasing for more than 20 years (figure 7).                                the population will be obese by the year 2010.
                                                                                                  In the 2001 Health Survey for England, 21% of men
                   30                                                                             and 23% of women were found to be obese. In a
                                                                                                  survey undertaken in CIoS schools in summer 2006
                                  women

                                                                                                  12.2% of children in reception year and year 6 were
                                  men
                   25
                                                                                                  found to be obese, and a further 13.0% were found
% obese (BMI>30)




                                                                                                  to be overweight. This means that over a quarter of
                   20

                   15                                                                             those surveyed were overweight or obese. At age 4-5
                                                                                                  (reception year) 9.0% were obese: the prevalence
                   10                                                                             increased to 15.1% by ages 10-11 (year 6). These
                                                                                                  figures are slightly lower than national figures but will
                   5
                                                                                                  need to be reviewed after information for 2007 becomes
                                                                                                  available, as there will be data from more schools.
                   0
                                                                                                  Obesity is estimated to reduce life expectancy by about
                        1980



                                1985



                                          1990



                                                     1995

                                                                1998

                                                                       2000



                                                                              2005



                                                                                      2010




                                                                                                  nine years, and 6% of deaths are attributable to obesity.
            FIGURE 7. TRENDS IN THE PREVALENCE          OF OBESITY AMONG MEN AND                  Figure 8 shows the health consequences of being
            WOMEN, EXTRAPOLATED TO 2010                                                           overweight or obese.
            SOURCE: HEALTH SURVEY FOR ENGLAND




                    Greatly increased risk                  Moderately increased risk                               Slightly increased risk

                    G    Type 2 diabetes                    G     Cardiovascular disease                 G   Some cancers (colon, prostate,
                    G    Gall bladder disease               G     Hypertension                               post-menopausal breast and endometrial)
                    G    Dyslipidaemia                      G     Osteoarthritis (knees)                 G   Reproductive hormone abnormalities
                    G    Insulin resistance                 G     Hyperuricaemia and gout                G   Polycystic ovary syndrome
                    G    Breathlessness                                                                  G   Impaired fertility
                    G    Sleep apnoea                                                                    G   Low back pain
                                                                                                         G   Anaesthetic complications
            FIGURE 8. THE      HEALTH CONSEQUENCES OF BEING OVERWEIGHT OR OBESE
            SOURCE: CARE PATHWAY FOR      THE MANAGEMENT OF OVERWEIGHT AND OBESITY.
            DEPARTMENT OF HEALTH                                                                                          Per cent exercising        Rank in
                                                                                                    Area                  three or more times      English LAs
                                                                                                                               per week
                                                                                                    Isles of Scilly                  32                 1
            Physical activity has a part to play in reducing obesity                                Penwith                         22.9               101
            but is important to all, not just the obese.                                            Carrick                         22.4               121
            Results from 2006 Active People survey, using a                                         Caradon                         21.2               174
            sample of adult residents in each local authority                                       North Cornwall                   20                235
            (figure 9), showed only about one in five residents of                                  Restormel                       19.9               240
            CIoS take part in 30 minutes of moderate intensity                                      Kerrier                         19.8               246
            physical activity (the Government recommendation is                                     Average value                    21
            30 minutes of activity five times per week).                                            for England
                                                                                                  FIGURE 9. PERCENTAGE   OF PEOPLE EXERCISING THREE OR MORE TIMES
                                                                                                  PER WEEK




                                                                                             13
Tackling Inequalities Strategy

The risks to health from insufficient physical activity are                  A measure of success will be that we have halted the
significant, and the most serious apply irrespective of                      rise in obesity among children aged under 11 years
body weight. Physically active people have 20-30%                            (measured as the percentage of children in reception
reduced risk of premature death and up to 50% reduced                        and in year 6 who are obese).
risk of major chronic disease such as coronary heart
disease, stroke, diabetes and cancer.
Exercise programmes of moderate intensity have been
shown in randomised controlled trials to improve mental
and physical health, without harmful side-effects.
Exercise is associated with reduced risk of dementia in
men, diabetes in men, and to have a protective effect
against certain common cancers. Physical activity is
especially important in early life.
Programmes to reduce obesity using slimming on
referral are being evaluated in west Cornwall, and if
                                                                                                            Photograph: Emma Rojano (Cornish Guardian)


shown to be successful could be made more widely
available.
                                                                                           Physical activity
The Health and Well Being Board suggested the
                                                                                          reduces the risk of
following actions to reduce inequalities to support
increased activity and reduced obesity:                                                     many diseases.
G   Provision of health trainers in disadvantaged
    communities
G   Support CIoS Strategy for Sport and Active                               Sex, drugs and alcohol, and safe,
    Recreation – effect cultural change, improve                             strong communities
    facilities, engage those not currently taking part,
    improve communications, and funding                                      Cornwall is seeing a sharp rise in the rate of detected
G   Provision of outdoor activities to hard to reach                         sexually transmitted infections (STIs). Part of this
    groups, such as the CREST scheme providing                               increase can be attributed to the better detection of
    surfing to young people in targeted areas                                Chlamydia trachomatis as a result of the screening
                                                                             programme which began in 2003; Cornwall was the
G   Reduce adult obesity as recorded in GP registers
                                                                             only pilot area in the south west. A significant rise in
    to below 20% by 2015
                                                                             STIs has been seen in the under 25s. However, rates
G   Support the CIoS Healthy Schools programme to
                                                                             of Chlamydia, genital warts, genital herpes and syphilis
    increase uptake of healthy eating and provision of a
                                                                             are also rising in the over 35s. There is likely to be
    range of opportunities to be physically active, and
                                                                             a pool of untreated STIs in this age group. There is
    help young people to understand how this can
                                                                             increased reporting of unprotected sex and subsequent
    benefit their health.
                                                                             abortion in the 35 years plus age range. This is in part
                                                                             explained by the increase in the average number of
                                                                             lifetime partners.
                                                                             More than a quarter of people in the UK do not use
                                                                             contraception when they lose their virginity. Fourteen
                                                                             per cent of people in the UK were under the influence
                                                                             of either drugs or alcohol when they first had sex.
                                                                             Whilst between 1998 and 2003, CIoS has seen a 10.1%
                                                                             reduction in the rate of under 18 conceptions, there has
                                                                             been little impact on the rate of under 16 conceptions
                                                                             (a rise of 0.1% between 1998 and 2002). Although the
                                                                             rate of under 18 conceptions for CIoS is less than the
                                                                             national rate, Cornwall has 15 wards that have an under
                                                                             18 conception rate among the highest 20% in England.
                                             Photograph: Timothy Reed




                                                                        14
Generally, these wards correspond with areas of higher             Domestic violence is defined as:
social deprivation. At district council level, there is            Patterns and incidents of threatening behaviour,
considerable disparity, with three out of six district             violence or abuse (psychological, physical, sexual,
councils having lowered their teenage conception rate              financial and emotional) between adults (over 18),
since 1997 (a reduction of 29.2% in Penwith), one district         who are or have been intimate partners or are family
council having remained static, and two district councils          members regardless of gender.
having seen their rate increase (by 8.4% in Restormel).
                                                                   Police data show that the trend in reported domestic
Alcohol can be a safe drug when used in a sensible                 violence is starting to rise. This can be seen as
and social way. However, nationally its misuse costs               positive, as it can indicate increased confidence in the
the NHS alone £1.7 billion. Up to 35% of all accident              police and other service providers. It could also mean
and emergency attendances and ambulance costs                      an increased level of domestic violence. Over 5,500
are estimated to be alcohol related. Preventative                  incidents of domestic violence are reported each year
interventions will provide the best method to tackle               in CIoS.
many alcohol related problems, but a significant number
                                                                   In 2005, the majority of these incidents (84%) were
of people develop more serious alcohol related
                                                                   relatively minor, in terms of physical injury. However,
dependence and will require treatment. Left untreated
                                                                   many of these assaults will be part of a long-term
these problems can lead to long term ill health and
                                                                   cycle of abuse. Penwith recorded the highest rate of
premature death. Forty-four per cent of violent crime
                                                                   incidents, whereas the greatest number of incidents
is alcohol related. Fifty-one per cent of recorded
                                                                   was in Restormel. People under the age of 25 are
domestic violence crimes were committed by an
                                                                   most likely to be victimised.
offender who was perceived to be under the influence
of an intoxicating substance.                                      The proportion of recorded incidents against males
                                                                   has increased, and CIoS appears to have a higher
The numbers of deaths in Cornwall each year from
                                                                   prevalence of reported domestic violence against
directly alcohol-related causes are about 40, with
                                                                   males (22.5%) than the national average (16%).
slightly more men than women.
                                                                   CIoS needs:
The rate of deaths for both men and women aged
between 35-54 has doubled between 1991 and 2005.                   G   A reduction in the rate of alcohol-related disorder,
Worryingly, deaths are becoming more common at                         alcohol-related accidents and incidents of domestic
younger ages. The most deprived fifth of the population                violence
suffer three to five times greater mortality due to alcohol        G   A reduction in the rate of drug-related offending
specific causes, with men suffering more than women.               G   Reduction in A&E workload due to alcohol related
Recorded crime is lower in CIoS than in other areas                    incidents
of the country. However, fear of crime is high, and                G   To reduce unwanted teenage conceptions and
this like actual crime has a negative effect on people’s               improve access to sexual health services with a
quality of life. There is a suggestion that there is a                 particular focus on young people, gay men and
considerable amount of unrecorded crime.                               over 35s
                                                                   G   To increase the number of people in treatment for
Crime is particularly prevalent in towns, and concern
                                                                       drug and alcohol problems by a minimum of 10%
about crime is highest in the evenings and during the
                                                                       per year, and offer greater accessibility to skilled
night. There is a link between tourism and crime,
                                                                       advice and treatment, including detox services
with reported incidents increasing by 10% during the
                                                                   G   Agree and implement campaigns to promote safer
summer. Those experiencing the most effects of crime
                                                                       sex and sensible drinking.
are those living in areas of greatest deprivation.
The number of recorded crimes shows an improving
trend. There are strong relationships between crime
and employment and income deprivation. During
2004/05 there were over 35,000 crimes recorded.
Criminal damage accounted for a quarter of these,
with theft accounting for almost another quarter.
However, 6,700 incidents of violent crime were
reported in Cornwall and the Isles of Scilly.



                                                              15
Tackling Inequalities Strategy

Emotional health and well being                                   also be measured in terms of how accessible services
                                                                  are to people with physical, or learning disabilities, or to
Mental health and emotional well being are areas where            people from minority ethnic groups e.g. the availability
the members of the Health and Well Being Board were               of interpreting services. Mental illness also leads to
keen to encourage new work. They were clear that                  isolation and exclusion from services.
we needed to improve the services available. As the
children and adolescent mental health services are                Although Cornwall is the second largest county in the
going through development, it is desirable to work                South West region, and has a GP registered population
together to achieve the best results. Multi-agency                of approximately 540,000, it has the lowest population
training should be part of taking this forward. The               density. This is made more startling when it is realised
Healthy Schools programme would aid this training.                that more than a quarter (27%) of the population lives
                                                                  in the larger urban areas of the county; this includes
Improving emotional well being and mental health were             Penzance, Camborne-Pool-Redruth, Falmouth-Penryn,
recognised as an important first step to reducing many            Truro, Newquay, St Austell and Bodmin. A further 29%
other inequalities. It would help to start on the path to         live in towns and villages with over 3,000 people, and
getting a job, reducing weight and stopping smoking.              44% live in other settlements of smaller size. People
Psychiatric disorders and suicide attempts are more               on the Isles of Scilly have particular issues with regard
likely to occur in people facing socio-economic                   to accessing services.
disadvantage (ONS 2003). Approximately 60-70 people
in CIoS die each year by suicide or injury of undetermined
intent; this is higher than the national average.
Although the data refers to residents of CIoS, people
from other parts of the country may also commit suicide
here, and there are a number of hot spots in CIoS.
Men are more likely to commit suicide than women.
Nationally most suicides are among young adult men.
However, in CIoS suicide rates have over the past ten
years or so, been higher in the middle years (35-64
years), and for women this continues into old age.
We need to examine data describing local deaths by
suicide and injury of undetermined intent to understand
the nature of such deaths, and identify possible ways to
prevent future deaths.

                                                                  The dispersed, spatial distribution of population across
                                                                  Cornwall and the Isles of Scilly has implications in terms
                                                                  of accessibility to transport, employment opportunities,
   We are developing an updated strategy
                                                                  community services and shops, and a range of other
   to prevent suicides and will continue to                       services including medical care. It is often the most
   monitor the suicide statistics to reduce                       vulnerable who are unable to access transport, and
               the suicide rate.                                  therefore effective integrated transport networks that
                                                                  meet the needs of everyone are essential, though costly
                                                                  and difficult to deliver.
                                                                  Consequently, within Cornwall there is a heavy reliance
Improve access to services                                        on private transport, and car ownership, often viewed
The term ‘access to services’ is often used                       as a sign of affluence, is relatively high across the
synonymously to describe the distances that people                county. Approximately 50% of the population own a car
have to travel to the places where services are delivered         and just over 30% of the population own two or more.
or the time it takes to reach them. However, access               The vehicles tend to be older than the national average
to services can also be measured in terms of the time             and a significant proportion of people’s incomes is spent
that patients have to wait before receiving treatment or          on running and maintaining them. Significantly, one in
appointments e.g. to see their GP. Equally, access can            five households does not own a car.



                                                             16
Each year, nearly 2,000 years of Cornish lives are                Sources
lost through accidents, mostly road casualties, many
                                                                  Acheson D. Independent inquiry into inequalities in health: the Acheson report.
avoidable. As people travel more their risk of                    London: Stationery Office, 1998.
experiencing an accident increases; this increased
                                                                  Department for Communities and Local Government. Strong and
exposure is mainly in cars. Cornwall’s low income
                                                                  prosperous communities: the local government white paper.
levels mean the cars are less modern, less safe in                London: Department for Communities and Local Government, 2006.
design, and possibly less well-maintained. There is
                                                                  Department of Health. National service framework for coronary heart
a strong association between accidents in childhood               disease. London: Department of Health, 2000a.
and social deprivation.
                                                                  Department of Health. The NHS cancer plan: A plan for investment, a plan
The costs of getting to hospital appointments,                    for reform. London: Department of Health, 2000b.

particularly for people needing frequent hospital visits          Department of Health. Modern standards and services models. Diabetes:
or who are under the care of several consultants, are             national service framework standards. London: Department of Health, 2001.
an issue for many people. Such costs include private              Department of Health. Tackling health inequalities: a programme for action.
transport, public transport, or the patient transport             London: Department of Health, 2003.
system. Issues about the cost of car parking, particularly
                                                                  Department of Health. Choosing Health: Making healthy choices easier.
at acute hospitals, are a source of anxiety, concern and          London: Department of Health, 2004a.
expense that many cannot afford.
                                                                  Department of Health. National standards, local action: health and social
                                                                  care standards and planning framework 2005/06 – 2007/08.
                                                                  London: Department of Health, 2004b.

                                                                  Department of Health. Delivering Choosing Health: Making healthier choices
       The Our health, our care, our say                          easier. London: Department of Health, 2005a.
        White Paper sets out a vision to
                                                                  Department of Health. Choosing a better diet: a food and health action plan.
       provide people with good quality                           London: Department of Health, 2005b.
      social care and NHS services in the                         Department of Health. National service framework for children, young
         communities where they live.                             people and maternity services. London: Department of Health, 2006a.

     One of the main themes of the White                          Department of Health. Review of Health Inequalities Infant Mortality PSA
    Paper, to which the Cornwall and Isles                        Target. London: Department of Health, 2007.

     of Scilly PCT is also committed, is to                       Department of Health. At least 5 a week: evidence on the impact of physical

     provide more care closer to people’s                         activity and its relationship to health – a report from the Chief Medical
                                                                  Officer. London: Department of Health, 2006b.
     homes. This will help address some
                                                                  Disability Rights Commission. Equal treatment: closing the gap. Stratford
       of the inequalities due to cost of                         upon Avon: Disability Rights Commission, 2006.
          accessing distant services.
                                                                  Healthcare Commission. Healthcare Commission strategic plan 2005/2008.
                                                                  London: Healthcare Commission, 2005.

                                                                  HM Government. Reaching out: an action plan on social exclusion.

Delivery
                                                                  London: Cabinet Office, 2006.

                                                                  National Centre for Social Research, Public Health at the Royal Free and
This strategy is being incorporated into the 20 20 health         University College Medical School. Health survey for England 2003.
and well being strategy for Cornwall and the Isles of             London: Department of Health, 2004.

Scilly, and will be delivered by the Health and Well Being        Office for National Statistics. Better or worse: a longitudinal study of
Board and their respective member organisations.                  the mental health of adults living in private households in Great Britain.
                                                                  Surveys of psychiatric morbidity among adults in Great Britain.
                                                                  London: The Stationery Office, 2003.

                                                                  Social Exclusion Unit. Making the connections: final report on transport and
                                                                  social exclusion. London: Social Exclusion Unit, 2003.

                                                                  Wanless D. Securing good health for the whole population.
                                                                  London: HM Treasury, 2004.

                                                                  Wanless D. Our Future Health Secured? London: King’s Fund, 2007.


                                                                  DSR: The directly standardised rate for CIoS is the rate of events that would
                                                                  occur in a standard population if that population were to experience the age
                                                                  specific rates of the CIoS population.




                                                             17
                                   THE HEALTH
                                   OF THE
                                   POPULATION
                                   Smoking




                                   THE ANNUAL REPORT OF THE
            2007




                                   DIRECTOR OF PUBLIC HEALTH FOR
                                   CORNWALL AND ISLES OF SCILLY




                                   Part 2
Cornwall and Isles of Scilly PCT
                                   please turn over
                                   report for part 1
The Health of the Population
                                                   Part 2
                                             Smoking
    Contents                                                                                           Page

    Introduction ......................................................................................... 1

    Section 1 .............................................................................................   2
         1.1 What impact does smoking have on health? ........................                                2
         1.2 Local impact of smoking ......................................................                   2
         1.3 Second-hand smoke (passive smoking)...............................                               2
         1.4 Costs of smoking ..................................................................              2
         1.5 Prevalence ...........................................................................           3

    Section 2 ............................................................................................    4
         2.1 Smoking and inequalities .....................................................                   4
         2.2 Minority ethnic groups ..........................................................                4
         2.3 Smoking in pregnancy..........................................................                   4

    Section 3 ............................................................................................ 5
         3.1 National policy ..................................................................... 5
         3.2 Brief intervention .................................................................. 5

    Section 4 ............................................................................................ 6
         4.1 Local action ......................................................................... 6

    Section 5 ........................................................................................... 8
         5.1 Strategic plan ...................................................................... 8
         5.2 Implementation .................................................................... 12
         5.3 Partners ............................................................................... 12
         5.4 Monitoring and evaluation ................................................... 12


                                     Other matters
    Infectious disease topics – Hepatitis C .............................................. 13

    Updates from 2006 and other Choosing Health updates .................. 14
        Climate change and health ........................................................ 14
        Obesity ....................................................................................... 15
        Sexual health ............................................................................. 17
        Mental health ............................................................................. 18
        Reducing harm and encouraging sensible drinking .................. 18

    Appendix – vital statistics ................................................................... 19
Introduction
With the introduction of smoke free legislation in         The Cornwall and Isles of Scilly Stop Smoking Service,
England on 1st July 2007 much attention has been           Smoke Free Cornwall and public health teams have
focused on the effects of smoking and second-hand          been working closely with partners from within and
smoke on the health of the population. These effects       outside the NHS to agree a revised strategy, which
include:                                                   builds on the considerable work and successes of the
                                                           previous strategy, and which takes into account the
                                                           changes in law and attitude that have developed over
                       Adults
                                                           the past few years.
   Stroke
   Cancer including
         Larynx
         Mouth
         Lung
         Bladder
         Pancreatic
         Throat
         Oesophagus
         Bowel
   Coronary heart disease
   Peripheral vascular disease
   Emphysema
   Chronic obstructive pulmonary disease
   (COPD)
   Gastric ulcers
   Dental – staining, gingivitis                           This report is divided into five sections
   Poor healing
                                                           Section 1 looks at the impact of smoking and
   Back pain
                                                                     second-hand smoke on health, the cost of
   Arthritis                                                         smoking to society and smoking prevalence
   Age-related macular degeneration                                  in adults and young people.
   Depressed immunity
   Impotence, infertility                                  Section 2 examines how smoking contributes to health
                                                                     inequalities.
   Osteoporosis
   Early menopause
                                                           Section 3 describes national policy and brief
                                                                     intervention.
              Children and babies

   Decreased intelligence                                  Section 4 gives details of local action, including
                                                                     smoking cessation, tobacco control, publicity
   Asthma
                                                                     and marketing.
   Respiratory disorders
   Frequent colds                                          Section 5 describes the recommended way forward
   Glue ear (otitis media)                                           and strategic plan for Cornwall and the Isles
   Low birth weight                                                  of Scilly.

   Sudden unexpected death in infancy
   Premature birth
   Hyperkinetic disease including ADHD




                                                       1
Section 1
1.1 What impact does smoking have                               (53% via the website and 47% by post). A summary
                                                                of the key findings provides clear and valuable evidence
on health?                                                      of the enormous public support that already exists to
Smoking is identified as the single most preventable            provide smoke free enclosed public places in the
cause of ill-health and premature death in the UK. It is        South West.
estimated that 114,000 deaths in the UK each year, or
one in five of deaths, at all ages are due to smoking.
In CIoS, over 1,000 people die each year as a result of
smoking; it also causes much illness.
                                                                1.3 Second-hand smoke (passive
                                                                smoking)
The three main causes of death from smoking are
                                                                Tobacco smoke contains over 4,000 chemicals in
cancer, chronic obstructive lung disease and coronary
                                                                gaseous and particulate form. Second-hand smoke is
heart disease. It is estimated that up to 84% of all lung
                                                                a mixture of side stream smoke from the burning end
cancer deaths, 83% of deaths from chronic obstructive
                                                                of the cigarette and mainstream smoke exhaled from
lung disease and 15% of all circulatory deaths in the
                                                                the smokers.
UK are due to smoking.
                                                                In November 2004 a report by the Scientific Committee
G   13 people die every hour
                                                                on Tobacco and Health (SCOTH) updated the evidence
G   40% die before retirement
                                                                on the health effects of second-hand smoke, reinforcing
G   80% start before age 15                                     the conclusions of their earlier report and strengthening
G   95% are addicted after six cigarettes.                      earlier estimates of the size of the health risk.
                                                                It confirmed that exposure to second-hand smoke
In CIoS in 2005, 258 deaths from lung cancer, 210
                                                                increased the risk of lung cancer and heart disease by
deaths from chronic obstructive lung disease, and 346
                                                                24% and 25% respectively. It also concluded that there
deaths from circulatory disease could be attributed to
                                                                was a strong link between exposure to second-hand
smoking.
                                                                smoke and adverse health effects in children, including
Deaths caused by smoking are five times higher than             serious respiratory illness and asthma attacks, sudden
the 22,833 deaths arising from: road traffic accidents          unexpected death in infancy and glue ear. This update
(3,439), other accidents (8,579), poisoning and                 confirmed that second-hand smoke represents a
overdose (881), alcoholic liver disease (5,121), murder         substantial public health hazard.
and manslaughter (513), suicide (4,066), and HIV
                                                                The British Medical Association’s Board of Science
infection (234) in the UK during 2002.
                                                                and Education estimates that in the UK at least 1,000
It has been found that men aged 35 years who continue           people die each year as a result of exposure to other
to smoke will, on average, die seven years earlier              people’s tobacco smoke. This equates to about 100
than men who have never been smokers. Likewise,                 deaths per year in the South West alone.
women of 35 years who continue to smoke will, on
average, die six years earlier than those who have
never smoked.                                                   1.4 Costs of smoking
The estimated cost to the NHS from smoking-related              Smoking costs society a significant amount each year
illness is between £1.4-1.7 billion annually.                   in terms of lost productivity and costs of health care
                                                                services. Each year the treatment of smoking-related
                                                                illnesses costs the NHS approximately £1.5 billion and
1.2 Local impact of smoking                                     accounts for 364,000 hospital admissions. The cost in
In the South West peninsula (Devon and Cornwall)                CIoS is approximately £12.5 million, and accounts for
nearly 3,000 people died every year between 1999 and            over 3,000 hospital admissions.
2002 from a smoking related illness.
                                                                Nationally over 34 million working days are lost per year
The Big Smoke Debate South West in 2004 asked                   as a consequence of smoking; in CIoS this is nearly
people living and working in the South West their               300,000 days. The estimated cost of smoking related
views on whether enclosed places such as restaurants,           absence in the UK is £400 million per annum, the
pubs, offices and shopping centres should become                equivalent of £3.3 million in CIoS. Total productivity
smoke free. A total of 23,843 people completed the              losses are estimated at approximately £3,000 million
survey via both the website and postal questionnaire            per annum (approximately £25 million in CIoS).



                                                            2
The careless disposal of cigarettes is one of the main          Children are three times as likely to smoke if both
causes of fire in homes and workplaces. Twelve per              of their parents smoke, and parents' approval or
cent of all accidental fires in the workplace are caused        disapproval of the habit is also a significant factor.
by smoking. The total losses directly attributable to           Numerous studies have shown that most young
fires caused by smoking materials are estimated at              smokers are influenced by their friends' and older
approximately £4 million each year.                             siblings' smoking habits.
It is estimated that smoking related litter accounts for        Children who smoke are significantly more susceptible
40% of all street litter.                                       to coughs and increased phlegm, wheeziness and
                                                                shortness of breath than those who do not smoke.
                                                                Consequently, young smokers take more time off school
1.5 Prevalence                                                  than non-smokers. The earlier children become regular
1.5 (i) Adults                                                  smokers and persist in the habit as adults, the greater
                                                                the risk of developing lung cancer or heart disease.
In England, it is estimated that 26% of adults (aged 16
                                                                Smokers are also less fit than non-smokers.
years and over) are cigarette smokers. The percentage
of smokers fell significantly in the 1970s and the early        Children are also more susceptible to the effects of
1980s (from 45% in 1974 to 35% in 1982) when the                passive smoking. Parental smoking is the main
link between smoking and ill health became widely               determinant of exposure in non-smoking children.
known. After 1982 the rate of decrease slowed and               Although levels of exposure in the home have declined
then levelled out from 1992, at around 26% to 28%.              in the UK in recent years, children living in the poorest
                                                                households have the highest levels of exposure as
Although overall, a greater proportion of men than
                                                                measured by cotinine, a marker for nicotine.
women smoke, this is not the case for those aged 16 to
19. In 2002/03, 29% of young women (aged 16 to 19)              Bronchitis, pneumonia, asthma and other chronic
were smokers compared to 22% of young men.                      respiratory illnesses are significantly more common in
Cigarette smoking prevalence is most common among               infants and children who have one or two smoking
people aged 20 to 34.                                           parents. Children of parents who smoke during the
                                                                child's early life run a higher risk of cancer in adulthood
There has been an increase in the proportion of men
                                                                and the larger the number of smokers in a household,
who have never smoked regularly (from 39% in 1993 to
                                                                the greater the cancer risk to non-smokers in the family.
44% in 2002) and a decrease in the proportion of men
                                                                For a more detailed overview of the health impacts of
who used to smoke cigarettes regularly but no longer
                                                                passive smoking on children see the ASH briefing:
smoke (from 33% in 1993 to 29% in 2002).
                                                                Passive smoking: the impact on children.
The proportion of women who have never smoked
                                                                All primary and secondary schools are required to
increased slightly from 52% in 1993 to 54% in 2002,
                                                                deliver tobacco education in the curriculum. The way
whilst the proportion that used to smoke regularly but
                                                                this is delivered varies from school to school. National
no longer smoke decreased from 22% in 1993 to 20%
                                                                and local evaluation of smoking education shows that
in 2002.
                                                                smoking education, delivered by adults, at best has no
                                                                positive effect on smoking prevalence, and, at worst,
                                                                increases it. Significant decreases can be achieved
1.5 (ii) Young people                                           through peer-led projects such as the Assist
In England about one fifth of Britain's 15 year olds –          programme, which has proved successful in a number
16% of boys and 25% of girls – are regular smokers –            of pilot areas in the UK.
despite the fact that it is illegal to sell cigarettes to
                                                                The Health Promotion Service Information and
children aged under 16.
                                                                Resources Service supplies teachers, school nurses
The proportion of children who have experimented with           and youth workers with information and educational
smoking has fallen from 53% in 1982 to 39% in 2004.             resources, and tobacco is a focus of the work being
Since 1993, girls have been more likely than boys to            undertaken within the Healthy Schools initiative.
have ever smoked. The proportion of regular smokers
increases sharply with age: 1% of 11 year olds smoke
regularly compared with 20% of 15 year olds.




                                                            3
Section 2
2.1 Smoking and inequalities                                      are particularly high in the Bangladeshi (40%), Irish
                                                                  (30%) and Pakistani (29%) populations. Among
The overall rate of 26% of adults who smoke masks                 women, smoking rates are low (at 8% or below) with
major differences between social groups in the UK.                the exception of Black Caribbean (24%) and Irish (26%)
In 2001, the prevalence of cigarette smoking continued            compared with the general population.
to be higher for people in manual than non manual
socio-economic groups (32% compared with 21%).
However, recent figures show smoking prevalence
                                                                  2.3 Smoking in pregnancy
among manual groups decreased from 33% in 1998 to                 The latest figures from the Infant Feeding Survey (2005)
31% in 2002. The differences in smoking rates between             showed a decrease in smoking rates during pregnancy.
groups are reflected in social gradients of deaths caused         In 2000, 35% of mothers in England smoked before or
by smoking. Premature deaths from lung cancer are                 during their pregnancy and 19% continued to do so
five times higher in men in unskilled manual work                 throughout their pregnancy. These figures were both
compared with those in professional occupations.                  lower in 2005 (32% and 17% respectively).
With little decline in smoking in the lowest income groups,       Despite this decrease, smoking during pregnancy
smoking is becoming concentrated in the poorest                   remains a serious issue. Significantly, women in routine
households in the region. Smoking is the greatest,                and manual occupations are three times more likely to
single factor in the different life expectancy between the        smoke throughout pregnancy than in managerial and
social classes. Death rates are now two to three times            professional occupations.
higher in disadvantaged social groups than in the more
                                                                  It is important to provide pregnant women and their
affluent, and poorer people can also expect to experience
                                                                  families with information about the particular dangers
more illness and disability problems. The economic
                                                                  of smoking and provide support to stop. This group
burden of smoking also weighs heaviest on the poorest.
                                                                  should remain a priority and it is hoped that the recent
The Family Expenditure Survey in 1998/99 (Department
                                                                  licensing of NRT for use with pregnant women will impact
of Health 2000) estimated that the average household
                                                                  positively on progress towards the target of 20% by 2010.
spent about 1.5% of their income on tobacco products,
compared to an expenditure of 15% of weekly income
in the poorest households.                                        It is important to reduce the number of women who
                                                                  return to smoking post-delivery. At present the vast
2.2 Minority ethnic groups                                        majority of women start smoking again once their
                                                                  baby is born.
Smoking rates vary considerably between ethnic groups.
In men (compared to the national average of 24%) rates




SOURCE: DEPARTMENT   OF   HEALTH




                                                              4
Section 3
3.1 National policy                                           smoking, and for those who already smoke, to help
                                                              enable them to quit. In response to this report, the
Smoking Kills (Department of Health, 1998) and the            Department of Health issued a consultation document
NHS Cancer Plan (Department of Health 2000) set out           Choosing Health: Making healthier choices easier
targets for reducing smoking prevalence in the overall        asking for public opinion on how best to improve the
population and within specific target groups to:              health of the nation.
G   reduce adult smoking from 28% in 1996 to 26%              Choosing Health highlighted the need to restrict
    by 2005 and 24% in 2010                                   smoking in most public places and workplaces to
G   reduce smoking among 11-15 year olds from 13%             protect the welfare of others, especially children, but
    in 1996 to nine per cent in 2010                          with exemptions for some pubs and private clubs
G   reduce smoking in pregnancy from 23% in 1995              because it allowed a degree of ‘choice’ for smokers.
    to 18% in 2005 and 15% by 2010                            The draft regulations were published in July 2006,
                                                              and removed the majority of the planned exemptions,
G   reduce smoking among manual groups from 32%               including pubs and clubs. When the law was
    in 1998 to 26% by 2010.                                   implemented on 1st July 2007, all enclosed workplaces
                                                              and public places became smoke-free. Hotel bedrooms,
In 2000, the Government launched the Tackling                 and designated rooms in care homes, hospices, long
Tobacco Smuggling Strategy to reduce smuggled                 stay mental health units and prisons will be exempt
cigarettes. It set a target:                                  from the legislation, but designated rooms with doors
                                                              that open onto smoke-free parts of premises will have
to reduce the proportion of smuggled cigarettes in            to have mechanical closing.
the market from 22% in 2000/01 to 17% by 2006.
                                                              Choosing Health highlighted the need for picture health
                                                              warnings on cigarette packets, due to be implemented
In 2003 the Government published Tackling health              in 2007/08 following a consultation process.
inequalities – a Programme for Action to reduce the
gap in infant mortality across social groups, and raise
life expectancy in the most disadvantaged areas               3.2 Brief intervention
faster than elsewhere. The plan set out a number of
smoking prevention strategies to meet this challenging        Brief intervention, carried out by health and social care
target.                                                       professionals, has been proven to be successful in
                                                              encouraging patients and clients to make a quit attempt.
In 2003, the UK Government signed the World Health
Framework Convention on Tobacco Control and is
working towards its ratification. This commits the                      Intervention               Success rate *
Government to a range of issues such as introducing
a comprehensive ban on tobacco advertising and                     No treatment                       5%
sponsorship, controls on labelling of products,                    NRT / Bupropion with
education about the health effects of tobacco, tackling            limited support                    13%
smuggling, protection of the public from the effects
of second-hand smoke, and measures to reduce the
                                                                   Behavioural support only           13%
availability and promotion of tobacco to young people.             Behavioural support
                                                                   with NRT / Bupropion               21%
The most recent estimates show 1 in 6 cigarettes and
about half of hand-rolling tobacco smoked in Britain
are smuggled imports resulting in a net loss to the           * approximate percentage of quit attempts achieving at
Government of more than £2 billion a year. It also            least six months of continuous abstinence as a function
means that tobacco is cheaper for the consumer –              of treatment.
so leading to higher consumption.
                                                              A scheme in the west of Cornwall has trained most
The Wanless Report (2004) suggested that in order to          community staff in the delivery and benefit of brief
meet the health needs of the population over the next         intervention, and provided information on the work of
ten years more effective preventive programmes should         the Stop Smoking Service.
be implemented to help prevent people from taking up




                                                          5
Section 4
4.1 Local action                                               case better than, services offered in surgeries. This
                                                               scheme has now been rolled out to other areas of the
4.1 (i) Smoking cessation                                      county to address gaps in service provision.
Stop smoking services were set up in England in 1999,
following the publication of Smoking Kills. The services
were initially set up using Health Action Zone funding,        4.1 (ii) Tobacco control
and provided help, support and one week’s free nicotine
replacement therapy through a scheme operated by               Tobacco control is the term used to describe a number
local pharmacies. The emphasis changed to services             of activities to reduce tobacco use and the harm caused
provided through GP surgeries when nicotine replace-           by tobacco. It is comprised of three key aims:
ment therapy (NRT) became available on prescription.           G   To reduce smoking prevalence

The Stop Smoking Service in Cornwall and the Isles             G   To reduce availability of tobacco products
of Scilly, funded through the PCT, helped 3,874 clients        G   To reduce exposure to second-hand smoke.
stop smoking at four weeks in 2006/07 (equating to
60% of clients quitting at four weeks). Evaluation             Effective tobacco control is important to smoking rates.
shows that 23% of these are still smoke-free after 12          Research shows that measures such as restricting
months.                                                        smoking in public places and underage sales laws,
                                                               increases the number of people making quit attempts,
The Stop Smoking Service in Cornwall and the Isles             reduces the number of cigarettes smoked and delays
of Scilly has over 100 trained, active advisers working        the age at which young people start smoking. Thus the
from a range of settings including GP surgeries,               ban on smoking in public places from July 2007 should
community clinics, workplaces, hospitals and community         make a substantial contribution to these aims.
centres.
                                                               There have, historically, been limited financial resources
In 2006 the service piloted a scheme in Restormel.             to address issues around tobacco control – policies,
This provided a patient group direction for pharmacists        underage sales, imported tobacco etc. Some monies
to provide NRT to clients, and to support them in their        have been made available through Government Office
quit attempt. The evaluation after six months showed           to develop tobacco alliances, encouraging partnership
that the scheme was popular in areas where there               working between health, local authorities, local
was a limited choice of services – the Clay area and           businesses, Customs and Excise, community groups
Newquay. The quit rate was as good as, and in one              etc. Through the Cornwall and Isles of Scilly alliance,




SOURCE: DEPARTMENT   OF   HEALTH




                                                           6
Smoke Free Cornwall has promoted smoke free                     Smoke Free Cornwall has provided support for
workplaces – shops, hotels, restaurants, playgroups etc.        employers who wish to implement a smoke free policy.
– through the Guide to smoke free Cornwall and Isles            This has included involvement with the development of
of Scilly. This has been a very positive approach to            the policy, consultation with staff and providing help
tobacco control, highlighting good practice to employers.       and support for those members of staff who wish to
                                                                stop smoking. In 2006 this was extended to include
In 2001, the Health Development Agency published                NHS trusts, helping them to meet the need to be smoke
the lessons learned from the National Tobacco Control           free by the end of the year. Over 100 members of staff
Alliance Scheme. It states that local alliances of              went on to stop smoking at four weeks.
partnerships can be very effective in taking action
to reduce smoking prevalence and that they tend to
‘broaden the scope of health organisations beyond
helping smokers to quit and increases public attention
and debate of tobacco control issues’.                          4.1 (iii) Publicity and marketing
                                                                In addition to the national helpline, a local helpline has
It described a number of factors needed for effective           been set up to signpost smokers to local services.
alliance working:                                               A local media campaign has also been undertaken to
G   Consensus among alliance members on their goals             promote the service, while national media campaigning
    and strategies                                              has been extended.

G   Sufficient funding                                          The Stop Smoking Service should take a proactive
G   Sufficient time                                             approach to raising awareness of the dangers of
                                                                smoking and the benefits of stopping, and promote
G   Senior level co-ordinator with administrative support
                                                                cessation services through a programme of advertising
G   Senior staff and experienced, knowledgeable                 and marketing, which uses a range of media.
    members who are centrally involved in the alliance
                                                                To contact the Stop Smoking Service,
G   Investment in training, e.g. in media skills, smoking
                                                                please call 01209 215666, or 0800 169 0 169.
    cessation interventions, evaluation methods
G   Coverage of an area that is not too diverse, e.g.
    covering rural and urban, or with health and local
    authorities covering different areas.




SOURCE: DEPARTMENT   OF   HEALTH




                                                            7
Section 5
5.1 Strategic plan

Objectives:
G   To reduce the overall prevalence of smoking
    in the county

G   To reduce the levels of smoking amongst
    pregnant women

G   To reduce the levels of smoking amongst
    young people

G   To reduce the levels of exposure to second-hand                SOURCE: DEPARTMENT   OF   HEALTH
    smoke in areas not covered by the smoking
                                                                   G   To work with other agencies to reduce sales of
    legislation, e.g. homes
                                                                       tobacco to under age persons (the age limit rose to
G   To target services in areas of the highest deprivation             under 18 in October 2007)

G   To work to improve the one year quit rate amongst              G   To work with other agencies to reduce the quantities
    those giving up tobacco                                            of smuggled tobacco available in the county.




                                                                                   Date

    Pregnancy            Action Point – To reduce the number                     Ongoing              Stop Smoking Service
                         of pregnant women smoking, by                                                Midwives
                         delivery of a midwife-led specialist                                         Children’s centres
                         cessation service to support pregnant
                         women and their partners to stop
                         smoking.


                         Action Point – To deliver a                              By 2009             Stop Smoking Service
                         programme of work to achieve the LAA                                         Health visitors
                         target to reduce the number of women                                         Children’s centres
                         who return to smoking post-pregnancy.
                         To develop a process to contact
                         mothers who gave up smoking before
                         or during pregnancy not through the
                         Stop Smoking Service.


                         Action Point – To investigate adopting              December 2008            Stop Smoking Service
                         the Smoke Free Homes programme                                               Health visitors
                         to encourage parents to allow their                                          Children’s centres
                         children to grow up in a smoke-free
                         environment.


                         Action Point – To provide brief                        June 2008             Stop Smoking Service
                         intervention training for all midwives,                                      PCT
                         health visitors and others who work
                         with families, encouraging health and
                         social care staff to engage with
                         smoking education/cessation.




                                                             8
                                                               Date

Young people    Action Point - To ensure all schools in    December 2008    Stop Smoking Service
                Cornwall and Isles of Scilly are trained                    Cornwall Healthy Schools
                to provide a programme of tobacco                           programme
                education through implementation of                         LEA
                the national recommendations on
                smoking prevention and education.


                Action Point – To pilot an Assist            July 2008      Stop Smoking Service
                programme in six schools in Cornwall;                       Cornwall Healthy Schools
                working with Cornwall Healthy Schools                       programme
                programme.                                                  School nurses/PCT
                                                                            Schools


                Action Point – To work with Cornwall       from July 2007   Stop Smoking Service
                Healthy Schools to ensure all schools                       Cornwall Healthy Schools
                have a tobacco policy, and to assist                        programme
                with the implementation of the
                requirements of the new smoking
                legislation.


                Action Point – To invite the County        October 2008     Stop Smoking Service
                Youth Service (In Touch) and other
                youth organisations to undertake brief
                intervention and smoking cessation
                training. This would allow those
                working with young people to address
                issues around tobacco with their
                client group.


                Action Point – To work with Healthy          April 2008     Stop Smoking Service
                Schools to provide training for                             Cornwall Healthy Schools
                Education out of School and Children                        programme
                in Care.


Publicity and   Action Point – To seek opportunities          Ongoing       Stop Smoking Service
marketing       to raise awareness of the dangers                           Media
                of smoking, the benefits of stopping,
                and promote cessation services
                through development of a structured
                communication and marketing
                programme.


                Action Point – To promote No                  Ongoing       Stop Smoking Service
                Smoking Day. Approximately 40,000                           Media
                people nationally quit smoking on this
                day every year.




                                                    9
Section 5.1 Strategic plan


                                                             Date

  Tobacco       Action Point – To co-ordinate tobacco       Ongoing      Stop Smoking Service
  control       control work in Cornwall and the Isles                   Local authorities
                of Scilly through development of a
                multi-agency partnership.


                Action Point – To contribute to the         Ongoing      Stop Smoking Service
                work of the environmental health                         Local authorities
                departments to provide support for
                workplaces around the new smoking
                legislation, including a website and
                seminars.


                Action Point – To work in partnership       Ongoing      Trading Standards
                to reduce the supply and availability                    Stop Smoking Service
                of tobacco products. This could be                       HM Customs and Excise
                done by promoting the proof of age
                and responsible retailer schemes
                with Trading Standards, reduction of
                smuggling of tobacco products and by
                working with the sub-regional alliance
                of HM Customs and Excise.


  General       Action Point – To achieve the               Ongoing      Stop Smoking Service
                nationally set targets for the number                    PCT
                of people stopping smoking at four
                weeks.


                Action Point – To provide brief            June 2008     Stop Smoking Service
                intervention training for primary                        PCT
                and secondary care NHS staff,
                encouraging them to engage with
                patients to address their smoking.


                Action Point – To provide training for      July 2008    Stop Smoking Service
                health trainers and health champions.     then ongoing


                Action Point – To improve access to         Ongoing      Stop Smoking Service
                smoking cessation services.


  Workplaces    Action Point – To raise awareness of        Ongoing      Stop Smoking Service
                the benefits of a smoke-free workforce.                  Local authorities
                                                                         Employers


                Action Point – To support employees         Ongoing      Stop Smoking Service
                including NHS staff, to stop smoking,                    Employers
                through development of a cessation
                service provided by the Stop Smoking
                Service.




                                                     10
                                                                                Date

   LAA                             Action Point – To develop and             March 2009     Stop Smoking Service
                                   deliver the smoking LAA to improve                       Health and Well Being
                                   the 12 month quit rate through                           Board
                                   development of a level III service, and
                                   support women to stay smoke-free
                                   post-delivery. To deliver specialised
                                   smoking cessation in the areas of
                                   highest deprivation.


                                   Action Point – To work in partnership     March 2009     Stop Smoking Service
                                   with other LAAs.


   Deprivation                     Action Point – To reduce the smoking        Ongoing      Stop Smoking Service
                                   rate for adults in deprived communities
                                   by development of targeted level III
                                   services.


   Mental Health                   Action Point – To work with Cornwall       July 2008     Stop Smoking Service
                                   Partnership Trust on implementing the                    CPT
                                   smoking legislation.                                     Cornwall County Council

                                   Action Point – To train mental health      July 2008     Stop Smoking Service
                                   workers in smoking cessation and brief                   CPT
                                   interventions.                                           Cornwall County Council

                                   Action Point – To work with the           January 2008   Stop Smoking Service
                                   Health Promotion Service’s Mental                        CPT
                                   Health Promotion Co-ordinator on
                                   the inclusion of smoking in a mental
                                   health strategy.




SOURCE: DEPARTMENT   OF   HEALTH




                                                                      11
Section 5.1 Strategic plan




5.2 Implementation                                             5.3 Partners
What needs to be in place to deliver?                          Local Authorities – Environmental Health, Trading
                                                                   Standards
1.   Sufficient funding.
                                                               Local Education Authority
2.   Appropriately trained staff.
                                                               Customs and Excise
3.   Strong partnerships, robust avenues of                    Healthy Schools
     communication and sharing of resources.                   Community organisations
4.   More effective ways of getting publicity into the         Health professionals – primary and secondary care
     media. Locally targeted campaigns.                        Youth Services
5.   Flexibility of approach – local situations require        Chambers of Commerce and other business groups.
     local responses.
6.   Continuation of current work placing level III            5.4 Monitoring and evaluation
     advisers with community organisations, allowing           It is essential for future service planning and design that
     them to develop relationships with other                  we know what the outcomes are for the people who
     organisations working in the area.                        access our smoking cessation services. Smoking
                                                               cessation activities should be monitored and analysed
7.   Continuation of current changes in providing
                                                               using a minimum set of indices to enable us to know
     facilities away from the NHS into more community
                                                               what is working and for whom. A national database
     venues including community centres and public
                                                               has now been set up for this purpose that will record
     houses.
                                                               information about each individual attending the smoking
8.   A holistic approach to smoking related issues –           cessation service, including their quit success at 4, 12
     working with Job Centres, CABs etc.                       and 52 weeks after the initial quit date. This is crucial
                                                               information to inform decisions about patterns of service
                                                               delivery.
                                                               Action Point – To continue to commission the 12 month
                                                               review of quitters including client satisfaction survey.



                                                          12
Infectious disease topic
Hepatitis C                                                          A hepatitis C health needs assessment in Cornwall
                                                                     and Isles of Scilly has been undertaken recently which
First identified in 1989, hepatitis C (non-A, non-B
                                                                     shows that with a total registered population of 536,450
hepatitis) is now recognised as a global public health
                                                                     in April 2006, an estimated 2,682 people have been
problem. It causes inflammation of the liver and can
                                                                     infected with hepatitis C and 2,146 are chronic carriers.
lead to other serious health problems, and can have
a massive impact on a person’s quality of life. It is a              The scale of the threat that hepatitis C poses to public
potentially fatal, chronic disease, caused by hepatitis C            health in England was flagged by the publication of the
virus (HCV) At the time of infection there are rarely any            National Strategy for Hepatitis C (2002). This was
symptoms, leading to it being labelled ‘the silent epidemic’.        followed by the Hepatitis C Action Plan (2004), aiming
Currently there is no vaccine for HCV. The World                     to support local activity to improve services. In the
Health Organisation estimates that 3% of the world’s                 light of these publications and the NICE guidance on
population has been infected. An estimated 0.5% of the               antiviral treatment for hepatitis C, a co-ordinated and
general population in England (approximately 250,000                 strategic approach is needed to tackle hepatitis C.
people) has been infected with hepatitis C. About 20%
                                                                     In Cornwall and Isles of Scilly we have agreed that
of those infected appear to get rid of the virus naturally
                                                                     we need to focus on the four key areas of prevention,
without treatment. Thus, 0.4% of the population (some
                                                                     testing, treatment and surveillance.
200,000 people) is chronically infected with hepatitis C.
However, there have been only 38,000 diagnoses of                    The main recommendations are to:
hepatitis C infection reported in England, so it must be
concluded that the majority of infected people are                   G   Review and strengthen local prevention activities
undiagnosed. Most people with diagnosed hepatitis C                      including needle exchanges with increased
infection are men aged between 25 and 45 years.                          collaboration between services with drug users
This reflects the fact that men are more likely than                     and prisoners as the priority groups for future
women to be injecting drug users (the major route of                     preventative activities.
transmission). Factors associated with more rapid
progression of disease are male gender, infection when               G   Increase public and professional awareness of
older (over 40 years) and alcohol consumption.                           hepatitis C and improve training for individuals and
                                                                         organisations involved with drug users and people
G   The relatively large number of people who are
                                                                         with hepatitis C.
    unknowingly infected will not be aware that reducing
    or stopping alcohol intake could help minimise the               G   Increase access to testing facilities provided in a
    liver damage from hepatitis C infection. They also                   range of clinical and community settings such as
    risk spreading the infection to others and may miss                  GUM clinics, drug services and primary care, and
    out on effective drug treatments.                                    dissemination of testing protocols and pathways
                                                                         across Cornwall and Isles of Scilly.
G   Moderate to severe disease can now be treated
    successfully in up to 55% of cases overall. If chronic           G   Improve access to treatment through provision of
    infection is left untreated, most people will eventually             treatment in primary, secondary and tertiary settings.
    develop symptoms, and one in five go on to develop                   Establish outreach clinics to support treatment in
    cirrhosis of the liver after 20 years or more. A small               community settings (e.g. drug services, GP practices)
    number develop primary liver cancer.                                 and GPs with a specialist interest, and specialist
                                                                         hepatology nurses to work across different settings
G   Chronic infection is now the leading indication for                  to support the delivery of treatment services.
    liver transplantation in developed countries and will                Cornwall and Isles of Scilly PCT has agreed to fund
    continue to pose an important public health and                      a pilot of delivering local treatment in the west of
    economic burden over the next 10-20 years. About                     Cornwall for hepatitis C patients from April 2008 using
    15% of liver transplants in England are undertaken                   this model to treat less complicated cases. Cornwall
    because of chronic hepatitis C infection. High costs                 and Isles of Scilly PCT and DAAT commissioners will
    of drug treatments (up to £12,000 per patient), other                jointly implement these local recommendations and
    medical interventions and liver transplants represent                develop services to respond to local levels of need.
    a substantial burden on the NHS. This underlines
    the importance of prevention of this infection and
    disease progression.



                                                                13
Updates from 2006 and other
Choosing Health updates
Climate change and health                                         to assume CIoS travel takes up at least a quarter of
                                                                  this total.
The 2006 annual public health report focussed on the
expected health problems that will occur as the effects           Some 86% of visitor and 77% of patient trips to
of global warming become more apparent. Put briefly               hospitals are by private car. Each year, the combined
we said that rising temperatures will lead to more insect         total of out-patient visits, hospital episodes, and visitor
borne disease e.g. malaria; to more food poisoning; and           trips to hospitals serving CIoS, exceeds one million.
to more heat-related deaths. The rising sea levels and
                                                                  Within the NHS in CIoS there has now been developed
greater variation in weather patterns will lead to more
                                                                  a Save It! programme with all staff encouraged to take
flooding so causing loss of homes and employment.
                                                                  steps to reduce energy consumption in their daily work.
This will lead in turn to more stress and ill health.
                                                                  This scheme also helps in reducing the energy bill for
During 2007 the Department of Health has updated its              the NHS. Regular reminders (e.g. ‘Lighting an office
2002 document Health Effects of Climate Change in the             overnight wastes enough energy to heat water for 1,000
UK and this is now out for comment. In brief, the authors         cups of tea’; ‘A typical window left open overnight in
say that it is now clearer than ever that the climate             winter will waste enough energy to drive a small car
is changing, and that an increase in temperature of               over 35 miles’) are publicised via the in-house web site.
between 2.5 and 3°C is likely by the end of the                   All chief executives in the NHS in CIoS are signed up to
century. There are also likely to be greater numbers              the Save It! programme.
of extreme weather events. In terms of vector-borne               As part of the NHS Strategic Review in CIoS in late
disease, the situation looks more encouraging, with               2006, a background paper on Sustainability/Carbon
outbreaks of malaria remaining rare. It is however,               Emission Reductions was produced and adopted.
important to remain vigilant. Warmer summers are
likely to be associated with an increase in food-borne            A major reduction in carbon emissions can be achieved
diseases. Even though summers in the UK have                      by implementing plans to move as much clinical care as
become warmer, there has been no change in the                    possible to more local settings. This reduces the need
number of heat-related deaths, suggesting that the                for patients and their relatives to travel to large, more
population is capable of adapting to warmer conditions.           distant NHS sites.
Heat waves however, still represent a serious risk. Air           With the restructuring of the PCT following the mergers
pollution is likely to change, with some pollutants likely        of the three former PCTs last year, many headquarters
to decrease in concentration. Ozone however, is likely            members of staff now have the opportunity of working
to increase in concentration. The number of cases of              in the base (Camborne, St Austell or Saltash) nearest
skin cancers is likely to increase.                               to their own home – so reducing home to work travel
Thus the NHS, all public and private organisations                emissions. The PCT provides ‘switch off ’ stickers for
and all individuals should do all they can to reduce their        electrical items in all NHS premises in the county and
carbon footprint.                                                 has formed a staff group to help consider what more
                                                                  can be done to reduce travel and other carbon emitting
The NHS in CIoS emits approximately 19,000 tons of                activities. It will be important to try and ensure all new
carbon annually through the use of 70,000 megawatts               buildings are carbon neutral.
per year in its buildings, and at a cost of between £3m
                                                                  Within CIoS the NHS is looking at the possibility of
and £4m.
                                                                  converting the output of one heating boiler at Royal
NHS staff in CIoS travel approximately 9 million miles            Cornwall Hospital from gas to woodchip (locally sourced
in their cars each year on NHS business, producing                supply), and at the possibilty of wind power on site.
about 600 tonnes of carbon (assuming a car travelling             At Penrice Hospital in St Austell, there is hope of sharing
15,000 miles a year produces about one tonne of                   technology with other bodies for a combined heat and
carbon emissions). This is likely to be exceeded by               power supply.
emissions arising from personal commuting.
                                                                  Another approach being pursued by the NHS in CIoS
In addition the ambulance and patient transport                   is to reduce the amount of ‘food miles’ travelled, by
fleets travel eight and half million miles per year for           seeking to locally source food for patient meals,
Somerset, Devon and CIoS. It is probably reasonable               combined with local production of such meals.



                                                             14
The possible conversion of some NHS vehicles to                      television, or working on computers at home and in
run on bio fuels, is under consideration, as is the                  offices. In a relatively short space of time, we have
encouragement through the lease car schemes of the                   re-designed our total environment to allow these trends
most fuel efficient vehicles (probably diesel engines                to become entrenched.
that have been fitted with particle filters (FAP)).
                                                                     Last year, the Primary Care Trust (PCT) published an
Cornwall County Council has an innovative scheme of,                 Obesity Strategy, and this section covers the highlights
one week a year, offering all staff the opportunity to try           of our progress in implementing that strategy. However,
public transport to travel to work at no cost to themselves.         it is certain that it has not yet reversed the rising trend
About 140 staff (out of a total of 16,000) have applied              in obesity, and has almost certainly not halted it. It has
for the scheme this year. Previous years’ analysis has               taken over fifty years for us to reach this state; it cannot
shown that these users of the scheme have found that                 be reversed overnight.
public transport is easier to use than they imagined, and
many have said they will continue to use public transport,
at least on some occasions. The County Council                       Early years and families
sponsoring of the Falmouth-Truro rail line upgrade to a              Infant feeding co-ordinators are now in post and
half hourly service from 2008 should increase the use                implementing training county-wide to increase
of public transport along that corridor – and given the              breastfeeding rates.
very frequent bus service from Truro station to Royal
Cornwall Hospital, may increase overall public transport             Healthy eating and physical activity advice is being
travel to that hospital site.                                        delivered in partnership with Family Services and
                                                                     Children’s Centres. Weaning and general dietary
For further information on reducing your carbon footprint,           advice is being given to new mothers. Health visitors
please visit:                                                        are involved in the Healthy Start voucher scheme and
http://www.direct.gov.uk/en/environmentandgreenerliving              vitamin supplement dispensing.
/actonco2/DG_067197
Fossil fuels now provide an increasing amount of                     School age
energy embodied in modern travel systems, buildings,
                                                                     The PCT is appointing additional school nurses, to
food, clothing and medicines. Usage has grown to the
                                                                     strengthen a team who are now required to add the
point at which consumption worldwide exceeds future
                                                                     annual measurement of primary school children’s height
production of material, which whilst apparently
                                                                     and weight to their already busy schedules. School
abundant, is in limited supply. Many of the measures
                                                                     nurses will be trained in the new Obesity Care Pathway.
described above to cut carbon emissions involve
reducing our dependency on fossil fuels; such actions                Recommendations for Children’s Centres to combat
will need to be much more extensive and enforced.                    obesity have been developed with multi-agency
                                                                     consultation. A Why Weight? pilot course for families
                                                                     with young children and weight concerns started in
                                                                     summer 2007 and will run to spring 2008.
Obesity                                                              A Healthy Start welfare food programme, first piloted in
                                                                     Cornwall Children’s Centres, is now rolled out nationally.
Introduction
                                                                     Ninety-five per cent of all CIoS state schools are
It is now known that the majority of adults in the UK are
                                                                     enrolled and actively engaged in the Healthy Schools
overweight or obese, and that for men the ratio is
                                                                     programme. The target of 50% of schools to achieve
approaching 2:1.i We do not have accurate data for
                                                                     Healthy School status by December 2006 has already
CIoS, but have no reason to believe it differs much from
                                                                     been exceeded. The programme is currently being
the national picture. So, to be overweight or obese is a
                                                                     enhanced to enable schools that are already validated
normal response in today’s society. Why should that
                                                                     to widen and deepen work on core themes, targeting
be, and what can be done by whom?
                                                                     interventions based on specific, assessed needs.
There is now such easy access to foods that are highly               There has been good progress in implementing the
calorific, or to labour-saving (i.e. effort-denying) devices,        healthy food and drink programme across schools, with
especially private cars.ii Never before have we spent                the standards now being extended to include breakfast
so much of our waking hours sitting still, watching                  and after-school clubs.



                                                                15
Updates from 2006 and other Choosing Health updates




In the 2006/07 financial year, cooking sessions were            increased year on year and 224 schools within CIoS
held with over 500 individuals (half led by family              (82%) requested resources for May 2007 WTSW.
learning tutors). Healthy eating sessions ran with five
                                                                Workplaces across CIoS are showing signs of an
hundred attendees. Over 90 cooking group tutors
                                                                increasing awareness of the need to keep employees
were trained. In addition, over 3,000 people benefited
                                                                active, and at least have the choice of healthier food.
from the grant scheme. The aim is to achieve at least
                                                                Ginsters in Callington is foremost, in appointing an
the same in 2007/08 and to make cooking sessions
                                                                activator who in six months encouraged two-thirds of
available to parents across the county through every
                                                                the workforce to take part in a range of activities, in
Children’s Centre.
                                                                their own time. The rate of participation is steadily
The Cornwall Healthier Eating and Food Safety Award             rising, as new activities are planned.
(CHEFS) – for catering outlets (including workplaces)
                                                                Through the Local Area Agreement, a programme of
is being promoted. Currently, 33 food premises
                                                                work has been agreed and is being implemented with
county-wide belong to the scheme.
                                                                the common aim of halting the rise in obesity. This is
One hundred and sixty-eight schools have approved               led jointly by the NHS and the Cornwall Sports
travel plans. The aim of the travel plan is to increase         Partnership. This fosters and encourages a range of
the number of children that walk or cycle to school, and        interventions, which are based on sound evidence,
reduce the number of children travelling by car. Our            delivered by trained and enthusiastic staff, and are
target is to have all 274 primary, secondary and nursery        reaching several thousand participants. They include
schools with travel plans by 2010. Therefore 35 travel          Eatsome, LEAPActive, Mobilise!, Stroll Back the Years,
plans require approval per year, for the next 3 years to        Pedal Back the Years, Bones in Mind, Keep on your
meet our target. We also encourage schools to partake           Feet, and street games (alternatives to team sport for
in Walk to School Week (WTSW) in May and October                young people).
every year. The number of schools partaking has



                                                           16
Publicity                                                              ii
                                                                         Davis A, Valsecchi C and Fergusson M. Unfit for purpose.
                                                                       How car use fuels climate change and obesity. London:
Lack of information has become less of a problem.                      Institute for European Environmental Policy, 2007.
The range, availability and attractiveness of leaflets
and websites has never been greater, with the West
Cornwall Healthy Living Centre’s (www.wchlc.org.uk),                   Sexual health
Sport England’s Active Places (www.activeplaces.org),                  Sexual health remains a priority for the Primary Care
Health Promotion (www.healthpromcornwall.org) and                      Trust, as nationally we are continuing to see an
Sustrans (www.sustrans.org.uk) being particularly                      increase in sexually transmitted infections (STIs) such
noteworthy.                                                            as HIV, syphilis, Chlamydia, genital herpes and warts.
                                                                       New diagnoses of HIV and other STIs are increasing
Over the last 12 months the following educational
                                                                       rapidly in the South West, although the rate of new
sessions have been held:
                                                                       diagnoses remains lower than the England average.
G   two full day educational sessions about tackling                   We are also seeing a higher rate of hospital admissions
    obesity, as part of the rolling programme of                       for pelvic inflammatory disease in the South West, a
    educational sessions for practice nurses,                          known complication of Chlamydia infection.
G   five evening sessions for pharmacy staff on                        The Sexual Health Local Implementation Group
    ‘promoting a healthy weight’,                                      (SHLIG), in collaboration with all stakeholders, has
                                                                       been undertaking a mapping exercise of all existing
G   one half day session on public health topics,
                                                                       sexual health services. This is being used to jointly
    including obesity, for junior doctors,
                                                                       create a sexual health strategy, which will assist with
G   a full day conference.                                             the modernisation and reshaping of sexual health
                                                                       services in Cornwall and Isles of Scilly.
Monitoring                                                             In Cornwall we also have a Local Area Agreement that
All GP practices in CIoS now have an obesity register,                 covers many aspects of sexual health, including the
which helps keep track of patients’ weight and prompts                 raising of awareness of sexual health issues, promoting
intervention. In the west of Cornwall this includes                    safer sex, increasing opportunities for screening and
the pilot Slimming on Referral project, which will be                  treatment, and reducing sexually transmitted infections.
evaluated in early 2008. The height and weight of
                                                                       By March 2008, 100% of patients attending GUM
schoolchildren is checked annually. Sport England
                                                                       services are to be offered an appointment within 48
funds an annual survey of the amount of physical
                                                                       hours of contacting the service. Both Royal Cornwall
activity that adults say they undertake.
                                                                       Hospitals Trust and Plymouth Hospitals Trust are
These initiatives are however not enough to reverse the                achieving good results in the Health Protection Agency
rising incidence of overweight and obesity. One part                   audit, which takes place on a quarterly basis. The most
of the UK that has lower rates of obesity, and where                   recent audit took place in February 2007 and RCHT
physical activity rates have risen markedly in recent                  achieved 89% and PHT achieved 94% access.
years, is London. The introduction of the congestion
                                                                       The CIoS Chlamydia screening programme was set up
charge in London in 2003 enabled a regular new source
                                                                       in 2003 as part of the government’s phase one roll out
of funding to be applied directly to increasing the opportunity
                                                                       of Chlamydia screening. The target group is sexually
for, and desirability of active modes of travel, especially
                                                                       active 15-25 year olds. Chlamydia is a public health
cycling and walking, and better public transport, which
                                                                       issue due to its easy spread, numbers infected, lack of
itself involves a walk as part of the journey. The charge
                                                                       symptoms, complications in both sexes with possible
proved a political success, and the area covered has
                                                                       long term health and financial implications. In 2005/06
subsequently been extended. All councils in England
                                                                       CIoS rates of infection were 1 in 9; national rates are
have the power to introduce a similar measure. It is a
                                                                       1 in 10. In 2006/07 our rate in those tested has
tried and tested way of getting people more physically
                                                                       dropped to 1 in 11 (9% positivity). This cannot be used
active in large numbers. In Cornwall and the Isles of
                                                                       to imply an improvement in disease burden but may be
Scilly we need to make changes that will have a similar
                                                                       an indication of increased genuine ‘opportunistic’
impact, and make healthier choices easier for all of us.
                                                                       screening through the programme.
i
 Source: http://www.statistics.gov.uk/CCI/nugget.asp?ID=1658
&Pos=3&ColRank=2&Rank=576 The actual values are 67% of                 Significant progress has been made in developing the
adult men overweight or obese; 57% women.                              Local Area Agreement to tackle teenage pregnancy.



                                                                  17
Updates from 2006 and other Choosing Health updates

The targets however, remain very challenging. During             Recreation placements, and a hard copy and online
2004/05 in the South West the number of conceptions              Stepped Care Resource Directory for Primary Care
per 1,000 women aged 15 –17 was 34·2. In Cornwall                Mental Health Services will be developed.
the number was 34·8 compared to the target of 28·7.
                                                                 We will also be improving our perinatal mental health
This has resulted in an amber/red rating for the county.
                                                                 service by employing an expert to support secondary
All of the posts identified in the strategy have now been
                                                                 mental health service teams with the prediction,
appointed. This has significantly enhanced the delivery
                                                                 detection, treatment and management of mental
of the strategy. We have also established a Teenage
                                                                 disorder in women planning a pregnancy and during
Pregnancy Steering Group, with representatives from
                                                                 the perinatal period. This person will also provide
voluntary and statutory bodies from all young people
                                                                 specialist mental health training, support, liaison and
agencies across Cornwall and the Isles of Scilly.
                                                                 advice to primary care health professionals, including
Our key priorities for sexual health in 2007/08 are to:          GPs, midwives and health visitors. The service will
                                                                 be accessible to people with additional needs such as
G   Modernise and redesign sexual health services,
                                                                 physical, sensory or learning disabilities and to people
    increase the number of service delivery locations,
                                                                 who do not speak or read English.
    and meet new targets
G   Modernise contraception services to enable broader
    access and choice                                            Reducing harm and encouraging
G   Extend the range of initiatives aimed at                     sensible drinking
    preventing STIs                                              The Government has launched the update to its alcohol
                                                                 strategy called Safe, Sensible, Social. This strategy
G   Reduce teenage conception rates
                                                                 shows the progress that is being made and reinforces
G   Increase the uptake to the Chlamydia screening               the direction in which it wants further work to go. It is
    programme.                                                   particularly keen to promote sensible drinking and
                                                                 enable individuals to be aware of their own drinking
Mental health                                                    levels. A national public awareness campaign is
We are close to implementing the Stepped Care Model              planned for early in 2008. This strategy is supported
for mental health in primary care. This model aims to            by a report on alcohol by the Public Health Observatory
match the needs of people with depression to the most            as part of their Indications of Public Health. This
appropriate services, depending on the characteristics           highlights that the most deprived communities suffer
of their illness and their personal and social                   most from the consequences of hazardous drinking.
circumstances. The service is in the process of being
                                                                 In Cornwall and the Isles of Scilly, action plans are
reconfigured in line with National Institute of Health
                                                                 being put in place to take forward our local strategy.
and Clinical Excellence (NICE) guidance and the
                                                                 There has been particular enthusiasm to work
ten high impact changes for mental health services.
                                                                 in partnership. One development has been the
These changes aim to make sure that every service
                                                                 recruitment of an officer to work with young people’s
user receives the best possible care every time.
                                                                 services to promote sensible drinking. This post has
The DH white paper Our health, our care, our say sets            been developed by representatives from health, the
out a radical and sustained shift in the way services            Drug and Alcohol Action Team (DAAT) and the
are delivered, with an emphasis on the realignment               voluntary and community sector.
of resources from secondary to community settings to
                                                                 Work continues to extend the community hospital
achieve optimum efficiency.
                                                                 detox service, where GPs are providing the medical
The service will increase the choice of interventions for        treatment and care. Development of screening and
people with mild to moderate mental health problems.             brief interventions continues including work with A&E
A number of new primary care graduate mental health              departments, and partners within primary care,
workers and community development workers will be                probation, and employment services.
employed. There will be the implementation of
computerised cognitive behaviour therapy as per NICE
guidelines and an enhancement of the Books on
Prescription scheme. There will also be an increase in
primary care referrals to Pentreath Industries Work and



                                                            18
Appendix – vital statistics
Table A: Population estimates
Estimates of resident population for England and Wales (mid year 2005) estimate on 2001 Census based on revisions
made in August 2006.
Cornwall resident relevant population estimates based on GP lists July 2006.




                   Note: columns may not add up due to rounding




                                                         19
Table B: Infectious diseases
Source: Cornwall & IoS Health Protection Unit 2007. Note: values between 0 and 10 or those allowing values between
0 and 10 to be determined by subtraction are shown as *.




                                                           20
Table C: All births showing age of mother by area of usual residence
Source: VS2 2006.




Table D: Under 18 conceptions: numbers and rates by mother’s area of usual residence
Source: Office of National Statistics, 2007, Teenage Pregnancy Unit.




Table E: Terminations by age, 2004
Source: Office of National Statistics, 2005, Teenage Pregnancy Unit.
Note: values between 0 and 5 or those allowing values between 0 and 5 to be determined by subtraction are shown as *.




(1) Rates for all ages are based on populations aged 11-49 and include cases with age not stated.
(2) Rates for ages under 18 are based on populations aged 11-17.
(3) Age not stated have been distributed pro-rata across age group 20-24.
(4) Rates for ages 35+ are based on populations aged 35-49.
Cornwall population taken from October 2004 resident population



                                                          21
Table F: Deaths by age
group 2006 and usual
area of residence
Source: VS3 2006.




Table G: Childhood
and infant deaths, 2006
Source: VS5 2006.
Note: Perinatal deaths: stillbirths
plus deaths in the first seven
days. Infant deaths: deaths in
the first year, excluding stillbirths.




Table H: Percentage of people in ethnic groups
Source: Office of National Statistics, 2001, Census.




                                                       22
Table I: SMRs for selected causes of death 2003-2005 with 95% confidence intervals
Source: Compendium of Clinical and Health Indicators 2007.
Note: values where the SMR would indicate a number of deaths between 0 and 5 are shown as *.
SMRs: Age standardisation facilitates comparison across geographical areas by controlling for differences in the age
structure of local populations, and the indirectly standardised mortality ratio (SMR) is the ratio of observed to expected
deaths in an area. The SMR of England for any given cause of death is always 100. Local SMRs greater than 100
indicate higher mortality than the national average, and SMRs less than 100 indicate lower mortality than the national
average. However, SMRs should always be compared with the standard, i.e. England, and not with each other.




                                                            23
Most causes of death in CIoS have rates, when adjusted for age and sex, that are lower than England and Wales (see
table 1). The charts below show trends over time for causes of death where SMRs are above the figures for England
and Wales. The causes for these high rates will be reviewed in more detail through 2008.




                                                         24
Table J: Deaths from selected causes
Deaths in 2005 by age and sex for selected causes, with rates for the period 2003 to 2005.
Source: Compendium of Clinical and Health Indicators 2007.
Note: values between 0 and 5 or those allowing values between 0 and 5 to be determined by subtraction are shown as*.




                                                         25
Table J (continued): Deaths from selected causes
Deaths in 2005 by age and sex for selected causes, with rates for the period 2003 to 2005.
Source: Compendium of Clinical and Health Indicators 2007.
Note: values between 0 and 5 or those allowing values between 0 and 5 to be determined by subtraction are shown as*.




                                                         26
Table K: Deaths from selected causes under the age of 75 years
Deaths in 2005 aged under 75 years at time of death.
Source: Compendium of Clinical and Health Indicators 2007.
*Females ** Males.




                                                       27
COUNCIL OF THE           HEALTH OVERVIEW             15.1.08         PART 1 DECISION
ISLES OF SCILLY          AND SCRUTINY                                ITEM 9

Title                   Future Shape of Cancer Services in the Peninsula
Author                           Assistant Chief Technical Officer

1        Introduction

1.1      The attached briefing paper is provided for Members to consider whether the
         proposals for Cancer Services in the Peninsula constitutes a significant
         variation from existing arrangements.

2        Information

2.1      See attached briefing paper from David Chambers, Director of the Peninsula
         Cancer Network.

3        Recommendation

3.1      That Members consider if the proposals are deemed to be a significant
         service change and warrant public consultation in the Isles of Scilly.




Implications  Environmental Impact                    None as a result of this report
              Community Health Implications           Implicit
              Crime and Disorder Reduction            None as a result of this report
              Best Value Implications                 None as a result of this report
              Financial Implications                  None as a result of this report
              Legal opinion Required/ Date            No: Date
WT/15 January 2008
        Future shape of Cancer services in the Peninsula




               Briefing for Overview and Scrutiny Committees




1. Summary




1.1   The purpose of this briefing is to outline how the shape of
      cancer services in Devon and Cornwall may need to change to
      improve the quality of care in the best interests of patients.


2. Background



2.1   The Peninsula Cancer Network (PCN) was formed in December 2000 to

      address the issues identified in the 1995 Calman-Hine report and the

      resultant NHS Cancer Plan issued in September 2000. The Cancer Plan set

      out a programme of investment and reform to improve outcomes and to

      tackle the problems of poor survival rates and variations in the quality of

      cancer services within the UK.




2.2   The Plan has a number of ambitious aims with the overall aim to save more

      lives and to improve the patient’s experience by ensuring that people with

      cancer have the best treatment through access to the right professional

      support, at the right time, in the right place.
2.3   All NHS organisations and associated voluntary bodies are represented

      through the Peninsula Cancer Network Executive Board and governance

      arrangements agreed with stakeholders enable it to work on behalf of all

      acute Trusts and PCTs.




3. Specialist centres


3.1   Much has been achieved across the Network but one of the
      biggest challenges we face is the re-shaping of services where
      cancers are rarer and where expertise – surgical in the main
      but not exclusively - needs to be concentrated in fewer places
      or ‘centres of excellence’.

3.2   Surgical specialisation is equally important for the less common
      cancers where surgery is usually required in addition to
      radiotherapy and/or chemotherapy. Currently this is usually
      performed by surgical teams in most hospitals however
      Calman-Hine indicated that patients in the UK experienced
      some of the highest mortality against comparable countries and
      recommended a greater degree of specialisation in the
      treatment of these less common cancers.

3.3   Since Calman-Hine, the National Institute for Clinical Excellence
      (NICE) has worked with groups of experts and professionals in
      the field and patients to develop best evidence based practice
      guidelines for all cancer care. Their recommendations on the
      best treatment possible for these cancers are published as
      Improving Outcomes Guidance (IOG). IOG reports have now
      been produced for most types of cancer with the earliest, for
      the most common cancers, Breast, Bowel and Lung, already
      fully implemented in Devon & Cornwall.

3.4   The move to perform the most challenging operations and
      treatments in specialist centres by highly experienced surgeons
      is driven by the aim to improve outcomes for patients. This is
      not a cost-cutting or cost-control agenda and indeed there has
      been an unprecedented increase in investment in cancer
      services across the NHS.

3.5   Although, patients may need to travel for the specific operation,
      cooperation between the clinicians in the Cancer Centre and
      local Cancer Units ensures that pre-operative assessment and
      any post-operative radiotherapy or chemotherapy is carried out
      locally.
4. Improving Patient Experience of Cancer


4.1   We have an active Patient & Carer Partnership Group which
      helps us develop and improve cancer services across the
      Network. A key part of our work in the Network is to look at
      services from the patient’s point of view and Partnership
      members sit on all our Tumour Site Specific and other groups.
      Through these we have developed patient pathways for most
      cancers which define the course of treatment from the first visit
      to the GP to discharge or ongoing long term care.

4.2   All patients with a diagnosis of cancer are now managed by a
      multi-disciplinary team (MDT) comprising all those who might
      be involved in their care even where they may work in different
      organisations. It is not sustainable for all MDTs to have input
      from all members of the team present at all acute Trusts and
      concentrating expertise on fewer sites for the less common
      cancers makes the best use of clinicians’ time.


5. IOG population criteria


5.1   For the less common cancers a critical mass or minimum
      number of cases is required to develop and maintain the
      expertise and skills to treat patients appropriately. The NICE
      guidance suggests for some tumours the occurrence in a
      population of around 1 million and a minimum number of
      patients are necessary for maintaining skills but these figures
      vary between different IOGs.

5.2   With a population of 1.7 million in the Peninsula, for most of the
      less common cancers we have been able to support two centres
      of excellence but for some tumours a population of 2 million
      (testicular) is required and for penile cancers it is over 4 million
      needing a supra-network specialist team. We have been
      developing our strategies around services since the network
      was established and for changes have already occurred for
      some cancers.

6. Gynaecological Cancers

6.1   The IOG defines a Gynaecological Cancer Centre as serving a
      population (men and women) of at least one million with
      around 200 new referrals per annum. A Gynaecological Cancer
      Unit would serve populations of at least 200,000 (anticipated
      range 100,000 – 400,000) this would usually represent about
      50 new referrals p.a.

6.2   In the Peninsula, the Gynae plan agreed in 2004 designated the
      Royal Devon & Exeter Hospital as the Gynae Cancer Centre
      providing all vulval and high grade cervical cancer surgery for
      Devon and Cornwall. Truro was designated a Cancer Unit
      continuing to provide endometrial and straightforward ovarian
      cancer surgery with non-surgical treatment of all Gynae cancers
      being provided in all five acute Trusts.

6.3   Full implementation of the plan has been delayed pending
      retirements but with the designation of Plymouth as an
      additional Cancer Unit, the Network Board has determined that
      the plan is should be completed by the end of December 2007.

6.4   For patients in North Devon and Torbay, their Gynae cancer
      surgery will take place in Exeter and cases of vulval and
      cervical cancer in Plymouth and Truro will receive their surgery
      in Exeter. The anticipated patient flows are as follows:

      Gynae activity 2006

               Plymouth          Cornwall             Exeter
            Torbay           NDevon
      Vulval          17          6             14           4
      3
      Cervical    26          23          38          13          6
      Endometrial     65             62         82           36
      22
      Ovarian     62          76          65          35          22
      Rare        4           4           6           8           0

      Total       174         171         205         96          53

      Anticipated Gynae surgical flows to Exeter in a full year

               Plymouth              Cornwall   Torbay
                  North Devon
                Gynae Unit           Gynae Unit already go already go

      Vulval            6            4
      Cervical   8            6
      Endometrial
      Ovarian
      Rare       4            4

      Total       18          14

      Anticipated Gynae workload 2008

               Plymouth              Cornwall            Exeter
                  Torbay           N Devon
                Gynae Unit        Gynae Unit    Gynae Centre
       Vulval          17-6      6-4                14 +6+4   4
       3
       Cervical   26-8      23-6                    38 +8+6   13
       6
       Endometrial     65        62                 82        36
       22
       Ovarian    62        76                65         35        22
       Rare       4-4       4-4               6 +4+4     8         0

       Total      174-18        171-14        205+32     96        53

       New Total 156            157           237

       This shows a net movement of around 18 patients from
       Plymouth and 14 from Cornwall.

6.5    The Royal Cornwall Hospitals Trust has recently appointed a
       replacement lead consultant who has an international
       reputation. It is hoped that his arrival in the Peninsula will
       provide a valuable opportunity for close collaboration with the
       specialist team at the Gynae centre in Exeter where he might
       make his skills available to patients from across the Network as
       a whole.

7. Upper gastro-intestinal Cancers

7.1    The implications arising from this NICE guidance are that we
       had to identify at least one or two centres for the surgical
       treatment of Upper GI cancers. This has been the subject of an
       external review which led to the decision by PCT Chief
       Executives to designate Derriford as the single centre for
       oesophago-gastric resections in the Peninsula.

7.2    To comply with the IOG and the findings of the 2006 Peer
       Review, the workload from Cornwall is expected to transfer to
       Plymouth by the end of December 2007. The anticipated
       patient flows are as follows:

       Anticipated Upper GI surgical flows to Plymouth in a full
year

                        RD&E            Cornwall   Torbay
                        North Devon
                          UGI Unit UGI Unit   via Plymouth          via
RD&E
       Total               55            20
      It is anticipated that the full workload of the single centre will
      be 120-150 per annum.

8. Head & Neck Cancers

8.1   The IOG for Head & Neck cancers states that these services
      should be concentrated in Head & Neck Cancer Centres serving
      populations of over 1 million patients and at least 100 newly
      diagnosed cases. We have obtained the agreement of the
      National Cancer Action Team to having two centres at Plymouth
      and Exeter with Specialist MDTs involving participation from
      clinicians from the other two Trusts which currently provide
      these services. Truro will work with Plymouth and Torbay with
      Exeter which already provides a service to North Devon.

8.2   Currently within the Peninsula there are four separate multi-
      disciplinary teams dealing with Head and Neck Cancer; Exeter
      already manages all patients from North Devon. These
      individual MDTs (or multi-professional joint clinics) have been
      established for many years and provide a high quality service
      fulfilling the majority of NICE Standards. The majority of
      patients are treated locally, but there is already some cross-
      referral for specialised procedures.

8.3   Discussions are progressing on the definition of which cases
      may still be treated surgically at Truro and Torbay with the
      transfer of the complex work to the two specialist centres due
      to be completed to Exeter by April 2008 and Plymouth by July
      2008. The anticipated patient flows are as follows:

      Anticipated Head & Neck surgical flows in a full year

                         From          From               From
                         Truro        Torbay      North Devon

      To Plymouth                65
      To Exeter                         50        already seen

      Total               65            50

9. Video Conferencing

9.1   The Cancer Network has funded the installation of video-
      conferencing facilities in each of the five Trusts to overcome the
      geographical challenges of the Peninsula. Their location in MDT
      rooms will ensure that clinicians will be able to fully participate
      in MDTs affecting their patients whilst remaining in their own
      hospital base. This brings economic advantages as well as
      minimising the time clinicians may lose by travelling to other
      sites for Joint MDTs.

10. Ensuring Quality

10.1 Clinical Governance arrangements in individual organisations
     require the standards of care to be consistent with the best as
     outlined by NICE to ensure equitable services to all our
     patients. The services involved in cancer care are subject to
     rigorous Peer Review every three years against defined quality
     measures which are derived from the NICE guidance.
     Organisations who fail to demonstrate good achievement will
     potentially face de-recognition as ‘accredited’ service providers.

10.2 Commissioners need to be satisfied that services are compliant
     with both the cancer measures and agreed patient pathways
     and service specifications. To buttress this, Peer Review for
     cancer care will soon be more closely linked with the Health
     Commission and their inspection of Trusts. All specialist teams
     will be required to present annual audits of their outcomes to
     their colleagues in the network and increasingly share these
     nationally.

11. Future Plans

11.1 Other NICE guidance has being published and the resultant
     plans are in draft form for Skin and Neuro-oncology. Sarcoma
     is awaiting national decisions on whether there can be a Soft
     Tissue Sarcoma centre for the Peninsula. Children and Young
     People’s services have been reviewed and as they span more
     than one Network are being coordinated across the south West
     SHA area as a whole.

12. Conclusions

12.1 We hope that this paper will provide OSCs with the information
     they require to judge whether the changes outlined require
     formal consultation.

12.2 Points to consider include:

      • In the past patients in Devon and Cornwall have regularly
        travelled to Bristol or London for specialist health services.
        These changes will establish specialist centres of excellence
        within the Peninsula;

      • The number of patients affected by the change is small. All
        pre-operative and post-operative assessment and continuing
        treatment will be provided locally. The only travel will be for
        the specific operative intervention. This is different from the
        situation where patients need to access the distant service
        repeatedly over months and years;

     • Other authorities have not considered a service variation as
       substantial if the proposed service change improves clinical
       governance, reduces risk and is based upon agreed best
       practice and national guidance.

12.3 The necessary commissioning decisions to support the
     implementation of these changes must be made by Primary
     Care Trusts. Before doing so, PCTs must inform their local
     OSCs of possible service changes and enable OSCs to come to a
     view, on behalf of their populations, as to whether formal public
     consultation is required.

12.4 One of the proposals, related to upper GI, has been deemed by
     Devon Overview and Scrutiny Committee to be a significant
     service change and as such, to warrant public consultation in
     Devon.

12.5 This briefing paper has been considered by the OSCs in
     Plymouth (7 November 2007), Torbay (20 November 2007) and
     Cornwall (27 November 2007). These committees have
     formally resolved that the proposed changes do not require
     formal public consultation. The Cornwall Health and Adult
     Social Care OSC resolved that ‘the Committee agrees that the
     proposals, in their entirety, do not represent a substantial
     change to services and therefore do not require a formal, 3
     month consultation process and therefore that the Trust is not
     required to take any further action’. The paper will be
     discussed with the OSC on the Isles of Scilly on 15th January
     2008. Members of the Cancer Network are available to attend
     to speak to this paper should this be required.




David Chambers
Director – Peninsula Cancer Network
COUNCIL OF THE     HEALTH OVERVIEW             15.1.08          PART 1 INFO
ISLES OF SCILLY      AND SCRUTINY                               ITEM 11

Title                        Star of Life Activity Report
Author                     South Western Ambulance Service




                  Report of the South Western Ambulance Trust
                                    Attached.
                                           Report to

                          The Council of the Isles of Scilly

                  Health Overview and Scrutiny Committee

Purpose

The purpose of this brief paper is to allow the South Western Ambulance Service NHS Trust
(SWAST) the opportunity to update The Council of the Isles of Scilly Health Overview and Scrutiny
Committee on the current position regarding the Ambulance Medical Launch (The Star of Life).

Background

The Star of Life has suffered a number of problems since its introduction, the majority of these are
linked to the twin Cummins engines which were installed when the launch was first built.

Most recently the Star of Life has been out of service since the middle of November 2007, although
it is well known that ambulance/medical provision has not been interrupted due to the
commissioning of the Blue Hunter. SWAST have been in contact with the owner of the Blue Hunter
to discuss the arrangement for hire and to ensure there is no foreseeable problems, in the short to
medium term, which would compromise cover. In the longer term any replacement to the Star of
Life will feature as part of the ongoing review of resources.

This most recent episode has prompted us to seek expert advice from engineers and the
manufacturers of the Star of Life’s engines, to ascertain how this latest negative event can be
turned into a positive.

It is our opinion we would be better to use the resources available to us presently, to resolve these
ongoing issues, with a view to improving the resilience offered by the Star of Life. We also believe
there is an opportunity to resolve a number of the issues raised by Health Overview and Scrutiny
Committee Report of the Single Issue Panel on the Ambulance/ Medical Launch Services, dated
December 2006.

Progress
As indicated above SWAST have used this current situation to review the potential for improving
the resilience of the Star of Life. In considering the best way forward we have consulted with
engineers and Cummins and can report the following;

      •   New engines will be purchased which are of a higher output compared to the originals,
          the old units were 315 hp the new units are 355 hp. This will provide power units which
          are considered to be superior to the old units and will therefore be more reliable.

      •   This power increase will allow the launch to come up on to the “plane” quicker, and will
          require less power to hold the launch there. In turn the Star of Life will use less fuel; this
          is in line with the wishes of several stakeholders and in line with our commitment to the
          Green agenda.

      •   Due to advances in technology, we are reliably informed by the manufacturers the new
          engines will be quieter; this is in tune with our commitment to reduce noise pollution.

      •   It is the opinion of the engineers that modifications to the launch would be
          advantageous. Work has commenced to modify the air inlets, water intakes & battery
          stowage; this work will also aid long term reliability.

      •   It is essential when fitting new engines that they are mated to the gearboxes. The boat
          gearboxes were delivered to the engine manufacture in Southampton on Wednesday the
          19th of December to carry this work out.

      •   Following the mating of the engines with the gearboxes they will be ready for fitting. We
          aim to have the finished units delivered to the islands during the Christmas/New Year
          period to allow installation to commence.

      •   This initiative, to improve the reliability of the Star of Life, represents a considerable
          commitment by SWAST. With this in mind and given there are several strands of work we
          will retain the services of a project manager based in Falmouth to oversee & manage the
          whole project.

      •   We plan to have the boat back in the water and operational by the 1st of February 2008.
          Whilst this may seem a considerable period of time, this is the perfect opportunity to
          complete this work due to the low numbers of activations at this time of year.

Recommendation

The Council of the Isles of Scilly Health Overview and Scrutiny Committee are recommended to
note the contents of this paper.
COUNCIL OF THE HEALTH OVERVIEW                         15.1.2008      PART 2 INFO
ISLES OF SCILLY AND SCRUTINY                                          ITEM 13

Title                           Joint Strategic Needs Assessment
Author                             Director of Community Services

1        Introduction

1.1      All local Authorities and PCT’s are required to produce a Joint Needs
         Assessment in order to plan for future sustainable service.

2        Information

2.1      Cornwall and CIOSPCT have produced a report looking at the needs of
         Cornwall.
         It has been suggested that for this year this report recognises the different
         needs of the Isles of Scilly and then over the course of the next year looks at
         the specific needs of the Islands in order to produce a separate report for next
         year.

2.2      At this time the Director has received a copy of the draft report and is looking
         at it given that a lot of this information has already been collected as part of
         the older person’s strategy. Where possible this report will be amended to
         include this more accurate information.

2.3      A copy of the first draft is attached for information

3        Financial Implications

3.1      None

4        Recommendations

4.1      That this report be accepted for information.




Implications  Environmental Impact                       None as a result of this report
              Community Health Implications              None as a result of this report
              Crime and Disorder Reductions              None as a result of this report
              Best Value Implications                    None as a result of this report
              Financial Implications                     See Paragraph 3
              Legal opinion Required/ Date               Yes/No: Date
PC/22 January 2006
                       HOS - 15.1.08 - Item 13 APPENDIX 1



Joint Strategic Needs Assessment for

      Cornwall & Isles of Scilly




      December 2007 Draft 1




                                                  2
INTRODUCTION ........................................................................................................ 4

PRESENT SITUATION IN CORNWALL AND ISLES OF SCILLY ............................ 5

Demography ........................................................................................................................................................ 5
  Age and size of the population ...................................................................................................................... 5
  Population Projections .................................................................................................................................... 6
  Ethnicity............................................................................................................................................................. 7
  Migrant Workers............................................................................................................................................... 8
  Refugees and Asylum Seekers ..................................................................................................................... 9
  Gypsies and Travellers ................................................................................................................................... 9

Social and Environmental Context .............................................................................................................. 10
  Deprivation...................................................................................................................................................... 10
  Housing ........................................................................................................................................................... 13
  Rurality and Access to Services .................................................................................................................. 13
  Income and Employment .............................................................................................................................. 14

Current Known Health Status of the Population ...................................................................................... 14
  Illness and Lifestyle ....................................................................................................................................... 14
  Chronic Illness in older people .................................................................................................................... 14
  Chronic Illness - Census 2001 ..................................................................................................................... 14
  Smoking .......................................................................................................................................................... 15
  Healthy Eating and Obesity.......................................................................................................................... 16
  Childhood Obesity ......................................................................................................................................... 16
  Teenage Pregnancy ...................................................................................................................................... 17
  Breastfeeding and Smoking ......................................................................................................................... 17

Current Met Needs of the Population.......................................................................................................... 18
  Social care ...................................................................................................................................................... 18
     Adult Social Care Provision in Cornwall .......................................................................................... 18
     Learning Disabilities .............................................................................................................................. 19
     Carers ........................................................................................................................................................ 21
     Dementia ................................................................................................................................................... 22
  Primary care ................................................................................................................................................... 24
     Disease Prevalence ................................................................................................................................ 24
     Immunisation ........................................................................................................................................... 27
  Hospital data .................................................................................................................................................. 27
  Patient/service user voice ............................................................................................................................ 28
     Complaints ............................................................................................................................................... 29

Issues in Cornwall............................................................................................................................................ 30
   Skin Cancer .................................................................................................................................................... 30
   Hip fracture ..................................................................................................................................................... 31
   Mental health .................................................................................................................................................. 32
   Alcohol ............................................................................................................................................................. 34
   Infant mortality................................................................................................................................................ 35


WHAT IS ALREADY BEING DONE? ...................................................................... 36

WHAT SHOULD WE DO NEXT? ............................................................................. 38


                                                                                                                                                                        3
Introduction
The Joint Strategic Needs Assessment is an opportunity to determine priorities
together across organisations in a geographic area. It is these priorities that can then
be taken forward. In Cornwall we have linked with other government initiatives to
ensure a joined up approach.
Document and strategies from Cornwall & Isles of Scilly that have informed this Joint
Strategic Needs Assessment are
      • Health Inequalities Strategy
      • Health & Well Being Strategy
      • The issues paper which inform the Sustainable Community Strategy for
          Cornwall
      • The Prospectus
      • Adult social care joint planning
      • Children and Young People’s Plan, particularly the needs assessment.
These documents allow a holistic view of the local priorities as they are built from
both quantitative data and qualitative views collected from the population through
community surveys, local council best value and many other sources (see
appendix1).
Throughout we look to define achievable improvements in health and well being and
build into the process the ability to inform the next stages of the commissioning cycle,
and enable the information to underpin, with the SCSC, the Local Area Agreement
for Cornwall.
Much of the information will include the needs of the Isles of Scilly but in addition the
Islands are developing their own assessment as they have very particular
requirements. The Island’s Local Strategic Partnership produce their own sustainable
community strategy and Local Area Agreement.
Climate change and demographic pressures have been identified by the Cornwall
Strategic Partnership as the two topics that are the most important for Cornwall to
address.
The Sustainable Community Strategy for Cornwall will be completed by April next
year. 17 issues papers have been written, from which the outcomes of the Local Area
Agreement will be chosen. Consultation on the Health and Well Being Strategy is
underway and will continue through the beginning of 2007.
Our JSNA will follow the initial guidance from the Department of Health
Commissioning framework for Health and well being. It includes the primary data as
highlighted in Table A and extends this to include issues that are important for
Cornwall.
 As we have gone through he information we have identified gaps where further
information is required, either to provide more robust information or where it would be
important to have it available at a finer geographical aggregation.
In addition to the present document we will provide the sources of the data to allow
further identification of problems.




                                                                                        4
Present Situation in Cornwall and Isles of Scilly



Demography


Age and size of the population

The total population of Cornwall is approximately 539,100. (Estimates of resident
population for England and Wales (mid year 2005) from 2001 Census based on
revisions made in August 2006). Population pyramids allow comparison between age
and sex structures of the populations of two areas. Figure 1 compares CIoS to
England and Wales. For both sexes there are smaller numbers of people under 45
years of age and greater numbers over the age of 50 in CIoS compared to England
and Wales as a whole.
BOTH POP PYRAMIDs are figure 1 – should be side by side




Figure 1. Population estimate 2005
Source: Office for National Statistics 2005 mid year population estimates




2029




                                                                               5
Population projection 2029
Source: Office for National Statistics 2005 mid year population projections



Population Projections
Comparing the projections shows an increasingly ageing population due to declining
fertility rates and declining mortality rates. Nationally there will be declining numbers
of under 16s and an increasing population aged 65 plus.

In Cornwall and the Isles of Scilly over many years there has been an inward
migration of people aged 50 and over and this is expected to continue. The
percentage of people aged 85 and over in CIoS in 2005 is 2.7% compared with 2.0%
nationally and in 2029 is projected to be 4.9% compared with 3.5% nationally. In
CIoS these percentages equate to 14,200 people over the age of 85 in 2005 and a
larger increase to 30,800 by 2029. People over the age of 85 are far more likely to
require health and social care support services and this projected growth in both
numbers and percentage terms will require planning for.

The general fertility rate for Cornwall in 2005 was lower than that of England. In
Cornwall there were 52.7 live births per 1000 women aged 15-44 in 2005 compared
with 58.5 in England.




                                                                                       6
It is yet to be seen if the opening of the Combined Universities in Cornwall helps
young people to remain in the county. House prices play a major role in preventing
young people from remaining in CIoS as affordable housing is very scarce.




Between 2007 and 2012 there is a projected increase in the population of Cornwall
and the Isles of Scilly of 4.9% with the population increasing by approximately 30,000
people. These projected increases are across all of the districts with an increase of
3.7% in Caradon, 4.2% in Carrick, 5.1% in Kerrier, 5.9% in North Cornwall, 3.4% in
Penwith and 6.6% in Restormel.
The projected increase in the South West’s total population is 3.5% compared with
4.9% in Cornwall.

In 2007 20.5% of the population of Cornwall are aged 65 years or above. The
projected population figures suggest that in 2012 those aged over 65 will make up
22.9% of the population. The Cornwall Carers Commissioing Strategy points out that
by 2021, the total number of people aged 65 and over is projected to be 154,600
people, which makes up 26.1% of its overall population compared with an England
average projection of 20.8%. Cornwall’s population is growing at a greater rate than
that of South West England. The projected increase in those aged 65 and over is
13.1% in South West England compared with 17% in England. The projected
increase in those aged 75 and over is 6.6% in South West England compared with
8.3% in Cornwall. The projected increase in those aged 75 years and over is 4% for
women and 14.2% for men.


When the population is split into 5 year age bands, it is seen that the greatest
percentage increase in Cornwall is projected to be in the 65-69 age band with an
increase of 35.7%. In the 5 year period there is a projected increase in those aged 65
and over of 17%. In this 5 year period there is a projected increase in those aged 75
and over of 8.3%. These projected percentage increases compare with a projection
of a 1.9% increase in those aged 0-64 years.



Ethnicity
In Cornwall and Isles of Scilly 95.6% of the population are ‘white British’ compared
with 85.3% of the population of England as a whole.
It is widely known that some people from a Black or Minority Ethnic (BME) group
experience poorer health and have unequal access to health services than the general
population. Diabetes, coronary heart disease, hypertension, stroke and osteoporosis
are more common in some BME groups. Survey results show higher consultation
rates for respiratory diseases, particularly asthma, among the Asian population and to
a lesser extent African-Caribbean populations. The overall rates of cancer are lower
in non-European ethnic groups. However there is some evidence that rates in these
groups living in the UK generally are increasing towards that of the whole population


                                                                                    7
possibly due to changes in exposure to risk factors such as diet and smoking. The
rates of Lung Cancer in Asian and African-Caribbean men are increasing
predominantly due to smoking. Higher rates of other cancers of the head and neck are
seen in Asians and African-Caribbean communities but lower rates of cancers of
stomach, colon, bladder, ovary and uterus. Some people who come from countries
with a high prevalence of Hepatitis B carriers have a higher risk of developing liver
cancer.

Key health issues for BME children are Sickle Cell disease and Thalassaemia, which
are higher in people from the African sub continent and some Mediterranean
countries. Immunisation uptake rates are usually higher in ethnic minority groups
when they have access to a GP or health visitor, but a higher percentage of this group
do not access health care. Haemophillis Influenza Type B (HIB) infection is
significantly more common in Black and Asian people so vaccination is particularly
important. Hepatitis B infection is also more common in South Asian children and
pregnant women who do not have a Rubella programme are at a higher risk. A
particular group of vulnerable children are unaccompanied 16-18 year old Refugee
and Asylum Seekers many of whom present with mental health problems.

Black African groups are disproportionately affected by HIV and AIDS. The national
picture also shows that many sexually transmitted infections are more common in
certain BME groups. However teenage pregnancies are lower in many BME
communities.

There is limited data nationally and anecdotal evidence show that drug and alcohol
use is evident in BME communities and that a range of drugs are used. Data
indicates that overall drug and alcohol use is more widespread among Whites than
any other ethnic group.

The hospital admission rate for mental illness in the ethnic minority population is on
average 9% higher than for the UK population as a whole. The highest rates are
found in Irish communities and the next highest in people from the Caribbean. South
Asians have lower than average admission rates.

There is much controversy over the reasons for these differences but no doubt
relatively high levels of socio-economic deprivation, cultural attitudes and
biological/genetic difference all play a part. Also different types of mental illness are
reflected within the different ethnic groups. Among African-Caribbean young men for
example a diagnosis of schizophrenia is 3-6 times more frequent than in the whole
population but there are potential issues here around diagnosis bias. Also studies
involving Asian people have not always given consistent results but there does seem
to be a consistently higher suicide rate among young Asian women.

A map illustrating ethnicity by super output area will be added.


Migrant Workers
One exceptional characteristic of ethnic mix of the population is the continuing
increase in the number of migrant workers. Migrant workers are defined as those
people born outside the UK, who have come to the UK within the last 5 years,
specifically to find or take up work, whether intending to remain permanently or


                                                                                      8
temporarily, and regardless of whether documented or undocumented. (Working
Lives Research Institute, London Metropolitan University)
At present locally developed systems for collecting intelligence on migrant workers
are in their infancy, therefore, it is still necessary to rely on nationally produced
statistics. There are a number of official data sources, which include National
Insurance number registrations from the Department for Work and Pensions and
data derived from various schemes from the Home Office e.g. Workers Registration
Scheme. The WRS was introduced in 2004 and only applies to those from the
Accession 8 Countries. WRS applications in Cornwall have tended to be
concentrated in West Cornwall with over 40% working in agriculture and a further
25% in manufacturing. Over 50% of WRS applications are from Polish workers and a
further 27% are Lithuanian. (Source: WRS registrations May 2004 – March 2006,
Home Office).
Not all employers or workers are aware of the legislation and therefore many workers
may not be registered. Indeed, many casual workers many not work for a single
employer for longer than a month. Casual work is particularly prevalent in the tourism
and agriculture sectors which both of which are important parts of the economy in
Cornwall. Workers may not register for a number of reasons including the fact that it
costs £70 to do so. Research has shown that in the studies carried out, for every 100
registered workers, there are possibly between 56 and 200 unregistered workers, a
significant range.
Migrant workers in Cornwall are likely to experience greater deprivation than the rest
of the population. They are likely to have poorer access to and knowledge of local
services than others.


Refugees and Asylum Seekers
There are very few refugees or asylum seekers in Cornwall. The Department of Adult
Social Care will be undertaking an equity audit in the new year.


Gypsies and Travellers
The 2004 report on the health status of Gypsies and Travellers in England
commissioned by the Department of Health confirmed that Gypsies and Travellers
experience health inequality that is even more pronounced than that experienced by
other socially deprived or excluded groups or ethnic minorities.

The Gypsies and Travellers who took part in the research reported poorer health
status over the past year than those in the housed population, and in terms of their
health on the day of the questionnaire they had more problems with mobility, self
care, undertaking usual activities, pain or discomfort and anxiety or depression.

Regionally and nationally the number of Gypsies and Travellers has been growing. In
Cornwall there has been an increase of 13% in caravan numbers between 2003 and
2005, largely on unauthorised sites. The County has a lower proportion of private
sites than elsewhere in the South West and the rest of England, and a higher
proportion of unauthorised encampments.

Health needs assessment information will be included.



                                                                                    9
Social and Environmental Context


Deprivation
Deprivation is frequently measured in England by the Indices of Multiple Deprivation
(IMD2004). IMD 2007 data has just been calculated and this report will be updated to
include this up-to-date data when it has been analysed. It combines income,
employment, education, barriers to housing and services, crime, living environment,
and health and disability into a measure that compares one geographical area with
another. The areas of deprivation include many of the people experiencing the
greatest inequalities. It is important to remember that the index is largely driven by
income and employment deprivation (these represent 45%). This is correct, as low
income is a good predictor for other inequalities. For both of these indicators
however, a person is only counted when they access welfare benefits or tax credits,
and there is a strong argument that in rural areas the take up of these benefits is low,
causing the deprivation to be hidden.


Elderly people are a group where benefit take-up is often low. Government
estimates reveal that each year over £4 billion goes unclaimed in four benefits alone
– Income Support, Job Seekers Allowance, Housing Benefit and Council Tax.

Many of our older citizens are unaware of the welfare benefits to which they may be
entitled. Age Concern estimates that about 1 million pensioners are entitled to
Minimum Income Guarantee but do not claim it.

The Cornwall Community Health Profile points out that 12% of Cornwall’s residents
are dependent on means-tested benefits, slightly lower than average. However, 1 in
5 children in Cornwall live in benefit-dependent households. The Real Choice Virtual
Wards Project, arising from ‘invest to save’ funding to reduce child poverty, is working
with families on benefits to enable parents to get back to work. Furthermore, looking
at total figures for Cornwall masks significant hotspots of deprivation.


CIoS has some of the most deprived areas in the country, as predicted by the
IMD2004 (figure 2). The indices of deprivation are mapped by super output area
(SOA); this is the smallest level at which deprivation can accurately be shown. Each
district council in Cornwall has some SOAs that are in the most deprived quintile, but
the west has the most. No SOA is in the least deprived quintile for England. The
Isles of Scilly’s isolation gives rise to issues for health and well being and access to
services.

People who experience material disadvantage, poor housing, lower educational
attainment, insecure employment and homelessness are among those more likely to
suffer poorer health, have poorer access to health care and die prematurely.




                                                                                      10
11
Indices of Deprivation by Super Output Area (Lower Layer)

                 LEGEND                                                                                                                 Bude

    Index of Multiple Deprivation (IMD) 2004
 Ranked in the top 20% nationally (most deprived)



 Least deprived 20% in the country

                                                                                                                                                          Launceston
                                                                                                                          Camelford




                                                                                                         Wadebridge


                                                                                                                      Bodmin
                                                                                                                                               Liskeard

                                                                                              Newquay
                                                                                                                          Lostwithiel
                                                                                                                                                                       Saltash

                                                                                                                                                                        Torpoint
                                                                                                            St Austell




                                                                                                Truro
                                                                                    Redruth
                                                                 St Ives

                                                                       Hayle


                                                                                              Falmouth
                                                            Penzance

                                                                               Helston




                                   0                 10        20
                                                    miles




                                                                                                                                                                                   12
Housing
Cornwall and the Isles of Scilly has a higher than average number of people over
65 living in a house with no central heating and the elderly and people with
existing health problems are particularly vulnerable to the cold.

There were 25,700 excess winter deaths in England and Wales in 2005/06, i.e.
deaths due to cold weather. The cold affects health by increasing blood pressure,
thereby increasing the risk of heart attacks and strokes. The cold lowers
resistance to respiratory infections. Mobility is affected and symptoms of arthritis
become worse; people are more likely to suffer falls. Damp, cold housing is also
associated with an increase in mental health problems. (Source: Issues paper,
health inequalities)

In Cornwall 45,489 households live in fuel poverty, giving rise to health problems,
especially amongst older people. Houses are expensive, private rented sector in
short supply and approximately 19,000 people are waiting for social housing. 181
households were homeless in Cornwall and the Isles of Scilly in the second
quarter of 2007. The majority of land on St Marys and all of the land on the off islands
of Scilly is owned by the Duchy of Cornwall and therefore land available to develop
social and affordable housing is very restricted

Most dwellings (72.3%) are owner occupied compared to 68.7% across England.
The proportion of dwellings which are locally authority rented at 6.3% is less than
half the rate across England.
According to the census, 5.1% of households in Cornwall were overcrowded,
below the 7.1% English average. Overcrowding is more prevalent amongst the
private rented sector (13.2%), other social rented (11.4%) and local authority
rented (10%), than amongst owner-occupied (2.4%).


Rurality and Access to Services
Cornwall is predominantly rural. In 2001 it was estimated that 37.7% of the
population lived in an urban or large market town compared to 65.9% across the
South West. Cornwall is the second largest county in the South West region at
1,374 sq miles ad has the lowest population density. 46% of the population live in
dispersed settlements of less than 3,000 and the largest town has a population of
only just over 22,700 people.
Delivering services to very rural areas presents challenges in terms of travel
times and patient choice.
The percentage of households without access to a car equals 20.5% in contrast
to 26.8% for England. The below average rates reflect limited alternative
transport options rather than affluence.



                                                                                     13
Income and Employment
Over 37,000 jobless people in Cornwall of working age claim benefits and of
these over 27,300 make claims due to ill-health. Debt, mental health and drug
and alcohol misuse are reported as key barriers to work by employment advisers
in Cornwall.
The Annual Survey of Hours and Earnings 2007, states that gross weekly
earnings in Cornwall are now £373.30, 81.7% of the UK figure of £456.70.




Current Known Health Status of the Population


Illness and Lifestyle


Chronic Illness in older people
The proportion of the Cornwall population who reported a long-term limiting
illness in the 2001 census is 21% compared with a national average of 18%.
(reduce isolation issues paper and carers strategy) It is estimated that there are
17.5 million adults in Great Britain living with chronic disease and it is likely that
75% of people over 75 years old are suffering from a chronic illness of which
45% have more than one condition. Consequently, with Cornwall’s resident
population aged over 75 projected to increase in the near future, combined with
the fact that there has already been a 21% increase in the resident population
aged over 75 during the past 10 years, it is likely that the number of people in
Cornwall who have a chronic illness will increase.



Chronic Illness - Census 2001
The number of persons with ‘limiting long-term illness’ i.e. chronic disease, is
generally positively correlated with the number of elderly people in an area as
previously discussed. Consequently, if an area has a high proportion of people
with a chronic illness, this could just be a reflection of the fact that the area has a
greater proportion of its population who are elderly than other areas. It is useful to
observe whether areas have a higher than average proportion of the population
with a chronic illness when the age structure is taken into account. In order to
make these comparisons this census data has been analysed with the age
structure of the population in mind to calculate an expected number and an
actual number of people with such conditions. These two figures are then
converted into a ratio, with England taken as the standard.




                                                                                    14
Cornwall as a whole has a higher than average rate of ‘limiting long-term illness’
i.e. chronic disease, than both England and the South West region, even when
the numbers of elderly people are taken into account. The ratio of expected to
actual cases is 103 in Cornwall. At a district level the ratio of expected to actual is
highest in Kerrier and Penwith at 109 and 110 respectively.

Table showing the expected and actual numbers of people with limiting long-term
illness in England, Cornwall and IoS and the districts of Cornwall
Area                         All expected   All actual   Ratio
England                      9065116        9035685      100
South West                   975462         898834       92
Cornwall and Isles of Scilly 104733         107408       103
Caradon                      16450          16209        99
Carrick                      18761          18508        99
Kerrier                      18958          20709        109
North Cornwall               17006          16546        97
Penwith                      13572          14942        110
Restormel                    19557          20226        103




Smoking
Cornwall’s Health profile (2007) states that 28.5% of people smoke in Cornwall &
the Isles of Scilly. This smoking prevalence, based on direct estimates from the
Health Survey for England, is higher than the figure for England of 26%. Data
from QMAS shows the prevalence of smoking amongst the population registered
at GPs. In Cornwall, this data is grouped into six commissioning localities. The
localities with the highest smoking prevalence are the North Cornwall and West
Cornwall Commissioning groups at 23.1% and 23.0% respectively.


 The health profile states that smoking kills over 1,000 people every year in
Cornwall & the Isles of Scilly. One third of all cancer deaths are attributable to
smoking and QMAS data shows that the prevalence of cancer is greater in
Cornwall at 1.1% than in England at 0.9%. * (This does not compare the same
time periods and is not statistically significant) Over 70% of smokers wish to stop.
Furthermore, 50% of the difference in life expectancy between the least and most
income deprived is caused by smoking. QMAS data shows that the prevalence of
Chronic Obstructive Pulmonary Disease (COPD), for which the main cause is
smoking, is 1.5% in Cornwall compared with 1.43% in England. In Cornwall the
highest prevalence of COPD is in the West Cornwall commissioning locality at
1.9%.
*Note about QMAS data comparisons – not comparing like with like




                                                                                    15
Healthy Eating and Obesity
Cornwall’s health profile shows that Cornwall has a significantly lower percentage
of adults who eat healthily than the England average at 15.8% compared with
23.8%. QMAS data shows that obesity prevalence is 8.5% of the GP-registered
population in Cornwall compared with an England average of 7.4% prevalence.
Of the Cornwall commissioning localities obesity is highest in the East Cornwall
and the West Cornwall locality groups.
It has been estimated that obesity accounts for around 30,000 deaths a year in
England and this is likely to rise. Department of Health figures attribute 58% of
type 2 diabetes, 21% of heart disease and between 8% and 42% of certain
cancers to excess body fat. Obesity is estimated to reduce life expectancy by
about nine years. Source: National Audit Office. Tackling obesity in England.
2001. London, The Stationery Office
Six percent of deaths are attributable to obesity. To put this into context, smoking
– another major public health problem that has been a regular feature in the
annual report of the Director of Public Health – is responsible for 10% of deaths.
Obesity greatly increases the risk of developing type 2 diabetes and coronary
heart disease. Obese people are also at increased risk of some cancers, most
notably breast cancer in postmenopausal women, but also endometrial, uterine
and gall bladder cancer in women and cancer of the colon, rectum and prostate
in men.
Source of above is Public health Annual Report 2006
.


Childhood Obesity
Evidence suggests overweight children are highly likely to become overweight
adults, with health problems getting worse as they get older. Obesity-related
chronic diseases are now showing up in children. Obese children can also suffer
psychological problems. Obesity has been linked with low self-image, low self-
confidence and depression. Obese children are often teased at school and
excluded from friendships.

During the summer of 2007, 140 primary schools in Cornwall and Isles of Scilly
took part in an annual national exercise to measure Body Mass Index (BMI) of
children in Reception Year and Year Six. This data formed part of the national
childhood obesity database.

The results indicate that approximately 9% of children aged under 5 years in the
county are obese, and a further 14% are overweight. Of children under eleven
years, approximately 17% are obese and 14% are overweight. A higher
proportion of girls than boys are obese in both age groups. (Source: Cornwall
Children and Young People’s Partnership: Draft Needs Assessment, November
2007)




                                                                                 16
Nationally, of those children measured, 13% of children in Year R were found to
be overweight, and 10% of children in the same year group were found to be
obese. In Year 6, 14% of children were overweight, and 17% of children were
obese.
Source; Analysis of the National Childhood Obesity Database 2005-06,
Crowther SEPHO



*based on direct estimates from the Health survey for England



Teenage Pregnancy
Cornwall as a whole has a teenage pregnancy rate significantly lower than that of
England. However, this masks geographical variations. In Kerrier, the under 18
conception rate for both 1997 –1999 and for 2003 – 2005 was significantly higher
than the England rate. However, between these 2 time periods the conception
rate reduced by 9%. In Penwith, the teenage pregnancy rate was significantly
higher than the England rate in 1997-99. However, by 2003-05 the rate had fallen
by 25% and was not significantly higher than the England rate.
In Restormel, the under 18 conception rate is higher than the England rate and
has increased by 7.9% between the two time periods of 1997-99 and 2003-05.
North Cornwall has a low rate which masks hot spots.


Breastfeeding and Smoking
Breastfeeding provides nutritionally the most suitable nourishment for the baby,
protecting against disease and boosting antibodies. In general, mothers who do
not initiate breastfeeding tend to be younger, less well educated and from lower
income groups. Infants who are not breastfed are 5 times more likely to be
admitted to hospital with infections in their first year of life. In Cornwall, the
percentage of mothers who initiate breastfeeding is 71.5% compared with 73.9%
for the South West region.

Smoking during pregnancy is a key determinant of low birth weight, which is the
single most important risk factor in perinatal and infant mortality. It is much more
prevalent among young mothers, and those that are from more disadvantaged
groups.

Other links include there being a very strong link with not breastfeeding and
smoking. Therefore, babies of these mothers have the double disadvantage of
being exposed to second hand smoke, and not receiving breast milk. Smoking
during pregnancy also increases the chance of developing asthma.




                                                                                 17
For 2005/06 and 2006/07, the percentage of mothers smoking at delivery has
been recorded at 20% (941 mothers in 2005/06 and 995 in 2006/07)




Current Met Needs of the Population


Social care
Data for 2005/06 shows that nationally, of all those receiving services as part of a
package of care following an assessment, 70% were aged 65 and over. 57%
were for people aged 75 and over.
Of all national new assessments in 2005-06 79% were classified as having ‘a
physical disability, frailty and sensory impairment’, 15% were classified as having
the primary client type ‘mental health’, 3% as vulnerable people and 1% related
to those with a learning disability.
Nationally 37% of contacts from new clients were referrals from a health source;
13% were referrals from primary/community health and 24% were from
secondary health sources.



Adult Social Care Provision in Cornwall
The following information refers to the delivery of social care to clients in
Cornwall.

In the Year 2005/06:

   •   75,000 contacts were made to the 7 Adult Social Care offices

   •   12,807 new assessments were completed

   •   25,386 re-assessments / reviews of service completed

   •   13,016 Carers received an assessment

   •   77% of people had their assessment started by the end of the next
       working day (Shire average is 75%)
   •   91% of people received their whole care package within 4 weeks of
       assessment (Shire average is 85%)

   •   32,976 people received a service
        Of which: 9,753 aged 18 to 64 years
                   23,223 aged 65 years and over


                                                                                 18
   •   170 people received a Direct Payment (Enabling people to directly arrange
       their own services)

   •   27,476 items of community equipment delivered - 92% of equipment
       delivered within 7 working days (Shire ave - 79.2%)

Each Week:

   •   Homecare is delivered to 4,271 people in 4,195 households across
       Cornwall

   •   33,331 hours of home care are delivered (Ave 8 hrs per h/hold)

   •   23,437 hours of home care are delivered by independent care agencies
       (thereby financially supporting the local economy)

   •    9,893 hours of homecare are directly delivered by the Adult Social Care
       Homecare Service

   •   The number of day service sessions for adults with learning disability is
       4,350 and for adults with mental health needs is 1,197


As at February 2007

   •   808 households received ‘Intensive Homecare’ (over 10 hours & 6+ visits
       per week)

   •   6,927 older people were ‘helped to live at home’

   •   2,681 adults with physical disability were ‘helped to live at home’

   •   1,762 people with mental health needs were ‘helped to live at home’

   •   904 adults with learning disability were ‘helped to live at home’

   •   2,421 people financially supported in residential or nursing care
             - 430 people aged 18 to 64yr & 1,914 people aged 65+


Learning Disabilities
With a population of 520,000 people in Cornwall, prevalence rates for learning
disability indicate there are between 15,000 and 20,000 people with moderate or
mild learning disability (IQ 50 to 70) and between 3,000 and 3,500 people with
severe or profound learning disability (IQ under 50). The majority if not all of



                                                                             19
those with severe or profound learning disability need ongoing health or social
care.

Over half are younger adults between the ages of 19 and 39, and the extent of
care being received by them is likely to need to be sustained until they die.
Longevity of adults with learning disability is increasing.

Overall prevalence is increasing due to higher survival rates of disabled children,
and there is increasing prevalence of people with complex, severe or profound
disability. This means there is a higher number of young people in transition from
children’s services to adult services, and this is creating dual cost pressures
where by there are increasing numbers of new cases, whilst existing cases are
living longer.

In short therefore it should be noted that:-

   a)     The number of people with a learning disability is growing with survival
          at birth (reduced infant mortality one of the key indicators), with a
          higher number of children leaving education at 16 each year, placing
          additional demands on adult services.
   b)     An increase in the prevalence of high / complex needs and people with
          a profound and multiple disability.
   c)     An increase in the trend to export clients with complex needs to
          agencies providing services out of county at high cost.
   d)     Increased life expectancy for those learning disabled due to advances
          in health care.
   e)     An increase in the prevalence of people with Autistic Spectrum
          Disorder.
   f)     Noting the increased life expectancy of People with Learning
          Disabilities, a growing number of older adults experiencing heart
          problems associated with ageing.
   g)     A wide spectrum of need is captured within the learning disability
          population:-

          h) multiple and profound disabilities.
          ii) those people who challenge services.
          iii)   adults with acute / severe mental health difficulties or mental
          impairment.
          iv) the needs of older learning disabled.
          v) majority with severe learning disabilities.
   i)      Allied to the above, is a growing number of older parents and carers
   who
           sustain the majority of learning disabled adults in the family home
   i)     The other end of the age spectrum, younger parents and carers with
          higher
           expectation of health and social care communities.



                                                                                20
Also it should be noted as highlighted in Valuing People that many people with
learning disabilities have greater health needs than the rest of the population. As
a result, people with a learning disability need better access to primary care,
secondary and specialist care services with a high level of understanding of the
particular needs of the service users concerned. National figures suggest that, for
example:

       90% of women over the age of 50 have never received a mammogram,
       75% of women between 20 and 70 have never received a smear test.
       11% of the Shropshire learning disabled population report having a
       hearing impairment. National prevalence statistics show that this figure is
       likely to be nearer 37% indicating a significant number of people with
       undetected hearing problems.
       Undetected visual impairments are also indicated by the low reporting of
       visual problems.

Screening services are available to people with Learning Disabilities but
nationally it has been shown that they are not provided in a way which
encourages these people to use the service.
Locally we are already addressing the need for screening in this vulnerable group
through additional training of staff, local policies and targeted information. We are
determining a more firm database of the local take up of the service through a
Health Equity Audit.



Carers
Cornwall County Council’s Department for Adult Social Care has recently
established a multi agency Carers Partnership Board and a strategy is under
development. This is a group of about 20 people who represent a wide range of
carers needs and who have responsibility for commissioning carers services in
the county.

In the 2001 Census, 55,791 people in Cornwall identified themselves as
providing unpaid care to family or friends who had an illness or disability.

Of these, 36,499 said they were providing between 1 and 19 hours of care per
week; 6,141 said they were providing between 20 and 49 hours of care per week
and, 151 were providing over 50 hours care per week.
(Census 2001)

There are future demographic pressures to be taken into account. By 2028
28.6% of the population in Cornwall will be over 65 years of age and one in five
people over 80 years of age will have dementia. This implies that the number of
carers needed will increase in future years. However, as there are likely to be



                                                                                  21
less people in Cornwall of working age, the ability of carers to provide such
intensive help and support to their loved ones will be significantly compromised.

Most carers are women looking after male partners, with 90% of carers looking
after someone in their immediate family. Consequently most carers live in the
same house as the person they care for. 56% of carers are between the ages of
18 and 64. Many people are caring for someone with more than one disability.
The nature of the disability of the person being cared for can be broken down as
follows:-

    •   Mental health 16%
    •   Physical disability/Long-term health problems 37%
    •   Learning disability 3%
    •   Frailty/old age 27%
    •   Sight and hearing loss 17%

Source: Carers Consultation Survey cited in Commissioning Strategy for Carers
in Cornwall

However, many people stated that the person they cared for had a range of
difficulties and so the main breakdown above only gives an indication of the main
needs of that person being cared for.

•   The proportion of people aged 50 and over living in Cornwall is much higher
    than that in England and Wales.
•   During the past 10 years in Cornwall there has been a 21% increase in the
    resident population aged over 75 years compared with 7% nationally, and a
    42% rise in the resident population aged over 85 years.
•   By 2028 there could be 7,000 people with dementia living in Cornwall and at
    least 17,740 age 65 years and over living with depression.
•   Of the 55,791 unpaid carers (2001) in the County, currently 13,123 many of
    whom are older people themselves, provide more than 50 hours per week of
    care.


Dementia
Dementia is a longstanding condition, which usually is progressive. It’s symptoms
therefore range from very mild forgetfulness at one end of the scale, to death at
the other, with many changing needs in between. Dementia has a changing
symptom pattern as the condition progresses.

Early in the illness, mood symptoms predominate, often prior to any cognitive
change. Next come cognitive symptoms, then function deteriorates, followed by


                                                                              22
behavioral symptoms and finally increasing physical difficulties. Widely different
services and resources are therefore required at differing points in the illness. For
example, in the early stages, accurate diagnosis, information and treatment tend
to outweigh physical care needs, whereas in the later stages, behavioral and
physical needs become more important. For a truly seamless care experience
throughout this chronic illness, either a single agency should provide all these
specialist functions (unlikely) or a variety of agencies must work together, “in an
integrated way to maximise the benefit for people with dementia and their
carers”. (“Dementia -Supporting people with dementia and their carers in health
and social care”, NICE, November 2006)

It is clear that differing agencies within Cornwall have differing roles to play at any
one time in any one individual or carer’s journey through a complex and
devastating illness. Coordinating these often highly specialised agencies’ work
has always been the key difficulty.




The national Prevalence (number of cases of a disease that are present in a
particular population at a given time) and Incidence (the number of newly
diagnosed cases during a specific time period) figures can be applied to
Cornwall’s population. Thus, the total number of cases of dementia in Cornwall at
any one time (estimated age-specific prevalence) should be 7362. This assumes
2001 population figures and that dementia prevalence matches national rates.

We can expect 3374 new cases (estimated age-specific incidence) of dementia
to arise in Cornwall each year, with the majority being aged 80 and above. This
will of course rise with the increasing population.

(Source:Dr Tim Booth, November 2007, Cornwall Older People’s Mental health
Services)
Sources: Dementia UK Report (2007); Matthews & Brayne,
PLOS Medicine, "The Incidence of Dementia in England and Wales”

Carers of people with dementia
Dementia does not simply affect the person with the condition, it also changes
the lives of family members who care for them. Dementia is a complex,
unpredictable and progressive illness. People with dementia have problems with
memory, communication, understanding and judgement. They may become
withdrawn, anxious or frustrated, have mood swings or behave in unusual ways.
They may not be safe alone. As the demenita progresses, sufferers are likely to
need someone to keep an eye on them most of the time, and help with most
everyday tasks.



                                                                                    23
Caring for someone with dementia can be difficult, exhausting, lonely and - at
times - overwhelming. Few carers have any previous experience of dementia or
know what to expect. Carers may find themselves helping with personal care,
dealing with incontinence, assuming responsibility for all household tasks,
finances, appointments and medication, as well as making all decisions. The
person with dementia may lack insight into their difficulties and resist help. They
may be agitated, repetitive, anxious or clingy, and need constant reassurance
and prompting. Over time, caring for someone with dementia is likely to become
a 24-hour responsibility. As well as the practical and physical demands, caring
for someone with dementia has a complex emotional impact on carers, which
adds to the stress of caring.

Dementia is an illness that mostly affects older people. Their carers are usually
their spouses or adult children. The husband or wife of someone with dementia
may themselves be frail or in poor health, and the physical and emotional
demands of a 24-hour caring role, for a partner who now seems like a different
person can be very stressful. Carers looking after a parent may experience
different kinds of stress: role reversal, loss of income if they give up working, loss
of time for other relationships, or constant worry if the parent lives alone. Either
way, carers of people with dementia often describe feeling exhausted, isolated
and          having         too        little       time        for       themselves.

Carers of people with dementia need a lot of support, and will need increasing
levels of support as the person’s dementia progresses. They need information
about dementia and what to expect; help with claiming benefits; help in accessing
services. They need respite – sitters, day care, longer breaks. They may need
practical help, aids and adaptations, help with personal care or household tasks.
They need advice about coping strategies. And they need emotional support, to
help them understand and come to terms with what is happening to their loved
one, and share their own complex feelings.


Primary care


Disease Prevalence

QMAS provides data on the prevalence of certain conditions amongst the total
population registered at each GP practice. The information presented here only
refers to raw (unadjusted) clinical prevalence. Raw prevalence = (number on
clinical register/number on practice list) * 100. Consequently, the prevalence
percentages recorded here do not take account of the different demographic
structures of the practice populations, for example, the fact that many practices in
Cornwall will have a much higher proportion of it’s population aged over 65
compared with the average for England.



                                                                                   24
It is difficult to interpret year-on-year changes in the size of QOF registers, for
example a gradual rise in QOF prevalence could be due partly to epidemiological
factors (such as an ageing population) or due partly to increased case finding.
Five clinical areas within the QOF (diabetes, epilepsy, chronic kidney disease,
obesity and learning disabilities) are based on clinical registers that relate to
specific age groups. Diabetes registers are based on patients aged 17 and over;
epilepsy, chronic kidney disease and learning disabilities registers are based on
patients aged 18 and over; and obesity registers are based on patients aged 16
and over. However the prevalence rates shown here for both England and
Cornwall for the clinical areas are based on whole practice list sizes (all ages) as
the denominator.




                                                                                 25
Table showing the prevalence (%) of clinical register conditions in England, Cornwall and GP Commissioning Groups




                  England    average
                  prevalence (QMAS     Cornwall                         East       Mid
                  database - 2006/07   prevalence                       Cornwall   Cornwall
Clinical          data as at end of    (snapshot      Carrick & Truro   Locality   Medical    Newquay         North
Register          June 2007)           of April 07)   Commissioning     Group      Group      Commissioning   Cornwall   West Cornwall
Asthma            5.8                  6.4            6.1               6          6.4        5.9             7          6.8
Atrial
Fibrillation      1.29                 1.7            1.8               1.7        1.6        1.4             1.9        1.8
Cancer            0.91                 1.1            1.1               1.3        1.1        0.9             1.2        1.1
Chronic Kidney
Disease           2.38                 1.1            0.8               1.8        1.3        0.9             1.8        0.5
COPD              1.43                 1.5            1.4               1.3        1.6        1.1             1.5        1.9
CHD               3.53                 4.2            4.1               3.8        4.4        3.7             4.3        4.5
Dementia          0.4                  0.5            0.5               0.5        0.3        0.5             0.6        0.5
Diabetes          3.65                 3.8            3.5               3.6        3.9        3.1             4.1        3.9
Epilepsy          0.6                  0.7            0.6               0.6        0.7        0.5             0.6        0.7
Heart Failure     0.78                 1              0.9               0.9        0.9        0.7             1.1        1.2
Hypertension      12.49                14             13.2              14.6       13.6       10.7            14.5       14.8
Hypothyroidism    2.55                 3.2            3.1               3.7        3.2        2.9             3.1        3.2
Learning
Disabilities      0.26                 0.3            0.3               0.2        0.3        0.2             0.4        0.3
Mental Health     0.71                 0.7            0.6               0.6        0.6        0.6             0.8        0.8
Obesity           7.41                 8.5            8.3               8.9        9          5.9             8.2        8.6
Palliative Care   0.09                 0.1            0.1               0.1        0.1        0.1             0.1        0.1
Stroke            1.61                 2              2                 1.8        1.9        1.7             2.3        2.2
Source of Data: England prevalence comes from QMAS database - 2006/07 data as at end of June 2007 published by
Eastern Region Public Health Observatory: http://www.erpho.org.uk/
Cornwall prevalence comes from QMAS database, snapshot as of April 07
* Please note that these prevalences therefore do not compare data taken at the same time. However, they do still
provide a good comparison



                                                                                                                                         26
It is seen that the prevalence of diabetes is 3.8% in Cornwall compared with
3.65% in England on average. It is highest in the GP commissioning locality of
North Cornwall. The prevalence of asthma is 6.4% in Cornwall compared with
5.8% in England. It is highest in the West Cornwall commissioning group at 6.8%.

Cornwall, at 4.2%, has a higher prevalence of CHD than the England average
(3.5%). Of the Cornwall practice localitites, CHD prevalence is highest in West
Cornwall at 4.5%.



We will do some work to pull out the GP practice age groups – so can calculate
prevalence based on age.




Immunisation

Flu vaccine
A policy exists of vaccinating patients at higher risk from influenza, defined as
those patients aged 65 years and over and those aged six months to under 65
years with an underlying medical risk. In 2002 a target of 70% uptake of the
vaccine in those aged 65 years and over was set. In the 2006/07 flu campaign,
which typically takes place during the September – January time period, a 73%
uptake of the vaccine was achieved in Cornwall. Although this achieves the
target, it is lower than the average uptake for England of 75.4%. (Source: HPA)

Childhood Immunisation Uptake
The latest uptake rates for childhood immunisations available at the time of
wrting are for those children who became 24 months old during the 3 month time
period of 01.07.07 – 30.09.07.
The rates of uptake are 86.1% for the MMR (measles, mumps and rubella)
vaccine and 94.3% for the DTaP/IPV/Hib (diphtheria, tetanus, pertussis, polio
and Haemophilus influenzae type b) vaccine and 80.2% for the PCV
(pneumococcal) vaccine.
MMR uptake rates are therefore falling short of the 95% uptake required to
provide nationwide protection of children.



Hospital data
Hospital admissions related to heart disease are the most costly. These are
strongly associated with smoking and obesity. For admissions ranked according


                                                                              27
to the longest length of stay, the most common are concerned with elderly
people. Stroke, which is related to lifestyle behaviours such as smoking, poor
diet and lack of exercise. Stroke patients over 70 have the longest lengths of
stay. The following tables illustrate the Health Resource Groups in descending
order of volume and of cost. Further analysis will be carried out of the HRGs of
those aged 75 and over who are admitted to hospital.

Table showing top 10 HRGs by activity (descending order)(2005,2006 and 2007
financial years) for all ages

HRG Description


(N12) Antenatal Admissions not Related to Delivery Event
(C58) Intermediate Mouth or Throat Procedures
(B13) Phakoemulsification Cataract Extraction and Insertion of Lens
(J37) Minor Skin Procedures - Category 1 w/o cc
(N07) Normal Delivery w/o cc
(F06) Diagnostic Procedures, Oesophagus and Stomach
(L21) Bladder Minor Endoscopic Procedure w/o cc
(F35) Large Intestine - Endoscopic or Intermediate Procedures
(B32) Non Surgical Ophthalmology with los <2 days
(S27) Malignant Disorder of the Lymphatic/ Haematological Systems with
los <2 days


Table showing top 10 HRGs by cost (descending order) (2005,2006 and 2007
financial years) for all ages

HRG Description
(E15) Percutaneous Coronary Intervention
(N12) Antenatal Admissions not Related to Delivery Event
(H04) Primary Knee Replacement
(A22) Non-Transient Stroke or Cerebrovascular Accident >69 or w cc
(H99) Complex Elderly with a Musculoskeletal System Primary Diagnosis
(C58) Intermediate Mouth or Throat Procedures
(N07) Normal Delivery w/o cc
(B13) Phakoemulsification Cataract Extraction and Insertion of Lens
(A99) Complex Elderly with a Nervous System Primary Diagnosis
(H80) Primary Hip Replacement Cemented




Patient/service user voice



                                                                             28
Patient Advice and Liaison Service (PALS)

Cornwall and Isles of Scilly PCT’s PALS provides information, advice and
support to patients, their families and their carers In the April 07 – March 08
financial year it is projected to have received 1,400 contacts.



   •   90% of people who contact PALS do so by phone. The next most popular
       contact method is email at 5% (T1).

   •   Nearly two thirds or people who contact PALS do so on their own behalf
       (T3).

   •   1 contact in 8 comes from a member of staff on behalf of a patient (T3).

   •   Almost twice as many women as men contact PALS (T4).

   •   Over half of people who contact PALS are seeking advice and information
       (T5).

   •   Almost one third of people who contact PALS have an issue they want
       help to resolve (T5).


Complaints
Complaints received by the PCT totaled 259 in 2006/07. Of these, 78 (30%) were
regarding ‘all aspects of clinical procedure’ and a further 50 (19%) were
regarding PCT commissioning (including waiting lists).

Table showing complaints by profession directed at 2006/07
                                           Total number of
                                          written complaints
               Profession                      received
Medical (including surgical)                      104
Dental (including surgical)                        29
Professions supplementary to medicine              20
Nursing, Midwifery and Health Visiting             33
Scientific, Technical and Professional             2
Ambulance crews (including
paramedics)                                       0
Maintenance and Ancillary staff                   2
PCT Administrative staff / members (exc
GP admin)                                        51
Trust Administrative staff / members              2
Other                                            16



                                                                                  29
Total                                                          259




Information from the Health and Wellbeing strategy about consultation will be
included.


Issues in Cornwall


Skin Cancer
Data from 1995-2004 on the incidence of malignant melanoma in Cornwall was
analysed. The average number of cases per year is comparatively small (46
cases per year in women and 53 per year in men). For women the rate appears
to be stable at approximately 17 cases per 100 000 women per year. For males
there has been an increase from approximately 10 cases per 100 000 men per
year in 1995 to 20 cases per 100 000 men in 2004. For 8 out of the last ten years
of available data rates for both men and women have been significantly higher
than England. For males this averages 86% higher than the average for England,
and for females 69%. The incidence rate for both males and females are shown
in the graphs.


                                  Age standardised incidence rate of malignant
                                         melanoma in Cornwall, Males
                           30.0
   Cases per 100 000 Men




                           25.0

                           20.0

                           15.0

                           10.0

                            5.0

                            0.0
                                   1995 1996 1997 1998 1999 2000 2001 2002 2003 2004




                                                                                       30
                                      Age standardised incicdence rate of malignant
                                             melanoma in Cornwall, Females
                             30.0
   Cases per 100 000 Women


                             25.0

                             20.0

                             15.0

                             10.0

                              5.0

                              0.0
                                    1995 1996 1997 1998 1999 2000 2001 2002 2003 2004



Age standardisation facilitates comparison across geographical areas by
controlling for differences in the age structure of local populations, and the
indirectly standardised mortality ratio (SMR) is the ratio of observed to expected
deaths in an area. The SMR of England for any given cause of death is always
100. Local SMRs greater than 100 indicate higher mortality than the national
average, and SMRs less than 100 indicate lower mortality than the national
average. In Cornwall, the SMR for malignant melanoma for 2003-05 was 136
(confidence intervals 98-184) for males and 124 for females (confidence intervals
85-175).

Over the 1996-2005 period there are an average of 12.7 male and 12.3 female
deaths from malignant melanoma per year. Comparing the year by year rate
data to the average rate over the 10 year period allows changes in the rate to be
examined. For males there is very little evidence of any reduction in deaths from
melanoma. 2001 showed a significantly low number of deaths, but the four years
since then have had mortality rates very close to the 10-year average. For
females there is some evidence that the mortality rate due to malignant
melanoma is decreasing. Three of the last four years have had a significantly low
number of deaths.




Hip fracture
The rate of hip fracture in people aged over 65 is higher than the England and
South West averages. Cornwall ’s directly aged-standardised rate is 706.2 per
100,000 population aged over 65 and over compared with the England average
of 565.3 per 100,000 population aged over 65. The total number of hip fractures



                                                                                        31
in Cornwall was 1004 in 2005/06. These figures are higher than data collected
locally which indicate about 520 fractures a year.

The likelihood of falling increases with age. The numbers of people over 65
years of age has increased in Cornwall and the Isles of Scilly although the
number of broken neck of femurs, over the last four years, have remained about
the same (522 2003/4 , 520 2006/7). This could be seen as encouraging;
however, numbers would be expected to start to decrease with the introduction of
an integrated falls service. The Royal College of Physcians Audit suggested
Cornwall and the Isles of Scilly has pockets of good practice but it was not
spread across the whole of the County, indicating there is work to be done.



Mental health
Cornwall’s Health profile 2007 points out that the rate of people claiming sickness
benefit because of mental health problems is higher than the England average.

 Mental health problems are common among all age groups and represent about
a third of all GP consultations. About 10% of children have a mental health
problem at any one time. Under the NSF services will improve over the next ten
years but it is recognized that CAMHS was under funded for many years. Young
people of the age 16 – 18 years also have not received a fair and equal access to
help. This is predominant in young offenders. (NI 50) and PSA12. Services to
Youth Courts are totally inadequate. Mental health problems are among the most
common of all health conditions, directly affecting about a quarter of the
population in any one year. Depression and anxiety are the most widespread
conditions. Only one in ten prisoners has no mental disorder.

Suicide
There are approximately 60-70 deaths each year in Cornwall and Isles of Scilly
attributed to suicide and injury of undetermined intent. This equates to an annual
rate of between 10 and 15 per 100,000 people compared with an annual national
rate of about 9 per 100,000.

Nationally the incidence of suicides has been falling. In Cornwall and Isles of
Scilly the rate has been consistently slightly higher than the national average
over recent years but the relatively small numbers and random year on year
variation mean it isn’t possible to detect a trend.

Men are more likely to die of suicide than women; women are more likely to self
harm and to use ‘passive’ methods of suicide that allow time to reconsider, or for
discovery and intervention. However, many people who self harm do go on to
commit suicide.

Hanging and poisoning by drugs are the most common methods used in


                                                                                  32
Cornwall and Isles of Scilly, followed by drowning, and (for men) poisoning by
gases (car exhausts),

The Hayle/Hell’s Mouth coastline and the railway line in Falmouth might be
considered hotspots.

Nationally the highest risk age group is 35-64 years, whereas in Cornwall and
Isles of Scilly those aged 75 years and over are at the highest risk. This was true
for both males and females. Although the rates are high, the numbers are not.
Twelve of the 62 suicides in Cornwall and Isles of Scilly during 2005 were of
people aged 75 years or older. However, completed suicides may only represent
the tip of the iceberg for psychological, physical and social health problems in
older age.

Older men are at higher risk of suicide than older women (as is true for all ages).

The progressive ageing of the population suggests that both the numbers and the
rates of suicide amongst older adults can be expected to increase. More people
will live longer, but as they get older an increased proportion will experience the
negative impacts of ageing. Society values youth, looks, wealth, material
possessions, health and employment. The loss of these with age can make older
people feel devalued by society.

Suicides and suicide attempts have a profound effect on family and friends and
are the cause of much distress and suffering. For individuals bereaved by suicide
the emotional impact may last for many years, and for families the consequences
may extend for generations.

Risk factors

Depression: Depression plays an important role in suicides of older adults. Many
older suicide victims are seen by their primary care provider a few weeks prior to
their suicide attempt and diagnosed with mild to moderate depressions.
Depression is the most common mental health problem for older adults, yet it is
often unrecognised since it is difficult to differentiate from the effects of many
illnesses that are common in older age, and the side effects of some medications
that are used to treat these illnesses.

Depression in older people is often sub clinical rather than a major depressive
disorder.

Depression is often not diagnosed or not treated, yet it is a treatable condition.
Older people respond well to psychotherapeutic interventions yet are less likely
to be offered them than younger patients are. This may be due to the unfounded
view that older people wouldn’t want to be treated by psychotherapy – that they
would rather be given medication.



                                                                                  33
Compared with young patients with depression, patients over 75 years of age
have been shown to be only 6% as likely to be asked about suicide, one fifth as
likely to be asked if they felt depressed, and one fourth as likely to be referred to
a mental health specialist.

Illness or disability: Older adults who are suicidal are also more likely to be
suffering from physical illness or pain, or to fear a prolonged illness. Identified
physical risk factors for suicide include neurological illnesses and malignancies.
Although physical health factors can be important in the cause of suicidal
behaviour, their effects are generally mediated by mental health factors, most
notably depression.

Isolation: At risk older people may have recently experienced major changes in
social status, such as retirement, or be socially isolated and lonely. Older men
who are suicidal tend more often to be divorced or widowed. Living alone puts
people at risk in various ways: they may suffer loneliness; have no one with
whom they can share their concerns; be less likely to be recognised as having a
problem; and be less likely to be discovered if they attempt suicide.

Cornwall may have a particular problem in that it is a popular retirement
destination. If a couple moves to Cornwall, away from long-developed social
networks, and then one partner dies, the widowed partner can be very isolated.
Loss of a partner can also mean the loss of private transport if that person was
the sole driver, and this can reduce social opportunities.




Alcohol
Cornwall’s Health profile 2007 points out that the rate of admission to hospital for
alcohol specific conditions is higher than the England average. In 2005/06 there
were 1401 hospital stays due to alcohol; this was a directly age sex standardised
rate of 275.5 people /100,000 compared with 247.7/100,000 in England.
DISTRICTS

Up to 140,000 working days are lost in Cornwall and the Isles of Scilly each year
due to alcohol related sickness. 44 % of violent crime is alcohol related and half
of recorded domestic violence crimes were committed by someone under the
influence of alcohol or drugs.




                                                                                    34
Infant mortality
Infant mortality is one of the historically earliest indicators used to show
differences in deprivation. In the west rates of infant mortality are low but there
are still marked differences between countries and groups of people within
countries.

The report produced by the Department of Health1
(http://www.dh.gov.uk/assetRoot/04/14/29/72/04142972.pdf) shows infant
mortality is higher in people working in the routine and manual (R&M) group,
which includes those in lower supervisory and technical, semi-routine and routine
occupations.
The 2001 Census shows that CIoS has a slightly higher percentage of men
employed in these groups than England and Wales. National figures show that
the gap in the baseline year, 1997 to 1999 was 13%; this has widened to 18%.

For the infant mortality target, the three main causes of death in infancy, and
which also account for most of the gap are:
   • Immaturity related conditions
   • Congenital anomalies and
   • Sudden unexpected death in infancy.
Additional risk factors are absence of breast feeding, maternal smoking, and
obesity of the mother.

In Cornwall the rate of deaths in those under one year of age has halved since
1976 and the number decreased from 64 deaths in 1976 deaths to 22 in 2005
(figure 5). The change in rate per 1,000 live births has been less marked as the
number of births has reduced. Infant mortality rates are decreasing in CIoS and
are similar and usually below the rates in England and Wales but over the last
five years this decrease has stalled.




                                                                                35
                                     Three year moving average for infant mortality for CIoS and E&W

                              16.0



                              14.0



                              12.0
 rate per 1,000 live births




                              10.0


                                                                                                       CIoS
                               8.0
                                                                                                       E&W


                               6.0



                               4.0



                               2.0



                               0.0
                              19 78

                              19 79

                              19 80

                              19 81

                              19 82

                              19 83

                              19 84

                              19 85

                              19 86

                              19 87

                              19 88

                              19 89

                              19 90

                              19 1

                              19 92

                              19 93

                              19 94

                              19 95

                              19 96

                              19 97

                              19 98

                              19 9

                              19 00

                              20 01

                              20 02

                              20 03

                              20 04

                                      5
                                   -9




                                   -9




                                   -0
                                   -

                                   -

                                   -

                                   -

                                   -

                                   -

                                   -

                                   -

                                   -

                                   -

                                   -

                                   -

                                   -



                                   -

                                   -

                                   -

                                   -

                                   -

                                   -

                                   -



                                   -

                                   -

                                   -

                                   -

                                   -
                                 76

                                 77

                                 78

                                 79

                                 80

                                 81

                                 82

                                 83

                                 84

                                 85

                                 86

                                 87

                                 88

                                 89

                                 90

                                 91

                                 92

                                 93

                                 94

                                 95

                                 96

                                 97

                                 98

                                 99

                                 00

                                 01

                                 02

                                 03
                              19




What is already being done?

Areas where we know there needs forward planning have been
well rehearsed in many settings both nationally and in CIOS.
These include climate change, an increasingly elderly
population, smoking, and obesity.
In addition we need to plan for our successes which include a
population that has more people reaching 85 years of age, more
people with learning disabilities reaching old age, a County
where people want to come to live causing population growth.
These successes provide challenges to our services especially
if we are to ensure our elders and those with learning disabilities
are to enjoy their old age not just prolong life, and people
coming to live in Cornwall are welcomed, add to Cornwall’s
society, and are able to use services.
Our affluence has allowed us to become obese and has enabled
us to have large carbon footprints.



                                                                                                         36
Analysis of the information shows that using national data we
have relatively high life expectancy but also high self reported
long-term limiting illness, high numbers of fractured neck of
femur, and high numbers in housing with no central heating.
It is essential that we continue to promote elders independence
and provide them with information to ensure take up of benefits.
We need to join together to provide warm, dry houses and jointly
work to reduce falls that cause serious injury and ensure that
there are good treatment services which help people back to
independence if they have a severe fall.
Many of the genetic conditions that have been or are still life
limiting such as Muscular Dystrophy, Multiple Sclerosis are
living longer and we need to again celebrate this but also to plan
services to support the people this refers to. More work is
needed to determine likely increased life expectancy of people
with these conditions.
Prevalence figures from the primary care data is being to
become more widely available and will be useful to compare
Cornwall & Isles of Scilly with England and within CIOS to look
at trends. Some of the variation is due to difference in GPs
recording rather than differences in prevalence of disease in that
practice. The inter GP variation will decrease enabling this
prevalence data to be an important planning tool.
Obesity is increasing in young people as well as adults and the
Government has set us the target to halt the rise in primary
school children. We need to work creatively to make physical
exercise and healthy eating the norm. The Children and Young
People’s Partnership will be important to drive this work
forward.
Alcohol consumption in young people is increasing with binge
drinking and hospital admissions in the under 18 year olds due
to alcohol related illness in CIOS are reported as high compared
to the expected number. The numbers are small so care must be
taken before extrapolating the implication of this information too
far. There is multi-agency planning to deliver the local Alcohol
Strategy for Cornwall & the Isles of Scilly, this has resulted in
appointment of a young people’s Health Promotion Officer to
work with the many services including schools, colleges, DAAT


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and CADA that provide advice and treatment. In addition detox
services are being further developed in Community hospitals
and in a person’s home.
We are working to both improve our services for ethnic groups
and our evidence to show the work we are doing. This work will
include the groups that are residents in Cornwall, gypsies and
travellers, who chose Cornwall as their base and migrant
workers. Primary care services are important for this groups and
evidence showing provision from these services continues to
improve indicating where more work needs to be done. An initial
example was the improved budget for translation services
within primary care. Practice Based Commissioning will be
important in taking this forward
The migrant workers information pack continues to develop and
the multi-agency group that delivers this work needs continued
support.



What should we do next?
Consultation on the Health and Well Being Strategy, the Sustainable Community
strategy for Cornwall, Joint planning for Social Care, and the Local Development
Plan for the PCT are being taken forward in 2008. The Children and Young
People’s Strategic Partnership continues to deliver work from within its Plan. The
Joint Strategic Needs assessment will feed into this Process. The evidence has
been produced in Combination with the Local Information Network Cornwall
(LINC) to ensure participation with partners.
We will consult with local partners and work to evolve a method of joint planning
that will work for Cornwall and the Isles of Scilly and fit with the evolving
Department of Health Guidance.




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