Agenda item

Purpose: To present the Annual Report from the Director of Public Health

The Board considered a report and presentation (Agenda Item 8) from the Director of Public Health (DPH). Section 31 of the Health and Social Care Act 2012 placed a duty on the local authority to publish the DPH’s annual report, while the Act required the DPH to write one.

This year’s annual report focused on children’s health in its broader sense. Each organisation was charged with improving the health of local residents and to reduce health inequalities. Giving children the best start in life was evidenced to be the most effective way to do this.

Lesley Wyman gave a presentation on Lise Llewellyn’s behalf, summarising the presentation included in the agenda for the meeting.

Infant mortality had decreased over the last 20 years from 12.0 deaths per 1,000 live births in 1980 to 3.8 in 2013. This was the lowest level recorded in England and Wales. Councillor Hilary Cole questioned how there could be .8 of a death. Lesley Wyman answered that the figure presented was a rate not an absolute figure. Councillor Gordon Lundie commented that he would like to see the numbers, noting that there was a higher infant mortality rate in the 10% most deprived areas in West Berkshire.

The Child Death Overview Panel (CDOP) reviewed information on all unexpected child deaths, recorded preventable child deaths and made recommendations to ensure that similar deaths were prevented in the future. The Berkshire CDOP reviewed cases across the county and reported into each Local Safeguarding Board. In West Berkshire in 2015 the main cause of death in infants was genetic or chromosomal abnormalities. Councillor Lynne Doherty asked whether screening could identify such abnormalities. Rachael Wardell advised that she was the Deputy Chair of the CDOP and explained that as a result she was aware that many were identified during pregnancy and were carried to term with significant medical intervention but unfortunately lost their life.

In 2014/15, 11.4% of mothers in England were smokers at the time of delivery. All of the Berkshire local authorities had a significantly lower level of smokers, from 6.3% in Wokingham to 9.2% in Reading. In West Berkshire, the level was 8.7%. Councillor Doherty commented that while the whole of Berkshire had low levels, West Berkshire had the second highest level of smoking and asked whether this was cause for concern. Lesley Wyman responded that Wokingham had an exceptionally low level of smoking in its population generally. West Berkshire’s smoking cessation service was paid additionally for supporting expectant mothers to quit smoking. Councillor Doherty asked if there were any lessons to be learnt from Wokingham’s low smoking rate. Lesley Wyman responded that Wokingham had reported low  levels of smoking since records on the measure began and could not be connected to any particular initiative.

Rachael Wardell indicated that the level of smoking amongst mothers at the time of delivery for Slough was an outlier when, based on other demographic factors it might be anticipated that it would have similar levels to Reading. It was interesting to consider what the drives for smoking behaviour were and suggested that cultural expectations of women’s behaviour might be a factor.

Turning to the issue of obesity, Lesley Wyman advised that rates of childhood obesity varied with socioeconomic status. In West Berkshire, 7.2% of children in Reception class were obese and 14.9% of children in year 6 were obese. The pattern was not predictable by ward as childhood obesity was prevalent in wards such as Mortimer and all the Thatcham wards, not just the wards that were typically considered the most deprived. Andrew Sharp asked if the Board could have confidence in the figures, indicating that in Falkland ward, there was little variation between Reception and Year 6 children. Lesley Wyman commented that some wards were very small and the cohort used to collect the data might not present a reliable picture.

Councillor Cole asked what work was being undertaken with schools to ensure children were being provided with healthy meals and were receiving sufficient levels of physical activity. Lesley Wyman responded that there was a huge amount of work done with schools and families, such as Green Badge schemes to encourage families to exercise together. There was also work to look at how school life could become more active. April Peberdy further commented that there had been a pilot project at Park House and Winchcombe seeking to achieve more standing in lessons. West Berkshire had been the first in the country to do this type of project with a secondary school and Cambridge University had expressed an interest. Lesley Wyman also mentioned the Beat the Street project undertaken by North and West Reading Clinical Commissioning Group. Councillor Mollie Lock commented that it had been a popular programme in Mortimer. Councillor Cole asked whether a similar project could take place in West Berkshire. Lesley Wyman replied that it would depend on whether the outcomes justified the cost. Dr Barbara Barrie commented that the outcomes from the project had not been reflected in the data presented as part of the DPH report.

Lesley Wyman went on to explain that lower income and social class had a marked impact on educational attainment. Children with higher cognitive ability but from lower socio-economic class in testing were overtaken in test results by children of lower ability but higher social background by the age of 7. In the UK, the largest influence on a child’s success at school was their father’s education level. Cathy Winfield questioned why paternal educational attainment was more influential than maternal. Lesley Wyman advised that the study in question had focused on fathers but would assume the same conclusion could be drawn from a consideration of mother’s education level.

Data was presented regarding the percentage of students achieving 5 A*-C grades at GCSE; in West Berkshire 34% of children eligible for Free School Meals achieved those grades. Councillor Cole stated that it was disgraceful that West Berkshire was being outperformed by Slough against this measure and asked what was being done. Councillor Doherty commented that to some extent interventions at school were too late and more focus was required at the early year’s stage.

Rachael Wardell agreed that there should be better performance against this measure and closing the gap at all Key Stages at which attainment is measured was included as a target in the School Improvement Strategy. Work was being undertaken to ensure take up of free places in early years care for children under two years of age who met the disadvantage criteria. In the context of a reduced footprint of the Children’s Centres, there would be a challenge to continue to target early years. The data presented was from small cohorts which year-to-year presented a varied picture. For example in some years in some schools the pupil premium cohort had performed better than their mainstream peers. Councillor Lundie asked if the Every Child A Talker programme still existed. Rachael Wardell responded that it did, though many programmes now have a reduced reach and level of support. The programmes will continue to target the most vulnerable children.

Councillor Doherty advised that this matter was the most concerning issue raised by the DPH report and felt there needed to be more cohesion between the health and education sectors. She continued that a holistic approach to perinatal care was required to provide a preventative service and if interventions were delayed until a child was aged two, if would be too late for the interventions to be effective.

Councillor Lock advised that primary schools reported that increasing numbers of children had poor speech and language and Children’s Centres had been doing good work around supporting parents to develop these skills.

Dr Bal Bahia identified that the best interventions would take place before pregnancy and asked what lessons could be learnt from Inner London which had performed well. Rachael Wardell commented that Inner London schools had been better funded than West Berkshire’s and also had larger cohorts of children eligible for Free School Meals which had been shown to make it easier to tackle the gap. London had also enjoyed a specific programme of support called “The London Challenge”. West Berkshire’s schools had more difficulties creating targeted programmes without the scale the Inner London schools could achieve. Another London effect was thought to be that, due to immigration, there was a higher number of non-British families on lower incomes but with higher educational ambitions. This resulted in children from minority ethnic groups outperforming their white working class counterparts.

Councillor Jones commented that there appeared to be an appetite from Board members to discuss this issue further. Councillor Lundie commented that previously a workshop held with other local authorities had been successful in educating members on this issue.

Councillor Cole enquired how local authorities and health partners could manage these issues once all schools became academies and outside direct control of the local authority.

Moving to the subject of Looked After Children (LAC) It was reported that one of the key duties of the Children's Act required the local authority to assess the health of all their looked after children annually. This included arrangements for mental and dental care, such as immunisations and dental check-ups, as well as a short behavioural screening questionnaire (SDQ).

The SDQ was an important measure of emotional distress in this vulnerable group. In 2014, 68% of looked after children had an SDQ score submitted in England, but the submission rate across Berkshire did vary significantly from 29% in West Berkshire to 93% in Bracknell Forest. Rachael Wardell commented that the 29% figure was a snapshot at a particular time and sothe data had been skewed by the submission deadline. However, later in the year the coverage had been significantly better.

Councillor Lundie, referring to the graph on page 40 of the agenda, noted that on 31^st March 2015 the rate per 10,000 population of LAC was 47, almost 1.5 times higher than in Wokingham. Rachael Wardell responded that there was no easy explanation for the difference in the rates but that the number of LAC was now as low as 161, including unaccompanied asylum seekers and the rate per 10,000 was now lower. The figure might have been collected at a time when the service was most under pressure and was struggling to achieve permanency for LAC. Some causes of the difference might be that Wokingham was using a signs of safety model across its services which west Berkshire had also implemented and which still required further embedding here. There was a Community Care article which had reported North Yorkshire achieving outstanding results from this model of working and it was hoped that similar outcomes would be seen in West Berkshire in due course.

Councillor Lundie asked for an update on the work being done around the Child and Adolescent Mental Health Service (CAMHS). Rachael Wardell advised that very good work had taken place. At tier 4, a large number of bed spaces had been realised in the Berkshire Adolescent Unit  The CCGs had committed to a significant increase in funding which had helped to reduce the waiting list a tier 3. At tier 2 the existing provision would be decommissioned as of 1^st April 2016 and replaced with the new Emotional Health Academy. Staff were in place and it would be launched the following week. There had already been triage work to reduce the waiting list at Tier 2. Councillor Lundie asked whether the Emotional Health Academy connected to the Brilliant West Berkshire scheme. Rachael Wardell responded that they were separate but connected projects, in that they both adopted the same working principles. In the Emotional Health Academy graduate psychologists had been recruited, some with significant experience, to provide support at a lower level to CAHMS tier 3. They would be able to intervene, whilst being supported with their professional development. Lynne Doherty asked whether there was scope to prioritise LACs in CAMHS waiting lists and whether there could be a dedicated emotional health worker for LACs. Rachael Wardell agreed to look further into a dedicated LAC emotional health worker. Cathy Winfield advised that at tier 3, children were prioritised according to clinical need.

Regarding use of hospital services, Lesley Wyman explained that in England (2008/09 to 2012/13), the number of attendances in A & E departments by those living in the most deprived 10% of areas was double that of those in the least deprived 10%. Children were key users of services, especially A & E, and were a key area of pressure in the NHS currently.

Councillor Jones asked how the Board could monitor this. Cathy Winfield responded that discussions were held at the Urgent Care Board and it was hoped that the NHS 111 service reprocurement would offer more triage strength. A project at the Reading Walk-In-Centre had been undertaken to prioritise appointments at school closing times for children but there had not been the expected take up. Attendance at A&E was a cost effective way of treating children so the main cause for concern was the reason why a child was then admitted to hospital. National reports had concluded that the highest cause of a child being admitted to hospital was dental extraction.

Councillor Jones asked how the Board or the Council might support this work. Cathy Winfield suggested that the Urgent Care Board were asked to respond regarding child A&E attendances and subsequent admissions.

Br Bal Bahia commented that a large number of agencies were involved and more attention needed to be paid to how the population could be empowered to make more informed, healthier choices. Work needed to be done to link different agencies and there needed to be more attention paid to achieving outcomes.

Rachael Wardell applauded the report for drawing attention to children’s health issues as she had long held the view that children’s issues were underrepresented at the Board. The graph on page 37 of the agenda most demonstrated the need to close the inequality gap. There were a number of initiatives such as Healthy Schools and the Emotional Health Academy. The Corporate Parenting Panel, chaired by Councillor Doherty, looked at all outcomes and focused on developing family and community wellbeing and targeting prevention initiatives. The fact that local authorities now commissioned the health visiting service was indicative of a set of activities being knitted together. There was a Children and Young People’s delivery group which sat underneath the Board and could be required to provide exception reports to the Board.

Andrew Sharp stated that the data was worrying because it painted a bleak picture of deprived children in West Berkshire. The concerns raised by the report needed to become the focus and priorities of the Board. Andrew Sharp further suggested that there should be more target setting in order to drive improvement.

Leila Ferguson expressed that she was pleased that the report had raised such important issues and asked whether the voluntary sector was represented on the Children and Young People’s delivery group. Leila Ferguson also reported that she was shocked to learn that the most common cause of a child’s admission to hospital was a dental extraction. Rachael Wardell confirmed that the voluntary sector was represented on the delivery group and noted that the number of dental checks being completed for LAC was now over 80%.

Dr Bal Bahia enquired how Brilliant West Berkshire was tied in to the prevention and education agenda. Rachael Wardell explained that officers were currently working on six community development projects including in Mortimer, which members had earlier in the meeting been surprised to learn had high rates of childhood obesity. The objective was to encourage communities to tackle issues for themselves and the strengths and assets based approach was proving successful.

RESOLVED that the report and accompanying presentation be noted. Rachael Wardell and Bal Bahia would coordinate an item regarding the educational attainment of children receiving Free School Meals to be added to the forward plan. The Urgent Care Board would be asked to respond to the Board regarding child A&E attendances and subsequent admissions. The Children and Young People’s delivery group would be required to provide an exception report to the Board.