Public Health (1992), 106,449-456
© The Society of Public Health, 1992
Transferable Deaths during 1990 for Residents of Camberwell Health Authority Y. G. Doyle, MRCPI MFPHM 1 and M. Conway, MB MRCP 2
?Consultant/Hon. Senior Lecturer and 2Registrar in Public Health Medicine, Camberwell Health Authority/South East London Commissioning Agency and King's College School of Medicine and Dentistry
Almost one quarter of all deaths among residents of Camberwell District Health Authority during 1990 occurred without the district ('transferable deaths'). These deaths differed from total deaths in that the main cause of study deaths was cancer, and many of these cases died in a hospice with which the district has no direct contact. However, the commonest location of deaths was in hospitals (57% of study death locations) and the majority of these cases died in London teaching hospitals with whom there are major contracts. As the three inner London South East Thames districts, including Camberwell, propose to merge into a single purchasing authority in 1993, all London hospitals where Camberwell residents died in this survey would be covered by the current range of contracts set by the three districts. The study identified a small but important group of deaths from HIV/AIDS, where it seems that people travelled, particularly, to West London for terminal care. A high proportion of deaths from injury and poisoning were either suicides or open verdicts. There were less transferable deaths among the major ethnic minorities in the district than expected, particularly among those of African and Caribbean descent. This may be due to the age and disease patterns in these populations, but may also require study into the need for terminal care among these groups. Transferable deaths are a useful source of epidemiological information and can highlight local health service strengths and deficits.
Introduction D e a t h certificates are still o n e of the m o s t c o m p l e t e a n d c o m p r e h e n s i v e s o u r c e s of i n f o r m a t i o n o n the e p i d e m i o l o g y of disease in the p o p u l a t i o n . R o y a l Colleges h a v e r e p e a t e d l y e n c o u r a g e d doctors to c o m p l e t e d e a t h certificates a c c u r a t e l y , a n d h a v e e n d o r s e d t h e i r use for e p i d e m i o l o g i c a l research.t-3 T h e Office of P o p u l a t i o n C e n s u s e s a n d S u r v e y s sent d a t a f r o m d e a t h certificates of r e s i d e n t s w h o died o u t s i d e the a u t h o r i t i e s ' b o u n d a r i e s ( t r a n s f e r a b l e d e a t h s ) to all h e a l t h a u t h o r i t i e s u n t i l 1981. This service was d i s c o n t i n u e d until 1984 a n d t h e n r e s u m e d . T h e r e s u m p t i o n was welc o m e d , 4 b e c a u s e the e p i d e m i o l o g y of m o r t a l i t y in the local p o p u l a t i o n was c o n s i d e r e d i n c o m p l e t e w i t h o u t such i n f o r m a t i o n , p a r t i c u l a r l y in L o n d o n . It is, h o w e v e r , a c k n o w l e d g e d that in areas o u t s i d e L o n d o n the c o n t r i b u t i o n of these d e a t h s to total statistics m a y n o t b e as great as it is within L o n d o n . 5 C a m b e r w e l l H e a l t h A u t h o r i t y is l o c a t e d in i n n e r s o u t h - e a s t L o n d o n with a p o p u l a t i o n of 210,000. It c o n t a i n s the t e a c h i n g hospitals of K i n g ' s C o l l e g e a n d the
Correspondence to: Dr Y. Doyle, Directorate of Public Health, South East London Commissioning Agency, Mary Sheridan House, 15 St Thomas's Street, London SE1 9RY.
Y. G. Doyle and M. Conway
Dulwich Hospitals. Since the NHS and Community Care Act 1990, the purchasing components of the three inner London districts of Camberwell, West Lambeth (containing St Thomas's Hospital) and Lewisham & North Southwark (containing Guy's and Lewisham Trust Hospitals) have joined to form the South East London Commissioning Agency (SELCA). Staff have been seconded to the agency, including those from Public Health Departments to purchase services for the local residents. There is considerable interest in the designation of resident flows out of these districts. This interest gave further impetus to our Department to examine transferable deaths. Separate monthly records of residents who have died outside Camberwell District Health Authority are sent to our department, and initial examination of these recently suggested a selective pattern of deaths among this population as compared with all deaths in the Camberwell population. Accordingly the present analysis was undertaken to profile deaths in this subset of the resident population, and the service implications of the findings. Methods
Figure 1 is a map of inner south-east London including the areas covered by (a) Camberwell Health Authority and (b) SELCA. Copies of death certificates of those whose addresses were designated to Camberwell DHA and who died out of the district were collected and an analysis of one year's total transferable deaths was performed on deaths occurring between 1st January and 31st December 1990. information was extracted from certificates about month and place of death, age, sex, place of birth, occupation and postcode of the individual and their cause of death. Resident status was validated by postcodes which were assigned by a mapping package to the correct district. Where this was in doubt, a special street map of the area, including postcodes, was consulted. Most Camberwell residents admitted for secondary care use King's College or Dulwich Hospitals which are within Camberwell Health Authority. In this research, seven categories classified the variable 'place of death without the district'. Three categories reflect the institutions most commonly used by Camberwell residents, namely (i) Guy's/St Thomas's, (ii) other London hospitals and (iii) other hospitals in the South East Thames region. To these three categories have been added death in (iv) any hospital, (v) a nursing home/hospice, (vi) a private dwelling and (vii) anywhere else (for example on the road). Place of birth has been coded according to an enhanced general classification in use in Camberwell Health Authority. The system is used because of the particular ethnic minority mix in the district. This comprises categories for those of UK, Irish, other European, Caribbean, African, Asian, American and Australian/New Zealand origins. The primary cause of death alone is used in this analysis. Data were coded and analysed using the SPSSX statistical package, supplemented by the Atlas Mapping, and Excel software packages. Results
There were 505 transferable deaths among Camberwell Health Authority residents during 1990. This represents 23.3% of all resident deaths for the year. Of the transferable deaths 54.3% were male and 45.7% were female; this compares closely
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with the sex breakdown of all residents' deaths. Amongst the study deaths 80% were aged over 54 years and 90% were aged over 33 years. Figure 2 shows the place of death; collectively hospitals accounted for 57% of locations where transferable deaths occurred. Figure 3 indicates that the main cause of transferable deaths was cancer; the commonest cancers were cancer of the lung, breast, prostate and colon respectively. Cardiovascular diseases (especially coronary artery and cerebrovascular disease) were the next commonest cause of study deaths. By contrast, in the total district population, cardiovascular disease accounts for 42% of all deaths, cancers (particularly lung cancer) for only 24%, chronic respiratory disease (particularly chronic lung disease) for 13% and injuries and poisoning for 5% of deaths. 6 Table I shows the major causes of death at the various locations. The hospital deaths resembled the usual profile of deaths among the general population of Camberwell D H A including cardiovascular, respiratory and cerebrovascular diseases, and cancers. Those dying in hospices or nursing homes mainly died from cancers, in particular cancer of the lung; hospital and hospice populations were usually middleaged and elderly. In contrast, residents who died outside of institutions were young, particularly those
Y. G. Doyle and M. Conway
4.67% •  
   5.00%
Guys/St Thomas's Other London hospital Other SETRHA hospital Any other hospital Hospice/Nursing home Private dwelling Any other place
Location of transferable Camberwell deaths, 1990
8.10' 41.50% •    
Cancers CVS disease Respiratory Trauma Other
Causes of Camberwell transferable deaths, 1990
dying of trauma and poisoning. Over one-third of the latter were either deaths by suicide or were given an open verdict. Although three deaths were certified as due to H I V / A I D S , this cause was strongly implicated in a further seven cases. The latter were all males between 24 and 45 years with diagnoses such as Kaposi's sarcoma, pneumonia and immunodeficiency. These ten deaths occurred in hospitals and hospices, particularly in West London. Analysis of the deaths attributable to various postcodes revealed that those living in the north, east and south-east of the district were drawn across these borders particularly to Guys, St Thomas's and St George's Hospitals (see Figure 1). In addition there is a large hospice south of Camberwell in a neighbouring district which accounted for many of the transferable cancer deaths; 36% of Camberwell residents who died in that hospice lived close to this district. H o w e v e r , the hospice also drew large numbers from the central areas of Camberwell.
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Y. G. Doyle and M. Conway
Almost 80% of deaths were among those born in the UK; the next commonest groups were of Irish (6.3%) and Caribbean (5.7%) birth. Other nationalities comprised the remaining 8% of deaths. The ethnic population structure of the area indicates that 46% are of UK birth, 4.6% are of Irish birth, and 21.2% are of Caribbean birth.7 The other prominent ethnic group in the general district population are African (5.3%): these only represented 2.2% of the study population deaths. The pattern of deaths among ethnic groups is, however, consistent with the age structures of these populations. While 27% of the general population of the district is aged over 50, and 9.5% over 70 years, only 11.7% of the major ethnic groups, for example African, Asian and Afro-Caribbean, are aged over 50 and 1.3% over 70 years, a The African groups have a particularly young population with over 50% aged under 25 and less than 1% aged over 70 years. The greatest burden of mortality among those with transferable deaths was age-related, particularly with regard to cancers and cardiovascular disease.
Almost one quarter of deaths among residents of Camberwell district were transferable in 1990, which compares closely with a previous study on such deaths in inner London. 4 Another study on transferable deaths, performed outside London, had found that only 5% of residents had transferable deaths. 5 It is likely that the high resident flows for health services noted in London since the introduction in 1990 of the Mersey national clearing house for documenting cross-boundary flows, are also reflected in more transferable deaths in London. The majority of the deaths occurred in two neighbouring South East Thames districts either in teaching hospitals or in a particular hospice, all within the SELCA area. There are major contracts with the teaching hospitals to provide care for Camberwell residents, and it is proposed in 1993 that SELCA becomes a single purchasing health authority. The information from this study would give further support to the proposed arrangement which will cover the majority of Camberwell residents. However, there are other important service implications in these results. For example, 35% of the transferable deaths (and 8% of all Camberwell resident deaths) were in mainly one hospice, where the outstanding cause of death was cancer. Currently this hospice care is subcontracted and it is an important service for the Camberwell residents. It is therefore important that purchasers make arrangements to have the quality and quantity of care regularly reviewed on behalf of their residents. A small but important group of deaths was either certified or strongly suspected as due to HIV/AIDS. It seems that this group travelled to West London--where there is known to be a strong service image--not just to their possible hospital of diagnosis but also for terminal hospice care. This phenomenon is also recognised among the non-terminal cases and studies are under way to investigate whether this is due to perceived lack of provision or unsuitability of local services. The proportion of suicides/open verdicts among the deaths from trauma and poisoning was high. Several open verdicts were due to poisoning or hanging. Many of this population may have suffered from acute or chronic mental illness and their mobility would have militated against them receiving appropriate mental health services at a time of crisis for them. The level of mental illness 9 and deaths from
suicide and injury up to age 65 years 6 among the district population of Camberwell is known to be high. It appears that those from the major ethnic minorities in the district tended to die less often out of district than those of U K birth. Some of this trend is explained by the large proportion of those of U K birth who died in hospice care, mostly from cancer of the lung, breast, prostate and colon. The major ethnic groups in Camberwell are of Caribbean and African backgrounds; it is known that standard mortality ratios from cancers of the lung, breast and colon are lower in these groups than in those of U K origins.l° Ischaemic heart disease, a further c o m m o n cause of transferable deaths in this study, is not a major cause of death among Caribbean and African ethnic groups. Rather cerebrovascular disease, diabetes and hypertension are important causes of death in these groups, n but these deaths were not in major evidence in the study population. Furthermore the age structure of these populations is heavily weighted towards the under 25 years group; the most recent wave of immigration from Africa into the district demonstrates an almost absent age group over 70 years. However, it may also be that the smaller numbers of transferable deaths among the ethnic populations were due to issues concerning their access to services, or their preferences about where they wished to die. Nurses employed in terminal care in Camberwell Health Authority frequently perceive that those of Caribbean origin who are terminally ill may choose hospice or community care less than other district residents, preferring to gain admission to hospital. Local research on the needs of the dying among ethnic minorities, particularly the Caribbean group, would be welcome. This study has provided us with useful epidemiological information and alerted us as purchasers to service needs in the resident population, particularly in the areas of terminal care and services for those with H I V / A I D S . It is r e c o m m e n d e d that purchasers in areas of multiple providers and known high resident flows regularly review their transferable deaths. References 1. Royal College of Physicians/Royal College of Pathologists (1982). Medical aspects of death certification. Journal of the Royal College of Physicians of London, 16,205-218. 2. Royal College of Physicians of London (1978). Death certification and epidemiological research. British Medical Journal, ii, 1063-1065. 3. Alderson, M. R., Bayliss, R. I., Clarke, C. A. & Whitfield A. G. A. (1983). Death certification. British Medical Journal, 287,444-445. 4. Fleissig, A. & Grant, K. A. M. (1984). 'Transferable deaths': their epidemiological importance. British Medical Journal, 288, 1128. 5. Jessop, E. C. (1983). Deaths occurring outside of the district of residence. Community Medicine, 5,224-226. 6. Director of Public Health for Camberwell Health Authority (1991). Annual Health Report of the Director of Public Health, 1990. Camberwell Health Authority: Department of Public Health & Epidemiology. 7. Inner London Education Authority, Research & Statistics (1989). Statistical Information Bulletin No. 25. Social & Ethnic Characteristics of ILEA Pupils 1987-88. London: London Residuary Body. 8. London Research Centre (1992). Demographic and Statistical Studies: Projections of Ethnic Minority Populations in London Boroughs by Age and Sex, 1991. London: London Research Centre. 9. Harris, T. & Brown, G. (1978). Social Origins of Depression: A Study of Psychiatric Disorder in Women. London: Tavistock.
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10. Adelstein, A. M. & Marmot, M. G. (1989). In: Cruikshank, J. K. & Beever, D. G. (eds). Ethnic Factors in Health and Disease. London: Wright, 35-48. 11. Balarajan, R. (1991). Ethnic differences in mortality from ischaemic heart disease and cerebrovascular disease in England and Wales. British Medical Journal, 302, 560-564.