People in Essex enjoy good health and wellbeing

1. People in Essex enjoy good health and wellbeing Essex County Council Commissioning Strategy Version: consultation draft

2. Contents page Indicators, Principles and Leads 2 Summary Slides 5 Relationship with other Outcomes and Strategies 7 Overarching Strategic Actions 8 Quality Criteria 9 People in Essex have a healthy life expectancy 11 Reduced differential in life expectancy across different areas of Essex 13 Prevalence of Healthy Lifestyles 16 Percentage of Children Achieving at School 34 Percentage of Working Age People in Employment 37 Percentage of People living in Safe and Suitable Housing 41 Percentage of Households living in Fuel Poverty 45 Prevalence of mental health disorders amongst Children 50 Prevalence of mental health disorders amongst Adults 54 Teenage Pregnancy Rates 58 Customer/User Views 63 Our Partners and our Relationship with them 64 Category Strategy 68 Risks and Mitigations 72 Delivering Change within our financial envelope 73 Information Governance and Information Technology Strategies. 75

3. 2. People in Essex enjoy good health and wellbeing

5. SUMMARY People in Essex enjoy good health and wellbeing Why is it important for the people of Essex to have good health and wellbeing? ECC are responsible for the health of the public we serve. Health may be seen as a “good” or right for people and is essential if people are to achieve their potential and to live a long life. We embrace the WHO (World Health Organisation) definition of health as a state of physical, mental and social wellbeing not just the absence of illness. What is the strategy? We are able as a whole County Council working with a range of partners to influence, impact and address all the key drivers for health. Our strategy is to recognise a broad definition of public health and to ensure public health considerations inform our commissioning decisions. Delivery of other Outcomes will be key to delivering this one as they are key drivers of health. Additionally we will commission bespoke public health interventions to enable individual s and communities to make the right lifestyle choices together with commissioning clinical interventions that improve health and prevent illnesses. Financial Challenge To deliver the Strategy and to meet any financial challenge will require us to pursue the DH with vigor through all possible routes to secure our fair share of the public health national resource in line with the ACRA formula. Robust and challenging commissioning will continue to secure efficiencies from the grant that will enable progress towards delivery of the strategy and to meeting financial challenge. Delivery in full would be not be possible with a level of funding 40% below our target (sum of distance from target. Savings made to date and a further 20% savings). The securing of the additional grant is therefore critical and is a key strategic action if we are to deliver on both the Outcome and financial challenge Measuring progress Many of the indicators supporting this outcome are infrequently measured and published data, which requires central collection and collation is often several years out of date. Some of the indicators will take some years to change even with optimal interventions and sometimes the link between specific agreed action and the change in an indicator can be hard to exactly ascribe. These issues are common to all preventive interventions. It is proposed that by using interventions where there is a strong evidence based link between that intervention and a given outcome, that delivery of relevant process measures, that can be recorded in real time, is a strong proxy that we are on track to deliver an agreed indicator..

6. SUMMARY How will the strategy secure improved health and wellbeing for the people of Essex? ECC are responsible for the health of the public we serve. While this was formalised with the shift of responsibility for public health from the NHS in April 2013, it has long been a recognised Council Outcome. Much of what we do impacts on public health whether it is a direct use of the public health grant to commission a specific service or the impact of our broader policies around social care, education , the economy and the environment and communities. Indeed the shift of public health responsibilities to the Council was driven by a national recognition of the critical importance of these factors in enabling good health and wellbeing. We will need to further integrate public health and public health skills and thinking into the organisation to best influence this broad agenda. Good health underlines and is interlinked with many of the other outcomes in our strategy. Material wealth and employment are critical drivers of health and depend on both a vibrant economy and education and learning. Similarly both a sense of control and a safe environment reduce stress and support health. Fundamentally future experience of health starts to be formed from conception and action in early years is crucial to ensuring optimal lifetime health and wellbeing.Links will be made to these outcome strategies, rather than replicating that here. Improving public health will require also a focus on lifestyle choices around smoking. alcohol, diet, physical activity, drugs and sexual health. This will involve both supporting the population to make healthy choices and helping them address unhealthy ones and their consequences. Additionally we must ensure clinical interventions that improve health such a s blood pressure, cholesterol and depression management are systematically available and of high quality.• Public Health principles in Essex have been set by a Member’s Reference Group and include a focus on addressing inequalities. This is an important driver in our actions to deliver this outcome. While generally an affluent county, the most deprived area in the whole of England lies within Essex and there are particular vulnerable groups within the Essex population who suffer poor health outcomes. Our strategic response needs to address this. We need to ensure that services are available to the whole population but are particularly targeted at those with the greatest needs who are often less likely to engage. We also need in some areas to have extra bespoke services addressing the specific needs of these people.. This approach is called Proportional Universalism The indicators chosen to support this outcome are varied and reflect the breadth of action required to deliver improved health. It is important however that our actions are focused broadly on delivery of the outcome rather than slavish adherence to chasing what is in effect a sample of indicators. Indeed there are a number of process measures that we should consider in ensuring progress towards this outcome. .• Delivery of this strategy will be within the financial envelope of the public health grant. To deliver under financial pressure we must ensure Essex receives its full fair share grant. Success in this work will require close work with other key partners who have a major impact on public health, these include the NHS, district , borough and city councils, schools, police, fire services and voluntary sector groups, local employers and communities. We will need to develop strong new links with DC/BC and City Councils.

7. Relationship with other Outcomes and Strategies Delivery of this Outcome is inextricably linked with other agreed outcomes. Longer term health and wellbeing will be delivered through material wealth in the population accompanied by sound lifestyle choices. The former will be delivered through action under our Outcomes around best start and around education and Lifelong learning , both ensuring young people can achieve their potential. The latter will be aided by action in early years and schools around healthy behaviours around diet, exercise, risk taking behaviours and sexual health. Health is similarly linked to the economy and employment so progress around our economic growth outcome will be crucial. It is likely that measurable geographical improvements in reducing measured inequality in areas such as Tendring will ONLY be possible through focussed economic action. Similarly the health of specific vulnerable groups such as those with mental health issues will require action in this area. There are numerous links with our safe communities outcome. Children in care have poorer educational outcomes and lifestyle choices than average and higher levels of poor mental health. Action to deliver reduced numbers of young people in care will therefore improve health. Similarly accident prevention has a link to health and action in this strategy around falls will help with indicators within the safer outcome. Victims of Domestic abuse suffer considerably in terms of both mental and physical health and action in this area will again improve health. High Quality sustainable environment overlaps directly in terms of the fuel poverty indicator. Our environmental Outcome has an indicator around cost of energy to homes, one of the key drivers of fuel poverty. Additionally access to open spaces can impact on physical activity and mental health and wellbeing. “People can live independently and exercise control over their lives “is closely linked especially around the proportion of people who can live independently. The ability to live independently is positive to wellbeing but crucially achieving this will require delivery of the actions outlined in this strategy to reduce vascular diseases and strokes, to reduce mental health issues including depression that predispose to dependency, and to reduce falls, diabetes, and lung diseases related to smoking.

9. Quality Criteria • The discussions that have taken place with operational teams on future plans; • This strategy will largely be delivered through procurement from external providers. While they have not as yet had sight of the strategy, they are aware of thinking around specific elements relevant to them. • Where there is an implication for ECC operational colleagues, they too have been aware of discussions eg Adult Ops colleagues in discussing involvement of social workers in screening older people for depression. • The research and analysis (e.g. benchmarking) that has been carried out to support the proposed strategic direction; • Where available national data has been used related to the Indicators. In a number of areas this has been insufficient to allow a trend to be developed so alternative measures have been used where historic trend is available to set direction. All proposed actions are evidence based . • The range of commissioners and members who have been involved in the development of the Strategy document; • The document has been shared with and benefitted from input from a wide range of People and Place commissioners including leads for all other Strategic outcomes as well as a range of Tier 3 and Tier 4 managers. • It has been developed throughout with input from Cllr Naylor and has been shared with a number of cabinet members including Cllr. Madden, Aldridge, Bentley and Gooding. It was also presented to Member’s Reference Group although attendance was low. • Externally It has been shared with CCG Accountable Officers and NHSE Executives with comments received from some. It has been shared with a number of DC/BC and there has been a presentation to Members in Tendring DC. Comments received from 3 CCGs and Chelmsford City (to date) have informed the text. • Governance arrangements for taking decisions on the issues highlighted by the strategy – in cases where partnership governance is an issue, this should be accompanied by an assessment of how strong the partnerships are, and what we will do to strengthen them; • We need to ensure the benefits of a County Council approach to public health are fully realised without losing the historic links to NHS commissioning and the need for local solutions in many instances.. This will involve ensuring the County Council as a whole recognise and embrace their public health role and that is recognised in our governance structure and system. • We need to recognise when a Essex wide approach to commissioning makes sense and when an integrated approach with resources aligned to CCGS is the right solution and consider in each case the appropriate governance arrangement. • The direction of travel for ECC and partner activity; • Links with CCG colleagues and public health have been well maintained since the transfer of Public Health to ECC. • Links to DC/BC/city while initially strengthened have slipped during T2. Going forward, if we are to best deliver this strategy we will need to re establish vibrant . Proactive and locally focused public health links with DC/BC/City. • We will retain and develop our links with the Police and Crime Commissioner and with provider representative bodies such as the LMC.

10. The high-level timetable for the strategic actions proposed • This is within the text • How the Strategy could help ECC to address its future funding gap. • The Strategy could help ECC funding gap through both driving efficiencies from use of the public health grant through delivering enhanced services while challenging the market hard. The timescale for this will be determined by the agreed length of existing contracts inherited from the NHS and will not have a full impact until 2016/17. • The strategy will also deliver savings through reduced demand on services in both ECC and CCGs with a short term gain possible within 1-2 years around initiatives around depression and blood pressure management.

11. Strategic analysis and insight – the story behind baseline position People in Essex have a healthy life expectancy This is a new composite measure looking at both life expectancy and self assessed sense of health from survey • Healthy Life expectancy, Essex 2009-11, Males 64.7, Females 66.7, England Males 63.2, Females 64.2 • As we have no trend data on this, below looks at total rather than healthy life expectancy

12. People in Essex have a healthy life expectancy The Baseline and the Story behind it. • While the chosen indicator is Healthy Life expectancy, this is a new measure with no trend data. We therefore use life expectancy to understand context and to set trajectory. • We have been seeing an increase in Life expectancy over recent years at Essex level. While still ahead of England, the improvement has been relatively poorer of latewith levels now below Regional average. This is likely to reflect particular issues in more deprived districts and boroughs. (see below) • Drivers include broad determinates such as material wealth, employment and poverty and these are in turn are driven by education and the economy as well as access to benefits. Other drivers are healthy lifestyle choices as well as preventative and curative clinical interventions. Changes to the drivers may take decades to impact on this measure eg Education, others especially clinical ones, as well as some lifestyles changes such as stopping smoking and undertaking physical activity may act quicker. • Key causes of death , as elsewhere in the developed world, remain cancers and cardiovascular disease including stroke with ill health additionally being caused by mental health issues together with frailty in the aging population. • We would expect to see continuing improvements in this measure as the economy improves and as we develop better public health services. • It must be remembered however that the key determinate of health is age and that an older population will tend to suffer poorer health than a younger one. It is likely then that absolute need for health and social care services will continue to grow as the population profile shifts to include a higher proportion of older people.. However we expect as the population ages , the health of an older person in the future will be better than that of an older person of the same age now mitigating to some extent the impact of aging on care needs. • With respect to healthy life expectancy we need especially need to consider the impacts of frailty, mental health issues, and stressors such as deprivation, debt, fear of crime and social isolation. These overlap with Outcomes around Safety, the Economy and Independence. The Curve we need to Turn • We would wish to see a proportional increase in the Life expectancy in Essex similar to that seen elsewhere in the Region and nationally. This is not a quick win and data is collected historically and takes several years to become available. The most recent data shows where we stood 3-5 years ago and given the often long term nature of interventions, it may take several years before any impact becomes visible. • We need to track progress then through clear process and impact measures and these will link to the raft of actions we take to deliver this indicator that are outlined in the Strategic Action section.

13. Reduced differential in life expectancy across different areas of Essex

14. Reduced differential in life expectancy across different areas of Essex The Baseline and the Story behind it • The indicator above looks at geographical variation across DC/BC which is easy to measure. We also can and will look at the differences between more and less deprived small areas (MSOAs). However, in addressing inequalities we need to also look at differences between certain vulnerable groups who experience inequalities in life expectancy including people with mental health issues, people with learning difficulties, gypsy and traveller groups and people who are homeless. These will be hard to measure locally but this must not detract from our endeavours to address these inequalities. • Clearly life expectancy (LE) is related to deprivation. The populations who suffer most material deprivation, and unemployment have lowest life expectancy. Separately from this issue, they also often make poorer lifestyle choices and find it harder to engage with services. All these issues need to be addressed. • While as expected from national trends most areas and groups in Essex are living longer lives, this is worryingly not true in Harlow and especially Tendring were LE is shortening. Similarly Rochford has not seen an increase ( but higher starting point). The issues in Tendring in particular highlight the increasing deprivation of the area. It must be remembered the LE seen is the result of decades of population experience of broader, lifestyle and clinical factors rather than quick impacts and where there is population movement , those dying now in the area may have spent most of there lives elsewhereand have experienced the socioeconomic impacts prevalent in that area. The Curve we need to turn • We wish to see continued improved LE in all areas but this indicator is around reducing the differences between areas. We will need to start as well to look at changes across deciles of deprivation but in the absence of historic baseline data , setting a trajectory will be problematic although given data lags we will likely have more historic data available to help inform this before we need to demonstrate the long term impacts of interventions described in this strategy. • In the interim we can look at DC/BC data as attached. For Tendring (and Harlow) we would expect to see further deterioration , given the historic nature of data and time taken to intervene ,for several years to come before we can slow and reverse this trend. • Early success will be through clinical activity and some lifestyle action . It is recognised these populations are at risk due to many years of deprivation and quickest action will involve addressing clinical risks such a high blood pressure and cholesterol followed by tackling lifestyle factors such as smoking. • Addressing the broader underlying determinates takes decades to see an impact and evidencing this depends on a static population. An influx of people from deprived London areas to Tendring or migration out of professional groups would lead to continued deterioration in LE. • Interventions need to address broad societal, lifestyle and clinical issues. The principle of proportional universalism will be followed with increased weighted access to the full range of interventions offered elsewhere as well as bespoke local interventions • Partnership work with the local district s/ borough and CCGS as well as local voluntary sector groups will be crucial

15. Addressing educational attainment will be key. Evidence suggests that educational performance in the more affluent areas is even better than would be expected given the wealth of the area but educational performance is even worse than expected given the level of affluence in the more deprived areas. This will drive a long term INCREASE in inequalities if not addressed through focussed action on areas performing less well • Delivering improved public health needs to recognise the breadth of intervention required. Some will be narrow and clinical where intervention prevents death and disability eg blood pressure management. Some will require specific interventions to improve lifestyle choices eg smoking services, others will address the wider societal context to improve lifestyle choices eg trading standards and highways. More fundamentally we need to optimise health through improving material wealth through educational attainment and economic growth and through access to benefits to those who need them. • As well as tackling the health needs of the whole population , we also need to address unacceptable inequalities in health across Essex both geographically and within vulnerable groups. This will involve Proportionate Universalism, a term derived in the Marmot report. It involves additional focus of the interventions described above targeted at the most vulnerable eg extra resources for health checks in deprived populations as well as specific initiatives directed at vulnerable groups eg ECTU (Essex County Travellers Unit,) Reach Out project in Jaywick. • In order to turn the curve we need to address people's attitude and the culture towards health and wellbeing. Individuals need to be encouraged to take responsibility for their health and the wider community also need to take some of that responsibility. There is a need to address some of the wider issues relating to the food, drinks and tobacco industry. • Key issues for public health commissioners will be:- • Address the high level of heart and stroke deaths and disability through commissioning evidence based preventive clinical interventions • Address morbidity related to mental health through improving lifestyle risk factors and access to screening, prevention and management in those who suffer, and addressing broader issues through improving employment and housing in this group. • Address common causes of ill health in older people including falls prevention, continence care, social isolation, depression and dementia. • Address the needs of vulnerable groups including those who misuse substances , prisoners, travellers , the homeless , people with learning difficulties, care leavers and looked after children • Improve lifestyle choices through services and system changes to support choices and address issues around smoking, alcohol, physical activity, diet, substance misuse and sexual health using universal and targeted interventions. • However the above will be of limited value without full involvement of People and Place colleagues to:- • Optimise parenting and early years support • Improve educational attainment • Support the economy and reduce unemployment • Support vulnerable groups including through floating support, ECTU, benefits advice, and social care input • Ensuring a safe environment , safeguarding vulnerable people, reducing domestic abuse and other crime • Developing an environment conducive to healthy choices around exercise and diet. Issues to address in order to turn the curve

16. Prevalence of healthy lifestyles:- Smoking Prevalence

17. Reduced Smoking Prevalence The Baseline and the Story behind it • Smoking is the biggest preventable cause of ill-health, disease and death and the single most important lifestyle factor affecting health inequalities. In Essex the adult smoking prevalence is 18.7%, but this varies across the localities and between those in the general population and those in routine and manual groups (R&M) with prevalence rising as high as 39% in R& M groups in Colchester • We have seen a decrease in smoking prevalence over recent years at an Essex level, but this has slowed recently. Essex still has lower rates than the national prevalence figure (20%) and the regional figure of 19.6% • Despite witnessing a decrease in overall prevalence, evidence suggests that certain population groups should be targeted. There needs to be a focus on increasing the number of quitters from those population groups who face the greatest barriers to giving up smoking • R&M groups • Children & young people under the age of 19 • Black and Minority Ethnic Groups • Nationally 4% of 11-15 year olds are regular smokers and this is replicated in Essex. Smoking in pregnancy is associated with poor pregnancy outcomes and needs special focus. • There is a strong link between smoking and deprivation and a danger that a single universal approach will better tackle those in more affluent areas. The principle of proportional universalism therefore needs to apply with services targeted in the most deprived MSOAs • Particular vulnerable groups such a s people with mental health issues have high rates of smoking and will benefit from particular focus. The Curve we need to turn • We wish to see a year on year reduction in smoking prevalence. • We want to see a reduction in smoking prevalence in the population groups outlined above. Issues to address in order to turn the curve • In order to achieve reduced prevalence there needs to be a combination of a wider tobacco control agenda as well as providing local Stop Smoking Support Services (SSSS) • Addressing inequalities will in part be achieved by targeting SSSS in the most deprived areas and at the relevant population groups. The principles of proportional universalism will be followed.

18. Obesity in Adults and Children

19. Obesity in Adults and Children • The Baseline and the Story behind it • Adult obesity continues to rise nationally, but the rate of increase appears to be slowing. The causes and drivers are complex and linked to changes in lifestyle linked to diet and physical inactivity. Around two thirds of adults are overweight or obese. • Prevalence within Essex is similar to England, however, there are variations between local authority districts. PHE data in February 2014 shows adult overweight and obesity levels within Essex ranging from 62% in Chelmsford to 73% in Castle Point. Although a comparatively small sample size with a wide confidence interval, this places Castle Point within the highest 10 districts in England. • Current adult weight management services within the county, previously commissioned by the 5 Essex PCTs vary widely, with inequity of provision between areas. Some areas have specialist services for morbidly obese adults only, others have lifestyle weight management services for the overweight and obese, whereas Castle Point and Rochford have no services for adults. • Child obesity measured through the NCMP programme shows a flat trend in recent years for both age groups following a strongly rising trend in recent decades. This is in line with national trends. • Current child (family) weight management services, like adult services similarly show variations in provision, with some areas having none. • The Curve We Need to Turn • We need to reverse the rising tide of obesity in adults. Preventative initiatives are often very long term and require action in childhood to impact on subsequent generations.We can expect little positive change to the population for some years but will see process measures demonstrating better access to weight management support and outcomes • Issues to address in order to turn the curve • The establishment of a clear county-wide obesity intervention pathway is a priority. A key element is the further development of partnership working with Clinical Commissioning Groups, focusing on the overweight or those at risk of being overweight, as opposed to the whole population. • Current geographical inequity of adult weight management service needs to be addressed through the commissioning of a county-wide Tier 2 model, aligned with CCG Tier 3 provision for the morbidly obese. • Interventions to ensure county-wide equitable provision of child (family based) weight management services, linked closely to the 5-19 pathway is an on-going priority. • Obesity interventions need to be closely aligned with interventions associated with increasing physical activity. • Specific commissioned services need to be supported by a raft of population wide activities around breast feeding, increased physical activity, healthy schools, school meals, improved access to healthy food choices and reduced access to unhealthy, options and both population and focussed education around cooking and eating.

20. Physical Activity

21. Physical Activity: Increasing levels of Physical Activity in Essex and its associated boroughs • The Baseline and the Story behind it • Evidence shows only 37.1% of Essex residents participated in at least 4 sessions of at least moderate intensity activity for 30 minutes in the previous 28 days. Also, 44.7% of residents take part in no sport or active recreation (NI8 APS 2011-13). • Physical inactivity is a significant, and independent risk factor for numerous physical and psychological conditions. It is associated with a greater risk of developing coronary heart disease, osteoporosis, hypertension, stroke, non-insulin dependent diabetes mellitus, obesity and depression. People who are physically active reduce their risk of developing such long-term diseases (coronary heart disease, stroke and type II diabetes by up to 50%, and premature death by 20-30%). • On average, an inactive person spends 38% more days in hospital than an active person, and has 5.5% more GP visits, 13% more specialist service and 12% more nurse visits than an active person (Sari, 2008). • Helping and supporting inactive people to move to a moderate activity level will produce the greatest reduction in risk of ill health and will contribute to reduction in risk of coronary heart disease and obesity, hypertension, cancer, osteoporosis, depression and anxiety (Physical activity in childhood has a range of benefits including healthy growth and development, maintenance of energy balance, mental well-being and social interaction. (Department of Health, 2004) • Increasing the amount of physical activity/ sport in a variety of settings, from active travel/ recreation and sporting environments is shown to create behavioural change and embedded lifelong participation, passed down into the next generation. • Increasing physical activity levels is a key component of reducing cardiovascular disease (CVD), cancer and diabetes; and obesity.Interventions focusing on behaviour modifications provide short-term benefits. Educating people and informing their lifestyle choices by promoting opportunities to participate and communicating the many health benefits of an active lifestyle is key. • The current evidence base recognises that for long-term benefits social, structural and economic factors need to be addressed, a range of complex factors combine to influence levels of sedentary behaviours, physical activity and sport participation. The curve we need to turn • We as elsewhere are starting from a very low base. We want to improve the numbers taking ANY exercise as well as the numbers undertaking nationally recognised amounts. Progress will be slow at best a percentage point a year • Issues to address in order to turn the curve • Place- Targeting environments to encourage and facilitate physical activity in public open space, cycle paths, schools, sports facilities & buildings, safer roads and communities. • People - Targeting groups with levels below recommended guidelines, eg Children and Families (who do not have a familial culture of physical activity), people living in areas of deprivation, Older people, Women, Black and Minority Ethnic Groups, people with learning disabilities and targeted early years settings, primary and secondary schools . • Essex requires a multi-agency approach to develop and direct holistic physical activity and sport. • Active Networks action plans should incorporate multi agency services for evidence based universal interventions (Tier 1) and targeted lifestyle interventions (Tier 2). • Active Essex will support and lead Active Networks to work with CCGs to maximise the opportunities at Tier 2. • Tier 1 and Tier 2 commissioned interventions to ensure impact on outcomes & indictors through performance measures. • District, Borough and City Councils are key partners in this endeavour.

22. Alcohol

23. Hospital Admissions due to Alcohol The Baseline and the Story behind it • The indicator above looks at the rate per 100,000 of admissions to hospital. This is calculated by applying certain criteria to Hospital Episode Statistics in relation to 47 conditions of which 13 are wholly attributable to alcohol consumption and 34 partially attributable • These include hypertensive diseases, mental and behavioural disorders and cardiac arrhythmias. In 2010 alcohol use was the third leading risk factor contributing to the global burden of disease after high blood pressure and tobacco smoking • Average alcohol consumption has gradually fallen in many OECD countries between 1980 and 2009 with an average overall decrease of 9%. The United Kingdom however, has seen an increase of over 9% in these three decades . • Additionally drinking in pregnancy is associated with increased fetal and infant mortality and morbidity including fetal alcohol syndrome. • In England in 2011/12 there were 49,456 hospital admissions for alcohol-related liver disease, which is the only major cause of mortality and morbidity which is on the increase in England whilst decreasing in other European countries • The most effective strategies to reduce alcohol-related harm from a public health perspective include, in rank order, price increases, restrictions on the physical availability of alcohol, drink-driving counter measures, brief interventions with at-risk drinkers, and treatment of drinkers with alcohol dependence • The picture in Essex closely follows that seen nationally with some occasional variations. The curve we need to turn Following several years of seeing significant rates of increase in Alcohol related hospital admissions we would be looking to see a reduction in the rate of increase before reducing the rate This is in the main due to the fact that many of those conditions considered will have significant delays in presenting themselves and effects of local investment and development have a reasonably long “lead time” before impact. Is seen. Issues to address in order to turn the curve • Historic investment locally in the provision of many interventions and treatment services has been patchy and service provision and service utilisation rates are significantly below those recommended by the Department of Health . • Early wins will be seen by monitoring a number of indicators and performance measures and developing a system of support and treatment that starts to meet the national minimum expectations and builds towards matching the system provided to address drug misuse issues • Building on the work with Trading Standards in relation to age related sales and supply of alcoholand with District/boroughs around work on Licensing, Community Safety, e.g. alcohol out reach, licensing traffic light system, reducing the strength project Commissioning a treatment system that addresses issues of dependence and also engages with hazardous and harmful drinkers at earlier stages • Developing a range of Brief Interventions strategies through ALL public facing provision and multi media/platform applications • Developing an Alcohol Harm Profile for Essex and acting on the intelligence gathered therein to impact on supply through licensing

24. Successful completion of drug treatment

26. Successful completion of drug treatment The Baseline and the Story behind it • Drug misuse is a complex issue. While the number of people with a serious problem is relatively small, someone's substance misuse and dependency affects everybody around them. • The most harm is associated with dependence in relation to Opiates (Illicit, prescribed and Over the Counter (OTC) ) and this is the major focus of treatment activities. • In Essex there are predicted to be in excess of 4500 Opiate users (as calculated using the Glasgow Estimate from Public Health England/DH). Measuring penetration into this population and the numbers of All Adults and Young People engaging with effective treatment allows us to see how our services and the system is engaging with drug users across the county. • It is shown that treatment works (various data and research products provided by the National Treatment Agency/Public Health England) and successful completion of drug treatment (within a recovery focussed system) is a useful measure to indicate a reduction in the harm caused by drug misuse. • In time we will also be measuring the numbers exiting treatment in a planned way and not representing to treatment within six months of discharge thereby providing more evidence of the reduction in harm. The curve we need to turn • As we have seen a significant increase in the numbers accessing and engaging with effective treatment we have seen this impact upon the “proportion” completing successfully. We have noticed a slight increase in the numbers leaving treatment in an unplanned way. Issues to address in order to turn the curve • We need to ensure we are working with commissioned treatment providers to reverse the decline and the curve we need to turn is to see an increase in the proportion of those in treatment completing successfully. • Work is already underway to review data collection and reporting and this has seen us halt the decline and we now need to target our joint efforts to ensure that clients are being managed effectively into recovery and “exited” from structured treatment more effectively and into recovery support provision.

27. Life Satisfaction Rates Life Satisfaction Life Satisfaction is determined by a range of interlinked factors as well as levels of expectation . Improvements to this trajectory will be sought and delivery will depend on overall progress across all outcomes in this strategy. The curve we need to turn Data above suggests a decline in life satisfaction in Essex while nationally satisfaction is improving. We wish to reverse this curve and see a rate of improvement in excess of that seen nationally to regain our relative difference in improvement.

28. Strategic Actions (given existing resource envelope) • n • People In Essex have a healthy life expectancy • Life satisfaction rates (ONS condition of wellbeing) • Percentage of Essex residents who consider themselves to be in good health • Strategically the above will be addressed through a combination of identification and management of people at high risk or with conditions, addressing lifestyle (discussed below) and addressing broad determinates.. • Key to success is to develop and deliver a public health strategy that recognises:- • The Broad range of determinates that affect health, and hence the wide range of areas in which ECC can influence outcomes • The role of all agencies , communities and individuals in delivering this agenda • The need to balance local , Essex and national solutions • The need to recognise process and output measures as relevant as we strive to achieve often very long term improvements in outcomes • The need to balance short term health gains and productivity with initiatives delivering crucial health gains often decades from now • The actions outlined below are key initiatives in delivering these outcomes • Broad Determinates • School Achievement (below and in our Best start in life and education and life-long learning commissioning strategies), • Employment (see below and our commissioning strategies for economic growth), • Giving children best start ( see our best start in life commissioning strategy) , • Safe community ( see our safer communities commissioning strategy)

35. Percentage of Children Achieving at school The Baseline and the Story behind it • Health is in large part determined by socio-economic factors throughout life. These factors including employment and housing are in large part related to material wealth and this in turn is driven by educational attainment. • Educational outcomes in Essex (measured by GCSE results) are now just above the national average in Essex and Statistical neighbours and are improving. • Evidence suggests that educational performance in the more affluent areas is even better than would be expected given the wealth of the area but educational performance is even worse than expected given the level of affluence in the more deprived areas. This will drive a long term INCREASE in inequalities if not addressed through focussed action on areas performing less well. • School readiness levels in Essex have been poor but again are improving with most recent data on readiness at the end of reception year now slightly above the England average at 52.5%. There is clear evidence that early years development in large part determines future academic progress and high levels of school readiness are essential • The high proportion who are not school ready (nearly 48%) suggests action needs to be directed universally to families as well as the specific focus needed on those with greatest needs. This requires universal support for strong effective parenting and preschool education. • Essex is far from homogenous with some areas of real excellence and others where educational attainment is poor. Tendring schools are currently doing less well relative to other areas of Essex. Areas which used to have poorly performing schools, eg. Basildon and Harlow, which have had recent ECC support have improved. • Details of what needs to be done and the action planned both to address school readiness and parenting is described through our “Children in Essex get the best start in life” strategy and action to improve educational attainment within schools is described through our “People have aspirations and achieve their ambitions through education, training and lifelong-learning” commissioning strategy. The Curve we need to turn • Essex wants to be in top quartile nationally for standard national benchmarked data for educational attainment . • These are described in detail through our commissioning strategies for Best Start in life and for education and life-long learning Issues to be addressed to Turn the Curve • These are described in detail through our commissioning strategies for Best Start in life and for education and life-long learning

37. Percentage of working age people in employment

38. Percentage of Working Age People in Employment The Baseline and the Story behind it • Employment is absolutely key to health. Studies have shown that unemployment has a serious detrimental impact on all aspects of the physical and mental health not just of the person who is unemployed but on their whole family. • This essential indicator of health and wellbeing will be tackled under our “Sustainable economic growth for Essex communities and businesses” outcome. • There are particular issues around levels of unemployment in population sub groups. Much of the harm to health in people with mental health issues is around their high levels of unemployment that is not directly related to the mental health issue. • Linked to the modest rate of economic growth in recent years there has been relatively slow growth in the number of jobs in Essex. Key locations for growth are Basildon, Braintree, Chelmsford, Colchester and Harlow. Key sectors are advanced manufacturing, low carbon and renewables, logistics, life sciences and healthcare, digital, culture and creative. The employment rate for December 2012 (73.9%) showed a continued trend of improvement since 2010 . It was slightly down on the East of England region (74.6%), but compared relatively well to Kent where employment rates continue to fall . The Essex figure was also greater than the National rate (70.9%). • The unemployment rate also increased in Essex in 2012 (7.2) compared to 2011 (6.7) reversing the improving picture identified between 2010 (7.3) and 2011 and bringing the unemployment rate back to just below 2010 levels. By contrast, East of England authorities showed general improvement in 2012, compared to a period of decline in 2011. Overall, whilst there may have been some year on year variation in results the East of England picture suggests that unemployment rates in general are back in line with 2010. Nationally 2012 rates (8.0) were higher than 2010 (7.8) although down slightly on 2011 (8.1). • Between July 2012 and June 2013 Harlow (9.8%), Tendring (9%) and Basildon (8.9%) had the highest unemployment rates of all the Essex districts. Unemployment hotspots in parts of the county are also worst affected by youth unemployment. The highest unemployment rate in Essex for Jul 2012 to Jun 2013 was for the age group 16 to 19 years (29.2%). This was not significantly different from the East of England and England rates. Nearly 8,000 16-24 year olds in Essex are claiming Job Seekers Allowance as of May 2012 - an increase of 12% since the same time last year. A further 6,720 are claiming other out of work benefits. • The actual number of unemployed in Essex increased significantly from 2011 (46,900) to 2012 (51,300),recording the highest level for many years. • To sustain economic growth in the context of substantial demographic growth between 2014 and 2021, we will need to secure an additional 33,000 jobs and an additional 34,000 homes

39. The Curve we need to turn • This is described in detail under our outcome for economic growth • Job growth and employment rates have begun to rise and we need to continue to support this direction of travel. • Continue efforts to reduce NEET figures under economic growth and education and life-long learning outcomes • There is a need to help people with mental health issues to keep or find work. • Reduction in health inequalities between geographic areas especially Tendring requires economy focused action and is unlikely to succeed without this. Issues to address in order to turn the curve • This is described in detail under our outcome for economic growth

42. Percentage of families living in safe and suitable housing The Baseline and the Story behind it • Homelessness, the threat of homelessness and poor quality accommodation can have a serious health impact on health and wellbeing. Unsuitable housing can have a detrimental effect on health (e.g. hypothermia), exacerbate ill-health (e.g. from dampness), pose risks (e.g. falls or accidents) and can cause anxiety and stress (e.g. fear of becoming homeless or overcrowding) leading to mental health conditions. • Numbers of homeless people will be a key measure to demonstrate the Council and partners’ commitment to reduce homelessness . This should include the number of housing brokerage supported by social workers to cater for vulnerable groups (e.g. people with learning disabilities, sensory or physical impairments). • Numbers of statutory homeless as attached is not the full picture. Many people will not be included such street homeless and people who are “sofa surfing” with friends or relatives. • Safe and Suitable Housing should include [i] Rented properties – advice on housing condition [ii] Housing Association support [iii] Supported and Sheltered accommodation [iv] Safety at Home and bogus caller support – fire, fall/accident prevention, DV, Telecare, Listed traders [v] Homebuy advice – debt prevention, mediation [vi] Home adaptations – older/disabled people [vii] Energy advice – heating, grants, tariff switching, low income families [viii] Homelessness [ix] Affordable Housing development • There are particular serious needs in those who are street homeless. These have been discussed in our Homeless needs assessment. These include high levels of mental health issues, alcohol and substance misuse and poor access to primary care services. • Families in temporary accommodation with insecure tenure face a different set of needs related to overcrowding and safety as well as a lack of continuity with an impact upon attachments to the community and fragmented school experience • People present as homeless to Districts and Boroughs. We need to ensure their needs are appropriately met. • We need to work to prevent housing crises especially in vulnerable groups including ex offenders, people with mental health issues or who misuse substances , people with a learning disability, care leavers and those living chaotic lives. • We need to ensure suitable quality private rented accommodation • Local Authorities can now discharge their housing responsibilities through private sector rented housing. People placed will almost certainly have less security of tenure, and possibly fewer rights compared with social housing. The quality of private rented housing is also variable, especially in regards to structural stability of houses, dampness, safety and efficiency of heating. • Any increase in mortgage repossessions should be viewed as a proxy measure for those at risk of less safe and suitable housing.

43. The curve we need to turn • We need to develop our understanding of available data. Discussion with partners and stakeholders on which sub cohorts of the population are at greatest risk will be important. • We will reverse the increase seen recently in statutory homeless • We will reduce the number of people with mental health issues at risk of homelessness Issues we need to address to Turn the Curve • This is crucially the role of Districts and Boroughs. We need to ensure an effective forum for addressing housing issues with providers and housing strategy leads within the districts. • Establish a COG to look at and address issues around housing and homelessness • Work with the Domestic Abuse COG will ensure appropriate accommodation and support options for those suffering DA.Regarding refuges, we need to pay specific attention to supporting families at risk through the locality options that are available, all of which will impact upon young children and the quality of school preparedness • We need to ensure acceptable quality of private rented accommodation. This will include the ECC Private sector landlord accreditation scheme • We need to consider with partners the management and allocation of Disabled Facilities Grants (DSGs) in supporting families caring for a disabled loved one, to have the optimal environment to learn and to live more independently. • Interventions include commissioned floating support service which directly supports vulnerable adults with housing needs, eg debt liaison, discussion with landlords , people at risk of domestic violence as well as the Council using its legal powers to protect tenants from harassment and unlawful eviction. • We will develop a strategic approach to the prevention and management of homelessness including a focus on risk groups such as people with mental health issues • We need to ensure the right level of provision for affordable housing, housing (e.g. ‘extra care’) to support people live more independently and the appropriate level of residential care home. • We need to Increase in the number of landlords claiming the Landlord’s Energy Saving Allowance (LESA) which will be an indication that they are making energy saving improvements

46. Percentage of Households living in Fuel Poverty The Baseline and the Story behind it • Excess winter deaths are associated with poorly heated homes and this in turn is associated with fuel poverty. • Fuel poverty and poorly heated homes are also associated with increased levels of poor mental health. • Fuel Poverty historically occurs when 10% of income is needed to heat the home to accepted standards. It depends on income, fuel price and how easy the home is to keep warm. • Particular cohort at risk are older people, including those who come into the social care system. Also those on benefits and low income families. Fuel poverty may be worse for people in private rented accommodation, and people who are single occupiers. • Fuel costs continue to rise at a rate exceeding inflation • Changes to the benefits system particularly aimed at working age adults may mean that some of these adults are drawn into fuel poverty. Also the increased threshold for single room rate means that more of the population group are affected and potentially subject to fuel poverty. The £500 per week benefits cap may impact on a small number of families in Essex . • The condition of the housing stock in Essex is also relevant. There are a large number of owner occupiers in Essex but some of these may be asset rich but cash poor. The condition of private rented accommodation is also relevant because private rented accommodation quality is often poorer than social housing. Tariffs for those on payment meters are also higher than tariffs for those who can pay on direct monthly debit. • Home insulation grants are now less available than they have been in the past, (for example, the Warm Front initiative expired a year ago). • Conversely more people are in employment although average wages have not increased in line with inflation but the minimum wage has increased. • There is variable information on home improvement information to reduce fuel poverty, so part of the role of Home Improvement Agencies (HIAs) is to help customers navigate this process • Given all the above it is hard to understand why the data suggests a reduction in the numbers in fuel poverty. . . .

47. The Curve we need to turn • While data suggests a reduction in numbers in fuel poverty, it is unclear why this should be the case given the economic downturn and the increasing cost of fuel. We need to better understand the trend but continued improvement may be a challenge in the short term and we might expect a continuing rise in numbers. • Improvements in the Essex economy will help address the numbers in fuel poverty so action under our commissioning strategy for economic growth is critical. Issues to address in order to turn the curve • Responsibility for housing is primarily with district , city an d borough councils and ECC needs to work in close partnership . A number of initiatives led by the district and borough councils are underway linked to their role in environmental health and housing.  These tend to take an education raising role, making residents and landlords aware of the problems and solutions available to them. One example is the work underway at Chelmsford City Council, who in December 2013 organised an information seminar to discuss the impact of cold and damp homes. This is likely to be an area of increasing focus for district and borough councils as the legislation around housing quality tightens. • From 2016 private residential landlords will be unable to refuse a tenants reasonable request for consent to energy efficiency programmes; whilst from 2018 it will be illegal to rent out a residential or business premise that does not reach a minimum energy efficiency standard to be set at Energy Performance Certificate (EPC) rating E. Currently nearly 9000 (14%) of Chelmsford homes are in bands F or G, and will not be legal to rent out when the legislation comes into force. • ECC are working with districts and boroughs to implement the Green Deal within Essex through the Essex Energy Partnership. . • We also need to work closely with private sector landlords as well as housing providers. • We have little control over fuel costs, we can address economic growth and support employment in some to get people out of fuel poverty and we can ensure access to benefits where appropriate ( this will alleviate the effects but not address the fuel poverty per se). • We also need to support improvements in housing stock. • We need to recognise that initiatives in the short term will need to focus on vulnerable groups to mitigate the impacts of fuel poverty rather than reduce fuel poverty per se. • ECC's sphere of influence to address fuel poverty is more with private rented accommodation and owner occupiers, and these should be priority groups for interventions, as they are relatively less well regulated. The key role of housing means we need to work with districts, city and boroughs in this area. • We need to ensure help reaches the most vulnerable clients. This will involve floating support • We need to ensure all services in contact with the population identify households at risk of fuel poverty , can offer simple advice and support or can appropriately refer. This may include proactive action in times of risk . • Continue to work with CVS to implement schemes to alleviate fuel poverty in those hardest hit.

50. Prevalence of mental health disorders among children and adults Children The Baseline and the Story behind it • National research highlights that good emotional and mental health is fundamental to the quality of life and productivity of individuals and families. Poor emotional wellbeing and mental health can lead to negative outcomes for children including educational failure, family disruption, poverty, disability and offending. These can lead to poor outcomes in adulthood such as low earnings, lower employment levels and relationship problems which can in turn affect the next generation. • Research has also shown that half of lifetime mental illness arises by the age of fourteen; that the most crucial influence on a child’s emotional wellbeing and mental health is parenting influence within the first year’s of a child’s life and that early attachment and bonding between parents/carers and their babies is vital for a child’s development. • Essex surveys of schoolchildren show that pupils with poor emotional wellbeing are twice as likely to say they are afraid to go to school because of bullying and that they have been a victim of crime; they are significantly less likely to enjoy school and more likely to want and need more help from teachers. • CAMHS services are complex and fragmented and commissioning is not joined up. The CAMHS Tier 2 service for those with emerging mental health issues Is commissioned and delivered by ECC; the 7 CCGs commission NEPFT to deliver Tier 3 for those with mental health issues in North Essex and SEPT to deliver Tier 3 in South Essex. • There is a continuing focus on early intervention based on national evidence that this saves costs upstream with support for school and community based provision . • The 2013 JSNA for Children’s Emotional Wellbeing and Mental Health found that fewer than the expected number of children needing a service at both Tier 2 and Tier 3 level were receiving support. • It concluded that there is a complex, fragmented and poorly understood set of services in place across Essex with a high degree of concern among professionals about access to CAMH Services. There is differing access criteria and service delivery across Essex with a lack of clarity on pathways between services. • Estimated need and demand levels are generally static (Child and Maternal Public Health Observatory CHiMAT estimate 7% children have a Tier 2 level mental health need and 1.85% children have a Tier 3 level need); however the complexity of referrals is increasing while resources are not. We are therefore seeking efficiencies through evidence based commissioning, reduced management costs, improved joint working with other services and increased support provided from universal services. • National benchmarking data shows that across Essex health invest less than the average health investment in CAMHS across England. • .