Tameside Strategic Partnership

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5. Healthcare Public Health and Preventing Premature Mortality

5.1 Under 75 mortality rate from all cardiovascular disease (CVD) and Improving recovery from stroke

Outcomes framework:

Public health 4.4; NHS 1.1 and 3.4

Implication for the population’s health & well-being:

Cardiovascular diseases are the main cause of death in the UK causing around 147,300 deaths in England in 2010 (around a third of all deaths). Around 45% of all deaths from CVD are from coronary heart disease (CHD) and more than a quarter from stroke (27%). CHD is the most common cause of death in England and Wales (15% of all deaths in 2010).

Benchmarking:

The cardiovascular disease health profile, released in 2012, includes the following as key messages for Tameside and Glossop in relation to CVD:

  • Early mortality rates from CVD (< 75 years) are significantly higher than the national rate, but have decreased by 55.2% since 1995.
  • Emergency admission rates for both CHD and stroke are significantly higher than the national rate.
  • The mortality rate within 30 days of a segment elevation myocardial infarction (STEMI) is similar to the national rate.
  • For people having myocardial infarction reperfusion in 2010, the median time to primary angioplasty treatment from a call for help was 129 minutes in Tameside and Glossop, this is higher than in Industrial Hinterlands and England (95 and 113 respectively).
  • Stroke patients under 75 years are less likely to be discharged back to their usual place of residence compared to the national picture

Figure 56: Under 75 mortality from cardiovascular disease by PCT, England and North West averages (2008-2010)

Graph showing under 75 mortality from cardiovascular disease

Source: NHS Information Centre 2012

Policy Context:

NHS organisations should implement clinical strategies aimed at reducing early mortality from CVD, including CHD, stroke, kidney disease and diabetes. There is strong evidence that early treatment supports better clinical outcomes. There are a number of key areas where commissioners and providers can work together to ensure earlier diagnosis and treatment.

What interventions work?

  • Healthy lifestyles and prevention interventions
  • Health Checks- Invite 20% of eligible population and deliver health checks to 75% of those invited
  • Quality Outcomes Framework (QOF) - Identify missing people from chronic disease registers
  • Design and implement a pathway for universal care of all CVD patients:
    • Embed referrals to health trainers into treatment pathway for people with CVD risk factors
    • To include referrals for: physical activity, obesity, affordable warmth
  • Quality, Innovation, Productivity and Prevention (QIPP) plans - Use QIPP plans to divert care from secondary to primary care.
  • Quality of care in hospital/secondary care -Use Sentinel audit to monitor improvement the quality of local stroke services in secondary care, including stroke and cardiac rehabilitation.

What are we doing now?

NHS Tameside and Glossop continue to deliver reductions in CVD mortality, but we are not addressing the gap between our population and the national and SHA population. We aim to reduce the incidence of CVD through our prevention work and also improve the management of the disease. Support is being given to primary care to help with disease management, identifying patients at risk and monitoring/preventing hospital admissions.

5.2 Under 75s mortality rate from cancer

Outcomes framework:

Public Health 4.5 and NHS 1.4

Implications for the population’s health and well-being:

Cancer is the commonest cause of premature death in people under 75 in Tameside and Glossop, and England as a whole. The chance of developing cancer increases with age, so as the number of older people continues to increase, so we can expect there to be more people with cancer. At the same time, death rates from cancer have reduced in the last twenty years, so the chance of dying from cancer is reducing. Stopping smoking, screening and better treatments have all helped to make this change. But if unchecked, current increases in obesity and alcohol consumption will result in increases in cancer in the future.

At risk or vulnerable groups:

Cancer is commoner and mortality generally higher in deprived communities, older people and men. There are significant differences between areas across England and within the North West.

According to the Reducing Cancer Inequality Report, it is also estimated that if survival from cancer in England was as good as the best in Europe about 66 lives would be saved in each PCT area per year.

Benchmarking:

Cancer is the most common cause of death in Tameside for males and females, and there are significantly more deaths than there should be, given the population age and gender profile.

  • Cancers are the commonest cause of premature death in Tameside – responsible for 36.5% of all deaths in males under 75 years, and 42.7% of deaths in females under 75 years in 2006.
  • Death rates for all cancers as a whole are higher in Tameside and Glossop than the average for the North West and England.

Figure 57: Mortality from all cancers: directly standardised rate, <75 years, Annual Trend for England, North West, Industrial Hinterland and NHS Tameside and Glossop, 2002 to 2010

Graph showing mortality from all cancers

Source: NHS Information Centre 2012

Figure 58: Mortality from all cancers: directly standardised rate, <75 years, 3-year average 2008-2010

Graph showing mortality from all cancers

Source: NHS Information Centre 2012

  • Of the common cancers death rates for lung, bowel and breast are above, and for prostate the same as, the England average. 5 year survival for bowel cancer is currently the lowest in Greater Manchester.

Figure 59: 5 year survival rate (%) for bowel cancer in Greater Manchester, with England and North West average (2001 to 2005)

Graph showing 5 year survival rate for bowel cancer

Source: NHS Information Centre 2012

  • There is significant variation in death rates from lung cancer between wards in Tameside and Glossop, and screening uptake also varies between general practice populations.
  • Deaths from cancer make a significant contribution to the excess deaths that result in a life expectancy gap between Tameside and England, making up 22% of the difference for men, and 20% for women. Health Inequalities Intervention Toolkit

Policy context:

What interventions work?

About 50% of cancer is preventable, and survival is improving for all cancers with early detection and better treatments. PREVENTABLE and TREATABLE: A Cancer Prevention, Early Detection and Inequalities Strategy for NHS Tameside and Glossop, sets out how the challenge of reducing the impact of cancer on local communities will be met. Alcohol and obesity make significant contributions to cancer risk. Effective and timely treatment is also essential to reducing cancer mortality.

What are we doing now?

The key issues for action in PREVENTABLE and TREATABLE: A Cancer Prevention, Early Detection and Inequalities Strategy for NHS Tameside and Glossop are grouped into four work-streams summarised below.

Table 20: Work-streams for cancer prevention, early detection and inequalities strategy in Tameside and Glossop

Works-stream 1: Reducing Inequalities

 

Gender:

Ensure all appropriate projects within this Strategy are accessible to men

Social deprivation:

Regular review of progress of milestones in all work-streams of this Strategy that give priority to deprived communities

Age:

Review and monitor local over 75yrs cancer mortality.

Ethnicity:

Local adoption of good practice in promoting awareness in South Asian communities identified by GM&C Cancer Network pilot project

Disability:

Review local implementation of national guidance on access to screening programmes

Work-stream 2: Lifestyle

 

Reduce the prevalence of smoking

Implementation of Tameside Tobacco Harm reduction Strategy

 

Smokefree Homes programme

 

AGMA initiatives on illicit and illegal tobacco trading

 

Review of local smoking cessation service

Improve the diet of the population

Tameside area-based action plan to ensure healthy diet for children

 

Tameside and Glossop Obesity Strategy and Action Plan

Reduce the prevalence of obesity and overweight

Practice-based one-to-one weight management service

increase the amount of physical activity

Tameside Sport and Physical Activity Strategy implementation

Reduce excessive consumption of alcohol

Tameside Alcohol Strategy

Workstream 3: Targeted programmes

Reduce exposure to specific causes of cancer

Reduce the spread of infections that can cause cancer

Workstream 4: Early detection

Improve communication about cancer signs and symptoms

Make diagnostic pathways follow best practice and be available to all

Improve attendance at cancer screening especially in disadvantaged groups by implementation of T&G Cancer Screening Promotion Action Plan

Source: PREVENTABLE and TREATABLE: A Cancer Prevention, Early Detection and Inequalities Strategy for NHS Tameside and Glossop

What needs to happen next, and by whom?

  • Stopping smoking, as well as taking up healthy eating, physical activity and reducing alcohol intake all help to prevent cancer. There are partnership strategies in place to address each of these and these should be actively supported as part of cancer prevention.
  • Deliver priorities for local action within PREVENTABLE and TREATABLE: A Cancer Prevention, Early Detection and Inequalities Strategy for NHS Tameside and Glossop.
  • Consistent achievement of good NHS Cancer Waiting Time performance.

5.3 Under 75 mortality rate from respiratory disease

Outcomes framework:

Public Health 4.7; NHS 1.2

Implications for the population’s health and well-being:

Respiratory disease, in particular Chronic Obstructive Pulmonary Disease (COPD) is a disabling illness. Although it affects people in different ways, those with COPD often have attacks of breathlessness, a bad cough and repeated chest infections. They produce a lot of sputum and can be affected both in the winter, in a cold snap, and in the summer, when air pollution can be high. Quality of life for people with advanced COPD is also affected. There are problems with restricted mobility and these are compounded by social isolation and self-esteem. The majority of COPD cases are caused by smoking, and stopping smoking, even after COPD is diagnosed can slow down the progression of the disease.

At risk or vulnerable groups:

The National Outcomes Strategy for COPD and Asthma identifies those most at risk as:

  • Current and ex-smokers are most at risk of contracting COPD
  • People who have been exposed to inhaled dusts and gases in the workplace
  • Those who have an inherited genetic problem that leads to the early onset of emphysema
  • Who may have had a previous diagnosis of asthma
  • Routine/manual workers
  • Bangladeshi men and women

Benchmarking:

Tameside and Glossop has one of the highest rates of mortality for COPD in Greater Manchester and is slightly above the North West (NW) and England average in respect of asthma mortality. Pneumonia related mortality within Tameside and Glossop is below the England average and slightly below the NW average however pneumonia continues to be a priority locally, as it has been identified as one of the most common causes of death for Tameside Hospitals Foundation Trust in 2010/11 as indicated by the Summary Hospital Mortality Index (SHMI) reports.

Figure 60: Directly Standardised under 75 mortality from bronchitis, emphysema and other COPD (2008-2010)

Graph showing mortality from bronchitis, emphysema and other COPD

Source: NHS Information Centre 2012

Figure 61: Directly Standardised under 75 mortality from Pneumonia (2008-2010)

Graph showing mortality from pneumonia

Source: NHS Information Centre 2012

Policy context:

NHS organisations should continue to support the other clinical strategies aimed at reducing early mortality from respiratory disease. There is strong evidence that early treatment supports better clinical outcomes. There are a number of key areas where commissioners and providers can work together to ensure earlier diagnosis and treatment.

What interventions work?

National Guidance from NICE recommends the following interventions in order to manage respiratory disease, reducing mortality:

  • Accurate diagnosis;
  • Stop smoking;
  • Promote effective inhaled therapy;
  • Provision of pulmonary rehabilitation;
  • Use non-invasive ventilation;
  • Manage exacerbations;
  • Ensure multidisciplinary working.

What are we doing now?

COPD: NHS Tameside and Glossop have high incidence of COPD. COPD has been identified as a priority area with support from the NHS Clinical Commissioning Group (CCG) to enhance the identification and management of COPD across Tameside and Glossop.

A COPD Project Group was established in readiness for the release of the National Outcomes Strategy for COPD and Asthma which has multi-disciplinary membership, comprising of representation from primary, secondary and community care and a local patient group representative. A project plan has been developed which incorporates the 6 objectives of the National Outcomes Strategy.

Considerable work is already underway against the project plan in respect of a training and education programme in primary care as well as the development of a local pathway. Work has already commenced to pilot case finding and screening in the community, the development of a primary/community pathway for COPD and provision of training across Primary/Community Care.

Asthma: A pilot training programme has commenced across several GP practices in order to appropriately diagnose asthma, develop and agree treatment plans with patients in order to manage their condition effectively.

Pneumonia: An ambulatory care pathway for community acquired pneumonia has been developed for Tameside and Glossop and has been implemented across primary, secondary and community care. The pathway ensures appropriate assessment, diagnosis and management upon presentation and subsequent discharge arrangements for management in the community.

What needs to happen next, and by whom?

Smoking cessation needs to be embedded within all stages of COPD care pathway, from prevention through to disease management.

Earlier identification and management of COPD/Asthma: We will continue to work with primary, secondary and community care in order to improve the identification and management of COPD. The release of the National Outcomes Strategy for COPD and Asthma identifies the early and accurate diagnosis of COPD as a key outcome. We will continue to work with secondary care colleagues in order to establish fully integrated pathways to reduce length of stay and safe transfer of patients to a community setting.

Pneumonia: Continually review the Community Acquired Pneumonia (CAP) pathway and its effectiveness, updating as required and in accordance with national guidance.

5.4 Mortality from communicable diseases

Outcomes framework:

Public Health 4.8

Implications for the population’s health and well-being:

Communicable diseases include a range of conditions, including the seasonal influenza virus, healthcare associated infections (HCIA), sexually transmitted infections (STIs) such as Human immunodeficiency virus (HIV) and gonorrhoea, among many others. They have diverse routes of infection, various associated risk factors, and extreme ranges of related mortality and morbidity. Indeed, while mortality is high in some communicable diseases, time from contraction to death can be relatively long with early detection and high quality care.

At risk or vulnerable groups:

Some populations are more susceptible than others to different communicable diseases.

HCAI: HCAI cover a range of diseases including meticillin-resistant Staphylococcus aureus (MRSA), meticillin-sensitive Staphylococcus aureus (MSSA), Clostridium Difficile (C. Difficile) and Escherichia coli (E. coli). HCAIs while often having low levels of infection in the general population, can be dangerous in environments (such as hospitals) where the infection can be spread quickly across a large number of people who are often already in poor health, e.g. the elderly, those with underlying illnesses, and anyone who is immune-compromised.

Seasonal Influenza: The most at risk from serious complications and mortality are those who already have underlying conditions, such as those with cardiac, respiratory, or immune system problems, as well as the elderly (who often have other conditions), and the young (who have not yet developed immunity).

Vaccine Protected Diseases: Vaccination up-take rates, particularly among children, vary according to a number of factors. There are significant reductions in vaccination rates among children in more deprived areas, those from large families, among travelling communities, and children by parents with chaotic lifestyles.

Policy context:

Getting ahead of the curve: A strategy for combating infectious diseases: This strategy sets out the priorities for the control and eradication of infectious diseases. It also sets out a vision for the modernisation of systems to respond to current challenges and future threats related to infectious diseases.

Benchmarking:

While work is needed to develop the detail for this indicator, there is information available related to mortality and years of life lost related to Infectious and Parasitic diseases. The figure below shows that Tameside and Glossop has higher rates of mortality from infectious and parasitic diseases that any of the other comparator PCTs, as well as the North West and England. During this period, Tameside and Glossop had 121 deaths, which equates to a directly age- standardised rate (per 100,000 of European standard population) of 10.3, compared to a rate of 6.4 for England.

Figure 62: Three Year Pooled Mortality Rate from Infectious and Parasitic Disease (2008 to 2010)

Graph showing mortality rate from infectious and parasitic disease

Source: NHS Information Centre 2010

The following figure shows the directly age- standardised rate (per 10,000 of European standard population) of years of life lost due to infectious and parasitic disease. The local rate is higher than the comparable PCTs, the North West and England, showing that there is opportunity to reduce the impact of infectious and parasitic disease locally.

Figure 63: Three Year Pooled Years of Life Lost due to Infectious and Parasitic Disease (2008 to 2010)

Graph showing years of life lost due to infectious and parasitic disease

Source: NHS Information Centre, 2011

What works?

Vaccination is key to reducing the spread of communicable disease. When a population has sufficient rates of immunity to prevent spread of a communicable disease, this is known as herd-immunity. The level of vaccination required to achieve herd immunity changes depending on the disease: measles, for example, requires a vaccination rate of between 92 and 95% to effectively block transmission, whereas Diphtheria only requires a rate of 80 to 85%.

HCAI: recruitment of modern matrons to promote improved clinical care standards in infection control; promotion of the use of alcohol hand gel; regular audits to ensure high standards of hand hygiene in healthcare environments; availability of isolation facilities; as well as a culture of continuous quality improvement.

Seasonal Influenza: to protect against the dangerous effects of seasonal influenza, vulnerable groups need to be targeted: those with respiratory conditions; the elderly, and the immune-suppressed. Having comprehensive plans in place to reduce the spread in healthcare settings are very important.

Vaccine Protected Diseases: The key to this approach is making vaccine uptake a priority. Vaccination clinics should be held at times which suit the population being targeted.

Vaccination should be combined with other appointment and clinic visits; ensure that all front line staff in clinics and practices are actively checking for immunisation status; work directly with communities who are under-vaccinated to increase vaccination rates; offer ‘domiciliary’ vaccination service for non-attendees; and use reminders to help promote attendance.

STIs and HIV: condom provision for high risk groups; condom subsidy schemes; Outreach health promotion and safe sex programmes for high risk groups and hard to reach groups; high quality integrated Sex and Relationships Education; short access times for GUM services.

What are we doing now?

  • work with local healthcare providers to reduce their HCAI rate through the development of guidance with support for education around antibiotics prescribing and hand hygiene;
  • providing specialist sexual health clinics; young person friendly community based sexual health and contraception services;
  • dedicated specialist Tuberculosis service;
  • primary care targeting of high-risk groups for vaccination;
  • Targeting vulnerable groups for administration of vaccine

What needs to happen next, and who needs to do it?

  • Season flu plans are being developed to ensure that the most vulnerable to the effects of seasonal flu are targeted for vaccination
  • Clear joined up plans need to be in place to ensure that progress in reducing HCAI is sustained and improved further
  • Vaccine uptake rates are high in Tameside and Glossop for vaccine-protected conditions. Long and medium term strategies must be developed to ensure the maintenance of this performance and to target specific groups with low uptake rates.

5.5 Mortality and hospital admissions due to serious mental illness, self harm and suicide

Outcomes framework:

  • Public Health 4.9: Excess under 75s mortality in adults with a serious mental illness
  • NHS 1.5: Excess under 75 mortality in adults with serious mental illness
  • Public Health 4.10: Suicide
  • Public Health 2.10: Hospital admissions as a result of self harm.

Implications for the population’s health and well-being:

Poor mental health has both personal and societal costs. The local mental health and well-being strategy highlights that people with severe mental illness are estimated to die on average 20 years earlier than the general population and 50 % of them also have a recognisable co-existing physical health conditions. Poor mental health is associated with an increased risk of physical illness, due in part to a less healthy lifestyle and more frequent health-risk behaviour while physical illness increases the risk of poor mental health.

People who harm themselves are subject to stigma and hostility. In contrast to the trends in completed suicide, the incidence of self-harm has continued to rise in the UK over the past 20 years and, for young people at least, is said to be among the highest in Europe. This high level of self-harm among different age and social groups is a worrying feature of our society.

A significant number of admissions to medical wards in England are as a result of deliberate self harm. With input from skilled mental health practitioners who can assess and provide evidence based treatment interventions, this can reduce the incidence of self harm.

At risk or vulnerable groups:

People of all ages and from all social and cultural backgrounds may harm themselves but some groups are especially vulnerable because of life experiences, personal or social circumstances, physical factors or a combination of these elements. There is a higher incidence of self-harm among prisoners, asylum seekers, veterans from the armed forces, people bereaved by suicide, some cultural minority groups, people with learning disabilities and people from sexual minorities.

Benchmarking:

Figure 64: Emergency Hospital Admissions for Self-Harm – 2009/10

Graph showing emergency hospital admissions for self-harm

Source: Association of Public Health Organisations 2012

Figure 65: Age standardised Mortality Rate from Suicide and Injury of Undetermined Intent per 100,000 Population (2008-2010)

Graph showing mortality rate from suicide and injury undetermined

Source: NHS Information Centre 2012

Policy context:

What interventions work?

  • Raising public awareness regarding mental health issues leads to improvement in attitudes
  • Training and education of staff regarding recognition of signs of distress and how to respond
  • GP education programmes aiming to increase detection of depression
  • Specific psychotherapies to prevent repetition of self-harm
  • Responsible approach to reporting suicide and mental health issues by the media

What are we doing now?

  • The Greater Manchester Police have produced a report focusing on analysis of initial deaths highlighting trends and identifying hot spots at Greater Manchester as well as locality level
  • A Greater Manchester approach is being developed by GM Suicide Prevention Group to address serious mental health issues
  • Extensive training is delivered locally within the acute sector to highlight the links between mental health and substance misuse

What needs to happen next, and by whom?

  • Ensure improvement in quality of suicide data linking initial death reports with coroner's outcomes
  • Improvement in capturing a data related to attempted suicide
  • Conduct a comprehensive gap analysis of patient care pathways for suicide prevention
  • Develop effective care plans and patient care pathways with support from a multi-disciplinary team to ensure effective and timely support for a person who self harms.

5.6 Reducing premature death in people with learning disabilities

Outcomes framework:

NHS 1.7

Implications for the population’s health and well-being:

People with learning disabilities (LD) have poorer health than their non disabled peers and these differences in health status are, to an extent avoidable.

The health inequalities faced by people with LD start early in life and result, to an extent, from barriers they face in accessing timely, appropriate and effective health care. The inequalities evident in access to health care are likely to place many NHS Trusts in England in contravention of their legal responsibilities defined in the Equality Act 2010, the Mental Capacity Act 1006 and the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010.

People with LD have a shorter life expectancy and increased risk of early death when compared to the general population. Life expectancy is increasing, in particular for people with Down’s syndrome, with some evidence to suggest that for people with mild learning disabilities it may be approaching that of the general population. Nonetheless, all cause mortality rates among people with moderate to severe LD are three time higher than in the general population, with mortality being particular high for young adults, women and people with Down’s Syndrome. Health Inequalities and People with Learning Disabilities in the UK 2011

At risk or vulnerable groups:

  • Those with learning difficulties and disabilities
  • Those not known to services
  • Those not accessing services
  • Young Adults
  • Women
  • People with Down’s Syndrome

Benchmarking:

There is no definitive record of the number of people with LD in England. However it is estimated that in England in 2011 1,191,000 people have learning disabilities. This includes:

  • 286,600 children (180,000 boys,106,000 girls) age 0-17;
  • 905,000 adults aged 18+ (530,000 men and 375,000 women), of whom 189,000 (212%) are known to learning disabilities services.

In Tameside there are 929 people with a LD who access learning disability services. The median age at death in Tameside is 5 years higher (60 years) than the England and the North West average (55 years). For more information see Tameside Learning Disabilities Profile 2012

Policy context:

What interventions work?

  • Specialist teams providing support
  • Delivery and access to NHS Health Checks
  • Maximising opportunities for Health Screening and Health Promotion
  • Maximising work opportunities for people with LD

What are we doing now?

  • The LD self assessment framework has been completed for the last 2 years and there are action plans to respond to the areas which need improvement.
  • There is a hospital liaison nurse who provides support for people with LD who attend hospital for either planned or unplanned admissions.
  • There is a GP liaison nurse who works with GP surgeries to understand the LD population and increase uptake of annual health checks. We are developing a Local Enhanced Service (LES) to support this increase.
  • There is a screening programme in place for early onset of dementia in people with LD
  • The LD self assessment identified specific groups of people with LD (older people, carers, Black and Minority Ethnic (BME), people with profound and complex needs, people with autism) that need specific support to enable them to access appropriate and accessible services
  • Following a local serious case review Tameside Adult Safeguarding Partnership developed an Action Plan which has now been implemented

What needs to happen next, and by whom?

  • Increase the number of NHS Health Checks and Screening opportunities delivered to adults with LD
  • Implementation of the LES for NHS Health Checks and follow up any issues highlighted
  • Further increase in awareness of the health issues experienced by people with learning disabilities
  • Further develop strategies to meet the needs of people with LD with profound and complex needs, carers, BME and older people.
  • Improved health promotion training and skill development for residential care staff
  • Improved access to familial information for staff and carers

5.7 Emergency admissions/readmissions and unplanned hospitalisation for chronic ambulatory care sensitive conditions

Outcomes framework:

  • Public Health 4.11: Emergency readmissions within 30 days of discharge from hospital
  • NHS 3b: Emergency readmissions within 30 days of discharge from hospital
  • NHS 3a: Emergency admissions for acute conditions that should not usually require hospital admission
  • NHS Operating Framework PHQ17: Emergency admissions for acute conditions that should not usually require hospital admission
  • NHS 2.3i: Unplanned hospitalisation for chronic ambulatory care sensitive conditions
  • NHS Operating Framework PHQ15: Unplanned hospitalisation for chronic ambulatory care sensitive conditions

Implications for the population’s health and well-being:

  • Maintaining wellness and independence in the community prevents deterioration in conditions and therefore results in better health outcomes.
  • Emergency admissions to hospital are distressing, so better management that keeps people well and out of hospital should lead to a better patient experience.
  • Reducing variations in ambulatory care sensitive (ACS) admissions by spreading existing good practice could produce cost savings of £170 to £250 million across England (NHS Institute 2011). This variation-based calculation may significantly underestimate potential savings from managing ACS more effectively as admission rates in all areas are significantly above what should be achievable.

Programme spend:

Locally, emergency ambulatory care generated a cost of around £11m in 2009/10 with 7,841 admissions.

At risk or vulnerable groups:

  • Older people; the risk of developing ACS conditions increases with age
  • People with mental health conditions; there is a strong association between mental and physical ill health.

Benchmarking:

The aim is to decrease over time the number of emergency re-admissions within 30 days of discharge. Locally, readmission rates for non-elective admissions have increased between 2010/11 and 2011/12 (Month 8 Data) by 17% however 2011/12 year to date is showing a very minimal decreasing trend.

Figure 66: Readmissions that occur within 30 days of any previous discharge.

Graph showing readmissions to hospital

Source: NHS Tameside and Glossop 2012

Policy context:

What interventions work?

Early identification of ACS patients is crucial if their management is to be successful. GPs are well placed to do this through the use of risk stratification tools and clinical decision support software within GP practices. Some progress can be made through relatively simple measures such as expanding vaccination, where available, to prevent the onset of a condition. For other ACS conditions (chronic and acute aggravated conditions), commissioners will need to encourage active disease management. This can include a number of elements, such as:

  • treatment decisions based on explicit proven guidelines
  • case management to support people with complex long-term conditions
  • disease management and support for self-management for those with less complex long-term conditions
  • telephone health coaching, and other behavioural change programmes, to encourage patient lifestyle change
  • easy access to urgent care for those with acute aggravated conditions

What are we doing now?

NHS Tameside and Glossop have a local Emergency Care Network, with membership from both Local Authorities (Social Care), Primary Care, Community services, our local Foundation Trust, North West Ambulance Service (NWAS), and GP Out of Hours. Rates for readmissions are currently under review and subject to new guidance due to be released in 2012.

During 2011-12 we have:

  • Continued to monitor readmission rates including previous years data for accurate comparison
  • Piloted and streamlined discharge processes from acute beds
  • Increased in-patient intermediate care capacity
  • Implemented local Commissioning for Quality and Innovation (CQUINs) with acute and community providers to support implementation of internal professional standards which includes early consultant specialist review, expected dates of discharge, care and discharge planning
  • Introduced 4 ambulatory care pathways (Cellulitis, Community Acquired Pneumonia (CAP), Urinary Tract Infections (UTI’s) and Deep Vein Thrombosis (DVT)), which support improved planned pathways of care for urgent presentations and reducing readmissions
  • Implemented the Integrated Discharge Team to support early facilitated discharge of older people within 24-48 hours of admission.
  • Piloted 15 recuperation beds
  • Implemented the care homes pilot delivering additional services to patients in care homes
  • Implemented the Short Stay Intervention Unit (SSIU) and Transitional Discharge Ward (TDW)
  • Tameside Hospital Foundation Trust (TFT) audit of 50 randomly selected readmission patients, the results of which will feed in to 2012/13 work streams

What needs to happen next, and by whom?

In 2012-13, the Emergency Care Network will continue to provide the leadership for this agenda, and plans include:

  • Procure 40 intermediate care beds, replacing all current community provision
  • Evaluate the SSIU & TDW with a view to continuing with the most successful model
  • Evaluate the care homes pilot with a view to refining content and continuing the service should admissions be reduced
  • Drive down Length of Stay (LOS) in all areas but particularly where we are an outlier for emergency admission stays and intermediate care stays
  • Continue to monitor the outcomes from the existing ambulatory care pathways
  • Implement a further 4 ambulatory care pathways

5.8 Unplanned hospitalisation for asthma, diabetes and epilepsy in under 19s and emergency admissions for children with lower respiratory tract infections

Outcomes framework:

  • NHS 2.3ii: Unplanned Hospitalisation for asthma, diabetes and epilepsy in under 19s NHS Operating Framework PHQ16: Unplanned Hospitalisation for asthma, diabetes and epilepsy in under 19s
  • NHS 3.2: Emergency admissions for children with lower respiratory tract infections

Implication for the population’s health and well-being:

Having long term conditions such asthma, diabetes and epilepsy as a young person can have a far reaching impact on a young person’s well-being throughout adolescence and into adulthood. These include increased rates of depression, increased dependence on parents, poor vocational education, lower employment rates and negative self image. The care and support young people receive can influence the prevalence and impact of the health outcomes. Health care providers play important roles in the lives of young people with chronic illnesses.

For children and young people with chronic health conditions, the aim of their treatment and care is to manage their illness in such a way that they are able to achieve their full potential. In order for this to be achieved, children, young people and their families should have access to services that help them to develop the self-confidence and self management skills, needed to deal with the impact of their condition upon themselves, their family or carers.

Current models of health service delivery are unlikely to cope with future demand. Inadequate and fragmented services for chronic illness contribute to unnecessary and costly hospital admissions and inconvenience for patients.

Programme spend:

Table 18: Cost of asthma admissions

Year

No. of admissions

Cost

2009/10

208

£164,024

2010/11

145

£99,858

2011/12

194

£137,890

Source: NHS Tameside and Glossop 2012

Note: The true prevalence of asthma admissions is difficult to determine due to the lack of a single objective diagnostic test and different methods of classification of the condition.

At risk or vulnerable groups:

There is a significant relationship between deprivation and child emergency hospital admissions for both asthma and epilepsy across England: as deprivation increases, admission rates increase. However, there is no such relationship between deprivation and child emergency hospital admissions for diabetes.

Benchmarking:

Benchmarked information is available on all three conditions as detailed in the following charts.

Figure 67: Rate of emergency hospital admissions for asthma (0-18 years) per 100,000 population 2009/10.

Graph showing rate of emergency hospital admissions for asthma

Source: Children and Maternal Health Observatory 2012

Figure 68: Rate of emergency hospital admissions for diabetes (0-18 years) per 100,000 population 2009/10.

Graph showing rate of emergency hospital admissions for diabetes

Source: Children and Maternal Health Observatory 2012

Figure 69: Rate of emergency hospital admissions for epilepsy (0-18 years) per 100,000 population (2007-2010)

Graph showing rate of emergency hospital admissions for epilepsy

Source: Children and Maternal Health Observatory 2012

Policy context:

What interventions work?

  • Public health interventions that may mitigate disease progression including reducing tobacco use, alcohol consumption, and illicit drug use, obesity, increasing physical activity.
  • Prevention, early identification and management of risk factors, including high cholesterol and blood pressure, diabetes and chronic kidney disease.
  • Better management of the condition in the community could reduce the number of emergency admissions for asthma.

What are we doing now?

A detailed analysis of activity in these areas has been carried out to support the work to be done in 2012-13. With an emergency admission rate and bed day rate higher than the national average, Asthma has been identified as the priority for action in the first year.

What needs to happen next, and by whom?

The roles and responsibilities for proactively managing long term conditions lie within primary care and community health services, supported by paediatrics. Evidence based pathways need to be developed locally to ensure that all services are equipped to play their part.

Asthma: The NHS Clinical Commissioning Group (CCG) has prioritised action on asthma for 2012/13. The following plan is underway:

  • Full data analysis of activity over last five years
  • Repeat admissions identified and case notes scrutinised
  • Local pathway developed to cover primary and secondary care and the community, notably in schools.
  • Clinical guidance developed as required

Diabetes: The CCG is working with providers to ensure that the paediatric diabetes standards are met and from this developing a service specification for the Paediatric Diabetes Service in line with the forthcoming Best Practice Tariff.

Epilepsy: For attention in 2013/14.

5.9 Preventable sight loss

Outcomes framework:

Public Health 4.12

Implications for the population’s health and well-being:

People with sight loss face huge challenges in undertaking everyday tasks that sighted people take for granted. Access to public services, leisure and employment opportunities can be seriously limited by inaccessible public transport and the lack of recognition in the benefits system of blind people's real transport costs. A visit to the local shops can be made hazardous by busy roads, street clutter and poor highway design.

At risk or vulnerable groups:

The Royal National Institute for the Blind (RNIB) has identified the following at risk or vulnerable groups:

  • Ethnic Minority Groups;
  • Age (Older People more prevalent of sight loss);
  • Diabetics;
  • Genetic links to Glaucoma;
  • Smokers

Benchmarking:

Data is not readily available for the incidence of preventable sight loss. The NHS information centre publish data detailing new registrations of blind and partially sighted persons, although it should be noted that this includes cases that are not considered preventable.

Figure 70: Rate of New Registrations of Blind Persons in Tameside and Greater Manchester Local Authorities 2010/11

Graph showing rate of new registrations for blind people

Source: NHS Information Centre 2012

Figure 71: Rate of New Registrations of Partially Sighted People in Tameside and Greater Manchester Local Authorities 2010/11

Graph showing rate of new registrations for partially sighted people

Source: NHS Information Centre 2012

Policy context:

NICE guidance

What interventions work?

  • Earlier detection through screening and accurate diagnosis. Research by RNIB suggests that 50% of cases of blindness and serious sight loss could be prevented if detected and treated in time
  • Encouraging those at particular risk of eye disease to seek an eye examination is seen as a public health imperative fundamental to early detection of preventable eye disease
  • On-going monitoring and surveillance of at risk/vulnerable groups

What are we doing now?

We have an established diabetic retinopathy screening service, delivered from several community locations (see indicator Access to non-cancer screening programmes), which increases access and choice for patients. Similarly, we have developed a community service for ocular hypertension, which is provided by community optometrists therefore increasing choice and accessibility for patients. We are in the process of reviewing ophthalmology pathways to ensure optimum care closer to home in order to improve access for patients and earlier intervention.

What needs to happen next, and by whom?

As part of the review of ophthalmology, we need to raise awareness amongst the population, to educate of the risk factors and promote earlier detection of potential sight loss. We need to develop and implement clear, local pathways for Age-related Macular Degeneration (AMD) and Glaucoma.

5.10 Health-related quality of life for older people

Outcomes framework:

Public Health 4.13

Implications for the population’s health and well-being:

The population is growing older. In England, the number of people aged over 65 is due to rise by a third by 2025. In the same period the number of people over 80 will double and the number over 100 will increase fourfold. This welcome increase in life expectancy is however associated with an increase in years spent with some disabling illness.

Our ageing society offers great challenges to health and social care providers. Investing in prevention services at a local level can help to meet these challenges. Older people’s prevention services are services that offer advice, support or interventions to help:

  • Older people who are healthy to continue to live independently for longer
  • Older people who are unwell to regain their independence or to prevent or delay the onset of further health problems

At risk or vulnerable groups:

  • Frail older people
  • Economically inactive
  • Older people with long term limiting illnesses
  • Older people living in poverty
  • Older people living in isolation or on their own

Benchmarking

Over the next 18 years the age profile of Tameside and Glossop will change quite significantly. The projections show a steep rise in the numbers of 80-89 year olds: from 8,500 in 2010 to 15,300 in 2025.They highlight an overall increase in all age ranges above 60 years.

Table 21: Tameside and Glossop: Population Projections

2010

2015

2020

2025

2030

Total Population

249,700

255,000

261,500

268,000

273,700

Age Group

60-69

27,500

28,100

27,500

31,500

34,300

70-79

16,900

18,800

22,300

23,000

22,800

80-89

8,500

9,000

10,700

12,500

15,300

90+

1,700

2,200

2,600

3,300

4,500

Source: Office of National Statistics 2010

Economic well-being has a direct correlation with the quality of life that older people can experience. Achieving economic well being is not just about ensuring that older people who are retired receive the benefits they are entitled to, but ensuring that as they approach retirement, at whatever age they choose, they are able to be as economically active as possible.

Older people in Tameside are becoming increasingly economically active, and Tameside has a higher rate than the national and regional averages as compared with 2004, where the rate was lower than these averages. Unemployment amongst people of working age over 50 has steadily declined since 2000. The decline in unemployment of people aged over 50 appears to be genuine and not just a function of people in this age group moving onto other forms of working age benefits. There has been a consistent reduction in the working age benefit claim rate for this group since 2000.

Policy context:

What interventions work?

Investing in prevention services at a local level can offer a more efficient use of resource and help deliver better outcomes for older people enabling them to live healthy, happy and independent lives.

The Prevention package for Older People promotes local provision of prevention services and best practice in the following areas:

  • Falls Prevention – an effective falls prevention service can help to save lives and save money.
  • Foot care – Providing foot care services can help prevent or delay the need for older people to access more costly acute care services
  • Intermediate Care, Telecare and Audiology – Getting people home quickly, and supporting them to stay there longer, can deliver multiple benefits

There is good evidence that exercise programmes for older people can improve strength, aerobic capacity, balance and function.

What are we doing now?

The development and implementation of an action plan across Tameside covering the following themes and priorities:

  • Creating a positive culture for older people where older people are seen as valued members of society, with intergenerational understanding, with all partners working together to engage with and meet the needs of older people
  • Information, communication, choice and control. This includes improving information for older people about what services are available for them; improving information for service providers about the needs of older people, especially those who are most vulnerable; and improving the engagement of older people in the shaping of and delivery of the services they need.
  • Feeling safer in the community including increasing the visibility of the uniformed services, reducing the fear of crime amongst older people and increasing security for older people
  • Lifelong Housing. In order for older people to remain active in their own homes, an appropriate supply of housing stock is needed which reflects the needs of the population of older people.
  • Healthy Lifestyles including creating more opportunities for older people to engage in activities which support healthy lifestyles (healthy nutrition, exercise and social activities). Improving access to preventative health checks, health promoting information, and opportunities to engage in volunteering activities.
  • Access to adequate income. Priorities include supporting older people to continue to be economically active for as long as they wish, improving the income of those who are not economically active and the financial literacy of older people.
  • Getting around. Access to goods, services , and social activities is needed for older people to maintain and enjoy a good quality of life including easy access to town centres and amenities

Additionally the District Nursing Team across Tameside and Glossop has been reorganised to become a 24hour 7 days a week service since January 2011. The Well-being and Prevention Service in Tameside provides person-centred and integrated support for older people through investment in preventative approaches which promote health, well-being and independence for older people.

What needs to happen next, and by whom?

All public, private and voluntary and community sector organisations must ensure that they are considering the needs and aspirations of older people in the way that they plan and deliver services

  • All services should promote the well being of older people by ensuring that universal services are readily engaging them in active community, along with specialised services being available when needed
  • Older people to play an active role in the life of their communities as valuable contributors to the economic and social life of the borough
  • A focus on older people with long term conditions for example diabetes and cancer to enable them to manage their conditions and maintain the best possible quality of life
  • A public information leaflet on existing entitlements including flu vaccination, cancer screening and sight tests

This needs to be carried out by Derbyshire and Tameside Health and Well-Being Boards and the Tameside Strategic Partnership and its thematic sub groups, particularly The Supportive Communities Partnership, which includes:

  • Key agencies from all sectors responsible for the planning, commissioning and delivery of services to older people
  • Representation from the Tameside Older People’s Advisory Group
  • Local people who have been elected onto regional or national Better Government for Older People’s Group

5.11 Re-ablement/rehabilitation of older people following discharge from hospital

Outcomes framework:

  • NHS 3.6: The proportion of older people (65 and over) who were still at home 91 days after discharge from hospital into reablement / rehabilitation services
    • i. The proportion still at home 91 days after discharge into rehabilitation
    • ii. The proportion offered rehabilitation following discharge from acute or community hospital
  • Adult Social Care 2B: Proportion of older people (65 and over) who were still at home 91 days after discharge from hospital into reablement/rehabilitation services

Implications for the population’s health and well-being:

When people develop care needs, it is important that they receive the support they need in the most appropriate setting, and they are supported to regain their independence. This measures the benefits to individuals from reablement, intermediate care and rehabilitation following a hospital episode, by determining whether an individual remains living at home 91 days following discharge – this is the key outcome for many people using reablement services. The outcome measures the success of reablement and rehabilitation services in supporting older people to return home and live independently after discharge from hospital.

At risk or vulnerable groups:

Adults aged 65 + who have been discharged from hospital to their own home, short term residential or nursing care home or extra care housing for rehabilitation, with a clear intention that they will move back to their own home.

Policy context:

Intermediate Care – Halfway Home Guidance 2009

Benchmarking:

Local performance is 84.3%, which is higher than both the NW average (78.3%) and the England average (82%). Local performance for patients discharged home from Shire Hill Hospital (which includes a Stroke Rehabilitation unit) is 86.8%.

Figure 72: Proportion of adults discharged from hospital and staying at home

Graph showing proportion of adults discharged from hospital and staying at home

Source: Tameside MBC 2012

What interventions work?

  • Re-ablement
  • Community Assessment and Rapid Access Team (CARA)
  • Aids, Equipment and Adaptations
  • Assistive Technology (Telecare / Telehealth)
  • Carers Services
  • Care Management
  • Personal Budgets
  • Well-being and Prevention
  • Well-being, Early Intervention and Prevention Services

What are we doing now?

  • Locally, our community inpatient facilities have agreed KPI’s to ensure that 70% of patients remain at home after 91 days after discharge. (Threshold of 65%). As indicated above, this target is being delivered.
  • Expansion of the Re-ablement service, with increased promotion of Assistive Technology.
  • Redesign of Intermediate Care services resulting from the Intermediate Care Strategy action plan.
  • Increased delivery of Personal Budgets offering greater choice and control.
  • Implementation of the Halfway Homes guidance
  • Redesign of the Well being and Prevention Service
  • Redesign of the Assessment and Care Management Service

What needs to happen next, and by whom?

  • Continue to monitor the performance of the community inpatient units and work with the new provider in 12/13 to stretch and improve this performance.
  • Expansion of Reablement by the Adults Management Team
  • Community and voluntary sector response
  • Continue to develop and expand the programmes above in response to the increasing demographics.
  • Driven and governed by the Health and Well-being Board to develop programmes of joint commissioning and integrated service delivery for Health and Social Care Services.

5.12 Access to GP services

Outcomes framework:

NHS Framework (4.4 i)

Implications for the population’s health and well-being:

General practice undertakes approximately a million consultations each working day and is the main point of entry to other NHS services. There is over £7.7 billion invested in General Practice every year.

Easy, timely and convenient access to GP services and appropriate onward referral to specialist services, with good patient experience are essential to ensure that all patients are offered high quality patient care and value for money.

At risk or vulnerable groups:

  • People with learning disabilities
  • Older people
  • Children and families living in deprivation
  • People with disabilities
  • People not registered with GP practices

Policy context:

High Quality Care for All – Primary Care and Community Care Services: Improving GP access and responsiveness, highlights what NHS commissioning organisations and GP practices can do to improve access to GP services.

Benchmarking:

Figure 73: Overall experience of making appointment, Quarter 2, NHS Tameside and Glossop, North West SHA and National 2011.

Graph showing overall experience of making appointments

Source: GP patient Survey- July to September 2011; data; survey results

What interventions works?

  • providing transparent information
  • ensuring minimum standards
  • providing regular insights into practice performance
  • undertaking research focused on understanding the needs of the local population to address their needs
  • supporting quality improvement
  • engaging key stakeholders
  • sharing views of the general public
  • understanding the demand for services and how it can be met
  • putting systems in place to manage this demand
  • ensuring that practice environment supports access to information in the waiting area
  • providing a patient-friendly service
  • setting up patient participation groups and methods of obtaining reliable feedback

What are we doing now?

NHS Clinical Commissioning Groups (CCGs) are currently scoping out the use of quantitative and qualitative information across primary and secondary care that would form a part of their regular flow of intelligence needed to inform their decision making.

What needs to happen next, and who needs to do it?

There is a need for the local NHS trust to record complaints, compliments and issues around access from patients, commissioners and providers in order to capture the right information at the right time so that it can have a positive impact on future planning and delivery.

5.13 Improving access to NHS dental services

Outcomes framework:

NHS outcomes framework (4.4ii)

Implications for the population’s health and well-being:

  • Dental disease can cause pain, sepsis, loss of appearance and confidence, loss nights’ sleep, missed work, and required avoidable and unpleasant dental treatment including extractions under general anaesthetic which represent an avoidable risk to life.
  • The latest Adult Dental Health Survey found that, in the North West of England, problems with teeth or gums cause problems cause problems to a third of the population, including eating for one fifth of the adult population and reluctance to smile to a further one fifth.
  • Good oral health is highly prized by the population, largely due to its link to good appearance and attractiveness.
  • The importance of access to dental care to citizens and communities has been recognised nationally by successive governments and has been the subject of campaigns locally by communities, elected members and members of parliament which have driven improvements in dental access across Tameside and Glossop.

Programme spend:

Tameside and Glossop spend on treatment of dental disease for 2010-11 was £11,572,000. This was spent of the provision of general and specialist (mainly orthodontic) primary dental care services including dental access services, urgent treatment services (in hours and out of hours), and domiciliary services.

At risk or vulnerable groups:

The adult dental health survey showed that social class of head of household or educational attainment or both are independently related to all the measures of oral health used – with higher levels of dental need and lower levels of dental attendance in those from less privileged backgrounds.

In addition particular groups of the Tameside and Glossop population have reported problems in gaining access to general dental services. These include those with mental health issues, learning disabilities, substance misuse issues, or those who have problems in attending a dental surgery due to physical, mental or social causes. Hospital in-patients have traditionally had problems in gaining access to dental services.

Benchmarking:

Figure 74: Patients seen in the previous 24 monthly at quarterly intervals

Graph showing patients seen in the previous 24 months

Source: NHS information centre March 2011

The Department of Health General Practice survey dental data (2010-11) showed that 96% of Tameside and Glossop residents who had tried to find a dentist in the previous 3 months were successful compared to 94% in England and the North West.

Policy context:

Pilot of new dental contract intended to improve oral health, access to dental services and quality of care.

What works?

  • Affordable dental services
  • Access to NHS dentistry
  • Focus of good dental health that goes beyond only treatment

What are we doing now?

The following services have been commissioned for the population of Tameside and Glossop:

  • A dental access helpline giving:
    • Access to urgent dental care, in hours and out of hours
    • Access to routine dental treatment guaranteeing access to all residents.
    • Domiciliary care for those unable to leave the house.
  • Specialist paediatric dental services including sedation, general anaethetic and special needs treatment.

Non-recurrent Department of Health funding in 2011-12 was used to fund additional dental capacity and a communications campaign to stimulate dental attendance.

In addition the dental health promotion team promote the uptake of NHS dental services across the community and also use a targeted approach to ensure equity among groups most at risk. These include users of substance misuse services, people in residential care, children and adults with physical disabilities, children and adults with mental health issues, families living in areas of social-economic deprivation and Black and Minority Ethnic (BME) communities.

Resources on how to access dental services are produced and distributed to health visiting teams, community mental health teams, GPs, pharmacists, housing associations, schools, Connexions and through the Tameside MBC website.

What needs to happen next, and by whom?

Responsibility for commissioning dental services has transferred to NHS Greater Manchester and will transfer to the NHS Commissioning Board from 2013. Locally there is a need to:

  • Maintain universal and targeted support for uptake of access to dental care.
  • Work through the Health and Well-being Board and the NHS National Commissioning Board to ensure that that clear pathways into appropriate dental care meet the needs of all communities within Tameside and Glossop.
 
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