This Evidence Summary presents an overview of the health and wellbeing needs in Nottingham City using the key findings from Nottingham City’s Joint Strategic Needs Assessment (JSNA).
JSNAs are local assessments of current and future health and social care needs. The aim of a JSNA is to improve the health and wellbeing of the local community and reduce inequalities for all ages through ensuring commissioned services reflect need. It is used to help to determine what actions local authorities, the NHS and other partners need to take to meet health and social care needs and to address the wider determinants that impact on health and wellbeing.
Nottingham City’s JSNA chapters each consider a particular health and social care issue or the health and social care needs of specific groups. The full JSNA can be accessed at www.nottinghaminsight.org.uk.It is only possible to present a brief overview of this information in this Evidence Summary and so it should be used in conjunction with the full JSNA.
All supporting data and information for this evidence summary, including references, can be found in individual chapters.
Nottingham City JSNA Evidence Summary prepared by:
Amy Pellow Assistant Strategic Insight Researcher, Nottingham City Council
15 March 2018
The latest estimate of the Nottingham City’s resident population is 318,900 having risen by over 4,600 since 2014. The population is projected to rise from 332,700 in 2014 to 361,300 in 2039. International migration (recently from Eastern Europe) and natural change (the excess of births over deaths) are the main reasons for the population growth recently. The number of births has risen slightly in the last year and remains higher than the start of the 2000's.
29% of the resident population is aged 18 to 29. Full-time university students make up about 1 in 8 of the population. The percentages in other age-groups are lower than the average for England, with the proportions of those between 65 and 79 being particularly low. Compared to some other local authority areas, Nottingham is unlikely to show much ageing or population growth in the short term to 2024.
The City gains young adults due to migration, both international and within Britain, whilst losing all other age groups - this includes losing families with children as they move to the surrounding districts. There is a high turnover of population; 21% of people living in the City changed their address in the year before the 2011 Census.
In terms of ethnicity, the 2011 Census shows 34.6% of the population as being from Black, Asian and Minority Ethnic (BME) groups. This is an increase from 19% in 2001.
The Asian/Asian British group is the largest BME group in Nottingham making up 13.1% of the total population; Black / African / Caribbean / Black British, mixed or multiple ethnicity and White (not White British) groups each account for 6.1 – 7.3% of the total population.
Despite its young age structure, Nottingham has a higher-than-average rate of people with a limiting long-term illness or disability.
White ethnic groups have higher rates of long-term health problems or disability overall, although this varies with age, with some BAME groups having higher rates in the older age groups
Nottingham is ranked 8th most deprived out of 326 districts in England in the 2015 Index of Multiple Deprivation (IMD), a relative decline on 20th in the 2010 IMD. About a third of the super output areas in the City are in the worst 10% nationally. 34% of children and 25% of people aged 60 and over live in areas affected by income deprivation. There are high levels of child poverty in the City. In 2014/15, 42,000 children and young people lived in workless or low income households.
13.4% of people aged 16-64 have no qualifications, higher than the national average of 7.8%. The difference is most evident in the 50-64 age group, where some 27.5% have no qualifications compared to 11.4% nationally. 29.6% of 16 to 64 year olds have qualifications at NVQ4 level – degree level or above, compared with 37.9% in England.
The employment rate for the City was 62.6% in 2016, compared with 74.3% for England. This figure is deflated by the presence of so many university students, but even if they are excluded the rate is still low (October 2014 to September 2015 figures: 72.5% compared with 78.1% nationally). 7.9% of the population aged 16-64 were claiming Employment and Support Allowance, Incapacity Benefit or Severe Disablement Allowance in November 2016, compared with 5.8% nationally. 3.3% were unemployed (claiming Job Seekers Allowance or Universal Credit claimants not in employment) in March 2017, compared with 1.9% nationally.
The most common oral disease in children is dental caries, which is more prevalent in children from poor or disadvantaged groups. In Nottingham, the proportion of 5-year-olds free from dental decay is 64.4%, compared with 75.2% in England.
Surveys of child dental health are undertaken as part of the Public Health England Dental Public Health Intelligence Programme. The 3-year-olds’ survey (2012/3) found that 16.6% of 3-year-olds in Nottingham City had decay experience, compared with 11.7% in England. The relationship to deprivation is not as strong as that seen in 5-year-olds. The 5-year-olds’ survey (2014/15) found that 35.6% of 5-year-olds in Nottingham City had decay experience, compared with 24.7% in England. The experience of decay correlates with deprivation, with Aspley, Bilborough and Leen Valley having the worse prevalence of decay (figure 1). The 12-year-olds’ survey (2008/09) found that 36% of 12-year-olds in Nottingham City had decay experience, compared with 33.4% in England. Again, this correlates with deprivation.
Figure 1:Percentage of 5-year-olds with tooth decay experience by area committee, Source: PHE, 2016
There is a reasonable geographic distribution of NHS dental practices in Nottingham City, although they are not necessarily located in the areas with the highest levels of deprivation where there is liable to be the greatest unmet need. Practices are not necessarily located in areas with high densities of children, and there is a lack of practices in areas with high densities of children such as Bulwell and Aspley. Almost all residents can access an NHS dental practice within walking distance, although there are some gaps. All practices are accessible via transport links.
The proportion of children living in Nottingham and accessing dental services is low compared to the Midlands and England. In the period October 2014 – September 2016, 66% of children in Nottingham City were seen by an NHS dentist. This compares to 70% in the Midlands and 68% in England.
The rate of referrals to Children’s Social Care in Nottingham in 2016 was 882 per 10,000, higher than the statistical neighbour average of 701 per 10,000. The rate of children on a child protection plan in Nottingham in 2016 was 83 per 10,000, higher than the statistical neighbour average of 57 per 10,000.
In 2016 there were 4,016 referrals to children’s social care in Nottingham. The greatest number of referrals came from schools/colleges (20%), followed by the police (20%). The lowest number of referrals came from learning disability and mental health staff (<1%).
In 2015/16, 3,885 Children’s Assessments took place in Nottingham. These assessments identified 9,728 risks, actual and potential (many children and young people had risks identified in more than one category). 51% of assessments identified risks related to domestic violence. Domestic violence was the most commonly identified risk in Nottingham during this period, as it was in England. 35% of assessments identified risks relating to parental substance misuse (figure 2).
Figure 2: Risks to children identified at initial assessment 2015-16
The rate of re-referrals in Nottingham in 2016 was 23%, similar to the statistical neighbour rate of 20%. The rate of re-referrals is decreasing, which suggests that while more children in Nottingham are supported through formal safeguarding procedures than in other local authorities, fewer are re-referred because children, young people and families receive the right support at the right time.
There are a number of challenges relating to safeguarding children, including the declining number of Public Health Nurses (formerly School Nurses); the high cost of specialist placements for children and young people; the number of children in care; worklessness/poverty increasing family stress and decreasing the capacity to parent effectively; and new and emerging groups such as refugee and asylum-seeking families and unaccompanied asylum-seeking children. Further insight is needed into the safeguarding needs of these groups. In addition, the number of children aged 15 years and under is projected to rise by 2,700 by 2020, not including children arriving from Europe and farther afield. If the proportion of children and young people requiring safeguarding increases in tandem then there will be an increased pressure on services.
There are approximately 69,000 children in the care of Local Authorities (LA) at any one time. The majority are Children in Care (CiC) due to abuse or neglect (61%). In September 2016 there were 605 CiC in Nottingham, with 63% being there due to abuse or neglect.
CiC have poorer outcomes than the general child population, primarily due to their early life experience prior to coming into care. These poorer outcomes can be seen across a variety of indicators, including educational attainment, school attendance, and school exclusion, offending behaviour, mental health, teenage pregnancy and substance misuse.
In Nottingham in 2015/16, the rate of CiC was 90 per 10,000 children and young people, significantly higher than the national average of 60 per 10,000. Children in the most deprived neighbourhoods have a greater chance of being on a child protection plan or being taken into care. Nottingham is ranked the 8th most deprived out of 326 LAs and the 4th most deprived for poverty relating to children; therefore it can be expected that Nottingham might have higher rates of CiC.
The number of children and young people aged 15 years and under in Nottingham is projected to increase by 2,700 by 2020. If the proportion of CiC increases in tandem then this will increase pressure on services. This figure does not include Unaccompanied Asylum-Seeking Children (UASC). There has been an increase in UASC, a group that can have significant physical and mental health needs.
It is estimated that within the UK there are 137,000 women aged 15 and over living with FGM. As FGM is a hidden issue this is likely to be a significant under-representation of the true size, which often only comes to light when related health problems occur or the woman is pregnant. In Nottingham there were 80 cases of FGM recorded by healthcare staff in 2015-16. For the majority of cases recorded (92%), FGM was undertaken between 0-9 years of age and all of these happened outside of the UK. Nottingham reported 53% of all recorded FGM cases in the NHS England North Midlands group, but it is unclear as to whether this is because Nottingham’s staff are better at reporting FGM or if there is truly a higher prevalence. In 2016, Nottingham became a ‘Zero Tolerance’ city in respect of FGM.
In Nottingham, there has been good progress made in reducing under-18 conception rates. The data for 2015 - the most recent available annual conception data - shows that Nottingham City has experienced a decrease in the rate of teenage conceptions from 32.7 per 1000 girls aged 15-17 in 2014 to 31.2 in 2015. In 1998, when action to reduce unplanned teenage pregnancy became a local and national priority, the conception rate was 74.7 per 1000. Nottingham’s under-18 conception rate is higher than the national average rate of 20.8 conceptions per 1000 in 2015 and the Core Cities average rate of 26.5 per 1000 (Core Cities: Birmingham, Bristol, Cardiff, Glasgow, Leeds, Liverpool, Manchester, Newcastle, Nottingham, Sheffield). The wards with the highest three-year aggregated rates of teenage conceptions over 2012-14 were Arboretum, Aspley and Bulwell, whilst Wollaton West had the lowest published rates.
Carers are Nottingham City’s largest form of ‘early intervention’, supporting vulnerable citizens and preventing the people they care for from requiring a greater degree of health and social care support. There are approximately 27,000 carers in Nottingham, which equates to 8.8% of the population. This is slightly lower than for England (10.2%) and the East Midlands (10.8%), although more adults aged 35 years and over are providing more hours of care per week than the national average. This figure is likely to be a significant underestimation as carers often do not identify themselves as such. In 2015/16, around 1,140 Carers’ Assessments were carried out in Nottingham City, which represents only a small proportion of carers in the City.
According to 2011 Census data, 3.52% of the Nottingham population aged 35-49 provides 50 or more hours of care per week, compared to 2.68% nationally. 4.98% of the Nottingham population aged 50-64 provides 50 or more hours of care per week, compared to 3.66% nationally. 5.90% of the Nottingham population aged 65 years and over provides 50 or more hours of care per week, compared to 5.29% nationally.
17% of Nottingham’s carers are 65 years and over, often providing high levels of care. 45% of these carers provide 50 or more hours per week.
7.98% of males and 10.40% of females in Nottingham provide some amount of care. The proportion of women to men is approximately the same for Nottingham, the East Midlands and England (1.3 female carers to male carers).
Overall there are slightly fewer carers in Nottingham compared to the national average, but these carers are providing more hours of care per week.
There are approximately 3,300 carers in Nottingham aged under 25 years old. 2.5% of carers are under 16 years and 10% are aged 16-24 years. 20% of carers aged under 16 years provide over 20 hours of care per week. Many young carers are ‘hidden’ and are not being identified or assessed for support. Reasons for this include family loyalty, stigma, bullying, a lack of awareness of formal entitlements and a reluctance to seek help.
The prevalence of carers amongst the BME community is approximately equivalent to that of the general population. Higher incidences of caring are reported amongst the Black Caribbean, Indian, Pakistani and Bangladeshi communities. 15% of Indian men and 19% of Pakistani women are carers, compared to 11% of the general population. It is likely that these figures represent only a fraction of carers amongst the BME community.
There are 7,700 children in Nottingham with Special Educational Needs and Disabilities (SEND). Many parents and carers report struggling to access services, lengthy processes and negative experiences. Many become disengaged from services.
The number of Nottingham residents aged 65 and over providing unpaid care is predicted to rise from 5,028 in 2015 to 6,626 by 2030, a 32% increase. In addition, the Nottingham City school population has risen by 3,248 since 2009, an increase of 8.45%. Pupils with SEND continue to increase in line with the population, and the number of parents/carers with them.
The number of people in the UK adult population with a learning disability (LD) is estimated to be 2%. Approximately one quarter of these are known to one or more local services (about 0.5% of the adult population).
Based on the above, the number of adults with LD in Nottingham City can be estimated to be 5,060. Based on GP registers, prevalence of adults with LD known to primary health care services is 0.54%. If the three predominately student practices are removed from the calculation then the prevalence rate rises to 0.67%. In 2017, a snapshot of social care records showed 1,145 adults known to adult social care services as having LD.
Adults with LD are likely to have unmet health needs. Obesity and overweight are disproportionately high in the LD population. The proportion of annual LD health checks at GP practices is variable and many people do not receive a full check or action plan (figure 3). It is estimated that approximately half of those eligible receive the service. There are low levels of employment and high levels of social vulnerability. Adults with LD may be at risk of hate crime, exploitation and substance misuse.
Figure 3: Nottingham City learning disability health checks by GP practice 2012/13
Future need for services is dependent on a rising, ageing and more diverse LD population. National estimates suggest sustained growth of 3.2% per year. For profound and multiple LD the estimated increase is 1.8% per year.
The number of adults in Nottingham predicted to have a moderate or severe LD is predicted to rise by 2% in 2020, 4% in 2025 and 8% in 2030; these are likely to be underestimates.
Viral Hepatitis is inflammation of the liver due to a viral infection. Hepatitis B and C are blood-borne viruses spread via blood or other bodily fluids. They can both result in chronic disease which can lead to liver cirrhosis and failure. Hepatitis A and E are spread through the consumption of food or water contaminated with faeces of an infected person. They usually resolve on their own.
It is difficult to ensure local data is accurate due to those infected often being symptomless and undiagnosed. According to Hospital Episode Statistics, during 2016 there were 130 admissions from Nottingham City where the primary diagnosis was viral hepatitis.
There is a strong relationship between viral hepatitis and deprivation. In hepatitis C this is due to its primary risk factor being injecting drug use and hepatitis B because it is primarily a disease of migrant populations where it is spread by maternal transmission or poor health care. In Nottingham, individuals in the most deprived quintiles are almost three times as likely to be admitted for viral hepatitis compared to individuals in the least deprived quintiles. Arboretum, Radford and Park, Berridge and the Dales had the highest number of episodes.
In 2015-16, 100% of eligible children under one year in Nottingham received three doses of the hepatitis B vaccine at any time by their first birthday. 95% received four doses at any time by their second birthday. Since 1st August 2017, all babies born in the UK will be eligible for the hepatitis B vaccine.
In Nottingham City in 2014-15, 17.5% of eligible individuals who entered substance misuse treatment completed a course of the hepatitis B vaccine, double the England average of 8.7%. 86.2% of individuals were tested for hepatitis C, slightly higher than the England average of 81.5%.
There are new, highly effective oral medications for hepatitis C, with cure rates being 97% or greater. NHS England has set a national target to cure 95% of patients with hepatitis C. Nottingham University Hospitals NHS Trust (NUH) has a CQUIN (Commissioning for Quality and Innovation) to ensure that delivery of the therapy hits the number of patients required by NHS England. Without a change in provision, NUH will fail to hit the target. Significant expansion of community and outreach services into high risk populations is required.
There is a lack of knowledge regarding viral hepatitis amongst disadvantaged and migrant groups, as well as amongst the public and health professionals. There is a lack of targeted prevention activities among disadvantaged groups who are vulnerable or socially excluded, such as homeless people, prisoners or people who inject drugs. There are no agreed national or local targets for testing of viral hepatitis and no agreed approach to testing for hepatitis B and C in those with risk factors who approach primary care services.
In 2015 there were 2,446 recorded deaths in Nottingham, which reflects the national picture in representing 1% of the population. 87% of deaths occurred in citizens aged 60 years or over and deaths were relatively equally distributed across gender (figure 4). The main causes of death were cancer, circulatory disease and respiratory disease, these three conditions being responsible for 70% of all deaths. It is estimated that 75% of deaths were not sudden, but expected, and so might have benefited from end-of-life intervention.
Figure 4: Deaths by age group and gender, Nottingham City 2015
In 2015/16, 0.35% of Nottingham’s registered GP population was on the palliative care register. In line with the national picture, this is considerably less than the 1% of the population that dies each year and the 0.75% of the population for whom death is not sudden, but expected.
During the period October 2015 to September 2016, 989 patients were registered on the Electronic Palliative Care Coordination System (EPaCCS). This represents 40% of annual deaths and 54% of anticipated deaths. During the period February 2016 to January 2017, approximately 1000 patients accessed one or more formal end-of-life care service. This represents 41% of annual deaths and 55% of anticipated deaths.
In Nottingham, the most common place of death is hospital (57%), followed by home (24%) care home (17%), other (2%) and hospice (0% - Nottingham provides community beds instead of hospice beds). In terms of ranking, this is consistent with the national picture, but there are some significant differences in place of death. Nottingham citizens are significantly more likely compared to England as a whole to die in hospital (57% and 47% respectively) and significantly less likely to die in care homes (17% and 23% respectively). Given that quality of end-of-life care is considered best in hospices, the home and care homes as opposed to hospitals, these statistics suggest that improvements are required to reduce the number of hospital deaths in Nottingham. Outcomes are significantly improved for citizens registered on the EPaCCS, the use of which increases the proportion of people dying in their preferred place.
National evidence has revealed differences in access and quality of care across a number of factors. These include age, diagnosis, ethnic background and social circumstances. Socio-economic deprivation has been identified as a risk indicator for poor end-of-life care outcomes. As Nottingham ranks 8th most deprived out of the 326 districts in England, this poses a challenge to ensuring positive outcomes. There are a number of disparities and unmet needs in terms of access to, and receipt of, care among the BAME population (the 2011 Census shows that Nottingham’s BME population is 35%). People with learning disabilities may also experience difficulties in accessing end-of-life care that meets their specific needs.
In Nottingham the population of citizens aged 60 years and over is expected to increase by 7% by 2021. This age group accounts for 87% of deaths. Dementia is expected to increase by 15% between 2015 and 2020, and there will also be an increase in limiting long-term illness and moderate or severe learning disability. As a consequence there will be an increasing demand for end-of-life care.
Like most other areas in the country, homelessness in Nottingham has increased over recent years. In 2016-17 there was an average of 19 approaches per day to the local authority Housing Aid service from new households requiring assistance as homeless or threatened with homelessness, a rate of 33 per 1000 households. 23% of approaches resulted in a homeless application. This represents a rate of 6.7 applications per 1000 households, higher than the national average of 4.9 per 1000 households. 48.2% of these applications were accepted, which is relatively in line with the national average.
43.4% of applications were as a result of a private sector tenancy ending (figure 5). This represents a dramatic rise on previous years. Other reasons include domestic violence, non-violent relationship breakdown and relatives or friends asking a person or persons to leave their home.
Figure 5: Ending of a private sector tenancy as percentage of all reasons for homelessness
The past year has seen a significant increase of 150% in the number of rough sleepers in Nottingham. The most recent official figure is 35 rough sleepers in 2016. The rough sleeping rate per 1000 households is now the same in Nottingham as in London.
It is important to note that the data does not give an absolute reflection of homelessness in the City, with the hidden homeless not being included.
Frontline agencies report the main issues for those who are homeless as poor mental health, multiple and complex needs, increased use of New Psychoactive Substances (NPS) and increased ethnic diversity and language barriers.