GWENT

2011

Annual Report of theDirector of Public Health

Our Healthy Future?

Acknowledgements I would like to thank everyone who helped to produce this first Annual Report from the Director of Public Health for Aneurin Bevan Health Board. I would like to especially thank:

• AB/Gwent Public Health Team • Public Health Wales Observatory • Public Health Wales Health Protection Team (Gwent) • Public Health Wales Environmental Health Team • Gwent Dental Public Health Team

In addition I would like to thank all the individuals who have allowed their images to be used for this publication. I would also like to pay tribute to the following individuals who have supported Public Health in Gwent since the last NHS reorganisation in 2003. Local Public Health Directors 2003 – 2009

Blaenau Gwent

Torfaen Monmouthshire Newport Caerphilly

Dr Jane Layzell

Mr Nigel Monaghan Dr Hugo van Woerden Ms Sandra Cairney Dr Subu Iyer Dr Sarah Aitken Dr Jane Layzell

Dr Laurence Hamilton-Kirkwood

Dr Marysia Hamilton-Kirkwood

Dr Gill Richardson

Dr Jenny Harries

Dr Chris Potter

Dr Chris Potter

Copyright © 2011 Aneurin Bevan Health Board

All rights reserved. No part of this report may be reproduced in any form or by any means without written permission. (Any unauthorised copying without prior permission will constitute an infringement of copyright.) Copyright in the typographical arrangement, design and layout belongs to Aneurin Bevan Health Board / Gwent Public Health Team.

Contents Page number Chapter 1 Setting the scene

1

Chapter 2 Babies and pre-school aged children

10

Chapter 3 Children and young people

25

Chapter 4 Adults

37

Chapter 5 Older people

49

Chapter 6 Frail people

58

Chapter 7 Public Health challenges

65

Chapter 8 Public Health support for healthcare services

72

References

75

Appendix Summary of key statistics for Gwent

76

Technical supplement (available to download from Aneurin Bevan Health Board website)

Director of Public Health Annual Report: Chart book Inequalities in mortality in Aneurin Bevan Health Board: interim

release to support Director of Public Health annual reports

List of figures 1.0 Driver diagram example – low birth weight as an indicator for

babies born healthy

2

1.1 Map showing the most and least deprived Lower Super Output Areas (LSOAs) in Gwent

4

1.2 Mortality from all causes in males aged under 75 years

7

1.3 Mortality from all causes in females aged under 75 years

7

1.4 Death rate in people aged under 75 per 100,00 resident population, by local authority area, 2007

8

2.0 Low birth weight babies as a percentage of singleton live births: 1998-2007

11

2.1 Low birth weight babies as a percentage of singleton live births in Gwent Middle Super Output Areas (MSOAs) : 1998-2007

11

2.2 Trends in childhood vaccine uptake rates in Aneurin Bevan Health Board: Quarter 1 2004 – Quarter 2 2010

13

2.3 Variation in oral health in five-year old children within Gwent: 2005-06

14

2.4 Location of injuries as a rate per 1,000 population in Wales: 2004

16

2.5 Breastfeeding at birth as a percentage of live births by Health Board: 2009

17

2.6 Breastfeeding at birth as a percentage of live births by locality: 2009

17

2.7 Diagram showing the relationships between outcome indicators, main determinants/causes and the area of focus for partnership to help ensure babies are born healthy

21

2.8 Diagram showing the relationships between outcome indicators, main determinants/causes and the area of focus for partnership to help ensure pre-school children are safe, healthy and develop their potential

22

3.0 Uptake of teenage 3 in 1 booster by age 16

26

3.1 Uptake of MMR (1 and 2) immunisation

27

3.2 Rate of teenage conceptions in Gwent localities 28

3.3 Diagram showing the relationships between outcome indicators,

main determinants/causes and the area of focus for partnership to help ensure school aged children and young people are safe, healthy and equipped for adulthood

34

4.0 Death rate (EASR per 100,000) from all causes

37

4.1 Death rate (EASR per 100,000) from cancers

37

4.2 Death rate (EASR per 100,000) from circulatory diseases

38

4.3 Death rate (EASR per 100,000) from respiratory diseases

38

4.4 Premature death rate (EASR 100,000) from coronary heart disease (under 75 years)

39

4.5 Diagram showing the relationships between outcome indicators, main determinants/causes and the areas of focus for partnership to help ensure working age adults live healthier lives for longer

46

5.0 Health Board trends in Seasonal Influenza vaccination uptake (%) among patients over 65 years

50

5.1 Emergency hospital admission rates (EASR per 100,000) among people aged under 75 years

52

5.2 Emergency hospital admission rates (EASR per 1,000) among people aged under 75 years, by local authority area

53

5.3 Diagram showing the relationships between outcome indicators, main determinants/causes and the areas of focus for partnership to help ensure older people age well into their retirement.

56

6.0 Excess winter deaths by age group in Wales, 1991/92 to 2008/09

61

6.1 Excess winter deaths (EWD) index for persons resident in Wales: August 2009 to July 2010

61

6.2 Excess winter deaths by underlying health cause 2005/06 to 2007/08

62

6.3 Diagram showing the relationships between outcome indicators, main determinants/causes and the areas of focus for partnership to help ensure that frail people are happily independent

63

List of tables 1.0 Growing up in Gwent; 100 born in Blaenau Gwent and 100 born

in Monmouthshire. If nothing changes this is what is likely to happen to them.

6

2.0 Infant mortality rates in Gwent and Wales (per 1000): 2004 -2008

10

2.1 Congenital anomalies as a rate per 10,000 births: 1998 -2008

10

3.0 Conceptions in females aged under 16 years (3 year average) 2005-2007

28

4.0 Percentage of adults reporting particular health conditions amongst the population of Aneurin Bevan Health

41

4.1 Lifestyle patterns and health outcomes shown at Local Authority Level

42

4.2 Overview of screening programmes

44

5.0 Health Board Seasonal Influenza vaccination uptake (%) among patients over 65 years

50

7.0 Notifications of infection in the Aneurin Bevan Health Board area

67

7.1 Activity by Local Authority Area

69

7.2 Activity by Health Board Area

69

Foreword The new Aneurin Bevan Health Board was formed in October 2009 bringing together Newport, Caerphilly, Torfaen, Blaenau Gwent and Monmouthshire Local Health Boards and the Gwent Healthcare NHS Trust. In January 2010 the post of Director of Public Health was created to cover all five previous local health boards’ areas for the first time since 2002. Dr Eddie Coyle was the post holder then and together with his team he had worked tirelessly to promote the importance of public health. This was followed in 2003 with the appointment of five Local Public Health Directors and their teams for the individual Local Authority / Local Health Board areas. It is a challenge indeed to follow in these footsteps, building on the strong foundations established, to fulfil the legacy of strong local partnership working, whilst facing all the new opportunities for integrated Gwent-wide work. The integration of the former NHS Trusts into the new Health Boards also means that the new Directors of Public Health and team take on new responsibilities for promoting public health action throughout hospital and community services. It is a privilege to be assuming this role in an organisation that bears the name of the founding father of the modern National Health Service, Aneurin Bevan (Minister of Health 1945–1951). He, like Dr. Coyle and the Local Public Health Directors that followed, was inspired to address the poverty and injustice that leads to people missing out on the foundational requirements for health. These include high quality nutrition, housing, education, employment and health and social care services. Integrated efforts starting from health promotion and ill health prevention through to evidence-based treatment and dignified care at the end of life are all parts of the public health pathway across the life-course. The Aneurin Bevan Health Board and all its partners still face the enormous task of addressing the injustice of inequities in life and health expectancy across the Gwent area. People living in socio-economically deprived areas are living shorter and less healthy lives than those who do not. Too many residents still die prematurely from heart disease, strokes and cancers. Many young people are also facing problems with their educational potential unachieved and a lack of meaningful employment opportunities. With their aspirations frustrated, they often turn to alternative lifestyles which may include the misuse of drugs and alcohol. Ultimately this can destroy individuals and communities. The cycle of dependency which can result from poverty, worklessness and low expectations must be urgently tackled through working closely together with our Local Authority and voluntary sector colleagues. Together we must understand that every effort made towards the promotion and protection of health and ill health prevention will reap enormous rewards in terms of people and communities achieving their full potential as disease patterns are changed, hospital admissions are lessened and early deaths are avoided. The Chief Medical Officer for Wales Dr Tony Jewell has launched a Public Health Strategic Framework, “Our Healthy Future” which outlines key areas for action. Whether or not the residents served by the Aneurin Bevan Health Board and the five Local Authorities will indeed have a healthier future is dependent, not just on

their personal lifestyle choices, but also on their life chances, the environments in which they live, work and play and the extent to which partners collectively invest expertise, time and money towards the vision. This Annual Report sets the scene for our work over the next few years and will serve as a baseline upon which we can measure progress. Any lasting improvement in the health for our population will only happen if there is genuine and dedicated partnership working using effective and prioritised public health actions as the basis for change. It is my opinion that our residents deserve nothing less. Dr Gill Richardson MBChB, MRCGP, MPH, MFPHMI, FFPH, M Inst LM

Executive Summary This first annual report of the Director of Public Health of Aneurin Bevan Health Board (ABHB) will serve as a baseline for future years to measure progress in improving the health of our residents. It will describe this in terms of health through the life course as outlined in the Wales Chief Medical Officer’s recently published public health strategic framework ‘Our Healthy Future’. Our vision is for ‘A healthier Gwent for all’. “Gwent” is used as the collective and historical description of the area served by Aneurin Bevan Health Board. To achieve this vision our aspirations are that in Gwent:

• Babies are born healthy • Pre-school children are safe, healthy and develop their potential • Children and young people are safe, healthy and equipped for adulthood • Working age adults live healthier lives for longer • Older people age well in to their retirement • Frail people are happily independent Inequities in health and wellbeing must be our primary focus. People who come from more affluent areas tend to have better early life experiences, better education and subsequent occupational status. Those from deprived areas often have worse lifestyle patterns and behaviours, living and working conditions and increased exposure to other environmental risks. Many more small areas (known as ‘Lower Super Output Areas’) across ABHB are amongst the most deprived fifth in Wales than are in the least deprived fifth. There is an inequity in life expectancy of several years between our least and most disadvantaged areas. Other population groups across ABHB may also experience adverse health outcomes. These include gypsy-travellers, minority ethnic communities, prisoners and probationers, homeless people, asylum seekers, refugees, and people with substance misuse problems. For each life stage we have prioritised the most important outcome indicators and underlying determinants to form the basis for prioritised public health actions. Statutory Partnerships may use these priorities to inform the development of their strategies and plans. Key issues for babies born in Aneurin Bevan Health Board include:

• young women should be encouraged to have the MMR vaccination if not protected, to reduce rubella associated congenital problems for babies

• preterm births accounting for almost a third of deaths after a live birth in Wales • less affluent localities and small areas have relatively high levels of low birth

weight

• mothers in Wales being more likely to smoke and less likely to give up than in other UK countries - smoking in pregnancy is associated with low birth weight and preterm birth

• efforts to ensure adequate nutrition including folic acid, help to quit smoking, and address alcohol intake should be midwifery priorities for the group

Key issues for infants and pre-school children include:

• all localities except Monmouthshire have lower levels of breastfeeding at birth than the Wales average

• MMR vaccination uptake across ABHB needs to be improved • there are socio economic gradients in childhood injuries centred around the

home • high levels of decayed teeth in 5 year olds especially in deprived areas Key issues for children and young people include:

• low teenage ‘booster’ immunisation and full-course MMR uptake by late adolescence

• 12 year olds in ABHB now have the worst teeth in Wales • the high proportion of young people who have been drunk frequently; are

overweight; do not eat enough fruit and vegetables or take enough exercise and the low proportion reporting they have excellent or good health and life satisfaction

• the high proportion of 15 year old girls who report they have had sex without a condom

• the relatively high rate of road traffic collisions with young pedestrians and cyclists

• self-harm in adolescent girls and suicide amongst young men • the steep social gradient in health inequities seen in most key health issues Key issues for working age adults include:

• wide inequities in mental and physical health between localities and between small areas within localities across ABHB

• higher mortality as small areas become increasingly more deprived – there is a five-fold difference between the two small areas with the highest and lowest premature circulatory disease mortality in ABHB

• each year ABHB has more than 1,000 deaths caused by smoking, around 10,000 hospital admissions linked to alcohol and around 400 hospital admissions due to other drugs

• almost a third of adults in some localities are regular smokers adversely influencing their healthy life expectancy

• almost half of all adults drink alcohol above the recommended levels and over a quarter binge drink

• more than half the population are either overweight or obese in all localities of ABHB reaching almost two-thirds in Blaenau Gwent

• low levels of physical activity and fruit and vegetable intake • uptake of cervical screening needs to be improved particularly in young women

living in deprived areas

• improved uptake for bowel and breast cancer screening in minority ethnic communities is also needed

Some key issues for older people include:

• the conditions causing ill-health and mortality such as cardiovascular disease and cancers display marked inequities across ABHB. Other common health problems such as dementia and falls continue to rise in line with an increasingly elderly population

• older people are at increased risk of hospitalisation or death from influenza and pneumococcal disease. Seasonal influenza vaccination uptake in ABHB could be considerably higher among people over 65 years (and in vulnerable groups under 65 years)

• the emergency hospital admission rate is higher than the Wales average for all localities except Monmouthshire. Blaenau Gwent has the second highest rate in Wales

• depression and social isolation affect about one in seven people over the age of 65. Suicide rate starts rising steeply after the age of 70 in men

• breast screening reduces mortality from breast cancer by about 30 per cent for women between 50 and 65 years, and by about 45 percent for women between 65 to 69 years

Some key health issues for frail people include: • frail people are vulnerable and less resilient to external factors which may

result in loss of independence. Appropriate housing conditions, transport, neighbourhood design and the built environment will determine whether frail people are able to participate in community life safely and access services, family, social networks and leisure. These have a major effect on mental and social wellbeing. Financial security or poverty has an impact on social and lifestyle patterns, home safety, material comfort, and ability to obtain care and assistance

• over 44% of older people living alone - up to 48% in Blaenau Gwent • in Wales, around 80% of excess winter deaths involve people aged 75 years or

over. Last winter, excess winter deaths in ABHB were 17% higher compared to non-winter months. Winter excess death rate and emergency hospital admissions correlate with home and external temperature, influenza activity, income poverty, pre-existing cardiovascular and respiratory disease and risk of falls including unaddressed visual problems. Many older people are affected by fuel poverty

• there is a need for client involvement in planning and co-ordination of end of life and palliative care

Public Health Challenges There is a need to guard against emerging and re-emerging health threats from infectious diseases, environmental hazards and other health protection issues. The current financial crisis also presents challenges to health and wellbeing. Communicable diseases remain important for health as evidenced by the outbreak of Legionnaire’s disease in 2010.

Environmental advice activities are relatively demanding. So far this year, Public Health Wales has advised on considerably more environmental health cases in ABHB than any other Health Board. Sustainable development is closely aligned to public health and improving the health of populations. The Aneurin Bevan Health Board is a signatory of the Welsh Assembly Government’s Sustainable Development Charter. Key issues for health and health inequities include sustainable local economies, transport, access to services and sustainable homes for all. The pressures of historical and long-lasting deprivation together with the current financial debt and uncertainty will present significant challenges for health in the years to come. It is imperative that investment in improving the population’s health continues. Prevention is better and cheaper than cure and that is why we need to invest sufficiently in preventing the preventable. Public Health support for Healthcare Services With the support of Public Health Wales NHS Trust, Aneurin Bevan Health Board Public Health Team supports health care services locally through contributing specialist skills to • assess the population-based health needs for services • assess the evidence of effectiveness of interventions and models of services • assess the quality and equity of services • evaluate services • protect and promote health and prevent disease and contribute to quality of

services The Public Health local team has completed five Needs Assessments for localities in 2010 to inform Health Social Care and Wellbeing strategies and Children & Young People plans. Working on orthopaedics issues in south Wales, we have contributed to some major reviews and supported the ABHB musculoskeletal programme. Other key activities include inputs to the obesity service pathway and other locality preventive obesity initiatives, projects funded by the British Heart Foundation and Big Lottery. Important smoking cessation initiatives are ongoing in this core public health service through the local Public Health Wales ‘Stop Smoking Wales’ Team. We also contributed to Health Board services through pharmaceutical public health and dental public health expertise. The Public Health Wales Primary Medical Care Advisory Team contributed to primary care development. A needs assessment and review of prison health services was conducted by team members in Monmouthshire locality for Usk and Prescoed prisons. Public Health has senior representation on the ABHB Area Planning Board for substance misuse. Drug and alcohol prevention and treatment services are important to get right as these issues can destroy the health and wellbeing of individuals, families and communities.

Conclusion The extent to which the public health issues will be addressed as priorities in Aneurin Bevan Health Board will depend on the extent to which investment is maintained and built upon as well as the extent to which partners merge priorities and enhance efforts in key priority areas. Future Annual Reports will outline progress.

Crynodeb Gweithredol Bydd yr adroddiad blynyddol cyntaf hwn gan Gyfarwyddwr Iechyd y Cyhoedd Bwrdd Iechyd Aneurin Bevan (BIAB) yn llinell sylfaen ar gyfer y blynyddoedd i ddod o ran mesur hynt y broses o wella iechyd ein trigolion. Bydd yn disgrifio hyn yn nhermau iechyd gydol oes fel yr amlinellir yn fframwaith strategol iechyd y cyhoedd Prif Swyddog Meddygol Cymru a gyhoeddwyd yn ddiweddar sef 'Ein Dyfodol Iach'. Ein gweledigaeth yw 'Gwent iachach i bawb'. Defnyddir "Gwent" fel y disgrifiad cyffredinol a hanesyddol o'r ardal a wasanaethir gan Fwrdd Iechyd Aneurin Bevan. Er mwyn cyflawni'r weledigaeth hon, rydym yn anelu at weld y canlynol yng Ngwent:

• Babanod iach yn cael eu geni • Plant cyn oed ysgol sy'n ddiogel, yn iach ac yn datblygu i'w potensial • Plant a phobl ifanc sy'n ddiogel, yn iach ac yn barod i fod yn oedolion • Oedolion oedran gweithio sy'n byw bywydau iachach am hirach • Pobl hŷn sy'n heneiddio'n dda i mewn i'w hymddeoliad • Pobl fregus sy'n annibynnol ac yn mwynhau bod felly Rhaid i ni ganolbwyntio ar anghydraddoldebau o ran iechyd a lles yn bennaf. Mae'r bobl hynny sy'n dod o ardaloedd mwy llewyrchus yn dueddol o fod wedi cael profiadau gwell yn gynnar yn eu bywydau ynghyd â gwell addysg a statws galwedigaethol dilynol. Yn aml mae gan y rheini o ardaloedd difreintiedig batrymau ffordd o fyw ac ymddygiad gwaeth, amodau byw a gweithio gwaeth ac maent yn fwy agored i risgiau amgylcheddol eraill. Mae llawer mwy o ardaloedd bach (sef 'Ardaloedd Cynnyrch Ehangach Is') ledled BIAB ymhlith y pumed mwyaf difreintiedig yng Nghymru o gymharu â'r pumed lleiaf difreintiedig. Ceir anghydraddoldeb o ran disgwyliad oes o sawl blwyddyn rhwng ein hardaloedd lleiaf a mwyaf difreintiedig. Gall grwpiau eraill o'r boblogaeth ledled BIAB hefyd brofi canlyniadau iechyd niweidiol. Ymhlith y rhain mae teithwyr-sipsiwn, cymunedau o leiafrifoedd ethnig, carcharorion a'r rheini sydd ar brawf, pobl ddigartref, ceiswyr lloches, ffoaduriaid a phobl â phroblemau camddefnyddio sylweddau. Ar gyfer pob cyfnod mewn bywyd rydym wedi blaenoriaethu'r dangosyddion pwysicaf o ran canlyniadau a phenderfynyddion sylfaenol i ffurfio sylfaen camau gweithredu ar iechyd y cyhoedd â blaenoriaeth. Gall Partneriaethau Statudol ddefnyddio'r blaenoriaethau hyn i lywio'r gwaith o ddatblygu eu strategaethau a'u cynlluniau.

Ymhlith y materion allweddol i fabanod a gaiff eu geni yn ardal Bwrdd Iechyd Aneurin Bevan mae:

• dylid annog merched ifanc i gael brechiad MMR, os nad ydynt wedi'u diogelu, er mwyn lleihau problemau cynhwynol sy'n gysylltiedig â rwbela ymhlith babanod

• mae genedigaethau cynamserol yn cyfrif am bron i draean o'r marwolaethau ar ôl genedigaeth fyw yng Nghymru

• mae gan ardaloedd ac ardaloedd bach llai llewyrchus lefelau cymharol uchel o bwysau geni isel

• mae mamau yng Nghymru yn fwy tebygol o ysmygu ac yn llai tebygol o roi'r gorau iddi nag yn unman arall yn y DU - mae ysmygu tra'n feichiog yn gysylltiedig â phwysau geni isel a genedigaethau cynamserol

• dylai ymdrechion i sicrhau maeth digonol gan gynnwys asid ffolig, help i roi'r gorau i ysmygu a mynd i'r afael â chymeriant alcohol, fod yn flaenoriaethau bydwreigiaeth i'r grŵp

Ymhlith y materion allweddol i fabanod a phlant cyn ysgol mae:

• mae gan bob ardal heblaw am Sir Fynwy lefelau is o fwydo ar y fron adeg geni na chyfartaledd Cymru

• mae angen cynyddu'r nifer sy'n cael brechiad MMR ledled BIAB • ceir graddiannau economaidd-gymdeithasol o ran anafiadau mewn plentyndod

sy'n digwydd gartref • lefelau uchel o ddannedd pwdr mewn plant 5 oed yn enwedig mewn ardaloedd

difreintiedig Ymhlith y materion allweddol i blant a phobl ifanc mae:

• nifer isel yn cael imiwneiddiad atgyfnerthu ar gyfer pobl ifanc yn eu harddegau a chwrs llawn o MMR erbyn iddynt gyrraedd blaenlencyndod hwyr

• erbyn hyn mae gan blant 12 oed yn BIAB y dannedd gwaethaf yng Nghymru • y gyfran uchel o bobl ifanc sydd wedi bod yn feddw'n rheolaidd; sydd dros

bwysau; nad ydynt yn bwyta digon o ffrwythau a llysiau; nad ydynt yn gwneud digon o ymarfer corff a'r gyfran isel sy'n nodi bod ganddynt iechyd ardderchog neu dda a boddhad bywyd

• y gyfran uchel o ferched 15 oed sy'n nodi eu bod wedi cael rhyw heb ddefnyddio condom

• y gyfradd gymharol uchel o wrthdrawiadau traffig ar y ffyrdd yn ymwneud â cherddwyr a seiclwyr ifanc

• hunan-niwed ymhlith merched yn eu harddegau cynnar a hunanladdiad ymhlith dynion ifanc

• y graddiant cymdeithasol serth o ran anghydraddoldebau iechyd a welir yn y rhan fwyaf o faterion iechyd allweddol

Ymhlith y materion allweddol i oedolion oedran gweithio mae:

• anghydraddoldebau eang o ran iechyd meddwl ac iechyd corfforol rhwng ardaloedd a rhwng ardaloedd bach o fewn ardaloedd ledled BIAB

• marwoldeb uwch wrth i ardaloedd bach fynd yn fwyfwy difreintiedig - ceir pum gwaith yn fwy o wahaniaeth rhwng y ddwy ardal fach â'r marwoldeb uchaf ac isaf o ganlyniad i glefyd cylchredol cynamserol yn BIAB

• bob blwyddyn mae BIAB yn gweld mwy na 1,000 o farwolaethau o ganlyniad i ysmygu, tua 10,000 o dderbyniadau i'r ysbyty mewn perthynas ag alcohol a thua 400 o dderbyniadau i'r ysbyty o ganlyniad i gyffuriau eraill

• mae bron i draean o'r oedolion mewn rhai ardaloedd yn ysmygwyr rheolaidd sy'n cael effaith niweidiol ar eu disgwyliad oes iach

• mae bron i hanner yr oedolion yn yfed mwy o alcohol na'r hyn a argymhellir ac mae dros chwarter yn goryfed

• mae mwy na hanner y boblogaeth naill ai dros bwysau neu'n ordew ymhob rhan o BIAB gan gyrraedd bron i ddwy ran o dair ym Mlaenau Gwent

• lefelau isel o weithgarwch corfforol ac o ran bwyta ffrwythau a llysiau • mae angen gwella cyfraddau sgrinio serfigol yn enwedig ymhlith merched ifanc

sy'n byw mewn ardaloedd difreintiedig • mae hefyd angen gwella cyfraddau sgrinio canser y coluddyn a chanser y fron

ymhlith cymunedau lleiafrifoedd ethnig Ymhlith rhai o'r materion allweddol i bobl hŷn mae:

• dengys cyflyrau sy'n achosi salwch a marwoldeb megis clefyd cardiofasgwlaidd a chanserau anghydraddoldebau nodedig ledled BIAB. Mae problemau iechyd cyffredin eraill megis demensia a syrthio yn parhau i gynyddu yn unol â phoblogaeth fwyfwy hŷn

• mae pobl hŷn yn wynebu mwy o risg o gael eu derbyn i'r ysbyty neu o farw yn sgîl ffliw a chlefyd niwmococol. Gallai nifer y bobl dros 65 oed (a'r rheini mewn grwpiau agored i niwed o dan 65 oed) sy'n cael brechlyn ffliw tymhorol yn BIAB fod yn sylweddol uwch

• mae cyfradd y derbyniadau brys i'r ysbyty yn uwch na chyfartaledd Cymru ymhob ardal heblaw am Sir Fynwy. Mae gan Flaenau Gwent y gyfradd uchaf ond un yng Nghymru

• mae iselder ac ynysu cymdeithasol yn effeithio ar tua un o bob saith o bobl sydd dros 65 oed. Mae cyfraddau hunanladdiad yn dechrau cynyddu gryn dipyn ar ôl 70 oed mewn dynion

• mae sgrinio'r fron yn lleihau cyfraddau marwoldeb o ganser y fron tua 30 y cant ymhlith merched rhwng 50 a 65 oed, a thua 45 y cant ymhlith merched rhwng 65 a 69 oed

Ymhlith rhai o'r materion iechyd allweddol i bobl fregus mae: • mae pobl fregus yn agored i niwed ac yn llai gwydn i ffactorau allanol a all

arwain at golli annibyniaeth. Bydd natur briodol amodau tai, trafnidiaeth, cynllun cymdogaeth a'r amgylchedd adeiledig oll yn pennu p'un a all pobl fregus gyfrannu at fywyd cymunedol mewn ffordd ddiogel a chael gafael ar wasanaethau, teulu, rhwydweithiau cymdeithasol a chyfleoedd hamdden. Caiff y rhain gryn effaith ar les meddwl a lles cymdeithasol. Mae sicrwydd ariannol neu dlodi yn effeithio ar batrymau cymdeithasol a ffordd o fyw, diogelwch yn y cartref, bod yn gysurus yn faterol, a'r gallu i dderbyn gofal a chymorth

• dros 44% o bobl hŷn yn byw ar eu pen eu hunain - i fyny i 48% ym Mlaenau Gwent

• yng Nghymru, mae tua 80% o farwolaethau ychwanegol y gaeaf yn ymwneud â phobl 75 oed neu drosodd. Y gaeaf diwethaf, roedd marwolaethau ychwanegol y gaeaf yn BIAB 17% yn uwch nag yn ystod adegau eraill o'r flwyddyn. Mae cyfraddau marwolaethau ychwanegol y gaeaf a derbyniadau brys i'r ysbyty yn gysylltiedig â thymheredd y cartref a'r tymheredd y tu allan, achosion o ffliw, tlodi incwm, clefydau cardiofasgwlaidd ac anadlol sy'n bodoli eisoes a'r risg o syrthio gan gynnwys problemau gweld nad ymdriniwyd â hwy. Mae tlodi tanwydd yn effeithio ar lawer o bobl hŷn

• mae angen cynnwys y cleient wrth gynllunio a chydgysylltu gofal diwedd bywyd a gofal lliniarol

Heriau Iechyd y Cyhoedd Mae angen gochel rhag bygythiadau iechyd newydd a'r rheini sy'n ailymddangos mewn perthynas â chlefydau heintus, peryglon amgylcheddol a materion diogelu iechyd eraill. Mae'r sefyllfa economaidd sydd ohoni hefyd yn peri heriau yng nghyd-destun iechyd a lles. Mae clefydau trosglwyddadwy yn parhau i fod yn bwysig i iechyd fel y gwelwyd gan yr achosion o glefyd y Llengfilwyr yn 2010. Mae gweithgareddau cyngor amgylcheddol yn gymharol heriol. Hyd yn hyn eleni, mae Iechyd Cyhoeddus Cymru wedi rhoi cyngor ar nifer sylweddol mwy o achosion iechyd yr amgylchedd yn BIAB nag mewn unrhyw Fwrdd Iechyd arall. Mae cysylltiad agos rhwng datblygu cynaliadwy ac iechyd y cyhoedd a gwella iechyd poblogaethau. Mae Bwrdd Iechyd Aneurin Bevan wedi llofnodi Siarter Datblygu Cynaliadwy Llywodraeth Cynulliad Cymru. Ymhlith y materion allweddol ar gyfer iechyd ac anghydraddoldebau iechyd mae economïau lleol cynaliadwy, trafnidiaeth, gallu cael gafael ar wasanaethau a thai cynaliadwy i bawb. Bydd pwysau amddifadedd hanesyddol a pharhaus ynghyd â'r ddyled ariannol a'r ansicrwydd presennol yn peri heriau sylweddol i iechyd yn y blynyddoedd i ddod. Mae'n hanfodol ein bod yn parhau i fuddsoddi yn y gwaith o wella iechyd y boblogaeth. Gwell atal clwy na'i wella a dyna pam mae angen i ni fuddsoddi digon mewn atal yr hyn y gellir ei atal. Cefnogaeth Iechyd Cyhoeddus i Wasanaethau Gofal Iechyd Gyda chefnogaeth Ymddiriedolaeth GIG Iechyd Cyhoeddus Cymru, mae Tîm Iechyd y Cyhoedd Bwrdd Iechyd Aneurin Bevan yn cefnogi gwasanaethau gofal iechyd yn lleol drwy gyfrannu sgiliau arbenigol i • asesu'r anghenion iechyd ar sail poblogaeth am wasanaethau • asesu tystiolaeth o effeithiolrwydd ymyriadau a modelau gwasanaethau • asesu ansawdd a natur gyfartal gwasanaethau • gwerthuso gwasanaethau • diogelu a hybu iechyd ac atal clefyd a chyfrannu at ansawdd gwasanaethau Mae'r tîm Iechyd y Cyhoedd lleol wedi cwblhau pum Asesiad o Anghenion ar gyfer ardaloedd yn 2010 er mwyn llywio strategaethau Iechyd, Gofal Cymdeithasol a Lles a chynlluniau Plant a Phobl Ifanc.

Gan weithio ar faterion orthopedig yn ne Cymru, rydym wedi cyfrannu at rai adolygiadau mawr ac wedi cefnogi rhaglen gyhyrysgerbydol BIAB. Ymhlith y gweithgareddau allweddol eraill mae cyfrannu at lwybr gwasanaeth gordewdra a mentrau gordewdra ataliol eraill yn yr ardal, sef prosiectau wedi'u hariannu gan Sefydliad Prydeinig y Galon a'r Loteri Fawr. Mae mentrau rhoi'r gorau i ysmygu pwysig yn parhau yn y gwasanaeth iechyd cyhoeddus craidd hwn drwy Dîm 'Dim Smygu Cymru' lleol Iechyd Cyhoeddus Cymru. Gwnaethom hefyd gyfrannu at wasanaethau'r Bwrdd Iechyd ar ffurf arbenigedd fferyllol a deintyddol ym maes iechyd y cyhoedd. Cyfrannodd Tîm Cynghori Gofal Meddygol Sylfaenol Iechyd Cyhoeddus Cymru at y gwaith o ddatblygu gofal sylfaenol. Cynhaliwyd asesiad o anghenion ac adolygiad o wasanaethau iechyd carchardai gan aelodau tîm yn Sir Fynwy ar gyfer carchardai Brynbuga a Phrescoed. Mae gan Iechyd Cyhoeddus uwch gynrychiolaeth ar Fwrdd Cynllunio Ardal BIAB ar gyfer camddefnyddio sylweddau. Mae'n bwysig cael gwasanaethau atal a thrin cyffuriau ac alcohol yn iawn oherwydd gall y problemau hyn ddinistrio iechyd a lles unigolion, teuluoedd a chymunedau. Casgliad Bydd y graddau yr eir i'r afael â materion iechyd y cyhoedd fel blaenoriaethau ym Mwrdd Iechyd Aneurin Bevan yn dibynnu ar y graddau y parheir i fuddsoddi ac yr ychwanegir at y buddsoddiad hwnnw yn ogystal â'r graddau y bydd partneriaid yn cyfuno blaenoriaethau ac yn gwella ymdrechion mewn meysydd blaenoriaeth allweddol. Bydd Adroddiadau Blynyddol yn y dyfodol yn amlinellu'r cynnydd a wneir.

Setting the scene

Chapter 1

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Setting the Scene Our vision for public health in Gwent ‘Our Healthy Future’1, the Welsh Assembly Government’s public health strategic framework, provides a strategic framework for public health action in Wales until 2020. In response to ‘Our Healthy Future’, I have recently published a local Public Health Strategic Framework for Aneurin Bevan Health Board ‘A Healthier Gwent for All’. The framework sets out the vision, aspirations, priorities for action, delivery system and how progress will be measured to improve the health and wellbeing of the population. This Annual Report and the Framework uses a ‘health through the life course’ approach as a structure. This is in recognition that disadvantage starts before birth and accumulates throughout the life course. Adopting the life course approach to public health is useful for a number of reasons: • the people, their needs and the opportunities for public services to intervene

are different at different stages in life • by identifying and acting on the needs specific to different life stages we can

help to prevent inequities in health • different front line services and professional groups are responsible for

providing care to people at the different stages of life – this has important implications for improved integration of overlapping services for particular population groups and for age-related transition through service systems

Differences in people’s health outcomes stem from their early life experiences, education and occupational status, lifestyle patterns and behaviours, social and family influences, living and working conditions and other environmental risks which they may encounter. Disadvantage starts before birth and accumulates throughout life. Public health action to reduce health inequalities must start before birth and be followed through the life of the child. This is vital to break the link between early disadvantage and poor outcomes throughout life. Meanwhile, there is much that can be done to improve the lives and health of people at every stage in their life. Services that promote the health, well being and independence of older people can prevent or delay the need for more intensive or institutional care and make a significant contribution to reducing health inequalities. Health outcomes depend on more than just the absence of disease or illness. Health should be viewed as a positive personal and social resource that helps to satisfy aspirations, fulfil needs, contribute to society and adjust to a changing environment. The following sections of my report cover important health outcomes at critical points in our lives. For each life stage I suggest some indicators that tell

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us about health within our population and highlight the main factors that affect health. How we have identified needs and priorities The Welsh Assembly Government has been advocating that health boards, local authorities and their partners adopt a outcomes-based approach – Results Based Accountability (RBA) – as the new framework for planning and monitoring public services. The advantage of RBA is that it provides a clear line of sight from the outcomes, to the causes and then to the priorities for action. To support the application of Results Based Accountability the Aneurin Bevan Health Board and Gwent Public Health Team have recommended a set of outcomes at critical points across the life course: • Babies are born healthy • Pre-school children are safe, healthy and develop their potential • Children and young people are safe, healthy and equipped for adulthood • Working age adults live healthier lives for longer • Older people age well in to their retirement • Frail people are happily independent. In this report we have started to identify the important outcome indicators for each of these stages (for example, low birth weight is a good indicator to tell us whether babies are being born healthy). Over the last year we have started to identify the main determinants of these outcomes which we established through a review of research literature and explored using ‘driver diagrams’ (see example, figure 1.0, below). Figure 1.0: Driver diagram example - low birth weight as an indicator for babies born healthy

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For each life stage we have identified and prioritised the most important outcome indicators and underlying determinants of these outcomes to form the basis of prioritised public health actions. The most important indicators and underlying determinants were identified using the following criteria: • Impact – the effect on health functioning in terms of size and severity; whether

the impact is short or long term; the opportunity for prevention/early intervention; whether the issue is significantly better or worse than other areas/national average; and will tackling this issue affect other health outcomes.

• Changeability – how strong is the evidence of effectiveness; is the change aligned to the national or local drivers; will the change be socially and culturally acceptable; is the change financially feasible; what will be the return on investment; can current resources be used differently; and will the change release resources/generate cost savings

As part of the needs assessment the Public Health Team developed a list of priority actions that organisations and partnerships could take forward to make an impact on the identified outcomes. I have recommended that statutory partnerships use these priorities to inform the development of their strategies and plans. I have also recommended that Local Authorities could take these forward through their outcome agreements with the Welsh Assembly Government. We have developed a set of report cards for each life stage which illustrate the clear link between outcomes, indicators, determinants, causes of ill health and evidence based actions. The report cards are incorporated in the Aneurin Bevan Health Board Public Health Strategic Framework. This first Annual Report serves as a baseline for future years to measure progress in improving the population health of our residents. Some key facts about Gwent • ABHB covers the geographical area of Gwent which represents around 8% of

the landmass in Wales. It provides services to 600,000 people which represents 19% of the Welsh population and small numbers of people in England

• Population density in Gwent local authority areas ranges from 104 persons per

square km in Monmouthshire, to 736 persons per square km in Newport.

• Car ownership is relatively low in the upper Gwent valleys areas. Lack of public transport in these areas and rural Monmouthshire is recognised to be a major problem for many people in terms of access to services.

• The resident population in the ABHB area is projected to increase by 9% from 2006 to 2031, typically 2,000 people per year.

• In 2006 there were 45,000 residents aged 75 and over, but by 2031 this will almost double to around 82,000

• The number of births per 1000 women of child bearing age (fertility rate) in 2007 was 59.7, compared with 59.4 for Wales

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• Newport has the largest minority ethnic community population. It is also a Home Office distribution area for Asylum Seekers. Young men from Asian and African countries make up a large proportion of these.

• Economic inactivity ranges from 29.9% in Blaenau Gwent to 20.6% in Monmouthshire.

A summary of key statistics for Gwent are presented in Appendix 1. More detailed data on demography, determinants of health, health services usage, and health status are presented in a technical supplement to this report and available to download from www. Health Inequalities I want to take this opportunity to show you the health inequalities that exist within the area and the challenge we face together with our partners to tackle the underlying determinants of health in our deprived communities. We know that people who come from more affluent areas tend to have a better education, higher paid employment, generally have better health and a longer life expectancy. In contrast people in more disadvantaged areas tend to have worse health, live in difficult circumstances and have a shorter life expectancy. Figure 1.1: A map showing the most and least deprived Lower Super Output Areas (LSOAs) in Gwent

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For the remainder of this section and the technical supplements we have ranked all Lower Super Output Areas (LSOAs) within the Health Board by Welsh Index of Multiple Deprivation 2008 deprivation score and have grouped them into fifths. This means that the distribution of the fifths is specific to Aneurin Bevan Health Board and will differ from Wales and from other health boards. This method of deriving fifths within areas is widely used in analyses of inequalities data in England and allows a more robust analysis at the local level. Any comparisons with other areas should be made with caution as any differences may not only be a difference in the mortality outcome but also a difference in the distribution of deprivation. This method, therefore, is designed to allow analysis of trends in inequalities in mortality within Aneurin Bevan Health Board area and comparison of different causes of mortality. Around 24 per cent of the LSOAs in Aneurin Bevan Health Board area are categorised nationally as being in the most deprived fifth (88 overall), and are shown in the darkest blue. In contrast around 36 per cent of the LSOAs are categorised as being in the top two least deprived fifths (134 overall) shown in the lightest blue. The inequalities technical supplement shows inequalities in mortality and shows trends for the main causes of death and life expectancy for 2001-03 to 2007-09

• Mortality from all causes aged under 75 years (Premature mortality) • Mortality from all causes, all ages • Mortality from circulatory disease • Mortality from respiratory disease • Mortality from cancers

For all of these indicators there are statistically significant differences in mortality between those living in the most and least deprived fifths. Inequities in health determinants These can be most usefully illustrated by following the fortunes of 200 babies born in two different localities. However, it is important to note that there are pockets of deprivation across all the localities in Gwent which are often hidden because they are small and isolated. Table 1.0 highlights the potential difference in life experiences for babies born today in Blaenau Gwent and Monmouthshire. If nothing changes in terms of their very different circumstances concerning, for example, family support, education, future job prospects, predicted adult lifestyle and the security and culture of the communities in which they will grow up, then the table well illustrates the stark differences in health, wealth and wellbeing they will experience in adult life. Overall life expectancy at birth for males in the area covered by ABHB is 77 years, which is comparable to Wales as a whole. However, there is a six year difference in life expectancy when comparing the most and least deprivation quintiles. This represents a male life expectancy of 80 years in the least deprived fifth and 74 in the most deprived. There is a similar pattern for women living in the ABHB area.

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Although the overall female life expectance at birth is 81 years, in the most deprived fifth this is 79 years and in the least deprived it is 85 years. Table1.0: Growing up in Gwent; 100 born in Blaenau Gwent and 100 born

in Monmouthshire. If nothing changes this is what is likely to happen to them:

Blaenau Gwent

Monmouthshire

Home & Family

Will claim Job Seekers Allowance benefit as adults1

6 2

Will be part of a workless lone parent family1

2 1

Education

Will get at least 5 GCSEs at grade A-C2

49 65

As a working age adult will be qualified to NQF level 3 (equivalent to 3 A-levels) or above3

38 62

Will leave full time education at aged 15 without a recognised qualification3

3 1

Work & Income

Will be in employment4 61 71

Will claim key benefits1 24 10

If in employment will become a manager or senior official4

10 20

Lifestyle & Illness

Will claim incapacity benefit (employment and support (ESA)) 1

14 7

Will report a mental health problems5 15 8

Will be smokers5

27 20 Will regularly binge drink5

29 27 Will be overweight or obese5 63 55 Have a limiting long term illness5 32 25 Will be permanently sick or disabled6

14 6

Community Life

Will be burgled7

1 1 Will experience crime or anti-social behaviour7

9 6

And finally…

If a boy will have a life expectancy of8

If a girl will have a life expectancy of8

75.6 years

79.1 years

79.5 years

83.3 years

Source: 1ELMS, WAG; 2 School Statistics, WAG; 3 ELLS, WAG 4ETES3, WAG; 5 Welsh Health Survey 2008 & 2009; 6 Census 2001;7 Home Office; 8ONS.

The size of the challenge One of the main challenges for Aneurin Bevan Heath Board and its partners is ‘levelling up’ the mortality (death) rate from the worst to the best. The chart below shows the rate of mortality for men and women in the ABHB area.

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You can see from figures 1.2 and 1.3 (below) that within the ABHB area there is significant variation in all-cause mortality among males and females under 75 years. The charts in the inequalities technical supplement show further inequalities in mortality and trends for the main causes of death including circulatory disease, respiratory disease and cancer. Figure 1.2: Mortality from all causes in males aged under 75 years

Figure 1.3: Mortality from all causes in females aged under 75 years

Source: Public Health Wales Observatory, using ADDE/MYE (ONS), WIMD 2008 (WAG)

1.9 1.9 2.2 2.2 2.2 2.1 2.0 0

50 100 150 200 250 300 350 400 450 500

2001 -03 2002 -04 2003 -05 2004 -06 2005 -07 2006 -08 2007 -09

Most deprived within Aneurin Bevan

All cause mortality, under 75, females, European age standardised rate (EASR) per 100,000, Aneurin Bevan HB and Wales, 2001- 09

Wales EASRLeast deprived within Aneurin Bevan Aneurin Bevan overall

1.9 2.0 2.1 2.3 2.4 2.3 2.1 0

100 200 300 400 500 600 700 800

2001 -03 2002 -04 2003 -05 2004 -06 2005 -07 2006 -08 2007 -09

Most deprived within Aneurin Bevan Wales EASRLeast deprived within Aneurin Bevan Aneurin Bevan overall

All cause mortality, under 75, males, European age -standardised rate (EASR) per 100,000, Aneurin Bevan HB and Wales, 2001 - 09

Source: Public Health Wales Observatory, using ADDE/MYE (ONS), WIMD 2008 (WAG)

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Whilst death is an inevitable fact of life, looking at deaths occurring before they might be reasonably expected (i.e. under 75 years) also demonstrates inequalities. Often these deaths are linked to largely preventable causes such as smoking and there is also a strong link with deprivation. Case study: Healthy Hearts Project

The Healthy Heart Project is a primary prevention programme, originally established to tackle the high heart disease mortality rates in Caerphilly County Borough. It aims to ensure the early identification, advice and treatment of those most at risk of cardiovascular disease.

GP practices identify patients aged 45-64 with no known risk factors for heart disease, who are not being treated for an existing condition such as hypertension or diabetes. These individuals are invited to attend a nurse-led clinic and are screened for risk factors associated with early heart disease and diabetes. Where appropriate, individuals are referred back to their GP for treatment and lifestyle advice to modify their risk

factors, or referred lifestyle programmes e.g. smoking cessation

Many people who were unaware of their high risk have been identified and treated. Also, individuals have a greater understanding of their risk factors and the steps they can take to minimize the risks. Since 2004, over 20 GP practices have been involved, and over 5000 patients screened. It is hoped that this approach, that has been evaluated as successful can now be rolled out across other areas in ABHB. Figure 1.4: Death rate in people aged under 75 per 100,000 resident population, by local authority area, 2007

050

100150200250300350400450

Blaena

u Gwent

Caerphilly

Newport

Monmouthshire

Torfaen

Dea

th ra

te u

nder

75s

Wales average = 332.1

Note: This information in this table is age standardised. Single year rates for local authorities may exhibit big fluctuations which could be due to nothing more than random year-to-year variation and the relatively small populations involved.

Source: ONS

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Case Study: MECHANIC (The Minority Ethnic Communities Health Association for Newport - Initiating Change) was launched on 26 March 2009 and aims to:

• exchange information and share best practice relevant to the objectives of the group • identify the health needs and make

recommendations regarding improved policies and practices, overcoming barriers to access, priorities for action and investment and appropriate research

• act as a research and consultation body for the promotion of the health of Minority Ethnic Communities in Newport

• provide cultural awareness training to assist health professionals in the delivery of culturally competent health services in Newport

• identify and secure funding for specific needs, as appropriate to the objectives of the group

• commission the production of culturally appropriate resources to address specific health issues

• liaise with similar organisations nationally to share best practice and information

• disseminate all work performed by the association to any interested bodies Currently the MECHANIC association has over 81 members.

There is more to this story than differences in death rates. We also have information that tells us, not only how long people live, but also how may of those years are spent in good health. The subsequent chapters are structured using the life course approach; firstly providing information on the health of the population in each life stage and then by outlining the most important indicators and listing the key public health actions. Special population groups Not all population groups across Gwent experience the same health outcomes. This is very often due to lack of access to and utilisation of preventative and medical services. These issues are known to be directly related to communities which are marginalised in our society. This can be as a result of social and economic deprivation and also due to difficulties in accessing health services (e.g. linguistic skills) and the ability to understand and therefore adopt advice. Such communities may include Gypsy-Travellers, Minority Ethnic Communities, Prisoners and Probationers, Homeless People, Asylum Seekers and Refugees and People with Substance Misuse Problems.

Babies and pre-school children are safe,healthy and develop their potential

Chapter 2

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Babies and pre-school aged children

Our aspiration is that babies are born healthy and pre-school aged children are healthy, safe and develop to their potential The foundations for our health are set before birth and in our very early years. Health in this life stage is particularly susceptible to inequalities in family wealth and resilience. Death rates in infants are categorised as perinatal (stillbirths, and deaths in the first week of life per 1000 lives), neonatal (deaths in the first 27 completed days of life per 1000 live births) and infant (age under one year per 1000 live births), see table 2.0.

Table 2.0: Infant mortality rates in Gwent and Wales (per 1000): 2004-2008

Perinatal Neonatal Infant

Blaenau Gwent 9.2 2.8 4.6

Caerphilly 7.6 2.8 4.7

Monmouth 6.3 2.3 3.5

Newport 7.7 3.3 5.3

Torfaen 8.1 2.7 4.4

Wales 7.4 3.1 4.5

Source: All Wales Perinatal Survey

Preterm births accounted for 31% of deaths after a live birth in Wales in 2008, and remain the major cause of infant mortality. Congenital anomalies caused death in 24.3%, 14.9% were due to infection whilst 10.8% were sudden unexplained death in infancy. Intrapartum events caused 6.8% of deaths after live birth.

Congenital anomalies The rate of congenital anomalies in Wales has been falling for the last decade from 597 (1998) to 345 per 10,000 births in 2008. With the exception of Blaenau Gwent, which has a rate of 576.1 per 10,000 births (1998 to 2008), localities have lower rates than the Wales average of 495 per 10,000 births (table 2.1).

Table 2.1: Congenital anomalies as a rate per 10,000 births: 1998 – 2008

Blaenau Gwent

Caerphilly Monmouthshire Newport Torfaen Wales

576.1 454.9 462.9 453.7 476.0 495.1

Source: CARIS

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Low birth weight Babies born weighing below 2,500 grams are at increased risk of adverse health outcomes. The ABHB localities have higher rates of low birth weight births than the Wales average of 5.8%, with the exception of Monmouthshire (figure 2.0).

Figure 2.0: Low birth weight babies as a percentage of singleton live births: 1998-2007

0123456789

Blaenau Gwent Caerphilly Monmouthshire Newport Torfaen

Perc

enta

ge

Source: ADBE/ONS Figure 2.1 shows that within each of the localities there are medium super output areas in which low birth weight rates are considerably higher than for the locality as a whole, and significantly higher than the overall percentage for Wales. Figure 2.1: Low birth weight babies as a percentage of singleton live births

in Gwent MSOAs: 1998 -2007

Source: ADBE/ONS

Wales

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Communicable disease For childhood communicable diseases, measles, mumps and rubella in the pre-school age group, data are only available at an all Wales level. Amongst infants aged under one year of age there were no confirmed cases of measles, mumps or rubella in 2010. For the age group from one to four years, there were no cases of measles, three of mumps and no rubella cases confirmed in Wales (2010). Communicable diseases are also discussed in a subsequent chapter. Immunisations A number of vaccines are given in childhood and the teenage years to offer protection as early as possible against a number of potentially serious communicable diseases. The vaccination schedule in the early years is as follows:

When to immunise

What vaccine is given

2 months old 5 in 1 (1) PCV (1)

Diphtheria, tetanus, pertussis (Whooping Cough), polio and Haemophilus influenza type b (Hib) (5 in 1) (dose 1) Pneumococcal Conjugate Vaccine (PCV) dose 1

3 months old 5 in 1 (2) MenC (1)

Diphtheria, tetanus, pertussis, polio and Hib (5 in 1) (dose 2) Men C (dose 1) (Vaccine against Meningococcus infection type C)

4 months old 5 in 1 (3) PCV (2) MenC (2)

Diphtheria, tetanus, pertussis, polio and Hib (5 in 1) (dose 3) Men C (dose 2) PCV (pneumococcal conjugate vaccine) (dose 2)

12 months old Hib/MenC

*Hib / Men C (booster)

Around 13 months old MMR(1) PCV

*Measles, mumps and rubella (MMR) (dose 1) PCV (booster)

Around 3 years, 4 months 4 in 1 MMR (2)

Diphtheria, tetanus, pertussis and polio (4 in 1) MMR (dose 2)

* In the future, in order to simplify the immunisation schedule, these vaccines will be offered at the same visit within one month after a child’s first birthday.

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Figure 2.2 Trends in childhood vaccine uptake rates in Aneurin Bevan Health Board: Quarter 1 2004 – Quarter 4 2011

Source: COVER From 2004 to the end of the fourth quarter 2010 the uptake rates for a completed course of the 5 in 1 vaccine (diphtheria, tetanus, pertussis [whooping cough], polio and Haemophilus influenza type b), and also for Men C by the age of 1 are very good, both above the Welsh Government target of 95%; as is the uptake of two doses of pneumococcal vaccine (96%). Uptake of the first dose of MMR vaccine is increasing, that of the second dose appears to be levelling out. Uptake of both the first and second doses needs to be higher (the target is 95%) to provide optimal levels of protection against measles, mumps and rubella in the Gwent population. Oral health Poor oral health has a significant impact on quality of life and general health. Tooth decay, due to its prevalence and impact, is a significant public health issue from birth throughout life. Dental caries is primarily a disease of childhood and early adult life.

60

70

80

90

100

2004

120

04 2

2004

320

04 4

2005

120

05 2

2005

320

05 4

2006

120

06 2

2006

320

06 4

2007

120

07 2

2007

320

07 4

2008

120

08 2

2008

320

08 4

2009

120

09 2

2009

320

09 4

2010

120

10 2

2010

320

10 4

% u

ptak

e

Cover quarter

5 in 1 at 1yr MMR 1 at 2yrs

MMR2 at 5yrs 4 in 1 at 5 yrs

Men C at 1 yr 95% target

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0

1

2

3

4

5

Gwent Wales Monmouth Blaenau Gwent

Area

Mea

n dm

ft

Figure 2.3: Variation in oral health in five-year old children within Gwent: 2005-06: mean numbers of decayed, missing or filled teeth per child by selected areas

Source: WOHIU

Dental decay is not inevitable, it is preventable. There is a marked correlation between levels of dental decay and social deprivation. The rate of improvement seen more recently in child dental health has now halted. However, the average number of decayed, missing or filled teeth in children aged 5 years in Gwent is 2.7 (figure 2.3), significantly worse than the Wales average of 2.4. Numbers range from 1.9 in Monmouthshire (statistically significantly better when compared to Wales) to 4 in Blaenau Gwent (Welsh Oral Health Information Unit (2005/06). The 2007/08 Dental Survey indicated that 63 percent of five year olds living in Blaenau

Case Study: Improving the diet of pre-school children in early years and childcare settings

Meithrin, nurseries and childminders. The award covers: policy, provision of healthy snacks, environment and hygiene criteria. The award has been successfully achieved by 101 settings in Caerphilly County, and is now being incorporated into an all Wales Health Early Years scheme. The award has been adopted by Cardiff and Vale, Merthyr and is being rolled out across ABHB.

Welsh data indicates that children’s consumption of fruit and vegetable is low, obesity rates are increasing and oral health continues to be of concern in 5 year olds in Caerphilly County. The public health team and partners in early years have developed a Gold Standard Healthy Snack Award scheme for settings including playgroups,

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Gwent had active and untreated decay. The most recent dental survey of twelve year old children living in ABHB area had the worst teeth in Wales. A preventative programme for nursery/primary school children - ‘Designed to Smile’ - was launched in Gwent in 2010. Children aged 6-8 will receive a Fissure Sealant programme as well as preventative advice on how to look after their oral health. Children aged 8 and over will receive an Oral Health Promotion Programme.

Injuries The injury rate in the home is particularly high for infants and pre-schoolers in Wales (figure 2.4). Most home injuries are not fatal. However, the home is the main location of injury death in infants from assault/homicide, and for 1-4 year olds from fire. Poisonings are also a significant issue as many hazardous substances such as bleach and medicines are kept within reach of infants and pre-school children. There are steep socioeconomic gradients for children under five injured by falls, poisoning and burns/fires. Steeper socio-economic gradients in serious injury rates tend to occur in rural areas for children suffering falls.

Case Study: Designed to Smile Initially pilots have been established working with Sure Start and Flying Start nurseries. This is a multi-agency approach, working with a wide range of professionals who work with young children. The aim is to give good consistent advice to parents, provide tooth brushing programmes and encourage registration with the dentist.

Designed to Smile is a national oral health improvement programme, which was launched in ABHB in September and is targeted at Flying Start and Communities First areas. One of the elements is a preventative programme for children from birth to 3 years.

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0

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Figure 2.4: Location of injuries by age group as a rate per 1,000 population in Wales: 2004

Source: AWISS

Multi-factorial injury prevention interventions have been shown to reduce injuries in the home. Some evidence-based interventions include installing smoke alarms; adopting legislation on the temperature of hot-water taps; treating children who have sustained fire-related burns in dedicated burn centres and placing guards on windows to prevent falls. High quality evidence for the effectiveness of measures to prevent child homicide is limited, but research shows efforts should be focused on children less than five years of age living in deprived areas. Further information is available at www.scotland.gov.uk/Publications/2005/07/1485820/58341

Breastfeeding Breastfeeding is the natural and holistic way of providing nutritional, emotional and social care for an infant. It is also beneficial to the environment and the economy. The longer the duration of breastfeeding, the greater the health benefits to both mother and infant. Breastfeeding confers both short term and long term health benefits for both mother and infant. Exclusive breastfeeding provides maximum health benefits. Breast fed babies have lower rates of respiratory and gastrointestinal infections and breast feeding seems to be a protective factor for breast cancer. All mothers should be encouraged and supported to breastfeed exclusively for 6 months and to continue doing so with the introduction of solid food, for a year or more2. Data from the National Community Child Health database for the calendar year 2009 shows that at 40% Aneurin Bevan HB has the lowest rate of women breastfeeding at birth of any Welsh HB and compares unfavourably with the Wales rate of 57% (figure 2.5). It should be noted however that breastfeeding status was not stated for 10% of all live births in Wales, which could have an effect on percentages in some areas.

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Figure 2.5: Breastfeeding at birth as a percentage of live births by Health Board: 2009

0102030405060708090

Ane

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Source: National Child Health Database (Percentage of live births where feeding intention stated)

The figure below shows that the rate of breastfeeding at birth in all localities, with the exception of Monmouthshire, is considerably lower than the Wales average. Figure 2.6: Breastfeeding at birth as a percentage of live births by locality: 2009

Wales

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Source: National Child Health Database (Percentage of live births where feeding intention stated)

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Case Study: Baby Friendly Initiative In order to improve breastfeeding rates, NICE guidelines state that the UNICEF Baby Friendly Initiative should be implemented as routine practice across NHS hospital and community settings. The World Health Organization and UNICEF introduced the initiative in recognition of the need to change hospital practices. It is a global programme aimed at introducing best practice standards for breastfeeding into all maternity health care services. These standards are the minimum that any mother has the right to expect from maternity services both in hospital and the community. Aneurin Bevan Health Board (ABHB) has achieved UNICEF Baby Friendly status in all three of its maternity units. The Baby Friendly Initiative also defines best practice for breastfeeding in community health services. This initiative is similar to the hospital initiative in that there is a three staged assessment process. However, standards are broader and enable services to provide ongoing support to mothers to encourage continuation of breastfeeding. Standards cover organizational policies and training and education of professionals together with less formal support such as peer support and breastfeeding support groups. The former LHBs took forward the community health services initiative independently and were all at different stages of UNICEF Baby Friendly Accreditation. An ABHB steering group was established to progress the initiative. ABHB has now achieved stage one and is working towards stage two accreditation.

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Maternal smoking Smoking in pregnancy is associated with a number of serious consequences for the health of the baby, including low birth weight, premature birth and perinatal death. In addition, growing up in a household exposed to cigarette smoke impacts on the health and wellbeing of a child in infancy and beyond. Data on maternal smoking are not routinely available as although midwives collect data this is not currently collated centrally. A UK survey in 2005 found that mothers in Wales were more likely to smoke and less likely to give up than in other UK countries. It reported that 37% of mothers in Wales smoked at some stage during their pregnancy or the year before it. Of these, 41% gave up at some point before the birth but 22% continued to smoke throughout the pregnancy3.

Case Study: Tackling parental smoking Working with Aneurin Bevan Health Board, the Public Health Wales Stop Smoking Wales programme has delivered two ‘Brief Intervention for Smoking Cessation’ training courses to Sure Start Health Visitors in Caerphilly and Newport. The training is accredited with the Royal College of Nursing (RCN) and Agored Cymru and aims to encourage the Health Visitors to raise the topic of smoking with clients and trigger a quit attempt to encourage clients to think about quitting.

Case Study: Supporting new parents with low English literacy skills In Newport Public Health Team and Sure Start ABHB Dietitians are producing a DVD for parents with limited English language skills on best practices for infant feeding. Funding from the Newport Children and Young People’s Partnership enabled this. The DVD is based on the Gwent Infant Feeding Guidelines (2005) which were adopted by WAG for an all Wales approach. This supplements the training aids already made for Health Visitors and will be produced with voiceovers in Arabic, Bengali Cantonese, English, Polish, Punjabi, and Somali.

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Linking actions to outcomes

The driver diagrams below (figures 2.7 and 2.8) show the linear relationships between the important outcome indicators and their determinants, developed as described in Chapter 1. Understanding the ‘story behind the baseline’ is important because it is those multiple causes of the outcome indicators, and therefore the outcomes, that we must focus our efforts on to achieve real change. The diagrams highlight that action to improve health must be multi-faceted and as such is beyond the control of a single agency. The priorities for partnership action that follow are based on the priority drivers in the diagram identified using published criteria as described previously.

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Figure 2.7: Diagram showing the relationships between outcome indicators, main determinants/causes and the area of focus for partnership to help ensure babies are born healthy

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Figure 2.8: Diagram showing the relationships between outcome indicators, main determinants/causes and the area of focus for partnership to help ensure pre-school children are safe, healthy and develop their potential

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Priorities for partnership action for babies and pre-school aged children

• Pre-conceptual health, folic acid intake and immunisation (especially against rubella) are important for women to give their babies the best start in life. Messages need to be given in personal and social education (PSE) in schools, and routine primary care.

• Partnerships should invest in approaches to reduce teenage pregnancies which

include parental education (e.g. ‘Speakeasy’ programme), dedicated contraceptive and sexual health services, sex and relationships education, youth support services and targeted intervention for vulnerable young people such as looked after children.

• Comprehensive pre-natal and ante-natal services should be in place to address

maternal smoking, alcohol consumption and ensure adequate nutrition including folic acid. Antenatal care should also include access to information and services relating to drug use, alcohol intake, clinical conditions (e.g. gestational diabetes), screening and mental health problems. Women needing additional care should receive appropriate assessment, intervention and support.

• Midwifery services have a key role in providing systematic brief interventions for

smoking cessation. This should be part of a wider tobacco control programme, which includes, for example, employers adopting ‘smoke free’ policies and providing support to pregnant women to give up smoking. Links to Stop Smoking Wales are key.

• Drug and alcohol services should be explicit about how they will improve

access to pregnant women. This should be complemented by enforcement action to reduce availability and the illegal sale of alcohol and illicit drugs.

• The universal Health Visiting service is vital to address key public health issues

such as immunisation uptake, parental smoking, breastfeeding, infant feeding, injury prevention, drug and alcohol misuse and post natal depression. Enhanced services such as Flying Start and Home Start are essential to promote the health and wellbeing of pregnant women by providing health and social support, advice and practical assistance to women in deprived areas.

• Evidence based parenting programmes are also important to support child

development and provide a vehicle for addressing other factors such as passive smoking, weaning, cooking, shopping, developmental play and home safety.

• Immunisation is one of the most important ways of protecting children and the

community from serious diseases. The Health Board should look at effective methods for raising rates of childhood immunisations to level required for ‘herd immunity’.

• Breastfeeding is important to help infants grow and develop and can reduce the

risk of infections and childhood illnesses. Breastfeeding is also important for physical and emotional bonding and helps to protect women against breast cancer in later life. Partnerships should support the UNICEF Baby Friendly

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Initiative which provides an evidence-based framework for maternity and community services.

• A major cause of ill health is exposure to passive smoking which has been

linked to childhood respiratory illness and sudden infant death syndrome. The ban on tobacco advertising and smoking in public places has helped to de-normalise smoking. Partners should explore ways of raising awareness about the harms of passive smoking and support parents to create ‘smoke free’ homes and cars. Agencies that work directly with families should also provide brief interventions and refer motivated parents, carers and older siblings to specialist smoking cessation services.

• Parental substance misuse is another major issue which should be addressed

through local partnerships. Evidence-based models are being developed through the Integrated Family Support Service (IFSS) pilots. It is also important that safeguarding services are in place and that social services are adequately resourced to tackle the issue of child abuse and neglect.

• Poor oral health is another preventable issue that should be addressed through

appropriate infant feeding, dental care and tooth brushing. The Community Dental Service should work in partnership with schools and other providers to address this issue through Designed to Smile and the Oral Health Promotion Strategy. Dialogue with water companies with regards to fluoridation should continue since this would vastly decrease tooth decay in our children.

• Partnerships should consider effective home injury prevention schemes. Housing and road safety also have roles in creating a safe environment for young children by, for example, introducing 20mph zones in residential areas and outside schools and other places where children congregate.

• The Children's Environment and Health Action Plan for Europe (CEHAPE) is an

initiative led by the World Health Organization Regional Office (WHO) for Europe. A Children’s Environment and Health Strategy for the UK provides a brief overview of children's health in relation to their environment in the UK and recommends areas that should be taken forward in order to protect and promote children's health in relation to water, sanitation and health, accidents, injuries, obesity and physical activity; respiratory health, indoor and outdoor air pollution; and chemical, physical and biological hazards.

• Poverty is a key factor associated with adverse health outcomes. A range of

organisations (e.g. Job Centre Plus, Local Authority and Voluntary Sector) have an important role in alleviating the impact of poverty by providing education, benefits uptake, debt counselling, credit unions and access to adequately paid employment. We must develop safe, high quality early year’s services and ensure the provision of high quality childcare to enable parental education and employment opportunities.

School-age children are safe, healthyand are equipped for adulthood

Chapter 3

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Children and Young People Our aspiration is that school aged children and young people are safe, healthy and equipped for adulthood This life course covers the transition from reception year at primary school through progression to secondary school, leaving school and on to adulthood. For some of our young people this might represent small changes such as further study at school or college. Others face different challenges like getting a job, leaving home or parenthood - or all of those things! For all children and young people this stage of life is characterised by the change in influence and control, from the home and family, to the increasing influence of peers and significant others as they begin making independent decisions and choices. Young children continue to develop language and the emotional base for good mental health through good parenting, quality education and childcare provision. Children and young people gradually start to make decisions about their own behaviours, from what to choose from the school dinner menu to whether to experiment with substances. The influence of peers is critical, but wider social norms and commercial advertising exert increasingly greater pressures. The effects of family life circumstances, deprivation, and parental education will also influence the development and behaviour of children and young people.

Immunisation – a foundation for health Childhood immunisations protect against a range of preventable, infectious diseases and are delivered according to a national schedule. Whilst uptake for most routine early childhood vaccinations in the Gwent area and across Wales is generally good, the uptake of vaccinations scheduled for teenagers, providing protection for adulthood needs to increase.

The uptake rate for the ‘teenage 3 in 1 booster’ which gives life long protection against diphtheria, tetanus and polio is low. For the most recent full year of data available (April 2010 to March 2011), the ‘booster’ 3 in 1 immunisation uptake rates by the 16th birthday reached 17.3% for Aneurin Bevan Health Board (ABHB) (Blaenau Gwent 5.5%, Caerphilly 12.0%, Monmouthshire 40.6%, Newport 16.3%, Torfaen 13.6%). This is compared to other areas such as Merthyr Tydfil and Rhondda, Cynon Taff where the uptake rates were 79.5% and 77.5% respectively as a result of a coordinated programme of vaccinations in school delivered by school health nurses (figure 3.0).

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Figure 3.0: Uptake of teenage 3 in 1 booster by age 16

Source: 2010/11 Cover stats - Public Health Wales

In 2010 a school-based vaccination programme for delivery was established by the Aneurin Bevan Health Board (ABHB), along with a ‘catch up’ campaign through General Practice, and the early indication is that with this action the uptake rates will increase significantly in forthcoming years. Uptake in children reaching their 15th birthday between 01/01/11 and 31/03/11 in the COVER (98) report was 63.2% for ABHB.

Case Study: ‘Get Protected’ campaign To improve teenage immunisation rates, a targeted health education campaign using social marketing techniques in consultation with young people launched in Gwent in 2010. The Get Protected Campaign aims to increase young people’s awareness of the importance of a teenage booster dose of tetanus, polio and diphtheria for future health protection.

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Only 81.7% of children in Aneurin Bevan Health Board (ABHB) reaching their 16th birthday in 2010-2011 had previously received a full course (2 doses) of MMR, leaving up to one in five unprotected against Measles, Mumps and Rubella. Wales and the UK have seen increasing incidence and outbreaks of these serious, preventable diseases due to the poor uptake rates of MMR vaccination. This ranged between 73.2% uptake in Monmouthshire, 80.1% Newport, 81.6% Caerphilly, 88.6% Torfaen and 87.4% in Blaenau Gwent. With the exception of Monmouthshire and Torfaen, the uptake rates have decreased since the previous year. Figure 3.1: Uptake of MMR (1 and 2) immunisation by age 16

Source: 2009/10 – 2010/11 Cover stats - Public Health Wales Rubella (German measles) can severely affect the health of unborn children. Therefore, in order to help ensure babies are born healthy, there is a need to ensure young women are immunised appropriately. In 2010-11, 81.1% of girls reaching their 16th birthday in ABHB had received 2 doses of MMR. This needs to be closer to the target of 95% in order to ensure herd immunity. In 2008, England and Wales scheduled a programme for girls aged 12 to 13 years to be vaccinated against Human Papillomavirus (HPV) which is the key cause of cervical cancer later in life. In Wales, this vaccination is delivered through a school based NHS programme and reported uptake for girls reaching age 14 between 01/09/2008 and 31/08/2010 and completing the full three doses of the vaccination was good: Blaenau Gwent 90.4%, Caerphilly 84.4%, Monmouthshire 72.2%, Newport 80.3% and Torfaen 86.8.7% (COVER Stats 2010-11).

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Teenage conceptions

The prevention of unwanted teenage conceptions is important due to the poorer health, social and economic outcomes for mother and child, including low birth weight and relatively high rates of infant mortality and the cost of continuing health and social support. Girls in less fortunate circumstances are much more likely to become teenage mothers than those from more affluent backgrounds, thus perpetuating health inequities. The conception rate for girls and women aged under 18 years ranged from 28.1 per 1000 in Monmouthshire to 51.4 per 1000 in Torfaen (Wales average 44.2) (2008) Whilst some conceptions in those aged under 18 years may be planned, conceptions in girls aged under 16 years are usually unplanned and these ranged from 6.9 per 1000 in Monmouthshire to 11 per 1000 in Torfaen (because of the small numbers involved, annualised three-year average rates are used to compare areas), see table 3.0. Table 3.0: Conceptions in females aged under 16 years (3 year average) 2005–2007

Rate per 1000 females aged 13-15 Caerphilly 8.8 Blaenau Gwent 8.3 Torfaen 11 Monmouthshire 6.9 Newport 8.8 Wales 8.3

The rate for Torfaen is significantly higher than the Wales rate of 8.3 per 1000 and equates to approximately 26 conceptions per year. In Monmouthshire (which has the lowest rate in the Gwent area), the number of conceptions would be approximately 17. Around half of conceptions in girls aged under 16 in Wales were legally terminated by abortion (ONS 2007). Strategies to prevent unplanned teenage conceptions should include easily accessible and acceptable high quality advice and provision of contraception. Figure 3.2: Rate of teenage conceptions in Gwent localities

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Health and health behaviours

There are very little systematically collected and collated data available at a sub national local authority area level about health behaviours in children and young people. Most of the data currently available is through the Health Behaviours in School-aged Children (HBSC) surveys and the recently introduced Children’s Health section of the Welsh Health Survey. However, we do know that for most indicators that are routinely available, Aneurin Bevan Health Board (ABHB) rates are similar or worse than the Wales average and that there is significant variation at a small area level. It is therefore reasonable to expect that there will be a similar picture of inequality amongst our children and young people as for adults throughout the area. The following paragraphs present information from the most recent HBSC survey (2006) “Young People’s Health in Great Britain and Ireland“(2009) and the 2009 Welsh Health Survey.

General health and wellbeing In Wales, fewer young people reported having excellent or good health and life satisfaction compared to England, Scotland and Ireland. The Welsh Health Survey reported that 94 percent of children experienced good or very good health (WHS, 2009). The most recent HBSC information which assesses those aged 11, 13 and 15 years, found that the percentage of young people who reported having excellent or good health was lowest in Wales at just over three quarters of young people. More girls than boys reported poor health and life satisfaction and the percentage of girls who reported poor health increased with age. Girls were also more likely than boys to report that they experienced regular health complaints such as headaches or stomach aches.

Obesity, food and fitness The percentage of young people in Wales who reported that they were overweight was significantly higher at 19.1% (HBSC, 2006), than other UK countries (England 11.9%; Ireland 13.5%; Scotland 15.3%). When considering the other available data the Welsh Health Survey reported that 34% of children were overweight/obese and 19% obese (WHS, 2009).

Case Study: The “C–Card” Scheme was initially developed and piloted within Gwent and across Wales in 2003, in response to rising rates of sexually transmitted infections (STI’s), and unwanted pregnancies. All localities with the exception of Monmouth operate a local C-card scheme. Each scheme provides a confidential, co-ordinated, free sexual health information and condom distribution network. The scheme aims to increase accessibility to young people aged between 14 and 25 years and is run through trained professionals such as youth workers, nurses, community development workers, and volunteers working in youth settings.

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Information on healthy eating shows that the percentage of young people who reported daily fruit consumption was lowest in Wales at 34.6% (HBSC, 2006) compared with the other countries involved the UK, and decreases as age increases. Fruit and vegetable eating was reported as more common among girls than boys and among young people with higher family affluence. Similar measures in the Welsh Health Survey showed that 60% of 4-15 year olds ate fruit daily and 49% ate vegetables daily (WHS, 2009). According to the HBSC data, young people with higher family affluence were more likely than those with medium or low family affluence to engage in regular vigorous activity. The Welsh Health Survey found that across Wales in 4-15 year olds the percentage reaching 60 minutes a day, 5 or more days a week was 63% for boys and 45% for girls, and those reaching 60 minutes daily was 47% for boys and 29% for girls (WHS, 2009). Young people with lower family affluence were most likely to play computer games for two or more hours a day, less likely to report daily fruit and vegetable consumption and take regular physical activity.

Risk taking behaviour Early onset of sexual activity and unprotected sex exposes young people to sexually transmitted infection and a greater risk of a teenage conception. More 15year old girls than boys reported that they had ever had sex, and only 70 percent of young people who had sex had used condoms at last intercourse. Those with higher family affluence were more likely to report condom use. Girls in Wales were most likely to report that they had ever had sex, while sexually active young people in Wales were least likely to report very early sex (at, or before the

Case Study: MEND (Mind, Exercise, Nutrition, Do it) is an intervention designed to address obesity early to reduce risk in childhood and in the future. Programmes are centred on parents and families for sustainable behaviour change as well as providing practical experience on food and physical activity. There are MEND programmes running in Blaenau Gwent, Monmouthshire, Newport and Torfaen, with Caerphilly having a similar programme called F3 (Fun, Food & Fitness) which in addition involves healthy home tutors. The programmes are jointly managed by the community dietetics service, local public health teams, local authorities and partners. For pre-school children and their families Mini-MEND and HENRY run in two areas of Aneurin Bevan Health Board and provide support to influence the behavioural and emotional causes of obesity as well as dealing with practical issues like healthy shopping on a budget and ‘fussy eating’.

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age of 14). Girls in Wales were also more likely to have used the contraceptive pill rather than a condom than sexually active girls in either England or Scotland. Therefore, young people in Wales are more at risk of contracting a sexually transmitted disease. In terms of substance use, girls were more likely than boys to smoke and drink alcopops, while boys were more likely than girls to drink beer, cider and spirits and to have taken cannabis. Daily smoking by young people was least likely in England followed by Ireland, Wales (6.7%) and Scotland. The highest percentage of young people who had been drunk at least four times was found in Wales (14.1%).

Injury prevention

The leading individual causes of injury death vary by age-group: highlighting pedestrian injury is the most common for 5-15 year-olds, and suicide for 16-25 year-olds.

Road traffic injuries Although child death from all causes is now rare in Wales and also in the Aneurin Bevan Health Board area, road traffic collisions (RTC) remain a leading cause of death and mortality inequity in school-aged children and young people accounting for a third of deaths. RTCs also cause a significant burden due to psychological trauma, non-fatal injury and disability. In children aged between five and fifteen years old, collisions with pedestrians and cyclists are the main cause of serious non-fatal and fatal injury. The highest rate is amongst secondary school-aged children peaking in the age-group 12 to 15. The majority of pedestrian and cyclist collisions occur in urban areas, in streets and roads close to where children live and play as well as on main roads, just outside schools or known hot spots. There are small peaks of accident numbers before school-opening and closing times (not restricted to the school vicinity), with larger and longer peaks at weekends and school holidays, especially in the summer. The risk of a child pedestrian or child cyclist being knocked down and injured by road traffic has been estimated to be as much as between five to seven times higher in the least affluent council wards compared to the others. Steeper socio-economic gradients in serious injury rates were identified in rural areas for cyclists. There are added negative effects on health, especially physical activity and active play, as the perception of danger from road traffic by some parents and children leads to less walking, cycling and outdoor playing.

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The highest injury rates from road traffic occur in young people aged 16 to 24. In this age-group injury and death tend to occur increasingly as they become drivers or passengers within vehicles rather than as pedestrians. Nevertheless, for motor-vehicle occupants, injury rates and mortality in Wales are amongst the lowest in Europe and continue to decrease. In contrast however, fatal and non-fatal child pedestrian and cyclist injury in Wales and the UK remains amongst the highest in Europe.

Effective prevention of child pedestrian and cyclist injury Reviews suggest that area-wide intense traffic calming in towns and cities reduce the number, rate and inequities of pedestrian and cyclist road traffic injuries and deaths. This also increases walking, cycling and outdoor active play. Studies show that only a very small proportion of urban and rural roads are currently adequately traffic-calmed. Placing the lower 20 mph speed limits on most urban roads and enforcing these is effective in reducing accidents. Reviews suggest prevention strategies should include comprehensive environmental measures such as overall reduction of traffic volume and speed throughout urban areas where children congregate and play. Prioritising public space, pedestrians, cyclists and public transport in sustainable spatial and transport planning is essential. The current urban street design guide Manual for Streets 2, as recommended in WAG policy, takes this approach.

Effective prevention of motor vehicle occupant death and injury should include addressing:

• Driver alcohol consumption • Not wearing front or rear seat-belts • High UK legal blood alcohol limit and lack of random testing • High speed limits and actual speed • Rural main roads and lanes and their road design • High rate of private motor vehicle use, poor public transport and ease of

car parking • Young male drivers especially • Driving inexperience • Driving late at night • Cars with many young passengers

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Alcohol-related intentional injury Alcohol plays a significant role in violence affecting children and young people in Wales, including assaults and sexual assaults. There were an estimated 18,000 incidents of violent crime attributable to alcohol in Wales in the year 2007/08. Recent data suggests Newport has the highest rate of alcohol related violent crime in Wales. These data on alcohol related violence are accordant with the data on binge drinking in children and young people in Wales are presented elsewhere in this report and shows that both Newport and Caerphilly have a higher rate than the Welsh average with Blaenau Gwent and Torfaen just below and Monmouthshire with the fourth lowest locality rates in Wales.

Linking actions to outcomes

The driver diagram below shows the linear relationships between the important outcome indicators and their determinants, developed as described earlier. Understanding the ‘story behind the baseline’ is important because it is those multiple causes of the outcome indicators, and therefore the outcomes, that we must focus our efforts on to achieve real change. The diagram highlights that action to improve health must be multi-faceted and as such are beyond the control of any single agency. The priorities for partnership action that follow are based on the priority drivers in the diagram identified using published criteria as described previously.

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Figure 3.3: Diagram showing the relationships between outcome indicators, main determinants/causes and the area of focus for partnership to help ensure school aged children and young people are safe, healthy and equipped for adulthood

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Priorities for partnership action

• Risk taking behaviour is a normal part of adolescence, but can result in adverse health outcomes. Creating safe environments and channelling risk taking behaviour is essential for protecting and therefore improving the health outcomes of young people. Programmes of activities by Youth Services and voluntary sector groups should engage young people in safe but challenging activities which are protective. Partnerships should explore ways of reducing the harms associated with alcohol and drug misuse. Youth support services should actively engage with young people, particularly young men, to develop evidence-based prevention and harm reduction interventions. The more detached youth service is ideally placed to engage with young people in relation to adolescent smoking, substance use, alcohol and binge drinking, sexual health and reckless driving.

• Partnerships should actively engage all agencies that have a role in reducing teenage pregnancies. A much higher priority should be given to high quality ‘market-tested’ PSE in schools, with support from the local authority to develop sex and relationships education. Dedicated and accessible sexual health and contraceptive services should be in place for young people, including such programmes as the C-Card (condom distribution) scheme. Specific interventions should be provided for vulnerable young people especially including those in the ‘Looked After’ system.

• Partnerships should coordinate the implementation of evidence-based guidelines to address the risk and protective factors for mental wellbeing. Self-esteem and emotional resilience are key issues that should be addressed. Support for the Healthy Schools Scheme is essential to provide a ‘whole school approach’ to the issues of physical and mental wellbeing and risk factors such as bullying, behaviour, low attendance and school exclusion. Schools and youth support services should have comprehensive programmes to develop personal and social education and health literacy. The school-based Social and Emotional Aspects of Learning (SEAL) programme is aligned with the recommendations of the National Institute for Health and Clinical Excellence (NICE) on promoting social and emotional wellbeing and literacy in primary and secondary schools. This should be complementary, to and work closely, with an effective Primary Mental Health Service including the provision of school-based counselling services.

• Finally, there are a number of vulnerable groups of children and young people that need additional support to ensure they are safe, healthy and equipped for adulthood. Family services should identify problems early and put families at the centre of decision-making in order to prevent problems escalating. This support should empower children, young people and parents with the knowledge and skills which enable them to take greater control over the factors that affect their health. The Common Assessment Framework (CAF) and Team Around the Child (TAC) are promising examples of early intervention where practitioners in universal, as well as targeted and specialist services, assess needs at an early stage.

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• Enhanced services should be coordinated and integrated for specific groups such as children with disabilities, teenage parents, young carers, looked after children, young offenders, children excluded from school, children and young people with mental health or substance misuse problems and young people not in employment, education or training.

Working-age adults live healthyand happy lives for longer

Chapter 4

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Adults Our aspiration is that working age adults live healthier lives for longer There is considerable variation in health in the Aneurin Bevan Health Board area when we look at data on a small area level; this reflects the demography and life circumstances of our total population showing Gwent to be a diverse area. Examining the data at a smaller area level helps us to understand that there are areas and populations in real need of more, different or better facilities and services delivered in different ways if we are going to turn the curve on the inequities in health that persist in Gwent and Wales. Death rates The maps below show small area variation in death rates from all causes, cancers, circulatory diseases and respiratory diseases. The rates are standardised for age and so account for variations in age between areas. The areas shaded darkest are the Middle Super Output Areas where the age-adjusted death rates are amongst the highest in Wales.

Source: Public Health Wales Observatory

Figure 4.0: Death rate (EASR per 100,000) from all causes

Figure 4.1: Death rate (EASR per 100,000) from cancers

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Source: Public Health Wales Observatory The negative association between deprivation and health is clearly apparent. Many health outcomes are statistically significantly worse than Wales as a whole in areas of high deprivation. These areas include, for example: Green Lane and Lansdown in Monmouthshire; Rassau and Sirhowy in Blaenau Gwent; Aberbargoed, Darren Valley and New Tredegar in Caerphilly; Pillgwenlly, Ringland and Victoria in Newport and; St Dials, Greenmeadow and Upper Cwmbran in Torfaen. The widest inequity in health between small areas in Gwent can be seen for premature mortality from circulatory disease where there is almost a five-fold difference between the highest Middle Super Output Area rates and the lowest (see figure 4.4 below). A health inequity of this magnitude, at a geographical level, must be a result of difference in life-circumstances, difference in health seeking behaviour and possibly service access. Two of the areas with the highest rates for premature death from circulatory disease are also amongst the most deprived in the whole of Wales.

Figure 4.2: Death rate (EASR per 100,000) from circulatory diseases

Figure 4.3: Death rate (EASR per 100,000) from respiratory diseases

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label MSOA name annual avg EASR18 Caerphilly 001 18 173.317 Newport 018 8 164.016 Caerphilly 003 10 151.115 Blaenau Gwent 006 13 144.814 Caerphilly 002 12 140.613 Newport 003 13 140.012 Blaenau Gwent 003 12 137.811 Caerphilly 012 10 137.810 Caerphilly 015 9 137.59 Blaenau Gwent 001 12 135.68 Newport 013 9 131.37 Newport 010 9 129.76 Torfaen 001 9 127.45 Blaenau Gwent 009 11 126.14 Caerphilly 004 9 125.83 Torfaen 010 10 124.32 Caerphilly 023 10 121.01 Caerphilly 022 12 120.9

Figure 4.4: Premature death rate (EASR per 100,000) from coronary heart disease (under 75 years)

Source: Public Health Wales Observatory The medium super output areas above have associated lower super output areas and electoral divisions, these are: Caerphilly 001 Moriah, Pontlottyn, Twyn Carno

Newport 018 Pillgwenlly

Caerphilly 003 Aberbargoed, Gilfach

Blaenau Gwent 006 Georgetown, Tredegar Central

Caerphilly 002 Darren Valley, New Tredegar

Newport 003 Bettws

Blaenau Gwent 003 Sirhowy and Tredegar Centre

Caerphilly 012 Hengoed, Maesycwmmer

Caerphilly 015 Cross Keys, Ynysddu

Blaenau Gwent 001 Beaufort, Rassau

Newport 013 Liswerry, Victoria

Newport 010 Ringland

Torfaen 001 Blaenavon

Blaenau Gwent 009 Llanhilleth, Six Bells

Caerphilly 004 Bargoed

Torfaen 010 Llantarnum, St Dials, Two Locks

Caerphilly 023 Morgan Jones, Penyrheol

Caerphilly 022 Morgan Jones, St James

- 40 -

Ill health among adults We can only present information on ill-health conditions at a local authority level which often, in areas of diversity such as Torfaen or Newport, hide significant health inequities. In Monmouthshire because of the greater affluence in larger parts of the County it may appear that there are absolutely no health needs at all, which of course is not the case. We must consider this when looking at the variations between local authority areas in table 4.0 below. The variation in people living with chronic health conditions gives us an indication of the larger health inequities that exist between small area populations in Gwent.

Case study: Improving health and work Public Health Wales Workplace Health Team is supporting public and private sector workplaces across Gwent to implement the Corporate Health Standard (CHS). The CHS is an initiative to improve the health of the workforce and their organisation. In 2009/10 a total of six organisations received the award with a further 8 working towards it in the Gwent area. This represented 42,674 employees. In addition, the Small Workplace Health Award Scheme is being introduced in the Gwent area with Workboost, which is confidential, practical and free advice to small businesses in Wales on workplace health and safety, management of sickness absence and return to work issues.

ABHB have set up a ‘Health and Work’ group chaired by the Director of Public Health to improve the health and wellbeing of employees, enhance occupational health skills in primary care and promote the importance of work as a determinant of health through links with Job Match and other services.

During recent workshops, GP training was provided on health and work and the management of musculoskeletal problems to help people stay in or return to work. These workshops were attended by over 70 GPs within Gwent and further training, accredited by the Royal College for General Practitioners has been planned for next year.

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Table 4.0: Percentage of adults reporting particular health conditions amongst the population of Aneurin Bevan Health Board

AB

HB

Cae

rphi

lly

Bla

enau

G

wen

t

Torf

aen

Mon

mou

thsh

ire

New

port

WA

LES

High blood pressure

22 24 25 23

17

21 20

Any heart condition excluding high blood pressure

9 10 10 10 8 9 9

Any respiratory illness

13 14 15 14 11 12 13

Any mental Illness

11 11 15 14 8 10 10

Arthritis

14 16 17 15 8 14 13

Diabetes

7 7 8 8 5 8 6

Have a limiting long-term illness

29 31 32 31 25 29 27

Source: Welsh Health Survey, 2008 and 2009 Lifestyles and behaviours In all local authorities within the area, more than half the population is overweight or obese (table 4.1). This is mirrored by low levels of physical activity, and only a third of people in the overall health board area meeting the guidelines for fruit and vegetable intake. Rates of smoking, and drinking above guidelines, are similar in the health board area to the Wales average. Yet more than 1,000 deaths and 10,000 hospital admissions each year are caused by smoking and alcohol respectively. Although numbering over 400 per year, rates of hospital admissions due to drugs are generally low, compared to Wales. Just as we have seen the variation in life circumstances, demography and health leading to significant inequities for our population, so we see the same for the health behaviours (table 4.1).

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Table 4.1: Lifestyle patterns and health outcomes shown at Local Authority Level Compared to Wales

Statistically significantly worse Not statistically significantly different Statistically significantly better

WA

LES

Cae

rphi

lly

Blae

nau

Gw

ent

Torfa

en

Mon

mou

thsh

ire

New

port

Aneu

rin B

evan

Annu

al n

umbe

r in

hea

lth b

oard

Adults who eat fruit and vegetables (5 a day) (%) a, 1

36 33 29 32 38 33 33 -

Adults who meet physical activity guidelines (%) a, 1

29 28 26 28 31 26 28 -

Adults who are overweight or obese (%) a, 1

57 61 63 60 55 58 59 -

Adults who smoke (%) a, 1

24 24 27 26 20 26 24 -

Death rate from smoking (males) b, 2, 3

340 379 413 359 272 334 350 640

Death rate from smoking (females) b, 2, 3

155 175 212 135 118 160 159 400

Smokers contacting Stop Smoking Wales (%) a, c

2.6 2.0 2.8 2.1 2.4 2.5 2.3 2660

Adults who drink alcohol above guidelines (%) a,1

45 44 45 43 45 47 45 -

Hospital admission rate due to alcohol (males) d,2,3

1940 2095 2654 1947 1539 2037 2033 6330

Hospital admission rate due to alcohol (females) d, 2, 3

1073 1160 1530 1161 950 1107 1157 4110

Death rate from alcohol (males) b,

2, 3 43 42 46 36 28 37 38 120

Death rate from alcohol (females) b, 2, 3

17 17 22 14 11 15 16 60

Hospital admission rate due to drugs (males) d, 3, 4

171 121 261 106 125 181 152 250

Hospital admission rate due to drugs (females) d, 3, 4

112 89 106 91 82 128 100 170

Teenage conception rate per 1,000 (under 16s) b

8.1 8.9 9.9 10.6 6.8 8.3 8.8 100

No. of decayed, missing or filled teeth (5 year olds) e

2.4 2.7 4.0 3.4 1.9 2.2 2.7 -

a Welsh Health Survey 2008 and 2009; b ONS (2007); c Stop Smoking Wales (2008/09); d PEDW (2008); e Welsh Oral Health Information Unit (2005/06) 1 Age-standardised; 2 Attributable deaths/admissions; 3 Age-standardised rate per 100,000; 4 Individuals with diagnosis directly related to illicit drugs Source: Public Health Wales Observatory

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Without action on these underlying determinants of health and healthy behaviour at the same time as the coordinated efforts to support people to change, it is unlikely that we will ever turn the curve on major and persistent inequities in health. If we consider the ageing population with its attendant rise in long-term health conditions we need to act together on inequities now, targeting the areas within Gwent most in need.

Case Study: Going for Gold ‘Going for Gold’ is Newport’s local brand of Health Challenge Wales. The aim is to improve the holistic health and wellbeing of Newport citizens through a variety of programmes and by providing accessible information and messages on how to live a healthy lifestyle.

The ‘Going for Gold’ scheme is free for residents of Newport to join, and rewards members for their healthy behaviours such as being active, eating healthy foods and much more.

Members of the scheme use their Going for Gold membership card in a similar manner as reward cards used in shops and supermarkets to collect points to earn rewards for their healthy behaviour. Members receive ‘Bronze’, ‘Silver’ or ‘Gold’ status depending on the number of activities they undertake.

Examples of activities that are rewarded through ‘Going for Gold’ include walking, cycling, gardening, healthy eating, working towards improving mental health and first aid.

Case study: Supporting people to stop smoking

Stop Smoking Wales is a free NHS service developed by Public Health Wales to help people quit smoking. Smokers are four times more likely to quit with the six-week support programme from

Stop Smoking Wales than going it alone. Support programmes are delivered in over 30 community venues across Gwent in the day and evening. In 2009/10, 1,347 smokers participated in the behavioural support programme across Gwent and of these 63% reported that they had quit at four weeks. Stop Smoking Wales can be contact on freephone 0800 085 2219 or visit www.stopsmokingwales.com Stopping smoking at least 4 weeks before an operation can reduce the chance of complications following surgery including breathing and lung problems, risk of infection and poorer healing of wounds.

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Early cancer detection Some early cancers can be detected by national screening programmes. Screening is a process of identifying apparently healthy people who may be at increased risk of a disease or condition4. Population screening programmes are designed to detect disease early, at a stage when treatment is more effective. Public Health Wales provides four national screening programmes across Wales. Each screening programme must operate within recognised guidelines and meet minimum standards and targets. The most recent available results of the screening programmes for residents in our area are in line or above the Welsh average, as table 4.2 illustrates. Table 4.2: Overview of screening programmes 2009/10 Aim of Screening Programme

Target Population

Target/ Standard

Wales uptake rate

Aneurin Bevan Health Board uptake

Newborn Hearing 5 Aim is to identify babies with hearing impairment which, without additional help and support, is of sufficient severity to cause or potentially cause a disability

Newborn babies within first month of birth

> 95% of eligible babies (who enter the screening programme) tested

99.7% of eligible and suitable babies tested

99.8% of eligible and suitable babies tested

Breast 6 Aim is to reduce mortality from breast cancer through early detection of breast cancer

Women aged 50 years and over

> 70% of invited women to attend for screening

75.6%

73.8%

Cervical 7 Aim is to reduce the incidence of, and morbidity and mortality from, invasive cervical cancer

Women aged 20-64 years

Five-year coverage >80% of women aged 25-64

76.5% 78.6%

Bowel 8 Aim is to reduce the number of people dying from bowel cancer in Wales by 15% by 2020

Men and women aged between 60-71 years *

Uptake of 60%

56.2% # 55.8% #

* Programme will be extended to everyone aged between 50 and 74 by 2015 # Nov 2008-Dec 2010 figures 5 Newborn Hearing Screening Wales (2009); 6 Breast Test Wales (2009b); 7 Cervical Screening Wales (2010); 8 Bowel Screening Wales (2011) There is a need to increase the uptake of cervical screening, particularly in young women living in deprived areas, and the uptake of all programmes in minority ethnic communities, especially for uptake of bowel and breast cancer screening. There are plans to introduce a new national screening programme for abdominal aortic aneurysm. The programme will aim to reduce the mortality from rupture of an aneurysm in the abdominal aorta.

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Linking actions to outcomes The driver diagram below (figure 4.5) shows the linear relationships between the important outcome indicators and their determinants, developed as described in the ‘Setting the Scene’ chapter. Understanding the ‘story behind the baseline’ is important because it explains the multiple causes that affect the outcome indicators. This helps us to understand the factors that affect the outcomes for working age adults and that we must focus our efforts to achieve real change. The diagram highlights that action to improve health must be multi-faceted and therefore is beyond the control of and single agency. The priorities for partnership action that follow are based on the priority drivers in the diagram identified using published criteria as described previously.

- 46 -

Figure 4.5: Diagram showing the relationships between outcome indicators, main determinants/causes and the areas of focus for partnership to help ensure working age adults live healthier lives for longer

- 47 -

Priorities for partnership action

• It is important that local strategies have a strong focus on prevention and early intervention to promote personal independence. Local partners should work together to improve life circumstances and tackle unhealthy lifestyles. In terms of the underlying determinants of health and inequalities, partnerships should tackle the negative health consequences associated with worklessness and economic inactivity. This should include action to mitigate the health impacts of poverty and ‘over-indebtedness’.

• Primary care has a central role in preventing chronic disease. In terms of primary prevention this should include for example vascular risk assessment and support which enables patients to take greater responsibility for their own health. Primary Care professionals can facilitate behaviour change through brief interventions, specialist smoking cessation services, weight management and exercise referral schemes. For high risk patients they should ensure effective clinical management of obesity, diabetes, hypertension and high blood lipids. In terms of preventable disease, action should also be taken to encourage uptake of national screening programmes.

• Adults with a long term condition may find it difficult to stay in work or return to work after a period of ill health. Healthy Working Wales has been developed to support employers, employees and health professionals to improve health at work, prevent ill health and to support return to work following ill health. GPs should receive support to develop occupational health skills and have access to evidence based guidelines and quality resources through, for example, Map of Medicine and the Welsh Backs programme. Locality partnerships should have established links with local and national schemes such as Condition Management Programme, Expert Patient scheme, Wellbeing through Work, Workboost Wales and the Health and Work Advice Line for Wales

• Front line workers often have to deal with people experiencing mental distress but may lack the skills and confidence to support them appropriately. Mental Health First Aid allows professionals to provide initial help to someone experiencing a mental health problem, deal with a crisis situation and guide people towards appropriate help and support. This should be supported by accessible primary care based counselling and psychological services.

• Work should be a source of good health for people. Employers should ensure that policies and programmes positively influence employee behaviour, management structures and the physical environment. This should encompass a range of areas such as smoking cessation, mental health, alcohol and substance misuse, food and fitness, musculoskeletal problems, occupational health and rehabilitation. Public sector employers should set an example by engaging in the Corporate Health Standard and demonstrate their corporate social responsibility and commitment to

- 48 -

sustainable development through energy use, procurement, facilities management, capital builds, employment and skills and community engagement. Additional support should be provided to small businesses with limited occupational health provision and those unable to commit resources to corporate health improvement.

• Programmes to support the long term unemployed are important in

maintaining health and wellbeing of this group.

Older people age wellinto their retirement

Chapter 5

- 49 -

Older People Our aspiration is that older people age well into their retirement There is a lack of routinely available data specifically relating to older people. Where data exists it is rarely available at a local authority level. However, the Older People’s Wellbeing Monitor for Wales published in 2009 suggests a number of indicators based on the Strategy for Older People in Wales (2008-2013) and the 18 United Nations Principles for Older Persons. These could help in tracking progress in future years. Morbidity and deaths The previous section detailed what we know about ill health, the leading causes of death and some of the prominent chronic diseases and their risk factors. Many of the issues for older people are the same, so although this data is relevant, it is not repeated here. There is also vast evidence about the benefits of healthy lifestyles in an older population. For example about 700,000 people over the age of 65 years in the UK have dementia which is due to vascular problems that may have been prevented by not smoking, having a healthy diet and taking regular physical exercise. Mental stimulation also seems to be protective. Preventable diseases Immunisations are acknowledged as highly cost-effective health interventions for prevention of disease. In Wales and the UK, vaccination against seasonal influenza (flu) is offered to all people aged 65 years and above. This is because older people are more likely than other age groups to suffer complications and hospitalisations as a result of flu if they are infected. For the 2010/11 seasonal influenza immunisation campaign the national uptake target was raised to the World Health Organisation (WHO) target of 75% uptake for people aged 65 and over and for those younger than 65 years in ‘at-risk’ groups. The uptake rate in those aged 65 years and over in 2010/11 for ABHB was reported as 66.2% (Table 5.0) compared to 63.3% in 2009/10 and 61.6% in 2008/09. This is similar to the Welsh uptake rate but some way below the national target of 75%. It suggests almost 34% of our older population may be unnecessarily at risk. Throughout 2010 and 2011, a significant amount of work has been undertaken by the STRIVE subgroup of the Gwent Immunisation and Vaccination Group. Their role has been to identify and share good practice in increasing the uptake rate of seasonal flu vaccination across ABHB and to identify and address systems errors which have occurred previously in the collection of COVER data.

- 50 -

Table 5.0: Health Board Seasonal Influenza vaccination uptake (%) among patients aged 65 years and over

Health Board Patients aged 65 and over Immunised (n) Denominator (n) Uptake (%)

Abertawe Bro Morgannwg University Health Board

52219 80853 64.6

Aneurin Bevan Health Board

58252 88025 66.2 Betsi Cadwaladr University Health Board

83165 122360 68.0

Cardiff and Vale University Health Board

44467 67466 65.9

Cwm Taf Health Board

30329 47525 63.8 Hywel Dda Health Board

43437 67729 64.1 Powys Teaching Health Board

15077 25632 58.8 Wales

326946 499590 65.4 *Data reported on April 05 2011

Note: Uptake rate for some HB areas may appear to have decreased slightly compared to the previous figures, this is due to differences in the weekly practice submission rate. A roll-up of figures will be conducted at the end of the season to ensure that data is as complete as possible. Figure 5.0: Health Board trends in Seasonal Influenza vaccination uptake (%)

among patients over 65 years#

#Based on weekly returns from General Practice collected through the Audit Plus Data Quality System, from 20/10/2010 to 05/04/2011 Note: Uptake figures for 20/12/2010 were affected by an unusually low submission rate, this was caused by a

temporary technical problem Source: Audit Plus Data Quality System

- 51 -

Pneumococcal vaccination is also offered to people over the age of 65 years and those with certain medical conditions which weaken the immune system, for whom pneumococcal infection is likely to be more common or serious. No annual data are reported regarding the uptake of pneumococcal vaccination in Wales.

Case Study: Keep Well This Winter Campaign The Keep Well This Winter campaign aims to provide information and support to people aged 65 and over to enable them to stay fit and healthy through the winter months. Key messages of the campaign are to encourage people to prepare for the winter and keep well by the following actions:

Heating your home well Keep rooms heated to a temperature between 18-210C

Dressing well for warmth Several layers of clothing are better than one thick layer

Getting financial support Grants and benefits are available to help with bills and energy efficiency

Eating well Have hot meals and hot drinks regularly throughout the day

Getting a flu jab Check you are eligible for a free flu jab from your doctor

In 2009/10 members of the Public Health Team working in Monmouthshire joined with local GP practices on a Keep Well This Winter roadshow. This included a mobile flu clinic, stalls and activities offering help and assistance to people aged over 65 years. In Tintern over 320 vaccinations were given and in Abergavenny 1,950 people were vaccinated at the roadshow events. The Gwent Public Health Team worked in partnership with Age Cymru to organise a multi-agency ‘Making Homes Warmer and Healthier to Live In’ training session, delivered by National Energy Action (NEA) Cymru. The training was aimed at professionals working with older people to raise awareness of the link between fuel poverty and health and to enable them to offer information and advice about grants, funding and support for home energy efficiency measures and low cost, no cost ways to save money on energy bills. The training was attended by representatives from social housing agencies, Age Cymru and Social Services.

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Chronic conditions

The most common health problems amongst older people are respiratory and heart disease, stroke, diabetes and fractures9. Evidence-based health promotion and disease prevention activities for these conditions are important. Services need to focus on supporting people to maintain their health, wellbeing and independence, to continually manage any chronic health conditions, prevent avoidable hospital admission through early intervention and enable older people to remain in their own home. The Welsh Assembly Government has estimated that of those patients admitted to hospital, 1 in 6 of all admissions and 1 in 4 emergency admissions are attributable to a chronic condition. The rates of emergency admissions among people under 75 years of age are shown in figure 5.1 (below) and figure 5.2. It has been suggested that many of these admissions are unnecessary, inappropriate and avoidable and that they are often as a result of inappropriate care (including self care) and an inadequate general support infrastructure for people with chronic conditions and their carers in the community10. Accidents and Injuries In Wales the overall injury rate starts increasing again after the age of 75 years. Mortality from injury is also higher in this age group especially for women, although in part this is explained by a shorter life expectancy in men. Older people have a higher risk of injury that results in hospitalisation or death than any other age group. Unaddressed visual problems can increase injury risk and delay hospital discharge. Eye checks for older people and those on benefits are free and regular checks should be encouraged. Many individuals can lose their independence and quality of life as a result of falls. Figure 5.1: Emergency hospital admission rates (EASR per 100,000) among people aged under 75 years: 2009

Source: PEDW/ONS

- 53 -

Figure 5.2: Emergency hospital admission rates (EASR per 1,000) among people aged under 75 years, by local authority area 95% confidence interval

70

.9

63

.4

67

.2

68

.1

63

.5

61

.1

55

.3

53

.8

59

.6

62

.3 76

.0

71

.2

65

.2

66

.8

60

.5

76

.9

97

.8

75

.4 86

.4

85

.0

68

.8 83

.4

Isle

of Angle

sey

Gw

yned

d

Con

wy

Den

big

hsh

ire

Flin

tshire

Wre

xham

Pow

ys

Cer

edig

ion

Pem

bro

kesh

ire

Car

mar

then

shire

Sw

anse

a

Nea

th P

ort

Talb

ot

Bridgen

d

The

Val

e of

Gla

mor

gan

Car

diff

Rhon

dda

Cyn

on T

aff

Mer

thyr

Tyd

fil

Cae

rphill

y

Bla

enau

Gw

ent

Torf

aen

Mon

mou

thsh

ire

New

por

t

Wales = 68.5

Areas ordered geographically from north west to south east

Source: Public Health Wales Observatory, using data from HSW (PEDW), ONS (MYE)

Injury in the home The majority of injuries in people aged 75 and over occur at home. Estimates suggest that one in three people aged 65 years and over experience a fall at least once a year – rising to one in two among 80 year-olds and over. Although most falls result in no serious injury, approximately 5% of older people in the community who fall in any year sustain a fracture or require hospitalisation. Incidence rates for falls in nursing homes and hospitals are two to three times greater than in the community and complication rates are also considerably higher because of a more vulnerable population. Around 10 to 25% of institutional falls result in fracture, laceration or need for hospital care, and 95% of hip fractures are the result of a fall. Falls have many risk factors including balance impairment, muscle weakness, environmental hazards and prescribed drug side effects and are potentially preventable. Their risk of falling increases, the greater the number of risk factors involved. Preventive programmes include exercise programmes, education programmes, medication review, environmental modification in homes or institutions and nutritional or hormonal supplementation, including vitamin D.

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Many of the most serious injuries in the home result from falls that lead to fractures, especially of the hip and wrist, and more so in women. Such fractures can lead to lengthy unscheduled hospitalisation and surgery, and can have serious medical consequences such as pneumonia and death.

Mental wellbeing Depression and social isolation can affect as many as one in seven people over the age of 65 and there is a growing body of evidence detailing the importance of the social and emotional aspects of wellbeing for older people. Social contact, rewarding activity, opportunities for engagement and participation are essential for the promotion of wellbeing and mental health, which may have consequences for physical health and sustaining independence. There is a need for additional social support to address loneliness and support the positive mental health of frail older people alongside the need for improved support for informal carers, many of whom are also elderly or frail. Suicide The suicide rate starts to rise steeply after the age of 85 in Wales, but only for males (see figure 3.3 earlier). Risk factors are discussed in the previous chapters, but for older men physical illness and being widowed become increasingly important risk factors for suicide.

Case study: EXTEND and Exercise Referral Scheme EXTEND provides gentle exercise to music classes for older people and for anyone of any age with a disability. Extend classes aim to promote health, increase mobility and independence, improve strength, co-ordination and balance and to counteract loneliness and isolation. EXTEND classes are suitable for all abilities and individuals work to their own level. EXTEND classes are delivered in many of our communities and are an excellent way of maintaining mobility and keeping active into our advancing years. Balance training is also an important intervention. The Exercise Referral Scheme also provides opportunities for people with certain conditions to keep active within a safe and fun environment. In Newport, exercise instructors have received training to introduce a new programme to reduce the risk of falls in older people.

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Oral health The need for oral healthcare can increase dramatically with the onset of old age, at the same time as frailty resulting in increased difficulties accessing dental services. Clinically, teeth retained into old age can become more prone to decay as a result of a number of inter-related factors. Many older people believe that they have good oral health and do not seek dental care, when only small proportions have clinically healthy mouths. Poor dental attendance is highly associated with deprivation. Dependence on others for general care brings additional risks of not receiving regular dental care. ABHB must look innovatively at ensuring dental provision for older people and link dental care with other services, such as general medical practice, chiropody and pharmacy. The use of domiciliary services should be considered carefully and are also another means through which dental care can be provided. Linking Actions to Outcomes The driver diagram (figure 5.3) shows the linear relationships between the important outcome indicators and their determinants, developed as described in the ‘Setting the Scene’ chapter. Understanding the ‘story behind the baseline’ is important because it explains the multiple causes that affect the outcome indicators. This helps us to understand the factors that affect the outcomes for older people and that we must focus our efforts on to achieve real change. The diagram highlights that action to improve health must be multi-faceted and therefore is beyond the control of any single agency. The priorities for partnership action that follow are based on the priority drivers in the diagram identified using published criteria as described previously.

- 56 -

Figure 5.3: Diagram showing the relationships between outcome indicators, main determinants/causes and the areas of focus for partnership to help ensure older people age well into their retirement

- 57 -

Priorities for partnership action • Partners should provide a range of community services for older people after

their retirement to improve quality of life, provide more opportunities to remain active in family and community life, maintain independence and reduce the need for acute and social care services. Growing older has been seen as a time of increasing dependency, when physical health declines and people are more subject to chronic and long-term conditions. Services and partnership strategies should aim to add life to year’s not just years to life. To achieve this priority, activities should include help to stop smoking and support to eat well and be physically active. This is particularly important to maintain bone and muscle health.

• We should also aim to increase the uptake of screening services which can

identify early signs and symptoms of cancer and other chronic conditions. We should take action to ensure that older people receive vaccination against seasonal influenza and pneumococcal disease.

• Partnerships should tackle issues relating to transport, financial security and

community safety to strengthen social and community networks. If these issues are not addressed they can lead to social isolation, sedentary behaviour, poor diet and poor housing conditions which in turn can exacerbate chronic conditions, accidents, falls and poor mental health. There should be an increased focus on intergenerational activities and opportunities for life long learning which increase skills, confidence and promote community participation. These approaches to community involvement will build social capital and ensure that older people feel valued, included and cared for in the community. These approaches will also have a significant impact on mental wellbeing and can help to reduce the rate of cognitive decline.

• The population is undergoing significant demographic change with a dramatic

rise in the older population. This will result in more homeowners and more people who want to remain in their own homes for longer. Housing support services need support to adapt to the likely changes in demand. The planning of homes and the wider built environment will need to take account of future needs and the social and lifestyle patterns associated with an ageing population, along the lines of ‘Homes for Life’.

Frail people are happily independent

Chapter 6

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Frail people Our aspiration is that frail people are happily independent Frailty is a difficult term to describe. It is associated with a high level of dependency and limitations on activities of daily living. Frail people will have one or more functional, cognitive or social limitations with a linked chronic condition. Frail people are particularly vulnerable and are less resilient to external factors that can result in a loss of their independence. For many frail people being happily independent means being able to remain in their own home with support, being listened to by people who are responsible for providing services to assist them, having their health and social care problems addressed quickly and as close to home as possible and being considered as a whole person. Frail people are not happily independent if they are regularly being admitted to hospital with urgent medical problems. Clearly not all emergency hospital admissions are due to frailty, but a large proportion will fit this category. A decline in independence can result in an admission to a residential or nursing care home temporarily or permanently. However, being independent is not just about remaining in your own home. We also want to empower and enable frail people to improve their quality of life and their social wellbeing. Many of the factors that cause frailty have been described in the previous chapter. Factors associated with successful ageing such as a healthy diet, being physically active, quitting smoking and falls prevention are all equally important to a frail population. Mental and social wellbeing Contact with friends, family and involvement in the local community are all important for mental health and wellbeing. The 2001 Census report highlighted that in the Aneurin Bevan Health Board area 44.2% of older people live alone compared to 43.0% in Wales as a whole. However, at the local authority area level figures vary from 42.4% in Newport to 47.5% in Blaenau Gwent. Living alone can increase the risk of isolation, and can affect an individual’s resilience to cope with everyday problems. It is also important that frail people live in dignity and security. They should be protected from crime (including the fear of crime) and be free from exploitation and physical or mental abuse. The wider physical environment and access to services can also affect a person’s mental and social wellbeing. Housing and the built environment Appropriate housing conditions will determine whether frail people live in an environment that is safe and adaptable to their personal needs and changing circumstances. Neighbourhood design and the built environment (buildings, roads, transport, pavements amenities) will determine whether frail people are able to

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participate in community life. Financial security also has an impact on social and lifestyle patterns, home safety, material comfort, care and assistance and is essential for peace of mind. Frail people should be able to access appropriate levels of day care, leisure and recreational facilities for socialisation, rehabilitation and mental stimulation in a secure environment. Transport is essential to maintain family and social networks, access leisure and recreational opportunities, and gives independent access to essential services such as shops and GP surgeries. Health and social care services Personal, social and environmental factors have a major impact on cognitive decline, mental and psychological function, and can make certain conditions worse. These factors can also increase the risk of falls, which can have a devastating effect on frail people which can lead to long-term health problems and a loss of independence. Frail people should be empowered to make decisions about the care and assistance they receive. Access to care and support should help them maintain or regain the optimum level of physical, mental and social wellbeing. This care should also prevent or delay the onset of illness and support activities of daily living. There are also a number of functional and physiological factors that affect whether a frail person is happily independent. These include physical fitness, body weight, skin integrity, sensory impairments, (including visual problems) continence and musculoskeletal problems. Smoking and poor nutrition directly affect the health of frail people and can make existing health problems worse. Access to well coordinated, holistic and timely primary care and community services are vital for frail people. The focus of this care should be on enabling them to remain happily independent. They should have access to preventative services (e.g. falls prevention) and vaccination against influenza and pneumococcal disease. Another important factor is being able to actively participate in formulating and implementing policies that directly affect the care and services they receive.

Case study: Gwent Frailty Programme The Public Health Team has been working with the Gwent Frailty Programme to undertake a literature review of the key causes of frailty. This is being used by the work stream to develop performance measures and outcomes indicators. In addition to this the Public Health Team has been invited to assist on the falls work stream to look at ways of reducing the impact of falls among frail people. This will initially focus on people that present in accident & emergency and care homes and will then focus on falls prevention in the community.

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Excess winter deaths

During the winter months the number of deaths is consistently higher than at other times of the year. Most excess winter deaths involve people aged 75 years or over, with particularly high rates affecting people aged 85 years or older. There are corresponding rises in excess winter unscheduled hospital admissions and re-admissions. Excess winter deaths are simply the average number of deaths in a given population from December to March minus the average number from April to November. The excess winter death index is then the percentage increase in the winter deaths compared with those in the non-winter months. In winter 2008/09, the number of deaths amongst those aged 85 or older was 34% higher than the average non-winter deaths in the same year. Excess winter deaths were 70% higher than the previous winter (see figure 6.0). The causes of excess winter deaths are complicated and many factors interact. Falling outdoor and indoor temperatures, outdoor ice and snow, higher influenza activity, the number of frail and older people in society, the number with existing cardiovascular and respiratory disease, risk of falls in the home, air pollution, poor nutrition, poor quality insulation of housing, lower household income, and fuel poverty all contribute to the risk of winter death. Many older and frail people in Wales and ABHB suffer high levels of many of these risk factors and so are vulnerable to excess winter death. Fuel Poverty occurs when a household cannot achieve temperatures in the home needed to maintain health and comfort for less than 10% of their income. An estimated 320,000 households in Wales were affected by fuel poverty in January 2009, an increase of 90,000 on the previous year. Many older and frail people find themselves in fuel poverty caused by a combination of low household income, unaffordable energy costs and inadequate thermal insulation and inefficient and uneconomic heating systems. Because the way these risk factors interact is not straightforward, the degree of excess winter deaths varies widely from winter to winter, especially in the 75 to 84 year age group. Provisionally for 2009/10, in Wales the winter excess for the 85 and older age group was 30%, similar to the previous year. Two facts are clear. Excess winter death rates in Wales are consistently much higher than in colder countries in Scandinavia and continental Europe. Excess winter deaths in Wales are consistently higher in the 85 year and older age group from year to year.

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Figure 6.0: Excess winter deaths by age group in Wales: 1991/92 to 2008/09

Source: ONS data

Similarly for ABHB as a whole there is a wide variation in excess winter deaths each year. For 2009/10 all age excess winter deaths were 17% higher than non-winter months, which was below the Wales average of 18.5% (see figure 6.1). Figure 6.1: Excess winter deaths (EWD) index for persons resident in

Wales: August 2009 to July 2010

Source: Produced by Public Health Wales Observatory using data from the Office for National Statistics (PHMF)

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It is important to consider differences across the five localities. Because of large year-to-year variations and smaller numbers, it is not possible to see a clear difference. Although Caerphilly, Blaenau Gwent, Torfaen and Monmouthshire were all above the Wales average for all age excess winter deaths in 2009/10, over the last five years there is no clear pattern. However, it appears that excess winter deaths may have been consistently higher in Blaenau Gwent and Caerphilly over the last few years. Very few excess winter deaths are directly from hypothermia, 35% are from circulatory disease and 34% are from respiratory disease (for both diseases, some deaths are in people with pre-existing disease, but many were not previously diagnosed). The remaining 20% are due to other causes such as falls (figure 6.2). Respiratory diseases and falls show the highest percentage winter increase compared with non-winter months. As explained, the underlying causes are complex over the winter months, but after a particularly cold period heart attacks are more likely in the two days following; strokes after five days and respiratory illness after twelve days. Figure 6.2: Excess winter mortality by underlying health cause: 2005/06 to 2007/08

Source: ONS End of life care As more people live into old age, end of life and palliative care become an increasingly important consideration for frail people. It is important that this care is appropriately planned and coordinated so that frail people do not experience pain or symptoms and are in familiar surroundings in the close company of family or friends. Linking Actions to Outcomes The driver diagram (figure 6.3) shows the linear relationships between the important outcome indicators and their determinants, developed as described in the ‘Setting the Scene’ chapter. Understanding the ‘story behind the baseline’ is important because it explains the multiple causes that affect the outcome indicators. This helps us to understand the factors that affect the outcomes for frail people and highlights where we must focus our efforts to achieve real change. The diagram highlights that action to improve health must be multi-faceted and therefore is beyond the control of any single agency. The priorities for partnership action that follow are based on the priority drivers in the diagram identified using published criteria (as described previously).

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Figure 6.3: Diagram showing the relationships between outcome indicators, main determinants/causes and the areas of focus for partnership to help ensure that frail people are happily independent

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Priorities for partnership action • The physical environment should be designed to take account of the needs of

frail people. In terms of housing conditions, action should be taken on home safety, fuel poverty, assistive technology, which together can help to prevent falls, reduce excess winter deaths and support activities of daily living. This should be supported by action to maximise uptake of welfare benefits and financial inclusion, which are important for material comfort and quality of life. Home safety checks should form part of the care of frail and older people.

• Access to high quality, well coordinated and responsive primary care and

community services (e.g. GP, rapid response, reablement, home care, assistive technology, respite, etc) is essential to tackle the causes and consequences of frailty. A comprehensive frailty service will address cognitive decline, falls, malnutrition, smoking, physical fitness, osteoporosis, sensory impairments, carer burden, medication reviews, pressure sores, skin ulcers, musculoskeletal problems, continence and worsening of chronic conditions. Frail people should also be offered vaccination against seasonal influenza and pneumococcal disease.

• Frail people also need care and assistance to maintain their social networks

and activities of daily living. This should include access to affordable transport, shops and amenities, leisure and recreational activities. Partnerships should also consider other issues such as fear of crime and community safety issues that can also have a detrimental impact on the mental wellbeing and quality of life. Crime prevention schemes help frail and elderly people to feel safe in their own homes.

• Finally, it is important that frail people are treated with dignity and respect in

relation to palliative and end of life care. Appropriate involvement in their care planning and coordination is important to ensure that people do not experience avoidable pain or symptoms, and wherever possible, are in appropriate environments and surroundings and close to company of friends and family. High quality care should be available wherever the person may be: at home, in a care home, in hospital, in a hospice or elsewhere.

Public health challenges

Chapter 7

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Public Health Challenges Public health plays a key role in supporting the development of partnership action to create environments to generate health improvement. The previous chapters highlight the important areas where evidence based approaches are advocated. However, it is important to highlight that this covers only some elements of public health focus. There is also a continuing need to guard against threats to health from newly emerging and/or re-emerging infectious diseases; environmental hazards and health protection issues that arise unexpectedly and to provide advice and guidance on mitigation strategies in a timely manner. In addition, the current financial situation we find ourselves in as a nation, can also add to the intangible yet real threats to our health that need to be at the forefront of our thinking when we attempt to address local health needs. Within all of this, it is important to ensure that the sustainability agenda runs like a thread throughout the work of the local partnerships in conjunction with public health. It should be viewed as an opportunity to support change, that may help mitigate some of the above threats. Protecting Public Health Investment The current global financial crisis leaves the UK and Wales with a large gap in public finances of around £86 billion, or 6% of the UKs GDP. Public spending cuts and tax increases are planned over the next four years to tackle the issue. Public debt is a dominant theme in national and global economic policy debates, along with the government’s response, and the potential impact on population health. Within the NHS in Wales, considerable improvements will be needed in terms of efficiency and productivity over the next few years, if the available budgets are to stretch to meet the ever increasing demands and costs. Difficult decisions will be needed in the future to determine priorities.

Improvements in public health, through sanitation, good hygiene, and the introduction of vaccinations in the early 20th century, have led to the control and virtual elimination of diseases that once killed millions of people worldwide.

However, we now live in a society where more people are living longer, and we are presented with a different set of challenges, such as frailty of an increasingly ageing population and other chronic diseases including heart disease, stroke, cancer, chronic respiratory disease and diabetes. Previous recessions have seen an upsurge in domestic abuse including child neglect and intentional injury.

The current economic climate presents an increasingly challenging environment, where resources are limited. Although many improvements in public health have occurred, there are still major areas which need to be tackled including smoking, alcohol, obesity and poor mental health. Despite the public health focus on the wider determinants of health, there is still evidence of significant inequities in health continuing within our communities.

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Evidence supports a focus upon early years, to reduce the adverse effects of deprivation and disadvantage experienced. The gap in health inequalities requires a sustained focus to ensure that where a person lives, or their social circumstance does not lead to a lesser quality of life or premature death. In a climate of scarce resources, and within a recession, job insecurities, unemployment and inadequate employment can all have a major impact on the health of individuals and their families, and the wider community. Limited resources can also result in a situation where services that are cut, are those which lack a strong advocacy base, rather than those lacking a strong evidence base for improving health over the longer term. It is vital that cuts and efficiency savings are not made in the short term, only to result in longer term challenges and higher treatment costs at a later stage. The pressures of historical and long-lasting deprivation, together with the current financial uncertainty, present significant challenges for health, not just now, but in the years to come. It is therefore imperative that investment in improving the population’s health continues and investing in prevention will provide good financial returns and improved health outcomes in the future. Prevention is better than cure and that is why we need to invest sufficiently in preventing the preventable. Communicable Disease Control Over many decades in the last century, deaths from communicable diseases such as measles, TB and meningitis have decreased due to improvements in nutrition, housing, vaccinations and antibiotics and antiviral medicines. However, as seen in last year’s swine flu pandemic, communicable diseases still present a challenge if unaddressed. The Director of Public Health is supported by local colleagues in Health Protection from Public Health Wales. Advice to local authorities, primary care practitioners, schools, prisons and the public is given and communicable disease incidents are responded to as required. Table 7.0 sets out information on communicable diseases and infections notified in ABHB, for the period January to October 2010. The data is provisional and subject to correction later in 2010.

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Table 7.0: Notifications of infections in the Aneurin Bevan Health Board area: 1 January – 31 December 2010 (provisional) Disease CountMEASLES 26 0 confirmed cases DYSENTERY 6WHOOPING COUGH *SCARLET FEVER 19VIRAL HEPATITIS 97MUMPS 104 19 confirmed cases RUBELLA 8 0 confirmed cases TYPHOID FEVER *FOOD POISONING 1,255TUBERCULOSIS 29MENINGITIS/SEPTICAEMIA 47 Of these, 1 was a Hib Meningitis and

1 was a Pneumococcal Meningitis

CHOLERA *DIPHTHERIA *INFLUENZA 13LEGIONELLOSIS 9OTHER ACUTE ENTERITIS NFB *FOOD POISONING-SUSPECTED 6OTHER NON-NOTIFIABLE 68 Cells with less than 5 cases are denoted with to maintain data protection. Source: CoSURV reports of diseases reported by GPs and hospital doctors, and laboratory reports of infections Notes:

1. Viral hepatitis includes acute or previous infection with hepatitis A, B, C and E. Laboratory reports of existing, rather than acute, hepatitis C infections account for the majority of the reports

2. Meningococcal disease includes both meningitis and septicaemia caused by the meningococci bacteria

Two noteworthy events in 2010 were the implementation of the Health Protection Regulations Wales 2010 and an outbreak and joint investigation of cases of Legionnaires’ disease during the summer. Health Protection Wales Regulations 2010 The Health Protection (Notifications) (Wales) Regulations 2010: These regulations include a revised list of communicable diseases that doctors must report to the Proper Officer of the local authority in the place where the patient resides. The regulations also include new provisions for cases that may have been caused by contamination with chemicals or radiation. From 1st October 2010, diagnostic laboratories have had to report if they found specific micro-organisms in human samples.

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Legionnaires’ disease Legionnaires’ disease is a bacterial infection, which can occur at any time of the year, although cases tend to peak in the summer and autumn. Between 300 and 350 cases a year are reported each year in England and Wales, around one-half of which are associated with travel abroad. On average there are around 13 cases a year in Wales. Legionella bacteria are widespread in the environment, being able to live in all types of water. This includes both natural sources such as rivers and streams, and artificial sources such as water towers associated with cooling systems, hot and cold water systems, and spa pools. They become a risk to health when the temperature allows the bacteria to grow quickly (between about 20 and 45ºC). This can happen in water systems that are not properly designed or installed or maintained. Systems such as cooling towers need to be regularly cleaned and disinfected to inhibit the growth of legionella. Legionnaires’ disease cannot spread from person to person. Given the ubiquitous nature of legionella bacteria it is often difficult to identify the source of infection. However, the process of finding out about patients’ activities can help to identify whether there could be links between cases that merit further in-depth investigation. In 2010, 15 cases of legionella were reported to the Health Protection Team. Of these, 5 were sporadic (i.e. not linked to other cases) and 10 were investigated as part of the cluster/outbreak in people resident or visiting the South Wales valley area. Each case is investigated by the local authority Environmental Health Officers in liaison with the Health Protection Team. The Seasonal Influenza immunisation programme The aim of the annual seasonal influenza immunisation campaign is to minimise illness, deaths and hospital admissions associated with influenza. The vaccine is offered to all people aged 65 years and over, and people between 6 months and 65 years of age with medical conditions likely to be made worse if the individual gets influenza. The vaccine is also recommended for residents of long-stay care homes and those who are the main carer for an elderly or disabled person whose welfare may be at risk if the carer fell ill. It is also recommended for frontline health and social care workers. The constituents of the vaccine are changed each year because of changes in the circulating strains. The World Health Organisation through a series of global influenza laboratories, monitors circulating strains and makes a recommendation based on this information on what components should be included in the vaccine for the forthcoming season. The vaccine is normally given in the period September to December each year, in order to provide timely protection. After immunisation it can take 10 to 14 days for antibodies to reach the optimal level of protection. Specific reference to percentage uptake in the ‘at risk’ populations has been made in earlier chapters.

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Environmental Health The Gwent Public Health Team advises on environmental health in our area. We are supported in this by Public Health Wales Health Protection colleagues and the Health Protection Agency CRCE (Wales). From 1st April 2010 to 30th September 2010 we advised on the following issues:

• Contaminated Land • Planning Applications (including Integrated Pollution Control applications) • Environmental Permit consultations • Chemical Incidents • Public Health Enquiries • Direct Enquiries by Members of the Public (MoP)

Activities by local authority area during the period 1st April 2010 to 31st March 2011 are presented in the table 7.1 below:

Table 7.1: Activity by Local Authority Area: 1/4/10 – 31/3/2011 Local Authority Area

Cont. Land

Planning Apps.

Chemical Incidents

IPPC (Env

permits)

Public Health Enquiry

WAG Enquiry

Direct MoP Enquiry

Total

Blaenau Gwent

0 3 1 1 1 0 0 6

Caerphilly

2 1 3 1 3 1 0 11

Monmouthshire

0 1 0 6 5 0 0 12

Newport

4 2 4 3 0 0 0 13

Torfaen

0 0 1 3 1 0 1 6

Environmental advice activities in the ABHB area are relatively demanding. A comparison to other health board areas activity is demonstrated in table 7.2 below which shows the activities across Wales over the same period (1st April 2010 to 31st March 2011):

Table 7.2: Activity by Health Board Area: 1/4/10 – 31/3/2011 Local Authority

Area Cont. Land

Planning Apps.

Chemical Incidents

IPPC (Env

permits)

Public Health Enquiry

WAG Enquiry

Direct MoP Enquiry

Total

Abertawe Bro Morgannwg University

2 9 2 4 2 0 0 19

Aneurin Bevan

6

7

9

14

10

1

1 48

Betsi Cadwaladr University

3 3 3 3 5 0 0 17

Cardiff and Vale University

2 0 4 1 0 0 0 7

Cwm Taf 1 5 1 1 3 2 0 13 Hywel Dda 5 2 0 4 3 0 0 14 Powys Teaching

6 1 1 2 4 0 0 14

Unknown/non area specific

0 0 0 0 0 2 3 5

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Sustainable Development and Health Improvement Sustainable development is a relatively recent concept for many people, but in fact is closely aligned to public health and improving the health of populations. The goal of sustainable development is to “enable all people throughout the world to satisfy their basic needs and enjoy a better quality of life without compromising the quality of life of future generations”11. In Wales, sustainable development means enhancing the economic, social and environmental wellbeing of people and communities, achieving a better quality of life for our own and future generations:

• in ways which promote social justice and equality of opportunity • in ways which enhance the natural and cultural environment and respect its

limits • using only our fair share of the earth’s resources and sustaining our cultural

legacy If we can move towards this, we will not just be contributing to a better and more equitable health status for our local population, but also for the global population. Aneurin Bevan Health Board has recently signed up to the Welsh Assembly Government’s Sustainable Development Charter. This essentially commits the organisation to promoting sustainability within all of its activities. Monmouthshire Local Service Board (working to the Wales Spatial Plan) with Aneurin Bevan Health Board have already signed-up to 10:10. A mass movement of people, organisations, education establishments and businesses across Britain working together to achieve a 10% cut in the UK's carbon emissions in 2010 as a first step towards a carbon zero society. 10:10 organisations make a commitment to try to reduce their carbon footprint by 10% in one year. More details are available at www.1010uk.org. They are encouraged to reduce their carbon footprint in:

• electricity • on - site fuel use • road transport • air travel

Some additional benefits of joining include:

• contributing to tackling the climate change challenge • receiving information to support our sustainability work • a means for getting staff commitment to reducing energy and car use • saving money on energy and transport

A high level of economic inactivity, at least partially due to a lack of employment opportunities, is one of our most fundamental public health problems in parts of the ABHB area. Obesity, a poor diet and low levels of physical activity, are additional widespread problems. Some actions which enhance sustainability will also help to address some of these issues.

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Local procurement of goods and services is one practical way of addressing ‘sustainability’. It can increase local jobs (and therefore health in the local population), reduce energy expenditure and therefore carbon use (by reducing transport miles), and possibly contribute to the maintenance of environmental diversity by supporting local agriculture. Local suppliers can also be more responsive to the needs of a consumer organisation. Fear of increased costs often discourage officers from pursuing local procurement, but there are examples of good practice from NHS organisations in other areas of the UK – e.g. the development of farmers co-operatives to supply meat. Another potential activity would be to use local labour to invest in social housing through the installation of (locally manufactured) insulation etc. Better home insulation reduces fuel poverty, leaving more household income available for food, and also addresses the potentially adverse effects of extreme hot or cold weather. Promoting active travel has multiple benefits in terms of both health improvement and reducing carbon emissions. Changing people’s behaviour to ‘normalise’ walking or cycling for short regular journeys gives people regular physical activity, but also reduces vehicle use and therefore air pollution and carbon emissions. Sustainable development could also play a significant role in reducing health inequities. Global warming and climate change has a disproportionate impact on already disadvantaged groups, both locally and globally. Without careful consideration, responses to climate change may increase negative effects on those on lower incomes. Many of the effective responses proposed here to prevent life course health inequities and major public health problems in the Aneurin Bevan Health Board area could have a longer lasting effect and a greater population impact, at less cost, if they were embedded within a multi-agency approach and seen in the context of sustainable development. In order to achieve this, it will require a coordinated implementation of economic, environmental and social policies to promote supportive ecosystems, social justice, and reduced health inequities. A collaborative approach to tackling these challenges is needed, and an acceptance of a shared responsibility to do so. In the current financial climate, effective partnership working, and utilising limited resources is vital to continue to improve the health and wellbeing of the population of Aneurin Bevan Health Board.

Public health support for healthcareservices in Aneurin Bevan Health Board

Chapter 8

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Public Health support for Healthcare Services Public health specialist skills can support and enhance the delivery of healthcare services in terms of

• the provision of appropriate services for population based on need and evidence of effectiveness

• the quality of services to increase health gain • evaluation of the health impact of services on population health

The Public Health Wales Observatory was recently established, which will assist Health Boards by publishing documents such as Key Small Area Indicators. Local Public Health Teams, although small, are also supporting health boards through identification and interpretation of the evidence-base for action, and by advising on appropriate data sets. Another important work area is the bringing together of various strands of services from across and outside the NHS to promote a care pathway from primary prevention to specialist treatment. The Gwent Public Health Team has been heavily involved in the Musculoskeletal Operational Group. To date, much of the work has revolved around orthopaedics given the current pressures that this service is under locally. Work has included reviews of the evidence base relating to various aspects of orthopaedic care. Three reviews have been completed:

• Estimated need for hip and knee arthroplasty and subsequent follow up. This review quantifies the demand for primary hip and knee replacements, estimates the need for these procedures and describes the evidence base relating to “true willingness” to undertake the procedure through fully informed consent. It also reviews the evidence base related to the follow up of patients post arthroplasty and proposes a pathway for such patients to be reviewed virtually.

• Management of chronic low back pain with a focus on the use of spinal injections. This review defines chronic low back pain and assesses the evidence for the management of such patients, based on several international guidelines. It focuses on the evidence base for use of X-Rays, Magnetic Resource Imaging (MRI), and other interventions including spinal injections and then proposes a pathway for treatment of such patients.

• Lifestyle management of patients with hip and knee pain as an alternative to immediate referral for surgery. This reviews the evidence base relating to numerous scoring systems that have been implemented in some areas of England and internationally as prioritisation tools for patients requiring hip or knee replacement. A pathway for patients with hip and knee pain suggestive of osteoarthritis is proposed, which includes generic lifestyle management but also referral to specific muscle strengthening exercise programmes.

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Public Health Consultants across South Wales have completed an Orthopaedic Review of the provision of the main orthopaedic procedures. These include:

• Hip and knee replacement • Shoulders • Ankle and foot • Hand • Spinal • Scoliosis • Knee arthroscopy

Work on reviewing strategies and policies for ‘Individual Patient Treatment Requests’ and interventions of low clinical effectiveness has been conducted to provide standardised policies which have been adopted by a number of health boards, including ABHB. A Public Health Consultant is a member of the Individual Patient Treatment Request (IPTR) Panel and provides the evidence base for the interventions being discussed at the fortnightly meetings. Public health supports the ‘Waste Harm and Variation’ group of ABHB to assist in identifying aspects of variation in service delivery both within and between boards. Public health also supports the ABHB Quality and Patient Safety Committee, the ‘Frailty’ Board, the ‘Setting the Direction’ Board (Primary and community resource teams), the ‘Clinical Futures’ Board and the Commissioning Group. As part of national work, Public Health Wales and University of Wales Institute, Cardiff (UWIC) are working on a programme of brief intervention training for Accident and Emergency department trauma and maxillofacial unit staff. This aims to reduce harmful consumption of alcohol in patients attending for follow up after alcohol related injuries. Work has also been undertaken in support of a ‘Save A&E for when you need it!’ campaign, aimed at reducing unnecessary A&E attendance. This included specialist mapping of A&E attendance by GP practice across Gwent, undertaken by locally based staff from the Public Health Wales Observatory. The national Pharmaceutical Public Health team models costs of new NICE approved drugs to support NHS planning; and locally staff have agreed topics for inclusion in the ‘health promotion’ elements of the Pharmaceutical Contract. The Gwent Public Health Team has also been involved in the local review of obesity services and preventive activity across both the NHS and local government and has delivered a training workshop on obesity for local GPs. In Torfaen locality, the Public Health Team has been supporting the development and planned evaluation of a British Heart Foundation funded, GP led obesity service. Local practitioners from the Public Health Wales ‘Stop Smoking Wales’ team have been working with the ABHB surgical divisions to introduce referral to the pre-operative smoking cessation service into the normal treatment pathway for surgical interventions. Information sessions have been delivered to front line staff in using

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‘brief advice’ techniques. This is a method to support patients to access Stop Smoking Wales either to stop smoking in the short term before their operation and the post-operative period, or longer-term. The ‘Stop Smoking Wales’ team also continues to provide the 6 week behavioural support groups for all clients wanting to quit smoking across ABHB. The Dental Public Health team have been supporting the ABHB oral health group, focusing on coordination of oral health services between General Dental Practitioners, the Community Dental Service and the Oral Surgery service. The Primary Medical Care Advisory Team within Public Health Wales is leading a programme of CPD events for GPs and their staff in optimal use of the new ‘fit notes’, and supporting working age adults to remain in employment wherever possible. Promoting equality of access to services is another strand of public health work. Newport Public Health Team, with support from national staff, have been running community events for ethnic minorities to encourage uptake of services, particularly from groups with higher incidence of conditions such as diabetes. This is part of a wider project on health improvement in ethnic minorities, which came under the banner MECHANIC (Minority Ethnic Community Health Association for Newport: Initiating Change). In Monmouthshire, the Public Health Team have supported ABHB in a needs assessment and review of prison health services which are based within the County. Area Planning Boards (APB) have been established in each of the seven local health board areas in Wales, in an attempt to ensure that substance misuse issues are addressed in an effective and holistic manner from both health services and Community Safety Partnership perspectives. The Director of Public Health for ABHB is the vice chair of the regional Gwent APB. Public health staff are supporting the commissioning of treatment services for young people in some localities, and also works around needle exchange, harm reduction interventions, drug related deaths and substance misuse in pregnancy. A Public Health Practitioner leads the Prevention and Education sub-group of the APB.

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Reference 1. Welsh Assembly Government (2009). Our Healthy Future. Cardiff: Welsh

Assembly Government

2. World Health Organisation. [Global Strategy for Infant and Young Child Feeding]. Geneva: WHO; 2003.

3. The Information Centre. Infant Feeding Survey 2005. Available from: http://www.ic.nhs.uk/webfiles/publications/ifs06/2005%20Infant%20Feedin g%20Survey%20%28Chapter%2010%29%20%20Dietary%20supplments %20smoking%20and%drinking%20during%20pregnancy.pdf [Accessed 29 November 2010] 4. National Screening Committee (2010) Accessed at:

http://www.screening.nhs.uk 5. Newborn Hearing Screening Wales (2009) Report of the Associate Director 2009. Accessed at:

http://www.screeningservices.org/nbhsw/reports/ 6. Breast Test Wales (2009b) Report: Local Health Board Uptake for the first five rounds of screening. Accessed at: http://www.screeningservices.org.uk/btw/reports/reports.asp 7. Cervical Screening Wales (2010) Cervical Screening Programme Wales

2009/10. KC53/61/65 Statistical Report 2009/10. Accessed at: http://www.screeningservices.org.uk/csw/prof/reports/index.asp 8. Bowel Screening Wales (2010) Accessed at: http://www.wales.nhs.uk/sites3/page.cfm?orgid=747&pid=34125 9. Welsh Assembly Government (2006) National Service Framework for Older

People. Accessed at: http://wales.gov.uk/docs/dhss/publications/060320nationalserviceframeworkforolderpeopleen.pdf

10. Welsh Assembly Government (2007) Designed to Improve Health and the

Management of Chronic Conditions in Wales. Accessed at: http://wales.gov.uk/dhss/publications/health/strategies/chronicconditions/chronicconditionse.pdf?lang=en

11. Secretary of State for Environment, Food and Rural Affairs. Securing the

Future the UK Strategy 2005. London: TSO; 2005  

Appendix: Summary key statistics for Gwent

WalesAneurin Bevan

Blaenau Gwent Caerphilly

Monmouth-shire Newport Torfaen

Mid-Year Population Estimates (in thousands) 2009A

Gender Age groupMales 0-15 282.5 55.7 6.4 17.6 8.3 14.6 8.8

16-24 191.7 33.8 4.4 10.2 4.4 9.3 5.625-44 362.0 67.5 8.2 22.0 9.5 17.3 10.545-64 387.5 73.3 8.8 22.3 12.9 17.1 12.165+ 241.8 43.2 5.6 12.5 8.0 10.0 7.1All Ages 1,465.5 273.6 33.4 84.6 43.2 68.4 44.1

Females 0-15 267.7 52.9 6.2 16.4 7.8 14.0 8.416-24 182.1 32.0 4.2 9.7 3.9 9.0 5.225-44 372.9 71.0 8.7 23.1 9.8 18.0 11.345-64 404.6 75.6 9.2 23.1 13.3 17.7 12.365+ 306.5 55.5 6.9 15.9 10.0 13.3 9.5All Ages 1,533.8 286.8 35.3 88.2 44.8 72.0 46.6

Persons 0-15 550.1 108.5 12.6 34.0 16.1 28.6 17.216-24 373.9 65.8 8.6 19.8 8.3 18.3 10.725-44 734.9 138.5 16.9 45.1 19.4 35.4 21.745-64 792.1 148.9 18.0 45.4 26.2 34.8 24.465+ 548.3 98.7 12.4 28.4 18.0 23.3 16.6All Ages 2,999.3 560.4 68.6 172.7 88.0 140.4 90.7

% under 25 30.8% 31.1% 31.0% 31.2% 27.7% 33.4% 30.8%% 65+ 18.3% 17.6% 18.1% 16.4% 20.5% 16.6% 18.3%

Population projections (in thousands) 2008-basedB

Age YearAll Ages 2015 - 569.9 69.8 176.1 90.1 143.2 90.7

2020 - 578.3 70.7 178.7 91.6 146.5 90.82025 - 584.9 71.3 180.6 93.0 149.6 90.52030 - 588.9 71.4 181.7 93.8 152.2 89.8

65+ 2015 - 113.7 14.0 33.3 21.7 25.8 19.02020 - 123.4 14.9 36.5 24.3 27.2 20.62025 - 133.5 15.9 39.7 26.6 29.3 22.02030 - 146.7 17.3 43.7 29.6 32.0 24.0

85+ 2015 - 15.0 1.7 4.0 3.0 3.6 2.62020 - 17.7 2.0 4.8 3.7 4.2 3.12025 - 21.5 2.4 6.0 4.5 5.0 3.62030 - 26.8 3.1 7.5 5.8 6.0 4.5

Sources: A = Office for National Statistics; B = Welsh Assembly Government

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WalesAneurin Bevan

Blaenau Gwent Caerphilly

Monmouth-shire Newport Torfaen

Live births 2009A

Number 34,937 6,770 791 2,140 802 1,947 1,090

Low birth weight 1998-2007C

Annual average number - 391 57 122 40 112 60% of singleton live births - - 7.8% 6.1% 4.9% 6.8% 6.0%

Congenital anomalies per 10,000 births: 1998-2008D

Rate 495.1 - 576.1 454.9 462.9 453.7 476

Infant Mortality rates (per 1000) 2004-2008 E

Perinatal 7.4 - 9.2 7.6 6.3 7.7 8.1Neonatal 3.1 - 2.8 2.8 2.3 3.3 2.7Infant 4.5 - 4.6 4.7 3.5 5.3 4.4

Immunisation uptake (%) Quarter 4 2010F

Age Vaccine1 year 5 in 1 95.9 95.7 96.6 96.8 93.3 94.7 96.71 year Men C 95.5 95.7 96.6 97.0 93.3 94.7 96.72 years MMR1 91.2 90.4 93.8 90.4 83.4 91.1 92.65 years MMR2 87.0 87.1 88.6 87.5 91.2 82.3 89.5

Dental decay in 5 year olds 2005/06G

2.4 2.7 4.0 2.7 1.9 2.2 3.4

Teenage conceptions 2006-2008A

Annual average numberUnder 16 478 100 12 28 14 24 22Under 18 2,599 538 68 168 59 142 101

Life expectancy at birth in years 2006-2008A

Males 77 77 75.3 75.6 78.7 77 77Females 81.4 81 78.8 80.9 83.4 81.5 81

Deaths from all causes for all persons 2004-08H

Annual average number 31,955 - 843 1,774 873 1,382 964635.1 - 751.9 697.9 533.2 635.3 636.6Rate (European age-

standardised per 100,000)

Sources: A = Office for National Statistics; C = Public Health Wales Observatory, using data from ONS (ADBE, MYE); D = CARIS; E = All Wales Perinatal Survey; F = CARIS; G = WOHIU; H = Public Health Wales Observatory, using data from ADDE/ONS

Average no. of decayed, missing or filled teeth

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WalesAneurin Bevan

Blaenau Gwent Caerphilly

Monmouth-shire Newport Torfaen

Smoking prevalenceAdults who smoke (%)I 24 24 27 24 20 26 26Death rate from smokingJ

Males 340 350 413 379 272 334 359Females 155 159 212 175 118 160 135

2.6 2.3 2.8 2.0 2.4 2.5 2.1

Alcohol consumption45 45 45 44 45 47 43

Males 1940 2033 2654 2095 1539 2037 1947Females 1073 1157 1530 1160 950 1107 1161

Males 43 38 46 42 28 37 36Females 17 16 22 17 11 15 14

Drugs

Males 171 152 261 121 125 181 106Females 112 100 106 89 82 128 91

Other Lifestyles36 33 29 33 38 33 32

29 28 26 28 31 26 28

57 59 63 61 55 58 60

Wider determinants3.5 - 6.2 4.5 2.3 4.6 4.1

9.6 - 14.2 12.4 6.6 9.0 10.5

63.7 - 48.7 61.2 64.7 66.6 62.2

66.4 - 60.7 62.3 70.8 67.0 65.6

7.9 - 9.0 7.4 6.2 12.2 8.3

Sources: I = Welsh Health Survey (2008 and 2009) Age standardised percentage; J = ONS (2007) Attributable deaths, age standardised rate per 100,000 ; K = Stop Smoking Wales (2008/09); L = PEDW (2008) Attributable admissions, age standardised rate per 100,000; M = PEDW (2008) Individuals with diagnosis directly related to illicit drugs, age standardised rate per 100,000; N = ELMS, WAG (Nov 2010); O = School Statistics, WAG (2009/10); P = ETES3, WAG (31 Dec 2010); Q = Home Office (2008-09)

Smokers contacting Stop Smoking Wales (%)K

Adults eating fruit & veg (5 a day) (%)I

Adults meeting physical activity guidelines (%)I

Adults who are overweight/ obese (%)I

Death rate from alcoholJ

Claiming Job Seekers Allowance(%)N

5 GSCEs at grades A - C (%)O

Employment rate (%) in 16-64 year oldsP

Claiming incapacity benefit (%)N

Experience crime or anti-social behaviour (%)Q

Hospital admission rate due to alcoholL

Hospital admission rate due to drugsM

Adults who drink alcohol above guidelines (%)I

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AAnuA Copyright © 2011

Anuerin Bevan Health Board