Health and Wellbeing priorities for Royal Borough Windsor, Maidenhead & Ascot from the 2010 JSNA and the New Public Health System Dr Pat Riordan, Director of Public Health, NHSBE GP Masterclass Windsor, Maidenhead & Ascot Presentation Version 4.6 15/02/2011

Marmot Themes Giving every child the best start in life Enabling children, young people and adults to maximise their capabilities Fair employment and good work for all Ensuring a healthy standard of living for all Create and develop healthy and sustainable places and communities Strengthen the role and impact of ill health prevention "There are two major challenges: to improve health for everybody and to reduce inequalities. In Britain, we have done well on the first; not on the second. Professor Marmot The Review estimated the cost of health inequalities in England: Productivity losses of £31-33 billion every year Lost taxes and higher welfare payments in the range of £20-32 billion per year Additional NHS healthcare costs well in excess of £5.5 billion per year Source: Marmot Review, 2010 2

Marmot Indicators for Royal Borough of Windsor and Maidenhead

Population Current: RBWM population Future: RBWM population projection, 2010 to 2025 Population RBWM Registered* 176,570 Resident** 143,900 Difference +32,670 Source: * Open Exeter, July 2010; **ONS 2009 Mid-Year Estimates Note: There is a large difference between resident and registered populations for RBWM as two Surrey Wards are also included in the GP registered estimates, whilst ONS only looks at the geographic boundaries. Resident population figures are derived from the Office for National Statistics (ONS), based on Census data. Registered population figures are based upon General Practice (GP) registration data taken from the Exeter System (NHS). Registration data are constantly updated and allow the calculation of a current population figure but do not usually have historic numbers. They are not estimates but can be used to derive estimates. The difference between the resident population and the registered population is not simply explained by time difference between the two datasets. The registration systems hold data on all registered patients resident in the area. They exclude two groups of patients: registered patients that live elsewhere, and unregistered persons. The registered population may also include ‘list inflation’ (i.e. patients remaining on GP lists after they have died or moved away). Despite the differences between the resident and registered population numbers, these estimates and future population projections are important for understanding current and future need, as well as health and social care service planning. Different population figures will be appropriate in different circumstances as all figures have strengths and weaknesses. Source: ONS mid year estimates, 2009

Giving every child the best start in life: Improve births and maternity outcomes Actual birth rates in Slough remain above the England average and continue to place demands on maternity and early years services Higher birth rates continue in the existing population and among new entrants (4,947 in 2009) Birth rate in Slough is 95/1,000 (2008 actual data) and projected to increase to above 120/1,000 by 2021. England birth rate around 62/1,000 (2008). Slough number of births is almost double Bracknell and RBWM (2008).

Causes of ill health Long term conditions above England and/or PCT average (QoF prevalence, 2009/10) Condition Bracknell Slough RBWM Berkshire East National Asthma 5.98% 5.35% 5.15% 5.43% 5.94% Atrial Fibrilation 1.02% 0.73% 1.38% 1.08% 1.39% Cancer 1.28% 0.80% 1.43% 1.19% 1.41% Coronary Heart Disease 2.49% 2.73% 2.76% 2.68% 3.44% Depression (age 18+) 11.73% 9.05% 8.88% 9.66% 10.91% Dementia 0.32% 0.21% 0.44% 0.33% 0.45% Diabetes (ages 17+) 4.66% 7.13% 4.42% 5.34% 5.40% Hypothyroidism 2.83% 2.51% 2.91% 2.92% Mental Health 0.59% 0.83% 0.58% 0.66% 0.77% Obesity (age 16+) 10.22% 10.64% 7.36% 9.13% 10.52% Stroke/TIA 1.14% 1.44% 1.68% QoF Prevalence Data 2009/10 Highlighted in red are conditions where prevalence is above national and PCT average, in blue only above PCT average. In Slough – CHD, Diabetes, Mental Health and Obesity in adults are above national (diabetes is statistically significantly above national average) In Bracknell Forest - Asthma, Depression (over 18 years) above national prevalence (Prevalence of depression is statistically significantly above national) In RBWM - Atrial fibrillation (equal to national), all cancers, CHD, hypothyroidism, Dementia, stroke and transient ischaemic attack (TIA) due to the age profile Dementia Prevalence is statistically significantly above England in Ascot. QoF prevalence = 0.66% in Ascot (212/32073) vs 0.45% national). QoF prevalence for all cancers in RBWM (1.43%) is marginally above national (1.41%) but considerably higher than the PCT prevalence (1.19%) Source: Quality Outcome Framework (QoF) Prevalence 2009/10 - NB not true prevalence as age-limited and based only on GP registered patients Prevalence of depression in Bracknell and diabetes in Slough is statistically significantly above national average

Unequal mortality outcomes Inequality of Outcome Bracknell Forest Slough RBWM All age all cause mortality S All cause mortality <75 years E, S Cardiovascular disease mortality Cardiovascular disease mortality <75 Coronary heart disease mortality Colorectal cancer Prostate cancer mortality Skin cancer mortality E Breast cancer mortality Diabetes mortality Stroke mortality <75 All age all cause mortality in Slough is statistically significantly above Southeast in persons and males, not for female only rates. All age all cause mortality under 75 years in Slough is statistically significantly above England and Southeast in persons and male only rates. CVD Cardiovascular mortality in Slough is statistically significantly above Southeast in persons and male only rates. Cardiovascular mortality in BF is above Southeast in male only (not statistically significant) Cardiovascular mortality in RBWM is above Southeast in male only (not statistically significant) Cardiovascular mortality under 75 years in Slough is statistically significantly above England and Southeast rates for persons, male and female. Cardiovascular mortality under 75 years in BF is above Southeast in male only (not statistically significant) Cardiovascular mortality under 75 years in RBWM is above Southeast in male only (not statistically significant) Stroke mortality under 75years in Slough is statistically significantly above Southeast rates for persons, and female only. CHD (all age) CHD mortality in Slough is statistically significantly above England and Southeast rates for persons, and male. Female rates are higher than Southeast only rates CHD mortality in BF is above Southeast in male only (not statistically significant) CHD mortality in RBWM is above Southeast in female and persons (almost statistically significant) Cancer In BF - Colorectal, prostate, and skin cancer mortality are above England and Southeast but not statistically significant In RBWM - Colorectal, prostate and breast mortality are above England and Southeast but not statistically significant. Skin cancer in females is just above England Diabetes mortality in Slough is above England and Statistically Significantly above England (E) and/or South East (S) level Above England (E) and/or South East (S) level (not statistically significant)

Further inequalities Inequality of outcome Bracknell Forest Slough RBWM Atrial fibrillation* E Tuberculosis (TB) incidence E, S HIV prevalence Hip fracture rates over 65 Heart Failure* Asthma* Diabetes* Depression* Dementia* Obesity in adults* Childhood obesity in Reception S Childhood obesity in year 6 TB in Slough (52.8 per 100,000) statistically significantly above England (14.1 per 100,000) and Southeast (8.4 per 100,000) HIV in Slough (3.96 per 1000 15-59 population) is statistically significantly above England (1.3 per 1000 15-59 population) Hip fracture rates in RBWM (615.4 per 100,000) are statistically significantly above England (479.2 per 100,000) Diabetes QoF prevalence in Slough (7.13%) is statistically significantly above national (5.4%) Heart Failure, Asthma are not statistically significantly above national Prevalence of Depression in Bracknell Forest (11.73%) is statistically significantly above national (10.9%) Prevalence of Obesity in adults in Slough (10.64%) is statistically significantly above national (10.9%) Prevalence of Obesity (2009/10 data) in children in Slough: Reception year (slough = 10.8%) statistically significantly above Southeast (8.7%) only, not England (9.8%). Yr 6 obesity prevalence (slough 21.4%) statistically significantly above Southeast (16.6%) and England (18.7%) Statistically significantly above England (E) and/or South East (S) level Above England (E) and/or South East (S) level (not statistically significant) *Quality Outcome Framework (QoF) Prevalence 2009/10- NB not true prevalence as age-limited and based only on registered patients

Ageing population with impact on Long Term Conditions Ageing population is projected to increase by 2025 Causes of ill health Dementia, Depression Falls and Fractures QoF Prevalence of Dementia RBWM = 0.44% (Ascot 0.66% - statistically significant) England = 0.45% PCT = 0.33% Rate of Hip Fractures per 100,000 RBWM = 615.4 England = 479.2 statistically significant Ageing population with impact on long term conditions – RBWM ageing population is projected to increase by 2025, the prevalence of LTCs and the number of patients is also projected to increase substantially, e.g. Dementia and Depression Prevalence of Dementia In RBWM - Dementia Prevalence is statistically significantly above England in Ascot. QoF prevalence = 0.66% in Ascot (212/32073) vs 0.45% national). Dementia and mental health prevalence is increasing, and although below national (depression=8.88%, mental health= 0.58% is under-reported) Falls and Hip fracture rates in RBWM (615.4 per 100,000) are statistically significantly above England (479.2 per 100,000) Continue to drive improvements in cardiovascular and stroke care pathways Stroke care and community care improvements

Causes of ill health Cancer Coronary Heart Disease ENG SE RBWM Breast cancer mortality rate Per 100,000 QoF Prevalence of Cancer RBWM = 1.43% England = 1.41% PCT = 1.19% (not statistically significant) Causes of ill health ENG SE RBWM Coronary Heart Disease Per 100,000 Colorectal cancer mortality rate Male Female Person Per 100,000 Male Female Person CHD (all age) mortality rate Cancer - QoF prevalence for all cancers in RBWM (1.43%) is marginally above national (1.41%) but considerably higher than the PCT prevalence (1.19%). Ascot prevalence (1.69%) and Maidenhead (1.53%) are above national levels. Mortality from Prostate cancer in RBWM (24.8/100,000) is above England (prostate = 24.53/100,000) and southeast (27.8/100,000); but not statistically significant as numbers are small (data is pooled 2006-2008) Breast cancer mortality per 100,000: RBWM = 29.4 is above National= 26.8, Southeast = 27.8 – not statistically significant although rising Colorectal cancer mortality not statistically significant RBWM: Male= 24.23, Female=13.83, person=19.02 England & Wales: Male=22.39, Female=14.17, Person=17.84 Southeast: Male=21.38, female=14.58, person=17.63 CHD – QoF prevalance for Atrial fibrillation in Ascot (1.43%) is above national (1.39%) but not statistically significant. Mortality from CHD (person) is below national rates (89.9/100,000) in RBWM (80.7/100,000) and above Southeast (76.3/100,000) rates but not statistically significant. All CHD all age mortality RBWM: Male=109.34, Female=58.85, Person=80.68 England & Wales: Male= 127.44, Female=59.22, Person=89.86 Southeast : Male=108.69, Female=50.28, Person=76.31

Reduce domestic abuse, violent crime, sexual abuse & alcohol harm Children 46% of domestic abuse incidents where children involved (Apr-Jun 2010) Reduce domestic abuse, violent crime, sexual abuse & alcohol harm Non domestic abuse Domestic abuse Domestic abuse rates remain greatest in deprived wards, e.g. Oldfield Non-domestic abuse rate increased up to 14.3 per 1,000 in some wards Reduce domestic abuse, sexual abuse and violent crime - these have been increasing according to data from police incidents recorded and in relation to alcohol harm, however increase is not statistically significant. Figures in 2009/10 : Domestic abuse rates monitored since 2006 and wards with greatest rates reported in most deprived (IMD2007) wards. No ward is statistically different to that expected. In RBWM – only Oldfield has a higher residual than expected. In the first quarter of 2010/11 (April to June 2010), 46% (n=200) of all domestic abuse incidents reported for RBWM in Thames Valley involved children. Similar to BF (204) but below Slough (393). Non-domestic abuse rate increased up to 14.3/1000. Evidence base: Exposure to child abuse and other violent and adverse events of childhood has been associated with a 4- to 12-fold risk for alcoholism, drug abuse, depression and suicide attempt; a 2- to 4-fold increased risk for smoking, poor self-rated health, and a 1.4 to 1.6 fold increased risk for physical inactivity and severe obesity’. Alcohol Alcohol attributable recorded crimes per 1,000 (crude rate): RBWM=10.4, regional=7.4 (statistically significantly above national and regional) Alcohol attributable mortality in RBWM women ( 16.8/100,000) above regional rates (12.6/100,000), but not statistically significant (2008 data) Alcohol Alcohol attributable crimes in RBWM above national and regional rates (statistically significant) Alcohol attributable mortality in women above national and regional rates (not statistically significant)

Windsor and Maidenhead Priority Needs 1) Ageing population with impact on long term conditions 2) Dementia 7) Reduce domestic abuse, sexual abuse and violent crime Windsor and Maidenhead Priority Needs 3) Coronary Heart Disease Ageing population and impact on Long Term Conditions - RBWM ageing population is projected to increase by 2025, the prevalence of LTCs and the number of patients is also projected to increase substantially, e.g. Dementia Dementia - QoF prevalence in Ascot (0.66%) is above national (0.45%) – this is not due to small numbers and yet dementia is under-diagnosed. Prevalence is statistically significantly above England in Ascot. CHD – QoF prevalance for Atrial fibrillation in Ascot (1.43%) is above national (1.39%) but not statistically significant. Mortality from CHD is below national rates (89.9/100,000) in RBWM (80.7/100,000) and above Southeast (76.3/100,000) rates but not statistically significant. Cancer - QoF prevalence for all cancers in RBWM (1.43%) is marginally above national (1.41%) but considerably higher than the PCT prevalence (1.19%). Ascot prevalence (1.69%) and Maidenhead (1.53%) are above national levels. Breast cancer mortality per 100,000: RBWM = 29.4, National= 26.8, Southeast = 27.8 – not statistically significant but rising Colorectal cancer mortality (19.02/100,000) – similar to national (17.8/100,000) and SE (17.6/100,000) not significantly above Prostate cancer mortality per 100,000: RBWM = 27.8, National= 24.5, Southeast = 24.3 – not statistically significant but rising 5. Falls and Hip fracture - hip rates in RBWM (615.4 per 100,000) are statistically significantly above England (479.2 per 100,000) Falls in some areas of RBWM reached 114 to 296 per 1,000 in 2009/10. Falls in the town centre are notable in ambulance records. 6. Alcohol – harm reduction programmes as alcohol attributable crimes above national and regional rates. Also alcohol attributable mortality and chronic liver disease in women is also above regional rates, but not statistically significant. 7. Reduce domestic abuse, sexual abuse and violent crime - figures increasing according to data from police incidents recorded (however increase is not statistically significant). Figures in 2009/10 : Domestic abuse rates monitored since 2006 and wards with greatest rates remain those reported as the most deprived in IMD2007 and no ward is statistically different to that expected. In RBWM – only Oldfield has a higher residual than expected. 46% (n=200) of all domestic abuse incidents reported for RBWM in Thames Valley involved children. Similar to BF (204) but below Slough (393). Non-domestic abuse rate increased up to 14.3/1000. 6) Alcohol 4) Cancer (Breast, Colorectal, Prostate) 5) Falls and Fractures

A new public health system

The Director of Public Health, a proposed role and GP consortia)

Public health funding and commissioning

Public health funding and commissioning -public health and the NHS

Public health funding and commissioning -allocations and the health premium

Public health funding and commissioning -accountability

Transition - a timetable