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Lifestyle and wider determinants

  • Alcohol
    • Summary

      Alcohol plays an important role in society, making an important contribution to the economy.[1] However misuse of alcohol leads to a range of public health problems. Acute conditions, such as alcoholic poisoning, violence and accidents as well as the more chronic effects, such as alcohol–induced pancreatitis, chronic liver disease and stomach cancer all potentially lead to reduced health and wellbeing and at worst, loss of life. Alcohol can and does affect all of society, from the burden on the NHS in terms of hospital admission and treatment in primary care, the economic burden due to loss of employment and reduced capacity to work, through to other negative effects of alcohol on the social and behavioural welfare of communities.[2]

      As alcohol has become increasingly affordable, consumption has increased by 121% between 1950 and 2000. It is estimated that alcohol misuse is now costing around £20bn a year. This is made up of alcohol–related health disorders and disease, crime and anti–social behaviour, loss of productivity in the workplace, and problems for those who misuse alcohol and their families, including domestic violence.[3] Health inequalities are clearly evident as a result of alcohol–related harm; Department of Health analysis of Office for National Statistics (ONS) data indicates that alcohol–related death rates are about 45% higher in areas of high deprivation, and liver disease represents one of the few diseases where the inequalities gap is increasing.

      Key issues and gaps

      1. Post–treatment and wrap–around services provision is currently under resourced. Treatment services are commissioned but access to aftercare/recovery support is limited for alcohol users.
      2. Dual–diagnosis continues to be a service gap with adequate provision and pathways for those with both substance misuse and mental health issues.
      3. Intervention and Brief Advice (IBA), alcohol referral and pathways are not embedded in the Foundation Trust Hospital but have been shown to prove effective in reducing repeat attendances and admissions.[4]
      4. Alcohol IBA is an intervention in itself and does not necessarily need to result in a referral to treatment services—this is not fully identified by healthcare professionals. Further training in IBA to all healthcare professionals to utilise IBA as an early prevention/intervention tool is required.
      5. Increased provision of services to meet DH recommendations of 15% of dependent drinkers.

      References

      [1]   Jones L, Bellis M, Dedman D, et al. Alcohol-attributable fractions for England June, 2008; Centre for Public Health, Liverpool John Moores University.
      [2]   Association of Public Health Observatories. Indications of Public Health in English Regions 8:Alcohol August, 2007; Association of Public Health Observatories.
      [3]   Prime Minister's Strategy Unit. Alcohol Harm Reduction Strategy for England 2004; UK Government. http://image.guardian.co.uk/sys-files/Society/documents/2004/03/15/alcoholstrategy.pdf .
      [4]   Ryder S, Aithal G, Holmes M, et al. Effectiveness of a nurse-led alcohol liaison service in a secondary care medical unit Clin Med 2010; 10 (9): 435-40.
    • Who is at risk and why?

      In 2009–10 4,418 people in Medway (1,570 people per 100,000 population) were admitted to hospital for alcohol-related harm. These figures reflect not only admission for alcohol specific conditions (e.g. alcoholic mental or behavioural problems and alcoholic liver disease) but also the significant contribution of alcohol misuse to increased cardiovascular, gastroenterological and cancer admissions: also admissions due to accidents on the road, in the workplace and in the home (including falls).
      Higher risk drinkers are at significantly greater risk of developing alcohol–related health harms.

      Men Women
      4 times Double
      Double 4 times
      1.7 times 1.3 times
      Triple Double
      13 times 13 times
      4–5.5 times 4–5.5 times
      1.5 times
      Table 1: Increased risks of ill health to harmful drinkers

      Research and statistics have consistently shown that:


      • Men consume more alcohol than women. However, drinking varies greatly across age and socio–economic group, resulting in a complex picture of alcohol consumption and alcohol–related harm across gender.[1]
      • National Alcohol segmentation analysis of Hospital Episode Statistics data[2] shows that those at highest risk of being admitted to hospital with a primary or secondary diagnosis that was linked to alcohol, are men aged over 35 who work in an unskilled or manual field or are unemployed.
      • People from most minority ethnic groups have higher rates of abstention and lower rates of consumption than the majority white ethnic group. However, drinking varies greatly both between and within minority ethnic groups and across gender and socio–economic group, resulting in a very complex national picture of alcohol consumption and alcohol–related harm across ethnicity.[3]
      • For women living in the most deprived areas, alcohol–related death rates are three times higher than for those living in the least deprived areas. For men living in the most deprived areas, this is even worse: alcohol–related death rates are over five times higher than for those living in the least deprived areas.[4]
      • Offenders in the criminal justice system are more likely than the general population to be drinking at increasing and higher risk levels. For example, the Social Exclusion Unit, [2002] notes that 63% of men in the prison population report drinking at hazardous levels, compared with 38% of men in the general population.
      • Results from a number of small studies in the UK suggest that there are higher levels of alcohol misuse among lesbian, gay and bisexual people.[4]
      • People with mental health problems are at increased risk of alcohol misuse. Depression, anxiety, schizophrenia and suicide are all associated with alcohol dependence.[3]


      References

      [1]   Burr T. Reducing Alcohol Harm: health services in England for alcohol misuse 2008; National Audit Office. http://www.nao.org.uk/publications/0708/reducing_alcohol_harm.aspx .
      [2]   Morleo M, Dedman D, O'Farrell I, et al. Alcohol-attributable hospital admissions: segmentation series report 3 2010; Liverpool Centre for Public Health and North West Public Health Observatory. http://www.cph.org.uk/showPublication.aspx?pubid=640 .
      [3]   Thom B, Lloyd C, Hurcombe R, et al. Report to the Department of Health:- Black and Minority Ethnic Groups and Alcohol: A scoping and consultation study 2010; Middlesex University, London and University of York, York and North West Public Health Observatory. http://www.alcohollearningcentre.org.uk/_library/BME_report_final_draft_30_July_2010_v4.pdf .
      [4]   Ellinas T, Garland L, Gohil D, et al. Alcohol misuse: tackling the UK epidemic 2008; BMA Board of Science. http://www.bma.org.uk/images/Alcoholmisuse_tcm41-147192.pdf .
      The dangers of heavy drinking

      Men and women who drink heavily are four to five and a half times more likely to get cancers of mouth, neck and throat.

    • The level of need in the population

      The key findings from the National Alcohol Health Needs Assessment Research Project (ANARP) showed that 26% of men and women (aged 16–64) had an alcohol use disorder. In England, 23% of the adult population are classified as hazardous or harmful drinkers. The annual number of alcohol related deaths more than doubled in the UK between 1991 and 2005 from 4,144 to 8,386 (ONS, 2006). Death rates are more than twice as high for men than women.

      Applying the ANARP findings to the Medway Population the following estimates can be made about the level of need.

        Percentage of
      adult population
      Estimated numbers
      of ‘problem’ drinkers
      Harmful drinkers 5.2 10,384
      Hazardous drinkers 19.3 38,542
      Binge drinkers 16.1 32,151
      Dependent drinkers 5.9 11,782
      Moderate dependence 0.4 799
      Severe dependence 0.1 200
      Table 1: Estimated numbers of adults with drinking problems in Medway
      (Based on 199,700 adults)

      DH guidance states at least 15% of dependent drinkers should be able to access services.[1] In Medway services should therefore have capacity for around 1,800 service users.

      ANARP and DH equate the need for a service with dependence. This is not to say that specialist alcohol services do not have a role with harmful, hazardous and binge drinkers, but this role should probably be confined to educating and supporting tier 1 providers (such as GPs and other health staff) in the appropriate competencies and interventions such as IBA. Findings from the ANARP showed there were low levels of formal identification, treatment and referral of patients with alcohol use disorders (AUD) by GPs. Of those identified as needing specialist treatment many were not referred due to difficulties in access and patient preference not to engage. In the South East only 1 in 20 in-need alcohol dependent clients were accessing treatment.

      Alcohol related hospital admissions

      In 2008 the alcohol-attributable admission rates for Medway Local Authority were significantly lower than the regional and national level. However the 2011 Local Alcohol Profile[2] shows that there is now no significant difference between Medway and England. The rate of admissions to hospital for alcohol in Medway rose by 9% between 2008/09 and 2009/10. This was a higher than the previous year of 4%, but still in line with the national aim to reduce the rate of increase of alcohol-related hospital admissions (ARHA). The ARHA indicator is complex. It includes all those admissions that are specifically due to alcohol such as alcoholic liver disease, but it is made up mainly made up of admissions where alcohol may be a contributory cause. For these where alcohol is a contributory cause, a calculation is applied which relates to the proportion of cases that are likely to be caused by alcohol according to scientific literature. So, if 60% of pancreatitis is considered to be caused by alcohol, for each admission to hospital for pancreatitis, this would count as 0.6 of an admission.

      Figure 1: Alcohol related age standardised admission rate
      Figure 1: Alcohol related age standardised admission rate

      Regionally Medway Local Authority has the 16th highest admission rate out of 67 local authorities. In Medway alcohol specific mortality for women has increased significantly since 2004 on par with regional and national levels. Male specific mortalities also follow national trends and are significantly higher than for women. Under 18s rates of admission have dropped slightly in line with national trends.

      Dual Diagnosis

      UK data generally show that:[3]
      • Increased rates of substance misuse are found in individuals with mental health problems affecting around a third to a half of people with severe mental health problems
      • Alcohol misuse is the most common form of substance misuse
      • Where drug misuse occurs it often co-exists with alcohol misuse
      • Homelessness is frequently associated with substance misuse problems
      • Community Mental Health Teams (CMHTs) typically report that 8–15% of their clients have dual diagnosis problems
      • Prisons have a high prevalence of drug dependency and dual diagnosis.


      References

      [1]   Department of Health. Signs for improvement - commissioning interventions to reduce alcohol-related harm 2009; http://www.skillsforhealth.org.uk/component/docman/doc_view/129-ad-commissioning-guidelines.html
      [2]   North West Public Health Observatory. Local Alcohol Profiles for England 2010;
      [3]   Crawford V, Clancy C, Crome IB. Co-existing problems of mental health and substance misuse (Dual Diagnosis): a literature review Drugs:Education, Prevention and Policy 2003; 10 (Suppl.): pp.S1-S74.

    • Current services in relation to need
      Figure 1:The range of alcohol treatments and interventions
      Figure 1:The range of alcohol treatments and interventions

      It is estimated that 36,520 adults in Medway are drinking at 'increasing risk' levels or 'high risk' levels.[1] The most appropriate intervention for these drinkers is Identification and Brief Advice (IBA); most recent national research (as yet unpublished) suggests that very brief intervention, not necessarily using accredited tools but designed for local use and targeted populations, is also effective.

      Department of Health commissioned research describes how intervening with men aged over 35 who regularly drink over 50 units could reduce alcohol-related admissions nationally by 13,000 over three years; this group of drinkers is shown to contribute greatly towards alcohol-related hospital admissions.

      To date 19 GP practices have received IBA training complete with referral pathways. Health and Lifestyle Trainers have received IBA and Motivational Interview training and complete an IBA with every contact. Contraceptive and Sexual Health (CASH) services have received IBA training and requirement to deliver IBA is included in the contract. IBA is also included in the NHS Medway Healthchecks programme.

      In order to reduce population prevalence and reduce ARHA we should aim to provide very brief Identification and Brief Advice to key recommended groups: NICE recommends the following groups in particular be routinely targeted with IBA. Those:
      • with relevant physical conditions (such as hypertension and gastrointestinal or liver disorders)
      • with relevant mental health problems (such as anxiety, depression or other mood disorders)
      • who have been assaulted
      • who are at risk of self-harm or domestic abuse
      • who regularly attend Genito-Urinary Medicine (GUM) clinics or repeatedly seek emergency contraception.

      There are an estimated 11,782 dependent drinkers in Medway. DH guidance states at least 15% of dependent drinkers should be able to access services.[2] In Medway services should therefore have capacity for around 1,800 service users. Data for 2009/10 from the National Drug Treatment Data Monitoring Service showed 466 people accessed alcohol services in Medway (a quarter of the DH guidance).

      In August 2011 the local Drug Interventions Programme (DIP) team were commissioned to provide alcohol screening and referral within custody.


      References

      [1]   North West Public Health Observatory. Local Alcohol Profiles for England 2010;
      [2]   Department of Health. Signs for improvement - commissioning interventions to reduce alcohol-related harm 2009; Department of Health. http://www.skillsforhealth.org.uk/component/docman/doc_view/129-ad-commissioning-guidelines.html .
    • Projected service use and outcomes in 3--5 years and 5--10 years

      According to national and local trends the rate of alcohol-related hospital admissions in Medway is expected to continue to rise. In the short term (3–5 years), increasing emphasis on alcohol misuse identification and very brief advice is likely to continue to increase demand for extended brief intervention and structured treatment services. Improved patient pathways from acute, primary care and community settings will magnify this effect.

      However the interventions that have been put in place should see reductions in alcohol misuse (as evidenced by the mortality rate due to liver disease and alcohol-specific admissions); some effect of this is already in evidence. This should ultimately have an impact on service use and alcohol-related hospital admissions.

    • Evidence of what works

      There is a body of evidence around effectiveness in alcohol interventions including new guidance published by the National Institute for Health and Clinical Excellence: NICE public health guidance 24(2010) Alcohol use disorders: preventing the development of hazardous and harmful drinking. This guidance complements the previous PH7 guidance on school-based interventions on alcohol.

      Review of the effectiveness of treatment for alcohol problemsRaistrick et al 2006 This outlines the evidence base for screening, brief interventions, less–intensive alcohol treatments, specialist treatment, detoxification and self help.

      NICE guidance PH7 for alcohol NICE published School based alcohol interventions 2007 which describes the role of schools in education and brief advice to prevent alcohol misuse.

      Other key guidance documents include: Models of Care for Alcohol Misusers (DH 2006) This provides best practice guidance for health organisations in delivering an integrated local treatment system and sets out a tiered approach for alcohol interventions

      Signs for improvement: Commissioning interventions to reduce alcohol–related harm (DH 2009) This publication describes how organisations should be commissioning interventions to reduce alcohol–related harm. It includes some evidence base for the 7 high impact changes

      Alcohol–Related Disease: Meeting the challenge of improved quality of care and better use of resources (Moriarty 2010)

    • User Views

      Medway Public Health Directorate consulted widely on The Medway Alcohol Strategy. It was cascaded through contact networks of Children, Families and Education, Kent Police, Kent Fire and Rescue, Community Safety Partnership and providers of Alcohol Treatment services. The Strategy was based on a strategic review published in 2008, which included consultations with young people, general public and professionals. A Better Medway Social Marketing Campaign included consultation with Medway residents about healthy living. The impact of binge drinking was highlighted as an area of concern and A Smart Medway campaign developed accordingly. Alcohol service users in Medway are able to voice their views on services through the Services Users forum MUST. MUST are represented at the joint commissioning group and have input into service design.

      Local People Local Solutions consultation in Luton & Wayfield identified public drink and drug use as a top three priority. During the listening events it became clear that proxy and underage sales were considered a significant issue and licensing have been in engaged.

    • Equality Impact Assessments
    • Unmet needs and service gaps

      Self Assessment against the NICE Guidance PH24[1] identified the following gaps:

      Whilst some training has been delivered it is unclear if NHS professionals routinely carry out alcohol screening as an integral part of practice. NICE recommend that discussions take place during new patient registrations, when screening for other conditions and when managing chronic disease or carrying out a medicine review. These discussions should also take place when promoting sexual health, when seeing someone for an antenatal appointment and when treating minor injuries. A process is required to ensure this can be effectively monitored and reviewed by Public Health to ensure priority target groups (especially relevant for cancer, gastro and CVD services (notably hypertension and stroke) are receiving Indentification and Brief Advice (IBA).

      Post-treatment and wrap-around provision is currently under-resourced. Future commissioning of services should follow the payment by results key outcomes to improve recovery.

      Alcohol IBA and referral to treatment services is not routinely undertaken by all criminal justice agencies. Offenders drinking at hazardous/harmful levels may not be routinely identified and opportunities for referral to treatment may be missing.

      Dual diagnosis services are also currently under-resourced for the level of need.


      References

      [1]   National Institute for Health and Clinical Excellence. Alcohol-use disorders - preventing the development of harzardous and harmful drinking 2010;
    • Recommendations for Commissioning


      • Commissioners should ensure at least one in seven dependent drinkers can get treatment locally, in line with 'Signs for Improvement'.
      • Post-treatment and wraparound provision is currently under-resourced. Future commissioning of services should follow the payment by results key outcomes to improve recovery.
      • Managers of NHS-commissioned services must ensure staff have enough time and resources to carry out screening and brief intervention work effectively. Staff should have access to recognised, evidence-based packs. These should include: a short guide on how to deliver a brief intervention, a validated screening questionnaire, a visual presentation (to compare the person's drinking levels with the average), practical advice on how to reduce alcohol consumption, a self-help leaflet and possibly a poster for display in waiting rooms.
      • Commissioners of Cancer, Gastro and CVD acute services should ensure that alcohol Indentification and Brief Advice (IBA) and referral mechanisms are explicit within their commissioned treatment pathways, using referral tools and pathways already agreed by commissioners and providers, and give consideration to the financial benefit of contributing to additional treatment service provision which will be needed as a result.
      • There is significant evidence as to the impact of Hospital based interventions for alcohol.[1] This is especially relevant for cancer, gastro and CVD services (notably hypertension and stroke) and Accident and Emergency. Commissioners should invest in hospital led alcohol project to realise long-term savings from reduced alcohol-related hospital admissions (ARHA).
      • NHS Acute contracting team need to ensure that Hospital Trusts provide accurate data recording and data extraction, to monitor progress of initiatives, by building specifications on this into contracts and service level agreements. This will ensure that relevant data are available for performance management and to inform further JSNA refresh.
      • Develop a joint working policy, procedure and care pathway for clients with mental health and alcohol misuse problems (significant co-morbidity with mental illness requires pathway development into alcohol/mental health dual diagnosis services). Use referral tools and pathways already agreed by commissioners and providers.[2]
      • Commissioners should include formal evaluation within the commissioning framework so that alcohol interventions and treatment are routinely evaluated and followed up. The aim is to ensure adherence to evidence-based practice and to ensure interventions are cost effective.
      • Ensure sufficient resources are available to prevent under-age sales, sales to people who are intoxicated, proxy sales (that is, illegal purchases for someone who is under-age or intoxicated), non-compliance with any other alcohol licence condition and illegal imports of alcohol.
      • Raise awareness through Smart Medway Campaigns in the press, radio and through partner newsletters including workforce initiatives about the risks of drinking at increasing and higher risk levels and binge drinking. Give consideration to wider distribution of culturally appropriate resources for new communities.


      References

      [1]   Moriarty KJ. Alcohol-Related Disease: Meeting the challenge of improved quality of care and better use of resources 2010; British Society of Gastroenterology and Alcohol Health Alliance UK and British Association for Study of the Liver. http://www.alcohollearningcentre.org.uk/_library/bsg_alc_disease_10.pdf .
      [2]   Department of Health. Dual Diagnosis: Best Practice Guidance 2002; Department of Health.
    • Recommendations for needs assessment work
      1. More analysis is needed on hospital admissions for people with alcohol-related brain injury to support decisions around the provision of alternative appropriate bed space in the community.
      2. The impact of Indentification and Brief Advice (IBA) training and the level of referrals resulting from IBA in the community needs to be evaluated.
  • Healthy weight
    • Obesity
      • Summary

        Overweight and obesity are terms used to describe increasing degrees of excess body fat. The prevention and treatment of overweight and obesity is a central public health policy goal. Excess weight is a significant risk factor for a number of diseases including type II diabetes, cancer and heart disease. Overweight and obesity can also affect mental health and self-esteem.

        Excess weight is caused by an energy imbalance between 'energy in' (food consumption) and energy expenditure (energy used by the body during activity and metabolism).[1] If there is greater energy intake than is required, the excess energy will become excess fat. However, the underlying causes of this energy imbalance, which result in weight gain, are complex. Behavioural, psychological, social, cultural and environmental factors are thought to determine the increasing prevalence of obesity seen throughout the world.

        Obesity in adults is measured and classified using the Body Mass Index (BMI) according to table 1.

          Body Mass Index
        Underweight < 18.5
        Healthy weight 18.5 – 24.9
        Overweight 25.0 – 29.9
        Obesity I 30.0 – 34.9
        Obesity II 35.0 – 39.9
        Obesity III < 40.0
        Table 1: Classifying overweight and obesity using BMI (kg/m2)

        The BMI classifications may be less accurate in highly muscular people. For some ethnicities, risk factors for obesity may occur at a lower BMI. The Scottish guidance [2] recommends that until specific cut-offs are validated, South Asian, Chinese and Japanese individuals may be considered overweight at BMI >23 kg/m2 and obese at BMI >27.5 kg/m2. Waist measurements are also used to assess the risk from overweight and obesity. Tables 2 and 3 detail the risks associated with an increased weight measurement.

          Low High Very high
        Male <94 94–102 >102
        Female <80 80–88 >88
        Table 2: Waist circumference classifications
          Low High Very high
        Overweight No increased risk Increased risk High risk
        Obesity I Increased risk High risk Very high risk
        Table 3: Waist circumference and risk associated with overweight and obesity

        The relative health risks of health problems associated with obesity are shown in table 4.

        Greatly increased risk
        (Relative risk much
        greater than 3)
        Moderately increased risk
        (Relative risk 2-3)
        Slightly increased risk
        (Relative risk 1-2)
        Type II diabetes Coronary heart disease Cancer
        Insulin resistance Hypertension Polycystic overy syndrome
        Gallbladder disease Stroke Impaired fertility
        Dyslipidaemia Osteoarthritis Low back pain
        Breathlessness Hyperuricaemia Anaesthetic risk
        Sleep apnoea Psychological factors
        Table 4: Relative risks of health problems associated with obesity (Relative risk — risk measured against that of non-obese person of same age and sex)[1]

        Childhood obesity, physical activity, diet and nutrition and breastfeeding (see pregnancy and maternities) are considered elsewhere.

        Key issues and gaps


        • Prevalence of obesity in Medway is estimated to be higher than the England average
        • Prevalence of adult obesity (and therefore costs to the NHS and social care) are projected to rise without significant intervention.
        • Obesity in adults is strongly correlated to obesity in children.
        • Due to the high prevalence of overweight and obesity whole population approaches are required.
        • National data shows that deprivation and low income is particularly related to higher prevalence of obesity
        • National data and research suggests that groups at greatest health risk due to obesity are: pregnant women, women from African-Caribbean and Pakistani communities and people with physical and learning disability.


        References

        [1]   Swanton DK. Healthy Weight, Healthy Lives: A toolkit for developing local strategies 2008; National Heart Forum. http://image.guardian.co.uk/sys-files/Society/documents/2008/10/07/heart.pdf .
        [2]   Scottish Intercollegiate Guidelines Network. Management of Obesity, A national clinical guideline 2010; Scottish Intercollegiate Guidelines Network. http://www.sign.ac.uk/pdf/sign115.pdf .
      • Who's at risk and why?

        The prevalence of overweight and obesity has increased in all communities, demonstrating that the whole population is at risk. According to the latest statistics for England,[1] around 23% of adults are obese and an additional 38% overweight. Among 2 to 15 year olds, 16% are obese and 14% overweight. Projections carried out on the basis of available data and set out in the 2007 Foresight report suggested that 60% of adult men, 50% of adult women, and 25% of children will be obese by 2050, with around 35% of adults, and 30% of children overweight.[2]

        Some sectors of the population however are more at risk of developing obesity or its complications and this contributes to inequalities in health. Obesity prevalence is influenced by age, gender, ethnicity and deprivation.

        The National Obesity Observatory has published briefing papers on obesity and health inequalities which can be accessed by following the links below.

        Obesity and Ethnicity
        Obesity and Life Expectancy
        Adult Obesity and Socio-economic Status

        The National Obesity Observatory produces a slide set of data and information on adult obesity, which can be accessed by following this link — Adult Obesity Slide Set

        The Observatory has also produced a brief evidence summary on TV viewing and obesity in children and young people. It is suggested that there is a raised likelihood of children and young people being overweight with increased TV viewing time. This is thought to be caused by a mixture of unhealthy dietary habits, sedentary behaviour and exposure to advertising that arises whilst watching TV. Children and young people consume more snacks and soft drinks whilst watching TV, and studies show a lack of awareness of actual food consumption which leads to increased calorie intake. There is evidence that high levels of sedentary behaviour, which can be brought about by TV watching, are linked to obesity, regardless of having high activity levels at other times. The last factor talked about in this brief is the advertising of food which is highly processed and energy dense. Children and young people who watch a lot of TV are particularly influenced by food advertising and boys are more influenced than girls. Australia and the US have adopted guidelines that advise parents to restrict children and young people to a maximum of 2 hours TV watching a day, but no guidelines have been issued in Britain.


        References

        [1]   The NHS Information Centre for Health and Social Care. Statistics on Obesity, Physical Activity and Diet: England, 2011 2011;
        [2]   McPherson K, Marsh T, Brown M. Foresight - Tackling Obesities: Future Choices - Modelling, Future Trends in Obesity & Their Impact on Health 2007; Government Office for Science. http://news.bbc.co.uk/1/shared/bsp/hi/pdfs/22_11_07_modelling_fat.pdf .
      • Level of need in the population

        The Government has determined a new ambition for adult obesity in its Obesity Call to Action: 'a downward trend in the level of excess weight averaged across all adults by 2020'.

        Synthetic estimates of obesity are available for Medway (see table 5). These are based on a statistical model which applies the local demographic characteristics of each local authority in England to the results of the Health Survey for England between 2006 and 2008.

          Prevalence (%) Lower limit (%) Upper limit (%) Significance
        England 24.2 23.6 24.7
        South East GOR 23.7 22.2 25.3 Not significantly different to England
        Medway 30.0 28.7 31.4 Significantly worse than England
        Table 1: Estimated prevalence of obesity, percentage of resident population, people aged 16 years and over, 2006-2008[1]

        The most recent version of the Sport England Active People Survey, conducted between January 2012 and January 2013, contained questions on self-reported height and weight for the very first time. A total of 422 people in Medway were questioned, of which, 22.8% were obese (compared to 23% across England) and 66.1% were either obese or overweight[2]. It is helpful to have local prevalence figures but as this survey is relatively new, the results should be interpreted with a degree of caution until it is possible to validate them by comparing with subsequent years.

        During pregnancy and childbirth obesity presents a series of health risks to the foetus, the infant and the mother. Obesity in pregnancy is associated with an increased risk of serious adverse outcomes including miscarriage, foetal congenital anomaly, thromboembolism, gestational diabetes, pre-eclampsia, dysfunctional labour, postpartum haemorrhage, wound infections, stillbirth and neonatal death. There is also a higher caesarean section rate and lower breastfeeding rate in this group of women compared with women with a healthy BMI.[3] Obesity in pregnancy also increases the risk of the child becoming over-weight and of developing type 2 diabetes.


        References

        [1]   Association of Public Health Observatories. Data for 2012 Health Profiles, Obese Adults 2012; http://www.apho.org.uk/resource/view.aspx?RID=117416
        [2]   Public Health England. Health ProfilesPublic Health England. http://fingertips.phe.org.uk/profile/health-profiles .
        [3]   Department of Health. Healthy lives, healthy people: a call to action on obesity in England 2011; Department of Health. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_130401 .
      • Current services in relation to need

        The Healthy Weight Team offer the following services: Infant Feeding Programme Medway Breastfeeding Network is a peer support network made up of local mums who have breastfed their own babies and who have had additional training so that they can give information and support to other mums. Members of the Network are available at various locations including local baby clinics, children's centres, breastfeeding drop-ins and at Medway Maritime Hospital.

        A cross-organisation Infant Feeding Strategy has been adopted by local stakeholders to work towards the achievement of UNICEF Baby Friendly Initiative Award in both maternity and community settings.

        Early Years Support

        The Healthy Weight team work together with key partners to develop a range of initiatives to support the adoption of healthy lifestyle practices from a young age. The Obesity in Pregnancy and Early Years network meets 4 times a year to share activities, receive updates and develop plans to expand the range of opportunities families can access in Medway.

        Early Years programmes include Mend 2–4, a lifestyle programme for families with children aged between 2–4 years, Start4life activities, Play days and support and training for early years practitioners.

        Healthy Start is a national scheme, which provides pregnant mothers or families with children under four years old with Healthy Start vouchers to help purchase foods, which could benefit their health (milk and fruit and vegetables). The scheme is means-tested and actively promoted across Medway by health professionals and children's centres. The Healthy Weight Team is involved in promotional activities to raise awareness of the scheme with particular regard to expanding access to vitamins for both mothers and children, and submission of uptake data to the Department of Health.

        MEND Portfolio

        Mend is a community based, family programme that delivers healthy lifestyle advice in a fun and informal way to encourage small changes to lifestyles. Programmes are age specific to ensure advice and delivery is appropriate for each age group.

        Mend 2–4 is open to all 2–4 year olds regardless of BMI. Topics covered during the programme include general healthy eating, fussy eating, active play, mealtimes and label reading.

        MEND 5–7 is a 10-week programme for families with children aged five to seven, whose weight is above the healthy range for their age. The course runs once a week after school.

        Mend 7–13 is a 10-week programme for families with children aged seven to thirteen, whose weight is above the healthy range for their age. The course runs twice a week and includes regular activity sessions.

        Mend Graduates is a local scheme that provides weekly groups and holiday activities to encourage Mend graduates (families who have completed Mend courses) to sustain their new lifestyle habits.

        Community Food Programme

        Medway's Community Food Programme aims to promote and sustain healthier food choices in communities, to increase the opportunity to enjoy a healthier diet. The programme provides healthy eating training, nutrition resources, guidance for existing food related projects and develops new initiatives to increase access to healthy eating.

        Medway Healthy Workplaces

        This is a free scheme open to businesses in Medway to help them implement health improvement initiatives in the workplace. Interested employers are encouraged to complete a staff needs assessment and to develop a local implementation plan with support from the Health Improvement Workplace Health Coordinator.

        Tipping the Balance

        Tipping the Balance is a community-based clinic designed to help people lead a healthier lifestyle. The main aims of the service are;
        • To help patients work towards a healthy weight
        • To encourage healthy eating and physical activity
        • To boost the patient's self esteem and confidence Patients are referred by their GP and have regular appointments with a Specialist Health Improvement Practitioner.

        Medway Health Walks

        Medway Health Walks is a volunteer lead programme that encourages people to use their natural environment, to achieve some regular physical activity. The walks take place across a range of urban, semi-rural and green spaces in Medway, and are free for residents to take part in. The schedule includes slower paced walks for families with young children to faster paced, longer duration walks for adults, so are an excellent opportunity for people to get some fitness gains and social interaction.

        Active Medway Cycling Groups

        Active Medway Cycling Groups aim is to provide cycling groups for adults, who have not been on their bikes for a number of years, and would like to rebuild their confidence in a safe and supportive group environment. These regular groups are facilitated by Ride Leaders (trained by British Cycling), with low traffic and less physically challenging routes chosen to cater for beginners.

        Medway Exercise Referral Programme

        Medway Exercise Referral programme is a 12-week programme for people diagnosed with a medical condition that would benefit from becoming more active. Patients are referred from a whole range of health professionals, who are then offered a choice of class or gym based opportunities. The scheme is hosted in the local authority leisure centres, where the exercise referral instructors assess, induct and provide supervised exercise sessions to people wanting to become more active.

        Bariatric Referrals

        NICE (2006) recommends surgery as a treatment option for patients that have a BMI of = 40kg/m2 or 35–40kg/m2 with other significant diseases such as type II diabetes and hypertension. NICE states that surgery should only be offered when all appropriate non-surgical methods have been tried but failed to achieve or maintain adequate clinically beneficial weight loss for at least 6 months. Individuals with a BMI>50 kg/m2 should be considered for surgery as a first-line option if surgery is considered appropriate.

        In Medway, patients can be referred to the Specialist Commissioning Panel by the community weight management service, Tipping the Balance or by their GP. Each individual is considered by the panel on a case-by case basis.

        Other Interventions

        Other interventions and services promoting the healthy weight agenda are offered across Medway and include:
        • Change4Life Change4Life has traditionally offered advice to families on achieving a healthy weight. The Government has now shifted towards a new life course approach to health improvement. Change4Life will expand to cover all nutrition-related messaging (including a new focus on the key area of calorie reduction) and to other topics that have relevance to target audiences, such as the harmful effects of drinking alcohol above the recommended daily limits. The Change4Life programme will continue its expansion into early years (via its sister brand, start4Life) and into advice for middle-aged adults.
        • Free swimming for adults aged 60+ in possession of a Medway City Card

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

        Projections carried out on the basis of available data and set out in the 2007 Foresight report suggested that 60% of adult men, 50% of adult women, and 25% of children will be obese by 2050, with around 35% of adults, and 30% of children overweight.[1]

        The estimated annual costs to the NHS of diseases related to overweight and obesity, and obesity alone are shown in table 5. These estimates are based on national estimates calculated as part of the Foresight (2007) report.[1]

        Estimated annual costs to NHS of diabetes related to overweight and obesity (£ million) Estimated annual costs to NHS of diseases related to obesity (£ million)
        2010 2015 2010 2015
        NHS Medway 72.3 77.4 39.2 45.0
        Table 1: Estimated annual costs to NHS of diabetes related to overweight and obesity (£ million)

        References

        [1]   McPherson K, Marsh T, Brown M. Foresight - Tackling Obesities: Future Choices - Modelling, Future Trends in Obesity & Their Impact on Health 2007; Government Office for Science. http://news.bbc.co.uk/1/shared/bsp/hi/pdfs/22_11_07_modelling_fat.pdf .
      • Evidence of what works

        It is very difficult to estimate cost effectiveness, as the effect of interventions is difficult to measure over long-term scales. However, given the high costs of managing obesity and related health conditions and the high and rising prevalence it is likely that the return on investment is high. At present a small fraction of expenditure is on prevention compared with dealing with the consequences of obesity.

        The National Institute of Clinical Excellence (NICE) (2006) Guidelines recommends that community weight loss programmes should meet best practice standards by:
        • Helping people decide on a realistic healthy target weight (usually to lose 5–10% of their weight)
        • Aiming at a maximum weekly weight loss of 0.5–1.0 kg
        • Focusing on long term lifestyle changes
        • Addressing both diet and activity, and offering a variety of approaches
        • Using a balanced, healthy eating approach
        • Offering practical, safe advice about being more active
        • Including some behaviour change techniques, such as keeping a food diary and advice on how to cope with 'lapses' and 'high risk' situations
        • Recommending and/or providing on-going support

        The following documents contain evidence of what works: Healthy Lives, Healthy People (2011): A Call to Action on Obesity in England
        NICE (2006) CG43 Obesity: the prevention, identification, assessment and management of overweight and obesity in adults and children
        NICE (2010) PH27 Weight management before, during and after pregnancy
        National Obesity Observatory (2009) Preventing childhood obesity through lifestyle change interventions. A briefing paper for commissioners
        Sacher PM, Chadwick P, Kolotourou M et al, Poster Presentation: From clinical trial to large-scale community implementation: evaluation of the Mend child weight management programme in the UK
        Foresight Report (2007) Tackling Obesities: Future Choices
        Healthy Weight, Healthy Lives (2008) A Cross Government Strategy for England
        Healthy Weight, Healthy Lives (2008) A Toolkit for Developing Local Strategies

        NICE are currently developing a number of pieces of Public Health guidance related to obesity. Updates can be found by following the links below: Obesity - working with local communities
        Overweight and obese adults - lifestyle weight management
        Overweight and obese children - lifestyle weight management
        Physical activity advice in primary care
        Walking and cycling

        Other relevant evidence and guidance would be:

        NICE (2008) PH11 Guidance for midwives, health visitors, pharmacists and other primary care services to improve the nutrition of pregnant and breastfeeding mothers and children in low income households
        Start Active, Stay Active: a report on physical activity for health from the four home countries' Chief Medical Officers (DH, 2011)
        Royal College of Obstetricians and Gynaecologists: Management of women with obesity in pregnancy (March 2010)

      • User views

        Every patient attending 'Tipping the Balance' is asked to provide feedback about the service they have received. Responses from the questionnaire are used to improve the service and to enable a process of continuous improvement. Patients are asked for their comments on the venues used, services offered, quality of service delivery and improvements that the service could make.

        Questionnaires are given to patients on the penultimate session. They are asked to complete the questionnaire and return it at their last session or to mail it back to the Project Administrator in a pre-paid, addressed envelope.

        Patients that complete the programme and the questionnaire are more likely to report a positive experience, so the opinions of those who do not complete the programme are also sourced.

        Since the questionnaire was introduced, the overwhelming majority of respondents report that they were very satisfied or satisfied with the service and that they strongly agreed that they would be able to continue with the lifestyle changes they had put in place as a result of attending.

        Of those who did not feel that the service met their expectations, the reasons given included a chaotic lifestyle that conflicted with their ability to make behaviour change (despite actually losing weight), a preference for evening group social events rather than individual support and difficulty increasing activity.

        Comments from patients who completed the programme include:

        “It is one of the services that has given me utmost satisfaction. Somehow or the other I have become a very optimistic person.”

        “I have valued the experience of advice, support and non-judgemental approach, and given chance to take part in exercise at gym and Pilates, which I am carrying on. It has changed my life.”

        “Whilst I was attending I managed to lose quite a bit of weight but because of stress at home with my family, being introduced to anti-rheumatoid arthritis tablets and the fact that I am still waiting for surgery I have now gained my weight”

      • Equality Impact Assessments

        The Department of Health have published an Equality Analysis to accompany their Call to Action. Equality Analysis: A call to action on obesity in England[1]


        References

        [1]   Department of Health. Healthy lives, healthy people: a call to action on obesity in England 2011; Department of Health. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_130401 .
      • Unmet needs and service gaps

        Weight management for pre and post pregnancy

      • Recommendations for Commissioning

        Commission weight management services for before and after pregnancy based on recommendations of needs analysis.

      • Recommendations for needs assessment work


        • Evidence of effectiveness of interventions to tackle obesity is lacking and more research is required to understand the cost effectiveness of different interventions over the longer term.
        • Pre and post pregnancy weight management

    • Diet and physical activity
      • Summary

        Poor diet and lack of physical activity are risk factors for obesity which synthetic modelling predicts affects approximately 30% of adults in Medway.

        Key issues and gaps


        • Currently there are no suitable methods for collecting comprehensive local data on diet and nutrition and physical activity
        • There are specific gaps in knowledge concerning intakes of fat, sugar and salt and issues relating to access to an affordable healthy diet.
        • There are gaps in the knowledge regarding the uptake of targeted schemes to promote good nutrition such as Healthy Start vouchers and vitamins.
        • Local planning levers such as Supplementary Planning Policies could be introduced to limit fast food takeaways in areas of existing high density and near schools, as highlighted in the Government's Call to Action on Obesity [1] and Healthy Places Planning Resource


        References

        [1]   Department of Health. Healthy lives, healthy people: a call to action on obesity in England 2011; Department of Health. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_130401 .
      • Who's at risk and why?

        Poor diet and lack of physical activity are risk factors for obesity which synthetic modelling predicts affects approximately 30% of adults in Medway. The Health Profile for Medway 2011 indicates that Medway is worse than the English average for healthy eating and physical activity amongst adults. Children are also less likely to be physically active compared to the English average.

        The National Obesity Observatory has published briefing papers on obesity, physical activity and diet which can be accessed by following the links below.

        Knowledge and attitudes towards healthy eating and physical activity Environmental influences on physical activity and diet Data sources:Knowledge of and attitudes towards healthy eating and physical activity Determinants of obesity: adult diet Determinants of obesity: adult physical activity Determinants of obesity: child diet Determinants of obesity: adult physical activity Statistics on obesity, physical activity and diet have been published by the Health and Social Care Information Centre using data from various national surveys

      • The level of need in the population

        Currently there are no suitable methods for collecting comprehensive local data on diet and nutrition.

        The percentage of adults achieving at least 150 minutes of at least moderate intensity physical activity per week (in accordance with UK CMO recommended guidelines on physical activity), is 53.4% in Medway, compared to 56% across England [1].

        Local Healthy Start data indicates that the uptake of vitamins for children and mothers are very low which reflects the national picture. Vouchers for fruits and vegetables are being used but the reason for the lack of vitamin uptake is unknown.


        References

        [1]   Public Health England. Health ProfilesPublic Health England. http://fingertips.phe.org.uk/profile/health-profiles .
      • Current services in relation to need

        The Healthy Weight Team offer the following services:

        Infant Feeding Programme

        Medway Breastfeeding Network is a peer support network made up of local mums who have breastfed their own babies and who have had additional training so that they can give information and support to other mums. Members of the Network are available at various locations including local baby clinics, children's centres, breastfeeding drop-ins and at Medway Maritime Hospital.

        A cross-organisation Infant Feeding Strategy has been adopted by local stakeholders to work towards the achievement of UNICEF Baby Friendly Initiative Award in both maternity and community settings.

        Early Years Support

        The Healthy Weight team work together with key partners to develop a range of initiatives to support the adoption of healthy lifestyle practices from a young age. The Obesity in Pregnancy and Early Years network meets 4 times a year to share activities, receive updates and develop plans to expand the range of opportunities families can access in Medway.

        Early Years programmes include Mend 2–4, a lifestyle programme for families with children aged between 2–4 years, Start4life activities, Play days and support and training for early years practitioners.

        Healthy Start is a national scheme, which provides pregnant mothers or families with children under four years old with Healthy Start vouchers to help purchase foods, which could benefit their health (milk and fruit and vegetables). The scheme is means-tested and actively promoted across Medway by health professionals and children's centres. The Healthy Weight Team is involved in promotional activities to raise awareness of the scheme with particular regard to expanding access to vitamins for both mothers and children, and submission of uptake data to the Department of Health.

        MEND Portfolio

        Mend is a community based, family programme that delivers healthy lifestyle advice in a fun and informal way to encourage small changes to lifestyles. Programmes are age specific to ensure advice and delivery is appropriate for each age group.

        Mend 2–4 is open to all 2–4 year olds regardless of BMI. Topics covered during the programme include general healthy eating, fussy eating, active play, mealtimes and label reading.

        MEND 5–7 is a 10-week programme for families with children aged five to seven, whose weight is above the healthy range for their age. The course runs once a week after school.

        Mend 7–13 is a 10-week programme for families with children aged seven to thirteen, whose weight is above the healthy range for their age. The course runs twice a week and includes regular activity sessions.

        Mend Graduates is a local scheme that provides weekly groups and holiday activities to encourage Mend graduates (families who have completed Mend courses) to sustain their new lifestyle habits.

        Community Food Programme

        Medway's Community Food Programme aims to promote and sustain healthier food choices in communities, to increase the opportunity to enjoy a healthier diet. The programme provides healthy eating training, nutrition resources, guidance for existing food related projects and develops new initiatives to increase access to healthy eating. The Programme also has access to a community food allotment site where local community groups can learn how to grow and cook their own food.

        Medway Dines

        Medway Dines is Medway's healthy eating award for food businesses in partnership with Medway Environmental Health. It rewards businesses that promote healthy eating and who make it easier for consumers to find healthier food choices when eating out or taking away. The award is open to all types of establishments that cater for the general public including takeaways, cafés, sandwich shops and restaurants. Premises are usually considered for an award at the time of a satisfactory routine food hygiene or food standards inspection, partial inspection or audit. In addition, premises may also be assessed if requested by a proprietor.

        It is not intended to apply to premises that cater for individuals with specific dietary requirements. These include care homes for older people, state schools and nurseries where there are already guidelines or measures in place to improve healthy eating.

        The Award uses the Eat Well plate food groups to review food options and preparation methods offered by businesses. Successful businesses will receive bronze, silver or gold award.

        Medway Healthy Workplaces

        This is a free scheme open to businesses in Medway to help them implement health improvement initiatives in the workplace. Interested employers are encouraged to complete a staff needs assessment and to develop a local implementation plan with support from the Health Improvement Workplace Health Coordinator.

        Tipping the Balance

        Tipping the Balance is a community-based clinic designed to help people lead a healthier lifestyle. The main aims of the service are;
        • To help patients work towards a healthy weight
        • To encourage healthy eating and physical activity
        • To boost the patient's self esteem and confidence Patients are referred by their GP and have regular appointments with a Specialist Health Improvement Practitioner.

        Medway Health Walks

        Medway Health Walks is a volunteer lead programme that encourages people to use their natural environment, to achieve some regular physical activity. The walks take place across a range of urban, semi-rural and green spaces in Medway, and are free for residents to take part in. The schedule includes slower paced walks for families with young children to faster paced, longer duration walks for adults, so are an excellent opportunity for people to get some fitness gains and social interaction.

        Active Medway Cycling Groups

        Active Medway Cycling Groups aim is to provide cycling groups for adults, who have not been on their bikes for a number of years, and would like to rebuild their confidence in a safe and supportive group environment. These regular groups are facilitated by Ride Leaders (trained by British Cycling), with low traffic and less physically challenging routes chosen to cater for beginners.

        Medway Exercise Referral Programme

        Medway Exercise Referral programme is a 12-week programme for people diagnosed with a medical condition that would benefit from becoming more active. Patients are referred from a whole range of health professionals, who are then offered a choice of class or gym based opportunities. The scheme is hosted in the local authority leisure centres, where the exercise referral instructors assess, induct and provide supervised exercise sessions to people wanting to become more active.

        Bariatric Referrals

        NICE (2006) recommends surgery as a treatment option for patients that have a BMI of >= 40kg/m2 or 35–40kg/m2 with other significant diseases such as type II diabetes and hypertension. NICE states that surgery should only be offered when all appropriate non-surgical methods have been tried but failed to achieve or maintain adequate clinically beneficial weight loss for at least 6 months. Individuals with a BMI>50 kg/m2 should be considered for surgery as a first-line option if surgery is considered appropriate.

        In Medway, patients can be referred to the Specialist Commissioning Panel by the community weight management service, Tipping the Balance or by their GP. Each individual is considered by the panel on a case-by case basis.

        Other Interventions

        Other interventions and services promoting the healthy weight agenda are offered across Medway and include:
        • Change4Life Change4Life has traditionally offered advice to families on achieving a healthy weight. The Government has now shifted towards a new life course approach to health improvement. Change4Life will expand to cover all nutrition-related messaging (including a new focus on the key area of calorie reduction) and to other topics that have relevance to target audiences, such as the harmful effects of drinking alcohol above the recommended daily limits. The Change4Life programme will continue its expansion into early years (via its sister brand, start4Life) and into advice for middle-aged adults.
        • Free swimming for adults aged 60+ in possession of a Medway City Card
        • Children's Centres offer support with diet and exercise to families with children aged 5 years and under. All Children's Centres have adopted a food policy, in partnership with the Healthy Weight team to improve the standard of food provision in that setting.
        • The Health Trainer programme provided by Sunlight Development Trust programme can offer signposting and basic health improvement advice to those wanting to effect lifestyle change.
        • Medway Community Learning Service provides courses to help people develop cooking skills and physical activity classes.
        • The Physical Activity Network, facilitated by the Healthy Weight Team, is a collection of partners from across Medway who meet quarterly to identify opportunities to increase physical activity in the groups they work with.

      • Projected service use and outcomes in 3-5 years and 5-10 years
      • Evidence of what works

        Relevant evidence and guidance includes:

        NICE (2008) PH11 Guidance for midwives, health visitors, pharmacists and other primary care services to improve the nutrition of pregnant and breastfeeding mothers and children in low income households.

        NICE (2010) PH27 Weight management before, during and after pregnancy

        Start Active, Stay Active: a report on physical activity for health from the four home countries' Chief Medical Officers (DH, 2011)

        NICE (2007) PH6 Behaviour change

        NICE (2006) PH2 Four commonly used methods to increase physical activity

        NICE (2008) PH6 Physical activity and the environment

        NICE (2009) PH17 Promoting physical activity for children and young people

        NICE (2008) PH13 Promoting physical activity in the workplace

        NICE are currently developing a number of pieces of Public Health guidance related to obesity. Updates can be found by following the links below: Obesity - working with local communities

        Physical activity advice in primary care

        Walking and cycling

      • User Views

        A Community Food consultation was carried out across Medway in 2010/11. The Consultation used large visual questionnaires in accessible places such as on-street, in superstores, markets and interactive workshops in community venues.


        • A total of 939 local people took part in the Consultation
            • 124 men
            • 482 women
            • 340 children and young people
        • 39% of respondents felt that a healthy diet should be balanced and contain plenty of fruit and vegetables
        • 16.8% were aware of the 5-a-day campaign
        • 3% were aware of Change4Life without further prompting
        • 36% always read food labels
        • 56% of respondents ate three meals a day
        • Breakfast was the meal that people were most likely to skip
        • 52% regularly cook and prepare meals using all unprepared items every day
        • On average it takes 16-30 minutes to prepare an evening meal
        • 75% identified that a female parent/carer was responsible for cooking and choosing family meals

        The results of the Consultation are being used to implement community food projects in communities with the greatest levels of obesity and deprivation.

      • Equality Impact Assessments

        The Department of Health have published an Equality Analysis to accompany their Call to Action.[1]


        References

        [1]   Department of Health. Healthy lives, healthy people: a call to action on obesity in England 2011; Department of Health. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_130401 .
      • Unmet needs and service gaps


        • Currently there are no suitable methods for collecting comprehensive local data on diet and nutrition and physical activity
        • There are specific gaps in knowledge concerning intakes of fat, sugar and salt and issues relating to access to an affordable healthy diet.
        • There are gaps in knowledge regarding the uptake of targeted schemes to promote good nutrition such as Healthy Start vouchers and vitamins.
        • Local planning levers such as Supplementary Planning Policies could be introduced to limit fast food takeaways in areas of existing high density and near schools, as highlighted in the Government's Call to Action on Obesity and Healthy Places Planning Resource Healthy Places Planning Resource

      • Recommendations for Commissioning


        • Ensure that evidence based messages and the 'Eatwell Plate' are used to promote consistent messages concerning a nutritionally adequate diet and healthy eating
        • Promote the Physical Activity Guidelines to all population groups to embed activity as a key part of a healthy lifestyle.

      • Recommendations for needs assessment work


        • Evidence of effectiveness of interventions to tackle obesity is lacking and more research is required to understand the cost effectiveness of different interventions over the longer term.
        • Currently there are no suitable methods for collecting comprehensive local data on diet and nutrition and physical activity.
        • There are specific gaps in knowledge concerning intakes of fat, sugar and salt and issues relating to access to an affordable healthy diet.
        • Potential for introduction of Supplementary Planning Resources to support healthy lifestyles.

  • Sexual health
    • Summary

      The health and economic wellbeing of any population and the wellbeing of individuals can be critically influenced by sexual health. The financial case for sexual health services has been made repeatedly; effective sexual health services and the prevention of sexually transmitted infections (STI) and unplanned conceptions are cost-saving.

      Since 2012, in England, total new STI diagnosis rates have fallen. Chlamydia infection is the most common followed by genital warts, non-specific genital infection (NSGI), gonorrhoea, herpes and syphilis (PHE, 2015). Chlamydia detection among 15-24 year olds has increased in Medway as screening in GPs and pharmacies has been promoted. However, late diagnosis of HIV is above the England average and remains a priority area.

      This needs analysis does not include teenage pregnancy specifically as this is addressed elsewhere (link to the teen pregnancy section).

      Key issues and gaps


      • Sexual ill health is not equally distributed among the population with the highest levels seen in men-who-have-sex-with-men (MSM), teenagers, young adults and some black and minority ethnic groups. It is therefore a necessary to promote sexual health in a multifaceted manner as it is influenced by a number of issues including socio-economic and cultural issues.
      • There is some correlation between deprivation and STI rates, with Chatham town centre having the highest concentration of GUM diagnoses per 100,000 population. The National Chlamydia Screening Programme (NCSP) has identified the highest rates of positivity in Strood North, Luton and Wayfield, and the Rochester wards; it should be noted that the Young Offenders Institution and the Secure Training Unit skew the data for Rochester West.
      • The highest HIV prevalence rates are shown in Chatham with lower prevalence in rural areas.
      • The Pelvic Inflammatory Disease rate is significantly higher in Medway than the England average.
      • The total abortion rate in Medway is significantly above England average.
      • It is anticipated that the move to an integrated service will improve access to STI screening generally.
      • Additional research may be required to understand the cause of high prevalence in some areas of Medway to target identified causes.

      Recommendations for Commissioning

      We aim to complete commissioning of the integrated sexual health service by October 2016. Once the service is embedded a needs assessment should be conducted to identify remaining or new gaps. Additional research is required in a number of areas as set out below.

    • Who's at risk and why?

      All people who engage in sexual activity are at risk of sexual ill-health or unplanned pregnancy; however risk is not distributed evenly.

      People from some Black and Ethnic Minority Communities

      In the UK 34% of those receiving treatment for HIV are black African [1], due, in part, to the higher incidence of HIV infection in sub-Saharan Africa. Efforts to tackle HIV among high risk groups should be supported with work to reduce stigma.

      Undiagnosed HIV, and therefore late diagnosis, is of concern among black Africans and in particular black African women [2]. People living with HIV who live outside London are at a higher risk of being undiagnosed than those living inside London. The ethnic groups black and black British are at higher risk of being diagnosed with an STI than the general population [3].

      Men who have sex with men

      Men-who-have-sex-with-men (MSM) face a range of health inequalities, including HIV and issues related to mental health and wellbeing, alcohol, drugs and tobacco [4].

      It is estimated that 7% of the population are lesbian, gay or bisexual, but in England MSM accounts for 11% of all new STI diagnoses (81% of syphilis and 55% of new HIV diagnoses) [5].

      While not relevent to all MSM, lifestyle factors including HIV sero-sorting, condomless sex, multi-partnering, chemsex, public sex environments all contribute to the risks of STI and HIV transmission. Increased extra-genital testing alongside improved laboratory testing are likely to have contributed to the increase in STI detection among MSM.

      Given that MSM are disproportionately affected by STIs, the emergence of antibacterial resistant gonnorhoea is likely to have greatest impact on this group.

      Young people

      The National Survey of Sexual Attitudes and Lifestyles (NATSAL) survey (2013) indicates that just under a third of young people aged 16-24 at the time of the survey had had sex before age 16. Young people aged 16-24 are experimenting with a range of sexual practices, 71% have given or received oral sex, 19% males and 17% females have had anal sex. Anal sex among this group is higher than any other age range and unless participants observe safer sex messages this can increase health risks.

      Young people are more likely to use contraception effectively if they are aware of the alternatives and are able to make their own choices. This group should be included in universal sexual health services, while acknowledging that those who are socially disadvantaged may require tailored support. Schools and other educational establishments have proved to be good sites to base contraceptive services. Due to the high prevalence of STIs condoms should be offered in addition to other forms of contraception [6].

      Looked-after children

      Looked-after children are at a high risk of teenage pregnancy and while there is much policy and guidance to reduce teenage pregnancy, little of the guidance is directly focused on this group's needs. The limitations of school-based programmes with this group are well recognised.

      Consultations with this group are key if targeted interventions are going to be effective [7].

      Sex workers

      A literature review conducted by Balfour and Allen (2014) indicates that there are several factors that can adversely affect the health of sex workers [8]. The different types of sex work carry varying risk; for example, low risk activities such as stripping, web-casting and other forms of non-contact sex have significantly different impacts on health to on- or off-street sex work.

      Even though some sex workers still engage in risky behaviour, research indicates that condom use among sex workers has increased over the last 30 years and incidence of HIV has decreased [8]. It should be noted that although potential for transmission is very high the actual rate of STI infection remains low. This may, in part, be due to the focus of support for sex workers being around sexual ill-health; prevention and support work should continue with this group.

      People subjected to sexual violence, abuse and exploitation

      A needs assessment for the Sexual Assault Referral Centre (SARC) for Kent & Medway has been carried out. Details of the SARC are available online on the Beech House webpage

      NATSAL, one of the largest scientific studies of sexual behaviour, indicated that 1 in 71 males and 1 in 10 females have had non-volitional sex (2013). The median age for this in males was 16 and for females 18 years.

      Sexual violence is often linked to domestic violence. The long-term health effects of sexual violence are associated with depression, anxiety, post-traumatic stress disorder, psychosis, substance misuse, self-harm and suicide.

      Violence in all its forms are common for many sex workers but reporting of violent crimes to authorities by commercial sex workers is low.

      Although the effects of sexual abuse on people are well documented, detection and prevention of Child Sexual Exploitation is a developing field. Victims are likely to be at increased risk of HIV, STIs and pregnancy.

      It is widely acknowledged that reliable information on the volume of sexual offences is difficult to obtain as a significant proportion of offences are not reported to the police, although the number of reported incidents is increasing.


      References

      [1]   NAT. HIV and Black African Communities in the UK 2014; http://www.nat.org.uk/media/Files/Publications/NAT-African-Communities-Report-June-2014-FINAL.pdfhttp://www.nat.org.uk/media/Files/Publications/NAT-African-Communities-Report-June-2014-FINAL.pdf .
      [2]   PHE. HIV in the UK - Situation Report 2015 2015; https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/477702/HIV_in_the_UK_2015_report.pdf .
      [3]   PHE. Table 3 (a): Number of new STI diagnoses in England by ethnic group, 2010 - 2014 2015;
      [4]   PHE. Promoting the health and wellbeing of gay, bixeual and other men who have sex with men (initial findings)
      [5]   PHE. Table 4 (a) Number of all STI diagnoses & services in England by gender & sexual risk 2010 - 2014 2015;
      [6]   NICE. Cost report: Contraceptive services with a focus on young people up to the age of 25 2014;
      [7]   SCIE. SCIE Research Briefing 9: Preventing teenage pregnancy in looked after children 2005; http://www.scie.org.uk/publications/briefings/briefing09/index.asp .
      [8]   Balfour J. A review of the literature on sex worwork and social exclusion 2014; UCL Institute of Health Equity for Inclusion Health.
    • The level of need in the population

      Local sexual health data is available through the Public Health England Fingertips website.

      Chlamydia Detection in young people

      Medway has made good progress detecting Chlamydia in young people.

      2014 detection rate aged 15-24 / 100,000 (PHOF indicator 3.02) 2014 Chlamydia proportion aged 15-24 screened
      Medway 2,048 26.90%
      South East Region 1,682 22.10%
      England 2,012 24.30%
      Table 1: Chlamydia detection and screening rates (PHE 2105d)

      Other STI prevalence

      Overall STI prevalence in Medway has fallen each year since 2012. In 2014 the most commonly diagnosed STI in Medway was chlamydia (333 per 100,000) followed by genital warts at 123.9 per 100,000; genital herpes 68.6 per 100,000; gonorrhoea 28.0 per 100,000 and syphilis 3.3 per 100,000. Although reducing, the prevalence of genital herpes is higher in Medway than both regional and England prevalence. Chlamydia detection has increased since 2012. Syphilis is almost exclusively diagnosed among MSM. Although not specifically an STI, Pelvic Inflammatory Disease (PID) can be caused by bacterial infections such as chlamydia and gonorrhoea; Medway has admission rates to hospital well in excess of regional and England rates [1].

      2014 detection rate aged 15-24 / 100,000 (PHOF indicator 3.02) 2014 Chlamydia proportion aged 15-24 screened
      Medway 351.2
      South East Region 232.3
      England 236.4
      Table 2: Pelvic Inflammatory Disease rates (PHE 2105d)
      2014 detection rate aged 15-24 / 100,000 (PHOF indicator 3.02) 2014 Chlamydia proportion aged 15-24 screened
      Medway 652
      South East Region 649
      England 829
      Table 3: Rates of all new STI diagnoses (PHE 2105d)

      HIV

      HIV prevalence in Medway has increased year on year since 2011 in line with the prevalence in England. There is no discernible trend in late diagnosis. Across Medway the prevalence rate is 1.44/1,000 but that prevalence is not equally distributed. Survey of Prevalent HIV Infections Diagnosed (SOPHID) data indicates that HIV diagnosis is highest in the ME4 and ME7 postcode areas. Adults aged 35-54 are most likely to be diagnosed with HIV in Medway than any other age group. The most common route of transmission was sex between men; the next common was women who had heterosexual contact. Black Africans are the ethnic group at highest risk of HIV infection. However, the vast majority of UK HIV diagnoses are in people born in the UK as opposed to born overseas.

      2012-2014 HIV diagnosed prevalence rate / 1,000 aged 15-59 HIV late diagnosis (%) (PHOF indicator 3.04)
      Medway 1.4 45.90%
      South East Region 1.7 45.30%
      England 2.2 42.20%
      Table 4: HIV diagnosis rates (PHE 2105d)

      Unplanned pregnancy, Abortions and Repeat abortions

      The highest number of unplanned pregnancies occurs in the 20 to 34 age range. Not all of these will lead to an abortion; outcomes for both mother and child are poorer than for a planned pregnancy [2]. Unplanned pregnancies are prevented by good access to all forms of contraception including long-acting reversible contraception (LARC). GPs are increasing the quantity of LARC they are prescribing but Medway is still below regional and England rates.

      2014 Total abortion rate / 1,000 2014 Under 25s repeat abortions (%)
      Medway 19.1 30.6
      South East Region 14.8 25.7
      England 16.5 27.0
      Table 5: Abortion rates (PHE 2105d)

      Other Needs


      • Females aged 15-24 are at higher risk of STIs than males of the same age.[3](p31)
      • Men-who-have-sex-with-other-men (MSM) are at greater risk of STIs than the general population and account of the majority of syphilis and gonorrhoea diagnoses in men. MSM are at higher risk of HIV. Diagnoses of chlamydia, syphilis and gonorrhoea are increasing among MSM.[3](p20, 21, 38)
      • Individuals who are from the black and black British ethnic groups are disproportionately affected by STIs.[3](p44)
      • Black Africans, and black African women, are disproportionately affected by HIV infections.[4]
      • Heterosexuals are at far greater risk of a late HIV diagnosis than MSM.[4]
      • There is insufficient data available to assess inequalities for those who have a physical or learning disability.


      References

      [1]   PHE. Fingertips - Sexual and Reproductive Health Profiles. 2015;
      [2]   Wellings JK.M.C.T.C.C.S.D.J.C.A.E.B.G.L.M.W.S.P.P.A. . JA. The prevalence of unplanned pregnancy and associated factors in Britain: findings from the third National Survey of Sexual Attitudes and Lifestyles (Natsal-3) Lancet 2013; 382: 1807-16.
      [3]   PHE. Sexually Transmitted Infections in England 2015;
      [4]   PHE. HIV in the UK - Situation Report 2015 2015; https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/477702/HIV_in_the_UK_2015_report.pdf .
    • Current services in relation to need

      Medway is currently working towards an integrated sexual health model. It is anticipated that the new model will be commissioned and fully operational by October 2016.

      Hospital-based genitourinary medicine

      Since 2013/14 a slight decrease has been seen in attendance at the hospital-based level 3 genitourinary medicine (GUM) clinic in Medway but it is too early to establish whether this trend is likely to continue in the longer term. Service performance data indicates that there were 10,981 service users attending GUM in 2014/15. Generally these users were representative of the wider population; however, when considering general population not adjusted according to need, black Africans are over represented and Asians are under-represented. The 19 to 35 year old age group make up the majority of service users (63%).

      Community-based Contraceptive and Sexual Health Services

      Attendance at level 1 and 2 Contraception and Sexual Health (CaSH) clinics has also decreased slightly over the same time period. In 2014/15 there were 10,042 contacts with the level 1 and 2 providers in all settings. Men are significantly underrepresented in level 1 and 2 services with only 5% of attendees in clinics being male.Men-who-have-sex-with-other-men (MSM) are also under represented. Asians are under-represented. Fifty per cent of all clinic attendees are aged 25 or under.

      Between all sexual health services level 1-3 there are approximately 27,000 patient contacts per annum, of which approximately 20,000 were in clinical settings.

      Young people are supported by a number of community-based CaSH clinics targeted to the under 20s. Some schools and educational establishments host student sexual health clinics. The Student Health Service in Medway operates in 8 educational establishments and provides a range of sexual health services.

      Sexual Health Services by other providers

      The C-Card condom distribution scheme has over 1,200 young people registered with over 50 individuals trained as registration or distribution points. The scheme is delivered by Medway Public Health and open to 13-20 year olds; the upper age will be increased to 24 as part of the Integrates Sexual Health Service. Venues include schools, youth settings, sexual health clinics and pharmacies. In 2014/15, there were 906 registrations and 1,674 distributions.

      Emergency hormonal contraception (EHC) is available to all women aged up to and including 30 through pharmacies via a Patient Group Direction (PGD). In 2014/15 EHC was prescribed on 1,399 occasions.

      GPs are commissioned to fit long-acting reversible contraception (LARC), including intrauterine devices (IUDs) or systems (IUS) and subdermal implants (SDIs), by Medway Public Health. In 2014/15 there were 1,981 LARC procedures by GPs. This compares to 2,465 fitted by CaSH clinics (data from the Public Health England LASER report which is not publically available).

      HIV point of care testing focussing on the black African community is currently provided by a local charity (Health Action Charity Organisation). The scheme will end 31 March 2016 as the responsibility for community-based HIV screening is taken on by the integrated sexual health service. Campaigns are used to amplify the messages of HIV testing week to MSM and the wider community.

      The National Chlamydia Screening Programme (NCSP) is funded and administered locally by Medway Public Health and promotes testing and treatment through GPs, pharmacies, sexual health clinics, outreach, mail out service and other community organisations.

      Medway Public Health supports Relationships and Sex Education (RSE) as part of Personal Health and Social Education (PHSE) by partnering with schools to ensure high quality delivery. RSE is operating in 12 of 18 secondary schools in Medway.

    • Projected service use and outcomes in 3-5 years and 5-10 years
        15 - 24 25 - 34 35 - 49 50 - 64 65 +
      2012 38.6 35.8 56.5 47.6 39.1
      2013 38.5 36.8 55.7 48.1 40.5
      2014 38.3 37.3 55.2 48.7 41.8
      2015 37.9 37.8 55.2 49.7 42.7
      2016 37.0 38.9 55.0 50.7 43.7
      2017 36.2 40.0 54.6 51.8 44.6
      2018 35.6 40.7 54.3 52.6 45.5
      2019 35.3 41.3 54.1 53.5 46.6
      2020 35.0 41.5 54.2 54.3 47.5
      2021 35.1 41.6 54.4 55.0 48.4
      2022 35.1 41.8 54.6 55.4 49.8
      2023 35.2 41.7 55.2 55.6 50.9
      2024 35.5 41.6 55.9 55.6 52.1
      2025 35.9 41.3 56.9 55.4 53.4
      2026 36.5 40.6 58.0 55.1 55.0
      Table 1: Medway population projections 2012 - 2026 (ONS sub-national population projections). Note: Figures are in thousands

      Older age groups, who have less contraceptive- or STI- related sexual ill-health, (50-64 and 65+) are projected to grow at a faster rate than younger groups. This older group may experience other forms of sexual ill-health but these are more likely to be age-related.

      The ONS figures suggest that 15-24 year olds in Medway will actually decrease over the next ten years and then gradually increase again. This dip may result in a decrease in sexual health and contraception needs short term but the interventions are likely to increase back to current rates.

      The net international migration component of these figures is fixed at about 500-600 people per year. Data from the 2011 census indicates that 1,953 Medway residents reported living outside the UK one year previously. The impact of the current migration trends is unclear.

      Factors that may contribute to a reduction in attendances:


      • Change to integrated sexual health services; service users will attend fewer appointments as they will be treated holistically.
      • Increase in home sampling/self-managed care; cost effective solutions will reduce physical attendances at clinics for regular testers and asymptomatic service users.
      • Increased focus on prevention is likely to reduce ill-health but may lead to an increase in lower level interventions such as contraception/contra-infection services.
      • Accessibility of purchased 'over-the-counter' and 'over-the-internet' screening at affordable prices; as screening becomes more accessible some potential service users may choose to access private health care to maintain anonymity.

      Factors that may contribute to an increase in attendances:


      • Gonorrhoea or chlamydia with antimicrobial resistance; STIs that do not respond to current treatment programmes will lead to an increase in follow-up visits and increased drug costs.
      • Improved accessibility of services will remove a barrier to asymptomatic clients, any anticipated increase should be met with cost effective solutions such as online services.

      HIV Pre-Exposure Prophylaxis (PrEP); trials have indicated the effectiveness of PrEP; this may be viewed as a cost effective preventive intervention and may be rolled out nationally.

    • Evidence of what works

      Sexual health services should be viewed as a whole system and commissioned accordingly, across as many areas of responsibility as appropriate. [1][2]

      A framework for sexual health improvement in England [3] sets out ten ambitions.


      • Build knowledge and resilience among young people
      • Improve sexual health outcomes for young adults
      • All adults have access to high quality services and information
      • People remain healthy as they age
      • Prioritise prevention
      • Reduce rates of STIs among people of all ages
      • Reduce onward transmission of and avoidable deaths from HIV
      • Reduce unwanted pregnancies among women of fertile age
      • Counselling for all women requesting an abortion (CCG responsibility)
      • Continue to reduce the rate of under-16 and under-18 conceptions

      Young person friendly services, including contraception and emergency contraception, need to be easily accessible.[2]

      Information for young people should be communicated using a variety of means through a variety of outlets.[2]

      Services should seek consent and ensure confidentiality.[2]

      Services should be based on the principle of progressive or proportionate universalism and tailored to the socially disadvantaged.[2]

      Contraceptive services should be provided after a pregnancy or an abortion.[2]

      Sexual health services should be provided in educational settings.[2]

      Condoms should be provided in addition to other forms of contraception.[2]

      Workforce and wider workforce should be trained in areas relating to sexual health.[2]


      References

      [1]   MEDFASH. Making it work: A guide to while system commissioning for sexual health, reproductive health and HIV 2015; Public Health England.
      [2]   NICE. Cost report: Contraceptive services with a focus on young people up to the age of 25 2014;
      [3]   DoH. A framework for Sexual Health Improvement in England 2013;
    • User Views

      A programme of quantitative and qualitative primary research was conducted in April 2014 with over 300 respondents. It is important to note that views expressed in surveys undertaken will reflect the opinions of the respondents only and, as such, may not accurately represent the views of the entire population.

      Key messages

      Sexual health promotion and education It was widely reported that the internet would be used as the primary source of additional information. 'Official' sites from recognised, trusted health bodies, such as NHS Choices were used.

      A broad cross-section of qualitative participants and almost all the stakeholders expressed concern that there was insufficient promotion of the local sexual health services. Students indicated that they would like campaigns based on local data.

      Attitudes, motivators and barriers towards accessing services The surveys revealed that people were most likely to attend services if they had genital discomfort or if their partner had an STI.

      There were several emotional barriers that people said would deter them from attending services. The most common of these was anxiety about confidentiality. People in the focus group explained that they were worried that they would be 'spotted' walking in/out of a clinic or sitting in the waiting room. Some said they would overcome this by attending a clinic in another locality. Having sexual health services placed alongside other health services was seen to be one way of avoiding the 'embarrassment' of being seen using the service.

      A few people also spoke very strongly, stating that they would feel anxious and put off attending because they wouldn't know what was expected of them. The most commonly noted practical barrier was the lack of evening or weekend opening hours.

      In response to the findings of the survey, the Integrated Sexual Health Service will provide services in the evenings and also on Saturday mornings. Webpages will be developed that will give service users an indication of what happens as the clinic and how testing is performed. Respondents wanted a degree of choice over the clinician they saw.

      Of those surveyed 40% had sought information and support for sexual health issues from their GP. This was the most commonly used health service. Seventeen per cent had visited the chemist, 17% the CaSH service and 14% the Medway Maritime Hospital GUM service.

      A smaller quantitative survey took place in youth settings in early 2015 that gave insight where the young people surveyed would prefer to attend services to improve their sexual health.Youth settings were popular for prevention and regular screening but for most other issues young people would prefer to access a Sexual Health Clinic.

      Medway Sexual Health Network (MSHN) is open to all professional or voluntary organisations and is a forum to disseminate information and receive feedback from partner agencies in relation to sexual health. MSHN actively contributed to the writing of the Integrated sexual health service specification.

    • Equality Impact Assessments
    • Unmet needs and service gaps

      HIV testing and diagnosis:

      Significant numbers of HIV cases remain undiagnosed and access to HIV testing and treatment and care for the positives requires further improvement. HIV knowledge and skills within primary care (GPs and nurse practitioners) and other health providers in related fields in Medway PCT do not appear to be sufficiently strong. Professionals at these touch points in the health system are not familiar with the many presentations of HIV and not confident in testing and care pathways.[1]

      Chlamydia screening:

      Increased screening through core services and targeted outreach is required to reach the proposed Public Health Outcome diagnosis range of 2,400 positives per 100,000 15-24 year old population.

      Community focused STI screening services:

      Limited understanding and delivery of sexual health services (such as screening, information and advice) through primary care. Improved management of the pathways between providers to ensure patients are accessing appropriate services efficiently.

      Targeted Outreach:

      CASH services need to develop a clear outreach strategy to engage those more at risk of sexual ill health including MSM, Black African Populations.

      Young peoples sexual health services:

      Access has improved and onsite services available in educational establishments. However need to ensure provision of services in Chatham area is maintained. Need to continue to work towards Your Welcome accreditation.

      Local termination of pregnancy services:

      Access has improved and women are presenting at earlier gestations (ytd in 2011 80% before 10 weeks). Referral pathway developed to local CASH services but need to monitor the effectiveness of this pathway. Levels of contraception provided has increased significantly but repeat abortions high so need to target LARC activity.

      Provision of Long Acting Reversible Contraception (LARC):

      Promotion and uptake of LARC will require improvement.

      Sexual Assault Referral Centre (SARC)

      Whilst there is a sexual assault referral service located at Darent Valley Hospital, the wrap around services are currently grant-funded.


      References

      [1]   Design Options. Rapid Sexual Health Needs Assessment 2007; Medway Primary Care Trust.
    • Recommendations for Commissioning
      1. Improved data collection across all sexual health services to better inform commissioners on gaps and any barriers in the pathways.
      2. HIV is of particular concern with late diagnosis of HIV posing serious problems at individual and community level in terms of onward transmission and more costly treatment regimes. Training needs among other medical disciplines to improve early diagnosis is required.
      3. As a large proportion of those affected by HIV and AIDS in Medway are of black-African origin, it is important to review services to ensure that they are accessible to this population.
      4. Improve sexual health services delivered by GPs, in particular access to LARC, Chlamydia screening, referral for full STI screen
      5. Establish access to SARC in line with national guidance.
      6. Community CASH clinics working in partnership with the acute trust
      7. Improve chlamydia screening rates through core services
      8. Expand the Student Health Service so all education settings in high-rate wards have clinics.
      9. Reduce the number of women who have repeat abortions
      10. Increase the uptake of LARC
    • Recommendations for needs assessment work

      The last Service review was conducted in 2007. There have been changes to the system since this time. An updated whole system review would help to establish if gaps have been met and where needs still exist prior to commissioning responsibility being split between Local Authority and NHS Commissioning boards.

  • Smoking and tobacco control
    • Summary

      Cigarette smoking remains the leading cause of preventable death in England today; it is estimated to be responsible for up to 86,500 deaths per year.[1]

      “Smoking has been identified as the single greatest cause of preventable illness and premature death in the UK. …it is estimated that half the difference in survival to 70 years of age between social class I and V is due to higher smoking prevalence in class V."[2] On average, those killed by smoking have lost 10–15 years of life.[3]

      Smoking is a key driver of demand for the NHS, causing the majority of respiratory diseases, around 30% of cancers, and nearly one in five cases of cardiovascular disease, as well as being a contributory factor in diabetes and many other disease disorders.[4]

      The local smoking prevalence in Medway has dropped from 31.8% in 2008 to 24.9% in 2010. These are based on national synthetic estimates and there is a need for more local data either through surveys or through an augmentation of the Annual Health Survey for England.

      Smoking results in considerable use of NHS services—in 2007/08, an estimated 440,900 admissions to NHS hospitals in England among adults over the age of 35 were attributable to smoking.[5] This is nearly 1,200 per day and 5% of hospital admissions in that age group.

      Stop smoking services should aim to treat a minimum of 5% of their local population of smokers in a year, but should take local needs into account. This is a minimum recommendation and the current national average is just under 10%.[6] In 2010/11 the Medway Stop Smoking Service treated 7.5 % of the local population.

      Key issues and gaps

      Smoking prevalence in Medway is 24.9%, however, there is a significant variation across the Medway area and smoking is a major reason for health inequalities. Helping people to stop smoking is a key part of the business of NHS services across Medway and four-week quitting remains a challenging target.

      Motivating people to stop smoking


      • Currently there are no local data on the prevalence of smoking and there is a reliance on national synthetic estimates. This needs to be addressed through either local surveys or through an augmentation of the Health Survey for England.
      • Continued focus on primary and secondary care is required, with an extension of this to frontline Council services, particularly in ensuring that sufficient and appropriate staff are trained in Brief Intervention, good quality Brief Advice/Intervention is given, and that referrals to stop smoking service are made proactively.
      • Evidence has shown that mass media campaigns are effective in reducing smoking prevalence and are associated with stop smoking activity. The reduction in the Department of Health-funded national mass media campaigns may result in a drop in activity/numbers accessing treatment.
      • Increased working with General Practitioners (GPs) to continue to refer patients that smoke to the stop smoking service.

      Smoking cessation services


      • The stop smoking service currently offers the 'abrupt quit' model to smokers wanting to quit.

      • It is unknown whether the current service provision adequately meets the needs of a certain groups with high smoking prevalence, such as those with mental health problems.
      • The smoking status amongst some pregnant women at point of booking and point of delivery is not being recorded and is causing confusion and results in inaccurate recording.
      • The lack of mobile technology and connectivity problems causes duplication in recording of patient outcomes. This is also causing an increase in use of financial and human resources. Improvements in this area will streamline processes, improve security and accuracy and enhance customer focus.
      • Engaging midwives to carry out carbon monoxide testing (CO) as per NICE guidance and to participate in level 1 and level 2 training.
      • The uptake of staff from Children's centres to access training to enable them to offer professional advice on smoking cessation.
      • IT systems at the acute trust not robust enough to support an electronic referral system.
      • Releasing staff from duties at the acute trust in order for them to attend the 1-hour Brief Training Programme.

      Protection from tobacco-related harm


      • Continue to raise awareness of tobacco control beyond health partners and highlight the impact to other agencies and departments, including: fire and rescue; housing; social care; and Human Resources.
      • Lack of understanding of the scale of illicit tobacco sales and counterfeit tobacco
      • Challenging to enforce the legislation about smoking in cars
      • Legislation for plain packaging of cigarettes not passed.

      Stopping Young People from starting to smoke


      • There is a lack of uptake of educational establishments working in partnership with the stop smoking service to design, deliver, monitor and implement stop smoking prevention activities.
      • No power to influence, investigate or accountability to implement the five NICE guidance recommendations.
      • Limited number of proactive schools supporting schools based interventions to prevent the uptake of smoking among children.
      • Number of young people accessing the 'go it alone programme', indicate that the outcomes are un-measurable.

      Improving evidence base


      • There is little published evidence of the effects of interventions that focus on cessation activity in adolescence. In 2010/11 23,229 smokers aged under 18 set a quit date, achieving all self-reported quit rate of 32% (7,327) quitters. Proportionately on a national basis 3% of service users aged 18 or under set a quit date. In Medway, 154 young people set a quit date in 2010/11 and of those, 54 quit successfully and achieved a 35% success rate. This equated to 4% of service users setting a quit date from the under 18 age group.


      References

      [1]   Twigg L, Moon G, Walker S. The Smoking Epidemic in England 2004; Health Development Agency. http://www.nice.org.uk/niceMedia/documents/smoking_epidemic.pdf .
      [2]   Wanless D. Securing Good Health for the Whole Population: Final Report 2004; Department of Health. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4074426 .
      [3]   Crosier A. Smoking and health inequalities 2005; Action on Smoking and Health. http://www.ash.org.uk/files/documents/ASH_98.pdf .
      [4]   Action on Smoking and Health. All Party Parliamentary Group on Smoking and Health http://www.ash.org.uk/APPG
      [5]   Diment E, Harris J, Jotangia D, et al. Smoking, drinking and drug use among young people in England in 2008 2009; The NHS Information Centre. http://www.ic.nhs.uk/webfiles/publications/sdd08fullreport/SDD_08_%2809%29_%28Revised_Oct_09%29.pdf .
      [6]   Department of Health. Service delivery and monitoring guidance, 2011/12 2011;
    • Who is at risk and why?

      Smoking prevalence rates are highest in the poorest areas of England and Wales, demonstrating the strong link between smoking and deprivation. There are also differences in prevalence between genders, socio-economic groups, ethnicities and age groups [1][2][3]

      Socio-Economic Status


      • Smoking is higher than average in lower socio-economic status Mosaic Groups O, N, K, and I. These groups make up 31.1% of the Medway registered population.[4]
      • Smoking prevalence in routine and manual workers continues to be higher at 29% than for those in the managerial and professional socio-economic group at 14%.[2]
      • Smokers in lower socio-economic groups are less likely to succeed when trying to quit smoking, due in part to a stronger addiction to nicotine.
      • At least 75% of lone parents in receipt of social security benefits smoke.
      • People on low incomes (the bottom 15% in terms of material deprivation) have a significantly higher rate of smoking — 45% of men and 40% of women were current smokers.[5]

      Gender


      • Smoking in England is slightly higher in men (21%) than women (20%), contributing to the life expectancy gap between the sexes.[2]
      • However, among children and young people in the South East more girls (8%) than boys (6%) smoke (2009 data).

      Ethnicity


      • Irish and Bangladeshi men have higher smoking levels than the general population, with Black Caribbean, Black African, Chinese, Pakistani and Indian men having similar levels; Black Caribbean and Irish women have similar smoking levels to the general population; Black African, Chinese, Pakistani, Indian and Bangladeshi women have significantly lower levels of smoking.

      Age


      • Those aged 20 to 34 reported the highest prevalence of cigarette smoking (32% among 20–24 year olds and 27% among 25–34 year olds) while those aged 60 and over reported the lowest (12%).[2]
      • Low Income Diet and Nutrition Survey 2007[5] found that older adults were much less likely to be current smokers than younger adults. Among men, the prevalence of current smokers was 54% for men aged 19–34, 58% for those aged 35–49, 52% for men 50–64 and 22% for men aged 65 and over. It is a similar pattern for women.

      Young people and children


      • Almost two thirds (65%) of current and ex-smokers who had smoked regularly at some point in their lives started smoking before they were 18.
      • Across the South East Coast, 36% of girls and 33% of boys aged 11–15 will have smoked at least once. 8% of girls and 6% of boys aged 11–15 will be classed as regular smokers, defined as smoking at least once per week.[6] This is slightly higher than the national average.
      • Nationally, 32% of pupils aged 11–15 have ever smoked, with a large variation by age: 55% of 15-year-olds have smoked at least once. The prevalence of regular smoking (at least once per week) also increases with age.
      • The odds of being a regular smoker are higher if pupils live with other people who smoke, and also increase with the number of smokers in the household; children who live with two adult smokers are four times more likely to be regular smokers themselves than children who live with non-smokers.
      • Smoking increases the risk of asthma in young people and aggravates asthma symptoms in those already diagnosed. It can also lead to impaired lung growth in children and young adults.[7]

      Other groups

      Pregnant women


      • Prevalence of smoking in pregnancy across England is approximately 14% (Department of Health, 2010). In Medway it is higher at 20%.[8]
      • Younger mothers are more likely to smoke throughout pregnancy than older mothers; 45% of mothers aged under 20 smoked throughout pregnancy compared with 9% of mothers aged 30 and over.
      • Mothers classed as having 'never worked' are significantly more likely to smoke throughout pregnancy than mothers in managerial and professional occupations.

      Prisoners


      • Smoking prevalence among prisoners is estimated to be approximately 80%, with the 1997 psychiatric morbidity survey of prisoners in England and Wales [9] reporting 82% of male prisoners and 81% of female prisoners being current smokers.
      • Smoking status should be routinely recorded in primary care records.
      • Mental Health Trust staff, for example Wellbeing nurses, Occupational Therapists and Physical Activity co-ordinators should be trained to level 2 in Smoking Cessation.
      • Patients who smoke should be offered referral to appropriate trained smoking cessation specialists on admission: or, if they do not wish to access this help at that time, a programme to promote readiness to quit should be agreed as soon as possible, and referral continue to be offered.
      • The Medway Stop Smoking Service, the Mental Health Care provider and Medway Social Services should work together to develop plans to bring the Forensic and Secure Units, and eventually the Residential Care home environment for this patient population towards completely smoke free status. The GPCCs will be expected to actively support these plans. Commissioners of Forensic Secure Unit providers should use contract review as an opportunity to instigate change following consultation with staff, clinicians and patients/service users.

      Mental Health


      • Approximately 70% of people on mental health inpatient units are current smokers and 50% smoke heavily (more than 20-a-day).

      • People with mental illness who are living in the community and who are less ill, smoke less, with up to 40% smoking and close to 30% smoking heavily.[10]


      References

      [1]   Crosier A. Smoking and health inequalities 2005; Action on Smoking and Health. http://www.ash.org.uk/files/documents/ASH_98.pdf .
      [2]   Office for National Statistics. General Lifestyle Survey 2008: Smoking and drinking among adults 2010; Office for National Statistics.
      [3]   The NHS Information Centre for Health and Social Care. Statistics on Smoking, England 2010 2010; http://www.ic.nhs.uk/pubs/smoking10
      [4]   Experian Ltd. Area Comparison Report: Medway Unitary Authority wards 2011;
      [5]   Food Standards Agency. Low Income Diet and Nutrition Survey 2007; http://food.gov.uk/science/dietarysurveys/lidnsbranch/
      [6]   Spencer S, Jolley J. Health Equity Audit - Stop Smoking Service: NHS Medway 2011; Kent & Medway Public Health Observatory. http://www.kmpho.nhs.uk/lifestyle-and-behaviour/smoking/?assetdet957414=216973 .
      [7]   Diment E, Harris J, Jotangia D, et al. Smoking, drinking and drug use among young people in England in 2008 2009; The NHS Information Centre. http://www.ic.nhs.uk/webfiles/publications/sdd08fullreport/SDD_08_%2809%29_%28Revised_Oct_09%29.pdf .
      [8]   London Health Observatory. Local Tobacco Control Profiles for England 2010; http://www.lho.org.uk/LHO_Topics/Analytic_Tools/TobaccoControlProfiles/default.aspx
      [9]   Ledar D, Singleton N, Melter H. Psychiatric Morbidity among Young Offenders in England and Wales 2000; Office for National Statistics. http://www.google.co.uk/url?q=http://www.ons.gov.uk/ons/rel/psychiatric-morbidity/psychiatric-morbidity-among-young-offenders/psychiatric-morbidity-among-young-offenders/psychiatric-morbidity---among-young-offenders.pdf&sa=U&ei=IL76T4iWNua_0QW5gdG6AQ&ved=0CBMQFjAA&sig2=FNcTvw3ut6Q3ECW8YXVH1Q&usg=AFQjCNEUyGTfisdcCS_-j6hee3hKvMpsBw .
      [10]   Jochelson K, Majrowski B. Clearing the Air: Debating smoke-free policies in psychiatric units 2006; King's fund. http://www.spacetobreathe.org.uk/uploads/ClearingtheAir.pdf .
    • The level of need in the population

      Smoking prevalence

      Nationally, the prevalence of smoking among adults dropped from 24% in 2005 to 21% in 2008.[1] Smoking prevalence in Medway in 2010 was recorded at 24.9% higher than the national average. Smoking prevalence in Kent was higher than the national figure at 24.9%. The variation in prevalence across the Medway area is significant and varies between 16.2% in Rainham Central and 39.8% in Chatham Central (see Appendix -> Health and social care maps). There were around 54,344 smokers in Medway in 2010.

      Figure 1: Smoking prevalence among over 18s in Medway and in England
      Figure 1: Smoking prevalence among over 18s in Medway and in England

      A Health Equity Audit (HEA) carried out in July 2011 by the Kent Public Health Observatory [2] on the Medway Stop Smoking Service found that groups I, E, K and J had a good level of uptake. Smoking prevalence is highest in Mosaic group I,K,N and O and these groups make up 31% of the Medway population. Although the service is doing well at attracting smokers from Mosaic Group I and K, it is likely that there is a potential to target more smokers from group N and O.

      The mosaic groups that are not well represented in Figure 21 are A, C and L, however smoking prevalence in these groups is lower than the England average so the number of smokers to target will be lower. Smoking prevalence is strongly linked to deprivation. 45% of men and 40% of women in the most deprived 15% of households are current smokers.[3]
      Routine and manual (R/M) smokers form the largest group of smokers among the general population and as stated, have higher smoking rates than other occupational groups in the general population (31% in R/M men and 27% in R/M women compared with 21% and 20% respectively in the general population).[4]

      Age


      • Those aged between 18 and 34 are setting the most quit dates. Those that are most successful in quitting are the older population aged 60 plus.
      • Those aged 20 to 34 reported the highest prevalence of cigarette smoking (32% among 20–24 year olds and 26% among 25–34 year olds) while those aged 60 and over reported the lowest (12%).
      • Low Income Diet and Nutrition Survey 2007 [3] found that older adults were much less likely to be current smokers than younger adults. Among men, the prevalence of current smokers was 54% for men aged 19–34, 58% for those aged 35–49, 52% for men 50–64 and 22% for men aged 65 and over. It is a similar pattern for women.

      Figure 2: Numbers of Medway residents quitting smoking by age group in 2010/2011
      Figure 2: Numbers of Medway residents quitting smoking by age group in 2010/2011

      Gender


      • Males are more successful at quitting than females. Medway have been more successful at getting both men and women to quit and are better than the South East Coast and England average.

      Figure 3: Numbers of Medway residents quitting smoking by gender in 2010/2011
      Figure 3: Numbers of Medway residents quitting smoking by gender in 2010/2011

      Young people


      • In recent years the proportions of young people smoking has declined. In 2006, the proportion of 11 to 15 year olds who said that they had smoked at least once in their lives was 39%; this fell to 33% in 2007 and 32% in 2008.[5] The survey defines regular smoking for this age group as usually smoking at least once a week. The proportion of this age group who were regular smokers was 9%in 2006, and 6%in both 2007 and 2008. Girls are more likely to smoke than boys and there is an increase in the prevalence of regular smoking with age.
      • In the south east 7% of young people between 11 and 15 years old smoke with more girls smoking than boys.[5] This is despite the increase in age at which it is legal to buy tobacco to 18.
      • Three in ten (29%) of pupils have tried smoking at least once. This proportion is the lowest measured since the survey began in 1982, when more than half of pupils (53%) had tried smoking. In the south east 35% of young people self-report ever smoking a cigarette, compared to 29% nationally. More girls have tried smoking at least once (36%) than boys (33%).
      • There are approximately 37% homes within England in which dependent children are living with smokers and potentially exposed to second-hand smoke.[6]

      Smoking in Pregnancy


      • The number of maternities has been fairly steady in Medway and is currently around 3500 per year.[7]
      • The prevalence of smoking during pregnancy is high among the Medway residents compared to the England Average of 14%; it is currently around 20% in Medway.
      • This level equates to approximately 700 Medway resident mothers still smoking at the time of delivery each year. It also indicates that around half the women who smoke are stopping smoking during pregnancy.

      Prisoners


      • The prevalence of smoking is much higher in the offender population than in the general population, for example it is estimated that at least 80% of prisoners smoke compared to 24% of the population of Medway.
      • The health needs of children and young people in the secure estate are noticeably higher than for those in contact with the YJS than they are in the community. Contact with the youth justice system (YJS) will produce positive health and well-being outcomes for children and young people. Early identification and attention to these needs should be considered integral to work to reduce youth crime and anti-social behaviour.[8]


      References

      [1]   Office for National Statistics. General Lifestyle Survey 2008: Smoking and drinking among adults 2010; Office for National Statistics.
      [2]   Spencer S, Jolley J. Health Equity Audit - Stop Smoking Service: NHS Medway 2011; Kent & Medway Public Health Observatory. http://www.kmpho.nhs.uk/lifestyle-and-behaviour/smoking/?assetdet957414=216973 .
      [3]   Food Standards Agency. Low Income Diet and Nutrition Survey 2007; http://food.gov.uk/science/dietarysurveys/lidnsbranch/
      [4]   Department of Health. Service delivery and monitoring guidance, 2011/12 2011;
      [5]   Diment E, Harris J, Jotangia D, et al. Smoking, drinking and drug use among young people in England in 2008 2009; The NHS Information Centre. http://www.ic.nhs.uk/webfiles/publications/sdd08fullreport/SDD_08_%2809%29_%28Revised_Oct_09%29.pdf .
      [6]   Action on Smoking and Health. Secondhand Smoke: the impact on children 2011; Action on Smoking and Health. http://www.ash.org.uk/files/documents/ASH_596.pdf .
      [7]   Office for National Statistics. Births by area of usual residence of mother, England and Wales 2010;
      [8]   Department of Health. 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, Ministry of Justice, Home Office and Department for Children, Schools and Families. http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_109772.pdf .
    • Current services in relation to need

      The Stop Smoking Service in Medway

      The service has a range of support options across Medway including group, workplace, one to one, drop in and telephone support as well as specialist pregnancy support. They also offer specialist support whilst you are in hospital. They can provide these services in a wide range of venues including health centres, pharmacies, GP surgeries, community centres, libraries, hospitals and many more. Nicotine replacement therapy (NRT) is available for a one off prescription charge (exemptions apply) and prescription medication is also available via your local GP (prescription charges apply). Staff are trained to deliver services within military, prisons, dental, young people's settings. The service employs a polish worker, who speaks Slovak, Bulgarian and Roma who delivers stop smoking support in these languages.

      All of the services recommend are provided by friendly trained stop smoking advisors, who offer a non-judgemental and supportive service. They will provide practical and expert advice on the most suitable treatment for you and give a wide range of coping strategies to help you be successful.

      There is a website which is designed to be a further source of support for Medway residents who are either interested in quitting themselves, or helping a friend or family member to quit successfully. Registering for the website is free and those who register will not be contacted by any of the team unless requested to.

      Registering as a member provides people with access to a wealth of information on how to quit smoking and the opportunity to join an online stop smoking group, so that they can receive specialist support from the comfort of their own home.

      2010/2011 was a successful year for the stop smoking service in Medway. The service exceeded their vital signs target by 194%.

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

      We expect the current trend in prevalence in Medway to continue to follow England's downward trend.

      However, the prevalence and rate of reduction varies widely across Medway and between groups within Medway, for example there is a far lower prevalence in managerial and professional groups than routine and manual groups. The reduction in routine and manual groups therefore needs to be greater if the gap is to be narrowed.

      Services will therefore need to be concentrated in areas that are most accessible for those groups that will continue to have a higher than average smoking prevalence, including routine and manual groups, geographical areas of high deprivation, offenders and mental health in-patients.

      The Department of Health estimates nationally that 67% of smokers want to quit. As smoking is de-normalised in Medway, more people are likely to want to quit and there is therefore likely to be an increase in smoking cessation service need over the next 10 years.

      As noted earlier, while the smoking cessation service is a highly cost-effective intervention, it is clear that this can only be one part of a comprehensive programme. A Smokefree Future: A Comprehensive Tobacco Control Strategy for England [1] describes the other two objectives as 'stopping the inflow of young people recruited as smokers' and 'protecting families and communities from tobacco-related harm'.

      Nationally, as the number of smokers reduces and there is less smoking-related morbidity, the average associated health care costs will fall. As smoking prevalence in Medway continues to reduce, there is likely to be a continued reduction in overall healthcare service use and costs associated with smoking if this continues. The cost to the NHS of smoking-related illnesses in the UK has been estimated at between £2.7 billion and £5.2 billion.[2][3]


      References

      [1]   Department of Health. A Smokefree Future: A Comprehensive Tobacco Control Strategy for England 2010; Department of Health. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_124917 .
      [2]   Action on Smoking and Health. The Cost of Smoking to the NHS 2008; Action on Smoking and Health. http://www.ash.org.uk/files/documents/ASH_694.pdf .
      [3]   Allender S, Balakrishnan R, Scarborough P, et al. The burden of smoking-related ill health in the UK Tobacco Control 2009; 18: 262-267.
    • Evidence of what works

      Medway evidence

      A Smoking Health Equity Audits for Medway has recently been produced. (ensure link is correct) The service attracts more people from areas where smoking prevalence and deprivation are the highest and quit rates tend to be slightly higher in the least deprived areas. Stop smoking services in Medway are well distributed although possibly limited in some areas of high smoking prevalence. Most people who quit smoking used community groups, drop in sessions, GP practices or pharmacies for support. People quitting from the military achieved the highest success rates at 86%, however the numbers were relatively low for this setting. The community groups achieved an overall success rate of 73% with a higher proportion of numbers. Referral pathways and CQUIN targets have been set up with the Medway Community Health Care Trust and the Acute Trust in Medway and the service has seen an increase in the number of referrals to the service.

      Figure 4: Numbers of Medway residents quitting smoking at 4 weeks 2005/2006 to 2011/2012
      Figure 4: Numbers of Medway residents quitting smoking at 4 weeks 2005/2006 to 2011/2012

      Research in Medway

      Medway is committed to participating in local research and developing the evidence base for effective tobacco control and smoking cessation services. The following pieces of research are currently underway:
      • Medway stop smoking service have supported Dr Michael Ussher (St Georges University London) with the LEAP Trial which investigated if physical activity was potentially effective and popular alongside behavioural support for smoking cessation during pregnancy.
      • The service is taking part in a study that is aimed at investigating a new method of encouraging people to attend the NHS Stop Smoking Services by offering taster sessions. This Start 2 quit trial is a randomised control trial that is being directed by UCL.

      National Evidence [links]


      • The Centre for Disease Control Best Practices for Comprehensive Tobacco Control programme states: “A comprehensive state wide tobacco control programme is a co-ordinated effort to establish smoke free policies and social norms, to promote and assist tobacco users to quit and to prevent initiation of tobacco use.”
      • The Health Inequalities National Support Team have published what works to improve uptake of SSS through their tobacco control visits Learning from National Support Team Visits Tobacco Control.
      • Ten High Impact Changes to achieve tobacco control (Department of Health, 2008) should be used to plan the development and delivery of best practice tobacco control interventions. These recommendations and identified gaps from the benchmarking exercise have been translated into 6 priority actions within the Tobacco Control Strategy and Action Plans. The document has been archived and is no longer accessible. The ten changes are as follows: (1) Work in partnership, (2) Gather and use the full range of data to inform tobacco control, (3) Use tobacco control to tackle health inequalities, (4) Deliver consistent, coherent and co-ordinated communication, (5) An integrated stop smoking approach, (6) Build and sustain capacity in tobacco control (7) Tackle cheap and illicit tobacco (8) Influence change through advocacy, (9) Helping young people to be tobacco free, (10) Maintain and promote smokefree environments.
      • The Health Act 2009 requires tobacco products to be removed from display in shops. This new law will be implemented for large retailers in October 2011 and small retailers in October 2013. The Act also enables the prohibition of tobacco sales from vending machines, although this still subject to Parliamentary consideration of regulations.
      • Beyond Smoking Kills (ASH, 2008) details a number of tobacco control priorities and contains new and useful research to support local priority setting.
      • A Smokefree Future: A comprehensive tobacco control strategy for England (Department of Health, 2010) details the rationale and evidence-based policies for future tobacco control work under three objectives:
      • To stop the inflow of young people recruited as smokers.
      • To motivate and assist every smoker to quit.
      • To protect families and communities from tobacco-related harm.


      • NICE public health guidance 10 (Smoking cessation services in primary care, pharmacies, local authorities and workplaces, particularly for manual working groups, pregnant women and hard to reach communities), public health guidance 23 (School-based interventions to prevent smoking) and public health intervention guidance 1 (Brief interventions and referral for smoking cessation in primary care and other settings) details the guidance and recommendations for preventing uptake of smoking, engaging people and successful smoking cessation.

    • User views

      Desire to give up smoking

      67% of smokers say they would like to give up smoking, with 75% having tried to give up smoking in the past.[1]


      References

      [1]   The NHS Information Centre for Health and Social Care. Statistics on Smoking, England 2010 2010; http://www.ic.nhs.uk/pubs/smoking10
    • Equality Impact Assessments

      Medway Stop Smoking Service Equality Impact assessment: the service is providing evidence of equitable uptake relative to need by diverse population groups in terms of smoking cessation.

    • Unmet needs and service gaps
    • Recommendations for Commissioners

      Motivating people to stop smoking


      • Provide training and ensure wider delivery of brief advice/interventions across primary and secondary care and frontline Council work (e.g. social care). Ensure systems are in place for those staff to proactively refer to the stop smoking services.
      • Consider a local survey to gain an accurate reflection of local smoking prevalence.

      Smoking cessation services


      • Continue the focus on: smoking in pregnancy; geographical areas of high prevalence; and routine and manual workers.
      • To have an input into influencing the new service specification on maternity services and implement guidance from NICE.
      • Review whether current provision meets the needs of groups with high smoking prevalence including: mental health in-patients; mental health patients in the community.
      • Ensure CQUIN targets continue within the Acute and Community Healthcare trusts.
      • Ensure robust service level agreements are in place with external providers, such as GP's, Pharmacies and Prisons.
      • Consider stop smoking interventions in any new commissioning contracts.
      • Consider a patient group direction (PGD) for Champix to enable patients to gain access to smoking pharmacotherapies quicker and easier.

      Protection from tobacco-related harm


      • Engage wider partners with the tobacco control agenda to ensure a mutli-agency tobacco control alliance is established and implement a local tobacco control delivery plan.
      • Formulate a clear communication approach, supported by community engagement activity.
      • Continue with the development of smoke free initiatives.
      • Continue development and implementation of workplace smoking policies for NHS and local authority organisations. Review policies of other partner organisations and Medway employers.
      • Support the multi-agency illegal tobacco campaign to reduce supply and demand of illicit tobacco in Medway.
      • Support Medway Maritime Hospital to achieve and maintain a Smokefree Hospital site.

      Stopping Young People from starting to smoke


      • Continue to support young people's section of the website and investigate other social media methods to engage young people.
      • The DH Tobacco Control Plan set out new national ambitions to reduce smoking prevalence among 15-year olds to 12% by the end of 2015. As the responsibility for public health moves to local authorities, it is important that elected members continue to play a key role and have access to the very strong evidence that exists to support continued local investment in tobacco control, to reduce the harms from smoking and tobacco use in their communities.
      • Investigate the possibility of carrying out a young people's survey to identify smoking prevalence among the 15 year olds to ensure that the 12% prevalence is met by 2015.
      • Enforcing schools to adopt NICE guidance

      Improving evidence base


      • Continue to work with UCL and support the 'start to quit' study to assess whether 'come and try it' taster sessions will attract more smokers to attend stop smoking services.

    • Further needs assessment required
  • Substance misuse in children and young people
    • Summary

      Problematic risk behaviours such as smoking and drug misuse during youth are strongly associated with social deprivation. However evidence of socio-economic variations in alcohol and drug misuse varies according to the definition of substance use that is adopted. Many UK surveys suggest a positive relationship between alcohol consumption and social status, young men and women from higher income groups drinking more frequently and in larger amounts. Similarly the use of cannabis and amphetamines does not appear to be strongly associated with social deprivation although young people who leave school at 16 appear more likely to have tried drugs than those who stay on to achieve higher qualifications. Against this highly problematic drug and alcohol use appear to be strongly associated with social disadvantage.

      The close correlation between substance misuse and unplanned teenage pregnancy has been highlighted in many studies, as risk taking behaviour in one may easily lead to experimentation in the other. Use of substances may lead young people to intimate sexual contacts, having unprotected sex, having sex with someone they don't know or becoming a victim of a sexual act.

      Key issues and gaps

      An increase in the number of young people presenting at specialist services who are injecting drug users. Poor pathways of care between the secure estate and the Youth Offending Team (YOT) regarding substance misuse services, both inside and outside of Medway. Looked after children (LAC) are not being referred from Children's services but are being identified through schools or the Youth Offending Team (YOT) following a crisis. A more proactive approach is required. No specifically funded work for children affected by someone else's substance use

      Recommendations for Commissioning

      To continue to establish levels of need in relation to young people's own substance use
      • During 2011/12, re-tender young people's substance misuse services within secure estates in line with new strategic direction and identified revised funding
      • Commission systemic work for children affected by parental/family substance use
      • Ensure that mechanisms continue to be in place to support workforce development within universal and targeted services.
      • Develop and ratify a needle exchange policy for under 18's
      • Commission educational and skills training for foster carers

    • Who's at risk and why?

      All children and young people are potentially at risk of misusing drugs and / or alcohol. There is evidence of a significantly increased propensity to misuse substances amongst certain vulnerable groups (as highlighted in Every Child Matters) including:
      • Children in care;
      • Persistent absentees;
      • Excludees;
      • Young offenders;
      • Homeless young people; and
      • Children affected by parental substance use.

      Substance misuse has a negative impact on children and young people across each of the five Every Child Matters Outcomes. Effects include the impact of drugs and/or alcohol in relation to sexual health and teenage pregnancy; failing in education, employment and training; and involvement anti-social and criminal activity. It should also be noted that children and young people may have multiple vulnerabilities, which are likely to increase the individual's propensity to use drugs and/or alcohol. Although consumption has increased for both boys and girls (25% of 16-24 year olds now drink more than the recommended weekly limit) a greater proportion of heavy drinkers (>50 units per week) are young men (9% compared with 6% of young women). It is important to note the increased potential risks and social costs associated with young women drinking heavily however. Alcohol can be toxic in pregnancy and may become an added complication in unplanned under 18 years conceptions . Alcohol use is disproportionately concentrated in areas of high deprivation. In the most deprived areas, alcohol-related death rates amongst women are three times higher than those women in the least deprived areas, for men they are five times higher. A recent study of 11,622 subjects from the 1970 British Birth Cohort Study, surveyed at aged 16 years (1986) and aged 30 years (2000) showed that binge drinking was reported in 17.7% of the cohort. It was associated with increased risk of drug/alcohol dependence, excessive regular consumption, illicit drug use, psychiatric morbidity, homelessness, convictions, school exclusions, lack of qualifications and lower adult social class. In short, adolescent binge drinking was a risk behaviour associated with significant later adversity and social exclusion and may contribute to the development of health and social inequalities during the transition from adolescence to adulthood.

      There is a genetic predisposition (generational transmission) and a higher risk in families already affected by alcohol abuse, and early exposure to drinking alcohol increases the risk of problematic drinking in adolescence. There is also strong association between parental substance misuse, domestic violence and mental health. The presence of any of these factors is likely to lead to an increase in emotional and behavioural difficulties and poor attachment impacting on current and future relationships. The presence of one or more of these factors has particular implications for safeguarding concerns and high numbers being referred into social care for these groups. Over 50% of serious case reviews include at least one of these factors. Given this correlation these factors, singularly or combined are seen as the 'trilogy of risk'.

    • The level of need in the population

      Medway has 28,000 10–17 year olds. 10.3 per cent of young people (in years 6, 8 and 10) reported either frequent misuse of drugs/volatile substances or alcohol or both.[1] There were 58 hospital admissions over a three year period of young people aged under 20 with mental and behavioural disorders due to substance misuse. During the same period there were 18 admissions of young people with poisoning by narcotics and psychodysleptics.[1] At any one time there are 66 young people engaged in structured treatment with KCA which offers a range of services to young people affected by their own or someone else's drug or alcohol misuse.[2]

      A range of research indicates that there is significantly increased drug use amongst vulnerable young people groups, including Children in Care, persistent absentees and truants, young offenders, young homeless and children whose parents misuse drugs and/or alcohol. The children and young people's plan for Medway estimates the number of children requiring Tier 3 level of intervention to be around 1,850 (this includes all children aged 0–19), with around 350 children in care with Medway Council. There were 526 first time entrants into the youth justice system in 2008.[1]


      References

      [1]   Medway Council. Children and Young People's Plan 2011; Medway Council. http://www.medway.gov.uk/pdf/031109_g4379_-_web_version-2.pdf .
      [2]   Medway Council. Medway Drug and Alcohol Service Providers 2012/13
    • Current services in relation to need

      Screening Training for the wider Children's Workforce to identify substance use/misuse and refer. Specialist input on diversionary programmes e.g. Fairbridge Drug Intervention Support Programme to reduce first time entrants into the criminal justice system for drug offences. Named Specialist Drug Worker with the Youth Offending Team (YOT) — screening 100% of YOT clients. Early Intervention worker — targeting links with sexual health and substance misuse, maintaining young people in educational settings, increasing protective factors for young people and reducing harm. Treatment services — for young people requiring 1-1 specialist treatment such as counselling and substitute prescribing. Since the last JSNA the balance of work has shifted towards a more treatment focus due to ongoing restrictions to funding.

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

      There has been a small increase in the incidence of Heroin use among under 18's in Medway this year. The DAAT are considering needle exchange options for young people in the interests of public and personal safety. It is possible that if the population of Eastern Europeans increases over the coming years the prevalence of under 18 heroin use will also continue to increase. The users we have in services are known to each other and from the Eastern European community. This will increase demand on prescribing and needle exchange services which is costly. Translators are also sometimes required. 'Feeder' initiatives, such as Triage in custody (a targeted youth support intervention) is likely to increase the demand on services due to early identification. Commissioned services may need to be restructured should the skills balance need to shift. In the second quarter 86% of Medway's young people in care had left in a planned way, compared to the national average of 79%. We would look to maintain this level.

    • Evidence of what works

      National Guidance:

      Every Child Matters: Change for Children Young People and Drugs Young People's Specialist Substance Misuse Treatment: Commissioning Guidance Young People's Specialist Substance Misuse Treatment: Exploring the Evidence Young people's substance misuse treatment services – essential elements Assessing Young People for Substance Misuse. Hidden Harm Report Advisory Council Misuse of Drugs 2003 Drug Use Among Vulnerable Young People: developing a local picture Crime and Drugs Analysis and Research Home Office 2007 Healthy Child Programme

      Summary of evidence base:

      There must be targeted interventions within generic children and young people's services for those at risk around substances (particularly for those most at risk, such as children of problem drug users, persistent truants and school excludees, looked after children, young offenders, and homeless young people). These interventions should include:
      • early assessment around substance misuse issues;
      • care management and appointment of a lead professional for all children and young people who need support and interventions around use;
      • integrated information systems to help agencies work together to track interventions with individual children and young people;
      • clear referral routes to specialist provision when needed. (ECM: Young People and Drugs) Service and workforce development is a key priority: all people working with young people have a key role to play in addressing substance misuse among children and young people. Substance misuse training should be available in every area and basis drugs awareness training should be incorporated into core professional training across the workplace (ECM: Young People and Drugs).

      Children and adult services must adopt a Think Family approach: by taking a whole family approach and by working closely together, drug and alcohol services, dedicated young carer services and children, parenting and family services can meet the needs of parents whose substance misuse is adversely affecting the whole family. (Department for Children, Schools and Families (DCSF), Department of Health (DH) and National Treatment Agency for Substance Misuse (NTA): Joint Guidance on Development of Local Protocols between Drug and Alcohol Treatment Services and Local Safeguarding and Family Services). Specialist services must take a care planning approach to treatment and tailor effective and individualised packages of care to the young person's specific needs. Specialist treatment provision must be closely integrated with wider children and young people's provision.

    • User Views

      KCA consult with service users with regards to service provision. Medway Council consulted with Medway residents when developing the children and young people's plan and found that young people are really concerned about the effects of smoking, taking drugs and drinking alcohol and the fact you often see young people smoking and drinking in places like parks. There were real concerns about young people who drink alcohol and not knowing what they might do.[1]


      References

      [1]   Medway Council. Children and Young People's Plan 2011; Medway Council. http://www.medway.gov.uk/pdf/031109_g4379_-_web_version-2.pdf .
    • Equality Impact Assessments
    • Unmet needs and service gaps


      • There is a lack of detailed information available on the number and needs of children and young people with substance misuse needs that are not in specialist dug and alcohol treatment.
      • Young people's drug and alcohol provision is largely funded through external grant funding. This is likely to reduce with implications for the level and structure of substance provision. Significant reductions in provision are likely to have longer term implications for increased levels of offending behaviour, higher numbers requiring adult treatment and a range of health implications.
      • As yet, no funding has been identified to ensure ongoing provision of targeted and specialist services for children affected by parental substance misuse. Lack of specialist provision is likely to have significant implications for safeguarding.
      • Looked After Children are being identified through schools or Youth Offending Team (YOT) following a crisis and referred into services. Yet the number of referrals to specialist drug and alcohol services from Looked After Children Teams are low.
      • The numbers of young people undertaking the transition into adult drug and alcohol services are very small.
      • Transitional arrangements between the secure estate and YOT regarding substance misuse services, both inside and outside of Medway need to be developed.
      • Needle Exchange Policy for under 18's needs ratified with the increasing presentation of injecting heroin users.

    • Recommendations for Commissioning


      • To continue to establish levels of need in relation to young people's own substance use
      • During 2011/12, re-tender young people's substance misuse services within secure estates in line with new strategic direction and identified revised funding
      • Commission systemic work for children affected by parental/family substance use
      • Ensure that mechanisms continue to be in place to support workforce development within universal and targeted services.
      • Develop and ratify a needle exchange policy for under 18's
      • Commission educational and skills training for foster carers

    • Recommendations for needs assessment work

      Switch the focus to quality local data now that the National Treatment Agency (NTA) are not so prescriptive about data collection. Treatment is a small part of the work we commission and we need to focus more on how our work impacts on the wider agenda.

      The NTA is about to provide us with needs assessment data capturing local activity and the complexity of the cohort within the specialist system. Later in the year the NTA will also be releasing an overview of data suitable for inclusion in the JSNA submission.

  • Substance misuse in adults
    • Summary

      Medway Community Safety Partnership (CSP) support Medway Drug and Alcohol Action Team (MDAAT) to deliver the National Drug Strategy (Drug Strategy 2010: Reducing demand, restricting supply, building recovery: supporting people to live a drug-free life). The strategy moves the focus of treatment away from increasing numbers and towards an increase in recovery.

      Key issues and gaps

      Medway still has a very low number of non-opiate drug users accessing the KCA service. The restructuring of this team should improve this situation and there has already been an increase in the number of non-opiate clients referring to the service.
      There is an increasing number of prescription drug clients accessing the drug service. Work needs to be done with GPs around this as well as more community focus on this area of work. There is a need to provide carer support in Medway which doesn't exist at the moment. Following an audit of all commissioned services this year there has been a need identified around Safeguarding Children and Hidden Harm within services. There is also more work needed around transitional age clients in the young people's service — particularly as they have an increasing number of young heroin users accessing their service who are prescribed for by the adult service.

      Recommendations for Commissioning

      Medway DAAT is currently undertaking its needs assessment but there are already indications that on-going training is needed for staff around working with non-opiate using clients, safeguarding children and Hidden Harm. Re-commissioning of Rochester Prison substance misuse service in line with national guidance.

    • Who's at risk and why?

      National Research conducted by the Home Office [1] has identified a group of risk factors for which may lead to drug use. These factors include parental discipline, family cohesion, parental monitoring, peer drug use, drug availability, genetic profile, self-esteem and hedonistic attitudes. There is less consistent evidence linking drug use to mental health, parental substance use, Attention Deficit Hyperactivity Disorder, religious involvement, sport, health educator-led interventions, school performance, early onset of drug use and socio-economic status. This review also recognised that there are certain groups of young people that are a greater risk of drug use, i.e. 17–24 year olds that:

      • have anti-social behaviour;
      • begin early smoking;
      • are in trouble at school (including truanting and exclusion);
      • are impulsive;
      • are un-sensitive
      • who belong to few or no groups.

      Further to this there is evidence from the Home Office British Crime Survey to suggest that Class A illicit drug use is increasing among 16 to 24 year-olds, with more than half a million young people taking cocaine and ecstasy in the last year. However, the latest findings from the British Crime Survey [2] confirm that the long term gradual decline in cannabis use among young people has continued. They also show that the profile of the most likely frequent illicit drug user is white, young, male, single, a regular clubber and likely to be seen in the pub (however, it must be recognised that this survey is completed by residents in households and a large proportion of problematic drug users will be homeless or not permanently housed). National research also estimates that 55% of prisoners are drug users. Prison is also where many problematic drug users (PDUs) will first use or be exposed to heroin. The health and wellbeing needs of offenders are considered elsewhere.

      Clients currently attending services are predominantly white British.

      The vast majority of clients accessing the KCA drug service are primary heroin users. There is a need to ensure that the non-heroin using population is also having their needs met by the service.
      More work needs to be carried out with adult substance misusers with children or who have access to children to address Hidden Harm issues.


      References

      [1]   Dillon L, Chivite-Matthews N, Grewal I, et al. Risk, protective factors and resilience to drug use: identifying resilient young people and learning from their experiences 2007; Home Office. http://webarchive.nationalarchives.gov.uk/20110218135832/http://rds.homeoffice.gov.uk/rds/pdfs07/rdsolr0407.pdf .
      [2]   Hoare J. Drug Misuse Declared: Findings from the 2008/09 British Crime Survey 2009; Home office. http://webarchive.nationalarchives.gov.uk/20110218135832/http://rds.homeoffice.gov.uk/rds/pdfs09/hosb1209.pdf .
    • The level of need in the population

      For Medway, the estimated number of Problematic Drug Users (PDUs) is 1,372 (95% CI 1,017–1,408).[1]

      Figure 1 displays a collection of indicators using data from the National Drug Treatment Monitoring System (NDTMS) (shown in colour) and other data sources relevant to substance misuse.[2] It shows the local value for each indicator compared to the highest and lowest value of all South East DAATs and the average for the South East. The darker shaded points show that the local value is outside the middle two quartiles of the South East range and the lighter shaded points show the local value is within the middle two quartiles of the South East range.

      Figure 1: National Drug Treatment Monitoring Unit DAAT Profile 2009/10
      Figure 1: National Drug Treatment Monitoring Unit DAAT Profile 2009/10 [2]

      The data shows that 694 PDUs were accessing treatment services suggesting that approximately 51% of the estimated population of PDUs are in structured treatment. The majority of clients accessing services are primary heroin users, reflecting the Glasgow research which estimates that 87% of PDUs will be opiate users.

      Medway has a lower than regional average number of Black and Minority Ethnic (BME) clients accessing treatment and there is a need to ensure our services are meeting the needs of the whole community. Over a third of clients accessing treatment are pregnant or have children. The Windmill Clinic is an ante-natal service for drug and alcohol users in Medway Hospital and these clients have a continuity of care following the birth of their children through appointments being held at Children's Centres. Following an audit of all commissioned services this year a need has been identified around Safeguarding Children and Hidden Harm within services.


      References

      [1]   Home Office. Measuring different aspects of problem drug use: methodological developments (2nd edition) Online report 16/06 2006; Home Office. http://webarchive.nationalarchives.gov.uk/20110218135832/http://rds.homeoffice.gov.uk/rds/pdfs06/rdsolr1606.pdf .
      [2]   Drug Treatment Monitoring Unit. DAAT Profile 2009/10 2010; Drug Treatment Monitoring Unit. http://www.dtmu.org.uk/sph-files/2009-10-team-profiles-docs/adult-daat/J14B_Adult_DAAT%20Profile_0910_Medway.pdf/view .
    • Current services in relation to need
        Estimates 2008/09 Numbers in effective
      treatment(03/11)
      Percent in
      treatment
      PDUs 1,372 681 50
      Opiate users only 1,196 486 41
      Crack Cocaine users only 176 195 111
      Drug injectors 786 353 45
      PDUs aged 15-24 221 34 15
      PDUs aged 25-34 581 278 49
      PDUs aged 35-64 570 369 65
      Table 1: Estimated numbers of adults with drinking problems in Medway
      (Based on 199,700 adults)

      KCA Medway Service provides prescribing, key working and group work for drug users and also provides the Alcohol Treatment Requirement (ATR) for clients on this probation order.
      CRI (Crime Reduction Initiatives) provide the Drug Intervention Programme (DIP) for clients in the criminal justice system as a result of their drug use, they provide assessments and referrals on to appropriate treatment services and case management. Care Management team provide support for complex clients and also provide Community Care Assessments for clients wishing to access residential rehabilitation. Inpatient detoxification and residential rehabilitation services are spot purchased from a variety of providers across the country based on the individual needs of clients.

      The Windmill Clinic provides ante-natal services for women who misuse substances.

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

      Home Office analysis of the British Crime Survey [1] indicates that illicit drug misuse among adults (aged 16–59) in England and Wales declined in 2009–2010 with 8.6% of adults using one or more illicit drug use within the last year, compared to 10.1 in 2008–2009 and 11.1% in 1996. The decline is mainly due to a decrease in cannabis use. Class A drug trends and specifically opiate and crack use remained stable. Although these are not statistically significant trends, it appears that in the short term (3–5 years), numbers are likely to remain the same or fall slightly, subject to continued levels of investment in drug treatment services.

      In the medium term (5–10 years), numbers may be seen to fall as a result of the redesign and re-tendering of drug and alcohol treatment services, in a new redesigned treatment system as part of the focus on recovery and re-integration.

      There is an expectation that the number of problematic drug users (PDUs) exiting structured treatment successfully will increase with more people achieving sustained recovery and freedom from dependence on drugs. There is a national decrease in the number of heroin users and it is expected that Medway service users will reflect this changing population. There is already an increase in the non-opiate using clients who are accessing the drug service and this is expected to expand. It is expected that there will be a significant increase in the number of prescription drug misusing clients accessing services in the coming years.

      Due to the introduction of the Treatment Review Panel and the restructuring of service provision in the drug service there has already been a significant increase in the number of clients who are completing treatment drug free. Medway is now above the regional and national average for clients completing treatment drug free.


      References

      [1]   Hoare J. Drug Misuse Declared: Findings from the 2008/09 British Crime Survey 2009; Home office. http://webarchive.nationalarchives.gov.uk/20110218135832/http://rds.homeoffice.gov.uk/rds/pdfs09/hosb1209.pdf .
    • Evidence of what works

      Drug treatment is effective — National Treatment Outcomes Research Study [1] highlights the positive outcomes which include a reduction in illicit drug use, abstinence, reduction in criminal activity, lower risk of overdose and the spread of blood borne viruses, and better health, which benefit the individual, their family and society.

      Gossop [2] also reviewed the evidence of the effectiveness of drug treatment from the last 30 years. Pharmacological interventions are shown to have better outcomes in terms of reduced illicit drug use, reduced criminal behaviour and lower levels of HIV risk, and better retention rates have been linked to methadone clients. Psychological interventions help in terms of greater treatment retention and fewer relapses, reduction in drug use. Residential rehabilitation has show positive outcomes in terms of improved rates of abstinence, drug injection and needle sharing. Needle exchange schemes reduce injecting risk behaviours, reduced public order problems, reduced HIV prevalence. Complementary therapies have been liked to better attrition.

      Drug users in treatment commit fewer crimes — [3] offences halved when drug users went into treatment, particularly acquisitive crime. For those that triggered test on arrest, there was a reduction of 61% in follow up offences. They also found a link between positive outcomes and treatment duration.

      National Guidance that is implemented: Drug Misuse and Dependence: UK Guidelines on Clinical Management Models of Care for Treatment of Adult Drug Users Nice Guidelines on Drug Misuse: Opioid Detoxification Nice Guidelines on Drug Misuse: Psychosocial Interventions Nice Guidance on the use of methadone and buprenorphine for opioid dependence Nice Guidance on the use of Naltrexone for the management of opioid dependence Reducing Drug-Related Harm: An Action Plan


      References

      [1]   Gossop M, Marsden J, Stewart D. National Treatment Outcomes Research Study: Changes in substance use, health and criminal behaviour during the five years after intake 2001; National Addiction Centre. http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4019729.pdf .
      [2]   Gossop M. Treating drug misuse problems: evidence of effectiveness 2006; National Addiction Centre.
      [3]   Millar T, Jones A, Donmall M, et al. Changes in offending following prescribing treatment for drug misuse 2008; National Treatment Agency. http://www.nta.nhs.uk/publications/documents/nta_changes_in_offending_rb35.pdf .
    • User Views

      All Medway service providers have service user involvement and there is a service user involvement organisation in Medway (MUST), which has representatives at the Joint Commissioning Group. Service users are involved in changing current drug services to be more recovery focused and some have been trained to support current clients as recovery coaches.

    • Equality Impact Assessments
    • Unmet needs and service gaps


      • There is a large number of Medway clients who drop out of drug services within the first 12 weeks of their treatment. If Medway moves towards payment by results contracts in line with national guidance the reasons for high drop out rates will need addressed.
      • The majority of our clients in treatment in our drug service are heroin users and more work needs to be done to meet the needs of non-heroin users.
      • More work needs to be carried out with substance misusing parents and the children of substance misusing parents.
      • Transitional age work needs to be instigated.
      • Community needle exchange provision needs to be extended.
      • Carer support needs to be developed.

    • Recommendations for Commissioning

      Medway DAAT is currently undertaking its needs assessment but there are already indications that ongoing training is needed for staff around working with non-opiate using clients, safeguarding children and Hidden Harm. Re-commissioning of Rochester Prison substance misuse service in line with national guidance.

    • Recommendations for needs assessment work


      • Identify areas of the community that are not currently accessing treatment services.
      • dentify alcohol needs and ways to meet these needs in the community.
      • Transitional age work and protocols.
      • Developing recovery focused provision.

  • Housing and homelessness
    • Summary

      Introduction

      Housing makes an important contribution to social and environmental objectives such as reducing health inequalities, improving educational attainment and community cohesion.

      Medway has benefited, and continues to benefit, from considerable investment arising from its strategic location within the Thames Gateway. Recent infrastructure investment includes Chatham Bus Station and the High Speed Rail Link. This is resulting in a welcome diversification of the economic base towards creative industries, financial services, business services, education, environmental and energy technologies. This has added to Medway's long-standing manufacturing strengths and important energy and port facilities located on the Hoo Peninsula. Good progress has been made in raising the skill levels, which are growing significantly faster than the regional and national averages. The unique cluster of universities and the Mid Kent College have contributed greatly to this. However, Medway remains a relatively low wage area with high numbers of people commuting out to work and skill shortages particularly at some levels.

      In recent years, as part of the Thames Gateway regeneration area, Medway has undergone extensive regeneration particularly in the former derelict riverside areas of Rochester, Chatham and Gillingham, which have been transformed into thriving business, higher and further education and residential communities. Medway is now looking to continue its regeneration along the riverside, in the town centres and through the only new settlement in the Thames Gateway at Lodge Hill, Chattenden, which will accommodate approximately 5,000 homes.

      The population of Medway is currently about 253,500 and is expected to grow to 280,000 by 2026. Overall, Medway is not a deprived area being ranked 150th most deprived local authority area out of 354 in England, but it has higher levels of deprivation than neighbouring local authorities in Kent and the South East. At ward level it has both some of the most affluent and some of the most deprived areas in the country. Within Medway are 25 neighbourhoods which fall into the 25% of most deprived areas in the country.

      Key issues and gaps

      The change of government in May 2010 has already seen a number of changes in housing policy introduced and others set for implementation over the coming months and years. Along with the Coalition's various policy announcements, the medium term housing financial landscape was completely re-drawn with the outcome of the 2010 Spending Review. The Spending Review has seen a reduction in Government funding for affordable housing investment nationally, a move towards charging affordable rents for new schemes coupled with the ending of 'tenancies for life' and the introduction of the New Homes Bonus. The Government has also proposed greater local freedom for the way social housing is allocated and how the homelessness duty can be discharged, and seeks to give local communities greater control over planning outcomes as a further way of encouraging development.

      Along with the Spending Review, the Coalition Government has introduced a number of other changes affecting housing. These include the abolition of a number of quangos including the Tenant Services Authority as the social housing regulator, with its powers being transferred to the Homes and Communities Agency (HCA); and the limiting of Local Housing Allowance payments from April 2011, with further changes to the Housing Benefit system to follow. Earlier cuts made to the Area Based Grant included the removal of the administration budget for delivering housing-related support services although the (Supporting People) funding for services themselves has largely been protected, as was the Homelessness Grant. Certain aspects of the previous government's housing and related policy will, however, continue to be pursued by the current government, including the transformation of social care through personalisation of service delivery.

      Range and Affordability of Housing in Medway

      There is a whole range of housing options within Medway from Temporary Accommodation for those in priority housing need to traditional home ownership and everything in-between. The primary obstacle to providing these options for all residents is that the market does not provide the type of housing needed at a cost many can afford. A key element to housing markets being able to function effectively is to enable choices to be made when seeking housing, regardless of income and financial circumstances. The housing offer of a community is one element to ensure that a diversity of households have their housing needs met. These choices are best represented through a continuum, depicted below.

      Figure 1: The Housing Continuum
      Figure 1: The Housing Continuum

      Traditionally the needs of those households unable to access the housing market have been met through social rented housing. Intermediate housing is affordable housing designed to assist those households not eligible for social rented housing but who are priced out of the private housing market by a combination of low wages and/or high house prices. The most common form of intermediate housing in Medway is shared ownership; however the amount and distribution is sensitive to changes in house prices. The credit crunch has lead to falling house prices in Medway. This was however accompanied by a credit squeeze making mortgage availability scarcer and more expensive. The credit crunch also led to the tailing off of private housing development and Registered Providers selling fewer properties for shared ownership. Property prices in Medway peaked in April 2008 and by May 2011 had fallen by an average £26,835. Over the first five months of 2011, house prices have fallen by £5,703. In June 2011, the Nationwide reported that there is uncertainty over whether house prices will rise or fall over the remainder of 2011. They have reported that economic growth looks set to gather pace but is likely to result in only modest gains in employment and wage increases, which will continue to keep many potential buyers unable to purchase property.

      Delivery of affordable housing

      Medway has a strong track record of delivering affordable housing, which has continued despite the downturn in the market. These affordable homes not only leveraged in large amounts of private finance toward the delivery of affordable housing but also have enabled many regeneration sites to continue delivering units during the market downturn. We have renegotiated through the planning system for key developments to bring forward affordable housing and remove some risk for developers during the early phases of development while the market recovers. However, we have taken a measured approach to guard against an oversupply of social rented housing.

      The recent Comprehensive Spending Review (CSR) announced a 60% reduction in the levels of government grant available for affordable housing. The gap left by the substantial cut in capital grant is expected to be met, in part, through revenue from the introduction of a new proposed 'affordable rent', to be charged for most newly built homes and many re-let properties. Despite these uncertainties, we are working in partnership with our Registered Provider partners, developers, planners and the HCA to ensure that where funding is needed and available this is secured. To date we have supported firm bids that if successful would deliver an additional 562 affordable units over the next 4 years. In addition to this, previously allocated funding (2008–11 NAHP) is due to deliver 443 affordable units over the current 2011–15 NAHP. Almost all of the units are currently under construction and will be delivered in the next couple of years. We have identified a further 325 affordable homes that have the potential to be delivered over the 2011–15 period without funding from the 2008–11 programme or have not been included in bids in the 2011–15 programme.

      Figure 2: Actual and Estimated Affordable Housing Delivery 2001--26
      Figure 2: Actual and Estimated Affordable Housing Delivery 2001–26

      Figure 2 shows current estimates of what could be delivered in terms of affordable homes over the next four years. We estimate that a total of 1,325 new affordable homes could be delivered. This will be reliant on a range of factors, not least a significant pick up in house building from what are currently very low rates in Medway. Only 650 completions are expected to be reported for 2010–11. This would need to almost double for all of the anticipated affordable units to be delivered.

      Making the best use of existing homes

      Key Achievements 2008–11
      • 454 empty properties brought back into use
      • 50 empty properties brought back into use as affordable housing through the Purchase and Repair Scheme
      • In 2010–11 we assisted 13 people to move to more suitable properties via our Mutual Exchange programme
      • Joined Kent HomeChoice in May 2010 to achieve better economies of scale and provide a more equitable and efficient service to our clients

      Empty homes represent economic, environmental and social costs to the community. As homes deteriorate they can become visually unattractive, therefore affecting the amenity of the local surrounding area as they create an impression of neglect and decline. This can encourage local property price devaluation, as an empty property can devalue neighbouring properties by as much as 20%. Empty homes can also be an attraction for vandalism and anti-social behaviour, which poses a risk for neighbouring properties and local residents, while increasing work for local fire and police services. At the end of March 2011, there were 1,281 empty homes in the private sector. This represents 1.37% of the total private sector housing stock. Whereas this is good progress against the Government target of 3%, one less empty property is a home for a household and less likely to be a potential source of anti-social behaviour.

      Ineffective use of the housing stock can result in overcrowding and underoccupation. Through our “Creating Space” initiative, we have identified households within the affordable housing stock whose current property does not meet their housing need.

      Sustainable and Cohesive Communities

      Key Achievements 2008–11
      • All new affordable homes achieved Code for Sustainable Homes Level 3 and some homes achieved Level 4
      • Nomination Rights were achieved for all new affordable homes
      • Contributed to the Development Brief for Rochester Riverside and other regeneration sites to secure the delivery of affordable housing
      • Developed and delivered the In Focus project to target resources in a specific area

      Sustainable communities are places where people want to live and work, now and in the future. They meet the diverse needs of existing and future residents, are sensitive to their environment and contribute to a high quality of life. This approach includes future proofing new properties to make sure they are adaptable to a household's future needs, developing mixed tenure communities, ensuring high quality design and build and considering affordability.

      Affordability in Rural areas can have an impact on the sustainability of a community. Young people may have to move away from the village they grew up in and older people may have to leave due to a lack of suitable housing which meets their needs.

      Quality of the housing stock

      Key Achievements 2008–11
      • 8,391 people were given energy efficiency advice by the Energy Savings Advice Centre

      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.

      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.

      Recommendations for consideration by commissioners

      Medway's priorities for Housing for 2011–14 are:

      Theme One: Bridging the Gap

      Working to create a pathway into suitable housing and home ownership by increasing choice

      Outcome One — Deliver a range of tenures, properties and locations to meet need Outcome Two — Make the best use of existing housing Outcome Three — Contribute to sustainable and cohesive communities

      Theme Two: Early Prevention

      Providing suitable, appropriate and timely housing advice to help people make the right housing choice

      Outcome Four — Provide advice across agencies to prevent crisis and increase choice and access Outcome Five — Improve housing offer to better meet a range of housing needs

      Theme Three: Health and Housing

      Improving health through quality housing and places

      Outcome Six — Ensure good quality homes, which are energy efficient Outcome Seven — Improve and maintain independence and inclusion by providing effective support

    • Who's at risk and why

      Vulnerable People

      Key Achievements 2008–11
      • Supported Housing Gateway system was set up, which since 1 April 2009 has placed 1,903 vulnerable people in supported accommodation or provided them with floating support.

      Young People

      Young people continue to be over-represented amongst those presenting as homeless and often have complex needs that require additional and on-going support. Of the people who were accepted as homeless in 2010-11, 38% were aged 16-24. This clearly shows that the younger generation in Medway are experiencing issues around accessing or maintaining accommodation or housing services. One of the main challenges we face is to help raise the profile of the advice and assistance that is available particularly for young people, who have raised this specific issue through our consultation work.

      Figure 1: Homeless Applications in 2010--11 by Age Group
      Figure 1: Homeless Applications in 2010–11 by Age Group

      Reasons for Homelessness

      The main reason for homelessness in 2010–11 was that parents/relatives were no longer willing to provide accommodation, with 81 approaches being made for this reason. Another 36 approaches were made due to rent arrears within private rented accommodation. Work should therefore be based around assisting people within these situations or facing housing barriers, whether it be better benefits advice and access to surgeries to apply for assistance or empowering people with the knowledge of their housing options so families are able to make decisions and choices to achieve suitable arrangements for their families in accessing their own homes.

      In terms of the reasons for accepted households being in priority need, during 2010–11, households with a dependent child accounted for the greatest proportion (55%); mental illness or disability accounted for 11%, physical disability for 8% and households including pregnant women 8%.

      Temporary Accommodation

      Effective support is provided to people living in Temporary Accommodation. Starter packs are provided for those with few possessions and there is also support for those leaving temporary accommodation. All tenants of social housing get a visit within two weeks of moving into their new homes and are then visited at least quarterly thereafter. A 'move on' protocol with social housing providers helps secure permanent accommodation and we target clients who have been in Temporary Accommodation the longest time. Over the last three years the number of people placed in Temporary Accommodation has reduced from 151 at the end of 2008-9 to 102 people at the end of 2010–11.

    • The level of need in the population

      It is an urban area made up of five towns (Chatham, Gillingham, Rochester, Strood and Rainham) and extensive rural areas on the Hoo Peninsula and the area of Cuxton and Halling to the west of the M2. The population of Medway is younger than the average population age for England. However it has an increasing older person population. 15% of the total population have a long term illness. Single person households make up a third of all households in Medway and around 5% are from ethnic minority communities.

      There are just over 110,000 dwellings in Medway at present, 85% of which are in the private sector. There are 16,328 affordable homes 3,056 of which are owned by the Council. Housing Associations own 13,272 with the majority being owned by mhs Homes (47%).

      Housing Requirement and Delivery

      The North Kent Strategic Housing Market Assessment (SHMA) provides an evidence base for Medway's housing requirement broken down by housing type and size. Although house prices have fallen since the peak in April 2008, the requirements still remain relevant due to the recovery in house prices to a similar level to November 2009.

        Total Housing Requirement
      2008–26
      Annual Housing Requirement
      Market Housing 9,522 529
      Intermediate Housing 2,979 166
      Social Housing 3,158 183
      Table 1: Housing requirement 2008–2026
      Figure 1: Demand for social housing
      Figure 1: Demand for social housing
      Figure 2: Demand for intermediate housing
      Figure 2: Demand for intermediate housing

      In June 2011, 9,912 households had asked to be placed on the Housing Register. Households have their housing situation assessed and a suitable priority awarded. There are currently 1,066 households identified as having urgent or high housing needs and of these, nearly 90 are homeless households in Temporary Accommodation and 200 are living in overcrowded accommodation.

      The demand for affordable housing in Medway outstrips the supply and it has been calculated that our housing need is for the delivery of 349 new affordable homes every year. However, we have estimated that our affordable housing programme will deliver 204 affordable homes each year. This leaves a shortfall of 145 homes per year, which will be addressed by using our existing stock more effectively.

      Specialist Accommodation Need

      We want to support people to remain in or work towards independent living, helping them to participate in mainstream society and make a contribution to the local economy. We hope to achieve this by looking at a range of opportunities to help improve access to different types of housing, delivering services to peoples homes and where appropriate developing purpose built specialist accommodation to meet needs. For the future we will focus our work on assisting people to live independently with support. We will also need to consider affordability issues for people to move into appropriate accommodation. We have identified a need to undertake further research into the housing and support needs of certain client groups - in particular people with learning disabilities, physical disabilities, mental health problems and people who are deaf and have sensory problems.

      In regards to people with Learning Disabilities, we have used the Valuing People Now Housing Commissioning Toolkit to build up a picture of the current situation in terms of housing demand and supply. The toolkit is intended to assist local authorities with their partners to plan effectively for the housing requirements of local people with learning disabilities and to be able to deliver a wider range of housing options in practice. It is intended to assist local authorities to deliver the objective of more people with moderate to severe learning disabilities living in their own homes. A comprehensive understanding of the future housing needs of people with learning disabilities is a core component of having a plan to extend housing options and choices. It is hard to plan services and accommodation if the housing need is not known. We have been working with Adult Social Care to cross match clients known to them with those on the Housing Register. We are extending this work to look at clients with physical disabilities and mental health issues.

      Actions 2011–14


      • Deliver 10 fully wheelchair compliant homes per year
      • Deliver 9 homes specifically designed for clients with Learning Disabilities
      • Provide at least 150 households with major adaptations within their home through our Home Adaptations Service
      • Through the HomeSafe scheme provide minor works, safety and security checks to allow 2,700 vulnerable people to feel safe within their own homes
      • Assist 3,940 vulnerable households to undertake adaptations, repairs and improvements to their home
      • Work with the Institute of Public Care and Adult Social Care to undertake housing needs analysis on a range of client groups including those with dementia and learning disabilities
      • Deliver a minimum of 100 extra care units by 2013 and identify development opportunities to meet the additional demand.

      Older Persons' Accommodation

      While residential care is the preferable option for some people, it is not the solution for everybody. As promoting choice and independence are key themes in national and local priorities, we are working to develop alternatives to residential care. By improving the housing offer in Medway we can enable people to make choices about the type of accommodation they would like to move in to. In 2009–10, 289 people aged 65 and over were admitted to permanent residential or nursing care purchased or provided by Medway Council. The Older People Strategic Plan 2010–13 identifies the long-term objective to ensure that all appropriate people can access Extra Care Housing as an alternative to residential care. Although we have a number of schemes currently in the pipeline or on-site, there is currently no Extra Care Housing in Medway. Analysis carried out by the Institute of Public Care at Oxford Brookes indicated a need for between 445 and 453 units of Extra Care Housing to match the requirements of the current older population.

    • Projected service use and outcomes

      Outcome One: Deliver a range of tenures, properties and locations to meet need


      • Secure at least 25% of newly built homes as affordable on any site meeting the Council's size threshold
      • Deliver at least 204 additional affordable homes per annum
      • Work with Registered Providers and the HCA to secure an annual investment in affordable housing of £20m
      • Deliver a minimum of 85 new HomeBuy units per annum

      Outcome Two: Make the best use of existing housing


      • Report the void levels within the affordable housing stock on a quarterly basis
      • Deliver the “Creating Space” initiative to help tackle overcrowding and improve the housing conditions of 15 households per annum
      • Achieve 25 on-line mutual exchanges per annum
      • Develop a range of options to help bring 100 empty homes back into use per annum
      • Maintain the number of long term private sector empty homes below 1.6% of all private sector stock
      • Consult, develop and implement a new Allocations Policy for Medway
      • Develop a delivery programme for Extra Care and Sheltered Housing to meet demand
      • Undertake a review of accommodation for older people in Medway

      Outcome Three: Contribute to sustainable and cohesive communities


      • Achieve a balanced approach with regards to tenure with 60% social rented homes and 40% intermediate homes
      • 100% of affordable housing schemes to meet Secured by Design standard
      • Lead on the development of the affordable element of Development Briefs for all major residential sites in Medway
      • Ensure new affordable housing schemes meet the standards set out within the “Creating Sustainable Communities in Kent and Medway” protocol
      • Adopt in association with Registered Providers Local Lettings Plans for all development of more than 10 units *Continue to target resources to improve the worst housing conditions primarily in the All Saints, Luton and North Gillingham areas
      • Work with partners to undertake proactive targeted multi agency operations to provide high profile interventions within target communities

      Outcome Four: Provide advice across agencies to prevent crisis and increase choice and access


      • Explore further ways of working with Medway Revenue and Benefits Service and the HRA to help prevent homelessness by ensuring that early warning is given of benefit refusals or suspension where eviction may ensue
      • Review the advice and assistance available in cases of domestic abuse and to those in the Sanctuary scheme
      • Consider the impacts of the Equality Duty 2011 and use analysis to tailor our services
      • Continue to work in partnership to develop a clear Housing Pathway for clients with Learning Disabilities
      • Review the range of debt and financial advice available and how these services are sign posted
      • Work in partnership with agencies to improve young people and parents' knowledge of housing issues

      Outcome Five: Improve housing offer to better meet a range of housing needs


      • In partnership with Registered Providers and Children's Services implement an initiative which will deliver at least 10 homes for Looked After Children
      • Maintain the Supported Housing Gateway with 1,200 referrals made per year to promote the most effective use of accommodation and support funded by Supporting People
      • Work with HomeChoice to improve the move on of clients out of Temporary Accommodation
      • In association with Children's Services, identify the resources required to ensure young vulnerable persons are being offered suitable housing options and choices
      • Maintain the Landlord Accreditation Scheme and Landlords' Forum to encourage and support private landlords
      • Review the use of the HomeBond scheme to help improve access to private rented accommodation

      Outcome Six: Ensure good quality homes, which are energy efficient


      • Continue to develop links with Health to assist in the delivery of an area based approach
      • License or take legal enforcement action against 100% of licensable HMOs
      • Maintain the program of inspections of non-licensable HMOs in accordance with the prioritisation scheme
      • Review the site licensing arrangements of residential mobile home sites
      • Reduce the number of vulnerable households living in non-decent sub-standard accommodation by 350 per annum
      • Provide financial assistance to 250 vulnerable and low income homeowners and tenants to meet minimum standards
      • Develop a scheme of professional development courses for accredited landlords to improve standards and professionalism
      • Assist 35 households per year via energy efficiency loans and grants and give advice to 1,500 people via the Energy Savings Trust Advice Centre

      Outcome Seven: Improve and maintain independence and inclusion by providing effective support


      • Deliver 10 fully wheelchair compliant homes per year
      • Deliver 9 homes specifically designed for clients with Learning Disabilities
      • Provide at least 150 households with major adaptations within their home through our Home Adaptations Service
      • Through the HomeSafe scheme provide minor works, safety and security checks to allow 2,700 vulnerable people to feel safe within their own homes
      • Assist 3,940 vulnerable households to undertake adaptations, repairs and improvements to their home
      • Work with the Institute of Public Care and Adult Social Care to undertake housing needs analysis on a range of client groups including those with dementia and learning disabilities


      • Deliver a minimum of 100 extra care units by 2013 and identify development opportunities to meet the additional demand

    • Evidence of what works

      Living Independent Lives

      We aim to enable people to live independently in their existing homes, and the Council has supported this approach through a shift from institutional care to more individually tailored services to assist people to live in the community through the provision of aids and adaptations and assistive technology, as well as targeted specialist accommodation and accessible social care support based on individual need and choice.

      The older population in Medway is increasing, with the numbers of people aged 65 and over projected to increase from 36,000 to 46,100 by 28% in the next ten years. The numbers aged 85 and over are projected to increase by 38% in the next ten years and more than double in the next 20 years. The steady overall growth in the population will put pressure on existing services. The Housing Strategy recognises that increasing proportions of the older population in future years are likely to own their own home. This has significant bearing on older people's housing aspirations and their expectations. Broadly, many homeowners will seek to stay in their existing homes for as long as they can. There will however still be significant numbers of older people who may need specialist accommodation that mesh support, care and housing provision. The Council is working to adapt homes and provide support so that people can remain living independently rather than in more costly supported accommodation. We work in partnership with Hyde In Touch to provide a Home Improvement Agency service in Medway. The service supports older or disabled people who need a repair or adaptation to their home, helping people maintain their independence, safety and dignity. The service helps with things like:


      • Organising repairs and adaptations
      • Making sure people are receiving the right benefits
      • A handyperson service to do small jobs around the home
      • Finding organisations that can help with other problems

      We work with the Occupational Therapy Service to help people with a disability to adapt their home to suit their needs. We provide advice that may be able to assist with the cost of funding the work via a Disabled Facilities Grant. Between 2008–9 and 2010–11 we assisted 445 vulnerable people to adapt their properties using a Disabled Facilities Grant.

      Key Achievements 2008–11

      Supported Housing Gateway system was set up, which since 1 April 2009 has placed 1,903 vulnerable people in supported accommodation or provided them with floating support.

    • Recommendations

      Medway's priorities for Housing for 2011–14 are:

      Theme One: Bridging the Gap

      Working to create a pathway into suitable housing and home ownership by increasing choice

      Outcome One — Deliver a range of tenures, properties and locations to meet need Outcome Two — Make the best use of existing housing Outcome Three — Contribute to sustainable and cohesive communities

      Theme Two: Early Prevention

      Providing suitable, appropriate and timely housing advice to help people make the right housing choice

      Outcome Four — Provide advice across agencies to prevent crisis and increase choice and access Outcome Five — Improve housing offer to better meet a range of housing needs

      Theme Three: Health and Housing

      Improving health through quality housing and places

      Outcome Six — Ensure good quality homes, which are energy efficient Outcome Seven — Improve and maintain independence and inclusion by providing effective support

  • Air Quality
    • Summary

      The impact of air quality upon health is unquestionable, and indeed has been a major driver in national and international attempts to reduce levels of air pollution. Long and short term exposure to poor air quality can have health impacts ranging from premature death due to cardiovascular disease and lung cancer, aggravation of asthma and other allergic illnesses, and reduced quality of life. Recent research has also linked air pollution to low birthweight.[1]

      Medway's position between London, Kent and continental Europe brings health challenges associated with its unique pollution profile. Medway's extensive transport network carries a disproportionate number of HGVs, with their associated carcinogenic diesel emissions. Easterly winds can bring pollution, from continental Europe, which affects the whole of Medway, raising levels of particulate matter and/or ozone. Winds from the opposite westerly direction can bring London's urban pollution plume drifting across the area.

      The Kent and Medway Air Quality Partnership provides strategic direction and support across the county, and has a health subgroup which provides advice to the respective partners on the health implications of air pollution. Medway Council is currently producing an Air Quality Action Plan, updating the previous edition published in 2005.

      Key issues and gaps

      Medway's Air Quality Management Areas, i.e. where pollution levels are monitored because quality does not meet the objective set by the EU Directive and the UK's own Air Quality Strategy, are in some of its most deprived wards. This correlates with the literature, in which deprived communities are most likely to experience the worst air quality.[2]

      The possibility of providing air quality text alerts for vulnerable groups (the young, elderly, pregnant women and those with existing COPD and respiratory conditions) could be explored, based upon existing services in Greater London, Surrey, Sussex and Southampton, and using existing data collected by Kent Air.

      The majority of air quality monitoring in Medway is focussed on measuring NO2 across 23 automatic monitoring sites. However, the Public Health Outcomes Framework provides data on PM2.5 as the pollutant most harmful to health. Medway has two sites that currently do so, but equipment to monitor this is expensive. The introduction of more affordable black carbon monitoring equipment, the data from which can be used as a proxy for PM2.5, may add greater detail to Medway’s air monitoring. To have sufficient detail to assess the health impact of air pollution in Medway, and make the case for evidence based measures to be implemented, it is important that PM2.5 is modelled in a range of locations.

      There is arguably insufficient awareness across Medway of the impact of air pollution on the public's health. A balance needs to be struck between educating and informing the public to achieve behaviour change and adaptive action by those most at risk, and unnecessarily causing concern to vulnerable groups. The role of GPs and environmental health officers in developing and delivering these strategies is important.

      Recommendations for commissioning

      Work with Kent to provide a Kent and Medway air quality text alert service based on existing services in London, Surrey and Sussex, using the data already collected by Kent Air. Provide information for GPs on air quality and its impact upon asthma and existing COPD conditions. An integrated approach that maximises active transport and minimises people's exposure to air pollution would multiple health benefits. Public health should work closely and collaboratively with environmental health, planning and transport to ensure that major developments and transport planning consider the impact upon air quality and by extension the public's health.


      References

      [1]   Pedersen et al. Ambient air pollution and low birthweight: a European cohort study (ESCAPE) Lancet Respiratory Medicine 2013; 1(9): 695-704.
      [2]   Walker G, Fairburn J, Smith G, et al. Environmental Quality and Social Deprivation: Phase II: National Analysis of Flood Hazard, IPC Industries and Air Quality 2003; Environment Agency. http://www.geography.lancs.ac.uk/envjustice/downloads/pr2.pdf?version=1%29 .
    • Who's at risk and why?

      The impact of air quality upon health is unquestionable, and indeed has been a major driver in national and international attempts to reduce levels of air pollution. Long and short term exposure to poor air quality can have health impacts ranging from premature death due to cardiovascular disease[1] and lung cancer,[2] aggravation of asthma and other allergic illnesses,[3] and reduced quality of life.[4] Recent research has also linked air pollution to low birthweight.[5]

      The human, and economic cost is considerable. The Committee on the Medical Effects of Air Pollutants (COMEAP) has calculated that in 2008, the long–term health effects on air pollution was the equivalent of 29,000 deaths at typical ages, and an associated loss of total population life of 340,000 life–years. This burden can also be represented as a loss of life expectancy from birth of approximately six months.[6] In economic terms, the Department for Environment, Farming and Rural Affairs (DEFRA) reports that the annual cost is £15 billion, within the range of £8–17 billion. To put this in perspective, they compare this to the economic costs of obesity and physical activity in urban areas, which is estimated as in excess of £10 billion per annum.[4]

      The arguments for improving air quality on both public health and economic grounds are therefore strong, and European agreement on reduction of air pollution is predicated on analysis by the World Health Organisation. The 2008 ambient air quality directive (2008/50/EC) sets legally binding limits for concentrations in outdoor air of major air pollutants. At a national level, DEFRA monitors national air quality objectives,[7] and the Environment Act 1995 and Air Quality (Standards) Regulations 2010 provide a framework for local management of air quality and translate the EU directives into English legislation.

      Both indoor and outdoor pollution impact upon people's health. Indoor air pollution may include particulate matter from domestic gas combustion (cooking and heating), volatile organic compounds (VOCs) from cleaning and decoration products, wood and coal fires, and second-hand smoke.[8] It is more difficult to monitor and legislate, but significant health gains have been achieved through, for example, smokefree legislation in England since 2007.

      Outdoor pollution includes nitrogen oxides (NOX), particulate matter (PM10, PM2.5), sulphur dioxide (SO2) and ozone (O3). Nitrogen oxides (nitric oxide (NO) and nitrogen dioxide (NO2)) are produced by combustion of fossil fuels i.e. heating, power generation and the internal combustion in motor vehicles. The most harmful nitrogen oxide for human health is NO2, and short-term impacts include shortness of breath, and irritation of the eyes and respiratory system.

      Particulate matter consists of those compounds which are emitted directly into the atmosphere and those which are formed within the atmosphere as a result of chemical reactions. Of greatest concern to public health are particles measuring less than 2.5 micrometres in diameter (PM2.5), small enough to be inhaled into the deepest parts of the lung. Studies link this fine particulate matter with asthma, bronchitis, acute and chronic respiratory symptoms such as shortness of breath and painful breathing, and premature deaths. The young and elderly are most at risk, the former because their lungs and respiratory systems are still developing, and the latter because of comorbidities and declining immune systems.[9] As a consequence, PM2.5 and its impact upon mortality is a new indicator in the Public Health Outcomes Framework (3.01).[10] Air Quality Objectives for local authorities are also in place for the protection of human health for PM2.5 and PM10 (particles of less than 10 micrometres in diameter).

      Sulphur dioxide is an acidic gas which combines with water vapour to produce acid rain. It is associated with asthma and chronic bronchitis.

      Ozone is a secondary pollutant and is formed by reactions between NO2, hydrocarbons and sunlight. Ozone can have an impact upon health in terms of respiratory irritation and airway inflammation, and can cause summer smog. However, formation of ozone can take place over several hours or days and may have arisen from emissions many hundreds of miles away. For this reason ozone is not considered to be a 'local' pollutant. The overall health effects of air pollution by severity and incidence are helpfully summarised by the American Thoracic Society[11]:

      Figure 1: Health effects of air pollution
      Figure 1: Health effects of air pollution

      Susceptibility to the adverse health effects of air pollution varies for different population groups. The young, older people, pregnant women, and those with pre–existing respiratory conditions and chronic illnesses such as asthma and chronic obstructive pulmonary disease are most at risk.

      The risks to pregnant women and their unborn child(ren) of prolonged exposure to air pollutants include low birthweight, intrauterine growth retardation, and an increased risk of chronic diseases in later life.[12]

      While two independent reviews by COMEAP[13] and the Health Effects Institute (HEI) of the evidence around onset of asthma and air pollution both concluded that there was insufficient evidence of a causative link, the latter reported a link with exacerbation of symptoms amongst asthmatic individuals, in particular children.[14]

      Currently, there is insufficient evidence available to attribute outdoor air pollution as the causative factor for COPD due to the lack of long–term studies, but there is an association between air pollution and acute exacerbation of existing COPD. This includes increasing symptoms to A&E visits, hospital admissions and even mortality.[15]

      Research conducted on behalf of the Environment Agency suggests a close link between air quality and deprivation. It concluded that in the 10 per cent of most deprived wards, the air quality was poorest (interestingly, the least deprived 10 per cent also experience above average concentrations of pollutants, although not as acutely as the most deprived).[16] Sir Michael Marmot's report on health inequalities, Fair Society, Healthy Lives reports that “Poorer communities tend to experience higher concentrations of pollution and have a higher prevalence of cardio-respiratory and other diseases … 66 per cent of carcinogenic chemicals emitted into the air are released in the 10 per cent most deprived wards."[17]


      References

      [1]   Shah et al. Global association of air pollution and heart failure: a systematic review and meta-analysis The Lancet 2013; 382 (9897): 1039 - 1048.
      [2]   Raaschou-Nielsen et al. Air pollution and lung cancer incidence in 17 European cohorts: prospective analyses from the European Study of Cohorts for Air Pollution Effects (ESCAPE) Lancet Oncology 2013; 14(9): 813-822.
      [3]   Krzyzanowski K.-D. Health effects of transport-related air pollution 2005; World Health Organization.
      [4]   Department for Environment, Food and Agricultural Affairs. Air Pollution: Action in a Changing Climate 2010; Department for Environment, Food and Agricultural Affairs.
      [5]   Pedersen et al. Ambient air pollution and low birthweight: a European cohort study (ESCAPE) Lancet Respiratory Medicine 2013; 1(9): 695-704.
      [6]   Committee on the Medical Effects of Air Pollutants. The Mortality Effects of Long-Term Exposure to Particulate Air Pollution in the United Kingdom 2010; Committee on the Medical Effects of Air Pollutants.
      [7]   Department for Environment, Food and Agricultural Affairs. National air quality objectives 2010; Department for Environment, Food and Agricultural Affairs. http://uk-air.defra.gov.uk/documents/National_air_quality_objectives.pdf .
      [8]   British Lung Foundation. Indoor Air Pollution http://www.blf.org.uk/Page/Indoor-Air-Pollution
      [9]   Air Quality Expert Group. Fine Particulate Matter (PM2.5) in the United Kingdom 2012; Department for Environment, Food and Agricultural Affairs. http://uk-air.defra.gov.uk/reports/cat11/1212141150_AQEG_Fine_Particulate_Matter_in_the_UK.pdf .
      [10]   Department of Health. Public Health Outcomes Framework 2012;
      [11]   World Health Organisation. Air Quality Guidelines: Global Update 2005 2006; World Health Organisation. http://www.euro.who.int/__data/assets/pdf_file/0005/78638/E90038.pdf .
      [12]   British Medical Association. Healthy Transport = Healthy Lives 2010; British Medical Association. http://bma.org.uk/transport .
      [13]   The Committee on the Medical Effects of Air Pollutants. Does outdoor air pollution cause asthma? 2010; http://www.comeap.org.uk/documents/statements/39-page/linking/53-does-outdoor-air-pollution-cause-asthma
      [14]   Health Effects Institute. Traffic-Related Air Pollution: A Critical Review of the Literature on Emissions, Exposure, and Health Effects: A Special Report of the HEI Panel on the Health Effects of Traffic-Related Air Pollution 2010; Health Effects Institute. http://pubs.healtheffects.org/view.php?id=334 .
      [15]   Ko F, Hui D. Air pollution and chronic obstructive pulmonary disease Respirology 2012; 17: 395-401.
      [16]   Walker G, Fairburn J, Smith G, et al. Environmental Quality and Social Deprivation: Phase II: National Analysis of Flood Hazard, IPC Industries and Air Quality 2003; Environment Agency. http://www.geography.lancs.ac.uk/envjustice/downloads/pr2.pdf?version=1%29 .
      [17]   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 .
    • Level of need in the population

      Medway's position between London, Kent and continental Europe brings health challenges associated with its unique pollution profile.

      Medway's extensive transport network carries a disproportionate number of HGVs, with their associated carcinogenic diesel emissions. Around the coast, shipping also brings an impact from marine diesel. Easterly winds can bring pollution, from continental Europe, which affect the whole of Medway, raising levels of particulate matter and/or ozone. Winds from the opposite westerly direction can bring London's urban pollution plume drifting across the area.

      The Environment Act 1995 places a statutory duty on local authorities to monitor air quality across their area. This duty is informed by an European-wide commitment to reduce air pollution. These are transposed into English policy by the Air Quality Standards Regulations 2010.[1]

      These Regulations include criteria for determining how achievement of the limit values should be assessed, including consideration of locations and length of exposure in relation to the averaging period of the limit values. Details of these obligations are available on the DEFRA website.

      In areas where air quality objectives are not likely to be met by the relevant target date, local authorities are required to declare an Air Quality Management Area (AQMA) and develop an action plan in pursuit of the air quality objectives. In other words, these are areas where there are consistent exceptions to meeting the objectives. There are currently three AQMAs in Medway. They are Central Medway, High Street, Rainham, and Pier Road, Gillingham.

      Medway has three continuous automatic air quality stations; one at an urban roadside location in Chatham, one at an urban background site at Luton and one at a rural location in Lower Stoke. Monitoring of NO2 and PM10 is undertaken at all three sites. Monitoring of PM2.5 is also carried out at the Chatham and Lower Stoke sites. The Lower Stoke and Luton sites also monitor sulphur dioxide. The latter site also monitors carbon monoxide. Alongside these 'automatic' monitoring areas, there is also a network of 23 NO2 diffusion tubes sites across Medway. The following graph shows the levels of NO2 in the three automatic monitoring sites, against the regulatory objectives, and pollution levels against Medway-wide levels.

      Figure 1: Trends in annual mean nitrogen dioxide concentration measured at diffusion tube monitoring sites
      Figure 1: Trends in annual mean nitrogen dioxide concentration measured at diffusion tube monitoring sites

      More detailed analysis of air quality has been produced by Environmental Health at Medway Council and the most recent progress report (June 2013, data from 2012), is available here. This latest progress report concludes that “exceedences continue to occur in each of the three AQMAs [whilst] there were no exceedences of the annual mean NO2 objective outside of areas declared as AQMAs."[2]

      Alongside these Regulations, the impact of air pollution on health in upper tier and unitary local authority areas is measured as part of the Public Health Outcomes Framework. Indicator 3.01 is "Fraction of mortality attributable to particulate air pollution” and Medway's rate is slightly higher than that of the English average, and its neighbouring local authority Kent, although caution is advised in comparing regions, the data being based upon estimates by COMEAP calculated from background levels of PM2.5. As mentioned above, local monitoring of PM2.5 is limited by cost which makes it currently impossible to produce accurate local data.

      Figure 2: Mortality attributable to particulate air pollution
      Figure 2: Mortality attributable to particulate air pollution

      Kent and Medway Public Health Observatory have additionally carried out some more detailed analysis of mortality attributable to particulate matter across the Kent and Medway region, as well as background levels of PM2.5.

      Figure 3: Number of deaths per 100,000 population attributed to pollution, 2011
      Figure 3: Number of deaths per 100,000 population attributed to pollution, 2011

      Data collected via the primary care Quality and Outcomes Framework (QOF) also provides information on COPD and asthma prevalence in Medway.

      There are 5,026 patients registered with a COPD condition, and this represents 1.8% of Medway patients (practice range 0.59%–3.14%). The following table illustrates mortality from COPD conditions over a four year period by ward. Again, it is striking that the wards within whose boundaries the AQMAs lie have the highest mortality over this period.

      Figure 4: COPD mortality by ward
      Figure 4: COPD mortality by ward

      There are 15,800 patients with asthma registered at GP practices in Medway, which represents 5.6% of the population (practice range 3.54% – 7.15%).


      References

      [1]   The Air Quality Standards Regulations 2010;
      [2]   Medway Council. Air Quality Progress Report for Medway Council 2012 2013; Medway Council.
    • Current services in relation to need

      Kent Air provides air monitoring throughout Kent and Medway, providing daily contemporaneous data on air quality, and using the Daily Air Quality Index (DAQI). This provides recommended actions and health advice. The index is numbered 1-10 and divided into four bands, low (1) to very high (10), to provide detail about air pollution levels in a simple way, similar to the sun index or pollen index. The data is based upon the automatic monitoring sites across Kent and Medway, and dependent on the site, provides information on NO2, PM2.5, PM10, ozone and sulphur dioxide, collating this to provide a risk rating.

      The following advice is given dependent on the risk rating.

      Figure 1: Advice by air pollution level
      Figure 1: Advice by air pollution level

      *Adults and children with heart or lung problems are at greater risk of symptoms. Follow your doctor's usual advice about exercising and managing your condition. It is possible that very sensitive individuals may experience health effects even on Low air pollution days. Anyone experiencing symptoms should follow the guidance provided above. Medway CCG made reduction of COPD emergency admissions a priority in 2013, and in pursuit of this, and in acknowledgement of environmental conditions as a contributing factor, a Met Office text alert service (Healthy Outlook® COPD Forecast Alert Service) was commissioned. However, the Met Office has now discontinued the service, in light of the recent changes in commissioning responsibilities in the NHS. The Kent and Medway Air Quality Partnership provides strategic direction and support across the county, and has a health subgroup which provides advice to the respective partners on the health implications of air pollution. Medway Council is currently producing an Air Quality Action Plan, updating the previous edition published in 2005.

    • Projected Service Use

      AEA have produced estimates for Defra in 2012, providing projections on air pollution for 2015, 2020, 2025 and 2030, based on three different scenarios.[1] The following table details the third scenario, considered to be the most realistically ambitious, factoring in economic growth, fossil fuel prices, and transport activity.

        PM10 PM2.5 NOx SO2
      2005 135.0 81.0 1,580.0 706.0
      2010 114.0 67.0 1,106.0 406.0
      2015 111.0 59.0 910.0 371.0
      2020 106.0 57.0 708.0 287.0
      2025 105.0 57.0 612.0 250.0
      2030 108.0 59.0 589.0 242.0
      Table 1: Pollutant in kilotonnes by year

      In other words, it is expected that pollutants, and those most relevant to health such as fine particulate matter (PM2.5) will fall, or plateau over the next two decades. Nonetheless, it is also worth noting that COMEAP comments that there are no 'safe' levels of PM2.5 so that even if the reduction of air pollution is encouraging, efforts still need to be redoubled to accelerate reductions. Furthermore, Medway has higher levels of PM2.5 than many other places in the UK, and given its position between London, Kent and continental Europe, this is likely to continue.


      References

      [1]   National Atmospheric Emissions Inventory. UK Emission Projections of Air Quality Pollutants to 2030 2012; National Atmospheric Emissions Inventory. http://uk-air.defra.gov.uk/reports/cat07/1211071420_UEP43_(2009)_Projections_Final.pdf .
    • Evidence of what works

      Improving air quality and mitigating the health impacts of air pollution have many synergies with other important measures to improve the public's health. Interventions addressing climate change adaptation and mitigation, increasing active travel and improving green spaces are all likely to have co-benefits for air quality.

      In its guidance on walking and cycling, NICE mentions air quality as a key benefit of encouraging active travel and moving away from a society predominantly reliant on motor vehicles: “Walking and cycling, like any form of transport, involve exposure to a certain level of risk. This includes the risk of injury from falls or from collisions and exposure to air pollution. These risks are not unique to transport involving physical activity. However, evidence shows that the health benefits of being more physically active outweigh these disbenefits. The whole population benefits from less exposure to polluted air and congested streets when there is a general shift away from motorised vehicles."[1]

      Defra has focused its policy on the interrelationship between climate change and air quality, with its 2010 publication Air Pollution: Action in a Changing Climate. It provided case studies in Greenwich and Perth and Kinross, which concentrated on creating Low Emission Zones, levers in planning policy and intelligent traffic management.

      Defra has also provided specific advice to public health departments on the impact upon health and actions that can be taken.

      The campaign group Clean Air in London, although primarily concerned with lobbying for improved air quality in the capital, has some useful advice for public health departments everywhere, arguing that: "Most important, we need to warn people about the dangers of air pollution and give them advice about protecting themselves (i.e. adaptation) and reducing pollution for themselves and others (i.e. mitigation). For example, people can reduce their exposure to air pollution by up to 50% by walking or cycling down side streets rather than busy roads. People can also reduce air pollution by walking or cycling or using public transport rather than driving a diesel vehicle."[2]

      Indeed, London is advanced in its adaptation strategies in that it has a text alert service AirText which provides free, localised advice by text message on environmental conditions for vulnerable groups and other interested parties that sign up via the website. There is a similar service available for Surrey, Sussex and Southampton, called AirAlert. This has recently been expanded to Sevenoaks in West Kent.


      References

      [1]   National Institute for Health and Clinical Excellence. PH41: Walking and cycling: local measures to promote walking and cycling as forms of travel or recreation 2012; National Institute for Health and Clinical Excellence. http://www.nice.org.uk/nicemedia/live/13975/61629/61629.pdf .
      [2]   Clean Air in London. Directors of Public Health and Health and Wellbeing Boards urged to act on air pollution 2012; http://cleanairinlondon.org/solutions/directors-of-public-health-and-health-and-wellbeing-boards-urged-to-act-on-air-pollution/
    • User views
    • Equality Impact Assessments
    • Unmet needs and service gaps

      It is immediately noticeable that Medway's AQMAs, i.e. where pollution levels are monitored because air quality does not meet the objective set by the EU Directive and the UK's own Air Quality Strategy, are in some of its most deprived wards. This correlates with the literature, in which deprived communities are most likely to experience the worst air quality.

      The possibility of providing air quality text alerts for vulnerable groups (the young, elderly, pregnant women and those with existing COPD and respiratory conditions) could be explored, based upon existing services in Greater London, Surrey, Sussex and Southampton, and using existing data collected by Kent Air.

      The majority of air quality monitoring in Medway is focussed on measuring NO2 across 23 automatic monitoring sites. However, the Public Health Outcomes Framework provides data on PM2.5 as the pollutant most harmful to health. Medway has two sites that currently do so, but equipment to monitor this is expensive. The introduction of more affordable black carbon monitoring equipment, the data from which can be used as a proxy for PM2.5, may add greater detail to Medway's air monitoring. To have sufficient detail to assess the health impact of air pollution in Medway, and make the case for evidence based measures to be implemented, it is important that PM2.5 is modelled in a range of locations.

      There is arguably insufficient awareness across Medway of the impact of air pollution on the public's health. A balance needs to be struck between educating and informing the public to achieve behaviour change (in terms of use of motorised vehicles) and adaptive action by those most at risk, and unnecessarily causing concern to vulnerable groups. The role of GPs and environmental health officers in developing and delivering these strategies is important.

      To ensure an integrated approach to air pollution, public health needs to work closely and collaboratively with colleagues in environmental health, planning and transport. The air quality, and by extension health implications of travel (including active travel) and planning developments should be discussed with relevant colleagues in public health and environmental health before plans are approved and implemented. Similarly, public health can add value to active travel strategies, town planning decisions, and green space developments.

    • Recommendations

      Work with Kent to provide a Kent and Medway air quality text alert service based on existing services in London, Surrey and Sussex, using the data already collected by Kent Air.

      Provide information for GPs on air quality and its impact upon asthma and existing COPD conditions.

      Public health should work closely and collaboratively with environmental health, planning and transport to ensure that major developments consider the impact upon air quality and by extension the public's health.

    • Recommendations for needs assessment work

      Explore the possibility of introducing black carbon monitoring equipment to enable a more sophisticated analysis of the effect of air pollution upon the Medway population's health.

      Produce more detailed analysis of the exposure to air pollution of different socioeconomic and age groups, similar to that conducted by Kings College London in South East London.

      Identify particular groups at risk in Medway (COPD, asthma, young, elderly or pregnant).

      Key Contacts

      DEFRA leaflet on air quality and public health

      Medway Council Air quality guidance for developers

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