A Joint Strategic Needs Assessment (JSNA) looks at the current and future health and care needs of local populations to inform and guide the planning and commissioning (buying) of health, well-being and social care services within a local authority area. This document, the Devon Overview, looks at the overall pattern of health and care needs in the county, including the impact of population change, deprivation and economic conditions.
Chapter 3: Population
Around 770,000 people live in Devon. The county has an older population profile than England with a higher proportion in older age groups. All Devon districts have a higher proportion of those aged 85 and over than England, with particularly high concentrations in coastal and market towns such as Sidmouth, Teignmouth and Dartmouth. The population of the county is changing, with a projected increase in population of over 100,000 in the next 20 years. This is illustrated by the number of persons aged 85 and over, which stood at 10,300 in 1981, 28,100 in 2016, and is set to rise to 62,500 by 2039, contributing to an increasing proportion of the population in older age groups, with consequences for both increased demand for health services and the availability of staff. Both in terms of volumes and net change, internal migration (movements within the UK) has a much more significant impact than international migration, with a strong net flow from the South East of England. The development and expansion of new towns, such as Cranbrook in East Devon and Sherford in the South Hams, coupled with continued housing and economic development in existing settlements will have an impact on local patterns of demand for health and care services. The population structure of new towns and significant housing developments is particularly young, providing new community-based opportunities for the primary prevention of disease.
Chapter 4: Equality and Diversity
The Equality Act 2010 identifies nine protected characteristics: age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex, and sexual orientation. The Act protects people from direct and indirect discrimination, harassment and victimisation because of a protected characteristic. The Act also includes a Public Sector Equality Duty (PSED), which requires public authorities to consider the extent to which they can eliminate discrimination, advance equality of opportunity and foster good relations in relation to the protected characteristics. The equality section of this report provides an overview of the population of Devon for each of the protected characteristics, a brief summary of health and wellbeing needs in respect of these characteristics, and links out to other documents and resources for further information. The Devon population is diverse in its needs and inequality can take many forms, resulting in differing health and care needs to which health and care commissioners need to respond.
Chapter 5: Economy
Devon has a culture of enterprise and resourcefulness. However average wages and productivity are low and given the variation across Devon, skills shortages present a barrier to growth in some parts of the county. Jobseekers Allowance claimant rates have decreased over recent years and are highest in Torridge. Average wages in Devon are below the England average and similar local authorities. The local authorities with the highest proportion of people with no qualifications are North Devon and West Devon and the lowest is Exeter. There is variation in the proportion of people claiming health-related benefits (Employment and Support Allowance and Incapacity Benefit) in Devon with the highest levels in North Devon and Torridge. Food poverty (the inability to afford or have reasonable access to food which provides a healthy diet) is a significant issue and is increasingly affecting people in low paid employment.
Chapter 6: Community and Environment
The Devon Strategic Assessment describes crime and community safety issues for Devon. Overall levels of recorded crime have been stable, although there is variation between different crimes. Increases in the levels of reporting for domestic abuse, violence without injury, sexual offences, shoplifting, public order offences, possession of weapons, hate crime and road traffic casualties, and reductions in robbery, burglary and vehicle crime have been seen over recent years. Natural Devon, the Devon Local Nature Partnership, was established in 2012 to protect and improve Devon’s natural environment, to grow Devon’s green economy and to reconnect Devon’s people with nature. A ‘State of the Environment’ report was published in 2014 describing the current condition of the environment. Poor air quality can have a negative impact on health, and whilst mortality attributable to air pollution is below the South West and England average, a number of Air Quality Management Areas (AQMAs) exist where air quality is actively monitored. Housing conditions can have an adverse impact on health. The affordability of housing in Devon is also an issue on account of relatively high house prices and relatively low wages. Levels of homelessness in the county are relatively high, and are associated with a range of physical and mental health problems. As a large, predominantly rural county, there are additional challenges in Devon in terms of access to health and care services. Social interaction and social support play an important part in our health and wellbeing. Issues such as isolation, loneliness and mental health conditions such as anxiety and depression can influence physical health and reduced life expectancy is linked to chronic mental health problems such as schizophrenia.
Chapter 7: Socio-Economic Deprivation
The term socio-economic deprivation refers to the lack of material benefits considered to be basic necessities in a society. Around 5% of the Devon population live in the most deprived national quintile (one-fifth). These areas include parts of Exeter, Ilfracombe, Barnstaple, Bideford, Dawlish, Dartmouth, Teignmouth, Newton Abbot and Tiverton. Within Devon rural areas are generally more deprived than rural areas elsewhere in England, whilst urban areas are generally less deprived than urban areas nationally. Whilst urban areas are usually more deprived than rural areas, the rural areas surrounding a number of towns in Devon are more deprived than the town itself, including Crediton, Great Torrington, Holsworthy, Honiton, Okehampton, South Molton and Tavistock. The pattern varies across different domains in the Indices of Deprivation 2015, with relatively low levels or crime, road traffic accidents and generally good air quality mean the majority of areas in Devon are in the least deprived quintile nationally for the crime and outdoor environment domains. This is largely reversed in the barriers domain (accessibility and affordability of housing, and distance from local services) with 27.45% of the Devon population in the most deprived group nationally, and the indoor environment domain (houses failing to meet the decent homes standard or without central heating), with 54.55% of the Devon population in the most deprived group nationally.
Chapter 8: Starting Well – Children, Young People and Families
There are over 7,000 births per annum in Devon. Average age at birth is increasing with the rate of births to mothers aged 40 above the rate in under 20 year olds which is showing a gradual decrease. Inequalities in health start before birth. Whilst life expectancy at birth is above the national average and improving for Devon as a whole, there is a 14 year gap between the wards with the shortest (Ilfracombe Central, 75 years) and longest (Orchard Hill, 89 years) average life expectancies. Major differences are also seen in breast feeding rates, the number of women smoking during pregnancy, accident and emergency attendances, emergency hospital admissions and educational attainment. At least 5,000 children in Devon are disabled, and up to 30,000 have a limiting long-term health problem or disability. Smoking and alcohol use is dropping rapidly in children and young people, with fruit and vegetable consumption and good general health increasing, although major differences still exist between communities. Levels of excess weight in childhood (overweight or obese) have been relatively stable over recent years, with levels above the national average at age four to five and below the national average at age 10 to 11. Teenage conception rates have fallen over recent years, but significant differences still exist with higher rates in more deprived areas. Common mental health problems in childhood include depression, generalised anxiety disorder, eating disorders and hyperactivity, along with post-traumatic stress disorder seen particularly in relation to cases of sexual and physical abuse. Rates of admissions for self-harm and levels of mental difficulties in looked after children are above the national average in Devon. Improving outcomes for children in care, and identifying and addressing Child Sexual Exploitation and all forms of abuse and neglect will be vital to efforts to improve health and wellbeing for children, young people and families in Devon. Domestic violence and abuse affects many families in Devon with children and young people present in around two fifths of incidents.
Chapter 9: Living Well – Adults
Through the national NHS and Public Health England publication ‘A Call to Action: Commissioning for Prevention’ a strong emphasis is placed on identifying the risk factors associated with ill-health and premature death and working proactively to address these issues during adulthood. Rates of smoking have fallen over recent years, but significantly higher rates in more deprived areas still persist. Over 230,000 people in Devon are estimated to be affected by high blood pressure (Hypertension) with just over half known to GP services. Over three in five adults in Devon (63.8%) are recorded as overweight or obese, a figure which has increased over recent years. An estimated 60.7% of adults in Devon achieved at least 150 minutes of moderate physical activity per week in 2015. The pattern of alcohol use both nationally and locally is changing, with the sharpest falls in use in younger age groups, and regular use more common in those with higher incomes. However, alcohol-related illness and death remains more common in those on lower incomes or living in more deprived areas. The pattern of drug use is also changing, and whilst overall drug use is falling in both younger and older age groups, the use of powder cocaine and new psychoactive substances (formerly known as legal highs) have increased significantly over recent years, and over the last year the use of Ecstasy has increase in young people and magic mushrooms for other age groups. Mental health problems in adulthood vary by area, and are closely associated with patterns of deprivation. Suicide rates in Devon have remained consistently above national levels in recent years. The pattern of risk factors coupled with an ageing population in Devon contribute to a growing number of people with long-term conditions in the county, which are typically higher in more deprived areas, with higher levels of complications in these age groups contributing to higher hospital admission and mortality rates. There is also a growing burden of those living with more than one long term condition (known as multi-morbidity) with around one in seven likely to have two or more conditions. Local and national evidence suggests people living in the most deprived areas are likely to experience multi-morbidity 10 -15 years earlier than those in the least deprived areas. There is also a strong relationship between mental health conditions and physical conditions with those on GP registers for depression and serious mental illness much more likely to also have physical long-term conditions.
Chapter 10: Ageing Well – Older People
The focus of prevention in older age groups is around healthy active ageing and supporting independence so older people area able to enjoy long and healthy lives, feeling safe at home and connected to their community. As with life expectancy at birth, variations also exist across Devon for life expectancy at the age 65, healthy life expectancy, and disability free life expectancy. An older population structure and stronger population growth in Devon mean that current and future demand for health and care services in Devon are likely to be greater than those seen nationally. Levels of frailty, accidental falls, visual impairment, social isolation, loneliness and dementia are higher than the national average and future growth will be greater. Similarly demand for general health and care services will also increase accordingly. Due to higher living costs and lower average household incomes, fuel poverty in Devon is higher than similar local authorities nationally, and particularly affects older age groups. The provision of unpaid care also has a major impact on older people, with those who provide unpaid care for 50 or more hours per week likely to experience more rapid deterioration in their own health as they get older.
Developing the JSNA in Devon
This document, the Devon Overview, is part of a wider suite of JSNA resources in Devon. Other elements include:
- Community Health and Wellbeing Profiles, providing a wide range of health and care information for geographic areas, including towns, local authorities, and GP practices
- The Devon Health and Wellbeing Outcomes Report, which monitors progress against the priorities identified in the Devon Joint Health and Wellbeing Strategy
- Locality Health Improvement Plans, which guide the work of the Public Health team and colleagues working in the NHS, the local authority and other organisations, identifying both priority issues and priority communities within local areas
- Outcomes reports, data downloads and links to other related documents
- A comprehensive library of topic based information, including needs assessments.
Detailed health needs assessments published since the last JSNA Devon Overview was completed in 2015 are available on the Devon Health and Wellbeing website http://www.devonhealthandwellbeing.org.uk/library/needs-assessments/ and include:
- Looked After Children Health Needs Assessment 2016
- Cranbrook Health Needs Assessment 2015-16
- Self-Harm Health Needs Assessment 2015
Areas for ongoing development include the further development of information relating to the public sector equality duty and qualitative information about health and wellbeing services and issues locally, as demonstrated in the green ‘Perceptions and Experiences’ boxes in the main report.
Further to this, the Devon Health and Wellbeing website
(www.devonhealthandwellbeing.org.uk) will be developed to include more interactive content, improved topic based information and document management.
Conclusion – the main challenges in Devon
The main health and wellbeing challenges in Devon are:
- An ageing population which is also growing faster than the national average increasing future demand for health and care services
- New towns such as Cranbrook and new housing developments in existing towns with a young population structure very different to the rest of Devon, and a different set of challenges relating to health-related behaviours, child health and sexual health. Community development and preventive approaches will be vital in these areas
- Increasing financial pressures affecting local authorities, Clinical Commissioning Groups and other agencies requiring changes to traditional patterns of service provision to ensure health and care services remain affordable
- A configuration of local authority and health organisations more complex than most other counties, with two-tier local authorities, and Clinical Commissioning Groups crossing local authority boundaries. This creates extra challenges in terms of the continuity of services, planning and effective partnership working
- A sparse and predominantly rural population, creating additional challenges around access to health and care services and the need for sophisticated models of home-based care, outreach and work to reduce social isolation. The effective utilisation of local resources, voluntary / community organisations and community assets will be critical
- Patterns of deprivation marked by isolated pockets and hidden need within communities and higher levels of rural deprivation, with groups experiencing health inequalities likely to be geographically dispersed. This creates additional challenges when addressing health inequalities and targeting services to those most in need
- A disparity between the quality of indoor and outdoor environments in Devon. According to the Indices of Deprivation 2015 over half the Devon population (54.55%) live in areas in the most deprived 20% in England for the quality of the indoor environment (decent homes standard and central heating), with no areas in the most deprived 20% in England for the quality of the outdoor environment (air quality and road traffic accidents affecting pedestrians and cyclists). Housing has a direct impact on health with poor housing leading to an increased risk of cardiovascular and respiratory disease, as well as anxiety and depression
- Average earnings below the national average and house prices and cost of living above the national average contribute to a number of issues including food poverty, homelessness, mental health and wellbeing, and fuel poverty
- The need for a focus on prevention at all stages of the life course aimed at improving health in later life for all, as well as narrowing the 10 to 15 year gap in health status between those living in the most deprived and least deprived areas. This will be critical to addressing the demographic and financial pressures that local organisations are facing
- The need for a focus on mental health and wellbeing throughout the life course with a particular emphasis on groups and geographic areas where outcomes are comparatively poor and socio-economic deprivation, and an understanding of the relationship between mental and physical health
- High levels of social isolation resulting in loneliness, which whilst most common on the older population, is evident in younger age groups, minority groups and people who are geographically isolated. This has an immediate impact on mental health and wellbeing and a long-term impact on general health
- Improvements in relation to health-related behaviours in younger age groups are not mirrored in older age groups, and considerable variations exist by sex, deprivation and other social and economic factors. These changing patterns of smoking, excess weight, physical activity, diet, alcohol, drug use and other behaviours should directly inform the planning of future interventions
- The growing number of people with long-term conditions, sensory impairment, dementia, cancer and other health problems. This requires a particular focus on those living with multiple health conditions, as traditionally health systems have been largely configured for individual diseases rather than multi-morbidity
- Growing levels of severe frailty in the population. Whilst frailty increases with age, signs of mild frailty can appear in people in the 20s and 30s, and more severe frailty in people in their 40s, 50s and 60s, with an earlier onset in more deprived areas. The detection of the early stages of frailty (known as pre-frailty) is important as the progression from pre-frailty to severe frailty typically takes 10 to 20 years, providing a window of opportunity to slow or ameliorate this progression. The detection of frailty in primary and community care, the early identification and treatment of disease, prevention, and the targeting of groups who are likely to be most affected are vital
- The Devon population is diverse in its needs and inequality can take many forms, resulting in differing health and care needs to which health and care commissioners need to respond.