Local Public Health Strategic Framework - Health in Wales

Version: 2

Local Public Health Strategic Framework Date to be reviewed:

Author(s):

Update and further refresh by May 2013 Note: September 2013 – LPHSF now incorporated into 3 Year Plan Jo Charles Dafydd Gwynne

No of pages:

41

Author(s) title:

North Wales Public Health Team

Andrew Jones

Executive Director of Public Health, BCUHB

Responsible dept / director: Approved by:

Executive Director of Public Health

Date approved: Endorsement by: Date endorsed: Date activated (live):

26th April 2012

Betsi Cadwaladr University Health Board

PROPRIETARY INFORMATION 1

This document contains proprietary information belonging to the Betsi Cadwaladr University Health Board. Do not produce all or any part of this document without written permission from the Betsi Cadwaladr University Health Board

Contents

Section

Title

Pages

1

Introduction and Background.

3-10

2

Driver Diagrams

10-15

3

Outcomes and Indicators

16-38

4

Demonstrating progress: Developing an outcomes-focussed approach for service planning

39-41

2

Section 1 This document presents a “refresh” of the Betsi Cadwaladr University Health Board Local Public Health Strategic Framework (LPHSF) submitted to Welsh Government in May 2011. In line with the guidance issued by the Chief Medical Officer in February 2012, we have chosen to take a “light touch” approach to the refresh of the Framework for 2012/13. This is in recognition of the fact that discussions are currently ongoing about the structure of key North Wales strategic partnerships, and future structures will offer new opportunities to streamline and strengthen our collective approach to population health improvement. This collective approach will need to be jointly developed and agreed by the Health Board, Local Authorities, other Public Sector bodies and voluntary / third sector partners. Further discussion is required with partners, once the partnership arrangements are clear, to agree the appropriate mechanisms whereby this can take place

1. Our Triple Aim As a Health Board, we have adopted the Triple Aim concept developed by the Institute of Health Improvement to guide the development of all our strategies and action plans. As the figure below illustrates, this has population health at its heart. IMPROVING THE HEALTH OF OUR POPULATION

WHAT PEOPLE WHO USE OUR SERVICES EXPERIENCE

THE COST OF DELIVERING SERVICES

3

2. Underpinning Themes As noted in the first iteration of our LPHSF, we suggest that the reduction of inequalities and inequities in health is a common aim running through each of the 10 areas in Our Healthy Future, rather than a separate area. For us, there is a key distinction between inequality and inequity: Inequality simply means there is a difference which may be largely unavoidable Inequity, however, suggests there is a remedy which has not been applied, and that the situation is thus unnecessary and avoidable, as well as unjust and unfair Implicit within this definition is the recognition that particular groups within the population are more likely to experience inequality and inequity than others. We have increasingly strong evidence and information supporting the association between socio-economic deprivation and inequality. Just as important, though considerably less well evidenced and with a paucity of data and information, is the inequality which can be experienced by individuals and groups covered by the protected characteristics defined by the Single Equality Duty (Age, Gender reassignment, Sex, Race, Disability, Pregnancy and Maternity, Sexual Orientation and Religion or belief). A key function of the LPHSF must be to explicitly support the Health Board and its partners to positively contribute to a fairer society through advancing equality for all through all aspects of their service delivery. Development work we have undertaken on the theme of Mental Well Being over the past year has begun to suggest to us that this theme may also be best seen as underpinning common aim running through many of the remaining 8 areas. The advantages of this, and its consequences for implementation, will be further explored during the coming year. Development has also taken place locally, in line with existing, and in anticipation of, further national work described in Fairer Health Outcomes for All, on the subject of Health Literacy. Optimal health literacy is an asset needed by everyone in order to exert greater control over their own health and over the range of personal, social and environmental determinants of health (Nutbeam 2008). It is specific to various health related contexts such as the day to day management of health, appraising the risks and benefits of screening and immunisation, managing chronic and acute illness, making decisions about clinical interventions and responding to environmental public health issues. Improved health literacy has the potential to impact significantly on the achievement of public health priority targets linked to tobacco, alcohol, obesity, sexual health and the early years setting. It also supports mental wellbeing, as health literacy is a key factor in maintaining control over

4

day to day health and general wellbeing, it is an asset to be drawn upon to manage illness and it contributes to confident participation and engagement with health services. Building on initial development work over the past year, during 2012 – 2013 we will explore further the benefits and opportunities to promote greater awareness and understanding of both mental well being and health literacy as fundamental building blocks of health improvement both for individuals and communities.

3. Our First Local Public Health Strategic Framework The first iteration of our LPHSF had introductory sections which outlined: What a LPHSF was and why it was needed; How the LPHSF had been developed; What the role of Public Health Wales was in the development of the LPHSF; How the delivery of the Framework would be managed and monitored; and The use of an approach known as Results Based Accountability (RBA) in formulating the Framework. These sections are not repeated here but remain relevant in establishing the context for the development of our Framework.

OUR FRAMEWORK What are we seeking to achieve for our population? People in North Wales have increased years of healthy life and fairer outcomes. As outlined in Fairer Health Outcomes for All, the aspiration for the whole of Wales is that by 2020 healthy life expectancy will be improved for everyone, and the gap between each quintile of deprivation will be closed by an average of 2.5%.

5

What will it look like when we have achieved this? As our focus will be on the whole population, it will need to cover each of 5 life course stages. We will know when we have achieved this, when all: Babies are born healthy Pre-school children are healthy, safe and develop to their full potential School-aged children and young people are safe, healthy and equipped for adulthood Working age adults live healthier lives for longer Older people age well in to their retirement (Adapted with permission from DPH Annual Report Aneurin Bevan Health Board)

Our Healthy Future has prioritised common causes / determinants which can have a significant impact on each of these, and these will also be indicators of success we can use. This will mean that: People do not smoke o Young people in North Wales do not start smoking; o Smokers in North Wales give up smoking; o Residents in North Wales live their lives in smoke free environments People maintain a healthy weight o People are physically active and o People eat a healthy balanced diet People who drink alcohol do so within recommended guidelines People do not take illegal drugs o Young people do not start taking illegal drugs; o People taking illegal drugs stop taking them and / or o Harm is minimised for those taking illegal drugs Women under 18 do not become pregnant People experience good mental health People do not self harm or take their own life Children and young people are not killed or injured in accidents 6

Older people do not fall Older people are protected by being vaccinated against influenza Children are protected against illness by being vaccinated

3.1.

Driver Diagrams

At the heart of the first LPHSF we developed a series of 5 Driver Diagrams, one for each of the Life Course stages. These were designed to capture the logic and thinking behind Results Based Accountability (RBA), the outcomes based approach on which we have modelled the Diagrams, but presented in a format more akin to the style used by the Health Board to describe its other key improvement work. Presentation and use of the Driver Diagrams in a wide variety of Health Board, Local partnership and public settings has resulted in very positive feedback, and therefore, with only slight adjustment these remain at the heart of our Framework document. They are included here in Section 2.

The edited Driver Diagram below illustrates key points about how outcomes based thinking works in this framework: Box A – summarises things which we know will work to ensure the delivery of both the Primary Drivers and the Outcomes and Indicators (Box B). All we need to know at service delivery level, therefore, is that these are being delivered appropriately to the whole population, recognising that “one size does not fit all”. Some of the actions relate solely to the NHS; others to Local Authorities or other partners – what matters is that the contribution of each service or function is delivered and recognised. Here, the question “How well?” relates in part to appropriate targeting of interventions to address differing levels of need relating to, for example, individuals or groups with recognised protected characteristics as defined by the Single Equality Duty, or those living in deprived circumstances.

7

3.2.

Other sections

The first LPHSF also included additional sections accompanying each Life Course stage. These focused on the proposed Outcomes and Indicators; discussion on the data available to monitor delivery of the primary drivers; description of those who have a contribution to the delivery of specified high level evidence based actions; and finally a summary of milestones for achievement during 2011/12.

8

We have redesigned the section on Indicators and Outcomes and present this at Section 3 which describes, where available, progress over time both at North Wales and at Local Authority Level. Work is ongoing both locally and nationally to further refine these, and to enhance the monitoring and reporting of progress against the primary drivers. Section 4 concludes this document by providing an overview of how the LPHSF aims to demonstrate progress by focussing on developing an outcomes-focused approach to service planning. A list of key milestones to be achieved within 2012/13 is provided as a separate attachment to this document.

4. Monitoring and reporting Current requirements for reporting progress against the delivery of our LPHSF are that 6 monthly reports are submitted to the Chief Medical Officer‟s department, for the period up to the end of September and the period up to the end of March. Internally, these will also be reported, by the Executive Director for Public Health, to the Health Board‟s Quality and Safety Committee. There are elements within the LPHSF which inevitably overlap with both the delivery and reporting requirements of a number of other key Health Board strategies, plans and reports. These include, most notably, the Quality and Outcomes Framework (as reported via the Primary Care Annual Report); the delivery of Setting the Direction: Primary and Community Services Strategic Delivery Programme; the Health Board and Clinical Programme Group Operational Plans; implementation of the Child Poverty Strategy; performance against the Standards for Health Services (in particular Standard 3); delivery of the Single Equality Duty and Human Rights responsibilities; and Director of Public Health Annual Reports. Whilst good progress has been made, it is recognised that there is further work to do within the Health Board to ensure that there is consistency between the LPHSF and other strategies and plans, and that reporting is streamlined. The Health Board‟s Planning and Performance Group is currently the main route via which this consistency can be achieved.

9

The first formal Annual Report presented by the Executive Director of Public Health focused on specifically on Early Years and covered the life course stages in respect of babies and pre-school age children. The second report due to be published in May 2012 again echoes the LPHSF in its focus on Older people. Following this refresh of the LPHSF, further work will now be possible in respect of identifying key public health measures which can be reported alongside other measures by which overall organisational progress is monitored and reported at CPG Board, Board of Directors, Executive Team, and Health Board levels. In line with the WG Guidance the approved final version of the LPHSF will be translated and made available on the BCUHB Internet site by the end of June 2012.

Section 2 Driver Diagrams Babies are born healthy Pre-school children are healthy, safe and develop to their full potential School-aged children and young people are safe, healthy and equipped for adulthood Working age adults live healthier lives for longer Older people age well in to their retirement

10

OUTCOME AND INDICATORS

PRIMARY DRIVERS (Our Healthy Future)

SECONDARY DRIVERS (High Level Evidence Based Actions)

Pregnant women are at or over the age of 18

Focus services and engagement with the more deprived communities in North Wales, i.e. proportional to need

Babies in North Wales are born healthy

Introduce systematic approaches to reducing unplanned pregnancy, including teenage pregnancy Pregnant women do not smoke

Targeted services for vulnerable young people (e.g. looked after children; parental drug / alcohol abuse) Deliver sex and relationships education in all schools

INDICATORS

Ensure equitable access to contraceptive and sexual health services

Pregnant women do not drink alcohol or misuse drugs

Deliver systematic brief intervention for smoking cessation (women and their partners / families)

Low Birth Weight Rate

Infant Mortality Rate

Women are at a healthy and safe weight for pregnancy, and eat a healthy balanced diet

Develop and implement a systematic approach to preconceptual care, including: o Nutrition (including folic acid) o Healthy and safe weight management o Smoking cessation advice & support o Alcohol Brief Intervention o Drug (illegal & prescription) advice o Immunisation (rubella, seasonal flu)

Pregnant women feel safe, supported and experience good mental health and well-being throughout their pregnancy and following the birth of their child

Provide high quality antenatal care to all women o Nutrition throughout pregnancy o Smoking cessation (brief intervention and referral) o Alcohol Brief Intervention o Healthy and safe weight management o Anxiety / depression / stress management

11




Children are breastfed Preschool children in North Wales are safe, healthy and develop to their full potential

INDICATORS

Childhood mortality under 5 years

•

Children are physically active and eat a healthy balanced diet •

Children experience good mental health and well being

• •

•

Children are not killed, poisoned or injured, in accidents or otherwise

•

Oral health (dmft in 5 year olds)

•

Children are protected against illness by immunisation

• • •

Overweight / Obesity Rates Children live in smoke free environments

Provide health visiting services which deliver interventions to support: o Breast feeding o Infant feeding o Whole family nutrition o Immunisation o Reduction in parental and whole family smoking o Injury prevention o Reduction in parental drug and alcohol abuse o Early recognition and treatment of post natal depression Systematic and co-ordinated partnership approach to increasing breastfeeding rates and achieving UKBFI accreditation for acute and community services Deliver oral health programmes for all preschool children Support parents / grandparents / extended families to provide positive influences in relation to smoking, nutrition and alcohol misuse Offer Alcohol Brief Interventions to parents / grandparents / extended family members to support role modelling behaviour Provide opportunities for all children to experience developmental play Provide effective child protection services and continue to embed child protection in al services Identify high risk areas and ensure creation of 20 mph traffic zones Implement immunisation programmes to meet national targets Support the reduction of poverty in families o Debt management / financial literacy o Increased benefits uptake

Promote access to education, training and employment o Provide accessible affordable childcare Support the reduction in exposure to second hand smoke through smoke free homes and cars o

•

Children are safe from harm (including injury and abuse)

12


School aged children and young people in North Wales are safe, healthy and equipped for adulthood



Children and young people are physically active and eat a healthy balanced diet

Children and young people do not smoke, drink alcohol or misuse drugs INDICATORS Overweight / Obesity Rates Hospital admission rates due to injury 0) in unitary authorities within Betsi Cadwaladr University Health Board, 2007-8

What does the Indicator tell us? The percentages having at least one decayed, missing or filled tooth ranged from 40.6% in Anglesey to 50.5% in Denbighshire. The 2007-08 survey of 5 year olds was the first to use positive consent. As a result participation rates have fallen; in Anglesey for example they fell by 30%. The data significantly under-estimates the true picture of oral health and need to be interpreted with caution until future surveys are available to monitor trends.

21

Indicator 3: Rate of Childhood Overweight / Obesity Initial data is awaited from the Child Measurement Programme. It is anticipated that data will be available from late summer 2012, but the reporting schedule has not yet been published. Results from the feasibility study undertaken to inform the design and delivery of the Child Measurement Programme, suggested that around 22% of children in reception classes are overweight / obese.

22

Why is this important? According to the World Health Organisation, childhood obesity is one of the most serious public health challenges of the 21st century. Following consultation on regulations, the Minister for Health and Social Services has directed Public Health Wales to establish a Child Measurement Programme for Wales. The programme will see the way primary school children are measured standardised across Wales. Data will be collected and used for surveillance of prevalence trends of underweight, overweight and obesity at a local authority level across Wales. The establishment of a programme follows the successful feasibility study carried out in 2009 by the Public Health Wales Observatory with support from other Welsh organisations. The programme will start with standardisation of measures in reception year. It is expected that measures in year four will be included at a later date.

Population Outcome: School aged children and young people are safe, healthy and equipped for adulthood Which indicators could help us show if we‟re achieving this? Indicator 1: Overweight / Obesity rates

Why is this important?

Figure 6: People aged 16+ who are overweight or obese

Obesity has a severe impact on the health of individuals, increasing the risk of type-2 diabetes, some cancers, and heart and liver disease.

Infant mortality (those aged less than one year) Rate per 1,000 live births, Betsi Cadwaladr University Health Board aged 16+ who are overweight or obese (BMI 25+), age standardised %, Betsi localPersons authority areas, 2001-05 to 2005-09 Produced by Public Health Wales Health Observatory, using dataauthority from ONS (ADDE, Cadwaladr University Board local areas,ADBE) 2004 to 2010 Produced by Public Health Wales Observatory, using WHS (WG)

Local authority

80

Isle of Anglesey

Gwynedd

Conwy

Denbighshire

The Welsh Health Survey asks adults to report their height and their weight. In order to define overweight or obesity, a measurement is required which allows for differences in weight due to height. The Body Mass Index (BMI) is calculated as weight in kilograms (kg) divided by squared height 2 (m ). Overweight and obese is defined as 2 2 BMI 25+kg/m . BMI 30+kg/m is defined as obese. Although this data is for people aged 16+, it does reflect the impact and outcome of overweight and obesity from childhood into adulthood.

60 40

20 5

Age standardised %

Rate per 1,000 live births

6

Wales

4

3

0

80 60 40

20 0

80

Do not use as chart Only to be used for chart title, legend and y axis label for the 6 micro charts  2001-05 Flintshire

2002-06

2003-07 Wrexham

2004-08

2005-09

60 40

20 0 2004-06 2005-07 2007-08 2008-09 2009-10

2004-06 2005-07 2007-08 2008-09 2009-10

What does the Indicator tell us? In line with the Welsh trend, overweight or obesity rates across North Wales Local Authority Areas are on average increasing slightly. By 2009/10, 55% of the population over the age of 16 in North Wales are overweight or obese; this is significantly lower than the Welsh average.

23

What does the Indicator tell us?

Indicator 2: Hospital admission rates due to injury < 18 years Figure 7 Emergency hospital admissions for injury or poisoning


Infant mortality (those aged less than one year) Rate per 1,000 live births, Betsifor Cadwaladr University Board Emergency hospital admissions injury or poisoning in Health all persons aged 18 and under, local authority areas, 2001-05 to(EASR) 2005-09 European age-standardised rate per 1,000 population, Betsi Cadwaladr University Produced by Board Public Health Observatory, data from ONS (ADDE, ADBE) Health local Wales authority areas,using 2000-09 Produced by Public Health Wales Observatory, using PEDW (NWIS) & MYE (ONS)

Local authority

30

95% confidence interval

Wales

Isle of Anglesey

Gwynedd

20 15

Hospital admissions data is taken from the Patient Episode Database for Wales (PEDW), which comprises records of all episodes of inpatient and day case activity in NHS Wales hospitals and Wales residents treated in NHS hospitals in other parts of the UK.

10 5

5 0

25 20

Do not use as chart Only to be used for chart title, legend and y axis label for the 6 micro charts 

15 10

5 0 30

2001-05 Flintshire

2002-06

2003-07 Wrexham

2004-08

2005-09


25 20 15

10 5

2009

2008

2007

2006

2005

2004

2003

2002

2001

2000

2009

2008

2007

2006

2005

2004

2003

0

2002

3

Denbighshire

Conwy

2001

4

30

2000

EASR per 1,000


6 25

Injuries are a leading cause of mortality and morbidity in children and young people. They are also an important cause of inequality with higher rates in children from more deprived socioeconomic backgrounds. Effective interventions are available to prevent many injuries.

24

Rates of hospital admission across most of North Wales have followed a similar pattern to that seen across Wales. However different patterns are seen for Anglesey and Gwynedd, where rates have generally increased.

Indicator 3: Teenage Conceptions under 16 years and Teenage conceptions under 18 years Figure 8: Under 16 conceptions

Infant mortality (those aged less than one year) Rate per 1,000 live births, Betsi Cadwaladr University Health Board local authority areas, 2001-05 2005-09 Under 16 conceptions, rate per to 1,000 females aged 13-15, Betsi Cadwaladr University Health Produced Public Health Wales Observatory, using data from ONS (ADDE, ADBE) Boardbylocal authority areas, 1999 to 2008 Produced by Public Health Wales Observatory, using Conceptions data (WG)

Local authority

20

Isle of Anglesey

Teenage pregnancy is a known cause of health inequality and childhood poverty. Evidence has shown that teenage pregnancy is related to poor maternal and child health outcomes. There is an increased risk of teenage mothers failing to complete their education, suffering from post natal depression and other mental health issues and of living in poverty.

15

5 5

0 20

Denbighshire

Conwy

4 15

5 0

20

2001-05 Flintshire

2002-06

2003-07 Wrexham


2004-08

2005-09

15 10

2008

2007

2006

2005

2004

2003

2002

2001

2000

1999

2008

2007

2006

2005

2004

2003

2002

2001

0 2000

Two separate analyses are provided here for the trend in teenage conceptions both in the under 16 (i.e. 13-15) age group and in the under 18 (i.e. 15 – 17) age groups. In both figures the overlapping confidence intervals suggest that rates have generally remained fairly consistent over the period 1999 to 2008.

5

1999

3


10


Gwynedd

10

Rate per 1,000 females aged 13-15


6


Wales

25

Infant mortality (those aged less than one year) Figure 9: Under conceptions Rate per 1,000 live 18 births, Betsi Cadwaladr University Health Board local authority areas, 2001-05 2005-09 Under 18 conceptions, rate per to 1,000 females aged 15-17, Betsi Cadwaladr University Health Produced Public Health Wales Observatory, using data from ONS (ADDE, ADBE) Boardbylocal authority areas, 2000 to 2009 Produced by Public Health Wales Observatory, using Conceptions data (ONS) & (WG)

Local authority

80

Isle of Anglesey

Gwynedd


60

40

As Figure 8 demonstrates, due to the very small numbers at Local Authority level on an annual basis there can considerable variation from year to year. Overall interpretation is challenging because of this, but the patterns do seem to demonstrate a steady decline in all areas. Higher overall rates are clearly demonstrated for the Wrexham area.

20 5

Rate per 1,000 females aged 15-17

0 80

Denbighshire

Conwy

4 60

20 0

80

2001-05 Flintshire

2002-06

2003-07 Wrexham

2004-08

2005-09

60 40 20

26

2009

2008

2007

2006

2005

2004

2003

2002

2001

2000

2009

2008

2007

2006

2005

2004

2003

2002

0 2001

3


40

2000


6


Wales

Figure 9 suggests that in the under 18 age group there is more variation between the Local Authority areas, both in terms of rates of teenage pregnancy and in the trends demonstrated over the 10 year period

Indicator 4: Young people not in education, employment or training (NEET) Figure 10: percentage of young people age 16-18 who are not known to be in education, training or employment

Percentage of young people age 16-18 who are not known to be in education, training or employment, Betsi Cadwaladr University Health Board area local authorities, 2010

Produced by Public Health Wales Observatory, using Careers Wales survey data (StatsWales) Wales Year 13 = 6.6 Wales Year 11 = 5.4

4.4

3.7

4.2

4.7

Being in education, employment and training at this age often increases a young person‟s resilience and is essential to their future employability and economic well-being. Being NEET between the ages of 16-18 is a major predictor of later unemployment, low income, teenage motherhood, depression, and poor physical health. In the UK rates of participation in education and training have historically been low compared to other countries in the OECD (Organisation for Economic Cooperation and Development). The indicator is defined as young people aged 16-18 (inclusive) who are not in education, employment or training, shown as a proportion of the total 16-18 year olds known to the local Connexions service.

Wrexham

Flintshire

2.8

Conwy

3.6 3.2

Gwynedd

Isle of Anglesey

3.9

Denbighshire

5.3

7.0

6.2

6.0


What does the Indicator tell us? There is a lot of variation amongst Local Authority Areas All Local Authority areas are below the Welsh average, except for Flintshire which has a higher % of young people in Year 13 who are NEET.

27

Population Outcome: Working age adults live healthier lives for longer Which indicators could help us show if we‟re achieving this? Indicator 1: Overweight / Obesity Rates Figure 11: Persons aged 16+ who are overweight or obese


Infant mortality (those aged less than one year) Rate per 1,000 live births, Betsi Cadwaladr University Health Board aged 16+ who are overweight or obese (BMI 25+), age standardised %, Betsi localPersons authority areas, 2001-05 to 2005-09 Produced by Public Health Wales Health Observatory, using dataauthority from ONS (ADDE, Cadwaladr University Board local areas,ADBE) 2004 to 2010 Produced by Public Health Wales Observatory, using WHS (WG)

Local authority

80

Gwynedd

The Welsh Health Survey asks adults to report their height and their weight. In order to define overweight or obesity, a measurement is required which allows for differences in weight due to height. The Body Mass Index (BMI) is calculated as weight in kilograms (kg) divided by squared height 2 (m ). Overweight and obese is defined as 2 2 BMI 25+kg/m . BMI 30+kg/m is defined as obese.

60 40

20 5

Age standardised %


6

Wales

Isle of Anglesey

4

3

0

80

Conwy

Denbighshire

60 40

20 0

80


2002-06

2003-07 Wrexham

2004-08

2005-09

60 40

20 0 2004-06 2005-07 2007-08 2008-09 2009-10

Obesity has a severe impact on the health of individuals, increasing the risk of type-2 diabetes, some cancers, and heart and liver disease.

2004-06 2005-07 2007-08 2008-09 2009-10

28

What does the Indicator tell us? In line with the Welsh trend, overweight or obesity rates across North Wales Local Authority Areas are on average increasing slightly. By 2009/10, 55% of the population over the age of 16 in North Wales are overweight or obese; however this is significantly lower than the Welsh average.

Indicator 2: Morbidity (Chronic Conditions Prevalence) Figure 12: persons aged 16+ with a limiting long term illness

Infant mortality (those aged less than one year) Rate per 1,000 live births, Betsi Cadwaladr University Health Board localPersons authority areas, 2001-05 to 2005-09 aged 16+ with a limiting long term illness, age standardised %, Betsi Cadwaladr Produced by Public Health Health Wales Observatory, using data from ONS (ADDE, ADBE) University Board local authority areas, 2004 to 2010 Produced by Public Health Wales Observatory, using WHS (WG)

Local authority

40

Isle of Anglesey

Gwynedd

30

10 5

0

4

3

40

The onset of chronic disease tends to increase with age. Rising life expectancy leads to a greater number of elderly individuals and a subsequent increase in the prevalence of chronic conditions among the population. The Welsh Health Survey includes questions on whether the respondent had a long-term illness and whether this limited their activities in any way (LLTI).

20

Age standardised %


6

Wales


Conwy

Denbighshire


30 20

10 0

40

The data here illustrate that between 20 and 30% of the North Wales population over the age of 16 consider themselves to have a limiting long term illness.


2002-06

2003-07 Wrexham

2004-08

2005-09

30 20

10 0 2004-06 2005-07 2007-08 2008-09 2009-10

2004-06 2005-07 2007-08 2008-09 2009-10

29

For treatment for a chronic condition, the reported rates range between 43% and 50% for North Wales, compared to a range of 40 – 56% for Wales as a whole. The map in Figure 21 shows the data relating to the WHS question specifically relating to chronic conditions. This uses new sub-local authority analysis (Upper Super Output Area).

Indicator 3: Smoking attributable mortality Figure 13: Males Smoking-attributable mortality, males, aged 35 and over, European age-standardised rate (EASR) per 100,000, Betsi Cadwaladr UHB and Wales, 2001 -09 Produced by Public Health Wales Observatory, using ADDE/MYE (ONS), WIMD 2008 (WG)

700

Most deprived within Betsi Cadwaladr (95%CI)

Wales EASR

Least deprived within Betsi Cadwaladr

Betsi Cadwaladr overall

Why is this important? There is a very strong social gradient in terms of smoking prevalence, with rates of smoking as much as 3 or 4 times higher amongst men in the most deprived groups.

600 500


400

Measuring Inequalities, the recently published profile of the impacts of inequalities in Wales, reports Smoking attributable mortality at Wales and Health Board level. The data are reported separately for males and females.

300 200 100 0

Rate Ratio - most deprived divided by least deprived 1.9

1.7

1.8

1.8

1.9

1.9

1.9

2001-03

2002-04

2003-05

2004-06

2005-07

2006-08

2007-09

The analysis is based on underlying causes of death from selected malignant cancers, and selected cardiovascular, respiratory and digestive diseases. Figure 13 demonstrates a steady fall amongst males in both the least and most deprived groups in the population. However, the gap between the 2 groups appears to have remained steady throughout this period.

30

Figure 14: Females Smoking-attributable mortality, females, aged 35 and over, European age-standardised rate (EASR) per 100,000, Betsi Cadwaladr UHB and Wales, 2001 -09 Produced by Public Health Wales Observatory, using ADDE/MYE (ONS), WIMD 2008 (WG)

300

Most deprived within Betsi Cadwaladr (95%CI)

Wales EASR



What does the indicator tell us? Figure 14 demonstrates a gradual fall amongst females in both the least and most deprived groups in the population between 2001-3 and 2006-8. In the period 2007-9 there is a suggestion of an increase in rates in the most deprived groups.

250 200 150 100 50 0

The gap between the 2 groups appears to have remained generally steady throughout this period.


2.2

2.3

2.1

2.1

2.1

2.3

2001-03

2002-04

2003-05

2004-06

2005-07

2006-08

2007-09

31

Indicator 4: Alcohol-attributable mortality Figure 15: Alcohol-attributed mortality Alcohol-attributable mortality, persons, European age-standardised rate (EASR) per 100,000, Betsi Cadwaladr UHB and Wales, 2001-09 Produced by Public Health Wales Observatory, using ADDE/MYE (ONS), WIMD 2008 (WG) Most deprived within Betsi Cadwaladr (95% CI)

Wales EASR



70 60 50 40 30 20 10 0

Rate 2.0 ratio

2.4

2.3

2.4

2.5

2.7

2.2

2001-03

2002-04

2003-05

2004-06

2005-07

2006-08

32

2007-09

Why is this important? Alcohol consumption above recommended guidelines is associated with a range of conditions and contributes to both overall levels of ill health and to premature mortality. Data from the Welsh Health Survey and numerous other national studies demonstrates that excess drinking is equally common across the socio-economic gradient, but mortality associated with alcohol is higher in more deprived groups What does the Indicator tell us? Measuring Inequalities, the recently published profile of the impacts of inequalities in Wales, reports Alcohol attributable mortality at Wales and Health Board level. The analysis is based on underlying causes of death from 45 disease groups, entirely or in part, attributable to alcohol consumption. Figure 15 demonstrates that alcohol attributable mortality has steadily increased for both least and most deprived populations in North Wales since 2001-3. However, the data also suggest that the gap between most deprived and least deprived has actually reduced, largely because of a marked increase in mortality in the least deprived population. It should be noted that this analysis is experimental and should thus be interpreted with caution.

Population Outcome: Older people age well into their retirement Which indicators could help us show if we‟re achieving this? Why is this important?

Indicator 2: Mortality Rates (Excess seasonal deaths) Figure 16: Excess winter deaths Excess winter deaths (EWD) index, Betsi Cadwaladr University Health Board and Wales, persons, 2005/06 to 2010/11 Produced by Public Health Wales Observatory, using PHMF (ONS)

BCU HB

Wales

Excess winter deaths index

30 25

Wales, in common with other European countries, experiences higher levels of mortality in the winter than in the summer. There is some evidence to suggest that excess winter mortality (EWM) is preventable. Mortality in winter increases more in Wales compared to other European countries with colder climates, suggesting that it is more than just lower temperatures responsible for the excess mortality in winter. The current ONS standard method for developing the Index defines the winter period as December to March, and compares the number of deaths that occurred in this winter period with the average number of deaths occurring in the preceding August to November and the following April to July.

20 15 10


5 0

2005/06

2006/07

2007/08

2008/09

2009/10

2010/11

33

The data suggest that the pattern of excess winter mortality in North Wales is similar to that experienced for Wales as a whole, but the Index is slightly higher. Data suggest that the number of excess deaths across North Wales has fluctuated between 300 and 400 over this period.

Indicator 2: Premature Mortality Rates (deaths under 75 years of age) Figure 17: Males All-cause mortality, under 75, males All-cause mortality, under 75, males, European age-standardised rate (EASR) per 100,000, Betsi Cadwaladr UHB and Wales, 2001-09

The Premature Mortality rate is considered a robust measure that reflects the health status of a population, and the need for systematic public health approaches to health promotion and disease prevention.

Produced by Public Health Wales Observatory, using ADDE/MYE (ONS), WIMD 2008 (WG)

800

Most deprived within Betsi Cadwaladr (95% CI)

Wales EASR




700 600

Premature mortality is defined as deaths occurring before age 75.

500 400 300


200 100 0


2.0

2.1

2.1

2.1

2.0

1.9

2001-03

2002-04

2003-05

2004-06

2005-07

2006-08

2007-09

34

Figure 17 presents all cause mortality data for males for the most deprived areas in North Wales compared to the least deprived. Trends in both groups suggest an improvement in rates since 2001-3, with a sharper rate of decrease in the most deprived populations. However, there remains a considerable gap between the two groups, with rates almost twice as high in the most deprived. Encouragingly, however, there does seem to be evidence that over the period shown the gap has begun to narrow.

Figure 18: Females All-cause mortality, under 75, females, European age-standardised rate (EASR) per 100,000, Betsi Cadwaladr UHB and Wales, 2001-09 Produced by Public Health Wales Observatory, using ADDE/MYE (ONS), WIMD 2008 (WG)

450

Most deprived within Betsi Cadwaladr (95% CI)

Wales EASR




400 350 300 250 200 150 100 50 0


1.9

2.0

2.0

2.0

1.9

2.0

2001-03

2002-04

2003-05

2004-06

2005-07

2006-08

2007-09

35

Figure 18 presents all cause mortality data for females for the most deprived areas in North Wales compared to the least deprived. Trends in both groups suggest an improvement in rates since 2001-3, with a similar rate of decrease in the most deprived populations. However, there remains a considerable gap between the two groups, with rates almost twice as high in the most deprived. The gap between groups does not appear to be narrowing as suggested by the data for males.

Figure 19: Mortality from circulatory disease

Infant mortality (those aged less than one year) Rate per 1,000 live births, Betsi Cadwaladr University Health Board local authority 2001-05 to 2005-09 Mortality fromareas, circulatory disease, European age-standardised rate per 100,000 persons, Produced Public Health Wales Observatory, data from ONS (ADDE, ADBE) Betsiby Cadwaladr University Health using Board local authorities, 2000 -2009 Produced by Public Health Wales Observatory, using ADDE/MYE (ONS)

Circulatory conditions (heart disease and stroke) are two of the biggest killers in North Wales. They are also the two major causes of premature mortality.

Denbighshire

Conwy


2009

2008

2007

2005-09

2006

2005

2004

2004-08

2003

2002

2001

2000

2009

2008

2003-07 Wrexham

2007

2006

2005

2004

2002-06

2003

2001-05 Flintshire

2002

160 140 120 100 80 60 40 20 0

Gwynedd

What does the indicator tell us?

2001

160 140 4 120 100 80 60 40 20 3 0


Wales

Isle of Anglesey

2000

160 6 140 120 100 80 60 40 5 20 0

European age-standardised rate per 100,000 persons


Local authority

36

Here, premature mortality from circulatory disease is presented for Local Authorities across North Wales from 2000 to 2009. In each of the areas, mortality rates have decreased in a similar way to that seen for Wales as a whole, although the pattern for Conwy is less clear.

Indicator 3: Hospital admissions – Hip fracture Figure 20: Hospital admissions for hip fractures Infant mortality (those aged less than one year) Hospital admissions for hipBetsi fractures, European age-standardised rate per 100,000 persons, Rate per 1,000 live births, Cadwaladr University Health Board Betsi Cadwaladr University Health Board local authorities, persons aged 65 & over, 2001 to local authority areas, 2001-05 to 2005-09 2010 Produced by Public Health Wales Observatory, using data from ONS (ADDE, ADBE)

Produced by Public Health Wales Observatory, using PEDW (NWIS) & MYE (ONS)

Local authority 200

Hip fracture is a major cause of disability and the leading cause of mortality due to injury in older people aged over 75. Hospital admission for fractured neckof femur is a good proxy measure of the incidence of hip fracture in older people.

Wales

Isle of Anglesey

Gwynedd

0 300

Denbighshire

Conwy

250 200

150 100 50 0 250 200

Do not use as chart Only to be used for chart title, legend and Flintshire y axis label for the 6Wrexham micro charts  2001-05

2002-06

2003-07


2004-08

2005-09

150 100 50

2010

2009

2008

2007

2006

2005

2004

2003

2002

2001

2010

2009

2008

2007

2006

2005

2004

0

2003

3

Hospital admissions data is taken from the Patient Episode Database for Wales (PEDW), which comprises records of all episodes of inpatient and day case activity in NHS Wales hospitals and Wales residents treated in NHS hospitals in other parts of the UK.

50

2002

4

100

2001


European age-standardised rate per 100,000 persons

6 150

5


37

The charts in Figure 20 illustrate the steady increase in hospital admissions for hip fracture across North Wales. The reason for the apparent fall in more recent years in the Wrexham LA area is not clear, and warrants further examination.

Indicator 4: Morbidity rates (Chronic conditions prevalence) Figure 21: % currently being treated for a chronic illness

Why is this important? Along with the question regarding long term limiting illness (see Figure 12 above), the Welsh Health Survey (WHS) also asks specifically about chronic illnesses. Chronic illnesses include heart disease, respiratory disease, cancer and diabetes. They are often life-long and can have significant impacts for the individual and family members and on the demand for health care services. Lifestyle factors such as smoking, unhealthy diets and being physically less active, and an ageing population are likely to increase the burden of ill health from chronic illnesses. This data presentation is taken from the recently published Sub-Local Authority Analysis of the Welsh Health Survey undertaken by the Public Health Wales Observatory. This analyses WHS data at the level of the 22 Upper Super Output Areas which cover North Wales to give a sense of the geographical distribution of chronic illness, with comparison with the rest of Wales.

38

Section 4 Demonstrating progress: Developing an outcomes-focussed approach for service planning As outlined in the introduction to this document (3.1 and 3.2), the first iteration of our LPHSF introduced an outcomes based approach to planning, based on Results Based Accountability (RBA). This approach emphasises the importance of „what will be different‟ and specifies the data that will be collected to gauge success or failure. Given the complexity of factors that contribute to an individual‟s health status, it is clear that improving the health of the whole population requires contributions from a wide range of sectors, organisations and services. Each service provided will benefit those who receive it, and will contribute to improving the health of the whole population – for example a smoking cessation service will help those people attending its clinics to give up smoking, and managers of the service are accountable for achieving this. However, to achieve a whole population that does not smoke means taking action across a much wider scope, including preventing young people from starting to smoke, working towards further controlling tobacco advertising and points of sale, and tackling illegal tobacco trade. This example underlines the importance of a whole system, joined up and partnership approach to health improvement. Accountability for improving the health of a whole population is therefore bigger than any one program or agency or one level of government: it requires the whole community, public and private partners to make a difference. Within the LPHSF, the actions listed as „secondary drivers‟ are those that are known to be effective in contributing to one or more of the population outcomes listed as primary drivers. As the LPHSF develops, the list of „high level evidence based actions‟ will grow to include those delivered by Local Authorities and other partners, as well as the Health Board, making clear the wide range of services and interventions that need to be in place to achieve improvements in the health of the whole population, not just in the health of those people who are directly receiving the service. As each of the secondary drivers is known to be effective, it can be assumed the people receiving the service will benefit in the way that is expected, provided that the services are delivered to the intended target groups, and to the right standard, Thus if service managers are able to provide information about the quantity („how much’) and quality (‘how well’) of their services, it is not always necessary to directly demonstrate the benefit to service recipients („is anyone better off’). As this quantity / quality information is typically that which is collected for performance management purposes, it is likely that is already being collected, and requiring it for the purposes of monitoring progress of the LPHSF will not add a further burden. Monitoring progress towards the achievement of the primary drivers and the overall outcome at each life course stage is by selected population health data items. These are available from a range of sources and will be provided by Public Health Wales. By examining changes in this data over time, it will be possible to evaluate the success of the LPHSF in improving the health of people in North Wales. The following examples illustrate the links between the LPHSF and components of action or delivery plans: 39

LPHSF: Evidence source

Target population

National Outcome

LPHSF outcome

Primary driver outcome (LPHSF)

Secondary driver (LPHSF)

How to stop smoking in pregnancy and following childbirth PH26 June 2010: http://guidance.nice.org.uk/PH26

Pregnant women

Welsh Government (2011) Tobacco Control Action Plan: Reduce smoking prevalence

Babies in North Wales are born healthy

Pregnant women do not smoke

Provide high quality antenatal care to all women, [including] smoking cessation brief intervention and referral

Extract from Tobacco Action Plan: secondary driver (LPHSF)

Organisation

Who should take action

What needs to be done -

Tasks

Provide high quality antenatal care to all women, [including] smoking cessation brief intervention and referral

BCUHB

Midwives

Identify pregnant women who smoke & refer them to SSW.

Ask women at booking visit about smoking status and record response. Provide info about benefits of quitting and offer support / referral to quit. Provide referral to SSW if indicated. Repeat at subsequent attendances.

Service / performance data to be collected to show 'how much'

40

number of women who are smokers at booking number of women wanting to quit number of women referred to SSW

Service / performance data to be collected to show 'how well'

number of women agreeing quit date with SSW number of women who are smokers at delivery

LPHSF: Evidence source

Target population

National Outcome

LPHSF outcome

Primary driver outcome (LPHSF)

Secondary driver (LPHSF)

NICE (2004) CG21: Clinical practice guideline for the assessment and prevention of falls in older people http://publications.nice.org.uk/fallscg21

older people

National Service Framework for Older People in Wales (2006): 'prevent falls, osteoporosis, fractures and other resulting injuries'

Older people in North Wales age well into their retirement

Older people do not fall

Provide tailored services through the National exercise on Referral Scheme (NERS) to promote physical activity in older people focussing on strengthening bone and muscle health and postural stability

Extract from Physical Activity Action Plan: secondary driver (LPHSF)

Organisation

Who should take action

What needs to be done -

tasks

Provide tailored services through the National exercise on Referral Scheme (NERS) to promote physical activity in older people focussing on strengthening bone and muscle health and postural stability

Local Authorities

Physical Activity staff with appropriate training

Receive referral and allocate to generic or specialist exercise programme as appropriate

Deliver accredited programme

41

Service / performance data to be collected to show 'how much' number of programmes delivered number of people participating

Service / performance data to be collected to show 'how well' % participants completing the programmes