Rationale for the indicators

Rationale for the indicators

1.2 School readiness

This is a key measure of early years development across a wide range of developmental areas. The data from the Early Years Foundation Stage Profile is used each year to inform plans for child development, informing Key Stage 1 teachers about each child's development and needs.

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1.3 Pupil absence

Improving attendance (tackling absenteeism) in schools is a crucial part of the Government's commitment to increasing social mobility and to ensuring every child can meet their potential. If we are to improve school attendance (reduce absence), then it is important that all services that work with young people talk to one another and agree local priorities. This indicator should help to achieve this.

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1.8 Employment for those with a long-term health condition including those with a learning difficulty/disability or mental illness

The recent review 'Is work good for your health and wellbeing?' concluded that work was generally good for both physical and mental health, and wellbeing. The strategy for public health takes a life course approach and this indicator provides a good indication of the impact limiting long-term illness has on employment among those in the 'working well' life stage. It also provides a link to indicators in the 'NHS outcomes framework'.

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1.9 Sickness absence rate

The independent review of sickness absence (published December 2011) was commissioned by the Government to help combat the 140 million days lost to sickness absence every year. The review provided an important analysis of the sickness absence system in the UK; of the impact of sickness absence on employers, the State and individuals; and of the factors that cause and prolong sickness. This is in line with the Government's strategy for public health, which adopts a life course approach and includes a focus on the working-age population in the 'working well' stage. As part of this stage, the Government aims to help people with health conditions to stay in or return to work.

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1.10 Killed or seriously injured casualties on England's roads

The indicator is an established measure used to assess improvements in road safety. Road safety has implications for the safety of communities, on the long-term costs to the health and social care systems, and to the wider economy.

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1.11 Domestic abuse

Tackling domestic abuse as a public health issue is vital for ensuring that some of the most vulnerable people in our society receive the support, understanding and treatment they deserve. The more we can focus in on interventions that are effective, the more we can treat victims and prevent future re-victimisation.

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1.16 Utilisation of green space for exercise/health reasons

Inclusion of this indicator is recognition of the significance of accessible green space as a wider determinant of public health. There is strong evidence to suggest that green spaces have a beneficial impact on physical and mental wellbeing and cognitive function through both physical access and usage.

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2.1 Low birth weight of term babies

This indicator is in line with the Government's direction for public health on starting well through early intervention and prevention. It has also been included in the Department of Health Business Plan within the context of addressing issues of premature mortality, avoidable ill health, and inequalities in health, particularly in relation to child poverty.

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2.2 Breastfeeding

Inclusion of this indicator will encourage the continued prioritisation of breastfeeding support locally. Increases in breastfeeding initiation and prevalence are expected to reduce illness in young children, which will in turn reduce hospital admissions of the under-1s (and the costs to the NHS that are associated with this). In the longer term, infants who are not breastfed are more likely to become obese in later childhood, develop type 2 diabetes and tend to have slightly higher levels of blood pressure and blood cholesterol in adulthood.

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2.3 Smoking status at time of delivery

Smoking during pregnancy can cause serious pregnancy-related health problems. These include complications during labour and an increased risk of miscarriage, premature birth, stillbirth, low birth-weight and sudden unexpected death in infancy. The Tobacco Control Plan contains a national ambition to reduce the rate of smoking throughout pregnancy to 11% or less by the end of 2015 (measured at time of giving birth). The inclusion of this indicator will ensure that local tobacco control activity is appropriately focused on pregnant women, in order to try to achieve this national ambition.

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2.4 Under-18 conceptions

Inclusion of this indicator signals the continuing importance of teenage pregnancy as a key measure of health inequalities and child poverty. Reducing under-18 conceptions has important benefits for short and long term health outcomes. Teenage parents are at increased risk of postnatal depression and poor mental health in the 3 years following birth. They are more likely than older mothers to have low educational attainment, experience adult unemployment and be living in poverty at age 30. Their children experience higher rates of infant mortality and low birth weight, A&E admissions for accidents, and have a much higher risk of being born into poverty.

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2.5 Child development at 2–2.5 years

The Government's Early Years Policy Statement 'Supporting Families in the Foundation Years' (published July 2011) sets out the Government's recognition of the importance of pregnancy and the first years of life and its strong commitment to ensuring all children get the best possible start in life. It also included a commitment to developing an outcomes measure at 2–2.5 years. Children's early life development is strongly related to an individual's lifelong healthy development. Many factors associated with poor health and wellbeing in later life have been shown to have their origins in pregnancy and early childhood.

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2.6 Excess weight in 4–5 and 10–11 year olds

Obesity is a priority area for the Government. The 'Healthy Lives, Healthy People: A call to action on obesity in England' document includes national ambitions relating to excess weight in children. Excess weight (overweight and obesity) in children often leads to excess weight in adults, and this is recognised as a major determinant of premature mortality and avoidable ill health.

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2.7 Hospital admissions caused by unintentional and deliberate injuries in under-18s

Injuries are a leading cause of hospitalisation and represent a major cause of premature mortality for children and young people. They are also a source of long-term health issues, including mental health related to experience(s). This inclusion of this indicator is key for cross-sectoral and partnership working to reduce injuries, including child safeguarding.

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2.8 Emotional wellbeing of looked-after children

The mental health of all children is important. With half of adult mental health problems starting before the age of 14, early intervention to support children and young people with mental health and emotional wellbeing issues is very important. Under Section 10 of the Children Act 2004, local authorities have a duty to cooperate to promote wellbeing among children and young people. The cross-government mental health strategy, 'No health without mental health', identifies looked-after children as one of the particularly vulnerable groups at risk of developing mental health problems. Inclusion of this indicator for looked-after children will send out a message that this group of young people is a priority for the NHS and local authorities in their new public health role. Without an indicator covering this group, there would be a risk of an even greater increase in rates of undiagnosed mental health problems, placement breakdown, alcohol and substance misuse, convictions and care leavers not in education, employment or training.

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2.9 Smoking prevalence –15 year-olds

Smoking is the primary cause of preventable morbidity and premature death. There is a large body of evidence showing that smoking behaviour in early adulthood affects health behaviours later in life. The 'Tobacco control plan' sets out the government's aim to reduce the prevalence of smoking among both adults and children and includes a national ambition to reduce rates of regular smoking among young people aged 15 years in England to 12% or less by the end of 2015.

This indicator will ensure that as well as focusing on reducing the prevalence of smoking among adults (primarily through quitting) local authorities will also address the issue of reducing the uptake of smoking among children.

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2.10 Hospital admissions as a result of self-harm

Self-harm is one of the top 5 causes of acute medical admission and those who self-harm have a 1 in 6 chance of repeat attendance at A&E within the year. People who self-harm describe contact with health services as often difficult, characterised by ignorance, negative attitudes and, sometimes, punitive behaviour by professionals towards people who self-harm. With the risk of death by suicide being considerably higher among people who have self-harmed and with their high rates of mental health problems, and alcohol and substance misuse, it is essential that healthcare professionals address the experience of care by people who self-harm.

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2.11 Diet

Diet and nutrition are a fundamental contributor to public health. Diet makes an important contribution to health outcomes such as the prevalence of obesity, stroke and cardiovascular disease and some cancers. The importance of including an indicator focusing on dietary indicators was noted in responses to the consultation to 'Healthy lives, healthy people'.

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2.12 Excess weight in adults

Obesity is a priority area for government. The forthcoming obesity 'Call to action' document will include national ambitions relating to excess weight in adults, which is recognised as a major determinant of premature mortality and avoidable ill health.

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2.13 Proportion of physically active and inactive adults

Lack of sufficient physical activity costs the NHS over £1 billion per year – £6.5 billion per year to the wider economy – and is one of the top few risk factors for premature mortality. The need for physical activity has become particularly high profile since the publication of the UK CMO guidelines and in the context of the 2012 legacy. Physical activity provides important health benefits across the life course. Participation in sport and active recreation during youth and early adulthood can lay the foundation for lifelong participation in health-enhancing sport and wider physical activity.

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2.14 Smoking prevalence – adults (over-18s)

Smoking is the primary cause of preventable morbidity and premature death, accounting for 81,400 deaths in England in 2009, some 18% of all deaths of adults aged 35 and over. The 'Tobacco control plan' includes a national ambition to reduce adult (aged 18 or over) smoking prevalence in England to 18.5% or less by the end of 2015.

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2.15 Successful completion of drug treatment

Individuals achieving this outcome demonstrate a significant improvement in health and wellbeing in terms of increased longevity, reduced blood-borne virus transmission, improved parenting skills and improved physical and psychological health. It aligns with the ambition of both public health and the Government's drug strategy of increasing the number of individuals recovering from addiction. It also aligns well with the reducing re-offending outcome (indicator 1.13) as offending behaviour is closely linked to substance use and it is well demonstrated that cessation of drug use reduces re-offending significantly. This in turn will have benefits to a range of wider services and will address those who cause the most harm in local communities.

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2.17 Recorded diabetes

This indicator will raise awareness of trends in diabetes among public health professionals and local authorities. Diabetic complications (including cardiovascular, kidney, foot and eye diseases) result in considerable morbidity and have a detrimental impact on quality of life.

Type 2 diabetes (approximately 90% of diagnosed cases) is partially preventable – it can be prevented or delayed by lifestyle changes (exercise, weight loss, healthy eating). Earlier detection of type 2 diabetes followed by effective treatment reduces the risk of developing diabetic complications.

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2.18 Alcohol-related admissions to hospital

Alcohol misuse is the third-greatest overall contributor to ill health, after smoking and raised blood pressure. Alcohol consumption is a contributing factor to hospital admissions and deaths from a diverse range of conditions. Over 1 million hospital admissions related to alcohol in 2009/10. The government has said that everyone has a role to play in reducing the harmful use of alcohol – this indicator is one of the key contributions by the government (and the Department of Health) to promote measurable, evidence-based prevention activities at a local level, together with a national ambition to reduce alcohol-related hospital admission. This ambition is part of the monitoring arrangements for the Responsibility Deal Alcohol Network.

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2.22 Take up of the NHS Health Check Programme by those eligible

NHS Health Checks will be a mandated service for local authorities to provide. Data collected for this indicator will provide information on the number of NHS Health Checks that are conducted and so will provide an indication of how well the programme is taken up and how accessible it is. An increased uptake is important to identify early signs of poor health leading to opportunities for early interventions.

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2.23 Self-reported wellbeing

Wellbeing is a key issue for the government, and the Office for National Statistics (ONS) is leading a programme of work to develop new measures of national wellbeing. People with higher wellbeing have lower rates of illness, recover more quickly and for longer, and generally have better physical and mental health. Local data on wellbeing is likely to be a key component of local joint strategic needs assessments and form an important part of the work of local health and wellbeing boards.

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2.24 Falls and injuries in the over-65s

Falls are the largest cause of emergency hospital admissions for older people, and significantly impact on long term outcomes, for example being a major precipitant of people moving from own home to long-term nursing or residential care. A measure that reflects the success of services in preventing falls will give an indication of how the NHS, public health and social care are working together to tackle issues locally.

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3.1 Air pollution

Poor air quality is a significant public health issue. The current burden of particulate air pollution in the UK is estimated to be equivalent to nearly 29,000 deaths in 2008 at typical ages and an associated loss of population life of 340,000 life years lost. Inclusion of this indicator in the 'Public health outcomes framework' will enable directors of public health to prioritise action on air quality in their local area to help reduce the health burden from air pollution.

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3.2 Chlamydia diagnoses rates (15–24 year olds)

Chlamydia causes avoidable sexual and reproductive ill health, including symptomatic acute infection and complications such as pelvic inflammatory disease (PID), ectopic pregnancy and tubal-factor infertility. The chlamydia diagnosis rate among under-25s is a measure of chlamydia control activities that can be correlated to changes in chlamydia prevalence (and thereby to changes in ill health due to chlamydia). Increasing the diagnostic rate will reduce the prevalence of asymptomatic infections. Inclusion of this indicator in the 'Public health outcomes framework' will allow progress that has already been made towards establishing widely available access to chlamydia screening though a range of health services to be built upon over the coming years.

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3.3 Population vaccination coverage

Vaccination coverage is the best indicator of the level of protection a population will have against vaccine-preventable communicable diseases. Coverage is closely correlated with levels of disease. Monitoring coverage identifies possible drops in immunity before levels of disease rise. This indicator will cover all vaccination programmes across the life course as previous evidence shows that highlighting vaccination programmes encourages improvements in uptake levels.

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3.4 People presenting with HIV at a late stage of infection

The late HIV diagnosis indicator is essential to evaluate and promote public health and prevention efforts to tackle the impact of HIV infection. Over half of patients newly diagnosed in the UK are diagnosed late and 90% of deaths among HIV positive individuals within 1 year of diagnosis are among those diagnosed late. Inclusion of this indicator in the 'Public health outcomes framework' will focus efforts to expand HIV testing and to reduce late HIV diagnoses in the UK. Without a reduction in late HIV diagnosis, consequences may include: continued high levels of short-term mortality in those diagnosed late, poor prognosis for individuals diagnosed late, onward transmission of HIV and higher healthcare costs.

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3.5 Treatment completion for tuberculosis (TB)

Tuberculosis re-emerged as a serious public health problem in the UK over the past 2 decades, with tuberculosis incidence rising above the European average. Timely treatment for tuberculosis is key to saving lives and preventing long-term ill health, as well as reducing the number of new infections and development of drug resistance. Preventing the development of drug-resistant tuberculosis is particularly important as it has more severe health consequences and is considerably more expensive to treat.

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4.1 Infant mortality

This indicator is in line with the government's direction for public health on starting well through early intervention and prevention. It has also been included in the Department of Health business plan within the context of addressing issues of premature mortality, avoidable ill health, and inequalities in health, particularly in relation to child poverty. The infant mortality indicator is a shared improvement area with the 'NHS outcomes framework', addressing issues of premature mortality, which are influenced by both the NHS and public health interventions.

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4.2 Tooth decay in children aged 5

Tooth decay is a predominantly preventable disease. Significant levels remain (31% of children), resulting in treatment need, pain, and in some cases treatment required under general anaesthetic. Inclusion of this indicator in the 'Public health outcomes framework' will encourage local areas to focus on and prioritise oral health and oral health improvement initiatives (which can be very effective in preventing tooth decay).

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4.3 Mortality from causes considered preventable

Preventable mortality can be defined in terms of causes that are considered to be preventable through individual behaviour or public health measures limiting individual exposure to harmful substances or conditions. Examples include lung cancer, illicit drug use disorders, land transport accidents and certain infectious diseases. The ONS is working on a definition of preventable mortality, following a public consultation earlier in 2011 and is expecting to report on this soon. There will be a clear role for public health to play in reducing preventable mortality in the general population. We suggest that this indicator could incorporate mortality associated with healthcare-associated infections in the community and that associated with food-borne illnesses. Both of these are reported to the Health Protection Agency and are therefore measurable.

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4.4 Under-75 mortality rate from all cardiovascular diseases (including heart disease and stroke)

Cardiovascular disease (CVD) is one of the major causes of death in under-75s in England. There have been huge gains over the past decades in terms of better treatment for CVD and improvements in lifestyle, but to ensure that there continues to be a reduction in the rate of premature mortality from CVD, there needs to be concerted action in both prevention and treatment. The inclusion of this indicator in the 'Public health outcomes framework' (alongside an equivalent indicator in the 'NHS outcomes framework') sends out a clear signal that prevention of CVD is just as important as treatment.

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4.5 Under-75 mortality rate from all cancers

Cancer is the highest cause of death in England in under-75s. To ensure that there continues to be a reduction in the rate of premature mortality from cancer, there needs to be concerted action in both prevention and treatment. The inclusion of this indicator in the 'Public health outcomes framework' (alongside several indicators in the 'NHS outcomes framework' relating to cancer survival rates) sends out a clear signal that prevention of cancer is just as important as treatment.

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4.6 Under-75 mortality rate from liver disease

Liver disease is one of the top causes of death in England and people are dying from it at younger ages. Most liver disease is preventable and much is influenced by alcohol consumption and obesity prevalence, which are both amenable to public health interventions. Inclusion of this indicator in the 'Public health outcomes framework' will provide an impetus for local authorities to prioritise action on the drivers of liver disease.

The inclusion of this indicator in the 'Public health outcomes framework' (alongside an equivalent indicator in the 'NHS outcomes framework') sends out a clear signal that prevention of liver disease is just as important as treatment.

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4.7 Under-75 mortality rate from respiratory diseases

Respiratory disease is one of the top causes of death in England in under-75s and smoking is the major cause of chronic obstructive pulmonary disease (COPD), one of the major respiratory diseases. This indicator will focus public health attention on the prevention of smoking and other environmental factors that contribute to people getting respiratory disease. The inclusion of this indicator in the 'Public health outcomes framework' (alongside an equivalent indicator in the 'NHS outcomes framework') sends out a clear signal that prevention of respiratory disease is just as important as treatment.

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4.8 Mortality from communicable diseases

Inclusion of this indicator in the 'Public health outcomes framework' will reinforce how seriously the government takes the control of communicable diseases and prevention of avoidable deaths. Prevention of spread of communicable diseases is an important issue for public health. There is evidence that rapid identification, treatment and prevention of spread can reduce mortality.

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4.11 Emergency readmissions within 30 days of discharge from hospital

This indicator will follow individuals discharged from hospital to monitor success in avoiding emergency readmissions. Health interventions and social care will play significant roles in putting in place the right care services for re-ablement, rehabilitation and intermediate care to support individuals in returning home or regaining their independence, so avoiding crisis in the short-term. This indicator is also included as a placeholder within the 'NHS outcomes framework'.

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4.13 Health-related quality of life for older people

One in 5 people are over 65 and this is set to rise to 1 in 3 by 2033. The number of 'oldest old' (over 85) has doubled in the past decade and the percentage of people dying before 65 has remained constant for the past 20 years. Older people are the biggest and costliest users of health and social care – those with complex needs, long-term conditions, and functional, sensory or cognitive impairment are the highest cost and volume group of service users. Dementia alone accounts for more expenditure than heart disease and cancer combined. This indicator will provide a greater focus on preventing ill health, preserving independence and promoting wellbeing in older people – this is key to keep systems functioning and to ensure that the needs of this large group of users are addressed.

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4.16 Dementia and its impacts

There are an estimated 610,000 people in England with dementia, a number expected to double in the next 30 years. Dementia accounts for more expenditure than heart disease and cancer combined and costs society over £20 billion a year. The inclusion of this indicator will help public health practitioners to recognise the contribution they can make to minimising the effects of dementia or preventing it through promoting better lifestyle and exercise as half of dementias have a vascular component.

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