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The Lancet: Study reveals England's improving health performance compared to other wealthy countries

But exposes persistent inequalities within regions -- Health gap between most- and least-deprived areas of England has hardly changed over past 23 years

The Lancet

In 2013, England performed better than average on a variety of key health outcomes compared with 18 other high-income countries in the European Union [1], and Australia, Canada, Norway, and the USA (EU15+), according to new research published in The Lancet.

However, the findings also reveal the impact of substantial health disparities within English regions, the significant toll of chronic disabling conditions, and the importance of tackling preventable diseases. It is likely that around 40% of NHS workload is due to potentially preventable risk factors.

Using data from The Global Burden of Diseases, Injuries, and Risk Factors Study 2013 (GBD 2013), Professor John Newton from Public Health England, London, UK and colleagues analysed patterns of ill health and death in England, calculated the contribution of preventable risk factors, and ranked England compared to the UK and the EU15+ countries in 1990 and 2013. Estimates were also produced for nine English regions and 45 sub-regional areas defined by level of deprivation (deprivation areas).

Between 1990 and 2013, England achieved one of the largest gains in national life expectancy among men at 6.4 years (to 79.5 years), behind Luxembourg, but on a par with Finland. For women, average national life expectancy increased by a more modest 4.4 years (to 83.2 years), but still equalling or surpassing all EU15+ countries except Finland, Germany, Ireland, Luxembourg, and Portugal (figure appendix 1).

However, national progress has not been accompanied by improvements in inequalities, and the gap in life expectancy between the most and least deprived regional groups in England has stayed unchanged for men (8.2 years) and declined by just 0.3 years in women (from 7.2 to 6.9 years) since 1990 (figure appendix 2).

"Inequality within regions is greater than it is among them," explains Professor Newton. "In 2013, those living in the most deprived areas still hadn't reached the levels of life-expectancy that less-deprived groups experienced in 1990."[2]

The research shows that improvements in life expectancy in England have been driven by declines in deaths from cardiovascular disease and some cancers. But, increases in death rates from liver disease, drug and alcohol misuse, and neurological conditions - which are highest in the most-deprived areas - have diminished these benefits (web table 5).

"England has done well over the past 23 years in many areas. But there is still plenty of room for bold action to reduce the significant toll of preventable conditions," says Professor Newton. "The country has done a good job preventing premature deaths but this has not been matched by declines in disability and illness, resulting in people living longer with disease. If the levels of health seen in the best-performing English regions could be achieved in the worst, then England could have a level of overall disease burden as low as any country in the industrialised world."[2]

"This analysis demonstrates the enormous importance of measuring disease burden at the subnational level," says Dr. Christopher Murray, Director of the Institute for Health Metrics and Evaluation (IHME), the coordinating center for the Global Burden of Disease study, and a Professor of Global Health at the University of Washington in the USA. "Examining leading causes of death, disability, and health loss only at the national level can obscure key local trends. Decision-makers need the best available evidence to determine the most locally-appropriate solutions to addressing health inequalities."[2]

Other key findings include:

  • For men, the highest life expectancies in 2013 (at 80 years or above) were in South West England, East of England, and South East England, which is better than all the EU15+ nations. For women, the highest life expectancies were in Spain, Italy, and France at 84.4 years or above, the next highest life expectancies were in Australia and South-East England at 84 years (Appendix figure 1).

  • Despite the same health and social care system, some English regions (eg, South West England, East of England, and South East England) now have similar or better levels of health than the best-performing EU15+ countries, whereas other regions (eg, North East England and North West England) rank amongst the worst performing nations (web table 3).

  • The degree of health inequality between regions largely follows their relative level of deprivation with more deprived populations having a greater burden of diseases, such as ischaemic heart disease and lung cancer, and risk factors, such as smoking and alcohol misuse. For example, in 2013, years of life lost to the top causes of death--ischemic heart disease, lung cancer, and chronic obstructive pulmonary disease (COPD)--largely mirror levels of deprivation (figure 2). In 2013, 91% of the difference in premature deaths in men was explained by deprivation area and only 5% by geographical region; for women 79% of this variation was explained by deprivation and 12% by region (table 1).

  • In England, the reduction in total disease burden in the last 23 years (-24%) has been achieved mainly through reductions in years of life lost to premature death (-41%) rather than declines in the burden of disability (-1.4%).

  • Sickness and chronic disability are causing a much greater proportion of the burden of disease as people are living longer with several illnesses. Low back and neck pain is the leading cause of overall disease burden, with hearing and vision loss and depression also in the top 10.

  • For several conditions, although death rates have declined, the health burden has not reduced to the same extent, or is increasing. For example, while deaths rates from diabetes fell by about 56%, increases in illness and disability associated with diabetes have been substantial, rising by around 75% over the last 23 years (table 2).

  • Known risk factors operating together explain 40% of ill health in England. Unhealthy diets (responsible for 10.8% of disease burden), smoking (10.7%), high body mass index (BMI; 9.5%), high blood pressure (7.8%), and alcohol and drug use (5.8%) top the list of individual risk factors contributing to poor health in 2013 (figure 6a-c).

  • Alcohol use is the third leading behavioural risk factor for overall ill-health in England, and is the largest risk contributing towards injury.

According to Professor Newton, "England has had some success finding solutions for cardiovascular diseases and some cancers, but it has yet to make the same kind of progress with the leading causes of ill health and disability. Health policies must address the causes of ill health, as well as those of premature death, with a particular focus on tackling the effects of deprivation in all regions."[2]

He adds, "If England can make progress with smoking, alcohol, dietary risk factors, physical inactivity, and obesity, it will see massive reductions in disability. This will require new approaches to support healthy behaviours, modify known risk factors, and alleviate the severity of chronic disabling conditions."[2]



This study was funded by the Bill & Melinda Gates Foundation and Public Health England.

[1] Austria, Belgium, Denmark, Finland, France, Germany, Greece, Ireland, Italy, Luxembourg, Netherlands, Portugal, Spain, and Sweden.

[2] Quotes direct from author and cannot be found in text of Article.

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