2011 Census analysis: Healthy Life Expectancy at Birth and at Age 65- Clinical Commissioning Groups 2010-12

• The gap in Healthy Life Expectancy (HLE) at birth between NHS Clinical Commissioning Groups (CCGs) was 17.8 years for males and 19.7 years for females.

• NHS Guildford and Waverley had the highest healthy life expectancy at birth and at age 65 for males and females (70.3 years and 71.3 years at birth, 12.4 years and 13.1years at age 65, respectively).

• The lowest HLE at birth was in NHS Bradford City for males and females; at 52.5 years and 51.6 years respectively.

• The top ten Clinical Commissioning Groups (CCGs) with the highest HLE were clustered in an area to the south and west of London.

• The bottom ten CCGs with the lowest HLE were located in the North, the Midlands and some ethnically diverse parts of East London.

• Females at birth and age 65 have longer LE and HLE than males but when comparing the proportion of life in ‘Good’ health males spend a greater proportion of their life in ‘Good’ health.

Notes for key points

1. The proportion of the life in 'Good' health is a relative measure which divides HLE by LE, and can be expressed as a percentage.

Life expectancy (LE) is an important outcome measure of mortality among an area’s residents; however, alone it does not tell us anything about the health related quality of life of these years. Healthy Life Expectancy (HLE) based on subjective self-assessed health adds value to life expectancy by estimating the average lifetime spent in a favourable state of health. HLEs are being used increasingly in government and the private sector for policy development and business planning to assess health and social care need and gauge population level health improvement: it also has use for pension provision planning and state pension age reviews.

Clinical Commissioning Groups (CCGs) became operational in April 2013 following the introduction of the Health and Social Care Act 2012 in England, and represent part of the new administrative NHS Structure in England. This short story is the first analysis to examine differences in healthy life expectancy, a summary measure of population health, across these areas around the time of the 2011 Census and how each compares with the national average for England.

What is healthy life expectancy?

Healthy life expectancy (HLE) estimates the average lifespan spent in very good or good health based on self assessed general health. These estimates add a quality of life dimension to life expectancy (LE) by dividing predicted lifespan into time spent in given states of health. The Office for National Statistics (ONS) routinely publishes two types of health expectancy estimates; these are HLE and Disability-free life expectancy (DFLE). Health Expectancies (HEs), (which include HLE and DFLE) are used as high-level outcomes to contrast the health status of different populations at specific points in time and to monitor changes in population health over time; providing context to the impacts of policy changes and interventions at both national and local levels.

The figures represent a snapshot of the mortality and health status of the entire specified area population in a given time period. They are not, therefore, the number of years that a person will actually expect to live in the area in a given health state. This is because both mortality and health rates (derived from the different surveys) are likely to change in the future, and people are likely to migrate and live in different areas for part of their lives.

Therefore the HLE figures must be interpreted as an average number of years a person is expected to live in a state of ‘Good’ health, under the assumption that he\she experiences the specific population mortality and health rate in a given time period throughout his\her life.

Clinical Commissioning Groups

This short story will be the first to estimate HLE by the Clinical Commissioning Groups in England (CCG). From April 2013, the Health and Social Care Act 2012 introduced a new administrative structure for the NHS across England. Primary Care Organisations were replaced by 211 CCGs. Within each CCG, General Practitioners are held responsible for the planning and commissioning of health care services based on what they assess are needed for their populations. The individual CCGs will make decisions regarding the allocation of NHS funds at local level and setting priorities for services; including emergency, maternity, hospital, community and mental health services.

Calculating HLE by CCG will help support planning of health and social care services and policies by identifying inequalities between administrative areas and variations from the national average. These comparisons can highlight the CCGs in which people spend more or less (i.e. health inequality) time in their life in a ‘Good’ health state compared to other areas in England. Identifying areas of concern can give focus to policies aiming to reduce inequalities in health between populations, which is a key objective for NHS England (2014), as well as for Public Health England and a central point made in the Marmot review (2010).

Continuing measurement of HLE by CCGs using future census data as well as alternative data sources will enable the monitoring of policies and services designed to reduce inequalities in health between administrations. Future estimates of HLE by CCGs are particularly important as they can help us understand whether changes in HLE keep pace with the expected increases in LE, which can be used to inform current debates in policy (e.g. State Pension Age).

How does the Census measure health?

The 2011 Census asked two questions relating to health. Question 13 (Box 1) was designed to capture self-assessed health. An individual responding Very Good or Good is classified as having ‘Good’ health, whereas an individual responding Fair, Bad or Very Bad is classified as having ‘Not Good’ health.

A similar analysis, using a second health question included in the Census 2011, will measure disability free life expectancy (DFLE) for NHS CCGs and be released on the 28th of March.

National healthy life expectancy at birth

CCGs aim to ensure a fair distribution of health care resources for their residents. Therefore to assess the CCGs commissioning performance, certain trusted markers are needed to monitor whether commissioned services meet the needs of the population. For this purpose, HLE at birth can be used as one such indicator both to assess need and to judge the impact of health care services on local health improvement at local level over time. .

Figure 1 shows the cross comparison between LE and HLE for males and females in England. These national figures provide a benchmark for other NHS Clinical Commissioning Groups to compare themselves with.

Figure 1: Life expectancy and Healthy Life Expectancy at birth for males and females in England, 2010-2012

Source: Census - Office for National Statistics

These results show that LE for males in England is estimated to be 79.2 years, while HLE is only 63.5 years, therefore it is expected that 15.7 years will be spent in ‘Not Good’ health. Females in England have a higher LE than males, of 83.0 years; however, 18.2 years is estimated to be spent in ‘Not Good’ health.

Even though females are estimated to have more life years in ‘Good’ health than males, males are estimated to spend a greater proportion of their lives in ‘Good’ health (80.2%) than females (78.0%) in England.

NHS Clinical Commissioning Groups (CCGs) HLE at birth

Table 1 (males) and table 2 (females) show the top and bottom ten CCGs ranked by Healthy Life Expectancy (HLE) at birth in England. Life expectancy (LE) and the proportion of life spent in ‘Good’ health are also shown for each area.

The CCGs which were ranked in the top ten, with the highest HLE estimates were the same for both males and females. These CCGs were located near the Local Authorities which experienced the lowest level of deprivation; located mainly in the commuter belts of Hampshire, Surrey, Windsor and Horsham and having extensive rural and semi-rural populations. In these top CCGs for male HLE, there was little inequality (ranging from 70.3 years in NHS Guildford and Waverley to 68.3 years in NHS West Hampshire); females had slightly higher HLE ranging from, 71.3 years in NHS Guildford and Waverley to 69.6 years in NHS North East Hampshire and Farnham.

CCGs appearing in the top and bottom ten showed a clear North-South divide. CCGs around the South of England had HLE above the national average (Table 1,2), while the bottom ten CCGs had HLE significantly lower than England, and consisted of areas where the level of deprivation was on average higher; for example, the North of England, the Midlands and some ethnically diverse parts of east London.

The inequality in HLE between the top and bottom ten CCGs was markedly larger than for LE for both genders; the gap was larger for females at 19.7 years, compared with 17.8 years for males. In contrast in LE; the gap between CCGs is larger for males at 9.1 years, compared with 6.5 years for females.

NHS Bradford City had the lowest HLE estimates at 52.5 years for males and 51.6 years for females, followed by NHS North Manchester (HLE of 53.8 years for males and 55.2 years for females). The gap between these two CCGs showed that females from NHS North Manchester are expected to live an extra 3.6 years in ‘Good’ health than the females from NHS Bradford City. This shows that inequality is not limited to the north/south divide but it also exists between some closely ranked CCGs in the bottom ten, but not in the top ten where HLE is more uniform.

In London, NHS Barking & Dagenham, NHS City and Hackney, NHS Tower Hamlets and NHS Newham all appeared in the bottom ten for females. However, only NHS Tower Hamlets and NHS Newham are in the bottom ten for both males and females and have HLE much lower than the national average. Previous publications by ONS including Healthy Life Expectancy at Birth in 2009-11, Activity Limitation and General Health also showed that health estimates of residents of Tower Hamlets and Newham are less favourable than in the other boroughs in London.

The ethnic minority Asian populations resident in NHS Newham and NHS Tower Hamlets are larger than in other London CCGs, and their makeup is mainly Pakistani, Indian or Bangladeshi. The Census 2011 showed that in NHS Newham 9.8% reported their ethnicity as Pakistani, 13.8% as Indian and 12.1% as Bangladeshi; however in NHS Tower Hamlets 32% reported their ethnicity as Bangladeshi. Furthermore Census releases on gender and ethnic health inequality showed that Pakistani and Bangladeshi women have limiting illness rates 10% higher than the White British women (Dynamic of diversity: evidence from the Census 2011). This indicates that ethnic composition may be contributing to the wider inequalities in HLE found in the bottom ten CCGs.

The largest difference in HLE between males (55.9 years) and females (59.2 years) was in NHS Blackpool where females are expected to live 3.3 years longer in a state of ‘Good’ health than males. On the other hand, there were only seven CCGs where males had higher HLE than females; NHS Bradford City (0.9 years), NHS Newham (0.9 years), NHS Tower Hamlets (0.6 years), NHS Harrow (0.6 years), NHS Barking and Dagenham (0.3 years), NHS Redbridge (0.1 years) and NHS Slough (0.1 years). In addition, there are only three CCGs which had similar estimates of HLE for males and females; these were NHS Enfield (62.9 years), NHS Leicester City (59.3 years) and NHS Sandwell and West Birmingham (57.4 years).

The maps below show the north/south divide for males and females by the new NHS geographies. In these maps, the darkest purple colour represents the CCGs with the highest HLE estimates; ranging from 68.2 years to 70.3 years for males and 69.6 years to 71.3 years for females. Conversely, the lightest shaded purple colour represents the CGGs with the lowest HLE estimates; ranging from 52.5 years to 57.9 years for males and 51.6 years to 59.0 years for females.

Healthy Life Expectancy (HLE) at birth for NHS Clinical Commissioning Groups (CCGs), England, 2010-12

Source: Census - Office for National Statistics

National healthy life expectancy at age 65.

In the last few decades, life expectancy at age 65 has increased notably for men and women, and there are several explanations for these increases leading to population ageing such as:

• Advances in secondary hospital care with greater access to life saving procedures and medical treatments

• Adopting healthier lifestyles, such as reductions in smoking prevalence

• Improving living conditions and general environment.

It is interesting to know whether longer life expectancies are also accompanied by longer durations of life spent in a state of good health. To gauge the extent of healthy life in later ages, HLE at age 65 is used, which is an important indicator for judging health and social care need, and pension provision and state pension age changes.

Figure 2: Life expectancy and Healthy Life Expectancy at age 65 for men and women in England, 2010-2012

Source: Census - Office for National Statistics

Figure 2 shows the LE and HLE at age 65 for men and women in England and these figures are set as a benchmark for other CCGs to compare themselves to the national average.

Men at age 65 could expect to live an additional 9.2 years in a favourable state of health in England and women slightly longer at 9.7 years. However, comparing national HLE with LE, there are stark differences. In figure 3, men in England are estimated to live a further 18.6 years at the age of 65, but half of this would be in ‘Not Good’ Health. Women in England are expected to live a further 21.1 years but more than half (11.4 years) of this would be in ‘Not Good’ health on average.

Therefore on the whole nationally, women at age 65 have longer LE and HLE than men, but when comparing the proportion of life spent in ‘Good’ health, men (49.7%) spend a greater proportion of their life in a favourable state of health than women (46.1%).

NHS Clinical Commissioning Groups (CCGs) HLE at age 65

Table 3 (men) and table 4 (women) show the top and bottom ten CCGs ranked by HLE at age 65 in England. Life expectancy (LE) and the proportion of life spent in ‘Good’ health are also shown for each area.

In the context of health inequality across CCGs, a north/south divide can also be seen at age 65. While men in NHS North Manchester can expect an additional five years in good health beyond age 65, this is less than half the length of time that men in NHS Guildford and Waverley (12.4 years) could expect to live in ‘Good’ health. For women, these gaps are slightly wider; where HLE was lowest in NHS Bradford City at 5.1 years and highest in NHS Guildford and Waverley at 13.1 years. This shows that inequalities are not only present at birth, but extend to older populations.

In terms of the proportion of life spent in ‘Good’ health at age 65, the inequality was wider for women than men; the proportion of life spent in ‘Good’ health in NHS Guildford and Waverley (58.1%) was double the proportion of life spent in ‘Good’ health in NHS Bradford City (27.3%), showing a wider gap between CCGs at age 65 for women.

The largest difference in HLE at age 65 between men (11.3 years) and women (12.7 years) was in NHS Richmond where women live 1.4 more years in a state of ‘Good’ health than men. Interestingly men (5.9 years) and women (5.9 years) from NHS Newham at age 65 have similar estimates of HLE; this is in contrast to HLE at birth, which was higher for men (0.9 years).

The data used in calculating the prevalence of self assessed ‘Good ‘general health by sex and five year age band is obtained from the Census 2011 general health question, with mortality data aggregated for the three year period (2010-2012) centred on the 2011 Census. Census data is combined with mortality data from interim life tables, along with national mid-year population estimates to ensure that all figures are based on a three-year period to get a sufficiently large number of deaths for accurate comparison.

UK health expectancies are generally calculated using the Sullivan method, which incorporate national period life expectancies (Jagger, 2006). Figures are published along with 95% confidence intervals to allow the user to identify significant differences between populations. Statistical significance is assigned on the basis of a Z test for the difference in HLE between populations with variance estimation proposed by the Sullivan guide.

Further information regarding the guide used to calculate UK health expectancies are available on the ONS website (188.2 Kb Pdf) .