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END OF LIFE – SUMMARY OF NEEDS (PART OF MARIE CURIE DELIVERING CHOICE REPORT) (Report was finalised in 2009 as part of Marie Curie Delivering Choice Programme for which Norfolk County Council and NHS Norfolk are the lead partners.) Chapter 6: Demography & Epidemiology Map 1: Map of Norfolk showing the main areas of population The map above illustrates the primary areas of population within Norfolk. The main areas are: Norwich and the surrounding area, Kings Lynn and Great Yarmouth, with smaller areas in Thetford, Dereham and Sheringham. The Local Authorities are the Councils that govern Norfolk under the guidance of Norfolk County Council. Both the Great Yarmouth PCT and the Norfolk PCT are served by Social Services through one Local Authority covering all of Norfolk. Whilst there are similarities between them all, each Local Authority has a different demographic, economic and geographic make-up to it, which is illustrated here and detailed throughout this section. Map 2: The Local Authorities in the NHS Norfolk area The Local Authorities are divided into the following geographical areas: 1. Kings Lynn & West Norfolk which covers the urban area of Kings Lynn and the market towns of Downham Market, Hunstanton and the surrounding rural areas in the west of Norfolk 2. Breckland which covers the market towns of Dereham, Swaffham, Watton, Attleborough and Thetford and the surrounding rural areas, and is situated in the centre of Norfolk 3. South Norfolk which covers the market towns of Diss and Wymondham, along with the Norwich over-spill in Costessey, in the south of Norfolk and is predominately rural in nature 4. North Norfolk encompasses the market towns of Fakenham, Holt, Sheringham and Cromer in the north and is predominately rural in nature and a popular holiday and retirement destination 5. Broadland which covers the over-spill of Norwich in the north (such as Old Catton) and to the east of Norwich (such as Thorpe St Andrew) and the rural areas north of the Norfolk Broads 6. Norwich which covers the urban area of Norwich and the Norfolk Broads. Population and age distribution: There are a total of 739,043 people living in Norfolk as of 2006; the breakdown per Local Authority is thus: Breckland 128,314; Broadland 122,184; Kings Lynn and West Norfolk 142,254; Norwich 129,535; North Norfolk 100,598; South Norfolk 116,158.1 The total population is set to rise 5.3% by 2011 to 840,945. By 2016 this will reach 885,095 and by 2021 this will be 930,412. Even if we assume the population of Norfolk increases evenly without a disproportionate increase in the elderly population (though all studies point 1 Information from Norfolk Insight, via Norfolk County Council’s website www.norfolk.gov.uk and www.norfolkinsight.org.uk towards the UK as a whole having an aging population)2, then that will still mean an increase of 8,000 people over the age of 65 by 2011 alone. The current services in Norfolk will need to be more stream-lined and effective to be able to cope with this increase in elderly people as their health needs will also increase as, generally, people are living longer than they used to and suffering from more complex illnesses. The population density of Norfolk is the 10th lowest in the UK at 1.55 persons per hectare (all figures for this section include the district of Great Yarmouth). However, in reality the rural areas have a significantly lower density. 38% of the population of Norfolk live in the city of Norwich and the two towns of Great Yarmouth and Kings Lynn. An additional 18% live in the market towns with the remainder living in the large rural areas. The Rural and Urban Area Classification 2004 showed that 46% of Norfolk was classified as either village, hamlet and isolated dwelling, as shown in the map below. Map 3: Rural and Urban classification of Norfolk 2 An example of this is via an interactive graphic displaying this via the BBC on http://news.bbc.co.uk/1/hi/uk/4045261.stm. Information compiled from the Office for National Statistics. Table 1: Age break-down and population totals Breckland Broadland Kings Lynn & West Norfolk North Norfolk Norwich South Norfolk Total 0 to 4 6,509 5,990 5 to 14 15,026 13,766 15-44 46,624 43,245 45-64 34,453 34,427 65-84 22,284 21,593 85+ 3,418 3,163 Total Population 128,314 122,184 7,374 4,052 6,663 5,491 36,079 15,897 10,217 12,066 14,079 81,051 48,929 29,752 64,628 39,545 272,723 38,996 29,914 26,458 33,713 197,961 27,334 23,009 16,624 20,400 131,244 3,724 3,654 3,096 2,930 19,985 142,254 100,598 129,535 116,158 739,043 As the above table shows, Kings Lynn & West Norfolk has more people living inside its boundary than in the other Local Authorities. North Norfolk has the smallest number of people living inside its boundaries. These figures demonstrate an increase in people aged over 65 in the coastal areas of Kings Lynn & West Norfolk and North Norfolk, which is not surprising as there are a lot of retirement homes around this area and both regions are regarded nationally as being places to retire to3. North Norfolk in particular also suffers from having poor transport links compared with the rest of the county. The city of Norwich has a University and subsequently it has a large 15-44 age-group and a younger population overall. Ethnicity This information dates from the 2006 survey of Norfolk from the Office for National Statistics. A small proportion of the BME population of Norfolk is made up of migrant workers, (for 2006 this makes up approx 5% of the total BME population) which may not have been captured by this survey. The known figures of approved work permits for 2006 are for 910 workers, and in 2005 there were a further 1432 seasonal workers.4 These figures will have changed but more recent data is not available at the time of writing. These figures do not take into account any migrant workers who have not registered for permits. 3 Information for top retirement areas (by region) at: http://www.50connect.co.uk/editors_blog/2008/august/has_britain_lost_its_mojo/recommended_links/the_best_locations_f or_retirement_living & http://www.telegraph.co.uk/property/retirementproperty/5158696/Top-10-places-forretirement.html & http://www.dailymail.co.uk/news/article-343199/Retirement-sea.html 4 Information taken from Norfolk Insight. For seasonal workers there is no information available for 2006. Figure 3: Norfolk population composition Ethnic Population 1% White British 1% 1% 1% 92% 4% Asian Black Other 3% Irish 1% Other White Mixed 92% of the population in Norfolk is classified as White British, which means there are approximately 51,000 people of a BME origin in Norfolk as of 2006. The largest BME group is primarily comprised of Portuguese, East European and Russian residents, making 21,000 people overall. The next largest group encompasses the Asian community (8,000) followed by those of mixed race (7,000). Whilst Norfolk is not as diverse as other counties in the UK, it has over 100 languages spoken inside its boundaries and a small but culturally diverse population who all have different needs and expectations. Map 4: Concentration of ethnic minorities within Norfolk The map above illustrates the concentration of BME residents represented as a percentage of the total population for all ethnicities other than White - British. The areas of higher concentration levels (marked in red and blue) include the towns of Thetford, Swaffham and Watton which have large Portuguese communities. Also included are areas of Norwich which has a large multi-cultural community, and Kings Lynn which has a large Eastern European community. The areas in black and grey have the largest concentrations of BME population, and are located near Thetford and Swaffham. It is likely these areas are higher than others due to a lower population overall, which increases the percentage numbers of BMEs. The other significantly higher area is located in and around the University of East Anglia which has a high number of overseas students.5 For example, the population of University has 14-18% of the total population comprised of members of the BME communities. There are a high number of Gypsy & Traveller communities across Norfolk and it is entirely possible the data for these groups has not been captured by the survey. Primarily the Gypsy & Traveller community is comprised of both White British and Other White, notably Eastern European migrant workers. Henceforth this population group will be referred to as Gypsy Travellers; however although there are commonalities in cultural identity their ethnic identity may differ. New Age Travellers have been identified separately where possible, as they have opted for an alternative lifestyle but are not of the same culture. Figures for the Gypsy Traveller population can be difficult to determine primarily due to the travelling component to their lifestyle. Other difficulties arise from ethnic classification of persons for the purpose of demographic data collection as the Gypsy Traveller population are not included as a separate group. There are 4 permanent Gypsy Traveller sites within Norfolk and these are: • • • • Saddlebow – Kings Lynn The Splashes- Swaffham Roundwell- Costessey Swanton Road- Mile Cross, Norwich A further new site, Mangreen near Harford Bridges is currently under consultation (January 2009). These sites are managed day to day by site managers who are usually themselves members of the travelling community. The site managers, with the support of Norfolk County Council Gypsy and Traveller Liaison team, sign-post people to specific services within Norfolk as well as the maintenance and running of the sites themselves. The numbers of people on the permanent sites can vary and the Gypsy and Traveller Liaison service only count pitches in their data and not people. The estimates from the service are approximately 200 people resident at any one time across the 4 permanent site. There is also a permanent site within Great Yarmouth and the estimated population for this is 50 residents. There are also 8 unofficial but tolerated sites whereby the landowner has given the travelling community permission to be resident. These sites tend to house family groups except where the site is made up of new age travellers. 5 Information produced via the 2001 Census and figures obtained via Norfolk Insight. Table 2: Estimated number of occupants per unofficial site All numbers are estimated Site Name Type of site Number of adults Costessey – park and ride Cringleford- Cantley Lane Seething Little Plumstead- Hospital site Thetford- Bridgeham Heath Earsham Holt- Letheringsett Gypsy Traveller Gypsy Traveller New Age New Age Gypsy Traveller New Age new site 10 8 12 12 7 7 unknown Number of children Total 16 6 0 0 1 2 unknown Total 26 14 12 12 8 9 unknown 81 plus There are several unauthorised sites and these are mainly situated in West Norfolk and Great Yarmouth and reportedly chiefly comprise people from Eastern European origin. Local evidence suggests that the elderly and the ill tend to move into either sheltered accommodation or into housing association accommodation (which can include sheltered accommodation) and this is supported by the Sheffield University 2004 report. Norfolk also has a transient population of Water Travellers but numbers are impossible to collate and regularly fluctuate. Deprivation Wards Whilst deprivation is not confined to one area of Norfolk, it is notable that the 19 most deprived wards (the worst 10%) are primarily located in Norwich and Kings Lynn & West Norfolk, in addition to the urban areas of Thetford and Cromer. Kings Lynn & West Norfolk and North Norfolk have the next 19 most-deprived wards, with Norwich and the urban area of Dereham making up the remainder. None of the worst 20% of wards are located in either Broadland or South Norfolk. Further detailed analysis indicates that the most deprived wards are located in the following local authority areas: Norwich: Mancroft, Mile Cross, Wensum, Bowthorpe, Thorpe Hamlet, Lakenham, Crome and Catton Grove. Kings Lynn & West Norfolk: North Lynn, St Margaret’s with St Nicholas, Fairstead, Gaywood Chase, South and West Lynn, Upwell and Delphe, Walpole, Mershe Lande. Breckland: Thetford Abbey, Thetford Saxon. North Norfolk: Cromer Town. Broadland: None South Norfolk None Nearly all of the urban areas of Norwich and Kings Lynn are deprived areas. Map 5: Map that shows concentration of deprivation in Norfolk. SOAs England contains 32,484 Super Output Areas (SOAs). These are geographic and demographic units that contain on average 1,500 people and are nestled within ward boundaries to allow comparison between evenly sized populations. Across the Norfolk PCT there are a total of 188 wards, which makes a total of 468 SOAs throughout the area. A total of 50 SOAs spread across 18 wards are in the worst 20% nationwide – these are concentrated in the urban areas of Norwich, Kings Lynn, Thetford and Cromer. The 50 SOAs represent a total of 10% approx of all SOAs in the Norfolk PCT area. The wards which have these SOAs within them are not all deprived themselves - for example, in the ward of Town Close in Norwich only 17% of the SOAs contained are within the most deprived (20%) nationally. Conversely, the ward of Mile Cross in Norwich is comprised of 100% of these deprived SOAs. Overall, those SOAs which are amongst the worst nationally encompass 60% of all SOAs in the wards in which they reside. This would seem to indicate that Norfolk is a diverse area as the difference in deprivation fluctuates within the small area of a ward. There are some common trends however, which are examined below. Despite the ease of access to services, it is the urban areas which are the most deprived as there are no rural wards or SOAs in the 20% worst nationally, and the mainly rural Local Authority areas of Broadland and South Norfolk have no affected SOAs between them. The rural area of Breckland has only 2 affected SOAs, both in an urban area, and the same is true for the 2 affected SOAs in North Norfolk Table 3: Index of deprivation 2004: Concentration of Deprivation in Norfolk PCT. Local Authority Breckland Broadland Kings Lynn & West Norfolk North Norfolk Norwich South Norfolk No. of SOAs in Ward Name Worst 20% nationally Thetford Abbey 3 1 Thetford Saxon 5 1 No SOAs in worst 20% South & West 3 1 Lynn St Margaret’s with 3 3 St Nicholas Fairstead 3 2 Gaywood Close 3 1 North Lynn 4 3 Upwell and 3 3 Delphe Cromer Town 3 2 Lakenham 6 4 Thorpe Hamlet 5 3 Town Close 6 1 University 5 2 Bowthorpe 5 4 Wensum 7 4 Mile Cross 7 7 Catton Grove 5 2 Mancroft 6 6 Crome 7 3 No SOAs in worst 20% Totals 89 53 Total Wards in Norfolk Number of Wards with worse 20% SOAs Percent of Wards with worse 20% SOAs Total SOAs in Ward Percent in Ward 33% 20% 33% 100% 66% 33% 75% 100% 66% 66% 60% 17% 40% 80% 57% 100% 40% 100% 43% 60% 188 19 10% Mortality, Place of death and Primary cause of death Mortality and place of death The annual incidence of deaths is the single most important indicator of palliative care need in a population since most palliative care arises in the last year of life (Tebbit, 2004). In 2006, there were a total of 7,907 deaths and for 2007 this was 7,871. The 2008 data will not be available until October 2009. Table 4: Deaths per Local Authority and per 100,000 population for 2006 and 2007 Breckland Broadland Kings Lynn & West Norfolk North Norfolk Norwich South Norfolk Total Number of Deaths 2006 Deaths Per 100,000 1407 1326 1621 1290 1161 1102 7907 1097 1085 1140 1282 896 949 1070 % of Total Deaths 17.8 16.7 20.5 16.3 14.7 14.0 100.0 2007 Deaths Per 100,000 1416 1310 1623 1260 1059 1203 7871 1104 1073 1143 1255 821 1037 1054 % of Total Deaths 18.0 16.6 20.6 16.0 13.5 15.3 100.0 Based on the data in Table 4 for the calendar years of 2006 and 2007 the actual numbers of deaths for both years were highest in Kings Lynn & West Norfolk. However examining the statistic regarding the number of deaths per 100,000 population demonstrates that North Norfolk has the highest deaths; which is not surprising as it contains the highest elderly population in Norfolk. Norwich has the smallest number of deaths per 100,000 population and this too is consistent with it’s having the smallest proportion of elderly residents. Table 5: Breakdown of deaths across the Norfolk PCT Deaths in 2006 % of Total Deaths Deaths in 2007 % of Total Deaths Home 1772 22.4% 1832 23.3% Care Home 1607 20.3% 1526 19.4% Hospice 216 2.7% 223 2.8% Hospital 4125 52.2% 4127 52.4% Other 187 2.4% 165 2.1% Total 7907 100.0% 7871 100.0% From the table above, we are able to identify that the locality of place of death was consistent in 2006 and 2007. The only change is that the number of people dying at home has increased by 1%, whereas the number of people dying in a care home has reduced by 1%. The “other deaths” category includes data where people died in road traffic accidents for example. Overall the current system in place shows 42% of people as dying in either at home or in a care home, with 53% of people dying in hospitals. As there is a negligible change for 2006 and 2007, it is reasonable to assume that the systems in place are consistent in their application. Once the 2008 data is made available these trends can be analysed to provide additional data. Table 6: Place of death on a National basis 2006 England & Wales – Cancer England & Wales – All Deaths Norfolk 2007 England & Wales – Cancer England & Wales – All Deaths Norfolk Hospital 55% 68% 53% Home 22% 19% 22% Care Home 3% 6% 20% Hospice 17% 5% 3% Other 1% 2% 2% 52% 67% 53% 25% 20% 23% 3% 7% 19% 17% 5% 3% 1% 2% 2% The above table shows where people died across England and Wales in 2006. Based on this, we can see that Norfolk has a similar number of Home deaths (at 23%), fewer Hospital deaths (53%) and a considerably higher number of Care Home deaths (20%). This is consistent with the health distribution across Norfolk, as Norfolk has 5.5 times more care homes per head of population than the national (England) average.6 For 2007 the results are much the same, with Norfolk having considerably higher deaths in a Care Home (19%) than the national average; and fewer Hospital deaths (53%) than the national average. This data can be broken down further in the table below which looks at the figures for the different Local Authorities within Norfolk Table 7: Place of death per Local Authority Total Number of Deaths Breckland Broadland Kings Lynn & West Norfolk North Norfolk Norwich South Norfolk Totals Deaths at Home Breckland Broadland Kings Lynn & West Norfolk North Norfolk Norwich South Norfolk Totals 6 2006 286 275 377 274 289 271 1772 2006 1407 1326 1621 1290 1161 1102 7907 % of Total Deaths 20.3% 20.7% 23.3% 21.2% 24.9% 24.6% 22.4% 2007 1416 1310 1623 1260 1059 1203 7871 2007 302 275 368 296 264 325 1832 % of Total Deaths 21.3% 21.0% 22.7% 23.5% 24.9% 27.0% 23.3% The figure for England in 2005 was 0.008 care homes per head, and for Norfolk in 2007 it was 0.044 care homes per head. Deaths in a Hospice Breckland Broadland Kings Lynn & West Norfolk North Norfolk Norwich South Norfolk Totals 2006 42 39 3 24 66 42 216 % of Total Deaths 3.0% 2.9% 0.2% 1.9% 5.7% 3.8% 2.7% 2007 37 42 2 32 61 49 223 % of Total Deaths 2.6% 3.2% 0.1% 2.5% 5.8% 4.1% 2.8% Deaths in a Care Home Breckland Broadland Kings Lynn & West Norfolk North Norfolk Norwich South Norfolk Totals 2006 344 308 307 320 134 194 1607 % of Total Deaths 24.4% 23.2% 18.9% 24.8% 11.5% 17.6% 20.3% 2007 362 308 303 272 103 178 1526 % of Total Deaths 25.6% 23.5% 18.7% 21.6% 9.7% 14.8% 19.4% Deaths in a Hospital Breckland Broadland Kings Lynn & West Norfolk North Norfolk Norwich South Norfolk Totals 2006 705 681 881 642 643 573 4125 % of Total Deaths 50.1% 51.4% 54.3% 49.8% 55.4% 52.0% 52.2% 2007 683 671 913 637 607 616 4127 % of Total Deaths 48.2% 51.2% 56.3% 50.6% 57.3% 51.2% 52.4% Other Deaths Breckland Broadland Kings Lynn & West Norfolk North Norfolk Norwich South Norfolk Totals 2006 30 23 53 30 29 22 187 % of Total Deaths 2.1% 1.7% 3.3% 2.3% 2.5% 2.0% 2.4% 2007 32 14 37 23 24 35 165 % of Total Deaths 2.3% 1.1% 2.3% 1.8% 2.3% 2.9% 2.1% The tables above illustrate the break-down of the total numbers of deaths per local authority and where the deaths occurred. For example, in North Norfolk in 2007 a total of 637 people died in Hospital, which is a decrease from 2006. Using this information, it becomes apparent that most deaths for both 2006 and 2007 occurred in Kings Lynn & West Norfolk. In terms of numbers they also had the most home deaths, but in terms of percentage of overall deaths, it is Norwich which had the greater numbers of home deaths for 2006, and South Norfolk for 2007. This information is further analysed for deaths per 1,000 population in the following and table Examining the numbers of people who died in hospital, again it is Kings Lynn & West Norfolk that has both highest numbers and the highest percentage of hospital deaths for both years and this is evident in the graphs below: Figure 4: Places of death per Local Authority Places of death per Local Authority 32 2007 Other 30 2006 Other 14 37 23 23 24 53 35 30 29 22 2007 Hospital 683 671 913 637 607 616 2006 Hospital 705 681 881 642 643 573 362 2007 Care Home 308 344 2006 Care Home 308 37 2007 Hospice 42 42 2006 Hospice 303 307 2 39 3 275 368 2006 Home 286 275 377 10% 20% 30% 40% 42 296 264 274 60% 194 49 66 50% 178 134 61 24 302 103 320 32 2007 Home 0% 272 289 70% 80% 325 271 90% 100% Breckland Broadland Kings Lynn & West Norfolk North Norfolk Norwich South Norfolk The above graph details numbers of home deaths and indicates that Kings Lynn & West Norfolk has the highest numbers of people dying at home. South Norfolk has experienced a large increase in the number of people dying at home in 2007. The graph illustrates the numbers of hospice deaths; indicating that the numbers of people dying in hospices from Kings Lynn & West Norfolk are negligible, although the geographical distance may be a contributory factor. Other limiting factors may be number of beds and the structure of the health service in Norfolk. There is one inpatient hospice covering Norfolk; situated in Bury St Edmunds, Suffolk which serves patients from Thetford area of Norfolk. There is also a Specialist Palliative care inpatient unit situated in Norwich. The third hospice, near Kings Lynn, is day patient only. Both inpatient units are fairly inaccessible for patients residing in Kings Lynn & West Norfolk. This is confirmed further by the high numbers of patients dying in hospices from Norwich and South Norfolk which are very close to one of these two hospices. The graph also illustrates the number of care home deaths with the greatest figure occurring in Breckland. Discounting Norwich, which will have lower deaths due to its younger population, South Norfolk has a lower number of deaths than the other regions. Breckland does not have the highest number of care homes in the region; in fact it has about 49 care homes whereas Broadland (at 67), North Norfolk (at 69) and Kings Lynn & West Norfolk (at 60) all have more care homes. In terms of numbers of care homes where someone died in 2007, Norwich has only 15 homes, North Norfolk 26, Kings Lynn & West Norfolk 22 and Breckland has 24. Broadland has one care home which recorded the greatest number of deaths out of all care homes accounting for its high figure. Breckland has several large care homes which recorded high numbers of deaths and the remainder are either equal or slightly above the average deaths per care home in the other regions. The graph also shows the amount of people who died in hospital, and indicates that the occurrence of hospital deaths in Kings Lynn & West Norfolk is higher than any other local authority. Otherwise, the number of people dying in hospitals has been fairly consistent, although South Norfolk recorded a fairly large increase in the numbers of people dying in hospital in 2007 compared with 2006. Once the 2008 data has been made available these figures can be further analysed to see if any trends begin to emerge. It will however take several more years worth of data before a meaningful study can be done on this. Map 6: Home and Care Home deaths for 2006 by Ward per 1,000 population The map above evidences those political wards having the highest number of deaths in a care home and at home per 1,000 population. The reason the figures are presented in this way is remove the inequities that the greater population density of areas such as Norwich have, and which would present an unrealistic map if this was not taken into account. As the map shows, despite a high number of blue areas (5.0 – 9.9 people per 1,000 population) most of Norfolk has only 3.0 – 4.9 people per 1,000 dying either at home or in a care home, shown in grey. The grey areas are concentrated around the coastal areas of North Norfolk where there are a large number of care homes. North Norfolk has a total of 69 care homes (the highest figure in Norfolk).7 There are also a large number of grey areas located in Kings Lynn & West Norfolk and in Broadland, both of which have high numbers of care homes (60 and 67 respectively). Map 7: Home and Care Home deaths for 2007 by Ward per 1,000 population By 2007 there has been a remarkable amount of change county-wide with a reduction in the number of people dying in either a care home or at home per 1,000 population. This could represent a focus on improving certain areas at the expense of others or conversely could be a result of demographic shift. It is worth noting that nearly all of the northern area of Kings Lynn and West Norfolk achieves a level of 3.0 people per 1,000 and greater (coloured in grey, blue or yellow), as does North Norfolk and South Norfolk. Only Breckland and Broadland still have substantial gaps, though Breckland has more blue areas (5.0 to 9.9) than it did in 2006. The southern area of Kings Lynn & West Norfolk also has a large amount of white, which indicates a low level of people dying at home or in a care home. Once 2008’s data has been received (which is due to be published in October 2009) any trends can be examined in more detail. 7 Please see the Care Homes section for a map showing the approximate locations of the care homes. Table 8: Place of death per Local Authority for 2006 Local Authority Total Population Total Number of Deaths Deaths per 1,000 population Deaths at Home Home deaths per 1,000 population Deaths in a Care Home Care Home deaths per 1,000 population Deaths in a Hospital Hospital deaths per 1,000 population Breckland Broadland Kings Lynn & West Norfolk North Norfolk Norwich South Norfolk PCT area 128,314 122,184 142,254 100,598 129,535 116,158 739,043 1,407 1,326 1,621 1,290 1,161 1,102 7,907 11.0 10.9 11.4 12.8 9.0 9.5 10.7 286 275 377 274 289 271 1,772 2.2 2.3 2.7 2.7 2.2 2.3 2.4 344 308 307 320 134 194 1,607 2.7 2.5 2.2 3.2 1.0 1.7 2.2 705 681 881 642 643 573 4,125 5.5 5.6 6.2 6.4 5.0 4.9 5.6 The table above is a breakdown of places of death per Local Authority. From the table, it would appear that the area where someone lives has an influence on where they die. For example, in Norwich 5.0 people per 1,000 died in a hospital, whereas in North Norfolk that figure is 6.4. Table 9: Place of death per Local Authority for 2007 Local Authority Total Population Total Number of Deaths Deaths per 1,000 population Deaths at Home Home deaths per 1,000 population Deaths in a Care Home Care Home deaths per 1,000 population Deaths in a Hospital Hospital deaths per 1,000 population Breckland Broadland Kings Lynn & West Norfolk North Norfolk Norwich South Norfolk PCT area 129,935 122,954 143,479 100,779 132,241 117,333 746,721 1,416 1,310 1,623 1,260 1,059 1,203 7,871 10.9 10.7 11.3 12.5 8.0 10.3 10.5 302 275 368 296 264 325 1,832 2.3 2.2 2.6 2.9 2.0 2.8 2.5 362 308 303 272 103 178 1720 2.8 2.5 2.1 2.7 0.8 1.5 2.3 683 671 913 637 607 616 3,933 5.3 5.5 6.4 6.3 4.6 5.3 5.3 As can be seen from the table above, the total number of deaths has fallen slightly in 2007 in comparison to 2006. Kings Lynn & West Norfolk continues to have the highest number of people dying in a hospital per 1,000 with 6.4 which is a slight increase from the previous year. Before October 2006 Norfolk consisted of 6 Primary Care Trusts (PCT) which were amalgamated to form a single PCT; NHS Norfolk. Map 8: The Six previous PCT areas On the map above, the old PCT areas are represented by the black lines and the coloured areas represent the Local Authority areas. Chapter 7: Primary Cause of Death and Palliative Care Need Primary Cause of death From the table below it is apparent that the primary cause of death across Norfolk (excluding Great Yarmouth) is from circulatory illnesses followed by cancer and then from respiratory illnesses. Despite the available data covering only for two years the ratios appear fairly constant across both of these years. Further data for 2008 and onwards will need to be collected and analysed in order to determine any overall trends. Table 10: Primary cause of death across the Norfolk PCT Norfolk PCT Circulatory Respiratory Cancer Other Total 2006 2899 864 2201 1943 7907 % 36% 11% 28% 25% 100% 2007 2818 898 2235 1919 7870 % 37% 11% 28% 24% 100% There is little change in the primary cause of death across both years, and on both occasions most people die from circulatory illnesses, followed by respiratory illnesses. This is consistent with the findings from other Marie Curie Delivering Choice Programmes in different parts of the country. This information can be broken down further into the primary causes of death for each Local Authority area, which has been detailed below: Table 11: Primary cause of death in the different Local Authorities Breckland Circulatory Respiratory Cancer Other 2006 513 164 368 362 % 36 12 26 26 2007 508 159 387 362 Broadland Circulatory % 36 11 27 26 2006 % 2007 % 481 36 462 35 Respiratory Cancer Other 148 356 341 11 27 26 132 368 348 10 28 27 Kings Lynn & West Norfolk Circulatory Respiratory Cancer Other 2006 580 188 426 427 % 36 12 26 26 2007 572 209 436 406 % 35 13 27 25 North Norfolk Circulatory Respiratory Cancer Other 2006 486 129 367 308 % 38 10 28 24 2007 475 147 364 274 % 37 12 29 22 Norwich Circulatory Respiratory 2006 454 123 % 39 11 2007 389 122 % 37 11 Cancer Other 337 247 29 21 294 254 28 24 South Norfolk Circulatory Respiratory Cancer Other 2006 385 112 347 258 % 36 10 31 23 2007 415 130 386 272 % 34 11 32 23 Palliative Care need The demand for palliative care services can be estimated in several ways. We have followed the work of Tebbit (2004), and employed the epidemiological approach to estimate need. Our estimates are based on data for the calendar years 2006 and 2007. Epidemiological Approach As highlighted by Tebbit, the annual incidence of deaths is the single most important indicator of palliative care need in a population since most palliative care need arises during the last year of life. Based on this work the number of patients needing palliative care in the Norfolk PCT area is 6024 and 6010 per year for the two years examined (Table 12). On average Kings Lynn & West Norfolk has the largest palliative care need and Norwich has the least palliative care need. The number of patients with palliative care needs was calculated using the following formula described by Higginson, 2001. Number needing palliative care = all cancer deaths plus 67% of all other deaths Table 12: Need for palliative care based on the number of deaths 2006 2007 Breckland 128,314 368 1039 Those needing Palliative Care 1064 Broadland 122,184 356 970 1006 368 942 999 Kings Lynn & West Norfolk North Norfolk Norwich South Norfolk 142,254 100,598 129,535 116,158 739,043 426 367 337 347 2201 1195 923 824 755 5706 1227 985 889 853 436 364 294 386 2235 1186 896 765 817 5635 1231 964 807 933 Population Total Cancer Deaths Other Deaths 6024 Cancer Deaths Other Deaths 387 1029 Those needing Palliative Care 1076 6010 Most symptoms towards the end of life are common regardless of disease. Higginson (1996) has provided a method of calculating the number of patients that will exhibit a symptom. Based on that method the number of deaths in each area is multiplied by a symptom percentage (percentages used are listed in the first column below). The end result is a figure of the number of patients exhibiting that symptom per area, shown in Table 13 The most prevalent symptom is pain and it is likely that there is a significant need for pain control followed by breathlessness and a loss of appetite (Table 13). Table 13 Expected number of patients with symptoms by area Breckland Broadland Cancer 387 368 Kings Lynn & West Norfolk 436 Other diseases 1029 943 2007 - Cancer & Other diseases % Symptoms North Norfolk Norwich South Norfolk 364 294 386 1190 898 769 818 Cancer Pain 84 325 309 366 306 247 324 Other diseases Pain 67 689 632 797 602 515 548 Cancer Trouble with breathing 47 182 173 205 171 138 181 Other diseases Trouble with breathing 49 504 462 583 440 377 401 Cancer Vomiting or feeling sick 51 197 188 222 186 150 197 Other diseases Vomiting or feeling sick 27 278 255 321 242 208 221 Cancer Sleeplessness 51 197 188 222 186 150 197 Other diseases Sleeplessness 36 370 339 428 323 277 294 Cancer Mental confusion 33 128 121 144 120 97 127 Other diseases Mental confusion 38 391 358 452 341 292 311 Cancer Depression 38 147 140 166 138 112 147 Other diseases Depression 36 370 339 428 323 277 294 Cancer Loss of appetite 71 275 261 310 258 209 274 Other diseases Loss of appetite 38 391 358 452 341 292 311 Cancer Constipation 47 182 173 205 171 138 181 Other diseases Constipation 32 329 302 381 287 246 262 Cancer Bedsores 28 108 103 122 102 82 108 Other diseases Bedsores 14 144 132 167 126 108 115 Cancer Loss of bladder control 37 143 136 161 135 109 143 Other diseases Loss of bladder control 33 340 311 393 296 254 270 Cancer Loss of bowel control 25 97 92 109 91 74 97 Other diseases Loss of bowel control 22 226 207 262 198 169 180 Cancer Unpleasant smell 19 74 70 83 69 56 73 Other diseases Unpleasant smell 13 134 123 155 117 100 106 Map 9: Map of Norfolk showing Local Authority boundaries and the main Hospitals Map 9 illustrates the two primary acute trusts providing services to this region; the Norfolk & Norwich University Hospital, which is the primary hospital for this area and the Queen Elizabeth Hospital in Kings Lynn. Two additional acute hospitals serve the population of Norfolk but are outside the scope of this project as they are the James Paget Hospital in Great Yarmouth and the West Suffolk Hospital in Bury St Edmunds.