JSNA Live Well - Healthy lifestyle and behaviours

1.1 Introduction to Health Behaviour

Human behaviour and lifestyle factors can affect every aspect of health and wellbeing both favourably or unfavourably and to a different degree throughout an individuals’ life. Lifestyles and health behaviours are complex and influenced by multiple factors including genetics, wider determinants of health, previous experiences throughout life, the environment, societal factors, cultural factors as well as individual and interpersonal factors. Therefore, the misconception that individual’s behaviour is due to ‘choice’ alone, over-simplifies our understanding.

When considering health behaviours and lifestyle, it is helpful to think of health and wellbeing on a dynamic continuum over the life course. While the degree of influence and need for intervention will vary based on individual circumstances and need, the fundamental components of a healthy lifestyle are relevant to all individuals, irrespective of health and wellbeing status and can favourably influence health and wellbeing at all life stages. Therefore, the potential benefit of healthy lifestyle behaviour change should not be under-estimated.

National evidence suggests that a quarter of England’s adult (age 16+) population engage in three or more behavioural risk factors ¹. The Wandsworth Joint Strategic Needs Assessment 2017/18 and Annual Report of the Director of Public Health 2017/18 ², highlighted a number of Wandsworth residents engage at least one behaviour that can have a detrimental impact on their health.

Based on most recent data, 7.8% of adults in Wandsworth are smokers ³, 1.5% of adults in Wandsworth are estimated to be dependent on alcohol ⁴ and 15.8% of people in Wandsworth are physically inactive, completing less than 30 minutes of physical activity per week.

Though we are unable to ascertain how many residents engage in multiple behavioural risk factors based on local data, current evidence suggests these behaviours tend to cluster together, creating multiple risk factors for poor health ⁵. Based on national estimates and the current population in Wandsworth (aged 15+), it would be expected that around 76,700 residents engage in three or more behavioural risk factors. The health of people of Wandsworth is generally faring better than the rest of England.

These behaviours are all modifiable have the potential to improve multiple areas of health and wellbeing for the residents of Wandsworth such as reducing the impact of and preventing long term conditions, improving mental health and wellbeing of residents and encouraging social connectedness of residents in the borough. Whilst there is good work happening across the borough and evidence of good practice, numerous residents are engaging in behaviours that are detrimental to health in both the short and long term or exposed to environmental and metabolic risks for poor health. This chapter considers the contribution of lifestyle and health behaviour on the health and wellbeing of the residents of Wandsworth based on current evidence and local data.

Life expectancy at birth for men and women of Wandsworth is 80.6 and 84.2 respectively, higher than national figures. Healthy life expectancy at birth for residents is also higher than the national figures for both men, at 62.7 years, and women, at 68.1 years. However, there are areas for improvement.

The impact of the COVID-19 pandemic on the lifestyles, health behaviours and health and wellbeing of local residents remains unclear. However, the need for supporting residents in improving physical and mental health, in part with promoting and facilitating healthy behaviours is a priority in light of the tragic COVID-19 pandemic.

1.2 Lifestyle Risk Factors for Long-term Conditions

Unhealthy behaviours tend to cluster together creating multiple risk factors for poor health both in individuals and communities. Chronic diseases are the leading causes of death and disability worldwide and the WHO acknowledges that rates of these conditions are accelerating globally and account for around 71% of deaths globally. The WHO states the 5 main risks for developing non-communicable disease risks are as follows, all of which involve modifiable human behaviours:

• Unhealthy diet: high in salt, sugar or unhealthy fats

• Tobacco use

• Air pollution

• Harmful use of alcohol

• Physical inactivity

Cardiovascular disease, cancer, respiratory diseases and diabetes account for most of deaths globally, with the local information on each of these long-term conditions has been explored in separate sections of the JSNA. These longterm conditions are of course also the result of a combination of genetic, physiological, social and environmental factors alongside the modifiable individual behaviours. However, each of the conditions listed can, to some degree, be prevented, outcomes improved and in some cases disease processes reversed with changes in lifestyle behaviour.

These lifestyle behaviours can be introduced at an individual, community and societal level. Wandsworth health data may fare relatively well when compared to national data for certain lifestyle behaviours, however, this can be falsely reassuring when considering the multiple detrimental impacts of physical inactivity, poor diet or substance misuse can have on all aspects of health and wellbeing both the short and longer term.

The relationship between risk factors and burden of disease is complex given the nature of the risks and interaction between behavioural, environmental, metabolic factors risk factor exposure. Depending on the disease considered, the degree of attributable risk varies, however, on the whole, the main risk factors accounting for the total burden of disease in England, according to PHE,14 15can be categorised into the following groups:

1.3 Inequalities in Health Behaviours

Health conditions are poorer in the top quintile of the most deprived areas in Wandsworth. 5.7% of people living in the most deprived areas of Wandsworth have bad or very bad health compared to 3.3% in all other areas of Wandsworth. In addition, 50% living in the most deprived areas consider themselves to have very good health. This is lower than the remaining population in Wandsworth (59.3%).

Often, clustering of behaviours detrimental to health is associated with social factors such as socio-economic status including educational attainment thus creating multiple risk factors for poor health. Individuals living in more deprived circumstances are more likely to be exposed to multiple risk factors, further influencing health behaviour and lifestyles which act to further widen social inequalities in health.

In 2019, the borough of Wandsworth ranked 173rd most deprived out of 317 local authorities across England: placing it within the 50% least deprived local authorities in England. The Annual Survey of Hours and Earnings (ASHE) estimates that Wandsworth residents working full-time earned £43,470 in 2019. This is amongst the top three annual earnings in London and England 35. However, there are income inequalities within the borough, that is how unequally income is distributed within the population; Wandsworth’s income inequality is the 6th highest in London ²⁵

Overall in 2018, there were 68,853 people living in the most deprived areas of Wandsworth. These are small areas that fall into the top 20% of deprivation compared to the rest of Wandsworth. Of these people 13,903 are children and 8,874 are adults over 60.

There are in total, 27,822 people from ethnic and minority backgrounds living in the top 20% most deprived areas of Wandsworth. This makes up the largest proportion of people from ethnic and minority backgrounds compared to the other deprivation quintiles. This quintile has the lowest proportion of white ethnic groups (36,105), compared to the other quintiles for deprivation ^{26 27}

The London Poverty Profile (2021) ranks London boroughs on key poverty and inequality indicators. In Wandsworth 11% of employed residents earn less than the London Living Wage - the joint lowest percentage in London, the poverty rate, that is the number of people that’s income falls below the poverty line is 22% of the population, this is below the London average (27%).

The average Income Deprivation Affecting Children Index (IDACI) score for the borough indicates that 15% of children (0-15) are affected by income deprivation (2019), compared to 21% in 2015. Despite this and a relatively less deprived rank (150/317) compared to 2015 (123/326), Wandsworth remains within the 50% most deprived children local authorities nationally.

The average Income Deprivation Affecting Older People Index (IDAOPI) score indicates that 21% of older people (60+) are affected by income deprivation in Wandsworth, compared to 23% in 2015. However, the borough’s rank has not experienced notable change since 2015, retaining a position amongst the 8% most deprived LAs in England (26/317) ²⁸

Given health behaviours begin to form in childhood and both older people and children are vulnerable to the increased risk of behaviours detrimental to health and that poor health behaviours are associated and exacerbated by socioeconomic status, addressing the wider determinants of health in children and older adults in Wandsworth is important.

The King’s Fund reported that individuals with no qualifications were more than five times as likely as those with higher education to engage in all four unhealthy behaviours including low physical inactivity, alcohol, smoking and poor diet. Wandsworth has one of the most educated populations with 66.5% have degree education or above, higher than England (36.8%), as of 2021. However, 1.4% of residents have no qualifications which is around 4,000 residents. While this is lower than England (6.5%), this accounts for 4,000 residents that are at higher risk of engaging in health harming behaviours than residents with higher education ²⁹. Alongside this, the harm from certain unhealthy behaviours is likely to be higher in certain groups, therefore the risk of harm from the same exposure can disproportionately cause harm to certain groups within the community.

1.4 Impact of the Local Environment on Health Behaviours

Increasing physical activity, improving nutrition, getting the recommended amount of good quality sleep, spending time in nature and connecting with others fostering positive relationships and reducing stressors or improving ability to cope with stressors promotes a healthier lifestyle for physical and mental health. Positive health behaviours can prevent and improve management of and improve recovery from illness as well improving general health and wellbeing. Therefore, there is potential for multiple gains from engaging in healthy behaviours and interventions to improve the health behaviour of local residents can seek to address multiple health benefits.

Understanding the basis of human behaviour can help to inform local decision making around lifestyle services and behaviour change interventions to provide effective, high quality, compassionate services.

Humans’ instinctive behaviours and responses can, in current modern-day living, be detrimental to our health and wellbeing whereas historically, these same behaviours would have been advantageous for survival. In a relatively short time the environment we live in has changed to lend itself to an increasingly sedentary, convenient lifestyle with regular access to unhealthy foods, artificial ‘rewards’ and constant exposure to stressors. However, over the same timeframe, the systems within our bodies remained largely unchanged and have not adapted to our new conditions.

1.5 Lifestyle and Health Behaviour Related Services

2.1 Smoking Prevalence

Smoking Prevalence in adults (18+) - current smokers (APS): In 2022, Wandsworth’s rate was 7.8%, which was the 6th lowest in London, 38.2% lower than the England average and 33.0% lower than the London average. The latest Borough figure for 2022 was also 50.0% lower than in 2011, in comparison with 36.2% decrease in England’s rate in the equivalent time period.

Source: OHID: Public Health Profiles

Source: OHID: Public Health Profiles

• Between 2017 - 19, 530 residents died from a smoking related death ³⁰ and in 2019/20 there were 1,265 smoking related hospital admissions ³¹. In 2018-19, 112 women were smoking at time of delivery.

• Smokers take more sick-leave from work than non-smokers.

• Smoking increases the risk of disability and premature death.

• £51,6m of potential wealth is lost from the local economy in Wandsworth each year due to smoking ³².

• 378 early deaths due to smoking result in 547 years of lost economic activity, costing businesses about £17.5m.

• A further 118 employees in Wandsworth are economically inactive and unable to work due to smokingrelated sickness, resulting in an annual £5.7m. It is estimated that smoking breaks cost businesses in Wandsworth £20m ³³.

• Many current/former smokers require care in later life as a result of smoking-related illnesses. Each year these cost society in Wandsworth an additional £2.7m. There is a significant number of older people suffering from smoking attributable illnesses whose needs remain unmet by formal care. If all such individuals were instead to receive a formal social care, it would cost the system a potential further £61m ³⁴.

• It is estimated that the London Fire brigade will attend about 15 smoking-related house fires each year in Wandsworth. £2m is lost annually in the Borough as a result ³⁵.

• Smoking materials constitute 35% of all street litter. The majority of cigarette filters are non-biodegradable and must be collected and disposed in landfill sites. Smokers in Wandsworth consume about 244,010 cigarettes every day. Of these roughly 206,600 are filtered, resulting in among 35kg of waste daily. This represents 13 tonnes of waste annually, of which 5 tonnes is discarded as street litter that must be collected by the Council ³⁶.

In Wandsworth, there are an estimated 246.1 smoking attributable deaths and 1154 potential years of life lost due to smoking related illness per 100,000 people. There are also 152.5 smoking attributable hospital admissions per 100,000 people in Wandsworth, which is less than the national average ³⁷.

In Wandsworth there are 1,417 smoking attributable hospital admissions per 100,000. Smoking-related mortality for certain conditions are given as follows: COPD 51.0, CVD 20.0, lung cancer 53.2 (per 100,000 population) ³⁸.

It is estimated that the annual cost of smoking in Wandsworth is £66.6m due to lost productivity (smoking breaks, sick days and early deaths), smoking related disease, social care costs, fires and passive smoking. Additional smoking related social care needs costs Wandsworth Borough Council £2.7 million per year, and local residents pay an additional £504,630 to self-fund their care ³⁹.

As smoking prevalence increases with deprivation, the increased expenditure on smoking imposes a comparatively higher cost on proportionally more low-income households compared to high income households. Smoking rates are higher within certain groups and deprived communities and the rate of decline of smoking prevalence has not been equal among all populations. Targeting groups that are more likely to smoke is, therefore, one of the ways that services seek to reduce health inequalities.

2.2 Recent Developments to the Smoking Landscape

Nationally and locally the demand and uptake of smoking services has been affected by falling prevalence and the advent of e-cigarettes. Notably, within the last few years, new developments have been taking place at regional, sub-regional and locality levels that will influence the future direction of travel of stop smoking services. This has created a level of uncertainty regarding the emerging commissioning landscape and its impact on the provider markets.

There is a range of influences on future smoking prevalence, including the effect of e-cigarette use on smoking cessation, with new research suggesting that e-cigarettes have contributed to tens of thousands of additional quitters in England, thus accelerating the drop-in smoking rates across the country ⁴⁸.

Public Health England (PHE) advise that vaping carries a small fraction of the risk of smoking. Using a nicotine-containing e-cigarette makes it much more likely that someone will quit successfully than relying on willpower alone – vaping is twice as effective for quitting smoking than NRT alone. But it is important to use UK-regulated e-liquids and never risk vaping home-made or illicit e-liquids.

Equally, it is important to address other forms of tobacco use, which are more common in certain communities. Shisha, which is one such use, creates smoke containing harmful chemicals, is becoming increasingly an area of concern. The populations where shisha is most commonly used, including BAME groups, are the same communities that are at higher risk of diseases such as heart attacks and stroke.

The health effects of Shisha smoking have received less research attention than cigarette smoking. However, the available evidence indicates that shisha smoking is associated with cancer, heart disease and lung disease. There have also been reports of increased risk of infectious disease, and the large amount of carbon monoxide created by the constant heating of tobacco by burning charcoal introduces the risk of carbon monoxide poisoning. The existing evidence base supports the need to monitor shisha smoking and minimise use, particularly regular use.

In recent decades, shisha has become more popular in western countries, particularly in young people. Despite a low prevalence of shisha use at the national level, additional data collected in specific communities highlight that shisha use is an issue of growing concern in certain areas. Local tobacco control programmes need to be sensitive to local cultural context ⁴⁹.

Smokers take more sick-leave from work than non-smokers and smoking increase the risk of disability and premature death. £51,6m of potential wealth is lost from the local economy in Wandsworth each year due to smoking ⁵⁰.

378 early deaths due to smoking result in 547 years of lost economic activity, costing businesses about £17.5m. A further 118 employees in Wandsworth are economically inactive and unable to work due to smoking-related sickness, resulting in an annual £5.7m. It is estimated that smoking breaks cost businesses in Wandsworth £20m ⁵¹.

Many current/former smokers require care in later life as a result of smoking-related illnesses. Each year this costs society in Wandsworth an additional £2.7m. There is a significant number of older people suffering from smoking attributable illnesses whose needs remain unmet by formal care. If all such individuals were instead to receive formal social care, it would cost the system a potential further £61m ⁵².

2.3 Stop Smoking Services

NICE recommends that services should aim to treat at least 5% of the estimated local population of people who smoke or use tobacco in any form each year. Of this figure, 35% are expected to be validated as 4-week quitters. Applying this figure to Wandsworth means that the annual target is 600 validated quits.

Smoking Cessation interventions are important in helping to improve people’s health, quality of life and life expectancy, as well as cut costs to healthcare and public services. In July 2017 the Government published the Tobacco Control Plan – Delivery Plan 2017-22 ⁵³. The plan identifies specific areas of focus including:

• Reduce the prevalence of 15-year olds who regularly smoke from 8% to 3% or less by the end of 2022
• Reduce smoking prevalence amongst adults in England from 15.5% to 12% or less by the end of 2022
• Reduce the inequality gap in smoking prevalence between those in routine and manual occupations and the general population by the end of 2022
• Reduce the prevalence of smoking in pregnancy to 6% or less by the end of 2022

Data relating to the local stop smoking service is provided through the data management system – Quit Manager. This data is used to determine quit figures for the borough, which are reported to the Department of Health (DoH) for inclusion within the national datasets. The Council is reliant on publicly available information, much of which has gaps in data and/or limitations in what is reported, particularly at a local level. For example, it is not currently possible to compare smoking prevalence rates at 15 years in Wandsworth to the region or England. Improved reporting of data and increased granularity in reported data would support work to increase targeting to most at risk populations and groups more likely to smoke.

The Wandsworth Business Plan emphasises the importance of investing in good local services that protect the most vulnerable. Key relatable actions include:

• Helping people get on in life
• Encouraging people to live health, fulfilled and independent lives

Two-thirds of smokers say they want to quit, however most try to do so unaided, which is the least effective method. Smokers who get the right support are up to four times as likely to quit successfully ⁵⁴.

Wandsworth Council operates a successful smoking cessation service. The service is delivered in collaboration with primary care (GP surgeries and pharmacies), NHS trusts, voluntary organisations and outreach with local community venues. The Council also has a team of smoking cessation sessional workers who support delivery in stop smoking interventions across all settings. Service users are supported with access to free Nicotine Replacement Therapy (NRT) for up to 6 weeks. The Council funds NRT provided through community pharmacists.

Wandsworth Council is also part of the London Smoking Cessation Transformation Programme (LSCTP). The LSCTP vision is to change smoking behaviours and encourage more quit attempts among the general population to support London to become the first smoke free city in England by 2029. Stop Smoking London is the public facing identity of the LSCTP ⁵⁵. Stop Smoking London offers telephone consultations for people who do not need face-to-face interventions or who are time-poor.

During 2018-19, Wandsworth Council supported 690 people to successfully stop smoking.

2.4 Smoking Related Mortality

Smoking attributable mortality (new method): In 2017 - 19, Wandsworth’s rate was 177.0 per 100,000 (n=530), which was the 15th highest in London, 12.5% lower than the England average and 3.3% higher than the London average. The latest Borough figure for 2017 - 19 was also 22.5% lower than in 2013 - 15, in comparison with 17.2% decrease in England’s rate in the equivalent time period.

Source: OHID: Public Health Profiles

Source: OHID: Public Health Profiles

Potential years of life lost due to smoking related illness: In 2016 - 18, Wandsworth’s rate was 1059.0 per 100,000 (n=3336), which was the 12th lowest in London, 19.3% lower than the England average and 6.1% lower than the London average. The latest Borough figure for 2016 - 18 was also 22.1% lower than in 2012 - 14, in comparison with 6.7% decrease in England’s rate in the equivalent time period.

Source: OHID: Public Health Profiles

Source: OHID: Public Health Profiles

2.4 Smoking Related Ill Health

Smoking attributable hospital admissions (new method). This indicator uses new set of attributable fractions, and so differ from that originally published.: In 2019/20, Wandsworth’s rate was 1130.3 per 100,000 (n=1265), which was the 14th lowest in London, 19.1% lower than the England average and 1.9% lower than the London average. The latest Borough figure for 2019/20 was also 21.3% lower than in 2015/16, in comparison with 11.1% decrease in England’s rate in the equivalent time period.

Source: OHID: Public Health Profiles

Source: OHID: Public Health Profiles

2.5 Evidence Based Interventions/Approaches

According to NICE, commissioners and providers of stop smoking services should implement the following approaches locally:

• Use sustainability and transformation plans, health and wellbeing strategies, and any other relevant local strategies and plans to ensure evidence-based stop smoking interventions and services are available for everyone who smokes

• Use Public Health England’s public health profiles to estimate smoking prevalence among the local population

• Prioritise specific groups who are at high risk of tobacco-related harm. These may include:

  • People with mental health problems, including mental health disorders (for example, see NICE’s guidelines on depression in adults and smoking: acute, maternity and mental health services) and smoking: acute, maternity and mental health services)

  • People who misuse substances (for example, see NICE’s guideline on coexisting severe mental illness and substance misuse: community health and social care services)

  • People with health conditions caused or made worse by smoking (for example, see NICE’s guidelines on cardiovascular disease: identifying and supporting people most at risk of dying early, type 1 diabetes in adults, asthma and chronic obstructive pulmonary disease)

  • People with a smoking-related illness (see NICE’s guideline on lung cancer)

  • Populations with a high prevalence of smoking-related morbidity or a particularly high susceptibility to harm

  • Communities or groups with particularly high smoking prevalence (such as manual workers, travellers, and lesbian, gay, bisexual and trans people)

  • People in custodial settings

  • People living in disadvantaged circumstances

  • Pregnant women who smoke (see NICE’s guideline on smoking: stopping in pregnancy and after childbirth).

In addition, NICE have produced a series of evidence-based recommendations for commissioners and providers of Smoking Cessation Services, which include the following:

• Ensure the following evidence-based interventions are available for adults who smoke:

  • Behavioural support (individual and group)
  • Bupropion
  • Nicotine Replacement Therapy (NRT) – short and long acting
  • Varenicline
  • Very brief advice

• Consider text messaging as an adjunct to behavioural support

• Offer Varenicline as an option for adults who want to stop smoking, normally only as part of a programme of behavioural support, in line with NICE’s technology appraisal guidance on varenicline

• For adults, prescribe or provide varenicline, bupropion or NRT before they stop smoking

• Agree a quit date set within the first 2 weeks of bupropion treatment and within the first 1 to 2 weeks of Varenicline treatment. Reassess the person shortly before the prescription ends

• Agree a quit date if NRT is prescribed. Ensure that the person has NRT ready to start the day before the quit date

• Consider NRT for young people over 12 who are smoking and dependent on nicotine. If this is prescribed, offer it with behavioural support

• Ensure behavioural support is provided by trained stop smoking staff (see the National Centre for Smoking Cessation and Training (NCSCT) training standard

3.1 Healthy Eating Definition

A healthy, balanced diet is vital to enable optimal health and wellbeing. In eating a wide variety of foods in the right proportions, we ensure enough intake of the nutrients essential for health. Forming part of healthy eating, good nutrition is not simply defined as following a diet which is low in fat, salt and sugar, rather it is eating a wide range of nourishing foods to enable the body to function well and help to protect against disease. This includes eating essential vitamins and minerals, as well as an appropriate energy (calorie) and macronutrients (fat, protein and carbohydrate) intake.

Consuming a healthy diet throughout the life course helps to prevent health problems caused by poor diet, as well as a range of non-communicable diseases and conditions. Current nutrition guidance from Public Health England (PHE) and the NHS, recommends that balance is the key to a healthy diet. Eating a variety of foods in the right proportions and consuming a suitable amount of food and drink during the differing life stages, will achieve and maintain a healthy body weight and help prevent diet-related health conditions.

Expert evidence-based scientific research forming these guidelines, promotes a diet based on starchy carbohydrate foods such as potatoes, wholegrain bread, rice and pasta; plenty of fruit and vegetables (recommendation is at least five portions a day); protein-rich foods such as meat, fish, tofu and lentils; milk and dairy foods; and limited fat, salt and sugar. By following these recommendations, intake of dietary fibre and ‘free’ sugars along national regulations will be easier to achieve; currently these two food groups are under and over consumed respectively across the general population.

The PHE ‘Eatwell Guide’ ⁵⁹ presented in Figure 28 highlights the different types of food that make up our diet and illustrates the proportions that should be eaten to achieve the recommendations.

The Eatwell Plate

3.2 Healthy Eating and Nutrition

Poor diet is a public health issue as it increases the risk of some cancers and cardiovascular disease (CVD), both of which are major causes of premature death. Dietary risks, such as low fruit and vegetable intake and obesity contributes to approximately one third of all deaths from cancer and CVD ⁶⁰. These diseases, along with type 2 diabetes (T2D), which increases CVD risk, are associated with obesity, which has a very high prevalence in adults in London and England ⁶¹. Alongside obesity, it is important not to forget the impact of malnutrition; under-eating, not having enough protein, vitamin rich foods and dehydration can also cause health problems, particularly amongst the young ⁶² and elderly ⁶³.

According to the National Institute for Health and Clinical Excellence (NICE), healthier diets could prevent around 1 in 20 cancers [URL: https://www.cancerresearchuk.org/about-cancer/causes-of-cancer/diet-and-cancer]. Regularly eating foods high in fibre can reduce the risk of some cancers and over consumption of processed and red meat, and alcohol can increase the risk of some cancers. Furthermore, controlling intake of salt, saturated fats and transfats can reduce the risk of CVD ⁶⁴. CVD is often caused by high blood pressure and high cholesterol, which can potentially be reduced without the need for medication by following a healthy diet and exercise plan.

The impact of good nutrition on brain health can also not be dismissed. Malnutrition affects both mental and physical wellbeing. Eating a nutrient-rich diet, particularly one that has lots of fruits and vegetables, omega 3 fats, and low amounts of sodium and saturated fats, helps to maintain good brain health, which is important for the prevention of dementia ⁶⁵, coronary heart disease, high blood pressure and high cholesterol; all these conditions can also be alleviated, to some extent, by following a healthy diet. Promoting optimal nutrition for all Wandsworth residents is important to prevent the onset of these long-term conditions.

The way we shop, cook and eat food has changed significantly over the last decade, particularly with the availability and affordability, of fast food and eating out. The increased production of processed food, rapid urbanisation and changing lifestyles has led to a shift in dietary patterns. People are now consuming more ‘ultra-processed’ foods, which are high in energy, saturated fats, free sugars and salt/sodium. Consequently, a significant proportion of the population are not consuming adequate intakes of fruit, vegetables and dietary fibre ⁶⁶. The number of takeaways in London alone has increased from 4,100 in 2010 to 5,335 in 2018 . The introduction of smart phone apps has made it even easier to have fast food delivered to home or work and this market has increased by 72% in the last decade ⁶⁷.

The food market has shown some positive steps towards healthy eating. For example, there are several companies offering households to subscribe to fruit and vegetable boxes or for deliveries of fresh ingredients to enable them to cook from scratch with pre-prepared ingredients delivered to homes and this represents a positive step towards healthy eating at home. However, this approach tends to serve those who have the financial resources and there remains population groups who face attitudinal, financial or knowledge barriers to benefit from healthy eating.

The issue of being overweight or obese is usually given most attention when healthy or unhealthy eating is being discussed. However, it is important to consider the other less visible effects of unhealthy eating and poor nutrition; the risk this poses to health and the groups who may be most affected. For example, a diet with high salt intake or low vitamin consumption may not cause weight gain but can still put an individual’s health at risk.

Sustainability and waste are also an issue associated with food. It is estimated that food and drink accounts for 10% of London’s total consumption-based greenhouse gas emissions. For every two tonnes of food eaten in the UK, another tonne is wasted ⁶⁸. Climate change impacts on fuel and food prices, which further impact on population groups that are already disadvantaged or vulnerable.

3.3 Risk Factors of developing or experiencing diet-related ill health.

There are several risk factors which help us to understand the key groups which would benefit from targeted work as they are at greatest risk of developing or experiencing diet-related disease. These risk factors are as follows:

• Age (being over the age of 60)
• Ethnicity (South Asian or Black African or Black Afro Caribbean)
• Carers
• Learning disability
• Low income
• Being overweight or obese

There are some population groups who may be more at risk of developing a diet related diseases for different reasons. The most prominent risk factors are outlined below.

3.4 Dietary Behaviours in Wandsworth

In Wandsworth, the proportion of adults meeting the recommended ‘5 a day’ on a usual day is broadly similar to the London and England average (58% vs 55%). In Wandsworth, 44% adults are reported to drink more than the recommended units of alcohol a week, which is the highest in London and well above the London average (26%).

Whilst there is no local data available about the diets of Wandsworth residents, the National Diet and Nutrition Survey (NDNS) provides an indicator that adults may not be consuming the right foods to support a healthy lifestyle ⁸⁰:

• The average daily intake of ‘free’ sugars (those added to food or drinks, or found naturally in honey, syrups and unsweetened fruit juices) is 11%, which is double the recommended daily intake of no more than 5%. Main sources of free sugars in all age groups are biscuits, buns, cakes and pastries; sugar, preserves and confectionery; cereal and cereal products; sugar sweetened beverages (SSBs) (including fruit juice), and for adult men, beer, lager and cider are also contributors ⁸¹.
• Only 9% of 19-64-year-olds and 7% of those aged 65 and above are meeting the recommended daily intake of fibre of 30g per day ⁸². Main sources of fibre include wholegrains (for example, brown pasta, breads and oats), vegetables and fruit (including their skins and peel)
• Average weekly consumption of oily fish is 77g which is around half the recommended amount (140g). Oily fish includes anchovies, carp, trout, mackerel, herring, pilchards, salmon (including canned), sardines, sprats, swordfish, tuna (fresh only)

3.5 The Obesogenic Environment

In recent years Britain has become a nation where being overweight is prevalent; by 2050, around 50% of adults and 25% of all children under 16 could be obese ⁸⁶.

Today’s ‘obesogenic’ environment, with its abundance of convenience and energy dense foods and increased sedentary lifestyles, reducing the prevalence of obesity is challenging. Exposure to fast food through advertising is known to influence the purchase and consumption of food and forms part of the issue that need addressing around the obesogenic environment. Locally, Public Health carried out a snapshot of fast-food adverts in Wandsworth and found that of the adverts advertising food products, the vast majority were for foods high in fat, salt and sugar.

A report published in 2018 by Cancer Research UK found young people who recalled seeing junk food adverts were more than twice as likely to be obese. The same study identified 87% of young people found adverts for high fat, salt and sugar products appealing, with three quarters tempted to eat a product after seeing such an advert. The purpose of the ban is to reduce this exposure to foods and drinks high in fat, salt and sugar and therefore reduce the likelihood of those foods being purchased and consumed.

3.6 Limitations to the Data/Information

Additional data would assist with building a more comprehensive picture locally about diet and nutrition. For example, the following health related behaviour measures relating to food and drink would be useful at a Borough level:

• Local data on fast food consumption and takeaway usage
• Local data based on diet and nutrition survey measures
• Local barriers to following a healthy diet
• Level of skills and education levels amongst adults around preparing nutritious meals
• Data on fizzy drink consumption
• Data on felt need/perceived need in relation to healthy eating
• Data from adults with learning disability about healthy eating

3.7 Current Services

The Council offers both public facing services and policy approaches to support healthy eating for adults in particular groups. These are as follows:

• Men’s Weight Management Programme Guys Get Active - In partnership with Wandsworth Council, Enable Leisure and Culture are relaunching a programme to help local men lose weight. Adapted to suit the current climate, Guys Get Active incorporates weekly physical activity and nutrition sessions delivered face to face as well as virtually. The programme is focused on creating peer to peer support between men who want to lose weight and improve their health. Led by qualified professionals who can adapt the exercises to suit individual needs, Guys Get Active is perfect for all abilities and fitness levels. These sessions are exclusively for men who live, work or are registered with a GP in the Wandsworth Borough with a BMI of 27.5+ or a diagnosis on type 2 diabetes, and a willingness to lose weight
• Wandsworth offers residents an Adult Weight Management Programme which offers vouchers for 12 weeks membership to either Slimming World or Weight Watchers. The vouchers are offered through GP or self-referral
• Including healthy catering criteria in Commissioned Service Contracts, for example Age Well Centres and Leisure Centres. Plans are being developed to influence the food environment by reducing exposure to unhealthy food through retail planning, healthy catering for restaurants and takeaways. The council is also considering the feasibility of limiting exposure to high fat salt sugar foods through advertising and marketing restrictions
• Including healthy eating criteria in the Quality Assurance Process in contracted supported living providers with a contract in Wandsworth

The Voluntary Sector also provides a number of services and projects for Wandsworth residents to help them and their families to eat healthily, particularly those who are low income or in need of emergency support. For example, Wandsworth Foodbank, Wandsworth Food Partnership and Waste Not Want Not, a food sharing and food sourcing scheme in Battersea. Age UK also offer support for older people such as the Man With A Pan cooking initiative for older men who live alone.

3.8 Evidence Based Interventions/Approaches

National Picture of Physical Activity

The national picture shows that over the last 50 years, the UK has experienced a 20% decline in PA levels (UK Active, 2014). It also shows that around 1 in 3 or 34% of men and 1 in 2 or 42% of women are not active enough for good health ⁹¹. The good news is that Wandsworth has over the past few years countered that trend. Wandsworth is currently way ahead of both the London and England average with circa 79% of residents (estimate of circa 211,60) self-reporting being physically activate and 13.6% as being inactive (circa 36,500 people aged 20 years or more) in the Active Lives Survey (November 2018/19)⁹², pre-pandemic. During the pandemic inactivity levels rose at the expense of people reporting being active or ‘fairly active’ ⁹³ but these were considered not significant changes by Active lives Survey report. The latest figures (period May 2020/21) are 73.3% active (150+ mins) and those who are inactive has increased to 17.9% (circa 48,400 residents) ⁹⁴. Regarding the latter that represents and additional circa 11,900 inactive people compared to almost 2-years ago.

The UK has experienced a 20% decline in PA levels (UK Active, 2014) to date. PHE estimates that if this trend continues, without any preventive measures, the number of people who are less active will increase to 35% of the UK population by 2030.

Wandsworth’s total population is circa 328,828 residents and is due to grow to circa 373,000 by 2029. The number of adults aged 18 years and over is circa 267,600 or from 20 years and above c.258,762 (second largest in Inner London). Wandsworth population is characterised by a higher percentage of people aged 26-34, a highly educated population, higher than average employment rates. The data we have on PA and inactivity is not broken down by age, nor do we have Wandsworth data by gender, ethnicity nor locality.

Declining Trend in Physical Activity

Over the last 50 years, the UK has experienced a 20% decline in PA levels (UK Active, 2014). If current trends continue unchallenged then it is estimated that 35% of people would become less active by 2030 . If applied to Wandsworth we would see the number of inactive people grow, based on May 2018/19 figures, from circa 13.6% (36,500 people aged 20 years or more) to circa 22.8% (54,618 people aged 30 years or more) by 2029. Sport England’s latest Active Lives Survey found that a quarter of adults (11.3 million) do less than thirty minutes of activity per week in the UK

The Active Wandsworth Strategy

The Active Wandsworth Strategy 2017-2021 has four key themes with several key outcomes and associated objectives. These all help to increase PA as part of a holistic approach, addressing both individual factors Such as psychology, food consumption, physical activity and biology as well as societal influences (this includes changes in the range, marketing, price and accessibility of energy-dense foods, which make it ‘harder to avoid’ obesity (King’s Fund), active travel, use of green spaces, etc ), to improve residents’ health and well-being. This approach also seeks to scale up professional to community-led initiatives that will make people more active.

The Active Wandsworth Strategy is due to be renewed in 2022/23 for the next 5-years. This JSNA will support and inform that process.

4.1 Physical Activity Guidelines

Both OHID and the UK Chief Medical Officer (CMO) have produced PA Guidelines, that cover older people, pregnancy and disability. These are summarised below.

4.2 Impact and Benefits of Physical Activity

Being active is also good for adults, children and old alike. Prevention has become increasingly important in recent years, as the cornerstone of the drive to improve peoples’ health and well-being as well as their quality of life. PA helps reduce peoples’ need for high-cost health treatments and care services. Therefore, prevention is now seen as everyone’s business and PA remains one of the core elements of a healthier lifestyle. PA also helps us get out our homes and connect with others, avoiding social isolation. It also helps mitigate against substantial economic burden ⁹⁶, as well as increasing social capital and community spirit.

The importance of being physically active and not having sedentary lifestyles is championed by CMOs. They advocate that the strength of the relationship between PA and health outcomes persists throughout people’s lives, highlighting the potential health gains that could be achieved if more people become more active throughout the life-course ⁹⁷.

This ties into the Council’s public health prevention focus on Start Well, Live Well and Age Well in this JSNA. Regarding the latter the evidence according to CMO is that:

• Regular PA contributes to the key determinants of healthy ageing: good physical and mental function; opportunities for social interaction; a sense of control over, responsibility for one’s own health and well-being; and managing or coping with disease symptoms and functional limitations.
• Increasing PA contributes to improving social functioning and reducing loneliness and social isolation, especially as you age
• PA contributes to increased physical function, reduced impairment, independent living, and improved quality of life in both healthy and frail older adults
• PA in later life can help treat and offset the symptoms of a range of chronic conditions (e.g., Depression, CVD, Parkinson’s Disease)
• New evidence, [specifically for older people] has strengthened and reinforced the main elements of those

The benefits of PA are not only vast for the individual, but it is also the same at a societal level. On an international scale, PA has been recognised as a contributing factor towards 13 of the 17 United Nations Sustainable Development Goals ⁹⁸. At a societal level, the higher the percentage of people engaged in PA can assist in tackling many of the important health and social care challenges faced by Wandsworth Borough and it can also have a positive economic impact. In relation to a positive economic impact, it is estimated that a 1% reduction in inactivity levels results in savings equivalent to £44 per household, and it also helps improve the health and well-being of the local community. The benefits of being physically active are summarised in the table below.

Benefits of Physically Active Lifestyle

In terms of health, it increases peoples’ risk and likelihood of developing disabilities and diseases. Inactivity and sedentary lifestyles and resulting overweight and obesity are both associated with higher risks of developing chronic diseases such as coronary heart disease (CHD), hypertension, stroke, type 2 diabetes, and certain forms of cancer such as breast and colon. It can also lead to increasing / multiple co-morbidities and can reduce life expectancy ⁹⁹. As you get older these risks become greater according to CMOs.

In fact, inactivity is the fourth largest cause of disease and disability in the UK ¹⁰⁰. At worse, inactivity and a sedentary lifestyle are one of the top leading risk factors of death ¹⁰¹. For example, physical inactivity is responsible for one in six UK deaths, equal to smoking, and globally is the 4th leading risk factor for mortality accounting for 6% of deaths globally ¹⁰². Also, higher sedentary time is associated with a higher risk of death and that this risk increases at levels greater than 9.5 hours a day.

At a societal level, inactivity and sedentary lifestyles puts pressure on both tight local government and NHS resources and funding, making services unsustainable. Across the UK physical inactivity is costing the UK an estimated £7.4bn a year ¹⁰³. For example, long-term conditions such as diabetes, cardiovascular and respiratory disease not only increase hospital admissions and GP visits. It can also lead to greater dependency on home, residential and ultimately nursing care, which puts a drain on resources as well as the personal strain it puts on families, individuals, and carers ¹⁰⁴. If current trends continue, and become more reflected in Wandsworth, the increasing costs of health and social care could destabilise public services and is likely to take a toll on the quality of life for individuals, carers and communities.

Importance of Targeting Inactivity and Increasing Impact on Health

According to the CMO, targeting and supporting inactive people to become more active, even if falling short of the recommended levels of activity, is where the biggest public health gains lie ¹⁰⁵. Therefore, getting inactive people to become active has greater health benefits than getting active people to do more activity. This is something that will take time to accomplish. The best approach to reducing sedentary time and subsequently increasing total PA is to take small steps as this is likely to be achievable for the majority of people ¹⁰⁶. This is supported by Sports England, Sporting Future Strategy where they maintain that we must have a stronger focus on tackling inactivity.

“Sporting Future makes it clear that in the past much of the action and funding supported people who would probably have been active anyway. It is important to ensure they continue to be catered for, however the biggest gains and the best value for public investment are found in addressing the people who are least active. This is based on scientific evidence. The figure below shows the value of getting people active from different starting points ¹⁰⁷. It illustrates that although increasing the activity of an already active person (say from 200 minutes to 300 minutes a week) will benefit that individual’s health, it is nowhere near the benefit experienced by a sedentary person who takes up even a small amount of activity”.

Dose-response curve for physical activity

Source: Sport England Strategy 2016-21, Nigam 2011 ¹⁰⁸

The predominant focus in the past has been on individual-level factors. There is now a movement to focus more on determinants which are at the other end of the ecological model spectrum. They take a broader view of health behaviour causation, with the social and physical environment included as contributors to physical inactivity, particularly those outside the health sector, such as urban planning, transportation systems, and parks and trails. In addition, more recent research on determinants is now identifying genetic factors that contributes to the propensity of people to be physically active as well as evolutionary factors and obesity that might predispose certain people to inactivity. An understanding of correlates and determinants as advocated by the ecological model (the figure below) it is argued would reduce the effect of future epidemics of inactivity and contribute to effective prevention of non-communicable diseases.

Adapted ecological model of the determinants of physical activity

Source: Bauman et al, Correlates of physical activity. The Lancet ¹⁰⁹

4.3 Prevalence and Picture of Physical Activity

The Active Wandsworth Strategy 2017-2022 was put in place in 2018 to address inactivity by striving to make Wandsworth the most physically active Borough in London. Wandsworth needs to continue to build on the success of the Active Wandsworth Strategy (2017-22), which drew on a several key strategic themes with associated outcomes and objectives.

Physical Inactivity Attributable Factors for Poor Health

The people who are inactive and have sedentary behaviours and lifestyles have greater risk of poor health and mental health. It is known that a mixture of physical inactivity, unhealthy diets and high BMI is the largest overall contributor to disability-adjusted life years (DALYs).

Government research shows that over a quarter of adults in the UK are classed as inactive, costing the UK economy £20b per year. The evidence-base suggests that general physical inactivity contributes to health risks and as the Lancet reports, it is an important contributor to non-communicable diseases in countries (like England) of high income, and increasingly so in those of low and middle income ¹¹³. This can be made worse for people who have sedentary behaviour such as high sitting time whether due to work or because they watch a lot of TV or both. Sedentary behaviour is associated with increased risks of several chronic conditions and mortality. It is argued that high levels of moderate intensity PA (i.e., about 60–75 minutes per day) seem to eliminate the increased risk of death associated with high sitting time. However, this high activity level attenuates, but does not eliminate the increased risk associated sedentary behaviour ¹¹⁴.

The causes of disease and disability are complex, interrelated and interconnected. Physical inactivity (and sedentary behaviour) is in the top 10 to 4 attributable factors for the burden of disease and disability as well as poor mental health and well-being. PHE report that physical inactivity is the 4th leading risk factor for global mortality accounting for 6% of deaths globally (figure below). In the UK, physical inactivity is responsible for one in six (circa 17%) UK deaths with estimated costs to the UK of £7.4 billion annually (including £0.9 billion to the NHS alone) ¹¹⁵. It has been estimated that 37,000 deaths a year could be prevented in England if everyone met the CMO’s PA guidelines for adults (UK Active, 2014) ¹¹⁶. The rise of sedentary office jobs and the gig economy has not helped, contributing to people becoming less active.

Attribution of deaths to risk factors, by broad cause of death, England 2013

The Wandsworth premature mortality rate for under 75 years all causes is 167.9 per 100,000. The highest number of preventable deaths in Wandsworth are due to cancer deaths (70 per 100k or n=360), CVD (48.7 per 100,000 or n=236), respiratory conditions (16.1 per 100k or n=74) and liver disease (10 per 100k or n=29).

All these conditions can be affected by a number of health behaviours that when addressed can reduce such preventable mortality, such as tobacco use, unhealthy diet, insufficient physical activity and the harmful use of alcohol ¹¹⁷. Physical Inactivity is estimated as the principal cause for approximately ¹¹⁸:

• 21–25% of breast and colon cancer burden
• 27% of diabetes burden
• 30% of ischaemic heart disease burden

4.6 Barriers to Participation

A wide range of barriers can affect people’s participation in any type of PA. These need to be continually identified and addressed to enable more people to get physically active. Wandsworth Council has not yet carried out its own specific survey of its residents on the subject of barriers to PA. However, the Council’s Sports Team anecdotally hear that cost and time are the key barriers often quoted to them when they ask people as to why they do not increase their PA level. These are but two of a wide range and at times interconnected barriers our residents could face.

Current generic research in England looking at barriers to PA have found the following factors listed below (these barriers can have a disproportionate effect on people’s ability to become more physically active as per the CMOs recommended guidelines):

• Personal barriers such as a person’s own perception of their health or age (too old) or disability
• Fear of feeling embarrassed or having negative body consciousness
• Lack of motivation support for people with long-term conditions, mental health or learning disabilities
• Lack of energy – perceived or actual
• Discouragement as the idea of getting physically active to the recommend level feels too daunting especially coming from a place of inactivity. This barrier was identified in the recent evidence review of PA for disabled adults and the latest guidance now recognised that for older adults “some is good, more is better” as “any activity is better than none, and more is better still” ¹²³.
• Lack of time – Too time poor as working long hours at work or due to shift patterns not coinciding with PA opportunities, and/or looking after their family
• Lack of motivation or interest, especially to start exercise from scratch
• Lack of peer support to encourage someone to get physically active
• A person may feel the benefit of PA does not outweigh the cost such as the pain and tiredness they feel or perceive
• Key barriers to walking according to Transport for London (TfL) were time constraints (most frequently cited reason for not walking more), followed by traffic levels being too high and cars travelling too fast. Other reasons were, personal security concerns, streets not being pedestrian friendly, a lack of fitness and having another preferred mode of travel are also common reasons given for not walking
• Key barriers to cycling according to TfL are fear of collisions, a perceived lack of fitness and a lack of confidence
• Isolation and loneliness can prevent people accessing options, especially without support or a companion
• Lack of support to enable a person to become physically active such as primary child carer or if they are a carer for someone to look after the person, they are taking care of so they can be free to exercise or become physically active
• Lack of awareness of what is on offer, the options, in their community
• Fear of injury or exacerbating a health issue, especially for those who are not regularly active, are disabled, have a health condition, are pregnant, or are older or frail
• Open Spaces either lacking or that are not developed or utilised appropriately and other barriers to participation such as not feeling safe (personal safety) or not easy to access or too far away or lack of toilet/ changing facilities
• Lack of transport or facilities nearby
• Limited active travel options
• Location, cost/ expense, and/or timing of physical activities such as sports or classes
• Internal barriers are perceived to be greater than external barriers to doing PA especially for people with long term conditions (LTCs).
• Perceptions of what sports or classes might be like such as will they make me too sweaty or too aggressive/ energetic or too loud (such as music), etc.
• Lack of certain activities of particular interest to men or women of certain faith groups (Muslim women’s preference for women only aerobics or swimming classes)
• Religious beliefs and associated cultural practices
• Bad weather

Internal barriers vs external barriers preventing people with LTC from doing physical activity

London Sport has identified seven different ‘less active’ segments. These are what people say prevent them becoming more physically active. These are outlined for Wandsworth below ¹²⁴.

London Sport, Less Active population Segments in Wandsworth

Source: London Sport.

Social Prescribing and other initiatives which offer people support to get physically active should help those individuals identify the barriers that affect them and provide mechanisms of support whether behavioural or physical (such a providing a befriender) to take them to their first activity.

4.7 Limitations to the Data/Information

Wandsworth has reported a good level of PA (73.3%) based on the Active Lives Survey (period May 2020/21). However, the limitations to this data are that they are all estimates based on a very small sample size. For example, the England total sample size in 2015/2016 was 198,911 and for Wandsworth 490. Whereas in the period May 2020/2021 it was 172,970 for England and Wandsworth it was only 551 respondents (In the period November 2018/2019 it was 181,535 for England and Wandsworth it was only 495 respondents). It has also been known, as noted earlier, that these types of surveys can be influenced by over-reporting or misunderstanding of what each category of intensity actually means in practice.

In the absence of ward level specific data in terms of PA or inactivity and other related data we have had to take Active Lives averages and estimates combined with findings from a literature review and the Active Wandsworth Strategy (2017-22), which incorporated a set of national and local guidance as identified above and apply these assumptions/ best practice to Wandsworth.

4.8 Current Services

Wandsworth Council has commissioned Enable Leisure and Culture to deliver the Councils Sports, Leisure and Parks Offer as well as to develop and deliver the Active Wandsworth Strategy 2017-22 that outlines what is on offer across the life course and how the PA offer and wider supporting system will develop in Wandsworth, including promoting and developing active travel in the Borough.

Wandsworth boasts numerous Sports and Gym Facilitates and Active Leisure and Culture Centres as well as parks and open spaces. Some parks have exercise equipment and outdoor gyms provided free to use, as well as several games areas for basketball, netball and 5-a-side football. The main commissioned services in Wandsworth supporting people to get physically active and eat more healthily in order to help them reduce their weight and live a better, healthier life with greater well-being are on a smaller scale, ‘Guys Get Fit’ two service offers’.

5.1 Sexually transmitted Infections (STIs)

Sexual health is an important public health issue with health, social and economic impacts that can affect the population across the life course and is a fundamental aspect of human identity and life experience. Wandsworth adopts the World Health Organisation’s current working definition of sexual health which is described as: “a state of physical, mental and social well-being in relation to sexuality. It requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence” ¹²⁵. Poor sexual health can lead to sexually transmitted infections (STIs), HIV and unintended pregnancies which can lead to further long-lasting and costly impacts for both individuals and wider society. However, they can be reduced through safer sex practices such as the use of condoms, regular testing and access to sexual health and reproductive services ¹²⁶. Sexual health services currently focus on treatment for sexual health transmitted infections, HIV and unplanned pregnancies as well as prevention.

Improving the sexual health of Wandsworth residents is a priority because it not only contributes to reducing inequalities in health across the life course but can deliver savings to the wider health and social care economy. Preventing STIs, HIV and unwanted pregnancies is cost effective and evidence of return on investment is strong. For every pound spent on sexual health services, for example, £86 could be saved on future public spending ^{127 128} and every pound spent on contraception saves £11 in reduced healthcare costs <[Kings Fund (2014) Health Select Committee Inquiry into public expenditure on health and social care: evidence submission.].

Nationally deprivation and socio-economic status are associated with poorer sexual health. The association between poor sexual health and deprivation is seen in Wandsworth with those in quintile 1 (the most deprived) experiencing the poorest sexual health ¹²⁹.

5.2 Sexual Health Indicators

National and local evidence clearly demonstrates that sexual health need varies according to factors such as age, gender, sexuality and ethnicity with inequalities in sexual health disproportionately affecting Black & Asian, Minority Ethnic (BAME) communities, those identifying as LGBTQ+, men who have sex with Men (MSM).

MSM are among the largest groups diagnosed with a new STI diagnosis and STI diagnosis is increasing among MSM. BAME communities in Wandsworth also experience a significantly higher proportion of STI diagnosis compared with the proportion of the population from ethnic groups. The age and gender distribution of new STI diagnoses (chlamydia, gonorrhoea, herpes, syphilis, warts) in Wandsworth residents in 2018 highlights that the largest number of newly diagnosed STI’s are in the 25 to 34-year-old age co-hort.

People identifying as LGBTQ+ can experience a greater degree of health inequalities, including sexual health ¹³⁰. National data shows that where gender and sexual orientation are known, MSM account for 29% of London residents diagnosed with a new STI in a specialist health clinic; 90% of those diagnosed with syphilis and 63% of those diagnosed with gonorrhoea. In line with the national picture, the number of diagnosis of gonorrhoea and syphilis are higher in gay men compared to heterosexual men.

When comparing new diagnosis of STIs by ethnic origin and sexual orientation a larger proportion of white gay/lesbian are newly diagnosed.

Deprivation can further exacerbate poor sexual and reproductive health with those living in deprived areas most at risk of unintended pregnancy ¹³¹. Furthermore, unintended pregnancy can cause additional financial, housing and relationship pressures as well as having an impact on existing children ¹³². In Wandsworth, women accessing Emergency Hormonal Contraception (EHC) are more likely to live in more deprived areas of the borough and identify as Black, Asian or Minority Ethnic (BAME) group; further detail is provided within the Wandsworth Sexual Health Story ¹³³.

The abortion rate is used as a proxy measure for unintended pregnancies. In Wandsworth in 2018 the total abortion rate stood at 16.8/1000 for 15 to 44-year olds. This is lower than that of both England and London, indicating women in Wandsworth have had good access to reproductive care over the last 6 years. However, more could be done as the percentage of conceptions leading to abortion has not changed since 2009 and has stood at 26%. The percentage of abortions performed under 10 weeks in Wandsworth, however, was 84.5% which is higher than both England (80.3%) and London (82.3%), indicating Wandsworth residents are getting swift access to abortion at an early stage. This trend has increased since 2012 when the percentage rate stood at 81%. 38% of all abortions were repeat abortions, 40% of which were repeat abortions in over 25s (ONS 2018).

The percentage of abortions performed under 10 weeks in Wandsworth, however, was 84.5% which is higher than both England (80.3%) and London (82.3%), indicating Wandsworth residents are getting swift access to abortion at an early stage. This trend has increased since 2012 when the percentage rate stood at 81%. 38% of all abortions were repeat abortions, 40% of which were repeat abortions in over 25s (ONS 2018).

Sexually transmitted infections in Wandsworth by disease and age group, October 2018 – September 2019

Source: GUMCAD Extracted Feb 2020

Reported STI diagnoses in Wandsworth by sexual orientation, Oct 18 to Sep 19

Source: GUMCAD Extracted Feb 2020

Reported STI diagnoses in Wandsworth by ethnicity and sexual orientation, Oct 18 to Sep 19

Source: GUMCAD Extracted Feb 2020

5.4 Abortion

Total abortion rate / 1000: In 2021, Wandsworth’s rate was 15.8 per 1,000 (n=1451), which was the 5th lowest in London, 17.7% lower than the England average and 24.4% lower than the London average. The latest Borough figure for 2021 was also 4.8% lower than in 2012, in comparison with 16.3% increase in England’s rate in the equivalent time period.

Source: OHID: Public Health Profiles

Source: OHID: Public Health Profiles

Abortions under 10 weeks (%): In 2021, Wandsworth’s rate was 90.2% (n=1255), which was the 3rd highest in London, 1.8% higher than the England average and 1.6% higher than the London average. The latest Borough figure for 2021 was also 11.1% higher than in 2012, in comparison with 14.3% increase in England’s rate in the equivalent time period.

Source: OHID: Public Health Profiles

Source: OHID: Public Health Profiles

5.6 Contraception

Long Acting Reversable Contraception (LARC) is known to be the most common form of effective contraception ¹³⁵. LARC usage (excluding injections) in Wandsworth had seen an increase in recent years and in 2019 the rate exceeded 50 per 1,000 females. However COVID-19 pandemic resulted in a significant drop in LARC prescriptions.

Total prescribed LARC excluding injections rate / 1,000: In 2022, Wandsworth’s rate was 41.4 per 1,000 (n=3935), which was the 7th highest in London, 6.2% lower than the England average and 24.6% higher than the London average. The latest Borough figure for 2022 was also 12.0% higher than in 2014, in comparison with 12.0% decrease in England’s rate in the equivalent time period.

Source: OHID: Public Health Profiles

Source: OHID: Public Health Profiles

Total prescribed LARC excluding injections rate / 1,000: In 2022, Wandsworth’s rate was 41.4 per 1,000 (n=3935), which was the 7th highest in London, 6.2% lower than the England average and 24.6% higher than the London average. The latest Borough figure for 2022 was also 12.0% higher than in 2014, in comparison with 12.0% decrease in England’s rate in the equivalent time period.

Source: OHID: Public Health Profiles

Source: OHID: Public Health Profiles

5.7 Current Services

Key messages from Public Health England on the detection, management and treatment of STIs suggest that approaches to promoting positive sexual health and reducing STI and HIV prevalence should include:

• The provision of open-access sexual health services providing rapid treatment and partner notification can reduce the risk of STI complications and the spread of infection.
• Focussing prevention, diagnosis, treatment and care of STIs on the general population as well as targeted groups.
• Continue to address the continued increase in syphilis diagnosis.
• Consistent and correct use of condoms to reduce STIs through condom distribution schemes.
• Annual testing for HIV and STIs for those not using condoms or sex with new or casual partners.
• Immunisation against hepatitis A and hepatitis B in MSM.

Wandsworth takes a joined-up approach to promoting positive sexual health and commissioning of sexual health services. Further detail is set out in the Wandsworth 2019 -2024 Sexual Health Strategy and corresponding Action Plan which set out the priorities and approaches for improving sexual health in the borough.

Sexual Health services are commissioned under the legal framework of the Health & Social Care Act 2012 and the subsequent transfer of public health responsibilities to local authorities in 2013. Local authorities therefore have a statutory duty to commission open access(Open access means that the local authority must pay for its residents wherever in the country they choose to access services), demand-led sexual health services, including contraception and testing and treatment of STIs. Open access services are therefore often, high demand and high volume in nature. In the first three quarters of 2019/20 the service recorded a footfall of 27680 patients attending clinics. From October 2018 to end Sept 2019 a total of 13718 patients with a recorded Wandsworth address attended the service.

Integrated sexual health and contraception services are delivered by Sexual Health South West London (CLCH) across Wandsworth, Richmond and Merton. Services, commissioned in line with national guidance ^{136 137}, offer a hub and spoke service model including both walk in and booked appointments. Dedicated clinics are also offered for young people, women, and men who are gay, bisexual and have sex with men. Clients contact the service via a single point of access phone number and are triaged accordingly. The table below provides an overview of the services on offer through the integrated sexual health provision and other voluntary and community sector services.

Local sexual health services

In Wandsworth there are 40 GP surgeries and 58 pharmacies contracted by the local authority to deliver sexual health services for residents. The services GP surgeries are contracted to deliver are chlamydia screening, HIV Point of Care Testing and Long Acting Reversible Contraception but are not offered universally across all GP surgeries. Pharmacies are contracted to deliver chlamydia screening and emergency contraception in line with Public Health England Pharmacy offer ¹³⁸. Services are demand led. This means that service activity will not be consistent throughout the year and varies based on the needs of service users at any one time.

Public Health England recognises that community pharmacies are a health, social and a community asset having strong links to the diverse and vibrant communities they serve. Pharmacies play an important role in supporting people with sexual health, reproductive health and HIV. They are accessible to all especially deprived communities who may not access other conventional NHS services, helping to reduce health inequalities and the burden on existing providers¹³⁹. Likewise, given the ongoing challenges, there remains a need for GPs to be able to manage patients swiftly, pragmatically and appropriately ¹⁴⁰.

In total, there are 98 contracted providers in Wandsworth. The geographical distribution of providers ensures there is coverage at borough, locality and ward level. Residents are typically registered to a GP surgery local to their home address and PCNs operate to offer appointments between 8am and 8pm as well as at weekends. All residents are within 1,200m (3/4 mile) of a commissioned pharmacy and there is seven- day access across the borough. An analysis of sexual health services in primary care finds that sexual health activity in primary care is high, however a number of contractors are inactive and there is wide variation across services and providers with the majority being attributable to particular GP surgeries and pharmacies.

Contraception activity is high and increasing, including presentations for emergency contraception. Over half of GP surgeries delivered less than the NICE recommended minimum number of insertions required within a 12-month period. STI screening activity is decreasing, and the available resource is underused. The chlamydia detection rate is higher in pharmacies than GP surgeries although the EHC to chlamydia screening conversion rate in pharmacies is low.

More women than men are accessing sexual health services in primary care. The majority of service users are aged 39 or under and the BAME population is over-represented in comparison with the borough profile for age range.

The delivery of sexual health in primary care story recommends that sexual health services should continue to be provided in GP surgeries and pharmacies. However, commissioning from 2020 should consider the variation in service activity that exists between providers, including those that are inactive. Work to rationalise GP surgeries and pharmacies should be undertaken with services situated in areas where they are most needed, where demand is highest and provided by those who have demonstrated that they are best able and motivated to deliver services to residents consistently.

Actions should be taken to optimise the effectiveness of services including work to increase the detection of chlamydia and HIV and the total number of prescribed LARC in the borough. Ways to maximise the primary care offer for sexual health should be explored and suggestions are given. Commissioners and Public Health should consider and respond to the demographic characteristics of service users and the positive and negative drivers of the overrepresentation of particular groups. This includes differences in the demand and utilisation of services between male and female and BAME and White service users.

Commissioners should regularly assess the continually changing landscape seeking opportunities that may arise for service development and contractual delivery following the maturation of PCNs, the transformation of CCGs and implementation of the NHS Long-Term Plan.

Latest available data in respect of the above services demonstrates that by the end of quarter two (2019/20) Wandsworth had conducted over 5000 chlamydia screens, with a positivity rate of 6%. Both GP and pharmacy screens are steadily increasing and there are encouraging signs that on-line activity is beginning to grow, rising to 439 by the end of quarter two, with positivity increasing from 4.9% to 6.2%. Screening provided at sexual health clinics also rose from 688 in quarter one to 759 in quarter two with positivity rising at this site from 6.7% to 7.2%. E-service use from clinics rose from 1,308 screens and 4.5% positivity during quarter two to 1,362 tests and 5.2% positivity for quarter two. This provides good evidence to suggest that the channel shift form clinic to e-services is starting to take hold. This will in-turn reduce pressure on clinic times to allow more complex sexual health cases to be addressed within clinic.

In addition to accessing services at the local ISH service, borough residents can also choose to access sexual health service anywhere in the country. Latest available service data shows that there has been good and improving access to the variety of sexual health services offered across the borough. In Wandsworth from Oct 2018 to 19 over 55,500 people accessed a sexual health service for the first time. Access was greater amongst females who represented 59% of attendees ¹⁴¹.

Alcohol Use Disorders

The NHS defines alcohol misuse as drinking “in a way that’s harmful” or dependence on alcohol. And advises all adults not to regularly drink more than 14 units a week.

The country still responds to the 2012 National Alcohol Strategy which set out the following ambitions:

• A change in behaviour so that people think it is not acceptable to drink in ways that could cause harm to themselves or others
• A reduction in the amount of alcohol-fuelled violent crime
• A reduction in the number of adults drinking above the NHS guidelines
• A reduction in the number of people binge drinking
• A reduction in the number of alcohol related deaths

Drug Use Disorders

The World Health Organisation defines Substance Misuse as ‘the harmful or hazardous use of psychoactive substances, which can lead to dependence syndrome’. In the UK, the most common illicit drug is cannabis, followed by cocaine and ecstasy. Other drugs include painkillers, prescription drugs, illegal highs and drugs used for chemsex.

Drug possession, supply and production comes under criminal law in the UK. Drugs are classified into A, B, C and Temporary Class Drugs; the maximum penalties for drug possession, supply and production are dependent on the class of drug.

There is a National Drug Strategy from 2017 which focuses on reducing demand by universal and targeted preventative action, restricting supply by tackling criminal activity and building recovery by improving treatment quality.

A new Richmond and Wandsworth Substance Misuse Strategy is currently under development and is likely to take a three-pillar approach to tackling drugs and alcohol with ‘prevention and behaviour change, treatment and enforcement and regulation’. Each pillar is based on the age group with Start Well, Live Well, Age Well. The substance misuse strategy development links into other local authority strategies, including Children and Young People Need’s Assessment, Sexual Health Strategies, Homelessness, Community Safety, Corporate Plan.

6.1 Risk Factors Associated with Substance Misuse

6.2 Population Prevalence and Need

Alcohol Use in Wandsworth

In England, there is estimated to be 589,000 dependent drinkers, of which less than 20% are receiving treatment. In Wandsworth it is estimated that there are 3,700 dependent drinkers (2014-15), 1.48% of the population. This is higher than the London (1.36%) and national (1.39%) averages. 43.9% of adults in Wandsworth drink over 14 units of alcohol a week, the highest percentage in London and more than double the London average of 21.8% (national average 25.7%).

Assuming no change in the proportions above, it is estimated that in 2020 there are 3,900 dependent drinkers in Wandsworth and 116,500 who drink over 14 units of alcohol a week (see table below).

Estimated numbers of dependent drinkers in Wandsworth, 2020-2050

The Borough also has issues with street drinking, a mobile issue in the Borough, with seasonal pockets of activity in Battersea and Tooting in particular. Some of these are homeless while others may be housed but are involved in the street lifestyle.

Premises Licensed to Sell Alcohol

Number of premises licensed to sell alcohol per square kilometre: In 2021/22, Wandsworth’s rate was 34.1 nan (n=1168), which was the 8th highest in London, 2599.2% higher than the England average and 149.3% higher than the London average. The latest Borough figure for 2021/22 was also 18.1% higher than in 2015/16, in comparison with 6.5% increase in England’s rate in the equivalent time period.

Source: OHID: Public Health Profiles

Source: OHID: Public Health Profiles

Volume of Alcohol Sales

Volume of pure alcohol sold through the off-trade: all alcohol sales: In 2014, Wandsworth’s rate was 6.1 l/adult (n=1535456), which was the 3rd highest in London, 10.1% higher than the England average and 30.4% higher than the London average. Time series data were not available for this indicator.

Source: OHID: Public Health Profiles

Alcohol-Related Admissions

Admission episodes for alcohol-related conditions (Narrow) - Under 40s: In 2022/23, Wandsworth’s rate was 76.2 per 100,000 (n=174), which was the 6th lowest in London, 44.7% lower than the England average and 19.8% lower than the London average. The latest Borough figure for 2022/23 was also 5.8% lower than in 2016/17, in comparison with 24.1% decrease in England’s rate in the equivalent time period.

Source: OHID: Public Health Profiles

Source: OHID: Public Health Profiles

Admission episodes for alcohol-related conditions (Narrow) – 40 to 64 years: In 2022/23, Wandsworth’s rate was 580.6 per 100,000 (n=503), which was the 9th lowest in London, 22.8% lower than the England average and 10.7% lower than the London average. The latest Borough figure for 2022/23 was also 8.7% lower than in 2016/17, in comparison with 0.3% decrease in England’s rate in the equivalent time period.

Source: OHID: Public Health Profiles

Source: OHID: Public Health Profiles

Admission episodes for alcohol-related conditions (Narrow) – 65+ years: In 2022/23, Wandsworth’s rate was 813.6 per 100,000 (n=263), which was the 16th lowest in London, 0.5% higher than the England average and 0.7% higher than the London average. The latest Borough figure for 2022/23 was also 9.5% higher than in 2016/17, in comparison with 2.7% increase in England’s rate in the equivalent time period.

Source: OHID: Public Health Profiles

Source: OHID: Public Health Profiles

Years of Life Lost due to Alcohol-Related Conditions

Males

Potential years of life lost (PYLL) due to alcohol-related conditions: In 2022, Wandsworth’s rate was 828.7 per 100,000 (n=986), which was the 9th lowest in London, 31.6% lower than the England average and 15.4% lower than the London average. The latest Borough figure for 2022 was also 14.3% lower than in 2016, in comparison with 11.1% increase in England’s rate in the equivalent time period.

Source: OHID: Public Health Profiles

Source: OHID: Public Health Profiles

Females

Potential years of life lost (PYLL) due to alcohol-related conditions: In 2022, Wandsworth’s rate was 373.2 per 100,000 (n=465), which was the 12th lowest in London, 30.3% lower than the England average and 7.6% lower than the London average. The latest Borough figure for 2022 was also 22.2% higher than in 2016, in comparison with 16.7% increase in England’s rate in the equivalent time period.

Source: OHID: Public Health Profiles

Source: OHID: Public Health Profiles

Drug Use in Wandsworth

The 2018/19 Crime Survey of England and Wales found that around 3.2 million adults (16-59 years) took an illicit drug during 2018 and 2019 in England and Wales. Young people are more likely to take drugs than older people and men were twice as likely than women to take any drug in the last year. Drug use is linked to frequent visits to nightclubs, pubs and bars and among 16-24-year olds there has been an increase in the use of Class A drugs, driven by an increase in powder cocaine and ecstasy use.

The estimated prevalence of opiate and/or crack cocaine use in Wandsworth is 1,500 people (2016-17) and is a lower prevalence than the London and England averages (6.4 in Wandsworth, 9.3 in London, 8.9 in England). Assuming 6.4 people per 1,000 18+ residents is a consistent prevalence; the 2020 estimate would be 1,700 people.

The Borough sees around 900 service users in its community needle and syringe programme. Most of these individuals inject street heroin. However, there are numbers who frequent the chemsex scene and there are steroid users.

People in Treatment

Nationally the figures for the number of people in treatment programmes between 2009-10 and 2017-18 have reduced:

• Opiate presentations fell by 6%
• Non-opiate presentations fell by 4.5%
• Alcohol only presentations fell by 6%
• Non-opiate and alcohol presentations fell by 4%

Only 49% of people who start a treatment programme will complete it, with opiate users the least likely to complete at only 25%. The average time taken to complete a treatment programme for opiate use was nearly three years, for non-opiate drugs and/or alcohol the average time was under 32 weeks (7-8 months)

Analysis of the local cohorts against the general population demonstrated that:

• BAME – 76% of people using the current services are White
• Older adults are increasingly experiencing physical health morbidities related to drug and alcohol use
• Younger adults aged 18-24 were less well represented in the service which is predominated by those aged 35-59

Wandsworth drug treatment penetration rate (36%) is lower than in London (41%) and England (51%) meaning Wandsworth is treating proportionately fewer of its opiate and crack cocaine users than the London and England averages. There has been a decline in the age groups (18-44years) in drug treatment locally and in London. In Wandsworth, the greatest fall has been among 18- 24-year olds. From 2009/10 to 2012/13 there was a 42% fall in the number of drug treatment for this age group

In Wandsworth Children Specialist Services, for those children categorised as children in need, drugs & alcohol are highlighted as an issue for 9.6% (106/1093) of cases. The number is likely to be underestimated as drug or alcohol issues are often identified later in the assessment.

The existing service contract for people who have a substance use disorder in Wandsworth is shortly to come to the end of the contract and a new service is shortly to become active (see the table below for details). The proportional performance of the Borough since the start of the contract is outlined below with the representative change over the intervening period. The information is taken from the representative Diagnostic Outcomes Monitoring Executive Summary reports and is indicative only of overall current performance.

People in treatment, 2015/16-2018/19

There have been no significant changes in the number of people in treatment during the period of the contract. Most of the individuals identified and treated by Borough services inject street heroin. It has been identified that there are a number of people engaging in ‘chemsex’ (table below).

Treatment success and re-presentations

While the proportion of those completing treatment has remained relatively static within the margin of error, there has been a significant increase in re-presentations amongst opiate users.

Drug and Alcohol Related Deaths

Nationally, the number of people in treatment has fallen, however the number of deaths related to the use of drugs and alcohol has risen consistently since 2012. Although London experiences significantly fewer than the rest of the country.

The ONS made the following observations on drug deaths in England and Wales from drug use in 2017: * There were 3,756 deaths relating to drug poisoning in England and Wales in 2017, a rate of 66.1 deaths per 1 million population, and similar to levels seen in 2016 * Two-thirds of drug-related deaths were related to drug misuse, accounting for 43.7 deaths per 1 million in 2017 * Deaths involving cocaine and fentanyl continued to rise while deaths related to new psychoactive substances halved in 2017 For alcohol, deaths are split between alcohol specific and alcohol related deaths. ONS commented on alcohol specific deaths for 2017 as follows: * In 2017, there were 7,697 alcohol-specific deaths in the UK, an age-standardised rate of 12.2 deaths per 100,000 population, over double that of drug related deaths * For the UK, alcohol-specific death rates have increased in recent years to similar rates observed in 2008 where they were at the highest recorded * Since the beginning of the time series in 2001, rates of alcohol-specific deaths among males have been more than double those observed among females (16.8 and 8.0 deaths per 100,000 in 2017 respectively) * In 2017, alcohol-specific death rates were highest among 55- to 59-year-old females and 60- to 64-year-old males

In Wandsworth between February 2017 and January 2018 there were 25 deaths recorded related to drug and alcohol use. The table below shows the breakdown of causes:

Breakdown of Causes of death, Feb 2017 - Jan 2018

Drug and alcohol related deaths at the last record were 2.3 per 100,000. The Borough is experiencing greater numbers of deaths due to physical co-morbidities and end-of-life scenarios in ageing opiates and alcohol cohorts. The key challenge is to access underserved groups and meet the challenges posed by new drug taking activities.

There are a number of groups currently underserved and the new service has been tasked with developing appropriate interventions over the next 4 years. These groups are:

• Women: Identified internationally as a significant and specific underserved group

• BAME groups: The latest EINAs demonstrated that the current services are mainly accessed by white males

• Younger adults: Services currently attract people in the age range 35 and upwards, who fit more traditional substance user profiles. This does not account for younger people who may purchase substances online whose using patterns do not fit those to which services are currently familiar

• Older adults with physical co-morbidities: Some 50% of recent drug and alcohol deaths in the two Boroughs, where a cause of death is known, have been because of physical co-morbidities.

• Co-occurring mental health and alcohol and drug use: In Wandsworth, there is a vibrant dual diagnosis group which has begun to coordinate service user needs with provider capacities and capabilities

• Alcohol liaison with local hospitals: Work with hospital liaison teams to affect a reduction in the use of hospital services, focussing particularly on:

  • Frequent attenders
  • People admitted for stays of 3 days or longer
  • People in receipt of ambulatory detoxification

• Intellectual and development disabilities (including people with diagnosed Autistic Spectrum Disorders): Little evidence exists concerning the co-morbidity of substance use disorders and such disabilities. However, a cohort study from 2016, reported in BMJ Open, demonstrated that substance use disorders were prevalent in 6.4% of the group compared to only 3.5% of those without IDD

• Suicide: Suicides are an increasing issue for Wandsworth and they have a significant impact within the deaths recorded as drug and alcohol

Limitations to the Data/Information

The key limitation is identification and managing the information. Aside from the visible homeless population, substance misuse can be difficult to identify.

Identification of the numbers of people with substance use disorders is not easy. Many feel a there is a stigma attached to substance use disorders, especially if it involves illegal substances, and are reluctant to engage with services. Prevalence rates are, therefore, estimates based on proxy measures.

6.3 Services on Offer

Wandsworth has a variety of services modelled around a consortium of four providers delivering pharmacological, psychosocial and Recovery Support Service (Volume 2 Service Specification).

The Borough has been well served by the previous contract with the system modelled around a consortium of three providers delivering pharmacological, psychosocial and recovery support services across community and criminal justice. The following services were also commissioned:

• A day programme predicated on co-production and partnership delivery principles
• Shared care across 12 general practices
• 44 active pharmacies providing supervised consumption, 11 of which also provide needle and syringe programmes
• A drug and alcohol liaison team at St Georges hospital in Tooting commissioned on behalf of the local CCGs

From April 2020 there is a new contract in place to expand and develop the previous services. Again, this is provided by a consortium of providers led by South London and Maudsley NHS Trust. The new service is designed around a progressive and innovative programme to deliver a strengths based service focussed on the needs of the individual to ensure:

• The reduction of harms to individuals, significant others and the general population
• A range of evidence-based interventions to support decision-making
• Achievement of intervention goals

The following key elements will be being developed and embedded over the next four years:

• Pharmacological interventions
• Psychosocial interventions
• Counselling and psychology
• Recovery support
• Online services and moderated communities
• Harm reduction services
• Low threshold support
• Aftercare and support
• Facilitated access to mutual aid
• Advice and support to deliver interventions to individuals who can self-direct care with support
• Training and information around identification and brief advice, signposting
• Cross-discipline use of resources to ensure good engagement with service users
• Health and nutrition and wellbeing including physical activity