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Ring of Roses The Health and Well Being of Children in Blackwater

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					Contents

                                                                        Page
List of Figures
                                                                         4
List of Tables
                                                                         6
Foreword
                                                                         7
Chapter 1         Introduction
                                                                         8
Chapter 2         Population and demography                              9

Chapter 3         The lives of children and young people: social and
                                                                         21
                  economic issues

Chapter 4         Education and health                                   28

Chapter 5         Childhood obesity and overweight                       35

Chapter 6         Tobacco smoking and children                           40

Chapter 7         Emotional wellbeing, mental health and staying safe    43

Chapter 8         Improving oral health                                  53

Chapter 9         Health protection for children and young people        57


Appendix 1        Child health: the policy context                       64

Appendix 2        Local Public Service Agreement (LPSA) to tackle
                                                                         70
                  childhood obesity

Appendix 3        Crime and Disorder Reduction Partnerships              72




3
List of Figures


Figure                                    Title                                   Page

         Map of electoral wards in Blackwater Valley and Hart Primary Care
    1                                                                              9
         Trust
         Resident population by age and sex – Rushmoor Borough Council
    2    (2006)                                                                    10


    3    Resident population by age and sex – Hart District Council (2006)         11

         Trend in the live births per 1000 women – by age of mother in
    4                                                                              12
         Rushmoor 1997 - 2004

         Live births per 1000 women – by age of mother in Rushmoor and
    5                                                                              13
         England & Wales, 2004

         Trend in the live births per 1000 women – by age of mother in Hart
    6                                                                              13
         1997 - 2004

         Live births per 1000 women – by age of mother in Hart and England
    7                                                                              14
         & Wales, 2004

         General fertility rate 2003 with 95% confidence intervals in electoral
    8                                                                              14
         wards in Rushmoor

         General fertility rate 2003 with 95% confidence intervals in electoral
    9                                                                              15
         wards in Hart

         Projected percentage change in the number of children and young
    10                                                                             16
         people in Rushmoor 2005 to 2011

         Projected percentage change in the number of children and young
    11                                                                             16
         people in Hart 2005 to 2011

         Percentage of resident population Age 0-19 years by electoral ward
    12                                                                             18
         (2005) in Blackwater and Valley Hart PCT

         Percentage of Under 16 Year Olds per Ethnic Category in Rushmoor
    13                                                                             19
         and Hart District Council Areas

         Employed adults in households with dependent children – electoral
    14                                                                             21
         wards in Rushmoor




4
         Employed adults in households with dependent children – electoral
    15                                                                         22
         wards in Hart

         Income deprivation affecting children in Rushmoor Borough Council
    16                                                                         23
         2004

    17   Income deprivation affecting children in Hart District Council 2004   24


    18   Family types of dependent children – electoral wards in Rushmoor      25


    19   Family types of dependent children – electoral wards in Hart          26


    20   Under 18 conception rates in Rushmoor and Hart                        26


    21   Educational attainment for 15 year old pupils 2002/03 in Rushmoor     28


    22   Educational attainment for 15 year old pupils 2002/03 in Hart         28

         Correlation between health and education indices of IMD 2004 in
    23                                                                         29
         super output areas in Blackwater and Hart PCT

         Trend in percentage of half days missed by primary school pupils
    24                                                                         30
         between 1997 and 2005 in Hampshire Local Education Authority

         Trend in percentage of half days missed by secondary school pupils
    25                                                                         30
         between 1997 and 2005 in Hampshire Local Education Authority

    26   Obesity trend by social class of head of household                    36

         Death rate from suicide and undetermined injury in the under 35s in
    27                                                                         47
         Rushmoor compared to England

         Death rate from suicide and undetermined injury in the under 35s in
    28                                                                         47
         Hart compared to England

    29   Mumps cases notified in Blackwater Valley and Hart PCT in 2004/05     59




5
List of Tables


Table                               Title                             Page

         Number of deaths by cause - age between 0 and 19
    1    years, Blackwater Valley And Hart PCT 1994-2004               17

         Ethnic distribution of children in Blackwater Valley and
    2                                                                  19
         Hart PCT
         Schools engaged in the Healthy Schools process: March
         2005 in North Hampshire and Blackwater Valley and Hart
    3                                                                  31
         PCT areas

    4    National trends in overweight and obesity prevalence
                                                                       35
         among children, 1995 – 2003

    5    Factors influencing children’s mental health                  44

         Prevalence of mental disorders by age and sex in
                                                                       45
    6    Blackwater Valley and Hart PCT

         Decayed, missing and filled teeth in 5-year-olds in
    7                                                                  53
         Hampshire and Isle of Wight

         Notification of infectious diseases in children 0-17 years
    8                                                                  57
         2004-2005

    9
         Immunisation uptake for the quarter April 05 to June 05       60




6
Foreword

This report covers the period from April 2004 to March 2005. It presents an
independent overview of the health issues affecting the children and young
people of Rushmoor and Hart.

Good health outcomes in today’s children will lead to a healthier future. There
are wider determinants like education, housing, parents’ income and social
support which influence health outcomes. This report has focused on creating
an understanding of those issues which determine better health among children
as well as their current health status. The audience for this annual public health
report is wide and includes service planners, health professionals, students and
partner agencies such as local authorities, the voluntary sector, the police and
local residents.

The report has identified key findings and recommendations which could be
implemented to improve the health of children. However it is important to note
that this is dependent on all partner agencies being able to identify and allocate
the necessary resources to implement them. The local strategic partnerships
should play a key role in ensuring that this is the case.

Finally, I would like to thank all those who have contributed in one way or the
other in the production of this report. I am particularly grateful to Catherine
Dummett, Aghdas Cullen, Anna Williams, Carol Janes, Colin Alborough,
Beverley Hall and Drs Alison Frater, Bob Coates, Gillian Spencer, Linda Booth,
Sakthidharan Karunanithi and all members of the wider public health team.


Dr Femi Oduneye
Director of Public Health
Blackwater Valley and Hart PCT




7
Chapter 1- Introduction

The health of children and young people is an important indicator of the overall
health of the population. Though children and young people (0-19) make up
over 25.9% of the population of Blackwater Valley and Hart Primary Care Trust
(BVH PCT) and are major users of health services, their health is determined by
early experience within the family and community. Factors such as family
income, housing, education, access to good nutrition and physical activity bear
strongly on the health of children and young people and their ability to take
control of their lives and future wellbeing. Health and health services for
children have improved considerably over the last century, though much still
remains to be done, particularly to address worrying trends in risks to health.
Smoking, use of alcohol, trends in obesity and drug misuse are worrying, though
amenable to change through the combined efforts of society. Health and local
authorities, businesses, schools and the voluntary sector all have their part to
play. This report describes the health and the determinants of health for
children and young people and aims to inform the increasingly successful
partnership now working to improve life chances across the population.           A
summary of the key policy initiatives relevant to the health of children and young
people is included as appendix 1.




8
Chapter 2 - Population and Demography

Introduction

This section describes the population and demographic characteristics of
children and young people (0-19) in the area covered by Blackwater Valley and
Hart Primary Care Trust (Figure 1). Socio-economic factors such as family
structure and levels of relative deprivation or affluence are major determinants of
future health and well being.

Figure 1: Map of electoral wards in Blackwater Valley and Hart Primary Care Trust




9
Population and Demography

There were 45,114 children and young people (0-19) making up 25.9% of the
population in the area covered by Blackwater Valley and Hart Primary Care
Trust in the 2001 census. This is higher than in Hampshire and the Isle of
Wight as a whole (24.7%) and is higher than the England average (25.1%).
There are 1,876 more boys than girls; a ratio of 1.09. As can be seen in the
population pyramids for the two local authorities, within the area covered by
Blackwater Valley and Hart PCT (Figures 2 and 3) there are differences in the
population structure which bear on the population trends for young children and
young people. Both Rushmoor Borough Council (RBC) and Hart District Council
(HDC) have higher estimated proportions of young people in the 5 year age
bands, 0-4, 5-9 and 10-14 than seen for England as a whole. This is in part
explained by the higher proportion of people in the main child bearing age
groups particularly in Rushmoor where proportions of the population in all age
groups from 20-44 are higher than for England. In Hart the same effect occurs
although from age 30. People in the age bands 20-29 are in fact under
represented in the Hart population which may be due to economic migration
from the area reflecting the relatively rural nature of this population.

Figure 2: Resident population by age and sex – Rushmoor Borough Council (2006)

                    Resident population by age and sex - Rushmoor local authority district (2005)

                                                            Age band
                                                            85+


                                                          80-84


                                                          75-79


                                                          70 -74


                                                          65-69


                                                          60-64


                                                          55-59


                                         Males            50-54         Females

                                                          45-49


                                                          40-44


                                                          35-39


                                                          30-34


                                                          25-29


                                                          20-24


                                                          15-19


                                                          10-14


                                                            5-9


                                                            0-4

                                                          Population
 8000     6000     4000               2000                                           2000                    4000             6000   8000


                               Source: Hampshire County Environment Department. 2005-based Small Area Population Forecasts.




10
Figure 3: Resident population by age and sex – Hart District Council (2006)

                           Resident population by age and sex - Hart local authority district (2005)

                                                                Age band
                                                                85+


                                                              80-84


                                                              75-79


                                                              70 -74


                                                              65-69


                                                              60-64


                                                              55-59


                                       Males                  50-54         Females

                                                              45-49


                                                              40-44


                                                              35-39


                                                              30-34


                                                              25-29


                                                              20-24


                                                              15-19


                                                              10-14


                                                                5-9


                                                                0-4

                                                              Population
 8000      6000     4000                  2000                                           2000                    4000             6000   8000


                                   Source: Hampshire County Environment Department. 2005-based Small Area Population Forecasts.




11
Population Trends

The size and structure of the population is determined by factors affecting the
rate of births, deaths and migration. Figure 4 shows changes in the birth rate for
women in different age groups in Rushmoor Borough Council (RBC). Women
aged 25-34 have the highest fertility rate. The birth rate amongst teenagers
aged 16-19 has dropped slightly, and though higher than the rate for mothers
over 40, is now lower than other age groups. Figure 5 shows that birth rates in
16-19 year olds and 20-24 year olds are much higher than the national average.
The birth rate amongst older women is less than that in England and Wales
across all age groups.

Figure 4: Trend in the live births per 1000 women – by age of mother in
Rushmoor 1997 - 2004
                                                       Trend in live births per 1,000 women - by age of mother
                                                                          Rushmoor 1997-2004
                               120




                               100




                                80
 Live births per 1,000 women




                                60                                                                                                                                                 16-19
                                                                                                                                                                                   20-24
                                                                                                                                                                                   25-34
                                                                                                                                                                                   35-39
                                                                                                                                                                                   40+
                                40




                                20




                                 0
                                 1997   1998   1999                    2000                     2001                     2002                      2003                     2004

                                                      Crown copyright material is reproduced with the permission of the Controller of HMSO and the Queen's Printer for Scotland.
                                                      North & Mid Hampshire Health Informatics Service Click-Use Licence No. C02W0004828.




12
Figure 5: Live births per 1000 women – by age of mother in Rushmoor and
England & Wales, 2004
                                                              Live births per 1,000 women - by age of mother
                                                                  Rushmoor and England & Wales, 2004




                    40+




 35-39




 25-34
                                                                                                                                                                                   England & Wales
                                                                                                                                                                                   Rushmoor




 20-24




 16-19




                                 0       20          40                          60                           80                           100                          120
                                                                 Live births by 1,000 women

                                                      Crown copyright material is reproduced with the permission of the Controller of HMSO and the Queen's Printer for Scotland.
                                                      North & Mid Hampshire Health Informatics Service Click-Use Licence No. C02W0004828.



In contrast, the age specific live birth rates in Hart DC show a converse pattern
(Figure 6), with higher rates of birth among older mothers. A comparison with
England and Wales in Figure 7 shows significantly higher rates of birth for
mothers aged 25-34, 35-39 and over 40 in Hart compared with England and
Wales, and significantly lower rates among 20-24 year olds. This reflects the
national trend in later pregnancies amongst more affluent populations. Maternal
age can have an impact on the health of children, with a higher risk of some
congenital abnormalities in older mothers. Access to screening services is
essential for early detection and management of foetal anomaly.

Figure 6: Trend in the live births per 1000 women – by age of mother in Hart
1997 - 2004




                                                      Trend in live births per 1,000 women - by age of mother
                                                                            Hart 1997-2004
                               120




                               100




                               80
 Live births per 1,000 women




                               60                                                                                                                                                       16-19
                                                                                                                                                                                        20-24
                                                                                                                                                                                        25-34
                                                                                                                                                                                        35-39
                               40                                                                                                                                                       40+




13                             20




                                0
                                1997   1998   1999                     2000                     2001                      2002                     2003                       2004


                                                     Crown copyright material is reproduced with the permission of the Controller of HMSO and the Queen's Printer for Scotland.
                                                     North & Mid Hampshire Health Informatics Service Click-Use Licence No. C02W0004828.
Figure 7: Live births per 1000 women – by age of mother in Hart and England &
Wales, 2004                   Live births per 1,000 women - by age of mother
                                      Hart and England & Wales, 2004




     40+




  35-39




                                                                                                                                                   England & Wales
                                                                                                                                                   Hart


  25-34




  20-24




           0   20         40                         60                            80                          100                          120
                                     Live births by 1,000 women
                           Crown copyright material is reproduced with the permission of the Controller of HMSO and the Queen's Printer for Scotland.
                           North & Mid Hampshire Health Informatics Service Click-Use Licence No. C02W0004828.




Distribution of Births

In the most recent figures (2003), there were 1172 births to residents living in
Rushmoor BC and 951 in Hart DC. This is a rate of 56 per 1000 women aged
15-44 in Rushmoor and 57.3 per 1000 women in Hart, compared with 58.8 in
England and Wales. Figures 8 and 9 show the distribution of births by wards in
Rushmoor and Hart respectively.

Figure 8: General fertility rate 2003 with 95% confidence intervals in electoral
wards in Rushmoor




14
                                                                                                                                                             General fertility rate (live births per 1,000 women age 15-44) 2003 with 95% confidence intervals
                                                                                                                                                                                                  Electoral wards in Rushmoor
                                                      100
                                                                                  Rushmoor (GFR=57.1)

                                                      90                          England & Wales (GFR=56.8)



                                                      80
General fertility rate per 1,000 women age 15-44




                                                      70

                                                      60

                                                      50

                                                      40

                                                      30

                                                      20

                                                      10

                                                       0
                                                             Cove and Southwood




                                                                                                                 Empress




                                                                                                                                                  Fernhill




                                                                                                                                                                           Grange




                                                                                                                                                                                               Heron Wood




                                                                                                                                                                                                                                   Knellwood




                                                                                                                                                                                                                                                                  Manor Park




                                                                                                                                                                                                                                                                                                Mayfield




                                                                                                                                                                                                                                                                                                                        North Town




                                                                                                                                                                                                                                                                                                                                                              Rowhill




                                                                                                                                                                                                                                                                                                                                                                                          St. John's




                                                                                                                                                                                                                                                                                                                                                                                                                     St. Mark's




                                                                                                                                                                                                                                                                                                                                                                                                                                           Wellington




                                                                                                                                                                                                                                                                                                                                                                                                                                                                          Westheath
                                                                                                                                                                                               Source: Vital Statistics Tables 2003 & HCC Small Area Population Forecasts for 2003-2008.
                                                                                                                                                                                               Crown copyright material is reproduced with the permission of the Controller of HMSO and the Queen's Printer for Scotland.
                                                                                                                                                                                               North & Mid Hampshire HIS Click-Use Licence no. C02W0004828.




Figure 9: General fertility rate 2003 with 95% confidence intervals in Electoral
wards in Hart

                                                                                                                                                                General fertility rate (live births per 1,000 women age 15-44) 2003 with 95% confidence intervals
                                                                                                                                                                                                         Electoral wards in Hart
                                                      120
                                                                                                                                                                                                                                                                                                                                                                                                                                                        Hart (GFR = 56.0)
                                                                                                                                                                                                                                                                                                                                                                                                                                                        England & Wales (GFR=56.8)


                                                      100
   General fertility rate per 1,000 women age 15-44




                                                       80



                                                       60



                                                       40



                                                       20



                                                        0
                                                            Blackwater & Hawley




                                                                                          Church Crookham East




                                                                                                                           Church Crookham West




                                                                                                                                                                Crondall




                                                                                                                                                                                    Eversley




                                                                                                                                                                                                            Fleet Central




                                                                                                                                                                                                                                  Fleet Courtmoor




                                                                                                                                                                                                                                                    Fleet North




                                                                                                                                                                                                                                                                               Fleet Pondtail




                                                                                                                                                                                                                                                                                                           Fleet West




                                                                                                                                                                                                                                                                                                                                     Frogmore & Darby Green




                                                                                                                                                                                                                                                                                                                                                                        Hartley Wintney




                                                                                                                                                                                                                                                                                                                                                                                          Hook




                                                                                                                                                                                                                                                                                                                                                                                                       Long Sutton




                                                                                                                                                                                                                                                                                                                                                                                                                                  Odiham




                                                                                                                                                                                                                                                                                                                                                                                                                                                           Yateley East




                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      Yateley North




                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      Yateley West




                                                                                                                                                                                                                            Source: Vital Statistics Tables 2003 & HCC Small Area Population Forecasts for 2003-2008.
                                                                                                                                                                                                                            Crown copyright material is reproduced with the permission of the Controller of HMSO and the Queen's Printer for Scotland.
                                                                                                                                                                                                                            North & Mid Hampshire HIS Click-Use Licence no. C02W0004828.




Future Trends

Small area population forecasts (for 2005-2011) made by Hampshire County
Council Environment Department suggest that the population of 0-19 year olds
in the area covered by Blackwater Valley and Hart PCT will show a small net
increase by 2011 with provision needed particularly to support the health needs
15
of older teenagers (15-19). As can be seen by Figures 10 and 11, there are
marked differences by 5 year age band across the 2 local authority areas
covered by the PCT with the main decrease anticipated in the 0-4 and 5-9 year
olds in Hart, and 5-9 and 10-14 year olds in Rushmoor. An increase is
anticipated in 0-4 year olds in Rushmoor reflecting the significantly high
proportion of young families moving into the area. 15-19 year olds are
anticipated to rise in both Rushmoor and Hart. It is important to note that
forecasting population change - particularly migration - can be imprecise and
factors such as a change in national policy on the number of houses that can be
built in an area can have a substantial influence on the future size of local
populations.




Figure 10: Projected percentage change in the number of children and young
people in Rushmoor 2005 to 2011
                                                  Projected percentage change in the number of children and young people in Rushmoor 2005 to 2011
                                                                                       By age band and in total
                               15%




                               10%
 Projected percentage change




                                5%




                                                                                                                                                                                    Males
                                                                                                                                                                                    Females
                                0%
                                      0-4 years                   5-9 years                 10-14 years                    15-19 years                 TOTAL 0-19 years




                               -5%




                               -10%
                                                                                                Source: Hampshire County Environment Department's 2004-based Small Area Population Forecasts.




Figure 11: Projected percentage change in the number of children and young
people in Hart 2005 to 2011




16
                                                  Projected percentage change in the number of children and young people in Hart 2005 to 2011
                                                                                   By age band and in total
                                6%



                                4%



                                2%



                                0%
                                      0-4 years                5-9 years                  10-14 years                    15-19 years                 TOTAL 0-19 years
 Projected percentage change




                               -2%



                               -4%
                                                                                                                                                                                  Males
                                                                                                                                                                                  Females
                               -6%



                               -8%



                               -10%



                               -12%



                               -14%
                                                                                              Source: Hampshire County Environment Department's 2004-based Small Area Population Forecasts.




Deaths among Children and Young People

Table 1 shows the numbers of deaths in children and young people resident in
the area covered by Blackwater Valley and Hart Primary Care Trust between
1994 and 2004.

Table 1
 Number of deaths by cause – age between 0 and 19 years
 Blackwater Valley and Hart Primary Care Trust 1994-2004


Cause of death                                                                                                           Number of deaths
Accidents                                                                                                                      35
Neoplasms                                                                                                                      23
Diseases of the nervous system                                                                                                 14
Congenital malformation, deformations
and chromosomal abnormalities                                                                                                                 12
Diseases of the respiratory system                                                                                                            9
Suicide and undetermined injury                                                                                                               8
Sudden Infant Death Syndrome                                                                                                                  6
Infectious and parasitic diseases                                                                                                             6
Diseases of the circulatory system                                                                                                            6
Perinatal conditions                                                                                                                          6

17
Endocrine, nutritional and metabolic
disorders                                                5
Others                                                   6

Neonatal deaths (under 28 days)                          79
ALL CAUSES                                              215

Source: Annual District Deaths Extract 1994-2004
Provided by The Office for National
Statistics

Death in infancy and childhood and among young people is uncommon (215
over 10 year period) and in the UK contributes little to changes in overall
population size. The main overall causes of death for 0-19 year olds are
accidents, diseases of the nervous system, cancer and congenital
malformations. Prematurity and sudden infant death, congenital malformations
and cancer account for the greatest number of deaths occurring immediately
after birth and between 0-4. Cancer accounts for almost 50% of deaths in 5-9
year olds and about a third of deaths in adolescents (10-14). Accidents and
suicides are the major causes of death in young adults (15-19) with risks being
greater among boys than girls. Those living in more deprived areas are more
likely to die as a consequence of house fires, pedestrian injury and falls or
poisoning.
Low birth weight, smoking in pregnancy and social deprivation all increase the
risk of death and are clear priorities for public health intervention.

Figure 12: Percentage of resident population age 0-19 years by electoral ward
(2005) in Blackwater and Valley Hart PCT




18
Distribution of Children and Young People

The map (Figure 12) shows the distribution of children by locality (electoral
ward) in the area covered by Blackwater Valley and Hart Primary Care Trust.
Fleet North ward in Hart has the highest proportion of children and young
people, in excess of the national average. Long Sutton, Crondall and Yateley in
Hart District Council all have proportions of young people in the population of
between 27.5 and 30%, as do parts of Aldershot in Rushmoor Borough Council.

Ethnicity

From the 2001 census, children aged 0-15 from an ethnic minority community
represent 3.2% of the population in the area covered by Blackwater Valley and
Hart PCT; 3.1% in Hart District council and 5.6% in Rushmoor Borough Council.
As can be seen in the pie chart, Figure 13, children with mixed origin make up
the largest proportion - 1.8% and 2.4% of the population respectively.




19
Figure 13: Percentage of under-16 year olds per ethnic category in Rushmoor
BC and Hart DC areas
          Percentage of Under 16 Year Olds per Ethnic Category in Rushmoor District Council Area




                                                                              Total White
                                                                              Total Mixed
                                                                              Total Asian or Asian British
                        94.4% (18408)
                                                                              Total Black or Black British
                                                                              Total Chinese or other Ethnic Group


                                                                         Numbers in brackets indicate total
                                                                         number of children




             Percentage of Under 16 Year Olds per Ethnic Category in Hart District Council Area




                                                                               Total White
                                                                               Total Mixed
                                                                               Total Asian or Asian British
                         96.8% (16536)
                                                                               Total Black or Black British
                                                                               Total Chinese or other Ethnic Group


                                                                        Numbers in brackets indicate total
                                                                        number of children




Table 2 from the census breakdown shows that under 16 year old age group
comprises primarily the White and Black Caribbean and White and Asian
children with a smaller proportion from White and Black African or other origin.
Asian or Asian British children are the next largest group making up 0.7% and
2% of the population in Hart and Rushmoor respectively.

Table 2: Ethnic distribution of children in Blackwater Valley and Hart PCT
                             Basingstoke East
                             & Deane          Hampshire Hart       Rushmoor
                             % of All Children
 Total White                 95.4%            97.7%        96.8% 94.4%
 Total Mixed                 2.4%             1.5%         1.8%    2.4%
 Total Asian or Asian
 British                     1.3%             0.4%         0.7%    2.0%
 Total Black or Black
 British                     0.4%             0.1%         0.2%    0.4%
 Total Chinese or other
 Ethnic Group                0.5%             0.3%         0.4%    0.8%




20
Sources of Information

http://www.statistics.gov.uk/census2001/profiles/24ul.asp

Hampshire County Environmental Department 2003 based Small Area Population
Forecasts.

www.statistics.gov.uk/about/methodology_by_theme/area_classification/ha/downloads/
corresponding_health_areas.xls

http://www.statistics.gov.uk/about/methodology_by_theme/area_classification/download
s/corresponding_authorities_LA.xls

http://www.statistics.gov.uk/about/methodology_by_theme/area_classification/ha/downl
oads/corresponding_health_areas.xls

Annual District Deaths Extract 1994-2004, Provided by the Office for National Statistics




21
Chapter 3 - The Lives of Children and Young People: Social and Economic
Issues

There is a wealth of research evidence suggesting that the early experience of
children has a marked impact on their future health and wellbeing. Most
children and young people growing up in the area covered by Blackwater Valley
and Hart Primary Care Trust live in relative affluence or in circumstances parallel
to England as a whole. There are, however, marked differences in some areas
where children live in poor quality housing or in low income families with parents
experiencing unemployment. Figures 14 and 15 from the 2001 census show
that a small proportion of children in Rushmoor and Hart live in households
where no adult has paid employment. The highest proportions are in Mayfield
(17.5%), Heron Wood (14.5%), Grange (13.8%) and North Town (14.1%) in
Rushmoor and in Eversley (7%), Yateley East (3.5%) and Frogmore and Darby
Green (3%) in Hart. There are similar findings for the proportion of children living
in rented accommodation or with no central heating.

Figure 14: Employed adults in households with dependent children – electoral
wards in Rushmoor
                                                                                                     Employed adults in households with dependent children - electoral wards in Rushmoor
                                                      100%



                                                      90%
 Percentage of dependent children in electoral ward




                                                      80%



                                                      70%



                                                      60%



                                                      50%                                                                                                                                                                                          2 or more
                                                                                                                                                                                                                                                   1
                                                                                                                                                                                                                                                   None
                                                      40%



                                                      30%



                                                      20%



                                                      10%



                                                       0%
                                                             Cove & Southwood




                                                                                                                                                            Mayfield




                                                                                                                                                                                     Rowhill
                                                                                          Fernhill




                                                                                                            Grange




                                                                                                                                   Knellwood




                                                                                                                                                                       North Town




                                                                                                                                                                                                 St. John's
                                                                                                                                               Manor Park




                                                                                                                                                                                                              St Mark's
                                                                                Empress




                                                                                                                      Heron Wood




                                                                                                                                                                                                                          Wellington




                                                                                                                                                                                                                                       Westheath




                                                                                                                                                                                    Source: 2001 Census - Theme Table TT01. ONS, Crown copright.




22
Figure 15: Employed adults in households with dependent children – electoral
wards in Hart

                                                                                                         Employed adults in households with dependent children - electoral wards in Hart
                                                     100%
Percentage of dependent children in electoral ward




                                                     80%




                                                     60%



                                                                                                                                                                                                                                                                                                                                                                  2 or more
                                                                                                                                                                                                                                                                                                                                                                  1
                                                                                                                                                                                                                                                                                                                                                                  None
                                                     40%




                                                     20%




                                                      0%




                                                                                                                                                                                                                                                                                                                    Yateley East



                                                                                                                                                                                                                                                                                                                                   Yateley North
                                                            Blackwater & Hawley




                                                                                                                                           Eversley
                                                                                                                                Crondall




                                                                                                                                                      Fleet Central




                                                                                                                                                                                                      Fleet Pondtail




                                                                                                                                                                                                                                                             Hartley Wintney
                                                                                                                                                                                                                                    Frogmore & Darby Green
                                                                                                                                                                                        Fleet North




                                                                                                                                                                                                                                                                                             Long Sutton
                                                                                                                                                                                                                                                                                   Hook




                                                                                                                                                                                                                                                                                                           Odiham




                                                                                                                                                                                                                                                                                                                                                   Yateley West
                                                                                  Church Crookham East




                                                                                                                                                                      Fleet Courtmoor




                                                                                                                                                                                                                       Fleet West
                                                                                                         Church Crookham West




                                                                                                                                                                                                                                                                               Source: 2001 Census - Theme Table TT01. ONS, Crown copright.




Children Living in Poverty

Living in poverty has been defined as living on less than 60% of contemporary
median net disposable income. A measure used to assess the number of
children living in poverty is a section of the income domain of the Index of
Multiple Deprivation (IMD) 2004 called the Income Deprivation Affecting
Children Index (IDACI) previously known as the Child Poverty Index. This
represents children living in families dependent on income support, income
based job seeker’s allowance, working families’ tax credit, disabled person’s tax
credit, and asylum seekers support. The IDACI is produced at sub-ward levels
able to characterise areas containing an average of 1500 people - so called
super output areas (SOAs). Using this measure, the maps in Figures 16 and 17
show the highly localised distribution of child poverty in both Rushmoor and
Hart.




23
Figure 16




24
Figure 17




25
Family Structure

Lone parenthood like teenage pregnancy can become part of a cycle of poverty
and social exclusion. Young people who experience early parenthood are
associated with having poor socio-economic backgrounds with low self-esteem
and low educational achievement. Children born in these circumstances are at
greater risk of poor health, with poorer prospects of social and economic
prosperity or educational outcomes than those born to older parents, or who live
with both parents; they are more likely to become young parents themselves.
The charts in Figures 18 and 19 below show the distribution of dependant
children living in lone parent families in Rushmoor and Hart from the 2001
census. There is a strong correlation between this distribution and areas of
relative deprivation across the two local authorities.

Figure 18: Family types of dependent children – electoral wards in Rushmoor
                                                                                                             Family type of dependent children - electoral wards in Rushmoor
                                                     100%



                                                     90%



                                                     80%
Percentage of dependent children in electoral ward




                                                     70%



                                                     60%



                                                     50%
                                                                                                                                                                                                                                      Not in a family
                                                                                                                                                                                                                                      Co-habiting couple family
                                                     40%                                                                                                                                                                              Married couple family
                                                                                                                                                                                                                                      Lone parent family

                                                     30%



                                                     20%



                                                     10%



                                                      0%
                                                            Cove & Southwood




                                                                                                                                                      Mayfield




                                                                                                                                                                              Rowhill
                                                                                                    Grange




                                                                                                                                                                 North Town
                                                                                                                             Knellwood
                                                                                         Fernhill




                                                                                                                                                                                           St. John's
                                                                                                                                         Manor Park




                                                                                                                                                                                                        St Mark's
                                                                               Empress




                                                                                                                                                                                                                    Wellington
                                                                                                                Heron Wood




                                                                                                                                                                                                                                 Westheath




                                                                                                                                                                                        Source: 2001 Census - Theme Table TT01. ONS, Crown copright.




26
Figure 19: Family types of dependent children – electoral wards in Hart
                                                                                                                                                                  Family type of dependent children - electoral wards in Hart
                                                           100%



                                                           90%



                                                           80%
Percentage of dependent children in electoral ward




                                                           70%



                                                           60%                                                                                                                                                                                                                                                                                                                  Not in a family
                                                                                                                                                                                                                                                                                                                                                                                Co-habiting couple family
                                                                                                                                                                                                                                                                                                                                                                                Married couple family
                                                           50%                                                                                                                                                                                                                                                                                                                  Lone parent family


                                                           40%



                                                           30%



                                                           20%



                                                           10%



                                                            0%
                                                                   Blackwater & Hawley




                                                                                                                                                                                                                                                        Frogmore & Darby Green
                                                                                                                                                                                      Fleet Courtmoor




                                                                                                                                                                                                                                                                                                                                                      Yateley North
                                                                                           Church Crookham East




                                                                                                                                                                                                        Fleet North
                                                                                                                                                                      Fleet Central




                                                                                                                                                                                                                                                                                                                                       Yateley East
                                                                                                                                                       Eversley
                                                                                                                                         Crondall




                                                                                                                                                                                                                                                                                                                            Odiham
                                                                                                                                                                                                                        Fleet Pondtail




                                                                                                                                                                                                                                                                                    Hartley Wintney



                                                                                                                                                                                                                                                                                                       Hook



                                                                                                                                                                                                                                                                                                              Long Sutton
                                                                                                                  Church Crookham West




                                                                                                                                                                                                                                                                                                                                                                      Yateley West
                                                                                                                                                                                                                                           Fleet West




                                                                                                                                                                                                                                                                                                              Source: 2001 Census - Theme Table TT01. ONS, Crown copright.




Figure 20 shows the under-18 conception rates for Rushmoor and Hart. While
the trend in both areas has been downward, further work is needed to integrate
the strategic approach co-ordinated by the teenage pregnancy partnership -
particularly within schools - with increasing access to sexual health services in
order to achieve the target of a 50% reduction by 2010 (on the 1998 baseline)
across Hampshire County Council.

Figure 20 Under 18 conception rates in Rushmoor and Hart
                                                                                                                                                                     Trend and trajectory for under 18 conception rates - 1997 to 2010
    Under 18 conception rate per 1,000 females age 15-17




                                                                   1998 baseline                                                                                                                                                         2004 target                                                                                                                  2010 target
                                                           50
                                                           45
                                                           40
                                                           35                                                                                                                                                                                                                                                                                                                                Hampshire County

                                                           30                                                                                                                                                                                                                                                                                                                                South East
                                                           25
                                                                                                                                                                                                                                                                                                                                                                                             England
                                                           20
                                                                                                                                                                                                                                                                                                                                                                                             Rushmoor
                                                           15
                                                           10
                                                            5
                                                            0
                                                            1997                         1998                     1999                              2000            2001                     2002                     2003                 2004                                  2005                 2006          2007             2008             2009                           2010




27
                                                                                         Trend and trajectory for under 18 conception rates - 1997 to 2010
Under 18 conception rate per 1,000 females age 15-17
                                                               1998 baseline                                    2004 target                                         2010 target
                                                       50
                                                       45
                                                       40
                                                       35                                                                                                                         Hampshire County

                                                       30                                                                                                                         South East
                                                       25
                                                                                                                                                                                  England
                                                       20
                                                                                                                                                                                  Hart
                                                       15
                                                       10
                                                       5
                                                       0
                                                        1997      1998     1999   2000   2001    2002    2003     2004        2005   2006   2007     2008    2009      2010




Children Looked After

Children Looked After (CLA) are those cared for by the local authority. Some
are placed with foster carers or placed in residential homes. There is clear
evidence of higher than average health needs and increased risk of disability.
Many have experienced families affected by drug or alcohol misuse or domestic
violence, or have come from a highly mobile family. Uptake of health services
among Children Looked After such as dental services, immunisations, health
surveillance and health promotion is frequently low. Referrals of children to
social services vary between years. Public information is mainly available at the
level of Hampshire County and not by each PCT area. This shows that around
15,000 children are referred to social services though a far smaller number of
these - less than 5% - are recorded as being looked after. The PCT is working
closely with social services to undertake regular health assessments for all CLA.
The PCT has provided designated nurse support for CLA and will be working
with them and their carers in addressing risk factors such as high smoking rates,
alcohol and drug use among this vulnerable group.


Sources of Information

2001 Census – Theme Table TT01, Office of National Statistics

The English Indices of Deprivation 2004: Summary (revised) Office of Deputy
Prime Minister (2004)

Hampshire Teenage Pregnancy Partnership Data and Information to Support
the Teenage Pregnancy Strategy for Rushmoor and Hart Local Implementation
Team (January 2005) Hampshire County Council

Promoting the health of looked after children (2002) Department of Health




28
Chapter 4 - Education and Health

The charts below (Figures 21 and 22) show a good educational attainment for
children and young people in Hart but a mixed picture for Rushmoor. In Hart, a
higher proportion of girls achieve in each outcome category than boys, however
in Rushmoor, the percentage of girls with no GCSE was higher than for boys in
Rushmoor and girls in England and the South East. Secondary level attainment
is a powerful predictor of future income.

Figures 21 and 22: Educational attainment for 15 year old pupils 2002/03 in Rushmoor
and Hart
                                                                           GCSE / GNVQ ACHIEVEMENTS FOR 15 YEAR OLD PUPILS 2002/03 [REFERENCED BY LOCATION OF PUPIL RESIDENCE]
                                                                                                     RUSHMOOR & SIMILAR LOCAL AUTHORITY DISTRICTS

                                                                           100%


                                                                            90%


                                                                            80%


                                                                            70%
                                          Percentage of all pupils




                                                                            60%


                                                                            50%


                                                                            40%


                                                                            30%


                                                                            20%


                                                                            10%


Source: The Department for                                                   0%
                                                                                                                                                                              Basingstoke &
Education & Skills.                                                                       England       South East GOR     Rushmoor       Bracknell Forest       Cherwell                           Swindon
                                                                                                                                                                                 Deane
   Boys achieving 5+ GCSEs A*-C                                                             48.0%               50.1%           46.3%          47.5%              41.9%           48.2%              45.7%
   Boys achieving 5+ GCSEs A*-G                                                             86.7%               89.1%           90.3%          93.9%              86.2%           91.6%              84.1%
   Boys with no GCSE passes                                                                 5.9%                5.0%             2.7%             3.7%            5.3%             4.4%               6.5%
   Girls achieving 5+ GCSEs A*-C                                                            58.1%               60.8%           55.5%          54.9%              51.6%           59.8%              53.9%
   Girls achieving 5+ GCSEs A*-G                                                            90.9%               92.5%           92.3%          94.7%              88.9%           93.5%              89.3%
   Girls with no GCSE passes                                                                4.1%                3.5%             4.9%             2.6%            5.3%             3.2%               4.0%




                                                                       GCSE / GNVQ ACHIEVEMENTS FOR 15 YEAR OLD PUPILS 2002/03 [REFERENCED BY LOCATION OF PUPIL RESIDENCE]
                                                                                                    HART & SIMILAR LOCAL AUTHORITY DISTRICTS

                                                               100%



                                                                     90%



                                                                     80%



                                                                     70%
                    Percentage of all pupils




                                                                     60%



                                                                     50%



                                                                     40%



                                                                     30%



                                                                     20%



                                                                     10%



Source: The Department     0%
for Education & Skills.                                                           England           South East GOR       Hart           Surrey Heath         Wokingham      West Berkshire    South Oxfordshire
  Boys achieving 5+ GCSEs A*-C                                                    48.0%                 50.1%            58.4%             61.4%               62.7%            53.9%              52.7%
 Boys achieving 5+ GCSEs A*-G                                                     86.7%                 89.1%            92.9%             91.2%               93.4%            91.1%              89.2%
 Boys with no GCSE passes                                                          5.9%                 5.0%             3.6%              5.2%                3.5%             4.7%                5.2%
 Girls achieving 5+ GCSEs A*-C                                                    58.1%                 60.8%            73.0%             71.5%               75.7%            67.7%              60.6%
 Girls achieving 5+ GCSEs A*-G                                                    90.9%                 92.5%            97.1%             95.7%               95.7%            94.7%              91.9%
 Girls with no GCSE passes                                                         4.1%                 3.5%             1.6%              2.3%                2.5%             2.4%                3.5%




29
Average attainment does, however, conceal poorer prospects in some parts of
Blackwater Valley and Hart. There is a clear association between poor health
and deprivation in childhood and low educational achievement, though access to
good education and training can offset the impact of socio-economic factors and
increase life chances. Figure 23 seeks to quantify the relationship between
health and education. The graph plots the health deprivation and disability
domain of the IMD 2004, identifying areas with higher rates of premature death,
poor physical or mental health and disability against the education skills and
training domain which identifies areas both of poor educational attainment and
lack of skills. Each point on the figure represents one Super Output Area in
Blackwater Valley and Hart Primary Care Trust. The result shows that as the
health of the population worsens so the level of educational attainment and skills
reduces.

Figure 23: Correlation between health and education indices of IMD 2004 in
lower layer super output areas in Blackwater and Hart PCT
                                                                                      Correlation between health and education indices of IMD 2004 - lower layer super output areas in Blackwater Valley & Hart PCT

                                                               80



                                                                        LLSOAs in Blackwater Valley & Hart
                                                               70       PCT
 Education, skills & training deprivation domain of IMD 2004




                                                               60




                                                               50




                                                               40




                                                               30




                                                               20




                                                               10




                                                                0
                                                                 -3.0         -2.5                   -2.0             -1.5                -1.0                -0.5                0.0                 0.5             1.0   1.5
                                                                                                                        Health deprivation & disability domain of IMD 2004




Absence from school bears significantly on educational outcomes and the high
rates of attendance at both primary and secondary level shown in Figures 24
and 25 are important as contributors to the overall achievement in Blackwater
Valley and Hart, and the opportunities for promoting health through school
based programmes.




30
Figure 24: Trend in percentage of half days missed by primary school pupils
between 1997 and 2005 in Hampshire Local Education Authority
                                             Trend in percentage of half days missed by primary school pupils (maintained schools)
                                                  Trend between 1997/98 and 2004/5 in Hampshire Local Education Authority
                         6.0%




                         5.0%

                                                                                                                                                                       Hampshire LEA

                                                                                                                                                                       National figures -
                                                                                                                                                                       England



                         4.0%
                                                                                                                                                                           1997/98
 % of half days missed




                                                                                                                                                                           1998/99


                                                                                                                                                                           1999/00
                         3.0%


                                                                                                                                                                           2000/01


                                                                                                                                                                           2001/02

                         2.0%
                                                                                                                                                                           2002/03


                                                                                                                                                                           2003/04


                                                                                                                                                                           2004/05
                         1.0%                                                                                                                                               [prov.]




                         0.0%

                                unauthorised absences                                                        authorised absences
                                                                                                                                             Source: The Department for Education &
                                                                                                                                     Skill




Figure 25: Trend in percentage of half days missed by secondary school pupils
between 1997 and 2005 in Hampshire Local Education Authority
                                            Trend in percentage of half days missed by seconday school pupils (maintained schools)
                                                   Trend between 1997/98 and 2004/5 in Hampshire Local Education Authority
                         9.0%




                         8.0%




                                                                                                                                                                       Hampshire LEA
                         7.0%
                                                                                                                                                                       National figures -
                                                                                                                                                                       England



                         6.0%
                                                                                                                                                                           1997/98
 % of half days missed




                                                                                                                                                                           1998/99
                         5.0%

                                                                                                                                                                           1999/00


                         4.0%                                                                                                                                              2000/01


                                                                                                                                                                           2001/02

                         3.0%
                                                                                                                                                                           2002/03


                                                                                                                                                                           2003/04
                         2.0%
                                                                                                                                                                           2004/05
                                                                                                                                                                            [prov.]


                         1.0%




                         0.0%

                                unauthorised absences                                                        authorised absences
                                                                                                                                             Source: The Department for Education &
                                                                                                                                     Skill




Healthy Schools Partnership


31
The Healthy Schools Partnership (HSP) is a scheme based on health and
education organisations working together. Its aim is to provide support for
school improvement through establishing a healthy school climate in which
improved health and wellbeing is reflected in raised educational standards. The
Partnership covers an area served by Hampshire Education Authority, together
with the seven local Primary Care Trusts (PCTs). The Healthy Schools
Partnership is a scheme accredited to the National Healthy School Standard 1.

Schools registered on the scheme work on a mandatory core of “whole school
elements”. In addition, they identify two or three focus areas in which they set
targets, develop plans and implement action. The choice of focus areas
currently includes Personal, Social and Health Education (PSHE), citizenship,
drug education, emotional health and wellbeing, the environment, healthy
eating, physical activity, safety education, and Sex and Relationship Education
(SRE).

School Engagement

The overview of schools within the North Hampshire and Blackwater Valley and
Hart PCT areas is presented in Table 3.

Table 3: Schools engaged in the Healthy Schools process: March 2005

School type    Total no. of        Total no. engaged * Total no. validated by
               schools             in the process      31/3/05
               NH      BVH         NH          BVH     NH         BVH
Primary        ** 84   61          64          49      27         19
Secondary      14      10          9           6       2          0
Special        ***6    2           5           1       2          0
Pupil Referral ***3    1           1           1       0          0
Units
Total – LEA 107        74          79         57         31          19
schools
Independent    11      9           2          0          0           0
schools


*      Engaged means the school has signed up to the scheme and teaching
staff have attended initial training. It should also be noted that some schools
have returned for re-training and therefore have not added to an increase in
numbers trained

**    An infant and junior school merged to form one primary so reducing the
      overall total

 ***   Owing to the re-organisation of Education Other Than At School (EOTAS)
provision across Hampshire and the merging of some special schools in
Basingstoke, it will be difficult to compare data with past figures.

32
As of March 2005, 69% of LEA schools in the NHPCT area and 77% of LEA
schools in the BVHPCT area are engaged in the Healthy Schools process. This
compares with the overall Hampshire LEA figure of 76%.


School Targeting and Engagement

The healthy schools programme is recognised as being a “key means of
reducing risk-taking behaviour and encouraging healthy, active lifestyles”,
especially in disadvantaged areas. Disadvantaged areas are being targeted
through schools with 20% or more Free School Meals Eligibility (FSME) with
2002 as the baseline. There is a national target to engage all such schools by
March 2006. In the NHPCT area, 14 schools have been identified with above
20% FSME; as of March 2005, 13 are engaged in the healthy schools process.
In the BVHPCT area, 9 schools have been identified with above 20% FSME; as
of March 2005, 7 are engaged in the healthy schools process.

In addition to newly recruited schools, a few existing schools whose progress
has slowed or halted owing to various external factors have re-engaged in the
process.

Focus Areas

The work undertaken by schools in meeting the whole school elements is vitally
important from an organisational development point of view. All schools
undertake this ‘core’ and it provides the solid foundations that allow schools to
build the stable systems and processes which underpin the work of the focus
areas. Schools must provide evidence of meeting the standards contained in
the whole school elements as part of their validation process.

In addition, schools must select two or three focus areas from the nine available
in which they must also show significant progress to meet the requirements of
validation. Once validated, a school will choose 2 or 3 further focus areas for
the next period of work towards revalidation. Up-to-date details of which focus
areas schools are currently undertaking can be provided by Senior Health
Promotion Specialist, NHPCT.

School Validation and Celebration

During 2004/05, 10 NH schools and 8 BVH schools have been successfully
validated. Two of the BVH schools were revalidations, demonstrating how the
schools were maintaining the standard they had already achieved. Validated
schools from this year and the second half of the academic year 2003/2004
were invited to celebrate their success at enjoyable awards ceremonies that
were held at the Great Hall in Winchester (July 2004 and January 2005). The
audience of pupils, teachers, parents, governors and invited guests normally
numbers more than 200 people.        Pupils participate by presenting a short
summary of the highlights of their healthy school’s work before collecting their

33
school’s plaque and certificate.

     Our Healthy Schools Project began with healthy eating and moved forward
     into all aspects of school life. It has encouraged all to take responsibility
     for everyone’s wellbeing and contributed to raising standards.

     Manor Infant School (Cove), January 05

Scheme Development

Following the publication of the Public Health White Paper ‘Choosing Health’ ,
which signalled the intention to widen the meaning of national healthy school
status and make it more rigorous and consistent, the National Healthy Schools
Programme has begun consulting on the detail of what this will mean for schools
and the local healthy schools programmes.

In addition, from September 2005, Ofsted expects schools to demonstrate how
they are contributing to the five national outcomes for children stipulated by
Every Child Matters and the Children Act (2004) - being healthy; staying safe;
enjoying and achieving; making a positive contribution; and economic well
being.

The draft guidance issued during spring 2005 sets out 4 compulsory core
themes: PSHE (to include SRE and Drug Education), physical activity, healthy
eating and emotional health and well-being. These are in addition to the whole
school elements that remain in their present form.

By 2009, the Government wants to be supporting every school to be working
towards achieving national healthy school status. Final guidance on the new
national healthy schools status will be issued by September 2005 but Hampshire
schools trained in February 2005 have already begun work, using the new draft
guidance.

Recommendations

     The PCT, through the Children’s Local Implementation Team (LIT), should
     invest in protected time for school nurses to proactively support the Healthy
     Schools programme.

     The PCT, through the Children’s LIT, should provide time for a Public Health
     Nutritionist to support teachers to develop their knowledge and skills so that
     they are able to work confidently on this subject with children and also with
     parent groups, particularly low income groups, in a way that will meet their
     various learning styles.

     The PCT, through the Mental Health and Children’s LITs, should invest in a
     mental health promotion programme which includes support for the
     emotional health and wellbeing focus area of Healthy Schools work.


34
     The PCT should ensure that the Local Strategic Partnerships (LSP)
     celebrate the achievements of the local schools which reach validation each
     year.

Sources of Information

The Department for Education and Skills,
http://www.dfes.gov.uk/performancetables/

Healthy Schools Partnership in Hampshire www.hants.org.uk/healthyschools/




35
Chapter 5 - Childhood Obesity and Overweight

The population is getting heavier. Change in body fat composition is becoming
a major new threat to public health and health policy is increasingly focused on
the problem and how it can be tackled. Similar problems are affecting Europe
and the USA. Obesity in England has doubled in six year olds to 8.5% and
trebled among 15 year olds to 15%. Maturity onset diabetes has been reported
in school children who are obese, where it had not been encountered previously
before middle age. Overweight and obesity in children and adolescents predicts
obesity in later life where it becomes a major risk factor for diabetes and
cardiovascular disease. Overweight adolescents have a 70% chance of
becoming overweight or obese adults (National Audit Office, 2001).

Table 4




Table 4 provides Department of Health statistics on the increase in obese and
overweight children aged 2-10yrs between 1995 and 2003. The data was
collected in the Health Survey for England and demonstrated a 3.8% rise in
obesity and 5% rise in overweight over 8 years. The level is broadly similar for
boys and girls with obesity in 14.9% of 2-10 year old boys compared with 12.5%
of girls and 29.6% of all boys (under 16) now overweight or obese compared
with 25.9% of all girls (under 16). The increases are most significant among
older children aged 8-10.

It is now clear that population based interventions are needed to tackle the
problem and we need to understand evidence-based approaches to tackling
overweight and obesity. We are gaining better insights into the social,
demographic and behavioural factors associated with the problem from national
surveys, but better local information is needed to target the problem more
effectively.

The risk factors include:

     Where children live
     Household income
     Prevalence of parental obesity
36
       Physical activity

Trend in overweight and obesity by social class

Social class was defined by occupation of the head of the household in the
health survey. Levels of obesity rose between 1995 and 2003 and the trend
was higher in manual households (5% increase) than non-manual households
(3% increase) (see Figure 26).

Figure 26
                           Obesity trend by social class of head of household

           18


           16


           14


           12
 % obese




           10


            8


            6


            4


            2


            0
                95    96          97        98            99    2000     2001   2002   2003

                                                 Non Manual    Manual




Obesity prevalence in children by parental body mass index (BMI)

Analysis of parental body mass index (BMI) showed a clear relationship with
rates of obesity among children. In households where both parents were obese
or overweight, 19.8% children were obese compared with 6.7% children in
households with neither parent obese or overweight. This highlights the
importance of family behaviours in tackling childhood obesity.

Relationship between obesity and physical activity

The health survey enabled a broad classification of physical activity into 3
categories:

       Active: 60 minutes exercise per day for 7 days a week. This broadly
       represents children achieving recommended levels of physical activity.
       Insufficiently active: 30-59 minutes of activity daily for 7 days - moderate
37
     activity each day.
     Sedentary: active at a lower level or not at all.

Interestingly, the tendency for obesity rates to rise was quite small across the
three groups, increasing from 14.8% among active children to 17.4% in those
classified as sedentary. This data was only available for a small sample of
children, and no statistical significance could be attached to the findings. The
data merits further investigation to better understand the relationship between
physical activity and obesity.

Obesity trends in older children

The existing survey data has demonstrated that obesity increased most among
children aged 8-10. Data on older children and adolescents confirm similar
levels of obesity continuing into adolescence. Prevalence among boys varies
between 15.4% and 22% between 11 and 15 years, and 15.6-19.8% for girls.

Local Estimates of Obesity Prevalence

Unfortunately, there are no accurate or direct measurements of population
obesity for the primary care trusts in Hampshire in either adults or children.
Estimates have been synthesised by the National Centre for Social Research.
This shows that the Hampshire PCTs have levels of obesity equivalent to that of
England as a whole. Mid Hampshire, Blackwater Valley and Hart, and North
Hampshire PCTs tend to have lower levels than the rest of the county. The Isle
of Wight and New Forest PCTs have the highest estimated obesity prevalence
in Hampshire. Trends in obesity have also been modelled between 1994 and
2002 in a regional report on obesity and overweight (Choosing Health in the
South East: Obesity). This concluded that Hampshire and the Isle of Wight has
the highest increase in obesity prevalence over this period. When overweight
and obesity prevalence are considered together, Hampshire and the Isle of
Wight has the highest level in the SE region, and this also exceeds the national
average.

Measuring Childhood Obesity

New public service agreement targets introduced by the Government aims to
halt the rise in obesity among school children by 2010. New guidance was
published in Jan 2006 on measurement of height and weight of primary school
children in the Reception year (ages 4-5) and in Year 6 (ages 10-11). PCTs will
need to agree how this information will be collected.

Measurement is for population monitoring and to inform the development of
effective intervention programmes. Results will not be kept on an individual
basis. The data will be analysed nationally to explore the potential for future
intervention programmes and research.


The guidance includes:
38
     The rationale for collecting data on children
     Definition of a core data set
     Role of PCT including staffing groups such as school nursing
     Explanation of population monitoring versus screening
     Good practice
     Linking with the national Healthy Schools Programme

Public Health Interventions

The Health Development Agency (HDA) reviewed effectiveness of interventions
on obesity and overweight. The briefing recommended the following broad
approaches to tackling the problem in children:

     Multi-faceted school based interventions.
     Exercise and behaviour modification programs to treat childhood obesity and
     overweight involving parents.

The programme for Choosing Health - the public health delivery programme -
suggests a series of “big wins” on obesity as follows:

     Simple labelling of packaged foods. To encourage reduced intake of fat,
     sugar and salt and to reverse the trend to increased portion size. Aspects of
     this policy remain controversial with some food producers.
     National obesity awareness campaign. Promoting healthier diets and
     promoting breast feeding.
     Helping those who want to lose weight. Screening by GPs and referral to
     obesity care pathways that improve access to medical and surgical
     programmes. This has just recently been extended from adult programmes
     to controversial plans for teenagers to access obesity drug treatment and
     surgery programmes.
     Food Promotion Programmes. Restricting food advertising and promotion
     aimed at children and teenagers.
     Encouraging Activity: Including a wide range of school and community based
     measures to increase physical activity and encourage walking to school.
     National Healthy Schools programme promoting a whole school approach to
     healthy living.
     High quality family and early years support.


A Local Public Service Agreement (LPSA) to tackle childhood obesity

A new series of public service agreements have been negotiated across
Hampshire for improving a variety of child and adult social and health outcomes
including tackling obesity and overweight. These include a range of partner
agencies. The LPSA on childhood obesity will run for 5 years in recognition of
the additional challenge inherent in achieving a sustained change. The aim is to
reduce the percentage of children under 11 in targeted areas who will become
overweight or obese over the coming 5 years. The target also includes 90% of

39
all Hampshire state schools achieving the National Healthy Schools Status by
2008. Schools are being asked to encourage healthy eating and physical
activity via the curriculum and changes to the school environment. The
agreement proposes that work is targeted at school communities in the more
deprived areas of Hampshire in the first instance. The programme includes a:
    County-wide nutrition and physical activity steering group
    County-wide Healthy School Programme
    Food Forum
    County-wide LPSA2 Childhood Obesity steering group.

Test Valley Borough Council is the project sponsor and budget holder for the
Hampshire PCTs. Further details about the target, and schools involved can be
found in appendix 2.

Recommendations

      There is an urgent need to develop plans for measuring height and
      weight among reception and year 6 pupils in the coming year.

      Choosing Health action plans and Local Area Agreements should reflect
      the current evidence of effectiveness in tackling overweight and obesity.

      School nursing and healthy schools co-ordinators should link plans to
      manage overweight and obesity working closely with the county-wide
      LPSA2 Childhood Obesity Steering Group and HIOW public health
      network.

      Continue to update local information and intelligences on obesity
      including evidence of effective interventions to tackle obesity and
      overweight, increasing the range of interventions currently in use across
      the county.

      Local policies on drug treatment and surgery for obesity in children need
      to be agreed in the context of a broader strategy for weight management.


Sources of Information

Obesity among children under 11
http://www.dh.gov.uk/PublicationsAndStatistics/Publications/PublicationsStatistic
s/PublicationsStatisticsArticle/fs/en?CONTENT_ID=4109245&chk=WB/AR1

Measuring childhood obesity: Guidance to primary care trusts.
http://www.dh.gov.uk/PublicationsAndStatistics/Publications/PublicationsPolicyA
ndGuidance/PublicationsPolicyAndGuidanceArticle/fs/en?CONTENT_ID=41263
85&chk=Qb6Blx



40
Chapter 6 - Tobacco Smoking and Children

Introduction

Tobacco smoking has contributed to a dozen times more deaths in the UK in the
past 40 years than British casualties from World War II – over 5 million. It
contributes to over 20% of all deaths and one third of deaths due to cancer each
year. Smokers are more likely to die from lung cancer, respiratory diseases and
coronary heart disease than non smokers and, apart from causing premature
deaths, it is responsible for more than 50 different types of disease and ill health.
It reduces fertility and causes eye problems, neck pain, depression, diabetes,
osteoporosis and pneumonia. Smoking not only affects those who smoke but
also those who inhale smoke passively.

Tobacco Control

Over four-fifths of smokers start as teenagers. Those who smoke early, for
example at age 15, are three times more likely to die of lung cancer than those
who take up the habit in their mid 20s. The White Paper, Smoking Kills,
launched in 1998, set the overall agenda on tobacco policy. This included a
target to reduce smoking amongst 11 to 15 year olds from 13 per cent to nine
per cent by 2010. Pregnant women and teenage mothers are also specific
target groups. Choosing Health included a programme promoting smoke free
enclosed public spaces, though the comprehensive ban agreed in the Smoking
Bill on Valentine’s Day (14 February 2006) will have a far greater impact on
reducing levels of tobacco use in teenagers and young adults.

Smoking in Pregnancy

Smoking can reduce fertility with associated psychological and emotional costs.
There is increasing evidence that children are significantly adversely affected by
passive smoking. The early effects of passive smoking start during pregnancy.
Babies born to mothers who smoke are lighter by an average of 200 grams. The
effects are also significant when their fathers smoke. Pregnant mothers who
smoke are at a higher risk of miscarriage, pre-term delivery, bleeding and
increased perinatal mortality. Babies whose mothers smoke are also more prone
to cot death, cleft palate, deafness, dental caries, colic, behavioural problems
and a reduction in growth and educational achievement.

Children exposed to second-hand smoke are more at risk of hospital admissions
than those living in smoke free homes. Symptoms of asthma are twice as
common in the children of smokers. It is an important cause of school
absenteeism and is a predictor of chronic obstructive airway disease and cancer
as adults.

Children and young people

Young smokers addicted to nicotine are prone to develop withdrawal symptoms
on stopping. It is also a marker for abuse of alcohol, cannabis and cocaine. The

41
risk of lung cancer and early occurrence of heart disease is higher in those who
start smoking earlier in their life. Smoking makes blood more likely to clot and
also has an adverse effect on blood lipids. The incidence of subarachnoid
haemorrhage is six times more common in young smokers than non-smokers.
Young smokers have been found to be less fit than non-smokers. It causes oral
lesions like leukoplakia, depigmented lip patches and increases skin ageing and
wrinkling. It impairs the immune system and is also associated with an increased
risk of acquiring HIV-1 infection.

There is also the risk of fires in the home associated with young people trying to
hide the evidence of smoking.

Prevalence of smoking in children

National

Recent national study showed that 26% of 14-15 year old girls and 17% of 14-15
year old boys smoked at least one cigarette during the previous week.

Sources of cigarettes

Sixteen percent of the 14-15 year old females were able to buy cigarettes from a
shop and 8% of the same group was supplied by friends.

Attitudes to Smoking

The number of regular smokers increases more than three times between 12
and 15 years of age. Up to 65% of young people will have smoked by Year 10.
The majority of current smokers say they would like to stop. Fifty six percent of
Year 10 females have a close friend who smokes. The contrast in smoking
between girls with or without friends who smoke is dramatic, but the greatest
predictor of smoking is if a sister or a parent smokes. Around 52% of all pupils
live in a 'smoky' home.

Children become aware of cigarettes at an early age. Three out of four children
are aware of cigarettes before they reach the age of 5 whether they have a parent
who smokes or not.

A local smoking prevalence survey in the year 2000 carried out in North
Hampshire and Blackwater Valley and Hart PCTs among 1560 secondary
school pupils showed the overall frequency to be similar to national figures. The
proportion of young people smoking ranged from between 1.4% of pupils aged
11 and 12 years old to 22.1% aged 15 and 16. Girls were more likely to be
regular smokers than boys. However, the average numbers of cigarettes
smoked by pupils in a week was 35 for boys and 25 for girls. The survey also
found out that smoking, alcohol consumption and the use of drugs were
significantly associated. Knowledge about the effects of nicotine and the anti-
cosmetic influence of cigarettes appeared to be poor; unlike national surveys,
only 10% wanted to stop smoking, but most young people who smoked believed

42
that they would give up when they were older.

Factors influencing children to smoke

Children develop a smoking habit through various stages from precontemplation
through contemplation, initiation, experimentation and regular smoking. Various
personal and social-environmental factors influence the different stages.
Parental smoking and attitudes strongly influence whether a child will smoke or
not. They are also influenced by their siblings, friends and other role models like
teachers.

Selling cigarettes to children less than 16 years is illegal. This is likely to
increase to 18 years with new legislation. Advertisements in the media, the price
of cigarettes and peer pressure play a major role in whether or not children take
up smoking. Establishing non-smoking societal norms is crucial in prevention
and cessation of smoking in the short and long term.

Recommendations

     Local authorities should review powers or encourage voluntary agreement to
     ensure that all enclosed spaces used by children and young people are
     smoke free. This should be subject to urgent action and in advance of
     national legislation.

     All premises run by local authorities, health organisations and other public
     sector organisations such as police, probation, youth services and schools
     should introduce smoke free policies without delay.

     A structured health education programme to reduce the uptake of smoking
     aimed at young people should be developed and implemented across all
     school and youth settings.

Sources of Information

Royal College of Physicians, Smoking and the Young 1992

Royal College of Physicians, Nicotine Addiction in Britain 2000

Fact sheet No 2 Action on Smoking and Health (ASH). March 2003

General Household Survey 2002. A Summary of Smoking over Time 2004

Evans S. Smoking among the Young in NE Hampshire, Unpublished 2000

Cancer Research Campaign Smoking policies and prevalence for 16-19 year
olds in schools and colleges, a report by the Public Attitude Surveys Ltd. London
1991

Department of Health and Children Press Release 26 Sept 2004
43
Chapter 7 - Emotional Wellbeing, Mental Health and Staying Safe

What do we mean by mental health?

“Children’s mental health is the strength and capacity of children’s minds to grow
and develop with confidence and enjoyment. It consists of the capacity to learn
from experience and to overcome difficulty and adversity. It’s about physical and
emotional wellbeing, the ability to live a full and creative life and the flexibility to
give and take in relationships. Children who are mentally healthy are not saints
or models of perfection, but ordinary children making the most of their abilities
and opportunities.”
Young Minds

There are many definitions of mental health, from a wide range of sources, but
the above definition from the charity Young Minds emphasises the importance of
developing children and young people’s mental health positively, rather than
focussing solely on mental disorders and ill health.

Risk factors and resilience

There are many factors that can influence mental health, and the way they
interact is complex. They can include factors in the individual, such as genetic
influences; in the family, such as style of parenting; and external factors in the
wider community and environment such as socio-economic status and school
ethos.

In order to promote mental health and reduce mental illness, it is important to
understand what protects and helps to build emotional resilience, as well as
being able to identify and modify risk factors.

Poor emotional health in children predicts poor mental health and social
functioning in later life. By age 28, the costs (crime, poor employment prospects,
poor health, being on benefits, needing social services) for individuals with
troubled behaviour as children are ten times higher than for those with no
problems.

Table 5 gives more detail of the risk and resilience factors identified through
research.




44
Table 5: Factors influencing children’s mental health
Factors influencing children’s mental health
              Risk                                      Resilience
Child                 Genetic influences                       Being female
                      Low IQ and learning disability           Higher intelligence
                      Specific developmental delay             Easy temperament as an infant
                      Communication difficulty                 Secure attachment
                      Difficult temperament                    Positive     attitude,   problem
                      Physical illness                         solving approach
                      Academic failure                         Good communication skills
                      Low self esteem                          Planner, belief in control
                                                               Humour, religious faith
                                                               Capacity to reflect
Family               Overt parental conflict                   At least one good parent child
                     Family breakdown                          relationship
                     Inconsistent or unclear                   Affection
                     discipline                                Supervision, authoritative
                     Hostile and rejecting                     discipline
                     relationships                             Support for education
                     Failure to adapt to a child’s             Supportive parental
                     changing needs                            relationship/absence of severe
                     Physical, sexual or emotional             discord
                     abuse
                     Parental psychiatric illness
                     Parental criminality,
                     alcoholism, or personality
                     disorder
                     Death and loss-including loss
                     of friendship

Community            Socioeconomic disadvantage            Wider supportive network
                     Homelessness                          Good housing
                     Disaster                              High standard of living
                     Discrimination                        High morale school with
                     Other significant life events         positive policies for behaviour,
                                                           attitudes and anti-bullying
                                                           Schools with strong academic
                                                           and non-academic
                                                           opportunities
                                                           Range of positive sport/leisure
                                                           activities
         Source: Bright Futures. Promoting children and young people’s mental health;
         The Mental Health Foundation, 1999




         45
Prevalence of mental disorders

A major national prevalence study of mental disorders in children and
adolescents was undertaken in 1999. This looked specifically at the prevalence
of three main categories of mental disorder: conduct disorders, emotional
disorders and hyperkinetic disorders. (Ref Meltzer ONS survey).

Nationally, this survey showed that among 5-15 year olds living in private
households, 10% had a mental disorder. Among 5-10 year olds, 10% of boys
and 6% of girls had a mental disorder; and among 11-15 year olds, 13% of boys
and 10% of girls had a disorder. So the prevalence of mental disorders is higher
in boys than girls, and increases with age for both. Further detail is shown in
table 6, together with estimates of the number of young people suffering from
mental disorders locally.

The prevalence rates of mental disorders were greater among children and
young people:
      In lone parent compared to two parent families (16% compare to 8%)
      In families with five or more children compared with two children (18%
      compared with 8%)
      If interviewed parent had no educational qualifications compared with a
      degree level or equivalent qualification (15% compared with 6%)
      In families with neither parent working compared with both parents at
      work (20% compared with 8%)
      In families with a gross weekly income of less than £200 compared with
      £500 or more (16% compared 6%)
      who are “looked after” (five times more likely to have a mental disorder)
      who have a learning disability are (three to four times more likely to have
      a mental disorder)

Table 6 Prevalence of mental disorders by age and sex in Blackwater
Valley and Hart PCT

Blackwater Valley and Hart PCT
                          Estimated number of 5-15 year olds with disorder (%)
                          Boys                Girls                All
Emotional disorders       533 (4.1)           547 (4.5)            1080
   Anxiety disorders      455 (3.5)           486 (4.0)            941
   Depression             117 (0.9)           122 (1.0)            239
Conduct disorders         964 (7.4)           389 (3.2)            1353
Hyperkinetic disorders    312 (2.4)           49 (0.4)             361
Less common disorders 91 (0.7)                49 (0.4)             140
Any disorder              1483 (11.4)         934 (7.6)            2417
Source: Mental health of children and adolescents in Great Britain
       H Meltzer et al, ONS, 2000

Whilst this study has given a lot of detailed information, it provides a snapshot
and does not consider how prevalence has changed over time; or how it

46
compares to other developed countries. More recent studies suggest that whilst
the prevalence of adult mental illness in the UK has remained unchanged
between 1993 and 2000 at 16%, there is strong evidence for a sharp rise in
mental health problems (particularly depression and anxiety) among children
and young people. This is not the case in all developed countries; the
prevalence rates being lower, and having stabilised in the Netherlands and US.

Whilst there is not yet a clear understanding of why this should be, early
research has pointed to the following possible contributors:
      Cultural conflict
      Models in media at odds with day to day reality
      Toxins and pollutants
      Increased affluence allowing easier access to relatively cheap drugs and
      alcohol
      Reduced community cohesion and responsibility
      Increased family disruption
      Increased educational expectations
      Increase in major decision making particularly around drug taking and sex
      Prolonged financial dependence on parents

Suicide and self-harm

Suicide is the leading cause of death in people aged 15-24. For each completed
suicide in young people there are approximately 100 suicide attempts. Suicide is
very rare in children under 12, but the incidence increases sharply during
adolescence to reach a peak in the mid 20s. It is more common in males and is
the most frequent cause of death in men under 30. Figures 27 and 28 show the
death rate from suicide and undetermined injury in the under 35s in Rushmoor
and Hart compared to England. Small numbers mean that the trends must be
interpreted with caution; and there are no significant differences from national
rates.




47
Figure 27: Death rate from suicide and undetermined injury in the under 35s in
Rushmoor compared to England
                                                                              Mortality from suicide and undeterm ined injury in the under 35s
                                                                          Crude rates per 100,000 resident population w ith 95% confidence intervals
                                                         25

                                                                                                                                                                                                    England
  Crude mortality rate per 100,000 resident population




                                                                                                                                                                                                    Rushmoor
                                                         20




                                                         15




                                                         10




                                                         5




                                                         0
                                                                  1997-1999                 1998-2000                 1999-2001                 2000-2002                 2001-2003                 2002-2004
                                                         Data Source: The Compendium of Clinical & Healt h Indicat ors. Crown copyright material is reproduced wit h t he permission of the Controller of HM SO and the
                                                         Queen's Print er for Scot land. North & M id Hampshire Healt h Inf ormatics Service Click-Use Licence No C02W0004828.



Figure 28: Death rate from suicide and undetermined injury in the under 35s in
Hart compared to England

                                                                              Mortality from suicide and undeterm ined injury in the under 35s
                                                                          Crude rates per 100,000 resident population w ith 95% confidence intervals
                                                         14

                                                                                                                                                                                                     England
  Crude mortality rate per 100,000 resident population




                                                         12
                                                                                                                                                                                                     Hart


                                                         10



                                                          8



                                                          6



                                                          4



                                                          2



                                                          0
                                                                  1997-1999                 1998-2000                 1999-2001                 2000-2002                 2001-2003                2002-2004
                                                         Data Source: The Compendium of Clinical & Health Indicators. Crown copyright material is reproduced with t he permission of the Cont roller of HM SO and the
                                                         Queen's Printer for Scotland. North & M id Hampshire Healt h Informat ics Service Click-Use Licence No C02W0004828.



Self-harm is more common amongst young women, and can take a variety of
48
forms including taking overdoses and cutting. Professionals in contact with
individuals who frequently self-harm often find their management difficult, and
can sometimes respond quite negatively, focusing only on the behaviour and
physical risk, rather than trying to help with underlying emotional distress.

Alcohol & Drug Misuse

British teenagers are some of the heaviest drinkers in Europe: more than a third
of 15 year-olds report having been drunk at age 13 or earlier compared to
around one in ten French or Italian children. By the age of 15, just under half of
all teenagers report drinking in the previous week, and the number of units
consumed has doubled from 5.3 in 1990 to 10.5 in 2002. This consumption is
more likely to be outside the home and less likely to be in the home under
supervision. A recent Lancet publication has identified worrying increases in
alcohol related liver disease and deaths in England and Scotland contrasting
with improving trends in other parts of Europe. In 2004, the Government
published its Alcohol Harm Reduction Strategy for England which set out four
key ways that Government can act to reduce alcohol related harms through:
        improved, and better-targeted, education and communication;
        better identification and treatment of alcohol problems;
        better co-ordination and enforcement of existing powers against crime
        and disorder; and
        encouraging the industry to continue promoting responsible drinking and
        to continue to take a role in reducing alcohol related harm.

Significant progress is being made on enforcing controls of sales of alcohol to
teenagers under 18, but uncertainty exists over the national policy to deregulate
the opening times of pubs and clubs that sell alcohol, and the relatively cheap
price of alcohol in the UK, both factors that encourage higher levels of
consumption.

What can we do to improve mental health?

Early years

The mental health benefits of an environment that supports parents and families
through pregnancy, childbirth and the first years of life are widely recognised.
Interventions in the following areas have been shown to have the most
significant impact on promoting children’s mental health:
        Improving parenting skills
        Strengthening child/carer relationships
        Addressing behaviour problems in infants and children
        Promotion of family mental health
Parenting has been shown to have the single greatest influence on children’s
health outcomes including accident rates, teenage pregnancy, substance
misuse, truancy, school exclusion and underachievement, child abuse,
employability, juvenile crime as well as mental illness.

Effective programmes work on multiple levels to strengthen the relationship
49
between parents and children, and to address socio-economic factors that
undermine positive parenting and family mental wellbeing.

There has been a decline in children’s linguistic skills, and a reduction in oral
communication between parents and small children, that has implications for
emotional development. Encouraging better communication, including reading to
pre-school children can promote language development and literacy, and has
cognitive and emotional benefits for young children.

Schools

The promotion of emotional health and wellbeing has now become one of the
essential criteria for National Healthy School status (see Chapter 3).

A curriculum resource on Social and Emotional Aspects of Learning (SEAL) has
been launched to support this work in primary schools. To achieve the best
outcome, this needs to be part of a wider programme to involve the whole
school, parents and surrounding community.

For older children, programmes to promote mental health and well-being
increase the effectiveness of other health promotion interventions (such as
those to reduce obesity). Improving self-esteem, communication and negotiation
skills; and addressing media influences and cultural norms will have a significant
impact on the effectiveness of health promotion with young people.

Anti-bullying strategies that involve the whole school, parents and the
community are effective and have significant long term impact on criminal
behaviour, alcohol abuse, depression and suicidal behaviour.

Staying safe

Living with violence, or the fear of violence is a significant risk factor for poor
mental health. Children who live with domestic violence are at increased risk of
behavioural problems and emotional trauma; and physical, sexual and emotional
abuse in childhood can lead to mental health disorders in children and in adult
life.

Child Protection

Local Authority Child Protection registers are separate from, though often
overlap those for, Children Looked After (see Chapter 2). The same children
may need the protection of both approaches. The register indicates that children
are at risk of abuse in the family. There are 4 categories: neglect, physical
abuse, emotional abuse and sexual abuse. Of around 500 referrals each year in
Hampshire the largest categories - around 40% - are for neglect or physical
abuse. There is a strong correlation between children on the register and levels
of deprivation.

Across Hampshire, there has been a decline in children on the register and the

50
length of time children spend on the register is declining. Children needing
additional support, and so at risk of being placed on the register, form about
20% of the caseload for health visitors. Increased joint planning between health
and social care will improve the response to children in need and is a priority for
action in the development of the new children centres.

Alcohol and violence

There is a strong link between drinking and domestic violence, sexual assault,
and child abuse. Work to reduce alcohol related harm, particularly through local
Crime and Disorder Reduction Partnerships (see appendix 3) will have a
significant part to play.
Evidence from research being undertaken in Cardiff indicates that targeted
policing, informed by accident and emergency (A&E) intelligence, can reduce
attendances at A&E and the severity of injuries. There is also the potential to
improve baseline data on domestic violence and child protection.


Current Crime and Disorder Reduction Partnership (CDRP) initiatives

The NHS is responsible for providing a range of services that are linked to the
consequences and prevention of crime. These include mental health services,
drug and alcohol dependency services, supporting children and young people
and the elderly who may be affected by domestic violence. The PCT is currently
supporting:

      Planning local responses with A&E, local authorities, CDRPs, the police,
      licensing trade, the fire authority and other local statutory and voluntary
      bodies to reduce crime and its impact.

      Sharing A&E intelligence regarding alcohol related admissions assist the
      Police in targeting drinking establishments significantly associated with
      violent incidents. This is being negotiated with both A&E at Frimley Park
      Hospital and North Hampshire Hospital.

      Contribution to Local Strategic Partnerships/CDRPs, such as data
      provision, reviewing progress and setting up new objectives and action
      plans.

      Health needs assessment for alcohol services across HIOW; alcohol
      training needs analysis for professionals and a planned way forward.

      As part of National Reassurance Policing Programme, Hampshire
      Constabulary selected Aldershot Town Centre as one of its pilot schemes
      to address fear of crime and quality of life issues. One of the aims was to
      establish the extent to which particular types of crime or anti social
      behaviour concerned the people most. Young people and alcohol
      provision was seen as the most important issue in need of attention (An
      Analysis of the Night Time Economy in Aldershot Town Centre 2004-05).
51
       Hart District Council intends to make an Order under section 13 of the
       Criminal Justice and Police Act 2001-Local Authorities (Alcohol
       consumption in designated public places) regulations 2001, to designate
       areas in Hart, where it will become an offence if a person continues
       drinking in designated areas, once asked by a police officer not to do so
       under section 12 of the Act. A similar service is planned for Rushmoor.

       A draft alcohol strategy and action plan for Hampshire has been
       published for consultation. It shows 52% of 11-18 year olds drink alcohol
       on a regular basis. It also shows long waiting lists for alcohol
       detoxification services.

Services for young people with social, emotional and mental health needs

In response to both Government and local concerns about the provision of child
and adolescent mental health services (CAMHS), Hampshire’s Children’s Trust
was established in 2004 for children and young people with social, emotional
and mental health needs. This is a formal partnership between Hampshire
County Council’s Children’s Services Department and seven primary care trusts
including Blackwater Valley and Hart PCT), with pooled development budgets.
The Children’s Trust commissions child and adolescent mental health services
from a range of agencies (including health, social services, education and the
voluntary sector) to provide health promoting activities, assessment, support and
interventions for children and young people with varying severity of emotional
and behavioural difficulties.

A needs analysis was undertaken in 2004-2005 to prioritise developments, and
funding has allowed the recruitment of 37 new mental health worker posts
across Hampshire, including primary mental health workers in North Hampshire.

Key priorities for 2006 include:

       Enhance emotional wellbeing and mental health of children and young
       people
       Increase capacity in local multi-agency teams
       Create a single point of access for referrals
       Offer flexibility in the way services are provided
       Set up a crisis out-of-hours service
       Enhance services for children with specific needs
       Provide a suitable service for 16-17 year olds in crisis
       Infrastructure in place for tiers 2 and 3


Recommendations

The PCT should:
     Ensure that the implementation of the health visitor service review
     supports evidence based early interventions with parents and families at
52
      greatest risk

      Support healthy schools work to improve emotional wellbeing (see
      chapter 3)

      Continue to work towards Hampshire’s Children’s Trust’s shared aims
      and objectives for improving child and adolescent mental health services
      in Blackwater Valley and Hart.

      Promote emotional wellbeing and good mental health as the foundation
      for the development of healthy lifestyles and behaviours; particularly in
      work with Local Strategic Partnerships and Crime and Disorder Reduction
      Partnerships.

      Work with A&E departments to develop information about alcohol and
      domestic violence related attendances that can help to inform local work
      to prevent injury and abuse.


Sources of Information

      Bright Futures. Promoting children and young people’s mental health; The
      Mental Health Foundation, 1999

      Survey of the mental health of children and young people in Great Britain, 2004.
      http://www.statistics.gov.uk/CCI/nugget.asp?ID=1229&Pos=1&ColRank=1&Ran
      k=374

      Mental health of children and adolescents in Great Britain, H Meltzer et al, ONS,
      2000




53
Chapter 8 - Improving Oral Health

Introduction

With the White Paper Choosing Health: Making Healthier Choices, the
Government initiated a programme to help people adopt healthier lifestyles. A
series of action plans were developed, including Choosing Better Oral Health: A
Oral Health Plan for England (November 2005).

The plan highlights:

     The significant improvements in oral health over the last 30 years, especially
     for children, but that there are still marked inequalities, linked to deprivation.
     The main causes of poor oral health.
     Key responsibilities of different organisations and groups, including Primary
     Care Trusts’ responsibilities to assess oral health needs, and commission
     appropriate services to tackle longstanding inequalities.
     Six key areas for action, and links to other health promotion programmes
     such as those to improve as diet and nutrition, and reduce smoking.
     Workforce requirements.

Local Dental Health

Child dental health in North Hampshire, Mid Hampshire and Blackwater Valley &
Hart is among the best in Hampshire as a whole and better than that of
England. Across the 3 PCTs 25 to 27% of five-year-olds having decayed,
missing or filled teeth (dmft) compared to 39% nationally.

Dental health surveys of children are undertaken regularly, as part of a national
programme. These enable dental health inequalities to be identified, and areas
of poor dental health targeted.

The National Oral Health Strategy (1994) targets for 2003 were that 70% of five-
year-old children should have had no decayed, missing (extracted) or filled teeth
(% dmft 0 = 70%) and that on average five-year-olds should have no more than
one decayed, missing (extracted) or filled tooth (mean dmft = 1). Local results
are shown in table 7.




54
Table 7: Decayed, Missing and Filled Teeth in 5-year-olds in Hampshire and
Isle of Wight (Care index = % mean dmft treated by filling)

                No examined Mean dmft              %dmft=0           Care index
England             159,524             1.47              61             13
South                29,453             1.11              67             16
HIOW SHA             15,733             1.14              68             14
Portsmouth            1,870             1.63              56             10
Southampton           2,166             1.51              63             11
Isle of Wight         1,163             1.32              66             13
E. Hampshire          1,667             1.31              63             12
Fareham       &       1,971             1.18              64             23
Gosport
New Forest            1211              1.02              70             16
Mid                   1549              0.99              70             14
Hampshire
Blackwater             232              0.95              73             13
Valley     and
Hart (sample)
Eastleigh and         1489              0.82              74             20
TVS
North                 1912              0.81              75             13
Hampshire
Source: 2002 dental survey of 5 year olds in Hampshire and Isle of Wight

Like many other diseases dental decay is a reflection of socio-economic
deprivation and the areas of worst dental health coincide with the most deprived
wards, where the prevalence and severity of dental disease are highest, and the
care index (reflecting dental treatment received, and thus access to and uptake
of care) is lowest. Dental decay at age five, in first teeth, is a statistically
significant predictor of decay at age twelve in permanent teeth.

A sample survey done in Blackwater Valley and Hart in 2003 found that in 8 out
of 24 schools the mean dmft score was 1.0 or higher. Almost 49% of children
attending schools in the Aldershot area had dental disease compared to just
over 17% in the Hart area.

This persisting problem of dental disease causes pain and sleepless nights for
young children and their families. The general anaesthetics necessary for dental
extractions, apart from being a traumatic experience for those involved, are a
significant cost to the PCT. Nationally, tooth extraction is the most common
reason for admission of children to hospital.

An increasing number of “dental phobic” adults seek dental care from the
Community and Personal Dental Services and such patients often cite an
unpleasant childhood dental experience as the cause of their fear of dentists.

Early extraction of first teeth frequently results in crowding and misalignment of
the second teeth, which then tend to drift forward in the jaw without the space-
55
maintaining and eruption guidance role of the first teeth.

Potential Solutions

Fluoride

Water fluoridation is the single most effective means of reducing dental health
inequalities. Children benefit most but adults benefit too, particularly those who
live most of their lives in a fluoridated area.

Fluoride can be made available to individuals via other mechanisms, but these
all require continuing positive personal action by the individual, a carer, or a
dental professional. Water fluoridation does not require any behavioural change
from its recipients, and studies comparing the cost-effectiveness of water
fluoridation with other strategies to reduce dental decay always conclude that
water fluoridation is generally the most cost-effective approach.

In north Hampshire dental health is generally good compared to the rest of
Hampshire and England, and so the overall need is low compared to other parts
of the county, albeit with demonstrable local inequalities. The water supply in
north Hampshire is dominated by bore hole supplies, which would mean a much
more complex and expensive delivery system for the fluoride; so it is less certain
that there would be a viable, cost-effective fluoridation scheme to implement
locally.

Given the lower need, doubt about a viable fluoridation scheme, current
resource constraints and imminent organisational changes, a pragmatic
approach suggested for now is “watchful waiting”. A repeat census survey of 5
year olds is due to be undertaken this year, and if this shows a widening in local
dental health inequalities and worsening in general dental health, then the Board
should have a more comprehensive debate about water fluoridation for the
community they serve.

Improving diet and reducing sugar intake

The frequent and high consumption of sugars is the major cause of dental
decay. Soft drinks, confectionery and biscuits are the main sources of sugars in
the diet. There is particular concern about pre-school children, adolescents and
older people (especially those in institutions).

Eating a healthy balanced diet which contains plenty of fruit and vegetables; is
low in fat, salt and sugar; and is based on whole grain products is important for
promoting good health generally. Snacking on fruit and vegetables rather than
snacks high in sugar can help to promote oral health and particularly help to
reduce the risk of dental caries.

Improving oral hygiene

Regular brushing of the teeth and gums from an early age with a fluoride

56
toothpaste will help prevent tooth decay and reduce gum disease. This can be
encouraged in a wide range of settings eg schools, Home Start groups and by a
range of professionals, often as part of more holistic health promotion activities.

Individuals in residential and care settings also need access to toothbrushing
facilities and need help to maintain oral hygiene

Reducing smoking

Tobacco use, especially smoking, increases the prevalence and severity of
dental and oral disease. It is the greatest risk factor for oral cancer, which is
increased further when combined with excessive alcohol consumption and poor
diet.
These risks can be reduced through the PCTs’ smoking prevention programme,
particularly supporting smokers to stop; and referring motivated smokers who
wish for help in stopping to local NHS Stop Smoking Services

Increasing early detection of mouth cancer

In 2000 there were nearly 2,300 new cases of oral cancer in the UK. It has a
high death rate, and survival rates increase dramatically if the disease is
diagnosed in its early stages. The five-year survival rate is over 80% when the
cancer is diagnosed at an early stage, but falls to below 20% when the tumour
has spread to other parts of the body.

Early detection by dentists and other primary care professionals should reduce
the high mortality rate.

Reducing dental injuries

Dental injuries may occur for a variety of reasons including playing contact
sports, violence and falls. These can be reduced by:
   creating safer environments for play, recreation and travel
   reducing trauma caused by violence and binge drinking
   implementing guidelines on first aid for dental injuries.


Recommendations

     Focus preventive actions on common risk factors as recommended in
     Choosing Better Oral Health, particularly on programmes to improve diet and
     nutrition, and to reduce smoking and alcohol misuse. These should be
     targeted towards areas where greater health inequalities have been
     identified. There should also be more information and education on the
     importance of oral health

     Ensure the PCT commissions dental services, which have an evidence
     based preventive focus and that are targeted towards the areas of greatest
     need
57
     Review the results of the 2006 dental health survey when available and if the
     prevalence of disease is increasing and the inequalities widening then the
     PCT Board should consider the option of water fluoridation.


Sources of Information

        Choosing Better Oral Health: An Oral Health Plan for England (November 2005).
        http://www.dh.gov.uk/PublicationsAndStatistics/Publications/PublicationsPolicyA
        ndGuidance/PublicationsPolicyAndGuidanceArticle/fs/en?CONTENT_ID=41232
        51&chk=63f8EG

        2002 dental survey of 5 year olds in Hampshire and Isle of Wight




58
Chapter 9 - Health Protection for Children and Young People

The Hampshire and Isle of Wight Health Protection Unit is part of the national
Health Protection Agency (HPA) which was established in 2003 to be the
national expert agency for public health issues concerned with infection,
chemicals and radiation. The HPA has brought together staff previously
employed in the public health departments of PCTs and Health Authorities
undertaking communicable disease with staff from former organisations such as
the Public Health Laboratory Service and the National Radiological Protection
Board.

The Health Protection Unit contributes to the control of communicable diseases
by receiving reports of infectious diseases from doctors in primary care and
hospitals and also laboratory reports of infections with public health implications.
Diseases requiring public health input include food poisoning, meningitis, TB
and hepatitis. Other infections which are reported include vaccine preventable
diseases such as measles, mumps and whooping cough. The reporting of
vaccine preventable infections is important as it informs national immunisation
policy.

Table 8 indicates the infectious diseases reported during the period 2004 to
2005 for children under the age of 17 years. Neighbouring local authorities are
included for comparison.




59
Table 8: Notification of infectious diseases in children 0-17 years 2004-2005
Disease notified to Health Basingstoke Part                of Hart      Rushmoor
Protection in children aged and Deane East
under 17 years in 2004/5                          Hants DC
                                                  within
                                                  NHPCT
                                                  area
Total cases of food poisoning: 54                 25          24        23

Campylbacter                       28          16          9         5
Cryptosporidia                     10          2           3         3
Esch col 0157                      1           1
Giardia                                        1           5


Salmonella spp/enteriditis         11          4           3         8
Salmonella chester                                                   1
Salmonella java                                1
Salmonella Lexington               1
Salmonella orienburg                                                 1
Salmonella typhimurium             2                       1         4
Salmonella unnamed                 1
Salmonella virchow                                                   1

Total salmonellae                  15          5           4         15

Organism        not    specified                           3
(clinical diagnosis)
Typhoid                                                              1
Dysentery due to
Shigella boydii                    1
Shigella flexneri                              2
Shigella sp                                                          1

Mumps *                            17          15          17        10
Measles *                          8           5           6         5
Rubella*                           9           2           4         5
Whooping cough                     2                       1
Scarlet fever                      7           3           4         3
Tuberculosis                       2           1           1
Meningococcal                      1           1           1         1
meningitis/septicaemia
Pneumococcal meningitis            3

* Salivary testing kits were sent to notified cases for microbiological
confirmation. There were no microbiologically confirmed cases of measles or
rubella in 2004/5.

Although there is likely to be underreporting of infections, trends can be seen
60
when comparing figures over time.

Mumps

During 2004/5 it became apparent that there was a significant increase in
mumps which was also occurring nationally. The increase in mumps was most
marked in the 16-24 year old age group and was due to this age group not
having had 2 doses of a mumps containing vaccine nor had they acquired
natural immunity through having mumps infection as children. The PCT
facilitated mumps immunisation by funding GPs to give MMR for this age group.
An outbreak occurred at Farnborough Sixth Form College and students were
offered MMR by the school nursing team. The mumps outbreak peaked in the
summer of 2005. During July 2005, an MMR open session was held at Frimley
Children’s Centre. There was general publicity in the local media and through
schools to encourage MMR uptake, particularly in the school leaving year.
Higher education students were recommended to have MMR immunisation prior
to starting courses in autumn 2005.
Figure 29 shows cases of mumps notified in the BVHPCT area during 2004/5.


Figure 29: Mumps cases notified in Blackwater Valley and Hart PCT in 2004/05
                                      Mumps notications: BVHPCT

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                                                                                   25 and over
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                               2004                                  2005
                                            Week




Childhood immunisation

Childhood immunisation is the single most important preventative measure for
childhood infections. During 2004, changes were made to the routine
immunisation programme. These included changing the type of whooping cough
vaccine from a whole cell vaccine to an acellular vaccine. This meant that fewer
reactions would occur and that the vaccine would be even more effective.
61
Another change was the replacement of the live oral polio vaccine with an
inactivated polio vaccine given by injection. This meant that the exceedingly
rare possibility of a polio type of illness being caused by the live oral vaccine
was removed. Unlike older injectable polio vaccines, the new injectable polio
vaccine is at least as effective as the oral vaccine.
These changes have been implemented and the medical reasons which
preclude children from having particular vaccines have been reviewed. There
are now very few reasons indeed why children cannot benefit from the
immunisations.
Immunisation data is recorded quarterly. Table 9 indicates the immunisation
uptake percentages in BVHPCT area. For comparison the average figures for
the south east region are included. However the data is only a snap shot in time
and figures for other quarters will be slightly different.

Table 9: Immunisation data for the quarter April 05 to June 05

           Diphtheria Pertusssis Tetanus        Polio    Hib      Men      MMR
                                                                  C
Children
aged 12
months
SE       91.6%          91.5%        91.6%      91.3%    91.4% 91.3%
average
BVHPCT 93.4             93.4         93.4       93.4     93.4     92.7

Children
aged 24
months
SE       93.8           93.5         93.8       93.6     93.7     93.5     82.2
average
BVHPCT 93.2             93           93.2       93.2     92.7     92.7     84.7

Children   Diphtheria Diphtheria Pertussis Hib           Men      MMR      MMR
aged 5y    3 doses    4 doses                            C        1dose    2doses
SE         93.7       81.9       93        93.3          91.7     88       74.2
average
BVHPCT     93.7         79.9         93.5       93.9     93.2     87.8     74.1


The immunisation uptakes in BVHPCT area are slightly higher than the regional
average at age 12 months and are around average at later ages. Nationally the
MMR uptake data continues to give cause for concern and higher coverage is
needed if measles outbreaks are to be prevented in the future.

Hib infection

Hib infection is caused by the Haemophilus influenza type b bacteria. These
infections occur typically in young children under the age of 4 and cause serious
illness such as meningitis, epiglottis (swelling of the throat affecting breathing)
62
and septic arthritis. Through the notification system for infectious diseases, it
became apparent that cases of Hib infection were occurring in children who had
been fully immunised. This resulted in a catch up campaign in 2003 to give an
extra dose of Hib vaccine to increase the protection of children against this
potentially fatal infection. Changes in the childhood immunisation schedule are
planned in 2006 to continue to protect children against Hib infection.

Chickenpox immunisation

Chickenpox immunisation is not offered routinely to children in the UK, although
it is given to children in the US. A new development during 2004/5 was the
national recommendation that health care workers should be offered
immunisation if they were not already immune. The priority groups for
immunisation were staff working with children, pregnant women and
immunosuppressed patients in whom chickenpox can be a very serious illness.
Exposure to chickenpox in pregnancy can have serious consequences
depending on the stage of pregnancy. Chickenpox immunisation of health care
workers has yet to be fully implemented.

Meningitis

Meningitis symptoms such as headache and neck stiffness can be a feature of
viral illnesses and are not reflected in the above figures. During 2004/5 there
were no deaths due to meningococcal infection in children.
It can be seen that the uptake of meningitis C vaccine is high.
Cases of pneumococcal meningitis continue to occur. During 2004/5 only a very
small number of children with special medical conditions were immunised
against pneumococcal infection. It is planned to introduce pneumococcal
vaccine as a routine childhood vaccine in 2006.

Tuberculosis

Tuberculosis (TB) is rare in children locally and indicates recent infection. The
Health Protection Unit undertakes contact tracing to try to identify the source of
infection if a case occurs in a child.
During 2004/5 BCG vaccine was offered to children born to parents from
countries with a high prevalence of TB. Adolescents were also offered BCG in a
routine schools based programme. In 2005 the schools BCG programme was
stopped nationally due to the changing epidemiology of TB. BCG immunisation
is now only recommended for infants and children with parents or grandparents
born in higher risk countries. In addition, some children may need BCG if they
will be at increased risk of TB due to travel abroad.

Hepatitis and HIV

An antenatal screening programme has been in place since 1999 so that
pregnant women are offered screening for hepatitis B and HIV. If women are
found to be positive, measures can be taken to greatly reduce the risk of
passing on the infection to the unborn child. This programme has a high uptake

63
rate.
Unlike most other countries in Western Europe and the US, all children are not
routinely immunised against hepatitis B. This situation is being kept under
review and it is possible that the immunisation could be introduced in the future.
As hepatitis B can be transmitted sexually, immunisation before sexual maturity
would be most effective.

Chlamydia and sexual health

Chlamydia is a bacterium which causes sexually transmitted infections.
Complications include pelvic inflammatory disease, ectopic pregnancy and
infertility. Screening programmes targeting young sexually active people
typically find around 10% to be infected. It is estimated that 1% of the general
female population aged 16-19years and 1% of the general male population aged
20-24 years are infected. . As 70% of chlamydia infection in women is
asymptomatic it is important to actively screen young people rather than relying
on people presenting with symptoms. The BVHPCT area will be offering
chlamydia screening in the future as part of the roll out of the National
Chlamydia Screening Programme.
There is currently interest in vaccines which could be given in adolescence to
help protect against sexually transmitted viruses linked to cervical cancer.

Outbreaks

The Health Protection Unit regularly advises on outbreaks or infectious disease
incidents affecting nurseries and schools. These include viral diarrhoea
outbreaks and cases of infectious disease such as mumps, scarlet fever,
measles, hand foot and mouth disease. During the mumps increase, several
nurseries had cases in their younger members of staff and were concerned for
the babies and young children in their care who were too young to have MMR
immunisation.
The Health Protection nurses are also able to advice nurseries on infection
control procedures to help prevent the spread of infection. An audit was carried
out of nursery immunisation policies. This showed that not all nurseries had up
to date immunisation records for children or staff.

Headlice and scabies

The Health Protection Unit continued to receive enquiries regarding head lice
and scabies and works with schools and primary care to help resolve intractable
head lice problems. Most scabies enquiries concern older people in care homes
but occasionally children are overlooked when a case of scabies in diagnosed in
an adult in their household. It is important with scabies that all skin to skin
contacts are treated. Scabies incidents in nurseries are very uncommon.

Recommendations

      Prompt reporting of notifiable infectious diseases to the local Health
      Protection
64
      Prompt discussion with Health Protection of any incident with public
      health implications. This includes infectious and non-infectious
      environmental hazards e.g. chemical incidents, unexplained clusters of
      unusual illness patterns, outbreaks in nurseries and schools.
      Work towards introduction of Chlamydia screening programme for 16 to
      24 year olds in BVHPCT area.
      Continuing efforts to increase the MMR coverage and to identify children
      who would benefit from BCG following abolition of schools programme.
      Continuing high immunisation uptake when implementing new
      immunisation regimes


Sources of Information

      Communicable Disease and Public Health, Tompkins et al, 1999

      Immunisation Against Infectious Disease - "The Green Book",
      http://www.dh.gov.uk/PolicyAndGuidance/HealthAndSocialCareTopics/GreenBo
      ok/fs/en




65
Appendix 1

Child health: the policy context

Child health has improved considerably over the last century, but health
inequalities remain and present a major challenge to policy makers, the health
sector and partner agencies that provide services to children. Some striking
facts illustrate the magnitude of the problem. The general experience in north
and mid Hampshire mirrors statistics from the 2005 SE regional report on child
health and wellbeing which reveal that:

       more than 10% of children in the SE region live in workless households,
       and almost one in 5 in lone parent families
       substantial numbers of primary and secondary school pupils fail to
       achieve developmental milestones though general educational attainment
       is good
       a large proportion of children do not eat healthily and almost 30% of
       young adults smoke cigarettes
       teenage pregnancy rates are among the highest in European countries,
       and vary 3-fold
       substantial numbers of children have a long term illness which limits daily
       life

Recent national policies set a strong strategic direction for regional and local
delivery programmes. Government announced specific targets in the 2004
spending review and in 2005 changes to local government structures
strengthened leadership for children's services and how they are delivered.

Overarching National Policies

       Child Poverty Review
       Every Child Matters and the Children’s Act
       National Service Framework for Children, Young People and Maternity
       Services
       Tacking Inequalities in Health

Child Poverty Review

In 2004 the Treasury published the Child Poverty Review. The review
concluded that the most efficient and sustainable way of reducing child poverty
involved:

1    Ensuring decent family incomes through full employment and a modern tax
     and benefit system
2    Helping unemployed parents into work through active labour policies,
     making work pay, supporting family friendly working practices, tackling the
     barriers to employment, and helping progression in work
3    Support for the parenting role
4    Delivering excellent public services for children and improving access.
66
Every Child Matters and the Children Bill

This policy was a direct result of tragic death of Victoria Climbie from protracted
and repeated abuse. Lord Laming, who led the enquiry, emphasized the need
to tackle systemic problems that had affected numerous other children and been
identified repeatedly in similar enquiries over the last 20 years. The repeated
failure of statutory agencies to intervene early in the course of these injuries and
their inability to work collaboratively was noted in detail. The appalling
consequences and the long list of failures resulted in a wide ranging series of
recommendations. Every Child Matters identified five outcomes important to all
children and young people:

• enjoying good physical and mental health, and living a healthy lifestyle
• staying safe, protection from harm and neglect, and being able to look after
themselves
• enjoying and achieving, getting the most out of life and developing broad skills
for adulthood
• making a positive contribution to society and not engaging in antisocial
behaviour
• achieving economic well-being.

It also set out a framework that covers the full scope of services for children and
young people, building on existing initiatives and introducing new policy. The
Children Bill that followed the inquiry places a formal duty on agencies to
collaborate and work together to deliver common outcomes for children. It
focuses on:

• interagency working with agreed shared outcomes across services
• an independent champion for children
• more robust and effective local partnerships
• reforms to safeguard children
• new approaches to commissioning children’s services and the development of
children’s trusts
• local authorities appointing a director of children’s services with responsibility
  for both education and children’s social services
• a lead council member for children
• an integrated inspection framework
• intervention powers
• formal protocols for sharing information

The policy has been implemented by Hampshire County Council, with
supporting systems of change, workforce development and capacity building to
ensure information sharing and common assessment systems for children. The
programme has included significant engagement of partner agencies and early
work to consult with children and develop systems that enable them to have a
greater influence on policy making and service reform.               Successful
implementation of the policy should not only protect children at risk of non
accidental injury, but also improve child health and help to tackle wider health

67
inequalities.

National Service Framework (NSF) for Children, Young People and
Maternity Services

The NSF was published in September 2004 and includes a total of 11
standards. It adds to the suite of national service frameworks produced by the
NHS over the last seven years. The first five standards are "core" standards
that apply to all children and young people; the next six apply to specific health
services or circumstances. The core standards include:

1.   promoting health and well-being, identifying needs and intervening early
2.   supporting parents
3.   child, young person and family-centered services
4.   growing up into adulthood
5.   safeguarding and promoting the welfare of children and young people

Specific standards

1.   children and young people who are ill
2.   children and young people in hospital
3.   disabled children and young people and those with complex needs
4.   mental health and psychological well-being of children and young people
5.   medicines for children and young people
6.   maternity services.

The National Service Framework is less specific in the definition of service
standards than some of the other NSFs. It adopts a broader approach that
requires services to:

• give children, young people and parents increased information, power and
  choice over the support and treatment they receive, and involve them in
  planning their care and services
• introduce a new health promotion programme designed to promote the health
  of children from pre-birth to adulthood
• promote physical health, mental health and emotional well-being by
  encouraging children and families to develop healthy lifestyles
• focus on early intervention based on timely and comprehensive assessment
• improve access to services for all children according to their needs, particularly
  by co-locating services and developing managed local children’s clinical
  networks for children who are ill or injured
• tackle health inequalities, addressing the particular needs of children and
  families who are likely to achieve poor outcomes


Tackling inequalities in health

The tackling health inequalities programme for action was published in 2003 and
set out plans to tackle health inequalities over a three year period. It established

68
the foundations needed to achieve the national target for 2010 to reduce the gap
in infant mortality across social groups, and raise life expectancy in the most
disadvantaged areas faster than elsewhere. Short-term interventions were
proposed to tackle the child health inequalities:

• improving the quality and accessibility of antenatal care and early years
  support in disadvantaged areas
• reducing smoking and improving nutrition in pregnancy and early years
• preventing teenage pregnancy and supporting teenage parents
• improving housing conditions for children in disadvantaged areas

Specific Policy Areas

These specific areas fit within the broader policies described above. They tackle
areas that act as specific determinants of health, with direct impacts on the
health and wellbeing of children. They cover:-
       housing
       education
       road safety
       choosing health delivery programme
       mental and physical health promotion


Homes and Sustainable Communities

The five year plan "Sustainable Communities Homes for All" was produced in
January 2005. The plan aims to:

1. Make sure that there are enough high quality homes across the whole
   spectrum of housing - owner-occupied, social rented and private rented
2. Make sure that all social tenants, and seven out of ten vulnerable people in
   the private sector, have a decent home
3. Provide for those who need more support to meet their housing needs and
   aspirations, including halving numbers in temporary accommodation
4. Provide for those who choose alternative types of accommodation, such as
   Gypsies and Travellers, but crack down on unauthorised development
5. Create sustainable, mixed communities in both rural and urban areas, with
   the jobs, services and infrastructure they need to thrive

The Government regards sustainable communities as those which provide:

1. opportunities for cultural, leisure, community, sport and other activities,
including for children and young people
2. user-friendly public and green spaces with facilities for everyone including
children and older people
3. high quality services for families and children (including early years child care)




69
Education

Educational attainment has a positive impact on the health of individuals and
communities. The Department for Education and Skills has published a five
year strategy for children and learners which promote improved secondary
schools with more flexibility and a much wider choice for young people from age
14 to enable them to get the skills they need to obtain good jobs. The
opportunity to improve health through every area of school life was emphasised
in the Healthy Living Blueprint published by the Secretary of State for Education
in September 2004. The objectives in the Blueprint promote a whole school
approach, an environment conducive to healthy living and full use of the
curriculum to enable understanding of healthy lifestyles including:

• food and drink in schools
• school sport and physical activity
• behaviours which affect lifelong health.

The five year strategy and the Healthy Living Blueprint expect every school to
become a healthy school with the national healthy schools programme central to
this vision. This will enable all schools to benefit from the positive impact of the
healthy schools programme.

Road Safety

Road traffic accidents are the leading cause of accidental injury amongst
children and young people. Every year, over 130 children die and more than
4,500 are seriously injured while walking and cycling, many of them close to
their homes. Another 60 die and over 1,100 are seriously injured travelling in
cars. Children should be able to walk and cycle in safety. They need the
freedom to use the roads for their social development and the exercise for their
general health and fitness. "Tomorrow’s Roads: Safer for Everyone" is the
Government’s road safety strategy which sets out detailed policies on how it
plans to make the roads safer for everyone. Transport plans are being reviewed
this year by many statutory agencies, and schools need to seize this opportunity
to encourage healthier and safer travel patterns between home and schools.


Mental Health

The National Service Framework for mental health covers health promotion,
assessment and diagnosis, treatment, rehabilitation and care, and encompasses
primary and specialist care and the roles of partner agencies. The Framework
touches on the needs of children and young people, highlighting areas where
services for children and adults interact, for example the interface between
services for 16 - 18 year olds, and the needs of children with a mentally ill
parent. NICE, the national guidance programme for the NHS has also produced
recent guidance on the diagnosis and management of mental illness in children.
This emphasised the need to improve diagnosis and focus on non drug
therapies in depressive illnesses.

70
 Choosing Health

Choosing health - making healthy choices easier was published in 2005. This
lays out a comprehensive public health programme for the public health White
Paper for England and a national and local delivery plan including targets to
improve people’s chances for better health and reduce health inequalities
through the PSA (Public Service Agreement) framework.

There are major strategic plans for
  Reducing smoking
  Reducing obesity and improving diet and nutrition
  Increasing Exercise
  Encouraging and supporting sensible drinking
  Improving mental health
  Improving sexual health

There are a number of modular programmes for specific public health action.
For example, ‘Choosing Activity’ a physical activity action plan for England lays
out an extensive range of commitments which seek to achieve a more active
and healthier population. The goals of the plan include encouraging activity in
early years, schools, further and higher education and extending use of
education facilities as a community resource for sport and physical activity,
including out-of-hours use. In 2004 the Government also published Choosing a
Better Diet: a food and health action plan which aims to improve diet and
nutrition in England and to contribute to a reduction in cardiovascular disease,
cancers and in particular obesity, which is a major risk factor for diabetes, heart
disease and some cancers. The plan includes actions to improve early year’s
nutrition and nutrition in schools.




71
Appendix 2

Local Public Service Agreement (LPSA) to tackle childhood obesity

The Target

The LPSA2 target is to improve the health of children under 11 years, by
reducing overweight and obesity. The table below shows the current levels of
overweight and obesity among children in Hampshire modelled from the Health
Survey of England. It also illustrates the levels of obesity expected by 2010
without the LPSA2.

Age                 2005                 Expected levels of   % increase
                                         obesity by 2010
                                         without the LPSA2
4-5 Obese           11.8%                13.3%                1.8
4-5 Overweight      24.8%                25.8%                1.2
6-7 Obese           14.4%                16.9%                3.0
6-7 Overweight      28.7%                33.2%                5.4
8-10 Obese          17.9%                21.4%                4.2
8-10 Overweight     34.0%                39.0%                6.0

Source: Health Survey for England 2003 applied to Hampshire County Council
small area statistics

The table below shows the current levels of obesity and overweight for the under
11 age group in Hampshire
                Current              Performance          Performance       to
                Performance     in expected in Under achieve with the
                Under 11s            11s without the LPSA2
                                     LPSA2                (percentage points
                                                          decrease shown in
                                                          brackets)
Obese           15.5%                17.7%                14.5 (3.2)
Overweight      20.8%                26.5%                19.8 (6.7)

Indicators(s) by which the childhood obesity performance will be measured;
    1. The percentage of children aged 10 and 11 (Year 6) that are classified as
       obese1 in targeted schools.
    2. The percentage of children aged 10 and 11 (year 6) that are classified as
       overweight2 in targeted schools.
    3. The number of schools achieving National Healthy School Status3 in the
       National Healthy School Programme.
1
   'Obesity' is defined in this target as above the 95th centile of the 1990 UK
reference data.
2
  'Overweight' is defined in this target as above the 85th centile of the 1990 UK
reference data and below the 95th centile.
3
  Indicator refers to 2005 National Healthy Schools Status (NHSS) Criteria. To
72
achieve the target the school must have evidence of the Core Themes of
Healthy Eating and Physical Activity.

Hampshire Partnership LPSA 2005-2010 Participating Schools

While all state schools in the PCT will be targeted for weight measurement and
the national healthy schools programs, the LPSA target will focus on targeted
schools. These are tabulated below.

Chineham Park Primary, Basingstoke                   Basingstoke    District
Marnel Community Infant School, Basingstoke          Council
Merton Infants, Basingstoke
Merton Junior School, Basingstoke
South View Infant, Basingstoke
Icknield Special School, Andover                     Test Valley Borough
Knights Enham Infant School, Andover                 Council
Knights Enham Junior, Andover
Norman Gate, Andover
Shepherds Spring Junior, Andover
Farnborough      Grange     Nursery/Infant School,   Rushmoor      Borough
Farnborough,                                         Council
Fernhill Primary School, Farnborough
Grange Comm.Junior School, Farnborough
Winnall Primary, Winchester                          Winchester        City
All Saints CofE Primary, Winchester                  Council




73
Appendix 3

Crime and Disorder Reduction Partnerships

On 30 April 2004, Primary Care Trusts (PCTs) in England became “responsible
Authorities” under the Crime and Disorder Act 1998, amended by the Police
Reform Act 2002. A joint Home Office and Department of Health guidance has
been produced to support the new requirements.

This means that PCTs now have a statutory responsibility to work in partnership
with other responsible authorities, namely the police, fire authority and local
authorities and co-operating bodies to tackle crime, disorder and substance
misuse.

The act places a duty on PCTs to participate in an audit of crime and disorder,
anti-social behaviour and drug and alcohol misuse for the Crime and Disorder
reduction Partnership (CDRP) areas in their locality; and to contribute to the
development of local strategies that effectively deal with the issues which are
identified.

The extent to which the PCT is involved in the delivery of the strategy is
determined through local negotiation and it is likely to be in areas where the
delivery of action on substance misuse and crime and disorder makes a
significant contribution to the PCTs own priorities, e.g. alcohol related issues.

The PCTs are encouraged to adopt the principle of preventing crime and
disorder by building crime reduction considerations into planning,
commissioning, and policy and service delivery.

Epidemiology and Impact of alcohol misuse

The general make-up of crime calls for a multidisciplinary actions. Alcohol
related violence and other anti social behaviour represents significant public
health challenges. While more attention is given to provision of services for drug
misuse, alcohol misuse has not received a similar consideration.
Alcohol is second only to tobacco as the main cause of preventable premature
death in the UK 1 . The financial burden of alcohol misuse is around £1.7 billion
annually to the NHS and over 2 £10 billion to society as a whole 3 .
The cost of treating physical injuries resulting from domestic violence was
estimated at £1.2 billion a year (2004). Other impacts of alcohol misuse include:

           Nearly half the victims of violent crime described their attacker as being
           under the influence of alcohol at the time 4 .
           About 2 in 10 male prisoners and 1 in 10 female prisoners reported that
           their drinking had caused injury to self or others in the year before coming
           into prison 5 .
1
     RCP response to “Choosing Health”. RCP Website April 2005
2
    -9 DH, Delivering Choosing Health 2005

74
       Up to 17 million working days are lost annually due to alcohol-related
       absence 6 .
       Over a million of children are affected by parental alcohol problems in the
       UK and a quarter of children under 16 drink alcohol on average 10 units
       per week 7 . Hampshire alcohol harm reduction strategy (Draft) 2005-2008
       showed 52% of young people aged 11-18 drink alcohol on regular basis.
       Alcohol misuse is a major cause of attendance and admission to general
       hospital in both, accident and emergency/trauma and non-emergency
       settings. This leads to 150,000 hospital admissions and 15,000-22,000
       deaths a year. Evidence suggests 70% of accident and emergency
       attendances during the night are alcohol related.

Anti-Social Behaviour Orders (ASBOs)

ASBOs are civil orders that protect the public from behaviour likely to cause
harassment, alarm or distress. They are not criminal penalties and are not
intended to punish the offender.
Crime and Disorder Act 1998, enables an ASBO to be made against anyone
aged 10 years or more where:
       The person has acted in an anti-social manner which has caused or is
       likely to cause harassment, alarm or distress to one or more persons not
       of the same household; and
       Such an order is necessary to protect persons in the area from anti-social
       acts.
Applications for ASBOs can be made by local authorities, the police, British
Transport Police, county councils, Registered Social Landlords and Housing
Action Trusts or by other relevant authorities as prescribed by the Secretary of
State.

Anti-social behaviour may include harassment, joyriding, verbal abuse, criminal
damage, vandalism, substance misuse, graffiti, assault, intimidating behaviour,
smoking or drinking whilst underage, engaging in threatening behaviour in large
groups.
The Crime and Disorder Reduction Partnership encourages the members of the
public to actively be part of improving the quality of life in their areas. They take
all reported incidents of anti-social behaviour seriously and use various
intervention models to prevent the “offender” entering criminal justice system
prematurely.

Anti-Social Behaviour Orders (ASBO) are not, as the media suggest easily
obtainable. They involve a very complex process and proof of evidence of anti-
social behaviour from more than just one source.
An alternative to an ASBO is an Acceptable Behaviour Contract (ABC) which
enables conditions to be placed upon individuals restricting their behaviour. The
signing of an ABC is voluntary but a breech could give supporting evidence




75
towards an ASBO. As with an ASBO records of anti-social behaviour are
required.

Prolific and Priority Offenders Scheme (PPO)

It is estimated that out of a million active offenders, 100,000 offenders have 3 or
more convictions and are responsible for half of all crime. The active offender
population is not static, 20,000 individuals leave this pool every year and are
replaced by another 20,000 offenders. The most active 5,000 of this group are
estimated to be responsible for one in ten offences and on 30th March 2004, the
Prime Minister announced an end to end strategy to address this group of
offenders. The strategy has 3 complementary parts:
        Prevent and Deter - to stop people (overwhelmingly young people)
        engaging in offending behaviours and graduating into prolific offenders;
        Catch and Convict - actively tackling those who are already prolific
        offenders; and
        Rehabilitate and Resettle - working with identified prolific offenders to
        stop their offending by offering a range of supportive interventions.
        Offenders will be offered the opportunity for rehabilitation or face a very
        swift return to the courts.




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