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Health, social care and support

Summary :: Our health and well-being :: Health, social care and support

Introduction

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

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

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

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

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

There are large numbers of people at this level and small changes can result in large total effects in the population and for the health economy. For example, having a high body-mass index (i.e. being over-weight or obese) is associated with increased risk of a number of conditions, such as diabetes, heart disease and cancer. In Medway almost two-thirds of adults are either obese or overweight [1] and 21.1% of children in year 6 are obese.[2]

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

Cancer

Cancer is another significant health problem that can be addressed at the population level. Prevention remains the best method of tackling cancer at the population level, reducing the burden caused by the disease and improving outcomes. Over half of all cancers can be prevented. Smoking is the single largest preventable risk factor for cancer and population-based interventions, such as the restrictions on smoking in public places, are highly effective. The proportion of adults aged 18 years and over who smoke in Medway (19%) [3] is significantly higher than the proportion in England. There were around 53,124 smokers in Medway in 2016.

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

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

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

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

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

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

As at 31 March 2016, breast screening coverage in Medway is 76.2%, similar to the coverage levels seen in the South East region (77.1%) and England as a whole (75.5%)[7]. The programme was extended to include women aged 47 to 73 years in 2011. In Medway, cervical screening coverage rates among 25-64 year olds are higher (75.4%) than England and the South East region.[8]

Level 2: High risk, requiring care management and support

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

Looked After Children

Any child can become a 'Looked After Child' but the likelihood is many times greater in children from low income/benefit dependent families and from parents with mental health, learning disabilities, drug, domestic violence or alcohol issues. These children are vulnerable and about 60% of those looked after in England have been reported to have emotional and mental health problems and a high proportion experience poor health, educational and social outcomes after leaving care. [9]

At the end of September 2017, Medway had 393 looked after children, representing a 4% decrease from September 2016. Medway's September 2017 rate of 62 children per 10,000 is identical to the March 2017 national rate. Comparison against other groups shows the Medway rate is between the South East average of 51 children per 10,000 and our statistical neighbour average of 73 children per 10,000.[10] The National Audit Office estimated a total of £2.5bn was spent supporting children in foster and residential care in 2012-13 at a national level.[11]

In September 2017, 196 children were placed with Medway in-house carers. This indicates an increase in use in-house provision of foster care albeit very slight. The in-house fostering service is currently developing its provision in meeting complex needs. Although the service will always have placements for all children, developing carers in this way allows us to reach, support and care for a larger group of Medway's children in the most appropriate and local way.[10]

Dependent drinkers

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

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

There are an estimated 11,782 dependent drinkers in Medway and, following Department of Health guidance, services should have capacity for around 1,800 service users. However, data for 2015/16 from the National Drug Treatment Data Monitoring Service showed only 340 people, less than one fifth of those expected, accessed alcohol services in Medway.[12]

Mental health

People with more complex mental health problems are also more likely to be users of services and require a higher level of support. In February 2017 9,480 people in Medway were claiming employment and support allowance, of whom 4,430 (46.7%) were claiming for mental health reasons.[13]

Diabetes

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

For 2015/16 Medway had 16,179 people aged 17 and above recorded on GP practice diabetes registers, a prevalence of 7%. This prevalence is higher than in England (6.6%). The proportion which have achieved good glucose control (HbA1c of 59 mmol/mol or less) is 69.7% (compared to 70.2% nationally)[14].

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

Cancer

In 2015, over 1,400 new cases of cancers were diagnosed in Medway. A third of these occurred in those aged 75 and over.[15] The incidence rate of all cancers in Medway has remained steady and is similar to incidence rates in the South East, comparator groups and England as a whole.

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

Chronic obstructive pulmonary disease (COPD)

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

In 2015/16 there were 5,368 people with a recorded COPD diagnosis in Medway[14].

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

Standardised spend for this group of patients [16] suggests that NHS Medway spends £5,249 on emergency admissions for obstructive airway disease per 1,000 population, a total of over a £1 million per year. Therefore it is important that GPs deliver effective treatment preventing or delaying the need for emergency hospital admissions.

Teenage pregnancies

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

In Medway the rate of under-18 conceptions has dropped from 33.6 per 1,000 in 2012 to 28.1 per 1,000 in 2015, the lowest since 1998. This represents 35 fewer conceptions than 2012 (140 compared to 175 in 2012). This reduction is in line with the England rate which has fallen from 27.7 per 1,000 in 2012 to 20.8 per 1,000 in 2015. However, the rate in Medway is higher than the England average.[17]

Level 1: Highly complex, requiring case management

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

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

Others in this category may include elderly people with dementia, or those who have suffered a severe stroke. The ageing of the population will lead to an increase in the number of people with dementia and the costs associated with providing them with health and social care. It is predicted that the number of people aged 65 and over with dementia in Medway will rise from 2,858 in 2017 to 5,195 by 2035. [18] Research estimates that in 2015 there were 850,000 people with dementia in the UK costing the NHS £26.3 billion a year.[19] The Death registrations summary tables [20] highlighted that 62,948 deaths per year are directly attributable to dementia. Reducing the onset of dementia by 5 years would lower this figure to 30,000.

The number of people aged 65 and over predicted to have a long standing health condition caused by a stroke will rise from 1,018 in 2017 to 1,595 by 2035 in Medway and the those aged 65 and over predicted to have diabetes will rise from 5,560 in 2017 to 8,414 by 2035 in Medway. [18]


References

[1]   Public Health England. PHOF: Excess weight in Adults 2017;
[2]   NHS Digital. National Child Measurement Programme 2016;
[3]   Public Health England. PHOF: 2.14 smoking prevalence 2016;
[4]   Cancer Research UK. Diet, healthy eating and cancer http://info.cancerresearchuk.org/healthyliving/dietandhealthyeating/
[5]   World Health Organisation, Food and Agriculture Organisation of the United Nations. Diet, Nutrition and the Prevention of Chronic Diseases, Report of a Joint WHO/FAO Expert Consultation 2003; World Health Organisation. http://www.fao.org/DOCREP/005/AC911E/AC911E00.HTM .
[6]   Public Health England. Estimated prevalence of common mental health disorders 2014/15 http://fingertips.phe.org.uk/profile-group/mental-health/profile/common-mental-disorders/data#page/1/gid/1938132720/pat/46/par/E39000035/ati/153/are/E38000104
[7]   Screening and Immunisations Team. Breast Screening Programme, England, Statistics for 2015-16 2017; https://digital.nhs.uk/catalogue/PUB23376
[8]   Screening and Immunisations Team. Cervical Screening Programme, England - 2015-16 2016; https://digital.nhs.uk/catalogue/PUB22414
[9]   National Institute for Health and Clinical Excellence. Promoting the quality of life of looked-after children and young people - NICE public health guidance 28 2010; National Institute for Health and Clinical Excellence. http://www.c4eo.org.uk/themes/vulnerablechildren/files/promoting_the_quality_of_life_of_looked_after_children_and_young_people.pdf .
[10]   Children and Adults. Statistics: looked-after children September 2017 2017;
[11]   National Audit Office. Children in care 2014; https://www.nao.org.uk/wp-content/uploads/2014/11/Children-in-care1.pdf .
[12]   National Drug Treatment Monitoring System. Alcohol users (18 and over) Apr 15 - Mar 16 June 2017;
[13]   NOMIS Office Labour Market Statistics. Mental health - employment and support allowance February 2017;
[14]   NHS Digital. Quality and Outcomes Framework
[15]   Public Health England. Cancer Stats https://nww.cancerstats.nhs.uk/
[16]   NHS Information Centre and NHS Connecting for Health. NHS Comparators 2011;
[17]   Public Health England. PHOF: 2.04 Under 18s conception rate / 1,000 2015;
[18]   Institute of Public Care and Oxford Brookes University. Projecting Older People Population Information System 2016;
[19]   Alzheimer's Society. Dementia 2015: Aiming higher to transform lives 2015; Alzheimer's Society. https://www.alzheimers.org.uk/download/downloads/id/2700/dementia_2015_aiming_higher_to_transform_lives.pdf .
[20]   Office for National Statistics. Death registrations in England and Wales, summary tables: 2016 2017;