The Joint Strategic Needs Assessment (JSNA) Prevention of Ill Health in Adults of Working Age is based on a model where health is determined by a wide range of factors. These include the wider determinants of health such as the socio-economic factors, the health behaviours that individuals adopt and protective actions such as screening.
The JSNA includes information about a wide range of health and wellbeing indicators, the views of the local people and gives examples of good practice, along with identifying gaps and areas for development. It also includes some of the substantial evidence that indicates that prevention works, that it can provide cost benefits and importantly that it can make significant improvements to the health of the population, decrease health inequalities and effectively address health and social problems.
The development and production of the JSNA has been overseen by a very active and committed Steering Group with membership from a wide range of organisations. For the first time a bespoke community consultation process was developed and implemented for this JSNA. This involved the use of social media, an online survey and focus groups. A Stakeholder Event that was well attended by representatives from the statutory and voluntary sectors reviewed the JSNA and highlighted key issues and prevention priorities.
The Wider Determinants of Health
- There is a clear negative downward trend across the socio-economic determinants of health. Although Cambridgeshire as a whole is relatively affluent, the patterns of inequality are mostly unchanged or worsened in some cases from previous years.
- Fenland and other areas in Huntingdonshire and Cambridge City continue to have higher levels of socio-economic deprivation than the rest of the county. There has been an increase however in all districts in the number unemployed between 2007 and 2010, though only Fenland was close to the national figure. Between August 2008 and 2010 the percentage of the population receiving benefits increased across all the districts with the highest proportion being in Fenland. In 2005-2009, the highest median household income was in South Cambridgeshire and the lowest was in Fenland.
- Nationally and locally demand for both affordable and market housing significantly outstrips supply. More detailed information is provided in the Strategic Housing Market Assessment (SHMA) (www.cambridgeshirehorizons.co.uk/shma). Private housing is particularly expensive in Cambridge City both to purchase and to rent. This has resulted in an increasing affordability gap between incomes and rents and house prices. In the past eight years, some 5,910 new affordable homes have been built across Cambridgeshire but the housing needs register for social rented properties has increased by around 10,000. There is widespread concern about planned changes and the effects of the Local Housing Allowance (LHA). These include unaffordable rents, leading to overcrowding, evictions and possible homelessness. The Supporting People Service helped around 2,000 people of working age in 2009/10 but there is inequity of provision.
- It was estimated that in 2008 there were 11.5% fuel poor households in Cambridgeshire compared to 6% in 2003. In addition there are Lower Super Output Areas where the proportion of the fuel poor households is above 20%. Most of those areas are in Fenland and East Cambridgeshire.
- Data from Cambridgeshire Citizens Advice Bureau has shown a steady and large increase in demand for advice on debt arrears especially in relation to fuel poverty, mortgage arrears and credit cards.
- Although there has been a reduction in deaths between 1998 and 2010 all the Cambridgeshire districts with the exception of Cambridge City have significantly higher death rates than England for road injuries and deaths. The greatest number of road traffic casualties occurs in the working age population with 17 to 25 year olds having the highest casualty rate per head of population. The highest mortality rate was in Fenland followed by Huntingdonshire. The evidence for prevention measures is strongest for environmental changes, such as area-wide traffic calming measures like speed bumps and cameras.
- Cambridgeshire has a number of Air Quality Management Areas (AQMAs). Areas of concern include the housing growth in the south of the county adjacent to existing AQMAs and the proximity of industrial pollutants to more deprived communities.
- Cambridgeshire is predominantly a rural county and access to all services is limited in many areas are especially in more deprived areas where car ownership is more limited. The full JSNA contains links to detailed maps that demonstrate the patterns and inequalities that are present in Cambridgeshire.
- In March 2011, 4.8% of 16-18 olds were Not in Education or Training (NEET). Localities with the highest proportion of people in the NEET group were in Wisbech (7.8%), Cambridge North (6.7%) and Cambridge South (6.5%). In 2009/10, more than 6,500 people (25-64 age group) were attending courses in Adult Learning in Cambridgeshire with an average 1.8% of people in the 19 - 64 age group. This was less than in the previous years. The proportion was smallest in Cambridge City and Fenland. Concerns for the future are the need to increase apprenticeship starts, the decline in other funded employee qualification routes, a lack of skilled workers and workers with sufficient employability skills.
- There is limited local data on employee health, occupational health services and prevention activities or opportunities in Cambridgeshire’s workplaces. The available information gives an insight into the marked differences in reported workplace injury rates by district council area with higher rates in East Cambridgeshire and Fenland.
- Surveys indicate that participation in physical activity decreases with age and that there has been an overall downward trend in participation rates with the exception of Huntingdonshire and South Cambridgeshire. Fenland has the lowest levels of participation in sport but scores highly on physical activity which is attributed to a high number of people in manual occupations. Participation in all groups is relatively low in Fenland and is generally lowest in the more deprived areas in each district, with the exception of East Cambridgeshire.
- Nationally the prevalence of obesity among adults has increased sharply in recent years. The estimated levels of obesity in Cambridgeshire (22.1%) are significantly lower than in England (24.2%). Fenland, with estimated obesity at 25.8%, is significantly higher than the county level (22.1%) but is not in comparison to the national levels (24.2%).
- Key factors for prevention of obesity are a healthy diet and physical activity. In Cambridgeshire 67.4% of the population is eating less than the recommended portions of fruit and vegetables a day.
- Tobacco use remains the leading cause of preventable morbidity and mortality worldwide. In Cambridgeshire nearly 20% of adults smoke. Although Cambridgeshire has relatively low smoking prevalence in comparison to national and regional figures this masks the range in smoking rates within Cambridgeshire. In Fenland the prevalence is 26.7% compared to the national figure of 21%. There are smaller areas that have rates higher than the national figure. Smoking prevalence is higher in more deprived populations and amongst the routine and manual group of workers.
- Overall the rate of Sexually Transmitted Infections (STIs) in Cambridgeshire has remained consistent between 2008 and 2010 with 575.5 cases per 100,000 in 2008 compared to 572.6 cases per 100,000 in 2010. There is a higher prevalence in the 15-24 age group. The number of people living with HIV in Cambridgeshire has increased since 2004 reflecting, to a large degree, better treatment methods. 28% of HIV-infected residents live in the most deprived 20% of areas (quintile) in Cambridgeshire. Over half are in the two most deprived quintiles. A third of HIV infected residents live in Cambridge City, with relatively high numbers also in Huntingdonshire (27%) and South Cambridgeshire (19%). Nationally there is also a concern with a high level of late HIV diagnoses which compromises treatment and potentially could increase the spread of the disease.
- The Cambridgeshire teenage conception rate has been consistently and significantly lower than the national and East of England rate with an overall downward trend over the past ten years. The rates vary across the county with Fenland having the highest rate and East Cambridgeshire the lowest in 2007-2009. Within districts there is variation in teenage conception rates.
- Cambridgeshire generally compares well to the national statistics on alcohol misuse but there are some concerns that are related to particular indicators and geographical areas where Cambridgeshire compares poorly to national figures. These include alcohol specific hospital admissions, alcohol-related harm, violent crime and binge drinking in Cambridge City.
- Although there are primary prevention interventions for drug misuse, most of these target young people and not those of working age. Prevention for the working age population is mostly secondary and occurs when individuals access the treatment service. Key issues for Cambridgeshire are that approximately one-third of the drug using population does not access any services.
- In 2004-06, 13% of the England population had a possible psychiatric disorder. The percentage was higher in Cambridgeshire (15%) but not significantly so. High suicide rates are found in Cambridge City and Fenland and in the homeless in Cambridge City. Current service provision is more focused on treating existing mental illness and further opportunities exist to invest in preventive interventions in a range of settings. Refer to the Mental Health JSNA www.cambridgeshirejsna.org.uk/mental-health-adults-working-age
- Local information about dental and oral health is routinely collected only at a regional level. The most recent adult data indicate that oral health is improving in adults of working age, particularly among the younger age group up to 45 years. However for those who do have decay or gum problems, disease can be very extensive and for many people in older middle age, dental needs can be very complex. The vulnerable and socio-economically disadvantaged groups are more likely to be at risk of poor dental and oral health. Adults who smoke, take drugs, binge drink or who are obese are more likely to suffer from gum disease and mouth cancer.
Other Areas of Prevention
- The screening programmes that are mostly accessed through general practices are well established and generally meet the targets to ensure that the population as whole is protected. However there is some inequity of service provision across the county and there is insufficient information about screening in vulnerable and hard to reach groups.
- Nationally there are estimated to be 15 million people living with one or more long term condition (LTC) with prevalence and severity being greater amongst the more deprived population. This will increase as the proportion of older people in the population becomes greater. Analysis at Local Commissioning Group (LCG) level in Cambridgeshire of five of the main LTCs indicates that there is higher prevalence in LCGs where there is known deprivation. Improving the health of those suffering from a long term condition can help stabilise conditions, reduce the need for health and social care and enhance the quality of life. There is a gap in secondary prevention services that could be incorporated into the long term condition pathways. The importance of secondary prevention is also considered for 14,000 estimated visually impaired people in Cambridgeshire.
- There has been a substantial increase in Domestic Violence in recent years. In the period 2005 – 2009, the number of incidents reported to the police has risen by more than 41.9%; subsequently the number of victims accessing services has risen dramatically. For example, the Independent Domestic Violence Advocacy Service received 324 high-risk referrals from the Constabulary in 2005. In 2008/09 that figure was1536 (an increase of 377%). There is a higher level of domestic abuse in Fenland, amongst women from A8 (Central And Eastern European countries, Gypsy/Traveller/Roma and other Black Minority Ethnic communities), teenage mothers, Looked after Children (LAC) and children subject to a Child Protection Plan. Key issues include under reporting, a lack of services to support victims and prevent further incidences and involvement from a wider range of services.
- There were 740 sexual offences recorded in Cambridgeshire during 2008-2009 with 755 recorded sexual offences in Cambridgeshire in 2009-2010, representing a 2% increase year on year. The Cambridgeshire and Peterborough Sexual Assault Referral Centre opened in 2010 provided services to 330 people in its first year, of which 112 clients were from Cambridgeshire. This new service is anticipated to identify unmet demand through increased reporting.
Key Findings from the Community Consultation
In the survey responses and focus groups, it was clear prevention is valued and that there was support for prevention activities. There was an understanding that health is a complex concept that is a consequence of the inter-relationship between the wider determinants of health, lifestyle choice and the support that is available through different services.
Improving lifestyle was seen as a challenge that demanded individuals taking responsibility for their health but that it would not be achieved without supportive services. However, the most common theme was how the current economic climate is perceived as affecting people’s health. Job loss, economic hardship, lack of housing and loss of motivation were seen as having a negative effect upon health.
There was an acknowledgement that there are prevention services that can be accessed across the county. However there are gaps in these services that to a large degree reflect personal financial constraints and service cuts creating an inability to meet demand. In terms of lifestyle services the gaps were mostly in terms of mental health and workplace schemes. General practice was found to be inaccessible to some groups and not fully effective at implementing prevention services. The services that target socio-economic issues were seen to be experiencing stress in the current financial climate. For example the Citizens Advice Bureau is not able to meet demand.
Overall there was shared expectation that the NHS and government had a responsibility to work with individuals and communities on the prevention agenda.
The persistent theme in the JSNA is that the current economic climate has created conditions that are well evidenced as having a negative effect upon health. Raised unemployment, increased demand for benefits, lower incomes and increased debt have all increased in Cambridgeshire in recent years. There is a particular concern with the availability and affordability of housing, which is accompanied by increasing levels of fuel poverty. In Cambridgeshire there are long standing areas of deprivation amongst vulnerable groups. Poorer health is experienced in these areas and these areas are where the impact of the negative socio-economic factors is greatest.
Alongside the wider determinants of health are the lifestyles that affect health, such as levels of physical activity, smoking, healthy diet and alcohol consumption. These are reflected in such outcome measures of lifestyle as levels of obesity and indicators of mental health and wellbeing. There is a well evidenced inter-relationship between lifestyle and deprivation and this association can be found in many of the lifestyle indicators Cambridgeshire.
The JSNA also looks at the impact of programmes that protect the population from ill health, primary and secondary prevention of key long term conditions and domestic violence. The common factor is inequity in prevalence or service provision and the lack of client/patient pathways between organisations that would facilitate prevention interventions. The JSNA includes a brief summary of the prevention needs that have been identified in previous JSNA work in Cambridgeshire. The consistent factor common to these groups is inequalities in health. These reflect a wide inter-related range of issues that directly affect health and the complexity of prevention needs. Refer to www.cambridgeshirejsna.org.uk for relevant JSNAs for vulnerable groups
Each of the JSNA topics includes areas for development that have been identified through the data, local views, the Steering Group and at the Stakeholder Event. In addition, the following overall prevention priorities were identified from the JSNA.
- Socio-economic factors especially housing
- Lifestyle Issues
- Workplace Health
- Long-term Conditions
- Domestic Violence
The Steering Group expressed a wish to continue to work together to address prevention across Cambridgeshire and to facilitate further partnership working. It was thought that the lessons learnt from the JSNA could inform the overall further development of the prevention agenda. These include adopting a life-course approach to prevention, as so many of the determinants cut across age groups and settings. This includes expanding the analysis of the effect of the physical environment and social cohesion on health. Analysis of current services or assets that support prevention would provide a fuller understanding of needs. Comprehensive or robust data are not available but are necessary for a fuller understanding of the needs of workplaces and those related to dental and oral health.