Search

Adults

  • Adult mental health
    • Summary

      Introduction

      Adults with mental health problems are one of the most socially excluded groups in society, and one in four adults will experience mental health problems at some point in their lives. Mental health and physical health are interlinked, with people with mental illness experiencing higher rates of morbidity and a lower life expectancy, and people with chronic physical health problems more likely to experience mental health problems.

      Mental health problems impact on individuals, families, communities and society as a whole, with immense social and financial costs. Mental health problems contribute a higher percentage of total disability adjusted life years in the UK than any other chronic illness (26.6% in 2004, compared to CVD 16.2%, cancer 15.6% and respiratory illnesses 8.3%) [1]. Recent estimates put the full cost of mental health problems in England at £105.2 billion, the majority due to the negative impact on the quality of life for individuals with mental health problems [2]. Mental illness accounts for about 11% of total NHS spend.

      This chapter focuses on adult and older people's mental health only. There is a separate chapter on dementia.

      This chapter will provide an overview of the level of need in the population in the key areas of


      • promoting mental health and wellbeing for the whole population and particular risk groups
      • Treatment and support for recovery for those who have mental ill-health
      • Preventing suicide

      Key issues and gaps

      Issues and gaps related to incidence / prevalence and service provision Mental health is responsible for 23% of disability adjusted life years in the UK which is higher than any other chronic illness.

      Of those Medway residents claiming incapacity benefit, 42% are claiming it due to mental health issues.

      The prevalence and incidence of both common mental health problems and psychosis in the population nationally appears to be remaining stable.

      However numbers of older people with depression will increase due to the demographic changes.

      The last JSNA highlighted issues around forensic maternal mental health: ADHD, autism, personality disorders. Service changes have been implemented to address these.

      Primary care remains a matter for concern.

      Recommendations for Commissioning

      1. Mental health promotion work needs to address wellbeing at work issues.
      2. Targeted interventions to prevent suicide are needed for middle-aged men
      3. Mental health primary care services are currently being reviewed and redesigned with pilots of primary mental health care workers being implemented. Interventions for mental health promotion should be integrated into the development of such services.
      4. Variation in primary care registers and QOF indicators relating to primary care need to be investigated and addressed.
      5. Work should continue to be done to identify issues along the pathway preventing uptake and retention in services and issues relating to access to services for vulnerable groups identified in the equity audit need to be addressed.
      6. Appropriate services for veterans mental health should be in place.
      7. Psychiatric liaison services in Medway Foundation Trust should continue to be supported including a substance misuse component should continue.
      8. Physical health checks for people with mental health issues. Currently low in KMPT. Best models of care and shared care protocols need to be developed.
      9. Low percentage of people in employment with severe mental illness needs to be addressed.
      10. Demand for inpatient services in Medway needs to be monitored on an ongoing basis to ensure that appropriate bed provision is available for those who need it.

      References

      [1]   Department of Health. New Horizons: a shared vision for mental health 2009; Department of Health. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_109705 .
      [2]   Centre for Mental Health. The economic and social costs of mental health problems in 2009/10 October, 2010; Centre for Mental Health. http://www.centreformentalhealth.org.uk/pdfs/Economic_and_social_costs_2010.pdf .
    • Who is at risk and why

      Mental health problems are extremely common. Up to 1 in 4 people will experience mental health problems at some point in their lives, with approximately one in six suffering from mental health problems at any one time.

      Mental health is influenced by diverse biological and social risk factors, including fixed factors such as genetic factors and biographic characteristics (age and sex) and modifiable factors such as family and socio-economic characteristics (marital status, number of children, employment), individual circumstances (life events, social supports, immigrant status, debt), household characteristics (accommodation type, housing tenure), geography (urban/rural, region) and societal factors (crime, deprivation index) [1].

      There are a number of groups within the population that are at particularly higher risk of developing mental health problems, including asylum seekers and refugees [2], black men, offenders, looked-after children, those with physical illnesses, lesbian, gay, bisexual and transgender adults, drug-users, the homeless and those experiencing fuel poverty [3]. The groups with increased risk are as follows:


      • Unemployed adults have a 5.6-fold increased risk of developing a mental health problem.
      • The homeless have a 5.3-fold increased risk of developing a mental health problem.
      • Those with a cold home or experiencing fuel poverty have a 4-fold increased risk of having depression or anxiety.
      • Adults with two or more physical illnesses have a 6.4-fold increased risk of having mental health problems.
      • Children who experience abuse have a 7-fold increased risk of recurrent depression and a 9.9-fold increased risk of developing post-traumatic stress disorder as an adult.
      • Black men are 3 times more likely to be represented on a psychiatric. ward and up to six times more likely to be detained under the Mental Health Act.
      • Under 15's who use cannabis are 6.7 times more likely to develop schizophrenia.
      • Offenders have a 5-fold increased risk of suicide (with an 18-fold increased risk.
      • Amongst young offenders, a 35.8-fold increased risk amongst female offenders and an 8.3-fold increased risk for recently released offenders).
      • Lesbian, gay, bisexual or transgender adults have a 4-fold increased risk of suicide.
      • Looked after children have a 4.5-fold increased risk of suicide attempt.
      • Children experiencing 4 or more adverse childhood experiences have a 12.2-fold increased risk of attempted suicide as an adult.
      • Adults experiencing relationship problems or bereavement.
      • Adult experiencing financial or debt problems.
      • Carers.
      • Those who are socially isolated.


      References

      [1]   The Government Office for Science, London. Foresight Mental Capital and Wellbeing Project (2008). 2008; The Government Office for Science, London. http://www.bis.gov.uk/foresight/our-work/projects/published-projects/mental-capital-and-wellbeing/reports-and-publications .
      [2]   Bunting R. Asylum Seekers and Refugee Health Needs Assessment 2009; NHS Nottingham City. http://www.hlg.org.uk/bamer-housing-and-homelessness-resources/234-asylum-seekers-and-refugee-health-needs-assessment .
      [3]   Department of Health. New Horizons: a shared vision for mental health December, 2009; Department of Health. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_109705 .
    • Level of need in the population

      This section will detail level of need in 3 areas: 1. Promoting mental health and wellbeing 2. Levels of mental ill health 3. Suicide rates

      1. Promoting mental health and wellbeing

      1.1 Positive mental health

      Positive mental health is more than an absence of mental illness. Mental wellbeing can be defined as “a dynamic state, in which an individual is able to develop their potential, work productively and creatively, build strong and positive relationships with others and contribute to their communities"[1].

      Promoting mental health and wellbeing is important in 3 key areas
      • Promoting population mental health and wellbeing
      • Promoting mental health and wellbeing in those most at risk of mental ill health.
      • Promoting mental health and wellbeing in those with existing mental health problems

      In 2012 the government published new national and local data on wellbeing. In July 2012 subjective data on wellbeing was published at local authority level and this is shown below.

      The government is still working on broader national wellbeing indicators but only the national figures for this have been published to date.

        Medway South East England
      Satisfaction with life overall (rated medium or high) 73.1 78.5 75.7
      Feeling worthwhile (rated medium or high) 79.4 82.2 79.9
      Happiness yesterday (rated medium or high) 73.2 72.8 71.0
      Anxiety yesterday (rated medium or low) 59.2 61.2 60.1
      Table 1: Measures of subjective wellbeing in Medway compared with the southeast and England 2012.
      Source: Office for National Statistics

      This data shows that Medway is significantly worse than the South East average with respect to life satisfaction but not significantly different with respect to people feeling that what they do is worthwhile, feeling happy yesterday or feeling anxious yesterday to either the England or the South East average.

      1.2 At risk groups

      Key data on risk groups for poor mental health who should be targeted for mental health promotion work (as outlined in the introduction) are as follows:

      1.2.1 Unemployment

      As stated previously, unemployment is associated with an increased likelihood of having a mental health issue hence this is a key group for targeted mental health promotion work in order to increase resilience and reduce the risk of mental health problems developing. The overall Job Seekers Allowance rate for Medway is 3.4% of adults aged 16-64 in August 2013. This is higher than both the South East rate at 2.1% and the England rate at 3.3%.

      The graph below shows the proportion of people on Job Seekers Allowance by ward in Medway which shows Chatham Central having the highest proportion of JSA claimants (7.1%) with Hempstead and Wigmore the lowest (1.0%).

      The total number of JSA claimants in August 2013 in Medway was 5,938.

      Figure 1: Proportion of the working age population claiming Jobseekers Allowance - August 2013.
      Figure 1: Proportion of the working age population claiming Jobseekers Allowance - August 2013
      Source: Office for National Statistics via NOMIS

      JSA claimant count records the number of people claiming Jobseekers Allowance (JSA) and National Insurance credits at Jobcentre Plus local offices. This is not an official measure of unemployment, but is the only indicative statistic available for areas smaller than Local Authorities.

      Rates for wards are calculated using the mid-2010 resident population aged 16-64. Rates for Medway Unitary Authority and England are calculated using the mid-2012 resident population aged 16-64.

      1.2.2 People claiming incapacity benefit due to mental health problems.

      A significant proportion of people claiming incapacity benefit do so because of mental health problems. In Medway 1.6% of the population claim incapacity benefit or severe disablement allowance which is higher than the SE region average but lower than the England average. The number of people claiming Incapacity Benefit/Severe Disablement Allowance in Medway as at February 2013 was 3,390. The proportion of these claiming incapacity benefit due to mental health issues is 41% (1,400).

      The graph below shows the proportion of the population by ward in Medway who claim incapacity benefit. Additional support needs to be given to this group in order to facilitate a return to good employment.

      Figure 2: Proportion of the population aged 16 years and over claiming Incapacity Benefit or Severe Disablement Allowance.
      Figure 2: Proportion of the population aged 16 years and over claiming Incapacity Benefit or Severe Disablement Allowance - February 2013
      Source: Office for National Statistics via NOMIS

      Incapacity benefit (IB) was introduced in April 1995 and is paid to people who are incapable of work and who meet certain contribution conditions. Severe Disablement Allowance (SDA) was paid to those unable to work for 28 weeks in a row or more because of illness or disability. Since April 2001 it has not been possible to make a new claim for SDA.

      Rates for wards are calculated using the 2011 Census resident population aged 16+. Rates for Medway Unitary Authority, South East and England are calculated using the mid-2012 resident population estimates aged 16+.

      Mental health promotion work to support employers to develop good practice around wellbeing in the workplace and also support for employees who are suffering from mental health problems will help to address this issue.

      1.2.3 Deprivation

      Mental health problems are also linked to living in an area of high deprivation. Figure 3 shows deprivation levels across Medway. Areas of high deprivation are likely to see a higher demand for mental health services.

      Figure 3: Locally ranked deprivation scores by Lower Super Output Area.
      Figure 3: Locally ranked deprivation scores by Lower Super Output Area
      Source: Indices of Multiple Deprivation 2010, Department of Communities and Local Government
      1.2.4 Homelessness and fuel poverty

      Homelessness and poor quality damp housing are risk factors for poor mental health. The table below sets out the rate of households accepted as being homeless and in priority need in Medway, the South East region and England since 2004/05. In 2012/13 there were 257 households accepted as being homeless in Medway. The chapter on seasonal excess winter deaths gives further information on fuel poverty and seasonal excess winter deaths.

        2004/05 2005/06 2006/07 2007/08 2008/09 2009/10 2010/11 2011/12 2012/13
      Medway UA 6.2 6.6 3.4 1.8 1.2 1.4 1.6 2.4
      South East 3.7 2.7 2.0 1.6 1.4 1.1 1.3 1.5 1.6
      England 5.7 4.5 3.5 3.0 2.5 1.9 2.0 2.3 2.4
      Table 2: Households accepted as being homelessness and in priority need per 1,000 households
      Source: Department of Communities and Local Government
      1.2.5 Carers

      Issues for carers are covered in more detail in the Carers chapter. However they are at greater risk of mental health problems than the general population so therefore should also be targeted for specific mental health promotion work.

      1.2.6 Social isolation

      It is difficult to capture social isolation accurately with routinely available data. Some possible proxy indicators include self assessed health status, older people living alone and single parents. It is also interesting to note the difference in prevalence of all common mental health disorders by marital status and gender. This indicates that a stable relationship is associated with better mental health.

      Figure 4: Prevalence of all common mental disorders in England PMS 2007, by marital status and gender.
      Figure 4: Prevalence of all common mental disorders in England PMS 2007, by marital status and gender
      Source: Adult psychiatric morbidity survey 2007, The NHS Information Centre for Health and Social Care.

      Geographically many of these indicators show high rates in our most deprived wards so reaching these groups would indicate a need to focus on these areas and also the employers of groups in these areas in order to tackle mental health inequalities more effectively.

      2 Mental ill health in the population

      There are different diagnoses of mental health disorders but they can be grouped together under the following main headings
      • Common mental health problems
      • Psychosis
      • Other mental health disorders including maternal mental health disorders, ADHD, personality disorder, PTSD

      2.1 Common mental health problems

      Common mental disorders (CMDs) are mental conditions that cause marked emotional distress and interfere with daily function, but do not usually affect insight or cognition. They comprise different types of depression and anxiety, and include obsessive compulsive disorder.

      The main nationally collected survey which measures mental ill health in the population is the Psychiatric Morbidity Survey. This survey was carried out in 1993, 2000 and 2007. The overall picture nationally indicates that after the rise in common mental health problems between 1993 and 2000, the rates between 2000 and 2007 remained similar. The 2007 psychiatric morbidity survey (PMS) found that 17.6% of the population surveyed met the diagnostic criteria for at least one CMD, with women (19.7%) more affected than men (12.5%)[2]. We use this data to estimate our local rates however it does not take into account deprivation or any other local variation so can only be taken as an estimate.

      Immediately below Figure 5 shows this estimate of common mental health disorders for all ages by age and gender across Medway using the PMS 2007 national prevalence rates applied to 2013 population projections for Medway. The total number of people in Medway living with a common mental health disorder at any one time in 2013 is estimated to be approximately 34,900. As can be seen prevalence is higher in women than in men in all age groups. Rates are also higher in younger and middle-aged groups rather than in older people.

      Figure 5: Estimated prevalence in Medway of all common mental disorders in past week, by age and gender
      Figure 5: Estimated prevalence in Medway of all common mental disorders in past week, by age and gender.

      Estimates of rates of common mental health problems in Medway compared with other areas have been produced using a model developed by the North East Public Health Observatory. This model is based on findings from the Psychiatric Morbidity Survey for Adults 2000, combined with indicators from the Heady and Ruddock model[3] and mid-2005 population estimates from Office for National Statistics. It estimates that the rate of any neurotic disorder in the past week in Medway is 161.2 per 1,000 population aged 16-74). The conditions included in the definition are mixed anxiety and depression, general anxiety disorder, depressive episodes, all phobias, obsessive compulsive disorder and panic disorder.

      Using this method which includes weighting for deprivation, Figure 6 below shows that Medway's rate for common mental health disorders is slightly below the England average and is near the middle of its ONS comparator group.

      Figure 6: Modelled rate of common mental health problems amongst 16-74 year olds by Primary Care Trust in England.
      Figure 6: Modelled rate of common mental health problems amongst 16-74 year olds by Primary Care Trust in England
      Source: North East Public Health Observatory, 2008

      Figure 7 shows that within Kent and Medway according to the modelling method above, Medway has the highest rate of common mental health problems second only to Thanet.

      Figure 7: Modelled rate of common mental health problems amongst 16-74 year olds by Local/Unitary Authorities in Kent & Medway.
      Figure 7: Modelled rate of common mental health problems amongst 16-74 year olds by Local/Unitary Authorities in Kent & Medway
      Source: North East Public Health Observatory, 2008

      However again these estimates can only be taken as a guide, as while they are the best available at the present time they are based on information which is now considerably out of date.

      Prevalence of common mental health problems nationally also varies by:


      • ethnicity, with South Asian women recording the highest prevalence (34.3%)
      • marital status, with a higher prevalence among divorced and separated adults, see previous section.
      • household income, with adults in the lowest quintile of household income more likely to have a common mental health problem than adults in the highest quintile. This is a particularly strong association among men, with men in the lowest household income quintile three times more likely to have a common mental health problem than men in the highest household income quintile.

      Primary care information

      There is no routinely collected local information on population prevalence of all common mental health problems. The Quality and Outcomes Framework primary care data collection does collect information on depression incidence and prevalence from depression registers held in GP practices and this information is shown below (Figures 8 and 9), but this does not cover all common mental illnesses and may also be subject to under recording by practices. It shows that there are 22,829 people aged 18 and over in Medway who have been diagnosed with Depression at some point in their lives. Between April 2011 and March 2012 2,583 people aged 18+ were newly diagnosed with depression. This equates to an incidence rate for Medway of 1.3% which is greater than the England rate of 1.1%.

      Figure 8: Depression prevalence (recorded ever) by GP practice in Medway 2011/12.
      Figure 8: Depression prevalence (recorded ever) by GP practice in Medway 2011/12
      Source: Quality and Outcomes Framework, NHS Information Centre for Health and Social Care
      Figure 9: Depression incidence (recorded in last year) by GP practice in Medway 2011/12.
      Figure 9: Depression incidence (recorded in last year) by GP practice in Medway 2011/12
      Source: Quality and Outcomes Framework, NHS Information Centre for Health and Social Care

      It appears that there is large variation in the prevalence and incidence of depression across GP practices which needs to be explored further.

      2.2 Psychosis and severe mental illness

      Psychoses are disorders that produce disturbances in thinking and perception severe enough to distort perception of reality. The main types are schizophrenia and affective psychosis, such as bi-polar disorder. In the Psychiatric Morbidity Survey 2007 the overall prevalence of psychotic disorder nationally was found to be 0.4% (0.3% of men, 0.5% of women).

      In both men and women the highest prevalence was observed in those aged 35 to 44 years (0.7% and 1.1% respectively). The age standardised prevalence of psychotic disorder was significantly higher among black men (3.1%) than men from other ethnic groups. The prevalence of psychosis (0.2%of white men, no cases observed among men in the South Asian or 'other' ethnic group). There was no significant variation by ethnicity among women[2]. Prevalence is also higher in people with lower household incomes (0.1% of adults in highest income quintile and 0.9% in adults in the lowest income quintile)[2].

      To estimate the prevalence of psychosis locally we have extrapolated the national prevalence reported in the Adult Psychiatric Morbidity Survey, to Medway using 2011 based population projections for 2013. This provides an estimate of approximately 862 people suffering from probable psychosis in Medway. The graph below shows the variation in prevalence across age and gender extrapolated to Medway also showing estimated local numbers in each category.

      Figure 10: National prevalence of psychotic disorder in past year by age and gender.
      Figure 10: National prevalence of psychotic disorder in past year by age and gender (estimated numbers living in Medway in 2013 shown in bars)

      Similarly to the information collected for depression GP practices maintain a register of patients that have schizophrenia, bipolar disorder and other psychoses as part of the QOF.

      In 2011/12 there were 1,740 patients recorded on the QOF mental health register across Medway's practices, giving a recorded prevalence rate of 0.6%, which is lower than the national rate of 0.8%. Recorded prevalence rates at practices in Medway practices ranged from 0.2 to 2.5%.

      Figure 11: Severe Mental Illness prevalence by GP practice in Medway.
      Figure 11: Severe Mental Illness prevalence by GP practice in Medway 2011/12
      Source: Quality and Outcomes Framework, NHS Information Centre for Health and Social Care

      Understanding the level of need for mental health services: MINI 2000

      The Mental Health Needs Index 2000 (MINI 2000)[4] has not been updated since 2000 and is therefore the information it contains is out of date. Using it as a predictor of need for hospital admission is also likely to be misleading as it does not take into account the development of new models of care such as crisis resolution home treatment services which means that the threshold for admission is likely to have increased. However it does provide some comparison of need for mental health services for those with severe mental health services in different areas in Medway.

      The level of mental illness severe enough to require hospital admission in Medway is identified by the MINI 2000. This is estimated to be slightly lower than the England average. (0.91 in Medway compared to 1 in England). Within Medway, wards that are identified as at least 20% more likely to require hospital admission than the England are shown in the darkest colour. These are Chatham Central, Luton and Wayfield, Rochester East and Gillingham South.
      This is broadly consistent with what we would expect given levels of deprivation in those wards.

      Note: As stated above the MINI Index has not been updated since 2000 however we do not have any alternative indices for comparison so it is still being used nationally as an aid to comparison between areas.

      Figure 12: MINI 2000 scores by electoral ward.
      Figure 12: MINI 2000 scores by electoral ward
      Source: North East Public Health Observatory (map produced by Kent & Medway Public Health Observatory)

      Compared with it's ONS cluster towns, Medway has the second highest MINI index score indicating a higher level of need than it's comparator areas.

      Figure 13: MINI 2000 scores Primary Care Trusts.
      Figure 13: MINI 2000 scores Primary Care Trusts in ONS Cluster group ‘New and Growing Towns’. Source: North East Public Health Observatory
      2.3 Veterans mental health

      A veterans mental health needs assessment was carried out for Kent and Medway by the Public Health Directorate in 2011[5]. There is no accurate local source of information as to current numbers of local veterans living in Kent and Medway and the level of mental health need in this group. The information below has been estimated using information taken from mapping work carried out by Royal British Legion in conjunction with Experian and, specifically with respect to mental health problems from the Kings Centre for Mental Health (KCMHR) cohort study commissioned by the MoD. This looked at the mental health of 9,990 serving personnel and veterans who had been deployed to Iraq and Afghanistan.

      Overall, using the best data which was available in 2010, 10.9% of Medway's over 16 population are estimated to be veterans. This equals 22,479. This figure is high because it still includes many WW2 veterans.

      However in more recent years, the recently deployed veteran population has been of increasing importance with respect to need for services. The information below sets out estimates of the mental health issues experienced by recently deployed veterans compared with the general population.

        Military General population
      Probable PTSD 4% 3%
      Common mental disorder ~20% ~20%
      Alcohol misuse 13% 6%
      Table 3: Comparison of mental health problem prevalence in military and general populations
      Source: KCMHR cohort study, 2010

      This indicates somewhat surprisingly that level of PTSD in the armed forces and amongst veterans in recent years is very similar to those in the general population and the level of common mental health problems is also broadly similar. However the level of alcohol misuse is significantly higher in the military population than in the civilian population.

      The study had a 56% response rate and although the results were adjusted to take into account the characteristics of non responders, there are still legitimate concerns that the results may not be representative of all veterans.

      From this work the number of veterans under 65 with mental health problems has been estimated in Table 4 below

        Kent & Medway Medway
      Probable PTSD 2,169 360
      Common mental disorder 10,843 1,798
      Alcohol misuse 7,043 1,170
      Table 4: Estimated Number of Veterans aged under 65 with mental health problems in Kent and Medway

      There are significant problems with this extrapolation, since the age structure, military experience and general lifestyle of the general veteran population is very different to that of the recently deployed population surveyed by KCMHR however it is the best data we have available at present.

      2.4 Maternal mental health

      Mental disorders during pregnancy and the postnatal period can have serious consequences for the mother, her infant and other family members. During this period, women are more likely to come into contact with mental health services, than any other time in their life, particularly those at an increased risk of relapse of an existing disorder.

      Low mood is thought to affect up to 15% of pregnant women. NICE guidance recommends psychological treatment or social support for pregnant women whose lives are significantly affected by sub-syndromal depression and anxiety, and the guideline estimates this prevalence at 2.6%.

      An estimated 10% to 15% of women suffer from depression after the birth of an infant[6][7], although studies vary considerably. However, it is argued that about half of these cases will never come to medical attention. 3% to 5% of women giving birth have moderate or severe depression, with about 1.7% being referred to specialist mental health services[8][9]. Thus, around 17 women per 1,000 live births may be referred to specialist mental health services with depression postnatally.

      Puerperal psychosis (i.e. in the early postnatal period, up to three months after delivery) is a severe and relatively rare form of postnatal mental illness affecting between 0.1% and 0.2% of all new mothers.

      If half of mothers experiencing postnatal depression request treatment, (5-7.5%) and if 0.1-0.2% per cent experience psychosis then this would equate to 270 and 10 Medway women in 2011 respectively (based on approximately 3550 births).

      Many women admitted with psychosis in the postnatal period have a pre-existing mental disorder, including bipolar disorder and schizophrenia.) The rate of recurrence of postnatal depression after a subsequent birth is about 30%. Relapse rates for bipolar disorder approach 50% in the antenatal period and 70% in the postnatal period[10].

      2.5 Personality Disorders

      Personality disorders are longstanding, ingrained distortions of personality that interfere with the ability to make and sustain relationships. Antisocial personality disorder (ASPD) and borderline personality disorder (BPD) are two types with particular public and mental health policy relevance.

      ASPD is characterised by disregard for and violation of the rights of others. People with ASPD have a pattern of aggressive and irresponsible behaviour which emerges in childhood or early adolescence. They account for a disproportionately large proportion of crime and violence committed. ASPD was present in 0.3% of adults aged 18 or over (0.6% of men and 0.1% of women). In Medway this equates to approximately 750 people.

      BPD is characterised by high levels of personal and emotional instability associated with significant impairment. People with BPD have severe difficulties with sustaining relationships, and self-harm and suicidal behaviour is common. The overall prevalence of BPD was similar to that of ASPD, at 0.4% of adults aged 16 or over (0.3% of men, 0.6% of women). In Medway this equates to approximately 950 people.

      3 Self harm and suicide and undetermined injury

      Suicide is a serious public health problem. In Medway in 2011 there were 13 suicides. As suicides are more likely to occur in younger age groups than most other causes of death they contribute a significant amount to total years of life lost for a population even though the number of deaths are small. The information below shows that over the last nearly two decades suicide rates nationally have been declining. This has to some extent been reflected locally although given the small numbers locally there has been considerable year on year variation and differences by local area.

      Figure 14: Trends in suicide and undetermined injury mortality rates.
      Figure 14: Trends in suicide and undetermined injury mortality rates
      Source: Health & Social Care Information Centre and Kent & Medway Public Health Observatory

      In Medway in 2010 suicide rates were below the England average. At this point the national data for 2011 has not been released so we cannot compare with the national position for 2011 and 2012.

      Common mental disorder Borderline personality disorder Antisocial personality disorder Psychotic disorder Two or more psychiatric disorders
      M F P M F P M F P M F P M F P
      2012 10,400 16,292 26,692 250 496 746 499 83 582 250 414 663 5,741 6,203 11,943
      2015 10,563 16,489 27,051 254 502 756 507 84 591 254 419 672 5,831 6,278 12,108
      2020 10,800 16,784 27,584 259 511 770 518 85 604 259 426 685 5,962 6,390 12,352
      2025 11,013 17,100 28,112 264 521 785 529 87 615 264 434 698 6,079 6,510 12,589
      2030 11,238 17,297 28,534 270 527 797 539 88 627 270 439 709 6,203 6,585 12,788
      Table 5: Numbers of suicide and undetermined injury in Kent and Medway by local authority area
      Source: Kent & Medway Public Health Observatory

      Some of the apparent variation in numbers and rates has also been due to the way suicide data is collected. Suicide data is recorded at the point of the coroners verdict so at the point of registration rather than at date of death so delays in inquests can skew figures. When actual date of death is looked at rather than point of death registration the variation for the last 4-5 years largely disappears. This can be seen in the table above where date of death figures (in red) are compared with the registration of death figures. So overall in Kent and Medway there has been no significant change in suicide rates or numbers over the last 5 years rather what we may be seeing is a flattening out of the suicide rates rather than an ongoing decrease.

      We have analysed figures by age and sex across Kent and Medway as analysis in Medway only at sub group level would not be possible given the small numbers. Nationally we know that approximately 75% of suicides are males. This is reflected in the Medway figures . The highest numbers and rates of suicide can be found in the 30-60 age group for men whereas in women suicide rates exhibit less variation between 10 year age groups after the age of 30.

      Figure 15: Rates of suicide and undetermined injury by age and sex, 2010-12.
      Figure 15: Rates of suicide and undetermined injury by age and sex, 2010-12
      Source: Kent & Medway Public Health Observatory

      With respect to method of suicide, between 2008-12, 49% of all suicides were due to hanging with 24% due to drugs and poisoning. Jumping from a high place accounted for 10% of suicides in Kent and Medway.

      Figure 16: Number of deaths due to suicide and undetermined injury by method, 2008-12.
      Figure 16: Number of deaths due to suicide and undetermined injury by method, 2008-12
      Source: Kent & Medway Public Health Observatory

      The most common method of committing suicide in men is hanging. There is no significant difference in method among women.

      Figure 17: Trends in number of deaths caused by hanging and poisoning by sex.
      Figure 17: Trends in number of deaths caused by hanging and poisoning by sex
      Source: Kent & Medway Public Health Observatory

      References

      [1]   The Government Office for Science, London. Foresight Mental Capital and Wellbeing Project (2008). 2008; The Government Office for Science, London. http://www.bis.gov.uk/foresight/our-work/projects/published-projects/mental-capital-and-wellbeing/reports-and-publications .
      [2]   McManus S, Meltzer H, Brugha T, et al. Adult psychiatric morbidity in England, 2007: Results of a household survey 2009; The NHS Information Centre for health and social care. http://bit.ly/GAxluS .
      [3]   Heady P, Ruddock V. Report on a project to estimate the incidence of psychiatric morbidity in small areas 1996; Office for National Statistics.
      [4]   Gyles Glover DW. A needs index for mental health care in England based on updatable data 2004; North East Public Health Observatory. http://www.nepho.org.uk/pages.php5?pg=140#d335 .
      [5]   Howarth G. Veterans (ex-military) Health Needs Assessment for Kent and Medway 2011; Kent Public Health Directorate. http://www.kmpho.nhs.uk/population-groups/veterans/ .
      [6]   Brockington I. Motherhood and Mental Health 1996;
      [7]   Nonacs R, Cohen L. Postpartum mood disorders: diagnosis and treatment guidelines Journal Clinical Psychiatry 1998; 59: Suppl 2:34-40.
      [8]   Cox JL, Murray D, Chapman G. A controlled study of the onset, duration and prevalence of postnatal depression British Journal of Psychiatry 1993; 163: 27-31.
      [9]   O'Hara MW, Swain AM. Rates and risk of postpartum depression -- a meta-analysis International Review of Psychiatry 1996; 8: 87-98.
      [10]   Viguera A, Nonacs R, Cohen L, et al. Risk of recurrence of bipolar disorder in pregnant and nonpregnant women after discontinuing lithium maintenance American Journal of Psychiatry 2000; 157: 179-184.
    • Current services in relation to need

      Mental health and wellbeing services are provided by a variety of agencies. They cover the spectrum of mental health and illness and are summarised below.

      1. Promoting mental health and wellbeing

      A partnership framework for action for Promoting Mental Health and Wellbeing in Medway is being finalised and a full-time mental health promotion specialist has been in post since April 2011 to support its development and implementation. This work is overseen by a Consultant in Public Health employed in the Medway Public Health Directorate.

      The Medway Promoting Mental Health and Wellbeing Framework for Action can be found at insert link

      Current key priorities which are being addressed are outlined below:

      Priority 1 - Promoting Mental Health in Primary Care

      About 90% of people with mental health conditions are managed in primary care. Improving the skills of primary care staff to enable them to recognise mental health conditions early, deliver appropriate treatments in a primary care setting and refer on to supporting agencies is fundamental. Ensuring primary care understand and can link to the full range of services available to support good mental health is key to a holistic approach to improving mental health. Facilitation between primary care and the voluntary sector improves outcomes [1].

      Priority 2 - Promoting Mental health and Wellbeing through Employment

      Unemployment is both a cause and consequence of mental health problems. Promoting healthy workplaces to ensure that people can stay in work and reducing stress related illness is an important area of mental health promotion work [2]. Work on this is already underway in Medway and includes working with businesses to raise awareness of mental health issues, reducing stigma through promotion of the Mindful Employer initiative and supporting small and medium sizes business to implement the NICE guidance on wellbeing at work.

      For people with existing mental health issues there are many barriers to gaining meaningful employment, in particular discrimination, issues with benefits and lack of available opportunity. Mental health promotion strives to address some of these barriers and promote recovery through working with partners to create training and work experience opportunities.

      Priority 3 - Mental Health Awareness Raising and Capacity Building in the Community.

      Through a programme of Mental Health First Aid training, professionals, population groups and communities in Medway can be supported to recognise the early signs of mental distress and different types of mental illness. This training has already been delivered to the Health and Lifestyle Training Team in Medway and a programme of further courses has been planned to include carers, those working with young people and in early years settings and other frontline voluntary agencies.

      Mental health promotion work will focus on campaigns supporting the Kent and Medway Live It Well strategy which raise awareness and improve understanding of how to achieve and maintain good mental health..

      Priority 4 - Promoting Mental Health through Healthy Lifestyle

      Having a mental health problem increases the risk of physical ill health. Depression increases the risk of mortality by 50% and doubles the risk of coronary heart disease in adults [3].People with mental health problems such as schizophrenia or bipolar die on average 16-25 years sooner than the general population. Mental health promotion work in Medway will aim to reduce this inequality in health by linking with partners such as primary care, smoking cessation services, healthy weight, physical activity teams and service users to address this important issue.

      2. Mental health services

      Common mental health problems

      Treatment of common mental health problems is provided by GP practices and the Primary Care Psychological Therapies Service (PCPTS) which is part of the national IAPT (Improving Access to Psychological Therapies) programme that was launched in 2008.

      The PCPTS is being delivered in Medway by a stepped care approach via Any Qualified Provider. The link below goes to the current list of qualified providers

      Step 2 provides low intensity treatment which consists of guided self help, guided use of computerised CBT, behavioural activation, structured exercise, psycho-educational groups, face to face CBT interventions and other therapies (up to 6 sessions)

      Step 3 provides high intensity treatment which normally consist of face-to-face interventions (80% CBT, 20% other therapeutic modalities) and up to 20 therapy sessions with an average of 12.

      The PCPTS programme has been designed to offer evidence based intervention and treatment choice to people with common mental health problems including depression and anxiety disorders including panic disorder, obsessive compulsive disorder, social phobia, generalised anxiety disorder, specific phobias and health anxiety.

      Referrals to the PCPTS can be either through primary care or via self-referral. In 2011/12 there were 6,263 people referred to the PCPTS service in Medway. Of these 3,616 entered the service. Of those having 2 or more sessions of therapy 718 had moved to recovery.

      Severe mental illness

      Those with more severe mental illness are referred to secondary mental health services. These are largely provided in Medway by the Kent and Medway NHS and Social Care Partnership Trust.

      Secondary mental health services in Medway currently provided by KMPT consist of:

      Community mental health teams (CMHTs) are provided by Kent and Medway NHS and Social Care Partnership Trust. These are split into 2 teams (Access and Recovery) who provide support for people who have just been referred to the service and for those with longer term mental disorders. As of March 2012 there were 780 patients on the caseload of the Recovery service and 686 patients on the caseload of the Access service. Since April 2013, KMPT has operated one team, Medway Integrated Team (MIT) replacing the Access and Recovery Team.

      Assertive Outreach Team works closely with CMHTs and take referrals for people who are difficult to engage and hard to reach groups and provide more intensive support. As of March 2012 there were 42 patients on the caseload of this team.

      Crisis Resolution Home Treatment Team which provides an intensive service to clients in crisis to help prevent hospital admissions.

      Early Intervention in Psychosis Team supports those aged 14-35 presenting for the first time with a psychosis. For Medway and West Kent combined there were 280 patients on the EIP caseload as of March 2012. For Medway this probably represents 40-50 patients.

      In patient services for those with mental health problems are provided largely in A block at Medway Maritime Hospital however this building is not considered to be fit for purpose in the longer term and alternative arrangements are being considered following a public consultation.

      The Medway Adult Mental Health Social Work Team has around 450 people on its caseload at any one time, and provides a Community Support and Outreach service to people with a severe mental illness living in their own homes in the community and assists with discharge and “re-ablement” following Hospital admission. A Day Resources Service is used by 80 people at any one time with a severe mental illness. The Social Work Team carry out an important statutory function in regard to assessing and detaining patients under the Mental Health Act. Currently, around 2/3 requests for assessments under the mental health act are received each day. About 60 people are assessed and supported through the Social Work team in 24 hour registered residential care placements.

      Social care for those with mental health difficulties.

      Current commissioned social care services for people with mental health issues are below


      • Winfield Trust: IT project for people with mental health issues to obtain relevant qualifications
      • The Medway 5 Carers Project is funded to provide mutual support to mental health Carers.
      • Medway Carers First employs a Dual Diagnosis Carers Support Worker.
      • MCCH provide supported housing for 25 people (this includes the Halpern Project). Sanctuary provide another 9 places at a higher level of weekly housing support.
      • Funded annual arts event for people with mental health issues
      • Supported housing
      • An employment retention specialist is employed by Medway Council and attached to the KMPT Primary Care Psychological Service.
      • A 24 hour/7 day a week specialist mental health helpline operated by Mental Health matters is available to users and carers.
      • MEGAN (Medway user engagement and network) is an independent user-led project providing a voice to users as well as peer support groups.
      • The Medway Recovery Hope Group, volunteer action co-ordinated through Rethink, has made strong links across black and other minority ethic (BME) communities and provides direct support to users from BME communities.

      Currently social work mental health services are provided directly by Medway Council.

      Specialist services

      Offender/secure mental health services


      • Custody diversion suites A custody diversion suite service has been set up in Medway. A Community Psychiatric Nurse is based at Chatham police station and is able to assess detainees immediately as referred by the police. This ensures that people with mental health issues are identified and appropriately referred. This service has been well received by the police.


      • Secure facilities Low, medium and high secure forensic mental health services are commissioned for Medway residents from a range of providers. Low secure services are provided by KMPT at the Allington Centre. Medium secure services are provided by KMPT at the Trevor Gibbons Unit and high secure services are provided nationally at Rampton and Broadmoor. Commissioners report an increase in numbers of people going into medium secure services


      • Mental healthcare and treatment in prisons Mental healthcare in prisons is provided by Oxleas NHS Trust and consists of a multi-disciplinary mental health team providing a range of services for prisoners with severe and common mental health issues including anxiety, alcohol, anger and sleep management support.

      Maternal mental health

      Perinatal mental health service

      Dual Diagnosis

      In response to issues identified previously, a dual diagnosis protocol has recently been completed which will clarify the arrangements for treatment of those with both substance misuse and mental health disorders.

      Veterans Mental Health

      Currently there are no local specialist mental health treatment services for veterans in Kent and Medway. However the following care pathway shows how veterans can access both local and national services from Medway. Veterans can access national specialised mental health assessment treatment services via the routes shown below.

      Figure 1: Veterans national specialised mental health assessment treatment services pathway
      Figure 1: Veterans national specialised mental health assessment treatment services pathway.

      However there is a national plan for the implementation of the recommendations of the Murrison report [4] which included the launch of a 24 hour Combat Stress helpline and, the Big White Wall Online support in 2011. In the South East Coast additional veteran specific clinical posts are being established in local mental health services to improve access to and effectiveness of these services for veterans.

      Eating Disorders

      A review of eating disorder services has taken place across Kent and Medway. An options paper containing proposals to significantly change the service model has been produced and consultation on these will take place in 2012/13 and a business case produced.

      Adult ADHD

      The delivery and availability of services for adults with ADHD is variable across Kent and Medway. Current treatment services are provided by a tertiary provider, South London and Maudsley Trust who offer assessment and treatment. A review is being carried out across Kent and Medway to assess the clinical and economic case for the establishment of a comprehensive ADHD service in the Kent and Medway area for the local population. Commissioners report high levels of referral due to lack of diagnosis during childhood and adolescence.

      Autistic spectrum disorder

      A business case for a specialist assessment and diagnosis service in Kent and Medway with ASD/Asperger's syndrome was approved in 2011/12 and the service will now be commissioned.

      Personality disorder

      The Brenchley Unit provides an intensive day treatment programme for Medway residents.

      Psychiatric liaison services

      A psychiatric liaison service is now in place at Medway Foundation Trust provided by KMPT. This provides mental health clinical support and expertise for A&E clinical staff and also where possible to clinical staff throughout the hospital on appropriate management of presenting mental health conditions in those with physical illness. About 1,500 people a year are seen in Medway Maritime Hospital in order to improve the mental health of those presenting with mental health issues. The liaison service in Medway has been extended to reach into acute hospital wards as well as emergency departments in order to offer assessment and support to those people presenting with a physical health problem and a mental health need.


      References

      [1]   Grant C, Goodenough T, Harvey I, et al. A randomised controlled trial and economic evaluation of a referrals facilitator between primary care and the voluntary sector British Medical Journal 2000; 320: 419-423.
      [2]   NHS Eastern and Coastal Kent. Promoting Mental Health and Wellbeing NHS Eastern and Coastal Kent 2010 v2 2010; NHS Eastern and Coastal Kent. http://www.kmpho.nhs.uk/geographical-areas/primary-care-trusts/eastern-and-coastal-kent-pct/?assetdet956088=100373 .
      [3]   Department of Health. No health without mental health: a cross-government mental health outcomes strategy for people of all ages February, 2011; Department of Health. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_123766 .
      [4]   Murrison A. Fighting Fit: A mental health plan for servicemen and veterans 2010; http://www.southofengland.nhs.uk/wp-content/uploads/2012/03/Murrison-Report-Fighting-Fit-Combat-veterans-Final2.pdf .
    • Projected service use and outcomes in 3-5 years and 5-10 years

      The tables below show the effect of demographic changes on the numbers of people predicted to have a mental health problem from 2012 -2021. Overall there are not expected to be significant changes except in the case of depression and dementia in older adults (as might be expected given the ageing population). However it is important to remember that there may also be changes due to the external environment, particularly economic and social factors. These have been shown to impact on common mental health problems and suicide rates but they have not been taken into account in the projections below.

      Projections applying to adults

      The national prevalence figures reported in the Adult Psychiatric Morbidity Survey [1], have been applied to Medway population figures in order to estimate the number of people with common mental disorders locally. Figures may not sum as rounding has been applied and a person may have more than one condition.

      MAD GAD Depression All Phobias OCD Panic Any CMD
      M F P M F P M F P M F P M F P M F P M F P
      2012 7,343 12,124 19,467 3,562 5,779 9,341 2,013 3,030 5,042 848 2,187 3,036 1,006 1,461 2,468 1,015 1,289 2,304 13,198 21,571 34,769
      2016 7,582 12,551 20,133 3,720 5,942 9,662 2,085 3,102 5,187 887 2,231 3,118 1,034 1,481 2,515 1,042 1,339 2,381 13,661 22,256 35,916
      2021 7,824 12,922 20,747 3,885 6,106 9,991 2,156 3,166 5,322 933 2,292 3,225 1,060 1,489 2,549 1,069 1,405 2,474 14,125 22,921 37,047
      Table 1: Estimated number of people living in Medway with common mental disorders in past week, 2013-2021
        2012 2016 2021
      Males 254 266 284
      Females 545 549 563
      Persons 799 816 848
      Table 2: Estimated number of people living in Medway with psychotic disorder in past year by gender, 2013-2021
      Suicide attempts lifetime Suicide attempts lifetime (self-completion) Self-harm (lifetime) Self-harm lifetime (self-completion)
      M F P M F P M F P M F P
      2012 3,938 6,383 10,322 4,586 7,519 12,105 3,633 3,944 7,577 4,685 6,111 10,796
      2016 4,081 6,527 10,608 4,752 7,686 12,438 3,700 3,915 7,615 4,799 6,091 10,890
      2021 4,206 6,695 10,902 4,907 7,869 12,776 3,779 3,880 7,659 4,900 6,060 10,961
      Table 3: Estimated numbers of people living in Medway having attempted suicide or engaged in self-harming behaviour, 2013-2021

      Projections applying to older people

      Figure 1: Trend in estimated number of people living in Medway with Depression aged 65 years and over.
      Figure 1: Trend in estimated number of people living in Medway with Depression aged 65 years and over
      Source: Projecting Older People Population Information System (POPPI).
        2012 2015 2020 2025 2030
      Depression 3,374 3,661 4,015 4,461 5,046
      Severe Depression 1,050 1,141 1,254 1,449 1,626
      Dementia 2,468 2,656 3,076 3,655 4,347
      Table 4: Trends in estimated number of people living in Medway with Depression and Dementia aged 65 years and over
      Source: Projecting Older People Population Information System (POPPI)

      References

      [1]   McManus S, Meltzer H, Brugha T, et al. Adult psychiatric morbidity in England, 2007: Results of a household survey 2009; The NHS Information Centre for health and social care. http://bit.ly/GAxluS .
    • Evidence of what works

      Current NiCE guidance on mental health can be found here.

      The Foresight report on Mental Capital and Wellbeing[1] pulled together the best available scientific and other evidence to develop a vision for reviewing the opportunities and challenges facing the UK over the next 20 years and beyond and the implications for everyone's “mental capital” and “mental wellbeing”, together with highlighting what all agencies will need to do to meet the challenges ahead, so that everyone can realize their potential and flourish in the future. The project also outlined the actions felt to be most important, and how available resources could be better allocated.

      Research reviews on prevalence, detection and interventions in parental mental health and child welfare: summary report[2] has identified a range of factors which inhibit good outcomes for parents and children where parental mental health issues are a feature of family life.


      References

      [1]   The Government Office for Science, London. Foresight Mental Capital and Wellbeing Project (2008). 2008; The Government Office for Science, London. http://www.bis.gov.uk/foresight/our-work/projects/published-projects/mental-capital-and-wellbeing/reports-and-publications .
      [2]   Parker G, Beresford B, Clarke S, et al. Research reviews on prevalence, detection and interventions in parental mental health and child welfare: summary report July, 2009; Social Care Institute for Excellence. http://www.scie.org.uk/publications/guides/guide30/files/YorkReviewSummary.pdf .
    • User Views

      As part of the Dec 2011 Medway CCG listening event, mental health was identified as one of the five top priorities for health in Medway indicating that it remains an overall priority within the area.

      As part of the 2010 consultation for the Kent and Medway wide Mental Health strategy Live It Well stakeholder events were held across the county and an online survey response tool was used to capture whether the priorities contained in the strategy for improving mental health were correct. A short summary of feedback is below.

      The 10 commitments are summarised as follows at the following link

      LINKs, User group forums, Jenny and Katherine

    • Equality Impact Assessment
    • Unmet needs and service gaps

      Promoting mental health and wellbeing:


      • Given the current economic climate and rising unemployment there should be a focus on promoting good quality employment and also ensuring appropriate interventions to strengthen resilience and build skills in the unemployed, particularly the young unemployed.

      Primary care


      • There appears to be significant variation in identification of common and severe mental health issues in primary care. This needs to be investigated further and appropriate action taken .
      • PCPTS provision ? level 3 comparison with the rest of the country. Equity audit re men and middle-aged people.

      Secondary care


      • Waiting times OK. Urgent and emergency referral rate is high.
      • High levels of urgent referrals by GPs possibly inappropriate.
      • High caseload for CMHTs means not as good therapeutic service so primary mental health practitioner planned in primary care. Focus on outcomes, so PBR care pathways being developed

      Inpatient care


      • MFT not fit for purpose Provision of appropriate inpatient services,
      • Better support physical health checks and nutrition.

      Social care


      • More involvement in EIP needed.
      • Older People's Mental Health: care management/statutory funtions
      • Carers assessments needs to be improved.
      • Working more with families to link with Family Intervention Project
      • Settled employment

    • Recommendations for commissioning
      1. Mental health promotion work needs to address wellbeing at work issues.
      2. Targeted interventions to prevent suicide are needed for middle-aged men
      3. Mental health primary care services are currently being reviewed and redesigned with pilots of primary mental health care workers being implemented. Interventions for mental health promotion should be integrated into the development of such services.
      4. Variation in primary care registers and QOF indicators relating to primary care need to be investigated and addressed.
      5. Work should continue to be done to identify issues along the pathway preventing uptake and retention in services and issues relating to access to services for vulnerable groups identified in the equity audit need to be addressed.
      6. Appropriate services for veterans mental health should be in place.
      7. Psychiatric liaison services in Medway Foundation Trust should continue to be supported including a substance misuse component should continue.
      8. Physical health checks for people with mental health issues. Currently low in KMPT. Best models of care and shared care protocols need to be developed.
      9. Low percentage of people in employment with severe mental illness needs to be addressed.
      10. Demand for inpatient services in Medway needs to be monitored on an ongoing basis to ensure that appropriate bed provision is available for those who need it.
    • Recommendations for needs assessment work

      Further work needs to be done to use new information available for Payment by Results clustering to see if more local information on the level of common mental illness in different geographical areas can be obtained and used to understand potential quality in care issues.

      An assessment of the local prevalence of Personality Disorder and its impact on the person, carers, family and the wider community should be undertaken.

      An assessment of the local prevalence of Dual Diagnosis and its impact on the person, carers, family and the wider community should be undertaken.

  • Cancer
    • Summary

      Cancer is the second leading cause of morbidity and mortality in Medway. Although there are over 200 types of cancer in the UK, over half of cancer deaths are due the top four most common cancers: lung, bowel, breast and prostate.

      Cancer is by far one of the largest contributors to excess mortality in Medway. Approximately, 1300 people are diagnosed with cancer each year.[1] Around 600 people die from cancer in Medway, accounting for about 1 in 3 (29%) of all deaths in Medway. Over the last ten years, the incidence of cancers in Medway has remained steady and similar to the incidence in the South East and England as a whole. There is a downward trend in mortality for all cancers in Medway (1997–2008) but the deaths have remained higher than in the South East and England.

      Key issues and gaps

      The Outcomes Framework emphasises the need to reduce cancer mortality and people dying prematurely from cancers before the age of 75. The risk of not delivering in other areas, such as smoking, physical activity, diet and obesity will have impact on cancer outcomes.
      • Smoking prevalence remains higher than the national average especially in pregnant women and young people
      • Attitudes and beliefs impact on late presentation- social marketing, combined with community engagement and empowerment approaches, needs to be continued
      • Cancer screening coverage and uptake: variation between GP practices needs to be reduced.
      • Variation in access to cancer services
      • Excess cancer deaths amongst the older age groups (over 75s)

      Recommendations for Commissioning


      • The Cancer Reform Strategy should be fully implemented
      • Achievements should be benchmarked against the Improvement Outcome for Cancer Strategy
      • Ensure the implementation of NICE guidance and Improving Outcome Guidance for Cancer
      • Ensure continuous improvement of GP access to diagnostic tests for cancer.
      • Working with primary care should continue to reduce practice variations in screening coverage, uptake and access to services.
      • The Cancer Network should work in partnership with the Acute Trusts to improve data collection, in particular tumour staging data at presentation, and provide high quality data on chemotherapy and radiotherapy to inform commissioning and monitor inequalities
      • The Cancer Network should work with acute trusts to ensure improvements in cancer outcomes such as quality of life, palliative care, family support, support for patients and carers and not just survival.
      • Work should continue in primary care to assess the extent of the variation in cancer referral rates, emergency admission rates and cancer screening uptake rates by practices. This is with a view to improving referrals, reduce primary care delays and improve cancer screening uptake rates.
      • Innovative social marketing should be combined with community engagement, targeting areas of low participation to improve awareness and increase participation in screening programmes. Clinical Commissioning Groups and the Cancer Networks should give high priority to increasing awareness of risk factors and encourage people to seek help earlier.
      • The Cancer Network should support GP Cancer leads to ensure the rollout and understanding of the GP Practice cancer profile by practice, identifying practices which are outliers for targeted support.
      • The use of the risk assessment tool (RAT) by practices should be evaluated to assess its effectiveness in supporting practices in identifying at risk patients who do not meet the two weeks referral criteria.
      • Excess cancer deaths amongst the older age groups (over 75s) should be reviewed.


      References

      [1]   Thames Cancer Registry. Cancer in Medway 2001-2010Kings College London.
    • Who's at risk and why?

      A number of factors play a part in determining an individual's risk of developing cancer and the outcome if they do develop it. Some of these are fixed such as age, sex and genetics. Others relate to the individual's lifestyle. Smoking is the single biggest cause of cancer and it is estimated that around 50% of all current smokers are likely to be killed by their smoking habits. Smoking increases the risk of cancers of the lung, bladder, cervix, kidney, larynx, lip, mouth and pharynx, oesophagus, pancreas, stomach and some types of leukaemia.[1] Alcohol has been linked to increased risk of cancer of the mouth, larynx, oesophagus, liver, breast and bowel.

      Diets high in fats and proteins and low in fruits, vegetables and fibre increase the risk of colorectal (bowel) cancer.[2] Being overweight or obese are the most important known avoidable causes of cancer after tobacco.[3] Other risk factors for cancer include: lack of exercise and excessive exposure to ultraviolet light.


      References

      [1]   Cancer Research UK. Smoking and Cancer http://bit.ly/J9SlFo
      [2]   Cancer Research UK. Diet, healthy eating and cancer http://info.cancerresearchuk.org/healthyliving/dietandhealthyeating/
      [3]   World Health Organisation, Food and Agriculture Organisation of the United Nations. Diet, Nutrition and the Prevention of Chronic Diseases, Report of a Joint WHO/FAO Expert Consultation 2003; World Health Organisation. http://www.fao.org/DOCREP/005/AC911E/AC911E00.HTM .
    • The level of need in the population

      Cancer Incidence

      In 2009, over 1,400 new cases of cancers were diagnosed in Medway. A third of this occurred in those aged 75 and over.

        Medway West Kent Eastern and Coastal Kent KMCN
      0-74 1,028 2,604 3,062 6,694
      75+ 404 1,212 1,646 3,262
      All ages 1,432 3,816 4,708 9,956
      Table 1: Cancer incidence. Number of new cases (2009)

      The incidence rate of all cancers in Medway has remained steady and similar to the incidence rates in the South East, comparator groups and England as a whole (Figure 1).

      Figure 1: Directly age standardised incidence rates for all cancers in Medway, South East Coast SHA and England, all persons, all ages, 1993 to 2008.
      Figure 1: Directly age standardised incidence rates for all cancers in Medway, South East Coast SHA and England, all persons, all ages, 1993 to 2008 [1]

      Between 2006 and 2009, there have been on average around 1,300 new cancer registrations recorded each year in Medway.

      Figure 2 shows the incidence of cancers by tumour sites in Medway, South East Coast SHA, Comparator groups and England.

      Figure 2: Cancer incidence rate (all ages) by cancer type 2006--2008.
      Figure 2: Cancer incidence rate (all ages) by cancer type 2006–2008 [2]

      The incidence of lung cancer is significantly higher in Medway than in the South East Coast. Medway has significantly lower incidence of colorectal cancer when compared with England and significantly lower incidence of skin cancer than other comparator areas.

      Prevalence

      In 2009/10, 3,489 people (1.2%) in Medway were registered with their GP as having a diagnosis of cancer. Practices serving more deprived areas have significantly lower recorded prevalence. This analysis has been based on 59 practices, since IMD score is not available for all practices.

      Figure 3: Prevalence by practice deprivation quintile.
      Figure 3: Prevalence by practice deprivation quintile [3]
      Figure 4: * Number of practices included in the analysis may differ from number reported on QOF as IMD is not available for all practices.
      Figure 4: * Number of practices included in the analysis may differ from number reported on QOF as IMD is not available for all practices [3]

      Mortality

      In 2010, there were over 660 deaths from cancers in Medway. Nearly half of this occurred in those aged 75 and over. This indicates cancer death in approximately 76% of those diagnosed with the disease in this age group.

        Medway West Kent Eastern and Coastal Kent KMCN
      0-74 359 806 967 4,441
      75+ 306 857 1,146 2,132
      All ages 665 1,663 2,113 2,309
      Table 2: Number of deaths from cancer, 2010

      There is a downward trend in mortality for all cancers in Medway since 1993 but cancer death rates in Medway have remained higher than comparator groups, regional and national rates (Figure 5).

      Figure 5: Trends in all cancer mortality rate (all ages): Directly age standardised mortality rates for all cancers in Medway, South East Coast SHA and England, all persons, all ages, 1993 to 2009}.
      Figure 5: Trends in all cancer mortality rate (all ages): Directly age standardised mortality rates for all cancers in Medway, South East Coast SHA and England, all persons, all ages, 1993 to 2009 [2]

      Figure 6 shows a 10.1% reduction in mortality rate from all cancers in Medway (from 234.7 per 100,000 in 1996 to 211.1 per 100,000 in 2010). A 12.1% reduction (from 152.9 per 100,000 to 134.4 per 100,000) in cancer mortality was observed in people aged under 75.

      Figure 6: Percentage change in mortality rates.
      Figure 6: Percentage change in mortality rates

      Figure 7 shows that there are three wards within Medway where death from cancer is significantly higher than the national rate, namely Luton and Wayfield, Strood South and Twydall.

      Figure 7: Directly age standardised mortality rates (DASMR) from all cancers, all ages, three year average 2006/08, Medway.
      Figure 7: Directly age standardised mortality rates (DASMR) from all cancers, all ages, three year average 2006/08, Medway

      Figure 8 shows that while death rates from all cancers for those aged under 75 has also decreased in Medway, it continues to be higher than in South East Coast SHA, comparator groups and national rates. Medway cancer mortality rate was about 24% higher than the national average in 2009. Cancer mortality is higher in males than females in Medway, similar to the national picture.

      Figure 8: Trends in all cancer mortality rate (under 75s): Directly age standardised mortality rates per 100,000, all cancers, in Medway, South East Coast SHA and England, all persons, <75 years, 1993 to 2009.
      Figure 8: Trends in all cancer mortality rate (under 75s): Directly age standardised mortality rates per 100,000, all cancers, in Medway, South East Coast SHA and England, all persons, <75 years, 1993 to 2009 [2]
      Figure 9: Trends in all cancer mortality rate (under 75s) by gender.
      Figure 9: Trends in all cancer mortality rate (under 75s) by gender [2]
      Figure 10: Directly age standardised mortality rates per 100,000 from cancer by site, <75 years ( 2007--2009).
      Figure 10: Directly age standardised mortality rates per 100,000 from cancer by site, <75 years ( 2007–2009) [2]

      The mortality rate for lung cancer is significantly higher in Medway than in the South East Coast SHA. Similarly, colorectal cancer mortality rate is higher in Medway, but not significantly so when compared to the other comparator areas.

      Hospital admissions

      The number of non-elective admissions for cancer has remained fairly constant over time, but the number of elective admissions increased significantly in 2009/10 and again in 2010/11 (29% and 44% respectively based on the previous year). The main reason for this increase is due to more chemotherapy being administered at Medway Foundation Trust with approximately 200 admissions in 2008/09, 750 in 2009/10 and over 2,000 in 2010/11. Other contributory factors include increased numbers of colonoscopies, excision of breast procedures and blood transfusions.

        2006/07 2007/08 2008/09 2009/10 2010/11 2010/11 (%)
      Elective 5,823 4,217 4,287 5,514 7,926 90.4
      Non-elective 823 825 894 922 837 9.6
      All admission methods 6,646 5,042 5,181 6,436 8,763
      Table 3: Trends in hospital inpatient activity by admission method [4]

      It is worth noting that within elective admissions, patients are likely to be counted more than once as they will be given regular appointments for treatment.

      Survival rates

      Figures 11 and 12 show the latest survival data available at Cancer Network level.

      Figure 11: One year survival following diagnosis by cancer type
      Figure 11: One year survival following diagnosis by cancer type (patients aged 15 to 99 years) diagnosed between 2000 and 2004, and followed-up to 31 December 2009 [2]

      The one year survival rate for prostate and lung cancer in Kent and Medway is significantly lower when compared with England. The five year survival rate is significantly lower for prostate, lung and colorectal cancers.

      Figure 12: Five-year survival rate for patients diagnosed 2002--04
      Figure 12: Five-year survival rate for patients diagnosed 2002–04 (followed up to 31 December 2009) by cancer type [2]

      Issues of inequality


      • Excess cancer deaths in those 75 and over
      • Higher cancer mortality rates in BME communities than the general population explained by the higher levels of lifestyle risk factor amongst this group. This has been observed nationally and may be applicable locally, although we do not have local data to support this.


      References

      [1]   The NHS IC Indicator Portal. Incidence of all cancers: directly standardised rate, all ages, annual trend, MFP
      [2]   The NHS IC Indicator Portal.
      [3]   South East Public Health Observatory. Cancer - Supporting Analysis of Data - Medway 2012;
      [4]   Health Informatics System Business Intelligence. Secondary User Service
    • Current services in relation to need

      Prevention

      Prevention remains the best method of tackling cancer, reducing the burden caused by the disease and improving outcomes. Over half of all cancers can be prevented. Smoking is the single largest preventable risk factor for cancer. (Appendices —> Background papers: Lifestyle and wider determinants —> Smoking and tobacco control)

      Healthier nutrition/Increasing physical activity

      Poor diet and obesity are linked to cancer. In Medway, we have an obesity strategy. (Appendices —> Background papers: Lifestyle and wider determinants —> Healthy weight)

      Alcohol

      Excessive alcohol consumption is strongly linked to an increased risk of several cancers. A Medway alcohol strategy aims to promote sensible drinking and to reduce the impact of alcohol misuse. (Appendices —> Background papers: Lifestyle and wider determinants —> Alcohol)

      Human Papilloma Virus (HPV) vaccination for cervical cancer

      HPV vaccination introduced in September 2008 is now well underway in Medway. In 2009/10, girls in years 8, 10 and 11 received their vaccination in school while those in years 12 and 13 were invited to their general practice. The routine vaccination programme will continue for year 8 girls. This offers a further opportunity in preventing cervical cancer.

      Increasing awareness and earlier presentation

      Improving cancer outcomes in line with the best cancer outcomes in Europe requires better awareness of cancer signs and symptoms to ensure earlier diagnosis and treatment.

      In 2009, an initial baseline assessment of cancer, cancer awareness measure survey and primary care cancer audit were undertaken in Medway. These highlighted areas to target public health interventions and local initiatives.

      Social Marketing campaign/Community led team approach

      A lung cancer campaign and community based lung cancer initiative was launched in Medway in 2010. This aimed to raise public awareness, promote earlier presentation of lung cancer symptoms to a medical professional and reduce health inequalities by targeting and working specifically with the more disadvantage population in Medway. Medway has been selected as a pilot site to run a breast cancer awareness campaign targeting women over 70 in 2012.

      Earlier diagnosis-cancer screening

      Cancer screening is a vital tool for the early detection of cancers and pre-cancerous changes. There are three national screening programmes in the UK: breast, cervical and bowel.

      Breast Screening

      Women aged between 50 and 70 are routinely invited to breast screening once every three years. In Medway there has been a slight increase in breast screening coverage in 2010/11 compared to 2009/10, rising to 80.3% from 79.9%, which is higher than the coverage levels seen in the South East Coast SHA and England as a whole (Table 1). The programme was extended to include women aged 47 to 73 years in 2011.

        2006/07 2007/08 2008/09 2009/10 2010/11
      England 73.8 75.9
      South East Coast SHA 75.1 76.7 76.1 76.8 77.6
      NHS Medway 73.8 80.7 80.7 79.7 80.3
      Table 1: Coverage of breast cancer screening, England, Medway and South East Coast SHA[1]
      Cervical Screening

      All women between the ages of 25 and 64 years are eligible for cervical screening every three to five years depending on their age. In Medway, cervical screening uptake rates are higher than uptake rates for England and the South East Coast SHA. This is true for both 3.5 year and 5 year coverage, with 76% of eligible women having been screened in the previous 3.5 years and 82% screened in the preceding 5 years.

      Figure 1: Cervical screening programme coverage.
      Figure 1: Cervical screening programme coverage (age group 25–64), 2007/08 and 2008/09, Kent and Medway PCTs and South East Coast SHA[1].

      The Human Papilloma Virus (HPV) testing of some samples commenced in March 2012. This will serve as a triage for women with mild or borderline results and abnormal results will be further investigated in the Trusts' colposcopy clinics.

      Bowel cancer screening

      The NHS Bowel Cancer Screening Programme offers screening to all men and women aged 60 to 69 every two years. People over 70 are offered screening on request. During 2011/12 the programme was extended to include men and women aged 70 to 75. The graph below shows the screening uptake by postcode.

      Figure 2: Bowel screening programme.
      Figure 2: Bowel screening programme.

      The national campaign for early recognition of bowel cancer which ran from January to March 2012 is likely to have a short term effect on public awareness. An effective and sustained health promotion programme to increase uptake will be required in the longer term.

      Improved access to diagnostic

      The review of access to diagnostic in line with the four national priority areas across Kent and Medway has commenced. These areas include: chest x-ray to support diagnosis of lung cancer, non obstetric ultrasound for the diagnosis of ovarian cancer, flexible sigmoidoscopy/colonoscopy for the diagnosis of colorectal cancer and Magnetic Resonance Imaging (MRI) brain for diagnosis of brain cancer.

      Ensuring better treatment

      Reducing waiting times: Table 2 shows the national targets were available for cancer waiting times with comparable figures for Medway and the KMCN.

        Operational
      standard
      Medway Kent and Medway
      Cancer Network
      62 day wait (urgent GP referral to treatment) for first treatment, all cancer 85% 88% 86.70%
      62 day wait for first treatment from consultant screening service referral, all cancer - 100% 100%
      62 day upgrade - 100% 87%
      31 day wait (diagnosis to treatment) for first treatment, all cancer 96% 96.20% 98.30%
      31 day wait for second to subsequent treatment: Chemotherapy 98% 100% 99.50%
      31 day wait for second to subsequent treatment: surgery 94% 95.50% 94.20%
      31 day wait for second to subsequent treatment: Radiotherapy - 100% 100%
      All cancer two week wait 93% 98.60% 97.80%
      Two week wait for symptomatic breast patients (cancer not intially expected) 93% 93.90% 95.30%
      Table 2: National targets for cancer waiting times[2]

      The monitoring of cancer waiting time targets remains a priority. For the majority of cancer patients in Medway, the two week, 31 and 62 days wait targets are being met.

      Living with and beyond cancer

      A Macmillan Information Centre and the Macmillan Chemotherapy unit is now available at Medway Maritime Hospital to support people living with and beyond cancer. NHS Medway, Macmillan Cancer support and Medway Council are working jointly to improve and provide access to advice and support on welfare benefits to people with cancer.

      Reducing cancer inequalities

      The Cancer Reform Strategy published in 2007, highlighted major inequalities nationally in cancer incidence, access to services and outcomes in relation to age, gender, deprivation, disability, religion and sexual orientation. Inequalities may impact at different stages along a patient journey such as prevention (awareness of cancer signs and symptoms), at screening, early diagnosis, treatment etc. NHS Medway's cancer campaign uses a community collaborative approach (engagement and empowerment) to address cancer inequalities by targeting electoral wards and communities known to have high cancer inequalities.


      References

      [1]   The NHS IC Indicator Portal.
      [2]   NHS. Open Exeter
    • Projected service use and outcomes in 3--5 years and 5--10 years

      With Medway's older population predicted to increase by 28.1% by 2020 in Medway,[1] we expect to see an increase in the incidence of cancer. The Department of Health predicts that the incidence of cancer will increase by a third between 2001 and 2020 as well as the need and demand for new cancer drugs and treatment.

      With ongoing national cancer awareness campaigns, it is expected that this would increase the detection of cancer as well as the need for treatment. The age extension of national screening programmes may increase cancer incidence and the need for treatment.

      More people are surviving cancer or living longer with the disease. These groups have different needs which are not provided by the usual cancer services.

      If current trends in lifestyle risk factor continue in Medway, for example smoking and obesity levels, these will further increase the incidence of cancer.


      References

      [1]   Medway Council. Population projection, Development Plans and Research Regeneration http://www.medway.gov.uk/pdf/Population%20projections%20Nov%2010.pdf
    • Evidence of what works

      Department of Health (2010) Improving Outcomes: A Strategy for Cancer Department of Health (2007) Cancer Reform Strategy National Institute for Clinical Excellence (NICE)
      • Prostate Cancer Diagnosis and Treatment (CG58 February 2008)
      • Early and locally Advanced Breast Cancer Diagnosis and Treatment (CG80 February 2009)
      • Diagnosis and Treatment of Lung Cancer (CG121, April 2011)
      • Referral Guidelines for Suspected Cancer (CG27 June 2005, updated April 2011)

      Guidance on Cancer Services: Improving Outcomes in Cancer Manual

    • User Views

      The National Cancer Patient Experience Survey 2010 Programme was published on 21 January 2011. The survey was undertaken between January and March 2010 by Quality Health, on behalf of the Department of Health, and was designed to understand patients' experience of cancer services. Several (158) acute hospital NHS trusts providing cancer services participated in the survey.

      Medway Foundation Trust (MFT) scored well in a range of areas, coming among the top 20% of trusts nationally in several questions, including:
      • 94% of patients given written information about the type of cancer they had;
      • 84% given written information about side effects;
      • 76% felt definitely involved in decisions about their treatment;
      • 76% of patients given written information about their operation;
      • 97% thought that the doctors had the right notes and other documentation with them;

      It also highlighted areas for further improvement, where the trust's scores fell within the lowest 20% of trust scores nationally, such as explaining what would be done during an operation, making sure understandable answers are given to important questions and ensuring patients are not talked to as if they were not there.

      The survey findings further revealed that patients with rarer cancer had less positive views of their treatment. In March 2010, the Cancer Awareness Measurement (CAM) Survey was conducted within the three PCT areas across Kent and Medway, to assess the population's level of knowledge and awareness of cancer risk factors and symptoms.

      The study showed that the public's awareness of the main preventable risks for cancer and symptoms is poor, especially amongst the 16-24 year olds. Only 5% of the population could identify cough/hoarseness as a symptom of lung cancer despite it being the biggest killer. Difficulty in making appointments, worrying about what doctors may find and embarrassment were identified as some of the key barriers to seeking help.

      A Lung Cancer Awareness campaign was launched in March 2011 and this was followed by a post campaign CAM survey. The results showed that Medway residents sustained a high recognition (59%) of the campaign comparable with the highest in the country (79%) and an improvement in recognition of cough/hoarseness of voice as symptoms of lung cancer. However, barriers to early presentation still exist. The campaign did not appear to have alleviated the public's concerns.

    • Unmet needs and service gaps

      The Outcomes Framework identifies the reduction in cancer mortality and fewer people dying prematurely from cancers before the age of 75. The risk of not delivering in other areas, such as smoking, physical activity, diet and obesity will have impact on cancer outcomes.
      • Smoking prevalence remains higher than the national average especially in pregnant women and young people
      • Attitudes and beliefs impact on late presentation- Social marketing combined with community engagement and empowerment approaches needs to be continued
      • Cancer screening coverage and uptake: variation between GP practices needs to be reduced.
      • Variation in access to services
      • Review of excess cancer deaths amongst the older age groups (over 75s)

    • Recommendations for Commissioning


      • The Cancer Reform Strategy should be fully implemented
      • Achievements should be benchmarked against the Improvement Outcome for Cancer Strategy
      • Ensure the implementation of NICE guidance and Improving Outcome Guidance for Cancer
      • Ensure continuous improvement of GP access to diagnostic tests for cancer
      • Working with primary care should continue to reduce practice variations in screening coverage, uptake and access to services
      • The Cancer Network should work in partnership with the Acute Trusts to improve data collection, in particular tumour staging data at presentation, provide high quality data on chemotherapy and radiotherapy to inform commissioning and monitor inequalities
      • The Cancer Network should work with acute trusts to ensure improvements in cancer outcomes such as quality of life, palliative care, family support, support for patients and carers and not just survival
      • Work should continue in primary care to assess the extent of the variation in cancer referral rates, emergency admission rates and cancer screening uptake rates by practices. This is with a view to improve referrals, reduce primary care delays and improve cancer screening uptake rates
      • Innovative social marketing should be combined with community engagement, targeting areas of low participation to improve awareness and increase participation in screening programmes. Clinical Commissioning Groups and the Cancer Networks should give high priority to increasing awareness of risk factors and encourage people to seek help earlier
      • The Cancer Network should support GP cancer leads to ensure the rollout and understanding of the GP Practice cancer profile by practice, identifying practices which are outliers for targeted support
      • The use of the risk assessment tool (RAT) by practices should be evaluated to assess its effectiveness in supporting practices in identifying at risk patients who do not meet the two weeks referral criteria
      • Review of excess cancer deaths amongst the older age groups (over 75s)

    • Recommendations for needs assessment work


      • A health equity audit of cancer care should be conducted e.g. Enhanced recovery following surgery
      • Health equity audit of cancer mortality in people over 70

  • COPD
    • Summary

      Chronic Obstructive Pulmonary Disease (COPD) is the name for a collection of diseases including chronic bronchitis, emphysema, and chronic obstructive airways disease. The disease is characterised by airflow obstruction and can lead to significantly impaired quality of life.

      The airflow obstruction is usually progressive, not fully reversible (unlike asthma) and does not change markedly over several months. It is treatable, but not curable, early diagnosis and treatment can markedly slow decline in lung function and hence lengthen the period in which a patient can enjoy an active life.

    • Who's at risk and why?

      Chronic Obstructive Pulmonary Disease (COPD) is the name for a collection of diseases including chronic bronchitis, emphysema, and chronic obstructive airways disease. The disease is characterised by airflow obstruction and can lead to significantly impaired quality of life.

      Figure 1: Trends in directly age-standardised COPD mortality.
      Figure 1: Trends in directly age-standardised COPD mortality

      Current and ex-smokers are most at risk of contracting COPD. Chemicals found in tobacco smoke stimulate inflammation in the lungs, leading to destruction of the alveoli and narrowing of the airways, which can cause COPD. Other people at risk of contracting COPD are those who have been exposed to inhaled dusts and gases in the workplace, those who have an inherited genetic problem that leads to the early onset of emphysema or those who may have previously been diagnosed with asthma. Occasionally COPD may be the result of inadequate lung development in childhood that can be trans-generational, or damage caused by infections in childhood that affect lung growth and development.

      Figure 2: Prevalence of GP registered COPD cases.
      Figure 2: Prevalence of GP registered COPD cases

      Figure 1 shows that generally COPD mortality is decreasing nationally, especially amongst males. In Medway and the SHA, there has been a slight rise amongst females, but the level still remains below that of males.

      Figure 2 demonstrates the difference in prevalence of GP registered cases across the deprivation quintiles of GP practices in Medway.

    • The level of need in the population

      The Quality and Outcomes Framework (QOF) for 2010/11 shows 4,552 people have a recorded COPD diagnosis in Medway, this represents a prevalence of 1.6%. The prevalence for the whole of England is also 1.6%.

      Figure 1: Standardised admission rate per 1,000 population.
      Figure 1: Standardised admission rate per 1,000 population

      However modelled estimates (East Of England Public Health Observatory December 2011) of COPD suggest that there could be 5,647 people with COPD in Medway, which represents a prevalence of 2.78% in the population aged 16+.

      This gap often described as the “missing millions” nationally is people with the disease who do not yet have a diagnosis. Often they are in the mild to moderate stages of the disease

      Comparison across the region shows that Medway has the highest admission ratio of 1.8 per 1000 population for obstructive airway disease (source NHS Comparators). The SHA average is 1.4. This represents an estimated additional 113 admissions annually. This is a 28% difference.

    • Current services in relation to need

      Medway currently offers a number of services across the pathway of care for people with COPD.

      In the early stages of disease the vast majority of care takes place in primary care managed by GPs and practice nurses, there is variability in the availability of practice nurses with specific training in COPD.

      For increased level of need there is a Community Respiratory Team (CRT) who carry out a number of services including routine clinics, an urgent “unwells” service and pulmonary rehabilitation. The CRT also carries out all home oxygen assessments ensuring that this drug is dispensed and used appropriately, this model of care has been copied nationally.

      For the most severe disease or where patient has specialist requirements acute services based at Medway Maritime Hospital led by consultants in respiratory medicine are available.

      Standardised spend for this group of patients (source NHS Comparators) suggests that NHS Medway spends £5,249 per 1,000 population on emergency admissions for obstructive airway disease, and a total expected cost in 2010/11 of £1,189,952. This is a little higher than the national average of £4,609 and substantially higher than the SHA average of £3,484.

      This suggests that Medway has worse outcomes for higher spend.

    • Projected service use and outcomes in 3-5 years and 5-10 years

      COPD numbers are expected to continue to rise in Medway reflecting the fact that Medway continues to have higher levels of adult smokers that the South East Coast average and the expected increase in the numbers of people over 65.

      A rise in the number of people with COPD will likely lead to an increase in demand for community services such as the CRT.

      The availability of pulmonary rehabilitation will be increase in both 2012/13 and 2013/14. Increasing pulmonary rehabilitation in the community will have a positive effect on outcomes leading to an expected reduction in emergency admissions in this group.

    • Evidence of what works

      All treatments used in management of COPD are evidence based and local guideline son management of this disease are based on NICE guidance and GOLD (Global Initiative on Lung Disease) guidelines.

    • User Views

      No user consultations were carried out in 2011/12 by commissioners. Representatives of Medway's Breathe Easy Group are active participants in strategic planning for COPD services.

    • Equality Impact Assessments

      An equality impact assessment was carried out in 2011 looking at the impact of increasing access to Pulmonary Rehabilitation (PR) it identified that increasing access to PR would not have a negative impact on equality and showed a positive impact in disability, socioeconomic status and age.

    • Unmet needs and service gaps


      • Finding the “missing millions” predicted to have COPD by modelled estimates, but are as yet undiagnosed
      • Delivering the NICE COPD Quality requirements

    • Recommendations for Commissioning

      Assess the local health economy against the NICE COPD Quality requirements.

  • CVD
    • Summary

      Cardiovascular disease (CVD) encompasses diseases of the heart and blood vessels and includes conditions such as coronary heart disease (CHD), stroke, heart failure, peripheral vascular disease and some other less common conditions.

      Lifestyle factors such as smoking, unhealthy diet and lack of physical activity and their consequences such as obesity, high cholesterol, high blood pressure and diabetes, are major risk factors for CVD.

      CVD is the biggest killer in Medway, accounting for 26.5% of all deaths in 2010.[1] Deaths from CVD in those under 75 years old are considered premature because most are preventable. About half (48%) the deaths from CVD are due to CHD and over a quarter (28%) is from stroke.[2] It is estimated that 20,000 strokes a year could be avoided in the UK, through preventive work on high blood pressure, irregular heartbeats, smoking cessation, and wider statin use.[2]

      Deaths from CVD are one of the main contributors to the inequalities gap in life expectancy between Medway and England as a whole. Tackling premature CVD is a key part of any strategy to reduce health inequalities and has been identified as a high priority for the Medway Commissioning Group.

      Key issues and gaps

      Early mortality rates from cardiovascular disease (< 75 years) in Medway, are similar to the national rate, and have decreased by 60.8% since 1995. However,
      • Emergency admission rates for CHD are significantly lower than the national rates, but for stroke the local rate is similar to the national rate.
      • The rates of angiography procedures in Medway are significantly lower compared to the national rate.
      • In 2010, the median time to primary angioplasty treatment from a call for help was 122 minutes in Medway, This is higher than in New and Growing Towns and England (116 and 113 respectively).
      • Patients under 75 years with stroke are less likely to be discharged back to their usual place of residence in Medway when compared to England.
      • Of the people diagnosed with hypertension, 18.7% are uncontrolled and over 19,700 are undiagnosed.
      • There is no data available on the estimated number of deaths from CHD due to poor psychological well being or the number of avoidable CVD deaths following increase in psychological well being.

      Recommendations for Commissioning


      • Work with primary care to improve the completeness and quality of disease register; ensure optimal control of hypertension and cholesterol.
      • Encourage audit of all premature CVD deaths at practice level.
      • Raise public awareness about CVD within Medway to address inequity, ensuring that this is aligned with already existing programmes which focus on healthy lifestyles.
      • Smoking cessation service should be prioritised to target specifically young people and pregnant women.
      • Support the implementation of Outreach Health Check programme, targeting men, people aged 50–54 years, black and minority ethnic groups including people living in the more deprived areas of Medway.
      • Improve joint health and social care commissioning arrangements to effectively target high risk and social disadvantaged groups, applying evidenced based social marketing techniques and evaluation.
      • The diagnostic pathway should be improved in line with NICE guidance
      • Local Cardiac Resonance Imaging (CMR) service for the patients of Kent & Medway should be developed to reduce referrals into London.
      • The provision of cardiac device implantation should be audited to reduce the variation in provision.
      • Repeated revascularisation rates should be audited to assess the long term cost.
      • Care pathways should be improved so that patients undergoing surgery outside Kent and Medway, can access pre and post surgical care within a local setting.
      • The cardiac rehabilitation needs assessment should be completed to inform resource needed to provide an efficient and equitable service.
      • Ensure that services are commissioned to meet the needs of people with CVD who have mental illness


      References

      [1]   The NHS IC Indicator Portal.
      [2]   British Heart Foundation. Coronary Heart Statistics- Mortality 2008 2008; British Heart Foundation. http://www.bhf.org.uk/publications/view-publication.aspx?ps=1001452 .
    • Who's at risk and why?

      Lifestyle factors such as smoking, unhealthy diet and lack of physical activity and their consequences such as obesity, high cholesterol, high blood pressure and diabetes, are major risk factors for CVD. The risk factors for both coronary heart disease (CHD) and cerebrovascular disease (CVD) are similar. They can be divided into unmodifiable and modifiable.

      Unmodifiable risk factors are:
      • Age - risk increased with age
      • Sex - more common in men than women until women reach the menopause
      • Family history - genetic predisposition
      • Ethnicity - some groups of people from South Asian descent have a CHD risk about 40% greater than the UK white population, while others of Afro-Caribbean descent have a 25–50% lower risk.

      The proportion of the population from the black and minority ethnic groups in Medway is estimated to be 9.3%. South Asian men are more likely to develop CHD at a younger age, and have higher rates of myocardial infarction. Black people have the highest stroke mortality rates.

      Modifiable risk factors include[1]:

      • Smoking
      • Hypertension
      • Obesity
      • Inactivity
      • Raised cholesterol
      • High triglyceride with low levels of high density lipoproteins
      • Excessive alcohol
      • Excessive stress
      • Raised plasma glucose

      An individual's risk of vascular disease within the next ten years can be predicted using a risk scoring equation, which takes into account the presence and severity of various risk factors. It is estimated that the majority (74%) of the population aged between 35 and 74 who do not have existing cardiovascular disease have a low risk of experiencing a cardiovascular event in the next 10 years. A further 18% are estimated to have a moderate risk, and 8.5% are estimated to be at high risk of CVD.[2] Increasing public awareness of these risk factors and tackling them can go a long way in reducing CVD and the need for NHS services.


      References

      [1]   Department of Health. Coronary heart disease: national service framework for coronary heart disease - modern standards and service models 2000; Department of Health. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4094275 .
      [2]   HippisleyCox J, Coupland C, Vinogradova Y, et al. Derivation and validation of QRISK, a new cardiovascular disease risk scores for the United Kingdom: prospective open cohort study British Medical Journal 2007; 335: 136.
    • The level of need in the population

      Prevalence

      There are 21,409 people estimated to have CVD in Medway, based on the ERPHO modelling. This represents 10.4% of the population aged 16 years and over (Table 1) [1].

        Number with CVD Number of
      persons (16+)
      Prevalence of CVD(%)
      persons 16+)
      Medway 21,049 203,164 10.4
      South East Coast 438,666 3,513,987 12.5
      England 4,938,452 42,105,309 11.7
      Table 1: Modelled estimates of CVD prevalence 2011 [1]

      It is estimated that 1,108 people in Medway have a CVD risk score ≥ 20 over the next 10 years. Figure 1 shows the recorded prevalence of CHD and stroke in NHS Medway compared to South East Coast SHA and England. The recorded prevalence for CHD and Stroke is lower in Medway than the South East Coast, Comparator areas (New and Growing towns) and England. This may be related to the younger population or due to the undiagnosed cases in Medway.

      Figure 1: General practice recorded prevalence of CHD and Stroke, March 2011.
      Figure 1: General practice recorded prevalence of CHD and Stroke, March 2011

      GP recorded versus estimated prevalence

      Table 2 shows the GP registered prevalence in 2010/11 compared with the East of England Public Health Observatory (ERPHO) estimated prevalence (2011) for CHD, stroke and hypertension in Medway, comparator areas and England in 2010. The gap between diagnosed and undiagnosed cases for these conditions has long been recognised.

      CHD Stroke Hypertension
      Recorded
      prevalence (%)
      Estimated
      prevalence (%)
      Recorded
      prevalence (%)
      Estimated
      prevalence (%)
      Recorded
      prevalence (%)
      Estimated
      prevalence (%)
      Medway 2.8 4.8 1.3 2.1 14.1 29.3
      New and growing towns 2.9 5.1 1.4 2.2 13.5 30.1
      England 3.4 5.8 1.7 2.5 13.5 30.6
      Table 2: GP recorded versus estimated prevalence [1] [2]

      Of the 39,671 people diagnosed with hypertension in Medway, 18.7% of these are uncontrolled [2], and an estimated 19,747 people are undiagnosed [1].

      It is worth noting that in 2010/11, the exception rate in Medway was 6% compared with England where the rates varied between 2.2% to 7.5%.

      Hospital admissions

      Emergency admissions where treatment is unplanned accounts for 59% of the total admissions and this has remained fairly consistent in the last 5 years (Table 3)

        2006/07 2007/08 2008/09 2009/10 2010/11
      Elective 1,577 1,545 1,512 1,743 1,480
      Emergency 2,143 2,105 2,377 2,380 2,300
      Total 3,720 3,650 3,889 4,123 3,780
      Table 3: Trends in Hospital admissions for cardiovascular disease by admission method [3]

      CVD

      Admission rates increase with age and are generally higher for men. In people aged 75 years and over, the emergency admissions rates increase rapidly as elective admission rates gradually declines.

      Figure 2: Age-specific rates of hospital admissions for all cardiovascular disease.
      Figure 2: Age-specific rates of hospital admissions for all cardiovascular disease by gender and admission method, 2010/11 [3]

      The emergency admission rate for CHD in Medway decreased by 23% between 2003/04 and 2010/11. In 2010/11, the emergency admission rate for CHD, all persons in Medway was 201.1 per 100,000 (638 admissions). This is significantly lower than England (225.9 per 100,000) and comparator areas (219.4 per 100,000).

      Figure 3: Trends in CHD emergency admission rate 2003/04 to 2010/11.
      Figure 3: Trends in CHD emergency admission rate 2003/04 to 2010/11 [4]

      CHD emergency admission rates are significantly higher for males (276.9 per 100,000) than females (142.8 per 100,000) and similarly, higher for people living in the most deprived areas of Medway (268.3 per 100,000) compared with those living in the least deprived areas of Medway (178 per 100,000).

      Heart Failure

      The emergency admission rate for heart failure in Medway has decreased by 37.6% between 2003/04 and 2010/11, a higher reduction when compared with England (22%) and other comparator areas (28.4%).

      In 2010/11, the emergency admission rate for CHD, all persons in Medway was 57.4 per 100,000 (206 admissions). This is significantly lower than England (59.8 per 100,000) and lower than comparator areas (58.1 per 100,000).

      Figure 4: Trends in heart failure emergency admissions rates in Medway, 2003/04 to 2010/11.
      Figure 4: Trends in heart failure emergency admissions rates in Medway, 2003/04 to 2010/11 [4]

      Heart failure emergency admission rates are significantly higher for males (71.7 per 100,000) than females (46.4 per 100,000) and similarly, higher for people living in the most deprived areas of Medway (77.4 per 100,000) compared with those living in the least deprived areas of Medway (32.2 per 100,000).

      Stroke

      The emergency admission rate for stroke in Medway has decreased by 28.9% between 2003/04 and 2010/11, a significantly higher reduction when compared with England (4.7%) and other comparator areas (14.2%). The rate of emergency re-admissions within 30 days for Medway is 4.8%. This is higher than England and other comparator areas (3.1% and 3.0% respectively).

      In 2010/11, the emergency admission rate for stroke, for all persons in Medway was 77.2 per 100,000 (251 admissions). This is lower than England (85.7 per 100,000) and lower than comparator areas (79.4 per 100,000).

      Figure 5: Trend in stroke rates (DSRs).
      Figure 5: Trend in stroke rates (DSRs), 2003/04 to 2010/11 [4]
      Figure 6: The emergency readmission rate for patients with stroke.
      Figure 6: The emergency readmission rate for patients with stroke, 2010/11 [4]

      Stroke emergency admission rates are significantly higher for males (96.1 per 100,000) than females (60.6 per 100,000) and similarly, higher for people living in the most deprived areas of Medway (108.1 per 100,000) compared with those living in the least deprived areas of Medway (73.4 per 100,000).

      Revascularisation and surgical procedures

      Angiography procedures

      In 2010/11, the angiography rate in Medway was 206.6 per 100,000 (597 procedures). This is significantly lower than England (272 per 100,000) and other comparator areas (285.3 per 100,000).

      The angiography rates in males (296.8 per 100,000) are over twice that in females (123.7) per 100,000, but with no difference in angiography rates between people living in the most deprived areas and those who live in the least deprived areas of Medway.

      Figure 7 shows a steady increase in angiography rates from 2003 onwards, with similar rates in the comparator areas and England as a whole in 2010/11. Angiography rates in Medway have increased by 9.6% between 2003/04 and 2010/11.

      Figure 7: Trends in directly age-standardised angiography rates .
      Figure 7: Trends in directly age-standardised angiography rates [4]
      Revascularisation

      Revascularisation encompasses any intervention that would improve the blood flow. This includes thrombolysis (breaking up the blood clots), angioplasty and coronary artery bypass graft (CABG). Figure X shows that non-elective angioplasty rates in Medway have increased between 2003/04 and 2010/11. Elective procedure rates have also increased in England and the South East Coast .Most of this increase has been observed in non elective procedures.

      Figure 8: Trends in directly age-standardised angioplasty rates.
      Figure 8: Trends in directly age-standardised angioplasty rates 2003/04 to 2010/11 [4]

      The target for the provision of pPCI is to achieve 75% of patients having a call to balloon time in 150minutes. This target has been achieved in Medway (122 minutes)

      In 2010/11, the CABG rate in Medway was 23.2 per 100,000 (69 procedure) less than in 2009/10 (30.4 per 100,000 -88 procedures). This is lower than England (29.6 per 100,000) and higher than South East Coast (30.2 per 100,000).[Figure X]

      Figure 9: Trend in CABG rates.
      Figure 9: Trend in CABG rates [4]

      CABG procedure rates in Medway have decreased by 28.5% between 2003/04 and 2010/11. In England and the comparator areas, CABG procedure rates have decreased by 26.2% and 26.7% respectively. In Medway, as expected, revascularisation rates for people who live in the most deprived areas are greater than those who live in the least deprived areas.

      Cardiac Devices

      The treatment of arrhythmias often results in the implantation of devices, such as pacemakers for slowing rhythm disturbances, implantable cardioverter debrifillators (ICD) for tachycardia and cardiac synchronisation therapy (CRT) devices for patients with heart failure and conduction disorder. The new ICD rate for Medway (106.1 per 100,000) is higher when compared to England (72 per 100,000). New pacemaker implant and total cardiac resynchronisation therapy device procedure rates in Medway are lower when compared to England.

      Mortality

      The CVD mortality rate in Medway for people under 75 was 65.6 per 100,000, a reduction by over 60% between 1995 and 2010. This reduction has been observed for both men and women in Medway as well as in other parts of the country.

      Figure 10: Trends in directly age--standardised mortality rate from cardiovascular disease .
      Figure 10: Trends in directly age–standardised mortality rate from cardiovascular disease (under 75s), 1995–2009 [5]

      In 2008–10, the CVD mortality for all persons in Medway was 174 per 100,000. This is higher than England (167 per 100,000) and lower than the comparator areas (166.2 per 100,000).

      CVD mortality rates in Medway are significantly higher for males (224.7 per 100,000) than for females (134.6 per 100,000) and similarly, higher for people living in the most deprived areas of Medway 227 per 100,000) when compared with those living in the least deprived areas of Medway (141.1 per 100,000).


      References

      [1]   Eastern Region Public Health Observatory. Model Disease estimates for PCTs in England 2011; Association of Public Health Observatories. http://www.erpho.org.uk .
      [2]   The NHS Information Centre for Health and Social Care. The Quality and Outcomes Framework
      [3]   Health Informatics System Business Intelligence. Secondary User Service
      [4]   South East Public Health Observatory. Cardiovascular disease PCT health profile - Medway 2012; South East Phublic Health Observatory. http://www.sepho.org.uk/NationalCVD/docs/5L3_CVD%20Profile.pdf .
      [5]   The NHS IC Indicator Portal. Dataset: 1.1 Under 75 mortality rate from cardiovascular disease 2011;
    • Current services in relation to need

      Prevention and Detection

      Primary prevention concentrates on altering modifiable lifestyle factors including diet, exercise and obesity as well as stopping smoking and reducing alcohol intake at a population level to reduce the risk of developing CVD. The association between CVD and socio-economic factors such as housing, education, employment and leisure is complex and intertwined with other factors such as smoking and nutrition.

      NHS Health checks programme in Medway is provided to people aged 40–74 years by all Medway GP practices and through an outreach programme aimed at targeting the hard to reach groups. This is followed by personalised lifestyle advice, individually tailored management and treatment. A Depression Risk Filter was piloted in 2011 in the outreach NHS Health Checks programme in a sub set of the population to identify people in the working age population, at risk of depression or already experiencing associated symptoms and who are not in contact with appropriate support systems or relevant health services.

      GPs keep disease registers to facilitate the management of patients with chronic diseases (including CVD) to support the planning and provision of health care, monitoring the burden of ill health in the population and the impact on services.

      Secondary Care

      In April 2010, the Kent Cardiovascular Network led the implementation of a primary angioplasty service (pPCI) to treat patients who have suffered an ST-elevated Myocardial infarction (STEMI).

      Cardiac imaging and diagnostics

      The provision of cardiac imaging across Kent and Medway is limited, All trusts provide echocardiograms and angiography but there is limited cardiac computerise tomography (CT), myocardial perfusion imaging (MPI) and no cardiac magnetic resonance imaging (CMRI).This means patients requiring these service have to travel either within Kent for local service or to London for CMRI,.

      Community services

      Arrhythmia service

      In November 2010, a community Arrhythmia service was set up to identify people with arrhythmia and ensure appropriate treatment was made available to prevent the onset of stroke.

      Cardiac rehabilitation

      The NHS National Service Framework for Coronary Heart Disease (NSF CHD) states that 80 per cent of people who have bypass surgery or heart attacks, should receive cardiac rehabilitation. Previous surveys of the provision of cardiac rehabilitation in the UK have shown that patients attending these programmes tend to be male, middle aged, and diagnosed with uncomplicated myocardial infarction (MI).

      In Medway, for Phase 1 and 2, PCT based staffs provide this service to Medway Foundation Trust. Phase-3 of the programme is delivered by Medway Community Health Care from various locations including healthy living centres and local authority sports centres. A needs assessment is underway to assess local needs for this service across Kent and Medway.

    • Projected service use and outcomes in 3--5 years and 5--10 years

      Based on Projecting Adult Needs and Service Information (PANSI), it is estimated that in 2011, 1,317 people aged 18 years and over who have had a stroke will be left with a long standing health condition caused by a stroke in Medway. This number is estimated to rise to 1,821 by 2030, a 38% increase.

      Figures 1 and 2 show the modelled prevalence estimates and projections of CHD and Stroke In Medway up 2020.

      Figure 1: Modelled estimates and projections of CHD prevalence.
      Figure 1: Modelled estimates and projections of CHD prevalence [1]
      Figure 2: Modelled estimates and projections of Stroke prevalence
      Figure 2: Modelled estimates and projections of Stroke prevalence [1]

      The Department of Health has re-modelled revascularisation rates up to 2015. using three activity rates (low, medium, high). The projected national revascularisation rates of 1900, 2200 and 2500 per million in 2015 have been based on the cardiac stocktake (South East) methodology. These rates varied across Kent and Medway, when adjusted for age, sex and relative mortality.


      References

      [1]   Eastern Region Public Health Observatory. Model Disease estimates for PCTs in England 2011; Association of Public Health Observatories. http://www.erpho.org.uk .
    • Evidence of what works
    • Unmet needs and service gaps


      • Gaps between the recorded and estimated CVD prevalence for Medway
      • Variation in the cardiac device implantation rates across Kent and Medway but also the ICD and CRT rates for Medway is below the national target.
      • There is a huge variation in the provision of cardiac rehabilitation programme across Kent and Medway.
      • The rates of angiography procedures in Medway are significantly lower compared to the national rate.
      • Delay discharge for stroke patients under 75 years back to their usual place of residence in Medway when compared to England.
      • Of the people diagnosed with hypertension, 18.7% are uncontrolled and over 19,700 are undiagnosed.
      • No data available on the estimated number of deaths from CHD due to poor psychological well being or the number of avoidable CVD deaths following increase in psychological well being.

    • Recommendations for Commissioning


      • Work with primary care to improve the completeness and quality of disease register; ensure optimal control of hypertension and cholesterol. Encourage audit of all premature CVD deaths at practice level.
      • Raise public awareness about CVD within Medway to address inequity, ensuring that this is aligned with already existing programmes which focus on healthy lifestyles.
      • Prioritise smoking cessation targeting young people and pregnant women.
      • Support the implementation of Outreach Health Check programme, targeting men, people aged 50-54 years, black and minority ethnic groups including people living in the more deprived areas of Medway.
      • Improve joint health and social care commissioning arrangements to effectively target high risk and social disadvantaged groups, applying evidenced based social marketing techniques and evaluation.
      • The diagnostic pathway should be improved in line with NICE guidance
      • Local Cardiac Magnetic Resonance Imaging (CMRI) service for the patients in Kent & Medway should be developed to reduce referrals into London.
      • Ensure that work is done to investigate further and reduce the variation in device implantation.
      • Review the rates of repeated revascularisation with a view to assess the long term cost.
      • Ensure improvement to care pathways so that patients undergoing surgery outside the county, can access pre and post surgery care within a local setting.
      • Ensure the completion of the cardiac rehabilitation needs assessment to inform resource needed to provide an efficient and equitable service.
      • Ensure that services are commissioned to meet the needs of people with CVD who have mental illness

    • Recommendations for needs assessment work


      • Monitor outcomes of stroke survivors including the ability to return to usual place of residence.
      • Review re-revascularisation procedure rates in Medway

  • Dementia
    • Summary

      Dementia is a global term used to describe a range of neurological disorders characterised by a decline in intellectual and other mental functions. It can affect people of any age, but is most common in older people and age is the greatest risk factor for dementia.

      Dementia affects one in fourteen people over the age of 65 and one in six over the age of 80. However, dementia is not restricted to elderly people: there are 15,000 people under the age of 65 with dementia in the UK, although this figure is likely to be an underestimate[1].

      Dementia costs the UK economy 23 billion pounds per year. This is more than cancer and heart disease combined. The average care costs per person are £29,000 per year[2].

      In the Medway local authority area in 2012, there were estimated to be 2,587 people living with dementia with 2,523 being over 65 years old. The number estimated for the registered population for Medway CCG is 2,783. Data from the Quality and Outcomes Framework primary care dementia registers in 2012/13 have only identified 1,332 patients in Medway as having dementia. The diagnosis rate of dementia for Medway CCG population is 47.87%, which is higher than the Kent and Medway average of 42.94% and the South of England average of 45.65%.

      Key issues and gaps

      1. Between 2012 and 2037, the number of older people living in Medway with Dementia is expected to increase from approximately 2,500 to 5,600. This is driven by projected changes in the age structure of the population. This will represent a huge challenge as current services will have to nearly double in capacity if in their present form or different approaches will need to be found. 45% of these will be likely to have moderate to severe dementia.
      2. Development of a clearly described integrated care pathway for dementia would assist both people living with the condition and professionals supporting people to access services without increasing the stresses and anxieties already likely to be present in people's lives.
      3. Current under-reporting in primary care (which is an issue nationally) and variation in primary care in quality of dementia care needs to be addressed to improve early diagnosis and intervention.
      4. Improving professional understanding and appropriate management of dementia is an ongoing need. This is the case for all health and social care professionals, including doctors, care staff and acute hospital staff.
      5. There is still stigma associated with dementia which means that people may be reluctant to seek help for themselves or their loved ones. Further campaigns (e.g. Dementia Friends) to change public perception and reinforce the importance of early diagnosis need to be supported locally.
      6. 24/7 practical support to carers needs to be further developed to ensure that people living with dementia are supported to remain in their own homes for as long as possible and for any admissions to acute settings can be as short as possible.
      7. Local stakeholder events have indicated that some support services are working well but there is a need for more support to carers, better information, earlier diagnosis but with additional support, clear pathways to services and better integration and coverage of what is available to ensure equality of opportunity across Medway. The absence of services for people with a learning disability who also develop a dementia illness was highlighted as a significant issue.

      Recommendations for Commissioning


      • The aims of the Dementia Strategy are being developed to take into account the growing needs within the Medway population and in recognition of changing priorities within health and social care. The Dementia Strategy when complete should inform commissioning activity on behalf of both Adult Social Care and the CCG.
      • Public awareness about dementia and its effect on people's lives should be the focus of attention within the community of Medway and the creation and support of a local Dementia Action Alliance is seen as the most effective was of becoming a dementia friendly community.
      • The role of the GP is central to meeting people's needs and there should be a continued development of understanding for the importance of early diagnosis, treatment through medication, and the care and support that is available through social care services including those provided by the independent sector.
      • The role and importance of the carer should be incorporated into the Strategy and supported by the commissioning options selected for implementation. A focus of attention will need to be given to ensuring that services are available to avoid and manage crises that might lead to avoidable hospital or care home admissions.
      • The Dementia Strategy should set out in the form of clear pathways the journey that people with a developing dementia disease are expected to take. Together with clear pathways there is a need to develop ways that information, guidance and support can be understood and available in easy to understand formats. Options being considered for practitioner and patient signposting should continue to be explored.
      • Achieving a dementia friendly community is one where people living with dementia can do so in a way that promotes a sense of value and ability to make a continued meaningful contribution to the community. The strategy will need to be developed from an understanding of the needs and aspirations heard from listening carefully to people living with dementia, both the person with the condition and their carers.
      • To ensure services provide quality at each point on a person's dementia journey, support and development will be necessary within the care home sector.


      References

      [1]   Emiliano DA, Banerjee PS, Dhanasiri S, et al. Dementia UK: The Full Report 2007; Alzheimer's Society. http://alzheimers.org.uk/site/scripts/download.php?fileID=2 .
      [2]   Health Economics Research Centre UoO. Dementia 2010: The economic burden of dementia and associated funding in the UK 2010; Alzheimers Research Trust. http://www.herc.ox.ac.uk/pubs/downloads/dementiafullreport .
    • Who's at risk and why?

      Dementia is a clinical syndrome characterised by a widespread loss of mental function, including memory loss, language impairment, disorientation, change in personality, self-neglect and behaviour which is out of character. [1]

      Risk factors

      The most important risk factor is age. Other risk factors are learning disabilities, socio-economic status and alcohol.

      Age and sex

      The table below shows estimated prevalence rates from the most recent consensus exercise [2] broken down by age group. Most dementia is late onset (affecting people aged 65 and over) with about 1 in 40 cases being early onset (up to the age of 64 years).

        Female rate per
      100,000 population
      Male rate per
      100,000 population
      30-34 9.5 8.9
      35-39 9.3 6.3
      40-44 19.6 8.1
      45-49 27.3 31.8
      50-54 55.1 62.7
      55-59 97.1 179.5
      60-64 118.0 198.9
      Table 1: Prevalence of early onset dementia in the UK by age and gender [2]
        Female percent Male percent
      65-69 1.0 1.5
      70-74 2.4 3.1
      75-79 6.5 5.1
      80-84 13.3 10.2
      85-89 22.2 16.7
      90-94 29.6 27.7
      95+ 34.4 30.0
      Table 2: Prevalence of late onset dementia in the UK by age and gender [2]

      Tables 1 and 2 highlight the importance of age as the key risk factor for dementia. 1–1.5% of 65–69 year olds are likely to have dementia compared with 30–35% of adults over 95. The prevalence of dementia increases significantly with age. A higher proportion of females experience dementia than males.

      Learning disabilities

      Early onset dementia can be linked to learning disabilities and there is a suggestion of increasing levels of alcohol related dementia. Not only can people with learning disabilities have an increased risk of developing dementia but the early stages of the condition can be missed or misinterpreted. As people with learning disabilities are living longer there is an increasing need for awareness and early detection of the condition. A study of people with Down's syndrome found the following prevalence of Alzheimer's disease: [3]
      • 30–39 years: 1 in 50
      • 40–49 years: 1 in 10
      • 50–59 years: 1 in 3
      • 60–69 years: more than half

      Studies have also shown that in later life almost all people with Down’s syndrome develop the changes in the brain associated with Alzheimer's disease, although not all develop the symptoms of Alzheimer's.

      Studies suggest the numbers of people with learning disabilities other than Down's syndrome who have dementia are approximately: [3]


      • 50–65 years: 1 in 10
      • 65–75 years: 1 in 7
      • 75–85 years: 1 in 4
      • 85+ years: nearly three-quarters

      These numbers indicate a risk about three to four times higher than in the general population.

      Socio-economic status

      The rate of cognitive problems has been found to be higher in people of lower social class and lower educational achievement. [4]

      Alcohol

      This is important particularly with respect to Korsakoff's dementia which is reported to affect 12.5% of dependent drinkers.

      Types of dementia

      There are a number of types of dementia which are caused by different diseases of the brain. These different types of dementia are associated with different risk factors.

      The most common type is Alzheimer's disease, affecting about 62% of those with dementia. Vascular dementia (17%), including multi-infarct dementia and Lewy Body dementia, are the next most common forms as well as mixed presentations. About 10% of people with dementia have both Alzheimer's disease and vascular dementia.

        Proportion of people
      with dementia
      Alzheimer’s disease 62
      Vascular dementia 17
      Mixed (AD and VD) 10
      Dementia with Lewy bodies 4
      Frontotemporal dementia 2
      Parkinson’s dementia 2
      Other 3
      Table 3: Types of dementia [2]
      Alzheimer's

      A physical disease affecting the brain leading to the death of brain cells. It is a progressive disease that becomes more severe over time. It is characterised by confusion and memory loss, mood swings, social withdrawal and poor social functioning.

      The primary risk factor is age. There is some evidence of genetic factors and also smoking and hypotension have been linked to increased risk of getting Alzheimer's.

      People with Downs Syndrome have increased risk of getting Alzheimer's due to chromosomal abnormalities

      Vascular Dementia

      Certain factors can increase a person's risk of developing vascular dementia. These include:
      • a medical history of stroke, high blood pressure, high cholesterol, diabetes (particularly type II), heart problems, or sleep apnoea (where breathing stops during sleep)
      • a lack of physical activity, drinking more than recommended levels of alcohol, smoking, eating a fatty diet, or leaving conditions such as high blood pressure or diabetes untreated
      • a family history of stroke or vascular dementia
      • gender - men are slightly more likely to develop vascular dementia
      • an Indian, Bangladeshi, Pakistani, Sri Lankan or African Caribbean ethnic background

      Mixed dementia — Alzheimer's and Vascular

      It is estimated that this form of dementia consists of 10% of the total number of people diagnosed with a dementia. Dementia with Lewy Bodies (DLB) and Parkinson's Disease Dementia (PDD) If symptoms of dementia are noted with a year of the person being diagnosed with Parkinson's, a diagnosis of DLB will be made. This is caused by tiny spherical protein deposits that develop inside nerve cells in the brain. These interrupt the brains normal functioning affecting the person's memory, concentration and language skills. If the symptoms appear over a year after the Parkinson's diagnosis, a diagnosis of PDD will be given.

      Korsakoff's / Alcohol-related dementia

      Those affected tend to be men between the ages of 45 and 65 with a long history of alcohol abuse. Although numbers affected by Korsakoff's are small (component of 'other' forms of dementia which make up 3% total cases), it is reported to affect 12.5% of dependent drinkers and has implications for health and social care services as it affects a younger age group where dementia support is targeted at older people.

      Other dementias

      Included in this are Fronto-Temporal Dementia (2% of total) along with less common types such as CJD.


      References

      [1]   Department of Health. National Framework for Older People 2001;
      [2]   Emiliano DA, Banerjee PS, Dhanasiri S, et al. Dementia UK: The Full Report 2007; Alzheimer's Society. http://alzheimers.org.uk/site/scripts/download.php?fileID=2 .
      [3]   Alzheimer's Society. Factsheet: Learning disabilities and dementia 2011;
      [4]   Ott A, Breteler M, van Harskamp F, et al. Prevalence of Alzheimer's disease and vascular dementia: association with education, the Rotterdam study British Medical Journal 1995; 310: 970-3.
    • The level of need in the population

      Local prevalence

      In the Medway local authority area in 2012, there were estimated to be 2,587 people living with dementia with 2,523 being over 65 years old. The number estimated for the registered population for Medway CCG is 2,783. Data from the Quality and Outcomes Framework primary care dementia registers in 2012/13 have only identified 1,332 patients in Medway as having dementia. The estimated prevalence of dementia for Medway CCG population is 47.87%, which is higher than the Kent and Medway average of 42.94% and the South of England average of 45.65%.

      Figure 1: Estimated prevalence of Dementia in people aged 65 years and over.
      Figure 1: Estimated prevalence of Dementia in people aged 65 years and over [1] Notes: Age-sex prevalence estimates have been taken from Dementia UK 2007 report produced for the Alzheimer’s society by King’s College London and the London School of Economics. [2]

      The prevalence rates have been applied to ONS population projections of the 65 and over population to give estimated numbers of people predicted to have dementia in 2012. These numbers are shown above the bars.

      Severity of need

      The severity of dementia is normally classified as mild, moderate or severe. At any one time about 55% of the population who have dementia will have mild dementia, 32% moderate dementia and 13% severe dementia. [2] The table below shows this in more detail broken down by age group. Applying the estimates in the first column to the Medway population numbers the second column shows the estimated total number of people in 2012 with mild, moderate and severe dementia.

        Mild.num Mild.pc Mod.num Moderate.pc Sev.num Severe.pc
      65-69 101.0 62 52.0 32 10.0 6
      70-74 157.0 63 75.0 30 17.0 7
      75-79 244.0 57 133.0 31 51.0 12
      80-84 349.0 57 196.0 32 67.0 11
      85-89 318.0 54 194.0 33 77.0 13
      90+ 226.0 47 158.0 33 91.0 19
      Table 1: Measures of subjective wellbeing in Medway compared with the southeast and England 2012.
      Source: Office for National Statistics

      Level of need for care

      Many of those with severe dementia, especially those over 85, have a combination of mental and physical problems. [3] On average, people with dementia live for seven or eight years after the problem has been first diagnosed, although there are wide individual variations [3]

      The Dementia UK 2007 report [2] estimates that 63.5% of people with late onset Dementia (aged 65 years and over) live in private households (the community) and 36.5% live in care homes. Applying these percentages to current Medway estimates, suggests that about 1,590 people with dementia are living in the community and 932 in care homes.

      Figure 2: Estimated number of people with dementia in Medway by residence type.
      Figure 2: Estimated number of people with dementia in Medway by residence type [2]

      Another way of understanding the level of need for care is to use the concept of “interval of care” [4] developed for use with older people.

      Using these classifications the table below shows the number of people in Medway aged 65 and over currently in these groups.

        Care interval/ndescription Requirement Proportion of/npeople/nwith dementia Number of/npeople/nin Medway
      1 critical (critical interval) constant care or supervision needed 34% 858
      2 substantial (short interval) care needed at regular intervals during the day for dressing, meals etc 48% 1,211
      3 moderate (long interval) care needed once a week 11% 278
      4 low (independent) care considered 6% 151
      Table 1: Care intervals [5]

      Carers needs


      • Many of the carers of older people with dementia are themselves fairly old.
      • Carers of people with dementia generally experience greater stress than carers of people with other kinds of need, nearly one-half having some kind of mental health problem themselves

      As can be seen above the majority of people living with dementia live at home. Supporting carers needs is essential if this situation is to continue especially as number of people with dementia increase.


      References

      [1]   Institute of Public Care and Oxford Brookes University. Projecting Older People Population Information System 2010;
      [2]   Emiliano DA, Banerjee PS, Dhanasiri S, et al. Dementia UK: The Full Report 2007; Alzheimer's Society. http://alzheimers.org.uk/site/scripts/download.php?fileID=2 .
      [3]   The Audit Commission. Forget Me Not: Developing Mental Health Services for Older People in England 2000; The Audit Commission.
      [4]   Melzer D, Pearce K, Cooper B, et al. Healthcare needs assessment: the epidemiologically based assessment reviews - 1st Series, 2nd edition 2004;
      [5]   London Centre for Dementia Care. London Borough of Sutton Older People with Dementia Service Redesign 2008; University College London. http://www.dhcarenetworks.org.uk/_library/Sutton_Borough_dementia_needs_assessment.pdf .
    • Current services in relation to need

      Primary care

      The number estimated for the registered population for Medway CCG is 2,783. Data from the Quality and Outcomes Framework primary care dementia registers in 2012/13 have only identified 1,332 patients in Medway as having dementia. The estimated diagnosis rate for Medway CCG population is 47.87%, which is higher than the Kent and Medway average of 42.94% and the South of England average of 45.65%. The diagnosis rate has fewer than half of the population who are estimated to have dementia receiving a diagnosis. This could be due to a number of factors including late presentation and underdiagnoses. Nationally late diagnosis has been recognised as a problem and earlier diagnosis could be more cost effective in that it could slow progression of the disease and reduce costs. There are a number of actions being undertaken to improve the diagnosis rate. These include;


      • Medication analysis — using Audit Plus to identify patients who have been prescribed dementia medication but who do not have a recorded diagnosis
      • Coding cleansing — based on work undertaken at Waltham Forest CCG to support GPs to identify problems in coding, which are contributing to low rates of dementia diagnosis on practice registers.

      • Care Home Population analysis — Liaison with care homes to identify residents who clearly have dementia and liaise with practices to check that formal diagnoses have been made

      The central role of GPs is recognised in the Dementia Strategy and initiatives are being developed to develop a greater understanding and awareness of the importance of early diagnosis, treatment and providing patients and carers with meaningful information about care and support services that are available through the NHS, Adult Social Care and the independent sector.

      An overriding approach adopted by the Dementia Strategy will see integration with the CCG's key clinical strategies and the Partnership Commissioning themes within the Better Care Fund. Knitting together the various strands that make up the communities complex needs is vital to ensuring those needs are met.

      Statutory services are trying hard to work together to ensure that the services they provide offer people a coherent pathway as their dementia illness develops and needs become more complex. Most people will approach their GP when they feel that something is not right and support is being provided to local Practices to help Doctors and other professionals gain a better understanding of dementia and the importance of obtaining an early diagnosis.

      Secondary care

      Medway Foundation Trust have made dementia the focus of much work in the last year and opened the dedicated Bernard unit to support people with dementia whilst they receive treatment. The Trust has also adopted the Butterfly scheme which allows people with memory impairments to request a particular person centred approach to their care – this operates throughout the hospital. In addition to these initiatives dementia awareness training for staff working in the hospital has also been given a priority.

      Kent and Medway NHS and Social Care Partnership Trust (KMPT) take referrals from GPs where there is an indication of a dementia disease and support people through an assessment process with both pre and post diagnostic counselling as part of their memory assessment service. This support is provided through a multi-disciplinary team which includes Admiral Nurses, who are mental health nurses that specialise in dementia. KMPT provide on-going support and guidance with the aim of working in a shared care approach with a person's GP.

      Community care

      Current services to support people living with dementia are wide and varied but are not always known about and those that operate in one area may not be present in another. There are dementia cafes run by voluntary sector organisations that provide an opportunity for those people with dementia and their carers to come together in an informal setting for mutual support and guidance. Organisations such as the Alzheimer's Society, Age Concern and the Sunlight Trust provide valuable support by telephone and face to face to help people deal with daily lives that are affected by dementia.

      Medway Community Healthcare (MCH) provide community based services and are registered to run Darland House a specialist residential facility providing nursing care to older people with mental health needs which are predominantly associated with dementia. Darland House offers people with complex needs an opportunity for careful assessment and for care plans to be developed that will help people live with needs that are often felt as very challenging to less specialist facilities.

      Medway Community Healthcare (MCH) provide a Dementia Support Service with a multidisciplinary team lead by an Admiral Nurse which responds to and works to prevent crises that might occur in people's homes where the main support for a person with dementia is being provided by a carer. It is the aim of the service to avoid, where possible and appropriate, an admission to hospital or care home. A move away from a familiar setting can be a highly traumatic experience which may exacerbate a decline in the person's wellbeing. Where a person is admitted to hospital it is important that where possible and appropriate that a return to home is arranged as early as possible and the hospital's new Integrated Discharge Team will work with the Dementia Support Service and Adult Social Care to ensure this is achieved.

      MCH are also overseeing a scheme that employs two Carer Support Coordinators from Carers First, with one being based with the Dementia Support Service in the community and the other based with the Integrated Discharge Team at Medway Maritime Hospital. This scheme provides support to carers to reduce the risk of crisis leading to avoidable hospital admissions or to support an earliest possible discharge.

      Medway's Council for Voluntary Service has been commissioned by Medway Council to achieve the following outcomes in the local area: Capacity Building; Co-ordination, Networking and Engagement; Encouragement and Development of Volunteering; Representation; Information, Support and Training

      A crisis support team has provides 24/7 support for people in dementia and their carers in the home when this support is needed.

      Residential care

      Medway Community Healthcare (MCH) provide community based services and are registered to run Darland House a specialist residential facility providing nursing care to older people with mental health needs which are predominantly associated with dementia. Darland House offers people with complex needs an opportunity for careful assessment and for care plans to be developed that will help people live with needs that are often felt as very challenging to less specialist facilities.

      In Medway, there are twelve independent sector nursing homes registered with the Care Quality Commission and most of these will support older people many of whom are likely to have varying degrees of dementia. However there are few dedicated nursing homes providing care to people with complex and often challenging needs arising from their dementia. A pilot scheme will provide these homes with additional support through a multi-disciplinary team in the form of the Integrated Care Home Model. The aim of this scheme is to support homes to achieve an equal and improved standard of care and reduction on secondary care services.

      Acute inpatient care at Medway Foundation Trust

      A psychiatric liaison team is in place at Medway Maritime Hospital who are also able to support appropriate management of Emergency Department attenders and inpatients with dementia. MFT and KMPT are currently developing a dementia pathway within Enhancing Quality Programme. This will include appropriate screening on entry during any stay and onward referral into dementia services and/or primary care or a return home with additional support services.

    • Projected service use and outcomes in 3--5 years and 5--10 years

      The most significant challenge with respect to the provision of dementia care is the increase in the ageing population over the next 20 years. The graph below illustrates the expected growth.

      Figure 1: Trends in estimated number of people living in Medway with Dementia aged 65 years and over
      Figure 1: Trends in estimated number of people living in Medway with Dementia aged 65 years and over [1]
        2012 2017 2022 2027 2032 2037
      Females 1,629.0 1,798.0 2,056.0 2,495.0 2,904.0 3,359.0
      Males 893.0 1,068.0 1,304.0 1,583.0 1,916.0 2,224.0
      Persons 2,522.0 2,866.0 3,360.0 4,078.0 4,820.0 5,583.0
      Table 1: Trends in estimated number of people living in Medway with Dementia aged 65 years and over [1] Please note, figures may not sum due to rounding

      Notes: Age-sex prevalence estimates have been taken from Dementia UK 2007 report produced for the Alzheimer's society by King's College London and the London School of Economics. The prevalence rates have been applied to ONS population projections of the 65 and over population to give estimated numbers of people predicted to have dementia.

      Between 2012 and 2037, the number of older people living in Medway with Dementia is expected to increase from approximately 2,500 to 5,600. This is driven by projected changes in the age structure of the population.

      Using the information in previous sections the proportions of the population expected to have mild, moderate or severe dementia the following table illustrates the expected changes over the next 25 years.

        2012 2017 2022 2027 2032 2037
      Mild 1,387.0 1,576.0 1,848.0 2,243.0 2,651.0 3,071.0
      Moderate 807.0 917.0 1,075.0 1,305.0 1,542.0 1,787.0
      Severe 328.0 373.0 437.0 530.0 627.0 726.0
      Total 2,522.0 2,866.0 3,360.0 4,078.0 4,820.0 5,583.0
      Table 2: Trends in estimated number of people living in Medway with Dementia aged 65 years and over by level of severity [1] [2]

      Notes: These predictions are based on prevalence rates in a report by Eric Emerson and Chris Hatton of the Institute for Health Research, Lancaster University, entitled Estimating Future Need/Demand for Supports for Adults with Learning Disabilities in England, June 2004. The authors take the prevalence base rates and adjust these rates to take account of ethnicity (i.e. the increased prevalence of learning disabilities in South Asian communities) and of mortality (i.e. both increased survival rates of young people with severe and complex disabilities and reduced mortality among older adults with learning disabilities). Therefore, figures are based on an estimate of prevalence across the national population; locally this will produce an over-estimate in communities with a low South Asian community, and an under-estimate in communities with a high South Asian community.

      This means there will also be an increase in the number of older people with learning disabilities which will also affect the need for services.


      References

      [1]   Institute of Public Care and Oxford Brookes University. Projecting Older People Population Information System 2010;
      [2]   Emiliano DA, Banerjee PS, Dhanasiri S, et al. Dementia UK: The Full Report 2007; Alzheimer's Society. http://alzheimers.org.uk/site/scripts/download.php?fileID=2 .
    • Evidence of what works

      'Department of Health (2009) Living Well with Dementia: a national dementia strategy': This strategy provides a strategic framework within which local services can; deliver quality improvements to dementia services and address health inequalities relating to dementia; provide advice and guidance and support for health and social care commissioners and providers in the planning, development and monitoring of services provide a guide to the content of high-quality services for dementia.

      'Department of Health (2013) Dementia: A state of the nation report on dementia care and support in England': This Dementia report, with its accompanying map of variation, available at http://dementiachallenge.dh.gov.uk/map/, shines a light on the quality of dementia care in England. The very best services are excellent and show what is possible. But the worst show that we still have some way to go. The message is clear: we can and must do better.

      'Dementia Challenge (2012)': The Prime Minister's Dementia Challenge launched in March 2012. It sets out plans to go further and faster in improving dementia care, focusing on raising diagnosis rates and improving the skills and awareness needed to support people with dementia - and their carers. It also has details of plans to improve dementia research.

      'Dementia Partnerships (2012)': Dr Edana Minghella, proposes a new understanding of the dementia journey and a revised model of care for dementia, aimed at improving experiences and outcomes, and informing service redesign and commissioning.

      'The Prime Minister's Challenge on Dementia (2012): delivering major improvements in dementia care and research by 2015: Annual report of progress': The progress of the Dementia Challenge is overseen by three groups of 'champions'. This is their latest progress report.

      'NICE/Social Care Institute for Excellence (2006) CG42 Dementia: supporting people with dementia and their carers in health and social care': This guideline makes recommendations for the identification, treatment and care of people with dementia and the support of carers. Settings relevant to these processes include primary and secondary healthcare, and social care. Wherever possible and appropriate, agencies should work in an integrated way to maximise the benefit for people with dementia and their carers.

      'NICE (2010) End of life care for people with dementia: commissioning guide: implementing NICE guidance': This commissioning guide has been developed to help support the local implementation of NICE clinical guidelines to commission integrated end of life care services for people with dementia. The guide makes the case for commissioning end of life care for people with dementia, highlighting key benefits.

      'NICE (2011) Dementia: care pathway.': This pathway covers supporting people with dementia and their carers in health and social care. It considers pharmacological and psychosocial interventions.

      'SCIE (2012) End of life care for people with dementia living in care homes': This research briefing is about the care provided in care homes to people with dementia in the period leading up to the end of their lives. It aims to provide an overview of a range of issues important to care home residents, carers and providers.

      'Alzheimers Society (2011) Optimising treatment and care for people with behavioural and psychological symptoms of dementia ': This best practice guide was developed in consultation with an advisory group of leading clinicians specialising in dementia. It is aimed at a wide range of health and social care professionals caring for people with dementia who have behavioural and psychological symptoms to provide evidence-based support, advice and resources.

      'Dementia Partnerships (2014) Dementia: 10 key steps to improving timely diagnosis': This Briefing is designed to support GPs and primary health care teams to improve the recognition, diagnosis and management of dementia.

      Pharmacological Interventions

      There are no drug treatments available that can provide a cure for Alzheimer's disease. Although there are medicines have been developed that can improve symptoms, or temporarily slow down their progression10. Medicines will not be effective for all individuals though. The brains of people with Alzheimer's disease show a loss of nerve cells that use a chemical called acetylcholine as a chemical messenger. The loss of these nerve cells is related to the severity of symptoms that people experience. Donepezil, Rivastigmine and Galantamine prevent an enzyme known as acetylcholinesterase from breaking down acetylcholine in the brain. Increased concentrations of acetylcholine lead to increased communication between the nerve cells that use acetylcholine as a chemical messenger, which may in turn temporarily improve or stabilise the symptoms of Alzheimer's disease.

      Non-Pharmacological Interventions

      An increasing number of non-pharmacological therapies are now available for people with dementia. These include standard therapies such as behavioural therapy, alternative therapies such as art or music therapy and brief psychotherapies such as cognitive behavioural therapy[1]. Each approach is rarely used in isolation, therefore a combination of treatments tailored to the individual requirements of the patient may be necessary.

      Receiving and early diagnosis

      Obtaining an early diagnosis enables a person with dementia and their family to receive help in understanding and adjusting to the diagnosis and to prepare for the future in an appropriate way. This might include making legal and financial arrangements, changes to living arrangements, and finding out about aids and services that will enhance quality of life for people with dementia and their family and friends. Early diagnosis can allow the individual to have an active role in decision making and planning for the future while families can educate themselves about the disease and learn effective ways of interacting with the person with dementia. There is evidence that the currently available medications for Alzheimer's disease may be more beneficial if given early in the disease process[2]. These medications can help to maintain daily function and quality of life as well as stabilise cognitive decline in some people. Early diagnosis allows for prompt access to medications and medical attention.

      Dementia Friendly communities

      A dementia-friendly community is one in which people with dementia are empowered to have aspirations and feel confident, knowing they can contribute and participate in activities that are meaningful to them. Many villages, towns and cities are already taking steps towards becoming dementia-friendly communities. One area that has successfully utilised this model is Motherwell in Scotland. It has involved working with shop assistants, public service workers, religious groups, businesses, police, transport and community leaders.

      Outcomes have been positive and included a range of activities undertake to increase community awareness of dementia including; promotional materials being distributed widely throughout the town, a successful Football Memories event held at Motherwell FC, awareness sessions with local fire fighters, Training of police officers and arrangement with Boots to distribute Alzheimer Scotland helpline cards.


      References

      [1]   S Douglas IJ. . CB. Non-pharmacological interventions in dementia Advances in psychiatric treatment 2004; 10: 171-177.
      [2]   Alzheimer's Society. Factsheet: Learning disabilities and dementia 2011; Alzheimer's Society. http://alzheimers.org.uk/site/scripts/download_info.php?fileID=1760 .
    • User Views

      In March 2012 a report was produced for Medway LINK by Lake Market Research. The executive summary of this report identifying the four key themes coming out of this report is inserted below. The report attempted to ascertain views of carers, providers and people with dementia but struggled to access views from people with dementia. 14 Medway carers were interviewed as part of this work and 10 providers of care. The findings from the report remain relevant and are being tackled by the development of the Dementia Strategy.

      There are some strong themes emerging from this piece of research which were echoed by both carers and providers:

      1. A lack of continuity throughout the dementia journey from diagnosis to end of life
      2. Services fragmented - too many different services not working together
      3. Greater professional understanding and awareness with more personalised care / attention to those with dementia
      4. More public awareness about dementia and reducing the stigma associated with the disease.

      1. A lack of continuity throughout the dementia journey from diagnosis to end of life

      The general consensus here, amongst carers and providers, is that the services on offer are not consistent and do not adapt as the condition worsens. Post diagnosis people generally felt that the services were adequate and it was possible to cope, however this was more to do with the condition being relatively early in its stages and therefore much easier psychologically and physically to access the services on offer. Furthermore with the sufferer being more aware this meant the effectiveness of the service was higher and there was less demand on the carer. As the condition worsened, the general feeling was that it became more difficult to access the types of services which would have made a difference. Furthermore, in the later stages people felt there was limited emergency help and advice twenty four/ seven and that practical help is sometimes needed at all times, to quote “dementia is not 9.00am to 5.00pm”.

      An extension to this theme addressed early onset dementia. Those with this condition often fell into “no man's land” because they were not considered elderly enough to access some of the dementia services on offer to them, or the services on offer were not appropriate due to the age of the person.

      “There appears to be a need to address the gap in service provision from early stages to later stages when the condition is more demanding as well as age considerations in terms of younger people getting dementia and offering services more appropriate for their age”.

      2. Fragmented - too many different services not working together

      Both carers and providers felt that there were lots of services out there but that none of them were joined up. This results in confusion because people are either passed from pillar to post or they don?t know where to start asking for help. The variety of services available is not the issue; it is the lack of communication between them which makes the process patchy. It does not necessarily matter where the person enters the system, as long as that person knows to pass them onto the most appropriate service. Alternatively, people felt there should be a central office / contact that can then refer them onto the most appropriate service or individual.

      Ambivalence can be seen in some of the scoring of the provision of dementia services locally, with scores hovering around the midpoint and tipping slightly towards dissatisfaction. This seems to be more associated with the process one has to go through to get into the system, rather than the quality of the service itself once you are there.

      “More co-ordinated provision of services is needed - a central office or greater communication between services to guide carers / people with dementia through the system to the most appropriate service”.

      3. Greater professional understanding and awareness with more personalised care / attention to those with dementia

      Overall, people felt more training was needed amongst professional staff across the board, this included hospital staff, doctors and care staff. As an example, a person may require medical attention that is separate to their dementia illness and often carers felt the staff did not recognise or understand that a dementia patient will act differently to patients who do not have dementia on the ward. In addition to this, people felt dementia care cannot be generalised; it needs to be specific to the person who has dementia.

      “More recognition of dementia within the professional environment and greater understanding of behavioural changes. Provision of services which offer more personalised activities tailored to individuals rather than generalised day centres to cater for all. Clearly this needs to be balanced with the feasibility of bespoke servicing but a greater understanding of the disease could highlight the benefits of providing more stimulating social activities and improving the quality of life for both carer and patient”.

      4. More public awareness about dementia and reducing the stigma associated with the illness

      There still appears to be a stigma associated with dementia which influences the effectiveness of the services on offer because people are not yet willing to admit they need help or their loved one needs help. Coupled with this, there is limited knowledge of the condition which makes it a daunting prospect to tackle and often problems are kept hidden as a result.

      There is also a sense of determination to just “get on and cope with it”; that it is “part and parcel” of one's commitment to their loved one to care for them. Whilst this is commendable, it seems people cope until it reaches crisis point and then it starts to break down. Acceptance of help earlier on could go some way to preventing it reaching this stage which would require a change in people's perception of dementia and recognition that these services are there to enhance the quality of life for both them and their loved one.

    • Unmet needs and service gaps
      1. Between 2012 and 2037, the number of older people living in Medway with Dementia is expected to increase from approximately 2,500 to 5,600. This is driven by projected changes in the age structure of the population. This will represent a huge challenge as current services will have to nearly double in capacity if in their present form or different approaches will need to be found. 45% of these will be likely to have moderate to severe dementia.

      2. Development of a clearly described integrated care pathway for dementia would assist both people living with the condition and professionals supporting people to access services without increasing the stresses and anxieties already likely to be present in people's lives.

      3. Current under-reporting in primary care (which is an issue nationally) and variation in primary care in quality of dementia care needs to be addressed to improve early diagnosis and intervention.

      4. Improving professional understanding and appropriate management of dementia is an ongoing need. This is the case for all health and social care professionals, including doctors, care staff and acute hospital staff.

      5. There is still stigma associated with dementia which means that people may be reluctant to seek help for themselves or their loved ones. Further campaigns (e.g. Dementia Friends) to change public perception and reinforce the importance of early diagnosis need to be supported locally.

      6. 24/7 practical support to carers needs to be further developed to ensure that people living with dementia are supported to remain in their own homes for as long as possible and for any admissions to acute settings can be as short as possible.

      7. Local stakeholder events have indicated that some support services are working well but there is a need for more support to carers, better information, earlier diagnosis but with additional support, clear pathways to services and better integration and coverage of what is available to ensure equality of opportunity across Medway. The absence of services for people with a learning disability who also develop a dementia illness was highlighted as a significant issue.

    • Recommendations for Commissioning


      • The aims of the Dementia Strategy are being developed to take into account the growing needs within the Medway population and in recognition of changing priorities within health and social care. The Dementia Strategy when complete should inform commissioning activity on behalf of both Adult Social Care and the CCG.


      • Public awareness about dementia and its effect on people's lives should be the focus of attention within the community of Medway and the creation and support of a local Dementia Action Alliance is seen as the most effective was of becoming a dementia friendly community.


      • The role of the GP is central to meeting people's needs and there should be a continued development of understanding for the importance of early diagnosis, treatment through medication, and the care and support that is available through social care services including those provided by the independent sector.


      • The role and importance of the 'carer' should be incorporated into the Strategy and supported by the commissioning options selected for implementation. A focus of attention will need to be given to ensuring that services are available to avoid and manage crises that might lead to avoidable hospital or care home admissions.


      • The Dementia Strategy should set out in the form of clear pathways the journey that people with a developing dementia disease are expected to take. Together with clear pathways there is a need to develop ways that information, guidance and support can be understood and available in easy to understand formats. Options being considered for practitioner and patient signposting should continue to be explored.


      • Achieving a dementia friendly community is one where people living with dementia can do so in a way that promotes a sense of value and ability to make a continued meaningful contribution to the community. The strategy will need to be developed from an understanding of the needs and aspirations heard from listening carefully to people living with dementia, both the person with the condition and their carers.


      • To ensure services provide quality at each point on a person's dementia journey, support and development will be necessary within the care home sector.

    • Recommendations for needs assessment work


      • Further research in relation to support and information needs of BME groups in relation to dementia and the resource implications of dementia prevalence in older people with learning disability.


      • Further research is also required around the dementia needs and the effects on personal identity for Lesbian, Gay, Bisexual and Transgender (LGBT) populations.

  • Dental health in adults
    • Summary

      Oral health refers to the condition of gums, teeth, surrounding bone and soft tissues of the mouth enabling function and being free of disease and pain. Although oral health in England has improved significantly over the past 30 years, not all have benefited from these improvements. According to the national Adult Dental Health Survey of 2009/10, one in five South East Coast adults has untreated tooth decay, most of whom are likely to be from lower socio–economic backgrounds. In addition, some 7% of adults reported experiencing some pain from their teeth or gums at the time of the survey. A significant minority of older adults also suffer from gum disease.

      Tooth decay is largely preventable. The risk factor is a frequent and high sugar diet, which is also common to diabetes and obesity. The availability of topical fluoride such as in toothpastes, varnishes and mouth rinses helps to prevent tooth decay.

      Key issues and gaps


      • Inequality in uptake of primary care dental services
      • Current available data suggest 20% of adults in South East Coast have active tooth decay and 25% of older adults have severe gum disease, with 7% reporting pain
      • The need for specialist dental services needs to be reviewed.

      Recommendations for consideration by commissioners


      • Promote orientation of primary care dental services to focus on prevention in line with Delivering Better Oral Health — a toolkit for prevention (Department of Health, 2009)
      • Improve uptake of services by local residents through provision of information to support uptake
      • Improving access to specialist services
      • Promote development of an appropriate skills–mix workforce in order to meet the dental needs of the population effectively and efficiently
      • Review the provision of domiciliary services according to evolving need
      • Develop oral health promotion initiatives for the elderly and other vulnerable adult groups
      • Develop stronger links between dental services and quit smoking services
      • Robust, annual monitoring and evaluation of dental practices

    • Who is at risk and why

      Marked inequalities in oral health are evident, with people living in areas of material and social deprivation having much higher levels of tooth decay. They are more likely to have high and frequent sugar diets and less likely to brush their teeth. Vulnerable groups of society such as those with a learning disability and mental illness also have poorer oral health.

      Other groups at risk include people in long–term institutional care (such as residential homes, psychiatric hospitals and prisons), homeless people and some refugee and asylum seeker groups. Some minority ethnic groups more likely to be living in areas of disadvantage may encounter language and cultural barriers to accessing care and advice.

      Young men from semi–skilled or unskilled manual backgrounds are less likely to use dental services in the transition from childhood to adult life. Expectant mothers and nursing mothers require special consideration. Elderly people living in residential care tend to have a poorer diet than those living in their own homes. Other vulnerable groups include people requiring palliative care and people undergoing chemotherapy, radiotherapy or a bone marrow transplant.

    • Level of need in the population

      Dental need may be estimated from the latest national Adult Dental Health Survey undertaken in 2009/10.[1] The findings indicate that oral health has improved significantly over the past few decades; for example, 6% of adults were assessed as having no natural teeth in 2009/10 compared to 28% in 1978 (Figure 1). However, as people retain their teeth for longer, the potential for dental diseases increases and the need for maintenance can be substantial. In 2009/10, one in five adults in the South East Coast SHA has active tooth decay and may need fillings, and over two in ten of those aged 55 years and older have severe gum disease that requires periodontal treatment.

      Figure 1: Oral health of adults in the South East Coast SHA compared to the England population.
      Figure 1: Oral health of adults in the South East Coast SHA compared to the England population. *LOA=loss of attachment, PUFA=pain, ulceration, fistula or abscess.[1]

      The findings of the Medway Adult Oral Health Survey 2009 provide a local indication of dental need. In Medway, the proportion of adults with at least one tooth was higher than in England but the proportion with 21 or more teeth was lower, i.e. there may be more people with teeth but the number of teeth present may not be adequate to enable acceptable social functioning.

      A significant 7%, compared to 10% for England, reported experiencing pain from their teeth or gums at the time of the national survey. Current pain was less common in the South East Coast although pain in the last 12 months was more prevalent. It is likely that people who experienced pain in the last 12 months had been able to access services for pain relief and therefore did not experience current pain. Medway adults were more likely than South East Coast adults to report having pain in the past 12 months.

      Experience of dental restorations was similar between South East Coast and England. However, in Medway the proportion having restorations was lower, as was the number of teeth filled or crowned. This comparison is made with caution as the England data were collected clinically whereas the Medway data were self–reported.

      Most adults brushed their teeth at least twice a day. The England ADHS reported that two in ten were current smokers, whereas in the Medway Adult Oral Health Survey, the prevalence of smoking was over 30%. Within Medway, smoking was more prevalent in Chatham, a recognised risk factor in incidence of oral cancer.

      Most adults visited their dentists regularly for check–ups, but a significant minority visited only when in trouble. In Medway a relatively high proportion had never been to the dentist. Among those who had not visited the dentist in the past two years, three in ten in the South East Coast had difficulties finding a dentist.


      References

      [1]   The Information Centre. The Adult Dental Health Survey 2009 2011;
    • Current services in relation to need

      Most NHS dental services are provided in the primary care setting. Dental services are commissioned geographically, but individuals may access any dentist they wish. Since the introduction of the new dental contract in 2006, primary care dental services have been procured in areas of need as identified in PCT's oral health needs assessments (OHNAs). There is some variation in commissioned dental activity across Kent and Medway, however the activity commissioned in Medway is relatively higher than in neighbouring PCT areas. In Medway, 1.9 Units of Dental Activity (UDA) is commissioned per resident compared to 1.2 UDAs per resident in West Kent.

      The use of dental services as measured by numbers of patients seen as a proportion of the population also suggests that Medway is relatively well served compared to neighbouring areas (Figure 1). For example, NHS dental access in Medway is higher than in West Kent. In the 24 months previous to 31 March 2011, the number of patients treated in Medway represented 70% of the Medway adult population (Figure 1). In Medway, there is generally good availability of services however the challenge in Medway is mainly uptake of services. Uptake of services may be improved by raising awareness and improving the information available about the provision of services.

      Figure 1: Dental access of residents in the South East Coast PCTs.
      Figure 1: Dental access of residents in the South East Coast PCTs
    • Projected service use

      Although oral health of adults is improving, there remain social and geographical inequalities in its distribution. Due to falling disease patterns and growing reluctance to have extractions and dentures, people are keeping their teeth longer. This may mean that there are more teeth at risk of decay and large numbers of heavily restored teeth which need expensive long term maintenance by dental services.

      In the report NHS Dental Services in England (2009)[1], Steele recognises the difficulty accessing an NHS dentist is a localised issue, but where it exists it is severe. Improving future capacity is a priority, but this alone will not lead to improved access. Empowering patients with information on how to access dental services through social marketing and ensuring the services are of a high quality are also essential.

      Population projections in Kent and Medway suggest dramatic increase in the elderly population. By 2020, 21% of the local population will be over 65 years, which suggests a high service need for dental care for this age group, and very likely a need for more complex maintenance care because of replacement of existing restorative work. There will be an increase in patients who are housebound or in residential care, meaning an increased need for domiciliary dental services.


      References

      [1]   Steele J. An independent review of NHS dental services in England 2009; Department of Health. http://webarchive.nationalarchives.gov.uk/+/dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_101137?IdcService=GET_FILE&dID=198219&Rendition=Web .
    • Evidence of what works

      Delivering Better Oral Health — a toolkit for prevention provides an evidence base of interventions for prevention of dental diseases in children[1]

      Valuing People's Oral Health provides guidance on the development of services for those with a disability (Department of Health, 2007).

      Dental recall: Recall interval between routine dental examinations provides guidance on the recall of dental attendance based on individual risk (NICE, 2004)


      References

      [1]   Department of Health and the British Association for the Study of Community Dentistry. Delivering Better Oral Health An evidence-based toolkit for prevention - second edition 2009; Department of Health. http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_102331 .
    • Unmet needs

      Although oral health of adults in Kent and Medway has improved, services are needed for those with active tooth decay and older adults with severe gum disease. Additionally, dental access rates are variable across Kent and Medway. Further capacity is needed in some areas, and action is needed to promote equitable access to dental services.

      The changing patterns of dental disease distribution, with older adults experiencing more disease compared to younger adults, means the need for services that are appropriate for complex dental need in those who are likely to be medically compromised and unable to leave their homes because of immobility. Young adults will need prevention services in order to maintain their level of oral health. There is therefore a need to develop specialist or special care dental services in the community setting.

    • Recommendations


      • Promote orientation of primary care dental services to focus on prevention in line with Delivering Better Oral Health — a toolkit for prevention[1]
      • Improve uptake of services by local residents through provision of information to support uptake
      • Improve access to specialist services
      • Promote development of an appropriate skills–mix workforce in order to meet the dental needs of the population effectively and efficiently
      • Review the provision of domiciliary services according to evolving need
      • Develop oral health promotion initiatives for the elderly and other vulnerable adult groups
      • Develop stronger links between dental services and stop smoking services
      • Robust, annual monitoring and evaluation of dental practices


      References

      [1]   Department of Health and the British Association for the Study of Community Dentistry. Delivering Better Oral Health An evidence-based toolkit for prevention - second edition 2009; Department of Health. http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_102331 .
    • Further needs assessment


      • Dental need of adults with a disability that limits their mobility
      • Dental need of older adults in residential and care homes

  • Diabetes
    • Summary

      Diabetes is a disease in which the amount of glucose in the blood is too high because the body cannot use it properly. There are two main types of diabetes:
      • Type 1 diabetes — where the body fails to produce insulin, accounting for 10% of people with diabetes
      • Type 2 diabetes — where the body cannot produce enough insulin and is resistant to what is produced, accounts for the remaining 90% of people with diabetes.

      Type 2 diabetes is often associated with being overweight and usually appears in people over 40, or over 25 in south Asian and African Caribbean people. More recently, a greater number of children are being diagnosed with Type 2 diabetes.

      Diabetes can have profound effects on health. People with diabetes are at increased risk of developing various forms of cardiovascular disease (e.g. angina, heart attacks, heart failure, strokes, pain in the legs on walking and foot ulcers that may result in the need for amputation).[1] Approximately 75% of people with diabetes develop cardiovascular disease. Prolonged exposure to raised blood glucose levels can also damage the eyes, kidneys and nerves. Diabetes is the leading cause of blindness in people of working age, the largest single cause of end stage renal failure and the second most common cause of lower limb amputation. This places a significant burden on health and social services.

      Life expectancy is reduced, on average, by more than 20 years in people with Type 1 diabetes and by up to 10 years in people with Type 2 diabetes.[1]

      Key issues and gaps


      • Diabetes is on the increase in Medway. This might be explained by the increasing prevalence of obesity and an ageing population.
      • There are over 14,065 adults aged over 17 (6.3%) known to have diabetes in Medway (QOF March 2011)
      • By 2030, it is estimated that over 19,000 will have diabetes in Medway. Most of these cases will be Type 2 diabetes mainly because of our ageing population and the rising numbers of people who are overweight or obese
      • Proportion of people with diabetes receiving all 9 care processes
      • There is variation in the management of diabetes in primary care
      • Care for adults with Type 1 on insulin pump is patchy
      • Information on the provision of diabetes services for children and young people
      • Information is on the provision of diabetes services for women with gestational diabetes

      Recommendations for Commissioning

      Commissioning plans for all services for people with diabetes should include:
      • The projected growth in the number of people with diabetes

      Prevention and early intervention


      • Proactively identify people with undiagnosed diabetes and promote timely and appropriate access to services
      • Address increasing incidence of diabetes by targeting high risk groups, promoting prevention, and increasing detection
      • Continue the roll out of Health Checks Outreach programme focusing on men and young age groups. The early detection and active management through the NHS Health Check, tackling: obesity, smoking, poor diet, blood pressure and physical activity should contribute towards prevention of diabetes.
      • Raise public awareness of diabetes and the importance of the screening programme and ensure the service is commissioned to provide at least 80% screening uptake and that appropriate activity is commissioned in secondary care for ongoing treatment and monitoring of people with diabetic eye disease

      Primary care and Community services


      • Implement agreed local pathways for patients' care that would reduce fragmentation and delay
      • Ensure appropriate training and education for health professionals
      • Ensure structured integrated care between primary care, community, acute care and self management
      • Addressing the variations in clinical outcomes between practices will contribute to the reductions in complications and related hospital admissions
      • Review prescribing of drugs for diabetes with a view to discouraging excess prescription of the newly available drugs for diabetes
      • Ensure the provision of a seamless personalised patient centred care plan

      Hospital services


      • Review current service provision for children, young adults and pregnant women
      • Review the commissioning of insulin pumps


      References

      [1]   Department of Health. The National Service Framework for Diabetes: Standards 2002; Department of Health. http://bit.ly/ICJaSC .
    • Who's at risk and why?

      Diabetes is becoming more common in all age groups including children and young people. Type 1 diabetes is not preventable, but Type 2 diabetes is linked with behavioural factors such as being overweight and physically inactive.

      The small but increasing number of children developing Type 2 diabetes at a very early age is linked to their weight and physical inactivity. The maps below show the findings from the National Child Measurement Programme 2009/10. Areas in red indicate places in Kent and Medway, where children are above the South East Coast average for being overweight or obese.

      Figure 1: Proportion of pupils in reception year classified as 'Obese or Overweight'
      Figure 1: Proportion of pupils in reception year classified as ‘Obese or Overweight’ in National Child Measurement Programme 2009/10 by electoral ward in Kent and Medway compared with south east region average
      Figure 2: Proportion of pupils in year 6 classified as 'Obese or Overweight'
      Figure 2: Proportion of pupils in year 6 classified as ‘Obese or Overweight’ in National Child Measurement Programme 2009/10 by electoral ward in Kent and Medway compared with south east region average

      It is estimated that 31.4% of adults living in NHS Medway were obese in 2006–08. This is statistically significantly higher than the whole of England (25%).[1] People living in more deprived neighbourhoods in England are 56% more likely to have diabetes than those in the least deprived areas.

      There is good evidence that lifestyle changes can reduce the risk of progression to Type 2 diabetes in overweight people with impaired glucose tolerance.[2] Once diabetes is present, good management of blood sugar levels and blood pressure can reduce the risk of complications. The main risk factors for developing Type 2 diabetes are:

      Age

      The risk of developing Type 2 diabetes increases with age; most cases of Type 2 diabetes develop in people aged over 40. Currently 47% of the population of Medway are aged 40 or over; this is projected to increase to around 51% by 2030. The proportion of the population aged over 65 is predicted to increase from 13.6% to 20.3% by 2030. This means that a greater proportion of the population of Medway will be at risk of developing diabetes.

      Ethnicity

      Type 2 diabetes is up to six times more common in people of South Asian descent and up to three times more common in those of African and African-Caribbean descent, compared with the white population. These groups are likely to develop the condition at a younger age. It is also more common in people of Chinese descent and other non-white groups.[3]

      Weight

      Over 80% of people diagnosed with Type 2 diabetes are overweight. The more overweight and the more inactive a person is, the greater their risk of developing diabetes. Information on the prevalence of obesity in Medway and levels of physical activity are presented in the healthy weight section (Appendices —> Background papers: Lifestyle and wider determinants —> Healthy weight).

      Waist Circumference

      The greater the waist circumference, the higher the risk of developing diabetes. For women, a waist measurement of 80cm (31.5in) or more confers an increased risk. Amongst men, a waist circumference of 94cm (37in) or more gives an increased risk of developing diabetes; this figure is lower for Asian men where a measurement of 90cm (35in) or more confers increased risk.[4]


      References

      [1]   Association of Public Health Observatories. Health Profile for Medway 2011; Association of Public Health Observatories. http://www.apho.org.uk/resource/view.aspx?RID=50215&SEARCH=medway&SPEAR= .
      [2]   J Tuemilehto and J Lindstrom et al. Prevention of type 2 Diabetes Mellitus by changes in lifestyle amongst subjects with impaired glucose intolerance New England Journal of Medicine 2001; 344: 1343-1350.
      [3]   Department of Health. The National Service Framework for Diabetes: Standards 2002; Department of Health. http://bit.ly/ICJaSC .
      [4]   Diabetes UK. What factors increase the risk of prediabetes? 2009; http://www.diabetes.org.uk/Guide-to-diabetes/Introduction-to-diabetes/What_is_diabetes/Prediabetes/Risk-factors-of-prediabetes/
    • The level of need in the population

      Prevalence

      Table 1 shows an increasing trend in the number of people diagnosed with diabetes in Medway, the South East Coast SHA and England as a whole.

      2006/07 2007/08 2008/09 2009/10 2010/11
      Number Prevalence Number Prevalence Number Prevalence Number Prevalence Number Prevalence
      Medway PCT 10,377 5.0 11,562 5.3 12,583 5.8 13,421 6.0 14,065 6.3
      South East Coast SHA 152,785 4.3 163,161 4.5 173,644 4.8 183,441 5.0 192,333 5.2
      England 1,961,976 4.5 2,088,335 4.8 2,213,138 5.1 2,338,813 5.3 2,455,937 5.5
      Table 1: General Practice recorded Diabetes prevalence (patients aged 17 years and over) [1]

      Recorded and Expected prevalence

      Figure 1 shows the proportion of potentially undiagnosed people for each general practice in Medway.

      Figure 1: Recorded prevalence of Diabetes by general practice as at March 2011.
      Figure 1: Recorded prevalence of Diabetes by general practice as at March 2011 [1] [2]

      The Long Term Condition modelling, suggests that for people in Medway with a diagnosis of diabetes, 11,252 (80%) should be able to achieve blood glucose control (Table 2).

      Table 2: Calculated using APHO prevalence model.
      Table 2: Calculated using APHO prevalence model which is adjusted for age, sex, ethnicity and deprivation [3]

      From QOF data, 6500 (46%) people have achieved glucose control, implying that 4,752 of the 5,326 poorly controlled patients would require additional support to achieve blood glucose control.

      Diabetes complications

      The complications of diabetes are the final outcomes of care. Of all aspects of diabetes they have the greatest costs to the patient and the health service. Complication prevalence is defined as the number of people who have had one or more records of a specific complication over the defined time period.

      Diabetes is associated with a range of complications including eye and foot problems, heart attacks, angina, stroke, kidney disease, nerve damage, sexual dysfunction and short term complications such as hypoglycaemia or diabetes ketoacidosis.

      These complications can lead to an increased need for secondary care (including, emergency services) and social care services. Diabetes data to support this are limited, mainly because the patient's primary diagnosis or cause of mortality is a complication due to diabetes, so it is unlikely that diabetes will be diagnosed or coded. Therefore, only a small number of cases of complications are recorded with a primary diagnosis of diabetes (Figure 2).

      Figure 2: Prevalence of Diabetic Complications.
      Figure 2: Prevalence of Diabetic Complications [4]

      Hospital admissions for diabetes

      Between 91–93% of patients with diabetes are admitted as emergencies. Poor diabetes control further contributes to the need for emergency admissions. In Medway, non-elective admissions have remained persistently higher compared to elective admissions (Figure 3). This is because most admissions are for short term complications such as diabetic ketoacidosis and hypoglycaemia. This is consistent with the variation in inpatient activity: diabetes tool, which showed that more people in Medway with diabetes (48.8%) are more likely to be readmitted as an emergency after a period of care than those without diabetes. [5]

      Figure 3: Trends in hospital admissions by admission method all ages.
      Figure 3: Trends in hospital admissions by admission method all ages (2006/07–2010/11 ) [6]

      Diabetes Retinopathy

      Diabetes retinopathy is the damage to the retina due to complications from the condition and it affects up to 80% of those who have had diabetes for 10 years or more.

      Medway PCT South East Coast England
      Percentage offered
      screening
      Percentage
      uptake
      Percentage offered
      screening
      Percentage
      uptake
      Percentage offered
      screening
      Percentage
      uptake
      Q3 2009/10 94.4 87.4 98.5 78.4 95.8 77.6
      Q4 2009/10 100.0 82.7 98.1 80.6 96.1 77.8
      Q1 2010/11 100.0 84.4 97.0 71.4 96.1 77.1
      Q2 2010/11 100.0 83.6 97.9 75.1 96.8 77.8
      Q3 2010/11 100.0 79.1 92.1 81.3 97.4 78.1
      Q4 2010/11 100.0 92.6 93.6 84.3 98.2 79.3
      Q1 2011/12 100.0 71.5 96.7 83.5 97.1 78.6
      Table 3: Diabetic Retinopathy screening [7]

      Between October 2009 and June 2011, the percentage of people with diabetes offered retinopathy screening in Medway PCT has remained consistently high and has been 100% for the past fifteen months. Over the same period, the percentage attending an appointment has shown a downward trend from 87% to 72%.

      Diabetes and psychological health

      Depressive symptoms affect one in four people with diabetes and it is associated with poor outcomes, lower levels of self care, more days off work and significantly higher medical costs. This group may need significant psychological support. [8]

      Changes in need since last JSNA


      • Increasing trend in diabetes prevalence: In 2010/11, 14,065 people with diabetes were registered with Medway GPs. An additional 2,503 people have been added onto the diabetes register since 2008/09, implying improved identification of people with diabetes as well as increasing trend in diabetes prevalence
      • Establishment of an integrated diabetes service model: An integrated diabetes service is currently being developed for people with diabetes in Medway


      References

      [1]   The NHS Information Centre for Health and Social Care. The Quality and Outcomes Framework
      [2]   Association of Public Health Observatories. Diabetes Prevalence Model
      [3]   Department of Health. Supporting People with Long Term Conditions: An NHS and Social Care Model to support local innovation and integration 2005; Department of Health. http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4122574.pdf .
      [4]   Yorkshire and Humber Public Health Observatory. Diabetes Community Health Profiles 2011; Yorkshire and Humber Public Health Observatory. http://yhpho.york.ac.uk/diabetesprofiles/default.aspx .
      [5]   NHS Diabetes. National Diabetes Inpatient Audit: Full Report 2010; Yorkshire and Humber Public Health Observatory. http://www.yhpho.org.uk/Diabetes_inpatient_audit .
      [6]   Health Informatics System Business Intelligence. Secondary User Service
      [7]   Department of Health. Diabetic Retinopathy Screening Statement
      [8]   Healthcare for London. Diabetes Guide for London 2009; Healthcare for London.
    • Current services in relation to need

      The NHS guidance encourages commissioners and service providers (community services, GPs, secondary services, public health, social care and voluntary sector) to agree local pathways for patient care to improve efficiency in care, reduce fragmentation of services and delay.[1]

      Primary care

      The majority of people with diabetes are managed in primary care. In general practice there is considerable variation between practices in the management of diabetes. Many people with Type 1 diabetes who can be managed in the community are being managed by the acute trust.

      NHS Health Checks are offered through a Local Enhanced Service (LES) contract to all Medway General Practitioners to identify people at risk of heart disease, diabetes and stroke, supporting them in making healthier lifestyle choices and also identifying and treating those with undiagnosed conditions. Between 2010/11 to 2011/12, the programme probably accounted for a significant proportion of the 644 newly diagnosed patients with diabetes in Medway. An outreach Health Check programme was also set up to target those on job seekers allowance, people from Asian origin and manual workers, identified from the evaluation of the programme undertaken in 2010.

      Evaluation of this programme showed that men and younger individuals within the target age group were less likely to attend. This suggests that, further work is required to increase awareness of the Health Check programme within the male and younger population aged 40–59 years.

      Community and Specialist Diabetes Service

      Adult specialist diabetes services in Medway are provided by both Medway NHS Foundation Trust (MFT) and Medway Community Healthcare (MCH). MFT provides a consultant led service with specialist nurse support for inpatients only. MCH provides a specialist nurse service. Both teams have access to podiatry and dietetic support. The care of patients provided between the community and hospital teams is not well coordinated however.

      Patients requiring support from the diabetes specialist nurse in the community are referred to the consultant diabetologists at MFT. Currently, patients who need insulin pumps have to travel to London to receive this service.

      Structured Education Programme

      The PCT has developed a structured education programme for people newly diagnosed with Type 2 diabetes and for those with Type 1 diabetes. It is unclear how many people were seen in this programme, what proportion of them were newly diagnosed cases or what proportion were referred for dietetic support and advice in 2010/11.

      Diabetes Retinopathy Screening Programme

      The PCT commissioned Paula Carr Trust in April 2011 to deliver two main targets:
      • 100% of people with diabetes aged 12 years and over offered screening, using only digital photography within the previous 12 months
      • 80% uptake of screening

      This service is offered from both static and mobile clinics in Medway and patients are referred to the service from GP practices. In Quarter 2, 2011/12, although screening was offered to all eligible patients, 81% attended the service. Uptake of this service has been on the decline since 2009. The service is working with GP practices to improve the accuracy of the screening list, promote the importance of eye screening and the key role of primary care in raising awareness amongst patients.

      Podiatry services

      All newly diagnosed patients have an initial assessment with a podiatrist. The recall of patients with diabetes is arranged by their GP surgery, where annual foot screening is undertaken. This will usually include: foot sensation testing, Doppler foot pulses, foot deformity and footwear inspection and foot risk assessment.


      References

      [1]   NHS Diabetes. Commissioning Diabetes Diagnosis and Continuing Care Services: Supporting, Improving, Caring 2010; NHS Diabetes.
    • Projected service use and outcomes in 3--5 years and 5--10 years
        2010 2015 2020 2025 2030
      Medway 6.8% 7.4% 8.0% 8.5% 9.0%
      South East Coast 7.2% 7.8% 8.3% 8.8% 9.4%
      England 7.4% 8.0% 8.5% 9.0% 9.5%
      Table 1: Estimate of prevalence of diabetes (diagnosed and undiagnosed) in those aged 16+ [1]

      The prevalence of diabetes in Medway in 2010 was estimated to be around 6.8% of the population aged 16 years and over. These estimates are modelled to take account of age, sex, ethnic group and deprivation and are, therefore, subject to a certain amount of uncertainty. For example, the 2010 figure is thought to lie somewhere between 4.9% and 9.8%. Therefore the differences in prevalence between areas in the table above are not statistically significant. By taking into account projected changes in the age structure of the population, combined with observed trends in obesity, the prevalence in Medway is expected to increase to 9% by 2030.

      In contrast, the average prevalence of diabetes recorded by general practices in Medway is 6.3% (approximately 14,000 patients) as at March 2010 according to the Quality and Outcomes Framework which is limited to patients aged 17 years and over. This suggests that approximately 0.5% of the population have undiagnosed diabetes in comparison with estimates of the underlying prevalence in the table above.


      References

      [1]   Association of Public Health Observatories. Diabetes Prevalence Model
    • Evidence of what works

      National Service Framework for Diabetes 2001

      Type 2 Diabetes Clinical Guideline: The management of Type 2 diabetes (update) 2008 Guidance 66 Guidance 43

      NICE, primary prevention of Type 2 diabetes mellitus among high risk black and minority ethnic groups (in progress)

      NICE, diagnosis and management of Type 1 diabetes in children, young people and adults

      Diabetes commissioning

    • User views

      A Health Care Commission survey in 2006 of patients with diabetes found that knowledge of their condition, self-management and involvement in care planning was inadequate.

      Evaluation of the NHS Health Checks programme in 2011 showed that people were generally satisfied with the outreach Health Checks programme and would attend again when invited in 5 years time. A few (21%) said they would have preferred having a glucose test included as part of the screening test.

      A stakeholder workshop was held on 11th March 2011, involving health care professionals and patient representatives. Some of the suggestions from the users were as follows:
      • Improved staff education
      • More and improved cross-boundary working
      • Improved patient education (especially structured education)
      • A high quality seamless diabetes service;
      • Local access to insulin pump therapy for adults;
      • Improved management of in-patient stays.

      Following the workshop, two working groups (Primary Care Working group and the Specialist/Community Care Working Group) were set up to progress the establishment of an integrated diabetes service in Medway to meet the needs of people with diabetes.

      The Medway Diabetes Strategic Change Group have incorporated the views of stakeholders in developing a proposal for the redesign of the local diabetes service towards the provision of an integrated and more efficient model.

      There has been a drive to improve patient experience through better IT systems, developing and enhancing the use of Audit Plus in primary care, improving the use of patient choice and encouraging participation in the National Diabetes Audit.

    • Unmet needs and service gaps


      • Undiagnosed people with diabetes and also the increasing prevalence of diabetes in Medway
      • Variation in care provided in primary care
      • Some newly diagnosed patients in Medway are undertaking a structured education programme, with only a small proportion of all patients with diabetes having been on a structured education programme. According to NICE this should be offered to everyone with diabetes and their carers at the time of diagnosis and thereafter annually.[1]
      • Inadequate provision of Insulin pumps for adults with diabetes
      • Diabetes retinopathy programme- 28.5% did not attend their annual screening.
      • There is currently no provision of psychological support for people with diabetes. NICE recommends that diabetes care teams should have appropriate access to mental health professionals to support them in assessment of psychological dysfunction and the delivery of psychological support[2] and psychological support for Type 2 diabetes, especially for those with complications such as erectile dysfunction and diabetes neuropathy.[3]
      • There is limited information on the extent and quality of care planning for diabetes in Medway. Care planning involves clinicians and patients working together to support diabetes self management. This may include prior notification of test results to patients before their annual review to enable patients enough time to think about the questions they would wish to ask the GP.


      References

      [1]   National Institute for Health and Clinical Excellence. Guidance on the use of patient education models for diabetes, Technology Appraisal 60 2003; National Institute for Health and Clinical Excellence.
      [2]   National Institute for Health and Clinical Excellence. Diagnosis and management of Type 1 diabetes in children, young people and adults, Clinical guidelines CG15 2004; National Institute for Health and Clinical Excellence. http://publications.nice.org.uk/type-1-diabetes-cg15 .
      [3]   National Institute for Health and Clinical Excellence. Type 2 diabetes: the management of type 2 diabetes, Clinical Guidance CG87 2009; National Institute for Health and Clinical Excellence.
    • Recommendations for Commissioning

      Commissioning plans for all services for people with diabetes should include:
      • The projected growth in the number of people with diabetes

      Prevention and early intervention


      • Proactively identify people with undiagnosed diabetes and promoting timely and appropriate access to services
      • Address increasing incidence of diabetes by targeting high risk groups, promoting prevention and increasing detection
      • Continue the roll out of NHS Health Checks outreach programme focusing on men and young age groups. The early detection and active management through the NHS Health Check, tackling obesity, smoking, poor diet, blood pressure and physical activity should contribute towards prevention of diabetes.
      • Raise public awareness of diabetes and the importance of the screening programme and ensure the service is commissioned to provide at least 80% screening uptake and that appropriate activity is commissioned in secondary care for ongoing treatment and monitoring of people with diabetic eye disease

      Primary care and Community services


      • Implement agreed local pathways for patients' care that would reduce fragmentation and delay.
      • Ensure appropriate training and education for health professionals
      • Ensure structured integrated care pathways between primary care, community, acute care and self management
      • Addressing the variations in clinical outcomes between practices will contribute to the reductions in complications and related hospital admissions
      • Review prescribing of drugs for diabetes with a view to discouraging excess prescriptions of the newly available drugs for diabetes
      • Ensure the provision of a seamless personalised patient centred care plan

      Hospital services


      • Review current service provision for children, young adult and pregnant women
      • Review the commissioning of insulin pumps

    • Recommendations for needs assessment work


      • Diabetes and pregnancy
      • Provision of service for children and young adults with diabetes
      • Provision of insulin pumps for adults with Type 2 diabetes

  • End of life
    • Summary

      End of Life care is care that helps people with advanced, progressive, incurable illness and the elderly live as well as possible until they die. It enables the supportive and palliative care needs of both patient and family to be identified and met throughout the last phase of life and into bereavement.

      It includes:[1][2]
      • All adults with advanced, progressive, incurable illness (such as heart failure, advanced cancer, dementia, chronic pulmonary disease, stroke, chronic neurological conditions e.g. multiple sclerosis, motor neurone disease)
      • Care provided in the last year of life (pain management and control of other symptoms)
      • Provision of social, psychological, spiritual and practical support for patients and their carers
      • Care provided in all settings (home, residential and nursing care homes, acute hospital, community hospitals, hospices, prisons and any other institutions)

      People approaching end of life, often have complex needs, requiring support from different agencies in various locations. The National End of Life Care Strategy indicates that the majority of people would prefer to die at home. The strategy highlights the opportunities for health and social care systems working together to provide coordinated care and support, opportunity for patients to discuss their personal needs, choice of where to be cared for and to die, appropriate advice and support for carers at every stage. In 2010, there were over 2000 deaths in Medway, about 52% of these occurred in hospital, 23% at home and 37% in their usual place of residence. The national target is that by 2015, 60% of deaths will occur in people's usual place of residence.

      Key issues and gaps


      • The main barrier to the delivery of good quality end of life care is because people are not identified early enough to provide this care as they are approaching end of life.
      • The majority of people in England would prefer to die at home, however lack of timely access to appropriate community services prevents more people dying in their place of choice. In Medway, over half of the deaths (52%) occur in hospital.
      • In 2010/11, 421 people were on the General Practice Palliative Care register, implying poor identification of patients with end of life care needs especially non cancer patients.
      • Lack of training and support for staff to ensure good end of life care is provided in all residential and care homes.
      • There is no existing mechanism for identifying the needs, wishes and preferences for end of life care for people with dementia.
      • The projected increase of the ageing population in Medway points to the future needs in developing skills in the community if admissions, especially emergency admissions, are to be avoided.
      • Lack of information and data to inform decisions regarding the end of life care needs specific to BME groups, including spiritual and cultural needs.
      • Co-ordination of care and communication between existing End of Life Care providers is inadequate.

      Recommendations for Commissioning


      • Encourage the use of the Gold Standard Framework's (GSF) Prognostic Indicator Guidance in primary care to ensure early identification of people approaching the end stages of their disease.
      • Continued commitment is needed to provide high quality care to enable people in Medway to die in the place of their choice.
      • Ensure workforce development (training and education) around the core competencies as outlined in the EOL Strategy: Assessment of needs and preferences, communication, advanced care planning and symptom management.
      • Encourage joint working and shared resources across all providers, with an identified lead provider coordinating all services that support the EOL pathway.
      • Support the development of a single point of access to services to improve the coordination of end of life services.
      • Voluntary sector organisations should be involved appropriately, especially around issues relating to culture and religion.
      • Disseminate information on integrated health and social care EOL teams to the public, to ensure timely access to continue care funding.
      • Develop a shared IT system to facilitate a more streamlined service through data sharing.


      References

      [1]   The National Council for Palliative Care. Palliative Care Explained
      [2]   Department of Health. National End of Life Strategy - promoting high quality care for all adults at the end of life 2008; Department of Health.
    • Who's at risk and why?

      The National Audit Office's report on end of life care suggests that approximately 40% of patients dying in acute hospitals do not have medical needs requiring hospital stay.[1] In Medway, this equates to about 435 people annually. The report suggests that people approaching end of life and their families are at a difficult time and may be at risk of poor end of life experience if their needs are not being met because they are in an inappropriate setting at the time and therefore not receiving the right and appropriate level of care and support. This issue is exacerbated for patients with a non cancer diagnosis. Early recognition of end of life is particularly problematic for patients with non cancer diagnosis as traditionally, end of life services have been provided to only cancer patients.

      Around half a million people die each year in England. The majority of these deaths occurres in people over 65 following chronic illnesses related to long term conditions such as cancer, heart disease, renal disease, liver disease, chronic respiratory disease, neurological diseases including dementia.[2] This implies, that the proportion of anticipated deaths from a long term condition can be estimated. However, comparison with the number of patients registered on the Quality Outcomes Framework (QOF) palliative care register indicates that patients are not currently being identified in the last year of life. This suggests that adults diagnosed with chronic long term illness nearing the end of life, are at risk of not gaining access to optimal end of life care.

      The Royal College of General Practitioners published the Prognostic Indicator Guidance in 2008.[3] This was to assist GPs identify patients who would most likely require end of life care in the coming year and thus provide through the QOF palliative care register, a more realistic estimate of need.


      References

      [1]   National Audit Office. End of Life Care 2008; National Audit Office. http://www.nao.org.uk/publications/0708/end_of_life_care.aspx .
      [2]   Department of Health. National End of Life Strategy - promoting high quality care for all adults at the end of life 2008; Department of Health.
      [3]   Royal College of General Practitioners. Gold Standard Framework Prognostic Indicator Guidance, Revised version 5 2008; Royal College of General Practitioners. Gold Standards Framework (GSF) Centre, Walsal. http://www.goldstandardsframework.nhs.uk/Resources .
    • The level of need in the population

      Mortality

      From 2003 to 2010, sudden deaths accounted for about 22% of deaths in Medway during this period. Table 1 shows that in 2010, there were over 2,000 deaths in Medway, implying that 1,699 people in Medway who died that year may have benefited from an end of life care.

        Sudden death Not sudden death Total number of deaths % sudden death
      2003 560 1,723 2,283 24.5
      2004 557 1,588 2,145 26.0
      2005 504 1,673 2,177 23.2
      2006 482 1,739 2,221 21.7
      2007 453 1,601 2,054 22.1
      2008 495 1,616 2,111 23.4
      2009 397 1,614 2,011 19.7
      2010 391 1,699 2,090 18.7
      Table 1: Total number of deaths and proportion of sudden deaths in Medway 2003–2010

      Figure 1 shows that the majority of these deaths occurred following a period of chronic illness, where deaths could have been anticipated and care properly planned.

      Figure 1: Number of deaths registered in 2010 in Medway by underlying cause of death
      Figure 1: Number of deaths registered in 2010 in Medway by underlying cause of death

      The three main diseases which contributed to 75% of all deaths were: cancers (neoplasms) -679 deaths (32.5%); circulatory diseases- 557 deaths (26.7%); respiratory diseases -333 deaths (15.9%).

      Death rates increase steeply with age, with 79.4% (1,659) of deaths occurring in people aged over 65 years and 62.4% (1,305) in people over 75.

      Figure 2: Number of deaths registered in 2010 in Medway by age
      Figure 2: Number of deaths registered in 2010 in Medway by age

      Place of death

      Most people die in hospital, although their preferred place of death would be at home as long as high quality care is received with minimal burden to their families and carers.

      In 2010/11, over half (52%) of the 2,090 deaths in Medway occurred in hospital as shown in Figure 3 below.

      Figure 3: Proportion of deaths by place of death in Medway (2010/11)
      Figure 3: Proportion of deaths by place of death in Medway (2010/11)
      Figure 4: Trends in place of death in Medway
      Figure 4: Trends in place of death in Medway

      Figure 5 shows that from 75 onwards the proportion of people dying in hospital increases exponentially.

      Figure 5: Number of deaths registered between January 2008 and December 2010 in Medway by age band and place of death
      Figure 5: Number of deaths registered between January 2008 and December 2010 in Medway by age band and place of death

      In Medway, the proportion of deaths in hospital has fallen from 58% in 2002 to 38% in 2011. In the same period, the proportion of deaths occurring at people's homes increased from 18% in 2002 to 34% in 2011. Figure 4 suggests a significant improvement with more deaths within Medway occurring at home. However, further work is still needed to ensure equality in access to services for all relevant conditions.

      It is worth noting that, more deaths, especially due to respiratory conditions tend to occur during the winter months, between December and March each year.

      Inequalities

      The evidence suggests that there is inequality in end of life outcomes amongst the UK population. The groups experiencing less favourable outcomes include: older people, those with dementia and learning disabilities, those with non-cancer diagnosis and black and minority ethnic (BME) groups.[1]

      In Medway, 72.9% of deaths occur in people over the age of 65 and 62.4% in those over 85, suggesting poor access to end of life services for older people. This group have complex needs due to their frailty, co morbidities and increased reliance on support from older carers.

      Figure 1 shows the number of deaths from cancer (679), circulatory disease (557) and respiratory disease (333). A proportion of these groups will also have had dementia. It is estimated that for those over 85, the prevalence of dementia is 21%.[2] This represents a significant group with unmet needs, people whose preferences for end of life care may not have been identified earlier and then provided appropriate support.

      In 2010, 32.5% of deaths were attributed to cancers in Medway, suggesting a large proportion of patients with non cancer diagnosis. The majority of these patients are older and frailer than those with cancer and thus requiring more support for longer periods.[3]

      Deprivation is a known risk factor for health inequalities and has been identified as a risk indicator for poor end of life care outcomes.[4] Social factors such as deprivation (lower income) increased age, and coming from a minority ethnic descent were associated with fewer home deaths. This may be explained by the lower income and resources available to afford adequate care at home.[5]

      Palliative care register

      The number of deaths due to long term conditions (2,090) when compared with the number of patients registered on the Quality of Outcomes Framework (QOF) palliative care register (421) indicates that patients are not being identified in their last year of life.


      References

      [1]   National Institute for Health and Clinical Excellence. Guidance on Cancer Services: Improving Supportive and Palliative Care for Adults with Cancer: The Manual 2004; National Institute for Health and Clinical Excellence. www.nice.org.uk/nicemedia/pdf/csgspmanual.pdf .
      [2]   Hofman A, Rocca W, Brayne C, et al. The Prevalence of Dementia in Europe: A Collaborative Study of 1980--1990 Findings International Journal of Epidemiology 1991; 20: 736-748.
      [3]   Murray S, Sheikh A. Palliative Care Beyond Cancer British Medical Journal 2008; 336: 958-959.
      [4]   Gomes I. Factors influencing death at home in terminally ill patients with cancer: systematic review British Medical Journal 2006; 332 (7540): 515-521.
      [5]   Higginson I, Jarman B, Astin P, et al. Do social factors affect where patients die: an analysis of 10 years of cancer deaths in England Journal of Public Health Medicine 1999; 21(1): 22-28.
    • Current services in relation to need

      The following services are available in Medway. These are provided by NHS, local authority and third sector providers.

      Primary Care


      • GPs provide generalist support for end of life patients in line with the Gold Standards Framework.
      • Medway on Call Care (MedOCC) manage the End of Life Register ('My Wishes'). GPs and nurses consult, visit patients, and provide telephone advice 24/7 and direct referrals to ACAT, rapid response, community teams and specialist teams.
      • The 'My Wishes Register' (Medway's End of Life Register) has now been implemented and allows patients to record electronically (via their health care worker) their wishes and advance care plans as well as their experience of the health service.

      Community based care


      • Marie Curie nursing, night nursing support, Crossroads, Sunflower volunteers and Social Services provide at home support for carers
      • The Community Team works with the Hospice in-patient unit and the Hospital Palliative Care Team, providing general support including bereavement support to patients discharged to their preferred place of care
      • A new Palliative Care helpline has been implemented to provide patients at the end of life, including their carers and family, access to 24/7 crisis support
      • Cruse Bereavement care was commissioned in February 2012 to provide comprehensive bereavement support to Medway residents

      Specialist Palliative Care


      • Community Palliative Care Team (The Wisdom Hospice) - Community nurse specialists and care home facilitators provide assessment, symptom management, advice and support for patients with complex life-limiting illness (cancer and non-cancer), as well as their family and carers. The team also provides support to the primary healthcare team.
      • Day Hospice - provides a psychosocial therapeutic environment for patients under the care of the Specialist Palliative Care team. Provides on-going assessment of the patient attending the Day Hospice, complementary therapies and provides access to other professionals as required.
      • The Wisdom Hospice provides a 15 bedded in-patient care for symptom management and end of life care for patients referred by the specialist palliative care team (admission to Hospice beds currently under review), facilitate discharge to preferred place of care/preferred place of dying, with input from the community palliative care team and the family and carers support team, including welfare advisors, specialist social workers and bereavement support.

      Hospital Care (Medway Foundation Trust)


      • Hospital Palliative Care Team - Provide assessment, advice, symptom management to patients with palliative care needs, and support for medical and nursing teams.
      • Liaise with the emergency department to prevent unnecessary admissions to wards if inappropriate to patient needs.
      • An End of Life Care Matron has been employed to sustain the use of the Liverpool Care Pathway (LCP) and to improve end of life care provision throughout the hospital.

      Integrated Health and Social Care teams


      • Community nursing/Care Management - provide care and arrange funded care packages (help at home to meet personal care needs). Community nursing provides care to housebound patients and patients who have difficulty accessing services including end of life care.
      • Working closely with the Hospice team and with all staff providing care and acting as the patient and family's advocate. Providing physical, spiritual, emotional support and symptom control for those living with a terminal illness. Care is provided to both patients and their family/carers, including post bereavement support.
      • Cardiac and community respiratory services support patients in discussing end of life and symptom control.

    • Projected service use and outcomes in 3--5 years and 5--10 years

      It is predicted that by 2020, the ageing population will increase globally, with more people dying from chronic rather than acute diseases[1] and health care will increasingly focus on achieving the best possible quality of life for patients and their families and providing palliative care. Part of this includes meeting their wishes with regards to place of care and of death. In Medway, it is anticipated that the over 65s population will increase by 28.1% from 2010 to 2020.

      Based on current trends, it is expected that the prevalence of major causes of death in Medway will continue to rise over the next 5 to 10 years. This increase in prevalence and an ageing population will impact on end of life care services within health and social care.


      References

      [1]   Davies E, Higginson I. Better Palliative Care for Older People 2004; WHO Europe. http://www.euro.who.int/__data/assets/pdf_file/0009/98235/E82933.pdf .
    • Evidence of what works


      • The National Gold Standard (GSF) aims to support best implementation of the GSF in all settings, using a common framework and toolkit of resources so that generalist frontline staff can provide quality of care for people nearing end of life, whatever their illness and wherever the setting.


      • The Liverpool Care Pathway is a framework to support those caring for people in the last few days of their lives to provide the best care possible and recommended as best practice model of care for people dying in the following documents: Department of Health 'End of life Care Strategy: quality markers and measures for end of life care'. DH. London. (2009) Department of Health 'End of Life Care Strategy – promoting high quality care for all adults at the end of life'. DH. London. (2008) Department of Health 'Our Health, Our Care, Our Say: a new direction for community services'. DH. London(2006)


      • Capacity, care planning and advance care planning in life limiting illness. A Guide for Health and Social Care staff (2011, revised 2014)


      • The Preferred Priorities of Care, National End of Life Programme (2007)


      • The National Carer's Strategy emphasises the need for mental well being and support for carers. (2008)

    • Unmet needs and service gaps


      • There is a need for a proactive identification of people approaching End of Life, better coordination of care and communication between services
      • There is currently no systematic approach to capturing patients' views in the use of the service, although there is patient representation within the End of Life Care Group.
      • More training is required for the wider workforce on End of Life Care
      • There is inequity in End of Life Care for non cancer patients especially those with Mental health problems e.g. Dementia
      • The main barrier to the delivery of good quality end of life care is because people are not identified early enough to provide this care as they are approaching end of life.
      • The majority of people in England would prefer to die at home, however lack of timely access to appropriate community services prevent more people dying in their place of choice. In Medway, over half of the deaths (52%) occur in hospital.
      • There is no existing mechanism for identifying the needs, wishes and preferences for end of life care for people with dementia.
      • The projected increase in the ageing population in Medway, points to the future needs in developing skills in the community if admissions, especially emergency admissions, are to be avoided.
      • Lack of information and data to inform decisions regarding the end of life care needs specific to BME groups, including spiritual and cultural needs.

    • Recommendations for Commissioning


      • Encourage the use of the Gold Standard Framework's (GSF) Prognostic Indicator Guidance in primary care to ensure early identification of people approaching the end stages of their disease.
      • Continued commitment is needed to provide high quality care to enable people in Medway die in the places of their choice.
      • Ensure workforce development (training and education) around the core competencies as outlined in the End of Life Strategy: Assessment of needs and preferences, communication, advanced care planning and symptom management).
      • Encourage joint working and shared resources across all providers, with an identified lead provider coordinating all services that support the end of life pathway.
      • Support the development of a single point of access to services to improve the coordination of end of life services.
      • Voluntary sector organisations should be involved appropriately, especially around issues relating to culture and religion.
      • Disseminate information on integrated health and social care EOL teams to the public, to ensure timely access to continue care funding.
      • Develop a shared IT system to facilitate a more streamlined service through data sharing.

    • Recommendations for needs assessment work


      • Review of patients place of death, cause of death and their preferred place of death in Medway

  • Excess winter deaths
    • Summary

      In common with other areas, Medway experiences higher levels of mortality in the winter than in the summer. Studies have found that mortality increases as mean daily temperatures fall (below 18 degrees) and, in England and Wales, the total excess winter mortality is estimated to be around 30,000 per annum. Although excess winter mortality (EWM) is associated with low temperatures, conditions directly relating to cold, such as hypothermia, are not the main cause of EWM. The majority of additional winter deaths are caused by cerebrovascular diseases, ischaemic heart disease and respiratory diseases. Mortality in England and Wales however, increases more than in other European countries with colder climates, suggesting that factors other than temperature also contribute. There is no clear cut explanation for excess winter mortality. It would appear to be due to a variety of factors. Consequently, the response needs to be similarly multi-faceted.

      Key issues and gaps

      Medway sees highest levels of excess winter mortality in Gillingham South, Watling and Strood North wards.

      Knowledge and research gaps:

      There is a relatively limited local understanding around excess winter death and morbidity, from the epidemiological standpoint, through to individual clinicians on the ground.

      Service gaps:

      Besides the seasonal flu vaccination programme, specific measures to tackle EWM are in their infancy. As such the main gap is the lack of a strategic, systematic partnership based approach with relevant measures beneath it.

    • Who's at risk and why?

      Many studies demonstrate links between winter mortality and climate, even quantifying the increase in mortality per degree drop in temperature, yet outdoor temperature alone cannot explain all excess winter mortality (EWM). The Eurowinter study showed that percentage increases in mortality per degree fall in temperature were surprisingly greatest in countries with more mild climates. [1] The rate of EWM in the UK also appears higher than in countries with lower winter temperatures such as Finland and Denmark. [2] Such findings have led many to conclude that there is a great potential in the UK to reduce excess winter deaths.

      Some argue that the high levels in the UK relate to poor insulation and housing standards resulting in low indoor temperatures, [3] [4] whilst others stress the importance of outdoor exposure. [5] Keatinge, [6] has argued strongly that campaigns remain overly fixated on indoor heating, when the cold stress experienced from minutes spent at a windy bus stop can exceed anything experienced indoors.

      It is likely that both these variables play important roles in EWM. Research has also demonstrated that there is no clear link between these deaths and the usual measures of deprivation or social class. [7] [8] [9] In fact, it was found in one study that people in the lowest socio-economic groups do not necessarily live in cooler homes as housing association and local authority dwellings tend to be well heated and well-insulated, whereas large owner-occupier houses tend to be those which are harder to heat. [10] However, the present policy focus on fuel poverty or affordable warmth acknowledges that socio-economic factors do play a role in the health inequalities associated with EWM, even if this cannot be easily demonstrated by the available data. Reliance on public transport however (a feature of deprivation), is thought to increase exposure to outdoor cold.

      Recent research has suggested a relationship between hospital admission rates and poverty using the fuel poverty risk index [11] and the Meteorological Office has done considerable work looking at temperature as a predictor of hospital admissions.

      The strongest risk factor is age, with most studies showing EWM concentrated in people over 75. This would suggest that interventions to tackle winter deaths should focus on this age group — although there is a rationale for also focusing on the very young, and those with specific circumstances and conditions that make them more vulnerable to cold-related illness. The research also suggests that future activities should focus on the private housing sectors — both owner-occupiers and private rented accommodation. Older people living in older housing, are particularly at risk. [12]

      Respiratory illness has a significantly higher excess winter death index than other illnesses and there is some national evidence that having an existing respiratory condition significantly increases the risk of winter death. A recent Nottingham Health Needs Assessment found that deaths from respiratory disease have an EWM index of around 43%, and that this was significantly higher than the indices of other disease categories. [13]

      A report has shown that asthma patients without a written personal asthma action plan are four times more likely to have to be admitted to hospital, due to an asthma attack, than those who do. At the time of report's writing, only 16% of people with asthma in England have a written personal asthma action plan. [14]

      The South East Public Health Observatory (SEPHO) report into EWM notes that there is a significantly greater increase in EWM ratios for care home residents. As care home residents generally lead a sheltered existence, protected from exposure to outdoor temperatures, damp housing or difficulties with heating their homes, it might be expected that EWM would be low for this group, when in fact, the opposite is true (another Winter mortality paradox). It is the case however, that people in care homes are likely to be the very oldest older people, many will have pre-existing conditions and they live in an enclosed space where infection can easily spread. Greater excess mortality amongst this group may also reflect seasonal patterns in care home use, for example, more patients being admitted to care homes shortly before death in the winter period. Whatever the explanation (and there are many), figures do demonstrate that the seasonal increase in mortality has a strong impact on care home residents. The report notes that guidance for care homes has been developed on dealing with heatwaves, and suggests that similar guidance for winter might also be beneficial. [12]

      A range of research has argued that vaccination of health care workers is important to limit spread of flu amongst vulnerable patients in hospitals and other healthcare settings. [15] [16]

      Figure 1: Epidemic curve of confirmed influenza cases.
      Figure 1: Epidemic curve of confirmed influenza cases, Royal Liverpool University Hospital, and influenza-like illness rates in Liverpool between week 47/2008 and week 2/2009

      A report from the North West Health Protection Unit (2009) [17] notes the importance of vaccination of staff. An outbreak of influenza occurred amongst patients and staff at an acute hospital in the North West of England in early December 2008. Over a three-week period in November/December 2008, rates of influenza-like illness in Liverpool increased from 26.7 per 100,000 population (in week 47) to 102.7 per 100,000 (in week 50). At the same time cases of influenza started presenting at the Royal Liverpool University Hospital. On 25th November a confirmed case of influenza, acquired in the hospital, was diagnosed on the haematology ward. The number of infections increased quickly until infection control and immunisation measures were put in place (Figure 1).

      The outbreak illustrated how easily influenza can spread in a health care setting when virus is circulating in the community and staff vaccination levels are low. It was a notable success in the management of the outbreak that high levels of vaccination were achieved in a short period of time, helping to reduce the exposure of vulnerable patients in hospital despite the ongoing seasonal influenza activity in the community.


      References

      [1]   Healy J. Excess winter mortality in Europe: a cross country analysis identifying key risk factors Journal of Epidemiology & Community Health 2003; 57(10): 784-9.
      [2]   Howden-Chapman P. Housing standards: a glossary of housing and health Journal of Epidemiology & Community Health 2004; 58(3): 162-8.
      [3]   Clinch J, Healy J. Housing standards and excess winter mortality Journal of Epidemiology & Community Health 2000; 54(9): 719-20.
      [4]   Blane D, Mitchell R, Bartley M. The inverse housing law and respiratory health Journal of Epidemiology & Community Health 2000; 54: 745-749.
      [5]   Wilkinson P, Landon M, Armstrong B, et al. Cold comfort: The social and environmental determinants of excess winter deaths in England, 1986-96 2001; The Policy Press, Oxford.
      [6]   Keatinge W. Winter deaths: warm housing is not enough British Medical Journal 2001; 323: 166.
      [7]   Shah S, Peacock J. Deprivation and excess winter mortality Journal of Epidemiology & Community Health 1999; 53(8): 499-502.
      [8]   Lawlor D, Maxwell R, Wheeler B. Rurality, deprivation, and excess winter mortality: an ecological study Journal of Epidemiology & Community Health 2002; 56(5): 373-4.
      [9]   Gemmell I, McLoone P, Boddy F, et al. Seasonal variation in mortality in Scotland International Journal of Epidemiology 2000; 29(2): 274-9.
      [10]   Hajat S, Kovats R, Lachowycz K. Heat-related and cold related deaths in England & Wales: who is at risk? Occupational and Environmental Medicine Journal 2007; 64: 93-100.
      [11]   Rudge J, Gilchrist R. Excess winter morbidity among older people at risk of cold homes: a population based study in a London borough Journal of Public Health Medicine 2005; 27: 353-58.
      [12]   Dinsdale H, Williams DE, Adur DF. Technical Report: Excess Winter Mortality 2006; South East public Health Observatory.
      [13]   Howard R, Copping J. Excess Winter Deaths: A Health Needs Assessment for NHS Nottingham City 2010; Nottingham City Council. http://www.nottinghaminsight.org.uk/insight/docs/resources.ashx?f=REPORTS.R_10_1783&title=Excess_Winter_Deaths_Health_Needs_Assessment .
      [14]   Asthma UK. The Asthma Divide - inequalities in asthma care for people with asthma in England 2007; Asthma UK. http://www.asthma.org.uk/document.rm?id=322 .
      [15]   Wilde J, McMillan J, Serwint J, et al. Effectiveness of influenza vaccine in health care professionals: a randomized trial Journal of the American Medical Association 1999; 281: 908-13.
      [16]   Hayward A, Harling R, Wetten S, et al. Effectiveness of an influenza vaccine programme for care home staff to prevent death, morbidity, and health service use among residents: cluster randomised controlled trial British Medical Journal 2006; 333: 1241-7.
      [17]   Health Protection Agency. Health Protection Weekly News Report 2009;
    • Level of need in the population

      Although analysis at a small area level can be problematic, the local picture of who is at risk and why is broadly similar to the national picture. Medway sees highest levels of excess winter mortality (EWM) in the wards of Gillingham South, Watling and Strood North (Figure 1 and Table 1).

      Key definitions

      EWM is calculated as the number of winter deaths (deaths occurring in December to March) minus the average of non-winter deaths (April to July of the current year and August to November of the previous year) (i.e. EWM = Number of winter deaths - (number of non-winter deaths/2) The Excess Winter Deaths Index (EWD Index), 2006–2009 is the excess of deaths in winter compared with non-winter months from 01.08.2005 to 31.07.2010 expressed as a percentage. The year runs from August to July. Winter months are classified as December to March, Non-Winter months are August to November and April to July.

      Figure 1: Medway excess winter mortality by Ward 2005--2009.
      Figure 1: Medway excess winter mortality by Ward 2005–2009
      Ward/area name 2002/04 2003/05 2004/06 2005/07 2006/08 2007/09 2005/09 Period ratio*
      Chatham Central 5.6 12.4 9.5 12.3 12.9 25.0 17.9 13.1
      Cuxton and Halling -5.4 7.5 -4.3 0.0 10.8 17.2 15.7 6.8
      Gillingham North 11.0 24.4 16.2 16.0 5.8 32.6 23.0 17.9
      Gillingham South 16.1 10.2 15.9 27.3 36.2 56.1 40.2 29.3
      Hempstead and Wigmore 21.3 41.2 33.3 21.0 17.4 16.8 21.8 21.6
      Lordswood and Capstone 0.0 9.2 9.6 4.6 31.4 41.4 21.8 13.0
      Luton and Wayfield 12.2 8.2 3.8 23.6 18.2 7.5 8.2 9.7
      Peninsula 24.3 29.7 13.7 21.2 20.5 37.5 23.9 24.1
      Princes Park 52.0 23.6 0.0 2.0 9.3 10.3 -1.3 16.2
      Rainham Central -3.5 -2.5 6.6 2.2 11.9 10.3 10.7 5.2
      Rainham North 14.5 22.0 -5.4 4.8 5.5 19.0 13.7 13.9
      Rainham South 21.4 19.7 29.1 18.4 15.0 1.1 10.2 14.0
      River 6.9 7.5 14.6 26.2 20.0 34.1 28.2 6.6
      Rochester East 27.6 37.6 18.2 12.3 8.5 22.7 17.4 21.2
      Rochester South and Horsted 3.3 5.3 14.8 21.3 25.4 13.8 18.9 13.3
      Rochester West -3.0 2.2 -4.5 2.5 -14.4 3.7 3.9 1.1
      Strood North 9.0 42.9 53.8 58.5 29.3 25.0 36.8 25.6
      Strood Rural 2.6 -2.4 -8.3 -0.9 19.2 26.0 10.3 7.6
      Strood South 17.4 13.1 13.0 0.5 10.0 9.5 6.8 10.7
      Twydall 4.0 14.8 27.8 24.8 24.3 9.1 17.4 12.0
      Walderslade 37.6 27.3 14.1 10.4 0.8 -1.6 3.7 16.0
      Watling 12.7 39.2 63.4 48.9 30.8 33.3 49.0 33.5
      Medway 11.4 17.1 15.6 16.9 16.1 19.9 18.3 15.6
      Eastern and Coastal Kent 16.7 18.4 18.1 14.7 18.5 17.4 17.4 16.9
      West Kent 18.9 18.8 16.0 13.0 14.3 16.3 16.3 17.1
      Kent & Medway 16.8 18.4 17.0 14.4 16.6 17.3 17.3 16.8
      Table1: Medway excess winter deaths by ward

      Figure 2 (below) shows how the excess winter deaths ratio has fluctuated in recent years. As has been alluded to earlier patterns of such death are affected by a range of factors and colder winters will generate fluctuation. Given the data period below however, it is possible that excess winter deaths in Medway have increased.

      Figure 2: Trends in Excess Winter Death indices.
      Figure 2: Trends in Excess Winter Death indices, 2002/04–2007/09 for Kent and Medway

      Housing

      As has been noted earlier, cold homes are a risk factor for EWM. For more information on housing, please see Appendices —> Background papers: Lifestyle and wider determinants —> Housing and homelessness

      A Housing Stock Survey was undertaken in 2007. In summary, the housing stock in Medway mainly comprises properties, which were built since 1945 (64%). 23% of the stock was built before 1919 and 13% between the wars. Aging properties generally require more work and investment to maintain them in good repair. In addition to this they present a challenge in terms of keeping them hazard free under the new Health and Housing Safety Rating System and meeting the Decent Homes Standard for vulnerable households. Most Medway stock is privately owned.

      The Housing Stock Condition survey highlighted a number of issues within the private housing stock in the Medway area and in particular that nearly 20% of homes fail the Decent Homes Standard, the majority doing so due to excess cold.

    • Current services in relation to need

      Influenza Immunisation

      As has already been noted, immunising those at risk can reduce excess winter mortality (EWM). The topic of Immunisation and Vaccination is covered in another chapter and can be found in Appendices —> Background papers: Children/Adults —> Immunisations and vaccinations. In summary, the influenza immunisation programme in Medway is well established and largely surpasses England and South East Coast Strategic Health Authority uptake averages (Table 1), although healthcare staff immunisation rates remain relatively low.

        Medway South East
      Coast SHA
      England
      Seasonal influenza vaccine uptake in those aged 65 years and over 73.3% 71.1% 72.8%
      Seasonal influenza vaccine uptake in those aged 6 months to under 65 at risk 51.8% 47.9% 50.4%
      Seasonal influenza vaccine uptake in Carers (aged under 65 years and not considered at risk) 54.5% 40.7% 42.7%
      All frontline healthcare workers 25.0% 28.2% 34.7%
      Table 1: Seasonal Influenza vaccine uptake Winter Season, 2010-11 (Medway, SHA and England

      Data coverage shows end of campaign cumulative vaccine uptake data for England, for seasonal flu vaccinations administered from 1st September 2010 to 28th February 2011.

      Data Source: DH ImmForm website: Registered Patient GP practice data Influenza Immunisation Vaccine Uptake Monitoring Programme. Seasonal influenza vaccine uptake amongst frontline healthcare workers (HCWs) in England

      Housing

      Medway Council has put initiatives in place to help residents reduce fuel poverty by supporting residents in their energy use. Between 2008 and 2011, 8,391 people were given energy efficiency advice by the Energy Savings Advice Centre.

      In addition, a joint scheme (between Medway Council and NHS Medway) which draws upon existing models (e.g. Clearing House model Greater Manchester) is being due to be piloted. This will use clinical systems in GP practices to identify those at most risk and create referrals for those individuals into a service which assesses houses, carries out improvements for eligible homes and offers advice on energy use or benefits entitlement. If successful this model may be extended to other GP Practices.

    • Projected service use and outcomes in 3-5 years and 5-10 years

      In common with the rest of the UK, Medway has an ageing population. This could mean that excess winter mortality (EWM) will increase when risk factors are conducive. As few services exist which specifically tackle EWM, it is difficult to model how this demographic change will affect those services. It is likely that the demand for influenza immunisation will increase.

      The importance of managing those risk factors which are within the ambit of the NHS and Local Authority will grow as morbidity associated with excess cold will place greater winter pressures on NHS acute capacity. The monthly pattern of respiratory admissions, influenza admissions, influenza and pneumonia admissions combined and influenza laboratory tests, show winter peaks similar to the all-cause mortality pattern.[1]

      In addition, it can be expected that the current economic climate, combined with the rising costs of fuel will increase fuel poverty and limit the amount of home maintenance undertaken.


      References

      [1]   East Midlands Public Health Observatory. Excess Winter Deaths in the East Midlands 2006/07: Report Update 2009. 2009; East Midlands Public Health Observatory. http://www.empho.org.uk/viewResource.aspx?id=9663 .
    • Evidence of what works

      Evidence on this topic suggests many different interventions may be beneficial, but stops short of quantifying what level of reduction in mortality might be expected by introducing various interventions. Risk reductions for example, are not calculated.

      It is widely accepted that pre-seasonal vaccination is effective in reducing the more serious manifestations of influenza, as has vaccination of health care workers. Campaigns to increase uptake of immunisation have been relatively successful amongst target groups in Medway, but uptake amongst health care workers remains poor. There is some evidence that early use of anti-virals amongst the very aged in residential and care home settings could limit the spread of influenza in institutional environments.[1]

      The large, cross-European study found robust relationships between energy efficiency levels and excess winter deaths, although they were still significant at the 5% level (cavity wall insulation p=0.02, double glazing p=0.02 and floor insulation p=0.03). The four countries with the poorest standard of housing in this respect (Portugal, Greece, Ireland and the UK) all score highly for excess winter deaths. The authors suggest that their findings support the theory that EWM can be reduced through not just targeted improvement of energy efficiency, but also socioeconomic progress (such as looking at poverty, income inequalities, fuel poverty and deprivation).[2]

      The research also suggests that interventions will be most effectively focused on the private housing sectors — both owner occupiers and private rented accommodation. Older people living in older housing, particularly those without central heating are particularly at risk.[3]

      National research has also shown that as well as the energy efficiency of the house, the way a householder uses the house (e.g. use of heating system, opening windows at night etc) is of crucial importance in maintaining a healthily warm home.

      There is some evidence to suggest that the Met Office runs a 'Healthy Outlook' service which is a preventative measure, aimed at helping people with Chronic Obstructive Pulmonary Disease (COPD) to stay well in cold weather is effective in reducing hospital admissions. It is operated through GP practices.


      References

      [1]   Health Protection Agency. A Winters Tale: coming to terms with Winter respiratory illness 2003; Health Protection Agency.
      [2]   Healy J. Excess winter mortality in Europe: a cross country analysis identifying key risk factors Journal of Epidemiology & Community Health 2003; 57(10): 784-9.
      [3]   Dinsdale H, Williams DE, Adur DF. Technical Report: Excess Winter Mortality 2006; South East public Health Observatory.
    • User views

      No user views have yet been elicited locally for this aspect of public health. It is envisaged that public engagement with appropriate groups should be sought as planning develops for reducing excess winter deaths.

    • Equality Impact Assessments

      Equality impact assessments will need to be completed as future services are planned. The Medway population is diverse and plans which affect health services and housing need to take account of this.

    • Unmet needs and service gaps


      • Other than the influenza vaccination programme and dedicated work carried out by Medway Council's housing department, systematic approaches to the reduction of excess winter mortality (EWM) are in their infancy and need to develop.

      • There are insufficient knowledge and tools to be able to identify Medway households most at risk of EWM.
      • There is currently no formalised system to generate referrals to energy efficiency services of vulnerable householders from frontline health staff.
      • There is currently no identified resource to operate targeted energy advice services in the homes of the most vulnerable householders across the Medway area.
      • There is a lack of public and professional awareness of the health problems associated with cold exposure and services available to tackle these.

    • Recommendations

      Measures should concentrate on vulnerable people (those living in care homes, those aged over 65, those with respiratory or cardiovascular conditions, older women, people reliant on public transport, sedentary people and older people who live alone). The CCG should develop procedures and systems to ensure that the referral of vulnerable older households to appropriate energy service happens systematically.

      Measures to reduce both indoor and outdoor cold stress are necessary to reduce levels of winter mortality. Warning people about outdoor cold exposure and protective measures is as important as messages about keeping their home adequately heated.

      Early use anti-virals amongst the very aged in residential and care home settings should be considered.

      The proportion of health care workers vaccinated should be increased to limit spread of flu to vulnerable patients in hospitals and other healthcare settings.

      As with many public health issues, the wider determinants (i.e. the 'causes of the causes') need to be considered. A strategic approach supported by the emerging Medway Health and Wellbeing Board, which maintains general aims to reduce poverty, increase economic development etc should run concurrently with more targeted programmes.

      Current mainstream commissioning programmes which seek to manage winter service pressures and acute admissions should include support preventative measures which seek to reduce excess winter death as these measures will also reduce morbidity.

      Guidance for care homes has been developed on dealing with heat waves, similar guidance for winter may be beneficial.

      The introduction of asthma plans for affected patients should be considered, to reduce admissions for the condition.

      The possibility of introducing heated waiting rooms/seating, wind-proof bus shelters and similar could be investigated, especially in areas populated by high numbers of older people who are reliant on public transport.

      Commissioning the Met Office's “Healthy Outlook” service for Medway should be considered.

    • Recommendations for needs assessment work

      More detailed analysis which combines housing and health data would allow for more appropriate development and targeting of interventions related excess winter mortality.

      Further assessment should be undertaken to examine the impact of cold homes on morbidity (illness) as well as deaths. This should include work to understand the impact of cold homes on mental health and wellbeing.

  • Immunisations and vaccinations
    • Summary

      Immunity is the ability of the human body to protect itself against infectious disease. Active immunity is protection that is produced by an individual's own immune system and is usually long lasting — it can be acquired by natural disease or via vaccination. Passive immunity is protection provided from the transfer of antibodies from immune individuals, most commonly across the placenta or less often from the transfusion of blood or blood products including immunoglobulin. Passive immunity is temporary but provides immediate short-term protection against disease.[1]

      After clean water, vaccination is the most effective public health intervention in the world for saving lives and promoting good health.[2] Vaccination generally provides a similar immunity to that provided by natural infection, but without the risk of complications of the disease. Vaccinations work by producing immunological memory, so that when the immune system is subsequently exposed to natural infection it is able to recognise and respond to it, thus preventing or modifying the disease. In some cases more than one dose of the vaccine may be required initially to produce this response and/or booster doses may be required to maintain it. While the main aim of vaccination is to protect the individual who receives it, high levels of immunity in a population mean those who cannot be vaccinated, for example because they are too young, are also at reduced risk of being exposed to a disease. This is known as herd immunity. When vaccine coverage is high enough a disease may be eliminated from a community, however if this is not maintained the disease may return.[1] Vaccine coverage is evaluated against World Health Organization (WHO) targets of 95% coverage annually for each vaccine (except Meningitis C) at the national level, and at least 90% in each Strategic Health Authority.[3]

      The 2009/10 Medway Annual Public Health Report (APHR)[4] contains detailed information on vaccine uptake in Medway in 2008/09 and the 2011/12 report[5] contains information on vaccine uptake in 2011/12.


      References

      [1]   Department of Health. Immunity and how vaccines work 2007;
      [2]   Public Health England. Vaccination, Immunisation
      [3]   Public Health England. Cover methods
      [4]   NHS Medway. Investing for Health - the Annual Report of the Director of Public Health 200910; NHS Medway. http://www.kmpho.nhs.uk/geographical-areas/primary-care-trusts/medway-pct/?assetdet956103=102411 .
      [5]   NHS Medway. Annual Public Health Report 2011/12 2012; NHS Medway.
    • Who's at risk and why

      There are no vaccinations that are routinely offered by the NHS to all adults. However, there are several vaccinations that are available on the NHS to adults in certain 'at risk' groups. These are:
      • annual seasonal flu vaccination if aged 65 and over, if in a clinical risk group and under 65 and all pregnant women
      • pneumococcal vaccination if aged 65 and over in an at risk group
      • hepatitis B vaccination if at increased risk of hepatitis B because of lifestyle, occupation or other factors e.g. a household contact of someone who is infected with hepatitis B
      • measles, mumps and rubella (MMR) post delivery — for women who do not have immunity against rubella identified via the antenatal screening programme
      • BCG vaccination if at increased risk

      Healthcare and laboratory staff should be offered appropriate vaccination in addition to those offered as part of the childhood vaccination as they are at higher risk e.g. hepatitis B, BCG (protects against tuberculosis), seasonal flu, varicella (protects against chickenpox and shingles). It is the employer's responsibility to provide these vaccinations

      Travel vaccinations are generally not funded by the NHS although there are some exceptions.

    • The level of need in the population

      Uptake rates in adults are only routinely collected for seasonal flu, pneumococcal disease and the BCG vaccinations given

      Seasonal flu

      Uptake of seasonal flu vaccination is measured as those who have been vaccinated from when the vaccine becomes available in September each year until the end of January the following year. In 2011/12 up take in NHS Medway was:
      • 75.2% in those aged 65 and older (73.3% in 2010/11)
      • 52.9% in those aged under 65 years within a clinical risk group (51.8% in 2010/11)
      • 33.3% in all pregnant women (38.3% in 2010/11). There were some data problems with the denominator for pregnant women nationally in 2011/12 so this figure needs to be treated with caution.

        65 years and over Under 65 and in at risk group Pregnant women
      NHS Medway 75.2 52.9 33.3
      SEC SHA 72.1 48.3 24.9
      England 74.0 51.6 27.4
      Table 1: Uptake for seasonal flu vaccination in patients Medway compared with the South East Coast (SEC) region and England (provisional data) 2011/12 [1]

      NHS Medway uptake rates were the highest in South East Coast (SEC) for all these categories but there were considerable differences between practices as can be seen in Figures 1–3.

      Figure 1: The percentage uptake of flu vaccine in over 65s .
      Figure 1: The percentage uptake of flu vaccine in over 65s [1]
      Figure 2: The percentage uptake of flu vaccine in those under 65 but in an at risk group .
      Figure 2: The percentage uptake of flu vaccine in those under 65 but in an at risk group [1]
      Figure 3: The percentage uptake of flu vaccine in pregnant women  .
      Figure 3: The percentage uptake of flu vaccine in pregnant women [1]

      The graphs show that half of Medway practices met the target for those aged 65 and over (70%). A much lower number met the targets for those aged under 65 years within a clinical risk group (60%) and for pregnant women (60%)

      Tables 2–4 show the improvements that some practices have made compared to 2010/11.

        Practice 2010/11 2011/12 Percentage point
      difference
      G82635 Pump Lane Surgery, Dr Bhatia 89.1 88.4 -0.7
      G82184 Medical Centre, Waltham Road, Dr Lakshman & Partner 86.7 88.1 1.4
      G82718 Broadway Practice, Dr Patel MG 87.0 86.0 -1.0
      G82741 Princes Park Medical Centre, Dr Aslam 75.0 84.1 9.1
      G82644 Wyvill Surgery, Dr Faramawi 81.9 83.7 1.8
      G82706 Brompton Medical Centre, Dr Singh BN 72.4 83.7 11.3
      G82763 Napier Road Surgery, Dr Jana 79.6 83.3 3.7
      G82708 Marlowe Park, Dr Juneja 83.4 82.3 -1.1
      G82180 The Surgery, Dr Shaunak & Partners 85.1 82.2 -2.9
      G82600 Eastcourt Surgery, Dr Nandini 80.8 81.8 1.0
      G82719 Matrix Medical Practice, Dr Stacey 80.8 81.6 0.8
      G82631 Medical Centre, Dr Chaudhry 77.2 81.4 4.2
      G82129 Glebe Family Practice, Dr Patel P & Partners 77.1 81.3 4.2
      G82108 King George Surgery, Dr Maheswaran & Partners 78.0 79.3 1.3
      Y02461 DMC Walderslade Surgery, DMC Healthcare 75.2 78.7 3.5
      G82203 Court View Surgery, Dr Spinks & Partners 78.6 78.3 -0.3
      G82154 Thames Avenue Surgery, Dr Fernando & Partners 80.0 77.9 -2.1
      G82737 Parkwood Health Centre, Dr Shah & Partners 77.4 77.9 0.5
      G82704 Church View Practice, Dr De Bie & Partners 78.6 77.7 -0.9
      Y00449 St Mary’s Island Surgery, Dr Lawrence 78.4 77.7 -0.7
      G82162 Rainham Healthy Living Centre, Dr Ferrin & Partners 76.3 77.6 1.3
      G82656 Tunbury Avenue Surgery, Dr Jha 75.5 77.6 2.1
      Y00198 Parks Medical Practice, Dr Green & Partners 73.9 77.4 3.5
      G82744 Halfway Surgery, Dr Ali 75.6 77.0 1.4
      Y02462 DMC Health Centre - Canterbury Street, DMC Healthcare 72.1 76.6 4.5
      G82739 Walderslade Medical Centre , Dr Padma 68.5 75.7 7.2
      G82100 Highcliffe Medical Practice, Dr Markwick & Partners 75.8 75.6 -0.2
      G82011 Sunlight Centre Surgery, Medway Community Healthcare 71.6 75.2 3.6
      G82711 Borstal Village Surgery, Dr Balachander 77.6 75.2 -2.4
      G82762 Upper Canterbury Street Surgery, Dr Silhi 68.3 75.0 6.7
      G82014 Woodlands Family Practice, Dr Rishi & Partners 67.2 74.9 7.7
      G82113 Stonecross and West Drive Surgery, Dr Mahapatra & Partner 74.0 74.8 0.8
      G82161 Walderslade Village Surgery, Dr Raval & Partners 74.5 74.6 0.1
      G82051 City Way Surgery, Dr Syed & Partners 72.3 74.4 2.1
      G82622 The Surgery, Dr Bhasme 40.0 74.4 34.4
      G82721 Parkwood Family Practice, Dr Selvan 73.4 74.2 0.8
      G82653 Rochester Community Healthy Living Centre, Dr Tandon & Partner 72.4 74.1 1.7
      G82230 Lordswood Healthy Living Centre, Dr Singh O & Partner 73.4 74.0 0.6
      G82821 Bryant Street Surgery, Dr Kanekal 70.1 74.0 3.9
      G82198 Medical Centre, Gun Lane, Dr Agarwal, Ray and Kumar 68.1 73.8 5.7
      G82676 Bryant Street Surgery, Dr Aly & Partner 71.2 73.3 2.1
      G82106 Riverside Medical Centre, Dr Sastry & Partners 74.1 73.2 -0.9
      G82727 Malling Health, Malling Health 69.8 73.2 3.4
      G82077 Elms Medical Practice, Dr Lee & Partners 70.0 72.6 2.6
      G82233 Hoo St Werburgh, Dr Davies & Partners 68.5 72.0 3.5
      G82095 Dame Sybil Thorndike Healthcare , Dr Tanday & Partners 69.1 71.9 2.8
      G82139 Maidstone Road Surgery, Dr Qureshi 71.3 71.7 0.4
      G82226 Wigmore Medical Centre, Dr Patel SKC & Partners 69.1 71.0 1.9
      G82697 Churchill Clinic, Dr Vibhuti & Partners 71.6 70.4 -1.2
      G82764 Esplanade Healthcare, Dr Hubbard & Partner 68.8 70.2 1.4
      G82753 Kings Family Practice, Dr Huxham & Partners 69.9 69.8 -0.1
      G82679 Apex Medical Centre, Dr Premeratne & Partners 70.0 69.6 -0.4
      G82670 Rochester Community Healthy Living Centre, Dr Elapatha 69.8 69.5 -0.3
      G82775 Medway Medical Centre, Dr Dharan & Partner 65.6 69.4 3.8
      G82109 Railside Surgery, Dr Ramesh 68.2 69.2 1.0
      G82133 St Marys Medical Centre, Dr Pancholi & Partners 70.2 68.9 -1.3
      G82123 Balmoral Gardens, Dr Karim & Partners 64.6 67.9 3.3
      Y02471 College Health - Boots, College Health 68.9 67.1 -1.8
      Y02472 College Health - Sterling House, College Health 69.4 66.2 -3.2
      G82820 Wayfield Road Surgery, Dr Mir 67.3 63.3 -4.0
      Table 2: Uptake of flu vaccine in over 65s by Medway GP [1]
        Practice 2010/11 2011/12 Percentage point
      difference
      G82706 Brompton Medical Centre, Dr Singh BN 59.6 78.4 18.8
      G82184 Medical Centre, Waltham Road, Dr Lakshman & Partner 69.9 73.3 3.4
      G82635 Pump Lane Surgery, Dr Bhatia 79.0 70.8 -8.2
      G82154 Thames Avenue Surgery, Dr Fernando & Partners 69.0 69.9 0.9
      G82763 Napier Road Surgery, Dr Jana 68.8 68.8 0.0
      G82718 Broadway Practice, Dr Patel MG 71.7 68.6 -3.1
      G82764 Esplanade Healthcare, Dr Hubbard & Partner 62.0 68.6 6.6
      G82644 Wyvill Surgery, Dr Faramawi 65.2 68.2 3.0
      G82719 Matrix Medical Practice, Dr Stacey 58.7 66.5 7.8
      G82653 Rochester Community Healthy Living Centre, Dr Tandon & Partner 63.5 66.4 2.9
      G82741 Princes Park Medical Centre, Dr Aslam 60.7 64.8 4.1
      G82708 Marlowe Park, Dr Juneja 63.6 63.7 0.1
      G82739 Walderslade Medical Centre , Dr Padma 48.2 63.6 15.4
      G82180 The Surgery, Dr Shaunak & Partners 59.3 62.4 3.1
      G82631 Medical Centre, Dr Chaudhry 65.7 62.2 -3.5
      G82679 Apex Medical Centre, Dr Premeratne & Partners 60.3 61.7 1.4
      G82203 Court View Surgery, Dr Spinks & Partners 60.5 60.8 0.3
      G82762 Upper Canterbury Street Surgery, Dr Silhi 57.6 60.5 2.9
      G82108 King George Surgery, Dr Maheswaran & Partners 61.5 59.6 -1.9
      G82226 Wigmore Medical Centre, Dr Patel SKC & Partners 45.9 59.2 13.3
      G82737 Parkwood Health Centre, Dr Shah & Partners 60.3 57.6 -2.7
      G82106 Riverside Medical Centre, Dr Sastry & Partners 54.8 57.2 2.4
      G82129 Glebe Family Practice, Dr Patel P & Partners 40.3 57.1 16.8
      G82676 Bryant Street Surgery, Dr Aly & Partner 48.7 56.9 8.2
      G82100 Highcliffe Medical Practice, Dr Markwick & Partners 57.0 56.3 -0.7
      G82161 Walderslade Village Surgery, Dr Raval & Partners 55.1 55.9 0.8
      G82744 Halfway Surgery, Dr Ali 68.2 55.3 -12.9
      G82014 Woodlands Family Practice, Dr Rishi & Partners 50.1 55.0 4.9
      G82697 Churchill Clinic, Dr Vibhuti & Partners 50.0 54.9 4.9
      G82230 Lordswood Healthy Living Centre, Dr Singh O & Partner 58.1 53.9 -4.2
      Y02462 DMC Health Centre - Canterbury Street, DMC Healthcare 51.0 53.6 2.6
      G82051 City Way Surgery, Dr Syed & Partners 51.0 53.4 2.4
      G82198 Medical Centre, Gun Lane, Dr Agarwal, Ray and Kumar 49.3 53.2 3.9
      G82704 Church View Practice, Dr De Bie & Partners 53.6 53.0 -0.6
      G82775 Medway Medical Centre, Dr Dharan & Partner 48.1 52.6 4.5
      G82011 Sunlight Centre Surgery, Medway Community Healthcare 49.8 51.6 1.8
      G82162 Rainham Healthy Living Centre, Dr Ferrin & Partners 48.8 51.2 2.4
      G82600 Eastcourt Surgery, Dr Nandini 60.3 51.1 -9.2
      G82670 Rochester Community Healthy Living Centre, Dr Elapatha 44.2 50.7 6.5
      G82727 Malling Health, Malling Health 47.6 50.7 3.1
      Y02461 DMC Walderslade Surgery, DMC Healthcare 56.3 50.5 -5.8
      Y00198 Parks Medical Practice, Dr Green & Partners 49.9 50.3 0.4
      G82721 Parkwood Family Practice, Dr Selvan 47.4 49.9 2.5
      G82820 Wayfield Road Surgery, Dr Mir 58.3 49.1 -9.2
      G82109 Railside Surgery, Dr Ramesh 50.1 49.0 -1.1
      G82077 Elms Medical Practice, Dr Lee & Partners 44.3 47.5 3.2
      G82753 Kings Family Practice, Dr Huxham & Partners 52.8 47.4 -5.4
      G82113 Stonecross and West Drive Surgery, Dr Mahapatra & Partner 46.6 47.2 0.6
      G82821 Bryant Street Surgery, Dr Kanekal 43.7 46.5 2.8
      G82622 The Surgery, Dr Bhasme 20.1 46.4 26.3
      G82123 Balmoral Gardens, Dr Karim & Partners 33.1 45.9 12.8
      G82233 Hoo St Werburgh, Dr Davies & Partners 45.8 44.9 -0.9
      G82711 Borstal Village Surgery, Dr Balachander 39.7 44.4 4.7
      G82133 St Marys Medical Centre, Dr Pancholi & Partners 49.2 43.9 -5.3
      Y00449 St Mary’s Island Surgery, Dr Lawrence 54.7 43.8 -10.9
      G82139 Maidstone Road Surgery, Dr Qureshi 38.0 42.5 4.5
      G82095 Dame Sybil Thorndike Healthcare , Dr Tanday & Partners 43.6 40.0 -3.6
      G82656 Tunbury Avenue Surgery, Dr Jha 44.4 39.7 -4.7
      Y02471 College Health - Boots, College Health 45.1 37.1 -8.0
      Y02472 College Health - Sterling House, College Health 41.0 34.7 -6.3
      Table 3: Uptake of flu vaccine in those under 65 but in an at risk group by Medway GP [1]
        Practice 2010/11 2011/12 Percentage point
      difference
      G82718 Broadway Practice, Dr Patel MG 100.0 86.7 -13.3
      Y00449 St Mary’s Island Surgery, Dr Lawrence 100.0 86.7 -13.3
      G82741 Princes Park Medical Centre, Dr Aslam 52.6 67.9 15.3
      G82113 Stonecross and West Drive Surgery, Dr Mahapatra & Partner 38.9 62.3 23.4
      G82721 Parkwood Family Practice, Dr Selvan 50.0 60.0 10.0
      G82154 Thames Avenue Surgery, Dr Fernando & Partners 100.0 58.1 -41.9
      G82129 Glebe Family Practice, Dr Patel P & Partners 36.6 55.4 18.8
      G82719 Matrix Medical Practice, Dr Stacey 50.0 52.2 2.2
      G82226 Wigmore Medical Centre, Dr Patel SKC & Partners 40.0 47.6 7.6
      G82635 Pump Lane Surgery, Dr Bhatia 42.9 47.6 4.7
      G82198 Medical Centre, Gun Lane, Dr Agarwal, Ray and Kumar 58.3 47.2 -11.1
      G82821 Bryant Street Surgery, Dr Kanekal 53.3 46.7 -6.6
      G82184 Medical Centre, Waltham Road, Dr Lakshman & Partner 75.0 43.8 -31.2
      G82704 Church View Practice, Dr De Bie & Partners 50.0 43.8 -6.2
      G82727 Malling Health, Malling Health 42.3 43.8 1.5
      G82203 Court View Surgery, Dr Spinks & Partners 74.1 43.4 -30.7
      G82679 Apex Medical Centre, Dr Premeratne & Partners 9.8 43.4 33.6
      G82180 The Surgery, Dr Shaunak & Partners 29.4 42.9 13.5
      G82670 Rochester Community Healthy Living Centre, Dr Elapatha 50.0 42.4 -7.6
      G82706 Brompton Medical Centre, Dr Singh BN 41.2 41.2 0.0
      Y00198 Parks Medical Practice, Dr Green & Partners 58.0 38.8 -19.2
      G82644 Wyvill Surgery, Dr Faramawi 66.7 36.4 -30.3
      G82711 Borstal Village Surgery, Dr Balachander 17.6 35.1 17.5
      G82014 Woodlands Family Practice, Dr Rishi & Partners 42.0 34.1 -7.9
      G82051 City Way Surgery, Dr Syed & Partners 52.9 33.8 -19.1
      G82077 Elms Medical Practice, Dr Lee & Partners 25.0 33.3 8.3
      G82737 Parkwood Health Centre, Dr Shah & Partners 70.0 33.3 -36.7
      G82133 St Marys Medical Centre, Dr Pancholi & Partners 16.0 32.8 16.8
      G82708 Marlowe Park, Dr Juneja 39.1 32.8 -6.3
      G82106 Riverside Medical Centre, Dr Sastry & Partners 57.1 31.9 -25.2
      G82775 Medway Medical Centre, Dr Dharan & Partner 44.4 31.8 -12.6
      G82100 Highcliffe Medical Practice, Dr Markwick & Partners 50.0 31.7 -18.3
      G82697 Churchill Clinic, Dr Vibhuti & Partners 33.3 31.6 -1.7
      G82764 Esplanade Healthcare, Dr Hubbard & Partner 37.5 31.3 -6.2
      G82600 Eastcourt Surgery, Dr Nandini 25.0 30.8 5.8
      G82233 Hoo St Werburgh, Dr Davies & Partners 38.7 30.3 -8.4
      G82230 Lordswood Healthy Living Centre, Dr Singh O & Partner 63.6 29.0 -34.6
      G82123 Balmoral Gardens, Dr Karim & Partners 26.3 28.3 2.0
      G82108 King George Surgery, Dr Maheswaran & Partners 44.1 28.2 -15.9
      G82095 Dame Sybil Thorndike Healthcare , Dr Tanday & Partners 40.0 28.1 -11.9
      Y02462 DMC Health Centre - Canterbury Street, DMC Healthcare 12.8 27.1 14.3
      G82162 Rainham Healthy Living Centre, Dr Ferrin & Partners 46.2 27.0 -19.2
      G82011 Sunlight Centre Surgery, Medway Community Healthcare 36.7 26.9 -9.8
      G82631 Medical Centre, Dr Chaudhry 35.3 26.5 -8.8
      G82762 Upper Canterbury Street Surgery, Dr Silhi 36.4 26.1 -10.3
      G82676 Bryant Street Surgery, Dr Aly & Partner 14.3 22.7 8.4
      G82656 Tunbury Avenue Surgery, Dr Jha 25.0 21.4 -3.6
      G82161 Walderslade Village Surgery, Dr Raval & Partners 25.8 20.7 -5.1
      G82139 Maidstone Road Surgery, Dr Qureshi 30.0 20.0 -10.0
      G82653 Rochester Community Healthy Living Centre, Dr Tandon & Partner 33.3 20.0 -13.3
      G82820 Wayfield Road Surgery, Dr Mir 50.0 18.2 -31.8
      Y02471 College Health - Boots, College Health 20.0 18.2 -1.8
      G82753 Kings Family Practice, Dr Huxham & Partners 90.9 18.0 -72.9
      G82763 Napier Road Surgery, Dr Jana 60.0 15.4 -44.6
      G82622 The Surgery, Dr Bhasme 0.0 11.6 11.6
      G82744 Halfway Surgery, Dr Ali 37.5 10.5 -27.0
      Y02461 DMC Walderslade Surgery, DMC Healthcare 0.0 8.7 8.7
      Y02472 College Health - Sterling House, College Health 45.0 4.3 -40.7
      G82109 Railside Surgery, Dr Ramesh 0.0 0.0 0.0
      G82739 Walderslade Medical Centre , Dr Padma 50.0 0.0 -50.0
      Table 4: Uptake of flu vaccine in pregnant women by Medway GP [1]

      A staff seasonal flu programme occurs every year. Uptake in 2011/12 was improved in healthcare provider organisations in Medway in 2011/12 compared to 2010/11.

        2011/12 2010/11
      NHS Medway (inc MCH) 39.5 25.0
      Medway Community Healthcare 39.8 20.8
      Medway Foundation Trust 44.3 38.1
      Kent and Medway Partnership 25.0 15.8
      Table 5: Staff uptake of flu vaccine 2011/12 compared to 2010/11 [1]
      Pnemococcal Vaccination

      See Figure 4 and Table 6.

      Figure 4: The percentage uptake of pneumococcal vaccine up to 31st March 2011 by Medway GP.
      Figure 4: The percentage uptake of pneumococcal vaccine up to 31st March 2011 by Medway GP [1]
        Practice 2010/11 2011/12 Percentage point
      difference
      G82718 Broadway Practice, Dr Patel MG 100.0 90.9 -9.1
      G82644 Wyvill Surgery, Dr Faramawi 76.3 87.6 11.3
      G82184 Medical Centre, Waltham Road, Dr Lakshman & Partner 86.3 87.5 1.2
      G82154 Thames Avenue Surgery, Dr Fernando & Partners 85.6 87.2 1.6
      G82635 Pump Lane Surgery, Dr Bhatia 86.2 87.1 0.9
      G82708 Marlowe Park, Dr Juneja 84.6 85.1 0.5
      G82631 Medical Centre, Dr Chaudhry 84.4 84.1 -0.3
      Y00198 Parks Medical Practice, Dr Green & Partners 80.0 83.3 3.3
      G82704 Church View Practice, Dr De Bie & Partners 81.1 82.7 1.6
      G82180 The Surgery, Dr Shaunak & Partners 79.9 82.0 2.1
      Y00449 St Mary’s Island Surgery, Dr Lawrence 80.4 81.4 1.0
      G82763 Napier Road Surgery, Dr Jana 80.5 80.6 0.1
      G82230 Lordswood Healthy Living Centre, Dr Singh O & Partner 78.4 80.3 1.9
      G82697 Churchill Clinic, Dr Vibhuti & Partners 78.2 80.2 2.0
      G82203 Court View Surgery, Dr Spinks & Partners 80.0 80.1 0.1
      G82737 Parkwood Health Centre, Dr Shah & Partners 79.7 80.1 0.4
      G82198 Medical Centre, Gun Lane, Dr Agarwal, Ray and Kumar 82.0 79.9 -2.1
      G82100 Highcliffe Medical Practice, Dr Markwick & Partners 78.1 79.6 1.5
      G82051 City Way Surgery, Dr Syed & Partners 34.0 78.0 44.0
      G82113 Stonecross and West Drive Surgery, Dr Mahapatra & Partner 72.0 76.8 4.8
      G82711 Borstal Village Surgery, Dr Balachander 72.9 75.2 2.3
      G82161 Walderslade Village Surgery 73.5 74.7 1.2
      G82719 Matrix Medical Practice, Dr Stacey 69.8 74.0 4.2
      G82226 Wigmore Medical Centre, Dr Patel SKC & Partners 73.4 73.8 0.4
      G82653 Rochester Community Healthy Living Centre, Dr Tandon & Partner 63.2 73.6 10.4
      G82133 St Marys Medical Centre, Dr Pancholi & Partners 74.3 73.1 -1.2
      G82108 King George Surgery, Dr Maheswaran & Partners 78.7 72.7 -6.0
      G82129 Glebe Family Practice, Dr Patel P & Partners 72.5 72.7 0.2
      G82739 Walderslade Medical Centre , Dr Padma 66.0 72.5 6.5
      G82679 Apex Medical Centre, Dr Premeratne & Partners 70.5 72.1 1.6
      G82139 Maidstone Road Surgery, Dr Qureshi 79.6 70.2 -9.4
      G82622 The Surgery, Dr Bhasme 70.8 70.2 -0.6
      G82077 Elms Medical Practice, Dr Lee & Partners 71.5 70.1 -1.4
      G82744 Halfway Surgery, Dr Ali 59.0 70.1 11.1
      G82095 Dame Sybil Thorndike Healthcare , Dr Tanday & Partners 70.4 70.0 -0.4
      G82727 Malling Health, Malling Health 60.9 70.0 9.1
      G82600 Eastcourt Surgery, Dr Nandini 64.8 69.7 4.9
      G82821 Bryant Street Surgery, Dr Kanekal 60.8 69.0 8.2
      G82721 Parkwood Family Practice, Dr Selvan 70.2 68.4 -1.8
      G82106 Riverside Medical Centre, Dr Sastry & Partners 36.3 68.2 31.9
      G82123 Balmoral Gardens, Dr Karim & Partners 7.4 68.2 60.8
      G82109 Railside Surgery, Dr Ramesh 66.0 67.8 1.8
      G82233 Hoo St Werburgh, Dr Davies & Partners 66.2 67.6 1.4
      G82753 Kings Family Practice, Dr Huxham & Partners 78.4 67.6 -10.8
      G82762 Upper Canterbury Street Surgery, Dr Silhi 68.3 67.5 -0.8
      G82162 Rainham Healthy Living Centre, Dr Ferrin & Partners 65.1 66.3 1.2
      G82741 Princes Park Medical Centre, Dr Aslam 10.2 63.8 53.6
      Y02462 DMC Health Centre - Canterbury Street, DMC Healthcare 45.9 62.9 17.0
      G82014 Woodlands Family Practice, Dr Rishi & Partners 63.5 61.9 -1.6
      G82011 Sunlight Centre Surgery, Medway Community Healthcare 62.9 61.8 -1.1
      G82775 Medway Medical Centre, Dr Dharan & Partner 6.2 61.5 55.3
      G82820 Wayfield Road Surgery, Dr Mir 59.9 61.0 1.1
      G82706 Brompton Medical Centre, Dr Singh BN 4.9 59.2 54.3
      G82676 Bryant Street Surgery, Dr Aly & Partner 58.6 58.6 0.0
      G82764 Esplanade Healthcare, Dr Hubbard & Partner 51.8 54.6 2.8
      G82670 Rochester Community Healthy Living Centre, Dr Elapatha 49.7 51.8 2.1
      G82656 Tunbury Avenue Surgery, Dr Jha 51.7 50.7 -1.0
      Y02472 College Health - Sterling House, College Health 41.2 46.0 4.8
      Y02461 DMC Walderslade Surgery, DMC Healthcare 16.1 44.2 28.1
      Y02471 College Health - Boots, College Health 35.8 36.2 0.4
      Table 6: Uptake of pneumococcal vaccine up to 31st March 2011 compared to 31st March 2010 by Medway GP [1]

      The BCG (Bacilus Calmette–Guérin) programme

      Data are not collected in a form that allows uptake rates to be calculated in adults only.

        2008/09 All ages 2008/09 age under 1 2008/09 age 1 and over 2009/10 All ages 2009/10 age under 1 2009/10 age 1 and over 2010/11 All ages 2010/11 age under 1 2010/11 age 1 and over
      Medway 582 321 261 560 339 221 447 292 155
      South East Coast 12,761 7,988 4,773 11,986 9,383 2,603 6,727 5,547 1,180
      England 239,241 148,948 90,293 223,167 115,611 67,556 225,316 153,253 72,063
      Table 7: The number of BCG vaccinations per 1,000 population over the past 3 years in Medway compared to SEC SHA and England [2] [3]

      References

      [1]   Department of Health. Immunisation
      [2]   The NHS Information Centre for Health and Social Care. NHS Immunisation Statistics, England 2010-11 http://www.ic.nhs.uk/statistics-and-data-collections/health-and-lifestyles/immunisation/nhs-immunisation-statistics-england-2010-11
      [3]   Child Health Records Department.
    • Current services in relation to need

      Vaccination of adults is undertaken in general practice. The HPU also provide a two day training programme on immunisation and vaccination for all new vaccinators and a half annual update for all others as per Health Protection Agency guidelines.

    • Projected service use

      The population of those aged 65 and over resident in Medway has increased by 8.6% over the past few years from 33,299 people (2006) to 36,172 (2010). It is predicted to increase to 41,900 by 2015 and 46,100 by 2020. This means that more people will be eligible for seasonal flu and Pneumococcal vaccination.

    • Evidence of what works

      Joint Committee for Vaccinations and Immunisations:

      The Joint Committee on Vaccination and Immunisation (JCVI) is an independent expert advisory committee first set up in 1963 to advise the Secretaries of State for Health, Scotland, Wales and Northern Ireland on matters relating to communicable diseases, preventable and potentially preventable through immunisation. JCVI gives advice to Ministers based on the best evidence reflecting current good practice and/or expert opinion. The process involves a robust, transparent, and systematic appraisal of all the available evidence from a wide range of sources. The committee is appointed by the Appointments Commission and is independent of the Department of Health.

      Heath Protection Agency (HPA):

      The Health Protection Agency is an independent UK organisation that was set up by the government in 2003 to protect the public from threats to their health from infectious diseases and environmental hazards. It does this by providing advice and information to the general public, to health professionals such as doctors and nurses and to national and local government and includes specific information about immunisations and vaccinations.

      NHS choices immunisation website:

      A comprehensive, up-to-date and accurate source of information on vaccines, disease and immunisation for the UK for the public can be found here

      Department of Health Immunisation against Infectious Disease:

      'The Green Book': The most recent printed version was published in 2006, but the website is regularly refreshed with updated chapters. Each chapter gives details on the disease, vaccine available, efficacy of the vaccine, contraindications, side effects and the correct dosage etc.

    • User views
    • Equality Impact Assessment
    • Unmet needs - service gaps

      This year 2012/13 there has been confusion concerning the responsibility of providing flu vaccination to health care students — while this does not appear to have been an issue in Medway, this needs to be resolved nationally.

    • Recommendations

      Ensure that all those who vaccinate are adequately trained and aware of issues such as the cold chain guidance and what to do if there is an incident

      Review the staff seasonal flu programme which has historically been led by Kent HPU and offered to all NHS staff in Medway with the coordination being led by public health in the light of changes within public health as a result of the Health and Social Care Bill

    • Further needs assessment required
  • Long term neurological conditions
    • Summary

      A long term neurological condition (LTNC) results from disease of, injury or damage to the body's nervous system. Many LTNCs severely affect quality of life and cause lifelong disability, with a range of co-morbidities that affect patients, carers and family members. This places a considerable burden on the health and social care sector.

      LTNCs affect individuals, families and carers in many different ways, physically, psychologically and socially. Many LTNCs severely affect quality of life and cause lifelong disability. People can experience a range of co-morbidities such as depression and anxiety, physical or motor problems, sensory problems, cognitive/behavioural problems, and communication problems.[1][2][3]

      Exclusions and relevance to existing work


      • Migraine is the most common neurological complaint. Its management has been addressed by the outpatient improvement programme at Medway Foundation Trust (MFT) so it has not been considered in detail in this work.
      • Acquired brain injury (ABI) has not been considered in detail, nor has stroke been included, on the advice of the CCG.
      • Specialist in-patient neuro–rehab has been a CCG focus since 2012, centred mainly on facilities and number of in-patient beds required for this function. For this reason it has not been considered in detail here.

      Key issues and gaps


      • Specialist nurses and multi–disciplinary teams — Specialist nurses (SN) are felt to be important in ensuring continuity of care. There is a lack of consistency nationally in the provision of SN support and the way in which services are designed around them. NICE recommends that every patient with epilepsy should have access to an ESN. There is only one ESN clinic a week in Medway at present.
      • Transition — Managing child to adult transition is an issue for both health and social care services. Transition is common for conditions such as epilepsy, which affects both children and adults, and increasingly for conditions such as Duchenne Muscular Dystrophy (DMD), for which medical advances have meant that more children are surviving into adulthood.
      • Palliative care — specialist palliative care services are needed for patients with advanced Parkinson's disease and the rapidly progressive 'Parkinson-Plus' syndromes (MSA and PSP). Their needs are similar in nature and severity to people with terminal cancer yet much of the burden of care of this group tends to fall on informal care givers. Motor Neurone Disease is such that serious patient episodes often occur outside of normal GP practice hours, and where out of hours services are unable to provide an acceptable level of care, the result is unnecessary and expensive hospital admissions, underlining the importance of appropriate specialist palliative care.

      Recommendations for commissioning


      • Develop a strategy for neurology that is jointly owned and developed by health services, social care and relevant third sector organisations
      • Improve community neuro–rehab to meet the on-going needs of people with LTNCs
      • Improve management of epilepsy through provision of epilepsy specialist nurse(s)
      • Provide appropriate emotional and psychological support to people with LTNCs
      • Establish arrangements for secure on-going provision of palliative and pre-palliative care


      References

      [1]   Shather Z. Commissioning Neurology Services in Richmond 2013; Unpublished.
      [2]   Pittam G, Haywood D. Health Needs Assessment for long term neurological conditions. A report for Oxfordshire PCT 2010; Oxfordshire PCT. http://mycouncil.oxfordshire.gov.uk/documents/s2460/JHO_MAY2010R07.pdf .
      [3]   Department of Health. National Service Framework for Long Term Conditions 2005; Department of Health. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/198114/National_Service_Framework_for_Long_Term_Conditions.pdf .
    • Who is at risk and why

      A long term neurological condition (LTNC) results from disease of, injury or damage to the body's nervous system. LTNCs are numerous and varied. Some may be present at birth and lead to learning disability. Some appear in childhood and others have an adult onset. The time course of different conditions also varies considerably, ranging from a few months to decades between diagnosis and death.

      Broadly speaking there are four categories of LTNC:
      • Sudden onset conditions – followed by a partial recovery, e.g. spinal cord injury
      • Intermittent and unpredictable conditions – causing variation in the level of care needed, e.g. epilepsy, or early multiple sclerosis (MS)
      • Progressive conditions – with increasing dependence on others for help as the condition deteriorates, e.g. motor neurone disease (MND), Parkinson's disease (PD) or late stages MS.
      • Stable neurological conditions – for which the needs change with development or ageing, e.g. post–polio syndrome or cerebral palsy in adults.

      Approximately 10 million people across the UK have a LTNC (migraine accounts for 8 million of these). The impact on the health and social care sector is considerable — it is estimated that LTNCs account for 19% of acute hospital admissions, 10% of visits to A&E and 17% of GP consultations (being the third most common reason for seeing a GP). They also make up 25% of the burden of chronic disability in people aged 16–64, affecting one in fifty of the UK's population. Approximately 350,000 people need assistance with daily living and around 850,000 people provide care for someone affected by a LTNC. Thirty-three percent of disabled people living in residential care have a LTNC.[1][2]

      A small number of LTNCs have relatively high prevalence. There are other conditions that are much rarer, but which collectively impose a large burden of illness on the population. People with LTNCs require support from a range of services, with much of the care for some conditions coming from specialties other than neurology, such as geriatrics and general medicine.[3]

      Studies have found it challenging to get a clear local picture of healthcare activity due to LTNCs. Routine data usually centre on hospital admissions, which are likely to underestimate the true level of overall activity. Admissions tend to be most concentrated around the time of diagnosis and/or changes with the stages of disease trajectory.

      Summary profiles can be found in a 2010 HNA for Oxfordshire,[4] providing 2–3 page summaries of a range of LTNCs. The information provided for each condition includes age of onset, symptoms, diagnosis, treatment, longer term support, and end of life care.


      References

      [1]   Shather Z. Commissioning Neurology Services in Richmond 2013; Unpublished.
      [2]   Skills for Health Workforce Projects Team. Long term neurological conditions: a good practice guide to the development of the mutlidisciplinary team and the value of the specialist nurse 2008; MS Society. http://www.mssociety.org.uk/sites/default/files/Documents/Professionals/Long%20Term%20Neurological%20Conditions_good%20practice%20guide_professionals%20resource.pdf .
      [3]   Fell, Gibbons C. Long Term Neurological Conditions - Strategic Health Needs Assessment 2010; Bradford and Airedale NHS.
      [4]   Pittam G, Haywood D. Health Needs Assessment for long term neurological conditions. A report for Oxfordshire PCT 2010; Oxfordshire PCT. http://mycouncil.oxfordshire.gov.uk/documents/s2460/JHO_MAY2010R07.pdf .
    • Level of need in the population

      Prevalence and incidence

      National estimates of prevalence and incidence for a range of conditions have been applied to the Medway population and summarised in Table 1, listed in order of prevalence (highest to lowest). Also included in the table are local estimates based on data from GP practice records and Quality Outcomes Framework (QOF) data, including numbers of people with Parkinson's Disease, Multiple Sclerosis and Muscular Dystrophy who also have a possible diagnosis of depression.

      Incidence Prevalence No. with possible depression
      per 100,000 (based on national estimate) Number per 100,000 (based on national estimate) Number (based on national estimate) Number (based on local data)
      Migraine 400 1,150 15,000 43,113 No data
      Traumatic brain injury leading to LTC 175 503 1,200 3,449 No data
      Essential tremor unknown unknown 850 2,443 328
      Epilepsy 80 230 500-1,000 1,437-2,874 2,065
      Parkinson’s disease 17 49 200 575 489 254
      Cerebral palsy unknown unknown 144 414 235
      Multiple sclerosis 4 11 144 414 475 285
      Post-polio syndrome unknown unknown 100-300 287-862 0
      Dystonia unknown unknown 65 187 No data
      Muscular dystrophy unknown unknown 50 144 39 32
      Spinal chord injury 2 6 50 144 No data
      Charcot-Marie Tooth unknown unknown 37 106 No data
      Spina bifida and congenital hydrocepalus unknown unknown 24 69 No data
      Hungtingdon’s disease unknown unknown 14 39 No data
      Myasthenia gravis unknown unknown 10 29 71
      Hereditary Ataxia unknown unknown 10 28 No data
      Motor neurone disease 2 6 7 20 38
      CNS infections 7 21 unknown unknown No data
      Table 1: Estimates of incidence and prevalence of LTNCs in Medway
      Notes on table 1


      • National estimates — All conditions based on various sources, applied to Medway's resident population of 287,417 (PCIS 2013 Q1 estimates).
      • Local estimates (epilepsy) — of all the LTNCs, QOF data is only available for epilepsy, and provides figures for adults (aged 18+) of 1,882 (QOF 2011/12). An estimate for Medway prevalence among children and young people is 183 (based on estimate produced by NICE).
      • Local estimates (all other conditions) — taken from clinical records of 54 of the 58 Medway GP practices. The registered population across these practices is 277,994, almost 10,000 people fewer than the resident population used to extrapolate from national estimates. The figures above were taken from an existing audit called 'Medway Prevalence' and were correct as at 28th August 2013.
      • Possible depression — taken from 'Medway Prevalence' audit with data for the three conditions shown.

      Differences between local and national estimates of prevalence

      Discrepancies exist between estimates of prevalence extrapolated from national figures and local data from GP records. Despite being one of the most prevalent conditions nationally, GP records show essential tremor to be less prevalent in Medway than epilepsy, PD and MS. Cerebral palsy is also far less prevalent than estimated from national figures and post-polio syndrome appears to be entirely absent in the local population.

      To some extent these differences are to be expected since Medway's population may not be representative of the national population. However, it possible that the large relative differences between national and local estimates for post-polio syndrome, essential tremor and muscular dystrophy are due to under- or misdiagnosis or people not being known to GPs.

      It is noteworthy that local numbers of patients registered with Motor Neurone Disease (for which misdiagnosis is less likely given its severity and rapid progression) are almost double that of the national estimates. This has potential implications when planning services, particularly palliative care, for this condition. The number of patients registered with myasthenia gravis is also much higher than the national estimates. There is a slight genetic predisposition towards developing this condition [1] and it is possible that this is partly responsible for the high numbers in Medway.

      Mental health co-morbidities

      It is clear from Table 1 that a large proportion of people with MS (60%), muscular dystrophy (82%) and PD (52%) may also have depression. This has implications for the way in which services for people with LTNC need to be integrated with mental health services to ensure that their needs are met holistically. Work is planned by Medway CCG to identify more fully the level of depression associated with long term conditions in general.

      Multiple Sclerosis and Parkinson's Disease prevalence

      Table 2 shows estimates of the number of people with these conditions by stage of progression.

        Multiple sclerosis Parkinson’s disease
      Diagnosis 22 53
      Minimum-moderate impairment (MS)/ Maintenance (PD) 199 198
      Complex 243 164
      Palliative 11 74
      Total 475 489
      Table 2: Prevalence breakdown by phase of progression for MS and PD. Source Neuronavigator, breakdown calculated using total prevalence from GP records
      Adult epilepsy prevalence

      As mentioned above, adult epilepsy is the only LTNC included within QOF. Figure 1 shows that Medway had a much higher prevalence in 2011/12 than England and all of the ONS cluster towns.

      Figure 1: Estimated prevalence per 1,000 of adult epilepsy in 2011/12.
      Figure 1: Estimated prevalence per 1,000 of adult epilepsy in 2011/12, comparing Medway with England and the ONS cluster. Source: QOF 2012, based on data collected for QOF indicator Epilepsy 5

      Mortality

      Standardised Mortality Ratios (SMR) associated with a neurological condition (as the underlying cause of death) are presented in figure 2 for the last ten years (2002–12). This shows an increasing trend in mortality in Medway to 2008 followed by a decreasing trend since. Compared to the Kent SMR for this period of 100, the SMR in DGS is the same (100), while it is higher in Medway (113) and Swale (114).

      Figure 2: SMR for deaths due to a neurological condition in Medway, DGS and Swale.
      Figure 2: SMR for deaths due to a neurological condition in Medway, DGS and Swale

      Table 3 shows condition specific mortality for the same period. There is also a description of the age distribution of deaths in 2012 across Kent and medway to give a picture of where the overall mortality burden lies.

        Number of deaths in Medway (2002-2012) 2012 deaths in Kent and Medway Description of age distribution
      Parkinson’s 178 136 All adults aged 60+
      Motor neurone disease and spinal muscular atrophy 70 68 Heavily skewed towards older adults with most in those aged 65+
      Multiple Sclerosis 44 49 Approximate bell shaped curve between the ages 35-39 and 85+
      Epilepsy 71 34 Very few children, fairly even distribution across adult ages until an increase in those 85+
      Cerebral palsy 13 8 Deaths in both children and young adults
      Huntingdon’s disease 30 9 All in adults aged 45+
      CNS infections 6 sup All in adults 75+
      Muscular dystrophy 9 sup
      Spinal chord injury sup sup
      Spina bifida and congential hydrocepalus sup sup Most in adults 70+
      Myasthenia gravis 6 sup All in adults 75+
      Guillain Barre syndrome sup sup All in adults 65+
      Total deaths (any underlying neurological condition) 437 324 Heavily skewed towards adults 65+
      Table 3: Number of deaths due to selected underlying LTNCs. Source: Office for National Statistics

      Deaths due to epilepsy in Medway accounted for 21% of the total mortality due to epilepsy across K&M in the period 2002–12, compared with DGS (11%) and Swale (7%). Deaths due to Huntington's Disease in Medway were also disproportionately high, although this is expected given the presence of two homes in Medway dedicated to the care of people with advanced HD that take patients from outside the area. For PD, MS and MND, Medway has lower numbers of observed deaths than DGS, despite having a higher expected prevalence due to its larger population.

      Admissions

      There is an increasing trend in rates of both elective and emergency hospital admissions, where neurological conditions were the main reason for admission, since 2006, as shown in figures 3 and 4.

      Figure 3: Elective admission rates due to LTNCs.
      Figure 3: Elective admission rates due to LTNCs, 2006/07–2012/13
      Figure 4: Emergency admission rates due to LTNCs.
      Figure 4: Emergency admission rates due to LTNCs, 2006/07–2012/13

      There is more variation shown in figure 4 between areas than figure 3.

      Age specific rates of emergency hospital admissions, where a neurological condition was the primary cause for admission, across Kent and Medway CCGs in the period 2010–13 are shown in figure 5. Medway CCG has the highest rates in the 65–84 and 85+ age bands and the second highest rate in the 0–19 age band. The emergency hospital admission rate for the 20–64 age band is relatively low. This could be of significance for provision of both palliative and paediatric care.

      Figure 5: Age specific rates of emergency admissions due to LTNC by CCG.
      Figure 5: Age specific rates of emergency admissions due to LTNC by CCG, 2010–13. Source: SUS, Office for National Statistics

      For elective admissions, the highest percentages of admissions in Medway are for patients aged 40 to 54 and 60 to 64. For emergency admissions, the highest percentages are for patients aged 0 to 4 and then over 40.

      Conditions for which emergency admissions made up at least 80% of all admissions in 2010/11–2012/13 are epilepsy, migraine, PD, CNS infections, Guillain Barre syndrome, and HD. There were a large number of emergency epilepsy admissions, which accounted for 31% of all admissions due to a LTNC in the period. There is scope to greatly reduce this figure through better management or self–management of this condition.

      The high proportion of elective MS admissions observed is due mainly to the presence of the Tysabri clinic at MFT, for which people with MS are admitted for a few hours so that they can be closely monitored during treatment.

      There is a strong downward trend in emergency admissions for neurological conditions from the most to least deprived quintiles. For elective admission rate, there is not such a clear pattern. This is shown in figure 6.

      Figure 6: Directly standardised rates of hospital admissions by deprivation quintile, Medway CCG, 2010--13.
      Figure 6: Directly standardised rates of hospital admissions by deprivation quintile, Medway CCG, 2010–13

      References

      [1]   Sear E, Rana B, Bibby A. Better Co-ordination; Better Care - A review of services for people with Neuromuscular Conditions in the South East Coast 2010; South East Coast Specialised Commissioning Group, West Sussex.
    • Current services in relation to need

      Community services

      Community neuro—physiotherapy: a neuro-phyiotherapist holds outpatient clinics at St Barts, MFT and the Walter Brice Centre for 130–150 patients.

      Specialist neurology services


      • PD and MS specialist nurses: MFT has two full time nurses for each condition, providing home visits, clinics, education and training.
      • Epilepsy specialist nurses: One clinic a week is held in Lordswood by the ESN who also covers Dartford and Gravesham. MFT has submitted a business plan to recruit an ESN to increase provision and improve links with consultants.
      • Tysabri clinic for MS: MS patients who stop responding to disease modifying therapies can be screened for suitability for Tysabri treatment, which takes place at Kings (London). Tysabri appointments occur every 4 weeks, with each one lasting a minimum of 90 minutes.
      • Huntingdon's disease specialist care in nursing homes: There are two nursing homes in Medway specialising in providing care for people with advanced HD, including many patients from outside of Medway.
      • Emotional support and psychological therapies: The CCG is providing training for staff to recognise anxiety and to ensure appropriate support pathways are in place.

      Social services

      Support from social services for people with LTNC comes mainly for people with associated physical disabilities that are severe enough to qualify for social care. People will often enter the system once their condition is quite far advanced. The exception to this is the large number of people receiving support from the learning disabilities team who also happen to have epilepsy.

      Social services at Medway Council is also diverting more resources into support for carers. They have started to implement a strategy for increasing the number of carer's assessments completed and increasing the amount of support available, with a dedicated care manager and care manager's assistant based at the council.

      Palliative and end of life care


      • MCH specialist palliative care service: MCH provides a specialist palliative care service, including Wisdom Hospice (15 beds), a day hospice and a home care team of nurses that care for about 350 patients in their homes at any one time. Outpatient clinics are provided at the Disablement Service Centre.
      • Multi–disciplinary team for MND: A multi–disciplinary team provides a service for patients with MND which is unfunded and reliant on the goodwill of its members to function. The team comprises a palliative care consultant, Wisdom Hospice, home care nurse, social worker, MND association rep, Occupational Therapist (OT) from MCH and speech and language therapists. The team is usually involved from diagnosis of the condition, since the prognosis is usually 2–3 years. Joint clinics are held for people requiring non–invasive ventilation. These clinics are also due to start with a nutrition nurse for people who may need percutaneous endoscopic gastrostomy (PEG) feeding.

      Third sector services


      • The Huntington's Disease Association: This is a small charity with one person working across Kent & Sussex and Bromley, Bexley and Dartford as a non-medical advisor, providing advice for individuals with HD, signposting them to services and also supporting professionals. The representative's support extends to families and she makes home visits in Medway as well as visiting nursing homes and clinics.
      • Parkinson's UK: A large charity which has had active involvement in Medway, notably through pump–priming of the two PD specialist nurse posts. It has a local branch which meets monthly in Chatham, offering information and support to individuals, families and carers.
      • MS Society: The MS Society has a local development support officer who works with branches as a volunteer. The Medway branch is quite active, organising social meetings and signposting people if they need support for advocacy. It also runs a drop in centre, has a helpline number and an active website. It organises speakers at its events such as the MS specialist nurse, who is also the charity's main interface with the health service. Support for carers is provided from support volunteers and the national centre, and in 2014 a big push in this area is planned, including a appointing strategic national lead for carers.
      • Carers First: Support to carers is available primarily through Carers First in Gillingham, although each of the condition-specific charities offer support to carers too.

    • Evidence of what works

      The National Service Framework (NSF) for LTNCs[1] is a comprehensive resource that, while out of date, outlines the key issues in this area. Its 11 quality requirements (QR) remain a useful gold standard for service provision for LTNCs across the health and social care sectors. A 2011 review of the NSF by the National Audit Office[2] was partly based on a systematic review of 146 documents. Included within these are fairly recent published audits of compliance with clinical guidance for a range of LTNCs.

      The QRs in the NSF have the common theme of 'integration' running across them, but very limited advice is given about how to implement this in practice nor how to evaluate whether the outcome of continuity of care has been achieved.[3] Continuity of care should comprise good continuity in healthcare and social care, but also improved social and economic inclusion. Three types of service are highlighted that have the various factors identified as being necessary to promote continuity of care: 1. community interdisciplinary neurological rehabilitation teams (CINRT) 2. specialist nurses (SN) 3. proactive, holistic day opportunities services[4]

      Common blockages to accessing these services include eligibility criteria, poorly-defined pathways and a lack of local availability or capacity. Third sector organisations also play an important role by improving access and promoting continuity of care.[3]

      It is clear is that specialist nurses play a crucial role within a multi-disciplinary team (MDT), which is felt to be the best way of ensuring patient–centred services are delivered. SNs can act as a catalysts for change, lead service development and be a constant figure for the patient.[5]

      An implementation framework now exists for end of life care in LTNCs. It notes that well delivered palliative care services, particularly if they are delivered holistically with pain and symptom management, can improve patients' quality of life as conditions progress.[6]

      NICE has published comprehensive clinical guidance (CG) on the diagnosis and management of MS (CG8, 2003), PD (CG35, 2006) and epilepsy (CG137, 2012). NICE quality standards (QS) have also been published for epilepsy in adults (QS26) and children and young people (QS27). Quality standards are also being developed for MS, MND, cerebral palsy, PD, and for 'relatively uncommon neurological problems e.g. muscular dystrophy'.

      The Association of British Neurologists has guidelines on the management of MND, viral encephalitis in adults and the treatment of MS.

      Map of Medicine has maps for a range of conditions: Bell's palsy in adults, epilepsy in adults, headache in adults, HD, MS, PD.

      Neurological Commissioning Support has also published care pathways for Progressive Supranuclear Palsy (PSP) and PD.


      References

      [1]   Department of Health. National Service Framework for Long Term Conditions 2005; Department of Health. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/198114/National_Service_Framework_for_Long_Term_Conditions.pdf .
      [2]   National Audit Office. Department of Health, Services for People with Neurological Conditions. Report by the Comptroller and Auditor General. 2011; National Audit Office. http://www.nao.org.uk/wp-content/uploads/2011/12/10121586.pdf .
      [3]   Bernard S, Aspinal F, Gridley K, et al. Integrated services for people with long-term neurological conditions: evaluation of the impact of the national service framework. Final Report. 2010; University of York. http://php.york.ac.uk/inst/spru/research/summs/ltnc.php .
      [4]   Department of Health Policy Research Programme. Improving outcomes for people with LTNCs. Building services for the future. 2012; Department of Health. http://www.ltnc.org.uk/ALMO/building_services_for_future.html#outcomes .
      [5]   Skills for Health Workforce Projects Team. Long term neurological conditions: a good practice guide to the development of the mutlidisciplinary team and the value of the specialist nurse 2008; MS Society. http://www.mssociety.org.uk/sites/default/files/Documents/Professionals/Long%20Term%20Neurological%20Conditions_good%20practice%20guide_professionals%20resource.pdf .
      [6]   National End of Life Care Programme. End of life care in long term neurological conditions a framework for implementation 2010; National End of Life Care Programme. http://www.endoflifecare.nhs.uk/assets/downloads/improving_eolc_neurology.pdf .
    • User Views

      It was not possible to meet with consultants at Medway Foundation Trust (MFT), nor have direct contact with patients as part of this work. The views of these key groups should be included as part of the process of implementing the recommendations.

    • Unmet needs and service gaps


      • At present on person from the Huntington's Disease Association works across Kent, Sussex, Bromley, Bexley and Dartford as a non-medical advisor, but given the limited resources of one individual, it is not possible to support all people with HD in Medway, nor provide a service whereby she proactively contacts people on a regular basis.


      • There is no GP with a Special Interest in neurology in Medway, resulting in frequent referrals to specialist nurses and consultant neurologists


      • Provision of an epilepsy specialist nurse is limited with the one clinic a week in Medway being run by an ESN from Darent Valley Hospital.

      Services in development


      • Community neuro–rehabilitation pathway: MCH is in the early stages of developing a community pathway to ensure people with LTNCs receive the right therapy from the right provider and to minimise duplication. This will create a single point of access for patients who will have their treatment or rehabilitation plan coordinated and supported.


      • Case management approach: MCH is liaising with the CCG regarding the restructuring of its services into a case management approach in order to give a holistic overview of complex cases.


      • Shared electronic patient record: this is being developed by MCH to contain MyPlan, which is filled in as part of an assessment and contains an individuals care plan, treatment and goals, which could then be viewed by all MCH services.


      • Proposed neuro rehabilitative palliative care service: A business case has been developed for a neuro rehabilitative palliative care service, comprising a doctor, community nurse, neuro nurse, physio, counsellor/social worker, speech and language therapist and OT. Having such a team in place would enable more regular visits to places such as Millstream and Frindsbury care homes, which provide support for patients with advanced HD. The team would also work with the MS specialist nurse to proactively identify and assess patients whose condition is deteriorating, and with the PD specialist nurse to support patients with MSA/PSP. This team could also be tasked with identifying the small numbers of people with rarer LTNCS that exist in the community. It was estimated that there are 20–30 people with these conditions in Medway and almost no expertise to cover them currently.

    • Recommendations for commissioning

      The following recommendations are those that are likely to be locally practicable and have the biggest impact, in terms of numbers involved, severity of the condition(s), risk and costs associated. The recommendations have tried to build upon or further inform existing opportunities and initiatives.

      1. Develop a strategy for neurology that is jointly owned and developed by health services, social care and relevant third sector organisations


      • Improved integration for patient-focused services
      • Ownership within healthcare to include different medical specialties
      • Inform service planning through better use of data and existing estimates

      2. Improve community neuro-rehab to meet the on-going needs of people with LTNCs


      • Appoint a community neurology specialist nurse to work closely within or alongside Medway Community Health's emerging community neuro-rehab pathway, case management approach, condition-specific specialist nurses and palliative care team.
      • Develop a structured programme of training for community physios with the aim of having at least two physios with confidence in dealing with specific LTNCs. Additional neuro-physio capacity is likely to be required in the short term to achieve this.

      3. Improve management of epilepsy through provision of ESN(s)


      • Pursue the plan to appoint an epilepsy specialist nurse at MFT as soon as possible
      • Closely monitor this nurse's caseload/performance and plan for the appointment of at least one additional ESN, based either at MFT or in the community.
      • Determine optimal configuration of ESNs via discussion with the current ESN at DVH/Lordswood and investigation of the model used in Canterbury

      4. Provide appropriate emotional and psychological support to people with LTNCs


      • Build a more complete picture of the need: a) run a complete audit of GP records combining all main LTNCs with a range of relevant mental co-morbidities; b) consider this alongside priorities expressed by SNs, charities and patients.
      • Explore opportunities for vocational rehab for people with LTNC such as MS to ensure they reap the mental health benefits of being in employment

      5. Establish arrangements for secure on-going provision of palliative and pre-palliative care


      • Consider and negotiate proposed arrangements for a neuro-rehab palliative care team and ensure that sustainable funding is available for the existing MDT for MND
      • Facilitate more proactive and regular assessment of people in the complex phase of MS that might require transition to palliative services
      • Pilot a MDT for advanced PD cases, coordinated by the PD specialist nurse. One major focus would be to ensure care is arranged for people with multiple morbidities that might not, taken individually, warrant referral to a specialist.

  • Maternity and pregnancy
    • Summary

      The health of a pregnant woman directly affects the health of her unborn child. What happens in the early years of life, starting in the womb, has lifelong effects on many aspects of health and well-being — from obesity, heart disease and mental health, to educational achievement and economic status. Giving every child the best start in life is crucial to reducing health inequalities across the life course.[1]

      In 2008 a maternity needs assessment was undertaken in Medway.[2] This provided a detailed snapshot of the needs and services within Medway and compliance with standards within the Department of Health 2007 publication Maternity Matters[3] using data mainly up to 2007.

      The Medway Annual Public Health Report 2009/10[4] also contained 2 chapters relating to maternity and the outcome of pregnancy. This chapter of the JSNA updates relevant information.


      References

      [1]   Marmot M. Fair Society, Healthy lives 2010; Strategic Review of Health Inequalities in England post-2010. http://www.instituteofhealthequity.org/projects/fair-society-healthy-lives-the-marmot-review/fair-society-healthy-lives-full-report .
      [2]   Bird A. Maternity Matters Needs Assessment 2009; NHS Medway. http://www.kmpho.nhs.uk/geographical-areas/primary-care-trusts/medway-pct/?assetdet956103=91215 .
      [3]   Department of Health. Maternity Matters: Choice, access and continuity of care in a safe service 2007; Department of Health. http://bit.ly/IDOqCe .
      [4]   NHS Medway. Investing for Health - the Annual Report of the Director of Public Health 200910; NHS Medway. http://www.kmpho.nhs.uk/geographical-areas/primary-care-trusts/medway-pct/?assetdet956103=102411 .
    • Who's at risk and why?

      While most births occur following an uneventful pregnancy, occasionally there are complications and rare tragedies which good antenatal care seeks to minimise. A maternal death is defined as 'the death of a woman while pregnant or within 42 days of termination of pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes'. There have been five maternal deaths in the last 10 years (that is with an underlying cause of death in chapter 'O' of the ICD 10 codes).[1]

      Babies may also die – in utero, during labour or in the early days, weeks and months of life.


      • Still births are deaths after 24 or more weeks of completed gestation — death may occur in utero or during labour.
      • Perinatal deaths are deaths from the 24th week of gestation up to 6 completed days of life (i.e. include still births)
      • Early neonatal deaths are deaths between birth and 6 completed days of life.
      • Late neonatal deaths are deaths from 7–27 completed days of life.
      • Neonatal deaths are deaths in the first 27 completed days of life.
      • Post neonatal deaths are deaths at 28 days but under one year of life.
      • Infant deaths are deaths between birth and under one year of life.

      Still births and deaths in infancy are fortunately relatively rare events. Confidential enquires into still births and neonatal deaths have been undertaken in the UK for many years and risk factors for these events have been identified.[2] They are:


      • Maternal age – greater risk if less than 20 or 40 years and over
      • Maternal Body Mass Index (BMI) – greater risk if underweight, overweight, obese or very obese.
      • Maternal smoking
      • BME ethnicity
      • Maternal country of birth is outside the UK
      • Maternal social deprivation – greater risk if living in more deprived area
      • Booking for antenatal care after 12 weeks gestation
      • Prematurity – greater risk if born before 37 weeks
      • Low birthweight – greater risk if less than 2,500g and even higher risk if less than 1,500g
      • Parity

      Smoking in pregnancy has significant health consequences. Babies of women who smoke during pregnancy are more likely to be born prematurely, have twice the risk of being low birthweight and are up to three times more likely to die from sudden unexpected death in infancy (SUDI).[2]

      Multiple births

      Twins are at a higher risk of stillbirth (2.5 times higher) and neonatal deaths (6.4 times higher) than singletons but more research is needed to determine whether this is due to prematurity and growth restriction rather than specific twin factors.[2]

      Causes of prematurity

      The causes of prematurity are complex and in many premature births are unidentifiable. However risk factors in addition to smoking are maternal pre-eclampsia (a condition causing hypertension, severe headaches, vision problems etc, the risk of which itself is increased by obesity), cervical incompetence (where the cervix begins to thin and dilate before the pregnancy has reached term), multiple births, infections, a previous preterm delivery, low BMI and domestic violence. Preterm babies often have low birth weights which is associated with inhibited growth and cognitive development, and chronic diseases later in life.


      References

      [1]   Office for National Statistics. Primary Care Mortality Database
      [2]   Centre of Maternal and Child Enquiries, CMACE. Perinatal Mortality 2009 2011; Centre of Maternal and Child Enquiries, CMACE. http://www.hqip.org.uk/assets/NCAPOP-Library/CMACE-Reports/35.-March-2011-Perinatal-Mortality-2009.pdf .
    • Level of need in the population

      Demographics and fertility rates

      Population estimates for 2012 indicate there are 54,972 women of childbearing age (15–44 years) residing in Medway. This represents 20.5% of the total (male and female) population, a slightly higher proportion than the national estimate of 20.0% and South East estimate of 19.2%.

      It is estimated that the number of women of this age group in Medway will increase in 2021 compared to 2011, by around 2,000 as shown in table 1.

      2011 2016 2021
      Number Number Difference (%) Number Difference (%)
      Medway 54600 55000 0.7 56500 3.5
      South East 1679900 1665400 -0.9 1675100 -0.3
      England 10725400 10711900 -0.1 10821300 0.9
      Table 1: Projections based on mid 2011 estimates of the population aged 15–44 years [1]

      Some areas in Medway have a larger percentage of women in this age group than others. Figure 1 shows where the highest proportions of women aged 15–44 live in Medway.

      Figure 1: Percentage of female population aged 15 to 44 years, by lower layer super output area, with ward boundaries.
      Figure 1: Percentage of female population aged 15 to 44 years, by lower layer super output area, with ward boundaries

      Figure 2 shows which wards in Medway have the highest number of women aged 15–44 residing of BME ethnicity.

      Figure 2: Number of females aged 15-44 with ethnicity other than White British, Irish or Irish/gypsy traveller.
      Figure 2: Number of females aged 15-44 with ethnicity other than White British, Irish or Irish/gypsy traveller

      In 2012, there were 3,693 live births to mothers usually resident in Medway. Table 2 shows the year on year increase since 2006. The increase between 2006 and 2012 is 436 (13.4%).

        2006 2007 2008 2009 2010 2011 2012
      Medway 3,257 3,345 3,419 3,515 3,538 3,564 3,693
      Table 2: Live births to Medway residents, 2006 to 2012 [2]

      The distribution of live births in 2012 by age of mother suggests that women in Medway are choosing to have babies younger than in the South East and England (figure 3).

      Figure 3: The percentage of 2012 live births per age band.
      Figure 3: The percentage of 2012 live births per age band [2]

      This is supported by analysing the general fertility rate by age group. Figure 4 shows that women aged under 30 resident in Medway have consistently had a higher general fertility rate than for the South East and England. For women aged 30 and over, however, this pattern reverses.

      Figure 4: General fertility rate (live births per 1,000 females aged 15-44) trend, by age band, 2003 to 2012.
      Figure 4: General fertility rate (live births per 1,000 females aged 15-44) trend, by age band, 2003 to 2012 [2]

      The overall general fertility rate for Medway residents in 2012 was 67.2 per 1,000 females aged 15-44, higher than for England (64.9 per 1,000). In line with national trends, this has increased over recent years (figure 5). In 2012, Medway's rate was significantly higher than for the South East.

      Figure 5: General fertility rate (live births per 1,000 females aged 15-44) trend, 2003 to 2012.
      Figure 5: General fertility rate (live births per 1,000 females aged 15-44) trend, 2003 to 2012 [2]

      The total period fertility rate (the average number of children a woman is expected to have during her reproductive life if she experiences the current age specific fertility rates) in Medway has been consistently higher than the England rate over recent years with the exception of 2008 when it was the same as the national rate of 1.97.

        2006 2007 2008 2009 2010 2011
      Medway 1.9 2.0 2.0 2.1 2.1 2.0
      England 1.9 1.9 2.0 2.0 2.0 1.9
      Table 3: Total period fertility rate, Medway and England 2006 to 2011 [3] [2]

      Abortions

      Some pregnancies are unplanned to the extent that they result in terminations. Figure 6 shows that the rate of terminations is significantly higher in Medway than in England. In 2012, there were 1,094 terminations in Medway resident women. The highest age group was 20-24 years old with 349 terminations. This suggests there is a need for more effective sexual health and contraceptive services in Medway.

      Figure 6: The rate of abortions per 1,000 Medway resident women,2012.
      Figure 6: The rate of abortions per 1,000 Medway resident women,2012 [4]

      Booking

      Women are encouraged to contact midwifery services as soon after they are aware they are pregnant as possible. Medway NHS Foundation Trust (MFT) offers “early bird group sessions” where women in the early stages of pregnancy have the opportunity to receive information and advice from community midwives prior to their booking appointment which is ideally at 8–10 weeks gestation (measured from the first day of a woman's last menstrual period). Data from MFT of the week of booking in is shown in table 4. Owing to the number of unknown/blank entries, definite conclusions cannot be drawn, but it seems most women are booking in prior to 12 weeks gestation and the number of unknown entries is reducing year on year.

        2009 2010 2011 2012 2013
      <6 weeks 181 594 554 342 216
      6-8 weeks 374 974 925 924 840
      8-10 weeks 574 1,271 1,396 1,490 1,468
      10-12 weeks 281 556 592 860 766
      12-16 weeks 115 232 253 375 358
      16-20 weeks 44 72 78 94 90
      20-24 weeks 21 57 58 60 54
      24-30 weeks 22 40 48 42 44
      30+ weeks 28 38 64 70 81
      Can’t remember/don’t know/blank 3,156 1,056 975 951 944
      Table 4: Gestation of women booking at MFT, 2009 to 2013 [5]
      Where do women booking at Medway hospital live?

      The majority of women registered with Medway GP practices are booked for maternity care with MFT. This hospital also provides maternity care for a large proportion of women in Swale. Table 5 shows the local authority of residence of women giving birth at MFT. The number of women from Maidstone district has almost doubled in 2012 compared to 2009. This could be partly due to the consultant-led maternity provision moving to Pembury hospital in Tunbridge Wells, although the number has reduced again in 2013. Figure 7 shows the same data, but hotspots by lower super output area (LSOA) the areas with the highest numbers of women booking into MFT.

        2009 2010 2011 2012 2013
      Medway 3,274 3,284 3,387 3,488 3,279
      Swale 1,263 1,351 1,284 1,361 1,339
      Maidstone 78 94 104 141 102
      Tonbridge and Malling 76 65 77 95 85
      Gravesham 34 22 34 36 38
      Canterbury 5 6 11 19 6
      Dartford 6 5 7 15 12
      Bexley 5 7 5 8 4
      Other 28 31 26 34 26
      Total 4,769 4,865 4,935 5,197 4,891
      Table 5: Local authority of residence of women booking at MFT
      Figure 7: Lower super output area of residence of women booking at MFT, 2009 to 2012.
      Figure 7: Lower super output area of residence of women booking at MFT, 2009 to 2012

      Table 6 shows that, of the women living in Medway and booking in at MFT, nearly 10% live in the Gillingham North ward. A high proportion of women also live in Chatham Central, Gillingham South and Luton and Wayfield. These 4 wards represent a third of women living in Medway and booking in at MFT.

        Number Proportion
      Gillingham North 1,535 9.3
      Chatham Central 1,488 9.1
      Gillingham South 1,316 8.0
      Luton and Wayfield 1,199 7.3
      Strood South 1,077 6.6
      Princes Park 770 4.7
      Strood Rural 758 4.6
      Rainham South 739 4.5
      Rochester East 734 4.5
      Strood North 739 4.5
      Twydall 721 4.4
      Peninsula 614 3.7
      Rochester South and Horsted 586 3.6
      Rochester West 584 3.6
      Lordswood and Capstone 554 3.4
      Walderslade 538 3.3
      Rainham Central 516 3.1
      Rainham North 508 3.1
      River 503 3.1
      Watling 435 2.6
      Hempstead and Wigmore 315 1.9
      Cuxton and Halling 207 1.3
      Table 6: The ward of residence of Medway women booking at MFT, 2009 to 2013 [5]

      Table 7 contains data for all women booking into MFT (not just those living in Medway) and so the deprivation quintiles used are for England. There is a reduction across the quintiles in 2013 compared to 2012 due to the lower number of births, with the exception of quintile 5 (least deprived).

        2009 2010 2011 2012 2013
      1 928 1,027 1,017 1,122 1,082
      2 1,639 1,583 1,648 1,729 1,603
      3 795 791 812 809 729
      4 612 703 635 775 691
      5 568 518 558 502 527
      Table 7: Deprivation quintile (England) of women booking at MFT, 1 = most deprived [5]

      The number of women booking in at MFT with ethnicity 'Any other white background' has risen by 70% between 2009 and 2012 (table 8).

        2009 2010 2011 2012 2013
      White British 4047 4087 4172 4,304 4,040
      White Irish <5 <5 <5 9 6
      Any other White background 209 275 279 355 343
      Indian 106 114 114 123 99
      Pakistani 26 28 26 22 28
      Bangladeshi 38 26 22 29 27
      Any other Asian background 32 51 46 48 65
      White and Asian <5 14 6 11 13
      White and black African 6 <5 7 7 6
      White and black Caribbean 7 11 9 15 9
      Any other mixed background 20 15 17 19 15
      Black African 110 142 128 140 130
      Black Caribbean 24 25 24 16 25
      Any other Black background 15 11 8 13 9
      Chinese 18 18 21 23 17
      Any other ethnic group 98 51 59 62 63
      Not collected/Not stated/blank 34 17 10 13 15
      Table 8: Ethnicity of women booking in at MFT [5]

      Parity and Gravidity

      Parity is the number of children previously born at a gestation of 24 weeks or more, regardless of whether they were live or stillborn, and gravidity is the number of times a woman has been pregnant. As mentioned in the last section, parity can be a factor in infant mortality. The number 'unknown' has fallen significantly in 2013.

        2009 2010 2011 2012 2013
      0 2,048 2,152 2,201 2,240 2,120
      1 1,526 1,595 1,564 1,809 1,734
      2 709 664 756 745 710
      3 271 282 268 304 234
      4 86 98 87 99 110
      5 36 40 38 25 34
      6 18 16 15 14 18
      7 and over 12 16 15 19 18
      Unknown 173 120 88 57 16
      Table 9: The number of births with the following parity [5]
        2009 2010 2011 2012 2013
      1 1,727 1,729 1,750 1,772 1,651
      2 1,447 1,531 1,471 1,542 1,458
      3 796 838 822 958 882
      4 362 399 449 479 474
      5 187 177 230 241 235
      6 90 91 104 121 133
      7 41 49 51 64 69
      8 21 21 25 36 33
      9 21 17 22 21 14
      10 12 6 7 11 9
      11 and over 175 125 102 67 35
      Unknown 0 0 0 0 1
      Table 10: The number of births with the following gravidity [5]

      Languages

      Table 11 shows the main languages spoken by women aged 16-49 resident in Medway and the five wards with the highest numbers of women of child bearing age. Women in these wards account for just over 31% of all women aged 16-49 in Medway, but they account for 60% of speakers of languages other than English. 78% with a main language of 'other South Asian language' live in these five wards along with 66% of Gujarati and 'other European language (non EU)' speakers. Please note this is a table of the main language spoken and English may be a second language for anyone not having it as their primary language.

        Medway Chatham Central Gillingham North Gillingham South Luton and Wayfield River
      English 58,399 3,581 4,569 3,702 3,110 2,276
      French 134 18 15 15 8 7
      Portuguese 101 20 11 7 8 6
      Spanish 91 15 6 3 5 10
      Polish 589 124 58 77 78 34
      Other European language (EU) 1,145 255 112 145 149 91
      Other European language (non EU) 383 79 31 39 46 34
      Arabic 70 5 10 6 3 15
      West/Central Asian language 88 14 6 15 7 10
      Panjabi 302 59 13 32 15 3
      Urdu 115 12 13 32 11 4
      Bengali (with Sylheti and Chatgaya) 207 57 11 31 13 8
      Gujarati 76 16 7 12 6 9
      Tamil 71 6 8 7 6 13
      Any other South Asian language 234 30 21 60 4 68
      Chinese 209 25 23 15 7 44
      Any other East Asian language 283 34 31 75 17 13
      African language 236 32 31 24 19 26
      Other language 28 4 6 3 2 2
      Total 62,761 4,386 4,982 4,300 3,514 2,673
      Table 11: The main language spoken by resident women aged 16-49 [6]

      Delivery

      Place of delivery

      The Birth Place opened in October 2011 and it can be seen in table 12 the impact this has had on the number of deliveries in the Delivery Suite. The number of deliveries in theatre has gone up however, in line with the increase in emergency caesarean sections shown in table 13. The number of planned homebirths decreased by nearly 40% between 2011 and 2012

        2009 2010 2011 2012 2013
      Delivery Suite 3036 3122 3067 2430 2374
      Theatre 1437 1472 1448 1696 1576
      The Birth Place <5 <5 152 882 770
      Planned homebirth 187 157 145 89 87
      Unknown 121 140 131 87 57
      Unplanned homebirth 56 52 46 72 73
      Other ward/triage/hospital grounds 29 27 29 31 44
      In ambulance on route to hospital <5 <5 <5 12 <5
      A&E <5 <5 6 10 5
      Other 6 5 6 <5 6
      Table 12: Number of births at each location between 2009 and 2013 [5]
      Type of delivery

      There has been a 19% increase in emergency c-sections between 2009 and 2012 (+149). The number of normal vaginal deliveries has also increased (7.5%, +234). 'Breech' means a breech vaginal delivery. The majority of breech presentations are likely to be delivered by caesarean. Despite the lower number of births in 2013, the number requiring forceps continues to rise.

        2009 2010 2011 2012 2013
      Delivery Suite 3036 3122 3067 2430 2374
      Theatre 1437 1472 1448 1696 1576
      The Birth Place <5 <5 152 882 770
      Planned homebirth 187 157 145 89 87
      Unknown 121 140 131 87 57
      Unplanned homebirth 56 52 46 72 73
      Other ward/triage/hospital grounds 29 27 29 31 44
      In ambulance on route to hospital <5 <5 <5 12 <5
      A&E <5 <5 6 10 5
      Other 6 5 6 <5 6
      Table 13: Method of delivery [5]

      Figure 8 is data taken from nationally published tables and shows that the proportion of elective caesarean sections has decreased slightly over the last four years; Medway is not significantly different to England. However, the proportion of emergency caesarean sections is increasing in Medway, whilst England is approximately stable meaning that Medway is significantly higher.

      Figure 8: The proportion of deliveries that are elective or emergency caesarean sections.
      Figure 8: The proportion of deliveries that are elective or emergency caesarean sections [7]
      Pain relief

      Table 14 shows the number of deliveries using the main types of pain relief. It is common for women to use more than one type of relief during labour and delivery. Regional anaesthesia is also known as a spinal block and is used for caesareans.

        Pethidine Epidural Entonox None Other Regional.Anaesthesia
      2012 912 790 3,022 1,145 101 67
      2013 798 782 2,867 733 85 47
      Table 14: The number of births involving each type of pain relief in 2012 and 2013 [5]
      Smoking at time of delivery (SATOD)

      Smoking in pregnancy has significant health consequences. Babies of women who smoke are more likely to be born prematurely, have twice the risk of being low birthweight and are up to three times more likely to die from Sudden Unexpected Death in Infancy (SUDI). Figure 9 shows the percentage of women smoking at time of delivery in Medway is significantly higher than in England.

      Figure 9: The percentage of women smoking at time of delivery.
      Figure 9: The percentage of women smoking at time of delivery [8]

      Accurate recording of smoking status at time of delivery has now been implemented as a CQUIN (Commissioning for Quality and Innovation) indicator meaning that, as of April 2013, more women have their smoking status accurately recorded at time of delivery.

        Number of mothers Number smoking at delivery Percentage
      Apr 2013 298 57 19.1
      May 2013 264 42 15.9
      Jun 2013 281 50 17.8
      Jul 2013 339 48 14.2
      Aug 2013 310 54 17.4
      Sep 2013 335 56 16.7
      Oct 2013 348 61 17.5
      Nov 2013 311 56 18.0
      Dec 2013 284 56 19.7
      Table 15: Number of mothers smoking at time of delivery [5]

      Mortality rates

      Still births and deaths in infancy are rare events so three year rolling averages are used for the presentation of this data. Figure 10 shows that the still birth rate for 2010-12 was 4.8 per 1,000 total births.

      Figure 10: Stillbirth rate in Medway and England, 3 year pooled data, 2001 to 2012.
      Figure 10: Stillbirth rate in Medway and England, 3 year pooled data, 2001 to 2012 [2]

      The neonatal mortality rate in Medway for 2010-12 was 2.1 per 1,000 live births, the lowest rate since 2001-03, but not significantly lower than England. The trend is shown in figure 11.

      Figure 11: Neonatal mortality rate in Medway and England, 3 year pooled data, 2001 to 2012.
      Figure 11: Neonatal mortality rate in Medway and England, 3 year pooled data, 2001 to 2012 [2]

      Table 16 shows the causes of neonatal deaths in England and Wales in 2011. The most common causes are conditions related to prematurity. This is supported when considering mortality rates by birthweight. In 2011, babies with birthweight <1,500 grams had a neonatal mortality rate of 145.4 per 1,000 live births in England and Wales. For babies with birthweight <2,500 grams, the neonatal mortality rate was 28.9 per 1,000 births compared to 0.7 per 1,000 live births with birthweight at least 2,500 grams.

        Number Proportion (%)
      Immaturity related conditions 1,207 57.6
      Congenital anomalies 553 26.4
      Asphyxia, anoxia or trauma (intrapartum) 185 8.8
      Antepartum infections 40 1.9
      Other conditions 33 1.6
      Infections 31 1.5
      Sudden infant deaths 22 1.1
      Other specific conditions 17 0.8
      External conditions 7 0.3
      Total 2,095
      Table 16: Causes of neonatal deaths in England and Wales, 2011 [9]

      Infant mortality rates have decreased nationally and in Medway over the past decade. Figure 12 shows that Medway's rate is lower than England, but not significantly so. The infant mortality rate in Medway for 2010-12 was 3.3 per 1,000 live births.

      Figure 12: Infant mortality rate in Medway and England, 3 year pooled data, 2001 to 2012.
      Figure 12: Infant mortality rate in Medway and England, 3 year pooled data, 2001 to 2012 [2]

      Birth weight

      Preterm babies often have low birth weights which is associated with inhibited growth and cognitive development, and chronic diseases later in life. Low birth weight also increases the risk of stillbirth. Figure 13 shows that the most common weight category is 3-3.5kg and most babies weighed between 3 and 4kg. Babies with a high birth weight are at higher risk of injuries during the birth and problems with blood sugar control. High birthweight is classified as more than 4.5kg (9lb 15oz).

      Figure 13: Weight distribution of live births, 2009 to 2012.
      Figure 13: Weight distribution of live births, 2009 to 2012 [2]

      APGAR

      The APGAR score was devised to quickly assess the health of a newborn baby by scoring 0 to 2 for: appearance/complexion, pulse rate, reflex irritability, activity and respiratory effort. Table 17 shows the APGAR scores of babies 5 minutes after birth. Babies with a 0 recorded have been excluded from table 17 due to uncertainty in recording practices.

        Number
      1 10
      2 8
      3 10
      4 19
      5 55
      6 107
      7 221
      8 568
      9 8,759
      10 13,941
      Table 17: The number of babies with the following APGAR scores at 5 minutes, 2009 to 2013 [5]

      Breastfeeding

      Increasing breastfeeding initiation rates is an important target for the NHS in Medway. Breastfeeding is a key indicator of child health and wellbeing, which contributes to reducing infant mortality, health inequalities and obesity. There is evidence that babies who are breast fed experience lower levels of gastro-intestinal and respiratory infection. Observational studies have shown that breastfeeding in associated with lower levels of child obesity.

      The UK Infant Feeding Survey 2010 [10] showed that 81% of women in the UK breastfed their babies after birth. By 6 weeks, this was down to 55% of mothers, 7 percentage points higher than in the 2005 survey. However, 85% of women stopping breastfeeding between 1 and 2 weeks said they would have preferred to breastfeed for longer. This suggests that much more could be done to support and help them to exclusively breastfeed up to 6 months of age, with continued breastfeeding along with appropriate complementary foods up to two years of age or beyond as per World Health Organisation guidance.

      Breastfeeding rates in Medway are well below the national average and have remained at that rate for several years. The percentage of mothers initiating breastfeeding in Medway was 71% in Q2 of 2013/14. Medway has consistently been below the national and regional level each quarter. By the age of 6–8 weeks, 39.8% of babies were still receiving breast milk in Medway. [11] This represents a significant fall in breastfeeding rates during the first two months after birth.

      Figure 14: Percentage of women initiating breastfeeding, 2009/10 -- 2013/14.
      Figure 14: Percentage of women initiating breastfeeding, 2009/10 – 2013/14 [11]

      Figure 15 shows the percentage of babies either totally or partially breastfed at 6–8 weeks of age. Totally breastfed is defined as infants who are exclusively receiving breast milk - that is, they are not receiving formula milk, any other liquids or food. Partially breastfed is defined as infants who are receiving breast milk and who are also receiving formula milk or any other liquids or food. [12]

      Figure 15: Percentage of women breastfeeding at 6--8 weeks, 2009/10 -- 2013/14 .
      Figure 15: Percentage of women breastfeeding at 6–8 weeks, 2009/10 – 2013/14 [11]

      Breastfeeding can contribute significantly towards reducing health inequalities amongst those in the UK least likely to breastfeed. These groups were identified in the Infant Feeding Survey 2010 as white, under 20 years old, having left school at sixteen or younger, never worked, and living in the most deprived quintile.

      In Medway, breastfeeding rates are highest among older mothers and those from the least deprived areas. White women are less likely to initiate breastfeeding than BME groups. Continuation of exclusive breastfeeding is lowest among younger mothers and White women. At the time of the Maternity Matters Needs Assessment (2007), only 25% of babies born to White women locally were receiving any breast milk at 6 to 8 weeks compared with 62% of babies born to women from Black/ Black British background. [13]

      Funding from the Department of Health in 2009 has enabled a programme of interventions to be put in place to increase breastfeeding in Medway. These interventions include:


      • Development of a cross-organisation Infant Feeding Strategy (see appendices) and a group which meets quarterly to implement it.
      • Implementation of the UNICEF UK Baby Friendly Initiative (BFI) as routine practice in maternity and community services.
      • Maternity services achieved the Certificate of Commitment for BFI in August 2011 and the Level 1 award in 2012.
      • Community services achieved the UNICEF UK BFI Level 2 Award in September 2011 and are working towards the Level 3 award with the assessment in summer 2014.
      • Introduction of a peer support network (Medway Breastfeeding Network) to support local mothers.
      • Implement workforce training and development in all maternity and early years settings to increase knowledge of infant feeding. The Infant Feeding Strategy Group is working on a training matrix to assess the level of breastfeeding knowledge and skill amongst the workforce. Training in introducing solids is now being delivered to Children's Centre staff.


      References

      [1]   Office for National Statistics. Sub-national population projections, 2008- based projections
      [2]   Office for National Statistics. Vital statistics tables
      [3]   The NHS Information Centre for Health and Social Care. The Indicator Portal
      [4]   Department of Health. Abortion Statistics, England and Wales 2013;
      [5]   Medway Foundation NHS Trust.
      [6]   Office for National Statistics. Table LC2104EW: Main language by sex and age 2012;
      [7]   Health ans Social Care Information Centre. NHS Maternity Statistics - England 2012-13 2013;
      [8]   Health and Social Care Information Centre. Statistics on Women's Smoking Status at Time of Delivery - England 2013;
      [9]   Office for National Statistics. Infant and Perinatal Mortality in England and Wales 2011, Table 8
      [10]   McAndrew F, Thompson J, Fellows L, et al. Infant Feeding Survey 2010 2012; The Information Centre for Health and Social Care. http://www.hscic.gov.uk/catalogue/PUB08694 .
      [11]   Department of Health. Statistical Release: Breastfeeding initiation and prevalence at 6-8 weeks 2013; Department of Health. https://www.gov.uk/government/statistical-data-sets/breastfeeding-statistics-q4-2012-to-2013 .
      [12]   Department of Health. Public Health Outcomes Framework 2012;
      [13]   Bird A. Maternity Matters Needs Assessment 2009; NHS Medway. http://www.kmpho.nhs.uk/geographical-areas/primary-care-trusts/medway-pct/?assetdet956103=91215 .
    • Current services in relation to need

      Ideally women should plan their pregnancies — this enables them to conceive a baby when they are physically as fit as possible — having given up smoking if they are smokers and gained a normal healthy weight. Planning a pregnancy also enables women to take a low dose of folic acid which has been proven to reduce neural tube defects such as spina bifida during the time when they are trying to conceive, vitamin D (deficiency impairs the absorption of dietary calcium and phosphorus, which can give rise to bone problems such as rickets in children, and bone pain and tenderness as a result of osteomalacia in adults) [1] and to discuss any changes in medication with their doctor if they have a chronic disease such as hypertension, epilepsy or diabetes so that they are not taking any drugs which might prove harmful to the baby and receive optimal care.

      Medway hospital has a range of maternity services: Consultant Led Unit — Primarily for women with complications identified in their previous medical history, previous birth experiences or their current pregnancy or labour. All aspects of intrapartum care can be provided within Medway NHS Trust without the need to transfer women to a neighbouring Trust or specialist unit. Midwifery Led Unit (MLU) — The Birth Place is staffed and led by midwives and is designed for women experiencing low risk pregnancies. It is a co-located unit at Medway Hospital and has been open since October 2011. The unit contains five birth rooms two of which also contain birth pools as well as a 4-bedded postnatal bay. If an unforeseen complication occurs or there is a change in risk status, there is direct and instant access to the consultant led unit along the corridor. Home Births — All four community teams offer a home birth service. A planned home birth is a safe option for women with low risk pregnancies. A midwife will help in preparation for the birth and two midwives will attend the birth to assist with labour and delivery. In the case of any concerns during labour or birth, the woman will be transferred to the local consultant-led unit by ambulance accompanied by the attending midwife.

      There are three wards that provide postnatal care.

      Specialist maternity services

      In every society there are some groups who are more vulnerable than others, brought about by societal factors and the environments in which people live. There are some common challenges across all vulnerable groups including the risk of stigma and discrimination, restricted access to educational opportunities and exclusion from income generation. Within these groups there are varying levels of vulnerability. This section illustrates the needs of some (it is not exhaustive) of the vulnerable groups in Medway and Swale. The intention here is to show how vulnerability is an important issue to consider in the design and implementation of services and programmes.

      Smoking

      The smoking status of the woman and her partner is assessed at booking and updated throughout her pregnancy. The effects of smoking on the fetus and new born baby are discussed. Smoking in pregnancy has significant health consequences. Babies of women who smoke are more likely to be born prematurely, have twice the risk of being low birthweight and are up to three times more likely to die from Sudden Unexpected Death in Infancy (SUDI). Carbon monoxide (CO) levels have been assessed at booking since April 2011 and smoking cessation clinic services are offered to couples in collaboration with Medway Public Health.

      Breastfeeding

      The benefits of breastfeeding for both mother and baby are widely recognised, however the choice of feeding for mothers in Medway and Swale doesn't reflect this (for current breastfeeding levels, see Level of Need). Peer support workers attend the post natal wards voluntarily to offer help and advice to all women. Those women with particular breastfeeding issues that cannot be addressed by the ward staff are referred to the breastfeeding midwifery specialist who assesses their needs, makes a plan of care in collaboration with the mother and supports both her and the staff to achieve success. Breastfeeding promotion needs to be continued throughout the first six months following delivery. A specialist clinic for 1:1 advice and assessment of breastfeeding is run on a weekly basis by the breastfeeding midwifery specialist and the Medway Public Health breastfeeding lead. There are 26 breastfeeding support groups throughout Medway, available for all mothers to attend, run by the same peer support workers who attend the wards to provide continuity for the women. The Trust has achieved the UNICEF accreditation in breast feeding standards

      Infectious Diseases and Haemoglobinopathy

      There are on average 10 HIV cases per year, 35 Hepatitis B cases per year, 10 Hepatitis C cases per year and 6 syphilis cases per year. Clients require Genito-Urinary Medicine (GUM) input, specialist referral for the Hepatitis B and C to gastroenterology and lead consultant input.

      There are 90 haemoglobinopathy (genetic defect that results in abnormal structure of one of the globin chains of the hemoglobin molecule, a common example being sickle-cell disease) carriers per year requiring partner testing. On average 10% will be carriers and require counselling from the Antenatal Screening Co-ordinator for Infectious Diseases and Haemoglobinopathies who has received additional training, to decide whether they wish invasive prenatal diagnosis followed by referral to fetal medicine. Around 50% choose prenatal diagnosis.

      Substance Misuse

      The Windmill Clinic is a joint midwifery and drug service clinic that is held on Tuesday afternoons alongside the Antenatal Clinic of the lead Obstetric Consultant for substance misuse. Any pregnant women with significant substance misuse issues including alcohol misuse can access care from a specialist midwife in substance misuse and a keyworker from KCA or Medway Alcohol Services.

      The aim of the clinic is not to replace normal midwifery care – it is an extra service to provide specialist input under one roof. Clients with recognised high risk pregnancies (as recognised by NICE [2]) have access to Consultant obstetric care, specialist midwifery care, drug service care and access to obstetric ultrasound, phlebotomy and neonatal input in one place. As part of the clinic a weekly multidisciplinary meeting is held where the drug and alcohol keyworkers, specialist midwives in substance misuse, safeguarding and mental health, the liaison midwife from the transitional care ward as well as the neonatal liaison sister can meet to discuss clients.

        Heroin Alcohol Cannabis Amphetamine
      2010 18 <5 <5 <5
      2011 5 <5 <5 <5
      2012 9 <5 <5 <5
      2013 11 <5 <5 <5
      Table 1: The number of women seen with substance misuse issues
      Antenatal and Postnatal Mental Health

      Women experiencing mental health problems during pregnancy or after birth are referred to the mental health specialist midwife who will offer them a one hour appointment to discuss their mental health needs, talk to them about how best to manage their psychological difficulties, advise them on the support available locally, and make referrals to specialist services if needed. Referrals come from other midwives, as well as GPs, obstetricians, social workers and health visitors.

      There is a clear robust pathway to ensure women are referred to the obstetric lead and Mother and Infant Mental Health Service (MIMHS). There is a weekly multidisciplinary team meeting to review all cases. Participants include the specialist midwife, the specialist obstetrician, the perinatal psychologist, the specialist nurse and a midwife from the antenatal department. Since the development of this position, women and their families have experienced much more coordinated support to help them to improve their mental health.

        Advice by letter Received a consultation
      2009 700 527
      2010 850 1,000
      2011 780 1,428
      2012 900 600
      2013 800 626
      Table 2: The number of women receiving advice from the specialist midwife
      Teenage Pregnancy

      The Swale community team has a lead midwife who looks after young parents. The teenagers would benefit from multiple services being offered in one location on the same day. Liaison with representatives from Health Visiting, support for finances, education and other Medway Public Health services would be essential. There is a Family Nurse Partnership scheme available if the young women agree to engage with them. The Family Nurse Partnership is a maternal and early years public health programme. It provides on-going, intensive support to young, first–time mothers and their babies (and fathers/other family members, if mothers want them to take part). Structured home visits are delivered by highly trained nurses and start in early pregnancy, continuing until the child's second birthday. [3] A seamless service of care is provided by ensuring that the community midwives work closely with the clinical lead for safeguarding and mental health issues and Medway Public Health services.

      Diabetes

      Women with diabetes or those who develop diabetes in pregnancy are seen in a specialist clinic supported by lead midwives for diabetes. They are monitored closely throughout their pregnancy, owing to the associated risks, in the fetal medicine department and at a specialist antenatal clinic. The multi-disciplinary clinic includes the obstetric lead, the specialist midwife and a dietician all working collaboratively to ensure the best care for the women.

      The specialist midwife for diabetes will accompany the woman to theatre, if an elective caesarean section has been decided upon, to provide continuity of care. During the postnatal period the clinical leads review the plans of care and support the ward staff to give the appropriate care. Training of all staff is a priority to ensure continuity of practise and the safe wellbeing of both the woman and her new baby.

      The number of women booking in with diabetes was 120 in 2011, 130 in 2012 and 165 in 2013. Of those booking in 2013, 122 had gestational diabetes, 25 had Type 1 diabetes and 18 had Type 2 diabetes.

      Obesity

      Maternal obesity is a significant challenge for maternity services. According to the national audit of obesity during pregnancy by the Centre for Maternal and Child Enquiries (CMACE), the UK prevalence of women with a known BMI >35 at any point in pregnancy, who give birth at 24+ weeks' gestation, is 4.99%. This equates to approximately 38,478 maternities each year. The prevalence of women with a pregnancy BMI >40 (Class III obesity) in the UK is 2.01%, while super-morbid obesity BMI >50 is 0.19% of all women giving birth.

      It is a challenge not only because of the increasing prevalence of the problem as almost one in five of pregnant women in the UK are obese, but also because of the impact that obesity has on women's reproductive health and the health of their babies. There are higher rates of miscarriage, fetal abnormality, blood pressure problems, diabetes, thrombosis, difficulty in delivery leading to higher caesarean rates and infection following delivery. Obesity also predisposes women to diabetes during pregnancy.

      Care provision has been enhanced for women with issues of obesity with the introduction of a clinical midwifery specialist since June 2012. The lead midwife for obesity runs a clinic with an obstetrician and a support group for the women in her care with assistance from Medway Public Health (IC Mum). CNST requires the provision of support services for all women with a BMI of 30kg/m2. A healthy living clinic is run for women with a BMI of 35-44kg/m2 with no medical conditions. A preconception clinic would be valuable.

      In 2013, 1,413 women booked in with a BMI 27–35 and 487 with a BMI over 35. In 2013, 252 new referrals attended who were then followed up in subsequent clinics. Five support group sessions were held with 20 couples at each.

      Learning Disabilities

      Working with colleagues at Medway Public Health has ensured that the Antenatal access pathway has appropriate and adequate steps in it for women with learning disabilities so that they are able to access maternity services. At booking the community midwives assess the women's needs and refer to other health professionals and care support as necessary. The women are assessed at each antenatal appointment to ensure that all risks are being addressed and that needs are met. Support from the specialist midwife for safeguarding and collaboration with social services will ensure that the mother and baby will be fully supported on discharge from the hospital and will have a safe transition into community care.

      Safeguarding Children

      The Trust has a specialist midwife who works collaboratively within a multidisciplinary team within health and social care, to assess risk factors and the needs of complex families. Through collaboration with the named community midwife, the specialist midwife will ensure that the care pathway is monitored throughout the antenatal period. All safeguarding referrals are alerted to the hospital staff to ensure continuity of information especially if circumstances change. The specialist midwife meets regularly with the women on the wards, during child protection conferences and pre discharge planning meetings in the community.

      Training is high on the agenda for the maternity directorate, Trust-wide and for the Local Safeguarding Children's Board (LSCB).All maternity staff are required to update on safeguarding issues on a three yearly basis. The training for this update is bespoke to the needs of maternity staff and is mainly delivered by the specialist midwife. This is an area within the maternity directorate that will be improved so that more in-house training sessions can be offered on a regular basis, with a stronger focus on other vulnerable groups, for example, those with learning difficulties and teenage pregnancy.

      The role has a responsibility to co-ordinate all cases. For child protection concerns, this is effective through ongoing supervision of each case and there is an essential bi-monthly meeting with the community midwives. For all other cases, for example concerns and vulnerability, there is a monthly meeting with each community team to monitor progress of the cases. The specialist midwife attends the child death overview panel meetings and contributes to investigations as necessary in order to support staff to learn from incidents, embed change and review policy.

      There is now a new role of a Band 6 midwife support which will relieve the lead from a lot of the clinical aspects and allow time to develop the role.

      Antenatal and newborn screening

      There are 6 antenatal and newborn screening national programmes in England which are offered to women as part of routine antenatal care and to newborns.

      The UK National Screening Committee (NSC) defines screening as “a process of identifying apparently healthy people who may be at increased risk of a disease or condition. They can then be offered information, further tests and appropriate treatment to reduce their risk and/or any complications arising from the disease or condition”

      Whilst screening has the potential to save lives or improve quality of life through early diagnosis of serious conditions, it is not a foolproof process. Screening can reduce the risk of developing a condition or its complications but it cannot offer a guarantee of protection. In any screening programme, there is a minimum of false positive results (wrongly reported as having the condition) and false negative results (wrongly reported as not having the condition). The UK NSC is increasingly presenting screening as risk reduction to emphasise this point.

      The NHS screening agenda is driven by a range of NHS and Department of Health policies and standards. These can be viewed at www.screening.nhs.uk

      The current UK National Screening Committee (UK NSC) programmes for antenatal and newborn screening are:

      Antenatal:
      • Sickle Cell and Thalassaemia
      • Fetal Anomaly (Down's syndrome and fetal anomaly ultrasound)
      • Infectious Diseases (Hepatitis B, HIV, Syphilis, Rubella)

      Newborn screening:
      • Newborn Blood Spot (Phenylketonuria, Medium Chain Acyl CoA Dehydrogenase Deficiency (MCADD), Cystic Fibrosis, Congenital Hypothyroidism, Sickle Cell)
      • Newborn and Infant Physical Examination
      • Newborn Hearing

      Figure 1 shows the optimum time for the various screening tests

      Figure 1: Antenatal and newborn screening timeline.
      Figure 1: Antenatal and newborn screening timeline
      Sickle Cell & Thalassaemia Screening Programme

      Sickle Cell disorders are a group of heritable genetic conditions in which there is an abnormality of the haemoglobin. Haemoglobin carries oxygen to the various organs of the body and is contained in the red blood cells. In the sickle cell disorders, some of the red blood cells assume a sickle shape following the release of oxygen. This abnormal shape causes the cells to clump together making their passage through smaller blood vessels difficult, which may lead to blockage of these small blood vessels, death of tissues and an associated inflammatory reaction. Sickle Cell Disease is now the most common serious genetic condition in England, affecting more than 1 in 2,000 live births.

      Thalassaemia major is a life threatening, genetically inherited, progressive anaemia common in the Mediterranean, Asian, South East Asian and Middle Eastern countries.

      The screening for Sickle Cell and thalassaemia is offered to women between 10 to 12 weeks of pregnancy. The antenatal screening policy has been defined into two categories, high and low prevalence, based on a fetal prevalence of sickle cell disorders. High prevalence is defined as a fetal prevalence of more than 1.5 babies with sickle cell disorders per 10,000 births.

      Kent and Medway were low prevalence areas until April 2011 when maternity units at Darent Valley Hospital (part of Dartford and Gravesham NHS Trust) were classified as high prevalence. In these sites all pregnant women are offered screening for sickle cell, thalassaemia and other haemoglobin variants rather than just those identified as high risk using a screening questionnaire asking about family history.

      Fetal Anomaly Screening Programme

      This programme offers screening for Down's syndrome and a minimum of two ultrasound scans during pregnancy to screen for physical (structural) abnormalities

      Down's Syndrome is a genetic disorder, therefore present at birth and lifelong. It affects approximately one in every 1,000 babies. This figure is similar in all ethnic populations and is an overall population risk, though it increases markedly with maternal age. Down's Syndrome is caused by the presence of an extra copy of chromosome 21 in a baby's cells. It affects the physical appearance and the ability to learn. The severity of Down's syndrome symptoms can vary from person to person. There is currently no cure for the condition. However, there are treatments that can help someone with the syndrome to lead an active and independent life and the average life expectancy of someone with Down's syndrome is now 60–65 years of age. There are about 600 babies with Down's Syndrome born each year in the UK. The condition tends to affect male and female babies equally. It is estimated that there are approximately 60,000 people with Down's Syndrome currently living in the UK.

      The recommended screening strategy for Down's Syndrome is for the combined test (blood test and nuchal translucency scan) undertaken between 10 and 14 weeks. Looking at two proteins in the blood test and measuring the thickness of the fluid in the back of the baby's neck calculates the risk of the women having a child with Down's Syndrome at her present age. If this is missed, a quadruple blood test can be done between 14 and 20 weeks which looks at four proteins.

      As part of the NHS Fetal Anomaly screening programme, all women in England should be offered a minimum of two ultrasound scans during their pregnancy to screen for physical (structural) abnormalities in their unborn babies.

      The first is an early scan, undertaken after eight weeks gestation and used mainly for dating the pregnancy and confirming viability. The second ultrasound scan is undertaken between 18+0 to 20+6 weeks of pregnancy and screens for major structural anomalies. In 2012/13, 3,647 women booking in Medway had a second ultrasound scan, of which 84 revealed a confirmed fetal anomaly (24 revealed serious cardiac abnormality).

      Infectious Diseases Screening Programme

      The Infectious Diseases in Pregnancy Screening (IDPS) Programme is responsible for ensuring that women with hepatitis B, HIV, syphilis and susceptibility to rubella infection are identified early in pregnancy, ideally between eight to twelve weeks. The tests can usually be taken from one blood test.

      The four infections screened for are:


      • Hepatitis B is a serious viral disease, which affects the liver. It is blood borne and may cause acute illness. Mothers can pass on their infection to their baby. An infected baby may develop liver problems later in life. To reduce the risk of infection, the newborn baby will be vaccinated within the first 24 hours of life and then given three further doses within the first 12 months.


      • HIV, human immunodeficiency virus (HIV) results in progressive destruction of the immune system. As a result of this, an infected individual becomes susceptible to a number of different infections and is also liable to become wasted and also to develop neurological problems. It can be passed on to the baby and risk of this can be reduced by, for example, drug treatment and elective caesarian section.


      • Rubella is no longer a common disease of childhood in the UK. This is a result of the Mumps, Measles and Rubella (MMR) vaccination programme . Rubella infection usually presents as a mild disease, often without symptoms. However if the infection occurs during pregnancy it can cross the placenta and pass to the fetus with serious consequences.


      • Syphilis is a bacterial infection that is typically passed on through sexual contact. However, it can be passed on by intravenous drug use (injecting drugs directly into the vein), blood transfusions and from an infected mother to her unborn child.

        No. of tests completed No. positive results
      Hepatitis B 5,505 21
      HIV 5,500 6
      Syphilis 5,502 8
      Rubella Negative 5,502 319
      Table 3: The number of women tested and found to have an infectious disease in Medway Foundation Trust in 2012/13 [4]

      Of the women booking at Medway hospital in 2012/13, 140 women were administered MMR vaccination prior to leaving the hospital. The GP practice of each of these women was informed so that a second dose could be arranged subsequently.

      Newborn Bloodspot Screening Programme

      Parents of every newborn baby are offered a Newborn Screening Test. A heel prick blood sample, routinely taken between day five and eight is currently screened for Sickle Cell disorder as described earlier and five other conditions:

      MCADD – 1 in 10,000 babies born in the UK has Medium Chain Acyl CoA Dehyrogenase Deficiency (MCADD).
      Babies with this inherited condition have problems breaking down fats to make energy for the body. This can lead to serious illness, or even death. Screening means that most babies who have MCADD can be recognised early, allowing special attention to be given to their diet, including making sure they eat regularly. This care can prevent serious illness and allow babies with MCADD to develop normally.

      Phenylketonuria – 1 in 10,000 babies born in the UK has phenylketonuria (PKU). Babies with this inherited condition are unable to process a substance in their food called phenylalanine. If untreated, they will develop serious, irreversible, mental disability. Screening means that babies with the condition can be treated early through a special diet, which will prevent severe disability and allow them to lead a normal life. If babies are not screened, but are later found to have PKU, it may be too late for the special diet to make a real difference.

      Congenital Hypothyroidism – 1 in 4,000 babies born in the UK has congenital hypothyroidism (CHT).
      Babies with CHT do not have enough of the hormone thyroxine. Without this hormone, they do not grow properly and can develop serious, permanent, physical and mental disability. Screening means that babies with CHT can be treated early with thyroxine tablets, which will prevent serious disability and allow them to develop normally. If babies are not screened and are later found to have CHT, it may be too late to prevent them becoming seriously disabled.

      Cystic Fibrosis – 1 in 2,500 babies born in the UK has cystic fibrosis (CF) The condition is characterised by early onset of severe intestinal malabsorption, failure to thrive and recurrent chest infections and pneumonia, which, if untreated, leads to death from malnutrition and respiratory failure in infancy or early childhood.

      Newborn Hearing Screening Programme

      The early identification of hearing loss is known to be important for a child's development. One to two babies in every 1,000 are born with a hearing loss in one or both ears. Most of these babies are born into families with no history of hearing loss. The aim of the NHS Newborn Hearing Screening Programme (NHSP) is to identify all children born with moderate to profound permanent bilateral deafness within four to five weeks of birth and to ensure the provision of safe, high quality age-appropriate assessments and world-class support for deaf children and their families.

        2012 2013
      Number of babies screened 5,202 4,984
      Bilateral referrals 29 41
      Unilateral referrals 174 168
      Table 4: Babies born in Medway and Swale screened by West Kent NHSP
      The Newborn and Infant Physical Examination Programme (NIPE)

      Newborn and Infant Physical Examination Programme (NIPE) offers parents the opportunity of a head to toe physical examination for their baby to check for problems or abnormalities. The examination is carried out within 72 hours of birth and then again at six to eight weeks of age, as some conditions can develop later and includes a general all over physical check, as well as specific examination of the baby's:


      • eyes
      • heart
      • hips
      • and testes, in boys.

      Quality Assurance

      National Quality Assurance teams have been developed and commissioning frameworks for antenatal and newborn screening programmes are now in place.

      Locally, Kent and Medway's Antenatal and Newborn Screening committee meet quarterly to review performance and promote compliance with national guidelines. Sub-groups have also been tasked to review individual programmes to ensure standards are met.

      Antenatal and Newborn Midwifery Screening coordinators, Child Health Record Departments and the Newborn Screening Laboratory now report key performance indicators on a quarterly basis; this will improve understanding of the programmes and provide relevant and accurate data to manage performance and track trends.


      References

      [1]   Department of Health. Vitamin D - advice on supplements for at risk groups - letter from UK Chief Medical Officers 2012; Department of Health. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/213703/dh_132508.pdf .
      [2]   National Institute for Health and Clinical Excellence. Pregnancy and complex social factors: A model for service provision for pregnant women with complex social factors September, 2010; National Institute for Health and Clinical Excellence. http://www.nice.org.uk/nicemedia/live/13167/50822/50822.pdf .
      [3]   Family Nurse Partnership. 2014;
      [4]   Kent and Medway Antenatal and Newborn Screening Coordinators.
    • Projected Service Use

      It is difficult to project use of maternity services. Over the last seven years looked at in this report, there has been a year on year increase of live births to Medway resident women, a total increase of 13% between 2006 and 2012.

    • Evidence of what works

      There have been several pieces of NICE guidance issued on maternity care in recent years, in addition to Maternity Matters[1] and standards for antenatal and newborn screening.


      References

      [1]   Department of Health. Maternity Matters: Choice, access and continuity of care in a safe service 2007; Department of Health. http://bit.ly/IDOqCe .
    • User views

      The percentage of women using the following services in December 2013 who would either highly or likely recommend them to friends and family: Delivery Suite – 87.5% The Birth Place – 93.3% Emergency Department – 59.5% Kent Ward – 89.5% Pearl Ward – 86.6%

    • Equality Impact Assessments
    • Unmet needs and service gaps

      There is a significant increase in women with an ethnicity of 'other white background' and the associated language and cultural needs must be addressed. A specialist midwife for teenage pregnancies is an area that needs to be reviewed. All other services must be reviewed regularly to ensure we are providing the most appropriate level of service.

    • Recommendations

      The information in this section is to be reviewed quarterly to address any issues, with a specific focus on ensuring that the community teams are aware of any changes in the demography and epidemiology of the women in their area so that adjustments to workload and demand can be implemented as necessary. Focus needs to remain on delivering a high standard of care according to the specific needs of the women and at the same time remain open and adaptable to new innovative ways of thinking when opportunities arise.

    • Recommendations for needs assessment work
  • Safeguarding
    • Summary

      'No Secrets' (2000) guidance gave local authorities the lead responsibility for developing and implementing local multi-agency processes for coordinating systems, polices and procedures to protect vulnerable adults from abuse. A review of No Secrets in 2009 highlighted that adult safeguarding systems were underdeveloped in the NHS and detailed guidance in safeguarding adults was published in 2011. Government has pointed to three key concepts involved in safeguarding: protection, justice and empowerment (Minister of State 2010). 'Vulnerable adults' are not a homogenous group but are individuals who because of certain vulnerabilities or circumstances are disproportionately likely to be victims of abuse. The work of the Kent and Medway Safeguarding Adults Executive Board is to coordinate agencies to safeguard these adults who are at risk of being abused. The Kent & Medway Safeguarding Vulnerable Adults Board takes a strategic lead on safeguarding matters and is co-chaired by the Assistant Director of Social Care in Medway. Safeguarding Vulnerable Adults work is concerned with the multi-agency approach to responding to and preventing the abuse of 'vulnerable adults'. Across Kent and Medway, there are multiagency policy, protocols and guidelines in place, which are updated twice a year. They are available to organisations and the public via the Kent and Medway Safeguarding Vulnerable Adults Executive Board's website.

      Key issues and gaps

      It is likely that there is considerable under reporting of adult abuse, whether in the community, residential or hospital settings and improved awareness raising and reporting may put pressure on the local authority and the wider partner agencies. There is a need to ensure the accessibility of main stream services that address domestic abuse and sexual abuse, to disabled people and in particular older women and create services that meet the need of disabled and older people who have been abused. Although there has been public awareness work, this now need to extend support and awareness to Black and Minority Ethnic (BME) and Lesbian, gay, bisexual and transgender (LGBT) groups in Medway. Current emphasis is on supporting individuals to remain living in their own homes and enable more people with Learning Difficulties to live more independantly in the community. The move to individual budgets and greater use of, for example Direct payments by individuals and carers, are intended to increase peoples choice and control and to ensure that services are better matched to individual needs. This also brings challenges in terms of safeguarding to ensure that the alternative solutions to meet the needs of people are achieved safely.

      Recommendations for Commissioning

      Commissioners have a key role in ensuring that multiagency capacity is sufficient to ensure that safeguards are effectively monitored and embedded across the region. Commissioners need to ensure that health and social care services are effectively resourced to respond, as the number of referrals continues to rise and support vulnerable people in reducing repeat referrals. Joined up working across health, social care and the criminal justice agencies is needed to ensure that each agency can respond in partnership to allegations of abuse of a vulnerable adult. Commissioners need to ensure that support, advice, advocacy and information are readily avaliable for service users and their carers to ensure that as they take on more responsibility for their own packages of care, that they know how to protect themselves from abuse and who to raise concerns with. Information should be avaliable in multiple formats and languages. Commissioners have a key role in ensuring that all providers, including personal assistants and independent contractors, are working in adherence with the Multiagency Adult Protection Policy, Protocols and Guidance for Kent and Medway.

    • Who's at risk and why?

      Vulnerable adults are defined by government guidance called No Secrets (2000) as people (a) who or may be in need of community care services because of mental or other disability, age or illness, and/or (b) who are unable to care for themselves or unable to protect themselves from significant harm or exploitation. The guidance refers to harm in terms of 'abuse'.

      Abuse is a violation of an individual’s human and civil rights by any other person or persons.

      Abuse of a vulnerable adult may consist of a single act or repeated acts. It may occur as a result of a failure to undertake action or appropriate care tasks. It may be an act of neglect or an omission to act, or it may occur where a vulnerable person is persuaded to enter into a financial or sexual transaction to which they have not, or cannot, consent. Abuse can occur in any relationship and may result in significant harm to, or exploitation of, the individual. However for some clients the issues of abuse relate to neglect and poor standards of care. They are ongoing and if ignored may result in a severe deterioration in both physical and mental health and even death. Abuse might be physical, sexual, psychological, financial or material, neglect and acts of omission, discriminatory or institutional. This could include people with learning disabilities, mental health problems, older people and people with a physical disability or impairment. It also includes people whose condition and subsequent vulnerability fluctuates. It may include an individual who may be vulnerable as a consequence of their role as a carer in relation to any of the above (on average, 20% of the referrals in Medway, cite the main carer as the alleged perpetrator). It may also include victims of domestic abuse, hate crime and anti-social abuse behavior. The persons' need for additional support to protect themselves may be increased when complicated by additional factors, such as, physical frailty or chronic illness, sensory impairment, challenging behaviour, drug or alcohol problems, social or emotional problems, poverty or homelessness. Many vulnerable adults may not realise that they are being abused. For instance an elderly person, accepting that they are dependent on their family, may feel that they must tolerate losing control of their finances or their physical environment. They may be reluctant to assert themselves for fear of upsetting their carers or making the situation worse.

    • The level of need in the population

      Over the last three years the number of reported and subsequently investigated referrals of alleged abuse in Medway has increased. In 2008/09, 2009/10 and 2010/11 there were 245, 277 and 324 referrals respectively. There has been a 17% increase in the number of referrals since 2009/10. It is believed that it is not the amount of adult abuse that has increased, but the level of reporting of incidents and concerns. This reflects the continuing efforts made to raise awareness of adult abuse. However, compared to other unitary authorities (The Health and Social Care Information Centre 2011) Medway Towns referrals are below average by approximently 30%. Within Medway, the primary client categories of the alleged victims of abuse, for the period of April 2009 to March 2011 are presented in Figure 1.

      Figure 1. Percentage of primary client type.
      Figure 1. Percentage of primary client type (2009–2011)

      Within the physical disability category, 65% of the alleged victims were over the age of 65 years and 30% were over the age of 85 years. It is widely recognized that individuals with learning difficulties or complex needs, such as mental health issues or drug and alcohol dependency, are at a heightened risk because they face additional barriers in disclosing abuse and neglect. Abuse and neglect can happen to anyone regardless of race or ethnicity. Although referrals regarding non-white citizens are increasing, from 2.2% (2010/11) to 13% in the first quarter of 2011/12, it is accepted that in order to continue to protect vulnerable adults, awareness raising must continue to reach all sections of Medway's diverse communities. Women are disproportinately more likely to be the victims of abuse. Of the 601 referrals during the period April 2009 to March 2011, 406 (68%) of the alleged victims were female and 195 (32%) male. The gender proportion varies by age, as 60% of the alleged victims were female in the group 16-64 years, and this increases to 80% in the over 85 year group. Research by Hague et al on behalf of Women's Aid (2008) also drew out important links between domestic abuse and safeguarding. The research revealed that people with disablities are more vulnerable to domestic abuse and will often face additional difficulties in attempting to access support. While one in four adult women and one in 13 adult men will experience domestic violence during their lifetimes, findings from the research found that vulnerable women and men are at increased risk of abuse; 50% of disabled women have experienced domestic abuse compared with a quarter of non disabled women. Any 'vulnerable adult' can be the victim of abuse regardless of sexuality. However, gay, lesbian, bisexual and transsexual 'vulnerable adults' are likely to face additional concerns about homophobia and gender discrimination. They may be concerned that they will not be recognised as victims or believed and taken seriously. Abusers may also be able to control their victims further through the threat of 'outing'. Currently, sexual orientation is not recorded as part of the referral process.

      Figure 2. Numbers types of alleged abuse.
      Figure 2. Numbers types of alleged abuse (2008–2011)

      In 2010, Kent police recorded 75 reports of sexual orientation and gender hate crime compared to 56 cases in 2009. Disability hate crime reporting had also increased from 21 to 51 cases respectively from 2009 to 2010. The victim's home is the primary location of the alleged abuse however 30% of referrals are reagrding people who live in residential care settings. The majority of these allegations implicate the staff working in these settings but will also include family and visitors as the alleged perpetrators.

      The primary types of alleged abuse are physical, financial and neglect. In the current economic climate, it is predicted that the incidence of financial abuse will increase.

    • Current services in relation to need

      Medway Council Adult Social Care is the lead coordinating agency for safeguarding adults. Joint working with other organisations with safeguarding responsibilities is essential. These agencies include National health Services (NHS), independent (private and voluntary) social and health care providers, housing providers, the police, the Crown prosecution Service (CPS), the Probation Service and the Benefits Agency. Over the last 3 years there has been investment of safeguarding services within the NHS. This has resulted within the Kent & Medway Cluster Primary Care Trust, the identification of nominated safeguarding adults lead oficers with responsibility for Medway, East and West Kent, and within this team there are also specialist advisors for care homes and domestic abuse. In Medway, both Medway Community HealthCare and Medway Foundation NHS Trust have nominated Safeguarding Vulnerable Adults leads/advisors.

    • Projected service use and outcomes in 3–5 years and 5–10 years

      As there is a steady increase in the percentage of allegations of abuse where it is happening in the vulnerable adult's own home. While we must continue with adult abuse awareness training for staff working in domiciliary care settings, we must ensure that service users, carers and other agencies vsiitng people at home and the wider community know how to identify and report abuse or concerns about abuse.

    • Evidence of what works

      Although the local authority leads on safeguarding vulnerable adults the current good partnership arrangements for conducting investigations, information sharing, training and supporting staff has been recognised in a recent independent audit of safeguarding arrangements in Medway. Following public awareness campaigns the number of referrals from the victim, family or friends has slowly increased. Medway Council is ranked second, in its comparator group, for the highest number of referrals from this source. This is a good indicator that safeguarding awareness is good in the community and routes for reporting are known.

    • User Views

      The views of service users who have experienced abuse need to be captured and fed back to develop improved safeguarding practices. Medway Council are developing these systems currently. Users and carers also have membership of the Medway Safeguarding Community Network (see website).

    • Equality Impact Assessments
    • Unmet needs and service gaps

      It is likely that there is considerable under reporting of adult abuse, whether in the community, residential or hospital settings and improved awareness raising and reporting may put pressure on the local authority and the wider partner agencies. It is recognised that younger people using mental health services are under represented in safeguarding adult's figures nationally and locally. Current emphasis is on supporting individuals to remain living in their own homes and enable more people with Learning Difficulties to live more independantly in the community. The move to individual budgets and greater use of, for example Direct payments by individuals and carers, are intended to increase peoples choice and control and to ensure that services are better matched to individual needs. This also brings challenges in terms of safeguarding to ensure that the alternative solutions to meet the needs of people are achieved safely. There is a very low rate of prosecution of crimes towards 'vulnerable adults'. The police need the capacity to repond to the complexity of cases where victims are often unable to give a clear and reliable account of what has happened to them. The views of service users who have experienced abuse need to be captured and fed back to develop improved safeguarding practices. We need to ensure the accessibility of main stream services that address domestic abuse and sexual abuse, to disabled people and in particular older women and create services that meet the need of disabled and older people who have been abused. We need to ensure that services meet the needs of vulnerable adults from LBGT and BME groups. We need to develop services that enable disabled people and those with impaired mental capcity to recover from abuse. There is a need for independent health contractors such as general practitioners and dentists etc require support and training in understanding their role and responsibilites in protecting vulnerable adults from abuse.

    • Recommendations for Commissioning

      Commissioners have a key role in ensuring that multiagency capacity is sufficient to ensure that safeguards are effectively monitored and embedded across the region. Commissioners need to ensure that health and social care services are effectively resourced to respond, as the number of referrals continues to rise and support vulnerable people in reducing repeat referrals. Joined up working across health, social care and the criminal justice agencies is needed to ensure that each agencies can respond in partnership to allegations of abuse of a vulnerable adult. Commissioners need to ensure that support, advice, advocacy and information are readily avaliable for service users and their carers to ensure, that as they take on more responsibility for their own packages of care, that they know how to protect themselves from abuse and who to raise concerns with. Information should be avaliable in multiple formats and languages. Commissioners have a key role in ensuring that all providers, including personal assistants and independent contractors, are working in adherence with the Multiagency Adult Protection Policy, Protocols and Guidance for Kent & Medway.

    • Recommendations for needs assessment work

      Within the context of adult safeguarding referrals there is a need to identify the incidence and needs of the Medway BME and LGBT population in Medway.

  • Offenders
    • Summary

      For many years it has been clear that individuals who come in contact with the criminal justice agencies are far more likely to come from some of our most vulnerable and disadvantaged groups in society, with the worst outcomes and greatest inequalities in health. Many of the factors that impact on poor health are the same as those leading to increased criminality such as poor housing, unemployment and poor educational attainment.

      Offenders and their families are more likely to have learning difficulties and disabilities, with poor educational attainment.[1] In a recent survey of young prisoners, most had been excluded from school with many failing to receive full time education after the age of 14 years.[2] Once they have been excluded it is easier to become part of groups who are engaged in disruptive and criminal behaviour, where taking drugs and abusing alcohol are commonplace. Risk taking behaviour will also include early sexual activity, with many becoming parents in their teenage years, continuing the cross generational cycle of disadvantage. It should not be surprising to find that this group is far more likely to suffer from mental health problems, which contribute to their problems.

      Families of offenders can often be chaotic with high levels of substance misuse, alcohol problems, and mental health issues and higher than normal levels of domestic violence. Young offenders are more likely to have been taken into the care of local authorities at some point in their childhood, and are more likely to have other members of the family known to criminal justice agencies. Medway PCT has already identified some of their most challenged families and are starting to work with them to try and break the cycle of disadvantage and criminality.

      Young men rarely take advantage of mainstream health services and are not commonly seen in primary care. Schools provide an important source of information on lifestyle choices, which lead to positive health outcomes, missed by those outside the mainstream schools. Contact with criminal justice agencies may provide the first opportunity for some of these young people to have their health needs assessed and addressed. It also could provide the opportunity to leave them, and their families, positive messages about how to improve their health in the future. NHS Medway is already contributing to this through their work with the Medway Youth Offending Team.

      Key issues and gaps

      The commissioning of healthcare in prisons should be equivalent level to that of the rest of the population, and Improving Health, Supporting Justice (November 2009)[3] sets very clear aims for each locality in terms of its offender health population.

      This coupled with Lord Bradley's recommendations (April 2009)[4] refers to the ability for a strong commissioning structure to contribute to reducing inequalities and support the justice system in reducing reoffending through the provision of an integrated and dynamic model of health care.


      • Commission the same range and quality of services for offenders as it does for general public


      • Target resources at reducing health inequalities in order to improve morbidity and mortality rates in this vulnerable group


      • Ensure that prison health services are appropriately reflected in the development and implementation of wider government policies, and the wider criminal justice system


      • Ensure that there is continuous service development for offender health services


      • Make the best use of available resources and ensure value for money in the commissioning of offender health services


      References

      [1]   Griggs J, Walker R. The costs of child poverty for individuals and society 2008; Joseph Rowntree Foundation.
      [2]   Shepherd G. A lifetime of exclusion? The psychologist 2010; 23:1: 24-25.
      [3]   Department of Health. Improving health, supporting justice: the national delivery plan of the Health and Criminal Justice Programme Board 2009; Department of Health.
      [4]   Bradley RHL. Lord Bradley's review of people with mental health problems or learning disabilities in the criminal justice system Department of Health; 2009.
    • Who's at risk and why?

      The cyclical nature of disadvantage is well recognised, culminating in the government paper Breaking the Cycle[1] which stresses the inability for one agency to tackle all of the issues and the great need for organisations, including health agencies, to work together to protect society, reduce criminal activity and improve the life chances for individuals. Medway has some of the most deprived communities in the South East of England, but partnership working has helped reduce re-offending. Medway is home to two prisons, HMP Rochester and HMYOI Cookham Wood.

      Information from the local criminal justice agencies and the prison service indicates that approximately 46,000 people are detained in custody each year within the Kent and Medway area. According to the probation service, there are approximately 1,300 individuals under supervision of the probation service across Kent and Medway at any one time. There are about 150–160 young people under the care of the Youth Offending Team at any one time and there are about 560 families in Medway with complex and chaotic lives that lead them to be in contact with criminal justice agencies. The highest proportions of offenders live in Chatham. Approximately 10% of offenders are women, but they tend to have complex needs.

      Prisons in Medway

      HMP Rochester
      • Operational capacity: 649
      • There are currently 565 prisoners between the age of 18 and 21 years old and 94 between the age of 22 and 68 years old (November 2011).
      • The prison holds convicted sentenced male offenders. It has some old accommodation and new purpose built accommodation which opened in 2008. The Chief Inspector of prisons commented[2][3] that the large area of the prison and some of the behavioural challenges encountered made this a difficult prison to operate.

      HMYOI Cookham Wood
      • Operational capacity: 143
      • The age range of prisoners is 15–18 years
      • Cookham Wood takes young men on remand or convicted, but not deemed suitable for secure local authority accommodation. There is a 60/40 split between sentenced and remanded prisoners. The turnover of population is estimated to be over 70%.
      • Proposals to build two new wings on the site are being actively considered, and it is anticipated that the prison roll is likely to increase from 143 to approximately 200 within the next 18 months

      High Risk of Suicide
      • Prisoners have higher rates of suicide whilst in prison compared to the general population. Young offenders aged 15–17 are 18 times more likely to commit suicide.[4]
      • Female ex-offenders are 35.8 times more likely, and male ex-offenders are 8.3 times more likely to commit suicide. The risk is especially high in the first month after release for older ex-offenders.[5]
      • Some of these deaths are related to loss of tolerance upon returning to drug misuse, but the majority are related to high psychiatric morbidity combined with a high stress situation.
      • Foreign National Prisoners (FNP) also experience high rates of suicide. There were over 20 apparently self-inflicted deaths of FNPs in prisons during 2007 compared to a historical annual average of 6. The Prisons and Probation Ombudsman (PPO) investigations into the deaths have not identified any clear link with immigration status (CSIP data 2007).
      • The suicide rate for offenders in custody and recently released is nine times the rate found among similar population in the community.
      • Hanging is the most common method (80%) associated with self inflicted deaths in prison.[6]

      Poor Mental Health Prisoners and ex-offenders are a group at particular risk of mental health problems.
      • Men and women in prison have a higher proportion of serious mental health problems, including psychosis.
      • The majority of prisoners have some degree of learning difficulty, with over one in 10 remand prisoners having an IQ under 65.[7]
      • For male and female prisoners, 27% have been in care as a child, compared to 2% in the general population.[8]
      • Many prisoners are released without mental health support, drug service throughcare, housing or income support.
      • Ex-offenders are more likely to suffer rejection and discrimination from families and wider society.
      • Prisoners generally have higher rates of mental illness and self harm and other associated risk factors, such as drug and alcohol misuse.
      • A high proportion of offenders have been found to suffer from drug and alcohol addiction.
      • In the young offender population, alcohol misuse is often of greater significance than drug misuse.

      Other conditions[9]
      • The incidence of sexual health problems is known to be significant among young offenders.
      • Chronic diseases such as heart disease and diabetes form a high proportion of the health care needs of prisoners. Incidence of such conditions is lower among young offenders. Early recognition and appropriate management of conditions such as asthma, epilepsy and diabetes are vital in preventing progression of these chronic conditions.
      • The prevalence of learning disabilities, including autism and Asperger's syndrome, and such conditions such as attention deficit hyperactivity disorder (ADHD) may require particular interventions in the under 21 population.
      • Poor oral health and dental disease is also a feature of prisoners, which requires the provision of a high standard and volume of care.


      References

      [1]   Ministry of Justice. Breaking the Cycle: Effective Punishment, Rehabilitation and Sentencing of Offenders 2010; Ministry of Justice.
      [2]   Shepherd G. A lifetime of exclusion? The psychologist 2010; 23:1: 24-25.
      [3]   Bradley RHL. Lord Bradley's review of people with mental health problems or learning disabilities in the criminal justice system Department of Health; 2009.
      [4]   Fazel S, Benning R, Danesh J. Suicides in male prisoners in England and Wales, 1978-2003 Lancet 2005; 366: 1301-1302.
      [5]   Pratt D, Piper M, Appleby L, et al. Suicide in recently released prisoners: a population based cohort study Lancet 2006; 368: 119-123.
      [6]   Burrows T, Brock AP, Hulley S, et al. Safer Cells Evaluation 2003; Jill Dando Institute, UCL. http://www.ucl.ac.uk/scs/downloads/research-reports/safercells-summary-report .
      [7]   Nurse J, Champion J. Mental Health and Well-Being in the South East 2006; Care Services Improvement Partnership, Department of Health. http://www.sepho.org.uk/Download/Public/10397/1/mentalHealth1_131206.pdf .
      [8]   Social Exclusion Unit. Reducing re-offending by ex-prisoners 2002; HMG Cabinet Office. http://www.thelearningjourney.co.uk/file.2007-10-01.1714894439/file_view .
      [9]   Norman S, Nayyar K. General Health Needs Assessment: HMYOI Cookham Wood and HMP YOI Rochester 2011; NHS Medway.
    • The level of need in the population

      Contact with the criminal justice system may provide the first point of contact with healthcare services for an individual offender. In 2011, 125 individuals who came into contact with the criminal justice system, aged between 40 and 74 years, agreed to undergo an NHS Health Check. Fifty of these were referred back to their GP for advice or treatment. The results showed that 57% were smokers and the same proportion were drinking alcohol at unsafe levels. Five were serious drinkers requiring referral to the alcohol treatment service and 13% were found to have a BMI which indicated obesity.

      The data obtained from the probation systems demonstrated that 922 offenders have a need related to alcohol; of those 35% have an alcohol treatment order. Alcohol misuse is linked to offending behaviour and risk of harm. There are also high needs for accommodation amongst those people accessing the probation service which may influence their health needs. Only 2.6% of offenders have a GP address recorded in the system.

      Nationally, there is a high prevalence of mental health conditions amongst offenders under the probation service. Twenty seven per cent of offenders currently have a mental health condition. Many young offenders are fathers; their health worker is able to liaise with the local family nurse practitioner, health visitors and safeguarding nurses to consider any child protection measures. As well as pre-existing health needs, offenders are also at risk of health problems created as a consequence of imprisonment: through overcrowding, isolation and exposure to violence and access to illicit drugs.[1]

      Mental Health

      A Mental Health Needs Assessment[2] carried out in both Medway prisons between June 2005 and November 2006 identified:
      • 17.9% of participants reported contact with the Mental Health Services whilst in custody
      • 15.4% reported prior contact with Mental Health Services
      • Of those interviewed, the majority left school under 16 years old
      • 35.9% had previously attended a special school
      • 38.2% were found to have an IQ score which suggested learning difficulties
      • 38.5% scored within the 'low IQ' range
      • The most common needs being reported as unmet needs were 'safety to others' (46.2%) and 'psychological distress' (28.2%)
      • The Psychiatric Diagnostic Screening Questionnaire indicated a range of features where participants scored on or above the threshold
      • Drug abuse/dependence was found to be 64.1%

      • Alcohol abuse/dependence was reported to be 51.3%

      • Obsessive Compulsive Disorder was also reported as 51.3% Therefore it is likely that prisoners will have high mental health needs

      Learning Disability

      Learning disability is not adequately screened at reception and is grossly under reported in prisons in the UK. There is an estimation that 23% of offenders under 18 years of age have an IQ of less than 70 and a further 25% have an IQ of less than 80. Below 80 is thought to be borderline intellectual functioning.[3]

      A reception screen for learning disability has been piloted by Offender Health. This screen is based on a simple seven question screen and will identify in a crude way any young man who may have a learning disability, although further assessment would be required to assess the disability fully.

      Having a learning disability whilst being in prison comes with many difficulties for the individual, from not being able to cope with the prison regime to bullying from other offenders. Therefore it is essential that offenders with a learning disability are identified at reception via screening and then adequately assessed as to the degree of their disability and an appropriate care/support plan drawn up.

      It should be noted that this does not include learning difficulties, which is a much wider issue that needs to be addressed. As the prisons do not currently have a measure of learning difficulties it has been challenging to quantify the scale of the issue.

      Substance misuse needs

      In the young offender population alcohol misuse is often of greater significance than drug misuse.

      In November 2011, the assessment data from HMP Rochester indicates
      • Opiates used in 10% of prisoners
      • Hazardous levels of alcohol used in 14%
      • Cocaine was used by 12%
      • Crack was used by 9%
      • Cannabis was used by 8%

      In November 2011, the assessment data from HMYOI Cookham Wood indicates
      • Opiates used in less than 5% of prisoners
      • Alcohol used in more than 75% of prisoners, with binge drinking being a key feature
      • Club drugs (Ecstasy, amphetamines and cocaine) were used by 25–30%
      • Benzodiazepine and Ketamine use was found to be very rare
      • Cannabis was used by 80–90% of prisoners

      Smoking Cessation

      Offenders display high levels of smoking prevalence as identified in the police cells, YOT and the prison service. In September 2011, there were 659 smokers across the two prisons, which represent 79% of the prison population (source: HMP Cookham Wood and HMP Rochester); the young age groups have the highest number of smokers however they represent the biggest proportion of the prison population. Stop Smoking Support in HM Prisons offers a best practice checklist for smoking cessation in prisons which should be incorporated in any future health promotion strategy.

      Immunisations and Blood Borne Viruses

      Many of the young people in the prison had irregular attendance at school and have often missed standard vaccinations and health interventions. There were three patients who tested positive for hepatitis C and as yet no patients have been diagnosed with Hepatitis B or HIV. Both hepatitis B and C are reported each quarter to the Health Protection Agency.

      Sexual Health

      Sexual health needs are relatively high with a disproportionate number requiring the services of an external Genito-Urinary Medicine Clinic.

      Chronic Diseases

      The incidence of chronic diseases is lower among young offenders, however early recognition and prevention of smoking is essential to reduce the future burden of disease and reduce inequalities. Information from both prisons indicates that the proportion and number of prisoners suffering from long term conditions is small, but good management is vital in preventing deterioration in conditions such as asthma, epilepsy and diabetes.

      Heart Disease

      There were 12 patients with heart disease at the time of this report (source: HMP Rochester, November 2011), but the population at this time was mostly young offenders under 21. It is expected that this number will increase with the population becoming older. In the UK prison population, chronic diseases such as heart disease and diabetes form a high percentage of the health care needs. The Prison and Probation Ombudsmen produced a report in 2010[4] which looked at 115 deaths from circulatory disease, and they found:
      • The average age at death from all circulatory diseases was 53 years. Thirty per cent of these deaths were of prisoners aged less than 45 years (34 of 115).
      • Of those who died as a result of ischemic heart diseases (82 cases), 35% had been diagnosed with ischemic heart diseases (most commonly angina) prior to death.
      • A further 19 were receiving medication for high blood pressure and/or high cholesterol (23%). Thirty-four were neither diagnosed with nor receiving treatment to prevent development of heart disease (41 per cent).

      Diabetes

      The expected prevalence for diabetes for Rochester Prison will change compared to historic prevalence. This is because the prison population will include a greater proportion of older people. It is estimated that 5.1% of the population of England has diabetes of either type. In September 2011, there were four people at HMP Rochester who were diabetic (0.6%). Therefore further work needs to be carried out to identify whether there are true differences in the populations or whether identification needs to be improved.

      Asthma and Respiratory Disorders

      The number of people receiving treatment for asthma in the UK is reported to be 5.4 million people of which 4.3 million are adults; this is almost 10% of the UK population. It has previously been reported that the prevalence of asthma amongst prisons is 13%, of which 5% will require treatment.[5] The local prison data indicates that 78 patients had a diagnosis of asthma which is 12% of the September 2011 population. In HMP Rochester, three patients were identified with COPD who are all aged between 35 and 50. The prevalence generally increases with age and long term smoking.

      Epilepsy

      The expected prevalence of epilepsy in the prison population is approximately 1% of the population.[5] According to NICE guidance, the age-standardised prevalence of epilepsy in the UK is estimated to be 7.5 per 1,000 population. This would suggest that at least seven patients at Rochester will have epilepsy. Local data indicates that seven prisoners had a diagnosis of epilepsy, although there is no chronic disease register for this disorder.

      Injuries

      The populations of both prisons are at risk from minor illness and injuries related to fights. Injuries are common reasons that necessitate external hospital appointments.

      Parenting Skills

      As with the experience in the YOT, many of the prisoners are young fathers, with poor experience of parenting and for whom parenting skills training would be potentially reduce the generational cycle of criminogenic activity.


      References

      [1]   De Viggiani N. Unhealthy prisons: exploring structural determinants of prison health Sociology of Health & Illness 2007; 29:1: 115-135.
      [2]   Harding C, Wildgoose E, Sheeran A, et al. A Mental Health Needs Assessment 2007; Kent and Medway Health and Social Care Partnership Trust (KMPT).
      [3]   Talbot J. No ones knows: identifying and supporting prisoners with learning difficulties 2006; Prison Reform Trust London.
      [4]   RyanMills D. Learning from PPO investigations: Deaths from circulatory diseases 2010; Prisons and Probation Obudsman for England and Wales.
      [5]   Marshall DT, Simpson DS, Stevens PA. Health care in prisons: A health care needs assessment 2000; University of Birmingham. http://www.bulger.co.uk/prison/needsassementbirmingac.pdf .
    • Current services in relation to need

      HMYOI Cookham Wood

      Her Majesty's Chief Inspector of Prisons (HMCIP) has not reported any serious concerns with the provision of healthcare. The most recent report comments on improvements in the service for young men with mental health problems. All offenders who are new in to custody, or are returning to the prison after a change of status, have to be assessed by the health team on admission.

      In 2008, HMP Cookham Wood changed from managing adult women to young teenage men. This presented a number of challenges for staff and concerns were noted by HMIP in 2009. The Inspectorate considered the accommodation unsuitable for young teenage men. The follow up inspection in 2010 identified considerable improvement with reduction in bullying and use of force. However, a survey in 2010 showed significant difference in the experiences for black and minority ethnic young men who were more negative about the relationship with staff.

      Healthcare is provided from a dedicated suite on the Cookham Wood site with a responder for unplanned incidents in the prison. These incidents have varied between 10 and 44 per month and remain largely unpredictable. Incidents include illness, accidents, use of force, fights and self-harm. The majority of activities take place by appointment, however there is a very high failure to attend rate. The healthcare delivery team is made up of a high number of long term agency staff and one challenge will be to develop a sustainable workforce to deliver high quality services.

      Funding for substance misuse is now channelled through the NHS and locally this is managed by Medway DAAT. Drug services are currently provided at Cookham Wood by three staff members who deliver the Substance Misuse Service. These individuals are part of the broader casework team and take the lead on substance misuse. The services that are provided are non-clinical and cover the psychological and social aspects of drug use. Clinical management and detoxification of opiates are undertaken at HMYOI Feltham.

      The core tasks for the service include:
      • Administration of medication
      • Immunisations and phlebotomy
      • Reception screening and secondary screening
      • Wellman clinic, Access clinic and Asthma clinic
      • Emergency response for the core
      • Pre/discharge/release assessment
      • Health promotion

      Most medicines are not given in-possession with the exception of antibiotics and inhalers for the treatment of asthma. Additionally, the following services are offered through providers working in association with the prison health team.
      • GP clinics
      • Out of hours GP cover
      • Optometry
      • Dentistry
      • Podiatry

      HMP Rochester

      Healthcare at HMP Rochester is a well-established and well-integrated service. The prison was inspected in February 2011 during which the healthcare service received a generally good review. The inspection team noted that “Prisoners had access to a wide range of health services. Health staff were well trained, highly motivated and prisoner-staff relationships were good.”[1]

      All new receptions are seen on the day of arrival for an initial reception assessment and they are all offered a follow up Wellman appointment within a week. Over a six month period there were 950 consultations for young men under 21 and 69 for prisoners aged between 22 and 72. There were on average 10 lost appointments a day through failure to attend. Most consultations were for minor illness or injury.

      Healthcare is now shared as the prison has integrated services for Young Offenders and Adults. This represents the recent re-rolling of the prison as a partial Category C Adult prison. The original healthcare site is now used to deliver services to the Young Offender population, whilst a new healthcare facility is dedicated to the adult population. The complement of staff provides healthcare to offenders at all stages of their stay at HMP Rochester.

      Core tasks for healthcare include:
      • Administration of medication
      • Risk assessment for in-possession medication
      • Twice daily dispensing of medication at both health care centres
      • Immunisations and phlebotomy
      • Reception screening and secondary screening
      • Wellman clinic, access clinic, smoking cessation and asthma clinic
      • On-call GP services
      • Pre-discharge for/release assessment, fitting forward/adjudication assessments
      • Mental health care
      • Emergency and contingency planning for healthcare specific issue, e.g. endemic flu planning

      In addition to this, the following services are also delivered to the prison by other providers,
      • GP clinics
      • Optometry
      • Dentistry
      • Podiatry
      • Mental health in-reach
      • Phlebotomy

      Sexually Transmitted Infections

      A sexual health clinic is run once a week at Rochester with Chlamydia being the most commonly diagnosed condition. It is difficult to establish the exact numbers of those diagnosed as the current information systems do not separate this information. During a nine month period for which data is available, 17 patients attended GUM clinics in the community for testing and diagnosis.

      Mental Health and substance misuse

      Health agencies in Medway have recognised the higher levels of mental health and substance misuse for offenders and services have improved through adult and CAMHS services. A high proportion of offenders have dual problems and it is not clear how the need for alcohol services is to be addressed though it is identified as a key priority in almost all of the local strategies.

      Substance Misuse

      HMP Rochester has been a clinical Integrated Drug Treatment Service (IDTS) site since 2008. Medway PCT commissions services in partnership with the prison and Medway DAAT. A newly commissioned IDTS (clinical) and psychosocial Counselling, Assessment, Referral, Advice and Through care teams(CARATs) service will commence in October 2012.
      The IDTS aims to expand the quantity and quality of drug treatment available at HMP Rochester by:
      • Increasing the availability and range of treatment options, particularly substitute prescribing
      • Integrating clinical substance misuse care with the services offered by the Drug Strategy/CARAT team with this including psychosocial treatment
      • Develop joint working between Healthcare and CARAT teams
      • Develop treatment delivery and joint care planning working to standards of care and models of treatment that integrate services and are agreed
      • Integrating prison and community treatment to prevent damaging interruptions to treatment either on reception into custody or on release back home

      Current Service Provision for Alcohol Reduction

      Rochester currently operates the COVAID (Control of Violence for Angry Impulsive Drinkers) programme. The programme provides ten sessions that are each two hours in length that follow a prescribed timetable. The sessions can be either individual or group. The sessions are structured within a cognitive-behavioural treatment programme. Over an 18 month period 91 young offenders attended the COVAID programme and from the results of the Alcohol Use Disorders Identification Test (AUDIT), we can see that the 91 offenders who completed the programme have scored highly; a score of more than 8 requires intervention.

      Chronic Diseases and their Management

      Chronic disease management is essential to primary health care and is monitored through performance indicators. There are currently two sessions that are set aside for chronic disease management, which are general clinics rather than disease specific clinics. There is good evidence that supports the notion that imprisonment is not conducive for good health outcomes. Currently there is limited need for chronic disease management but this will change as the establishment has greater number of older offenders. The two sessions currently available for chronic disease management may not be adequate if the prison population increases and there is an increased number of older prisoners.

      Outpatient Appointments in Hospital

      Over an 18 month period between February 2010 and August 2011, a total of 280 patients attended hospitals as outpatients (source: HMP Rochester). Diagnostic imaging for radiography is the most common reason for attendance at the local hospital. Most patients who required a radiograph were due to suspected hand or face injuries sustained during fights. The reports from the healthcare staff indicate that most of these were soft tissue injuries. It was reported by staff that a high number of the emergency calls were for fights or self-injury. A large proportion of the patients required ultrasound for investigation of testicular lumps, which may be related to the increased awareness due to health promotion during induction. The number of patients requiring escorts has increased and may represent the higher healthcare needs of the adult population. It is anticipated that the number of patients requiring escorts could increase even further as the adult population of HMP Rochester also increases.

      Failure to Attend

      The number of failed appointments appears to be generally problematic; this was previously identified in the last health needs assessment that was undertaken in 2009. The service providers report that approximately half of all appointments are lost due to failure to attend.

      The failed appointments during the period 1st October 2011 to 17th November 2011 totalled 510 appointments, which equated to an average of almost 10 failed appointments per day. These missed appointments represent 109 hours of clinical activity over the 48 days period assessed, excluding failed appointments within mental health.

      If prisoners do not arrive at either of the Health Care Centres via the “free flow system” then it is impossible for them to attend their appointment unless they are given an escort; access to an escort is dependent on the availability of prison officers. Prisoners do not get flexible access to clinics as they often arrive at the same time and have to wait together in the waiting room until they are seen. This can lead to prisoners having to wait in the waiting area for long periods of time which can become problematic from an order and control perspective.

      The prison will be changing its regime - the free flow period will be available all morning and during the unlock period in the afternoon. This will enable patients to attend their appointments without the need to wait for escorts. This should improve access to services.


      References

      [1]   Her Majestys Inspectorate of Prisons. Report on an announced inspection of HMYOI Rochester, 14--18 February 2011 2011; HM Inspectorate of Prisons. http://www.justice.gov.uk/downloads/publications/inspectorate-reports/hmipris/prison-and-yoi-inspections/rochester/Rochester-June-2011.pdf .
    • Projected service use

      The offender and ex-offender health population will change over the next 10 years. There are changes that will be brought about from tackling the wider determinants of health and aimed at reducing the number of people coming into contact with the criminal justice system. There will also be those system wide changes that are designed to reduce the number of people reoffending. Better recognition of the association between Looked After Children and the likelihood of contact with the criminal justice system may help local authorities implement preventative measures much earlier on. Disease patterns and health needs are also likely to change in the prison population, in part this will be due to the change in age profile of prisoners. Greater emphasis on mental health and improved access to services for children and young people may result in fewer people entering the criminal justice system.

        Frequency Indicative activity
      for 12 months
      Access clinics Daily 2,819
      Chiropodist 6 Weekly 8
      Chlamydia screens On demand 199
      Dentist Weekly 185
      GP (appointments) Daily 1,147
      GUM referrals As required 19
      Health promotion Twice weekly 444
      Immunisation and vaccination Twice weekly 206
      Optician 4-6 weekly 57
      Physio On demand 9
      Receptions Daily 444
      Wellman Twice weekly 444
      Table 1: Estimated service use over the next 12 months for HMP Rochester

      The Ministry of Justice has estimated prison population projections for the period 2011–2017 which are considered alongside legislation and sentencing activity on the prison population.[1] The three projected trends reflect the cumulative impacts of the various circumstantial, sentencing, legislative and procedural assumptions and are modelled on 'lower', 'medium' and 'higher' scenarios in 2011 projections. Recent public disorder impacts on prison population trends.

      Following the medium projection, the prison population rises gradually (between 0.0 and 0.7 % year on year) to 2017, which is an increase from 85,200 in 2011 to 88,900 in 2017. This gradual rise is principally due to a steady rise in the indeterminate sentence population, but is also influenced by a rise in the non-criminal population over the first year of the projection and a later rise in the determinate sentence population. The exception to this is a projected 2.0% rise from June 2011 to June 2012 which is partly a consequence of the August 2011 public disorder events. This brings the projected prison population to 86,900 by June 2012. There is 0% growth in the projected prison population in the following year as the majority of public disorder prisoners complete their sentence and the total projected prison population remains at 86,900.

        Frequency Indicative activity
      for 12 months
      Access clinics Daily 2,819
      Chiropodist 6 Weekly 8
      Chlamydia screens On demand 199
      Dentist Weekly 185
      GP (appointments) Daily 1,147
      GUM referrals As required 19
      Health promotion Twice weekly 444
      Immunisation and vaccination Twice weekly 206
      Optician 4-6 weekly 57
      Physio On demand 9
      Receptions Daily 444
      Wellman Twice weekly 444
      Table 2: Estimated service use over the next 12 months for HMYOI Cookham Wood

      Following the lower projection, the prison population generally falls (between 0.2 and 0.6% year on year) to 2015 due to a projected decrease in the level of immediate custodial conviction. After 2015 it rises slightly as the indeterminate sentence population continues to rise against a background of levelling determinate sentence, remand and recall populations. Following the higher projection, the prison population generally rises (initially at around 2% year on year, reducing to less than 1% year on year by 2015) throughout the modelled period. At the end of June 2011 the published prison population was within 0.2% (200 in 85,400) of the medium projection, and within -0.9% of the high projection. At the end of September 2011 the published prison population was within 0.7% (600 in 87,500) of the medium projection, and within -0.9% of the high projection. Based on medium and high projections, service use within prisons is likely to increase. A low projection would indicate a possible reduction in service use.

      HMP Rochester

      The current total operational capacity is 664 offenders, and current population is 577 (June 2012). A refurbishment is currently taking place which will result in the capacity increasing to 724. Once the A wing opens (estimated to open in July 2013) the capacity will increase to 804. It is expected that 60% of the prisoners will be older adults and 40% will be younger males. The average length of stay is 4.5 months. The indicative service use over the next 12 months has been estimated for this prison to help plan health services (table 1)(source: HMP Rochester and NHS Medway).

      HMYOI Cookham Wood

      Current total operational capacity is 143 people and the current population is 110. There is a proposed new build at the prison which will increase the population capacity to 179 in the future. The average length of stay is 3–4 months (table 2).


      References

      [1]   Ministry of Justice. Prison population projections
    • Evidence of what works

      Crime and Offending
      Breaking the cycle: Effective Punishment, rehabilitation and Sentencing of offenders[1]

      The Ministry of Justice identifies the need to bring together agencies involved in criminal justice to provide a more coherent and coordinated approach, including engagement of health services for offenders with mental health, alcohol and substance misuse problems. It focuses on the increasing role of the police in turning offenders away from crime and the importance of the court system in protecting the public and reducing reoffending through the use of community orders for drug treatment. Police, probation and other agencies are already working closely together in Medway in the management of prolific offenders. There is an Offender Management Unit that brings together police and probation. The Medway Drug and Alcohol Team is actively involved in supporting offenders with substance misuse problems and there is a Forensic Mental Health Team that works with the police to divert mentally ill offenders into appropriate treatment and provide court reports to support appropriate sentencing. Locally, West Kent is a pilot site, leading to the commissioning of a new service to provide an integrated drugs and alcohol service based on payment by results, which if successful may be rolled out across Kent and Medway.

      Mental health and substance misuse
      No health without mental health. A cross government mental health outcomes strategy for people of all ages[2]

      This strategy aims to improve the mental health and well-being of the population and improve outcomes for people with mental health problems through high-quality services that are equally accessible to all. The incidence of mental health problems can increase in times of economic and employment uncertainty, and there are indications that behavioural and emotional problems are now more prevalent in young people. The strategy promotes early intervention as it can improve health and well-being and prevent mental illness, but also reduce costs incurred by ill health, unemployment and crime. There are critical priorities in the strategy which are relevant to the lives of offenders such as supporting young people and their families, improving parenting skills to reduce the generational cycle of offending, improving access to psychological therapies, reducing drug use, supporting the positive mental health from employment and improving access to services for those who are homeless. It is estimated that 90% of all prisoners have a diagnosable mental health problem with or without a substance misuse problem. The strategy aims to reduce this by recommending that more individuals with mental health and learning difficulties are diverted away from criminal justice agencies and into treatment and social support.

      Anti-social personality disorder

      Many offenders can be identified as having an anti-social personality disorder. The National Institute for Clinical Excellence estimates that half of the prison population has such a disorder. Following consultation on offender personality disorders, the government's response[3] indicates the need for criminal justice agencies and the NHS to work more closely together to ensure patients get access to the services, recognising that the affected individuals may be in prison or in the community. The protection of the public from the more serious cases would fall to the prison service. The National Offender Management Service (NOMS) and NHS are encouraged to work together to develop services along the offender pathway, providing psychological support by appropriately qualified staff. There was a particular focus on the needs of young people to prevent reoffending and the intergenerational cycle of crime. Agencies should ensure that services are targeted with an emphasis on screening and assessment. Appropriate treatment programmes should be provided within prisons or NHS secure estate supported by psychologically informed planned environments. The existing MAPPA (Multi Agency Public Protection Arrangements) programmes should have extra support to manage offenders in the community. The National Institute for Clinical Excellence has produced guidelines on the treatment, management and prevention of anti social personality disorder for adults over 18 years of age.[4]

      The Drug Strategy 2010: Reducing demand, restricting supply, building recovery[5]

      Drug use by young people has fallen by a third in the last decade, but the UK still has the highest rates of cannabis use and binge drinking amongst young people in Europe. This strategy focuses particularly on the impact of drugs and alcohol on young people and especially vulnerable groups, such as those in contact with criminal justice agencies, excluded from school or with parents with drug and alcohol problems who need targeted support and early intervention. Early drug and alcohol use is related to a host of educational, health and social problems.

      The strategy requires that young people will get rapid access to specialist support for both drug and alcohol problems. The service should be recovery based both in the community and in treatment based accommodation, supported by CAMHS (Child and Adolescent Mental Health Services), the Public Health grant and the Early Intervention grant. There is particular emphasis on liaison and diversion from police and courts.

      A third of the adult treatment (drug or alcohol) population has parental responsibility for a child, but there are family focused interventions, which provide evidence of reduction in anti social behaviour, crime, truanting and domestic violence. There is also a need to develop recovery-based services in prisons.

      The Patel Report[6]

      The Patel report reviewed substance misuse therapies available in the prison and community setting by looking at reduction in drug use and reoffending. It also looked at how current regimes improved social functioning and relationships or improved employment or workforce skills. However it found a need for greater continuity in management for substance misusers between prisons and community agencies including housing.

      Children and young people

      Healthy children, safer communities - a strategy to promote the health and well-being of children and young people in contact with the youth justice system[7]
      Many children and young people in the YJS (Youth Justice System) come from vulnerable families living in disadvantaged areas where health outcomes are noticeably worse than for other children; particularly so for children from black and minority ethnic (BME) groups. High numbers of children and young people in the YJS experience domestic violence, neglect, and physical and sexual abuse within their family. These are risk factors for the development of mental health problems as well as for offending. For those in the secure estate there are particular concerns in relation to restraint, bullying, self-harm and the risk of suicide.

      Many are not registered with a GP, increasing the risk that screening and developmental checks for children will be missed. In addition, many of these children and young people suffer from physical health problems such as poor oral health, respiratory problems, smoking, sexually transmitted diseases and pregnancy.

      The strategy recognises the need to identify mental health problems, learning disabilities and communication problems when children and young people are in police custody, because such problems increase children's vulnerability. Understanding a child's health problems will also help the police, the Crown Prosecution Service (CPS) and the Youth Offending Team (YOT) to decide the most appropriate action to take and wherever possible divert them from criminal justice agencies towards more appropriate treatment and support services.

      Looked After Children and Young People (NICE Guideline 28)[8]

      The guidance covers children and young people from birth to age 25, wherever they are looked after. The guideline applies to secure settings such as young offenders institutions (e.g. Cookham Wood and Rochester), recognising the constraints of working with some of the most challenging behaviour and attitudes. It is recommended that services are commissioned which are dedicated to looked after children and young people that are integrated, preferably on the same site, and have expert resources to address physical and emotional health needs. These services should have links with universal services, be friendly, accessible and non-stigmatising.


      References

      [1]   Ministry of Justice. Breaking the Cycle: Effective Punishment, Rehabilitation and Sentencing of Offenders 2010; Ministry of Justice.
      [2]   HM Government. No health without mental health: a cross-government mental health outcomes strategy for people of all ages 2011; Department of Health.
      [3]   Department of Health. Response to the offender personality disorder consultation 2011; Department of Health. http://www.dh.gov.uk/health/2011/10/offender-personality-disorder-consultation-response/ .
      [4]   National Institute for Health and Clinical Excellence. CG77 Antisocial personality disorder: Treatment, management and prevention 2009; National Institute for Health and Clinical Excellence. http://publications.nice.org.uk/antisocial-personality-disorder-cg77 .
      [5]   HM Government. Drug Strategy 2010 Reducing demand, restricting supply, building recovery: supporting people to live a drug free life 2010; HM Government. http://www.homeoffice.gov.uk/publications/alcohol-drugs/drugs/drug-strategy/drug-strategy-2010?view=Binary .
      [6]   Professor Lord Patel of Bradford OBE. The Patel report: Reducing drug-related crime and rehabilitating offenders 2010; Independent Prison Drug Treatment Strategy Review Group. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_119851 .
      [7]   Department of Health , Department for Children and Schools and Families , Ministry of Justice , et al. Healthy children, safer communities -- a strategy to promote the health and well-being of children and young people in contact with the youth justice system 2009; Department of Health. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_109771 .
      [8]   National Institute for Health and Clinical Excellence. PH28 Looked-after children and young people 2010; National Institute for Health and Clinical Excellence. http://www.nice.org.uk/PH28 .
    • Unmet needs and service gaps

      The prisons undertake an assessment of their performance using the Prison Health Performance and Quality Indicators. The results for HMP Rochester and HMYOI Cookham Wood indicate that there are some unmet needs and service gaps that require development.

      HMP Rochester


      • Improving services for the management of chronic disease and long term conditions
      • Developing prison dental services
      • Developing services for older adults
      • Improving services for those with learning disabilities
      • Implementing the Care Programme Approach Audit
      • Developing health promotion
      • Improving health services in accordance with the Equality Act and Human Rights Act
      • Increasing service user involvement
      • Developing corporate governance and information governance
      • Working with providers to plan the healthcare workforce

      HMYOI Cookham Wood


      • Improving health services in accordance with the Equality Act and Human Rights Act
      • Implementing alcohol screening, intervention and support
      • Developing services for children and younger people
      • Improving services for those with learning disabilities
      • Developing health promotion
      • Improving communicable disease control services

    • Recommendations for consideration by commissioners

      Engagement


      • Links need to be developed with the Health and Wellbeing Board to ensure the greater needs of offenders are taken into account when tackling health inequalities
      • Engagement with Clinical Commissioning Groups to ensure that primary care services are aware of the risks and opportunities in the management of offenders and their families

      Working with external agencies


      • Services need to be developed that allow early identification of health needs in conjunction with the probation service and court service. These services need to enable access to wider health and social services working with the wider criminal justice system.
      • The probation services and the courts should be assisted to make better use of Alcohol Treatment Orders for those people known to be suffering from alcohol related problems to help prevent them reoffending

      Developing Services


      • Ensure that all new receptions have their peak flow taken as part of the Wellman clinic. Ensure that spirometry is available at the establishment to aid diagnosis of respiratory conditions.
      • All future chronic disease management clinics should be run in line with best clinical practice and complies with the relevant National Institute for Health and Clinical Excellence guidance. The new service provider to improve the data quality, clinical coding and to ensure that chronic disease registers are in place.
      • Focus on the development of positive relationships between staff and offenders, especially BME offenders
      • Substance misuse services at Cookham Wood should be developed to meet National Service Specifications
      • Identify health services and preventative services that can be more easily delivered in the 'wings' to improve access for prisoners
      • Improve collaboration between prisons to share health resources and improve access to specialised services
      • Introduce a screen for diabetes as part of Wellman clinics
      • Increase uptake of smoking cessation at HMP Rochester
      • Identify health promotion needs and develop a health promotion plan
      • Develop services for those with learning difficulties across both HMP Rochester and HMYOI Cookham Wood
      • Consider developing the workforce to deliver services equitable to a minor injury unit to deal with fights
      • Reduce failed appointments - Consider for the new model of care and the employment of a nursing assistant/porter to act as a movements officer to ensure patients can get to their appointments and are returned to work/wing without delay
      • The commissioner should consider the possibility of providing onsite Diagnostic Imaging (Ultrasound and Radiography), GUM and Dermatology clinics for both Cookham Wood and Rochester

    • Further needs assessment required


      • Further needs assessment is required to compare the service utilisation and needs in these prisons with similar prisons and with other prisons in the area
      • User involvement should be encouraged as part of future needs assessment with better mechanisms to collate service user views
      • As systems develop, incidence and prevalence of disease conditions needs to be gathered
      • The effectiveness and cost-effectiveness of services that are currently provided need to be considered
      • Service use projections should be calculated over 3–5 years and 10 years. This will be needed to consider the increasing prison population and increase in the age range of the prisoners.
      • Further analysis needs to be included of all unplanned admissions to hospital

  • Carers
    • Summary

      Summary

      The term “unpaid carer” encompasses individuals of any age who provide unpaid support to a relative partner, a child or friend who could not manage without this help.[1] This could include the provision of support to someone who is ill, frail, disabled or has mental health or substance misuse problems. In Medway there are an estimated 25,000 unpaid carers,[2] although many carers do not make themselves known to services, and as such this number is likely to underrepresent the actual value. Caring can have detrimental effects on the health of the carer and also in their ability to remain financially independent, as many have to give up work in order to provide care. It is important that carers are identified and supported early to ensure that the health and wellbeing of the carer, and the person being cared for, are protected. Those particularly vulnerable are carers that are very young or elderly.

      Key issues and gaps

      The Care Act 2014 came into force in April 2015 and, for the first time, allows carers the same rights to assessment and support as the persons they care for.[3] This shift in focus has highlighted the need for change nationally, to put legislation from the health and social care reforms into action. This includes the increased monitoring of the impact on carers, to ensure that future priorities for action to support carers are identified. In response to the Care Act 2014, Medway has formed a new strategy entitled “NHS Medway and Medway Council Joint Carers' Strategy”,[4] which sets out to identify carers in need of help and put in place the structures necessary to deliver advice and support. This support is hoped to maximise the carers' potential through the delivery of training, identification of resources already available to them in their family and community networks and, in some instances, provision of financial assistance.


      References

      [1]   HM Government. Recognised, valued and supported: next steps for the carers strategy 2010; HM Government. http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_122393.pdf .
      [2]   ONS. Census 2011;
      [3]   Government H. Carers Strategy: Secon National Action Plan 2014 - 2016 2014;
      [4]   NHS Medway and Medway Council. Joint Carer's Strategy 2015 - 2017 2015;
    • Who's at risk and why?

      In any one year an adult has a 6.6% chance of becoming a carer; this likelihood is greater in women than it is in men (7.3% and 5.8% respectively). By the time a woman has reached the age of 59 she has a 50% chance of having had significant caring responsibilities at least once; for a man the equivalent age is 74 years.[1]

      Caring may have a substantial negative economic impact as a significant number of carers also either give up or reduce their hours of work in order to care. There is also a cost to society in terms of both reduced income from taxation and increased benefits payments. It has been estimated that carers in the UK miss out on between £750 million and £1.5 billion a year in earnings.[2] A Carers UK survey found that one third of carers were unable to afford their utility bills and almost half were cutting back on essentials such as food and heating.[3]

      Caring is associated with an increase in health problems in those providing the care. Common problems include physical injuries and mental health problems such as depression and anxiety.[3] Among older people mortality rates may also be higher in carers than in non-carers.[4] However, carers do not visit the doctor any more than non-carers, suggesting that they may not be accessing the services that they require.[5] If carers are struggling with the demands of caring this may also have consequences on the health of the person being cared for. In one study, the carer's inability to cope was found to be the principal reason for re-admission of patients in 14% of cases, but problems with the carer were felt to contribute to as many as 62% of re-admissions.[6]

      Nationally, we are seeing an ageing population and correspondingly the number of carers over the age of 65 is increasing more rapidly than the general carer population; increases of 35% and 11% respectively seen in England between 2001 and 2011 Census surveys.[7] See table below for breakdown of increases in elderly carers by age. Elderly carers may have health problems of their own, so developing adequate support for this group of carers is essential.

        Number of older carers 2001 Number of older carers 2011 % increase
      Aged 65 to 74 582,287 725,251 25%
      Aged 75 to 84 261,240 377,923 45%
      Aged 85 and older 38,291 87,346 128%
      Total 881,818 1,190,520 35%
      Table 1: Breakdown of elderly carers in England from 2001 and 2011 Census data. [7]

      Anyone under the age of 18 who is in some way affected by the need to take physical, practical and/or emotional responsibility for the care of another person is termed a 'young carer'. Young carers can be particularly vulnerable as they are often undertaking a level of responsibility that is inappropriate to their age or development and for this reason may also be reluctant to seek help.


      References

      [1]   MGeorge, Carers UK. It could be you. A report on the chances of becoming a carer 2001; Carers UK. http://www.carersuk.org/media/k2/attachments/Itcouldbeyousummary.pdf .
      [2]   Buckner L, Yeandle S. Valuing carers 2011. Calculating the value of carers' support 2011; Carers UK. http://www.carersuk.org/media/k2/attachments/Valuing_carers_2011___Carers_UK.pdf .
      [3]   Carers UK. The cost of caring 2011; Carers UK. http://www.carersuk.org/professionals/resources/research-library .
      [4]   Schulz R, Beach S. Caregiving as a risk factor for mortality: the caregiver health effects study Journal of the American Medical Association 1999; 282(23): 2215-2219.
      [5]   Polen M, Green C. Caregiving, alcohol use, and mental health symptoms among HMO members Journal of community health 2001; 26(4): 285-301.
      [6]   Williams E, Fitton F. Survey of carers of elderly patients discharged from hospital British Journal of General Practice 1991; 41: 105-108.
      [7]   Carers UK. Caring into later life: The growing pressure on older carers. 2015;
    • The level of need in the population

      Although it is difficult to measure the current overall level of unpaid care provided by Medway's residents, the most recent Census data provides us with our best indication. In 2011, the number stood at approximately 25,000, accounting for 9.5% of the total population.[1] Overall, this places Medway below the national and regional averages in terms of unpaid care provision, with England and South East revealing values of 10.2% and 9.8% respectively.[1] The breakdown of unpaid carers within Medway by age and gender can be seen below in Figure 1. The largest group of unpaid carers were women aged 55-59, of which 22.0% were providing unpaid care. Using figures from the 2011 Census, there are an estimated 661 children and young people in the age range 0 - 15 provided unpaid care in Medway, with an additional 1,632 in the 16 - 24 age range.

      Figure 1: Percentage of the population in each age group in Medway who are providing unpaid care, 2011 census.
      Figure 1: Percentage of the population in each age group in Medway who are providing unpaid care, 2011 census.

      National trends reveal an overall increase in the level of reported unpaid care, with an increment of 11.3% in England between the 2001 and 2011 Census surveys. In Medway, the number of unpaid carers increased by 16.5% from that recorded in the previous (2001) Census; including a 51.1% increase in unpaid care provision by those aged 65 and over. Changes to the age ranges displayed at Local Authority level mean that direct comparisons for the younger age ranges cannot be made with previous surveys. However, national figures in the 2011 Census show a 2.1% rise in young carers identified as providing unpaid care compared with the preceding survey.[2]

      If we look at the level of care provided, slightly fewer carers in Medway provide the lower (1 to 19 hours per week) and medium (20 to 49 hours) levels of care than the national average, whilst there are slightly more carers in Medway than the national average providing higher (50+ hours) levels of unpaid care.[1] Unpaid carers reported poorer health than those not delivering unpaid care (4.7% and 6.5% respectively); with carers delivering 50 hours or more of care revealing the highest levels of poor health (11.7%).[3]

      At ward level Peninsula, Gillingham North and Gillingham South have the greatest proportions of unpaid carers; Cuxton & Halling, River and Lordswood & Capstone have the lowest.[4] There is no obvious correlation between the level of deprivation in a ward and the percentage of the population who are carers. Similarly to the general population, the majority of carers in Medway were of white ethnicity; in this group 9.8% provided unpaid care.[5] Most unpaid carers are still economically active (65.7%). However, a higher proportion of part-time workers, working in an employed or self-employed capacity, undertake caring responsibilities than those working in a full-time role.[6] It is likely this is due to the requirement of carers to reduce work hours in order to provide care.


      References

      [1]   ONS. Census 2011;
      [2]   ONS. Census 2001;
      [3]   NOMIS, ONS. Provision of unpaid care by general health by sex by age 2015;
      [4]   NOMIS, ONS. Sex and age by general health and provision of unpaid care, by ward. 2015;
      [5]   NOMIS, ONS. Ethnic Group by provision of unpaid care by general health. 2015;
      [6]   NOMIS, ONS. Economic activity by provision of unpaid care by general health by sex. 2015;
    • Current services in relation to need

      For an up-to-date list of current services please contact Caroline Friday.

    • Projected service use and outcomes in 3--5 years and 5--10 years

      It is estimated that 3 in 5 people will act as a carer at some point in their lives.[1] However, carers are not a static population, every year millions of people take on caring responsibilities, whilst for millions of carers caring comes to an end as the person they care for recovers, moves into residential care or passes away.[2] As such, it is very difficult to calculate the number of carers that will be required in subsequent years.

      Table 2 shows projected carer provision required in the years 2017 to 2037. These projections assume that the proportion of the population providing care in the future, by age, remains the same as in 2011.[3] This assumption is unlikely to be accurate as it does not take into account changes in the prevalence of age-related conditions, such as dementia, which has shown a rapid increase in prevalence. In addition, the proportion recognised as providing care is likely to increase due to better identification of unpaid carers. Thus we are likely to see much higher numbers recorded in the future than those estimated in Table 2.

        2017 2022 2027 2032 2037
      0 to 15 701 740 759 765 770
      16 to 24 1,548 1,495 1,577 1,697 1,749
      25 to 34 2,680 2,800 2,673 2,626 2,793
      35 to 49 6,851 6,851 7,428 7,755 7,780
      50 to 64 9,387 10,040 9,913 9,677 9,768
      65 and over 5,680 6,343 7,196 8,151 8,890
      Total 26,605 27,800 28,938 29,991 30,987
      Table 2: Estimated number of carers in Medway, by age, 2017 to 2037. Projections calculated using Census 2011 carer numbers and 2012-population projections (ONS).

      Using figures from the 2011 Census, Carers UK predict that there will be a 40% rise in the number of carers needed by 2037, resulting in an estimated 9 million carers nationally.[2] If we were to crudely (with no age-standardisation) apply this 40% increase in the number of Medway carers, we would expect to see 35,004 unpaid carers by 2037. However, the methodology used by Carers UK has not been published and as such cannot be verified.

      A recent paper looking at the supply of unpaid care for older people by their adult children, suggests that demand for unpaid care will begin to exceed supply by 2017 and that the unpaid 'care gap' will grow rapidly from then onwards.[4] Estimates by POPPI suggest that the number of older carers (aged 65 years and over) in England is set to increase to over 1.8 million by 2030.[5]


      References

      [1]   MGeorge, Carers UK. It could be you. A report on the chances of becoming a carer 2001; Carers UK. http://www.carersuk.org/media/k2/attachments/Itcouldbeyousummary.pdf .
      [2]   Carers UK. Facts about Carers policy briefing 2014;
      [3]   ONS. Census 2011;
      [4]   Pickard. A growing care gap? The supply of adult unpaid care for older people by their adult children in England to 2032. Ageing & Society 2015; 35: 96-123.
      [5]   Projecting Older people population Information (POPPI). Population projections 2014;
    • Evidence of what works

      The literature on support interventions for carers shows a wide range of interventions have been tried to support carers of people with a variety of different conditions, with mixed results. The provision of short breaks to carers has been shown to have beneficial effects; one particular intervention showed that short breaks for families of disabled children led to a positive impact on the wellbeing of most disabled children and their families.[1] There is also evidence to show that cognitive reframing can have some effect on anxiety, depression and subjective stress in dementia carers.[2]

      Providing primary care teams with training and awareness of issues faced by carers can be successful. Options to increase identification of carers may include routinely asking about whether someone is a carer at new registrations and routine health checks, or on repeat prescriptions. Carer support workers may be helpful in providing carers with advice and signposting to relevant agencies.[3] For hospital patients, comprehensive discharge planning, which includes both patients and their carers has been found to be related to shorter hospital stays and reduced re-admissions.[4]


      References

      [1]   Robertson J, Hatton C, Wells E, et al. The impacts of short break provision on families with a disabled child: an international literature review Health and Social Care in the Community 2011; 19(4): 337-371.
      [2]   Vernooij-Dassen M, Draskovic I, McCleery J, et al. Cognitive reframing for carers of people with dementia (review) 2011; The Cochrane Library (no. 11). http://www.thecochranelibrary.com/details/file/1391689/CD005318.html .
      [3]   Arksey H, Hirst M. Unpaid carers' access to and use of primary care services Primary healthcare research and development 2005; 6: 101-116.
      [4]   Bauer M, Fitzgerald L, Haesler E, et al. Hospital discharge planning for frail older people and their family. Are we delivering best practice? A review of the evidence Journal of Clinical Nursing 2009; 18: 2539-2546.
    • User Views

      In 2012 four focus groups were held with carers from across Medway, with adult carers, young carers, carers from black and minority ethnic groups and carers for people with mental health problems. One of the key points raised was identification. Carers felt that there was often a delay in recognition of their role as a carer, by authorities and the carer themselves. Carers felt that GPs and hospitals were in an ideal position to recognise that they were carers and offer support and felt that the carer should be identified as soon as the person being cared for received their diagnosis.

      There was felt to be a lack of training for unpaid carers in the skills they needed in their caring role, for example using a hoist. Carers also expressed that they would like more information about the condition of the person they cared for as well as clear information relating to available support. Carers felt that a single information booklet with necessary information and contact details would help greatly.

      In order to keep themselves healthy, carers highlighted a need for support to take breaks from their caring responsibilities in addition to respite care, which was deemed too costly for some. In addition, counselling was mentioned as something that could be useful in helping carers maintain their mental health. Carers also expressed the desire for free travel and other treatments, such as free swimming.

      Further consultation will be undertaken in the 2017 leading up to review of the carers' strategy.

    • Unmet needs and service gaps

      Out of the estimated 25,000 carers identified in the 2011 census, only a small proportion of carers in Medway appear to be known to services. This would suggest that there is a need to improve the way in which carers are identified in order that they are provided with appropriate support. The discussion of a carers' lead role in GPs surgeries is planned to take place shortly will assist in raising the awareness and better identification of carers and carers' issues within primary care settings. Once identified carers should be given the correct information and training for their needs to support them in their caring role.

      Anecdotally, working age carers do not appear to be well engaged with the Medway Carers' Centre. Further work needs to take place to identify how best to support this group of carers.

    • Recommendations for Commissioning

      Medway Council and Medway NHS CCG value their adult, parent and young carers. As such, there is the recommendation to ensure that carers should be recognised by the wider community and receive appropriate support where necessary to help them provide care safely and maintain a balance between their caring responsibilities and a life outside caring. This includes assisting them in achieving their potential, maintaining mental and physical health and wellbeing, ensuring access to training and employment and supporting them to be as independent as possible.[1]

      A list of principles underpinning 'Medway's Commitment to Carers' can be found under section 7 of the NHS Medway and Medway Council Joint Carers' Strategy 2015–2017. The ongoing development and testing of the new Citizen's Portal, MyMedway.org, will carry a full suite of information, advice and guidance as well as an “E-Marketplace” which is being developed to ensure that those looking for support can research appropriate solutions for themselves.[1]

      In line with the requirements of the new Care Act 2014, Medway Council will offer assessments for carers who request them. This will enable the council to determine the carers' level of need, including whether or not they are eligible for any additional funding from adult social care.


      References

      [1]   NHS Medway and Medway Council. Joint Carer's Strategy 2015 - 2017 2015;
    • Recommendations for needs assessment work

      A detailed needs assessment was carried out and published in October 2012.

  • Falls
    • Summary

      A fall is defined as 'an event whereby an individual comes to rest on the ground or another lower level with or without the loss of consciousness' (American Geriatric Society, 2001).

      Falls are an increasingly significant public health issue due to our ageing population. Older people have the highest incidence of falls and the greatest susceptibility to injury. Up to 35% of people aged 65 and over fall each year increasing to up to 42% for those aged 70 years and above. [1]

      Falls may result in loss of independence, injuries such as fractures and head injuries (20% of fallers sustain serious injury such as hip fracture), mobility loss, pressure related injuries, infection and sometimes injury–related death. The most common serious consequence of falling is a hip fracture (fractured neck of femur). Often the elderly will require hospital admission and rehabilitation following a fall. In the UK there were 647,721 Accident and Emergency (A&E) attendances and 204,424 hospital admissions for falls–related injuries in those aged 60 years or above in 1999. [2] Falls and fractures in the >65s account for four million hospital bed days/year in England.

      Older people who fall are likely to fall again, usually requiring further use of health and social care services. Recurrent fallers are also more likely to have a fall–related fracture. [3] Half of people suffering a hip fracture never return to their previous level of independence and experiencing falls is a strong predictor of needing placement in a nursing or care home in the future. [4]

      Osteoporosis, a condition characterised by a reduction in bone mass and density, increases fracture risk when an older person falls. Osteoporotic fractures are increasing in the UK, a trend which is likely to continue as the elderly population increases. It is estimated that 3 million people in the UK have osteoporosis and that around 230,000 osteoporotic fractures occur in the UK each year. In 2001, the combined NHS and social care costs for a single hip fracture in the UK were estimated to be ?20,000 with an estimated total of more than ?1.73 billion per year for all UK hip fractures.

      The financial impact of falls and fractures on health and social care is substantial. As the rate of falls is expected to rise with an ageing population, developing effective interventions to prevent falls becomes increasingly important as they will have significant implications for health and social services.

      The Department of Health published “Falls and Fractures. Effective interventions in health and social care” in 2009, the aim of which was to improve NHS falls and fracture services and care for older people. Four key objectives were set out within the document, prioritised in the size of health gain, which commissioners should consider in the context of local services for falls, falls prevention and fractures (figure 1).

      Figure 1: Department of Health: Systematic Approach to Falls and Fracture Prevention.
      Figure 1: Department of Health: Systematic Approach to Falls and Fracture Prevention— Four Key Objectives.

      Key issues and gaps


      • Falls are a public health problem nationally due to an ageing population. Medway's 50+ population is expected to increase by 16% from 2013 to 2021. The number of people over 85 will grow by 27% over the same time period.
      • Osteoporosis is common, especially in older females, and is a major cause of fractures in fallers. Osteoporosis prevalence is likely to increase with Medway's ageing population.

      • Hospital admissions for hip fractures following falls are expected to rise by 29% from the 2010–2012 baseline by 2021 in those aged 50 years and above. For all falls–related admissions in Medway patients aged 50 years and above the expected increase from baseline is 27% by 2021. By far the greatest burden in Medway of hip fracture following falls occurs within the 85+ age group.
      • The highest rates of falls related Medway admissions in 2012 were for non–hip fractures (“other fracture”) and injuries other than fractures (“other injury”). In 2012, Hip fractures accounted for just 11.4% of all falls–related admissions in Medway compared to 52.6% of admissions where no fracture took place. The remaining 36% of falls related admission in 2012 were for non–hip fractures.
      • Directly standardised hospital admission rates for all falls in those aged over 50 years saw a general upward trend from 2007–2011, with a similar trend in admission rates for hip fractures following falls. An unexpected situation can be noted for Medway where admissions for all falls and for hip fractures has declined over the last couple of years following the earlier rise. Although data from subsequent years is required in order to determine whether this decline is an enduring trend, its possible causes are worthy of further investigation.
      • Mean length of stay for hip fracture admissions was 16.1 days (median 12 days) for Medway in 2012: lower than the 2012 national mean of 20.2 days. [5]
      • The total number of admissions coded as “other diagnoses” involving no injury such as Senility, Urinary Tract Infections, Pneumonia etc. saw a striking increase of 51% from 2007 to 2011, followed by a fall of 53% from 2011 to 2012. The cause of this pattern is unclear and needs further investigation.

      Recommendations for commissioning


      • Projected increases in the burden of falls and falls–related injury together with fewer resources available for health and social care mean that falls and falls prevention should be a priority issue for commissioners and providers.
      • A Medway Falls Strategy should be developed and implemented as a framework for consideration of the whole falls care pathway by commissioners.

      • Falls should continue to be included as a topic within the JSNA and the findings should be brought to the attention of the Health and Wellbeing Board.
      • Effective falls prevention schemes can be implemented at little cost with the involvement of professionals working in health, social care and in the community. The majority of falls in Medway occur in the home or in residential care settings, highlighting the need to examine the existing provision of home safety information in the community and the need for a better understanding of falls prevention activities within care settings. All care homes should have falls prevention strategies in place, the objectives of which should include more robust recording and reporting of data on falls.
      • Commissioning of the enhanced falls pathway and falls fast track clinic
      • Service users should have greater involvement in service development and monitoring.
      • Audit of the accuracy/ appropriateness of coding for falls related admissions
      • Further in depth analysis of falls data, including data on A&E attendances and locations of falls in the community, is required in order to achieve a better understanding of the pattern of falls across different groups and different settings in Medway.
      • Detailed mapping of all falls services delivered across all sectors and organisations in Medway, including the voluntary sector, should be undertaken.

      • Falls Prevention should also consider the wider environment, for example, through partnership working with town planners to ensure that the risk of falls to older people is taken into account.


      References

      [1]   World Health Organisation. WHO Global Report on Falls Prevention in Older Age 2007; World Health Organisation. http://www.who.int/ageing/publications/Falls_prevention7March.pdf .
      [2]   National Institute for Health and Care Excellence. The assessment and prevention of falls in older people 2013; http://www.nice.org.uk/Guidance/cg161
      [3]   NHS Confederation. Falls Prevention 2012; NHS Confederation. http://www.nhsconfed.org/Publications/Documents/Falls_prevention_briefing_final_for_website_30_April.pdf .
      [4]   Mary E Tinetti, Christianna S Williams M. Falls, injuries due to falls, and the risk of admission to a nursing home New England Journal of Medicine 1997; 337 (18): 1279-1284.
      [5]   National Hip Fracture Database. National Hip Fracture Database National Report 2012; National Hip Fracture Database. http://www.nhfd.co.uk/003/hipfractureR.nsf/luMenuDefinitions/CA920122A244F2ED802579C900553993/$file/NHFD%20National%20Report%202012.pdf?OpenElement .
    • Who is at risk and why

      The risk of falling increases with age and frailty for a number of reasons. Risk factors for falls include:


      • Balance or mobility problems including those due to degenerative joint disease and motor disorders such as stroke and Parkinson's disease
      • Taking four or more medications, particularly sedating or blood pressure lowering drugs.
      • Certain drugs, e.g., alcohol, psychotropic drugs, benzodiazepines and antidepressants [1]
      • Visual impairment
      • Impaired cognition or depression
      • Postural hypertension
      • Risk factors at home such as poor lighting, steep stairs, loose carpet, slippery/rough floors and obstacles can cause falls for all people but particularly for older people who may already have other risk factors [2]
      • Certain demographic groups, e.g., older populations (aged 85+), females, those from the least advantaged social groups [3] These risk factors become more common with age and there is therefore a high prevalence of falls related injury amongst older people: more than 30% of people aged <65 and 50% of people aged >80 fall each year. Multiple factors, many of which are modifiable, can combine to cause falls. Identifying and modifying risk factors is therefore vital to falls prevention.

      Older people who experience a fall are also more likely to fall again. Figure 1 shows that Medway's hospital admission rates for all falls increased with age in 2012. It should be noted that calendar year, rather than financial year, has been used throughout this needs assessment due to the availability of more current data with this method. A particularly rapid acceleration in the rate occurred from age 70–74 years onwards, with the rate for females aged 85+ reaching almost 12%.

      Figure 1: Falls related hospital admission rate (all falls) in Medway by age and gender, 2012.
      Figure 1: Falls related hospital admission rate (all falls) in Medway by age and gender, 2012 Source: Secondary Uses Service via KMHIS data warehouse and Office for National Statistics.

      Osteoporosis is most common in older white women. After the menopause, osteoporosis prevalence in women increases markedly with age from approximately 2% at 50 years to more than 25% at 80 years. [4] The most common osteoporotic fractures resulting from a fall occur in the hip, spine and wrist. These often result in substantial morbidity and mortality: the risk of death in older people following a hip fracture is approximately 11–23% at six months and 22–29% at a year after injury. [1] In the UK, 1 in 2 women and 1 in 5 men will suffer a fracture after the age of 50. [5]

      Figure 2 shows that the Medway hospital admission rate in 2012 for hip fractures in both men and women increased with age and was by far the highest in those aged 85 years and above.

      Figure 2: Falls related hospital admission rate (all falls) in Medway by age and gender, 2012.
      Figure 2: Falls related hospital admission rate for fractured neck of femur in Medway by age and gender, 2012 Source: Secondary Uses Service via KMHIS data warehouse and Office for National Statistics.

      Falls in older persons are around three times more common in residential care settings than in the community, reflecting a higher incidence of risk factors such as poor mobility, visual impairment and dementia in these settings. [6] Up to 75% of nursing home residents fall annually — twice as high as older people living in the community. An estimated 10–25% of falls in institutional settings result in fracture or injury requiring hospital attention, compared with 5% in the community. [7]


      References

      [1]   Leipzig R, Cumming R, Tinetti M. Drugs and falls in older people: a systematic review and meta-analysis: I. Psychotropic drugs Journal of the American Geriatrics Society 1999; 47 (1): 30-39.
      [2]   Connell B. Role of the environment in falls prevention Clinics in Geriatric Medicine 1996; 12(4): 589-80.
      [3]   Department of Health. National Service Framework for Older People 2001; Department of Health. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/198033/National_Service_Framework_for_Older_People.pdf .
      [4]   National Hip Fracture Database. National Hip Fracture Database National Report 2012; National Hip Fracture Database. http://www.nhfd.co.uk/003/hipfractureR.nsf/luMenuDefinitions/CA920122A244F2ED802579C900553993/$file/NHFD%20National%20Report%202012.pdf?OpenElement .
      [5]   National Osteoporosis Society. Osteoporosis key facts and figures 2006; National Osteoporosis Society. http://www.nos.org.uk/Document.Doc?id=47 .
      [6]   Handoll H. Prevention of falls and fall related injuries in older people in nursing homes and hospitals Injury Prevention 2010; 16: 137-138.
      [7]   Rubenstein LZ, Powers CM, MacLean CH. Quality Indicators for the Management and Prevention of Falls and Mobility Problems in Vulnerable Elders Annals of Internal Medicine 2001; 135: 686-693.
    • Level of need in the population

      Demographics

      Increasing life expectancy and a reduction in fertility is leading to an ageing of England's population. Medway's population is currently younger than the national average but population projections (please see 'Our People and Place') suggest that the number of people 50 years or above will increase from 88,000 in 2013 to 102,000 by 2021 and the number of people over 85 years will grow by 27% to 5,800.

      This expected growth in the older population has important implications for falls prevention strategies, healthcare and social care services. There are differences in the age distributions of Medway's wards. Rainham Central, Hempstead & Wigmore and Rainham North have the largest proportions of older people with one fifth or more of their population aged 65 years and above. 51% of falls amongst Medway residents aged 50 years and above which required hospital admission in 2012 occurred at the patient's home. 9% occurred within a residential institution. Table 1 gives a breakdown of place of occurrence of these falls.

        Percentage
      Home 50.7%
      Residential/nursing institutions 8.9%
      School, other institution and public administrative area 4.4%
      Sports and athletics area 0.4%
      Street and highway 5.9%
      Trade and service area 2.5%
      Industrial and construction area 0.1%
      Farm 0.1%
      Other specified places 1.2%
      Unspecified place 26.0%
      Table 1: Place of occurrence of falls requiring hospital admission, Medway residents aged 50+ (n = 1260), 2012 Source: Secondary Uses Service via KMHIS data warehouse

      Table 1 shows that in over a quarter of cases the place of occurrence is coded as 'unspecified'. Although this proportion has decreased compared to previous years, the reliability of the data is limited.

      Hospital admissions

      Figure 1 shows that the falls admission rate for Medway residents (males and females combined) aged 50 years and above rose by 23% from 2007 to 2011 when a peak of 1488.2 per 100,000 was reached in before falling again from 2011–2012. A similar pattern to that seen in figure 1 applies to admission rates for falls amongst those aged over 65 years. Further surveillance of falls–related admissions will determine whether or not this decline is an enduring trend.

      Figure 1: Directly standardised hospital admission rates, all falls in >50s, 2007--2012, Medway Source: Secondary Uses Service via KMHIS data warehouse and Office for National Statistics .
      Figure 1: Directly standardised hospital admission rates, all falls in >50s, 2007–2012, Medway Source: Secondary Uses Service via KMHIS data warehouse and Office for National Statistics

      In 2012, neck of femur (NOF) fractures accounted for 11.4% of all falls–related admissions in Medway compared to 52.6% of admissions where no fracture took place. Falls–related admissions for hip fractures made up 24.1% of admissions for all fractures following falls in 2012. Figure 2 shows that the highest rates of falls related Medway admissions in 2012 were for non–hip fractures ('other fracture') and injuries other than fractures ('other injury'). Over the period from 2007–2012, admission rates for 'other fractures', 'other injury" and 'other diagnoses' have been consistently higher than for 'neck of femur fracture' and 'other femur fracture'. The admission rates for all primary diagnosis categories apart from 'other fracture' have declined over 2007–2012: the rate for 'other fracture' has seen an increase from 2010–2012 (although not statistically significant). Admission rates for 'other diagnoses' (i.e., diagnoses without injury or fracture) rose steeply from 2008–2011 and then declined sharply.

      Figure 2: Trends in directly age--standardised rates for falls related hospital admissions, Medway residents aged 50+, by primary diagnosis code, 2007--12 Source: Secondary Uses Service via KMHIS data warehouse and Office for National Statistics.
      Figure 2: Trends in directly age–standardised rates for falls related hospital admissions, Medway residents aged 50+, by primary diagnosis code, 2007–12 Source: Secondary Uses Service via KMHIS data warehouse and Office for National Statistics

      Table 2 shows the change in numbers of falls related hospital admissions for each of the five diagnosis categories over the period 2007–2012.

        Fractured neck of femur Other femur fracture Other fracture Other injury Other diagnosis
      2007 120 102 302 420 273
      2008 131 84 304 409 270
      2009 145 85 378 505 383
      2010 168 79 331 461 451
      2011 155 83 373 445 557
      2012 144 69 384 400 263
      Table 2: Numbers of falls related hospital admissions, Medway residents aged 50 years and above, by year of occurrence and primary diagnosis code, 2007–2012 Source: Secondary Uses Service via KMHIS data warehouse.

      Figure 3 shows that the admission rates for hip fractures following falls rose steadily from 2007 to 2010 and then saw an overall decline from 2010–2012 which was most marked amongst females. Further surveillance of falls–related admissions will determine whether or not this decline is an enduring trend.

      Figure 3: Trends in directly age--standardised hospital admission rates for fractured neck of femur following falls, Medway residents aged 50 years and above, by primary diagnosis code, 2007--12 Source: Secondary Uses Service via KMHIS data warehouse and Office for National Statistics.
      Figure 3: Trends in directly age–standardised hospital admission rates for fractured neck of femur following falls, Medway residents aged 50 years and above, by primary diagnosis code, 2007–12 Source: Secondary Uses Service via KMHIS data warehouse and Office for National Statistics

      Admissions for “other diagnoses” (i.e., involving no falls related injury) saw a striking increase of 51% in their total number from 273 in 2007 to 557 in 2011 (an increase in the rate of admissions of 48% from 253.5 to 489.0 per 100,000) followed by a fall of 53% in numbers of admissions from 557 in 2011 to 263 in 2012 (a decrease in the rate of admissions of 53% from 489.0 to 228.9 per 100,000). The pattern of admission rates for “other diagnoses” is shown in figure 7.

      Figure 4: Trends in directly age--standardised hospital admission rates for 'other diagnoses' following falls, Medway residents aged 50 years and above, 2007--12 Source: Secondary Uses Service via KMHIS data warehouse and Office for National Statistics.
      Figure 4: Trends in directly age–standardised hospital admission rates for ‘other diagnoses’ following falls, Medway residents aged 50 years and above, 2007–12 Source: Secondary Uses Service via KMHIS data warehouse and Office for National Statistics

      The International Classification of Diseases (ICD) is used to classify diseases and other health problems recorded on many types of health and vital records including death certificates and health records. The ICD–10 is the 10th revision of the classification and is the version which is currently in use.

      The steep drop from 2011–2012 in admissions for “other diagnoses” represents a fall in actual numbers of these admissions of 294 between 2011 and 2012: admissions coded as senility account for 61% of the total drop in admissions. Table 3 shows the breakdown of the top eight diagnosis codes within the “other diagnosis” category which were most frequently used to classify falls–related hospital admissions in Medway for 2011 and 2012.

        ICD 10 description 2011 2012 % change
      R54 Senility 177 39 -78%
      N39 Other disorders of urinary system 47 27 -43%
      M25 Other joint disorders, not elsewhere classified 42 25 -40%
      J18 Pneumonia, organism unspecified 32 17 -47%
      M54 Dorsalgia 25 11 -56%
      R55 Syncope and collapse 14 7 -50%
      I63 Cerebral infarction 7 7 0%
      J22 Unspecified acute lower respiratory infection 10 6 -40%
      Other Further separate diagnoses 203 124 -39%
      Total 557 263 -53%
      Table 3: Number of falls–related hospital admissions without an injury or fracture recorded in primary diagnosis, 2011 & 2012, Medway residents aged 50 years and above Source: Secondary Uses Service via KMHIS data warehouse.

      Median length of stay for falls–related hospital admissions in people aged over 65 years (all falls) was 7 days (mean 12.1) in 2012. The median length of stay for admissions for hip fractures was 12 days (mean 16.1). Median length of stay was longest for the “other femur fracture category at 17 days (mean 24.5).

      Ambulance callouts

      Data on ambulance callouts was obtained from the South East Coast Ambulance Service (SECAMB). SECAMB classify callouts by problem nature and response using NHS Pathways, a clinical triage system, which replaced the Advanced Medical Priority Dispatch System (AMPDS) triage software in 2011. Callouts to Medway residents classified as either 'fall <12ft' or 'falls–assistance only' have been included in the following analyses. 2,746 emergency calls were made to SECAMB in 2012/13 based on the inclusion criteria above. Of those, 150 were removed as they were either duplicates or call–backs from a clinician. A total of 2,596 incidents were analysed. Figure 5 shows the age and gender distribution for all Medway residents who called for an ambulance following a fall in 2012/13. Patients represented by the bars labelled "unknown” represent those where age and/or sex had not been recorded.

      Figure 5: All SECAMB falls--related callouts, 2012--13, Medway residents by age and sex Source: South East Coast Ambulance Service NHS Foundation Trust, July 2013.
      Figure 5: All SECAMB falls–related callouts, 2012–13, Medway residents by age and sex Source: South East Coast Ambulance Service NHS Foundation Trust, July 2013

      Figure 6 shows that numbers of callouts for falls increased with age of patient (median age of patient 80 years, range 4 months– 105 years). The 80–90 year age group made up a third of all incidents throughout last year. The over 50's group (target audience) accounts for 85% (2,208/2,596) of all SECAMB callouts for falls. The proportion of falls–related callouts for female patients aged 50 years and over (66%) was almost double that of males for 2012/13.

      Increases in falls–related callouts occurred during the winter months of 2012/13 — these monthly differences are in–line with overall SECAMB activity during those periods.
      Of the 2,596 falls–related callouts, 371 (14%) falls had occurred in a public place. The response rate was 95% (2,477/2,596) with 119 incidents being cancelled before the ambulance arrived. The conveyance rate was 39% (962/2,477) with 1,515 patients not being conveyed to hospital. Of those patients who were conveyed to hospital, the final destination for 99% (952/962) was Medway Foundation Trust.

      Falls related mortality

      The falls–related mortality rates provided by the Kent & Medway Public Health Observatory (KMPHO) are based on the underlying cause of death between ICD–10 codes W00 and W19, registered anytime over the five year period from 2008–2012. The Clinical Commissioning Group populations have been sourced from the Exeter database via the Primary Care Information System.
      Deaths following falls across Kent CCGs are presented in figure 6 as pooled data (age standardised mortality rates) for 2008–2012 as the numbers of deaths recorded in each year were small. In total, 55 deaths were recorded in Medway for 2008–2012 for male and female patients aged 65 years and above. The reliability of the rates presented here may be affected by the small numbers of deaths due to falls.

      Figure 6: Mortality rates from falls, Kent & Medway CCGs, 2008--2012, males and females aged over 65 years (D,G and S = Dartford, Gravesham and Swanley) Source: Public Health Mortality File, PCIS populations.
      Figure 6: Mortality rates from falls, Kent & Medway CCGs, 2008–2012, males and females aged over 65 years (D,G and S = Dartford, Gravesham and Swanley) Source: Public Health Mortality File, PCIS populations

      For males aged 65 years and above, the age standardised mortality rate for Dartford and Gravesham CCG is significantly lower than all other Kent CCGs for 2008–2012. For all other Kent CCGs, including Medway, the falls–related mortality rates are not significantly different, and although Medway CCG's rate appears to be higher than Kent & Medway as a whole, the difference is not statistically significant. For females aged 65 years and above, the age standardised mortality rate for Medway CCG for 2008–2012 is not significantly different to the other Kent CCGs and is similar to the overall rate for Kent & Medway as a whole.

    • Current services in relation to need

      Medway Foundation Trust Falls Emergency Department Pilot

      The Falls Emergency Department pilot commenced following identification of the need for a clear pathway for fallers presenting at Medway Foundation Trust (MFT) Emergency Department (ED). The pilot initially ran for one and a half months from January 2012 and then resumed for 6 months from October 2012 following agreement from the Urgent Care Programme Management Group and MFT.
      The objectives of the pilot were to:
      • Identify the numbers of fallers presenting to ED
      • Establish the percentage of patients already known to the MCH Community Falls Service
      • Understand the impact of the enhanced falls assessment process and new fast track clinic

      The project scope comprised:
      • Mapping the desired ED Falls pathway
      • Developing assessment criteria and tools for use in ED to identify fallers for triage
      • Triage process in place to refer patients to most appropriate service — GP, MCH Community Falls Service or MFT Fast Track Clinic
      • Undertaking of comprehensive medical review at the fast track clinic on appropriate patients to reduce the risk of recurrent falling and prevent further ED attendance and emergency admissions. Once seen within the fast track clinic, a patient may be referred by the Consultant Geriatrician to Medway's Community Falls Service if required.

      Presentations were given to GPs during GP Protected Learning Times, clarifying the GP pathway and assessment tool for fallers. Prompts are currently being considered for GP clinical IT systems to help identify existing and potential new fallers in primary care, who can then be assessed using the Falls Assessment Tool and managed appropriately thereby reducing further ED attendances and non–elective admissions.

      Evaluation of the pilot demonstrated that the proposed pathway change yields significant improvements in patient care, providing rapid access for complex patients to be reviewed and prevents avoidable re–attendance to ED. The Falls ED pilot review has been presented to the Urgent Care Programme Management Group (UCPMG) and the Medway Clinical Commissioning Group Commissioning Committee who supported a permanent pathway change.

      Fracture Liaison Service (Medway Foundation Trust)

      A Fracture Liaison Service (FLS) is a multidisciplinary service which ensures that every person over the age of 50 who suffers a fragility fracture is identified, recorded and given an assessment for their future fracture risk. The fracture liaison nurse then helps to ensure that patients are prescribed bone protecting treatments where appropriate, reducing their risk of suffering further fractures later on in life. A comprehensive FLS will also ensure that high standards of post–fracture care are delivered, and that the complex range of health and social care services that patients need following a fragility fracture, including falls services, are co–ordinated.

      Medway Foundation Trust provides a comprehensive FLS led by a dedicated Nurse Specialist, working under the guidance of a Specialist Consultant. The service aims to identify all patients over the age of 50 years presenting with a new fragility fracture and to offer the opportunity to have Bone Density Measurement (DXA) if considered at risk.

      Fracture clinics, trauma wards, Occupational Health and Physiotherapy departments and the Emergency Department are all targeted for case finding. Outpatients are invited by letter to attend for DXA and Bone Health assessment. In–patients are visited by one of the Osteoporosis team, assessed and invited for DXA and Bone Health assessment. An individual management plan is then produced for implementation in primary care. In all cases, the GP is alerted that the patient has had a recent fracture.

      Medway Community Healthcare Community Falls Service

      The MCH Falls Prevention Service is provided by a multiprofessional team which can take referrals from any health professional as well as self–referrals.

      On initial referral the patient is contacted by Falls Multi Professional team member, who could be either a Nurse, Occupational Therapist or, Physiotherapist. Each patient will then be triaged and assessed according to clinical need and a personalised treatment plan will be agreed with the patient. Patients can be seen in either their own home environment or in a clinical setting according to their individual circumstances.

      Complex cases are referred to a secondary care geriatrics consultant.

      Rapid Response

      The Rapid Response Team is jointly funded by Medway Community Healthcare and Medway Council and consists of two teams: 1. Admission Avoidance (hospital– based) team 2. Community based team

      The teams assists patients who have fallen or are at risk of falls and help to assemble a care package that may involve integrated working with other health and social care professionals. The care package is tailored to the individual needs of each patient, and can include:
      • Social care arranged through a care manager
      • Nursing care
      • Rehabilitation from occupational and physiotherapists
      • Group exercise programme

      The Rapid Response team can be involved in patients' care for up to six weeks, in the patient's own home or place of residence. The Rapid Response service does not accept patients who have been diagnosed with dementia or who are confused– Medway Community Healthcare provides a separate dementia support service for people with dementia who live at home and their carers.

      Exercise programmes

      Medway Community Healthcare Falls Service

      Following an initial assessment by the Medway Community Healthcare Falls Team, appropriate patients may be considered to commence a tailored programme of exercise classes which aim to build strength, balance and confidence. The course consists of 12 sessions over a 12 week period, with the opportunity to attend a further class if deemed to be required following assessment or progressed to the next level of programme if appropriate. For house bound patients a tailored programme based upon the same principles of the taught group sessions will be provided in the patient's own home.


      • Chair Based Exercise
      • Otago
      • Postural Stability

      Exercise programmes are currently held at various locations across Medway, including:


      • Lordswood Healthy Living Centre
      • Rochester Healthy Living Centre
      • St. Bartholomew's Hospital, Rochester
      • Twydall church hall

      Medway Council Health Improvement Team Exercise Referral Scheme

      The Health Improvement Team within Medway Council's Public Health Directorate offer an exercise referral programme to which residents of Medway with a wide rage of medical conditions can be referred by their GP, practice nurse or other health professionals (such as the MCH Falls Team). People living with a long–term health condition are eligible for the programme, which is delivered across Medway Council's leisure centres. A risk classification tool is used to determine eligibility for the programme, with individuals classified as medium or high risk being deemed suitable. Low risk clients are referred directly to a host of community activity sessions, including walking and cycling groups, exercise, sport and dance classes. The programme consists of a 12–week course of physical activity sessions. There is a small charge for each activity session, with participants offered the choice of gym or class–based sessions. Since the service was launched in 2010, 29 referrals have been received with the primary referral reason being stated as 'falls prevention', with 13 referrals coming directly from MCH's Falls Prevention Team, 7 referrals from Primary Care and the remainder from social care, physiotherapy and other public health colleagues. A large proportion of individuals referred to the programme are older people and often state falls prevention as a key reason for attending. Balance training is therefore built in, where possible, into the gym and class based programmes.

    • Projected service use

      The projected number of falls admissions has been calculated by applying the admission rates (by five-year age band and gender) observed over 2010– 2012 to ONS population projections for 2013–2021. This methodology assumes that admission rates in the baseline period will remain constant in future years.

        Admissions for fractured neck of femur Admissions for all falls
      2007 120 1,217
      2008 131 1,198
      2009 145 1,496
      2010 168 1,490
      2011 155 1,613
      2012 144 1,260
      2013 163 1,519
      2014 165 1,544
      2015 169 1,579
      2016 173 1,614
      2017 179 1,662
      2018 185 1,708
      2019 190 1,755
      2020 195 1,801
      2021 201 1,852
      Table 1: Projected numbers of hospital admissions for fractured neck of femur resulting from falls and for all falls, Medway patients aged 50 years and above Source: Medway Public Health Intelligence Team, April 2013.

      Table 1 shows that the overall percentage change from the 2010–2012 baseline in projected number of hospital admissions for hip fractures resulting from falls in Medway patients aged 50 years and above is 29% by 2021. For all falls related admissions in Medway patients aged 50 years and above the percentage change from baseline is 27%. Years beyond 2012 are projected numbers.

    • Evidence of what works

      Department of Health (2009). Falls and fractures. Effective interventions in health and social care (Accessed 5 May 2013)

      National Institute for Health and Care Excellence (2013). The assessment and prevention of falls in older people (Accessed 15 June 2013)

      Gillespie LD et al. Interventions for preventing falls in older people living in the community. Cochrane Database of Systematic Reviews 2012, Issue 9 (Accessed 15 June 2013)

      Cameron ID et al. Interventions for preventing falls in older people in care facilities and hospitals. Cochrane Database of Systematic Reviews 2012, Issue 12 (Accessed 15 June 2013)

    • User views

      Community Falls Service (Medway Community Healthcare)

      A survey was carried out in 2012 by Medway Community Healthcare with the aim of assessing the patient experience of the Community Falls Service. The survey response rate was 33%. The overall rating of the service was 96%. 95% of service users reported that they had been treated fairly by the service. The friends and family test is a national validated patient experience outcome measure which enables local and national comparisons to be made across services. The test produces a percentage score between -100 to +100. Medway's Community Falls Service scored 60% (“excellent”) for quarter 2 of 2012. The overall percentage positive experience score for 2011/12 and 2012/13 was over 96%. The following comments were made by service users completing the survey and have led to Action Plan recommendations:
      • Inadequate information given to patients regarding the service before their appointment
      • Patients are not offered a copy of their treatment plan
      • Patients are finding it difficult to contact the service

      Plans are now in place to address the above comments.

      Exercise Referral Service (Medway Council, Public Health Directorate)

      All patients using the service, including falls patients, are asked to complete a patient experience survey on completion or discharge from the service. A general review of survey responses is undertaken quarterly with a detailed review taking place annually. Key performance indicators used by the service include the following:
      • Adherence (% of patients attend the first session who complete the course)
      • % of patients reporting an increase in their physical activity level on completion/ discharge compared with baseline
      • Change in self-reported wellbeing score on completion of course compared with baseline score

      For 2012/13:
      • Adherence was 50%
      • 79% of people were more physically active on discharge from the course compared with baseline
      • 62% patients had an increase in their wellbeing score on discharge from the course compared with baseline.

      Recommendations from service users for improvement in 2012 focused mainly on issues relating to the venues used for the exercise classes. These recommendations have been actioned where possible by the Exercise Referral Team.

    • Recommendations


      • Projected increases in the burden of falls and falls-related injury together with fewer resources available for health and social care mean that falls and falls prevention should be a priority issue for commissioners and providers.
      • A Medway Falls Strategy should be developed and implemented as a framework for consideration of the whole falls care pathway by commissioners.

      • Falls should continue to be included as a topic within the JSNA and the findings should be brought to the attention of the Health and Wellbeing Board.
      • Effective falls prevention schemes can be implemented at little cost with the involvement of professionals working in health, social care and in the community. The majority of falls in Medway occur in the home or in residential care settings, highlighting the need to examine the existing provision of home safety information in the community and the need for a better understanding of falls prevention activities within care settings. All care homes should have falls prevention strategies in place, the objectives of which should include more robust recording and reporting of data on falls.
      • Commissioning of the enhanced falls pathway and falls fast track clinic
      • Service users should have greater involvement in service development and monitoring.
      • Audit of the accuracy/ appropriateness of coding for falls related admissions
      • Further in depth analysis of falls data, including data on A&E attendances and locations of falls in the community, is required in order to achieve a better understanding of the pattern of falls across different groups and different settings in Medway.
      • Detailed mapping of all falls services delivered across all sectors and organisations in Medway, including the voluntary sector, should be undertaken.

      • Falls Prevention should also consider the wider environment, for example, through partnership working with town planners to ensure that the risk of falls to older people is taken into account.

  • Learning disabilities
    • Summary

      The Learning Disabilities Observatory describes learning disabilities as “significant and widespread difficulty in learning and understanding that has been present since childhood.” The term learning disabilities does not include specific learning disabilities such as dyslexia, specific social/communication difficulties such as Asperger's syndrome or significant and widespread difficulty in learning and understanding that are acquired in later life.

    • Who's at risk and why?

      There is much published evidence relating to the poorer health and health outcomes faced by those with LD.

      Within information provided to support the national Joint Health and Social Care Self Assessment Framework (as published by the Public Health Observatory) it is referenced that people with learning disabilities are 58 times more likely to die before the age of 50 than the general population (Hollins et al 1999). Continuing to explain some of the history behind this the Observatory highlights that people with learning disabilities are disadvantaged by:

      1. Greater risk of exposure to social determinants of poorer health such as poverty, poor housing, unemployment and social disconnectedness.

      2. Increased risk of health problems associated with specific genetic, biological and environmental causes of learning disabilities.

      3. Communication difficulties and reduced health literacy.

      4. Personal health risks and behaviours such as poor diet and lack of exercise.

      5. Deficiencies relating to access to healthcare provision.

    • The level of need in the population

      Work is currently being undertaken in Medway to look at learning disabilities in depth. The new Joint Health and Social Care Self-Assessment Framework (JHSCSAF) replaces the Valuing People Now Self-Assessment and the Learning Disability Health Self-Assessment. All Local Authority areas are required to complete the self-assessment working with their local partners including Clinical Commissioning Groups. Please follow the link to the Joint Health and Social Care Self-Assessment Framework for more information.

      There is good evidence that, across the country, patients with learning disabilities have more health problems and die at a younger age than the rest of the population.

      Since April 2008 GP practices have been supported to identify Learning Disability patients aged 18 or over with the most complex needs and to offer them a health check. The rationale is to target people with the most complex needs and, therefore, at highest risk from undetected conditions (usually people with moderate to severe learning disabilities) and to develop a health action plan for them. From the prevalence figures available, it is estimated that approximately 240,000 patients fall into this category across the country.

      In January 2014 there were 901 patients aged 18 years and over with a learning disability in Medway of whom 585 were identified as benefiting from eligibility for an annual healthcheck. In 2012/13 43% of eligible learning disability patients received a healthcheck. A range of actions are in place to increase uptake in 2013/14 including automatic prompts when a patient's record is opened at their GP practice and an easy read invite letter is under development.

      People with learning disability have been identified as attending national screening programmes (bowel/breast/cervical/abdominal aortic aneurysm/diabetic retinopathy) less often where compared to the general population. A Kent and Medway policy is in place to support equitable access, reasonable adjustment and good access to cervical screening services. This good practice should be duplicated for other screening programmes also.

      For more information on national screening programmes, click here

    • Current services in relation to need

      Primary service provision for people who have a learning disability is the same provision as for the general Medway population, but with the expectation that providers make reasonable adjustment to the way that service is provided to enable equal access. Two examples of reasonable adjustments are allowing longer appointment times for patients with learning disability and providing information in “Easy Read”. This approach defines much of the focus with regard to learning disabilities to ensure that those with learning disability are supported to access care services and that they are not disadvantaged as a result of their learning disability.

      In support of the above Medway Community Healthcare adult learning disability (health) team supports access to health care for people who have a learning disability and a Medway GP, and who can't manage adequate access to health care by themselves or through their carers. The team works closely with mental health learning disability professionals locally, and with social services and hospital teams. The teams support includes expert assessment of needs, advice and therapy training, and practical support too.

      A Learning Disability Liaison Nurse (LDLN) has been in post at Medway NHS Foundation Trust since April 2010. The LDLN's work is focussed in areas where care of patients with learning disabilities is high. Medway NHS Foundation Trust actively identify learning disability patients admitted for care enabling the LDLN to focus support where it will be of greatest benefit. The LDLN also delivers training to improve awareness of learning disabilities amongst all ward staff.

      A Partnership Commissioning Team has been established between Medway Council and Medway Clinical Commissioning Group which works across health and social care in order that a whole systems approach to commissioning can be adopted to deliver improved outomes, risk management and effective investment to meet local need. The Partnership Commissioning Team leads on learning disability services.

      Medway Council provides a free bus pass scheme for those with specified disabilites to travel off-peak, not just within the Council area, but around England. The Council also provides home to school transport which supports those wanting to remain in education.

    • Projected service use and outcomes in 3--5 years and 5--10 years

      The Learning Disabilities Observatory highlights the expectation that over the next 20 years we will see an increase in the number of people with learning disabilities and that by 2030 the number of people aged 70 and over with learning disabilities will more than double. This is expected to be accompanied by an increase in the complexity of needs as young people with learning disabilities with extremely complex needs are now living well into adulthood.

    • Evidence of what works

      The Public Health Observatory has published a number of reports investigating the health inequalities faced by people with learning disability that can be accessed here.

      Key recommendations from these reports are to:
      • Reduce exposure to health harms for people with learning disabilities
      • Increase the uptake of annual health checks
      • Ensure there is equitable access to screening (eg cervical)
      • Support carers in understanding the health needs of people with learning disabilities
      • Make reasonable adjustments to health services
      • Address avoidable death inequalities

    • User Views

      During 2013, Medway Clinical Commissioning Group (MCCG) held three engagement events to gain the views of those with learning disabilities/parents or carers of those with learning disability. The events gave MCCG an opportunity to explain what they do and to seek views of the attendants regarding what is working well and what needs to be improved in Medway. The key messages from attendants were:
      • People were keen to understand more regarding mental capacity, decision making, equality and reasonable adjustments
      • It was felt that greater use should be made of easy to read information/letters
      • The importance of making reasonable adjustments was flagged with regard to longer appointments, time to talk, reminders/texts
      • Improve the availability of healthcare checks
      • Communication about learning disabilities can be improved across all providers

      Engagement with Medway LD representatives identified the desire for and the potential to increase the use of easy read appointment letters.

      In the 2012/13 Adult Social Care Survey, 48% of participants with learning disabilities said they had adequate control over their daily lives and 52% said they had as much control as they would like. Nobody said they were dissatisfied overall. In response to the question on feelings of safety, 83% said they felt as safe as they would like to feel, 15% said they felt generally safe and 2% said they felt less than adequately safe. 100% agreed that Adult Social Care services help them to feel safe though.

      In the 2012/13 Carer's survey, of those who care for someone with a learning disability:
      • 64% were extremely, very or quite satisfied with the support or services they receive. 12% were fairly, very or extremely dissatisfied.
      • The ratio of carers responding positively or negatively to the ease of finding information was exactly 50:50, indicting an area for improvement.

    • Unmet needs and service gaps

      Medway participates in the learning disability self assessment framework that enables health and social care organisations to review how well learning disability services reflect best practice recommendations. Medway's 2013 Self Assessment Review identified key areas as the focus for change in 2014, namely:


      • Developing Clinical Commissioning Group capture of demographic/needs information.


      • Ensuring that GPs notify other healthcare providers of a a patient's learning disability status when referring them. This is key in enabling receiving healthcare providers to make reasonable adjustments in advance of patients attending for care.


      • Support increased uptake of health checks and associated health action plans to improve the way that GPs pro–actively manage patients health needs to try and avoid medical problems from developing and/or to offer earliest intervention to prevent medical conditions from worsening.


      • Reduce inequalities in access to national screening programmes between those with a learning disability and those without.

    • Recommendations


      • Consider the recommendations from 'Health Inequalities and People with Learning Disabilities in the UK: 2010' and the views of the MCCG engagement, combined with the findings of the JHSCSAF.


      • Address the unmet needs detailed in the Unmet Needs and Service Gaps section.

    • Further needs assessments

      Intend to continue participating in the annual self–assessment framework.

  • Domestic Abuse
    • Summary

      Domestic abuse is defined by the Home Office as any incident or pattern of incidents of controlling, coercive or threatening behaviour, violence or abuse between those aged 16 years old or over who are or have been intimate partners or family members regardless of gender or sexuality. This can encompass but is not limited to the following types of abuse:
      • psychological
      • physical
      • sexual
      • financial
      • emotional

      The definition from the Home Office includes so called 'honour' based violence, female genital mutilation (FGM) and forced marriage. It does not confine victims to gender or a particular ethnic group.

      More than 1 in 4 women and around 1 in 6 men have experienced domestic abuse since the age of 16 [1]. Women are more likely than men to experience longer periods of partner abuse, repeat victimisation and injury or emotional effects as a result of the abuse [1]. National research has found that nearly 1 in 4 young people witnessed at least one type of domestic violence during childhood [2].

      Under-reporting makes it in difficult to gain a complete picture of the extent of domestic abuse. The most comprehensive national data comes from dedicated sections of the British Crime Survey. The 2012-13 survey estimated that nationally there are 1.2 million female victims of domestic abuse and 700,000 male victims [3].

      NICE guidance on domestic abuse in relation to how health services, social care and the organisations they work with can respond effectively was published in February 2014 [4].

      The Kent and Medway Domestic Abuse Strategy (2013-2016) has been developed and the key objectives are listed in Table 1. A Kent and Medway domestic abuse strategic group exists and oversees the implementation of the strategy. The strategy group is a multi-agency partnership that has the aims of reducing domestic abuse and changing attitudes by increasing knowledge and understanding of the impact of domestic abuse across communities and agencies highlighting the fact that it is everyone's responsibility to tackle domestic abuse whilst emphasising the effectiveness of early identification and intervention.

        Explanation
      Preventing abuse To prevent domestic abuse from happening in the first place, by challenging the attitudes and behaviours which foster it and intervening early to prevent it
      Provision of services Provide adequate levels of support when domestic abuse occurs
      Justice outcomes and risk reduction Take action to reduce the risk to domestic abuse victims and ensure that perpetrators are brought to justice
      Partnership working Work in partnership to obtain the best outcomes for those affected by domestic abuse and their families
      Table 1: Key objectives of Kent and Medway Domestic Abuse Strategy

      Risk assessment is based on structured professional judgement. It structures and informs decisions that are already being made. It is only a guide/checklist and should not be seen as a scientific predictive solution. Its completion is intended to assist professionals in the decision making process on appropriate levels of intervention for victims of domestic violence. The Domestic Abuse, Stalking and Harassment and Honour Based Violence Risk Identification, Assessment and Management Model (DASH) was established in 2009 and allows relevant agencies to use a common checklist for identifying and assessing risk, which will save lives. The tool allows different levels of risk to be identified. These include standard, medium and high; High Risk - There is imminent risk of serious harm. The potential event is more likely than not to happen imminently and the impact could be serious. There may be need for immediate intervention. It may be necessary for agencies to notify the Police and/or Children and Young People's Services immediately, without the consent of the victim. Where any agency assesses risk as 'High' an immediate referral to MARAC is normally required, with or without consent.

      Medium Risk - There are identifiable features of risk or serious harm. This level of risk should be referred to the local specialist domestic violence and abuse 'Outreach' services with the consent of the individual.

      Standard Risk - While risk indicators may be present, it is deemed neither imminent, nor serious. Action should involve advice stating that nobody needs to live with domestic violence and abuse and that there is support out there.

      Key issues and gaps


      • Greater awareness of the training available to professionals from different agencies across Medway. A needs analysis and mapping should be undertaken.
      • Ensure frontline staff in services are trained to recognise the indicators of domestic violence and abuse and can ask relevant questions to help people disclose their past or current experiences of such violence or abuse.
      • Perpetrator programmes need to be in place in Medway.
      • Develop or adapt clear protocols and methods for sharing information, both within and between agencies, about people at risk of, experiencing, or perpetrating domestic violence and abuse.
      • Help people who may find domestic violence and abuse services inaccessible or difficult to use. This includes: people from black and minority ethnic groups or with disabilities, older people, transgender people and lesbian, gay or bisexual people. It also includes people with no recourse to public funds.
      • Improve the level of support to victims of domestic abuse. This should include ensuring that multiple needs are also taken into account (ie mental health, substance misuse, parental/child disabilities)
      • The need to ensure that learning from domestic homicide reviews is disseminated to front line practitioners.

      Recommendations for commissioning


      • Perpetrator programmes need to be prioritised in Medway
      • Ensure that the needs of children affected by domestic violence perpetrated by parents as well as within their own relationships are identified and met.
      • Require A and E staff to be trained in understanding of issues relating to domestic violence and to be able to signpost callers to the relevant services
      • An integrated pathway should be developed for identifying, referring (either externally or internally) and providing interventions to support people who experience domestic violence and abuse, and to manage those who perpetrate it. The pathway should include children who may be affected, people who misuse alcohol or drugs, people who have mental health problems and the perpetrators of, the violence and abuse should be kept separate from each other when receiving support


      References

      [1]   Home Office. Home Office Statistical Bulletin: Homicide, Firearm Offences & Intimate Violence 2008/09 2010; Home Office. http://webarchive.nationalarchives.gov.uk/20110218135832/http:/rds.homeoffice.gov.uk/rds/pdfs10/hosb0110.pdf .
      [2]   Radford L, Corral S, Bradley C, et al. The Maltreatment and Victimisation of Children in the UK: NSPCC Report on a national survey of young peoples', young adults and caregivers' experiences 2010; NSPCC. http://www.nspcc.org.uk/inform/research/findings/child_abuse_neglect_research_PDF_wdf84181.pdf .
      [3]   Office for National Statistics. Focus on: Violent Crime and Sexual Offences, 2012/13 -- Chapter 4: Intimate Personal Violence and Partner Abuse 2014; Office for National Statistics. http://www.ons.gov.uk/ons/dcp171776_352362.pdf .
      [4]   National Institute of Health and Clinical Excellence. Domestic violence and abuse: how health services, social care and the organisations they work with can respond effectively 2014; National Institute of Health and Clinical Excellence. http://www.nice.org.uk/guidance/PH50 .
    • Who's at risk and why

      Gender

      Women are much more likely than men to experience domestic abuse. The 2012-13 Crime Survey for England and Wales estimated that nationally there are 1.2 million female victims of domestic abuse [1]. Nationally, women are much more likely to be high-risk victims, indicated by the fact that they account for 96% of all Multi-Agency Risk Assessment Conference (MARAC) referrals (HMIC 2014). Women victims of partner abuse were more likely to have been abused more than once in the last year by their partner (30%) than to have only been abused once (19%). For men there was no statistically significant difference between being abused once or more than once (22% and 27%). The level of repeat victimisation is not statistically different between men and women

      The 2012-13 Crime Survey for England and Wales estimates that there are nationally 700,000 male victims of domestic abuse [1]. Nationally, the most prevalent age group for male victims is 16-24 year olds, with 16-19 year olds at greatest risk [1].

      Pregnant women can be particularly vulnerable to domestic abuse. McWilliams and McKiernan (1993)[2] found that 30% of domestic violence cases start during pregnancy and mothers who suffer domestic abuse during pregnancy are at an increased risk of having low birth weight infants, miscarriage or stillbirth, and are more likely to have abortions.

      Age

      Younger women — Women aged between 16 and 19 and between 20 and 24 were more likely to be victims of any domestic abuse (11.3% and 12.5% of the respective population) compared with those aged between 45 and 54 and between 55 and 59 (4.7% and 2.7% respectively)[1].

      Children and young people — Domestic abuse is a child protection issue and children can experience abuse both directly and indirectly. The Home Office estimate that three quarters of a million children witness domestic abuse every year and that three quarters of children living with a child protection plan live in households where domestic violence occurs[3]. Domestic abuse can have an impact upon a child's emotional, behavioural and cognitive development. Its effects can include anxiety, fear, withdrawal, highly sexualised and aggressive behaviour, reduced educational attainment, failure to acquire social competence, anti-social behaviour and also in some cases the use of substances

      Older people –– Older people may become more vulnerable due to a range of factors that include poor quality long-term relationships, a carer's inability to provide the level of care required; and a carer with mental or physical health problems who feels under stress within the caring relationship. Elder abuse can present in several different forms including physical abuse, sexual abuse, emotional abuse, financial exploitation and neglect.

      Lesbian, Gay, Bisexual and Transgender (LGBT)

      Lesbian and bisexual women experience domestic violence and abuse at a similar rate to women in general (1 in 4), although a third of this is associated with male perpetrators[4]. Compared with 17% of men in general, 49% of gay and bisexual men have experienced at least one incident of domestic violence and abuse since the age of 16. This includes domestic violence and abuse within same-sex relationships[5].

      Ethnicity

      National data from the 2012-13 Crime Survey for England and Wales highlights that there is no significant difference in the risk of domestic abuse by ethnicity[1]. However, women from ethnic minorities may have greater difficulties in accessing services due to language, inter-generational issues, and cultural differences. It is difficult to estimate the prevalence of so-called 'honour'-based violence and forced marriage, but we do know that the incidences of both are under-reported. Both can occur in Christian, Jewish, Sikh, Hindu, Muslim and other communities. They are probably more common in some groups, for example, some Pakistani, Kurdish, and Gypsy and Traveller communities, reflecting a more oppressive patriarchal ideology[6][7].

      Socio-economic Status

      Domestic abuse occurs across society in all social classes. However, reported domestic abuse is more closely associated with those in the more deprived communities. Domestic violence can also lead to poverty as it can create instability, difficulties in maintaining employment and increases in ill health.

      Disability

      National research shows that women with a disability are twice as likely to experience abuse as women living without a disability. Issues facing disabled women can make it harder for them to access support. They may be more physically vulnerable and socially isolated than other women relying heavily on the abuser for basic care needs and access to the wider community[8].

      Substance misuse

      A UK study showed that 51% of respondents from domestic violence agencies claimed that either themselves or their partners had used drugs, alcohol and/or prescribed medication in problematic ways in the last five years[9]. A number of studies have found that the perpetrators use of alcohol, particularly heavy drinking, was likely to result in more serious injury to their partners than if they had been sober[10]. Gilchrist et al, 2003[11] found that from 336 convicted offenders of domestic violence, found that alcohol was a feature in 62% of offences and 48% of offenders were alcohol dependent.


      References

      [1]   Office for National Statistics. Focus on: Violent Crime and Sexual Offences, 2012/13 -- Chapter 4: Intimate Personal Violence and Partner Abuse 2014; Office for National Statistics. http://www.ons.gov.uk/ons/dcp171776_352362.pdf .
      [2]   McWilliams M, McKiernan J. Bringing it out into the open 1993; Belfast: HMSO.
      [3]   Department of Health. Women Health into the Mainstream 2002;
      [4]   Hunt R, Fish J. Prescription for Change, Lesbian and bisexual women's health check 2008 2008; Stonewall.
      [5]   Stonewall. Gay and Bisexual Men's Health Survey 2012; Stonewall. http://www.stonewall.org.uk/documents/stonewall_gay_mens_health_final_1.pdf .
      [6]   Home Affairs Select Committee. Domestic Violence, Forced Marriage and ''Honour''-Based Violence Sixth Report of Session 2007--08 2008; Home Affairs Select Committee. http://www.publications.parliament.uk/pa/cm200708/cmselect/cmhaff/263/263i.pdf .
      [7]   Brandon J, Hafez S. Crimes of the Community: Honour Based Violence in the UK 2008; Centre for Social Cohesion; London.
      [8]   Hague G, Thiara R, Magowan P, et al. Making the Links: Disabled Women and Domestic Violence 2008;
      [9]   Humphreys C, Thiara R, Regan . Domestic Violence and Substance Misuse, Overlapping Issues in Separate Services 2005; Greater London Authority and the Home Office.
      [10]   Brecklin L. The role of perpetrator alcohol use in the injury outcomes of intimate assaults Journal of Family Violence 2002; 17(3): 185-196.
      [11]   Gilchrist E, Johnson R, Takriti Rea. Domestic violence offenders: characteristics and offending related needs 2003; Home Office.
    • Level of need in the population

      The Violence against Women and Girls 'Ready Reckoner'[1] estimates that out of a population of 265,000 in Medway the numbers of women likely to have been affected in the past year are shown in table 1.

        Estimated number Margin of error
      Women and girls aged 16-59 have been a victim of domestic abuse 8,613 1,728
      Women and girls aged 16-59 have been a victim of sexual assault 4,373 1,390
      Women and girls aged 16-59 have been a victim of stalking 10,679 2,126
      Table 1: Estimated domestic abuse numbers for women aged 16-59 in Medway during the previous year

      These estimates are based on population size and regional data from the British Crime Survey. The estimates are necessary because of the relatively high proportion of domestic abuse that is not reported. The estimates are only for women, but national data suggests that around one third of victims are male. Using the data from table 1, we could estimate that there were around 4,300 male victims in the past year in Medway.

        Qtr 3 2012/13 Qtr 4 2012/13 Qtr 1 2013/14 Qtr 2 2013/14 Qtr 3 2013/14
      Number of DA incidents in Medway 1123 1135 1119 1464 1412
      % Female victims 75.6% 77.8% 78.7% 77.0% 74.3%
      % Male Victims 24.4% 22.1% 21.3% 23.0% 25.7%
      Number of repeat victims (victim more than once in preceding 12 months) 239 196 351 399 289
      % of repeat victims of DA in preceding 12 months 21.4% 17.3% 31.4% 27.3%
      Number of cases seen at MARAC 67 72 82 71 83
      % of repeat victims seen at MARAC 24% 26% 23% 27% 24%
      Number of clients seen at One Stop Shop 37 37 45 52 76
      Table 2: Medway Domestic Abuse Service Data

      The data in Table 2 shows that generally around three quarters of victims using domestic abuse services are female. The proportion of repeat victims in the preceding 12 months varies in different quarters and ranges between 17.3%-31.4%. The overall percentage of repeat incidents is just below 50%. The number of cases seen at MARAC ranged from between 67-83 pre quarter (roughly around one quarter of cases).

      For quarters 1-3 for 2013/14, there were 234 victims of domestic abuse referred to Independent Domestic Violence Advisors (IDVAs) in Medway. 87% of all Multi Agency Risk Assessment Conferencing (MARAC) cases have had an offer of support. They have engaged 84% of all referrals which is higher than the benchmark set by Coordinated Action Against Domestic Abuse (CAADA). 86% of clients were contacted within 48 hours.


      • Kent Police recorded 1,043 harassment offences, of these 558 were domestic abuse related. This is 53% of all harassment offences recorded for the 12 months to the end of August 2013.


      • For every 100 domestic abuse crimes recorded, there were 89 arrests in Kent. Compared to 37 other forces, Kent ranked as having the 6th highest rate.


      • Kent and Medway recorded 9,010 domestic crimes between August 2012 and August 2013.


      References

      [1]   Home Office. Violence Against Women and Girls Ready Reckoner 2009;
    • Current service in relation to need

      Multi Agency Risk Assessment Conferencing (MARAC)

      The role of the MARAC is to facilitate, monitor and evaluate effective information sharing to enable appropriate actions to be taken to increase public safety. It combines up to date risk information with a comprehensive assessment of the victim's needs and links those directly to the provision of services for all those involved in a case: victim, children and perpetrator. The victim does not attend the meeting, nor does the perpetrator or the crown prosecution service. The victim will be represented by the IDVA.

      The Medway MARAC is supported by multi agency partners across Medway including Kent Police, Children's Social Care, Kent Probation, Adult Social Care, Mental Health, Housing and both statutory and voluntary partners. They provide joint multi agency, safety planning for victims assessed as being high risk.

      The MARAC receives multi agency referrals, this fluctuates during the year but on average Kent Police referrals account for 65.5% of them. The repeat victimisation rate is currently 26%, which is below the benchmark set by CAADA of 28%. The MARAC is at capacity, discussing on average 87 cases per quarter for 2013.

      The MARAC coordinator is currently funded by police. Medway CSP along with other partners across the county have provided additional funds to support the MARAC coordinators over the course of 2014/15.

      In March 2013 a multi-agency lean event for County MARACs was held, this was to ensure sustainability and funding options to secure the MARACs for the future, as all the projections show that we will continue to increase MARAC numbers by 10% a year for the next year or two at least. A business case is being developed, this should be available by the end of 2014.

      Independent Domestic Violence Advisors (IDVAs).

      In April 2013 the Kent and Medway Domestic Abuse Strategic Group's partners commissioned the Kent Domestic Abuse Consortium (KDAC) to provide County wide Independent Domestic Violence Adviser (IDVA) services. This was to offer a consistent advocacy service to victims of domestic abuse, assessed as being at high risk of serious harm or homicide. In Medway, as part of KDAC, Kent Domestic Abuse Support and Help (KDASH) initially operated this contract and were then merged with North Kent Women's Aid (NKWA). The IDVAs support victims of domestic abuse through the MARAC (Multi Agency Risk Assessment Conference) process as the independent voice of the victim and provide support through the Specialist Domestic Violence Court (SDVC), One Stop Shops (OSS) providing risk assessments, individual safety support plans (ISSP), multi-agency working and developing action plans for both the victim and children. A total of 349 referrals have been received in the first year, and 86% of all MARAC cases have had an offer of support in Medway. Reduction of risk is currently 68%, which is a successful outcome against the CAADA benchmark of 63%.

      One Stop Shop

      Overseen by Medway domestic abuse forum and is part funded by Medway Community Safety Partnership. MDAF oversee the One Stop Shop (OSS). Based at the Sunlight Centre and well established within the community, this offers anonymity for clients and offers free, practical support from a range of agencies. Operating on a Tuesday morning any victim of domestic abuse can access the service and speak to multi agency partners. These include an IDVA, Health Visitor, Floating Support Worker, Solicitor and Citizens Advice Worker for welfare, housing and debt. Further agencies are currently being identified to support the OSS. Kent Fire and Rescue Service now support the OSS, providing advice and direct referrals to their home safety assessment.

      Freedom Programme

      The freedom programme is a 12-week nationally recognised programme, which offers an insight into the behaviour and tactics of the abuser. Medway has consistently offered all victims of domestic abuse a place on a course, currently funded by Medway Council and operated through All Saints Children's Centre.

      Kent and Medway Domestic Abuse Website

      The Kent and Medway Domestic Abuse Website remains an invaluable resource for both practitioners and victims of domestic abuse. From January to March 2014 there were 3,536 unique visitors to the website up 21.85% from 2,902 during October to December 2013. The weekly number of visitors varies from 309 to 372 on average, and this is increasing. There is an exit now button on the website, to enable victims to exit the site quickly, during this period this was clicked 251 times compared to 187 clicks the three previous months. Further advertising of the website will be progressed over the coming year.

      Domestic Homicide Reviews

      Domestic Homicide Reviews (DHR) Lessons Learnt Seminars have taken place during the year. The CSP, assisted with the coordination of the event held at Kings Hotel was well attended by multi agency partners. The Kent and Medway Domestic Homicide Review Steering Group retains ownership of all County DHR's and is attended by the CSP.

      Domestic Abuse Notification

      The Domestic Abuse Notification (DAN) was piloted in 2013 and due to the success it was rolled out in February 2014 throughout Medway. The DAN is received from Kent Police into the Medway Triage social care, regarding a domestic abuse incident that has taken place. A notification is made:


      • Where information indicates that the case meets Standard or Medium risk, but the child is open to Children's Social Care e.g. child in need, subject to a CP plan, child looked after (including subject to proceedings)
      • Where is it the first DA report but the victim details historic abuse where children normally reside, that indicates Medium level of risk.
      • Where risk is deemed as standard but a child is under 1 year old or unborn regardless of whether present or not, even if a single incident.
      • Medium risk – where an incident is assessed as medium risk but wider factors surrounding the circumstances indicate increased risk for children e.g. wider factors including significant drug/alcohol misuse, mental health or serious threats against the victim or child.

      The information on the notification includes; the child and siblings details, parental details and other involved in the situation, details of the incident, any additional information or concerns, previous relevant history and the current situation.

      Young Person's IDVA

      In March 2013 the Home Office definition for domestic abuse was updated to include coercive control and 16 and 17 year olds. Due to this, the Department of Education have funded the Coordinated Action Against Domestic Abuse (CAADA) and partners to train and support the Young Person's Violence Advisers nationwide. From April 2014 the Medway Domestic Abuse Coordinator will now include the coordination of this role for the next 2 years. The YPVA will support 13-17 year olds who are victims of intimate abuse including domestic abuse, child sexual exploitation (CSE), gang violence, Honour Based Violence (HBV) forced marriage (FM) and Female genital mutilation (FGM). This services will be based within the Family Support Service.

      The preliminary findings from the first 45 (National) cases in the programme have seen that 93% were female, 62% were 17 years old, 17% of the girls were pregnant, 47% were assessed as high risk and 80% were referrals for intimate partner violence. The role of the YPVA will be based within Early Help working alongside Children's social care. The programme is being launched in 2014.

      Training

      Training on domestic abuse is delivered in partnership by the Medway DA coordinator, MCSB and the DA Lead for Health. A full day's multi agency training focuses on domestic abuse, prevalence, elder abuse, children witnessing domestic abuse, teenage domestic abuse and forced marriage and honour based violence. Following on from this training participants can opt for a further half a day training on using the DASH domestic abuse, stalking, harassment and honour based violence risk assessment tool.

    • Projected service use and outcomes in 3-5 years

      The domestic abuse trend for Medway has increased over the last three years from 15 cases per 1,000 population to 18 per 1,000 population. The rate for Medway is one of the highest in the Kent county and more than double the rate for the Sevenoaks area. Currently, services are working at full capacity and with domestic abuse rates rising are likely to continue to do so in the near future. In the future, there may be a decrease in repeat victimisation there are improvements in support services such as IDVAs. There are a number of potential factors that suggest that there could be an increase in the demand for domestic abuse services over the next few years. These include;
      • Benefit changes brought about by the recent welfare reforms which could impact upon a victim’s ability to make safe decisions about their relationship
      • Legal aid reform which came into force last April (2013) could impact on victims who do not have evidence of abuse due to legal aid now only being provided in cases where statutory evidence of domestic abuse can be produced (i.e. evidence from Police, social services or healthcare professional).
      • The expansion of the domestic abuse definition to include 16-17 year olds from April 2013 is likely to have an impact on how acts of domestic abuse are dealt with by agencies.

    • Evidence of what works

      Multi-Agency Risk Assessment Conferences (MARAC)

      Regular meetings at which information about people experiencing domestic violence or abuse and who are at high risk (those at risk of homicide or serious harm) is shared between local agencies. Whenever possible, the person who experiences the violence is represented by an independent domestic violence adviser or advocate (IDVA). Participants aim to draw up a coordinated safety plan to support the person. In many areas they are funded by the local community safety partnership, in some areas they are funded by the police or local authorities. It was established originally in Cardiff and the evaluation showed that at the six month stage 63% of people were living free from violence and harm and at the twelve month stage this figure had fallen to 42%[1].

      Independent Domestic Violence Advisors (IDVA)

      IDVAs work primarily with people at high risk of domestic violence and abuse, independently of any one agency, to secure their safety and the safety of their children. Serving as the primary point of contact, IDVAs normally work with their clients from the point of crisis to assess the level of risk, discuss the options and develop plans that address their immediate safety, as well as longer-term solutions. In many areas they are funded by the local community safety partnership, in some areas they are funded by the police or local authorities. A multi-site evaluation of Independent Domestic Violence Advisors[2] found that abuse stopped completely in two-thirds of cases where there was intensive support from an IDVA service including multiple interventions.

      Children affected by domestic abuse

      It is important for agencies to work concurrently with both the non-abusive parent or carer and child, rather than just focusing on the parent. It is also important to ensure that services are appropriate to the age, gender and developmental stage of the child or young person. For example, teenagers may not want to be seen at the same time as their non-abusive parent or carer.

      Perpetrator programmes

      There is a lack of consistent evidence on the effectiveness of programmes for people who perpetrate domestic violence and abuse. Some evaluations take account of the partner's health and wellbeing and include their perception of any changes in the perpetrator's behaviour, but these tend to be small-scale, uncontrolled studies.

      The Rotterdam Code of Conduct for Reporting Domestic Violence and Child Abuse

      This is a step-by-step action plan for care providers and institutions that can be followed where domestic violence or child abuse are suspected or detected. The action plan offers carers support by making clear what is expected of them. This clarity is not only important for the care provider, but also for providing effective help to the victim and the perpetrator. The reporting code involves 5 key steps : Step 1: Identifying the signs Step 2: Peer consultation and, if necessary, consultation with the relevant counselling body Step 3: Interview with the client Step 4: Assess the information and the risk Step 5: Reaching a decision: organising or reporting assistance

      It was introduced to all care providers and institutions that offered education, shelter, assistance, care or support (e.g. teachers, social workers, doctors, nurses and psychiatric nurses, childcare employees, carers). These organisations became legally required to sign the 'Code of Conduct' assigning responsibility onto themselves and their staff to report cases of abuse and suspected abuse. As soon as a care provider started work at an institution that had signed the protocol, the employer was required to ensure that their new employee was capable of effectively following the protocol. Before 2006, approximately 1,200 cases of domestic abuse were logged each year in the City of Rotterdam. Following implementation of the 'Code of Conduct', the number of cases logged increased to around 6,000 to 7,000 per year. This confirmed that, previously, domestic abuse cases had been severely under-reported and that, as a result of the changes, more abuse cases were now being realised. Excluding the increased levels in reporting, the true extent of the effectiveness of the new 'Code of Conduct' policy has still yet to be clarified.


      References

      [1]   Robinson A. Domestic Violence MARACs (Multi-Agency Risk assessment Conferences) for Very High-Risk Victims in Cardiff, Wales: A Process and Outcome Evaluation 2004; Cardiff University. http://www.cardiff.ac.uk/socsi/resources/robinson-marac.pdf .
      [2]   Howarth E, Stimpson L, Barran D, et al. Safety in Numbers. A Multi-site Evaluation of Independent Domestic Violence Advisor Services 2009; The Hestia Fund, The Sigrid Rausing Trust and The Henry Smith Charity. http://www.henrysmithcharity.org.uk/documents/SafetyinNumbers16ppSummaryNov09.pdf .
    • User views

      National research[1] shows that all women think that the NHS (health visitors, GPs, hospitals, dentists, sexual health services, practice nurses) has a vital role in early identification and response to violence – particularly for those who are isolated and therefore more vulnerable – and also should have a key role in supporting and safeguarding women and children. Survivors saw the main issues and barriers to getting the help they needed as:
      • healthcare staff not having time to let them disclose violence and see how to meet their needs;
      • healthcare staff not knowing what to do with the problems of women who have experienced domestic violence, whether currently or in the past;
      • healthcare staff not believing they had a problem, thinking it was part of their lifestyle or culture; and
      • healthcare staff listening to accompanying abusive partners or family members instead of to the woman herself, or not understanding violence issues for lesbian and transgender women. Similar issues exist for other groups of women who might have had difficulty in communicating them: older women, women with learning disabilities or mental health issues, and women with language barriers, particularly if dependent on violent partners for translation.

      Two management exercises were carried out in spring 2010, a “deep dive” by the Audit Commission and a “lean management” event attended by 25 officers representing the majority of public agencies and voluntary organisations that contribute to domestic abuse services across Kent and Medway. Reports back from both these assessment exercises identified that current services are:
      • Failing to achieve a downturn in reported incidents of domestic abuse;
      • Complex and fragmented with gaps and unclear processes, which can be very confusing for both victims and professionals often leading to failed prosecutions: and
      • There are short and long term resourcing issues for locally based services.


      References

      [1]   Taskforce on the Health Aspects of Violence Against Women and Children. Responding to violence against women and children the role of the NHS 2010; Taskforce on the Health Aspects of Violence Against Women and Children. http://www.health.org.uk/media_manager/public/75/external-publications/Responding-to-violence-against-women-and-children%E2%80%93the-role-of-the-NHS.pdf .
    • Unmet needs and service gaps


      • Greater awareness of the training available to professionals from different agencies across Medway. A needs analysis and mapping should be undertaken.
      • Ensure frontline staff in services are trained to recognise the indicators of domestic violence and abuse and can ask relevant questions to help people disclose their past or current experiences of such violence or abuse.
      • Perpetrator programmes need to be in place in Medway.
      • Develop or adapt clear protocols and methods for sharing information, both within and between agencies, about people at risk of, experiencing, or perpetrating domestic violence and abuse.
      • Help people who may find domestic violence and abuse services inaccessible or difficult to use. This includes: people from black and minority ethnic groups or with disabilities, older people, transgender people and lesbian, gay or bisexual people. It also includes people with no recourse to public funds.
      • Improve the level of support to victims of domestic abuse. This should include ensuring that multiple needs are also taken into account (ie mental health, substance misuse, parental/child disabilities)
      • The need to ensure that learning from domestic homicide reviews is disseminated to front line practitioners.

    • Recommendations for commissioning


      • Perpetrator programmes need to be prioritised in Medway


      • Ensure that the needs of children affected by domestic violence perpetrated by parents as well as within their own relationships are identified and met.


      • Require A and E staff to be trained in understanding of issues relating to domestic violence and to be able to signpost callers to the relevant services


      • An integrated pathway should be developed for identifying, referring (either externally or internally) and providing interventions to support people who experience domestic violence and abuse, and to manage those who perpetrate it. The pathway should include children who may be affected, people who misuse alcohol or drugs, people who have mental health problems and the perpetrators of, the violence and abuse should be kept separate from each other when receiving support

    • Recommendations for needs assessment work


      • A detailed needs assessment should be undertaken to fully understand the Medway picture. This could include information regarding the views of service users in terms of how appropriate the current services are in meeting need and exploration of volume of local needs in Black and Minority (BME) groups across Medway and the extent to which cultural issues can act as a barrier in victims seeking support. This should also improve local understanding of specific types of domestic abuse that may be more prevalent in certain communities such as honour based violence and forced marriage.


      • Extent of the hidden harm needs experienced by children.


      • Greater understanding of the needs in certain vulnerable populations (e.g. veterans and ex-offenders)

  • Social Isolation
    • Summary

      Summary

      Social isolation occurs when a person has little or no social interaction with other people and society. It is different from loneliness, which is concerned with negative feelings that an individual may have due to of a lack or loss of meaningful social relationships.

      Social isolation can affect anyone, although, older people are one group of the population at particular risk. Older people may experience a reduction in household income, loss of a partner and deterioration of physical health. All of which can have an impact on social contact.

      The concepts of social isolation and loneliness are frequently used interchangeably but are defined as two distinct concepts. Loneliness' is a subjective negative feeling of a lack or loss of meaningful social relationships (e.g. loss of a partner or children relocating), while 'social isolation' is an objective measurement to indicate a lack of social interaction and relationships caused by loss of mobility or deteriorating health.[1]

      It is possible to have very few social contacts or relationships without feeling lonely and conversely individuals can live a seemingly rich social life and feel lonely nevertheless.[2]


      References

      [1]   Biordi D, Nicholson N. Social Isolation In: Larsen, P.D. and Lubkin, I.M. (Eds) Chronic illness: Impact and intervention (7th ed) 2008;
      [2]   Coyle C, Dugan E. Social isolation, loneliness and health among older adults. Journal of aging and health 2012; 24 (8): 1346-1363.
    • Who is at risk and why

      Loneliness and social isolation can have a considerable impact on the health and wellbeing of an individual. Loneliness is associated with a range of negative health outcomes including mortality, dementia, high blood pressure, increased stress levels and suppression of the immune system .[1] Research has shown that people with stronger social relationships have a 50% increased likelihood of survival than those with weaker social relationships. This difference on survival is comparable with well-established risk factors for mortality such as smoking, obesity and physical inactivity.[1]

      There are a number of population groups that have an increased vulnerability to social isolation. Older people are significantly more likely to suffer from social isolation with contributing factors being “loss of friends and family, loss of mobility or loss of income”. Other population groups at risk include, carers, refugees and those with mental health problems.[2]


      References

      [1]   Holt-Lunstead ST, Layton J. Social relationships and mortality risk: a meta-analytic review PLoS Medicine 2010; 7 (7): doi:10.1371/journal.pmed. 1000316.
      [2]   for Excellence SCI. Research Briefing 39. Preventing Loneliness and Social Isolation: Interventions and Outcomes. 2011;
    • Level of need in the population

      It is estimated nationally that across the present population aged 65 and over, that 5%–16% are lonely [1] and 12% feel socially isolated.[2] If this estimate was applied to Medway this would result in an estimate of 4,698 people over 65 years old being socially isolated and between 1,958 and 6,264 people being lonely. Population projections for Medway highlight that the rapid increase in the ageing population, the need to plan for this across all areas of health and social care and the importance of feeling safe within the home to reduce social isolation.

      In order to identify the areas within Medway where social isolation is more likely to occur, one data source to consider is the census. A crude way to do this is to use the 2011 Census to calculate the proportion of the population living alone, which can be done separately for those under 65 and those aged 65 years and over. This is a reliable source of data but does not take account of people's circumstances in terms of health, mood, mobility and engagement with social networks.

      Another way to identify areas within Medway where social isolation is more likely to occur is to use modelled estimates based on other data. MOSAIC Public Sector is a tool designed to help understand the characteristics and distribution of different types of people living within an area. It is produced by Experian Ltd and is one of a number of social-segmentation products available on the market today. The classification is built by drawing on a large database of Census and consumer demographic variables. Statistical analysis is used to identify clusters of associated variables to form distinct person types which have similar needs, attitudes or behaviours. Every household and residential postcode in the UK has been classified into a number of 'groups' which sub-divide into 'types'. The underlying premise is that similar people live in similar places, do similar things and have similar lifestyles, although it is important to take account that every individual has a unique set of circumstances and values and not all of the population within a given area may have similar characteristics.

      The MOSAIC social segmentation system from October 2013 has been used as the basis of this report. Although updated in 2014, the older version has been used for two main reasons: 1. The background indicators are more relevant to social isolation and therefore provide a better set of proxy measures. 2. The number of households of each MOSAIC type living in Medway was not available at the time of writing the report.

      The results are highlighted in figures 2 and 3.

      Figure 1: Medway ward map
      Figure 1: Medway ward map
      Figure 2: Relative social isolation per household at lower super output area level of persons under 65.
      Figure 2: Relative social isolation per household at lower super output area level of persons under 65.
      Figure 3: Relative social isolation per household at lower super output area level of persons aged 65 and over.
      Figure 3: Relative social isolation per household at lower super output area level of persons aged 65 and over.

      Figure 3 shows the estimated proportion of households for people aged 65 years old or over in Medway who are estimated to be socially isolated according to the developed composite index. Areas estimated to have the highest proportion of households that contain socially isolated people aged 65 years old or older include parts of Chatham Central, Peninsula, Princes Park, Rainham South, River, Rochester East, Rochester South and Horsted, Rochester West, Strood Rural, Strood South, Twydall and Walderslade. The map shows the specific communities where the highest proportion of households estimated to be socially isolated are located.

      Figure 4 shows the distribution of a measure of health and disability for Medway. The measure includes reduced quality of life that is a result of poor mental and physical health. The areas that have the highest deprivation of health and disability are similar to ones that high levels of overall deprivation and those estimated to have relatively high levels of social isolation per for people aged below 65 years old.

      Figure 4: Health & Disability domain - IMD 2010 local quintiles for Medway using Lower Super Output Area (LSOA).
      Figure 4: Health & Disability domain - IMD 2010 local quintiles for Medway using Lower Super Output Area (LSOA).

      References

      [1]   O'Luanaigh C, Lawlor B. Loneliness and the health of older people International Journal of Geriatric Psychiatry 2008; (23): 1213-1221.
      [2]   Greaves C, Farbus L. Effects of creative and social activity on the health and well-being of socially isolated older people: outcomes from a mulit-method observational study The Journal of the Royal Society for the Promotion of Health 2006; 126 (3): 136-142.
    • Current services in relation to need

      Medway men's health group

      The focus of the group is on reducing the isolation of men. It was established in November 2013 and is supported and facilitated by Rethink. The group meets weekly at the Sunlight Centre, in Gillingham and usually over 20 men attend. The men attending the session feel that they are in a comfortable environment where they can discuss any problems or concerns that they have, receive peer support, and receive health promotion information.

      Flexicare housing

      Flexi-care housing in Medway is a model of supported accommodation which provides 24 hour care on site and allows older people to live as independently as possible. Flexi-care housing provides an opportunity to preserve or rebuild independent living skills which makes independent living possible for people with a range of abilities. Flexi-care is available to older people aged 55 and over including those with sensory needs, mental disorder including dementia, short- or long-term illnesses, and those who require end of life care.

      Befriending schemes

      The Hands & Gillingham Volunteer Centre and Rochester Hands Volunteer Bureau offer befriending schemes to provide support and information to the community and to develop the involvement of other voluntary and statutory organisations. It is offered primarily to elderly or disabled people who have difficulty leaving the house to due to their infirmity, and therefore can become isolated.

      Suitable befrienders are matched to clients and visit them at home. During the visit, they can chat about everyday issues, enjoy a game of cards or encourage the client to contact old friends again. Befrienders are also able to take clients on days out to local amenities, such as the park or shops, giving them the opportunity to meet others and enjoy the fresh air. Regular contact between the client and befriender can establish a strong bond and encourage participation in community activities to encourage independence.

      Leisure, arts and cultural activities delivered by Medway Council

      There is currently a wealth of activities being offered across Medway including leisure (including physical activity) and education sessions delivered by Medway Adult and Community Learning Service. Medway Sport is working with partner organisations to launch initiatives such as boccia coaching for care home staff and afternoon tea dances. Medway Sport provide the Sports centre senior offer. The over 60s can enjoy a comprehensive timetable of activities at sport and leisure sites ranging from badminton, short tennis and table tennis to short mat bowls, chairobics, walking football and senior step. Most sites also offer a friendly social element with external trips and activities. The Senior Sports programme is also offered to help older people to live better, healthier lives.

      Medway Libraries' host regular groups which bring together a wide range of people who enjoy reading and talking about books

      Activities delivered by volunteer organisations in Medway

      Medway Voluntary Action provides a range of support to help not-for-profit organisations in Medway to assist them to be sustainable and connected. Both the voluntary sector and Medway Council offer a wide range of volunteering opportunities in local communities. Many other voluntary sector organisations such as Carers First and Age UK also support the reduction of social isolation.

      The Women's Royal Voluntary Service (WRVS) has recently opened an information centre for people over 55 in Medway. This is funded mainly by Medway Council, with a contribution from WRVS, the centre offers information and signposting on a range of issues that older people identify as being important to them. The centre is based in Central Chatham and is staffed by a team of local volunteers, led by a centre manager. In addition to the provision of information, the centre also provides the opportunity for older people to learn how to use computers. It has a small community cafe and will provide the opportunity for other organisations to hold regular 'surgeries' when older people can get expert advice on specific issues.

    • Projected service use
    • Evidence of what works

      Reducing social isolation and loneliness can reduce the demand for health and social care interventions and the evidence shows that there are a number of interventions that can have a positive impact on reducing social isolation or loneliness, although the quality of the relationships in the interventions is a vital component. Also, some caution is needed when interpreting the research outcomes because there are a variety of populations that may have a different response to interventions (ie those who are very frail, those from different cultural backgrounds).

      1. Befriending schemes

      Butler (2006) found that befriending schemes can have a positive impact on reducing loneliness.[1] Befriending schemes are an intervention, that introduce an individual to one or more individuals, with the aim of increasing additional social support through the development of sustaining an emotion-focused relationship over time. They can include home visits by volunteers or paid workers or telephone or group support and often provided by community or voluntary organisations such as Age UK.

      2. Community Navigators

      Community Navigators are usually volunteers who provide 'hard-to-reach' or vulnerable people with emotional, practical and social support, acting as an interface between the community and public services and helping individuals to find appropriate interventions. There is evidence that people who used community navigator schemes became less lonely and socially isolated following such contact (Windle et al 2008).[2]

      3. Supportive group services

      Supportive group services (such as lunch clubs, bereavement support groups), and social group schemes which aim to help people widen their social circles can be effective in reducing loneliness and social isolation. A study by Savikko et al. (2010) showed a support group that offered social group activities ('art and inspiring activities', 'group exercise and discussion' and 'therapeutic writing and group therapy') reported that 95 per cent of the participants (mean age 80) felt that their feelings of loneliness had been alleviated during the intervention.[3] Pitkala et al. (2009) found that group based interventions that included art and cultural activities (eg music sessions, cultural events and sights, and production of their own art) and exercise and health discussion groups, (eg walking, strength training, swimming, or senior dancing) had a significant reduction in measured hospital bed days, physician visits and outpatient appointments.[4] A systematic review by Dickens et al (2011) found that sessions offering social activity and/or support within a group format were effective in alleviating social isolation.[5]

      4. Mentoring schemes

      Mentoring schemes involve working with people with the goal of providing clients with the necessary skills and abilities to ensure that they are able to continue and sustain any achieved change following withdrawal of the service. There is evidence that mentoring schemes can have a positive impact in improving symptoms of depression and after 12 months follow-up.[6]

      There is very limited evidence on the cost-effectiveness of interventions to reduce social isolation or loneliness and it is relatively complex to measure accurately. Knapp et al (2010) demonstrated the economic impact of Befriending Interventions and Community Navigators, compared with what might have happened in the absence of any such service.[7] Along with the costs of 'formal' service provision, those unpaid 'resources' and 'opportunity costs' provided by family and/or informal carers were included. They found that a typical service for befriending would cost around £80 per older person within the first year and provides about £35 in 'savings' due to the reduced need for treatment and support for mental health needs. Pitkala et al. (2009) estimated cost-savings of supportive closed groups and found that there was a saving of €62 per person due to a reduction of hospital bed days, physician visits and outpatient appointments.[4] This saving took the cost of the intervention into account.


      References

      [1]   Butler SS. Evaluating the Senior-Companion Program: a mixed-method approach Journal of Gerontological Social Work 2006; 47 (1-2): 45-70.
      [2]   Windle G, Hughes D, Linck P, et al. Public health interventions to promote mental well-being in people aged 65 and over: systematic review of effectiveness and cost-effectiveness 2007; University of Wales Bangor: Institute of Medical and Social Care Research.
      [3]   NSavikko RT, Pitkala K. Psychosocial group rehabilitation for lonely older people: favourable processes and mediating factors of the intervention leading to alleviated loneliness International Journal of Older People Nursing 2010; 5 (1): 16-24.
      [4]   Pitkala RP. KH, Tilvis R. Effects of pyschosocial group rehabiliation on health, use of health care services, and mortality of older persons suffering from loneliness: a randomised, controlled trial Journal of Gerontolgy: Medical Sciences 2009; 64A (7): 792-800.
      [5]   Dickens RS. GC, Campbell J. Interventions targeting social isolation in older people: a systematic review BMC Public Health 2011; 11: 647.
      [6]   Greaves C, Farbus L. Effects of creative and social activity on the health and well-being of socially isolated older people: outcomes from a mulit-method observational study The Journal of the Royal Society for the Promotion of Health 2006; 126 (3): 136-142.
      [7]   Knapp BA. PM, Snell T. Building community capacity: making an economic case, PSSRU Discussion Paper 2772 2010; London: PSSRU.
    • User views

      A total of seven focus groups were undertaken to find out more about the views of population groups in Medway at risk of social isolation. Focus groups were undertaken with older people (Age UK day centre in Gillingham), carers (Carers First support group), mental health service users (MEGAN support group), black and minority ethnic communities (two groups were undertaken, one with the Medway BME Forum and the other with the Medway African and Caribbean Association), residents from Peninsula ward (parents at Grain Sure Start group) and a men's health support group (weekly group, based at the Sunlight Centre, Gillingham facilitated by Rethink Mental Illness).

      A number of key themes emerged from the focus groups that included access barriers influencing isolation, transport, involvement of communities, information, what works well currently and solutions. The table below summarises key points raised for each theme from the groups. Key points from the themes were utilised in the development of the first social isolation strategy for Medway 2014-2018.

    • Equality Impact Assessments
    • Unmet needs and service gaps


      • Identifying people at risk of loneliness can be difficult, but targeting those disproportionately affected by loneliness – lower socio-economic groups, the widowed, the physically isolated, people who have recently stopped driving, those with sensory impairment and the very old – has proven most effective.


      • Individuals within local communities should be encouraged to take some responsibility for identifying, 'reaching out' and supporting potentially isolated people within their own area. In order to achieve this, statutory, voluntary and community organisations need to work in partnership to build greater community capacity and better social outcomes for risk populations. The DERIC project which is being piloted in Medway and looks to do this should be supported.


      • Reducing social Isolation needs to be built in to care pathways for a range of different conditions. Health professionals should be mindful of the effects that social isolation have on health and refer into a befriending group or community group.


      • We will ensure that we will continue to offer the wide range of high quality services that are currently available across Medway in leisure centres, libraries and adult education centres.


      • Ensuring that social isolation is embedded in any relevant future strategies and JSNA chapters.


      • There is a need to undertake marketing and promotional work to raise the profile of social isolation in the Medway population.


      • There is a need to improve awareness of social isolation via training among frontline professionals that include; health professionals, social care workers, community safety wardens, housing officers, community development workers and floating support staff. The increased knowledge will help them to have an increased awareness of the risks of social isolation and knowledge of how to address it.


      • It is important to ensure we utilise opportunities to work with faith groups as partners to identify and support people at risk of being isolated.


      • There is a need to utilise the opportunity from public health programmes to target raising awareness for social isolation and signpost people to support and activities. Examples of programmes include health checks, stop smoking, substance misuse.


      • It is important to improve the availability of information and advice on existing services and activities that reduce loneliness and isolation. Local authority websites, book and social network groups, sports clubs, art groups, transport links and volunteering opportunities can all help reduce social isolation. It is important to ensure that information on these activities are available in day centres, health centres, schools, youth projects, housing offices and other settings within the local community.


      • Evaluation is a key component of any future programmes in Medway. Self-reporting is regarded as the best means of measuring social isolation and loneliness amongst older people. Measurements using valid scales such the Friendship Scale should be utilised. In order to assess whether specific programmes are able to change individuals' quality of life, or impact on their care pathway, participants need to be asked their views before the start of the intervention as well as following it.

    • Recommendations


      •  Interventions that have an evidence base of being effective to reduce social isolation, such as befriending programmes, should be considered for further commissioning support.


      • Frontline health and social care workers should receive training and information that will help them to have an increased awareness of the risks of social isolation and find ways to connect people to activities or organisations that can help.


      • There should be an emphasis to support people to engage with the wide range of opportunities (i.e. leisure facilities, drama groups) in Medway which would address social isolation. A greater understanding of people's behaviour in terms of what would make them utilise facilities is needed. This could be undertaken via action research.


      • To ensure the development of the care navigator programme appropriately signposts the population in Medway to improve the interface between the community and public services in helping socially isolated individuals to find appropriate interventions.


      • There is a need to increase the number of supportive groups in Medway, such as the men's health group operating at the Sunlight Centre to support vulnerable populations at risk of being socially isolated.

    • Further needs assessment required

Other sections

Downloads