Lewisham Shadow Health and Wellbeing Board

1. Lewisham Shadow Health and Wellbeing Board Towards a Lewisham Health & Wellbeing Strategy

2. Where have we got to so far?

3. Previously, on ‘The Shadow Health and Wellbeing Board’ …. We identified 9 possible priorities for a health and wellbeing strategy based on … • Biggest burden on life expectancy & QoL • Multi agency approach can make a difference • Current delivery plans don’t go far enough

4. but … Existing JSNA doesn’t completely address all 9 areas

5. therefore … NHS & Council Officers have completed ‘mini’ JSNA summaries for each of the 9 proposed priority areas

6. The tasks for the H&WB Board today

7. Review 9 ‘mini’ JSNA summaries and agree the priorities for Lewisham’s Health & Wellbeing Strategy

8. 2. Start a deliberation on what each H&WB Board member organisation can do to help deliver these priorities

9. From the 9 priorities, select 3 for the focus of H&WB Board work over the next 12 months (on the basis that they present either a quick win, a knotty problem, or engage all members)

10. Agree a process for addressing the 3 chosen priorities at each of the next 3 H&WB Board meetings

11. 5. Agree a timetable for producing a 10 year Health & Wellbeing Strategy for Lewisham

12. ‘Mini’ JSNA Summaries For each of the 9 proposed H&WB Strategy priorities

13. Tobacco Control: What do we know? Facts & Figures Key Inequalities • • low income twice as likely to smoke as more affluent • Children with mother/both parents smoke 2-3 times more likely to smoke themselves • More than 40% of total tobacco consumption is by those with mental illness • The number of smokers in Lewisham is between 45,000 and 50,000 • Smoking is the primary cause of premature death and preventable illness • 710 new young smokers a year, mostly 11-15 year olds Local Views What works Reducing smoking in young people • Peer support • comprehensive strategy for preventing take-up: mass media; education programmes; cessation support services; community programmes; reducing the number of parents who smoke • Year 8s question why it’s legal when they learn about industry’s marketing to young people to recruit replacement smokers. • • The Young Mayor’s advisors say young people are influenced by other young people and people they look up to e.g. footballers and athletes. We have to combat smoking as ‘cool’.

14. Tobacco Control: What is this telling us? Gaps knowledge/services On the horizon • No information about scale and impact of illegal trade in tobacco in Lewisham • No strategic approach to prevent uptake of smoking among young people • Stop smoking service only reaches 7% of smokers • • Users of addictive substances likely to relapse at time of recession • Tobacco industry targets vulnerable groups e.g. young people in countries where regulation is tighter What should we consider doing next? • Promote the de-normalisation of smoking • Prioritise tackling illegal trade in tobacco products to protect children • Focus on preventing uptake of smoking • Promote smoke free homes • Ensure everyone in Lewisham knows how to access help to stop smoking • Ensure sign up and representation on delivery group from all partners

15. Reducing Alcohol Harm: What do we know? Facts & Figures Key Inequalities • Alcohol use has a major impact on health, anti-social behaviour, crime • In Lewisham an estimated: 11365 higher risk, 31,873 increasing risk, 118,194 lower risk drinkers • Alcohol-related admissions high in Lewisham and rising • • men > twice likely to die from alcohol than women, but death rate decreasing for men and increasing for women • <18s women twice admission rate as men, >18s three times as high for men • Whites over represented admissions/treatment Local Views What works • Street drinkers continue to be identified as problem by some Lewisham residents • Different sites for treatment and recovery services • Increase the speed of access to detox. services and links with rehab. services • Make information on services/referral pathways more readily available to GPs and other agencies • Population based public health approaches • Screening, brief interventions for both young people and adults • parental supervision and parental drinking in front of children • School-based alcohol use prevention programmes

16. Reducing Alcohol Harm: What is this telling us? Gaps knowledge/services On the horizon • New national alcohol strategy December 2011 • Potential reductions in current funding • Public Health and NTA structural changes 2013 • Scored high on NTA self evaluation tool, but gap in clinical engagement from acute sector • Limited capacity at each tier What should we consider doing next? • Prevention of uptake by young women through: use of social marketing; involving families; school programmes • Promoting use existing licensing powers and good practice; working with alcohol sellers to ensure compliance with licensing regulations; A&E data sharing to ensure targeted approach to tackling alcohol related violence. • Improve referral pathways and expand interventions to support those most at risk through: identification; early intervention and brief advice by key professionals; interventions through the criminal justice system; primary care helping people onto treatment pathways; accessible levels of treatment

17. Immunising Children <5yrs: What do we know? Facts & Figures Key Inequalities • • At risk not being immunised: looked after children; children with physical/learning difficulties; children of teenage/lone parents; children not registered with GP; travellers, asylum seekers, homeless • Uptake of vaccines varies greatly by GP practice in Lewisham • Uptake of vaccines below target • Significant numbers of children in Lewisham are not protected against potentially serious infections • Outbreak of measles in Lewisham in 2008 with a total of 275 confirmed or suspected cases. Local Views What works • little effort in recent years to understand the views of parents locally, nor to identify barriers to immunisation • Parental resistance, especially to MMR, probably does not account for most of the gap between performance and relevant targets • London-wide and local plans have been based on elements of the approach that the city of Birmingham has taken to this issue and which have been clearly demonstrated to have a major impact on uptake

18. Immunising Children <5yrs: What is this telling us? Gaps knowledge/services On the horizon • Possibility of inclusion of influenza vaccine in routine immunisation programme for all children • Possible availability of a vaccine against Group B Meningococcus, the most important cause of meningococcal disease in this country. • Continued failure to meet most targets on immunisation, particularly MMR and PSB. • Continued need to improve information systems and to use information to make things better. • Variation between GP practices. What should we consider doing next? • Working with relevant stakeholders to ensure implementation of a preschool booster pathway (similar to the MMR pathway). • Engaging with primary schools and early years providers to implement standardised collection of information on the immunisation status of new entrants, exploring options for offering vaccinations to under-vaccinated children, and identify opportunities to promote immunisation (e.g. among childminders). • Continued work on MMR pathway, improved information systems and with GPs. • Survey of parents to better understand barriers to immunisation. • Opportunistic immunisation of children whenever they present within the health service.

19. Improving Mental Health: What do we know? Facts & Figures Key Inequalities • • SMI in those from African Caribbean and Black African backgrounds 7 or 8 times higher than white populations • Women more frequently affected by CMI than men, southern Asian women higher risk. • Poor maternal mental health associated 4-5 fold increase conduct disorder in children. • Common Mental Illness estimated to afflict 19.8% Lewisham’s population at any one time (higher than London and England) • Severe Mental Illness estimated to affect 1.1% of Lewisham’s population (England 0.7%) • Most mental disorder begins before adulthood Local Views What works • Prevention of conduct disorder through social and emotional learning programmes result in total returns of £83.73 for each £ invested • universal and targeted interventions in primary schools • Employment support for those recovering from mental illness • IAPT warmly received by patients with high satisfaction rates. • In patient services at the Ladywell issues around sub-optimal patient experience

20. Improving Mental Health: What is this telling us? Gaps knowledge/services On the horizon • - high rates of unemployment and immigrant demographic will increase need for both CMI and SMI services • - £5.6M worth of efficiencies need to be found across mental health services by 2013/14, in addition to 4% efficiency saving which must be achieved by the provider • large proportion of people with mental health problems never seek healthcare • no generic mental health voluntary support organisation What should we consider doing next? • Tackling stigma and facilitating work for those with mental health problems is possible through concerted community action. • Early intervention services, particularly in childhood are cost effective mechanisms for reducing the long term impact of conduct disorders, antisocial personality disorders and mental ill health in adolescents and adulthood and should be investigated further for local implementation. • As part of the reconfiguration of CMHTs and the care offer available to people with mental health problems, the development of commissioned voluntary sector support should be prioritised.

21. Improving Cancer Survival: What do we know? Facts & Figures Key Inequalities • • Cancer incidence and mortality generally higher in deprived groups Breast cancer higher incidence in more affluent groups, but mortality higher in less affluent women • Variance in mortality partly attributed to delayed diagnosis amongst deprived groups and certain BME groups (for breast cancer) • In Lewisham approximately 1000 Lewisham residents are diagnosed with cancer each year • The premature mortality rate ( under 75years) for males in Lewisham is 24% higher than that of England and 10% higher for females • Smoking is the single, largest preventable cause of cancer Local Views What works • The Healthy Communities Collaborative Cancer Project worked with a team of lay volunteers to organise and facilitate cancer awareness workshops, presentations, festival or group meetings, which attract a diverse population in terms of age and ethnicity. • Research suggests major explanation for poorer outcomes in England is that cancers are diagnosed at a later stage • Raising awareness of signs and symptoms of lung cancer in Doncaster resulted in rates of early diagnosis increasing by 70% from 11% to 17%

22. Improving Cancer Survival: What is this telling us? Gaps knowledge/services On the horizon • Improved detection will increase proportion of cancers requiring active, curative and intensive treatment. • Increased demand for adjuvant therapy • Improved survival rates will lead to increased workload in monitoring and treatment of recurrence • Increased demand for emotional support. • Lack of Scale of primary prevention interventions • Effective interventions needed to increase uptake of screening and awareness of symptoms and signs of cancer in the population as a whole and in specific population groups. What should we consider doing next? • Need to increase the scale of primary prevention interventions to reducing smoking prevalence, promote healthy eating and physical activity, promote sensible drinking and to sustain the skin campaign. • List validation in primary care and checking patient contact details including telephone numbers key to increase uptake of screening • Practices to promote screening and to actively follow up patients that have DNAed their screening appointments. • Active promotion of cancer screening programmes to eligible communites

23. Promoting Healthy Weight: What do we know? Facts & Figures Key Inequalities • • In adults higher level of obesity found among more deprived groups. Association stronger for women • Obesity in children increases with increasing levels of children eligible for Free School Meals. • In adults obesity higher in women of Black Caribbean, Black African and Pakistani groups compared to the general population. • Local maternal obesity data show more women overweight (31%) or obese (24%) in Lewisham compared with England as a whole (28% and 17%). • Over 48,000 adults in Lewisham obese, over 70,000 adults with raised waist circumference • Over 40% of Lewisham10-11 year olds and over 25% of 4-5 year olds were overweight or obese Local Views What works • Joint partnership working to tackle obesity promoting environments • Breastfeeding • Multi-component interventions for promoting behaviour change that target dietary and physical activity behaviours that use individual or group based strategies • Family based programmes for children • Public consultation by PCT identified reducing childhood obesity as key priority area • Consultations with children and young people through student councils and the young mayor’s advisors have highlighted obesity and healthy living to be a concern to children

24. Promoting Healthy Weight: What is this telling us? Gaps knowledge/services On the horizon • Limited local information on: incidence obesity in children below school age, during pregnancy and adults, diet/activity levels children and adults. • Capacity for weight management support inadequate for level of need. • Nationally the prevalence of obesity in children levelled over the past few years but too early to know if this is a trend. • The recession may influence types of foods purchased which are likely to be energy dense and contribute to excess weight. What should we consider doing next? • Extend and reinforce the healthy weight strategy for Lewisham and include measures to prevent and reduce obesity together with treatment of individuals already identified as overweight or obese. • Expand on workplace health • Work with fast food outlets to increase range of healthy options available to customers. • Expand on work with housing and planning to create a healthier built environment.

25. Improving Sexual Health: What do we know? Facts & Figures Key Inequalities • • Teenagers from Black ethnic groups are 74% more likely to get pregnant than those from White ethnic groups • Late HIV diagnosis more common in Black Africans, particularly heterosexual men • sexual health needs of men who have sex with men not well met within borough • In 2009 the teenage conception rate in Lewisham had fallen 31% since 1998 (17th highest rate in England and 4th highest in London) • 1,360 people have HIV infection in Lewisham (8th highest prevalence in UK). • 10% 15-24 year olds have Chlamydia Local Views What works • Young parents valued dedicated youth workers within ‘virtual team’ (including young persons midwifery services and Sure Start based at Connexions) • 2010 SHEU survey in secondary schools found that 16% of year 10 students could not recall any SRE lessons in school • contraception responsibility of female, condoms perceived to be for preventing STIs, linked to promiscuity, erratically used. • Multifaceted approaches work best for teenage pregnancy (high quality SRE, accessible services, broader work to raise self esteem and aspiration • HIV testing offered in range of non-sexual health settings such as primary care and community settings reaches people who don’t usually present to sexual health services

26. Improving Sexual Health: What is this telling us? Gaps knowledge/services On the horizon • Inequity in SRE provision • currently no abortion service based in Lewisham • local sexual health services not attracting men who have sex with men • Increased use of e-technologies and self testing • Implementation of a sexual health tariff from April 2012 (financial implications not yet clear) What should we consider doing next? • Promote broader range of settings to deliver sexual health including pharmacies, GPs, schools and web based services. • Further develop the roll out of peer educators particularly in FE colleges • Roll out HIV testing in primary care planned for 2012 onwards. Opportunities to increase HIV testing in other settings such as hospitals and opportunistically in primary care should also be a priority. • Targeted work with Black African communities to better understand the high rates of repeat abortion and any barriers to accessing sexual health services. • Expansion of pan-London c-card scheme into more settings.

27. Reduce Emergency Admissions for LTCs: What do we know? Facts & Figures Key Inequalities • • Cardiovascular disease main contributor to life expectancy gap between Lewisham and England • COPD estimated to contribute 11.3% to Lewisham life expectancy gap for men and 9.1% for women • People from BME communities at increased risk of diabetes, hypertension, stroke and renal disease • Lewisham COPD emergency admission rate significantly higher than the national average. • There were 13,406 people on Lewisham GP Diabetes Registers in 2010/11 aged 17+ • There were 5,581 people on Lewisham GP Coronary Heart Disease (CHD) Registers in • 2010/11 aged 17+ Local Views What works • Tiered, Managed Care Model for diagnosis and management of Long Term Conditions in primary and secondary care, including clinical guidelines, referral protocols, key worker, community matron, early supported discharge, specialist nurse led community clinics • LTCs Support Group (now a patient‐led group) • Diabetes UK input into the Lewisham Diabetes tier 1 and 2 service • ‘Breathe Easy’ Group

28. Reduce Emergency Admissions for LTCs: What is this telling us? Gaps knowledge/services On the horizon • Telehealth and telecare offer opportunities for delivering care more efficiently. Use of both these technologies in a transformed service can lead to significant reductions in hospital admissions and better patient outcomes. • Lack of evidence on effectiveness of combinations of interventions to reduce emergency admissions • Gaps in transfer of patient care from one care setting to another What should we consider doing next? • Integrating health and social care may be effective in reducing admissions. An independent enquiry into the quality of general practice underlined the importance of better co-ordination and engagement with social care • Developing a shared vision and strategy for ‘integration’ across the heath economy in Lewisham.

29. Reduce need for long term care and support: What do we know? Facts & Figures Key Inequalities • 2,862 (11.8% ) Lewisham older adults aged 65+ receive social care • Approx 290 adults aged 65 + receive residential and nursing home packages • 153 adult safeguarding referrals for clients aged 65 and over were received • More women than men receive services – more than borough average for population • More White British service users than borough average for this age group. • There are more female safe guarding alerts in 2010/11 compared to males. Local Views What works 2 Lewisham social services IAS System • The Partnerships for Older People Projects (Popp) cost-effective compared with usual care (small housing repairs, gardening, limited assistive technology or shopping) with improved quality of life & wellbeing. • Evidence for Care services efficiency delivery (CSED) that 36-48% of users who complete reablement required no homecare package two years later • Annual self-assessment, service user questionnaires, monitoring visits (announced and unannounced) reports form advocacy organisations, lay visitor scheme are examples of tools used locally to collect local views from clients, carers and families.

30. Reduce need for long term care and support: What is this telling us? Gaps knowledge/services On the horizon • Closer scrutiny of care standards locally in the light CQC and Health Service Ombudsman reports • Moves from process/output based performance management to outcome based framework across adult social care, NHS and public health. • Poor co-ordination between Adult social care, customer services and Lewisham Homes in provision of sheltered/extra care housing in Lewisham. • Lack of systematic mapping to predict real impact of intermediate care services • Gaps in knowledge about uptake of social care services for this age group by ethnicity, religion etc. What should we consider doing next? • Further work required on systematic collection, evaluation and interpretation of data sources • Improve strategic co-ordination between Adult social care, customer services and Lewisham Homes in provision or re-provision of sheltered/extra care housing provision in Lewisham. • Further work to map older adults residential, nursing and domiciliary pathways, to predict real impact of intermediate care services (reablement, sheltered accommodation) on reducing demand and spend on residential, nursing and domiciliary care packages

31. Review 9 ‘mini’ JSNA summaries and agree the priorities for Lewisham’s Health & Wellbeing Strategy -------- Start a deliberation on what each H&WB Board member organisation can do to help deliver these priorities --------

32. From the 9 priorities, select 3 for the focus of H&WB Board work over the next 12 months (on the basis that they present either a quick win, a knotty problem, or engage all members)

33. Breakout Groups

34. We Recommend the following three priorities: • Reducing Smoking • Improving Mental Health • Reducing Emergency Admissions for people with Long Term Conditions

35. Agree a process for addressing the 3 chosen priorities at each of the next 3 H&WB Board meetings

36. We recommend the following process At each of the next three H&WB Board meetings we: • Review the more detailed JSNA evidence; 2. Examine the existing delivery plan; • Assess current performance; 4. Identify what more we can do collectively and individually to accelerate progress

37. Agree a timetable for producing a 10 year Health & Wellbeing Strategy for Lewisham

38. We recommend: • Senior Officers, with input from Voluntary Sector, LHNT, SLAM and Clinical Commissioners, bring first draft H&WB Strategy to next H&WB Board

39. We recommend: • Present findings of initial consultation at next Board meeting • Complete consultation and bring final draft for approval at second Board Meeting

40. Lewisham Shadow Health and Wellbeing Board Towards a Lewisham Health & Wellbeing Strategy