This Evidence Summary presents an overview of the health and wellbeing needs in Nottingham City using the key findings from Nottingham City’s Joint Strategic Needs Assessment.
Joint Strategic Needs Assessments (JSNAs) are local assessmentsof current and future health and social care needs. The aim of the JSNA is to improve the health and wellbeing of the local community and reduce inequalities for all ages through ensuring commissioned services reflect need. It is used to help to determine what actions local authorities, the NHS and other partners need to take to meet health and social care needs and to address the wider determinants that impact on health and wellbeing.
Nottingham City’s JSNA contains over 40 chapters each considering a particular health and social care issue or the health and social care needs of specific groups. The full JSNA can be accessed at www.nottinghaminsight.org.uk. It is only possible to present a brief overview of this information in this Evidence Summary and so it should be used in conjunction with the full JSNA.
All supporting data and information for this evidence summary including references can be found in individual chapters.
Nottingham City JSNA Evidence Summary prepared by:
Dr Rachel Sokal Consultant in Public Health, Nottingham City Council
Louise Noon Insight Specialist – Public Health, Nottingham City Council
30 Nov 2015
The latest estimate of the Nottingham City’s resident population is 314,300, having risen by over 6,000 since 2012. The population is projected to rise from 308,700 in 2012 to 323,400 in 2022 and to 352,200 in 2037. More people are registered with a Nottingham City CCG than live in the city, the registered population is 357,900. International migration (recently from Eastern Europe) and natural change (the excess of births over deaths) are the main reasons for the population growth recently. The number of births has risen considerably in recent years although the latest figures show a small decline.
Over one quarter (28%) of the resident population is aged 18 to 29. Full-time university students make up about 1 in 8 of the population (figure 1). Almost 15% of the Nottingham population is aged 20-24 years, more than double the national average. Compared to England as a whole, Nottingham is unlikely to show much ageing or population growth in the short term to 2022.
The City gains young adults due to migration, both international and within Britain, whilst losing all other age groups - this includes losing families with children as they move to the surrounding districts. There is a high turnover of population; 21% of people living in the City changed their address in the year before the 2011 Census.
In terms of ethnicity, the 2011 Census demonstrated that two-thirds (65.4%) of Nottingham’s population are White British and one-third (34.6%) from Black and Minority Ethnic (BME) groups, which are defined as everyone who is not White British. This is an increase from 19.0% in 2001 and these populations make up a greater proportion of Nottingham’s population than England’s (20.2%).
The Asian / Asian British group is the largest BME in Nottingham making up 13.1% of the total population; Black / African / Caribbean / Black British, mixed or multiple ethnicity and White (not White British) groups each account for 6 – 7% of the total population (see figure 2).
The ethnic profile of the city’s residents varies by ward and age group, for example 89.0% of Clifton South residents are White British compared to 50.4% of people in Arboretum and 50% of pupils are members of BME groups compared to 34.6% of the total population.
Deprivation, socio-economic status and wider determinants of health
Research shows that many health and wellbeing outcomes are linked to socio-economic factors and the ‘wider determinants of health’ (figure 3). It is therefore important to understand the socio‑economic context of the City when trying to understand and improve health and health inequalities.
The Index of Multiple of Deprivation (most recently published in 2015) gives a good summary measure of a range of wider determinants and allows comparison of the City with England and other areas, and also identification of inequalities within the City.
There are high levels of deprivation in Nottingham City: it is the eight most deprived local authority in England out of 326 (Index of Multiple Deprivation 2015, ranked on average score measure). There are also particularly deprived areas within the City: 61 of the 182 City LSOAs fall amongst the 10% most deprived in the country and all of the LSOAs in Aspley rank in the 10% most deprived. This pattern is reflected in the health and wellbeing of Nottingham’s residents.
The Annual Population Survey shows 12.9% of the 16-64 age group have no qualifications, higher than the national percentage (England 9.1%). The difference is most evident in the 50-64 age group, where some 25.2% have no qualifications compared to 14.1% nationally. 29.3% of 16 to 64 year olds have qualifications at NVQ4 level – degree level or above, compared with 35.0% in England.
The latest employment rate for the City is 63.2%, compared with 72.5% for England. This figure is deflated by the presence of so many university students, but even if they are excluded the rate is still low (October 2013 to September 2014 figures: 72.4% compared with 77.1% for England).
In Nottingham, life expectancy at birth is 76.6 years for males and 81.6 years for females (2009-2013 data, ONS 2015). Life expectancy is increasing both nationally and locally in both men and women; in Nottingham for men it has increased by 3.9 years in the last 10 years and by 2.9 years for women.
The latest figures show that life expectancy in Nottingham’s men is 2.3 years lower than England overall and although the width of the gap fluctuates from year to year, the overall trend since 2001 is to narrow the gap (figure 4). A similar picture is seen in women, the overall trend is a reduction in the gap from over 2 years to 1.5 years since 2001-2003.
Although overall life expectancy in the city has improve, this masks substantial inequalities within the city. There is an 9.9 year gap in life expectancy between areas in Wollaton West and Arboretum for men, and a 10.2 year gap between Wollaton West and Bridge for women (PHE, 2015). Maps illustrating life expectancy across the city are contained in the appendix.
Premature death (defined as deaths under 75 years) is an important driver of low levels of life expectancy. Nationally and locally, four big causes of premature death have been identified; these are cancer, circulatory disease, respiratory disease and liver disease and are responsible for over three quarters of premature deaths.
Analysis of the broad categories of disease which contribute to the gap in life expectancy between Nottingham and England are illustrated in figure 5. The largest contributors to our gap are circulatory disease, cancer, respiratory and digestive (liver) diseases. Tackling these diseases is key to improving life expectancy in Nottingham and addressing health inequalities.
Healthy Life Expectancy
Healthy life expectancy describes how long a person might be expected to live in ‘good health’ based on data from the Annual Population Survey. Both life expectancy and healthy life expectancy have increased nationally and locally over recent years; however, life expectancy is increasing at a faster rate meaning that the population is spending a greater proportion of its total life in poor health. This has implications for both individuals – due an increased proportion of life spent with illness and disability – and society due to associated health and social care costs. As with total life expectancy, inequalities in healthy life expectancy exist by deprivation (figure 6). Maps illustrating the healthy life expectancy across the city are contained in the appendix.
In Nottingham, healthy life expectancy for males is 57.8 years and 59.2 years for females compared to a life expectancy of 76.6 years for males and 81.6 years for females (2009-2013 data, ONS 2015). This means that the local population can be expected to live approximately a quarter of their life in poor health although women will spend more of their life in ill-health then men.
People in Nottingham will spend more of their life living in poor health than those living in other areas. In terms of the proportion of total life expectancy spent in a healthy state, the city is ranked the seventh lowest local authority (from 152) for men and women (2009-2013 data, ONS 2015). .
Analysis across England[i] shows that on the whole the diseases that impact the greatest on life expectancy (cancer, circulatory disease, respiratory) also have the greatest impact on people’s health and quality of life. Other conditions – such as mental health problems and musculoskeletal disease – have less of an impact on overall life expectancy but make an important contribution to ill-health.
In summary, compared to England as a whole, people in Nottingham are expected to live shorter lives with a greater proportion of time spent in poor health. This emphasises a need for a focus on the prevention of diseases to maximise time individuals can live in good health.
[i] Newton et al. (2015) The Lancet DOI: 10.1016/S0140-6736(15)00195-6
Smoking, harmful use of alcohol, physical inactivity and poor diet are key lifestyle factors which both cause and affect the consequences of many major illnesses. These are heavily influenced by the wider determinants of health and therefore are a major driver of health inequalities. Supporting individuals and populations to maintain healthy lifestyles will result in both the primary and secondary prevention of disease improving both life expectancy and healthy life expectancy in the city.
Smoking causes 80,000 deaths in England each year, more than any other preventable cause.
The smoking prevalence in Nottingham City is 27.4% which is significantly higher than the national prevalence of 18%. Nottingham has significantly higher rates of lung cancer, COPD, cardiovascular disease and other conditions compared to England due to higher levels of smoking. There are strong correlations between smoking prevalence and deprivation; Aspley, St Anns, Bulwell and Clifton wards have a smoking prevalence significantly higher than the city average and almost double the England average.
The high smoking rates during pregnancy in the city (18.5%), compared to England (12.5%), are of particular concern. Smoking in pregnancy increases risk of complications, which affect mothers and babies health, and increase risk of miscarriage and maternal death. Children who grow up in families and communities with a high proportion of smokers are more likely to become smokers themselves.
Being overweight or obese significantly increases the risks of developing and dying from cardiovascular disease, kidney and liver disease and cancer and the risk increases as BMI increases.
Obesity prevalence in the city is likely to be within the range of 23- 27%of the population aged 18 years and over and over 60% of adults are overweight or obese. Nottingham's children have a significantly higher prevalence of obesity compared to the England average at age 4 to 5 years (10.7% compared to 9.5%) and at age 10 to 11 years (23.3% compared to 19.1%) (Public Health England, 2015). Current trends suggest that 80% of children who are obese at age 10–14 will become obese adults. More immediate consequences for children are social and psychological, including stigmatisation, bullying, low self-esteem and depression.
Physical activity, diet and nutrition
An individual’s physical activity level and diet and nutrition status has both a direct impact on health status as well as an indirect one through the maintenance of a healthy weight.
It is estimated that a third of adults in Nottingham are ‘inactive’ and three-quarters do not eat the recommended fruit and vegetable portions (according to Department of Health classifications and recommendations).
Nottingham has a significantly higher rate of alcohol related hospital admissions and mortality than England and it is increasing by approximately 11% each year.
Synthetic estimates suggest that we would expect a higher proportion of people in Nottingham City drinking within the higher risk category than the national average and that there are approximately 10,687 dependent drinkers in Nottingham drinkers, i.e. those who experience an increased drive to drink alcohol and difficulty in controlling its use.
Children and young people
More than a quarter of the population of Nottingham is under the age of twenty. There are an estimated 21,000 infants aged 0-4 years and 58,600 children and young people aged 5-19 years resident in the City. The number of births has risen considerably in recent years and is likely to continue to do so. The projected population (age 0-19 years) in 2022 is 83,100. In 2014, 27.0% of births were to mothers born outside of the UK, more than double the percentage in 2001 (16.5%) and 50% of school children are from a black or minority ethnic group (School Census 2015).
More than a third of Nottingham’s children are living in poverty compared to less than a fifth in England as a whole. Deprivation strongly influences children’s health outcomes throughout all aspects of their development. Poor maternal health and lifestyle choices, premature labour, low birth weight and social / physical developmental problems are strongly associated with higher levels of poverty and worse health outcomes.
The health and well-being of children in Nottingham is generally worse than the England average for both 0-4 and 5-19 year olds. Focusing on prevention and early intervention has a vital role to play in improving child health outcomes and breaking the cycle of health inequalities within families.
The first five years of a child’s life are critical to their future development and opportunities. A child’s physical, social and cognitive development strongly influences how ready they are to start school and their educational attainment, as well as their health and employment prospects as an adult.
The infant mortality rate in Nottingham has fallen from 9.6 per 1000 births in 2001-2003 to 5.2 per 1000 births (2011-13) yet this remains significantly higher than the England average (4.0 per 1000 birth; 2011-2013). 8.4% of all Nottingham births during 2013 had a low birth weight. This is statistically higher than the England average (7.4%).
Breastfeeding is a crucial in decreasing inequalities in children’s health, including: lowering infant mortality rates, reducing preventable infections and unnecessary hospital admissions in infancy, halting the rise in obesity and promoting cognitive development, increased academic attainment and maternal/child bonding. There appears to be a steep increase in breastfeeding prevalence from 2013/14; Nottingham’s prevalence in 2014/15 (48.6%) is significantly higher than the England average (43.8%). However, there remains considerable variation in uptake between different groups and geographic areas in Nottingham and breastfeeding rates locally are strongly linked to the age of the mother. During 2012/13, just over a quarter (26%) of local women aged less than 25 years were still breastfeeding their babies at 6 – 8 weeks of age, compared to 60% of those aged 30 and over. White women are less likely to breastfeed than any other ethnic group. In addition, women living in some of the most deprived areas in the City are less likely to breastfeed, adding to inequalities in health and contributing to the cycle of deprivation.
Nottingham’s prevalence of smoking in pregnancy (18.5%) is significantly higher than the England average (12.0%; 2013/2014). Smoking during pregnancy is the single most modifiable risk factor influencing adverse health outcomes in children. Smoking during pregnancy can increase the risk of infant death by up to 40%. Smoking in pregnancy is also associated with the mother’s age, level of education or whether her partner also smokes. In addition, recent studies show a negative effect of prenatal nicotine exposure on infant neuro-behaviour as well as on long-term behaviour, cognition, language, and achievement.
An important developmental milestone in every child’s life is the formation of an attachment bond to the parent. Secure attachment relationships have a long-lasting impact on development, the ability to learn, capacity to regulate emotions and form satisfying relationships. Research has inextricably linked attachment to school readiness and school success. During 2015, 58% of children in Nottingham reached a good level of development by age 5, this is significantly less than the England average (66.3%).
Immunisations and vaccinations
High uptake of childhood immunisations is important to prevent outbreaks of communicable diseases for example mumps, measles and rubella, which can have serious complications. It is important to achieve levels of ‘herd immunity’ whereby the majority of children are protected and national targets are set accordingly. This ensures low levels of disease in the population and also provides a level of protection to those that aren’t vaccinated. Locally the majority of children’s immunisation targets are being met although there is room for improvement with levels lagging slightly behind England. For example 85.7% of 5 year olds in the City have had their MMR (two doses) compared to 88.3 nationally (2013/14) and 92.0% of children in the City have received their PCV (pneumococcal) vaccine by their first birthday compared to 94.1% for England.
Nottingham's children have a significantly higher prevalence of obesity compared to the England average at age 4 to 5 years (10.7% compared to 9.5%) and at age 10 to 11 years (23.3% compared to 19.1%). These figures also indicate that child obesity doubles between the ages of 4 to 5 and 10 to 11. Excess weight in children is strongly associated with deprivation. There is a clear trend locally and nationally of increasing levels of obesity with increasing deprivation as illustrated below in figure 7.
Mental health and emotional wellbeing
Good mental and emotional health is essential to enable children and young people to fulfil their potential. Levels of self-harm amongst young people are increasing both nationally and locally. It is estimated that one in 12 young people in the UK have self-harmed at some point in their lives. Locally services, such as school nursing and the healthy schools team, have identified self-harm as an increasing issue of concern in Nottingham
In Nottingham, there has been good progress made in reducing under-18 conception rates. The data for 2013, the latest available full year of data, shows that Nottingham City has experienced a decrease in the rate of teenage conceptions to 37.5 per 1000 girls aged 15-17 compared to 74.7 in 1998; a reduction of 49.8% (see figure 8). The national average in 2013 was 24.3. However, some Nottingham wards have under-18 conception rates twice the national average. In 2011-13 Aspley, Bulwell and Bilborough had the combined highest rates and numbers of teenage pregnancies and almost a third of teenage conceptions in Nottingham are to young women in these three wards.
Looked after children
Looked after children and young people share many of the same health risks and problems as their peers, but often to a greater degree. Children often enter the care system with a worse level of health than their peers and the health outcomes for these children are known to be poor. There are also a disproportionately larger number of children and young people with disabilities in care compared to the general population.
Disabled children and children with complex needs
There are estimated to be around 4,000 disabled children living in Nottingham City, of which 1,000 are severely affected. The fastest growing section of the disabled population is the under 16 age group. Disabled children and young people have many of the universal needs of their non-disabled peers. Nevertheless, substantial inequalities persist between disabled children and young people and their peers e.g. access to universal services including education and social and leisure opportunities.
Young people who are part of the Youth Justice System
It is well established that young offenders (YO) are a vulnerable group; with complex psychosocial and physical health needs and that they have greater health needs than their peers who are not offending. Their unmet health needs are also a contributing factor to their offending behaviour. In 2014, approximately 0.7% of the Nottingham City population aged 10-19 years were clients of the Youth Offending Team.
There are a significant number of adults in the City have diverse needs and may require considerable input from health and social care services. This group includes those with long term conditions, the vulnerably housed, as well as those with physical and/or sensory impairments or learning disabilities.
The number of adults in these groups is increasing. For instance, we know homelessness is increasing, as well as the incidence of learning disability (as well as increased life expectancy of those with learning disabilities). The number of carers has increased significantly between the 2001 and 2011 Census, with 27,000 citizens now providing unpaid care compared to 24,000 in 2001. The health and wellbeing of carers is important as this group provide an essential informal support system to local health and social care services and are also more likely to have increased health needs of their own.
Long-term conditions and cancer
Although Nottingham City has a relatively young population, the high levels of unhealthy lifestyle behaviours and long term conditions mean that adults living in the City are living with higher levels of ill-health than elsewhere. For example emergency admissions to hospital for lung disease are among the highest in England and levels of preventable sight loss due to diabetes are twice the national average. This has a direct impact on health services and likelihood of being admitted to a care home.
Cancer is the second highest cause of premature death in Nottingham, accounting for 27% of all deaths in the city. The incidence is increasing nationally and locally and mortality rates locally are significantly higher than the national average and have remained higher for many years. Thus the prevention, early identification and effective treatment of cancer are key priorities in Nottingham.
There are 635 per 100,000 new cases of cancer in Nottingham, higher than the England average (599 per 100,000) and 334 deaths per 100,000 in Nottingham compared to 290 per 100,000 in England (2012 data). The proportion of people in Nottingham who are alive one year after diagnosis is lower in Nottingham than in England (66 vs 68%).
The evidence indicates that of all cancer-related deaths, almost 25–30% are due to tobacco and as many as 30–35% are linked to diet. Most skin cancers are the result of excess exposure to sunlight. Primary prevention is an essential aspect of reducing the burden of cancer in Nottingham. Over 4 in 10 cancers in the UK are thought to be preventable, primarily through lifestyle factors.
Many people are unaware of the common early symptoms of some cancers. In turn this leads to late presentation, diagnosis and treatment of disease leading to poorer outcomes. Uptake of all three national cancer screening programmes for breast cancer, bowel cancer and cervical cancer has been reducing recently and uptake rates in Nottingham are below that of most other areas in the East Midlands. All national cancer screening programmes have been shown to reduce mortality, so it is important that Nottingham citizens are encouraged and enabled to take up these screening opportunities.
Coronary Heart Disease
Coronary Heart Disease (CHD) is a major cause of ill health nationally and locally and a major contributor to the gap in premature mortality between Nottingham and England. Mortality from CHD accounts for 45% of under 75 mortality from cardiovascular disease. In 2013, the early mortality rate for CHD in NHS Nottingham City CCG was 59.3 per 100,000. This is a decrease of 53% since 2003, which is higher than the England change. In England, the mortality rate has decreased by 47% over the same 10 years. These figures indicate major improvements in Nottingham, however, substantial inequalities between Nottingham and England remain. Prevention and effective treatment of CHD is vital in improving the health and life expectancy of Nottingham’s citizens.
In 2013/14 there were 9,454 people who had been diagnosed with CHD in NHS Nottingham City CCG. Based upon Health Survey for England results applied to this CCG, the total number of expected CHD cases is likely to be around 14,700. This is important as late diagnosis leads to increased risk of heart attack and poorer outcomes. Premature mortality (under 75 years) rates from coronary heart disease are significantly higher than the national rate although they have decreased by 53% since 2003.
In 2013/14 the admission rate for heart failure for all persons, in NHS Nottingham City CCG was 179.3 per 100,000 (365 admissions). This is significantly higher than England. The admission rate for heart failure in NHS Nottingham City CCG has decreased by 22% between 2003/04 and 2013/14.
Stroke is the fourth biggest cause of death in England after cancer, heart disease and respiratory disease causing almost 50,000 deaths. Of those who survive a stroke 60% with have a degree of disability.
In 2013/14 there were 4,818 (1.4%) people who had been diagnosed with a stroke in NHS Nottingham City CCG. The estimated prevalence of stroke in the CCG is 1.8%, i.e. proportion of citizens who have had a stroke in the past. This compares to 2.0% for England and 1.9% for comparator CCGs[i].This means 78% are potentially diagnosed here compared to 85% nationally.
Early mortality rates (under 75 years of age) for stroke in NHS Nottingham City CCG were 21.7 per 100,000 people. This was significantly higher than the England rate (13.7). Later mortality (over 75 years of age) rates from stroke in NHS Nottingham City CCG were 528.5 per 100,000 people. This was similar to the England rate (601.8). Due to increasing population and improving rates of survival following a stroke, the number of people living with a longstanding health condition caused by stroke is projected to steadily increase in both men and women across Nottingham between 2010 and 2020 (figure 9).
[i] 2011 estimates in Cardiovascular disease profile: Stroke, March 2015, PHE).
Hypertension – defined in the Quality Outcomes Framework – as a blood pressure measurement of 150/90. Uncontrolled hypertension is a major risk factor for stroke, heart attack, heart failure, aneurysms and chronic kidney disease. Accordingly the effective identification of hypertension and its management through medication and lifestyle is vital to reduce associated morbidity and mortality.
In 2014 there were 37,151 people on GP lists in NHS Nottingham City CCG with diagnosed hypertension. This equated to 10.5% of the population registered with a GP. However, it was estimated the expected prevalence of hypertension in the CCG was 20.8%, meaning that 10.4% or 37,000 adults could have hypertension that has not been diagnosed. Effective identification and management of hypertension in these individuals would greatly reduce morbidity and mortality in the city.
Atrial fibrillation is a known risk factor for stroke. Effective identification and treatment of AF can prevent complications, in particular stroke, and alleviate symptoms. The diagnosed prevalence in Nottingham City CCG is 1.1% and the estimated prevalence is 1.7% - there could be an additional 2,300 people with undiagnosed atrial fibrillation. In Nottingham, 28.8% of stroke patients admitted who had a history of atrial fibrillation were prescribed anticoagulation prior to their stroke. This is lower than the England rate (39.7%).
Respiratory disease is a major cause of ill health in Nottingham City, both in terms of unplanned admissions to hospital and premature mortality. This definition includes COPD (Chronic Obstructive Pulmonary Disease), asthma and bronchiectasis. The major risk factor for developing COPD is smoking. High levels of deprivation are linked to high smoking and COPD prevalence.
In 2013/14 there were 5,708 people diagnosed with COPD although an estimated 11,600 have the condition. The diagnosed prevalence is 1.6% compared to 1.8% nationally, although it is estimated the prevalence is 3.4% compared to 2.9% nationally. The estimated percentage detected is only 41.9% compared to 57.1% nationally. This is important because if there are a large number of people being diagnosed at a later stage in their condition it is likely their condition will worsen whilst not receiving medication and care and will mean they have a more serious condition and worse outcomes by the time they are diagnosed. This contributes to inequalities in life expectancy, both between Nottingham City and England, and also within the City.
Around 130 people in Nottingham die due to COPD each year. In 2011-2013, the mortality rate from COPD in Nottingham, 67.6 deaths per 100,000, was statistically significantly higher than the England rate of 51.8 per 100,000. In 2014, 130 deaths in Nottingham due to COPD accounted for 6% of deaths overall, 39% of who were people aged under 75 years. Men contribute to more than half (56%) of the deaths from COPD in Nottingham.
Planned and emergency admissions in COPD patients are higher in Nottingham than the England average. The cost of COPD admissions to the CCG was £1.76 million (2010/11) and inhaled corticosteroids was £3.9 million (2012/13).
In England death rates from liver disease are increasing. This contrasts with other EU countries where rates are falling. In Nottingham City between 2001 and 2013 there has been a 25% rise in death rates and under 75 mortality is significantly higher than in England for both males and females.
Over 90% of liver disease is caused by three preventable risk factors: alcohol consumption, viral hepatitis and obesity. Nottingham has high rates of each of these risk factors compared to other areas which in turn leads to high rates of morbidity and mortality.
There are over 15,000 adults (17 years and over) in Nottingham who have been diagnosed with diabetes. In addition there were an estimated further 5,300 people who remain undiagnosed suggesting the total number of adults with diabetes in the CCG was around 20,400. The diagnosed prevalence in 2014 was 5.2% compared to 6.2% in England, and estimated prevalence is 7.2% compared to 7.3%. This means we have only diagnosed an estimated 72% of people with diabetes in Nottingham City, compared to 85% nationally.
In addition to this, an estimated 24,000[i] people aged 16+ have ‘non diabetic hyperglycaemia’ which refers to raised blood glucose levels but not in the diabetic range. As such there are over 45,000 people in Nottingham City with or at high risk of diabetes. There is a clear challenge here in terms of prevention and a need to target lifestyle interventions at this group, to minimise the number of people that go on to develop type 2 diabetes.
Type 2 diabetes is six-times more common in people belonging to certain BME groups compared to the white British population. The evidence also shows that people from black and south Asian groups in the UK develop type 2 diabetes about ten years earlier than the white British population.
In terms of the care people with diabetes in the City receive, a higher percentage of people diagnosed with diabetes receive the eight recommended care processes, compared to nationally, 67.8% compared to 59.5%. However, a slightly lower percentage of people diagnosed with diabetes achieve an HbA1C less than 58mmol/mol than do nationally, 60.8% compared to 62.4%. This is important as a raised HbA1C is associated with higher rates of complications including blindness, and reduced life expectancy, due in part to people with diabetes being at higher risk of having a heart attack or stroke.
Musculoskeletal (MSK) conditions – including osteoarthritis and back and neck problems – are the greatest cause of disability in the UK[ii]. Treating MSK problems is one of the areas of biggest spend for Nottingham City CCG although this under-represents the true cost of these conditions which are born by individuals (through pain and decreased activity) and society (due to individuals’ inability to work). Health and safety statistics (Labour Force Survey for 2011/12) suggest that musculoskeletal disorders accounted 41% of all work related illness in the UK and 20% of local Employment and Support Allowance claims.
Precise estimates of the prevalence of MSK conditions in the population are limited. Applying estimates from national GP data to Nottingham’s population indicates that 21% (n=10,100) of women and 13.7% (n=6,900) of men aged over 45 have knee osteoarthritis[iii]. Given that these figures are based on individuals who visit their GP and relate to one type of MSK problem, the true burden of disease in the city will be considerably higher.
Musculoskeletal related disability will increase because of the ageing population, increased levels of obesity and lack of physical activity. Thus a new emphasis on the primary and secondary prevention of musculoskeletal problems is required to minimise future pain and the disability.
Physical disability and sensory impairment
According to the 2011 Census, 9.1% of adults in Nottingham City have a long term health problem or disability which limits their daily activities “a lot”, compared to 8.3% of adults nationally. This varies considerably across the City with the highest ward being Bilborough at 16.1% and the lowest Dunkirk and Lenton at 3.8%.
Recently published data indicates that sensory impairment makes an important contribution to the quality of life of people in England (seventh most important factor affecting individual’s health[iv]). In terms of sensory impairment there is a mixed picture in Nottingham. For example the crude rate of preventable sight loss from age related macular degeneration (AMD) in adults over 65 is higher than England (125.4 per 100,000 compared to 118.8) whereas diabetic eye disease is slightly lower (2.6 per 100,000 compared to 3.4).
Mental Health and Well-being
Mental health problems impact on individuals, families, communities, and society as a whole, with immense social and financial costs.
Nottingham City has high levels of risk factors for poor mental health for both children and adults. At any one time in Nottingham, there are estimated to be over 51,000 people (aged 16+) with a mental health problem, of whom 41,000 will have common mental health problems such as depression or anxiety, about 7,000 will have post-traumatic stress disorder and 3,000 people will have severe mental health problems such as psychosis or personality disorder. These estimates are considerably greater than the number of people recorded on local GP registers for depression (n=20,000) and severe mental health (n=3,500; 2014 QOF data) suggesting that people with these conditions may not be getting sufficient support to meet their health and wellbeing needs.
Mental wellbeing is a broad term that does not necessitate an absence of mental illness. Measures of mental wellbeing, in the Nottingham Citizen Survey, suggest that 13.6% of Nottingham’s residents describe themselves as having poor mental wellbeing (figure 10, range by wards 8.3% Wollaton West – 20.3% Aspley, WEMWBS measure). However, Nottingham compares closely with England (score of 50.7 vs 50.4, possible scores range from 14 to 70).
[ii] Newton et al. (2015) The Lancet DOI: 10.1016/S0140-6736(15)00195-6
[iii] Arthritis Research UK (2015) Arthritis Calculator http://www.arthritisresearchuk.org/arthritis-information/data-and-statistics/musculoskeletal-calculator/analysis.aspx?ConditionType=1,2&ChartType=2&Region-0=E06000018&Gender=1,2
[iv] Newton et al. (2015) The Lancet DOI: 10.1016/S0140-6736(15)00195-6
High levels of deprivation, high levels of unemployment, low educational attainment, high levels of domestic violence, a high rate of looked after children, and unhealthy lifestyles (high smoking, poor diet and low physical activity) all have an influence on mental health and health inequalities. People with severe mental illness are three times more likely to be a victim of any crime than those without. Black men are three times more likely to be represented on a psychiatric ward and up to six times more likely to be detained under the Mental Health Act.
Mental illness is under diagnosed and under treated - only a minority of people with clinically recognisable mental illness in the UK receive treatment. People with serious mental health problems may have complex needs and require high levels of care involving community and hospital services, and social care.
Poor mental health is strongly linked with poor physical health, resulting in over four times the risk of dying early for those with long term mental health problems (standardised excess under 75 mortality rate in adults with serious mental illness in Nottingham 457, 2013/14 data). Those with depression have double the risk of heart disease. Most early deaths are from preventable causes that are similar to the wider population[i]. CVD accounts for most years of life lost. Poor health is influenced predominantly by unhealthy lifestyle behaviours, particularly smoking, and may be exacerbated by medication used to treat mental health problems. It has also been shown that health services have not been as responsive in identifying or meeting the physical health needs of people with mental health problems.
Mental illness, unlike other health problems tends to start early in life and persist into and throughout adulthood. It is recognised that about half of all lifetime mental health problems have started by the age of 14. It is estimated that 1 in 10 children have a clinically recognisable mental health problem with boys more likely than girls to have a mental health problem, with the highest prevalence amongst 11-16 year olds.· A range of behavioural and emotional problems in young children have been linked to maternal anxiety during pregnancy. Self-harm is an emerging public health issue, particularly with regard to young people
[i] Hiroeh et al. Deaths from natural causes in people with mental illness Journal of Psychosomatic Research. Mar 2008 vol. 64(3) pp.275-83
Sexually transmitted infections (STIs), including HIV, remain one of the most important causes of illness due to infectious disease among young people (aged between 16 and 24 years old). If STIs, including HIV, are not diagnosed and treated early, there is a greater risk of onward transmission to uninfected partners, and a greater risk that complications might occur. Many STIs have long-term effects on health, for example chlamydia can lead to infertility and some HPV is are associated with cervical cancer.
The impact of STIs remains greatest in young heterosexuals under the age of 25 years and in men who have sex with men (MSM). There is a clear relationship between sexual ill health, poverty and social exclusion: the highest burden of sexually related ill-health is borne by groups who often experience other inequalities in health, including gay men, teenagers, young adults, some black and minority ethnic groups, and more deprived communities (Department of Health, 2013a).
Current figures show that some sexually transmitted infection rates are increasing in Nottingham City in line with the trend nationally. In 2014, Nottingham was ranked 13 (out of 326 local authorities, number one has the highest rates) in England for rates of acute STIs. This is likely to be due to both a higher prevalence of infection and also better detection than other areas.
Service data from 2014 demonstrates that Nottingham City has a high (defined as 2 + per 1,000) prevalence of HIV infection, 2.92 per 1,000 resident aged 15-59 years. This has been increasing in recent years and is higher than the prevalence in England (2.22 per 1,000).
There were 644 HIV diagnosed persons seen for HIV care. Of these 35% were aged over 45 years. In terms of late diagnoses 55.3% of adults aged 15-59 with a recent diagnosis of HIV were diagnosed late (CD4 count less than 350 cells per mm3). This compares with 42.2% for England.
Nearly half (46%) of those seen for HIV care in Nottingham are defined as black African and 12% black Caribbean or black other. 65% are live in the most deprived quintile in the city.
Heterosexual contact remains the largest defined ‘probable’ route of HIV infection for those seen for care, accounting for just under two-thirds of infections.
Other sexually transmitted infections
The rate of chlamydia detection in Nottingham in 2014 was 2,807 per 100,000 young people indicating the right people are being tested , and that there are high rates of infection. The rate of new STIs (excluding Chlamydia) for those aged less than 25 years is 1,156 per 100,000 population aged 15-59
The rate of syphilis diagnosis is 6.8 per 100,000 – and whilst relatively low has been increasing in recent years. The Gonorrhoea diagnosis rate in Nottingham has witnessed significant increase in recent years and thus is not accounted for by increasing testing – indicating a real increase. In 2014, the rate of diagnosis was 140.6 per 100,000