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Summary

  • Foreword

    Through the Health and Social Care Act the Government has established the Joint Strategic Needs Assessment (JSNA) as a fundamental part of the planning and commissioning cycle at a local level. Central to this vision is that decisions about services should be made as locally as possible, involving people who use them and communities to the maximum degree.[1]

    The government's intentions for JSNAs are ambitious: they are to provide the evidence base of “all current and future health and social care needs of the entire population”, be “more than just a collection of evidence… and be an analysis and narrative” and provide a “comprehensive picture of place.” The JSNA is a continuous process involving engagement and review and will therefore be updated regularly.

    As part of this process the Local Government Group has published guidance on the kinds of data that might be useful in a JSNA.[2]

    In addition to the guidance on the JSNA, the current health and social care environment also includes new Outcomes Frameworks that focus on a number of key domains of health and social care.

    In Medway's JSNA we aim to provide a comprehensive picture of place based on evidence by describing “our people and place”, “our health and wellbeing”, “our community” and “our programmes and services”, structured around core elements of the outcomes frameworks. The narrative section of the JSNA presents the big picture, while more detailed background papers and a data inventory can be found in the appendices.

    Medway's JSNA is a “living document”. A new version will be released every three months, ensuring that the data are up-to-date and that issues can be developed further and refined based on feedback from those who read the JSNA.


    References

    [1]   Department of Health. JSNAs and joint health and wellbeing strategies---draft guidance Jan, 2012; HM Government.
    [2]   Local Government Group. Joint Strategic Needs Assessment: Data Inventory 2011; HM Government.
    What is the JSNA?

    “…all current and future health and social care needs of the entire population…more than just a collection of evidence…an analysis and narrative…a comprehensive picture of place.”

  • Executive summary
    • Key messages
    • Introduction

      The current period presents the people of Medway and their representatives with a number of challenges, but also opportunities. Health has generally been improving over many years and with it peoples' expectations have increased. The constraints imposed by the economic crisis mean that it is more important than ever to deliver health and social care as efficiently and effectively as possible. A number of changes are being introduced to facilitate this, including:


      • The establishment of Health and Wellbeing Boards to bring strategic leadership to the health and wellbeing agenda in top tier authorities
      • The establishment of Clinical Commissioning Groups to strengthen clinically led commissioning of health services
      • New public health responsibilities for local authorities that will result in Public Health functions moving from the NHS to local government
      • An emphasis on 'localism' where decisions are driven locally rather than nationally
      • A re-emphasis on personal responsibility for health

      To respond to these challenges and opportunities for health and well-being Medway's Health and Wellbeing Board has developed a Joint Strategic Needs Assessment (JSNA). The JSNA is an objective assessment of local needs and is intended to address all current and future health and social care needs. It is an extensive document that will evolve over time as new evidence and intelligence about the needs in Medway are developed. The JSNA is divided into two broad parts: 1) a narrative 'picture of place'; and 2) a number of appendices that provide detailed information on the health and social care needs and situation within Medway. This picture of place is contained within the printed volume and divided into five sections: Our people and place; Our health and well-being; Our community; Our programmes and services and Our health inequalities. The appendices are available online.

      Challenges and opportunities

      •  Health has generally been improving over many years and with it peoples' expectations have increased.
      •  Health and Well-being boards
      •  Clinical Commissioing Groups (CCGs)
      •  public health responsibilities for local authorities

    • Overview of the JSNA

      Our people and place

      According to the Office for National Statistics (ONS) mid-2015 population estimate, Medway's resident population is 276,492, an increase of 27,004 (10.8%) since 2001[1]. The population has increased naturally every year since 2001, with 3,609 live births in 2015[2]. However net out-migration since 2001 has reduced overall population growth over this period.

      Approximately 2,300 Medway residents die each year (2,313 deaths in 2015)[3], with significantly higher mortality rates found in males than females. There is considerable variation in mortality rate by ward; mortality rates in the five wards with the highest rates are significantly higher than in the five wards with the lowest rates. Average life expectancy in Cuxton and Halling, Rainham Central, and Hempstead and Wigmore is significantly greater than in Chatham Central, Luton and Wayfield, and River wards. Life expectancy is highest in Cuxton and Halling at 85.6 years, and lowest in River at 78.1 years[4].

      The majority of the population (85.9%) in Medway are classified as White British, with the next largest ethnic group being Asian or Asian British (5.0% - not including Chinese). The three wards with the most ethnically diverse school populations are Chatham Central, Gillingham South and River wards[5]. Within these wards 70% to 75% of pupils are White and at least 7% have mixed parents. There are increasing numbers of Slovak and Polish pupils in our schools[5].

      Medway has a higher proportion of unemployment than the England average, but has achieved a decrease compared to last year. In June 2014 the number of people claiming job seekers allowance (JSA) in Medway was 4,631, a decrease of 1,554 (25.1%) compared to the previous 12 months[6]. However, this decrease is smaller than that seen nationally (30.5%) and regionally (33.6%) in the same period[6]. Unemployment is an important factor driving the health and well-being of a population and this is likely to be playing a key role in the health inequalities seen in Medway.

      The population of Medway is slightly younger than the national average[1]. However, 2015 to 2025 projections suggest that the proportion of the population aged 65 years or over will increase from 15.4% (42,600) to 17.4% (53,000)[7]. The equivalent change in those aged 85 years and over is from 1.7% (4,800) to 2.3% (6,900)[7]. The number of people over 65 years with a limiting long-term illness is expected to increase by 48.3% from 2014 to 2030, which would have a significant impact on the demand for health services for the management of long term conditions such as dementia, heart disease and diabetes as the incidence of these conditions increases with age[8].

      Our health and well-being

      Between 2012 and 2014 Medway was ranked 87th out of 150 local authorities for overall rate of premature deaths with an age-adjusted rate of 371 per 100,000[9]. Of the roughly 2,200 deaths that occur in Medway each year, almost a third of deaths in females and almost half of deaths in males occurring before the age of 75 (29% and 45% in 2012-2014 respectively). In both males and females the leading cause of premature deaths is cancer, accounting for almost half of deaths in women (46.7%) and two in five men (39.9%) of this age[10]. There has been a downward trend in mortality for all cancers in Medway since 1993 but cancer death rates have remained higher than in comparator groups, regional and national rates. Currently, there are an estimated 162 premature deaths per 100,000 resulting from cancer, equating to a ranking of 119th out of 150 local authorities[9].

      The next largest cause of death in those under the age of 75 years is cardiovascular disease (for example heart attacks, stroke and heart failure), accounting for 10.5% of premature deaths in women and 24.0% in men[10].

      A further 10.3% of premature deaths are due to respiratory diseases[4], notably chronic obstructive pulmonary disease (COPD), primarily caused by chronic tobacco smoking.

      Premature mortality is strongly associated with deprivation; the Slope Index of Inequality (SII) for life expectancy by deprivation deciles is significantly above zero in both males and females[11].

      A considerable proportion of the health and social care challenge relates to chronic conditions or situations. Increasing numbers of older people means that there will be increasing numbers of people developing chronic conditions who will become intensive users of services. For example, the number of people aged 65 and over predicted to have a long standing health condition caused by a stroke will rise from 889 in 2012 to 1,657 in 2037 and those aged 65 and over predicted to have diabetes will rise from 4,870 to 8,687 in the same time frame[12]. Ageing of the population is likely to result in a substantial increase in costs to the health and social care system and primary and secondary prevention of conditions such as diabetes, COPD and heart disease, combined with improved care for people with conditions such as dementia, is essential to reduce or limit the numbers of high-intensity users of services and reduce the costs to the health and social care system.

      Our community

      Engagement with the community is an essential part of delivering services that are appropriate for the population. A recent engagement event to determine the needs and priorities of people in Medway found four main themes: continuity and availability of care, for example better continuity of care so there is a seamless transition between GPs and either community services or secondary care; “people power”, for example more support for self-management of long term conditions; education, e.g. increase public understanding of commissioning groups and processes; and communications and engagement, e.g. reassurance that public voice will be heard, including feedback when public consultation has been sought to show the opinions have been considered.

      The Public Health White Paper released by the Department of Health in 2010 outlined a new approach to improving health through greater emphasis on well-being and prevention. This is done by transferring ownership to local communities to tackle the wider determinants of health such as social relationships. This approach, termed the 'asset based approach', identifies skills, strengths, capacity and knowledge of individuals within a community which are used to contribute towards sustainable development. In the JSNA we have begun to document the assets in Medway and in future will engage further with community groups to identify assets that are currently unrecognised.

      Our programmes and services

      Medway provides services and programmes in a number of domains. In primary care there are 231 GPs in 54 practices, 33 dental practices, 58 community pharmacies and 19 optometry practices [13][14]. Community care is provided by three providers and health improvement, covering smoking, healthy weight, infant feeding, sexual health, teenage pregnancy, and alcohol is provided jointly by NHS Medway and Medway Council.

      Local acute care is provided mainly by Medway NHS Foundation Trust, while mental health care is provided by Kent and Medway NHS and Social Care Partnership Trust and other NHS providers and independent organisations offering provision from psychological therapies to secure accommodation.

      Our health inequalities


      • Overall both male and female life expectancy in Medway is significantly worse than the England average. Compared with other LAs of a similar deprivation status it has one of the lower life expectancies.


      • Within Medway the Slope Index of Inequality for life expectancy-the 'Life Expectancy Gap'-shows that in 2014 the difference in between the 10% most and least deprived in the population is 5.8 years for men and 4.8 years for women.


      • The main disease contributors to the life expectancy gap are the same as the major killers, with cancer and respiratory disease contributing the most to the life expectancy gap.


      • While in both men and women the gap in life expectancy due to circulatory disease is decreasing the gap in life expectancy due to cancer is static overall, with an increase in the inequality gap in men.


      • There is significant variation in access to and uptake of primary and secondary health care within Medway.


      • Smoking, obesity, alcohol and poor mental health are all key lifestyle issues which impact on health inequalities.


      • Social determinants of health have been recognised to be key determinants of health inequalities. With respect to Medway's position relative to England the Marmot indicators show that the number of unemployed people and long-term Job Seekers Allowance claimants are significantly worse than the national average. Medway is also in the worse quartile for use of outdoor space for leisure and exercise.

      Appendices

      The online appendices of the JSNA contain much detailed information including background papers on specific issues related to children, adults and life-style and wider determinants of health. There is also a data inventory containing key statistics on health and well-being, and links to a number of other additional resources.

      Specific recommendations for commissioners can be found in the background papers on children, adults, lifestyle and wider determinants in the appendices.

      The appendices, along with this narrative summary, are available online at www.medwayjsna.info


      References

      [1]   Office for National Statistics. Mid-2015 population estimate 2016;
      [2]   Office for National Statistics. Birth summary tables in England and Wales: 2015 2016;
      [3]   Office for National Statistics. Death registrations in England and Wales, summary tables: 2015 2016;
      [4]   Medway Public Health Intelligence team. Primary Care Mortality Database analysis
      [5]   Office for National Statistics. 2011 Census: Local Characteristics on Ethnic, Identity, Language and Religion for Output Area in England and Wales - links to tables on Nomis 2013;
      [6]   Nomis office for labour market statistics. Labour Market Profile 2014;
      [7]   Office for National Statistics. Mid-2014-based subnational population projections for England
      [8]   Projecting Older People Population Information (POPPI). Population by age: Population aged 65 and over, projected to 2030 2014;
      [9]   Public Health England. Mortality Rankings: Medway
      [10]   HSCIC Indicator Portal. Premature mortality from various causes
      [11]   Public Health England, Association of Public Health Observatories. Slope Index of Inequality Data for LAs 2011;
      [12]   Projecting Older People Population Information (POPPI). Long standing heath conditions
      [13]   Primary Care Information System.
      [14]   NHS England. NHS Organisation data
      Medway faces significant challenges…

      Of the roughly 2,000 deaths that occur in Medway each year, almost a third of deaths in females and almost half of deaths in males are premature .
      Both male and female life expectancy in Medway is significantly worse than the England average.
      Smoking, obesity and alcohol and poor mental health are all key lifestyle issues which impact on health inequalities and need to be addressed.

      …but also has assets to draw on

      Through the JSNA we will be gathering and providing information about local assets that improve health and reduce inequalities

    • Key themes for Medway

      The evidence in the JSNA points to five key themes for Medway:


      • Giving every child a good start
      • Enable our older population to live independently and well
      • Prevent early death and increase years of healthy life
      • Improve physical and mental health and well-being
      • Reduce health inequalities

      Giving every child a good start

      There is increasing evidence that investment in the early years of life (0–5 years) is highly effective both in terms of the impact on future health and wellbeing and in being cost-effective. What happens during these early years, starting in the womb, has lifelong effects on many aspects of health and wellbeing, from obesity, heart disease and mental health, to educational achievement and economic status. It is important that mothers are supported to have good mental and physical health during pregnancy and early years. Smoking in pregnancy, which is a real challenge in Medway, impacts negatively on both maternal and child health. Parenting skills are important in improving outcomes and a particular focus is required on supporting the most vulnerable families to improve parenting and help very young children be school-ready.

      The provision of good social care for children is important to ensure that children have a good start in life. In England the number of referrals to children's social care has increased in recent years and a similar pattern has been seen in Medway over the last two years, where the number of referrals has increased 63%, from 3,292 in 2009/10 to 5,364 in 2011/12. Of these, 383 children were subject to child protection plans in March 2012, higher than the national average but broadly in line with other similar unitary authorities of a similar size, for example Luton and Southend.

      There has also been an increase in the number of children in care. In March 2011 Medway had 446 children in care, 19 more than in 2010/11. With 73 children in care per 10,000 children this is higher than the national average but again in line with other similar unitary authorities.

      The number of children with special educational needs (SEN) is also expected to increase in the next five years. This may result in an additional 300 pupils with statements requiring specialist provision, over and above the number projected through normal population growth.

      To respond to the care needs of children and young people, social workers play an important role in supporting children and young people to develop their emotional resilience and good physical and mental health. Medway is doing well at ensuring there are enough social workers with only 6.4% of social worker positions vacant in March 2012, the lowest level since at least 2006.

      Enable our older population to live independently and well

      The rapid increase that Medway will see in the number of people aged 65+ and 85+ over the next decade is something that should be celebrated. It is in part the result of steady improvements over many years in health care and public health. Many of these new older people will be healthy and strong and able to live independently; however, it is inevitable that there will also be an increase in the number of people who will need health and social care and support. In particular we can expect to see more people who have dementia, and others who become physically frail.

      An increase in the number of older people is not a new phenomenon. In 1901 less than 5% of the UK population was over the age of 65 years. Since then there has been a steady increase and as a society we have made many changes during this period. As we go forward further changes are needed to ensure that we are able to provide affordable and high quality care for older people.

      The government commissioned an independent body to review the funding system for care and support in England and national policy is awaited. Within this national context the options for how Medway chooses to care for and provide support for older people will also include the core themes of localism and personal responsibility noted above. Many home-owners will seek to stay in their existing homes for as long as they can and will need additional support to do so. There will also be increasing numbers of older people who will need specialist accommodation that mesh support, care and housing provision.

      Older people are more likely to have multiple health and social needs which will require an integrated response from local services.

      Prevent early death and increase years of healthy life

      Over recent decades public health and improved health care have led to dramatic reductions in the number of deaths. For example the mortality rate from heart attacks in Medway fell 79% from 160 to 33 per 100,000 between 1995 and 2014[1]. About half of this reduction was due to improved health care and half was due to public health measures, such as reductions in smoking.

      The current leading causes of early death and illness in Medway include cancer, cardiovascular disease (e.g heart attacks, stroke and heart failure) and respiratory disease, conditions that share many common causes. Prevention strategies are needed to reduce the numbers of people who will develop these conditions in the future. Early diagnosis can improve outcomes in some diseases and strategies are needed to promote early diagnosis through raised awareness and efficient diagnostic pathways.

      Increasing years of healthy life will include improving care and treatment for those with mental health problems and long term health conditions such as diabetes and epilepsy. Most people with long-term conditions have a single condition and can be helped to manage their condition at relatively low cost. It is important that effective interventions are provided systematically and equitably across the population if health inequalities are to be reduced. However, as people age and if prevention and treatment are not optimal, more people begin to develop other conditions. As the number and severity of these conditions increases the complexity and cost of managing them becomes much greater. Addressing these conditions requires well-integrated health and social care systems to provide treatment and support for those who have the conditions.

      Improve physical and mental health and well-being

      Increasing attention is being paid not just to how long people live, but also how well they live. Quality of life is affected by many issues, including crime and the perception of crime, unemployment, the quality of employment for those who do have work, stress, the ability to live independently and autonomously and freedom from pain and ill-health. Quality of life is also very strongly affected by physical health and four main risk factors need to be reduced: tobacco use, harmful use of alcohol, physical inactivity and poor diet. While smoking prevalence has fallen nationally and in Medway in recent years, the prevalence in 2013 among those aged 18 years and over was 21.8%, which is 3.4% higher than the England average[2]. There is also considerable variation in the prevalence across Medway with 16.2% in Rainham Central and 39.8% in Chatham Central. There is much evidence to support the positive health effects of smoking cessation and continued efforts to reduce smoking must be supported.

      The other major causes are more difficult to address than smoking, and recent trends have shown there have small increases in alcohol-related hospital admissions in Medway and increases in obesity. Each of these risk factors are aspects of “lifestyle”, a concept that superficially sounds quite simple, yet involves a complex interaction of personal choice and responses to the social and physical environment. People need to make the right choices as they have a personal responsibility for their own health, and this happens more readily in an environment in which these choices are the easy or are the default choices.

      One particularly important aspect of well-being is mental well-being. According to estimates derived from the 2007 psychiatric morbidity survey for England, in Medway in 2014 there are 27,207 people at any one time living with common mental health problems and 668 with a psychotic disorder. In May 2015 the total number of people in Medway claiming employment and support allowance was 9,310. Of these, 4,140 (44%) were claiming incapacity benefit for mental health reasons[3].

      Nationally a five step approach is being promoted to improve mental well-being. These steps are directed at individuals, however creating a supportive environment that makes it easy for people to take these steps is likely to lead to more people doing so. This may involve, for example, encouraging neighbours to work together on a local project or engage together in a celebration; ensuring that Medway is a pleasant and safe place to walk and cycle; providing courses or venues for others to run courses; and promoting volunteering.

      Reduce health inequalities

      Inequalities are a fundamental underlying feature of most health outcomes in Medway. Rates of death are higher in those who are more disadvantaged, as are emergency hospital admissions and rates of long-term illness. Health outcomes are not only worse in those who are the most disadvantaged; the inequalities follow a gradient and as such the response also needs to follow a gradient. This has been called “proportionate universalism” and simply means that health and social care provisions need to be made available to all, with increasing effort needed for those who are increasingly disadvantaged.

      The Marmot Review identified six key areas for action, the first and highest priority area being to give every child the best start in life. This is because there is strong evidence that what happens in the early years has an effect on future employment prospects and health and well-being outcomes.

      As well as the moral imperative to tackle inequalities there is a good business argument to do so. Emergency hospital admissions or more years spent with a long-term illness mean greater costs for health and social care systems. Taking action through prevention, education and improved health care to reduce inequalities by raising levels of health and well-being to reduce inequalities will result in reduced costs for the health and social care system caused by the major health and social care problems faced by Medway now and in the immediate future.


      References

      [1]   HSCIC Indicator Portal. Mortality from acute myocardial infarction: directly standardised rate, all ages, annual trend, MFP https://indicators.ic.nhs.uk/webview/
      [2]   Public Health England. PHOF: smoking prevalence 2015;
      [3]   NOMIS. Benefit claimants - employment and support allowance 2015; ONS. https://www.nomisweb.co.uk/ .
      Five key themes for Medway


      • Giving every child a good start
      • Enable our older population to live independently and well
      • Prevent early death and increase years of healthy life
      • Improve physical and mental health and well-being
      • Reduce health inequalities

    • The Joint Health and Wellbeing Strategy

      The themes identified in the JSNA have been developed in the Joint Health and Wellbeing Strategy (JHWS) by the Health and Wellbeing Board.

      The evidence in the JSNA points to five key themes for Medway:


      • Giving every child a good start
      • Enable our older population to live independently and well
      • Prevent early death and increase years of healthy life
      • Improve physical and mental health and well-being
      • Reduce health inequalities

      Download the strategy (PDF, 5Mb)

  • Our people and place
    • Key messages


      • The population of Medway was estimated to be 276,492 in the 2015 mid-year estimates (Office for National Statistics), a 10.8% increase from that measured during the 2001 Census.
      • There is much variation between the Medway wards in terms of population density, deprivation, and death rates.
      • Approximately 2,300 Medway residents die each year (2,313 deaths registered in 2015).
      • The all-age, all-cause mortality rate is higher in Medway than in England and the South East average.
      • Life expectancy is highest in the Cuxton and Halling ward at 85.6 years, and lowest in River ward at 78.1 years (life expectancy at birth, 2011 to 2015).
      • In every ward life expectancy is greater in females than it is in males.
      • There were 3,609 live biths in Medway in 2015.
      • In 2015 the rate of live births to women aged 15-44 was higher than South East region and England averages.
      • The general fertility rate varies considerably between the wards, ranging from around 48 in Rainham Central to 79 in Luton and Wayfield. Areas with higher GFR will need more children services and interventions to ensure that children have a healthy start in life.
      • Teenage pregnancy rates are higher in Medway than in the South East and in England overall; both for under 18 and under 16 year olds.
      • The number of people migrating into Medway is greater than the number moving out, both in terms of Long-Term International migration and Internal (within UK) migration.
      • In the last couple of years there has been a decrease in the percentage of pupils at the end of Key stage 4 achieving 5 plus A* to C grade (including English and maths) GCSEs in Medway. In 2013/14, 58.8% achieved these grades, down from 61/3% in 2011/12. This downward trend mirrors the pattern seen in England overall, which shows 53.4% in the same period (down from 59.4% in 2011/12).
      • Central parts of Medway have the lowest median annual household incomes with higher incomes in non-central areas, particularly to the south east side of Medway.
      • By January 2012 the number of people claiming job seekers allowance was 7,416, an increase of 14% compared to 12 months previously. Nationally the claimant count has increased by 10% and regionally 9%. Medway's claimant rate is 4.4%, 6th highest out of the 67 local authorities in the South East.
      • The proportion of JSA claimants is higher in Medway (2.2%) than in the South East (1.2%) and Great Britain overall (1.9%). The proportion of JSA claimants has reduced in Medway since February 2012; this pattern is also evident in the South East and Nationally (from 4.4%, 2.8% and 4.1% respectively).
      • From 2015 to 2025 the number of people aged 65 and above is estimated to increase by 24% to 53,000.
      • Over the same period, the number of people over 85 years is projected to increase by 44% to 6,900.
      • From 2012 to 2020 the number of people over 65 years with a limiting long-term illness is expected to increase by 21%

    • Demography

      View Larger Map
      Map 1: Medway

      Medway Unitary Authority (“Medway”) was formed in 1998 and consists of five main towns (Strood, Rochester, Chatham, Gillingham, and Rainham) and a number of smaller towns and villages, now contained within 22 electoral wards. The built areas of the main towns have expanded over time and in places there is little demarcation between the end of one town and the beginning of another. The distance from the centre of one of these main towns to the next is between one and two miles.

      The total area covered by Medway is 19,200 hectares (1 hectare is about the same size as an international rugby pitch or about one and half times the size of an international football pitch). While the towns are densely populated there are larger, much more sparsely populated rural areas in the Hoo Peninsula to the north of Medway, and the ward of Cuxton and Halling in the west. Parts of the Hoo Peninsula are within the North Kent Marshes, an environmentally significant wetlands region with several Sites of Special Scientific Interest (SSSIs).

      There is one main hospital (“Acute Trust”), Medway NHS Foundation Trust, located about halfway between Chatham and Gillingham railway stations.

      Population size

      There were approximately 276,492 people resident in Medway in 2015, according to figures produced by the Office for National Statistics[1].

      The 2015 mid-year population estimate shows an increase of 12,567 (4.8%) from the 2011 Census (263,925), and an increase of 27,004 (10.8%) since the Census in 2001 (249,488).

      Compared to England the population of Medway has a smaller proportion of people over the age of 65 years (Medway 15.4% and England 17.7%). Medway has a larger proportion between the ages of 0 and 14 years than England (19.1% and 17.9% respectively) and between the ages of 15 and 24 years (10.4% and 9.7% respectively). The population of Medway is therefore younger than the population of England overall.

      Figure 1: The population structure of Medway and England in 2015
      Figure 1: The population structure of Medway and England in 2015.[1]

      There are slightly more females than males (male to female sex ratio: 0.99).[1]

      Population within Medway

      At first glance Medway may appear to be largely homogenous, but this belies considerable variation. The largest ward is Gillingham North, with 19,071 people, and the smallest ward is Cuxton and Halling, with 5,583 people.[2]

      There is considerable variation in population density, ranging from 1.8 people per hectare in the Peninsula to 85.3 people per hectare in Gillingham South in 2011. The median density is 37 per hectare, and Rainham Central, Watling and Strood South have approximately this density.[3]

      The least densely populated wards are Peninsula, Cuxton and Halling and Strood Rural, and the most densely populated wards are Rochester East, Chatham Central and Gillingham South.

      There are also differences in the age distributions of the ward populations as described below.

      Wards with a population greater than 12,000: Chatham Central, Gillingham North, Gillingham South, Luton and Wayfield and Strood South wards are the most populated in Medway and have a high proportion of younger people, particularly children aged under 5. Peninsula, Twydall, Rainham Central and Rochester South and Horsted have older populations. Strood Rural, Strood South and Rainham South are large wards with a mix of young and older populations.[2]

      Wards with a population smaller than 12,000: Lordswood and Capstone, Princes Park and Rochester East have a younger age profile. Conversely Cuxton and Halling, Walderslade, Hempstead and Wigmore, Rainham North, Rochester West and Watling have an older population. River ward is slightly unusual in terms of having a very high proportion of its population between 18 and 64 and also an above average proportion aged under 5.[2]

      Mortality and life expectancy

      Approximately 2,300 Medway residents die each year (2,313 deaths registered in 2015).[4] The all-age, all-cause mortality rate is statistically significantly higher in Medway than in England and the South East average.[5]

      The mortality rate among males is significantly higher than females; therefore the life expectancy is significantly higher in females than it is for males. Life expectancy from birth (a summary measure of current mortality patterns) in Medway is nearly four years greater in females (82.0 years) than in males (78.3 years) over the period 2011-2015.[6]

      There are also differences in life expectancy between the wards. Average life expectancy in Cuxton and Halling, Rainham Central, Rainham South, Walderslade and Hempstead and Wigmore is significantly greater than seven wards including Chatham Central, Luton and Wayfield, and River wards. Life expectancy is highest in Cuxton and Halling at 85.6 years, and lowest in River at 78.1 years (2011 to 2015).[6]

      In every ward life expectancy is greater in females than it is in males. The greatest difference in life expectancy is between females in Cuxton and Halling (87.7 years) and males in River ward (74.8 years), a difference of 12.9 years.[6]

      Fertility

      In 2015 there were 3,609 live biths in Medway to women.[7] The general fertility rate (GFR), a summary measure of fertility in women between the ages of 15 and 44 years, in Medway in 2015 was 65.2 births per 1,000. This value is higher than South East region and England averages (61.7 and 62.5 births per 1,000 respectively).

      The GFR varies considerably between the wards, ranging from around 48 in Rainham Central to 79 in Luton and Wayfield (using data from 2013 to 2015). The five wards with the highest GFR are Luton and Wayfield, Chatham Central, Strood South, Gillingham South and Princes Park. Areas with a higher GFR will need more children services and interventions to ensure that children have a healthy start in life.[8]

      Teenage pregnancy is an important problem in Medway. The under-16 and under-18 conception rates are higher in Medway than the South East and National average, although there has been a general decrease over the past few years, both at a local and National level.

      Between April and June 2014 the under-18 conception rate in Medway was 32.9 conceptions per 1,000 females aged 15–17. This value is above the 75th percentile for all the local authorities in England; the average under-18 conception rate in England in the same period was 23.3 conceptions per 1,000.

      In 2013 Medway had an under-16 conception rate of 5.2 conceptions per 1,000 females aged 13–15 years compared to 3.8 per 1,000 (South East) and 4.8 per 1,000 (England). The proportion of conceptions to young women aged 13–15 years which lead to a termination of pregnancy is lower in Medway than nationally and in the South East. Over half (57.7%) of conceptions, however, result in an abortion.

      Teenage pregnancy is covered in more detail in the Teenage pregnancy chapter in Appendices -> Background papers: children.

      Migration

      Medway's population has increased naturally every year since 2001. However, the population has been growing more rapidly in recent years.[9]. In 2012, inward migration to Medway exceeded outward migration, contributing to this growth, with an estimated net inflow of 1,800 persons. This is the largest net inflow to Medway in the last ten years, which, prior to 2005 saw a net migratory outflow. The vast majoriy of migration into Medway is internal, i.e. from other areas of the UK.[9]

      Migration flows primarily from from London and across North Kent, with significant inward migration to Medway from South East London boroughs as well as Gravesham (+375), Dartford (+186) and to a lesser extent Sevenoaks. Outward migratory destinations from Medway are most notably: Tonbridge & Malling (-141), Canterbury (-109) then Maidstone.[9]

      The age of the migrants into Medway are slightly younger than those leaving, with those in their twenties accounting for just over half of net migration into Medway (+800). Only those in their 60's are the only significant outflow from Medway (-90). In contrast, the age profile of residents moving to London from Medway (-1851) is younger than those moving from London to Medway (+3515), perhaps relating to job opportunities in the capital. [9]

      Education

      Following the trend seen in England as a whole in the last couple of years there has been a decrease in Medway in the percentage of pupils at the end of Key stage 4 achieving 5 plus A* to C grades, including English and maths GCSEs. In 2013/2014 58.8% of students acheived these grades, down from 61/3% in 2011/12. This is similar to the England average of 56.8% in 2013/2014, which fell from 59.4% in 2011/12.[10]

      Ethnicity

      The majority of the population (89.6%) in Medway are classified as White, with the next largest ethnic group being Asian or Asian British (5.2%) including Chinese.[11] The proportion of the population that is White is slightly larger than in England and slightly lower than in Kent, although these differences are not significant. There are also no significant differences in ethnicity by gender.

      Figure 2: Population (%) by ethnicity. Medway and comparators.
      Figure 2: Population (%) by ethnicity. Medway and comparators.
      Source: Census 2011, Office for National Statistics.

      Data collected by Medway Council in 2011 from schools in Medway show some small but interesting differences compared to the overall population distribution, with 85.7% of pupils reported as White, significantly smaller than the overall Medway population (90.6%) estimated using ONS data.

      The three wards with the most ethnically diverse school populations are Chatham Central, Gillingham South and River wards. Within these wards 70% to 75% of pupils are White and at least 7% have mixed parents. Cuxton and Halling, Peninsula, and Lordswood and Capstone are amongst the wards with the most homogenous schools populations.

      Main language

      The table below shows the number and proportion of people in Medway by main language spoken as reported at the time of the 2011 Census. The list has been shortened to those languages spoken by at least 500 people. Multi-lingual speakers are only counted once. The full table can be found in the Population section in the Data Inventory.

        Count Percentage
      All usual residents aged 3 and over 253,480 100.0
      English 240,267 94.8
      Polish 1,598 0.6
      Panjabi 1,415 0.6
      Slovak 785 0.3
      Bengali (with Sylheti and Chatgaya) 694 0.3
      Lithuanian 532 0.2
      Russian 500 0.2
      Table 1: Main languages spoken in Medway

      References

      [1]   Office for National Statistics. Mid-2015 population estimate 2016;
      [2]   Office for National Statistics. Ward Level Mid-Year Population Estimates (experimental) 2015;
      [3]   Office for National Statistics. 2011 Census: Table QS102EW - Population Density 2011;
      [4]   Office for National Statistics. Death registrations in England and Wales, summary tables: 2015 2016;
      [5]   The Health and Social Care Information Centre Indicator Portal. Mortality from all causes: directly standardised rate, all ages, 3-year average, MFP https://indicators.ic.nhs.uk/webview/
      [6]   Medway Public Health Intelligence team. Primary Care Mortality Database analysis
      [7]   Office for National Statistics. Birth summary tables in England and Wales: 2015 2016;
      [8]   Medway Public Health Intelligence team. Public Health Births File Analysis
      [9]   Tim Stephens DP, Engagement C, Culture . Migration 2012 - Medway Council 2013;
      [10]   Public Health England. Health ProfilesPublic Health England. http://fingertips.phe.org.uk/profile/health-profiles .
      [11]   Office for National Statistics. Table KS201EW: 2011 Census: Ethnic group, local authorities in England and Wales 2012; http://www.ons.gov.uk/ons/publications/re-reference-tables.html?edition=tcm%3A77-286262

    • Economy and Infrastructure

      The Medway Council Facts and Figures webpage contains information on employment, unemployment, business, and gross value added.

      In 2009, the Economic Development Strategy for 2009-12 was adopted in Medway, in which five priority areas were identified:


      • Sector development — includes providing facilities for creative industries and establishing centres for environmental technologies
      • Skills development — aiding training and fulfilling skill gaps in the work force
      • Higher education — encouraging employers to recruit apprentices and graduates and raising the aspirations of young people. Medway Council is a partner in the 100 apprentices recruited in 100 days challenge
      • Employment space — auditing suitable land sites for future development
      • Image building — host a range of cultural events to improve the overall image of Medway as a place to visit and stay

      Household income

      The median annual household income in Medway in 2011 was £31,400. This is above the national level (£29,000) but below the median income in the South East (£33,900). There is considerable variation in household incomes between areas in Medway from £24,800 in Chatham Central up to £44,800 in Hempstead & Wigmore. [1]

      Other wards which show a relatively low household income include: Luton & Wayfield (£25,200) and Gillingham North and Twydall (£27,100).The Medway Council Household income factsheet shows that 29% of households in Medway survice on an income of less than £20,000 per annum; approximately 10% of households have an income of less than £10,000.[1]

      Employment

      In 2014 the number of people listed as economically active (working age residents in employment or actively seeking employment) was 77.6%, which is in line with the England average (77.4%), but below that of the South East in general (79.7%). As at April 2015, the number of job seekers allowance (JSA) claimants in Medway was 3,856, accounting for 2.2% of the working-age resident population; this is a decrease of 1,224 claimants compared to 12 months prior.

      There have been very similar percentage reductions in Kent, the South East region and England. As at November 2013, Medway's claimant rate was the fifth highest out of the 67 local authorities in the South East.[2]

      Medway Kent South East England
      No. Rate No. Rate No. Rate No. Rate
      Jan-06 4,411 2.7 17513 2.0 82,161 1.5 786,824 2.9
      Jan-07 4,387 2.6 16785 1.9 81,708 1.5 804,585 2.9
      Jan-08 3,464 2.0 13464 1.5 68,096 1.3 690,667 2.5
      Jan-09 5,501 3.2 22452 2.5 119,762 2.2 1,065,839 3.8
      Jan-10 7,659 4.4 29673 3.3 162,568 3.0 1,369,811 4.9
      Jan-11 6,508 3.7 26593 2.9 135,253 2.5 1,224,055 4.4
      Jan-12 7,416 4.2 30297 3.3 146,956 2.7 1,355,582 4.8
      Jan-13 6,913 4.0 28914 3.2 137,436 2.5 1,292,542 4.5
      Jan-14 5,404 3.1 22645 2.5 101,709 1.8 1,001,862 3.5
      Jan-15 3,932 2.2 15553 1.7 68,099 1.5 669,223 2.3
      Table 1: JSA claimant number and rate (proportion of resident population aged 16-64) in Medway over time compared to Kent County, the South East and England.

      Table 1 shows that Medway has a consistently higher JSA claimant rate than Kent, the South East region and England. It should be noted that these counts do not yet include recipients of Universal credit.

      For more information on employment, please see Our people and place —> Vulnerable groups

      Major employers

      In 2014 there were 6,865 businesses in Medway. This is a 6% increase on the 2013 level - the largest increase in the past four years and higher than growth seen nationally (+4.4%).

      Construction - Medway's largest sector - accounts for just under a fifth of businesses; this is considerably higher than levels in the South East (13%) and United Kingdom (12%).

      Other sectors which are proportionally larger in Medway than nationally are: retail (9%) 'transport & storage' (5%), 'health' (5%) and 'production' (7%).

      Medway's second largest sector, 'Professional, scientific & technical' representing 15% of business and accounts for the largest growth in businesses in 2014, up by 12%. In the last four years this sector has increased by almost one quarter[3].

      Transport

      Medway's location means that it is very accessible by rail, road and through the ports. There is ready access to the M2, M20 and M25, the Channel Tunnel, Channel Tunnel Rail and, although not a commercial airport, Rochester has a landing strip for private use. For more information, please see the parking and transport section of Medway Council's website.

      Education

      There are 78 primary schools in total in Medway. Fifty-six are maintained schools and 22 are academies. Of these, there are 15 infant schools, 16 junior schools and 51 full primary schools.

      There are five special schools (three maintained schools and two academies) and two Pupil Referral Units.

      There are 17 secondary schools in Medway; all except one is an academy.

      In addition, there are three colleges offering a range of more vocational subjects alongside traditional subjects. One of these, Medway University Training Centre, is a new build school for 14–19 year olds specialising in Engineering, Construction and Design.

      (Please note: figures correct as at November 2015).

      Universities at Medway is a partnership comprising the University of Greenwich, the University of Kent, Canterbury Christ Church University and Mid-Kent College at a shared campus at Chatham Maritime. The £120 million scheme is the first of its kind in the country and aims to increase student numbers in Medway to more than 10,000 by 2012.

      Each of the four institutions offers its own range of courses, both full and part-time, drawing on its own individual academic strengths, and has its own buildings. By being on a shared campus, students have access to a wide range of first-class facilities. Universities at Medway is supported by the Higher Education Funding Council for England; The South East England Development Agency (SEEDA); Medway Council; and Communities and Local Government: Thames Gateway Funding (see link below).

      Rochester is host to one of the five campuses which belong to the University of Creative Arts, specialising in courses relating to photography, sculpture and textiles.

      Other important links:

      Medway Renaissance

      Thames Gateway Kent Partnership


      References

      [1]   Development Policy & Engagement Team TS. Household Income, Medway Council 2012;
      [2]   Medway Council. Unemployment 2014; Medway Council. http://www.medway.gov.uk/pdf/Info%20bulletin%20Unemployment%20Jan%202014.pdf .
      [3]   Planning Service. Businesses and employment January, 2015; Medway Council.
    • Vulnerable groups

      In every society there are some groups who are more vulnerable than others, brought about by societal factors and the environments in which people live. There are some common challenges across all vulnerable groups including the risk of stigma and discrimination, restricted access to educational opportunities and exclusion from income generation. Within these groups there are varying levels of vulnerability and that just because a person is older, for example, they are not necessarily vulnerable.

      This section illustrates the needs of some of the vulnerable groups in Medway. It is not a complete list of all vulnerable groups and should not be seen as excluding the groups that are not mentioned here. The intention here is to show how vulnerability is an important issue to consider in the design and implementation of services and programmes.

      Vulnerable people are a wide ranging group and include:[1]


      • Adults living with a disability
      • Carers
      • Older people
      • People with mental health needs
      • Adults with long-term conditions
      • Children in care
      • Minority groups
      • Homeless people

      Gypsies and Travellers

      Research[2] has shown that Gypsies and Travellers have significantly poorer health status and more self-reported symptoms of ill-health than other UK resident, English-speaking minorities. Gypsies and Traveller's health beliefs demonstrate a cultural pride in self reliance — there is more trust in family carers than professionals. To maintain a sense of independence and autonomy, it is of great importance to travellers to choose whether and how they continue to live a travelling lifestyle. Gender roles are strictly defined, meaning that women's access to health services could be restricted.[2]

      Cancer, and other illnesses perceived as terminal, are feared and so screening is avoided. Patient-held records would improve care continuity greatly as they could be taken wherever the patient goes. Severe educational disadvantage and poor levels of literacy were highlighted as issues so audio methods of communication may work better. Gypsies and Travellers access fewer services and therapies despite having greater health needs.[2]

      GPs are either reluctant to register Gypsies and Travellers or visit their sites, creating a barrier to primary care. Expectations of Gypsies and Travellers and health staff also differ and attitudes or perceived attitudes have prevented Gypsies and Travellers from seeking help.[2]

      As at July 2015, Medway had 15 Traveller caravans. A count is conducted twice a year in January and July. This number has fluctuated between 15 and 18 since January 2014. This was the lowest number across Kent and Medway with the exception of Shepway (2) and Thanet (0). Maidstone district had the highest count of caravans (350).[3]

      The number of people declaring their ethnicity as 'Gypsy or Irish Traveller' at the time of the 2011 Census in Medway was 510 (0.2% of the total population). This suggests that a substantial section of this community are living in accommodation other than caravans which is something also observed at a national level.[4]

      Children in care

      Early experiences may have long-term consequences for the health and social development of children and young people. A number have positive experiences in the care system and achieve good emotional and physical health, do well in their education and have good jobs and careers. However, entering care is strongly associated with poverty and deprivation (for example, low income, parental unemployment, relationship breakdown).[5]

      The number of children in the care (CIC) of Medway Council has increased by 29% from December 2009 to December 2011, which is in line with national increases. Any child can become a CIC but the likelihood is many times greater in children from low income/benefit dependent families and from parents with mental health, learning disabilities, drug, domestic violence or alcohol issues. About 60% of those looked after in England have been reported to have emotional and mental health problems and a high proportion experience poor health, educational and social outcomes after leaving care.[5]

      One third of all children and young people in contact with the criminal justice system have been looked after.[6] However, a substantial majority of young people in care who commit offences had already started to offend before becoming looked after.[5]

      As at 31st December 2011 there were 449 children in care of Medway Council. This represents 73 per 10,000 of the 0–18 year olds in Medway compared with a national average of 59 per 10,000. These children and young people are some of the most challenging and needy in Medway due to their life experiences.

      (For more information go to Appendices -> background papers: children -> children in care)

      People with mental health problems

      People with mental health conditions (including schizophrenia, bipolar disorder, depression, epilepsy, alcohol and drug use disorders, child and adolescent mental health conditions, and intellectual impairments) have tended to be overlooked in the planning of development programmes. This is despite the high prevalence of mental health conditions, their economic impact on families and communities, and the associated stigmatisation, discrimination, and exclusion that can occur, bringing about vulnerabilities.[7]

      People with mental health conditions are often are not given the opportunities by communities and governments to reach their potential as contributors to economic prosperity and well-being. This leads to deeper economic and social marginalisation. They are often excluded from participating fully in society, and are not empowered to change factors which oppress them.[7]

      Mental ill health represents up to 23% of the total burden of ill health in the UK — the largest single cause of disability[8]. At least one in four people will experience a mental health problem at some time in their life and one in six will be experiencing a common mental health problem at any one time[9]. Approximately one in 10 children aged between 5–16 years has a mental health problem.[10]

      As such, mental health affects a large number of people in Medway. It is estimated that 29,600 people aged 16–74 have 'any neurotic disorder' and 2,390 people aged over 65 have dementia.[11]

      (For more information go to Data inventory -> health and wellbeing status -> mental health)

      Long-term unemployed

      There is strong evidence that work and paid employment are generally beneficial for physical and mental health and well-being. There is a strong positive association between unemployment and increased rates of overall mortality and morbidity from CVD, lung cancer and suicide. It can affect mental health and lead to poorer psychological well-being. The impact of unemployment can alter depending on socio-economic status, income and financial anxiety.[12]

      As at January 2014, the number of job seekers allowance (JSA) claimants in Medway was 5,404, a decrease of just over 1,509 (22%) compared to 12 months prior. There have been very similar percentage reductions in Kent, the South East region and England. As at November 2013, Medway's claimant rate was the fifth highest out of the 67 local authorities in the South East.[13]

      Within Medway, wards with the highest unemployment rates are Chatham Central (6.7%) and Luton & Wayfield (6.3%). Wards that have seen the largest proportional decrease in JSA claims over the past twelve months are: Watling (-34%), Peninsula (-33%) and Strood South (-32%). Gillingham North has seen the largest decrease in the number of claims (-181).[13]

      Longer-term JSA claims in Medway are down on 2012 levels and have almost returned to 2011 levels, with claims over 6 months in duration having dropped by one fifth compared to twelve months ago. Longer-term claims in Medway now stand below the national level, with 30.5% of claims being by claimants who have been out of work for over twelve months – this compares to 31.1% nationally.[13]

      Younger claimants – those aged 16-24 – account for over one-third of JSA claims, however claims in this age group peaked in early 2010, but have since dropped by almost 40% since then.[13]

      Older people

      Compared to England the population of Medway has a smaller proportion of people over the age of 65 years (Medway 15.4% and England 17.7%)[14]. Medway also has a larger proportion between the ages of 0 and 14 years (19.1% and 17.9%) and between the ages of 15 and 24 years (10.4% and 9.7%). The population of Medway is therefore younger than the population of England overall.

      Rainham Central, Rainham North, Hempstead and Wigmore, Peninsula and Rochester South and Horsted have larger proportions of older people, with at least one fifth of their populations aged 65 years and above.

      People aged 85 and over make up only 1.7% of Medway's population (4,799 people according to 2015 estimates). Hempstead and Wigmore, Rainham Central, Rainham North, Rochester South and Horsted, Rochester West have the highest number of people aged 85 and over as a percentage of their total ward population, whilst Princes Park and River ward have the least. People aged 85 years old and older are particularly vulnerable because they are more likely to be frail and have mental health problems such as dementia.

      (For more information go to Our people and place -> demography and -> Medway in the future)

      Each of these groups, and others not specifically mentioned here are particularly vulnerable to abuse. Abuse can take various forms including: physical, sexual, psychological, financial, neglect, discriminatory and institutional abuse. It may consist of a single act or repeated acts, but it can also be an omission to act, or it may occur when a vulnerable person is persuaded to enter into a financial or sexual transaction to which he or she has not consented, or cannot consent. Abuse can occur in any relationship.[1]


      References

      [1]   Medway Council. My Say, My Way in Medway - Medway's Strategy for Advocacy Services 2010; Medway Council. http://democracy.medway.gov.uk/mgConvert2PDF.aspx?ID=3771 .
      [2]   Parry G, Cleemput P, Peters J, et al. The Health Status of Gypsies and Travellers in England 2004; University of Sheffield.
      [3]   Young M. Count of Traveller Caravans England 2015;
      [4]   ONS. 2011 Census Analysis, What does the 2011 Census tell us about the Characteristics of Gypsy or Irish Travellers in England and Wales? 2014;
      [5]   National Institute for Health and Clinical Excellence. Promoting the quality of life of looked-after children and young people - NICE public health guidance 28 2010; National Institute for Health and Clinical Excellence. http://www.c4eo.org.uk/themes/vulnerablechildren/files/promoting_the_quality_of_life_of_looked_after_children_and_young_people.pdf .
      [6]   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 .
      [7]   World Health Organisation. Mental Health and Development: Targeting people with mental health conditions as a vulnerable group 2010; World Health Organisation. http://whqlibdoc.who.int/publications/2010/9789241563949_eng.pdf .
      [8]   World Health Organization. The Global Burden of Disease: 2004 update 2008;
      [9]   McManus S, Meltzer H, Brugha T, et al. Adult psychiatric morbidity in England, 2007: Results of a household survey 2009; The NHS Information Centre for health and social care. http://bit.ly/GAxluS .
      [10]   Green H, McGinnity A, Meltzer H, et al. Mental Health of Children and Young People in Great Britain, 2004. 2005; Office for National Statistics. Basingstoke: Palgrave Macmillan.. http://www.ic.nhs.uk/webfiles/publications/mentalhealth04/MentalHealthChildrenYoungPeople310805_PDF.pdf .
      [11]   Mental Health Observatory. Estimating the prevalence of common mental health problems in PCTs in England - Brief no. 4 2008; Mental Health Observatory. http://www.mentalhealthobservatory.org.uk/uploads/doc261_1_mho_brief_4.pdf .
      [12]   Waddell G, Burton K. Is Work Good For Your Health and Well-Being? 2006;
      [13]   Medway Council. Unemployment 2014; Medway Council. http://www.medway.gov.uk/pdf/Info%20bulletin%20Unemployment%20Jan%202014.pdf .
      [14]   Office for National Statistics. Mid-2015 population estimate 2016;
    • Medway in the future

      Population ageing

      Increasing life expectancy and a reduction in fertility is leading to an ageing of the population in England. Substantial changes in population structure have profound implications for the provision of health and social care services.

      Even though Medway has a slightly younger population than the national average, projections from 2015 to 2025 suggest that the number of people 65 years of age or over will increase by 24% to 53,000 and the number of people over 85 years will grow by 44% to 6,900.[1]

      Looking further ahead, Medway's population is predicted to reach 330,200 by 2035, growing by about 53,400 people between 2015 and 2035, a growth rate of 19%.

      Figure 1: Projected population change in Medway between 2015 and 2025
      Figure 1: Projected population change (thousands) in Medway between 2015 and 2025[1]

      The number of people over 65 years with a limiting long-term illness is expected to increase by 21% from 2012 to 2020 [2] assuming the age-related prevalence from the 2001 Census is constant in the future. This will have a significant impact on the demand for health services for the management of long term conditions such as dementia, heart disease and diabetes as the incidence of these conditions increases with age. There will also be a need to increase preventative programmes such as influenza vaccination for the over 65s.

      The numbers in other age groups are all expected to increase over the same period with the exception of the 15-24 and 40-49 age groups.

      Figure 2: Projected percentage population change 2015--2025 by broad age group
      Figure 2: Projected percentage population change 2015–2025 by broad age group.[1]
        2016 2017 2018 2019 2020 2021 2022 2023 2024 2025
      0-4 0.0 -0.5 0.0 1.1 2.2 3.3 4.3 4.9 5.4 6.0
      5-19 1.0 1.9 2.7 3.9 4.7 6.0 7.6 8.9 10.3 11.8
      20-64 0.8 1.7 2.6 3.3 4.0 4.7 4.9 5.4 5.8 6.2
      65plus 2.3 4.5 6.6 8.7 10.8 13.4 16.0 18.5 21.8 24.4
      All ages 1.0 2.0 3.0 4.0 5.1 6.1 7.1 8.1 9.1 10.0
      Table 1: Projected percentage population change 2015–2025 by broad age group.

      Development based projection

      As part of the Thames Gateway regeneration project, River ward and Strood Rural ward are both areas that are marked for significant development. River ward includes developments at Chatham Maritime (including St Mary's Island) and Rochester Riverside, development within Strood Rural includes Wainscott and Chattenden. These two wards account for 60% of planned residential development up to 2028. Consequently the population of River ward is projected to almost triple in size between 2001 and 2026 - the population of Strood Rural is likely to more than double in size.

      The main growth period is shown to be between 2016 and 2020, however with a declining head count per household over this period - housing completions do not correspond with an increased population of equal size.

      Over the next twenty years Medway will need more accommodation to house a given population, due to the reducing average household size, a trend which is reflected nationally, but which is particularly pronounced in Medway and the Kent Thames Gateway.[3]


      References

      [1]   Office for National Statistics. Mid-2014-based subnational population projections for England
      [2]   Institute of Public Care and Oxford Brookes University. Projecting Older People Population Information System http://www.poppi.org.uk
      [3]   Medway Council. Population projection, Development Plans and Research Regeneration http://www.medway.gov.uk/pdf/Population%20projections%20Nov%2010.pdf
  • Our health and well-being

      This part of the JSNA aims to combine core themes from three outcomes frameworks: the Adult Social Care Outcomes Framework; the NHS Outcomes Framework; and the Public Health Outcomes Framework.

      As there is currently no outcomes framework for social care of children, the needs of children in Medway have been included by making reference to the Children and Young People Plan (CYPP). [1]


      References

      [1]   Medway Children's Trust. CYPP - Children and Young People's Plan 2011 to 2014 October, 2011; Medway Children's Trust. http://www.medwaychildrenstrust.co.uk/documents/children-and-young-peoples-plan-2011-to-2014-1316617995.pdf .
    • Key messages
    • Premature mortality

      The age which deaths are considered to be premature has increased as health and life expectancy has increased and currently deaths under the age of 75 years are classified as premature.

      Between 2012 and 2014 Medway was ranked 87th out of 150 local authorities for overall rate of premature deaths with an age-adjusted rate of 371 per 100,000[1]. Of the roughly 2,300 deaths that occur in Medway each year, almost a third of deaths in females and almost half of deaths in males occurring before the age of 75 (29% and 45% in 2012-2014 respectively). In both males and females the leading cause of premature deaths is cancer, accounting for almost half of deaths in women (46.7%) and two in five men (39.9%) of this age[2]. There has been a downward trend in mortality for all cancers in Medway since 1993 but cancer death rates have remained higher than in comparator groups, regional and national rates. Currently, there are an estimated 162 premature deaths per 100,000 resulting from cancer, equating to a ranking of 119th out of 150 local authorities[1].

      The smoking prevalence in Medway is consistently higher than the national average, especially in pregnant women and young people, and this is known to be the biggest cause of cancer. There is also shown to be correlation between deprivation and cancer prevalence. There are many services available to help people change their lifestyles including the Stop Smoking Service, the MEND programme and Tipping the Balance. For more information on these services, please see the 'Our Programmes and Services' section. For support living with and following on from cancer, there is now a Macmillan Information Centre at Medway Maritime Hospital.

      The next largest cause of death in those under the age of 75 years is cardiovascular disease (for example heart attacks, stroke and heart failure), accounting for 10.5% of premature deaths in women and 24.0% in men[2]. Lifestyle factors such as smoking, unhealthy diet and lack of physical activity and their consequences such as obesity, high cholesterol, high blood pressure and diabetes, are major risk factors for CVD.

      A further 10.3% of premature deaths are due to respiratory diseases[3], notably chronic obstructive pulmonary disease (COPD). COPD is primarily caused by chronic tobacco smoking. The likelihood of developing COPD increases with age and cumulative smoke exposure, and almost all life-long smokers will develop COPD. Airflow obstruction is progressive and whilst it is treatable, it is not curable. Early detection is vital to allow a patient to enjoy an active life. See the Appendices —> Background papers: Adults —> COPD for more information on COPD in Medway.

      There are four times as many premature deaths due to suicide or unexplained injuries in men as there are in women. The numbers are relatively small in statistical terms, however most of these deaths occur under the age of 65 years.

      Premature mortality and deprivation

      Premature mortality is strongly associated with deprivation. The mortality rate in the most deprived twenty percent of the population is double the rate in the least deprived twenty percent, and there is a clear mortality gradient in both males and females from the least to the most deprived. This is a very vivid example of the inequalities highlighted in the Marmot report.[4] The Slope Index of Inequality (SII) for life expectancy by deprivation deciles is significantly above zero in both males and females[5].

      Figure 1: Age-standardarised mortality rates per 100,000 in Medway.
      Figure 1: Age-standardarised mortality rates per 100,000 in Medway from all causes, 2008–10 (All ages).
      Source: Primary Care Mortality Database (ONS)

      The gradient in mortality rates is also seen in individual causes, with premature mortality rates increasing with deprivation in cancer, circulatory disease, heart disease, and respiratory disease, and also likely in other diseases, although the numbers are smaller and it is harder to show this association statistically. Issues of deprivation and health are covered in more detail in “Our inequalities”.

      Premature mortality by ward

      There is great variation in premature mortality rates by electoral ward, although the number of deaths per ward is relatively small and as a result the most of the differences are not statistically significant. The differences at the extremes, however, are statistically significant, with age-standardised rates in Princes Park and Watling three times the rates in Hempstead and Wigmore. [6]


      References

      [1]   Public Health England. Mortality Rankings: Medway
      [2]   HSCIC Indicator Portal. Premature mortality from various causes
      [3]   Medway Public Health Intelligence team. Primary Care Mortality Database analysis
      [4]   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 .
      [5]   Public Health England, Association of Public Health Observatories. Slope Index of Inequality Data for LAs 2011;
      [6]   NHS Medway, Medway Council. JSNA Appendices -> Data Inventory -> Health and well-being status -> Main causes of mortality. 2012;
    • Experience of health and social care

      GP patient survey, Department of Health

      For each measure Medway has been compared with West Kent, Eastern and Coastal Kent and England. Percentages relate to 'very' or 'fairly' unless otherwise stated.

      Accessing GP services

      For each of the four main measures under this heading, Medway has the lowest percentage of 'very' or 'fairly good' responses. The range of percentages across the four areas, however, is not large. For example, for the 'ease of getting through to someone at a GP on the phone' measure, the range between the four areas is 80.3% to 82.2%. Another factor not mentioned in the tables is whether patients are overheard in the reception area. 26.2% of Medway patients said that they were overheard and they weren't happy about it, 2.7 percentage points above the England average.

        Ease of getting through
      to someone at GP
      on the phone
      Helpfulness of
      receptionist
      Experience of making
      an appointment
      Opening hours
      satisfaction
      NHS Ashford CCG 67% 88% 73% 72%
      NHS Canterbury and Coastal CCG 77% 89% 78% 79%
      NHS Dartford, Gravesham and Swanley CCG 62% 86% 69% 70%
      NHS Medway CCG 62% 84% 65% 65%
      NHS South Kent Coast CCG 70% 89% 77% 76%
      NHS Swale CCG 64% 87% 66% 69%
      NHS Thanet CCG 53% 86% 67% 74%
      NHS West Kent CCG 73% 89% 78% 75%
      England 70% 87% 73% 75%
      Table 1: Accessing GP services, aggregated data collected from Jan-Mar and Jul-Sept 2015
      Patient experience: out of hours services

      In contrast to the measures above, Medway has the highest percentage satisfaction for out of hours services, 4.9 percentage points higher than the England average. Patient's perception of the speed of care provided being very or fairly good was quite low across the four areas at between 62.4% and 68.6% and this has impacted on the overall experience percentage.

        Speed of care was
      about right
      Confidence and trust
      in person seen or spoken to
      Overall
      experience
      NHS Ashford CCG 56% 86% 67%
      NHS Canterbury and Coastal CCG 66% 82% 63%
      NHS Dartford, Gravesham and Swanley CCG 51% 88% 63%
      NHS Medway CCG 62% 85% 60%
      NHS South Kent Coast CCG 67% 84% 67%
      NHS Swale CCG 50% 86% 66%
      NHS Thanet CCG 61% 76% 64%
      NHS West Kent CCG 62% 84% 63%
      England 62% 87% 69%
      Table 2: Out of hours services, aggregated data collected from Jan-Mar and Jul-Sept 2015
      Patient experience: GP services

      Medway patients are least likely to recommend their GP to someone new to the area out of the four areas looked at, being 6.8 percentage points under the England average. The overall experience for Medway patients was 4.2 percentage points lower than the England average.

        Would recommend
      GP surgery
      to someone
      Overall
      experience
      NHS Ashford CCG 77% 84%
      NHS Canterbury and Coastal CCG 83% 89%
      NHS Dartford, Gravesham and Swanley CCG 73% 81%
      NHS Medway CCG 68% 76%
      NHS South Kent Coast CCG 78% 86%
      NHS Swale CCG 70% 80%
      NHS Thanet CCG 72% 81%
      NHS West Kent CCG 81% 87%
      England 78% 85%
      Table 3: Overall experience of GP services, aggregated data collected from Jan-Mar and Jul-Sept 2015
      Accessing NHS dental services

      94.5% of patients in Medway seeking an NHS appointment in the last 2 years were successful, higher than the national average by 1.5 percentage points. Medway also has the lowest percentage of people who didn't know you could get an NHS appointment. West Kent has the highest percentage at 17.1%.

        Successful in getting
      an NHS appointment
      Didn’t think you
      could get one
      NHS Ashford CCG 91% 16%
      NHS Canterbury and Coastal CCG 94% 18%
      NHS Dartford, Gravesham and Swanley CCG 91% 15%
      NHS Medway CCG 92% 7%
      NHS South Kent Coast CCG 91% 10%
      NHS Swale CCG 88% 12%
      NHS Thanet CCG 92% 10%
      NHS West Kent CCG 87% 19%
      England 92% 12%
      Table 4: Accesing NHS dental services, aggregated data collected from Jan-Mar and Jul-Sept 2015
      Patient experience: NHS dental services

      Medway patients have the highest satisfaction of their overall experience of an NHS dentist at 84.5%, 0.3 percentage points higher than the England average. Both West and Eastern and Coastal Kent have satisfaction nearly 3 percentage points lower than the England average.

        Overall
      experience
      NHS Ashford CCG 79.8%
      NHS Canterbury and Coastal CCG 79.5%
      NHS Dartford, Gravesham and Swanley CCG 82.8%
      NHS Medway CCG 84.2%
      NHS South Kent Coast CCG 82.1%
      NHS Swale CCG 79.4%
      NHS Thanet CCG 79.3%
      NHS West Kent CCG 76.9%
      England 84.1%
      Table 5: Overall experience of NHS dental services, aggregated data collected from Jan-Mar and Jul-Sept 2015

      Care Quality Commission

      For each measure, Medway has been compared with the three hospital trusts in Kent. Scores are out of a possible 10.

      Outpatients

      The lowest score for Medway in this section is for waiting in hospital. This is scored low across all four hospitals though suggesting that this either needs to be improved consistantly or that patients prefer this aspect of appointments the least. All four hospitals are scored quite evenly for each measure. Medway scored lowest out of the four trusts for tests and treatment at 7.6 (only 0.1 lower than Dartford and Gravesham) and highest for 'leaving the outpatients department'. The category scoring highest was seeing a doctor.

        Medway Foundation
      Trust
      Maidstone and
      Tunbridge Wells
      East Kent Hospitals
      Foundation Trust
      Dartford and
      Gravesham
      Before the appointment 7.4 7.7 7.3 7.3
      Waiting in hospital 5.1 4.7 5.1 4.6
      Hospital environment and facilities 8.3 8.6 8.4 8.4
      Tests and treatments 7.6 8.1 8.1 7.7
      Seeing a doctor 8.6 8.5 8.6
      Seeing another professional 8.5 8.6 8.9 8.6
      Overall about the appointment 8.2 8.2 8.1 8.0
      Leaving the outpatients department 7.2 6.8 6.9 7.1
      Overall impression 8.5 8.5 8.6 8.4
      Number of recipients 370.0 497.0 474.0 466.0
      Table 6: Outpatients Between June and October 2011, a questionnaire was sent to patients who had recently attended an outpatient appointment.
      Maternity services

      National surveys were used to find out about the experiences of people who receive care and treatment. During the summer of 2013, a questionnatire was sent to all women who gave birth in February 2013 (and January at smaller trusts). Questions were asked about different aspects of teh mother's care and treatment. Based on the responses, each NHS trust was given a score out of 10 for each question (the higher the score the better). [1]

        Medway Foundation
      Trust
      Maidstone and
      Tunbridge Wells
      East Kent Hospitals
      Foundation Trust
      Dartford and
      Gravesham
      Labour and birth 9.0 8.9 9.0 8.7
      Staff during labour and birth 8.8 8.7 8.9 8.6
      Care in hospital after the birth 8.3 8.6 7.6 8.2
      Feeding the baby during the first few days 8.0 8.4 8.0 7.9
      Care at home after birth 8.4 8.6 8.3 8.4
      Number of recipients 128.0 202.0 206.0 170.0
      Table 7: Maternity services: summary of feedback from maternity experience questionnaire sent to all women who gave birth in February 2015.
      Inpatients

      Each of the four hospital trusts has been scored around 6 for overall views and experiences of inpatient care, which is quite low considering the measures listed above. Waiting lists and planned admissions and leaving hospital have the lowest scores whilst doctors and nurses have the highest.

        Medway Foundation
      Trust
      Maidstone and
      Tunbridge Wells
      East Kent Hospitals
      Foundation Trust
      Dartford and
      Gravesham
      A&E dept 7.8 8.5 8.0 8.3
      Waiting lists and planned admissions 8.8 8.9 8.8 8.6
      Waiting to get a bed on a ward 6.2 7.3 7.5 7.3
      The hospital and ward 7.5 8.2 8.1 7.7
      Doctors 8.0 8.4 8.2 8.3
      Nurses 7.9 8.5 8.2 8.3
      Care and treatment 7.2 7.7 7.5 7.4
      Operations and procedures 8.1 8.2 8.3 8.4
      Leaving hospital 6.4 7.3 7.2 6.8
      Overall views of care and services 4.9 5.6 5.6 5.1
      Overall experience 7.4 8.1 8.1 8.0
      Number of recipients 369.0 471.0 372.0 389.0
      Inpatients during 2014, a questionnaire was sent to 850 recent inpatients at each trust.

      References

      [1]   Commision CQ. Maternity services survey 2013 2013;
    • Health, social care and support

      Introduction

      A considerable proportion of the health and social care burden relates to chronic conditions or situations. The Adult Social Care Outcomes Framework, NHS Outcomes Framework and the Public Health Outcomes Framework all contain elements that focus on delaying and reducing the need for care and support and helping people to recover from episodes of ill health.

      The amount and complexity of health and social care and support needed by people varies and can be represented as a pyramid, with the most complex at the top and the least complex at the bottom. The width represents the number of people. This section of the JSNA examines the health and social care burden by working from the base of the pyramid up to the top (Level 1) illustrating important issues in Medway at each level. These examples are drawn from the background papers that can be found in the Appendices. As the number of people in Medway in the older age groups becomes larger there will be increasing numbers of people at the higher levels of the pyramid.

      Figure 1: A pyramid of health and social care needs
      Figure 1: A pyramid of health and social care needs.
      (Based on the Kaiser pyramid)

      Level 4: The base of the pyramid—very large numbers, small changes can have a large total effect.

      The base of the pyramid represents the general population, those who have yet to develop a chronic health or social care problem. People at this level may be at risk of developing a chronic health or social care problem and action is taken at a population-level to try to prevent this from happening. For example, health promotion activities to encourage physical activity and healthy eating, and to encourage healthy sexual behaviour. Other examples include fluoridation of water to protect teeth, restrictions on the sale of cigarettes to children, and banning of smoking in public places.

      There are large numbers of people at this level and small changes can result in large total effects in the population and for the health economy. For example, having a high body-mass index (i.e. being over-weight or obese) is associated with increased risk of a number of conditions, such as diabetes, heart disease and cancer. In Medway two-thirds of adults are either obese or overweight[1] and 20.2% of children in year 6 are obese.[2]

      Reducing the extent to which the population of Medway is over-weight will reduce the burden of ill health in the future. At a broad population level this involves creating the environment and infrastructure to encourage active living through walking and cycling and providing green spaces for playing.

      Cancer

      Cancer is another significant health problem that can be addressed at the population level. Prevention remains the best method of tackling cancer at the population level, reducing the burden caused by the disease and improving outcomes. Over half of all cancers can be prevented. Smoking is the single largest preventable risk factor for cancer and population-based interventions, such as the restrictions on smoking in public places, are highly effective. The proportion of adults aged 18 years and over who smoke in Medway (21.8%) [3] is significantly higher than the proportion in England. There is considerable variation in prevalence across Medway, with 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.

      Diets high in fats and proteins, low in fruits, vegetables and fibre increase the risk for bowel cancer. [4] Being overweight or obese are the most important known avoidable causes of cancer after tobacco. [5]

      Level 3: Possibly large numbers, self-care with support

      Many people do eventually develop a health or social care need that is relatively under control often requiring low level of care or support. People in this situation need supported self-care, where professionals collaboratively help individuals and their carers to develop the knowledge, skills and confidence to care for themselves and their situation effectively. Effective support of this large group of people will delay or prevent their situation or condition from progressing to point where they need more intensive support.

      Examples at this level include those who are trying to give up smoking, or those who are over-weight and wish to become more active or improve their diet. It also includes people who have recently developed diabetes and are able to manage their condition with diet and physical activity, or people with common mental health problems.

      It is estimated that in Medway in 2011 there were 33,500 people at any one time living with common mental health problems (see Appendices -> Adults -> Mental Health) many of whom will be able to manage their condition with support.

      Improving cancer outcomes requires better awareness of cancer signs and symptoms to ensure earlier diagnosis and treatment. In 2009 an initial baseline assessment of cancer, cancer awareness measure survey and primary care cancer audit were undertaken in Medway to inform areas to target public health interventions and local initiatives. In 2010 a lung cancer campaign and community based lung cancer initiative was launched and Medway has been selected as a pilot site to run a breast cancer awareness campaign targeting women over 70 in 2012.

      As at 31 March 2015, breast screening coverage in Medway is 76.4%, similar to the coverage levels seen in the South East region (76.8%) and England as a whole (75.4%)[6]. The programme was extended to include women aged 47 to 73 years in 2011. In Medway, cervical screening coverage rates among 25-64 year olds are higher (75.6%) than England and the South East region.[7]

      Level 2: High risk, requiring care management and support

      Level two of the pyramid represents people with greater needs, for example disease-specific care management that involves providing people who have a complex single need or multiple conditions with responsive, specialist services using multi-disciplinary teams and specific protocols and pathways. These people are at high risk of becoming intensive users of services and appropriate care and support to limit more intensive demands on services in the future.

      Children in care

      Any child can become a child in care but the likelihood is many times greater in children from low income/benefit dependent families and from parents with Mental Health, Learning disabilities, Drug, Domestic Violence or Alcohol issues. These children are vulnerable and about 60% of those looked after in England have been reported to have emotional and mental health problems and a high proportion experience poor health, educational and social outcomes after leaving care. [8]

      At the end of 2011 there were 449 Children in Care (CIC) of Medway Council. This represents 73 per 10,000 of the 0–18 year olds in Medway, higher than the national average of 59 per 10,000. The average cost of a child in care is approximately £50,000 per year and the increase from December 2010–2011 of 61 children represents over £3m of increased expenditure for Medway Council.

      Currently there are 134 approved in-house foster carers who offer placements for a total of 320 children and young people. This represents 53% of all Medway's Children In Care placed with in-house foster carers, better than the national figure of 42%.

      Dependent drinkers

      In the UK increased rates of substance misuse are found in individuals with mental health problems and alcohol misuse is the most common form of substance misuse. Drug misuse often co-exists with alcohol misuse, and homelessness is frequently associated with substance misuse problems.

      Harmful use of alcohol increases the risk of liver disease by thirteen times, increases the risk of stroke in women and hypertension in men by four times and increases the risk of several other chronic conditions.

      There are an estimated 11,782 dependent drinkers in Medway and, following Department of Health guidance, services should have capacity for around 1,800 service users. However, data for 2014/15 from the National Drug Treatment Data Monitoring Service showed only 316 people, one quarter of those expected, accessed alcohol services in Medway.

      Mental health

      People with more complex mental health problems are also more likely to be users of services and require a higher level of support. In May 2015 9,310 people in Medway were claiming employment and support allowance, of whom 4,140 (44%) were claiming for mental health reasons.

      Diabetes

      People who have diabetes need to maintain good control of their blood glucose levels, blood pressure and cholesterol levels, and need to take care of their feet to prevent foot ulcers. Poorly-controlled diabetes leads to a range of complications such as eye problems (including blindness), foot problems that can lead to amputations, heart attacks, angina, stroke, kidney disease, nerve damage, sexual dysfunction and life-threatening short-term complications such as hypoglycaemia or diabetes ketoacidosis. These complications lead to increased need for secondary care, including emergency services and social care services.

      There are 15,701 people aged 17 and above recorded on GP practice diabetes registers in Medway, a prevalence of 6.9%. This prevalence is higher than in England (6.4%). The proportion which have achieved good glucose control (HbA1c of 59 mmol/mol or less) is 69% (compared to 70% nationally)[9].

      Primary care is provided by GPs, and additional services include the community and specialist diabetes service; a structured education programme; the diabetes retinopathy screening programme for eyes; and podiatry services for feet.

      Cancer

      In 2009, over 1,400 new cases of cancers were diagnosed in Medway. A third of these occurred in those aged 75 and over. The incidence rate of all cancers in Medway has remained steady and is similar to incidence rates in the South East, comparator groups and England as a whole.

      A Macmillan Information Centre and the Macmillan Chemotherapy unit is now available at Medway Maritime Hospital to support people living with and beyond cancer. The NHS Medway cancer campaign uses a community collaborative approach (engagement and empowerment) to address cancer inequalities by targeting electoral wards and communities known to have high cancer inequalities.

      Chronic obstructive pulmonary disease (COPD)

      Current and ex-smokers are most at risk of contracting COPD. COPD mortality is decreasing in Medway, especially amongst males where rates were very high due to smoking in previous decades. Rates are higher in people who live in more deprived areas.

      There are 5,176 people with a recorded COPD diagnosis in Medway[9], with modelled estimates suggesting an additional 1,000 people who are undiagnosed.

      In the early stages of disease the vast majority of care takes place in primary care managed by GPs and practice nurses, there is variability in the availability of practice nurses with specific training in COPD. For the most severe disease or where patient has specialist requirements acute services based at Medway Maritime Hospital led by consultants in respiratory medicine are available.

      Standardised spend for this group of patients [10] suggests that NHS Medway spends £5,249 on emergency admissions for obstructive airway disease per 1,000 population, a total of over a £1 million per year. Therefore it is important that GPs deliver effective treatment preventing or delaying the need for emergency hospital admissions.

      Teenage pregnancies

      Teenage mothers are less likely to finish their education, and more likely to bring up their child alone and in poverty, have higher infant mortality rate than older mothers, have three times the rate of post-natal depression of older mothers and a higher risk of poor mental health for three years after the birth, and children of teenage mothers are generally at increased risk of poverty, low educational attainment, poor housing and poor health, and have lower rates of economic activity in adult life.

      In Medway the rate of under-18 conceptions has dropped from 38.8 per 1,000 to 33.6 per 1,000 in 2012, the lowest since 1998. This represents 31 fewer conceptions than 2011 (175 compared to 206 in 2011). This reduction is in line with the England rate which has fallen from 30.7 per 1,000 in 2011 to 27.7 per 1,000 in 2012. However, the rate in Medway is still significnatly higher than the England average.

      Level 1: Highly complex, requiring case management

      At the top of the pyramid are a relatively small number of people with highly complex needs who are usually very high intensity users of unplanned secondary care and of social care. These people need identification and a case management approach, with a care-worker to anticipate, co-ordinate and join up health and social care.

      These people have multiple conditions, for example having a harmful dependency on alcohol or other substance, with mental health problems and chronic conditions such as COPD or diabetes.

      Others in this category may include elderly people with dementia, or those who have suffered a severe stroke. The ageing of the population will lead to an increase in the number of people with dementia and the costs associated with providing them with health and social care. It is predicted that the number of people aged 65 and over with dementia in Medway will rise from 2,468 in 2012 to 4,347 in 2030. [11] In the UK there are 800,000 people with dementia costing the NHS £23 billion a year. This will grow to £27 billion by 2018. [12] A report in 2007 [13] highlighted that 60,000 deaths per year are directly attributable to dementia. Reducing the onset of dementia by 5 years would lower this figure to 30,000.

      The number of people aged 65 and over predicted to have a long standing health condition caused by a stroke will rise from 885 in 2012 to 1,377 and the those aged 65 and over predicted to have diabetes will rise from 4,866 in 2012 to 7,296 in 2030. [11]


      References

      [1]   Public Health England. PHOF: Excess weight in Adults 2016;
      [2]   Health and Social Care Information Centre. National Child Measurement Programme 2015;
      [3]   Public Health England. PHOF: smoking prevalence 2015;
      [4]   Cancer Research UK. Diet, healthy eating and cancer http://info.cancerresearchuk.org/healthyliving/dietandhealthyeating/
      [5]   World Health Organisation, Food and Agriculture Organisation of the United Nations. Diet, Nutrition and the Prevention of Chronic Diseases, Report of a Joint WHO/FAO Expert Consultation 2003; World Health Organisation. http://www.fao.org/DOCREP/005/AC911E/AC911E00.HTM .
      [6]   Screening and Immunisations Team. Breast Screening Programme, England, Statistics for 2014-15 2016; http://www.hscic.gov.uk/catalogue/PUB20018
      [7]   Screening and Immunisations Team. Cervical Screening Programme, England - 2014-15 2015; http://www.hscic.gov.uk/catalogue/PUB18932
      [8]   National Institute for Health and Clinical Excellence. Promoting the quality of life of looked-after children and young people - NICE public health guidance 28 2010; National Institute for Health and Clinical Excellence. http://www.c4eo.org.uk/themes/vulnerablechildren/files/promoting_the_quality_of_life_of_looked_after_children_and_young_people.pdf .
      [9]   NHS Digital. Quality and Outcomes Framework
      [10]   NHS Information Centre and NHS Connecting for Health. NHS Comparators 2011;
      [11]   Institute of Public Care and Oxford Brookes University. Projecting Older People Population Information System 2010;
      [12]   Lakey L, Chandaria K, Quince C, et al. Dementia 2012: A national challenge 2012; Alzheimer's Society. http://alzheimers.org.uk/site/scripts/download.php?fileID=1389 .
      [13]   Personal Social Services Research Unit. Dementia UK: A report into the prevalence and cost of dementia 2007; London School of Economics and King's College London. http://alzheimers.org.uk/site/scripts/documents_info.php?documentID=342 .
    • Safety and protection from avoidable harm

      Vulnerable adults

      A vulnerable adult is defined as follows by the Department of Health in No Secrets: [1] “An adult (a person aged 18 years or more) who is or may be in need of community care services by reason of mental or other disability, age or illness and who is or may be unable to take care of him or herself or unable to protect him or herself against significant harm or exploitation.”

      No Secrets [1] gave local authorities the lead responsibility for developing and implementing multi-agency processes to coordinate systems, policies and procedures to protect vulnerable adults from abuse. The work of the Kent and Medway Safeguarding Adults Executive Board is to coordinate agencies to safeguard these adults who are at risk of being abused. The Kent and Medway Safeguarding Vulnerable Adults Board takes a strategic lead on safeguarding matters and is co-chaired by the Assistant Director of Social Care in Medway.

      Safeguarding Vulnerable Adults work is concerned with the multi-agency approach to responding to and preventing the abuse of 'vulnerable adults'. Across Kent & Medway, there are multiagency policy, protocols and guidelines in place, which are updated twice a year.

      It is thought that there is considerable under reporting of adult abuse. Work has been done to increase public awareness, but this now needs to extend to BME and LGBTQ groups in Medway.

      For more information, see: Appendices ➜ Background papers: Adults ➜ Safeguarding

      Patient safety incidents

      During the period 1st April to 30th September 2011, 1,925 incidents were reported to the National Reporting and Learning System (NRLS) as happening at Medway Foundation Trust (MFT). [2] Of the 49 medium acute organisations, MFT's reporting rate (5.5 incidents per 100 admissions) lies just above the lowest 25%. This has decreased consecutively over time, from 8.5 incidents per 100 admissions for the reporting period 1st October 2009 to 31st March 2010. Organisations that report more incidents usually have a better and more effective safety culture, so in this instance a low reporting rate is an area for improvement. [2]

      Figure 1: Top 10 incident types, April to September 2011
      Figure 1: Top 10 incident types, April to September 2011 [2]

      At MFT, 50% of incidents were reported to NRLS more than 48 days after the incident, compared to more than 36 days for all incidents. If serious incidents are not reported promptly, steps cannot be taken to prevent harm to others. [2]

      Figure 2: Incidents reported by degree of harm for medium acute organisations
      Figure 2: Incidents reported by degree of harm for medium acute organisations, April to September 2011 [2]
        Count
      None 1,381
      Low 443
      Moderate 85
      Severe 11
      Death 5
      Table 1: The number of incidents reported by degree of harm, Medway Foundation Trust [2]

      Health protection

      Air pollution

      Air pollution can have a negative impact on health. Estimates suggest that it reduces life expectancy within the UK by an average of six months. The main pollutants in the UK include particulate matter (PM), nitrogen oxides and ozone. Road transport is a key source of air pollution, which tends to be worse in more deprived areas. In terms of health effects, the most important air pollutant is PM. This consists of small particles which may be emitted from vehicle exhausts or chimneys, or they may form in the air as a result of reactions between other pollutants. Nitrogen Dioxide at high concentrations can also exacerbate lung conditions such as asthma. Ozone is formed as a result of the reaction between sunlight and other pollutants and can also cause breathing difficulties. [3]

      Air pollution may also have an effect on children's lung function in the long term. As lung development is generally complete by the age of 18, this is unlikely to recover. The Health Protection Agency estimates that up to 57 children aged 0–15 per 1,000 in England and Wales may have reduced long–term lung function as a result of air pollution. In 2010, there were 51,600 children aged 0–15 living in Medway. This could mean as many as 2,941 children living in Medway have reduced lung function as a result of air pollution. [3]

      Children, in particular those with asthma, will benefit from a reduction in levels of air pollution. It has been estimated that 30% of acute exacerbations of asthma may be related to environmental factors. In the UK, 36 children and 30 adults per 1,000 population may have asthma which is attributable to chemical pollution. This means that as many as 1,858 children (aged 0–15) and 6,156 adults (aged 16 and over), living in Medway could have asthma attributable to chemical pollution. [3]

      As well as the association with respiratory disease, a relationship has also been shown between the number of particles in the air and admissions to hospital with cardiovascular disease. A report from the HPA suggests that a reduction in PM10 (particulate matter less than 10 micrometers in diameter) might be associated with a 0.8% reduction in all age, all cause cardiovascular hospital admissions. In Medway, in 2010/11, there were 2,001 emergency cardiovascular admissions, which would mean 16 fewer admissions a year if PM10 levels were reduced. [3]

      Please see the Kent Air website for pollution readings around Kent and Medway

      Chlamydia diagnoses (15–24 year olds)

      Chlamydia is the most commonly diagnosed sexually transmitted infection in England, with the highest rates being seen in those under the age of 25. Many infections cause no symptoms and thus remain undiagnosed. Untreated, it can lead to pelvic inflammatory disease in women, which can result in infertility or ectopic pregnancy. [3]

      Figure 3: Rate of 15--24 year olds screened through the National Chlamydia Screening Programme and percentage of positive tests
      Figure 3: Rate of 15–24 year olds screened through the National Chlamydia Screening Programme and percentage of positive tests, January to December 2014 [4]

      The National Chlamydia Screening Programme was established in England in 2003. It aims to provide early detection of chlamydia, allowing treatment of asymptomatic infections, reducing the risk of complications and further spread of the disease. It is targeted at sexually active young people under the age of 25. [3]

      Public Health England recommends that local authorities should be working towards achieving a detection rate for chlamydia among 15 to 24 year olds of at least 2,300 per 100,000 population. In Medway in 2014, there were 10,340 tests carried out, equating to 26.9% of the 15–24 year old population. Of these, 7.6% (786) tested positive for chlamydia. This equates to a detection rate in Medway of 2,048 per 100,000. Although this does not quite meet the PHE recommendations, this value lies above the rates per 100,000 achieved for the South East and England overall (1,665 and 1,978 respectively). [3]

      Population vaccination coverage

      Immunisation is the most important public health intervention, other than clean water, for saving lives and improving health.

      Age Vaccine Diseases.protected.against
      2 months DTaP/IPV/Hib (Pediacel or Infanrix IPV Hib) Diptheria, tetanus, pertussis (Whooping cough), polio and Haemophilus influenzae type b (Hib)
      2 months PCV (Prevenar 13) Pneumococcal disease
      2 months Rotavirus (Rotarix) Rotavirus
      2 months MenB (Bexsero) Meningococcal group B (MenB)
      3 months DTaP/IPV/Hib (Pediacel or Infanrix IPV Hib) Diptheria, tetanus, pertussis, polio and Haemophilus influenzae type b (Hib)
      3 months MenC (Neisvac C) Meningococcal group C disease (Men C)
      3 months Rotavirus (Rotarix) Rotavirus
      4 months DTaP/IPV/Hib (Pediacel or Infanrix IPV Hib) Diptheria, tetanus, pertussis, polio and Haemophilus influenzae type b (Hib)
      4 months PCV (Prevenar 13) Pneumococcal disease
      4 months MenB (Bexsero) Meningococcal group B (MenB)
      12 to 13 months Hib/MenC (Menitorix) Hib/MenC
      12 to 13 months PCV (Prevenar 13) Pneumococcal disease
      12 to 13 months MMR (Priorix or MMR VaxPRO) Measles, mumps and rubella (German measles)
      12 to 13 months MenB (Bexsero) Meningococcal group B (MenB)
      2 to 6 years Flu nasal spray (Fluenz Tetra) Influenza
      3 years 4 months FTaP/IPV (Infanrix or Repevax) Diptheria, tetanus, pertussis and polio
      3 years 4 months MMR (Priorix or MMR VaxPRO check first dose has been given) Measles, mumps and rubella (German measles)
      12 to 13 years - girls only HPV (Garasil) Cervical cancer caused by human papillomavirus types 16 and 18 (and genital warts caused by types 6 and 11)
      Around 14 years Td/IPV (Revaxis) and check MMR status Tetanus, diptheria and polio
      Around 14 years MenACWY (Nimenrix or Menveo) Meningococcal groups ACWY
      Table 2: The complete routine childhood immunisation schedule for summer 2015 [5]

      Vaccination generally provides a similar degree of immunity to that provided by natural infection, but without the risk of complications of the disease. Vaccinations work by producing immunological memory, so that when the immune system is subsequently exposed to natural infection it is able to recognise and respond to it, thus preventing or modifying the disease. In some cases more than one dose of the vaccine may be required to produce this response and/or booster doses to maintain it. While the main aim of vaccination is to protect the individual who receives it, high levels of immunity in a population mean those who cannot be vaccinated because, for example, they are too young, are also at reduced risk of being exposed to a disease. This is known as herd immunity. [3]

      When vaccine coverage is high enough, a disease may be eliminated from a community. However if high coverage is not maintained, the disease may return. Vaccine coverage is evaluated against World Health Organization (WHO) targets of 95% coverage annually for each vaccine (except Meningitis C) at the national level, with at least 90% in each Strategic Health Authority (SHA). [3]

      The schedule for routine vaccinations in childhood is defined by the Department of Health on the advice of the Joint Committee on Vaccination and Immunisation (JCVI) and has changed over time as new vaccines have become available. [3]

      People presenting with HIV at a late stage of infection

      In 2010, an estimated 50% (3,300) of adults were diagnosed at a late stage of infection in the UK (with a CD4 cell count <350 cells/mm3 within three months of diagnosis) including 28% (1,870) who were severely immunocompromised (CD4 cell count <200 cells/mm3) at diagnosis. [6]

      HIV attacks CD4, or T-cells, and uses them to make more copies of HIV. In doing so, HIV weakens the immune system, making it unable to protect the body from illness and infection. [7] It is recommended that patients should begin anti-retroviral therapy when CD4 cells counts drop <350 cells/ mm3. [8]

      The routine offer of HIV testing has been recommended to all sexual health clinic and antenatal care attendees over the past decade. Over this period, the proportion of people diagnosed late has declined significantly overall, from 59% in 2001 to 50% in 2010, and across all exposure groups. [6]

        Number with cell
      count <350mm3
      Percentage of
      all diagnoses
      Significance compared
      to England
      Medway PCT 16 76.2 higher
      West Kent PCT 19 59.4 not significant
      Eastern and Coastal Kent PCT 11 52.4 not significant
      South East Coast SHA 161 52.4 not significant
      England 2,333 51.3
      Table 3: Percentage of late diagnosis of HIV, 2009 [9]

      Delayed HIV diagnosis is associated with an increased risk of AIDS and death. Reports of AIDS-defining diseases declined rapidly following the advent of antiretroviral therapy in the mid-1990s. They have, nevertheless, continued over the past decade, with 640 AIDS diagnoses reported in 2010. The majority of AIDS diagnoses are made in people who were diagnosed late. In 2010, four in every five AIDS diagnoses were reported simultaneous to or within three months of an HIV diagnosis (96% of whom had a CD4 <350 cells/mm3 at diagnosis). Late diagnosis also means that a person has remained unaware of their HIV status for many years, increasing the risk of onward transmission.[6]

      Prevalence of diagnosed HIV in Medway is not significantly different to England.

      Accidents

      Unintentional injury is a leading cause of death and hospital admission among children aged 0–14. In 2014, 151 children aged under 15 years died from unintentional injury in England and Wales, of which 52 were due to land transport accidents.[10]

      Most injuries result from accidents in the home and there are inequalities between groups in the likelihood of these occurring. Many fall accidents are caused by pushing, shoving and wrestling. Children have also died or have been seriously injured by heavy objects such as furniture and televisions being pushed or pulled onto them.[3]

      Unintentional injury rates in under 16 year olds are higher in lower socio-economic groups. Inequalities also exist in relation to sex, age, ethnicity and geographical region. Home safety schemes are not universally available and are often confined to more deprived neighbourhoods. Inequalities may be exacerbated by this approach because there will be people from less deprived groups living in deprived areas who receive help that they may not need. Of greater concern is that there may be people not getting help they need from projects like Surestart because, while they live in a less deprived area, they are themselves from a more deprived group.[3]

      In 2014/15, 256 under 5s in Medway were taken to A&E for 'other accidents' (which excludes road traffic accidents); 128 boys and 127 girls. The most common primary diagnosis was head injury, with 77 children attending for this, followed by laceration (25).[11]

      Within the national curriculum, there is a requirement to teach children about hazards, risks and controls, as well as road safety. SureStart also offers a range of services, including low cost home safety equipment and conducting home safety outreach interventions.

      The majority of accidents involving older people are falls, with almost three-quarters of falls in people 65 years and over resulting in injuries to arms, legs and shoulders. One in every five falls in women aged 55 and over results in a fracture. The most serious accidents involving older people often occur on stairs or in the kitchen whilst the most common places for all accidents are the bedroom and living room.

      In 2014/15, there were 3,113 admissions for people registered with a Medway GP in relation to an accident. The number of patients was 2,924, of which 151 were admitted more than once within these 12 months.[11]

      Road traffic accidents

      The number of casualties from collisions on Medway's roads has reduced, from 1,253 in 1998 to 845 in 2014, of which 57 people were either killed or seriously injured. Serious injury includes fractures, severe lacerations, paralysis and extended stay in hospital. Slight injury includes whiplash, sprain and minor lacerations.

      Medway council works closely with Kent Police to gain information on any collisions which occur in Medway. As a picture is built up over time, sites with multiple crashes (cluster sites) are investigated by road safety engineers who look at the factors leading up to a collision, visit the site and gain insight from residents and the local community. This informs road improvement initiatives such as speed limit reduction, changes to road markings or restructuring junctions.[3]

      Work-related accidents

      In 2014/15, 1.2 million people suffered from work-related illness, 142 people were killed at work and 76,000 injuries were reported under 'Report Injuries, Diseases and Dangerous Occurrences' (RIDDOR) in Great Britain.

      In 2014/15 (provisional), there was 1 fatality, 66 major injuries and 169 injuries where symptoms lasted over three days in Medway. The first two categories are roughly stable but there has been a decrease in the number of 'over three day' injuries in the last five years. The fatality occurred in the construction industry whilst the highest number of injuries occurred in the services sector. The 'services' category includes a wide range of industries, for example, education, scientific research and development, accommodation and air transport.[12]


      References

      [1]   Department of Health. No secrets: guidance on developing and implementing multi-agency policies and procedures to protect vulnerable adults from abuse 2000; Department of Health. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4008486 .
      [2]   National Reporting and Learning System, National Patient Safety Agency. Organisation Patient Safety Incident Report: Medway NHS Foundation Trust, 1 April 2011 to 30 September 2011 2012; National Reporting and Learning System and National Patient Safety Agency. http://www.nrls.npsa.nhs.uk/EasySiteWeb/getresource.axd?AssetID=133125&type=full&servicetype=Attachment .
      [3]   NHS Medway. Annual Public Health Report 2011/12 2012; NHS Medway.
      [4]   National Chlamydia Screening Programme. Chlamydia testing data for 15-24 year olds in EnglandPublic Health England. http://www.chlamydiascreening.nhs.uk/ps/data.asp .
      [5]   PHE. The complete routine immunisation schedule 2015;
      [6]   Health Protection Agency. HIV in the United Kingdom: 2011 Report 2011; Health Protection Agency. http://www.hpa.org.uk/hivuk2011 .
      [7]   Cichocki M. What is a CD4 Count and Why is it Important? 2012;
      [8]   Association of Public Health Observatories. Sexual Health Balanced Scorecard: Percentage HIV diagnoses with CD4 cell count <350mm3 at time of diagnosis, 2009 technical report 2010; Association of Public Health Observatories. http://www.apho.org.uk/resource/view.aspx?RID=74115 .
      [9]   Association of Public Health Observatories. Percentage HIV diagnoses with CD4 cell count < 350mm3 at time of diagnoses, 2009 2010;
      [10]   Office for National Statistics. Death Registrations Summary Tables, England and Wales, 2014 2015;
      [11]   Medway Public Health Intelligence team. Secondary Uses Service Hospital activity analysis
      [12]   Health and Safety Executive. Reporting of Injuries, Diseases and Dangerous Occurrences 2015;
  • Our community
    • Key messages

      This part describes the views of the community about their needs and also what assets the community has to contribute to improving health and social care.

    • Community involvement

      Community involvement is an essential part of the planning of health services. It is also important in its own right as it strengthens democratic processes and encourages active citizenship. Under the Health and Social Care Bill, it will be a requirement that patients, the public, communities of interest, health and wellbeing boards and local authorities are included by Medway Commissioning Group (MCG) in everything it does, especially its decision making processes. Included in this will be mechanisms for gaining a broad range of views then analysing and acting on these so that it is clear and apparent how the engagement has influenced decision making. This will be done proactively rather than waiting for people to approach the commissioners. [1]

      Patients registered with Medway GPs and everyone who usually lives in Medway, regardless of whether they are registered with a GP, are the responsibility of MCG. [1] In future, the registered population could potentially be harder to reach, as people will be allowed to register wherever they like, for example near where they work. This will require a rethink as to how commissioners can capture their patients' views.

      The commissioners will have a duty to ensure that all communications and engagement activity is inclusive and does not disadvantage anyone in the community. This will mean ensuring that people who may not have equal access to information or opportunities to engage, are not disadvantaged by doing the following: [1]


      • Working with Medway LINk/HealthWatch and community, patient and faith groups.
      • Including the opinions of a wide range of people by establishing methods to make the Medway Health Network as representative as possible.
      • Ensuring MCG's public events are accessible to everyone and that there is equal opportunity for people to be involved.
      • Making it easy for everyone to access information and engage with MCG by making all of its information and communication channels accessible.
      • Promoting ways that people can receive information from MCG in alternative formats and languages.
      • Working closely with voluntary organisations to regularly review and test the accessibility of our information.

      Individuals, groups and populations that historically have not accessed appropriate health services, or have sought the services at a later stage of their illness or condition, will be asked to work with MCG closely to address this problem.

      Current mechanisms for engagement

      Currently NHS Medway has a variety of channels and resources to communicate and engage with patients and residents, including meetings, printed media and electronic communications. Of the people in Medway who have access to the internet, 97% have access at home and 50% have access at work indicating potential access to several communication channels that are internet based. The following methods are currently in use:

      Electronic

      YouTube — 1,108 people have viewed the You Tube channel and the videos have been viewed 1,719 times. The videos promote services available across a number of issues including long acting reversible contraception (LARC) and dementia support.

      Twitter — an online social networking and micro blogging service that enables its users to send and read text-based posts of up to 140 characters, known as “tweets”. NHS Medway has two Twitter accounts: one, @NHSMedway, covers a wide range of topics including Chlamydia testing, CPR and what to do if you get injured, whilst the other, @ABetterMedway, covers health improvement issues such as exercise, stop smoking and healthy eating. Tweets are sent out randomly and only as often as is required to get a message across.


      • @NHSMedway — there are 351 followers and since June 2011 there have been 387 tweets. Since the PCTs have clustered, the 3 accounts are managed centrally and a lot of the tweets are being distributed across West Kent and Eastern and Coastal Kent as well. This means that the reach of Medway's news is being made to people further afield (1,429 followers in West Kent and 1,217 followers in Eastern and Coastal Kent, all of which could potentially “retweet”). Users have utilised this channel to provide their feedback following a good or bad experience. (Numbers correct as at 7am on 6th March 2012)


      • @ABetterMedway — there are currently 558 followers and this has increased by about 75 per month since the account was created last August. There have been a total of 225 “retweets”/ mentions/ discussion messages with followers from the Medway community since the account started. “Tweets” highlight campaigns, signpost to resources on the website and keep people up to date of current events. As at 7am on 6th March 2012, there have been 1,054 tweets sent out.

      ISSUU — is an online platform designed to make it easier for people to find, read and follow NHS Medway's publications. There are 18 publications on our website including the Annual Public Health Report and 'Health Matters' (see below). Since it joined the site in March 2011, NHS Medway's documents have been viewed a total of 18,961 times with 370,158 unique page views.

      Printed

      Health Matters — is a magazine, approximately 20 pages long, that is published twice a year and delivered to all Medway residents. Smaller editions are included in the council's magazine, Medway Matters, six times a year. It covers a number of current health issues using case studies.

      Growing Healthier — is a newsletter sent by email to everyone who has signed up for it. Currently around 1,000 people receive it, although only about 20% actually open it.

      Groups and events

      Medway Health Network (currently Medway LINk) — anyone can join this network to find out about and get involved in decision making to do with local healthcare. There are currently 365 members of the public and 143 voluntary and community organisations involved, plus around 650 businesses on the Network's database.

      Medway Health Debate — The Medway Health Debate last year captured all strands of diversity as it was a culmination event following months of different engagements. Medway Commissioning Group is going to host similar events in the future to talk about commissioning.

      Media — press releases and interviews with local and regional press. Interactions tend to be reactive, but if good work has been done, PCT staff will approach the media. There are also standard campaigns, for example breast cancer in women over 70.

      Marketing and campaigns — there are a number of campaigns throughout the year supported by posters, leaflets and other media to advertise and inform. Examples are the current radio campaign for bowel cancer and the billboards that promoted the NHS health checks programme during April 2012.

      Board meetings — are held bi-monthly and members of the public are welcome to observe the meetings and ask the Board questions. The location is published beforehand on the NHS Medway website along with the papers from previous meetings.

      Partner's communication channels — mentions and links on other organisation's websites mean that the reach of information is widened. For example, Medway Council's site has links to NHS Medway's site and also contains information on wider issues such as winter health.

      In order to reach all community groups, the NHS Medway Communications Team attends meetings already taking place in the community so that people do not have to attend more meetings than are necessary. When specific projects are undertaken, a certain demographic of the population is targeted.

      The NHS Medway Communications Team is helping GPs to set up patient participation groups to capture the views of people who do not necessarily live in Medway but are registered here.

      The following list is some of the communication methods MCG would like to explore and use in future: [1]

      Questionnaire surveys — to measure attitudes and motivations, emotions, behaviour and self-perception. It could be written down or read out, carried out one-to-one, by post, via the internet or placed in a newsletter/paper/magazine. Satisfaction surveys — to measure the satisfaction of service users with regards to a product or service that they have received, for example a patient information leaflet. Interviewing — can be conducted in person or by telephone. They are helpful to identify issues that may not have been anticipated. Focus groups — bringing together a group of people with a common characteristic, to explore their attitude towards a service, concept or idea. Questions are asked to encourage participants to freely talk with other group members. Workshops — used to gather people together to problem solve the question under investigation and is reliant on the involvement of the participants and good facilitation. Patient panels — this approach involves the recruitment of volunteers (patients and carers) to join as panellists. Panel members are asked to give their views on a particular topic, concept or idea, for example hospital service changes. Involvement in the patient panel may be through meetings, workshops or questionnaire completion and participants should be provided with some background information. Citizens' juries — this technique allows jury members to thoroughly explore a particular issue and make informed recommendations, following presentation of evidence, to service providers. A jury is a group of people usually from 12 to 50. This approach is useful in clarifying and identifying issues.

      Information and help will be available to people in a range of applications, from traditional leaflets and media to innovative smart phone apps and online applications in future, to make support from MCG easier to access and to improve the relationship between users and the provider. [1]

      The Public Services (Social Value) Act

      Receiving Royal Assent in March 2012, this Act requires public authorities to have regard to economic, social and environmental well-being in connection with public services contracts. [2] This means that public bodies, including councils, will commission services from providers who are committed to supporting the boroughs and communities they are working in whilst charging a fair price for the work. [3] Social enterprises use business to tackle social problems, improve life chances and improve the environment. It is a growing sector which currently employs almost one million people in the UK. They reinvest any profit back into the business/social endeavour and do not make profit for owners or stakeholders. [4] In practice this means that companies looking to provide a service will also need to consider how they will contribute to the community. For example, a public body may contract a company to undertake property repair work, which in turn commits to employing long term unemployed in the area and promoting construction in the local schools.


      References

      [1]   Lanker DS, Gaylor F, Patrick L. No decision about me, without me: Communications and Engagement Strategy 2011-13 2012; Medway Commissioning Group.
      [2]   Public Services (Social Value) Act 2012 2012;
      [3]   Social Enterprise UK. Public Services (Social Value) Act 2012;
      [4]   Social Enterprise UK. Public Services (Social Value) Act 2012: A brief guide 2012; Social Enterprise UK. http://www.socialenterprise.org.uk/uploads/files/2012/03/public_services_act_2012_a_brief_guide_web_version_final.pdf .
    • Community needs

      When commissioning services in Medway, knowing the view of the community is essential. Analysing data cannot necessarily tell commissioners the reality of people's experiences and it does not answer questions such as why the hard to reach groups are not accessing certain services. By engaging with the community directly and asking what people need, commissioners can see first hand the real issues experienced.

      In November 2011, a community engagement event was held in Rochester with Medway LINk — an independent network of local people and community groups working together to influence health and social care. Over 110 people attended from more than 30 third sector organisations which broadly represented Medway's diverse population. The discussion was centred around the proposed changes to the NHS and Medway Commissioning Group (MCG) was introduced as the future commissioner for healthcare in Medway. [1]

      During the afternoon there were workshops to investigate what the top health priorities are for people in Medway and what MCG can do to support people to lead healthier lives and make good lifestyle choices. When the attendees were asked about the PCT's communication channels they said that Medway Matters and Health Matters were effective and informative, whilst Medway LINk and the electronic communications channels were not as well known. Those who had not previously seen any of the communication channels said that communication needs to be co-ordinated so that people aren't bombarded with the same information from a number of sources. People also felt that jargon should not be used and a variety of methods used, not just electronic. It will therefore be important to be flexible and work with communities to identify the best way to get messages out. [1]

      The needs that were identified in the workshop can be grouped into four main themes. It should be noted that the event was held on a midweek afternoon and the attendees were mostly white females aged 50 and over and this should be taken into account when looking at the views below. In future, a broader representation will be sought by holding events at different times, days and venues. The key points are listed below.

      Continuity and availability of care


      • Better continuity of care so there is a seamless transition between GPs and either community services or secondary care.
          • This will improve care of the elderly upon leaving hospital.
          • It would also improve duplication of communications between the services and reduce time delay.
      • Improved access to services including transport (better bus services on Sunday, bank holidays and evenings and less expensive car parking), flexibility of opening hours and home visits.

      People power


      • More support for self management of long term conditions
      • Support community groups who can help each other through peer support — work together to improve social and physical wellbeing
      • Encourage exercise at home
      • Involve community champions
      • Involve patients in decision making
      • Work with employers to promote healthy living
      • Support network in community

      Education


      • Increase public understanding of commissioning groups and processes
      • Improve preventative health through education, including showing children the bad effects of substance misuse
      • Increase GP's understanding of learning disabilities
      • Use nurses to support patients so they understand their condition, maybe in the form of group seminars
      • Advice sessions/centres where people can drop in and get quick reassurance that they do not need to see a doctor for their ailment.
      • Provide better understanding of official pressures and ways to complain/ raise issues
      • Drop in sessions for hard to reach groups, providing information or support on aspects of the wider determinants of health, for example housing

      Communications and Engagement


      • Reassurance that public voice will be heard, including feedback when public consultation has been sought to show the opinions have been considered
      • Engagement with everyone — old and young, minority groups, hard to reach groups and catering for different languages
      • Facilitate greater awareness of health issues and the services available
      • Put more information in the local paper
      • Consider access to a computer/ the internet when sharing information
      • Promote healthcare as part of people's daily lives — supermarket, train station, buses etc
      • Make sure reception staff understand the importance to a patient of seeing who they would like to see

      As part of the concluding section, a request was made by the commissioners for people to recognise when they are in a section of society that the service provision is not addressing, to tell the commissioners how to make it better. With participation from service users, commissioners can continue to learn and make sure the correct services are in place. [1]


      References

      [1]   Medway Commissioning Group. The future of healthcare in Medway 2011; Medway Commissioning Group.
    • Community assets

      The Public Health White Paper released by the Department of Health in 2010 outlined a new approach to improving health through greater emphasis on well-being and prevention. This is done by transferring ownership to local communities to tackle the wider determinants of health such as social relationships. This approach, termed the 'asset based approach', identifies skills, strengths, capacity and knowledge of individuals within a community which are used to contribute towards sustainable development.

      “A health asset can be defined as any factor (or resource), which enhances the ability of individuals, communities and populations to maintain and sustain health and well-being. These assets can operate at the level of the individual, family or community as protective (and/or promoting) factors to buffer against life's stresses.” — Harrison et al (2004) Assets for Health and Development European programme: Developing a conceptual framework, Geneva: WHO [1]

      This approach aims to promote self-reliance within a community rather than relying on services purely provided by the NHS which is currently facing severe financial constraints. It aids social cohesion as people come together to help and get to know each other. Some examples of assets within Medway are the Medway cycling group and Medway cooks (see appendices —> Data inventory —> Social and place wellbeing —> Community assets).


      References

      [1]   North West Public Health Observatory. The Asset Approach to Living Well unknown; North West Public Health Observatory.
  • Our programmes and services
    • Overview

      The programmes and services designed to improve the health and well-being of people in Medway can be broadly divided into two categories. The first concerns population based measures which aim to influence patterns of behaviour as well as improve the environmental conditions and risks to which people are exposed. The second category involves direct contact with people and can be provided in one of three forms comprising one-off or infrequent interventions which produce long-lasting positive effects, counselling and health education programmes and lastly ongoing interventions with vulnerable people as well as those who have complex needs.

      Before discussing these in more detail it is helpful to also consider the impact of socio-economic factors on health and well-being. Low income and educational attainment combined with unequal opportunities and access to services combine to worsen the standard of living for people within society. The kinds of measures which can tackle these issues involve coordination of policy at a national, regional and local level and can take generations to take effect. However, improvements in this area are arguably the most effective of all [1]. For further information please see the 'Our Health Inequalities' section of this document.

      The primary data sources used for this section are the background chapters written by topic leads available in the appendices section, the A Better Medway website and Medway Council website.

      Summary of commissioned services

      Primary care (as at October 2015)

      • 231 GPs in 54 practices [2]
      • 33 NHS dental practices[3]
      • 58 community pharmacies[3]
      • 19 Optical practices that deliver NHS sight testing[3]

      Six of the above dental practices offer IMOS (Intermediate Minor Oral Surgery) services at various locations within Medway. IMOS, a Kent & Medway wide intiative, is a service which treats patients that have been triaged as needing oral surgery which is above the capability of the referring dentist but not deemed difficult enough to warrant a referral to hospital. This is a relatively new service which has been extended to 31/03/2016 following an agreement to renew the contract.

      There is one specialist orthodontic practice, one home-visiting dentist (treatment limited to predominantly making dentures and scale & polish), the emergency out of hours dental service (DentaLine) and special needs dentistry provided via three dental clinics based in Medway (managed by Medway Community Healthcare).

      Only those contractors holding an General Opthalmic Services (GOS) contract can deliver NHS sight tests. Domicilary NHS sight testing is available for those patients unable to attend a high street optician.

      Community care


      • Medway Community Healthcare (38 services including district nursing, health visiting, speech and language therapy, podiatry, occupational therapy, nutrition and dietetics, physiotherapy, continence, blood tests, help with breathing problems, diabetes, heart or stroke problems, assessing difficulties with muscles or bones, end-of-life care and equipment loans)
      • Kent Community Health (newborn hearing screening, care management and secure placement services for people with learning disabilities, plus contraception and sexual health services)
      • Kent and Medway NHS and Social Care Partnership Trust (wheelchair services)

      Health improvement


      • Joint NHS Medway / Medway Council Directorate (Stop Smoking support, healthy weight advice and programmes, co-ordination of infant feeding strategy, sexual health advice, Chlamydia testing, co-ordination of teenage pregnancy strategy, tobacco control programme, and alcohol strategy).
      • The Sunlight Development Trust run a number of projects with the local community including the Well-being cafe, Dementia family support service and the 'Men in Sheds' programme.

      Acute care


      • Any hospital of people's choice for most treatments so long as it offers care to NHS standards for NHS prices. (Mental health services, urgent care and very specialised care are excluded).

      In practice, most people choose to have their care in Medway or at other providers in Kent — including at Medway Maritime Hospital (run by Medway NHS Foundation Trust), the Will Adams NHS Treatment Centre and the Spire Alexandra Hospital.

      Mental health


      • Kent and Medway NHS and Social Care Partnership Trust
      • Independent organisations offering provision from psychological therapies to secure accommodation

      Prisons


      • GP, dental, optical and pharmacy services for offenders at Rochester and Cookham Wood Young Offenders' Institutions
      • Mental health services including Child and Adolescent Mental Health Services and substance misuse services
      • Pharmacy services for all ten prisons in Kent and Medway


      References

      [1]   Marmot M. Fair Society, Healthy lives 2010; Strategic Review of Health Inequalities in England post-2010. http://www.instituteofhealthequity.org/projects/fair-society-healthy-lives-the-marmot-review/fair-society-healthy-lives-full-report .
      [2]   Primary Care Information System.
      [3]   NHS England. NHS Organisation data
    • Population based measures

      The 'A Better Medway' website contains a range of advice to people wishing to improve their diet and activity levels, reduce their alcohol consumption or manage stress better. The site also has links to useful resources and further support such as the breastfeeding support network and the Mental Health matters helpline. In a similar way, the Medway Council website has sign-posting to clubs and societies as well as Leisure Centre contact details. The Public health department in Medway facilitate numerous community based projects such as the community food allotment and local walking and cycling groups to encourage people to take more exercise and provide an opportunity for socialising.

      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.

      Policy changes can have a dramatic effect on the background environment within which people make lifestyle choices. Nationally, anti-tobacco campaigns have produced more smoke-free zones, a ban on tobacco advertising and additional taxation resulting in an overall reduction in smoking prevalence. [1] Locally, Medway Council has put initiatives in place to help residents reduce fuel poverty by supporting them in their energy use. A pilot scheme is underway to target potentially at risk residents for further assessment and home improvement. Furthermore, the free bus pass, available to Medway residents aged over sixty or with certain disabilities, complements the blue badge scheme for parking concessions to allow people with reduced mobility similar levels of access as the rest of the population. The Medway City card (a reward scheme for Medway residents) enables free swimming to people aged under 11 and over 60.


      References

      [1]   The NHS Information Centre for Health and Social Care. Statistics on Smoking, England 2011 2011;
    • Infrequent interventions with long-lasting positive effects

      There are numerous services which focus on early intervention within Medway. The government funded 'Healthy Start' programme issues vouchers to women who are pregnant and/or with young children on benefits (or pregnant women under the age of eighteen) to be spent on milk, vitamins, fruit and vegetables. Another example is how the Medway Youth Offending team works with young people and their families to curtail anti-social behaviour and prevent crime. It is also possible to improve the accessibility of certain services. Examples include the C-card scheme in which young people can register for the service and obtain free condoms from a number of accredited locations around Medway or the 'Early Bird' maternity clinics to encourage women to book their first appointment with a midwife as soon as possible.

      There is a comprehensive vaccination programme to immunise the population against certain communicable diseases. The service is mainly provided by general practices and school nursing although the neonatal BCG (Bacillus Calmette-Guérin) programme against tuberculosis is delivered via the chest clinic at Medway NHS Foundation Trust.

      Screening is an important tool to protect the health of the population. There are a total of six antenatal and new-born screening programmes which check for sickle cell and thalassaemia, fetal anomaly (e.g. Downs syndrome), infectious diseases (Hepatitis B, HIV, Syphilis and Rubella), new-born blood spot (test for various diseases see more), new-born and infant physical examination and new-born hearing test. Screening for cancer of the breast, cervix and bowel is conducted according to a nationally agreed timetable by using the NHS call and recall system. Newly diagnosed diabetic patients are offered an initial assessment with a Podiatrist and every year all eligible diabetic patients are offered an eye screen with the Paula Carr Trust. The NHS Health Checks programme is concerned with screening undiagnosed patients for heart disease, stroke, diabetes and kidney disease every five years. Screens usually take place at the patient's own general practice.

      Examples of other services which generally work with people for a short period of time are the CASH (Contraception and Sexual Health) clinics, GUM (Genito-urinary Medicine) clinics, respite care offered to carers and the occupational therapy service which provides information and advice, adaptations to the home and can arrange loan of specialised equipment to support people remain as independent as possible.

    • Counselling and health education

      To a certain extent the number of people requiring this type of intervention should be minimised by co-ordinated actions taken to address socio-economic factors which impinge on health and well-being combined with effective population based measures. However, it should also be recognised that not everyone is able to benefit from these contextual changes to the same degree and some people require additional support to lead healthier lifestyles.

      Perhaps the best known example is smoking cessation advice. The Medway Stop Smoking service offers group and one-to-one sessions, telephone advice and specialist pregnancy support at a variety of venues such as health centres, community centres as well as in hospital. People can also receive support from their general practice or pharmacy. NRT (Nicotine replacement therapy) is available as a one-off prescription charge.

      The Windmill clinic at Medway hospital provides antenatal clinic for women with substance misuse issues. There is also a weekly postnatal drop-in breastfeeding clinic at Medway hospital which in turn, serves to direct women to further advice and the breastfeeding support network.

      Starting in April 2012, the Medway Community food team are running a series of free healthy cookery workshops for families with children in Medway. The aim is to help families feel more confident about how to cook healthy meals and learn some new cookery skills. The MEND (Mind, Exercise, Nutrition, Do it) programme is a holistic approach to improving the fitness, nutrition and self-esteem of children and their parents/carers through a series of games, educational sessions and activities. For adults, there is the 'Exercise Referral' scheme which enables healthcare professionals to refer patients for supervised exercise at reduced, or no cost. The 12-week programme is coordinated by the health improvement team and based in local leisure centres. Furthermore, the 'Tipping the Balance' scheme offers 12 one-to-one appointments with a health improvement specialist nurse over the course of a year. Participants are offered a range of activities to increase fitness combined with counselling to address some of the underlying issues which lead to people becoming overweight in the first place. Medway Community Healthcare runs two Diabetes patient education programmes which aim to empower the individual with better self-management skills. The first for adult newly diagnosed type 1 diabetics, known as BERTIE (Bournemouth Type 1 Intensive Education), consists of one whole day a week for four weeks. The second is for type 2 diabetics, known as X-PERT (eXpert Patient Education versus Routine Treatment), consists of six two hour sessions and is for newly diagnosed patients and those already with the condition who feel they would benefit from the course.

      Working under the Medway DAAT (Drug and Alcohol Action team) KCA (Kent Council on Addition) treats patients with a range of issues related to substance misuse. Services include one-to-one key working, group work, substitute prescribing and other community interventions including pathways into inpatient detoxification and residential rehabilitation. In addition, the Kent & Medway Partnership Trust provides a similar service for those affected by alcohol misuse. KCA also treats young people with substance and alcohol misuse problems.

      Talking therapies can help people cope with conditions like: stress, anxiety, depression, habits like Obsessive Compulsive Disorder, phobias, anger management and bereavement, and are free to those meeting eligibility criteria as assessed by a GP. Treatment can include: guided self help booklets, life skills workshops, focused counselling, employment related support and therapy. Provision of these therapies is in line with NICE guidance.

      MIND and It's Good to Talk provide information on all the different types of therapies available

    • On-going interventions with vulnerable people or with complex needs

      The Children's Social care service acts to safeguard the welfare of children from physical, emotional and sexual abuse as well as neglect. In Medway there are 134 in-house foster carers who offer placements for a total of 320 children and young people plus one in-house residential unit offering eight beds. External residential units and independent fostering agencies are also used. The Medway Family Nurse Partnership was initiated in 2010 to offer first time parents under the age of 20 a specially trained family nurse who provides one to one intensive support from early pregnancy and throughout the first two years of the child's life. The service is provided by Medway Community Healthcare and supported by partner agencies. Medway Youth Offending team provides intensive supervision and surveillance programmes for persistent young offenders. It also operates plans for preparing young people to return into the community from custody and reduce risk of re-offending.

      According to a NICE (National Institute of Clinical Excellence) recommendation from 2006, bariatric surgery is offered to people with a very high BMI (body mass index) of 40 or more and those with a BMI of 35–40 who have a significant other disease such as diabetes or hypertension. Surgery is only considered once all non-surgical approaches have proven unsuccessful. Each patient is assessed on an individual basis by the specialist commissioning panel.

      The GUM clinic at Medway Hospital offers two clinics per week for patients who are HIV positive or diagnosed with AIDS and follows the national guidelines provided by the British HIV Association. Social care and psychological support is provided by Medway Council based within the hospital.

      The management of patients with long-term conditions is generally performed in primary care. The Quality and Outcomes framework rewards general practices for comprehensive monitoring of patients with multiple indicators across 20 clinical areas. Some patients with more complex needs are managed by a Consultant led team in Medway Foundation Trust. For example in April 2010, the Kent Cardiovascular Network led the implementation of a primary angioplasty service (pPCI) to treat patients who have suffered an ST-elevated Myocardial infarction (STEMI). Medway Community Healthcare provides specialist nurse support such as the Community Respiratory team for COPD patients. Part of their role is to carry out all home oxygen assessments ensuring the drug is dispensed and used appropriately. Often, these same patients also receive community care from social services in the form of day care, home care and residential care. The service is available to people who are elderly and frail or have a physical disability, a learning disability, a mental health problem, a drug/alcohol problem, HIV/Aids or who are registered blind and/or deaf. The aim is to enable people to retain as much of their independence as possible.

      In terms of end of life care, General Practitioners provide generalist support in line with the Gold Standards Framework. Medway on Call Care (MedOCC) manage the End of Life Register known as “My Wishes” which allows patients to record electronically (via their health care worker) their wishes and advance care plans as well as their experience of the health service. Community nursing/Care Management provides care and arranges funded care packages such as help at home to meet personal care needs. The Community Palliative care Team within the Wisdom provides assessment, symptom management, advice and support for patients with complex life-limiting illness (cancer and non-cancer), as well as their family and carers. The team also provides support to the primary healthcare team. The Wisdom Hospice has a 15 bedded unit for in-patient care for symptom management and end of life care for patients referred by the specialist palliative care team. Cruse Bereavement care was commissioned in February 2012 to provide comprehensive bereavement support to Medway residents.

  • Our health inequalities
    • Key messages


      • Health outcomes for people in Medway are generally worse than those in the rest of England.
      • The life expectancy of the people in Medway is significantly below that of the national average. There is a clear social gradient in life expectancy, with individuals from the most deprived Medway wards expected to live approximately 8 years fewer than those from more affluent wards.
      • The time spent in good health in Medway women has fallen below the England average (61.1 years vs. 64 years respectively). Black and minority ethnic groups generally have worse health outcomes than the general population; combined these groups make up approximately 4.5% of the Medway population.
      • Level of poverty is associated with both premature mortality and poor health outcomes throughout an individual's life course. Medway shows a higher percentage of dependent children in relative poverty.
      • Differences in lifestyle and other wider determinants of health can lead to different health outcomes by altering an individual's susceptibility to a particular condition. In addition, variations in the quality of health care may further exasperate differences in health outcome and life expectancy.
      • In Medway, an inequality gap exists in the mortality rate for cancer; cardiovascular and respiratory diseases.

    • The importance of health inequalities

      Health inequalities are unjust differences between individuals or groups. They come about due to differences in social, geographical, biological or other factors that influence people's behaviours and lifestyle choices, as well as their risk of illness and actions taken to deal with illness when it occurs. Although some factors are fixed, others are avoidable or can be lessened, such as those relating to social, economic or geographical factors; these are known as health inequities (NICE).

      The Marmot Review, entitled 'Fair Society, Healthy Lives' (2010), sets out the health inequalities challenges for England and includes priorities for action and evidence about how these could be applied. Importantly the focus is on reducing health inequalities by addressing the social gradient and imbalance in health outcomes; a lower social position equates to poorer health outcomes.

      For an overview of and access to the full report 'Fair Society Health Lives' (The Marmot Review.

      The two key indicators used to monitor health inequalities, are life expectancy (LE) and healthy-life expectancy (HLE). LE is the estimate of how many years a person might be expected to live and HLE, also called disability-free life expectancy (DFLE), is an estimate of how many years that individual might live in a 'healthy' state, defined as time without disability or illness.

      Figure 1 shows the relationship between the gradient in neighbourhood income and life expectancy. It shows that people in poorer areas not only die sooner, but also spend more of their lives with a disability (Marmot review, 2010). In England, people living in the poorest areas will, on average, die seven years earlier than people in the richest neighbourhoods and the average difference in healthy-life expectancy is 17 years. The figure highlights the economic issue that a greater proportion of individuals from the more deprived neighbourhoods will be unable to work due to disability prior to the age of retirement.

      Figure 1: Life expectancy by income deprivation - national picture (The Marmot Review)
      Figure 1: Life expectancy by income deprivation

      Social determinants of health

      Social determinants of health are the conditions, in which people are born, grow, work, live and age (WHO). They include the forces acting upon people at each of these phases that can shape the conditions of daily life, including education; housing; environment; employment, economic, political and social influences. Evidence suggests that societies with bigger income differences suffer a wider range of health and social problems in each of the following areas: [1]


      • Physical health
      • mental health
      • drug abuse
      • education
      • imprisonment
      • obesity
      • social mobility
      • trust and community life
      • violence
      • teenage births
      • child well-being

      In order to reduce health inequalities action is required across all social determinants of health, as well as the health and social care services. Working to reduce the health gaps between the richest and the poorest in the population will benefit society in many ways by increasing economic productivity and reducing health care costs.


      References

      [1]   Wilkinson R, Pickett K. The Spirit Level 2009;
    • Medway in a national context

      Each year Public Health England (PHE) produce a set of key indicators of the social determinants of health, health outcomes and social inequality for each local authority. These broadly compare to the policy recommendations outlines in the Marmot review and can be found on the Public Health England Marmot Indicators for Local Authorities webpage.

      In addition, PHE also publish the Public Health Outcomes Framework, encompassing indicators surrounding wider determinants of health; health improvement; health protection and healthcare and premature mortality. These can be viewed at a local, regional and national level, as well as allowing insight into inequalities by providing the ability to breakdown certain indicators by gender and deprivation decile.

      Some of the key indicators relating to health inequalities in Medway have been listed below:

      1.Life expectancy

      There has been a steady increase in male and female life expectancy at birth over the last 15 years both locally and nationally (PHOF; data from ONS). However, Medway has consistently shown a LE significantly below that of the national average in both sexes (PHOF). In 2012-14 the LE at birth for males was 78.7 years in Medway, compared to 79.5 seen nationally. For females during the same time period the LE at birth was 82.2 and 83.2 for Medway and England respectively.

      2. Healthy life expectancy

      In 2012-14 the number of years that a man living in Medway would expect to live in good health was 62.6 years. This figure has remained relatively consistent over the last few years and is similar to that seen across England (63.4 years; PHOF). Conversely, female healthy life expectancy in Medway has fallen in the last few years to 61.1 years in 2012-14, taking it significantly below the England average of 64.0 years; South East average for this period was 66.6 years HLE.

      3. Index of Multiple Deprivation (IMD)

      In England much work has been done to develop robust methods of measuring deprivation resulting in the creation of the Index of Multiple Deprivation (IMD). This index comprises seven domains: income; employment; health and disability; education, skills and training; barriers to housing and services; crime; and the living environment. Medway is currently ranked 118 out of 326 local authorities in England; where 1 is the most deprived and 326 is the least deprived (rank of average IMD 2015 score).

      4. Children in poverty

      The Marmot review (2010) suggests that childhood poverty can lead to premature mortality and poor health outcomes in adulthood. Therefore, reducing the level of child poverty should also improve health outcomes in adults as well as healthy life expectancy. The percentage of dependent children aged under 20 in relative poverty in Medway is higher than the national average (19.7 versus 18.0 in 2013) (PHOF; data from HM Revenue and Customs Child poverty statistics). This pattern has been evident since 2010 as numbers in Medway have remained consistent and failed to show the decline seen nationally. Similarly the percentage of children under the age of 16 years in Medway in low income families is also higher than the national average (20.8 versus 18.6 in 2013) (PHOF). Again, national numbers have fallen over the last few years, but remained consistently high in Medway.

      A list of children health profiles can be found on the National Child and Maternal Health Intelligence Network data atlas, covering birth, pre-school and school aged children.

    • Health inequalities within Medway

      1. Life expectancy in Medway by Ward

      Within Medway, there is a clear social gradient in health; the lower a person's socio-economic position, the worse his or her health. This also equates to a shorter average life expectancy; women in the most deprived Medway wards have an average life expectancy 8.1 years lower than the least deprived. For males this gap widens to 8.6 years as shown in Figure 1. Wards with the lowest life expectancies overall include River; Luton and Wayfield; Chatham Central; Gillingham North; and Gillingham South. Conversely, wards with the highest life expectancies overall include Cuxton and Halling; Hempstead and Wigmore; Rainham Central; Lordswood and Capstone; and Strood Rural.

      Figure 1: Life expectancy at birth by ward, 2011--2015
      Figure 1: Life expectancy at birth by ward, 2011–2015

      2. Deprivation in Medway and health inequalities

      Figure 2 shows the number of people in each deprivation quintile within each ward in Medway, with deprivation quintile 1 being the most deprived. It is clear that deprivation is more prevalent in certain wards than others. However, this figure also shows that certain wards contain individuals across a range of deprivation levels.

      Figure 2: Number of people in each deprivation quintile by ward
      Figure 2: Number of people in each deprivation quintile by ward, 2015 [1]

      The Slope Index of Inequality (SII) at birth is a measure of the social gradient in life expectancy, i.e. how much life expectancy varies with deprivation . It takes into account health inequalities across the whole range of deprivation and summarises this in a single number; based on statistical analysis of the relationship between life expectancy and deprivation across all deprivation deciles. In Medway the SII was 6.3 years for males and 4.3 years for females (2012-14; PHOF); these values have not changed significantly over the past 10 years (PHOF trends).

      The SII is displayed for males and females in the figures below, where life expectancy for each deprivation decile is plotted in blue and the SII is the gradient of the line of best fit (red). The most deprived decile in Medway the life expectancy for males and females is 74.0 and 80.6 years respectively. These values are significantly lower that the life expectancies of males and females in the least deprived decile; 81.7 and 84.8 years respectively. In males life expectancy appears to be directly related to deprivation decile (figure 3). Although a similar relationship is seen in females in Medway, the correlation is less consistent across all deciles in females (Figure 4).

      Figure 3: Life expectancy by deprivation decile with the slope of inequality for Medway PCT, males, 2012--14
      Figure 3: Life expectancy by deprivation decile with the slope of inequality for Medway, males, 2012–14.
      Slope index of inequality = 5.8 years (95% confidence interval: 3.8 to 7.8) [2]
      Figure 3: Figure 4: Life expectancy by deprivation decile with the slope of inequality for Medway PCT, females, 2012--14.
      Figure 4: Life expectancy by deprivation decile with the slope of inequality for Medway PCT, females, 2012–14.
      Slope index of inequality = 4.8 years (95% confidence interval: 1.1 to 8.5) [2]

      3. Ethnic differences in health inequalities in Medway

      The most recent data relating to ethnicity is from the 2011 Census, which showed that the largest ethnic group in Medway was White British (85.5%) and the next largest was Asian or Asian British (5.2%). Black/African/Caribbean and Black British residents made up 2.5% of the population and Mixed/multiple ethnic groups made up 2.0% of the population. More information relating to ethnicity can be found in the following location of the Medway JSNA: Summary -> Our people and Place -> Demography -> Ethnicity.

      It is known that there are differences in risk factors between ethnic groups. Black and minority ethnic (BME) groups generally have worse health outcomes than the overall population. Evidence suggests that the poorer socio-economic status of BME groups and associated factors are the driving force behind ethnic health inequalities.[3]

      Nationally, smoking prevalence is particularly high amongst Black Caribbean and Bangladeshi men. In Medway, a recent Smoking Health Equity Audit (HEA) showed that the lowest proportion of successful quits were in the Black or Black British ethnic group.[4]

      Under the Race Relations Amendment Act (2000) all public bodies have a legal obligation to outlaw racial discrimination and promote equal opportunities. All policies should therefore take ethnic diversity into account to ensure the reduction of ethnic health inequities.[5]


      References

      [1]   Smith T, Noble M, Noble S, et al. English Indices of Deprivation 2015; Department for Communities and Local Government. https://www.gov.uk/government/statistics/english-indices-of-deprivation-2015 .
      [2]   Public Health England. PHOF: Life Expectancy 2010-2012;
      [3]   POST. Postnote - Enthicity and Health 2007; Parliamentary Office of Science and Technology.
      [4]   Zaveri S, Thomas J, Kent & Medway Public Health Observatory . Health Equity Audit: Medway Stop Smoking Service 2013;
      [5]   Becares L. Which ethnic groups have the poorest health? Ethnic health inequalities 1991 to 2011 2013;
    • Understanding health inequalities in Medway

      By looking at disease areas it is possible to understand where the greatest contributors to health inequalities lie. Figure 1 shows the higher levels of mortality experienced by the bottom deprivation quintile in Medway, by different causes. The impact of Circulatory disease and Cancer on mortality for the bottom quintile is noticeable.

      Figure 1: Cause-specific mortality rate profiles for NHS Medway Bottom quintile and NHS Medway Top quintile
      Figure 1: Cause-specific mortality rate profiles for NHS Medway Bottom quintile and NHS Medway Top quintile, 2005–09 combined [1]

      The Life Expectancy Segment Tool [2] identifies the percentage of the life expectancy gap in men and women caused by specific disease areas. It can be seen in figure 2 that the biggest contributor to the life expectancy gap in men is cancer followed by circulatory disease. For women it is circulatory disease followed by respiratory disease.

      Figure 2: Life expectancy gap between the most and least deprived quintiles in Medway by cause of death
      Figure 2: Life expectancy gap between the most and least deprived quintiles in Medway by cause of death, 2009–11 [2]

      The causes of death that contributed most to the equalities gap in Medway in 2009 11 for men were CHD at 16.1%, cancers (except lung) at 13.9%, followed by lung cancer 12.2% and COPD at 10.6%.

      For women, the main contributors were CHD at 19.8%, lung cancer at 15.6% and COPD at 9.9%.

      In terms of mortality caused by circulatory disease (Figure 3), the inequality gap seems to be reducing over time. Whilst encouraging, it should be noted that CHD is still the largest overall cause of the inequality gap in life expectancy.

      Key
      Key
      Figure3: Trend in directly age-standardised circulatory disease mortality rate
      Figure3: Trend in directly age-standardised circulatory disease mortality rate (2001–09 and projected for 2010–12) [1]

      This picture is less encouraging for cancer, where mortality and the inequality gap appears relatively static (Figure 4).

      Figure 4: Trend in directly age-standardised cancer mortality rate
      Figure 4: Trend in directly age-standardised cancer mortality rate (2001-9 and projected for 2010-12) [1]

      Having noted that Medway sees some health inequality differences between genders, cancer mortality also shows interesting differences. Whilst mortality rates overlap for women in the highest and lowest quintiles (Figure 5), men's mortality shows marked and increasing differences between the deprivation quintiles (Figure 6).

      Figure 5: Trend in directly age-standardised female cancer mortality rate
      Figure 5: Trend in directly age-standardised female cancer mortality rate (2001-9 and projected for 2010-12) [1]
      Figure 6: Trend in directly age-standardised male cancer mortality rate
      Figure 6: Trend in directly age-standardised male cancer mortality rate (2001-9 and projected for 2010-12) [1]

      There are 3 main areas that contribute to the differences in mortality in these diseases between different socio-economic groups.


      • Variation in quality of health care
      • Differences in lifestyle
      • Wider social determinants of health

      Variation in the uptake and quality of health and social care

      Figures 7 and 8 show that emergency admissions to hospital for all causes is associated strongly with deprivation status whereas elective admissions are not. Research shows that this is likely to be because uptake of preventive services such as screening is worse in more deprived areas and because people from deprived areas are less likely to visit their GP early on when they have symptoms of ill health and more likely to attend A&E at a later stage of illness.

      Figure 7: Emergency Admissions All Causes by Medway Practices
      Figure 7: Emergency Admissions All Causes by Medway Practices [3]
      Figure 8: Elective Admissions All Causes by Medway Practices
      Figure 8: Elective Admissions All Causes by Medway Practices [3]

      Quality and Outcomes Framework data from primary care also shows a variation in care across Medway

      Differences in lifestyle

      Lifestyle issues including smoking, obesity and alcohol are key contributors to high mortality rates of the major killers. Smoking in particular is a key contributor to health inequalities. Figure 9 shows the difference between the top and bottom quintiles for lung cancer rates.

      Figure 9: Age-specific mortality rates for selected NHS Medway deprivation quintiles
      Figure 9: Age-specific mortality rates for selected NHS Medway deprivation quintiles, 2005–9 combined (Lung Cancer) [1]

      Wider social determinants of health

      Providing quality and equitable health services is important and so is encouraging lifestyle change. However we also know that providing good quality health and health improvement services won't reduce health inequalities as much as we'd wish for. This is because the causes of ill health are rooted in what are called the 'wider' or 'social' determinants of health, i.e. physical environment, social environment, economic environment etc.

      The Marmot Review (2010), which pulled together all the evidence as to the most effective ways of tackling health inequalities supports this view. Marmot says: “Action on health inequalities requires action across all the social determinants of health.”

      The review notes six policy objectives most of which are directly related to the wider determinants of health which could be expected to have the biggest impact on reducing health inequalities.


      • Give every child the best start in life
      • Enable all children, young people and adults to maximise their capabilities and have control over their lives.
      • Create fair employment and good work for all
      • Ensure healthy standard of living for all
      • Create and develop healthy and sustainable places and communities
      • Strengthen the role and impact of ill health prevention

      The Marmot indicators which were shown in a previous section give an indication of how Medway is doing compared with national rates on some of these issues.

      Taking deprivation as an overall marker for social determinants of health the IMD 2010 gives an indication of how these are distributed in Medway.

      (Please see the Kent and Medway Public Health Observatory Health and Social Care maps, page 5)


      References

      [1]   South East Public Health Observatory. Health Inequalities Gap Measurement Tool 2011;
      [2]   London Health Observatory and East Midlands Public Health Observatory. The Segment Tool - Segmenting life expectancy gaps by cause of death 2014;
      [3]   East of England Public Health Observatory. National General Practice Profiles Tool
  • Our Joint Health and Wellbeing Strategy

      The evidence in the JSNA points to five key themes for Medway:


      • Giving every child a good start
      • Enable our older population to live independently and well
      • Prevent early death and increase years of healthy life
      • Improve physical and mental health and well-being
      • Reduce health inequalities

    • Theme 1: Giving every child a good start

      There is increasing evidence that investment in the early years of life (0–5 years) is highly effective both in terms of the impact on future health and wellbeing and in being cost-effective. What happens during these early years, starting in the womb, has lifelong effects on many aspects of health and wellbeing, from obesity, heart disease and mental health, to educational achievement and economic status. It is important that mothers are supported to have good mental and physical health during pregnancy and early years. Smoking in pregnancy, which is a real challenge in Medway, impacts negatively on both maternal and child health. Parenting skills are important in improving outcomes and a particular focus is required on supporting the most vulnerable families to improve parenting and help very young children be school-ready.

      The provision of good social care for children is important to ensure that children have a good start in life. In England the number of referrals to children's social care has increased in recent years and a similar pattern has been seen in Medway over the last two years, where the number of referrals has increased 63%, from 3,292 in 2009/10 to 5,364 in 2011/12. Of these, 383 children were subject to child protection plans in March 2012, higher than the national average but broadly in line with other similar unitary authorities of a similar size, for example Luton and Southend.

      There has also been an increase in the number of children in care. In March 2011 Medway had 446 children in care, 19 more than in 2010/11. With 73 children in care per 10,000 children this is higher than the national average but again in line with other similar unitary authorities.

      The number of children with special educational needs (SEN) is also expected to increase in the next five years. This may result in an additional 300 pupils with statements requiring specialist provision, over and above the number projected through normal population growth.

      To respond to the care needs of children and young people, social workers play an important role in supporting children and young people to develop their emotional resilience and good physical and mental health. Medway is doing well at ensuring there are enough social workers with only 6.4% of social worker positions vacant in March 2012, the lowest level since at least 2006.

    • Theme 2: Enable our older population to live independently and well

      The rapid increase that Medway will see in the number of people aged 65+ and 85+ over the next decade is something that should be celebrated. It is in part the result of steady improvements over many years in health care and public health. Many of these new older people will be healthy and strong and able to live independently; however, it is inevitable that there will also be an increase in the number of people who will need health and social care and support. In particular we can expect to see more people who have dementia, and others who become physically frail.

      An increase in the number of older people is not a new phenomenon. In 1901 less than 5% of the UK population was over the age of 65 years. Since then there has been a steady increase and as a society we have made many changes during this period. As we go forward further changes are needed to ensure that we are able to provide affordable and high quality care for older people.

      The government commissioned an independent body to review the funding system for care and support in England and national policy is awaited. Within this national context the options for how Medway chooses to care for and provide support for older people will also include the core themes of localism and personal responsibility noted above. Many home-owners will seek to stay in their existing homes for as long as they can and will need additional support to do so. There will also be increasing numbers of older people who will need specialist accommodation that mesh support, care and housing provision.

      Older people are more likely to have multiple health and social needs which will require an integrated response from local services.

    • Theme 3: Prevent early death and increase years of healthy life

      Over recent decades public health and improved health care have led to dramatic reductions in the number of deaths. For example the mortality rate from heart attacks in Medway fell 79% from 160 to 33 per 100,000 between 1995 and 2014[1]. About half of this reduction was due to improved health care and half was due to public health measures, such as reductions in smoking.

      The current leading causes of early death and illness in Medway include cancer, circulatory disease (e.g heart attacks, stroke and heart failure) and respiratory disease, conditions that share many common causes. Prevention strategies are needed to reduce the numbers of people who will develop these conditions in the future. Early diagnosis can improve outcomes in some diseases and strategies are needed to promote early diagnosis through raised awareness and efficient diagnostic pathways.

      Increasing years of healthy life will include improving care and treatment for those with mental health problems and long term health conditions such as diabetes and epilepsy. Most people with long-term conditions have a single condition and can be helped to manage their condition at relatively low cost. It is important that effective interventions are provided systematically and equitably across the population if health inequalities are to be reduced. However, as people age and if prevention and treatment are not optimal, more people begin to develop other conditions. As the number and severity of these conditions increases the complexity and cost of managing them becomes much greater. Addressing these conditions requires well-integrated health and social care systems to provide treatment and support for those who have the conditions.


      References

      [1]   HSCIC Indicator Portal. Mortality from acute myocardial infarction: directly standardised rate, all ages, annual trend, MFP https://indicators.ic.nhs.uk/webview/
    • Theme 4: Improve physical and mental health and well-being

      Increasing attention is being paid not just to how long people live, but also how well they live. Quality of life is affected by many issues, including crime and the perception of crime, unemployment, the quality of employment for those who do have work, stress, the ability to live independently and autonomously and freedom from pain and ill-health. Quality of life is also very strongly affected by physical health and four main risk factors need to be reduced: tobacco use, harmful use of alcohol, physical inactivity and poor diet. While smoking prevalence has fallen nationally and in Medway in recent years, the prevalence in 2013 was 21.8%, significantly higher than the national average. There is also considerable variation in the prevalence across Medway with 16.2% in Rainham Central and 39.8% in Chatham Central. There is much evidence to support the positive health effects of smoking cessation and continued efforts to reduce smoking must be supported.

      The other major causes are more difficult to address than smoking, and recent trends have shown there have small increases in alcohol-related hospital admissions in Medway and increases in obesity. Each of these risk factors are aspects of “lifestyle”, a concept that superficially sounds quite simple, yet involves a complex interaction of personal choice and responses to the social and physical environment. People need to make the right choices as they have a personal responsibility for their own health, and this happens more readily in an environment in which these choices are the easy or are the default choices.

      One particularly important aspect of well-being is mental well-being. According to estimates derived from the 2007 psychiatric morbidity survey for England, in Medway in 2011 there were 33,500 people at any one time living with common mental health problems and 783 with a psychotic disorder. In February 2011 the total number of people in Medway claiming incapacity benefit was 7,120. Of these, 2,950 (42%) were claiming incapacity benefit for mental health reasons.

      Nationally a five step approach is being promoted to improve mental well-being. These steps are directed at individuals, however creating a supportive environment that makes it easy for people to take these steps is likely to lead to more people doing so. This may involve, for example, encouraging neighbours to work together on a local project or engage together in a celebration; ensuring that Medway is a pleasant and safe place to walk and cycle; providing courses or venues for others to run courses; and promoting volunteering.

    • Theme 5: Reduce health inequalities

      Inequalities are a fundamental underlying feature of most health outcomes in Medway. Rates of death are higher in those who are more disadvantaged, as are emergency hospital admissions and rates of long-term illness. Health outcomes are not only worse in those who are the most disadvantaged; the inequalities follow a gradient and as such the response also needs to follow a gradient. This has been called “proportionate universalism” and simply means that health and social care provisions need to be made available to all, with increasing effort needed for those who are increasingly disadvantaged.

      The Marmot Review identified six key areas for action, the first and highest priority area being to give every child the best start in life. This is because there is strong evidence that what happens in the early years has an effect on future employment prospects and health and well-being outcomes.

      As well as the moral imperative to tackle inequalities there is a good business argument to do so. Emergency hospital admissions or more years spent with a long-term illness mean greater costs for health and social care systems. Taking action through prevention, education and improved health care to reduce inequalities by raising levels of health and well-being to reduce inequalities will result in reduced costs for the health and social care system caused by the major health and social care problems faced by Medway now and in the immediate future.

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