Living in Tower Hamlets Findings and Conclusions from Tower Hamlets JSNA Presentation to HWB Strategy Subgroup Dr Somen Banerjee, DPH 3

rd

April, 2012

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What is Health?

‘Health is a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity’

WHO Constitution, 1946

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What makes for a healthy life?

Throughout life •Having an income that is enough for healthy living •Living in quality housing •Living in an environment that supports health •Having strong social networks •Living in a place with a sense of community •Staying fit, eating healthily, sensible drinking •Living in a place with high quality public services Being born •The health of your mother •High quality maternity services Growing up •Good parenting •High quality preschool provision •High quality education Being an adult •A sense of control of one’s life •Secure and decent employment Growing old •Staying fit and eating healthily •Maintaining strong family and social relations •Services that are integrated and built around your needs 3

What will improve health?

• • • • • •

Giving every child the best possible start in life Enabling all to make the most of their capabilities and have control over their lives Creating fair employment and good work for all Ensuring a healthy standard of living for all Creating and developing healthy and sustainable places and communities Strengthen the role and impact of ill-health prevention

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What will make this happen?

• • • • • • • • • Getting vision and strategy clear High level strategic engagement across the partnership Making partnership work at all levels Doing things systematically and at the right scale Getting the workforce right Identifying the missing thousands Meaningful and systematic community engagement Being ambitious about achievement overall and for those in greatest need Being driven by high quality information 5

Simplifying the approach..

Tower Hamlets • People • Place Life in Tower Hamlets • Being born • Growing up – early years • Growing up – childhood and adolescence • Being an adult • Growing old 6

People in Tower Hamlets

Headlines

Life expectancy remains lower than rest of country but continues to improve:

Determinants

Growing population (expected to increase by 25000 in 5 years from 242,000 in 2010) Male life expectancy 75.3 years compared to 77 years nationally Young population (37% aged 20-39 cf 27% E) Female life expectancy 80.4 years compared to 81.1 years nationally High population churn (24% around, into or out of borough/ year) 51% non white (34% Bangadeshi) Life expectancy gap between least and most deprived deprivation is 11.2 years in males and 6.5 in females 33% families live on income less than £20,000 (22% E) Amonst highest emergency admission and lowest elective rates in London 12% working age unemployed (9% L) 3.7% provide 20 hr or more unpaid care (50% provide 50 hrs +)

Evidence of effective intervention

Marmot review Give every child the best possible start in life Enable all to maximise capabilities and have control over their lives Create fair employment and good work for all Ensure health standard of living for all Create and develop healthy and sustainable places and communities Strengthen role and impact of ill health protection

Strategy Conclusions

Community Plan and all that sits under it ‘Reducing the inequalities and poverty that we see all around us, strengthening cohesion and making sure our communities live well together’ Tower Hamlets Community Plan, One Tower Hamlets Vision Encouraging that life expectancy continues to increase but inequality persists The major vehicle for improving health and wellbeing in the long term is the community plan through its impact on wider determinants – imperative to continually evaluate its impact on health and wellbeing and threats to delivery Current economic climate and welfare reform will impact on physical and mental health 7

Tower Hamlets as a place

Headlines

Ward life expectancy varies by 8 years in males and 6 years in females The clearest difference is between the two most affluent wards and the variation is less marked between the other 15 wards

Determinants

16 of 17 wards in 20% most deprived wards (12 in lowest 5%) 54% living in social housing compared to 37% in London Higher levels of overcrowding 3 rd highest rate of people killed or seriously injured on the roads in London Substantial housing growth 1.1 hectares green space per 100 people compared to 2.4 nationally 42 fast food outlets per secondary school(2 nd highest in London)

Evidence base for effective intervention

Create and develop healthy and sustainable places and communities - Improve active travel - Improve availability of green spaces - Improve food environment - Integrate planning, transport, housing, environmental and health systems to address social determinants of health in locality - Support community regeneration in increase participation and reduce isolation

Strategy

Community Plan and all that sits under it Particularly: - Localisation agenda - Local Development Framework - Housing strategy - GP networks - CHS localisation 46% residents perceive high levels ASB (27% L)

Conclusions

The Local Development Framework is a major vehicle for shaping Tower Hamlets into a place that builds health and wellbeing into everyday life - it is critical that health and wellbeing impacts are factored into signficant developments in the borough There is a significant opportunity to drive more integrated and innovative working at the locality level between the NHS and LA as both move towards more locality and sublocality planning arrangements 8

Being born in Tower Hamlets

Headlines

Infant mortality not significantly different to London (4.4 per 1000 live births < 1 year)

Determinants

High deprivation linked to low birth weight 45% of births to Bangladeshi mothers

Evidence base for effective intervention

Ensure women have adequate income in pregnancy to maintain health and nutrition

Strategy

Community Plan Children and Young Peoples Plan Higher percentage of low birth weight babies to London (9% compare to 7.5%) 3.3% smoke in pregnancy but 16% white mothers Substance misuse, problem drinking, poor diet , poor mental health general issues 17% reduction teenage pregnancy since 1998 (now average for London) Access to strong midwifery workforce ensuring early access and avoiding unnecessary intervention Address behavioural risk factors eg smoking, diet, substance misuse • • Healthy Improvement Strategy for Maternity Services • Antenatal elements: HWHL Tobacco Control Substance Misuse Child Death Overview Panel Intensive home visiting programmes during and after pregnancy Average early access to maternity services (improving but only 65%), patient experience issue

Conclusions

The evidenc e base highlights the importance of the prenatal period for future health Whilst overall there is encouraging progress eg early access, improvements in patient experience and birth outcomes are relatively good, this could mask particularly poor outcomes in certain population segments Equality impact assessment is therefore essential in monitoring outcomes 9

Growing up in Tower Hamlets Early years

Conclusions Headlines

By the age of 5 only 46% of Tower Hamlets infants have achieved a good level of cognitive development compared to 56% nationally 13.3% are obese - 7 highest in the country 39% have experience of tooth decay compared to 31% th nationally - declining

Determinants

55% children in Tower Hamlets classified as living in poverty 80% mothers initiate breast feeding at birth and 68% are still breast feeding at 6-8 weeks (cf 72% and 45% England)

Evidence base for effective intervention

Early years experience has lifelong effect on health and wellbeing Supporting families to achieve improvement in early child development Providing good quality early education and childcare Immunisation uptake in under 5s is amongst the highest in the country (94% have second dose MMR) Good nutrition important for future health: breast feeding, good feeding practices

Strategy

Community Plan Children and Young Peoples Plan Healthy Improvement Strategy for Maternity Services Immunisation Action Plan • • • Early years elements: Healthy Weight, Healthy Lives Tobacco Control Substance Misuse 40% of under 16s are estimated to have Vit D deficiency Benefits of childhood immunisation far outweigh any adverse effects The Marmot review is unequivocal in stating the critical importance and need to prioritise early years. Despite some encouraging outcomes, there is strong evidence Tower Hamlets infants have outcomes at age 5 that are linked to poorer health and wellbeing outcomes in later life.

Good early education, access to childcare and support to family are evidence based interventions to give Tower Hamlets infants the best start in life 10

Growing up in Tower Hamlets Children and Young People

Conclusions Headlines Determinants

25.7% 10-11 year olds are obese (3 plateaued rd highest in the country) 55% children in Tower Hamlets classified as living in poverty 8 sexually transmitted infections in the country 2 th nd highest incidence of highest rate of injuries (deliberate and unintentional) to children and young people 52% pupils entitled to free school meals (highest in country) Improvement at key stages 1, 2 and 4 to above national average 49% pupils (yrs 1-13) participate in at least 3hrs high quality PE/Sport in week (69% nationally) 17% reduction teenage pregnancy since 1998 (now average for London) 1 in 10 children are estimated to have a mental health disorder 1 in 5 children under 15 have tried a cigarette 3 in 10 an alcoholic drink by age 15

Evidence base for effective intervention

Extending the role of schools in support families and communities Developing schools based workforce to support the health and wellbeing of children Support and advice for 16-25 year olds on life skills, training and employment Whole systems approaches to tackling obesity Peer led approaches in supporting behaviour change Health/social care tailored to CYP needs

Strategy

Community Plan Children and Young Peoples Plan CYP elements - HWHL - TH Healthy Borough - Tobacco Control - Substance Misuse - Sexual Health Educational attainment is a major determinant of health. The improvement in educational outcomes in Tower Hamlets is a fantastic achievement in the context of the levels of child poverty in the Borough It is good news that the rise in childhood obesity in plateauing but it remains 1 in 4 There have been improvements in the extent to which schools have promoted health within schools but there remains significant scope for further improvement 11

Being an adult in Tower Hamlets

Headlines Determinants

Amongst the highest premature death rates from the major killers in London - 3 - 5 rd th highest CVD - Highest Cancer highest COPD People and place factors outlined previously 27% smokers compared (21%) 12,000 adults with diabetes and increasing (17,000 by 2020) 43% drinkers (50%) have hazardous or harmful patterns (21%) Amongst highest rates of HIV, TB and sexually transmitted infections 68% do not do recommended levels physical activity (68%) 5 th highest admission rates for mental health reasons in London 88% do consume recommended 5 a day (70%) Levels of long term illness/disability 34% higher than national average (2001 census) Highest rate of problem drug users (23/1000 cf 12/1000) Improving health and social care outcomes

Evidence base for effective intervention

Addressing wider determinants of health Environmental intervention to make healthy living easier Structured behavioural change programmes

Strategy Conclusions

Community Plan/ Improving HWB strategy Healthy Lives Strategy: Sustaining peoples income, housing and employment through the economic downturn is a critical health intervention Tobacco control, Healthy Weight, Health Lives (obesity), Tower Hamlets Healthy Borough, Substance Misuse, Sexual Health Remains scope to further embed healthy lifestyles into frontline services and target at risk groups Screening /early awareness programmes At risk/ disease registers providing systematic, person centred care Structured rehabilitation programmes High quality health and social care services Health and social care: Transforming Adult Social Care, Primary Care Investment Programme Care Closer to Home, Cancer Strategy, Mental Health Whole System review, Carers Strategy Successful implementation of new substance misuse strategy Improving health and wellbeing strategy needs to be refreshed -Care packages -Prevention emphasis -Personalisation -Integration 12

Growing old in Tower Hamlets

Headlines

56% of 65-84 year olds report long term limiting illness compared to 48% nationally People and place factors outlined previously Higher proportion living alone 80% of over 65s have at least one chronic condition of which 35% have at least 3 comorbid conditions 80% of TH residents aged 65+ do not meet recommended physical activity levels Underdiagnosis of dementia 2 nd highest stroke mortality in London Falls admissions lower than London average high in some wards Most people do not die in their place of choice (over 60% in hospital)

Determinants

Service data - At least 20% have significant hearing loss?

- 60-75% on DN caseloads have incontinence problems?

- Adult protection need?

Evidence base for effective intervention

As for adults (root out age discrimination)

Strategy

Community Plan/ Improving Health and Wellbeing Strategy Promotion of healthy lives and social contact to delay onset and reduce impact of mental and physical illness and disability Older People’s Housing Strategy Transforming Adult Social Care Integrated services for complex needs - Single assessment - Integrated commissioning - Integrated service provision Integrated pathways: falls, stroke, continence, dementia, end of life

Conclusions

Older people in Tower Hamlets are a smaller proportion of the population but the evidence suggests their health is generally worse than elsewhere Promoting Independence Strategy - Information - Linkage Plus - Reablement - Telecare - Carers Support Older People’s Delivery Group - Integrated model of care There is some distance to go to get to level of integration and the targeting of resources to meet their needs more effectively It is recommended that this is an area for focussed review across the partnership Community Virtual Ward 13

Top 10 considerations from JSNA (1)

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The economic downturn will impact on health and particularly the health of those who already have the worst health outcomes in the borough Tower Hamlets is not an easy place to be healthy. If it is to become an easier place, health needs to be at the heart of housing and planning strategy There is a big opportunity to drive more integrated and innovative partnership working at a very local level and to involve local people much more in improving local services There are 20,000 under 5s in Tower Hamlets and what is happening to them right now will have far reaching impacts on how healthy they will be for the rest of their lives Education is a major determinant of health. The improvements in educational attainment this year mean that today’s Tower Hamlets school children are likely to have better health in their adult lives 14

Top 10 considerations from JSNA (2)

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Young adulthood is when despite an absence of disease, problems accumulate that manifest in later life. The high levels of smoking, problem drinking, drug use, poor diet and sedentary lifestyles mean people get disease earlier and die younger in Tower Hamlets.

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Diabetes outcomes in primary care are improving but numbers are increasing. This is particularly an issue in Tower Hamlets because of ethnicity. Diabetes can be prevented and if this trend continues costs to health and social care services will become unsustainable Death rates and survival from cancer are amongst the worst in the country and this is driven by both high levels of smoking resulting in lung cancer and also late presentation to health services 9.

One in five over 65s in Tower Hamlets have at least four chronic conditions at the same time. This means services need to be integrated around their needs across health and social care services and wider council services . Patient are asking for better integration too.

10. Older people in Tower Hamlets are more socially isolated, have higher level of poverty, poorer housing quality and this is manifest in poorer health. There is a lot going on across the PCT and council to support older people but should there be an overarching strategy?

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JSNA Process and Accountability Health and Wellbeing Board JSNA Programme Board

Senior level partnership group NHS/LA/THInK

JSNA PMO

Officer group: corporate, adults, childrens, public health

What is the local picture?

What should we be doing?

What are we doing?

What is the user/community perspective?

What more do we need to know?

What are the priorities?

JSNA Products

Summmary

- People - Place - Being born, growing up, adult

life and growing old in TH (setting out local picture, evidence base, strategy, recommendations)

Summary Document

Disaggregation of data by : Place (locality, LAP, ward) Socioeconomic determinants Equality dimensions Predictive variables (eg social marketing) Provider (eg primary care, CHS, social care, polysystems, acute trusts)

Topic specific factsheets Data Repositary (quantitative, qualitative, evidence base) 17