District Health Authorities In England Research Articles

The potential for measles transmission in England

BackgroundSince the schools vaccination campaign in 1994, measles has been eliminated from England. Maintaining elimination requires low susceptibility levels to keep the effective reproduction number R below 1. Since 1995, however, MMR coverage in two year old children has decreased by more than 10%.MethodsQuarterly MMR coverage data for children aged two and five years resident in each district health authority in England were used to estimate susceptibility to measles by age. The effective reproduction numbers for each district and strategic health authority were calculated and possible outbreak sizes estimated.ResultsIn 2004/05, about 1.9 million school children and 300,000 pre-school children were recorded as incompletely vaccinated against measles in England, including more than 800,000 children completely unvaccinated. Based on this, approximately 1.3 million children aged 2–17 years were susceptible to measles. In 14 of the 99 districts, the level of susceptibility is sufficiently high for R to exceed 1, indicating the potential for sustained measles transmission. Eleven of these districts are in London. Our model suggests that the potential exists for an outbreak of up to 100,000 cases. These results are sensitive to the accuracy of reported vaccination coverage data.ConclusionOur analysis identified several districts with the potential for sustaining measles transmission. Many London areas remain at high risk even allowing for considerable under-reporting of coverage. Primary care trusts should ensure that accurate systems are in place to identify unimmunised children and to offer catch-up immunisation for those not up to date for MMR.

Understanding variation in measles–mumps–rubella immunization coverage—a population-based study

Coverage of the Measles-Mumps-Rubella combined vaccine (MMR) has declined in recent years in the UK, following adverse publicity about possible links between the vaccine, autism, and Crohn's disease. The objectives of this study were to assess geographical variation in trends in MMR coverage and to identify the factors affecting MMR uptake at population level. We conducted an ecological study of immunization coverage by second birthday, based on routinely collected data from 1993-2004 for England. Trends in MMR uptake were assessed in 95 District Health Authorities in England over the study period. We investigated the relationship between MMR immunization uptake and deprivation, ethnicity, education, population density, rurality, and socioeconomic class. Since 2000, MMR coverage has declined significantly in virtually all areas of England. Population density and deprivation were both strongly correlated with low MMR uptake. The decline in coverage since 1993-94 was significantly related to the proportion of educated population and was greater in densely populated areas. Decline in MMR coverage now affects most areas of England. The lowest rates of MMR coverage remain in urban areas, particularly in inner cities, which also tend to show high levels of deprivation. Public health resources should continue to target inner city areas, as well as focus on the concerns of the better educated about vaccine safety.

The distribution of health authority health promotion and education expenditure in England: A preliminary assessment

This paper asks whether the distribution of district health authority spending on health promotion and education in England is ‘where it should be’. This is aided by simple graphical and statistical analysis using an under-utilised dataset, the Health Service Indicators, which contains information on expenditure by District Health Authorities.It is found that health promotion and education spending varies tremendously across District Health Authorities in England. In order to judge whether this may be justified it is analysed in relation to district-level indicators of ‘need’ as proxied by various measures including standardised mortality ratios for premature ischaemic heart disease, acute myocardial infarction, cerebrovascular disease, suicides, childhood mortality and a deprivation index.Much of the variation seems unexplained, and if confirmed, raises serious questions for policy-makers over how best to ensure that the distribution of such expenditure is more appropriate in future.

Abortion rates in England in 1995: comparative study of data from district health authorities

Lifetime fertility, abortion rates, and the proportion of pregnancies resulting in induced abortion were investigated in 105 district health authorities in England. In 1995, a total of 147,851 abortions occurred...

Life expectancy in England: variations and trends by gender, health authority, and level of deprivation.

STUDY OBJECTIVES: To investigate variations and trends in life expectancy in English district health authorities in relation to gender and Jarman deprivation level. DESIGN: Mortality data for English health authorities...

Local population differences and the needs of people with cognitive impairment

Introduction. Variations in local population age structure have attracted less attention than national population ageing. As moderate and severe cognitive impairment is a major cause of need for long-term care, population-based estimates of the numbers and characteristics of this group were calculated, to explore the effects of local differences. Method. The UK Office of Population Census and Surveys (OPCS) study of disability in adults (N > 14000) was reanalysed. A group with moderate or severe cognitive impairments was identified and age-specific estimators of sociodemographic characteristics, household types, disabilities and service use were combined with population estimates for district health authorities in England and Wales. Results. The proportion of the 65 plus population who are 85 plus varies from 8% to 15% across districts, equivalent to national population projections for 1986 and 2031 respectively. The estimated prevalence of the study group varies from 53 to 70 per 1000 population aged 65 plus, with 34–48% of cases aged 85 plus. Curiously, the proportion with severe disabilities varies little across districts. If national norms applied, local rates of institutionalization would vary from 18 to 27 per 1000 aged 65 plus. Conclusion. Local differences in population age structure are large compared to national changes over decades. Local differences have substantial effects on overall prevalence and on the proportion of the cognitively impaired who would be institutionalized if national patterns applied. Service design should be influenced by these complex variations, with estimates modified by local surveys. © 1997 John Wiley & Sons, Ltd.

Local population differences and the needs of people with cognitive impairment

Variations in local population age structure have attracted less attention than national population ageing. As moderate and severe cognitive impairment is a major cause of need for long-term care, population-based estimates of the numbers and characteristics of this group were calculated, to explore the effects of local differences. The UK Office of Population Census and Surveys (OPCS) study of disability in adults (N > 14000) was reanalysed. A group with moderate or severe cognitive impairments was identified and age-specific estimators of sociodemographic characteristics, household types, disabilities and service use were combined with population estimates for district health authorities in England and Wales. The proportion of the 65 plus population who are 85 plus varies from 8% to 15% across districts, equivalent to national population projections for 1986 and 2031 respectively. The estimated prevalence of the study group varies from 53 to 70 per 1000 population aged 65 plus, with 34-48% of cases aged 85 plus. Curiously, the proportion with severe disabilities varies little across districts. If national norms applied, local rates of institutionalization would vary from 18 to 27 per 1000 aged 65 plus. Local differences in population age structure age large compared to national changes over decades. Local differences have substantial effects on overall prevalence and on the proportion of the cognitively impaired who would be institutionalized if national patterns applied. Service design should be influenced by these complex variations, with estimates modified by local surveys.

Child Health Surveillance in England and Wales: the bad news.

Postal surveys were conducted in 1993 among all, or samples of, six groups of providers and managers of pre-school child health surveillance (CHS) in England and Wales. Content analyses were also carried out of strategic policy statements for CHS produced by 54 district health authorities in England and Wales. The surveys aimed to document the views and experiences of CHS providers and managers about the impact of recent changes affecting the structure and operation of CHS, including the publication of Health for All Children, the 1990 Contract for General Practitioners (GPs), the implementation of the National Health Service and Community Care Act 1990, and the changing roles of community doctors and health visitors. Four adverse findings from the surveys are discussed: fragmentation in the child health service; the unwanted effects of the NHS internal market; the adverse consequences of the changing role of health visitors; and the concerns voiced by the community doctors about the quality of CHS in general practice.

Child Health Surveillance in England and Wales: the good news.

Postal surveys were conducted in 1993 among all, or samples of, six groups of providers and managers of pre-school child health surveillance (CHS) in England and Wales. Content analyses were also carried out of strategic policy statements for CHS produced by 54 district health authorities in England and Wales. The surveys aimed to document the views and experiences of CHS providers and managers about the impact of recent changes affecting the structure and operation of CHS, including the publication of Health for All Children, the 1990 Contract for General Practitioners (GPs), the implementation of the National Health Service and Community Care Act 1990, and the changing roles of community doctors and health visitors. Five positive findings from the surveys are discussed: the impact of the first edition of Health for All Children; improvements in the development and use of child health information systems; the beneficial effects of the growing Involvement of GPs in CHS; the developing understanding of, and commitment to, the principle of clinical audit in CHS; and the growing collaboration between providers in the NHS internal market. A separate paper reports the negative findings from the study.

Delays and diversity in the practice of local research ethics committees.

To compare the practices of local research ethics committees and the time they take to obtain ethical approval for a multi-centre study. A retrospective analysis of outcome of applications for a multi-centre study to local research ethics committees. Thirty-six local research ethics committees covering 38 district health authorities in England. Response of chairmen and women, the time required to obtain approval, and questions asked in application forms. We received replies from all 36 chairmen contacted: four (11%) granted their approval, and 32 (89%) required our proposal to be considered by their local research ethics committee. Three committees asked us to attend their meetings. The application was approved by all 36 local research ethics committees but the time to obtain ethical approval varied between six to 208 days. One third of the committees did not approve the project within three months, and three took longer than six months. There was considerable variation in the issues raised by local research ethics committees and none conformed exactly to the Royal College of Physicians' guidelines. Obtaining ethical approval for a multi-centre study is time-consuming. There is much diversity in the practice of local research ethics committees. Our data support the recommendation for a central or regional review body of multi-centre studies which will be acceptable to all local research ethics committees.

A comparison of data envelopment analysis and ratio analysis as tools for performance assessment

This paper compares data envelopment analysis (DEA) and ratio analysis as alternative tools for assessing the performance of organisational units such as bank branches and schools. Such units typically use one or more resources to secure one or more outputs, the inputs and/or outputs being possibly incommensurate. The assessment of District Health Authorities in England on the provision of perinatal care is used as a vehicle for comparing the two methods. The comparison focuses on how well the two methods agree on the performance of a unit relative to that of other units, and on the estimates of targets each method provides for improving the performance of units. It is found that provided the performance indicators capture all variables used in the DEA assessment the two methods agree reasonably closely on the performance of the units as a whole, though this depends on the way the performance indicators are combined into a summary figure of performance. The two methods can disagree substantially on the relative performance of individual units. Ratio analysis, unlike DEA, is not found to be suitable for setting targets so that units can become more efficient. This is mainly due to the fact that DEA takes simultaneous account of all resources and outputs in assessing performance while ratio analysis relates only one resource to one output at a time. However, the two methods can support each other if used jointly. Ratios do provide useful information on the performance of a unit on specific aspects and they can support the communication of DEA results to non-specialists when the two methods agree on performance.

Role of screening in reducing invasive cervical cancer registrations in England.

To estimate the effect of screening on invasive cervical cancer registrations in England. The Health of the Nation target for cervical cancer seeks to reduce the incidence of invasive cases (ICD 180) by at least 20% between 1986 and 2000. The available area-level statistics on invasive cervical cancer registrations, screening activity, and socioeconomic and behavioural characteristics for 145 district health authorities in England over the period 1985-91 were collected. A multiple regression analysis sought to explain variations in incidence rates by relating screening and socioeconomic and behavioural variables to registration rates. Districts with higher unemployment levels and higher numbers of pregnancies in young women had higher registration rates for invasive cervical cancer. The cervical smear rate for women aged 35-64 in a district was positively related to registrations, whereas the relation was negative for the 20-34 age group. The higher registration rates for invasive cervical cancer in districts with higher cervical smear rates for women aged 35-64 may reflect historically lower screening cover. The negative relation between the cervical smear rate and invasive cervical cancer registrations in women aged 20-34 is accompanied by high registration rates for preinvasive (CIN III) cervical cancer (ICD 233.1). For the advantages of the Pap test to be fully realised, and for invasive cervical cancer registrations to fall in line with the Health of the Nation targets, a comprehensive screening programme, with a high take up rate is required. The various changes to the screening programme introduced since 1988 should help to achieve this. Public health policy should focus on educating the population about the risk factors for cervical cancer and the significance of screening.

Underprivileged area score, ethnicity, social factors and general mortality in district health authorities in England and Wales.

To analyse the relation of ethnicity, social deprivation (Underprivileged area, UPA-score), social class V, unemployment and overcrowding on age- and sex-standardized mortality ratio (SMR). This ecological study used the SMR for people under the age of 65 years as dependent variable. Mortality data for 1983, classified by total population of country of birth (New Commonwealth and Pakistan), unskilled (social class V), unemployed, and overcrowded (>1/room) population with data from 1981 censuses. Underprivileged Area (UPA) score was applied in this study, an index widely used in the UK to identify underprivileged residential areas, calculated from information combining eight variables derived from the decennial census. The data were analysed by multiple regression (least square estimation) with SMR as dependent variable and the other social factors as independent variables. All 192 district health authorities in England and Wales. There was a significant association between UPA-score and SMR (R-square = 0.53, p = 0.0001). The second model included the four variables: % unskilled, % unemployed of economically active population, % of residents living in overcrowded households, and % of population from New Commonwealth and Pakistan. This model explained about 77% of the variance. All variables were significant. All coefficients except ethnicity were positive, i.e. the higher the coefficients, the higher the SMR. This paper shows that social deprivation, unemployment and overcrowding were related to mortality in district health authorities in England and Wales. The finding that ethnicity was inversely related to general mortality might be important and needs to be further analysed.

Palliative care services: what needs assessment?

A survey of all district health authorities in England was conducted in order to describe current patterns of needs assessment and contract setting for palliative care services. Outcome measures included the completion of needs assessments in the past five years, the type of data used for needs assessment, and recommendations for service development. Copies of contracts for palliative care services were requested and analysed according to duration of contract, and audit requirements. A 74% response rate was achieved. Over half the health authorities had not carried out a needs assessment or service review of palliative care services in the past five years. Of those that had undertaken needs assessment, about one-quarter were planning more review work, and most of the reports expressed the need for more information on many aspects of palliative care. Copies of contracts with specialist palliative care providers were supplied by 38 health authorities, with the majority being of only one year's duration. Although conducted within an English context, the study findings have wider implications for the process of effective health care purchasing.

Reduction in mortality associated with influenza vaccine during 1989-90 epidemic

Influenza epidemics are associated with excess winter mortality. Risk factors for influenza complications and death include chronic illness and living in residential care. In the UK uptake of influenza vaccine among high-risk groups is only 10-40%, partly because of scepticism about vaccine efficacy. We have assessed the efficacy of influenza vaccine in reducing mortality from certified influenza by a case-control study of subjects aged 16 years or older who died between Nov 4, 1989, and Feb 23, 1990, in 36 district health authorities in England. We reviewed general practitioners' records for 315 patients who died of influenza and 777 controls, matched for age, sex, and area of residence, who died a year after the epidemic. Information was collected on demography, the usual place of residence (institutional or non-institutional), and the existence of chronic illness. Conditional logistic regression analysis for matched case-control studies showed that influenza vaccination reduced mortality by 41% (95% Cl 13-60) for all subjects. Further adjustments showed that among subjects who received the vaccine for the first time in 1989, vaccination reduced mortality by 9% (0-59); however, among those who had also been vaccinated previously, mortality was reduced by 75% (31-91). We detected no significant differences in the effect of vaccine between subjects who lived in institutions and in the community (p=0·16), or between subjects with high-risk medical conditions and those without (p=0·76). Influenza vaccine is effective in reducing mortality from influenza, and efficacy seems to be greater after repeated annual vaccination than after first administration.

A new method for active surveillance of adverse events from diphtheria/tetanus/pertussis and measles/mumps/rubella vaccines

We describe a new method for active post-marketing surveillance of vaccine safety based on patient records. We studied the association between diphtheria/ tetanus/pertussis (DTP) vaccination and febrile convulsion, and between measles/mumps/rubella (MMR) vaccination and febrile convulsion and idiopathic thrombocytopenic purpura (ITP) in five district health authorities in England by linking vaccination records with computerised hospital admission records. We found an increased relative incidence for convulsions 0-3 days after DTP vaccination. The effect was limited to the third dose of vaccine for which the attributable risk (all ages) was 1 in 12 500 doses. Completion of vaccination by 4 months instead of 10 months after the change in the UK to an accelerated immunisation schedule may have resulted in a 4-fold decrease in febrile convulsions attributable to DTP vaccine. 67% of admissions for a convulsion 6-11 days after MMR vaccination were attributable to the measles component of the vaccine (risk 1 in 3000 doses). An excess of admissions for a convulsion 15-35 days after MMR vaccination was found only for vaccines containing the Urabe mumps strain (1 in 2600 Urabe doses). There was a causal association between MMR vaccination and ITP resulting in admission 15-35 days subsequently; there was no evidence of a mumps strain-specific effect. The estimated absolute risk of 1 in 24 000 doses was 5 times that calculated from cases passively reported by clinicians. This finding emphasises the need for active surveillance of adverse events. The record linkage method that we used is an effective way to identify vaccine-attributable adverse events.

Coronary heart disease: Trends in spatial inequalities and implications for health care planning in England

The idea of health gain has recently received particular emphasis in health policy in England. One of the areas where there is considerable scope for health gain is in the reduction of mortality due to Coronary Heart Disease. Some reduction in mortality rates due to this cause have already been achieved in England in the 1980s. However, the change in standardised mortality rates varies around the country. A review of studies of geographies of declining CHD mortality shows that such geographical variation is typical of other countries which have recently experienced a reduction in the CHD epidemic. The paper presents the results of an analysis of change in spatial inequality in coronary heart disease mortality among the population aged 35–74 for the 190 District Health Authorities in England over the period 1982–1989. Data were derived from counts of cause-specific deaths and population estimates published by the Office of Population Censuses and Surveys. Various approaches were used to assess the change in spatial disparity which has accompanied the average overall reduction in mortality rates over the study period. The results show that the trends vary between age and sex groups in the population and that, particularly for older people, overall health gain across the country is being achieved at the cost of greater inequality in health between areas. The implications for local health strategies with respect to coronary heart disease reduction are discussed.

Capitation funding: population, age, and mortality adjustments for regional and district health authorities in England.

To assess the effect of each of the components of the national capitation funding formula--population projections and age and mortality weighting--at regional and district level. Application of age-cost and mortality weights to the projected 1997 populations of regions and districts, based on the Department of Health public health common dataset. Regional and district health authorities in England. The application of the age-cost and mortality weights to projected populations resulted in greater changes in the shares of weighted populations relative to the estimated 1991 population at district level (mean 0, range -17% to 28%) than at regional level (mean 0, range -9% to 6%). At district level mortality weights had less scope for influence (mean 0, range -9% to 14%) than population projections (mean 0, range -16% to 31%) or age weights (mean 0, range -20% to 30%). The adjustments to the 1991 population shares due to the application of the national capitation funding formula depend on the interaction of three elements: the projected population by age group, the age-cost weight, and the mortality weight. Since each is open to uncertainty, either in terms of measurement (projected population, particularly for births and the over 85s) or method (derivation of the age-cost and mortality weights), the formula should be implemented cautiously at district level. Ways should be considered of incorporating elements of uncertainty into the model. Further research is required on the elements and degree of uncertainty in each of these components, as well as on the relative health needs of different populations.

BCG immunisation in England and Wales: a survey of policy and practice in schoolchildren and neonates.

To determine the policy and practice of district health authorities in England and Wales for BCG immunisation in schoolchildren and neonates. Self completion postal questionnaire survey. District immunisation coordinators. 199 district health authorities in England and Wales. Questionnaires were received from 186 districts, a response rate of 94%. Considerable uniformity was observed in many aspects of BCG immunisation policy and practice but some important variations were found. 15 districts no longer carry out a routine schools programme. 148 districts offer BCG to selected groups of neonates and five to all neonates, but 31 districts do not offer BCG to this age group. The recommended action in response to different levels of tuberculin sensitivity in schoolchildren and neonates varied among districts. Despite the recommendations of the Joint Committee on Vaccination and Immunisation some districts do not offer BCG immunisation to neonates at high risk of tuberculosis and there are important variations in other aspects of BCG policy.

Vaccine coverage: recent trends and future prospects.

To assess the feasibility of achieving the target of 95% coverage for the childhood immunisation schedule by 1995 and to determine the influence of sociodemographic factors and information systems on recent trends. Analyses of trends in quarterly vaccination data for diphtheria, pertussis, and measles in health districts between February 1988 and February 1991. District health authorities in England and Wales, and health and social services boards in Northern Ireland. Cohorts of children whose youngest member had reached the target age of 18 months for receiving the third doses of diphtheria and pertussis vaccines and 2 years for receiving measles vaccine. Predicted coverage levels for mid-1995 were in excess of 95% for diphtheria, pertussis, and measles vaccines. In the 118 districts that continuously reported between February 1988 and February 1991 the increase in coverage was 6% for diphtheria and 13% for pertussis and measles vaccines. 1991 coverage depended primarily on 1988 coverage. The additional effects of deprivation, change in computer system, and child population size achieved at most only marginal statistical significance. The government's target of 95% coverage by 1995 is realistic, although projections should be viewed with caution. Several national vaccination initiatives are likely to have contributed to the recent steady increase in coverage. Updating and validation exercises are likely to improve recorded coverage.