Living Well for Longer in Cheshire East The Annual Report of the Director of Public Health 2012-2013 Contents Figures ..................................................................................................................................................... 5 Maps ....................................................................................................................................................... 7 Tables ...................................................................................................................................................... 8 Foreword ............................................................................................................................................... 10 Chapter One – A Call To Action ............................................................................................................. 14 Key Facts About Premature Mortality in Cheshire East .................................................................... 16 Conclusion ......................................................................................................................................... 24 Key Findings ...................................................................................................................................... 25 Chapter Two – Introducing Proportionate Universalism in Cheshire East ........................................... 26 Conclusion ......................................................................................................................................... 36 Key Findings ...................................................................................................................................... 37 Chapter Three - Cancer ......................................................................................................................... 39 Preventing Cancer ............................................................................................................................. 43 Cancer Screening Programmes ......................................................................................................... 49 Awareness and Early Diagnosis ......................................................................................................... 50 Conclusion ......................................................................................................................................... 52 Key Findings ...................................................................................................................................... 52 Chapter Four – Cardiovascular Disease ................................................................................................ 54 The Causes of Cardiovascular Disease .............................................................................................. 56 NHS Health Checks ............................................................................................................................ 58 Managing Risk in Primary Care ......................................................................................................... 59 Better Early Management and Prevention in the Community ......................................................... 60 Familial hypercholesterolemia ...................................................................................................... 60 Atrial fibrillation ............................................................................................................................ 60 Stroke ............................................................................................................................................ 61 Heart attack care ........................................................................................................................... 62 People Living with Cardiovascular Disease ....................................................................................... 63 Conclusion ......................................................................................................................................... 63 Key Findings ...................................................................................................................................... 63 Chapter Five – Other Main Causes of Premature Death ...................................................................... 65 2 Lung Disease ......................................................................................................................................... 65 Early Deaths from Respiratory Disease ............................................................................................. 66 Asthma .............................................................................................................................................. 69 Chronic Obstructive Pulmonary Disease ........................................................................................... 71 Conclusion ......................................................................................................................................... 74 Key Findings ...................................................................................................................................... 75 Liver Disease – A Growing Epidemic ..................................................................................................... 77 Deaths from Liver Disease ................................................................................................................ 77 An Overview of Liver Disease ............................................................................................................ 78 Effective Interventions to Reduce Harm From Alcohol .................................................................... 81 Key Findings ...................................................................................................................................... 81 Chapter Six – Road Traffic Accidents and Suicide ................................................................................. 83 Road Traffic Accidents .......................................................................................................................... 83 Road Traffic Accidents in Cheshire East ............................................................................................ 84 Road Traffic Accident Hospital Admissions ....................................................................................... 86 Road Use in Cheshire East ................................................................................................................. 87 Interventions ..................................................................................................................................... 89 Conclusion ......................................................................................................................................... 92 Key Findings ...................................................................................................................................... 93 Suicide ................................................................................................................................................... 94 Hospital Admissions due to Self-Harm ............................................................................................. 94 Early Deaths due to Suicide in Cheshire East .................................................................................... 95 Improving Mental Health and Wellbeing: Effective Interventions ................................................... 97 Recommendations for Healthcare Commissioners and Providers ................................................... 97 Conclusion ......................................................................................................................................... 98 Key Findings ...................................................................................................................................... 98 Chapter Seven – Mental Health and Premature Death ...................................................................... 100 Cheshire East: Depression and Anxiety Disorders .......................................................................... 100 Cheshire East: Psychoses ................................................................................................................ 100 Conclusion ....................................................................................................................................... 104 Key Findings .................................................................................................................................... 104 Chapter Eight - Vision .......................................................................................................................... 106 3 References .......................................................................................................................................... 108 Appendix One: Premature Mortality, Directly Standardised Rate per 100,000, Males aged under 75, 2009-11 ............................................................................................................................................... 112 Appendix Two: Premature Mortality, Directly Standardised Rate per 100,000, Females aged under 75, 2009-11 ......................................................................................................................................... 113 4 Figures Figure 1: The New Paradigm ................................................................................................................. 11 Figure 2: Cheshire East Premature Mortality Pyramid ......................................................................... 15 Figure 3: Directly Standardised Premature Mortality Rate in Cheshire East - All Causes .................... 18 Figure 4: Premature Mortality, Directly Standardised Rate per 100,000, Persons Aged Under 75, 2009-11, Local Authorities Ranked by Mortality Decile ....................................................................... 20 Figure 5: Directly Standardised Mortality Rates for All causes by deprivation quintile, Crewe LAP, aged under 75, Males & Females, 2009-11 provisional (using Mid2011 population estimates) ......... 21 Figure 6: Four main causes of death in women under 75, Cheshire East, 2009-2011 ......................... 24 Figure 7: Directly Standardised Mortality Rates for All causes Cheshire East Local Area Partnerships, aged under 75, Males & Females, 2009-11 Provisional (using Mid 2011 population estimates) ........ 24 Figure 8: The Three Domains of Prevention, Early Diagnosis and Treatment ...................................... 27 Figure 9: Health Mapping - Improving Physical Health......................................................................... 30 Figure 10: Directly Standardised Mortality Rates for All Causes by deprivation decile, Cheshire East, aged under 75, Males & Females , 2009-11 provisional (using Mid 2011 population estimates) ....... 33 Figure 11: Life Expectancy and Healthy Life Expectancy for males at birth, 2009-11 (upper tier authorities) ............................................................................................................................................ 34 Figure 12: Life Expectancy and Healthy Life Expectancy for females at birth 2009-11 (upper tier authorities) ............................................................................................................................................ 35 Figure 13: Healthy Life Expectancy at birth, Males, 2009-2011 ........................................................... 36 Figure 14: Healthy Life Expectancy at birth, Females, 2009-2011 ........................................................ 36 Figure 15: The Lifetime Risk of Developing Cancer in Cheshire East .................................................... 39 Figure 16: Emergency Presentations for Cancer ................................................................................... 40 Figure 17: Cancer in Cheshire East in 2010, aged under 75 ................................................................. 41 Figure 18: Premature Mortality from Cancer, Directly Standardised Rate per 100,000, persons aged 75 and under, 2009-2011, Local Authorities Ranked by Mortality Decile ............................................ 42 Figure 19: Directly Standardised Mortality Rates for All Cancers (C00-C97) Cheshire East Local Area Partnerships, aged under 75 by gender, 2009-11 provisional (using Mid2011 population estimates) 43 Figure 20: Incidence and Mortality of Main Tumour Types by Town, All Ages, 2005-2010 ................. 47 Figure 21: New Cases of the Main Cancers in People Under 75 in Cheshire East in 2008-10 (dividing the population into fifths by level of deprivation) ................................................................................ 49 Figure 22: Premature Mortality from Cardiovascular Disease, Directly Standardised Rate per 100,000, persons aged under 75, 2009-2011, Local Authorities Ranked by Mortality Decile ............................ 54 Figure 23: Time Trends in Premature Mortality from Cardiovascular Disease in Cheshire East .......... 55 5 Figure 24: Direct Standardised Mortality Rates for All Circulatory Disease (ICD10 I00 - I99) Cheshire East Local Area Partnerships, aged under 75, Males & Females, 2009-11 provisional (using Mid2011 population estimates) ........................................................................................................................... 55 Figure 25: Distribution by exposure level of cardiovascular disease (CVD) burden attributable to selected continuous risk factors ........................................................................................................... 56 Figure 26: Cheshire East Health Checks 2013/14: Eligible Population ................................................. 58 Figure 27: Premature Mortality from Respiratory Disease, Directly Standardised Rate per 100,000, persons aged 75 and under, 2009-2011, Local Authorities Ranked by Mortality Decile ..................... 66 Figure 28: Premature Mortality Rates due to Respiratory Disease (J00-J99) in Cheshire East ............ 67 Figure 29: Premature Mortality Rates due to COPD (J40-J44) in Cheshire East ................................... 67 Figure 30: Smoking Quit Rates, Percentage successfully quit at 4 weeks, persons aged 16+, 2010/11 .............................................................................................................................................................. 68 Figure 31: Premature Mortality from Liver Disease, Directly Standardised Rate per 100,000, persons aged under 75, 2009-2011, Local Authorities Ranked by Mortality Decile .......................................... 78 Figure 32: Directly Standardised Premature Mortality Rates in Cheshire East - Liver Disease (B15-B19, C22, I81, I85, K70-K77, T86.5) ............................................................................................................... 78 Figure 33: Factors Contributing to Liver Disease: Cheshire East's Position Nationally by Quintile ...... 79 Figure 34: Killed or Seriously Injured Casualties on England’s Roads, all ages, per 100,000 resident population 2010-2012 .......................................................................................................................... 85 Figure 35: Number of Fatal and Serious Casualties per Billion Vehicle Miles Where the Local Authority is the Road Owner in 2011 ................................................................................................... 85 Figure 36: Direct Standardised Premature Mortality Rates in Cheshire East - Transport Accidents (V01-V99) .............................................................................................................................................. 86 Figure 37: Directly Standardised Hospital Admission Rate Amongst the Under 75s in Cheshire East - Transport Accidents (V00-V98) ............................................................................................................. 87 Figure 38: Vehicle Accident Rate in Cheshire East, 2012 ...................................................................... 88 Figure 39: Directly Standardise Admission Rate for people aged under 75 in Cheshire East - Intentional Self-Harm (X60-X84) ........................................................................................................... 94 Figure 40: Directly Standardised Mortality rate in persons aged under 75 in Cheshire East - Intentional Self-Harm (X60-X84) ........................................................................................................... 96 Figure 41: Directly Standardised Mortality rate in persons aged under 75 in Cheshire East - Suicide and Injury Undetermined (ICD10 X60-X84, Y10-Y34, excluding Y33.9) ................................................ 96 Figure 42: Directly Standardised Excess Mortality Rate per 100,000, adults aged under 75 with Serious Mental Illness, 2010/11.......................................................................................................... 102 Figure 43: Comparing General Population Mortality Rates (Gen) with Mortality Rates for People with Serious Mental Illness (SMI), mortality rates per 100,000 adults ...................................................... 103 6 Maps Map 1: Cheshire East Premature Mortality 2009-2011 ........................................................................ 14 Map 2: Crewe LAP Premature Mortality ............................................................................................... 22 Map 3: Macclesfield LAP Premature Mortality ..................................................................................... 23 Map 4: Cheshire East - Index of Multiple Deprivation 2010 Internal Quintile ..................................... 32 7 Tables Table 1: Premature Deaths in Cheshire East by Cause ......................................................................... 17 Table 2: Decrease in directly standardised premature mortality rate in Cheshire East between 2001- 2003 and 2009-2011 ............................................................................................................................. 18 Table 3: Similar Areas Ranking Table .................................................................................................... 19 Table 4: Five-Year Relative Survival (%) by Cancer Type and Stage at Diagnosis ................................. 40 Table 5: Patients with a diagnosis of cancer, ranked by crude prevalence .......................................... 42 Table 6: Directly standardised rates of new cases of cancer, by tumour type, all ages, for the six-year period from 2005 to 2010 ..................................................................................................................... 45 Table 7: Directly standardised rates of mortality from cancer, by tumour type, all ages, for the six- year period from 2005 to 2010 ............................................................................................................. 46 Table 8: Main Hospital of Treatment for all Cancers Diagnosed in 2010, Cheshire East Council ......... 51 Table 9: Lifestyle Risk Factors in Cheshire East with National and International Comparisons ........... 57 Table 10: Health Checks in Cheshire East ............................................................................................. 59 Table 11: Cheshire East Residents with Undiagnosed Risk Factors for Cardiovascular Disease .......... 59 Table 12: Identification and Management of Hypertension in Cheshire East, 2011/12 ...................... 60 Table 13: High Risk Atrial Fibrillation Patients Stroke Risk, Cheshire East ............................................ 61 Table 14: Hospital Performance and Use of Primary PCI in Cheshire East patients with STEMI .......... 62 Table 15: Hospital Prescribing of Secondary Prevention in Cheshire East patients with nSTEMI ........ 62 Table 16: Children with Chronic Respiratory Disease, Ages 6 months to 15 years, Cheshire East ....... 66 Table 17: Young People aged 14 to 19 years with Asthma with Smoking Status Recorded in the Last 15 Months ............................................................................................................................................. 69 Table 18: Patients on GP Asthma Registers, 2011/12 .......................................................................... 70 Table 19: Patients aged 8 years and over diagnosed with Asthma since 1 April 2006 with Measures of Variable Lung Function, 2011/12 .......................................................................................................... 70 Table 20: Patients with Asthma who have had an Asthma Review in the Preceding 15 Months, 2011/12 ................................................................................................................................................. 71 Table 21: Patients on GP COPD Registers, 2011/12.............................................................................. 72 Table 22: Patients with COPD Diagnosed during 2011/12 where the diagnosis was confirmed by post bronchodilator spirometry .................................................................................................................... 73 Table 23: Patients with COPD with a record of FEV1 in the Preceding 15 Months, 2011/12 .............. 73 Table 24: Patients with COPD who have had a clinical review and assessment of breathlessness, 2011/12 ................................................................................................................................................. 74 Table 25: Factors Contributing to Liver Disease in Cheshire East ......................................................... 80 8 Table 26: Factors associated with an increased risk of the occurrence of a road traffic accident ....... 83 Table 27: Premature Deaths and Death Rate due to Road Traffic Accidents by Sex, Cheshire East (2009-2011) ........................................................................................................................................... 86 Table 28: Roads in Cheshire East .......................................................................................................... 87 Table 29: Vehicle Miles Travelled by Vehicle, Cheshire East and Nationally ........................................ 88 Table 30: Summary of EuroRAPs published ‘Britain’s persistently highest risk roads’, summarising roads from Cheshire East ...................................................................................................................... 89 Table 31: Key National Road Safety Documents ................................................................................... 90 Table 32: Premature Deaths due to Deliberate Self-Harm and Deliberate Self-Harm and Injury Undetermined in East Cheshire, 2009-2011 ......................................................................................... 95 Table 33: Prevalence of Schizophrenia, Bipolar Illness and Other Psychosis ..................................... 101 Table 34: Burden of Disease in Cheshire East, 1992-2031 ................................................................. 107 9 Foreword In April 2013, across England and Wales, the responsibility for Public Health transferred from the NHS to Local Authorities. It is with great pleasure that I bring you this, my first Annual Report, as Director of Public Health for Cheshire East. I am required by law to write an annual report on the health of the local population. This is an independent report which describes a number of key aspects of local health, highlights areas of excellence and concern and sets out headline recommendations to tackle these issues. In June 2013, Public Health England published Longer Lives (www.longerlives.phe.org.uk). Longer Lives described premature mortality (defined as deaths under the age of 75) by local authority area. It broke down premature deaths by the top four killers; cancer, heart disease and stroke, lung disease and liver disease. This report focuses on premature mortality within Cheshire East. National comparisons reveal that Cheshire East has relatively low levels of premature mortality, th ranked 38 out of 150 local authorities. The number of premature deaths locally has also fallen over the past nine years by 22%. There is a lot to celebrate. However, further improvements in health and reductions in premature mortality are possible as 1. Over 1,000 people die before the age of 75 each year. 1 2. Nearly 800 of these deaths are avoidable . 3. More men die prematurely than women in Cheshire East, though the number of men dying prematurely has been reducing since 2001. 4. The reduction in premature deaths in women has stalled since 2005-2007. 5. There are wide variations within Cheshire East, depending on where you live, on your risk of premature death. The data above starts to illustrate local health inequalities and the potential impact of the wider determinants of health on early death. These issues were highlighted by The Marmot Review, Fair Society Healthy Lives, published in 2010. This report linked poor health outcomes with lower socioeconomic standing and highlighted that ‘the link between social conditions and health is not a footnote to the ‘real’ concerns with health – health care and unhealthy behaviours – it should become the main focus’ (Marmot, 2010, pg 3). However, the Marmot Review highlighted that to reduce health inequalities it was not enough to focus just on the most disadvantaged, but that action should be taken across a community with ‘an intensity that is proportionate to the level of disadvantage’ (Marmot, 2010, pg 10). This is the significant challenge for all who live and work in Cheshire East. 1 Avoidable deaths are those that would not have happened if appropriate medical and/or public health interventions had taken place to reduce a person’s risk of dying prematurely. 10