Lead organisation / SOUTH EAST CLINICAL NETWORK
Partner Organisations / Clinical Commissioning Group / Local Authority
Ashford
Brighton & Hove
Canterbury & Coastal
Coastal West Sussex
Crawley
Dartford Gravesham & Swanley
Eastbourne Hailsham & Seaford
East Surrey
Guildford & Waverley
Hastings & Rother
High Weald Lewes Havens
Horsham & Mid Sussex
Medway
North East Hampshire & Farnham
North West Surrey
South Kent Coast
Surrey Downs
Surrey Heath
Swale
Thanet
West Kent / Surrey CC
Brighton and Hove CC
Medway CC
Kent CC
West Sussex CC
East Sussex CC
Lead contact for partnership / NICKY JONAS
JACKIE HUDDLESTON
2. Call off volumes
Referral Numbers / Total referral / Lower uptake 25% / Upper uptake40%
2016/17 / August / 0 / Q2 / 0 / 0 / 0
September / 0
October / 285 / Q3 / 856 / 214 / 342
November / 285
December / 286
January / 407 / Q4 / 1222 / 306 / 489
February / 407
March / 408
2017/18 / April / 874 / Q1 / 2622 / 656 / 1049
May / 874
June / 874
July / 1080 / Q2 / 3240 / 810 / 1296
August / 1080
September / 1080
October / 1171 / Q3 / 3513 / 878 / 1405
November / 1171
December / 1171
January / 1220 / Q4 / 3660 / 915 / 1464
February / 1220
March / 1220
2018/19 / April / 1220 / Q1 / 3660 / 915 / 1464
May / 1220
June / 1220
July / 1220 / Q2 / 3660 / 915 / 1464
August / 1220
September / 1220
Y1 TOTAL / 2078 / 520 / 831
Y2 TOTAL / 13035 / 3259 / 5214
Y3 TOTAL / 7320 / 1830 / 2928
ALL TOTAL / 22433 / 5608 / 8973
3. Partnership Geography
Overview
Total population of 4.5 million spread across approx. 3600 square miles There are real extremes of affluence and deprivation - Surrey and West Sussex are amongst the most affluent areas in the country, while areas of north Kent and East Sussex have high levels of deprivation.
The urban to rural split is 20%: 80%.
Much of the area is well served by road, rail and bus links, however road congestion, overcrowding, poor transport in rural areas, lack of parking and non-car ownership may produce barriers to people accessing behavioural Intervention courses in certain areas.
KSS partners will be interested in learning how Providers can address some of these issues in order to optimise take up and attendance on courses
Geographical spread / Urban/Rural / Transport Links
Brighton & Hove / Brighton & Hove is the largest conurbation in Sussex, a hilly city located in a geographic administrative area of approximately 40 square kilometres /15 square miles with 11 kilometres of seafront and a population of almost 275,000 people. / The urban area is contained within the A27 road by-pass which represents a barrier to the chalk downland to the north and constitutes the general boundary of the national park in the west. Between the built-up area and the South Downs National Park lie more than fifty varied parcels of ‘urban fringe’ land) which cover a total area of 479 ha (~6% of BHCC) especially in east Brighton / Transport links in the city are good with no person being more than 0.6km from their GP surgery. 38% of households have no car in Brighton and Hove compared with 26% across England Brighton is a congested city, and not easy to drive or park in.
There is an extensive bus network in Brighton and Hove. In the city centre, services are very frequent. The service isn't cheap with a flat fare of £2 for single journeys or £4.60 for an all-day ticket
Brighton Railway Station is one of the most important rail terminals in the South East and from here the city of Brighton has a small suburban rail network with trains serving areas of Hove, Preston Park and also to the main campuses of the universities (Moulsecoomb, Falmer)
East Sussex / East Sussex covers an area of 660 square miles (1,725 sq. km). The county includes the boroughs of Eastbourne and Hastings and the districts of Lewes, Rother and Wealden, each with a distinct identityand particular local issues to address. It is home to around 500,000 people, with about 1 in 4 (24%) people are aged 65 years and over and 4% are aged 85 years and over. Within the county Bexhill and Seaford and parts of Eastbourne and the surrounding areas, have the oldest age profiles.
The most significant areas of deprivation are concentrated in the county’s coastal towns. Hastings is the most deprived of the local authority areas. However, there are pockets of deprivation scattered across some of the smaller towns and the more rural parts of the county. / East Sussex is a predominantly rural county ofvaried landscapes with remote ruraland environmentally sensitive areas,interspersed with villages and historicmarket towns. Two thirds of the countyis designated as an Area of Outstanding Natural Beauty (AONB) or National Park. More than half the population living on the coastal fringe in three main urban areas – Hastings, Bexhill, Eastbourne and surrounding settlements, and the coastal towns of Newhaven, Seaford and Peacehaven, with 26% of the population residing in rural communities. / The main coastal urban areas are linked east-west by parallel road (A27/ A259) and rail (East Coastway) links. There are two strategic corridors from the county north towards London – from Brighton via the A23/M23 and the Brighton Mainline and from Hastings via the A21 and the Hastings to Tonbridge rail line – whilst the Uckfield line provides a link to London from the centre of the county.
The main transport infrastructure challenges are: lack of a high standard road infrastructure; restricted rail network;road; traffic level growth;
The urban areas of the county are generally well served by commercial bus operators; however the needs of the rural areas and small market towns are less well served.
Surrey / Surrey is the one of the most densely populated shire counties in England with 6.9 persons per hectare. The overall population density of England is 4.1 persons per hectare. Woking is the most diverse district in Surrey with 75.0 per cent of its population identified as White British. Waverley is the least diverse with 90.6 per cent White British.
Elmbridge has the highest proportion (10.4 per cent) in all other white groups with Tandridge the lowest (4.6 per cent) Spelthorne has the highest proportion of Indian ethnic group (4.2 per cent) and Woking has the highest proportion of Pakistani ethnic group (5.7 per cent). / In the most urban districts, Epsom & Ewell and Spelthorne, there are more than 20 persons per hectare, but in the highly rural districts, Mole Valley, Tandridge and Waverley, there a fewer than 4 persons per hectare. 87% of inhabitants live in urban areas and yet 73% of land in Surrey is green belt. / As one of the most densely populated counties in the UK with traffic flows on A roads almost double the national average, transport related problems are a major concern for people living and working in Surrey.
Car ownership levels in Surrey are considerably higher than in England as a whole. However the complex geography of the county means there are significant concerns regards access to services and transport in the rural parts of Surrey.
While the county has a generally comprehensive rail network and a large number of rail stations, many services are at capacity and suffer from peak time overcrowding.
West Sussex / West Sussex covers 769 square miles, bordering Hampshire to the west, Surrey to the north, Brighton, Hove and East Sussex to the east and the sea to the south. 821,370 people reside in West Sussex, living mainly, along the coastline, a rural inland with key market towns and the economic area around Gatwick Airport.There are 7 districts, Arun, Chichester, Horsham, Crawley, Mid Sussex, Worthing, and Adur.The largest towns are Crawley, Worthing, Horsham and Bognor Regis. Deprived wards sit alongside some of the most affluent. The most deprived wards are located in Arun, (6 wards) Adur, (6 wards) Worthing (4 wards) Crawley (3 wards) and Chichester (1 ward). / Urban / Rural
West Sussex / 76.3% / 23.7%
Adur / 98.7% / 1.3%
Arun / 83.0% / 17.0%
Chichester / 47.0% / 53.0%
Crawley / 99.7% / 0.3%
Horsham / 39.4% / 60.6%
Mid Sussex / 82.0% / 18.0%
Worthing / 100.0% / 0.0%
/ M23 runs north from Bolney connecting to the M25
A23, A24, to Brighton and Worthing respectively. The A27, A29, A259, (coastal) A272 (mid Sussex) traverse the county east to west. The A27 connects to the M27 and M3 in Hampshire.
Rail links to London - connecting hubs at Barnham, Horsham, Haywards Heath and Brighton.
Coastal rail links run east to west connecting towns and larger villages from Brighton to Portsmouth and Southampton.
Buses serve all towns and villages - rural village services may be less frequent – some local community transport. The 700 Coast-Liner runs between Portsmouth and Brighton.
Gatwick Airport – Crawley
Medway / Demonstrator Site – NDPP will not be delivering a service in this area
Kent / Kent has a land area of 1,368 square miles and just over 350 miles of coastline. The map below sets out the towns, the economic zones and main transport routes which follow the Downs east and west in and through Kent
Its population is 1,510,400. 89.1% are recorded as being white, 6.3% as BME, and 1.24% as Asian (British). 3.5% are from other ethnic groups.
Thanet is the most deprivedarea and Sevenoaks the least. Deprivation has increased in Shepway, Thanet, Swale and Dover. Margate Central is the most deprived ward / People living in urban areas make up 73% of the Kent population but they only occupy 22% of the total land area.
- 85% of the land area is classed as green space,
- 6% of land accounts for domestic gardens
- Less than 2% of the land is covered by buildings.
- The deprivation map below gives a sense of the mainly coastal and urban nature and of Kent’s deprivation challenge.
This planned growth alone is predicted to result in 250,000 extra journeys on Kent’s roads by 2026 increasing congestion further. Kent’s population is ageing and this will put pressure on local community services. Providing access to these services for those without a car will continue to be a challenge.
Additional information
The South East is a highly complex healthcare landscape with 21 Clinical Commissioning Groups (CCGs), 13 acute provider NHS Trusts (some Foundation) across 19 acute hospitals, one ambulance service Foundation Trust, 3 Mental Health Partnership Trusts, 6 Community providers with a range of community hospitals, 6 Health & Wellbeing Boards, 5 Local Authorities and 600 GP practices
There is a high burden of long term conditions with 17.6% of Kent's population having an illness or condition which limits their day to day activities in some way.
4. Partnership Demographics
Population total with breakdown / Total:
Age / Male / Female
18-44yrs / 740,123 / 752,378
45-64yrs / 588,068 / 605,566
65+yrs / 401,098 / 493,626
Number of GP Practices / CCG / Number of Practices
NHS Ashford CCG / 14
NHS Canterbury and Coastal CCG / 21
NHS Dartford, Gravesham and Swanley CCG / 34
NHS Medway CCG / 56
NHS South Kent Coast CCG / 30
NHS Swale CCG / 19
NHS Thanet CCG / 17
NHS West Kent CCG / 61
NHS Brighton and Hove CCG / 45
NHS Coastal West Sussex CCG / 54
NHS Crawley CCG / 12
NHS East Surrey CCG / 18
NHS Eastbourne, Hailsham and Seaford CCG / 21
NHS Guildford and Waverley CCG / 21
NHS Hastings and Rother CCG / 32
NHS High Weald Lewes Havens CCG / 21
NHS Horsham and Mid Sussex CCG / 23
NHS North West Surrey CCG / 42
NHS Surrey Downs CCG / 33
NHS Surrey Heath CCG / 9
NHS Farnham and North Hants CCG / 24
Number of NHS Health Check Providers / Primary Care / In-house (by LA) / Other provider (e.g. 3rd sector outreach providers, etc.) / Comments
GP practice / Pharmacy
Surrey / 80 / 59 / 1 Bank advisor team, work on ad hoc bases, targeted delivery e.g., workplace and carers / 3 leisure Centres
West Sussex / 72 / 71 / Providing outreach in the community and workplaces) - 1 NHS Community Trust and 1 commercial 3rd sector company.
East Sussex / 71 / ES commissions GP providers in primary care only, and that is from all 71 GP practices in East Sussex
Medway / 54 / Medway only providers are GPs
Kent / 199
/ 40 / 5 -District Authorities, only 2 delivering / 1 Private provider Kent Community NHS Foundation Trust –Commissioned Provider (in house Checks: community clinics/ outreach) / These are all the providers that can provide checks, but not all of them are currently doing so; for example we have 5 district authorities listed but only 2 are actively delivering checks this year
Ethnic Mix / CCG / Population from Black ethnic groups / Population from Asian ethnic groups
NHS Ashford CCG / 1.17% / 3.38%
NHS Canterbury and Coastal CCG / 1.04% / 2.79%
NHS Dartford, Gravesham and Swanley CCG / 2.89% / 7.01%
NHS Medway CCG / 2.52% / 5.16%
NHS South Kent Coast CCG / 0.40% / 2.74%
NHS Swale CCG / 1.24% / 1.22%
NHS Thanet CCG / 0.68% / 1.87%
NHS West Kent CCG / 0.58% / 2.51%
NHS Brighton and Hove CCG / 1.53% / 4.13%
NHS Coastal West Sussex CCG / 0.49% / 1.83%
NHS Crawley CCG / 3.25% / 12.97%
NHS East Surrey CCG / 1.39% / 4.17%
NHS Eastbourne, Hailsham and Seaford CCG / 0.55% / 2.11%
NHS Guildford and Waverley CCG / 0.91% / 3.73%
NHS Hastings and Rother CCG / 0.76% / 1.79%
NHS High Weald Lewes Havens CCG / 0.33% / 1.27%
NHS Horsham and Mid Sussex CCG / 0.60% / 2.63%
NHS North West Surrey CCG / 1.27% / 7.89%
NHS Surrey Downs CCG / 0.95% / 5.19%
NHS Surrey Heath CCG / 0.99% / 5.96%
NHS Farnham and North Hants CCG / 1.20% / 6.20%
Languages spoken / Overview
KSS enjoys a diverse population with many languages spoken, and significant numbers of people who do not have English as a preferred language.
The KSS Partnership will be interested to hear how providers can encourage participation in the Behaviour Intervention (BI) Courses, not just in terms of languages spoken, but understanding of cultural factors - especially around food choices, exercise and attitudes to health.
Weare also interested in hearing about how providers have thought about offering people a range of opportunities (in consideration of cultural requirements) for attending and participation in courses, in person/remotely/group/1:1
Brighton & Hove / 8.3% do not have English as their preferred or first language. 0.8% is Arabic; 0.8%, Polish; and 0.7%, Chinese.
East Sussex / The proportion of the population from non-white Black and Minority Ethnic (BME) groups was 8%, compared to 20% nationally and 15% regionally. This group tends to be younger than the White British and Northern Irish group. (Census 2011)
Surrey / Nearly 65,000 Surrey residents speak a main language other than English, the most common other languages spoken are Polish (6.634 speakers) and Chinese languages (4,426 speakers). Most can speak English, but almost 7,500 residents cannot speak English well.
Nepalese, Polish, Somalian, Spanish, Italian and South Asian languages such as Urdu, Hindi, and Guajarati are also spoken
West Sussex / The population is predominantly white British (88.9%). White other and Asians hold the second and third largest shares with 4.0% and 3.3% respectively. 37,000 (4.7%) of the total population has a main language other than English; of which over 30,000 can speak English “well” to “very well”. 36% of those that do not have English as a main language reside in Crawley.
Other languages include French, Spanish and Portuguese (12% of 37k); Other EU ( 23% of 37k), West Asian/African ( 9% of 37k) and South East Asian – various languages (21% of 37k); and Chinese (4% of 37k)
Medway / Demonstrator Site – NDPP does not need to offer a service in Medway.
Kent / According to the census approximately 1,350,000 of the population speak English. The details of all languages can be found in the link below:
Of note, in South Kent there are Polish, Greek, Romanian and Nepalese speaking communities
In Gravesend the main languages spoken after English are Slovak, Russian, Polish and Turkish.
Dartford has a high proportion of Mandarin speakers and Swanley has an Italian community.
Gujarati, Punjabi, Hindu, and Urdu are some of the main Asian languages spoken.
In West Kent, after English, the following are the top 10 most commonly spoken languages in Kent and Medway: Nepali, Bengali, Polish, Panjabi (Gurumukhi), Panjabi, Tamil, Slovak, Yoruba, French, Malayalam.
In Thanet, after English, Polish and Slovak are the only languages spoken by more than 0.5% (0.8% and 0.6% respectively)
Type 2 diabetes prevalence / CCG / Recorded Prevalence / Estimated prevalence
NHS Ashford CCG / 6.1 / 7.1
NHS Canterbury and Coastal CCG / 5.8 / 7.2
NHS Dartford, Gravesham and Swanley CCG / 6.3 / 7.2
NHS Medway CCG / 6.7 / 6.7
NHS South Kent Coast CCG / 6.9 / 7.9
NHS Swale CCG / 7.1 / 7.1
NHS Thanet CCG / 7.2 / 8.2
NHS West Kent CCG / 5.5 / 6.7
NHS Brighton and Hove CCG / 4.1 / 6.2
NHS Coastal West Sussex CCG / 6.5 / 7.9
NHS Crawley CCG / 6.2 / 6.9
NHS East Surrey CCG / 5.0 / 6.7
NHS Eastbourne, Hailsham and Seaford CCG / 6.2 / 8.2
NHS Guildford and Waverley CCG / 4.3 / 6.4
NHS Hastings and Rother CCG / 6.5 / 8.4
NHS High Weald Lewes Havens CCG / 5.4 / 7.3
NHS Horsham and Mid Sussex CCG / 5.1 / 6.5
NHS North West Surrey CCG / 5.4 / 6.8
NHS Surrey Downs CCG / 4.8 / 6.8
NHS Surrey Heath CCG / 5.3 / 6.6
NHS Farnham and North Hants CCG / 5.2 / 6.3
There are an estimated 266,350 people in the South East coast with diabetes, when adjustments are made for age, sex, ethnic group and deprivation. This is 7.3% of the adult population, higher than the average prevalence for diabetes for England as a whole of 7.4%.
Diabetes Public Health Profile. PHE
Modelled Numbers at risk of Type 2 diabetes / CCG / At risk population (registered) / Prevalence
NHS Ashford CCG / 11,030 / 10.9%
NHS Brighton & Hove CCG / 22,013 / 8.4%
NHS Canterbury and Coastal CCG / 19,773 / 10.9%
NHS Coastal West Sussex CCG / 52,484 / 12.5%
NHS Crawley CCG / 10,804 / 10.4%
NHS Dartford, Gravesham and Swanley CCG / 23,005 / 11.1%
NHS East Surrey CCG / 15,546 / 10.9%
NHS Eastbourne, Hailsham and Seaford CCG / 20,703 / 12.9%
NHS Guildford and Waverley CCG / 19,598 / 10.8%
NHS Hastings & Rother CCG / 19,474 / 12.6%
NHS High Weald Lewes Havens CCG / 16,746 / 12.1%
NHS Horsham and Mid Sussex CCG / 21,508 / 11.4%