‘A Picture of Health’ Lincolnshire and Boston

Philip GarnerPublic Health and Partnerships

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‘A Picture of Health’

The DPH annual report for 2007– ‘Something old , something new something borrowed ….’– Covers the county but will emphasize issues locally relevant– Focus on

Population needsThe response by the local NHSPotential impacts – short and long term Brief mention of Commissioning for outcomes

What are we comparing ourselves with – what is our aspiration?

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DPH Annual Report for 2007 designed to support a:

SHIFT towards services that are personal, sensitive to individual need

maintaining independence and dignity

STRATEGIC REORIENTATION towards promoting health and well-being, investing now to reduce future health costs

STRONGER FOCUS on commissioning services/ interventions that will achieve better health across health and local government everyone working together to promote inclusion and tackle health inequalities .

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The Population of LincolnshireLincolnshire resident patient count in 1 year age bands (1998 to 2007)

0

500

1,000

1,500

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3,500

4,000

4,500

5,000

5,500

6,000

6,500

7,000

7,500

8,000

8,500

9,000

9,500

10,000

10,500

11,000

11,500

12,000

0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 42 44 46 48 50 52 54 56 58 60 62 64 66 68 70 72 74 76 78 80 82 84 86 88 90

Age of patient (years)

Num

ber o

f pat

ient

s

January 1998 January 1999January 2000 January 2001January 2002 January 2003January 2004 January 2005January 2006 January 2007

Post WW1 baby boom (peak crossed 75 year old

barrier in 1995)

Post WW2 baby boom.Note increasing peak indicates

inw ards migration into Lincolnshire

Decrease in 18 to 25 year oldsbetw een 1994 and 1998,

now increasing due to University

WW1 Flu epidemic and low births numbers during WW1

Consistent year on year inw ard migration in the teenage

and middle age bands (teenagerspossibly the children of the middle

aged persons)

Yearly decrease in new bornsor infant population to 2003,

now increasing 65 y

ear o

ld

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Number of Births: 2000-2006

2000 2001 2002 2003 2004 2005 2006Boston 579 538 568 547 644 683 712 23.0%East Lindsey 1128 1038 1037 1060 1114 1188 1153 2.2%Lincoln 1030 945 1007 1070 1026 1045 1065 3.4%

North Kesteven 888 919 805 923 912 949 1005 13.2%South Holland 675 682 726 701 731 750 788 16.7%South Kesteven 1223 1258 1170 1234 1273 1252 1324 8.3%

West Lindsey 653 643 702 714 751 807 783 19.9%Lincolnshire 6176 6023 6015 6249 6451 6674 6830 10.6%

Calendar YearDistrict Council % Increase

in Births

Boston – 8% increase in crude birth rates

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Population: Projections by Cluster – 65yrs and Over

GP Cluster 2007 2027 2007 2027

Boston 15,006 21,520 19.6% 19.6% 0.1%

East Lindsey 18,199 34,651 21.1% 30.9% 9.8%

South Holland 15,021 29,683 21.5% 33.8% 12.2%

Lincoln South 18,260 23,839 16.7% 15.6% -1.1%

Mid Kesteven 22,884 55,039 18.2% 34.1% 15.8%

Welland 13,563 21,031 17.2% 19.8% 2.6%

Skegness & Coast 17,736 31,528 25.0% 35.6% 10.6%

North West Lincolnshire 18,352 37,240 17.4% 27.5% 10.2%

Lincolnshire 139,021 254,533 19.2% 26.7% 7.5%

Number 65 and OverPercentage 65 and

OverChange in

Percentage 65 and Over

•In many GP Clusters, by 2027, numbers aged over 65 yrs will approx. double, exceeding 30% of total residents. • These increasing numbers will increase the number of people living with a long term condition.

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Population Projections

NUMBER PERCENTAGE

Age Band 2007 2012 2017 2022 2027 Age Band 2007 2012 2017 2022 2027

00-04 3,786 4,736 5,676 6,616 7,556 00-04 4.9% 5.7% 6.2% 6.6% 6.9%

05-19 13,154 13,724 15,059 17,417 20,247 05-19 17.1% 16.4% 16.5% 17.4% 18.5%

20-39 18,732 20,898 23,286 24,718 25,684 20-39 24.4% 25.0% 25.5% 24.7% 23.4%

40-64 26,033 27,965 29,518 31,943 34,564 40-64 33.9% 33.4% 32.3% 31.9% 31.5%

65-69 7,891 8,992 10,241 10,583 11,323 65-69 10.3% 10.8% 11.2% 10.6% 10.3%

75-84 5,365 5,415 5,528 6,634 7,835 75-84 7.0% 6.5% 6.1% 6.6% 7.2%

85+ 1,750 1,903 2,056 2,209 2,363 85+ 2.3% 2.3% 2.3% 2.2% 2.2%

Grand Total 76,711 83,634 91,364 100,122 109,572 Grand Total 100.0% 100.0% 100.0% 100.0% 100.0%

vi) Boston

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Population: Age Standardised Premature Mortality (/100,000 pop.2004-06)

(mortality rate based on deaths recorded on GP Clinical system from NSTS and is death rate for those registered with PCT and not Lincolnshire resident rate.)

0

50

100

150

200

250

300

350

400

Skegness &Coast

North WestLincs

MidKesteven

Boston SouthHolland

LincolnSouth

EastLindsey

Welland

Lincolnshire PCT Rate

• Skegness & Coast cluster rate significantly above County rate.

• East Lindsey and Welland cluster rate significantly below.

• The different rates, as might expect, follow pattern of deprivation.

• However, when deprivation accounted for, picture changes dramatically.

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Population: Age Standardised Premature Mortality – Adjusted for Deprivation (2)

Boston Cluster has a lower age standardised rate, when adjusted for deprivation – by 2.9%

Ratio of Actual to Expected Mortality Rate Based on Deprivation in each Cluster

85

90

95

100

105

110

Skegness &Coast

North WestLincs

Mid Kesteven Boston South Holland Lincoln South East Lindsey Welland

Norm = 100

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Population: Main Causes of Premature Death

AreaAll

CancersBreast Cancer

Colorectal Cancer

Prostate Cancer

All Circulatory

Disease CHD Stroke COPD DiabetesAll

Accidents

England 119.0 22.0 11.4 9.3 90.5 52.5 17.4 13.0 3.4 11.4

Boston 114.2 16.3 17.3 5.2 98.0 57.1 17.5 10.4 4.3 20.6

East Lindsey 112.3 14.1 8.1 9.0 88.1 49.7 15.9 11.4 5.1 15.4

Lincoln 122.6 21.4 12.6 10.1 110.1 64.4 21.5 21.2 5.8 14.8

North Kesteven 114.5 29.3 11.6 12.2 80.6 50.3 14.3 7.5 3.2 13.2

South Holland 105.8 17.7 9.9 12.7 88.7 47.5 14.9 11.1 2.6 21.0

South Kesteven 99.4 21.6 13.6 9.1 83.2 48.6 15.9 9.9 3.7 13.4

West Lindsey 132.3 27.3 14.0 13.4 88.9 52.3 18.3 13.0 3.8 15.6

Lincolnshire 113.3 20.9 11.9 10.4 89.0 51.5 16.4 11.6 4.1 15.5All Age, All Cause - 1993 to 2005

500

600

700

800

900

1000

1

#REF!

#REF!

Mortality Rate Per 100,000, All Cause, All Age 2003 to 2005 (Pooled)

500550

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Some Potential Impacts

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Summary Number of People Who May Have a LTC in Next 20 Years

Disease 2007 2012 2017 2022 2027

Hypertension 96764 110262 121679 131345 141616 44852 46.4%CHD 32649 39862 44642 50369 57202 24553 75.2%Stroke 13407 16220 18717 21050 23822 10415 77.7%Cancer 6265 6922 7767 8770 9735 3470 55.4%COPD 12204 14709 17063 19252 21863 9659 79.2%

Diabetes 29244 34652 39238 44089 49844 20600 70.4%

Total 190533 222626 249106 274875 304083 113550 59.6%

No of Persons on The GP Registers Increase in No. of

Persons

Percentage Increase in No. on

Register

• Projections based on changes in population as earlier and assuming services in Lincolnshire remain same.

• Increase in those living with a LTC could increase by nearly 60%.

• The above increase will consume significant resources within the NHS which may well be beyond the financial means of the NHS in Lincolnshire.

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Forecast Persons on GP Registers with CHD 2007-27

Cluster 2007 2012 2017 2022 2027

Boston 3288 3841 4197 4579 5062 1774 54.0%East Lindsey 4156 4979 5827 6651 7648 3492 84.0%Lincoln South 4235 4685 5018 5319 5853 1618 38.2%Mid Kesteven 5140 7055 8751 10306 12019 6879 133.8%North West Lincs 4458 5363 6355 7279 8335 3877 87.0%Skegness & Coast 5253 6106 5461 6129 6855 1602 30.5%South Holland 3332 4237 5035 5736 6488 3156 94.7%Welland 2787 3597 3998 4369 4940 2153 77.3%

Lincolnshire 32649 39862 44642 50369 57202 24553 75.2%

No of Persons on GP Register With CHDPercentage Increase in No. on CHD

Register

Increase in No. of

Persons With CHD

•County overall could see increase of 75%•% increase for Clusters ranges from 30.5% in Skegness & Coast to 133.8% in Mid Kesteven.•These figures would be reduced as a result of reduction in smoking and excess alcohol, and improvements in diet and amounts of physical activity undertaken.

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•Estimates based on numbers known to the NHS. However, not all diabetics are diagnosed, so these are likely to underestimate the actual numbers of diabetics in the County. Approx.4,300 diabetics could be undiagnosed in 2027.• Mid Kesteven cluster will again see greatest impact but also significant figures for East Lindsey•Again, lifestyle changes would impact on these numbers, most diabetics being Type 2.

Cluster 2007 2012 2017 2022 2027

Boston 731 700 759 837 914 183 25.0%East Lindsey 805 916 1035 1169 1298 493 61.3%Lincoln South 819 859 918 1004 1091 272 33.2%Mid Kesteven 1002 1245 1467 1715 1937 935 93.3%North West Lincs 897 956 1090 1247 1390 493 54.9%Skegness & Coast 779 841 931 1037 1139 360 46.2%South Holland 568 726 823 937 1045 477 83.9%Welland 664 679 743 826 922 258 38.9%

Lincolnshire 6265 6922 7767 8770 9735 3470 55.4%

No of Persons on GP Register With DiabetesPercentage

Increase in No. on Diabetes

Register

Increase in No. of Persons With

Diabetes

Forecast Persons on GP Register with Diabetes, 2007-27

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The Cost of Acute Care For LTCs in Lincolnshire

• The increase in the number of people living with a LTC was nearly 60%, however, the cost of acute care alone could rise by 227% from 2007 to 2027.

• The greatest % increase in cost will be seen for treatment of COPD, though the greatest financial burden will be for Cancer and Diabetes.

Disease 2007 2012 2017 2022 2027CHD £13,885,623 £20,559,090 £27,695,737 £37,052,765 £49,545,226 £35,659,603 256.8%

Stroke £5,805,210 £7,767,498 £10,430,112 £13,968,747 £18,257,736 £12,452,526 214.5%

Cancer £22,789,658 £30,748,293 £41,353,084 £55,445,207 £72,494,461 £49,704,803 218.1%

COPD £2,992,384 £4,415,807 £6,186,896 £8,326,705 £11,192,587 £8,200,203 274.0%

Diabetes £22,057,857 £29,689,608 £39,852,690 £53,340,529 £69,674,234 £47,616,377 215.9%

Total £67,530,732 £93,180,296 £125,518,519 £168,133,953 £221,164,244 £153,633,512 227.5%

Increase In Cost of

Treatment

Percentage Increase In Cost

of Treatment

Cost of treatment Assuming a 4% Annual Increase in Cost

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Cluster 2007 2012 2017 2022 2027

Boston £2,656,252 £3,079,682 £3,995,793 £5,223,323 £6,712,763 £4,056,510East Lindsey £2,791,894 £3,842,793 £5,200,112 £6,961,130 £9,102,574 £6,310,680Lincoln South £2,584,940 £3,281,144 £4,194,563 £5,440,969 £6,961,943 £4,377,002Mid Kesteven £3,178,462 £4,780,918 £6,736,999 £9,339,950 £12,424,495 £9,246,032North West Lincs £2,558,956 £3,299,963 £4,504,741 £6,107,811 £8,016,252 £5,457,297Skegness & Coast £3,468,326 £4,531,450 £6,005,333 £7,925,015 £10,250,206 £6,781,880South Holland £2,939,149 £4,546,894 £6,170,347 £8,328,137 £10,928,580 £7,989,431Welland £1,879,877 £2,326,764 £3,044,801 £4,014,194 £5,277,422 £3,397,545

Lincolnshire £22,057,857 £29,689,608 £39,852,690 £53,340,529 £69,674,234 £47,616,377

Cost of Admissions for Diabetes (Assuming 4% increase in cost)Increase in

Cost of Admissions for

Diabetes

Est.Cost Acute Hospital Admissions, Diabetes, 2007-07

• Shows the total cost of treatment for diabetic patients, almost £70 million (increase almost £48 million). These costs may, therefore, also be included in those for other long term conditions as patients with diabetes might also have had a primary diagnosis of CHD, stroke etc.

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Response to NHS Service User Needs

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0.00%

1.00%

2.00%

3.00%

4.00%

5.00%

6.00%

7.00%

8.00%

Boston EastLindsey

LincolnSouth

MidKesteven

North WestLincs

Skegness &Coast

SouthHolland

Welland

Lincolnshire Average

Proportion of Patients on CHD Registers

•The CHD Register is typical of all Registers and the relative position for each Cluster changes very little for each of the conditions reported (Hypertension, Stroke / TIA, Diabetes, COPD)

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GP Response via Quality & Outcomes Framework (QOF)

Proportion CHD Patients Whose Cholesterol is 5mmol/l or Less

• National guidelines recommend patients with cholesterol level greater than 5 mmol/l should be offered lipid lowering therapy.

• The fact that fewer patients in Skegness & Coast cluster have a cholesterol level of 5mmol/l or less does not necessarily mean that they have lower prescribing of Statins.

• Patient self management will also play a part in the ability to control Cholesterol levels.

• Statin prescribing in Skegness and Coast is in fact higher than both the County and national figures.

60.00%

65.00%

70.00%

75.00%

80.00%

85.00%

90.00%

Boston EastLindsey

LincolnSouth

MidKesteven

North WestLincs

Skegness &Coast

SouthHolland

Welland

Lincolnshire Average

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% Patients with History MI(Diagnosed after 1 April 2003) and currently treated with ACE Inhibitor/Angiotensin II Antagonist

74.00%

76.00%

78.00%

80.00%

82.00%

84.00%

86.00%

88.00%

90.00%

92.00%

Boston East Lindsey LincolnSouth

MidKesteven

North WestLincs

Skegness &Coast

SouthHolland

Welland

Lincolnshire Average

• In Skegness and Coast cluster fewer than 80% of MI patients appear to be prescribed the appropriate drug, while in Welland and Mid Kesteven the figure is above 90%.

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80.00%

82.00%

84.00%

86.00%

88.00%

90.00%

92.00%

Boston EastLindsey

LincolnSouth

MidKesteven

North WestLincs

Skegness &Coast

SouthHolland

Welland

Lincolnshire Average

CHD and BP 150/90mmHg or less

• British Hypertension Society Guidelines proposes audit standard BP reading of 150/90 or less.

• A reduction of 5 – 6 mmHg in blood pressure sustained over 5 years been shown to reduce coronary events by 20 – 25% in patients with CHD.

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80.00%

81.00%

82.00%

83.00%

84.00%

85.00%

86.00%

87.00%

88.00%

Boston East Lindsey LincolnSouth

MidKesteven

North WestLincs

Skegness &Coast

SouthHolland

Welland

Lincolnshire Average

Stroke/TIA with BP 150/90 or Less

A long term difference of 5 – 6 mm Hg in usual diastolic blood pressure has been shown to be associated with 36% - 40% less stroke over five years.

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High BP and last BP 150/90mmHg or less

66.00%

68.00%

70.00%

72.00%

74.00%

76.00%

78.00%

Boston EastLindsey

LincolnSouth

MidKesteven

North WestLincs

Skegness &Coast

SouthHolland

Welland

Lincolnshire Average

Trials of HBP treatment have shown significant reduction in incidence of stroke and CHD in patients with treated hypertension.

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Deaths Amenable to Intervention

condition

Boston

East Lindsey

Lincoln South

Mid K

esteven

North W

est Lincs

Skegness & C

oast

South Holland

Welland

Lincolnshire PCT

Percentage of Total A

menable to H

ealthcare

IHD - 0 to 74 148 126 151 199 182 173 104 94 1177 44.2%

CVD - 0 to 74 41 49 67 52 63 43 33 33 381 14.3%

Cancer, Colorectal - 0 to 74 27 32 45 54 44 24 26 23 275 10.3%

Cancer, Female Breast - 0 to 74 24 26 44 50 40 29 24 21 258 9.7%

Pneumonia - 0 to 74 22 16 17 21 27 32 22 13 170 6.4%Perinatal and other Childhood Death - 0 to 6 14 16 22 16 20 6 8 7 109 4.1%

Hypertensive Disease - 0 to 74 3 3 10 6 7 9 2 2 42 1.6%

Other 42 27 28 53 26 29 23 21 249 9.4%

Total Amenable To healthcare 321 295 384 451 409 345 242 214 2661 100.0%

Total Deaths Under 75 876 882 992 1165 1133 977 693 540 7258 n/a

Total Deaths All Ages 2663 2873 3021 3391 3122 2828 2137 1714 21749 n/aPercentage Amenable to Healthcare (Under 75) 37% 33% 39% 39% 36% 35% 35% 40% 37% n/a

Percentage Amenable to Healthcare (All Ages) 12% 10% 13% 13% 13% 12% 11% 12% 12% n/a

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Summary Deaths Amenable to Intervention

• Circulatory diseases account for more than 22%, of total deaths under 75 years old, 60% of those amenable to healthcare

• Some of these lives could be saved with statins, and other drugs, and with smoking cessation and therapeutic/surgical intervention

• Cancers account for more than 7.3%, of premature deaths, 20% of those amenable to interventions, through awareness raising, screening, and smoking cessation

• Lincs PCT 37% premature deaths amenable to intervention (range 33% E Lindsey cluster- 40% Welland).

•Boston had 37% of deaths amenable to healthcare.

• Costs for prescribing and Primary Care are needed to get complete picture along the care pathways, so not possible to draw any conclusions as to whether overall balance of spend by condition and geography is appropriate

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2010 Health Inequalities Target

• Dept. of Health review of trends in life expectancy, 1995 – 2004, Lincoln City: second slowest progress in England re. female LE. progress for males assessed as being “just adequate”.

Need to focus on cancers, circulatory disease, respiratory disease, digestive disease for both men and women

National modelling highlights addressing smoking prevalence, primary and secondary prevention of circulatory diseases, improving blood pressure and cholesterol control, will make most significant contributions to narrowing the gap.

For longer term, these interventions need to be considered in the context of wider determinants of health and lifestyle issues.

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Longer Term Implications: Lifestyles- Smoking

• Biggest single- preventable cause of premature deaths - cause of health inequalities

• Synthetic Estimates- 21.1% adults smokers (Eng.26%)Boston and Lincoln LAs’ rates significantly higher than national average.

• 10% patients with LTC in Boston, East Lindsey and Skegness and Coast clusters smoking status not recorded

• 20% & 15%,resp., patients where smoking status known in Boston and Skegness and Coast clusters not offered smoking cessation

• Need to - increase awareness and referrals - increase cessation services in Practices and Pharmacies - address differences in prescribing NRT/drug treatments

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Longer Term Implications: Lifestyles- Obesity(1)

• Being obese - increases risk of wide range of diseases - reduces life expectancy by 9 yrs on ave.

• 30.8% adult pop. Obese (sig higher Eng. ave.21.8%)•Boston ……•Boston, E.Lindsey and Lincoln LAs sig. worse rates re. healthy eating (19.3%,21.6% & 18% resp. Eng 23.8%)

•Active People Survey – Lincs one of least active counties in the Country•Boston and Sth.Holland LAs two of least active Districts

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Longer Term Implications: Lifestyles- Obesity(2)

Data based on measurements 2007 for approx.half (7,676)children within the target group.

• Overall 31% of children in Lincolnshire measured as overweight

•Year Reception – 9% of children obese•Year 6 17% of children obese.

Nationally suggested that, as response rate increases the higher apparent prevalence of obesity, more closely approaching true prevalence.

Significant implication for all LAs on changing behaviour and recognition/acceptance by individuals and families that obesity is a problem!

(New national obesity strategy due)

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Reflection on LincolnshireSummary of Key Points (1)

By comparison to national and county averages – doing quite well… but no room for complacency :

Boston life expectancy for males is significantly worse than a

national averagePremature deaths for males is significantly worse than

national averageLifestyle information – healthy eating and physical

activity are the lowest

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Reflection on LincolnshireSummary of Key Points (2)

As well, remember: Population growth and aging Smoking and obesity and the impact of obesity Maintaining progress on teenage pregnancy and improve STI service

usage by highest risk groups Preventive screening – infections, childhood immunisations If nothing changes projected costs will be unaffordable in £ terms and

unacceptable in health and well being terms Reallocation of resource is improving local funding but coastal cluster is

still underfunded

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Commissioning for OutcomesSome key challenges

Tensions relate to need to balance: - Better outcomes and effectiveness - Equality and equity - Benefits to service users (personal health) and to population outcomes

(population health) Consideration also be given to : - Result longevityNeed for ‘balanced portfolio’ also encompasses: Different timescales, i.e. short term, often ‘fire-fighting’, and longer term, The “bigger picture” with prevention and promotion The traditional and innovative, with established and new providers. Not only configured around the needs, but also the preferences, of the ‘citizen’. - Key part to play, in that outputs and outcomes influenced by their attitudes and

behaviours knowledge,.