Director of Public Health report 2022

Contents

1. Foreword
2. Introduction
   2.1 The four community types in Greater Lincolnshire
3. Urban centres
4. Urban industrial centres
5. Coastal communities
6. Rural and market towns
7. Conclusion and recommendations
8. References
9. Annex – Reflections on 2021 Annual Reports
   Lincolnshire
   North Lincolnshire
   North East Lincolnshire

1. Foreword

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.

Population

(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+).

Income

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

Work

• 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.

Education

• 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.

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%

Summary

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.

Population

(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+).

Income

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

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%

Summary

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.

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+).

Income

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

Work

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.

Education

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.

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%

Summary

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.

Population

(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+).

Income

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

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%

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.