City and Hackney JSNA City Supplement - Hackney Council

City and Hackney JSNA City Supplement - Hackney Council

City and Hackney Joint Strategic Needs Assessment City Supplement July 2014 © City of London PO Box 270 Guildhall London EC2P 2EJ www.cityoflondon...

6MB Sizes 0 Downloads 5 Views

Recommend Documents

Hackney regeneration estates leaseholder and - Hackney Council
In many cases, Hackney Council will need to purchase your leasehold or freehold property before work can proceed. This p

Delegated Decisions - Hackney Council
Apr 1, 2007 - 13 Digby Crescent. London. N4 2HS. Proposed erection of a single-storey ...... Mr Kristian Garrecht &. Mrs

inside - Hackney Council
Sep 21, 2015 - www.hackney.gov.uk. Hackney History hackneytoday. Issue 363 21 September 2015. Circulated to 108,000 home

drivers jonas - Hackney Council
DRIVERS. JONAS. Drivers Jonas LLP. '\._ 85 King William Street. London. Tel 020 7896 8000. Fax 020 7896 8002 www.clriver

inside - Hackney Council
Feb 23, 2015 - 23 February 2015. Until 21 March, Forman's Smokehouse Gallery, Stour Road, E3. PREVIEW. Harry Potter acto

city of york council hackney carriage and private hire licensing
You must provide details of your national insurance number, UK driving licence number and ..... Private hire vehicle pla

Hackney Carriage - Swindon Borough Council
relating to the operation of Hackney Carriages and Private Hire vehicles and to the administrative ... Upon receipt of t

HT issue 353 - Hackney Council
Apr 27, 2015 - of Hackney, Maurice. Bishop House ...... Today, 1st Floor, Maurice Bishop House, 17 Reading. Lane, E8 ...

City and Hackney - Friends, Families and Travellers
In the United Kingdom the umbrella term “Gypsy Traveller” consists of Welsh and English Romanichal or Romany Gypsies

HT issue 352 - Hackney Council
Apr 13, 2015 - The Leaside Trust gives ... Based on the banks of the River Lea, in Upper Clapton, the Leaside Trust deli

City and Hackney Joint Strategic Needs Assessment

City Supplement

July 2014 © City of London PO Box 270 Guildhall London EC2P 2EJ www.cityoflondon.gov.uk

City and Hackney Joint Strategic Needs Assessment

City Supplement

1

City and Hackney JSNA City Supplement

Acknowledgements We would like to thank the Public Health Team at the London Borough of Croydon for their innovative approach to Joint Strategic Needs Assessment, which has been instrumental in shaping this document.

2

City and Hackney JSNA City Supplement

Contents 1. Background

8



9

City and Hackney Joint Strategic Needs Assessment



The City Supplement: a City Digest



What the City Supplement is used for

9 9

The social determinants of health

10



The health map

10



Health in All Policies

12



Life course approach

13



Format of the City Supplement

14



Limitations of the dataset

15



Resident data

15



City worker data

15



Rough sleeper data

15

2. The City’s geography

16

3. The City’s population

18







Residents

20



Population size and age profile

20



Population density

24



Population change and migration

26



Ethnicity

29



Religion

30



Languages

31



Overall health

32



Students

32



Carers

33



Travellers and Gypsies

33

City workers

33



Population density

33



Age and sex

34



Ethnicity

35



Religion

36



Residency

36



Passport designation and access to healthcare

37



Overall health

38

Rough sleepers

39



Population size

39



Sex, age and ethnic origin

40



Overall health

40

3

4. Community life Quality of local area

44



Community cohesion and neighbourhood attachment

44



Transport

45



Green spaces

47



Noise pollution

49



Leisure facilities

50



Cultural facilities

52



Air quality

54



Climate change

56



Crime and safety

57

Deprivation

58

Housing

58



Housing stock and households

59



Housing standards

62



Fuel poverty

63



Overcrowding

63

Homelessness

63

Rough sleeping

64

5. Early life and family life

66

Young people

68



Local policy context

Population

Demographics

Education and training

68 68 69 70



Schools

70



Apprenticeships

72

Child poverty and deprivation

4

42

72



Free school meals

73



Early years support

73



Youth services

75



Child and adolescent mental health services

75

Families and households

75

Maternity

76



Smoking and pregnancy

76



Antenatal care

76



Place of birth and delivery method

76



Terminations

77



Breastfeeding

77

City and Hackney JSNA City Supplement

6. Working age

78

Economic participation among residents

81

Unemployment and out-of-work benefits

81



Adult learning

82

Jobs within the City

83

Education and qualifications

85

Workplace health

86

Lifestyle and behaviours

88



Smoking

88



Physical activity

90



Obesity

91



Alcohol

92



Substance misuse

94

Sexual health

Sexually transmitted infections (STIs)

Mental health

96 96 97



Prevalence of mental illness

97



Social care for people with mental health difficulties

99

Carers

101



Support for carers

101



Carers in the City

101

Disability

102



Learning disabilities

102



Physical disabilities

102

7. Later life

104

Older people

106



Life expectancy

108



Deaths

109

Telecare and telehealth

110

Loneliness and social isolation

111

Dementia

112

End-of-life care

113

8. Healthy life

114

Chronic disease

116

Cancer

116

Diabetes

118



119

Stroke and transient ischemic attack (TIA)

Hypertension

119



Coronary Heart Disease (CHD)

120



Sickle cell disease

121

5

City and Hackney JSNA City Supplement

Infectious diseases

Hepatitis C



Tuberculosis (TB)

Health services

122 122 122 123



Primary care

123



GP registrations

123



Dental services

125



Optometry

125



Pharmacies and prescribing

127



Rough sleepers

128

Social care services

130



Performance data

131



Direct payments

133



Safeguarding

133

The voluntary and community sector

Time Credits

133 134

Appendicies Appendix 1:

Data limitations

137



Resident data

137



City worker data

138



Rough sleeper data

139

Appendix 2: Demographics

140

Appendix 3: Ethnicity

142

Appendix 4: Religion

144

Appendix 5: Languages

146

Appendix 6:

Road casualties

147

Appendix 7:

Families and households

148

Appendix 8:

Learning disabilities

150

Appendix 9:

6

Death rates

151

7

1. Background

8

City and Hackney Joint Strategic Needs Assessment The City of London has a statutory duty to conduct Joint Strategic Needs Assessment (JSNA) as required. This is a process which examines the health and wellbeing needs of the people in the locality. The City currently conducts JSNA with the London Borough of Hackney, as we share a health budget and much of our data is currently aggregated with Hackney’s. This joint document is published as the City and Hackney Health and Wellbeing Profile. JSNA brings together detailed information on local health and wellbeing needs and looks ahead at emerging challenges and projected future needs. JSNA is an ongoing, iterative process, led by the Public Health Team and involving the City of London Corporation (Community and Children’s Services), NHS City and Hackney Clinical Commissioning Group (CCG), City of London Healthwatch, the voluntary and community sector and other partners.

The City Supplement: a City digest The City Supplement is the first report to pull together all the data that is available and disaggregated specific to the City’s population. This includes evidence from the City and Hackney JSNA process, as well as evidence from independent reports commissioned by the City to inform the health needs of the City’s population. The City and Hackney Health and Wellbeing Profile was refreshed in January 2014. Although this refresh has met the statutory minimum requirements, it does not provide all the information needed to commission local services in the City; nor does it provide a complete sense of the City as a separate place to Hackney. As a result, this City Supplement has been produced to provide a City-focused Health and Wellbeing Profile, as requested by the City of London’s Health and Wellbeing Board.

What the City Supplement is used for1 ■■To supplement the City and Hackney Health and Wellbeing Profile in providing a City-focused picture of the health and wellbeing needs of the City of London (now and in the future), covering residents, workers and rough sleepers. ■■To inform decisions about how the City designs, commissions and delivers services, and also about how the urban environment is planned and managed. 1 London Borough of Croydon (2012)

9

City and Hackney JSNA City Supplement

■■To improve and protect health and wellbeing outcomes across the City while reducing health inequalities. ■■To provide partner organisations with information on the changing health and wellbeing needs of the City of London at a local level, to support better service delivery. ■■As the evidence base for the Joint Health and Wellbeing Strategy, to identify important health and wellbeing issues for the City and support the development of action plans for the priorities named in the strategy.

The social determinants of health The beginning of every chapter summarises key findings from the needs assessment. These are followed by recommendations based on evidence and questions addressing challenges for commissioners. The social determinants of health are “the socio-economic conditions that influence the health of individuals, communities and jurisdictions as a whole. These determinants also establish the extent to which a person possesses the physical, social and personal resources to identify and achieve personal aspirations, satisfy 2

needs and cope with the environment.”

Lack of income, inappropriate housing, unsafe workplaces and poor access to healthcare are some of the factors that affect the health of individuals and communities. Similarly, good education, public planning and support for healthy living can all contribute to healthier communities.

The health map Barton and Grant and the UK Public Health Association strategic interest group 3

(2006) developed a health map which shows how individual determinants – including a person’s age and sex and hereditary factors – are nested within the wider determinants of health. The health map (below) places people at the centre but sets them within the global ecosystem, which includes: ■■natural environment ■■built environment ■■activities such as working, shopping, playing and learning ■■local economy, including wealth creation and markets ■■community – social capital and networks ■■lifestyle

10

2 Raphael, D (2004) Social Determinants of Health: Canadian perspectives. Toronto: Canadian Scholars’ Press Inc. 3 Barton, H and Grant, M (2006) ‘A health map for the local human habitat’. The Journal of the Royal Society for the Promotion of Health, 126 (6), 252–253. ISSN 1466–424

City and Hackney JSNA City Supplement

These are the social, economic and environmental determinants of health. Figure 1.1 Health map

BAL ECOSYSTEM GLO

Climate c han ge Natural ha bita ts Buildings Pla c g Workin Shoppin es g M Wealth crea tio o n Social ca pi t

rsity dive Bio ter Land Wa Air nd routes ts a ee Learning g Str yin arkeTs Pla M tworks Ne

L ENVIRONM TURA ENT NA I R V O N N E T MEN BUIL TIVIT T IES AC g CAL ECONOM vin LO Y MMUNITY CO al LIFESTYLE

People Age, sex hereditary factors

y, es om orc n o lf ec a o- lob r ac , G M tics li Po

O

th

er n an eig d hb re ou gi on rho s o

ds

The determinants of health and well-being in our neighbourhoods

The health map above challenges the notion that health is the domain of the NHS and brings it squarely into the arena of local government. In fact, many would argue that the health sector has a relatively minor role in addressing inequalities and the social determinants of health. The majority of local government services impact on or can influence the conditions in which people live and work and, to a certain extent, the life chances of individuals.

11

Health in All Policies Health in All Policies (HiAP) is a collaborative approach that integrates and articulates health considerations into policymaking across all sectors, and at all levels, to improve the health of all communities and people. As shown above, public policies at all levels have health impacts which need 4

to be accounted for. The HiAP approach aims to improve the accountability of policymakers for health impacts at all levels of policymaking by: taking into account the health and health system implications of decisions across sectors; seeking synergies; and avoiding harmful health impacts in order to achieve better population health and health equity. Incorporating health considerations into policies across all sectors is challenging and, even when decisions are made, implementation may only be partial or 5

unsustainable. One public health think tank suggests the following actions to achieve successful collaboration: ■■identify shared goals ■■engage partners early and develop relationships ■■define a common language ■■activate the community ■■leverage funding The JSNA process takes a collaborative approach between different partners for identifying health needs and seeks to establish a common language for intervention. It can be considered the first step in establishing groundwork for an HiAP approach.

12

4 M  inistry of Social Affairs and Health, Finland (May 2013) Health in All Policies: Seizing opportunities, implementing policies 5 Association of State and Territorial Health Officials. See: www.astho.org/HiAP/?terms=health+in+all+policies

Life course approach A complementary way to view the effects of social determinants of health is to take a temporal rather than a spatial approach. This is the approach taken by the Marmot Team in their 2010 report on health 6

inequalities in England, Fair Society, Healthy Lives.

■■The report takes the broadest view of the factors that affect health but describes these principally in terms of the life course, set in a context of sustainable communities and healthy standards of living. ■■A particular emphasis is given to the beginning of the story: action to reduce health inequalities must start before birth and be followed through the life of a child. The top recommendation of the report is that every child should be given the best start in life. ■■The report also identifies the many opportunities through school and education, working life and older life to minimise adverse health impacts and maximise positive impacts. Figure 1.2 Areas of action and intervention across the life course

Areas of action Sustainable communities and places Healthy standard of living Early years

Skills development

Employment and work Prevention

rse

ou fe c

Li

Accumulation of positive and negative effects on health and wellbeing Prenatal

Pre-school

School

Training

Employent

Retirement

Family building Life course stages 6 Marmot M (2010) Fair Society, Healthy Lives

13

Format of the City Supplement The City Supplement incorporates both a spatial view of health and wellbeing – beginning with the population profile and socio-economic context – and a life course view, moving from the needs of infants, children and young people to the needs of adults and older people. Together, these two ways of describing health and wellbeing needs provide a comprehensive view of the issues that need to be considered when planning for the protection and improvement of the health and wellbeing of the people of the City of London. The City Supplement follows the structure of the life course approach, with chapters ranging from 7

community and early life through to later life.

Below is a brief overview of the topics covered in each section:

Section

Community life

Definition

Topic areas

Influences on health and

Community cohesion and neighbourhood

wellbeing occurring through

attachment, air quality, transport, green spaces,

the environment

noise pollution, leisure and cultural facilities, climate change, crime and safety

Early life and family life

Most aspects of health and

Young people’s policy context, demographics,

wellbeing from birth up to

education and training, poverty and deprivation,

age 18, followed by aspects

families and households, maternity

relating to families

Working age

Aspects of health and

The City’s economy, jobs within the City,

wellbeing relating to those

education and qualifications, unemployment

aged between 16 and 65

and out-of-work benefits, workplace health, sexual health, smoking, physical activity, alcohol, substance misuse, carers, disability, mental health

Later life

Over 65 years of age

Older people, end-of-life care, life expectancy, infectious disease, chronic disease

Healthy living

14

Health outcomes and

Health services, disease prevalence, social care

usage of health and social

services and usage, voluntary and community

care services

service assets

7 London Borough of Croydon (2012)

Limitations of the dataset Resident data City resident-specific data has always been challenging to obtain and report due to the small numbers involved, which makes it difficult to compare with local and national indicators. Historically, health-specific data has been aggregated with data for Hackney due to pooled budgets. This is a challenge for the City, as without the disaggregated figures it is difficult to decipher if any trends observed truly represent the City population or are mainly a reflection of Hackney.

City worker data In October 2013, a new release of Census 2011 data estimated the population and characteristics of the workday population across England and Wales. This Census intelligence is the first of its kind, and is of particular importance to the City of London since the workday population is 56 times higher than the resident population. Two independent reports have also been commissioned to provide insights into the health needs of City workers: The Public Health and Primary 8,9

Healthcare Needs of City Workers and Insight into City Drinkers.

Rough sleeper data The main source of data on rough sleepers in the City comes from the Combined Homelessness and Information Network (CHAIN) database. The CHAIN database is commissioned and funded by the Greater London Authority and managed by Broadway. Research into rough sleeper health needs has also been recently conducted by NHS North West London. For more information on data sources and a detailed explanation of data limitations, please see Appendix 1, ‘Data limitations’. To paint a clearer picture of the City’s needs, aggregated figures reported jointly for the City and Hackney have been omitted from this report. For a full overview of figures, including those that have been aggregated, see the City and Hackney JSNA (www.hackney.gov.uk/jsna).

8 The Public Health and Primary Healthcare Needs of City Workers (2012) 9 Insight into City Drinkers (2012)

15

2. The City’s geography

Lower Super Output Areas (LSOAs) are statistical regions with an average population of 1,500 that are used for local area statistics. The City comprises six LSOAs. Unlike most local authorities, the City’s electoral wards (shown below in red) are smaller than its LSOAs. Figure 2.1 Map of the City of London showing LSOAs in black and ward boundaries in red

Four of the City’s LSOAs broadly correspond to particular residential populations in the Barbican, Golden Lane and Portsoken Estates, while the other two represent a slightly more dispersed population (see Figure 2.1). Look for subtitles marked ‘City workers’ or ‘Rough sleepers’ throughout the report, where more in-depth evidence or data exists for further analysis. LSOA 001A

Broad electoral ward Aldersgate

Major populations Barbican West

001B

Cripplegate, south

Barbican East

001C

Cripplegate, north

Golden Lane Estate

Portsoken

Mansell Street and

001E 001F 001G

Middlesex Street Estates Rest of City

Queenhithe and Carter Lane

East Farringdon and Castle

City West and the Temples

Banyard

17

3. The City’s population

The first step in a needs assessment is to define the population under investigation. Understanding the structure of the population and the way demographics change – including such characteristics as age, gender, disability and ethnicity – forms the basic intelligence on which many commissioning decisions are made. In the City there are three populations with distinct health needs: the residents, City workers and rough sleepers.

Key findings Residents ■■The City has a small population, which is projected to grow slowly in the coming decades. ■■Those aged 65 and over are projected to contribute the most to this growth, with their numbers increasing rapidly in the next decade. (For more information on the health needs of this group, see Chapter 7, ‘Later life’.) ■■Almost 40% of City residents are migrants. ■■The City’s residents are predominantly white and speak English as their main language. ■■There are relatively few children in the City.

City workers ■■The workday population in the City is 56 times higher than the resident population. ■■City workers have a male-dominant and younger age profile (20 to 50 years old). ■■City workers are a transient population and about one-third are migrants. ■■Most City workers perceive themselves to be in ‘very good health’. However, independent reports suggest that alcohol, smoking and mental health remain major risk factors. ■■Low-paid migrant workers are at greater risk of poor health due to decreased access to care and increased care costs.

Rough sleepers ■■The City has the sixth highest number of rough sleepers in London. ■■Rough sleepers in the City are predominantly male and the majority are aged between 20 and 50. ■■About half the rough sleepers are British nationals and the remainder come from Eastern Europe. ■■Over half the rough sleepers have alcohol problems, around half have mental health problems, and almost one-third have drug problems.

19

Recommendations ■■Commissioners and strategy leads will want to be confident that all new and existing strategies and commissioning decisions take account of the changes in the City’s demographics anticipated over the next 10 years. New and existing services will need to adapt to meet the needs of our changing population.

Questions for commissioners ■■How can the City plan its services to meet the health and other needs of the rapidly expanding older population? ■■What is being done to tackle the alcohol, smoking and mental health risk factors facing City workers? ■■How can commissioners tackle the risks of poor health to low-paid migrant workers? ■■How can commissioners progress integrated health and housing care for rough sleepers?

Residents Population size and age profile The City’s resident population is growing slowly. The 2012 mid-year estimate in the City was 7,604, an increase of 3.1% from the figure in 2011. Table 3.1 presents the population in five-year age bands, with population pyramids for the area in Figure 3.1. There are a particularly small proportion of children in the City. The geographical spread of age groups in the population is shown in Figure 3.2. School age children are located in the most easterly part of the City, Portsoken. The working age population is generally spread throughout the City, except in the north and eastern parts. Populations of older people are more heterogeneous, with particular concentrations in the northern and eastern parts of the City.

20

Table 3.1 Estimated population of the City of London by five-year age group (Office for National Statistics (ONS) 2012 mid-year estimate) Age

Population

0–4

297

5–9

205

10–14

165

15–19

231

20–24

495

25–29

949

30–34

826

35–39

622

40–44

663

45–49

598

50–54

504

55–59

470

60–64

473

65–69

363

70–74

263

75–79

192

80–84

155

85–89

86

90+

47 7,604

All ages

Figure 3.1 Population of the City of London by five-year age group and gender (ONS 2012

Age group

mid-year estimate) 90+ 85 to 89 80 to 84 75 to 79 70 to 74 65 to 69 60 to 64 55 to 59 50 to 54 45 to 49 40 to 44 35 to 39 30 to 34 25 to 29 20 to 24 15 to 19 10 to 14 5 to 9 0 to 4

MALE

15

10

FEMALE

5

0 % in each age group

5

10

15

21

Figure 3.2 Geographical age structure: percentage aged 0–4

Source: ONS 2012 mid-year estimates. This product includes mapping data licensed from Ordnance Survey with the permission of Her Majesty’s Stationery Office (HMSO). © Crown copyright 2013. All rights reserved. Licence number 100019635. 2013. © Bartholomew Ltd. Reproduced by permission, HarperCollins 2012.

Figure 3.3 Geographical age structure: percentage aged 5–19

Source: ONS 2012 mid-year estimates. This product includes mapping data licensed from Ordnance Survey with the permission of HMSO. © Crown copyright 2013. All rights reserved. Licence number 100019635. 2013. © Bartholomew Ltd. Reproduced by permission, HarperCollins 2012.

22

Figure 3.4 Geographical age structure: percentage aged 20–65

Source: ONS 2012 mid-year estimates. This product includes mapping data licensed from Ordnance Survey with the permission of HMSO. © Crown copyright 2013. All rights reserved. Licence number 100019635. 2013. © Bartholomew Ltd. Reproduced by permission, HarperCollins 2012.

Figure 3.5 Geographical age structure: percentage aged over 65

Source: ONS 2012 mid-year estimates. This product includes mapping data licensed from Ordnance Survey with the permission of HMSO. © Crown copyright 2013. All rights reserved. Licence number 100019635. 2013. © Bartholomew Ltd. Reproduced by permission, HarperCollins 2012.

23

Population density Figure 3.6 Historical and projected population density in the City of London 50,000

40,000

Residents per sq km

30,000

20,000

10,000

0 1801

1851

1901

1951

2010

2051

Source: Greater London Authority (GLA)

The Census 2011 estimates the City of London’s population density to be 2,552 residents per km2. This figure remains historically low, although the current trend is rising (Figure 3.6). However, the population density is greater than this when residents occupying a second home in the City are included. The Census 2011 estimates that there are 1,370 people resident elsewhere in the UK as well as in the City. Including these people increases the population density to 3,024 residents per km2. The majority of the City’s land is in office use, with housing occupying only a small proportion of land. Therefore residential densities in the City, as seen in the north (Figure 3.7) are very high, as the majority of housing schemes are multi-storey with 10

little or no outdoor space or car parking. However, density measured by the number of people per household remains low (Figure 3.8).

24

10 City of London Local Development Framework. Core Strategy: Delivering a World Class City (2010)

Figure 3.7 Population density: number of people per hectare

This product includes mapping data licensed from Ordnance Survey with the permission of HMSO. © Crown copyright 2013. All rights reserved. Licence number 100019635. 2013. © Bartholomew Ltd. Reproduced by permission, HarperCollins 2012.

Figure 3.8 Population density: number of people per household

This product includes mapping data licensed from Ordnance Survey with the permission of HMSO. © Crown copyright 2013. All rights reserved. Licence number 100019635. 2013. © Bartholomew Ltd. Reproduced by permission, HarperCollins 2012.

25

Population change and migration ONS estimates show that the City’s population is growing slowly. It is subject to migration from within the UK and internationally, with large numbers of migrants moving into and out of the City. This is likely to reflect the people of working age who come to the City of London for a specific job or employer. ONS estimates are rounded to the nearest 100, which is not entirely helpful in the City context. In future JSNA publications, it is envisaged that more accurate data for births and deaths will be available. GLA estimates expect the City’s population to grow from 7,600 in 2012 to 9,200 in 2037. The majority of growth will be in the working age and ageing populations; however, the number of older people is projected to increase more rapidly in the near future. The amount of growth is guided by planning policies, and the City of London’s Core Strategy contains a target to increase the number of dwellings in the City by 110 units per year until 2016. This target is derived from the Mayor’s London Plan, which sets housing targets for all boroughs. The City’s housing is clustered in certain areas and policies of the Core Strategy and Local Plan require that new housing should only be located in these identified residential areas.

Core Strategy and Local Plan The City Corporation is responsible for planning the Square Mile. Its vision and policies for shaping the future of the City are currently contained in its Core Strategy, adopted in 2011, and this will be replaced by a Local Plan in 2015. These plans set out the policies for guiding new development, while ensuring co-ordination with other strategies operating in the City, including those for health and wellbeing. The planning strategies promote the City’s position as the pre-eminent financial centre and are based on forecasts of substantial economic and employment growth. At the same time the plans seek to maintain the quality of the City’s environment and promote the provision of many amenities needed by the workforce and residents, such as recreational and social facilities and open spaces. The plans seek a balance of activities in the City, including the provision of housing, retailing and cultural facilities. The plans also ensure that development is co-ordinated with the provision of social, transport, telecommunications, environmental and other infrastructure. For more detailed population estimates and projections, see Appendix 2. The City of London regularly produces detailed reports on its resident population and housing projections. These can be found at www.cityoflondon.gov.ukservices/ environment-and-planning/planning/development-and-population-information/

26

demography-and-housing/Pages/default.aspx

Figure 3.9 Identified residential areas in the City of London

Table 3.2 Components of change in population estimates for the City, 2011–12 (numbers rounded to nearest 100) Number Mid-2011 population estimate

%

7,400

Natural change +100

+0.8

Deaths

–0

–0.5

Net natural change

+0

+0.3

+700

+9.4

Live births

Migration International migration: in International migration: out

–500

–6.6

UK internal migration: in

+900

+11.5

UK internal migration: out

–900

–12.1

Net migration

+200

+2.3

Mid-2012 population estimate

7,600

Source: ONS

Of the Census 2011 population, 2,700 (37%) were born abroad, with 44% of these resident in the City for 10 or more years. The main countries of origin are recorded in Table 3.3.

27

Table 3.3 Top 20 countries of birth for residents of the City born outside the UK Country of birth

% of population

United States

2.8

France

2.0

Australia

1.9

Germany

1.6

Ireland

1.5

India

1.4

Italy

1.4

Bangladesh

1.3

China

1.3

New Zealand

1.1

Hong Kong

1.0

South Africa

1.0

Spain

1.0

Canada

0.9

Japan

0.7

Greece

0.7

Malaysia

0.7

Russia

0.7

Colombia

0.7

Poland

0.6

Source: Census 2011

There was a decrease in new GP registrations for people previously living abroad. This indicator captures most migrants and their dependants, but excludes those who do not register with a GP, such as short-term economic migrants and those who have access to private health services.

28

Figure 3.10 New GP registrations for people previously living abroad per 1,000 population,

New registrations per 1,000 population

2003–12

100

80

60

40

20

0

Source: ONS

2003/4

2004/5

2005/6

2006/7

2007/8

2008/9

2009/10

2010/11

2011/12

Ethnicity White populations are particularly concentrated in the City. There are concentrations of people of Asian ethnicity in the east of the City, but overall very few black people and people who identify as mixed origin. Table 3.4 Proportions of population of the City in broad ethnic groups Ethnicity

% of population

White

78.6

Black

2.6

Asian

12.7

Mixed/multiple

3.9

Other

2.1

Source: Census 2011

29

Table 3.5 Proportions of population of the City in main (>1%) narrow ethnic groups Ethnicity

% of population

White British

57.5

Black African

1.3

Black Caribbean

0.6

Turkish/Turkish Cypriot

0.2

Asian Indian

2.9

Asian Bangladeshi

3.1

White Irish

2.4

Asian Chinese

3.6

White Polish

0.5

Source: Census 2011 See Appendix 3, ‘Ethnicity’, for more information.

Religion The City is a diverse area, with a wider range of religious identities than England as a whole (Table 3.6). In the City, 45.3% of residents identify as Christian, with 34.2% having no religion. The next largest religion is Islam, with 5.5% of residents, followed by 2.3% who are Jewish and 2.0% who are Hindus. Buddhists make up 1.2% of City residents and Sikhs 0.2%. Since the previous Census, the proportion of the population identifying as Christian has fallen by around 10%, while the proportion identifying as having no religion has increased by roughly the same amount. See Appendix 4, ‘Religion’, for more information.

30

Table 3.6 Proportions of population by religious identification in the City, London and England City

London

England

% of population

% of population

% of population

Christian

45.3

48.4

59.4

No religion

34.2

20.7

24.7

5.5

12.4

5.0

Not stated

8.8

8.5

7.2

Jewish

2.3

1.8

0.5

Buddhist

1.2

1.0

0.5

Religion

Muslim

Sikh

0.2

1.5

0.8

Hindu

2.0

5.0

1.5

Other religions

0.4

0.6

0.4

Source: Census 2011

Languages In the City, most residents speak English as their main language (82.9%), with most others speaking different European languages (11.2%). South Asian languages are spoken by 2.1% of residents and East Asian languages by 2.5% (Table 3.7). Most of those who do not speak English as their main language speak English well or very well (15.8% in the City), which is higher than the national figure (6.1%). In the City, 1.4% stated that they do not speak English well or at all, which is the same as the national figure. The main individual languages spoken in the City are shown in Table 3.8. Table 3.7 Proportion of respondents’ main language groups in the population of the City Language

% of population

English

82.9

Other European languages

11.2

East Asian languages

2.5

South Asian languages

2.1

Other languages

1.3

Source: Census 2011

31

Table 3.8 Proportion of respondents’ main languages widely spoken (>1%) in the population of the City Language

% of population

English

82.9

French

2.2

Spanish

1.8

Bengali

1.6

German

1.2

Italian

1.1

Source: Census 2011 See Appendix 5, ‘Languages’, for more information.

Overall health Most City residents consider themselves to be in good or very good health (88% of all residents). However, around one in eight households contain someone with a disability or long-term health problem. This figure is lower than in London or elsewhere nationally, but there are variations in health between neighbourhoods, reflecting the patterns of relative social and economic deprivation in the City. Poor health is more prevalent in the Portsoken and Golden Lane areas, where ill health and disability affect around 20% of households. Many of the people affected have a physical disability, are frail or elderly, or suffer with mental health problems. They are most likely to require specialist forms of housing or adaptations and support services to help them remain living independently in their homes.

Students The Census 2011 was carried out on 27 March 2011. On this date, 400 (6.2%) of those in the City reported that they were full-time students aged over 18. This is lower than the London figure (8.1%) and close to the England figure of 5.4% (see Figure 3.10). It should be noted that students are a particularly mobile population, and this figure will vary widely across the academic year.

32

Figure 3.11 Proportion of students in the population of London by borough (Census 2011) 15%

5%

Camden

Newham

Tower Hamlets

Islington

Southwark

Kingston Upon Thames

Brent

Westminster

HACKNEY

Hillingdon

Hammersmith and Fulham

Haringey

Greenwich

Lewisham

Waltham Forest

Lambeth

Kensington and Chelsea

Ealing

Redbridge

Barnet

Hounslow

Enfield

Barking and Dagenham

Harrow

Wandsworth

Merton

CITY OF LONDON

Croydon

Richmond upon Thames

Sutton

Bexley

Bromley

LONDON

Havering

0% ENGLAND

% Population full-time students (>18 years)

10%

Carers See Chapter 6, ‘Working age’, for detailed information on carers.

Travellers and Gypsies The Census 2011 records that fewer than five residents of the City of London described themselves as Gypsies or Irish Travellers.

City workers Overall, the findings from the Census 2011 are consistent with previous independent reports. New insights for City workers not previously available are the age and sex profile by year, religion, housing tenure (see ‘Housing’ in Chapter 4), education, residency and passport designation.

Population density Population density in the City is 3,024 per km2 for the usual residents and 12,426 per km2 for the workday population. A total of 360,075 people surveyed by the Census 2011 gave a workday location within the City, of whom 359,455 were aged 16 or older. The Core Strategy predicts that City employment will increase significantly to

33

428,000 by 2016. Planning policies aim to accommodate this growth through substantial increases to office floorspace and an uplift in the overall density of the City.

Age and sex City workers are mainly aged between 20 and 50. Most women working in the City are in their mid-20s to mid-30s, while most men are in their mid-20s to mid-40s. There are over one-third more male (220,265) than female (139,813) daytime City workers, which is the reverse trend to that seen across London as a whole (Figure 3.12). The younger age and male-dominated profile of City workers is consistent with findings from previous independent reports, and is most likely influenced by the male-dominated finance and insurance industries representing a large portion of 11,12

the workforce.

City workers tend to be healthier because they are younger than

the general adult population. Health from this point forward is largely determined by factors related to their lifestyle, such as smoking, alcohol consumption, levels of 13

physical activity and diet.

Although female workers in the City are proportionately fewer in number than male workers, their health needs should not be overlooked and may be unique. For example, Insight into City Drinkers found that both female and male City workers drink higher amounts than the national average, suggesting that women in the City may in part drink more because they have been influenced by a wider ‘social 14

norm’ of heavy drinking. This may also apply to other health needs affecting female City workers surrounded by a predominantly male working population.

34

11 ibid 12 The Public Health and Primary Healthcare Needs of City Workers (2012) 13 ibid 14 Insight into City Drinkers (2012)

Figure 3.12 Profile of City and London workers by sex and age 9,000

180,000

8,000

160,000

7,000

140,000

6,000

120,000

5,000

100,000

4,000

Population

80,000 60,000

3,000

40,000

2,000

20,000

1,000 0

0 16 20

24

28

32

36

40

44

48

52

56

60

64

68

72

76

80

84

Age

Ethnicity The ethnic profile of City workers overall reflects the London profile (see Figure 3.13). The majority are white (79%), a relatively large proportion are Asian of Indian origin (6%) and the remaining Asians represent another 6%. A total of 5% are black, 3% are of mixed origin and less than 1% are of Arab origin. These figures 15,16

are consistent with previous independent reports on City workers. Figure 3.13 Ethnic profile of City workers

15 The Public Health and Primary Healthcare Needs of City Workers (2012) 16 Insight into City Drinkers (2012)

35

Religion The religious profile of City workers is broadly representative of that across London and England. Half of City workers are Christians, while another third have no religion. A total of 4% are Hindus, 3% are Muslims and 2% are Jewish. Sikhs and Buddhists represent 1% each. Nationally, there is a greater proportion of Christians (59%), and across London there are more Muslims (12%) than among City workers. Figure 3.14 Religious affiliation of City workers

Residency The majority of City workers were either born in the UK or are short-term residents; both these figures are slightly higher than the London average. Some 68% of City workers are UK-born and 17% are short-term residents who have been in the UK less than 10 years. Taken together, one-third of all City workers are migrants. Most migrants are young and healthy. The risk factors most relevant to migrant City workers’ health include language and cultural differences, stigma, discrimination, social exclusion, separation from family and sociocultural norms, administrative hurdles and legal status. Migrants tend to travel with health profiles, values and beliefs that reflect their community of origin. Such profiles and beliefs may have an impact on the health 17

of, and usage of health services by, migrants.

36

17 World Health Organization (2010) Health of Migrants – The Way Forward

Figure 3.15 Residency profile of City workers 70% 60% 50% 40% 30%

Percentage

20% 20% 10% 0%

Born in the UK

Resident in UK: Less than 2 years

Resident in UK: 2 years or more but less than 5 years

Resident in UK: 5 years or more but less than 10 years

Resident in UK: 10 years or more

Passport designation and access to healthcare In total, 78% of City workers have UK passports (see Figure 3.16). Of those with non-UK passports, one-third are from countries that were EU members in March 2001 (Germany, France, Italy, Portugal, Spain and others) and 10% are from countries that joined the EU between April 2001 and March 2011 (Lithuania, Poland and Romania). Another 9% come from each of South Asia, Ireland and Australasia, and 7% are from North America. Access and entitlement to free NHS treatment are dependent on the length and purpose of residence in the UK, not on nationality. In addition to the common health risks for migrants described above, non-UK nationals encounter some reduced social security and health protection, even as UK residents. For both UK and non-UK citizens, NHS hospital treatment is free and accessible at the point of need, for example in Accident and Emergency (A&E) departments. However, charges apply to non-UK citizens where subsequent treatments are necessary and the patient is admitted to hospital. There is some discrepancy among non-UK citizens regarding access to a GP, as 18

GP practices are not legally bound to accept non-UK citizens. The decision is ultimately at the discretion of the practice, which may prove a barrier to access. Even when registered with a GP, non-UK citizens must pay for dental treatments 19

and prescription drugs. Therefore non-UK citizens face some extra administrative barriers and fees compared with UK nationals. 18 Citizens Advice Bureau (2013) NHS charges for people from abroad 19 ibid

37

It is worth noting that a considerable number of City employers offer private healthcare, which may fill some of these gaps in protection. However, those most at risk are the low-paid migrant workers who are not covered by private healthcare, and the low-paid UK workers who are entitled to free NHS treatment 20

but cannot access these services due to long or inconvenient work hours. (For more information see Chapter 8, ‘Healthy Life’.) Figure 3.16 Passport designation of City workers

Overall health Most City workers (62%) perceive themselves as having ‘very good health’ (Figure 3.17), which is a higher figure than the London average of 51%. This perception is consistent with the findings from the 2012 independent survey The 21

Public Health and Primary Healthcare Needs of City workers. It is most likely related to City workers’ age and particular migrant profile, coupled with selection 22

effects (i.e. the City offers demanding jobs that tend to attract healthy people). In addition, the combination of being highly educated and earning a higher income is associated with better health outcomes. Despite this, there is strong evidence of a culture of long working hours and regularly feeling stressed among City workers, which – coupled with heavy 23

alcohol consumption and smoking – may lead to future health problems.

For more information, see the sections ‘Lifestyle and behaviours’ and ‘Mental health’ in Chapter 6, ‘Working age’.

38

20 The Public Health and Primary Healthcare Needs of City Workers (2012) 21 ibid 22 ibid 23 ibid

Figure 3.17 Self-perceived overall health of City workers 70% 60% 50% 40%

Percentage

30% 20% 10% 0%

Very good health

Good health

Fair health

Bad health

Very bad health

Source: Census 2011

Rough sleepers Rough sleeping is the most acute and visible form of homelessness, and an issue that remains a challenge within the City of London. Those that find themselves homeless on the streets are intensely vulnerable to crime, drugs and alcohol, and at high risk of physical and mental illness and premature death. Many people come to the streets with complex personal issues, some have limited entitlement to services – often because their connections are to an area far from where they are sleeping rough – and some are resistant to and refuse the support that is available to them. For those that remain sleeping rough, the aim of returning to a stable life in their own home becomes harder to achieve the longer they call the streets their home.

Population size On average, approximately 20–25 people sleep on the streets of the City of London every night. The City has the sixth highest number of rough sleepers in 24

London, after Westminster, Camden, Lambeth, Southwark and Tower Hamlets. In 2012/13, a total of 284 people were seen sleeping rough in the City by 25

outreach teams. Of these, 112 (39%) were new to the streets, another 112 (39%)

24 Broadway (2013) CHAIN Street to Home Annual Report 2012/13 25 Broadway (2013) CHAIN Annual Report for City of London 2012/13

39

were longer-term rough sleepers who had been seen both in the reported year and in the year before, and 60 (21%) had returned to the streets after a period away.

Sex, age and ethnic origin The rough sleeper population in the City is overwhelmingly male – 94% of those seen in 2012/13 were men – and 85% were aged between 26 and 55, with a further 11% aged over 55. The majority of those seen (57%) were British nationals, with the bulk of the remainder coming from Europe (predominantly Eastern European countries; see Figure 3.18).

Overall health Rough sleepers have high needs relating to alcohol, drugs and mental health. In 2012/13, 46% of rough sleepers in contact with services in the City had alcohol problems, 30% had drug problems and 45% had mental health problems. Many had more than one of these problems. For more information, see the sections on rough sleepers in Chapter 8, ‘Healthy life’. 26

Rough sleepers are generally in much worse health than other homeless people. National estimates show that the homeless population uses acute hospital services about four times more than the general population, costing at least 27

£85m per year. Rough sleepers access A&E seven times more than the general population, and are more likely to be admitted to hospital in an emergency, 28

which costs four times more than treating an elective in-patient.

Rough sleepers have an increased prevalence of health issues, including chronic chest problems, tuberculosis, skin complaints and mental ill health. These are often compounded by substance misuse. Rough sleeping is linked with premature death, with rough sleepers having an average life expectancy of 43. Despite this, rough sleepers can face barriers to accessing services due to attitudes, service models, inability to register with a GP, lack of knowledge of services, lack of continuity of care, transiency, lack of local connection and cost.

40

26 Bines W (1994) The health of single homeless people. York: Centre for Housing Policy. For full references on the health of rough sleepers see NHS City and Hackney (2010) Health and Housing in Hackney and the City 27 Brodie et al (2013). Rough sleepers: Health and healthcare. London: NHS North West London 28 ibid

Figure 3.18 Nationality of rough sleepers in the City of London, 2012/13 (Broadway)

Figure 3.19 People seen sleeping rough by age, 2012/13 100 90 80 70 60 50 40 30 20 10 0

18–25 years

26–35 years

36–45 years

46–55 years

over 55 years

41

4. Community life

Our surroundings and how we interact with them are an integral part of our wellbeing. The importance of community and societal factors as determinants of health has been recognised for thousands of years. The World Health Organization, in its ground-breaking definition of health, states: ‘Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity’. Our health and wellbeing are influenced by both the physical environment (i.e. our housing, transport, access to green spaces and air and water quality) and the people and networks within our communities. Although harder to quantify than aspects of the built and natural environment, issues such as community cohesion, social isolation, trust and fear are also important determinants of wellbeing.

Key findings ■■More than nine in ten residents, workers, executives and businesses are satisfied with the City as a place to live, work and run a business. ■■Health-based targets for air quality are not being met. Air quality is a challenge in the City due to its central location and the vast transport network catering to the large daytime worker population. The City has been responding with initiatives to improve air quality and reduce the population’s exposure to air pollution. ■■Increases in cycling in the City have been accompanied by an increase in traffic casualties. The City is urgently reviewing options for reducing road danger. ■■Housing is a key determinant of health. Housing and homelessness will continue to be a growing challenge in coming years. The City has begun responding by aiming to build a more resilient community, a priority linked with the local housing strategy. ■■The City is mainly covered by office buildings and lacks green space. Many cultural assets are available to residents and City workers. Despite this, social isolation may be an issue. ■■Overall crime rates in the City are falling; however, some categories of crime are increasing. ■■The majority of City workers and residents are either homeowners or rent privately, with both groups containing fewer social housing tenants than the national average. ■■The City has a very low rate of fuel poverty. ■■The City provides a wide range of services to help rough sleepers leave the streets, and has received several awards for innovation in this area.

43

Recommendations ■■Air quality cannot just be addressed locally, as it is heavily impacted by activities in surrounding areas. It will be important to work together with neighbouring local authorities and other London boroughs to achieve improvements in air quality. ■■As space in the City is limited, planning developments have a significant impact on the health of residents and workers in the City. Conducting health impact assessments on major projects will help to ensure that health impacts have been considered and incorporated.

Questions for commissioners ■■How do commissioners plan to work with other bodies to improve air quality? ■■How can commissioners enable services to support the City’s aspirations to build more resilient communities?

Quality of local area Community cohesion and neighbourhood attachment 29

Results from a local survey published in May 2013 reported that satisfaction with the City as a place to live, work and run a business remains high, with over nine in ten residents, workers, executives and businesses satisfied with the local area in this respect. Residents are the group most likely to be ‘very satisfied’. Satisfaction among businesses has increased by nine percentage points since 2009. The survey reported the perceptions of City workers, City residents, City businesses and senior City executives. Workers and businesses were most likely to see the location of the City and the ease and convenience of getting there as its good points. Areas for improvement for both City workers and businesses were traffic congestion, parking, building work/roadworks and expense. The City scores well on all the indicators of satisfaction and participation in civil society (Table 4.1). City residents see traffic congestion and pollution as needing improvement, followed by road and pavement repairs, affordable decent housing, parks and open spaces and shopping facilities.

44

29 City of London Corporation polling, 2013

Table 4.1 National indicators of strength of civic society and satisfaction with local area, 2008 The City

London

92%

76%

59%

52%

People who believe people from different backgrounds get on well together People who feel that they belong to their neighbourhood Civic participation in the local area

26%

17%

People who feel they can influence decisions

42%

35%

Overall satisfaction with local area

92%

75%

Participation in regular volunteering

24%

21%

Environment for a thriving third sector

24%

21%

Transport The City of London is situated at the heart of London’s extensive public transport system. Seven of the 11 London Underground lines and the Docklands Light Railway serve the City via 13 underground stations. There are seven mainline rail stations, four of which are major rail termini. Fifty-two bus routes serve the City’s streets. There are also various commuter coach services and riverboat services that operate from piers at Blackfriars, London Bridge and Tower Hill. The City of London has a public transportation accessibility level rating of 6b (the highest level), indicating excellent accessibility. However, because most of the numerous visitors, students, workers and residents travel to and from the City by public transport, these services can be overcrowded and congested. The Core Strategy predicts that City employment will increase significantly to 428,000 by 2016. This will have major implications for all aspects of transport. The growth in numbers commuting to the City will be accommodated by Crossrail, which is due to commence operation in 2018, as well as by upgrades currently underway to Thameslink and the Northern Line, with further improvements expected in future. Planning policies seek to promote pedestrian movement within the City, so significant improvements to the pedestrian environment and facilities are underway and will continue in the future. Residents of the City make an average of 3.4 trips per day, of which the majority (56%) are on foot. Those who use public transport tend to use the Underground. Cycle use by residents is low, although there has been a significant overall increase in cycling in the City in recent years due to the popularity of commuter cycling and the Mayor’s bike hire scheme. The City of London currently provides public cycle parking facilities for 6,761 bikes. In addition, there are an estimated

45

4,663 cycle parking spaces within buildings in the City. This total provision of 11,424 spaces is 31% of the estimated demand of 37,000 spaces. Under the bike hire scheme there are 36 bike docking stations in the City, accommodating approximately 900 bikes. Pedestrian flows are high at certain times during the week. With an estimated 368,000 workers, 16,000 students and 8,870 residents walking in the City, pedestrian facilities can be inadequate at peak times. The City is therefore actively pursuing opportunities to provide enhanced facilities for pedestrians, such as wider footways and pedestrian areas, through a programme of area enhancement strategies. The increase in cycling in the City has unfortunately been accompanied by an increase in traffic casualties. In 2011, 49 people were seriously injured on the City’s roads and a further 360 were slightly injured. This is an increase from 2010, when 41 people were killed or seriously injured and 339 were slightly injured. In 2011 vulnerable road users accounted for the vast majority of the 49 people seriously injured (pedal cyclists 47%, pedestrians 24%, motorcyclists 27%, vehicle occupants 2%). The Public Health Outcomes Framework identifies the City of London as having a very high rate of deaths and serious injuries on the roads. However, this statistic is based on the total number of incidents that occur in the City (involving both workers and residents) divided by the City’s resident population. This shows an error in the calculation methodology, as it uses different populations to calculate the rate. The City has started an urgent review of options for improving safety for all road users, particularly cyclists and pedestrians, whose numbers are expected to continue to grow. The first stage was the adoption of the City’s Road Danger Reduction Plan at the beginning of 2013. This sets out an action plan containing a series of measures such as street safety audits and more focused education, training and enforcement which, taken together, are intended to reduce casualties. A 20 mile per hour speed limit for the whole of the City of London was approved in September 2013 and is to undergo public consultation in early 2014. The second strand of the Road Danger Reduction Plan is to work with the Mayor of London to help realise his ‘Vision for Cycling in London’. The Mayor is making £913m available for cycle improvements (£400m over the next three years) and intends to implement a central London grid of cycle routes. The grid will comprise superhighways with a high level of segregation between cyclists and other traffic on strategic routes such as Upper and Lower Thames Street, and ‘Quietways’ on side streets with lower traffic levels. For more information on road casualties, see Appendix 6, ‘Road casualties’.

46

Green spaces Open spaces in the City of London are an important resource for residents, workers and visitors. A survey of the large daytime population in 2012 found that 86% use the City’s public gardens regularly, with 36% visiting at least once per week. Almost all users (79.4%) rate these spaces as good or very good. As at 31 March 2012, the City of London was found to have 32.09 hectares (320,900m2) of open space (this does not include land closed due to construction work). In the City, 71% of all space that is openly accessible to the public is deemed appropriate for disabled access. The City’s Open Space Strategy, drawn up as part of the preparation of the Core Strategy, aims to encourage healthy lifestyles for all the City’s communities through improved access to open spaces, while encouraging biodiversity. Given the constraints on land in the City, the City of London Corporation focuses on improving the quality of the limited open space available and, where possible, seeks to identify opportunities to increase provision of green space. One such way is by seeking to maintain a ratio of at least 0.06 hectares of high-quality, publicly accessible open space per 1,000 weekday daytime population. The Core Strategy sets the target of increasing open space in line with the working population. Figure 4.1 shows the green spaces in the City of London, where the pink areas are defined as areas of deficiency in access to local, small and pocket parks. In the City, there are 5.2 hectares (51,800m2) of parks and gardens, of which 88% are open to the public. This space, separate from classified civic and market squares, provides accessible high-quality opportunities for informal recreation and community events.

47

Figure 4.1 Green spaces in the City

Source: Better Environment, Better Health: a GLA guide for London’s Boroughs

Eleven of the open spaces within the Square Mile are Sites of Metropolitan, Borough or Local Importance for Nature Conservation, due to their importance to wildlife. The Open Spaces Department works with residents, local schools and volunteers to maintain these important sustainable assets, as well as delivering a range of opportunities for education and healthy lifestyles. In 2012, the City’s gardens won gold and were named category winner in the London in Bloom competition. They also won gold awards in a number of individual disciplines. Bunhill Fields won both a Green Flag Award and a Green Heritage Award, and received Grade One status on the National Register of Parks and Gardens.

48

The Aldgate project The Aldgate gyratory lies on the eastern edge of the Square Mile. Having adopted the Aldgate and Tower Area Strategy in 2012, the City proposes to introduce two-way traffic on Aldgate High Street, Minories, St Botolph Street and a section of Middlesex Street. These changes will enable a new public space to be provided between Sir John Cass’s Foundation Primary School and St Botolph without Aldgate Church. A smaller public space is also planned for the southern end of Middlesex Street. The project aims to make Aldgate feel safe, inviting and vibrant by: ■ enhancing safety for road users ■ improving cycling routes ■ improving pedestrian routes and connections ■ introducing more greenery ■ creating a flexible public space for events, leisure and play ■ improving lighting The City is working with the London Borough of Tower Hamlets and TfL in developing these proposals. The Mayor of London’s Cycling Vision and TfL’s Better Junctions programme have contributed to the proposals to provide cyclists with a less intimidating and higher-quality experience as they move through the area. The health and wellbeing benefits of this new space include reductions in noise and air pollution, as well as increased pedestrian and cycling space.

Noise pollution Excessive noise seriously harms human health and interferes with people’s daily activities at school, work, home and during leisure time. It can disturb sleep, cause cardiovascular and psychophysiological changes, reduce performance 30

and provoke annoyance and alterations in social behaviour.

The City of London received 1,075 complaints about noise in 2013/14 from both residents and businesses. These concerned a range of sources, but were predominantly related to construction sites, street works and entertainment venues. 30 WHO (2011) Burden of disease from environmental noise: Quantification of healthy life years lost in Europe

49

The City’s Noise Strategy was adopted in 2012 and an action plan is currently being implemented. This brings together the different strands required to maintain or improve the City’s noise environment. It addresses the following: new developments, transport and street works, dealing with complaints, and tranquil areas. It is hoped that the plan will contribute to the health and wellbeing of the City’s communities and support businesses by minimising or reducing noise and noise impacts. The Public Health Outcomes Framework reports that a very high percentage of the City’s population is affected by noise. However, this statistic is based on total noise complaints (including those from both residents and businesses) divided by the resident population, and so uses two different populations to calculate the figure.

Leisure facilities Golden Lane Sport & Fitness (formerly known as Golden Lane Leisure Centre) has been open since January 2012. The centre offers programmes and memberships aimed at engaging the wider community, including City workers, residents and children. There are currently over 1,100 prepaid members who regularly use the centre, and approximately 2,000 casual pay-and-play visits per month. This is in addition to school and after-school swimming lessons; various clubs and courses ranging from taekwondo and gymnastics to netball and tennis; and the sports activity programmes being continually developed by the Sports Development Team. The high land values and density of existing buildings in the City mean that space for developing new sports facilities is limited, and often comes at a significant premium. Therefore the Sports Development Team makes use of the City’s landscape, which provides an environment conducive to active travel, walking, jogging, cycling, running and participating in activities such as Street Gym (where the landscape is the equipment). A number of sports programmes and activities have been held in unconventional City spaces, such as the dance floors in bars and on the streets. These aim to engage with City workers and residents who cannot afford to access the large number of private gyms in the area. Table 4.2 shows the accessibility of facilities for sport and physical activity in the City of London. It shows which facilities are accessible by private members, which are bookable by the public and which offer full public access.

50

City and Hackney JSNA City Supplement

Table 4.2 Facilities in the City by accessibility Facility type

Private

Bookable –

Public –

Total

Artificial/turf pitches

1

Gyms/fitness centres

29

1

1

31

Parks and open spaces





39

39

Playgrounds





6

6

Squash courts

5





5

Sports halls

3

1

2

6

13



1

14

Swimming pools Tennis courts Total

1



1

2

3

51

3

51

105

Source: City and Hackney Healthy Weight Strategy: Facility Audit, Active Places Power

Targeted services A range of targeted programmes has been designed specifically for those who are most inactive and/or people with specific health conditions that could be improved through physical exercise. These include activities and health advice to help workers, residents and families adopt a healthier lifestyle. In January 2013 the City of London piloted an ‘exercise on referral’ scheme. Following its success, the programme was launched in March 2013.

Young at Heart Young at Heart is a City-led programme offering opportunities to people over the age of 50 to improve their physical and mental health, fitness and wellbeing through physical activities, health seminars, wellness events and free quarterly health checks and advice. Now in its eighth year, the scheme has engaged over 700 individuals in activities including gentle exercise, line dancing, short mat bowls, swimming, gym workouts, chairbased exercise, Pilates, ballroom dancing, table tennis and guided walks. The programme also has social aspects and runs events such as back correction workshops and nutrition talks.

51

City of Sport City of Sport is a project launched in 2011 aimed at lower-paid and inactive City workers. The calendar of events includes training sessions with fully qualified coaches in fencing, Pilates, Zumba, badminton, table tennis, swimming and tennis. It offers 14 hours of quality coaching per week to increase participation in sport on a pay-as-you-go basis, in order to break down access barriers. The programme was awarded the Inspire Mark by the London Organising Committee of the Olympic Games.

Cultural facilities Libraries, museums, theatres and art galleries deliver many benefits for local communities, promoting education and learning, creativity and personal development, and greater identification and belonging for residents and workers within their locality. They also offer an opportunity to communicate with users about health and wellbeing through embedded programmes and marketing and media opportunities. Research into personalised budgets in adult social care has highlighted the likely increase in demand for cultural and leisure services from people receiving these budgets. Such mainstream services are likely to play an important role in helping people socialise, meet others, go out and engage in specific activities like art 31

and music.

Libraries The City of London has five major libraries: Barbican Library, Guildhall Library, Shoe Lane Library, City Business Library and the new Artizan Street Library and Community Centre (replacing the former Camomile Street Library). Some of these libraries are designated as being of regional or national importance. For example, City Business Library provides its users with access to a wide range of financial and business data, and runs a full programme of events to support business start-ups and sole traders. Guildhall Library specialises in the history of London and the City, and holds significant collections, including those of many livery companies, the Stock Exchange and Lloyd’s of London. And Barbican Library houses a specialist music library which is a centre of regional importance and holds an international award for excellence.

52

31 Wood, C (2010) Personal Best. London: DEMOS

The libraries in the City also provide local communities with a wide variety of services and learning resources. These include community language collections, help and advice sessions, English for Speakers of Other Languages and self-help classes, a toy library and an extensive programme of work with local schools, nurseries and children. There are Rhymetime and Stay and Play sessions for under-fives with their carers at all lending libraries, and a Read to Succeed reading scheme, which partners children with trained volunteer reading mentors, at Barbican and Artizan Street Libraries. An evaluation of services offered to families in the City in 2011 found that libraries are the most 32

used and the most valued. The great majority of City residents (85%) use the City’s public libraries and are members of at least one City library (75%). In total, 33% of City workers and 11% of people living and working outside the City are members of a City library. The Barbican and Barbican Children’s Libraries attract 35% and 20% of visitors from all categories respectively. All libraries take health and wellbeing information provision very seriously and offer a wide variety of self-help books for loan. Additionally, libraries are a good source of public health leaflets and information and offer customers the opportunity to participate in regular health-related events and activities.

Museums and theatres Museums in the City include the Museum of London, the Clockmakers’ Museum, the Bank of England Museum and Dr Johnson’s House. Galleries include Guildhall Art Gallery and the two art galleries at the Barbican Centre. The Barbican also houses a concert hall, two theatres and three cinemas, and presents a variety of world-class performing and visual arts. Every year the City of London spends over £80m on its culture and leisure services, including everything from libraries, open spaces and the street scene to arts institutions, festivals, museums, galleries, music ensembles and the Guildhall School, one of the UK’s leading conservatoires. In addition to the many other attractions surrounding the Square Mile, City arts festivals and institutions regularly attract over 10 million visitors per year.

33

Satisfaction is very high for libraries (93%), museums/galleries (87%) and theatres/concert halls (85%) in the City.

34

In 2011, 94% of service users agreed

that the City’s libraries and archives and Guildhall Art Gallery offered appropriate and accessible learning opportunities for citizens and community groups, while 99% of parents, carers and teachers agreed that the services and activities offered by the City’s libraries and archives and Guildhall Art 32 City Family Festival Life Survey, 2011 33 City of London Cultural Strategy 2010–14 34 Public Library Users Survey, 2010

53

Gallery contributed to the enjoyment and achievement of children and young people through increased participation in a broad range of high-quality activities.

Air quality Air pollution in urban environments, even at the relatively low levels seen in London, is recognised as a threat to human health, warranting further action to improve air quality over coming years. At the levels found across London and the City, air pollution is a significant cause of disease and death – heart disease and lung cancer in particular, but also respiratory disease and asthma. Department of Health figures suggest that it may even be the fifth highest cause of death in London, ahead of communicable 35

disease, passive smoking, alcohol abuse, road accidents and suicide.

As pollution particles pass into the blood and travel throughout our bodies they inflame many organs, and there are now associations with Alzheimer’s disease, Parkinson’s disease, Type 2 diabetes, cognitive impairment and learning problems 36

in children. Air pollution disproportionately affects the elderly, poor, obese, children and those with heart and respiratory disease, but it has effects on everyone exposed to it. The Public Health Outcomes Framework identifies the City as having the highest fraction of mortality attributable to particulate air pollution. This is based on modelled estimates using the air quality readings in the local area.

Source and levels of air pollution in the City Air pollution is made up of gases and very tiny particles that are not visible to the naked eye. The main source of air pollution in the City of London is diesel vehicles. Air quality is monitored in the City and this data is compared with health-based targets. The targets for small particles (PM10) and nitrogen dioxide are not being met. Levels of tiny particles (PM2.5) also need to be reduced. At busy roadsides in the City, the annual average level of nitrogen dioxide is around three times the target. Figure 4.2 shows the annual average levels of nitrogen dioxide across the City.

54

35 Kilbane-Dawe, I and Clement, L (2014) Report to the City of London Health & Wellbeing Board on Air Pollution. London: Par Hill Research Ltd 36 City of London Air Quality Strategy 2011

Figure 4.2 Annual average concentrations of nitrogen dioxide across the City

Improving air quality The City published an Air Quality Strategy in 2011, which outlines plans and programmes to improve air quality in the Square Mile. The City is implementing a number of actions to reduce emissions of pollutants. Key areas are: ■■reducing emissions of pollutants from the City’s own vehicles and buildings ■■taking action to reduce pollution from idling vehicle engines by requiring drivers of parked vehicles to turn their engines off ■■gaining the support of City businesses to reduce pollution through the CityAir programme ■■using planning policy to help improve local air quality ■■controlling emissions of pollutants from construction and demolition sites ■■considering air quality in traffic management decisions ■■working with the Mayor of London, other London boroughs and the government to improve air quality across London ■■encouraging and rewarding action by other organisations through the annual Sustainable City Award, the Clean City Award and the Considerate Contractors Environment Award ■■reducing emissions associated with taxis by improving taxi ranks and encouraging taxi drivers and the public to use them The City also monitors air quality to assess levels of pollution and measure the effectiveness of plans and policies to improve air quality.

55

Reducing exposure to air pollution Despite the many programmes in place to improve air quality, pollution levels in the City can be high in certain weather conditions. The City of London Corporation provides information in a number of ways to help people who spend time in the City to reduce their exposure. Additional initiatives include: ■■working with Barts Health NHS Trust to provide information directly to patients who are vulnerable to poor air quality, as well as improving air quality around Barts Hospital sites across London ■■working with Sir John Cass’s Foundation Primary School to help the children understand urban air quality and improve air quality around the school ■■producing and promoting a smartphone app, CityAir, to help people reduce their exposure to pollution across London ■■monitoring air quality with City residential communities to increase their understanding of how pollution varies in urban areas, and what can be done to reduce exposure

Climate change Climate change in the City In the City, carbon emissions overwhelmingly come from commercial buildings (Figure 4.3). The overall level of carbon emissions fell by 13.7% between 2010 and 37

2011, from 1,621,700 tonnes of CO2 to 1,388.800 tonnes of CO2. Per capita CO2 emissions are not relevant in the City due to the small resident population. Figure 4.3 Sources of carbon dioxide emissions in the City, 2005–11 1,800 1,600 1,400 1,200 1,000

1,000 tonnes CO2

800 600 400 200 0 2005

56

2006

2007

2008

2009

2010

2011

37 Department of Energy and Climate Change (2011) Local and regional CO2 emissions estimates for 2005–2011 (plus subset data for CO2)

Climate change is expected to have major implications for public health: for example, more intense and frequent heat waves in summer are predicted, which are expected to increase mortality. The City’s Climate Change Adaptation Strategy identifies the threats and sets out measures to deal with them in the Square Mile.

Crime and safety Crime affects the health of individual victims and the communities in which they live and has an impact on local health services. Perceptions of the incidence of crime and feelings about personal safety can have widespread effects on the way we live. Fear of crime can be a debilitating experience for many people. In 2008, almost all City residents said that they felt safe when outside in the local area during the day, and more than four out of five felt safe after dark. Residents viewed drunkenness and rowdiness in public places as the biggest local antisocial behaviour issues, followed by noisy neighbours, teenagers hanging around 38

on the streets, and rubbish and litter.

Policy on crime and community safety in the City is overseen by the Safer City Partnership. The 2013/14 priorities for this partnership are: ■■anti-social behaviour ■■domestic abuse ■■reducing reoffending ■■night-time economy issues ■■fraud and economic crime ■■counter-terrorism ■■civil disorder The most common reported crime in the City is theft, which includes shoplifting, pedal cycle theft and theft from a person. From 2011/12 to 2012/13 overall crime in the City fell by 9.5% (586 offences). Despite this overall decrease, there were still increases in some crime categories (violence against the person with injury, rape, personal robbery, non-dwelling burglary and public disorder). However, even in these categories crime levels remain comparatively low. The City’s night-time economy has grown over recent years, with a large number of people now visiting the City in the evening specifically to socialise. There have been significant changes around the opening hours and licensing of venues,

38 Ipsos Mori/City of London Corporation (2009) Assessing the City of London’s Performance: Results of the Place Survey 2008/09 for the City of London Corporation and partners

57

particularly with regard to alcohol licensing and smoking legislation. While the nighttime economy can be a source of income and employment in the City, it also has negative effects in the form of violence, noise and other anti-social behaviour. In 2012/13 there were 140 domestic abuse incidents reported in the City. Of these, 118 were reported to the City of London Police and 22 were reported to other agencies (City of London Corporation or City Advice).

Deprivation In 2010, the City of London was ranked 262 out of 326 English boroughs, with 326 39

being the least deprived. However, there is considerable variation between wards. Clear socio-economic differences remain between the Mansell Street and Middlesex Street Estates in Portsoken and the wealthier Barbican Estate in the northwest of the City.

Housing Housing tenure has been consistently found to be associated with morbidity and mortality, with health outcomes worse among those who live in social housing. Tenure is often a reflection of socio-economic factors and advantage, which are also determinants of good health and wellbeing. However, factors such as the physical quality of housing and its local environment (such as damp, overcrowding, crime and poor amenities) may also determine poor health outcomes independent of factors such as income. The City, like much of central London, has a housing stock polarised between very high cost owner-occupied or private rented housing and social rented housing. Despite its small residential population, the City faces key challenges, including overcrowding, housing affordability and homelessness, particularly rough sleeping. The City’s Housing Strategy 2014–19 includes a priority to support vulnerable groups within their local area, with the aim of building more resilient communities. Prevention, promoting independence and earlier intervention are central to this approach, which focuses on the following: ■■preventing homelessness ■■tackling rough sleeping ■■supporting people with disabilities ■■supporting older people ■■intervening early to reduce inequalities and tackle deprivation

58

39 City of London Department of Planning and Transportation (2010) City of London Resident Population Deprivation Index 2010

Housing stock and households As it is primarily a business district, the City has an unusual housing and household profile. The City of London Core Strategy (September 2011), which sets out the City’s vision for planning, divides the major planning areas into five Key City Places (Figure 4.4). Study Areas indicate the spatial concentration of housing units. The majority of the City’s units – 3,718 units, or 61.3% of the total – are located in the north of the City. This is due to the presence of large concentrations of dwellings, particularly at the Barbican Estate (2,069 units), Smithfield (736 units) and Golden Lane (651 units). The Key City Places of Aldgate, Thames and Riverside and the Rest of the City are areas of mixed land use, while Cheapside, St Paul’s and the Eastern Cluster are Key City Places focused on business activity and have the lowest number of units. A total of 50% of dwellings in the City have two or fewer 40

‘habitable rooms’, with 20% having only one habitable room.

Housing tenure There were 6,064 dwellings in the City of London as of 31 March 2011. The most common type of housing tenure in the City is private rented accommodation, which makes up 36% of all households. This is greater than the figure for both Greater London and England and Wales. Housing tenure with a mortgage in the City (17%) is significantly less common than in Greater London (27%) and England and Wales (33%). There are a relatively high percentage of households in the City that are ‘rent free’ – 5%, compared with 1% in both Greater London and England and Wales. This could be explained by residents living in company-owned flats. Figure 4.5 compares housing tenure in the City with Greater London and England and Wales. There are three social housing estates, two of which are owned or managed by the City of London Corporation. Most of the rest of the City’s residential accommodation is either owner occupied or privately rented. Overall, 83% of dwellings are owner occupied or privately rented, and 16% are social rented. In the City, more than 50% of households comprise one person, which is significantly higher than the profile for Greater London and England and Wales, where the figure is approximately 30%. Within the City, 12% of single-person 41

households are of pensionable age, according to the Census 2011.

40 City of London Corporation (2011) Housing info, 31 March 2011. The term ‘habitable room’ refers to any room within a housing unit, apart from a bathroom, kitchen or hallway 41 For these purposes, ‘pensionable age’ refers to anyone aged 65 or over, although pensionable age can be anything from 61 to 68 years of age

59

The City of London has a very high percentage of households with no children (80%). The number of households with dependent children is very low: just 10% of 42

all households.

The City of London Corporation produces regular reports on housing characteristics and trends within this City. These can be found at www.cityoflondon.gov.uk/services/environment-and-planning/planning/ development-and-population-information/demography-and-housing Figure 4.4 Dwellings in the City of London, March 2012

60

42 Census

2011: City of London, Residential Population, Households

Figure 4.5 Household tenure (Census 2011) 100% 90% 80% 70% 60% 50% 40%

Percentage

30% 20% 10% 0%

City of London

Greater London

England and Wales

City workers The new Census data has provided an opportunity to examine the housing tenure of daytime City workers. In total, 48% of City workers own property with a ‘mortgage or loan’, which is notably higher than the London average of 33%. Another 28% live in privately rented property, which is slightly higher than the London average. A very small proportion of City workers live in social rented homes (3% rented from the council and another 3% rented from other social housing bodies). The pattern of housing tenure overall can be seen as consistent with the average income profile of City workers: that is, the City of London has the highest median 43

weekly wage of all local authorities in the UK. Therefore the low percentage of workers in social housing is to be expected. Although private renting can offer some of the poorest housing quality and worst overcrowding, in the City the proportion of renters affected by this may be diminished, since those with above average earnings 44

can afford better standards of rented accommodation. Despite this, there are some City workers who are not in the higher income bracket – for example, those working in retail – and they are also likely to fall into the ‘private rented’ category. The relatively large proportion of private renters may reflect the transient nature of the City’s population. This may affect health by increasing the chance of gaps occurring in health records when people move GPs. Finally, the large proportion of home owners with a ‘mortgage or loan’ is also predictable in this population, who tend to earn higher than average incomes early in their career.

43 ONS (2012) Annual Survey of Hours and Earnings, 2012 Provisional Results 44 Scottish Government (2010) A select review of literature on the relationship between housing and health

61

Figure 4.6 Housing tenure of City workers Owned: owned outright Owned: owned with a mortgage or loan Shared ownership (part owned, part rented) Social rented: from Local Authority Social rented: other social rented Private rented: landlord or letting agency Private rented: employer of a household member Private rented: relative or friend of household member Living rent free 0%

10%

20%

Housing standards Poor housing conditions can affect health in a variety of ways. They are associated with increased incidence of infections, respiratory disease, asthma, heart disease and hypothermia. Poor housing conditions can also increase depression, stress and anxiety. The World Health Organization identified the main hazards associated with poor housing conditions as poor air quality, tobacco smoke, poor temperature, slips, trips and falls, noise, house dust mites, radon and fires. Since 2000 there has been a clear government focus on improving the quality of the existing social housing stock. This focus recognises that well-maintained homes that meet a minimum standard of decency are fundamental to the health and wellbeing of individuals and the community. The standard set – the Decent Homes Standard – requires social homes to be in a reasonable state of repair, to have reasonably modern facilities and services, and to provide a reasonable degree of thermal comfort. The City met its Decent Homes target by 2010, with the exception of Great Arthur House, a listed tower block on Golden Lane Estate where progress has been slowed by the building’s listed status. The City has agreed with the Greater London Authority that work on Great Arthur House will be completed by 2015, and more broadly continues to improve the condition of its housing assets through programmed works to meet and maintain decent standards.

62

30%

40%

50%

Fuel poverty The level of fuel poverty in the City is relatively low and has been relatively stable since 2006, despite rising energy costs. It is estimated that 163 households (3.4%) in the City need to spend more than 10% of their household income to heat their home to a comfortable standard. In 2013, the definition of fuel poverty was changed. According to the government’s new definition, a household is said to be in fuel poverty if: ■■they have required fuel costs that are above average (the national median level) and ■■were they to spend that amount, they would be left with a residual income below the official poverty line According to this new definition, 120 households in the City (2.5%) are in fuel poverty. Both methodologies identify LSOA 001A (Aldersgate) as being the area with the highest rate of fuel poverty. However, all areas in the City are below the national average of 11% fuel poverty.

Overcrowding Around one in three of all households in the City lives in accommodation lacking one or more rooms. In terms of demand for social housing, 326 of the households (218 applicants and 108 existing tenants) on the City’s housing register are overcrowded. Overcrowding has implications for health and child development and impacts disproportionately on certain sectors of the population, such as black and minority ethnic households. Overcrowding can also contribute to family breakdown, noise nuisance and perceptions of anti-social behaviour, especially where people live in close proximity with neighbours.

Homelessness In 2012/13, the City took 37 applications from households who were homeless or at risk of homelessness. This level of applications has increased markedly in the last two years, and is set to continue at this level in 2013/14. Of those who applied for assistance in 2012/13, 20 were both homeless and in priority need and the City accepted a duty to secure settled accommodation for them. The City also provided temporary accommodation to 25 households who were either homeless applicants awaiting a decision on their case, or people whom the City had a duty to house who were awaiting an offer of settled accommodation. The City is rarely able to provide temporary

63

accommodation within its boundaries but, for the majority, temporary accommodation stays are less than six months in duration. Advice services commissioned by the City provided assistance to 19 people at risk of homelessness in 2012/13. In addition, the City Housing Needs and Homelessness Teams provided advice and assistance to prevent or end the homelessness of a further 51 households.

Rough sleeping The City funds Broadway (a London-based homelessness charity) to provide outreach to rough sleepers in the area and arrange accommodation through links with hostels. It also refers rough sleepers to No Second Night Out and No-one Living on the Streets, which are rapid assessment and response services for rough sleepers who are new to the streets and intermediate-term rough sleepers who wish to stop living on the streets. The City also supports the Middle Street Hostel financially, and funds a part-time support post there. The City has developed innovative accommodation and service models to help its most entrenched rough sleepers leave the streets. Working with St Mungo’s, it has developed a new model of hostel accommodation for long-term rough sleepers, whose needs are distinct from those of more transient or chaotic rough sleepers. The accommodation, known as The Lodge, breaks away from the traditional model and approach of a hostel to offer hotel-style accommodation. In doing so, The Lodge has succeeded in engaging, accommodating and supporting a client group that would not otherwise have been helped. Some long-term rough sleepers remain resistant to support from services. In 2010 the City of London’s Outreach Team piloted a new way of working with this group, focusing on personalisation. The project moved away from the standard model of outreach to provide longer-term, more intensive engagement, and the offer of a personal budget to enable flexible and creative approaches. The project was developed and is delivered by Broadway. To date it has succeeded in engaging 27 City rough sleepers and accommodating 26. It was rolled out across London in 2011, and the City of London, in partnership with Broadway, received the Andy Ludlow Award for this work. The City of London has recently introduced new ‘pop-up hubs’ in association with Broadway and local churches, which take the form of a five-night intensive support facility staffed by a multidisciplinary team. These hubs provide an opportunity for those sleeping rough to engage with a number of key services, all

64

in the same venue, to help them find the support they need to leave the streets.

65

5. Early life and family life

This section covers key aspects of the health and wellbeing of children and young people aged from birth to school leaving age (i.e. 0 to 18). It also deals with matters relating to family structure and maternity. Influences on health and wellbeing begin before birth. Our development, the environment we grow up in and the behaviours and attitudes we take on in our early years impact on our health and wellbeing for the rest of our lives. As we get older, the influences of our education, socialisation, peer pressure and support, and the difficult transition from adolescence to adulthood become more important.

Key findings ■■There are relatively few families and few births in the City. The majority of households in the City are single people. ■■Of the children and young people aged 0–19 in the City, 43% are from black and minority ethnic (BME) backgrounds. ■■The City has a good record of caring for looked-after children. ■■Children in the City have excellent early years provision and perform very well in primary school. ■■In the City’s one maintained school, 100% of school pupils participate in at least 2.5 hours of organised physical education per week. ■■Local figures identify that 21% of children living in the City are in low-income households. Previous national figures calculated that 19% of children in the City live in poverty. ■■22% of primary school children are eligible for and claiming free school meals.

Recommendations ■■It is an important period to monitor evidence-based outcomes in children, in order to assess the impact of recent policy and service provision changes.

Questions for commissioners ■■How are commissioners preparing for the transfer of public health responsibility for 0 to five-year-olds to the local authority in October 2015? ■■A total of 43% of children and young people are from BME backgrounds. How can commissioners ensure that these young people and their families are supported effectively and are receiving appropriate services? ■■Are commissioners and commissioned services fully utilising the City’s resources to support families out of poverty?

67

Young people Local policy context The Children and Young People Plan (CYPP) 2013 reflects the City’s ambition to use the power of partnerships and multi-agency working to improve outcomes for all children and young people, with a particular focus on preventative services. The CYPP is a strategic plan that supports service planning and delivery against seven key priority areas. These are: ■■Stronger Safeguarding ■■‘Early Help’ ■■Children’s Workforce Development ■■Healthy Living ■■Achievement and Learning ■■Partnerships ■■User Engagement The City’s Education Strategy 2013–15 also sets out a vision, which is: ■■To educate and inspire children and young people to achieve their full potential. Four key themes from this strategy define the City of London Corporation’s approach to education: ■■a commitment to creating a family of schools from its schools portfolio, which will have a shared culture and a common ethos ■■a commitment to improving the governance and accountability frameworks of the education offer ■■recognising the role the City of London Corporation can play in its outreach provision across London and seeking to strengthen this offer ■■confirming the City of London Corporation’s commitment to providing pathways to employment and bridging the gap between education and employment, making use of the livery and business links within the Square Mile

68

Population Demographics The population data from the Census 2011 shows that there are 269 primary age (four to 10) and 147 secondary age (11 to 16) children living in the City of London, 45

out of an estimated total of 843 0 to 19-year-olds. Of these 843 young people, 46

361 (43%) are from BME backgrounds.

The City’s Resident Insight Project recorded that in November 2012 there were 898 young people aged 0 to 19 resident in the City, of whom 604 were aged 0 to nine and 294 were aged 10 to 19. Out of these 898 children and young people, 21% were identified as living in low-income homes, i.e. homes with a low income 47

supplemented by benefits.

At the age of 11, when children leave the local state primary school, it becomes harder to track their whereabouts in terms of schooling. Although around 18 children per year register to attend state maintained schools outside the City, it is not known whether these children remain City residents as they grow into older teenagers. Additionally, it is not known whether other children, who do not register, are going on to attend private schools outside the City, or whether the whole family is moving out of the City and becoming resident in another borough with more suitable housing for teenagers.

Disabilities There were fewer than 10 children and young people with disabilities known to the City in 2013. The City’s Special Educational Needs and Disability (SEND) Strategy 2013–17 describes the City’s strategy for children and young people aged 0 to 25 with SEND. A disability register is also currently under review.

Looked-after children The City has a good record of caring for looked-after children. All looked-after children in the City have stable placements and accommodation. There were fewer than five children (aged 0 to 16) looked after by the City of 48

London in 2012/13. All the children in the City who had been looked after for at least 12 months as of March 2013 had up-to-date health checks, immunisations, dental checks and health assessments. This maintains the 100% record of the previous year.

45 ONS mid-year estimates for 2013 46 City of London Corporation (2013) Primary Education in the City of London: Annual Report 2013 47 ibid 48 City of London Corporation (2013) Safeguarding Children Annual Report, 2012/13

69

No resident children of the City of London were made subject to a court order, 49

adopted or accommodated in 2012/13. Table 5.1

Number of children looked after by the local authority, 2009–13 Year

Number

2009

15

2010

15

2011

10

2012

5

2013

5

Physical activity In the City’s one maintained school, 100% of school pupils participate in at least 2.5 hours of organised physical education per week. They also have access to further physical activities if they so choose, through playtimes (up to four hours per week) and after-school clubs (up to four hours per week).

Education and training Schools The City of London has one maintained primary school and three sponsored city academies in neighbouring boroughs. It also supports three independent schools based in the City. The one maintained primary school is Sir John Cass’s Foundation Primary School, which includes the Cass Child & Family Centre, the City’s sole children’s centre. Of the pupils attending the school, many of whom do not live in the City, 68% (971) are from BME backgrounds. Primary aged children attend Sir John Cass and a small number of schools in Islington, Camden and Westminster. Secondary age children attend a range of schools, including Islington secondaries and schools in other neighbouring local authorities such as Tower Hamlets and Hackney. The City currently funds fewer than five children to be educated outside mainstream local authority provision. In terms of youth ‘not in employment, education or training’, numbers in the City are too low to report with accuracy.

70

49 ibid

Primary school performance In the City, 75% of eligible children aged five achieved at least 78 points across the Early Years Foundation Stage (2012), with at least six points in each of the scales in personal, social and emotional development and communication, language and literacy. These results are the second highest in the country and the highest in London. The 2011 Ofsted inspection of City of London Corporation children’s services found that all provision for early years education and childcare was good or outstanding, with all provision for early years education judged to be outstanding. Achievement at age five was found to be well above average and continues to improve far more quickly than it does nationally. Sir John Cass’s Foundation Primary School’s most recent Ofsted inspection was in April 2013, when it was deemed to be outstanding in all aspects.

Attainment in higher education The number of young residents (aged 18 to 24) entering the first year of their first undergraduate degree at a UK higher education institution (either full-time or part-time) decreased over the five-year period from 2007/8 to 2011/12 (Figure 5.1). In the 2010/11 academic year, within six months of completing their higher education 33% were in full-time employment, 17% were in part-time employment and 11% were self-employed. A total of 22% were not employed and were not looking for work, while only 6% were unemployed and looking to be employed. Figure 5.1 Young residents progressing to higher education, 2007/8 to 2011/12 (Higher Education Statistics Agency) 60

50

40

Young residents

30

20

10

0 2007/8

2008/9

2009/10

2010/11

2011/12

71

Apprenticeships Apprenticeships are about helping young people fulfil their potential through personal and social development. Apprenticeship programmes can help tackle youth unemployment by matching the skills demanded by employers with those available among the population, especially young workers. The City of London Corporation provides a free apprenticeship placement service to support businesses in employing young people who are starting their careers. Unemployed school leavers aged 16 to 18 are eligible. This service gives candidates a first experience of the workplace while also boosting employer performance. The programme supports apprenticeships within the Corporation, as well as with recognised names in banking, insurance, property and many other sectors.

Child poverty and deprivation Child poverty needs The City of London Corporation will be conducting a new Child Poverty Needs Assessment in 2014. This will be used to review the delivery and targeting of services to better meet families’ needs. According to previous national figures, 145 City children (19%) were living in poverty in 2010. This figure was calculated using the relative poverty measure, which is defined as the proportion of children living in families in receipt of out-ofwork benefits or tax credits whose reported income is less than 60% of the median income. In July 2013, the Resident Insight Project revealed that 960 children were living in the City of London, of whom 21% (197) were in low-income households (defined as households in receipt of low-income-based benefits). These locally derived figures are slightly higher than the official estimates; this may be due to undercounting in the national figures. Because these two figures use different definitions of poverty, they are not directly comparable. Of the 197 children living in low-income households, 76 (39%) were in workless households, with the remaining 61% in working households. This reflects the national figures, where the majority of children growing up in poverty (63%) have at least one parent or carer who is in work. This is an increase from 2000/01, when 51% of poor children

72

nationally (on the relative low-income measure) were from working households.

Although the Resident Insight Project does not identify particular concentrations of child poverty in the City, there is likely to be a higher rate in the areas of social housing around Portsoken and Golden Lane.

Free school meals In the City of London, 22.3% of primary school children were eligible for and claiming free school meals. This is lower than the level in inner London and London as a whole, but just over 5% higher than the national average. There is one maintained primary school in the City, Sir John Cass’s Foundation Primary School, and no maintained secondary schools. Of the children attending this 50

school, 22% are entitled to free school meals. A total of 73 out of 1,428 children at the school are City residents aged three to 11. Table 5.2 Free school meals in state-funded primary schools Location

% eligible for and claiming free school meals

City of London

22.3

Inner London

31.9

London

23.7

England

18.1

Early years support Local estimates from the Resident Insight Project show that there are 364 children aged 0 to four currently residing in the City of London, of whom 79% are registered with the early years system Synergy Connect. In total, 44 of the 364 children live in a home with a low income: 82% of this group are registered with the children’s centre system and 26 are regular users of the Cass Child & Family Centre. Twenty-seven of the 364 children live in a home where workless benefits are being claimed: 74% of this group are registered with the children’s centre system and 26 are regular users of the Cass Child & Family Centre. There were 2,635 visits to the Cass Child & Family Centre in the period April to August 2013. Of these, 42 were related to targeted family support. The number of City of London children and families requiring statutory social care interventions is low compared with other local authorities. Very few children (six) were subject to a child protection plan in the City of London in 2012/13. 50 School Census 2013

73

Case study S came into care five years ago. Before coming into care, she had witnessed several incidents of violence between her mother and her mother’s boyfriend. She was engaging in unsafe play and displayed aggressive behaviour towards adults and other children. She was referred to anger management services to help her come to terms with her past experiences. Accessing the service When concerns arose about S, the carer and social worker discussed these with child and adolescent mental health services (CAMHS), who were willing to see her. S was seen by CAMHS for individual sessions and her carer was also offered support to help her deal with S’s behaviour effectively. An improvement in S’s behaviour was observed; for example, she previously displayed outbursts of anger, but this behaviour has now ceased both in school and at home. She has been given strategies to deal with her emotions in a more appropriate way and she has been observed doing this effectively by her foster carer and social worker. In discussions with her therapist and with her foster carer and social worker, it was decided that S could stop attending sessions with CAMHS; her progress was then reviewed at a meeting with her foster carers, CAMHS worker, social worker and S herself. All were in agreement that she had made significant progress and that she should be discharged by CAMHS. Should it be necessary, it was made clear that she could be referred again in the future.

74

Youth services In 2012, youth services changed from being provided in-house to being a commissioned service. Since 1 April 2013 the City of London’s youth services have been delivered to 10 to 19-year-olds (and to those with special needs up to the age of 25) by commissioned providers. There are five strands of youth services in the City, run by three service providers who took over contracts in April 2013. The services contracted are: provision of information, advice and guidance; universal youth services; targeted youth services; youth participation; and provision of a client caseload management information system. These changes are expected to improve outcomes-based results and offer better value for money.

Child and adolescent mental health services Mental health services for children and adolescents in the City are provided jointly with Hackney. As of 2013/14 the services encompassed the following: ■■community child psychology services ■■specialist child and mental health services ■■integrated clinicians in other services for young people The CAMHS Framework 2013–15 outlines the vision for the development of CAHMS and for improving emotional health and wellbeing, including an action plan with measurable outcomes aligned with wider national policy.

Families and households The type of housing available in the City is not particularly suited to family life, particularly for older children. For example, 50% of accommodation has two bedrooms or fewer. Additionally, there is just one state school in the City, which is for primary aged children only. Despite this, there are some families in the City, with particular concentrations in the areas around Barbican, Golden Lane, Mansell Street and Middlesex Street. The Census 2011 includes detailed information about household structure within the City. Single people are the predominant group (60%) seen throughout the City (see Appendix 7). Almost 30% of households in the north of the City are couples without children. ‘Others’, which mainly includes those in shared housing, are concentrated in the east on the Mansell Street and Middlesex Street Estates. Couples with children are mainly concentrated in the east, with some in the north.

75

Figure 5.2 Household structure in the City: percentage of couples with children

This product includes mapping data licensed from Ordnance Survey with the permission of HMSO. © Crown copyright 2013. All rights reserved. Licence number 100019635. 2013. © Bartholomew Ltd. Reproduced by permission, HarperCollins 2012.

Maternity Smoking and pregnancy In 2010/11 none of the pregnant women resident in the City reported being smokers at the time of delivery.

Antenatal care Over the six months from April to September 2011, 21 women from the City registered for maternity care. Three-quarters had registered by the 12th week of pregnancy.

Place of birth and delivery method Between January 2010 and October 2011, 98% of births to City residents took place in hospital, mainly at University College London Hospitals and the Royal London Hospital.

76

Figure 5.3 Place of birth of babies with mothers living in the City, January 2010 to October 2011 (hospital data)

Terminations The abortion rate for City residents in 2012 was 11.7 per 1,000 women, which is much lower than the national and London averages.

Breastfeeding In 2010/11 all babies born to City mothers were recorded as being breastfed at the age of six to eight weeks.

77

6. Working age

People of working age, particularly men, tend to be the group least likely to engage with traditional health professionals. This is one of the many reasons that make the workplace a key setting for the promotion of health and wellbeing. The nature of the work undertaken by an individual and the culture of the employing organisation can have both positive and negative effects on their health. For example, most jobs offer opportunities to network with others, give structure and meaning to life, and offer an income. Many jobs, however, are now largely sedentary, while contracts can be short or insecure and unhealthy amounts of stress and pressure can be placed on individuals in a society which has some of the longest working hours in Europe. According to the World Health Organization (WHO) Life Course Approach, 51

functional capacity peaks in early adulthood. Therefore early adulthood is a critical period for interventions that can have a springboard effect to alter 52

subsequent life course trajectories, with implications for health in older life.

Healthcare needs in this group tend to relate to specific short-term issues such as flu symptoms, as well as to services aimed at slowing the rate of decline by reducing unhealthy lifestyle behaviours. Maintaining functional capacity – for example through supportive working conditions and options for starting a family 53

or achieving work–life balance – are equally important to this age group.

Key findings ■■The City has a new responsibility for co-ordinating and implementing work on suicide prevention; however, as very few people in the City are residents, there is a limit to what can be done locally. ■■In total, 24% of incidents reported to the City of London Police were alcohol related or connected with licensed premises. ■■More women than average (both residents and non-residents) do not participate in the recommended levels of physical activity.

Residents ■■Unemployment is a significant contributor to poor health and wellbeing. There are discrepancies in unemployment in working age residents between the different housing estates in the City. ■■Smoking and obesity rates are much higher in Portsoken than in the rest of the City. ■■Depression rates in residents vary from 2% to 5%, depending on the data source. ■■The City recognises the important contribution that carers make to population wellbeing and has developed support for carers. 51 WHO (2000) A Life Course Approach to Health 52 ibid 53 The Public Health and Primary Healthcare Needs of City Workers (2012)

79

■■Unpaid carers provide vital support to vulnerable people in the City, and it is important that they receive appropriate support. ■■The profile of residents using treatment services has changed from unemployed homeless drug users to those in stable housing and employment who have an alcohol problem.

City workers ■■Between 2001 and 2012, the City of London saw the biggest increase in employees across all 983 areas in London (36%), with finance remaining the dominant sector in the City. ■■The majority of City workers (two-thirds) are university graduates, which is twice the London average. ■■City workers smoke more than the London average. Quit rates among City workers are relatively high (50%). ■■Alcohol misuse among both male and female City workers is considerably higher than the national average. Young white males are the predominant misusers of alcohol. ■■Over one-fifth of City workers report suffering from depression, anxiety or other mental health conditions, with one-third reporting that their job causes them to be very stressed on a regular basis. ■■The younger age profile of City workers also puts them at greater risk of sexually transmitted infections and drug misuse. ■■The City has been working to promote workplace health within the Square Mile and to develop support for businesses in achieving this. The City has commissioned research and initiated a business network. ■■It is likely that many City workers have caring responsibilities.

Rough sleepers ■■Rough sleepers are particularly vulnerable to smoking, alcohol misuse, substance misuse and sexually transmitted diseases, and may encounter barriers to accessing services for these health issues.

Recommendations ■■As risk factors for alcohol, smoking and mental health are closely linked, it is important to continue tackling these issues concurrently and comprehensively in order to be as effective as possible in improving health outcomes. Provision should consider the needs of all three populations: residents, City workers and rough sleepers.

Questions for commissioners ■■What are commissioners doing to tackle unemployment in the City? ■■How are commissioners adapting the substance misuse treatment and

80

prevention services available to residents in line with the change in profile of those needing these services? ■■What are commissioners doing to reduce obesity rates in Portsoken? ■■How can commissioners prevent the alcohol misuse and mental health issues associated with City workers? ■■What are commissioners doing to increase smoking quit rates for City workers and residents in Portsoken? ■■How are commissioners ensuring that services are integrated to ensure holistic health support for rough sleepers? ■■In conjunction with information in Chapter 4, ‘Community life’, how can commissioners support organisations in building the resilience of City residents, including encouraging a greater take-up of physical exercise?

Economic participation among residents 54

In the City, 77% of the resident population is of working age. The population is too small for reliable estimates of economic activity to be made. The Public Health Outcomes Framework identifies sickness absence among City residents as very high. However, this is based on survey data that drew upon an extremely small sample from the City, and is therefore unreliable. The Framework does not give a sickness absence figure for City workers, which would have been a useful indicator for the City’s Health and Wellbeing Board.

Unemployment and out-of-work benefits Unemployment is bad for health. Unemployed people, particularly those who have been unemployed for a long time, have a higher risk of poor physical and mental health. Unemployment is linked to unhealthy behaviours such as smoking and drinking alcohol and lower levels of physical exercise. The detrimental health effects of a long period of unemployment can last for years. In September 2013, only 4.8% of the working age residents of the City of London (100 people) were claiming Jobseeker’s Allowance. The proportion of City residents claiming Incapacity Benefit is also relatively low at 2.3% (140 people). It is likely, however, that there are distinct differences between people living on estates within the City. The Resident Insight Database has indicated that 7% of households with children have no one working, and that 10% of children live in a workless household. A survey of the tenants of the Golden Lane and Middlesex 54 NOMIS, 2011

81

City and Hackney JSNA City Supplement

Street Estates found significant levels of unemployment among working age adults: 40% of respondents were either job seekers or not actively seeking work, including 16% who were unable to work because of long-term sickness or disability. The City of London Corporation is currently concentrating efforts to tackle worklessness on the wards of Portsoken and Cripplegate, which have the highest levels of unemployment in the Square Mile. An employability project part funded by the City of London and the European Social Fund, City STEP, aims to place residents from these wards into sustained employment during 2014. Table 6.1 Key benefits claimed by residents of the City of London, May 2013. Percentages are of the working age population (NOMIS/Department for Work and Pensions) The City

London

Number

%

%

Jobseeker’s Allowance

100

1.7%

3.9%

Incapacity Benefit/Employment and

130

2.3%

5.5%

Support Allowance –



1.5%

Carers

20

0.3%

1.0%

Others on income-related benefits

10

0.1%

0.4%

Disabled

30

0.5%

0.8%

10

0.1%

0.1%

240

3.2%

10.9%

Lone parents

Bereaved Key out-of-work benefits

Adult learning There is growing evidence of an association between participation in various types of adult learning and improvements in wellbeing, health and health-related behaviours. These benefits can be particularly strong for those people who left school without any qualifications, as well as older people. The Marmot Review identified lifelong learning as one of the key interventions to reduce health inequalities. Participation in adult learning may reduce the risk of developing depression, and may also encourage other healthy behaviours such as participation in exercise. There is a strong relationship between participation and self-reported life satisfaction and/or psychological wellbeing, and some studies also show that participation in adult learning can help older people to retain verbal ability, verbal memory and verbal fluency.

82

The City of London Adult Skills and Education Service aims to provide high-quality, responsive lifelong learning opportunities to City residents and workers of all ages by facilitating a vibrant, world class, urban learning community at the heart of the capital. Many and varied people participate in lifelong learning courses in the City of London each year, with more than 50 subjects taught at different locations across the Square Mile. These include community centres, libraries, primary schools, children’s centres, the Bishopsgate Institute, the Museum of London and Guildhall Art Gallery. In 2012, there were over 2,000 learners participating in 223 courses.

Jobs within the City The Office for National Statistics reported that there were 353,800 employees in the City of London in 2012. Between 2001 and 2012, the City of London saw the biggest increase in employees across all 983 areas in London. In 2001 there were 259,500 people working in the City, and by 2012 this figure had risen to 353,800. This is the highest number of employees for any year in the dataset, and between 2011 and 2012 alone it rose by 26,300. This represents an increase of 36% in just over a decade (Figure 6.1). The Core Strategy predicts that City employment will increase significantly to 428,000 by 2016. Employment trends show that the financial sector remains the dominant sector in the City (41%). A steady increase in employment levels since 2008 has seen professional and estate become a considerable industry in the City, comprising 27% of employment. Other sectors combined make up almost one-third (32%) of employment in the City, the most significant of which is administrative and education, which accounts for 15% of City employment (Figure 6.2).

83

Figure 6.1 Change in number of employees working in London, 2001–12

Figure 6.2 Employment by industry in the City, 2011 (Business Register Employment Survey)

84

There are distinct gender differences within the occupation profiles of jobs within the City. Management and senior official positions are more likely to be occupied by men. Administrative and personal services jobs are more likely to be occupied by women (Figure 6.3).

Figure 6.3 Employment within the City: occupations by sex, 2010/11 (Labour Force Survey) 100% 90% 80% 70% 60% 50% 40%

Percentage

30% 20% 10% 0%

Male

Female

Education and qualifications City workers Two-thirds of City workers have at least a level 4 qualification, which exceeds the London average by 27%. Qualification levels are based on the Qualifications and Credit Framework, where levels 4 to 8 are obtained at university and include everything from certificates of higher education through to doctorates. This greater proportion of level 4 qualifications is consistent with the work sectors traditionally seen in the City – that is, the financial and insurance sector (37%) and the associated professional services (18%), which require a higher level of education. Education, income and housing tenure all have enduring associations with health, over time and across different diseases.

85

A highly educated working population is consistent with greater incomes and increased home ownership. Figure 6.4 Highest levels of qualifications in London 70% 60% 50% 40%

Percentage

30% 20% 10% 0%

No qualifications

Level 1 qualifications

Level 2 Apprenticeship Level 3 Level 4 qualifications qualifications qualifications and above

Workplace health Improving the health of adults of working age is a national public health priority. Workplace health is an essential component of the UK government strategy to tackle health inequalities and increase healthy life expectancy. Working age ill health is estimated to cost the UK economy over £100bn a year. In 2011, a total of 131 million working days in the UK were lost because of sickness absence. The City of London Corporation is committed to supporting and promoting the City as the world leader in international finance and business services. It has set out its intent to establish the City as the world’s foremost ‘healthy workplace setting’ for the people who commute into the area on a daily basis. Current evidence suggests that public health interventions in the workplace can deliver considerable benefits to the City itself, as well as to the wider health and social care economy. For City businesses, public health interventions that address behavioural risk factors (such as poor diet, excessive alcohol consumption, physical inactivity and smoking) can play a significant role in improving

86

employees’ physical health and mental wellbeing, increasing workplace

Other qualifications

productivity and output and boosting staff retention and recruitment, as well as reducing sickness absence. The City of London was chosen as a pilot area for the London Healthy Workplace Charter, which is an initiative developed by the Department of Health (DH) and currently run by the Greater London Authority. The Healthy Workplace Charter is an accredited scheme for employers to demonstrate their commitment to workplace health. The scheme is being used within the City of London Corporation to demonstrate the Corporation’s commitment to addressing these issues for its own staff. The Corporation has set the ambitious target of reaching the Charter’s ‘Excellence’ standard, and is also responsible for supporting other City-based organisations to achieve the Charter. The City of London Corporation has also commissioned and published a piece of research on best practice in workplace health, looking at national and international examples and comparing these with current practice within the Square Mile. It is hoped that this research will be used by organisations in the City to inform and further improve their workplace health activities, with a particular focus on mental health and resilience. The City is also in the process of establishing a network of businesses within the City, the Business Healthy Circle, to share best practice on workplace health and provide a business-led response to workplace health issues.

Business Healthy Conference In March 2014, the City held an inaugural conference on workplace health. This conference brought together key decision-makers from the business world to improve awareness of the link between healthy workplaces and improved business productivity. The conference also aimed to start a dialogue about how to shift the focus of workplace health from ‘health and safety’ to holistic wellbeing, including tackling stress and mental health in modern workplaces.

87

Lifestyle and behaviours Smoking Prevalence Residents Among City residents, there is currently no robust data for smoking prevalence, although patients registered with the Neaman practice have rates of current smoking of around 15% (as disclosed to their GPs). This is lower than the average for London. Primary care data extracts for the whole City population show that 11% of residents are current smokers, but this figure rises to 21% for patients who are not registered with the Neaman practice (i.e. those who live in Portsoken).

City workers 55

A survey of City workers in 2012 reported that 24.7% of respondents were smokers, representing approximately 91,000 people. This was above the average for both London (17%) and England (20%). Of the respondents who reported smoking, about 15.1% smoked regularly and 9.7% were occasional smokers.

Rough sleepers Research suggests that rough sleepers have very high smoking rates, with surveys 56

showing that around 80 to 90% of people sleeping rough are smokers. It is likely that smoking is a contributing factor to the poor health of rough sleepers, but that rough sleepers find it much harder to access the smoking cessation services that more advantaged people take for granted.

Quitting In the City, 1,145 people set a quit date in 2012/13, of whom 606 (53%) went on to be successful four-week quitters. Table 6.2 shows the quit rates across different population subgroups. The majority of those accessing stop smoking services were City workers rather than residents, and most were in managerial or professional roles. However, quit rates were slightly higher among the smaller numbers of people in intermediate professions, those not employed and those aged 60 or over. Quit rates were lower among 18 to 34-year-olds and the white British/Irish population.

88

55 The Public Health and Primary Healthcare Needs of City Workers (2012) 56 Health Development Agency (2004) Homelessness, smoking and health

Table 6.2 People in the City not smoking four weeks after quitting: absolute number and percentage quit rate by population subgroup, 2012/13 (Source: DH)

Number of four-week quitters

Percentage

Male

352

53%

Female

254

52%

18–34

255

49%

35–44

202

55%

45–59

128

59%

16

64%

461

53%

White other

50

54%

Black

19

58%

Asian

35

47%

Mixed

29

54%

20

57%

Employed: managerial/professional

471

52%

Employed: intermediate professions

9

56%

35

52%

Population group

quit rate

Gender

Age

60+ Ethnicity White British/Irish

Work/socio-economic status Not employed

Employed: routine and manual

Smoking cessation support services A total of 16 pharmacies in the City have signed up to deliver Level II smoking cessation support services. These pharmacies display the local ‘Quit Here’ branding in order to raise the profile of the service. In 2012/13, 64% of smokers accessing support to give up smoking in the City did so through their local pharmacy. In 2012/13, the pharmacy-led service performed well. Although it fell short of its target (by just two quitters), its overall quit rate of 51% greatly exceeded the DH recommended minimum quit rate of 35%. Its carbon monoxide validation was exceptionally high at 97% (the DH minimum standard is 80%).  In total, 87% of the pharmacies achieved or exceeded the minimum recommended quit rate, although overall there was a slight decrease in the

89

number of four-week quitters compared with the previous year. This mirrors the national trend of a decrease in the number of smokers using stop smoking services, which is thought to be linked to the introduction of e-cigarettes (that is, more smokers are choosing to quit without help from services). The quit rate increased from 44% to 51%, which suggests that the quality of stop smoking services in pharmacies is increasing. The profile of smokers who access the pharmacy stop smoking services in the City continues to mirror the profile of the City working population as a whole. In total, 56% of smokers accessing the service are male. They are predominantly white British (76%) and 83% work in managerial or professional occupations.  Level III specialist services are for patients who require longer-term, more intensive support. These include patients who: have made more than three serious failed quit attempts; smoke within an hour of waking; have chronic diseases (such as chronic obstructive pulmonary disease, coronary heart disease, diabetes, hypertension and/or stroke); have multiple illnesses; or have psychiatric problems. The specialist Level III service runs a range of clinics across the City. These include weekly drop-in clinics and workplace clinics that are run on an ad hoc basis. The Level III service exceeded its 2012/13 target (108%) and achieved a 61% quit rate, with 87% of quitters carbon monoxide-validated. The population accessing the Level III service is very similar to that accessing the pharmacy service: 68% are white British and there are more men (65%) than women. When the data is broken down by socio-economic status, the majority of people accessing the service are from managerial and professional occupations (67%). However, routine and manual workers make up 14% of the smokers accessing the Level III service. This is considerably higher than the percentage accessing the pharmacy service, where routine and manual workers make up only 4% of the total. The Queen Mary service has a team of health psychologists who are able to provide a more intensive level of support and who are trained in behaviour change. They are therefore able to provide a more appropriate service for routine and manual workers, who often have higher levels of dependency.

Physical activity Sport and physical activity among adults Sport England’s Active People Survey for 2012/13 (published in June 2013) states that 38% of adults resident in the City take part in at least one 30-minute session of moderate intensity activity per week. This compares with a London average of 36% and a national average of 35%.

90

A local survey conducted with both residents and non-residents in the City revealed that the non-participation rate among females is above the national average at 29%, compared with 19% for males. There is also a high nonparticipation rate (34%) among people with a disability (the national average is 25%). Encouragingly, 58% of survey participants did all their sport inside the Square Mile, and 69% of City workers said that they would like to do more sport (32% of those were specifically interested in swimming). Respondents said that if the location was convenient – for example, accessible during lunchtimes – then their levels of activity would increase.

Obesity Obesity data comes from two sources: Quality and Outcomes Framework (QOF) data for patients registered at the Neaman practice in the north-west of the City (which the GPs compile); and primary care data extracts, which are of unknown accuracy. Around 4% of adults registered with the Neaman practice are obese, which is lower than the rates for surrounding areas and London as a whole (Figure 6.5). Primary care data extracts for the whole City population estimate that 9% of residents are obese, but that obesity might be as high as 15% in patients who are not registered with the Neaman practice (i.e. those who live in Portsoken). Figure 6.5

Obesity prevalence (GP-registered population)

Obese adults as recorded in general practice (QOF) 10%

5%

0% 2006/7

2007/8

2008/9

2009/10

2010/11

2011/12

91

Alcohol Levels of alcohol consumption Synthetic estimates of alcohol consumption in 2012 by City residents suggest a slightly higher level of risk than the average for London (Table 6.3). Compared with the previous year, there seems to be a variable trend in risk. The number of individuals who abstain from alcohol has decreased, but those deemed to be at increasing risk has also reduced compared with the previous year. This may be linked to the ethnic profile of City residents.

City workers A report on drinking among City workers published in January 2012 found the prevalence of alcohol misuse in 2011 to be a significant issue, as summarised in Table 6.3. A total of 33.4% of City drinkers are at increased risk of alcohol-related 57

harms, compared with 20.1% nationally. These drinkers are not yet necessarily experiencing alcohol-related harms, but are increasing their risk of health and social problems. In total, 12.4% of City drinkers were drinking at a higher risk level, 58

compared with 3.8% in the national population and 8% in London as a whole.

Higher risk drinkers are already experiencing alcohol-related harms and many have some level of alcohol dependency. The scores are derived from the Alcohol Use Disorders Identification Test (AUDIT), a validated health screening tool developed by the World Health Organization. The full 10-question AUDIT places respondents in one of four main categories, ranging from ‘lower risk’ to ‘possible dependence’. Alcohol misuse in the City may in part be attributed to a complex range of factors such as higher average wealth, high-pressure or risk-based work environments, a culture of entertaining clients and high use of public transport. Alcohol misuse among both male (56.2%) and female (34.1%) City drinkers is considerably higher than the national averages (33.2% for men and 15.7% for 59

women). Young white males are the predominant misusers of alcohol.

92

57 Insight into City Drinkers (2012) 58 ibid 59 ibid

Table 6.3 Estimates of alcohol consumption by City residents and City drinkers by DH risk 60,61,62

category, 2011 and 2012

Abstain (%) 2011 City residents City workers London National

19%

2012 14%

– 24% –

– 22% –

Lower (%) 2011 50% – 52% –

2012

Increasing (%) 2011

70% – 73% –

22% 33% 16% 20%

2012 22% – 20% –

Higher (%) 2011

Source

2012

8%

9%

12%



8% 4%

7% –

NWPHO Insight into City Drinkers NWPHO APMS 2007

Table 6.4 AUDIT categories by score range Audit score

Lay category

Medical category

0–7

Lower risk

Lower risk

8–15

Increasing risk

Hazardous

Comment/summary Includes abstainers – unlikely to experience alcohol-related harm Drinking above the guidelines therefore increasing the individual’s risk of alcoholrelated health or social problems Regularly drinking (on most days) at least

16–19

Higher risk

Harmful

twice the recommended guidelines. Already likely to be experiencing alcoholrelated harms. Dependence may be mild, moderate

20+

Possible

Possible

or severe. Loosely defined as a strong

dependence

dependence

desire to drink and/or difficulty controlling alcohol use.

Source: Insight into City Drinkers (2012)

Health impacts of alcohol The annual alcohol-attributable death rate in the City’s resident population is 49.6 per 100,000 men and 2.3 per 100,000 women (age-standardised rate). This gives the City the second lowest rate in the country for women. However, it should be noted that rates in the City can jump dramatically due to the low resident numbers. Alcohol-attributable hospital admissions are also very low in the City’s resident population (Table 6.5). There were 17 individuals in contact with structured alcohol treatment in 2012/13, 40% of whom completed treatment successfully.

60 North West Public Health Observatory (2012) Local Alcohol Profiles for England (2012 Refresh) 61 Insight into City Drinkers (2012) 62 Adult Psychiatric Misuse Survey 2007

93

Table 6.5 Alcohol-attributable hospital admissions for men and women in the City in 2012/13, compared with London average, and national rank 63

(where rank 1 is best)

The City

London

Rate per 100,000

National rank

Rate per 100,000

standardised

(out of 354)

standardised

Men

969.7

7

1,535.9

Women

289.0

1

810.9

City workers Compared with national averages, alcohol-related problems in City workers may be disproportionately social rather than health harms. Health-related problems were less reported than social or behavioural problems (e.g. injury or remorse).

Crime and anti-social behaviour In 2012/13 the London Ambulance Service dealt with 26 calls regarding alcohol overdoses or alcohol-related accidents in the City, with 18 (69%) of these coming from the Bishopsgate area. This is an increase on the previous year, when there were 22 alcohol-related calls. During 2012/13 the City of London Police were notified of 5,454 incidents. Of these, 1,292 (24%) were alcohol related or connected with licensed premises (public houses, nightclubs and wine bars). A total of 178 (32%) were deemed violent offences and 1,013 (27%) acquisitive offences. In general, alcohol-related offences happen after 7pm from Monday to Friday and fall off by midnight. On Thursday, Friday and Saturday, offences are likely to happen through the night until 4am. A total of 957 (74%) offences occurred between Thursday and Sunday, with 679 (53%) occurring between 6pm and 2am on those days. There were 175 arrests for drunkenness offences and 121 arrests for road traffic offences relating to breath tests (failure to provide, positive and refusal).

Substance misuse Prevalence of drug use Local research carried out via the Project Eclipse initiative in night-time venues across the City appeared to show that cocaine was the major drug being confiscated and deposited in amnesty bins. It also showed that over half of the

94

63 North West Public Health Observatory (2011) Local Alcohol Profiles 2011

patrons in these venues were working in the City. National data reveals that the ‘prosperous urban’ demographic tends to use more drugs than other groups, including cocaine.

Health impacts of drug use Between April 2007 and March 2013, there were 36,356 incidents leading to ambulance callouts in the City of London, with 304 (0.8%) flagged as being drug related. A total of 48% of the callouts were for individuals under the age of 35, 56% were for males and 41% were for females (3% were not recorded).

Emerging trends in drug use Residents The City’s treatment services have always been used by more males than females, and this is consistent with services across England. Clients are predominantly of British nationality. The majority of individuals who use the City’s services are not parents, and at least 18% of the client population is not heterosexual. In 2011/12 there were no clients who had ‘wages’ as an income source; this has now changed in 2012/13. In previous years the majority of individuals using treatment services were street homeless or in unstable accommodation. The reverse is now true, with the majority being in stable accommodation with no housing problems. This change goes hand in hand with the increase in the numbers of people who are employed and the increase in those with a primary alcohol problem.

Treatment and engagement Residents A total of 24 individuals entered the treatment system in 2012/13, adding to the 17 who were already in treatment on 1 April 2012. It is encouraging that the highest number of referrals were self-referrals; the second highest number came from GPs. These were predominantly for people with a primary alcohol problem. In 2012/13, 11 people received structured drug treatment through the City of London Substance Misuse Partnership. Of these, nine were opiate and/or crack users. The overall proportion of those leaving treatment successfully in the City (23%) is higher than the national figure (15%). None of those who left successfully returned to treatment; however, the numbers in treatment (and therefore the numbers of associated successful completions) are decreasing.

95

Harm reduction Residents The prevalence of hepatitis C in injecting drug users is around 50% nationally. The prevalence of hepatitis B in injecting drug users is around 17% nationally. The estimated prevalence of current injecting drug users in the City is 17. Public Health England estimates that there are 77 people infected with hepatitis C in the City of London, of whom 64 are current or previous injecting drug users. In 2012/13 the local needle exchange was used by 23 people, with a total of 266 packs given out. Hepatitis C testing is offered to all new clients who currently inject or who have a history of injecting. In 2012/13 the uptake of testing was 88%, compared with 73% nationally.

Sexual health Sexually transmitted infections (STIs) In total, 89 acute STIs were diagnosed in residents of the City of London in 2012 (81% in males and 19% in females). This equates to a rate of 1,201 per 100,000 residents (1,742 for males and 519 for females). Fluctuations in the rates of diagnosis and reinfection within the City from one year to another are not significant due to the small absolute numbers and low population baseline.

Chlamydia screening Since chlamydia is most often asymptomatic, a high diagnosis rate reflects success at identifying infections that, if left untreated, may have serious reproductive health consequences. Public Health England recommends that local areas achieve a testing rate of at least 2,300 per 100,000 resident 15 to 24-year-olds, a level which is expected to produce a decrease in the prevalence of chlamydia. Nationally between January and December 2012, 26% of 15 to 24-year-olds were tested for chlamydia, with an 8% positivity rate. In the City the diagnosis rate is well below the suggested threshold, although the numbers involved are small. The 2012 chlamydia diagnosis rate in 15 to 24-yearolds was 1,080 per 100,000. A total of 17% of 15 to 24-year-olds were tested for chlamydia, with eight cases diagnosed (a positivity rate of 6%).

Human Immunodeficiency Virus (HIV) In 2011, the diagnosed HIV prevalence rate in the City of London was 10.8 per 1,000 population aged 15 to 59, compared with 2.0 per 1,000 in England. A total of 62 adult residents received HIV-related care, fewer than five of whom were female. Of these, 90% were white. As regards exposure, 84% probably acquired

96

their infection through sex between men and 6.5% through sex between men and women. Where resident information was available, data showed that six adult residents (aged 15 or older) were newly diagnosed in 2011. All these individuals were male and had acquired HIV through sex between men. Between 2009 and 2011, 32% of HIV diagnoses were made at a late stage of infection. The proportion was 35% for men who have sex with men and 0% for heterosexuals. The small numbers involved mean that differences for the City are not statistically significant.

City workers The City of London’s worker population is young and predominantly male. This group is at a higher risk of STIs, and may be less inclined to access sexual health services in their home areas or from their family GPs.

Rough sleepers No prevalence data on sexual health exists for City rough sleepers. However, research identifies the sexual health needs of homeless people as a key health priority, with rough sleepers suffering from high rates of sexually transmitted diseases, including HIV.

Mental health Prevalence of mental illness It is estimated that one in four people in the UK will suffer a mental health problem over the course of a year. At any one time, an estimated one in six adults of working age experiences symptoms of mental illness that impair their ability to function. A further sixth of the population have symptoms (such as anxiety or depression) that are severe enough to require healthcare treatment. Between 1% and 2% of the population are likely to have more severe mental illnesses such as schizophrenia or bipolar affective disorder, which require intensive and often continuing treatment and care.

Depression Data on depression in City residents comes from three sources: QOF data for patients registered at the Neaman practice in the north-west of the City (which

97

the GPs compile); primary care data extracts, which are of unknown accuracy; and modelled estimates, based on the ‘types’ of people who live in the City. In 2012/13, the crude prevalence of depression recorded by the Neaman practice was 3.4% (267 individuals). Primary care data extracts for the whole City population show that 2% of residents have depression, although some modelled estimates put the prevalence of depression as high as 5%.

Severe mental illness There is no data on severe mental health conditions among residents of the City, except for those residents registered at the Neaman practice in the north-west of the area. In 2012/13, the crude prevalence of severe mental health conditions recorded by the Neaman practice was 0.8% (69 individuals).

Suicide Under the Health and Social Care Act 2012, co-ordinating and implementing work on suicide prevention is now a local authority responsibility. The City of London has three potential population groups at risk of committing suicide: residents; people who work in the City; and people who travel to the City with the intention of committing suicide from a City site, but who have no specific connection with the City. DH recently published Preventing suicide in England: A cross-government outcomes strategy to save lives. Much of this strategy focuses on what primary health services (GP practices) can do to prevent suicide; however, the vast majority of people in the City do not live there, and so are registered with GPs in other local authorities. The suicide prevention strategy identifies some effective local interventions as: ■■prevention – putting up barriers, nets, etc and providing emergency telephone numbers ■■working with planning departments and developers to include suicide risk in health and safety considerations when designing tall buildings ■■working with the media to encourage responsible reporting of suicides Local advice services have been found to be effective in preventing suicide, as they can help with debt, bereavement and wider mental health issues. In the context of the City, Toynbee Hall provides the City Advice Service, which offers information, advice and guidance to City residents and workers, as well as signposting to relevant health services.

98

City workers A total of 21% of City workers report suffering from depression, anxiety or other mental health conditions, with 33% stating that their job causes them to be very stressed on a regular basis. Those who report being very stressed several months per year are 2.6 times more likely to identify themselves as being in ‘poor health’. City workers report taking fewer than the UK average number of sick days (6.5 days per year). This suggests either that City workers are generally healthier or that they still come to work when they are ill.

Rough sleepers A national audit of the health and wellbeing of homeless people found that seven out of 10 had one or more mental health needs, a rate over twice that of the general population. Within the City, the Combined Homeless and Information Network (CHAIN) database has identified 45% of rough sleepers as having a mental health issue.

Social care for people with mental health difficulties In 2012/13 the City of London provided services to 84 adults with mental health problems, 20% of whom were aged over 65. Based on the Mental Health Minimum Data Set for 2011/12, 89.6% of adults receiving secondary mental health services in the City lived in settled accommodation. Figure 6.6 Number of adults (aged 18 to 64) with mental health problems receiving care packages per 100,000 population, 2005–13 1,400

1,200

1,000

800

Number of adults

600

400

200

0 2005/6

2006/7

2007/8

2008/9

Source: National Adult Social Care Intelligence Service

2009/10

2010/11

2011/12

2012/13

99

Case study G is a 59-year-old woman of white British origin. G met her partner T eight years ago and has been married for five years. Caring role G is the informal carer for T, who suffers from a neurodegenerative condition and is dependent on G in all areas of daily life. T is in a wheelchair and has some speech limitations, which means that G occasionally has to articulate his wishes for him. Carer needs and support G feels that being T’s informal carer can be challenging at times, as she has to live a very structured life. She acknowledges that being a fulltime informal carer has imposed restrictions on her social life and that she has lost friends who were unable to understand her caring role. G is no longer able to work full-time. She had a carer’s assessment from adult social care and was awarded a non-means-tested carer’s individual budget to aid her in her caring role. This is in addition to her Carer’s Allowance, which is a benefit entitlement from the government. She has also been provided with support from the City Carers’ Service and advice from City Advice. Despite the challenges she faces, G feels that she has found a home since meeting T and has established roots in the City. She acknowledges that being an informal carer can be difficult at times, but feels that being T’s carer has been very good for her and has enriched her life in other ways.

100

Carers Support for carers Carers are people who provide help and support to a friend or family member who, due to illness, disability or frailty, cannot manage without their support. Carers are unpaid, although they may be in receipt of benefits related to their caring role. Performing a caring role can have major implications for someone’s life: young carers can suffer a loss of education and life chances; carers of working age can see their employment opportunities limited and can suffer poverty as a result; and older carers are particularly vulnerable to the impact on health and wellbeing that caring for someone else can have. Carers play a vital role in supporting family members or friends to live independently and maintain their wellbeing. However, many carers are also frail or in poor health and so may need support themselves. According to the legislation, carers have the right to request an assessment and subsequent review of their own needs. Carers can have a joint assessment or review with the person they care for, or can request a separate assessment or review for themselves. The number of carers receiving services as a result of these assessments and reviews is an indication of the extent to which a council is working with and for carers.

Carers in the City The City Carers’ Register lists 58 known carers of clients aged over 18. According 64

to the Census 2011, 576 City residents (7.8%) have some caring responsibilities, with 121 of these carers providing over 21 hours of unpaid care per week. Although lower than the national average, this figure indicates that many people are giving care in the City who are unknown to the Carers’ Register. Since 2012, the City of London has commissioned its own City Carers’ Service (provided by Elders Voice). Both individual and group services are offered, including access to respite care. The service is also tasked with finding hidden carers. The City Carers’ Service offers outreach to carers, providing emotional support, support in accessing health and social care, and information and advice, including advice on welfare benefits. It also organises support groups with speakers on relevant subjects, outings and training sessions depending on specific need.

64 Office for National Statistics, Census 2011

101

Crossroads is commissioned to offer planned and emergency respite to carers, while City50+ is another commissioned service which targets those aged over 50. Activities include organising coffee mornings and working as a conduit to refer people on to other services – specifically focusing on carers, dementia and reducing hospital admissions. Full carers’ needs assessments are provided based on eligibility criteria. For those with a lack of means, a means-tested carer’s individual budget is available, which ranges from £150 to £3,000 per year. The adult social care service assesses the entitlement to care and support of both the carer and the cared-for. 65

The City of London Carers’ Strategy, published in 2011, recognises the significant contribution that carers make to the wellbeing of service users and residents. It sets out an approach whereby carers are able to design and direct their own support by engaging in the support plan of those they care for, and ensuring that support is tailored to their specific needs.

City workers Due to the sheer number of City workers, it is very likely that many also hold caring responsibilities. This data may become available in future Census 2011 releases.

Disability Learning disabilities In 2012/13 the City of London provided services to 15 clients with learning disabilities. In total, 86.7% (13) of these clients are living in settled accommodation. The number of clients with learning disabilities receiving care packages increased in 2011 and has since remained fairly stable (see Appendix 8). Estimates of learning disability prevalence are based on national prevalence rates with some adjustment for local demographics, which may not be reliable given the unusual profile of the City’s population. A Disability Register is currently under review, which aims to consolidate a more up-to-date profile of disability in the City. For more information about learning disabilities, see Appendix 8, ‘Learning Disabilities’.

Physical disabilities In 2012/13 the City of London provided services to 113 clients with physical disabilities, of whom 80% were aged over 65. A total of 56% of these clients

102

65 City of London Carers’ Strategy, 2011

received community-based support (not including home care). Equipment and adaptations were provided to 31 clients. Professional support was provided to 11 clients and 53 clients received direct payments to purchase their own care. The number of people receiving ongoing support from the City of London Corporation has decreased since 2005/6, with a 46% drop in the rate per 100,000 population (Figure 6.7). Figure 6.7 Adults with physical disabilities receiving care packages per 100,000 population, 2005–13 1,200

1,000

800

Number of adults

600

400

200

0 2005/6

2006/7

2007/8

2008/9

2009/10

2010/11

2011/12

2012/13

Visual impairment In 2010/11 there were nine people on the City’s Visual Impairment Register, with fewer than five registered in each category as partially sighted, blind or deaf/blind.

Accessibility The City of London Corporation actively pursues measures to adapt the environment to make it more accessible to people with disabilities. The Core Strategy sets out planning requirements for making the City’s streets, spaces and buildings accessible. Further guidance is provided by the Access Team, while the City has an Access Group to provide advice.

103

7. Later life

The health and wellbeing needs of those who are beyond working age differ significantly from those of younger groups. Most health behaviours, attitudes and exposures have already been established by later life. In addition, many people will already be living with one or more long-term health conditions. Maintaining quality of life and preventing deterioration begin to take on more importance than preventative and behaviour change activities. Preventing social isolation and providing continued independence are also key social goals.

Key findings ■■Life expectancy is expected to remain high among City residents. ■■The number of older people in the City is small but is projected to increase rapidly in the next decade. ■■Trends show that older people wish to remain living independently in their own homes for as long as possible. ■■The incidence of age-related health problems such as reduced mobility, dementia and social isolation, as well as the need for additional support and care, is likely to increase. ■■The City has been adapting to the increasing demands of the ageing population through increased provision of telehealth, measures to prevent social isolation and creation of a dementia-friendly City.

Recommendations ■■Provision for the ageing population should continue to meet the increasing demand projected over the coming decade. ■■The provision of health, social care and housing will need to become increasingly interdependent if we are to maintain independence and good quality of life for our ageing City residents.

Questions for commissioners ■■What are commissioners doing to ensure that their commissioning strategies and commissioned services are prepared for the rapid increase in older people in the City and the likely associated health needs? ■■How can commissioners creatively consider the use of new and emerging technologies and services to support older people to stay in their own homes and enable residents to have varied choices for care? ■■How well does the City of London Corporation know the likely future need for its social care services? A clear understanding of need is vital to enable social care services to be appropriate and responsive to need.

105

Older people In 2012/13, the City of London Corporation provided services to 142 clients aged over 65. Of these, 90 (63%) had a physical disability, 44 (31%) had mental health problems, fewer than five had a learning disability and seven (5%) had problems with alcohol or substance misuse or were vulnerable. Over the last three years, the number of people aged over 65 in the City receiving social care packages has declined (Figure 7.1). A survey of residents living on the Golden Lane and Middlesex Street Estates found that people on these estates had a slightly different age profile from the general profile for the City, with greater numbers of older people and high disability rates in the oldest groups (Figure 7.2). Figure 7.1 Older people (aged 65 and over) receiving care packages per 100,000 population, 2005–13 25,000

20,000

Number of adults

15,000

10,000

5000

0 2005/6

2006/7

2007/8

2008/9

Source: National Adult Social Care Intelligence Service

106

2009/10

2010/11

2011/12

2012/13

Figure 7.2 Age and disability of tenants of Golden Lane and Middlesex Street Estates

Number of residents reporting a disability

30

25

20

15

10

5

0 0–9

9–19*

20–29*

30–39

40–49

50–59

60–69

70–79

80+

* Fewer than five individuals were reported Source: City of London

107

Life expectancy In the City, both the male (83.8 years) and female (88.6 years) life expectancies are higher than the figures for England (78.6 years for males and 82.1 years for females) and the surrounding boroughs. Figure 7.3 Life expectancy for males in Hackney and the City 2006–10 (London Health Observatory (LHO)) 87 83.8 82.1 81.2

108

Hackney Central

Queensbridge

77.4

78.3

Brownswood

75.3

Cazenove

Leabridge

74.9

Wick

73.3

74.7

75.6

74.3

75.0

74.1

Hackney Downs

73.2

Chatham

75

Lordship

76.9

78.1

Kings Park

76.9

Haggerston

78

78.1

De Beauvoir

81 78.7

79.1

79.7

72

69

City of London

Springfield

Dalston

New River

Victoria

Hoxton

Clissold

Stoke Newington Central

66 Hackney

Male life expectancy at birth-years

84

Figure 7.4 Life expectancy for females in Hackney and the City, 2006–10 (LHO) 93

88.6

83.7

83.9

Springfield

Haggerston

Hoxton

Wick

85.1

Stoke Newington Central

83.5

85.0

Kings Park

83.3

84.8

Brownswood

83.1

84.8

Lordship

83.1

New River

Hackney Downs

83.1

Clissold

82.0

82.3

Chatham

81.0

81.7

Hackney Central

80.8

De Beauvoir

81

Dalston

84 83.1

Queensbridge

87

89.7

86.0

77.5

78

75

72

Cazenove

City of London

Victoria

Leabridge

69 Hackney

Female life expectancy at birth-years

90

Deaths In 2009, 41 residents of the City of London died: 19 females and 22 males. The age-adjusted rate was 309 deaths per 100,000 residents, although this figure is very variable year-on-year due to the small numbers of deaths and the small population.

109

The social prescribing pilot project In partnership with City and Hackney Clinical Commissioning Group, the City and Hackney Health and Social Care Forum is working with the London Borough of Hackney, the City of London Corporation and the voluntary and community sector to develop a system for social prescribing. Social prescribing is a process whereby GPs refer patients with social, economic, emotional, practical and/or wellbeing needs (whether or not they also have identified physical or other medical issues) to a range of local support services. These might include welfare advice, befrienders, walking clubs, art clubs and exercise groups. This process is sometimes called ‘community referral’, as activities and services are on offer locally and are mostly provided by the voluntary and community sector. A major aim of this referral system is to tackle social isolation in the elderly. The premature death rate in the City is low: in 2009, 13 City of London residents aged under 75 died. The trend is erratic due to the small number of deaths but nonetheless demonstrates a long-term decline. For more information see Appendix 9, ‘Death rates’.

Telecare and telehealth Telecare and telehealth services use technology to help people live more independently at home. They include personal alarms and health monitoring devices. Telecare and telehealth services are especially helpful for people with long-term conditions. They can help an individual live independently in their own home for longer, avoid a hospital stay or put off moving into a residential care home. In the City there are approximately 107 telecare users in general housing and 33 in sheltered accommodation. These figures regularly fluctuate dependent on need and demand. The call handling service receives between 60 and 110 calls per month. Telecare services in the City of London include a 24-hour call handling service and a mobile rapid response team who can offer visits and assistance.

110

Loneliness and social isolation Case study K is an 85-year-old man of white British origin. K is single and lives in a studio property on Golden Lane Estate. He has no surviving family or friends. Independence and health issues K does not cook but has meals in his local café. He has a condition that requires district nurses to attend daily and is on a selection of medication. He has also had physiotherapy and occupational therapy. K is otherwise independent in daily living tasks with access to a care alarm and bathing aids. He tends to find change difficult and has declined referral to the local luncheon club, although he is visited by the Barbican mobile library. Dementia condition and support K has a diagnosis of dementia and paranoia and has been known to adult social care for several years. He reports seeing people in his flat and property going missing. He telephones the City of London Police regularly and is on their Pegasus system for vulnerable residents. The local police community support officers and ward beat officer visit him, which enhances his feeling of security. K’s dementia is reported to be manageable in his home environment. He is known to the City and Hackney Mental Health Team and has had community psychiatric nurse input in the past. He is also visited monthly by support workers from the Hackney and City Alzheimer’s Society.

A report from Age UK on loneliness and isolation states that 7% of people aged 65 or over in England say they always or often feel lonely. Including those who say they are sometimes lonely, the figure rises to 33%. The relationship between isolation and loneliness is a complex one, involving social contact, health (physical and psychological) and mood. Both loneliness and isolation appear to increase with age, and among those with long-term health problems. Within the City, 2,472 households are made up of one person, with 526 of these aged 65 or over. About 58% of these older residents are women and 42% are men. In the City, the growing ageing population (see Appendix 2) suggests that loneliness and social isolation may be increasingly prevalent. In addition,

111

anecdotal evidence from housing officers and City residents suggests that the socially isolated ageing population tends to be concentrated in the north of the City, and may be ‘asset rich and income poor’.

Dementia There are estimated to be more than 67 people in the City of London with dementia, and this number is set to increase by more than 40% in the next 20 66

years. Adult social care and the local GP practice have confirmed that they currently know of 15 people living in the community and five people in nursing care, but acknowledge that there may be many more people who are not formally diagnosed or who have not accessed statutory social care. This is recognised as quite a large discrepancy. As a result, the Neaman practice is reviewing its diagnoses of patients who may have signs and symptoms of dementia as a co-morbid factor with their primary diagnosis, and are referring them to the local memory clinic for a further assessment where necessary. In 2014 the City committed to providing the best possible services to this particularly vulnerable group through its Dementia Strategy. The strategy commits the City of London Corporation to creating a ‘dementia-friendly City’, where residents and local retail outlets and services will develop a keen understanding and awareness of the disease and offer support in a respectful and meaningful way.

112

66 This data is derived from a synthetic estimate based on national prevalence rates and Census data

End-of-life care In 2010/11, over 25% of deaths among residents of the City took place at home – this was the highest average across all London boroughs and higher than the averages for London and England (Figure 7.5). Generally, more men die at home than women. Figure 7.5 Percentage of deaths taking place at home, 2008–10 (Health and Social Care Information Centre)

10

CITY OF LONDON

Islington

Westminster

Southwark

Kensington and Chelsea

Hammersmith and Fulham

Lambeth

HACKNEY

Camden

Richmond upon Thames

Hounslow

Tower Hamlets

Hillingdon

Harrow

Haringey

Greenwich

Brent

Bromley

Barking and Dagenham

Bexley

Wandsworth

Havering

Newham

Merton

Kingston upon Thames

Ealing

Lewisham

Redbridge

Waltham Forest

Barnet

Croydon

Sutton

Enfield

LONDON

0 ENGLAND

% Deaths at home

20

113

8. Healthy life This final section concentrates on those aspects of wellbeing that are most closely aligned with health and healthcare. It contains some information on disease prevalence, hospital utilisation and user satisfaction. It also covers services in social care, as well as the local voluntary and community services the City has to offer.

Key findings ■■There is potential to expand pharmacy services to meet local health needs. Many residents use community pharmacists located outside the City. Pharmacies can also be used to deliver services to City workers. ■■The City has a vibrant voluntary and community sector, as well as a Time Credits scheme, which together help to strengthen and build communities.

Residents ■■A total of 20% of City residents are registered with GPs outside the City – this has implications for how cross-border health services are provided. ■■Deaths from all cancers and from premature cancer are well below the average for London, and premature deaths from cancer have fallen markedly over the last six years. ■■Other disease prevalence estimates for residents show that there are some health inequalities between those living in Portsoken and the rest of the City. ■■Adult social care in the City has been modernised, and most users of adult social care are happy with the service they receive. ■■Introduction of the Better Care Fund may enable better joined-up working between healthcare and social care services.

City workers ■■Many City workers, particularly those in lower-paid sectors and roles, find it hard to access primary care services, as doing so requires taking time off work for appointments. ■■One-third of City workers would choose to register with a GP near work rather than one near home, if they were allowed. ■■Musculoskeletal, respiratory and mental health problems are the main health conditions reported by City workers.

Rough sleepers ■■Rough sleepers tend to have co-morbidities, and are likely to use Accident and Emergency (A&E) departments much more than the general population. ■■Rough sleepers are particularly vulnerable to infectious diseases such as tuberculosis. ■■In the City, GP registration for rough sleepers is a priority. Rough sleepers can register with two local GP practices.

Recommendations ■■Expanding pharmacy services could be an effective way to improve the health of City workers. ■■Better linkage of health and social care with community assets from the

115

voluntary sector has the potential to relieve pressures on care services, while building a more resilient community for the City’s resident population.

City workers ■■It is important to assess how primary care services for workers could be funded and resources allocated while ensuring that the level of service for residents is maintained.

Rough sleepers ■■The City should continue reducing barriers and supporting rough sleepers in accessing services. Commissioners should look to work across agencies and with other commissioners in order to develop models of care for rough sleepers.

Questions for commissioners ■■How are commissioners working with service providers in other local authorities to ensure equity of service provision for City residents? ■■Are commissioners looking at different locations and providers for public health services in order to improve the health of City workers?

Chronic disease Cancer Prevalence Data on cancer prevalence comes from two sources: QOF data for patients registered at the Neaman practice in the north-west of the City (which the GPs compile); and primary care data extracts, which are of unknown accuracy. In 2011/12 the crude prevalence of cancer recorded by the Neaman practice was 1.5% (134 individuals). This rate is relatively high due to the older population (rates are not age-standardised). Primary care data extracts for the whole of the City suggest that the prevalence of cancer might be as high as 3%.

116

Figure 8.1 Crude prevalence of cancer in the GP-registered population, 2006–12 (QOF) 2.0%

GP-registered population

1.5%

1.0%

0.5%

0.0% 2005/6

2006/7

2007/8

2008/9

2009/10

2010/11

2011/12

2012/13

Death and survival rates In the City, the annual death rate from cancer over the three years from 2007 to 2009 was an average of 15 people (43% women and 57% men). This is an agestandardised rate of 128 deaths per 100,000 population per year. Figures 8.2 and 8.3 illustrate the long-term trends in deaths from all cancers and from premature cancer (cancer affecting the under-75s). Both rates in the City are well below the average for London, and premature deaths from cancer have fallen markedly over the last six years. Figure 8.2 Long-term trend in deaths from all cancers, at all ages (Thames Cancer Registry)

Cancer deaths per 100,000 population

300

250

200

150

100

50

0 1990–94

1992–96

1994–98

1996–2000 1998–2003

2001–03

2003–07

2005–09

117

Figure 8.3 Long-term trend in deaths from premature (<75) cancer (Thames Cancer Registry) 200

Cancer deaths per 100,000 population

180 160 140 120 100 80 60 40 20 0 1990–94

1992–96

1994–98

1996–2000 1998–2003

2001–03

2003–07

2005–09

Diabetes Data on diabetes prevalence comes from two sources: QOF data for patients registered at the Neaman practice in the north-west of the City (which the GPs compile); and primary care data extracts, which are of unknown accuracy. In 2011/12, the crude prevalence of diabetes recorded by the Neaman practice was 2.4% (215 individuals). Primary care data extracts for the whole City population are similar, suggesting that diabetes affects about 3% of the City’s population. Figure 8.4

Diabetes prevalence (GP-registered population)

Prevalence of diabetes, 2004–12 (QOF)

118

6%

4%

2%

0% 2004/5

2005/6

2006/7

2007/8

2008/9

2009/10

2010/11

2011/12

Stroke and transient ischemic attack (TIA) Data on stroke and TIA prevalence comes from two sources: QOF data for patients registered at the Neaman practice in the north-west of the City (which the GPs compile); and primary care data extracts, which are of unknown accuracy. In 2011/12, the crude prevalence of stroke recorded by the Neaman practice was 1.0% (88 individuals) (Figure 8.5). Primary care data extracts for the whole City population are similar, showing that 1% of City residents are affected by stroke. Figure 8.5

Stroke/TIA prevalence (GP-registered population)

Crude prevalence of stroke/TIA in the GP-registered population, 2004–12 (QOF) 1.5%

1.0%

0.5%

0.0% 2004/5

2005/6

2006/7

2007/8

2008/9

2009/10

2010/11

2011/12

Hypertension Data on hypertension prevalence comes from two sources: QOF data for patients registered at the Neaman practice in the north-west of the City (which the GPs compile); and primary care data extracts, which are of unknown accuracy. In 2011/12, the crude prevalence of hypertension recorded by the Neaman practice was 8.4% (746 individuals). This rate has been stable for the last four years (Figure 8.6).

119

Primary care data extracts for the whole City population estimate that 10% of residents have hypertension, but that this figure might be as high as 16% in patients who are not registered with the Neaman practice (i.e. those who live in Portsoken). Figure 8.6

Hypertension prevalence (GP-registered population)

Crude prevalence of hypertension in the GP-registered population, 2004–12 (QOF) 1.5%

1.0%

0.5%

0.0% 2004/5

2005/6

2006/7

2007/8

2008/9

2009/10

2010/11

2011/12

Coronary heart disease (CHD) Data on CHD prevalence comes from two sources: QOF data for patients registered at the Neaman practice in the north-west of the City (which the GPs compile); and primary care data extracts, which are of unknown accuracy. In 2010/11, the crude prevalence of CHD recorded by the Neaman practice was 1.9% (173 individuals). This is comparable with the average for London. Prevalence has fallen slightly in the past eight years (Figure 8.7). Primary care data extracts for the whole City population are similar, showing that about 2% of residents have CHD.

120

Figure 8.7

CHD prevalence (GP-registered population)

Prevalence of CHD in the GP-registered population, 2004–12 (QOF) 1.5%

1.0%

0.5%

0.0% 2004/5

2005/6

2006/7

2007/8

2008/9

2009/10

2010/11

2011/12

Sickle cell disease There were no hospital admissions for sickle cell disease in the City in 2010/11.

City workers When asked, ‘Do you have a health problem which has lasted, or is expected to last, at least 12 months?’ City of London workers listed a range of conditions (multiple answers per respondent were allowed). Musculoskeletal, respiratory and mental health problems were the most common health conditions identified (Figure 8.8). Figure 8.8 City worker responses to the question, ‘Do you have a health problem which has lasted, or is expected to last, at least 12 months?’ Muscle, bones, joint or bad back Breathing problems (e.g. asthma or hayfever) Anxiety, depression or any mental health condition Heart disease or high blood pressure Digestive Diabetes Cancer Other Rather not say/Don’t know 0%

2%

4%

6%

8%

10%

121

12%

Infectious diseases Hepatitis C Public Health England estimates that there are 77 people infected with hepatitis C in the City of London, of whom 64 are current or previous injecting drug users. This figure is based on modelled estimates and may not reflect the City’s unusual population.

Tuberculosis (TB) The rate of TB incidence among City residents has been steadily declining over the last few years, with a small upturn between 2012 and 2013. However, these rates are based on very small numbers. Figure 8.9 TB incidence among residents of the City, Hackney and London, 2009–13 (Public Health England) 60

50

40

30

TB incidence

20

10

0 2009

2010

2011

2012

2013 (to 30 Sept)

City workers As already discussed, a significant number of City workers are migrants and some come from countries where TB is prevalent. The Health Protection Team at Public Health England is responsible for following up cases of TB in City workers and ensuring that co-workers who may have been exposed to the infection are screened. City workers who are found to have TB are usually treated by health services local to where they live.

122

Rough sleepers Rough sleepers are vulnerable to TB, with some studies showing that up to 15% of rough sleepers have past or active TB. Compliance with treatment can be a particular issue for rough sleepers. The City’s Homelessness Team works closely with Public Health England to manage active cases of TB in rough sleepers.

Health services Primary care Primary care services include the many services provided at GP practices, dentists, pharmacists and optometrists. The geographical distribution of these services in the City is shown in Figure 8.10. In addition, optometry is delivered in residents’ homes where necessary, and GPs also offer home visits to residents. Figure 8.10 Primary care services in the City

GP registrations The majority of City residents are registered with the Neaman practice in the City of London (81%), with the second largest registration being at the Spitalfields practice in Tower Hamlets (9%) (Figure 8.11).

123

Overall, 18% of residents are registered outside City and Hackney Clinical Commissioning Group (CCG); the majority of these (12%) are registered with GPs in Tower Hamlets. While the practice with the third largest registration of City residents is in Camden, only 4% of City residents are registered with a GP in Camden CCG. The Portsoken ward contains two social housing estates at Mansell Street and Middlesex Street. Some of this residential accommodation was originally in Tower Hamlets, but was transferred to the City under The City and London Borough Boundaries Order 1993. The ward’s relatively recent addition to the City means that the Portsoken area’s links to Tower Hamlets are still strong, and not all of the services in the area are provided by the City. The catchment area of the City’s only GP practice does not cover the Mansell Street and Middlesex Street Estates, meaning that residents of these two estates must register with GPs from Tower Hamlets. A Tower Hamlets GP practice currently provides services to Portsoken residents at the Green Box Community Centre, located on the Mansell Street Estate. Figure 8.11 GP registration of City residents

Source: ‘Mapping of health services in the City of London’, 2012

City workers City workers who are entitled to register with a GP must do so in their home locality. This means that many City workers, particularly those in lower-paid sectors and roles, find it hard to access primary care services, as doing so would require taking time off work to attend the appointment.

124

Research conducted with City workers showed that one-third of City workers would choose to register with a GP near work rather than one near home if they were allowed, and 82% would choose dual registration if this were to become possible. Allowing City workers to register close to work has the potential to make services more accessible, support longer-term health needs, provide more opportunities for screening and prevention, and require less time off work to access services. Research shows that City workers wish to access health services and clinics during early mornings, lunchtimes and evenings. The short waiting times for services at private sector clinics are seen as a distinct advantage; however, private services are only available for those who can afford them. NHS walk-in centres around the country have higher throughputs and longer waiting times than private clinics, but they are also open to all and free of charge. However, the only NHS walk-in clinic in the City was closed in 2010.

Rough sleepers Rough sleepers can register at the Neaman practice in the City, but most choose to register at Health E1, a specialist GP surgery for homeless people which is just outside the City. The City’s Homelessness Strategy has made GP registration a priority for rough sleepers.

Dental services There are two dental practices in the City: the Barbican Dental Centre, which offers a range of private and NHS treatments, and the specialist Barbican Orthodontic Clinic, which serves children and young people aged 0 to 18. During the period April 2010 to March 2011, residents of the City accessed NHS dental services in the neighbouring boroughs of Hackney, Tower Hamlets, Camden and Islington. The number of people living in the City of London who attended an NHS dental practice was 620: 557 of these were adults and 63 were children.

Optometry In 2009/10, NHS sight tests in the City were predominantly performed on people aged 40 or over.

125

Figure 8.12 Age profile of those receiving NHS sight tests from optometrists located in the City 1,200

Number receiving NHS sight tests

1,000

800

600

400

200

0 0–9

10–19

20–29

30–39

40–49

50–59

60–69

70–79

80–89

90–99

Age

In 2009/10, only 5% of reported NHS sight tests in the City were performed on City residents, with the rest being performed on non-residents, including 8% on people from Hackney (Figure 8.13). Figure 8.13 Residency of those undergoing NHS sight tests with optometrists located in the City

126

Pharmacies and prescribing Community pharmacies have had an important role to play in reducing health inequalities, through increasing access to health information, prevention and screening services, signposting patients to other services and supporting them to take medication. There is potential to expand pharmacy services in order to meet local health needs. There are 16 community pharmacies in the City. Essential services include dispensing NHS prescriptions, and local enhanced services include the following: ■■chlamydia screening and treatment services, targeting young people in particular ■■minor ailments service ■■weight management service, designed to help people manage their diet and exercise and maintain a healthy weight ■■emergency hormonal contraception service ■■Freedom condom distribution service ■■drug misuse services, including needle exchange and supervised consumption ■■TB treatment supervision service, supporting people with TB to adhere to therapy ■■seasonal flu vaccination service ■■stop smoking service An analysis of prescriptions issued by the Neaman practice between June and December 2011 showed the locations where prescriptions were being dispensed. As can be seen, the majority of prescriptions were dispensed from two independent pharmacies, one of which is located in Islington. Figure 8.14 Percentage usage of pharmacies by Neaman practice patients, 2011

1% 2% 3% 5% 28% 48%

1% 2% 3% 5% 28%

28%

City of London boundary

City of London Boundary

127

Case study K is a 27-year-old man currently sleeping rough in an underpass. He was born in London and was taken into care at a young age. He was placed with five different foster families and started using heroin and crack cocaine at the age of 17. Housing history K was accommodated by the City, but then evicted for a combination of rent arrears, non-engagement and hoarding, despite numerous case conferences to prevent this. He was then accommodated in a hostel, but was evicted for assault the following year. Health issues K’s drug use in one year was estimated at £100 worth of heroin and crack per day on top of methadone script. He has multiple health problems and frequently attends hospital. Other issues There have been issues of violence and domestic abuse with K’s current partner, but they continue to stay together. He has been a prolific beggar in the City since 2010. Three voluntary organisations are working with him – in addition to City Outreach, the Substance Misuse Partnership and the police – but his case is extremely complex and his behaviour persists in being very challenging.

Rough sleepers Although there is no City-specific data, the healthcare utilisation and costs of rough sleepers in the City are likely to reflect patterns seen among rough sleepers assessed in the London boroughs of Hammersmith and Fulham, Kensington and Chelsea and Westminster. The following healthcare needs and utilisation patterns were observed: ■■Secondary healthcare costs are at least five times higher for rough sleepers than for the general population. ■■Rough sleepers access A&E seven times more than the general population.

128

City and Hackney JSNA City Supplement

■ They are more likely to be admitted to hospital as emergency cases, costing four times more than elective in-patients. ■ They are four times more likely to attend out-patient health appointments (discounting ‘did not attends’) than the general population. ■ They stay in hospital twice as long as the general population. ■ They have more co-morbidity. One in five rough sleepers who has had contact with a hospital has had three or more diseases. ■ Their healthcare usage increases over time. ■ Hospital usage is highest among 30 to 49-year-old men and costs are significantly higher than for the general population. ■ Most rough sleepers have clinical conditions related to mental health, trauma and orthopaedics, the digestive system and ophthalmology. Nearly half of those rough sleepers who attend hospital use all three hospital services (out-patient, in-patient and A&E).

Better Care Fund The Better Care Fund (BCF) was announced as part of the government’s 2013 Spending Review. It brings together separate strands of funding, providing an opportunity to transform local services in order to deliver better integration of care and support, and better outcomes for individuals. The City’s BCF Plan was developed in consultation with service users, service providers, commissioners and the Health and Wellbeing Board. It will deliver the City’s vision for: ■ person-centred care and support ■ seven-day services in health and social care ■ early intervention and prevention ■ better data and information sharing to support care ■ joined-up and co-ordinated services, and support for carers In doing so, the Plan will reduce the burden on acute hospital services by supporting people to remain in, or return more quickly to, their homes. In 2014/15 the City of London will work with health partners to put in place the changes to deliver the BCF plan fully from 2015/16.

129

Social care services In 2011 the City of London held a number of consultations with service users and partners on changes to the way adult social care was to be delivered. In the wake of these consultations, the following changes were made: ■■Supported Assessment Questionnaire (SAQ) The SAQ is designed to enable adult social care staff to gather relevant information from individuals who may require support to maintain their independence and choice. ■■Resource Allocation System (RAS) RAS allocates points to propose an indicative individual budget and agree a support plan, which can be managed through a direct payment to the service user themselves or via a third party agency. ■■Service user contributions The new process requires full financial assessment and disclosure of savings, income and assets. An annual review of the individual budget, alongside a financial reassessment, is now a routine part of work with service users. ■■Adherence to the Fair Access to Care Services (FACS) eligibility criteria Under FACS there are four bands of eligibility: – Substantial/Critical: eligible for an individual budget – Low/Moderate: eligible for advice and information ■■Carers’ Strategy and carer’s individual budgets Carers are assessed through the SAQ so that their needs are addressed. The amount of financial support offered to carers has been increased. Those with Moderate eligibility receive an individual budget of £150; those with Substantial eligibility receive £750; and those with Critical eligibility receive £3,000. ■■Small grants scheme The small grants scheme was implemented to support the formation and maintenance of community groups. The scheme has provided small grants to maintain social clubs for elderly residents, as well as providing art and exercise classes for residents. ■■Service directory A comprehensive service directory has been created for service users, which forms a resource manual for those seeking to manage their individual budgets.

130

Performance data In 2011/12 the City of London carried out its first Adult Social Care User Survey. The survey had an excellent response rate of 63%. Of those who responded, 83% felt that the services they received made them feel safe and secure. In total, 74% of users felt that they had control over their daily life, and 70% of users found it easy to access information about services. In 2012/13 the City of London Corporation provided services to 224 people with a wide range of needs, both at home and in care homes. Approximately 84% of clients received services in the community. The majority of clients (63%) were older people, aged 65 or over. In this older age group, there were more women than men (58% vs 42%). In the younger (under-65) age group, there were fewer women than men (33% vs 67%).   These social care clients were 88% white, 5% Asian, 3% black and 4% of mixed or other ethnicities. Compared with the Greater London Authority ethnic profile for the City, white clients are over-represented and Asian clients are under-represented. However, the numbers are relatively small so variations do not necessarily reflect inequalities.   The graph below shows the range of social care services provided to City residents by the City of London Corporation in 2012/13. These services are dominated by clients receiving direct payments. Professional support and equipment and adaptations are also well represented. Figure 8.15 Community social care services received from the City of London Corporation, 2012/13 (some clients receive more than one service) Homecare 0 Daycare

5*

Meals 0 Short-term residential

5*

Direct payments

111 30

Professional support

32

Equipment and adaptations 17

Other 0

20

40

60

80

100

120

Number of users * Fewer than five individuals were reported

131

Case study A is a 93-year-old widower who lives alone in a City flat. He suffers from severe arthritis, which restricts his mobility. He is dependent on a walking frame both indoors and outdoors and occasionally uses a wheelchair. A was admitted to hospital after he was found by district nurses (who visit three times a week) to be suffering from dehydration and confusion. He had been so confused that he had not used his pendant alarm. He was discharged back home with help from the reablement service, with care to be provided by an agency during evenings and weekends. A reablement worker visited A one morning to discover him semi-naked, having struggled with dressing and personal care. Further investigation by the reablement worker showed that he had not been given his medication over the weekend and that the carer had not logged in. The reablement worker informed A’s GP about the medication and saw to his immediate needs before raising a safeguarding alert. Safeguarding process The allocated social worker arranged for care to be taken over by a different home care agency with immediate effect. The decision was taken to suspend any future referrals to the previous agency until systems were in place to prevent a recurrence. The agency worker who failed to attend was suspended pending further investigation and was dealt with by the agency’s disciplinary procedures. The cause was identified during the investigation as the carer taking annual leave without appropriate approval, after which the agency responded with adjustments to their policies. All care staff continue to be monitored on all bookings by telephone spot checks, and the agency is also looking into other ways of monitoring workers’ visits, which may include telephone check-in systems. A has continued to have support from his new agency without incident.

132

Direct payments Direct payments and personal budgets are designed to give people control over their lives by providing an alternative to the community social care services commissioned by councils. They offer an opportunity to increase independence and exercise choice. However, they are better suited to some individuals than others. The City of London Corporation has a duty to make direct payments where individuals express an interest and are able to manage them, with or without assistance. Some people may request support with a direct payment to organise and pay for care, in which case it is set up and delivered in the way they wish. ■■In 2012/13 the City had 111 clients in receipt of direct payments and individual budgets. Of this total, 48% had a physical disability, 40% had mental health needs, 8% had learning disabilities and 4% had substance misuse needs or were vulnerable.

Safeguarding ■■In 2012/13 there were 20 alerts, 11 referrals and 11 completed referrals to the Safeguarding Adults Board. An alert is a concern that an adult is at risk or may be a victim of abuse or neglect. A referral is when an alert (following a decision made by a manager of the Adult Social Care Team) is accepted to be a safeguarding issue and is managed through the safeguarding process. This includes referrals for City residents who are placed in residential or nursing homes outside the authority, but for whom the City still has a duty of care. Of the 20 alerts, six were for residents placed outside the City.

The voluntary and community sector There are around 350 organisations operating or based in the City, ranging from small neighbourhood groups and churches to large national charities and regional funders such as the City Bridge Trust and the various livery companies. The way the City commissions services from the voluntary and community sector (VCS), including from organisations based in the City, Hackney, Islington and Tower Hamlets, is guided by best value principles and the Local Procurement Directive. The City’s relatively small resident population and large daytime population of commuters and workers provide a unique environment for the VCS. There are many opportunities for City workers to volunteer both time and resources, particularly in the City Fringe area, and several City organisations exist to support

133

this. For example, City Action is a free service provided by the City of London Corporation which introduces City businesses to a diverse and creative range of skills-based volunteering opportunities. These opportunities are carefully matched with the objectives and interests of employees.

Time Credits Time Credits have been trading in the City since June 2012, and since then over 1,700 hours have been contributed by 180 people through 21 connected providers and community groups. The focus of the programme has been on developing Time Credits in the Portsoken ward, one of the most deprived areas of the City. The charity Spice has been liaising with the Commissioning Team to involve users in commissioning, designing and delivering services – and in training providers to adopt the Time Credits system – and is currently working with City Gateway, CSV, Recycling, Fusion, Toynbee Hall, Artizan Street Library and Community Centre and Healthwatch. Local residents are also growing in confidence and are starting to set up more community-led groups, including gardening clubs, good neighbours’ schemes, activity groups such as Zumba and sewing, and social groups for women and young people. By encouraging more people to get involved in services, local community groups and third sector organisations, Time Credits create opportunities for individuals to learn new skills, gain confidence and raise their aspirations. By spending Time Credits, individuals can try new activities and improve their health and wellbeing. Many participants have commented that, through the Time Credits Network, they have been able to try activities they could not previously afford. As a result of their increased participation, individuals have better access to peer and community support networks, and a more positive perception of their ability to contribute to the local community. Initial findings from our evaluation survey, carried out a year after rollout, show that 31% of people involved with Time Credits have never previously volunteered within their community. In total, 62% feel that the scheme is helping to improve their quality of life.

134

135

Appendices

Appendix 1: Data limitations Resident data City resident-specific data has always been challenging to obtain and report due to the small numbers involved; this makes it difficult to compare with local and national indicators. Historically, health-specific data has been aggregated with data for Hackney due to pooled budgets.

Census 2011 Data on the demographics of residents is available from the Census 2011. However, due to the small numbers living in the City, many reported figures are not statistically significant. This means that the depth of analysis is limited.

Health service performance data Most of the reported data for health service utilisation and health outcomes is aggregated with the data for Hackney. This is a challenge for the City, as without the disaggregated figures it is difficult to decipher whether any trends observed truly represent the City population or are mainly a reflection of Hackney’s population.

Social care service performance data Most social care data is collected from the City’s Community and Children’s Services Team. Similar challenges exist, i.e. figures are too small to report meaningfully.

Early life and childhood data Data covering education comes direct from the one primary school in the City, Sir John Cass’s Foundation Primary School. Early years data is kept with the Education and Early Years or Commissioning and Performance Teams in the City’s Community and Children’s Services Department, or may come from nationally monitored government sources such as the school census and early years census. Similar challenges exist, i.e. figures are too small to report meaningfully.

Housing data Most of this data is derived from the Census 2011 and is compiled by the City’s Department of the Built Environment.

137

City worker data In October 2013, a new release of Census 2011 data estimated the population and characteristics of the workday population across England and Wales. This Census intelligence is the first of its kind, and is of particular importance to the City of London as the City’s workday population is 56 times higher than its resident population. Two independent reports have also been commissioned to gain insights into the health needs of City workers: The Public Health and Primary 67,68

Healthcare Needs of City Workers and Insights into City Drinkers.

Census 2011 The workday population of an area is defined as ‘all usual residents aged 16 and above who are in employment and whose workplace is in the area, and all other usual residents of any age who are not in employment but are resident in the area’. Those excluded from this definition are: ■■those with a place of work in England and Wales who are not usually resident in England and Wales 69

■■short-term residents

The Public Health and Primary Healthcare Needs of City Workers The City of London Corporation, in conjunction with NHS North East London and The City, appointed the Public Health Action Support Team CIC to undertake research into the current and future public health and primary healthcare needs of City workers. The research and subsequent report were based on a mix of qualitative and quantitative methods, including a review of existing data and street- and webbased surveys of City workers at all levels from senior management to entry level.

Insights into City Drinkers This report was commissioned by the City of London Substance Misuse Partnership to gain an insight into the prevalence and nature of alcohol consumption among City workers and identify segments within the community of City workers who could be targeted with public health information about the risks associated with consuming alcohol.

138

67 The Public Health and Primary Healthcare Needs of City Workers (2012) 68 Insights into City Drinkers (2012) 69 Office for National Statistics (2013) The Workday Population of England and Wales: An Alternative Census 2011 Output Base

The report defined alcohol misuse as drinking at ‘increasing’ or ‘higher risk’ levels as identified by a validated screening tool. Alcohol misuse in itself does not infer problematic drinking, although those drinking at higher risk levels are likely to be experiencing harms, including possible dependency.

Rough sleeper data CHAIN database The main source of data for rough sleepers in the City is the Combined Homelessness and Information Network (CHAIN) database. The CHAIN database is commissioned and funded by the Greater London Authority (GLA) and managed by Broadway. It records information about contacts and work done with rough sleepers and members of the wider street population in London. Outreach teams, hostels, day centres and a range of other homelessness services across London access and update the system. City-level data exists for some basic demographic details of rough sleepers, such as age, sex and ethnicity.

Rough sleepers: health and healthcare needs A report by NHS North West London entitled Rough sleepers: health and healthcare provides evidence of the health needs of rough sleepers where detailed City-specific data does not exist.

139

Appendix 2: Demographics Table 9.1 Projected population age groups in the City to 2037, with percentage rise over the previous five years (numbers rounded to nearest 100) The City

Year 2007 2012 2017 2022 2027 2032 2037

0–4 N (% rise) N (% rise) N (% rise) N (% rise) N (% rise) N (% rise) N (% rise)

5–19

20–65

>65

All

300

600

(22.2)

(–0.7)

5,900

900

7,600

(3.6)

(4.4)

(3.9)

300

600

5,700

1,000

7,600

(–7.2)

(4.9)

(–2.1)

(10.9)

(–0.2)

300

600

6,000

1,200

8,100

(8.2)

(8.1)

(4.4)

(17.3)

(6.5)

300

700

6,200

1,300

8,400

(–0.8)

(7.7)

(2.7)

(11.3)

(4.3) 8,700

300

700

6,300

1,500

(–0.8)

(4.4)

(2.0)

(10.1)

(3.4)

300

700

6,300

1,600

9,000

(–0.4)

(0.3)

(1.0)

(13.2)

(2.9)

300

700

6,400

1,800

9,200

(0.4)

(–0.4)

(1.2)

(9.6)

(2.6)

Source: GLA

Figure 9.1 Intercensal population growth (NB: 2001 populations may be underestimated in some areas)

This product includes mapping data licensed from Ordnance Survey with the permission of HMSO. © Crown copyright 2013. All rights reserved. Licence number 100019635. 2013. © Bartholomew Ltd. Reproduced by permission, HarperCollins 2012.

140

Figure 9.2 Percentage of population who were not born in the UK

This product includes mapping data licensed from Ordnance Survey with the permission of HMSO. © Crown copyright 2013. All rights reserved. Licence number 100019635. 2013. © Bartholomew Ltd. Reproduced by permission, HarperCollins 2012.

141

Appendix 3: Ethnicity Figure 9.3 Ethnicity in the City: percentage of residents who are white

This product includes mapping data licensed from Ordnance Survey with the permission of HMSO. © Crown copyright 2013. All rights reserved. Licence number 100019635. 2013. © Bartholomew Ltd. Reproduced by permission, HarperCollins 2012.

Figure 9.4 Ethnicity in the City: percentage of residents who are black

This product includes mapping data licensed from Ordnance Survey with the permission of HMSO. © Crown copyright 2013. All rights reserved. Licence number 100019635. 2013. © Bartholomew Ltd. Reproduced by permission, HarperCollins 2012.

142

Figure 9.5 Ethnicity in the City: percentage of residents who are Asian

This product includes mapping data licensed from Ordnance Survey with the permission of HMSO. © Crown copyright 2013. All rights reserved. Licence number 100019635. 2013. © Bartholomew Ltd. Reproduced by permission, HarperCollins 2012.

Figure 9.6 Ethnicity in the City: percentage of residents who are of mixed/multiple ethnicity

This product includes mapping data licensed from Ordnance Survey with the permission of HMSO. © Crown copyright 2013. All rights reserved. Licence number 100019635. 2013. © Bartholomew Ltd. Reproduced by permission, HarperCollins 2012.

143

Appendix 4: Religion Figure 9.7 Main religions in the City: percentage of residents who are Christian

This product includes mapping data licensed from Ordnance Survey with the permission of HMSO. © Crown copyright 2013. All rights reserved. Licence number 100019635. 2013. © Bartholomew Ltd. Reproduced by permission, HarperCollins 2012.

Figure 9.8 Main religions in the City: percentage of residents who are Jewish

This product includes mapping data licensed from Ordnance Survey with the permission of HMSO. © Crown copyright 2013. All rights reserved. Licence number 100019635. 2013. © Bartholomew Ltd. Reproduced by permission, HarperCollins 2012.

144

Figure 9.9 Main religions in the City: percentage of residents who are Muslim

This product includes mapping data licensed from Ordnance Survey with the permission of HMSO. © Crown copyright 2013. All rights reserved. Licence number 100019635. 2013. © Bartholomew Ltd. Reproduced by permission, HarperCollins 2012.

Figure 9.10 Main religions in the City: percentage of residents with no religion

This product includes mapping data licensed from Ordnance Survey with the permission of HMSO. © Crown copyright 2013. All rights reserved. Licence number 100019635. 2013. © Bartholomew Ltd. Reproduced by permission, HarperCollins 2012.

145

Appendix 5: Languages Figure 9.11 Percentage of households in the City with no speakers of English as a main language

This product includes mapping data licensed from Ordnance Survey with the permission of HMSO. © Crown copyright 2013. All rights reserved. Licence number 100019635. 2013. © Bartholomew Ltd. Reproduced by permission, HarperCollins 2012.

146

Appendix 6: Road casualties In the City, 58 people were killed or seriously injured on the roads in 2012, an increase of 18% on the previous year. With smaller numbers in the City, there is even more year-on-year variability in this data (Table 9.2). However, since 2003 the long-term trend on a three-year rolling average shows a generally consistent number of casualties (Table 9.3). The unusual resident population in the City makes it inappropriate to present the road casualty figures in direct comparison with those for neighbouring boroughs. Table 9.2 Road casualties by road user type, 2012 (DfT) City of London

London

England

(N=58)

(N=3,022)

(N=21,630)

Pedestrian

33%

44%

31%

Pedal cycle

45%

23%

16%

Motorcycle

16%

21%

22%

Car

3%

16%

35%

Bus or coach

3%

3%

1%

Van/light goods vehicle

0%

1%

1%

HGV

0%

0%

1%

Figure 9.12 Three-year rolling average of people killed or seriously injured in the City, 2003–12 (DfT) 60

50

47.7

49.3

50.7

53.3 48.3

44.0

49.3 46.0

45.3

Crude rate per 100,000 people

41.3

40

30

20

10

0 2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

147

City and Hackney JSNA City Supplement

Appendix 7: Families and households Figure 9.13 Household structure in the City: percentage of couples without children

This product includes mapping data licensed from Ordnance Survey with the permission of HMSO. © Crown copyright 2013. All rights reserved. Licence number 100019635. 2013. © Bartholomew Ltd. Reproduced by permission, HarperCollins 2012.

Figure 9.14 Household structure in the City: percentage of lone parent households

This product includes mapping data licensed from Ordnance Survey with the permission of HMSO. © Crown copyright 2013. All rights reserved. Licence number 100019635. 2013. © Bartholomew Ltd. Reproduced by permission, HarperCollins 2012.

148

Figure 9.15 Household structure in the City: percentage of single-person households

This product includes mapping data licensed from Ordnance Survey with the permission of HMSO. © Crown copyright 2013. All rights reserved. Licence number 100019635. 2013. © Bartholomew Ltd. Reproduced by permission, HarperCollins 2012.

Figure 9.16 Household structure in the City: percentage of other households

This product includes mapping data licensed from Ordnance Survey with the permission of HMSO. © Crown copyright 2013. All rights reserved. Licence number 100019635. 2013. © Bartholomew Ltd. Reproduced by permission, HarperCollins 2012.

149

Appendix 8: Learning disabilities The only general practice data in the City is for those residents registered at the Neaman practice in the north-west of the area. In 2011/12, the prevalence of learning disability recorded by the Neaman practice was 0.1% (fewer than five individuals). Figure 9.17 Adults with a learning disability receiving care packages per 100,000 population, 2005–13 400

300

200

100

0 2005/6

2006/7

2007/8

2008/9

2009/10

2010/11

2011/12

2012/13

Source: NASCIS

Figure 9.18 Prevalence of recorded learning disabilities in GP-registered populations over

Learning disabilities prevalence (GP-registered)

time (QOF)

150

0.3%

0.2%

0.1%

0.0% 2006/7

2007/8

2008/9

2009/10

2010/11

2011/12

Appendix 9: Death rates Figure 9.19 Age-adjusted death rates (males) per 100,000 population, 2000–09

Age-adjusted deaths per 100,000 population

(National Centre for Health Outcomes Development (NCHOD)) 1,200

1,000

800

600

400

200

0 2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2008

2009

Figure 9.20 Age-adjusted death rates (females) per 100,000 population,

Age-adjusted deaths per 100,000 population

2000–09 (NCHOD) 1,200

1,000

800

600

400

200

0 2000

2001

2002

2003

2004

2005

2006

2007

151

Figure 9.21 Age-adjusted premature (<75) death rate (males) per 100,000 population, 2000–09 800

600 500 400 per 100,000 population

Age-adjusted premature deaths

700

300 200 100 0 2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

Figure 9.22 Age-adjusted premature (<75) death rate (females) per 100,000 population, 2000–09 800

600 500 400 per 100,000 population

Age-adjusted premature deaths

700

300 200 100 0 2000

152

2001

2002

2003

2004

2005

2006

2007

2008

2009