Hull Public Health 

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Joint Strategic Needs Assessment 2018


Healthier, Longer, Happy Lives (Working-age Adults)

The “Hull – Healthier Together” Health and Wellbeing Strategy 2014-2020 [1] are covered in three broad outcomes:

1. The best start in life;
2. Healthier, longer, happy lives; and
3. Safe and independent lives.

“Everyone should have the same opportunity to have the same life expectancy no matter where they live. People with long-term conditions can live a full life. Mental health is as important as physical health and mental illness should not mean worse physical health or reduced life expectancy. The key to a healthier life comes from feeling in control, being involved in the community, being able to make choices, to access secure employment, being socially connected and feeling fulfilled. People who are involved in decision-making about their lives tend to feel healthier and happier” [1].

This section includes topics which generally relate to working-age adults, although there is information relating to working-age adults in other sections, such as population, ethnicity and population projections, health, wellbeing and use of health services including dental services, behavioural and lifestyle risk factors, educational attainment and qualifications, vaccinations and immunisations among those at risk, learning disabilities, serious mental ill health and suicide and undetermined injury.

This section provides some general information on the labour market and benefit claimants (although information on young people not in education, employment or training is given in the section on Best Start in Life and Transition into Adulthood), and on screening of diseases, but mainly provides information on specific diseases and medical conditions, the majority of which will also apply to older people and vulnerable groups and may also apply to children and young people.

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Labour Market and Benefit Claimants

What’s the issue?

Long-term unemployment can have a very high negative influence on both physical and mental health. People who are long-term unemployed or are in short-term or low paid jobs with little stability including those on zero-hour contracts, have increased stress levels, lower self-esteem, and have a much higher risk of benefit dependence. This not only affects the individuals, their families and communities, but influences the local economy of Hull. Entrenched worklessness affects the entire family, and children living in families where parents are not working are more likely to live in poverty, leave school with none or low levels of qualifications, and be unemployed themselves or have low paid employment. This can become a vicious circle where children and young people imitate parents' behaviours, and do not value education and employment, and find it difficult to find regular well-paid employment particularly so if they have lower educational attainment.

What’s our situation?

From the official labour market statistics [225], in the year October 2016 to September 2017, 67,700 Hull men (76.4%) were in employment, compared to 77.8% for the region and 79.3% for GB, and 52,200 women (63.5%) compared to 68.2% for the region and 69.8% for GB, with an employment rate of 70.1% for Hull males and females combined (having increased from 63,600 (72.5%) and 53,300 (62.3%) for women since the previous year October to September). The unemployment rate in Hull was 6.8% among men (compared to 5.1% for the region and 4.6% for GB) and 8.2% among women (compared to 4.6% for the region and 4.4% for GB) with 4,900 men and 4,700 women unemployed in Hull. Of the 40,500 Hull people aged 16-64 years who were economically inactive, 23.8% were students, 29.1% were looking after the home or family, 24.7% were long-term sick or disabled, 8.6% were retired, 10.5% had other reasons for not working, with the remaining 3.3% either temporarily sick or disabled or discouraged. Of these 40,500 people, 12,600 (31.0%) wanted a job. One in twenty Hull people in employment are mangers, directors and senior officials (6.2%), 13.2% have professional occupations, 13.0% have associate professional and technical occupations, 8.9% work in administrative or secretarial occupations, 13.4% have skilled trades occupations, 11.6% working in caring, leisure and other service occupations, 9.4% work in sales and customer service occupations, 10.8% are process plant and machine operatives, and 13.2% have elementary occupations. The percentages for these nine occupational groupings for GB are 10.9%, 20.2%, 14.3%, 10.3%, 10.3%, 9.2%, 7.5%, 6.3% and 10.6% respectively. Earnings were also lower with a full-time worker in Hull earning 10.9% less than a full-time worker in the region (19.0% lower than GB). The gap between residence-based and workplace-based figures, indicate that people who come into Hull to work earn more than the people who live and work in Hull. Since 2013, the unemployment rate has decreased considerably in Hull from a high of 16%. Since July 2014 to June 2015, there has also been an upward shift in the occupational groupings with 34% in the highest three occupational groups compared to 32.5%, although over the same period, among those who are economically inactive, a higher percentage want a job (up from 23.6% to 31.0%).

In 2014-16, 3.65% of employees had had at least one day off in the previous week, higher than England (2.15%) and highest among 11 comparator areas (range 0.92% to 3.54%). The percentage of working days lost due to sickness the previous week was third highest of comparator areas at 2.23%, but considerably higher than England (1.20%). These percentages have increased considerably in Hull since 2009-11 when 1.7% of employees had had at least one day off the previous week and 1.4% of working days has been lost due to sickness in the previous week [27, 28].

There has been a recent focus on a new "entrenched worklessness" indicator, which is high for Hull. For Hull over the period April 2014 to March 2015, it was estimated that there were 132,000 people aged 22-59 years of whom 13,780 (10.4%) were claiming Job Seeker's Allowance (JSA), in either the Assessment Phase or the Work Related Activity Group of Employment and Support Allowance, or a lone parent in receipt of Income Support on the 31st March 2015, and that 8,590 (62.3%) of them had been claiming benefits for at least three out of the last four years (“entrenched worklessness”). This is up from the previous year when it was 60.5% [226].

As at November 2016, there were 30,140 working-age benefit claimants in Hull, which represents around 17.6% of the working-age population. This is considerably higher than the region (12.8%) and England (11.0%) [225], although has decreased in Hull from May 2015 when it was 19.8% [227]. In August 2016, St Andrew's (30.6%), Orchard Park and Greenwood (30.1%) and Branshome West (29.5%) have the highest claimant rates, and substantially higher than King's Park (6.7%) and Beverley and Holderness (both 8.0%) [65, 228]. For November 2016, 9.3% of the working-age people are claiming Incapacity Benefit, Severe Disablement Allowance or Employment Support Allowance in Hull with 15,910 claimants [228]. In November 2016, the highest claimant rate was in Myton (15.7% overall and 9.0% for mental health reasons out of the working-age population) and St Andrew's (17.5% overall and 9.4% for mental health reasons). The type of accommodation such as supported housing and hostels is likely to be influential for these wards.

Information on the percentage of young people aged 16-18 year who are not in education, employment or training (NEET) is given in the section on Best Start in Life and Transition into Adulthood, and educational attainment is given i nthe section on Schools and Educational Attainment.

The influence of unemployment on health and wellbeing was mentioned among participants living in the most deprived areas of Hull when taking part in a local qualitative research project, summed up by the following quote: “I think that's the worst thing is the high unemployment. I think if you can get people into work it's good for their minds and it's good for their bodies as well. Motivation, everything, I think it goes hands in hand really. You know, they can feel much better about themselves, give themselves more confidence. A better lifestyle as well, financially of course” [11].

What are the strategic needs?

Children should be given the best start in life to give them the opportunity to enjoy good employment prospects (see here). All adults especially those who are long-term unemployed should be given good, appropriate, timely advice, help and support, and additional training to improve their reliance, wellbeing and confidence so that they can achieve good future employment, and improve their health and wellbeing. Everybody should have the opportunity to improve their employment and life choices through increased education, training and knowledge. There needs to be good quality, affordable child care available to maximise parental choice in employment.

Hull’s City Plan in 2013 [2] aimed to create 7,500 jobs for local people over the next 10 years sits at the heart of the developing ‘energy estuary_’, making Hull the UK hub for renewable energy industries and investment due to its location. The City Plan also aimed to make Hull a world-class visitor destination with visitor numbers trebling, boosted by the City of Culture 2017 (see the JSNA Glossary). Between 2013 and 2017, there has been a huge increase in public and private investment in the city which has resulted in lower unemployment and increased visitors to Hull. A 20 year legacy programme has been put in place as the City of Culture 2017 year draws to a close. The intension is to maintain the momentum of change and success that has occurred in Hull following the City of Culture 2017 and enable the plans within the City Plan (see the JSNA Glossary).

A ‘health first’ approach should be used to tackle worklessness by promoting opportunities for people to be fit for work and fit in work. There also needs to be support for initiatives that create and provide access to quality sustainable jobs. It is necessary to ensure that local residents have the good health, fitness, skills, education and training required to take up employment opportunities.

Further information on the Priority Families programme in Hull is given within the Hull Early Help and Priority Families Strategy 2015-2020 [119] is discussed in the JSNA Glossary. One of the criteria for being a Priority Family is worklessness and financial exclusion within the family, and the programme aims to change repeating generational patterns of poor parenting, abuse, violence, drug use, anti-social behaviour and crime in the most troubled families in Hull. One of the aims of the Priority Families programme is to improve the employment prospects of the people living in these families, although more widely within the Early Help and Priority Families Strategy 2015-2020 is the universal response to build resilience in children and young people and their families, and provide early help for those requiring additional support to improve the quality of their lives which includes their educational attainment, aspirations, and employment prospects.

The Social Prescribing Service (Connect Well Hull – see the JSNA Glossary) aims to help people feel more linked in with their local communities and provide advice and support on a range of issues such as money and benefits.

This 2018 JSNA section on Labour Market and Benefit Claimants (3 pages)
The full 2018 JSNA report (139 pages)
JSNA Toolkit: Deprivation and Associated Measures (243 pages)

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Screening

What’s the issue?

There are a number of screening programmes in place in the UK relating to antenatal and newborn, and abdominal aortic aneurysm (AAA), diabetic retinopathy, breast cancer, cervical and bowel cancer in adults [229]. “Tests in pregnancy and in the newborn after birth are designed to help make the pregnancy safer, check and assess the development and wellbeing of the woman and her baby, and screen for particular conditions” [178, 179, 180]. Most of the screening programmes in adults can detect the condition before the person experiences symptoms, and thus can be treated earlier to prevent the disease developing or increase survival (further information in the JSNA Glossary). There is also the NHS Health Check programme which “aims to help prevent heart disease, stroke, diabetes, kidney disease and certain types of dementia. Everyone between the ages of 40 and 74, who has not already been diagnosed with one of these conditions or have certain risk factors, will be invited (once every five years) to have a check to assess their risk of these conditions, and will be given support and advice to help them reduce or manage that risk” [230].

What’s our situation?

From the Public Health Outcomes Framework [27, 117], 69.8% of eligible women in Hull aged 53-70 years were screened for breast cancer in the three years up to 31st March 2016. This was lower than the percentage screened in England (75.5%), and marginally below the target of 70%. The percentage of women aged 25 to 64 years attending cervical screening within the last three years (aged 25-49) or five years (aged 50-64) as at 31st March 2017 for Hull was 73.1%. Whilst this was slightly higher than England (72.0%), it had fallen slightly since 2010 from 75.8% and is below the target of 80%. For bowel cancer, the percentage of eligible men and women aged 60-74 years screened in the last 2½ years in Hull was 55.0% compared to 57.9% for England for 2015/16. The low uptake rate is recognised nationally [231, 232]. Eight in ten (81.0%) eligible men had AAA screening within the year of their 65th birthday in Hull for 2016/17 which was identical to the percentage in England [233]. For 2015/16, the uptake rate for the newborn bloodspot screening was 97.0% in Hull which was higher than the national average of 95.6%. Almost all of newborn infants had their hearing screening test in Hull (99.7%) which was slightly higher than England (98.7%). For 2012/13, under three-quarters (73.9%) of Hull residents aged 12+ years with diabetes attended diabetic retinopathy screening. This was lower than for England (79.1%), the region (79.2%) and all ten comparator areas (range 74.3% to 83.5%). The rate in Hull had been 77% in the previous two years so has fallen for the most recent year [87]. More recent data is not available by local authority. For the NHS Health Check [27, 117], up to 2016/17, 76% of those who were eligible were offered a check (slightly higher than England at 74%). However, uptake rates in Hull were far lower (32%) than England (49%) which meant that only 25% of those eligible for the NHS Health Check had had their check compared to 36% in England (12,548 receiving an NHS Health Check with 39,063 offered and 51,113 eligible for Health Checks). Information on screening uptake is not available on all medical conditions.

What are the strategic needs?

There are relatively large variations in screening uptake rates within primary care practices, perhaps associated with the patients within those practices (for example, people living in more deprived areas), and it may be useful to work with practices with relatively low uptake rates to improve their rates. Where uptake rates are low, further work may be required to assess why this is the case. Furthermore, from anecdotal evidence, it is possible that some women who attend screening and have abnormal results are not attending follow-up appointments, and this should be investigated.

This 2018 JSNA section on Screening (2 pages)
The full 2018 JSNA report (139 pages)
JSNA Toolkit: Screening (168 pages)

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All Cardiovascular Diseases

What’s the issue?

“Cardiovascular disease (CVD) is a common condition caused by atherosclerosis (furring or stiffening of the walls of arteries). Although CVD may manifest itself differently in individual patients, CVD in practice represents a single family of diseases and conditions linked by common risk factors and the direct effect they have on CVD mortality and morbidity. These include coronary heart disease, stroke, hypertension, hypercholesterolemia, diabetes, chronic kidney disease, peripheral arterial disease and vascular dementia. Many people who have one CVD condition commonly suffer from another and yet opportunities to identify and manage these are often missed” [234]. Cardiovascular disease (CVD) affects the lives of millions of people and is one of the largest causes of death and disability in England. Significant improvements have been made in the prevention and treatment of CVD in the past ten to fifteen years following the publication of the National Service Frameworks for coronary heart disease, diabetes and renal services, and the National Stroke Strategy, with mortality rates in under 75 year olds falling by 40% [234]. In Hull for 2012-14, it is estimated that mortality from CVD is responsible for nearly one-quarter of the life expectancy gap between Hull and England (28.7% for men and 23.3% for women). Over the three year period, there would be 222 fewer male and 214 fewer female deaths and life expectancy would increase by 0.77 and 0.55 years for males and females respectively if Hull experienced the same CVD mortality rates as England [235].

“In some people, a high cholesterol concentration in the blood is caused by an inherited genetic defect known as familial hypercholesterolaemia (FH). Siblings and children of a person with FH have a 50% risk of inheriting the condition, and those with heterozygous (defective gene from one parent only) FH have a 50% risk of coronary heart disease (CHD) in men by the age of 50 years and at least 30% in women by the age of 60 years. The prevalence of heterozygous FH is estimated to be 1 in 500. Homozygous (defective gene from both parents) FH is rare with around one case per million, but symptoms appear in childhood and is associated with early death from CHD” [236]. FH also increases the risk of other CVD [236].

What’s our situation?

Between 2008/09 and 2010/11 there were 8,296 admissions into hospital for cardiovascular diseases among Hull men, and 6,498 among Hull women, that is 2,765 men and 2,166 women per year or 7.5 men and almost 6 women per day. The admissions rate was highest among those living in the most deprived fifth of areas of the city (199 per 100,000 residents), lowest amongst those living in the least deprived fifth of areas (134 per 100,000 residents) [237].

In 2014-16, the under 75 directly standardised mortality rate (DSR) for all cardiovascular diseases was 149 per 100,000 men and 72 per 100,000 women, having decreased by 41% for men and by 33% for women since 2001-03. For 2014-16, there were 1,961 deaths in Hull from cardiovascular disease over the three year period [104, 238], of which 618 occurred prior to the age of 75 years, and 392 of these premature deaths were considered preventable [27, 98, 103]. The DSR for cardiovascular diseases that were considered preventable was 71 per 100,000 population (100 for men and 42 for women per 100,000 population).

The change over time (from 2001-03 to 2013-15) was very similar for both premature and preventable mortality among both males and females (40% reduction). However, whilst the national and local inequalities gap had reduced, mortality rates in Hull compared to England was 44% higher for premature mortality for both men and women, and 43% higher for men and 58% higher for women for preventable mortality [27, 98, 99, 103]. The national inequalities gap had reduced more for men than for women, but the reverse was true for the local inequalities gap.

What are the strategic needs?

It is necessary to work together to ensure people understand the benefit of positive life choices and know how to access information and seek early support to change. People need to know that stopping smoking has immediate health effects [135, 136] with substantial reductions in the risk of heart disease and stroke occurring within 1-5 years [137, 138].

People aged 40-79 years who are eligible for the NHS Health Check should be encouraged to attend, and those who have already been diagnosed with a cardiovascular disease should attend their annual reviews so that they get the best on-going treatment for their condition in order to minimise the likelihood of a further cardiovascular event.

The local NHS Hull Clinical Commissioning Group's Cardiovascular Disease Outcomes Strategy details local on-going programmes and work areas to reduce CVD and its effects in relation to integrated care, prevention and risk management, improving acute care, improving and enhancing case finding in primary care, better identification of very high risk families and individuals, and better early management and secondary prevention in the community [234].

A new Yorkshire and Humber Familial Hypercholesterolaemia Service has been launched in 2017 which is identifying people with FH and then offering cascade testing of relatives of the index case to identify other family members affected. Once identified, with FH statin treatment, risk of having a cardiac event can be reduced to the level of risk in the general population.

This 2018 JSNA section on All Cardiovascular Diseases (2 pages)
The full 2018 JSNA report (139 pages)
JSNA Toolkit: All Circulatory Diseases (99 pages)

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Coronary Heart Disease

What’s the issue?

“Coronary heart disease (CHD) is the term that describes what happens when your heart’s blood supply is blocked or interrupted by a build-up of fatty substances in the coronary arteries. The main causes are smoking, high cholesterol, high blood pressure and diabetes” [239]. “CHD is the leading cause of death both in the UK and worldwide. It’s responsible for more than 73,000 deaths in the UK each year. About one in six men and one in ten women die from CHD. In the UK, there are an estimated 2.3 million people living with CHD. CHD generally affects more men than women, although from the age of 50 the chances of developing the condition are similar for both sexes. As well as angina (chest pain), the main symptoms of CHD are heart attacks and heart failure. However, not everyone has the same symptoms and some people may not have any symptoms before CHD is diagnosed” [239]. Nationally, CHD has the second highest disability adjusted life years (DALY – see the JSNA Glossary) and thus has a substantial impact on the quality of people’s lives [102].

What’s our situation?

For 2016/17, CHD prevalence was higher for Hull (3.59%) compared to England (3.15%) with 11,073 people in Hull diagnosed with CHD [115]. There was no statistically significant association between deprivation and prevalence across the general practices in Hull. This could simply reflect increased undiagnosed disease among those living in the more deprived areas rather than a lack of a true underlying relationship, and could be influenced by the higher mortality rate among those living in the most deprived areas. Based on modelling in 2011, it is estimated that 15,676 (5.50%) registered patients have CHD in Hull so over 4,000 patients with undiagnosed CHD (it has not been possible to update the model). There were a total of 3,329 and 1,919 admissions for CHD for men and women respectively over the three year period 2008/09 to 2010/11 [240]. The directly standardised admission rate was higher among men (81) compared to women (40) per 10,000 population. Just under half of these admissions (48.1%) were elective. CHD accounts for around one in eight of all premature deaths in Hull, and over the three year period 2013-15 there were a total of 936 deaths from CHD of which 346 occurred prior to the age of 75 years [98, 104, 240]. For 2012-14, the age specific mortality rates among those aged 35-64 years in Hull were almost 50% higher compared to England, 40% and 71% higher for men and women respectively among those aged 65-74 years, and 16% and 26% higher for men and women respectively among those aged 75+ years. The premature standardised mortality ratio in Hull was 145 for men and 162 for women, so 45% and 62% higher than England respectively [99]. Whilst the prevalence of CHD in the least deprived quintile was the same as the most deprived quintile, the hospital admission rate was 42% lower, angiography (diagnostic test) rates were 37% lower, revascularisation (treatment) rates were 32% lower and the premature mortality rate was 68% lower [240]. This suggests that there is inequality present, but it is complex and there are many potential reasons for the differences observed.

What are the strategic needs?

It is necessary to work together to ensure people understand the benefit of positive life choices and know how to access information and seek early support to change. People need to know that stopping smoking has immediate health benefits [135], with heart rate and blood pressure dropping within 20 minutes [241], excess risk of coronary heart disease reducing to half that of a continuing smoker's after one year [137], and risk of coronary heart disease reducing to that of a non-smoker's after 15 years [138].

People aged 40-79 years who are eligible for the NHS Health Check should be encouraged to attend, and those who have already been diagnosed with CHD should attend their annual reviews so that they get the best on-going treatment for their condition.

People at risk of familial hypercholesterolaemia should be identified so that they can commence treatment and/or be referred for specialist care [236].

“Cardiac rehabilitation is a structured set of services that enables people with CHD to have the best possible help (physical, psychological and social) to preserve or resume their optimal functioning in society” [242]. Cardiac rehabilitation also supports patients’ return to work, improves their functional capacity and physical activity status, perceived quality of life and supports the development of self-management skills. It is proven to be cost effective, with a lower cost per QALY (Quality Adjusted Life Years, see the JSNA Glossary), compared with all other cardiology treatments. The benefits of a menu driven approach, with a choice of setting and individually identified patient goals are increasingly recognised [242]. This service should be available to all, and all people who would benefit should be encouraged to participate in a cardiac rehabilitation programme.

This 2018 JSNA section on Coronary Heart Disease (2 pages)
The full 2018 JSNA report (139 pages)
JSNA Toolkit: Coronary Heart Disease (101 pages)

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Stroke

What’s the issue?

“A stroke is a serious, life-threatening medical condition that occurs when the blood supply to part of the brain is cut off. Strokes are a medical emergency and urgent treatment is essential because the sooner a person receives treatment for a stroke, the less damage is likely to happen” [243]. “A transient ischaemic attack (TIA) is caused by a temporary disruption in the blood supply to part of the brain, causing sudden symptoms similar to those of a stroke. However, a TIA does not last as long as a stroke. The effects often only last for a few minutes or hours and fully resolve within 24 hours” [244]. A TIA can be a precursor to a stroke. The two major types of strokes are ischaemic strokes resulting from a blood clot reducing the blood supply to the brain (85%) and haemorrhagic strokes resulting from a bleed on the brain (15%) [243, 245].

Strokes can cause lasting damage, affecting mobility, cognition, sight, movement of the upper limb or communication. Thus strokes can have a major impact upon individual lives and their families, and is the one of the largest causes of adult disability in the UK [246]. Nationally, stroke has the third highest disability adjusted life years (DALY – see the JSNA Glossary) [102]. There is also a high social and economic cost to the community. Stroke is often preventable and there are more treatment options than ever before. After stroke individual recovery can be enhanced through specialist therapy and wider social support.

One survey, by examining the population attributable risk (PAR), found that history of hypertension (PAR 35%), current smoking (19%), waist-to-hip ratio (27%), diet risk score (19%), regular physical activity (29%), diabetes (5%), alcohol intake (4%), psychosocial stress (7%), depression (5%), cardiac causes (7%) and the ratio of apolipoproteins B to A1 (25%, for definition see the JSNA Glossary) collectively accounted for 88% of the PAR for all stroke [247]. Atrial fibrillation is also a risk factor for stroke (see here).

What’s our situation?

For 2016/17, stroke and transient ischaemic attack prevalence is lower for Hull (1.52%) compared to England (1.75%) and six of seven comparator areas (range 1.68% to 2.21% except Leicester 1.18%) with 4,698 patients on the disease register [115]. There was no statistically significant association between deprivation and prevalence across the general practices in Hull [248]. This could simply reflect increased undiagnosed disease among those living in the more deprived areas rather than a lack of a true underlying relationship, and could be influenced by the higher general mortality rate among those living in the most deprived areas. Based on modelling on the GP population as at October 2016, it is estimated that there are 5,317 (1.81%) registered patients who have had a previous stroke, so around 700 patients with undiagnosed stroke or TIA [248]. There were 792 and 777 admissions for stroke for men and women respectively over the three year period 2008/09 to 2010/11 giving an annual average of 523 admissions per year [248]. The directly standardised admission rate was higher among men (183) compared to women (131) per 100,000 population [248]. For 2011/12, there were 408 emergency hospital admissions for stroke giving an indirectly age-standardised rate of 179 per 100,000 persons. Around 11% were re-admitted to hospital within 28 days of their discharge from hospital following an emergency admission for stroke, which was similar to comparator areas. For 2012-14, the age specific mortality rates for men and women were higher than England particularly so for both men and women aged 35-64 years and men aged 65-74 years (all 46-47% higher) [99]. The premature standardised mortality ratio in Hull was 144 for men and 135 for women, so 44% and 35% higher than England respectively. The SMR has decreased from 245 in 2001-03 (almost 2½ times higher than England for both men and women), although for men the current rate is significantly higher than England, and for women the SMR had decreased to 135, 114, 121 and 109 in 2008-10, 2009-11, 2010-12 and 2011-13, so has increased for the latest year [98, 99, 104, 248]. Over the three year period 2013-15, there were 517 deaths in Hull from stroke, of which 106 occurred prior to the age of 75 years [98, 99, 104, 248]. There was no statistically significant association between diagnosed prevalence or premature mortality and deprivation fifths, but there was for hospital admissions [248]. This suggests that there is inequality present, but it is complex and there are many potential reasons for the differences observed.

Social marketing research, completed in Hull during September 2009, to assess general public knowledge and perception of stroke revealed a relatively high awareness of the risk factors for stroke (lack of physical activity, poor diet, alcohol and smoking) and the most commonly named symptoms were drooping mouth, facial weakness, tingling down one side, paralysis down one side with most knowing that ‘time’ was important in terms of reaction time from the national “Stroke ACT FAST” advertisement campaigns (see the JSNA Glossary). Although no-one knew what a TIA was, after an explanation one or two knew that a ‘mini-stroke’ could be a warning for a more serious stroke in the near future. Some people might behave differently if they were the ones – rather than someone else – having the symptoms “I think you treat yourself differently. You get up and carry on” [10].

What are the strategic needs?

It is necessary to work together to ensure people understand the benefit of positive life choices and know how to access information and seek early support to change. People need to know that stopping smoking has immediate health effects [135], with heart rate and blood pressure dropping within 20 minutes [241], and stroke risk falls to that of a non-smokers after 2-5 years [137, 138]. There is also the need for opportunistic testing for atrial fibrillation.

Work should continue to ensure that people realise that stroke is a medical emergency, and people with symptoms of a stroke or a TIA seek medical help immediately.

People aged 40-79 years who are eligible for the NHS Health Check should be encouraged to attend, and those who have already had a stroke or TIA should attend their annual reviews so that they get the best on-going treatment for their condition.

There is a need to work with partners to ensure that services are integrated, high quality and accessible in ways that offer people appropriate choices. Also working with partners to promote self-care, reablement or mutual support in community settings so this is viewed as the norm and reduce reliance on residential or home care.

The intention is to reduce mortality and levels of dependency following an acute stroke, reduce length of stay of stroke patients in bed-based services, reduce re-admission rates, facilitate earlier hospital discharge home to usual place of residence with the necessary support or into stroke community rehabilitation units, to increase numbers of patients supported to maximise their ability and independence in their own home, improve stroke survivor experience, improve detection and management of psychological issues in stroke survivors and ensure routine use of assessment tools to systematically assess patients at six months. National clinical guidelines for stroke are available [249, 250] which detail how to achieve these outcomes.

This 2018 JSNA section on Stroke (2 pages)
The full 2018 JSNA report (139 pages)
JSNA Toolkit: Stroke (109 pages)

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Heart Failure

What’s the issue?

Heart failure occurs when the heart is unable to pump blood at a rate sufficient for metabolic requirements. It is caused by structural or functional abnormalities of the heart. The most common causes of heart failure in the UK are coronary artery disease and hypertension. It has a poor prognosis with 30-40% of patients diagnosed with heart failure dying within a year; thereafter mortality is less than 10% per year [251].

What’s our situation?

For 2016/17, there were 2,017 (0.65%) registered patients diagnosed with heart failure which was lower than England (0.79%) and seven comparator areas (range 0.67% to 1.01%) [115]. There was no statistically significant association between deprivation and prevalence across the general practices in Hull [252]. This could simply reflect increased undiagnosed disease among those living in the more deprived areas rather than a lack of a true underlying relationship, and could be influenced by the higher mortality rate among those living in the most deprived areas. Based on modelling (October 2016), it is estimated that there are 4,033 (1.4%) patients with heart failure in Hull. It is not known if the model provides a reasonable estimate for Hull, but if it does it suggests that there are slightly more registered patients with undiagnosed heart failure than there is with diagnosed heart failure [252].

There were 1,000 inpatient admissions over the three year period 2008/09 to 2010/11 for heart failure giving annual average directly standardised admission rates of 111 per 100,000 men and 67 per 100,000 women [252]. There was an association between hospital admissions and deprivation with increased admissions among people living in the most deprived areas, and as there was no significant association between diagnosed disease prevalence and deprivation, this suggests that there may be inequities present with higher rates of undiagnosed disease or admission rates among those living in the most deprived areas.

There were only 7 deaths from heart failure in Hull residents aged under 75 years, but 56 deaths (21 men and 35 women) occurring for ages 75+ years registered during 2013-15 [98, 252].

What are the strategic needs?

People aged 40-79 years who are eligible for the NHS Health Check should be encouraged to attend, and those who have already have diagnosed heart failure should attend their annual reviews so that they get the best on-going treatment for their condition.

Testing for Brain Natriuretic Peptide (BNP and NT Pro-BNP; see the JSNA Glossary) can act as a cost effective pre-screening tool to ensure only those patients deemed at higher risk are referred on for specialist assessment with echocardiography. Practices have access to BNP testing for patients with suspected heart failure, and across the region could help save over £200,000 and means valuable resources are used effectively [253].

A diuretic is a medicine which increases the amount of water that passes out of the kidneys. Whilst they are often used to treat heart failure, they are also used to treat other conditions such as certain liver and kidney disorders, and sometimes hypertension. Patients without heart failure who are taking loop diuretics (one type of diuretics) should be assessed to ensure they do not have heart failure through BNP testing.

Patients with heart failure require specialist heart failure assessment followed by systematic care with medication and rehabilitation once their condition is stable [251]. Hull CCG commissions a tele-health service which include tele-monitoring provision for patients with heart failure. Rehabilitation should include education, lifestyle advice, physical activity and self-management advice [253]. Cardiac rehabilitation should be available to all people with heart failure who would benefit, and people who would benefit should be encouraged to participate.

Furthermore, as the prognosis of heart failure is poor, appropriate palliative care and end of life care should be provided where necessary (see here).

This 2018 JSNA section on Heart Failure (2 pages)
The full 2018 JSNA report (139 pages)
JSNA Toolkit: Other Circulatory Diseases (156 pages)

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Atrial Fibrilation

What’s the issue?

“Atrial fibrillation is a heart condition that causes an irregular and often abnormally fast heart rate. A normal heart rate should be between 60 and 100 beats a minute when resting, and is regular. In atrial fibrillation, the heart rate may be over 140 beats a minute, although it can be any speed” [254].

“If left untreated atrial fibrillation is a significant risk factor for stroke and other morbidities. Men are more commonly affected than women and the prevalence increases with age” [255]. The increase with age is relatively marked; the prevalence is estimated to be less than 2% for men aged under 65 years and around 1% or lower for women aged 65 years, but is estimated to be around 5% for men and 3% for women aged 65-74 years, then doubling to around 9% for men and 7% for women aged 75-84 years and 11% for men and women aged 85+ years [256, 257].

What’s our situation?

For 2016/17, there were 4,531 (1.47%) registered patients diagnosed with atrial fibrillation which lower than England (1.85%) and six of seven comparator areas (range 1.62% to 2.19% except Leicester 0.98%) [115]. This suggests that Hull has a relatively high rate of undiagnosed atrial fibrillation. Indeed, using a model to estimate the number of people with atrial fibrillation (October 2016) produced an estimate of 6,392 patients. If the model is reasonably accurate this suggests there are over 2,000 patients with undiagnosed atrial fibrillation.

There was no statistically significant association between deprivation and prevalence across the general practices in Hull [252].

There were 1,056 inpatient admissions over the three year period 2008/09 to 2010/11 for atrial fibrillation and flutter giving annual average directly standardised admission rates of 131 per 100,000 men and 88 per 100,000 women [252].

For 2013-15, there were a total of 82 deaths over the three year period from atrial fibrillation and flutter which included 12 deaths among those who died prior to the age of 75 years. A further 21 males and 49 females died from atrial fibrillation and flutter who were aged 75+ years [252].

What are the strategic needs?

People aged 40-79 years who are eligible for the NHS Health Check should be encouraged to attend and the check should include a pulse check to identify people who may have undiagnosed atrial fibrillation. Those who have diagnosed atrial fibrillation should attend their annual reviews so that they get the best on-going treatment for their condition.

Opportunities should be taken to identify people with undiagnosed atrial fibrillation through pulse checking and/or use of blood pressure monitors which can detect irregular pulse.

Appropriate treatment should be given, for example, anti-coagulation, for patients newly diagnosed with atrial fibrillation.

This 2018 JSNA section on Atrial Fibrilation (2 pages)
The full 2018 JSNA report (139 pages)
JSNA Toolkit: Other Circulatory Diseases (156 pages)

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Hypertension (High Blood Pressure)

What’s the issue?

Blood pressure is measured in millimetres of mercury (mmHg) and is recorded as two numbers: the first is systolic pressure (pressure of the blood when the heart beats to pump blood out) and the second is diastolic pressure (pressure when heart rests between beats) [258]. “It rarely has noticeable symptoms. Around 30% of people in England have high blood pressure but many don’t know it. If left untreated, high blood pressure increases the risk of a heart attack or stroke. It is often referred to as a “silent killer”. The only way of knowing there is a problem is to have blood pressure measured. All adults should have their blood pressure checked at least every five years” [258]. As well as having trained staff who have periodic review of their performance, and properly validated and calibrated equipment, guidelines recommend that hypertension should be diagnosed using (24 hour) ambulatory blood pressure monitoring [259]. The chances of having high blood pressure increase with age. Whilst there is often no clear cause, the following increase the risk of high blood pressure: obesity; family history; smoking; African or Caribbean descent; eating too much salt; not eating enough fruit and vegetables; lack of physical activity; drinking too much coffee or caffeine-based drinks; and drinking too much alcohol [258]. Just a 2mmHg increase in systolic blood pressure increases the risk of cardiac death by 7% and stroke by 10% [259]. Given the high prevalence of risk factors for hypertension in Hull, this puts a large proportion of Hull patients at an avoidable risk of stroke, other serious cardiac events, diabetes and chronic kidney disease.

What’s our situation?

For 2016/17, there were 42,618 (13.8%) patients diagnosed with hypertension (high blood pressure) on the GP disease registers [115], which was comparable to England (13.8%) but lower than other similar geographical areas (range 12.0% to 16.6%). Based on modelling (October 2016), it is estimated that there around 68,000 patients with hypertension in Hull [252]. It is not known if the model provides a reasonable estimate or not, but if it does, it suggests that there are at least 25,000 patients with undiagnosed hypertension in Hull. For 2013/14, among the 135,732 registered patients aged 40+ years, 122,491 (90.2%) had had their blood pressure measured within the last five years (which was similar to England and comparator areas) [260]. The data for 2013/14 was a one-off and this indicator has not been included in 2014/15. The local Hypertension Equity Audit 2011 found that diagnoses of hypertension and management of hypertension in primary care appeared to be equitable with respect to deprivation and age. There was no statistically significant association between deprivation and prevalence across the general practices in Hull, nor was there an association between deprivation and the percentage who had their blood pressure measured within the last five years [252]. This could simply reflect increased undiagnosed disease among those living in the more deprived areas rather than a lack of a true underlying relationship.

What are the strategic needs?

People aged 40-79 years who are eligible for the NHS Health Check should be encouraged to attend and all adults should have their blood pressure measured every five years. People already diagnosed with high blood pressure or other cardiovascular disease should attend their annual reviews so that they get the best on-going treatment for their condition. Opportunistic approaches should be taken to detect those with undiagnosed hypertension including the use of 24 hour blood pressure monitoring devices.

There is a need to increase the number of patients achieving blood pressure targets. Achieving blood pressure targets for patients, particularly those with diabetes and hypertension, shows that serious events such as fatal and non-fatal strokes are significantly reduced [259]. This further reduces unplanned hospital admissions, reducing NHS costs. Patients who are not achieving the nationally recognised blood pressure target should be referred to the correct healthcare professional for review and treatment [259].

People who have hypertension and who at risk of familial hypercholesterolaemia (FH, see JSNA Glossary) should be identified so that they can commence treatment and/or be referred for specialist care for FH as their risk of coronary heart disease will be high [236].

This 2018 JSNA section on Hypertension (High Blood Pressure) (2 pages)
The full 2018 JSNA report (139 pages)
JSNA Toolkit: Other Circulatory Diseases (156 pages)

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Abdominal Aortic Aneurysm

What’s the issue?

“An abdominal aortic aneurysm (AAA) is a swelling (aneurysm) of the aorta – the main blood vessel that leads away from the heart, down through the abdomen to the rest of the body. The abdominal aorta is usually around 2cm wide but can swell to over 5.5cm. Large aneurysms are rare, but can be very serious. If a large aneurysm bursts, it causes huge internal bleeding and is usually fatal (with 8 in 10 dying before they reach hospital or do not survive the surgery). Although what causes this weakness (and subsequent bulging) of the aortic wall is unclear, smoking and high blood pressure are thought to increase the risk of an aneurysm. AAAs are most common in men aged over 65. This is why all men are invited for AAA screening when they turn 65. A rupture accounts for more than 1 in 50 of all deaths in this group and a total of 6,000 deaths in England and Wales each year” [261]. The prevalence of AAA in men aged 65-74 years is approximately 1.7% [262]. Research has shown that this ultrasound screening of men in their 65th year could reduce the rate of premature death from ruptured AAA by up to 50% [263, 264]. “Men whose results are normal at screening (abdominal aorta diameter is less than 3cm), will not be invited back for another scan as an AAA grows slowly, and the chance of developing one after the age of 65 are very small” [265].

The NHS AAA Screening Programme was set up in England in 2009 and has been offered throughout the UK since the end of 2013 (for more information on screening see here). Women are not offered AAA screening, because the detection rate is considerably lower than men. Due to the higher probability of rupture among women, the mortality rates are only slightly lower than men despite the much lower underlying prevalence of AAA.

What’s our situation?

The Office for National Statistics estimate there are 10,435 men living in Hull aged 65-74 years [266], and with a prevalence of 1.7% [262] this would mean around 177 men in Hull within this age range have an AAA.

The percentage of men offered AAA screening within the year of their 65th birthday was 82.4% in 2015/16 in Hull which was higher than England (79.9%) and the average of 10 comparators (75.9%) [27, 117]. Overall, 1,036 men had attended screening out of the 1,258 men invited in 2015/16. The rate had also increased in Hull from 77.5% in 2013/14.

Over the three year period 2013-15, there were 18 deaths (mainly men) from AAA in Hull residents aged under 75 years [98, 252]. There were a further 55 deaths (27 men and 28 women) among those aged 75+ years. The total number of deaths over the three year period was 73 giving an average of 24 per year. Whilst the numbers of deaths among those aged under 75 years has reduced by 40% since 2001-2003 (when there were 30 deaths in this age group reducing to 18 in 2013-15), there has been relatively little change among those aged 75+ years.

What are the strategic needs?

Among men aged 65 years, screening is an effective way of detecting an AAA early and reducing the risk of dying from an AAA by about a half. Men invited to attend AAA screening should be encouraged to attend.

This 2018 JSNA section on Abdominal Aortic Aneurysm (2 pages)
The full 2018 JSNA report (139 pages)
JSNA Toolkit: Other Circulatory Diseases (156 pages)

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Periperal Arterial Disease

What’s the issue?

“Peripheral arterial disease (PAD) is a common condition, in which a build-up of fatty deposits in the arteries (a process called atherosclerosis) restricts blood supply to leg muscles. It is also known as peripheral vascular disease (PVD). Many people with PAD have no symptoms. However, some develop a painful ache in their legs when they walk, which usually disappears after a few minutes‘ rest. The medical term for this is “intermittent claudication”. The risk of developing PAD increases with age. It is estimated that around one in every five people over the age of 60 are affected by the condition to some degree. Men tend to develop the condition more often than women. Smoking is the most significant risk factor for PAD as well as diabetes, high blood pressure and high cholesterol. Exercising regularly and stopping smoking can ease the symptoms of PAD and reduce the chances of the condition getting worse. If applicable, treating the underlying conditions of high blood pressure, high cholesterol and diabetes and surgery can improve blood flow in the legs. Whilst not immediately life-threatening, the process of atherosclerosis can lead to serious and potentially fatal problems such as heart attack and stroke. There is also the risk that leg tissue will begin to die (gangrene) and in severe cases this can lead to amputation of the lower leg” [267].

Within a systematic review examining global prevalence estimates and risk factors for peripheral arterial disease [268], it states that “about 10–20% of people with peripheral artery disease have intermittent claudication [269, 270], another 50% have atypical leg symptoms [270], and those without exertional leg pain have poor mobility compared with individuals without peripheral artery disease [271]. Patients with and without leg ischaemic symptoms have roughly a three-fold increase in risk of mortality and major cardiovascular events (heart attack and stroke) compared with those without peripheral artery disease [272, 273, 274].”

What’s our situation?

For 2016/17, there were 1,790 (0.58%) registered patients diagnosed with peripheral arterial disease which was similar to England (0.60%), but lower than six of seven comparator areas (range 0.60% to 1.01% except Leicester 0.33%) [115]. The prevalence was slightly higher among the practices serving the more deprived populations, but the difference was not statistically significant [252].

Based on modelling, it is estimated that there are almost 14,000 (4.7%) patients with peripheral arterial disease in Hull (October 2016) [252]. If this is an accurate model, this suggests that there are high levels of undiagnosed peripheral arterial disease in Hull patients with around 12,000 having peripheral arterial disease, and potentially between 1,400 and 2,800 patients having intermittent claudication and a further 7,000 have atypical leg symptoms in Hull [252, 268, 275].

What are the strategic needs?

People aged 40-79 years who are eligible for the NHS Health Check should be encouraged to attend. People already diagnosed with peripheral arterial disease should attend their annual reviews so that they get the best on-going treatment for their condition.

Those individuals already diagnosed with a condition that acts as a risk factor for cardiovascular diseases should have their condition optimally managed using the most appropriate evidence-based approach.

Practices should be supported in terms of case finding with regard to cardiovascular diseases. Where a patient has one cardiovascular condition, clinicians should proactively seek to assess the risk and diagnose other cardiovascular conditions such as peripheral arterial disease with a standard cardiovascular assessment undertaken to examine the existence of and/or risk of hypertension, familial hypercholesterolaemia, coronary heart disease, stroke, type 2 diabetes, and kidney disease. People at risk of familial hypercholesterolaemia should be identified so that they can commence treatment and/or be referred for specialist care [236].

This 2018 JSNA section on Periperal Arterial Disease (2 pages)
The full 2018 JSNA report (139 pages)
JSNA Toolkit: Other Circulatory Diseases (156 pages)

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All Cancers

What’s the issue?

“Cancer is a condition where cells in a specific part of the body grow and reproduce uncontrollably destroying healthy tissue including organs and can spread to other parts of the body (metastasis). There are over 200 different types of cancer, each with its own methods of diagnosis and treatment. Cancer is very common. In 2011, over 330,000 people were diagnosed with cancer, and one in three people will develop some form of cancer in their lifetime. In the UK, breast cancer, lung cancer, prostate cancer and bowel cancer account for just over half (53%) of all new cases” [276]. “Treatment is often simpler and more likely to be effective when cancer is diagnosed at an early stage, so finding cancer early can make a real difference” [277]. “There are two major components of early detection of cancer: education to promote early diagnosis, and screening” [278]. With the ageing population, it is likely that the incidence and prevalence of cancer will increase [279, 280].

In Hull for 2012-14, it is estimated that mortality from cancer is responsible for just under one-third of the life expectancy gap between Hull and England (28.9% for men and 32.4% for women). Over the three year period, there would be 229 fewer male and 207 fewer female deaths and life expectancy would increase by 0.78 and 0.82 years for males and females respectively if Hull experienced the same cancer mortality rates as England [281].

“Healthy eating, taking regular exercise and not smoking helps lower the risk of developing cancer” [276]. Changing lifestyle behaviours can have a dramatic effect. For instance, the health benefits from quitting smoking reduces cancer risk within 5-10 years [135], specifically after five years, the risk of cancer of the mouth, throat, oesophagus and bladder are cut in half, and the cervical cancer risk falls to that of a non-smoker [137, 138], and after 10 years, the risk of dying from lung cancer is about half that of a person who is still smoking, and risk of cancer of the larynx and pancreas decreases [136, 137].

Screening programmes are in place for cancers of the breast, cervical and bowel (see here).

What’s our situation?

All-age cancer incidence in 2012-2014 for all cancers excluding non-melanoma skin cancer was 15% higher among men in Hull than in England, 9% higher among women (compared to 17% and 11% respectively for 2011-13). Among men, the incidence of stomach cancer was 75% higher in Hull than in England, lung cancer 56% higher, oesophageal cancer 34% higher, and bladder cancer 24% higher, colorectal cancer 14% higher, with prostate cancer incidence 9% lower in Hull. Among women, the incidence of lung cancer 69% was higher in Hull than in England, cervical cancer 39% higher, bladder cancer 30% higher, oesophageal cancer 16% higher and colorectal cancer 2% higher, although incidence from breast cancer was 11% lower than England. The incidence of malignant melanoma in Hull was 35% and 41% lower than England for men and women respectively [282].

Between 2008/09 and 2010/11 there were 10,026 admissions with a primary diagnosis of cancer (3,342 per year or 9 per day) [282]. Lung cancer accounted for the highest proportion of clinician episodes (13%), followed by breast cancer (12%), colorectal and bladder cancer (10% each).

For 2012-14, the age-specific mortality rates in Hull compared to England were around 30% higher for men aged 35-64 and 65-74 years, around 20% higher for men aged 75+ years and women aged 65-74 and 75+ years, and 44% higher for women aged 35-64 years [99, 282]. The under 75 standardised mortality ratio (SMR) for cancer was 132 for Hull men and 133 for Hull women, (so 32% and 33% higher than England), and high relative to comparator areas.

For 2014-16, there were 2,053 cancer deaths (1,091 men and 962 women) over the three year period representing 27.5% of the total deaths [104, 238]. Half of these cancer deaths were prior to the age of 75 years (554 men and 477 women), and of these premature deaths, 667 were considered preventable (350 men and 317 women). There were 182 deaths per 100,000 women (directly standardised rate) for premature cancer deaths which was considerably higher than England (137). The DSRs were 203 for men in Hull (England 152) and 163 for women (England 123). The preventable premature cancer DSRs was 118 deaths per 100,000 persons (England 79), being 129 for men (England 86) and 108 for women (England 73) [27, 103].

What are the strategic needs?

It is necessary to work together to ensure people understand the benefit of positive life choices and know how to access information and seek early support to change. In order to do this effectively, health care organisations need to work together with different communities to use existing assets to realise the benefit of positive life changes, and treating people as individuals.

Everybody should know the importance of early diagnosis, and should be encouraged to seek medical help early if they experience symptoms, and undertake screening for cancer when eligible. People need to know that stopping smoking has immediate health effects and substantially reduces the risk of most cancers within 5-10 years.

The Humber, Coast and Vale Sustainability and Transformation Partnership (STP, see the JSNA Glossary) [3] Cancer Alliance aims for better cancer care through plans that seek to improve cancer survival rates by ensuring more people are diagnosed at an earlier stage by improving awareness and uptake of screening. By working across this larger geographical area, expertise and knowledge can be brought together to improve the way cancer is diagnosed (including improved diagnosis provision) and treated. It is expected that all providers will deliver the cancer waiting targets or have a clear action plan to deliver progress in line with the joint working agreed across the STP’s Cancer Alliance. In addition, there is an intention to support work to implement the recent proposals around acute oncology services as a method of better support patients with acute symptoms and to reduce unplanned attendances to A&E by offering a more systemised approach. There is an intention to set out an agreed programme of work across the STP which covers early diagnosis, revised lung cancer and other agreed pathways; from prevention to palliative care; and living with and beyond cancer.

The National Institute of Health and Care Excellence (NICE) compliant referral proformas will be the start of agreed timed pathways for common cancers. These timed pathways will be utilised in daily practice for forward capacity planning as well as patient management.

The existing work designed to increase direct access to diagnostics to aid early cancer referral and diagnosis will be built upon to ensure that clinically appropriate diagnostics, in line with agreed timed pathways are available to primary and community care. This will be supported by a finalised, jointly agreed diagnostic demand and capacity analysis to ensure that sufficient capacity is in place to manage the workload. Reports arising from these direct access diagnostics will be developed that support GP decision making as to care pathways.

This 2018 JSNA section on All Cancers (3 pages)
The full 2018 JSNA report (139 pages)
JSNA Toolkit: All Cancers (145 pages)

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Lung Cancer

What’s the issue?

The majority of lung cancer cases are preventable as it is estimated that 81% of all cases of lung cancer are directly attributable to smoking [121]. Changing lifestyle behaviours can have a dramatic effect with the risk of dying from lung cancer falling after 10 years to about half that of a person who is still smoking, and risk of cancer of the larynx after 10 years also decreases [136, 137]. Nationally, lung cancer has the fifth highest disability adjusted life years (DALY – see the JSNA Glossary) and thus has a substantial impact on the quality of people‘s lives [102].

What’s our situation?

The age-standardised all age incidence of lung cancer among men in Hull in 2012-2014 (147 per 100,000) was 56% higher than for England (94 per 100,000); among women lung cancer incidence in Hull (113 per 100,000) was 72% higher than for England (66 per 100,0000) [282]. During 2008/09-2010/11 there were 1,416 admissions in men and 1,158 in women due to lung cancer. The standardised admission rate (using the 1976 European Standard Population) for lung cancer was twice as high among men in the most deprived fifth of areas of Hull compared with men in the least deprived fifth of areas (473 versus 231 admissions per 100,000 men) and three times as high among women (526 versus 165 admissions per 100,000 women) [283]. For 2012-14, the age-specific mortality rates were around 50% higher in Hull compared to England for both men and women aged 75+ years and men aged 35-64 and 75+ years, more than 70% higher for both men and women aged 65-74 years, and among women aged 35-64 years the rate in Hull was more than double that of England (24.2 versus 54.5 deaths per 100,000 population) [99]. For 2013-15, the directly standardised mortality rates (DSR) among women in Hull were 75% higher than England (84 versus 48 deaths per 100,000 women), and for men the mortality rate was more than half as much again as England (117 versus 74 per 100,000 men) [99]. The under 75 lung cancer DSR was strongly associated with deprivation (88 per 100,000 persons in most and second least deprived fifth of areas of Hull compared to 27 per 100,000 persons in the least deprived fifth of areas of Hull) [283]. There were 622 deaths over the three year period 2013-15 representing 8% of all deaths, of which 282 occurred prematurely representing 12% of all premature deaths [98, 104, 283]. There was approximately the same number of deaths for men and women (180 male and 160 female deaths prior to 75 years, and 141 deaths each for men and women among those aged 75+ years) [104]. One-year survival rates from lung cancer are low, at 35% among people in Hull diagnosed during 2014 (having increased by 42% since 1999), but remain slightly below the England figure of 37%. Five-year survival from lung cancer remains much lower, at 9% among people diagnosed during 2008-2010 in the Humber, Coast and Vale Cancer Alliance area (not published at local authority or /CCG level), which is a little lower than the 9% in England [283]. “quit and you’ll die!”with a denial “it’s not related to me” attitude [10]. Whilst this work was around COPD, the findings were very relevant to lung cancer.

What are the strategic needs?

Survival rates from most lung cancers are relatively low so prevention is extremely important. Not smoking should be seen as the norm, with the aim of creating a smoke free generation. It is necessary to work together to ensure people understand the benefit of positive life choices and know how to access information and seek early support to change. Health care providers need to work together within communities to realise the benefit of positive life changes. People need to know that stopping smoking has immediate health effects and substantially reduces the risk of lung cancer within 5-10 years, and that coughing up blood, pain when coughing, and persistent chest infections, breathlessness and a cough can be a sign of lung cancer [284].

This 2018 JSNA section on Lung Cancer (2 pages)
The full 2018 JSNA report (139 pages)
JSNA Toolkit: Lung Cancer (90 pages)

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Colorectal Cancer

What’s the issue?

“Bowel cancer is a general term for cancer that begins in the large bowel. Depending on where the cancer starts, bowel cancer is sometimes called colon or rectal cancer. Bowel cancer is one of the most common types of cancer diagnosed in the UK, with around 40,000 new cases diagnosed every year. About one in every 20 people in the UK will develop bowel cancer during their lifetime. There is an increased risk of bowel cancer among those aged 60+ years, who eat a diet high in red or processed meats and low in fibre, who are overweight or obese, physically inactive or smokers, have a high alcohol intake, have a family history of bowel cancer, or have another medical conditions such as severe ulcerative colitis or Crohn's disease” [285].

A national screening programme is in place for bowel cancer (see here).

What’s our situation?

The age-standardised all age colorectal cancer incidence in Hull in 2012-2014 was 103 per 100,000 men which was 14% higher than England (90 per 100,000), and was 61 per 100,000 women (similar to England at 60 per 100,000) [282]. During 2008/09-2010/11 there were 1,397 admissions among women in Hull due to colorectal cancer. The standardised admission rate (using the 1976 European Standard Population) for colorectal cancer was twice as high among men in the most deprived fifth of areas of Hull compared with men in the least deprived fifth of areas (475 versus 243 admissions per 100,000 men), while among women admission rates were lower among those in the most deprived fifth of areas compared to those in the least deprived areas (103 versus 176 admissions per 100,000 women) but highest for those in the second most deprived fifth of areas (250 admissions per 100,000 women) [286]. For 2012-14, premature age-standardised colorectal cancer mortality rates in Hull (20.7 per 100,000 men and 12.4 per 100,000 women) were slightly higher than those for England (16.1 and 10.2 per 100,000 men and women respectively) [99]. Premature colorectal cancer mortality is associated with deprivation with 18.3 and 11.6 deaths per 100,000 population in the most and least deprived fifth of areas of Hull respectively [98, 286]. There were 195 deaths over the three year period (108 men and 87 women), 83 of which occurred under the age of 75 years (50 men and 33 women) [98, 104, 286]. One-year survival rates from colorectal cancer are 74% among people in Hull diagnosed during 2014 (having increased by 16% since 1999), but remain lower than for England (77%). Five-year survival from colorectal cancer has increased since 1985-1989 by one third in Hull, reaching 49% among patients diagnosed during 2001-2005. Despite this it remains lower than for both the Humber and Yorkshire Coast Cancer Network (52%) and England (53%), although the differences were not statistically significant. More recent survival data are based only on cancers of the colon, and are presented for the Humber Coast and Vale Cancer Alliance area (not published at local authority or CCG level), nut these show five-year survival of 54% among those diagnosed during 2008-10, slightly below the 56% seen for England [286].

What are the strategic needs?

It is necessary to work together to ensure people understand the benefit of positive life choices and know how to access information and seek early support to change. In order to do this effectively, health care providers need to work together with different communities to use existing assets to realise the benefit of positive life changes, and treating people as individuals. In relation to poor diet, the family or household environment can have a strong influence, so any approach to improving diet which involves the entire family is more likely to have a better degree of success than dealing with just the individuals. People need to have the knowledge and confidence to cook cheap, healthy meals, and further education or training may be necessary to help with this. People need to be able to access good quality fresh fruit and vegetables. Maintaining a healthy weight and improving diet should be tackled using a life course whole system approach (see the section on Overweight and Obesity) looking at a combination of strategies and settings.

This 2018 JSNA section on Colorectal Cancer (2 pages)
The full 2018 JSNA report (139 pages)
JSNA Toolkit: Colorectal Cancer (79 pages)

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Prostate Cancer

What’s the issue?

“Prostate cancer is the most common cancer in men in the UK, with over 40,000 new cases diagnosed every year. Prostate cancer usually develops slowly, and some men can have it for many years without knowing. Symptoms often only become apparent when the prostate is large enough to affect the urethra. The causes of prostate cancer are largely unknown. However, certain things can increase the risk of developing the condition such as age (most cases among those aged 50+ years), ethnicity (more common in men of African-Caribbean or African descent, and less common in men of Asian descent) and men who have a first degree male relative (such as a father or brother) affected by prostate cancer are also at slightly increased risk” [287].

Many men die with prostate cancer, not because of it: “Many men with prostate cancer are older and may not die from their cancer, but from other illnesses, such as heart disease. Prostate cancer can be slow to develop. So, many men with early stage prostate cancer will eventually die of something else not related to their prostate cancer” [288]. Nevertheless, there were 9,133 deaths in England during 2012 from prostate cancer giving a crude rate of 34.7 deaths per 100,000 population.

What’s our situation?

The age-standardised incidence of prostate cancer in Hull in 2012-2014 (165 per 100,000 men) which was 9% lower than for England (182 per 100,000 men) [282]. During 2008/09-2010/11, there were 450 hospital admissions among men due to prostate cancer [289]. For 2012-14, mortality rates from prostate cancer in Hull were similar to those for England, with age-standardised rates of 44.8 per 100,000 men in Hull and 49.5 per 100,000 men in England [99]. There were 104 deaths over the three year period, 27 of which occurred under the age of 75 years [98, 104, 289]. One-year survival rates from prostate cancer are high, at 97%, similar to both England and the Humber and Yorkshire Coast Cancer Network (HYCCN). Five-year survival rates have almost doubled between 1985-1989 and 2001-2005, reaching 78% in Hull, although lower than for HYCCN (83%) statistically significantly lower than for England (84%). More recent survival data published for the Humber, Coast and Vale Cancer Alliance area (not published by local authority or CCG) showed 5-year survival at 82%, similar to England at 81% [289].

The Cancer Reform Strategy in 2007 [290] suggested considering alternatives to hospital based follow-up (including nurse-led and proactive case management e.g. in a community setting or by telephone), and this has been undertaken locally for patients with stable prostate cancer.

Since January 2015, the Hull and East Yorkshire Hospitals NHS Trust have utilised a discharge pathway for prostate cancer patients who are stable on treatment. Patients are discharged from the hospital to be followed up, monitored and managed within primary care. NHS Hull Clinical Commissioning Group (CCG) has commissioned five primary care / GP practices to undertake this process and manage these patients. The service is delivered utilising computer software that sits alongside the practice computer system; it is a web based cancer decision support tool and directs the practice to the next steps for the patient, such as review appointments or referral back into secondary care.

What are the strategic needs?

Men who are of African-Caribbean or African descent and men who have first degree male relatives affected by prostate cancer should be aware that they are at a slightly higher risk of developing prostate cancer. Men should also be aware of “the symptoms, such as an increased need to urinate, straining while urinating and a feeling that the bladder has not fully emptied, should be investigated, but that such symptoms could be a sign of benign prostatic hyperplasia or prostate enlargement rather than cancer” [287]. Support should be given to men living with prostate cancer as, whilst they “can live for decades without symptoms or needing treatment, it still can have an effect on their lives causing physical problems such as erectile dysfunction and urinary incontinence, as well causing anxiety and worry” [287].

This 2018 JSNA section on Prostate Cancer (2 pages)
The full 2018 JSNA report (139 pages)
JSNA Toolkit: Prostate Cancer (68 pages)

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Breast Cancer

What’s the issue?

“Breast cancer is the most common type of cancer in the UK. In 2011, just under 50,000 women were diagnosed with invasive breast cancer. About one in eight women are diagnosed with breast cancer during their lifetime. Most women who get it are over 50, but younger women, and in rare cases, men, can also get breast cancer. If it's treated early enough, breast cancer can be prevented from spreading to other parts of the body” [291]. There were 58 deaths among men and 9,698 deaths among women during 2012 in England from breast cancer giving a crude rate of 35.7 deaths per 100,000 population for women [292].

“As the causes of breast cancer aren't fully understood, it's not possible to know if it can be prevented altogether. Studies have looked at the link between breast cancer and diet and, although there are no definite conclusions, there are benefits for women who maintain a healthy weight, exercise regularly and who have a low intake of saturated fat and alcohol. It's been suggested that regular exercise can reduce your risk of breast cancer by as much as a third. Being overweight or obese, particularly after the menopause, causes more oestrogen to be produced, which can increase the risk of breast cancer”" [291]. Family history is also an important risk factor for breast cancer. The risk of getting breast cancer by the age of 70 if you have BRCA1 or BRCA2 breast cancer gene faults is between 45 and 65% [293].

Screening for breast cancer is the single biggest factor that allows early diagnosis, and there is a national screening programme in place for breast cancer (discussed here).

What’s our situation?

The age-standardised all age breast cancer incidence among women in Hull in 2012-2014 (152 per 100,000) was statistically significantly lower than England (170 per 100,000) [282]. During 2008/09-2010/11 there were 2,647 admissions among women in Hull due to breast cancer. The standardised admission rate (using the 1976 European Standard Population) for breast cancer was two thirds higher among women in the least deprived fifth of areas of Hull compared with women in the most deprived fifth of areas (793 versus 476 admissions per 100,000 women) [294]. For 2012-14, premature age-standardised breast cancer mortality rates in Hull (21.4 per 100,000 women) were similar to England (21.9 per 100,000 women) [99, 294]. There were 142 deaths over the three year period, 84 of which occurred in women under the age of 75 years [98, 104, 294]. One-year survival rates from breast cancer are high, at 96% among women in Hull diagnosed during 2014, similar to, but slightly lower, than that for England (97%), although the differences are not statistically significant. Five-year survival from breast cancer has been increasing in most years since 1985-1989, being 24% higher in relative terms in 2001-2005 than in 1985-1989, although at 81% it remains lower than both England (84%) and the Humber and Yorkshire Coast Cancer Network (83%), although the differences were not statistically significant. More recent data on 5-year survival were available for the Humber, Coast and Vale Cancer Alliance area (not published by local authority or CCG), which showed 5-year survival amongst those diagnosed during 2008-10 of 82%, similar to, but very slightly better than, the 81% seen for England [294].

What are the strategic needs?

As survival rates are high for most types of breast cancer provided it is detected in its early stages, it is vital that women check their breasts regularly for any changes and always get any changes examined by their GP. They should also attend screening when invited as this is the best available method of detecting an early breast lesion [291]. Healthcare providers and women need to be aware that family history of breast cancer is an important risk factor, and that the National Institute for Health and Clinical Excellence have produced guidelines in relation to breast cancer screening for women with a family history of breast cancer [295].

This 2018 JSNA section on Breast Cancer (2 pages)
The full 2018 JSNA report (139 pages)
JSNA Toolkit: Breast Cancer (88 pages)

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Diabetes

What’s the issue?

“Diabetes is a lifelong condition that causes a person's blood sugar level to become too high. There are two main types of diabetes – type 1 diabetes and type 2 diabetes. The charity Diabetes UK estimates that around 850,000 people in England have diabetes but haven't been diagnosed. Many more people have blood sugar levels above the normal range, but not high enough to be diagnosed as having diabetes. This is sometimes known as pre-diabetes. If blood sugar level is above the normal range, the risk of developing full-blown diabetes is increased. It's very important for diabetes to be diagnosed as early as possible because it will get progressively worse if left untreated. In type 1 diabetes, the body's immune system attacks and destroys the cells that produce insulin. As no insulin is produced, your glucose levels increase, which can seriously damage the body's organs. Type 1 diabetes is often known as insulin-dependent diabetes. It's also sometimes known as juvenile diabetes or early-onset diabetes because it usually develops before the age of 40, often during the teenage years. Type 2 diabetes is where the body doesn't produce enough insulin, or the body's cells don't react to insulin. This is known as insulin resistance. In the UK, around 90% of all adults with diabetes have type 2 diabetes. Control of symptoms may be managed through healthy eating, exercising regularly, and monitoring your blood glucose levels, although eventually medication may be required. During pregnancy, some women develop gestational diabetes (affecting up to 18% of women during pregnancy)” [296]. People with pre-diabetes have an increased risk of developing type 2 diabetes [297, 298].

Obesity, family history, ethnicity, high blood pressure, poor diet and lack of physical activity are the main key risk factors for type 2 diabetes [299]. For women, having had gestational diabetes in pregnancy also increases the risk of type 2 diabetes (to about 30% versus 10% for the general population [296]). The effects of diabetes can be made worse by smoking [121].

With the ageing population and the increasing trends in the prevalence of obesity, it is anticipated that the number of people with diabetes will increase.

What’s our situation?

For 2016/17, there were 16,717 patients aged 17+ years registered with Hull GPs who were diagnosed with (type 1 or 2) diabetes representing 6.78% of the population aged 17+ years which was similar to England (6.67%) [115]. There was a statistically significant increasing trend in the prevalence with increasing deprivation. The eight practices with the highest mean patient deprivation scores serving the most deprived fifth of Hull’s population had a prevalence of 7.76% compared to 6.23% among the nine practices with the lowest mean patient deprived scores [300]. Using modelling [300, 301], it is estimated that 19,377 (8.2%) of registered patients aged 16+ years have diagnosed or undiagnosed diabetes (increasing to 21,000 by 2025). So it is estimated that there are currently around 3,500 patients with undiagnosed diabetes. The same modelling estimates that there are 16,610 residents aged 16+ with diabetes (increasing to 18,000 by 2025).

It is further modelled that 20,882 (10.0%) residents of Hull, and 23,933 (10.2%) patients registered with Hull GPs who are aged 16+ years have non-diabetic hyperglycaemia (pre-diabetes) using 2015 data [302].

There were a total of 1,021 hospital admissions over the three year period 2008/09 to 2010/11 with a primary diagnosis of diabetes, giving an annual average of 340 per year [300]. There were statistically significant differences in the diabetes admission rates across the wards for both men and women, and across deprivation quintiles. The rate of lower limb amputations in diabetic patients is almost twice that of England and statistically significantly higher for 2011/12 (with a standardised admission rate of 21.8 per 100,000 population compared to 11.6 for England) with 51 lower limb amputations compared to an expected number of 24 based on the age and gender structure of Hull’s population [99, 300]. The rate of emergency hospital admissions for diabetic ketoacidosis and coma is also significantly higher than England (51.3 versus 29.7 per 100,000 population for 2012/13) with 135 admissions compared to an expected number of 70 admissions [99, 300].

For 2013-15, there were a total of 38 men and 35 women in Hull who died of diabetes (14 men and 9 women prior to 75 years) [98, 99, 104, 300]. The all age standardised mortality ratio for 2012-14 for Hull was 137 (95% CI 99 to 188) for men and 117 (95% CI 82 to 163) for women so 37% higher than England for men and 17% higher for women in Hull compared to England [99, 300]. However, due to the wide confidence intervals, there were no statistically significant differences in the rates between Hull and England.

Inequality was suggested within both the Diabetes Health Equity Audit and subsequent analysis [300, 303]. Among people living in the least deprived fifth of areas of Hull, the prevalence was 21% lower than the most deprived fifth, but the hospital admission rate was 56% lower and the premature mortality was 44% lower. This suggests that relative to diagnosed diabetes prevalence levels, hospital admissions and premature mortality are both higher in the most deprived group compared to the least deprived group.

What are the strategic needs?

People aged 40-79 years who are eligible for the NHS Health Check should be encouraged to attend. People already diagnosed with diabetes should attend their annual reviews so that they get the best on-going treatment for their condition.

Pre-diabetes is poorly understood across the medical profession, therefore education amongst health professionals is an essential focus. The screening, treatment and appropriate management of pre-diabetes are essential for the prevention of diabetes in later life.

The NHS Diabetes Prevention Programme will be implemented locally in 2018, and therefore it is essential that those at risk are referred in appropriately.

Diabetes management is challenging as it fits within a wide spectrum of long term conditions care. The overarching need is to ensure that diabetes care is managed in an integrated fashion, adequately resourced, with appropriate governance and staff who have the necessary competencies to deliver care.

People who have diabetes and who are at risk of familial hypercholesterolaemia (FH, see JSNA Glossary) should be identified so that they can commence treatment and/or be referred for specialist care for FH as their risk of coronary heart disease will be high [236].

This 2018 JSNA section on Diabetes (3 pages)
The full 2018 JSNA report (139 pages)
JSNA Toolkit: Diabetes (116 pages)

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Chronic Kidney Disease

What’s the issue?

Chronic kidney disease (CKD) is a long-term condition where the kidneys do not work effectively, which does not usually cause symptoms until it reaches an advanced stage. Symptoms include tiredness, swollen ankles, feet or hands, shortness of breath, nausea and blood in the urine. It is usually detected at earlier stages by blood and urine tests [304]. The evidence indicates that high blood pressure (hypertension) causes just over a quarter of all cases of kidney failure. Diabetes has been established as the cause of around a quarter of all cases [305]. Age and ethnicity are the other main risk factors for CKD.

Different stages of severity of kidney disease have been defined on the basis of how quickly the kidneys are cleaning the blood and is reported in millilitres per minute (mL/min). Normal glomerular filtration rate (GFR) is 90mL/min or more. The original stages were defined by the US National Kidney Foundation Kidney Disease Outcomes Quality Initiative in 2002 Patients with stage 1 had kidney damage with normal or high GFR of 90mL/min or more, patients with stage 2 CKD had kidney damage and a mild decrease in GFR of 60-89mL/min, patients with stage 3 CKD had a moderate decrease in GFR of 30-59mL/min, patients with stage 4 CKD had a severe decrease in GFR of 15-29mL/min, and patients with stage 5 CKD had established renal failure with a GFR of less than 15mL/min or are on dialysis [306]. An updated guideline in 2008 suggested sub-dividing stage 3 into 3a (GFR 45-59mL/min/1.73m²) and 3b (GFR 30-44 mL/min/1.73m²) [307]. An updated guideline [308] also recommends classifying CKD using a combination of GFR and albumin creatinine ratio (ACR). For 2015/16, the GP disease registers use stages G3a-G5 to classify a patient as having CKD [206, 307], but for previous years the register used stages 3-5 [309].

What’s our situation?

For 2016/17, the prevalence of diagnosed CKD (stages G3a-G5 of the disease) was 3.61% among registered patients aged 18+ years in Hull with a total of 8,786 patients diagnosed [115]. The prevalence was lower than England (4.09%) and the average of seven comparator areas (3.83%).

There was no statistically significant association between deprivation and prevalence across the general practices in Hull. This could simply reflect increased undiagnosed disease among those living in the more deprived areas rather than a lack of a true underlying relationship, and could be influenced by the higher mortality rate among those living in the most deprived areas [310].

Modelling (October 2016) suggests that almost 19,000 of the registered patients aged 18+ years have CKD (stage 3-5 of the disease), so only around half of patients are diagnosed [310].

Over the three year period 2013-15, there were 24 deaths (12 men and 12 women) from CKD in Hull, and five of these deaths occurred prior to the age of 75 years [98, 310].

What are the strategic needs?

Whilst a minority of people with high blood pressure suffer symptoms such as persistent headache, blurred vision or double vision, nosebleeds or shortness of breath, most people with high blood pressure have no symptoms. As high blood pressure is a strong risk factor for CKD, it is therefore important that people have their blood pressure measured at least once every five years [311].

People aged 40-79 years who are eligible for the NHS Health Check should be encouraged to attend. People already diagnosed with diabetes, high blood pressure or CKD should attend their annual reviews so that they get the best on-going treatment for their condition, and other medical conditions such as CKD are picked up quickly.

This 2018 JSNA section on Chronic Kidney Disease (2 pages)
The full 2018 JSNA report (139 pages)
JSNA Toolkit: Chronic Kidney Disease (70 pages)

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Respiratory Disease

What’s the issue?

The main respiratory diseases and conditions are respiratory infections, asthma, influenza and pneumonia, pneumonitis (inflammation of the lung tissue which is not a specific disease but a sign of an underlying condition), bronchitis and emphysema, and other chronic obstructive pulmonary diseases (COPD).

Around 80% of lung cancer and COPD cases are directly attributable to smoking [121], and other lung conditions such as the common cold, asthma and influenza are made worse by smoking [121]. However, the health benefits are immediate after quitting smoking [135], with carbon monoxide levels in the blood drop to normal within 12 hours [312], circulation improves and lung function increases within 2-13 weeks [136], and coughing and shortness of breath decreases and start to regain lung function after 1-9 months [136].

In Hull for 2012-14, it is estimated that mortality from respiratory disease is responsible for around one-fifth of the life expectancy gap between Hull and England (19.6% for men and 29.0% for women). Over the three year period, there would be 169 fewer male and 234 fewer female deaths and life expectancy would increase by 0.53 and 0.73 years for males and females respectively if Hull experienced the same respiratory disease mortality rates as England [281].

What’s our situation?

There were 7,496 and 7,329 admissions for respiratory diseases for men and women respectively over the three year period 2008/09 to 2010/11 giving an annual average of 2,499 admissions of men and 2,443 admissions of women per year. The directly standardised admission rate was higher among men (188) compared to women (166) per 10,000 population [313].

In 2014-16, there were 1,204 deaths from respiratory disease (566 men and 638 women) [238] with 363 of them under the age of 75 years (191 men and 172 women) [27, 98, 103, 313]. The premature directly standardised mortality rate (DSR) for all respiratory diseases was 69.7 per 100,000 men and 61.5 per 100,000 women, which was similar to the rate in 2001-03 for men (70.0) but a 15% increase for women (53.6). Hull had the highest DSR among 11 comparator areas and had DSRs almost twice that of England (39.2 for men and 28.7 for women). Of the 363 premature deaths, 230 were considered to be preventable (118 men and 112 women), and Hull had the highest DSR for preventable premature respiratory deaths for both men and women among 11 other comparators. The DSRs had also increased considerably between 2001-03 and 2014-16, by 35% overall (from 31.6 to 42.6 per 100,00 0 population) and by 24% for men (from 35.9 to 44.2) and by 47% for women (from 27.9 to 40.9). The latest DSRs are more than twice as high as England (20.8 versus 44.2 for men and 16.5 versus 40.9 for women). Given the prevalence of smoking in Hull, it is not surprising that the premature mortality rate for respiratory diseases is so much higher than for England, with almost half of respiratory disease deaths directly attributable to smoking, including almost 80% of COPD deaths [121].

What are the strategic needs?

People should be aware that smoking can cause respiratory conditions such as COPD and make other respiratory conditions such as asthma worse. People should also be aware that stopping smoking has immediate health effects within lung function improving within a year. Not smoking should be seen as the norm, with the aim of creating a smoke free generation.

It is necessary to work together to ensure people understand the benefit of positive life choices and know how to access information and seek early support to change. In order to do this effectively, health care providers need to work together with different communities to use existing assets to realise the benefit of positive life changes, and treating people as individuals.

People should attend their annual reviews (generally within primary care) for asthma and COPD so that they get the best on-going treatment for their condition.

This 2018 JSNA section on Respiratory Disease (2 pages)
The full 2018 JSNA report (139 pages)
JSNA Toolkit: All Respiratory Diseases (88 pages)

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Asthma

What’s the issue?

“Asthma is a common long-term condition that can cause coughing, wheezing, chest tightness and breathlessness. The severity of these symptoms varies from person to person. Whilst there is no cure, asthma can be controlled well in most people most of the time to lead a normal active life, although some people may have more persistent problems. Control can be achieved through the tailored use of medication (usually inhalers) and to some extent by avoiding things that the individual knows will make their symptoms worse (triggers)” [314]. One potential trigger is cigarette smoke [121]. “Occasionally, asthma symptoms can get gradually or suddenly worse (“asthma attack” or “exacerbation”). Severe attacks may require hospital treatment and can be life threatening, although this is unusual. In the UK, 5.4 million people have asthma (1 in 12 adults and 1 in 11 children)” [314]. In England, there were 1,037 deaths (284 aged under 75 years) in 2013 [99], 65% of which are said to be preventable [315]. There are wide variations in outcomes for people living with asthma [316]. Nationally a five-fold difference has been demonstrated between some areas in hospital admissions for adults with acute exacerbation of their asthma and as much as a six-fold difference for children.

What’s our situation?

For 2016/17, there are 18,247 (5.91%) registered patients (adults and children) on the asthma GP disease registers, which is similar to England (5.94%) and the average of seven comparators (5.78%) [115]. There was no statistically significant association between deprivation and prevalence across the general practices in Hull [206, 317]. This could simply reflect increased undiagnosed disease among those living in the more deprived areas rather than a lack of a true underlying relationship [317].

Modelling (October 2016) gave an estimate of 26,790 patients with asthma, which suggests that around 8,500 patients with asthma are undiagnosed assuming the model is accurate [317].

Over the three year period 2008/09 to 2010/11, there were an average estimate of 372 admissions per year (170 for men and 203 among women). There was a statistically significant difference in the directly standardised admission rate among Hull's seven Areas for both men and women. There was also a relatively strong association between the inpatient admission rate and deprivation, with more admissions for residents in more deprived areas [317].

In Hull, there were 29 (11 men and 18 women) asthma deaths over the three year period 2013-15, 21 (72%) of which occurred at age 75+ years [98, 99, 104, 317].

What are the strategic needs?

Asthma prevalence can be reduced over the long-term by reducing air pollution and cigarette smoking, and by increasing breastfeeding rates. In order to treat effectively, diagnoses need to be made in Primary Care. Asthma symptoms can be better controlled by having an asthma review once a year. Self-management of symptoms can be improved by the use of asthma action plans and better education, which have been shown to reduce admissions by more than half. The 2012 National Paediatric Asthma Audit demonstrated that only 45% of children admitted were given an action plan at discharge and 43% of children didn't have their inhaler technique checked before discharge [318]. For the 2012 National Adult Asthma Audit, 20% of newly-diagnosed asthmatics and 30% of known asthmatics were not commenced on inhaled corticosteroid therapy at discharge. Nine percent of patients were non-adherent to their asthma treatment. Just under half (49%) had their inhaler technique reviewed, but 26% of patients were found to have poor technique. A clinic review appointment was scheduled in 67% of patients within four weeks of discharge, and 43% had a written record of advice to see their GP within a week of discharge [319].

This 2018 JSNA section on Asthma (2 pages)
The full 2018 JSNA report (139 pages)
JSNA Toolkit: Asthma (77 pages)

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Chronic Obstructive Pulmonary Disease (COPD)

What’s the issue?

“Chronic obstructive pulmonary disease (COPD) is the name for a collection of lung diseases including chronic bronchitis, emphysema and chronic obstructive airways disease. People with COPD have difficulties breathing, and often have a persistent cough with phlegm and frequent chest infections” [320].

“Some cases of COPD are caused by fumes, dust, air pollution and genetic disorders, but these are rarer” [320]. The most common cause is smoking, and it is estimated that 78% of all COPD deaths directly attributable to smoking [121].

“COPD is one of the most common respiratory diseases in the UK. It usually only starts to affect people over the age of 35, although most people are not diagnosed until they are in their 50s. It is thought there are more than 3 million people living with the disease in the UK, of which only about 900,000 have been diagnosed. There are around 25,000 deaths each year in the UK from COPD” [320]. Nationally, COPD has the fourth highest disability adjusted life years (DALY – see the JSNA Glossary) and thus has a substantial impact on the quality of people's lives [102].

Health benefits are immediate after quitting smoking [135]. Within 12 hours, carbon monoxide levels in the blood drop to normal levels [312]. Within 2-13 weeks, circulation improves and lung function increases [136]. After 1-9 months, coughing and shortness of breath decreases, and people start to retain lung function [136].

What’s our situation?

The prevalence of smoking in Hull (31%) [86] – around 50% higher than England – results in high levels of COPD in Hull. From the local adult Prevalence Survey 2014 [86], the smoking prevalence was twice as high as the rate in England among Hull residents living in the most deprived fifth of areas (44%) compared to a rate similar to England among those living in the least deprived areas of Hull (17%). For 2016/17, the prevalence of diagnosed COPD is higher for Hull (2.59%) than England (1.87%) and the average of seven comparator areas (2.39%) with only South Tees having a higher prevalence at 3.08% [115]. There were 7,999 patients on the COPD disease register. There was a statistically significant increasing trend in the prevalence with increasing deprivation [206, 321]. The eight practices with the highest mean patient deprivation scores serving the most deprived fifth of Hull's population had a prevalence of 3.27% compared to 2.10% among the nine practices with the lowest mean patient deprived scores [321]. Based on modelling (October 2016) it is estimated that there are 12,875 (4.4%) registered patients who have COPD [321]. If the model gives a reasonable estimate then there are over 5,000 patients with undiagnosed COPD.

During the three year period 2008/09 to 2010/11, there were almost 3,500 admissions for COPD for Hull residents (annual average of 1,165 admissions) giving annual average admission rates of 386 and 363 per 100,000 men and women respectively. The rates in the wards differed from 61 to 727 per 100,000 residents. This was strongly influenced by the association between deprivation, smoking and COPD as the admission rates varied from 160 to 633 per 100,000 persons in the least deprived fifth compared to the most deprived fifth [321].

Around one in every 12 people who died in Hull died of COPD [104]. The under 75 standardised mortality rate (SMR) for COPD for 2012-14 for Hull was 226 so the premature mortality rate was more than twice that of England (193 for males and 266 for females), and substantially higher than the average of comparator areas [99]. During 2013-15, premature mortality was more than five times higher in the most deprived fifth of areas compared to the least deprived fifth of areas of Hull (directly standardised mortality rates (DSR) 73.0 versus 14.1 per 100,000 population) [98]. Over the three year period, there were a total of 582 deaths (279 men and 303 women) of which 225 (109 men and 114 women) occurred among people aged under 75 years [104, 206, 321]. All age DSRs were 140 per 100,000 men and 79 per 100,000 women in Hull for 1995-97, and fell to a low of 91 per 100,000 men in 2005-07 and to a low of 59 per 100,000 women in 2002-04, but has since increased slightly for men to 107 per 100,000 men and has since increased considerably for women to 90 per 100,000 women in 2012-14 [98, 99, 321].

Whilst the prevalence in the least deprived quintile is 62% that of the most deprived quintile (or 38% lower), the hospital admission rate is 75% lower and the mortality rate is 88% lower. This suggests that there is inequality present as those residents in the least deprived areas having fewer hospital admissions and fewer deaths in relation to the prevalence, but it is complex and there are many potential reasons for the differences observed [321, 322].

Social marketing research completed in Hull during September 2009 to assess general public knowledge and perception of COPD found a perceived health danger relating to quitting smoking – “quit and you'll die!” together with a “prove it” attitude with a lack of trust in the link between COPD and smoking and a denial “it's not related to me” attitude. In general, there was a low awareness of COPD and barriers relating to a “what's the point”" attitude [10].

NHS Hull Clinical Commissioning Group (CCG) and East Riding of Yorkshire CCG are currently reviewing the community COPD provision and are developing a joint Integrated COPD pathway and service with community providers and secondary care.

What are the strategic needs?

Although the damage that has already occurred to the lungs cannot be reversed, the progression of the disease can be slowed, and stopping smoking is particularly effective at doing this [320]. Symptoms can be relieved with medication such as using an inhaler to make breathing easier, and pulmonary rehabilitation may also help [320]. As COPD cannot be cured, prevention is very important. Not smoking should be seen as the norm, with the aim of creating a smoke free generation.

It is necessary to work together to ensure people understand the benefit of positive life choices and know how to access information and seek early support to change. In order to do this effectively, health care providers need to work together with different communities to use existing assets to realise the benefit of positive life changes, and treating people as individuals.

People need to know that stopping smoking has immediate health effects with lung function improving within a year.

People already diagnosed with COPD should attend their annual reviews (generally within primary care) so that they get the best on-going treatment for their condition.

This 2018 JSNA section on Chronic Obstructive Pulmonary Disease (3 pages)
The full 2018 JSNA report (139 pages)
JSNA Toolkit: Chronic Obstructive Pulmonary Disease (105 pages)

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Musculoskeletal Disorders

What’s the issue?

Musculoskeletal (MSK) disorders covers any injury, damage or disorder of the joints, ligaments, muscles, nerves, tendons or other tissues in the limbs or back [323]. There are numerous specific MSK disorders, but information has not been given below on all possible conditions (and not even the most common or more severe ones).

Back pain is common, and often it is non-specific back pain where no specific problem or cause is diagnosed [324], although sometimes it can be due to an injury such as a sprain or strain, and occasionally the cause is a specific medical condition such as a slipped or prolapsed disc, or sciatica. In general, back pain can be reduced by staying as active as possible and trying to continue daily activities, as resting for long periods is likely to make the pain worse. Exercises and stretches for back pain, swimming, walking, yoga and pilates may also be helpful. Anti-inflammatory painkillers and hot or cold compression packs can be used to ease the pain [324]. Specialist treatment can help in specific cases [324]. Joint pain is also a common condition and can be caused by an injury or arthritis. In older people, joint pain that gets steadily worse is usually a sign of osteoarthritis [325]. Other injuries such as tennis elbow [326] and repetitive strain injury [327] can be caused by repetitive actions. Tennis elbow can be caused by tennis, decorating or playing the violin. RSI is often work-related, and can result from jobs such as working on an assembly line, at a supermarket checkout or typing at a computer [327]. Each year in the UK, about five in every 1,000 people go to see their GP about tennis elbow [326]. For these types of injuries it is necessary to stop the repetitive activity for improvement. Sometimes MSK disorders can take a long time to improve, for instance, frozen shoulders usually takes at least 1½ to two years to get better, and can sometimes take up to five years [328]. It is estimated that 5% of people are affected by a frozen shoulder in the UK at some point in their lives [329].

Nationally, lower back and neck pain has the highest disability adjusted life years (DALY – see the JSNA Glossary) and thus has a substantial impact on the quality of people's lives [102].

What’s our situation?

Whilst lower back and neck pain have the highest DALYs in England, information relating to prevalence and levels of disability are relatively limited, although some information is available through benefit claimants. Almost one in ten (9.5%) working-age people are claiming Incapacity Benefit, Severe Disablement Allowance or Employment Support Allowance in Hull with 16,075 claimants [228]. Overall, 2,130 of these claimants were claiming these benefits due to musculoskeletal conditions (1.3% of working-age population). The highest claimant rates for musculoskeletal conditions were in Orchard Park and Greenwood and St Andrew's wards (both 2.2%) followed by Bransholme East, Bransholme West and Longhill (all 1.9%). The lowest claimant rate for musculoskeletal conditions were in King's Park and Holderness wards (both 0.5%), and Beverley and Bricknell wards (both 0.6%).

What are the strategic needs?

Often there is relatively little GPs can do to relieve symptoms and pain from MSK disorders. In general, staying active and exercising reduce pain and improves recovery time, although this depends on the specific cause or problem. Therefore, it is important that people suffering with MSK disorders get the right treatment and are aware of the best way to deal with their MSK condition. People need to be aware that there are risks in taking anti-inflammatory painkillers over a long period of time, or taking too many within specific time frames. People should also be aware of the ways to reduce risk of a MSK disorder through regular exercises and stretching, staying physically active, avoiding sitting too long at work or driving, taking care when lifting objects, maintaining good posture, avoiding repetitive actions, ensuring the mattress on the bed gives sufficient support, and maintaining a healthy weight [324].

In June 2017, NHS England have mandated that all Clinical Commissioning Groups (CCGs, see the JSNA Glossary) will implement MSK clinical review and triage for all orthopaedic referrals from primary care, to control the demand for elective care services which continues to grow as more patients are being referred for consultant opinion than hospitals are able to manage. This is leading to an overall increase in national waiting lists and declining performance against the Referral to Treatment standard.

MSK clinical triage services provide specialist clinical review of referrals after a GP has made a referral for a MSK condition. This can either be a review of the paper referral or face to face. They are commonly delivered by NHS (Hospital or Community) or independent providers in a community setting. Patients are reviewed by physiotherapists, advanced physiotherapy practitioners, or GPs with a special interest who will ensure that patients are directed to the right place for further treatment and/or diagnosis.

MSK conditions affect 1 in 4 of the adult population, approximately 9.6 million adults in England and Wales. By ensuring that patients are seen in the most appropriate setting across the primary, secondary and voluntary sectors, triage services ensure that referrals who need to be seen by a hospital consultant are seen as quickly as possible. This also reduces demand on secondary care services which have traditionally seen a high level of growth in MSK. Triage schemes can reduce referrals by approximately 30% which is equivalent to 3% of all GP referrals.

The NHS England RightCare programme has identified that 31% of total elective opportunities involve MSK pathways. During Wave 1 of the RightCare programme involving around 70 CCGs, MSK was the most frequently chosen pathway (46 CCGs).

The local community MSK Service provider treats service users with a range of MSK conditions affecting their neck; spine and lower back; and upper and lower limbs; including foot procedures. The triage process was implemented in October 2017 and the benefits will be: (i) Reduce the overall number of referrals to hospital based outpatient services; (ii) Increase the likelihood of GPs referring when necessary; (iii) Improve the quality of referrals; (iv) Improve interdisciplinary care and case management; (v) Improved patient access and availability of service; (vi) Provide better prevention, support for self – care and shared decision making; (vii) Evidence – based care including the appropriate conservative therapies; and (viii) Effective communication with patients, GPs and other stakeholders.

The Demand Management Good Practice Guide is being utilised across the system with a focus on service redesign and effective pathways management to ensure that alternative care models / pathways are introduced. This proposed new clinical review triage pathway will mean that patients benefit from shorter pathways, quicker access to assessment and treatment (“one stop shop”) and an excellent overall experience, reducing waiting lists and costs to local CCGs and GPs. More patients are managed in the community closer to home and there is a significant reduction in referrals to secondary care.

This 2018 JSNA section on Musculoskeletal Disorders (3 pages)
The full 2018 JSNA report (139 pages)
JSNA Toolkit: General Health, Disabilities, Caring and Use of Healthcare Services (240 pages)

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Epilepsy

What’s the issue?

“Epilepsy is a condition that affects the brain and causes repeated seizures, which were sometimes previously referred to as “fits”. Epilepsy is estimated to affect more than 500,000 people in the UK (around 1% of the population). The severity of seizures can differ from person to person. Some people simply experience an odd feeling with no loss of awareness, or may have a “trance-like” state for a few seconds or minutes, while others lose consciousness and have convulsions (uncontrollable shaking of the body). Epilepsy can start at any age, but it most often begins in childhood. It's often not possible to identify a reason why someone develops the condition, although in some cases it can be associated with damage to the brain from strokes, brain tumours or severe head injuries. For most people, anti-epileptic drugs are effective in controlling seizures (although it can take time to find the right type and correct dose of medication). It is important to stay healthy through regular exercise, getting enough sleep, eating a balanced diet and avoiding excessive drinking. People may also need to think about their epilepsy before undertaking things such as driving, using contraception and planning a pregnancy” [330].

What’s our situation?

For 2016/17, there were 2,587 (1.06%) patients aged 18+ years who were on the epilepsy GP disease registers [115]. This was much higher than England (0.80%) and slightly higher than the average of the comparator areas (0.98%).

There was a statistically significant increasing trend in the prevalence with increasing deprivation. The eight practices with the highest mean patient deprivation scores serving the most deprived fifth of Hull's population had a prevalence of 1.27% compared to 0.79% among the nine practices with the lowest mean patient deprived scores [331].

For 2014/15, emergency admissions for epilepsy in Hull (262 per 100,000 population) were the highest among all 211 CCGs (see the JSNA Glossary), and the percentage of patients remaining seizure-free in the previous year was second highest for Hull (46.5%) [309]. There was a five-fold and two-fold difference in these measures for 2012/13 and 2014/15 respectively [332]. So considerable difference among the CCGs.

During 2013-15, there were a total of 19 deaths virtually all occurring prior to the age of 75 years and the deaths occurred mainly to men [98], but this had been 30+ deaths the previous three years, and had ranged between 19 and 36 deaths over the last 12 years. For 2012-14, the under 75 standardised mortality ratio was 283 for men and 219 for women in Hull denoting mortality rates that were almost three times and almost twice as high as England respectively after adjusting for the age structure of Hull's population. The under 75 SMR was ranked 3rd and 19th highest among 325 local authorities for men and women respectively (although not statistically significantly higher for women due to small number of deaths) [99, 331]. Over the period 2001-14, there was a statistically significant association between the percentage of deaths from epilepsy and deprivation [98, 331] with 76 epilepsy deaths over the 14 year period (representing 0.46% of all deaths) among people living in the most deprived two-fifths of areas of Hull compared to 25 (0.23%) among people living in the least deprived two-fifths of Hull, although the trend was not over all five deprived fifths with the second most deprived fifth having a higher rate compared to the most deprived fifth, and the least deprived fifth having a higher rate compared to the second least deprived fifth.

What are the strategic needs?

“A person should have regular reviews of their epilepsy and treatment, usually carried out by their GP, but sometimes by their neurologist and their team. The reviews should be at least annually, and more frequently if the epilepsy is not well controlled. It is also useful for people suffering with epilepsy to keep diaries to note what they had been doing beforehand which may help them work out if they have anything that triggers their seizures” [333].

This 2018 JSNA section on Epilepsy (2 pages)
The full 2018 JSNA report (139 pages)
JSNA Toolkit: Epilepsy (72 pages)

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Infectious Diseases

What’s the issue?

“Infectious diseases are caused by pathogenic microorganisms, such as bacteria, viruses, parasites or fungi; the diseases can be spread, directly or indirectly, from one person to another. Zoonotic diseases are infectious diseases of animals that can cause disease when transmitted to humans” [334]. “Infectious agents can enter the body through skin contact or injuries, inhalation of airborne germs, ingestion of contaminated food or water, tick or mosquito bites, and sexual contact” [335]. There are many such infectious diseases, however, mortality is low within England with the exception of pneumonia and septicaemia. Some vaccines available which are generally given within the first five years of birth, for example, for vaccines for diphtheria, polio, measles, etc.

“Tuberculosis (TB) is one infectious disease which is a serious condition, but can be cured with proper treatment. It usually only spreads after prolonged exposure to someone with the illness. Some people can have latent TB where the bacterium is in the body but does not spread or cause symptoms, but this can develop into an active TB infection at a later date. Before antibiotics were introduced, TB was a major health problem in the UK. Nowadays, the condition is much less common. However, in the last 20 years TB cases have gradually increased, particularly among ethnic minority communities who are originally from places where TB is more common. In 2013 around 8,000 cases of TB were reported in the UK (over 5,000 among those born outside the UK). It is estimated around one-third of the world's population is infected with latent TB. Of these, up to 10% will become active at some point. With antibiotics, TB can usually be cured, but some forms of TB are resistant to certain drugs (then treatment can take up to two years). In the UK, the Bacille de Calmette et Guérin (BCG) vaccine provides effective protection against TB in up to 80% of people who are given it. The vaccine is only offered to people at a higher risk of developing TB” [336].

What’s our situation?

The incidence of TB was much lower in Hull compared to England for 2014-16 with 59 new cases diagnosed in Hull (6.2 and 10.9 per 100,000 population for Hull and England respectively). In 2012, 21 out of 23 (91.3%) of drug-susceptible TB cases reported in Hull completed treatment within 12 months, which was higher than England (83.8%), and data in Hull is not available for the years 2013 to 2015 as the numbers treated are too small [27, 57].

In 2014-2016 the all age directly standardised mortality rate (DSR) for communicable diseases (infectious and parasitic disease, and influenza) was 13.9 per 100,000 population in Hull which was higher than England (10.7) [27, 98, 103]. There were 81 deaths in total. For 2013-15, the DSR for people living in the most deprived fifth of areas of Hull was around double that of those in the least deprived fifth of areas [103, 337]. There were 75 deaths from certain infectious and parasitic diseases (30 prior to the age of 75 years), and 335 deaths from influenza and pneumonia (57 prior to the age of 75 years) [104]. For 2012-14, the under 75s pneumonia standardised mortality ratio was 136 for men and 128 for women denoting a mortality rate around 30% higher for Hull compared to England, but it was not significantly higher than England [99, 337]. In 2012-2014 the all age DSR for infectious and parasitic diseases was 17.1 per 100,000 men and 9.7 per 100,000 women which was statistically significantly higher than England for men (11.0) but not for women (9.1) [99].

What are the strategic needs?

People can reduce their risk of getting an infection and spreading any infection to other people by “washing hands, avoiding touching your eyes, nose or mouth with their hands, getting vaccinated, staying at home if signs and symptoms of infectious diseases such as vomiting or fever are present, preparing food safely, practicing safe sex, not sharing personal items such as toothbrushes or drinking glasses, and travelling wisely by getting special vaccinations” [335]. Identify those at risk of TB and protect them with the BCG vaccine, and ensure those who are receiving treatment for TB continue to take their medication.

This 2018 JSNA section on Infectious Diseases (2 pages)
The full 2018 JSNA report (139 pages)
JSNA Toolkit: Infectious Diseases (64 pages)

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Liver Disease

What’s the issue?

“There are more than 100 different types of liver disease, which together affect at least 2 million people in the UK. The liver is the second largest organ in the body. It works hard, performing hundreds of complex functions, including: fighting infections and illness; removing toxins, such as alcohol, from the body; controlling cholesterol levels; helping blood to clot; and releasing bile, a liquid that breaks down fats and aids digestion. Liver disease doesn't usually cause any obvious signs or symptoms until it’s fairly advanced and the liver is damaged. The most common liver diseases are alcohol-related liver disease which can lead to cirrhosis (scarring of the liver), non-alcoholic fatty liver disease (build-up of fat within liver cells usually in people who are overweight or obese), and hepatitis (inflammation of the liver caused by a viral infection or exposure to harmful substances such as alcohol). In the UK, liver disease is on the increase, and represents a significant health problem. Three of the main causes of liver disease are obesity, an undiagnosed hepatitis infection and alcohol misuse” [338].

What’s our situation?

There were 136 deaths (87 men and 49 women) from premature liver disease over the three year period 2014-16 of which 118 (77 men and 41 women) were considered preventable [27, 98, 103]. Whilst the directly standardised mortality rate for premature liver disease in Hull (22.5 deaths per 100,000 population) was higher than England (18.3), it was lower than most comparator areas (ranked third lowest of 12 comparator areas). This was also true for males (28.9 versus 23.9, ranked 3rd) and women (16.2 versus 12.8, ranked 5th). It was also the case for premature liver deaths that were considered preventable for men (25.6 versus 21.5, ranked 2nd), women (13.5 versus 10.9, ranked 5th) and persons overall (19.5 versus 16.1, ranked 3rd) [27, 98, 103].

Since 2001-03, premature live disease mortality rates have increased by 50% although by far more among women (122%) compared to men (26%) with similar increases for men and women for premature preventable liver disease mortality [27, 98, 103].

What are the strategic needs?

It is necessary to ensure people understand the benefit of positive life choices and realise that excessive alcohol consumption and obesity are problems. People need to know how to access information and seek early support to change. In order to do this effectively, health care providers and others such as the police and schools need to work together with different communities to use existing assets to realise the benefit of positive life changes. Family or household environment can have a strong influence of poor diet and lack of physical activity, so any weight reduction programme that involves the entire family is more likely to succeed. People need to have the knowledge and confidence to cook cheap, healthy meals. People may need information about alcohol units and the calorie content of alcoholic drinks. Further information is available in the section on behavioural and lifestyle risk factors which relate to diet, physical activity, obesity, and alcohol consumption.

People at risk of hepatitis A and hepatitis B should get vaccinated. This includes some healthcare workers, those who are travelling abroad to specific countries, and drug users. The risk of hepatitis can be reduced by not having unprotected sex, not sharing needles when injecting drugs, and avoiding blood-to-blood contact [339].

This 2018 JSNA section on Liver Disease (2 pages)
The full 2018 JSNA report (139 pages)
JSNA Toolkit: Digestive Diseases (92 pages)

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Sexual Health

Information on sexually transmitted infections is given here, and information on under 18 conceptions is given on here.

What’s the issue?

“Sexual health is a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled” [340].

What’s our situation?

In 2014, there were 3,537 live births to females aged 11-49 years in hull giving a birth rate of 65.3 per 1,000 female population aged 15-44 years (compared to 62.2 for England). The distribution of the births differed between Hull and England with higher percentage of births at younger ages in Hull in particular among those aged under 20 years (6.2% versus 3.7%) and 20-24 years (25.7% versus 16.0%), and a lower percentage in Hull among those aged 35-39 years (9.5% versus 16.7%) and 40+ years (1.8% versus 4.2%). There was little difference in the percentage of births among those aged 11-15 years for Hull (0.3% of all births) and England (0.2%). As the distribution in age differs so much between Hull and England, it is not possible to compare the overall fertility rate in terms of the crude birth rate as this will differ depending on the age distribution of the populations. In order to compare the fertility rates it is possible to use the total period fertility rate (TPFR; see the JSNA Glossary for an explanation). The TPFR was 1.82 (95% confidence interval 1.76 to 1.88) in Hull for 2014 which was virtually the same as England (1.83, 95% confidence interval 1.83 to 1.84), and had decreased slightly in Hull from 1.90 in 2014 [99, 341].

There were 832 terminations among women during 2014 in Hull giving a rate of 15.4 per 100,000 females aged 11-49 years, which was statistically significantly lower than England (16.6) even though it had increased in Hull since 2013 (13.6). With the exception of under 20s, the termination rate per 100,000 women was lower in Hull compared to England in all age groups (under 18s, 18-19, 20-24, 25-29, 30-34 and 35+ years). For both under 18s and those aged 18-19 years, the rate was only slightly higher than England and not statistically significantly so (13.7 versus 11.2 for under 18s and 24.5 versus 23.5 per 100,000 population for 18-19 year olds). There were 57 terminations among Hull women aged under 18s and 75 terminations among Hull women aged 18-19 years during 2014. Over all ages, there was no statistically significant difference in the percentages of terminations that occurred after 12 weeks gestation in Hull as England (6.4% versus 8.2%), but a statistically significantly higher percentage occurred at 10-12 weeks in Hull (13.7% versus 11.3%). The total period termination rate (TPTR; see the JSNA Glossary for explanation) was 0.43 (95% confidence interval 0.40 to 0.46) which was significantly lower than England (0.49, 95% confidence interval 0.49 to 0.50). So the total period termination rate as a percentage of the potential fertility rate (TPTR divided by TPTR and TPFR combined) was lower in Hull at 19.1% compared to England (21.1%), although had increased in Hull from 17.0% in 2013 [99, 341].

There are currently around 60 new cases of female genital mutilation (FGM) that are being reported each year in Hull although many will have occurred some time ago.

What are the strategic needs?

Locally, there are programmes in place to educate and change behaviour, and not just treat sexually transmitted infections, but allowing people to make positive proactive choices about contraception.

Hull Clinical Commissioning Group and Hull City Council offers an integrated community-based service. Over the last decade Hull has significantly changed the way it delivers sexual health services, with an increasing emphasis on prevention and health promotion to challenge perceived social norms and deliver behaviour change.

A multi-agency strategy is currently being developed to prevent FGM and those who have been subject to it.

This 2018 JSNA section on Sexual Health (2 pages)
The full 2018 JSNA report (139 pages)
JSNA Toolkit: Sexual Health (97 pages)

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Sexually Transmitted Infections

What’s the issue?

“Sexually transmitted infections (STIs) are passed from one person to another through unprotected sex or genital contact. Chlamydia is one of the most common STIs, and most people do not experience any symptoms. Gonorrhoea is a bacterial STI and around 50% of women and 10% of men do not experience any symptoms. Chlamydia and gonorrhoea can both be easily treated with antibiotics, but can lead to serious long-term health problems if left untreated including infertility. Syphilis is a bacterial infection that in the early stages causes a painless but highly infectious sores lasting up to six weeks. Secondary symptoms such as a rash, 'flu-like illness or patchy hair loss may then develop, followed by a symptom-free period. The late stage of syphilis usually occurs after many years and can cause serious conditions, such as heart problems, paralysis, and blindness. It can be treated with antibiotics, and when treated properly the later stages can be prevented. Human immunodeficiency virus (HIV) attacks and weakens the immune symptoms making it less able to fight infections and disease. There is no cure, but treatments allow most people to live a long and otherwise healthy life. Acquired immunodeficiency syndrome (AIDS) is the final stage of an HIV infection when the body can no longer fight life-threatening infections” [342]. Other STIs include genital warts, genital herpes, trichomonas vaginalis, pubic lice, and scabies [342].

What’s our situation?

There were 1,449 new diagnoses of Chlamydia in Hull for 2016 (three-quarters of which were among those aged 15-24 years – which is not surprising given the lack of symptoms and the screening programme available for this age group) [27, 87, 343]. For 2016, this equated to a rate of 2,727 per 100,000 people aged 15-24 years [27] with 1,044 positive tests out of 7,420 tests (19.4%) [344]. This was higher than England (1,882) and the region, and higher than each of the 11 comparator areas, although the rate depends on the programmes in place and does not necessarily reflect the underlying disease prevalence. Nevertheless, Hull has achieved the rate identified by Public Health England sufficient to reduce infection rates. There were 19, 13, 6 and 8 new diagnoses of HIV in 2013, 2014, 2015 and 2016 [343, 344], giving an overall prevalence rate of 1.2 per 1,000 population aged 15-59 years (compared to 2.3 per 1,000 for England) [344]. Around two thirds of Hull residents (22 out of 37; 59%) diagnosed with HIV in 2013-15 presented at a late stage (higher than England at 40%) [27]. In 2016, 207 residents received HIV-related care (130 men and 80 women) [344]. The number of reported cases of other STIs have increased substantially between 2009 and 2013 (although there had been a local reporting error to the national data set which was not resolved until 2013 which might explain why initial figures were relatively low). In Hull, the number of cases of gonorrhoea increased from 40 in 2009 to 126 in 2013, remaining at 122 in 2016 (a diagnosis rate of 47.1 per 100,000 population), cases of herpes increased from 129 in 2009 to 207 in 2015 and 195 in 2016 (rates 50.4, 79.9 and 75.2 per 100,000 population respectively), cases of syphilis increased from 12 in 2009 and 2010 combined to 24 in 2013 but has since fallen to between 7 and 11 per year (11 in 2016, rate 4.2 per 100,000 population) and cases of warts has remained reasonably consistent at around 400 cases per year except for 2012 when it was 199 cases with 382 cases in 2016 (rate 147 per 100,000 population) [343]. For 2016, the rates per 100,000 population for England were 64.9 for gonorrhoea, 57.2 for herpes, 10.6 for syphilis and 113 for warts, so rates higher in Hull for herpes and warts, but considerably lower in Hull for syphilis and gonorrhoea. In 2016, overall 2,702 new STIs were diagnosed among Hull residents giving a rate of 1,043 per 100,000 residents (compared to 750 per 100,000 residents) [344]. Half (51%) of new STI diagnoses were among young people aged 15-24 years in England, but this was higher at 63% in Hull [344]. Excluding Chlamydia diagnoses among those aged 15-24 years, Hull had the 37th highest rate of new STIs with a rate 951 per 100,000 population compared to 795 per 100,000 population for England [344].

What are the strategic needs?

It is necessary to work together to ensure that people know that there is an increasing problem with STIs, and that the risk can be reduced by not having unprotected sex. People need to be aware that symptoms are not always present, and that if they think they might have been exposed or have an STI should be encouraged to seek medical help. Locally, there are programmes in place to educate and change behaviour, and not just treat STIs.

This 2018 JSNA section on Sexually Transmitted Infections (2 pages)
The full 2018 JSNA report (139 pages)
JSNA Toolkit: Sexual Health (97 pages)

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Road Traffic Accidents

What’s the issue?

“The UK has one of the best road safety records in the world, but more can be done to prevent deaths and serious injuries” [345]. The cost of road traffic accidents is high both to individuals affected and insurance companies (and ultimately the drivers), as well as to public services including emergency and health services, and the community and economy in terms of traffic congestion [345]. Nationally, “the number of cyclists seriously injured has increased in recent years, faster than the increase in cyclists out on the roads, and motorcyclists account for 19% of all road user deaths despite representing only 1% of vehicle traffic” [346]. Children and young persons are at increased risk of being involved as pedestrians or cyclists due to their lack of experience at being able to assess risk and vehicle speed, and are more likely to be distracted.

What’s our situation?

In 2016, there were 809 reported accidents in Hull which resulted in 998 casualties, and 151 killed or seriously injured (KSI) in road traffic accidents (seven fatalities and 144 seriously injured), which included 13 KSI children aged under 16 years. This represents quite an increased from 2015 when there were 105 KSI. The reporting system has changed so that figures for 2016 are not comparable to earlier years. However, other areas within Humberside did not record such a large increase and the increase in Hull cannot be explained by the differences in the reporting system change alone so there has been a real increase in KSI in Hull between 2015 and 2016.

Most of the KSI casualties were cyclists (42; 27.8%), motorcyclists (42; 27.8%) or pedestrians (33; 21.9%) with the rest made up from car users (25; 16.6%), bus, coach, van or heavy goods vehicles users (4; 2.6%) and mobility scooter users, electric motorcyclists or other vehicle users (5; 3.3%).

Young people aged 16-24 years had the highest KSI rate at 136 per 100,000 population which was almost double of that of other age groups with the next highest rates (72.2, 67.7, 61.4 and 42.4 per 100,000 population aged 35-44, 45-54, 25-34 and 85+ years respectively). Children aged under 16 years had a KSI rate of 25.6 per 100,000 population which was higher than those aged 55-64 years (31.9) and 65-74 years (28.2) but lower than those aged 75-84 years (16.0). Overall, there were 260,240 residents in Hull giving a KSI rate of 58.0 per 100,000 population. In England, there were 1,792 deaths and 24,101 seriously injured giving a KSI rate of 46.8 per 100,000 population. Hull, as any city, will tend to have a high concentration of pedestrians, cyclists, motorcyclists and drivers, so it is not especially surprising that the KSI rate is higher than England. Hull is relatively flat and there are a relatively high number of cyclists in Hull. Between 2013-15, there were 343 residents KSI on the roads giving a rate of 44.3 per 100,000 residents which was higher than England (38.5) [27].

What are the strategic needs?

The risk of road traffic accidents can be reduced through reducing the number of drivers on the road that should not be driving (those drinking alcohol and taking prescribed and illegal drugs, disqualified drivers, drivers without licences, and uninsured drivers), ensuring drivers and their passengers are as safe as possible in their cars by keeping to speed limits and not using mobile phones when driving, and ensuring seatbelts and proper child restraints are used. Ensuring pedestrians, cyclists and motorcyclists are as visible as possible with their clothing, lights and protective helmets and clothing where appropriate, and increasing training for all road users.

Nationally, the Department for Transport (DfT) are working to reduce road traffic accidents though new drug driving legislation and more sophisticated road side testing devices [345], revising and reissuing speed limit guidance to help local councils improve safety on their roads [347] as well as providing a speed limit appraisal tool, a computer-based database to help councils assess the full costs and benefits of any proposed speed limit changes [345], reviewing the motorcycle test [345], extending Transport for London's THINK! Cycling ‘Tips’ to other cities [346], and promoting THINK! education resources and other road safety campaigns [345]. The DfT are also looking at ways to reduce the number of uninsured and unlicensed drivers on the roads, looking at driving and riding tests and standards, and adding case studies to the theory test to improve attitudes to driving, and offering more support to new drivers [345].

Locally, a number of interventions have been used to reduce road accidents, including car seat information for new parents, regular free car seat clinics (80% seats were unsafe), resources for any nursery or primary school to play out traffic intervention scenarios, pedestrian skills available to every primary school in Hull (classroom resources and independent assessment of each child), Bikeability program for any Year 5/6 child (ages 9-11) to build confidence on the road (free cycle helmet), transition to secondary training (an hour long session encouraging children to pre-plan their commutes to their new secondary school), “Rusty Rider” cycling programme for adults, and young and old driver assessments (through Institute of Advanced Motorists at a discounted rate focusing on speed and judging situations for young and age reactions and medication interactions for older drivers).

This 2018 JSNA section on Road Traffic Accidents (2 pages)
The full 2018 JSNA report (139 pages)
JSNA Toolkit: Accidents (91 pages)

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