1. Surrey Heath CCG: How healthy is our population? Prepared by Surrey Public Health

2. Outline Population demographics and future projections Where are the most deprived areas in Surrey Heath and which groups require a targeted approach How healthy is the population relative to benchmarks What are the preventable conditions contributing to excess morbidity and mortality Programme budgeting data

3. Demographics

4. Current population profile Relative to England (dark outlines), Surrey Heath has a: – Similar proportion of children aged 0-14 – Significantly smaller proportion of young adults aged 15-30 – Significantly larger proportion of older adults aged 35-60 – Similar proportion of over 65s

5. Population projections Nationally we have an ageing population, and the population of Surrey Heath is ageing faster than average 20% of the population of Surrey Heath is projected to be over the age of 65 by 2020

6. Population projections The over 85 population is also growing at a faster rate than the national average 3.3% of the population of Surrey Heath is projected to be over the age of 85 by 2020

7. Cost Impact of ageing population Average cost of attendance by age for Surrey Heath (Non-Elective and Emergency Inpatients, 2010/11)

8. Overview of morbidity in over 65s Aged 65+ population predicted to: Number in Surrey Heath Range for all Surrey CCGs Be unable to manage at least 1 domestic task on their own67346734 – 25112 Be unable to manage at least 1 self care task on their own55325532 – 20638 Be unable to manage at least 1 mobility activity on their own30433043 – 11471 Have a bladder problem at least once a week26942694 – 9919 Be admitted to hospital as a result of falls341341 – 1293 Have a long term health condition caused by a stroke376376 – 1377 Have type 1 or type 2 diabetes20312031 – 7359 Have dementia117524 – 87 Have depression14191419 – 5154 Have severe depression449449 – 1660 Have a moderate or serious visual impairment (65-74)485485 – 1675 Have a moderate or serious visual impairment (75+)949949 – 3664 Have registrable eye conditions (75+)490490 – 1891 Have a moderate or severe hearing impairment69926992 – 26237 Have a profound hearing loss186186 – 715

9. Deprivation

10. Deprivation and Health Following the publication of the Marmot Review in 2010, it is clear that there is a strong association between health inequalities and other measures of deprivation, including education, skills and employment, income, and housing. The Index of Multiple Deprivation (IMD) measures deprivation by a weighted average of seven domains: income, employment, health and disability, education, housing, crime, and environment. Accordingly, areas with higher IMD scores are likely to also have a poorer health status and health outcomes.

11. Deprivation in Surrey Heath 1 16 1 3 4 5 6 7 8 9 10 11 12 13 142 15 16 Ward legend: 1. Bagshot 2. Bisley 3. Chobham 4. Frimley 5. Frimley Green 6. Heatherside 7. Lightwater 8. Mytchett and Deepcut 9. Old Dean 10. Parkside 11. St Michael’s 12. St Paul’s 13. Town 14. Watchetts 15. West End 16. Windlesham

12. Deprivation in Surrey Heath Overall, Surrey Heath is the 3 rd least deprived LA in the country (out of 326), and the CCG population is correspondingly well-off However, the overall picture masks inequalities within Surrey Heath, and these 'deprivation hotspots' are where life expectancy is lower, health outcomes are poorer, more children are living in poverty, and educational attainment is lower: – Old Dean – St Michael’s – Watchetts – Town

13. Life expectancy at birth by ward

14. Specific groups in Surrey Heath Specific groups requiring a targeted approach in Surrey Heath include: – Carers: need to be supported to lead healthy, happy lives alongside their role as unpaid carers for loved ones – Older people: particularly with the high rate of falls, hip fractures, and increasing impact of excess winter deaths on local populations – GRT: 3 authorised GRT sites in Surrey Heath, and the most marginalised group in the country – Armed service personnel and veterans: large number of army personnel and family at Sandhurst, and veterans and reservists in the local area, with particular health needs – Prisoners and ex-offenders: Coldingley prison located just outside the CCG boundary

15. Specific condition and risk factor prevalence

16. Most prevalent conditions Prevalence of most common conditions in Surrey Heath CCG (QOF 2012-13)

17. Specific conditions: local performance The prevalence of most diseases logged by QoF (2011/12) in Surrey Heath is lower than the Surrey average, with slightly higher figures for: – CHD (2.9%, 3 rd worst CCG in Surrey) – Hypertension (13.0%, 3 rd worst CCG in Surrey) – Asthma (5.8%, 2 nd worst CCG in Surrey) – Obesity (8.0%, 2 nd worst CCG in Surrey) – Diabetes (5.0%, 2 nd worst CCG in Surrey) – CKD (4.4%, 2 nd worst CCG in Surrey)

18. Disease Rank in Surrey (1=best) Prevalence in Surrey Heath Surrey Average Prevalence Surrey Highest Prevalence Surrey Range Surrey Lowest Prevalence CHD3 (5)2.9%2.8%3% 2.63% CHF3 (5)0.5% 0.6% 0.5% CVA/TIA4 (5)1.6% 1.7% 1.5% Hypertension3 (5)13.0%12.8%13.8% 12.1% COPD4 (5)1.2% 1.3% 1.1% Hypothyroidism2 (5)3.3%3.5%4.1% 3.1% Cancer4 (5)2.0% 2.2% 1.9% Psychoses1 (5)0.5%0.7%0.8% 0.5% Asthma4 (5)5.8%5.5%6.0% 5.1% Dementia1 (5)0.5%0.6% 0.5% AF1(5)1.4%1.6% 1.4% CVD4(5)1.6% 1.7% 1.3% Obesity (16+)4(5)8.0%7.0%8.1% 5.9% Diabetes (17+)4 (5)5.0%4.8%5.3% 4.3% Epilepsy (18+)3 (5)0.6%0.7%0.8% 0.6% Depression (18+)4(5)11.4%11.3%12.5% 10.5% CKD (18+)4(5)4.4%4.2%4.5% 3.9% Learning disabilities1 (5)0.2%0.4%0.7% 0.2%

19. Specific conditions: further data – Incidence of malignant melanoma: is in line with the national average (13.7/100,000 vs. 13.6/100,000) – Incidence of TB: is similar to the national average (9.5/100,000 2008-2010 vs. 15.3/100,000 2008-2010) – Acute STIs: is lower than the national average (605/100,000 vs. 775/100,000) – Hip fractures in over 65s: is the highest in the country (655/100,000, national average: 452/100,000) – Falls: An estimated 40% of admissions are due to falls nationally, and this is expected to be mirrored in Surrey Heath, which registers approximately 1,200 emergency ambulance calls for falls per year.

20. Risk Factors The top 10 risk factors contributing to the overall burden of disease in the UK are: 1.Smoking (~12%)6. Diet (low fruits) (~5%) 2.Hypertension (~9%)7. High total cholesterol (~4%) 3.High BMI (~9%)8. Diet (low nuts/seeds) (~3%) 4.Physical inactivity (~5%)9. High fasting glucose (~3%) 5.Alcohol (~5%)10. Diet (high sodium) (~3%) Source: Global Burden of Disease Study 2010 (Lancet, March 2013)

21. Smoking Smoking rates are lower than the national average, BUT: – Smoking remains the single most important cause of ill-health and premature death in Surrey – There are particularly high rates of adult smoking in Old Dean (38%), St. Michaels (28%), and Frimley (23%)

22. Smoking

23. Alcohol Surrey Heath LA has: – One of the highest rates of increasing risk drinking (formerly hazardous drinking) in the country (rank 306/326 LAs) – A lower rate of higher risk drinking (rank 21/326 LAs) and binge drinking (rank 77/326 LAs) than the national/regional average Hospital admissions for alcohol related conditions is increasing at a faster rate than the national average, doubling between 2002/3 and 2009/10

24. Alcohol

26. Diet, Obesity, and Exercise Diet, obesity, and exercise rates are slightly better than the national average, but still remain very low: – Less than a third of adults eat healthily – Over a fifth are obese – Almost 9/10 adults are not physically active – 13.3% of year 6 children obese is also lower than average, but still higher than we should be aiming for.

27. Diet, Obesity, and Exercise

28. Health behaviours: further data Surrey Heath, relative to the national average, has: – A higher rate of road injuries and deaths (55.7 vs. 44.3/100,000) – A lower level of drug misuse (5.9 vs. 8.9/1,000 15-64 year olds using opiates/crack cocaine) – A higher percentage initiating breastfeeding (84.2% vs. 74.5% - though significant drop at 6-8wks) – Lower immunisation (especially MMR and pertussis) and Chlamidya screening rates – Fewer teenage mothers (19.3 vs. 38.1/1,000 females), though this rate is higher in more deprived wards: St. Michael’s (43/1,000 females), Town (36/1,000 females) and Watchetts (34/1,000)

29. Causes of greatest morbidity and mortality in the UK

30. Global Burden of Disease Study 2010 The Global Burden of Disease Study 2010 (GBD 2010) UK analysis was published in March 2013 and looks at the major causes of premature mortality, disability, and attributable risk factors in the UK. It covers 259 diseases and injuries and 67 risk factors

31. Mortality The top 10 causes of mortality in all age groups in the UK are: 1.IHD6. Colorectal cancer 2.Lung cancer7. Breast cancer 3.Stroke8. Self harm 4.COPD9. Cirrhosis 5.LRTI10. Alzheimer’s disease

32. Mortality The top 10 causes of mortality in 20-54 year olds in the UK are: 1.IHD6. Drug use disorders 2.Self harm7. Lung cancer 3.Cirrhosis8. Stroke 4.Breast cancer9. Colorectal cancer 5.Road injury10. LRTI

33. Morbidity The top 10 causes of morbidity in all age groups in the UK are: 1.Low back pain6. Anxiety disorders 2.Falls7. COPD 3.(Major) depression8. Drug use disorders 4.Neck pain9. Asthma 5.Other MSK10. Migraine

34. Local indicators of mortality and hospital admissions

35. CCG Indicators Relative to the rest of Surrey, Surrey Heath CCG: – Has the lowest years of life lost to causes amenable to healthcare for women, and the highest for men – Has the lowest under 75 mortality rate from all cardiovascular diseases, cancers, and liver disease – Has the 3 rd highest mortality rate from all respiratory diseases

36. CCG Indicators CCG Indicator 1.1: Potential years of life lost to causes considered amenable to healthcare per 100,000 population (females) Females Rank (Surrey)CCG NameGenderDSR (2012)CI LowerCI Upper 1GUILDFORD AND WAVERLEY CCGFemales12441178.51312.1 2EAST SURREY CCGFemales1267.51192.91345.5 3NORTH WEST SURREY CCGFemales1267.91215.31322.3 4SURREY HEATH CCGFemales1378.512741489.3 5SURREY DOWNS CCGFemales1430.21370.21492.2 Males Rank (Surrey)CCG NameGenderDSR (2012)CI LowerCI Upper 1SURREY DOWNS CCGMales1398.61338.61460.5 2GUILDFORD AND WAVERLEY CCGMales1616.21540.71694.5 3NORTH WEST SURREY CCGMales1644.11583.91706.1 4SURREY HEATH CCGMales1716.71601.11838.4 5EAST SURREY CCGMales1875.51784.61969.9 CCG Indicator 1.2: Under 75 mortality rates from cardiovascular disease per 100,000 population [cause of death ICD-10 I00-I99] Rank (Surrey)CCG NameDSR (2012)CI LowerCI Upper 1GUILDFORD AND WAVERLEY CCG39.0330.848.79 2SURREY DOWNS CCG39.5532.5247.64 3EAST SURREY CCG43.6833.955.39 4NORTH WEST SURREY CCG48.0940.6856.44 5SURREY HEATH CCG52.6138.570.18 CCG Indicator 1.6: Under 75 mortality rates from respiratory disease per 100,000 population [cause of death ICD-10 C00-C97] Rank (Surrey)CCG NameDSR (2012)CI LowerCI Upper 1SURREY HEATH CCG15.03825.7 2SURREY DOWNS CCG16.8212.3622.37 3NORTH WEST SURREY CCG18.9414.3824.49 4GUILDFORD AND WAVERLEY CCG19.2913.6526.48 5EAST SURREY CCG29.0821.1239.05 CCG Indicator 1.7: Under 75 mortality rates from liver disease per 100,000 population [cause of death ICD-10 K70-77, B15-19, I81, I85, T86.4] Rank (Surrey)CCG NameDSR (2012)CI LowerCI Upper 1SURREY HEATH CCG4.381.1911.23 2EAST SURREY CCG9.395.2515.49 3SURREY DOWNS CCG9.456.2313.75 4GUILDFORD AND WAVERLEY CCG10.56.516.06 5NORTH WEST SURREY CCG13.449.7118.11 CCG Indicator 1.9: Under 75 mortality rates from cancer per 100,000 population [cause of death ICD- 10 C00-C97] Rank (Surrey)CCG NameDSR (2012)CI LowerCI Upper 1NHS SURREY DOWNS CCG92.5181.62104.45 2NHS SURREY HEATH CCG94.4775117.44 3NHS GUILDFORD AND WAVERLEY CCG101.7388.14116.81 4NHS EAST SURREY CCG110.2294.34128.01 5NHS NORTH WEST SURREY CCG120.16108.27133

37. CCG Indicators Relative to the rest of Surrey, Surrey Heath CCG: – Has the highest rate of unplanned hospitalisation for chronic ambulatory care sensitive conditions – Has the second highest rate of unplanned hospitalisation for asthma, diabetes, and epilepsy in under 19s – Both these figures have increased from 2010/11 to 2011/12

38. CCG Indicators CCG Indicator 2.6: Unplanned hospitalisation for chronic ambulatory care sensitive conditions per 100,000 population Rank (Surrey)CCG Name DSR (2012/13)CI LowerCI Upper DSR (2011/12)CI LowerCI Upper 1NHS EAST SURREY CCG247224271.6260.8237.2286 2NHS SURREY DOWNS CCG477.8453.7502.7509.9485.2535.6 3NHS GUILDFORD AND WAVERLEY CCG525.7496556.7486.3457.9515.9 4NHS NORTH WEST SURREY CCG596.7571.5622.7577.8553.1603.4 5NHS SURREY HEATH CCG639.3588.4693.5727.7673.7784.9 CCG Indicator 2.7: Unplanned hospitalisation for asthma, diabetes, and epilepsy in under 19s per 100,000 population Rank (Surrey)CCG Name DSR (2012/13)CI LowerCI Upper DSR (2011/12)CI LowerCI Upper 1NHS SURREY DOWNS CCG208.3174.6246.7211.8177.8250.3 2NHS SURREY HEATH CCG221.9161.8297274.7206.8357.6 3NHS GUILDFORD AND WAVERLEY CCG235.1192.8284168.4133.1210.3 4NHS NORTH WEST SURREY CCG273237.9311.8226.4194.4262.2 5NHS EAST SURREY CCG287.9237.6345.6344.3289.1406.9

40. CCG Indicators Relative to the rest of Surrey, Surrey Heath CCG: – Has the second highest rate of emergency admissions for acute conditions that should not usually require hospital admission (rate increasing), and emergency readmissions within 30 days of discharge from hospital – Has the lowest rate for emergency admission for children with LRTIs (rate decreasing) – Has the 3 rd highest rate of emergency admissions for ALD (rate increasing)

41. CCG Indicators Indicator 3.1: Emergency admissions for acute conditions that should not usually require hospital admission per 100,000 population Rank (Surrey)CCG Name DSR 2012/13CI LowerCI Upper DSR 2011/12CI LowerCI Upper 1NHS EAST SURREY CCG595.5559.7633.1480.2448.2513.9 2 NHS GUILDFORD AND WAVERLEY CCG762.7726.2800.5718.3683.1754.9 3NHS SURREY DOWNS CCG885.9852.7920740.4710.2771.5 4NHS NORTH WEST SURREY CCG1054.11020.51088.4968.1936.11001 5NHS SURREY HEATH CCG113410651206.2947.5884.81013.4 Figure 37: CCG indicator 3.2: Emergency readmissions within 30 days of discharge from hospital per 100,000 population Rank (Surrey)CCG Name ISR 2011/12CI LowerCI Upper 1 NHS Guildford and Waverley CCG10.510.0210.99 2NHS Surrey Downs CCG11.4711.0411.9 3NHS North West Surrey CCG11.9811.5912.39 4NHS Surrey Heath CCG12.3711.6513.12 5NHS East Surrey CCG13.0612.5213.62 CCG Indicator 3.4: Emergency admissions for children with lower respiratory tract infections per 100,000 children Rank (Surrey)CCG Name DSR (2012/1 3)CI LowerCI Upper DSR (2011/1 2)CI LowerCI Upper 1 NHS NORTH WEST SURREY CCG281.7245.8321.3240.2207.4276.8 2NHS SURREY HEATH CCG308.6233.6399.9233.6169.6313.7 3NHS SURREY DOWNS CCG338290.8390.6273231.4319.8 4 NHS GUILDFORD AND WAVERLEY CCG355.9298.7420.8259.1211314.8 5NHS EAST SURREY CCG435.8370.7509428.5364.5500.5 CCG Indicator 1.8: Emergency admissions for alcohol related liver disease per 100,000 population Rank (Surrey)CCG Name DSR (2012/1 3)CI LowerCI Upper DSR (2011/1 2)CI LowerCI Upper 1NHS EAST SURREY CCG10.15.5*7.83.913.9 2NHS SURREY HEATH CCG17.39.229.613.46.424.6 3NHS SURREY DOWNS CCG18.713.625.115.811.121.8 4 NHS NORTH WEST SURREY CCG23.618.230.122.617.329 5 NHS GUILDFORD AND WAVERLEY CCG***11.87.218.2 *= data suppresed due to small numbers

43. Hospital admission and mortality data The data presented so far is for 2011/2012, and is single year data published by the Health and Social Care information Centre for CCGs Prior to the publication of this data, the same raw data sources were used to collate mortality data for 2008-10 and hospital admissions for 2011 for local geographies, and provide more specific performance data This is presented next, but cannot be directly compared to the previous data, particularly for mortality from cardiovascular disease, as the coding for vascular dementia changed from CVD to mental health amongst other changes

44. Hospital admissions (2011) Relative to the rest of Surrey, Surrey Heath CCG: – Has the highest rate for hospital admissions for COPD, CHD, and diabetes per 100 persons on the disease register – The second highest rate for hospital admissions through A&E and long term neurological conditions – This indicates significant room for improved outpatient management (primary and secondary care) of these patients, and a role for improved out- of-hours GP care, e.g. through urgent care centres

45. Disease Rank in Surrey (1 = best) Admissions per 100 people on disease register in Surrey Heath CCG Surrey CCG average Surrey CCG worst Range Surrey CCG best Cancer4 (5)71.6575.73103.55 60.36 COPD5 (5)14.1911.5214.19 8.62 CHD5 (5)18.715.1218.7 12.75 Diabetes5 (5)1.981.631.98 1.33 Mental health1 (5)0.781.111.19 0.78 Emergency4 (5)82.9977.4387.69 69.39 Long term neuro3 (5)5.735.665.99 5.21 Surrey Heath CCG Hospital Admissions

46. Mortality (2008-10) Relative to the rest of Surrey, Surrey Heath CCG: – Had the highest all-age mortality for COPD, CHD, and stroke – Had the second highest all-age mortality for all cancers, circulatory disease, and suicide – Remained a poor performer with regard to under 75 mortality

47. Key messages regarding preventable conditions Improve morbidity, mortality and unplanned admissions by: – Early identification and management of risk factors such as smoking, alcohol, diet, obesity, and exercise – Prompt diagnosis and effective management of long-term conditions with treatment based on evidence based guidelines – Improving the quality of care received by people, whether at home or in residential care, e.g. relating to recognising the symptoms of a stroke

48. Surrey Heath CCG under 75 mortality

49. Surrey Heath CCG all age mortality

50. Quadrant Analysis from SPOT

51. Top Programme Budgeting Categories

52. Further information Further sources: – Surrey JSNA Health Profiles – NHS Health and Social Care Information Centre – NHS England CCG Commissioning Support Packs – Quality and Outcomes Framework Data – APHO health profiles – POPPI/PANSI databases – Murray CL et al. UK health performance: findings of the Global Burden of Disease Study 2010. Lancet 2013; 381: 997-1020 Contacts: – Dr Nadeem Hasan, Specialty Registrar in Public Health Nadeem.hasan@surreycc.gov.uk – Jon Walker, Public Health Analyst Jon.Walker@surreycc.gov.uk