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Joint Strategic Needs Assessment 2018


Further Information

This section provides information on abbreviations and terminology used, as well as further additional information on relevant topic such as Clinical Commissioning Groups, Joint Strategic Needs Assessment, local surveys completed, comparator areas, the Public Health Outcomes Framework, screening programmes, etc.

The abbreviations / glossary section is then followed by a full list of references.

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Abbreviations / Glossary

A full list of abbreviations and complete glossary is also available at www.hullpublichealth.org/jsnatoolkit.html

AAA – Abdominal Aortic Aneurysm.

Alcohol-attributable fractions (for hospital admissions and mortality) – Each hospital admission or death is assigned an ‘alcohol attributable fraction’ (AAF) which has been determined through research and analysis of hospital admission and death data nationally.  It is not based on ‘real’ data (with the exception of alcohol-specific conditions), and only represents a modelled estimate of the numbers and rates of alcohol-related admissions and deaths.  The AAF values ranges from zero to one.  The AAF are based on quite rigorous research, so are probably quite accurate, but the estimated number and percentages of alcohol-related admissions and deaths can differ substantially depending on whether all secondary diagnoses codes are used in calculating the AAF for a specific admission or death, or just some secondary diagnoses codes such as those relating to external sources.  There are different AAF values depending on whether admissions or deaths are being considered, and the following text refers to admissions only for simplicity, but the same methodology and calculations apply to deaths.  Different AAF values are assigned on the basis of the diagnosis codes for different age groups, and the value of the AAF often differ between males and females.  It is relatively easy (and accurate) to assign an AAF to conditions that are entirely due to alcohol such as alcoholic liver disease and ethanol poisoning (assigned a value of 1).  Some conditions will be assigned a value of zero as there is no current evidence that they are alcohol-related.  Virtually all admissions among children and young people are assigned a value of zero.  Other specific conditions where there is evidence that alcohol is (sometimes) involved or is a contributing factor will be assigned an AAF value between zero and one.  For instance, the AAF value of 0.19 has been assigned to colorectal cancer admissions among men aged 45-54 years denoting that around 19% of the disease is estimated to be attributable to alcohol, and admissions for road or pedestrian traffic accidents have an AAF value of 0.31 for men aged 25-34 years denoting that around 31% of these admission are attributable to alcohol.  Admissions have a primary diagnosis code and can have numerous secondary diagnoses codes.  Each admission is assigned an AAF which is the maximum AAF of the AAF for the primary diagnosis and the AAFs for some or all of the secondary diagnoses.  For many admissions, the maximum AAF of the primary and secondary diagnoses will be zero.  All these individual AAFs can be summed over all admissions over a specific period of time, to estimate the total number of admissions that are alcohol-related.  For instance, in the three examples above with AAF values of 1, 0.19 and 0.31, there would be three admissions in total and 1.5 alcohol-related admissions.  The Alcohol Profiles [382] use these AAFs to estimate the number of hospital admissions (and deaths) for each local authority that are alcohol-related.  There are three main methods of assigning the AAFs within the Alcohol Profiles: (i) alcohol-specific admissions where any of the primary diagnosis or secondary diagnosis codes relate to an alcohol-specific condition (where AF is one), i.e. where primary diagnosis or any of secondary diagnoses are for alcohol-specific conditions, such as alcoholic liver disease or ethanol poisoning; (ii) alcohol-related admissions “narrow measure” where individual admissions are assigned an AAF based on the primary diagnosis code and only secondary diagnoses codes that are due to an external cause such as a road traffic accident, intentional self-harm, fire, assault, fall, etc.; and (iii) alcohol-related admissions “broad measure” where individual admissions are assigned an AAF based on the primary diagnosis code and all secondary diagnosis codes.  The alcohol consumption section of this report (see the JSNA section on Alcohol Consumption) uses the alcohol-specific and narrow alcohol-related measures.

AIDS – Acquired immunodeficiency syndrome.

Apoliopoprotein - Apoliopoprotein B is the main apolipoprotein of chylomicrons and low density lipoproteins (LDL) “bad cholesterol” and apoliopoprotin A1 is the major protein component of high density lipoproteins (HDL) “good cholesterol”.

Asset-based approach – see the section on social capital and asset based approach

BCG – Bacille de Calmette et Guérin (BCG vaccine for tuberculosis).

Bias – In general, in statistics, one wishes to find out about the population, but cannot sample all individuals from that population so a sample of individuals from that population is used with the aim of generalising the findings from that sample to the overall population.  This can only be done well if the sampling and research process is free from bias.  “Biases can be introduced at each stage of the research process.  Systematic errors are potentially serious and can lead to bias and invalid conclusions.  An example of a systematic error is where a nurse always measures blood pressure lower than colleagues.  Random errors give rise to reduced precision but not in general to validity.  Random errors can occur through data collection through questionnaire or equipment faults, observer error, responder mistakes, during data processing through coding, copying, data entry, programming and calculating errors.  There are three main types of bias: selection bias; confounding bias and information bias.  Selection bias occurs when the selected subjects (for the sample) differ in some systematic way from those not selected.  This could be through high survey non-response, loss to follow-up of inappropriate choice of sampling frame (a list from which your sample is drawn) or sample.  It can also occur through inappropriate choice of comparison group.  Confounding bias occurs when researchers have failed to take into account an unknown or unrecorded factor that is associated with both the two factors being examined in the research (see confounding below).  Age, gender, deprivation and socio-economic status are some common confounders.  Information bias occurs due to systematically incorrect measurements or responses, or misclassifications of disease or exposure status which can result from questionnaire faults (culturally inappropriate questions, ambiguous wording, too many questions, etc.), observer errors (misunderstanding of procedures, misinterpretation, interviewer bias, etc.), responder errors (misunderstanding, faulty recall, wanting to give the ‘right’ answer, embarrassment, suspicion, etc.) and instrument errors (faulty calibration, incorrect dilution, inaccurate diagnostic tests, etc.)” [383].

BMI - Body mass index.  Definitions of underweight, desirable weight, overweight and obesity among both adults and children are defined on the basis of the body mass index (BMI) which is a measure of the weight to height ratio.  It is calculated by taking the weight (in kilograms) and dividing it by the square of height (in metres).  Among adults, underweight is defined as having a BMI of either less than 18.5 or less than 20, overweight is defined as having a BMI of 25 or more, obese is defined as having a BMI of 30 or more, and morbidly obese is defined as having a BMI of 40 or more.  Among children, the cut-off values to define overweight and obesity differ depending on the age and gender of the child.  The cut-off values are based on 1990 reference curves [384] and defined on the basis of centiles.  Underweight was defined as a BMI less than or equal to the second centile, healthy weight as a BMI above the second centile but less than the 85th centile, overweight as a BMI the 85th centile or above but less than the 95th centile, and obese as a BMI the 95th centile or higher [385].  Thus in 1990, 2% of all children were defined as underweight, 15% as overweight and 5% as obese.

BNP – Brain natriuretic peptide.  Both BNP and NT Pro BNP (see below) levels in the blood are used for screening, diagnosis of acute congestive heart failure and may be useful to establish prognosis in heart failure, as both markers are typically higher in patients with worse outcome.

Causality – Just because an association has been found to exist between two factors does not necessarily imply there is causality.  For example, you could find an association between the prevalence of a disease like lung cancer in relation to exposure to a risk factors like smoking.  In order to examine causality in more detail, firstly, it is useful to assess if the relationship is valid?  There are three main questions to address related to chance (see statistical testing below), bias (see above) and confounding (see below).  If you then consider the relationship valid, there are numerous other factors to consider in relation to starting to make the case for causality such as temporality (exposure must precede the disease or factor being examined [For instance, ex-smokers often have higher mortality rates compared to current smokers after surgery.  Does this mean that quitting smoking is bad?  No, it just means that their exposure occurred before they quit.  The ones that quit had the poorest health prior to surgery and were more likely to quit prior to surgery following medical advice.  Current smokers may have smoked less and have been in better health prior to surger]), strength of relationship (the stronger the association the more likely it is causal), plausibility (proper scientific explanation whey exposure might cause the disease), experimental evidence (stopping the exposure should stop the disease), biological gradient (higher exposure levels leads to a higher likelihood of disease), consistency with other research and evidence, specificity (causality argument helped if exposure is associated with a specific disease as opposed to a wide range of diseases), coherence (consistent with national history of disease, e.g. lung cancer rates higher in countries where more people smoke), and analogy (causality argument also helped if scientific mechanisms can be examined as further evidence).  Thus if an association or relationship is found between two or more factors, it does not necessary mean it is causal.

CCG – NHS Hull Clinical Commissioning Group.  NHS Hull CCG has responsibility for the commissioning of health services to meet the health needs of the people of Hull.  Prior to 2013, Primary Care Trusts (PCTs) had this responsibility.  CCGs have a statutory responsibility for commissioning most NHS services including urgent and emergency care, acute care, mental health and community services. Increasingly they are also involved in commissioning primary care and some specialised services.

CHD – Coronary Heart Disease (also called ischaemic heart disease).

CI – Confidence Interval.  A confidence interval (CI), calculated using statistical methods, gives a range of likely values for the parameter of interest (e.g. average, percentage or mortality rate).  There is usually random variation present, such as variation in the number of deaths each year, and it is useful to have a range for the parameter of interest as well as a single value to get an idea of the range of the likely values and the degree of variability.  The usual CI calculated is the 95% CI, in which we are 95% confident that the interval obtained (from the sample) will contain the true underlying measure of interest (of your population of interest).  The interval also takes into consideration the number of people on which the estimate is based, so that if there are many people surveyed the interval tends to be narrower (and therefore more useful).  If the CI is wide then there is a high degree of uncertainty around the parameter of interest, and caution should be used when interpreting the findings.

City of Culture 2017 – In November 2013, Hull was announced the winner of the UK City of Culture 2017.  “The award is given every four years to a city that demonstrates the belief that the transformational power of culture.  Hull City Council set up Hull UK City of Culture 2017 as an independent company and charitable trust.  The arts and cultural programme for 2017 celebrates the unique character of the city, its people, history and geography.  Each of the four seasons of the programme has “something distinctive and intriguing, created to challenge and thrill”. The team are working with artists of Hull to celebrate the culture of the city and its place in the wider cultural offer of the North making Hull a cultural destination for must-see events.  Young people are at the heart of the programme, and thousands of volunteers are helping deliver the cultural programme in 2017.  Working with businesses and organisations, the aim is to make Hull a better place for the people who live and work in Hull.  Multi-million pound investments have revitalised and transformed the city centre” [9].  “The team behind Hull's tenure as UK City of Culture 2017 have revealed plans to ensure the year-long celebration leaves a lasting legacy.  Since Hull was confirmed as the host of next year's initiative back in 2013, investments of more than £1 billion have flowed into the city, creating thousands of jobs, and over £3 billion in total from public and private investment that is currently being developed, in delivery or have been completed.  These include plans by Siemens to build a £310m offshore wind manufacturing plant at Alexandra Dock, the £200m Energy Works development opened by Spencer Group, RB's (Reckitt Benckiser) £100m investment in a research and development centre, £200m at the University of Hull, £90m in Fast Lightstream from KCOM, £50m in a Smith and Nephew medical devices centre, £25m in a new Hilton Hotel, £20m in expansion and redesign of Princes Quay shopping centre, £20m investment in Atlas Leisure at Priory Park, £80m in the redevelopment of the Fruit Market area of the city, £9m in Kreate Training and Enterprise Centre, and £11m in Ron Dearing University Technical College.  Now, a ten-year Cultural Strategy 2016-2026 has been launched in a bid to sustain the economic boom.  The strategy will "put culture and the arts at the heart of Hull's regeneration and development" with a view to establishing a sustainable visitor economy in the city.  A new partnership will be established and tasked with developing plans to capitalise on the city's maritime and international connectivity. It will also shape an "ambitious, distinctive artistic and cultural programme" for 2018 and beyond.  The partnership's priorities will include making Hull Old Town a UNESCO World Heritage site and securing a £30m funding bid for projects which will allow the Hull to exploit its historic role as Yorkshire's maritime city.  Further infrastructure projects would include £50m investment to build a cruise terminal and the delivery of the £194m Highways England scheme to improve the A63.  With a £2.6m legacy fund already established by Hull City Council and the Hull 2017 Company, work to develop Hull's 2018 programme has begun” [386].  Legacy has been embedded in every stage of the UK City of Culture journey and has been the topic of the 2016 Director of Public Health Annual report [6].  “Projects and initiatives set to be in place for Hull UK City of Culture include improved facilities at the Ferens Art Gallery and Hull New Theatre, the new 3,500-seat Hull Venue, a transformed public realm, a revitalised Fruit Market and waterfront, and the preservation and enhancement of some of the city's most important historic sites and buildings” [386].

Nine in ten people in Hull have taken part in City of Culture events and there are 300,000 volunteer hours to date (November 2017).  Ferens art gallery and museums have had 1,200,000 visitors up to September 2017 with hotel occupancy at 88%, and 13% more rail passenger journeys.

City Plan – As quoted in Hull’s evolving City Plan [2] “Exciting plans and multi-million pound investments are revitalising Hull – capitalising on the city’s position at the heart of the UK’s biggest port complex and its role as UK City of Culture 2017.

The evolving City Plan aims to bring the whole community together to make Hull a place that is brimming with culture, enterprise and opportunity; a place where people want to live, work, play, study and do business; a city where those in the greatest need are valued and supported; a place that people will be proud to call home.

Launched in the summer of 2013, the City Plan aims to create 7,500 jobs for local people through projects and investments that will drive the delivery of a clear set of ambitions.

Achieving these ambitions will help Hull seize the once-in-a-generation opportunity it now has to reassert its role as a gateway to Europe and part of the Northern Powerhouse of cities that will help to rebalance the economic, social and cultural fabric of the UK.

The ambitions cover both economic growth around making Hull UK’s energy city and increasing visitor numbers, and inclusive growth by supporting the most vulnerable with three themes of: (1)  UK Energy City – As the city at the heart of the UK’s biggest port complex and home to Europe’s biggest wind turbine manufacturing plant, Hull is on its way to becoming a leading hub for renewable energy industries;  (2) Destination Hull – The city’s proud heritage, its role as UK City of Culture 2017 and the multi-million pound investments now being delivered in our cultural and tourism infrastructure, are major steps towards realising Hull’s long-term ambition to become a world-class visitor destination;.  (3) Community and Opportunity – Hull aims to be a place of opportunity for all, as highlighted by three City Plan ambitions designed to build strong, resilient communities by focusing on: (i) safeguarding the most vulnerable; (ii) prevention and early intervention; and (iii) making money go further” [2].

Since the launch of the City Plan 2013, more than £3 billion of public and private investment is currently being developed, in delivery or has been completed (see City of Culture above for more information).

CLeaR – Public Health England have published a handbook illustrating good practice around three areas: Challenge Service (C), Leadership (Lea) and Results (R) to help Local Priorities [387].  Hull took part in a CLeaR tobacco control peer assessment in 2017 which examined local information, services, leadership and results around tobacco control.

COMEAP – Committee on the Medical Effects of Air Pollutants.

Comparator geographical areas – As Hull is much more deprived than the national average, the majority of indicators associated with employment, housing, crime, educational attainment, prevalence of risk factors, health status, mortality rates, etc. will generally be worse in Hull than England.  Therefore, it is difficult to assess the degree to which the indicator might be worse than England given Hull’s deprivation, and as a result it is often useful to compare indicators with geographical areas that have similar characteristics as Hull.  However, no two geographical areas are extremely similar in terms of population size, age structure of population, deprivation, ethnicity, housing, the economy and labour market, etc.  In practice, different people and organisations have grouped different geographical areas together in order to try to assess similarity of different geographical areas, and in doing so have generally used slightly different measures to assess similarity.  As a result, there are a number of different ‘sets’ of geographical areas that are quoted as being similar to Hull.  In the local Joint Strategic Needs Assessment (JSNA) Toolkit reports (from Release 4), a consistent set of comparator areas have been used, although a subset have been used when examining NHS data (e.g. disease prevalence information from the Quality and Outcomes Framework) as the Clinical Commissioning Group (CCG) boundaries do not necessary match historical boundaries of previous Primary Care Trusts.  The comparators areas used here have also been used in local analyses of the Public Health Outcomes Framework data.  The comparator areas used in this report are Coventry, Derby, Leicester, Middlesbrough, North East Lincolnshire, Plymouth, Salford, Sandwell, Stoke-on-Trent, Sunderland and Wolverhampton.  For NHS comparisons, Leicester, North East Lincolnshire, Salford, South Tees, Stoke-on-Trent, Sunderland and Wolverhampton have been used.  The boundaries of Middlesbrough local authority and Redcar and Cleveland local authority form South Tees CCG (Redcar and Cleveland is not one of the comparator areas used in the JSNA, but it is similar to Hull and has been included in ‘sets’ of comparators for Hull by others).  These 11 comparator areas are not the same as those often used within Hull City Council as the criteria and aims are different, e.g. local authority comparators take into account information less relevant to health such as local authority financial information.

Confounding – Confounding occurs when another factor (or factors) influences the association of interest.  This occurs when this other factor is associated with both the risk factor of interest and the outcome of interest.  For example, if examining the association between alcohol consumption and lung cancer mortality, it might be that an association is found.  However, smoking is a confounder.  There is an association between smoking and alcohol consumption as people who tend to smoke also tend to drink more alcohol.  There is also an association between smoking and lung cancer mortality, therefore, it is possible that there is no real association between alcohol consumption and lung cancer mortality and smoking is acting as a confounder.  Failure to take into account or consider smoking when examining this association can lead to biased results – known as confounding bias.  Age, gender and deprivation are frequently related to the prevalence of behavioural risk factors, and poor health and mortality are also associated with age, gender and deprivation.  Therefore, any of these factors can act as confounders when examining the relationship between risk factors and poor health.  Therefore, examining the relationship between two factors is not straightforward, and can be further complicated by effect modification and interaction (see effect modification and interaction below for more information on these topics).

Connect Well Hull – A Social Prescribing Service which offers advice and will help residents help access support and guidance on a range of issues – providing Choice (“helping you feel more linked in with your community”), Advice (“helping you on issues such as money, benefits and housing”), Support (“helping you with physical or emotional difficulties”) and Active (“helping you get active and feel better”).  Connect Well Hull is a friendly, free and confidential service for people who live in Hull or are registered with a Hull GP.

COPD – Chronic Obstructive Pulmonary Disease.

CVD – Cardiovascular Disease (also called Circulatory Disease).

DALY – Disability Adjusted Life Years. This measures the years of life lost (YLL) for each person who dies prematurely (before the age of 75 years) taking into account the quality of life. It is similar to quality adjusted life years (QALY – see below) where the quality of the life is taken into consideration as well as the duration of life. In the calculation of YLL, if 1,000 people die from a particular medical condition, 10 of them prematurely at an average age of 67 years (eight years prior to age 75 years) then the average YLL per person would be eight years, and the total YLL over all persons would be 80. However, if disability adjusted life years is estimated instead, then a measure of disability if required. This is frequently estimated using statistical modelling. The DALY is the sum of the YLL plus the years of life lost through disability (YLD). This is the number of years lost through the person being disabled in some way by having the disease or medical condition. Also see quality adjusted life years (QALY), years of life lost (YLL) and life expectancy (as healthy life expectancy uses quality of life) below.

DEFRA – Department for Environment, Food and Rural Affairs’.

Deprivation – See Index of Multiple Deprivation (IMD) below.

DSR – Directly Standardised Rate.  Mortality rates, hospital admission rates and other rates can be calculated for different geographical areas.  For example, a mortality rate would be calculated as the number of deaths out of the total population, and could be expressed as the number of deaths per 100,000 population, and thus the deaths divided by the population figure is then multiplied by 100,000.  Often it is useful to compare the resulting rates with other geographical areas to ascertain whether the rate is particularly high or low in relation to the national rate (e.g. the rate for England) or in relation to similar geographical areas (e.g. in terms of deprivation).  However, when rates from two or more different geographical areas are compared, any differences among the rates could be due to differences in the age and gender structure of the populations.  For two areas with a population of 100,000, the geographical area with the older population would tend to have a higher mortality rate.  It is possible to ‘standardise’ the rate using a standard population to ‘adjust’ the resulting rate so differences in the age (and gender) population structures are taken into account.  Indirect standardisation produces a Standardised Mortality Ratio (see SMR).  Direct standardisation produces a Directly Standardised Rate (DSR).  The DSR involves applying the rates of condition (deaths, admissions, disease prevalence etc.) observed in the study or local population to a ‘standard’ population.  For example, when calculating a directly standardise mortality rate this would involve calculating the number of deaths that would have occurred in the standard population if the age-specific (mortality) rates of the local population were applied to the standard population.  The DSR is generally standardised to the European Standard Population (the most recent version is the ESP 2013).  When the DSR is referred to within this document, it is generally referring to a mortality rate.  All mortality DSRs within this document are standardised to the ESP 2013, and are given as the number of deaths per 100,000 population (essentially the number of deaths that would have occurred within the ESP per 100,000 population).  Once the DSR has been produced for a specific time period, it is not necessary to recalculate it when new data is available (for the next period of time) as nothing has changed, although this is not the case when using indirect standardisation (see SMR).

.DTP – Diphtheria, Tetanus and Pertussis (whooping cough) vaccine given to one and two year old children.

Early Help and Priorities Family Strategy – 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]. It also sets out information related to the Troubled Families Programme which is a national programme, and in Hull the programme is called the Priority Family Programme. "The Early Help delivery model aims to identifies individuals or families with problems 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, thus improving outcomes for families and reducing demand in the system on more costly, acute and specialist services. The local strategy was developed with input from a wide range of partner agencies across Hull whose close collaboration and alignment is necessary to ensure an effective early help delivery model is embedded across the city" [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: (i) no additional needs which is the universal response to build resilience in children and young people; (ii) additional needs involving prevention and early help; (iii) complex needs involving a targeted response of early help and interventions; and (iv) risk of significant harm which includes child protection procedures and safeguarding services. The strategy describes the delivery model, the integrated delivery network, and the analysis of need, gaps and capacity of the service delivery model, as well as evidence-based programmes, Priority Families and performance.

Effect modification – It is possible that one factor modifies the effect of one factor on another (effect modification). For example, it could be that there is a strong association between two factors at younger ages, but at older ages the association could disappear. Age is modifying the association between the two factors of interest. Therefore, examining the relationship between two factors is not straightforward, and can be further complicated by confounding and interaction (see confounding above and interaction below for more information on these topics).

ESP – European Standard Population. This is a fictitious population used in the calculation of directly standardised mortality rates (see DSR). The DSR is a mortality rate which has been standardised to take into account differences in the age (and gender) structure of the population. If the age (and gender) structure of the populations are not taken into consideration, then any differences in the mortality rates between the two populations could be potentially explained by differences in the age (and gender) structures of the populations. This 'standardisation' allows two mortality rates to be compared on a like-for-like basis. The standard population for comparison of DSRs is usually the ESP. The ESP was updated in 2013, and the majority of analyses present DSRs standardised to the ESP 2013. However, some reported analyses use the previous ESP produced in 1976. A higher proportion of older people occur in the fictitious ESP 2013 compared to the ESP 1976 to reflect the aging population. This greatly affects the resulting DSRs, and can have a dramatic effect as illustrated in local analyses [381].

Excess Winter Mortality Index - Ratio of winter (December to March) to non-winter (April to July current year and August to November previous year) deaths, e.g. 275 winter and 230 non-winter monthly average deaths gives index of 19.6 (275÷230=1.196).

FAST – Face: "has their face fallen on one side?" – Arms: "can they raise both arms and keep them there?" – Speech: "is their speech slurred?" – Time: "time to call 999 if you see any single one of these signs".

FH – Familial hypercholesterolaemia.  An inherited condition which results in a high cholesterol concentration in the blood which increases the risk of coronary heart disease and other cardiovascular events.

Health and Wellbeing Board – “The Health and Social Care Act 2012 establishes health and wellbeing boards as a forum where key leaders from the health and care system work together to improve the health and wellbeing of their local population and reduce health inequalities. Health and wellbeing board members will collaborate to understand their local community's needs, agree priorities and encourage commissioners to work in a more joined-up way.  As a result, patients and the public should experience more joined-up services from the NHS and local councils in the future.  Each top tier and unitary Local Authority has established its own health and wellbeing board in shadow form from April 2012.  Boards will take on their statutory functions from April 2013.  The Health and Social Care Bill mandates a minimum membership of: a local elected council member, the director of public health for the local authority and representatives of the local Healthwatch organisation, local clinical commissioning group, director for adult social services, director for children's services and director of public health” [388].  Also see Joint Health and Wellbeing Strategy (JHWS).

HJealth Life Expectancy – see Life Expectancy.

Hib – Haemophilus Influenza type b vaccine given to one and two year old children.

HIV – Human immunodeficiency virus.

HPV – Human Papillomavirus (types 16 and 18) vaccine given to young girls.

IHD – Ischaemic Heart Disease (also called coronary heart disease).

IMD – Index of Multiple Deprivation.  The IMD 2015 [26] score is a measure of deprivation produced nationally and derived for each lower layer super output area (LLSOA; geographical area which is described in more detail below) in England. The IMD 2015 is based on seven domains which are weighted according to their relative importance in relation to the overall score (weights in brackets): (i) income deprivation (22.5%); (ii) employment deprivation (22.5%); (iii) health deprivation and disability (13.5%); (iv) education, skills and training deprivation (13.5%); (v) barriers to housing and services (9.3%); (vi) living environment deprivation (9.3%); and (vii) crime (9.3%). The IMD 2015 score measures deprivation, but is not such a good measure of affluence. As it is applied to a geographical area, it relates to average levels of deprivation within an area. Therefore, there may be some residents of the area who are very much more deprived or very much better-off relative to the average. A high score denotes more deprivation. Hull has a high IMD 2015 score and is ranked as the 3rd most deprived local authority out of 326 across England. The scores are often classified into groups, and different characteristics, indicators and measures can be compared among people living in different LLSOAs which have different IMD 2015 scores. The deprivation scores are frequently divided into five or ten groups. These groups can be determined at a national or local level. For instance, 87 (52%) of Hull's 166 LLSOAs fall within the bottom or most deprived 20% (fifth) of England's LLSOAs, and there is only one (0.6%) of Hull's LLSOAs in the least deprived fifth of areas of England. As so few of Hull's LLSOAs fall within the least deprived areas nationally, it is not sensible to examine deprivation in relation to the national groupings (as the numbers of people, events, deaths, hospital admissions are too small among those living in the least deprived national fifth of areas). As a result, deprivation is generally examined within this JSNA and the JSNA Toolkit reports in relation to locally deprived fifths. Thus the 166 LLSOAs are grouped based on their deprivation scores into five groups from the most deprived fifth locally to the least deprived fifth locally. Characteristics can then be compared across these five groups, such as life expectancy, mortality rates, smoking prevalence, hospital admissions, etc.

Incidence – The incidence rate is the rate at which new events occur in a population. The numerator is the number of new events that occur in a defined period or other physical span. The denominator is the population at risk of experiencing the event during this period, sometimes expressed as person-time; it may instead be in other units, such as passenger-miles. "The number of instances of illness commencing, or of persons falling ill, during a given period in a specified population. More generally, the number of new health-related events in a defined population within a specified period of time. It may be measured as a frequency count, a rate, or a proportion" [389]. Also see Prevalence.

Interaction – Interaction between two different factors can occur which influence the relationship with another factor. For example, there could be twice the risk of developing a disease for a smoker compared to a non-smoker, and twice the risk of developing the same disease if the person is overweight compared to someone who is within the 'desirable' weight category, but for an overweight smoker the risk of developing the disease may be ten times greater than a person who is a non-smoker and not overweight. This type of effect occurs for oral cancers, where the risk among smokers who drink alcohol is much higher than either one alone. Therefore, examining the relationship between two factors is not straightforward, and can be further complicated by confounding and effect modification (see confounding and effect modification above for more information on these topics).

IPV – Inactivated Polio Vaccine given to one and two year old children.

JHWS – Joint Health and Wellbeing Strategy. "The Health and Wellbeing Board has a responsibility for producing a JHWS. Priority areas identified from the Joint Strategic Needs Assessment are key for the development of joint strategies which in turn feed into commissioning plans. As part of the prioritisation process, Health and Wellbeing Boards will also need to look at which areas need de-prioritisation and de-commissioning" [388]. Hull's Health and Wellbeing Board Strategy 2014-2010 [1] has strong links with the City Plan [2] and had strong links to Hull's 2020 Vision [353, 390], although Hull's 2020 Vision has been superseded by the Sustainability and Transformation Partnerships (STP). Within Hull's Health and Wellbeing Board Strategy 2014-2010, there are three broad overarching outcomes outlined in the strategy: (1) the best start in life; (2) healthier, longer, happy lives; and (3) safe and independent lives. Within the strategy it is acknowledged that "This strategy cannot be delivered without the commitment of everyone who lives or works in Hull and cares about its future. The strategy sets out how we can work together to reduce health inequalities and improve people's health. It describes where we want to get to and how we will do it." [1].

JSIA – Joint Strategic Intelligence Assessment. "In 2006, a review of the Crime and Disorder Act 1998 [391] lead to a requirement to produce a detailed Crime and Disorder audit; consult with key agencies and the wider community; use the findings to identify strategic priorities and set targets and performance measures. The legislation requires partnerships to include the following components in a Strategic Assessment: analysis of the levels and patterns of crime, disorder and substance misuse; changes in the levels and patterns of crime, disorder and substance misuse since the last strategic assessment; analysis of why these changes have occurred; and assessment of the extent to which last year's plan was implemented. The purpose of the JSIA is to provide knowledge and understanding of community safety problems that will inform and enable the partners to: understand the patterns, trends and shifts relating to crime, disorder and substance misuse; set priorities for their partnership; develop activity that is driven by reliable intelligence and meets the needs of the local community; and deploy resources effectively and present value for money" [392].

JSNA – Joint Strategic Needs Assessment. "The Health and Wellbeing Board has a responsibility for producing a JSNA which provides local policy-makers and commissioners with a profile of the health and well-being needs of the local population. The aim of JSNAs is to improve commissioning and reduce health inequalities by identifying current and future health trends within a local population" [388].

KSI – Killed or seriously injured (in the context of KSI on the roads).

Life Expectancy – Life expectancy at birth is a commonly used method of assessing health, improvements in health over time, and differences in health between different groups (defined on the basis of geography, deprivation, social class, smoking status, etc.). A common misconception is that life expectancy at birth measures the expected or average duration of life of a newborn; it does not. It is a measure of life expectancy assuming that the current age-specific mortality rates continue throughout an entire lifetime. Advances in healthcare, changes in political and social circumstances, changes in the prevalence of risk factors and changes in diseases and medical conditions (such as acquired immunodeficiency syndrome (AIDS), bird 'flu, diseases resistant to antibiotics, etc.) and many other factors which influence health and life expectancy cannot be anticipated, so it is not possible to predict mortality rates for each age group in the future. This is particularly the case for newborns, as the future mortality rate in 90 years' time when that person is 90 years of age would need to be estimated. Life expectancy at birth is frequently used, but it is possible to calculate life expectancy at any age. For example, life expectancy at age 65 years could be calculated. This will tend to be closer to the true or actual duration of life than life expectancy at birth would be for a newborn. This is because trends in mortality rates will tend to be reasonably gradual, so that the current rates of mortality (on which life expectancy calculation is based) might be a reasonable prediction of mortality rates in the next 20 years or so (but not of the next 80 years or so, which is the assumption required for life expectancy at birth). Life expectancy at birth is calculated for an arbitrary 100,000 males or females and is the average of how long they will live based on current actual age-specific mortality rates. For example, if the mortality rate within the first age of life was 5 deaths per 1,000 live births, then this would equate to 500 deaths in our arbitrary 100,000 population at one year. Their 'contribution' to the life expectancy calculation might be 0.1 years or 50 years in total (as many of the infants who die within their first year of life die within the first seven days of life, their contribution will be relatively low compared to other age groups). If the mortality rate in the second year of life is 40 deaths per 100,000, then there would be around 40 deaths (among the remaining 99,500 individuals) and their 'contribution' would be around 20 years (half a year on average). These calculations continue for each age or age group with the 'contribution' in the final (open ended) age group (e.g. 90+ year age group) calculated in a slightly different method. In most cases the calculation is undertaken for grouped ages (5-year age bands, e.g. 0, 1-4, 5-9, 10-14, 15-19, ..., 90+) rather than for single years of age. The 'contributions' for each age group are summed and divided by 100,000 (the starting number of individuals) to obtain the average life expectancy at birth over these arbitrary 100,000 individuals. Healthy life expectancy can also be estimated. This is a modelled estimate of the average number of years a person would expect to live in good health based on current mortality rates and prevalence of self-reported good health. Good health is based on the response to the question "How is your health in general; would you say it was very good, good, fair, bad or very bad?". The responses "very good" and "good" were categorised as "good health". For instance, if only 10% of people in the 70-74 year age group classify their health as "good" then the 'contribution' to the life expectancy calculation would be 10% or one-tenth that for overall life expectancy calculation.

Legal High - The term ‘legal high’ was used on the questionnaire as at the time they were generally called this, however, they are no longer legal and are correctly termed New Psychoactive Substances (NPS).

Level 2 (ICT) - Level 2 refers to being able to use Information and Communications Technology to "communicate, as well as enter and edit small amounts of information in ways that are fit for purpose and audience".

LLSOA – Lower Layer Super Output Areas. The geographical areas on which the Index of Multiple Deprivation is based (see IMD above). Hull has 166 LLSOAs. The boundaries of each LLSOA were created so that the LLSOAs are relatively uniform in terms of population size (for statistical comparison reasons) with each LLSOA having a minimum population of 1,000 residents and an average of 1,500 residents. They were first derived nationally following the 2001 Census when there were 163 LLSOAs in Hull. Prior to that, information was often presented at ward level, but the population size across the entire country varied dramatically, which meant that the statistical certainty differed considerably, and in some cases, numbers were too small to present the information for some of England's smallest wards. Due to population changes between 2001 and 2011, the LLOSA boundaries were changed slightly following the 2011 Census. One of the LLSOAs (in Kingswood ward) was divided into four new LLSOAs in 2011. Another LLSOA was divided into two new LLSOAs in 2011. Another two LLSOAs in 2001 were combined into a single LLSOA in 2011, but unfortunately the original LLSOAs were in two different adjacent wards so this meant the LLSOAs for 2011 were not coterminous with wards. Another LLSOA in 2001 was changed in 2011 in some way, and the LLSOA code was changed (the reason for the change was not known). There are currently 166 LLSOAs in Hull.

Local Health and Lifestyle Surveys and Social Capital SurveysA number of local surveys (and qualitative research projects) have been undertaken in Hull in the last decade or so. Adult Health and Lifestyle Surveys have been completed in Hull during 2003, 2007 and 2011-12, and mini adult Health and Lifestyle Surveys ("Prevalence Surveys") have been completed in 2009 and 2014. Adult Black and Minority Ethnic (BME) Health and Lifestyle Surveys, and Gypsy and Traveller Health and Lifestyle Surveys have both been completed in 2007 and 2011-12. A Veteran's Health and Lifestyle Survey was completed in 2009. Adult Social Capital Surveys have been completed in 2004 and 2009, although the 2007, 2011-12 and 2014 Health and Lifestyle Surveys also included some questions on social capital. Children and Young People Health and Lifestyle Surveys have been completed in 2002, 2008, 2012 and 2016. Further details on these surveys including the questionnaire and final reports can be found at www.hullcc.gov.uk/pls/hullpublichealth/.

MenC – Meningococcal C vaccine given to one and two year old children.

MMR – Measles, Mumps and Rubella vaccine given to two and five year old children.

MSK – Musculoskeletal (disorders). Covers any injury, damage or disorder of the joints, ligaments, muscles, nerves, tendons or other tissues in the limbs or back.

NICE – National Institute for Health and Clinical Excellence.  NICE provide guidance, advice, quality standards and information services for health, public health and social care in order to improve health and social care.

NO2 – Nitrogen Dioxide.  One of the measures of air pollution.

NOx – Mono-nitrogen Oxide (NO) and Nitrogen Dioxide (NO2).  One of the measures of air pollution.

NT Pro BNP – N-terminal of the prohormone brain natriuretic peptide. Both BNP (see above) and NT Pro BNP levels in the blood are used for screening, diagnosis of acute congestive heart failure and may be useful to establish prognosis in heart failure, as both markers are typically higher in patients with worse outcome.

ONS – Office for National Statistics (www.ons.gov.uk).

PANSI – Projecting Adult Needs and Service Information System (www.pansi.org.uk).

PCV – Pneumococcal Conjugate Vaccine given to one and two year old children.

PHE – Public Health England.

PHOF – Public Health Outcomes Framework. From the Introduction to the Public Health Outcomes Framework (PHOF) 2013 to 2016 [393] produced in January 2012, "The responsibility to improve and protect our health lies with us all – government, local communities and with ourselves as individuals. There are many factors that influence public health over the course of a lifetime. They all need to be understood and acted upon. Integrating public health into local government will allow that to happen – services will be planned and delivered in the context of the broader social determinants of health, like poverty, education, housing, employment, crime and pollution. The NHS, social care, the voluntary sector and communities will all work together to make this happen. The new Public Health Outcomes Framework that has been published is in three parts. Part 1 introduces the overarching vision for public health, the outcomes we want to achieve and the indicators that will help us understand how well we are improving and protecting health [394, 395]. Part 2 specifies all the technical details we can currently supply for each public health indicator and indicates where we will conduct further work to fully specify all indicators [394, 395]. Part 3 consists of the impact assessment and equalities impact assessment. The vision for the PHOF is "to improve and protect the nation's health and wellbeing, and improve the health of the poorest fastest". There are two overarching outcomes to "increase healthy life expectancy and to reduce differences in life expectancy and healthy life expectancy between communities." There are also four domains: (1) Improving the wider determinants of health (improvements against wider factors that affect health and wellbeing, and health inequalities); (2) Health improvement (people are helped to life healthier lifestyles, make healthy choices and reduce health inequalities); (3) Health protection (the population's health is protected from major incidents and other threats, while reducing health inequalities); and (4) Healthcare public health and preventing premature mortality (reduced numbers of people living with preventable ill health and people dying prematurely, while reducing the gap between communities). National data is available on the majority of the PHOF indicators from the PHOF data tool [27]. Local analysis has been undertaken on these indicators with information for each indicator summarised concisely on a single page, examining the indicator for Hull in relation to comparator areas, trends over time, national inequalities gap, local inequalities gap and at ward level, although not all information is available locally to examine the local inequalities gap or at ward level for the overarching indicators [101] and all the indicators in each of the four domains separately [396, 397, 398, 399, 400]. A summary document has also been produced which examines some key measures with each indicator summarised in a single line of a table [401]. These documents are all available on www.hullcc.gov.uk/pls/hullpublichealth/.

PM2.5 – A measure of air pollution.  It is the mass (in micrograms) per cubic metre of air of individual particles with an aerodynamic diameter generally less than 2.5 micrometres.

PM10 – A measure of air pollution.  It is the mass (in micrograms) per cubic metre of air of individual particles with an aerodynamic diameter generally less than 10 micrometres.

POPPI – Projecting Older People Population Information system (www.poppi.org.uk).

PPV – Pneumococcal Polysaccharide Vaccine given to those aged 65+ years.

Prevalence – The prevalence is "a measure of disease occurrence: the total number of individuals who have an attribute or disease at a particular time (it may be a particular period) divided by the population at risk of having the attribute or disease at that time or midway through the period. When used without qualification, the term usually refers to the situation at a specified point in time (point prevalence). A measure of occurrence or disease frequency, often used to refer to the proportion of individuals in a population who have a disease or condition. It is a proportion, not a rate." [389]. Also see incidence above.

PPV – see Troubled Families for more information on the national programme. Also see Early Help and Priority Families Strategy above for more information on the local strategy. Priority Families in Hull have been identified (following the launch of the National Troubled Families Programme in 2011 which intended to change the repeating generational patterns of poor parenting, abuse, violence, drug use, anti-social behaviour and crime in the most troubled families in the UK) and by November 2014, the majority of identified Priority Families in Hull had been 'turned around' [65]. The Government's Troubled families initiative moved into Phase 2 of the programme in April 2015. The ambition of the programme is to provide effective support to families which is evidenced by achieving outcomes for all identified reasons the family need support. The framework has six strands of inclusion criteria which are: school attendance; crime and anti-social behaviour; worklessness and financial exclusion; domestic abuse; children who need help; and families with health problems. Since the programme commenced in April 2015 the local authority have identified over 2,500 families in Hull that meet the criteria for the programme and have achieved all outcomes for over 700 families.

QALY – Quality Adjusted Life Years. A QALY is often used to compare different health interventions and treatments. A QALY is based on the how long a person having an intervention would live, but it also takes into account the quality of that life. Each year in perfect health is assigned a value of one (with death assigned a value of zero). If the person does not have perfect quality of life a value between zero and one is assigned for each year. The cost effectiveness of treatments can be compared using the cost of the intervention and the QALY of that intervention. Interventions with a lower cost to QALY ratio are better than those with a high cost to QALY ratio. Quality as well as duration of life are also used in relation to disability adjusted life years (see DALY) and health life expectancy (see Life Expectancy).

QOF – Quality and Outcomes Framework. As part of the General Medical Services contract implemented in April 2004, the Quality Outcomes and Framework was set out as a means for practices to measure achievement against a set of clinical and other indicators that reflected the quality of care provided to their patients. GP practices have been submitting QOF data since this time. A national system has been established to support the calculation of GP practice payments according to the achievements against QOF. Some of the indicators or measures included in the QOF relate to establishing a register of patients diagnosed with a specific disease or medical condition. From this information, an estimate of the diagnosed prevalence of these specific diseases can be calculated for each GP practice. The Excel data tables can be downloaded from NHS Digital [206]. Further information is available relating to the quality of care received by patients on the specific disease registers. For instance, the number of people on the diabetes register who have had retinal screening during the previous 15 months, the number of people on the coronary heart disease register in whom the last blood pressure reading (measured in the last 15 months) was 150/90 or less, the number of patients on a specific medication, the percentage of patients with coronary heart disease who have had their influenza vaccination, etc. Patients can be counted as 'exceptions' if there is a medical reason for them not to have that specific treatment or intervention. There are a number of reasons why patients can be made an 'exception' from specific quality of care measures. These include medical associated reasons such as experiencing side-effects of specific medications, or on other medications more suited to that patient due to multiple medications taken, but patients can also be made an 'exception' when they are invited to three review or annual check appointments and fail to attend. These 'exceptions' are allowed so that practices are not penalised financially on not achieving set levels for the quality of care measures due to influences outside their control. Practice targets relate to achieving a specific percentage of patients who have had the intervention or care measure after 'exclusions' have been removed. However, in terms of examining coverage, it is often useful to report on the percentage of patients having the intervention out of the entire patient population diagnosed with the condition. In this document, where the percentage of patients who have had their influenza vaccination for patients diagnosed with coronary heart disease, stroke, diabetes or chronic obstructive pulmonary disease ('at risk' patients), the percentages are reported as the percentages out of those diagnosed.

Due to the way in which the QOF data is defined and presented (with list size data extracted on the 1st April 2017 and the prevalence data extracted on the 6th July 2017) and the high number of practices that merged during or just after the financial year 2016/17, the list size within the national QOF data file was artificially inflated for Hull as some practices were included when they had already merged with another (and closed). The 'true' list size as at 1st April 2017 from the April 2017 GP registration file is 295,969 registered patients. However, for the purposes of reporting the 2016/17 QOF data, a denominator of 292,167 (3,802 lower) has been used as two practices have been excluded (they had data within the April 2017 GP registration file (i.e. they had registered patients at the time), but the practices did not have any QOF data or the QOF prevalence data was zero).

Screening programmes – 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 women and her baby, and screen for particular conditions" [178, 179, 180]. Most of the screening programmes in adults can detect the condition prior symptoms being present, and thus can be treated earlier to prevent the disease or increase survival. "In England, there are 1,280 new cases of blindness caused by diabetic retinopathy each year, and annual screening among those aged 12+ years who have diabetes can prevent this" [402]. "Men are offered screening for AAA during the year they turn 65 years of age, and this can reduce the number of deaths from ruptured AAA by up to 50%" [403]. "All women aged 50 to 70 are invited for breast screening every three years (although there are trials running in some geographical areas among women aged 47 to 49 and 71 to 73 years to assess whether it is worthwhile to extend the breast screening age range). Breast cancer is detected in around one women in every 100 screened, and lives are saved because cancers are diagnosed and treated earlier" [404]. "Cervical screening is offered to all women aged between 25 and 64 years (every three years to age 49 then every five years). Early detection and treatment can prevent around 75% of cancers developing with up to 4,500 lives saved each year in England" [405]. "Bowel cancer screening is offered to all men and women aged 60-69 years every two years (currently being extended to age 74 years). In the UK, 5% will develop bowel cancer in their lifetime, and over 16,000 die from it each year. Regular bowel cancer screening has shown to reduce the risk from dying from bowel cancer by 16%" [406]. "The NHS Health Check programme 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].

SMR – Standardised Mortality Ratio. Mortality rates, hospital admission rates and other rates can be calculated for different geographical areas. For example, a mortality rate would be calculated as the number of deaths out of the total population. Often it is useful to compare the resulting rates with other geographical areas to ascertain whether the rate is particularly high or low in relation to the national rate (e.g. the rate for England) or in relation to similar geographical areas (e.g. in terms of deprivation). However, when rates from two or more different geographical areas are compared, any differences among the rates could be due to differences in the age and gender structure of the populations. For two areas with a population of 100,000, the geographical area with the older population would tend to have a higher mortality rate. It is possible to 'standardise' the rate using a standard population to 'adjust' the resulting rate so differences in the age (and gender) population structures are taken into account. Direct standardisation produces a Directly Standardised Rate (DSR – see above). Indirect standardisation produces a Standardised Mortality Ratio. The SMR involves applying the rates of disease in a 'standard' population to the study or local population. For example, when calculating an SMR, this would involve using the age-specific (mortality) rates within the standard population and applying them to the local population. In this document, the SMR is generally standardised to the English population, so the age-specific mortality rates are applied to the age and gender structure of the local population to calculate the expected number of deaths in the local population. This expected number of deaths is then divided by the observed number of deaths within the local population to produce a ratio, and it is often multiplied by 100 so an SMR of 100 denotes that the mortality rate of the local population is the same as the standard population after taking into account the differences in the age and gender structure. In most cases, a SMR relates to mortality, but the same methodology can be used to report on indirectly standardised hospital admission rates. However, in this report, an SMR relates to mortality, with England as the standard population. If the SMR is more than 100 then the local mortality rate is higher than England, and can be expressed as the relative differences compared to England. For instance, an SMR of 130 denotes that the mortality rate of the local area is 30% higher than England (after adjusting for the population structure), and an SMR of 89 denotes that the local mortality rate is 11% lower than England (after adjusting for the population structure). As the age-specific mortality rates change over time in the standard population, it is necessary to take this into consideration when examining trends over time. All SMRs give the (mortality) position relative to England's mortality rates at a specific point in time. Thus if an SMR has been produced for a specific geographical area for 2012-14 (i.e. in relation to England's age-specific mortality rates), then when new data is available (for the next period of time), it is possible to recalculate the SMR, and the SMR for 2012-14 could also be recalculated for the geographical area which show the area's mortality relative to England 2013-15. In general, the trends over time will be based on the SMR using the more recent age-specific mortality rates in the standard population. This means that the SMR for the standard population will be 100 for the latest period, but will different for earlier years. For all causes combined, mortality rates have been decreasing, so the SMRs for England will generally be higher for earlier years. The SMR can increase even when mortality rates have reduced in the local area as they reflect the relative mortality position relative to England. For instance, if the age-specific mortality rates have all fallen in the local area, but the SMR has increased over the same time period, then this would simply reflect the fact that the mortality rates have fallen in the local area but at a slower rate compared to England thus inequalities have increased.

Standardisation – see Directly Standardised Rate (DSR) and Standardised Mortality Ratio (SMR)

Statistical testing – It is often useful to compare a particular summary parameter (for instance, mean, median, measure of risk) among different groups. Since there is natural variation associated with virtually all measurements and since we generally only have a sample and have not measured the entire population (even when data from a population is known, for example, the total number of deaths within a specific geographical area over a specific period of time, there will still be year-on-year random variation and variability in the number of deaths, so significance testing can be undertaken. There will be random factors which will influence the number of deaths such as the weather, accidents, 'flu epidemics, etc.), it is necessary to distinguish between differences which are close enough together to be explained by chance and differences which are 'unlikely' to be explained by chance. Such a comparison can be undertaken using a statistical test which takes into the account chance variation. When undertaking a statistical test, we assume that there is no difference in the summary measure among the groups and then calculate the probability of obtaining the difference we observe in our sample (i.e. in the data we have). If the calculated probability, or so-called p-value, is small then this means that there is a small chance of obtaining such a result under the assumption that there is no difference. Therefore, if the probability is small enough (generally, less than one in twenty or less than 0.05) then we assume that the original assumption must be incorrect and that there really is a difference. Since this is based on probabilities and assumptions, just because a small p-value is observed, it does not necessarily mean that the original assumption of no difference between the groups is untrue. However, clearly the smaller the p-value, the more likely it is that the original assumption is untrue. Similarly, just because you obtain a large p-value and therefore have no evidence to reject the original assumption, it does not mean that it is actually true, it could be that there is simply insufficient evidence to show otherwise (for example, a small number of people or small number of people with a particular event). If a small p-value is obtained (p<0.05) then the difference is deemed 'statistically significant'. However, this does not necessarily mean that the result is important clinically. It is possible that 50% of those living in one area report poor health compared to another area whose residents report 45%. If the number of people involved in the survey was sufficiently large, it is possible to obtain a statistically significant difference between these areas. However, from a medical point of view it may be considered not very important and the fact that both areas report high levels of poor health may be more important.

STP – Sustainability and Transformation Partnerships. STPs [12] have been established creating 44 STP areas in England. Hull is included within the Humber, Coast and Vale (HCV) STP [3, 13], which also includes NHS East Riding of Yorkshire CCG, NHS North Lincolnshire CCG, NHS North East Lincolnshire CCG, NHS Scarborough and Ryedale CCG, and NHS Vale of York CCG. STPs were announced in NHS planning guidance published in December 2015. NHS organisations and local authorities in different parts of England have come together to develop five-year 'place-based plans' for the future of health and care services in their area covering all aspects of NHS spending in England as well as focusing on better integration with social care and other local authority services. The scope of the STPs are broad with initial guidance setting around 60 questions to be covered in local plans under three headline issues of improving quality and developing new models of care, improving health and wellbeing, and improving efficiency of services. The HCV STP aim is: we want everyone in our area to start well, live well and age well. To achieve this vision the blueprint for the future system will begin with people and be built around their needs rather than being built around organisations, processes or pathways. It focuses on the wider determinants of health in our footprint and how public services will work together to support everyone to take more responsibility for their own health. Our proposals aim to design a healthcare system that by 2021 helps people to start well, live well and age well, that improves the quality of care and services that you receive and ensures that the system is financially sustainable for the long-term so that we can continue to deliver the services that you need. We will deliver our ideas by concentrating on three things in our footprint. These are our 'triple aim's: achieving our desired outcomes ('will the service by good?'); maintaining quality services ('will the service by safe and operational sustainable?); and closing our financial gap ('will the service by financially sustainable?'). Our vision for 2021 is a system that supports everyone to manage their own care better, reduces dependence on hospitals and uses our resources more efficiently. We have put six priorities at the heart of the change we want to achieve. These are:

i. Healthier people We want to improve the health and life expectancy of our population through prevention initiatives and support for people to take care of themselves and their loved ones;

ii. Better out of hospital care We want to create a wider range of services in local communities that are properly joined-up so people only go into hospital when it is absolutely necessary and do not stay longer than they need to;

iii. Better in hospital care We want to create more efficient hospital-based services for those who need them, making the best use of the resources and workforce across the system to plan and deliver hospital-based services;

iv. Better mental health care We want to ensure that mental health is seen to be equally important as physical health and that the services we offer promote the best mental health for our local population;

v. Better cancer care We want to help more people to survive cancer and support people in our region to live well with and beyond cancer;

vi. Balancing the books We want to make the most of every penny and all the other assets available to us to deliver good quality local services within the funding available.

Improving our health and care system in the way we describe will not happen overnight. We are trying to resolve challenges that our communities and public and voluntary sector organisations have been dealing with for a long time. It will also require a significant change in the way we work as organisations. We are putting in place some processes to help us make this happen. These processes involve finance (We have developed a plan that will support us in closing the 'do nothing' £420m funding gap by 2021. Big changes in the way we will work involve us delivering a system control total. This will involve planning and monitoring our services based on what people in the communities think is important rather than the number of times we see patients.); governance (Our Strategic Partnership Board and our Strategic Executive Group support is in making the right decisions. Our Clinical Advisory Group will make sure clinical views are at the heart of what we do, but we know we have to do more to support clinicians in this role. We have begun to recruit into our programme team and our governance and resources model will continue to strengthen as we move to implementation.); workforce (Our Local Workforce Action Board has planned two initiatives to help us to deliver our strategy. These initiatives involve developing both support staff and advanced practice staff at scale. Both of these initiatives will significantly help us to fill the gaps we have in our workforce.); our estate (Implementing this plan means we will have different estate needs across Humber Coast and Value public sector partners. As demand changes we will need to use our estate flexibly to support delivery of our strategy.); communication and engagement (We have challenging proposals for Humber Coast and Vale and are working on a comprehensive communications and engagement plan that has citizens and patients, staff and partners at its heart. We will not make any decisions without consulting our population and our staff on the changes we believe are needed,); and technology (We have a single plan across Humber Coast and Vale for using technology to transform our health and care services. This includes developing a single electronic care record that can be shared and accessed by health and care professionals, meaning that people will tell their story only once.)" [3].

TB – Tuberculosis.

TIA – Transient ischaemic attack (mini stroke).

Troubled Families – In April 2012, the government launched the Troubled Families Programme in order to turn around the lives of 120,000 Troubled Families by May 2015. This was known as phase 1 of the Programme and in June 2013, the government announced plans to expand the Troubled Families Programme for a further five years from April 2015, taking the programme to a significantly greater scale, to reach up to an additional 400,000 families across England. The programme aims, to improve the lives of families with multiple, high cost problems, transform local public services and reduce costs to the public purse in the long term. Families are identified through the merging of many data sets and to be eligible for phase two of the programme a family must have at least two of the following six problems: (1) Parents and children involved in crime or antisocial behaviour; (2) Children who have not been attending school regularly; (3) Children who need help: children of all ages, who need help, are identified as in need or are subject to a Child Protection Plan; (4) Adults out of work or at risk of financial exclusion or young people at risk of worklessness; (5) Families affected by domestic violence and abuse; and/or (6) Parents and children with a range of health problems. Families are prioritised for inclusion in the programme on the basis of they are families with multiple problems who are most likely to benefit from an integrated, whole family approach, and who are the highest cost to the public purse. Every identified family will have a keyworker or leadworker. A families leadworker will help the family identify the changes that need to take place and give the family the support that is needed to access other agencies. Lead Workers are trained practitioners that will work closely with the family. They come from a variety of services, with a wide range of skills and experience. Every local authority has an outcomes plan, which is used to monitor the progress of the whole family and on achieving all the required outcomes a payment will be received from central government. In addition to this Family Progress Data across 13 areas of family life is collated at the start, during and post intervention. A random sample of families will also have cost benefit analysis undertaken to evidence savings made in relation to the whole family. The programme in Hull is called the Priority Families Programme and further information is given under Early Help and Priority Families Strategy.

TPFR/TPTR – Total Period Fertility/Termination Rate. Since there are differences in the number of births amongst women of different ages, one measure of fertility is the number of births per 1,000 women for a specific age-group. For example, 203 births per 1,000 women aged 25-29 years. However, this method results in different fertility estimates for each age group, and the overall fertility rate among different geographical areas cannot be easily compared. This is particularly the case, if there are differences in the age women tend to have their children among different geographical areas or countries. The TPFR is a convenient summary measure of the fertility. It is a hypothetical estimate of completed fertility. It indicates how many births a woman would have by the end of her reproductive life, if, for all of her childbearing years, she was to experience the age-specific birth rates for a given year (e.g. current fertility rates). It takes into account the differences in the fertility rates within different reproductive age groups, and enables comparisons to be made between different geographical areas and between different time periods, because it is not affected by the age distribution of the women in the reproductive age-groups. The TPTR is a similar measure of terminations rather than births over all age groups. These rates are not predictions of fertility as the measures use the current rates.

Vision 2020 – This was NHS Hull Clinical Commissioning Group's vision and strategic plan for Hull [353, 390] for 2014/15 to 2019/20. It has been superseded by the Sustainability and Transformation Partnerships (STP) – see STP above. The vision 2020 was undertaken in conjunction with eight other partner organisations: Hull City Council, Healthwatch, Hull and East Yorkshire Hospitals NHS Trust, City Health Care Partnership, Yorkshire Ambulance Service, Humber NHS Foundation Trust, Humberside Fire and Rescue Services, and Humberside Police. Some of the same aims of "working together better to enable the people of Hull to improve their own health and wellbeing and to achieve their aspirations for the future" [353, 390] have been retained within the local Humber, Coast and Vale "Start Well, Live Well and Age Well" STP [3]. Vision 2020 also incorporated plans for greater collaboration across public services as well as private, voluntary and charitable sectors within Hull. It recognised that significant change was essential in order to ensure that sustainable, high quality services were available to meet the needs of the population. The defined outcomes of the Hull 2020 programme were: (i) clearly defined, equitable and quality seven day services available on the basis of need; (ii) people are aware of the services available to them, and confident that they can access what they need when they need it; (iii) information is shared across public services to speed up and coordinate care and support and reduce duplication; (iv) a single system that removes traditional organisational boundaries – enabled by integrated governance and partnership; (v) making the best use of the available money in Hull public services, to meet the needs of the local people; and (vi) a workforce that is fit for the future to meet the needs of the population [353, 390].

YLL – Years of Life Lost. This measures the number of years of life lost for each person who dies prematurely (before the age of 75 years). It can be used to examine different causes in relation to the total YLL for all persons dying of that cause of death or the average YLL for each person who dies of that cause of death. For instance, if 1,000 people die from a particular medical condition, 10 of them prematurely at an average age of 67 years (eight years prior to age 75 years) then the average YLL per person would be eight years, and the total YLL over all persons would be 80. Deaths with the greatest overall YLL will tend to have a high YLL per person where the person dies young (infant deaths, suicide and underdetermined injury, alcohol or drug related deaths, etc.) or a relatively low YLL per person with deaths occurring at older ages but a high number of overall deaths (coronary heart disease, lung cancer, etc.). Also see disability adjusted life years (DALYs).

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