Health and Social Care in Birmingham: A summary of the JSNA
HEALTH & SOCIAL CARE IN BIRMINGHAM
A summary of the Joint Strategic
Needs Assessment for Birmingham
JSNA Summary
2012
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Health and Social Care in Birmingham: A summary of the JSNA
CONTENTS
1.
Introduction: What is a JSNA supposed to do? ............................................................................... 3
2.
Birmingham’s Profile ....................................................................................................................... 6
3.
Starting Well: Conception and Childhood ..................................................................................... 11
What we don’t know – Gaps in Knowledge / Data / Intelligence ................................................... 13
4.
Developing Well: Childhood into Young Adulthood ..................................................................... 14
What we don’t know: Gaps in Knowledge / Data / Intelligence..................................................... 17
5.
Living Well: Healthy Lives across the Lifecourse ........................................................................... 18
What we don’t know: Gaps in Knowledge / Data / Intelligence..................................................... 22
6.
Working well: Better Employment, Better Health ........................................................................ 24
What we don’t know : Gaps in Knowledge / Data / Intelligence .................................................... 24
7.
AGEING WELL: Healthy Older Life is Important ............................................................................ 25
What we don’t know: Gaps in Knowledge / Data / Intelligence..................................................... 30
8.
Dying Well: End of Life Care and Support ..................................................................................... 31
What we don’t know: Gaps in Knowledge / Data / Intelligence..................................................... 32
8.
Cross-System Issues ....................................................................................................................... 33
9. Discussion: Issues and Next Steps ..................................................................................................... 38
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Health and Social Care in Birmingham: A summary of the JSNA
1. INTRODUCTION: WHAT IS A JSNA SUPPOSED TO DO?
The Joint Strategic Needs Assessment is an overview of the health and social care needs of
an area. The Local Government and Public Involvement in Health Act 2007 and guidance
issued in 2008 states that the Director of Public Health, Director of Adult Social Services and
Director of Childrens Services collaborate on producing it, consult on the product and the
Local Authority is required to publish it.
As part of the Government’s health and care reforms, draft guidance has been issued which
puts the JSNA in a new strategic context. The Health and Wellbeing Board (to be established
under the Health and Social Care Bill when it becomes law) must use the JSNA to inform the
development of the Health and Wellbeing Strategy for the area, which it will be required by
law to produce.
New draft guidance makes it clear that the JSNA is not intended to be an exhaustive
statement of everything we know about an area, it is a “narrative on the evidence gathered
to identify the needs of the population now and in the future.”
The guidance also makes clear that the JSNA is a part of the cycle which starts at assessing
need, moves through to identifying priorities, embeds these in commission plans and then
assesses outcomes and need, so starting the cycle again. The new draft guidance expresses
this in the diagram below.
Diagram of relationship between JSNA and Health and Wellbeing Strategy (Dept of
Health, 2012)
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Health and Social Care in Birmingham: A summary of the JSNA
The JSNA, therefore, is one step in the cycle. It identifies need. The next stages are for a
Health and Wellbeing Strategy to be produced from some agreed priorities, and for these to
be embedded by commissioners into commissioning plans.
The identification of interventions to be commissioned comes after an analysis of efficacy,
evidence and resources where commissioners, public health and stakeholders work together
to identify what can best address the needs of the population within resource and policy
constraints.
In Birmingham The Health and Wellbeing Board have adopted the Marmot Framework as
the framework for our JSNA. This framework provides a set of outcomes across the Lifespan
from conception to death, based on a comprehensive national summary of evidence.
THE STRUCTURE OF BIRMINGHAM’S JSNA
The Structure adopted for the JSNA, because of the size and complexity of the City, was a
pyramidal structure, with each level providing a higher level of detail. This document is the
top level - it provides a summary of the work undertaken on Birmingham’s JSNA. The next
level down are locality profiles for every Ward, Constituency and Clinical Commissioning
Group area (and for each GP practice) published most recently from Winter 2011 (and
revised for Clinical Commissioning Groups in 2012 with further revision due) and which look
at local areas. CCG profiles are important in informing the CCG public health plans and CCG
commissioning plans. The final level is that of “deep-dive” themed reports where a topic is
considered in significant detail to identify issues of need, equity and suggested unmet need
for commissioners. All of these documents are published.
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Health and Social Care in Birmingham: A summary of the JSNA
The Structure of Birmingham’s JSNA
This summary of the Joint Strategic Needs Assessment is the last document in the JSNA
process ending in 2012.
Behind these documents lies a process of working with users and commissioners to identify
unmet need and seek to quantify this. The Mental Health JSNA themed report, for example,
involved over 20 meetings with commissioners, users, carers and providers, and final
approval from the Integrated Commissioning Board before then working with
commissioners to begin to identify interventions to deliver need.
An outline of the process to deliver a JSNA product
THE NEW JSNA PROCESS – ENGAGEMENT AND ASSETS
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From the promulgation of the Government’s new guidance on the JSNA, we will start a new
process to deliver the JSNA for the future.
This process will still be layered with citywide, locality and in some cases themed reviews. A
detailed standards and processes document will be made available shortly which will explain
further how we will produce the new JSNA.
We have engaged stakeholders and communities in the JSNA to date. We intend to do this
differently from 2012 onwards.
We will also be seeking to produce a Joint Strategic Assets Assessment, which identifies the
assets in our communities which can be harnessed to meet need across our populations. We
are starting with three engagement workshops with third sector agencies in March 2012,
and a series of engagement meetings with LINk and other stakeholders.
A stakeholder event will be held on 19th April to help move from the JSNA to the Joint Health
and Wellbeing Strategy.
When finally approved by the Health and Wellbeing Board, this document will be used to
inform the development of the Joint Health and Wellbeing Strategy.
2. BIRMINGHAM’S PROFILE
Birmingham is 267.8 square km in size, and divided into 40 electoral wards which are used to
elect local councillors. Most of the area is urban, and the city centre accommodates
important financial, legal, and retail centres outside London.
Birmingham has reinvented itself over the last fifteen years to become a vibrant city with
many leisure attractions and quality urban spaces. More than one fifth of the city consists of
open space and 16% of Birmingham’s land area is designated as Green Belt.
Despite the success of the city as whole there are still unacceptable inequalities between
those areas that are wealthy and thriving, and those areas that suffer from high levels of
multiple deprivation, which the local authority and partners are committed to address and
promote better living space for the whole local population.
DEMOGRAPHY
Birmingham’s estimated population was 1,036,878 in 20101. Birmingham has a young
population with 66% being under 44 years old and the 20-29 age group representing around
19% of the total population (see Figure 1). The population over 65 years old represents
around 13% of (136,617) of the population.
1
ONS Population Estimation 2010
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THE GROWTH OF THE POPULATION HAS BEEN STEADY SINCE 2000; THE MALE POPULATION
YEAR-AVERAGE INCREASE IS AROUND 0.6%, AND FOR FEMALES IS 0.5%.IT IS ESTIMATED
THAT THE POPULATION WILL INCREASE BY 14% TO REACH 1,183,200 INHABITANTS AND
THE POPULATION OVER 65 YEARS OLD WILL INCREASE AROUND 23% TO REACH 168,000
INHABITANTS, BY 20302.
Overall, Birmingham is the most ethnically diverse city in the United Kingdom. White, Asian
and Black background represent 68%, 20%, and 7%, respectively. Among the Asian
population, Pakistani ethnicity is the most represented.
Life Expectancy is increasing, which for Birmingham is 76.4 and the gap between England
(78.33) is narrowing; however there is gap of 7 years among deprived and most affluent
areas in the city.
FIGURE 1 BIRMINGHAM ESTIMATED POPULATION, 2010
Source: Office for National Statistics estimates 2010
DEPRIVATION
Birmingham is ranked 9th most deprived in England out of 354. It has the largest number of
Lower Super Output Areas4 that are amongst the most deprived in 2010, this was also the
case in 2007. The population is evenly distributed across the five (5) deprivation quintiles
(around 20%), implying that around 40% of the population is classified as living in the most
deprived areas.
2
POPPI and PANSI estimation
3
ONS 2007-2009
4
Lower Super Output Areas – are homogenous small areas of relatively even size (around 1,500 people) of which there are
32,482 in England.
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Health and Social Care in Birmingham: A summary of the JSNA
Whilst overall the city is thought to be deprived there are huge differences within the local
area, with much of the centre of the city being worse off than other areas. The map below
shows this discrepancy by showing deciles of deprivation according to local rankings.
EMPLOYMENT
Latest employment rate in the public sector is 19.75% and in the private sector 48.1% the
latter is significantly lower than the England average. Over the last ten years until 2008 the
employment rate has presented a modest increase, 3%, and it has not increased as fast as
England average, 9%. The manufacturing industry has lost 50% of the workforce, which is
comparable with the increase in employment rate in services and tourism areas. Services
area employment rate is higher than West Midlands and the Great Britain average.
WORKLESSNESS
The number of working age residents claiming workless benefit in Birmingham was 121,960
in May 2011. The worklessness rate is 18.1%— lower than a year earlier (18.4%). Although,
higher compared to the West Midlands and England, 13.6% and 11.8% respectively.
5
Source ONS, 18/11/2011. Public/Private sectors jobs located in the region divided by the region
population 16-64 year old.
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There is a significant difference between the male worklessness rate and the female rate. In
May 2011, 20.1% of working age males was workless in Birmingham compared with 16.2%
of females. In deprived areas the rate is higher as 26.9%, and 56% of incapacity claimants are
living in areas with a deprivation index above Birmingham average6.
EARNING
Birmingham’s average weekly earnings are lower than England and West Midlands, and it
has been increasing by 2.3% annually since 2002; however between 2010 and 2011 there
was a decrease of 1.6%. Although male based gross weekly earnings is higher than for
female (£67 more in average) the gender pay gap has been decreasing since 2002.
TABLE 1 AVERAGE EARNINGS FOR FULL TIME WORKER, 2011
Hourly £ Median
Weekly £ Median
England
12.88
507.6
West Midlands
11.85
470.5
Birmingham
11.77
458.2
Source: ONS
LOCAL AUTHORITY ADMINISTERED BENEFITS
There are 143,380 working age 16-64 claimants (21.3%), from which 17,240 are lone
parents7 . By contrast in the most deprived areas benefit claimants take up is 61%, three
times the city average.
HOUSING AND LIVING
Birmingham has a count of 424,194 households of which 85% are privately owned (either by
owner occupier or for private renting), 15% are local authority owned. The mean house price
is £160,120, lower than West Midlands (£177, 913) and England (£240,033) average. The
number of affordable dwellings built in 2010/11 was 1,100. Between 2008 and 2033, the
number of households is projected to increase in Birmingham from 406 thousand to 505
thousand, a 24 per cent increase. This is greater than the percentage increase in West
Midlands (20%)8.
6
Source BCC/NOMIS/ONS
7
ONS, 2011
8
Source ONS Local Profiles
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There is a clear association between standards of accommodation and improving health
outcomes. In 2010, 98.6% of the local authority owned homes complied with the Decent
Home Standard, but the properties registered with social landlords and private housing does
not comply with these guidelines. Birmingham also has high percentage of people classified
as homeless and in priority needs 4,207 which is 9% of the homeless estimated for England
(2010/11).
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Health and Social Care in Birmingham: A summary of the JSNA
3. STARTING WELL: CONCEPTION AND CHILDHOOD
‘Giving every child the best start in life is crucial to reducing health inequalities across the
life course’
KEY FACTS AND FIGURES FOR BIRMINGHAM
SOCIAL AND LIFESTYLE DETERMINANTS

Birmingham is one of the most deprived 5% of districts in the country. Deprivation
is associated with smoking, teenage alcohol consumption, unhealthy eating, high
levels of obesity and low levels of physical activity. The same is true for mental
health problems and non accidental injuries.

5% of children under 5 in Birmingham are in households accepted as homeless

High smoking prevalence means that large numbers of children spend their
childhood exposed to tobacco smoke

Registration at Children’s Centres for children under 5 in some parts of the city is
low relative to need. This is highlighted in Ward and Constituency profiles.

Unemployment is particularly high in Birmingham which has a huge impact on
families

Obesity, smoking and substance misuse are areas for consideration because of their
impact on children and young people

Maternal nutrition, hypertension and smoking during pregnancy are areas of
concern in the city
BABIES AND PARENTS FROM CONCEPTION TO BIRTH

The under 18 conception rate for Birmingham is 52.1 per 1,000 compared to the
England average 41.0

10% of babies born in Birmingham weigh less than 2.5 kg compared to 7.5% in
England. Low birth weight is as high as 29% in some super output areas

Birmingham has high rates of perinatal and infant mortality. The infant mortality
rate is 7.7% compared to the England average of 4.7%. Rates are significantly higher
in ethnic minority groups
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
Severe pulmonary immaturity and congenital abnormality are the main causes of
infant death in the West midlands

The city is a high risk area for intrauterine growth restriction and prematurity
BREAST FEEDING

Breast feeding initiation is low at 68.1% compared to 74.6% nationally
SMOKING IN PREGNANCY

Levels of smoking in pregnancy are significantly worse in Birmingham than the
England average
CHILDREN FROM BIRTH TO 11 YEARS
IMMUNISATION

Immunisation rates vary across the city. Rates of MMR vaccination are lower in the
South Birmingham compared to the rest of the city
OBESITY

Obesity is a key issue in Birmingham, 11.2% of 4-5 year olds are obese which places
Birmingham just outside the top 20% of local authorities in terms of obesity for
children

Obese children are more likely to become obese adults

Black and Black-British children are the most overweight or obese

Obesity has a direct link to many other illnesses including Type 2 Diabetes, some
cancers and heart and liver disease

Children in Birmingham were less likely to participate in at least 3 hours of sport
than England as a whole
HOSPITAL ADMISSIONS

The majority of hospital admissions for accidents are in the 0-4 age group and from
those with a low socio-economic background

The social gradient for hospital admissions of 2-19 year olds is significantly greater in
deprived wards
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DENTAL HEALTH

The percentage of children in Birmingham aged 4-5 years with decayed or filled
teeth is higher than the national average
SPECIAL EDUCATIONAL NEEDS (SEN) AND PHYSICAL DISABILITY

Birmingham has an average of 3.5% of children under 16 claiming DLA at both lower
and higher rates

There are higher than average rates of congenital malformation with the highest in
Heart of Birmingham and some parts of South Birmingham. This is highlighted in
Ward and Constituency profiles.

There is an overrepresentation of Asian children in the SEN population
CANCER

Childhood cancer incidence and mortality rates have remained steady in the West
Midlands between 2000 and 2009 with no statistically significant changes occurring
across the five-year groups. Childhood cancer is rare, with fewer than 14 cases
diagnosed annually in every 100,000 children in the West Midlands.
ASTHMA

Asthma usually occurs in childhood, in a 2006 study one in five children aged
between 6 and 7 had clinically diagnosed asthma

Emergency admissions in central Birmingham are high but there is a low recorded
prevalence

Smoking and associated environmental tobacco smoke can have a significant impact
on asthma. Whilst not found to be a cause of the condition, it helps to prolong it.
WHAT WE DON’T KNOW – GAPS IN KNOWLEDGE / DATA / INTELLIGENCE






Local data on prevalence of Asthma & better recording of asthma in Primary
schools
Data on the sexual and reproductive health of young people lacking( nationally
and locally)
Data on prevalence of female genital mutilation lacking.
Needs assessments lack information on children in care.
Comprehensive analysis of Health and well being needs of children with a
‘statement of special emotional needs’.
social gradients of people using A&E services and the effect of walk in centres
and services commissioned for minor injuries ( across life course)
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4. DEVELOPING WELL: CHILDHOOD INTO YOUNG ADULTHOOD
‘Inequalities in educational outcomes affect physical and mental health, as well as income
employment and quality of life. To achieve equity from the start, investment in the early
years is crucial from the start.’
KEY FACTS AND FIGURES FOR BIRMINGHAM
Social Determinants

Child poverty is high in Birmingham at 36.1%, which has a detrimental effect on
children and their families

The city has significantly lower rates of healthy eating and physical activity
compared to England as a whole

Immunisation for looked after children is low at 51% compared to 83.9% England
average

Family homelessness is particularly high in Birmingham

Inadequate housing has a detrimental effect on health and can cause respiratory
conditions as well as mental health issues

Birmingham’s GCSE results have improved year-on-year and performance is among
the highest of the large urban authorities.

The groups most at risk of underachieving in education are African-Caribbean boys,
White boys eligible for free school meals and looked-after children.

Post-16 participation in education and training is lower on average for white
disadvantaged boys and girls, mixed race boys and looked-after children.

Rates of congenital malformation are higher in areas of high deprivation

Some BME communities, particularly from Horn of Africa countries practice female
genital mutilation which has profound lifelong health implications

Looked after children experience higher levels of behavioural and mental health
issues than other children
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
First time entrants to the youth justice system is higher than the national average at
1,810 compared to 1,472

The percentage of children that have participated in a positive activity outside
school is 54.8%, England is 65.8%

More than one third of LGBT people indicated that they had been bullied at school
BIRMINGHAM’S 12 TO 18YEAR OLDS
Teenage pregnancy

The under 18 conception rate for Birmingham is 52.1 per 1,000 compared to the
England average 41.0. Termination rates have increased but the number of live
births is still high and alternatives to termination are variable across the City.

There is a discernable social gradient in the prevalence of under 18 conceptions

Young women who are black or have mixed parentage are overrepresented amongst
under 18 conceptions

Rates of teenage pregnancy are higher in some ethnic minority groups

It is estimated that around 20% of births conceived to under 18’s are to young
women who are already teenage mothers

Mothers under 20 have a 26% higher chance of stillbirth

Risk of infant death is increased by 47% for mothers under 20
Sexual Health (data not age specific)

There is evidence that Gonorrhoea rates are high in Birmingham

Testing rates for Chlamydia vary considerably throughout the city with higher rates
of Chlamydia in areas of higher deprivation
Drugs and Alcohol

The peak age for attendance at treatment centres for drug and alcohol abuse is 18.
Cannabis and alcohol are the main substances used

The proportion of white people attending treatment centres is high relative to
expected rates
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Smoking

Smoking prevalence in 2009 was 26% amongst 16-19 year olds, higher than the
national average and higher than the Birmingham all age prevalence. This suggests
smoking initiation and cessation among 16-19 year olds remains a concern.
Asthma

The number of 14-19 year olds with asthma who have a recorded smoking status is
approx 90%.
Special Educational Needs (SEN) learning and Physical Disability

There are no dedicated health care services for children and young people with
learning disability once leaving school and many are lost in the system

Birmingham has an average of 3.6% of children under 16 claiming Disability Living
Allowance

Children from a lower social gradient have higher rates of SEN

Numbers of Pakistani and Bangladeshi children with learning disability is increasing

Obesity is common in people with learning disabilities and is related to conditions
such as Down’s syndrome and Prada-Willi disease.

Washwood Heath has particularly high levels of children classified as having a
profound and multiple learning disability

Transition to adulthood is more challenging for people with learning difficulties,
physical disabilities, care leavers, young people with severe learning disabilities
and/or those with complex needs

People with learning difficulties are overrepresented in the prison service, however
less than 2% of young people seen by the Youth Offending Service are assessed as
needing a CAMHS assessment

44.3% of SEN children in the 13 to 18 age range have learning disabilities

12.7% of 16-19 year olds with learning disability were NEET

Children with higher educational outcomes are more likely to enjoy good health and
wellbeing as adults
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What young disabled people and their carers tell us

Their hopes and aspirations are high

They want to be economically active

They want to be able to do the same as everybody else

They want inclusion in the community, a safe place to live reasonably close to an
important person in their life

There are many examples of poor communication, poor preparation and poor
planning across all agencies

Carers wish to have more certainty, equity and flexibility with regard to short breaks
WHAT WE DON’T KNOW: GAPS IN KNOWLEDGE / DATA / INTELLIGENCE





Data related to the sexuality of young people ‘coming out’ as LGBT and those
who are disabled is not readily available
Local data is limited on substance misuse by age, gender or ethnicity
There is a lack of linked data in order to produce a true picture of learning
disability
accident and emergency utilisation trends
Ongoing consultation with children and young people to determine needs and
wants
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5. LIVING WELL: HEALTHY LIVES ACROSS THE LIFECOURSE
‘Communities are important for physical and mental health and wellbeing’
‘Many of the key health behaviours significant to the development for chronic disease follow
the social gradient’
KEY FACTS AND FIGURES FOR BIRMINGHAM
Social determinants

Rates of statutory homelessness in Birmingham are the highest in England

Family homelessness is particularly high in Birmingham

80% of homeless people present with stress or anxiety

Inadequate housing has a detrimental effect on health and can cause respiratory
conditions as well as mental health issues

Rates for violent crime in the city are significantly higher than the England average.

People with low educational attainment are more likely to live in deprived areas and
have poor health outcomes.
Learning disability

More than 50% of Disability Employment Service clients are in the 18-30 age group

It was forecasted in 2001 that 56% of young adults (age 20-39) with learning
disability in Birmingham in 2011 will belong to a minority ethnic group

The percentage of people with learning difficulty aged 18-64 who find employment
is 1.5% compared to 7.5% in England (those known to social services)

People with learning disability form a large percentage of the prison population

Waiting times for transfer from hospital are in the lower quartile for England for
learning disabled adults, mainly due to time awaiting assessment and getting public
funding agreed
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19-25 year age group

Parents with children with learning difficulties have a higher health risk as once their
children reach 16 they become more difficult to handle

There are no dedicated health care services for children and young people with
learning disability once leaving school

Hospital admission records show that 70% of the patients identified as having a
learning disability are under 25 and present with a number of conditions, Epilepsy,
Downs Syndrome and Autism being the most common

In Birmingham there are over 2,000 Health Action Plans for young people aged 1825 recorded within the GP disability database
26-49 year age group

People with learning disabilities are 58 times more likely to die under the age of 50
than the general population

It was forecasted in 2001 that 56% of young adults (age 20-39) with learning
disability in Birmingham in 2011 will belong to a minority ethnic group

Adaptations are provided principally to the group aged 25-44
Physical disability

The ration of younger adults 18-64 years to older adults 65+ receiving nursing or
residential care has become more similar over time, there are approximately 3
younger adults to 37-38 older adults. The gap in community care has widened over
time at 3 younger adults to 10 older adults

The number of people in the age group 18-64 receiving direct payments increased
from 199 in 2005-6 to 410 in 2008-9
26-49 year age group

There is a marked social gradient of people claiming Disability Living Allowance for
ages 25-49.
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Mental health
There is little age specific information in the JSNA on Mental Health services.

The ethnicity breakdown of the population receiving services from Birmingham and
Solihull Mental Health Foundation Trust is 73% White, Asians 11.1% and Black
populations 5.4%

Black ethnic groups present higher rates of referrals and detention under the Mental
Health Act than average

Prescriptions for anti depressants, stimulants and drugs for attention deficit
hyperactivity have been increasing at a rate of 5% per year. In Birmingham some
general practices prescribe very high volumes of anti-depressant drugs

There is a social gradient in self-harm and some wards present a significantly higher
rate of self harm and suicide than Birmingham generally
26-49 year age group

There is a higher concentration of hospital admissions for the 35-49 age group for
schizophrenia and mood conditions
Cancer

10% of female cancer patients are younger than 46.4 years, this is caused by the
early onset of prominent female cancers (breast, ovaries, cervix, prostate)

Sex specific cancer rates were highest for breast cancer in 2006 however rates are
slightly lower in Birmingham than nationally

Birmingham cervical screening rate in 2009 was 75%, this is 4% lower than the
England average

Cervical cancer in South Birmingham is 50% higher than in England

There has been an increase in skin cancer in both sexes

According to Duke’s classification, colorectal cancer when diagnosed in patients
younger than 50, has already reached the stage where the lymph nodes are
affected. There is a need for improvement in early detection and intervention.

Survival rates for one year from breast cancers show a clear socio-economic
gradient, with the rate from the least deprived area being significantly higher than
from the most deprived
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Diabetes Mellitus

90% of people with Diabetes Type 1 are diagnosed by the age of 30. The average age
of people with Type 1 Diabetes is 17 years

Obesity levels, low levels of physical activity and social deprivation have a direct
influence on prevalence of diabetes. Because of Birmingham’s young population, if
current trends of rising obesity persist, a higher share of the increase in diabetes
prevalence will be caused by obesity

Type 2 diabetes is 2-4 times as common in people of South Asian origin as those of
Caucasian origin. People of African Caribbean origin prevalence of diabetes is high,
and the majority of diabetes is type 2

The top three co-morbidities with diabetes are hypertension, CHD and Asthma
Substance misuse

There has been an increase in rates of hospital admissions due to substance misuse

The percentage of heroin and crack users in Birmingham is higher than the national
average

Drug and alcohol users experience a range of related health problems (respiratory
problems, TB, diabetes, heath disease) as a result of excessive smoking, poor diet,
poor housing

The numbers of indirect deaths from drug/alcohol related illness is increasing

20% of alcohol specific hospital admissions are for mental and behavioural
conditions due to alcohol
Chronic Obstructive Pulmonary disease (COPD)

COPD is the UK’s fifth leading cause of death, and the second highest cause of
emergency hospital admission in the UK

Its prevalence is 1.9% across Birmingham which is lower than the England average of
1.48% although much may go undiagnosed

Patients of South Asian origin are not interacting with COPD services,
This may explain the low prevalence in wards that have high levels of ethnic
minorities

COPD is largely preventable and directly related to smoking
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
It represents a significant financial burden to the health service. 2004 estimates are
£500 million a year

Awareness of COPD is low and diagnosis occurs usually when the disease has already
caused permanent lung damage

There is a predicted increase in COPD across Birmingham
Epilepsy

Rates of epilepsy in Birmingham are slightly lower than the England rate however,
despite epilepsy being generally age related, in 2007 the number of people in
Birmingham with epilepsy was higher in younger groups aged 25-34 mainly due to
the young population.

The number of people with epilepsy in Birmingham is predicted to rise in the next
few years
Long term conditions (LTC’s) all

For the age group 16-49 years slightly higher proportions of LTC’s were seen in the
ethnic groups White Irish (15.6%) Asian Pakistani (13.2%) and Black Caribbean
(12.6%)

The highest proportion of LTC’s was seen in those who never worked (34.2%)
followed by long term unemployment (18.9%)

The prevalence rate for LTC’s is linked to deprivation in Birmingham

People with stroke, multiple sclerosis, cerebral palsy, arthritis and mental health
issues are particularly high users of social care services and people with mental
health issues, CKD, CVS are high users of secondary care services.

LTC’s are responsible for 70% of all premature death. In Birmingham death rates for
the majority of LTC’s are considerably higher than the national average
WHAT WE DON’T KNOW: GAPS IN KNOWLEDGE / DATA / INTELLIGENCE





Need to disaggregated needs assessment data into smaller age band widths,
Data on disability is limited to those accessing social services therefore does not
reflect the learning disability population as a whole, we need more data on this
Misdiagnosis rates for epilepsy are high, and as anti-epilepsy drugs are also used
for pain relief, prevalence measured by prescription rates is likely to be
inaccurate
Data is needed on the impact of mental health in young (18-29) black ethnic
groups, and in the Birmingham Irish community
High rates of admissions for mental health are prevalent in certain areas of
Birmingham, and some BME communities, there is a gap in identifying causes
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

Poor information on life expectancy of people with learning disability in
Birmingham
There is no local information on learning disability and hearing and sight
problems or dental health
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6. WORKING WELL: BETTER EMPLOYMENT, BETTER HEALTH
‘Having insufficient money to lead a healthy life is highly significant cause of health
inequalities’ Work can be very good for you but working conditions and low paid, insecure
work can also be bad for physical and mental health.
KEY FACTS AND FIGURES FOR BIRMINGHAM

Birmingham is ranked as the 10th most deprived local authority in England in terms
of overall Index of Multiple Deprivation scores, and the most deprived local
authority in terms of income and employment.

50% of the Birmingham population belongs to the 20% most income deprived
population in England.

Birmingham’s unemployment rate remains significantly above the national and core
cities average. Of the eight core cities, Birmingham’s rate is the highest, and it is
nearly two thirds higher than England’s rate

The Birmingham seasonally adjusted unemployment benefit claimant count
increased to 51,747 and the rate increased to 12.8%. The England rate remained at
5.5%.

Low education attainment leads to dependency on benefits or low paid work.
WHAT WE DON’T KNOW : GAPS IN KNOWLEDGE / DATA / INTELLIGENCE

More work needs to be undertaken in under this Marmot theme. Although it is
recognised that there is a range of initiatives and consultation exercises
undertaken by partner organisations, these need to be pulled together to
inform the JSNA.
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Health and Social Care in Birmingham: A summary of the JSNA
7. AGEING WELL: HEALTHY OLDER LIFE IS IMPORTANT
KEY FACTS AND FIGURES FOR BIRMINGHAM

The make up of Birmingham’s population is relatively young, however people aged
45 and over make up 33.7% of the population (ONS 2007)

Life expectancy for Birmingham (75.6 for male and 80.8 for female) is below the
England average and the gap is greater for the male population

Help the Aged estimates that social care and health care resources for older people
take up approximately 43% of the annual budget, amounting to £35 - 40 billion per
year.

The largest movement amongst older people is out of the city as they approach
retirement age. There is a net movement into the city by the 80-84 age groups
which is thought to be for better access to health services

The high incidence of poverty, deprivation and low income prevalent in many parts
of the city, is a key factor in determining mortality

Lifestyle and income are key factors in determining quality of life for older people,
for example smoking is associated with poverty and 50% of Birmingham’s population
is in the top 20% of the most income deprived in England

The JSNA looks at people over 50 but sometimes information is only available for an
older group 65 year plus
LIFESTYLE

Obesity is a key contributory factors to many long term conditions

Across Birmingham only 45% of people aged 45 or more engage in at least 3 sessions
per week of 30 minutes of moderate participation in sports.

The NHS Information Centre estimates that 25.1% of Birmingham’s population
consume at least 5 portions of fruit and vegetables per day which compares to the
England average, however, less than 10% of people with learning disabilities have a
balanced diet

Smoking is the largest single cause of death and ill health in the UK. The prevalence
in Birmingham is 25.2% which is higher than the national figure of 22.0%. 28% of
former smokers are 65 or over
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Health and Social Care in Birmingham: A summary of the JSNA
HOUSING

The proportion of the older population without central heating in Birmingham is
over double that of the England average

Fuel poverty is particularly prevalent in Birmingham city centre

Homelessness figures are high for the city, this is linked to a number of problems
including substance misuse, depression etc.

People living on higher floor levels of buildings report greater long term illnesses.
Those living in a caravan or temporary structure have worse health than those living
up to the fourth floor of accommodation

People living in social rented housing report higher levels of long term limiting illness
and poor health than those owning property or privately renting and those living
rent free.

Poor housing can trigger problems of anxiety, stress, depression and respiratory
disease
TRANSPORT

51.3% of pensioners living alone in the City don’t have access to their own transport
limiting access to services.

40% of UK pedestrians killed in road accidents in 2001 were over 60 years of age
HEALTH ISSUES FOR POPULATION AGED 50+
Cancer

90% of cancer is diagnosed on those aged 50 or over

The four major cancers in the city are Colorectal, Prostate, Breast and Lung.

Virtually all cancer site specific one year and five year survival rates for Birmingham
are higher than those for England

Lung and Colorectal cancer are the most common types of cancer. The 1 year
survival rate for colorectal cancer is around 72% and for lung cancer 32%. The 5
year survival rate is 43% for colorectal cancer, for lung cancer very few survive for 5
years. The male population is most affected by these two conditions and in
Birmingham rates are consistently higher than England
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
Breast cancer is the highest prevalence for sex specific cancer, followed by prostate
cancer, male lung cancer, male colorectal cancer and male upper GI cancer.

Ethnicity is a big predictor of a person’s chance of developing cancer. Someone
from a Asian, Chinese or mixed race background has only about a 60% of the chance
that a white person has of getting cancer. However, black men are prone to
prostate cancer

Three quarters of the incidences of prostate cancer are in men over the age of 65,
the largest number being in the 75-79 year old age range

Colorectal cancers are higher for men and women in the 65+ age group
Falls

Falls are a key area of concern in older people

Birmingham has higher rates of falls than England

Osteoporosis, arthritis and other conditions are often diagnosed as a result of falls
rather than independently

Many older people end up in hospital because of either the direct result of a fall or
the consequences of a fall caused by other factors

There has been an increase in both hip and knee replacement procedures in the last
few years in Birmingham. Hip replacement is most common in the age group 80
years or older; knee replacement is most likely in the 60-80 group.
Mental health and learning disability

Mortality, morbidity rates and negative determinants of health are increased in
people with learning difficulties

As life expectancy improves, the number of older people with learning disabilities
requiring services also rises; this includes dental, hearing and sight and lifestyle
interventions such as tackling obesity and smoking

Older people are particularly vulnerable to the effects of stress. Accumulative stress
can lead to physical illness such as gastric ulcers, and in extreme cases may
ultimately lead to suicide

Hospital admission for depression rises significantly in those above 50

Estimates state that there are 15,000 people under the age of 65 suffering from
Dementia in the UK
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Health and Social Care in Birmingham: A summary of the JSNA

Substance misuse can lead to depression and associated mental health issues. Drug
related mental health disorder is the highest mental health category for hospital
admissions in Birmingham

People with mental health problems living alone have higher admission rates than
those not living alone, particularly men.
Mental Health/Dementia

Mental illness was by far the top long term condition that accounted for one in
every five hospital bed days in Birmingham

In the UK it is suggested that mental health problems are present in 40% of people
65 and over who visit their GP, in 50% of adult in-patients in hospital and 60% of
residents in care homes

Dementia is thought to cost the economy £17 billion per year (2009)

Mental health issues are highest in those aged 70 or older

In the UK mental health problems are suggested to be present in 40% of people 65
years or older who visit their GP, in 50% of adult in-patients in general hospital and
60% of the residents of care homes

Dementia figures are expected to double over the next 30 years
Hypertension and Diabetes

Hypertension and diabetes have higher prevalence in Birmingham than the national
average. Hypertension is a clinical risk factor for most vascular illnesses and as such
should be given priority for intervention

Prevalence of Diabetes is linked to ethnicity, obesity and social deprivation
Long Term conditions (LTC’s)

People with LTC’s are intensive users of health and social care services. People with
Stroke, Multiple Sclerosis, Cerebral Palsy, Arthritis and mental health problems are
high users of social care services. Those with mental health conditions, CVD and
CKD are high users of secondary care services.

LTC’s account for about 70% of premature death in Birmingham which is much
higher than the national average

The national target of reducing emergency beds (2008) is still challenging for the city

Co-morbidities of LTC’s i.e. Hypertension, Diabetes, Asthma, CHD and mental illness
are the most common LTC’s that exist with other LTC’s
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Chronic Heart Disease

Projected prevalence of all of the above has a steep age profile with most prevalent
being in the 75-85 group.

The figures for the older population 75 and over for CHD is 25.9% for males and
21.4% for females

From the age of 45-54 for every move to the next 10 year age group prevalence of
CHD doubles
Hypertension

Hypertension has high prevalence in Birmingham at 12%, this is a concern because
of its contribution to many other conditions
Chronic Obstructive Pulmonary Disorder (COPD)

COPD is the UK’s fifth leading cause of death and the second highest cause of
emergency admission to hospital

73% 0f COPD mortality is associated with smoking and it is estimated that 50% of
smokers develop COPD

Amongst people 75 years and older the COPD prevalence rate for Birmingham is
13%. The rate is expected to rise over the years. In younger people under 45, the
rate is expected to remain constant at 2%

Factors like damp housing, higher occupational exposure to dust/asbestos are
factors increasing the risk of COPD
Chronic Kidney disease (CKD)

CKD was the top long term condition that accounted for nearly one in every five
hospital admissions in Birmingham

CKD is predicted to increase by 2020 across all age groups particularly in elderly men
aged 65+
Epilepsy

Epilepsy prevalence is associated with age. Overall the prevalence for males and
females is similar but in the age group 70+ is more common in males. Rates are
expected to rise in Birmingham in the next 10 years. Note: misdiagnosis of epilepsy
is high therefore numbers are not accurate
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Hospital admissions

For the over 85 age group the seven most frequent causes of hospital
admissions are:

Ill defined symptoms

Kidney related illness

Digestive tract diseases

Other disease of CNS

Disease of bones and connective tissue

Injury other than head or femur

Pneumonia
WHAT WE DON’T KNOW: GAPS IN KNOWLEDGE / DATA / INTELLIGENCE










Only people with complex needs are known to disability services and these are a
minority of the entire learning disability population
Alcohol and drug misuse is clearly a problem in Birmingham particularly in deprived
areas, however age specific data is not available
There is little specific research available on the health needs of older ethnic minority
groups.
More work is needed on social determinants in relation to the health of older people
i.e. recording of social care information in terms of the cause and effects of social
isolation
Current data on the need for psychiatric evaluation and existing variations of service
provision for people with dementia is not available for Birmingham
Fuel poverty and lack of central heating in relation to respiratory conditions and
winter deaths is an area that requires further exploration
At present, there is a particular gap in drug misuse services for middle to older aged
males. Alcohol and drug abuse research needs to include areas specific to older
adults
Staging data for cancers in Birmingham does not give a clear picture of whether or
not cancers are detected at early enough stages
Nationally we know that Cancer incidence varies according to ethnic group but data
is not available for Birmingham
Reliable predicting models for future prevalence of diseases are necessary as
present models are not suitable
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Health and Social Care in Birmingham: A summary of the JSNA
8. DYING WELL: END OF LIFE CARE AND SUPPORT
We know that some people including children die before their expected lifespan from illness
or accident; this is an area that may require more investigation as data is not available in
current needs assessments. For the purpose of this report, Dying Well covers the older age
group.
KEY FACTS AND FIGURES FOR BIRMINGHAM

The high incidence of poverty, deprivation and low income prevalent in many parts
of the city, is a key factor in determining mortality

For the age group 45+, the four leading causes of death are ischaemic heart disease,
cerebral-vascular disease, cancers (malignant neoplasm of trachea, bronchus and
lung) and pneumonia.

Two thirds of people would prefer to die at home, but in practice only about one
third actually do

The percentage of people on GP lists receiving palliative care is slightly higher in
Birmingham than the England average

In 2007 1,366 people in Birmingham used day care before they died, 7,787 people
aged 65+ died having received home care

There were 934 residents in Birmingham’s nursing homes in August 2009. In 2009
non white nursing home residents made up 17.6 % of the population of older adults,
which is lower than the total population of older none white people in Birmingham
at 20.7%.

Asian people make up less than1% of the nursing home population whereas the
overall Asian population in the city is 6.5%. This is probably due to more people
from Asian backgrounds being cared for in their home environment

There were 1554 residents in Birmingham’s care homes in 2009, 4% of which were
in homes rated as poor by the QCC. Over half of residents were aged 85 or older.

Data suggests that the city appears to offer very little in terms of specialist provision
for older people
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
Specialist dementia care makes up 0.1% of overall housing provision totalling 6 units

Birmingham gives relatively few people the support they need to keep them living at
home

Birmingham does not perform well in transfer of care which can cause distress in
older people
WHAT WE DON’T KNOW: GAPS IN KNOWLEDGE / DATA / INTELLIGENCE







The national indicator for end of life care covers the percentage of people who die
at home but not the services provided by hospices and other institutions
Quality of care received by people at the end of their lives is not adequately
recorded and data generally needs developing in this area
Information is needed on how dementia is linked to the current housing situation
There is no definitive list of people requiring palliative care as people with long term
conditions may be registered on more than one list. However, even if we assume
that potential demand on palliative care is only 10% of the total list, the demand still
far exceeds the number currently in receipt of care.
We need to know more about how and when someone becomes classified as a
palliative care patient and whether the care received is holistic or short-term
terminal care
More needs to be known about the quality of care received at the end of life both at
home and in hospital or residential home
Data for England shows that on average women and men live through respectively
10.8 and 8.7 unhealthy years, there is no Birmingham data for this area
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8. CROSS-SYSTEM ISSUES
During the production of the summary report, we identified a range of cross-system issues
which are listed below. These do not sit readily in any single Marmot Outcome, they tend to
cross outcomes and run across the Lifespan, which is why we have highlighted them here.
LEARNING DISABILITIES

There is no framework for the registration and monitoring of people with learning
disabilities to help them maintain and enhance their independence over the entire
life cycle

We need to improve the procedures ensuring a smooth transition from childhood to
adulthood and from adulthood to old age, especially in mental health and learning
disabilities, and particularly for children with disabilities

Evaluation of need for specific support of people with learning disability in the
Bangladeshi and Pakistani communities given the higher prevalence of severe and
profound/multiple learning disability and the expected increase of older people in
this population in the medium term

Introduction of systematic follow ups of people with learning disabilities in transition
and beyond

Reductions of health inequalities in people with learning disability by coordinating
access to health and social care and welfare support

Reduction of hospital admissions due to injury, poisoning and other conditions
deriving from external causes

Targeting of people with learning disability and epilepsy to improve management of
condition

Reduction of obesity prevalence in people with learning disability

Delays in transfer of care

Services to carers, young people and young mothers with learning disability

Raising awareness of the needs of people with learning disability among nonspecialist front line workers in Health Care and Public services
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ADVOCACY SERVICES
The review of advocacy services highlighted the following issues

Current and future demand outstrips the available offer

Lack of specific health advocacy services

Need for city wide transition advocacy

Need to meet increasing demand from the BME community

Need to provide advocacy training to volunteers and paid staff

Need to train carers and people with learning disability to conduct self-advocacy
wherever possible

Need to shift from crisis management to early prevention
DELAYED TRANSFERS OF CARE
Design improved systems for crisis management, delayed transfer of care and reduce the
length of time to assess and provide services that address current challenges
MENTAL HEALTH

Developing Pathway approached and integration of commissioning and care

Enhancing provision of community based services

Improving quality and consistency of primary care based services

Ensuring a balance in specialist services (acute and other services)

Addressing equity, access, system and other issues
Pathway approaches and integration of commissioning and care

Pathways need to make clearer the balance between pharmacological therapies in
primary care and ensure choice of provision for psychological therapies, especially
the steady rise in anti-depressant prescription

The effectiveness and quality of primary care management of mental ill-health
needs to be improved

The improvement of the physical health and reduction in inequalities in physical
morbidity and mortality must be incorporated into pathways
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
Joining up services for people with mental health problems arising from,
contributing to, or co-diagnosed with drug and alcohol problems should be a priority
in order to deliver more effective and efficient pathways
Community Based Services

Commissioners should ensure that services and interventions for people with a)
stress related problems and b) behavioural and emotional problems with onset
usually occurring in childhood and adolescence are put in place

Commissioners should review services that address antenatal and post natal
depression to ensure they are effective, have clear case finding protocols and reach
those who can benefit from them

Commissioners should seek to create joint programmes with other agencies which
improve local community public mental health, with an initial focus on Acocks
Green, Ladywood, Sparkbrook, Nechells and Stockland Green
Primary Care based Services

Addressing the physical health of people with mental health problems should be a
priority throughout the care pathway. This could begin in primary care as part of the
routine cardiovascular and physical health work of GP’s with vulnerable populations

It is important to reduce the variation in care in general practice. Such a programme
could be a major driver of improved care, early detection and cost savings.
Commissioners should enhance primary care mental health quality by promoting
integrated programmes and clinical leadership. DH policy and other guidance
suggests that improving shared care and transfer of care between GP’s and clinicians
in secondary care to enhance early recognition; and improve primary care
management of mental health problems may be beneficial
Specialist Services (acute and other services)

Commissioners should seek to improve carer/patient participation in care plans

Commissioners should seek to commission programmes that are appropriate for all
ethnicities

There needs to be greater focus on early detection of mental health conditions and
early intervention to reduce avoidable exacerbation of problems
Public mental health
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Health and Social Care in Birmingham: A summary of the JSNA

We still have significant opportunity to address public mental health issues such as
maintaining resilience and wellbeing through low level interventions to prevent
people becoming ill

There is still a lack of interventions across the pathway that place increased focus on
self-management including change in lifestyle to improve mental wellbeing

Commissioners and providers do not consistently promote physical activity and
healthy lifestyles as a way of supporting and maintaining good mental health in
populations at higher risk of developing mental ill-health

There remains concern that assessment of mental health problems and service
provision for black (British, African and Caribbean) and Asian populations is not
sufficiently culturally acceptable and accessible,
PHYSICALLY DISABLED ADULTS
 collection and analysis of relevant information has significant gaps

Care pathways do not fully support the individual budgets, personalisation and
independent living agenda
OLDER PEOPLE

Better recording of data to be used to study underlying causes and to project and
predict future trends

There remains significant isolation across the City for many older people

Hypertension and other lifestyle factors are still not being addressed equitably
across the City
LGBT POPULATIONS

Significant unmet mental health need

Significant avoidable self-harm

A range of physical health problems which could be resolved including higher
smoking prevalence, higher eating disorder prevalence and higher risk of avoidable
death from Cancer and CVD

Significant feeling in the LGBT communities that services are not LGBT friendly
CANCER

Lifestyle factors (weight/obesity, healthy diet, physical exercise, smoking and
alcohol) are key risk factors for many types of cancer, yet these factors are poorly
recorded and some people are not accessing prevention
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
Study the effectiveness of cancer screening programmes and whether their
implementation reduces or promotes health inequalities?

Access to services and awareness need to improve

Better recording of staging data is crucial as this will guide efforts to diagnose cancer
at an earlier stage

Screening uptake across ethnic groups remains a concern, some groups are underrepresented

Improved patient experience
CHILDREN AND YOUNG PEOPLE

Child and adolescent sexual and reproductive health needs including resilience and
comfort in sexual orientation and identify are still areas of unmet need

harmful drug and alcohol misuse amongst young people remains a significant issues

the effects of parents and carers problematic substance misuse on children remains
a significant issue

There is still a significant issue with obesity in children, with causal factors ranging
across many agencies especially in relation to Birmingham’s obese-genic
environment

smoking initiation and cessation for adolescents is still not well developed

There are still avoidable accident resulting in injury across the city
LONG TERM CONDITIONS

There is a need to improve sharing of primary care and social care data on
individuals, to enable accurate modelling

Self-management programmes to avoid hospital admission are variably run across
the city and access may not be equitable
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9. DISCUSSION: ISSUES AND NEXT STEPS
Refreshing the JSNA to reflect the Marmot themes has enabled a better understanding of the
populations ‘ health and wellbeing issues across the life course. It has identified those issues
and concerns that impact most at different stages of life . It has also enabled the matching of
the needs of the Birmingham population to key policy areas in Marmot and therefore enables
planners and commissioners to identify which parts of Marmot Policy are relevant to
Birmingham and where the focus of work needs to be to ‘improve the health of the poorest
the fastest’.
This approach has also identified a gap in the JSNA regarding the social determinants of
Health. This will be addressed in future work on the JSNA. Public Health moving to the local
Authority will enable this aspect of the work to become more streamlined.
The next stage is for the Birmingham Health and Wellbeing Partnership to develop a Health
and Wellbeing Strategy that will identify key priority areas for Birmingham – informed by the
JSNA.
The key priority areas for Birmingham to focus on will be selected through a prioritisation
approach which will be aligned to the Marmot framework and informed by the evidence base
and policy recommendations in Marmot. It will also reflect the Public Health Outcomes
Framework by which the improvements in the health of the population will be monitored.
This JSNA refresh has also considered whether the right organisations and right people have
been adequately represented or involved in the earlier needs assessments. Where that
citizen voice and service user voice has been heard we have made sure that we have
captured that view within the assessments. We do however acknowledge that more needs
to be done over the period of the next JSNA to improve on how we capture these voices. We
intend to do this by;
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Developing a Community Engagement and Intelligence Strategy
Working closely with the Link’s membership and with the 3rd Sector through BVSC.
Running a pilot to access traditionally ‘hard to reach’ communities through working in a
different way with two CIC’s (Community Interest Companies?).
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