Joint Strategic Needs Assessment

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					Sefton’s Joint Strategic Needs Assessment 2010

On behalf of:

Joint Director of Public Health

Director of Health and Wellbeing

Director of Children’s Services

October 2010
                                             Sefton‟s JSNA 2010

Contents ....................................................................................................... page

What is a Joint Strategic Needs Assessment for? ................................................ 3

How have we produced this Joint Strategic Needs Assessment? ........................ 4

Our People ............................................................................................................ 5

   Children and Young People .............................................................................. 5

   Older people .................................................................................................... 10

   Long term conditions ....................................................................................... 13

   Mental Health and Wellbeing........................................................................... 17

   Health Inequalities ........................................................................................... 20

Our Places .......................................................................................................... 24

   Strong Communities ........................................................................................ 25

   Access to healthy choices ............................................................................... 25

   Housing ........................................................................................................... 25

   Environment .................................................................................................... 26

   Climate Change............................................................................................... 27

   Transport ......................................................................................................... 27

Our Priorities ....................................................................................................... 30

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                                    Sefton‟s JSNA 2010

What is a Joint Strategic Needs Assessment for?

A Joint Strategic Needs Assessment (JSNA) is a report that is based on the results of
other work done to find out about:

   The health and wellbeing needs of the local community
   Any groups whose needs are not being met

It gives:

   Information which can be used to plan, develop and deliver health and wellbeing
    services for the next three to five years

It aims to:

   Plan a clear direction for the next three to five years
   Help reduce health inequalities

Key Themes
This JSNA has two main themes, „our people‟ and „our places‟

Our People
This section looks at what we need to concentrate on in the short term for people in
Sefton, so that:

   Our older people will have the best quality of life
   Our children, families and adults will reach their full potential

Our Places
This section looks at what we need to concentrate on in the short term for places in
Sefton, so that:

   Our most deprived neighbourhoods will be regenerated
   All our neighbourhoods will be attractive, safe and connected

Sefton must improve the health of local people and reduce inequalities by tackling the
issues of place but our greater focus in this document is on working with and for our
residents. You can find out more about „our places‟ in Sefton‟s Sustainable Community
Strategy and the Sefton Director of Public Health annual reports.

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                                  Sefton‟s JSNA 2010

How have we produced this Joint Strategic Needs
Sefton‟s first JSNA was published in March 2008. During 2010, Sefton Council, NHS
Sefton and Sefton Council for Voluntary Services have worked together on this second
JSNA by:

   Reviewing progress against the priorities in the first JSNA
   Considering the feedback from engagement with the public and professionals on the
    first JSNA
   Appraising the findings from over 35 needs assessments and key documents about
   Identifying the issues from consultations and engagements in Sefton on specific

All the information has been used to help us set out what we think are the main issues
affecting people‟s health and wellbeing in the borough.

The sections entitled „What we have achieved‟ highlight examples of what has happened
since our first JSNA. A full list of achievements is available in the supporting documents.

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                                  Sefton‟s JSNA 2010

Our People

Children and Young People

What we know

Focusing on children and young people is very important. This is because what happens
to people in their early years has a lifelong effect on many aspects of health and
wellbeing. Generally, health outcomes for Sefton‟s children and young people are
improving but most are still below the England average.

The number of births to non British-born mothers is rising though it is quite a small
proportion of births. This increase is particularly amongst Polish and Latvian born
mothers so services will need to be targeted to meet their needs.

Obesity is a growing problem across the country. Results from the National Child
Measurement Programme (NCMP) show that Sefton‟s rates of overweight and obese
children do not differ significantly from national and regional rates.

                     In Reception (age 4-5 years), 14.4% of children were overweight
                      and 9.7% were obese. (08/09)

                     In Year 6 (age 10-11 years), 14.0% of children were overweight and
                      17.8% were obese. (08/09)

Children in Sefton need more opportunities for regular exercise. Ensuring children start
life with good nutrition through breastfeeding and supplementary vitamins will prevent
obesity in later life. Improving school dinners with better variety and value for money will
help to support children to eat a more healthy diet.

Poor mental health in childhood has major lifetime effects on mental wellbeing and

                     In a survey of Year 10 pupils in Sefton, 74% said that they worried
                      about at least one problem „quite a lot‟, or „a lot‟. (2006)

                     Nationally, 10% of young people have some form of mental
                      disorder. Based on this, the number for Sefton is likely to be around

                     Approximately 1,000 young people in Sefton have a learning

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                                 Sefton‟s JSNA 2010

                    250-480 young people have both a learning disability and a mental
                     health problem

                    There are over 600 children on Sefton‟s voluntary disabled children

Hospital Admissions
Most planned admissions to hospital for under 18 year olds are for ear, nose and throat
conditions. Emergency admissions tend to be for care of newborn babies with
gastroenteritis or problems related to breathing. Sefton is working with neighbouring
Primary Care Trusts (PCTs), maternity hospitals and the voluntary sector to promote
breastfeeding. This will help to reduce such admissions.

Children and alcohol
Youth drinking has consequences throughout life including alcohol abuse and
dependency. Drinking amongst children appears to be decreasing. In a survey of year
10 pupils in Sefton during 2006, 37% had at least one alcoholic drink in the previous
week. Sefton has high levels of hospital admissions for alcohol-related problems for
under 18s. Local surveys have shown that many college students believe it is okay to
get drunk. We need to change the way drinking alcohol is linked to leisure time and
reduce the harm that results from this. The Tellus4 survey results tell us our young
people think that the work done in schools around drug, alcohol and sexual health is

Child Protection
Sefton is committed to safeguarding and promoting the welfare of children. The different
organisations in Sefton work well together and share information when child welfare
concerns arise.

                 In January 2010, there were 320 children in Sefton subject to a child
                 protection plan. These cases are according to the following categories:

                    Sexual          36
                    Emotional       45
                    Physical        111
                    Neglect         138

There are 397 children “looked-after”, which is a significant increase over the previous
year of almost a quarter. This could be a response to increased scrutiny following the
Baby P case and changes in thresholds. We know that looked-after children and those
in contact with youth offending services are at increased risk of mental health problems.

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                                  Sefton‟s JSNA 2010

Dental Health
The health of children‟s teeth reflects their diet and nutrition. Overall dental attendance
amongst very young children is low.

              There is considerable variation in dental attendance for 3-5 year olds
              ranging from 44% in Derby to 89% in Blundellsands.

The wards with the higher rates of attendance are Ainsdale, Birkdale, Blundellsands,
Victoria and Ravenmeols. The wards with the lowest attendance rates are also
consistently areas of poor child dental health: Derby, Linacre, Litherland, Netherton /
Orrell and St Oswald.

A recent survey showed that the average number of decayed, missing, or filled teeth per
child appears to be reducing. However, we need to make sure that children with poor
dental health are not opted out from the survey by their parents.

              Looked-after children are more likely than average to receive an annual
              health check but less likely than average to receive an annual dental check.

Sexual health
Sexually transmitted infections affect all ages. However, the highest rates of diagnosis
are in young adults. There is evidence that across Cheshire and Merseyside the number
of infections increases with increasing deprivation. There are higher levels of sexually
transmitted infections in younger adults in the most deprived areas. Not enough young
adults are being screened for Chlamydia in Sefton. Teenage pregnancy rates are also
higher in more deprived areas, though Sefton‟s overall rate continues to be the lowest in
the North West. In Sefton, there are increasing abortion rates for all ages, including

What we have achieved for children and young people

   98% of schools are taking part in the Healthy Schools Programme. This is better
    than what is happening nationally.
   A child measurement programme linked to healthy schools has started to tackle the
    issue of obesity amongst primary school children The rates of overweight and obese
    children in Reception (aged four to five years) has declined in Sefton for two
    consecutive years.
   Children‟s centres are being increasingly used to deliver interventions such as a new
    weight management programme (see below in the Our Places section „access to
    healthy choices‟ - fruit and vegetable cooperatives) and access to supplementary
    vitamins for those who do not receive Healthy Start.
   Money has been invested in 24 nurseries in deprived areas to support healthy

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                                 Sefton‟s JSNA 2010

   A Healthy Community Collaborative has been established to tackle obesity through
    involving communities and clinical staff. This collaborative will develop community-
    based prevention and treatment programmes which promote healthy lifestyles.
   NHS Sefton and its partners have registered their intention to achieve the UNICEF
    Baby Friendly status – these are a set of hospital and community standards that
    have been shown to increase the level of women breastfeeding.
   There was a massive 90% take-up of the HPV (Human Papilloma Virus) vaccine
    among young women (12-13 years) for protection against invasive cervical cancer.
   We have appointed a local GP as Clinical Lead for children‟s health
   We have started a review of children‟s community services to identify what needs to
    go in our 5 year plan to buy children‟s services for Sefton. This involves discussions
    with the public, children and other key people to help us develop services for the
   Family information leaflets on topics such as breast feeding and safe sleeping have
    been translated for non British-born mothers
   Sefton now has an integrated community sexual health service with clinics across
    Sefton, including:
        - A dedicated young person clinic in each of the three areas of Sefton (Bootle,
            Maghull, Southport)
        - Chlamydia screening now available across Sefton (via integrated sexual
            health service (ISIS), Parenting 2000, GPs, Pharmacies, postal kits, website)
        - Outreach clinics in further education colleges
        - Interactive lessons on sexual health, including how to access local services,
            developed for use with Year 9-11 pupils

What further work needs to be done?

We need to:

   Improve the uptake of Healthy Start vitamins in Sefton. The target groups are
    pregnant women and 0-4 year olds.

   Expand the peer mentor programme for breastfeeding targeting women in the lowest
    breastfeeding groups

   Increase access to dental services to 66% by 2012. The new practice in Bootle will
    target families with children

   Further understand sexual health issues locally in certain vulnerable groups,
    including the following:

–   People with physical and learning disabilities
–   Migrant workers and asylum seekers
–   Looked-after children
–   Black and minority ethnic groups
–   Lesbian, gay, bisexual people and sex workers

   Meet the Chlamydia screening target (we achieved less than 20% in 2009/10 – and
    the target was 25%) The 2010/11 target is 35%. Services developed and
    implemented in 2009/10 should lead to achievement of the target in 2010/11

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                                    Sefton‟s JSNA 2010

   Continue support to prevent unplanned pregnancies and support teenage parents.
    We also need more information on second and subsequent births to teenage young

   Explore how information on local services on reducing smoking in pregnancy can be
    easily distributed by midwives during appointments

   Bridge the gap in provision of services for 16-18 year olds in Sefton, and clarify and
    appropriately manage the cross over of young people between children‟s and adult

   Improve services for children with learning disability, physical disability, mental health
    problems and from black minority and ethnic communities in Sefton and ensure they
    are able to meet local need

   Review and improve the work done in schools around drug, alcohol and sexual

   Support parents to develop their skills so that they can better talk to their children.
    We should be looking at models such as Speakeasy that have been successful with
    sexual health

   Develop a youth advocacy programme for young people building on the experience
    of D-MYST1 in Liverpool and our work with Smokefree North West

   Adult services need to address family issues through a Think Family2 approach

 A Smokefree movement led by and for young people
 This is a programme that involves different departments to make sure that the support provided
by children‟s, adults' and family services is coordinated and takes account of how individual
problems affect the whole family

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Older people

What we know

Ageing is to be celebrated.      Our older people are active citizens and we should
recognise the contribution they make to our communities.

Older people are not a uniform group and they have a wide range of needs. Older age
can be seen broadly as having three phases:

   Entering old age – people who have completed their career in paid employment
    and/or child rearing. These people may be as young as 50 and are active and

   Transitional phase – in transition between healthy, active life and frailty. The goals of
    health and social care are to identify emerging problems in order to prevent crisis
    and long term dependence

   Frail Older People – these people are vulnerable as a result of health problems such
    as stroke, dementia or social care problems

The majority of older people continue to live in the community in private households.
However, they can face barriers to participation in community life, including financial
hardship and difficulties with travel.

The number of people who live in Sefton has been falling every year for the last decade.
Currently, 273,300 people are thought to live in Sefton. Over the next twenty years this
should decrease slowly to around 266,000 people by 2033. Nevertheless, we know that
the population is getting older.

                          Compared with 10 years ago there are now:
                           Fewer under 45s
                           More people aged 45+ (particularly aged 45-64)

                             Amongst metropolitan boroughs, Sefton has the country‟s
                              highest proportion of residents aged 65 and older, and
                              residents aged 75 and older
                             Currently 20% of Sefton‟s population are aged 65 and older

This is important as certain illnesses and long-term conditions tend to appear in middle-
aged and older age groups. There has also been an increase in the number of older
people with complex care needs. There is a greater concentration of older people in the
north of Sefton.

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Older people may be more likely to need admission to hospital, particularly if they have
more than one illness or long-term condition. As the population of Sefton changes we
need to make sure that we plan services that can meet this need. A greater number of
older people will need palliative care and we need to ensure that we have sufficient and
appropriate resources to support people with advanced disease in hospitals, and in the

We are working to ensure that older citizens of Sefton with dementia can access
appropriate and effective services that will support them in living as independently and
healthily as possible.

What we have achieved for older people

We have :
 Produced a number of strategies and started their implementation:

          Strategy for Older Citizens
          Dementia strategy
          End of Life Care Strategy

   Included older people in the development of preventive services and the launch of a
    prevention strategy in the borough
   Produced booklets for older people in Sefton:

          The Essential Living Handbook. The handbook contains useful information,
           hints, tips and advice on keeping well, staying active and keeping safe.
          The Welcome to North Sefton booklet aimed at helping older people to
           remain well and promotes involvement with family, friends, the community,
           and activities available in their local neighbourhood.

   Developed Sefton Careline. This aims to enhance the quality of life of vulnerable
    residents within the borough by supporting people who have specific needs to
    continue to live safely and independently within their own homes. At present, Sefton
    Careline is supporting 6444 people. They currently use a variety of services

       –   Telecare
       –   Telehealth
       –   Community Support
       –   Hearing Impairment Equipment
       –   Community Alarms
       –   Carers Cards

   Developed the Community Support Programme which consists of five community
    support assistants. These assistants support clients over a 6-18 month period to help
    them get used to living in the community again after discharge from hospital. A total
    of 245 people have been supported since the introduction of the scheme in January
    2008. There were 30 new clients in 2009-10
   Provided support to keep older people fit and active e.g. free and subsidised

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     Established Creative Alternatives3. This helps address mild to moderate mental
      health issues. Many participants are older people.

What further work needs to be done?

We need to:

     Promote the Healthy Sefton Lifestyles initiative for older citizens across Sefton, e.g.
      prevention of falls, reduction of emergency admissions

     Deliver the action plan that is part of the Sefton strategy for Older Citizens. This plan
      aims to:

          –   Strengthen the financial security of our older people. (This is particularly
              important given the current difficult economic situation and the need for us to
              respond to proposed welfare reform)
          –   Improve customer service quality and consistency
          –   Join up health and wellbeing services
          –   Improve a sense of personal safety and social connection
          –   Improve communications, participation and involvement
          –   Raise the profile of older people‟s contribution and value

    This is an arts and drama activities programme

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Long term conditions

What we know

Sefton has higher levels of long term conditions compared with the average for the North
West region and England. Lifestyle factors that contribute to this are improving the
situation but it still varies across the borough. Expected levels of long term conditions
are higher than levels currently recorded, so there may be large numbers of people with
undiagnosed conditions.

The number of people with diabetes in Sefton has risen over the last four years and is
predicted to continue to rise by 42% in the next twenty years. With the predicted future
rise in rates of diabetes, it is thought that around half of those diagnosed as having
diabetes will be from disadvantaged areas.

The number of people in Sefton with stroke and Transient Ischemic Attacks (TIA) are
above average and expected to rise sharply in coming years. Levels of stroke and TIA
vary across Sefton but appear to be slightly higher in Southport. Similarly, rates of
hospital admission are highest in Cambridge, Dukes and Ainsdale wards. We need to
make sure that the services we are currently providing are effective and that we can
meet the increase in need in the coming 5-10 years. We also need to focus on
prevention and decreasing risk factors in people over the age of 40.

Chronic Pain
Pain is subjective and not easily measured but can have a major impact on people‟s

              In Sefton, between 22,200 and 38,800 people are likely to be experiencing
              chronic pain.

Chronic pain becomes more common with age. It is difficult to measure unmet need
locally. However, we know that with an ageing population and rising levels of people with
long term conditions, the number of people with chronic pain is set to increase.

Avoiding long term conditions - lifestyle risk factors
Life expectancy in Sefton varies. Males living four miles apart could have a difference in
life expectancy of 11 years (Sudell compared to Linacre), and females could have a
difference of 10 years within two miles (Molyneux compared to Linacre). The gap in life
expectancy in Sefton is largely due to diseases of the heart and circulatory system, lung
cancer and chronic obstructive pulmonary disease (COPD). People live with some of
these diseases for a long time. We need to continue to support people in changing their
lifestyles to reduce the risk of developing long term conditions.

We know smoking is a significant risk factor for these diseases.

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                  Based on local surveys, about 18% of people in Sefton are smokers and
                  this number is falling.

Smoking rates are highest in the most deprived areas of Sefton but rates are also known
to be falling fastest in these areas.

We are developing a greater range of insight into the needs of local communities
through engagement work. This is a mix of local work and collaborative work with
partners such as Cheshire and Merseyside Public Health Network (CHaMPs). Our
insight work will influence the design of future programmes, such as working with young
men in deprived areas (who are the most likely to want to quit smoking) and providing
extra support for people on weight management courses to quit smoking. The work will
continue to prioritise those with the greatest levels of need in the most deprived areas in
Sefton, as we know that having a long term, sustained focus is what is needed to
address long standing inequalities in health.

Obesity is thought to reduce life expectancy by around nine years and contributes to
major killers such as cardiovascular disease and certain types of cancers, and long term
conditions such as diabetes.

                In Sefton, about 120,000 adults are overweight or obese
                For adults, 55% of men and 42% of women are overweight or obese

Results from the Sefton Citizen‟s Panel 2010 showed that of the people who responded:

                 96% were aware of the recommended number of fruit and vegetables that
                  a person should eat per day but 61% of people ate less than this amount
                 61% of people are aware that physical activity sessions should last 30
                  minutes but only 25% of people responded were aware that it is
                  recommended to do physical activity five times a week to benefit health
                 39% think the recommendation is three times a week
                 16% report doing physical activity five or more times a week

People drinking too much is a problem across the borough.

                   In Sefton, one in five men and one in 10 women drink more than the safe
                  recommended weekly amounts.

Sefton has one of the highest levels of binge-drinking within the region.

                  One in five men and one in eight women binge drink

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There is an increase in harmful drinking due to the rise in „pre-loading‟ (drinking before
going out) and buying alcohol from supermarkets.

The number of hospital admissions due to alcohol-related problems in Sefton has been
rising and has almost doubled over the last seven years. Sefton has the lowest rate in
Merseyside but it is still higher than other similar Local Authority areas and 28% higher
than the national average. Sefton has a high number of people dying from alcohol-
related problems.

What we have achieved for people with long term conditions

   The introduction of the Healthy Sefton phone line (0300 100 1000) during 2009/10
    provides a single number for members of the public to access lifestyle support
    services such as weight management, stop smoking and alcohol services. Within 12
    months approximately 20% of people completing the Citizen‟s Panel survey were
    aware of the service.
   We have developed a new Living Well programme. This programme teaches and
    enables people with a long term condition to take control of their condition, enjoy a
    better quality of life and, where possible, avoid the need for continual input from
    health service professionals
   Sefton offers NHS health checks to help prevent heart disease, stroke, diabetes, and
    kidney disease. High risk patients are being reviewed in GP practices, and checks
    are being done in pharmacies when the opportunity arises. In the first 12 months
    over 470 checks took place in pharmacies.
   Emergency hospital admissions for chronic obstructive pulmonary disorders (COPD)
    have decreased in line with our Commissioning Strategic Plan target. In quarter
    three of 2009/10, there were 280.6 per 100,000 population compared with 295.7 per
    100,000 population in the previous quarter
   Over the last three years, 8066 people have quite smoking in Sefton
   A total number of 4317 people were referred to the Active Sefton weight
    management programme for the time period April 2009-March 2010. The adherence
    rate to the programme was 81.25%
   The majority of clients referred into Sefton Alcohol Treatment and Interventions
    Nursing Service (SATINS) are aged between 30 and 49, accounting for 697 (59%) of
    the 1,178 referrals received during April 2009-March 2010. A further 320 (27%)
    clients referred to the service are aged between 50 and 69. Overall, males account
    for 775 (66%) and females account for 395 (34%) of the 1,178 referrals
   We have appointed GPs as Clinical Leads for priority issues including COPD,
    cardiovascular disease and diabetes

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What further work needs to be done?

We need to:

   Increase information on how common diabetes is in children and other vulnerable
    groups in Sefton. Improve knowledge of the symptoms and signs of diabetes
    through awareness and education sessions. Plan high quality diabetes services
    which will be able to respond to the expected changes in the Sefton population.
    These services should also narrow inequality gaps in risk factors, improve access to
    services and reduce the occurrence of complications.
   Improve identification and management of Chronic Obstructive Pulmonary Disease.
   Increase the number of pharmacies in Sefton delivering an intermediate level stop
    smoking service
   Continue to provide training and promote the use of brief interventions throughout
    primary care, and with other partners (e.g. in the criminal justice system), to address
    common lifestyle issues such as smoking, alcohol and physical activity.
   Work with partners on physical activity and obesity prevention programmes such as
    Let‟s Get Moving and Change4Life.
   Strengthen alcohol service provision
   Focus on building awareness and usage of the new Healthy Sefton service,
    particularly amongst deprived communities and the professionals who serve them.
   Further develop our programme to test people for risks of high blood pressure and
    heart disease.
   Strengthen stroke service provision through:
    – Better early identification of risk factors
    – Increasing rapid access to dedicated stroke services
    – Development of rehabilitation following stroke
   There are variations in access to pain services across Sefton. We need to plan pain
    services to address this inequality and meet rising demand in the future with better
    support for frontline health care staff. We must improve information on the numbers
    of adults and children living with chronic pain in Sefton. We should consider moving
    more pain services and staff into the community and involve both patients and health
    care staff in these decisions.

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Mental Health and Wellbeing

What we know

Mental health modelling for Sefton has suggested the following:

                        There could be over 50,000 people with mild to moderate mental
                         health problems4
                        27,000 with mixed anxiety or depression
                        8,000 suffering depressive episodes
                        These would be the seventh highest rates in England

Within Sefton, the predicted levels of mental ill-health in the population are highest in
deprived areas.

                        There are 2,600 people on GP registers for mental health conditions
                        There are 1600 on GP registers for dementia, although this could be
                         an underestimate.
                        GP practice-recorded rates of mental ill-health and dementia are
                         highest in central Southport and Bootle, and lowest in Ford

Most practices have more patients than expected on their mental health registers.
Recorded levels of dementia are lower than expected in all but three practices.
Prescribing rates for mental health conditions vary throughout Sefton.

People with long term mental health conditions have the lowest employment rates but
highest „want to work‟ rates.

The North West Mental Wellbeing Survey showed that there are two main elements of
mental wellbeing: feeling good and functioning well. There is a strong association of
high levels of mental wellbeing with work, education, relationships, health, life
satisfaction and lifestyle. Mental wellbeing in Sefton is similar to the North West

What we have achieved

     We are working in partnership with Sefton Council and Mersey Care Trust to improve
      coordinated care for people with mental health problems
     We have bought extra Child and Adolescent Mental Health (CAMH) inpatient beds

    Examples would be anxiety, phobias, mild depression, obsessive compulsive states

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   We have established a Sefton mental health service user forum so that users can
    contribute their knowledge and experience to influence local mental health services
   Admissions for mental health in-patient care have reduced significantly since
    2004/05 following the development of community-based services. A further 10%
    reduction in admission rates is predicted as a result of developments in mental
    health services
   The death rate from suicide and undetermined injury fell to 6.9 per 100,000 of the
    population in October 09 - September 10. It was 7.5 per 100,000 of the population in
    the previous quarter
   We have produced a Sefton Dementia Strategy with various partner organisations.
    This highlights the special circumstances of the borough and plans developments
    over the next five years.
   We have raised general awareness of dementia through Memory Matters road
    shows across Sefton
   We have established social prescribing services for adults in Sefton. These provide a
    range of non-medical interventions that promote wellbeing and self-care. The
    outcomes we have measured from these services show the following:
        – Statistically significant reductions in anxiety and depression
        – Improved lifestyle behaviours, such as reduction in smoking and alcohol
        – Improved daily functioning
        – Reduced GP consultations
        – Reduced medication prescribing

What further work needs to be done?

We need to:

   Adopt the recommendations of the „National Guidance on Commissioning for Well-
    being and Public Mental Health’ 5

   Build upon the established Sefton positive mental wellbeing programmes and widen
    the area that they cover

   Increase the uptake of these programmes through Healthy Sefton and integrate
    them into primary care referral pathways for those with mental health and long-term

   Develop programmes to improve the wellbeing of women, particularly for those in the
    more deprived areas

   Continue suicide prevention initiatives

   Develop personality disorder services

 Practical commissioning guidance on how to focus on mental wellbeing as a key strand of
commissioning activity for health and wellbeing, produced by the National Mental Health
Development Unit in 2009.

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   Commission an adult attention deficit hyperactivity disorder (ADHD) service

   Improve awareness and response to dementia patients in general hospitals

   Review employment services for adults with mental health problems and commission
    services to meet identified need

   Pilot personal health budgets for adults with mental ill health

   Further develop the Sefton mental health service user forum

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Health Inequalities

In Sefton, as in the rest of England, people living in the poorest neighbourhoods have
poorer health and will die earlier than those in the richest neighbourhoods. The higher
people‟s social position, the better their health is likely to be. It is unjust that in Sefton
today, people in different social circumstances experience avoidable differences in
health, wellbeing and length of life.

The Director of Public Health’s Annual Report has focused on health inequalities over
the past three years. These three reports are accessible on the NHS Sefton website6.
They describe existing health inequalities and actions required over a short, medium and
long term to reduce these inequalities. Together they set the direction to be taken in
Sefton and should be read alongside this Joint Strategic Needs Assessment.

What we know

We know a number of factors in Sefton have an impact that causes inequalities in
people‟s health and wellbeing. These factors include where people live (geography),
social class, age, gender, and whether they belong to a „vulnerable‟ group. (Age
inequalities are covered in the sections on Children and Young People and Older

Estimates for different geographical wards show that the gap between the highest and
lowest life expectancy can be as great as 11 years for males and 10 years for females.
Even excluding the 5% poorest and richest wards in Sefton, the gap in life expectancy is
nine years for males and eight years for females. This shows that everyone, other than
the very well-off, experiences some degree of health inequalities.

Social class
In Sefton, there is a strong relationship between social position and mental wellbeing.
Residents in the most deprived 20% households are almost four times more likely than
those in the 60% least deprived households to have below average mental well being.
(Further information on mental wellbeing inequality is covered in the section on Mental
Health and Wellbeing.)

The 2001 Census estimated that there were pockets of people from a black and minority
ethnic (BME) background throughout Sefton.

                     In mid 2007, only 2.7% of Sefton‟s population were estimated to be
                      from a BME group
                     This equates to about 7,500 people
                     This figure shows a rise from the 4,600 (1.6%) that was recorded in
                      the 2001 Census


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The rise in BME populations is likely to have occurred mainly in the 16-64 age group.
There has been a rise in non-British or Irish white residents. This reflects the growing
community of international workers and their families in Sefton. BME communities within
Sefton often work long hours and cannot access GP surgeries and health services within
normal opening times. Language and interpretation is also sometimes a barrier.


                           It is estimated that 13,300 people aged 18-64 have a moderate
                            physical disability, and 4,000 have a severe physical disability
                           Just under half of these (8,100) are likely to require personal care

These numbers are not predicted to alter much in the coming years.

                          10,500 people aged 65 and over are unable to manage at least one
                           mobility activity on their own. This is predicted to rise by 9% in the
                           next 5 years
                          It is predicted that the number of people who are aged 65 and over,
                           and who are able to be registered partially sighted or blind will rise by
                           almost 9% between 2010 and 2015
                          Over 31,000 adults are predicted to have a moderate, severe or
                           profound hearing impairment

There is an estimated 2% of the population in England with learning disabilities. That is
210,000 people with severe learning disabilities in England and 1.2 million people with
mild to moderate learning disabilities7. However, over future years these figures will alter
due to changes in the population profile of adults with learning disabilities. Estimates
highlight that there will be an 11% increase in the total number of adults with learning
disabilities in England over the next two decades.

                 In Sefton there are 1,790 people with learning disabilities known to both
                 health and social care services

The focus for NHS Sefton is to ensure equal access to healthcare, improve health
outcomes and reduce the health inequalities experienced by people with learning

Sefton Learning Disability Partnership Board has started work on better understanding
the health needs of people with learning disabilities and how to improve living
arrangements, employment, and support networks. The group leading the work includes
both service users and carers of people with learning disabilities. We are working in

    Department of Health, Valuing People 2001

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                                  Sefton‟s JSNA 2010

partnership with people with a learning disability on improving their health in acute
hospitals in the community.

Homeless people are another vulnerable group whose health status usually reveals
inequalities and issues in accessing health and other public services. Homelessness
rates in Sefton are below the national and regional averages but targeted work is
required for the small numbers of people who are homeless.

The impact of drug use is wide ranging and those using drugs are a vulnerable group
within our society.

                     In a survey of Year 10 pupils in 2006 in Sefton, 25% said that they
                      had taken some form of illegal drug
                     One in three people in treatment for drug use are parents

A large proportion of people are leaving treatment without completing the course. Some
people are leaving drug treatment courses with no fixed address.

Supporting Families
Recent policy research suggests that taking action early is crucial in breaking the cycle
of inequality passing from parents to children. The way parents interact, and are
supported in their parenting role during the sensitive period of a child‟s development, is
critical in avoiding longer term problematic and risky behaviour.

Families of offenders at HMP Kennett undergoing resettlement and rehabilitation into the
community have highlighted a number of issues which affect the process. These include
the need for long-term accommodation, education, employment and training. They also
need mentoring to build confidence, and help with debt and financial problems.
Particular health-related needs that they have include mental health, depression,
anxiety, and alcohol use.

What we have achieved to address inequalities

   Sefton was the first Primary Care Trust in the country to introduce a new service
    called Looking Local. This enables local people to access information about health
    and to access services such as GP appointments and repeat prescriptions, through
    their television set. This service is particularly aimed at people living in deprived
    areas who do not have internet access.
   We have improved access to primary care through the introduction of two new
    practices. A third is in development.
   The new dental contract was designed to ensure general dental care meets the
    needs of vulnerable groups. The majority of older patients attend general dental
    services. However some community provision is made available through Liverpool
    PCT for patients who are immobile / housebound.

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     We have been working with Sefton Young Carers to see how we can provide them
      with more help and support and improve services
     Smoking rates are highest in the most deprived areas but are also falling the fastest
      in these areas with 11.8% reduction over four years compared with 2.4% in other
      areas of Sefton. This is mainly due to targeted interventions. This has contributed to
      reducing the gap in death rates across Sefton
     We now have Specialist Learning Disability Services to support mainstream health
      services in delivering good quality general healthcare to people with learning
     The opening of a single point of access to Drug Treatment Services, and the delivery
      of services tailored to personal multiple needs and outcomes has been welcomed by
      people who use the services. „Fast tracking‟ e.g. going straight to detox from the
      Single Point of Assessment, was seen as a real breakthrough. This takes Sefton
      Drug Action Team beyond traditional processes, boundaries and barriers

What further work needs to be done?

We need to:

     Reduce the health gap between social groups in Sefton by taking action across all
      the social groups, but concentrating resources on the groups that have the greatest

     Target resources to issues which will give the best return on investment when there
      is a reduced amount of money available. In relation to inequalities, this could mean
      allocating a larger proportion of funding to services focused in geographical areas
      that are more deprived. This would be where people are less likely to be employed,
      where housing conditions are poorer, educational achievement is lower and people
      have higher levels of illness.

     Improve our detox services to make sure they are appropriate and effective

     Improve access to accommodation for drug treatment service users in the
      community and on release from HMP Kennett through housing advice and links to
      housing providers.

     Refine health care services at HMP Kennett and ensure needs are met in the most
      cost-effective way to build on the feedback that they are broadly meeting the needs
      of the prisoners and are well-regarded by service users

     Appropriately train staff to meet the needs of vulnerable citizens. Safeguarding
      vulnerable adults through prevention is a responsibility across all sectors (health and
      social care, private and voluntary sector).

    For more details on actions see Sefton Director of Public Health‟s Annual Report 2010

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Our Places

What we know
Sefton is made up of several different and unique communities which make it a place
that people want to live.

                    The most deprived areas are concentrated in the south of the
                    People in the north are generally better off. However, there are also
                     pockets of deprivation around Southport

The areas with lowest income levels for older people are also concentrated in the south
of the borough and in central Southport. We know that where people live in the borough
can affect their health, and people in the north tend to have better health than those in
the south.

The „Place‟ Survey is carried out by all local authorities in England and is designed to
measure the opinions of local residents on their local area and services.

                    Sefton‟s, residents rated their satisfaction with their local area as
                     79.2%. This is higher than the average among all city areas, but a
                     little lower than the national average
                    The Sefton Citizen‟s Panel Survey carried out in 2008 reported that
                     90% of people taking part agreed that they liked living in their

Sefton‟s economy has grown more slowly than the rest of the region, though Sefton has
fewer people claiming benefits. Incapacity benefit claims are higher among males and in
more deprived areas.

                 Sefton‟s unemployment rate has been lower than Liverpool City region
                 average since the beginning of 2008, and is now lower than the regional

However, the rate of those in Sefton who are not working, not in full-time education or
training and are not actively seeking work is higher than the regional and national
averages. (This situation is referred to as „worklessness‟) This could be partly due to
the numbers of people not in education, employment or training (NEET) in Sefton having
increased over the last year, with the highest rates in the south of the borough. Also,
more people may be choosing to not work due to family responsibilities or early

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                                  Sefton‟s JSNA 2010

retirement. Despite worklessness having increased between November 2008 and
February 2009, the increase was less than across the North West or nationally.

Strong Communities

Creating safe communities in Sefton is one of the four main themes of the Community

                     Sefton crime rates are either equal to or lower than the average for
                      our neighbouring authorities in the Liverpool City Region
                     Alcohol-related crime is falling in Sefton and mainly occurs in Bootle
                      and Southport town centres
                     The number of anti-social behaviour incidents across Sefton as a
                      whole has fallen between 2007 and 2009

Creating community cohesion is key to tackling health inequalities. This means making
sure that people's different backgrounds and viewpoints are mutually respected, that
they feel a sense of belonging and are confident working together to improve their

                  The North West Mental Wellbeing Survey 2010 found that Sefton‟s
                  residents have a higher than average „ability to rely on others for
                  support” and “satisfaction with personal relationships‟

Sefton residents displayed a stronger sense of place and community than the North
West average but were less likely to participate in organised activities. Antisocial
behaviour, drunkenness and drug-related problems are all seen as important issues for
cohesive communities.

Access to healthy choices
The location of services and amenities has an impact on whether people have the
opportunity to make healthy lifestyle choices. For example, availability of healthy food is
being addressed in Sefton through fruit & vegetable co-ops which support the 5 A DAY
message. They have been set up in areas where access to good quality, affordable fruit
and vegetables is poor.

There are considerable housing pressures across Sefton and a lack of affordable
housing. Poor housing is often associated with other factors such as low income and
unemployment. There is greater need for renewal and regeneration of housing markets
in the south of the borough.

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              During consultation on the „Housing Strategy for Sefton 2008-13‟, many
              people said that the environment and safety of the local area is just as
              important as the condition of the property itself in contributing to feeling
              happy in their home.

Meeting the costs of living, including fuel, was a concern for everyone taking part.

              An overall need for 1,261 affordable housing units to be provided each year
              was identified by the Housing Needs Assessment update in 2005

The NewHeartlands Housing Market Renewal Initiative is having a huge impact on south
Sefton with a number of new housing developments now complete or near completion.

              Homelessness in Sefton has declined since 2006 and remains the lowest in
              the Greater Merseyside area

Within Sefton we need to tackle homelessness through prevention, thus reducing the
number of people becoming homeless.

We do not have enough houses that are designed as permanent homes for people who
become disabled, and those we do have are in the wrong places. This means that
people with disabilities can find it difficult to stay in their own homes. Too often, they
have to move away from friends and family to find a house which is suitable for their

People with long term health conditions are very vulnerable to the effects of poor
housing. Because we have areas of poor quality housing in Sefton and high numbers of
people with long term health conditions, it is likely that many people with long term health
conditions live in poor housing. This will make it more difficult for them to manage their

Overcrowded housing is a particular problem in Southport, and parts of the south of the
borough, especially in Linacre and Derby wards. Affordable housing is also a problem in
Southport, as well as the high number of large houses that are sub-divided into flats that
may not meet decent homes standards.

Green spaces are a positive influence on the health of local populations in many ways.
They can:
 Provide opportunities for physical activity
 Improve mental health and wellbeing
 Promote healing and recovery after illness or an accident
 Provide opportunities for education, social inclusion and cohesion
 Help reduce the impact of climate change.

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                                  Sefton‟s JSNA 2010

The quantity, quality and accessibility of green space vary in different parts of Sefton, so
targets have been set to reduce the differences:
     Quantity – to increase the amount of green space in areas of greatest deficiency
     Quality – to increase the number of Green Flag or Green Pennant awards
        (national quality standards)
     Accessibility – everyone to live within 15 to 20 minutes of a larger park or nature

              A telephone survey of local residents in Sefton indicated that 75% of
               people responding used parks or other green spaces all year round
              More than 80% of people responding said they agreed that being able to
               use parks and other open spaces is important to their quality of life

Climate Change
Climate change will have a range of health effects and greater impact on those with poor

                  C02 emissions in Sefton have fallen by 2.6% between 2003 and 2005.

Sefton Council has adopted a carbon management plan, initially running from 2006 to
2010 with a target to achieve a 12% reduction in emissions by 2010. Air quality in
Sefton is monitored at a number of stations which record pollution levels.

The impact on health is a key consideration in the Local Transport Plan. The document,
Building a new mobility culture, challenges and opportunities for future transport
provision in Merseyside, includes references to health related issues. It states that
transport must play a full part in addressing climate change and supporting a healthy
community. The goals guiding the development of the third transport plan include:

   To provide and promote a clean and low carbon transport system
   To ensure the transport system promotes and enables improved health and
   To ensure the transport system allows people to connect easily with employment,
    services and social activities

The proposed new mobility culture will deliver a transport network free of congestion
levels that can damage business efficiency, quality of life and health. It will encourage
many more people, particularly young people, to be active as part of their daily lifestyles,
increase social inclusion and cut the carbon footprint of travel as a major contribution to
the City Region‟s low carbon economy. Good transport planned around green public
space can create the conditions for greatly increased cycling and walking.

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In addition, a health impact assessment (HIA) of the next Local Transport Plan (LTP) is
being undertaken as part of an integrated assessment. This follows on from the HIAs
that were undertaken on both the previous LTPs.

What we have achieved

   We are working through our local Safer and Stronger Communities Partnership to
    reduce alcohol-related crime and disorder. Crimes that have been recorded that
    have alcohol as the cause are 5.2 per 1000 population lower than the regional
    average of 7.8 per 1000 population (crude rate)
   There are many projects happening across Sefton that support older people with the
    aim of reducing social isolation. Organisations that are involved in this include:
    Merseyside Fire and Rescue Service, Netherton Feelgood Factory and Sefton
    Council for Voluntary Service.
   Across the borough, housing development sites are being brought forward. They are
    required to provide a proportion of affordable housing to meet existing need. The
    Council discounts the value of its land assets wherever it can so it can boost the
    supply of affordable housing
   A health promotion officer post was created jointly between NHS Sefton and One
    Vision Housing (OVH) in 2009 to develop and promote residents‟ health through
    increased community involvement and engagement. OVH accommodation is
    located in some of the most deprived areas in Sefton. Outcomes achieved include:
        – Working in partnership with other organisations such as Women‟s Royal
           Voluntary Service (WRVS) to set up fresh fruit and vegetable pick up points
           within OVH high rise flats
        – Developing links and support to the WRVS Good Neighbours Scheme. This
           involves visiting, supporting and helping elderly residents in OVH and in the
           wider community.

   The council has improved its processes for approving Disabled Facilities Grants.
    These provide adaptations to houses occupied by disabled people to enhance
    quality of life and encourage independent living at home.
   We have delivered the national „Warm Front‟ programme. This programme is
    designed to improve heating and insulation in the most vulnerable and deprived
    communities within Sefton. Sefton‟s „House Warmers‟ project has recently been
    named as best in the North West by the fuel poverty charity, National Energy Action.
    There are over 300 front line workers actively involved in the „House Warmer‟ referral
    network, who have been briefed on fuel poverty. As a result they regularly help
    households in need of assistance to get local services to make their homes warmer
    and healthier.
   We have installed two outdoor gyms at Crosby Lakeside and Bedford Park,
    Southport, to encourage people to exercise in a natural green environment
   Tree planting and the creation of new green spaces is being promoted across the
    borough in order to reduce the impacts of climate change.
   In Sefton, 109 schools out of 116 schools (94%) have developed School Travel
    Plans. Introduction of measures from the plans has helped towards creating a safer
    environment for the local community and an increase in the number of children
    choosing to walk to school.

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What further work needs to be done?

We need to:

   Continue to work to improve the overall health of the residents of Sefton and reduce
    the differences in health related to where people live

   Help people cope with change and encourage them to play a part in improving their

   Support Sefton‟s voluntary sector and work in partnership with them to help improve
    community cohesion

   Continue to reduce homelessness via a responsive and high quality preventative

   Seek additional resources to improve the energy efficiency of the most inefficient
    housing in the borough. These are mostly the Victorian Terraces built before 1919

   Implement the Landlord Accreditation Scheme

   Ensure the planning processes in Sefton promote green space and prioritise the
    need for people to be physically active as a routine part of their daily life

   Ensure local services and facilities are easily accessible on foot, by bicycle and by
    other modes of transport involving physical activity

   Some specific examples of things we plan to do are:

         –   Develop Sefton as a Blue Gym9 location where the canal, coast and areas
             close by are used to encourage physical activity and be easily accessible
         –   Consider installing further outdoor gyms if the pilot sites have positive results
         –   Continue to implement the Cycling Demonstration Town plans and roll out
             positive results to other parts of Sefton

 This uses local geographical water features and their surroundings as an area for physical activity and

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Our Priorities
Building on what we know already, we have summarised themes from the previous
sections and set out below the main priorities that we need to address in the coming

We need to continue to focus on the major themes of:

      Reducing health inequalities within Sefton
      Reducing health inequalities between Sefton and other areas
      Focusing on prevention and early detection of illness
      Reducing the levels of behaviours that carry risk for future health

              The behaviours that we want to tackle are:
               Smoking
               Drinking alcohol
               Taking drugs
               Physical inactivity
               Unhealthy eating patterns
               Unsafe sex

      Tackling the main diseases from which people die

              These are:
               Heart disease
               Cancers
               Respiratory illness

Focusing on services that are delivered for Sefton residents we need to:

      Build on what is already working well and extend those services, if required

              The things we need to build on include:
               Pharmacies offering stop smoking services
               Energy efficiency support in inefficient housing
               Cycling schemes and outdoor gyms
               Positive mental wellbeing programmes

      Increase appropriate use of services through providing information to people in
       Sefton and professionals who help them

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                                 Sefton‟s JSNA 2010

               Increase the use of the Healthy Sefton service
               Improve access to dental services
               Increase the use of services to reduce smoking in pregnancy
               Further promote the older citizen‟s Healthy Sefton Lifestyles service

      Improve specific services that have been highlighted in previous sections

              These include:
               Services for children with learning disabilities or mental health
               Schools work on drugs
               Alcohol and sexual health services
               Access to dedicated stroke services
               Strengthened alcohol service provision and detox services

      Develop new services to meet the needs of our population

              So, develop services for expected change in demand for:
               Diabetes services
               Chronic pain services
               Stroke services
               Youth advocacy programme tackling smoking
               Personality disorder service
               Personal health budgets for people with mental ill health

      Ensure services are provided in the most appropriate setting for access and
       safety, whether hospital or community
      Target services to those in greatest need and who will gain the greatest benefit
      Improve links between services to ensure people do not fall in the gaps

We need to build on the resources of the people who live in Sefton but also support
them in developing skills to make choices about their health, to become advocates for
healthy behaviour and to manage their conditions.

We need to take an all round approach to needs and services for people throughout their
lifetime, focusing on tackling issues early (in childhood or early presentation). But we
also need to address the links between the individual, their circumstances and family
situation, and the local environment in which they live.

We need more information on particular issues to understand better the needs and what
action should be taken.

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