Director of Public Health report 2022

1. Foreword

Welcome to my fourth annual report as Director of Public Health, but my first for the whole of Greater Lincolnshire. Lincolnshire and neighbouring authorities of North and North East Lincolnshire have faced huge public health challenges over the past few years in steering residents through the Covid-19 pandemic as safely as possible.

As we have emerged more fully from the restrictions that the pandemic brought to us all, we have faced new challenges, not least the mental wellbeing and other health related issues arising from periods of lockdown. And new concerns have arisen such as the cost of living challenge brought about by the economic crisis.

Over recent years, previous annual reports have centred on themes such as the burden of disease, response to the pandemic and the impact of Covid-19 on children and young peoples’ health and wellbeing. The Chief Medical Officer’s annual report for 2021 highlighted coastal communities as having some of the worst health outcomes in England and the lack of data and understanding of the different communities in areas which would help plan local strategies and improve outcomes for health. Both Lincolnshire and North East Lincolnshire were “coastal case studies” in Professor Whitty’s report.

Greater Lincolnshire typically has large areas of rural land and urban centres of differing sizes. So having analysed local data, this report identifies the four types of community we have – urban centre, urban industrial, coastal community and rural and market town – and the differences and opportunities for health and wellbeing.

There are significant challenges for preventing ill health and improving life expectancy across Greater Lincolnshire. Each community has different characteristics and opportunities that lead to different health outcomes. But the challenges can also have common themes
across the region. Poor housing and fuel poverty require different solutions in urban and rural areas but is a consistent problem. The lack of a teaching hospital means recruitment and retainment of a health and care workforce is a challenge over all of Greater Lincolnshire, although it is felt more acutely in coastal strips. Poor air quality not only affects urban areas but agricultural air pollution is also a growing concern.

The report sets out how different health needs in the four types of community need different approaches. The local environment and its assets also need to be harnessed to improve health and wellbeing in our communities. We live in a beautiful, green and blue county and we should maximise the health and wellbeing benefits of being outdoors in the countryside and along our coastline and rivers.

There are also ways in which we can maximise training opportunities and recruitment to health and care, flexing the workforce to improve health and wellbeing and the support available. By developing a better understanding of the complexity of our local communities we can target and tailor our approach to prevention and treatment which meets the needs of local people.

Finally, I’d like to acknowledge and thank all of those who have supported the writing and production of this year’s Director of Public Health Annual Report.

Derek Ward
Director of Public Health for Greater Lincolnshire

2. Introduction

In this Annual Report, we have analysed local data and identified four types of community across Greater Lincolnshire. In the following pages we will describe the four types of community and highlight key challenges and opportunities for health and wellbeing, which vary across the different places. We hope this fresh perspective will add value to the work of those supporting health and wellbeing, and delivering health and care services, across Greater Lincolnshire.

Coastal communities have some of the worst health outcomes in England, including low life expectancy and high rates of major diseases. In 2021, the Chief Medical Officer (CMO) highlighted the challenges of coastal communities in his Annual Report, including case studies on coastal communities in Lincolnshire and North East Lincolnshire. The report identified some of the reasons for inequalities and set out a range of recommendations to improve outcomes (DHSC, CMO Annual Report, 2021).

An important challenge noted by the CMO is the lack of data and understanding at this geography to help plan national and local strategies to improve outcomes. The Coastal Communities All Party Parliamentary Group (APPG) agreed in June 2022 that a coastal strategy is needed to address inequalities in education, health, and housing in coastal areas.

In addition to 50 miles of coastline, Greater Lincolnshire has large expanses of rural land and urban centres of different size and make-up. There are some obvious geographic distinctions between these places and each has different challenges and opportunities when
it comes to health and wellbeing. Some are subtle differences, for example proximity to neighbouring service centres, which if better understood will help us to promote health, reduce inequalities and provide services to those who need them. Until now, there has been limited work to explore the main characteristics of these different communities and what those characteristics mean for health and wellbeing, and service delivery.

2.1 The four community types in Greater Lincolnshire

To classify communities, we used small geographies (known as Lower Super Output Areas or LSOAs) to segment areas according to key characteristics. Those key characteristics included features such as building density, industrial make-up, and proximity to the coastline. We have distilled this complex landscape into four “summary-type” models as we describe below. Clearly the geography of the county is far more complex, but to help planning and service delivery we think it is important to simplify whilst still highlighting the key differences.

The four types of community identified across Greater Lincolnshire are:

  • Urban centre
  • Urban industrial
  • Coastal community
  • Rural and market town.

Each type, and the challenges and opportunities for health and wellbeing, are described in more detail in the chapters that follow.

In summary, urban centre communities can be categorised as those where building density is highest. Urban industrial communities also have a high building density but, in addition are characterised by their links to heavy industry such as electricity generation, gas, steel, mining, and quarrying, with a low amount of agricultural work, financial, professional, and scientific services. Coastal communities are those directly situated on the coast, with local business dominated by accommodation, leisure, and food services. The remaining areas are classified as rural and market town communities. See Figure 1 below for a map showing the different communities.

Whilst this work has identified distinct geographies with different characteristics, it is important to note that many places have features of more than one type of area.

The types are intended to provide greater understanding of the challenges involved in improving health and delivering services across an area as diverse as Greater Lincolnshire.

Areas may fall between two types and have characteristics of either, or both, depending on their connections. In some instances, an area may have strong linkages with a neighbouring category which changes the challenges and opportunities in that community. A judgement should be made of the most important factors when considering each community, to apply the findings to strategy development and the planning of services.

To understand the main differences between, and typical natures of, each type of community, only the most central LSOAs for each category were used in statistical analyses. The LSOAs used in analyses are shown in Figure 2.

Map of greater Lincolnshire showing main towns including Lincoln, Grimsby, ScunthorpeFigure 1: The four types of community in Greater Lincolnshire and where they are found

Lower super output areas map
Figure 2: Lower Super Output Areas utilised in category analyses

3 Urban centres

Urban centres in Greater Lincolnshire – places such as Lincoln, Grantham, and Boston – provide a range of services to surrounding communities as well as significant employment opportunities and transport linkages. Out of a total population in Greater Lincolnshire of around 1.1 million people, an estimated 325,000 live in urban centres. They are often attractive places to live and work because of the cultural, heritage and economic benefits, which mean large numbers of people choose to live in these communities. There are pockets of strong employment, coupled with low social mobility in places. Urban centre communities are younger than average, made up of an economically active population with lower-than-average levels of deprivation and living in good housing. These communities have good access to community and health services.


(There is an overlap between those who are aged 0-19 and 16-64).

  • 23% are aged 0-19 years
  • 63% are working age (16 to 64 years)
  • 19% are older adults (65+).


  • 15% of children live in low income households
  • 11% of people receive pension credit
  • 15 % of people receive universal credit.


  • 71% of people are economically active (People not in employment who have not been seeking work within the last 4 weeks and/or are unable to start work within the next 2 weeks).

Of people in employment:

  • 27% work in process, plant or machine operative roles
  • 21% work as mangers, directors or senior officials.


  • 59% at Key Stage 4 achieve a 4+ in English and Maths
  • 4 in 10 young people participate in higher education
  • 25% of adults hold no qualifications.

Aerial view Boston

Aerial view of Boston

Lincoln is a regional service sector hub, with dominant employment opportunities in public services across local government and the NHS. The retail, heritage and cultural offer in the city is also strong, bucking the trend of high street decline in similarly sized towns and cities in the East Midlands. The city has a particularly young demographic due to development and investment in the University of Lincoln, and together, the University of Lincoln and Bishop Grosseteste University attract approximately 16,000 students.

Grantham has a strong manufacturing base, although employment is dominated by public services, food, and logistics. The town is well connected to national infrastructure, intersected by both the A1 and the East Coast mainline. The strategic location of Grantham has led to recent investments to help grow the town, such as the Grantham Southern Relief Road, which will connect the A52 to the A1, bypassing the town centre and creating significant opportunity for development space.

Boston serves as a hub to the nationally important food sector, and therefore food production, haulage and logistics are the key employment sectors in the town. A large proportion of the population is employed in agency activities, servicing the food and land- based sector. Boston also has a large population of first and second generation migrant workers, particularly from Eastern Europe. As a result, Boston’s population has grown more quickly than other towns in Lincolnshire.

With a lower-than-average skills level, employment and wages pose significant risks to the town. Boston Borough is ranked as the most deprived of all local authorities in England in the ‘Skills’ domain of the 2019 Index of Multiple Deprivation (Department for Levelling Up, Housing and Communities & Ministry of Housing, Communities and Local Government, 2021). It has a more limited sectoral make up compared to Lincoln and Grantham. Levels of entrepreneurialism are low resulting in a relatively ‘static’ economy. The town centre is attractive, with significant cultural assets; however, infrastructure is a major challenge, particularly given the large flows of goods movement from the food sector and the Port of Boston into the national network.

Urban centre communities have good access to health services. In Greater Lincolnshire, urban centres have above average access to general practice, pharmacy and hospitals using public or private transport and walking. However, health problems like obesity, respiratory problems, cancer, and diabetes are made worse by unhealthy living and working conditions, inadequate green space, and noise and air pollution (e.g. from traffic congestion and industry). Safe space for walking, cycling and active living can be more limited in urban centres, discouraging healthy behaviours such as active travel.

Overall, urban centres have lower than average rates of elective and emergency hospital admissions. However, hospital admissions due to some specific causes such as cancer and emergency admissions due to falls are higher in urban centres (NHS Digital, Hospital Episode Statistics, 2022). Mortality rates are higher than average in urban centres than across Greater Lincolnshire. The highest all-age disease specific mortality rates are cancer (282 deaths per 100,000 population) and cardiovascular disease (CVD) (272.4 deaths per 100,000 population).

Additionally, the all-age suicide rate is also higher than average, although this difference is not statistically significant (NHS Digital, Civil Registration Mortality data, 2022).

The Index of Multiple Deprivation (IMD) is a measure of small area deprivation in England. IMD divides England into 32,844 small areas (average population 1,500 people/650 households) and ranks them from 1 (most deprived) to 32,844 (least deprived). For each of the areas of life presented here (e.g. income, crime, etc), the % represents the number of small areas in this type of community that fall into the 20% most deprived nationally. A higher percentage than 20% means there is more deprivation than the average for England.

16% of small areas in urban centres are in the 20% most deprived nationally:

  • Income – 18%
  • Employment – 19%
  • Education and skills – 28%
  • Crime – 6%
  • Barriers to housing – 6%
  • Living environment – 17%
  • Health and disability – 17%
Index of multiple deprivation 3

Key challenges for urban centre communities

Within urban centre communities, key challenges include:

  • Clustering of people from vulnerable groups, usually in the most deprived areas where there are fewer opportunities and more challenges around access to services, work, and health literacy. Areas of deprivation and affluence often sit closely alongside each other and so the geographical scale of analysis matters when targeting support and initiatives.
  • Over recent years Boston has seen an influx of Eastern European migrant workers, and the agri-food industry in the surrounding rural area is reliant on this workforce. There have been some issues with community cohesion, as well as instances of exploitation of migrant workers defined as modern day slavery.
  • In some areas, overcrowding can be an issue with concentrations of houses of multiple occupation (HMOs) in the private rented sector. Boston and Lincoln also have the highest number of homeless people and rough sleepers in Lincolnshire. Rough sleeping is known to lead to a significant reduction in life expectancy. The homeless problem is exacerbated where people have no recourse to public funds due to not having settled status in the United Kingdom.
  • The risk of outbreaks of infectious diseases is higher in urban, overcrowded environments; for example, as observed through the Covid-19 pandemic. Health conditions such as Tuberculosis are more common in urban centres and the spread of such infectious diseases is likely to be exacerbated by overcrowded living conditions and rough sleeper congregations on the streets.
  • Urbanisation is linked to high rates of depression, anxiety, and mental ill health, and is a growing People living in urban areas can suffer from social isolation even though they live near other people. Students, young professionals, and migrant workers who have re-located to urban centres are often distanced from their families and usual support networks, and so are at increased risk.
  • Urban populations are among the most vulnerable to climate change, experiencing higher temperatures due to the effect of large concrete expanses and lack of green cover (known as urban heat islands). This is something made more acutely obvious during the heatwaves of summer 2022. Parts of Lincoln and Boston are also at risk from fluvial flooding (where rivers, lakes, and streams overflow).

Key opportunities for urban centres

  • Training opportunities at undergraduate and postgraduate level are limited due to the lack of teaching hospitals in Greater Further opportunities could be explored to help seek further investment in a teaching hospital that could help to overcome the challenges presented in the recruitment and retention of a health and care workforce, such as The Campus for Future Living planned in Mablethorpe.
  • Increase awareness of opportunities for people to connect and create meaningful community relations and interactions to reduce isolation and increase the feeling of belonging to benefit people’s mental health and wellbeing. Continued promotion and development of the Connect to Support Lincolnshire directory of services and community assets would support this.
  • Expanding accessible green space and active travel routes would improve health and wellbeing through the reduction of vehicle traffic and would also increase healthy behaviours such as physical activity.
  • Traffic congestion in urban areas can lead to longer journey times and contribute to air and noise Three of the air quality management areas across Greater Lincolnshire are in Lincoln, Boston, and Grantham. There is an opportunity to support more research into air pollution, particularly how to monitor and tackle particulate air pollution from industries and traffic.
  • There should be consistent and concerted use of health impact assessments for new developments (urban extensions) and regeneration schemes. These should consider the potential to exacerbate inequalities between these and unimproved communities.


Urban centre communities are younger than average, made up of an economically active population with lower-than-average levels of deprivation usually living in good housing. These communities have good access to community and health services. However, health outcomes in some domains are worse, particularly cancer, cardiovascular disease, and suicide. Reducing environmental challenges such as air pollution, poorer access to green space and the high density of fast-food outlets would have a significant impact on the health and wellbeing of urban centre communities.

4. Urban industrial centres

Characterised by heavier industry and industrial heritage, including oil, gas, chemicals, steel and mining, urban industrial centres are another ‘type’ of community identified in Greater Lincolnshire. The urban industrial area of Greater Lincolnshire centres around the three towns of Scunthorpe, Grimsby and Gainsborough. An estimated 253,000 people live in urban industrial communities. The heavier industrial base (as well as the industrial heritage) influences the local culture, the types of employment available and the skills needed to take up those jobs, and this is reflected in the health challenges faced. As in other urban centres, there are pockets of strong employment growth, but in urban industrial centres higher levels of economic inactivity and low social mobility are more pronounced.

These areas have a younger than average age profile, with over 60% of the population aged under 50 years and almost a quarter under 19.


(There is an overlap between those who are aged 0-19 and 16-64).

24% are aged 0-19 years
61% are working age (16 to 64 years)
19% are older adults (65+).


27% of children live in low income households
15% of people receive pension credit
20 % of people receive universal credit.

Port of Immingham
Aerial view of the Port of Immingham


68% of people are economically active (People not in employment who have not been seeking work within the last 4 weeks and/or are unable to start work within the next 2 weeks).

Of people in employment:

31% work in process, plant or machine operative roles
18% work as mangers, directors or senior officials.


58% at Key Stage 4 achieve a 4+ in English and Maths
3 in 10 young people participate in higher education
29% of adults hold no qualifications.

Although their expansion was driven by different industrial drivers – steel for Scunthorpe, port trade and engineering for Gainsborough, and fishing, as well as imported and exported goods, for Grimsby – in modern times all three towns face deep seated socio-economic challenges following rapid de-industrialisation. In many communities, unemployment and economic inactivity is high with low aspiration amongst communities. The Humber bank is the single most polluting cluster in the whole of the UK, connected to 25% of the UK’s energy generation. This means that the area has a major role to play in reaching net zero and big economic opportunities around decarbonisation.

Significant levels of investment in the area are anticipated over the coming years making the Humber a major hub for renewables in the UK.

Urban industrial areas are dominated by single people renting low-cost homes in the short- term, families with limited resources, and elderly people. Levels of deprivation are high, much higher than in urban centre communities and rural and market towns. Educational outcomes are worse than average for Greater Lincolnshire, with fewer children achieving a Level 4 in English and Maths at Key Stage 4 and a lower-than-average proportion of young people participating in further education. Grimsby and the surrounding areas have among of the lowest levels of qualifications in the country. Almost a third of the population is employed in process, plant, and machine operative occupations – the highest across Greater Lincolnshire (ONS, 2011 Census, 2022).

Overall, inequalities in healthy life expectancy are stark, affecting many of the communities living closest to the docks in Grimsby and Scunthorpe, and Gainsborough’s most urban areas. Within Scunthorpe and Grimsby, there are general hospitals supporting the local and surrounding populations with acute care. These hospitals also serve some residents from neighbouring rural areas of Lincolnshire. They are also well served by GP surgeries, and pharmacy provision, however the need for specialist care can result in referral to nearby cities such as Hull, or Sheffield. In comparison, residents of Gainsborough will typically travel to Lincoln for acute hospital care.

Urban industrial centres typically present higher rates of both elective and emergency hospital admissions compared to the wider Greater Lincolnshire population. Hospital admissions due to liver disease are highest here, and admissions due to respiratory disease, cardiovascular disease, and substance misuse are all also higher than average.

Rates of admissions due to cancer are lower- than-average, but cancer mortality rates are significantly higher, which may suggest issues around late diagnosis. Beside cancer, urban industrial areas also have higher mortality rates from cardiovascular, liver, and respiratory disease, as well as above average all-cause mortality rates (NHS Digital, Civil Registration Mortality Data, 2022).

The Index of Multiple Deprivation (IMD) is a measure of small area deprivation in England. IMD divides England into 32,844 small areas (average population 1,500 people/650 households) and ranks them from 1 (most deprived) to 32,844 (least deprived). For each of the areas of life presented here (e.g. income, crime, etc), the % represents the number of small areas in this type of community that fall into the 20% most deprived nationally. A higher percentage than 20% means there is more deprivation than the average for England.

42% of small areas in urban industrial centres are in the 20% most deprived nationally:

  • Income – 43%
  • Employment – 43%
  • Education and skills – 47%
  • Crime – 50%
  • Barriers to housing – 1%
  • Living environment – 23%
  • Health and disability – 33%
Index of multiple deprivation 4

Key challenges for urban industrial communities

Within urban industrial communities, key challenges include:

  • Older terraced houses in these towns are more likely than housing in other areas to be poorly maintained, resulting in damp or mould. Often also poorly insulated, these properties can be difficult to heat in winter and vulnerable to extremes of heat in summer (Tunstall, 2013). Increasingly available to residents as short-term private lets, such properties and the associated ‘churn’ of residents moving in and out of the area, can generate instability in the local population (e.g. affecting personal support networks) and pose a challenge for continuity of services for residents with health or care needs (USCREATES, 2017).
  • Urban industrial communities are exposed to higher levels of air pollution from traffic or adjacent industry (Environment Agency, 2021). Two Air Quality Management Areas (AQMAs) are currently in action, one within central Grimsby and the other within Scunthorpe, for Nitrogen Dioxide (NO2) and particulate air pollution respectively (Defra, 2022).
  • The environment is vital in supporting healthy living; however, urban industrial areas have a higher concentration of amenities such as betting shops and fast-food restaurants, as well as poorer access to green open spaces. Rates of anti-social behaviour are higher and litter is much more common, which can affect physical activity levels and reduce mental wellbeing and social connectivity (Glasgow Centre for Population Health, 2013).
  • Although physical access to healthcare services is better than in other communities across Greater Lincolnshire, potential barriers remain, such as the ability to attend appointments during the working day due to working long hours or zero hours contracts, as well as educational These potential barriers are interrelated with the social determinants of health, as well as a lack of system knowledge, and these factors are likely to influence a person’s ability to access healthcare in a timely way (Ensor, et al. 2004).
  • Geographic isolation combined with poor transport connectivity can make access to employment opportunities in other areas more Many younger adults move away from home to university or for work and never return to the area. There are enormous challenges within health and social care, in particular the recruitment of professional staff in healthcare with numerous long-term vacancies and considerable agency dependence at the local hospitals.

Key opportunities for urban industrial communities

There are also important advantages and opportunities for our urban industrial areas:

  • Northern Lincolnshire is uniquely positioned to be at the centre of growth in offshore wind and green energy The ports of Grimsby, Immingham and Killingholme are collectively amongst the biggest ports by tonnage in the UK. The Humber has been made a Freeport which should facilitate the attraction of inward investment to build new facilities (such as manufacturing or research and development), with the likely accompaniment of jobs in the area. The local economy needs stronger foundations and the right support to fully exploit these growth industries and integrate them into the wider economy and community (ultimately translating into better living standards for people in the most deprived neighbourhoods).
  • Levelling Up funding has the potential to dramatically improve currently under- utilised, and in parts run down, town In Grimsby major plans are underway to reconnect the “Top Town” area, which includes the Freshney Place shopping centre, to the waterfront areas of the town. This development will include a new cinema, leisure facilities and revitalised indoor market. The potential for developing new healthcare facilities within existing empty town centre buildings are also being explored. The transformation of Scunthorpe town centre as part of the Scunthorpe Town Deal will seek to reduce the number of larger unoccupied shops to create a positive future for many more independent businesses and add jobs in the town centre. There are also plans to revolutionise transport and travel across Barton and Brigg.


Urban industrial communities, like urban centres, are younger than average and have good access to services and support infrastructure. However, urban industrial communities are particularly challenged by historically embedded, extensive deprivation. There are fewer opportunities for higher education in urban industrial centres and the economy is predominantly focused on heavy industry and plant/process operation occupations. This contributes to preventable ill health and early mortality. However, there are some important opportunities on the horizon for our urban industrial communities and it is vital that we work together across sectors to make the most of these inward investment opportunities.

5. Costal communities

From the Humber Estuary to the north and the Wash in the south, Greater Lincolnshire has more than 50 miles of coastline. The coastline is diverse, with coastal resort towns that attract tourists and day trippers (such as Skegness and Mablethorpe) alongside rural coastal communities such as Ingoldmells and Anderby Creek. In Greater Lincolnshire, an estimated 29,000 people live in coastal communities. Coastal communities have a strong local identity and clear patterns of seasonality in business and leisure activity, as well as population.


(There is an overlap between those who are aged 0-19 and 16-64).

19% are aged 0-19 years
54% are working age (16 to 64 years)
31% are older adults (65+).


27% of children live in low income households
18% of people receive pension credit
29 % of people receive universal credit.


45% of people are economically active (People not in employment who have not been seeking work within the last 4 weeks and/or are unable to start work within the next 2 weeks).

Of people in employment:

27% work in process, plant or machine operative roles
20% work as mangers, directors or senior officials.


46% at Key Stage 4 achieve a 4+ in English and Maths
3 in 10 young people participate in higher education
43% of adults hold no qualifications.

Aerial view of Skegness town and beach

Aerial view of Skegness town and beach

Coastal communities such as Skegness and Mablethorpe all developed in the 19th Century when improving transport routes facilitated the development of these modern-day coastal resorts. Transport routes to coastal areas are limited and so the coast is relatively remote, especially as Lincolnshire’s coastal communities are surrounded by large rural areas. All of Greater Lincolnshire’s coastal communities have a large number of retired people who often live in residential or holiday parks, which means Greater Lincolnshire’s coastal communities have an older than average age profile.

Coastal communities experience significant challenge. They are characterised by high levels of deprivation, with nearly 9 out of 10 coastal community areas in the 20% most deprived areas of England, and over a quarter of children living in low-income households (Ministry of Housing, Communities & Local Government, English Indices of Multiple Deprivation, 2019).

Educational attainment is much lower than in other communities, both among children at Key Stage 4 and in adults (Nexus, 2022). Coastal communities also have significantly higher rates of reported crime when compared to other areas, with the exception of urban industrial communities. This may be a result of the large seasonal influx of people to tourist destinations.

Local employment is dominated by low skill and low wage jobs with significant seasonality (East Lindsey District Council and Connected Coast, 2021). Given the heavy reliance of coastal communities on the visitor economy, towns such as Mablethorpe and Skegness were heavily economically impacted during Covid-19 (Centre for Towns, 2020). Flood risk continues to be a major constraint on development, particularly housing, whilst connectivity remains a significant challenge. There are high levels of fuel poverty and poor-quality housing.

The Greater Lincolnshire coastline is beautiful. This blue space includes wild coast, extensive dune-backed salt marsh, internationally recognised Special Protected Areas (SPAs), Sites of Specific Scientific Interest (SSSIs), Special Areas of Conservation (SAC), and national nature reserves fronting the Humber Estuary and the Wash. Residents on the coast can benefit from this extensive green and blue space, which brings benefits for health and wellbeing.
Evidence suggests that it is important to regularly visit such sites to enjoy the health benefits, which include a positive association with mental wellbeing and negative association with mental distress (White et al. 2021).

Caravan parks are a particular feature of coastal communities, with upwards of 24,000 static caravans along the Greater Lincolnshire coastline (East Lindsey Core Strategy, 2018). Caravan parks bring challenges, including a seasonal influx
of temporary residents who often have higher health and care needs.

Coastal communities have good access to both GP surgeries and pharmacies; however, access to more specialised services (such as acute hospitals) is poor. As an example, the journey from Mablethorpe or Skegness to Lincoln Hospital is a 77-mile round trip.
Coastal communities have the highest rates of many unhealthy behaviours (e.g. physical inactivity, smoking, poor diet) and there is a seasonal influx of people with specific needs linked to homelessness and drug or alcohol misuse that creates a challenge for local service delivery. Coastal community residents have the highest rates of both elective and emergency hospital admissions. Admissions for a range of long-term conditions such as cancer, chronic obstructive pulmonary disease (COPD), cardiovascular disease (CVD) and intentional self-harm are significantly higher in coastal communities compared to Greater Lincolnshire as a whole (NHS Digital, Hospital Episode Statistics, 2022). In addition, coastal communities have the highest all-cause mortality rates (both for all ages and for under 75s). The highest disease specific mortality rates in coastal communities are cardiovascular disease and cancer.

The Index of Multiple Deprivation (IMD) is a measure of small area deprivation in England. IMD divides England into 32,844 small areas (average population 1,500 people/650 households) and ranks them from 1 (most deprived) to 32,844 (least deprived). For each of the areas of life presented here (e.g. income, crime, etc), the % represents the number of small areas in this type of community that fall into the 20% most deprived nationally. A higher percentage than 20% means there is more deprivation than the average for England.

88% of small areas in urban industrial centres are in the 20% most deprived nationally:

  • Income – 69%
  • Employment – 94%
  • Education and skills – 94%
  • Crime – 25%
  • Barriers to housing -0%
  • Living environment – 13%
  • Health and disability – 88%
Index of multiple deprivation 5

Key challenges for coastal communities

Coastal communities across Greater Lincolnshire experience the most entrenched issues. Key challenges include:

  • High inward migration of older adults, the economically inactive and people in poorer health, coupled with outward migration of young adults, many of whom leave the area to go to college, university, or for work, and do not return.
  • The employment market is dominated by low paid, low skilled, seasonal work, leading to low income and poor long-term career prospects and progression. This contributes to a vicious cycle with educational attainment, leading to significantly lower levels of qualifications, impacting opportunities for higher skilled employment.
  • Lower educational attainment also affects health literacy, meaning people may have less understanding about how behaviours affect their health and wellbeing, and around how to make changes to their behaviour.
  • Coastal areas often have higher concentrations of fast-food takeaway and gambling outlets, increasing the opportunities for unhealthy behaviours. These structural and environmental factors can impact on the success of individuals and families who are seeking to change health behaviours.
  • Coastal communities present a unique challenge in relation to housing. Houses of multiple occupation and temporary accommodation (e.g. static caravans) are common. Whilst more affordable, these units are usually the worst type of accommodation for energy efficiency, contributing to fuel poverty. As static caravans are not meant for permanent living, they are exempt from regulations to control their condition meaning many older, vulnerable people are living in substandard shelter. Additionally, the popularity of coastal areas among retirees has driven up local house prices and newbuild locations are limited due to the coastal flood risk (with some areas, such as the Humberston Fitties, having previously experienced substantial coastal flooding).
  • Recruiting and retaining skilled and experienced workers across health and social care (e.g. GPs, experienced practice nurses, dentists and health visitors) is a significant challenge. Delivery of health services is becoming ever-more challenging in coastal areas where they struggle to reach the critical mass needed to be sustainable.
  • The health services infrastructure, pharmacies, hospitals, and GPs are put under extra strain during peak holiday season, due to the influx of tourists. Holiday periods, and especially the ‘summer swell’, cause a lot of demand on Urgent Care Services (Out of Hours) and temporary GP registrations increase across all coastal practices. This is a particular problem as it generates a large volume of work at weekends and bank holidays on an already fragile system.

Key opportunities for coastal communities

Greater Lincolnshire’s coastal communities have some exciting opportunities ahead:

  • The high, and increasing, number of older people provides an opportunity to develop more localised coastal health and care provision, such as the proposed Campus for Future Living in Mablethorpe. This is a medical and innovation hub of national significance, focusing on attracting and developing healthcare professionals, research, and providing intergenerational future living (Connected Coast, 2022).
  • The coastal towns of Mablethorpe and Skegness could benefit from a combination of Towns Regeneration Funding or Levelling-Up and UK Renewal Investment to help develop infrastructure in local areas that can support vibrant social networks. Good transport links, community facilities and design that considers how people live and interact are all vitally important to help people to access work, stay healthy and remain linked into their communities.
  • The Government’s Levelling-up White Paper discusses prosperity across the nation, investing in the poorest communities, giving everyone access to good schools and the opportunity to receive excellent education and training. It identifies good health as being just as important in “spreading opportunity, contributing not only to the economy but also ensuring that everyone, wherever they live, can enjoy fulfilling, happy and productive lives”. To achieve this, we need “strong public services not only to support positive health and educational outcomes but also attract new talent and investment to an area, boosting local economies.” (Department for Levelling Up, Housing and Communities, 2022). Greater Lincolnshire coast communities must benefit from this agenda.
  • Create more opportunities to utilise blue space in coastal regions, for example, by promoting the benefits for both physical and mental health and wellbeing through regular visits to the sea.


Coastal communities are challenged by an ageing population and pockets of considerable deprivation. As a result, on average local people have more complex health and care needs than the wider Greater Lincolnshire population. Meeting those more complex needs is challenged by the geographical isolation of coastal communities. Many of the factors contributing to health risks in coastal communities relate to the wider social determinants of health as well as access to health and care services, so working together with partners across all sectors is especially important. Additionally, there are specific opportunities in our coastal communities (e.g. The Campus for Future Living in Mablethorpe) that, if we work together to deliver, should bring significant benefits to the socioeconomic circumstances and health and wellbeing of coastal community residents.

6 Rural and market towns

Greater Lincolnshire has large areas of open countryside and farmland, dotted with market towns, villages, and hamlets. In these rural and market town communities, the local population density is low, on average 30 times lower than the national average. That said, an estimated 311,000 people live in rural and market town communities across Greater Lincolnshire. Most people live a long way from urban areas, and this means that many towns and villages have remained self-contained. They often have shops, pubs, post offices, local halls, chapels, and churches, which offer a variety of social activities for residents.


(There is an overlap between those who are aged 0-19 and 16-64).

20% are aged 0-19 years
57% are working age (16 to 64 years)
28% are older adults (65+).


16% of children live in low income households
9% of people receive pension credit
11 % of people receive universal credit.

Aerial view of Epworth
Aerial view of Epworth


67% of people are economically active (People not in employment who have not been seeking work within the last 4 weeks and/or are unable to start work within the next 2 weeks).

Of people in employment:

21% work in process, plant or machine operative roles
26% work as mangers, directors or senior officials.


67% at Key Stage 4 achieve a 4+ in English and Maths
4 in 10 young people participate in higher education
27% of adults hold no qualifications.

Rural and market town communities are characterised by lower levels of deprivation, apart from barriers to housing and services. Fuel poverty is a challenge for some, with many houses not connected to the gas network and so reliant upon oil or solid fuel for heating. The housing stock is often older and less energy efficient. Both transport and digital connectivity is poorer; the road network is made up of extensive single-track roads which can be a challenge for modern traffic volumes, and digital infrastructure often trails behind urban areas.

This can impact on social isolation and limit access to employment and further education.

Greater Lincolnshire’s rural and market town communities have good access to green space, with well-evidenced benefits for physical and mental health. Access to formal leisure facilities and events is likely to require access to a car or public transport, so interventions which make the most of abundant open space, such as health walks, are beneficial. Rates of recorded crime are lowest across Greater Lincolnshire in rural communities. Many people living in rural areas are asset rich in terms of property ownership, but they can be cash limited which may bring additional challenges as the cost of living continues to rise.

The dispersed nature of rural and market towns impacts on access to services, with provision usually more limited than in urban areas. Health outcomes such as life expectancy, infant mortality and premature mortality are better; however, average outcomes can mask small pockets of significant deprivation and poor health (Local Government Association, 2017). Additionally, whilst premature mortality from cardiovascular and respiratory disease is significantly lower than average, hospital admissions for cancer and mental health are above average. This might suggest a lower awareness of certain types of support (e.g. cancer screening and mental health services) and/or that such services are more difficult to access.

To improve health and wellbeing outcomes in rural and market town communities, we must make outreach – physically or digitally enabled – a priority for service development. This is because evidence tells us that the further an individual must travel to health services, the less likely they are to use those services (LGA, 2017). Patients in rural areas under-use health care services (Asthana et al., 2003) and tend to be in worsening health when they do present (Campbell et al., 2001), requiring a more intensive response (Rural England, 2016).

North East Lincolnshire and Lincolnshire’s district councils are key to reducing health inequalities, influencing planning and housing policy, managing developments, homelessness prevention, energy efficiency promotion and Disabled Facilities Grants. Town and parish councils can also help develop an understanding of the local health profile and proactively promote health in their communities (LGA, 2017).

The Index of Multiple Deprivation (IMD) is a measure of small area deprivation in England. IMD divides England into 32,844 small areas (average population 1,500 people/650 households) and ranks them from 1 (most deprived) to 32,844 (least deprived). For each of the areas of life presented here (e.g. income, crime, etc), the % represents the number of small areas in this type of community that fall into the 20% most deprived nationally. A higher percentage than 20% means there is more deprivation than the average for England.

7% of small areas in urban industrial centres are in the 20% most deprived nationally:

  • Income – 5%
  • Employment – 11%
  • Education and skills – 14%
  • Crime – 1%
  • Barriers to housing -38%
  • Living environment – 23%
  • Health and disability – 6%
Index of multiple deprivation 6

Key challenges for rural and market town communities

Within rural and market town communities, key challenges include:

  • Outward migration of younger people and inward migration of older people. Older adults are likely to have comparatively more complex health and social care needs and experience greater levels of frailty than the healthier working age individuals moving out of the area, increasing pressure on health and care services.
  • Increasing demand for rural living and migration from high income urban households is contributing to an acute housing crisis in rural areas and driving out low-income households. Only 8% of the housing stock in rural areas is affordable housing, compared to 20% in urban areas. This 8% is insufficient to meet demand (Institute for Public Policy Research (IPPR), 2018).
  • Pastoral and arable farming are both common, affecting air quality on farms and in surrounding communities. Farm workers are particularly vulnerable to respiratory conditions, dizziness, nausea and even death, from direct and prolonged exposure to
    emissions. With limited regulations other than Environmental Permitting in place to protect them, nearby communities may experience dirt and dust exposure and excessive plant and algal growth (eutrophication) of fresh water. This is an area of limited understanding but an important issue for the health of our rural communities.
  • Farmers work with potentially dangerous machinery, chemicals, livestock, at height or near pits and are exposed to harsh weather, vibration, noise, and dust. The nature of the work is physically demanding and repetitive. As a result, the number of fatalities, serious injuries, illness, or disabilities directly caused by agricultural work is significantly higher than other sectors (HSE, 2010). The personal and societal costs of this can be devastating and the true levels of ill health are unclear because often individuals in this sector do not consult their doctor or report incidents.
  • International migration, particularly around Boston and South Holland, where many Eastern European migrants have travelled to for employment opportunities. They often live in rented accommodation, accepting poor and overcrowded conditions, which can contribute to the spread of communicable diseases.
  • Much of the employment in rural and market town communities is precarious, low paid and seasonal in nature, contributing to poverty. Further, the transient nature of the workforce affects our understanding of population health needs. Lincolnshire continues to work with the National Centre for Rural Health and Care to develop this evidence base.
  • Recruiting and retaining an appropriately sized and skilled health and care workforce is challenging and a priority for the Lincolnshire Integrated Care System. Challenges include the social (e.g. housing availability and lack
    of leisure opportunities), the professional (e.g. limited specialist roles and the risk of professional isolation) and the demographic (e.g. age means that many professionals are leaving the workforce).
  • Rural health and care services face additional costs due to diseconomies of scale, local markets for land, building and labour, longer travel times and high staff turnover. One of the biggest challenges in rural Greater Lincolnshire is the provision of community support (home care) to speed up hospital discharge. The ageing and geographically dispersed population makes care provision costly, contributing to higher charges for social care.
  • Rising costs are threatening the viability of residential care homes and there is an under- representation of sheltered housing in rural areas (Rural England, 2017). Increasing the provision of housing with care, with a range of tenure options including shared ownership and private purchase is necessary.

Key opportunities for rural and market town communities

There are also important advantages and opportunities for our rural communities, including:

  • Rural neighbourhoods tend to have a strong community identity. This can lead to good community assets such as Good Neighbour Schemes and Men’s Shed projects. Involvement with the voluntary sector such as the Humber and Wolds Rural Action, YMCA and branches of Age UK provides support for local communities and helps reduce isolation.
  • Lincolnshire’s rural strategic partnership with the Centre for Ageing Better is supporting our ageing population. East Lindsey has recently become the UK’s first age-friendly district.
  • Environmental Land Management Scheme funding could be used to better support rural Lincolnshire areas. Farmers and other land managers enter into financial agreements to deliver clean and plentiful water, clean air, thriving plants and wildlife, protection from environmental hazards, reduction of and adaptation to climate change and beauty, heritage, and engagement with the environment.
  • There are specific opportunities to enhance rural connectivity and access to services through enhancing provision of JustGo, Call Connect and voluntary car schemes (providing on-demand travel services), using public estates to develop rural multi-use centres and community hubs, and delivering services more rurally by using outreach, mobile services, and technology.
  • Exploring use of the government’s Rural Gigabit Voucher Scheme and Project Gigabit to improve broadband in rural Lincolnshire by 2026. This would enhance employment opportunities
    and reduce wider digital exclusion currently experienced in some rural areas.


Rural and market town communities are made up of an older middle age and ageing population, which is highly dispersed across large spaces.

Communities are more affluent (with small pockets of significant rural deprivation), but there are specific challenges, for example, energy inefficient properties. Access to health and community services is poorer than average; however, the health of the population is generally better than average. There are specific opportunities to improve the health and wellbeing of the local population, for example through government schemes around land management and digital infrastructure, and through adapting services to increase outreach into local, often isolated communities.

7 Conclusion and recommendations

We have identified four dominant ‘types’ of community in Greater Lincolnshire:

  •  Urban centre
  • Urban industrial
  • Coastal community
  • Rural and market town

Whilst each community faces a set of opportunities and challenges that lead to different health outcomes, there are also commonalities in the challenges facing communities in Greater Lincolnshire. For example:

  • Poor housing and fuel poverty are issues in pockets across the whole region but for different reasons, that require different solutions, in our urban versus rural areas.
  • The lack of a teaching hospital makes it more difficult to recruit and retain a health and care workforce across the entire county, but the problem gets worse closer to the coast.
  • Poor air quality is known to be a challenge in urban areas, but the impact of agricultural air pollution and its effect on farmers and farm workers is poorly understood.

So what does this mean for improving health and wellbeing across Greater Lincolnshire?

Different health needs necessitate different approaches

Differences in health outcomes, as well as access to primary and secondary care services across Greater Lincolnshire, are stark. The inverse care law states that those who most need medical care are least likely to receive it. There are several reasons for this, that vary by place, and which is why the Integrated Care Partnership must work together to understand local need and tailor services accordingly. For example, services in our coastal communities are challenged by the wicked combination of geographical isolation and low levels of local skilled workforce. Coastal and urban industrial communities are challenged by low levels of education which impact on health literacy and a person’s ability to navigate our complex health system. And so on… There is significant analysis underpinning this Annual Report that can be used, alongside Population Health Management, to develop a more nuanced approach to health improvement and healthcare delivery across Greater Lincolnshire.

Flexing the workforce is key to improving health and wellbeing

There are health and care workforce challenges across Lincolnshire, and many of the shortages faced locally are also national challenges that are well rehearsed. Additionally in Greater Lincolnshire, as there is no teaching hospital, there are limited training opportunities at undergraduate and postgraduate level, which adds to challenges around recruitment and retention of the workforce. As a health and care system, Greater Lincolnshire needs to maximise the impact of developments such as the Medical School at the University of Lincoln and The Campus for Future Living planned in Mablethorpe on the workforce, for example through creating opportunities for training and recruiting health and care professionals.

Lincolnshire’s coastal and rural communities also have an aging population and supporting older working age adults to participate in the health and care workforce could be another important way to expand the workforce, reduce dependency on agencies and improve health and care outcomes. The Centre for Ageing Better are working across Lincolnshire to explore how best to support older adults in the workforce (e.g. their GROW programme), and collaborating around health and care roles specifically could be a good way to tackle some of the workforce challenges across the county.

Harness local environment and assets

The local environment is an important enabler for health and wellbeing, but we do not always make the best use of the environment in supporting our local communities. For example, there is a growing evidence base on the benefits of blue space (both coastal and inland) for health and wellbeing, but it is not enough to have the blue space nearby to reap the benefits. Regular visits – i.e. twice a week – bring the most health benefits. We need to make sure that our health and care workforce knows about, and knows how to support, local people to make the most of evidence-based opportunities to strengthen health and wellbeing that are on the doorstep of our different communities.

There are significant challenges for preventing ill health and improving life expectancy across Greater Lincolnshire. With the areas of greatest need also those literally the hardest to reach, there are significant challenges ahead for improving health and wellbeing and reducing health inequalities. By developing a better understanding of the complexity of our local communities, we can begin to tailor our approaches to prevention and treatment in a way that better meets the needs of local people.


  1. Improve awareness of the diversity of Greater Lincolnshire’s communities, and specifically what this means for health and wellbeing, across the workforce and volunteer community.
  2. Embed recognition of, and a requirement to respond to, Greater Lincolnshire’s diverse communities within practice across the Integrated Care Systems, to inform a more nuanced approach to service design and intervention delivery.
  3. Explore opportunities to build understanding and intelligence around diverse communities into the Population Health Management approach across Greater Lincolnshire’s Integrated Care Systems.
  4. Support local communities to know about and act upon the benefits that natural and man-made assets, which vary across Greater Lincolnshire’s diverse communities, can bring to health and wellbeing.
  5. Raise awareness, across the health and social care system, of significant inward investment that has the potential to improve health and wellbeing, and how we can shape and influence these developments (e.g. around workforce development).
  6. Be innovative in designing and delivering a health and care workforce to meet the needs of Greater Lincolnshire, including working with communities who may be looking for increased flexibility.

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9 Reflections on 2021 Annual Reports


The 2021 DPH Annual Report for Lincolnshire focused on the impact of Covid-19 on the children and young people (CYP) of Lincolnshire. During the pandemic, the support needs of CYP and their parents and carers increased. For example, there was an increased demand for services to support parental mental health and behavioural support for pre-school children.

Lincolnshire also saw an increase in support needs for school-aged children; for example, to support children returning to school or who were missing school because of anxiety.

Emotional and mental well-being has been a growing concern since the start of the pandemic, with children’s mental health services under growing pressure.

A set of priorities were identified that have formed the core focus of much of the work in Lincolnshire as we moved into a period of recovery from the pandemic. Key developments against those priorities since the publication of the report include:

  • Work towards full restoration of the Healthy Child Programme to pre-covid levels.
  • Recommissioning Best Start Lincolnshire Services from 2023 to provide early learning activities for all children in their early years and their parents/ carers, supporting the development of children from age 0-5 to give them the best start in life and be ready for school.
  • Additional central government investment into Lincolnshire that will help us, and our partners,
    to build on the strong provision of children’s centres and early help for families in Lincolnshire through the creation of Family Hubs.
  • The continued focus on trauma-informed training for teachers to support pupils returning to school and a focus in the school improvement commission on ‘Recover Lincolnshire’ with bespoke sessions for school leaders supporting them in dealing with the pandemic.
  • The establishment of a Children in Care Transformation Programme, which aims to ensure that when children do need to be in the care of the local authority, outcomes for
    Lincolnshire CYP are improved by providing care locally within Lincolnshire.
  • The start of a Children’s Mental Health Transformation Programme that aims to create a seamless service for children and their families.
  • Supporting partners in Lincolnshire to develop and launch a new ten year all age strategy for physical activity and commissioning a new child and family weight management service.
  • Through the Integrated Care Board Health Inequalities programme, ensuring preventative and health care services reach and prioritise those most in need, such as Lincolnshire’s most deprived communities.
  • A full update on developments since the 2021 report can be requested.

North Lincolnshire

The previous DPH Annual Report for North Lincolnshire was released in 2020. This report focussed on the three key themes of supporting positive mental health and wellbeing, encouraging people to be more physically active and taking a whole-system approach to creating healthy environments.

Within North Lincolnshire, partnerships and strategies have been refreshed to help improve mental wellbeing and resilience across communities and work continues to expand across Greater Lincolnshire. Progress has included:

  • Promotion of the Five Ways to Wellbeing.
  • Development and delivery of Make Every Contact Count (MECC) for Mental Health and Safe Talk and Assist suicide prevention training programmes.
  • Collaboration with colleagues across the Humber region to introduce real-time surveillance and postvention (an intervention conducted after a suicide) support to reduce the impacts of suicide.
  •  Introduction of Qwell, a free, anonymous online counselling and emotional wellbeing service for men.
  • Development of the Social Prescribing Model for North Lincolnshire, which enables GPs and practice nurses to provide non-clinical services, like supporting uptake of physical activity.

Exercise can benefit both physical and mental health and a variety of schemes to increase uptake of physical activity have been implemented. In 2019, the North Lincolnshire Physical Activity Partnership was established. The partnership has improved physical activity via a range of initiatives, providing better information around ways to be active, promoting active travel and working with schools.

Key achievements have included expanding the Walking the Way to Health scheme and providing funding to satellite clubs, which support community/after school offers aimed at CYP who would not usually participate in after school sports. A partnership approach to
support hospital discharge patients and prevent deconditioning has been adopted.

Unhealthy weight is another key priority for North Lincolnshire, the causes of which are complex and can be influenced by the environment in which we live, work and play. To help to understand the range and diversity of factors that may influence people’s weight, a systems approach which involved a wide range of partners to identify solutions was adopted.

One of the main outcomes was a research project led by young people, which explored and documented issues in their local environment that they felt contributed to unhealthy weight (such as prevalence of fast-food establishments). Many other outcomes have been achieved, such as:

  • Working with leisure facilities to improve their range of healthier food options.
  • Developing key health policies within the Local Plan (subject to approval) to include a 400m hot food takeaway exclusion zone around schools and colleges.
  • Introducing health impacts assessments for future housing developments with more than 50 dwellings.
  • Working with our partners to increase Active Travel for school pupils and people travelling to work.

North East Lincolnshire

The key priority of the 2021 DPH Annual Report for North East Lincolnshire was mental health, particularly in relation to the impacts of the Covid-19 pandemic. The pandemic had negative impacts on the mental health of a considerable number of people and mitigating these effects will be a key priority for public health policy over the coming years.

The 2021 DPH annual report highlighted many examples of ways in which the pandemic disrupted lives, impacted mental health, and undermined coping mechanisms. People in all stages of life experienced challenging circumstances, including missing education, enduring social isolation, and becoming unemployed. The range of effects suggests that recovery will be prolonged and complex for many.

Another focus of the report was the ability of mental health services to respond to these issues. Many traditional mental health services in North East Lincolnshire are under considerable strain with long waiting times, especially adolescent mental health services. Therefore, the report highlighted opportunities for other organisations to support mental health and wellbeing, such as schools, workplaces, and the voluntary sector. The report also emphasised the critical importance new and emerging NHS structures should attach to improving these services.

However, there have been positive aspects of mental health practice which can be built on to enhance mental wellbeing across all ages. For instance, the first national lockdown coincided with abnormally fine spring weather and reduced traffic levels. This led to a large, though short term, surge in people adopting healthier lifestyle behaviours, such as enhanced walking or cycling. There has also been an increase in the number of volunteers providing support to people in more difficult circumstances. For many, voluntary activities have provided a sense of purpose to help them through these challenging times.

The report produced 11 recommendations for a range of organisations in North East Lincolnshire. These were strongly backed by the Place (Health and Wellbeing) Board at its meeting in July 2022 and all organisations have been asked to come back to the Board to identify how the recommendations are being implemented within their organisations and services.