There are marked differences in life expectancy, mortality and illness rates in Portsmouth and South East Hampshire. Shorter life expectancy and increased mortality rates for all causes, lung cancer and coronary heart disease are linked to material and social deprivation.

Mortality

The all causes standardised mortality ratio (SMR) for Portsmouth and South East Hampshire residents has declined by 13% over the past 13 years (Fig 2.1.1). Yet the rate of decline for females (6%) has been much lower than that for males (19%). There are marked differences in mortality rates amongst local authority areas with the SMR for Portsmouth City being 31% higher than that for Winchester (Fig 2.1.2). Even greater variation is found amongst wards with wards such as Warren Park (112), St Jude’s (106) and Battins (105) having standardised mortality ratios nearly twice as high as those for Warsash (59) and Petersfield Heath (61).

There is a clear relationship between high death rates and deprivation. Table 2.1.1 shows that the wards with the highest levels of deprivation, as measured by the Jarman score, also have high SMRs. There is a strong relationship between levels of deprivation, and mortality for coronary heart disease and lung cancer (Fig 2.1.3). When compared to residents of the most affluent wards, those of the most deprived wards were about 24% more likely to die of coronary heart disease and 41% more likely to die of lung cancer.

Life Expectancy

Life expectancy is a useful supplement to mortality rates as a measure of health status. Life expectancy varies between Portsmouth and South East Hampshire local authorities. Inequalities in longevity are greater in men than women and for both sexes associated with deprivation. Men in Portsmouth City are dying up to 2.9 years earlier than men in Fareham. Women in Portsmouth City and Gosport are dying 1.8 years earlier than women in Winchester (Fig 2.1.4).

Ill Health

The proportion of Portsmouth and South East Hampshire people reporting a long standing illness/disability has risen from 31% in 1993 to 44% in 1999. People in social classes IV and V were more likely (46%) than those in the other social classes (42%) to report a long standing illness or disability. People in East Hampshire (pt) were less likely to have a long-standing illness/disability than people in other localities. People in Portsea Island were considerably more likely (45%) than people in the other primary care groups to report a long-standing illness/disability (Table 2.1.2).

Asthma

Fourteen percent of Portsmouth and South East Hampshire's population aged over 16 reported being diagnosed as having asthma (Table 2.1.2). More people (15%) in social classes IV and V reported having asthma than people in other social classes (13%). Fewer people in Winchester(pt) (8%) reported having asthma compared with people living in Portsmouth City (15%) and Havant (15%).

The annual reports submitted by GP practices who take part in the Chronic Disease Management Programme for asthma show wide variations in reported prevalence, treatment and outcomes of this disease. Thus the prevalence of asthma across the district is 10.4% in the under-15 age group, and 6.5% in the over-15 age group. However, prevalence rates reported by individual practices range from 4.4% to 24.8% in the under-15s, and from 2.7% to 11.4% in the over-15s.

Similarly, the average admission rate for asthma in Portsmouth and South East Hampshire is 15.6/10,000 population. However, individual practice rates vary from 0 to 51/10,000 population. Some of this variation can be explained by the small numbers involved, especially for smaller practices, but nevertheless the chances of admission seem to vary greatly from one practice to another, even allowing for the different prevalence rates.

Treatment also varies. One measure of treatment is to look at the ratio of bronchodilators (relievers) to corticosteroids (preventers). National guidelines recommend starting prophylaxis in any patient requiring a bronchodilator more than once daily, so the ratio should certainly be less than two, though the ideal ratio is not known. The ratio across the district is 1.8, but the individual practice ratios vary from 1.2 to 2.9.

Two potential explanatory factors are deprivation and locality. Though there is no clear trend between individual practice deprivation scores and admission rates, a pattern emerges if practices are grouped by their deprivation scores. Fig 2.1.5 shows the admission rates for 1996-98 by practice deprivation quintiles. Quintiles represent fifths of the number of practices. It can be seen that admission rates for the three fifths of practices who are most deprived are approximately twice those for the two fifths who are least deprived. This is not explained by different prevalence rates.

Similarly, asthma admission rates also vary by locality, with admission rates for Gosport Primary Care Group being twice that for the neighbouring Fareham, despite similar prevalence (Fig 2.1.6)

To some extent, these factors are interrelated, as Gosport has a more deprived population than Fareham. This does not fully explain the picture, and it is also likely that much of the variation relates to characteristics within each practice, both relating to definitions used to reach diagnosis, and subsequent medical management. More detailed examination of those practices at either end of the range will be needed to gain fuller understanding and primary care groups are ideally placed to take this forward.

Diabetes

The annual reports submitted by practices who take part in the Chronic Disease Management Programme for diabetes, also show wide variations in prevalence and admission rates at practice level. Thus the prevalence of diabetes in Portsmouth and South East Hampshire is 2.3%, with a practice range of 1% to 5.5%. Some of the variation relates to practice population. The most common type of diabetes is Type 2 diabetes, which is predominantly non-insulin dependent. The prevalence of this condition rises steeply with age, and so practices with an older population will have higher rates of diabetes. Similarly, diabetes is much more common in Asian and Afro-Caribbean communities, and so practices with higher numbers of patients from these communities will also have higher rates. However, such population characteristics do not seem to explain fully the ranges of prevalence seen. Neither is there any relationship between prevalence and either locality or practice deprivation score.

The average admission rate is 7.3/10,000 population, with a practice range of 1.3 to 20.4/10.000 population. There is no significant association between admission rates and locality. Though there is no clear trend between individual practice deprivation scores and admission rates, some pattern emerges if practices are grouped by their deprivation scores, though this is less evident than for asthma. Figure 2.1.7 shows the admission rates for 1996-98 by practice deprivation quintiles. It is evident that admission rates for the practices with the most deprived populations are higher than those with more affluent populations, a relationship that is not explained by different prevalence rates.

Much of the variation still remains unexplained by the factors that we are able to explore using this routine data. It is therefore likely that much of the explanation relates to the characteristics within each practice. This will include the degree to which the diagnosis is considered in patients who may often present with vague symptoms, and subsequent medical management. More detailed examination of those practices at either end of the range will be needed to gain a fuller understanding, and primary care groups are ideally placed to take this forward.

Coronary Heart Disease

The 1999 Health and Lifestyle Survey identified that 7% of Portsmouth and South East Hampshire's adult population had suffered a heart attack or had angina. People in social class III (manual) were more likely (8%) to report these problems. More deprived populations have higher rates of coronary heart disease and this is reflected in the high prevalence of these conditions in the most deprived local authorities in the district - Havant (8%) and Portsmouth City (7%) .

Reducing the delay between the onset of symptoms and the start of clot busting therapy (thrombolytic therapy) is essential to reduce deaths from heart attacks. This data is not routinely available and we have used as a proxy the Ambulance Response time for all emergency calls and the hospital admission rate for acute myocardial infarction. Overall, in 53% of all emergency calls in Portsmouth and South East Hampshire, the ambulance reaches the patient within eight minutes of the call. However, the proportion of ambulances responding within eight minutes is lower in Havant (45%) and highest in Portsmouth City (70%) with no clear evidence that such variation is linked to deprivation.

Both admission rates for acute myocardial infarction and death rates for coronary heart disease for East Hampshire and Portsea Island Primary Care Groups' residents are higher compared with those for Gosport residents (Fig 2.1.8). There is also variation between admission rates amongst different wards, with the most deprived wards having higher admission rates than the most affluent ones. This reflects the level of need in these populations.

There is also variation in access to treatment across localities. Thus, the coronary revascularisation rate (coronary bypass graft surgery and percutaneous transluminal coronary angioplasty) for patients living in the most affluent wards are higher than that for people living in the most deprived wards. Amongst primary care groups, Fareham, which has the least deprived population, has the highest revascularisation rate of all primary care groups (Fig 2.1.9).

Practices with high deprivation indices also prescribe fewer statins to their patients than less deprived practices (Fig 2.1.10). Statins are drugs which reduce blood cholesterol levels.

Accidents

Fewer than one in ten adults in Portsmouth and South East Hampshire (7%) reported having a non-fatal accident in 1999 compared with 8% in 1993. The likelihood of accidents was higher in the lower social classes (Table 2.1.2). Portsmouth City and Portsea Island Primary Care Group had the highest rates of accidents. For both men and women, the commonest location of accidents was the home or garden.

Key Issues

• There are marked differences in life expectancy, mortality and illness rates in Portsmouth and South East Hampshire
• Shorter life expectancy, and increased mortality rates for all causes, lung cancer and coronary heart disease are linked to material and social deprivation.
• Long term limiting illness/disability and accidents were also linked to deprivation.
• There are variations in the prevalence, treatment and outcomes of asthma, diabetes and coronary heart disease.
• Though prevalence and mortality is clearly linked to deprivation, access to treatment is not. Some of the most affluent areas appear to have better access to certain treatment than less affluent ones. Some of these variations are related to the characteristics of GP practices and their ability to recognise, treat and refer for specialist opinion.

Recommendations

• A key role of primary care groups is to work with other agencies towards reducing inequalities in health.
• Primary care groups should work with partner local authorities and other agencies to promote economic growth and reduce social deprivation
• Primary care groups and the Health Authority should work with individual practices to promote best practices in the management of asthma and diabetes.
• Primary care groups together with NHS Trusts should ensure that access to effective treatment for coronary heart disease is available to people in greatest need.
• Primary care, community, and local authority staff should take every opportunity to advise on the prevention of home accidents.

Produced by Ann Edmeades, IT Services, Hampshire County Council
for Portsmouth and South East Hampshire Health Authority
© Copyright Portsmouth and South East Hampshire Health Authority 1998
Last Updated 1st September, 1999