There are obvious differences in access to primary, preventive and secondary care services to people living in Portsmouth and South East Hampshire, with poorer access to care affecting those most in need.

The key aim of the NHS is to provide equitable access to effective health care for those who need it. In the case of primary care, it is important that services are readily accessible as well as effective. For some specialist hospital services, a different balance needs to be struck between local access and securing an effective critical mass of services to achieve the best outcomes. We explore here whether there are any obvious differentials in access to primary, preventive and secondary care services to people living in Portsmouth and South East Hampshire.

Access to Primary Care

Access to effective primary care is influenced by several “supply” factors such as the geographical distribution and availability of primary care staff, the range and quality of primary care facilities, cultural sensitivity, timing and organisation of services, distance and the availability of transport. To assess the effect of some of these in Portsmouth and South East Hampshire we looked at staffing levels, workload and utilisation of primary care services by the level of disadvantage. Disadvantage was assessed by either the social class or the Jarman score of the population served. Each practice was given a Jarman score, which is an index of disadvantage calculated from the characteristics of the wards the practice population lives in.

The 1999 Health and Lifestyle survey showed no clear pattern of GP consultation with social class, although people in social classes IV and V were more likely to have visited their GP within the past month (Table 2.3.1). The proportion that had visited a GP within the last month ranged from 22% of those living in Winchester (pt) to 30% of those living in Portsmouth City.

Use of dental services by people in Portsmouth and South East Hampshire has not changed since 1993 with 67% of the adult population having visited their dentist within the past year. However, people in social classes III (manual), IV and V were less likely to have been to the dentist within the last 12 months than people in social classes I, II and III (non-manual). Within local authority areas, people in Portsmouth City were least likely (58%) to have been to the dentist within the last year, compared to 79% of people in Winchester (pt). There was no correlation between use of dental services in different local authorities and the proportion of patients registered with dentists for NHS treatment. A higher proportion of residents were registered for NHS dental treatment in areas such as Portsmouth City, Havant and Gosport than in Fareham, Winchester and East Hampshire(pt). People in social classes III (manual), IV and V were least likely to have had their eyes tested within the last two years, than people in social classes I, II and III (non-manual). People in Gosport were least likely to have had their eyes tested in the past two years (61%) compared with those in East Hampshire (69%) (Table 2.3.1).

Fig 2.3.1 shows that the rate of night visits by GPs is greater in the more deprived areas of Portsmouth and South East Hampshire. This may reflect the illness rates in these areas or different thresholds for consultation. The distribution of general practitioners is however, the same (0.5 WTE per 1000 registered population across all areas), indicating that GPs in the most deprived areas have a higher workload. For district nurses, there is a decreasing proportion of district nurses per 1,000 practice population aged 65 years and over as one moves from the most deprived wards to the most affluent ones (Fig 2.3.2). The most affluent group of wards, however, have higher staffing level in relation to need. The ratio of health visitors per 1,000 children under five appears to be in line with need, with the most deprived wards having higher ratios of health visitors than the most affluent wards (Fig 2.3.3). However, this crude ratio does not take into account the complexity of caseloads in deprived areas which includes high numbers of children with special needs or on the child protection register.

Access to Preventive Services

Preventive services include cancer screening, health promotion and immunisation programmes. Local studies have shown that there is differential access to these services in Portsmouth and South East Hampshire. Thus women (all ages) in social classes III (manual), IV and V were least likely to have had a smear test within the past three to five years and also more likely to have never been offered one than women in the other social classes (Table 2.3.2).

Yet the population coverage of the cervical screening programme for women 20-64 in Portsmouth and South East Hampshire is high with all except one practice achieving 80% coverage. Fig 2.3.4 shows the uptake rate of the cervical screening programme by practice deprivation. Practices with the highest deprivation scores have the lowest uptake rates. Portsea Island has the lowest uptake rate (81.3%) of all primary care groups.

The effectiveness of this screening programme is determined by the quality of smear taking and this is influenced by the training of the smear taker. There is variation in the quality of smear taking across the district, with Gosport (11.9%) and East Hampshire (9.8%) primary care groups having the highest rates of inadequate smears. East Hampshire (18.9%) and Portsea Island (17%) primary care groups had the highest rate of smears with no evidence of cells from the crucial transformation zone (Table 2.3.3).

The picture is similar for breast screening with women (all ages) in social classes IV and V being least likely, and those in social class III (non manual) the most likely, to have had a mammogram. The proportion of those who had never had a mammogram was greater in Portsea Island (70%) and Gosport (68%) primary care groups (Table 2.3.2). The uptake rate of the screening programme for women 50-64 varies between primary care group areas and practice deprivation quintiles. Thus, the least deprived practices have the highest uptake rates (81%) and the most deprived the lowest (68%) (Fig 2.3.5). Portsea Island Primary Care Group has the lowest uptake rate (71%) and Fareham (81%) the highest (Fig 2.3.6).

Access to Secondary Care

Evidence on variation in access to secondary care is often difficult to interpret, since many studies do not adjust for case mix or distinguish between emergency and elective care. Monitoring equity of access to secondary care from routine sources of information is difficult since data on ethnicity, socioeconomic status and utilisation of the private sector are incomplete.

Sixteen percent of Portsmouth and South East Hampshire population is covered by private health insurance. This proportion varies between localities, with the most affluent areas of the district ((East Hampshire (pt) (28%), Winchester (pt) (27%) and Fareham (19%)) having higher levels of cover than the most deprived localities (Gosport (12%), Portsmouth City (13%) and Havant (16%)). There has been a 2% increase in Portsmouth and South East Hampshire residents' private insurance coverage since the 1993 Health and Lifestyle survey. Besides coverage, there is currently no data on how much use local residents make of the private sector. It is suggested that the distribution of, and access to, private health care compounds existing inequalities.

As outpatient data are currently not coded by postcode or general practitioner, we make use of hospital episode data. This data is used in conjunction with measures of need (limiting long term illness and standardised mortality ratio for general hospital admission and the mental illness needs index (MINI)) to check whether use of hospital services by people living in different areas is related to need in those populations. Caution is needed in interpreting data from the Royal Hospital Haslar as 44% of all finished consultant episodes had no diagnostic code.

The results show higher total admission rates for people living in the Portsea Island and Gosport Primary Care Groups. This may be due to the closeness of acute hospital facilities or the general level of ill health of these populations. Similarly, the emergency admission rates for Portsea Island Primary Care Group is 44% higher than for the Fareham Primary Care Group. The admission rate for children under five is much greater for the Gosport Primary Care Group compared with that for East Hampshire. For mental health, the admission rate for people from Portsea Island Primary Care Group is 82% higher than that for the Fareham Primary Care Group (Table 2.3.4). This is consistent with higher levels of mental health need as measured by the MINI.

When admissions are analysed by the ward deprivation score, there is also evidence that the most deprived wards also have the highest rates of admissions for all specialties, emergencies, older people, children and mental health services. This reflects increased use of hospital services with increasing deprivation in line with measures of need such as long term limiting illness, percentage of low birth weight and the mental health needs index (MINI) (Table 2.3.5 and Fig 2.3.7)

Access to Selected Operations

A number of operations have been chosen by the NHS Executive(1) as indicators of the success of health authorities in securing clinically effective and appropriate services for their population. These comprise a set of 10 operative procedures where the evidence for their effectiveness or otherwise is well established. The age standardised admission rates for these procedures are analysed here for both primary care group area and by ward deprivation score.

Coronary Artery Bypass Grafts (CABG) and Coronary Angioplasty (PTCA) – These are effective surgical interventions in improving symptoms of angina, which does not respond to medical treatment. The rate for Portsmouth and South East Hampshire is lower at 45 per 100,000 population compared with the England rate of 57 per 100,000 population. There are fluctuations between primary care group areas, with the lowest rates being for East Hampshire Primary Care Group and the highest for Fareham Primary Care Group (Table 2.3.6). People in the most affluent wards undergo higher rates of CABGs and PTCAs than people in the most deprived wards (Fig 2.3.8)

Total Hip Replacement (THR) and Total Knee Replacement (TKR) in Persons Aged 65 and Over – these are two common and effective procedures, but there is wide variation in the rate of surgery across the country, which is reflected in Portsmouth and South East Hampshire primary care group areas. The expectation is that the rates will increase over time to improve the quality of life for those people who would benefit from these procedures.

The England rate for THR is 316 per 100,000 population compared with 379 for Portsmouth and South East Hampshire. The Portsmouth and South East Hampshire rate for TKR is 235 and the England rate is 221. Again, there are variations between primary care groups with Fareham having much higher rates of THR (357) than Gosport (284). For TKR, East Hampshire has the highest (291) operation rate and Gosport the lowest (214) (Table 2.3.6). Again, people from the most affluent wards undergo higher rates of these procedures (Fig 2.3.8)

Cataract Surgery (all ages) – there is good evidence to suggest that cataract surgery is an extremely cost effective treatment which significantly improves the quality of life for people.

As with other indicators there is variation in operation rates with the rates for Portsmouth and South East Hampshire at 258 per 100,000 population being higher than those for England (214). The rates for Portsea Island and Fareham Primary Care Groups are the highest in the district and 1.7 times higher than those for Gosport (Table 2.3.6). However, there is no obvious difference in access to this procedure between the most affluent and deprived wards (Fig 2.3.8)

Dilatation and Curettage (D&Cs) performed in women 15-39 – there is good evidence to suggest that D&Cs performed on women under 40 years of age are ineffective. As new techniques are developed, which are less invasive and without loss of diagnostic accuracy, the need to perform this procedure should reduce to very low rates over time. The rate for England is 30 per 100,000 compared with 5 per 100,000 for Portsmouth and South East Hampshire. However, the rate of these operations varies between primary care groups, with higher rates in Fareham and Gosport (Table 2.3.6).

Surgical Interventions for Glue Ear (Grommet surgery) - evidence suggests that some surgical interventions for glue ear may not be appropriate and that a significant proportion of children may benefit from watchful waiting, resulting in lower intervention rates. The England rate is around 341 per 100,000 population and the rate for Portsmouth and South East Hampshire is 347 per 100,000. However, these vary between localities, which may in part be explained by clinical practice (Table 2.3.6). The highest rates were found in Gosport (404) and Portsea Island (400).

Wisdom Teeth Extraction – there is evidence to suggest that the cost and risk of removing asymptomatic wisdom teeth as a preventative measure outweighs the benefits. This is supported by the Dental Royal Colleges. Therefore it is desirable to reduce wisdom teeth extraction to those undertaken for symptomatic reasons only.

The Portsmouth and South East Hampshire rate is higher (220 per 100,000 population) than the England rate at 143 per 100,000 population (this only includes those extractions carried out as FCEs in hospitals). There are variations amongst primary care group areas with Fareham (252) and Portsea Island (233) primary care groups having the highest rates of wisdom teeth extractions. The rate for Fareham is 42% higher than that for Gosport, (Table 2.3.6) People in the most deprived wards undergo slightly higher rates of these operations compared to people in the most affluent ones (Table 2.3.8)

Hysterectomy in Women Aged Under 50 Years – alternative treatments for menorrhagia in pre-menopausal women can be as effective, less invasive and more cost effective than hysterectomy. Thus the use of alternative management should be considered before hysterectomy is undertaken.

The rate of hysterectomy per 100,000 women under 50 years in Portsmouth and South East Hampshire (265) is comparable with the England rate of 268. Gosport (382) and East Hampshire (357) Primary Care Groups have the highest rates for this procedure (Table 2.3.6). Women in the most deprived wards undergo higher rates of hysterectomies (Fig 2.3.8).

Hip Replacement Revisions – an increasing proportion of the total expenditure on hip replacement surgery is on revisions due to the failure of hip prostheses. The revision rate for THR is widely regarded as a marker for the quality of the primary surgery. The rates of revisions for Portsmouth and South East Hampshire residents are higher than those for England. Rates vary across PCG areas with Fareham and East Hampshire having higher revision rates than Gosport and Portsea Island (Table 2.3.6).

Varicose Veins – there is evidence that surgery for asymptomatic varicose veins is not effective. Therefore, the rate of such operations should decline over time.

The rate for Portsmouth and South East Hampshire residents was 118 per 100,000 population. There are variations between primary care group areas with the operation rate for Fareham residents being the highest and 35% higher than that for Portsea Island (Table 2.3.6). People in the most deprived wards undergo higher rates of this procedure than those in least deprived wards (Fig 2.3.8).

Caesarean Section as a Proportion of all Hospital Deliveries – there is variation in the elective caesarean section rate across the country. Although the general direction of change is up, there is no evidence that the rate of delivery complications which require a caesarean section is on the increase. The elective caesarean section rate for Portsmouth and South East Hampshire is 20% of all hospital deliveries compared with the rate for England of 17%. Women in the Gosport Primary Care Group area have the highest rates of elective caesarean sections in the district (22%) and East Hampshire the lowest (20%) (Table 2.3.6). There are no obvious difference in access to these procedures between affluent and deprived wards (Fig 2.3.8).

Key Issues

• There are clear variations in access to health services across Portsmouth and South East Hampshire with poorer access to care affecting those most in need.

Access to Primary Care

• People in the lower social classes are more likely to have consulted their GP in the past month but least likely to have gone to the dentist in the past 12 months or to have their eyes tested.
• Night visits by GPs are higher in more deprived areas but the rate of GPs per 1000 population is the same for all areas
• The distribution of district nurses and health visitors appears to be in line with need but does not take into account the complexity of caseloads in deprived wards.

Preventative Services

• For both cervical and breast screening, lower uptake rates are found in areas serving the most disadvantaged populations.
• Portsea Island has the lowest uptake rate for both programmes.
• There are variations in the quality of smear taking between primary care groups which are unrelated to deprivation.

Access to Secondary Services

• Private insurance cover is higher in the most affluent parts of the district: East Hampshire (pt), Winchester(pt) and Fareham.
• Admission rates for all specialties, emergency admissions, admissions of people over 75 and children under five are higher for the most deprived areas of the district.
• Admission rates for mental illness are clearly associated with deprivation. The admission rate for the Portsea Island primary care group is 82% higher than that for the Fareham primary care group.

Access to Selected Operations

• People in the most affluent parts of the district have greater access to effective procedures such as coronary revascularisation, hip and knee replacements and cataract operations procedures.
• People in the most deprived wards appear to have higher rates of operations which are considered not to be effective or for which there is an effective alternative. This includes grommet and varicose vein operations and hysterectomies in women under 50.
• People in the middle quintile have the highest rates of operations for which there is an equally effective alternative. Examples of these are hysterectomy to women under 50, dilatation and curettage to women aged 15-39 and wisdom teeth extraction.
• Analysis of access between primary care groups shows major differences in access. Fareham primary care group has high access rates for a number of elective procedures such as wisdom teeth extraction, hip revisions, cataract and varicose veins surgery.

Recommendations

• The Health Authority should ensure that the provision of equitable access to effective care in relation to needs is the guiding principle in all its policies.
• A more equitable allocation of resources to primary care groups should be developed to take account of the differences in health needs and a "pace of change" agreed.
• Primary Care Groups should review the distribution of GPs, district nurses, and health visitors within their area and ensure the most deprived areas staffing levels match need.
• Portsea Island Primary Care Group should take action to improve uptake rates of both cervical and breast screening programmes. All Primary Care Groups should consider additional training for smear takers.
• The development of acute hospital services for people with a mental illness should ensure appropriate number of beds in Portsmouth City.
• Primary Care Groups and the Health Authority should work with hospital clinicians to reduce rates of elective operations which are not clinically effective and of those for which there are equally effective alternatives.
• The Health Authority and Primary Care Groups should avoid creating incentives which lead to increases in ineffective procedures being funded through waiting list initiatives.
• The Health Authority and Primary Care Groups should raise patients and practitioners awareness of the effectiveness or otherwise of certain common operations.

References:

1.Quality and performance in the NHS: High level performance indicators. NHS Executive. June 1999

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