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Summary

  • Foreword

    Introduction

    Joint Strategic Needs Assessments (JSNAs) identify the current and future health and social care needs of the local community[1] and are a fundamental part of planning and commissioning (buying) services at a local level.

    JSNAs were introduced in the Local Government and Public Involvement in Health Act 2007 and retained in the Health and Social Care Act 2012.[1]

    Local authorities and clinical commissioning groups (CCGs) have equal and joint duties to prepare the JSNA through the health and wellbeing board.[1]

    JSNAs are unique to each local area and provide the basis for the Joint Health and Wellbeing Strategy (JHWS). Together the purpose of the JSNA and JHWS is to improve the health and wellbeing of the local community and reduce inequalities for all ages.[1]

    The JSNA is a continuous process involving engagement and review, and is therefore updated regularly.

    Medway's JSNA

    Medway's JSNA aims to provide a comprehensive picture of the health and social care needs of the people living in Medway. It is an extensive document that takes into account emerging evidence.

    The summary section provides an overview of the JSNA and presents our key issues and headline priorities. An overview of place is included, which utilises current statistics to describe “our people and place”, “our health and wellbeing”, “our community”, “our programmes and services”, and “our health inequalities”.

    The main body of the JSNA includes over 30 topic-specific chapters, which detail a wide range of factors that can impact a person's health and wellbeing throughout their life. Each chapter contains local and national data, evidence of what works, local views, and proposed recommendations for commissioners.

    Finally, our profiles provide an overview of the variation in health and social care outcomes within Medway across a wide range of indicators. Data is presented in the form of charts, maps and infographics, and is available for specific wards, sub-hubs (groups of extended practices in the Medway Model), and early help hubs.

    The Medway Health and Wellbeing Board has produced this JSNA to assist individuals and organisations working to improve the health of the population of Medway. It aims to improve their ability to better understand the needs of local residents and make more informed judgements when commissioning or prioritising resource allocation. JSNA's can also help residents and other interested parties to measure and challenge the progress being made to protect and improve the public health.

    Medway's JSNA is a “living document”. It is regularly updated as new evidence and intelligence on the needs of local people emerge.

    Sustainability and Transformation Partnerships

    The current transformation of the health and social care system in England, may impact on future iterations of the Medway JSNA. This is because the manner in which the strategic organisations currently tasked with commissioning and providing NHS care and support locally, is under review.

    The development of Sustainability and Transformation Partnerships (STPs) have significant implications for public services. Local authorities, the NHS and other stakeholders, such as the voluntary and private sector, are being brought closer together to improve the way in which care and support is provided to communities.

    The key factors to note regarding potential impact of STP's in Kent and Medway are:


    • The creation of a single strategic NHS commissioning body for Kent and Medway. This body will take on delegated responsibility for delivering some of the statutory functions of the 8 CCGs in Kent and Medway, in addition to some of the functions of other NHS organisations, such as NHS England and NHS Improvement.
    • The development of a model of Accountable Care Partnerships, aligning NHS commissioning structures with that of local authorities. The purpose is to deliver better outcomes for residents and improve the efficiency of service provision through a local care model.
    • Improving access to high quality services. This will be achieved through building workforce capacity and capability, transforming the NHS estate and the way in which people access certain services. Using technology to facilitate quality improvement and focusing on prevention to address the risk factors that lead to health inequalities and poor outcomes for our communities.


    References

    [1]   Department of Health. Statutory guidance on joint strategic needs assessments and joint health and wellbeing strategies 2013; Department of Health. https://www.gov.uk/government/publications/jsnas-and-jhws-statutory-guidance .
    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
    • Introduction

      The current economic and social climate presents the people of Medway and their representatives with a number of challenges, but also opportunities. Nationally, and within Medway, life expectancy at birth has steadily increased over the past few decades. Recent evidence however, suggests that although people are living longer, their quality of life is reducing. There has been an increase in the number of people experiencing physical and mental disabilities, which impacts on their ability to undertake basic activities of daily living. Evidence suggests that the recent increase in population disability can be associated with the impact of preventable chronic long term health conditions, such as high blood pressure, diabetes and cardiovascular disease.

      People living in the most disadvantaged areas often experience higher levels of premature mortality and disability than those living in more affluent areas. Within Medway there is a recognition that concerted action is required to address health inequalities. There is a commitment to an approach that improves the health of the whole population, whilst at the same time tackling issues that are impact on the wellbeing of the most vulnerable, such as children.

      Making sure every child is given the best start in life is a priority for Medway Council and its strategic partners. Of particular concern is the need to improve outcomes for children looked after, children identified as at risk from neglect, or exposure to domestic abuse, child sexual exploitation or abuse. Understanding the needs of children with physical, mental health or sensory disabilities is also a key focus.

      In line with the requirements of the Health and Social Care Act 2012, Health and Wellbeing Boards are responsible for produced and publishing Joint Strategic Needs Assessments (JSNAs). The Medway JSNA is an objective assessment of local needs. It aims to provide an overview of all current and future health and social care needs within Medway. It is an extensive document that takes into account emerging evidence.

      The JSNA is divided into three broad parts: 1) a narrative 'picture of place'; 2) over 30 topic-specific chapters; and 3) health and social care profiles, which together provide detailed information on the health and wellbeing needs of the local residents and Medway context. It is regularly updated as new evidence and intelligence on the needs of local people emerge.

      The Medway Health and Wellbeing Board has produced this JSNA to assist individuals and organisations working to improve the health of the population of Medway. It aims to improve their ability to better understand the needs of local residents and make more informed judgements when commissioning or prioritising resource allocation. JSNA's can also help residents and other interested parties to measure and challenge the progress being made to protect and improve the public health.

      Readers should note the current transformation of the health and social care system in England may impact on future iterations of the Medway JSNA. This is because the manner in which the strategic organisations currently tasked with commissioning (buying) and providing NHS care and support locally, is under review.

      The development of Sustainability and Transformation Partnerships (STPs) have significant implications for public services. Local authorities, the NHS and other stakeholders, such as the voluntary and private sector, are being brought closer together to improve the way in which care and support is provided to communities.

      The key factors to note regarding potential impact of STP's in Kent and Medway are:


      • The creation of a single strategic NHS commissioning body for Kent and Medway. This body will take on delegated responsibility for delivering some of the statutory functions of the 8 Clinical Commissioning Groups in Kent and Medway, in addition to some of the functions of other NHS organisations, such as NHS England and NHS Improvement.
      • The development of a model of Accountable Care Partnerships, aligning NHS commissioning structures with that of local authorities. The purpose is to deliver better outcomes for residents and improve the efficiency of service provision through a local care model.
      • Improving access to high quality services. This will be achieved through building workforce capacity and capability, transforming the NHS estate and the way in which people access certain services. Using technology to facilitate quality improvement and focusing on prevention to address the risk factors that lead to health inequalities and poor outcomes for our communities.

      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-2017 population estimate, Medway's resident population is 277,616, an increase of 13,691 (5.2%) since 2011[1]. The population has increased naturally every year since 2011, with 3,657 live births in 2016[2]. Migration to Medway has dropped since peaking around 2011/12. For the first time in six years Medway saw an outward flow in internal migration - that is to other parts of the country - while international migration to Medway remained constant at +1,000 in 2016.

      Approximately 2,150 Medway residents die each year (2,197 deaths in 2017)[3]. Life expectancy from birth (a summary measure of current mortality patterns) in Medway is 3.5 years greater in females (82.3 years) than in males (78.8 years) over the period 2013 to 2017.[4]. There is also considerable variation in life expectancy between the wards. Average life expectancy in Cuxton and Halling, Hempstead and Wigmore, Rainham Central, Lordswood and Capstone, and Rainham North is significantly greater than 10 wards including Chatham Central, Watling, and Gillingham South wards. Life expectancy is highest in Cuxton and Halling at 85.1 years, and lowest in Chatham Central at 78 years (2013 to 2017).[4]

      The majority of the population in Medway are classified as White British (85.5%), with the next largest ethnic group being Asian or Asian British (4.8% - not including Chinese).[5] The three wards with the most ethnically diverse school populations are Chatham Central, Rochester East, and Gillingham North. Within these wards 53.8% to 62.9% of pupils are White British and at least 36.6% of pupils are of minority ethnic origins.[6]

      Medway has a higher proportion of unemployment than the England average, but has achieved a decrease compared to last year. In January 2017 the number of people claiming Jobseeker's Allowance (JSA) in Medway was 2,487, a decrease of 717 (22.4%) compared to the previous 12 months. This decrease is larger than that seen nationally (21.6%) and regionally (18%) in the same period.[7] Unemployment is an important factor driving the health and wellbeing 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, with a larger proportion aged 0 to 24 years. However, the 2016 to 2026 projections suggest that the proportion of the population aged 65 years or over will increase from 15.6% (43,600) to 17.7% (54,500). During the same time period, the proportion of the population aged 85 years and over is also expected to increase from 1.7% (5,000) to 2.3% (7,100). [8] The number of people aged 65 and over with a limiting long-term illness in Medway is projected to rise by 23% between 2017 and 2025[9]. This 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.

      Our health and well-being

      Between 2014 and 2016 Medway was ranked 98th out of 150 local authorities for overall rate of premature deaths with an age-adjusted rate of 378 per 100,000.[10] 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 occur before the age of 75 (30.5% and 44.7% respectively; 2014-2016). [4]

      In both males and females the leading cause of premature death is cancer, accounting for almost half of deaths in females (47.5%) and over a third of deaths in males (36.9%) under 75 years (2014-2016). [4] There has been a downward trend in the premature mortality rates from cancer in Medway since 2005-07, however these rates have remained consistently higher than both the South East region and England. Currently, there are an estimated 158 premature deaths per 100,000 resulting from cancer, equating to a ranking of 120th out of 150 local authorities.[10]

      The next largest cause of death in those under the age of 75 years is circulatory disease (including coronary heart disease and stroke), accounting for 23.5% of premature deaths in males and 16.7% in females (2014-2016).[4] A further 10% of premature deaths are due to respiratory disease, [4] notably chronic obstructive pulmonary disease (COPD), which is primarily caused by smoking.

      Premature mortality is strongly associated with deprivation. The Slope Index of Inequality (SII) is a measure of the social gradient in life expectancy at birth. In 2013-15, the SII in Medway was 8.2 years for males and 5.8 years for females; these values have increased since 2012-14 for both males (6.6 years) and females (5.2 years).[11]

      A considerable proportion of the health and social care challenge relates to the impact of chronic long-term health conditions. 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-term condition caused by a stroke will rise from 1,018 in 2017 to 1,595 by 2035 and those aged 65 and over predicted to have diabetes will rise from 5,560 to 8,414 in the same time frame.[9]

      Ageing of the population is likely to result in a substantial increase in costs to the health and social care system, as well as the primary and secondary prevention of conditions, such as diabetes, COPD and heart disease. Combined with improved care for people with conditions such as dementia. It is therefore essential to reduce or limit the number of high-intensity users of services and reduce the costs to the health and social care system.

      Our community

      Community involvement is an essential part of the planning, and increasingly the delivery, of health and wellbeing services. In Medway, DERiC (Developing and Empowering of Resources in Communities) works with WALT (Walderslade Together) and wHoo Cares (Hoo Peninsula Carers) to help build resilient communities in Walderslade and the Hoo Peninsula. These community interest companies aim to reduce social isolation by identifying additional support that could improve a person's life and helping people access local services. This may be, for example, a chat and a cup of tea once a week, help getting to the local coffee morning or support getting to GP or hospital appointments.

      Further to this, a new initiative, called Involving Medway, is designed to encourage people to get involved with and help make decisions about health provision in the area. Red Zebra leads this project and works in partnership with six other community organisations. Grants are available to Medway community groups looking to engage local residents in leading healthier and more active lifestyles. Involving Medway are looking to support community-focused projects that need help to, for example, hire a hall for a coffee morning or organise a day out for a carers group. Understanding the needs of the community, is also an essential part of delivering efficient, effective and responsive services. As part of the development of the Kent and Medway STP process, a specific workstream focused on the development of a 'Local Care Model' across Kent and Medway has been established. The aim of the local care workstream is to transform the way in which services are provided and develop preventative and innovative approaches to address some of the entrenched issues impacting on the health and wellbeing of the population.

      Within Medway, the aspirations of the local care workstream are being taken forward in the guise of the 'Medway Model'. The Medway Model brings together a range of key stakeholders to build on and further develop local community assets. The Medway Model segments Medway into 6 distinct areas formed around natural units of care (General Practices). The JSNA highlights the key health and wellbeing issues within these communities, providing invaluable insight to inform action to address the problems identified.

      Through the work of the local care workstream, Medway should see an increase in proportion of vulnerable people able to actively 'self-manage' and take action to manage the impact of long-term chronic health conditions. People will also be able to access a range of services in community locations that were previously only available in an acute hospital setting. There will be a focus on developing new ways of working, and building capacity and resilience in the Medway community. This 'asset based approach' will identify the skills, strengths, capacity and knowledge of individuals within a community, which will be used to contribute towards sustainable development.

      Our health inequalities

      Overall both male and female life expectancy in Medway is significantly worse than the England average. Compared with other local authorities of a similar deprivation status it has one of the lower life expectancies.[14]

      Within Medway, the Slope Index of Inequality (SII) shows that the difference in life expectancy at birth between the 10% most and least deprived in the population is 8.2 years for men and 5.8 years for women (2013-2015).[11]

      The main disease contributors to the life expectancy gap are the same as the major killers, with circulatory disease and respiratory disease contributing the most to the life expectancy gap in Medway.[4]

      The causes of health inequalities are complex, but there appears to be three main areas that contribute to the differences in health between different socio-economic groups: 1) variation in quality and uptake of health care; 2) differences in lifestyle factors; 3) wider determinants of health.

      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 Jobseekers Allowance claimants are significantly worse than the national average.[15]

      Appendices

      The online appendices of the JSNA contain much detailed information, including over 30 topic-specific chapters related to lifestyle and wider determinants of health, children, and adults. Each chapter contains local and national data, evidence of what works, local views, and proposed recommendations for commissioners.

      There are also profiles that provide an overview of the variation in health and social care outcomes within Medway across a wide range of indicators. Data is presented in the form of charts, maps and infographics, and is available for specific wards, sub-hubs (groups of extended practices in the Medway Model), and early help hubs.


      References

      [1]   Office for National Statistics. Mid-2017 population estimate
      [2]   Office for National Statistics. Birth summary tables in England and Wales: 2016 2017;
      [3]   Office for National Statistics. Death registrations in England and Wales, summary tables: 2017 2018;
      [4]   Medway Public Health Intelligence Team. Primary Care Mortality Database Analysis
      [5]   Office for National Statistics. Table KS201EW: 2011 Census: Ethnic group, local authorities in England and Wales.
      [6]   Department for Education. Schools, pupils and their characteristics
      [7]   NOMIS official labour market statistics. Jobseeker's Allowance with rates and proportions.
      [8]   Office for National Statistics. Mid-2014-based subnational population projections for England
      [9]   Projecting Older People Population Information System. People aged 65 and over with a limiting long-term illness, by age, projected to 2035. 2017;
      [10]   Public Health England. Mortality Rankings: Medway 2014-16
      [11]   Public Health England. Slope index of inequality in life expectancy at birth 2013-2015;
      [12]   NHS Digital. GP and GP practice related data 2017;
      [13]   NHS England. NHS Organisation data
      [14]   Public Health England. Life expectancy at birth 2013-2015;
      [15]   Public Health England. Public Health Outcomes Framework data tool
      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 good evidence that investment in the early years of life (0-5 years) is highly effective in terms of the impact on future health and wellbeing and is highly 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.

      Ensuring that every child in Medway has a good start in life is therefore essential for the future success of Medway and the health and wellbeing of people in Medway. For some aspects of child health and wellbeing Medway is doing well, such as 5-year-olds achieving a good level of development and hospital admissions for dental caries (0-4 years), and we must maintain and build upon this level of performance. For others there are important and persistent issues where there are opportunities for improvement, for example in smoking during pregnancy, or the emotional well-being of looked-after children.

      Enable our older population to live independently and well

      Over the next five years the number of people aged over 65 years will increase by over four thousand (10%) and the number aged over 85 years will increase by 900 (18%). Increasing numbers of older people mean that there will be increasing numbers of people developing chronic conditions who become intensive users of services (assuming age-specific rates remain constant). This ageing of the population is likely to result in a substantial increase in costs to the health and social care system. Therefore, primary and secondary prevention of conditions such as diabetes, chronic obstructive pulmonary disease (COPD) and heart disease (see next theme), 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. While not limited to older people, addressing social isolation is one important aspect of improving health and wellbeing and the findings of the council's Social Isolation Task Group will help to guide this.

      Many older people prefer to stay in their own home for as long as they can and to do so they may need additional support. There have also been increasing numbers of older people who need specialist accommodation that combines support, care and housing provision. Carers play an essential role in supporting older people and their role will become increasingly important as the older population increases.

      Prevent early death and increase years of healthy life

      This theme focuses mainly on improving healthcare to prevent early death and improve quality of life. This includes improving early diagnosis and therefore allowing more timely intervention which can significantly improve outcomes in some diseases.

      The leading causes of early death and illness in Medway include cancer, circulatory disease (e.g. heart attack, stroke and heart failure) and respiratory disease, conditions that share many common causes. Over recent decades public health action and improved health care have led to dramatic reductions in the number of deaths from these causes. For example, the mortality rate from heart attacks in Medway fell 85 per cent from 108 to 17 per 100,000 between 1993 and 2010. About half of this reduction was due to improved health care and half was due to public health measures, such as reductions in smoking.

      Improving mental and physical health and well-being

      Increasing attention is being paid to not just how long people live, but also how well they live.

      Mental and physical health and wellbeing are affected by many issues, including crime and the perception of crime, proximity to green spaces, housing, unemployment, the quality of employment for those who are in work, debt and income level, the ability to live independently and autonomously, and freedom from pain and ill-health.

      Reduce health inequalities

      In Medway rates of long-term illness, emergency hospital admissions and death are higher in those who are more disadvantaged. 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 means that health and social care provisions need to be made available to all, with increasing effort needed for those who are increasingly disadvantaged. For example, individuals with a learning disability and individuals with mental illnesses have, on average, a significantly lower life expectancy compared to the general population. Other groups include those in the criminal justice system and armed forces. For these groups national strategies and policies apply, and the local public health team works with these groups and national teams where appropriate.

      Taking action through tackling the wider determinants of health, lifestyle factors and improved health and social care to reduce health inequalities will result in reduced costs for the health and social care system. Some interventions will have a rapid effect, while others will take longer to affect health inequalities.

      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 informed, and 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
      • Improving mental and physical 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 277,616 in the 2017 mid-year estimates (Office for National Statistics), a 5.2% increase from that measured during the 2011 Census[1].
      • There is much variation between the Medway wards in terms of population density, deprivation, and death rates.
      • Approximately 2,150 Medway residents die each year (2,197 deaths registered in 2017)[2].
      • The all-age, all-cause mortality rate is significantly higher in Medway than in both England and the South East.
      • Life expectancy at birth is highest in Cuxton and Halling at 85.2 years, and lowest in Chatham Central at 77.8 years (2012-2016).
      • In every ward life expectancy is greater in females than it is in males.
      • There were 3,657 live births in Medway in 2016[3].
      • In 2016 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 wards, ranging from 52 in Watling to 78 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.
      • Migration to Medway has dropped since peaking around 2011/12. For the first time in six years Medway saw an outward flow in internal migration (within UK), while international migration to Medway remained constant in 2016.
      • The percentage of pupils at the end of Key stage 4 achieving 5 plus A* to C grades, including English and Maths GCSEs, in Medway increased from 57.8% in 2014/15 to 60.0% in 2015/16. Medway remains above the national average of 53.5%.
      • The median gross annual pay of a full-time employee in Medway in 2016 was £29,503. This is above the national level (England £28,503), but below the median income in the South East (£30,752).
      • Some of the most income deprived neighbourhoods in Medway are in Gillingham North, and Luton and Wayfield.
      • As at August 2017 the number of people claiming Jobseeker's Allowance (JSA) was 2,336, a decrease of 14% compared to 12 months previously. Nationally the claimant count has decreased by 13% and regionally 8%.
      • Medway's claimant rate is 1.3%, 6th highest out of the 67 local authorities in the South East. The proportion of JSA claimants is higher than in the South East (0.7%) and England (1.1%). The proportion of JSA claimants has reduced in Medway since August 2016; this pattern is also evident in the South East and England (from 1.5%, 0.8% and 1.2% respectively).
      • From 2016 to 2026 the number of people aged 65 and above is estimated to increase by 25% to 54,500.
      • Over the same period, the number of people over 85 years is expected to increase by 42% to 7,100.
      • From 2017 to 2025 the number of people over 65 years with a limiting long-term illness is projected to increase by 23%.


      References

      [1]   Office for National Statistics. Mid-2017 population estimate
      [2]   Office for National Statistics. Death registrations in England and Wales, summary tables: 2017 2018;
      [3]   Office for National Statistics. Birth summary tables in England and Wales: 2016 2017;
    • 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 277,616 people resident in Medway in 2017, according to figures produced by the Office for National Statistics[1].

      The 2017 mid-year population estimate shows an increase of 13,691 (5.2%) from the 2011 Census (263,925), and an increase of 28,128 (11.3%) 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 15.7% and England 18%). Medway has a larger proportion between the ages of 0 and 14 years than England (19.5% and 18.1% respectively) and between the ages of 15 and 24 years (9.6% and 9.3% respectively). The population of Medway is therefore younger than the population of England overall.

      Figure 1: The population structure of Medway and England in 2017
      Figure 1: The population structure of Medway and England in 2017.[1]

      There are slightly more females than males (male to female sex ratio: 0.98).[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 19,883 people, and the smallest ward is Cuxton and Halling, with 6,222 people.[2]

      There is considerable variation in population density, ranging from 1.8 people per hectare in 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: Gillingham North, Chatham Central, Gillingham South, Strood South, and Luton and Wayfield are the most populated wards in Medway and have a high proportion of younger people (ages 0-24). Rainham Central, Peninsula, Rochester South and Horsted, and Twydall have older populations. Strood Rural, Strood North, and Rainham South are large wards with a mix of young and older populations.[2]

      Wards with a population smaller than 12,000: Princes Park, Rochester East, and Lordswood and Capstone have a younger age profile. Conversely Hempstead and Wigmore, Rainham North, Cuxton and Halling, Watling, Walderslade, and Rochester West 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 2,150 Medway residents die each year (2,197 deaths registered in 2017).[4] The all-age, all-cause mortality rate is statistically significantly higher in Medway than in both England and the South East (2015).[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 3.5 years greater in females (82.3 years) than in males (78.8 years) over the period 2013 to 2017.[6]

      There are also differences in life expectancy between the wards. Average life expectancy in Cuxton and Halling, Hempstead and Wigmore, Rainham Central, Lordswood and Capstone, and Rainham North is significantly greater than 10 wards including Chatham Central, Watling, and Gillingham South wards. Life expectancy is highest in Cuxton and Halling at 85.1 years, and lowest in Chatham Central at 78 years (2013 to 2017).[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 Rainham Central (87.2 years) and males in River (75.8 years), a difference of 11.4 years (2013 to 2017).[6]

      Fertility

      In 2016 there were 3,657 live births in Medway. The general fertility rate (GFR), a summary measure of fertility in women between the ages of 15 and 44 years, in Medway in 2016 was 66.2 births per 1,000. This value is higher than South East region and England averages (61.4 and 62.5 births per 1,000 respectively).[7]

      The GFR varies considerably between the wards, ranging from around 52 in Watling to 78 in Luton and Wayfield (using data from 2014 to 2016). The five wards with the highest GFR are Luton and Wayfield, Peninsula, Chatham Central, Gillingham South, and Strood South. 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 2016 the under-18 conception rate in Medway was 22.3 conceptions per 1,000 females aged 15–17. The average under-18 conception rate in England in the same period was 19.3 conceptions per 1,000. [9]

      In 2015 Medway had an under-16 conception rate of 5.3 conceptions per 1,000 females aged 13–15 years compared to 2.9 per 1,000 (South East) and 3.7 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. Just under half (44%) of conceptions, however, result in an abortion.[10]

      Teenage pregnancy is covered in more detail in the Teenage pregnancy chapter in Children -> Teenage pregnancy.

      Migration

      Migration to Medway has dropped since peaking around 2011/12. For the first time in six years Medway saw an outward flow in internal migration - that is to other parts of the country - while international migration to Medway remained constant at +1,000 in 2016.

      Neighbouring areas to Medway show the highest in and out migration flows: Swale, Maidstone, Gravesham then Tonbridge and Malling.

      Migration flows to Medway originate from the west; just under two thirds of inward flows to Medway are via London, with flows from six South East London authorities representing just under half of all inflows to Medway: Bexley, Greenwich, Lewisham, Bromley, Croydon and Southwark.

      The net migration flow to Medway from London has increased in recent years; the 2016 inward flow from the capital of 2,141 is 28% higher than in 2012.

      There appears to be a younger flow into Medway than out, with a net inflow of younger migrants (0-15) and an outflow of older residents (65+). The outflow of working-age residents from Medway is notable.

      The in and out flow of 19 to 20 year olds is significant, which is closely linked to moves for higher education. Outward moves are also notable around 23-25 years, which is likely linked to a combination of reasons; higher education, employment and or family age specific moves.[11]

      Education

      In Medway, the percentage of pupils at the end of Key stage 4 achieving 5 plus A* to C grades, including English and Maths GCSEs, increased from 57.8% in 2014/15 to 60% in 2015/16. Medway remains above the national average of 53.5%.[12]

      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.[13] 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 from the January 2017 School Census shows that 81.5% of pupils in Medway are classified as White, with mixed ethnic origin being the second largest ethnic group (5.9%).[14] This may suggest a change in the overall population distribution in Medway since the 2011 Census.

      Some wards are considerably more diverse than others. The three wards with the most ethnically diverse school populations are Chatham Central, Rochester East, and Gillingham North. Within these wards 53.8% to 62.9% of pupils are White British and at least 36.6% of pupils are of minority ethnic origins. Rainham South, Peninsula, and Cuxton and Halling are amongst the wards with the most homogenous school populations, as 86.7% to 89.1% of pupils are White British.[14]

      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.[15]

        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-2017 population estimate
      [2]   Office for National Statistics. Ward Level Mid-Year Population Estimates (experimental) 2017;
      [3]   Office for National Statistics. 2011 Census: Table QS102EW - Population Density.
      [4]   Office for National Statistics. Death registrations in England and Wales, summary tables: 2017 2018;
      [5]   Public Health England. Directly Age Standardised Mortality Rate (ASMR), Persons, All Ages
      [6]   Medway Public Health Intelligence Team. Primary Care Mortality Database Analysis
      [7]   Office for National Statistics. Birth summary tables in England and Wales: 2016 2017;
      [8]   Medway Public Health Intelligence Team. Public Health Births File Analysis
      [9]   Office for National Statistics. Quarterly conceptions to women aged under 18, England and Wales, April to June 2016
      [10]   Office for National Statistics. Conception Statistics, England and Wales, 2015
      [11]   Regeneration, Culture, Environment and Transformation. Migration 2016
      [12]   Department for Education. Revised GCSE and equivalent results in England: 2015 to 2016
      [13]   Office for National Statistics. Table KS201EW: 2011 Census: Ethnic group, local authorities in England and Wales.
      [14]   Department for Education. Schools, pupils and their characteristics
      [15]   Office for National Statistics. Table QS204EW: Main language (detailed). 2013;

    • 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

      Income

      Average earnings in Medway increased significantly in 2016 which continues the upward trend in earnings locally over the last five years.[1] The median gross annual pay of a full-time employee in Medway in 2016 was £29,503. This is above the national level (England £28,503), but below the median income in the South East (£30,752). Full-time male workers earn an average of £32,254 in Medway, compared to £22,219 for females.[2]

      The English Indices of Deprivation (IMD) 2015 presents data on income deprivation, which measures the proportion of the population experiencing deprivation linked to low income. This includes both those people that are out-of-work, and those that are in work but who have low earnings.[3] Medway is ranked 102 out of 326 local authorities in England for income, where a ranking of 1 is the most income deprived.[4]

      The income deprivation data is also broken-down into Lower-layer Super Output Areas (LSOAs), which can commonly be regarded as 'neighbourhoods'. Medway has 29 neighbourhoods ranked in the 20% most deprived areas nationally and, within those, 10 neighbourhoods are ranked in the 10% most deprived areas. This is up on the 2010 index position, with 5 extra neighbourhoods in the 20% most deprived areas and 4 extra neighbourhoods in the 10% most deprived areas. Of the 10 most income deprived neighbourhoods in Medway, 3 are in Gillingham North and 3 are in Luton and Wayfield.[3]

      Employment

      In 2016 the number of people listed as economically active (working age residents in employment or actively seeking employment) was 80.0%, which is above the England average (78.1%), but below that of the South East in general (81.0%).[5]

      As at August 2017, the number of Jobseeker's Allowance (JSA) claimants in Medway was 2,336, accounting for 1.3% of the working-age resident population. Medway's claimant rate was the sixth highest out of the 67 local authorities in the South East. Since August 2016 there has been a decrease in the number of claims in Medway (-369) and there have been very similar reductions in Kent, the South East region and England.[6]

      Medway Kent South East England
      No. Rate No. Rate No. Rate No. Rate
      Jan-08 3,464 2.0 13,464 1.5 68,096 1.3 690,667 2.0
      Jan-09 5,501 3.2 22,452 2.5 119,762 2.2 1,065,839 3.1
      Jan-10 7,659 4.4 29,673 3.3 162,568 3.0 1,369,811 4.0
      Jan-11 6,508 3.7 26,593 2.9 135,253 2.5 1,224,055 3.6
      Jan-12 7,416 4.2 30,297 3.3 146,956 2.7 1,355,582 4.0
      Jan-13 6,913 3.9 28,914 3.1 137,436 2.5 1,292,542 3.8
      Jan-14 5,404 3.1 22,645 2.4 101,709 1.8 1,001,862 2.9
      Jan-15 3,932 2.2 15,553 1.7 68,099 1.2 669,223 1.9
      Jan-16 3,204 1.8 12,614 1.3 53,540 1.0 516,520 1.5
      Jan-17 2,487 1.4 10,961 1.2 43,899 0.8 405,001 1.2
      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.

      Major employers

      As at March 2017, there were 8,425 businesses in Medway. This is a 5.6% increase on the 2016 level, which is higher than growth seen regionally (South East +3.0%) and nationally (England +4.8%).[7]

      Construction - Medway's largest sector - accounts for just over a fifth of businesses (20.9%); this is considerably higher than levels in the South East (13.1%) and England (12.0%). Other sectors which are proportionally larger in Medway than nationally are health (5.9%), transport & storage including postal (5.7%) and motor trades (3.4%).

      The second largest sector in Medway - professional, scientific and technical - represents 15.3% of business and the third largest sector - business, administration and support services - represents 8.2%.

      The sector with the largest growth in Medway - transport and storage (including postal) - increased by 18.5% since 2016.[7]

      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-only schools in total in Medway. Forty-six are academies and 32 are maintained schools. Of these, there are 15 infant schools, 11 junior schools and 52 full primary schools.

      There is 1 all-through school in Medway (age 4-19), which was recently created when The Hundred of Hoo Academy opened a primary phase.

      There are 5 special schools (1 maintained school and 4 academies) and 2 pupil referral units.

      There are 17 secondary-only schools in Medway; all except 2 are academies. One of these, Medway University Technical College, is a new build school for 14-19 year olds specialising in Engineering, Construction and Design.

      In addition, there are 2 colleges offering a range of more vocational subjects alongside traditional subjects.[8]

      (Please note: figures correct as at October 2017).

      Universities at Medway is a unique 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 open up higher education to as many people as possible.

      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 four campuses which belong to the University of Creative Arts, specialising in courses relating to photography, sculpture and textiles.

      Other important links:

      Thames Gateway Kent Partnership


      References

      [1]   Medway Council. Average Earnings 2016 May, http://www.medway.gov.uk/pdf/Average%20Earnings%202016.pdf .
      [2]   NOMIS official labour market statistics. Annual Survey of Hours and Earnings - Resident Analysis, 2016
      [3]   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 .
      [4]   Medway Council. Index of Deprivation 2015 February, http://www.medway.gov.uk/pdf/Index%20of%20Multiple%20Deprivation%202015.pdf .
      [5]   NOMIS official labour market statistics. Economically active 2016;
      [6]   NOMIS official labour market statistics. Jobseeker's Allowance with rates and proportions.
      [7]   Office for National Statistics. UK business; activity, size and location : 2017
      [8]   Department for Education. Get information about schools 2017;
    • 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 January 2017, Medway had 48 Traveller caravans. A count is conducted twice a year in January and July. This number has fluctuated between 11 and 48 since January 2015. This was the fourth lowest number across Kent and Medway. Thanet (0), Shepway (7) and Dover (45) had the lowest counts of caravans and Maidstone had the highest (561).[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]

      Looked after children

      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]

      Any child can become a looked after child 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 March 2017 there were 390 looked after children in Medway. This represents 61 per 10,000 children under 18 years old in Medway compared with a national average of 62 per 10,000. The number of looked after children in Medway has decreased by 9.3% from March 2016 to March 2017, compared to the national average which has increased by 3.2%.[7] 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 Children -> Looked After Children

      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.[8]

      People with mental health conditions are often 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.[8]

      Mental ill health represents up to 23% of the total burden of ill health in the UK — the largest single cause of disability[9]. 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[10]. Approximately one in 10 children aged between 5–16 years has a mental health problem.[11]

      As such, mental health affects a large number of people in Medway. It is predicted that 28,012 people aged 18–64 have a common mental disorder[12] and 2,858 people aged over 65 have dementia.[13]

      For more information go to:
      • Adults -> Adult mental health -> Dementia
      • Children -> Emotional health and wellbeing of children and young people

      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 cardiovascular disease, 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.[14]

      As at August 2017, the number of Jobseeker's Allowance (JSA) claimants in Medway was 2,336, a decrease of 369 (14%) compared to 12 months prior. There have been very similar percentage reductions in Kent, the South East region and England. As at August 2017, Medway's claimant rate was the sixth highest out of the 67 local authorities in the South East.[15]

      Within Medway, the wards with the highest unemployment rates are Luton & Wayfield (2.7%), Chatham Central (2.4%), and River (2.4%). Wards that have seen the largest proportional decrease in JSA claims over the past twelve months are: Twydall (-36%), Cuxton and Halling (-29%), and Rainham South (-27%). Chatham Central has seen the largest decrease in the number of claims (-55). In contrast, Rainham Central (21%) and Waldersade (9%) saw an increase in JSA claims over the past twelve months.[15]

      Longer-term JSA claims in Medway have decreased over the last 12 months. As at August 2017, there were 1,240 claiming over 6 months and 850 claiming over 12 months in Medway, which is at least a 12% reduction since August 2016. Despite this fact, longer-term claimants in Medway stand above the national level, with 36.3% of claims being by claimants who have been out of work for over twelve months - this compares to 33.0% nationally.[15]

      Younger claimants (aged 18-24) account for 12.2% of all JSA claims. Claims in this age group peaked in August 2012 (2,220 claims), but have dropped by almost 90% since then.[15]

      Older people

      Compared to England the population of Medway has a smaller proportion of people over the age of 65 years (Medway 15.7% and England 18%). Medway also has a larger proportion between the ages of 0 and 14 years (Medway 19.5% and England 18.1%) and between the ages of 15 and 24 years (Medway 9.6% and 9.3%).[16]. The population of Medway is therefore younger than the population of England overall.

      Rainham Central, Hempstead and Wigmore, Rainham North, Peninsula, Rochester South and Horsted, and Cuxton and Halling have larger proportions of older people, with at least one fifth of their populations aged 65 years and above.[17]

      People aged 85 and over make up only 1.8% of Medway's population (5066 people according to 2017 estimates)[16]. Hempstead and Wigmore, Rochester South and Horsted, Rainham Central and Walderslade have the highest number of people aged 85 and over as a percentage of their total ward population.[18] People aged 85 years old and over are particularly vulnerable because they are more likely to be frail and have mental health problems such as dementia.

      (For more information go to Summary -> Our people and place -> Demography -> 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]   Department for Communities and Local Government. Count of Traveller Caravans England 2017;
      [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]   Department for Education. Children looked after in England including adoption: 2016 to 2017
      [8]   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 .
      [9]   World Health Organization. The Global Burden of Disease: 2004 update 2008;
      [10]   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 .
      [11]   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 .
      [12]   Projecting Adult Needs and Service Information. People aged 18-64 predicted to have a mental health problem, projected to 2035. 2017;
      [13]   Projecting Older People Population Information System. People aged 65 and over predicted to have dementia, by age and gender, projected to 2035. 2017;
      [14]   Waddell G, Burton K. Is Work Good For Your Health and Well-Being? 2006;
      [15]   NOMIS official labour market statistics. Jobseeker's Allowance with rates and proportions.
      [16]   Office for National Statistics. Mid-2017 population estimate
      [17]   Office for National Statistics. Ward Level Mid-Year Population Estimates (experimental) 2016;
      [18]   Office for National Statistics. Ward Level Mid-Year Population Estimates (experimental) 2017;
    • 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 2016 to 2026 suggest that the number of people 65 years of age or over will increase by 25% to 54,500 and the number of people over 85 years will grow by 42% to 7,100.[1]

      The numbers in other age groups are all expected to increase over the same period with the exception of the 20-29 and 45-54 age groups.

      Looking further ahead, Medway's population is predicted to reach 332,600 by 2036, growing by about 53,000 people between 2016 and 2036, a growth rate of 19%.

      Figure 1: Projected population change in Medway between 2016 and 2026
      Figure 1: Projected population change in Medway between 2016 and 2026[1]

      The number of people aged 65 and over with a limiting long-term illness in Medway is projected to rise by 23% between 2017 and 2025, from 21,507 to 26,493[2] assuming the age-related prevalence from the 2011 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.

      Figure 2: Projected percentage population change 2016--2026 by broad age group
      Figure 2: Projected percentage population change 2016–2026 by broad age group.[1]
        2017 2018 2019 2020 2021 2022 2023 2024 2025 2026
      0-4 -0.5 0.0 1.1 2.2 3.3 4.3 4.9 5.4 6.0 6.0
      5-19 1.0 1.7 2.9 3.6 5.0 6.5 7.9 9.2 10.7 11.7
      20-64 0.9 1.8 2.5 3.2 3.9 4.1 4.6 5.0 5.4 5.7
      65plus 2.1 4.1 6.2 8.3 10.8 13.3 15.8 19.0 21.6 25.0
      All ages 1.0 2.0 3.0 4.0 5.0 6.0 7.0 8.0 8.9 9.9
      Table 1: Projected percentage population change 2016–2026 by broad age group.

      Regeneration and Major Development

      Medway Council is preparing a new Local Plan to provide direction on the future growth of the area and looks forward to 2035. The aim of the Local Plan is to ensure Medway grows sustainably, to provide land for the homes, jobs and services that people need, whilst protecting and enhancing the area's environment and heritage.

      Medway is one of the largest urban areas in the south east, similar in size to cities like Brighton and Hove, and Plymouth. The Local Plan is an opportunity to establish a positive strategy to guide Medway's development over the next 18 years. The Development Options consultation document includes a range of scenarios to help provide the basis for Medway's development up to 2035. [3]

      There are two notable residential developments that have recently gained permission to build new homes in Medway.

      Countryside Properties have won the contract to develop Rochester Riverside with 1300 homes, a school, a nursery, hotels, restaurants, a gym and offices. Construction could be underway by the summer of 2017 and completed around the summer of 2028.

      Kitchener Barracks in Dock Road Chatham, is a surplus Ministry of Defence site, Sandhurst Block has gained permission for conversion to residential flats whilst the other buildings on site will be demolished and replaced with three apartment blocks. [4]


      References

      [1]   Office for National Statistics. Mid-2014-based subnational population projections for England
      [2]   Projecting Older People Population Information System. People aged 65 and over with a limiting long-term illness, by age, projected to 2035. 2017;
      [3]   Medway Council. Medway Council Local Plan 2017;
      [4]   Medway Council. Medway Authority Monitoring Report 2016
  • Our health and well-being
    • Introduction

      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 .
    • 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 2014 and 2016 Medway was ranked 98th out of 150 local authorities for overall rate of premature deaths with an age-adjusted rate of 379 per 100,000[1]. There are roughly 2,150 deaths that occur in Medway each year. Almost a third of deaths in females and almost half of deaths in males occur before the age of 75 (30.5% and 44.7% in 2014-2016 respectively).[2] Between 2014-2016 for both males and females the leading cause of premature deaths is cancer, accounting for almost half of deaths in women (47.5%) and two in five men (36.9%) 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 158.8 premature deaths per 100,000 resulting from cancer[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 a correlation shown 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 a Macmillan Information Centre at Medway Maritime Hospital.

      The next largest cause of death in those under the age of 75 years is circulatory diseases (for example heart attacks, stroke and heart failure), accounting for 16.7% of premature deaths in women and 23.5% in men between 2014-2016[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 circulatory diseases.

      A further 10% of premature deaths are due to respiratory diseases, 2014-16[2], 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 Adults —> COPD for more information on COPD in Medway.

      There are three 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.[3]

      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, 2014–16 (Under 75).
      2013 European standard population
      Source: PHIT analysis on 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. The highest mortality rates include River, Chatham Central, Luton and Wayfield and Gillingham North. The lowest mortality rates include wards Hempstead and Wigmore, Rainham Central, Cuxton and Halling and Lordswood and Capstone. [6]


      References

      [1]   Public Health England. Mortality Rankings: Medway 2014-16
      [2]   Medway Public Health Intelligence team. Primary Care Mortality Database analysis
      [3]   Public Health England. Suicide rate 2013-2015;
      [4]   Marmot M. Fair Society, Healthy lives 2010; Strategic Review of Health Inequalities in England post-2010. http://www.instituteofhealthequity.org/resources-reports/fair-society-healthy-lives-the-marmot-review .
      [5]   Public Health England, Association of Public Health Observatories. Slope Index of Inequality Data for LAs 2011;
      [6]   Medway Public Health Intelligence Team. Primary Care Mortality Database Analysis
    • 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 the four main measures in this section, Medway has the lowest percentage of 'very' or 'fairly good' responses for 'Helpfulness of receptionist' and 'Opening hours satisfaction'. The range of percentages across the four sections varies from 47% to 90%. Another factor not mentioned in the tables is whether patients are overheard in the reception area[1].

        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% 89% 76% 75%
      NHS Canterbury and Coastal CCG 73% 89% 79% 82%
      NHS Dartford, Gravesham and Swanley CCG 57% 84% 64% 68%
      NHS Medway CCG 57% 83% 63% 67%
      NHS South Kent Coast CCG 65% 88% 61% 75%
      NHS Swale CCG 57% 83% 66% 70%
      NHS Thanet CCG 47% 86% 65% 76%
      NHS West Kent CCG 71% 90% 77% 74%
      England 68% 86% 73% 76%
      Table 1: Accessing GP services, data collected from Jan-Mar 2017
      Patient experience: out of hours services

      Medway has the lowest percentage satisfaction for 'Speed of care was about right' and is lower for 'Confidence and trust in person seen/spoken to' and 'Overall experience' in comparison to 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 54% and 64% and this has impacted on the overall experience percentage.area[1].

        Speed of care was
      about right
      Confidence and trust
      in person seen or spoken to
      Overall
      experience
      NHS Ashford CCG 56% 76% 59%
      NHS Canterbury and Coastal CCG 64% 76% 57%
      NHS Dartford, Gravesham and Swanley CCG 61% 87% 67%
      NHS Medway CCG 54% 83% 60%
      NHS South Kent Coast CCG 61% 85% 64%
      NHS Swale CCG 62% 89% 64%
      NHS Thanet CCG 59% 84% 66%
      NHS West Kent CCG 60% 84% 68%
      England 61% 87% 67%
      Table 2: Out of hours services, data collected from Jan-Mar 2017
      Patient experience: GP services

      Medway patients are least likely to recommend their GP to someone new to the area out of the seven areas looked at, being 10 percentage points under the England average. The overall experience for Medway patients was 8 percentage points lower than the England average.[1]

        Would recommend
      GP surgery
      to someone
      Overall
      experience
      NHS Ashford CCG 81% 88%
      NHS Canterbury and Coastal CCG 84% 90%
      NHS Dartford, Gravesham and Swanley CCG 72% 80%
      NHS Medway CCG 67% 77%
      NHS South Kent Coast CCG 76% 84%
      NHS Swale CCG 68% 77%
      NHS Thanet CCG 74% 82%
      NHS West Kent CCG 81% 86%
      England 77% 85%
      Table 3: Overall experience of GP services, data collected from Jan-Mar 2017
      Accessing NHS dental services

      93% of patients in Medway seeking an NHS appointment in the last 2 years were successful, equal to the national average. Medway also has same percentage, in comparison to the England average, of people who didn't know you could get an NHS appointment. West Kent and Swale have the highest percentage at 17%.[1]

        Successful in getting
      an NHS appointment
      Didn’t think you
      could get one
      NHS Ashford CCG 95% 14%
      NHS Canterbury and Coastal CCG 94% 13%
      NHS Dartford, Gravesham and Swanley CCG 92% 14%
      NHS Medway CCG 93% 12%
      NHS South Kent Coast CCG 92% 12%
      NHS Swale CCG 93% 17%
      NHS Thanet CCG 91% 9%
      NHS West Kent CCG 92% 17%
      England 93% 12%
      Table 4: Accesing NHS dental services, data collected from Jan-Mar 2017
      Patient experience: NHS dental services

      Medway patients have the highest satisfaction of their overall experience of an NHS dentist at 86%, 1 percentage point higher than the England average. South Kent Coast have satisfaction 3 percentage points lower than Medway.[1]

        Overall
      experience
      NHS Ashford CCG 84.00%
      NHS Canterbury and Coastal CCG 84.00%
      NHS Dartford, Gravesham and Swanley CCG 83.00%
      NHS Medway CCG 86.00%
      NHS South Kent Coast CCG 82.00%
      NHS Swale CCG 85.00%
      NHS Thanet CCG 84.00%
      NHS West Kent CCG 84.00%
      England 85.00%
      Table 5: Overall experience of NHS dental services, data collected from Jan-Mar 2017

      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.[2]

        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 2015, a questionnatire was sent to all women who gave birth in February 2015 (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).[3]

        Medway Foundation
      Trust
      Maidstone and
      Tunbridge Wells
      East Kent Hospitals
      Foundation Trust
      Dartford and
      Gravesham
      Care during pregnancy 9.2 8.9 8.8
      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 5 for overall views of care and services, which is quite low considering the measures listed above. Interestingly each hospital's overall experience has scored quite highly.[4]

        Medway Foundation
      Trust
      Maidstone and
      Tunbridge Wells
      East Kent Hospitals
      Foundation Trust
      Dartford and
      Gravesham
      A&E dept 7.7 8.3 8.1 8.5
      Waiting lists and planned admissions 8.8 8.7 8.7 8.4
      Waiting to get a bed on a ward 6.1 6.5 7.4 7.1
      The hospital and ward 7.3 8.0 7.9 7.8
      Doctors 8.2 8.4 8.5 8.5
      Nurses 7.3 8.0 7.8 8.0
      Care and treatment 7.1 7.7 7.6 7.6
      Operations and procedures 8.4 8.4 8.5 8.2
      Leaving hospital 6.5 6.9 7.1 6.8
      Overall views of care and services 4.8 5.5 5.4 5.1
      Overall experience 7.4 8.0 8.0 7.9
      Number of recipients 474.0 601.0 551.0 495.0
      Inpatients during 2016, a questionnaire was sent to 2,121 recent inpatients across the trusts.

      References

      [1]   NHS England. GP Patient Survey January-March 2017 2017;
      [2]   Care Quality Commission. Outpatient survey June to October 2011 2012;
      [3]   Care Quality Commision. Maternity services survey 2015 2015;
      [4]   Care Quality Commision. Adult inpatient survey 2016 2016;
    • 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 almost two-thirds of adults are either obese or overweight [1] and 21.1% 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 (19%) [3] is significantly higher than the proportion in England. There were around 53,124 smokers in Medway in 2016.

      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 2014/15 there were 31,053 people at any one time living with common mental health problems many of whom will be able to manage their condition with support.[6]

      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 2016, breast screening coverage in Medway is 76.2%, similar to the coverage levels seen in the South East region (77.1%) and England as a whole (75.5%)[7]. 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 (75.4%) than England and the South East region.[8]

      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.

      Looked After Children

      Any child can become a 'Looked After Child' 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. [9]

      At the end of September 2017, Medway had 393 looked after children, representing a 4% decrease from September 2016. Medway's September 2017 rate of 62 children per 10,000 is identical to the March 2017 national rate. Comparison against other groups shows the Medway rate is between the South East average of 51 children per 10,000 and our statistical neighbour average of 73 children per 10,000.[10] The National Audit Office estimated a total of


      References

      [1]   Public Health England. PHOF: Excess weight in Adults 2017;
      [2]   NHS Digital. National Child Measurement Programme 2016;
      [3]   Public Health England. PHOF: 2.14 smoking prevalence 2016;
      [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]   Public Health England. Estimated prevalence of common mental health disorders 2014/15 http://fingertips.phe.org.uk/profile-group/mental-health/profile/common-mental-disorders/data#page/1/gid/1938132720/pat/46/par/E39000035/ati/153/are/E38000104
      [7]   Screening and Immunisations Team. Breast Screening Programme, England, Statistics for 2015-16 2017; https://digital.nhs.uk/catalogue/PUB23376
      [8]   Screening and Immunisations Team. Cervical Screening Programme, England - 2015-16 2016; https://digital.nhs.uk/catalogue/PUB22414
      [9]   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 .
      [10]   Children and Adults. Statistics: looked-after children September 2017 2017;
    • 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: Adults ➜ Safeguarding

      Patient safety incidents

      During the period 1st October 2016 to 31st March 2017, 4,375 incidents were reported to the National Reporting and Learning System (NRLS) as happening at Medway Foundation Trust (MFT). [2] Of the 136 Acute (non-specialist) organisations, MFT's reporting rate (46.74 incidents per 1,000 bed days) lies within the highest 25% of reporters. This has insreased over time, from 14.77 incidents per 1,000 admissions for the reporting period 1st October 2015 to 31st March 2016. Organisations that report more incidents usually have a better and more effective safety culture, so this an improvement for MFT. [2]

      Figure 1: Top 10 incident types, October 2016 to March 2017
      Figure 1: Top 10 incident types, October 2016 to March 2017 [3]

      50% of all incidents were submitted to the NRLS more than 24 days after the incident occurred. At MFT, 50% of all incidents were reported to NRLS more than 30 days after the incident. 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, October 2016 to March 2017 [2]
        Count
      None 3,419
      Low 840
      Moderate 84
      Severe 17
      Death 15
      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. [4]

      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 2016, there were 56,669 children aged 0–15 living in Medway.[5] This could mean as many as 3,231 children living in Medway have reduced lung function as a result of air pollution. [4]

      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. [4]

      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. [4]

      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. [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. [4]

      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. [4] In Medway in 2016, there were 7,662 tests carried out, equating to 20.5% of the 15–24 year old population. Of these, 8.6% (656) tested positive for chlamydia. This equates to a detection rate in Medway of 1,754 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). [6]

      Population vaccination coverage

      Immunisation is the most important public health intervention, other than clean water, for saving lives and improving health. The complete list of complete routine immunisation schedule is available at GOV.UK's website

      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. [4]

      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). [4]

      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. [4]

      People presenting with HIV at a late stage of infection

      In 2015, 39% (1,920) 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 21% (1,030) who were severely immunocompromised (CD4 cell count <200 cells/mm3) at diagnosis. [7]

      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. [8] It is recommended that patients should begin anti-retroviral therapy when CD4 cells counts drop <350 cells/ mm3. [9]

      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 39% in 2015 [7], and across all exposure groups. [10]

        Number with cell
      count <350mm3
      Percentage of
      all diagnoses
      Medway 17 39.5
      Kent 84 56.8
      South East region 613 43.4
      England 5,136 40.1
      Table 3: Percentage of late diagnosis of HIV, 2014 - 16 [11]

      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 372 AIDS at HIV diagnosis reported in 2015. The majority of AIDS diagnoses are made in people who were diagnosed late. Late diagnosis also means that a person has remained unaware of their HIV status for many years, increasing the risk of onward transmission.[7]

      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 2016, 134 children aged under 15 years died from unintentional injury in England and Wales, of which 52 were due to land transport accidents.[12]

      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.[4]

      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.[4]

      In 2016/17, 93 under 5s in Medway were taken to A&E for 'other accidents' (which excludes road traffic accidents); 51 boys and 42 girls. The most common primary diagnosis was head injury, with 32 children attending for this, followed by laceration and Contusion/abrasion (both 13).[13]

      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 2016/17, there were 2,930 admissions of Medway residents to Medway Foundation Trust in relation to an accident. The number of unique residents was 2,625. This means that 305 were admitted more than once within these 12 months.[13]

      Road traffic accidents

      The number of casualties from collisions on Medway's roads has reduced, from 1,253 in 1998 to 856 in 2015, of which 77 people were either killed or seriously injured.\cit{RTA2015} 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.[4]

      Work-related accidents

      In 2016/17, 1.3 million people suffered from work-related illness[14], 137 people were killed at work and 70,116 injuries were reported under 'Report Injuries, Diseases and Dangerous Occurrences' (RIDDOR) in Great Britain.[15]

      In 2016/17 (provisional), there were 0 fatalities, 75 specified injuries and 162 injuries where symptoms lasted over seven days in Medway. There has been a slight decrease over the last five years for the total number of reported non-fatal injuries. Specified injuries have remained fairly constant but there has been a decrease in the number of 'over seven day' injuries. Medway had no fatalities in this period.[15]


      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 October 2016 to 31 March 2017 September, 2017; National Reporting and Learning System and National Patient Safety Agency. https://report.nrls.nhs.uk/explorerTool/PdfReport.aspx .
      [3]   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 .
      [4]   NHS Medway. Annual Public Health Report 2011/12 2012; NHS Medway.
      [5]   Office for National Statistics. Mid-2016 population estimate
      [6]   National Chlamydia Screening Programme. Chlamydia testing data for 15-24 year olds in EnglandPublic Health England. https://hivstiwebportal.phe.org.uk/login.aspx .
      [7]   Public Health England. HIV in the UK 2016 report 2016; Public Health England. https://www.gov.uk/government/publications/hiv-in-the-united-kingdom .
      [8]   Cichocki M. What is a CD4 Count and Why is it Important? 2012;
      [9]   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 .
      [10]   Health Protection Agency. HIV in the United Kingdom: 2011 Report 2011; Health Protection Agency. http://www.hpa.org.uk/hivuk2011 .
      [11]   Public Health England. 3.04 - HIV late diagnosis 2014 to 2016;
      [12]   Office for National Statistics. Death registrations in England and Wales, summary tables: 2016 2017;
      [13]   Medway Public Health Intelligence team. Secondary Uses Service Hospital activity analysis
      [14]   Health and Safety Executive. Reported road casualties in Great Britain 2017;
      [15]   Health and Safety Executive. Reported road casualties in Great Britain 2017;
  • Our community
    • Key messages

      Community involvement is an essential part of the planning and delivery of health and wellbeing services. In Medway, several community interest companies aim to reduce social isolation by identifying additional support that an individual may need and helping people access local services; whether it's a chat and a cup of tea or support getting to a GP appointment. Also, through a grants scheme, community-focused projects are supported to engage local residents in leading healthier and more active lifestyles.

      Understanding the needs of the community is also an essential part of delivering efficient, effective and responsive services. The local care workstream of the Kent and Medway Sustainability and Transformation Partnership (STP) aims to address some of the issues that impact on the health and wellbeing of the local population and transform the way in which services are provided. The key focus is to build on and further develop local community assets.

    • Community involvement

      Community involvement is an essential part of the planning, and increasingly the delivery, of health and wellbeing services. Examples of community involvement in Medway include the work that DERiC does with WALT and wHoo Cares (community interest companies) to help build resilient communities in Walderslade and the Hoo Peninsula. Another example is Involving Medway, a project that aims to encourage people to get involved with and help make decisions about health provision in the Medway.

      DERiC

      DERiC (Developing and Empowering of Resources in Communities) is a community interest company (CIC), which works to create and sustain partnerships between people in communities and the public bodies that provide services to them. DERiC aims to develop new and innovative forms of community-owned social enterprise and deliver outcomes that improve people's lives and enhance community control and engagement.

      In Medway, there are two CICs in Walderslade and the Hoo Peninsula that work in partnership with DERiC and Medway Council. Walderslade Together CIC WALT and Hoo Peninsula Carers CIC wHoo Cares were created to support individuals in their local communities and reduce social isolation. These CICs were developed by a group of volunteers (currently serving as the Board of Directors) and a team from DERiC along with the support of Medway Council, and have been registered since July 2015.

      A Community Life-Planning Coordinator works with an individual to create a person-centred life-plan, which identifies additional support and things that could make a difference to the person's life. A person is then linked with services, groups or events in their community and if required matched with a volunteer (community supporter) that helps the individual to utilise and access these resources. This may be, for example, a chat and a cup of tea once a week, help getting to the local coffee morning or support getting to GP or hospital appointments.

      Volunteering not only helps to support individuals who feel isolated, but also improves employability within the local community.

      Involving Medway

      Involving Medway is a new initiative designed to encourage people to get involved with and help make decisions about health provision in the area. The project is funded by Medway Clinical Commissioning Group (CCG), which is responsible for planning and buying local NHS services. The pilot was launched in March 2017.

      Involving Medway is a partnership between seven community organisations:

      1. Red Zebra: A community infrastructure organisation leading Involving Medway
      2. Spice Innovations Limited: Will introduce Medway Time Credits, an innovative way to reward social action and volunteering
      3. Kent Community Foundation: Administering small grants to fund activities to build stronger communities
      4. Medway Voluntary Action: Supporting voluntary and community organisations to work more closely with decision makers in health and involve residents in the design and delivery of services
      5. Tess Luetchford: Training a group of volunteer community health researchers to gather views and make sure residents have their voices heard.
      6. Arches Local: A lottery 'Big Local' area which provides partnership in the Luton Arches area of Chatham
      7. New Economics Foundation: Bringing national expertise to creating social change

      Grants of up to

    • Community needs and assets

      Understanding the needs of the community is an essential part of delivering efficient, effective and responsive services. As part of the development of the Kent and Medway Sustainability and Transformation Partnership (STP) process, a specific workstream focused on the development of a 'Local Care Model' across Kent and Medway has been established. The primary objective of the local care workstream is to transform the way in which services are provided. It aims to develop preventative and innovative approaches to address some of the entrenched issues impacting on the health and wellbeing of the population.

      Within Medway, the aspirations of the local care workstream are being taken forward in the guise of the 'Medway Model'. The Medway Model brings together a range of key stakeholders. These include Medway Council, NHS Medway CCG, local third sector and voluntary organisations, and a number of other public sector bodies. The focus of the Medway Model is to build on and further develop local community assets. It aims to do this through the analysis and use of high quality data combined with local insight gained from community listening events.

      The Medway Model segments Medway into 6 distinct areas formed around natural units of care (General Practices). The JSNA highlights the key health and wellbeing issues within these communities, providing invaluable insight to inform action to address the problems identified. Overtime Medway should see an increase in proportion of people able to actively 'self-manage' and take action to manage the impact of long-term chronic health conditions. People will also be able to access a range of services in community locations that were previously only available in an acute hospital setting. There will be a focus on developing new ways of working and building capacity and resilience in the Medway community. 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.

  • 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 people in Medway is significantly below that of the national average.
      • There is a clear social gradient in life expectancy; individuals from the most deprived Medway wards are expected to live approximately 8 years fewer than those from more affluent wards (2012-16).
      • Male healthy life expectancy has remained similar to that seen across England (61.8 years vs. 63.4 years respectively). However, female healthy life expectancy has fallen below the England average (59.7 years vs. 64.1 years respectively; 2013-15).
      • 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 outcomes and life expectancy.
      • In Medway, an inequality gap exists in early deaths. Individuals living in the most deprived quintile in Medway have a higher early death rate than those living in the least deprived quintile. The early deaths inequality gap exists for both sexes, but the gap is wider for men.

    • The importance of health inequalities

      Inequalities in health exist between individuals or groups due to differences in social, geographical, biological or other factors. These can 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, see '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 Wider Determinants of Health tool.

      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:

      Life expectancy

      Life expectancy at birth measures the average number of years a person would expect to live if the morality rate remains constant. Life expectancy at birth in England has generally increased in recent decades. While Medway has experienced similar increases, life expectancy at birth has decreased over the last few years by 0.3 years for males and 0.4 years for females (2011-13 to 2013-15).

      Life expectancy in Medway is consistently below that of the national average in both sexes. In 2013-15 the life expectancy at birth for males was 78.4 years in Medway, compared to 79.5 years in England (PHOF). For females during the same time period life expectancy at birth was 82.0 years in Medway and 83.1 years in England (PHOF).

      Healthy life expectancy

      In 2013-15 the number of years that a man living in Medway would expect to live in good health was 61.8 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 (HLE) in Medway has fallen in the last few years to 59.7 years in 2013-15, taking it significantly below the England average of 64.1 years (PHOF).

      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; education, skills and training; health and disability; crime; barriers to housing and services; and living environment.[1] 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).[2]

      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 under the age of 20 years in relative poverty in Medway is higher than the national average (20.8% versus 19.9% in 2014) (PHOF). This pattern has been evident since 2011 as numbers in Medway have remained consistently higher than those 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 (21.4% versus 20.1% in 2014) (PHOF).

      A list of child health profiles can be found on Public Health England, Child and Maternal Health, covering pregnancy and birth; early years; school-age children; and young people.


      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]   Medway Council. Index of Deprivation 2015 February, http://www.medway.gov.uk/pdf/Index%20of%20Multiple%20Deprivation%202015.pdf .
    • 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, which also equates to a shorter average life expectancy. This is shown by the difference in life expectancy between deprived and affluent wards in Medway. The gap in male life expectancy is 9 years between Hempstead and Wigmore, and River and the gap in female life expectancy is 8.1 years between Rainham Central, and Watling as shown in Figure 1. Wards with the lowest life expectancies overall include Chatham Central; Watling; Gillingham South; Gillingham North; and River. Conversely, wards with the highest life expectancies overall include Cuxton and Halling; Hempstead and Wigmore; Rainham Central; Lordswood and Capstone; and Rainham North (2013-2017).[1].

      Figure 1: Life expectancy at birth by ward, 2013-2017
      Figure 1: Life expectancy at birth by ward, 2013-2017

      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 [2]

      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 8.2 years for males (PHOF) and 5.8 years for females (PHOF; 2013-15); these values have increased since 2012-14 for both males (6.6 years) and females (5.2 years).

      The SII is displayed for males and females in the figures below for 2013-15, where life expectancy for each deprivation decile is plotted in blue and the SII is the gradient of the line of best fit (red). In the most deprived decile in Medway the life expectancy for males and females is 73.8 and 79.5 years respectively. These values are significantly lower that the life expectancies of males and females in the least deprived decile; 82.9 and 84.8 years respectively. In both males and females life expectancy appears to be directly related to deprivation decile (figures 3 and 4).[3]

      Figure 3: Life expectancy by deprivation decile with the slope of inequality for Medway, males, 2013--15
      Figure 3: Life expectancy by deprivation decile with the slope of inequality for Medway, males, 2013–15.
      Slope index of inequality = 8.2 years (95% confidence interval: 6.6 to 9.7) [4]
      Figure 3: Figure 4: Life expectancy by deprivation decile with the slope of inequality for Medway, females, 2013--15.
      Figure 4: Life expectancy by deprivation decile with the slope of inequality for Medway, females, 2013–15.
      Slope index of inequality = 5.8 years (95% confidence interval: 4.3 to 7.3) [4]

      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 (89.6%) 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.[5] 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.[6]

      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.[7]


      References

      [1]   Medway Public Health Intelligence Team. Primary Care Mortality Database Analysis
      [2]   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 .
      [3]   Public Health England. Life expectancy at birth 2013-2015;
      [4]   Public Health England. Slope index of inequality in life expectancy at birth 2013-2015;
      [5]   Office for National Statistics. Table KS201EW: 2011 Census: Ethnic group, local authorities in England and Wales.
      [6]   POST. Postnote - Ethnicity and Health 2007; Parliamentary Office of Science and Technology.
      [7]   Becares L. Which ethnic groups have the poorest health? Ethnic health inequalities 1991 to 2011 2013;
    • Understanding health inequalities in Medway

      Inequalities in mortality

      By looking at broad disease categories it is possible to understand where the greatest contributors to health inequalities lie. Figure 1 shows that higher levels of mortality are experienced by the most deprived quintile in Medway.

      Cancer is the main cause of morality in Medway, but there is a relativity small difference in the mortality rates between the most and least deprived quintiles in Medway.

      The main contributors to mortality inequalities in Medway are circulatory disease and respiratory disease, which both have significantly higher mortality rates for the most deprived quintile in Medway compared to the least deprived quintile (2012-2016).[1]

      Figure 1: Cause-specific mortality rate profiles for the most and least deprived quintiles in Medway, 2013-2017
      Figure 1: Cause-specific mortality rate profiles for the most and least deprived quintiles in Medway, 2013-2017

      Inequalities in life expectancy

      The 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 for both sexes is circulatory disease followed by respiratory disease.

      Figure 2: Life expectancy gap between the most and least deprived quintiles in Medway, by broad cause of death
      Figure 2: Life expectancy gap between the most and least deprived quintiles in Medway, by broad cause of death, 2012-2014 [2]

      In 2012-14, the causes of death that contributed most to the inequalities gap in Medway for men were coronary heart disease (CHD) at 18.5%, external causes (excluding suicide) at 12.2%, and chronic obstructive airways disease at 10.4%. For women the main contributors were chronic obstructive airways disease at 15.8%, CHD at 11.7%, and circulatory diseases (excluding CHD and stroke) at 10.7%.[2]

      Changes in health inequalities over time

      The Health Profiles provide charts that show changes in health inequalities over time. These charts show the changes in death rates in people under 75 (early deaths) between the most and least deprived quintiles in Medway; figure 3 for men and figure 4 for women.[3]

      There are marked differences in early death rates between the most and least deprived quintiles in Medway for both sexes. Individuals living in the most deprived quintile in Medway have a higher early death rate than those living in the least deprived quintile.

      The early death inequality gap appears to be widening for both men and women since 2012, however there has been a larger widening of the gap for men.


      Figure 3: Early deaths from all causes: men
      Figure 3: Early deaths from all causes: men [3]
      Figure 4: Early deaths from all causes: women
      Figure 4: Early deaths from all causes: women [3]

      NOTE: Data from 2010-12 onwards have been revised to use IMD 2015 to define local deprivation quintiles (fifths), all prior time points use IMD 2010. In doing this, areas are grouped into deprivation quintiles using the Index of Multiple Deprivation which most closely aligns with time period of the data. This provides a more accurate way of discriminating changes between similarly deprived areas over time.[3]

      Causes of health inequalities

      The causes of health inequalities are complex, but there appears to be 3 main areas that contribute to the differences in health between different socio-economic groups:


      • Variation in quality of health care
      • Differences in lifestyle factors, such as smoking, nutrition and exercise
      • Wider determinants of health, such as poverty, housing and education [4]

      Variation in the uptake and quality of health and social care

      Figures 5 and 6 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. Also 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 5: Emergency Admissions All Causes by Medway Practices
      Figure 5: Emergency Admissions All Causes by Medway Practices [5]
      Figure 6: Elective Admissions All Causes by Medway Practices
      Figure 6: Elective Admissions All Causes by Medway Practices [5]

      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 7 shows the difference between the most and least deprived quintiles in Medway for lung cancer mortality rates.[1]

      Figure 7: Age-specific lung cancer mortality rates for the most and least deprived quintiles in Medway, 2012-2016
      Figure 7: Age-specific lung cancer mortality rates for the most and least deprived quintiles in Medway, 2012-2016

      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 (Summary -> Our health inequalities -> Medway in a national context) 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 2015 gives an indication of how these are distributed in Medway.

      Maps showing the distribution of deprivation for each Medway ward can be found in the Health and social care profiles (page 18). See Profiles -> Health and social care profiles


      References

      [1]   Medway Public Health Intelligence Team. Primary Care Mortality Database Analysis
      [2]   Public Health England. Segment Tool
      [3]   Public Health England. Medway Health Profile 2017
      [4]   House of Commons Health Committee. Health Inequalities: Third Report of Session 2008-09
      [5]   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
      • Improving mental and physical health and well-being
      • Reduce health inequalities

    • Theme 1: Giving every child a good start

      There is good evidence that investment in the early years of life (0-5 years) is highly effective in terms of the impact on future health and wellbeing and is highly 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.

      Ensuring that every child in Medway has a good start in life is therefore essential for the future success of Medway and the health and wellbeing of people in Medway. For some aspects of child health and wellbeing Medway is doing well, such as 5-year-olds achieving a good level of development and hospital admissions for dental caries (0-4 years), and we must maintain and build upon this level of performance. For others there are important and persistent issues where there are opportunities for improvement, for example in smoking during pregnancy, or the emotional well-being of looked-after children.

      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 the last two years, however Medway has seen a decrease in the number of referrals for the same period. Medway has seen a 16.1% decrease, from 3,114 in 2015/16 to 2,612 in 2017/18.[1] Of these, 365 children were subject to child protection plans during the year ending March 2018, lower than the national rate. [1]

      There has also been an increase in the number of looked after children. At the end of March 2018, Medway had 414 looked after children, representing a 6.2% decrease from March 2017.[2] With 65 looked after children per 10,000 children this is the same as the national average, based upon the latest data at March 2018.[2]

      The number of children with a special educational need or disability (SEND) is also expected to increase in the next five years. This may result in additional pupils with Statements or Education, Health and Care plans (EHCPs) requiring specialist education provision.[3]

      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 had 30.6% of children's social worker positions vacant in September 2016.[4]

      Priorities


      • Reduce childhood obesity
      • Reduce smoking in pregnancy
      • Ensure that childhood vaccination rates are high enough to provide herd immunity
      • Improve the emotional well-being of looked after children


      References

      [1]   Department for Education. Characteristics of children in need: 2017 to 2018
      [2]   Department for Education. Statistics: looked-after children 2017-18 2018;
      [3]   Medway Council. Medway SEND and Inclusion Strategy 2016-2020
      [4]   Department for Education. Children's social work workforce 2016 2017;
    • Theme 2: Enable our older population to live independently and well

      Over the next five years the number of people aged over 65 years will increase by over four thousand (10%) and the number aged over 85 years will increase by 900 (18%). Increasing numbers of older people mean that there will be increasing numbers of people developing chronic conditions who become intensive users of services (assuming age-specific rates remain constant). This ageing of the population is likely to result in a substantial increase in costs to the health and social care system. Therefore, primary and secondary prevention of conditions such as diabetes, chronic obstructive pulmonary disease (COPD) and heart disease (see next theme), 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. While not limited to older people, addressing social isolation is one important aspect of improving health and wellbeing and the findings of the council's Social Isolation Task Group will help to guide this.

      Many older people prefer to stay in their own home for as long as they can and to do so they may need additional support. There have also been increasing numbers of older people who need specialist accommodation that combines support, care and housing provision. Carers play an essential role in supporting older people and their role will become increasingly important as the older population increases.

      Priorities


      • Support work to identify and support those who are socially-isolated
      • Support work to develop local care and ensure co-ordination with adult social care
      • Support the development of the new strategy for carers and the delivery of its actions

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

      This theme focuses mainly on improving healthcare to prevent early death and improve quality of life. This includes improving early diagnosis and therefore allowing more timely intervention which can significantly improve outcomes in some diseases.

      The leading causes of early death and illness in Medway include cancer, circulatory disease (e.g. heart attack, stroke and heart failure) and respiratory disease, conditions that share many common causes. Over recent decades public health action and improved health care have led to dramatic reductions in the number of deaths from these causes. For example, the mortality rate from heart attacks in Medway fell 85 per cent from 108 to 17 per 100,000 between 1993 and 2010. About half of this reduction was due to improved health care and half was due to public health measures, such as reductions in smoking.

      Approximately 2,150 Medway residents die each year (2,197 deaths registered in 2017).[1] The all-age, all-cause mortality rate is statistically significantly higher in Medway than in both England and the South East (2015).[2]

      There are also differences in life expectancy between the wards. Average life expectancy in Cuxton and Halling, Hempstead and Wigmore, Rainham Central, Lordswood and Capstone, and Rainham North is significantly greater than 10 wards including Chatham Central, Watling, and Gillingham South wards. Life expectancy is highest in Cuxton and Halling at 85.1 years, and lowest in Chatham Central at 78 years (2013 to 2017).[3]

      Most people with long-term conditions have a single condition and can be helped to manage their condition at relatively low cost. 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.

      Priorities


      • Determine the drivers behind Medway's consistently high cancer mortality rates
      • Promote cancer screening, including supporting the Time to Test campaign
      • Support action being taken to reduce variation in quality of primary care across Medway


      References

      [1]   Office for National Statistics. Death registrations in England and Wales, summary tables: 2016 2017;
      [2]   Public Health England. Directly Age Standardised Mortality Rate (ASMR), Persons, All Ages
      [3]   Medway Public Health Intelligence Team. Primary Care Mortality Database Analysis
    • Theme 4: Improving mental and physical health and well-being

      Increasing attention is being paid to not just how long people live, but also how well they live.

      Mental and physical health and wellbeing are affected by many issues, including crime and the perception of crime, proximity to green spaces, housing, unemployment, the quality of employment for those who are in work, debt and income level, the ability to live independently and autonomously, and freedom from pain and ill-health.

      In addition to the wider determinants of health and wellbeing above, the Joint Strategic Needs Assessment identifies key individual-level risk factors that affect health and wellbeing on which we need to take action:


      • tobacco use, both preventing people from starting smoking and helping people to stop smoking;
      • harmful use of alcohol and drugs;
      • physical inactivity;
      • poor diet;
      • high stress levels and poor mental wellbeing;
      • poor sexual health.

      Each of these risk factors is an aspect of 'lifestyle', the 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 easy or are the default choices.

      Changing behaviour is difficult and behaviours are shaped by experiences and where we live. People who are isolated or going through stressful life circumstances find it very difficult to make lifestyle changes.

      Improving mental and physical health and wellbeing therefore involves broader changes to the wider determinants that influence us all and specific changes for those with particular needs.

      Priorities


      • Support actions to make Medway a Dementia Friendly Community
      • Influence the shaping of the environment in Medway to make healthy choices the easy choices
      • Encourage initiatives to improve self-management of long-term conditions
      • Support people with mostly good mental wellbeing to consciously maintain a good mental health
      • Support the implementation of the suicide prevention plan
      • Support work to reduce domestic abuse
      • Reduce drug-related deaths

    • Theme 5: Reduce health inequalities

      In Medway rates of long-term illness, emergency hospital admissions and death are higher in those who are more disadvantaged. 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 means that health and social care provisions need to be made available to all, with increasing effort needed for those who are increasingly disadvantaged. For example, individuals with a learning disability and individuals with mental illnesses have, on average, a significantly lower life expectancy compared to the general population. Other groups include those in the criminal justice system and armed forces. For these groups national strategies and policies apply, and the local public health team works with these groups and national teams where appropriate.

      Taking action through tackling the wider determinants of health, lifestyle factors and improved health and social care to reduce health inequalities will result in reduced costs for the health and social care system. Some interventions will have a rapid effect, while others will take longer to affect health inequalities.

      The publication Fair Society, Healthy Lives: Strategic Review of Health Inequalities in England post 2010 (Marmot Review)[1] reviewed the evidence on what is effective in tackling health inequalities. This focuses largely on the social determinants of health and is based around six key policy recommendations for the most effective ways to reduce the health inequalities gap. These policy recommendations are woven into the JHWS and are as follows: 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 a healthy standard of living for all; create and develop healthy and sustainable places and communities and strengthen the role and impact of ill health prevention.

      Priorities


      • Monitor the variation in key outcomes across Medway, including school readiness
      • Influence the delivery of services to reduce variation across Medway
      • Reduce variation in healthy life expectancy
      • Support early help to families


      References

      [1]   Marmot M. Fair Society, Healthy lives 2010; Strategic Review of Health Inequalities in England post-2010. http://www.instituteofhealthequity.org/resources-reports/fair-society-healthy-lives-the-marmot-review .

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