. 2015 Dec 5;386(10010):2257-74.

doi: 10.1016/S0140-6736(15)00195-6. Epub 2015 Sep 14.

Changes in health in England, with analysis by English regions and areas of deprivation, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013

John N Newton¹, Adam D M Briggs², Christopher J L Murray³, Daniel Dicker³, Kyle J Foreman³, Haidong Wang³, Mohsen Naghavi³, Mohammad H Forouzanfar³, Summer Lockett Ohno³, Ryan M Barber³, Theo Vos³, Jeffrey D Stanaway³, Jürgen C Schmidt⁴, Andrew J Hughes⁴, Derek F J Fay⁴, Russell Ecob⁴, Charis Gresser⁴, Martin McKee⁵, Harry Rutter⁶, Ibrahim Abubakar⁷, Raghib Ali⁸, H Ross Anderson⁹, Amitava Banerjee¹⁰, Derrick A Bennett¹¹, Eduardo Bernabé¹², Kamaldeep S Bhui¹³, Stanley M Biryukov³, Rupert R Bourne¹⁴, Carol E G Brayne¹⁵, Nigel G Bruce¹⁶, Traolach S Brugha¹⁷, Michael Burch¹⁸, Simon Capewell¹⁶, Daniel Casey³, Rajiv Chowdhury¹⁹, Matthew M Coates³, Cyrus Cooper²⁰, Julia A Critchley²¹, Paul I Dargan²², Mukesh K Dherani¹⁶, Paul Elliott²³, Majid Ezzati²⁴, Kevin A Fenton⁴, Maya S Fraser³, Thomas Fürst²⁵, Felix Greaves²⁶, Mark A Green²⁷, David J Gunnell²⁸, Bernadette M Hannigan²⁹, Roderick J Hay³⁰, Simon I Hay³¹, Harry Hemingway³², Heidi J Larson³³, Katharine J Looker²⁸, Raimundas Lunevicius³⁴, Ronan A Lyons³⁵, Wagner Marcenes³⁶, Amanda J Mason-Jones³⁷, Fiona E Matthews³⁸, Henrik Moller³⁹, Michele E Murdoch⁴⁰, Charles R Newton², Neil Pearce⁶, Frédéric B Piel², Daniel Pope¹⁶, Kazem Rahimi⁴¹, Alina Rodriguez⁴², Peter Scarborough⁴³, Austin E Schumacher³, Ivy Shiue⁴⁴, Liam Smeeth⁴⁵, Alison Tedstone⁴, Jonathan Valabhji⁴⁶, Hywel C Williams⁴⁷, Charles D A Wolfe⁴⁸, Anthony D Woolf⁴⁹, Adrian C J Davis⁵⁰

Affiliations

¹ Public Health England, London, UK; University of Manchester, Manchester, UK. Electronic address: john.newton@phe.gov.uk.
² University of Oxford, Oxford, UK.
³ Institute for Health Metrics and Evaluation, Seattle, WA, USA.
⁴ Public Health England, London, UK.
⁵ Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK.
⁶ London School of Hygiene & Tropical Medicine, Oxford Martin School, University of Oxford, Oxford, UK.
⁷ Public Health England, London, UK; Centre for Infectious Disease Epidemiology and MRC Clinical Trials Unit, London, UK.
⁸ INDOX Cancer Research Network, Oxford, UK; John Radcliffe Hospital, Oxford, UK; Green-Templeton College, University of Oxford, Oxford, UK.
⁹ Population Health Research Institute, Hamilton, ON, Canada; MRC-PHE Centre for Environment and Health, London, UK; St George's, University of London, London, UK.
¹⁰ University of Birmingham, Birmingham, UK.
¹¹ Clinical Trials Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK.
¹² King's College London Dental Institute, London, UK.
¹³ Wolfson Institute of Preventive Medicine, Barts & The London School of Medicine, Queen Mary University of London, London, UK.
¹⁴ Vision & Eye Research Unit, Anglia Ruskin University, Cambridge, UK.
¹⁵ Cambridge Institute of Public Health, University of Cambridge, Cambridge, UK.
¹⁶ University of Liverpool, Liverpool, UK.
¹⁷ University of Leicester, Leicester, UK.
¹⁸ Great Ormond Street Hospital for Children, London, UK.
¹⁹ University of Cambridge, Cambridge, UK.
²⁰ MRC Lifecourse Epidemiology Unit, University of Southampton, Southhampton, UK.
²¹ St George's, University of London, London, UK.
²² Guy's and St Thomas' NHS Foundation Trust, London, UK.
²³ Department of Epidemiology and Biostatistics, MRC-PHE Centre for Environment and Health, Imperial College London, London, UK.
²⁴ MRC-PHE Centre for Population Health, School of Public Health, Imperial College London, London, UK.
²⁵ Department of Infectious Disease Epidemiology, Imperial College London, London, UK.
²⁶ Public Health England, London, UK; Department of Primary Care and Public Health, Imperial College London, London, UK.
²⁷ School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK.
²⁸ School of Social and Community Medicine, University of Bristol, Bristol, UK.
²⁹ Public Health England, London, UK; Ulster University, Coleraine, Northern Ireland.
³⁰ International Foundation for Dermatology, London, UK.
³¹ Institute for Health Metrics and Evaluation, Seattle, WA, USA; Wellcome Trust Centre for Human Genetics, University of Oxford, Oxford, UK.
³² University College London, London, UK; Farr Institute of Health Informatics Research, London, UK.
³³ Institute for Health Metrics and Evaluation, Seattle, WA, USA; Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK.
³⁴ University of Liverpool, Liverpool, UK; Aintree University Hospital NHS Foundation Trust, University of Liverpool, Liverpool, UK.
³⁵ Farr Institute, College of Medicine, Swansea University, Swansea, UK.
³⁶ Queen Mary University of London.
³⁷ Department of Health Sciences, University of York, York, UK; Adolescent Health Research Unit, University of Cape Town, Cape Town, South Africa.
³⁸ Cambridge Institute of Public Health, University of Cambridge, Cambridge, UK; Institute of Health and Society, Newcastle University, Newcastle, UK.
³⁹ Cancer Epidemiology and Population Health, King's College London, London, UK.
⁴⁰ West Hertfordshire Hospitals NHS Trust, Hertfordshire, UK.
⁴¹ George Institute for Global Health and Division of Cardiovascular Medicine, Oxford Martin School, University of Oxford, Oxford, UK.
⁴² Department of Epidemiology and Biostatistics, MRC-PHE Centre for Environment and Health, Imperial College London, London, UK; Mid Sweden University, Sundsvall, Sweden.
⁴³ British Heart Foundation Centre on Population Approaches for NCD Prevention, University of Oxford, Oxford, UK.
⁴⁴ University of Edinburgh, Edinburgh, Scotland; Northumbria University, Newcastle upon Tyne.
⁴⁵ Farr Institute of Health Informatics Research, London, UK; London School of Hygiene & Tropical Medicine, Oxford Martin School, University of Oxford, Oxford, UK.
⁴⁶ NHS England, Leeds, UK; Imperial College Healthcare NHS Trust, London, UK; Imperial College London, London, UK.
⁴⁷ University of Nottingham, Nottingham, UK.
⁴⁸ King's College London, London, UK.
⁴⁹ Royal Cornwall Hospital, Treliske, UK.
⁵⁰ Public Health England, London, UK; London School of Economics, London, UK; University College London, London, UK.

PMID: 26382241
PMCID: PMC4672153
DOI: 10.1016/S0140-6736(15)00195-6

Changes in health in England, with analysis by English regions and areas of deprivation, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013

John N Newton et al. Lancet. 2015.

. 2015 Dec 5;386(10010):2257-74.

doi: 10.1016/S0140-6736(15)00195-6. Epub 2015 Sep 14.

Authors

Affiliations

¹ Public Health England, London, UK; University of Manchester, Manchester, UK. Electronic address: john.newton@phe.gov.uk.
² University of Oxford, Oxford, UK.
³ Institute for Health Metrics and Evaluation, Seattle, WA, USA.
⁴ Public Health England, London, UK.
⁵ Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK.
⁶ London School of Hygiene & Tropical Medicine, Oxford Martin School, University of Oxford, Oxford, UK.
⁷ Public Health England, London, UK; Centre for Infectious Disease Epidemiology and MRC Clinical Trials Unit, London, UK.
⁸ INDOX Cancer Research Network, Oxford, UK; John Radcliffe Hospital, Oxford, UK; Green-Templeton College, University of Oxford, Oxford, UK.
⁹ Population Health Research Institute, Hamilton, ON, Canada; MRC-PHE Centre for Environment and Health, London, UK; St George's, University of London, London, UK.
¹⁰ University of Birmingham, Birmingham, UK.
¹¹ Clinical Trials Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK.
¹² King's College London Dental Institute, London, UK.
¹³ Wolfson Institute of Preventive Medicine, Barts & The London School of Medicine, Queen Mary University of London, London, UK.
¹⁴ Vision & Eye Research Unit, Anglia Ruskin University, Cambridge, UK.
¹⁵ Cambridge Institute of Public Health, University of Cambridge, Cambridge, UK.
¹⁶ University of Liverpool, Liverpool, UK.
¹⁷ University of Leicester, Leicester, UK.
¹⁸ Great Ormond Street Hospital for Children, London, UK.
¹⁹ University of Cambridge, Cambridge, UK.
²⁰ MRC Lifecourse Epidemiology Unit, University of Southampton, Southhampton, UK.
²¹ St George's, University of London, London, UK.
²² Guy's and St Thomas' NHS Foundation Trust, London, UK.
²³ Department of Epidemiology and Biostatistics, MRC-PHE Centre for Environment and Health, Imperial College London, London, UK.
²⁴ MRC-PHE Centre for Population Health, School of Public Health, Imperial College London, London, UK.
²⁵ Department of Infectious Disease Epidemiology, Imperial College London, London, UK.
²⁶ Public Health England, London, UK; Department of Primary Care and Public Health, Imperial College London, London, UK.
²⁷ School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK.
²⁸ School of Social and Community Medicine, University of Bristol, Bristol, UK.
²⁹ Public Health England, London, UK; Ulster University, Coleraine, Northern Ireland.
³⁰ International Foundation for Dermatology, London, UK.
³¹ Institute for Health Metrics and Evaluation, Seattle, WA, USA; Wellcome Trust Centre for Human Genetics, University of Oxford, Oxford, UK.
³² University College London, London, UK; Farr Institute of Health Informatics Research, London, UK.
³³ Institute for Health Metrics and Evaluation, Seattle, WA, USA; Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK.
³⁴ University of Liverpool, Liverpool, UK; Aintree University Hospital NHS Foundation Trust, University of Liverpool, Liverpool, UK.
³⁵ Farr Institute, College of Medicine, Swansea University, Swansea, UK.
³⁶ Queen Mary University of London.
³⁷ Department of Health Sciences, University of York, York, UK; Adolescent Health Research Unit, University of Cape Town, Cape Town, South Africa.
³⁸ Cambridge Institute of Public Health, University of Cambridge, Cambridge, UK; Institute of Health and Society, Newcastle University, Newcastle, UK.
³⁹ Cancer Epidemiology and Population Health, King's College London, London, UK.
⁴⁰ West Hertfordshire Hospitals NHS Trust, Hertfordshire, UK.
⁴¹ George Institute for Global Health and Division of Cardiovascular Medicine, Oxford Martin School, University of Oxford, Oxford, UK.
⁴² Department of Epidemiology and Biostatistics, MRC-PHE Centre for Environment and Health, Imperial College London, London, UK; Mid Sweden University, Sundsvall, Sweden.
⁴³ British Heart Foundation Centre on Population Approaches for NCD Prevention, University of Oxford, Oxford, UK.
⁴⁴ University of Edinburgh, Edinburgh, Scotland; Northumbria University, Newcastle upon Tyne.
⁴⁵ Farr Institute of Health Informatics Research, London, UK; London School of Hygiene & Tropical Medicine, Oxford Martin School, University of Oxford, Oxford, UK.
⁴⁶ NHS England, Leeds, UK; Imperial College Healthcare NHS Trust, London, UK; Imperial College London, London, UK.
⁴⁷ University of Nottingham, Nottingham, UK.
⁴⁸ King's College London, London, UK.
⁴⁹ Royal Cornwall Hospital, Treliske, UK.
⁵⁰ Public Health England, London, UK; London School of Economics, London, UK; University College London, London, UK.

PMID: 26382241
PMCID: PMC4672153
DOI: 10.1016/S0140-6736(15)00195-6

Abstract

Background: In the Global Burden of Disease Study 2013 (GBD 2013), knowledge about health and its determinants has been integrated into a comparable framework to inform health policy. Outputs of this analysis are relevant to current policy questions in England and elsewhere, particularly on health inequalities. We use GBD 2013 data on mortality and causes of death, and disease and injury incidence and prevalence to analyse the burden of disease and injury in England as a whole, in English regions, and within each English region by deprivation quintile. We also assess disease and injury burden in England attributable to potentially preventable risk factors. England and the English regions are compared with the remaining constituent countries of the UK and with comparable countries in the European Union (EU) and beyond.

Methods: We extracted data from the GBD 2013 to compare mortality, causes of death, years of life lost (YLLs), years lived with a disability (YLDs), and disability-adjusted life-years (DALYs) in England, the UK, and 18 other countries (the first 15 EU members [apart from the UK] and Australia, Canada, Norway, and the USA [EU15+]). We extended elements of the analysis to English regions, and subregional areas defined by deprivation quintile (deprivation areas). We used data split by the nine English regions (corresponding to the European boundaries of the Nomenclature for Territorial Statistics level 1 [NUTS 1] regions), and by quintile groups within each English region according to deprivation, thereby making 45 regional deprivation areas. Deprivation quintiles were defined by area of residence ranked at national level by Index of Multiple Deprivation score, 2010. Burden due to various risk factors is described for England using new GBD methodology to estimate independent and overlapping attributable risk for five tiers of behavioural, metabolic, and environmental risk factors. We present results for 306 causes and 2337 sequelae, and 79 risks or risk clusters.

Findings: Between 1990 and 2013, life expectancy from birth in England increased by 5·4 years (95% uncertainty interval 5·0-5·8) from 75·9 years (75·9-76·0) to 81·3 years (80·9-81·7); gains were greater for men than for women. Rates of age-standardised YLLs reduced by 41·1% (38·3-43·6), whereas DALYs were reduced by 23·8% (20·9-27·1), and YLDs by 1·4% (0·1-2·8). For these measures, England ranked better than the UK and the EU15+ means. Between 1990 and 2013, the range in life expectancy among 45 regional deprivation areas remained 8·2 years for men and decreased from 7·2 years in 1990 to 6·9 years in 2013 for women. In 2013, the leading cause of YLLs was ischaemic heart disease, and the leading cause of DALYs was low back and neck pain. Known risk factors accounted for 39·6% (37·7-41·7) of DALYs; leading behavioural risk factors were suboptimal diet (10·8% [9·1-12·7]) and tobacco (10·7% [9·4-12·0]).

Interpretation: Health in England is improving although substantial opportunities exist for further reductions in the burden of preventable disease. The gap in mortality rates between men and women has reduced, but marked health inequalities between the least deprived and most deprived areas remain. Declines in mortality have not been matched by similar declines in morbidity, resulting in people living longer with diseases. Health policies must therefore address the causes of ill health as well as those of premature mortality. Systematic action locally and nationally is needed to reduce risk exposures, support healthy behaviours, alleviate the severity of chronic disabling disorders, and mitigate the effects of socioeconomic deprivation.

Funding: Bill & Melinda Gates Foundation and Public Health England.

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Figures

**Figure 1**
The 25 leading GBD level 3 causes of years of life lost (YLLs) in England, both sexes combined, 1990, 2005, and 2013, with age-standardised median percent change Ranks are based on the number of YLLs. 95% UIs for mean rank are from 1000 draws of YLLs. UI=uncertainty interval. COPD=chronic obstructive pulmonary disease.

**Figure 2**
Age-standardised rates of years of life lost (YLLs) for England and the nine English regions relative to EU15 countries, Australia, Canada, Norway, the USA, Scotland, Northern Ireland, and Wales for both sexes combined in 2013 EU15+ countries, UK constituent countries, and English regions are ordered by the overall mean age-standardised YLL rate. To facilitate comparison, England and the nine English regions are shown in bold. For illustrative purposes only, UK constituent countries and the English regions have been included where they would rank if they were one of the EU15+ countries; this is not to suggest that the health system in a given English region is equivalent to that of any of the countries to which it is adjacent in the list. Rates are colour-coded to denote statistically significant differences from the mean across this set of English regions and countries. Lung cancer=lung, bronchus, and trachea cancer. COPD=chronic obstructive pulmonary disease. Alzheimer's disease=Alzheimer's disease and other dementias. Other cardiovascular=other cardiovascular and circulatory diseases. Cirrhosis hepatitis C=cirrhosis of the liver secondary to hepatitis C. Brain cancer=brain and central nervous system cancer.

**Figure 3**
Age-standardised rates of years of life lost (YLLs) for England relative to the deprivation levels in the nine English regions for both sexes combined in 2013 To facilitate comparison, England is shown in bold. Lung cancer=lung, bronchus, and trachea cancer. COPD=chronic obstructive pulmonary disease. Alzheimer's disease=Alzheimer's disease and other dementias. Other cardiovascular=other cardiovascular and circulatory diseases. Cirrhosis hepatitis C=cirrhosis of the liver secondary to hepatitis C. Brain cancer=brain and central nervous system cancer.

**Figure 4**
The 25 leading GBD level 3 causes of disability-adjusted life years (DALYs) in England, both sexes combined, 1990, 2005, and 2013, with age-standardised median percent change Ranks are based on the number of DALYs. 95% UIs for mean rank are from 1000 draws of DALYs. UI=uncertainty interval. COPD=chronic obstructive pulmonary disease.

**Figure 5**
Proportion of all-cause DALYs (A), cardiovascular disease DALYs (B), neoplasm DALYs (C), and injury DALYs (D) attributable to behavioural, environmental and occupational, and metabolic risk factors and their overlaps for all ages in 2013

**Figure 6**
Disability-adjusted life-years (DALYs) attributed to level 2 risk factors in 2013 in England for both sexes combined (A), men (B), and women (C)

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Comment in

Will Public Health England lead research?
McCarthy M. McCarthy M. Lancet. 2015 Dec 5;386(10010):2232-4. doi: 10.1016/S0140-6736(15)00196-8. Epub 2015 Sep 14. Lancet. 2015. PMID: 26382242 No abstract available.

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Changes in health in England, with analysis by English regions and areas of deprivation, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013

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Changes in health in England, with analysis by English regions and areas of deprivation, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013

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