A JSNA Steering Group with representatives from across the 3 statutory directorates (NHS Nottingham City, Children’s Services and Adult Support and Health) leads the JSNA process. Chapters are written by a range of authors from across the 3 directorates, including commissioning managers, thereby ensuring the JSNA is fully embedded in our commissioning processes.

There has been a long tradition in Nottingham City of a commitment to partnership working, and particularly of the need for ‘shared intelligence’ for better decision making. To facilitate this, in 2005 we set up a ‘Nottingham Insight Network’, which developed a web-based knowledge management system, ‘Nottingham Insight’ , which is regarded as the definitive site for all local data and resources. The website hosts our JSNA (see Figure 1), alongside a range of supporting data and documents, and is used as an evidence base for commissioning decisions across all partners. These shared intelligence arrangements have been invaluable for the JSNA process, in terms of facilitating user-friendly data sharing, carrying out the joint needs assessment work and also dissemination of the chapters, which are all publically available.

Nottingham’s first JSNA was completed in 2008 with the development of robust processes for sharing intelligence to ensure needs-based commissioning for health and wellbeing in Nottingham City. Each year a full review of each chapter is undertaken, with the third review due for completion by April 2010.

Participation in the 2009 Department of Health JSNA dataset project has supported us to give increased focus to the ‘joint’ element of the needs assessment work, looking at systematically embedding user and front line staff views and combining data and information from populations known to contribute to the risks of young children.

Figure 1: Homepage of Nottingham’s web-based Joint Strategic Needs Assessment

 

The chapters in the JSNA are divided into the following 5 sections:

1. Demographics and Social and Environmental Context
2. Life Expectancy
3. Behavioural Factors
Alcohol, Problem drug use in adults, Substance Misuse in children and young people (alcohol and drugs), Diet and nutrition, Adult obesity, Child obesity, Physical activity, Smoking
4. Children, Young People and Families
Avoidable injuries, Carers, Children in Care, Dental health, Disabilities and learning difficulties, Domestic violence, Immunisations and vaccinations, Maternities and pregnancy, Mental health, Safeguarding of adults & children, Sexually transmitted diseases including HIV and AIDS, Teenage pregnancy
5. Adults
Adult Dental Health, Asylum seekers, Refugee workers and Migrant workers, Avoidable injuries, Cancer, Cancer screening, Cardiovascular Disease, Carers, Chronic Obstructive Pulmonary Disease, Dementia, Diabetes, Domestic violence, End of Life, Homelessness, Housing, Immunisations and vaccinations, Learning disabilities, Mental health, Long-term health conditions and older people, Offenders’ health & wellbeing, Physical and sensory impairment, Sex workers, Stroke

3.1 Where are we now?
Demography
In 2008, Nottingham City’s resident population was estimated to be 292,400. Nottingham’s population may be larger than this census-based figure: in 2008, there were 306,876 people resident in the City registered with primary care practices – an additional 14,476 over and above the census estimate. Overall, there is a rising trend in the population, with a 23,500 increase since 2001 and a projected rise to at least 301,400 by 2013 and 309,600 by 2018. While the population increase remains significant, it seems to be slowing down.

The main reasons for the population increase are international migration (recently from Eastern Europe) and an increase in university students, supported by a big increase in house building. The number of births has risen considerably and is likely to continue to rise over the next five years. However, the proportion of children is lower than average, although much less so for under-fives. This may indicate that although birth rates are comparatively high, a considerable number of parents and children leave the City before starting school. The City therefore gains young adults due to migration while losing all other age groups.

The City has a very young population (Fig.2), with a high proportion (30%) of people aged 18 to 29, due largely, but not entirely, to the presence of the two universities (students account for approximately 1 in 9 of the population). The percentages in other age-groups are commensurately lower than average, with the proportion aged 40 to 69 being particularly low. The trends in the age structure of the city do not follow the average national trends. In the short to medium term, the city is unlikely to follow the national trend of increasing numbers of people over retirement age.

Figure 2 Age structure for Nottingham City

Deprivation, socio-economic status and Mosaic® segmentation
The Index of Multiple Deprivation (2007) ranks Nottingham 13 out of the 354 local authority districts in England. The high level of deprivation affects an extensive part of the city, with 56 of the 176 Super Output Areas being within the 10% most deprived in the country, and 106 in the worst 20%. Sixty percent of residents live in the 20% most deprived areas of the country.

Mosaic © is a geo-demographic tool to describe different groups within a population. This sophisticated tool includes extensive information on socio-economic and lifestyle factors. Figure 3 shows the ten Mosaic groups living in Nottingham, with the population per group and their proportion. This illustrates that there are a number of dominant groups in Nottingham, compared to the national average – Groups D, E, F and G. Figure 4 shows where Groups F and G live in Nottingham.

Figure 3 Nottingham’s Mosaic profile with key national Mosaic lifestyle indices.

Figure 4 Nottingham City: where Mosaic Groups F and G live, and levels of deprivation. Source: Index of Multiple Deprivation (IMD) 2007, Experian Public Sector Mosaic

Ethnicity
The large majority of people who live in Nottingham are White British, although 24% of Nottingham’s population described themselves as being from Black and minority ethnic (BME) groups, compared to 16% nationally (ONS 2007). This proportion has been steadily increasing and is projected to increase to at least 25% by 2016. The Pakistani, Indian, African Caribbean and mixed heritage groups are the largest Black and minority ethnic groups within Nottingham.

BME groups generally have a younger age structure than the overall population and account for more than one in three (37%) of Nottingham school pupils. The mixed groups (46%) and the Pakistani group (30%) have the highest proportion of their total population aged under-16. These compare with only 16% of White British people.

Figure 5 Black and minority ethnic groups in Nottingham compared to England. Source: ONS, 2007

Life expectancy
In overall terms the City’s residents are less healthy than elsewhere in the country. Life expectancy in Nottingham for men is 75 years, compared with 78 for Greater Nottingham and for England, and for women 80 years compared with 82 for Greater Nottingham and England . The gap in life expectancy between Nottingham and England has been widening since the early 1990s (Figure 2). Within the City there are high levels of health inequalities – life expectancy varies by 10 years between the most and least deprived wards of St Ann’s and Wollaton West. 15 of the 20 wards have significantly lower life expectancy than the regional average.

The most significant disease contributors to our lower than average life expectancy are premature deaths caused by cardiovascular disease (CVD), respiratory diseases and cancers.

Figure 6: The growing gap in life expectancy for men between Nottingham, England and our ONS cluster.

The level of premature death from CVD (which includes heart disease and stroke) has fallen significantly in Nottingham (a 46% fall between 1997 and 2007) mirroring the national trend, although the gap with the rest of the country is not closing. Locally the marked gap persists between the most deprived and least deprived fifth of areas.

Mortality rates from cancers are 20% higher than the national picture. Locally a large proportion of the cancers occurring are lung, which is related to the high prevalence of smoking in the City. This has poor survival rates compared to other cancers. The City’s high rate of infant mortality also impacts significantly on life expectancy. The infant mortality rate in Nottingham is consistently higher than the national average and is the 2nd highest in the East Midlands.

Wellbeing and specific needs
Adults with mental health support needs are one of the most socially excluded groups in society. Mental illness can be both a cause and effect of not working, and the City has higher than average numbers claiming Incapacity Benefit for mental health reasons. It is difficult to measure both mental health and mental illness, but in Nottingham it has been estimated that around 40,000 people have a common mental health problem. The level of severe mental illness in the City is 45% above the national average. Around 1000 people have a psychotic disorder.

Another group experiencing deep and persistent exclusion are Problem Drug Users. There are an estimated 4000 Problem Drug Users in the City. As well causing harm to the individual (including premature death and illness), there is an impact to the immediate family and friends and/or the wider community e.g. violent and acquisitive crime. Alcohol misuse is another feature of the City that contributes to lower life expectancy, as well as to greater violence and disorder and mental health problems. It is estimated that there are over 15,000 harmful drinkers and 4,500 dependant drinkers in Nottingham, and that 1 in 20 deaths in the City are alcohol related. There are also rising rates of alcohol-related hospital admissions.
An estimated 8,700 people have a severe disability of some kind, but only around 15% of this number use health and social care support services. Older people with physical disabilities or difficulties are the largest social care client group. The Department of Health records 770 people registered as blind in Nottingham and 1090 people registered as partially sighted. There are 615 people registered as hard of hearing and a further 555 registered as deaf, the largest group of which will be aged 65 plus due to increased incidence of hearing impairment with age. This figure is likely to be an undercount as registration is voluntary with no immediate benefit to the individual.
We estimate that there are nearly 6000 people aged 18+ with a learning disability in the City. The South Asian community has a three times higher prevalence of learning disability due to complex factors. Whilst the complexity of disability and overlap with other health and wellbeing issues makes it difficult to gain a clear picture, client data suggests that there are many people in this situation who may be entitled to support, but are not receiving it. There is also evidence that need is in excess of supply in relation to housing-related support packages for people with a learning disability.

Older people
Analysis using MOSAIC® profiling data shows a higher than average proportion of ‘Twilight Subsistence’ households in the City. These are characterised as households with older people living in social housing with high care needs. One third of City residents aged 60 plus claim Pension Credit, an entitlement intended to raise their income to a minimum level, compared to just over one fifth in Greater Nottingham and England. Within Nottingham, areas with the highest proportions of income deprived older people tend to be areas where relatively few older people live, which can create isolation. Those of pensionable age also tend to have low levels of car ownership (unless they live with somebody of a younger age), which can act as a barrier to accessing services.
Older peoples’ health is generally much worse than that of other groups, with the Census reporting that nearly half had a limiting long term illness or disability. Two thirds of clients receiving adult social care support are older people. Most of these require help because of a physical disability (including sensory impairment) or frailty, and one in ten needs support due to mental health. The City has a very high rate of avoidable injury in the over 64 year olds. 70% of these injuries are due to falls, which can directly lead to disability or death for older people.

Carers
Many people provide care for a family member or friend who is elderly, disabled or in poor health. According to the 2001 Census there were more than 24,000 people in the City providing care duties each week. This equates to 9% of the population, slightly below the England rate of 9.9% which probably reflects the younger age structure of the City. Of these carers, 26% (6,240 individuals) provided in excess of 50 hours care per week, and in the region of 2000 carers are currently known to Nottingham City Council Adult Services. Around one quarter of carers are aged 60 years or above.

Children and young people
Teenage pregnancy is high in the City compared to the rest of the country at 67.3 conceptions per 1000 girls aged 15-17, compared to 41.4 nationally. Some wards in the city have a rate higher than twice the national average. This overall high rate for the City remains static despite implementation of interventions that have been effective elsewhere. 20% of year 6 age children are classed as obese, and are likely to grow into obese adults at risk of heart disease, stroke and type 2 diabetes. The City has high rates of referrals to Children’s social care and a high proportion of children who are subject to a child protection plan; both are twice the rate of our statistical neighbours whilst our numbers of Looked After children are relatively low. Children under 5 are most
at risk of death or serious injury as a consequence of child protection issues , this risk is further increased if they are living in households where domestic violence is present and/or their parents/carers have mental health or substance misuse issues and Nottingham City has higher levels of these risk factors than the national average.

3.2 Why are we here?
Nottingham's high levels of deprivation, high level of unemployment, low educational attainment and unhealthy lifestyle (high smoking, poor diet, low physical activity) are all interrelated determinants of its poor health outcomes and high level of health inequalities.

3.3 Where are we going?
Nottingham’s focus on improving lifestyle risk factors for disease is beginning to have encouraging results, with an increase in physical activity levels in the city. However other risk factors for the main killer diseases, such as smoking, remain high and there are concerning trends of an increase in obesity and alcohol abuse. The proportion of the population belonging to BME groups is increasing, and these groups will be at increased risk of stroke in the future. The current national trend of rising obesity levels is set to continue with obese children at high risk of becoming obese adults. 40% of Britons are predicted to be obese by 2025 and nearly 60% of the UK population could be obese by 2050. The levels in the City will almost certainly follow this trend and may well be higher. These factors are likely to detrimentally impact on the recent improvements in life expectancy in the City and are of particular concern given the levels of inactivity noted above.

The number of people with mental health problems may increase in the short to medium term because of the current economic climate causing increased financial hardship and unemployment. This could also increase smoking prevalence and obesity levels which may have a further detrimental effect on life expectancy.

Sexual health trends also provide concern for a city with large numbers of young people. Rates of HIV in the City have climbed rapidly over the last 3 years with a doubling of the number of people with HIV. Around 50% of all new cases are people recently arrived from abroad.

The City will also face challenges in its provision of health and social care. The numbers of residents aged 85 years and above is projected to increase, with a knock-on effect on carers, many who will be elderly themselves. A local mapping exercise of people with learning disabilities concluded that the number of day service users could increase by 73% by 2020. Medical advances which have increased survival rates of premature babies and life expectancy, are expected to lead to growing numbers of people with disabilities and in particular, more complex disabilities and needs.

The JSNA is an ongoing, iterative process that needs to be firmly embedded in the commissioning cycles of our respective organisations. This JSNA will provide accurate, relevant and up-to-date information for our commissioning for 2010/11.