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									                                                                                Life Expectancy


     Outcome:         Life Expectancy                            Leads:                Pat Diskett & Jackie Beavington & Claire Tiffany & Deborah Lee

     A    Executive Summary
          Context:
           Life expectancy at birth (LEB) in Bristol is just below the England average i.e. 0.7 years below for males and 0.4 years below for females. Life expectancy will need
          to be increased by 2.1% (1.6 years) for males and 1.4% (1.1 years) for females over the next 4 years in order to reach the national Public Service Agreement [PSA]
          target.
           The national PSA target for life expectancy is 78.6 years for males in 2009-11 and 82.5 years for females in 2009-11 (see B3).
           Trends: Over the last 4 years (from 2001-3 to 2005-7) Bristol has seen an improvement in male life expectancy that is greater than that for England, South West and
          the Core Cities. However, the improvement rate for female life expectancy in Bristol is less good when compared with other Core Cities i.e. is higher only than
          Sheffield's (see B11).
           Health Inequalities: There is a 8.8 year difference in life expectancy across Bristol wards for all persons i.e. there is a 8.8 year difference between Henleaze (one of
          the least deprived wards) and Southmead ward (one of the most deprived wards), due to socio-economic, educational and lifestyle factors (see B11).
          Three core work programmes have been identified based on the analysis below:
          1. Risk Assessment and early intervention in primary care: Local analysis suggests that the greatest gains in life expectancy will come from tackling those diseases that
          cause premature mortality and which are either preventable and/or amenable to early diagnosis, prompt intervention and effective (evidence-based) treatment (to give
          improved long term control of the condition and/or prolong life). Based on this analysis, and using the wider evidence–base (of effectiveness of interventions), in Bristol,
          local priorities are COPD, Cancer, Cirrhosis of the liver and CVD (CHD and Stroke) - this approach is often referred to as secondary prevention
          2. Primary prevention: At the same time it is important to tackle underlying risk factors (e.g. smoking, obesity and lack of physical activity, alcohol misuse etc) i.e.
          primary prevention
          3. Tackling infant mortality: Finally, there is a need to improve infant mortality, which is higher in areas of deprivation and in specific groups e.g. tackling teenage
          pregnancies (which can be linked to low birth weight/prematurity), ensuring early ante-natal booking in high risk groups (especially teenagers and some BME
          groups), increasing breast feeding rates and supporting smoke free homes etc.

          Deliverables:
          These three work programmes are reflected in 8 of the WCC Outcome Action Plans and are matched to the Health Inequalities Action Plan. The selection of these
          priority outcomes was based on the analysis above but also on an analysis of the potential to improve further (over and above what we are already doing) in order to
          achieve the required outcome – improved life expectancy. All outcomes chosen were designed to be mutually supportive and complementary i.e.
          1. Risk assessment in primary care: Deliverables are those described in the Cancer, CHD and Stroke/TIA templates.
          2. Primary prevention: Deliverables those shown in the smoking quitters, tackling childhood obesity and alcohol misuse templates.
          In addition, other deliverables include tackling adult obesity (increasing physical activity e.g. through the Active Bristol programme and the development of weight
          management care pathways including in primary care - see delivery plan attached).
          3. Infant mortality: The key deliverables are demonstrated through the Teenage Pregnancy Action Plan and the Childhood Obesity Action Plan (i.e. increasing breast
          feeding).
            Other evidence-based deliverables include increasing early ante-natal booking in high risk groups, promoting smoke free homes (to improve child respiratory health)
           and tackling maternal obesity (see adult obesity above).
           Health Inequalities:
            There is a close correlation between overall life expectancy and socio-economic inequalities (especially for income) at the national level. Countries such as Japan,
           Sweden, Norway, Canada, and Greece have a high life expectancy, they also have low financial inequalities. Countries such as the USA and the UK with much wider
           financial inequalities have much lower life expectancies. Thus being poor in an unequal society is much worse for your health than being equally poor in an equal
           society. Thus measures to reduce inequalities will also help improve life expectancy overall - please see separate Health Inequalities Action Plan.
          Planned improvements in life expectancy – a cautionary note:
           Life expectancy calculations are often predicated on a static population. However, as people in deprived areas become more affluent, educated and healthier (and
          their life expectancy improves), they often move out to more affluent areas. In contrast, inward migrants are often drawn to deprived areas where property and rents are
          cheaper. Bristol, like similar core cities elsewhere, has a changing population e.g. younger, often international migrants arriving and older people moving out; a high
          student population, and changes in equality groups. Each of these populations have different lifestyle risk factors and thus changes will impact on life expectancy
          targets.
           Planned improvements in life expectancy need to take these factors into account. Based on evidence of effectiveness, the anticipated improvement in life expectancy
          for individuals is achievable, but whether or not those individuals stay in Bristol, is not predictable, as the population is not static. Hence targeting of interventions (high
          risk groups, highly mobile localities etc) is key.
           Total new investment 2009/10-2012/13 = £300,000 (see delivery plan D).
           Partnership arrangements (see Health inequalities Summary Sheet for wider determinants of health and partnerships).

     B    Background

     B1   Brief description of health outcome:
          To increase life expectancy at time of birth with outcome as the extra years gained. Links to improving outcomes for cancer, CHD, CVD/Stroke; reducing Health
          Inequalities and tackling teenage pregnancy, smoking, obesity and alcohol harm reduction.

     B2   Please state the rationale for choosing this health outcome:
          National health outcome for all PCTs. However, life expectancy at birth (LEB) in Bristol is slightly less than the national average and there is a 8.8 year difference in
          LEB across Bristol wards, thus there is a need to improve LEB and narrow this inequalities gap. Similarly, infant mortality rates also show an inequalities gap and
          contribute to the headline LEB target, thus these also need to be improved in at risk groups.

     B3   Brief description of indicator:
          The national Public Service Agreement target for life expectancy is:
          • 78.6 years for males in 2009-11
          • 82.5 years for females in 2009-11

     B4   Vital Signs
          The Department of Health is using All Age All Cause Mortality (AAACM) as a proxy to measure progress against the national life expectancy targets. AAACM is a more
          locally relevant measure, closely related to life expectancy and based on the same death data.

          For Bristol PCT the trajectories required to meet the 2011 AAACM target are: males from 764 per 100,000 in 2006 to 685 per 100,000 in 2011 and females from 513
          per 100,000 in 2006 to 502 per 100,000 in 2011.

                                                                    2006 baseline             2008            2009               2010              2011
                      Mortality rate per 100,000 (directly age
          VSB01_01    standardised) population, males, from               764                 740              721               703               685
                      all causes at all ages
          VSB01_02    Population at all ages, males                                          205,190        207,044            208,888           210,715
                      Mortality rate per 100,000 (directly age
          VSB01_05    standardised) population, females,                  513                 522              516               509               502
                      from all causes at all ages
          VSB01_06    Population at all ages, females                                        204,631        205,541            206,471           207,424

          Projected 2010 AAACM figures for Bristol are based on current trends using single year observed AAACM rates for 1997 to 2006.




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                                                                              Life Expectancy


     B5   Causation Analysis and Evidence Base
          Analysis shows that the greatest gains will come from tackling those common diseases (and related risk factors) that cause premature mortality and which have an
          evidence base that they are preventable, amenable to early intervention and/or treating them prolongs survival. Diseases that fulfil these criteria include CHD,
          CVD/stroke, lung cancer, cirrhosis of the liver, and chronic obstructive airways disease. Key risk factors relating to these diseases also need to be addressed, to bring
          about sustainable improvements. These include: smoking, obesity/lack of physical activity and alcohol/substance misuse. Given Bristol's history (employment in the
          tobacco industry) and recent trends (increase in obesity and alcohol misuse) a focus on primary prevention and early intervention/treatment for key diseases and
          targeted groups is key. Clearly if a condition kills early in life (such as in the first year or for someone in their twenties) then these deaths make a much greater impact
          on life expectancy data than would the death of a seventy year old, albeit numbers are much smaller. Infant mortality is considered a key contributor to life expectancy
          and significant gains can also be made through actions to reduce infant mortality - although benefits might take longer to be realised.
          Another major consideration when planning to improve overall life expectancy is to be aware that of the link between overall life expectancy and socio-economic
          inequalities (especially for income) found at the national level. Countries such as Japan, Sweden, Norway, Canada, and Greece have high life expectancies, they also
          have low financial inequalities. Countries such as the USA and the UK with much wider financial inequalities have much lower life expectancies. Thus being poor in an
          unequal society is much worse for your health than being equally poor in an equal society. Thus reducing inequalities will also improve life expectancies overall - please
          see separate health inequalities briefing sheet.
          Health Inequalities Intervention Tool for Bristol with the comparator area as the local authority average: Life Expectancy years gained if the Most Deprived Quintile
          (MDQ) of Bristol UA had the same mortality rate as the local authority average for each cause of death.




          The graph shows that the greatest possible gain for life expectancy and tackling male inequalities is for CHD with a gain of 0.6 years, suicide with 0.4 years and stroke
          with 0.3 years. The next greatest possible gains for men are for lung cancer, other cancers, ill-defined conditions, and cirrhosis of the liver (all about 0.2 years). For
          women the greatest gains for life expectancy and tackling inequalities are similar to the male ones, except that chronic obstructive airways disease is more prominent
          and ill-defined conditions none existent. NB: Note that suicide data should be treated with caution as numbers are generally small and thus rates fluctuate annually.

          Evidence from the literature, Cochrane Reviews and NICE suggests, in relation to the above, that Bristol PCT can achieve most benefits for its local population through:
          a) identification of at risk patients in primary care, ensuring primary prevention, early intervention and prompt treatment (see CVD, Cancer and Stroke/TIA outcomes)
          and through b) primary prevention of those diseases e.g. smoking cessation, obesity reduction/increased levels of physical activity, alcohol harm reduction (see
          relevant outcomes). The DH has also identified key interventions for improving infant mortality that will also contribute to overall improvements in LEB. In the Bristol
          context tackling teenage pregnancy [TP] (see TP outcome briefing paper) is key. However others, such as increasing breast feeding, reducing smoking in pregnancy,
          ensuring early ante-natal booking in deprived groups also will make a difference - some of these are dealt with through the LAA and a separate Maternity and Newborn
          action plan is under development (through the Maternity Services review group).

     B6   Summary of Strategy:
          As defined above, the greatest gains in life expectancy will come, in the short to medium term, from tackling those common diseases (and their related risk factors) that
          cause premature mortality and which have an evidence base that they are preventable and/or treating them prolongs survival. Diseases that fulfil these criteria include
          CHD, stroke, lung cancer, cirrhosis of the liver, and chronic obstructive airways disease. Reducing inequalities will also have a positive impact on improving Life
          Expectancy thus this strategy should be read in conjunction with that for Health Inequalities. This strategy therefore is derived from a) analysis of need (see JSNA) b)
          opportunities for health improvements (see analysis B5 above) and c) analysis of what is already in place, leading to the choice of 8 outcomes that feed into both this
          and the Health Inequalities Strategy/Outcome.

     B7   Demonstrate the links to the Strategic Plan and Joint Strategic Needs Assessment (JSNA):
          The Joint Strategic Needs Assessment identified a number of trends (including difficulties in closing the inequalities and life expectancy gaps across the city), related
          risk factors (e.g. obesity, smoking etc) and underlying wider determinants of health (e.g. education, housing/homelessness etc). Tackling these is therefore a priority
          and is reflected in the PCT's Strategic Plan, the Local Area Agreement and the Bristol City Council Corporate plan.




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                                                                                                                                                       Life Expectancy


     B7   Data from national data set (available to assessment panel):


     B8   Data sources:
          National Statistics via Compendium of Clinical and Health Indicators / Clinical and Health Outcomes Knowledge Base (www.nchod.nhs.uk or nww.nchod.nhs.uk).
          Health Inequalities Intervention Tool (London health Observatory at http://www.lho.org.uk/NHII/interventions.aspx?la=00HB&comp=1&IMMValue=24&IMFValue=24

     B9   Is the national data robust? How have we come to this conclusion?
          Yes, but there is at least a 12 month time lag in annual data becoming available. 2005-2007 data was released February 2009.

     B10 Please state current performance against target outcome:
         Male life expectancy in Bristol is currently 77 years, representing an increase of 1.2 years (1.6%) over the 3 year period from 2002-4 to 2005-7. Female life expectancy
         in Bristol is currently 81.4 years, representing an increase of 0.8 years (1%) over the 3 year period from 2002-4 to 2005-7. Life expectancy will need to be increased by
         1.6 years (2.1%) and 1.1 years (1.4%) over the next 4 years for males and females respectively in order to reach the national PSA targets. Currently males in Bristol
         have a life expectancy 0.7 years lower than England, females 0.4 years below the England average.

     B11 Do we know the current rate of improvement? If so, please provide details:
         In Bristol in the last year (2004-6 to 2005-7) male life expectancy increased by 0.1 years and female life expectancy by 0.2 years. Male life expectancy has risen
         steadily in Bristol from 75.3 in 2001-3 to 77 in 2005-7. The average annual percentage increase over this 4 year period was 0.6%. Female life expectancy has risen in
         Bristol from 80.5 in 2001-3 to 81.4 in 2005-7. The average annual percentage increase over this 3 year period was 0.3%. (Source: National Centre for Health Outcomes
         Development)
         Life expectancy is an artificial construct. It does not take into account migration, changes in health behaviours or health services, or unusual demography, all of which
         might alter the expected pattern of mortality. Bristol as elsewhere has a changing population - changing migration patterns, a high student population, and changes in
         equality groups. Each of these populations have different lifestyle risk factors.

          There are strong correlations in Bristol between deprivation and life expectancy. Life expectancy varies across wards and deprivation quintiles (graphs below). Life
          expectancy in Bristol is correlated with smoking patterns and chronic obstructive pulmonary disease mortality rates within wards.

          Figure 1: Life expectancy trends in Bristol

                                                                Trend in Life Expectancy at Birth, Bristol compared to South West and England

                                        84                                                                                                                                                                            Fig 1. Male life expectancy
                                                                                                                                                                                                                      in Bristol been getting closer
                                        82
                                                                                                                                                                                                                      to the England average,
                                                                                                                                                                                                                      however the rise has slowed
                                        80
                                                                                                                                                                                                                      down recently. Female life
             Life expectancy at Birth




                                                                                                                                                                                                                      expectancy in Bristol is also
                                        78
                                                                                                                                                                                                                      lower than the England
                                                                                                                                                                                                                      average but is staying in line
                                        76
                                                                                                                                                                                                                      with the rise in England. The
                                                                                                                                                                                                                      South West has the highest
                                        74
                                                                                                                                                                                                                      female life expectancy and
                                                                                                                                                                                                                      second highest male life
                                        72                                                                  England - Male                                         South West - Male
                                                                                                                                                                                                                      expectancy in England.
                                                                                                            Bristol - Male                                         England - Female
                                        70
                                                                                                            South West - Female                                    Bristol - Female

                                        68
                                               1991-     1992-        1993-     1994-      1995-     1996-       1997-      1998-     1999-       2000-       2001-       2002-      2003-       2004-       2005-
                                               1993      1994         1995      1996       1997      1998        1999       2000      2001        2002        2003        2004       2005        2006        2007




          Figure 2: Recent life expectancy improvements for men showing comparisons for Bristol

                                                      Life expectancy males: Average annual percentage change 2001-3 to 2005-7 Bristol, South West, England
                                                                                             and core city comparison


             0.7%
                                                                                                                                                           0.58%                             0.58%            0.56%
             0.6%                                                                  0.56%
                                                                                                                      0.50%
                                                 0.47%                                                                                0.47%                               0.46%
             0.5%                                                0.43%                              0.41%
             0.4%

             0.3%

             0.2%

             0.1%
                                                                                                                                                                                                                             Figs 2 and 3. Over the last 3
                                                                                                                                                                                                                             years (from 2001-3 to 2005-7)
             0.0%
                                                                                                                                                                                                                             Bristol has seen an
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                                                                                                                                                                                                                             England, South West and half
                                                                                                                                                                                                                             the core cities. The
                                                                                                                                                                                                                             improvement rates for female
          Figure 3: Recent life expectancy improvements for women showing comparisons for Bristol
                                                                                                                                                                                                                             life expectancy are lower than
                                                      Life expectancy females: Average annual percentage change 2001-3 to 2005-7 Bristol, South West, England                                                                males in all cities. In Bristol the
                                                                                              and core city comparison                                                                                                       rate of improvement is higher
                                                                                                                                                                                                                             only than Sheffield's.
            0.6%
                                                                                                                                                                                            0.51%
            0.5%

            0.4%                                 0.34%           0.34%             0.35%                                                               0.35%              0.34%
                                                                                                    0.32%
                                                                                                                                     0.28%                                                                   0.28%
            0.3%                                                                                                    0.25%

            0.2%

            0.1%

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                                                                                   Ward level life expectancy at birth: Bristol 2003 - 2007
                                        90


                                        85
            (years)




2a383fbb-2a50-4d33-a0d0-454293fd41b0.xls
               80                                                                                                                                                     3                                                                                            7/21/2010
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                                                                                                                                                                                                                                                                                                                                 Life Expectancy


          Figure 4: Life expectancy variation by electoral ward within Bristol
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 Fig 4. There is a 8.8 year
                                                                                                                                                         Ward level life expectancy at birth: Bristol 2003 - 2007
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 difference between the
                                                     90
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 highest and lowest life
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 expectancy at birth (LEB)
                                                     85                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          for all persons across
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 wards in Bristol.

            life expectancy (years)
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 Henleaze has the
                                                     80
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 highest, and Southmead
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 the lowest LEB.
                                                     75
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 Note: To calculate life
                                                     70
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 expectancy at ward level
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 a minimum of five years
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 of mortality and
                                                     65                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          population data are
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 needed.
                                                     60




                                                                                                                                                                                                                                                                                                                                 Ashley
                                                                                                                                                                                                      Henbury
                                                                                               Lockleaze




                                                                                                                                             Avonmouth




                                                                                                                                                                                                                                                                                                                                                                                                                                                             Hengrove
                                                                                  Southville




                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           Henleaze
                                                                                                                                                           Cabot




                                                                                                                                                                                                                                                                                            Whitchurch Park




                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   Westbury-on-Trym
                                                                                                                                                                                                                                                                                                                                                                                                                                                                         Clifton
                                                                        Filwood




                                                                                                                                                                   Hartcliffe




                                                                                                                                                                                                                 Eastville



                                                                                                                                                                                                                                                          Stockwood


                                                                                                                                                                                                                                                                                Horfield




                                                                                                                                                                                                                                                                                                                                                                                                                          Redland
                                                                                                                                                                                                                                                                                                                                                                                                                                     Knowle
                                                                                                                                                                                                                                                                                                                                                                          Frome Vale
                                                                                                           Lawrence Hill




                                                                                                                                                                                                                                                                                                                                                                                                                                              Clifton East
                                                                                                                           St George West




                                                                                                                                                                                                                                                                                                                                          St George East




                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      Cotham
                                                                                                                                                                                                                                             Hillfields
                                                                                                                                                                                             Easton




                                                                                                                                                                                                                                                                      Bristol
                                                            Southmead




                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               Stoke Bishop
                                                                                                                                                                                                                             Windmill Hill




                                                                                                                                                                                                                                                                                                              Brislington East




                                                                                                                                                                                                                                                                                                                                                                                                       Brislington West
                                                                                                                                                                                Bedminster




                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              Bishopston
                                                                                                                                                                                                                                                                                                                                                            Kingsweston


                                                                                                                                                                                                                                                                                                                                                                                        Bishopsworth
            Source: Bristol PCT using South East Public Health Observatory calculation methodology


          Figure 5: Trends in the Bristol life expectancy inequalities gap
                                                                                                                                          Bristol - Life Expectancy at Birth
                                                                                                                           Differences between the least deprived and most deprived areas                                                                                                                                                                                                                                                                                                                                                                      Fig 5. The life expectancy
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               gap between the least
                                                      86.0                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     deprived quintile and the
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               most deprived quintile is
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               widening.
                                                      84.0

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               Note: Calculated using
                                                      82.0                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     South East Public Health
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               Observatory life
                     No. Years




                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               expectancy calculator.
                                                      80.0                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     August 2008. Source:
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               Office for National
                                                      78.0                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     Statistics (ONS) Mortality
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               files for Bristol; GP
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               registered population
                                                      76.0                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     (Exeter).

                                                      74.0
                                                                        1997- 1998- 1999- 2000- 2001- 2002- 2003- 2004- 2005- 2006- 2007- 2008- 2009- 2010-
                                                                        1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012



                                                                                                                                                                                   Least deprived quintile                                                                                   Most deprived quintile


     B12 Include benchmarking data where available:

          Figure 6: Male and female life expectancies for Bristol compared to other Core Cities

                                                                                                                                                     Bristol life expectancy at birth 2005-7 compared to core cities
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      Fig 6. Bristol has the
                                                     84.0                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             second highest life
                                                                                                                                                                                                                                                                                                 81.8                            81.8
                                                                                                                                                                                                                                                                                                                                                      81.4
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      expectancy for men
                                                     82.0                                                                                                                                                                                                                                                                                                                    81.2
                                                                                                                                                                                                                                                                                                                                                                                                       80.8
                                                                                                                                                                                                                                                                                                                                                                                                                               80.5                                                                                                                   (after Sheffield) and the
                                                                                                                                                                                                                                                                                                                                                                                                                                               80.1
                                                     80.0                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             second highest life
                                                                                                                                                                                                                                                                                                                                                                                                                                                                        78.9                 78.7
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      expectancy for women
                           life expectancy (years)




                                                               77.7
                                                     78.0                         77.2                 77.0                   76.9                                                                                                                                                                                                                                                                                                                                                                                                                    (after Leeds) when
                                                                                                                                                          75.7            75.6                                                                                                                                                                                                                                                                                                                                                                        compared with other
                                                     76.0
                                                                                                                                                                                             74.6                                                                                                                                                                                                                                                                                                                                                     Core Cities
                                                                                                                                                                                                                73.9
                                                     74.0                                                                                                                                                                            73.4


                                                     72.0


                                                     70.0


                                                     68.0
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     B13 Is there an LAA or SHA stretch target? If so, please provide details:
         No.

     B14 Are there any links to other WCC health outcomes? If so, please provide details:
         Health inequalities, CVD, cancer, alcohol misuse, smoking, TIAs, childhood obesity and teenage pregnancy.




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                                                                                          Delivery Plan

C       Delivery Plan Actions & Indicators

Please state the main actions to be undertaken in order to improve health outcomes:
Life Expectancy at Birth: Strategy and Action Plans

Improving life expectancy overall (through stabilising and then closing the inequalities gap), requires both a multi-sectoral population-based approach and carefully
targeted interventions, reflecting the need to reduce inequalities and achieve a long term sustainable improvement in life expectancy for all sectors of the population.
The problem is multi-causal and therefore needs a multi-sectoral and targeted approach. Thus a number of PCT/BCC policies and strategies will contribute to this
outcome.

The overarching Inequalities Framework and the PCT Strategic Framework bring together a number of strategies, priority outcomes and action plans that will
contribute to this outcome (SA = Strategic Ambition).

No                          Actions                        Delivery                Indicators/Data Collection                                        Evidence Base
                                                             Date
         Specify the units of activity and exactly what   When will       What data/indicators will be collected/used to                   Why will the action be carried out?
                   outcome this will lead to.             the action                 demonstrate success?
                                                          be carried
                                                             out?


                                                                                2008/09
      1 Risk Assessment in primary care, early interventions and treatment
    1.1  Cardio Vascular Disease (CVD)                   See briefing papers for indicators of                           Evidence base indicates that risk assessment and early
        Mortality (see Health Outcome briefing           success.                                                          detection with effective management and systematic review
        papers: CVD Mortality and TIA                                                                                      in primary care are key. QOF evidence suggests that not all
        Management).                                                                                                       high risk individuals are identified and even if identified are
                                                                                                                           not necessarily receiving optimum treatment. It is likely that
                                                                                                                           there will be an inequality with the more disadvantaged
                                                                                                                           being less likely to receive treatment.
    1.2  Cancer (see Health Outcome briefing                           See cancer mortality outcome briefing             Please see cancer strategy and Smoke Free Bristol
        paper: Cancer Mortality).                                      paper indicators of success.                        strategy.
    1.3  Chronic Obstructive Pulmonary                                 All patients with COPD to receive influenza Respiratory Service design group is currently reviewing the
        Disease (COPD) Mortality.                                      vaccine and community-based pulmonary          care pathway.
                                                                       rehab service.
    1.4  Cirrhosis of the liver (see Health                            See alcohol outcome paper.                   Alcohol harm reduction strategy screening in primary care
        Outcome briefing paper: Alcohol                                                                               and A&E and Maternity services, using standardised
        misuse).                                                                                                      assessment packager and stepped care approach to
                                                                                                                      alcohol treatment includes inpatient care.
    1.5  Suicide.                                                      National target for suicide prevention is to See Bristol Suicide Prevention Strategy and Action Plan
                                                                       reduce the death rate from suicide and         2008-11 also see the Domestic Abuse Strategy and HV
                                                                       undetermined injury by at least a fifth by     targeted risk assessment for post natal depression
                                                                       2010 (from a baseline rate of 9.2 deaths per (Edinburgh Post Natal depression scale) but problems with
                                                                       100,000 population in 1995/6/7 to 7.4 deaths recording as some will be recorded on GP systems but
                                                                       per 100,000 in 2009/10/11).                    others on HV paper records.
    1.6  Prevention of harm from substance                             National Substance misuse target:                 See DPH Annual Report for 2007 and Harm Reduction
        misuse.                                                        Numbers of drug misusers retained in                Strategy (Safer Bristol Partnership).
                                                                       treatment.
      2 Primary prevention
    2.1  Stopping smoking (see Health                                  PCT SA 31: Contribute to a reduction in           See smoking outcomes paper .
        Outcome briefing paper: Smoking                                smoking levels by meeting the challenging
        Quitters).                                                     annual targets for '4-week quitters'. To
                                                                       achieve a quit rate of 870/100,000
                                                                       population in the neighbourhood renewal
                                                                       areas.
    2.2  COPD.                                                         See smoking quitter briefing papers
                                                                       indicators of success.
   2.3  Prevention of obesity.
2.3.1  Prevention of childhood obesity (see                            See Childhood Obesity briefing papers
       Health Outcome briefing paper:                                  indicators of success.
       Childhood Obesity).
2.3.2  Prevention of adult obesity.                                    PCT SA targets 19, 20, 29 and 30 relating         Link to Weight Management Strategy, Food & health
                                                                       to weight management, physical activity and         Strategy and Physical Activity Strategy Link to infant
                                                                       healthy food.                                       mortality.
    2.4  Prevention of harm from alcohol                               See alcohol briefing papers indicators of         See Alcohol Harm reduction strategy.
        misuse (see Health Outcome briefing                            success.
        paper: Alcohol misuse).
    2.5  Mental health.                                                National target for suicide prevention is to See Bristol Suicide Prevention Strategy and Action Plan
                                                                       reduce the death rate from suicide and         2008-11 also see the Domestic Abuse Strategy.
                                                                       undetermined injury by at least a fifth by
                                                                       2010 (from a baseline rate of 9.2 deaths per
                                                                       100,000 population in 1995/6/7 to 7.4 deaths
                                                                       per 100,000 in 2009/10/11).
     3 Infant Mortality


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                                                                                Delivery Plan

        Modelling for the Department of Health has identified interventions that will contribute to improving infant mortality and reducing the inequalities gap. As applied
        to Bristol, these are reflected in points 3.1 to 3.6 below. In addition, two other key areas are:
         Meeting the child poverty target to halve the number of children in relative low-income households between 1998–99 and 2010–11, by increasing the income
        in the routine and manual occupational group by an average of 18%.
         Reducing housing overcrowding in the routine and manual occupational group through the effect on reducing SUDI (sudden unexpected death in infancy).
        These are best addressed in partnership – please see the health inequalities template.
    3.1  Reduction in teenage pregnancy (see                     See teenage pregnancy outcome briefing      See also Teenage Pregnancy Strategy.
         Health Outcome briefing paper:                          paper indicators of success.
         Teenage pregnancy).
    3.2  Improve breastfeeding rates (see                     See childhood obesity briefing paper
        Health Outcome briefing paper:                        indicators of success.
        Childhood Obesity).
    3.3  Increase the proportion of smoke free                PCT SA 20: By March 09 all 8 month               See Strategic Framework.
        homes.                                                checks on children carried out by Health
                                                              Visitors are to routinely include a discussion
                                                              of the benefits of a smokefree home. To be
                                                              recorded in 85% of the Child Health
                                                              Records. The same target to be at 90% by
                                                              2012.
    3.4  Improve rates of early ante-natal                    Targets yet to be set.                     Inequalities identified through the Maternity services health
        booking.                                                                                           equity audit - a particular problem locally in specific groups/
                                                                                                           communities (e.g. Somali women).
    3.5  Reduce rates of smoking in                           PCT SA stretch target 46. Reduce smoking Integral to the Smoking Quitters target.
        pregnancy.                                            rates during pregnancy to a level which is
                                                              half those of women in that age group in the
                                                              general population of the South West.

    3.6  Sudden infant death.                                 Primary prevention advice routinely given        Evidence suggests that reductions in sudden unexpected
                                                              by the health visiting team during routine         death in infancy (SUDI) can be achieved by persuading
                                                              visits/contacts i.e. to all families. All sudden   those (especially in the routine and manual occupational
                                                              infant deaths are subject to Child Death           group) to avoid sharing a bed with their baby or putting their
                                                              reviews and PCT is represented on the              baby to sleep prone (on its front) - would be recorded on HV
                                                              Panel.                                             notes (some paper and some electronic - thus not easily
                                                                                                                 extracted).
                                                                                       2009/10

                                                                                       2010/11


D       Total Investment

D1      Please provide details of the total new investment between 2009/10-2012/13:
        £300,000

D2      Please include comments if funding is subject to Operational Planning Process (OPP) approval:
        Most costs are already included in either the other WCC outcomes, Darzi and OPP bids.

E       Partnership Arrangements

E1      Which organisations will help us deliver this plan? If key posts are part of another organisation please provide details:
        See Assurance Framework (attached) and Health Inequalities Outcome - which gives partnership arrangements.




             2a383fbb-2a50-4d33-a0d0-454293fd41b0.xls                                  6                                                                 7/21/2010
                                                                                                            Assurance Framework




                                                                                                Life Expectancy at Birth: Strategy and Action Plans

                                                A number of factors contribute to inequalities in life expectancy (JSNA). The JSNA suggests a need for a stronger focus on primary
                                                prevention, addressing underlying determinants of health and associated risk factors (smoking, obesity, physical activity levels,
                                                environment, housing etc). At the same time there is a need to improve access to quality services and clear care pathways
                                                (specifically targeting cancer, CVD/CHD, COPD) alongside improved management of a range of long term conditions i.e. service
                                                development and redesign will be needed in some areas. It also involves tackling inequalities in infant mortality and working in
                                                partnership (e.g. practice based commissioners, local authority, NHS partners and providers including the voluntary and community
                                                sector) to address the wider determinants of health and tackle health inequalities.

                                                Improving life expectancy overall (through stabilising and then closing the inequalities gap), requires both a multi-sectoral
                                                population-based approach and carefully targeted interventions, reflecting the need to reduce inequalities and achieve a long term
                                                sustainable improvement in life expectancy for all sectors of the population. The problem is multi-causal and therefore needs a
                                                multi-sectoral and targeted approach. Thus a number of PCT/BCC policies and strategies will contribute to this outcome.

                                                The overarching Inequalities Framework and the PCT Strategic Framework bring together a number of strategies, priority outcomes
                                                and action plans that will contribute to this outcome. Here we have identified a number of linked strategies and action plans that will
                                                be reviewed annually to assess their contribution towards this Outcome.


    Assurance Framework
                    Linked Strategies/Actions                         Responsible/Lead             Frequency of review by         Date of next review by              Indicators/Data Collection                            Investment
                                                                                                     responsible group           oversight group (PD/JB +
                                                                                                                                           DMT)
      What is going to be done to improve health outcomes?     Lead group (PCT/PH named lead)                                            2008/09             What data/indicators will be collected/used to     What investment is required? Utilise
      Include evidence base and data - numbers/%/trajectory                                                                                                             demonstrate success?                           programme budgeting




    Inequalities Framework                                    Bristol Partnership (VH)   Annual review                          Annual review - Dec         As per current monitoring arrangements
    Local Area Agreement                                      H&W_B delivery group and   Quarterly reports and                  Annual review - May         As per current monitoring arrangements
                                                              LAA performance management annual review (May)
                                                              challenge group (JB)

    Smoke Free Bristol Strategy                               Bristol Partnership (WP)          Annual review            Annual review - Sep      As per current monitoring arrangements
    Weight Management strategy                                Bristol Partnership (NF)          Annual review            Annual review - June     As per current monitoring arrangements
    Food and Health Strategy                                  Bristol Partnership (NF)          Annual review            Annual review - June     As per current monitoring arrangements
    Physical Activity Strategy                                Bristol Partnership (NF)          Annual review            Annual review - June     As per current monitoring arrangements
    Active Bristol                                            Bristol Partnership (NF)          Annual review            Annual review - June     As per current monitoring arrangements
    Bristol Suicide Prevention Strategy                       PCT-led Steering group (CG)       Annual Audit (Feb)       Annual review - March    As per current monitoring arrangements
    Harm Reduction Strategy                                   Safer Bristol Partnership (BC)    Annual review            Annual review - March    As per current monitoring arrangements
    Alcohol Harm reduction strategy                           Safer Bristol Partnership (BC)    Annual review (Sep)      Annual review - Oct      As per current monitoring arrangements
    Older People Strategy                                     Bristol Partnership (JB)          Annual review            Annual review - Sep      As per current monitoring arrangements
    PCT Strategic Ambitions                                   PCT (PD)                          Annual review            Annual review - April    As per current monitoring arrangements
    The Cancer Reform Strategy                                PCT (AR)                          Cancer ReformAction Plan under review June 2008; See work of BHSP Cancer Service Design Group
    Sustainable Communities Strategy                          Bristol Partnership (HA)          Annual review            Annual review - June     As per current monitoring arrangements
    Local Development Framework                               Bristol Partnership (HA)          Annual review            Annual review - June     As per current monitoring arrangements
    Children and Young People's Strategy                      CYP (NF)                          Annual review            Annual review - May      As per current monitoring arrangements
    Carer's Strategy                                          ACC (RL)                          Annual review            Annual review - June     As per current monitoring arrangements
    Parks and Green Space Strategy                            BCC (JB)                          Annual review            Annual review - June     As per current monitoring arrangements
    Community Cohesion Strategy                               Safer Bristol Partnership (CG)    Annual review            Annual review - June     As per current monitoring arrangements
    Domestic Abuse Strategy                                   Safer Bristol Partnership (JB)    Quarterly                Annual review - June     As per current monitoring arrangements
                                                                                                monitoring/Annual review
    Health Trainers Programme                                 PH Directorate (JB)               Annual review            Annual review - June     As per current monitoring arrangements Increase capacity
    Other Outcomes (CHD/CVD/Cancer)                           PH Directorate (VH/AR)            Annual review            Annual review - June     As per current monitoring arrangements
    BCC Corporate Plan                                        PH Directorate

    Action Plan
    Data Development equalities groups (DH/CG)                Ethnicity project, prison HNA     Disablility, mental health                                                                                    Under development
    Minimum Data Set/JSNA (JT/                                Mainstreaming                     Data refresh                    Data refresh                Annual updated report                             Mainstreaming required
    Equality Impact Assessments of all strategies                                               Scoping/proofing                Monitoring system           Summary report and action taken                   Capacity/monitoring systems
    Rolling Programme Health Equity Audits (HN)               Scoping                           2-3 audits                      2-3 audits                  Audit reports and action taken                    Increase PH consultant and analyst
                                                                                                                                                                                                              capcity

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                                                                                    Route Map (M)


                  Relative contributions of the three work streams - Males
                                                                                                      Using this model:

10 years            Benefits                                               Age
                    accrual                                                groups            0-1      Reducing male infant mortality for Bristol by 1/3rd over 5 years will contribute a
                                                    Infant                                   years    0.1 year improvement in LEB for males (i.e. more than 0.2 years over 10
                                                  mortality                                           years).
                                                  0.2 years




                                                                                              50      Primary prevention is key to ensure medium to long term (sustainable) benefits
5 years                                                                                      years    and if not addressed will lead to increased pressures on scarce NHS
                                             Primary prevention =                                     resources as the burden of ill health in the population grows.
                                             ? 0.7- 1.4 years




3 years                                                                                      50-80+
                                                                                             years


                                                                                                      Some of the necessary gains in the first three years (2008-2010 inclusive) can
                                 Secondary prevention (Risk assessment
                                                                                                      be achieved by secondary prevention, although primary prevention (stop
                                 and management in primary care) = ? 0.7
                                                                                                      smoking, tackling obesity and alcohol misuse, etc) are still clearly important,
                                              years LEB
                                                                                                      although maximum benefits for some of the key lifestyle changes become
                                                                                                      more apparent after 5 years.




           Need to improve LEB for males by 1.7 years by 2010




           2a383fbb-2a50-4d33-a0d0-454293fd41b0.xls                                      8                                                                         7/21/2010
                                                                                           Route Map (F)




                        Relative contributions of the three work streams - Females


    10 years                Benefits
                                                                                  Age
                            accrual
                                                                                  groups                     Reducing female infant mortality for Bristol by 1/3rd over 5 years can
                                                         Infant                                     0-1
                                                       mortality 0.2                                years    contribute a 0.1 year increase in LEB for females (i.e. more than 0.2 years over
                                                         years
                                                                                                             10 years)




    5 years                                                                                          50
                                                                                                             Primary prevention is key to ensure medium to long term (sustainable)
                                                                                                    years
                                                      Primary prevention
                                                   Primary prevention = =                                    benefits and if not addressed will lead to increased pressures on scarce NHS
                                                   0.7? 0.9 - 1.8 years
                                                      years                                                  resources as the burden of ill health in the population grows.




    3 years
                                                                                                    50-80+
                                                                                                    years
                                                                                                             Some of the necessary gains in the first three years (2008-2010 inclusive) can
                                        Secondary prevention (Risk assessment                                be achieved by secondary prevention, although primary prevention (stop
                                        and management in primary care) = ? 0.9                              smoking, tackling obesity and alcohol misuse, etc) are still clearly important,
                                                     years LEB                                               although maximum benefits for some of the key lifestyle changes become
                                                                                                             more apparent after 5 years.




               Need to improve LEB for females by 1.3 years by 2010




2a383fbb-2a50-4d33-a0d0-454293fd41b0.xls                                                        9                                                                                               7/21/2010

								
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