Executive Summary: The main challenges in Devon

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 760,000 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 100,000 over the next 20 years. This is illustrated by the number of persons aged 85 and over, which stood at 10,300 in 1981, 28,300 in 2015, and is set to rise to 64,900 by 2037, 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.

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. Welfare reform is expected to have a considerable impact in Devon with estimates suggesting that more than £250 million will be taken out of the Devon economy in 2015-16. 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 there has been a reduction in crime across Devon, although there is variation between different crimes. There has been an increase in arson, domestic abuse, violence against a person, other thefts, shoplifting and hate crime. There has been a reduction in anti-social behaviour, criminal damage, vehicle crime, non-dwelling burglary, dwelling burglary, sexual offences and robbery. 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. Whilst measures of social connectedness highlight that almost half of the people receiving care services in Devon have as much social contact as they would like. 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 2010, 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 32.5% 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 47.3% 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 15 year gap between the wards with the shortest (Ilfracombe Central, 74.6 years) and longest (Newton Poppleford and Harpford, 89.6 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. 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. Child Sexual Exploitation and Female Genital Mutilation have a major impact on the health and wellbeing of children and work is focused locally on identifying victims and working to prevent future cases in Devon. Domestic violence and abuse affects many families in Devon with children and young people present in over a third (36%) of incidents reported to police in 2013-14.

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 225,000 people in Devon are estimated to be affected by high blood pressure (Hypertension) with just over half known to GP services. Around three in five adults in Devon (60.6%) are recorded as overweight or obese, a figure which has increased over recent years. An estimated 60.9% of adults in Devon achieved at least 150 minutes of moderate physical activity per week in 2013. 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. Mental health problems in adulthood vary by area, with the mood and anxiety disorder indicator from the 2010 Indices of Deprivation highlighting higher levels of need in parts of Exeter, Exmouth, Teignmouth, Dawlish, Newton Abbot, Totnes, Ilfracombe, Bideford and Barnstaple. 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, with 65 year olds in the least deprived areas (21.8 years) likely to live 3.4 years longer than those in the most deprived areas (18.4 years). 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 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 are caring for 50 or more hours per week likely to experience more rapid deterioration in their own health as they get older.