Appendix A: Maidstone Health Inequalities 2015/16 Progress Report
Information prepared by Maidstone Borough Council and supported by Kent County Council, Kent Public Health
In 2012, Kent County Council launched Mind the Gap. Mind the Gap is Kent’s Health Inequalities Action Plan which aims to improve health and wellbeing for everyone in Kent by narrowing the gap in health status between the most and least deprived communities. It provides a framework and tools to identify, analyse and evaluate actions that contribute to reducing health inequalities.
The Maidstone Health Inequalities Action Plan was developed following the transfer of public health responsibility to local authorities from the NHS. Tackling inequalities is a task that will require the efforts of all; across multiple organisations and within communities themselves. District Councils have a key role to play in keeping us healthy. We have a distinct, local role in service provision, economic development, planning, and helping to shape and support our communities – all key areas that are increasingly recognised as vital components of a true population health system.
There are 6 policy objectives embedded into the action plan based on the principles of the ‘Fair Society, Healthy Lives’ written by Professor Sir Michael Marmot.
· Give every child the best start in life
· Enable all children, young people and adults to maximise their capabilities and have control over their lives
· Create fair employment and good work for all
· Ensure a healthy standard of living
· Create and develop healthy and sustainable places and communities
· Strengthen the role and impact of ill health prevention
Health is impacted by wider determinants of health such as education, employment, housing, physical environment, relationships/networks; and these need to be addressed in order to improve health and wellbeing. Health services are not always the solution.
Now we are nearly two years in, it is an opportunity to review progress against actions and move forward in closing the gap in health inequalities.
Measuring Health Inequalities
Overall indicator of progress in tackling health inequalities is to look at how mortality rates have changed over time for the most deprived compared to our least deprived.
It can be seen that although people’s life expectancy is increasing, the gap in mortality rates between the most and least deprived remains largely unchanged.
The graph below looks at life expectancy by deprivation of those living in the bottom quintile and top quintile within the Maidstone Borough from 2013-2015. It shows that those living in the most deprived areas have a lower life expectancy than those living in the least deprived areas.
Although mortality rates have been falling over the past decade, the ‘gap’ in mortality rates between the most and least deprived persists (all lines are decreasing). The red line shows the most deprived population and the bottom line shows the least deprived population.
This persistent gap in health outcomes is not a phenomenon that is unique to Maidstone or Kent; the Office of National Statistics recently reported that there has been a persistent fixed gap in the life expectancy across England as a whole.
In 2015, the deprivation score for Maidstone is 15.6 which is significantly lower than the deprivation score for England (21.8). This disguises pockets of deprivation at ward level and lower super output areas (LSOA)
Within the Maidstone borough, Park Wood; Shepway South and High Street are identified as areas of deprivation. It is important to remember that other pockets of deprivation do exist across the borough.
Indices of multiple deprivation 2015
Progress to date
Actions listed within the Maidstone Health Inequalities Action Plan were time-bound to 2015 and 2020 to assist with monitoring. However, it is hard to develop trends over a short period of time and to see statistically significant difference, particularly when there is a change of data collection so no comparisons can be drawn.
Progress has been noted against each priority and provided as an overview of each action. It is important to note that information cannot necessary be drawn from the data alone.
Priority 1: Give every child the best start in life
A child’s early years lay down the foundation for the rest of their life, and the first three years are most crucial. This is a crucial period of physical, intellectual and emotional development.
Inequalities are introduced before birth, as the health of a child is greatly affected by the health of their mother during pregnancy. Maternal stress, diet, smoking, drug and alcohol use all influences a baby’s development in the womb.
Breastfeeding contributes significantly to the long term health of both infants and mothers and increases maternal bonding.
Breastfeeding initiation in Maidstone is better than national and Kent figures but has been less significantly worse than the South East. The breastfeeding initiation rate in Maidstone for those mothers who breastfeed their babies in the first 45 hours after delivery has increased slightly from 74.6% to 75.8%.
Data is insufficient to report on the prevalence of breastfeeding at 6-8 weeks.
Excess Weight in Children
Although the prevalence rates in Maidstone for overweight children at Year R and Year 6 are similar to England and South East rates, childhood obesity remains a priority for Kent and for the West Kent Health and Wellbeing Board.
Data from the National Child Measurement Programme shows a reduction in the number of obese children in reception year (10.7% down to 8.2%) and year 6 (20.0% down to 14.9%). However it is important to note that new cohorts of children are measured each year. Experiences in childhood affect behaviours and habits into adulthood.
Priority 2: Enable all children, young people and adults to maximise their capabilities and have control over their lives
As children develop into young adults, they go through physical, emotional and psychological changes as they establish their own identities, independent from their families and carers. This is a time when services can offer children and young people opportunities to improve and shape their lives for the better, with impacts which last long into adult life.
The Under 18 conception rate in Maidstone is similar to the rate in England the South East and is declining. However, this disguises higher rates in Park Wood, Shepway South and High Street.
In 2015, Maidstone has seen an improvement from the South East and National average with only 13.2% of the population smoking.
However, smoking attributable mortality in Maidstone is similar to the England and the South East region; deaths from Chronic Obstructive Pulmonary Disease (COPD) are significantly higher. This is also reflected in a higher rate of Emergency admissions for COPD.
Hospital Stays for Self-Harm
Maidstone is not significantly different to the England average for hospital stays for self-harm, however a slight reduction has been noted from 215.3/100,000 to 205.67/100,000 (2014/15 data)
The rate of injuries due to falls in the over 65s is higher in Maidstone than the England and South East. The rate of falls is significantly higher in over 85 year old men and women, although similar to those aged 65 to 74.
Priority 3: Create fair employment and good work for all
Patterns of employment both reflect and reinforce the social gradient, and being in good employment is protective of health. Unemployment leads to financial insecurity, psychologic stress, anxiety, depression and unhealthy behaviours such as smoking and alcohol consumption.
The quality of work is also important. Jobs that are insecure, low-paid and fail to protect employees from stress and physical danger lead to poorer health.
In Kent, the unemployment rate has been reducing over the last few years in all districts as the nation’s economic recovery continues. The long-term unemployment rate in Maidstone is better than the England average.
Businesses and workplaces have a key role to play in support good health and reducing health inequalities. Supervisor and peer support, stable rotas, safe conditions, an opportunity for training and promotion, and greater autonomy in the workplace are all factors that increase employees’ wellbeing. In Maidstone, we work alongside Kent County Council to deliver the Kent Healthy Business Awards. The awards are self-assessed standard to help improve the health of the workforce. In 2014/15, 10 businesses had signed up to the awards in Maidstone, increasing to 31 businesses in 2015/16 with 5 achieving the awards.
Priority 4: Ensure a healthy standard of living for all
Income is a key determinant of health. Insufficient income is associated with worse outcomes in long term health and life expectancy. Income alone does not give a full picture of living standards.
Children in low income families (under 16s)
Maidstone is not significantly different to the region average for the number of children living in low income families; 14.1% in Maidstone compared to 13.7% South East region.
The people most likely to die or become ill during the cold weather are those least about to afford to heat their homes. Living in a cold home can lead to or worsen a large number of health problems including heart disease, stroke, respiratory illness, falls, asthma and mental health problems. The fuel poverty rate in Kent was 8.6% in 2013, less than the national rate of 10.4%. The number of excess winter deaths in Maidstone is not significantly different to the Kent average. Latest data available has Kent at 11.6% and Maidstone at 15.6%.
Please note the excess winter death trends seen below are only available to July 2013.
Priority 5: Create and develop healthy and sustainable places and communities
Creating a physical environment in which people can lead healthier lives is crucial to tackling health inequalities. Green spaces such as parks, woodland and other open spaces are associated with a number of health outcomes, relating to physical health, mental health and general wellbeing. There are many indirect benefits too, for example, providing space for social activity, sports and recreation and improving air quality.
Housing is a key aspect of inequalities; poor quality housing is a risk to health, and rates of overcrowded accommodation and shared dwellings are strongly associated with levels of deprivation.
Homelessness can be more hidden in the form of temporary accommodation. This transient living can lead to poor continuity of care and service provision. In Maidstone, Statutory homelessness is persistently reported as red in Maidstone (significantly higher than the England average). The measure is the count of households who are eligible, unintentionally homeless and in priority need, for which the local authority accepts responsibility for securing accommodation under part VII of the Housing Act 1996 or part III of the Housing Active 1985. This comes from a return provided by housing authorities to the Department for Communities and Local Government (DCLG).
In Maidstone, between April and June of 2016, 176 households have met the threshold to make a homelessness application. 149 decisions were made. In the same quarter in 2015/16 there were 150 applications and 132 decisions made.
(Approximately a 1/3 of those presenting as homeless are placed in temporary accommodation)
The length of stay in temporary accommodations has been reduced to 39.67 (2015/16); achieving the 2015 target of 42 days.
Maidstone has significantly higher rates of violent crime than the South East average, higher than the national rate but lower than the Kent figure. It has risen from 12/13 to 14/15. The rate for violent crimes per 1000 is also higher in Maidstone than the South East. The rate of sexual violence per 1000 is not.
Priority 6: Strengthen ill-health prevention
Strengthening ill-health prevention also required improve partnership working amongst the public, private and voluntary sector to find new ways to target and deliver services particularly with those who are hard to reach.
Maidstone Borough Council staff have been trained in Making Every Contact Count (MECC) as an approach to behaviour chance that utilises day-to-day interactions with our clients to support them in making positive changes to their physical and mental health and wellbeing.
Obesity/excess weight in adults data has changed over time, from 2006-2013 it was a % modelled estimated derived from the Health Survey of England using 2006-2008 data. From 2014, excess weight in adults was measured using Active People Survey 2014. Latest data shows 65.5% of Maidstone residents (aged 16 and over) have a BMI greater than or equal to 25kg/m².
The modelled data goes down to ward level to provide an indication of the relative prevalence. Shepway North, Shepway South and Park Wood are estimated to have 25% more prevalence of adult obesity.
Malignant Melanoma is not significantly different to the England average. The risk factors associated with malignant melanoma including being white, the high number of sunlight hours and being over 65 years old. This in itself may be why the South East is generally higher than the England average.
NHS Health Checks
The NHS Health Check programme is a national cardiovascular screening programme for all individuals aged 40-74 who are not already treated for cardiovascular disease. Since cardiovascular disease will affect many people as they age getting five-yearly check of blood pressure, weight and cholesterol is a way of identifying risks and getting advice and support to change lifestyles for the better.
The number of NHS Health Checks carried out within the borough exceeded our target of 1,500 to 2,908 (93.86% above target)
Indicators for Health Inequalities Action Plan
Actions identified within the Maidstone Health Inequalities Action Plan were time bound to 2015-2020. Kent Public Health Observatory has mapped Maidstone’s progress to date, although this data cannot be used as standalone data due to inconsistency of data collected and reported.
Care needs to be taken in interpreting population health indicators and the changes that may have occurred in data may arrive as not statistically different.
The action plan is a partnership plan and not the sole responsibility of Maidstone Borough Council. Tackling health inequalities requires a co-ordinated approach.
Health Inequality Indicators for Maidstone – June 2016
Taking into account our current Health Inequalities Action Plan and the need to understand what data is available; Public Health England have a list of indictors which have been considered and organised across the life course, consistent with the national strategy for tackling health inequalities. Indicators have been selected based on:
· Each indicator must relate to health inequalities (e.g. social determinants of health, health behaviours, health service uptake/use, health outcomes)
· Indicators collectively cover a wide breadth of issues, but minimising overlap
· Data for each indicators must be collected in a robust way, and consistent methodology, at least at County level, and ideally at District level (indicated where this is the case)
· Must be accessible on Public Health England (PHE) Fingertips website, for ease of access: fingertips.phe.org.uk/
· Data for each indicator must have been collected recently (post-2011) and must continue to be collected routinely and on a regular
The colour denotes whether the latest district value is better or worse than the national value or target value. This is currently only provided for Kent level data.
Looking at the latest district data from June 2016 the following areas are significantly better than the national average:
· Child Poverty (% of children under 16 in low income families)
· GCSE Attainment (% achieving 5 good GCSEs A*-C including English and Maths)
· Households that experience fuel poverty (%) (low income, high cost methodology)
These areas are significantly worse than the national average:
· Statutory Homelessness Acceptances (per 1000 households)
· Admission episodes for alcohol-related conditions (ASR per 100,000)
· Excess winter deaths (single year, all ages/person)
Whereas, these are not significantly different than the national average:
· Excess weight in adults
· Killed and seriously injured on roads, crude rate per 100,000
· Emergency readmissions within 30 days of discharge from hospital
Kent Public Health approach to health inequalities
Kent County Council, Mind the Gap strategy came to an end in 2015. The County Council’s new strategy ‘Mind the Gap 2016’ is currently in draft format. This strategy is not time-bound as changes to health inequalities are recognised over longer periods of time.
Kent County Council is concentrating on lower super output areas in each district with the aim of community transformation; empowering individuals and communities for better health and wellbeing. This will be achieved through community ‘asset based’ approach.
Needs based approach
Asset based approach
Focus on deficiencies
Focus on strengths
Respond to problems
Provide services to users
See residents as co-producers
Short term solutions
Sustainable long-term change
Top down: residents have little say in local issues
Bottom up: empower residents to be part of the process
It is a unified plan that recognises improving the health of an entire population does not necessarily address the health inequalities that exists between different parts of the society. Closing the ‘health gap’ will require a faster improvement in health in the most deprived areas.
Within Maidstone, Kent County Council has recognised Lower Super Output Areas (LSOA) of Park Wood, Shepway South and High Street as areas of deprivation. They have adopted Chris Bentley’s Ten Point Plan of ‘System and Scale into Community Empowerment’ to tackle health inequalities within these areas.
1. Prioritisation of areas – most in need
2. Defining communities – should be self-defining where possible
3. Asset mapping – stocktake of positive resources in place
4. Behaviour of Partners – agreed ways of working and sharing resources
5. Community profiles - collating top-down and bottom-up
6. Neighbourhood Action Plans (NAPS) – linking aspirations and objectives
7. Community based research (CBR) – train residents to be involved
8. Outreach models – using community venues
9. Community Links Strategy – gathering intelligence from community infrastructures
10. Transfer of Service Ownership – appropriate segments
Maidstone’s approach to health inequalities
As a district council we are in a unique position to help Kent County Council Public Health deliver a health agenda particularly around the wider determinants of health.
A whole systems approach to public health can ensure our actions have a positive impact on public health, taking on more of an enabling role in the health of our residents and communities, ensuring actions are cost-effective and, where possible, offer a positive return on investment. Health Inequalities should be a major focus within this approach but should not be the ‘sole’ public health strategy but form part of a wider public health strategy as at county level.
Our health is primarily determined by factors other than health care. District councils are in a good position to influence many of these factors through their key functions and in their wider role supporting communities and influencing other bodies.
So how can Maidstone Borough Council achieve a whole systems approach to improving the health and wellbeing of our residents?
1. Working in partnership and alignment
We need to work in partnership with other agencies, ranging from Public Health England and other tiers of local government and directors of Public Health, to the local NHS, the voluntary and business sectors and communities themselves.
This will enable us to share resources and achieve results.
2. To demonstrate effectiveness and return on investment
We should be more proactive in collating existing evidence on the health economics of our activities in order to guide decisions on our communities’ health and wellbeing.
This could help us in attracting funds and other forms of support from other bodies, including health and higher tiers of local government.
3. To lead innovation in services and their delivery
Invest in health impact assessments (HIA) to move beyond innovative case studies to processes to show demonstrable improvements in health outcomes.
4. To strength our enabling role in the health of our communities
Actively engage with our communities involving them directly in decisions which affect their health and wellbeing.
There is growing recognition that although disadvantage social groups and communities have a range of complex and inter-related needs, they also have assets at the social and community level that can help improve health, and strengthen resilience to health problems.
1. To embed health within the culture of Maidstone Borough Council to deliver a whole systems approach producing a ‘District Health Deal’ with Kent County Council Public Health.
2. Produce and deliver a learning and development package to staff and councillors on the importance of health and how their role contributes and can contribute further to improving health and wellbeing of residents. This will include embedding this approach in the Council’s Business Plan and appraisals.
3. Support the implementation and delivery of the Mind the Gap 2016 which focuses on a community asset based approach in lower super output (Parkwood, Shepway and High Street ward). We are close enough to our communities to understand how they work and how to best reach and support them.
Model for impacting health at a population level (Chris Bentley 2012)
4. Establish a good working relationship with the Kent Public Health Department so health data is readily available dependant on the needs and change of our population. Using their expertise to understand what is underneath the data and what the intelligence tells us which must include qualitative information. (Intelligence based approach)
5. Establish collaborative working agreements (internal) and partnership working agreements (external) for partners to work together on achieving shared outcomes in improving resident health and wellbeing.
6. Produce Health Impact Assessments on all future strategies produced by Maidstone Borough Council.
7. Review progress of health inequalities to date and implement a refreshed action plan examining strategic direction for future delivery.
8. To confirm key objectives and priorities for the refreshed health inequalities action plan, taking note of significant trends highlighted by data provided by the Public Health Stakeholders.
· Violent Crime
· Statutory homelessness
Children and Young People:
· Breastfeeding initiation and maintenance at 6/8 weeks
· Excess weight in children
· Teenage Conceptions and Teenage Parents
· Emotional Health and Wellbeing (linked to admissions for injuries)
· Emotional and Mental Health including social isolation
· Excess Weight
· Dementia Prevention – physical activity, smoking cessation
With regards to populations of people: young parents; Black and Minority Ethnic (BME); older people and homeless individuals are recommended.
The priorities above have been identified by: looking at public health outcomes; appraising data available; benchmarking against England, South East, Kent and other wards; looking at trends; and identifying actions and making links to strategic priorities for Kent.
Maidstone Health Inequalities Action Plan 2014-2020
Kent County Council, Mind the Gap: Kent’s Health Inequalities Action Plan 2012-2015
Kent County Council, Mind the Gap 2016
The Marmot Review, ‘Fair Society, Healthy Lives’, 2010
The Kings Fund, The district council contribute to public health: a time of challenge and opportunity
Kent and Medway Public Health Observatory
Public Health England
Public Health Profiles
 Office for National Statistics. Statistical Bulletin Health Expectancies at birth by Middle Layer Super Output Areas, England, Inequality in Health and Life Expectancies within Upper Tier Local Authorities: 2009 to 2013. 2015:1-22.