This chapter provides a brief overview of the health needs of the residents of Northumberland, highlighting in particular those health needs which may be amenable to intervention by services delivered through community pharmacies and those needs which should be met in order to achieve the objectives in the five year Strategic Plan.
Local priorities include reducing alcohol related harm, tackling obesity through diet and exercise and promoting mental wellbeing. Further details are available in the Joint Strategic Needs Assessment5, and the Northumberland CCG Five Year Plan.
3.1 Geographical characteristics
The north of the county is very sparsely populated. The principal towns of Alnwick, Berwick and Morpeth serve geographically large catchments that are also partially influenced by both Edinburgh to the north and Tyneside to the south. Many of the communities in this area are characterised by extreme physical remoteness, lack of
services and rural disadvantage. This is one of the most sparsely populated areas of England.
The west of the county is distinctly rural, albeit split by major road and rail transport corridors running into Newcastle and Gateshead. The towns of Ponteland and Hexham are desirable places to live and visit, placing considerable demands on their services and infrastructure. Many of the communities in this area are characterised by an economic and cultural interdependence with the Tyneside conurbation. The far west of the County is also sparsely populated.
The southeast corner of the county is compact coastal lowland intersected by several river estuaries. It is distinctly built up, with the county’s largest towns of Ashington, Blyth and Cramlington in the northern fringe of Tyneside. Many of the communities in this area are characterised by high levels of multiple deprivation following the decline of coal mining and other industries.
The county’ demographic profile – very distinct settlements in each locality – means that one size does not fit all. It is therefore vital that services are customised to local needs. The extreme remoteness of some parts of the county makes service delivery challenging and costly.
3.2 Population profile
The last official estimate of the Northumberland population was produced by the 2011 Census and this was confirmed by the Office for National Statistics in June 2014 as a mid-2013 population estimate of 315,8066.
The mid-2013 age profile for Northumberland is considerably different to that of the North East and England in that Northumberland has much smaller populations for those aged 20 to 40, then much larger populations aged between 50 and 70. The population lessens for the older ages, with higher populations among females than the corresponding male age groups (see Figure 1). Northumberland has a high number of over 65s, accounting for 21.9% of its population, compared to 18.4% across the North East and 17.3% across England.
Figure 1: Population pyramid of Northumberland compared to England
The over 65 population is expected to account for over 30% of the total population in Northumberland by 20357. The rural areas of North Northumberland, West Northumberland and Morpeth already have a high proportion of their population over 65. These dramatic changes in the balance of the population are part of an historic shift which is being experienced across the developed world; but they are happening earlier in Northumberland (especially rural Northumberland) than in most of England. This high number of over 65s could be expected to increase demand on health services.
In contrast, the number of children and young people resident in Northumberland is expected to be fairly static over the same period. The number of persons under the age of 15 will decrease slightly from 50,025 in 20118 to around 49,000 in 20169. To accommodate the increase in household numbers and to attract economically active families into Northumberland, Northumberland County Council plans to meet national housing targets by encouraging limited development around the main towns of Hexham, Ponteland, Morpeth, Ashington, Blyth and Alnwick (see Table 1 and Table 2 ).
Table 1: Housing scale and distribution by area
It is unlikely that developments of this scale will significantly impact on health service delivery. More GP capacity may be needed in the Ashington, Blyth and Cramlington areas over the next 3 -5 years.
Culture and ethnicity may influence health beliefs and behaviours, and may therefore impact on health and wellbeing. In the 2011 Census (the latest year for which data are available), 98.4% of the population of Northumberland classified themselves as White. People from BME groups now represent 1.6% of the Northumberland population, compared with 4.7% in the North East and 14.5% nationally.
Table 2: Housing Plan – proposed annual development by town (*plan period: 2011-2031)
Within Northumberland in particular, access to health services can be hampered by transport issues – this is partially because of the problems of rurality, with a very sparsely populated county of more than 2,000 square miles. The maps in Section 4 and some of the maps in the appendices show settlement types, which highlights the rurality of Northumberland. Public transport in these rural areas can be poor and infrequent.
The link between social and economic deprivation and poor health has long been recognised. People living in areas with higher levels of deprivation tend to have poorer health than those living in more affluent areas. Northumberland is characterised by areas of rural poverty hidden amidst relative affluence, with the postindustrial areas of Ashington and Blyth suffering from multiple deprivation. Berwick is a town isolated from the rest of the county but suffering from unemployment and social deprivation similar to the south east of the county (see Map 2).
3.5 Lifestyle risk factors
Smoking remains the greatest contributor to premature death and disease across Northumberland. It is estimated that up to half the difference in life expectancy between the most and least affluent groups is associated with smoking. It is estimated that 87% of deaths from lung cancer are attributable to smoking, as are 73% of deaths from upper respiratory cancer and 86% of chronic obstructive lung disease. Smoking is also a major factor in deaths from many other forms of cancer and circulatory disease. Overall, smoking mortality is significantly higher in Northumberland than the England average, although smoking prevalence is now below the England average (17.6% compared to the England average of 19.5%). It is important to note, however, that there is much disparity within Northumberland and this is not a true reflection of every locality in Northumberland.
Alcohol is the second biggest lifestyle risk factor after tobacco use. Recent figures from the Local Authority Profile for England (LAPE) show Northumberland has the sixth highest rate in the UK for binge drinking with 29.8% of those surveyed reporting drinking more than twice the recommended amount of alcohol in a single session.
Alcohol misuse is a major problem within Northumberland in terms of health, social and economic consequences which affect a wide cross section of the county at a considerable cost. The pattern of drinking has a socio-economic gradient with a higher proportion of both men and women in managerial and professional
households exceeding the recommended maximum intake on at least one day per week(10).
Map 2: Distribution of Index of Multiple Deprivation 2010 in Northumberland
Source: Northumberland InfoNet research report – English Indices of Deprivation 2010
There are rising trends in the levels of hospital related admissions for both men and women in the county. Between 2010/11 and 2012/13 there were 27 under 18 admissions to hospital for alcohol specific conditions. In 2012/13 alone there were 20 2,556 adult admissions for alcohol related harm, the rate of which (788 per 100,000) is significantly above the England average (637 per 100,000).
Drug addiction leads to significant crime, health and social costs. Evidence-based drug treatment reduces these and delivers real savings, particularly in crime-related costs, but also in savings to the NHS through health improvements, reduced drugrelated deaths and lower levels of blood-borne disease. Tables 3a and 3b show the estimated prevalence of drug misuse in Northumberland.
Table 3a: Estimated prevalence rates per 1,000 population aged 15 to 64 (2010/11)
When engaged in treatment, people use fewer illicit drugs, commit less crime, improve their health and manage their health better. Preventing early drop-out and keeping people in treatment long enough to benefit contributes to these improved outcomes. In 2013 there were 943 adults in drug treatment. During this time 242 adults started a new treatment journey, 85% of which were retained for at least 12 weeks11.
Table 3b: Estimated prevalence of opiate or crack use by age – rates per 1,000 population
Data source: National Drug Treatment Monitoring System
In Northumberland in 201212, 72% of adults were classed as overweight or obese13. This is nearly 10% more than national prevalence. The Health Survey for England (HSE) 2014 indicates that 25% of both men and women are obese (25%) but that men are more likely to be overweight (32% for women and 42% for men). This also shows that the adult prevalence of severe obesity is 2.4%.
Figure 2: Adjusted prevalence of excess weight among adults, 2012
Data source: Active People Survey 6
Table 4: Prevalence of obesity (adults) 2012/13
Source: Monitoring data on QOF 2012/13, HSCIC
Between 1993 and 2012, obesity has risen from about 15% to 25% and projections show no halt to the rise in adult obesity. Women living in lower income households are more likely to be obese: obesity prevalence falls from 31% in the lowest income quintile to 19% in the highest income quintile. There is no clear pattern for men.
The latest data from the NCMP identified that 10% of Reception aged children were obese and 23% recorded with excess weight. By Year 6, this figure was 18% obese and 33% with excess weight.
Figure 3: Excess weight prevalence by age
Data sources: NCMP 2010/11-2012/13; APS 6
The underlying causes of obesity are considered to be the ready availability of high calorie food, and a more sedentary lifestyle caused by a reduction in activity and manual labour, and greater use of the car as a means of transport. Obesity is associated with a range of health problems including Type 2 Diabetes, cardiovascular disease and cancer. The resulting NHS costs attributable to overweight and obesity are projected to reach £9.7 billion by 2050, with wider costs to society estimated to reach £49.9 billion per year (Foresight 2007).
Sexual health and teenage pregnancy
Good sexual health forms a fundamental aspect of an individual’s general wellbeing and state of health, and is also an important public health issue - poor sexual health imposes significant social, economic, emotional and health costs. The highest burden of sexual ill health is borne by gay and bisexual men, young people and black and minority ethnic groups. Reducing the burden of HIV and STIs requires sustained approaches to support early detection, successful treatment and partner notification in conjunction with safer sex health promotion and the promotion of safer sexual behaviour.
Rates of teenage conception in 2012 were 28.4 per 1,000 women aged 15-17 in Northumberland which is lower than the rate for the North East (35.5 per 1,000) but higher than England (27.7 per 1,000).
Within Northumberland, there are a number of identified ‘hot spots’ based on teenage pregnancy rates within different parts of the county. Most are in the former districts of Blyth Valley and Wansbeck, although Haydon ward in Tynedale, Lesbury and Alnwick in Alnwick and Lynemouth and Chevington in Castle Morpeth also feature. There are also a number of other wards spread across Blyth Valley, Wansbeck, Castle Morpeth and Alnwick which have rates above the England average.
The reduction of the teenage pregnancy rate has been a key target across Northumberland. Key actions have included work targeting young people in schools, and communities in teenage pregnancy ‘hot spot’ areas. The objectives are to improve access to responsive services and sex and relationship education, and to increase the use of long acting reversible contraception.
Death rates from all cancers have decreased significantly over the last 2 decades due to a combination of early detection and the efficacy of treatment. However within Northumberland cancer remains a significant cause of premature death (death under 75 years) and health inequalities. Cancer is the commonest cause of premature death in Northumberland closely followed by cardiovascular disease. The under 75 mortality rate from cancer considered preventable is 89 per 100,000 population in Northumberland. This is similar to the England average but significantly lower than the regional average(14).
3.7 Long term conditions
Cardiovascular disease (CVD)
Cardiovascular disease (CVD) covers a number of different problems of the heart and circulatory system, such as coronary heart disease (CHD), stroke, and peripheral vascular disease (PVD). It is strongly linked with other conditions, notably obesity and diabetes, and is more prevalent in lower socio-economic and ethnic minority groups. CVD is a major contributor to health inequalities in Northumberland. The under 75 mortality rate from cardiovascular diseases considered preventable is 53.9 per 100,000 population in Northumberland. This is similar to the England average but significantly lower than the regional average(15).
Coronary heart disease (CHD)
Coronary heart disease (CHD) prevalence, as recorded for the monitoring of the Quality and Outcomes Framework (QOF) – the system for measuring quality of service in general practice – is higher than the regional and national average.
Table 5: Diagnosed CHD prevalence (all ages) 2012/13
Source: Monitoring data on QOF 2012/13, HSCIC
Data collected to monitor the Quality and Outcomes Framework (QOF) shows hypertension prevalence to be higher than the regional and national average, which may be partially due to better case finding. However, a prevalence model16 developed to predict the number of people with hypertension suggests that there are large numbers of people who remain undiagnosed. The 2012/13 QOF data indicate that there were 55,016 patients on Northumberland GP registers with hypertension.
Table 6: Diagnosed hypertension prevalence (all ages) 2012/13
Source: Monitoring data on QOF 2012/13, HSCIC
Diabetes is a chronic and progressive disease that impacts upon almost every aspect of life. It can affect infants, children, young people and adults of all ages, and is becoming more common. Diabetes can result in premature death, ill-health and disability, yet these can often be prevented or delayed by high quality care.
Preventing Type 2 diabetes (the most common form) requires prevention activities to tackle obesity and lifestyle choices about diet and physical activity.
Data collected as part of the monitoring arrangements for the QOF shows that the prevalence of diagnosed diabetes in Northumberland is higher than the regional and of people with diabetes suggests a significant gap between predicted and measured (or diagnosed) levels.
Diabetes can remain undiagnosed for many years; people who are undiagnosed will not receive the routine care and monitoring required to optimise wellbeing and minimise long-term complications. Identifying people who are undiagnosed and providing systematic care for them is therefore a priority if diabetes is to be managed effectively.
Table 7: Diagnosed diabetes prevalence (% of population aged 17+) 2012/13
Source: Monitoring data on QOF 2012/13, HSCIC
Chronic obstructive pulmonary disease (COPD)
COPD is a chronic lung condition resulting from damage to the lung and leads to breathing difficulties. One of the main causes of COPD is smoking, so prevention of COPD is linked to smoking cessation activities, which can be provided by community pharmacies.
Table 8: Diagnosed COPD prevalence 2012/13
Source: Monitoring data on QOF 2012/13, HSCIC
The female premature mortality rate in Northumberland from respiratory disease considered preventable is 19.5 per 100,000 population. This is significantly higher than the England average but similar to the regional average18. COPD is a contributor to health inequalities.
COPD prevalence as recorded within QOF is higher than the average for England as a whole (2.3% versus 1.5%). However, a prevalence model19 developed to predict the number of people with COPD suggests that there are significant numbers of people who have COPD but who are not on GP practice COPD registers.
3.8 Older persons
Many of the people whose lives are substantially affected by long-term illness or disability are in their eighties or nineties and have age-related conditions such as osteoarthritis, visual or sensory impairment, or Alzheimer’s disease. But there are also older people who are disabled by health problems much earlier in life, for instance people who suffer a severe stroke or early-onset dementia.
Population projections indicate the number of persons in Northumberland, aged 65 years and over will increase to over 30% of the total population by 2035. The proportion of people aged 85 and over is projected to increase from 3% of the population to 5% by the year 203020, creating additional demands for social care, housing support and health services. Long term conditions and dementia will be among the biggest challenges faced by health services going forwards.
People with dementia require substantial amounts of care, particularly social care. Pharmacists can contribute to the care of those with dementia by reviewing their medication, and helping to ensure that patients remember to take the medicines they require by advising on and supplying appropriate support where necessary. The number of patients with dementia is expected to rise as the number of elderly people in Northumberland increases. According to the 2012-13 QOF data, there are 2,243 people recorded by Northumberland GP practices as having dementia.
An ageing population will be associated with more harm as a result of falls, in relation to emergency hospital admissions for fractured proximal femur at all ages. Community pharmacists are in an ideal position to review medication which could contribute to dizziness and falls.
As the population ages the proportion of people with a disability is also likely to increase creating additional demands for service provision. In a rural county like Northumberland, provision of these services will be difficult and costly due to the rural nature of the County.
Map 3: Northumberland mid-2012 population estimates – 65+ population
Data source: ONS population estimates
3.9 Mental health
Poor mental health and wellbeing in parts of the county are inextricably linked to socio-economic deprivation and vulnerability and premature mortality. People suffering from serious mental illnesses like schizophrenia or bipolar disorder have a life expectancy that can be 10 to 15 years lower than the average in the local population.
According to the 2012-13 QOF data 0.8% of the Northumberland population have a mental health problem21. Depression in adults is higher than the England average with 6.9% of adults diagnosed with depression on practice disease registers.22 The estimated prevalence of any mental health disorder in those aged 5 to 16 years is 9.5%(23).
3.10 Learning Disability
Life expectancy for people with learning disabilities is lower than for the rest of the population. Evidence shows that people with learning disabilities are 2.5 times more likely to have health problems than other people but are less likely to receive regular health checks or to access screening programmes.
Practice registers show that 6.43 adults per 1,000 registered with a GP have a known learning disability. This is significantly higher than the England average of 4.54 per 1,000. The rate of children known to have learning difficulties is 25.19 per 1,000 pupils.(24)
Northumberland compares favourably with both the North East and England with regard to immunisation rates for children. It also compares favourably with regard to pneumococcal and influenza vaccine rates for the over 65s, which are 74% and 76% respectively(25).
3.12 Prison health needs
Northumberland has one prison, HMP Northumberland. It is a category C prison holding 1,348 male offenders. As in the general population, the average age of prisoners is increasing and consequently their health needs reflect this aging population.
The pharmaceutical needs of the prison population are served through an outsourced healthcare provider. The pharmaceutical needs of those within the criminal justice system who are not incarcerated are met by community services, i.e. community pharmacy. The particular needs of this population require consideration given their high incidence of mental health problems and illegal drug issues.
Northumberland attracts a significant number of holiday makers and visitors. Their health needs are usually met through community pharmacies providing self-care and emergency supply of medicines, or primary care provided by general practice when patients are registered as temporary residents.
There is a small travelling community within Northumberland which makes infrequent but regular camps within the county. A number of travellers are now living on one of three permanent sites in Northumberland. Permanent residents will normally be registered with a GP, others will normally be treated as temporary residents or receive self-care from community pharmacies.