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1 Appendix 3 Executive Summary - Ealing JSNA Background Joint Strategic Needs Assessments (JSNAs) are assessments of the current and future health and social care needs of a local community. These are needs that could be met by the Local Authority, Clinical Commissioning Groups (CCGs), or the National Health Service (NHS) 1. JSNAs are produced by health and wellbeing boards and are unique to each local area. The policy intention is for health and wellbeing boards to also consider wider factors that impact on their communities health and wellbeing, and local assets that can help to improve outcomes and reduce inequalities. Under the Health and Social Care Act , JSNAs and Joint Health and Wellbeing Strategies (JHWSs) form the basis of the CCG, the NHS Commissioning Board and local authority commissioning plans, across all local health, social care, public health and children s services. The Ealing Health and Wellbeing Board delegated the responsibility of developing the JSNA to a steering group made up of CCG, local authority departments, Healthwatch and the voluntary sector representatives. The implementation process has been led by the Public Health department. The steering group agreed to adopt the Marmot approach 3 in developing the JSNA. The approach which is widely used in England is based on the work of Professor Sir Michael Marmot who in 2008 was asked by the then Secretary of State for Health to chair an independent review to propose the most effective evidence-based strategies for reducing health inequalities in England. The final report, 'Fair Society Healthy Lives' 4, was published in February 2010, and concluded that reducing health inequalities would require action on six policy objectives: 1. Give every child the best start in life 2. Enable all children, young people and adults to maximise their capabilities and have control over their lives 3. Create fair employment and good work for all 4. Ensure healthy standard of living for all 5. Create and develop healthy and sustainable places and communities 6. Strengthen the role and impact of ill-health prevention 1 Guidance-on-Joint-Strategic-Needs-Assessments-and-Joint-Health-and-Wellbeing-Strategies-March-2013.pdf

2 The JSNA chapters are based on the above policy objectives. The JSNA process has been divided into two phases. The first phase, which was implemented between June and September 2014, addresses policy objectives 2 (partially) and 6. The rest of the objectives will be addressed in the second phase to be implemented in This chapter summarises the JSNA 2014, highlighting the key findings and recommendations. The JSNA chapters on Dementia and Socioeconomic Factors were updated in 2013/14. For the executive summary findings and key recommendations from these chapters, the information can be accessed by using the link below 5. An Ealing Adult Carers survey is done biennially, the next one due to be completed by March 2015 and analysed by the end of Following this, the Carers Strategy will be refreshed during Ealing s Population Characteristics The population of Ealing has risen from 286,400 in 1994 to 342,500 in 2013 according to the latest Office of National Statistics (ONS) mid-year estimates. Ealing has a higher proportion of both males and females aged 0-9 and 25-44, but a lower proportion of persons aged 50 and above as compared to the England average. According to the 2013 mid-year population estimates, Ealing is the third largest London borough in terms of population, after Croydon (372,800) and Barnet (369,100). At 63 persons per hectare Ealing is also the third most densely populated borough in Outer London (after Brent and Waltham Forest). There are 407,541 people registered with 79 GP practices in Ealing 6. Out of this, 49% (200,317) are aged % of all registrations are male and 48% female. Average number of registered persons per GP practice in NHS Ealing CCG is 5,159 (7,041 average in England in 2013). According to the Greater London Authority (GLA) population projections (Figure 1), the White ethnic group population is expected to have a small drop in numbers 5 Link: ddvckoobfuuzkjy5c75kwh1ejwx1ujwj069h4a%3d%3d&ruzwrpf%2bz3zd4e7ikn8lyw%3d%3d=pwre6agjfl DNlh225F5QMaQWCtPHwdhUfCZ%2fLUQzgA2uL5jNRG4jdQ%3d%3d&mCTIbCubSFfXsDGW9IXnlg%3d%3d=hFfl UdN3100%3d&kCx1AnS9%2fpWZQ40DXFvdEw%3d%3d=hFflUdN3100%3d&uJovDxwdjMPoYv%2bAJvYtyA%3d %3d=ctNJFf55vVA%3d&FgPlIEJYlotS%2bYGoBi5olA%3d%3d=NHdURQburHA%3d&d9Qjj0ag1Pd993jsyOJqFvmy B7X0CSQK=ctNJFf55vVA%3d&WGewmoAfeNR9xqBux0r1Q8Za60lavYmz=ctNJFf55vVA%3d&WGewmoAfeNQ16 B2MHuCpMRKZMwaG1PaO=ctNJFf55vVA%3d 6 Source: NHS Ealing CCG,

3 between 2010 and 2025 (from 167,000 to 163,900), but then rise again to 2010 levels by For all other ethnicities the projections indicate a steady rise in numbers over the 30 years period: Asian/Asian British by 41%, Black/Black British by 49% and Chinese by 38%. Figure 1: Ealing Population Estimates by Ethnic Group, The White British population remains the largest group in Ealing schools, but continues to fall in numbers despite an increase of over 1,000 in the overall school population. There are 281 less White British pupils in Ealing schools than there were in 2013.The Eastern European, Asian and Arab populations continue to grow steadily. There are now 4,597 Eastern European pupils (an increase of 387 in the last year), 3,500 Asian pupils (nearly half of whom are Tamil speakers) (an increase of 183), and 1,788 Arab pupils (an increase of 186) in Ealing schools. Ealing s crude general fertility rate (GFR) (71.9/1,000 females) is significantly higher than the England average (63.7/1,000 females) 8. The only wards with significantly lower fertility rates than England are Ealing Broadway, Ealing Common and Hanger Hill which have significantly lower fertility rates. Southall Green (76.9) and Northolt West End (77.4) have significantly lower male life expectancies at birth as compared to the England average (78.8). South Acton (80.4) and Norwood Green (81.1) have significantly lower female life expectancies at birth as compared to the national average (82.7). 7 Please note: GLA Aggregated Ethnic Group (AEG) classification White group includes Irish and White Other; Mixed White and Black ethnic group is counted as Black Other (so within Black/Black British in the table); Mixed White and Asian ethnic group is under Other Asian (so Asian/Asian British here); any other mixed ethnic heritage is counted under Other ethnic group. 8 Source: HSCIC, NHS Indicators Portal,

4 The majority (73%) of homeless people in England reside in London. Ealing s homeless rate (8.6/1,000) is significantly lower than the London average (11.9/1,000) but more than three times the England average (2.4/1,000). Lower Super Output Areas (LSOAs) within Norwood Green and Elthorne wards are among the 10% most health deprived in the country. 3 Ealing borough outcomes 9 The Public Health Outcomes Framework sets out outcomes and indicators to help us understand how public health is improved and protected in Ealing compared to the rest of England. There are two overarching outcomes relating to life expectancy and inequalities in life expectancy and further indicators clustered into four domains of 1) wider determinants of health 2) health improvement (lifestyles and choices) 3) health protection and 4) healthcare public health and premature mortality and finally, preventable ill health. Ealing does better on breast feeding, school readiness, hospital admissions due to childhood accident/injury, NHS health checks and premature cancer mortality. Below is a selection from the framework of areas of challenge for Ealing: Ealing s female healthy life expectancy at birth (60.1) is significantly lower than the national (64.1) or London average (63.6). There has been a slight decline since 2009/11. Ealing s premature mortality rate (under 75) is significantly higher than the national average (353/100,000 versus 350/100,000 in 2010/12) and has risen since 2009/11. At 3.6%, Ealing s low birth weight is similar to London average (3.2%), but higher than England average (2.8%). MMR and flu vaccine for two doses (5 years old) at a rate of 82.5% of population is lower than the national average (87.7%) and has declined since 2011/12. However, the borough s rate is higher than the London average (80.8%). The excess weight prevalence rates among Ealing children aged years (37.9%) is higher than the national average (33.3%), but on London level (37.4%). This has risen since 2011/12. At 1,392, chlamydia detection rates among young people in Ealing are lower than the national set targets of 2,300 or more. For London, the achieved figure was 2,179 and in England, Overall Ealing s rate has risen since the previous year, although among males the rate has slightly declined. 9 Source: Public Health Outcomes Framework (PHOF) 4

5 Ealing s utilization of outdoor space 10 (10.2%) is significantly lower than the national average (15.3%, although similar to London s figure (10.5%). However this is a substantial improvement from 6.6% in 2011/12. The incidence of TB in Ealing (69.1 per 100,000) is higher than for both London average (41.4 per 100,000) and the national average (15.1 per 100,000) and has risen since 2009/11. At 67.6%, breast cancer screening rates in Ealing are lower than those for London (68.6%) and national average (76.3%) and have declined since The figures for cervical cancer screening are similar: in 2012/13 Ealing rates were 64.6%, compared to London (68.6%) and England (73%). Emergency hospital admission rates due to falls among older people in Ealing are higher than the national and London average and have risen since 2011/12. 4 Older People The population of persons aged over 65 in Ealing in 2014 is estimated as 39,200. This represents 11.3% of the total population (345,800 people), the majority of who are females (54%). Approximately 10,364 older people were predicted to have a fall in The number is predicted to rise to 15,646 by 2030 (51%). The highest rise will be among older people aged 85 and over (78%). There are 12,772 households in Ealing that are known to experience fuel poverty. This is equivalent to a rate of 10.8% which is significantly higher than the London (8.9%) and England (10.4%) averages. 11 There are approximately 18,748 older people with limiting long-term illness in Ealing. Limiting long-term illness is self-reported and defined as any long-term illness, health problem or disability which limits someone s daily activities or the work they can do. The number is predicted to rise to 21,002 by 2020 (17.4%). The highest rise will be among older people aged 85 and over (40.8%). 10 Percentage of people using outdoor space for exercise/health reasons. Visits to the natural environment are defined as time spent "out of doors" e.g. in open spaces in and around towns and cities, including parks, canals and nature areas; the coast and beaches; and the countryside including farmland, woodland, hills and rivers. This could be anything from a few minutes to all day. It may include time spent close to home or workplace, further afield or while on holiday in England. However, this does not include: routine shopping trips or time spent in own garden - Source: PHOF ( Natural England: MENE Survey) 11 Department of Energy and Climate Change (DECC). 5

6 A total of 1,496 deaths of persons aged 65+ were reported in Ealing in Circulatory disorders (32%), cancer (25%) and respiratory disorders (16%) were the top three underlying causes of death. Develop an integrated falls prevention plan across Ealing and improve access to primary and community health services such as dentistry, podiatry, continence services through engagement of commissioners and all service providers. Reduce excess winter deaths amongst older people via uptake of winter fuel payments, fuel poverty schemes and the promotion good health during winter times. Extend intermediate care to provide care closer to home and support patient independence and recovery to reduce rates of care home admissions for all causes. Signpost to and enable opportunities for older people living alone to prevent social isolation and improve mental and physical health. 5 Ill Health Prevention 5.1 Chronic Obstructive Pulmonary Disease (COPD) In 2010/11 there were 386 COPD inpatient admissions among Ealing GP registered patients. The vast majority of these were unscheduled emergency admissions (96%). There were 246 COPD related deaths in Ealing during period. This was equivalent to a rate of 21.8/100,000 population, compared to London figure of 25.5/100,000 and England average (32.9/100,000). Ealing s all persons and male mortality rates were significantly lower than the England averages. Males had a significantly higher COPD mortality rate than females. The majority of COPD deaths in Ealing occur in the hospital (73%). End of life care is managed in primary and secondary care settings, however there is no comprehensive end of life pathway or service specifically for COPD patients. Improve awareness of lung health across all population groups and ensure stop smoking services are offered to all patients who smoke. Improve the value and quality of community based diagnostic spirometry service e.g. improved accessibility and acceptability. 6

7 Improve the value and quality of pulmonary rehabilitation service in Ealing and address health service gaps in COPD pathway of care. Assess current COPD self-care management interventions and opportunities to improve effectiveness. 5.2 Asthma A total of 19,834 patients were recorded as having asthma by their GPs in Ealing (2012/13).This was equivalent to a prevalence rate of 4.9% which is higher than the London average (4.7%), but lower than the England average (6%). Ealing has a significantly higher rate of asthma hospital admissions (3.4/100 for males and 3.2/100 for females) than the London or England averages. Hospital admissions rates are more than twice as high for both males and females in Ealing compared to the England average. Over 90% of hospital admissions are emergency admissions. Evidence shows that 70% of asthma hospital admissions may be preventable. Further investigate the admission rates for asthma, by age, ethnic group and locality to identify which population groups have higher demand for secondary care. Work with primary, community and secondary care providers to explore opportunities that exist to improve the asthma care and support the implementation of current and forthcoming guidelines from NICE and the key recommendations from the National Review of Asthma Deaths (NRAD). 5.3 Diabetes In 2012/13 there were 21,890 (6.8%) people aged 17 years and older diagnosed with diabetes in Ealing. This is due to increased detection of cases, however it is estimated there are 5,659 adults with undiagnosed diabetes. Ealing has the joint 5th highest diabetes prevalence (6.8%) (with Barking & Dagenham and Enfield) across London. The average diabetes prevalence rate is lower for England, at 6%. 7

8 Data from GP patient survey show that the percentage of people with long term conditions (including diabetes) who feel they have received enough support from their local organisation (56%) and are confident of managing their own health (90%) is lower than the London or England average (92% and 93% respectively). Ealing s male all age diabetes mortality rate (8.7/100,000 population) for the period was significantly higher than the London figure (6.1/100,000) or England average (6.0/100,000). All high risk patients or pre-diabetes should be referred to evidence based quality assured intensive lifestyle programme that cover physical activity, weight management, diet and behaviour changes techniques. In order to reduce the number of people dying from diabetes and its complications, there is a need to increase awareness of the risks, bring about wholesale changes in lifestyle, improve self-management among people with diabetes and improve access to community diabetes care services. A proactive approach is required to identifying people at high risk and 5,659 people with undiagnosed type-2 diabetes in Ealing. The best approach to achieving this would be to accelerate the NHS Health Checks programme, which will lead to both diagnosis of diabetes and identification of those at higher risk in whom preventive interventions are appropriate. 5.4 Cardiovascular Disease (CVD) It is estimated that CVD in Ealing affects 24,063 people. About 9.4% of the adult (aged 16+) population is affected by CVD. This is lower than both London (9.7%) and England (11.7%). Ealing has a higher CVD emergency admission rate (3.8/1,000) than the England average (3.3/1,000). In 2012/13 a total of 963 admissions were reported which was higher than expected (159 more admissions). There were a total of 1,875 deaths reported in Ealing in Circulatory vascular disease accounted for nearly a third of all deaths (568 deaths, 30%). There were more circulatory vascular disease related deaths than expected in Ealing during the period. Among Ealing wards, Dormers Wells, Southall Broadway, Southall, Northolt West End and Norwood Green had more than expected number of deaths. 8

9 Commissioners need to ensure that there is provision of support for lifestyle interventions such as physical activity, healthy eating, sensible drinking, smoking cessation and weight management; and consider the creation of an integrated community lifestyle service model. Commissioners across the partnership need to identify how to integrate work on the wider long term conditions agenda to streamline pathways of care, with a focus on putting prevention first, reducing unnecessary hospital admissions, and ensuring early discharge from hospitals. Active case management of patients with CVD within community should be considered to reduce the rate of emergency admissions and complications. The implementation of community based cardiology service may result in lower admission rates. 5.5 Musculoskeletal Conditions Access to community MSK services is lower from areas with high deprivation and high black and minority groups. GPs in the West of the borough make half the number of referrals to community musculoskeletal interface services 12 per 1,000 registered population compared to Ealing, Northolt and Greenford areas (7.5/1,000 patients vs. 13.9/1,000). Ten percent of the local population is estimated to have troublesome pain and symptoms due to osteoarthritis of the hip and knee. Population projections estimate that the number of patients consulting with lower limb osteoarthritis will rise by 3.8% per annum between 2010 and The Spend and Outcomes tool for showed that expenditure and outcomes for musculoskeletal disorders was significantly below average. Over the last two years, expenditure on community musculoskeletal services has increased by 60%, the number of patients seen has increased by 40% and waiting times have fallen from a median of 17 weeks to 4 weeks. 12 An NHS Interface service incorporates intermediate levels of triage, assessment and treatment between traditional primary care and secondary care. (See also: 9

10 Increasing activity levels, reducing obesity, reducing smoking prevalence and improving nutrition are key interventions for the prevention and treatment of musculoskeletal disorders. These interventions are also important in the prevention and treatment of co-morbid diseases (which appear in the same person at the same time) such as heart disease, chronic lung disease and diabetes. These key interventions can therefore improve health for people with a single health problem and people with multiple diseases, as well as benefiting the population at large. Consider how to engage particular groups with interventions to improve musculoskeletal health and reduce health inequalities; viz. ethnic minorities, GPs and practice nurses in areas of higher deprivation, pregnant women and people caring for young children, elderly people and people with mental health problems resulting in poor nutrition and social isolation, and people at risk of injury in the workplace such as construction workers and nurses. 5.6 Alcohol Misuse Twelve percent of the Ealing population aged 16 and over is engaged in binge drinking (according to 2007/08 data). The rate is significantly lower than the London and England averages (14% and 20% respectively). In 2012/13, 48 cases of alcohol related crimes were recorded in Ealing which equates to a rate of 13/100,000. This was significantly higher than the England average (12/100,000). The alcohol related mortality rate among males in Ealing (69/100,000 population) remains higher than the statistical neighbours, London s and England s averages. Locality level data (from probation and the new community rehabilitation company, safeguarding teams, hospital admission, antisocial behaviour events and GPs) have not been co-ordinated and joint mapping is a recognised gap. The high levels of alcohol related ill health, crime and consumption indicate that funding for integrated treatment services must be maintained to address demand and need. 10

11 High levels of alcohol related crime indicate that criminal justice elements of the integrated RISE 13 model must adapt to meet this need. This includes working with Recovery Intervention Service Ealing (RISE) to support criminal justice re-modelling to extend alcohol arrest referral in custody suites, and identifying alcohol users amongst existing probation cohort where alcohol is indicated as a criminogenic factor. Co-ordination of different data sources to ensure needs are met and also to develop intelligence to inform licensing policy and reviews. 5.7 Drug Misuse The prevalence of co-existing mental health and substance use affects between 30% and 70% of those presenting to health and social care services in Ealing. The proportion of the drug treatment population reporting sex working in Ealing is high hence the need to address sexual health issues alongside drug treatment programmes. In recent years there has been an increase of adults in Ealing who are subject to immigration control, do not have the right to work and have no entitlement to welfare benefits, public housing or asylum support. There is a limitation of treatment options for this group due to their status, and risks of overdosing and double prescriptions is high. Ensure commissioning and operational approaches address the issue of dual diagnosis across the treatment system by working in partnership with the CCG and mental health providers to review current arrangements and develop a strategic approach. Work in partnership with surrounding boroughs to ensure that sex workers are able to access treatment and have a route out of prostitution. Conduct a comprehensive needs assessment of substance misuse via engagement with key stakeholders (service users, CCG, criminal justice partners and others). Establish clear treatment pathways for those with no right to work /welfare benefits and follow up with an annual audit to assess impact

12 5.8 Obesity Approximately 57% of adults in Ealing are overweight or obese. Data compiled from the Health and Social Care Information Centre s (HSCIC) Hospital Episode Statistics on Obesity, Physical Activity and Diet (2014) shows that 536 per 100,000 Ealing residents were admitted to hospital with a primary or secondary diagnosis of obesity during the year 2012/13. Explore possibilities to promote healthy weight and weight management amongst women of a childbearing age, with a view to preventing maternal obesity. Use the NCMP data locally to inform the local healthy weight, healthy lives action plan (the local obesity action plan). Develop an Adult Obesity Care Pathway in partnership with Ealing CCG, Ealing Hospital Trust, third sector and commercial providers. Work with a wide range of partners to enable local implementation of the government s Change4Life movement, which primarily focuses on eating well and moving more for children and families, with the inclusion of messages and campaigns for other targeted/specific groups. 12

13 5.9 Physical Activity Ealing s participation rate in physical activity is lower than the London and England averages. Figure 2: Once a week sport participation in Ealing, APS 2011/12 According to the Active People Survey 2011/12 (Figure 2), Southall, West Greenford, Northolt and East Acton areas have the lowest physical activity participation rates and therefore should be targeted more in current intervention strategies. Obesity prevalence rates are highest in areas where participation in physical activities is low, hence the need to address the issue of low physical activity uptake as a core strategy in reducing obesity prevalence. Focus on adult service provision and participation, specifically amongst older people and those managing long term conditions and those with elevated CVD risk factors. Work with a wide range of partners to enable local implementation of the government s Change4life movement, which primarily focuses on eating well and 13

14 moving more for children and their families, with the inclusion of messages and campaigns for other targeted/ specific groups. Increase training opportunities offered and the understanding of how to integrate promotion of active living and physical activity across a range of settings (e.g. public health, primary care, transport, the environment, education, childcare and social care) Sexual Health Rates of acute sexually transmitted diseases have been rising in Ealing. In 2013, there were 101.9/100,000 people with gonorrhoea and 9.1/100,000 with syphilis. In 2013, the rate for chlamydia diagnosis amongst year olds was 1,392 per 100,000. This rate is below both national and London figures (2,016/100,000 and 2,179/100,000 respectively). The rate of ectopic pregnancy admissions in Ealing is increasing, from 90/100,000 in 2008/9 to 144.9/100,000 in 2012/13. In 2012/13, 79.1% of years old females in Ealing received a HPV vaccination. This is just above the London coverage (78.9%), but below the national one (86.1%). In Ealing, between 2009 and 2011, 53% of HIV diagnoses were made at a late stage of infection, compared with 50% for England. In 2011, the diagnosed HIV prevalence rate in Ealing was 3.2 per 1,000 compared to 2 per 1,000 in England. In 2012/13 in Ealing, the rate of GP prescribing Long Acting Reversible Contraceptives (LARCs) per 1,000 females aged was significantly lower than the London (23.2 per 1,000) and England (49.0 per 1,000) averages. GUM services should remain open-access and prevention strategies strengthened to reduce the burden of poor sexual health in Ealing, including high rates of repeat STI s and late diagnosis of HIV. Increase service access and public awareness of, and adherence to, a wider range of contraception choices to avoid unwanted pregnancies and abortions. Increase targeted interventions amongst those groups identified as having poorer sexual health, such as men who have sex with other men (MSM), BME groups, younger people and more vulnerable groups such as people with learning disabilities. 14

15 Pilot new prevention efforts, such as online HIV and chlamydia testing where appropriate to provide enhanced choice, amongst targeted groups identified as having high internet use. 5.11Tuberculosis In 2013/14 Ealing had the second highest TB notification rate in the North West sector (60.8/100,000 population), which was nearly twice the London average (35.2/100,000 population). The majority of TB notifications in LB Ealing are of young people aged Most were born outside the UK. Almost half of all cases are of Indian ethnic origin and the majority (90%) were born in India. More than 1 in 10 (13%) patients in Ealing diagnosed with Tuberculosis do not complete their treatment within one year of notification. Seven percent of TB cases in Ealing are resistant to Isoniazid and 1% are multidrug resistant. Raise TB awareness in the local population and strengthen the TB community outreach work in order to better engage local communities and vulnerable groups. Screen domiciled high risk groups within 2-5 years of entry to the UK for TB and latent TB and GP registrations from high risk populations for TB and latent TB, targeting areas with the highest incidence (South West Ealing). Support TB patients to complete their treatment, especially those being treated in other hospitals. This should involve establishing better communication and coordination of care between Ealing Hospital Trust (EHT) and the other TB services commonly used by Ealing residents Adult Oral Health An important aspect of the effectiveness of dental commissioning is the ability of patients to obtain needed dental treatment when they request it. One measure used to assess this, describes the number of patients seen as a proportion of the resident population, the access rate. 15

16 In Ealing, almost half (49%) of adults (aged 19 years and above) had visited the dentist in the last 24 months as at 31 March This access rate is above the one for London (44%), but below the national average (52%). Making Every Encounter Count approach should be adopted by health professionals. This involves attempting to deliver brief intervention including oral health at every opportunity and patient interaction. Encourage parents to start brushing their baby s teeth as soon as the first tooth comes through. Babies should be taken to the dentist at around 1 year old, so they get used to going to the dentist and should subsequently be taken to the dentist at least once a year, or more frequently as recommended by the child s dentist. Strategies to promote health and wellbeing and policies tackling obesity, cancer, cardiovascular disease and tobacco cessation and prevention of uptake should include oral health improvement. Ensure the commissioning of nursing and residential homes includes training of staff about looking after people s mouth and dentures. Implement healthy eating policies in nursing homes, care homes and homes for vulnerable groups, especially reduction of sugary foods and drinks. Increase the availability of fluoride, in particular fluoride toothpaste and higher fluoride toothpaste for those especially at risk of dental decay and root caries. 6 Future plans The Ealing JSNA steering group is committed to producing a JSNA that addresses all the policy objectives as specified in the Marmot s review report. Other broad policy areas to be addressed during the 2 nd phase expected to commence in 2015 include: 1. Giving children a healthy start in life 2. Enabling children & young people to maximise the capabilities and have control over their lives 3. Enabling adults to maximise the capabilities and have control over their lives 4. Creating employment and good work for all 5. Creating and developing sustainable places and communities 6. Enabling a healthy standard of living for all 16

17 Appendix: Ealing Health Profile For the full Ealing Health Profile document, please go to: 17