Joint Strategic Needs Assessment (JSNA) reports are used to help determine priorities for Knowsley’s Joint Health & Wellbeing Strategy and to inform the ‘Strategy for Knowsley’.

The duty to undertake the Joint Strategic Needs Assessment (JSNA) was originally set out in Section 116 of the Local Government and Public Involvement in Health Act (2007). The Health and Social Care Act 2012 amended that Act to introduce duties and powers for Health and Wellbeing Boards in relation to JSNAs and Joint Health and Wellbeing Strategies. Since April 2013, Local authorities and Clinical Commissioning Groups (CCGs) have an equal and joint duty to prepare JSNAs and Joint Health and Wellbeing Strategies through the Health and Wellbeing Board.

Alcohol is considered the second biggest cause of preventable death in the UK (after smoking), with alcohol misuse affecting most sectors across society; health, family breakdown, anti-social behaviour and crime (road traffic collisions, anti-social behaviour, and domestic violence). Alcohol is estimated to cost society £21 billion per year with costs to the NHS directly estimated at £3.5 billion per year; accident and emergency attendances, ambulatory service, hospital services, and treatment.

Generally, most adults in the UK consume alcohol with its use influenced by, social and cultural norms.
Drinking above the recommended 14 units per week can increase the risk of developing a range of health problems including chronic alcohol related diseases such as liver disease; high blood pressure and cardiovascular disease; depression and anxiety and some cancers (eg breast cancer, head and neck cancers); weight gain and sexual performance. There can also be psychosocial impacts on relationships, employment, and debt in problem drinkers.

Knowsley Alcohol Use
•Over a quarter of adults in Knowsley drink above the recommended guidelines each week
•12.7% of adults do not drink alcohol at all
•The number of young people (11 to 15 years) having drank alcohol in the last week is falling
•More 14 to 17 year olds have tried alcohol in the last week compared to 11 to 15 year olds
•Over two thirds of 14 to 17 year olds think that getting drunk is fun and over half think it is normal to get drunk
Health Impact
•Knowsley’s mortality rate from alcohol has risen in the last 9 years whilst North West and England rates have fallen.
•Knowsley alcohol hospital admissions are significantly higher than the North West and England
•Male mortality rate and alcohol related hospital admissions from alcohol are over double that for females
•In the last 5 years successful completion of treatment has risen – with almost half of people in treatment completing
•The most common age for those adults in treatment was 50 to 59 years
•Over 40% of those in treatment referred themselves

For further information and reading on alcohol in Knowsley the full JSNA report, and other relevant documents are available below

JSNA Report – Alcohol



Drug use disorder is a complex issue and has a major impact on the health and wellbeing of individuals, families and communities. Those affected by drugs use them compulsively and the effects of substance misuse are cumulative, significantly contributing to poor health, homelessness, family breakdown and offending.

Drug dependence varies from substance to substance, and from individual to individual. Dose, frequency, the pharmacokinetics of a particular substance, route of administration, and time are critical factors for developing drug dependence.

In 2016/17, the proportion of all opiate users in treatment in Knowsley who had successfully completed treatment and did not return within 6 months was 5.6%, which is lower than England (6.7%). In comparison, the proportion of all non-opiate users in treatment in Knowsley who had successfully completed treatment and did not return within 6 months was 41.5%, which is higher than the national figure of 37.1%.

Cannabis was the substance most commonly used by young people in specialist substance misuse services in Knowsley during 2016/17, with 92% doing so (88% nationally). Alcohol was the next most commonly used substance (5% compared to 49% nationally) with 3% of young people accessing drug use disorder services in Knowsley using stimulants (ecstasy, cocaine, amphetamines), compared to 11% nationally citing problematic ecstasy use, 9% citing problematic cocaine use and 3% citing problematic amphetamine use.

The full JSNA report for Drug Use Disorder is available here JSNA Report – Drug Use Disorder 

Supporting Documents

Needle Exchange Services in Knowsley: An investigation into the needs and experiences of staff and service users –  Needle-Exchange-Service-in-Knowsley

The prevention of obesity is currently a major public health challenge in the UK. Over the last couple of decades there has been a rapid increase in the proportion of people classified as being obese. Obesity is associated with a range of health problems, and the resulting costs to the NHS attributable to the overweight and obese population are estimated to be £6.3 billion per year, with wider costs to society estimated to be £27 billion per year. These costs are projected to increase over the next few decades with a greater proportion of the NHS budget being consumed by obesity related causes.

Obesity prevalence for females increases with age up until the 65-74 age group, and is higher than male prevalence in each age group other than between the ages of 45 and 64. Prevalence of obesity in males also increases with age but peaks earlier between the ages of 45 and 64, falling sharply and earlier than females after this age group.

Obesity prevalence in adults increases with age. It is lowest under the age of 35 and peaks between the ages of 45 and 74. Thereafter, it decreases in adults over 75 years of age.

Adults with disabilities such as arthritis, back pain, mental health disorders and learning disabilities have higher rates of obesity than those without disabilities, and obese adults may experience disabilities related to their weight9. A third of obese adults in England have a limiting long term illness or disability compared to a quarter of adults in the general population.

The proportion of Knowsley residents categorised as being obese was 22% in 2012/13, marginally higher than across the whole of Merseyside (21%). However, the proportion of obese adults in Knowsley by comparison is lower than England as a whole (25%).
More than a third of Knowsley adults (37%) are overweight with 3% being classed as underweight. Almost 4 in 10 (39%) Knowsley adults are deemed to have a healthy weight, slightly lower than across Merseyside (41%).

Knowsley females are marginally more likely to be obese than males, 23% compared to 21% respectively. This mirrors the national picture. However, males are significantly more likely to be overweight (43%) than females (31%).

Overall, 26% of adults in Knowsley consume fast food at least once a week. A further 55% consume fast food once or twice a month or less, and one in five never eat any form of fast food (19%).

People in Knowsley are more likely to consume a hot food take-away from a local non-chain outlet, such as a chip shop, Chinese, Indian or pizza restaurant at least once a week (22%), than to have a hot food take-away from a large chain restaurant such as McDonalds, KFC, Burger King or Dominos (14%).

The full JSNA report is available here JSNA Report-Healthy Weight – Obesity

Oral health is important to overall health and wellbeing. It can promote good communication, good nutrition and reduces discomfort from the teeth or mouth. Toothache, infections and tooth loss can have a significant effect on wellbeing and the condition of our teeth has a direct effect on other serious health issues.

The World Health Organisation defines oral health in broad terms. ‘It means more than simply having ‘good teeth’: oral health is integral to general health, is essential for wellbeing, and is a determinant of quality of life. It allows us to speak, smile, kiss, touch, taste, chew, swallow and cry. Poor oral health ‘restricts activities in school, at work and at home causing millions of school and work hours to be lost each year the world over. Moreover, the psychosocial impact of these diseases often significantly diminishes quality of life’.

The first ever nationally coordinated survey to assess the dental health of 3 year old children in Knowsley was undertaken in the school year of 2012/2013. The results of this survey showed that the percentage of 3 year old children in Knowsley (10.5%) who have experienced decay by this age was lower than both the North West regional average (14.3%) and the English average.

In 2013, 0.5% of all 0-4 year olds’ admissions to hospital in Knowsley were for dental treatment under general anaesthesia (17). This proportion was higher than both the North West regional average of 0.4% and national English average of 0.3%.

Children living in deprived communities tend to have poorer oral health than their counterparts living in more affluent communities resulting in inequalities in the oral health of children across the borough.

The full JSNA can be accessed here: JSNA Report -Oral Health

The World Health Organisation defines respiratory diseases as “diseases that affect the air passages, including the nasal passages, the bronchi and the lungs. They range from acute infections, such as pneumonia and bronchitis, to chronic conditions such as asthma and chronic obstructive pulmonary disease”.

Chronic Obstructive Pulmonary Disease (COPD) is the fifth biggest killer disease in the UK, killing approximately 25,000 people a year in England. Premature mortality from COPD in the UK is almost twice as high as the European average (EU-15).
Premature mortality for asthma in the UK is over 1.5 times higher than the European average (EU-15). Evidence shows asthma has become more common over the last 30 years possibly as a result of our changing lifestyles, homes with central heating and fitted carpets with little ventilation and diets with fewer fresh foods.

Knowsley CCG spends around £17 million in 2013/2014 on problems of the respiratory system, the majority of which is split between secondary care non-elective activity (£ 7.5 million) and primary care prescribing and pharmaceutical services (£4 million), the remainder (£5.5 million) being spent on elective inpatient and outpatient care. In terms of COPD and conditions relating to COPD the spend within secondary care on emergency admissions was approx. £4.2 million (56% of the £7.5m spent on secondary care non-elective activity).
In 2013/14 NHS Knowsley CCG spent £1.765 million treating and caring for people with asthma.

Across Knowsley there is a wide variation on mortality rates for respiratory diseases with the most deprived areas of the borough having double the mortality rates compared to the least deprived areas. Historically COPD detection rates have been lower in these more deprived areas.

For 2013/14 GP reported COPD prevalence ( the number of people who appear on GP registers with a diagnosis of COPD compared to the total GP practice population) in Knowsley is over double the England rate with approximately 3.5% of the registered population (5,558 people) compared with the England rate of 1.8%. Prevalence of asthma in Knowsley is, however, below national levels (5.4% in Knowsley compared to 5.9% nationally).

Knowsley had the 6th highest mortality rate due to respiratory disease in England out of 326 local authority areas between 2011 and 2013. Premature female mortality from respiratory disease was 46.0 deaths per 100,000 population in 2011-13, a decrease of 27% in the 10 years since 2001-03. For males, premature mortality was 72.2 deaths per 100,000 population, representing no real change since 2001-03.
In 2013 Knowsley had the 7th highest premature COPD mortality rate in England, out of 326 local authorities. Premature female mortality from COPD was 32.9 deaths per 100,000 females in 2011-13, a decrease of 11% since 2001-03. Premature male COPD mortality was slightly higher at 37.4 deaths per 100,000 males in the same period, however this represented a reduction of 15% over the previous 10 years.

The full JSNA report can be accessed here: JSNA Report-Respiratory

The World Health Organization (WHO) defines sexual health as a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health 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.

Sexual health concerns anyone in the community aged 16 or over, or who are sexually active. Therefore it is important to implement services that are easy to access regardless of age or area of residence, that provide appropriate treatment, good advice and methods of contraception in order to reduce the number of unwanted pregnancies and abortions.

The full JSNA report is available here: JSNA Report-Sexual-Health

Supporting Documents

Sexual and Reproductive Health Profiles (Public Health England) 

Smoking is the biggest cause of preventable ill health and premature death in England, causing health inequalities across the UK such as life expectancy. The health implications of smoking are substantial and people who smoke are more at risk of developing cancer (lung, mouth, lip, throat, liver, kidney, stomach and cervical) chronic obstructive pulmonary disease (COPD), other respiratory conditions and heart disease.

There are around 7.3 million adult smokers in England and more than 200 people a day die from smoking (approximately 80,000 people die each year) due to smoking related illness, accounting for 16% of all deaths.

Smoking costs the UK economy £14.2bn per year. The cost to the NHS of treating smoking related illnesses is estimated to be £2.0bn per year, including the costs of hospital admissions, GP consultations and prescriptions.

Knowsley Smoking Prevalence
•Smoking prevalence among adults is significantly higher when compared to the North West and England
•Within Knowsley, smoking prevalence ranges from 6.6% in Halewood North ward to 27.5% in Stockbridge ward
•Smoking at the time of delivery continues to decline in Knowsley but remains above the North West and England
•79% of 11 to 15 year olds had never smoked and those that do smoke don’t do very often
•28% of 11 to 15 year olds had tried e-cigarettes, with 15% having used one once or twice

Health Impact
•Lung cancer incidence is significantly higher than the North West and England and has increased by 14.5% in the last 10 years
•Although lung cancer incidence is higher for males, there has been a 4.3% reduction in the rate of new male cases compared to a 44.3% in females in the last 10 years
•COPD prevalence is the 2nd highest rate in the North West and the 4th highest rate nationally
•2nd highest smoking attributable mortality rate in the North West
•Lung cancer deaths account for 30.2% of all cancer deaths
•Female lung cancer mortality rate has increased by 10.5% in the last 10 years compared to a 23.0% reduction in males
•COPD accounts for almost half of all respiratory deaths
•Female COPD mortality rate has increased by 36.7% in the last 10 years compared to a 34.0%

Knowsley Stop Smoking Service
•The rate of residents setting a quit date in 2016/17 was the third highest in England
•Knowsley has a (self-reported) – a quit rate of 46.0%

For more information the full JSNA report can be found here: JSNA Report-Smoking-and-Tobacco

Mental health is complex and covers a wide range of conditions such as depression, anxiety and obsessive compulsive disorders, through to severe conditions like schizophrenia. Due to the complexities and variations in the types of data it is difficult to determine in some areas the exact prevalence of mental health conditions

Mental health disorders do not just affect individuals but also their families, friends and colleagues. Sickness absence due to mental health problems costs the UK economy £8.4 billion a year and also results in £15.1 billion in reduced productivity. Mental ill health is the largest single cause of disability in the UK, representing up to 23% of the total burden of ill health. The total economic cost of mental health problems in England is estimated to be around £105 billion and it has been estimates that cost of health services to treat mental illness could double over the next 20 years.

According to the Public Health England Community Mental Health Profile 20144 the overall prevalence rate (proportion of people with the condition over a set period) for depression in adults in Knowsley was 5.2 compared to the England rate of 5.8. Similarly the incidence rate (rate of new cases of condition over a set period) in Knowsley for the same year was also lower than the England rate (0.8 compared to 1.0).

Local activity data suggests that in Knowsley, 3,737 people (per 100,000 population) had contact with mental health services in comparison to the England rate of 2,176 people per 100,000 population7. This includes the number of people admitted to NHS funded adult specialist mental health services, regardless of a formal diagnosis. It also includes use of community as well as hospital based services and it can be compared with the levels of health and illness for a CCG to see whether the use of services is relatively high or low, given the recorded prevalence of mental illness.

According to the Public Health Community Mental Health Profile8 Knowsley also has a significantly higher number of attendances at A&E for a psychiatric disorder per 100,000 population than the rest of England (603.0 per 100,000 compared to 243.5 in England) and a higher number of bed days used in secondary mental health care hospitals than the rest of England (4,974 days per 100,000 population compared to 4,686 in the rest of England).

The full JSNA report can be found here: JSNA Report – Adult Mental Health and Wellbeing Final

During 2016, around 166,000 people in the UK died from the disease, with lung, prostate, breast and bowel cancers accounting for 45% of all Cancer deaths in the UK in 20162. Cancer was the cause of over a quarter (28%) of all deaths in the UK in 2016 and is the most common cause of death by broad disease group2. Around one in two people will develop cancer at some point in their lives and it causes around one in four deaths3. Cancer is largely preventable and there is a significant focus locally on the prevention and early diagnosis of cancer.

It is estimated that more than four in 10 cancer cases could be prevented by lifestyle changes, such as not smoking, cutting back on alcohol, maintaining a healthy body weight, and avoiding excessive sun exposure (Parkin et al 2010). Given that there is an ageing population within Knowsley and cancer is predominantly a disease of ageing it is expected that the number of new cases of cancer each year will increase in the future.

In 2017/18, prevalence of cancer in Knowsley was 2.82%; this was above England (2.73%) and North West 2.83%. Knowsley cancer prevalence increased from 1.24% in 2009/10 to 2.82% in 2017/18. Over the same period, cancer prevalence has increased significantly both nationally and locally, with Knowsley more than doubling (increase of 127.8%), this increase being higher than England (92.9%) and the North West (94.0%)

Cancer incidence is the number or rate (per head of population) of new cases of cancer diagnosed in a given population in a defined time period (in this case a year), this does not include secondary cancers or recurrences. Knowsley CCG area has the 2nd highest incidence all cancers combined (out of 195 CCG areas) in the 2015/17 period.

There were 8,242 new cases of cancer diagnosed in Knowsley between 2009 and 2017 (average of 916 per year). Of these, just under half are cases related to males, (48.5% of total cases). There were 3,994 cancer cases related to males (circa 444 per year). The rate of cancer incidence for males was 761.5 per 100,000 males in 2015-17. The most prevalence Male cancers in Knowsley were prostate cancer (21%) and Lung cancer (18%) in 2015-17, totalling nearly 40% (2 in 5 cases) of all Cancer incidences.

There were 4,248 cancer cases related to females in Knowsley between 2009 and 2017 (circa 472 per year). The rate of cancer incidence for females was 629.3 per 100,000 females in 2015-17. The most prevalence female cancers in Knowsley were Breast cancer and Lung cancer in 2015-17, responsible for 27.7% and 19.0% of all new cases each, totalling 46.7%, nearly half of all cancer incidences in females.

For further reading the JSNA can be found here: JSNA Report-Cancer

Cardiovascular disease accounts for approximately 25% of all local deaths and such deaths account for some of the gap in life expectancy between Knowsley and England. In 2012, 349 people died of Cardiovascular Disease. Tackling premature CVD death is vitally important if we are to reduce health inequalities in the borough.

Programme budgeting analysis done by Yorkshire and Humber Public Health Observatory suggests Knowsley CCG spends £146 per head of population on Circulatory disease conditions (2013/2014) compared to £120 for England and £119 for comparable CCGs. This means relatively higher spend and worse outcomes compared to other areas in England (SPOT, 2013/14 figures). The total spend on circulatory conditions was reported to be £7,178,675 in 2013/14 with approximately 60% of this spent within secondary care – this includes elective and Non elective points of delivery ( Planned and Unplanned care treatments).

In 2013/14 the prevalence of coronary heart disease (CHD) in Knowsley was higher than observed nationally (4.45% in Knowsley compared to 3.4% nationally), this is a slight reduction on that reported the previous year of 4.53% (-129 cases).
Hypertension (high blood pressure) is also higher in Knowsley compared to nationally (14.69%, 23,619 people, compared to 13.7%). However, prevalence of stroke and TIA was 1.7%, just short of that reported as the national position.

Knowsley had the 27th highest mortality rate due to cardiovascular disease in England out of 326 local authority areas in 2011- 13. The premature mortality rate from cardiovascular disease in Knowsley between 2011 and 2013 was 74.7 deaths per 100,000 population. Knowsley’s rate was significantly higher than England (78.2), and marginally higher than the North West region (92.8); the Liverpool City Region (92.2) and Knowsley Statistical Neighbour Group (97.8)

Premature CVD mortality is just under double (43%) the rate in males compared to females. Premature mortality rate was 131.0 deaths per 100,000 population in 2011-13 for males in comparison to a female rate of 74.7 deaths per 100,000 population. Premature female and male CVD mortality has fallen by 82% during the period 2000-02 to 2010-12.

Since 2001/02, there has been an average of 70 excess winter deaths per year in Knowsley meaning that the number of EWDs in 2012/13 was 71% above average. Excess mortality in England in 2012/13 coincided with influenza, respiratory syncytial virus (RSV) and cold weather, with an unusually prolonged influenza season and late cold period reported and is the likely cause of the excess mortality in Knowsley during this period. EWD for CVD was 24.5 in 2012/13, approximately 20% of all EWDs

For further information the full JSNA report can be read here: JSNA Report-Cardiovascular Disease

Dementia impacts upon people and families in a number of ways, the most obvious impacts relate to an individual’s ability to function in relation to key tasks, something which deteriorates over time although initially may not prevent an individual functioning well.
There are significant impacts upon partners, families and loved ones, especially those with carer responsibilities, again these impacts escalate over time although some aspects of behaviour may be significant at earlier stages of disease progression.

Local prevalence for Knowsley was reported to be 69.3% of those expected to have a diagnosis with a formal diagnosis (September 2015). Prevalence of dementia as reported via the Quality Outcomes Framework for 2014/15 tells us that nationally circa 0.75% of the population has dementia, in Knowsley the prevalence is 0.70% of the population which places the CCG in the third quartile ranking it 137 out of 209 CCG’s.

the rate of diagnosis for Knowsley which has risen steadily in recent years. Whilst the CCG has increased dementia diagnosis rates over the last few years to place it in the upper part of the third quartile of those patients diagnosed with dementia nationally, there is still a gap (March 2015) between the expected number of those diagnosed and the actual numbers diagnosed.

The biggest risk factor for dementia is age, the older people are the more likely they are to develop the condition, but it is not an inevitable part of ageing. About two in 100 people aged 65 to 69 years have dementia, and this figure rises to one in five for those aged 85 to 89. Evidence suggests this appears to be true for Dementia With Lewy Bodies (DLB) also, however, there is very little evidence about the risk factors for this disease.

The full JSNA report can be read here: JSNA Report – Dementia

Read the full Breastfeeding JSNA here

Read the full Falls JSNA here