Hull Public Health 

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Joint Strategic Needs Assessment 2018


Safe and Independent Lives (Older People and Vulnerable Groups)

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 feel safe and fulfilled no matter what his or her circumstances. Many people of all ages are living with conditions or situations that mean they need extra support to get the most out of life. There is good evidence that people who have control over their care and support are better able to live safely and independently in their community. This then reduces the burden of ill health for individuals, their families/carers and the health service and enables people to live full and satisfying lives” [1].

This section includes topics which generally relate to vulnerable groups which include older people.

There is information relating to older people in other sections, such as population and population projections, health, wellbeing and use of health services including dental services, behavioural and lifestyle risk factors , and screening of diseases.

The majority of the information on specific diseases and medical conditions are covered in the section on adults and many of these conditions will apply to older people and vulnerable groups as well as the adults.

Information relating to vulnerable groups is also mentioned within other sections, such as safety and social isolation, health and wellbeing, and behavioural and lifestyle risk factors.

The majority of the vaccinations and immunisations relate to children and young people so are included in the Best Start in Life section. Information relating to the influenza vaccine and pneumococcal polysaccharide vaccine given to people aged 65+ years and at risk groups is also included on that section.

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Learning Disabilities

What’s the issue?

“A learning disability (LD) affects the way a person understands information and how they communicate. Around 1.5m people in the UK have one. This means they can have difficulty: understanding new or complex information; learning new skills; and/or coping independently. It is thought that up to 350,000 people have a severe LD. This figure is increasing” [348]. There are systems in place to identify children with a LD in school, and approaches to their education can be modified to maximise educational attainment. There are varying degrees of LD and definitions used, so different data sources and models often produce quite different estimates.

Following the Children and Families Act 2014, children and young people (under the age of 25 years) who have special educational needs may have an Education, Health and Care (EHC) plan, developed by all professionals and the family working together, to address all needs that a child or young person has within education, health and care. Prior to the Act, children were on School Action, School Action Plus or have SEN statements (three classifications in order of severity of additional need requirements). Within the Act, SEN Support replaces School Action and School Action Plus (in schools), and children with a learning disability assessment should have their EHC plan by September 2016 and children with statements should have their EHC by April 2018 (see the section on Schools and Educational Attainment for more information on SEN / EHC among school age children).

What’s our situation?

From GP registers for 2016/17, practices in more deprived areas had significantly higher levels of LD in their practice populations. The eight practices serving the patients living in the most deprived areas had a prevalence of 0.52% compared to 0.33% among the nine practices serving the least deprived practices. The overall rate of LD in adults recorded by practices (1,565 (0.51%) patients for 2016/17 [115]) is lower than England (0.47%) and six of seven comparator areas (range 0.56% to 0.68% and 0.45% for Salford), with modelled estimates confirming that there may be much undiagnosed or unrecorded LD [116]. Models from PANSI [349] and POPPI [350] estimate that for 2017 there are 4,851 residents (rather than registered patients) aged 18+ years with LD in Hull (including 781 with moderate and 247 with severe LD), and 104 residents with Down's syndrome and 2,031 residents with Autistic Spectrum Disorder (ASD). From the Learning Disability Profiles 2016 [351], for 2014/15 there are 645 adults aged 18-64 years with LD who are getting long-term support from their local authority giving a rate of 3.9 per 1,000 population, which is similar to England (3.7).

Using statistical modelling [116, 351, 352], it is estimated that there are around 84 pupils aged 7-15 years in Hull with severe LD, 29 with profound and multiple LD, 1,404 with moderate LD and 246 with ASD, although another model suggests the numbers with ASD might be more than double this at 563 [116]. From the Learning Disability Profiles 2016 [351], out of 38,784 school pupils, 810 pupils were known to have moderate LD (20.9 and 28.6 per 1,000 population for Hull and England respectively), 291 severe LD (rates 7.50 and 3.80), 30 profound and multiple LD (rates 0.77 and 1.29), 353 autism (rates 9.10 and 10.8), and 1,131 LD overall (rates 29.2 and 33.7).

In 2015/16, 490 (74.7%) of the 656 working-age learning disabled clients were living in stable and appropriate accommodation in Hull which was similar to England (75.4%), and slightly lower among women (201 out of 277; 72.6%) than men (289 out of 379; 76.3%). The rate had increased since 2011/12 for both Hull (from 66.4%) and England (from 70.0%) but at a faster rate in Hull [27, 28]. The inequalities gap in the percentage of the working-age population who were in employment for learning disabled clients compared to the general population in Hull was 66.0 percentage points which was similar to England (68.0) [27, 28]. As the employment rate of the general population was 66.9% in Hull and 73.9% in England (see the section on Labour Market and Benefit Claimants), this means that the employment rate of learning disabled clients was as low as 1% in Hull but around 7% for England.

What are the strategic needs?

It is necessary to work with schools and early years settings to identify children who need additional support so that the children are identified early and obtain the most appropriate help and support for their specific circumstances (also see the section on Schools and Educational Attainment).

Hull’s Early Help and Priorities Family Strategy 2015-2020 sets out proposals to continue to build an integrated Early Help delivery model for children, young people and families in Hull [119]. The vision is that “The Children, Young People and Families Board is committed to working together to make Hull an inspiring and enterprising city – safe and healthy to learn, play, work and live in. We want all children, young people and their families to be able to make healthy lifestyle choices, be safe from harm and have the confidence to be ambitious and achieve their aspirations” [119]. The framework outlines the approach to ensure that collaboration and alignment of services, and that early help may be ‘early in life or at the earliest opportunity’ which is also part of the day job, helpful, non-stigmatising, preventative, targeted and tailored [119]. There are four thresholds of need with higher levels of targeted support given to children and families with additional needs and complex needs.

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, and improving their health and wellbeing. 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, and where appropriate, ensure provision of specialist and adapted housing that is fit for purpose. Within Hull’s 2020 Programme, there is a Frailty and Isolation work stream, which aims to ensure “a range of services are provided across Hull to meet the needs of some of the most vulnerable in society, including those with learning disabilities” [353].

The period of transition for young people who have a learning disability into adulthood is known to be a time of considerable change and often uncertainty. There needs to be a clear transition pathway identified with partners across adult social care, children’s services, education and health in order to facilitate a smooth transition into adulthood.

There is also a need to explore meaningful employment opportunities for people with a learning disability as the figures for Hull are considerably lower than the national and regional averages. Given the link between employment and wellbeing and between unemployment, poverty and impaired health, we could expect positive health and wellbeing outcomes to arise from improved employment opportunities.

Progress has been made across the health and care system to transform care for people with learning disabilities and/or autism who have a mental illness or whose behaviour challenges services, but it is recognised that much more needs to be done. Sir Stephen Bubb’s report commissioned by NHS England describes how to accelerate this transformation of care. “The work to be taken forward through this programme will be wide-ranging, and will be co-designed and co-produced in partnership with people with learning disabilities and/or autism, their families, clinicians, commissioners, providers, and other national organisations in the health and care system” [354].

The Humber Transforming Care Partnership [355] was established in 2015 across a foot print which included Hull, the East Riding of Yorkshire and North East Lincolnshire. A Joint Transformation Plan was published in 2016 in response to Building the Right Support [356] and the national service model [357] which set out a national vision for a radical shift in the delivery of care and support for people with a learning disability and/or autism. The plan which covers a three year period described the intention of the Partnership to improve the quality of care and life experience of people with a learning disability and/or autism in order to reduce reliance on inpatient care. The vision of the plan, underpinned by the nine principles of ‘Building the Right Support’, is a commitment to improving safe care and treatment to make sure that Children, Young People and Adults with a learning disability and/or autism have the same opportunities as anyone else to live satisfying and valued lives and be treated with dignity and respect.

This 2018 JSNA section on Learning Disabilities (3 pages)
The full 2018 JSNA report (139 pages)
JSNA Toolkit: Mental Health and Learning Disabilities (375 pages)

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Severe Mental Ill Health

What’s the issue?

“Severe mental illness affects about 1% of the population. There are many types of mental illness but most of them can be classified as either psychotic or neurotic. Neurotic conditions are related to ‘normal’ emotions but are more extreme, and are the most common types of mental illness. Being clinically depressed is a far deeper experience than ‘feeling depressed’, and has a marked effect on life, preventing the patient from looking after themselves or being able to work, and in extreme cases can lead to suicide. Other examples of neurotic illnesses are phobias, obsessive compulsive disorder and anxiety. Psychotic conditions are unrelated to normal emotions, and the word psychosis is used to describe symptoms or experiences that happen together. These symptoms cause the patient to not experience reality like most people. Symptoms may include hallucinations, delusions, thought disorder, lack of insight and not recognising that they are unwell, and appearing unusually excited or withdrawn and avoiding contact with other people. Examples include schizophrenia, bipolar disorder (manic depression) and psychotic depression” [358]. Serious mental illness obviously has a huge effect on mental wellbeing, but can also influence physical health. People with serious mental health are more likely to have poor physical health, and people with poor physical health are more likely to have poor mental health [359]. People with serious mental illness are also more likely to have unhealthily lifestyles further affecting health and wellbeing. For example, around one-third of people with mental health problems and two-thirds of people in psychiatric units smoke [360]. Also see the section on Emotional Health and Wellbeing.

What’s our situation?

For 2016/17, there were 2,688 registered patients diagnosed with a serious mental ill health on the GP disease registers for Hull. The prevalence at 0.87% was lower than England (0.92%) and all seven comparator areas (range 0.91% to 1.07%) although North East Lincolnshire which is often used as a comparator area had a lower prevalence at 0.82% [115]. Given Hull's levels of deprivation, this suggests that there is undiagnosed disease in Hull [116, 206].

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 1.18% compared to 0.62% among the nine practices with the lowest mean patient deprived scores [116].

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]. Almost half of claimants were claiming due to mental health reasons with the highest prevalence in St Andrew’s (9.4% of working-age population), Myton (9.0%), Bransholme West (6.6%), Orchard Park and Greenwood (6.5%) and Longhill (6.3%), and lowest in King’s Park (1.3%). The high rates could be influenced by the relatively high number of supported housing and hostels available.

During the three year period 2008/09 to 2010/11 [116], there were 266,244 daycase and inpatient clinician episodes of which 3,526 (1.3%) had a primary diagnosis of mental and behavioural disorders. Almost half of all clinician episodes for mental and behavioural disorders were for mental and behavioural disorders due to psychoactive substance abuse with a further 12% for schizophrenia, schizotypal and delusional disorders, 11% for neurotic, stress-related and somatoform disorders, 10% for mood disorders and 9% for dementia [116].

From the Child Health Profiles 2017 [19], during 2015/16, there were 43 hospital admissions for mental health conditions among under 18s which is lower than England (77.3 versus 85.9 per 100,000 population) and has been consistently lower than England over the last three years [21, 361, 362]. There were 153 hospital admissions as a result of self-harm among those aged 10-24 years during 2015/16 which was considerably lower than England (291 versus 431 per 100,000 population). The rate in Hull has been consistently decreasing in Hull. The rates per 100,000 population were 427 in 2012/13 (246 admissions) which was higher than England (346) [21], and 552 in 2013/14 (304 admissions) also higher than England (412) [361], and 400 in 2014/15 (210 admissions) which was the same as England (399) [362].

The percentage of people in contact with secondary mental health services in Hull is quoted as being more than twice as high in Hull compared to England (12.5% versus 5.3% in 2013/14 and 13.0% versus 5.4% in 2014/15) [27]. The rate in Hull was second and fourth highest in 2013/14 and 2014/15 respectively among 150 upper-tier local authorities (highest around 14.5%) [27]. The rate in Hull seems particularly high, and it is not known if this is due to a recording error or not.

In 2015/16, 73.4% of adults aged 18 to 69 years who are in contact with secondary mental health services live in stable and appropriate accommodation which is considerably slightly higher than England (58.6%) [27, 28]. The gap in the employment rate for those in contact with secondary mental health services and the overall employment rate was 60.1 percentage points which was slightly lower than England (67.2) [27, 28]. As the employment rate of the general population was 66.9% in Hull and 73.9% in England (see the section on Labour Market and Benefit Claimants), this means that the employment rate of people in contact with secondary mental health services is around 7% in Hull which is similar to England. The excess under 75 mortality rate in adults aged 18-74 years with serious mental health is around 2.5 to three times higher than the general population [27, 103]. For the last two years, it has been lower than England and comparator areas. It would be anticipated that this might be higher given Hull’s deprivation. However, if the indicator relating to the percentage of people in contact with secondary mental health services in Hull is incorrect and too high, then this would likely affect this excess mortality indicator. So it is possible that this indicator is also incorrect.

What are the strategic needs?

People with mental illness need to be identified early and encouraged to seek help early so that the consequences in terms of the effects on family and employment are minimised. This will reduce the number of issues which escalate and so reduce the levels of need for crisis and/or medical interventions. For both children, young people and adults, help and support should be provided on an individual basis taking into account the person’s circumstances. This early help should be timely, appropriate and build in resilience to help people cope with life challenges. A culture across Hull that celebrates diversity, gives respect and has a zero tolerance on hate crime should be encouraged, so that people feel able to come forward and are not stigmatised by seeking help.

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. People need to be seen quickly and there is a real need to reduce waiting times.

Within Hull’s 2020 Programme, there is a Frailty and Isolation work stream, which aims to ensure “a range of services are provided across Hull to meet the needs of some of the most vulnerable in society, specifically this includes those such as dementia patients, elderly people, those with mental health and learning disabilities” [353].

Mental illness is very common, and is generally more debilitating than most chronic physical conditions, yet only a quarter of those with mental illness such as depression are in treatment. NHS England has established a Parity of Esteem Programme in order to focus effort and resources on improving clinical services and health outcomes so that “if I become unwell I use services which assess and treat mental health disorders or conditions on a par with physical health illnesses” [359]. There are three initial priorities for urgent focus: (i) improving access to psychological therapies; (ii) improving diagnosis and support for people with dementia; and (iii) improving awareness and focus on the duties within the Mental Capacity Act.

The Mental Health Crisis Care Concordat is a national agreement between services and agencies involved in the care and support of people in crisis. It sets out how organisations will work together better to make sure that people get the help they need when they are having a mental health crisis. Help is available for organisations and their partners to create and submit a mental health crisis declaration statement and an action plan to make the principles of the Crisis Care Concordat a reality in the local area [363].

The delivery model of Hull’s Early Help and Priority Families Strategy (see the JSNA Glossary for more information) aims to identifies individuals or families with problems (such as those with severe mental ill health) and brings together different services and agencies to collectively look at what support is needed and then work together to deliver the required support in an coordinated way. The aim is to improve outcomes for the entire family as well as reducing demand in the system on more costly, acute and specialist services.

This 2018 JSNA section on Severe Mental Ill Health (3 pages)
The full 2018 JSNA report (139 pages)
JSNA Toolkit: Mental Health and Learning Disabilities (375 pages)

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Suicide and Undetermined Injury

What’s the issue?

“A suicidal person may not ask for help, but that doesn’t mean that help isn’t wanted. Most people who take their own lives don’t want to die – they just want to stop hurting. Suicide prevention starts with recognising the warning signs and taking them seriously” [364], but recognising these signs is difficult. “Even mental health professionals find it hard to know when a person is particularly at risk. ‘Once a person has decided to take their life, they can go to great lengths to cover up their plans,’ says Professor Keith Hawton from the Centre for Suicide Research, University of Oxford” [365].

Suicide rates are highest among those aged 35-64 years (13.3 deaths per 100,000 for 2011-13 for England), with rates relatively uniform across other age groups (15-34 years: 7.9 deaths; 65-74 years: 7.2 deaths and 75+ years: 8.4 deaths per 100,000 population) [99]. So it affects people at younger ages compared to the majority of other medical diseases and medical conditions.

There are also huge effects on family and friends. “The loss of someone you’ve been close to, whatever the cause of their death, can bring intense feelings of grief. But losing someone through suicide can cause reactions and emotions that are different to those felt after death from illness, an accident or natural causes. The fact that a person’s death involved an element of choice raises painful questions. Shock, social isolation, feelings of intense guilt, self-blame and self-questioning can be greater when bereavement is caused by suicide than when it’s caused by other types of death. ‘The grieving process is characterised by questioning and a search for an explanation. Suicide is still a stigmatised topic, which can reinforce feelings of shame and stigma in the bereaved, and make the person feel worse and more isolated’, says Hawton” [365]. There is an increased risk of suicide, depression and admission to psychiatric care among those bereaved by suicide [366], and increased risk of a suicide attempt among those affected by a schoolmates suicide [367].

What’s our situation?

Over the period 2014-16, there were 92 deaths from suicide and undetermined injury in Hull. There is considerably year-on-year variability in the mortality rate from suicide and undetermined injury due to the relatively small number of deaths. Since 2001-03, the rate in Hull has been consistently higher than England (range 2.0 to 4.5 deaths per 100,000 population higher), although the rate in Hull has fallen at a slightly faster rate than England over this time period (–0.09 versus –0.01 deaths per year per 100,000 population) [27, 98, 99, 103, 116].

What are the strategic needs?

Reducing suicide involves a multi-factorial approach as the causes and reasons why people consider taking their own lives are complex. There is an increased risk with deprivation and poverty, and among those who have already presented for mental health issues. Unemployment, debt, problems with relationships, drug and alcohol abuse, child abuse, and a wide range of other factors can have an influence. There is a need to identify the most vulnerable citizens and work with them to address their specific needs. Strategies to reduce poverty, unemployment and crime levels, and improve educational attainment, health and resilience should have an influence on suicide.

People should be encouraged to seek help and support if they are considering taking their own life, and help should be given to families and friends so that they recognise the signs and have the support they need to help. Online training is also available [368].

There is a requirement for all local authorities to develop and implement a local plan which should include provision for bereaved families [369]. The suicide prevention strategy included six key areas: (i) reducing the risk of suicide in key high-risk groups; (ii) tailor approaches to improve mental health in specific groups; (iii) reduce access to the means to suicide; (iv) provide better information and support to those bereaved or affected by suicide; (v) support the media in delivering sensitive approaches to suicide and suicidal behaviour; and (vi) support research, data collection and monitoring [370]. Documents are available to help local authorities with this requirement [371, 372].

The Hull Mental Health and Suicide Prevention Plan was launched in November 2017 together with the Director of Public Health Annual Report. The aim is that “if suicide does occur, we react, learn and make changes as a system, to avoid it happening again” [7]. There are ongoing audits of suicide deaths with the intention learning and reducing future risk.

This 2018 JSNA section on Suicide and Undetermined Injury (2 pages)
The full 2018 JSNA report (139 pages)
JSNA Toolkit: Mental Health and Learning Disabilities (375 pages)

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Dementia and Alzheimer’s Disease

What’s the issue?

“Dementia is a common condition that affects about 800,000 people in the UK. The risk of developing dementia increases with age, and usually occurs in people aged 65+ years. Dementia is a syndrome (a group of related symptoms) associated with an ongoing decline of the brain and its abilities. This includes problems with memory loss, thinking speed, mental agility, language, understanding and judgement. People with dementia can become apathetic or uninterested in their usual activities, and have problems controlling their emotions. They may also find social situations challenging, lose interest in socialising, and aspects of their personality may change. They may lose empathy (understanding and compassion), may have hallucinations (see or hear things that other people do not), or may make false claims or statements. As dementia affects a person's mental abilities, they may find planning and organising difficult. Maintaining their independence may also become a problem. A person with dementia will therefore usually need help from friends or relatives, including help with decision making. Most types of dementia can't be cured, but if it is detected early there are ways you can slow it down and maintain mental function” [373].

With the ageing population, the numbers of people with dementia will increase. It is predicted that the numbers of people aged 65+ years with dementia in England will increase from an estimated 679,000 in 2015 to 1,073,500 by 2030, an increase of 58% [350].

Nationally, Alzheimer’s disease has the sixth highest disability adjusted life years (DALY – see the JSNA Glossary) and thus has a substantial impact on the quality of people's lives [102] as well as substantially affecting the lives of carers.

What’s our situation?

For 2016/17, the percentage diagnosed with dementia (on the GP disease registers) was second lowest out of seven comparator areas at 0.69% for Hull (range 0.77% to 0.91% for other six comparators and 0.64% for Leicester) [206]. There was no association between the diagnosed prevalence and deprivation. A total of 2,132 patients were on the dementia disease register in Hull. Based on modelling (October 2016), it is estimated that there are 2,740 practice patients with dementia. If the model is reasonably correct, then it suggests around 700 people in Hull have undiagnosed dementia. The diagnosis rate is estimated to be around 63% for Hull compared to 59% in England for 2014/15 [103, 116]. The same model estimates that around 2,611 people living in Hull aged 65+ years have dementia (excluding East Riding of Yorkshire residents registered with Hull GPs and Hull patients aged under 65 years), but this is projected to increase to 3,704 by 2030 [96].

During the three year period 2008/09 to 2010/11, there were 266,244 daycase and inpatient clinician episodes of which 306 (0.1%) had a primary diagnosis of dementia [116].

There were 496 dementia deaths (479 aged 75+ years) over the three year period 2012-14 giving a directly standardised mortality rate of 76.6 per 100,000 population having increased from a rate of 89.2 per 100,000 population for 2011-13 (with 441 deaths) [374]. There was a strong association between mortality and deprivation with mortality rates much higher in the more deprived fifth of areas of Hull (129 deaths per 100,000 population) compared to the least deprived fifth of areas of Hull (48 deaths per 100,000 population) [206, 374]. There are nursing homes in the more deprived areas of Hull, and this could partly explain the differences in the mortality rates among the most and least deprived areas. However, it could also mean that there is inequity present and/or a higher prevalence of undiagnosed dementia among those living in the most deprived areas (with the lack of an association between deprivation and prevalence on the GP disease registers).

What are the strategic needs?

Many of the disabling effects of dementia can be combated using the social model of disability, and Hull is seeking to become a Dementia Friendly City by providing advice and training to people providing universal services, such as bank and shop staff so that people with dementia can use local services independently, increasing their wellbeing and reducing their reliance on carers and on paid support. Making them feel empowered to have aspirations and feel confident, knowing they can contribute and participate in activities that are meaningful to them. There are four broad work streams: (i) stimulate demand and awareness; (ii) invest in early detection; (iii) access to treatment; and (iv) support to carers.

There is a need to work with partners to ensure that there is a shared understanding of people's needs and that services are integrated, high quality and accessible in ways that offer people appropriate choices such as care organised around care hubs. There is a need to work together 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 most vulnerable citizens should be identified so their specific needs are addressed in the way they wish. The new Care Act 2014 focuses around meeting needs and promoting wellbeing rather than simply the provision of services and on preventing, reducing or delaying the development of need, so individual needs should be assessed holistically within the context of their support network and each individual's circumstances considered to provide the most appropriate care, help and support for that individual. These individual needs will need to consider the caring arrangements, and how carers need to be supported in their role, and that their health needs do not suffer.

People (supported by their carers where necessary) should be encouraged to attend their NHS Health Check if they are eligible, and people already diagnosed with dementia 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 Dementia and Alzheimer’s Disease (2 pages)
The full 2018 JSNA report (139 pages)
JSNA Toolkit: Mental Health and Learning Disabilities (375 pages)

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Osteoporosis, Falls and Hip Fractures

What’s the issue?

“Osteoporosis is a condition that weakens bones, making them fragile and more likely to break. It’s a fairly common condition that affects around three million people in the UK. More than 300,000 people receive hospital treatment for fragility fractures every year as a result of osteoporosis” [375]. Osteoporosis can also be made worse by smoking [121]. Treatment for osteoporosis is based on treating and preventing fractures and using medication to strengthen bones [375]. Taking regular exercise, healthy eating including foods rich in calcium and vitamin D, giving up smoking and reducing alcohol intake can help reduce the risk of developing osteoporosis [375]. “Anyone can have a fall, but older people are more vulnerable than others. This is mainly because long-term health conditions increase the chances of a fall. Falls are a common but often overlooked cause of injury, and sometimes death. Around one in three adults over 65 who live at home will have at least one fall a year, and about half of these will have more frequent falls. Most falls do not result in serious injury, but there is a risk of problems such as broken bones. Falls can also have an adverse psychological impact on elderly people (losing confidence, becoming withdrawn, losing independence)” [376]. With the ageing population, it is predicted that the number of people in England aged 65+ years admitted to hospital as a result of a fall will increase [350]. Hip fractures can be very serious in older people. “Some people find it hard to recover after a hip fracture, up to one in three people die within 12 months (although most deaths aren't caused by the fall itself but by pre-existing illnesses)” [377]. “Over 70,000 hip fractures occur in the UK each year. The annual cost for all hip fractures in the UK, including medical and social care, is about £2 billion”[377].

Nationally, falls results in the ninth 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, 264 patients aged 50+ years were on the GP disease register (aged 50-74 years with a diagnosis of osteoporosis confirmed by a DXA scan or aged 75+ years with a fragility fracture on or after 1st April 2014) [206]. The prevalence in Hull at 0.26% was considerably lower than England (0.47%) and comparator areas.

Among those aged 65+ years, during 2015/16, there were 991 emergency hospital admissions for injuries related to falls (directly age standardised rate 2,681 per 100,000 population) [27]. The rate has increased from 2010/11 when it was 2,408 admissions per 100,000 population, and the gap between Hull and England had widened (from 282 to 511 admissions per 100,000 population). Admission rates in 2015/16 in Hull were higher among women than men (3,138 versus 2,030 per 100,000 population) and higher among those aged 80+ years compared to those aged 65-79 years (6,732 versus 1,284 per 100,000 population with 644 and 347 admissions respectively). In 2012/13, rates were twice as high in Myton, Newington and Southcoates West compared to Holderness, Pickering and Beverley [117, 374]. Among those aged 65+ years, 75 men and 215 women were admitted with hip fractures during 2014/15 giving an age standardised rate of 783 per 100,000 population). The number of admissions were highest among older people (157 for women and 44 for men aged 80+ years, and 58 for women and 31 for men aged 65-79 years) [27]. In 2012/13, admission rates were three times higher in Bransholme East and King's Park compared to Pickering, Marfleet and Bricknell [103, 374].

What are the strategic needs?

Exercise and physical activity can improve strength and balance and reduce the likelihood of falls. Among those at risk of a fall, risk can be reduced by removing hazards from the home, and having regular sight tests and hearing tests [375]. Steps could include using walking sticks and other walking aids, using non-slip mats in the bathroom, mopping up spills to avoid wet floors, getting help lifting and moving items, removing clutter from the home, ensuring the home is properly lit, etc. People at risk of a fall can request a home hazard assessment. Age UK also offer advice about adapting the home so older people can remain independent and safe in their own home [378]. The National Institute for Health and Care Excellence recommend a co-ordinated programme of care for people who have fractured a hip [379].

This 2018 JSNA section on Osteoporosis, Falls and Hip Fractures (2 pages)
The full 2018 JSNA report (139 pages)
JSNA Toolkit: Older People (203 pages)

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Palliative Care and End of Life Care

What’s the issue?

The aim of palliative care and end of life services is to enable patients with advancing progressive life limiting illness to be cared for and to die in their preferred place of care with optimal pain and symptom management, supported by skilled staff. It is generally recognised that too many people die in hospital and that this might not be their preferred place of death, and a proportion of these people might prefer to die at home provided that the right care is in place.

What’s our situation?

The palliative care disease register was introduced in 2006/07 and Hull practices had 268 (0.09%) of registered patients on the register, and this has steadily increased to 741 (0.25%) for 2016/17, but is lower than England (0.34%) and among the lowest of seven comparator areas (range 0.25% to 0.56%) [206]. There was a statistically significant increasing trend in the prevalence with increasing deprivation [380].

The eight practices with the highest mean patient deprivation scores serving the most deprived fifth of Hull’s population had a prevalence of 0.48% compared to 0.16% among the nine practices with the lowest mean patient deprived scores [206, 380].

Modelling suggests that three times as many patients require palliative care than are on the palliative care registers, and if the model is accurate then there are a high proportion of patients who are not receiving the care they need [380].

Since 2001-03, the percentage of people dying in their own home has steadily increased in Hull from 17.2% in 2001-03 and just under 17% between 2002-04 and 2004-06 to 22.3% in 2012-14 and 22.4% in 2013-15. This has mainly due to a fall in the percentage of death occurring in hospital which has decreased from over 60% between 2001-03 to 2009-11 (range 60.3% to 63.9%) to 57.1% in 2010-12, 53.5% in 2011-13, 51.6% in 2012-14 and 50.6% in 2013-15.

The percentage of deaths occurring in care homes was just over 16% between 2001-03 and 2003-05, but fell to a low of 13.2% in 2008-10, but has gradually increased to 19.2% in 2013-15. The percentage of deaths occurring in a hospice followed a similar pattern, and was 4.0% in 2001-03, before falling to a low of 3.0% in 2004-06 and 2005-07 before gradually increasing to 5.6% in 2013-15. The percentage of deaths occurring elsewhere has been relatively consistent over this time period ranging from 2.0% to 2.5%, and for the latest period 2013-15 was 2.2% areas [98, 380, 381].

What are the strategic needs?

There is a need to work with partners to ensure that palliative and end of life care services are integrated, high quality and accessible in ways that offer people appropriate choices. There is a need to work with partners to promote self-care and mutual support in community settings including hospices and the patient’s home so this is viewed as the norm and reduce reliance on residential or care homes. There is a need to reduce inappropriate hospital admissions and to ensure robust and effective “wrap around care” covering 24 hours and to focus on earlier advance care planning which respects individual needs and allows for people’s cultural and religious preferences. Advice and support needs to be timely, and advice and support around other areas which can cause stress, such as housing and benefits, would be of benefit to individual and their families. This in turn will improve quality of end of life and ensures that people receive care in their preferred place and die in their preferred place. In order to achieve this it is imperative that we have a suitably skilled and competent workforce delivering high quality care supported through a comprehensive end of life care education programme.

This 2018 JSNA section on Palliative Care and End of Life Care (2 pages)
The full 2018 JSNA report (139 pages)
JSNA Toolkit: Palliative Care (82 pages)

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