Coastal Health Outcomes - Contributing to the Chief Medical Officer’s Annual Report 2021

Looking down over the village of Torcross and the beach at Slapton Sands on the south coast of Devon.

Professor Sheena Asthana and Dr Alex Gibson contributed to the UK’s Chief Medical Officer’s 2021 Annual Report on ‘Health in Coastal Communities’. Their work, which compared coastal and non-coastal areas using the Quality Outcome Framework – found:

a higher burden of heart disease, diabetes, cancer, mental health and COPD in coastal areas,
age and deprivation are two causes of this but health service standards, indicators and emergency admissions may also play a part,
life expectancy is significantly lower in coastal areas,
lower participation in Higher Education, as well as higher rates of hospital admissions for young people with ‘health-risking behaviour’, show the effects of socio-psychological and economic dislocation in coastal communities.

Their findings also point to the lack of available data for small areas on or beyond the coastal fringe.

Prevalence rates in coastal communities

Crude GP QOF attributed to LSOAs 2014/15-2018/19

Crude GP QOF Prevalence of

CHD attributed to LSOAs 2014/15-2018/19.

CHD

Heart failure

Stroke

The burden of ill-health

Coastal communities appear to include a disproportionately high burden of ill health and this is demonstrated in the mapping of Coronary Heart Disease (CHD). Between 2014-2019, nearly 60,000 more people were on CHD registers in coastal areas (mapped by Lower Layer Super Output Areas or LSOAs) – or 17.8%.

Conditions including hypertension, stroke and transient ischemic attack (TIA), heart failure and peripheral arterial disease (PAD) show similar differences in prevalence between inland and coastal communities.

Age and deprivation go some way to explain this – both factors are associated with increased risk of diseases, higher prevalence of CHD and other cardiovascular diseases. Coastal residents are more likely to be older and live in a more deprived area. However, Professor Asthana and Dr Gibson found that these factors do not fully account for the difference – rates are still higher in deprived coastal areas compared to similarly deprived inland areas. Similarly, they also found that the ‘coastal effect’ is associated with ill-health that cannot be wholly explained by demography or ethnicity.

The ‘coastal effect’ in Primary Care

Professor Asthana and Dr Gibson’s research found lower recorded recommended treatment rates in coastal areas, in comparison to non-coastal areas. For example, 39.9% of Type 1 diabetes patients in coastal areas received at least eight of the recommended care processes for the condition, compared to 40.8% in non-coastal areas. This represents a marginally lower, but still significant difference.

Similarly, cancer conversion rates – the percentage of urgent suspected cancer referrals which result in a diagnosis of cancer – is 8.4% in coastal areas, compared to 7.4% in non-coastal areas. This difference could be a reflection of late presentations by older, more deprived populations but may also be because they face greater barriers to secondary treatment. Between 2015-2019 there were, on average, 2,127 patients per full-time equivalent (FTE) GP in coastal areas, compared to 2,079 in non-coastal areas. This is despite the fact coastal populations are older and more deprived.

It is concluded that there is a substantial health service deficit in coastal communities that is leading to a small, but significant ‘coastal effect’ of ill-health.

Life expectancy in coastal areas

Mortality rates categorised by Middle Layer Super Output Area (MSOA) demonstrate that deaths from all causes are, on average, 8.8% higher in coastal areas. Standardised mortality rates (SMRs) are higher in coastal areas for cancer, circulatory disease, stroke, respiratory disease and ‘preventable disease’ – a category that is defined as ‘causes where all or most deaths could potentially be prevented by public health interventions in the broadest sense'.

It is recognised that this could also be influenced by a greater proportion of people smoking in coastal areas, as well as higher rates of obesity and more ‘health-risking behaviours’ of coastal residents.

Life expectancy: Difference between average MSOA-level SMRs in coastal and
non-coastal areas as a percentage of average SMR for non-coastal MSOAs

Living on the periphery

There are a number of reasons why coastal communities experience poorer than expected health outcomes – even when allowing for demography and deprivation. The labour market is one of them. The coastal labour force tends to work in sectors that are relatively low-skilled, low-paid and service-sector orientated.

The Office for National Statistics in 2020 demonstrated that nine of the 13 council areas with the lowest average weekly wages were in coastal areas – Boston, Rother, Blackpool, Great Yarmouth, North Devon, North Norfolk, Torbay, Cornwall and Kingston upon Hull.

Low pay and low job security reduce access to decent housing, healthy food and increase exposure to occupational hazards. Furthermore, these areas, that rely on tourism, have been hard hit by Covid-19.

The young’s health-risking behaviour

The effects of limited employment opportunities in coastal communities are likely to affect the development of children and young people. There is a significant disparity between coastal and non-coastal areas in terms of hospital admissions due to ‘health-risking behaviour’. For example, self-harm amongst 10-24-year-olds and due to drug/alcohol misuse for under18s is substantially higher in coastal areas.

Whilst negative outcomes are often associated with poor performance, children in coastal areas only perform slightly less well than elsewhere. What is more significant is the educational capital supporting children, and those who progress onto higher education. Coastal communities see a higher proportion of working-age adults without educational qualifications, and a low proportion of those achieving two A levels or equivalent.

Read the Chief Medical Officer Annual Report 2021.

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