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Health of the Region 2020

Section 1 - Health and health inequalities in the West Midlands region

This section describes the people who live in the WMCA’s seven constituent local authority areas, how long they live, and the factors that contribute to inequalities in health, wellbeing and quality of life It also considers who is most vulnerable to COVID-19, both in terms of health and economic impacts

Who are our people?

The West Midlands Combined Authority (WMCA) membership consists of 18 local authorities (seven of which are constituent members) and three Local Enterprise Partnerships (LEPs) (Figure 2) For the purpose of this report, the main focus will be on the seven constituent authority areas: Birmingham, Coventry, Dudley, Sandwell, Solihull, Walsall and Wolverhampton However, many of the issues and approaches identified will be applicable across the West Midlands region as a whole, particularly in relation to groups that may be disproportionately affected by the health and economic impacts of COVID-19

The WMCA has a population of approximately 2 9 million
people Birmingham is the largest constituent authority with approximately 1 1 million residents; the remaining population is more or less evenly distributed between the other six constituent local authorities The population of the WMCA is diverse, both between and within Local Authority areas.

Population density is the highest in Birmingham, with 42 6 people per hectare and lowest in Solihull with 12 2 people per hectare (2019 mid-year population estimates, ONS) The population has grown faster than previously anticipated and is projected to increase by 9 6% by 2038

Age and sex

Figure 3 shows the distribution of female and male residents across 5-year age bands On average, the population is slightly younger than the England average and has a slightly higher proportion of working age people However, this varies considerably across the region, ranging from 32 1 years in Coventry to 43 1 years in Solihull.

Table 1: WMCA population estimates by age group

Total Population
Aged 0-15
Working age population
Aged 65+
Dependency ratio

2,916,415

626,190

1,839,350

450,875

0.59

49 5% male; 50 5% female

21 5% (England average = 19 2%)

63 1% (England average = 62 6%)

15 5% (England average = 18 2%)

England average = 0 60

 

 

% of total population in each age band

Male

  • 7.1

Female

  • 6.6

Male

  • 7.3

Female

  • 6.7

Male

  • 6.7

Female

  • 6.2

Male

  • 6.5

Female

  • 6.0

Male

  • 8.0

Female

  • 7.6

Male

  • 8.0

Female

  • 7.7

Male

  • 7.2

Female

  • 2.0

Male

  • 6.6

Female

  • 6.6

Male

  • 5.8

Female

  • 5.7

Male

  • 6.4

Female

  • 6.4

Male

  • 6.2

Female

  • 6.4

Male

  • 5.6

Female

  • 5.6

Male

  • 4.6

Female

  • 4.7

Male

  • 4.3

Female

  • 4.1

Male

  • 3.7

Female

  • 4.1

Male

  • 2.7

Female

  • 3.2

Male

  • 2.0

Female

  • 2.6

Male

  • 1.6

Female

  • 2.7

Figure 3: WMCA population Estimates by 5-year age band

Mid-year estimates, ONS (2018)

Ethnicity

The WMCA population is more ethnically diverse than that of both England and the West Midlands region overall, and a high rate of international net in-migration with variations in the origins of migrants means that this diversity is likely to increase with our growing population In the WMCA an estimated 30 6% of our residents are from BAME groups compared with 14 0% in England and 17 4 across the whole of the West Midlands This ranges from 9 0% in Dudley to 43 0% in Birmingham

We also have slightly more residents who were born outside the UK or do not have English as their main language, though the gap is far smaller In the WMCA 16 6% of the population were born outside the UK (England average 13 8%), and just 5 7% are in households where no members have English as a first language (England average 4 4%; ONS Census 2011) These figures will include people from White non-British backgrounds

This reflects the nuanced relationship between ethnicity
and nationality, and the fact that many families from diverse ethnic backgrounds have been settled in the UK for a number of generations This is especially relevant when considering approaches to community engagement: although there may be characteristics and experiences that are common among specific groups, the categories are broad and it is important to understand the diversity of the populations – and their needs and experiences as individuals and families - within them Rather than providing an in-depth analysis of the issues affecting specific demographic groups, these profiles serve as indicators of where further attention may be needed.

Sexual Orientation

In 2018, 94 4% of the England population aged 16 years and over identified as heterosexual or straight This represents a continuation of the decrease seen since 2014, when 95 1% of the population identified themselves as heterosexual or straight 2.3% of people identified as lesbian, gay or bisexual, with 0.6% identifying as ‘other’ and 2.8% stating that they did not know or did not want to say 17 It is acknowledged that there is likely to be underreporting of LGB identities, and the actual figure is estimated to be around 5-7% 18

The East Midlands and West Midlands were the regions that saw the largest change in the proportion of people identifying as LGB over the last four years, with both increasing from 2014 to 2018 (from 1.2% to 2.2% and 1.3% to 2 3% respectively)

No robust data on the UK transgender population exists; however, the Government Equalities Office tentatively estimates that there are approximately 200,000-500,000 trans people in the UK 19.

Faith or Belief

People in the West Midlands region have a greater level of religious affiliation than in England & Wales overall (ONS Census 2011) The majority of the population (60 2%) are Christian (E&W 59 0%), and 6 7% are Muslim (E&W 5 0%) 22 0% declared that they have no religion compared with 25% in England & Wales 20

Disability

Almost 1 in 5 people in the West Midlands Metropolitan area (19 2%) has a limiting or long-term illness or disability This is higher than England overall (ONS Census 2011)

The Equality Act defines disability as any physical or mental impairment that has a substantial and long term effect on people’s ability to carry out day to day activities This covers a broad spectrum of conditions including mobility difficulties, sight loss, hearing loss, people with mental health impairments, dyslexia and other neurodiverse conditions, speech impairments and people with learning disabilities Progressive conditions such as HIV, cancer, dementia and multiple sclerosis are also included

Life expectancy and quality of life

How long are lives?

Life expectancy is the average number of years that an individual is expected to live based on current mortality rates People in the WMCA have shorter lives than the average for the UK, with women living a little longer than men in line with national trends (Table 2) Life expectancy in the WMCA is 82 2 years for females and 78 0 years for males – this is 1 0 years lower than England for females and1 6 years lower for males respectively This corresponds to a higher level of socioeconomic deprivation across the WMCA overall compared to the national average.

The length of life also varies significantly within the WMCA area People live longest in Solihull and lives are shortest in Sandwell and Wolverhampton, again reflecting patterns of socioeconomic deprivation There is also variation within these areas Inequality in life expectancy at birth is a measure of disparity which shows how much life expectancy varies with deprivation within England as a whole and within local areas Within the WMCA region, inequality in life expectancy at birth is greatest in Coventry and Solihull, indicating that the relative advantages these areas have are not distributed evenly across their populations (see Table 2)

Whilst most people live long lives, it is also sadly true that more babies die here before the age of one than they do on average in the rest of England Our infant mortality rate is 6 7 per 1,000 live births compared with a national figure of 3 9 Again, there are differences across the region, from 4 4 per 1,000 live births in Dudley to 8 2 in Sandwell

Table 2: Overview of health inequalities in the WMCA

Indicators
Period
England
WMCA
Birmingham
Coventry

Deprivation score (IMD 2019)

2019

21.7 31.9 38.1 25.6

Life expectancy at birth (Female)

2016-18

83.2 82.2 82.2 82.1

Life expectancy at birth (Male)

2016-18

79.6 78.8 77.7 78.5

Inequality in life expectancy at birth (Female)

2016-18

7.5 - 5.6 8.3

Inequality in life expectancy at birth (Male)

2016-18

9.5 - 8.3 10.7

Infant mortality (persons <1 yr) – crude rate per 1000 live births (2016-18)

2016-18

3.9 6.7 7.4 5.0

Mortality from causes considered preventable - age- standardised rate per 100,000 population (2016-18)

2016-18

180.8 219.0 225.7 217.6

 

Dudley
Sandwell
Solihull
Walsall
Wolverhampton
24.1 34.9 17.4 31.6 32.1
82.8 81.1 84.1 82.0 81.4
79.0 76.9 80.3 77.5 77.2
7.6 8.0 9.8 8.8 6.3
9.0 8.6 12.3 10.4 7.8
4.4 8.2 5.4 7.1 6.0
207.2 241.3 165.3 226.0 237.2
Quality of Life

Health is not only measured in how long we live It is also measured by the quality of our lives Here too, the picture is generally not as good here as it is elsewhere in the UK Healthy life expectancy is measured as the number of years we live in generally good health Data show the same pattern of below average outcomes, and of variation across and within our region (Table 3 & Figure 4)

Table 3: Quality of life measures in the WMCA – local area comparisons.

Indicators
Period
England
WMCA
Birmingham
Coventry

Healthy life expectancy at birth (Female)

2016-18

63.9

59.8

59.6

62.5

Healthy life expectancy at birth (Male)

2016-18

63.4

59.6

59.2 61.9

School readiness: percentage of children achieving a good level of development at the end of Reception - %

2018/19

-

71.8 - 68.0

Health-related quality of life for older people

2016/17

0.735 0.696 0.696 0.703

Self-reported well-being - high satisfaction score: % of respondents

2018/19

7.8 - 7.4 9.8

Self-reported well-being - high happiness score: % of respondents

2018/19

19.7 - 17.2 21.7

 

Dudley
Sandwell
Solihull
Walsall
Wolverhampton
60.3 57.9 64.3 55.7 58.0
59.4 57.1 65.3 56.4 58.7
69.0 67.1 66.8 72.6 67.5
0.713 0.660 0.744 0.683 0.697
8.1 8.9 6.7 10.5 7.8
17.8 17.2 19.4 23.8 14.4
Impacts of of COVID-19 on length and quality of life

At present it is too early to say how life expectancy and healthy life expectancy may change over the longer term as a result of the pandemic In addition to deaths resulting from COVID-19, it is also important to look at what is happening with trends in deaths from other causes

Figure 5 shows rates of confirmed COVID-19 cases across the West Midlands region as of 29th October 2020 It is clear that the WMCA has a higher rate
of cases overall than the region as a whole, with Birmingham and Sandwell most affected. Rates are also high in Solihull, Walsall and Wolverhampton

Figure 6 shows that there was an increase in excess deaths from the week ending 27 March, peaking in the week ending 10 April before declining and returning to baseline levels in the week ending 22 May While many of these were COVID-19 related, a marked proportion of excess deaths during this period did not have COVID-19 mentioned on the death certificate, suggesting an increase in deaths from other causes during this period.

As of October 2020, the overall rate of deaths in the WMCA region is not significantly different to previous years, with 6 0% of those deaths known to be COVID-19 related.

 

Who is most at risk

Our interim report details existing risk factors and inequalities in the WMCA that are associated with increased risk of infection and death or complications from COVID-19 The risk associated with age – of those 80 or older – is lower in the WMCA area than the national average; however, this appears to be countered by other risk factors and inequalities, most notably socioeconomic deprivation, ethnicity, occupation and prevalence of excess weight and diabetes.

National data show that disabled people (those limited a little or limited a lot in their day-to-day activities) made up almost 6 in 10 (59%) of all deaths involving COVID-19 during the period from 2 March to 14 July 2020 After adjusting for region, population density, socio-demographic and household characteristics, the relative difference in mortality rates between those disabled and limited a lot and those non-disabled was 2 4 times higher for females and 2 0 times higher for males. 22

Table 4: COVID-19 cases and deaths by Local Authority, WMCA 23

Upper Tier Local Authority District name (2019)
IMD (2019) Average Rank per 1,000
Number of confirmed COVID-19 cases
Rate of confirmed COVID-19 cases per 100,000

Birmingham

25.32

17,896 1,567.3
Coventry 19.43 4,054 1,091.2
Dudley 18.19 2,924 909.2
Sandwell 25.28 4,721 1,437.4
Solihull 12.51 2,703 1,249.2
Walsall 22.16 3,765 1,287.3
Wolverhampton 23.27 3,288 1,248.5
WMCA 20.88 39,351 1,343.68
West Midlands 14.26 65,597 1,105.4
England 16.36 647,025 1,149.5

In line with national findings, aggregate data for the region shows that higher rates of COVID-19 deaths were broadly associated with Walsall Sandwell greater levels of deprivation and a higher proportion of residents Solihull Wolverhampton from BAME communities (Table 4 and Figures 7a and 7b) National Birmingham WMCA analyses showed that as of April 2020, men and women in the black 80 Dudley West Midlands community were over four times (4 2 and 4 3 times respectively) as England likely to die from COVID-19 than the white population once age had Rate of COVID-19 related deaths per 100,000
60 been accounted for Men of Bangladeshi and Pakistani origin were Coventry 3-6 times more likely to have a COVID-19 related death, while the fig4u0re for women was 3 4 times more likely. 24

Once geography (region, area deprivation and whether rural/ urban), household composition, socio-economic status and health had been adjusted for, the risk reduced considerably: Black men and women were both 1.9 times more likely to die from COVID-19 than the white population, while the figures for men and women of Bangladeshi and Pakistani origin were 2.1 and 1.6 respectively.

The SAVI is an empirically informed measure of COVID19 vulnerability for each Middle Super Output Area (MSOA) in England The SAVI index investigates the association between each predictor (proportion of the population from Black, Asian and Minority Ethnic (BAME) backgrounds, income deprived, over 80 years old, living in care homes, living in overcrowded housing and having been admitted in the past 5 years for a chronic health condition) and COVID19 mortality using a multivariable Poisson regression, whilst accounting for the regional spread and duration of the epidemic

The SAVI provides a score for each MSOA in England that indicates the relative increase in COVID mortality risk that results from the level of each of the six vulnerability measures for each area

Nationally, high levels of vulnerability to COVID-19 have been found to cluster in the North West, West Midlands and North East regions Out of the 513 MSOAs covering the WMCA 3 LEP area there were 49 MSOAs (10%) that had a score under 1 whilst 15 MSOAs had a score of 2 plus (3%) The most vulnerable MSOA within the WMCA 3 LEP area was Tettenhall South in Wolverhampton with a score of 2 89 for increase in risk (the 16th highest score in England) Within the West Midlands region, there were high scoring clusters in Wolverhampton, Birmingham, Bromsgrove, Wyre Forest, Stratford-on-Avon and Rugby.

PHE’s more recent analysis,25 which included age, sex, deprivation, region and ethnicity, showed that the risk of dying following a positive test for COVID-19 (pillar 1) was:

  • 70 times higher in people 80 years or older than those under 40

  • Higher in males than females (2x in working ages)

  • Higher in those living in the more deprived areas vs those living in the least deprived areas (2x)

  • Higher in many Black, Asian and Minority Ethnic (BAME) groups than the White British ethnic group (up to 2x)

  • Compared with the White British group, the risk of dying following a positive pillar 1 test was:

  • 2.0 times higher for the Bangladeshi group

  • 1.4 times higher for the Pakistani group

  • 1.3 times higher for the Chinese group

  • 1.2 times higher for the Indian group

  • 1.1 times higher for the Other Asian group

  • 1.1 times higher for the Black Caribbean group

  • 1.4 times higher for the Other Black group

  • Not significantly different for those in the Other ethnic group

The analysis did not include comorbidities, and it was noted that other evidence had shown a marked reduction in risk of death by ethnic group among hospitalised patients when comorbidities had been taken into account More recently, the Race Disparity Unit’s first quarterly report on progress to address COVID-19 health inequalities confirmed that the evidence showed an increased risk for Black and South Asian ethnic groups, with a reduced relative risk of mortality when taking into account socioeconomic and geographical factors associated with different ethnic groups such as occupational exposure, population density, household composition and pre-existing health conditions It was noted that deprivation is a good marker of many of these factors However, despite most of the increased risk for ethnic minorities being readily explained by these factors, it was not fully explained for some groups such as Black men. 26

What this tells us is not that the risks presented by COVID-19 are any less severe for people from ethnic minority groups than we had first thought It tells us what is driving those risks - namely occupation, housing, income - and is a powerful illustration of how structural disadvantage is entrenched in the social, economic and environmental determinants of health.

This is emphasised in the findings and recommendations of the Doreen Lawrence Review (2020) on the ‘avoidable crisis’ that is the disproportionate impact of COVID-19 on people from BAME communities.

The review demonstrates how people from BAME communities have been overexposed, under protected, stigmatised and overlooked during the pandemic, and calls for urgent action to reduce health inequalities and tackle systemic racism. 27

Box 1: Why have our Black & Minority Ethnic (BAME) communities been most affected by COVID-19?

National and regional evidence suggests that increased risk among BAME communities is due to a number of intersecting factors, including:

  • Increased prevalence of chronic disease

  • Reduced likelihood of using primary care services

  • Being more likely to work in sectors associated with increased risk, particularly in the health and care, hospitality and transport sectors

  • Failure to protect key workers and a lack of PPE in the early stages of the pandemic

  • Income inequality and deprivation, including household overcrowding

  • A system that is inadequately equipped to address the issue, including a lack of complete and high-quality ethnicity data and a lack of funding where it is most needed

  • These factors are not independent of one another, but instead interact to increase not just the direct risks associated with COVID-19, but its socioeconomic and psychosocial impacts

  • Systemic racism and discrimination operates across the health and wider system to influence all of these factors

Regionally, this was explored in greater depth through the West Midlands Inquiry Into COVID-19 fatalities in the West Midlands published in August 2020 28 The Inquiry reported evidence given to Birmingham Health and Wellbeing Board that in March 2020, 64% of COVID-19 deaths in Birmingham City Hospital where from ‘the Black African and Asian communities’ and in April, the figure was 50% It concluded that a ‘perfect storm’ of factors meant the BAME community was hit the hardest: increased prevalence of chronic disease, reduced likelihood of using primary care services and failure to protect key workers, particularly in the health and care, hospitality and transport sectors, placed individuals from BAME communities at disproportionate levels of risk Income inequality was identified as a key factor in exacerbating the risk further

These findings have been supported by regional analyses and additional evidence submitted by stake holders.

An analysis of occupation and its intersection with ethnicity revealed that the WMCA area has a higher proportion of jobs within sectors associated with a higher increase in excess all cause deaths and increased exposure to infection – and that jobs in these sectors are disproportionately held by ethnic groups associated with poorer COVID-19 health outcomes 29 Exacerbation of existing inequalities, disproportionate impacts on people from BAME communities and access to healthcare were prominent themes in the evidence provided by local stakeholders regarding the impacts of COVID-19 in their communities (see Appendix 2)

The inquiry also highlighted system issues that make us inadequately equipped to tackle entrenched systemic discrimination, including a lack of complete and high-quality data on ethnicity, and a lack of funding where it is most needed It was revealed that the most diverse areas in the West Midlands – Birmingham, Wolverhampton and Sandwell – have suffered the greatest cuts in public health funding over the last 5 years, with cuts of 9%, 8% and 15% respectively (England average 5%)

A recent report from University Hospitals Birmingham NHS Foundation Trust, which found that there were more admissions from South Asian patients than would be expected based on the local population Those patients were admitted with a worse severity of COVID-19 respiratory compromise without a significant delay in presentation and experience a higher level of mortality even when differences in age, sex, deprivation and key comorbidities were taken into account. 30

Overall, the factors driving the association between ethnicity and COVID-19 risks and outcomes are multi-faceted and interact with one another Later in this paper in Section 1 5, we also consider the role of structural racism.

The role of underlying inequalities and structural disadvantage is nevertheless key, and it is clear that change is needed over the longer term to address these inequalities In the short to medium term, it is important to identify where action can be more readily taken to improve outcomes A review paper by the Scientific Advisory Group for Emergencies (SAGE) of the drivers of increased COVID-19 incidence, mortality and morbidity among minority ethnic groups concluded that although the relative importance of different pathways causing ethnic inequalities in outcomes is not well understood, we should focus on understanding those that are immediately modifiable for example occupation and healthcare access 31 The review also emphasised the importance of data quality, noting that limited information on the clinical presentation of the disease and the social determinants of health limits insights that can be gained from detailed quantitative analysis.

Impacts on wellbeing

Effects on wellbeing are more readily measurable at this point, although the issue of whether population wellbeing has declined as a result of the pandemic is less straightforward Data on self- reported wellbeing measures from the first week post-lockdown (week ending 22 March) to the most recent data available (w/e 02 August) show that in England, percentages of people aged 16+ reporting high anxiety and low life satisfaction, self-worth and happiness were generally higher throughout 2020 than in 2019. 32

Nationally, while low self-worth and low life satisfaction have fluctuated over this period, anxiety and low happiness have generally declined since the start of lockdown In the West Midlands region:

  • The percentage of people reporting a high anxiety score was 47 9% during the week ending 22 March compared with 41 2% during the week ending 02 August - baseline 21 9% (England averages 50 6 and 35 2 respectively – baseline 22 6) In the West Midlands, anxiety was the only measure which showed a statistically significant increase from baseline to the most recent measure

  • The percentage of people reporting a low life satisfaction score was 3 8% during the week ending 22 March compared with 9 4% during the week ending 02 August – baseline 9 7% (England averages 7 7 and 8 1 respectively – baseline 5 7)

  • The percentage of people reporting a low self-worth score was 5 6% during the week ending 22 March compared with 6 9% during the week ending 02 August - baseline 4 9% (England averages 7 0 and 7 7 respectively – baseline 2 9)

  • The percentage of people reporting a low happiness score was 14 5% during the week ending 22 March compared with 10 7% during the week ending 02 August - baseline 8 4% (England averages 20 9 and 10 0 respectively – baseline 8 2)

Loneliness is a key contributor to poor mental wellbeing Figures 9a and 9b show the percentages of people in England who reported feeling ‘often lonely’ or ‘never lonely’ since the start of April 2020 On average, people reporting feeling ‘often lonely’ ranged from 4 9% to 6 5% over this period; when disaggregated by age group, this was generally higher for younger people (16- 34) and lower for older people (65+), although this fluctuated over the lockdown period (Figure 9a) Conversely, the percentages of people who reported feeling ‘never lonely’ was consistently highest for older people (65+) and lowest for younger people (16- 35), with those in the middle age group (36-64) consistently in between (see Figure 9b; England average range 17 9% to 21 7%).

This may reflect those in education or employment experiencing greater changes to their usual levels of social contact as a result of lockdown However, people who had an underlying health condition were consistently more likely to report often feeling lonely, which is consistent with data showing that a large proportion of adult social care users experience social isolation (see 1 5 below).

Data from the online mental health support services Kooth and Quell33,34 released in May 2020 demonstrated an increase in requests for support nationally compared to the same period in 2019, for both children and young people (33% increase)
and adults (53% increase) In areas that were most affected by COVID-19, there was a sharp increase in children and young people seeking support for bereavement and loss of families Among adults, the health of others was a key concern, as well as the pressures of changing work cultures and environments, and increases in loneliness, sadness and depression In the Midlands region overall, presentations to the service by children and young people decreased for sadness, sleep issues, family relationships and loneliness, but increased for eating issues, school/college worries and suicidal thoughts Among both age groups there was a national increase in presentations relating to abuse; this is discussed further in section 1 5 It is important to note that these data only include those with access to online support, and may not reflect additional challenges faced by those who are digitally excluded (Box 4).

Causes of ill health, early death and preventable disease

There are many different ways to answer the question of what causes early death and ill- health We need to know more about the different conditions which have led to the death, and we need to know more about what increases the risk of developing these conditions

It is important to note that averages across local authorities may mask inequalities at smaller area levels, or between demographic groups Nationally, there is a marked social gradient in the causes of premature death considered preventable, with significantly higher rates in more deprived areas In addition, degree of caution is needed when interpreting data on service use and benefit claims Higher values may reflect higher population prevalence of a condition, but alternatively they may indicate increased likelihood of diagnosis and access to support

Conditions

Any death under the age of 75 years is considered to be a premature death, and many of the diseases that cause these deaths are preventable The gap in life expectancy between the WMCA and England overall is due to increased premature death from a number of preventable conditions Under 75 mortality from preventable cancers and from cardiovascular, liver and respiratory diseases are all higher in the WMCA than the national average This is broadly consistent among all constituent authorities, with the exception of Solihull where rates are generally lower Alcohol- specific mortality follows a similar pattern Excess winter deaths, and deaths from drug misuse and suicide across the region generally reflect the national average, but this does not diminish their importance and impact

Table 5: Health outcomes in the WMCA – local area comparisons

Indicators
Period
WMCA Number
England
WMCA
Birmingham

Under 75 mortality from cancer considered preventable - directly standardised rate per 100,000 population

2016-18

5,512 76.3 87.0 88.8

Under 75 mortality from cardiovascular diseases considered preventable - directly standardised rate per 100,000 population

2016-18

3,706

45.3 58.5 61.9

Under 75 mortality from liver diseases considered preventable - directly standardised rate per 100,000 population

2016-18

1,451

16.3 22.0 21.4

Under 75 mortality from respiratory diseases considered preventable - directly standardised rate per 100,000 population

2016-18

1,402

19.2 22.6 23.2

Excess winter deaths index (Aug 2017-Jul 2018)

Aug17- Jul18

2,263

30.1 29.0 27.9

Alcohol-specific mortality - directly standardised rate per 100,000

2016-18

1,155

10.8 15.6 15.0

Deaths from drug misuse - age-standardised rate per 100,000 population

2016-18

- 4.5 4.6 6.3

Suicide (persons, 10+ yrs) – age-standardised rate per 100,000 population

2016-18

- 9.6 - 8.1

Diabetes: QOF prevalence (18+)

2018/2019

210,154

6.9 8.4 8.7 

CHD: QOF prevalence (18+)

2018/19

98,372

3.1 3.1 2.7

People reporting a long term musculoskeletal (MSK) problem - %

2018/19

- 16.9 17.5 17.9

Depression: Recorded prevalence (aged 18)

2018/19

- 9.9 9.6 9.2

Estimated prevalence of common mental disorders: % of population aged 16 & over (modelled)

2017 - 16.9 - 21.1

ESA claimants for mental and behavioural disorders: crude rate per 1,000 working age population

2018 59,470 27.3 33.3 36.0

 

Coventry
Dudley
Sandwell
Solihull
Walsall
Wolverhampton
85.7 90.1 87.7 69.0 89.3 93.9
56.2 48.6 68.5 39.7 61.6 68.1
20.1 21.9 26.2 16.9 22.1 26.3
21.4 20.1 27.7 15.5 22.6 23.4
27.9 28.2 27.8 30.7 31.6 31.1
13.5 16.0 20.7 9.6 16.1 18.9
3.3 4.2 1.2 4.8 4.6 4.0
8.6 9.7 10.6 12.2 8.2 9.0
6.7 8.0 9.5 7.3 9.2 8.4
2.3 4.1 3.6 3.2 3.9 3.1
18.5 15.4 16.5 21.5 20.3 16.9
9.3 11.7 8.6 9.0 10.5 10.0
19.1 17.4 21.5 14.7 19.4 20.5
31.4 24.9 37.0 22.0 36.5 35.2

 

Mental health problems and inequalities

Physical and mental health are inextricably linked Poor mental health is both a cause and consequence of poor health in general across the life course, with most mental health problems developing before the age of 25 People with severe mental illness (SMI) die 15-10 years earlier on average compared with the general population

and two thirds of these deaths are from preventable physical illnesses, including cancer and heart disease The determinants of physical and mental health problems often overlap; mental health problems disproportionately affect people living in poverty, those who are unemployed and who already face discrimination 35 Poor mental health also has a detrimental effect on health behaviours; for example, 40 5% of adults with SMI in England are smokers compared with 13 9% of the general population In the WMCA these figures are 40 3% and 14 6% respectively (PHE Tobacco Control Profiles)

The health data show that mental health and well-being in the WMCA is of concern as well as physical health As might be expected from an understanding of the causes of the causes of poor physical health, it also shows the pattern of variation between the different parts of the WMCA area Here, the comparison with the UK average is not so stark; however, this should again be understood in the context that wellbeing across the UK is also of concern Walsall and Wolverhampton have a higher recorded prevalence of depression, and a higher proportion of people claiming ESA for mental and behavioural problems This is in in line with lower levels of self- reported wellbeing in these areas For Solihull these are generally lower Among other areas, however, there appears to be little consistency between these indicators (Table 5) Figure 10 shows the excess under 75 mortality rate in adults with serious mental illness in the WMCA; rates are highest in Birmingham and Wolverhampton and lowest in Sandwell and Solihull.

People from BAME communities are significantly more likely to suffer poorer mental health outcomes due to facing more barriers to accessing treatment and poorer experiences of services Ethnic minorities are at an increased risk of involuntary detention under the Mental Health Act, but less likely to access earlier intervention and treatment High levels of inequality in access to, and experience of, mental health care are also evident for children and young people; lesbian, gay, bisexual, transgender and/or queer/ questioning ‘plus’ (LGBTQ+); homeless people; and people living with physical or learning disabilities There is often intersection across these groups and with other determinants of health. 36

At its simplest, unhealthy lifestyles increase our chances of ill-health There are four major, relatively straightforward, behaviours which will increase the risks of ill-health and death from these preventable diseases These are smoking; taking too little exercise; eating too much of foods that are high in fat, salt and sugar; and drinking too much alcohol Figures 11a and 11b show the main causes of preventable deaths in the WMCA, and the key health behaviours associated with those risks.

People in the WMCA are more likely than the England average population to smoke, drink too much alcohol, be overweight or obese, and be physically inactive In some cases, it can be seen that the figures are high nationally too It is important that this does not dilute the need to pay attention to reducing these figures in the West Midlands These are worrying signs that unhealthy lifestyles across the UK are very common and that improvements are not yet being made across the wider system to support people to live healthier lives

Unhealthy lifestyles are not only evident amongst adults. A younger generation of residents are now likely to grow up into being unhealthy adults, whose quality of life is not as good as it could be Here, as nationally, this may be the first generation of children who do not live as long as their parents.

Table 6: Health behaviours and risks in the WMCA – local area comparisons

 

Indicators
Period
WMCA Number
England
WMCA
Birmingham

Smoking prevalence in adults (18+): current smokers - % (APS)

2019 - 13.9 14.6 14.8

Smoking status at time of delivery - %

2018/2019 3,514 10.6 10.5 8.6

Smoking prevalence in adults with anxiety or depression (18+): current smokers (GPPS) - %

2016/2017 - 25.8 25.6 26.6

Smoking prevalence in adults with a long term mental health condition (18+): current smokers (GPPS) - %

2017/2018 - 25.6 26.6 24.9

Admission episodes for alcohol-specific conditions – DSR per 100,000

2018/2019 18,422 626 718 762

Percentage of adults who abstain from drinking alcohol

2011-2014

- 15.5 - 30.9

Percentage of adults drinking over 14 units of alcohol a week

2011-2014

- 25.7 - 18.9

Percentage of dependent drinkers

2014/2015 35,660 1.39 1.67 1.66

Admission episodes for alcohol-specific conditions (under 18s) – crude rate per 100,000

2016-2017-18-19 440 31.6 21.3 16.2

Estimated prevalence of opiate and/or crack cocaine use - crude rate per 1,000

2016/2017 21,945 8.9 11.9 14.2

Baby's first feed breastmilk - % (2018/19)

 

2018/19

- 67.4 - 68.2

Adults meeting the recommended '5-a-day' on a 'usual day'- % (2017/18)

2018/19

- 54.6 46.7 47.8

Adults (aged 18+) classified as overweight or obese - %

2018/19

- 62.3 65.5 61.7

Reception: Prevalence of obesity (including severe obesity) - %

2018/19

4,254 9.7 11.4 11.4

Year 6: Prevalence of obesity (including severe obesity) - %

2018/19

9,529 20.2 25.5 25.7

Physically active children and young people - %

2018/19

- 46.8 - 44.2

Physically active adults - %

2018/19

- 67.2 60.9 63.3

Physically inactive adults - %

2018/19

- 21.4 27.2 24.8

Adults walking for travel at least three days per week - %

2017/2018 - 23.1 - 22.5

Adults cycling for travel at least three days per week - %

2017/2018 - 3.2 - 2.9

 

Coventry
Dudley
Sandwell
Solihull
Walsall
Wolverhampton
15.1 13.5 15.3 12.6 15.0 15.1
10.6 12.8 10.1 8.3 11.5 16.7
24.9 22.9 27.2 17.4 28.1 25.5
22.9 27.2 17.4 28.1 25.5 34.5
925 561 741 527 650 756
18.9 14.6 28.4 13.5 22.7 36.0
1.81 1.56 1.95 1.09 1.61 1.84
30.0 29.1 24.7 28.6 14.9 22.2
7.5 10.5 11.7 7.8 11.0 13.6
62.6 61.3 63.5 63.0 52.2 59.9
43.6 49.4 35.7 57.0 42.4 51.0
62.9 71.5 70.9 62.8 73.2 67.3
10.2 10.3 13.0 8.1 12.4 13.5
22.6 24.2 28.3 18.3 26.2 29.3
50.8 41.6 43.4 48.6 38.8 46.5
61.1 59.5 54.7 68.1 55.9 58.0
27.4 26.1 32.6 23.2 32.1 29.8
24.0 18.6 21.9 19.2 20.5 21.6
2.4 1.0 2.1 1.6 0.3 0.8

 

Smoking

Smoking prevalence among adults in general and those with anxiety, depression or a long-term mental health condition are broadly similar in the WMCA to the England average However, national data show a marked social gradient, highlighting smoking as a key cause of health inequalities Over a quarter of adults with mental health problems are smokers compared with approximately 15% of the general population Smoking status at delivery shows marked inequalities across the region; while overall WMCA prevalence is similar to the national average, it is significantly higher in Dudley and Wolverhampton.

Alcohol and drug use

The WMCA has a higher than national average prevalence of dependent drinkers Above average rates of hospital admissions for alcohol-specific conditions are driven by high rates in Birmingham, Coventry, Sandwell and Wolverhampton However, most of these areas also have a higher than average percentage of adults who abstain from drinking altogether, which may reflect the cultural diversity of localities The rate of alcohol-specific admissions for under 18s is also lower than average overall The percentage of adults drinking above the recommended 14 units per week is similar to or lower than the England average across WMCA areas; however, it should be noted that this still nearly 1 in 5 adults in the WMCA The rate of opiate or crack cocaine use is similar in the WMCA to the national average, but masks significant inequalities across the region with high rates in a number of areas.

Nutrition and obesity

Nationally, just over two thirds of babies have breastmilk as their first feed With the exception of Birmingham, this is significantly lower across constituent local authorities Among adults, less than half in the WMCA report having the recommended ‘5 a day’ portions of fruit and vegetables – significantly lower than the England average.

Physical activity

For adults across the WMCA, rates of physical activity are lower and rates of physical inactivity are higher compared with England overall 27 2% of adults in the WMCA are doing less than 30 minutes of physical activity per week Only 61% of adults and less than half of children and young people are meeting recommended weekly levels of physical activity Both regionally and nationally, less than a quarter of adults walk at least three times per week for travel; only a small minority (<3%) cycle for this purpose.

Supporting people to live healthier lives would have substantial health and economic benefits for the region Alcohol misuse is estimated to cost the NHS about £3 5 billion per year and society as a whole £21 billion annually Reducing alcohol-related harm is one of Public Health England’s seven priorities for the next five years (from the Evidence into action report 2014) Low physical activity is one of the top 10 causes of disease and disability in England, and regular physical activity can help to prevent and manage over 20 chronic conditions and diseases; persuading inactive people (those doing less than 30 minutes per week) to become more active could prevent 1 in 10 cases of stroke and heart disease in the UK and 1 in 6 deaths from any cause 37 There are also significant inequalities in physical activity, with people from BAME groups, women, people from lower socio-economic groups and disabled people less likely to be active In the West Midlands, 52% of disabled adults are inactive. 38

Diet and physical activity habits often begin in childhood, and are influenced from pre-conception and beyond, so it is important to act as early as possible to embed positive behaviours at the earliest opportunity However, it is never too late to support people to live healthier and more active lives, and taking action across the life course can help to reduce the health inequalities associated with obesity and physical inactivity.

Screening and early intervention

Unhealthy lifestyles increase the risk of developing preventable disease However, many of these diseases are identifiable and treatable in their early stage There are significant differences across the region, and between different groups of people, in terms of whether or not people receive this early help

Screening is carried out on healthy populations, or those without symptoms of a disease, to identify those who may have an increased risk of a particular condition Cancer screening is one of the most effective ways to reduce the risk of premature mortality Breast screening is offered to women aged 50 to 70 to detect early signs of breast cancer, and is estimated to save 1,400 lives in England each year Cervical screening enables detection of cell abnormalities that may become cancer and is estimated to save 4,500 lives in England each year Bowel cancer screening targets older adults aged 60 to 74 to support early detection of cancer and polyps that may develop into cancers over time.

Screening is also important to identify early signs of poor health leading to opportunities for early interventions The NHS Health Check programme targets adults aged 40 to 74 to help prevent heart disease, stroke, diabetes and kidney disease Eligible people who have not already been diagnosed with one of these conditions are invited for a health check every five years to assess their risk, raise awareness and support them to manage their risk of cardiovascular disease.

Table 7: Screening and early intervention in the WMCA – local area comparisons

Indicators
Period
WMCA number
England
WMCA
Birmingham

Cancer screening coverage - breast cancer

2019

193,280

74.5 69.8 68.2

Cancer screening coverage - cervical cancer (25-49 years old)

2019

354,810

69.8 65.8 61.9

Cancer screening coverage - cervical cancer (50-64 years old)

2019

173,834

76.2 74.2 73.4

Cancer screening coverage – bowel cancer

2019

195,329

60.1 53.4 48.9

Chlamydia proportion aged 15 to 24 screened

2019

62,669

20.4 15.3 17.1

Cumulative percentage of the eligible population aged 40-74 who received an NHS Health check

2015/16-19/20

386,098

41.3 52.8

54.5

 

Coventry
Dudley
Sandwell
Solihull
Walsall
Wolverhampton
69.8 75.4 70.7 73.4 73.5 60.1
65.7 72.1 66.0 72.5 71.2 66.7
76.1 73.2 72.7 77.4 76.0 72.7
55.5 58.5 50.7 61.4 56.5 52.1
15.6 12.4 13.6 17.6 9.8 13.6
51.3 69.1 53.6 48.8 54.3 28.5

*Please note that there may be data quality issues with these figures Source: PHE Public Health Profiles

In 2019, the percentage of eligible WMCA residents who attended screening for breast, cervical and bowel cancer was significantly lower than the England average, with approximately a third to a quarter of the target populations not being screened (Table 7) Chlamydia screening was significantly lower than the national average for all WMCA areas For NHS Health Checks, the WMCA generally performed better than the national average, with over half the eligible population receiving their health checks during the 4-year period from 2015/16 to 2019/20 Screening coverage in the WMCA has declined in recent years for breast and cervical cancer.

If the WMCA reached the national average benchmark for the year:

  • 12,196 more women would be screened for breast cancer

  • 20,331 more women aged 25-49 and 4,554 more aged 50-64 would be screened for cervical cancer

  • 21,779 more people would be screened for bowel cancer

  • 15,667 more young people would be screened for chlamydia

  • The COVID-19 pandemic has had an impact on cancer services Referrals on the urgent two week wait cancer pathway showed a significant reduction as the pandemic hit the Midlands By September referral rates had increased to over 90% of previous activity levels and continue to grow Restrictions in out-patients, diagnostics and treatment capacity, due to social distancing and infection control measures, have significantly reduced patient throughput, against increasing demand Systems across the West Midlands have worked hard to return cancer services as quickly as possible, adopting alterative models of care and digital technologies such as telephone and video consultations, community tele-dermatology clinics and alternatives to endoscopy, such as FIT testing

  • There are plans in place to protect cancer services with the cancer treatments and other clinically urgent patients being prioritised There are some patients who are reluctant to attend, as they are concerned about the risk of infection, and work is ongoing to provide reassurance and encouragement to these patients to attend their appointments

Breast screening

The four breast screening providers that cover the WMCA area have all restored screening They are working through the backlog, and commissioners (NHSE/I) are supporting services to get to a capacity that is greater than 100% that will be needed
to catch up to the required screening intervals All services have implemented national changes to the programme to aid the return to the three-year screening intervals, including the open first appointments There has been some excellent innovation in the WMCA screening providers in an attempt to return to the three year round length, such as novel invitation models, and services are putting in addition actions to improve uptake, such as additional phone calls to some women

Bowel screening

All four screening centres in the WMCA area have restored the assessment element of the screening pathway, and have cleared the backlog of screen positive patient left during the first peak of the Covid pandemic All centres have also switched on the new screening invites (and home test kits) This currently ranges from 91 to 138 percent of the pre-Covid invite rates Commissioners have set providers a deadline of 31st August 2021 to return to the two-yearly screening rounds.

Cervical screening

The national call-recall system in the cervical screening programme has begun an invite schedule that will mean that the programme has caught up – with women returning to the correct screening intervals – by May 2021 The HPV laboratories will have increased numbers of samples to process compared to pre-Covid.

Through winter 2020/21, with primary care taking more samples

Through the early stages of the Covid pandemic (~March-April 2021), colposcopy units deferred the appointments of some low- grade patients They have now caught up, and are appointing women in line with the pre-Covid programme guidance

Impacts of COVID-19 on health behaviours and risks

The pandemic has the potential to exert indirect effects on health in two ways: firstly, by altering health behaviours, and secondly by reducing access to services and routine care Changes to health behaviours may include negative coping strategies to manage anxiety, for example drinking or smoking more, or lockdown measures providing more (or fewer) opportunities to take part in physical activity Reduced access to services may present additional risk if existing or emerging health conditions are not adequately managed

Health behaviours

In the West Midlands region overall:39

  • From 3rd April to 3rd August 2020, nearly a fifth of adults (18%) reported doing at least 30 minutes of physical activity on 0 days while just under a third (31%) reported doing it on
    5 or more days (compared with 19% and 31% respectively in England) Nationally, men were significantly less likely than women to be physically inactive (21% vs 18%) and significantly more likely to be active (34% vs 29%)
  • Compared with a typical week before introduction of COVID-19 restrictions, 34% of adults reported doing less, 34% reported doing more while 30% reported doing the same amount of physical activity Nationally, women were significantly more likely to report doing less exercise (40% vs 36%)
  • 18% of parents reported their children doing the recommended 60 minutes or more of physical activity per day in the period 3 April to 25 May 2020, 33% reported doing 30-60 minutes, 38% reported doing less than 30 minutes, and more than a tenth (11%) reporting doing nothing – the highest regional level in the country
  • In the West Midlands, the prevalence of smoking during lockdown (the 4-week period ending 19 April 2020) was lower that reported in 2018 at (14% and 16% respectively)

Nationally, over half of respondents (pooled data up to 10 Aug 2020) (52%) said that the amount of alcohol they were consuming had not changed during lockdown 24% said they were drinking more and 24% said they were drinking less

Healthcare access and screening

Between 13th May and 10th August 2020, 13.1% of people surveyed in England reported having a worsening health condition during the last week This generally increased with age, from 12.5% in 18-24 year olds and 17.6% in over 75s Approximately
half (50.4%) reported not seeking advice during this period; this varied by age group but was lowest in those aged 65+ Of these respondents, over half stated that this was to avoid putting pressure on the NHS, with approximately a third raising concerns about catching coronavirus or leaving the house, and another third citing another reason While significantly more women than men reported a worsening health condition (14 9% vs 11 2%), were no significant sex differences in not seeking help

The NHS are dealing with a significant backlog of non-COVID related morbidity and it is likely that the effect of this will widen existing health inequalities and lead to avoidable cancer death as a result of diagnostic delays 40 Across the UK it is estimated that
2 1 million people have missed out on screening, while 290,000 people with suspected symptoms have not been referred for hospital tests This means that more than 23,000 cancers could have gone undiagnosed during lockdown 41 Given that screening coverage is already lower in the WMCA than the national average, it is likely that these effects are also being felt in the region

In the WMCA, barriers to healthcare access identified by voluntary, community and faith organisations were largely practical These included reduced availability and capacity of services; challenges with online or telephone services; and lack of access to linguistically and culturally accessible public health information Stigma, misinformation or lack of clarity, and mistrust in government were also cited There were intersections with themes relating to disproportionate impacts on BAME communities and marginalised groups, including refugees and migrants, and the widening of existing inequalities (see Appendix 2) This links to the issue of digital inclusion, which is picked up in Box 4

Causes of unhealthy lifestyles: understanding the ‘causes of the causes’

The conditions in which we are born, grow, live, work and age have important implications for our physical and mental health, as individuals and across wider society We understand much more now about why so many people live in ways that affect their health so badly The 2010 Marmot review on health inequalities42 first articulated the importance of understanding the ‘causes of the causes’ of ill-health Often, unhealthy behaviours are coping mechanisms for people who live in challenging circumstances, or reflect the limitations of the environments they live in Many times, people want to make positive changes to improve their health, such as being more active or giving up smoking, but are not supported to do so The conditions of many people’s lives within the WMCA are hard There is clear evidence that too many people live in challenging circumstances which may well result in their needing unhealthy coping strategies, and in their feeling powerless to make positive change.

This is not to say that those living in challenging circumstances are destined to have poor health Rather, the focus should be on creating the conditions to enable people to live healthier lives, and to make healthier options the default This means considering individual health-related behaviours in their social, cultural, economic and environmental contexts, and working to overcome the barriers these present (e g food poverty, limited time or skills, or lack of access to green space) rather than only targeting the behaviours themselves

Table 8: Wider determinants of health in the WMCA – local area comparisons

Indicators
Period
WMCA number
England
WMCA
Birmingham

Statutory homelessness: Eligible homeless people not in priority need - crude rate per 1,000

2017/2018 - 0.9 0.6 3.6

Statutory homelessness: Households in temporary accommodation - crude rate per 1,000

2017/2018

2,668

4.7 2.0 0.1

Adults in contact with a learning disability who live in stable and appropriate accommodation - %

2018/2019

4,286

77.4 69.5 77.2

Adults in contact with secondary mental health services who live in stable and appropriate accommodation - %

2018/2019 - 58.0 41.0 57.0

Children in low income families (under 16s) - %

2016 - - - 27.6

Fuel poverty - % of households

2018

142,685

10.3 12.4 14.2

Average weekly earnings - £

2018 - - - 417.6
16-17 year olds not in education, employment or training or whose activity is not known % 2018 4,400 5.5 6.6 8.5

People aged 16-64 in employment

2019/20

1,268,200

76.2 69.0 64.6 

Gap in the employment rate between those with a long-term health condition and the overall employment rate - % points (2018/19)

2018/2019 - 11.5 11.6 7.1

Gap in the employment rate between those with a learning disability and the overall employment rate - % points (2018/19)

2018/2019 - 69.7 66.2 64.2

Gap in the employment rate between those in contact with secondary mental health services and the overall employment rate - % points (2018/19)

2018/2019 - 67.6 64.0 61.5

Density of fast food outlets - crude rate per 100,000

2014 2,573 88.2 91.6 96.1

Access to Healthy Assets & Hazards Index: Population living in 20% poorest performing LSOAs - %

2017 550,682 21.1 9.5 8.0

Air pollution: Fine particulate matter - mean: μg/m3

2017 - 8.9 - 9.8

Utilisation of outdoor space for exercise/health reasons - %

Mar2015-Feb2016 - 17.9 - 18.4

 

Coventry
Dudley
Sandwell
Solihull
Walsall
Wolverhampton
0.6 3.6 0.5 1.4 0.1 2.2
2.0 0.1 0.3 1.1 1.0 0.7
49.3 79.0 63.0 86.7 64.3 85.4
16.0 63.0 53.0 5.0 3.0 15.0
21.8 20.7 25.5 15.9 25.8 26.3
12.1 10.6 12.0 8.2 11.8 12.7
454.2 425.9 398.5 474.2 399.9 402.4
5.4 6.8 4.3 5.1 5.3 4.5
72.1 73.8 69.9 77.1 71.5 68.2
14.9 11.8 17.6 11.3 15.3 15.2
68.7 66.7 70.2 74.5 69.6 57.8
61.7 64.6 66.0 66.0 63.8 64.8
83.6 81.7 114.3 54.3 93.7 95.7
8.7 6.9 20.3 11.0 9.6 5.2
9.7 8.7 10.1 9.4 9.8 8.6
15.1 20.5 18.2 24.7 18.0 27.6

 

Housing

Adults in the WMCA with a learning disability and those in contact with secondary mental health services are significantly less likely to be in stable and appropriate accommodation, in line with national figures

Income

Significantly more children in the WMCA are in low income families compared to England overall In several areas this corresponds to increased rates of fuel poverty and a household income lower than the national average National evidence demonstrates that childhood poverty leads to premature mortality and poor health outcomes for adults 43 Reducing the numbers of children who experience poverty should improve these adult health outcomes and increase healthy life expectancy

Education and employment

Employment rates are also low among adults with a learning disability and those in contact with secondary mental health services In most WMCA areas the percentage of young people not in education, employment or training (NEET) is lower than the England average, but higher in Birmingham Overall employment rates across the WMCA are lower than the national average, which may reflect poorer health among adults in the older working age groups

Built and natural environment

Overall the WMCA has a similar density of fast food outlets to England overall, but this varies across the region, with Birmingham and Sandwell having a higher rate of outlets per 100,000 population compared with the national average Air quality and access to healthy assets and hazards vary across the region; however there is likely to be substantial variation within localities depending on proximity to town and city centres Utilisation of outdoor space for exercise or health reasons is similar to the England average for most areas in the WMCA but significantly higher in Wolverhampton; nevertheless this is still less than a third of residents

Health and Wealth

Global evidence shows that population health is a good measure of social and economic progress Inequalities in health are not inevitable but reflect avoidable inequalities in society and can be reduced by putting wellbeing at the centre of economic policy Health and wealth are two sides of the same coin: improving health and reducing inequalities is fundamental to wealth creation and brings a range of social and economic benefits through improving productivity, reducing demand on services, and increasing social cohesion

An analysis by Liverpool City Region (LCR) found that closing their health and life expectancy gap would increase employment by 5 6 percentage points which equates to an increase in Gross Value Added (GVA) of £3,353 per head It is estimated that 54% of the productivity gap between LCR and the rest of England is due to ill-health and reducing this health gap would generate an additional £5 2bn in GVA 44
It can be safely assumed that there would be similar, if not greater, economic benefits for the West Midlands In addition, increasing healthy life expectancy is likely to have wider implications for wellbeing and quality of life

  • The productivity gap between the WMCA and England is £14 8bn45, approximately £5bn of which is accounted for by the gap in employment rate (based on 2018/19 estimates)
  • In the WMCA, 31% of the working age population age 16-64 is unemployed and it is estimated that 22% (125,000 people approx ) is due to poor health - predominantly musculoskeletal problems and mental health problems, many of which are preventable and/or manageable This therefore accounts for approximately £1 1bn of the gap in GVA - although the wider health impacts on our economy are likely to be much larger
  • There is a percentage point gap of 9 5 between people in the WMCA with a long -term health condition and the general population (England 10 5)
  • For people in contact with secondary mental health services, the percentage point gap is 64 0 (England 67 6)

 

The economic and environmental impact of COVID-19

Economic shock has been a major consequence of the pandemic, with the measures needed to control the spread of the disease having a significant impact on the national and regional economy There is substantial evidence on the detrimental impact of economic shock on physical and mental health and wellbeing, for example in times of recession 46 However, the COVID-19 pandemic has an additional dimension of direct health impacts, which in turn has an effect on anxiety and wellbeing alongside that relating to economic factors This has contributed to the exacerbation of existing inequalities, both with increasing unemployment in more precarious sectors, and increased risk among those who have needed to attend their workplaces rather than working at home Some of the people working in the lowest paid and/or least secure jobs have also been those most likely to come into contact with the virus, meaning that they have faced the dual impact of increased infection risk and economic consequences.

There have nevertheless been some positive impacts through changes to ways of working in a number of sectors With more people working remotely, human benefits have included improved work-life balance and more time to participate in activities to improve health and wellbeing The increased availability of activities online and rapid adoption of online platforms for face-to-face communication have increased opportunities for social connection and participation in the arts for many who were previously limited by their ability to travel However, these benefits have not been realised equally across the population In addition to those unable to carry out their roles remotely, people who are digitally excluded or face additional challenges may be left behind if their needs are not considered The disruption in routine human activity (‘anthropause’) has also shown emerging benefits for the environment and climate, with lockdown measures (most notably the reduction in planned travel) having immediate impact on air quality worldwide 47 While the longer term benefits remain to be seen depending on the direction of recovery approaches taken, it is clear that there is an opportunity to learn from the pandemic about what it is possible to achieve

Employment and sector impacts

The State of the Region 2020 report48 provides a detailed analysis of the economic impact of COVID-19 in the WMCA, considering both the short-term consequences of the pandemic and the implications for economic recovery over the longer term The report presents a mixed picture for the region, highlighting the following key issues in relation to employment and the economy:

  • The West Midlands may face the largest economic decline of all regions at 9 2% (fall in GDP), however it may see the largest growth in 2021 at 8 1%, based on having the largest number of temporary closures and an expectation of most reopening

  • Youth unemployment has almost doubled, with the youth claimant count rising to 41,225 by May 2020 - 8 3% of the young population It now sits 5th amongst combined authority areas but the rate of increase was much higher than elsewhere

  • Overall claimants stand at 208k, which is 6 3% of the working age population a rise from 115,000 and 3 5% in February, however overall increase in claims has been slower than other areas despite extensive furloughing

  • The number of people furloughed currently stands at 496k in the WMCA area, which equates to 26 9% of jobs Headline analysis suggests that the public sector (including higher education) and the visitor economy sector will be the sectors most impacted from the Covid-19, followed by construction, manufacturing and retail Analysis suggests that the life science and healthcare may be the only sector that will be relatively unscathed, but notably it is also one of main sectors that has took the brunt of the human impact from Covid-19

  • The WMCA has the highest level of apprenticeship vacancies compared to other regions (1,643), which is a positive for the region However this has declined recently, and recent business surveys show a decline in training and apprenticeship opportunities

  • Purchasing Managers Index (PMI) show business activity has dropped from 51 2 (over 50 signals growth, under 50 signals contraction) to 10 9, the lowest levels ever and back to 27 9 However the PMI future business activity is holding up, rising from 55 9 to 62 1 (down from 72 3% signalling businesses are positive about the future once lockdown ends)

While the furlough scheme was generally seen as a positive policy approach by businesses, there is also concern that it may simply be delaying redundancies further down the line if the reduction in consumer spending and business activity continues over the longer term Regionally, businesses are already concerned about the impacts of lockdown and social distancing measures on trade, and are reluctant to take on debt having already utilised spare funds and resources There is considerable uncertainty around recovery of the worst hit sectors given the emergence of a second wave and continued lockdowns, including local restrictions in high-incidence areas which are already likely to be more deprived.

As described in our interim report, younger people are likely to be disproportionately impacted by closures due to being more likely to be employed in vulnerable sectors This presents particular challenges in the WMCA due to the region having high numbers of young people, who also face additional difficulties through disruption to the education system and the weakening of transition points between school, further and higher education and employment

The pandemic has also brought about changes in culture and behaviour that may persist beyond the crisis period A reduction in travel, changes to ways of working and changing attitudes to what consumers need and value could have significant implications
for economic recovery, particularly post-Brexit Although there are a number of positive impacts of these changes which are described in the sections below, it is important that businesses are supported to adapt to ensure that existing socioeconomic inequalities are not exacerbated further

Use of outdoor space for physical activity

Access to outdoor space, particular green space and ‘blue’ space (i e proximity to water) has direct benefits for mental wellbeing, 49,50 as well as increasing opportunities to participate in physical activity Access to natural outdoor spaces varies considerably across the region; areas bordering on Green Belt land in Shropshire, Staffordshire, Warwickshire and Worcestershire.

are very different to the more urban areas in the centre of the region Yet this is not to say that residents in more urban areas do not have access to outdoor spaces that enable them to connect with nature Birmingham has 35 miles of canals, which is said to be more than Venice, and they are enjoyed by walkers, runners, cyclists and narrowboaters Across the West Midlands as a whole, there are 20,534 78 hectares of green space (34 53m2 per person) – 1,032 66 hectares of which are legally protected – and approximately 95% of the population live within a 10m walk of green space 51 West Midlands residents have a similar distance to travel to a park or public garden at 968m (average distance from an address in the region) compared with an average of 987m for England, and around 90% of addresses in the West Midlands had access to private outdoor space in April 2020 compared with an average of 88% in England 52

Research by Fields in Trust (2018)53 indicated that lower socio- economic groups assign a higher relative value to parks and green spaces than higher socio-economic groups, and urban residents value parks and green spaces higher than the UK average BAME groups value parks and green spaces more highly than white groups, particularly once income is accounted for, and also tend to use them more for social purposes (e g meeting friends, children’s activities and sports) Given that the WMCA area is more urban and more ethnically diverse than the region as a whole, our parks and green spaces are a valuable asset in reducing health inequalities in the region

The WMCA has launched a number of initiatives with national and regional partners to encourage more outdoor activity in local areas These include Love Exploring Black Country developed with Active Black Country and local authorities, which uses a walking app for people to capture their walks and find out about local history and nature; and a Public Space Trial, which has invested WMCA and Sport England funding into co-designing and repurposing sites in some of the most deprived areas of Sandwell, Walsall and Coventry to encourage more people to walk and be active in their local areas.

Transport and Travel

Public opinion survey data from Transport for West Midlands (TfWM) show that the pandemic has seen unprecedented changes in travel demands and behaviours (see Figures 12a and 12b) The immediate impact has been a general reduction in all modes of transport (including car usage) as a result of lockdown This in turn has had many positive aspects such as improved physical activity, air quality, reduced carbon emissions and safer roads, as more people have chosen to walk and cycle.

TfWM’s Health and Transport Strategy (2019)54 demonstrates how encouraging physical activity by making it easier to walk, cycle and use public transport has significant impacts on everyone’s health, such as by reducing air pollution, increasing feelings of safety and creating environments in which people choose to participate and take up active travel The region’s transport network has operated at around 50% to 75% coverage and frequency throughout the pandemic, thus ensuring that our most vulnerable communities and those without access to a car could continue to access vital services (retail/health) and key workers could continue to access work – which was vital during lockdown.

Our transport system often shapes what is possible and impacts on the people and places around it COVID-19 has given us a new perspective on what our economic, social and environmental priorities are, and what changes may be possible Therefore, there is an opportunity to reshape our transport network for the better.

In surveys of public attitudes during the crisis (covering over 6,000 responses), the majority of respondents wanted to see changes in areas such as cleaner air (81%), reduced traffic on roads/ reduced car use (75%) and improved work/life balance (67%), demonstrating a need for a more inclusive transport system.

Improving the interface between active travel and public transport is key to encouraging uptake Grants of between £10,000 and £180,000 from the Better Streets Community Fund (BSCF) have been awarded to pay for a range of projects across the West Midlands including better paths, improved street lighting, secure bike storage and safe crossings, with around 40 projects supported across the region Investment into active travel through the DfT’s Active Travel Fund (see section 2 4 5) includes the Living Streets Walk to School initiative, whereby TfWM have local activators to encourage more young people to walk to school with their parents.

Living with challenges

There are a number of specific groups of people that not only have an increased risk of poor physical and mental health, but social, economic and digital exclusion These groups are also more likely to face additional difficulties as a result of the pandemic In this section we address a number of these key groups

Structural racism and ethnic disparities as determinants of health

Structural racism has been consistently cited both regionally and nationally as a key factor in poorer health and wellbeing outcomes for people from BAME communities, including COVID-19 deaths and complications 55,56,57 Prof Sir Michael Marmot has emphasised the need to act now on systemic racism and the structural determinants of health, rather than putting it off until the immediate crisis has been dealt with 58 This is because these are causal factors in the crisis, and addressing them is key to prevention and resilience over the longer term

A national survey of over 14,000 adults by the mental health charity Mind revealed that existing inequalities in housing, employment, finances and other issues have had a greater impact on people from BAME groups than on white people

The reduction in access to health and wider services due to control measures is also likely to have a disproportionate impact on BAME groups and people with severe mental illness 59 Experiences of discrimination and structural racism as barriers to accessing services are well documented,60 and was a key theme identified through community engagement activities in the region 61,62,63

Key observations from the West Midlands Inquiry into COVID-19 Fatalities in BAME communities are summarised in Box 2 Many of these observations were echoed in the submissions received to the call for evidence, particularly around access to care and funding, disruption to ways of life, communication and lack of confidence for change (see Appendix 1)

Box 2: COVID-19 BAME Evidence Gathering Taskforce – Labour party Key observations from testimony
  • Fear of inequitable treatment that might be received in the NHS was a deterrent for many in the BAME asking for help quickly enough

  • Our BAME community experienced an NHS and care system that was overwhelmed

  • Public health messages about symptoms or what to do when in need were poorly communicated by Government to our BAME communities

  • The voice of the BAME community has simply not been heard in
    the way our health services are designed and delivered

  • The disruption to the traditions and process for grieving has created significant mental health risks

  • Many of the groups that worked with people with long-term health conditions have been underfunded

  • Many BAME frontline workers had direct experience of inadequate provision of PPE

  • Data we need to track the impact of the pandemic is not available, such as ethnicity recording on death certificates

  • A clear strategy for understanding the scientific evidence for the disproportionate impact of COVID-19 on the BAME community has not been communicated effectively

  • Confidence that lessons will be learned and change will come about is low to non-existent

While it is essential to address the role
of systemic discrimination and racism in the system, care must be taken to avoid stereotyping and assuming that people from BAME communities all face the same challenges (even within specific ethnic groups) and therefore require the same approaches to engagement Research has highlighted the importance of language in our communication (even around the term ‘BAME’ itself, as discussed previously), and the importance of developing ‘race fluency’ and confidence to enable meaningful and inclusive communication around issues affecting particular ethnic groups 64

Vulnerable children and young people

As outlined in section 1 2, facing challenges earlier in life can limit opportunities later on and lead to poorer health outcomes PHE West Midlands established a task and finish group to focus on vulnerable children and young people, considering the impacts of COVID-19 and identifying ways to strengthen multi- agency working in understanding vulnerability and supporting recovery 65 Children in care (i e those looked after by the local authority); those subjected to trauma, violence and exploitation; youth offenders; and children with special educational needs & disabilities (SEND) were identified as being at potentially increased risk as a consequence of the pandemic

Children with experience of care have significantly poorer educational outcomes than their peers, which has implications for their future employment and life chances, and there is evidence that the gap persists even when additional needs are taken into account 66 Children and young people at risk of offending or within the youth justice system often have more unmet health needs than other children, including an increased risk of suicide 67 Providing unpaid care can have a significant impact on carers throughout the life course, affecting their education, employment, relationships, household finances, health and wellbeing These effects tend to worsen with the more care provided 68

Childhood trauma is both a cause and consequence of social disadvantage and inequalities in physical and mental health. 69

In addition to ensuring that disadvantaged children and young people are able to access the opportunities and support they need, it is also essential to adopt trauma-informed approaches in providing this support.

 

Table 9: Living with challenges in the WMCA – local area comparisons

Indicators
Period
WMCA number
England
WMCA
Birmingham

Children in care - crude rate per 10,000 (2019)

2019

- 65 - 67

Children providing unpaid care (aged 0-15) - % (2011)

2011 6,636 1.11 1.15 1.10

Children providing 20+ hours/week of unpaid care (aged 0-15) - % (2011)

2011

1,442

0.21 0.25 0.25

Young people providing unpaid care (aged 16-24) - % (2011)

2011

20,600

4.8 5.6 5.8

Young people providing 20+ hours/week of unpaid care (aged 16-24) - % (2011)

2011

6,271

1.3 1.7 1.8

Unpaid carers - % (2011)

2011

77,216

2.37 2.82 2.66

Teenage mothers - % (2019)

2019

305 0.6 0.8 0.7

Social Isolation: percentage of adult social care users who have as much social contact as they would like (18+ yrs) - % (2018/19)

2018/19

14,140 45.9 46.6 44.0

Social Isolation: percentage of adult carers who have as much social contact as they would like (18+ yrs)

2018/19

830

32.5 32.4  25.1

Pupil absence - % of half days

2017/18

7,306,605 4.8 5.0 5.13

Primary school fixed period exclusions: rate per 100 pupils

2016/17

4,735 1.4 1.6 1.95

Secondary school fixed period exclusions: rate per 100 pupils

2016/17

16,291 9.4 8.5 7.5

Sickness absence: Employees who had at least one day off in the previous week - %

2016-18

- 2.1 2.1 2.8

Sickness absence: Working days lost - %

2016-18

- 1.1 1.3 1.6

Hospital admissions caused by unintentional and deliberate injuries in children (aged 0-14 years) - crude rate per 10,000

2018/19

6,715 96.1 113.5 115.6

Hospital admissions caused by unintentional and deliberate injuries in young people (aged 15-24 years) - crude rate per 10,000

2018/19

4,940 136.9 120.5 113.9

Children in the youth justice system (10-18 yrs) - crude rate per 1,000

2017/18

1,686 4.5 5.2 5.2

First time entrants to the youth justice system (10-17 yrs) - crude rate per 100,000

2018 88 238.5 308.0 377.7

First time offenders - crude rate per 100,000

2018 5,926 211 238 266

Reoffending levels - % of offenders who reoffend

2017/18

- 29.1 29.9 31.3

Violent crime: Violence offences per 1,000 population - crude rate

2018/19 76,186 27.8 26.3 28.8

Violent crime: Sexual offences per 1,000 population - crude rate

2018/19 7,175 2.5 2.5 2.8

 

Coventry
Dudley
Sandwell
Solihull
Walsall
Wolverhampton
89 95 109 90 90 102
1.37 1.03 1.21 1.03 1.18 1.20
0.30 0.21 0.29 0.18 0.23 0.24
4.7 5.8 6.3 5.1 5.6 5.7
1.2 1.7 2.1 1.3 1.9 1.8
2.50 3.03 3.23 2.48 3.26 2.97
0.9 0.8 0.8 0.5 1.4 1.3
47.3 47.5 52.2 45.1 43.1 51.6
38.2 43.4 27.7 28.6 25.5 36.1
4.86 5.02 4.75 4.88 4.99 4.62
1.88 1.52 1.27 1.29 1.67 0.75
11.0 10.0 9.6 8.3 7.6 8.3
1.8 2.6 1.1 1.8 2.4 1.3
0.9 1.7 0.9 1.0 1.3 0.7
184.9 85.5 105.6 103.8 93.3 82.7
129.0 105.6 119.9 155.5 110.6 144.3
5.2 4.5 6.4 2.5 3.9 8.4
244.8 260.1 239.9 120.3 248.7 423.6
228 174 244 127 206 328
30.0 26.4 29.3 21.1 29.7 30.0
23.0 22.4 27.2 17.6 25.8 31.2
2.4 2.2 2.3 1.8 2.2 2.7
Care and carers

The rate of children looked after by the local authority is higher than the England average in all areas except Birmingham The WMCA has significantly more people providing unpaid care than the national average, including children and young people providing substantial levels of care The population proportion
of teenage mothers, who are at increased risk of poverty and poor health if they are not adequately supported, reflects the national average across most areas but is significantly higher in Birmingham, Walsall and Wolverhampton Social isolation is a key issue for both providers and recipients of care While more adult social care users in the WMCA reported having as much social contact as they would like, this is still less than half Only a third of adult carers, both regionally and nationally, have as much social contact as they would like, with substantial variation across areas

Absenteeism and exclusions

Rates of school absences and primary school exclusions are significantly higher for the WMCA than for England overall, but lower for secondary school exclusions Among working age adults, sickness absence rates are broadly similar to the national average but the number of days lost to sickness is higher, which may be due to higher rates of longer-term absence

Injury and crime

Hospital admissions for intentional or unintentional injuries in children and young people are significantly higher for the WMCA than for England overall, and appear to be driven by high rates in a few areas First time entrants to the youth justice system and first time offences are significantly higher in the WMCA than the national average Rates of children and first time entrants to the youth justice system, first time and repeat offences, and violent and sexual crimes are consistently lower in Solihull and Dudley, and consistently higher in Birmingham and Wolverhampton.

Disability and long-term health conditions

Disability intersects across a wide range of health, wellbeing and social factors, including physical activity, education, employment and social participation In addition to increased risk of death from COVID-19, people with disabilities or long- term health conditions are more likely to experience additional health impacts relating to access to services and essentials, and disproportionate social and economic impacts due to existing inequalities.

The ONS Opinions and Lifestyle Survey on the social impact of the COVID-19 pandemic in Great Britain included indicators relating to the impact on disabled people For the purpose of the analysis this included anyone with a self-reported long-standing illness, condition or impairment that reduced their ability to carry out day-to-day activities More than 8 in 10 (83%) disabled people compared with around 7 in 10 (71%) non- disabled people said they were “very worried” or “somewhat worried” about the effect that the pandemic was having on their life in September 2020; for disabled people, but not for non-disabled people, this was a similar level to that reported earlier in the pandemic (86% and 84% respectively in April 2020) In September 2020 disabled people reported lower ratings for all wellbeing measures than non- disabled people, and were more worried than non-disabled people about the effect of COVID-19 on their well-being, health, relationships, access to healthcare for non- coronavirus related issues and access to groceries, medication and essentials People with mental health, social or behavioural or learning impairments tended to be most concerned about the impact of the coronavirus on their wellbeing, whereas people with dexterity, mobility, stamina, vision or other impairments were more worried about access to healthcare and treatment for non-coronavirus related issues Disabled people were also more likely than non-disabled people to report their treatment was cancelled or never started before lockdown. 70

Inclusion health and vulnerable groups

People in excluded or marginalised groups are at a higher risk of being exposed to the virus, as well as being more likely to suffer adverse impacts on physical and mental health and wellbeing through social and psychosocial impacts; impact on employment and finance; and reduced access to housing and services 71

A people with no recourse to public funds (NRPF)

In the West Midlands region in 2019, there were 5,236 asylum seekers in receipt of Section 95 support - 4,304 (82%) of which were in the West Midlands Metropolitan area, with the vast majority receiving both accommodation and subsistence support 72 During the pandemic the Home Office made the decision to suspend evictions from asylum accommodation, move some processes online, and extend payments for those granted refugee status until they received their first welfare benefits payment

However, many asylum seekers are at increased risk of contracting COVID-19 through living in close quarters and sharing facilities with others, in addition to issues around access to testing, facilities and support 73

People with no recourse to public funds (NRPF) are at high risk of homelessness and destitution because they cannot access mainstream housing, welfare benefits and employment 74

Research by the University of Wolverhampton (August 2020)75 found that:

  • There was a lack of information available for people with NRPF: Only 5 of the 151 local authorities in England had publicly-available NRPF policies which were accurate, up to date and contained referral contact details More than 40 percent of local authority websites did not contain any information at all about NRPF
  • Only 7 percent of local authority websites surveyed in April had information on COVID 19-related support for people with NRPF When the survey was repeated a month later, this number had increased to 12 percent 6 out of 10 organisations who responded to the call for evidence had not received updated information from their local authority since the start of the pandemic
  • Numbers of service users with NRPF who had COVID-19 symptoms were relatively small, but those who did have symptoms were particularly likely to die or become seriously ill: More than half of organisations that responded to the call for evidence knew of service users who had been diagnosed with COVID-19 Although most knew of relatively small numbers who were experiencing symptoms, of those who did, more than half had become seriously ill or died
  • People with NRPF struggled to access food, shelter and subsistence support during the pandemic: The most commonly reported impact of the pandemic was not having enough food More than 8 out of 10 organisations identified this as a concern for their service users

The study also found that the most commonly reported difficulty across all user groups was being refused support from the local authority For those already accessing support, the most commonly experienced difficulty amongst children and families was inadequate accommodation for self-isolation For adults with care needs, it was being unable to get in contact with the local authority For homeless adults, the most commonly reported problem was having no provision made for their food or subsistence needs

Homelessness and rough sleepers

People who sleep rough experience some of the most severe health inequalities and much poorer health than the general population 76 The average age at death for people who experience homelessness is 44 years for men and 42 years for women – accidents (including drug poisoning), suicide and diseases of the liver accounted for over half of all deaths of homeless people

in 2017 A University College London study found that a third of deaths among homeless people were due to preventable or treatable conditions such as tuberculosis and gastric ulcers 77
This is related to exposure to poor living conditions; difficulty in maintaining personal hygiene; poor diet; high levels of stress; and drug & alcohol dependence Access to primary care is still a major issue, despite homeless people having the right to register with a GP without identification or a fixed address

Many homeless people have co-occurring mental ill health and substance misuse needs, physical health needs, and have experienced significant trauma in their lives Data from the Combined Homelessness and Information Network (CHAIN) in London shows that 50% of people sleeping rough have mental health needs, 42% have alcohol misuse needs, and 41% have drug misuse needs 78 The COVID-19 pandemic therefore presents additional risks not only in terms of infection, but in reducing access to support services for mental health and addiction problems.

Nationally, the pandemic has prompted rapid action79 on homelessness, with over 90% of rough sleepers now in accommodation As of the 1st of May across the WMCA region, over 800 potential and actual rough sleepers have been accommodated as part of the COVID-19 response – with almost 150 having no recourse to public funds Of those coming in from the streets, 10 returned and a further 40 refused offers of help The WMCA Homelessness Taskforce has observed evidence of greater engagement with the support and services that are offered, and emphasises the need to maintain and build on this trust as we enter the next phase. 80

Drug and alcohol dependence

Data from the National Drug Treatment Monitoring System for the West Midlands region show that from February 2020 to date, compared to the average of the same periods between February 2018 to January 2020:81

  • The number of individuals in treatment and the number of deaths in treatment have increased
  • The number of new presentations and successful treatment completions have decreased
  • Numbers of individuals with housing needs have also decreased
People with complex needs and carers

People with disabilities or complex medical needs are significantly more likely to be at risk of complications from COVID-19 and are therefore more likely to be shielding Parents Opening Doors (PODs) is a peer led charity based in Telford & Wrekin that involves and supports families of children and young people (aged 0-25 years) who have an additional need, or a disability, or SEND The charity is becoming increasingly concerned by reports from families regarding a lack of support, and families of children with complex needs who are reaching breaking point. A survey of their members carried out in June 202082 found that 71% of respondents were shielding; approximately 59% of families said they were ‘doing ok’, 26% were ‘not doing very well’ and around half of these said they were ‘doing really bad’.

Many families reported positive aspects to lockdown, including more time to spend with their children and on play, and being able to access activities, music and virtual performances online However, mental health and wellbeing was a major concern for both parents and children, particularly stress and loneliness Parents had accessed emotional support from a range of sources, including family and friends (88%), the wellbeing line or befriender scheme (26%), social media (25%), mental health professionals (20%) and faith groups (2%) Many felt abandoned by services and the system, with many cancelled appointments, and there were concerns around furlough and economic recovery Under half had attended virtual meetings, with 35% of these saying it had worked for them and 8% saying it had not Some parents did not receive their shielding letters and found that local authorities were slow to react, and felt that CCG commissioning changes needed to be communicated more effectively.

Prison population

People who are incarcerated experience a higher burden of chronic illness, mental health and substance misuse (drugs, alcohol and tobacco) problems than the general public, as well as significantly higher risks of infectious diseases including blood- borne viruses such as Hepatitis B Members of this group often come from already marginalised and underserved populations in the wider community; improving the physical and mental health of people in prison would benefit wider society as well as individuals, including by reducing reoffending rates As well as an increased risk of infection from coronavirus for those currently incarcerated, spending more time in isolation is likely to have a detrimental impact on mental health and exacerbate existing difficulties.

Gypsy, Roma and Traveller people

It is estimated that between 100,000 to 300,000 Gypsy/Traveller people and up to 200,000 Roma people are living in the UK While they have historically lived nomadic lives, they have increasingly moved into housing; the 2011 census for England and Wales recorded 74% of Gypsies and Travellers as living in houses, flats, maisonettes or apartments 83 In January 2020, the number of traveller caravans in WMCA constituent authorities was 232, with the majority (91%) on authorised sites (i e with planning permission) 84 The count of travelling show people caravans was 37, all of which were on authorised sites.

People from Gypsy, Roma & Traveller (GRT) communities experience some of the poorest physical and mental health outcomes in society, even when compared with other socially deprived or excluded groups, and with other ethnic minorities 85 Accommodation insecurity, living conditions, social exclusion and discrimination are among the main causes authorised and unauthorised caravan sites are often in environments that promote poor health (e g by busy roads or heavy industry), and a lack of recognition by local councils and communities of GRT people’s social and legal entitlements to live and work in their areas has a direct detrimental impact on planning decisions, quality of accommodation, and health and wellbeing, as well as education and employment. 86

The higher prevalence of existing health conditions, and additional risks presented by insecure accommodation or restricted access to amenities as a result of the pandemic, means that people from GRT communities are at a disproportionate risk of experiencing severe illness from COVID-19 Guidance published by Friends, Families and Travellers for supporting people living on Traveller sites, unauthorised encampments and canal boats87 sets out key recommendations for local authorities, Traveller site managers and organisations managing canals and waterways to ensure that households can isolate safely and securely, and have access to necessary facilities including water, sanitation and rubbish disposal.

Box 3: Impact of COVID-19 on women

The economic impact of the COVID-19 pandemic on women could potentially result in significant reversals of the progress made over recent decades Research from the Fawcett Society revealed that women are bearing the brunt of extra childcare and housework, and are losing jobs in greater numbers than men 88 Women are also more likely to become infected due to being more likely to work in health and care settings, and are disproportionately more likely to be victims of domestic violence and abuse.

A survey carried out in the WMCA area by West Midlands Women’s Voice and the Fawcett Society89 found that four fifths of employed women have seen their job change in some way; more than a quarter are struggling to make ends meet; more than a third say their mental health has suffered; yet very few reach out to support networks The survey noted some differences between how different demographic groups of women have handled the pandemic, but these tended to be small and usually, consistent across all questions, implying something more to do with cultural response biases rather than specific coronavirus-related demographic differences. Many are using an increase in available time to consider retraining and upskilling Women in the West Midlands reported feeing positive towards their local and combined authorities - they were keen to access services, believed them to be important, and would feel comfortable in using them.

While 41% of women reported having more time for exercise and keeping healthy during lockdown, 31% reported no change in the time available for these activities, and 21% reported having less time This is consistent with national data showing that women were more likely to be doing less physical activity during lockdown (see Health behaviours above), and is likely to contribute to a widening of sex-based inequalities in physical activity participation overall In England, almost half of women (42%) are not active enough for good health compared with approximately a third of men (34%).90

Increasing risk of harm through violence and exploitation

The additional risks presented by isolation and social distancing measures to people whose homes are not places of safety has been recognised from the outset The British Crime Survey reports that only 43% of violence is reported to the police;91 it is therefore important to develop ways of identifying those at risk in other settings where they may come into contact with public service professionals

Injury Surveillance to Tackle Violence (ISTV) is a multi-disciplinary initiative led by the West Midlands Injury Surveillance System (WMISS) Steering Group, funded by the Police and Crime Commissioner The group is made up of multi-disciplinary partners with the aim of monitoring the patterns and trends of violence within the West Midlands WMISS uses anonymised data on injury related consultations in emergency departments, West Midlands Ambulance injury data and West Midlands Police data across the West Midlands, with the aim to identify the root causes to violent related injury and inform local decision making in mitigating these causes

A major issue with reduced access to face-to-face services during the pandemic is that there are fewer contact points and opportunities for these individuals to be identified and offered appropriate support Nationally, Refuge reported a 700% increase in calls to its helpline at the start of lockdown, and a 25% increase in calls from perpetrators seeking support to change their behaviours 92 The Counting Dead Women project recorded 16 domestic abuse killings of women by men between 23 March and 12 April, which is double the average for that period; this rose to 25 women between 23 March and 20 May 93 Long-term underfunding of the sector means that there are limited resources and refuge spaces to meet this growing demand.94

While much of the focus is on victims of domestic violence and abuse, health, emergency and support services also provide opportunities for contact with victims of exploitation, including modern slavery The most common forms of modern slavery include labour, sexual and criminal exploitation, and domestic servitude TAs with domestic abuse and violence, modern slavery is a hidden crime where victims may be further isolated and hidden from view during the pandemic The Home Office sets out guidance for identifying and supporting victims of modern slavery, including during the pandemic 95

Box 4: Digital inclusion and the ‘digital divide’

The move towards many jobs and services, including healthcare, to online platforms presents an additional risk for widening health inequalities COVID-19 has highlighted the ‘digital divide’, with the factors underpinning digital exclusion often the same as those underpinning social exclusion overall – which increase the risk of poverty and poor health Just under 60% of individuals from lower income groups do not have access to the internet whereas 99% of individuals within higher income groups do 96 The barriers by which people are excluded fall into three broad categories: accessibility and affordability of technology; lack of confidence; or lack of digital skills and education 97 As society shifts more towards online systems and phasing out face-to-face interaction, those who face these barriers will struggle to adapt As a result of this, the inequality gap will widen, with these individuals becoming more excluded and isolated.

In the West Midlands, 3% of the population do not have a bank account and rely solely on cash as a means of purchasing goods and accessing services Nationally, 7.5% of adults have never used the internet and within the West Midlands Metropolitan area, 13% of residents have never sent an online message or email In general, disabled individuals are more likely to be digitally excluded compared to those who are not disabled 95% of non-disabled adults were listed as recent internet users whereas this was only 78% for disabled adults However, the internet usage of young disabled adults (age 16-14) is similar to that of non-disabled young adults (98% and 99% respectively), suggesting that digital exclusion is more prevalent among disabled older adults This is consistent with lower internet usage among older adults in general; almost half of people aged 75+ are not recent internet users, and are also more likely to have issues around hearing, manual dexterity or proficiency with technology that may make digital solutions less appropriate for this group. 98

Even prior to the pandemic, digital exclusion was contributing to widening health, social and economic inequalities with the gradual shift towards online provision of services and goods, including government forms, bill payments and banking with more and more services publicised and accessed via the internet, those who are digitally excluded are also less likely to access the unlikely to receive the right information or access the right opportunities and even money saving deals: according to recent government estimates, predominantly offline households spend an average of £560 more per year on shopping and utility bills, compared to families which use the internet to compare prices and access better deals.

During Covid-19 most services and social interaction shifted to online modes (in some cases with a long-term view to retain this, therefore further widening the digital divide and making accessing services more difficult for the most disadvantaged).

During lockdown primary care and outpatient consultations shifted to online, including mental health and drug & alcohol support services – which required service users to not only have the right equipment and internet access, but a physically and psychologically safe space in which to receive that support Public libraries and local community centres closed, leaving behind those who previously depended on those places for internet access. The tasks which were previously difficult for people who are digitally excluded became impossible with lockdown. Given that the groups who are most likely to be digitally excluded are also those who are most likely to benefit from public services, this is likely to widen existing inequalities among these groups

Digital technology has enabled an increase in home and flexible working during the pandemic, which for many has increased opportunities to improve work-life balance – for example, by balancing work with care responsibilities and using the time usually spent commuting to engage

in health and wellbeing improving activities However, not everyone has been able to benefit from this due to the nature of their roles; many key workers have had to continue attending their workplaces, including those in low paid and insecure employment Moreover, low income and older workers (who are more likely to be digitally excluded) are also more like to lose pay as a result of the pandemic.

Section 1 Summary

This first part of the report has described the health of the population of the WMCA, and where COVID-19 has had both direct and indirect impacts on health inequalities.

It shows that, whilst most of the population is healthy, there are very large proportions who are not It shows that health here is not in general as good as the national average People live shorter lives here and a greater part of their life is lived in poor health It shows too that much of the risk of poor health is predictable and is linked to the way people live, and that this in turn is shaped by the places where they live And it is clear that different groups of people within areas have different outcomes, including those relating to COVID-19 In particular, sex, ethnicity, and deprivation, are all shaping the health outcomes of our residents differently.

There will always be new pressures in our society Many future health challenges are known For example, we know that our system cannot easily cope if the numbers of people living with long-term disease continue to rise; we know that we can extend length of life through technological advance but that this can be at the expense of quality of life; we know that a rapidly changing population brings new issues of social cohesion and access to services; and we know that issues such as microbial resistance are emerging We did not specifically know of the emergence of COVID-19, but we did know that any new pandemic would bring premature death and a threat to our health and care systems It is important that the impact of COVID-19 is specifically understood so that we can build our future differently In the short term, services are being expanded and are coping In the longer term, the impact of the disease has been felt disproportionately by the very sectors of the population who are identified in this report as having the poorest outcomes Those who are overweight or smoke, the BAME communities, and the lower paid have all had the highest risks of complications and death following testing positive for COVID-19 This is not consistent with our national values of a National Health Service and equality We must make sure that our approach is ‘future proofed’ and that actions are taken now which reduce health inequalities in the longer term.

Description brings this informed understanding of our population But this is only of real value if it enables decision-makers to have impact in bringing improvement The second part of this report outlines an approach to far-reaching and impactful change